Features of the gut microbiota have been associated with several chronic diseases and longevity in preclinical models as well as in observational studies. Whether these relations underlie causal effects in humans remains to be established. We aimed to determine whether the gut microbiota influences cardiometabolic traits as well as the risk of chronic diseases and human longevity using a comprehensive 2-Sample Mendelian randomization approach. We included as exposures 10 gut-associated metabolites and pathways and 57 microbial taxa abundance. We included as outcomes nine cardiometabolic traits , eight chronic diseases previously linked with the gut microbiota in observational studies , stroke, osteoporosis and chronic kidney disease), as well as parental lifespan and longevity. We found 7 associations with evidence of causality before and after sensitivity analyses, but not after multiple testing correction (1198 tests). Most effect sizes (4/7) were small. The two largest exposure-outcome effects were markedly attenuated towards the null upon inclusion of BMI or alcohol intake frequency in multivariable MR analyses. While finding robust genetic instruments for microbiota features is challenging hence potentially inflating type 2 errors, these results do not support a large causal impact of human gut microbita features on cardiometabolic traits, chronic diseases or longevity. These results also suggest that the previously documented associations between gut microbiota and human health outcomes may not always underly causal relations.The online version contains supplementary material available at 10.1186/s12967-022-03799-5. The human gut microbiota is the microbial symbiotic organ residing in the gut. It is involved in key metabolic and immunological processes including host immunity, food digestion, intestinal endocrine function and intestinal permeability . SeveralOver the past few years, the gut microbiota emerged as a therapeutic target of great interest to prevent and/or treat chronic diseases and improve human lifespan and healthspan. An overwhelming amount of supportive evidence from preclinical models contributed to the widely accepted view that a large number of diseases and pathological processes could be influenced by the microbiome, from early metabolic perturbations to full-blown diseases and premature mortality. Fecal transplantation studies in rodents have provided promising results for the treatment of obesity , type 2 This finding was deemed “implausible” by the authors of this systematic review . AccordiMR is an epidemiological approach that mitigates many of the biases of observational studies such as reverse causality or confounding. Under specific assumptions, it has the potential to evaluate potential causal effects between multiple exposures (gut microbiota features) and outcomes . Briefly, MR uses genetic variants strongly associated with an exposure (gut microbiota features) to infer causality with an outcome . Twin studies have shown that heritability of the abundance of different bacterial taxa is on average 20%, although some variation exists between taxa , 27. Thith percentile). In this large-scale MR study, we first investigated the potential causal effect of micriobiota associated metabolites on diseases, metabolic risk factors and lifespan. Second, we leveraged summary statistics from two large genome-wide association studies (GWAS) of gut microbiota abundance to investigate the causal effect of genetically predicted taxa abundance on chronic diseases and human longevity.Here, we used a 2-sample MR study design to investigate the potential causal links between gut microbiota features and nine cardiometabolic traits  eight chronic disease outcomes encompassing different body systems , and human lifespan  and negatively associated with human longevity . Altogether, this analysis identified some blood and gut-derived metabolites that may be associated with cardiometabolic traits, chronic diseases and human longevity but their effect sizes were small. Spurious associations also cannot entirely be ruled out since none of the metabolites were associated with outcomes of interest after correction for multiple testing.We first sought to determine whether 10 blood metabolites associated with the gut microbiota and fecal microbial metabolites or their functional pathways could influence cardiometabolic risk factors, chronic diseases and longevity. We selected genetic instruments for short-chain fatty acids such as fecal propionate, a gut metabolite linked with T2D in a recent MR study, from a GWAS of 898 participants  and acetWe explored the impact of different taxa abundance on health-related outcomes. We included available genetic information on 57 microbial taxa abundance from the two recent GWAS studies of Kurilshikov et al., and Rühlemann et al. , 55. We P-value  < 0.05) to estimate the robustness of our primary causal estimates to pleiotropy. We used four different methods that make different assumptions about the nature of the underlying pleiotropy: the weighted median, the MR-PRESSO or when it could not be performed the MR-Radial and the contamination mixture approaches. Consistency across the estimates of the methods provides support to causality. The MR-Egger intercept was also used to assess robustness to horizontal pleiotropy. We removed the MR results that were not supported by robust MR analyses , contamination mixture (P > 0.05). Of the 76 associations tested, 7 remained as they were consistent with a true causal effect unlikely to be confounded by pleiotropy  and  respectively. This analysis identified some gut microbiota associated features that may be worth exploring in further studies.One of the key assumptions underlying MR is that genetic instruments affecting gut microbiota features do not affect diseases or longevity by other mechanisms than the one associated with gut microbiota features . This phenomenon is known as horizontal pleiotropy . We perfP = 2.0e-01) upon inclusion of alcohol intake frequency as covariate and the causal effect of the order Lactobacillales on type 2 diabetes risk attenuated towards the null to  upon inclusion as BMI as covariate.Obesity and alcohol intake frequency were recently identified as major confounding factors in microbiome-disease associations . We perfIn order to determine whether previously reported studies using preclinical models or observational study designs in humans were consistent with causal effects, we assessed the roles of a wide range of microbial factors and nine cardiometabolic risk factors, eight chronic diseases as well as human longevity using MR. We found 7 associations with evidence of causality before and after sensitivity analyses, but not after multiple testing correction.Most effect sizes were small. The causal effect of serotonin levels on CAD and of the Lactobacillales order abundance on T2D were strong, but their effect substantially decreased upon inclusion of BMI and alcohol intake frequency in multivariable MR analyses. Altogether, results of this study suggest that previously reported associations between the human gut microbiome and human disease might have been due to biases such as reverse causality or confounding and that the impact of the gut microbiota on cardiometabolic traits, chronic diseases and human longevity may not be as prominent as previously suggested.P < 0.001) [P = 9.9e-02), despite precisely estimating the effect size, as previously suggested in another MR investigation on CAD [Our results generally contrast with those from previous observational studies. Microbial metabolites have been associated with health and disease such as neurological disease, NAFLD, cardiovascular disease, survival and T2D  . This re< 0.001) . In mice< 0.001) . By contn on CAD . Dietaryn on CAD .Clostridioides difficile infections [Several differences in the microbial composition of diseased and healthy individuals have been identified, but causality remains to be elucidated. RCT of fecal microbiome transfer (FMT) in humans are currently employed to establish causality between microbiome and health, but few have been attempted, and even fewer have been conclusive , 50. To fections  and somefections . Mice FMfections . For exafections , 76, butfections . For humfections . Moreovefections .Altogether, the large proportion of null findings  is in line with recent literature showing an overwhelming positive publication bias in the microbiome literature . PublicaAn important strength of this study is the use of the MR design with the largest publicly available GWAS datasets. Because alleles are randomly assigned and fixed at conception, biases due to confounding and reverse causality are mitigated in an MR analysis . A furthOur study, however, has limitations. Robust genetic instruments for microbial species are challenging to find. First, microbiome heterogeneity and interindividual variability are high, substantially reducing the statistical power of microbiome GWAS analyses. Second, the phenotype is distal from individual genes making it a complex polymorphic trait with many variants of small effect size which could be prone to pleiotropy. Lastly, the twin heritability for gut microbiota taxa abundance is only on average 20% , 27. ThiThe Steiger test we performed can be biased in the presence of a difference in measurement error between the exposure and the outcome . TypicalA third limitation is the difference in ancestry from data in the MiBioGen and CARDIoGRAMplusC4D consortium that could potentially violate the independence assumption through population stratification. Population stratification occurs in the advent that population subgroups have different disease rates or different distributions of continuous traits and have different frequencies of alleles. This phenomenon could violate the independence MR assumption. However, this bias is likely to be minimal as principal components were included and participants were mostly from European descent.Using MR, an approach less subject to reverse causality and confounding factors in comparison to traditional methods, we showed that several features of human gut microbioata including plasma metabolites and microbial taxa abundance had no evidence of causal effect on nine cardiometabolic traits, eight chronic diseases and human longevity. While finding robust genetic instruments for microbiota features is challenging potentially inflating type 2 errors, these results do not support large causal effects of the human gut microbiota and microbial metabolites on human chronic diseases and longevity. As the microbiome field matures, the use of larger microbiome GWAS study taking advantage of discriminatory potential of the full 16S RNA gene is warranted to fully elucidate the association of the human gut microbiota in the etiology of chronic diseases.P-value  < 1e-5; except Lotta et al.: P-value  < 1e-6) as genetic instruments. Genetic instruments for fecal propionate and PWY-5022 were obtained