Assisted reproduction faces a significant obstacle in the form of poor ovarian response (POR) to controlled ovarian stimulation. To address this challenge, mesenchymal stem cell therapy has been proposed as a potential treatment for female infertility and/or restoration of ovarian function in POR women. Our previous research has demonstrated that menstrual blood-derived-mesenchymal stromal cells (MenSCs) injected into the ovaries of women with POR can increase pregnancy rates. The objective of this study was to examine whether MenSC therapy could enhance ovarian reserve parameters and pregnancy outcomes in a larger population of individuals with POR.This study consisted of 180 infertile individuals with POR who declined oocyte donation. Participants were divided into two groups: those who received bilateral MenSCs intraovarian injection and those who received no intervention. Our primary aim was to compare the rates of spontaneous pregnancy between the two groups, followed by an investigation of any alterations in the ovarian reserve parameters, such as serum FSH, AMH, and AFC levels, as well as the ICSI/IVF outcomes, in both groups of participants.P < 0.005) and an improvement in anti-Müllerian hormone (AMH) levels (P = 0.0007) and antral follicle count (AFC) (P < 0.001), whereas the control group demonstrated a considerable decline in these parameters (Both P < 0.001). The MenSC therapy led to a greater number of mature oocytes and embryos among women who underwent ICSI/IVF. Our age subgroup analysis demonstrated a significant difference in the number of spontaneous pregnancies and ICSI/IVF outcomes between the treatment and control groups only among individuals below 40 years of age.The MenSC therapy exhibited a favourable tolerability profile and did not raise any safety concerns. Following the 2-month follow-up period, women who received MenSC treatment demonstrated a significantly higher rate of spontaneous pregnancy (The results of our study indicate that MenSCs treatment may be a viable option for treating women experiencing POR. However, in order to be widely implemented in clinical practice, the clinical effectiveness of MenSCs therapy will need to be established through rigorous prospective randomized clinical trials.Trial registration: ClinicalTrials.gov Identifier: NCT05703308. Registered 01/26/2023, retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT05703308. IRCT, IRCT20180619040147N4. Registered 08/01/2020. Nowadays, more women seek infertility therapy due to economic development's impact on reproductive delays . DespitePOR accounts for 9–24% of controlled cycles of in vitro fertilization (IVF) , which iRecently, with the advent of regenerative medicine, several preclinical studies have been conducted to assess the safety and efficacy of stem cell therapy in treating female reproductive disorders –14. AdulAn essential point is that in patients with diminished ovarian reserve (DOR), the ovary contains residual dormant primordial follicles that theoretically might be activated by stem cell therapy. In fact, Herraiz et al.  reportedIn recent years, one of the favourite sources for researchers to access stem cells has been endometrium. It was discovered in 2004 that the basal layer of the endometrium contains clonogenic stromal cells that proliferate on a regular and dynamic basis. The phenotype, self-renewal capacity, transdifferentiating capacity, and expression pattern of various cell surface antigens of these cells endow them with biological properties comparable to stromal-like MSCs , 31. SinZheng et al., for first time in 2018, speculate that MenSCs could be an effective medical tool for repairing and regenerating reproductive system cells and tissues . MenSCs Based on this evidence, we attempted to assess the safety and efficacy of intraovarian injection of MenSCs for the treatment of infertility in POR patients in previous study . In thisThe present clinical trial was a non-randomized, open-label, parallel-group study conducted between June 21, 2020, and September 22, 2021, at Avicenna Fertility Clinic in Tehran, Iran. The study consisted of 180 women with a history of POR who provided informed consent after receiving a detailed explanation of the procedure from the physicians. The data and safety monitoring board of the Avicenna Research Institute closely monitored and analysed the data during the trial. The study was approved by the Biomedical Research Ethics Committee of the Academic Center for Education, Culture, and Research (ACECR) and recorded in the Iranian Registry of Clinical Trials (IRCT20180619040147N4).n = 180) were allocated to either the MenSCs therapy group (n = 90) or the control group . Patients in the treatment group were monitored for spontaneous pregnancy for 2 months following stem cell transplantation, whereas patients in the control group were followed up 2 months after their last ovarian stimulation for ICSI or IVF. In the cell therapy group, if no pregnancy was reported during the first 2 months after the injection, the patient entered the ICSI/IVF cycle. Ovarian reserve tests were performed on the second or third day of the menstrual period before cell injection and 2 months later. The pregnant participants were closely monitored throughout the conception period, and any information on pregnancy complications and foetal health was meticulously documented.The enrolled patients with POR had a history of at least one standard ICSI cycle with an oocyte number less than four and AMH levels lower than 1.1 ng/ml. Table 2+ or Mg2+. The samples were then transferred immediately to a class B cleanroom for MSC isolation and culture under PICS/GMP and ISO9001 regulations, as described in a previous publication [2 incubator. The medium was changed every 48 h to eliminate non-adherent cells. On day 14, the cells that adhered to the cell culture flask and formed colonies were 80–90% confluent. The cells were separated into several cell culture flasks for propagation and passaged using the animal-origin-free TrypLE express enzyme  to obtain enough MSCs for further use. Confluent cells in passage 2 were isolated and cryopreserved at a density of 1.5 106/1.8 mL cryovials. They were placed in a pre-master cell bank for quarantine. In this step, the cells were assessed for microbiological sterility test (direct inoculation), mycoplasma assay (culture and PCR according to USP Chapter <63> Mycoplasma Assays), endotoxin assay , and immunophenotyping analysis of CD marker expression . The cells were kept in the master and working cell banks once the quality control tests were successful. The cryopreserved vials were thawed 2 weeks before administering the cells. Confirmatory tests were performed by the International Society of Cell Therapy (ISCT), including analyses of cell morphology, cell viability using trypan blue, flow cytometry, MSC multilineage differentiation , and G-banding karyotyping analysis. As soon as the finished product met the acceptable parameters, it was released and sent to the clinic for injection.The group undergoing treatment with MenSCs had their menstrual blood collected using sterile menstrual cups  on the second day of menstruation. An ultrasound  was used to measure the number of antral follicles. Following this, the samples were placed in collection tubes containing Gibco Dulbecco Modified Eagle Medium-F12 (DMEM-F12), 100 g/mL streptomycin, 2.5 mg/mL fungizone, 100 U/mL penicillin, and 0.5 mg/mL EDTA in Good Manufacturing Practices (GMP)-grade phosphate-buffered saline (PBS) without Calication . The sam6 cells/ml, was delivered to the infertility clinic on the day of injection. Under general anaesthesia with midazolam  and fentanyl , 150 μl of the prepared solution were injected intravaginally into each patient's ovary. AMH and FSH levels and AFC were checked before cell transplantation. To reduce discrimination, one doctor injected MenSCs into the ovaries. Patients were checked for spontaneous pregnancy 2 months after the injection. When a pregnancy did not happen spontaneously, ICSI was employed.The final product, with a density of 20 × 10To evaluate the safety and efficacy of MenSCs injections in the enrolled participants, we examined their medical histories, vital signs, blood chemistry, physical examination reports, vaginal sonography, and ovarian function tests at baseline and at 2 months follow-up. At each clinic during pregnancy, pregnancy problems such as miscarriage, ectopic pregnancy, preeclampsia, preterm rupture of membranes, intrauterine foetal mortality, and diabetes were assessed. Throughout pregnancy, patients got the appropriate attention and routine screening testing.Ovarian stimulation of participants was done by the GnRH antagonist protocol. In brief, the contraceptive pill  was administered during the cycle preceding ovarian stimulation. Following the injection of recombinant human FSH  and Human Menopausal Gonadotropin (HMG) , the size of ovarian follicles and their growth rates were evaluated by vaginal ultrasound. GnRH antagonists  were introduced when the primary follicle grew to 14 mm, and their effects were followed by vaginal ultrasound . Every day until at least two follicles were at least 18 mm wide, 0.25 mg was administered subcutaneously. Egg retrieval was performed by vaginal ultrasound 36 h after intramuscular administration of 10,000 IU HCG (Choriomon® (IBSA)). On the third or fifth day following the oocyte retrieval, an embryo transfer (ET) was performed. When an endometrial line wasn't suitable for a patient, embryos were frozen and transplanted during the frozen embryo transfer cycle. Twice daily vaginal administration of Cyclogest 400 mg suppositories  was initiated prior to ET followed by an interval of every 8 h post-embryo transfer for nine weeks.P ≤ 0.05 was considered statistically significant.Analyses were performed by subjects blinded to the study groups. Results are presented as Mean ± Standard Deviation, median, and interquartile range. Qualitative data were expressed as frequencies and percentages. The chi-square test (Fisher's exact test) was used to examine relationships between qualitative variables. Comparisons between groups were made using the Mann–Whitney U test and the Wilcoxon signed-rank test (for nonparametric data). Before and after treatment datasets were evaluated in each group using a paired t test analysis in GraphPad PRISM 6.0. The analysis of one variable at several intervals was performed by a repeated-measures ANOVA test. The Pearson correlation test was used to measure a linear dependence between two variables. N = 90). Two MenSC patients were disqualified because they refused to inject cells after providing a monthly blood sample. Subsequently, over the course of 2 months post-injection, eight patients opted to discontinue the therapy, with four electing to pursue egg donation and the others declining further treatment. Additionally, after the initial 2-month follow-up, nine patients from the control group were also removed from the research. Five patients changed their treatment plans to receive donor eggs. Four other patients entered the IVF cycle at their request before completing the initial 2-month period , CD73 99.2 ± 0.9%), and CD105 (94 ± 2.6%) markers, and negative for the hematopoietic marker CD45 (1.5 ± 1.1%). In addition, a typical karyotype pattern was ascertained, and the absence of microbial growth was observed. The endotoxin samples exhibited no LAL clot formation. Furthermore, DNA amplification analysis on the samples was unconstructive for mycoplasma expression  were reported following IVF/ICSI.P = 0.005).As demonstrated in Fig. P = NS). The remaining pregnancies resulted in timely deliveries. Therefore, 10/18 (55.5%) of spontaneous pregnancies in MenSCs treated resulted in livebirth in comparison to 4/6 (66.6%) in the control group (P = NS).8 of the spontaneously conceived pregnancies were lost as spontaneous miscarriages in the cell-treated group, compared to 2 in the control group (P = 0.03). However, the live birth rate following spontaneous conception between the two groups showed no significant difference  Table . MoreoveP < 0.0001), while the control group exhibited a notable decrease in AMH levels  , while the control group showed declines in the aforementioned measures of 32% (P < 0.0001) .Oocyte retrieval was performed on 52 women in the treated group (83.9% of those stimulated), while 30 women in the control group (40%) were unable to undergo oocyte retrieval due to stimulation failure (P < 0.0001), respectively. In contrast, the control group had 40% fewer oocytes on average after a 2-month follow-up (P < 0.0001).It was noted that the average number of oocytes per retrieval before and after stem cell therapy was 1.5 ± 0.2 and 2.6 ± 0.3 (P = 0.005).Among the women who underwent oocyte retrieval, 51 women in the treated group (98%) and 41 women in the control group (89.1%) achieved at least one mature oocyte (P < 0.0001).In 49 women of the treated group (79% of those stimulated), at least one cleavage-stage embryo was obtained, as compared to 32 women of the control group (42.6% of those stimulated) (P = NS). Six pregnancies in the treated group and two pregnancies in the control group resulted in live births (P = NS). It is worth noting that all born babies were healthy and were followed up for 3 months.Among the cell-treated group, 16.3% (8/49) of those who underwent IVF with embryo transfers (ETs) resulted in clinical pregnancies, compared to 12.5% (4/32) of the control group . However, in the age group above 40 years, although there was a noticeable enhancement in ovarian reserve indicators, no substantial variance in the number of pregnancies resulting from ICSI/IVF or the quantity of live births compared to the control group was found. A comprehensive breakdown of the data is presented in Table Post-hoc analyses were conducted on subgroups utilizing a 40-year age threshold, which revealed that only the younger cohort exhibited a statistically significant increase in pregnancy and live birth rates subsequent to undergoing ICSI/IVF . Additionally, similar positive associations were observed between AFC and the number of retrieved oocytes, the number of mature oocytes, and the number of embryos . Specifically, patients who exhibited higher levels of AMH and AFC after cellular treatment demonstrated a better response to COH  and European Medicines Agency (EMA). In this manner, our primary focus was on the safety, efficacy, and consistency of the cell products. Moreover, there exist potential hazards associated with MSC application, particularly in specific cellular microenvironments, which demand careful consideration in long-term monitoring and follow-up assessments. Hence, further randomized parallel studies with a larger sample size and an extended follow-up period are indispensable to definitively establish the impact of MenSCs on ovarian function and live birth rate, thereby validating the applicability of our findings in a clinical context.In conclusion, it may be deemed appropriate to consider the administration of autologous MenSCs via intraovarian injection in females experiencing POR. It is suggested that individuals under the age of 40 years old would be the most suitable candidates for this approach, as it could potentially enhance pre-existing ovarian reserve and improve ICSI/IVF outcomes. However, in order to broaden the scope of clinical implementation, several queries will need to be addressed through prospective randomized clinical trials. These include, but are not limited to, determining the duration of stem cell efficacy, identifying more appropriate clinical cases for this therapy, and validating the appropriate dose of MenSCs.


