The nuclear transport system has been proposed to be indispensable for cell proliferation and invasion in cancers. Prognostic biomarkers and molecular targets in nuclear transport systems have been developed. However, no systematic analysis of genes related to nuclear transport in gliomas has been performed. An integrated prognostic classification involving mutation and nuclear transport gene signatures has not yet been explored.n = 660) and validation cohort  to develop a prognostic nuclear transport gene signature and generate an integrated classification system. Gene set enrichment analysis (GSEA) showed that glioblastoma (GBM) was mainly enriched in nuclear transport progress compared to lower-grade glioma (LGG). Then, we developed a nuclear transport risk score (NTRS) for gliomas with a training cohort. NTRS was significantly correlated with clinical and genetic characteristics, including grade, age, histology, IDH status and 1p/19q codeletion, in the training and validation cohorts.In the present study, we analyzed gliomas from a training cohort (TCGA dataset, High group. Subgroup survival analysis revealed that NTRS could differentiate the outcomes of low- and high-risk patients with wild-type IDH or mutant IDH and 1p/19q non-codeletion.Survival analysis revealed that patients with a higher NTRS exhibited shorter overall survival. NTRS showed better prognostic value compared to classical molecular markers, including IDH status and 1p/19q codeletion. Furthermore, univariate and multivariate analyses indicated that NTRS was an independent prognostic factor for gliomas. Enrichment map and Gene Ontology analysis demonstrated that signaling pathways related to the cell cycle were enriched in the NTRSNTRS is associated with poor outcomes and could be an independent prognostic marker in diffuse gliomas. Prognostic classification combined with IDH mutation, 1p/19q codeletion and NTRS could better predict the survival of glioma patients.The online version contains supplementary material available at 10.1186/s12885-020-07552-3. Eukaryotic cells are divided into the nucleus and cytoplasm by the nuclear membrane. The movement of macromolecules between the nucleus and the cytoplasm, mostly including proteins and RNAs, occurs via the nuclear transport system . The nucGliomas are the most common primary tumors of the central nervous system and are classified by histologic and genomic phenotype , 10. IDHIn this study, using RNA-seq data from TCGA as a training cohort and data from CGGA as a validation cohort, we established a nuclear transport risk score (NTRS) and tested the correlations between NTRS and clinicopathologic characteristics. We found that NTRS was an independent biomarker of prognosis and was associated with cell cycle-related pathways. Finally, combined with IDH mutation and 1p/19q codeletion, the value of NTRS in prognostic classification was validated. Taken together, our results indicated that the nuclear transport-related gene signature was strongly associated with poor outcomes and could serve as a novel biomarker for prognostic classification in diffuse gliomas.n = 660) with LGG and GBM from cBioPortal  [n = 668) came from CGGA (http://www.cgga.org.cn/index.jsp) [http://gliovis.bioinfo.cnio.es/) [The data from the TCGA training set included RNA-seq data and clinical data from patients  , 13. Thedex.jsp) . The micnio.es/) . The pathttp://software.broadinstitute.org/gsea/msigdb). Univariate Cox regression analysis was carried out to pre-filter genes associated with nuclear transport(n = 336) and 251 genes correlated with survival (P ≤ 0.01). Seven genes and their regression coefficients were calculated according to least absolute shrinkage and selection operator (LASSO) regression using the R package “glmnet “with parameters  [The nuclear transport gene set was collected from the Molecular Signature Database v7.0 ds = 10) . The ris0 . The rhttp://software.broadinstitute.org/gsea/msigdb/genesets.jsp?collection=BP) [GSEA was performed with Gene Ontology (GO) biological process related gene sets (4436) (tion=BP) . Enrichmtion=BP) . GO clustion=BP) .The human glioblastoma cell line (LN-229) was obtained from ATCC and not passaged for more than half a year. Cells were cultured in DMEM (Gibco) containing 10% FBS and were incubated at 37 °C.The plasmids of NTRS related genes were obtained from Hanbio Inc. the transfection was performed according to the procedure of Lipofectamine 3000(Thermofisher). Three days after transfection, total RNA was extracted using RNAiso kit (Fastagen) and was reverse-transcribed (Takara). qRT-PCR was performed with SYBR Premix (Takara) using Bio-Rad RT-PCR System (CFX96). The results were normalized against GAPDH. The sequences of the primer were listed in Supplementary Table P < 0.05 was considered statistically significant. .The optimal cut-off value for NTRS was determined via ROC curve analysis. Briefly, in the ROC curves, the x-axis was plotted as “1-specificity” , and the y-axis was plotted as the “sensitivity” (true positivity). The optimal cut-off value was determined on the basis of the Youden index (Y), which was the point with maximum sensitivity and specificity (Y = sensitivity+ specificity − 1) . Student, we analyzed the expression of the nuclear transport gene set with the TCGA dataset. GBM showed distinct nuclear transport phenotypes from LGG  by univariate Cox regression analysis . In the multivariable analysis, NTRS , age , grade , IDH status  and chromosome 19/20 status were independently associated with overall survival , GO analysis verified that the cell cycle and immune responses were significantly enriched in NTRSHigh patients  were associated with a low NTRS, whereas only 4% of gliomas diagnosed as WHO grade III (3/74) were associated with a low NTRS. In gliomas with IDH mutations and without 1p/19q codeletion, the rate of high NTRS values increased according to the WHO grade . In gliomas without IDH mutations, 56% of gliomas diagnosed as WHO grade II (10/18), 94% as WHO grade III (68/72) and 100% as WHO grade IV (143/143) exhibited a high NTRS , gene signatures have been broadly applied in the clinic for the prediction of recurrence and the response to therapy –33. GeneSince the publication of the 2016 WHO classification of tumors of the central nervous system, integrated classification has been generally applied to glioma. With the availability of public databases, the integration of data on histology and mutation, methylation and mutation or mRNA expression and mutation can divide patients into different subgroups , 35, 36.Risk score based on nuclear transport system is significantly associated with poor clinicopathologic characteristics and is an independent prognostic marker in diffuse gliomas.The nuclear transport risk score combined with IDH mutation and 1p/19q codeletion could better predict the overall survival of glioma patients.Additional file 1: Supplemental Figure 1. Heatmap of nuclear transport genes in lower-grade gliomas and glioblastomas.Additional file 2: Supplemental Figure 2. FPKM value of NTRS related seven genes in patients stratified by WHO grade.Additional file 3: Supplemental Figure 3. Distribution of NTRS in patients stratified by WHO grade (A), age (B), IDH status (C), 1p/19q status (D), histology (E) and molecular subtype (F) in the training set. *P < 0.05; **P < 0.01; ***P < 0.001.Additional file 4: Supplemental Figure 4. overall survival analysis of glioma patients with a high NTRS (NTRSHigh) versus low NTRS (NTRSLow) in Rembrandt, Grevendeel and Kamoun dataset. Median of NTRS as cut-off value.Additional file 5: Supplemental Table 1. The clinicopathological characteristics of the glioma patients enrolled in this study.Additional file 6: Supplemental Table 2. Clinical characteristics and NTRS groups of the training cohort (n = 660).Additional file 7: Supplemental Table 3. Clinicopathological characteristics and NTRS groups of the validation cohort (n = 668).Additional file 8: Supplemental Table 4. The sequences of the primers.Additional file 9: Supplemental Table 5. The list of 336 nuclear transport related genes.Additional file 10: Supplemental Table 6. The list of 251 genes filtered by Univariate Cox regression analysis.


Neoadjuvant therapy can shrink tumors, increase anus preservation rate, and protect anal function. Radical surgery need cut off the diseased bowel, clean up the lymph nodes, and then restore bowel function. It could bring traumatic effect and poor postoperative quality of life to the patient. Local resection requires removal of the diseased bowel with circular negative margin. The surgical trauma is small, and the postoperative quality of life is good. In this meta-analysis, we aimed to evaluate the efficacy and safety between wait and see strategy (WS), radical surgery (RS), and local excision (LE) of rectal cancer patients with clinical complete response (cCR) response after neoadjuvant chemoradiotherapy.We searched PubMed, Cochrane Library, CNKI , and Wanfang databases to compare wait and see strategy with radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy up to March 2020. We collected the data of local recurrence, distant metastasis, cancer-related death, overall survival, and disease-free survival and used RevMan 5.0 to carry out the meta-analysis. Continuous data were evaluated by the standardized mean differences (SMD) with 95% confidence intervals (95% CIs), and dichotomous data were evaluated by relative risks (ORs or RRs) with 95% CIs. We aimed to compare the advantages and disadvantages of the three groups.P < 0.001). There was no significant difference in the other data between the three groups.Eleven English studies with 1131 patients were included. There were 412 patients in WS group, 678 patients in RS group, and 41 patients in LE group. WS group had a higher local recurrence rate than RS group (OR 7.32, 95% CI 3.58 to 14.95, Compared with the RS group, the WS group had an increased risk of local recurrence. However, the WS group had a similar DFS and OS compared with the RS group and the local excision group. Hence, we speculated that the WS group would have similar results as the surgery group for patients with cCR status. Colorectal cancer is a serious threat to human health. Mid-low rectal cancer accounts for 70% of colorectal cancer , 2. RadiIn 2004, Habr-Gama published the results of rectal cancer patients with cCR status after neoadjuvant chemoradiotherapy. Habr-Gama first proposed the WS strategy of treating rectal cancer patients with cCR status and pointed out that the WS strategy could achieve similar clinical effects as surgery . The 5-yThere were several meta-analyses related to this topic, such as Li’s research, Dossa’s research, and some other papers published in a Chinese magazine –14. The We carried out this meta-analysis by using the PRISMA guidelines. The details of PICOS were as follows: Population: rectal cancer patients with a cCR response after neoadjuvant chemoradiotherapy; Intervention: wait and see strategy; Comparator: radical surgery or local excision; Outcomes: long-term outcomes including local recurrence, distant metastasis, cancer-related death, disease-free survival (DFS), and overall survival (OS) which were analyzed and compared , and Wanfang databases (up to March 2020). Articles about wait and see versus radical surgery or local excision after neoadjuvant chemoradiotherapy for rectal cancer were collected. To avoid missing useful articles, we expanded the scope of search terms and find articles for the purpose by manual screening. The search terms were “wait and see” or “nonoperative management” and “neoadjuvant chemoradiotherapy” and “rectal cancer.” The details are shown in additional file There were 4 inclusion criteria: 1) pathological and long-term outcomes were compared between wait and see and radical surgery or local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy; 2) surgery included radical surgery and local excision; (3) cCR response after neoadjuvant chemoradiotherapy (criteria for ccR were mentioned above) ; and (4) patholog surgery There were 3 exclusion criteria: (1) studies with no valuable outcome; (2) patients were not well grouped or groups were confusing and not suitable for the purpose of the article; and (3) bad clinical response of rectal cancer after neoadjuvant chemoradiotherapy. Bad clinical response included larger residual tumor in endoscopy and DRE, positive biopsies, and larger tumor and lymph nodes in MRI. The details of inclusion and exclusion criteria are in additional file Using the Newcastle-Ottawa