This study aimed to investigate the frequency and risk factors for cerebral artery stenosis and occlusion in patients with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome.We reviewed results of magnetic resonance angiography (MRA) or computed tomography angiography (CTA) in 61 patients with POEMS syndrome seen between 2010 and 2017. Stenosis or occlusion was assessed in the initial MRA/CTA. Multivariate analysis was used to identify risk factors for artery stenosis/occlusion. In an autopsy case, pathologic examination was conducted of the occluded middle cerebral arteries.P = 0.014). An autopsy study showed occluded middle cerebral arteries by fibrous and myxomatous thickening of intima with splitting of the internal elastic lamina. Follow-up MRA in 23 patients showed improved, worsened, and unchanged stenosis in 20.7 %, 8.7 %, and 69.6 %, respectively.Stenosis (> 50 %) or occlusion of the major cerebral arteries was found in 29 (47.5 %) patients on the initial MRA/CTA. The internal carotid artery was involved most frequently (32.8 %), followed by the anterior (21.3 %) and middle (16.4 %) cerebral arteries. The basilar (1.3 %) and vertebral (3.6 %) arteries were rarely affected. Cerebral infarction developed in eight (13.1 %) patients. The serum vascular endothelial growth factor (VEGF) level was an independent predictor for stenosis/occlusion (odds ratio, 1.228; 95 % confidence interval, 1.042–1.447; Cerebral large-vessel stenosis or occlusion is frequently seen in approximately half of patients with POEMS syndrome. Vasculopathy was related to serum VEGF levels and thereby disease activity. Assessment of cerebral vessels is recommended in these patients to improve management.The online version contains supplementary material available at 10.1186/s12883-021-02260-2. Polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome is a rare multisystemic disease associated with plasma cell dyscrasia . UpregulWhereas peripheral neuropathy is a core manifestation of the disorder, central nervous system involvement in POEMS syndrome has not been sufficiently investigated. However, previous studies have described stroke, papilledema, and pachymeningeal involvement in patients with POEMS syndrome –7. One cMajor cerebral vessel stenosis or occlusion and ischemic stroke have been reported in patients with POEMS syndrome , 6. CereWe therefore studied systematically the frequency and features of changes in large cerebral arteries in patients with POEMS syndrome.Any data not published within the article will be anonymously shared upon request from any qualified investigator.Of 75 consecutive patients with POEMS syndrome screened at Chiba University Hospital between January 2010 and July 2017, 61 were included in this study. Inclusion criteria were fulfilling the recently proposed diagnostic criteria for POEMS syndrome  and suffMedical records were reviewed for clinical and laboratory data. Relevant comorbidities, such as cerebral infarction, Castleman disease, and pulmonary hypertension, were reviewed from onset of POEMS syndrome to the last follow-up by January 2018. Other clinical and laboratory data ware reviewed up to the initial MRA/CTA. Hypertension was defined as taking antihypertensive drugs, diabetes as taking antidiabetic agents or a hemoglobin A1c ≥6.5 %, and dyslipidemia as taking antihyperlipidemic drugs and total, low-density, or high-density cholesterol levels of ≥ 220, ≥140, or < 40 mg/dL, respectively. Smoking was defined as regular smoking within the last 3 years. Serum VEGF levels were measured by enzyme-linked immunosorbent assay, as previously described .This study procedure was approved by the institutional review board of the Chiba University Graduate School of Medicine, and the need for informed consent was waived. Additional written informed consent was obtained for our reported case.Two experienced neuroradiologists (H.Y. and H.M.), who were blinded to the clinical data, evaluated the initial MRA/CTA of each subject. Intracranial vasculature evaluated included the anterior cerebral (ACA), middle cerebral (MCA), vertebral (VA), posterior cerebral (PCA), internal carotid (ICA), and basilar (BA) arteries. The degree of cerebral artery stenosis was visually assessed as grade 0 (0–50 % of the vascular diameter), grade 1 , and grade 2 . Arterial stenosis was graded by comparing the diameters of the maximally stenosed artery and the more proximal normal segment of the same vessel . Grade 1t-test and Mann–Whitney U test for continuous variables and the χ2 and Fisher’s exact probability tests for categorical variables. Variables with P < 0.1 after univariate analysis were included in a multivariate analysis by logistic regression to identify the independent predictor for cerebral artery stenosis/occlusion on MRA/CTA in POEMS syndrome. A forward stepwise logistic regression analysis, with the likelihood method , was used. P < 0.05 was considered statistically significant. Weighted κ statistics were calculated to assess inter-rater agreements.All statistical analyses were performed using SPSS software, ver. 25.0 . Demographic and clinical variables between patients with and without stenosis/occlusion were compared using the Student’s Table P = 0.785). The κ value for inter-rater agreement between the two examiners was 0.739.All patients underwent brain MRA, except one who underwent only CTA. MRA was performed on a 1.5-T MRI system in 44 patients and a 3-T system in 16. There was no statistically significant difference in type of MRI system between the stenosis/occlusion and no stenosis/occlusion groups  in 29 (47.5 %) of 61 patients (Table  or 2 in n = 29) and without (n = 32) stenosis/occlusion on the initial MRA/CTA are compared in Table The patient groups with . The model was significant , and the Hosmer–Lemeshow χ2 goodness-of-fit statistic was nonsignificant (P = 0.111). Nagelkerke and Cox-Snell R2 values were 0.128 and 0.170, respectively. The model accurately identified 72.1 % of patients with POEMS and cerebral artery stenosis/occlusion on MRA/CTA.For variables with The follow-up MRA was performed on a 1.5-T MRI system in 20 patients and a 3-T system in 3. Median time from initial to follow-up MRA was 1.0 (0.1–6.0) years. The κ value for inter-rater agreement between the two examiners was 0.779. Compared to the initial MRA, the findings on follow-up MRA were improved, worsened, and unchanged in 5 (21.7 %), 2 (8.7 %), and 16 (69.6 %) patients, respectively . Four months after diagnosis, he underwent autologous peripheral blood stem-cell transplantation. Five years later, edema of the lower limbs and repeat elevated serum VEGF levels were observed. He was included in a randomized clinical trial, the POEMS Syndrome Thalidomide (J-POST) Trial, and was assigned to the placebo group . Four moTwo weeks after implantation, he presented with recurrent left hemiplegia, which was elicited by rising from a lying posture. CTA revealed bilateral MCA stenosis Fig. . Seven wAutopsy demonstrated infarction in the bilateral MCA territories and both MCAs were occluded or severely stenosed (≥ 95 %) Fig. . MicroscWe demonstrated that about half of the patients with POEMS syndrome had stenosis/occlusion of the major cerebral arteries on the initial MRA/CTA. Multiple vessel involvement was observed in approximately one-third of all patients. In addition, multivariate logistic regression analyses showed that maximum serum VEGF was the independent predictor for cerebral artery stenosis/occlusion. An autopsy case showed severe stenosis of both MCAs with fibrous and myxomatous intimal thickening. Stenotic lesion improvement was observed in approximately one-fifth of patients who underwent a follow-up MRA.Cerebral artery stenosis/occlusion on MRA/CTA is not a rare finding in POEMS syndrome. This condition was noted in approximately half of our patients with POEMS syndrome and the Castleman disease variant. Cerebral infarction was observed in 13.1 % of patients and was comparable in frequency to the previously reported overall 5-year risk of 13.4 % , 11, 15.Our study also suggested that the main cause of cerebral artery stenosis/occlusion in POEMS syndrome is not atherosclerosis or inflammatory changes, but vasculopathy related to disease activity of the POEMS syndrome itself. In our study, cerebral artery stenosis/occlusion was related to maximum serum VEGF level, which presumably reflected disease activity of the POEMS syndrome. The frequency of risk factors for atherosclerosis was not different between POEMS syndrome and the Castleman disease variant among patients with and without cerebral artery stenosis/occlusion.In our autopsy case, in which antemortem CTA revealed MCA stenosis, autopsy confirmed fibrous and myxomatous intimal thickening without apparent atherosclerotic or inflammatory changes. As with our case, a previous autopsy case with quasi-moyamoya disease associated with POEMS syndrome showed duplication of the internal elastic lamina and marked fibrous thickening localized to the intima of the MCA without evidence of vasculitis or atherosclerosis . In 2017Previous reports also have considered the nature of cerebral vasculopathy in POEMS syndrome as noninflammatory due to the benign manifestation of the cerebrospinal fluid , 17. On VEGF might have a pivotal role in cerebral vasculopathy development in POEMS syndrome. In our study, multiple logistic regression showed that maximum serum VEGF level was the independent predictor for cerebral artery stenosis/occlusion on MRA/CTA in patients with POEMS syndrome. A previous autopsy report also suggested that high VEGF levels accelerate intimal thickening via ectopically existing SMA-positive smooth muscle cells . In the Large cerebral artery stenosis in POEMS syndrome occasionally shows mild improvement and might be at least partially reversible. In our study, improvement of stenotic lesions was observed in approximately one-fifth of patients who underwent follow-up MRA. Among the five patients with improved stenosis on follow-up MRA, improvement of all lesions was noted in two and of only one lesion in the remaining three. No patient had improved cerebral artery occlusion. In a case of POEMS syndrome with multiple cerebral artery stenoses/occlusions, mild improvement of stenotic lesions has been described . These iThere are several limitations in our study. First, this was a retrospective study and did not include consecutive patients during the study period; the cerebral vessels were not assessed in some patients. Second, some variables were reported to be associated with increased risk of cerebral infarction in POEMS syndrome, such as elevated blood platelet count and evidence of plasma cell proliferation on bone marrow biopsy . Since eIn conclusion, stenosis or occlusion of the cerebral arteries is seen in approximately half of patients with POEMS, as vasculopathy is associated with the disease activity of POEMS syndrome. Cerebral vasculopathy in POEMS syndrome might be a heterogeneous condition with reversible nature and irreversible vascular structural changes presumably mediated by elevated inflammatory cytokines.Additional file 1:Table S1. Clinical data and MRA findings of cases with improved stenosis/occlusion on follow-up MRA. (xls.)