Neoadjuvant chemotherapy (NAC) is increasingly used in locally advanced gastric cancer (LAGC), but the clinical safety and efficacy are still controversial. This study aims to compare perioperative chemotherapy (PEC) with adjuvant chemotherapy (AC) for resectable LAGC.Patients who underwent D2 gastrectomy for resectable LAGC were retrospectively reviewed, and divided into NSA group (NAC plus surgery and AC) and SA group (surgery followed by AC). The baseline characteristics and perioperative data were compared. Survival analysis was based on Kaplan–Meier method. Multivariate analyses for prognostic factors were based on the Cox regression.P = 0.014), excised tumor size (P = 0.038), and tumor downstage . NAC did not affect postoperative complications or AC-related grade 3/4 adverse events. Patients in NSA group achieved significantly longer OS (P = 0.021) and DFS (P = 0.002). The Cox regression model showed that NAC was independently associated with better OS  and DFS .A total of 450 patients were eligible for this study. 218 patients received NAC plus surgery and AC, while 232 upfront surgery followed by AC. The baseline characteristics were comparable between the two groups. NSA group showed significant superiority in R0 resection rate (Compared with SA, the administration of NSA was considered safe and feasible for achieving higher R0 resection rate without increasing the postoperative complications or AC-related grade 3/4 adverse events, and NAC was independently associated with better OS and DFS for resectable LAGC. Gastric cancer (GC) is the fifth most frequently diagnosed malignancy, accounting for the third leading cause of cancer-related death worldwide . Due to Large tumor burden, metastatic lymph nodes and systemic micrometastasis are unfavorable factors for curative resection. In response, NAC has been investigated to diminish tumors, reduce metastatic lymph nodes and micrometastases so as to improve curative resection rate for LAGC , 11, 12.Therefore, we conducted this retrospective study to compared the clinical safety and efficacy between PEC and AC strategy, with the primary aim to investigate whether the presence of NAC could further improve the long-term survival of LAGC patients on the basis of AC following curative gastrectomy. The secondary aim was to assess the impact of NAC on postoperative complications and adverse events occurring during AC.Patients who received treatment for gastric cancer between March 2012 and December 2016 at the department of general surgery of Peking Union Medical College Hospital were retrospectively reviewed from our prospectively collected database. Patients treated with neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy, or surgery followed by adjuvant chemotherapy were included while patients suffering from other synchronous and/or prior malignant tumor; receiving radiotherapy; lacking some information on diagnosis, therapy or evaluation were excluded. Finally, a total of 450 patients were included. This retrospective study was reviewed and approved by the Institutional Review Board of Peking Union Medical College Hospital. Written informed consent of each patient was obtained.The demographic and clinicopathologic characteristics, including age, gender, initial body mass index (BMI), tumor location, tumor size, tumor differentiation, signet ring cell features, Lauren type, clinical T stage, clinical N status and clinical TNM stage  were collected . In addiAll patients were required to visit the outpatient clinic at 3 months interval during the first 2 years after completing treatment, and 6 months interval thereafter for 3 years. After 5 years, consultation and follow-ups occurred once per year. The dates and events of relapse and death were collected from telephone interviews or electrical medical records. The primary end points were overall survival (OS) and disease-free survival (DFS). OS was defined as the intervals from the date of surgery to death from any cause. DFS was determined as the interval from the date of surgery to either the first relapse or death from any cause. The last follow-up date was September 2022. The secondary end points were postoperative complications and adverse events occurring during adjuvant chemotherapy of patients.2 test or Fisher’s exact test, and continuous data were analyzed by using the Student’s t test or the Mann–Whitney U test. Survival curves for OS and DFS were evaluated using the Kaplan–Meier method, and the log-rank test was used to compare survival difference. The Cox regression analysis was adopted to assess the prognostic risk of demographic and clinicopathologic characteristics on OS and DFS, and the statistically significant factors from the univariate analysis were then taken into the multivariable analysis. Statistical analyses were performed using SPSS 22.0  and GraphPad Prism 8 , and P values < 0.05 was considered statistically significant.Categorical variables were described as proportions and continuous variables were described as mean ± standard deviation. Categorical variables were analyzed by using the χP > 0.05). Initial body mass index (BMI) and pre-therapy tumor size were comparable between the two groups. For regimens of NAC, 115 patients (52.8%) received SOX regimen, 76 (34.9%) received XELOX and 27 (12.4%) received FOLFOX6 regimen. NAC was performed 2 to 4 cycles in the group. No major adverse events related to NAC were noted and none of the patients required termination of therapy in the cohort due to NAC-related complications.A total of 450 patients were eligible for this study. 218 of these patients underwent neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy (NSA group), while 232 underwent surgery followed by adjuvant chemotherapy (SA group). The baseline characteristics of these patients are summarized in Table P = 0.014) and smaller excised tumor size , while the duration of operation, the amount of estimated blood loss, the number of resected lymph nodes, the distributions of intraoperative blood transfusion and the extent of resection were comparable between the two groups  (Table P < 0.001), and there was a significant tumor downstaging in pathological T stage (P < 0.001), pathological N stage (P < 0.001) and pathological TNM stage (P < 0.001). Furthermore, patients in NSA group had a pathologic complete response rate of 8.3% (18 of 218 patients), indicating better tumor downstaging associated with NAC.For the analysis of surgical outcomes, patients in NSA group achieved higher R0 resection rate . Totally, the rate of postoperative complications was 24.8% and 19.8% for NSA and SA group (P = 0.207), respectively. As regards to each subtype of postoperative complications, including surgery-related and system-related complications, no statistical difference was observed between the two groups . Table P = 0.002), leukopenia/neutropenia  and hand-foot syndrome  of all grades than the SA group. However, the occurrence rates of grade 3/4 adverse events were comparable between the two groups .As shown in Table P = 0.021; DFS: P = 0.002). The median OS in NSA group and SA group were undefined and 51.0 months with the 3-year OS rate of 68.8% and 61.2%, and the 5-year OS rate of 60.9% and 49.8%, respectively. In addition, patients in NSA group achieved an improvement in 3-year DFS (64.6% vs 58.0%) and 5-year DFS rate (58.2% vs 42.2%) compared with patients in SA group, and the median DFS was 61.0 and 36.5 months, respectively. Univariable Cox regression analysis revealed that pre-therapy tumor size, clinical TNM stage, NAC, pathological T stage, pathological N stage, lymphovascular invasion and pathological TNM stage were associated with OS and DFS (Table P = 0.012), NAC , pathological T stage  and pathological TNM stage  were independently predictive factors for OS, while pre-therapy tumor size , NAC , histological grade , lymphovascular invasion  and pathological TNM stage  were independently associated with DFS . Kaplan–Meier survival curves for OS and DFS are depicted in Fig. t choice for LAGC in both Asian and Western countries, whereas locoregional recurrence and systemic micrometastases seriously affected patients’ prognosis [Curative gastrectomy combined with D2 lymphadenectomy has been accepted as the main treatmenrognosis , 18. In rognosis –6, 19. Arognosis –6, 9, 10The MAGIC and FNLCC/FFCD trials have confirmed the superiority of perioperative chemotherapy over surgery alone, with higher R0 resection and pCR rates and better OS, even though fewer than 50% patients completed the postoperative chemotherapy and a subset of patients were actually diagnosed with gastroesophageal junction tumor in these two trials , 11. As At present study, a total of 450 patients with cT2-4bNanyM0 stage met the inclusion criteria. All patients underwent D2 gastrectomy followed by adjuvant chemotherapy, and patients were divided into the NSA group and SA group, according to whether they have received neoadjuvant chemotherapy or not. There was no significant difference in the baseline characteristics between the two groups. Consistent with the previous results of several studies, our results suggested a superior tumor downstage rate in NSA group , 23, 24.One of the major arguments with the use of PEC is that it might increase the perioperative complications and chemotherapy-related adverse events . In the There have been currently no unified standard indications for the application of neoadjuvant chemotherapy in LAGC. The Japan Clinical Oncology Group suggested that LAGC patients with clinical T3/T4 and cN+ stage were suitable to receive neoadjuvant chemotherapy . The indWe acknowledge that the present study contains certain limitations. Due to its retrospective nature and relatively limited number of patients at a single institution, potential selection bias and excessive hazard ratios in the analysis might exist. Second, even chemotherapy regimen was basically based on platinum drugs and 5-fluorouracil regimens, it was not standardized for NAC or AC, the effects of different regimens were not analyzed. Third, the patient cohort is a selected group , and thus, the conclusion could not be extrapolated to all LAGC patients. Finally, our follow-up was relatively short. Despite the limitations above, the present study verified the superiority of perioperative chemotherapy for Asian patients with LAGC to a certain extent.Compared with SA, the administration of NSA was considered safe and feasible for achieving higher R0 resection rate without increasing the postoperative complications or AC-related grade 3/4 adverse events, and NAC was independently associated with better OS and DFS for resectable LAGC. Our findings are expected to be supported by more high-quality prospective data.