Scale (NOS) guidelines, two reviewers searched the literatures (GHZ and DMY) independently . We collI2 statistic and funnel plots separately. When huge heterogeneity existed (I2≧50%), we used random-effects models to analyze the data. We used fixed-effects model to analyze the data with little heterogeneity (I2 < 50%).We used RevMan 5.0 to carry out the meta-analysis. Continuous data were evaluated by the standardized mean differences (SMD) with 95% confidence intervals (95% CIs), and dichotomous data were evaluated by relative risks (ORs or RRs) with 95% CIs. Heterogeneity and publication bias were estimated by n = 527), no control group (n = 851), and insufficient data (n = 455). Regarding study information, after we read the remaining studies carefully, 11 English studies with 1131 patients were included [Duplicated records were deleted. We deleted 1843 studies after reading the titles and abstracts carefully. Deleted studies were due to not of rectal cancer . The score indicated three levels of quality: low 1–3), moderate (4–6), and high (7–9). We included 11 studies in our study ) with moderate to high quality. No relevant RCTs were found during the database search. The details are shown in Table –3, moderP < 0.001, chi2 = 4.51, P = 0.81, I2 = 0%, Fig. P = 0.02, chi2 = 2.03, P = 0.36, I2 = 1%, Fig. P < 0.001, chi2 = 0.69, P = 0.95, I2 = 0%, Fig. P = 0.92, chi2 = 13.01, P = 0.11, I2 = 38%, Fig. P = 0.22, chi2 = 4.07, P = 0.25, I2 = 26%, Fig. The WS group had a higher recurrence rate than the RS group. Other primary objectives were similar in the two groups. The details were as follows: 9 studies reported clinical data on local recurrence, and the WS group had a higher recurrence rate than the RS group in the fixed-effects model . Surgery should be approximately about 6–8 weeks and 12 weeks at the maximum. In this way, the tumor can shrink to a minimum and the edema of the irradiation field completely disappeared, improving the PCR and anus preservation rate [The details of the neoadjuvant treatment are shown in additional file ion rate . The incAlthough Professor Dossa included 23 studies in his research, only 15 studies had control groups and 5 studies had specific data of comparison between two groups. He proposed that there were no significant differences in non-regrowth recurrence, cancer-specific mortality, overall survival, and disease-free survival. There were 9 studies in Professor Li’s research, and he reported that two patient groups were similar in distant metastasis rates, disease-free, and overall survival, but the non-surgical group had a higher risk of 1-, 2-, 3-, and 5-year local recurrence. Our report also showed a higher local recurrence rate in the WS group than the RS group, which affirmed the effect of wait and see strategy for patients with cCR status. Subgroup analysis of Eastern and Western studies were also performed, and we hoped that more studies about cCR-related research of the WS group versus radical surgery or local excision would appear .Arauio and Smith had patients with Stage IV; thus, we removed those two studies. More cases with T3–4 and N1–2 stage are more needed to perform neoadjuvant treatment than T1–2 and N0 stage. We found that some patients with T3–4 and N1–2 stage could obtain cCR after neoadjuvant treatment with better prognosis than adjuvant treatment. Sometimes, T1–2 and N0 stage might be treated directly with surgery and obtained a considerable effect. However, the relevant prognosis of patients with T and N stage were not specified in the article, and we could not use the meta-analysis to define the specific meaning of T and N stage for cCR. Most patients had achieved T and N stage reduction after neoadjuvant therapy, but there was too little available information to form a conclusion about a specific treatment method for these patients.This study might have several limitations. First, 11 studies (4 RCNT and 7 PNCT) with a total of 1131 patients could not represent the highest level of evidence due to the non-included RCTs. Second, incomplete clinical data and some unbalanced baseline characteristics could affect the results. Third, differences between Eastern and Western population groups could cause potential selection bias. Finally, more cCR patients need to be included. Furthermore, more RCTs for the wait and see strategy versus surgery for cCR are necessary.In summary, this study compared the reliability and safety of the wait and see strategy to radical surgery and local excision for rectal cancer with cCR response after neoadjuvant chemoradiotherapy. The WS group had higher local recurrence rate than the RS group. There was no significant difference in other data. With neoadjuvant chemoradiotherapy development and appropriate salvage therapy for local recurrence, the wait and see strategy could minimize surgical trauma and preserve the anus and had the advantages for cCR patient. Therefore, we propose that the wait and see strategy could be a feasible model for cCR patient.Additional file 1:.Additional file 2:. The details of diagnostic criteria of each method in each study.Additional file 3:. The details of PICOSAdditional file 4:.Additional file 5:. The details of neoadjuvant treatment of studiesAdditional file 6:. The details of Inclusion and Exclusion CriteriaAdditional file 7:.Additional file 8:.


The aim of the study was to estimate the rate of adverse reactions to live BCG Moreau vaccine, manufactured by Biomed in Poland, in severe combined immunodeficiency (SCID) patients.The profiles of 52 SCID patients vaccinated at birth with BCG, hospitalized in Children’s Memorial Health Institute, Warsaw (CMHI), in the years 1980–2015 were compared with those of 349 BCG-vaccinated SCID patients from other countries analyzed by Beatriz E. Marciano et al. in a retrospective study , with no death in patients treated with SCID anti-TB drug, except one in lethal condition. In our study, disseminated BCG infection was observed only in SCID with T-B+NK- phenotype and significantly lower NK cell counts (p = 0.0161). NK cells do not influence on the frequency of local BCG reaction. A significantly higher number of hematopoietic stem cells transplantations (HSCT) were performed in CMHI study (p = 0.0001). Anti-TB treatment with at least two medicines was provided.Significantly less disseminated BCG infections  occurred in comparison with Marciano study—119 out of 349, 34%  contains supplementary material, which is available to authorized users. BCG vaccination administered at birth or shortly after birth is included in vaccination schedules in countries with a high prevalence of tuberculosis (TB). At present, three different BCG vaccine substrains, Danish 1331, Tokyo 172–1, and Russian BCG-I, are recommended by the World Health Organization (WHO) as International Reference Reagents (IRR). These three substrains constitute the major proportion of BCG vaccine production worldwide as they are supplied by the United Nations Children’s Fund (UNICEF) .Differences in reactogenicity between vaccines can be observed, and they relate to particular substrains. In 1955, the highly reactogenic BCG Danish vaccine was replaced in Poland by the locally produced BCG Moreau vaccine, a descendant of Brazilian BCG Moreau substrain. The BCG Danish 1331 vaccine and the Pasteur substrains have generally been considered reactogenic –10. The On the basis of the results obtained by Zapaśnik-Kobierska and Stopnicka, lymphadenitis complications in newborns vaccinated with BCG Moreau, BCG Danish 1331, or BCG Pasteur in the vaccinated cohort were found to stand at 0.3%, 2.4%, and 4.9%, respectively . FurtherThe frequency of fatal BCG disseminated infection is estimated at approximately 0.06–1.56 cases per million doses of vaccine administered, typically in primary immunodeficiency disease (PID) –34. The The aim of the present study was to estimate the frequency of complications and the risk associated with BCG vaccination in SCID patients hospitalized in the Department of Immunology, CMHI in Warsaw, over the period of 35 years, and to compare the results with those described in the retrospective study of SCID patients vaccinated with a variety of BCG vaccines containing different substrains used worldwide [https://esid.org/Working-Parties/Registry-Working-Party/Diagnosis-criteria). Localized BCG infection was referred to as a lesion inside the inoculation site (> 10 mm) and/or lymphadenitis limited to the region of the inoculation site while disseminated BCG infection was defined as a persistent process spreading over two or more regions beyond the inoculation site. The Mycobacterium tuberculosis complex molecular analysis was conducted using the PCR (MTD Gen-Probe) test and the analysis of mycobacterium culture was performed in a BACTEC 460 Tb or MGIT 960 system. Mutation analysis in PID patients was performed at the Department of Immunology, Erasmus MC in Rotterdam, Netherlands, in the Center for the Study of Primary Immunodeficiencies, Assistance Publique, Hopitaux de Paris, Necker Hospital, 75,015 Paris, France. Absolute numbers and percentages of circulating B and T subsets CD19/CD20, CD3, and natural killer cells (NK-CD56/CD16) were assessed and compared with reference values established in age-matched groups of healthy children [t test or Mann-Whitney U test. The Chi-squared test and Fisher’s exact test for independence was used for qualitative variables. In order to determine dependence, strength and direction between variables, correlation analysis was used by determining the Pearson or Spearman’s correlation coefficients. In all calculations, the statistical significance level of p = 0.05 was used. The statistical analysis of the retrospective study of 52 SCID patients hospitalized at CMHI was compared with that of 349 SCID patients investigated by Beatriz E. Marciano and co-authors [As many as 1727 patients were diagnosed with PID in the Department of Immunology, CMHI, Warsaw, between 1980 and 2015. A total of 52 Caucasian origin SCID patients, born in Central-Eastern Poland, were vaccinated with BCG at birth. The incidence of BCG-associated infections following vaccination with the BCG Moreau vaccine produced by Biomed, Lublin, Poland, was analyzed in a group of SCID patients susceptible to BCG infection. BCG disseminated infections were diagnosed based on clinical, microbiological, and histopathological findings following ESID diagnostic criteria [children . Statist-authors .This study was approved by the Bioethics Committee of CMHI—resolution no 51/KBE/2017, 06 September 2017.p = 0.1510) from the Marciano study.In 52 SCID patients diagnosed in CMHI, the mean age at which first SCID symptoms occurred was 3.3 months (in the range of 1.0–24.0), the age of SCID diagnosis was 13.5 months (in the range of 1.0–63.0). In 19 out of 52 cases, the diagnosis with SCID was carried out at the age of 7–12 months, which was comparable with 94 patients . In three infants, SCID diagnosis was established before 1985, when they were admitted in the terminal stage to the intensive care unit. Two of them died soon in the course of multiple organs insufficiency, postmortem examination found granulomas, which is the full field diagnosis criteria of possible form of disseminated BCG infection [https://esid.org/Working-Parties/Registry-Working-Party/Diagnosis-criteria). The third one, with a positive family history  was admitted because of respiratory insufficiency and hepatosplenomegaly. Bronchopulmonary lavage samples were tested for Mycobacterium tuberculosis complex; positive PCR and culture results led to the diagnosis as a definitive form of the disease [https://esid.org/Working-Parties/Registry-Working-Party/Diagnosis-criteria). He died after 4 months, despite the administration of 5 anti-TB medications in a course of overwhelming BCG infection. The HSCT procedure was not considered because of serious condition of this child.Disseminated BCG infection occurred in 10 SCID patients out of 52 vaccinated with BCG, twelve localized complications were present in both group, separately or together with disseminated BCG infection. (Table S1). Disseminated BCG infection was diagnosed in 10 SCID patients with TB+NK-phenotype, in 6 with IL2RG mutation, in one patient with JAK3 deficiency and in 3 with unknown mutations. Disseminated BCG infection was not present in the group of TB-NK+SCID patients, including 16 patients with RAG1/2, 2 patients with IL7RA and 2 with Artemis mutation, 1 patient each with MHC II, ZAP-70, and Cernunnos, and in 10 patients with unknown mutations (Table S1). Among SCID patients, the