from a GWAS on 952 normoglycemic participants of the LifeLines-DEEP cohort, a population-based cohort from northern Netherlands (age ranges 18–84 years) [We derived our ten gut microbiota-derived exposures of interest from five different publicly available data sources  . Fecal p4 years)  and Meta4 years) . Genotyp63. Genotyping was conducted using the Affymetrix 500 K mapping array and the Affymetrix 50 K gene-focused MIP array. The participants all provided their informed consent and the study was approved by the Boston University Medical Center.Genetic instruments for plasma TMAO and indole-3-propionate were extracted from a GWAS conducted in 2076 participants from European ancestry from the Framingham Heart Study (FHS) offspring cohort . The FHSGenetic instruments for acetate were extracted from a meta-analysis of GWAS conducted on 10 European cohorts totalizing 24,925 individuals . Human bP-value  < 1.0e-6 for all taxa abundance present in their analysis and kept only exposures with at least three shared mbQTLs with mean F statistics  > 10. The study of Lopera-Maya et al., and Qin et al., were removed as none of the exposures satisfied our criteria . In total, we derived our microbiota taxa abundance exposures of interest from two different publicly available data sources  [We first identified 4 recent GWAS on gut microbe abundance with available summary statistics , 53, 55.We used publicly available GWAS summary statistics of the largest GWAS of nine cardiometabolic traits, eight chronic diseases, parental lifespan and longevity. Relevant information on the GWAS summary statistics are presented in Additional file gwwasvcf package in R [2 [TwoSampleMR package [We first identified all SNPs associated with exposures. Summary parameters for genetic instrument selection can be found at Additional file age in R . Instrumage in R , and the in R [2 . Variant package . When a sdY.est function in the coloc package [We conducted primary MR analysis on each outcome and exposure association. As primary method for causal inference, we performed the IVW method with multiplicative random effects with a standard error correction for under dispersion as recommended by recent MR guidelines . The IVW package . The othP-value  < 0.05, we performed sensitivity analyses to estimate the robustness of our primary causal estimate. We used 5 different robust methods that make different assumptions about the nature of the underlying pleiotropy. As a general test of the presence of pleiotropy, we used the intercept term from MR-Egger regression), MR-Egger is similar to the IVW method except the regression model estimates an intercept [59. It assumes that not all genetic variants are valid IVs and runs a likelihood function to categorize genetic instruments as valid or invalid. As a general test of robustness of the IVW-MR estimates, we used the weighted median. The weighted median estimates an unbiased causal effect if the “majority valid” assumption is upheld, that is if up to 50% of the weights comes from variants that are valid IVs [For associations with IVW-MR ntercept . An intentercept 59. It asalid IVs . Finallyalid IVs . This mealid IVs . When thHLA, ABO and APOE genetic regions. We also performed Steiger filtering to remove variants with evidence of a stronger association with the outcome than its association with the exposure. The Steiger test provides a p-value under the null hypothesis that the difference in variance explained is null [As additional sensitivity analysis, we excluded variants from known pleiotropic gene regions and performed Steiger filtering. Because of their known association with pleiotropic pathways, we excluded from the analysis all SNPs of the  is null .MendelianRandomization package [Obesity and alcohol intake frequency were recently identified as major confounding factors in the gut-disease associations  because  package .Additional file 1: Table S1. Description of the datasets used. Table S2. Description of the metabolites selection rational. Table S3. Summary of the instrument selection criteria for each data source. LD R2, pvalue treshold and Fstatistics. Table S4. Harmonised dataset for each exposure outcome. Table S5. Primary MR results and associated statistics. Table S6. Robust MR results and other sensitivity analyses results. Table S7. Multivariable MR results and associated statistics.


Radioresistance is the major obstacle after cancer radiotherapy. The dysregulation of long non-coding RNAs (lncRNAs) was closely related the radioresistance response. This meta-analysis was aimed to interpret the relationship between lncRNAs and radiotherapy responses in different cancers.The studies were selected from databases including PubMed, ISI Web of Science, Embase, Google Scholar, PMC, and CNKI . The publication time was limited to before March 20, 2021. The hazard ratios (HRs) and 95% confidence interval were calculated with random-effects models. Subgroup analyses, sensitivity analyses, and publication bias were also conducted.Twenty-seven lncRNAs in 14 cancer types were investigated, in which 23 lncRNAs were upregulated and four lncRNAs were downregulated. Dysregulation of these lncRNAs were found to be related to radioresistance response. The pooled HR and 95% confidence interval for the combined up-regulated lncRNAs was 1.73  and down-regulated lncRNAs was 2.09 . The HR values of the subgroup analysis for glioma , non-small cell lung cancer , nasopharyngeal carcinoma , and breast cancer  were obtained. Moreover, the expression of lncRNAs was significantly related to overall survival of patients no matter if the sample size was >50 or not. In addition, the HR values of the subgroup analysis for lncRNA H19 , lncRNA FAM201A , and lncRNA HOTAIR  were also obtained.LncRNAs can induce cancer radioresistance by regulating cell death-related signaling pathways. Results indicated that lncRNAs, especially lncRNA H19, FAM201A, and HOTAIR, could be considered as a predictive theragnostic biomarker to evaluate radiotherapy response. Cancer is one of the dominant factors causing global death, and deaths caused by cancer have far exceeded those caused by infectious diseases such as human immunodeficiency virus (HIV) and tuberculosis (TB) . GLOBOCARecently, it has been demonstrated that the dysregulation of long non-coding RNAs (lncRNAs) after ionizing radiation (IR) was different between radioresistant and radiosensitive patients –14. LncRHowever, these previous studies only focused on one single lncRNA based on small sample size or one study center. The association between lncRNAs and cancer radioresistance is still poorly understood. Therefore, more functional lncRNAs related to the radioresistance or radiosensitivity response need to be explored based on multiple centers and big sample size. Meta-analysis pooled large amount of available data and provided more precise estimates. Therefore, this study was performed to provide novel insights into lncRNAs associated with radioresistance and radiosensitivity of various cancers by a systematic review and meta-analysis. Studies were selected based on the inclusion and exclusion criteria. The extracted HRs and the corresponding 95% CIs were calculated followed by sensitivity analyses, publication bias assessment, as well as subgroup analysis.The present meta-analysis was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines .The topic related literature was searched by two authors independently through PubMed, PMC, ISI Web of Science, Embase, Google Scholar, Cochrane Library, the Chinese National Knowledge Infrastructure (CNKI), and Chinese Biomedical Literature Database (CBM). The studies were limited to English or Chinese language which published before June 30, 2021. The terms “long non-coding RNA,” “lncRNAs,” “radioresistance,” “radiosensitivity,” “cancer,” “tumors,” “neoplasm,” and “overall survival” were used to search the related studies. Articles in the references listed in the studies were also searched to avoid missing the relevant studies.Inclusion and exclusion criteria were chosen as the following. Retrieved studies were included if they met the following characteristics: 1) human individuals; 2) the diagnosis of cancer disease was clinically confirmed according to the disease guideline; 3) the expression of lncRNAs and its related overall survival were evaluated; 4) lncRNAs were involved in radioresistance or radiosensitivity in cancer therapy; 5) case group size, control group size, HR value, and its related 95%CIs were provided; 6) the publication language was limited to Chinese or English.Studies were excluded if they met the following characteristics: 1) cell line or animal studies, case reports, comments, abstract, or review articles; 2) not related to radioresistance or radiosensitivity and cancer; 3) repeated studies; 4) insufficient data to calculate the HR value; 5) studies not related to the topics.Two authors retrieved the following data independently from the included studies: first author, publication year, country, sample characteristic, sample source, type of cancer, involved lncRNAs, detection method, related therapy, the case and control size, and the HR value and its 95CIs. If the included studies didn’t provide detailed data, the HR value and its 95CIs would be calculated based on the overall survival curves. If there was any inconsistency, the third researcher checked and resolved.For further assessment of the quality of the included studies, two of the authors independently evaluated studies using the Newcastle-Ottawa Scale (NOS) . Studies2I statistic. When 2I value was 25%, 50%, and 75%, it was low, moderate, and high degrees of heterogeneity, respectively. The pooled effect was conducted by the random-effects model when I2 value was > 75%. Otherwise, a fixed-effects model was used. The Begg and Egger’s tests were used to assess potential publication bias. All statistical analyses were conducted by Stata software version 12.0 . The statistical significance was considered as a P-value< 0.05.The hazard ratios (HRs) with 95% confidence intervals (CIs) of lncRNAs and patients in included studies were extracted, and then the HRs and 95% CI as the effect magnitude were calculated as the amount of the combined effect. Subgroup analysis was conducted according to cancers difference, case sample size >50 or not, and the different expression trend of lncRNAs. The heterogeneity across studies was assessed using the The characteristics of the studies and individuals included are presented in In total, 27 lncRNAs in 14 cancer types were studied in our systematic review and meta-analysis. Twenty-three lncRNAs were upregulated and four were downregulated compared with healthy individuals. Higher expression of lncRNA01057 in glioma, lncRNA00520 in HNSCC, lncRNA CCAT2 in EC, lncRNA HOTAIR in breast cancer and colorectal cancer, lncRNA Rpph1 in EC, lncRNA FAM201A in NSCLC, lncRNA LINC02582 in breast cancer, lncRNA 00511 in breast cancer, lncRNA FAM83H-AS1 in OC, lncRNA H19 in cardiac carcinoma, lncRNA CYTOR in NSCLC, lncRNA 00483 in NSCLC, lncRNA UCA1 in prostate cancer, lncRNA PVT1 in NSCLC, lncRNA MALAT1 in NPC were associated with radioresistance. While lower expression of lncRNA TPTEP1, DRAIC in glioma, lncRNA NKILA in laryngeal cancer, and lncRNA MEG3 in thyroid carcinoma were correlated to radioresistance.http://rbpdb.ccbr.utoronto.ca/index.php), and conducted the protein-protein interaction (PPI) network based on the STRING database (https://string-db.org/), which covered almost all functional interactions between the expressed proteins (http://metascape.org/). Our results indicate that these lncRNAs play key roles in radioresistance during cancer therapy by involving these pathways.Then, we searched the target protein of these lncRNAs in RDPDB database ; the projection of Zhejiang Health Commission (2018KY593); the project of Hangzhou Medical Key Discipline Construction; the Natural Science Foundation of Zhejiang Province (LQ20H250001), funds from the Health Bureau of Zhejiang Province , the project of Hangzhou technology plan (ZD20220005).