The risk of thyroid malignancy assessment may include certain ultrasound features. The analysis is lacking for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). Our meta-analysis aimed to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. Based on twenty studies describing sonographic features of 10,215 nodules, we found that the most crucial feature associated with an increased risk of FTC were tumor protrusion (odds ratios—OR = 10.19), microcalcifications or mixed type of calcifications: 6.09, irregular margins: 5.11, marked hypoechogenicity: 4.59, and irregular shape: 3.6.Certain ultrasound features are associated with an increased risk of thyroid malignancy. However, they were studied mainly in papillary thyroid cancers (PTCs); these results cannot be simply extrapolated for the differentiation of follicular thyroid adenomas and cancers (FTAs and FTCs). The aim of our study was to perform a meta-analysis to identify sonographic features suggesting malignancy in the case of follicular lesions, potentially differentiating FTA and FTC. We searched thirteen databases from January 2006 to December 2020 to find all relevant, full-text journal articles written in English. Analyses assessed the accuracy of malignancy detection in case of follicular lesions, potentially differentiating FTA and FTC included the odds ratio (OR), sensitivity, specificity, positive and negative predictive values. A random-effects model was used to summarize collected data. Twenty studies describing sonographic features of 10,215 nodules met the inclusion criteria. The highest overall ORs to increase the risk of malignancy were calculated for tumor protrusion , microcalcifications or mixed type of calcifications : 6.09 (3.22–11.50), irregular margins: 5.11 (2.90–8.99), marked hypoechogenicity: 4.59 (3.23–6.54), and irregular shape: 3.6 (1.19–10.92). The most crucial feature associated with an increased risk of FTC is capsule protrusion, followed by the presence of calcifications, irrespectively of their type. Ultrasound-guided fine-needle aspiration biopsy (FNAB) is a widely used procedure and a gold standard for the evaluation of thyroid nodules . HoweverDespite increasing accessibility of novel imaging methods, e.g., positron emission tomography with computed tomography, they were not demonstrated to result in a dramatic reduction of unnecessary thyroidectomies performed among patients with FNAB Bethesda IV category. Another option is the identification of particular genetic markers obtained from cytological material . HoweverAfter a complete systematic review was performed, 20 studies met the inclusion criteria. They covered analyses of 10,215 nodules. The search results and steps of selection are shown in the flowchart . The oveSpecificity to predict FTC for individual features varied from 18% to 100%, and the sensitivity ranged from 3% to 93%. Negative predictive value (NPV) was 64% to 90%, and positive predictive value (PPV) was 28% to 96% . All tabThe highest overall odds ratio in increasing the risk of malignancy was calculated for tumor protrusion odds ratio (OR) ) = 10.19 (2.62–39.71), microcalcifications or mix type of calcifications : 6.09 (3.22–11.50), irregular margins: 5.11 (2.90–8.99), marked hypoechogenicity: 4.59 (3.23–6.54), and irregular shape: 3.60 (1.19–10.92). The lowest OR was characteristic for a Doppler pattern of three or more: 1.44 (0.76–2.74).The highest overall sensitivity with its 95% CI was 93% (87–97%) for solid or mainly solid structure, and the lowest was for taller than wide size: 3% (0–10%). The highest specificity was 100% (99–100%) for tumor protrusion, and the lowest was for solid or mainly solid structure: 18% (6–31%). Accordingly, the highest PPV was 96% (70–100%) for tumor protrusion; the lowest was for solid or mainly solid structure 28% (20–37%) and for a Doppler pattern of three or more 28% (10–51%). Furthermore, the highest NPV was 90% (81–96%) for solid or mainly solid structure, and the lowest was for tumor protrusion: 64% (61–68%). I2 = 0.0%, p = 0.4350. The specificity (95% CI) of this feature reached 1.00 (0.99–1.00) with low sensitivity (95% CI) of 0.06 (0.03–0.09).Patients finally diagnosed with FTC were more than 10 times more likely to have a tumor protrusion —OR 95% . The anaI2 = 0%, p-value = 0.5494) and publication bias was not reported . Summary OR, presented as an overall OR (95% CI) = 6.09 (3.22–11.50), meaning that cancer patients are more than six times more likely to have a positive microcalcifications or mixed type  than those with adenoma. There was relatively low overall sensitivity (95% CI) = 0.10 (0.03–0.19) and overall PPV (95% CI) = 0.53 (0.19–0.86) but quite high overall specificity (95% CI) = 0.97 (0.95–0.99) and overall NPV (95% CI) = 0.78 (0.69–0.88). Overall sensitivity and specificity determined jointly in the hierarchical summary receiver operating characteristic (HSROC) model was similar and amounted to overall sensitivity (95% CI) = 0.1 (0.04–0.21), overall specificity (95% CI) = 0.98 (0.95–0.99).The analysis of microcalcifications or mixed type  was based on nine publications covering 1199 patients . No recep-value = 0.0980). Strong study heterogeneity was detected (I2 = 75.3%. p < 0.0001) which resolved after excluding four outlier studies. As a result, outliers were identified based on sensitivity analysis and funnel plot inspection. After removal of the outlier, the group was more homogeneous  and based on 1227 patients. Originally overall OR (95% CI) was 3.49 (1.66–7.35) and after exclusion of the indicated study, the summary OR increased to the value of overall OR (95% CI) = 5.11 (2.90–8.99). Overall sensitivity (95% CI) was quite low = 0.24 (0.13–0.37) and overall NPV (95% CI) = 0.80 (0.74–0.86) and overall specificity (95% CI) was high = 0.94 (0.90–0.96) and overall PPV (95% CI) was = 0.53 (0.34–0.71). High specificity and quite low sensitivity were also confirmed by the HSROC curve analysis: overall specificity (95% CI) = 0.94 (0.89–0.96), HSROC overall sensitivity (95% CI) = 0.24 (0.15–0.37).For irregular margins, initially, the analysis covered 14 papers and a total of 1721 patients . Studiesp-value = 0.2811). Strong study heterogeneity was detected  which resolved after excluding two outlier studies. As a result, outliers were identified based on sensitivity analysis and funnel plot inspection. After removal of the outlier, the group was more homogeneous  and based on 1610 patients. Originally overall OR (95% CI) was 3.69 (2.30–5.92) and after exclusion of the indicated study, the summary OR increased slightly to the value of overall OR (95% CI) = 4.59 (3.23–6.54). High overall sensitivity (95% CI) = 0.74 (0.60–0.86) and overall NPV (95% CI) = 0.87 (0.81–0.92) and quite high overall specificity (95% CI) = 0.63 (0.53–0.73) and overall PPV (95% CI) = 0.44 (0.35–0.53). High sensitivity and specificity values were also confirmed by the HSROC curve analysis: overall sensitivity (95% CI) = 0.74 (0.62–0.84), HSROC overall specificity (95% CI) = 0.63 (0.53–0.73).For hypo- and markedly hypoechogenic structure, initially, the analysis covered 16 papers and a total of 1864 patients . StudiesThe incidence of differentiated thyroid cancer (DTC) has risen considerably over the past few decades. It is attributed mostly to the increasing rate of PTC, which constitutes the primary histological type of thyroid cancer . The exaThe issue of sonographic features of malignancy has been covered in a few large meta-analyses. Brito et al., in their meta-analysis covering 31 studies including 18,288 focal lesions, indicated that the best predictor of malignancy was the shape of the lesion; “taller than wide” lesions were 11 times more likely to be diagnosed with thyroid cancer than those oval or round. The second important ultrasound feature that was most strongly associated with malignancy risk was the presence of microcalcifications (OR = 6.8) . The sizOur meta-analysis demonstrated that the sonographic feature the most strongly increasing the risk of FTC, but not underlined in the previous studies, was capsule protrusion. Although only