Lachancea thermotolerans, Starmerella bacillaris, Metschnikowia pulcherrima and S. cerevisiae. We could clearly differentiate wines according to the yeast strain used in single cultures and markers, which reflect important differences between the yeast species, were extracted and annotated. Moreover, uHRMS revealed underlining intra species metabolomics differences, showing differences at the strain level between the two Starmerella bacillaris. Non volatile metabolomics analysis of single and sequential fermentations confirmed that mixed fermentations lead to a different composition. Distinct metabolites appeared in wines from sequential fermentation compared to single fermentation. This suggests that interactions between yeasts are not neutral.As a complex microbial ecosystem, wine is a particularly interesting model for studying interactions between microorganisms as fermentation can be done by microbial consortia, a unique strain or mixed culture. The effect of a specific yeast strain on its environments is unique and characterized by its metabolites and their concentration. With its great resolution and excellent mass accuracy, ultrahigh resolution mass spectrometry (uHRMS) is the perfect tool to analyze the yeast metabolome at the end of alcoholic fermentation. This work reports the change in wine chemical composition from pure and mixed culture fermentation with  Under oenological conditions, when yeasts grow simultaneously during alcoholic fermentation, they often do not coexist passively, and in most cases, physiological and metabolic interactions are established between them. The interactions between the different strains of Saccharomyces and non-Saccharomyces yeast can be direct or indirect, through the physicochemical changes in the environment caused by one strain reacting to the other. In oenology, the effect of these interactions is characterized as being positive, negative or neutral3. Genomics and proteomics provide an understanding of the interaction5 but none of them could yet provide significant progress on the microbial interaction mechanisms. Recently, high resolution mass spectrometry has been used to elucidate interactions between yeasts and bacteria in the malolactic fermentation by comparison of extracellular metabolic profiles6. Even more recently, ultrahigh resolution mass spectrometry (uHRMS) confirmed that cell-cell contact influences the metabolism of L. thermotolerans and S. cerevisiae7. Therefore, metabolomics seems to be a suitable tool to better understand the microbial interactome in order to control fermentation by multi-starters. Metabolomics is defined as the study of all metabolites given in a biological system under particular physiological conditions8. The analytical techniques developed for metabolomics studies allow the screening of hundreds of metabolites from complex biological samples with high-throughput10. Therefore, the level of metabolites represents integrative information of the functional status of the cell and defines the phenotype of a cell in response to genetic or environmental changes11.Microorganisms coexist in most environments and interact with each other. These interactions happen in nearly every niche on the planet and in numerous processes such as bioremediation of pollutants, farming, biotechnology, medicine or food-processing12. Yeasts, bacteria and filamentous fungi all contribute to the chemical composition of wine. Among these, yeasts have the highest influence because of their role in conducting the alcoholic fermentation13. Although Saccharomyces species are the main fermenting yeast strains other non-Saccharomyces yeasts can be responsible for alcoholic fermentation14. In all fermented products the microbiota contribute to a large extent to the development of the typical color, flavor, and texture of the final product15. Within the great diversity of yeast types, non-Saccharomyces are more and more studied because of their capability to improve the complexity of the wine aroma by increasing the concentration of specific aromatic molecules, terpenoids, higher alcohols21 or glycerol23.The chemical composition of wine can be described as a complex product integrating signatures from many factors, including grape variety, geographical origin, viticultural condition of grape cultivation, microbial ecology of the grape, fermentation process and winemaking practicesof Saccharomyces cerevisiae have been demonstrated by Howell et al.24. In an original and very interesting way, this study highlights that the wines produced by assembling wines from pure cultures had a different composition of volatile compounds compared to wines produced by co-cultivation. This study showed that within the same species different strains interact and that these interactions have an impact on the composition of the final wine sensory profile. King et al.25 and Capece et al.26 conducted similar studies and confirmed that Saccharomyces cerevisiae co-cultures differ from single cultures in the sensory profile of the final product but also differ from the wine assemblages of each mono-culture. However, the nature of the interactions and mechanisms that regulate microbial interactions, population composition, dynamics, and performance remain largely elusive.Interactions between strains 4. Moreover, investigation of the behavior of strains in mixed cultures suggests that cell-cell contact and aggregation are indispensable to gain the dominance of one strain over another27. Likewise, after 65 generations, co-evolved strains and strains evolved independently show heritable variation in growth as well as flavor and aroma profiles28. Additionally, metabolic footprints of multiple yeast strains in monocultures, mixed cultures or blended samples showed differences in the sensory profile, which highlights the impact of one strain on the metabolic behavior over others29. Moreover, NMR-based metabolomics was recently used to identify metabolites that discriminate single and mixed cultures of two yeast during fermentation30. However, reciprocal responses of both microorganisms have not been studied.In recent years, “omics”-technologies were used to discover new aspects of microbial interactions. For instance, transcriptomic analysis combined with physiological data provided an integrated view into the response of a yeast to the environment during mixed culture fermentation35 but very few have been interested in non-volatile composition. In this study, we aimed to characterize different non-Saccharomyces yeast species and to compare their non-volatile metabolic fingerprint to the most frequently used species in winemaking, i.e. Saccharomyces cerevisiae. For this purpose, we used three different non Saccharomyces (NS) species, L. thermotolerans (LT), S. bacillaris (SB1 and SB2) and M. pulcherrima (Mp) that have been reported to complete alcoholic fermentation36 and one Saccharomyces cerevisiae strain (Sc). It has been previously shown that interactions between yeasts in sequential cultures lead to wines that differ from wines with single cultures in their volatile compounds37. Then, another goal was to study the influence of these non-Saccharomyces strains in sequential cultures with Saccharomyces cerevisiae on the non-volatile wine metabolome.More and more work focused in the study of volatile metabolome and inter-strains variabilityS. cerevisiae (Sc), L. thermotolerans (LT), S. bacillaris (SB1 and SB2) and M. pulcherrima (Mp), respectively. After 24 h, Sc was added to five of the aliquots  and a sugar concentration lower than 2 g.L−1. Therefore, differences in the final wine compositions are characteristic to the impact of the yeast or the mixture of yeasts used for the fermentation.Chardonnay must was divided into 10 aliquots, which were inoculated with pure cultures of m/z 100 to 1000. For example, signals at m/z 259.01291 and m/z 259.02243, corresponding to the molecular formulae [C6H11O9S]− and [C9H11N2O3S2]−, respectively, showed strong differences in their ion abundances .A visual comparison of FT-ICR-MS raw spectra of Chardonnay wines, which only differ in the yeast used for the alcoholic fermentation  is presented in the supplemental Fig. 42. NMR-based metabolomics was recently used in order to discriminate yeast cultures during alcoholic fermentations, but unfortunately, NMR was not able to fully discriminate all yeasts30.The principal component analysis (PCA) of FT-ICR-MS raw data from the single-culture experiments Fig.  illustraIn order to visualize and characterize the impact of yeasts on the final wine composition, we computed ANOVA statistics for all compounds detected by FT-ICR-MS. Consequently, we retrieved a subset of features that showed significant differences in their mean peak intensities (p < 0.05) between the different sample groups. These extracted features can be used as markers to distinguish and characterize the wine depending on the yeast used for the fermentation. The subset contained 336, 255, 572,102 and 234 possible markers specific for Sc, LT, SB1, SB2, and Mp yeasts, respectively Fig. . The numStarmerella bacillaris (SB) strans differ in the produced metabolites. Our results confirmed that different NS species have a wide intra specific variety46.In addition to the specific markers, we found 40, 19, 28, 68 and 11 metabolites which could exclusively be detected in Sc, SB1, SB2, Mp, and LT samples, respectively. Moreover, metabolomics highlighted the diversity within species. Indeed, Fig. 47. By comparison, SB1 markers are mainly composed of CHO in the van Krevelen diagram are of O/C > 0.8 and 1.6 < H/C < 2.7 . Possible structural assignments for compounds that discriminate the wine samples could be obtained from the literature and relevant databases . Only a low number of the detected molecular formulae led to possible structure assignments in the databases. We found 16 (4.7%), 8 (3.1%), 79 (13.8%), 14 (13.7%) and 17 (7.2%) possible metabolite markers for the Sc, LT, SB1, SB2, and Mp sample, respectively . Using uHRMS, like FT-ICR-MS, a wider range of metabolically relevant features can be detected. We confirm that tremendous differences exist between species and extract hundred of non volatile metabolites specific to the yeast or the mixed of yeast used during alcoholic fermentation. The presence of compounds which are specific to a yeast strain can be used to find the identity of yeasts involved in the fermentation. Another important aspect that stands out from our study is the significant contribution of non-Saccharomyces yeasts together with Saccharomyces cerevisiae to the non-volatile composition of wines. Indeed, while we clearly showed that single cultures could be easily discriminating from sequential cultures based on their metabolite profile, our data are consistent with the existence of positive or negative interactions between yeast species. In fact, the wine composition of sequential culture is not only the addition of metabolites from each species but is the result of complex interactions causing the presence or the absence of specifics compounds. The complexity of wine composition and yeast interaction require instrumental analytics and scientific methods that can detect, identify, quantify and characterize metabolite. uHRMS analysis may be used for understanding metabolic changes during wine fermentations where yeast cultures are used in sequential fermentation. However, information obtained using FT-ICR-MS is neither quantitative nor complete in terms of structure elucidation and improvement of metabolome databases would certainly allow to unravel how the metabolism of one species is modulated by the presence of another species.Previous metabolome studies of wine from single and mixed cultures typically focus on targeted analysis and volatiles analysis by GC-MSSaccharomyces yeast strains were obtained from the collection of the Burgundy University Vine and Wine Institute. The strains selected for this study were Lachancea thermotolerans (LT), two strains of Starmerella bacillaris (SB1 and SB ∙ 2), Metschnikowia pulcherrima (Mp) and a commercial strain of Saccharomyces cerevisiae (Sc) used as a reference and for sequential inoculation  and supplemented with 0.2 g.L−1 of chloramphenicol7. Yeasts were pre-cultured for 24 h in 250 mL sterile Erlenmeyer flasks, closed with dense cotton plugs, containing 150 mL of modified YPD medium under agitation (100 rpm)7.All yeast strains were grown at the controlled temperature of 28 °C on modified yeast extract dextrose medium (YPD 20 g.L6 cells were centrifuged (9000 g for 5 min). The pellet was suspended in 1 mL MacIlvaine’s buffer . The first tube was used as a control. The second tube was complemented with 2 µL of the viability probe 5-CFDA, AM  to achieve a final concentration of 1.5 mM and incubated for 25 min in darkness at room temperature before flow cytometry (FCM) analysis. The FCM analysis was performed with a BD Accuri C6 flow cytometer. The 5-CFDA (second tube) was excited by the flow cytometer laser at 488 nm and emitted green fluorescence collected by the filter 530 nm + /− 15 nm (FL1 channel). The results were compared to the control tube to eliminate cellular autofluorescence. Data were analyzed using statistic tables that indicate the number and percentage of viable cells as well as the fluorescence intensity.After yeast growth in YPD medium, 2 microtubes containing one milliliter of yeast culture with 10−1 of glucose/fructose, a pH of 3.41 and 251 mg.L−1 of total assimilable nitrogen. The must was centrifuged at 7,000 g for 7 min at 4 °C. Sugar concentration and ethanol production were monitored by Fourier transform infrared spectroscopy .Fermentations were carried out in duplicate in white must (Chardonnay) containing 212 g.L6 cells.mL−1) and incubated at 20 °C without agitation.Single-culture fermentations were carried out in 250 mL Erlenmeyer flasks, closed with sterile cotton wool, containing 100 mL of Chardonnay must. Each sample was inoculated with pre-cultured yeast cells (106 cells.mL−1 non-Saccharomyces (NS) yeast . 