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Moreover, the consumption of other food-derived MUFA (ODM) significantly decreased TG concentration ), but did not affect the level of TC, LDL-C, or HDL-C. Findings from this study suggest that MUFA-rich food might be beneficial to modulate the blood lipid profile.Since the effects of mono-unsaturated fatty acids (MUFA) on lipid profile are still controversial, a meta-analysis of randomized controlled trials was conducted in the present study to assess the effect of MUFA-rich food on lipid profiles. The study was designed, conducted, and reported according to the guidelines of the 2020 preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. A systematic and comprehensive search was performed in several databases from inception up to 30 January 2022. The results showed that the intake of edible oil-derived MUFA (EDM) could increase the blood HDL-C level (mean difference = 0.08; 95%CI: −0.01, 0.17,  Dyslipidemia, clinically featured by abnormally high blood lipid concentrations, is frequently associated with atherosclerotic heart disease, including coronary heart disease, stroke, and peripheral artery disease ,2,3. EviStudies have shown that dyslipidemia is associated with an increased incidence of diabetes-related complications as well as the development of cancer . In addiMono-unsaturated fatty acids (MUFA) are fatty acids with single double bond . In contHowever, results from different research on MUFA are conflicted. A study found that adding cashews to the typical American diet reduced total cholesterol and LDL cholesterol, as compared to a control diet . HoweverOur study was designed, conducted, and reported according to the guidelines of the 2020 preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement.Relevant literatures were identified via a systematic and comprehensive search from the PubMed, Web of Science, Embase, and Cochrane library databases up to 30 January 2022. We only included the literature published in English. The search used the terms combined with MeSH. The search string is as follows:  and (“Cholesterol” OR “HDL” OR “LDL” OR “Triglycerides” OR “Lipoprotein” OR “low-density lipoprotein” OR “LDL-C” OR “VLDL” OR “HDL-C” OR “TG” OR “TC” and (“Adults” OR “Men” OR “Women” OR “Children” OR “Adolescent”). The reference lists of each study, systematic reviews, and meta-analyses were also reviewed to detect any relevant studies that might have been missed.The meta-analysis selected original studies that met the following inclusion criteria: (a) the study design must be a randomized controlled trial which investigated the effects of MUFA-rich food on blood lipids; (b) the outcome should include at least one of the changes of TC, LDL-C, HDL-C or TG level; (c) all of the data must be complete and available; (d) the dose of MUFA in the intervention group was significantly higher than that in the control group. The following exclusion criteria were used: (a) cell experiments, animal experiments, meta-analyses, reviews, conference papers, case reports, and editorials; (b) studies that clearly did not meet the above criteria.Two reviewers evaluated and extracted data independently from eligible articles by a specially designed data collection form. The following information was extracted: the name of the first author, year of publication, country, mean participant age, study design, the number of subjects, intervention group and control group, MUFA source, and the daily intake amount of MUFA. Moreover, standard deviation and net mean change of TC, TG, LDL-cholesterol, and HDL-cholesterol in each of the literature were also extracted.The seven validity questions of the Cochrane Risk of Bias Tool were applied to evaluate the literature quality evaluation of the included studies; and the tool assessed the random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective outcome reporting, and other bias. According to the recommendations of the Cochrane Handbook, each item was judged to have a “Low”, “High”, or “Unclear” risk of bias.p < 0.05 was considered statistically significant. The mean value of relevant indicators was calculated by subtracting the average change . If there were more than one endpoint, the last endpoint value was used. For the parallel controlled study, we calculated the mean difference in effectiveness (MD) by comparing the change from control to baseline and the change from intervention to baseline. For the crossover test, serum lipid values at the end of the control period and at the end of the intervention period were extracted, and MD in effect was calculated. If the study did not provide a net change in SD, the net change in SD was calculated according to this formula. Since some data were not presented in a uniform way in the original literature, we converted the different units of blood lipid levels to mmol/L (1 mg/dL = 0.0258 mmol/L). In addition, several studies only provided standard error (SE) and 95% CIs of the data, so we calculated the standard deviation (SD) as appropriate. Furthermore, the mean net change was calculated by subtracting the mean value of the endpoint from the corresponding mean value at the basal line. The net change of SD was calculated using the formula: SDchange = (SD2baseline + SD2endpoint − 2R × SDbaseline × SDendpoint) 1/2, correlation coefficient R = 0.5 [2 metrics and chi-squared statistics were used to assess the heterogeneity. When I2 > 50% or p-value of χ2 test < 0.10, which indicates a high level of heterogeneity, the random-effects model was applied. Additionally, subgroup analyses were conducted based on the source of MUFA and the background information of participants. Funnel plots and Egger’s regression test were applied to investigate potential publication bias. Moreover, the sensitivity analysis was used to evaluate the influence of a single study on the overall results.All statistical analyses were conducted using Stata 15.0, and  R = 0.5 . I2 metrThe complete flow diagram of the selected studies is shown in These studies were published from 2005 to 2021 and included 248 subjects. Two studies were conducted in Asia ,24, one Since the MUFA involved in the included studies was derived from either edible oil or other food sources (avocado or oleic acid), all of the trials were divided into two groups including edible oil-derived MUFA (EDM) and other food-derived MUFA (ODM) for the subsequent analyses.p = 0.03, I2 = 33.2%). However, there was no significant effect of EDM consumption on serum TC , LDL-C , or TG concentration .The results in p = 0.01, I2 = 6.5%). On the contrary, the effects of ODM consumption on TC , LDL-C , and HDL-C level  were insignificant , we then performed the subgroup analyses with the trials in the EDM study. Reduction of the heterogeneity was observed in TC, LDL-C, and TG, which might be relevant to two factors that performed subgroup analyses (Since only the result of the effects of EDM showed the heterogenicity (Ianalyses . ParticuThere was no publication bias in the visual inspection of the funnel plot. Meanwhile, the results of Egger’s test showed no evidence of potential publication bias in the combined results of the four effect indexes (detailed in The beneficial effects of dietary unsaturated fatty acids have been recognized. While the majority of the previous studies concentrated on the protective role of PUFA in improving lipid profile, there were few studies reporting the influence of MUFA on lipid spectrum . In receThe results from the present meta-analysis showed significant increase in HDL-C following the consumption of MUFA-rich edible oil, but there was no significant change in TC or LDL-C. Such findings were consistent with previous reports which showed that the serum level of HDL-C could be increased by the consumption of high-oleic acid ground beef ,34. AddiDifferent from the effects of EDM, the effect of ODM on TG, but not HDL-C, was significant, which was consistent with previous reports showing that the serum level of TG could be reduced by MUFA-rich food in individuals with or without hypertriglyceridemia ,36. The Of note, there has been a lot of compelling and convincing evidence that PUFA has a TG lowering effect ,43,44. IIn the subgroup analysis, it was found that there was a significant reduction in TC, HDL-C, and TG in the subset of palm olein, while only HDL-C levels gained a significant increase in the subset rapeseed oil. This suggested that MUFA-rich food may be more effective in improving lipid profile levels in people with disease than in healthy people. The results of the subgroup analysis suggested that the source of MUFA and participants’ condition may be the sources of heterogeneity. It has to be admitted that heterogeneity between studies was high in some results and was significant in some subgroups despite our efforts to find the source of heterogeneity in the subgroup analysis. Moreover, the components of the MUFA-enriched food are so diverse that it is not possible to determine whether nutrients other than MUFA affect the lipid profile.It has to be admitted that heterogeneity between studies was high in some results and was significant in some subgroups despite our efforts to find the source of heterogeneity in the subgroup analysis. Moreover, the components of the MUFA-enriched food are so diverse that it is not possible to determine whether nutrients other than MUFA affect the lipid profile.Collectively, results from this meta-analysis indicated that the intake of edible oil- EDM could increase the level of blood HDL-C, and the consumption of ODM could significantly decrease the TG concentration. In addition, no compelling evidence of an effect of MUFA-rich food consumption on TC or LDL-C concentration was found. However, well-designed and high-quality randomized controlled trial studies with larger-scale participants are necessary to validate current findings.