two studies took into account this feature, it turned out to be the substantial differentiating factor between FTA and FTC, with an OR at the level of 10.19 ,32. CapsMany studies have identified the presence of calcifications as malignancy predictors. While microcalcifications are one of the features significantly associated with the diagnosis of PTC, our results demonstrated that malignancy of follicular lesion might be suggested by the presence of not only microcalcifications but also mixed calcifications of a different type. In our meta-analysis, the presence of entirely macrocalcifications (>1 mm) was associated with a moderate risk of FTC with ORs between 2–3. Quite similar results were obtained by Kunt et al., where authors aimed to identify the risk factors of malignancy in a group of nodules preoperatively diagnosed as suspicion of FTC, and intranodular calcifications increased by about three times the relative risk of malignancy when present . The diaAnother essential feature confirmed to be associated with FTC risk was a solid character of a lesion as well as heterogeneous and hypoechogenic echostructure. Hypoechogenicity was the most frequent ultrasound feature, occurring in 82% of FTCs reported by Sillery et al. . In anotIrregular (microlobulated or spiculated) margins  increaseThe characteristic “taller than wide” shape of a lesion, so strongly associated with malignancy rate if PTCs are concerned, does not seem to play an important role in the case of FTCs. Our results demonstrated that OR for this feature was equal to 2.81. In another study by Chng et al., evaluating lesions diagnosed as follicular neoplasm on cytology and taller than wide morphology was not very frequent in FTCs (17.1%) but occurred rarer in FTAs (0.9%) . In the An OR between 2–3 was yielded for lack of halo or presence of thick halo and solitary lesions. Our conclusions about the halo sign are consistent with the risk factors for thyroid malignancy in general. Recent European Thyroid Association Guidelines indicate that a thin halo decreases the malignancy risk by about three-times (OR = 0.3), while thick or lack of halo increase the malignancy risk, with ORs equal to 3.4 and 7.1, respectively ,40,44. HLess important feature suggesting the malignant character of follicular lesions in our meta-analysis was size > 4 cm. The median volume of FTC (11.75 mL) was larger than FTA (5.95 mL) in the study by Sillery et al. . PreviouOne of the less useful features of FTCs in our meta-analysis was the presence of central vascularization. The vascularization pattern on the Color Doppler examination was not a helpful feature in the differentiation of FTC and FTA by Sillery et al. . In anotOnce sonoelastography was introduced to thyroid diagnostics, it raised hopes that it would be of value in presurgical and non-invasive differentiation of follicular lesions. Fukunari et al. analyzed 56 follicular lesions. Out of 51 FTAs, 48 (94.1%) presented with normal elasticity, while all FTCs demonstrated a characteristic pattern of elasticity, corresponding with an elastic central part and a stiff peripheral region. The authors concluded that sonoelastography might reflect the differences in the histopathological structure of follicular lesions and might be helpful in differentiation between benign and malignant follicular lesions. Another communication from this research group resulted in the conclusion that over 70% of FTCs present with such a sonoelastographic pattern . HoweverThe most crucial feature associated with an increased risk of FTC is capsule protrusion, followed by the presence of calcifications, irrespectively of their type. The most important ultrasound malignancy risk factors for PTC were rather taller than wide , which was only the tenth feature in our analysis for FTC with an OR = 2.52. However, microcalcifications and irregular margins seem to be common malignancy ultrasound features both for FTC and PTC ,50.Currently, due to the inconsistency of ultrasound terminology and to enable easier risk of malignancy determination for thyroid nodules ultrasound assessment, there are many risk stratification models comprising conventional ultrasound and elastography characteristics. They enable a better combined evaluation of thyroid nodules and are considered an important step in endocrinology ,53,54,55We carried out the meta-analysis following the guidelines formulated in the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . We searWe included studies, regardless of their sample size, with the investigation of the association between one or more ultrasound feature and the risk of follicular thyroid malignancy, which did not have any restriction criteria for the inclusion of detected nodules in the study, such as nodule size or thyroid-stimulating hormone (TSH) levels . We consThe search strategy included Medical Subject Headings terms and keywords: “thyroid and (“follicular cancer” or “follicular carcinoma” or “follicular neoplasm” or “follicular adenoma” or “follicular nodule”) and (ultrasound or ultrasonography or elastography or “color doppler” or “power doppler”)”. Reference lists of all the selected articles, previous meta-analyses, and reviews were hand-searched for any additional articles.Two authors (M.B. and E.J.S.) independently selected papers, which fulfilled the inclusion criteria and extracted data for the outcomes using a standardized data extraction form. Relevant data included articles assessing echogenicity, calcifications, presence of a “halo”, size, shape, protrusion, margins, Doppler pattern, solitarity, and structure of nodules. Another author (E.S.P.) rechecked the extracted data.The risk of bias in the included studies was independently assessed by two authors , sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). A random-effects model described by DerSimonian and Laird was used to summarize collected data.I2 statistics. The publication bias was explored by visual inspection of funnel plots, and asymmetry was tested formally with Egger’s regression test [I2 > 50% and p < 0.05), outlying studies were identified. The meta-analysis was repeated to confirm the obtained results, excluding outliers and the overall OR, and the heterogeneity test results were given again. In the event of a zero outcome, continuity correction was performed by adding a correction factor of 0.5.In the first stage, we calculated ORs and assessed studies’ heterogeneity and publication bias. Statistical heterogeneity between the studies was examined using Cochrane’s Q statistics and ion test ,61. FurtIn the second stage, after outliers exclusion, based on the number of true positive (TP), true negative (TN), false positive (FP), and false negative (FN) results univariates of sensitivity, specificity, Negative Predictive Value (NPV), and Positive Predictive Value (PPV) with 95% confidence intervals were estimated using the exact binomial Clopper-Pearson method. In the meta-analysis, the pooled estimation was calculated after Freeman-Tukey Double Arcsine Transformation to stabilize the variances . Additiop = 0.05 was assumed in all analyzes. The analysis of the odds ratio was carried out in the PQStat v1.6.6 program, while the results regarding sensitivity, specificity, PPV, and NPV were obtained in the Stata v14 package, using the metaprop and metandi functions.The significance level In conclusion, sonographic features associated with the malignancy of follicular lesions are distinct from those widely reported for all thyroid cancers, of which the predominant histological type is PTC. The most crucial feature associated with an increased risk of FTC is capsule protrusion, followed by the presence of calcifications, irrespective of their type. Less specific but more frequent are the irregular shape of the lesion, solid character of the lesion, and hypoechogenicity. On the other hand, a high probability of a diagnosis of FTA is suggested by an oval or round shape of the lesion and the presence of a cystic component. Less specific features suggesting benign lesions are a lack of calcifications and a visible halo.


