This study aimed to evaluate the efficacy and safety of acupuncture for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). A search of PUBMED, EMBASE, Central Register of Controlled Trials (CENTRAL), Web of Science, Chinese Biomedicine Literature (CBM), China National Knowledge Infrastructure (CNKI), Wang-Fang Database, Chinese Scientific Journal Database (VIP), and other available resources was made for studies (up to February 2019). Searches were limited to studies published in English and Chinese. Only randomized controlled trials (RCTs) related to the efficacy and/or safety of acupuncture for CP/CPPS were included. Two investigators independently evaluated the quality of the studies. A total of 11 studies were included, involving 748 participants. The results revealed that compared with sham acupuncture (MD: −6.53 [95% CI: −8.08 to −4.97]) and medication (MD: −4.72 [95% CI: −7.87 to −1.56]), acupuncture could lower total NIH-CPSI score more effectively. However, there are no significant differences between acupuncture and sham acupuncture in terms of IPSS score. In terms of NIH-CPSI voiding domain subscore, no significant differences were found between acupuncture and medication. Compared with sham acupuncture (OR: 0.12 [95% CI: 0.04 to 0.40) and medication (OR: 3.71 [95% CI: 1.83 to 7.55]), the results showed favorable effects of acupuncture in improving the response rate. Acupuncture plus medication is better than the same medication in improving NIH-CPSI total score and NIH-CPSI pain domain subscore. In conclusion, the evidence suggests that acupuncture may be an effective intervention for patients with CP/CPPS. However, due to the heterogeneity of the methods and high risk of bias, we cannot draw definitive conclusions about the entity of the acupuncture's effect on alleviating the symptoms of CP/CPPS. The adverse events of acupuncture are mild and rare. Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a complex clinical entity consisting of urogenital pain, lower urinary tract symptoms, and/or sexual dysfunction that lasts for at least 3 months in the past 6 months . CP/CPPSCP/CPPS is a severe challenge and difficult problem for urologists, and there is no “golden standard” to treat the disease because pathogenesis remains unclear and some researchers think CP/CPPS is a multifactorial disease such as abnormal immune response, genetic predisposition, pathogen infection, neuromuscular factors, and intraprostatic ductal reflux . So it iAt present, antibiotics, anti-inflammatory drugs, alpha-blockers, and neuromodulators are the most commonly used drugs in the treatment of CPPS. However, the use of antibiotics remains controversial because there are no isolated bacteria . AntiobsAcupuncture is a form of alternative medicine and a key component of traditional Chinese medicine (TCM). It is most often used to relieve pain, though it is also recommended by acupuncturists for a wide range of other conditions. Different methods are used during acupuncture such as manual manipulation, electrical stimulation, and heat. Another form of acupuncture is acupoint catgut embedding. Studies reported that acupuncture had the effect of anti-inflammatory, immune modulation and neuromodulation. In 2016, Liu et al.  conducteThe style of reporting the findings in the manuscript was performed in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement .A search of PUBMED, EMBASE, CENTRAL, Web of Science, CBM, CNKI, Wang-Fang Database, VIP, and other available resources was made for studies (up to February 2019) that compared the efficacy and safety of acupuncture with sham acupuncture or medication . The search terms related to acupuncture, chronic prostatitis, chronic pelvic pain syndrome, and randomized controlled trials. Searches were limited to studies published in English and Chinese  were included. CP/CPPS was defined as urogenital pain, lower urinary tract symptoms, and/or sexual dysfunction that lasts for at least 3 months in the past 6 months in the absence of any urinary tract infection. Participants with benign prostatic hypertrophy, acute bacterial prostatitis, prostate cancer, severe heart disease, hepatic and kidney dysfunction, severe mental disease, or other serious diseases were excluded.Acupuncture compared to western drugs, acupuncture with drugs compared to the same drugs, and acupuncture compared to sham acupuncture were included. In addition, for the purposes of this review, we focused on acupuncture that can be performed in primary care settings, including any type of penetrating acupuncture . Comparison of two different types of acupuncture, acupuncture injections and acupuncture combined/compared with Chinese herbal medicine or acupuncture as a supplement to the effectiveness of the above interventions was excluded.Changes in the total NIH-CPSI score , NIH-CPSWe extracted the information of characteristics of participants, types of treatments and control groups, outcome measures, adverse events, and the follow-up period, if available  and the IPSS . The scores of the acupuncture and control groups at the end of the original study period were compared. Response rate was defined according to the definitions in the original studies.X2 statistical tests (Q statistics) and the I2 test were used to test the heterogeneity between the trials. The parameters with mean value and 95% confidence interval were transformed into mean values with standard deviation for calculation of weighted mean difference.All analyses were performed by the Review Manager statistical software (version 5.3). The continuous outcomes were analyzed using mean difference (MD) as the summary statistic. The dichotomous outcomes were analyzed using odds ratios (ORs) as the summary statistic. Cochrane Collaboration tool was used As shown in the flow chart of selection , a totalFinally, a total of 11 studies –25 were The quality of the enrolled studies was evaluated by the Cochrane Collaboration tool. Information of all included RCTs on subsequent allocation is not clear, thus all 11 trials were rated as having unclear risk of bias in this domain. Six RCTs comparing acupuncture to medication did not provide sufficient blinding information , 23, 24,I2 = 52%)  with moderate heterogeneity (2 = 52%) .I2 = 85%) (I2 = 5%) with an average pain reduction of 2.13 (MD: −2.13 [95% CI: 2.76 to −1.50])  with high heterogeneity (2 = 85%) . A sensi −1.50]) .I2 = 13%)  with low heterogeneity (2 = 13%) .I2 = 71%) (I2 = 47%) with an average pain reduction of 1.58 (MD: −1.58 [95% CI: −2.26 to −0.89])  with high heterogeneity (2 = 71%) . After s −0.89]) .I2 = 0%  with I2 = 0% .I2 = 52%)  with moderate heterogeneity (2 = 52%) .I2 = 92%)  with high heterogeneity (2 = 92%) . BecauseI2 = 0%)  with low heterogeneity (I2 = 0%) .I2 = 86%) (NIH-CPSI voiding domain subscore: 3 RCTs involving 168 participants that compared acupuncture to medication in NIH-CPSI voiding domain subscore. The results showed that there was no significant difference between the acupuncture and medication (MD: 0.36 [95% CI: −0.75 to 1.47]) with high heterogeneity (2 = 86%) . BecauseI2 = 0%)  with low heterogeneity (I2 = 0%) .I2 = 3%)  with low heterogeneity (I2 = 3%) .I2 = 12%)  with low heterogeneity (2 = 12%) .I2 = 0%)  with low heterogeneity (I2 = 0%) .Four of the 11 trials reported the occurrence of adverse events (ADs) in the acupuncture group , 20, 25,P < 0.05), NIH-CPSI pain domain subscore , NIH-CPSI voiding domain subscore , NIH-CPSI quality of life domain subscore , and response rate . However, there is no significant difference between acupuncture and sham acupuncture in improving IPSS , which is different from previous meta-analyses results [P < 0.05), NIH-CPSI pain domain subscore , NIH-CPSI quality of life domain subscore , and response rate , except NIH-CPSI voiding domain subscore . In addition, this review reveals that acupuncture plus medication is better than the same medication in improving NIH-CPSI total score  and NIH-CPSI pain domain subscore . As a result, acupuncture may be recommended as a major treatment for patients with CP/CPPS who have no signs of bacterial infection. However, the small number of cases and the variety of treatment options hinder the determination of the efficacy of acupuncture treatment. More high-quality RCTs are needed to verify the exact efficacy of acupuncture for CP/CPPS.This study is a systematic review and meta-analysis of the therapeutic effect of acupuncture on patients with CP/CPPS. To investigate the efficacy of acupuncture, we combined the experimental data to calculate the mean difference by comparing the baseline and endpoint results of the control group. The results show that acupuncture is superior to sham acupuncture in terms of NIH-CPSI total score  performed better. Although the current meta-analysis shows encouraging results, further research is necessary to determine what kinds of patients could benefit from acupuncture.Acupuncture may be an effective intervention for patients with CP/CPPS. Compared with sham acupuncture, real acupuncture yielded a significant reduction in the NIH-CPSI score. Compared with medication, acupuncture is better in improving NIH-CPSI total score, pain domain subscore, and quality of life domain subscore. In addition, acupuncture plus medication is better than the same medication in improving NIH-CPSI total score and NIH-CPSI pain domain subscore. However, due to the heterogeneity of the methods and high risk of bias, we cannot draw definitive conclusions about the entity of the acupuncture's effect on alleviating the symptoms of CP/CPPS. The adverse events of acupuncture are mainly hematoma and local pain, which could be quickly relieved, and no other serious side effects were found.


