The methods used in low- and middle-income countries’ (LMICs) household surveys have not changed in four decades; however, LMIC societies have changed substantially and now face unprecedented rates of urbanization and urbanization of poverty. This mismatch may result in unintentional exclusion of vulnerable and mobile urban populations. We compare three survey method innovations with standard survey methods in Kathmandu, Dhaka, and Hanoi and summarize feasibility of our innovative methods in terms of time, cost, skill requirements, and experiences. We used descriptive statistics and regression techniques to compare respondent characteristics in samples drawn with innovative versus standard survey designs and household definitions, adjusting for sample probability weights and clustering. Feasibility of innovative methods was evaluated using a thematic framework analysis of focus group discussions with survey field staff, and via survey planner budgets. We found that a common household definition excluded single adults (46.9%) and migrant-headed households (6.7%), as well as non-married (8.5%), unemployed (10.5%), disabled (9.3%), and studying adults (14.3%). Further, standard two-stage sampling resulted in fewer single adult and non-family households than an innovative area-microcensus design; however, two-stage sampling resulted in more tent and shack dwellers. Our survey innovations provided good value for money, and field staff experiences were neutral or positive. Staff recommended streamlining field tools and pairing technical and survey content experts during fieldwork. This evidence of exclusion of vulnerable and mobile urban populations in LMIC household surveys is deeply concerning and underscores the need to modernize survey methods and practices.The online version of this article (10.1007/s11524-020-00485-z) contains supplementary material, which is available to authorized users. In low- and middle-income countries (LMICs), household survey methods have remained consistent, while population trends have changed substantially over 40 years. This mismatch has likely increased exclusion of vulnerable and mobile populations from survey data. LMIC survey best practices were established when LMICs were majority rural by agencies that have been critiqued for holding a “sedentary bias” in development initiatives , 2. GlobRapid in-migration to LMIC cities is accompanied by increased socioeconomic inequalities, growth in slum populations, and housing crises, all of which contribute to increasingly complex living arrangements , 6. As uThe largest survey programs in LMICs include the Demographic and Health Surveys (DHS), Multiple Indicator Cluster Surveys (MICS), and Living Standard Measurement Surveys (LSMS), which essentially use the same methods and tools . CollectUnintentional exclusion of vulnerable and mobile populations, particularly slum dwellers, can additionally occur in three ways. First, if structures built and occupied since the last census are over-represented in deprived areas, vulnerable and mobile populations are systematically under-represented in the first-stage sample frame. Second, two-stage sample designs result in a gap of several months between the mapping-listing and interview activities, resulting in systematic non-response from vulnerable and mobile populations not present at time of interview, and exclusion of recently occupied dwellings (living spaces). Third, disproportionate exclusion of vulnerable and mobile populations can result from poorly defined or difficult to operationalize mapping-listing protocols in the time allotted for fieldwork, for example, assuming that one household occupies each dwelling. In this case, systematic under-listing of vulnerable and mobile households who share a dwelling results in their exclusion during the second stage of sampling .These three issues are labeled coverage error, non-response error, and sampling error, respectively, in the total survey error framework, and threaten to bias survey results . AdditioIn recent years, national surveys that developed field-referenced slum/non-slum urban sample frames in Bangladesh  and IndiTo address problems of unintentional exclusion of vulnerable and mobile households in surveys, the Surveys for Urban Equity (SUE) project piloted and evaluated three survey innovations in Kathmandu, Dhaka, and Hanoi: (1) use of modeled gridded population data as a sample frame which was assumed to be more current and have better coverage of the entire population than census, (2) area-microcensus sample design to remove the time-lag between mapping-listing and interviewing, and (3) mapper-lister protocols including a script, OpenStreetMap and OpenDataKit tools, and a broadened household definition to identify atypical dwellings and households. We were not able to obtain maps of deprived/non-deprived areas to stratify the surveys to address problems of robustness. Here, we present results of the pilot including the extent to which populations were unintentionally excluded from a standard survey design. Further, we evaluate the feasibility, cost, and skills required to implement our novel methods in complex urban settings.We evaluated whether three survey innovations resulted in samples of different types of households and individuals compared with standard surveys. To establish feasibility of the innovations, we recorded costs and team skills required, and conducted focus group discussions (FGDs) to explore enumerator experiences.We selected Kathmandu, Nepal; Dhaka, Bangladesh; and Hanoi, Vietnam, as they typify different points on the urbanization trajectory. The pace of growth in South Asia has particularly strained urban housing markets, increasing the number of people living in atypical arrangements and locations . While sIn 2017 and 2018, we conducted three cross-sectional household surveys in Kathmandu, Dhaka, and Vietnam .The survey in Kathmandu was of the general population, while the surveys in Dhaka and Hanoi focused in areas where vulnerable and mobile population were likely located. Nepal’s government is in transition to a new federal republic system, and administrative boundaries were recently updated. Old Kathmandu municipality boundaries only included the city center, while new municipality boundaries included rural communities beyond the peri-urban reach . To ensuA cluster sample of 20 households was chosen for ease of fieldwork, and to be consistent with other routine surveys such as the DHS, MICS, and LSMS. The survey in Kathmandu targeted 1200 households in 60 clusters to estimate depression and injury prevalence with a maximum 95% confidence interval of ± 4.27% (assuming the most conservative scenario where an indicator is estimated at 50%) . This asGiven the chance of selecting areas without residential buildings  from gridded population data and the possibility of selecting cells with no buildings, we selected 30% back-up clusters for each sample. This meant that we sampled 78 clusters in Nepal, and 26 clusters in Dhaka and Hanoi, before randomly assigning 60 (or 20) clusters to the main sample. If a sampled cluster had no residential buildings, then it was replaced with a randomly selected back-up cluster. Four additional back-up clusters were sampled in Hanoi after masking already selected clusters, because more than 6 clusters were dropped.Area-microcensus sampling  meaWe used WorldPop gridded population estimates as sample frames rather than older censuses. At the time of planning, the last censuses in Nepal 2011), Bangladesh (2011), and Vietnam (2009) were seven or more years old . WorldPo1, BanglaAt the time of survey, the GridSample R package was the only publicly available tool to perform PPS sampling from gridded population data . The algIn Kathmandu, all clusters were initially sampled from 100 × 100 m cells and “grown” to a minimum of 820 people (approximately 200 households)  or 20 (area-microcensus) households. Segment boundaries followed roads and property fences and had approximately equal populations; then, one segment was selected at random to represent the cluster Fig. .The mapping-listing trainings were each one-week and involved lectures, role-play, group discussion, and a field test. Before fieldwork, mappers-listers updated buildings, roads, and pathways in each cluster in OpenStreetMap using the iD editor tool . In ArcGTo ensure that interviewers would find approximately 20 households in each area-microcensus cluster, any such cluster with more than 25 dwellings was segmented manually in ArcGIS by a GIS specialist and the survey coordinator after mapping-listing fieldwork, ensuring equal numbers of dwellings in each segment .The DHS and MICS define household members as (i) usual residents or people who slept in the dwelling the previous night and who (ii) share living arrangements and (iii) share food , 14. Thedwellings, and the household listing was performed by interviewers on the day of interview. Due to time constraints in Hanoi, mapping, listing, and interviews were wrapped into one activity and conducted by public health specialists. This meant that maps used by interviewers in Kathmandu and Dhaka were field-verified, while in Hanoi, maps had only been updated during pre-field enumeration using satellite imagery.In the Kathmandu two-stage arm, geospatial specialists mapped and listed households, while public health specialists conducted interviews with sampled households later Table . In KathIn all three surveys, the SUE household definition was used to determine eligibility, and respondents provided written informed consent and were 18+ years of age and usually a senior household member. The interviewers read questions and recorded responses on a tablet in GeoODK. The household questionnaire collected demographics, assets, income/savings/expenditures, social capital, migration, and injury information. We also collected information about living arrangements, meals, and length of time at the dwelling to classify individuals and households that met DHS/MICS and LSMS definitions during analysis. One adult in each household was randomly selected using the Kish method to complete an individual questionnaire with mental health and migration questions .Members of the public, including survey respondents, were not involved in setting the research questions, outcome measures, design, or implementation of the study, nor the dissemination of study results.Sample weights were calculated separately according to the SUE and DHS/MICS household definitions. We analyzed survey results in Stata 14.0 with svy commands, adjusting for sample weights and estimating Taylor-linearized variances to account for clustering of observations within clusters . The analyses in Kathmandu were stratified by arm (area-microcensus/two-stage), and the analysis in Dhaka was stratified by community (ward/slum).p values). This approach with dichotomous variables is the survey analysis equivalent of the McNemar test for paired data [p values) adjusted only for the clustering of households within cluster. For every 20 comparisons, we would expect one comparison to be statistically significant by chance (type I error). With this in mind, our interpretation focuses on characteristics which were statistically significant, and for which a large percentage and number of people were excluded.In the area-microcensus samples in all cities, we evaluated whether use of the DHS/MICS household definition resulted in different estimates of individual and household characteristics compared with use of the SUE household definition using percentages and logit regression at 5% alpha level