Air pollution has been associated with metabolic disease and obesity. Adipokines are potential mediators of these effects, but studies of air pollution-adipokine relationships are inconclusive. Macrophage and T cells in adipose tissue (AT) and blood modulate inflammation; however, the role of immune cells in air pollution-induced dysregulation of adipokines has not been studied. We examined the association between air pollution exposure and circulating and AT adipokine concentrations, and whether these relationships were modified by macrophage and T cell numbers in the blood and AT.Fasting blood and abdominal subcutaneous AT biopsies were collected from 30 overweight/obese 18–26 year-old volunteers. Flow cytometry was used to quantify T effector  and regulatory  lymphocytes and M1 [inflammatory] and M2 [anti-inflammatory]) macrophage cell number. Serum and AT leptin and adiponectin were measured using enzyme-linked immunosorbent assay (ELISA). Exposure to near-roadway air pollution (NRAP) from freeway and non-freeway vehicular sources and to regional particulate matter, nitrogen dioxide and ozone were estimated for the year prior to biopsy, based on participants’ residential addresses. Linear regression models were used to examine the association between air pollution exposures and adipokines and to evaluate effect modification by immune cell counts.An interquartile increase in non-freeway NRAP exposure during 1 year prior to biopsy was associated with higher leptin levels in both serum [31.7% ] and AT [19.4% ]. Non-freeway NRAP exposure effect estimates were greater among participants with greater than median Teff/Treg ratio and M1/M2 ratio in blood, and with greater M1 counts in AT. No adipokine associations with regional air pollutants were found.Our results suggest that NRAP may increase serum leptin levels in obese young adults, and this association may be promoted in a pro-inflammatory immune cell environment in blood and AT.The online version contains supplementary material available at 10.1186/s12940-022-00842-2. Childhood obesity is a major public health problem in the United States and is a strong risk factor for the development of metabolic diseases, such as type 2 diabetes, non-alcoholic fatty liver disease, and cardiovascular disease, which can lead to increased morbidity and mortality in adult life –5. HowevA growing number of epidemiological studies suggest that air pollutants, especially near-roadway air pollutants (NRAP), and other environmental exposures may act as obesogens in children –19. EpidAT homeostasis is influenced by resident T-lymphocytes and macrophages, which can play important roles in modulating AT inflammation. AT homeostasis requires a balance of both these pro-inflammatory (M1) and anti-inflammatory (M2) macrophage subtypes. Excess M1 macrophage infiltration (M1 polarization) results in increased AT inflammation due to excessive production of pro-inflammatory adipocytokines and is associated with metabolic and vascular disease –37 . EmeWe evaluated the effect of air pollution on AT homeostasis as assessed by circulating and tissue levels of the adipokines leptin and adiponectin. We also examined a novel hypothesis that inflammatory (M1 and T effector) and anti-inflammatory (M2 and T regulatory) cells in AT modify  the effects of air pollution on adipokines.2 (in)].This cross-sectional study included 30 overweight and obese 18–26 years old participants from a convenience sample of volunteers recruited primarily through Craigslist advertisements. Participants came from across Southern California including Los Angeles, Orange, Ventura, Kern, and Riverside counties. Participants were excluded if they had taken medications known to affect insulin and/or glucose metabolism or body composition, been diagnosed with any major chronic illness since birth, or had type 1 or type 2 diabetes. Demographic characteristics collected included sex, race and ethnicity. Smoking history was categorized as never or ever even a single cigarette. BMI was calculated using participant’s weight and height ) or number (%), as appropriate. The estimates of the associations are reported as percentage changes in leptin and adiponectin levels per IQR increase in air pollution concentrations. A two-tailed age in R .N = 4) or obese (N = 26) young adult participants. The mean age was 22.0  years. There were more female participants (60%) than male, and 73.3% of the study population was Hispanic. Each participant had complete serum adipokines and blood flow cytometry data. AT adipokines and flow cytometry were available for 29 participants.Table 2.5, PM10, NO2, and O3, were 11.6 μg/m3, 29.4 μg/m3, 15.9 ppb, and 45.4 ppb, respectively. Correlations of air pollution exposures were less than 0.50 except PM2.5 with PM10 (r = 0.54), NO2 with O3 (r = − 0.78) and freeway with total near-roadway air pollution (r = 0.99)  in AT but not in serum  (data not shown). Serum leptin (r = 0.63) and the ratio of serum leptin/adiponectin (r = 0.64) were positively correlated with BMI . In AT, leptin (r = 0.35) and ratio of leptin/adiponectin (r = 0.54), but not adiponectin, were also positively correlated with BMI.Leptin and adiponectin concentrations were higher in serum than in AT Table , consistThe distribution of type 1 and 2 macrophages and Teff and Treg cells in blood and in AT are shown in Supplementary Table p = 0.09)  higher leptin concentration in serum and 19.4%  higher leptin level in AT, after adjusting for age, sex, race, and ethnicity  was associated with non-freeway but not with freeway NRAP . A few onot responsible for these effects. One Southern California study showed that the chemical composition of gasoline SI engine emissions had greater amounts of high-molecular-weight particulate polyaromatic hydrocarbons (PAHs) than did emissions from CI engines more common on freeways [2.5 in Atlanta, Georgia, a major urban population center which like Southern California has relatively high emissions of PM2.5 from traffic sources, reported that PM2.5 from light-duty gasoline vehicles exhibited the highest oxidative potential, followed by biomass burning, and by heavy-duty diesel vehicles [Gasoline spark ignition (SI) engines are the primary combustion source of non-freeway NRAP in Southern California. Non-freeway roadways have very little heavy duty truck traffic with diesel compression ignition (CI) engines that are largely restricted to freeways. Therefore, although the reason non-freeway NRAP was more strongly associated with leptin concentrations is not clear, the results indicate that diesel exhaust was freeways . A Texasfreeways . There hvehicles . Thus, tThis was the first epidemiological study to examine the role of macrophages and T-cells as modifiers of NRAP effects on adipokines. Emerging data from animal and human studies suggest that T cell counts in blood modulate AT inflammation and insulin resistance , 73, 74.We observed positive correlations between leptin and adiponectin in AT, which was unexpected, as previous studies have reported inverse correlations between leptin and adiponectin in blood –83. To oStrengths of this study include a unique study population of overweight/obese young adults at risk for developing metabolic disease, from whom both adipose and blood samples were available. This allowed us to identify novel associations of adipokines specifically with non-freeway NRAP and to explore the role of pro-inflammatory T cell and macrophage profiles in these associations. The generally consistent associations with of serum leptin with NRAP in blood and AT suggest that blood may be a good proxy for effects in the AT. We also acknowledge some limitations. The analysis was cross-sectional, limiting the directional interpretation of these relationships. We conducted multiple testing for associations of several air pollution exposures with leptin; however, the association between NRAP and serum leptin level was significant even after Bonferroni correction. Information about time spent at home and outdoors was not available. However, measurement error due to time away from home is likely to be non-differential with respect to adipokine concentrations, and time outside exercising might increase both inhaled dose of air pollution and reduce leptin; therefore, observed effects of NRAP may have underestimated the true associations. We did not have data on participant physical activity, which might have increased the dose of air pollution. However, the association between air pollution exposure and physical activity, and the combined effect on health, is inconclusive ; a randoThe results of this study have potential policy implications. A common wisdom is that diesel engine exhaust is the more toxic component of traffic related air pollution –87. HoweAdditional file 1. Supplementary Material.