clinical manifestation of disseminated BCG infection was recognized as meningitis in 1 patient, bronchopneumonia in 4, disseminated skin infection in 3, single skin abscess in 2, and osteomyelitis and/or pathological fractures occurred in 6 patients. Infiltrations in spleen and liver abscess were observed in 5 patients. No brain abscess, lymphadenitis, and other localization of BCG infection were observed. The infection was confirmed with the positive polymerase chain reaction (PCR) for the iagnosis  (https:/p = 0.0028). However, in 12 (24%) SCID patients with localized BCG, the rate was higher, but not significantly, compared with the Marciano study’s 60 (17%) (p = 0.2417). Mortality caused by BCG-associated complications in the Marciano cohort of SCID patients was higher, but not significantly: 46 (13%) deaths out of 349 (p = 0.1724). In the CMHI cohort, 3 (5%) deaths occurred before 1985.Disseminated BCG infections in 10 (19%) SCID patients hospitalized at CMHI constitute a significantly lower score in comparison with 119 (34%) in the Marciano study (p = 0.0915), while the absolute number of B cells was significantly higher (p = 0.0126) and the number of NK cells was significantly lower (p = 0.0161) in the group with BCG complications in the CMHI study (Table S2).The median absolute number of T cells at the time of SCID diagnosis in patients with disseminated BCG-associated complications was found to be insignificant (p < 0.000001), localized complications were observed in both groups; insignificantly higher in NK+SCID patients (p = 0.4859) (Table S3).Disseminated BCG-associated complications in the CMHI study were found only in 18 out of 52 SCID patients with a low number of NK cells (p = 0.0001). Fifty-eight out of 349 SCID patients were diagnosed in Brazil, constitute the largest cohort of this study [p = 0.0001). Polish and Brazilian cohorts were vaccinated at birth with a locally produced BCG Moreau vaccine [Dual drug anti-TB therapy (isoniazid and rifampicin) was administered to 17 patients (33%) with local BCG complications. In 7 out of 10 SCID patients, BCG disseminated infection was successfully treated in all of them with 4 or 5 anti-TB drugs . In our study, the mean age at HSCT was 21.4 m. (a range of 4.0–96.0 m.). HSCT was administered in 43 patients (83%) in total vs 190 (54%) SCID patients in the Marciano study, the number being significantly higher in the CMHI study  with a satisfying stem cell engraftment, in one patient transient, moderate course of this disease was observed. Mixed chimerism concerning various cell lines was observed in 4 infants and is still present in one. Antimycobacterial treatment was discontinued within 8–15 months in all 7 treated patients, which coincided with immunological reconstitution. In 2 post-HSCT patients local and disseminated reactivation of BCG occurred within 3 months after transplantation. One of the patients was treated with 2 anti-TB drugs because of local BCG infection. He began to lose weight and a subfebrile condition developed. Infiltrations in spleen, liver, pathological fracture of the right hand third and fourth finger distal bones and disseminated skin abscess appeared. During the next 15 months, clinical improvement and full chimerism occurred. In the other patients with local BCG infection following HSCT, treatment with 2 anti-TB drugs was discontinued within the next few weeks. Enlargement and infiltration in the occultation site was observed and slowly dispersed during the 8 months of therapy with 3 anti-TB drugs.In the last three decades, numerous studies on BCG complications in PID patients have been published by national and regional or local centers. The cumulative study of 349 patients with SCID from 17 countries vaccinated with BCG constitutes the biggest record published to date . The preThroughout the years, a great number of publications on BCG-associated complications in PID patients susceptible to this infection have reflected the differences in the reactogenicity of various BCG vaccines produced with different substrains –34. A suThe safety profile of the Polish Moreau BCG vaccine in SCID in comparison with other substrains used worldwide has been documented.In Africa, where the BCG Danish substrain vaccine is widely used, the risk of disseminated BCG infection is several hundred-fold higher in HIV-infected infants compared to the documented risk in HIV-uninfected children , 37, 38.Mycobacterium bovis BCG Moreau Rio de Janeiro substrain [. Since various BCG substrains have been associated with different reactogenicity, genetic variations might also be involved in the level of potential BCG complications [Rv3887c, a region involved in the membrane transport protein which constitutes part of the ESX-2 type VII secretion system. The role of Rv3887c is not well known, but homology with the components of the ESX-1 secretion system might influence immunogenicity [The Moreau BCG substrain used in vaccine production in Poland is a descendant of the parent ubstrain –44. A reubstrain . The majubstrain . Out of ubstrain . By contications –44. Krysications –44. The genicity . These fgenicity –45. The https://esid.org/Working-Parties/Registry-Working-Party/Diagnosis-criteria). Anti-TB therapy is continued after HSCT, when local or disseminated symptoms are present or reactivation of BCG infection occurred, usually a few weeks after transplantation. Isoniazid and rifampicin constitute a base treatment in local complication, if disseminated process occurred after other anti –TB drugs were administered. In our group of SCID with BCG – associated complication, treated with anti-TB drugs, full recovery was observed, with no relapse during long-lasting observation, except one patient from early 80s in whom anti-TB treatment was ineffective, because of the severity of the overwhelming BCG infection.Immunological reconstitution by HSCT and treatment of mycobacterial infection are the key elements of successful therapy in SCID patients. HSCT as the major type of intervention affecting the survival rates in patients with SCID was also confirmed by Marciano et al. . In the Mycobacterium tuberculosis infection involves a complex cellular process which is not fully understood. Protection from disseminated disease in children is associated with a Th1-type response involving CD4+ T cells which produce interferon-gamma (IFN-γ). The study by Marciano et al. revealed that a lower number of T cells in SCID patients increased the probability of them developing BCG-associated complications. In our study, the number of T cells did not have an impact on the occurrence of disseminated BCG in any type of patient diagnosed with SCID . The number of B cells in SCID does not play a role in the defense against pathogens, since B cells, if present, do not produce antibodies [The immune response to tibodies .Mycobacterium bovis BCG substrain and thus contribute to the non-specific beneficial effects of BCG vaccination [Mycobacterium bovis BCG in the absence of accessory cells has also been observed by other investigators [Mycobacterium bovis BCG against malignancies [Mycobacterium tuberculosis infections induces long-lived BCG-reactive NK Cell responses [RAG1 and RAG, and TB-NK+ revealed that the presence of NK cells may provide a defense against the development of disseminated BCG infection, which confirms the important role of NK cells in the defense against Mycobacterium bovis BCG infection. However, Marciano study shows that patients with and without BCG- associated complications were not significantly different in natural killer cell number [NK cells can provide the primary source of IFN-γ production during blood exposure to the cination . The protigators . The IL-tigators . IFN-γ pgnancies . It has esponses . The invl number .Mycobacterium bovis substrains, only local BCG complications appeared. In all but one patient, the absolute number of NK cells was within the normal range of 0.2–1.2 × 10E9/L [Our findings demonstrate that the non-specific immune response evoked by NK cells protects against the overwhelming mycobacterial infection not only in RAG1/2 SCID deficiency patients, but also other SCIDs with the presence of NK cells (Table S1). In a multicenter study, in SCID patients with a recombination-activating gene RAG1/2 mutation, vaccinated at birth with BCG vaccines containing a variety of × 10E9/L . However× 10E9/L . The imp× 10E9/L , 52.In our study, disseminated BCG infection was observed only in SCID patients with the IL2RG and JAK3 deficiency (T-B+NK-) (Table S1). Defects impairing cellular immune response, phagocytic function, and IFN-γ production are associated with BCG complications. Our findings demonstrate the major role played by the number of NK cells in preventing BCG complications as compared to the number of T cells.In summary, for more than 50 years of the BCG Moreau vaccine being produced in Poland, with its confirmed genetic changes, it has proven to possess a well-documented safety profile, recently also confirmed in our paper, in comparison with the Rio de Janeiro parent BCG substrain and to the Danish and Pasteur substrains , 49, 50.ESM 1(DOCX 26 kb)


Patients with follicular lymphoma (FL) frequently require multiple treatments during their disease course; however, survival based on lines of treatment remains poorly described in the post-rituximab era. Also, the Follicular Lymphoma International Prognostic Index (FLIPI) score was developed to predict survival at diagnosis, yet it remains unknown whether increase in FLIPI score following an initial observation period is associated with less-favorable outcomes. To address these knowledge gaps, we retrospectively studied 1088 patients with FL grade 1–3A managed between 1998 and 2009 at our institution. Median overall survival (OS) and progression-free survival (PFS) after first-line treatment were not reached and 4.73 years, respectively. Following successive lines of treatment, years of median OS and PFS were, respectively: after second-line, 11.7 and 1.5; third-line, 8.8 and 1.1; fourth-line, 5.3 and 0.9; fifth-line, 3.1 and 0.6; sixth-line, 1.9 and 0.5. In initially observed, subsequently treated patients, FLIPI score increase after observation was associated with inferior survival following first-line treatment. The reduced survival we observed after second-line and later therapy supports the development of new treatments for relapsed patients and benchmarks historical targets for clinical endpoints. This study also highlights the utility of changes in FLIPI score at diagnosis and after observation in identifying patients likely to have worse outcomes. While FL remains incurable, overall survival (OS) continues to improve due to improvements in diagnostic tools and supportive care, the development of the monoclonal anti-CD20 antibody rituximab, and the increasing number of FDA-approved therapies5. Current first-line regimens for FL typically achieve high response rates12. As the disease recurs, patients are treated with multiple lines of therapies during their lifetime. The outcome of these different regimens and the impact on patient survival remain understudied in the modern era. A secondary analysis from the LymphoCare study recently reported progression-free survival (PFS) but not OS for first- through fifth-line therapy13. We investigated how the survival outcomes OS, PFS, and event-free survival (EFS) evolved after multiple lines of therapy, information that should aid in estimating clinical endpoints when designing clinical trials for multiply-relapsed patients. Another aim of this study was to provide treating physicians with additional biomarkers predictive of high-risk patients that might permit identification for early treatment intervention.Follicular lymphoma (FL) is the second most common lymphoma in the United States, with approximately 14,000 patients being diagnosed each year15. Even so, patients who undergo initial observation follow a heterogenous clinical course. The FL International Prognostic Index (FLIPI), a five-factor risk model based on age, stage, lactate dehydrogenase and hemoglobin levels, and number of nodal areas, has been validated as a diagnostic model in both the pre- and post-rituximab eras. It is used to predict patient survival and to stratify patients in clinical trials16. However, many patients are initially observed and have prolonged lead time from diagnosis to first treatment. Moreover, there are no data on the stability of FLIPI score in initially observed patients, nor the impact of changes in FLIPI score during initial observation on