with “exclusion from DHS/MICS” as the dependent variable and one characteristic as the independent variable. In these comparisons, the DHS/MICS households are a subset of the SUE households and thus treated in regressions as a matched pair by including “SUE vs. DHS/MICS ID” in the svyset statement as a second-stage cluster to correctly estimate variances and differences  . IndividDays worked by each staff member and costs were recorded by the survey coordinator in each city. Time spent by survey coordinators to develop and learn the novel methods was excluded from cost calculations. However, time spent training mappers-listers and interviewers was included. In Kathmandu, we estimated costs for the area-microcensus and two-stage arms separately by holding constant costs of administration, training, and durable goods, and varying days of fieldwork.An FGD was held with each of mapping-listing teams using the same guide covering topics of OpenStreetMap enumeration, mapping-listing, and workflow. Additional questions exploring differences in area-microcensus and two-stage clusters were included in the Kathmandu FGD. FGDs were facilitated and audio-recorded by two trained qualitative researchers and conducted in the local language. The recordings were transcribed into the local language and then translated into English. We performed a thematic Framework Analysis in NVivo 11, coding every line by theme and summarizing positive/neutral experiences, challenges, and recommendations .Ethics approvals were obtained from the University of Leeds (ref.: MREC16-137), University of Southampton (ref.: 26819), Nepal Health Research Council (ref.: 1761), Bangladesh Medical Research Council (ref.: BMRC/NREC/RP/2016-2019/317), and Hanoi University of Public Health (ref.: 324/2017/YTCC-HD3).In Kathmandu, 15% of clusters were dropped and replaced. No clusters were dropped in the targeted areas of Dhaka, and 45% were dropped and replaced in the Hanoi district  compared with the SUE definition Table . In the Applying the DHS/MICS household definition, we compared area-microcensus and two-stage samples in Kathmandu to understand how sample design might influence types of respondents Table . We founBuilding off the previous analysis, we compared the area-microcensus sample with SUE definition and the two-stage sample with DHS/MICS definition in Kathmandu to understand the combined effects of survey design and household definition. In the area-microcensus-SUE sample, there were more single adult (10.4% vs. 4.5%) and non-family households (6.0% vs. 1.9%), plus inclusion of hostel-dwellers 3.8%), street-sleepers (1.0%), and long-term guesthouse residents (0.1%) who did not meet the DHS/MICS household definition  and Hanoi (US$76) differed due to cost of living and limited economy of scale in those smaller samples. The main cost difference between Kathmandu’s survey arms was the mapping-listing activity; costs were 2.5 times greater in the two-stage arm due to larger clusters , GeoODK (to collect building GPS points during the listing), and OSMAnd and MAPS.ME (used for navigation) were updated 1–30 days after a change was made to OpenStreetMap.A second problem was the number of unintegrated applications that the mapping-listing staff were expected to use, resulting in lost time and confusion. Despite having multiple navigation applications and a paper map, mappers-listers in all cities reported delays and difficulty navigating to clusters. Once in a cluster, however, mappers-listers did not report challenges identifying cluster boundaries, despite their blocky shapes. Mappers-listers also found recording the listing data in GeoODK was arduous, and they often took notes on paper when speaking to residents and then entered information into the tablet immediately after.Third, the location precision within OSMAnd and GeoODK was poor, often showing a circle up to 36 m in which the tablet could be located. Location precision was a particular problem in high-density areas  and resulted in a few instances of a mapping-listing team starting their work and then realizing that they were recording data one or two streets away from the cluster.By comparing DHS/MICS and SUE household definitions, and area-microcensus and two-stage sampling, we found evidence that standard household survey methods unintentionally omit single adults and non-family households, both of which are more likely to represent disjoined households or be mobile compared with stable nuclear family households , 43, 49.Although the same protocols and household definitions were used to identify households in Kathmandu’s area-microcensus and two-stage arms, the quality of the household listing data appeared to be more thorough in area-microcensus clusters where interviewers (rather than mapper-listers) listed households. Interviewers had more skills to interact with the public and substantially more time at each building while administering questionnaires (2.5–3 h per household as opposed to 15 min per household) to build rapport with residents and learn about atypical and informal housing arrangements. Indicator design effects point to another possible benefit of the area-microcensus design. Although one might expect larger design effects in area-microcensus clusters because near neighbors are assumed to be more similar than far neighbors , the DEFWithout urban strata, the two-stage sample in Kathmandu was better able to measure tent and shack dwellers than the area-microcensus sample, likely due to the larger area of two-stage clusters. The only way to ensure representative surveys of shack/tent dwellers and other vulnerable populations concentrated in slums is to treat deprived/non-deprived areas as strata, in both area-microcensus and two-stage designs. Others have suggested that censuses classify EAs as slum/non-slum to support stratified urban surveys and numerous initiatives to improve the well-being of slum dwellers and the health of cities . Given tWe found that response rates in area-microcensus clusters were lower than in two-stage clusters. This may have been due to the greater proportion of vulnerable and mobile households identified in area-microcensus clusters if they were less willing to participate, more likely absent, or felt disempowered to respond. Readers who are interested in area-microcensus survey designs should take account of lower response rates and potentially higher design effects for certain indicators when calculating sample size. The surveys conducted in Dhaka and Hanoi focused on vulnerable and mobile communities, so rates of exclusion identified in this study may have been higher than in the general population.Societal changes, particularly rapid urbanization in LMICs, have likely caused decay in survey data accuracy due to increased complexity in living arrangements, urban disparity, and population mobility. Not only are vulnerable and mobile populations more likely to be intentionally excluded from surveys, but also they are at increased risk of unintentional, unmeasured exclusion, and their data are masked in urban averages when they are sampled. Given the importance of household survey data to policy-making, planning, and monitoring progress toward development goals, it is time to evaluate new survey tools and protocols that ensure inclusion of all households.ESM 1(DOCX 31 kb)


P-trend < 0.0001 for all). Associations between PDI and individual lipid disorders differed by sex. The PDI was inversely associated with risk of developing hypertriglyceridemia in men and with risk of developing low high-density lipoprotein cholesterol in women. The hPDI was inversely associated with risk of all lipid disorders, whereas the uPDI was positively associated with individual lipid disorders. The quality of plant foods is important for prevention of dyslipidemia in a population that consumes diets high in plant foods.We evaluated the associations among different types of plant-based diet indices, risk of dyslipidemia, and individual lipid disorders in Asian populations with different dietary patterns from Western populations. Participants included 4507 Korean adults aged ≥40 years without dyslipidemia and related chronic diseases at baseline (2001–2002). Dietary intakes were assessed using an average of validated food frequency questionnaires measured twice. We calculated three plant-based diet indices: overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI). During a follow-up of 14 years, 2995 incident dyslipidemia cases occurred. Comparing the highest with lowest quintiles, the multivariable-adjusted hazard ratios (HRs) for incident dyslipidemia were 0.78  for PDI, 0.63  for hPDI, and 1.48  for uPDI ( Dyslipidemia is a major risk factor of cardiovascular disease (CVD), the top cause of death in the USA and worldwide . DyslipiRecently, investigators have developed new indices that considered gradations of adherence to a predominantly plant-based diet . Plant-bFurther, limited evidence on plant-based diets and chronic diseases are available in Asian populations who have different dietary patterns from western populations ,15. SpecIn this context, we aimed to evaluate the associations between different types of plant-based diet indices  and risk of dyslipidemia and individual lipid disorders using data from a community-based cohort of middle-aged and older Korean adults.Analyses were based on data from the population-based cohorts in the Korean Genome and Epidemiology Study (KoGES) , which wn = 410), had CVD or cancer at baseline (n = 304), individuals who had dyslipidemia at baseline (n = 4076), refused to participate in follow-up examinations (n = 470), had missing information (n = 263), were excluded. Our final sample was 4507. Similarly, for the analysis of individual lipid disorders, 6373 individuals for hypertriglyceridemia, 5963 individuals for high cholesterolemia, 7176 individuals for low high-density lipoprotein cholesterol (HDL-C), 6110 individuals for high low-density lipoprotein cholesterol (LDL-C) and 6816 individuals for high total cholesterol/HDL-C.For dyslipidemia analysis, individuals with extraordinary energy intake  . ReproduFor the calculation of the PDI, hPDI, and uPDI scores, we used the approaches outlined in previous studies . BrieflyAfter grouping foods, we adjusted for total energy intake, and ranked participants into quintiles. For the PDI score, all plant foods  were positively scored. For instance, subjects in the highest quintile of fruits consumption received a score of 5, and those in the lowest quintile received a score of 1. For the hPDI, only healthy plant foods were positively scored. For the uPDI, only less healthy plant foods were positively scored. Animal foods were negatively scored in all plant-based diet indices. For instance, those in the highest quintile of egg consumption received a score of 1, and those in the lowest quintile received a score of 5. After adding up the scores across these categories for plant and animal foods, we divided the overall diet scores into quintiles for analyses.n = 40) was duplicated and tested. All laboratory assessments showed very high reproducibility (Pearson’s correlation >0.99) [Participants self-reported medical history and medication use. On an annual basis, trained staff measured participants’ height and weight, and blood specimens were collected. The study procedures have been described in detail previously . Blood sn >0.99) .Dyslipidemia was defined as having one of the following symptoms : (1) hyp2) was calculated from measured height (cm) and weight (kg). Residential location was assessed as urban or rural. Educational level was