Teaching techniques considered ‘extremely effective’ were life examples (47.6% of athletes), hands-on activities (30.6%), and discussions with a facilitator (30.6%). Setting personal nutrition goals was important to most athletes (83.9%), along with two-way feedback with a facilitator (75.0%). General nutrition topics considered ‘essential’ were energy requirements (52.9%), hydration (52.9%), and nutrient deficiencies (43.3%). Performance topics considered ‘essential’ were recovery (58.1%), pre-exercise nutrition (51.6%), nutrition during exercise (50.0%), and energy requirements for training (49.2%). Athletes preferred a ‘combination of in-person group and one-on-one sessions’ (25% of athletes), ‘one-on one sessions’ (19.2%) and ‘in-person group sessions’ (18.3%), with only 13.3% interested in ‘exclusively online delivery’. Sessions of 31–60 min (61.3% of athletes) held monthly (37.5%) and undertaken with athletes of the same sporting calibre (61.3%) were favoured by the participants. The preferred facilitator was a performance dietitian or nutritionist (82.1% of athletes), who had knowledge of the sport (85.5%), experience in sports nutrition (76.6%), and credibility (73.4%). This research provides novel insights into the factors that need to be considered when designing and implementing nutrition education for athletes.Nutrition education (NE) is one of several strategies aimed at enhancing the dietary intake of athletes. This study investigated NE preferences of New Zealand and Australian athletes competing nationally and internationally. Athletes ( High-quality dietary intake is important for an athlete’s performance and overall health status . Sports Previous research has pointed to gaps in the nutrition knowledge of athletes ,10, whicCurrently, there are a range of methods used to deliver NE interventions, which impacts nutritionists’ and sporting organization’s decisions on what design elements and content to include for the most effective NE . In addiWhilst preferences for NE have been explored qualitatively and quantitatively in non-athlete groups ,19, inveThe study is a descriptive cross-sectional analysis where participants completed a survey developed by the research team exploring athlete preferences for NE. Recruited participants were over 16 years of age  and tier 3  and tier 4  based on the classification framework by McKay et al. . Ethics Recruitment was undertaken using convenience sampling. In New Zealand, the survey was shared through existing industry contacts and advertising on social media channels . In Australia, sports nutrition practitioners across the National Institute Network (NIN) were informed of the research and interested practitioners forwarded the survey to athletes within their network. Data were collected from early September through to late November in 2021.A draft survey was developed by the lead researcher . Apart from the questions on sports/demographics, all survey questions were developed from scratch. The development of survey topics and questions was heavily informed by the literature, including the use of resources for the development of online surveys ,25, quesPre-testing was undertaken with a convenience sample of 10 experienced ex-athletes (tier 3 and tier 4)  to ensurn = 11; 7 females) were athletes from badminton (n = 4), athletics (n = 2), motorsport (n = 2), water polo, swimming, and soccer , who all provided feedback via email. Changes made following this feedback included rephrasing of questions for participant comprehension and shortening the survey.Prior to pilot testing, the survey took approximately 20–25 min to complete. Following adaptation , 20 New Zealand-based tier 3 and tier 4 athletes  were invChanges to reduce the survey length included consolidation of questions/topics in the pedagogy section to ensure all questions/topics were relevant and different; reducing the thought processes for some questions by asking athletes to “check all that apply” rather than asking participants to rank in order; and asking participants to rank only the top three statements in ranked order questions. Athletes involved in pre- and pilot testing did not participate in the final survey.The final survey consisted of six parts. Part 1 included questions on level of interest in performance nutrition  and previous sources of NE (1 multiple choice question). Parts 2–6 covered preferences for pedagogy: content; format; facilitator; and a sport/demographic section. The section on pedagogy aimed to understand participant preferences for effective teaching techniques , along with the importance of the use of various feedback and monitoring strategies , as well as two questions regarding whether enjoyment and engagement were needed for success in NE . For content, participants were asked how much they prioritised curricular topics related to general , performance , and skills related nutrition information , as outlined in the model by Parks et al. . Two queData was entered and analysed using IBM SPSS Statistics (version 27.0). Descriptive statistics  for non-parametric data) were calculated for all variables following normality testing of the data.Of 138 completed responses, two were <16 years of age, 11 were not competing at a tier 3 or 4 level, and one did not provide consent, leaving 124 responses for analysis. Mean completion time of the survey was 18.4 ± 8.4 min. Of the 124 athletes, 54.8% were female; 101 athletes lived in New Zealand (81.5%), 19 in Australia (15.3%), and four elsewhere (3.2%). Over half (55.6%) had completed or were completing a university qualification, with 8.9% undertaking nutrition related university studies. Athletes mainly competed in rowing (26.6%), athletics (8.9%), and cycling (8.9%) . AthleteMost athletes thought NE should be engaging (96%) and enjoyable (81.4%) ‘always’ or ‘often’. Athletes (83.9%) thought setting goals for their nutrition within NE sessions was ‘very’ or ‘extremely’ important. The need for these goals to be monitored by the facilitator was rated as ‘very’ or ‘extremely’ important by 53.2% of athletes, while 75.0% ranked receiving some two-way feedback between themselves and the facilitator as ‘very’ or ‘extremely’ important.Preferred teaching techniques were a mixture of kinaesthetic , aural , and visual techniques . Teaching techniques related to reading, writing, or recording  were less preferred. Teaching techniques involving competition  showed a mixed response .Credible content in NE was important for 91.1% of athletes ‘always’ or ‘often’. Most (69.4%) athletes felt topics should be repeated ‘sometimes’. General nutrition topics considered ‘essential’ were energy requirements (52.9% of athletes), hydration (52.9%) and nutrient deficiencies (43.3%). ‘Essential’ performance nutrition topics were recovery nutrition (58.1%), before and during exercise nutrition , as well as overall energy requirements (49.2%). Adapting meals for training requirements (37.9%) and behaviour change techniques (26.6%) were considered ‘essential’ nutrition-related life skills see .Athletes preferred a ‘combination of in-person group and one-on-one sessions’ (25% of athletes), ‘one-on one sessions’ (19.2%), and ‘in-person group sessions’ (18.3%). The least preferred delivery settings were ‘exclusively online delivery’ (13.3%), ‘one-on-one sessions combined with online delivery’ (7.5%), and ‘in-person group sessions combined with online delivery’ (2.5%). Webinars (65.8% of athletes) ranked as the preferred online delivery method. Less than ten percent of athletes ranked emails (7.3%), podcasts (6.5%), social media (5.7%), websites (5.7%), apps (4.1%), and forums (2.4%) as their preferred online delivery method. Athletes preferred that NE group sessions be undertaken with athletes of the same sporting calibre (61.3% of athletes), of similar age (52.4%), with teammates, and with coaches (both 51.6%) .Approximately half of respondents indicated a preference for NE to run continuously throughout the year (50.8%), rather than intermittently (29.0%) or as a short course (16.1%). For those athletes who did not prefer the NE to be continuous (45.2%), their preferences were for it to occur at the beginning of season (21.8%) or the off season (16.1%). Most athletes (62.1%) preferred smaller numbers in group sessions (up to 10 people). The most preferred duration and frequency for a single session was 31–60 min (61.3% of athletes), held once per month (37.5%) or once every two (29.0%) months. Overall, 1–10 sessions were favoured (74.6%) .To our knowledge, this is the first study to quantify elite and highly trained athletes’ preferences in NE across the areas of pedagogy, content, format, and facilitator. Athletes preferred engaging NE taught through a mixture of kinaesthetic, aural, and visual techniques. Athletes prioritised key topics  pertaining to general and performance nutrition, with adapting meal requirements being the most valued nutrition-related life skill. A combination of group and one-on-one sessions was favoured. Preferred length of sessions were 31 to 60 min, occurring every one to two months as part of a continuously running NE programme. Finally, athletes valued a credible facilitator such as a performance dietitian or nutritionist with professional experience who was knowledgeable in the sport and non-judgmental.Perception of what is considered an engaging and effective teaching technique will likely depend on the preferred learning style of the individual. The most preferred teaching techniques in this study were aligned with a kinaesthetic learning profile  and learning through discussion and engagement. Braakhuis et al.  also fouSetting performance nutrition goals within the NE session was perceived to be important for almost all athletes in the present study. Involving athletes in planning has been shown to facilitate athlete motivation and intervention compliance . For neaThe inclusion of activities such as cooking classes, supermarket tours, and nutrition-related calculations are known to improve athlete knowledge, capabilities, and dietary behaviour ,35,36,37Athletes wanted information on energy, macro- and micronutrient requirements, and hydration, with a preference for performance nutrition topics focusing on before and during exercise and recovery nutrition. These topics are fundamental components of basic sports nutrition recommendations , which aOther studies have shown athletes prefer a diverse education curriculum which includes discussions on interpreting nutrition information  and behaAthletes preferred in-person group and one-on-one sessions combined or separately. Qualitative studies found professional Australian footballers who had free access to a sports dietitian preferred one-on-one consultations with a sports dietitian , while hOverall, athletes preferred up to 10 NE sessions held every one or two months. While preferred duration of NE was not specifically considered in the current study, a recent systematic review in non-athletes showed that one of the major factors for successful behavioural changes for good health was a NE programme duration greater than or equal to five months . HoweverThe performance nutritionist is responsible for a breadth of activities  and for This research provides insights that dietitians and nutritionists can use to develop nutrition education interventions for athletes. More research is needed to investigate and compare other cohorts of athletes  as nutrition education preferences for these athletes may be different. The findings of this study set the stage for a randomised controlled trial to be conducted to investigate the efficacy of various nutrition education modalities and platforms for improving nutrition knowledge and improving dietary behaviour in athletes.While the study was able to recruit a good sample size of athletes from a broad spectrum of sports, there were some limitations. Setbacks to distributing the survey included athlete and practitioner commitments in an Olympic year, as well as recruitment being undertaken during strict government lockdown restrictions within Auckland, New Zealand due to the COVID-19 outbreak. During this period, many athletes were unable to meet in person and had to use online methods of learning and communication. Previously online methods of communication may have been seen as novel; however, during this time it is a possibility that participants were experiencing screen fatigue  which maAthletes wanted engaging and enjoyable NE taught through a mixture of kinaesthetic, aural, and visual techniques. They thought setting goals was important and valued two-way feedback with the facilitator. Athletes wanted credible education on energy, macro- and micronutrient, and hydration needs, as well as pre-, during- and post- (recovery) exercise requirements. Including nutrition-related life-skills in NE, such as how to adapt meals to meet nutrition requirements, was a high priority for most athletes. Athletes preferred a combination of in-person group and one-on-one sessions. For group sessions, having small groups of up to 10 athletes of the same sporting calibre was preferred. For most athletes, NE sessions would be 31 to 60 min and held every one to two months. A performance dietitian or nutritionist with experience in sports nutrition was the preferred facilitator. Being knowledgeable, relatable, likeable, and non-judgmental as well as willing to learn more about the sport were also important characteristics of the facilitator. Further research should be undertaken to investigate whether there are differences in NE design and content preferences of athletes based on age, sport, calibre , and participation in previous NE. More research is needed to investigate NE preferences of athletes who live in different countries and cultures, as well as those who have less of an interest in performance nutrition.