24 h after the NS yeast inoculation, a second inoculation with 106 cells.mL−1Saccharomyces cerevisiae was done.Sequential fermentations were carried out in 250 mL Erlenmeyer flasks, filled with 100 mL of must and inoculated with 1048. For MS analysis, samples were diluted 1:100 (v/v) in methanol 49. The diluted samples were infused into the electrospray ion source with a flow rate of 120 μL.h−1 49. Settings for the ion source were: drying gas temperature 180 °C, drying gas flow 4.0 L.min−1, capillary voltage 3,600 V. Spectra were first externally calibrated by ion clusters of arginine (10 ppm in methanol). Internal calibration of each spectrum was conducted with a reference list including selected wine makers and ubiquitous fatty acids. The spectra were acquired with a time-domain of 4 megawords and 400 scans were accumulated within a mass range of m/z 92 to 1000. A resolving power of 400,000 at m/z 300 was achieved49.Ultrahigh-resolution FT-ICR-MS were acquired with a 12 T Bruker Solarix mass spectrometer  equipped with an APOLLO II electrospray source in negative ionization mode49. All exported m/z features were aligned into a matrix containing averaged m/z values  and corresponding peak intensities of all analyzed samples48. Molecular formulae were assigned to the exact m/z values by mass difference network analysis using an in-house developed software tool60. In total, the matrix containing the entire sample set contained 5979 detected features that could be assigned to distinct and unique molecular formulae. More than 90% of all assignments were found within an error range lower than 0.2 ppm. All further calculations and filtering were done in Perseus 1.5.1.6  and R Statistical Language (version 3.1.1).Raw spectra were post-processed by Compass DataAnalysis 4.2  and peaks with a signal-to-noise ratio (S/N) of at least 6 were exported to mass listsQuality control (QC) samples were prepared by pooling equal amounts of all samples. QC samples were injected at the beginning and after every 10 samples to monitor the reproducibility of the measurements overtime  in water and Eluent B of 100% ACN, both with 0.1% formic acid49. Detection was carried out in negative ionization mode with the following parameters: Nebulizer pressure = 2.0 bar, dry gas flow = 8.0 l.min−1, dry gas temperature = 200 °C, capillary voltage = 3,500 V, end plate offset = −500 V49. The flow rate was 0.4 mL.min−1. UHR-ToF-MS acquisitions were carried out in profile spectra mode with a total scanning rate of 1 Hz. Instrument tuning focused on detection and resolution of molecular weight compounds in the mass range of 50 to 2,000 Da. Mass calibration was carried out with low concentration ESI Tuning Mix 49. After acquisition, MS/MS spectra were manually extracted using Bruker Data Analysis 4.4 .Discriminative markers found after chemometric analyses were subjected to tandem-MS experiments. Samples were directly injected into the LC-MS/MS system without dilution. Metabolites were separated using a Waters Acquity UPLC system coupled to a Bruker maXis UHR-ToF-MS. A reversed-phase (RP) separation method was employed which separates middle to non-polar metabolites using a BEH C18 column v/v) and after purification using C18 SPE cartridges (100 mg.ml−1 Backerbond SPE columns) were compared by FT-ICR-MS . Principal component analysis (PCA), hierarchical cluster analysis (HCA) and analysis of variance (ANOVA) were performed using Perseus 1.5.1.6 . For HCA, Euclidean distance and average linkage were chosen. Van Krevelen diagrams  and multidimensional stoichiometric compounds classification (MSCC) have been used to elucidate main compound categories commonly defined as lipids, peptides, amino sugars, carbohydrates, nucleotides and polyphenols compoundsSupplementary information.


The use of Oxford Unicompartmental Knee Arthroplasty (UKA) has increased rapidly in both Western and Asian populations, with excellent functional outcomes and high patient satisfaction. While previous evidence regarding clinical outcomes and survival rates after Oxford UKA was based on studies in Western populations, the results may be different in Asian patients. The relevance of age for postoperative function after Oxford UKA also remains unclear. Hence, the aim of our study was to clarify the effectiveness and safety of Oxford UKA in Asian patients aged over 80 years.A retrospective review was performed and included 195 patients (209 knees) who underwent an Oxford UKA between June 2015 and July 2018. We divided the patients into three groups by age: Group 1, 60–69 years; Group 2, 70–79 years; and Group 3, over 80 years. We used the Hospital for Special Surgery (HSS) score and Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index score to evaluate the general condition of the patients’ knees before surgery and at last follow-up. We also recorded perioperative and short-term complications.P < 0.05), but the HSS scores and the WOMAC scores were significantly improved in all three groups. In terms of perioperative and other complications, the three age groups did not differ significantly.Group 1 consisted of 60 patients (60 knees); Group 2, 70 patients (79 knees); and Group 3, 65 patients (70 knees). The mean follow-up was 21.34 ± 12.04, 22.08 ± 11.38, and 21.76 ± 10.20 months in groups 1, 2, and 3, respectively. At last follow-up, the patients in Group 3 showed lower function scores compared to groups 1 and 2 (Oxford UKA is an effective and safe treatment for osteoarthritis, even in elderly patients in China. Elderly patients have lower knee function scores than younger patients. However, the knee joint pain of the elderly patients was relieved and function improved compared to the preoperative condition. Oxford unicompartmental knee arthroplasty (UKA) is one of most effective surgical procedures for the treatment of isolated medial compartment osteoarthritis. Compared to total knee arthroplasty (TKA), UKA (including both fixed-bearing UKA and mobile-bearing UKA) can provide better physiological function, quicker recovery, shorter hospital stay, and fewer perioperative complications, especially for early arthritis , 2. ReceAsian populations have different lifestyles, such as squatting and sitting on the floor, from those of Western populations. Therefore, Asian populations need more range of motion (as they often flex the knee to more than 120 degrees) to perform daily activities , 6. A prWe retrospectively reviewed 195 knee osteoarthritis patients who underwent medial Oxford UKA  between June 2015 and July 2018. The study protocol was reviewed and approved by the hospital institutional review board. All patients provided informed consent for participation in the study. All patients were diagnosed with anteromedial osteoarthritis (AMOA) of the knee based on history, physical examination, and radiographs. Before surgery, all patients had standard X-ray views taken: anteroposterior (AP) and lateral radiographs; full-length standing, weight-bearing AP, and lateral radiographs; and patella tangential view radiographs. Magnetic resonance imaging (MRI) was also done to evaluate the ligament, meniscus, and lateral compartment.The indication criteria for UKA were: older than 55 years; a correctable varus deformity (varus less than 15 degrees); flexion deformity less than 15 degrees; intact ligaments, especially the anterior cruciate ligament (ACL) and medial collateral ligament (MCL) which should be functionally normal; an intact lateral compartment; proper range of motion (at least 0–100 degrees); and no inflammatory disease. We observed the stage of deterioration of the ACL intraoperatively. If the ACL deficiency was less than grade 2 we performed an Oxford UKA .Exclusion criteria: The lateral side of the patellofemoral joint exhibited bone loss with eburnation and longitudinal grooving; absent or severely damaged ACL (or PCL or MCL).The same group of surgeons performed all the operations. The patient was placed in the supine position and a tourniquet was applied to the proximal thigh on the operative side. All patients underwent the standard Oxford UKA surgical procedure . All patients received an analgesic intra-articular cocktail mixture injection containing ropivacaine, parecoxib sodium, oxycodone, epinephrine, and tranexamic acid. Patients received an intravenous infusion of drugs to control pain for 3 days after surgery. All patients routinely received a drainage tube; removed on the first day after surgery. All patients received anticoagulant therapy from 1 day after surgery until 2 weeks after surgery.We used the Hospital for Special Surgery (HSS) Knee score and Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index to evaluate the general condition of the patients’ knees. Preoperative and postoperative range of motion (ROM), HSS, and WOMAC score were used to assess patient function at final follow-up. Postoperative radiographs in three groups, collected at the latest follow-up, were reviewed by the authors to identify any signs of radiolucency, loosening, and progression of arthritis in the lateral and patellofemoral compartments.Depending on the age of the patients, we divided all patients into three groups . Patient records were reviewed and the following data collected: American Society of Anesthesiologists (ASA) score, body mass index (BMI), type of anesthesia, length of stay, hemoglobin values (before surgery and three days after surgery), change of hematocrit , tourniquet time, and previous basic disease . We used the Mercurialis method to calculate the volume of blood loss [P < 0.05).The statistical software used for all analyses was SPSS 22.0 . Continuous variables are reported as means ± standard deviation (with range). Discrete variables are reported as number (percent). Chi-squared test or Fisher’s exact probability method was used to compare binary variables (demographic data and complication rates). We used analysis of variance (ANOVA) for comparison of clinical scores  between the three groups  of the WOMAC score was 11 for pain, 9 for function, 8 for stiffness, and 10 for the total WOMAC score [One-way ANOVA was used for the comparison of the means between the three groups. Homogeneity of variance is needed before conducting ANOVA. First, we calculated a global/overall model. Only in case of significance, Bonferroni adjusted pairwise comparisons are needed to detect which groups differ significantly. The binary variables between the multiple groups is expressed in percentage (P) and was compared using Fisher’s exact probability method or chi-square test.One hundred ninety five patients enrolled in our study. Among the patients, 60 (60 knees) were 60–69 years old Group 1); 70 patients (79 knees), 70–79 years old (Group 2); and 65 patients (70 knees), older than 80 years (Group 3). The mean follow-up was 21.34 ± 12.04, 22.08 ± 11.38, and 21.76 ± 10.20 months in groups 1, 2, and 3, respectively. Table ; 70 patip < 0.05). There were no significant differences in ASA scores, BMI, and other basic diseases between the three groups. There were no significant differences in preoperative ROM.The patients’ characteristics and perioperative variables between different groups are shown in Table p < 0.05). A total of 13 patients suffered superficial infection after surgery. They received vacuum sealing drainage (VSD) and recovered. There were no significant differences in other perioperative complications.The postoperative variables and perioperative complications between the different