AGTR1 rs5186 polymorphism and restenosis after percutaneous coronary intervention (PCI) have been published, but the result remains controversial. The study aimed to explore the relationship between rs5186 polymorphism and the risk of restenosis after PCI. Methods: We performed a systematic search on PubMed, Web of Science, Embase, CNKI, and Wan Fang databases up to December 2021. Two authors individually extracted all useful data of each study involved in this meta-analysis and assessed the study quality using the Newcastle-Ottawa scale. Odds ratios (ORs) and 95% confidence intervals (CIs) were combined in different genetic models for evaluation using a random-effects model or fixed-effect model. Results: There were eventually 8 studies of 1111 cases and 4097 controls eligible for this meta-analysis. Significant associations were found between rs5186 polymorphism and restenosis after PCI.allelic , homozygous , heterozygous , recessive , dominant genetic model . Subgroup analyses indicated a significant association in Asians. Conclusions: The rs5186 polymorphism in the AGTR1 gene increases the risk of restenosis after PCI in Asians significantly.Background: Progress has been made in genetic investigations on restenosis for the past 20 years, many studies regarding  Cardiovascular disease (CVD) remains a major cause of premature mortality and rising healthcare costs . The CVDCoronary atherosclerotic heart disease (CHD) is one of the major cardiovascular diseases. In addition to medical therapy, percutaneous coronary intervention (PCI) has become an important treatment for CHD. Primary PCI modalities include percutaneous transluminal coronary balloon angioplasty, coronary stenting, and others, which reduce CHD-related mortality significantly . HoweverAGTR1) rs5186 polymorphism and restenosis after PCI have been published. Due to the small sample size and low statistical power of individual studies, the consolidated result is still controversial. In this paper, we conducted a meta-analysis of the rs5186 gene polymorphism in all patients with restenosis versus no after PCI from the enrolled studies to investigate the association between rs5186 polymorphism and the risk of restenosis after PCI.The pathophysiological of restenosis after PCI is damage to vascular endothelial cells, leading to hyperplasia of the neovascular endothelium. Angiotensin II in the renal angiotensin aldosterone system (RAAS) would stimulate the expression of smooth muscle cell growth factor to promote smooth muscle cell hyperplasia, migration, and thus the occurrence of restenosis . With thWe followed the methods of Jiang et al.  to perfoAGTR1, A1166, polymorphism, variant, and mutation. This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [A systematic search was conducted in the PubMed, Web of Science, Embase, CNKI, and Wan Fang databases from inception to December 2021 with no language restrictions, combined with a manual search of reference lists from the identified articles. The following terms were used in the literature search: restenosis, rs5186, (PRISMA) . The proStudies meeting the following criteria were included: (1)Case-control studies; (2) Investigating the association of the rs5186 polymorphism and risk of restenosis; (3)Studies had data of odds ratios (ORs) and 95% confidence intervals (95% CI) or had sufficient data to calculate it.Two of the authors independently extracted data from eligible studies. The process was as follows: (1) read the article title and exclude duplicate studies; (2) Titles and abstracts were read, and irrelevant literature was excluded; (3) The full texts were read in detail, and the literature that met the inclusion and exclusion criteria were finally identified. Conflicts were discussed with a third reviewer. Extraction of study data: author, publication year, country, ethnicity, number of patients, source of controls, PCI type, genotyping method, and genotype distribution. The 9-point Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality included .2 >50% indicating heterogeneity. Otherwise, the fixed-effect model would be used. We also performed subgroup analyses to identify the underlying heterogeneity according to ethnicity, study sample size, and PCI type. The analyses were conducted in 5 genetic models: allele , homozygote model (AA vs. CC), heterozygote model (AC vs. AA), recessive model (CC vs. AC + AA) and dominant model (CC + CC vs. AA). A sensitivity analysis was performed to evaluate the stability of the results. We investigated publication bias by calculating the Egger test and drawing the Begg funnel plot.This meta-analysis was performed using Stata version 14.0. We did Hardy-Weinberg equilibrium (HWE) tests for every study included. We explored the associations between rs5186 polymorphism and risk of restenosis by combining ORs and 95% CIs under a random-effect or fixed model. A random-effects model for pooled analysis would be adopted when In = 2), insufficient data (n = 2), and not relevant to restenosis (n = 1). n = 3) and Caucasian . All included studies fitted in with the HWE test. The results of NOS are shown in The search of the five databases identified 51 records. After removing the duplicated studies, there were 34 studies left for screening. Twenty-one irrelevant pieces of literature were excluded after reading the title and abstract of the article. Finally, 13 studies were read in full-text, and five full-text articles were excluded because of unmatched study design , homozygous , heterozygous , recessive , dominant genetic model  in the whole population , homozygous , heterozygous , recessive , dominant genetic model . In the Caucasian subgroup, we also found association under allelic , homozygous  recessive . In summary, our meta-analysis suggested that rs5186 polymorphism in the AGTR1 gene increased the risk of restenosis after PCI, particularly in Asians. We also carried out subgroup analyses according to sample size, and PCI type. The detailed information is presented in AGTR1 gene increased the risk of restenosis after PCI.In the subgroup analyses by ethnicity , the assWe carried out the sensitivity analysis to find whether the omission of each study would change the pooled ORs quantitatively. No changed results are shown after the individual study was omitted in p = 0.59). We computed the Egger test and drew the Begg funnel plot to estimate the publication bias. We could see that all eight studies were distributed on two sides of the Begg funnel plot , which iCVD is the leading cause of global mortality. Prevalent cases of total CVD nearly doubled from 271 million in 1990 to 523 million in 2019, and the number of CVD deaths steadily increased from 12.1 million in 1990, reaching 18.6 million in 2019 [AGTR1. Genes regulating levels and activity of the RAAS contribute to vasoconstriction and neointimal hyperplasia and are associated with restenosis following intracoronary stent placement [AGTR1 was a risk factor for restenosis after PCI [The renal angiotensin aldosterone system (RAAS) has been implicated in the development and progression of neointimal hyperplasia predominantly through angiotensin II(Ang II)  Angiotenlacement ,25. Withlacement ,18,19,20AGTR1 and the relationship with restenosis after PCI. All results indicated that the rs5186 polymorphism would increase the risk of restenosis after PCI. Subgroup analyses showed a higher risk of restenosis after PCI in subjects with the risk allele in the Asian population; we also conducted subgroup analyses according to sample size and PCI type. A similar association was observed in both sample size (≥400) and PCI type (stent) subgroups that rs5186 polymorphism in the AGTR1 gene increase the risk of restenosis after PCI. There was no publication bias in our meta-analysis.Our meta-analysis consolidated eight eligible studies on the rs5186 polymorphism of Limitations of our meta-analysis should be acknowledged. First, all eight studies included in this meta-analysis were written in English and Chinese, so studies in other languages and possibly unpublished articles did not attend, which may cause selection bias. Second, there were no studies including Africans. The sample size of three studies, including Asians, was less than five studies, including Caucasians in this meta-analysis, which may influence the results. Third, genetic susceptibility may also depend on the coincidence of several gene polymorphisms acting together, which may influence the results.AGTR1 gene increases the risk of restenosis after PCI in Asians. It could be a promising locus for genetic therapy in the clinical management of restenosis after PCI. More case-control studies need to be carried out to further validate and strengthen the conclusion of this meta-analysis.We finally concluded that the rs5186 polymorphism in the