survival or the rate of subsequent histological transformation to other types of lymphoma. Here we investigate, for patients who were initially observed, whether FLIPI risk group had changed between time of diagnosis and the time of initial treatment, and whether increased FLIPI score impacted outcomes after treatment.Prior studies have shown patients with FL with low tumor burden can be initially observed without impacting survivalWe retrospectively examined outcomes for patients diagnosed during the years 1998−2009 with de novo FL managed at Memorial Sloan Kettering Cancer Center (MSK). The beginning year was selected to capture patients with exposure to rituximab, FDA-approved for non-Hodgkin’s lymphoma in 1997; end year was chosen to ensure at least 10-year follow-up. The institutional review board approved this retrospective analysis; all patients had given written informed consent to biospecimen protocols. We excluded patients who were <18 years old; were diagnosed with an active concurrent malignancy; had grade 3B FL at diagnosis because of it’s management similar to diffuse large B cell lymphoma; or whose pathology showed composite histology at diagnosis. We also excluded patients who were managed with fewer than three visits at our institution, indicative of a consultative role; but not patients who had died before their third visit. At least one pathology specimen for each patient with FL was centrally reviewed at our institution. Documentation of transformations to other forms of lymphoma was based on biopsy confirmation. Clinical staging and best overall response, as assessed by treating physicians, were extracted from chart review. Ambiguity in staging or response to therapy was settled by review of available radiographic and pathologic reports.Intention of treating physician to manage certain patients with active surveillance was assessed by medical record review. Patients whose first-line treatment began ≥12 months after diagnosis were considered initially observed. For all other patients, charts were reviewed to determine the physician’s intent of observation or initial treatment.All authors had access to the study data. Chart review was performed by C.L.B., A.A., F.S., K.S., J.S., and Z.Y.; data were analyzed by A. Ni, C.L.B., A.Y., F.S., V.E.S., and A.A.Patient outcome was analyzed by OS, PFS, and EFS. OS was calculated either from time of diagnosis or from time of treatment commencement, as indicated on the figure, until last follow-up or death. PFS and EFS times for sequential lines of therapy were calculated from treatment commencement until qualifying event . EFS12 failures were defined as patients with disease progression, change of therapy or death within 12 months of treatment initiation (EFS12). Date of progression was assessed based on chart review; for cases of unclear documentation, radiographic imaging was reviewed. Patients with inadequate response to treatment, change of treatment, or stable disease without subsequent documented progression were censored in the PFS analysis. Overall survival from time of transformation to diffuse large B-cell lymphoma (DLBCL) or DLBCL with features of Burkitt lymphoma was calculated from the time of first recorded pathologic transformation. OS, PFS, and EFS were evaluated using the Kaplan−Meier method. The OS, PFS, and EFS times for sequential lines of therapy were compared across lines of therapy using the log-rank test with adjustment for within-patient correlation. PFS and EFS were compared to other clinical variables using the log-rank test. Chi-squared method was used to compare PFS curves between groups by stage.The risk of biopsy-proven transformation to DLBCL or DLBCL with features of Burkitt lymphoma was assessed using a competing risk analysis wherein patients can experience either transformation or death without transformation. Time origin was set at time of diagnosis; rates of transformation and death without transformation at specific time points were calculated.17. In patients with incomplete FLIPI components, risk category was determined if omission of a component did not alter the risk category. Stable FLIPI was defined as retaining the original low or intermediate risk score between diagnosis and initiation of treatment . FLIPI was defined as increased between diagnosis and initiation of treatment if the risk category increased . This secondary FLIPI analysis excluded patients whose FLIPI score decreased or remained high risk from diagnosis to initiation of treatment . Overall survival was compared among the entire cohort as well as between the FLIPI categories (stable vs increased). Chi-squared test and Fisher’s exact test were used to compare categorical variables by FLIPI score change status.We assessed patients’ FLIPI score at diagnosis and at initiation of first treatmentFor de-identified original data, please contact leec@mskcc.org. Requests would be submitted to our institutional review board for consideration and review prior to any data sharing.d-glucose integrated with computed tomography (PET/CT) was available for 60% of patients at diagnosis. Of the 924 patients who required treatment, 468 (51%) patients were managed with an anthracycline during their treatment course and 739 (80%) were treated with rituximab-containing therapy.We identified 1446 consecutive adult patients (≥18 years) diagnosed with FL at MSK from January 1, 1998 to December 31, 2009. We excluded 358 patients who had active concurrent malignancy, grade 3B FL, mixed histology at initial diagnosis, or fewer than three visits to our institution , median duration of observation was 3.9 years . For patients who were initially observed and subsequently treated (n = 305), median time to first treatment was 2.3 years . In the initially treated population (n = 617), median time from diagnosis to first treatment was 0.14 year . Overall survival was not adversely affected by observation strategy (p = 0.206) , 2001–2005 (n = 448), and 2006–2009 (n = 437). We selected the initial period of 1998–2000 assuming that time was needed for rituximab adoption in the community; the two subsequent time periods divided the following decade. Median OS was not reached at any of the three time frames (log-rank p = 0.144)   and chemotherapy alone in 10.3% (n = 95) (Supplementary Table n = 167) and 15.5% (n = 143) of the population, respectively. Recurrent uses of single-agent rituximab and radiotherapy were common throughout multiple lines of therapy. Alkylator-based chemotherapy represented 22.3% of second-line therapy. Radioimmunotherapy made up 3–9% of treatments in second- to sixth-line therapy. Ten percent of treated patients (91/922) received stem cell transplants during their course of therapy, 6% (n = 54) autologous stem cell transplant and 4% (n = 37) allogeneic stem cell transplant. Investigational therapies were uncommon in first-line therapy but increased to 8–22% with increasing lines of therapy.Among the 922 patients who received treatment, first-line therapy was rituximab in combination with chemotherapy in 52.1% (n = 164); however, one patient had a later diagnosis of peripheral T-cell lymphoma and two patients had later diagnoses of marginal zone lymphoma. Of the 164 patients who transformed to DLBCL or DLBCL with features of Burkitt lymphoma, transformation occurred prior to therapy in 19% (31/164) and after first-line therapy in 81% (133/164) of patients. For patients with a transformation event after first-line therapy but after diagnosis of FL, anthracycline was a component of prior therapy in 71/133 (53%) events. Competing risk analysis showed risk of histological transformation at 2, 5, and 10 years after diagnosis to be 3%, 8%, and 16%, respectively. Risk of death without transformation at 2, 5, and 10 years after diagnosis was 2%, 6%, and 14%, respectively  patients (median follow-up 8.3 years (range: 0.2–17.5)). Follicular lymphoma most commonly transformed to diffuse large B-cell lymphoma (DLBCL) or DLBCL with features of Burkitt lymphoma (p = 0.010) , whereas median OS in patients who transformed after frontline therapy (n = 133) was 7.6 years . Five-year OS from time of transformation was 83%  for patients who transformed prior to frontline therapy and 55%  for patients who transformed after frontline therapy.We compared OS in patients whose transformation event was before or after first-line therapy. The latter was associated with increased risk of death . EFS after first-line therapy was also statistically significantly longer for stage I patients (chi-squared p = 9 × 10–4). However, stage at first treatment was not prognostic for PFS or EFS following second-line or later therapy  and 3.7 years  for patients with increased FLIPI (n = 76), Wilcoxon test p < 0.001. For the 114 patients who were observed ≥12 months, eventually required therapy, and had stable or increased FLIPI, median time to first treatment was 2.9 years  for patients with stable FLIPI (n = 45) and 3.9 years  for patients with increased FLIPI (n = 69), Wilcoxon test p = 0.002.Among the 144 patients who were observed ≥6 months who eventually required therapy and had stable or increased FLIPI Fig. , median We sought to understand the causes of FLIPI score changes by analyzing the components contributing to the change. For patients initially observed before treatment, increased FLIPI was driven by increased nodal involvement in 41/76 (54%) observed ≥6 months and 36/69 (52%) observed ≥12 months. Other contributing factors were increased stage (in 31/76 [41%] patients observed ≥6 months and 30/45 [67%] observed ≥12 months); abnormal LDH (26/71 [37%] observed ≥6 months and 24/64 [38%] observed ≥12 months); increasing age (21/76 [28%] observed ≥6 months and 21/69 [30%] observed ≥12 months); and reduced hemoglobin (19/70 [27%] observed ≥6 months and 19/64 [30%] observed ≥12 months).n = 61) vs increased FLIPI (n = 27)  Fig. . Factorsp = 0.011)     Fig. . Median 02) Fig. . The med06) Fig. . The med11) Fig. .Increased FLIPI during observation was also associated with a higher rate of EFS12 failure after treatment initiation. For 76 patients who were observed ≥6 months and subsequently treated with increased FLIPI, 21 (27.6%) failed EFS12 after treatment. In comparison, for 68 patients who were treated with stable FLIPI after ≥6 months of observation, only 8 (11.8%) failed EFS12. Similarly, the EFS12 failure rates in patients with increased or stable FLIPI after ≥12 months of observation were 27.5% (19/69) and 8.9% (4/45), respectively  of the patients who required therapy never had rituximab exposure throughout their course of therapy; however, 52% (97/185) of these patients were treated with radiotherapy.19.We found outcomes of this generation of patients are improving. Median OS for all patients has not been reached even with nearly 20 years follow-up on the earlier patients. Five-year OS was 92% for all patients, highlighting the good outcomes of most patients with FL. Progression-free survival improved during the study period, likely through improved therapies. This study supports earlier studies demonstrating patients receiving initial observation have the same OS as those treated promptly after diagnosis20. Our study reports median OS is not reached for patients diagnosed during time periods 1998–2000, 2001–2005, and 2006–2009; and median PFS improved from 2.5 years for 1998–2000 to a range of 4.8–6.0 years in the latter two time frames. We note this improved PFS despite the lack of maintenance rituximab in 80% of our patients6. We found 5-year PFS for patients after first-line therapy to range from 40 to 55%. In comparison, the PRIMA study demonstrated a 6-year PFS estimate of 43% in the no-maintenance arm and 69% in the rituximab maintenance arm12. The FOLL05 study of advanced-stage FL did not incorporate maintenance rituximab and had an 8-year PFS of 48%7. The StiL study demonstrated median PFS not reached, with median 3.75 years of follow-up in R-bendamustine arm and 3.4 years in the RCHOP arm10.The Stanford University FL experience demonstrated improved OS over multiple eras, with stable PFS of approximately 2 years across all eras between 1960 and 200326. Similar to results from the PRIMA trial where 194/1018 (19%) patients had documented histologic transformation with a median follow-up of 6 years21, we identified 167 histologic transformation events in 1088 patients (15%) with a median follow-up of 8.9 years. The data support an adverse prognosis in patients with FL who transform after first-line therapy. In PRIMA, 5-year OS of the transformed population was approximately 