groups are shown in Table p < 0.05) showed a lower mean function score in HSS and WOMAC scores, but this was improved compared to the preoperative condition. The MCID of the WOMAC score was 10 and the MCID of HSS score was 6 [There were also no statistical differences in preoperative and postoperative HSS or WOMAC scores Table . Althougre was 6 , 10. TheTable There were no major systemic complications following 209 consecutive Oxford UKAs (195 patients). This study revealed no significant differences in the perioperative complication rates in patients between the different groups. All patients obtained satisfactory clinical outcomes, but compared to patients over 80 years old, patients between the ages of 60–79 had a higher function score in both HSS and WOMAC scores.Iacono et al.  evaluateConcerning the clinical outcomes in very old patients who underwent Oxford UKA, a recent study from the Oxford center analyzed 1000 Oxford UKAs and found that at 10-year follow-up, patients younger than 60 at the time of the operation had significantly better American Knee Society Score Function (AKSS-F) score, Oxford Knee Score (OKS), and Tegner Activity Score than patients older than 60, but no difference in functional outcomes was seen between the groups . A meta-In our study, there was a clear improvement in HSS and WOMAC scores in both groups after surgery. WOMAC scores evaluate efficacy through three aspects: function, pain, and stiffness. HSS scores evaluate efficacy through two aspects: function and pain. There was no statistical difference between the three groups in the total HSS score and WOMAC score. However, Group 3 had lower scores in the functional dimension in HSS and WOMAC scores, and there was no statistical difference in the pain aspects in HSS and WOMAC scores. According to previous study , 10, theIn Asian populations, body size, BMI, lifestyle, and knee morphology of Asian populations differ from those in Western countries. A proportion of patients, whose knees flex more than 120 degrees, are required to perform daily activities that include squatting and sitting on the floor, which may lead to different clinical outcomes from Western populations. Lim et al. reported that Oxford UKA can yield satisfactory clinical and functional results and has a 10-year survival rate of 94% in Korean patients . YoshidaOne systematic review assessed over 8000 Oxford UKA patients and found the 10-year survival to be 93%, 15-year survival to be 89%, and a medical complication incidence of 0.8%. Very good outcomes were achieved by both designing and non-designing surgeons . The litOne patient suffered a bearing dislocation four months after surgery. Figure One patient (81 years old) developed a periprosthetic fracture 2 months after surgery due to a fall, and we performed an open reduction of the tibial fracture with internal fixation. Figure The major perioperative complications in our study were calf muscular vein thrombosis (CMVT) and superficial infection. There were no deaths during the perioperative period, pulmonary embolisms, or symptomatic deep vein thrombosis (DVT).Chan et al. compared one-stage and two-stage bilateral unicompartmental knee replacements during the first 30 days postoperatively and found that the rates of proximal DVT, pulmonary embolus, and death secondary to pulmonary embolus to be 0.9, 1.9, and 0.3%, respectively . PostopeWe conclude that Oxford UKA is a safe procedure with a low rate of perioperative complications, similar to previous studies . PreviouThere are several limitations in our study. The study sample was relatively small, and the follow-up relatively short. Further research, large samples, and long-term follow-up are required to evaluate function. The mean follow-up time of the study group in the present study was 21.76 months, which is comparatively long-term if the entry age of 80 years is considered. Moreover, we did not consider the potential influence of sex, and there was no control group in this study.Oxford UKA is an effective and safe treatment for osteoarthritis, even in elderly adult patients in China. The knee joint pain symptoms of elderly patients are relieved, and the function improved but was still poor compared with younger patients. The rate of perioperative and other complications in the elderly patients was almost the same as in younger patients. Our study shows the safe use of Oxford UKA in octogenarians in China.


Acute kidney injury (AKI) is a life-threatening complication of rhabdomyolysis (RM). The aim of the present study was to assess patients at high risk for the occurrence of severe AKI defined as stage II or III of KDIGO classification and in-hospital mortality of AKI following RM.We performed a retrospective study of patients with creatine kinase levels > 1000 U/L, who were admitted to the West China Hospital of Sichuan University between January 2011 and March 2019. The sociodemographic, clinical and laboratory data of these patients were obtained from an electronic medical records database, and univariate and multivariate regression analyses were subsequently conducted.P < 0.01). The clinical conditions most frequently associated with RM were trauma (28.3%), sepsis (14.6%), bee sting (12.8%), thoracic and abdominal surgery (11.2%) and exercise (7.0%). Furthermore, patients with RM resulting from sepsis, bee sting and acute alcoholism were more susceptible to severe AKI. The risk factors for the occurrence of stage II-III AKI among RM patients included hypertension (OR = 2.702), high levels of white blood cell count (OR = 1.054), increased triglycerides (OR = 1.260), low level of high-density lipoprotein cholesterol (OR = 0.318), elevated serum phosphorus (OR = 5.727), 5000<CK ≤ 10,000 U/L (OR = 2.617) and CK>10,000 U/L (OR = 8.093). Age ≥ 60 years (OR = 2.946), sepsis (OR = 3.206) and elevated prothrombin time (OR = 1.079) were independent risk factors for in-hospital mortality in RM patients with AKI.For the 329 patients included in our study, the incidence of AKI was 61.4% and the proportion of stage I, stage II, stage III were 18.8, 14.9 and 66.3%, respectively. The overall mortality rate was 19.8%; furthermore, patients with AKI tended to have higher mortality rates than those without AKI (24.8% vs. 11.8%; AKI is independently associated with mortality in patients with RM, and several risk factors were found to be associated with the occurrence of severe AKI and in-hospital mortality. These findings suggest that, to improve the quality of medical care, the early prevention of AKI should focus on high-risk patients and more effective management. Rhabdomyolysis (RM) is a syndrome characterized by the disruption of skeletal muscle cell integrity, with subsequent release of intracellular components into the extracellular environment. There are numerous reported causes of RM, and the most frequently associated etiologies are trauma, immobilization, sepsis and surgery –3. The cThe present study was a retrospective analysis of data collected from the West China Hospital of Sichuan University, from patients admitted between January 2011 and March 2019. All patients over 18 years old with CK levels > 1000 U/L were eligible. The exclusion criteria were as follows: (i) Patients with pre-existing end-stage renal disease; (ii) patients who had received a kidney transplant; (iii) patients with abnormal CK elevation from acute myocardial infarction; and (iv) patients with incomplete data. To avoid bias among patients who were repeatedly admitted to hospital during the study period, only the first admission was included.Patient sociodemographic, clinical and laboratory data were obtained from an electronic medical records database. Sociodemographic data included age, sex and date of admission. Clinical data included etiology, smoking history, alcoholism and chronic disease history , the presence of sepsis and the outcomes . Laboratory data comprised blood levels of CK, baseline biomarkers of renal function (serum creatinine (SCr), blood urea nitrogen (BUN), cystatin C and uric acid), levels of phosphate, calcium, potassium, aminotransferase, albumin, bilirubin, hemoglobin, lipoprotein and prothrombin time, as well as white blood cell (WBC) and platelet counts.In the present study, AKI was defined per the Kidney Disease Improving Global Outcomes criteria (KDIGO) : An absoP < 0.05 (two-sided) was considered to indicate a statistically significant difference.Categorical covariates were recorded as frequency distributions and proportions. According to the distribution pattern, continuous variables were recorded as the mean ± standard deviation (SD). Univariate analysis was employed to predict disease etiology, using a binomial distribution; the Students t-test and Pearson χ2 test were used to estimate baseline characteristics. Independent predictors of AKI incidence and in-hospital mortality were evaluated by univariate and multivariate logistic regression, which were utilized to calculate odds ratios (ORs) and 95% confidence intervals. Only the significant risk factors identified by univariate analysis were considered for multiple regression analysis. The data were analyzed using SPSS 22.0  and P < 0.01). The clinical conditions most frequently associated with RM were trauma (28.3%), sepsis (14.6%), bee sting (12.8%), thoracic and abdominal surgery (11.2%) and exercise (7.0%). Other causes are shown in Table In the present study, we identified 383 hospitalizations of adults with a CK level > 1000 U/L between January 2011 and March 2019. After excluding 6 patients with pre-existing end-stage renal disease or who had received a kidney transplant, 1 case of acute myocardial infraction, 7 patients aged< 18 years and 40 with incomplete data, the final study population included 329 patients , elevated WBC count , triglycerides , HDLC  and serum phosphorus , 5000 < CK ≤10,000 U/L  and CK>10,000 U/L  , which was within the wide range of reported mortality rates for his condition [Patients with RM-related AKI are associated with an increased risk of death and total health-related costs than those who do not develop AKI. Our analysis showed that the total mortality rate of these patients was 19.8%, whereas AKI patients experienced a significantly higher mortality rate than those without it  play an important role in the variations in AKI-associated morbidity, and the subsequent mortality rates of RM patients. In addition, different inclusion criteria  may also affect these results. A previous study reported that the incidence of AKI was highest according to the KDIGO definition, followed by the Acute Kidney Injury Network criteria and the Acute Dialysis Quality Initiative’s RIFLE criteria .We revealed that hypertension was one of the independent risk factors for stage II-III AKI in RM patients; likewise, a previous study reported that diagnosed hypertension was an independent risk factor for AKI in patients with chronic kidney disease or after emergency department contrast-enhanced computerized tomography , 20. In Low levels of HDLC have been associated with worse short-term and long-term renal outcomes in patients who suffer AKI caused by sepsis and underwent percutaneous kidney biopsy for histological diagnosis of AKI , 29. In Hyperphosphatemia is a common complication of RM with several proposed pathogenic factors, including the release of inorganic phosphorus into the plasma and reduced urinary phosphate excretion , 33. In The significant correlation between serum CK level and the risk of RM-induced AKI has been demonstrated in previous studies –39, our The present study includes the following limitations. Firstly, most of the recruited patients were identified by discharge diagnoses in an electronic medical record database; hence, a proportion of the patients with elevated serum CK were missed due to a lack of RM diagnosis. Secondly, where existing urine volume data were not available, AKI diagnosis was based on SCr alone; thus, the incidence of AKI may have been underestimated. Thirdly, some of the possible risk factors for AKI, such as the level of myoglobin, lactic acid, associated drugs, as well as the severity-of-illness scores, were not included due to incomplete data. Finally, no follow-up study was conducted; thus, long-term patient prognoses  were not determined.The occurrence of AKI increases the mortality rate of patients with RM. The early evaluation and diagnosis are crucial for the prevention of AKI and improved patient prognosis. Our study demonstrated several risk factors for RM-induced stage II-III AKI and in-hospital mortality in RM patients with AKI. These findings may facilitate the effective prevention and management of RM patients with AKI. However, it also has several limitations. We will conduct further research to improve the study.