categorized as ≤6, 7 to 12, and >12 years. Pack-years of cigarettes were calculated by multiplying the number of packs of cigarettes smoked per day and the number of years the person has smoked. Alcohol consumption was calculated by summing alcohol intake from different types of alcoholic drinks consumed within one year [Data on demographic characteristics and lifestyle factors were examined at baseline using structured questionnaires. Body mass index (BMI in kg/mone year . Physicaone year .Characteristics of participants at baseline are expressed as mean and standard deviation (SD) or median and range (continuous variables) or number and percentage . Comparisons of variables across quintiles of plant-based diet indices were conducted by either chi-square tests or generalized linear regressions, as appropriate.Hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of dyslipidemia according to quintiles of plant-based diet indices were calculated using multivariable Cox proportional hazards models. We adjusted for the same set of covariates in both studies. Model 1 adjusted for age and sex. Model 2 was additionally adjusted for residence area, BMI, education level, physical activity, pack-years of cigarettes, alcohol consumption, and total energy intake. Linear trends were tested by using the median score within each quintile. Then, using the same set of covariates, we modeled all plant-based diet indices as a continuous variable and calculated measures of association per 1 SD higher score. Next, we used restricted cubic splines with 4 knots at the 5th, 35th, 65th, and 95th percentile to examine the shape of the associations. Next, we examined if plant-based diets were associated with individual lipid disorders  in the fully adjusted models. This analysis was separated by sex because the response of individual lipids to diet may differ by sex . For thePerson time was calculated as the time from baseline examination until the date of dyslipidemia event or censoring. Censoring was defined as those who did not return for a follow-up visit. It is possible that participants did not return for a follow-up visit due to death or moving, but these data were not available.p < 0.05 was considered statistically significant for two-sided tests.The proportional hazard assumption was confirmed graphically using log–log plots and statistically using Schoenfeld residuals . We did Those in the highest quintiles of PDI and hPDI were more likely to be older, women, had lower education level and pack-years of cigarettes, consume lower amounts of alcohol, and more physically active . Those iThose in the highest quintiles of all plant-based diet indices had a higher consumption of carbohydrate, lower consumption of protein, fat, and cholesterol . Those iP-trend < 0.0001 for all)  participants developed dyslipidemia. Comparing the highest with the lowest quintile, the multivariable-adjusted HR of incident dyslipidemia were 0.78  for PDI, 0.63  for hPDI, and 1.48  for uPDI  . The strp < 0.0001 for all).We found approximately linear associations between all plant-based diet indices and incident dyslipidemia when we examined the shape of associations . When plAssociations between plant-based diet indices and individual lipid disorders differed by sex . Among mIn a community-based cohort, greater adherence to PDI or hPDI was associated with a lower risk of incident dyslipidemia, whereas greater adherence to uPDI was associated with a higher risk, after adjusting for demographic characteristics and lifestyle factors.Stronger inverse associations were observed for hPDI than PDI. Association between PDI and individual lipid disorders differed by sex. Among men, greater adherence to PDI was inversely associated with hypertriglyceridemia whereas among women, PDI was inversely associated with low HDL-C. Associations of hPDI or uPDI with risk of individual lipid disorders did not differ by sex. These findings highlight the importance of defining plant-based diets in terms of the quality of plant foods for the prevention and management of dyslipidemia. In addition, our results suggest sex differences for the association between plant-based diet and individual lipid disorders.Our results were aligned with the findings of prior studies. A meta-analysis of clinical trials and cross-sectional studies reported that vegetarian diets were associated with lower levels of total cholesterol, LDL-C, and HDL-C . AnotherA traditional Korean diet is comprised of a variety of grains and vegetables. Koreans consume various plant foods in every meal and their habitual diet has been similar to a plant-based diet for a long period of time. It has been shown that plant-based diets are low in saturated fat and cholesterol and high in unsaturated fat . This liInterestingly, hPDI was inversely associated with low HDL-C, whereas uPDI was positively associated with low HDL-C in contrast to the result from a meta-analysis showing a positive association between vegetarian diet  and low HDL-C . The difThe association between PDI and individual lipid disorders differed by sex. An inverse association of PDI with hypertriglyceridemia or high LDL-C was observed in men whereas the association with low HDL-C was observed only in women. The mechanism for sex difference is not clear. Different metabolic responses to individual lipid disorders may be due to differences in dietary habits between men and women. Women have dietary behaviors more similar to plant-based diets than men ,37, wherOur study evaluated prospective associations between different types of plant-based diets and risk of dyslipidemia using recently developed plant-based diet indices. Our results expand the understanding of how diets rich in plant foods for a longer period may be associated with dyslipidemia by influencing different types of lipids.Strengths of our study include the use of data from a population-based cohort, validated FFQ, repeated dietary assessments, and sufficient follow-up period to ascertain incident dyslipidemia cases. Our data also contribute to the literature with a unique focus on Asian populations who have different dietary patterns than western populations. However, several limitations need to be taken into account. We made slight changes to the categorization of foods, because certain less healthy plant foods and healthy plant foods were asked together. Further, there was no data on vegetable oil intake in this population, which could have affected blood lipids. However, vegetable oil would be the predominant source of fat consumption for most participants. Lastly, although we adjusted for important confounders, there may still be residual confounding factors.In populations who habitually consume diets rich in plant foods, great adherence to three types of plant-based diets were differentially associated with risk of incident dyslipidemia. Our study strongly supports considering the quality of plant foods for dyslipidemia prevention. Prospective studies are needed to confirm the relationship between a plant-based diet and dyslipidemia in diverse populations with different dietary habits.


Wine is a widely consumed beverage thanks to its unique and pleasant sensory properties. Wine is composed of more than one thousand chemical compounds  resulting from several chemical and biochemical processes ,2. NowadAs a result, we proposed “Chemical/Instrumental Approaches to the Evaluation of Wine Chemistry” as an interesting topic for a Special Issue in the Molecules journal. This Special Issue aims to update the top-of-the-art extraction procedures ) and analytical tools , inductively coupled plasma mass spectrometry (ICP-MS), ultra-performance liquid chromatography tandem mass spectrometry (UPLC-MS/MS)), emphasizing their use as suitable platforms for the establishment of the chemical composition of wine . In addition, information related to wine sensorial properties, contaminants, authenticity, and chemometric tools used for data treatment will be described in this issue. Thus, this Special Issue includes eight publications using different analytical approaches for the evaluation of wine chemistry ,12,13,14Primula veris L. In addition, a novel and accurate method based on ultrahigh performance liquid chromatography (UHPLC) with a photo-diode array detector (PDA) and charged aerosol detector (CAD) was developed for simultaneously determining nine sweeteners (most authorized for use in China) in white spirits by Ma et al. [Related to liquid chromatography, Tarapatskyy et al.  used ulta et al. .Deng et al.  used indThis Special Issue is accessible through the following link:https://www.mdpi.com/journal/molecules/special_issues/instrumental_wine_chemistryAs Guest Editors for this Special Issue, we would like to thank all the authors and co-authors for their contributions, all reviewers for their effort in revising the manuscripts, as well as the editorial office of Molecules journal for their generous help in organizing this Special Issue.


Both cystic fibrosis (CF) and non-cystic fibrosis bronchiectasis are characterized by permanent bronchial dilation, impaired mucociliary clearance, and development of chronic colonization and infection. Although the major airway microbiota in both CF and non-CF bronchiectasis may be similar, there are some differences in clinical and microbiologic features. There may also be differences in antibiotic susceptibility patterns between the CF and non-CF populations. Therefore, analysis and comparison of the microbiota and antibiotic susceptibility pattern in CF bronchiectasis versus non-CF bronchiectasis would help to improve the management of both conditions.I2 method. We will contact the corresponding authors of studies where data is/are missing and try to obtain the missing data. We will undertake sensitivity analysis to explore the impact of study quality and subgroup analysis based on pre-set criteria. We will prepare a summary of findings’ table and assess the confidence in the evidence using the GRADE methodology.Two authors will independently search the electronic databases PubMed, EMBASE, the Cochrane Library, and LIVIVO, for studies reporting bacterial colonization of the respiratory tract in adults and children diagnosed with bronchiectasis in either CF or non-CF. We will include studies examining any respiratory tract specimen, using conventional bacterial culture or other specialized techniques such as molecular methods. We will also examine the antimicrobial susceptibility patterns in people with CF bronchiectasis versus non-CF bronchiectasis. The authors will independently assess the risk of bias in each included study using the Newcastle Ottawa Scale (NOS). We will present the data with descriptive statistics and provide pooled estimates of outcomes, wherever it is feasible to perform meta-analysis. Heterogeneity in studies will be explored by visual inspection of forest plots as well as using the Higgins and Thompson To date, there are no locally applicable evidence-based guidelines for antimicrobial treatment of non-CF bronchiectasis patients. In general, treatment is based on extrapolation of evidence in people with CF bronchiectasis. An insight into the microbiota and antimicrobial susceptibility patterns in the two conditions would facilitate appropriate rather than empiric antimicrobial therapy and hopefully reduce the burden of antimicrobial resistance created by rampant usage of antibiotics.CRD42020193859).The protocol has been registered in PROSPERO on July 26, 2020 (PROSPERO registration number: The online version contains supplementary material available at 10.1186/s13643-020-01557-6. Staphylococcus