Biological soil crusts (BSCs) are distributed in arid and semiarid regions, and they function as important microhabitats for nitrogen fixation. The diazotroph community is critical for nitrogen fixation in BSCs and their subsoils. However, little is known about the key groups in different types of BSCs and subsoils in temperate semi-arid or arid deserts.Here, we sampled three types of BSCs and their subsoils from the Inner Mongolian plateau, investigated the distribution characteristics of the diazotroph community by high-throughput sequencing, predicted keystone species using the molecular ecological network analyses pipeline (MENAP), and verified their close relationship with the available nitrogen (AN) content.Skermanella, Scytonema, Azohydromonas, Nostoc and Trichormus were the dominant phyla, families, and genera, respectively. The dominant groups belong to Skermanella, Scytonema, and Nostoc formed the core diazotroph community in the three types of BSCs and subsoils, and each had a close relationship with AN.The results showed that available nitrogen content in BSCs was higher than that in subsoils in three different types of BSCs, and there were differences among seasons and according to the mean annual precipitation. The abundance of diazotrophs was higher in Cyano-BSCs, while diversity had no significant difference among BSCs and subsoils. Cyanobacteria and Proteobacteria, Nostocaceae and Scytonemataceae, These results indicate that diazotrophs in BSCs and subsoils had high diversity, and the core diazotroph communities have a close relationship with nitrogen fixation and that they may be the main contributor to nitrogen fixing in BSCs and subsoils in temperate deserts. They arMicrocoleus vaginatus or M. steenstrupii) are numerically dominant in BSCs diazotroph communities; heterocystous cyanobacteria  increase in abundance during crust succession and are abundant in mature crusts , non-heterocystous genera , could efficiently elevate soil N availability through nitrogen fixation in desert ecosystems  the diazotroph communities were different in abundance, diversity and structure among three types of BSCs and their subsoils, (b) core diazotroph communities were the key in accumulation of available nitrogen during BSCs succession. To test these hypotheses, three types of BSCs  and their subsoils were collected from deserts in the western region of the Inner Mongolia plateau, China. We analyzed the diazotroph community structure based on the 2.2.1.The Inner Mongolia plateau is the second largest plateau in China, and BSCs are widely distributed in the major western deserts. Cyano-BSCs, Lichen-BSCs, and Moss-BSCs are found in the region, and our seven sampling sites were located in five deserts . The nat2.2.The sampling sites were distributed in five deserts in semi-arid and arid regions of Northwestern China, namely Badain Jaran (S1), Tengger (S2), Wulanbuhe (S3), Hopq (S4) and Mu Us (S5) deserts from the western to eastern . Average2.3.nifH gene is the key gene in coding the nitrogenase enzyme, and this gene was used to quantify the absolute abundance of diazotroph communities. Quantitative PCR (q-PCR) was conducted to evaluate nifH gene abundance in diazotroph bacteria in different samples. nifH gene fragments were amplified by primers polF (5′-TGCGAYCCSAARGCBGACTC-3′)/polR (5′-ATSGCCATCATYTCRCCGGA-3′) (product size about 300 bp) , 0.4 μL of 10 mM primers (each), 7.2 μL of sterilized MilliQ water, and 2 μL of standard or extracted soil DNA. The PCR used the following program: initial denaturation at 95°C for 1 min, followed by 40 cycles of 95°C for 15 s/10 s for denaturation, 58°C for 15 s/20 s for annealing and elongation, and a final cycle at 60°C for 30 s for cooling. All analyses were carried out with a thermocycler . A standard curve for the nifH gene  was obtained and used to calculate the absolute abundance of nifH genes. The melting curve was obtained to confirm that the amplified products were of the appropriate size.The molybdenum-iron (MoFe) nitrogenase enzyme ([1.18.6.1]) can fix dinitrogen into ammonia, and as such, it is the key enzyme of nitrogen-fixing microorganisms in the environment . The nif 300 bp) . The tar2.4.® soil DNA Kit  according to the manufacturer’s protocols. The final DNA concentration and purification were determined using a NanoDrop 2000 UV–vis spectrophotometer , and DNA quality was checked by 1% agarose gel electrophoresis. The nifH genes were amplified with the primers nifHF (5′-AAAGGYGGW ATCGGYAARTCCACCAC-3′)/nifHR (5′-TTGTTSGCSGCRTACATSGCCA TCAT-3′)  according to the manufacturer’s protocol. Purified amplicons were pooled in equimolar volumes and paired-end sequenced (2 × 300) on an Illumina MiSeq platform  according to standard protocols by Majorbio Bio-Pharm Technology Co. Ltd. . The raw reads were deposited into the NCBI Sequence Read Archive (SRA) database, with the BioProject accession number of PRJNA649746.Microbial DNA was extracted from samples using the E.Z.N.A.TCAT-3′) . The PCRRaw fastq files were demultiplexed, quality filtered by Trimmomatic (v3.02) , and mernifH gene)  were clustered with a 95% (fH gene)  similarifH gene) , and chifH gene) . The tax2.5.http://ieg4.rccc.ou.edu/mena/, following the default settings   at samples) . The co-samples) . Networksamples) .2.6.nifH copy numbers and the Shannon index was calculated for different types of BSCs and their subsoils. The figures were generated with GraphPad Prism 7.0 .One-way analysis of variance and Tukey’s test were carried out using SPSS 19.0 software  to determine the differences in available nitrogen (AN) content, 2 tests, the comparative fit index (CFI), and root mean square error of approximation (RMSEA). Low χ2 values (p > 0.05), high CFI (>0.90), and low RMSEA (<0.08) indicated sound fits of the model  were constructed with the Amos 21.0 software  to evaluate direct and indirect paths through which soil carbon content (SOC) and AN content influenced diazotroph community structures. Model adequacy was evaluated through χhe model .Multivariate analysis by linear models analysis (MaAsLin) is a multivariate linear modeling tool with boosting that tests for associations between specific microbial taxa and metadata, which could reduce the total amount of correlations to be tested, and allow for improvements in the robustness of the additive general linear models . In this3.3.1.p < 0.05), respectively (The contents of AN in the three types of BSCs were higher than those of their corresponding subsoils . The conectively .3.2.nifH copy numbers were significantly different (p < 0.05) in BSCs and their subsoils, varying from 1.23 × 104 to 9.88 × 106 in BSCs and from 8.94 × 102 to 7.41 × 103 in subsoils. The average copy number of nifH in BSCs was above 105, about two orders of magnitude greater than that in subsoils with significant difference (p < 0.05). Higher numbers were observed in Cyano-BSCs than in the other two successional stage BSCs, but slightly greater numbers appeared in subsoils of Lichen-BSCs at similar locations (p < 0.05) (The  < 0.05) .3.3.nifH gene sequences were retrieved with average lengths of 427 bp, and 31,593 OTUs were generated using a threshold of 95% similarity. The Shannon indexes of subsoils were significantly higher than those of BSCs (p < 0.05) (p < 0.05) but increased slightly from Cyano- to Lichen- and Moss-BSCs. The similar shifts of Shannon index in subsoils were observed  . Except  < 0.05) , most saobserved .3.4.R = 0.226, p = 0.001)  and analysis of similarity (ANOSIM) based on OTUs based on the OTU level (= 0.001) . From in= 0.001) . Notably= 0.001) , where t= 0.001) . In addi= 0.001) .Nostoc, Azohydromonas, Azospirillum, Skermanella, Scytonema, Anabaena, Trichormus, and Rhodomicrobium), the numbers of unique genera in subsoils also were much higher than that in BSCs (Scytonema was dominant (53.21%) in Cyano-BSCs but decreased to 34.96% in Lichen-BSCs and to 16.29% in Moss-BSCs, while many unclassified bacterial genera appeared in higher BSCs succession stages. There were many more unclassified bacterial genera in subsoils, and the highest relative abundance was 26.17% in subsoils of Lichen-BSCs. The three types of BSCs and their subsoils shared four genera, one unclassified genus in Proteobacteria and three genera in the top 10, consisting of Skermanella, unclassified_f__Rhodospirillaceae, and Scytonema . For individual samples, trace abundance was detected in samples collected from Badain Jaran and Hopq deserts  in subsoil of Moss-BSCs . Besides in BSCs . The phycytonema . Besides3.5.Using random matrix theory (RMT)-based modeling with different threshold values , co-occuSkermanella, Nostoc, and Scytonema were the three dominant genera in BSCs; their relative abundances were 16.42–18.64%, 7.46–8.47%, and 7.46–8.47%, respectively, and these were stable following the development of BSCs. In subsoils, the genus of Skermanella had the highest abundance in Moss-BSCs, being 2.56 and 3.93 times that in Lichen- and Cyano-BSCs, respectively. The relative abundance of Scytonema also increased BSCs in subsoils of higher BSCs successional stages .The majority of nodes in the six networks belonged to two phyla and unclassified bacteria, but their distribution varied substantially among different phylogenetic groups . ProteobScytonema, Nostoc and Skermanella. In Cyano-BSCs and their subsoils, six OTUs belonged to Cyanobacteria  as members of the core diazotroph community. Core diazotrophs (belonging to Nostocaceae and Scytonemataceae) were directly affected by the AN , SOC , and the diazotroph population [the relative abundance of Scytonemataceae was also influenced by the copy number of nifH ], which in turn showed significant correlations with their community composition. Standardized total effects derived from the SEM indicated that core diazotrophs (belonging to Nostocaceae and Scytonemataceae) could determine the diazotroph communities, also had tightly correlations with the AN content.Structural equation model was applied to disclose the relationships of core microbiome with AN. The fitted models explained 85% of the variance in diazotroph community composition in BSCs and their subsoils , and diaScytonema and Skermanella) were significantly associated with the AN content in three types of BSCs and subsoils  had positive correlation with it  through N-fixation , which c4.1.nifH copy number of diazotrophs in BSCs was almost 100 times higher than that in their corresponding subsoils, a pattern that may be due to the contents of soil nutrient substances  being higher in BSCs  in relative abundance. Proteobacteria (56%) and Cyanobacteria (10%) were the most abundant soil nitrogen-fixers  were the dominant genera and were distributed in all samples, and the main difference was in the relative abundance.In summary, the diazotroph communities in different types of BSCs had higher absolute abundance and lower diversity than their corresponding subsoils. Proteobacteria and Cyanobacteria were the dominant phyla; 4.2.nifH absolute abundance showed significant differences among the types of BSCs and their subsoils, but this did not match the pattern of AN content, possibly due to some bacteria being unable to fix nitrogen, even though they had nitrogen-fixing genes in their genomes  are widely recognized as important N2-fixing components of BSCs  can be found in the article/KT carried out the experiments and prepared the manuscript draft. KT, YL, and BY analyzed the data. YL and BY helped in the sampling from deserts and preparing the experiments. JM and FF designed the research and wrote the manuscript with input from KT. All authors contributed to the article and approved the submitted version.This study was financially supported by the Program of the National Natural Science Foundation of China (32001220), the Applied Technology Research and Development Fund of Inner Mongolia (2021GG0360), and Inner Mongolia Agricultural University High-level/Outstanding Doctoral Introduction Talents Research Start-up Project (NDYB 2021-24), Program for improving the Scientific Research Ability of Youth Teachers of Inner Mongolia Agricultural University (BR230149).