Escherichia coli in Germany was conducted between 2009 and 2010. The aim of this study is to provide longitudinal epidemiological data on neonatal and young infant sepsis caused by GBS and E. coli to reevaluate existing data and to inform clinical decision-making. Every positive blood culture for GBS and E. coli within the first 90 days of life that occurred at our center from 2008 until 2018 was identified. The epidemiological, clinical, laboratory, and microbiological data of all affected patients were analyzed through retrospective chart review, along with the pathogen’s antimicrobial susceptibility results. In total, 106 episodes of neonatal sepsis were described; 31% (n = 33) being caused by GBS and 69% (n = 73) by E. coli; 87% of GBS early-onset disease (EOD) cases did not receive intrapartum antibiotic prophylaxis (IAP). Contrary to general trends, the proportion of resistant E. coli isolates decreased for all tested antibiotics over time. Coincidentally, antenatal antibiotic use beyond IAP during that period decreased significantly in our center.The last nationwide surveillance study on neonatal and young infant sepsis due to Group B Streptococci (GBS) and Conclusions: (1) Data at our center suggests at least a regional implementation gap in GBS screening and IAP. (2) The decline in the resistance rate of E. coli for all antimicrobial substances might indicate that the reduction of prenatal antibiotics use is beneficial and that neonatal antibiotic stewardship programs should include pregnant women as well.The online version of this article (10.1007/s00431-020-03659-8) contains supplementary material, which is available to authorized users. Escherichia coli (E. coli) and Group B Streptococci  are the most common etiologic pathogens [E. coli [Neonatal sepsis is a major cause of mortality and morbidity in infants . Escheriathogens . Antenatathogens , 23. How[E. coli . Germany[E. coli . Current[E. coli .E. coli in Germany was last conducted between 2009 and 2010 [E. coli over the past decade in a large German neonatal center.It is important that physicians understand epidemiological changes in order to be able to perform informed clinical decision-making, especially regarding appropriate empirical antibiotic therapy. The German Neonatal Infection Surveillance Network  provides valuable data regarding longitudinal epidemiology; however, it only focuses on very low birth weight (VLBW), < 1500 g, premature infants [and 2010 , 23. TheE. coli and GBS isolates from positive blood cultures within the first 90 days of life were identified at the Department of Pediatrics, University Hospital Dresden, TU Dresden, Germany. The detection of E. coli or GBS in blood cultures was the criterion for inclusion to the study. The epidemiological, clinical, and microbiological data of the infants and their mothers were collected through retrospective chart review.Between January 2008 and December 2018, all patients with Early-onset disease (EOD) was defined as infections occurring between the first and sixth day of life, infections occurring between the seventh and the 90th day of life were classified as late-onset disease (LOD).Not every infant was born at our center, therefore not every infant’s and mother’s clinical history could be retrieved retrospectively. On this account some data is incomplete. Accordingly, not every of the 106 infant-mother-pairs offer complete data of antenatal microbiological swabs and use of IAP. IAP was considered adequate if there was documentation of at least 2 doses of penicillin G or ampicillin > 4 h before delivery.However, for all infants weighing < 1500 g who were born at our institution from 2014 to 2018, data on antenatal antibiotic administration in women with pending premature birth at our center was available. This data of very low birth weight (VLBW) infants was collected separately within the perinatal conference at our center.Bacterial isolates from positive blood cultures  and screening swabs were identified based on colony morphology on Columbia blood agar using VITEK 2 , agglutination tests for ß-hemolytic streptococci , and, since 2011, MALDI-TOF MS . Antimicrobial susceptibility testing was performed according to criteria of the European Committee on Antimicrobial Susceptibility Testing (EUCAST) of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), according the CLSI-standard  . MicrobiWhite blood cell count (WBC), immature to total neutrophil ratio (ITQ), C-reactive protein (CrP), and Interleukin-6 (IL-6) were analyzed as indications of bacterial infection. WBC 5 to 21 GPt/L, CrP < 10 mg/L, IL-6 < 150 pg/mL, and ITQ < 0.2 were considered typical values for healthy individuals.n (%) for categorical variables for the statistical analysis. The calculated percentage values always reflect the available data for that specific variable  for continuous variables and le Table .The binon = 33) caused by GBS and 69% (n = 73) by E. coli. The infection rate was higher for male  than female infants . There was no significant difference found between the male/female ratio for GBS  and E. coli . However, the predominance of male infants could be detected only for EOD  and not for LOD   Fig. .Fig. 1RaE. coli and GBS neonatal sepsis ranged from 1:1 to 7:1, without any identifiable trend  than E. coli ; even when analyzed for EOD and LOD separately, this did not change (EOD p = <0.001 / LOD p = 0.02) .GBS blood stream infections were more common in full-term infants , additional to the fact that they were more preterm (p = 0.02), were more often born via C-section than infants with GBS infection  (A1 Table 3).The overall number of C-sections did not differ between GBS and E. coli (52%) at the time of infection onset. Approximately one-third of the infants were colonized with another pathogen than the one causing invasive disease .During routine microbiological screening swabs as recommended by the KRINKO, neonatal colonization with the pathogen causing invasive disease did not differ between GBS (55%) and n = 2, 6%) and E. coli  mortality. Significantly more GBS infected infants suffered from meningitis . Specifically, LOD with GBS occurred with 58% (n = 7) of meningitis cases, in contrast to 9% (n = 3) for E. coli (p = 0.001) (A1 Table 3). Overall, complications like intracerebral hemorrhage (ICH) and bronchopulmonary dysplasia (BPD) affected more E. coli- than GBS-infected children (p(ICH) = 0.01; p(BPD) = 0.006)  of all EOD  had IL-6 levels < 150 pg/mL; 90% (9/10) of these infants were preterm. Only in GBS LOD, all patients presented at least one abnormal blood marker.Laboratory studies at disease onset and after 36–72 h were analyzed. The data for WBC, ITQ, CrP, and IL-6 is summarized in Table E. coli and GBS infection regarding any of the analyzed biomarkers. Between first and second blood samples, however, the increase in CrP as well as the decrease in ITQ were significant (p(CrP) = 0.0005 and p(ITQ) = 0.0001) (A2 Table 5).There were no statistically significant differences between n = 7, 80%) compared with children with E. coli sepsis .The results of maternal laboratory tests were analyzed for EOD cases. The proportion of increased CrP at delivery (> 10 mg/L) was significantly higher in women giving birth to children with GBS . In C-sectioned women, amniotic swabs demonstrated detection rates of 100% for GBS and 81% for E. coli with regard to diseased infants.Prepartal vaginal swabs and amniotic membrane swabs taken at time of the C-section were compared with the infants’ blood culture results. Results of prepartal vaginal or amniotic swabs were not available for all women. Amniotic swabs and vaginal swabs were available for nearly every C-section that was performed at our center. Regarding all women, prepartal vaginal swabs, that were taken a few days or hours before delivery, were available in 67 of 106 cases. Focusing only on EOD, prepartal vaginal swabs were available in 10 of 21 GBS and 34 of 38 E. coli  than EOD GBS cases  (p = 0.03). Antibiotic administration for PROM was significantly more frequent in mothers whose children developed E. coli EOD  compared with GBS  (Table Only two infants (13% of GBS EOD cases), both preterm, developed early onset GBS disease despite intrapartum prophylaxis. The rate of premature rupture of membranes (PROM) > 18 h was significantly higher in EOD All GBS isolates were susceptible to penicillin, 6% were resistant to clindamycin, and 18% were resistant to erythromycin Fig. .Fig. 3AnE. coli isolates decreased during the 10-year period for all tested antibiotics. Ampicillin resistance decreased from 64 to 36% (p = 0.11), piperacillin-tazobactam resistance from 35 to 21% (p = 0.47), cefotaxime resistance from 21 to 7% (p = 0.37), and gentamicin resistance from 9 to 0% (p = 0.51). Overall 55% of E. coli isolates were resistant to ampicillin, 25% to piperacillin-tazobactam, 11% to cefotaxime, and 4% to gentamicin. All isolates were susceptible to meropenem , with significantly reduced rates of carbapenems and cephalosporins .The higher incidence of ICH and BPD in We confirmed the reasonable high sensitivity of ITQ and IL-6 at the time of diagnosis, indicating that biomarkers indeed may help to rule out neonatal and young infant sepsis and thereby help to reduce the well-described antibiotic overuse in this age group .However, there was no significant, detectable increase in CrP levels before 36–72 h after disease-onset. . InteresE. coli EOD. This suggests that negative laboratory studies should never be seen to definitely rule out sepsis, in particular not in preterm infants with a high risk of E. coli sepsis.Maternal biomarkers seem to be pathogen-dependent, with higher positive rates in GBS than Universal antenatal GBS screening and IAP) in the United States led to a six-fold decrease in the incidence of EOD, and currently, approximately equal rates of EOD and LOD . Wicker E. coli disease in premature infants highlights the need for effective prevention. Administration of broad-spectrum antibiotics based on maternal microbiological sampling has been suggested [E. coli can only be detected in one-third of the respective EOD cases in prepartal vaginal swabs, making it difficult to identify patients at risk for E. coli sepsis. More importantly, there is data that suggest that antenatal antibiotic use might increase the risk of E. coli EOD [E. coli in EOD infants that were prenatally exposed to antibiotics in our study substantiates these findings and calls this approach into question.The high burden of uggested , 24, 25.coli EOD . The higE. coli, on the other hand, were cumulatively higher than those reported in this previous study, especially for ampicillin and third-generation cephalosporins. In addition, we found a decline in resistance rates over time for all antimicrobial substances in our study, and notably for ampicillin. An explanation might be the reduction in use of prenatal antibiotics in our obstetrics and gynecology department, especially broad-spectrum antibiotics such as cephalosporins and carbapenems. This coincides with the decrease in resistant E. coli in neonatal sepsis, contrary to the previously published findings; Dona et al. as well reported about a decrease in extended spectrum beta-lactamase (ESBL) producers E. coli [Antimicrobial resistance rates for GBS were overall low and consistent with results from a previous nationwide surveillance study in Germany in 2009–2010 , 7, 23.  