aureus, Pseudomonas aeruginosa, Haemophilus influenzae, or Burkholderia cepacia complex (Bcc) [Cystic fibrosis (CF) is an autosomal recessive disorder caused by mutations in cystic fibrosis transmembrane conductance regulator (CFTR) gene. This gene regulates the activity of sodium and chloride channels across the epithelial cells, thereby facilitating appropriate hydration of mucins and effective muco-ciliary clearance in various organs . Impaireex (Bcc) . The infex (Bcc) .Besides CF, bronchiectasis is associated with various other conditions such as immunodeficiency disorders, autoimmune diseases, ciliary abnormalities, connective tissue diseases, airway injury, malignancy, inflammatory bowel disease, alpha-1 antitrypsin deficiency, or hypersensitivity . These are collectively termed as non-CF bronchiectasis .There are many similarities between CF and non-CF bronchiectasis. Both are associated with severe airway inflammation, mucus obstruction, reduced lung function, progression over time, and frequent pulmonary exacerbations , 7. HoweVarious biological specimens have been analyzed for identifying bacterial colonization patterns in people with bronchiectasis. Sputum is the preferred specimen for culturing bacteria and is also tested for acid-fast bacilli in non-CF bronchiectasis . BronchoStaphylococcus aureus, Pseudomonas aeruginosa, Burkholderia cepacia complex, Haemophilus influenzae, Stenotrophomonas maltophilia, and Achromobacter xylosoxidans are commonly associated with CF bronchiectasis [Haemophilus influenzae, Pseudomonas aeruginosa, Moraxella catarrhalis, or non-tuburculous Mycobacteria (NTM) are the predominant bacterial species associated with non-CF bronchiectasis [Streptococcus pneumoniae and Staphylococcus aureus are rarely associated with non-CF bronchiectasis unlike CF bronchiectasis [The major microbiota colonizing the airways are similar in both CF and non-CF bronchiectasis. iectasis  while Haiectasis , 9. Gramiectasis . Furtheriectasis , 11.Antibiotics are the mainstay of treatment of bronchiectasis in both CF and non-CF patients. The choice of antibiotics is based on an understanding of the predominant respiratory tract colonizers in individual patients, as well as local antimicrobial susceptibility testing (AST) patterns. The appropriate use of antibiotics is associated with improved pulmonary function and survival .AST may predict the success or failure of specific antibiotics, by sorting out the resistant bacteria from the susceptible ones on the basis of Minimal Inhibitory Concentration (MIC) breakpoints. These are determined by breakpoint committees such as the European Committee on Antimicrobial Susceptibility Testing (EUCAST) or the Clinical and Laboratory Standards Institute (CLSI). However, the epidemiological cut-off is determined using the susceptibility data from the wild-type population and does not take into consideration any mutant strains , which aTherefore, a detailed comparison of respiratory pathogen colonization in people with CF bronchiectasis and non-CF bronchiectasis, and the antimicrobial susceptibility patterns in them, could improve management of both conditions.What are the bacteria colonizing the respiratory tract in people with cystic fibrosis bronchiectasis, compared to non-cystic fibrosis bronchiectasis?How does the antibiotic susceptibility profile of specific bacteria, differ between people with CF bronchiectasis versus non-CF bronchiectasis?This systematic review aims to compare the microbiota and antimicrobial susceptibility profile in people with CF bronchiectasis versus non-CF bronchiectasis. We propose to undertake a systematic review of literature to address the following research questions:The protocol of this systematic review has been registered in the PROSPERO database, the International prospective register of systematic reviews on July 26, 2020 CRD42020193859). This protocol is in accordance with the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA-P) guidelines , one or other arm of controlled clinical trials (randomized or non-randomized), or case series.Adults and children diagnosed with CF bronchiectasis or non-CF bronchiectasis.We will include studies reporting bacterial colonization of the respiratory tract determined by examination of any respiratory tract specimen, by conventional bacterial culture or molecular techniques, and/or antimicrobial susceptibility testing by any method.Those which include people with CF or non-CF conditions, but without bronchiectasis.Those in which data of patients with and without bronchiectasis cannot be distinguished.Those in which the underlying cause(s) of bronchiectasis cannot be distinguished as CF or non-CF.Those wherein multiple clinical conditions were studied, but it is not possible to obtain or analyze data for CF or non-CF bronchiectasis.Those reporting microbiology data wherein the underlying clinical condition(s) are not specified.Those in which non-standard culture methods were used to identify organisms.Case series with less than 10 participants.Studies conducted in animals or animal models, or studies wherein already identified organisms were evaluated further for genotypic or phenotypic characteristics.We will exclude the following studies:Clinical or microbiological studies of any design , reporting bacterial colonization of the respiratory tract  in CF and non-CF bronchiectasis, and/or antimicrobial susceptibility in both types of patients. Such studies will be considered direct comparisons.Clinical or microbiological studies of any design , reporting bacterial colonization of the respiratory tract, and/or antimicrobial susceptibility in either CF or non-CF patients, within a 3-year period. Such studies will be considered indirect comparisons.Clinical or microbiological studies of any design , reporting bacterial colonization of the respiratory tract, and/or antimicrobial susceptibility in either CF or non-CF patients, within any time period, if they are from the same institution. Such studies will also be considered indirect comparisons.Bacteria identified in the respiratory tract in people with CF bronchiectasis versus non-CF bronchiectasis.Relative proportion of various bacterial species identified in the respiratory tract in people with CF bronchiectasis versus non-CF bronchiectasis.Number of bacterial species identified per person with CF bronchiectasis versus non-CF bronchiectasis.Bacteria identified in people with non-CF bronchiectasis, with a known cause versus unknown cause(s).Proportion of specific bacterial species susceptible to specific antimicrobial agents.Proportion of specific bacterial species resistant to specific antimicrobial agents.Proportion of specific bacterial species with intermediate susceptibility to specific antimicrobial agents.Time-trend of antimicrobial sensitivity patterns in 10-year epochs.Bronchiectasis AND Cystic fibrosis AND non-cystic fibrosis AND  AND (susceptibility OR sensitivity OR resistance)Cystic fibrosis AND bronchiectasis AND  AND (susceptibility OR sensitivity OR resistance)Non-cystic fibrosis AND bronchiectasis AND  AND (susceptibility OR sensitivity OR resistance)Pulmonary exacerbation AND  AND (susceptibility OR sensitivity OR resistance)Bronchiectasis AND Cystic fibrosis AND non-cystic fibrosis AND (microbiota OR pathogens OR colonizers OR bacteria OR microbiology)Cystic fibrosis AND bronchiectasis AND (microbiota OR pathogens OR colonizers OR bacteria OR microbiology)Non-cystic fibrosis AND bronchiectasis AND (microbiota OR pathogens OR colonizers OR bacteria OR microbiology)Two authors will independently search the electronic databases PubMed, EMBASE, the Cochrane Library, and LIVIVO. Grey literature will be searched using the search engines, Open Grey and Google Scholar. Figure Studies will be screened by examining titles and abstracts. Those identified as potentially relevant will be retrieved and full text examined. Each full-text article will be evaluated for eligibility to be included in the review. There will be no language restriction. Manual search of the reference lists of the included studies will also be performed. We will inform the date last searched for each of the databases. Disagreements/discrepancies will be resolved by discussion and if necessary, arbitration by the third author.Data will be independently extracted by two reviewers into a special data extraction form.From each included study, the following information will be extracted: Identification data , study design, institution, country or countries, time-period of study, whether clinical or microbiological analysis, inclusion criteria of patients (CF and non-CF bronchiectasis), age of patients, clinical state of patients , underlying clinical condition, duration of illness if known, presence of co-morbidity, specimen tested, specimen collection method, whether already on antibiotics, micro-organisms identified, bacteriological method used for identification , bacterial quantification, biofilm formation, antimicrobial susceptibility profile, method of testing antimicrobial susceptibility, definition of sensitivity, and clinical/bacteriological outcome Tables  and 2.T> 6, from a maximum of 9 points [Two authors will independently assess the risk of bias in each included study using the Newcastle Ottawa Scale (NOS) . The NOS9 points .We will present the data with descriptive statistics and provide pooled estimates of outcome parameters, wherever it is feasible to perform meta-analysis. Pooled estimates will be presented with a 95% confidence interval. The default analysis will be with a random effects model.We will contact the corresponding authors of studies where data is/are missing and try to obtain the missing data. If this fails, we will try and impute data where possible. If that is not feasible, we will state as such.I2 method [I2 heterogeneity will be categorized as follows: 0–50% low, 50–75% moderate, and > 75% considerable heterogeneity. Where I2 is greater than 50%, we will try to identify possible explanations using subgroup analysis and meta-regression analysis based on the most important characteristics of the studies.Heterogeneity in studies will be explored by visual inspection of forest plot as well as using the Higgins and Thompson 2 method . The I2 Wherever possible, we will obtain the original trial protocols for comparison with the published papers to ensure that all outcomes were reported. If it is not possible to obtain the trial protocols, we will scrutinize the “Methods” section of the published paper(s) to ensure full reporting of all measured variables. If negative data were not fully reported, we will contact the primary investigators for these data. We will explore reporting bias using a funnel plot. We will also assess publication bias by looking for evidence of conference presentations not followed by subsequent journal publications.In order to assess whether the results are substantially influenced by the presence of any individual study, we will perform a sensitivity analysis by systematically removing studies with a high risk of bias and recalculating the results.> 18 years).Age group of patients: Children (< 18 years) versus adults , consistency across studies, directness of the evidence, precision of estimates, and presence of publication bias using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach . The bodTo date, there are no locally applicable evidence-based guidelines for antimicrobial treatment of non-CF bronchiectasis patients. In general, treatment is based on extrapolation of evidence in CF bronchiectasis , 25. HenAdditional file 1. PRISMA-P 2015 Checklist.