The COVID-19 pandemic has contributed to unprecedented worries and challenges for pregnant women due to social restrictions and changes in maternity care provision. We aimed to investigate the mental health impact of COVID-19 pandemic on pregnant women in Sweden and explore factors associated with poor perinatal mental health in this specific context.This was a nation-wide cross-sectional survey of pregnant women living in Sweden. Validated questionnaires were distributed through non-profit organizations´ websites and social media channels from May 2020 to February 2021. Perinatal depression, anxiety, and acute stress reaction were assessed using the Edinburgh Postnatal Depression Scale (EPDS), Generalized Anxiety Disorder-7 (GAD-7) and Impact Event Scale (Revised) (IES-R), respectively. Sociodemographic characteristics and self-perceived mental well-being were also obtained. Factors associated with mental health outcomes were analyzed using multivariate logistic regression model.n = 203) reported depression (EPDS ≥13), 25.7% (n = 121) moderate to severe anxiety (GAD-7 score ≥ 10), and 23.7% (n = 110) moderate to severe acute stress reaction (IES-R ≥ 33). 27.4% participants (n = 129) expressed concerns regarding their mental well-being during the pandemic. Pregnant mothers who had sick family members reported poorer mental health outcomes than those who did not (median [Interquartile range (IQR)] EPDS scores: 14.0 [8.75–18.0] vs 11.0 [6.25–15.0], p < .001; median (IQR) GAD7 scores: 7.0 [4.0–12.25] vs 6.0 [3.0–9.0], p = .003); median (IQR) IES-R scores: 20.0 [9.0–38.0] vs 15.0 [7.0–30.0], p = .048). Logistic regression analyses revealed that risk factors for poor mental health outcomes were having a sick family member with any illness, unemployment, and experiencing a substantially stressful life event. Having a higher educational level and a younger age during the pandemic were protective.Among a total of 470 participants, 43.2% (Depression and anxiety were highly prevalent among pregnant women in Sweden during the COVID-19 pandemic, indicating a need for professional mental health support for this vulnerable group of population. Unemployment was an associated risk factor whereas younger age and higher educational level were protective suggesting an important role of socio-economic factors in modulating the impact of COVID-19 pandemic on perinatal mental health.The online version contains supplementary material available at 10.1186/s12884-022-04553-x. The consequences of the COVID-19 pandemic on global mental health are significant and its long-term impact on the global burden of disease is likely to be high. The COVID-19 pandemic has a profound impact on healthcare systems and potentially on pregnancy outcomes . Rapid cGlobally, maternal and perinatal outcomes have worsened during the COVID-19 pandemic, with an increase in maternal deaths, stillbirths, ruptured ectopic pregnancies, and maternal depression . During Mental disorders are a common cause of morbidity during pregnancy both in high and low resource countries. Sweden is an affluent country with a well-functioning national healthcare system. In 2020, the total population of Sweden was 10,379,295, the fertility rate was 1.67 children per woman and there were 113,077 total livebirths , 9. thatSweden chose a different approach in mitigating the impact of the COVID-19 pandemic, compared to other neighboring Scandinavian countries . SocietyWe hypothesized that the changes and adjustments required in pregnant women’s personal life as well as in the routine maternity care services due to COVID-19 pandemic might have a negative impact on maternal mental health. In this context, this study aimed to investigate the impact of the COVID-19 pandemic on the mental wellbeing of pregnant women in Sweden and explore both traditional  and pandemic-specific risk factors associated with poor perinatal mental health.This study is part of a global survey investigating the impact of the COVID-19 pandemic on pregnant women’s mental health, including perinatal depression, anxiety, and acute stress reaction. This multi-national project includes an anonymous web-based survey distributed to pregnant women in China (Hong Kong SAR and Shanghai), Norway, Sweden, Switzerland, Taiwan and all states of the United States of America (USA). The Swedish part of the survey was started in May 2020 and completed in February 2021.Pregnant women who 1) resided in Sweden during the COVID-19 pandemic and 2) could understand Swedish could participate in the study. Exclusion criteria were 1) unconfirmed pregnancy status (if the pregnancy was not confirmed by a midwife or a doctor yet) and 2) inability to use a web-based application to answer the survey questionnaires. The pregnant women are recruited via non-profit organizations´ websites and social media channels. Via the web link, the participants were guided to the research website where they could read information about the project and answer the questionnaires anonymously if agreed to participate in the study. Data were collected using Qualtrics, a widely used online survey platform for social science research.Sociodemographic data were self-reported by the participants, including age, marital status , working hours , monthly family income , and education level . Family health status was assessed by the question, ‘in the past 12 months, do you have any sick family members?’ In addition, the anonymous survey included assessments of symptoms of perinatal depression, anxiety and PTSD using validated instruments –18 .Depressive symptoms among pregnant mothers were assessed by EPDS . EPDS isnot at all to nearly every day (scored from 0 to 3). Total score of GAD7 ranges from 0 to 21, higher scores indicate a higher level of generalized anxiety. The total score of GAD7 will be further categorized into severity categories of minimal (0–4), mild (5–9), moderate (10–14), and severe (15–21) anxiety. In this study, we used the Swedish version of GAD7 [The GAD7 is a globally used self-report scale that assesses participants’ level of generalized anxiety in the past 14 days. The 7-item Likert-4 scale measures the frequency of being distressed by anxiety-related symptoms, with options ranging from  of GAD7 , which hnot at all to extremely, 0–4). Total score of IES-R ranges from 0 to 88, higher scores indicate higher levels of distress from acute stress reactions. The total scores are further categorized into categories of minimal (0–23), mild (24–32), moderate to severe concern for PTSD (33–88). In this study, IES-R is administered as event-oriented to the covid-19 pandemic. We used the Swedish version of IES-R [The IES-R is a 22 item self-reported measure designed to assess acute stress reactions and probable post-traumatic distress following stressful life events in the past 7 days . Each itof IES-R , 22, whiThe perceived mental well-being of participants was assessed by a single 10-point Likert scale enquiring overall mental health status in the past 12 months. Participants were then asked to fill in a stressful event checklist assessing their exposures in the past 1 year, which included marriage, divorce, death in the family, career change, unemployment, and other.p-value of < 0.05. All statistical analyses were performed with the Statistical Package for the Social Science (SPSS) version 26 (IBM® SPSS® Statistics).Participants’ characteristics and scores obtained from mental health assessments were analyzed by descriptive statistics. Continuous variables are presented as means and standard deviations (SD), while categorical variables are presented as number (n) and percentage (%). Associations were analyzed using Chi-squared test. The total scores of the three mental health status measurement tools  were not normally distributed, and so are presented as medians with interquartile ranges (IQR). Non-parametric Mann-Whitney U test was applied to compare the severity of symptoms between families with sick family members (including COVID-19 and other illnesses) and those without sick family members. Associations between mental health outcomes  and demographic characteristics of participants were estimated by univariate and multivariate logistic regression, and are presented as odds ratios (ORs) with 95% Confidence intervals (CIs). The statistical significance was set at a SD = 4.21) years. Most women lived in cohabitation with a partner  or were married . The majority  were working 40 h a week. Two third of the participants  had a bachelor degree or above, and 30.2% (n = 142) had at least one sick family member.Of a total of 522 study participants, 52 women were excluded as their responses indicated that they had either given birth or were not pregnant at the time when they replied to the survey questionnaires. Thus, data from 470 pregnant women who completed the survey were analyzed. The sociodemographic characteristics of the participants, their self-perceived overall mental health status, and stressful event exposure are presented in Table n = 203). One fourth  of Swedish pregnant women participating in the study displayed moderate to severe generalized anxiety symptoms (GAD-7 ≥ 10). 23.7% (n = 110) of the participants had moderate to severe concern for PTSD (IES-R ≥ 33).The overall prevalence of probable depression for pregnant women during the pandemic (EPDS ≥13) was 43.2%  but not acute stress reactions  vs 6.0 (3.0–9.0), p = .003; median IES-R scores: 18.5 (7.25–34.0) vs 15.0 (7.0–30.0), p = .048)  on the EPDS for depression, GAD7 for anxiety, and IES-R for acute stress reaction among women were 11.0 (7.0–16.0), 6.0 3.0–10.0), and 16.0 (7.0–31.75) respectively. Similar to findings in severity categories of women, women whose families had sick members had higher scores for all mental heatlh outcomes compared with those who did not (median EPDS scores: 14.0 (8.75–18.0) vs 11.0 (6.25–15.0), .0–10.0, p < .001), anxiety by 2.2 times , and perceived worsening mental health in the past 12 months by 2.2 times . Birth giving increased the odds of acute stress reaction by 2.4 times . Unemployment increased the odds of depression by 2.7 times  and acute stress reaction by 3.2 times . Encountering an exceptional stressful life event increased the odds of depression , anxiety , and perceived worsening mental health in the past 12 months   and acute stress reaction . Women in the age group of 26 to 30 were less likely to develop both depression  and anxiety , and less likely to have perceived worsening mental health in the past 12 months . Women in the age group of 18 to 25 were less likely to develop anxiety  (Tables Having a higher level of education (i.e. having a bachelor degree or above) decreased the odds of depression , but not acute stress reaction   than women assessed before the pandemic was declared [Women’s healthcare is often adversely affected by humanitarian disasters . Our findeclared . Similardeclared  and in adeclared .In our study, the prevalence of depressive symptoms among pregnant women in Sweden was exceptionally high, both in comparison with pre-pandemic prevalence studies from Sweden , neighboThe inclination of “adopting social distancing measures” is often thought to be positively associated with worsened mental health during the pandemic. However, it has proven not to be the case in a study in New York City . Silvermn = 110 vs mean: 11.63, n = 470). Similarly, the pre-pandemic prevalence of anxiety symptoms in pregnant women residing in Sweden (HADS-A scores ≥8 during early pregnancy) was 15.6% , while during the pandemic the point prevalence (GAD7 scores ≥10) has increased to 25.3%. However, this needs to be interpreted with caution as the women participating in our study were at variable stages in their pregnancy.The prevalence of depression (EPDS scores