E. coli , 20. NevOur study is limited by its retrospective design leading to incomplete data especially in mothers who were not treated at our institution. In addition, we provide regional data only from a single center that might not necessarily reflect the situation in other parts of Germany accurately. We feel confident though that our findings warrant additional studies in Germany in regard to the nationwide implementation of screening and prophylaxis and the development of resistance rates.Given the documented regional implementation gaps of the risk-based GBS screening further studies are needed to evaluate the nationwide implementation of current guidelines. A universal GBS screening could reduce infant mortality and morbidity in Germany.E. coli EOD and leads to antimicrobial resistance. Rational antenatal antibiotic prescription might help reduce the problem of multi-drug resistance in neonatal and young infant sepsis. It is important that neonatal ASPs include pregnant women as well.Antenatal long-term administration of broad-spectrum antibiotics to women with pending premature birth might increase the incidence of ESM 1(PDF 269 kb)ESM 2(PDF 123 kb)


The effect of biologic therapy on the incidence of inflammatory bowel disease (IBD)-related hospitalizations is controversial. The high efficacy of biologic agents is weighted against potential therapy-related adverse events, however, there are no data on the effect of biologic therapy on the indications for hospitalization in IBD. We aimed to evaluate the impact of biologic therapy on the indications and rate of hospitalization in pediatric IBD.This retrospective cohort study included all children (< 18 years of age) with IBD who were hospitalized in our medical center from January 2004 to December 2019. Data on demographics, disease characteristics and course, and therapy were collected, as were the indications for and course of hospitalizations. We evaluated the relationship between therapy with biologic agents, indications and rates of hospitalization.p = 0.829). Among children under biologic therapy, a decrease in the rate of hospitalizations from 1.09 (0.11–3.33) to 0.27 (0–0.47) per year was observed for patients that were hospitalized during 2016–2019 (p = 0.043).Included were 218 hospitalizations of 100 children, of whom 65 (65%) had Crohn’s disease and 35 (35%) had ulcerative colitis. The indications for hospitalization were IBD exacerbations or complications in 194 (89%) and therapy-related adverse events in 24 (11%). The patients of 56 (25.7%) hospitalizations were receiving biologic therapy. In a multivariate analysis, no correlation between therapy and indication for hospitalization was found (Biologic therapy did not influence the indication for hospitalization, but were associated with a decrease in the rate of hospitalization during 2016–2019 in pediatric IBD. Inflammatory bowel disease (IBD) comprises of Crohn’s disease (CD) and ulcerative colitis (UC), which are chronic immune-mediated disorders. IBD is characterized by periods of remissions and exacerbations that often require in-hospital treatment. Several studies have shown a trend of increased IBD-related hospitalizations in both the pediatric and adult IBD populations –3. VesteBiologic therapy in general and anti-tumor necrosis alpha (TNF-α) agents specifically are an effective therapy for IBD in adults and children –14. The Although the incidence of IBD-related hospitalizations has been investigated in depth, data on the effect of biologic therapy on the indications for hospitalizations in IBD are scarce. A focus paper by the epidemiology committee of the European Crohn’s and Colitis Organization identified the obstacles of evaluating this effect, including the difficulty to distinguish between disease-related hospitalizations from those provoked by the adverse events of drug therapy . The incAll children (< 18 years of age) with the diagnosis of IBD who were hospitalized in our medical center from January 2004 to December 2019 were included in this study. The Pediatric Gastroenterology Unit at Dana-Dwek Children’s Hospital in the Tel Aviv Sourasky Medical Center is a tertiary referral center for pediatric patients with IBD. The diagnosis of IBD was made according to the European Society for Pediatric Gastroenterology Hepatology and Nutrition Porto criteria and the revised Porto criteria for the diagnosis of IBD in children and adolescents , 26. We We retrospectively reviewed the medical records and retrieved the study participants’ demographic data as well as disease characteristics, including IBD location, behavior, and extent according to the PARIS classification , IBD coup > 0.1 was taken as the threshold for removal). Wilcoxon signed rank test was employed to compare the number of hospitalizations per year before and after treatment with biologic agents. All of the statistical tests were 2-tailed. A p value of < 0.05 was considered significant. SPSS was used for all statistical analyses Continuous variables were evaluated for normal distribution by applying histograms and Q-Q plots. Normally distributed continuous variables were expressed as mean and standard deviation (SD). Non-normally distributed continuous variables were expressed as median and interquartile range (IQR). Categorical variables were presented as frequency and percentage. The categorical variables were compared between indication for hospitalization by means of the chi-square test or Fisher-exact test, and continuous variables were compared with the independent samples t-test or Mann-Whitney test logistic regression was applied for the multivariate analysis with the backward stepwise method .Overall, 517 hospitalizations were recognized. Of them, 299 were excluded: 40 hospitalizations were due to the first presentation of IBD, 97 were elective admissions and 162 hospitalizations that were unrelated to IBD  IBD exacerbations or complications and 24 (11%) therapy-related adverse events. The therapy-related complications included 10 (41.7%) infectious conditions , 8 cases of pancreatitis (33.3%), and one case each of drug-induced hepatitis, drug reaction with eosinophilia and systemic symptoms, acute tubular necrosis, vomiting, fever of unknown origin, and Hodgkin lymphoma.The characteristics of hospitalizations due to disease exacerbations and therapy-related adverse events are described in Table The patients in 162 (74.3%) hospitalizations were naïve to biologic therapy. The 21 patients in 56 (25.7%) hospitalizations were receiving biologic therapy: 40 (71.4%) infliximab, 10 (17.9%) adalimumab, 5 (8.9%) vedolizumab, and 1 (1.8%) golimumab. The hospitalizations of patients under biologic therapy included 16 (28.6%) who were treated with combination therapy (14 azathioprine and 2 methotrexate). In addition to biologic agents, in 24 hospitalizations (42.9%) the patients were treated with 5-ASA compounds.n = 144, 88.9%) were due to IBD exacerbation and 18 (11.1%) were due to therapy-related adverse events. Fifty (89.3%) hospitalizations of patients undergoing biologic therapy were due to IBD exacerbation and 6 (10.7%) were due to therapy-related adverse events (p = 0.945). The characteristics of hospitalizations in patients under biologic therapy compared to biologic-naïve patients are presented in Table Most of the hospitalizations of the biologic naïve patients (Fifty 89.% hospitap = 0.829). In addition, no correlation between therapy and indication for hospitalization was found in a sub-analysis of CD and UC separately.A multivariate analysis adjusted for age, gender, and disease type failed to show any correlation between therapy and indication for hospitalization  were due to IBD exacerbation while 10 hospitalizations of patients undergoing biologic therapy  were due to IBD exacerbation (p = 0.656). In the latter period, 94 of the biologic naïve patients  were due to IBD exacerbation while 39 hospitalizations of patients undergoing biologic therapy  were due to IBD exacerbation (p = 0.951).Of the cohort, 65 (29.8%) hospitalizations were during 2004–2011 and 153 (70.2%) hospitalizations were during 2012–2019. In the former period, 51 of the biologic naïve patients (p = 0.086). The rate of hospitalizations in patients under biologic therapy was not affected by disease behavior (p = 0.968 for inflammatory phenotype and p = 0.568 for penetrating or stricturing CD).Overall, 34 children (34%) were treated with biologic agents before or after hospitalization and had a median follow-up of 5.35 (2.93–7.63) years. Sixteen children (47.1%) received infliximab, 8 (23.5%) infliximab and adalimumab, 5 (14.7%) adalimumab, 2 (5.9%) infliximab and vedolizumab, 2 (5.9%) vedolizumab, and 1 (2.9%) infliximab and golimumab. The median number of hospitalizations per year in these children was 0.47 (0–2.13) before biologic therapy compared to 0.33 (0–0.85) after biologic therapy, representing a decrease of 0.24 [(− 0.37)-(+ 2.08)] hospitalization per year (p = 0.271). In the latter period, the median number of hospitalizations per year was 0.72 (0.14–3.12) before biologic therapy compared to 0.33 (0–0.92) after biologic therapy (p = 0.081). Of 16 patients that were hospitalized during 2016–2019, the median number of hospitalizations per year was 1.09 (0.11–3.33) before biologic therapy compared to 0.27 (0–0.47) after biologic therapy (p = 0.043).Of these 34 children, 8 had a first hospitalization during 2004–2011 and 26 were first hospitalized during 2012–2019. In the former period, the median number of hospitalizations per year was 0.19 (0–0.61) before biologic therapy compared to 0.33 (0.28–0.63) after biologic therapy (The effects of biologic therapy on the incidence of IBD-related hospitalizations are controversial, and currently available data on those effects in pediatric IBD are scarce. This study included 218 hospitalizations of 100 pediatric IBD patients, and the results showed that 89% of the hospitalizations were due to IBD exacerbations or complications, while 11% were due to therapy-related adverse events. The use of biologic agents did not change