Long-acting muscarinic antagonist (LAMA) monotherapy is recommended for chronic obstructive pulmonary disease (COPD) patients with high risk of exacerbations. It is unclear whether long-acting β2-agonist (LABA)/LAMA fixed-dose combinations (FDCs) are more effective than LAMAs alone in preventing exacerbations. The aim of this study was to systematically review the literature to investigate whether LABA/LAMA FDCs are more effective than LAMA monotherapy in preventing exacerbations.We searched several databases and manufacturers’ websites to identify relevant randomized clinical trials comparing LABA/LAMA FDC treatment with LAMAs alone ⩾24 weeks. Outcomes of interest were time to first exacerbation and rates of moderate to severe, severe and all exacerbations.p = 0.71], moderate to severe exacerbations , severe exacerbations , and a marginal superiority in terms of all exacerbations . The incidence of all exacerbation events was lower in the LABA/LAMA FDC group for the COPD patients with a history of previous exacerbations and those with a longer treatment period (52–64 weeks).We included 10 trials in 9 articles from 2013 to 2018 with a total of 19,369 patients for analysis in this study. Compared with LAMA monotherapy, LABA/LAMA FDCs demonstrated similar efficacy in terms of time to first exacerbation [hazard ratio, 0.96; 95% confidence interval (CI) 0.79–1.18; This study provides evidence that LABA/LAMA FDCs are marginally superior in the prevention of all exacerbations compared with LAMA monotherapy in patients with COPD.The reviews of this paper are available via the supplemental material section. In recent years, LABA/LAMA fixed-dose combinations (FDCs) have increasingly been used to treat COPD due to greater improvements in lung function, symptom scores, and health status when compared with LABA or LAMA monotherapy.25 There is solid evidence showing that LAMAs are superior to LABAs with regards to exacerbation prevention.6 However, the advantage of LABA/LAMA over LAMA in preventing exacerbations has not been consistently demonstrated, so the use of LABA/LAMA FDCs as initial treatment is currently guided by the level of symptoms but not the risk of exacerbations. According to the 2019 and 2020 revised Global Initiative for Chronic Obstructive Lung Disease (GOLD) reports, LAMA monotherapy is recommended as the initial choice of therapy for patients at high risk of COPD exacerbations (group C and D). LABA/LAMA FDC is an alternative choice for those with more severe symptoms. In addition, for patients with persistent exacerbations on long-acting bronchodilator monotherapy, escalation to LABA/LAMA is also recommended in current guidelines.7 The currently available LABA/LAMA FDCs, including olodaterol/tiotropium, indacaterol/glycopyrronium, formoterol/aclidinium, and vilanterol/umeclidinium, are widely used to treat COPD patients. However, few studies have investigated whether these LABA/LAMA FDCs offer additional benefits over LAMA monotherapy in exacerbation prevention. Recently, a large randomized controlled trial demonstrated that combining tiotropium and olodaterol did not reduce exacerbation rates as much as expected compared with tiotropium alone.8 Given the increased number of LABA/LAMA FDCs for clinical use in COPD patients, the initial choice of these agents or LAMA alone remains under debate in terms of exacerbation prevention. The aim of the current analysis was therefore to evaluate the comparative efficacy of LABA/LAMA FDCs and LAMA monotherapy in preventing exacerbations.Chronic obstructive pulmonary disease (COPD) represents a significant health burden and is currently the third leading cause of death worldwide.9 The inclusion criteria were: (a) patients with stable COPD according to the GOLD diagnostic criteria; (b) randomized controlled trials comparing LABA/LAMA FDCs and LAMAs; (c) at least 24 weeks of treatment duration; and (d) endpoints meeting any of our outcomes of interest . We also included studies with subgroup analysis comparing LAMA/LABA FDCs with individual LAMA components.We performed a systematic literature search to identify randomized controlled trials (RCTs) evaluating the efficacy and safety of long-acting bronchodilators for COPD using PubMed, EMBASE, Cochrane Library, and Trip databases for relevant studies published up to August 1, 2019. In addition, reference lists of the included studies were scanned, and experts and physicians in this field were also consulted. This systematic review was drafted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols (PRISMA-P) guidelines.The title and abstract of each study were independently assessed by three authors  to confirm the eligibility for analysis, and any difference in opinion was resolved by consensus. Data from the included studies were independently extracted and checked by C-YC and Y-FW Two reviewers (C-YC and W-CC) independently assessed the risk of bias of the included studies according to the recommendations in the Cochrane Handbook for Systematic Reviews of Interventions 5.1. Disagreements were resolved by consensus or assessed by other authors (Y-PH and C-HH).versus low-risk populations, and tiotropium versus non-tiotropium groups.The outcomes of interest were the frequency of acute exacerbations . Frequencies of exacerbations were also analyzed according to the treatment duration, high-risk 10 A 95% confidence interval (CI) was set to determine statistical significance. Between-study heterogeneity assessed using the I2 test was considered to be moderate to high at a p-value < 0.10 and I2 value > 50%. Publication bias was examined using eyeballing, funnel plots and Egger’s test. Sensitivity analyses were performed to assess the contribution of each study to the pooled estimate by excluding individual studies one at a time and recalculating the pooled HR estimates for the remaining studies . For any three-arm trials (e.g. indacaterol/glycopyrronium versus glycopyrronium versus tiotropium), each pairwise comparison  was used in the meta-analysis by dividing the sample size in half to match the total sample size when adding together. High-risk versus low-risk exacerbation patient groups were defined according to the previous exacerbation history (⩾1 versus no exacerbations) or lung function (⩾50% versus <50% of forced expiratory volume in the first second) for the majority patients in the study. The meta-analysis was performed using Review Manager Software version 5.3 .Studies were pooled using risk ratios (RRs) for dichotomous outcomes and hazard ratios (HRs) for time to event outcomes in random effect models, respectively.12 Finally, a total of 19,369 patients were included in nine published articles from 2013 to 2018.1219 Among these included articles, two compared indacaterol/glycopyrronium, glycopyrronium, and tiotropium; two compared tiotropium/olodaterol and tiotropium; two compared aclidinium/formoterol and aclidinium; one compared umeclidinium/vilanterol, umeclidinium, and tiotropium; one compared umeclidinium/vilanterol and tiotropium; and one compared glycopyrrolate/formoterol fumarate, glycopyrrolate, and tiotropium.The relevant research and studies are shown in 18 We paired the LAMA/LABA FDCs and compared them with individual or different LAMA components in the studies including three or more comparators. The characteristics of the included studies are summarized in All the studies were RCTs and double-blinded, with a treatment period from 24 to 64 weeks. Three of the articles reported outcomes from two duplicate RCTs, and one of them reported outcomes of two trials separately.18 and detection bias may have occurred in two studies due to incomplete descriptions of the blinding of outcome assessments.17Risk of bias assessments for the included studies were performed by the review authors independently. Most of the studies had a low risk of bias as shown by sufficient evidence of random sequence generation, double blinding protocol, and complete outcome assessment . Howevern = 5293) reported the time to first exacerbation as the endpoint . Subgroup analyses according to different LAMAs (tiotropium and non-tiotropium), treatment duration (24 weeks and 52–64 weeks), and risk of exacerbations (by exacerbation history) were all not statistically significant .Four publications . Overall, 30.0% (1620/5389) of the patients receiving LABA/LAMA FDCs experienced moderate-to-severe exacerbations, compared with 31.7% (1714/5402) of the patients receiving LAMAs alone , and no statistical difference was found. We then analyzed LABA/LAMA FDCs compared with different LAMAs (tiotropium and non-tiotropium), treatment duration (24 weeks and 52–64 weeks), and risk of exacerbations (by exacerbation history), but no statistically significant differences were found .Moderate-to-severe exacerbation data were available in four articles  reported severe exacerbations as one of the endpoints. There was no statistical difference between the LABA/LAMA FDCs and LAMA groups in terms of severe exacerbations , with an RR of 0.92  (Only two publications (I2 = 0%) .n = 7941) was lower in those treated with LABA/LAMA FDCs than in those treated with LAMAs , with an RR of 0.92  (p = 0.04) . Other analyses according to the risk of exacerbations , demonstrated a lower rate of all exacerbations only in the high-risk population stratified by exacerbation history  .The incidence of all exacerbations from six articles  . SubgrouThe results of this meta-analysis demonstrated that LABA/LAMA FDCs were marginally beneficial in the prevention of all exacerbations compared with LAMA monotherapy in COPD patients. According to the revised GOLD reports, LAMA monotherapy is preferred as the initial treatment choice in group C and D COPD patients, and LABA/LAMA FDCs are an alternative choice for those with more symptoms.7 Escalation to LABA/LAMA is also recommended for patients with persistent exacerbations on LAMA monotherapy. Nevertheless, the 2019 updated National Institute for Health and Clinical Excellence (NICE) guidelines recommended LAMA+LABA dual therapy, but not monotherapy, as the preferred initial treatment in stable COPD patients who remain breathless or have exacerbations despite optimal non-pharmacological management and after using a short-acting bronchodilator.20 The NICE guidelines also state that LAMA/LABA dual therapy provides the greatest benefit to overall quality of life compared with monotherapy, and that dual therapy is better than other inhaled treatments for many individual outcomes (such as reducing the risk of moderate-to-severe exacerbations) and is the most cost-effective option. Nevertheless, the currently available evidence is not consistent with regards to whether LABA/LAMA combination therapy is more effective than LAMA monotherapy in preventing exacerbations.et al. demonstrated greater efficacy and comparable safety profiles with LABA/LAMA combinations versus LAMAs. However, the COPD exacerbation rate was not reported due to insufficient data.21 Rogliani et al. assessed the evidence for LABA/LAMA FDCs in the treatment of COPD. They analyzed trial results of the available LABA/LAMA FDCs and found that only indacaterol/glycopyrronium demonstrated superiority to glycopyrronium, but that there was no statistically significant difference versus tiotropium.22Previous meta-analyses have focused on comparisons of LABA/LAMA combinations and LAMA monotherapy. One meta-analysis conducted by Rodrigo et al. conducted a comprehensive Cochrane review of different groups of inhalers (including LABA/LAMA combinations and LAMA monotherapy) in patients with moderate-to-severe COPD. They analyzed eight studies comparing different LABA/LAMA combinations and LAMA monotherapy, and demonstrated no statistical differences in terms of severe exacerbations  and moderate-to-severe exacerbations .23 Although this finding is consistent with our results, Oba’s review enrolled two studies with LABA/LAMA combinations in two