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Metabolic disorders were a health problem for many adults with congenital heart disease, however, the differences in metabolic syndrome-related metabolite levels in adults with congenital heart disease compared to the healthy population were unknown.We collected 18 studies reporting metabolic syndrome-associated metabolite levels in patients with congenital heart disease. Data from different studies were combined under a random-effects model using Cohen’s d values.The results found that the levels of total cholesterol , high-density lipoprotein cholesterol , and low-density lipoprotein cholesterol  were significantly lower in congenital heart disease patients compared with controls. Congenital heart disease patients also had a lower body mass index  compared with controls. On the contrary, congenital heart disease patients had higher levels of hemoglobin A1c  than controls. Meanwhile, there were no significant differences in triglyceride , blood glucose  levels, systolic  and diastolic blood pressure  between congenital heart disease patients and controls.The lipid levels in patients with congenital heart disease were significantly lower than those in the control group. These data will help in the health management of patients with congenital heart disease and guide clinicians.CRD42022228156.The online version contains supplementary material available at 10.1186/s12872-023-03455-w. Congenital heart disease (CHD) is the most common cause of congenital abnormalities . In receMetabolic syndrome (MS) usually includes a combination of any three of the following metabolic disorders: including obesity, dyslipidemia, hyperglycemia, and hypertension , 8. ClinDespite this, there is still a lack of systematic review and meta-analysis of the differences in MS-related metabolite levels between adults with CHD and healthy controls. In this study, we systematically assessed the differences in blood lipid , HbA1c, glucose levels and blood pressure between adult CHD patients and the normal population through the meta-analysis. Our findings will help guide the future management of adult CHD and provide guidance for clinicians.We used PubMed  and Web Studies on CHD published in English were included in the title and abstract screening stage. The full texts of all relevant literature were further evaluated. If the study was  English Evaluation and extraction of the data contained in the literature were performed independently by 2 authors and in consultation with the third author in case of disagreement. The following data were mainly extracted: authors, year of study publication, geographic area of the research, type of study design, the period for collecting cases, sample size, age, gender and body mass index (BMI) of the participant, whether the case group was operated or not, metabolite level data and classification of congenital heart disease.The quality of studies included was guaranteed by using the Newcastle-Ottawa Scale (NOS), which is a tool recommended by the Cochrane Collaboration for observational studies to assess the risk of bias . The staP-value and I2 statistics corresponding to the Cochran Q test. The I2 statistic was used to assess the percentage of total variation across studies that is due to heterogeneity rather than chance . If P-value < 0.05 and I2 > 50%, the analysis was performed using a random-effects model, and if P-value > 0.05 and I2 < 50%, the analysis was performed using a fixed-effects model. To explore the source of heterogeneity, subgroup analysis was carried out by dividing the different geographical areas where the study was located. The symmetrical distribution of the funnel chart and the Egger’s test assessed publication bias (P < 0.05 indicates that the results were significant and there was publication bias). All statistical analyses were conducted in R software, version 4.0.4.In this meta-analysis, the method of standardized mean difference  was used as the effect size to compare the differences in TC, HDL-C, LDL-C, TG, HbA1c, blood glucose levels, blood pressure and BMI between CHD patients and healthy controls under a random-effect model or a fixed-effect model. The units of metabolite levels reported in all studies were normalized to mg/dl before analysis. The normal control ranges for human lipid levels are: Total cholesterol, ideal value: <200 mg/dl; critical value: 200-239 mg/dl; excessive value: >240 mg/dl. Triglycerides, ideal value: <150 mg/dl; critical value: 150-199 mg/dl; excessive value: >200 mg/dl. HDL cholesterol, ideal value: >50 mg/dl; critical value: 35-50 mg/dl; risk value: <35 mg/dl; LDL cholesterol, ideal value: <130 mg/dl; critical value: 130-159 mg/dl; excess value: >160 mg/dl. Cohen’s d is a parameter used to compare the magnitude of the mean difference effect, which can indicate the magnitude of the difference between the overall means under different treatments and can be compared across studies. Cohen’s d values were considered a small effect size at 0.2, a moderate effect size at 0.5, and a large effect size at 0.8 . The effAt first, a total of 7257 articles meeting the requirements were collected with 5783 of them from PubMed and 1474 of them from the Web of Science. Among them, 188 duplicate studies were excluded, and then 6961 studies including reviews, conference papers, case reports, or studies that did not meet our inclusion criteria were excluded by reading the titles and abstracts. After reading and evaluating the full texts of the remaining 108 studies, 18 of them met the inclusion criteria and were included for meta-analysis . All literatures included were published between 2001 and 2021. There were 1993 male CHD patients and 1620 female CHD patients matched 2782 male controls and 2882 female controls. Almost all studies were based on adult CHD patients except for 5 studies including Santos 2001 (age 27.0 ± 12.0), Katayama 2006 (age 15.3 ± 11.9), Martínez 2010 and 2014 (selection criteria were 14 years and older), Jan 2015 (age 27.3 ± 12.1). A total of 13 studies reported the BMI of subjects, 10 studies were matched for BMI between cases and controls. Among the CHD patients, 637 were without surgery, 760 were treated with surgery, and 2216 were unclear whether they were treated with surgery or not. The candidate studies were 3 retrospective case-control studies, 3 prospective case-control studies, 1 observational case-control study, 1 Cross-sectional cohort study and 1 randomized case-control study. Besides these, 9 studies were conducted in Europe , 4 studies were conducted in Asia (Japan), 3 studies in the Americas , and 2 studies in Europe combined with Oceania .In terms of all CHD patients, there were 872 patients with CCHD, accounting for 24.14%, and 2741 patients with ACHD, accounting for 75.86% . All literature included ranks above 6 stars, indicating the high quality of the studies and meeting the requirements of meta-analysis. 88.9% of studies (16/18) provided a clear case definition and underwent independent validation of the case in the original studies. Subjects included were diagnosed at least 2 times or based on at least 2 diagnostic methods, including echocardiography and/or cardiac magnetic resonance and/or cardiac catheterization; or by looking up original records such as hospital medical records. The cases collected in all studies were representative, eligible CHD patients were collected within a specified time, or all cases came from a specific hospital. Controls in 66.7% of studies (12/18) were selected from normal communities, and another 33.3% of studies also clearly defined selected controls. In 15 studies, the case and control groups were matched for sex and/or age. A total of 13 studies reported data on lipid levels. For the measurement of blood lipid levels, 6 studies did not report detailed methods, 3 studies used spectrophotometry, 2 studies used enzymatic colorimetry, and the other 2 studies used laboratory or hospital standard methods.I2 = 88%, P < 0.01 , I2 = 69%, P < 0.01 , .01 Fig. A. The co.01 Fig. B. The co.01 Fig. C. Cohen’.01 Fig. D.P = 0.1308)       and systolic blood pressure (P = 0.8641) . Also, no publication bias was observed by visual inspection of funnel plots . But for HDL-C levels (P = 0.0453)  and BMI (P = 0.0118) , both Egger’s test and funnel chart showed that there may be publication bias (P < 0.05). Nonetheless, further analysis using the trim and fill method showed that the comprehensive effect size of HDL-C (Cohen’s d = -0.3201) and BMI (Cohen’s d = -0.1115) were consistent with the results before the analysis , Europe , and Europe combined with Oceania  were significantly lower than controls, but not in Asians  , Europe , and Europe combined with Oceania  were significantly lower than control groups, while the HDL-C levels of the Americans  was not significantly different between CHD patients and the control groups . There were no significant differences in LDL-C levels between CHD patients from Asia , America , and Europe combined with Oceania  and the controls  patients. There were no significant differences in TG levels between CHD patients and controls in Asian  and European  . The HbA1c levels in the Europe combined with Oceania  population and the glucose levels in the European populations  were not significantly different between CHD patients and the control groups  and Asia  had a lower BMI, while in the Americas  and Europe combined with Oceania  had a BMI that did not differ from the control groups , but in Europe combined with Oceania populations CHD patients had lower blood pressure  [Genetic variants may also be associated with lipid levels. Apolipoprotein (APOB) and lipoprotein-related receptor protein 2 (LRP2) play roles in lipid metabolism as LDL apolipoprotein and transport of cholesterol, respectively , 50. Rare (HLHS) . These fOur research did find differences in blood lipid levels of adult CHD between diverse populations. We considered that the living environment and diet were partially responsible for this difference. For example, adherence to the Mediterranean diet could reduce the prevalence of obesity  and MS , 53. StuOur results also showed that the HbA1c levels of CHD patients were significantly higher than healthy controls. A total of 5 studies reported HbA1c levels of 191 CHD patients, of which 175 were CCHD patients. Research had shown that long-term hypoxemia in CCHD patients could significantly increase the number of red blood cells, thereby prolonging the blood passage time and headed to a reduction in blood rheology . ElevateThere were some limitations in our study. First, for most results, there was a varying degree of heterogeneity between studies. This is because CHD comprises a spectrum of very different anatomical, physiological and clinical conditions. We hypothesize that the source of heterogeneity may be the specific classifications of CHD and whether surgical interventions were performed in CHD patients, which needs to be determined by more detailed clinical studies in the future. More importantly, the subgroup analysis revealed variations in the levels of relevant biomarkers across different populations. For example, Americans exhibited lower TG levels, although only one study was included. Conducting more clinical studies could help mitigate study bias and provide further insights into the variation in TG levels among CHD patients. Additionally, it can shed light on the impact of genetics and diet on their lipid levels in different regions.Our study identified significantly lower lipid levels in patients with CHD than in control group. We hypothesize that low lipid levels pose a disadvantage in patients with CHD due to the adult heart’s heavy reliance on mitochondrial oxidative phosphorylation to produce ATP for energy , CardiomThe lipid levels in patients with congenital heart disease were significantly lower than those in the control group. These data will help in the health management of patients with congenital heart disease and guide clinicians.Below is the link to the electronic supplementary material.Supplementary Material 1Supplementary Material 2