Background Oxidative stress is considered to be involved in the pathogenesis of coronary heart disease (CHD). Glutathione-S-transferase (GST) enzymes play important roles in antioxidant defenses and may influence CHD risk. The present meta-analysis was performed to investigate the link between glutathione S-transferase M1 (GSTM1) null genotype and CHD and to get a precise evaluation of interaction between GSTM1 null genotype and smoking by the case-only design.Methods PubMed and EMBASE databases were searched through 15 December 2020 to retrieve articles. Odds ratios (ORs) were pooled using either fixed-effects or random-effects models.Results Thirty-seven studies showed that GSTM1 null genotype was associated with risk of CHD in total population, Caucasians and Asians : 1.15, 1.65; for Caucasians, OR = 1.34, 95% CI: 1.04, 1.72; for Asians, OR = 1.40, 95% CI: 1.11, 1.77). After adjustment for heterogeneity, these relationships were still significant. After adjustment for heterogeneity, case-only analysis of 11 studies showed a positive multiplicative interaction between GSTM1 null genotype and smoking (ever smoking vs. never smoking) .Conclusions The overall results indicated that GSTM1 null genotype was associated with a higher risk of CHD, and the association may be affected by smoking status. This is the first meta-analysis to prove a positive effect of the interaction between GSTM1 null genotype and smoking status on the risk of CHD. Well-designed studies are needed to investigate the possible gene–gene or gene–environment interactions. Coronary heart disease (CHD) is the leading cause of mortality and a major cause of morbidity and disability all over the world ,2. CHD iThere is compelling evidence that cigarette smoking is one of the strong risk factors for CHD. Multiple chemicals in cigarette smoke can cause endothelial dysfunction, smooth muscle cell proliferation, generation of reactive oxygen species (ROS) and DNA damage, which can lead to atherosclerosis and, hence, CHD . HoweverThe glutathione S-transferases (GSTs) are an important family of phase II isoenzymes which can detoxify electrophilic compounds generated by smoking, including toxins, DNA adducts, and carcinogens, mainly by changing them to harmless products through conjugation to glutathione ,8. In adGSTM1) gene, which is mapped to chromosome 1p13.3. Three alleles of the GSTM1 locus have been identified: GSTM1 null and two others (GSTM1a and GSTM1b) that differ by C→G substitution at base position 534. The C→G substitution leads to the substitution Lys→Asn at amino acid 172 [GSTM1 locus have been associated with no enzymatic functional activity and increased vulnerability to cytogenetic damage [Human cytosolic GST enzymes which comprise multiple isoenzymes are divided into eight separate classes: GSTM (mu), GSTP (pi), GSTT (theta), GSTA , GSTK (kappa), GSTO (omega), GSTS (sigma), and GSTZ (zeta) . The Mu acid 172 . Personsc damage ,13, and c damage .GSTM1 genetic polymorphism and risk of CHD. However, results have been inconsistent [GSTM1 null genotype and smoking is unclear. To our knowledge, two previous meta-analyses [GSTM1 null genotype and CHD risk have yielded contradictory findings. One previous meta-analysis [GSTM1 null genotype may be an independent risk factor for CHD and the other meta-analysis [GSTM1 null genotype and CHD risk. To help clarify the inconsistent findings, we conducted a meta-analysis to investigate the association between polymorphism of GSTM1 and CHD risk. Furthermore, we performed a case-only design to get a more precise evaluation of interaction between GSTM1 null genotype and smoking on CHD risk.Our previous meta-analysis have proved that the null genotype of GSTT1 was associated with an increased risk of CHD . Indeed,nsistent , and theanalyses ,52 invesanalysis  reportedGSTM1 genotype (null genotype vs. wildtype) and the risk of CHD. The terms used for searching included glutathione S-transferase, GST, GSTM1; gene, polymorphism; and coronary heart disease, CHD, myocardial infarction, MI, coronary artery disease, CAD, ischemic heart disease. References cited in retrieved articles and published review articles were also screened to identify additional publications. If there were several publications from the same study, we selected the most complete or most recent publication for meta-analyses. To minimize potential publication bias, studies without any special restriction were included.We searched electronic databases, including PubMed and Embase, for all articles published through 15 December 2020, which had investigated the association between GSTM1; (ii) presenting original data for the calculation of odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs); (iii) clear definition of CHD. The exclusion criteria were: (i) case-only studies, animal studies, simply commentaries, case reports and review articles; (ii) studies with other genotypes of GST or other disease.The inclusion criteria were: (i) studies with case–control design examining the association between CHD risk and polymorphism of Characteristics abstracted from the articles included the name of the first author, year of publication, country, ethnicity, genotyping method, control source, number of cases, number of controls, cases null, controls null, Hardy–Weinberg equilibrium , and adjustment covariates. When specific results were not reported, we used available tabular data to calculate them. When data were unavailable, we contacted the corresponding author by email for additional information. Different ethnicities were categorized as Caucasian, Asian, and Mixed. The bibliographic search, data extraction, and quality assessment were conducted independently by two authors, and any disagreements were resolved by consensus with a third investigator.We assessed quality of included studies based on Newcastle–Ottawa Scale (NOS) . The NOSGSTM1 null genotype and risk of CHD. Cochran's χ2 based Q-statistic test and 2I test were performed to precisely assess possible heterogeneity, which quantified between-study heterogeneity irrespective of the number of studies [P<0.1 (Cochran's χ2 based Q-statistic test), a random-effects model (DerSimonian–Laird method) [2I value less than 50% was considered to indicate low heterogeneity [Based on the genotype frequencies, crude ORs corresponding to 95% CI were calculated to measure the association between  studies . If hete method)  was used method)  was cond method) ,58. An Iogeneity . The metogeneity . The intogeneity . The outogeneity .GSTM1 null genotype and smoking (ever smoking vs. never smoking) on CHD risk, we also performed a case-only design in present meta-analyses [To investigate the multiplicative interaction between analyses ,64. All