separate inhalers and one study which was a 12-week study that was inappropriate to evaluate exacerbation outcomes. In addition, the largest DYNAGITO trial was not included for analysis in their review.Oba et al. reviewed 10 trials comparing tiotropium plus a LABA to tiotropium or a LABA alone and concluded that adding tiotropium to a LABA reduced exacerbations, but that adding a LABA to tiotropium did not.24 Another comprehensive systematic review reported by Halpin et al. demonstrated that tiotropium was beneficial in reducing the risk of exacerbations compared with other maintenance treatments. Their analysis showed that tiotropium provided similar efficacy to glycopyrronium and a LABA/LAMA FDC (glycopyrronium/indacaterol), although not all studies were sufficiently powered to demonstrate differences in exacerbation outcomes.25 However, the large DYNAGITO trial reported that a combination of tiotropium and olodaterol failed to reduce the exacerbation rate as expected when compared with tiotropium alone.8 Given the conflicting results, we stratified and analyzed different LAMAs as tiotropium and non-tiotropium. Our analysis showed that exacerbation events in those receiving LAMA/LABA FDCs were not significantly different compared with those receiving tiotropium or non-tiotropium therapy.Farne 14 In addition, LABA/LAMA FDCs showed a small benefit in the incidence of all exacerbation events for those with a longer treatment period (52–64 weeks compared with 24–26 weeks), probably due to the long-term effects of LABA/LAMA combination therapy in terms of lung function improvements.In the current study, we also compared LABA/LAMA FDC and LAMA therapy in patients grouped by the risk of exacerbations and treatment duration. We analyzed the COPD patients with a high or low risk of exacerbations in the studies according to lung function or previous exacerbation history. Our results demonstrated that only the incidence of all exacerbation (but not severe or moderate to severe exacerbation) events was lower in the LABA/LAMA FDCs for COPD patients with a history of previous exacerbation. However, this result was from the SPARK study in which most of the patients had a previous history of exacerbation .The GOLD reports recommend escalating to LABA/LAMA treatment for patients with persistent dyspnea or exacerbations on long-acting bronchodilator monotherapy. This escalation strategy is supported in part by this systematic review, in that LABA/LAMA FDCs may provide better efficacy in the prevention of all exacerbations compared to LAMA monotherapy, although the incremental benefit was small.There are several limitations to this study. First, the results of this meta-analysis could not indicate differences between the various LABA/LAMA FDCs and LAMAs , and their efficacy may not be exactly the same. Second, assessments of the high- and low-risk patients in the included studies were not consistent, even though we stratified the majority of the study patients by lung function or previous exacerbation history. Third, exacerbation type (requiring antibiotic or systemic steroid therapy) was not analyzed due to insufficient data in the included studies.In conclusion, our meta-analysis suggests that LAMA/LABA FDCs produce a small benefit in the prevention of all exacerbations compared to LAMA monotherapy, but similar efficacy in terms of time to first exacerbation, the rate of moderate-to-severe, and severe exacerbations. In addition to greater improvements in lung function, symptom scores, and health status, our findings provide evidence that LABA/LAMA FDCs are also better than LAMA monotherapy in terms of all exacerbation prevention and could be considered as the first-line treatment for COPD patients, especially in those with a history of previous exacerbations.Click here for additional data file.Supplemental material, Author_Response_1 for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory DiseaseClick here for additional data file.Supplemental material, Author_Response_2 for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory DiseaseClick here for additional data file.Supplemental material, Reviewer_1_v.1 for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory DiseaseClick here for additional data file.Supplemental material, Reviewer_1_v.2 for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory DiseaseClick here for additional data file.Supplemental material, Reviewer_2_v.1 for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory DiseaseClick here for additional data file.Supplemental material, Supplemental_Figures for LABA/LAMA fixed-dose combinations versus LAMA monotherapy in the prevention of COPD exacerbations: a systematic review and meta-analysis by Ching-Yi Chen, Wang-Chun Chen, Chi-Hsien Huang, Yi-Ping Hsiang, Chau-Chyun Sheu, Yung-Che Chen, Meng-Chih Lin, Kuo-An Chu, Cheng-Hung Lee and Yu-Feng Wei in Therapeutic Advances in Respiratory Disease


The purpose of this recommendation of the Oncology Task Force of the European Society of Paediatric Radiology (ESPR) is to indicate reasonable applications of whole-body MRI in children with cancer and to address useful protocols to optimize workflow and diagnostic performance. Whole-body MRI as a radiation-free modality has been increasingly performed over the last two decades, and newer applications, as in screening of children with germ-line mutation cancer-related gene defects, are now widely accepted. We aim to provide a comprehensive outline of the diagnostic value for use in daily practice. Based on the results of our task force session in 2018 and the revision in 2019 during the ESPR meeting, we summarized our group’s experiences in whole-body MRI. The lack of large evidence by clinical studies is challenging when focusing on a balanced view regarding the impact of whole-body MRI in pediatric oncology. Therefore, the final version of this recommendation was supported by the members of Oncology Task Force. Whole-body MRI has been increasingly used in diagnosing pediatric oncological and non-oncological diseases over the last two decades –13. WholRegarding local staging and response assessment of solid malignant tumors in children and adolescents, MRI is the modality of choice in most cases, whereas whole-body MRI represents a non-standard method and is not generally considered in the protocols of the international oncological pediatric societies . However, in contrast, at a number of institutions whole-body MRI is now integrated into the diagnostic workup in children with cancer. Unfortunately, the diagnostic value has been evaluated mostly in small single-center projects. It is primarily in this context that the value of whole-body MRI for detecting osteomedullary metastases has been assessed , 25, 26.In summary, on the one hand, whole-body MRI exists as a valuable tool in the daily practice of pediatric oncology and is frequently performed in specialized centers. On the other hand, there are major concerns about the level of scientific evidence. Hence, the presented recommendations summarize a consensus statement by experts in the field of whole-body MRI where large evidence is lacking. Finally, the confusion about the protocols and techniques needs to be harmonized. Therefore, this recommendation of the Oncology Task Force aims to specify applications of whole-body MRI, to describe the technical pre-requisition, and to define useful protocols to maximize the diagnostic accuracy and confidence.Whole-body MRI enables the investigation of systemic spread of solid malignant tumors.Whole-body MRI is useful for surveillance in cancer predisposition syndromes.Imaging protocol adaption to each child’s age and the indication is mandatory to maximize diagnostic performance.The high sensitivity of STIR MRI regarding bone marrow changes has to be considered to avoid overinterpretation of normal findings.Additional imaging might be necessary in particular tumor entities or diagnostic scenarios.Hodgkin lymphoma and non-Hodgkin lymphoma together are the third most common form of malignancy in children and adolescents . Non-HodStandard imaging procedure: In Hodgkin lymphoma, [F-18]2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET)/CT remains the first-line modality for staging and response assessment, providing both structural and functional metabolic information [ormation . In non-Review and comments on the literature: Because both PET and contrast-enhanced CT involve substantial radiation exposure and children often undergo several PET/CT examinations during the course of treatment, there is an increasing interest in the use of whole-body MRI as a good radiation-free alternative. Several studies have shown that whole-body MRI is feasible even in children [children , 29, 42.Staging: In a study by Punwani et al. [2. The authors acknowledged that using higher b values could decrease perceptual errors for extranodal disease assessment. Indeed, higher b values are preferred to optimize background body signal suppression and improve lesion conspicuity, in particular in organs/regions with normal intrinsic diffusion restriction.i et al. , the auti et al.  showed ai et al. , 8. Thisi et al. . Interesi et al.  used a hResponse assessment: Early recognition of therapy response or failure to chemotherapy enables better selection of children who need more or less intensive therapy. The concept of early response assessment with FDG PET/CT in lymphoma has received considerable attention in the last few years, although it is still not officially recommended outside clinical trials [l trials . The roll trials  showed il trials , 29, 44.l trials  recentlyAccording to the currently available literature, whole-body MRI is a good alternative for contrast-enhanced CT in staging pediatric lymphoma. However, FDG PET with low-dose CT for attenuation correction remains vital for interim response assessment and therefore cannot be omitted during staging or interim response assessment in lymphoma.Key recommendation in pediatric lymphoma: Whole-body MRI is a good alternative for contrast-enhanced CT in staging pediatric lymphoma. However, for FDG-avid lymphomas, 18F-FDG PET remains vital for staging and response assessment.Neuroblastoma is a neoplasm arising from primordial neural crest cells and is the second most common solid extracranial tumor in children, accounting for about 6% of all childhood cancers . It can Standard imaging procedure: Accurate staging is pivotal for planning treatment. Furthermore, a systematic assessment of the relationship between the primary tumor and the adjacent structures according to a series of imaging-defined risk factors is mandatory to evaluate tumor resectability [tability . TypicalReview and comments on the literature: The availability of studies on the role of whole-body MRI in neuroblastoma is still very limited. Furthermore, some of them included children not only with neuroblastoma, but also with other common pediatric tumors. In 2003, Pfluger et al. [r et al.  retrospeIn 2013, Siegel et al.  comparedDiffusion-weighted imaging can be effectively integrated in MRI studies in children with neuroblastic tumors: Peschmann et al.  observedThe studies on the role of whole-body MRI in neuroblastoma are still scarce, based on a limited number of patients, and in some cases with contradictory results. Nevertheless, whole-body MRI could be a promising, radiation-free modality for detecting bone and bone marrow metastases . Whole-body MRI might, at present, be considered in addition to basic imaging recommendations for children who would probably benefit from whole-body imaging without increasing their cumulative radiation dose.Key recommendations in sarcomas: Whole-body MRI could be considered in addition to imaging recommendations of international oncology groups. Children with sarcoma who have disseminated disease might benefit from whole-body MRI without increasing their cumulative radiation dose.Langerhans cell histiocytosis is characterized by accumulation of clonal CD1a-positive immature dendritic cells, so-called Langerhans cell histiocytosis cells, together with eosinophils, macrophages, lymphocytes and osteoclast-like giant cells. In children younger than 15 years, incidence of Langerhans cell histiocytosis is 4–5 cases per million per year . LangerhStandard imaging procedure: Diagnostic evaluation and treatment are based on the ongoing LCH-IV International Collaborative Treatment Protocol for Children and Adolescents with Langerhans cell histiocytosis (EudraCT Nr.: 2011–001699-20). According to this protocol, diagnostic imaging at onset should include an abdominal US study for evaluating size and structure of the liver and spleen, a chest radiograph and a radiologic skeletal survey. Functional imaging like bone scan or FDG PET is optional and can be performed in addition to the skeletal survey. Chest CT is needed in case of lung involvement, whereas head CT or MRI should be performed in case of craniofacial lesions or mastoid involvement. Neurologic abnormalities or suspected endocrine abnormalities require a head MRI, and MRI of the spine is necessary in cases of suspected vertebral lesions.Review and comments on the literature: Langerhans cell histiocytosis can be a multisystem and multifocal disease. Therefore, whole-body MRI could be an excellent method for evaluating the whole body in one examination. Nevertheless, very few studies with preliminary results on the role of whole-body MRI in Langerhans cell histiocytosis are available. The number of children included in these studies is limited (range 2 to 46) [2 to 46) , 60–62. 