the indication for hospitalization. Moreover, there was no change in the rate of hospitalization before and after treatment among the children receiving biologic therapy, except for patients that were treated during 2016–2019. In concurrence with the reported increase in the incidence of pediatric IBD , the ratSince biologic therapy was claimed to achieve better disease control compared to traditional IBD therapies along with some potential serious adverse events, it is noteworthy that most of IBD-related hospitalizations in our study were due to IBD exacerbations or complications while the minority were due to therapy-related adverse events. Importantly, we did not observe any relation between therapy with biologics and indication for hospitalization. The lack of a shift toward more hospitalizations resulting from adverse events of biologic agents could be explained by a lower rate of adverse events in real-life compared to the number of adverse events recorded during clinical trials, or, alternatively, frequent but mild adverse events that do not require hospitalization. Moreover, the pediatric population with fewer comorbidities may be at lower risk of therapy-related adverse events compared to the adult population. Furthermore, while a difference between characteristics of hospitalizations due to IBD exacerbation and those due to therapy-related complications could be anticipated, all hospitalizations in our study were similar in terms of patient age, gender, disease type, length of hospitalization, and work-up evaluation.The impact of the introduction of biologic therapy on disease-related hospitalizations has been investigated in previous studies with inconsistent results. Comparable to the current study that showed a similar hospitalization rate before and after biologic therapy, several studies, mainly in the adult population, reported no change in the rates of IBD-related hospitalizations , 38. OthThe effect of biologic agents on the rate of IBD-related surgery is also a controversial matter. Several studies reported reductions in surgery rates among IBD patients treated by biologic agents –44, whilIn parallel with a reduced risk of developing IBD complications under biologic therapy , adverseTo the best of our knowledge, this is the first study to describe indications of hospitalization in pediatric IBD in the era of biologic therapy. The major strength of our study lies in the data having been based on a large demographic and clinical database of children with IBD , that enIn conclusion, IBD exacerbations continue to be the major indications for hospitalizations of pediatric IBD patients. Our current findings suggest that biologic therapy did not influence either the indication or the rate of hospitalizations, except a small group of patients that were treated during 2016–2019. A better optimization of the use of biologic agents may have the potential to improve health outcome, including the hospitalization rate and the course of disease. Future controlled prospective studies are needed to confirm these conclusions. New therapeutic options for improving disease control may also reduce the risk of hospitalization in pediatric IBD patients.


Carbapenem-resistant enterobacteriaceae (CRE) bloodstream infections have been rapidly spreading worldwide with a high mortality and pose a challenge to therapeutic decision-making, especially in premature neonates because insufficient empirical antimicrobial therapy is independently associated with high mortality. This case reported that a premature infant with CRE bloodstream infection was treated successfully with high-dose meropenem treatment with model-based therapeutic drug monitoring (TDM). In clinical settings, treatment target attainment of meropenem can be improved by increasing the frequency of administration, prolonging the infusion time, and using a high dose. This case report shows a successful regimen for CRE infection in a premature neonate and emphasizes the utility of model-based TDM of high-dose meropenem treatment. The adequate antimicrobial benefit provided by innovative techniques could ensure the efficacy and safety of high-dose meropenem therapy for CRE infection. K. pneumoniae. Carbapenems have been used successfully for the treatment of severe infections with sensitive Gram-negative bacteria (Carbapenem-resistant enterobacteriaceae (CRE) bloodstream infections have been rapidly spreading worldwide with a high mortality rate of about 30–70% . One of bacteria . Howeverbacteria . Severalbacteria  along wibacteria . HoweverA neonate born prematurely at 27 weeks’ gestation with a birth weight of 970 g was admitted to the neonatal intensive care unit. Apgar scores were 5, 7, and 7 at 1, 5, and 10 min. On arrival, clinical examination did not show any abnormal findings, and the neonate had an unremarkable clinical course during the first 2 weeks of life with normal repeated clinical and laboratory evaluations.th day of life the neonate developed signs of neonatal sepsis based on clinical signs including oxygen fluctuations and abdominal distension and a clearly abnormal laboratory work-up that showed metabolic acidosis (blood pH 7.15)  and several abnormal inflammatory indices such as elevated procalcitonin (PCT) concentration (12.6 ng/ml) , C-reactive protein (CRP) (14.8 mg/l) , white blood cell count (WBC) (2.19 × 109/L) , and platelets (PLT) (51 × 109/L) . Antibacterial treatment was started immediately and consisted of meropenem  and vancomycin . On the same day neonatal sepsis with Gram-negative bacteria was confirmed by blood culture using BacT/Alert 3D Blood Culture Systems, and also a rapid increase in levels of PCT (116.1 ng/ml) and CRP (54 mg/l) was seen. Cerebrospinal fluid could not be obtained due to the neonate’s poor clinical condition and intolerance to the attempted lumbar puncture. Nevertheless, neonatal meningitis was suspected and the meropenem dose was increased from 20 to 40 mg/kg; meanwhile, vancomycin was discontinued. A high-dose meropenem regimen  was given off-label by intravenous infusion over 30 min for a week (days 15 to 21). In order to monitor the effectiveness of treatment and avoid occurrence of adverse reactions, model-based therapeutic drug monitoring (TDM) was performed. The covariate values of albumin and serum creatinine were 33.8 g/L and 80 μmol/L, respectively. The sample for TDM was obtained using an opportunistic sampling approach before and during the high-dose meropenem treatment. The concentration of meropenem was measured by high performance liquid chromatography , indicating CRE infection. The isolate was also resistant to other antibiotics, such as imipenem, piperacillin/tazobactam, cefoperazone/sulbactam, cefotaxime, ceftazidime, aztreonam, ertapenem, and cefuroxime. The isolate was sensitive to levofloxacin and amikacin, but the use of fluoroquinolones and aminoglycosides is not allowed for use in neonates in China. The meropenem concentrations of samples obtained 0.4 h (day 15) and 0.9 h (day 19) post dose were 37.9 and 26.6 ug/ml, respectively. The model-based pharmacokinetic–pharmacodynamic analysis by NONMEM software according to the population pharmacokinetic model of meropenem in premature and term infants reported by P. Brian et al. , protein: 1.56 g/L , glucose: 2.35 mmol/L ]. Adverse effects possibly due to meropenem were not observed during the treatment. Written informed consent was obtained from the minor’s legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.On day 18, an antimicrobial susceptibility test (AST) was conducted using VITEKn et al.  showed tn et al. Figure 2This case reported that a premature infant with CRE bloodstream infection was treated successfully by high-dose meropenem treatment with model-based TDM. Insufficient empirical antimicrobial therapy is independently associated with high mortality . In clinThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The studies involving human participants were reviewed and approved by the Medical ethics committee of The First Affiliated Hospital of Shandong First Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the minor's legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.WZ and X-YC coordinated and supervised data collection and critically reviewed and revised the manuscript. Y-EW performed TDM and data analysis and drafted the initial manuscript. H-YX and H-YS managed the patient, collected the clinical data, and reviewed the manuscript. JA provided advice, critically reviewed and revised the manuscript. All authors contributed to the article and approved the submitted version.This work was supported by the Young Research Programme of the Health and Family Planning Commission of Hebei Province [grant number 20150275] and course development grants  from Shandong University and Shandong Province.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Systematic retroperitoneal lymphadenectomy has been widely used in the surgical treatment of advanced ovarian cancer patients. Nevertheless, the corresponding therapeutic may not provide a survival benefit. The aim of this study was to assess the effect of systematic retroperitoneal lymphadenectomy in such patients.n = 170): patients did not undergo lymph node resection; lymph nodes resection or biopsy were selective. Group B (n = 240): patients underwent systematic retroperitoneal lymphadenectomy.Patients with advanced ovarian cancer  who were admitted and treated in Zhejiang Cancer Hospital from January 2004 to December 2013 were enrolled and reviewed retrospectively. All patients were optimally or suboptimally debulked  and divided into two groups. Group A . Subsequently, there was no significant difference in 5-year OS and 2-year PFS between the two groups stratified to histological types (serous type or non-serous type), the clinical evaluation of negative lymph nodes or with macroscopic peritoneal metastasis beyond pelvic (IIIB-IV). Multivariate Cox regression analysis indicated that systematic retroperitoneal lymphadenectomy was not a significant factor influencing the patients’ survival. Patients in the lymphadenectomy group had a higher incidence of postoperative complications .A total of 410 eligible patients were enrolled in the study. The patients’ median age was 51 years old . The 5-year overall survival (OS) and 2-year progression-free survival (PFS) rates were 78 and 24% in the no-lymphadenectomy group and 76 and 26% in the lymphadenectomy group (Our study showed that systematic retroperitoneal lymphadenectomy did not significantly improve survival of advanced ovarian cancer patients with residual tumor < 1 cm or absent after cytoreductive surgery, and were associated with a higher incidence of postoperative complications. Ovarian cancer