Anemia has up to 87% prevalence in high tuberculosis (TB) and human immunodeficiency virus (HIV) burden settings of the sub-Saharan Africa (SSA) including Ethiopia. It increases lost to follow-up (LTFU) rate, reduces quality of life, and shortens the survival of TB/HIV coinfected patients. However, there is limited information on severity level and determinants of anemia in TB/HIV coinfected adults in the study setting in particular. Therefore, this study is aimed to assess severity level and determinants of TB/HIV-associated anemia.  A hospital based retrospective study was conducted among 305 TB/HIV coinfected adults who enrolled for antiretroviral therapy (ART) from January, 2009 to December, 2016 in two public hospital of Mekelle, Ethiopia, by reviewing ART register. A multiple logit model was fitted to identify the baseline determinants of anemia using 95% confidence level or 5% level of significance for adjusted odds ratio (AOR).  In the current study, the cumulative baseline prevalence of anemia was 59.0% (95% CI: 53.3%–64.6%). Considering severity level, the prevalence was 6.2%, 28.2%, and 24.6% for severe, moderate, and mild anemia, respectively. Being female , body mass index  reduces the odds of developing anemia whereas baseline ambulatory functional status , bedridden functional status , HIV clinical stage III , and HIV clinical stage IV  increased the odds of developing anemia for TB/HIV coinfected adults.  In the current study, significant TB/HIV-associated severe anemia was assessed which accounted for nearly one-ninth of all anemia cases while nearly half were moderate anemia. Therefore, curious attention has to be given for the management of TB/HIV-associated severe anemia in particular and anemia in general to reducing anemia associated bad outcomes most importantly death. According to the World Health Organization (WHO), anemia is defined as hemoglobin level's of <12.0 g/dl in women and <13.0 g/dl in men though other factors such as race, physiological status, and pregnancy status have to be taken into consideration .Though etiology of anemia is multifactorial, evidences have been showed that HIV and tuberculosis (TB) are both strongly significantly associated with anemia. HIV and its viral proteins as well as immune suppressions during the natural course of HIV infection were found to be responsible for bone marrow suppression which most likely leads to HIV-associated anemia , 6. FurtAnemia is frequently manifested among HIV patients of Antiretroviral Therapy (ART)-naïve in SSA, with a prevalence that ranged from 45% to 87% –13. AnemHIV-infected people with low CD4+ cell count, high erythrocyte sedimentation rate, and vitamin D deficiency was identified the main predictors of anemia , 23. LitTo the level of our understanding, only few studies were conducted on HIV-associated anemia in Ethiopia, but none were in TB/HIV coinfected patients. Consequently, these studies reported the prevalence of anemia that varied from 23.0% to nearly 43.0% with the highest contribution being not on ART. Rural place of residence, WHO clinical stage III/IV, presence of TB coinfection, and low baseline CD4 cell count were reported as positive predictors of HIV-associated anemia in one and/or more of these studies –28. HoweA baseline hospital based cross-sectional study was conducted among TB/HIV coinfected adults who started ART from September, 2009–December, 2016 at two governmental hospitals namely–Mekelle hospital and Ayder comprehensive specialized hospital (ACSH)–Mekelle, Ethiopia. Mekelle is the capital city of the national regional state of Tigray which is 783 kilometers far from Addis Ababa, the capital of Ethiopia. ART service has been begun since 2004 in Mekelle Hospital and since 2009 in ACSH. To date, the ART clinics are active to provide ART services, and above tens of thousands of HIV patients utilized the service collectively in the two hospitals. Data were extracted from March 1 to April 31, 2017 by reviewing ART registers. All active TB and HIV coinfected adults who fulfilled the eligibility criteria were included in the current study. TB/HIV coinfected adults who had no baseline measurement of hemoglobin were excluded from the current study analysis.We used the single population proportion formula to estimate the minimum sample size considering the following key assumptions: 95% confidence level, 5% acceptable level of precision (margin of error), and overall prevalence of anemia (23%) among HIV patients irrespective of TB status conducted in Debre-Tabor, Ethiopia .(1)nminiEventually, 305 TB/HIV coinfected patient registers were reviewed in the current study using all consecutive sampling approach.Baseline socio-demographic characteristics of TB/HIV coinfected adults .2, serum alanine transferase (ALT) level, serum aspartate transferase (AST) level, and CD4+ cell count (in cells/mm3).Baseline clinical and laboratory characteristics of the participants, i.e., functional status, WHO clinical stage, Body Mass Index (BMI) in kg/mHemoglobin concentration (g/dl) of TB/HIV coinfected adults. In the current study, hemoglobin was considered as the proxy indicator of anemia to classify the study subjects as nonanemic (hemoglobin ≥12 g/dl for women and ≥13 g/dl for men) or anemic (hemoglobin <12.0 g/dl for women versus <13.0 g/dl for men). Anemia is further classified in adult men as mild anemia (11.0–12.9 g/dl), moderate anemia (8.0–10.9 g/dl), and severe anemia (<8.0 g/dl). On the other hand, the classification of anemia is slightly different in adult women as mild anemia (11.0–11.9 g/dl), moderate anemia (8.0–10.9 g/dl), and severe anemia (<8.0 g/dl) [A well-organized data abstraction sheet (checklist) was prepared and then modified considering the most important baseline socio-demographic and clinical characteristics of the target participants. After training on how to review data was given to data collectors, the following data elements were collected from the ART registers using a well standardized checklist:The variable place of residence is operationalized as urban  or rural . Thus, some participants who were from urban area might be classified as rural considering the operational definition.∗ 100%.First, data were entered, exported, and then cleaned in STATA version 14.2 statistical tool. The participants were described using frequency and percent. Serum ALT and AST levels, age, and BMI were described using median and interquartile range (IQR). The adequacy of cell count was also checked using cross-tabulation prior to run the binomial model. The severity of anemia was presented using bar graph. Model fitness and diagnostics  were checked prior to declare the best fitted model. The logit model was fitted as a parsimonious model explaining the anemia data very well so that determinants of anemia were identified according to the final logit model fitted in the current study. Finally, the strength of association of each statistically significant predictor was measured and interpreted based on the adjusted odds ratio (AOR) and its corresponding 95% confidence interval (CI). For the categorical predictors, the AOR was interpreted in comparison to the reference category for the odds of developing anemia. On the other hand, for the continuous predictor particularly baseline BMI, the AOR was interpreted as a unit increase in the continuous predictor BMI decreases the odds of developing anemia by (1 − AOR) Ethics approval was issued by the Institutional Review Board (IRB) of Mekelle University-College of Health Sciences, and the consent to participate was fully waived by the IRB since secondary data were extracted from HIV registers. However, data were kept confidentially, and no personal or identifiable information was used in the present study.Based on the baseline hemoglobin measurement (g/dl) as a proxy indicator of anemia, anemia was reported in 180  of TB/HIV coinfected adults. With regard to severity, moderate, and severe anemia were reported in 86 , and 19  of TB/HIV coinfected adults, respectively. Nearly half (47.8%) of the anemia cases were moderate compared to 41.7% of mild and 10.6% of severe types .In the current study, the overall prevalence of anemia in TB/HIV coinfected males was 68.2% as compared to 50.2% for females. However, the prevalence of severe form of anemia was significantly higher in females (7.6%) than in males (4.7%). The overall prevalence of anemia ranges from 52.1%  in TB/HIV coinfected adults with secondary education to 66.7%  among adults with primary level of education. However, 75% of Muslim TB/HIV coinfected adults reported to have anemia with equal share of the three anemia levels–25% each. Though there was insignificant difference in the prevalence of anemia by place of residence, severe anemia had exceeded by 3% in patients from rural areas .3 as compared to patients with CD4+ cell count >200 cells/mm3 (64.0% versus 36.4%) in which 6.8% of patients with low CD4+ cell count tend to develop severe anemia. The median baseline BMI was 17.4 kg/m2 while the median serum ALT and AST levels were 34.5 and 40 IU/l, respectively  to stage IV (67.6%) where the severe type of anemia was increased from 0% in adults with baseline stage I or II to 9.2% in stage IV. The prevalence of anemia was almost twice in patients with baseline CD4+ cell count ≤200 cells/mmectively .2). Keeping other variables constant, female TB/HIV coinfected adults were protected by at least 35.6% and utmost 77.4% (62.0% on average)  from developing anemia than males. Reversely, the odds of developing anima among TB/HIV coinfected adults with baseline ambulatory functional status, bedridden functional status, WHO clinical stage III and IV were increased by 114% , 121% , 157% , and 159% , respectively, as compared to their respective reference categories. However, a unit increase in BMI (1 kg/m2) reduces the odds of developing anemia by almost 9% on average  in TB/HIV coinfected adults , functional status (ambulatory and bedridden), WHO clinical stage (III and IV), and BMI  of adults coinfected with TB and HIV were anemic, and 6.2% had severe anemia at ART enrollment. Moreover, being female, baseline ambulatory functional status, baseline bedridden functional status, baseline WHO clinical stage III, baseline WHO clinical stage IV, and baseline BMI were identified as statistically significant determinants of baseline anemia in the current study.In this study, the overall prevalence of anemia at baseline was found to be 59.0%  which almost exactly in line to findings obtained across Europe though the target groups were HIV patients of HAART naïve . The curIn the current study, female sex is negatively statistically associated with the anemia prevalence in adult TB/HIV coinfected patients prior to ART initiation. The finding was in agreement with other studies conducted in Benin city (Nigeria) and Zewditu Memorial Hospital (Ethiopia) which have been reported all the low prevalence of anemia in females as compared to male HIV patients of ART naïve or ART experienced , 25. How2) is also significantly negatively predicting the odds of developing anemia among TB/HIV coinfected adults. A unit increase in baseline BMI tends to protect the odds of developing anemia by almost 9% in the current study. This finding was consistent with other studies conducted in South Africa, Uganda, and Rwanda which all have supported the inverse relationship between baseline BMI and anemia [12 play a major role in causing nutrition-related anemia in HIV and/or TB infected/coinfected adults [BMI  might tend to be affected by different opportunistic infections that could negatively affect iron concentration and absorption in which iron deficiency anemia could account for the highest share of anemia in the current study.Similarly, HIV adults of ART naïve with WHO clinical stage III and IV were more likely to develop TB/HIV-associated anemia than those with clinical stage I/II. The result of the current study was supported by the findings of other studies conducted in Uganda and South Africa which have been reported that the odds of developing anemia was increasing as patients clinical stage advanced from stage I/II to III and then IV , 33. TheDespite an appropriate study designed, the current study was not free of limitations. The study population were considered as TB/HIV coinfected adults at baseline regardless of the exact time of TB development. The pregnancy status of women at baseline was not known, and thus, the anemia classification did not consider pregnancy status for women that could underestimate the prevalence of anemia in female participants. Most literature used in the current study was HIV-associated anemia irrespective of TB status at enrollment since studies assessed TB/HIV-associated anemia were scarce.In the current study, approximately six in ten TB/HIV coinfected adults had laboratory evidence of anemia with almost one-ninth, and half of the anemia cases were severe and moderate anemia, respectively, at baseline. Low baseline BMI, ambulatory functional status, bedridden functional status, WHO clinical stages III and IV increased the odd of developing TB/HIV-associated anemia. Thus, curious attention has to be given for severe anemia in particular, and it has to be managed accordingly so as to limit anemia/severe anemia associated bad outcomes of TB/HIV coinfection most importantly death.