Shorter leukocyte telomere length (LTL) is associated with aging and dementia. Impact of lifestyle changes on LTL, and relation to cognition and genetic susceptibility for dementia, has not been investigated in randomized controlled trials (RCTs).z-score). Relative LTL was measured using quantitative real-time polymerase chain reaction .Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability is a 2-year RCT enrolling 1260 participants at risk for dementia from the general population, aged 60–77 years, randomly assigned (1:1) to multidomain lifestyle intervention or control group. The primary outcome was cognitive change  was −0.016 (0.19) in the intervention group and −0.023 (0.17) in the control group. Between-group difference was nonsignificant . Interaction analyses indicated better LTL maintenance among apolipoprotein E (APOE)-ε4 carriers versus noncarriers: 0.054 (95% CI 0.007 to 0.102); younger versus older participants: −0.005 (95% CI −0.010 to −0.001); and those with more versus less healthy lifestyle changes: 0.047 (95% CI 0.005 to 0.089). Cognitive intervention benefits were more pronounced among participants with better LTL maintenance for executive functioning  and long-term memory , with a similar trend for Neuropsychological Test Battery total score .This exploratory LTL substudy included 756 participants  with baseline and 24-month LTL measurements. The mean annual LTL change (This is the first large RCT showing that a multidomain lifestyle intervention facilitated LTL maintenance among subgroups of older people at risk for dementia, including APOE-ε4 carriers. LTL maintenance was associated with more pronounced cognitive intervention benefits.NCT01041989 Telomeres are segments of DNA located at the ends of eukaryotic chromosomes, with an essential role in protecting chromosomes from damage and ensuring genome stability . TelomerThe impact of lifestyle interventions on telomere length has so far been investigated in a small number of trials focusing primarily on other conditions and predominantly targeting unimodal interventions. A 6-month randomized controlled pilot trial in 33 older individuals with mild cognitive impairment suggested that telomere shortening was attenuated by ω-3 polyunsaturated fatty acid supplementation . In the The Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER) has previously reported cognitive benefits for a 2-year multidomain lifestyle intervention versus health advice control in 1260 older individuals at risk for dementia . The FINFINGER is a 2-year multidomain randomized controlled trial carried out in 6 sites in Finland and enrolled at-risk participants from the general population. The trial protocol and primary findings have been previously described ,18. FINGThis exploratory LTL substudy included 756 of the 1260 trial participants with LTL measurements at both baseline and 2-year visit  group in a 1:1 ratio. Allocations were computer-generated in blocks of 4  at each site after the baseline assessment by the study nurse. Outcome assessors and lab technicians analyzing biological samples were blinded to allocation and were not involved in intervention tasks.nutritional component based on the Finnish Nutrition Recommendations was carried out by study nutritionists in individual and group sessions with the participants. The exercise training program followed international guidelines, was led by study physiotherapists, and included aerobic training as well as strength and balance training at the gym  was measured from DNA extracted from peripheral blood collected at baseline and 2-year visits. As a relative measure, LTL does not have a specific measurement unit.Blood samples for DNA were collected in ethylenediaminetetraacetic acid (EDTA) tubes, tubes were turned a few times and then immediately stored at −20°C at the study centers. The blood samples were shipped monthly in dry ice to the laboratory at the Finnish Institute for Health and Welfare, where they were stored at −20°C until the time of DNA extraction. Genomic DNA was extracted from venous blood samples with Chemagic MSM1 from PerkinElmer using magnetic beads according to the manufacturer’s protocol. Prior to genotyping, DNA quality was determined using NanoDrop and PicoGreen, and DNA concentration normalized to 50 ng/µL.Relative LTL measurements and quality control were conducted at the laboratory of Professor Iiris Hovatta at the Molecular and Integrative Biosciences Research Program, University of Helsinki, Finland.Samples from each participant (baseline and follow-up) were assayed on the same 384-well plate. There was a random distribution between plates, but ensuring that the age, sex, and group allocation of participants (intervention vs control) were similar across plates. A quantitative polymerase chain reaction (qPCR)-based method was used as described previously ,23, withSD greater than 0.5 between triplicates were omitted from the analysis. Plate effect was controlled for by analyzing 5 genomic DNA control samples on every plate. We normalized the telomere and Hgb signal values separately to the mean of these control samples before taking the relative telomere to single-copy gene (T/S) ratio. The control samples were used for calculating the coefficient of variation value that was 8.35%.Bio-Rad CFX Manager software was used to perform quality control, and samples with z-scores standardized to the baseline mean and SD, with higher scores suggesting better performance)   at baselormance) . Secondaeviously ,17.The FINGER LTL exploratory substudy was planned with no available effect size references from clinical trials testing the impact of multidomain lifestyle interventions on LTL in older adults at risk for dementia. No power calculations were thus conducted specifically for the LTL substudy.t tests were used to compare baseline characteristics of FINGER participants with and without available LTL measures, and intervention and control groups in the LTL subpopulation.Chi-square and Z-scores for each index component were standardized to the baseline mean and SD, and the difference between 24-month and baseline visit was calculated. The overall index was calculated as the mean z-score change  if data were available in at least 2 of the 3 lifestyle domains.Change in relative LTL was calculated as the difference between 2-year and baseline LTL, divided by time. Positive values indicated an observed increase, and negative values indicated a decrease in relative LTL. A linear regression model was used, with change in relative LTL as a dependent variable, and randomization group, baseline relative LTL, age, sex, study site, and healthy lifestyle change index as independent variables. Healthy lifestyle change was calculated for all participants as a composite index based on measures of diet  was also investigated. For each factor, the linear regression model described above additionally included (a) APOE and randomization group × APOE interaction, (b) group × sex interaction, (c) group × age (continuous) interaction, and (d) lifestyle index (continuous) and group × index interaction.p values.Results are reported as unstandardized β-coefficients (95% CIs) and xtmixed command in Stata, with 95% CI and p values. Group × time × LTL change interactions with p < .10 are also presented as graphs showing intervention effects on cognition (intervention–control difference) for different levels of change in LTL.Zero-skewness log-transformations were applied to skewed NTB components. Mixed effects regression models with maximum likelihood estimation were performed to assess the change in cognitive scores as a function of randomization group, time, LTL change, their 2-way interactions, and a group × time × LTL change interaction. All models were adjusted for age, sex, study site, baseline LTL, and healthy lifestyle change index. Results are reported as estimates from the We use the term “intervention benefit” to refer to differences between the intervention and control groups that favored the intervention group.Level of significance was less than 5% in all analyses. Stata software version 13  was used.The FINGER trial is registered with ClinicalTrials.gov, number NCT01041989.n = 631) or control group (n = 629). The full trial profile has been previously described (n = 756) had a higher education level (p = .039), lower systolic blood pressure (p = .003), and better cognitive performance on the total NTB (p = .001), executive functioning (p ≤ .001), and processing speed (p = .035) domains compared with the rest of the FINGER participants  at baseline was 1.075 (0.325) for participants aged 60–70 years and 1.042 (0.338) for participants aged 70–77 years. Because there is no “general reference scale” for the size of change in relative LTL values over time, and LTL decreases with age, these mean baseline values per age decade are provided as reference.Mean relative LTL (SD) was −0.016 (0.19) in the intervention and −0.023 (0.17) in the control group (unadjusted p = .58). Increase in relative LTL was observed in 45.4% of the intervention group and 42.5% of the control group. No significant difference between intervention and control groups in change in relative LTL was found after adjusting for age, sex, baseline LTL, study site, and lifestyle change index . However, effect modifications on LTL maintenance by APOE-ε4 allele, age, and lifestyle changes were observed (p = .026), younger versus older participants , and participants with more pronounced versus less pronounced healthy lifestyle changes . Findings were similar when analyses were re-run without adjustment for baseline LTL , p = .031 for long-term memory. No significant randomization group × time × LTL change interactions were found for processing speed: −0.087 (−0.268 to 0.094), p = .347 or memory: 0.152 (−0.074 to 0.378), p = .187. Findings were similar when analyses were re-run without adjustment for baseline LTL  tended to be more pronounced with increasing relative LTL . The rantive LTL  and C. Tline LTL .No serious intervention-related adverse events were reported .FINGER is so far the largest clinical trial investigating the effects of a multidomain lifestyle intervention on change in LTL and the first to relate the change in LTL to change in cognition in older adults at risk for dementia from the general population. Overall, LTL change during 2 years was not significantly different between the intervention and control groups. However, there were significant intervention benefits on LTL maintenance in APOE-ε4 carriers, younger individuals, and participants with healthier lifestyle changes during the 2-year trial. No differences were found between men and women. Intervention benefits on the primary cognitive outcome  were more pronounced with better LTL maintenance. Intervention benefits on long-term memory and executive functioning, but not memory or processing speed, were significantly more pronounced with better LTL maintenance.These findings add to the sparse literature on multidomain lifestyle interventions and LTL. For ethical reasons, the FINGER control group also received advice on lifestyle, metabolic, and vascular risk factors, and this may have diluted the effects compared with a “do-nothing” control group. Mean LTL decreased during the 2-year trial, which was expected given the participants’ age. Intervention effects on LTL maintenance were also less pronounced with older age at baseline. This suggests that LTL maintenance through healthy lifestyle changes may decrease with age and thus emphasizes the importance of early interventions.Improvement in lifestyle among FINGER participants was directly associated with LTL maintenance. This finding is consistent with previous observational studies on lifestyle and LTL, and most importantly with the notion that healthy behaviors act in synergy to affect LTL positively . In the http://www.alzgene.org/). APOE-ε4 carriers also have a more rapid LTL attrition rate (Interestingly, there were more pronounced FINGER intervention benefits on LTL maintenance in APOE-ε4 carriers. The APOE-ε4 allele is the strongest known genetic risk factor for AD, and it has also been linked to other neurological and cardiovascular conditions (ion rate  and are ion rate . It has ion rate . Consistion rate , the curion rate , and it Several mechanisms have been suggested for LTL shortening, including, for example, oxidative stress, inflammation, chronic stress, and hyperactivation of the hypothalamic–pituitary–adrenal axis . These sMechanisms related to LTL shortening have also been linked to pathophysiological processes in dementia-related conditions and cognitive decline , which mThis study has some limitations. LTL was only measured in a subsample of FINGER participants, although this subsample was very similar to the rest of the target population. The FINGER trial was not powered to detect intervention effects on cognition by change in LTL. LTL was only measured at baseline and at the 2-year follow-up, limiting a more detailed assessment of change trajectories. For example, previous evidence suggested that while the annual LTL decline is linear among older adults, it is more accelerated after approximately age 69 years , which cStrengths of the study include the large sample of older individuals at risk for dementia, the multidomain lifestyle intervention with a long duration, carefully controlled LTL measurements pre- and post-intervention, and the comprehensive neuropsychological test battery. The 2-year FINGER trial did not have dementia as outcome, but indicators derived from the cognitive test battery were used. The ongoing extended follow-up will facilitate analyses of LTL changes and dementia incidence.In conclusion, findings from the FINGER exploratory LTL substudy support the beneficial effects of a multidomain lifestyle intervention on LTL maintenance particularly among individuals genetically susceptible to Alzheimer’s disease, that is, APOE-ε4 allele carriers, younger-old individuals, and those who succeed in making healthier lifestyle changes. In addition, better LTL maintenance was associated with more pronounced intervention benefits on cognition in individuals at risk for dementia from the general population. LTL is a suitable biomarker for inclusion in lifestyle interventions and may aid in identifying subgroups that benefit from such interventions.glaa279_suppl_Supplementary_TablesClick here for additional data file.