In total, 37 studies from 35 articles matching the search terms, comprising 16684 cases and 36510 controls, were retrieved from databases. A flow chart describing the exclusion/inclusion of individual articles has been presented as GSTM1 null polymorphism. Heterogeneity between studies was suggested , thus the random-effects model was used to pool data. The results indicated that the GSTM1 null genotype was significantly associated with CHD  . Besides, sensitivity analyses which yielded a range of ORs from 1.28  to 1.40  suggested that the results of this meta-analysis are stable. For meta-analysis of total studies, fifteen studies were spotted by Galbraith plot as possible major sources of heterogeneity [2I = 40.2%; P=0.027), and meta-analysis showed GSTM1 null genotype was also associated with increased risk of CHD    . For meta-analysis of Asian studies, four studies were spotted by Galbraith plot as possible major sources of heterogeneity [2I = 44.2%, P=0.073). Subgroup analysis by source of controls yield an OR of 1.47  and 1.33  resulted for null genotype, among hospital-based controls and healthy controls, respectively    . There w P=0.499 . The metogeneity ,41,43,505, 1.31) . By straP<0.001)  and 1.40P<0.001)  resultedogeneity ,30,46,50ectively . Stratifectively . Among sP<0.001) . Among nP<0.001) .2I = 83.3%; P<0.001), and thus the random-effects model yielded an OR of 2.16  (P=0.735) and Egger's test (P=0.808) showed no publication bias. After the exclusion of 4 studies [2I = 10.9%; P=0.324). Thus, the fixed-effects model was used to pool the ORs, and the result was not substantially changed . We performed a sensitivity analysis by omitting one study at a time, which yielded a range of ORs from 1.95  to 2.04 .There are 22 studies ,44–46,497, 2.62) . The Beg studies ,27,32 spGSTM1 null genotype and smoking status (ever smoking vs. never smoking) . After omitting one study [GSTM1 null genotype and smoking on CHD risk was also statistically significant   .GSTM1 genetic polymorphism with risk of CHD. Moreover, to our knowledge, this is the first case-only designed analysis to prove a positive effect of the interaction between GSTM1 null genotype and smoking on CHD risk.The current meta-analysis provided a comprehensive evaluation of the association between Two previous meta-analyses were performed to evaluated the association between GSTM1 genetic polymorphism with risk of CHD.The first one, performed in 2010 by Wang et al. , include2I values surpassed the threshold of 50% in the present meta-analyses, indicating the presence of heterogeneity and insufficient power [GSTM1 null genotype still increased risk of CHD in total population, Caucasians and Asians, respectively  between smoking status and the nce, CHD ,4,6. Anince, CHD ,68. Morence, CHD . Componence, CHD  and DNA nce, CHD . Oxidatince, CHD ,72. A hoThis meta-analysis had several limitations. First, the eligibility criteria for inclusion of controls were different. Some studies selected healthy individuals as controls, while the controls in other studies were selected from non-CHD individuals. Thus, selection bias might exist. Second, this meta-analyses were based on unadjusted estimates because many studies did not provide adjusted data. Third, some of these studies had relatively small sample sizes, which decreased their statistical power. Fourth, a possible publication bias may exist because only published studies were included, though there was no evidence of publication bias by visual examination of Begg's funnel plot or test results from Egger's test.GSTM1 null genotype seems to be a risk factor for CHD. And the association may be affected by smoking status. The interaction between the GSTM1 null genotype and smoking status on CHD risk suggests that smoking is more detrimental to persons who carry the GSTM1 null genotype. Well-designed, population-based studies of adequate size are needed to investigate the possible gene–gene or gene–environmentinteractions in the association between gene polymorphisms and CHD risk.In conclusion, the present study showed that Click here for additional data file.


Background: Cerebral palsy (CP) is a syndrome of non-progressive motor dysfunction caused by early brain development injury. Recent evidence has shown that immunological abnormalities are associated with an increased risk of CP.Methods: We recruited 782 children with CP as the case group and 770 healthy children as the control group. The association between IL-23R single nucleotide polymorphisms  and CP was studied by using a case–control method and SHEsis online software. Subgroup analysis based on complications and clinical subtypes was also carried out.Results: There were differences in the allele and genotype frequencies between CP cases and controls at the rs11805303 and rs10889677 SNPs , and the difference in genotype frequency of rs10889677 remained significant after Bonferroni correction (Pgenotype = 0.048). Subgroup analysis revealed a more significant association of rs10889677 with CP accompanied by global developmental delay (Pgenotype = 0.024 after correction) and neonatal encephalopathy (Pgenotype = 0.024 after correction).Conclusion: The present results showed a significant association between IL-23R and CP, suggesting that IL-23R may play a potential role in CP pathogenesis. Cerebral palsy (CP) is a central motor disorder syndrome that manifests with abnormal muscle tension and motor function , low birth weight (LOW), and pathogenic jaundice , also known as p19, is a member of the IL-12 heterodimer cytokine family . Drugs targeting IL-23 have been used in clinical research regarding immunologic diseases  through its N-terminal immunoglobulin domain, which activates downstream signaling pathways and exerts biological functions. Human IL-23 receptors (IL-23R) are mainly expressed in activated memory T cells, natural killer (NK) cells, and intrinsic immune cells (ILCs). Its extracellular domain contains a signal sequence, one N-terminal Ig-like domain, and two cytokine receptor domains. In a genome-wide association study in 2006, IL-23R was significantly associated with Crohn's disease, an inflammatory bowel disease. The A allele of rs11209026, a low-frequency IL-23R variant, was negatively correlated with Crohn's disease  and 240 females (30.7%), and the mean age was 18.5 ± 15.4 months. The control group comprised 771 healthy children, including 515 males (66.8%) and 256 females (33.2%), and the mean age was 19.3 ± 16.8 months .In the case group, we excluded children diagnosed with congenital metabolic diseases and myopathy as well as children with a family history of nervous system diseases. Pediatric rehabilitation specialists confirmed the CP diagnosis using standard