Pretransplant osteoporosis and vascular calcification probably increase the risk of fractures and cardiovascular events after kidney transplantation. In the present study, we investigated the related risk factors of osteoporosis and vascular calcification among end-stage renal disease (ESRD) patients awaiting kidney transplantation.A total of 221 ESRD patients  awaiting kidney transplantation were enrolled in this cross-sectional study. Serum levels of bone turnover markers and intact parathyroid hormone (iPTH) were analyzed from fasting morning blood samples. Dual-energy X-ray absorptiometry was used to measure bone mineral density (BMD). Vascular calcification was evaluated by lateral abdominal radiography and plain radiographic films of the pelvis and hands.The osteoporosis prevalence was 27.6% in this cohort of kidney transplantation candidates, and the prevalence of vascular calcification was 51.1%. The related factors for osteoporosis and vascular calcification were similar and included older age, longer dialysis duration, parathyroid hyperplasia, and higher levels of iPTH and bone turnover markers. In the multivariable regression model, age and iPTH were independent risk predictors of both vascular calcification and osteoporosis. There were strong, positive correlations between iPTH and all bone turnover markers. The moderate and severe hyperparathyroidism (iPTH 600–1499 pg/ml and iPTH 1500 pg/ml) were related to reduced serum albumin and hemoglobin levels.The involvement of high iPTH levels in vascular calcification, osteoporosis, and malnutrition indicated the need of treating hyperparathyroidism early in patients awaiting kidney transplantation. Prospective studies are needed to further examine the utility of bone turnover markers. Mineral and bone disorder (MBD) is a common complication of chronic kidney disease (CKD), with increasing prevalence as CKD progresses. CKD-MBD is characterized by abnormal mineral metabolism, renal osteodystrophy, and/or extraosseous calcification . Renal oExtraosseous calcification, especially cardiovascular calcification, predicts subsequent cardiovascular mortality and all-cause mortality in end-stage renal disease (ESRD) patients . A numbeBone biopsy with histomorphometry is the gold standard for the diagnosis and classification of renal osteodystrophy. However, bone biopsy is an invasive procedure and is not practical to perform in all patients. Noninvasive approaches, such as dual energy X-ray absorptiometry (DXA) and biochemical biomarkers of bone turnover, are considered surrogate measures to assess fracture risk . Bone hoFurthermore, the relationship between bone remodeling and vascular calcification is perplexing. The purpose of the present study was to explore the risk factors for osteoporosis and vascular calcification and evaluate their relationship with biochemical markers among ESRD patients awaiting kidney transplantation.Enrolled patients were ESRD patients and registered on a kidney transplant waitlist at the First Affiliated Hospital, College of Medicine, Zhejiang University during November 2018 and June 2020. Candidates were excluded if they had previously undergone parathyroidectomy, had primary hyperparathyroidism, had new-onset fracture within 12 months, received bone-affecting treatment , or lacked adequate laboratory data. This study was approved by the Ethics Committee of the First Affiliated Hospital, College of Medicine, Zhejiang University , and complied with the principles of the Declaration of Helsinki. All patients provided written informed consent.Blood samples were collected from each patient in the morning after an overnight fast. In hemodialysis (HD) patients, blood was collected before the initiation of dialysis. The serum concentrations of intact parathyroid hormone (iPTH), 25 hydroxyvitamin D [25(OH)D], P1NP, OC and CTX were measured using an electrochemiluminescence immunoassay analyzer . Serum alkaline phosphatase (sALP), phosphate, and calcium were analyzed by standardized methods throughout the study period. Serum calcium levels were corrected for serum albumin.BMD was measured using DXA  at the lumbar spine (L2 through L4) and femoral neck. The diagnosis of osteoporosis was determined by the occurrence of a fragility fracture or the World Health Organization (WHO) cutoff value of a T score of ≤ − 2.5 at the spine and femur in patients without fracture. Vascular calcification was evaluated by lateral abdominal radiography and plain radiographic films of the pelvis and hands. The presence of linear calcifications was considered vascular calcification. Echocardiogram was also used to detect the presence or absence of valvular calcification. Parathyroid hyperplasia was identified by ultrasound exam and technetium-99m-sestamibi scintigraphy.t test or one-way analysis of variance (one-way ANOVA). The risk factors for osteoporosis and vascular calcification were evaluated by binary logistic regression analysis. Variable with P value < 0.05 in the univariate logistic regression analysis was exported to multivariable binary logistic regression analysis. The cutoff values of risk factors were determined by receiver operating characteristic (ROC) curves. A P value less than 0.05 was considered statistically significant. SPSS statistical software  was used for all calculations.Descriptive data are presented as the mean  for normally distributed variables and as the median (interquartile range) for non-normally distributed variables. Categorical variables are expressed as absolute numbers with percentages. Categorical variables were compared by Chi-square test. The analysis of variance test was performed for the comparison of parameters between groups by the independent-samples 2. In addition, 215 patients (97.3%) had been on dialysis , and 6 patients were given conservative treatment without dialysis. The median dialysis duration was 61.0 months (range 0–186 months). The median level of iPTH was 852.0 pg/ml (range 113.4–3864.0 pg/ml). Osteoporosis was present in 27.6% (61/221) of patients, parathyroid hyperplasia in 69.7% (154/221) of patients, and vascular calcification in 51.1% (113/221) of patients.Two hundred and twenty-one patients were enrolled in the present analysis. The mean age was 43.4 ± 14.3 years; 56.6% were male. The mean body mass index (BMI) was 21.8 ± 3.1 kg/mp < 0.001) and female (p = 0.01) and to have a longer dialysis duration (p < 0.001). The level of serum albumin was lower (p = 0.002), and the levels of bone metabolism markers, including intact PTH (p < 0.001), sALP (p < 0.001), ß-CTX (p = 0.01), and P1NP (p < 0.001), were significantly higher in osteoporosis patients. Compared to nonosteoporosis patients, the incidence of parathyroid hyperplasia  and vascular calcification  was higher in osteoporosis patients.The characteristics of ESRD patients categorized by osteoporosis status are shown in Table In multivariable binary logistic regression analysis, osteoporosis was significantly positively associated with age and the level of iPTH Table . Accordip < 0.001), were more likely to be on hemodialysis (p = 0.02), had a longer dialysis duration (p < 0.001) and had a reduced level of serum albumin (p < 0.001). The levels of intact PTH, sALP, ß-CTX, P1NP (p < 0.001), OC (p = 0.005) and 25(OH)D (p = 0.04) were significantly higher in patients with vascular calcification. Compared to patients without vascular calcification, patients with vascular calcification had a higher incidence of parathyroid hyperplasia  and osteoporosis .The clinical and biochemical parameters of the study participants by vascular calcification status are shown in Table Vascular calcification was significantly positively associated with age and the levels of 25(OH)D and iPTH according to multivariate analysis  guidelines recommend maintaining iPTH levels in the range of approximately 2 to 9 times the upper normal limit in patients with CKD G5D . In a laIn this study, we also discovered that moderate and severe hyperparathyroidism (iPTH 600–1499 pg/ml and iPTH 1500 pg/ml) were related to reduced levels of serum albumin and hemoglobin. Malnutrition is linked to an increase in morbidity and hospitalizations in patients with chronic renal disease and kidney transplants. Recent research indicated that individuals receiving maintenance hemodialysis for severe hyperparathyroidism had nutritional decline . The invIncreased levels of both formative and resorptive markers were associated with decreased MBD and worsening parameters of bone quality. The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), in collaboration with the International Osteoporosis Foundation (IOF) and the National Bone Health Association (NBHA) in the US, have designated serum P1NP and serum ß-CTX in blood as reference standard bone turnover markers . HoweverOur study has several limitations. The small number of patients and the cross-sectional design may influence the power to assess the relationship between osteoporosis, vascular calcification and other factors. The lack of bone biopsy data made us unable to accurately diagnose the histological type of renal osteodystrophy. In addition, the patients in this study had high levels of iPTH, and a population with low bone turnover status may be uncovered.There is a high prevalence of vascular calcification and osteoporosis in ESRD patients awaiting transplantation. They shared similar risk factors, including older age, longer dialysis duration, parathyroid hyperplasia and higher levels of iPTH and bone turnover markers. In the multivariable regression model, age and iPTH were independent risk predictors of both vascular calcification and osteoporosis. Furthermore, the moderate and severe hyperparathyroidism were related with lower levels of serum albumin and hemoglobin. The involvement of high PTH levels in vascular calcification, osteoporosis and malnutrition indicated the need of treating hyperparathyroidism early in patients awaiting kidney transplantation. Bone turnover markers were positively correlated with the levels of PTH and ALP, but the diagnostic value of bone turnover markers has not been validated in ESRD patients. Prospective studies are needed to further examine the utility of bone turnover markers.