Long-term exposure to excessive aldosterone secretion from the adrenal gland may cause renal damage in patients with primary aldosteronism (PA). The aldosterone-to-renin ratio (ARR) may be significantly affected by renal function, especially in patients with renal damage related to long-term PA. The objective of this study was to investigate the association between the estimated glomerular filtration rate (eGFR) and ARR as well as its effect on screening for PA.  This study was performed in Zhongshan Hospital, Fudan University, China. 803 patients with hypertension were consecutively recruited from 2012 to 2015. All participants underwent routine biochemical measurements, including plasma renin activity (PRA) and plasma aldosterone concentration (PAC). In all patients with a PAC higher than 10 ng/dl, a saline perfusion test was conducted, and a CT scan or adrenal venous sampling was also performed if needed. Receiver operating characteristic (ROC) analysis was conducted in all eGFR < 90 and eGFR ≥ 90 groups separately to determine the optimal cut-off values of ARR. 2, and 18 ng/dl per ng/ml.h in subjects with an eGFR lower than 90 ml/min/1.73 m2. Patients with an eGFR higher than 90 ml/min/1.73 m2 had significantly lower PRA and higher ARR levels than patients with an eGFR lower than 90 ml/min/1.73 m2 (P < 0.05).  The optimal cut-off point for PA was an ARR of 40 ng/dl per ng/ml.h in the whole population, 52 ng/dl per ng/ml.h in subjects with an eGFR higher than 90 ml/min/1.73 m Unsuppressed renin and lower ARR levels were associated with decreased eGFR in patients with primary aldosteronism. Diagnostic criteria of ARR by stratified eGFR may be an optimal strategy for the screening of primary aldosteronism. Primary aldosteronism (PA) is one of the most common causes of secondary hypertension in adults, with prevalence ranging from 3.2 to 20% in different populations . The aldRenal function and glomerular filtration rate are closely associated with the regulatory role of renin synthesis and secretion  and the Considering the use of ARR in screening for PA, the effects of renal function on the PRA and ARR values need to be further clarified. In the present study, we will use estimated glomerular filtration rate (eGFR) as the major indicator of kidney function. The eGFR-associated change in ARR values may lead to an increased risk of a false diagnosis of PA in a hypertensive patient if the criteria are determined using patients with normal renal function. On the other hand, a lower threshold could result in too many false positives in the normal renal function group. An ideal optimized cut-off for initial outpatient screening for PA would have high sensitivity, be stable and simple to use, and be cost-effective.This study was aimed to investigate the association between eGFR and PRA and ARR values in PA patients and to determine the optimal eGFR-dependent screening thresholds.Patients with hypertension were consecutively enrolled from the Hypertension Clinic of Zhongshan Hospital, Fudan University, Shanghai, China, from 2012 to 2015. All of the hypertension patients met the 1999 WHO/ISH criteria . WrittenClinical data including age, gender, and duration of hypertension, the status of BP control, numbers, and dosage of all medications and history of other chronic diseases, including primary kidney disease, were obtained from the clinical documents of the Hypertension Clinic. According to the routine protocol, the results of a complete physical examination including height, weight, waist circumference, body mass index (BMI), and BP were recorded. After 5 min of rest in a sitting position, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured in participants by a nurse using a mercury sphygmomanometer adapted for arm size.BP was measured twice with a 5 min interval, and the mean was used for the analysis. Resistant hypertension was defined in our study as the following criteria: on each of three measurements obtained on different days, with hypertension (BP > 140/90) resistant to three conventional antihypertensive drugs (including a diuretic), or controlled BP (>140/90) on four or more antihypertensive drugs. The general laboratory tests included measurements of serum sodium, potassium, blood urea nitrogen (BUN), and serum creatinine (Scr) levels. eGFR was calculated using the abbreviated Modification of Diet in Renal Disease Study Group (MDRD) equation. Patients were divided into two groups according to the median value of eGFR.Venous blood was sampled in the morning two hours after waking, after 5–10-minute rest in a sitting position. Plasma aldosterone concentration (PAC) and plasma renin activity (PRA) were measured by radioimmunoassay. PRA was measured by indirect assay involving the generation of angiotensin I . The lower limit of detection for PRA in EH and PA subgroup is 0.02 ng/ml/h. Saline perfusion test (SPT) was conducted in all patients with a PAC higher than 10 ng/dl shown in  17]. A . A 17]. Among patients with positive saline perfusion tests, a diagnosis of PA was further considered. For subtyping, the diagnosis of aldosterone-producing adenoma required fulfillment of all of the following criteria: unilateral excessive aldosterone secretion confirmed by AVS and evidence of a unilateral adrenocortical nodule on CT scan, pathologically confirmed adenoma after surgery, and complete biochemical success during the postadrenalectomy follow-up. Patients for whom surgery was not indicated received spironolactone treatment. Idiopathic hyperaldosteronism (IHA) was diagnosed in patients with bilateral hyperplasia of the adrenal gland by CT scan, normokalemia and the normalization of BP (140/90 mmHg without the aid of antihypertensive agents) after spirolactone treatment, or significant improvement of hypertension (decrease in mean BP by 20% and fewer antihypertensive agents taken to control BP after spirolactone treatment at follow-up).t-test, one-way ANOVA, or χ2 test for continuous or categorical variables. Spearmen correlations were performed to investigate the possible correlation between ARR and eGFR in PA patients. Sensitivity and 1 − specificity for different cut-offs of the ARR were plotted in receiver operating characteristic (ROC) curves. The optimal cut-off point was assessed using Youden's J statistic. The analyses were performed using SPSS software for Windows, version 13.0 . P value <0.05 was considered to be statistically significant.Normally continuous variables were expressed as the mean ± standard deviation (SD); the non-normally-distributed variables were expressed as the median and interquartile range. Non-normally-distributed values were log-transformed before analysis. Comparisons between the groups were performed with Student's As shown in P < 0.05). In each group, all subjects were divided into two subgroups according to the median eGFR  and higher borderline ARR levels (P=0.06) than patients with lower eGFR. In the PA group, patients with higher GFR were younger, were younger at onset of hypertension, had lower SBP, DBP, and PRA levels, and had significantly higher ARR levels than patients with lower eGFR (P < 0.05). The differences in ARR levels remained significant after adjustment for age, gender, and hypertension duration (P < 0.05). In this study, correlations were performed and our results indicated that eGFR significantly correlated with ARR levels in PA cases .The differences in ARR levels remained significant after adjustment for age, gender, and hypertension duration (P < 0.001) in all (P < 0.001) in eGFR < 90 (P < 0.001) in eGFR ≥ 90 patients  in all , 0.996  in PA cases. The variation of ARR may be significantly affected by renin levels among these patients. Renin is synthesized by juxtaglomerular epithelioid cells in the medial layer of renal afferent arterioles. Renal function and glomerular filtration rate are the major factors influencing renin synthesis and secretion in normal and pathophysiological situations. Under prolonged hypertension and high aldosterone levels, decreased eGFR may also stimulate the synthesis and secretion of renin in PA patients. Accordingly, unsuppressed PRA may contribute to lower ARR values in PA cases with renal damage. Our results showed that decreased eGFR was strongly associated with substantially increased PRA and earlier onset of hypertension in PA cases, which might reflect the natural history in patients with long-term PA.2 (18 ng/dl per ng/dl/h) and patients with an eGFR above 90 ml/min/1.73 m2 (52 ng/dl per ng/dl/h) will improve the accuracy of using ARR. It is strongly recommended to use a decreased cut-off point (18 ng/dl per ng/dl/h) instead of using the single cut-off point (40 ng/dl per ng/dl/h) in patients with eGFR below 90 ml/min/1.73 m2; otherwise, the sensitivity would dramatically decrease to 85.2%, which would lead to the misdiagnosis of 8  PA patients whose eGFR was below 90 ml/min/1.73 m2.Considering the significant key findings on the correlation between ARR and eGFR, it is evident that eGFR-specific diagnostic criteria can be used to optimize the sensitivity and specificity of screening for PA. The proposed decision limits of patients with an eGFR below 90 ml/min/1.73 mThe protocol used in our study tried to ensure an accurate diagnosis of PA. Confirmation tests were conducted in every hypertension case with PAC higher than 10 ng/dl to fully ensure no PA cases were missed, regardless of the ARR value. PA was carefully diagnosed in cases with positive confirmation test results and clinical outcomes. The strict diagnosis criteria used here strongly support the diagnosis among PA patients.There were still several limitations in our study: (1) confirmation tests for PA were not conducted in all cases; (2) we only used eGFR to evaluate renal function; it would be more accurate enough if we included more parameters; (3) this study was a monocentric study and we only enrolled patients from one medical institution. At present, we are not yet able to perform any external validity due to lack of participants elsewhere. We would explore the internal validity and external validity in the future to make the results of our study be more broadly applicable; (4) our study was retrospective; therefore, we could not identify cause-and-effect relationship of PA and renal damage. Follow-up data remained to be included to further investigate the relationships of plasma renin and aldosterone levels with pre- and posttreatment renal function; (5) the current literature does not identify a gold-standard confirmatory test for PA, so we have also taken the operative diagnosis, effective surgery, and medication together into account to obtain a final diagnosis of PA.2) and 52 ng/dl per ng/dl/h (eGFR ≥ 90 ml/min/1.73 m2) can be recommended as optimized cut-off points.ARR must now be regarded as an initial test, with further diagnostic confirmation tests for PA in patients with hypertension. Using eGFR-dependent decision limits will optimize the diagnostic accuracy of using ARR; decision values of 18 ng/dl per ng/dl/h (eGFR < 90 ml/min/1.73 m


COMP mutations.Multiple epiphyseal dysplasia (MED) is a skeletal disorder characterized by delayed and irregular ossification of the epiphyses and early-onset osteoarthritis. At least 66% of the reported autosomal dominant MED (AD-MED) cases are caused by We recruited a four-generation Chinese family with early-onset hip osteoarthritis, flatfoot, brachydactyly, and mild short stature. An assessment of the family history, detailed physical examinations, and radiographic evaluations were performed on the proband and other family members, followed by the performance of whole-exome sequencing (WES). The pathogenicity of the candidate mutation was also analyzed.COMP gene. This mutation was assessed as 'pathogenic' because of its low allele frequency and its high likelihood of co-segregation with disease in the reported family. Sanger sequencing validated the novel heterozygous mutation c.1153G > T (p. Asp385Tyr) in exon 11 of COMP in all affected individuals in the family.An AD-MED family with 10 affected members and 17 unaffected members was recruited. The main radiographic findings were symmetrical changes in the dysplastic acetabulum and femoral heads, irregular contours of the epiphyses, a shortened femoral neck, and flatfoot. Lower bone density was also observed in the ankle joints, wrist joints, and knees, as well as irregular vertebral end plates. In the proband, we identified the missense mutation c.1153G > T (p. Asp385Tyr), located in exon 11 of the COMP  mutation in AD-MED disease. We have therefore expanded the known mutational spectrum of COMP and revealed new phenotypic information for AD-MED.Our results underlined a key role of the Asp385 amino acid in the protein function of COMP and confirmed the pathogenicity of the  COMP, COL9A1, COL9A2, COL9A3 and MATN3) and one gene that causes autosomal recessive MED  [COMP mutations [COMP-MED), and are characterized by mild short stature, premature osteoarthritis of load-bearing joints, and abnormalities of the epiphyses of hands, long bones, and hips [Multiple epiphyseal dysplasia  is a skeletal disorder characterized