criteria related to non-progressive disorders of movement control and posture , perinatal asphyxia, and threatened premature labor], CP complications [such as global developmental delay (GDD)], and neonatal complications (such as HIE).GDD diagnosis is limited to individuals under the age of 5 years old when the clinical severity level cannot be reliably assessed during early childhood. GDD is diagnosed when an individual fails to meet the expected developmental milestones in several areas of intellectual functioning and applies to individuals who are unable to undergo systematic assessments of intellectual functioning, including children who are too young to participate in standardized testing. Neonatal encephalopathy (NE) is a clinical syndrome that includes HIE, intracranial hemorrhage, various metabolic disorders, neurodegenerative diseases, and so on; its diagnosis requires at least two senior neonatologists.IL-23R, a minor allele frequency (MAF) >0.1, and potential function, we selected seven SNPs  location in http://analysis.bio-x.cn/) that can test Hardy–Weinberg equilibrium (HWE) and linkage disequilibrium (LD) and calculate allele frequencies, genotype frequencies, and haplotype frequencies for each SNP locus in the case group and control group. The P values were two-tailed, and we considered P < 0.05 to be significant. We also calculated the odds ratio (OR) and its 95% confidence interval (CI). We employed the Bonferroni correction to account for multiple testing on each individual SNP and haplotype. We used the G*power 3.1 software to evaluate the statistical efficacy.We performed statistical analysis with SHEsis, an online program (P = 0.011); therefore, we only analyzed the remaining six SNPs, namely, rs10889657, rs6682925, rs1884444, rs1004819, rs11805303, and rs10889677. There were two linked LD blocks with coefficient D′ value more than 0.8  when using an effect size index of 0.1. The genotype distributions of rs17375018 among control subjects showed a significant deviation from HWE (than 0.8 . Block 1P = 0.014) and rs10889677 (P = 0.048) and the genotype frequencies of rs10889657 (P = 0.028), rs11805303 (P = 0.023), and rs10889677 (P = 0.008) were significantly different between CP patients and controls. After Bonferroni correction, only the rs10889677 AA genotype frequency was significantly more enriched in CP children than in controls   .P = 0.036) and TA (P = 0.013) presented a significant association with CP; the positive association of TA with CP was significant even after Bonferroni correction (P = 0.039). Furthermore, there was a statistically significant global effect of the haplotype (P = 0.039)  .P = 0.024, CP is a highly heterogeneous condition that likely has multiple etiologies. It is reasonable to speculate that the broad clinical spectrum of CP can be at least partially attributed to considerable genetic heterogeneity. Therefore, we conducted subgroup analysis according to clinical phenotypes. There was a significant association of CP + GDD with rs10889657, rs1004819, rs11805303, and rs10889677, and the association of rs10889677 met the Bonferroni correction cut-off for multiple testing  and nephropathy (rs10805303)   (Safrany0805303) .IL-23R rs10889677 increases susceptibility to CP at the overall level and in some subgroups. These findings suggest that IL-23R is a potential susceptibility gene for CP. Furthermore, studies have shown that rs10889677 is related with different diseases in different races, such as Crohn's disease in both Jewish and non-Jewish populations, ankylosing spondylitis in Caucasian patients, Graves' disease in North Americans, and ulcerative colitis in Europeans  Increased inflammatory cytokines promote the release of nitric oxide synthase and free radicals and excitatory amino acids, which have toxic effects on neurons, especially developing brain tissue. (2) They will trigger a systemic inflammatory response that leads to brain damage when undergoing intrauterine infection. (3) Endothelial cell damage can cause thrombosis. Inflammatory factors will activate platelets, lead to their aggregation, activate coagulation factors, and damage white matter neurons. (4) The damage will increase the permeability of the blood–brain barrier, thereby allowing peripheral bacteria and inflammatory factors to enter the brain, aggravating brain damage. (5) They promote the release of prostaglandins and other substances, resulting in pregnancy's advance labor, leading to an increased risk of CP.Given that IL-23R rs10889677 SNP and CP, further functional and replicated studies are necessary to verify the association of IL-23R with CP, which is of great significance to identify the CP etiology and pathogenesis.Our study has some limitations. First, this is a study based on a single gene for susceptibility to CP. Given the genetic heterogeneity and gene–gene interaction involved in the CP etiology, other candidate genes that are part of the IL-23R signaling pathway need to be analyzed together. Second, we were unable to measure IL-23R protein expression in the brains of the subjects in the current study; future studies are encouraged to examine the inflammatory cytokine alteration in the brain. Third, although our study demonstrated an association between the IL-23R and CP was firstly detected in Han Chinese, suggesting that the IL-23R gene has a significant effect on the risk of CP, especially in subjects with GDD or NE. The inflammatory response and cytokine cascade are likely to play a role in the occurrence and development of CP. This result needs to be further validated with well-designed studies with large sample sizes and in other populations. We should also pay attention to the possibility of increased risk of CP if the fetus is found to carry the IL-23R risk genotypes before or after delivery.In summary, a significant association between The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Zhengzhou University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.QX and CZ conceived and designed the study. YX, JS, LX, QS, CG, and DZ recruited subjects and sorted out clinical information. YW and DB performed all of the laboratory work. YW and YF performed all data and statistical analyses. YF drafted the manuscript, and QX, CZ, XW, YW, and YX revised the manuscript critically for important intellectual content. YQ and JS provided data, developed models, reviewed results, and provided guidance on the methods. All authors contributed and critically reviewed the final version of the manuscript. All authors have read and approved the final manuscript.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. The reviewer HB-P declared a past co-authorship with the authors XW and CZ to the handling editor.