40% at 5 years21, similar to our 5-year OS estimate of 55% in patients who transformed after first-line therapy.Transformation to aggressive lymphoma has been linked to adverse prognosis28. Prior to the widespread use of rituximab, retreatment after multiple lines of therapy was required every 2.75 years and median OS after first relapse was 5 years27. The development of more effective FL therapies has improved outcomes. In our dataset, median OS for patients who received second-line treatment was >10 years.Outcomes in FL after multiple lines of therapy have been incompletely described in the literature, another reason for our current study. Follicular lymphoma is typically responsive to frontline chemotherapy but may later become refractory31. PFS remains a reasonable clinical trial endpoint. We demonstrate that at fourth-line therapy and beyond, PFS is less than 1 year, providing a clinical endpoint that is robust and feasible to assess within a clinical trial context. This is supported by the National LymphoCare study that also showed PFS decreasing with increasing lines of therapy: 6.6, 1.5, 0.83, 0.69, and 0.68 years after first, second, third, fourth, and fifth-line therapy, respectively13. Both our and the LymphoCare analyses provide a benchmark for future drug approval in relapsed FL.The availability of new treatments for FL also reflects a need for new benchmarks to identify effective treatment strategies. In many tumors, improvement in OS remains the gold standard for clinical approval; however, the long heterogenous course of FL makes OS a challenging primary endpoint. Progression at 24 months is a potential endpoint for FL; however, its impact on prognosis is less validatedThis study also assessed the impact of changes to the FLIPI score during observation as a marker for adverse prognosis. Patients observed for ≥6 or ≥12 months were evaluated for increased FLIPI between diagnosis and prior to first-line treatment. We found that subsequently treated patients whose FLIPI increased during observation had inferior OS and PFS. FLIPI increase was most commonly associated with increased nodal involvement, progression to advanced stage, and abnormal LDH. Of course, the increased FLIPI population may reflect patients who had adverse biology at diagnosis, especially since we continue to demonstrate that observation had no impact on OS. Nonetheless, in this era of readily available, easily tolerated therapies, it may be questionable whether initial observation is the ideal strategy. Future randomized trials comparing observation to upfront treatment may be warranted.The strength of this analysis lies in the large cohort. However, it is limited by its single-center and retrospective nature. Though our patients received heterogenous treatments reflecting a real-world strategy, they lack the greater diversity of patients treated by multiple unaffiliated practices.This study benchmarks a single institution’s outcomes of FL in the post-rituximab era. The work identifies higher number of lines of therapy and increased FLIPI score as markers for high-risk biology in FL. Based on EFS and PFS observed in this large retrospective series, we can consider designing clinical trials for fourth-line treatment of FL. Future prospective studies are needed to assess a possible correlation between increased FLIPI score and inferior outcomes.Supplementary information


The role of uric acid on metabolic syndrome (MetS) has always been controversial. This study aims to explore associations between uric acid with MetS and its components in Chinese female health check-up population. SLC2A9) as an instrument for uric acid.  1381 subjects constituted the longitudinal health check-up cohort. Health examination and genotyping were performed. Unadjusted and adjusted observational analyses were implemented to evaluate observational associations between uric acid with MetS and its components. Mendelian randomization analysis was performed to estimate the causal effect using variation at rs11722228 ( An increase of 65% in risk of MetS per standard deviation increase in uric acid was found using unadjusted observational analyses. This association attenuated on adjustment for potential confounders. Similar patterns were found in the association analyses of uric acid with hyperglycemia, hypertension, and dyslipidemia. Neither by performing unadjusted nor adjusted analysis did we see evidence for association of uric acid on overweight and obesity. Mendelian randomization analyses showed no evidence of causal association between uric acid and MetS and MetS components.  We found no causal evidence to support that increased serum uric acid is a causal risk factor for MetS or its components. Hence, there remains no strong evidence for the effeteness of undergoing urate-lowering therapy to prevent the onset of MetS or cardiovascular disease in health management. Metabolic syndrome (MetS) is a constellation of risk factors for cardiovascular disease (CVD). Epidemiological studies have found that uric acid was an independent predictor of CVD  and was SLC2A9  in chromosomal region 4p16.1 is found to be strongly associated with serum uric acid [Cohort study design is a prevailing study design for epidemiologists to discover causal relationships between risk factors and outcome diseases. However, as a kind of observational studies, the cohort study also suffers from the drawbacks of etiological mechanism distort caused by the existence of confounding, bias, and reverse causation. To avoid such disadvantages, the Mendelian randomization method is designed to introduce a randomization scheme into an observational study . Accordiric acid  and has ric acid .The causality between uric acid and MetS and its components should provide theoretical support for effeteness of urate-lowering therapy on preventing the onset of MetS and its components and further lowering the risk of CVD. Therefore, the purpose of this study is to investigate the causal relationship between uric acid with both MetS and its components using a Mendelian randomization analysis.A prospective cohort study was generated from the Shandong multicenter longitudinal cohort for health management. This database provided questionnaires, physical examinations, and laboratory index information of participants who conducted the annual health examination at the centers. To control for gender bias, the study subjects were restricted in female population. Participants aged more than 20 years and had at least 2 health check-up records at Shandong Qianfo Mountain Hospital from 2010 to 2015 were included in the baseline of the prospective cohort study. Among them, genotyping analysis was performed on blood samples from 1404 randomly selected subjects. Participants with MetS, cardiovascular, or cerebrovascular diseases at their first check-up were excluded. Finally, a total number of 1381 females constitute the Chinese MetS cohort study. We further established four MetS component subcohorts from the original MetS cohort study by excluding subjects with specific MetS component at their baseline health check-up, respectively. The study protocol was approved by Shandong University, and informed consent was obtained from all study participants.A standardized questionnaire data was collected by trained interviewers via face-to-face interviews. Information on socio-demographic factors, health and medication status, and lifestyle was included in the questionnaires. The general health examination was performed at the same time. Body mass index (BMI) was calculated as weight in kilograms divided by square of height in meter. All subjects were examined in the morning after overnight fasting. For each individual, fifteen milliliters of fasting blood was drawn and distributed into three tubes: two ethylenediaminetetraacetic acid anticoagulant tubes for plasma and DNA and one coagulation tube for serum. Uric acid, triglyceride (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), and blood glucose levels were measured by the hospital's laboratory.2; (2) hyperglycemia: fasting blood glucose (FPG) ≥6.1 mmol/L and/or postload glucose (2hPG) ≥7.8 mmol/L, or previously diagnosed as type 2 diabetes mellitus (DM) and received treatment; (3) hypertension: systolic blood pressure (SBP)/diastolic blood pressure (DBP) ≥140/90 mmHg, or previously diagnosed as hypertension and received treatment; and (4) dyslipidemia: TG level ≥1.7 mmol/L, and/or HDL-C level <0.9 mmol/L (men) or <1.0 mmol/L (women) [In this study, outcome information was collected and verified by combining laboratory indexes and self-reported disease history. MetS was defined according to the criteria recommended by the Chinese Diabetes Society in 2004. Patients with three or more of the following disturbances were diagnosed with metabolic syndrome, they are as follows: (1) overweight/obesity: BMI ≥25.0 kg/m (women) .z score  were coded by applying an additive genetic model based on information from a genome-wide association study [In this study, rs11722228, a functional mutation locus of urate transporter gene d design , 16. TheIn this study, data were available for age, smoking status, and alcohol status from questionnaire information. According to the respondents' self-reported smoking status, smoking was categorized as smokers (current smokers or ex-smokers) and nonsmokers. Alcohol status was categorized as self-reported drinkers (current drinkers or ex-drinkers) and nondrinkers. Other variables were dichotomized as ‘yes or no' on the basis of the responses to questions on the use of lipid or blood pressure or blood glucose lowering drugs. Observational associations were estimated with and without adjustment for potential confounding factors.SLC2A9 (rs11722228), we investigated deviation from the Hardy–Weinberg equilibrium using a Pearson χ2 test. Cox proportional hazards regression models were performed to estimate the associations of the SNP and uric acid and other covariates with MetS and its components. General linear models were applied to examine the relationships of the genotype and uric acid. We tested the associations of the individual SNP with category covariates by logistic regression models.For β3 estimates. The β3 estimates for the SNP to evaluate the association between uric acid and risk of MetS, and its components can be calculated from the direct measurements β1 (the estimate of effect size of the SNP on uric acid) and β2 (the estimate of effect size of the SNP on MetS and its components) as β3 = β2/β1 [β3 is calculated using the delta method. That is, S2 is the SE of β2 [β1 is the estimate of effect size of the SNP on standardized uric acid and β2 is the loge HR estimate of MetS and its components for the SNP. The HR for MetS and its components associated with each 1 SD lower genetically determined uric acid can be given by exp . All analyses were performed using R version 3.4.2.In this study, we performed both observational analysis, which was conducted using the cox proportional hazards regression model to test association between uric acid and outcomes with and without confounding and Mendelian randomization analysis. Mendelian randomization analysis was conducted to estimate causal effects. A schematic presentation of the Mendelian randomization analysis is shown in  = β2/β1 . The SE SE of β2 . In thisFrom 2010 to 2015, 1381 eligible participants aged from 21 to 81 years were enrolled in the Chinese (CH) MetS cohort. The median follow-up years were 2.01. At the end of the follow-up period, 61 subjects developed MetS. The incidence density was 19.96/1000 person-years. Detailed description of MetS components cohorts is in μmol/L (standard deviation (SD): 52.80 μmol/L) for the whole population and 286.26 μmol/L (SD: 62.94 μmol/L), 258.56 μmol/L (SD: 50.37 μmol/L), 273.63 μmol/L (SD: 57.91 μmol/L), 269.64 μmol/L (SD: 54.22 μmol/L), and 263.98 μmol/L (SD: 52.24 μmol/L) for individuals developed MetS or four MetS components, respectively. Serum uric acid level was significantly associated with all four outcomes except for overweight and obesity in univariate cox proportional hazards regression analyses. The P value for serum uric acid level associated with overweight and obesity was 0.088. For the prevalence of smoking and drinking was low in Chinese female population, the corresponding associations with health outcomes were not significant in most cases. Therefore, we did not further adjust those two confounders in the following analyses.SLC2A9 (rs11722228) and uric acid was roughly linear (SLC2A9 (rs11722228) was not associated with