by delayed and irregular ossification of the epiphyses as well as early-onset osteoarthritis [utations . These cand hips .COMP gene encodes cartilage oligomeric matrix protein (COMP) made up of 757 amino acids [COMP [4 mutation is significantly associated with MED compared with other T3 repeats. These mutations affect the secretion of extracellular matrix proteins and extracellular matrix integrity, often leading to skeletal abnormalities including pseudoachondroplasia (PSACH) and MED [The no acids . COMP isno acids , 10. Theno acids . Since tds [COMP , 11. The and MED .Here, we report a four-generation Chinese family with early-onset hip osteoarthritis, flatfoot, brachydactyly, and mild short stature. An assessment of the family history, detailed physical examinations, and radiographic evaluations were performed on the proband and other family members, followed by the performance of whole-exome sequencing (WES). The pathogenicity of the candidate mutation was then analyzed.The proband (III-10) was initially diagnosed with Legg–Calvé–Perthes disease based on the observed radiographic changes, including uneven density of the bilateral femoral head and bilateral femoral head collapse, which indicates avascular necrosis of the femoral head. After an investigation of the proband’s family history, a four-generation pedigree with 27 family members was recruited from Shanxi Province, China. Clinical evaluation including medical history, physical examination, and radiographic assessment, as well as peripheral venous blood (EDTA-K2 anticoagulant) was collected from all recruited individuals. For patients who cannot visit our hospital for clinical evaluation, we collected their clinical information by telephone interviews. Their consent forms and anteroposterior radiographs of pelvis were delivered by the express. Written informed consent was obtained from each participant; if the participant was younger than 16 years old, written informed consent was obtained from their parents or legal guardians. The Ethics Committee of Peking Union Medical College Hospital (PUMCH) approved this study.According to the manufacturer’s protocols, genomic DNA samples were extracted from peripheral blood leukocytes of each family member by peripheral blood DNA extraction kit . Purified DNA was qualified by Nanodrop2000  and quantified by Qubit 3.0 using the dsDNA HS Assay Kit .WES was performed on genome DNA of the proband (III-10) and individual II-6, II-9, III-6, III-18, and IV-12. The genomic DNA was broken into 180 to 280 base pair (bp) fragments by ultrasonoscope. Illumina paired-end libraries were prepared from DNA samples. The exome sequenced captured by the SureSelect Human All Exon V6 + UTR r2 core design  were sequenced on an Illumina HiSeq 4000 platform . The raw sequencing data were analyzed through Genome Analysis Toolkit . The error assessment, variant calling and annotation were performed through in-house developed Peking Union Medical College Hospital Pipeline (PUMP) .http://gnomad-old.broadinstitute.org/). (2) Variants were filtered out when they were synonymous mutation or located in introns without influence on splicing and biological function. (3) Variants were reviewed by taken into consideration of phenotype evaluation, inheritance model, reported documents as well databases like Human Gene Mutation Database (HGMD) and Online Mendelian Inheritance in Man (OMIM) (available at: https://omim.org/).The interpretation of variants was performed according to the American College of Medical genetics and Genomics (ACMG) guideline . The varhttp://primer3.ut.ee/) to amplify the Exon 11 of COMP gene. The PCR program was 95 °C for 3 min, followed by 38 cycles at 94 °C for 30 s, 58–60 °C for 30 s, 72 °C for 50 s, and a final extension at 72 °C for 8 min. All the collected samples in this family were used as DNA temple, the products of PCR analyzed in 2% agarose gels and purified by QIA quick PCR purification kit . Sequencing was performed on ABI3700 sequence Detection System . The reference sequence of the candidate gene was obtained from UCSC Genome Browser (http://genome.ucsc.edu) and compared with sequencing data through CodonCode Aligner .A pair of PCR (Polymerase chain reaction) primers  were designed using Primer 3 (https://swissmodel.expasy.org/), which were then viewed and edited by the molecular visualization system PyMOL .3-D protein structures of both wild and variant type COMP protein were predicted using an online modeling server, SWISS-MODEL program  that contributed to the disease phenotype [In a previous study by Mabuchi et al., a different mutation at the same position  has been reported to cause MED . Furtherhenotype .COMP  in AD-MED disease.Consistent with the previously reported phenotypes, our pedigree cases also showed symptoms of classical AD-MED, such as femoral head necrosis, mild short stature, early-onset osteoarthritis of the knee and hip, and brachydactyly. These symptoms highlight the key role for Asp385 amino acid in the protein function of COMP and confirm the pathogenicity of COMP-associated MED. According to the ACMG guideline and our study, this variation: a) is absent from the records of any frequency database, such as the 1000 Genomes Project and gnomAD, indicating that this mutation is rare (ACMG pathogenicity criteria: PM2); b) is located in a well-established functional domain (PM1); c) is co-segregated with disease in multiple affected family members (PP1); and d) has computational evidence supporting a deleterious effect on the gene (PP3). Based on these lines of evidence, we classified this mutation as pathogenic, with an important role in the genetic etiology of our family.In the current study, we investigated a four-generation family with early-onset hip osteoarthritis caused by a heterozygous c.1153G > T mutation. Their prominent symptoms included severe osteoarthritis, knee pain, and femoral head necrosis, which is consistent with COMP gene was identified to be related to the MED phenotype of this family [A different mutation at the same position  has been reported to cause MED . In thiss family . The phes family  were par5–7 usually cause PSACH, while missense mutations in T33–4 are more likely to cause MED. Our novel c.1153G > A mutation is located in the T33–4 repeat of COMP. The aforementioned mechanisms may explain some of the phenotypes in our family, such as mild short stature and early-onset osteoarthritis.The precise function and pathogenic mechanisms of mutant COMP in MED have not been fully defined. However, compelling evidence indicates that COMP proteins play an important role in maintaining cartilage and extracellular matrix integrity. The misfolding of mutant COMP affects its normal secretion from the endoplasmic reticulum of chondrocytes, and this intracellular retention is toxic to these cells, resulting in premature chondrocyte death , 18. TheSLC26A2 at birth. In addition, Superti-Furga et al. [DTDST mutation. In our study, all affected individuals in the family had flatfoot except for a single patient (III-2). However, other intra-familial differences in phenotype were observed in our family. For example, one patient (III-18) had mild sacroiliitis, with lower back pain at the age of 18, and also had gait abnormalities, mild short stature, flatfoot, and hip osteoarthritis. In addition, two male patients  had brachydactyly, but the other patients in this family did not have this phenotype. Furthermore, the male patients in this family were generally shorter in height, but it is unclear if this is related to the c.1153G > T mutation. In a pedigree study conducted by Sakamoto et al. [Clubfoot is a rare radiological finding that has been observed mostly in association with rMED. In a previous study , rMED paa et al.  describeo et al. , intra-fo et al.  also repient III-8 had milCOMP from an AD-MED family that exhibited COMP-associated MED, and other phenotypes including flatfoot. Our results expanded both the mutational and phenotypic spectra of COMP and suggested that this mutation of a key amino acid residue is disease-causing.We identified a novel heterozygous pathogenic mutation in


Euryale ferox Salisb. is an economically important crop in China and India. Unfortunately, low yield limitations seriously hinder market growth. Unveiling the control of seed size is of remarkable importance in improvement of crops. Here, we generated a new hybrid line (HL) with larger seeds by crossing South Gordon Euryale and North Gordon Euryale (WT) which hasn’t been reported before. However, the functional genes and molecular mechanisms controlling the seed size in Euryale ferox Salisb. remain unclear. In this study, we focused on the differentially expressed genes in the auxin signal transduction pathway during fruit development between HL and WT to explore candidate regulatory genes participated in regulating seed size.Aquatic Both concentration and localization of indole-3-acetic acid (IAA) at two growth stages of fruits of WT and HL were detected by LC-MS and immunofluorescence. Although IAA content between the two lines did not differ, IAA distribution was significantly different. To elucidate the mechanism and to seek the key genes underlying this difference, RNA-seq was performed on young fruits at the two selected growth stages, and differentially expressed genes related to the auxin transduction pathway were selected for further analysis.Euryale ferox Salisb. expressed significant heterosis, resulting in non-prickly, thin-coated, large seeds, which accounted for the significantly larger yield of HL than that of WT. Our study indicated that Small Auxin Up RNAs (SAURs) -mediated localization of IAA regulates seed size in Euryale ferox Salisb. We found that some SAURs may act as a positive mediator of the auxin transduction pathway, thereby contributing to the observed heterosis.Hybrid  Euryale ferox Salisb., an important food, ornamental, and medicinal species widely distributed in the southern region of China and North Bihar, India [Euryale semen, also called ‘fox nut’ and ‘Qian shi’ in mandarin, is the seed of r, India . The sper, India . Furtherr, India –5.Euryale ferox Salisb. can be divided into two main types: North Gordon Euryale (wildtype or WT) and South Gordon Euryale (SE) type, as shown in Fig. − 1, 35% greater than the yield of the WT in 2018. However, the seed number per plant did not show any difference between the WT and HL, indicating the yield evaluation in HL was mainly attributed to the size and weight of seeds. In a previous study, we did not detect any difference between WT and SE at the DNA level, which suggested both types belong to the same species, whereby transcriptional differences must be the cause for the phenotypic differences between them.Small Auxin Up RNA (SAUR), Glycoside Hydrolase 3 (GH3) and AUX/IAA genes are three primary auxin-responsive gene families; unfortunately, functional studies on SAURs have lagged behind [Endogenous phytohormones are well known to play critical roles in plant physiological and biochemical processes at the molecular level –9. Amongd behind . The repd behind –24. In ad behind –27. It’sEuryale ferox Salisb., we subjectively divided growth into stages I through V according to fruit growth regulation in Euryale ferox Salisb., after observing largely difference in phenotype and IAA distribution between WT and HL. Then, RNA-seq was performed on fruits at stages II and III to identify the differentially expressed genes (DEGs) involved in the IAA signal transduction pathway. These results indicated that SAURs-mediated localization of IAA regulates seed size in Euryale ferox Salisb.Due to the distribution of WT is much broader than the distribution of SE in China and India, and most studies investigated formerly used WT as experimental material, only WT was thereby employed as a wild-type control in this study , 29. To After growing for 21 weeks, the two plant types matured and their seeds were collected. It is worth noting that the seed number per plant did not show any difference between the two lines in our data , which indicated that the yield difference between these two lines was probably attributed to seed size and weight. Although the weight per seed of HL (range from 1.1 g to 1.7 g) was much heavier than that of WT (range from 0.5 g to 0.9 g), we paid more attention to seed size than to weight because, during the growth of reproductive, weight gain is most noticeable in the rapid changes in seed size . All seeEuryale ferox Salisb., we divided development into five stages (I through V), as in rice studies [p < 0.05), consequently, we selected samples at stages II and III , 18,229 (9.24%), 26,746 (13.56%), 9633 (4.88%), 3632 (1.84%), and 2879 (1.46%) showed significant similarity in the GO, Pathway Pfam, TMhmm, Eggnog, SignalP, and Uniprot databases, respectively. In all, 71,399 unigenes  were successfully annotated in at least one database  were detected by RT-qPCR  and South Gordon Euryale , were used as plant materials in this study. Seeds of WT were originally obtained in 2001 from the wild (Gaoyou lake of Jiangsu province) and cultured in the experimental field of Jiangsu