is the second most common cancer in females worldwide, with about 225,500 new cases occurred globally every year, and its mortality rate is as high as 47%, which is higher than that of any other gynecological malignancies . OvarianIn addition, retroperitoneal lymphadenectomy may increase intraoperative and postoperative complications, such as bleeding, vascular injury, lymphocysts, infection, intestinal fistula, chylous fistula, lower limb edema, pulmonary embolism, repeat laparotomy and post-operative mortality. Hence, the role of retroperitoneal lymphadenectomy in advanced ovarian cancer surgery deserves our attention.In view of the results above, we performed a retrospective analysis of this issue again.All primary ovarian cancer patients treated in Zhejiang Cancer Hospital from January 2004 to December 2013 were retrospectively reviewed and a total of 410 patients with International Federation of Gynecology and Obstetrics  stages III and IV were enrolled in this study. All of them underwent complete surgical staging including total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy, additionally, to achieve optimal debulking, surgical procedures like retroperitoneal lymph node resection , resection of other organs  were performed. Furthermore, to eliminate the effect of large-volume residual disease on patients’ survival, all patients included in this analysis were optimally debulked  or sub optimally debulked . Patients who underwent initial surgical exploration elsewhere or received neoadjuvant chemotherapy before surgery were excluded.n = 170) (no-lymphadenectomy group): patients did not undergo lymph node resection; or lymph nodes resection or biopsy were selective. Group B (n = 240): patients underwent systematic retroperitoneal lymphadenectomy. And patients were divided into two histological types, serous and non-serous. Lymph nodes were diagnosed by intraoperative palpation and preoperative imaging .Patients in our analysis were divided into two groups. Group A , FIGO stage, surgical information , histological subtype, intraoperative and postoperative complications, primary systemic therapy, and follow-up information.Progression-free survival  and overall survival  were used to assess the patients’ survival.P < 0.05 was considered statistically significant.In the present study, OS, PFS, and the incidence of intraoperative and postoperative complications were selected as primary outcomes. All statistical analyses were carried out using the Statistical Package for Social Sciences (SPSS) statistical software (version 17.0). Categorical data were assessed using chi-square test or Fisher’s exact test. Multivariate Cox regression model were used to evaluate the influences of different covariates on OS and PFS, and were expressed as hazard ratio (HR). Meanwhile, survival curves were assessed using the Kaplan-Meier method, and the difference in survival was evaluated using the log-rank test. A two-sided A total of 410 advanced ovarian tumor patients were analyzed in this study, 170 cases in Group A and 240 in Group B, and the characteristics of the two groups are listed in Table n = 320; 78%), followed by endometrioid , mucinous , clear cell  and 14 patients (3.4%) had others histological types. In addition, the mean intraoperative blood loss in Group B was slightly higher than that in Group A (542.5 ± 352.4 vs 537.7 ± 335.3 ml). There was no significant difference in the patients’ clinical characteristics between the two groups, including the age (P = 0.257), median serum CA-125 level (P = 0.532), intraoperative blood loss (P = 0.889), FIGO stage (P = 0.686), or pathological type (P = 0.475).The median age of patients in Groups A and B was 54 (29–72) and 51 (28–71) years old, respectively. The median serum CA-125 level was 606.8 U/mL (13–6743 U/ mL) in Group A and 455.1 U/mL  in Group B. The majority of patients in Groups A and B were at FIGO stage III (82.4% of Group A and 84.2% of Group B), and a few cases were at stage IV (17.6% of Group A and 15.8% of Group B). Out of 410 total patients, serous tumors were the most common pathological subtype (The postoperative complications and primary systemic treatment in Groups A and B are summarized in Table P = 0.027) and the incidence of lymph cysts . In addition, the main reason for repeat laparotomy of complications in Group B (2.5% [6 of 240 patients]) was postoperative bleeding, intestinal fistula or lymph cysts, and the main reason in Group A (1.2% [2 of 170 patients]) was fistula.It was found that the patients in lymphadenectomy group had a higher incidence of postoperative complications than those in no-lymphadenectomy group. Especially for the incidence of infection treated with antibiotics  as well.With respect to primary systemic treatment after cytoreductive surgery, the majority of patients received adjuvant chemotherapy, 98.4% of the patients in Group B and 97.6% of those in Group A were treated with paclitaxel or docetaxel and platinum. No significant difference was found between the two groups . The survival curves of these two groups were examined by Kaplan–Meier analysis, as shown in Fig. The 5-year OS and 2-year PFS rates were 78 and 24% in no-lymphadenectomy group and 76 and 26% in lymphadenectomy group . The survival curves are displayed in Fig. When patients without residual tumor were analyzed, the 5-year OS and 2-year PFS rates were 73 and 31% in no-lymphadenectomy group and 69 and 26% in lymphadenectomy group, the difference was not statistically significant . The survival curves are illustrated in Fig. Similarly, when confining analysis to patients with serous type or non-serous type, the difference in 5-year OS and 2-year PFS between the two groups was no significant . The survival curves are shown in Fig. In subgroup analysis of patients with negative lymph nodes , the difference in the 5-year OS and 2-year PFS was also not statistically significant . The survival curves are presented in Fig. In the separate analysis of patients with macroscopic peritoneal metastasis beyond pelvic (FIGO stage IIIB-IV), there was no significant difference in 5-year OS and 2-year PFS between the two groups , histological types (serous/non-serous), and lymphadenectomy (no/yes) were imported into this model. The results showed that, systematic retroperitoneal lymphadenectomy was not a significant factor influencing the patients’ survival.Lymph node metastasis is one of the main metastatic pathways of ovarian cancer, with a total probability of 20 to 41%, while retroperitoneal lymph node metastasis rate of advanced ovarian cancer is as high as 50 to 75% , 13. TheSome studies indicated survival benefit of lymphadenectomy in patients with early-stage ovarian cancer. Chan JK et al.  conducteP = 0 .0166); besides, lymphadenectomy showed a significant survival influence on those patients without clinically suspected nodes ; meanwhile, patients with small residual tumor also showed a positive effect on lymphadenectomy regardless of clinical lymph node status. A retrospective study consisting of 488 patients with untreated advanced ovarian cancer also revealed that among patients with optimal or suboptimal cytoreduction, 5-year survival in patients who underwent lymphadenectomy was higher than the patients who did not  [P = 0.01). Chan JK et al. [P = 0.02) [However, results of studies on whether systemic retroperitoneal lymphadenectomy can improve the prognosis of advanced ovarian cancer patients were different. The majority of early retrospective studies have suggested a favorable prognosis of systematic retroperitoneal lymphadenectomy in patients with macroscopically completely resected advanced ovarian cancer. du Bois A et al.  reviewed< 0.005) . Aletti K et al.  reported = 0.02)  indicateHowever, a number of studies have reported that systematic pelvic and para-aortic lymphadenectomy has no benefit to patients’ prognosis.P = 0.853) or PFS  between patients who underwent systematic retroperitoneal lymphadenectomy and others. In addition, there was no therapeutic benefit for advanced ovarian cancer patients who underwent systematic retroperitoneal lymphadenectomy during interval debulking surgery after neoadjuvant chemotherapy [Spirtos NM et al.  reviewedotherapy .Based on the results achieved in our study, no remarkable improvement was noted in survival of advanced ovarian cancer patients with optimal or suboptimal cytoreduction who underwent systematic retroperitoneal lymphadenectomy (either 2-year PFS or 5-year OS).n = 216) and resection of bulky nodes only group (n = 211). After a median follow-up of 68.4 months, the risk of recurrence was significantly lower in the systematic lymphadenectomy group  than in the no-lymphadenectomy group, while the risk of death was similar in both groups . The majority of ovarian cancer patients treated in our hospitals had macroscopic peritoneal metastasis beyond pelvic. Thus, in the current research, we also performed a subgroup analysis of stage IIIB-IV ovarian cancer patients. Our findings indicated that lymphadenectomy had no significant effect on patients’ survival, 5-year OS rate was 77 and 78% in the lymphadenectomy group and no-lymphadenectomy group, P = 0.440; 2-year PFS was 26 and 24% in the two groups, P = 0.331.Panici PB et al.  conductePatients with serous ovarian cancer has a higher rate of lymph node metastasis than other types of epithelial ovarian tumors . TakeshiLymphadenectomy in patients without clinically suspect lymph nodes and small residual disease intraperitoneally might not change the residual disease status but may reduce tumor burden that is possibly resistant to chemotherapy. In the Lymphadenectomy in Ovarian Neoplasms (LION) trial, 647 patients with newly diagnosed advanced ovarian cancer (FIGO stage IIB-IV) who had undergone macroscopically complete resection and had normal lymph nodes both before and during surgery were intraoperatively randomly assigned to lymphadenectomy and no lymphadenectomy groups. It was revealed that systematic pelvic and paraaortic lymphadenectomy in these patients was not associated with longer survival than no lymphadenectomy and was associated with a higher incidence of postoperative complications, such as incidence of lymph cysts, infection treated with antibiotics, repeat laparotomy and mortality within 60 days after surgery . SimilarRoutine systematic pelvic and paraaortic lymphadenectomy does not confer any survival benefit in advanced ovarian cancer patients who have no gross residual disease or residual disease < 1 cm at the end of resection, while unnecessary surgical procedure increases the risk of postoperative complications . This was a retrospective study conducted at a single institution; thus, the limitation of data collection was tangible.