potential confounders: age, smoking, and drinking status  in the CH cohort . After aSimilar patterns were also found in association with hypertension and dyslipidemia. Before adjustment, the significant observational associations were observed between serum uric acid with hypertension and with dyslipidemia. After adjustment for corresponding confounders, the association remained significant with hazard ratio as 1.21 (95% CI: 1.02 to 1.43) for hypertension and 1.18 (95% CI: 1.01 to 1.38) for dyslipidemia, respectively.The increase of serum uric level was also associated with increased risk of hyperglycemia with hazard ratio corresponding to 1.34 (95% CI: 1.04 to 1.72). Nevertheless, this association was not observed after adjustment for confounders . Before adjustment or not, there was no evidence for association between uric acid and overweight and obesity.To explore the causal relationships, we further performed Mendelian randomization analysis to estimate the causal effect size of genetically determined uric acid on MetS and its components in CH MetS cohort. The causal hazard ratios for MetS was 0.70 (95% CI: 0.12 to 4.12) per standard deviation increase in uric acid. For four MetS components, there were no evidence for causal associations too . The cauWe found no evidence for the casual effect of uric acid on the risk of MetS or MetS components. An increase of 65% in risk of MetS per standard deviation increase in uric acid was found using unadjusted observational analyses. This association attenuated on adjustment for potential confounders. The similar pattern was present in the association analyses of uric acid on hyperglycemia, hypertension, and dyslipidemia. Neither by performing unadjusted nor adjusted analyses did we see evidence for association of uric acid on overweight and obesity. Mendelian randomization analyses showed no evidence of causal association between uric acid and MetS or MetS components.Uric acid is a metabolite derived from the purine catabolism . AlthougThe role of uric acid in the development of MetS has always been controversial. In this study, unadjusted and adjusted observational analyses showed positive relationship between increased serum uric acid level and increased risk of MetS and four MetS components. Mendelian randomization analysis, though not significant, indicated uric acid as a protective factor of MetS, overweight and obesity, and hyperglycemia. Those findings which were consistent with experimental studies suggested uric acid as an antioxidant , 26. ThiSLC2A9) as the instrument and found causal associations between uric acid with hypertension [Estimates derived from this Mendelian randomization here resumptively agree with certain recent studies. McKeigue et al. implemented Bayesian methods for instrumental variable analysis and failed to find evidence for a casual effect of uric acid on MetS in a Scottish population isolate . Use of rtension . Those iThe major strength of our study includes the combination of observational analyses and causal relationship analyses in a prospective cohort study. In this study, the Mendelian randomization method was performed to control confounding and reverse causation, and therefore, the causal effect of uric acid on MetS and its components was derived. In addition, the results derived from Mendelian randomization suggested that there remained no strong evidence for clinical practice of urate-lowering therapy as MetS preventing treatment.The limitation of this research is as follows: first, the definition of MetS components may be influenced by measurement bias; second, being limited by the study follow-up period, the sample size of CH cohorts was not quite large; and last, using single SNP as an instrument may be limited by pleiotropy and complicated gene interactions. Hence, further studies need to explore the pleiotropy and interactions between uric acid-related genes, and this may help finding explanations for observational associations between uric acid and health outcomes.In conclusion, we found no causal evidence to support that serum uric acid is a causal factor of metabolic syndrome and its components. Hence, there remains no strong evidence for the effeteness of undergoing urate-lowering therapy to prevent the onset of MetS or cardiovascular disease in health management.


For pediatric lymphoma, quantitative FDG PET/CT imaging features such as metabolic tumor volume (MTV) are important for prognosis and risk stratification strategies. However, feature extraction is difficult and time-consuming in cases of high disease burden. The purpose of this study was to fully automate the measurement of PET imaging features in PET/CT images of pediatric lymphoma.18F-FDG PET/CT baseline images of 100 pediatric Hodgkin lymphoma patients were retrospectively analyzed. Two nuclear medicine physicians identified and segmented FDG avid disease using PET thresholding methods. Both PET and CT images were used as inputs to a three-dimensional patch-based, multi-resolution pathway convolutional neural network architecture, DeepMedic. The model was trained to replicate physician segmentations using an ensemble of three networks trained with 5-fold cross-validation. The maximum SUV (SUVmax), MTV, total lesion glycolysis (TLG), surface-area-to-volume ratio (SA/MTV), and a measure of disease spread (Dmaxpatient) were extracted from the model output. Pearson’s correlation coefficient and relative percent differences were calculated between automated and physician-extracted features.max values matched exactly the physician determined values in 81/100 cases, with Pearson’s correlation coefficient (R) of 0.95. Automated MTV was strongly correlated with physician MTV (R = 0.88), though it was slightly underestimated with a median (IQR) relative difference of − 4.3% (− 10.0–5.7%). Agreement of TLG was excellent (R = 0.94), with median (IQR) relative difference of − 0.4% (− 5.2–7.0%). Median relative percent differences were 6.8%  for SA/MTV, and 4.5%  for Dmaxpatient, which was the most difficult feature to quantify automatically.Median Dice similarity coefficient of patient contours between automated and physician contours was 0.86 (IQR 0.78–0.91). Automated SUVAn automated method using an ensemble of multi-resolution pathway 3D CNNs was able to quantify PET imaging features of lymphoma on baseline FDG PET/CT images with excellent agreement to reference physician PET segmentation. Automated methods with faster throughput for PET quantitation, such as MTV and TLG, show promise in more accessible clinical and research applications.The online version contains supplementary material available at 10.1186/s40658-020-00346-3. Pediatrle score . Howeverle score –12 and ple score , 14 HL pDespite their clinical utility, the full potential of quantitative PET imaging metrics may not be reached in both adult and pediatric lymphoma due to the difficulty of delineating the entire lymphoma volume. Lymphoma can be highly heterogeneous in shape, size, and location. In order for physicians to extract quantitative PET information from disease, an analysis workflow can take up to 30–45 min per patient for difficult cases . For comSeveral methods have been developed that automatically detect and segment disease on FDG PET/CT images of adult lymphoma patients specifically –20 and iThe purpose of this work was to develop a fully automated method for extraction of PET features for pediatric HL. The model was trained and tested using PET images of pediatric HL patients acquired at multiple centers as part of a multi-center clinical trial.Patients included in this study were enrolled in a multi-center Children’s Oncology Group (COG) clinical trial, AHOD0831 high-risk pediatric HL phase 3 clinical trial (NCT01026220) using risk-adapted therapy in pediatric patients with high-risk HL . Patientmax and SUV > 2.5) within the template ROIs for segmentation of the lymphoma disease. Final segmentations, which were used for training and testing of the CNN, were generated by taking the union of the output of the two thresholding methods. This was done to ensure small, low-uptake lesions that can occur next to large, high-uptake lesions were not missed due to thresholding based on SUVmax. Small, 1-voxel islands that can occur with thresholding algorithms were removed.Using Mirada XD  imaging software, PET images for each patient were analyzed by one of two nuclear medicine physicians with experience and board certification in nuclear medicine (JK and IL). Large template regions of interest (ROIs) were placed around areas containing disease , excluding areas of osseous/bone marrow involvement and normal physiology such as the heart. Two thresholding segmentation methods were then applied (40% of tumor SUVN = 20 patients per fold).PET and CT images were resampled to a cubic voxel size (2 × 2 × 2 mm) using linear resampling and normalized such that values inside the patient had a mean of 0 and a variance of 1. Labels were resampled to the same voxel size using nearest neighbor resampling. Patients were split randomly for 5-fold cross-validation , DeepMedic , was useDeepMedic  was traimax) within each of the contours generated by the 3 separately trained CNNs. The intersection of the 3 contours was taken as the final ensemble model output. As bone marrow activity was not considered in our model, any contours containing bone (CT Hounsfield Units > 150) were excluded from analysis.The output of the CNN was further processed by applying the same thresholding scheme , and Dice similarity coefficient (DSC) of a patient’s contours.max, total body lymphoma MTV, and TLG. Two additional quantitative features were extracted for analysis: the ratio of tumor surface area to metabolic tumor volume (SA/MTV) and the distance between the two lesions that are farthest apart (Dmaxpatient), as both have been shown to be independent prognostic metrics in lymphoma [From final contours, quantitative imaging metrics were extracted, including SUVlymphoma , 24. Autpatient, and differences in DSC and MTV relative percent difference (RPD) were compared between subgroups. Wilcoxon rank sum tests were used to assess differences in DSC and absolute RPD of MTV.Subgroup analysis was performed to see if errors in segmentation and MTV estimation were influenced by certain characteristics of the subjects’ disease. Patient groups were dichotomized by median MTV, SA/MTV, and DmaxA summary of the patient and scan characteristics is shown in Table p = 0.5 as the cut point, median DSC was 0.86 (IQR 0.78–0.91). The median (IQR) for sensitivity and PPV were 0.85 (0.79–0.90) and 0.88 (0.80–0.96), respectively.Segmentation performance of the final model is shown in Fig. max values matched exactly in 81/100 cases, with a Pearson’s correlation coefficient for SUVmax of R = 0.86. Automated MTV was strongly correlated with physician MTV (R = 0.88), though the model slightly underestimated MTV with a median (IQR) relative difference of − 4.2% (− 10–5.7%). Agreement of TLG was excellent (R = 0.94), with median (IQR) relative difference of − 0.4% (− 5.2–7.0%). Results were largely influenced by a handful of outlier patients , the agreement between the automated measurements and the physician measurements are shown in Fig. patient, with median relative percent differences for SA/MTV of 6.8%  and for Dmaxpatient of 4.5% .For SA/MTV and disease dissemination . In addition, lesions with smaller SA/MTV  had significantly improved DSC compared to lesions with higher SA/MTV . A large spread in model performance was found across all subpopulations.Results of the subgroup analysis are shown in Fig. max, MTV, TLG, and SA/MTV ratio) were able to be automatically extracted with excellent agreement with physician derived features. The implementation of an ensemble CNN showed significant improvements to using only a single CNN.In this study, an ensemble of 3D convolutional neural networks was implemented for an automated assessment of 100 pediatric HL patients. Quantitative imaging features that have been shown to be prognostic on baseline PET images in HL . For comparison, a recent automated method for segmentation of lymphoma using 2D CNNs found mean ± std of DSC of 0.73 ± 0.06 when compared to manual physician contours in 80 adult patients . Anothersholding .patient, was not easily replicated using automated contours in this study. This was primarily due to the model placing small false-positive regions in the salivary glands, tonsils, and ureters. This poor performance has implications for the use of a fully automated method without physician