P=0.002), CC vs TT  and allelic  models. No strong associations were observed for the OPG SNP G1181C, T245G and G209A with CAD risk. When evaluating the OPG SNP T245G and T950C associations with ischemic stroke, we found the OPG SNP T245G to be significantly associated with increased risk of ischemic stroke among Chinese via recessive  and CC vs AA  models. Our results suggested that the OPG SNP T950C was associated with increased risk of CAD among Asians, and the OPG SNP T245G was associated with enhanced ischemic stroke risk among Chinese.Osteoprotegerin (OPG) is involved in the development of atherosclerosis and cardio-cerebrovascular disease. The goal of this meta-analysis was to evaluate the association of OPG single nucleotide polymorphisms (SNPs) with coronary artery disease (CAD) and ischemic stroke. A total of 15 eligible studies were extracted from electronic databases. Odds ratios (ORs) were presented, with 95% confidence intervals (CIs), to assess the associations. Meta-analysis was conducted using MetaGenyo, STATA, and Comprehensive Meta-Analysis. Meta-analysis of our data showed that the OPG SNP T950C was significantly associated with increased CAD risk among Asians via recessive (OR 1.55, 95% CI 1.18–2.04,  Osteoprotegerin (OPG) is a member of the tumor necrosis factor (TNF) receptor superfamily, also termed as TNF receptor superfamily member 11B (TNFRSF11B) . Althoughttp://qikan.cqvip.com), and China National Knowledge Infrastructure (http://www.cnki.net). The search terms used in literature search were limited to the following: ‘osteoprotegerin or osteoclastogenesis inhibitory factor or tumour necrosis factor receptor superfamily member 11B’ and ‘coronary heart disease or coronary artery disease or ischemic stroke’ and ‘polymorphism or gene or risk’. We did not apply any geographical restrictions or time restrictions. Reference lists of included studies and of previous related reviews were searched for additional titles. Unpublished data were not considered in this meta-analysis.A systematic literature search was performed in March 2020 using the following databases: PubMed, Embase, China Science and Technology Journal Database (Studies were eligible for inclusion upon meeting the following criteria: (1) case–control studies or cohort studies or retrospective studies; (2) studies evaluated the association of OPG SNPs with CAD or ischemic stroke risk; and (3) studies contained applicable data on allele or genotype distribution in both cases and controls. Exclusion criteria were as follows: (1) familial-based studies or studies using siblings; (2) studies that recruited only cases; (3) published abstracts; and (4) allele or genotype distribution can not be extracted. When studies used similar sources of data, only the study with the largest sample size, or with the most detailed information was selected.A standardized data-extraction form was developed for use in our meta-analysis to extract key information from the included articles. Specifically, one reviewer (J.W.) extracted data from the included articles and a second independent reviewer (X.L.) validated the data. The following information was collected: the last name of the first author, country, year of publication, ethnicity, the number of cases and controls, diagnosis method, the mean/range of participants’ age, percentage of male subjects, methods for genotyping OPG SNP, genotype frequency, and Hardy–Weinberg equilibrium (HWE). We did not email the corresponding authors of the eligible studies for additional information.Following the selection of final studies, the Newcastle–Ottawa Scale (NOS) was used to assess study quality . It is w2I statistic and interpreted based on the study by Higgins et al. [The odds ratios (ORs) and 95% confidence intervals (CIs) were used to compare distributions of alleles and genotype contrasts between cases and controls. Allelic, dominant, recessive and co-dominant models were applied to assess the association. Pooled ORs and 95% CIs were calculated using the Mantel–Haenszel fixed-effects model and the DerSimonian–Laird random-effects model ,18. Fores et al. , where 2s et al. , and ComThe initial electronic database search identified 622 citations. The reference lists of the review articles were hand-searched; one related article was found. P=0.002), CC vs TT , and allelic  models   models . FurtherP=0.007) .P=0.367; OR 1.45, 95% CI 0.99–1.78, recessive model, P=0.060; OR 1.33, 95% CI 0.88–2.01, CC vs GG model, P=0.176; OR 1.17, 95% CI 0.97–1.40, allelic model, P=0.105) (Six studies involving 1126 CAD patients and 813 controls provided results on the association of the OPG SNP G1181C with CAD risk . The pooP=0.105) . StratifP=0.105) .Four studies including 754 cases and 517 controls examined the associations of the SNP T245G with CAD risk, while three studies with 576 cases and 205 control subjects performed evaluation of the association between the OPG SNP G209A and CAD . In the P=0.039) and CC vs AA  models  models  among Ch) models . Subgrou2I < 50%) in most pooled estimates (P>0.10). Sensitivity analysis was performed to evaluate the robustness of the observed outcomes. The relevant pooled ORs were not considerably altered after excluding any study (Supplementary Information).When evaluating the association between OPG polymorphisms and CAD, there was no significant heterogeneity , especially in Asian subjects. Studies of the OPG SNP G1181C, T245G, and G209A showed no significant association with CAD risk.Jia et al.  meta-anaThe OPG SNP T950C lies in the OPG gene promoter (129 bp upstream from the TATA box). Previous studies reported that the SNP was significantly and independently associated with increased circulating OPG levels . It was Ischemic stroke is the most common form of stroke. Previous studies have observed a relation between a higher level of OPG and ischemic stroke severity and outcome ,9,12. ToOur meta-analysis has some limitations. First, for some studies, the selection of CAD patients might bias the results. These studies recruited hospital patients undergoing diagnostic coronary angiography for suspected CAD, who were generally a highly selected population ,22,26. SIn summary, the present meta-analytic study identified a significant association between the OPG SNP T950C and the risk of CAD among Asians via recessive, CC vs TT and allelic models. Additionally, we showed the OPG SNP T245G to be significantly associated with increased ischemic stroke risk among Chinese via recessive and CC vs AA models. We are hopeful that our findings would be further evaluated by adequately powered and well-designed studies, especially in non-Asian populations.


Enlarged perivascular spaces (ePVS), visible on magnetic resonance imaging (MRI), are associated with aortic pulse wave changes produced by arterial stiffening. However, the relationship between ePVS and cognition is still unclear. We aimed to benchmark current knowledge of associations between ePVS and cognitive function using a meta-analysis of all available published data. We searched three databases for studies examining ePVS and cognition, identified seven studies involving 7,816 participants, plotted multivariate-adjusted odds ratio (OR) and 95% CI and generated summary OR with a fixed effects model. EPVS were related to the risk of impaired cognition  with low heterogeneity. There was publication bias, which could be corrected by trimming and supplementation . EPVS were associated with impaired cognition and may be a sign of cognitive impairment rather than particular diseases. More studies are required to validate ePVS as a measurable risk marker for cognition using consistent methods to determinea characteristic appearance of ePVS. Perivascular spaces (PVS), also known as Virchow-Robin spaces, are a fluid-filled structure lined with tubes found at specific locations throughout the brain . They caWe aimed to benchmark current knowledge of the associations between ePVS and cognitive function, using meta-analysis of all available published data.We used the meta-analysis of observational studies in epidemiology (MOOSE)  checklisTwo independent investigators (WJ and GHL) selected all relevant studies based on title and abstract, retrieved selected full texts, performed eligibility assessments, extracted data, and assessed risk of bias. Disagreements between the reviewers were resolved by consensus. A third independent reviewer (ZL) resolved any persisting disagreements.We comprehensively searched for studies published in full up to 27 August 2019, in PubMed, MEDLINE, and Ovid EMBASE. The following search terms were used:’(((((((Virchow-Robin Spaces) OR Perivascular Spaces) OR