This study aimed to investigate the causal association between unhealthy lifestyle factors and diabetic retinopathy (DR) risk and to determine better interventions targeting these modifiable unhealthy factors.Two-sample Mendelian randomization (MR) analysis was performed in this study. The inverse variance-weighted method was used as the primary method.Our study included 687 single-nucleotide polymorphisms associated with unhealthy lifestyle factors as instrumental variables. Aggregated data on individual-level genetic information were obtained from the corresponding studies and consortia. A total of 292,622,3 cases and 739,241,18 variants from four large consortia  were included.P < 0.001] and cigarettes per day  were genetically predicted to be causally associated with an increased risk of DR, while patients with higher hip circumference (HC) had a lower risk of DR . In the analysis of subtypes of DR, the results of BMI and HC were similar to those of DR, whereas cigarettes per day were only related to proliferative DR (PDR) . In the MR-PRESSO analysis, a higher waist-to-hip ratio (WHR) was a risk factor for DR and PDR  after removing the outliers. Furthermore, no pleiotropy was observed in these exposures.In the MR analysis, a higher body mass index (BMI) (odds ratio [OR], 95% confidence interval [CI] = 1.42, 1.30–1.54; Our findings suggest that higher BMI, WHR, and smoking are likely to be causal factors in the development of DR, whereas genetically higher HC is associated with a lower risk of DR, providing insights into a better understanding of the etiology and prevention of DR. MoreoveConsidering unhealthy lifestyle a modifiable factor, mounting observational epidemiological studies have focused on the association between unhealthy lifestyle and DR. However, based on the current studies, the results of some unhealthy lifestyle factors are controversial and inconsistent –7. AccorMendelian randomization (MR) analysis utilizes genetic predictors as instrumental variables (IVs) to investigate the causal association between risk factors and diseases . Because22.1P < 5 × 10−8) were extracted as IVs. To ensure that they were entirely independent, linkage disequilibrium analysis was performed using a threshold of r2 < 0.001. Additionally, we extracted the summary data and effects of each SNP and calculated the effect sizes and standard errors using the MR-Base platform  (ukb-a-248), waist circumference (ieu-a-67), hip circumference , and waist-to-hip ratio  as indicators of obesity. Single nucleotide variants (single-nucleotide polymorphisms [SNPs]) for BMI were retrieved from the Neale Lab consortium, and the rest were retrieved from a published meta-analysis of genome-wide association studies (GWAS) datasets summarized by Shungin  dataset and the platform . Details2.2https://gwas.mrcieu.ac.uk/)  (.ac.uk/) . To eval.ac.uk/) Table 1..ac.uk/) , 14.2.3We used a two-sample MR approach to examine the potential causal association between unhealthy lifestyle and DR incidence. The MR method must satisfy three assumptions: (i) the IVs need to be robustly related to the exposures; (ii) the instruments influence the outcome only through the exposures of interest; and (iii) the IVs are independent of any confounders of the exposure–outcome association Figure 1In the MR analyses, the inverse-variance weighted (IVW) model was the main method used in this study. The MR-Egger regression and weighted median (WM) models were also used to test the coherence of the causal estimates. The IVW method treated each SNP as a valid natural experiment, assessing the causal effects of each SNP on the outcome, and used the outcome as weights for meta-analysis to evaluate the combined causal effect. The IVW (fixed-effect) method provides an unbiased estimate in the absence of horizontal pleiotropy or when horizontal pleiotropy is balanced . If heteIn sensitivity analyses, the MR-Egger-intercept test was used to determine pleiotropy. We also applied the MR pleiotropy residual sum and outlier (MR-PRESSO) method to identify outlying SNPs and examine whether the causal effect would change after removing these outliers . CochranP value < 0.05 divided by 27  was considered a significant causal association to adjust for multiple testing. A P-value between 0.05 and 1.852e–3 was considered suggestive of a potential association. All statistical analyses were performed in R (version 4.1.0) using the R package “Two sample MR” (version 0.5.6) and “MR- PRESSO” (version 1.0) (The results were shown as odds ratios (ORs) with their corresponding 95% confidence intervals (CIs). Because we included analyses of nine exposures with three outcomes, using a conservative approach, a Bonferroni-corrected ion 1.0) .33.13.1.1An overview of the MR analysis results is shown in 3.1.2P < 0.001*) and an approximately 20% increase in the risk of cigarettes per day . Interestingly, higher HC decreased 15% lower risk in DR incidence per SD . A forest plot of SNPs associated with cigarettes per day, BMI, and HC is presented in P = 9.389e–16).The IVW method indicated an over 40% increased risk of DR incidence per standard deviation (SD) increase in BMI  and PDR . In the WM method and MR-Egger model, BMI also indicated an analogous causal effect. Higher HC was a protective factor in BDR  and PDR . The result of cigarettes per day indicated an increased risk of PDR . The forest plot of SNPs associated with the above exposures and the risks of BDR and PDR are presented in P = 1.687e–5; PDR, P = 4.085e–11).In DR subtypes, a genetically predicted higher BMI increased the risk of BDR . Hence, we used a multiplicative random-effects model to re-estimate the MR effect of BMI. The results showed a causal association and positive correlation between BMI and DR risk (P = 4.24e–13*).We assessed heterogeneity using Cochran’s Q test and horizontal pleiotropy from the MR-Egger regression analysis. There was no evidence of directional pleiotropy using MR-Egger regression Table 3.3.2.2P < 0.05). The results of multiplicative random effects showed that BMI was a causal risk factor for BDR (P = 1.06e–04) and PDR (P = 6.05e–09). Directional pleiotropy was found in alcohol intake frequency in PDR (P = 0.024*) using MR-Egger regression. No evidence of directional pleiotropy was found in the other exposures  and PDR . In the remaining cases, the results remained consistent with the original results after the removal of these outliers. The corrected results of the MR-PRESSO analysis are listed in We applied MR-PRESSO to recognize outlying SNPs that might cause horizontal pleiotropy effects. Several outliers were identified during the MR-PRESSO analysis. After removing these outliers, we found that a higher WHR indicated a higher risk of DR (OR = 1.24; 95% CI, 1.02–1.50; 3.2.4The leave-one-out analysis suggested that the risk estimates of cigarettes per day, BMI, and HC for DR, BDR, and PDR generally remained consistent after eliminating each single SNP at a time Table S74The present study demonstrated a causal association among cigarettes per day, BMI, and WHR and an increased risk of DR, whereas HC was found to have a lower risk of DR. In subgroup analyses, we found that higher BMI increased the risk of all types of DR, especially BDR. Cigarettes per day was only associated with PDR. Additionally, HC decreased the risks of BDR and PDR. These results were contrary to those of several previous conventional observational studies –7. A posThe mechanisms underlying the associations among cigarette smoking, BMI, HC, WHR, and DR remain unclear. In smoking patients, nicotine causes a vasoconstrictive effect. This reduces the blood flow of the retina and makes it difficult for the retinal blood vessels to autoregulate hyperoxia , 22. AddFor obesity, a higher BMI is often associated with dyslipidemia – a disease that may be responsible for the development of DR . MoreoveThe present study has several strengths. First, very few studies have comprehensively investigated the association between unhealthy lifestyles and DR incidence. To the best of our knowledge, our study is the first to investigate the potential causal association between unhealthy lifestyles and the risk of DR employing the MR approach and a large GWASs data. Second, due to the use of MR analysis, our findings were less likely to cause confounding and reverse causality, when compared to those of conventional observational studies. Third, the accuracy of our findings might be higher as we applied analysis of subtypes stratified by clinical classification to investigate the consistency of the pooled effects. Finally, the sample overlap only could account for up to 6.94%, and the exposure and outcome data were obtained from different databases, thereby reducing the bias of the estimate in the direction of observational association. These strengths of MR analysis, as a result, might increase the reliability of our findings.However, certain limitations were found in our study. The SNPs were obtained from five large European populations-based consortia, which, therefore, might affect the generalization of our findings in other populations and regions. Otherwise, our study only performed MR analysis with summarized statistics. This could only allow us to make a preliminary conclusion on the causal association between unhealthy lifestyles and DR but fail to further investigate this association in terms of age, sex, type of diabetes, and DR severity. Additionally, it is hardly possible to remove all pleiotropy in our studies, especially the correlated horizontal pleiotropy. Consequently, some undetected confounders between exposures and outcomes may bias our results. Therefore, our findings should be cautiously interpreted and confirmed through further studies.In conclusion, we demonstrate that smoking, BMI, and WHR are risk factors for DR. For future studies, informed by the work reported here, individual-level data and basic science approaches are required to investigate the further mechanism underlying the association between cigarette intake and obesity and DR development. In addition, due to the contrary results of WHR and HC, more emphasis should be placed on how different fat distributions relate to DR, which can disclose the underlying association between obesity and DR and strengthen the understanding of obesity. For clinical practice and public health strategies, the present study highlights the importance of lifestyle management in patients with diabetes and provides a reference for the future refined identification of high-risk individuals for DR. Health education can be strengthened to suggest avoiding unhealthy lifestyles. In addition, more frequent ocular examinations may be essential in patients with diabetes with such risk factors.The original contributions presented in the study are included in the article/FJ and XW were responsible for the concept and design of the study, interpretation of data, and drafting and writing of the article. ZS and ZW were contributed equally to the manuscript as joint first authors. The other authors were responsible for interpretation of data and revision of the intellectual content. All authors contributed to the article and approved the submitted version.