of ≥13) among Swedish pregnant women during the pandemic was high at 42.5% compared to 12% before the pandemic , and theWith regards to acute stress reaction, the estimated lifetime prevalence of acute stress and in severe conditions of probable PTSD among women in Sweden is 7.4%  using diWhen we compared participants, who were from families that had sick members and those who were not, we found that poor family health status had increased the odds of having perinatal mental health issues, including poorer outcomes in depression and anxiety. Pregnant women who had sick family members were more likely to score over the cutoff of EPDS and GAD7. This is a good indication and stratifying strategy, potentially applied in early mental health prevention. Since family health status traditionally being considered a precipitating and maintaining factor for health anxiety in family medicine.Unemployment and exceptionally stressful encounters were also associated with an increasing likelihood of exhibiting probable perinatal mental disorders during the COVID-19 pandemic. This is not surprising as lower socio-economic status is known to be associated with higher risk of perinatal mental health problems. Rectifying long-standing health inequalities in the societies is equally important while making swift responses to the impact of the pandemic.In our study, women in the age of 26 to 40 years showed significantly lower levels of anxiety. It could be related to the fact that in this age group, most mothers have stable families, economic stability, and good social networks.Our study is one of the first in Sweden to evaluate mental health of pregnant women during COVID-19 pandemic. Data collection took place form May 2020 to February 2021, initiating the data collection during the peak of the pandemic in Sweden. Due to the long timeframe, both peaks and lows with regards to the severity of the pandemic were included. However, our study is not without limitations. Convenient sampling method used limits the generalizability of our findings, and the cross-sectional design did not allow to explore the trends over a longer time and differences in mental health status of pregnant women during different stages of gestation and during different severities of the pandemic. The study population of 470 pregnant women, represents only a tiny fraction of women who were pregnant during the study period as the total number of livebirths during this period was 93,528. Furthermore, as the questionnaires had to be filled out online without having any direct contact with the researchers and inability to use a web-based application to answer the survey questionnaires was one of the exclusion criteria, women who were not able to read or did not have excess to internet could not participate in this survey introducing sampling bias/selection bias. Moreover, misinterpretation of questions by participants cannot be excluded as the survey was self-administered online. The prevalence of perinatal mental health disorders can be affected by pre-existing comorbidities. Although, we did not ask specific questions about pre-existing physical or mental illness, our question about overall mental health status should have captured any history of psychiatric morbidity.The prevalence of anxiety, depression, and stress in pregnant women was found to be very high, and future studies with larger sample size are needed to evaluate the prevalence of perinatal mental health disorders due to the COVID-19 pandemic in Sweden. However, a much larger survey performed in the last week of April 2021 in neighboring Norway has shown similar results with 32% (1164/3642) of women having postpartum depressive symptoms compared to 10% (225/2217) in a pre-pandemic survey . GeneralThe consequences on global mental health due to COVID-19 will be significant and cause long-term impact on the global burden of disease. Mental health problems cannot not be overlooked in this regard. It is important to understand what women need to cope with and navigate their pregnancies during this pandemic. Since pregnant women reported frequently reading and searching for information on social media, health care professionals have to become more engaged in informing pregnant women via different channels to ensure accuracy of information accessible to them. It is important that women receive reliable information and advice from their healthcare providers rather than from the social media as a primary source of information.The high prevalence of perinatal mental health problems found in this study suggests the need for a systematic approach to screening pregnant women and providing professional support to those at high risk. Providing psychological first aid and counselling are essential during a pandemic. It helps in reducing the psychological distress and promoting adaptive coping strategies to deal with the situation short and long term , 35. WebDepression and anxiety were highly prevalent among pregnant women in Sweden during the COVID-19 pandemic indicating a need for professional mental health support for this vulnerable group of population. Unemployment was an associated risk factor whereas younger age and higher educational level were protective suggesting an important role of socio-economic factors in modulating the impact of COVID-19 pandemic on perinatal mental health.Additional file 1: Table S1. Factors associated with depressive symptoms (EPDS ≥13) among pregnant women. Table S2. Factors associated with anxiety symptoms (GAD7 ≥ 10) among pregnant women. Table S3. Factors associated with acute stress symptoms (IES-R ≥ 33) among pregnant women.


Escherichia coli (n = 260), Pseudomonas aeruginosa (n = 86), Klebsiella pneumoniae (n = 47), Enterobacter cloacae complex (n = 45), and Staphylococcus aureus (n = 38) were included. The median CA was 95% . The colony characteristics  were not indicative for dASP. PV showed a high categorical agreement in the AST categories. This observation supports a test strategy to perform AST for only one colony of PV.Phenotypic variants (PV) are colonies of the same species in the same specimen with different morphological features. It is controversial whether antimicrobial susceptibility testing (AST) should be done for all PV. The objectives of this study were to quantify the proportion of differing antimicrobial susceptibility patterns (dASP) among PV and to identify species and antimicrobial compounds that are mostly affected. All PV from routine diagnostics  were subjected to species identification (matrix-assisted laser desorption ionization–time of flight mass spectrometry [MALDI-TOF MS]) and AST (Vitek 2). To assess the dASP, only antimicrobial agents were considered for which Vitek-derived MIC were available . The categorical agreement  of the PV was calculated. The PV of IMPORTANCE Phenotypic variants of bacteria are frequent in routine diagnostics and can display differing antimicrobial susceptibility patterns. We found that the likelihood of different antimicrobial susceptibility is low among PV. To save laboratory resources, only one isolate per PV could be tested to guide the antimicrobial treatment of patients. Klebsiella pneumoniae) (Pseudomonas aeruginosa in cystic fibrosis (CF) patients are often aminoglycoside resistant  of the same bacterial species in the same specimen are considered colonies with different morphological features. In addition to size, shape, color, margin, elevation, and texture , colonieumoniae) . In addiesistant , small-chenotype , and moscrobials . There acrobials , 7. Howen = 525), followed by triplets (n = 11) and one quartet. Of these 537 PV, 61 (including 17 species) were removed due to small sample sizes .In total, 1,087 isolates covering 22 species from 537 individual patients were enrolled. In the majority of cases, we observed pairs of PV (n = 237) of the patients from which the PV originated were female, and the median age was 62.3 years . The specimens were from infection  or colonization (n = 67). PV were detected among pairs (n = 467), triplets (n = 8), and quartets (n = 1) of morphologically distinct colonies. The included PV comprised the following species: Escherichia coli (n = 260), P. aeruginosa (n = 86), K. pneumoniae (n = 47), Enterobacter cloacae complex (n = 45), and S. aureus (n = 38). Taken together, the median categorical agreement (CA) for all species was 95%  were differentiated based on the margin , fermentation of lactose , color , size/shape , and hemolysis .The PV of E. coli. The median number of antimicrobial agents affected by dASP was 3 . The CA was lowest for penicillins with/without beta-lactamase inhibitors (84.6 to 85.3%) and quinolones . However, none of the categories to describe PV were significantly associated with and therefore predictive of a dASP.A dASP was detected in 116 (44.6%) PV of P. aeruginosa (n = 86) were based on margin , color , or colony size/shape . Twenty-one P. aeruginosa PV (24%) showed a dASP. The median number of dASP among the PV was 0 . The CA for the tested antimicrobial agents was 92 to 97% (P. aeruginosa were associated with dASP (P > 0.5).The PV in 2 to 97% . None ofK. pneumoniae (n = 47) were distinguished according to the fermentation of lactose , margin , color , and shape/size . Of the 47 PV, 16 (34%) had a dASP. Of these, the median number of antimicrobial agents that caused dASP was 2 . Apart from amoxicillin-clavulanic acid, piperacillin-tazobactam, and cefpodoxime, the CA was ≥90% for the tested antimicrobial agents (P > 0.4).The PV of l agents . None ofE. cloacae complex (n = 45) were differentiated based on the fermentation of lactose , margin , color , and colony size/shape . Of these, 33% (n = 15) had a dASP. The median number of antimicrobial agents that caused dASP was 1 . The lowest proportions of CA had cefepime (84%) and cefpodoxime  were associated with the presence of dASP (P > 0.3).The PV of the ime 89%; . None ofS. aureus (n = 38) were related to hemolysis , color , or colony size/shape . Eight PV of S. aureus (21%) had dASP. The median number of dASP among PV was 0 . The CA for individual agents ranged between 90 and 100% (P = 0.06).The PV of and 100% . None ofE. coli could be traced back to ATUs . The number of differing test results was comparable between PV from infection and colonization (P = 0.2).The majority of dASP among PV could not be explained by areas of technical uncertainty (ATUs). Only a notable proportion of differing test results for ciprofloxacin susceptibility testing in E. coli, E. cloacae complex, K. pneumoniae, P. aeruginosa, S. aureus) from routine diagnostics and found that the CA of AST results between PV was high .We assessed the proportion of dASP in the PV of major species  of one species in one specimen. However, particularly in chronic infections or low-grade infections, up to five PV of the same species were found in one patient .E. coli); however, this does not reflect the high CA of AST results in PV when looking at individual antimicrobial agents .Looking only at the proportion of dASP is short-sighted and might be misleading, as the proportion of dASP can be up to 44.6%  We did not perform genotyping  and are therefore unable to state whether PV were clonally related and to what extent clonality had an impact on the amount of CA. (ii) Serial passages were not performed to assess the stability of PV and whether the AST pattern can revert. (iii) The study population represents patients from a tertiary care hospital with higher exposure to antimicrobial agents. Our results might therefore not be applicable to settings of primary or secondary care levels. (iv) The influence of chronic infections on the detection of PV could not be excluded, as we did not verify underlying chronic infections. As most PV occurred in pairs, it