2 to 46) , 60–62. 2 to 46) . T1-W fa2 to 46) , and T1-2 to 46) . All stuThe standard of reference for comparison with whole-body MRI was skeletal survey or plain radiographs in four studies , 60, 61,According to the results of their study, Steinborn et al.  concludeAccording to the scientific literature available, whole-body MRI could be the imaging modality of choice for assessing skeletal involvement at onset, thus replacing radiologic skeletal survey and bone scintigraphy. Conventional radiologic studies could be performed only of bones with positive findings on whole-body MRI. Whole-body MRI should include at least T1-W FSE and STIR images in coronal and sagittal planes, whereas it is unclear whether T1-W contrast-enhanced images improve the accuracy of the study. None of the published studies assessed the role of diffusion-weighted imaging. The role of whole-body MRI during follow-up seems to be questionable because persisting signal abnormalities could be caused by post-therapy tissue reorganization. In addition, the role of whole-body MRI in evaluating extraskeletal disease is promising but not finally approved. New and larger prospective multicenter studies are therefore needed.Key recommendations in Langerhans cell histiocytosis: Whole-body MRI could replace skeletal survey and bone scintigraphy for assessing skeletal involvement at onset. Its role in assessment of extraosseous disease and follow-up is still unclear. Thanks to its high sensitivity and accuracy, whole-body MRI should always be considered in children with Langerhans cell histiocytosis at onset, especially if sedation is not needed.Cancer predisposition syndromes comprise entities characterized by a risk of development of specific tumors or co-occurrence of tumors caused by a germ-line mutation in one or more cancer-related genes . These cStandard imaging procedure: The role of imaging in cancer predisposition syndromes is to be part of tumor surveillance and to allow for detection of tumor recurrence. Furthermore, imaging enables assessment of individuals and family members identified as being at risk for tumors on the basis of an abnormal genetic test result. Because of the increased sensitivity of children to ionizing radiation, most surveillance imaging protocols rely more on US and MRI (whole-body MRI) than nuclear medicine and CT [e and CT , 11. BecReview and comments on the literature: Variations in screening protocols arise from institutional preference and technological capabilities. Whole-body MRI can be performed with the additional use of regional MRI  [emities) , 11. It emities) . GeneralTP53 variants is associated with improved long-term survival. Their protocol included physical examination and frequent biochemical and imaging studies . O’Neill et al. [In a retrospective study of 50 whole-body MRIs in 24 pediatric patients with cancer predisposition syndromes, Anupindi et al.  demonstrl et al.  recentlyl et al. .From these studies, it can be concluded that whole-body MRI complemented with targeted imaging  when indicated can properly fulfill the need for a radiation-free method for early tumor detection in pediatric cancer predisposition syndromes. However, Anupindi et al.  showed tSummary of screening in cancer predisposition syndromes (Table ): Whole-body MRI can reveal multifocal disease in cancer predisposition syndromes and can be complemented by dedicated regional studies with small field-of-view (FOV) imaging if indicated. The absence of ionizing radiation is an advantage in the pediatric population. Standard whole-body MRI methodology and imaging protocols for screening of many pediatric cancer predisposition syndromes are not clearly established. While modernization of MRI devices is in progress globally, the same technical level of MRI scanners, technologists’ expertise and radiologists’ experience in cancer predisposition syndromes interpretation cannot be guaranteed yet. There is a need for large prospective multicenter studies to establish the role, effectiveness and costs of screening with whole-body MRI in pediatric cancer predisposition syndromes. Despite the lack of standardization in the screening and evaluation of multifocal lesions in pediatric patients, whole-body MRI is certainly among the imaging methods of first choice.es Table : Whole-bKey recommendations in cancer predisposition syndromes: Whole-body MRI plays an increasing role in the surveillance of children with cancer predisposition syndromes. In cancer predisposition syndrome surveillance with whole-body MRI, knowledge of the tumor spectrum per syndrome and knowledge of the imaging characteristics of specific tumors and normal variants are mandatory to improve lesion detection and reduce false-positive findings.Given a larger field of view and a more stable magnetic field, a 1.5-tesla (T) scanner might be preferable to a 3.0-T device for whole-body MRI. The diagnostic performance of MRI depends substantially on the sequence type and scan parameters, especially the spatial resolution. The variety of technical options renders it a versatile modality, but for the same reasons it is highly operator-dependent and difficult to standardize. The often long duration of the examination directly affects patient comfort. Thus, a modular approach consisting of basic and advanced sequences is useful , 67, 68.In young children the company of a parent, adequate introduction to the examination, and distraction by audio or video equipment during the scan help to reduce motion artifacts and even the necessity of sedation or general anesthesia. These preparations might seem time-consuming, but their influence on image quality should not be underestimated.In agreement with previous publications, we propose a high-resolution fat-saturated T2-weighted sequence  with slice thicknesses of 3–4 mm in coronal orientation as the mainstay of the basic module. To avoid limitations due to partial volume effects, additional sections in transverse orientation in the regions of the head, neck and trunk are recommended , 67–69. In addition to whole-body examinations, dedicated imaging of body regions such as orbits, hands and feet, and the evaluation of small lesions in residual or relapsing disease require optimized equipment and coil configuration , 67–69. 3 in the coronal plane and of 0.8×0.8×3.0 mm3 in the transverse plane. However, the subsequent signal loss should be compensated , resulting in a longer acquisition time. Therefore, an optimal compromise between tolerable signal-to-noise ratio loss and measurement time should be found. It is advantageous that the number of blocks/stations in the Z-direction and thus the total acquisition time can be reduced based on the body geometry of small children. The use of predefined protocols optimized to different body sizes facilitates adaptation in daily practice.In the literature, most protocol recommendations for whole-body MRI in children and adolescents give a fixed FoV, resolution matrix and slice thickness and thus a fixed voxel size. However, as is typical in pediatric MRI, these sequence parameters should be adapted to the indication as well as the various body sizes from infant to adolescent because the spatial resolution is significant for diagnostic sensitivity . Especia


Mesenchymal stem cells (MSCs) were known to have excellent properties in cell therapy. However, the risk of immune rejection associated with cell transplant therapy hampers its use. Extracellular vesicles secreted by MSCs derived from different sources that contain therapeutic molecules such as RNA and proteins, which is a novel strategy for cell-free therapy. Recently, researches show EVs from MSCs (MSC-EVs) of different sources have special functions and effects on different diseases. Here, we collected these researches and compared them to each other. In addition, their potential and possible application in clinical treatment are described. Mesenchymal stem cells(MSCs)are kinds of stem cells that play an important role in regeneration and restoration because of its multi-lineage differentiative capacity. They have the potential to differentiate to form connective tissues, skeletal muscle cells, and cells of the vascular system . MSCs arIt has been shown that the therapeutic functions of MSCs mediated partly through paracrine effects. The various bioactive molecules that MSCs secreted can modulate immune, inhibit apoptosis and fibrosis, promote angiogenesis and the growth of stem and progenitor cells . Some ofIn addition, EVs from different MSCs may show a unique tendency to the therapy of some diseases. And they appeared differently in the same diseases , 21. TheIn this review, we mainly compared the therapeutic effects of four different extracellular vesicles of mesenchymal stem cells (MSCs-EVs) and discussed their potential applications in diseases which include that they act as carriers of active biological molecules.Extracellular vesicles derived from bone marrow mesenchymal stem cells is the most common one. And it is also a conventional way to obtain the MSCs-EVs, which is to harvest bone marrow from adult rats or humans , 24. ForEVs from hBM-MSCs have also shown good efficacy in the treatment of the renal injury. For chronic kidney injury caused by long-term exposure to heavy metals such as cadmium, Intravenous injection of high-purity EVs from hBM-MSCs repaired damage to renal proximal tubules, glomerular podocytes, bone deformation, and improved survival . And in In the aspect of anti-inflammation, EVs from hBM-MSCs works in several different ways. First, they downregulated the production of IL-23 and IL-22 and enhanced the anti-inflammatory phenotype of mature human regulatory macrophages (Mregs) . Second,Another application of EVs from hBM-MSCs is Graft-Versus-Host Disease Amelioration. Systemic infusion of hBM-MSCs EVs could prolong the survival time of aGVHD mice and reduce pathological damage of various GVHD-targeted organs. This was due to the immunosuppressive effect of hBM-MSCs derived extracellular vesicles. CD4 + and CD8 + T cells were inhibited in EV-treated GVHD mice. While inhibiting the functional differentiation of T cells from naive to effector type, EVs derived from BM-MSCs also retained the CD4 + CD25 + Foxp3 + regulatory T cell (Tregs) population . EVs canCompared