This review aimed to investigate the association of insulin resistance (IR) in women with recurrent pregnancy loss compared to women with normal pregnancy history.th of October 2022. Outcomes assessed in this review and meta-analysis included fasting blood glucose, fasting plasma insulin, homeostasis model assessment for IR, glucose to insulin ratio. Mean differences, odds ratios with 95% confidence interval were pooled using the fixed or random effect models. Sensitivity analyses were performed to validate the robustness of the results. Review Manager version 5.4.1 and Stata version 8.0 were used.PubMed, EMBASE, the Web of Science and Google Scholar databases were accessed to collect published observational studies that compared IR of recurrent pregnancy loss women with healthy women until the 6A total of nineteen studies involving 4453 individuals were included. Recurrent pregnancy loss patients presented significantly higher fasting blood glucose, fasting plasma insulin, homeostasis model assessment for IR, and lower glucose to insulin ratios. Additionally, recurrent pregnancy loss patients had higher rates of IR as defined by abnormal fasting plasma insulin, homeostasis model assessment for IR, and glucose to insulin ratio. Sensitivity analyses validated the robustness of the results.In the current review, we show that recurrent pregnancy loss is associated with a higher degree of IR and highlight the importance of screening and treatment of IR.The online version contains supplementary material available at 10.1186/s12884-022-05256-z. Recurrent pregnancy loss (RPL) affects approximately 2–5% of women . Common . suggested that IR was an independent risk factor for spontaneous abortion in women who received infertility treatment ). The funnel plots showed possible asymmetry . Additionally, the sensitivity analysis did not identify any single study which altered the effect size. Subgroup analyses indicated that factors such as whether the patients were matched for confounders and the exclusion of known factors associated with RPL were correlated with between-study heterogeneity   . Furthermore, the sensitivity analysis did not identify any single study which altered the effect size. Subgroup analyses indicated that the geographic region, the definition of RPL, whether the patients were matched for confounders, measurement timing, and the exclusion of known factors were not associated with between-study heterogeneity  Fig. . The fun%]) Fig. . The Egg2 = 89% [77%-95%]) . Additionally, the sensitivity analysis did not identify any single study which altered the effect size. Subgroup analyses indicated that the exclusion of known factors associated with RPL was associated with between-study heterogeneity (P < 0.00001)   Fig. . The Egg1) Table .Fig. 5MeP = 0.986), abnormal GI ratio  and abnormal FIN . Subgroup analysis to assess the association between IR status and RPL was not performed due to the limited number of studies included.The meta-analysis revealed a significantly higher rate of IR in RPL patients defined by abnormal HOMA-IR, abnormal GI ratio and abnormal FIN compared to healthy controls Fig. . The funThe data from this meta-analysis suggested that glucose metabolism was associated with RPL. RPL women had higher FBG, FIN, and HOMA-IR, and a lower GI ratio relative to healthy controls. Additionally, RPL women were observed to have a higher rate of IR status.. found that elevated maternal HCY is associated with defective chorionic villous vascularization [. reported that the exposure of mouse embryos to HCY induced cardiac defects [First, homocysteine (HCY) and folate have been hypothesized to influence RPL in recent years. In animal and human studies, it has been shown that IR is associated with HCY . One metrization . Additio defects . The autSecond, the placenta serves as the main interface between the mother and the fetus and it is understood that peripheral IR status is changed during pregnancy . This inThird, efficient vessel functioning is vital during normal pregnancy. During early human pregnancy, extravillous trophoblast cells from the placenta invade the uterine decidual spiral arterioles and mediate the vessel remodeling to ensure that low pressure, high blood flow can be supplied to the placenta . The devFurthermore, IR may impair the procedure from oocyte development to embryo development. IR is associated with decreased percentage of mature eggs and poor embryo quality in , 53. IR . suggested that IR was an independent risk factor for spontaneous abortion in women undergoing assisted reproduction [Previous study has provided evidence supporting the association between IR and spontaneous pregnancy loss. Tian et aloduction . From ouoduction . In agreMeanwhile, subgroup analyses showed that geographic region, whether the patients were matched for confounders, and whether the exclusion of known factors might have a significant influence on the association between IR and RPL. The differences observed for the geographic region may reflect ethnic heterogeneity. Matched confounders might have associations with IR and, therefore, influence the subgroup analysis. Additionally, our results indicate that the relationship between IR and RPL was stronger when excluding known factors of RPL, suggesting the possible role of IR in unexplained RPL.Several factors might influence our results. First, not all confounders related to IR were fully adjusted for in the included studies. For example, the BMIs of all the women were not similar between the RPL and control women. Furthermore, additional confounders that may affect a person’s IR parameters, such as smoking  and life. reported that metformin therapy in pregnant women with PCOS was associated with a significant reduction in the rate of early pregnancy loss [In the current review, RPL women were found to be associated with IR. The screening and prevention of IR may provide health benefits for women with RPL. Al-Biate et alncy loss . Furtherncy loss . HoweverThe search strategy and systematic methods, including quality assessment, publication bias assessment, subgroup analyses and sensitivity analyses are among the strengths of this study. Our study has several limitations. First, the sample size for some indices was relatively small. Most studies were case–control studies, and we are unable to fully access the causality between IR and RPL. Furthermore, the diagnostic criteria for RPL were heterogeneous between studies. Additionally, the quality of several of the studies was not enough. Lastly, some covariates that may affect IR status, such as smoking, lifestyle, were not evaluated.In conclusion, women with RPL were associated with IR and impaired FBG, FIN, HOMA-IR, and GI ratios. Our study provides improved insight into the understanding of the pathophysiology of women suffering from RPL. The early screening and management of IR may help to improve the pregnancy outcomes of women with RPL and future studies are warranted to further explore the underlying mechanism between IR and RPL.Additional file 1: Supplementary table 1. PRISMA checklist.Additional file 2: Supplementary Table 2. Search strategy.Additional file 3: Supplementary Figure 1. Funnel plot in the meta-analysis on the association of FBG between RPL and control group. Supplementary Figure 2. Funnel plot in the meta-analysis on the association of FIN between RPL and control group. Supplementary Figure 3. Funnel plot in the meta-analysis on the association of HOMA-IR between RPL and control group. Supplementary Figure 4. Funnel plot in the meta-analysis on the association of GI ratio between RPL and control group. Supplementary Figure 5. Funnel plot in the meta-analysis on the association of IR by abnormal HOMA-IR between RPL and control group. Supplementary Figure 6. Funnel plot in the meta-analysis on the association of IR by abnormal GI ratio between RPL and control group. Supplementary Figure 7. Funnel plot in the meta-analysis on the association of IR by abnormal FIN between RPL and control group.


There was no significant publication bias (p = 0.432). In conclusion, diabetes could increase the risk of AVN in sites other than the jaw, but the available evidence is limited. There is a need for large, well-designed, population-based studies.Avascular osteonecrosis (AVN) is caused by the disrupted blood supply to the bone. Most AVN cases occur in the femoral head, but other sites might be affected as well, including the jaw or distal bones of the extremities. Previous studies suggested that diabetes could increase the risk of AVN of the jaw, but the relationship between diabetes and AVN in other bone sites is unclear. This systematic review and meta-analysis aimed to summarize the evidence from studies that had reported on the occurrence of AVN in sites other than the jaw, depending on the diagnosis of diabetes. Overall, we included 6 observational studies carried out in different populations: primary or secondary AVN of the femoral head, Takayasu arteritis, general population, kidney transplant recipients, systemic lupus erythematosus, and primary brain tumors. A random-effects meta-analysis showed that the risk of AVN in sites other than the jaw was non-significantly increased in patients with diabetes . The pooled estimate increased and was significant after the exclusion of one study . There was a significant heterogeneity (I Avascular osteonecrosis (AVN) refers to the death of bone cells due to disruption of the blood supply, which typically occurs in bone areas with limited collateral circulation . The deaAVN may be caused by trauma, such as fracture, particularly displaced fractures , or it cPrevious studies on medication-related osteonecrosis of the jaw reported that 15–70% of patients with this condition had diabetes ,29. In cThe protocol for this systematic review and meta-analysis was prepared in compliance with the preferred reporting items for systematic review and meta-analysis protocols (PRISMA) guidance . The proWe searched the PubMed and EMBASE databases for studies published until 29 July 2022 in English, Polish, or Spanish. We used the following keywords: “AVN”, “sterile necrosis”, “osteonecrosis”, “diabetes”, “hyperglycemia”, and “risk factor”. The exact search phrases are shown in the study protocol. The titles and abstracts were screened to select studies for full-text review. When studies were carried out in overlapping samples, we chose the one with the greatest sample size.Two investigators assessed the eligibility of the studies. The more experienced investigator decided on the eligibility when there was a discrepancy. Included were studies that reported sufficient data to obtain or calculate the total number of cases and the number of AVN events in groups with diabetes and without diabetes. Eligible were studies with a score of 5 or more on the Newcastle–Ottawa Scale to exclude studies with a high risk of bias (scores 4 or lower). Case reports, case series among 15 patients or fewer, reviews, and letters to the editor were excluded.Two investigators independently extracted the following data: the name of the first author, the publication year, the study design, and characteristics of AVN cases .2 and the Q-profile method for the confidence interval of tau2 and tau. Heterogeneity was expressed with the I2 and τ2 statistics, and it was evaluated with Cochran’s Q test. A prediction interval was estimated to take heterogeneity into account. Sensitivity analyses included leave-one-out analyses. Publication bias was assessed using the Eggers regression test and by inspection of a funnel plot and using fail-safe N analysis. A p-value of less than 0.05 was considered statistically significant. The R software (version 4.1.3) was used for all analyses.We calculated odds ratios (OR) using inverse variance for the risk of AVN in patients with diabetes vs. without diabetes (OR > 1 indicated an increased risk of AVN in patients with diabetes). A random-effects meta-analysis was carried out with the restricted maximum-likelihood estimator for tauA total of 963 citations were identified, and 39 articles were retrieved in full text. After a full-text review, 31 studies were excluded due to insufficient data, 1 due to poor quality (low NOS score) and 1 due to an overlapping cohort . OverallThe studies were carried out in various populations: primary or secondary AVN of the femoral head, Takayasu arteritis, general population, kidney transplant recipients, systemic lupus erythematosus, and primary brain tumors. Nearly all of the AVN cases were reported in the femoral head, with few cases in the femoral condyle, humerus, and ankle see . The meaThe ORs for AVN risk among patients with diabetes in individual studies ranged from 0.81 to 8.02. The ORs among patients with diabetes were significantly increased in three studies: Lai et al. , Tse et 2 = 65%, tau2 = 0.48, and p = 0.01; prediction interval, 0.21–16.84; p = 0.34). Based on Rosenthal’s analysis, the number of fail-safe (n = 15) was greater than the number of included observations (n = 6) (p = 0.001), which means there is no risk of publication bias.The pooled estimate indicated a non-significantly increased risk of AVN in patients with diabetes  and those with fractures of extremities (n = 489). These investigators reported that diabetes was associated with a non-significantly lower risk of femoral head AVN . However, the study was carried out in a single hospital, and the control group was older than the patients with AVN (65 vs. 57 years). This age imbalance could partly account for the largest prevalence of diabetes in the control group than the AVN group (9.2% vs. 7.6%), which resulted in a lower risk of AVN associated with diabetes. After the exclusion of the study by Yang et al., the pooled estimate increased and was significant . Felten et al. studied the risk of AVN in 805 kidney transplant recipients, with a total of 18 cases of new-onset avascular necrosis (8 in patients with diabetes); patients with or without new-onset AVN after transplant were of a similar age (51 vs. 55 years) [Lai et al. published the largest study to date, with 146 cases of non-traumatic AVN of the femoral head among patients with diabetes . In that5 years) . The sig5 years) . Tse and5 years) . Similar5 years) . The risA potential relationship between the risk of AVN and diabetes was first noticed among patients treated with bisphosphonates who developed AVN of the jaw. Bisphosphonates, which inhibit osteoclastic bone resorption, are used commonly to treat bone diseases such as osteoporosis, multiple myeloma, and bone metastases . A systeOur study had several limitations. We included only six studies, most of which were not designed specifically to study diabetes as a risk factor for AVN in sites other than the jaw. Moreover, the generalizability of the meta-analysis results is limited by substantial heterogeneity, which could be due to the inclusion of studies carried out in very heterogenous populations. The heterogeneity did not decrease in the leave-one-out sensitivity analyses, and there were too few studies to carry out subgroup analyses for different populations. Moreover, corticosteroid use, an established risk factor for AVN, was prevalent in the studies included.In conclusion, although the pooled estimate from this meta-analysis suggests that diabetes might increase the risk of AVN in sites other than the jaw, the existing evidence is limited. The relationship between diabetes and the risk AVN should be further investigated in well-designed, population-based studies with well-matched control groups.