can be assumed that chronic infections were rare among our samples, because chronic infections are usually associated with more PV  .The PV of one species from one specimen showed a high categorical agreement in the AST categories S , I , and R (resistant). Thus, it appears sufficient to select only one colony of PV for antimicrobial susceptibility testing.Ethical approval was obtained from the institutional review board . The IRB granted a waiver for obtaining signed written informed consent from patients.per se high prevalence of PV in isolates from respiratory specimens; and (iii) species for which EUCAST clinical breakpoints are not yet available.This cross-sectional study was performed in a routine laboratory  between 1 September 2019 and 31 August 2020. The inclusion criteria were PV from colonization and infection. The exclusion criteria were as follows: (i) follow-up PV of the same species from the same patient; (ii) CF patients, due to a Staphylococcus aureus in nasal swabs or colonization with multidrug-resistant Gram-negative bacteria in anal swabs) or “infection” .The decision to send a specimen for microbiological analysis was solely based on the physicians’ judgment. For patients, we recorded the age, sex, and specimen sent for analysis. The specimens were stratified into “colonization” . We defined PV as two  or more  colonies of the same species in the same specimen that are morphologically distinguishable on one agar plate. One clinical microbiologist or laboratory technician screened bacterial colonies during routine diagnostics for PV based on the categories form, color , margin, hemolysis, or the ability to ferment lactose  and incubated at 35 ± 2°C under aerobic, anaerobic, or 5% CO lactose  (1).Enterobacterales from urine (AST-N387), Enterobacterales from other specimens (AST-N214), P. aeruginosa (AST-N248), Staphylococcus spp. (AST-P654), and Enterococcus/Streptococcus spp. . Only colonies from primary cultures were used for AST. The laboratory successfully participates quarterly in external quality assessments and performs weekly quality controls for species identification and AST.The species were identified by matrix-assisted laser desorption ionization–time of flight (MALDI-TOF) mass spectrometry . Antimicrobial susceptibility testing (AST) was done using the Vitek 2 automated system  and interpreted using the EUCAST clinical breakpoints version 9.0 (2019) or 10.0 (2020) . A standSpecies were considered in the final analysis for which case counts of PV reached ≥30. We attributed each PV to the category in which the respective isolates differed . We compared the AST results of PV to identify differing antimicrobial susceptibility patterns . Antimicrobial agents were only considered if the Vitek 2-derived MICs were available. Intrinsic resistances were not considered in the assessment of dASP .The CA  among the two or more bacterial colonies defining one PV was calculated for each antimicrobial agent . In casehttps://cran.r-project.org).An association between the category of PV and the presence of dASP was assessed using a logistic regression model. The numbers of differing AST results was compared between the PV of different species using pairwise Wilcoxon rank sum tests and the Holm adjustment for multiple testing. Statistical analyses were conducted using R version 3.6.1 (significance level, 0.05; epiDisplay package,


Salmonella pullorum is one of the most harmful pathogens to avian species. Magnolol and honokiol, natural compounds extracted from Magnolia officinalis, exerts anti-inflammatory, anti-oxidant and antibacterial activities. This study was conducted to evaluate the effects of dietary supplemental magnolol and honokiol in broilers infected with S. pullorum. A total of 360 one-day-old broilers were selected and randomly divided into four groups with six replicates: the negative control group (CTL), S. pullorum-infected group (SP), and the S. pullorum-infected group supplemented with 300 mg/kg honokiol (SPH) or magnolol (SPM).S. pullorum impaired growth performance in broilers, as indicated by the observed decreases in body weight (P < 0.05) and average daily gains (P < 0.05), along with increased spleen (P < 0.01) and bursa of Fabricus weights (P < 0.05), serum globulin contents, and the decreased intestine villus height and villus/crypt ratios (P < 0.05). Notably, supplemental magnolol and honokiol attenuated these adverse changes, and the effects of magnolol were better than those of honokiol. Therefore, we performed RNA-Seq in ileum tissues and 16S rRNA gene sequencing of ileum bacteria. Our analysis revealed that magnolol increased the α-diversity  and β-diversity of the ileum bacteria (P < 0.05). In addition, magnolol supplementation increased the abundance of Lactobacillus (P < 0.01) and decreased unidentified Cyanobacteria (P < 0.05) both at d 14 and d 21. Further study confirmed that differentially expressed genes induced by magnolol and honokiol supplementation enriched in cytokine-cytokine receptor interactions, in the intestinal immune network for IgA production, and in the cell adhesion molecule pathways.The results showed that challenging with S. pullorum-induced impairments in growth performance, and the effect of magnolol was better than that of honokiol, which could be partially due to magnolol’s ability to improve the intestinal microbial and mucosal barrier.Supplemental magnolol and honokiol alleviated The online version contains supplementary material available at 10.1186/s40104-021-00611-0. Salmonella pullorum is one of the most harmful pathogens in poultry, leading to high economic losses in developing countries because of its extensive transmission routes [S. pullorum can cause intestinal injury, acute systemic disease, compromised production performance, and high mortality in young chickens [n routes . S. pullchickens . In the chickens . TherefoMagnolia officinalis. Magnolol and honokiol are involved in anti-inflammatory, antioxidant, and antibacterial physiological activities [In recent years, plant extracts have been used as potential approaches to protect poultry against bacterial challenges , 5. Magntivities , and mettivities . In additivities . A previtivities . Therefotivities . HoweverS. pullorum.The avian intestinal tract provides a biological environment for nutrient digestion and absorption, and plays a crucial role in protecting against pathogens and toxins. Additionally, the intestinal microbiota plays a pivotal role in nutrient delivery and the maintenance of multiple physiological processes related to host health. However, it is not clear whether magnolol and honokiol supplementation can moderate the gut microbial and mucosal barriers. Hence, the present study was performed to evaluate the effects of dietary magnolol and honokiol supplementation on the growth performance and intestinal health of chicks challenged with S. pullorum-challenged control group (SP); (3) chicks that received a basal diet supplemented with 300 mg/kg honokiol and treated with S. pullorum (SPH); and (4) chicks that received a diet supplemented with 300 mg/kg magnolol and treated with S. pullorum (SPM). The basal diet was a standard maize/soybean meal diet  broilers were randomly assigned to four dietary treatments, with six replicates of 15 chicks. The four treatments were designed as follows: (1) the negative control group with a basal diet, free of any challenges (CTL); (2) the S. pullorum stain (C79–3) was thawed and cultured in Luria-Bertani (LB) broth to activate for three times . After activating bacteria, expanding propagating and centrifugation, S. pullorum was resuspended in sterilized PBS and counted by plate cultivation. Chicks in the SP, SPH, and SPM groups were orally treated with a 0.5 mL (4 × 108 CFU/mL) S. pullorum solution at 5 days of age, while chicks in the CTL group received the same amount of sterilized PBS at the same age.The frozen The supplied and residual feed intakes of each replicate were recorded weekly to calculate the feed conversion ratio (FCR) and average daily feed intake (ADFI). Body weight (BW) and average daily gain (ADG) were measured on days 14 and d 21. At 14 and 21 days of age, one chick from each replicate was randomly selected to be weighed and slaughtered by jugular exsanguination after a 12-h fasting period. The weights of the liver, spleen, and bursa of Fabricus were recorded. Blood samples were collected and centrifuged to separate the serum samples. A 1-cm long section from the distal parts of the jejunum and ileum was collected and fixed in a 10% neutral buffered formalin solution for the histological studies. The tissue and content samples of the ileum were collected and frozen in liquid nitrogen until their use.Total protein (TP), albumin, globulin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and triglyceride were determined using a colorimetric method  with the aid of a commercial kit .After being fixed in the formalin solution for 24 h, the intestinal tissues were embedded in paraffin and sectioned. The sections were then stained with hematoxylin and eosin (HE). Eight complete intestinal villi of each slice were randomly selected to measure the villus height, crypt depth, and thickness of the intestinal muscularis using a micro-image processing system .http://www.arb-silva.de/) and threshold value set as 0.8 ~ 1. Alpha diversity, including observed species, Shannon, Simpson, Chao1, abundance coverage-based estimator (ACE) and PD whole tree, and beta diversity were analyzed using QIIME (Version 1.9.1) [The microbial genomic DNA extraction from the cecal content samples was carried out using the hexadecyltrimethylammonium bromide (CTAB) method. Using genomic DNA with the required purity and concentration as templates, the V3 and V4 hypervariable regions of the microbial 16S rDNA gene were amplified using primers 341F (5′-CCTACGGGRBGCASCAG-3′) and 806R (5′- GGACTACNNGGGTATCTAAT-3′). The indexed adapters were added to the ends of the 16S rDNA amplicons to generate indexed libraries ready for sequencing on an Illumina NovaSeq 6000 platform  performed by Novogene Co., Ltd. . The obtained clean sequences were aligned into operational taxonomic units (OTUs) with a 97% similarity. A species annotation analysis was carried out against the OUTs using the SSUrRNA database of Silva 123 (n 1.9.1) . PrincipP-value < 0.05, and log2 (fold-change) > 0.5, or log2 (fold-change) < − 0.5 as determined by DESeq2 were considered differentially expressed. A KEGG enrichment analysis of differentially expressed genes was performed using the clusterProfiler R package (3.4.4).Total RNA was isolated from the ileum using the TRIzol reagent . The purity of the total RNA was analyzed using a NanoPhotometer spectrophotometer . RNA integrity was assessed using the Bioanalyzer 2100 system . The cDNA library was constructed using the NEBNext UltraTM RNA Library Prep Kit for Illumina. The library preparations were sequenced on an Illumina NovaSeq 6000 platform  performed by Novogene Co., Ltd. . Clean reads were obtained by removing reads containing adapters and mapping them to the reference genome. Differential expression analysis was performed using the DESeq2 R package (1.16.1). Genes with an adjusted SAT1, accession: NM_204186), alkaline sphingomyelinase , chemokine ligand 19 , chemokine receptor 7 , joining chain of multimeric IgA and IgM , claudin 1, claudin 5 (CLDN5 accession: NM_204201.1) for confirmation using qRT-PCR, which was performed using TB Green Premix Ex Taq II  by LightCycler 96 PCR . The primers used are shown in Additional file -∆∆Ct normalizing to β-actin.To confirm the RNA-Seq results, we selected seven differentially expressed genes (DEGs) including spermidine-spermine acetyltransferase 1 . Differences were considered significantly at S. pullorum