Seed and Seed Breeding Base, and seeds of SE were originally obtained from the wild (Suzhou of Jiangsu province) and also grown in the experimental field of Jiangsu Seed and Seed Breeding Base who provided permission for their use in this scientific research. HL (containing 3 lines) were constructed from WT as the female crossed with SE to generate F1 hybrid in Gaoyou , Jiangsu province, China in 2015; later, F1 was selected and self-pollinated to generate F2 in Nanzha , Jiangsu province, China in 2016; and F2 individuals were used to produce F3 by self-fertilization in Gaoyou , Jiangsu province, China in 2017; finally, F3 generation and both of its parents were cultured in the experimental field of Jiangsu Seed and Seed Breeding Base . All plant materials used in this study were supplied by the Jiangsu Seed and Seed Breeding Base. Collection of all samples completely complies with national and local legislation permission, and no specific permission was required for collecting these plants. The plant materials were formal identified by Professor Qinan Wu, and a voucher specimen of this material has been deposited in Nanjing University of Chines Medicine. HL and the WT were sown in a completely randomized block design with three replications in April 22, 2018. Each plot consisted of 160 individual lines, each separated 2 m from its neighboring lines. The two lines were selected in this study to measure phenotypic traits and conduct transcriptome analyses. The young fruits selected for sampling at the designated development stages were collected and stored at − 80 °C for RNA-seq and RT-qPCR analysis. Seeds were collected at maturity on September 9, 2018; they were selected with 10 replicates for yield traits; additionally, each sample had at least three biological replications to minimize systematic errors.18 HPLC column  for LC-MS  analysis. An IAA standard  was used as the external standard.IAA was quantified by liquid chromatography-mass spectrometry (LC-MS), essentially as described . BrieflyImmunofluorescence staining for IAA was performed on sections of fruits as follows: Briefly, 60 μm fruit sections were cut using a cryotome  and affixed onto glass slides, followed by dehydration in ascending and descending ethanol solutions. After washing three times for 10 min in phosphate buffer saline (PBS) buffer with 0.1% (v/v) Tween 20, sections were pre-treated with 5% (w/v) bovine serum albumin in PBS for 1 h at room temperature to reduce non-specific binding, followed by incubating overnight with anti-IAA antibody  at 4 °C. After washing three times with 0.1% (v/v) Tween 20 in PBS buffer for 10 min, sections were incubated with Alexa Fluor 594 , SA00006–4, Proteintech Group, USA) as a secondary antibody for 1 h in darkness at room temperature. Samples were washed three times for 10 min with 0.1% (v/v) Tween 20 in PBS. Sections were imaged using a Carl Zeiss Axio Scope fluorescence microscope . Samples incubated with PBS instead of primary antibodies were used as negative controls, and there was no unspecific binding of the secondary antibody in this study.Before total RNA was extracted from samples, 12 frozen tissue samples were fully grinded separately under liquid nitrogen. RNA quality was determined by Agilent 2100 BisAnalyzer , and samples with both RIN ≥ 7 and To construct the cDNA libraries, 5 μg total RNA per sample was used as the template. The NEBNext Ultra RNA Library Prep Kit for Illumina  was used to generate a series of corresponding libraries, and index codes were applied to each sample. Briefly, mRNA was purified from total RNA using oligod (T) beads. RNA fragmentation was carried out at high temperature in the presence of divalent cations in NEBNext First-Strand Synthesis Reaction Buffer (5X). First-strand cDNA was synthesized using random hexamer primers and M-MLV Reverse Transcriptase. Second-strand cDNA synthesis was subsequently performed using DNA polymerase I, RNase H, dNTP and buffer. Then, the cDNA fragments were purified, end repaired, and poly (A) added, followed by adapter ligation. The selected ligation product was amplified and, subsequently, sequenced with Illumina HiSeq TM X10 by Gene Denovo Biotechnology Co. .3 with de Bruijn graph.After high-throughput sequencing, raw reads with too many unknown bases (> 5%) or low-quality bases  were excluded to obtain clean reads. The remaining clean reads from each sample were then assembled by Trinity− 5, and the annotations were only saved when the “-max_target_seq” was “1”.The unigene sequences were annotated using the following public databases: Universal Protein (Uniprot), evolutionary genealogy of genes (Eggnog), Pfam protein domain database (Pfam), signal peptide server , Hidden Markov Model-based transmembrane protein database (TMhmm), Kyoto Encyclopedia of Genes and Genomes (KEGG), and Gene Ontology (GO). The unigene sequences were aligned using BLASTx with an e-value of < 1012 software with the EM method. We quantified gene expression levels in terms of Fragments Per Kilo bases per Million (FPKM), calculated the false discovery rate (FDR), and estimated the fold change (FC) and log2 values of FC. Transcripts that exhibited an FDR ≤ 0.01 and an estimated absolute │log2(FC) │ ≥ 1 were considered to be significantly differentially expressed.Differential expression was estimated and tested using the RSEMRNA was extracted using TRIzol  and 1 μg used for cDNA synthesis with the PrimeScript RT Master Mix kit . RT-qPCR was performed with a QuanStudio 3 instrument , using 5 μL cDNA, NovoStart SYBR qPCR SuperMix Plus , and 0.2 μL each of two gene-specific primers Table  in a fint-test and P < 0.05 was considered to indicate a statistically significant difference. Statistical analysis was performed with GraphPad Prism 6.0 software .All data were expressed as the mean ± standard error of the mean. Differences between two groups were analyzed using Additional file 1: Figure S1. The development stage division of fruits.Additional file 2: Figure S2. Width of fruits in HL and WT.Additional file 3: Figure S3. Concentration and distribution of IAA at stage II.Additional file 4: Figure S4. Distribution of IAA in fruits of SE.Additional file 5: Table S1. Detail information of Unigenes.


Dalea purpurea Vent.), a native legume forage, with native cool-season grasses on the in vitro fermentation and in situ digestibility of mixed forages.Incorporation of legume species into native North American pastures is considered an effective method to increase native pasture productivity and improve the nutritive value of forage. This study evaluated the effects of inclusion of purple prairie clover , in vitro DM disappearance (IVDMD), total volatile fatty acids (VFA) and ammonia-N production. Mixtures of forages harvested when the PPC reached the FL stage and 50:50 mixture of forages harvested at VEG, FL and SP stages were incubated in the rumen of three heifers for 0, 2, 6, 12, 24, 48, 72 and 96 h to determine in situ degradabilities of DM, neutral detergent fibre (aNDF) and crude protein (CP).Whole plant PPC and mixtures of cool-season grasses were harvested when the PPC reached the vegetative (VEG), full flower (FL) and seedpod (SP) stages, and were combined in ratios (DM basis) of 0:100, 25:75, 50:50, 75:25 and 100:0 at each maturity. P < 0.01), while CP decreased (P < 0.001) as PPC matured. Concentrations of extractable condensed tannins in PPC ranked as FL > VEG > SP (P < 0.05). Regardless of PPC proportions in the mixture, GP decreased (P < 0.05) with increasing PPC maturity. Increasing PPC proportions linearly increased (P < 0.001) GP, IVDMD and total VFA at VEG, but linearly decreased (P < 0.001) them at SP. Irrespective of PPC maturity, ammonia-N production linearly increased (P < 0.01) with increasing proportions of PPC and the concentration was higher (P < 0.05) at VEG than at FL and SP stages. Increasing proportion of PPC at either maturity linearly increased (P < 0.001) molar percentage of acetate (A) and branched-chain VFA, but linearly decreased (P < 0.001) molar percentage of propionate (P), resulting in a linearly increase (P < 0.001) in the A:P ratio. Increasing FL PPC in the mixture linearly and quadratically (P < 0.01) increased a (soluble fraction), but linearly and quadratically decreased (P < 0.01) b  for DM and aNDF, resulting in linear (P < 0.05) and quadratic (P < 0.01) increases in DM and aNDF maximum potential degradabilities (a + b). Effective degradabilities of DM and aNDF were also linearly and quadratically increased (P < 0.05), and CP was quadratically increased (P < 0.05) with increasing FL PPC, with the greatest effective degradability being observed with ratios between 50:50 and 75:25. Ruminal maximum potential degradabilities of DM and aNDF decreased (P < 0.001) as the forage matured. Effective degradability of DM ranked as VEG > FL > SP (P < 0.001), whereas the effective degradability of aNDF was similar between VEG and FL and both were greater (P < 0.01) than SP.Contents of aNDF and ADF increased (Inclusion of vegetative PPC in a mixed forage diet resulted in the greatest digestibility and incorporation of PPC before seedpod stage with native grasses had a positive effect on ruminal fermentation. Effects of PPC on ruminal digestion depend on both the stage of maturity and its proportion in mixed legume-grass pastures. Pastures containing 50% of PPC in full flower stage would likely provide the greatest quality diet to grazing ruminants subject to potential animal selectivity. Grasses in native pasture are usually the principal forage source in the prairie region of North America during late season grazing. However, nutritive value of grasses rapidly declines in the latter half of the grazing season . InclusiDalea purpurea Vent.) is a perennial native legume that is well adapted to the North American prairies and has higher palatability and digestibility than other native legumes such as false indigo (Amorpha fruticosa L.), blue wild indigo  R. Br.) and wild senna  Irwin & Barneby)  ek) L−, which was set at 0.02 for aNDF and 0.05 for both DM and CP -grass (timothy (Phleum pratense L.) and smooth meadow grass (Poa pratensis L.) mixed forages [in vitro fermentation as a result of mixing a tropical grass  and a temperate legume  but not between peanut vines (Arachis pintoi), sainfoin (Onobrychis viciifolia) and grasses of axonopus and tall fescue (Festuca arundinacea).The reduction in the ruminal fermentation of PPC and cool-season grasses from vegetative to seedpod stages was reflected in the increase in ADF content of the two forages. Negative effect of ADF content on forage digestion has been demonstrated in literature . Interes forages . A quadr forages  reportedin vitro fermentation. Ammonia-N accumulation in closed in vitro system is the net result of ammonia from the degradation of dietary protein and utilization by microbes for microbial protein synthesis. The linearly-increased ammonia-N accumulation with increasing PPC at all maturities is a reflection of the increasing protein concentration in the mixture. Whether microbial protein synthesis (ammonia-N utilization) was affected by the inclusion of PPC was not determined in this study. Nevertheless, Jin et al. [in vitro experiment. Dal Pizzol et al. [Crude protein content in PPC was higher than that in cool-season grasses throughout the growing season. This resulted in an increase in the protein concentrations of the PPC-grass mixtures and the subsequent increase in ammonia-N concentration during n et al.  found thn et al. . Decreasn et al. , 11, 13.l et al.  also repl et al. , 37. Becin vitro and in vivo studies [Prevotella bryantii [Ruminobacter amylophilus [The result that increasing PPC proportion in the PPC-grass mixture increased acetate: propionate ratio by increasing acetate and decreasing propionate was consistent with Jin et al. . The var studies , 11, 13.bryantii  or Ruminlophilus , becauselophilus .in vitro and in situ studies showed PPC CT at concentrations up to 82 g/kg DM had minimal impact on ruminal feed digestion [It is generally regarded that the nutritional role of CT in ruminant nutrition depends on their dietary concentrations and chemical composition , 42, 43.igestion , 12. In igestion . Huang eigestion  found thPurple prairie clover contained higher protein than cool-season grasses throughout the growing season and therefore the incorporation of PPC into cool-season grasses would increase the protein content of forage in rehabilitated native pasture. However, the improvement in nutritive value of the forage by the incorporation of PPC into native pasture depends on the PPC growth stage, with greatest benefit being obtained at the vegetative stage followed by full flower and seedpod stages. Considering the faster decline of nutrient digestion of PPC over the growth season than cool-season grasses and balanced by N content of the two types of forages, it seems that about 50% of PPC in the PPC-grass mixed forage would provide most benefit for the purpose of extending the grazing season. These results need to be confirmed with field trials to better understand competition ability between PPC and cool season-grasses.