The connection between B and T lymphocyte attenuator rs1982809 polymorphism and cancer risk has been investigated by several studies and yielded different results. Therefore, we adopted the meta-analysis method to assess the association of rs1982809 polymorphism with the susceptibility of cancers synthetically.Eligible publications were gathered by retrieving PubMed, Web of Science, Embase, Wan Fang, and China National Knowledge Infrastructure. We utilized odds ratio (OR) and 95% confidence intervals (95% CI) to assess correlation intensity and performed subgroup analyses, sensitivity analyses, and publication bias assessments.= 1.11, 95% CI = 1.04–1.19, Pheterogeneity= .096). Subgroup analyses revealed that this SNP is regarded as a susceptible factor for cancers in the dominant, heterozygous, and additive model  in Caucasians; And this SNP may increase the susceptibility to lung cancer .Six researches that encompassed 3678 cases and 4866 controls were incorporated into our meta-analysis. The rs1982809 polymorphism was proved to be connected with cancer risk by the meta-analysis in the additive model (G vs A: OR The paper concludes that B and T lymphocyte attenuator rs1982809 polymorphism may contribute to cancers, especially in Caucasians, and it may associate with lung cancer. So many causes, including diet, lifestyle, heredity, and environmental factors, contribute to tumors. Hereditary factors probably play a crucial role in the genesis and progression of cancers among them. Moreover, molecular epidemiological studies have shown that genetic factors, such as single nucleotide polymorphisms (SNPs), might also be associated with the pathogenesis of cancers.–4As the primary cause of morbidity and mortality worldwide and in every region of the world, cancers place a tremendous burden on the global medical systems, regardless of the level of human development. Immunotherapy has ushered cancer treatment into a new era, programmed death 1 (PD-1) and cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) inhibitors are particularly prominent in this field. As the third inhibitory receptor on T lymphocytes, BTLA is similar to PD-1 and CTLA-4, dampening immune responses. BTLA molecule plays a significant role in sustaining immunological self-tolerance and preventing autoimmunity,,9 but its high level of expression can reduce the body’s immunity and cause people to develop various diseases, even cancers. It is reported that the overexpression of BTLA has been observed in a variety of tumors.Many studies have revealed that the immunity system has played a significant role in preventing tumorigenesis and tumor progression during the past decade. and expressed on B and T lymphocytes, antigen-presenting cells, and natural killer cells. An extracellular domain, a transmembrane region, and a cytoplasmic region are contained in the BTLA. Herpesvirus entry mediator (HVEM), the ligand of BTLA, belongs to TNF family members. When BTLA bound its ligand (HVEM), the tyrosine of the cytoplasmic region in the BTLA gene will be phosphorylated by recruiting Src homology phosphatase-1 and Src homology phosphatase-2 to significantly lower the serum level of IL-1, IL-10, and IFN-γ, and some studies have utilized the mouse models to identify the role of BTLA/HVEM pathway. As a CD28/B7 superfamily member, BTLA has a similar framework and functions to PD-1 and CTLA-4, which delivers prohibitive signals to lymphocyte cells. Therefore, this negative effect will be magnified when the organism is pathological or under some genetic factors. Some SNPs in BTLA may cause its overexpression to increase the risk of some diseases, and this has been shown in some studies. Two studies indicated that BTLA gene polymorphism contributes to the occurrence and progression of rheumatoid arthritis.,16 The research of Fu et al. suggests BTLA gene polymorphisms might be correlated with susceptibility and prognosis of sporadic breast cancer in Chinese women. During the past few years, increasing studies have found SNPs in BTLA are a risk factor for tumorigenesis and tumor progression, especially rs1982809. Lidia Karabon and Anna Partyka found that SNP in the BTLA rs1982809 was an increased risk factor for chronic lymphocytic leukemia (CLL) and renal cell carcinoma (RCC) in the Polish people.,19 Tang et al. reported that rs1982809 polymorphism was proved to be correlated with Esophagogastric junction adenocarcinoma (EGJA) in smoking patients. This SNP is not associated with Esophageal squamous cell carcinoma (ESCC) in Chinese in the study of Cao et al., and the latest study in Tunisia showed that BTLA rs1982809 might cause lung cancer (LC). However, Wang et al. found that rs1982809 polymorphism reduced the risk of LC. Based on the above, we conducted a meta-analysis to comprehensively assess the relationship between BTLA rs1982809 polymorphism and tumor susceptibility.The BTLA gene, composed of 5 exons, is located on the q13.2 region of chromosome 3All data of this study were rooted in published literature and did not involve patients directly. Hence, we do not need the approval and informed consent of the ethics committee.https://doi.org/10.37766/inplasy2021.3.0023).The protocol for this systematic review was registered on INPLASY (202130023) and is available in full on inplasy.com  by 2 independent investigators. The keywords we utilized were: “B and T lymphocyte attenuator or BTLA or LOC112268446 or rs1982809 or rs386551325 or rs60386396” and “neoplasm or tumor or cancer or carcinoma” and “polymorphism or SNP or allele or variation”. There are no language restrictions on the search for articles. The search deadline is January 2021.Researches were filtrated based on the inclusion criteria:(a) the studies investigated the connection between BTLA rs1982809 polymorphism and tumor risks; (b) the studies were case-control studies, tumor patients were included in the case group and healthy people were included in the control group; (c) the studies provided detailed genotype frequencies. Exclusion criteria:(a) non-human trials; (b) duplicate articles. Inconsistencies between the 2 researchers were discussed with a third till a consensus was reached.P-value of the HWE test for the control groups, were extracted by 2 independent researchers from each eligible publication. Each item was researched by consensus by 2 reviewers.The data, including first author, publication year, country, ethnicity, cancer types, control source, genotype frequencies of the case and controls, and a Both researchers assessed the quality of the included experiments based on the Newcastle–Ottawa Scale (NOS). The case-control trials were scored on 3 dimensions: selection, comparability, and exposure, with a total score of 9. A score of 5–9 was considered high quality, while a score of 0–4 was considered low quality. In case of disagreement between 2 investigators, discussion with a third party was required until an agreement was reached between the 3 parties.P > .05. ORs were merged via the random or fixed-effects model, and the selection of models depends on the heterogeneity of studies. We used the Q and I² tests to evaluate the heterogeneity of genetic models. The random-effects model was applied when heterogeneity exists in available studies ; oppositely, the fixed-effects model was utilized. Sensitivity analysis was applied to evaluate the stability of the results via the leave-one-out method. Begg’s test was utilized for evaluating the publication bias of 5 genetic models; statistical significance was hypothesized at P < .05. Subgroup analysis based on the ethnicity, cancer type, and control source was conducted.All statistical analyses included in our study were enforced by the STATA 12.0. Pooled ORs and 95% CI were utilized to assess the relation between BTLA rs1982809 polymorphism and tumor susceptibility in the dominant, recessive, homozygous, and heterozygous additive models. We used the χ² test to measure the HWE for each study; the standard for which studies conformed to HWE is 158 records were retrieved based on the primal search strategy. A total of 56 duplicated records were excluded, 96 articles were excluded by reading titles and abstracts. We read the full text of the remaining articles. Finally, 6 studies were identified to explore the relationship between the BTLA rs1982809 polymorphism and tumor risk. Figure The quality assessment results are shown in Table = 1.11, 95% CI = 1.04–1.19, Pheterogeneity = .096). Figures The connection between BTLA rs1982809 polymorphism and tumor susceptibility was evaluated in 6 case-control studies, including 3678 cases and 4866 controls. And all the results can be seen in Table = 1.46, 95% CI = 1.19–1.80, Pheterogeneity= .592; AG vs AA: OR = 1.47, 95% CI = 1.19–1.82, Pheterogeneity= .536; G vs A: OR = 1.32, 95% CI = 1.12–1.55, Pheterogeneity= .745). For Asians, no correlation between rs1982809 polymorphism and tumor was shown in the 5 genetic models.Ethnicity-based subgroup analysis was performed and revealed that the risk of cancer in Caucasians was increased in 3 genetic models  and other cancers (including RCC and CLL) were associated with rs1982809 polymorphism, but esophageal neoplasms  were not.Subgroup analysis based on cancer-type showed that lung