are shown in Table S. pullorum infection significantly decreased the broilers’ average weight and ADG at 14 d (P < 0.01), and tended to decrease at 21 d (P < 0.1). Magnolol supplementation increased their average weight and ADG at 14 d (P < 0.01). In addition, the SP group had a higher FCR on d 1 to 21 compared to the other three groups.The effects of magnolol and honokiol on the growth performance of broilers challenged with S. pullorum are shown in Table S. pullorum infection and the supplementation of honokiol and magnolol had no effects on liver weight or liver index (P > 0.1). The SP group showed an increased spleen weight, spleen index (P < 0.01), and bursa of Fabricius weight (P < 0.05) compared to the other three groups. The bursa of Fabricius index in the CTL and SPH groups was lower than that in the SP group (P < 0.05). At d 21, the above indices were not significantly different among the four groups (P > 0.1).The effects of magnolol and honokiol on the immune organ index of the broilers that were challenged with S. pullorum are shown in Table S. pullorum infection and the supplementation of honokiol and magnolol had no effects on the levels of albumin / globulin (A/G), AST, ALT, and triglyceride at the two time points (P > 0.1). Compared to the SP group, the CTL and SPM group had lower levels of TP and globulin (P < 0.05) at d 14. The SPH group tended to have an increased level of albumin at d 21 (P = 0.08).The effects of magnolol and honokiol on the serum biochemical indices of the broilers challenged with S. pullorum are shown in Table P < 0.05), while the SP group showed the lowest V/C in the jejunum and ileum (P < 0.01). At day 21, the jejunum villus height of the SP group was lower than that of the CTL and SPM groups (P < 0.05), while the ileum villus height of the SPM group was higher than that in the SP and SPH groups (P < 0.05). In addition, the SPM group had the highest V/C values compared to the other groups (P < 0.01). S. pullorum infection and the supplementation of honokiol and magnolol had no effect on the crypt depth and the thickness of the intestinal wall at d 14 and d 21 (P > 0.1).The effects of magnolol and honokiol on the intestinal histomorphology of the broilers challenged with P < 0.05). Decreased ACE occurred in all three S. pullorum-infected groups. At d 21, SPM group had high level of the number of observed species, and the indices of Chao1, ACE, and PD whole tree compared to the SP group (P < 0.05).The α-diversity, including observed species, Shannon, Simpson, Chao1, ACE, and PD whole tree index of ileal microbiota is shown in Fig. P < 0.01). At d 21, the PCoA plot showed that the ileal microbial community of the SPM group showed a trend of separation with the CTL and SPH groups. The β-diversity index of the SPM group was higher than that of the other groups (P < 0.001). In addition, this index was higher in the CTL group than in the SP group (P < 0.05).The β-diversity is shown in Fig. P < 0.05) and in the SPH and SPM groups at 21 d compared to the CTL group (P < 0.05). Meanwhile, the relative abundance of Cyanobacteria was decreased in the SPM group at 14 d (P < 0.05) and in all treatment groups at 21 d compared to the CTL group. In addition, the SP and SPH groups had a lower percentage of Bacteroidetes than the SPM group (P < 0.05). At the genus level  compared to the CTL and SP groups, and decreased the abundance of unidentified Cyanobacteria (P < 0.05) compared to the CTL group. The relative abundance of unidentified Enterobacteriaceae in the SPM group was higher than in the SP group (P < 0.05). Honokiol supplementation increased the abundance of Romboutsia compared to the CTL and SP groups (P < 0.05), and there was a decreased amount of Bacteroides (P < 0.05) and Streptococcus (P < 0.01) compared to the CTL group. Both magnolol and honokiol decreased the abundance of Pseudomonas compared to the SP group (P < 0.01). At 21 d, magnolol supplementation increased the abundance of Lactobacillus compared to the CTL and SP groups, and decreased the abundance of Streptococcus compared to the SP group. Both magnolol and honokiol had a lower abundance of unidentified Cyanobacteria and Romboutsia than the CTL group.At the phylum level Fig. A, B, C, vel Fig. D, E, LacP < 0.01). Conversely, pathways related to valine, leucine, and isoleucine biosynthesis metabolism, C5-Branched dibasic acid metabolism, and biosynthesis of ansamycins were higher in the SPM group than in the SP group at d 14 (P < 0.01). Compared to honokiol, magnolol could increase the number of microbial genes involved in propanoate metabolism, valine, aspartate, and glutamate metabolism, fatty acid and lysine degradation, tryptophan metabolism, ascorbate and aldarate metabolism, and inositol phosphate metabolism, and decreased the number of microbial genes involved in alanine, aspartate, and glutamate metabolism at d 14 (P < 0.01).The changes in the presumptive functions of the ileum microbiota are shown in Fig. S. pullorum infection increased the expression of IL18RAP, CCL19, CCR7 and decrease the expression of LEPR and IL17D. Compared to the SP group, magnolol and honokiol supplementation could decease the expression of CSF1R, IL21R, IL16, TNFSF8, TNFRSF18, CCR7, IL2RA, IL2RG, CD4, IL18R1, CCR5, TNFRSF8, CXCR1, CXCR5, TNFRSF13C. In addition to these genes, magnolol could decrease the mRNA level of CCL19, IL20RA, IL18RAP, IL13RA2, TNFRSF4, IL21R and increase the expression of BMP2, GDF6, LEPR, IL1RL1 while honokiol could decrease the mRNA level of CCL17, CXCR4, CCR6 and increase IL17A and IL17D expression.In the present study, we assessed the impact of magnolol and honokiol on ileum gene expression in broilers infected with Salmonella pullorum on d 14. Volcano plots of transcriptome sequencing data were used to visualize the distribution of differentially expressed genes (DEGs) between the two groups Fig. A. The toSAT1, ENPP7), immune , tight junction proteins  to validate using RT-qPCR . Compared with SP group, dietary magnolol and honokiol supplementation could decrease the expression of CCR7, JCHAIN and increase the expression of CLDN5 (P < 0.05). In addition, magnolol could also increase the expression of SAT1, ENPP7, CLDN5 and decrease the expression of CCL19 while honokiol could also enhance the expression of CLDN1 (P < 0.05). The results showed a good correlation between the RT-qPCR results and the RNA-seq data.We listed the top 100 DEGs according to their FPKM values  and claudin-5 (CLDN5), key component of tight junction protein genes, play important roles in gut barrier formation [CLDN1 and CLDN5 in this study. Remarkably, magnolol had a better effect than honokiol in increasing the height of the ileum villus at 21 d. Therefore, these different effects of magnolol and honokiol in defending against S. pullorum infection, to some extent, are related to improvements in the structure of the intestinal mucosal and to its barrier functions.Intact intestinal mucosal structures are essential to maintain the health and production performance of animals. Villus heights, crypt depths, and villus/crypt ratios are important indices of the intact intestinal mucosal structure . Some stpt ratio , 22. Coning hens . Magnolowu ducks . Consistormation . Reducedormation . It is wS. pullorum challenge has been suggested to result in intestinal health problems and disturbances to the gut microbiota in chickens [S. pullorum infections significantly reduced the community richness and phylogenetic diversity of intestinal bacteria of broiler at 14 d, as indicated by the reduced ACE estimator and PD whole tree index, respectively. Magnolol effectively increased the community richness and diversity of the bacterial community at 21 d, as indicated by the increased observed species, Chao, ACE, Shannon and PD whole tree index. In addition, the β-diversity analysis indicated a distinction in the SPM microbial community structure relative to SP group. These results explain magnolol’s improved effect at protecting broilers from S. pullorum infections.The intestinal microbiota plays a pivotal role in nutrient delivery and in the maintenance of multiple physiological processes that are related to host health. The diversity of the intestinal bacteria is beneficial for maintaining the stability of the bacteria and the environment in the intestines, as well as to resist the invasion of pathogenic bacteria . Lower gchickens . Changinchickens , 31. BasKluyveromyces marxianus may be linked to the improved feed efficiency and intestinal structure of broilers [Consistent with the results of previous studies, Firmicutes and Cyanobacteria were the most abundant in the ileum at the phylum level , 32. Firbroilers . In the broilers , 38. Notlactobacilli are dominant in the ileum at the genus level [lactobacilli, as the most important microbiota in animal intestines, have various biochemical functions, including in the protection of the integrity of the intestinal mucosal, the invasion of pathogens, and stimulation of the immune system [lactobacilli have been widely used in poultry production [Streptococcus was highly abundant in the ileum microbiota of broiler chicks with necrotic enteritis associated with Salmonella challenge [Streptococcus [Lactobacillus and decrease the abundance of Streptococcus and unidentified Cyanobacteria at the genus level. Remarkably, changes in these microbiotas were consistent at different detection time points. Except for these three genera, some genera showed different changes under different detection time points, such as Pseudomonas, Bacteroides, and Romboutsia. These results may be due to the weakened effects of Salmonella challenge in an increasing number of days.Consistent with other reports, us level , 40. Seve system , 42. Manoduction . The genhallenge . A studytococcus . Our finS. pullorum, while magnolol could increase these pathways. Leucine, valine, and isoleucine, which are representative of branched-chain amino acids, have key physiological roles in the regulation of immunity [The predicted functions of the ileum microbiota showed that pathways related to valine, aspartate, glutamate, and C5-branched dibasic acid metabolism were decreased in broilers challenged with immunity  and fat immunity . Severalimmunity , 49. In immunity . TherefoSalmonella infection [ENPP7 and SAT1, while honokiol had no significant effect on these genes. These results may partly explain that magnolol had better effect on alleviating S. pullorum-induced impairment in growth performance and intestinal villi structure. In order to better understand the mechanism of magnolol and honokiol, further studies are needed on the interaction between microorganisms and the gene expression of the host mucosa.Besides affecting gut metabolism by regulating flora composition, magnolol and honokiol had different effects on gut gene expression related to metabolism. Intestinal alkaline sphingomyelinase (ENPP7 or NPP7), an enzyme that hydrolyzes sphingomyelin to ceramide, can inhibit inflammation and stimulate cholesterol absorption . Ceramidnfection . SAT1 plnfection . MagnoloS. pullorum-induced impairment in growth performance and intestinal villi structure, and the effect of magnolol was better than that of honokiol, which could be partially due to magnolol’s ability to improve the composition of gut bacteria and improve the mucosal immune response. This study expands our fundamental knowledge concerning the role of gut microbiota in mediating the functional difference between magnolol and honokiol in broilers infected with S. pullorum.In conclusion, supplemental magnolol and honokiol alleviated Additional file 1. Ingredients and nutrient levels of basal diets.Additional file 2. Primers used in this study.Additional file 3. The top 100 differentially expressed gene.