Papillary renal cell carcinoma (RCC) is the second most common subtype of RCC, after clear cell RCC. This study aimed to investigate the usefulness of FDG PET/CT in primary and recurrent papillary RCC, and the role of staging FDG PET/CT in predicting survival.A total of 66 patients with histopathologically confirmed papillary RCC who underwent either staging or restaging FDG PET/CT scans  were retrospectively included in this study. The sensitivity and specificity of restaging FDG PET/CT for detecting recurrence were assessed by histopathology and/or clinical follow-up as standard reference.P = 0.008). The SUVmax was not significantly different between type 1 and type 2 papillary RCCs . Of the 38 patients, 12 developed disease progression during the follow-up period. Patients with primary tumor SUVmax> 5.85 were associated with significantly shorter progression-free survival (PFS) than those with tumor SUVmax≤5.85 (P = 0.005). Restaging FDG PET/CT scans were performed in 36 patients with suspected recurrent papillary RCCs. FDG PET/CT showed a sensitivity and specificity of 100 and 72.7% for detecting recurrent disease. Comparison of PET/CT scans with CT/MRI imaging was available in 23 patients. FDG PET/CT revealed additional findings in 11 patients, mainly including lymph node and bone metastases. FDG PET/CT findings led to change in management in 5.3% (2/38) of patients in the staging setting and 16.7 (6/36) of patients in the restaging setting.Staging FDG PET/CT scans were performed in 38 patients, of which 31 (81.5%) showed FDG-positive primary renal lesions. The SUVmax of high-grade (WHO grade 3 and 4) papillary RCCs were significantly higher than that of low-grade (WHO grade 1 and 2) tumors (9.44 ± 6.18 vs 4.83 ± 3.19, FDG PET/CT had a sensitivity of 81.5% for detecting primary papillary RCC, and tumor SUVmax derived from staging FDG PET/CT was a predictor of PFS. In the restaging process of papillary RCC, FDG PET/CT was very effective for detecting recurrent disease.The online version contains supplementary material available at 10.1186/s40644-021-00393-8. Surgery is currently the treatment of choice for organ-confined tumor, while locally advanced or metastatic disease often requires pharmacological or targeted therapy [Renal cell carcinoma (RCC) accounts for approximately 90% of renal malignancies and is a heterogenous group of various subtypes of cancer , 2. Papi therapy . It is g therapy , 7. Imag therapy –12.18F-FDG PET/CT, a noninvasive molecular imaging modality, has been extensively applied in clinical practice. It has emerged as one of the most important imaging methods for staging, restaging, and monitoring therapeutic response in most malignancies. Unlike for most other malignancies, the application of FDG PET/CT in the preoperative evaluation of RCC is limited, primarily due to the physiological excretion of FDG from the kidneys [ kidneys . Althoug kidneys . FDG PET kidneys , 16. How kidneys –21, and  kidneys , 23. Res kidneys –26. ThisWe retrospectively reviewed patients with histopathologically confirmed papillary RCC who received either staging FDG PET/CT or restaging FDG PET/CT for suspected recurrence in our hospital from January 2010 to July 2020. For the staging group, inclusion criteria were as follows: newly diagnosed, histologically confirmed pRCC; nephrectomy or biopsy performed at our hospital; FDG PET/CT performed before initial treatment; interval between PET/CT scan and surgery/biopsy within 30 days; availability of patient’s follow-up information. Exclusion criteria were as follows: therapy prior to FDG PET/CT; nephrectomy or biopsy not performed at our hospital; incomplete clinical records. For the restaging group, inclusion criteria were as follows: histologically proven pRCC; history of previous treatment for primary pRCC; FDG PET/CT performed for restaging; the presence of standard reference . Nuclear grading and histopathological subtypes (type 1 and 2 papillary RCC) data were available in 34 patients who underwent staging FDG PET/CT. Nuclear grading was determined based on World Health Organization (WHO)/International Society of Urological Pathology (ISUP) grading system [18F-FDG (5.5 MBq/kg). After FDG injection, they rested for approximately 60 min. PET/CT images were acquired supine from the skull base to the midthigh level using a combined PET/CT biograph . A low-dose CT scan was obtained for attenuation correction and anatomical reference. PET scans were acquired in a three-dimensional mode (2–3 min/bed position).All patients fasted for at least 4 to 6 h and had a blood glucose level of less than 200 mg/dL, before receiving an intravenous administration of All images were retrospectively read by 2 experienced nuclear medicine physicians. Semiquantitative analysis of abnormal FDG uptake for lesions was performed using the maximum standardized uptake value (SUVmax). The SUVmax of primary renal tumor was measured by drawing a region of interest over the primary tumor avoiding physiological activity of the renal calyces as much as possible. Staging FDG PET/CT scan was defined as positive if the tumor uptake was higher than normal renal parenchyma or surrounding extrarenal soft tissues in the case of exophytic tumor, while was considered negative if the tumor uptake was lower than /equal to normal renal parenchyma or surrounding extrarenal soft tissue. The tumor size was defined as the longest diameter of the primary renal lesion. Restaging PET/CT scan was defined as positive if at least one site of abnormal uptake suspected of recurrence was detected. Specifically, a lesion was positive if the FDG activity was moderately or markedly increased relative to surrounding soft tissues or comparable normal structures. On the contrary, a lesion showing no or faint uptake of FDG was regarded as negative even if a suspicious recurrent lesion had been detected by CT. True positive PET/CT scan corresponded to an abnormal finding confirmed by histopathology or follow-up. PET/CT scan was deemed false positive if the histopathological results from a suspected FDG-positive lesion revealed no evidence of malignancy or the lesion remitted/showed no change without therapy during the follow-up period. A negative PET/CT scan was considered false negative if the lesion was detected by CT and was confirmed by histopathology or by clinical or imaging progression. True negative PET/CT scan corresponded to the absence of abnormal imaging findings confirmed by negative histopathological results or lack of recurrence during the follow-up.The lesions found on staging FDG PET/CT images were verified by histopathology from surgery or biopsy. For both ethical and practical reasons, not every suspected recurrent lesion observed on restaging FDG PET/CT could be investigated by histopathology. Therefore, for restaging FDG PET/CT scan, a reference standard was determined on the basis of histopathology (if available) and clinical/imaging follow-up  for at least 6 months. For example, lesions that showed an increase in number/size on CT or MR or an increase in FDG uptake on follow-up PET/CT, or showed a response to anticancer therapy during the follow-up were considered as recurrent lesions even if a histopathological examination was unavailable.P < 0.05 were selected for multivariate analyses by means of a cox regression model. To evaluate the usefulness of FDG PET/CT in the restaging of papillary RCC, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), and accuracy were calculated on a per-patient basis. P value less than 0.05 was considered statistically significant. The statistical analyses were performed using SPSS .SUVmax was compared between high-grade and low-grade papillary RCCs, as well as between type 1 and type 2 tumors using the Mann-Whitney U test. Prognostic value of SUVmax derived from staging FDG PET/CT in papillary RCC patients was investigated. Progression-free survival (PFS) was defined as the time from primary surgery to the appearance of clinical or radiological progression. To determine the prognostic factors associated with PFS, univariate analysis of variables, including tumor SUVmax, primary tumor size, age, gender, pTNM stage, nuclear grade was performed. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values for SUVmax, primary tumor size and age. Patients were then divided into two groups according to the cutoff values for SUVmax, primary tumor size and age. Progression-free survival rates were obtained using the Kaplan-Meier method. Variables with log-rank P = 0.008). While the SUVmax was not significantly different between type 1 and type 2 papillary RCCs  , adrenal gland metastasis (n = 1), and renal venous tumor thrombus (n = 2).Of the 38 patients, management was changed in 2 patients (5.3%) as a direct result of the PET/CT findings. In one patient, FDG PET/CT identified unsuspected left supraclavicular and mediastinal nodal metastasis, which was biopsied and confirmed as metastatic papillary RCC. The treatment plan was then switched from surgery to targeted therapy. In the other case, management was changed as a result of detection of synchronous lung adenocarcinoma on FDG PET/CT. In the remaining 36 patients, 4 patients were found with metastasis at the time of diagnosis, including regional nodal metastases . The median PFS time was 32 months . From the ROC curve analyses, the optimal cutoff value of SUVmax, primary tumor size, and age for estimating PFS were 5.85, 4.3 cm and 48.5 years, respectively.Restaging PET/CT scans for suspected recurrent papillary RCC were performed in 36 patients Table . FDG PETAs described in Table Based on the findings on FDG PET/CT, change in management was undertaken in 6 of 36 patients (16.7%) in the restaging setting. One patient being treated with targeted therapy alone was subsequently treated with additional radiotherapy after FDG PET/CT detected bone metastases. In 4 patients, management was changed from observation to targeted therapy after FDG PET/CT detected multiple