cancer ; However, studies using SNPscan did not yield positive results.Different outcomes were shown in different studies using different genotyping methods. Studies using TaqMan showed rs1982809 polymorphism was associated with tumor susceptibility , but not in the hospital-based studies.As for control source, we found that rs1982809 polymorphism was associated with tumor susceptibility in the population-based studies  in the study of Chen et al., and potential clinical value showed in the combined application of chemotherapy and anti-BTLA antibody for the therapy of EOC patients. Liu et al. found that BTLA/HVEM might serve as an attractive target for hepatocellular carcinoma immunotherapy. However, some research showed diverse outcomes, a study showed that BTLA is an underlying factor for prolonged survival in colorectal cancer (CRC). To sum up, BTLA may be a new and powerful immunotherapy target after PD-1 and CTLA-4. Therefore, studies of BTLA gene polymorphism are of great significance to further prove that BTLA is a potential target for immunotherapy.BTLA will take a particular place in immunotherapy for tumors according to robust evidence offered by a sufficient number of studies. The overexpression of BTLA and HVEM is concerned with the progression and adverse outcomes of gastric cancer by Lan X et al., and BTLA/HVEM pathway is deemed to be a potential treatment option for gastric cancer.However, our research also has some limitations. First, the lack of data in this study led to an inability to analyze some clinical factors, including age, gender, living conditions, and biochemical characteristics. Second, the sub-group analysis did not include the black human race.All in all, our study is significantly meaningful, we found that rs1982809 polymorphism in BTLA may be a risk factor for cancer, especially in Caucasians, and this SNP might contribute to lung cancer. However, well-designed studies with larger sample sizes and multicenter are required to further probe the connection between the SNP of rs1982809 and cancer susceptibility.Study design/planning: Yingliang Li, Jian Chen.Data collection/entry: Jian Chen, Jun Wang, Ruihao Liu.Data analysis/statistics: Jian Chen, Xuan Liu, Mingjun Shang.Data interpretation: Yingliang Li, Jian Chen, Qiang Li.Preparation of manuscript: Yingliang Li, Jian Chen, Yingying Liu, Mingzhi Zha.Literature analysis/search: Jian Chen, Jun Wang, Ruihao Liu.Founds collection: Yingliang Li.


The current study is aimed at updating the observational studies on the relationship between threatened abortion and the risk of ASD. I2 statistic to show the heterogeneity among articles. I2 more than 50% was considered high heterogeneity. Egger's and Begg's line regression tests were used for evaluating the publication bias. The random-effects model was applied for the analysis of the findings. The Stata 13.0 software package was applied for analysis and indicated p value less than 0.05 as a significant level.  The search keywords were covered in three electronic databases PubMed, Web of Science, and Scopus up to April 2022. The modified Newcastle–Ottawa scale (NOS) was applied to detect the quality of epidemiological studies. We used the chi-square test and the I2 = 59.5.0%) and in crude studies . The evidence of publication bias was not found.  The pooled analysis reported significant differences between threatened abortion and the risk of ASD in adjusted studies (OR = 1.93; 95% CI: 1.12, 2.73;  The findings suggest that threatened abortion is a risk factor for ASD. As a result, screening tools to detect are necessary in mothers facing a threatened abortion. Autism spectrum disorders (ASD) are an evolutionary neurological disease severely limiting social activity. This condition is becoming more common around the world . These pThe correlation between behavioral and psychiatric assessments and diagnosis and genetic assessments are discussed, along with psychiatric treatment and drug approaches for selecting a medication for treating challenging behaviors or common comorbidities in ASD. Treatment varies depending on the patient's diagnosis, severity, cause, and comorbidities .Preliminary studies recommend ASD screening in children aged 18 to 30 months with the nonsuspected disorder.On the other hand, early behavioral intervention based on functional behavior analysis appears to improve cognitive, language, and adaptive skills . This diSome studies have found a link between the threat of abortion and the risk of ASD. Threatened abortion has been linked to an increased risk of ASD . HoweverWang et al. conducted a meta-analysis study in 2017. They discovered that threatened abortion is a risk factor for autism . HoweverOur meta-analysis was performed based on the PRISMA statement.Population: pregnant womenIntervention: threatened abortionComparison: without threatened abortionOutcome: risk of ASD among childrenThe epidemiological studies were included in the present meta-analysis. Examining the association between threatened abortion and the risk of ASD among children was conducted based on the PICO model:The exposure variable and outcome of interest were threatened abortion and ASD, respectively. No language, age, race, publication date, and nationality restrictions were applied. The exclusion studies were meta-analyses and review articles, case reports, experimental articles, and letters to Editor.The search keywords were covered in three electronic databases PubMed, Web of Science, and Scopus up to April 25, 2022  , and any disagreement between the two authors was solved by the supervisor (F.E). Then, full articles that met the inclusion criteria were synthesized.Data extracted from full articles were inserted in the sheet in the Stata software. The data titles were first author, year of article publication, location, study's design, population, controlling for confounding variables, child age, and ASD diagnostic criteria.The modified Newcastle–Ottawa scale (NOS) was applied to detect the quality of epidemiological studies . The NOSI2 statistic [I2 of more than 50% was considered high heterogeneity [We used the chi-square test  and the tatistic  to show ogeneity . Egger'sogeneity  line regp value less than 0.05 as a significant level.All findings were considered dichotomous variables (threatened abortion and ASD children). Therefore, they were expressed as the odds ratio (OR) with 95% confidence intervals (95% CIs). The random-effects model was applied for the analysis of the findings . The StaIn total, 401 publications were included until April 25, 2022. Due to duplicate records, 15 were removed. Of these, 368 studies were eliminated after the screening stage (title and abstract reviewing). Eighteen records were included for the last screening (reading the full papers), four of which were deemed ineligible. Finally, 12 studies were included in the present meta-analysis. We identified three cohort studies , 20, sevAmong the included studies, one outlier article was not included in the current meta-analysis because it reported threatened abortion as a protective factor for ASD  .I2 = 59.5.0%) and in crude studies   .p values for Begg's and Egger's regression were 0.891 and 0.323, respectively. The evidence of publication bias was not found (Begg's and Egger's methods were used to detect publication bias. ot found .According to the NOS, six studies were of high quality, while eight were of low quality .The current meta-analysis was based on observational studies examining the association between threatened abortion and the risk of ASD. According to our findings, threatened abortion is a risk factor for ASD.ASD is one of the reasons for mental retardation in children worldwide. Investigating potential factors may be effective in preventive measures. This association between threatened abortion and the risk of ASD is described by the issue that threatened abortion is related to many developmental disorders in children. It is most likely to be caused by factors such as genetic defects in the fetus, maternal reproductive environment, maternal exposure to toxic, harmful substances, and physical and mental trauma . HoweverFetal hypoxia may be at the root of a possible link between threatened abortion due to bleeding and ASD. It has also been reported that hypoxia following a threatened abortion increases dopaminergic activity. Therefore, there is evidence of dopamine overactivation in ASD children . HoweverWang et al. conducted a systematic review of the relationship between prenatal, perinatal, and postnatal factors with autism in 2017 . ThreateOne outlier study  was not Some limitations cannot be controlled by the authors. The majority of the studies were of low quality and had not been adjusted for confounding variables. Also, we must consider the possibility that the missing data from the gray literature will affect the overall effect estimates.According to the current meta-analysis, which included 394,675 participants, threatened abortion is a risk factor for autism spectrum disorders in children. In addition, evidence of publication bias was not found.The findings suggest that threatened abortion is a risk factor for ASD. As a result, screening tools to detect are necessary in mothers facing a threatened abortion.