to EVs from hMSC, mouse bone marrow derived MSC-EVs have similar functions in tissue regeneration , protectExosomes are one type of extracellular vesicles, which size is smaller than others, for about 100 nm . They haMore effects were investigated in mouse bone marrow MSCs derived exosomes. For inducing macrophage polarization, exosomes derived from mBM-MSCs have the same effect. In a study of wound healing, hBM-MSCs exosomes mainly regulated the polarization of macrophages by targeting pknox1 with mir-223 in exosomes . HoweverAs vesicles secreted by cells, the contents of EVs have something in common with BM-MSCs, such as RNA. Some specific microRNAs secreted by BM-MSCs regulate cells function through EVs transportation. For example, EVs derived from BM-MSCs contains miR-146a which is a famous anti-inflammatory microRNA. Studies about Inflammatory bowel disease (IBD) showed that overexpressing miR-146a inhibited TNF receptor-associated factor 6 (TRAF6) and IL-1 receptor-associated kinase 1 (IRAK1) expression in TNBS-induced colitis of rats. And the administration of EVs containing miR-146a down-regulated the increased phosphorylation levels of NF-κB p65 and IκBα, so that suppressed inflammation factors such as tumor necrosis factor-α (TNF-α), Interleukin-6 (IL-6) and Interleukin-1β .For exosomes, a type of smaller and more homogeneous extracellular vesicles, studies on microRNAs associated with them have been more extensive. At present, many microRNAs contained in exosomes have been revealed to associate with organ repair and other functions. It has been reported that low levels of miR-224-3p in BM-MSCs derived exosomes promote endothelial cell proliferation, migration, invasion, and angiogenesis by targeting focal adhesion kinase family interacting proteins (FIP200) . In a stIn addition to the transport of endogenous RNA, BM-MSCs EVs can also act as carriers for the transport of other small molecules. Because of its own therapeutic effect on some diseases or targeting ability or greater affinity to specific cells, it may be suitable for EVs to transport therapeutic components. As one type of EVs, microvesicles were found to be endogenous carriers for delivering paclitaxel to pancreatic cancer cells. Microvesicles capsuled Paclitaxel proved to have strong anti-proliferation activity on pancreatic cancer cells . HoweverFurthermore, some researchers have combined exosomes with other drug delivery systems so that improve the therapeutic effect of EVs. Small extracellular vesicles (sEVs) derived from BM-MSC are widely used in the treatment of myocardial infarction (MI). Researchers designed an alginate brine gel with sEVs (sEVs-gel) in it to increase its retention in the heart in order to improve treatment. Experiments proved that it reduced the apoptosis of cardiomyocytes and promoted the polarization of macrophages. Moreover, the sEVs-gel group had significantly better measurements of cardiac function and infarct area than the sEVs group .To sum up, EVs from BM-MSCs have a wide application in many diseases and have been studied extensively. They showed the potential to be modified or engineered to suit clinical proposes. And they can be also administered in a variety of ways. However, the mechanisms by which it works needs further research.The human umbilical cord is an excellent source of MSCs, as the human umbilical cord can be largely expanded and has clinical potential in the treatment of some diseases including nerve, cardiovascular, liver, kidney and skin wounds. However, there is growing evidence that EVs from mesenchymal stem cells may contribute to these effects and are considered a potential alternative to stem-based therapies. By exploring the effect and mechanism of hepatic ischemia–reperfusion injury (IRI), it has been revealed that human umbilical cord MSCs-EVs (huc-MSCs-EVs) can reduce the infiltration of neutrophils and reduce the oxidative stress of liver tissue in vivo, so as to protect the liver cell apoptosis induced by IRI to some extent. Further studies showed that the mechanism that EVs reduces oxidative stress is that the enzyme manganese superoxide dismutase (MnSOD) which has anti-apoptosis and anti-oxidation ability is encapsulated in the huc-MSCs-EVs . In addiAnother type of MSCs is from a peculiar structure in the umbilical cord named Wharton’s Jelly. It is a kind of gelatinous matrix that surrounds and protects the umbilical cord blood vessels . At presIn several studies comparing umbilical cord and bone marrow derived mesenchymal stem cell EVs, these two types of EVs were nearly identical in their physical properties and cargo content, especially for transcripts involved in immunomodulation and proliferation. The obvious difference is that Huc-MSCs produce a higher rate of EVs . HoweverExosomes derived from Huc-MSCs (HuC-MSC- Ex) have some therapeutic potentials similar to hBM-MSCs-Ex in neural restoration , heart rIn addition, some studies have pretreated exosomes such as blue light to investigate the effect on them. Under blue light exposure, HuC-MSC- Ex can promote angiogenesis in vivo and enhance its ability to promote angiogenesis. It was confirmed that the exosomes treated by blue light stimulated the activation of endothelial cells by upregulating the two miRNAs of mir-135b-5p and mir-499a-3p .Compared to other sources of MSCs, exosomes from huc-MSCs have advantages in gynecological and infant diseases, but the reason remains unknown. Additionally, some external stimulation of exosomes may also promote its therapeutic effect.It is well known that exosomes contain small molecules that regulate cell function, including RNA and proteins. microRNAs and proteins in exosomes derived from Huc-MSCs have been further studied in many pieces of research. For example, it was found that miR-146a which was an anti-inflammatory miRNA, was strongly upregulated in TNF-α-stimulated Huc-MSCs and was enriched in exosomes. The exosome containing mir-146a was successfully uptake by fibroblasts. And it inhibited fibroblast activation and associated inflammatory responses, which may result in inhibiting urethral stricture . AnotherAs for adipose tissue-derived mesenchymal stem cells, it is made from adipose tissue extracted from healthy adult donors or animals . The maiEVs from human adipose tissue-derived mesenchymal stem cells (AD-MSCs) was shown to be effective in a variety of disease. Most of the functions of hAD-MSCs EVs were basically the same as those of the other two sources, such as tissue repair, reduction of injuries and anti-inflammation. Many studies have further investigated the mechanism by which EVs regulates inflammation in various disease models. In studies of osteoarthritis, EVs from AD-MSCs stimulated with interleukin- (IL-) 1β reduced the production of inflammatory mediators IL-6 and prostaglandin E2 significantly . In anotEVs from murine AD-MSCs have also been shown to reduce neuroinflammation. Prophylactic intravenous injection of AD-MSCs nanovesicles which was 40-100 nm diameter extracellular vesicles, prior to onset significantly reduced experimental autoimmune encephalomyelitis (EAE) severity, reduced spinal cord inflammation, and demyelination . And LowStudies have shown that there were differences in uptake efficiency between the EVs of BM-MSCs and AD-MSCs, but the reason for this phenomenon has not been found yet .Exosomes derived from AD-MSCs have similar functions to other sources of exosomes, such as anti-inflammation. In a study of atopic dermatitis, AD-MSCs exosomes significantly reduced mRNA expression of various inflammatory cytokines such as interleukin (IL)-4, IL-23, IL-31, and tumor necrosis factor-α (TNF-α) in atopic dermatitis skin lesions of the mouse model . The decPrevious studies reported that transplanting AD-MSCs with miR-122 modification suppressed liver fibrosis . TherefoExosomes from ADSCs works in a wide and dispersed range of diseases , and a gHuman embryonic mesenchymal stem cells are MSCs formed by the special induced differentiation of embryonic stem cells . The proAt present, researches on ES-MSCs EVs are still at an early stage. The therapeutic effect of ES-MSCs EVs to various diseases need to explore. In a study of liver injury, Mardpour et al. showed that ES-MSCs EVs reduces liver fibrosis and collagen density. Further researches have shown that EVs upregulated apoptotic gene (BCL-2) and anti-inflammatory cytokines (TGF-β1 and IL-10) and showed immunoregulatory activity comparable to that of parental cells. These results indicated that ES-MSCs EVs ameliorated cirrhosis effectively . Due to Human embryonic mesenchymal stem cells have incomparable advantages over other sources, that is, longer telomeres, fast growth, a wider differentiation potential than adult MSCs . Howeverhttps://clinicaltrials.gov/. Clinical trials of EVs from UC-MSCs are the most, including chronic kidney disease, macular degeneration, dry eye, and diabetes mellitus. In the trials of kidney diseases, the improvement of renal function was observed, indicating the promising clinical potential of UC-MSCs [At present, some translations of MSCs-EV based therapy entered into clinical practice Table  and the  UC-MSCs . In anotAlthough clinical trials of MSCs-EVs have made some progress, there are also challenges for clinical translational studies. First, the side effects of MSCs-EVs in clinical applications are not clear. Besides, they lack standardized manufacturing processes and methods, which need to be solved in the future.EVs, widely found in body fluids are produced by almost all cell types. Most mature cells produce very little EVs, thus it is hard to translate applications . At presEVs secreted from different MSCs are proved to have effects on cardiac, kidney, liver and brain diseases and the functions have been summarized in Table Although the origins of MSC-EVs are different, they have something in common. EVs derived from different sources of MSCs all have promoting angiogenesis effect. And EVs from bone marrow MSCs, human umbilical cord MSCs and human embryonic MSCs can enhance tissue repair. Except for EVs from BM-MSCs, three other kinds of MSC-EVs can suppress inflammation, but the mechanisms are a little bit different.One of these four MSCs-EVs will show a better therapeutic effect than other kinds of EVs in certain diseases. For neurodegenerative pathologies, menstrual Mesenchymal stem cells derived exosomes enhanced neuritic outgrowth most among 4 sources MSC exosomes, including menstrual, umbilical cord, bone marrow MSCs and chorion stem cells. The research also indicated that microvesicles had opposite effects on neurons, inhibiting the growth of neurons . As for Proteomic analysis of EVs also suggested their functions. For EVs from different sources of MSCs, they contain partly similar proteins. Similar proteins account for nearly half of all proteins . AdditioThrough proteomic analysis, the mechanism of the therapeutic effect of EVs can be found. And the selective enrichment of protein of different MSCs-derived EVs indicated the difference of functions of EVs from various MSCs and the preference in Proteomic of different EVs. It partly confirms its therapeutic effect. And the effect can be changed through knockdown of specific proteins. Also, the functions of some groups of proteins can be predicted by GO analysis and this may provide directions for further research.EVs from different sources of MSC has some unique effects in some diseases and need further studies of the mechanisms. In addition, EVs are also a promising carrier, for they have better biocompatibility and intrinsic targeting ability than ordinary nanocarriers such as liposomes. Considering the specific clinical diseases, EVs from different sources can be selected and designed. Apart from exploring continually the clinical applications of MSC-EVs, we need some methods to get a large quantity of stable EVs quickly and identify the side-effect in clinical trials.