metastases. In the remaining one patient, an intramuscular soft tissue metastasis was detected by FDG PET/CT, which was treated with surgery.In the present study, we found that the tumor SUVmax derived from staging FDG PET/CT could predict prognosis in patients with papillary RCCs. The application of FDG PET/CT in oncology is based on the correlation between tumor glucose metabolism and the degree of aggressiveness, and metabolic quantitation by SUVmax may play a role in the prediction of patient’s prognosis. Nakajima et al. evaluated the prognostic role of preoperative FDG PET/CT in patients with primary RCC, including 115 clear cell RCC, 15 papillary RCC, and 9 chromophobe RCC. They found that higher tumor SUVmax (> 3.83) was significantly associated with decreased PFS time in patients with RCC . Our resFor the evaluation of primary RCC, the role of FDG PET/CT is considered quite limited. A review article by Wang et al. noted that FDG PET or PET/CT had a sensitivity of only 62% for the detection of primary RCC . In a reP = 0.563). Our result suggested that FDG PET/CT may not be able to distinguish papillary RCC subtypes. Still, the number of type 1 cases was quite small in this study. Future studies with larger sample size are needed to validate this result.In the present study, where only papillary RCCs were included, FDG PET/CT had a relatively favorable performance for primary renal tumor detection with a sensitivity of 81.5%. The mean tumor SUVmax of papillary RCC in our study was 6.88 ± 5.27. Our results also showed that high-grade papillary RCCs had significantly higher SUVmax than that of low-grade tumors. Similarly, in the study of Nakajima et al., which included 17 papillary RCC cases, the mean SUVmax of high-grade tumors was significantly greater than in low-grade tumors . In theiAlthough the utility of FDG PET/CT in assessing primary renal tumor is controversial, it has been considered more effective in the detection of metastatic or recurrent disease, thus affecting therapeutic management. Previous studies have reported various sensitivity and specificity rates of FDG PET/CT in utilization for recurrent RCC , 29. In Our study also showed relevant results regarding the clinical management of pRCC patients. FDG PET/CT could detect occult metastasis that may be undetected by conventional imaging or distant metastasis that could not be assessed on available imaging due to limited/regional field of view, thus influencing therapeutic management. In the staging setting, therapeutic management was modified in 5.3% of patients. FDG PET/CT detected distant lymph node metastasis in one patient, thus rendering the patient unsuitable for curative surgery and avoiding the possible morbidity and mortality associated with surgery. In the other patient, management was changed due to the detection of synchronous primary malignancy. In this study, FDG PET/CT findings also led to management changes in 16.7% of patients in the restaging setting. One patient being treated with targeted therapy received additional radiotherapy for bone metastases detected by FDG PET/CT. In 4 patients, management was switched from observation to targeted therapy following the detection of multiple metastases on PET/CT. In the remaining one patient, the detection of intramuscular soft tissue metastasis by FDG PET/CT led to surgery. To date, few studies have assessed the impact of FDG PET/CT in the management of patients affected by RCC. In a study on 104 patients with recurrent RCCs, Alongi et al. reported that FDG PET/CT altered management in 43% cases [Several limitations of this study should be pointed out. First, this is a retrospective study that uses existing data, the study could be subject to selection bias. Second, the number of type 1 papillary RCC cases was quite small compared to that of type 2 cases. Thus, the analysis of comparison of SUVmax between histological subtypes would be under-powered. Third, histopathology would have been an ideal reference standard, but was not feasible in all patients and for each FDG-avid lesion because of practical and ethical reasons. Additional limitation of this study was the small number of enrolled patients.FDG PET/CT had a sensitivity of 81.5% for detecting primary papillary RCC, and tumor SUVmax derived from staging FDG PET/CT was a predictor of PFS. In the restaging process of papillary RCC, FDG PET/CT was very effective for detecting recurrent disease.Additional file 1.Additional file 2. Kaplan-Meier survival graphs showing significant differences in progression-free survival between the groups categorized according to pTNM stage, SUVmax, primary tumor size, and WHO grade. High pTNM stage, SUVmax > 5.85, primary tumor size > 4.3, high WHO grade (G3 and G4) were associated with decreased progression-fee survival


The phase III DATA study compared 6 and 3 years of adjuvant anastrozole following 2–3 years of tamoxifen in postmenopausal breast cancer patients. This pre-planned side-study assessed the relationship between a reduced bone mineral density (BMD) and distant recurrence-free survival (DRFS), and evaluated the effect of bisphosphonates on DRFS.We selected all patients with a BMD measurement within 3 years after randomisation (landmark) without any DRFS events. Kaplan–Meier methods and Cox proportional hazards models were used for analyses.Of 1860 eligible patients, 1142 had a DEXA scan before the landmark. The BMD was normal in 436 (38.2%) and showed osteopenia in 565 (49.5%) and osteoporosis in 141 (12.3%) patients. After a median follow-up of 5.0 years from the landmark, neither osteopenia nor osteoporosis  were associated with DRFS in both the 6-year  and the 3-year arm . Moreover, bisphosphonate use did not impact DRFS.No association was observed between a reduced BMD and DRFS. Neither did we observe an impact of bisphosphonates on DRFS.The online version of this article (10.1007/s10549-020-05567-9) contains supplementary material, which is available to authorized users. In the 3-year treatment arm the 5-year residual DRFS rate was 89.2% in the osteopenia group, 89.7% in the osteoporosis group and 85.8% in the normal BMD group   we neither observed an impact of BMD on late DRFS  . Of the patients in whom bisphosphonates were prescribed, the majority used oral bisphosphonates  and few used intravenous bisphosphonates   during follow-up. Adjustment for bisphosphonate use was not performed, patients were treated with tamoxifen instead of an aromatase inhibitor, and importantly, no information on BMD measurements was available [p < 0.001). The fourth study, the MA.27 trial, examined the effects of self-reported osteoporosis and osteoporosis therapy on breast cancer outcomes. The study included 7576 postmenopausal patients during adjuvant aromatase inhibitor treatment (anastrozole/exemestane) for breast cancer [n = 193) and 87% (95% CI 86–89%) in patients without osteoporosis (n = 4672) (no HR reported). While their findings are in line with the results of the current study, it should be recognised that in the MA.27 trial no detailed information was collected on BMD assessments and information on osteoporosis was self-reported [Multiple observational trials observed that a reduced BMD was associated with a lower risk of developing breast cancer , 11, butvailable . Also a vailable . None ofvailable . Nevertht cancer . Of patireported . TherefoA possible explanation for not finding an association between a reduced BMD and a lower breast cancer recurrence risk might be that women with osteoporosis have less benefit of aromatase inhibitors because their oestrogen levels tend to be lower than in women with a normal BMD. Hence, in patients with lower intrinsic oestrogen levels—resulting in higher risk of osteoporosis—the breast recurrence risk is reduced in a similar way as in patients with intrinsic higher oestrogen levels treated with aromatase inhibitors.Earlier studies found bisphosphonates to be valuable in both breast cancer prevention and improved breast cancer survival (when given as adjuvant therapy) irrespective of bisphosphonate type –3, 7, 19Bisphosphonates inhibit osteoclastic bone resorption by attaching to bony surfaces undergoing active resorption and prevent osteocyte and osteoblast apoptosis , 25. Thrp = 0.026) in a study population of postmenopausal women using AIs, who were generally at a low risk of recurrence (25% received prior chemotherapy) [p = 0.57) [More recently, the effect of the anti–receptor activator of nuclear factor kappa-B ligand denosumab on breast cancer survival was investigated, showing contrasting results , 32. The = 0.57) . A subgr = 0.57) . Because = 0.57) . The ABC = 0.57) .Even though this was a planned side-study of the DATA trial, the execution of DEXA scans was not protocolized but was advised to adhere to (inter)national guidelines. This probably explains the absence of BMD measurements within 3 years after randomisation in about one third of the patients. Furthermore, 19.1% of the women with osteoporosis did not use any bisphosphonates which was not in accordance with the recommendations in the national guideline. Additionally, the use of bisphosphonates was not randomised but based on the outcome of the DEXA scans, therefore confounding by indication could not be ruled out. The occurrence of bone metastases was not registered as specific item anymore after the occurrence of distant metastases elsewhere, and therefore we could not use bone metastases free survival as an outcome. Also, with longer follow-up results may change. Nevertheless, this is the first prospective trial studying the relationship between BMD and DRFS with detailed information on BMD in 1142 patients.In conclusion, we observed no association between BMD and late DRFS in this pre-planned DATA sub-study. Neither did we observe a relationship between bisphosphonate use for a decreased BMD and late DRFS.Supplementary file1 (DOCX 16 kb)Supplementary file2 (PDF 34 kb)Below is the link to the electronic supplementary material.