Enlarged Virchow-Robin Spaces) OR Enlarged Perivascular Spaces) OR Virchow-Robin Spaces Enlargement) OR Perivascular Spaces Enlargement)) AND (((((((Cognitive) OR Cognition) OR Cognitive Disorder) OR Cognitive Impairment) OR Cognitive Dysfunction) OR Cognitive Impaired) OR Dementia)’. We applied no language or calendar date restrictions. We checked reference lists of eligible papers and hand searched related literature to identify further relevant studies.We aimed to include all papers that reported on ePVS associations with cognitive function. We included cohort studies in adults with standardized risk estimates that were reported as odds ratios (ORs), relative risks (RRs), or hazard ratios (HRs) and excluded case reports, animal studies and reviews without original data. Studies were also excluded if they reported on linear associations (expressed as β-coefficients) on the relation between ePVS and cognition.We removed repetitive articles, screened the remaining titles and abstracts, removed irrelevant papers and assessed the remaining potentially eligible papers for inclusion. The following data were extracted: name of the first author, publication year, country of publication, publication type, sample source, sample size, age (mean), subject characteristics, follow-up time, grouping, ePVS location , the results of associations , adjustment factors, statistical methods, rating scale for ePVS, type of scanner and MRI sequence, and psychological assessment method. For those studies with many sets of adjustment factors, we extracted the most-adjusted risk estimate, and for those with groups, we merged their ORs.We evaluated the study quality with the Newcastle-Ottawa scale (NOS). The scale uses a “star” rating system (maximum of nine stars) to assess the quality of case-control and cohort studies based on three aspects: selection of participants, comparability of study groups, and ascertainment of outcomes of interest . If the 2 test was used to calculate the percentage of variance between studies due to heterogeneity rather than random factors. I2 of 25% or less was considered to be low, 26% to 50% or less moderate, 51%–75% or less high, and 76% or more was considered to be very high heterogeneity .We used a fixed effects model, plotted multivariate-adjusted ORs and 95% CI and generated summary ORs. Chi-square test was used to assess interstudy heterogeneity, and P <0.05 was considered statistically significant. Higgin’s Iogeneity . The sigWe identified 746 articles. After screening titles and abstracts and deleting duplicate papers, we obtained 39 study reports for full-text review. After a full-text review, we finally included seven reports comprising 7,816 individuals for analysis . Overall2 = 11.88, P=0.157, I2 = 32.6). The ePVS were significantly associated with cognitive function  , case-control studies (n=3), and cohort studies (n=5), have investigated the association of ePVS and cognition, but the results were inconsistent. Most of the cross-sectional studies using adjusted OR have suggested that ePVS were related to cognition,  which waIn our study, the heterogeneity analysis indicated low heterogeneity, so we combined the adjusted ORs with the fixed effects model. However, to reduce the error caused by small samples, we compared the results of the random effects model and the fixed effects model and found that there was little difference between the two results. Despite the publication bias, we suggested that the publication bias had no significant effect on the results through the trim and fill method. The results were stable based on the sensitivity analysis. The subjects included in our meta-analysis included a variety of clinical diseases, such as Parkinson’s disease, Alzheimer’s disease and cerebrovascular disease, which have different clinical pathogenesis. However, these results were consistent with our meta-analysis. This implies that ePVS, previously considered one of the markers of small vascular diseases and was most closely related to vascular cognitive impairment , may be However, the article has some limitations. Some studies have suggested that different ePVS locations have different outcomes, and the etiology of ePVS in different locations may be different . UnfortuEPVS counts were associated with impaired cognition in risk-factor–adjusted meta-analysis. EPVS may be a sign of cognitive impairment rather than a sign a particular diseases. More research is needed to further validate ePVS as a measurable risk marker for cognition using consistent methods to determine a characteristic appearance of ePVS.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.HZ and ZL contributed to the conception and design of the meta-analysis. WJ, GLin, LL, and GLia were involved in the acquisition and analysis of the data. MO and ML interpreted the results. WJ and GLin drafted the manuscript. All authors read and approved the final manuscript.This work was supported by funding from the Natural Science Foundation of China (grant number 81400986), the Science and Technology Planning Project of Zhanjiang (grant number 2018A01021) and the Affiliated Hospital of GDMU .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.


A total of 10%–20% of patients develop long-term toxicity following radiotherapy for prostate cancer. Identification of common genetic variants associated with susceptibility to radiotoxicity might improve risk prediction and inform functional mechanistic studies.Pmeta less than 5 × 10−8 were considered statistically significant. Bayesian false discovery probability provided an additional measure of confidence. Statistically significant variants were evaluated in three Japanese cohorts (n = 962). All statistical tests were two-sided.We conducted an individual patient data meta-analysis of six genome-wide association studies (n = 3871) in men of European ancestry who underwent radiotherapy for prostate cancer. Radiotoxicities  were graded prospectively. We used grouped relative risk models to test associations with approximately 6 million genotyped or imputed variants (time to first grade 2 or higher toxicity event). Variants with two-sided Pmeta = 6.2 × 10−10), rs10969913 with decreased urinary stream (Pmeta = 2.9 × 10−10), and rs11122573 with hematuria (Pmeta = 1.8 × 10−8). Fine-scale mapping of these three regions was used to identify another independent signal (rs147121532) associated with hematuria . Credible causal variants at these four signals lie in gene-regulatory regions, some modulating expression of nearby genes. Previously identified variants showed consistent associations  in new cohorts. rs10969913 and rs17599026 had similar effects in the photon-treated Japanese cohorts.Meta-analysis of the European ancestry cohorts identified three genomic signals: single nucleotide polymorphism rs17055178 with rectal bleeding (This study increases the understanding of the architecture of common genetic variants affecting radiotoxicity, points to novel radio-pathogenic mechanisms, and develops risk models for testing in clinical studies. Further multinational radiogenomics studies in larger cohorts are worthwhile. Long-term side effects following radiotherapy affect the health-related quality of life for cancer survivors . RadiatiGenetic predisposition to radiotoxicity in nonsyndromic individuals is poorly understood. Preclinical studies suggest that the biologic mechanisms are complex, involving cell death, premature senescence, inflammation, tissue remodeling with development of fibrosis, and vascular damage. Large genetic studies are difficult because it is challenging to build cohorts associated with a phenotype that takes months to years to develop. In addition, the radiosensitivity phenotype varies by tumor site and means of assessment.In prostate cancer patients, common radiotoxicities include increased urinary frequency, radiation cystitis , urinary retention, and rectal bleeding ,8. RadioDespite approximately 50% of cancer patients undergoing radiotherapy, the collection of radiotoxicity data is sporadic and inconsistent. Most centers do not collect data routinely with the detail and standardization required to conduct radiogenomic studies. There is also a clear potential for clinical impact, for example, with an option for modified radiotherapy planning as increasingly conformal dose delivery techniques become available. The Radiogenomics Consortium was established to facilitate data sharing and develop methods for meta-analyses. Our first pooled genome-wide association study (GWAS) performed in prostate cancer survivors demonstrated that it was possible to meta-analyze data and identify genomic risk regions despite the