adjudication for staging of lymphoma, as staging considers whether disease is located on both sides of the diaphragm. As patients in this study were all high risk, stage III–IV, the majority of patients had disease on both sides of the diaphragm. It also illustrates that some imaging metrics are much more sensitive to full automation than others. For example, MTV is hardly affected when the model mistakenly contours very small benign regions, whereas these small false-positives can have a large impact on metrics like Dmaxpatient or possibly staging.A metric describing the distance between the two lesions that are furthest apart, Dmaxmax. This was because the ensemble CNN reduced false-positives by ensuring all three CNNs positively identified each region. As the majority of false-positives were located in areas of high FDG uptake , the reduction of false-positives had a significant impact on SUVmax quantification. Because the false-positives were typically small, the ensemble had only a minor impact on the other PET imaging metrics.The use of an ensemble CNN as opposed to an individual CNN was found to produce only moderate improvements for quantification of volume-based metrics (MTV and TLG). However, the ensemble model substantially improved measurements of SUV3) and lesions with a low surface-area-to-volume ratio (SA/MTV < 2.4 cm−1). These significant differences in DSC across MTV are not surprising, as in general a high DSC value is easier to achieve in larger volumes. In addition, disease with a low SA/MTV are larger, more massive lesions, and are easier to contour with a high DSC value compared to smaller, more fragmented disease. More patients are needed to ensure this trend remains across a wider variety of disease types.Consistent performance of MTV quantification was found across different subgroups of patients. However, significantly better performance in DSC was achieved in larger lesions (MTV > 487 cmThe main limitation of this study is that ground-truth contours were obtained from only a single physician using PET SUV-based thresholding techniques. This prevents an analysis of interphysician variability in labeling, although this interphysician variability is expected to be somewhat low given that PET SUV-based thresholding was used to define tumor boundaries. The use of thresholding as opposed to manual segmentation results in better repeatability across observers, but its use remains controversial due to its many limitations. This study was limited to high-risk stage IIIB and IVB pediatric HL patients. Similar results are expected for adult lymphoma populations with high disease burden ; howeverA fully automated, 3D CNN-based method of lymphoma identification and quantitation in PET/CT images showed good agreement with physician labels. Overall, these techniques show promise in standardizing and improving lymphoma patient care, while also expanding the potential of quantitative PET imaging in lymphoma.Additional file 1.


The aim of our study was to compare the course of TBE in children and adults. A retrospective analysis of the medical records of 669 patients was performed. The patients were categorized into 2 groups: Group I with 68 children and group II with 601 adults. TBE symptoms in children were milder compared with adults, with meningitis in 97% of cases. In adults, meningoencephalitis and meningoencephalomyelitis made up 49.26% of cases. Nausea and vomiting are more frequent in children, while neurological manifestations are more frequent in adults. There were no differences in CSF pleocytosis at the onset of disease in both groups, while CSF protein concentration was higher in adults. Children treated with corticosteroids over 7 days had higher checkup pleocytosis than pleocytosis at the onset of disease compared with adults. Corticosteroid use prolongs the disease duration but does not influence the development of TBE sequelae. Children had more favourable outcomes than adult patients. Flavivirus genus. There are 3 subtypes of TBEV: the European subtype , the Far-Eastern subtype (endemic in Far-Eastern Russia and in forested regions of China and Japan), and the Siberian subtype   is a common infectious disease in northeastern and central Europe that affects adults and children. TBE is the clinical presentation of infection with tick-borne encephalitis virus (TBEV), a member of the The number of TBE cases in Europe varies depending on country and ranges from a few cases up to over 600 cases annually  using the Virion/Serion kit  according to the manufacturer’s instructions during hospitalization.TBE-specific IgM and IgG antibody titers were measured using the Enzygnost Anti-TBE/FSME Virus Siemens test . For the quantitative antibody determination of anti-TBE virus IgG, the measuring range was 7–700 U/ml.The result of the IgM test was quantified by forming a quotient from the absorbance value of the test sample and the appropriate cut-off as the index. The index for the upper margin for retesting (“retest index”) was calculated by dividing the value of the upper margin for retesting (cut-off + 0.100) by the cut-off. An index 1.4-fold higher than the retest index was considered a positive result according to the instructions provided by the manufacturer.Diagnosis of TBE was made based on the clinical presentation, presence of inflammatory parameters in the CSF and specific IgM and IgG antibodies in serum and CSF according to the case definition, i.e. the presence of clinical signs of meningitis, meningoencephalitis or meningoencephalomyelitis, an epidemiological link, CSF pleocytosis (> 5 cells/dL), and demonstration of recent TBEV infection by the presence of specific serum IgM and IgG antibodies Kaiser . After 2Flaviviridae exclusion. To date, no confirmed human case of West Nile virus or yellow fever virus infection has been reported in Poland. None of the patients were vaccinated against TBE.All patients were local inhabitants and did not report recent journeys abroad; therefore, there was no need for cross-reactive reaction with other Early subjective (< 1 month), such as headache and vertigoEarly mental (< 1 month), such as memory impairment, loss of concentration, sleep disturbances, depression and anxietyEarly neurological conditions (< 1 month), such as upper/lower limb paresis, cranial nerve paresis and cerebellar syndromeLate subjective (≥ 1 month), such as headache and vertigoLate mental factors (≥ 1 month), such as memory impairment, loss of concentration, sleep disturbances, depression and anxietyLate neurological conditions (≥ 1 month), such as upper/lower limb paresis, cranial nerve paresis, and cerebellar syndromeSequelae were also analysed and classified as follows:U test for nonparametric distribution data. Correlations were performed with the Spearman test. All statistics were performed using STATSOFT STATISTICA, version 12 .The results are expressed as percentages, mean ± SD, medians, and ranges. Comparisons among groups were carried out using the chi-square test for dichotomous data or the Mann-Whitney The study was approved by the Local Bioethics Committee at the Medical University of Bialystok, Poland.Group I consisted of 31 (45.5%) females and 37 males (54.5%). A total of 43 (63%) patients were inhabitants of rural areas, and 25 (37%) lived in urban areas. Most of the cases were registered in May, July, August and September  females and 371 (61.73%) males. Two hundred eighty-five (47.42%) patients were inhabitants of villages, and 316 (52.58%) were inhabitants of cities. Most cases were registered in August, September, October and November , and white blood count (WBC) was elevated in 40 children (58.8%) and in 295 adults (49.1%) (p = 0.12). The erythrocyte sedimentation rate (ESR) was elevated in 50 children (75%) and in 275 (48.8%) adults (p < 0.05). Platelet (PLT) count was decreased in 8 children (11.8%) and 87 adults (14.5%) (p = 0.54), alanine aminotransferase (AlAT) activity was increased in 5 children (7.4%) and in 60 adults (10%) (p = 0.49), and aspartate aminotransferase (AspAT) activity was increased in 4 children (5.9%) and in 35 (5.8%) adults (p = 0.98). Cerebrospinal fluid (CSF) cytosis was increased in all children and adults. Protein concentration in CSF was increased in 25 children (36.8%) and 455 (75.7%) adults (p < 0.05).In group I, the C-reactive protein (CRP) concentration was elevated in 55 (80.9%) children and in 295 adults (49.1%) , dexamethasone was used.In group I, 10 (14.7%) cases were treated with dexamethasone at a dosage of 1–16 mg/day for 1–11 days. In group II, 278 (46.2%) patients received dexamethasone at a dosage of 16–24 mg/day for 3–17 days.p < 0.05). Treatment with dexamethasone correlated with pleocytosis in the control CSF examination in children, which may indicate that dexamethasone usage prolongs the disease.The children who received dexamethasone over 7 days had a significantly higher pleocytosis II to pleocytosis I ratio (0.56 ± 0.289) than other patients (Seven (10.29%) children had third lumbar puncture, while 175 (29.1%) adults required third lumbar puncture, and 4 (0.66%) even required a fifth lumbar puncture, which reflects the prolongation of the inflammatory process in adults.The follow-up examination regarding sequelae analysis was performed in 22 children and 600 adults. Six (27%) children developed sequelae, while 253 (42.1%) adults developed sequelae.p < 0.05) except early subjective (p = 0.2). There are differences in the frequency of all sequelae: headache, vertigo, memory impairment, loss of concentration, sleep disturbances, depression, anxiety, upper/lower limb paresis, cranial nerve paresis and cerebellar syndrome between children and adults.Comparison of sequelae groups showed significant differences between all groups  patients were co-infected with Borrelia burgdorferi.In children, 10 (14.8%) patients were co-infected with In group I, the duration of dexamethasone treatment correlated with pleocytosis in the control CSF examination. Pleocytosis at admission correlated with protein concentration in CSF and then with pleocytosis and protein concentration in the control CSF examination.In group II, the duration of dexamethasone supply and initial dose of dexamethasone correlated with pleocytosis in the control CSF examination. ESR and CRP correlated with AlAT, AspAT activities, pleocytosis and protein concentration in the CSF at admission.Our study is the first comparison of children and adults with TBE in Poland. The majority of the results of our study confirms the results obtained by authors from other countries. According to epidemiological data, the incidence of TBE in children is ten times lower than in adults Kaiser . The resThe incubation period of TBE usually varies from 4 to 28 days   between adults and children were observed. Additionally, differences in pleocytosis in the control examination but not in pleocytosis at admission were stated. It may be indirect proof that TBE affects the brain more frequently in adults than in children.The treatment of TBE is symptomatic, but when the disease takes a severe course, dexamethasone may be used. In our study, some adults as well as children received dexamethasone. We observed that treatment with dexamethasone correlated positively with pleocytosis in the checkup CSF in children. There were no significant differences in sequelae development between children treated and not treated with dexamethasone. This may indicate that dexamethasone usage prolongs the disease but does not influence sequelae development. However, since the treatment with dexamethasone is more a causal result than a controlled study, the finding should be interpreted with caution.The World Health Organization (WHO) recommends vaccination for people of all age groups, including children, in highly endemic areas . The disease in children is generally milder, although severe illness may occur and even lead to permanent impairment of the quality of life owing to neuropsychological sequelae. Therefore, immunization should be offered to all children living in or travelling to endemic areas (Kunze et al. The presentation of TBE in children is milder than in adults.Nausea and vomiting are more frequent in children, while neurological manifestations are more frequent in adults.There were no differences in cerebrospinal fluid pleocytosis between children and adults with TBE, whereas the protein concentration was higher in adults on admission.Sequelae after TBE are less frequent in children than in adults.Dexamethasone usage prolongs the disease but does not influence sequelae development.