Petrocodon jingxiensis  A. Weber and Mich. Möller was determined in this study. The cp genome was 153,056 bp in length including two inverted repeats (IRs) of 25,405 bp, which were separated by LSC and SSC of 84,154 bp and 18,092 bp, respectively. The GC content was 41.9%. The genome encoded 112 functional genes, including 79 protein-coding genes, 29 tRNA genes, and four rRNA genes. This plastid genome is the first report for the Petrocodon in Gesneriaceae which will be useful data for developing markers for further studies on resolving the relationship within the genus.The complete chloroplast genome of  Petrocodon Hance (Gesneriaceae), is a small genus growing in mountainous karst habitats of S China, N Vietnam and NE Thailand  and immediately dried by silica gel for DNA extraction. Voucher specimen (WF046) of this collection was deposited at IBK. The total genomic DNA was extracted using the CTAB method . We used Map to Reference function in Geneious R11  as reference. The cp genome was manually adjusted to remove ambiguous sites. The annotation process was performed following Liu et al. (Primulina huajieensis (MF472012) as the reference. The complete chloroplast genome of Petrocodon jingxiensis was 153,056 bp in length (MK887172), the GC content was 41.9%. LSC and SSC contained 84,154 bp and 18,092 bp respectively, while IR was 25,405 bp in length. The plastid genome encoded 112 functional genes, including 79 protein-coding genes, 29 tRNA genes, and four rRNA genes.In the present study, mature and healthy leaves of u et al.  using PrPetrocodon jingxiensis was most closely related to the members of Primulina (Petrocodon jingxiensis will provide essential data for further study on the phylogeny and evolution of the genus Petrocodon and of the family Gesneriaceae.The maximum likelihood phylogenetic analysis of 10 chloroplast genomes showed that rimulina . The new


Atopic dermatitis (AD) is a common chronic relapsing inflammatory skin disease associated with a personal or family history of atopic diseases. Determining the objective severity scoring of AD index (SCORAD) and total immunoglobulin E (IgE) to help to stage the severity (lesions extent and intensity of the lesions and then the itch and sleep disturbance they may cause) of AD in children.In this study, we adopted the SCORAD index, which consists of severity, area, and sleep disturbance, to evaluate the AD status of children up to 18 years old. We examined the blood levels of total serum IgE, white blood cell count/differential count (WBC/DC), eosinophil counts (EC), eosinophil cationic protein (ECP) and specific IgE.P < .001), total WBC count , EC , and specific IgE to Cheddar cheese  remain different. After applying the Phi coefficient, we found that specific IgE to tuna (r = 0.632), codfish (r = 0.613), and clam (r = 0.613) each had a moderate correlation with specific IgE to Cheddar cheese. The 6 most common allergens were found to be mite (D. Farinae: 65.9%), mite (D. Pterony: 64.9%), house dust (47.6%), cockroach mix (37.0%), shrimp (30.8%), and crab (22.6%). Covariates of SCORAD index, severity, area, and sleep disturbance differed.A total of 208 children with AD were enrolled in this study. Serum IgE values and a number of specific IgE that are positive significantly different SCORAD index through simple linear regression; however, after multiple linear regression, only IgE values (95% CI: 0.001–0.004, In this study, we found that total IgE values, specific IgE values, WBC, EC, and specific IgE to Cheddar cheese have significant correlations with SCORAD index in AD of Taiwanese children. Atopic dermatitis is a common chronic relapsing inflammatory skin disease that is typically associated with a family history of atopic diseases. AD often announces the presence of other atopic diseases, so studying the early events of the “atopic march” can be helpful with regard to investigating and treating atopic diseases. According to Taiwan's national insurance database survey between 1999 and 2003 for preschool children, around 20% of children have AD and from other report that 15% of AD children have previously had KD history.,4The incidence of allergic diseases , and atopic disease (atopic dermatitis [AD]) has increased globally.ORAI1) have been found to be associated with atopic diseases. In fact, aberrant adaptive immune responses, such as skewed T cell polarization with predominant Th2 responses, are frequently associated with such disease. Eosinophil cationic protein (ECP), elevated blood total immunoglobulin E (IgE), and multiple allergen sensitizations are also regularly present in patients suffering from those diseases. Recently, feeding type of increased protein-hydrolyzed formula (HF) feeding population in Taiwan, as described in our previous report having impact on decreasing food sensitization but not on the development of AD.Atopic diseases include a group of allergic diseases defined by the organs they target. The pathogenesis of these diseases seems to involve both significant genetic influences and interactions with environmental allergens. These complicated interactions play vital roles in the disease's onset, severity, and progression. Recent findings in genetic analysis, such as genome wide association studies (GWAS) and new generation sequencing (NGS), have suggested several candidate pathogenetic genes for consideration. For example, filaggrin mutations are observed in approximately 50% of patients with AD. Many immunological regulatory genes  and subjective (daytime pruritus and sleep loss) criteria. Serum levels of IgE,,11 interleukin (IL)-16, ECP,,12 and total eosinphil counts (EC),10 have been reported to correlate with SCORAD index in children with AD and can service as marker for monitoring disease activity. Based on the literature review, few studies have focused on allergens and SCORAD in childhood AD. Therefore, we analyzed clinical laboratory data, including ECP, IgE, complete blood count/differential count (CBC/DC) and allergens with childhood AD via the SCORAD index system in order to provide clinicians with other tools to monitor the severity of AD.The assessment of AD patients for general disease severity was using The Severity Scoring of Atopic Dermatitis Index (SCORAD),22.1,14) and were treated at the Pediatrics Department of Chang Gung Children's Hospital at Kaohsiung upon obtaining written informed consent from their parents or guardians. AD patients under treatment with systemic steroid or immunosuppressant were excluded for study. This study was approved by the Chang Gung Memorial Hospital's Institutional Review Board . CBC/DC data were collected from central laboratory of hospital for analysis. We assess the severity of AD in these subjects by the SCORAD index. The same trained physician assistant has scored all the children. The higher the SCORAD index, the higher the severity of the AD.For this study, we recruited children (under the age of 18 years old) who fulfilled the AD criteria , which uses an in vitro diagnostic test to simultaneously determine the specific IgE of 36 different allergens. The results were categorized as class 0 to 4 using the MAST Optigen luminometer. Any class ≥1 was considered positive.We adopted the Pharmacia CAP system  to determine levels of IgE and ECP concentration.2.3P value less than .05 was considered statistically significant. All statistical analyses were performed using IBM SPSS statistical software for Windows version 22.0 .Data are presented as mean and standard deviation (or median and interquartile range) for continuous variables and as percentage for categorical variables. We applied Pearson correlation and Spearman's rank–order correlation to measure the correlation between 2 random variables. Phi coefficient was adopted to measure the association between 2 nominal variables. We further used partial correlation to analyze the association between 2 random variables by adjusting for the effect of a set of controlling random variables. We adopted a linear regression model to identify the major factors related to the outcomes. A 33.1P = .081), but are significant in relation to the severity of lesions score (P = .006) and the area of lesions score(P = .008). The age distribution in each group is shown in Table P < .001, in different age groups respectively), but no difference was found in ECP level (P = .61) or eosinophil percentage (P = .618). The 6 most common allergens were Mite Farinae (D.f.: 65.9%), Mite Pterony (D.p.: 64.9%), house dust (47.6%), cockroach mix (37.0%), shrimp (30.8%), and crab (22.6%). The 3 least common allergens were Ragweed Mix 1 (1.4%), Timothy Grass (1.9%), and Bermuda Grass (2.4%), all of which have pollen. Positive allergens with pollen or mold were less common in children with AD in Taiwan. The allergen data of the different groups are shown in Tables We enrolled a total of 208 patients with AD in this study during 2015 to 2017. The SCORAD index , demographic data, IgE values, ECP, body weight, gender, age, and positive rate of specific IgE are shown in Table oach mix 7.0%, shr3.2P < .001) (Tables P < .05). In the group of patients under 6 years old (N = 124), IgE levels demonstrated a positive relationship with age (P < .001) and body weight (P < .001), but this is not observed for ECP values (Table P < .001) but not with age or body weight  with partial correlation analysis. There were no significant difference in SCORAD index, severity, and sleep disturbance (P> .05), but lower distribution area  when comparing children with only AD to those with multiple allergic diseases. Those who were food sensitized had higher SCORAD index, severity, area, and sleep disturbance  when compared to those not food sensitized.Regarding the under 6 years old group, Tables 3.4P < .001). If a patient is allergic to Cheddar cheese, the AD score is 8.591  higher than a non-allergic person's index. Each additional unit (103/μL) of WBC count and eosinophil count results in a change of 0.924  and 3.375  of the SCORAD index, respectively.To model the relationship between SCORAD index and covariates, we adopted a simple linear regression to select a set of potential covariates and then adjusted multiple linear regressions to determine which covariates from the aforementioned potential set were relevant. In Table r = 0.632), codfish (r = 0.613), and clam (r = 0.613), all of which fall within the seafood classification. Crab and shrimp also have a significantly moderate correlation with Cheddar cheese, with r = 0.458 and 0.429, respectively.The significant associations of Cheddar cheese with other covariates through Phi coefficient analysis were analyzed. The top 3 associations with Cheddar cheese are tuna , strongly correlated with Cheddar cheese, which may be caused by cross-reactivity but still need further studies to confirm this finding. The limitations of this study included the missing data of feeding pattern and MAST allergen test, which was not followed with a food challenge test.Different allergens had various effects on SCORAD index, with cheese on the SCORAD index and sleep disturbance, wheat on the distribution area, and tuna on severity. IgE levels showed a greater correlation with SCORAD index than ECP in childhood AD, thus indicating that the pathogenesis of childhood AD may differ from that of adulthood AD. The findings of this study maybe advise patients who show sensitization to foods to avoid when poor control of AD severity or arrange food challenge test. This current work is the first to report an association between Cheddar cheese and childhood AD. Cow's milk is a common allergen, and cow milk-derived cheese retains an appreciable level of allergenicity. However, during the cheese-making process, milk proteins are degraded by chymosin, as well as milk-derived and bacterial proteases. In recent decades, the incidence of food allergy has increased in developed countries. Western diets are high in advanced glycation end-products (AGEs), which come from cooked meat, oils, and cheese. Yao et al previously reported that sensitization to the following allergens indicated a significant association with a higher fraction of exhaled nitric oxide (FeNO) in a Taiwanese population: Dermatophagoides pteronyssinus, Dermatophagoides farina, Blomia tropicalis, cat, German cockroach, oriental cockroach, codfish, crab, shrimp, and cheese. This finding suggests that sensitization to certain food allergens may contribute to rapid airway inflammation.In our previous cohort study, we observed egg white sensitization as the key factor in persistent infantile AD.In conclusion, SCORAD index showed significant association with serum IgE levels but not with ECP levels. The positive laboratory tests of different allergens had varying impact on SCORAD index, sleep disturbance, area, and severity. This study is the first to show the importance of cheese's influence on AD.Ho-Chang Kuo acquired and analyzed the data, drafted the article, revised the article for intellectual content, and provided final approval of the version to be published. Chi-Hsiang Chu and Yu-Jih Su acquired data, helped review the article, and provided approval of the version to be published. Chih-Hung Lee helped review the article and provided approval of the version to be published. Ho-Chang Kuo carried out conception and design, acquired the data, revised the article for intellectual content, and provided approval of the version to be published.