The use of recombinant human follicle-stimulating hormone (r-hFSH) in ovarian stimulation protocols for infertility treatment in assisted reproductive technology (ART) clinical practice is well established. More recent advancements include the availability of biosimilar r-hFSH products, which expand the choices available to healthcare practitioners and patients. Better understanding of how such a product contributes to routine clinical practice is valuable to help prescribers make informed treatment choices. The objective of this study was to examine the effectiveness and safety of ovarian stimulation (OS) with follitropin alfa  for routine IVF or intracytoplasmic sperm injection treatment in gonadotropin-releasing hormone (GnRH) antagonist cycles in real-world ART clinical practice.2, menstrual cycle 24–35 days and anti-Müllerian hormone ≥1 ng/mL, who were undergoing a first OS cycle exclusively with Ovaleap® during routine ART using a GnRH antagonist protocol. Primary effectiveness outcomes were number of retrieved oocytes after OS and clinical pregnancy rate (CPR). Secondary outcomes included fertilization rate, number of transferred embryos, live birth delivery rate, safety, and user satisfaction with the Ovaleap® pen.This non-interventional, multicenter, prospective study was initiated in 34 specialized reproductive medicine centers in Germany. Eligible women were 18–40 years old with a body mass index < 30 kg/mOf 507 women screened, 463 received at least 1 dose of Ovaleap® and 439 had Visit 2 data . The mean(±SD) number of retrieved oocytes was 11.8 ± 7.2 (PPP). The CPR among women with documented embryo transfer was 41.3% (158/383), resulting in a live birth delivery rate of 31.6% (138/437) among PPP patients with available follow-up information. Overall, 8.6% (40/463) of women reported ≥1 adverse drug reaction. Ovarian hyperstimulation syndrome occurred in 23 (5.0%) patients, rated mild in 14 (3.0%), moderate in 8 (1.7%), and severe in 1 (0.2%). Patients reported high user satisfaction and high convenience with use of the Ovaleap® pen.The effectiveness and safety of OS with Ovaleap® in a GnRH antagonist protocol were extended to real-world ART clinical practice for the first time.NCT02809989).Registered on 22 June 2016 (retrospectively registered) at ClinicalTrials.gov ( Infertility treatment with assisted reproductive technology (ART) often includes ovarian stimulation (OS) with exogenous gonadotropins. Recombinant human follicle-stimulating hormone (r-hFSH) was developed as an alternative to urinary-derived FSH, allowing for greater availability, decreased variability, and possibly reduced risk of immunological reactions during infertility treatment –3. CompaOvaleap®  is an r-hFSH developed as a biosimilar to Gonal-f®, administered subcutaneously by the use of a multidose, reusable, semi-automated pen injector and approved by the European Medicines Agency (EMA) in 2013 . OvaleapReports from clinicians within an IVF-Worldwide web-based survey indicated that while 67.3% reported awareness of biosimilar r-hFSH products, only 25.6% had experience with biosimilar products and 92% indicated they would like more information on these products . One cliThe objective of this current multicenter, prospective, non-interventional study was to examine effectiveness of OS with Ovaleap® for routine in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) in real-world ART clinical practice using a GnRH antagonist protocol. The primary endpoints examined were number of retrieved oocytes and clinical pregnancy rate (CPR). Safety and user satisfaction with the Ovaleap® reusable semi-automated pen were also evaluated.http://www.vfa.de/de/forschung/nisdb/]). It was reviewed by the appropriate ethics committees. Patients provided written informed consent prior to study participation and enrollment began March 2016 and ended May 2017.The study was a multicenter, prospective, open, non-interventional study that initially included 34 specialized reproductive medicine centers in Germany; the final number included in the present analysis was 33, due to one center not being able to participate. The study was conducted in accordance with Section 4  and Section 67 (paragraph 6) of the German Medicines Act (“Arzneimittelgesetz” – AMG) . The proTo determine the number of patients to enroll, a sample size calculation was carried out based upon the estimated pregnancy rate from national data. It could be estimated that a study size of 400 women would be sufficient. This was carried out using PASS 11 software.Study visits included information at screening and assessment at baseline (Visit 1), final maturation trigger, oocyte retrieval and embryo transfer (Visit 2), and the clinical pregnancy examination (Visit 3). Visit 2 involved multiple components, and patients who completed Visit 2 may not necessarily have had an embryo transfer. The observation period lasted approximately 6 to 8 weeks from the start of stimulation therapy. Patients with a sonographically verified intrauterine pregnancy  were followed up until the end of the pregnancy or delivery of the baby/babies.2, menstrual cycle duration 24 to 35 days, and anti-Müllerian hormone (AMH) ≥1 ng/mL (assessed within the previous 12 months), who were undergoing a first stimulation cycle for ART. Women with PCOS, endometriosis (American Fertility Society grades 3 and 4), uterine myoma , or hydrosalpinx were excluded. Also excluded were women receiving combined application of IVF and ICSI or OS for fertility preservation.Patients eligible for inclusion were women undergoing IVF or ICSI following OS with Ovaleap® during routine ART and using a GnRH antagonist protocol. Duration of treatment was for one stimulation cycle. Inclusion criteria included patients age 18 to 40 years old, with body mass index (BMI) < 30 kg/mThe decision to treat a patient with Ovaleap® was made separately from the decision to include the patient in the study. As a first step and prior to patient assessment, the participating physicians were free to choose the stimulation drug and the protocol according to their experiences and preferences. If a physician chose to treat her/his patient with Ovaleap® in an antagonist protocol she/he then screened the patient and checked for inclusion/exclusion criteria as a second step. If the patient fulfilled the criteria and was willing to participate, she was finally eligible to be included in the study. FSH treatment, administered subcutaneously daily, typically began on the second or third day of the menstrual cycle, with the duration and dosage at the discretion of the physician. Dosage was adjusted according to ovarian response and continued until sufficient development of follicles . Suppression of an endogenous LH surge was achieved by a GnRH antagonist. Type of GnRH antagonist and type of oocyte maturation trigger were at the discretion of the treating physician. For final oocyte maturation and timing of oocyte retrieval, a single dose of recombinant human chorionic gonadotropin (r-hCG), urinary hCG was administered, or alternatively a GnRH agonist.The primary effectiveness endpoints included number of oocytes retrieved and CPR. Secondary effectiveness endpoints included total dose and administration duration of r-hFSH, serum estradiol level at the time of last examination prior to oocyte maturation trigger, endometrial thickness at the time of last sonography prior to trigger, drugs used for final oocyte maturation and timing oocyte retrieval, number of metaphase-II (MII) oocytes, percentage fertilization rate after IVF or ICSI, day of ovum pick-up (OPU), number of transferred embryos, and live birth delivery rate.Safety and tolerability were examined by frequency and intensity  of adverse drug reactions (ADRs), defined as adverse events with an at least suspected relationship with Ovaleap®, including non-serious and serious ADRs. Frequency and intensity of OHSS were assessed at the discretion of the reporting physician.Patient-reported outcomes for satisfaction with the Ovaleap® reusable semi-automated pen were evaluated with a previously described 7-question questionnaire , 18 afteThe total treated population (TTP) included all patients who received at least 1 administration of Ovaleap®. The per protocol population (PPP) included all patients who received at least 1 administration of Ovaleap®, completed through to embryo transfer day  and adhered to all study documentation criteria. Patients in whom all fertilized or unfertilized oocytes were frozen after OPU were not evaluated further. The planned analyses assessed outcomes using descriptive statistics . A multivariate general linear model (GLM) analysis was performed to examine the effect of age (< 35 vs ≥35 years old), AMH level (≤2.5 ng/mL vs > 2.5 ng/mL), FSH total stimulation dose (≤1500 IU vs > 1500 IU), and FSH treatment duration (≤9 days vs > 9 days) on number of retrieved oocytes in PPP patients. The safety analysis included TTP patients. SAS version 9.4 was used for all statistical analyses.Of the 507 women who were screened for enrollment in the study, 463 received at least 1 dose of FSH (TTP group) and 439 had Visit 2 data (PPP group)   in PPP patients.Mean numbers of retrieved oocytes were 11.8 in PPP patients, 12.1 in the subset of women undergoing ICSI, and 11.5 in the subset of women receiving IVF  and 36.0% (158/439) in the TTP and PPP groups, respectively; CPR per embryo transfer was 41.4% (165/399) and 41.3% (158/383) in women with embryo transfer in the TTP and PPP groups, respectively Table .n = 437); thus, the live birth delivery rate was 31.6% (138/437) among patients with available follow-up information.The mean number of MII oocytes was 9.2 , moderate , or severe . No cases of life-threatening OHSS were reported. The majority of patients , experiencing OHSS had AMH levels > 3.5 ng/mL.Patients reported high levels of both user satisfaction and convenience with the Ovaleap® pen (full data not shown). In the PPP, 97.4% of patients reported they were sure or very sure about adjusting the daily dose of the drug, and 96.9% were sure or very sure that they had injected the correct dose. Instructional text was rated as easy or very easy to understand by 96.0% of women. Being satisfied or very satisfied with the Ovaleap® pen was reported by 99.8% of women, and the Ovaleap® pen was reported as convenient or very convenient to use by 99.0% of women.This prospective, multicenter, non-interventional study extends the knowledge of the effectiveness of Ovaleap®, to a broader population of women, undergoing routine IVF/ICSI treatment, with a GnRH antagonist protocol. In the 2017 German IVF-Registry (DIR) annual report, 64.2% of patients received GnRH antagonist therapy, compared to 18.5% who received long GnRH agonist treatment overall . CompareThe patient population studied here, based on mean age, is representative of the 30–34 year age range reported in 2018 DIR annual report, the most recent comprehensive analysis of trends in German IVF practice. This age range accounts for 30% of all oocyte retrievals done in Germany . AmongstAdditionally, in this non-interventional study of GnRH antagonist treatment, the primary endpoints of number of oocytes retrieved and CPR compared favorably with previous studies using a GnRH agonist protocol and in women of < 35 years old . Other sThe primary endpoints in the current study are also comparable to previous randomized comparative r-hFSH studies examining follitropin alfa  –29, follComparison of the current non-interventional study’s number of retrieved oocytes  and CPRs among patients with embryo transfer (41.3%) with those of an observational, non-interventional study evaluating dosing regimens of follitropin alfa  in routine clinical practice demonstrated similar number of oocytes retrieved (11.4 ± 6.7) and CPRs (39.5%) . AltogetNumber of retrieved oocytes is a valuable primary endpoint as it has been associated with live birth rate , 35 and In view of the estimated global need for ART (≥1500 cycles/million population per year) , there iLimitations of the current study are those associated with observational, non-interventional studies, including lack of randomization or controlled comparison, possible selection bias in the treated patients, and dependence on accurate reporting from the treating physicians. Strengths of the current study include the large patient sample, inclusion of a broader population of infertile women who may be more representative of the general population seeking ART treatment compared with the highly selected participants in randomized controlled trials, and greater representation of routine clinical practice in which treatment decisions are at the discretion of the treating physician. This approach has been advocated in order to provide clinical insights on newly introduced stimulation agents . AltogetEffectiveness, safety, and high user satisfaction with controlled OS with the Ovaleap® pen were extended to real-world ART clinical practice, including IVF and ICSI treatment, using a GnRH antagonist protocol. The real-world outcomes of this multicenter, prospective, open-label, non-interventional study are consistent with those previously reported in randomized controlled clinical trials.Additional file 1. Patient satisfaction questionnaire.Additional file 2. Patient disposition.