To depict a comprehensive changing landscape of anti-lymphoma drug clinical trials in mainland China from 2005 to 2020.A systematic review was conducted on the China National Medical Products Administration Center for Drug Evaluation platform, the Chinese Clinical Trial Registry and ClinicalTrials.gov websites.A total of 797 anti-lymphoma drug clinical trials registered from Jan 1st, 2005 to Aug 1st, 2020 were identified. The number of trials increased gradually over time, and a notable increase was observed in 2016, with the number growing from 29 in 2015 to 72 in 2016. Trials in phase I (26•1%) and phase II (26•6%) represented the majority, followed by phase III (12•5%) and phase IV (7•4%). Regarding sponsorship, industry-sponsored trials (53•2%) accounted for a slightly larger proportion than investigator-initiated trials (IITs) (46•8%). A dramatic growth for IITs was seen during 2017–2020, with the number increasing from 36 in 2017 to 96 in 2020. Additionally, the proportion of trials involving targeted agents (50•2%) accounted for the largest, followed by trials involving immunotherapy agents (41•0%), and cytotoxic agents (8•0%). Besides, a sustainable growth was observed in the number of leading anti-lymphoma drug clinical trial units in mainland China over the past 15 years. The majority of leading principal units (60•8%) were from Beijing, Shanghai, Guangdong and Jiangsu.In the past 15 years, the research and development of drugs and clinical trials for lymphoma in mainland China has achieved much progression. Future efforts are needed for improving innovation and sustainability of pharmaceutical research and development.China National Major Project for New Drug Innovation (2017ZX09304015); Chinese Academy of Medical Sciences (CAMS) Innovation Fund for Medical Sciences (CIFMS) (2016-I2M-1-001). We searched PubMed for papers with the terms “Lymphoma”, “Clinical trials”, and “China” for articles published from Jan 1st, 2005 to Aug 1st, 2020. There were three previous studies focusing on the whole landscape of anti-cancer drug clinical trials in China and two studies analysing CAR-T cell therapy in China. The available studies mainly focused on the whole landscape of all kinds of anti-cancer drugs research and development (R&D) in China, without specific attention on lymphoma. To our knowledge, the study of analysing and reviewing the development of anti-lymphoma drug clinical trials in China is lacking.The rapid increase of newly registered clinical trials showed the progression of R&D in clinical trials for anti-lymphoma drugs through these years. The number of clinical trials increased gradually over the past 15 years, with a notable increase observed after 2016. The number of investigator-initiated trial has increased during 2011–2020. For industry-sponsored trial (IST), immunotherapy agents and targeted drugs have compromised over 80% of ISTs. CD20 monoclonal antibody and BTK inhibitor are the most commonly tested targeted drugs, and anti-PD-1 monoclonal antibody and CAR-T cell therapy have emerged as a new force for clinical trials of lymphoma in mainland China.This systemic review provides evidence for the changing landscapes of anti-lymphoma drug clinical trials in the past 15 years (2005–2020) in mainland China. This study also suggests unmet clinical needs and the relevant data for clinicians, investigators, pharmaceutical enterprises, policy makers and other stakeholders, which can shed some light on future strategies in R&D of anti-lymphoma drugs.1Cancer has become a major public health problem worldwide and is the leading cause of death in China, causing much disease burden Lymphoma is a heterogeneous malignancy and is mainly treated with drug therapy. Encouraging the research and development (R&D) of anti-lymphoma drugs is important for increasing the availability of new drugs and improving the survival outcomes for lymphoma patients. The Chinese government has issued a series of regulatory policies for promoting the development of innovative drugs and clinical trials since 2015 Therefore, we conducted this systematic review to analyze the trend of drug clinical trials for lymphoma in mainland China from 2005 to 2020. We also aimed to provide insight for the changing landscape in biopharmaceutical research, potency of investigator-initiated trial (IIT) and industry-sponsored trial (IST), unmet clinical needs and the supportive data for clinicians, investigators, pharmaceutical enterprises, policy makers and other stakeholders.22.1https://clinicaltrials.gov/) websites. CDE registration platform is established for new drug registration trials. Registration on CDE registration platform is mandatory for new drug registration trials in China according to NMPA. Unlike CDE registration platform, ChiCTR receives registration of all interventional clinical trials and observational clinical trials. Detailed information of NMPA, CDE and ChiCTR can be found in Supplementary Material. In October 2004, the global clinical trial registration system was established and led by World Health Organization (WHO). Therefore, we chose Jan 1st, 2005 as the start date in this study. Trials initiated before this date and retrospectively registered were excluded from this study. The cut-off date of this study was Aug 1st, 2020. The study was in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines A systematic review of registered clinical trials for lymphoma in mainland China was conducted on the Center for Drug Evaluation (CDE) of China National Medical Products Administration (NMPA) website (http://www.cde.org.cn/), the Chinese Clinical Trial Registry (ChiCTR) (http://www.chictr.org.cn) and ClinicalTrials.gov  were included. Thirdly, only trials of which study sites included mainland China were deemed eligible.To identify the final data set for analysis, two investigators (HZC and YZ) independently reviewed the official title, cancer type, study design and study locations of the above 1084 trials. Disagreements about particular trials were discussed and resolved by consensus with all investigators. 287 trials were further excluded, including those not meeting the eligible criteria above, and those duplicately registered. Thus, a total of 797 anti-lymphoma drug clinical trials initiated between Jan 1st, 2005, and Aug 1st, 2020 were identified. The selection process is displayed in 2.3Two investigators (HZC and YZ) independently extracted data from all the trials. Any discrepancy was resolved with the consensus of all investigators. The following characteristics were extracted for further analysis: trial identifier, sponsorship (ISTs or IITs), the phase of trial , pathological subtype, primary tested drug, type and mechanism of drug, date of submission, number of participating centers, geographic region of leading unit, study design, recruitment status, key inclusion criteria, exclusion criteria, and primary and secondary endpoints.ISTs are financially supported by the industry. Only drugs evaluated in ISTs were deemed as newly tested drugs, usually covering domestic innovative drugs, domestic biosimilars, generics, and global agents. IITs were defined as clinical trials proposed upon the initiative of clinical sponsor-investigators and without the company taking the role as a sponsor. Drug types were classified as cytotoxic agents, targeted agents, immunotherapy agents and SCT. Notably, targeted and immunotherapy drugs were sometimes not strictly mutually exclusive. Monoclonal antibodies, in a sense, belonged to both targeted agents and immunotherapy agents, whereas they were classified as targeted drugs in this study.3P value of less than 0•05 was considered statistically significant. All statistical analyses were performed using the R software, version 3•6•2 (http://www.r-project.org/).Descriptive statistics were performed to summarize the trial data with frequencies and percentages. Characteristics were compared using Chi-squared or Fisher's exact tests for categorical variables. We further analysed the time trends for specific indicators, comprising the number of registered initiated trials, the proportion of trials in each phase, the number of trials classified by sponsorship, the number of newly tested drugs, the number of trials involving different drug types and mechanism, and the number of leading clinical trial units. A two-sided 3.1The funding source of this study do not influence or involve in study design; collection, analysis, and interpretation of data; the writing of the report; and the decision to submit the paper for publication. All authors had full access to the data and had final responsibility for the decision to submit for publication.44.1In total, 797 drug clinical trials conducted for lymphoma were registered on the three platforms from Jan 1st, 2005 to Aug 1st, 2020 in mainland China. 