Allergic rhinitis (AR) is believed to be a complex genetic disease. The last decade has been marked by the publication of more than 20 genome-wide association studies (GWASs) of AR and associated allergic phenotypes and allergic diseases, which have shown allergic diseases and traits to share a large number of genetic susceptibility loci. The aim of present study was therefore to investigate the highly replicated allergy related genes and variants as candidates for AR in Han Chinese subjects.A total of 762 AR patients and 760 control subjects were recruited, and a total of 58 susceptible variants previously reported to be associated with allergic traits were choose for replication.P = 0.029, OR = 1.469 for GG vs. AA); rs6554809 in DNAH5 ; rs1438673 in WDR36-CAMK4 loci , rs7775228 in HLA region , rs7203459 in CLEC16A .Logistic regression analyses revealed that in the co-dominant-effect model as assessed by the AIC, compared with wild-type carriers, significant AR risk were associated with rs9865818 in LPP (We replicated Han Chinese AR-specific susceptibility loci in LPP, DNAH5, HLA, CLEC16A and WDR36-CAMK4. Further understanding the molecular mechanisms underlying these associations may provide new insights into the etiology of allergic disease. Allergic rhinitis (AR) is a major chronic respiratory disease induced by an immunoglobulin E (IgE)‐mediated reaction in allergen‐sensitized subjects. It is believed that AR and the comorbid conditions including allergic asthma, eczema, or any other allergic disease, are complex genetic diseases resulting from the effect of both multiple genetic and interacting environmental factors on their pathophysiology. Moreover, Barnes  has prop. [The last decade has been marked by the publication of more than 20 genome-wide association studies (GWASs) of AR, atopy and the associated allergic phenotypes and allergic diseases and traits . Andiapp.  reported. , suggest. , 16. TheThe study protocol was approved by the Ethics Committee of Beijing TongRen Hospital and performed in accordance with the guidelines of the World Medical Association’s Declaration of Helsinki. All subjects involved were adults (≥ 18 years) of Han Chinese ethnic origin from the Beijing region, China, and provided written informed consent prior to entry in the study.Der f and Der p); seasonal grass pollens ; animal hair (dog and cat); molds  and cockroach. Subjects were also considered to be sensitized to allergens when the serum sIgE was greater than 0.35 kU/l. AR subjects with (i) co-morbid asthma, eczema, or any other allergic disease; (ii) hypertension, diabetes or other chronic diseases; or (iii) tumor in the nasal cavity or any other inflammatory nasal disease were excluded. The diagnosis of asthma was confirmed by a physician according to Global Initiative for Asthma (GINA) guidelines [Two rhinology specialists (Y. Z. and L. Z.) were responsible for the screening the study subjects in outpatient clinic of Allergy department at Beijing TongRen Hospital, during the study period from February 2010 to February 2011. Finally, a total of 762 consecutive adult subjects with physician-diagnosed clinical AR were recruited. The flow diagram of recruitment was shown in Additional file idelines .A total of 760 adult healthy control volunteers were also recruited during the study period. For matching with AR groups, health control group had similar age distribution, gender ratio, and also Han Chinese ethnic origin from the Beijing region for an ethnically similar local population to determine background population allele frequencies. None of the control subjects had a history of allergic or any nasal disease, nor demonstrated any abnormal clinical features in the nasal cavity or positive serum sIgE by Phadiatop  testing.A 2-ml volume of venous blood samples from each participant was taken in citrate-anticoagulated glass tubes, and were frozen at − 40 °C. Total genomic DNA of the leucocyte was extracted from 1 ml of peripheral blood using the Whole Blood DNA Extraction Kit , according to the manufacturer’s instructions. Genomic DNA extracted was dissolved in 0.1× TE buffer  and stored at − 20 °C.58 susceptible single nucleotide polymorphisms (SNPs) in 55 gene/regions previously reported as highly associated with allergic traits –13, 15 wSNPs were typed using iPLEX chemistry on a matrix-assisted laser desorption/ionization time-of-flight mass spectrometer  . In brie2-test. Mann–Whitney test was used to compare serum total IgE level between case and control groups, and between different genetic models in dominant or recessive models. Kruskal–Wallis test was used to compare serum total IgE level among different genotypes in co-dominant model.Values are expressed as mean ± standard deviation or as numbers and percentages. Differences in age between case group and control group were evaluated using the t-test. Differences in gender and frequencies of the alleles and genotypes between case group and control group were evaluated using the χhttp://ihg.gsf.de/cgi-bin/hw/hwa1.pl). It was tested in the control group by the Chi square test for goodness of fit, and a P-value of < 0.05 was considered to be statistically significant. Akaike’s information criteria were used to select the most parsimonious genetic model for each SNP [P-value of 0.05 after corrections with 100,000 permutations. All P values are two tailed. These analyses were conducted with Stata statistical package .Hardy–Weinberg Equilibrium (HWE) was tested by the Chi square test for goodness of fit with a Web program (each SNP . Odds raP = 0.167) or the ratios for males/females (P = 0.372) between the control and AR groups. The median total serum IgE measurements were significantly increased in AR group than control group . Furthermore, 273 (35.8%), 168(22.0%), and 321 (42.2%) of AR subjects, respectively, were found to be allergic to HDMs alone, seasonal pollens alone, and mixed allergens.The demographic characteristics of the study population are shown in Table P < 0.0001). The minor allele frequencies (MAF) of four selected SNPs, such as rs6673480, rs17513503, rs7032572 and rs1250761 could not satisfy association study (MAF < 0.01). The four SNPs, rs3860069, rs11680788, rs9303280 and rs12973620 failed in assay design. Thus, we finally enrolled 47 SNPs to process the next analysis , rs1438673: T>C (P = 0.029), rs7775228: T>C (P = 0.001), and they remain associated after 100,000 permutations (P < 0.05). The distribution of the genotypes of rs6554809, rs1438673 and rs7775228 showed significant difference between cases and controls.The genotype distributions of 47 selected SNPs in the case group and control group are summarized in Table P = 0.029, OR = 1.469, 95% CI 1.041–2.074 for GG vs. AA); rs6554809 in DNAH5 ; rs1438673 in WDR36-CAMK4 loci , rs7775228 in HLA region . However, it was a protective factor with the SNP in rs7203459 in CLEC16A . The detailed data was shown in Table Logistic regression analysis showed significantly related to AR risk compared with wild-type carriers in the codominant effect model assessed by AIC. The result showed that it was a risk factor with the SNP in rs9865818 in LPP  and in rs7775228 , while protective effect was found in rs7203459 in CLEC16A . In addition, under recessive model, rs7617456 in TMEM18 was also revealed with protective effect , and rs1438673 was evaluated with AR risks . The detailed data was shown in Table Under dominant model, the significant AR risks were observed in rs6554809 in DNAH5  and reviewed in Table The functions and effects of these positive SNPs were retrieved from HaploReg v4.1 tool (P < 0.0001). No significant association with serum total IgE was observed under recessive model for rs7775228. The co-dominant model analysis for rs7775228 found a significant decrease of serum total IgE among TT carries (median 49.8 KU/L) compared to CC  and TC carries , respectively , as well as under co-dominant model, significant elevation of serum total IgE was detected among CC carries (median 60.50 KU/L) comparing with TC carries (median 54.6 KU/L) (P = 0.0413)  and it cis-regulates HLA-DRB410, similar with our present findings.Actually, it is almost 4 decades since an association between genetic variants in the HLA region and specific allergen sensitization was reported , and varP = 3.3 × 10−6) was firstly detected as a candidate gene for AR and grass sensitization through a genome-wide meta-analysis by Ramasamy et al. [DNAH5 . Bønnelykke et al. [P = 3.4 × 10−6). Here we also replicated rs9865818 of LPP using diagnosed AR population. Several new allergy-associated loci are in or near genes involved in T-helper cell differentiation. The association between LPP and allergy may be mediated by an effect on the expression of BCL6 (B cell lymphoma 6), a transcription factor that represses the STAT6-mediated response to IL-4 and IL-13 and IgE class switching [Hinds et al.  conductee et al.  performewitching  and inhiwitching . Conerniwitching , while twitching .In this study, we found that the SNPs in rs1438673 and in rs7775228 had strongly association with serum total IgE in AR group. The variant near the HLA-DQB1 was regarded as a predictor of total serum IgE levels in multiple race-ethnic groups, which was identified by an independently meta-analysis . The serIt is striking that in the present study, variants in only 5 of 58 previously identified candidate genes demonstrated significant association with Han Chinese AR. Of these variants, rs6554809-T allele in DNAH5 was the risk factor for AR in our study, which was opposite to Ramasamy et al. . These oHowever, the findings of our study are slightly limited, particularly in view of associations in only 6 genome-wide studies due to a limited number of SNPs in two genotyping assays. Furthermore, this study is somewhat limited in the sample size and the results did not exclude the potential false positive and negative associations, although we enrolled well-diagnosed AR to avoid population stratification as well as adjustment for multiple testing involved in 47 SNPs. Further studies would also be performed in larger cohorts and assess associations in a larger number of loci for identification of susceptibility to AR.Intriguingly, whereas, it’s indubitable that the analysis driven by statistical and knowledge-based evidence represents a promising approach for identifying new genes or targets involved in complex traits and an important next step will be to more carefully characterize the extent to which indi-vidual associations lead to a global predisposition to allergy compared to effects on specific target tissues, such as skin, lung or mucosa.In summary, here we replicated shared and AR-specific susceptibility loci in LPP, DNAH5, HLA, CLEC16A and WDR36-CAMK4 which were also plausible candidates in terms of their biological function in the development of AR. Further understanding the molecular mechanisms underlying these associations may provide new insights into the etiology of allergic disease in Han Chinese.Additional file 1. Additional tables and figures.