This study aimed to compare the efficacy and safety of high-dose methotrexate (HD-MTX) versus teniposide (TEN) in patients with newly diagnosed immunocompetent primary central nervous system lymphomas (PCNSLs).The study included immunocompetent, adult patients with newly diagnosed PCNSL at 22 centers in China from 2007 to 2016. The patients received HD-MTX or TEN as first-line induction therapy. The objective response rate, progression-free survival, and overall survival were analyzed for each patient cohort.P = 0.627). The median progression-free survival was 28.4 months [95% confidence interval (CI): 13.7–51.2] in the MTX cohort and 24.3 months (95% CI: 16.6–32.1) in the TEN cohort (P = 0.75). The median overall survival was 31 months (95% CI: 26.8–35.2) in the MTX cohort and 32 months (95% CI: 27.6–36.4) in the TEN cohort (P = 0.77). The incidence of any grade of coagulopathy/deep-vein thrombosis and gastrointestinal disorders was significantly higher in the MTX cohort than in the TEN cohort; no significant difference was found in the incidence of other adverse events between the two cohorts.A total of 96 patients were eligible: 62 received HD-MTX, while 34 received teniposide. The overall response rate was 73.2% and 72.7% in the MTX and the TEN cohorts, respectively (This was the first multicenter study using TEN as the main agent compared with HD-MTX in newly diagnosed primary CNS lymphoma. The TEN-based regimen was non-inferior to the HD-MTX-based regimen with similar overall responses.This study provided Class III evidence that the teniposide-based regimen was non-inferior to high-dose methotrexate − based regimen with similar overall responses and long-time survival in immunocompetent patients with PCNSL. Primary central nervous system lymphoma (PCNSL) accounts for 2%–3% of all non-Hodgkin’s lymphoma cases with increasing incidence, particularly for elderly patients . The sta2) to overcome the BBB , PFS, and OS. The OS was calculated from the time of diagnosis to death of any cause or, for the patients alive, to the date of the last follow-up, whereas PFS was the time from diagnosis to the time of relapse or progression or death from any cause. The International PCNSL Collaborative Group Response Criteria  was usedP value < 0.05 on UVA were included in the stepwise multivariate Cox proportional-hazards model. Hazard ratios (HRs) and their 95% confidence intervals (CIs) were calculated. The Cox proportional-hazards model was recalculated with the addition of an induction regimen as a variable to evaluate the impact of the induction regimen. Kaplan–Meier survival curves were generated. Analyses were done with IBM SPSS software (version 20·0). The differences in categorical data were calculated using the chi-square or Fisher’s exact test with significance defined as P ≤ 0.05. All P values were two tailed.The baseline (pretreatment) and treatment variables were collected, along with dates of first progression, last follow-up, and death. The normally distributed variables were expressed as mean ± standard deviation (SD), and the skewed or unknown distributed variables were displayed as the median and interquartile range (IQR). The categorical variables were presented as count (percentage). The univariate analyses (UVA) for OS were performed using each of the pretreatment variables evaluated. The survival analyses were performed regardless of the duration or type of therapy received. PFS and OS rates were estimated using the Kaplan–Meier method, and differences were assessed with the log-rank (Mantel–Cox) test. Variables with a P = 0.047). No significant differences were found in age, sex, ECOG performance status, IELSG risk, LDH level, CSF cytology, lymphoma categories, comorbidities, and the combination of MTX/TEN with rituximab and radiotherapy between the 2 cohorts (Table P = 0.655). The ratio was 1.13:1 in all patients, with no difference between the two cohorts. Nearly half of the patients had poor performance status (ECOG PS ≥ 2). More than 95% patients in both cohorts had B-cell lymphoma, and most of them had diffuse large B-cell lymphoma. Most patients were diagnosed by stereotactic or surgical biopsy, and only one patient in the MTX cohort was diagnosed by cytology from CSF. The comorbidities in two groups were similar, including hypertension, coronary disease, diabetes, hyperlipidemia, viral hepatitis B. In MTX group, there was one patient with depressive state, one patient cured gastric cancer, and one patient with hysterectomy. In TEN group, there was 1 patient with a mass on kidney without pathological diagnosis and 1 patient with hysterectomy. Less than half of the patients in both cohorts received MTX or teniposide with rituximab as the first-line induction therapy, and nearly half of the patients received radiotherapy as a consolidation therapy after MTX or teniposide.Full survival data were available for 96 eligible patients from 22 centers in China. Of these, 62 patients received treatment with MTX monotherapy with or without rituximab (MTX cohort), and 34 patients received teniposide monotherapy with or without rituximab (TEN cohort). The proportion of patients whose tissue samples were obtained by stereotactic biopsy in the MTX cohort was significantly lower than that in the TEN cohort , while the proportion of patients whose tissue samples were obtained by surgical partial resection was significantly higher than that in the TEN cohort (70.5% vs 50.0%) (ts Table . The medP = 0.627). The complete response rate in the MTX cohort was higher than that in the TEN cohort, with no statistically significant difference (P = 0.182). According to the IELSG score, no difference in overall responses was found among three levels (P = 0.467). Four patients in the MTX cohort and 1 patient in the TEN cohort received autologous hematopoietic stem cell transplantation (ASCT) after the methotrexate and teniposide induction therapy. It might partially explain the higher complete response rate in the MTX cohort. None of the enrolled patients underwent allogeneic hematopoietic stem cell transplantation. Of all 89 patients who received at least 1 dose of first-line chemotherapy and fulfilled all eligibility criteria, 2 (3.6%) died during first-line therapy in the MTX cohort. The causes of death were cerebral bleeding  and acute toxic effect   in the MTX cohort and 39 months  in the TEN cohort. The ORR was 73.2% and 72.7% in the MTX and TEN cohorts  in the MTX cohort and 24.3 months (95% CI: 16.6–32.1) in the TEN cohort (3.7–51.2 P = 0.009).The univariate analysis found that age, ECOG, IELSG risk, rituximab, and radiotherapy were not significantly associated with PFS. The multivariate analysis found radiotherapy was significantly associated with PFS  .Table The most common adverse reactions during treatment in patients in the MTX and TEN cohorts included neutropenia, thrombocytopenia, anemia, febrile neutropenia/infections, hepatotoxicity, nephrotoxicity, coagulopathy/DVT, gastrointestinal, mucositis, and acute neurotoxicity. In the MTX cohort, common grade 4 adverse events included neutropenia (19.2%), thrombocytopenia (13.5%), anemia (19.2%), febrile neutropenia/infections (1.9%), mucositis (1.9%), and acute neurotoxicity (1.9%). Common grade 5 adverse events included febrile neutropenia/infections (1.9%), coagulopathy/DVT (1.9%), and acute neurotoxicity (1.9%). In the TEN cohort, the most common grade 4 adverse events included neutropenia (24.2%), thrombocytopenia (9.1%), anemia (3%), and febrile neutropenia/infections (6.1%). Grade 5 febrile neutropenia/infections occurred in only 1 (3%) patient  and median OS (31 months vs 32 months) between MTX and TEN cohorts. The results of an open, randomized, phase 2 trial showed that patients with PCNSL treated with methotrexate and methotrexate plus cytarabine had an ORR of 40% and 69%, respectively . A retroTEN was used as a main drug in our study for several reasons. It is lipophilic to cross the BB and is eliminated at a slow rate . SeveralP = 0.14), but omitting WBRT might not be associated with inferior OS . A similar result was obtained in another retrospective research of 103 patients with PCNSL [NCT05011045.) was conducted to explore the impact of consolidative WBRT. In our study, deferred WBRT improved PFS, but not OS. This could be clinically relevant in terms of lower incidence of neurotoxicity.Although the combination of HD-MTX-based chemotherapy followed by consolidative WBRT is still commonly used, the role of whole-brain radiotherapy after induction chemotherapy is controversial. G-PCNSL-SG-1 , a phaseth PCNSL . Howeverth PCNSL . In a muWhether intravenous rituximab accumulated sufficiently in the CNS to exert an effect was debatable. Holdhoff et al.  reportedNearly half of the patients with PCNSL are aged > 60 years, with 1 tenth of these aged ≥ 80 years . DespiteOur study had a few limitations. It had intrinsic limitations given that it was a retrospective analysis. Also, the radiology review was not done in a blinded manner. Although the survival in the MTX cohort was similar to the published findings , the timIn conclusion, the findings of this study indicated that TEN was well tolerated and effective in patients with PCNSL and could be used as an alternative to HD-MTX in patients who could not afford the risk of side effects. These findings should be confirmed in a prospective, randomized, controlled trial. In addition, further large-sample studies with longer follow-up are required to investigate the regimen of TEN combined with other drugs.