734 out of 797 (92•1%) clinical trials were domestic trials, of which 355 (48•4%) trials were conducted in single center and 379 (51•6%) in multiple centers. The remaining 63 (7•9%) trials were international multi-center trials. During 2005–2013, the number of clinical trials was extremely low, though it increased slowly over time . BetweenRegarding the distribution of study phase, phase Ⅰ and phase Ⅱ trials represented the majority proportion (52•7% [420/797]), with phase Ⅰ accounting for 26•1% (208/797) and phase Ⅱ accounting for 26•6% (212/797). For all 797 trials, a total of 100 (12•5%) trials was phase Ⅲ while 59 (7•4%) trials were phase IV, with 88 (11•0%) and 11 (1•4%) trials in phase Ⅰ/Ⅱ and phase Ⅱ/Ⅲ, respectively. Additionally, of 797 trials, 42 (5.3%) trials were pilot studies, and the phase information for 77 (9.7%) trials was unavailable on the registered platforms. Among the four different phases (phase Ⅰ-Ⅳ), the largest growth was observed in phase Ⅰ, followed by phase Ⅱ, phase Ⅳ and phase Ⅲ, with average annual growth rates of 47•5%, 35•4%, 22•8% and 19•6%, respectively.4.2n = 178), followed by extranodal NK/T-cell lymphoma (n = 60), peripheral T-cell lymphoma (PTCL) (n = 51), chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) (n = 33) and HL (n = 33). Only 14 trials involved marginal zone lymphoma, eight involved lymphoblastic lymphoma and two involved lymphoplasmacytic lymphoma. Detailed pathological subtypes identified are shown in Supplementary Fig. S1.Diffuse large B cell lymphoma (DLBCL) is the most prevalent lymphoma subtype, comprising 33•27% of all lymphomas in Chinese population. When compared with Western countries, natural killer (NK)/T-cell lymphoma was more common, comprising 21•38% of all lymphomas in China, while HL and follicular lymphoma (FL) were less common 4.3In terms of sponsorship, ISTs (53•2% [424/797]) accounted for a slightly larger proportion compared with IITs (46•8% [373/797]). All IITs were registered on ChiCTR or ClinicalTrials.gov platforms. Of 424 ISTs, 349 (82•3%) trials were sponsored by domestic pharmaceutical companies, and 75 (17•7%) trials were sponsored by overseas or multinational pharmaceutical enterprises. The number of ISTs increased gradually during 2011–2017, with an average annual growth rate of 53•7%, whereas it remained stable during 2018–2020. IITs are usually funded by academic institutions  and government. For clinical trials conducted on lymphomas in mainland China, the number of IITs displayed a continued increase during 2011–2020, with an average annual growth rate of 36•1%. A dramatic growth was seen during 2017–2020, with the number of IITs increasing from 36 in 2017 to 96 in 2020. Overall, IITs appeared quite active and played a vital role for anti-lymphoma drug clinical trials in mainland China. Details can be found in 4.4n = 34), 184 new drugs were newly added between 2016 and 2020, representing an approximately 5•4-fold increase .Newly tested drugs investigated in ISTs were further analysed. From 424 ISTs, a total of 218 newly tested anti-lymphoma drugs were involved in clinical trials during 2005–2020. According to mechanism, 9•2% (20/218) of drugs were cytotoxic agents, with 46•3% (103/218) and 44•5% (97/218) of drugs belonging to targeted agents and immunotherapy drugs, respectively. The number of drugs tested in clinical trials increased over time, with an annually average growth rate of 40•2% during 2005–2020, and the accumulative total number had reached 218 at the cut-off date of Aug 1st, 2020. Compared with the accumulative total number of newly tested drugs by 2015  investigated monoclonal antibodies against the CD20 B-cell antigen. Fifty-two (24•41%) clinical trials involved Bruton's tyrosine kinase inhibitors (BTKi), 23 (10•8%) involved phosphatidylinositol 3-kinase inhibitors (PI3Ki) and 19 (8•92%) involved histone deacetylase inhibitors (HDACi). In addition, bispecific antibody (BsAb), a promising treatment strategy, is an emerging field. There were three registered trials focusing on BsAb during 2019–2020, including two on CD3/CD19 (CTR20190205 and CTR20191955) and one on CD20/CD47 (CTR20192612).n = 7), CD7 (n = 3), CD30 (n = 3), CD22 (n = 3) and B cell maturation antigen (BCMA) (n = 2). Additionally, a total of 11 trials tested two CAR-T targets  either simultaneously or sequentially. PD-1/PD-L1 were also well-studied targets of immunotherapy in lymphoma, especially in HL. In 174 trials investigating immunotherapy, there were 29 (16•67%) and 12 (6•9%) trials targeting PD-1 and PD-L1, respectively, all of which were monoclonal antibodies. Also, BsAbs have emerged as a promising therapeutic strategy in cancer immunotherapy in recent years. There were two trials involving BsAbs for lymphoma in China to date, with one focusing on anti-cytotoxic T lymphocyte associate protein-4 (CTLA-4) /PD-1 (NCT04444141) and one on anti-CTLA-4/PD-L1 (NCT03733951).As for immunotherapy, CAR-T cell therapy, a major source of immunotherapy for lymphoma in mainland China, represented the hottest strategy, with 116 of 174 (66•67%) trials evaluating it. CD19 was the most common CAR-T target, and there were 92 trials having CD19 as a target. Other CAR-T targets tested in clinical trials included CD20 (4.6n = 238), Shanghai (n = 105), Guangdong (n = 90) and Jiangsu (n = 64). By contrast, the number of trials led by PI from several provinces, such as Jilin (n = 3), Xinjiang (n = 2), Guizhou (n = 1) and Jiangxi (n = 1), were less than five, reflecting a severe uneven geographical distribution in clinical trials for lymphoma across China. Detailed geographical distribution of clinical trials is demonstrated in Overall, 797 clinical trials were conducted at 25 different provinces or municipalities across China. 497 of 797 (60•8%) clinical trials were initiated by principal investigators (PI) from Beijing . In addition, the proportion of domestic trials increased from 79•6% during 2005-2015 to 94•1% during 2016-2020 (P<0.001). Regarding the drug type, 5•9% of trials involved immunotherapy drugs during 2005-2015, compared to 48•2% during 2016-2020 (P<0.001). However, 27•9% and 4•2% of trials investigated cytotoxic agents during 2005-2015 and during 2016-2020 (P<0.001), respectively. This finding indicated that researchers shifted their focus from chemotherapy to immunotherapy.In 2015, the State Council of the People's Republic of China issued the policy "Opinions on reforming the examination and approval system for drug and medical devices" 5Lymphoma is a heterogeneous disease that is usually approached with different treatment modalities, among which medication therapy is the most important therapeutic strategy for most lymphoma subtypes. The first-developed anti-cancer agent, nitrogen mustard was applied in the treatment for HL The rapid growth of anti-lymphoma drug clinical trials is largely contributed to the policy support by Chinese government. Backlog of new drug application caused by long time of review and scarcity of domestic new drugs has hampered the development of anti-cancer drug innovation Immunotherapy agents and targeted drugs have compromised over 80% of industry sponsored clinical trials. Increasing trend of newly tested targeted drugs can be seen from 2015 to 2020. Among the targeted drugs, CD20 monoclonal antibody is the most commonly tested. The bloom of CD20 monoclonal antibody mainly attributed to the increasing investigation in the biosimilar of rituximab. In February 2015, CDE of NMPA launched “Guidelines for the research, development and technique assessment of biosimilar drugs ”, which accelerated the development of biosimilar drugs in China Another hotspot for targeted drugs is BTKi, which accounted for 24•29% of targeted drugs in clinical trials for lymphoma. Zanubrutinib is a Chinese original innovative BTKi and is the first new drug simultaneously developed in both China and US Another prosperous area of clinical trials for anti-lymphoma drug is immunotherapy. Numerous immunotherapeutic agents targeting PD-1, PD-L1, CTLA-4 have revolutionized treatment for cancer, including lymphoma. Among these, anti-PD-1 monoclonal antibody and CAR-T cell therapy are mostly investigated. On the one hand, anti-PD-1 monoclonal antibody has shown efficacy for the treatment of r/r cHL in recent clinical studies and has changed the treatment paradigm Besides the hotspots mentioned above, biopharmaceutical development has broadened the pipeline into newer attempts of clinical trials in lymphoma. First, more different types of lymphoma are under clinical trials, including some rare types with poor prognosis. For instance, results of this study showed that clinical trials for PTCL, an uncommon type of NHL which accounts for around 25% of NHL patients in China and about 10% in US and Europe ,28, accoSince the first anti-cancer drug clinical trial of N-formyl botulinum toxin conducted in 1960s in China There are some concerns that should be addressed in the anti-cancer drug clinical trials for lymphoma. The geographic distribution of leading clinical trial unit across mainland China is uneven . AdditioIt is important to note that this study has limitation. The major limitation lies in the fact that monoclonal antibodies were directly classified into the targeted therapy category. We recognize that for some readers, monoclonal antibodies will be categorized as immunotherapy, given its mechanism of action such as antibody-dependent cell-mediated cytotoxicity or antibody-dependent phagocytosis, etc. However, we wanted to emphasize the role of CAR-T and other cell therapies as a main responsible source for anti-lymphoma drug clinical research growth in mainland China. Another limitation is that the ChiCTR registration platform was established in 2007 and CDE of NMPA registration platform was established in 2013. Although the registration of clinical trials was mandatory since 2007 according to WHO International Clinical Trials Registry Platform requirement and the Declaration of Helsinki (2008), the clinical trials that finished before 2007 and not registered retrospectively might have been omitted. Despite that the limited number of clinical trials from 2005 to 2007 would not have impact on the overall result and conclusion of this study, caution must be applied when interpretation of this result.In conclusion, this systematic review provides an overview of anti-lymphoma drug clinical trials in mainland China from 2005 to 2020. With the rapid capability of clinical development and the sustained policy support from Chinese government, dramatic progress has been achieved in the R&D of anti-lymphoma drugs in the past 15 years in mainland China. Increasingly large numbers of clinical trials were conducted for lymphoma, and several representative drugs have been successfully approved in mainland China, which will further benefit Chinese lymphoma patients and make contributions for the global drug pipeline. Future efforts are needed for improving innovation and sustainability of pharmaceutical R&D.All data analysed during this study are included in this article. No additional data are available.Editor note: The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.YKS and XHH contributed to the study concept and design. YKS, XHH, HZC and YZ contributed to data quality control and data interpretation. HZC and YZ performed the systematic search, data extraction and data analysis. YKS, XHH, HZC and YZ drafted and revised the manuscript. All authors confirm that they have full access to all the data in the study and accept responsibility to submit for publication.All authors declare no competing interests.