heterogeneity inherent in radiotherapy cohorts .As part of a long-term goal to identify sufficient variants to develop a polygenic risk model for radiotoxicity, we undertook a larger meta-analysis on six cohorts comprising 3871 prostate cancer survivors. Secondary aims were to validate previously published single nucleotide polymorphisms (SNPs) and evaluate risk SNPs in Japanese cohorts. STROGAR guidelines  for repoThe study included individuals with prostate adenocarcinoma, treated with radiotherapy with curative intent, and followed prospectively for development of toxicity. All participants gave written informed consent, and cohorts were collected following standards indicated by the Declaration of Helsinki. Participants were from either hospital-based cohorts or clinical trials ; and/or Toxicity was assessed from 6 months up to 5 years after the start of radiotherapy, with the exception of the UGhent cohort (follow-up from 18 to 30 months only). Different toxicity assessments were used .Germline DNA from whole blood was genotyped for published GWASs ,10,22–25Genetic variants were tested for associations with toxicity using a grouped relative risk model adjusting for androgen-deprivation therapy, prior prostatectomy, age at treatment, and total BED. Covariables were selected a priori to reduce heterogeneity. A per-allele additive genetic model was assumed. In RAPPER  and GeneP value (Pmeta) was less than 5 × 10-8 and the chi-squared test of heterogeneity P value was greater than .05. The likelihood that an association is nominally statistically significant at a given threshold depends not only on the P value but also on the power to detect a given association. We therefore assessed the likelihood that our statistically significant associations represent false positives using the Bayes false discovery probability ; all P values were greater than .05. Additional details are in the Clinical and genetic variables were combined using cohort-stratified grouped relative risk models. Stepwise model selection was used to identify parsimonious multivariable models for each toxicity outcome. Confidence intervals and Pmeta = 6.2 × 10−10), rs10969913 with decreased urinary stream (Pmeta = 2.9 × 10−10), and rs11122573 with hematuria (Pmeta = 1.8 × 10−8). Variants with minor allele frequency 1%–4% and SNPs falling just short of our criteria, including several variants associated with a secondary endpoint of overall toxicity measured using STAT score  at chromosome (chr)1: 230337180–231337180 was associated with hematuria. The first signal  and COG2  in multiple tissues including arteries  and ARV1 . The risk alleles in the second signal were also associated with differential expression of two noncoding (nc) RNAs: decreased expression of ncRNA AL512328.1 (ENSG00000244137.1), which overlaps partially with AGT and CAPN9, and increased expression of ncRNA LOC101927604 (ENSG00000223393.1). At the chr5: 156903410–157903410 region associated with rectal bleeding, a 15 CCV signal accounts for 98% posterior probability at the region (P > .05). At the chr9: 30366808–31366808 region, associated with decreased urinary stream, a single 15 CCV signal accounts for 99% of the posterior probability (P > .05).Fine-scale mapping identified CCVs (P < .05) with multiple toxicities  and nc RNAs , pointing toward possible functional mechanisms. For example, AGT encoding angiotensinogen is converted to the active enzyme angiotensin II by angiotensin-converting enzyme (ACE). Prior studies suggest angiotensin signaling may influence radiation-induced blood vessel wall injury and interstitial fibrosis , highlighting the importance of functional studies as complementary to association studies.Our analysis is the largest GWAS of late radiotoxicity. Although heterogeneity across cohorts adds noise and masks statistically significant SNP-toxicity associations, our analysis plan addressed heterogeneity. Use of individual patient data meta-analysis maximizes statistical power when combining information across multiple studies ,50. In auropeans . HoweverThe multivariable risk models demonstrate that genetic variants, treatment variables, and other clinical factors are independent predictors for radiotoxicity, supporting the suggestion that common variants can improve traditional normal tissue complication probability models ,52. AlthA strength of our study is the prospective longitudinal assessment of toxicity enabling use of time-to-event analysis to maximize information across multiple toxicity assessments. Long-term follow-up is clearly important for radiogenomic studies, and future work should use longitudinal analysis when possible. A second strength of our work is the inclusion of Japanese ancestry cohorts. Most GWAS to date focused on populations of European ancestry, because ethnicity inflates type I error rates and reduces statistical power because of population heterogeneity in allelic effects on a trait . It is iLimitations include the lack of detailed dosimetry and comorbidity data for all cohorts, although our stratified analysis maximized use of data across all studies for multivariable models. In addition, although this is the largest GWAS of its kind to date, the sample size is modest compared with disease susceptibility GWAS and was powered only to detect SNP-toxicity associations with relatively large effect sizes. Our study was too small for multi-SNP modeling, such as polygenic risk score and machine learning-based methods. The latter were successful for other polygenic traits and diseases  and shouIn summary, by performing the largest GWAS meta-analysis and first fine-mapping study in radiogenomics, to our knowledge, we identified four new regions associated with radiotoxicity in prostate cancer. We showed the signals affect gene regulation rather than gene coding sequences. This study increases our understanding of the architecture of common genetic variants affecting radiotoxicity and demonstrates that further multinational radiogenomics studies in larger cohorts are worthwhile.This work was supported by the US National Institutes of Health , the United States Department of Defense (PC140371 to BSR and HO), and the European Union’s Horizon 2020 research and innovation programme under the Marie Sklodowska-Curie grant agreement No. 656144. Genotyping via the OncoArray was funded by the NIH (U19 CA 148537 for ELucidating Loci Involved in Prostate cancer SuscEptibility [ELLIPSE] project and X01HG007492 to the Center for Inherited Disease Research [CIDR] under contract number HHSN268201200008I) as well as C8197/A16565. Additional analytic support was provided by NIH NCI U01 CA188392 (PI: Schumacher). RAPPER was supported by Cancer Research UK grants C1094/A18504, C147/A25254, and C147/A25254 and NIHR Manchester Biomedical Research Centre funding. The PRACTICAL consortium was supported by Cancer Research UK Grants C5047/A7357, C1287/A10118, C1287/A16563, C5047/A3354, C5047/A10692, and C16913/A6135; European Commission’s Seventh Framework Programme grant agreement No. 223175 (HEALTH-F2-2009–223175); and the NIH Cancer Post-Cancer GWAS initiative grant: 1U19 CA 148537–01 (the GAME-ON initiative). CMLW is supported by the NIHR Manchester Biomedical Research Centre and the EU’s 7th Framework Programme Grant Agreement No 601826. GP and MEA’s work was also partially supported by NIH grant R01GM114434. RADIOGEN research was supported by Spanish Instituto de Salud Carlos III funding, an initiative of the Spanish Ministry of Economy and Innovation partially supported by European Regional Development FEDER Funds , and through the Autonomous Government of Galicia (Consolidation and structuring program: IN607B) given to AV. DPD was supported by the NIHR Royal Marsden Hospital and Institute of Cancer Research Biomedical Research Centre.The funders had no involvement in the study design, data collection, analysis and interpretation, writing of the report, or the decision to submit the paper for publication. The authors have no conflicts of interest directly related to this study to disclose.http://practical.icr.ac.uk/) for providing genotyping data for studies genotyped using the Oncoarray. We are grateful to the collaborating clinicians for participation in the PRRG study. This work was enabled by the computational resources and staff expertise provided by Scientific Computing at the Icahn School of Medicine at Mount Sinai and the University of Rochester Center for Integrated Research Computing (CIRC).The authors thank the Prostate Cancer Association Group to Investigate Cancer Associated Alterations in the Genome (PRACTICAL) Consortium (djz075_Supplementary_DataClick here for additional data file.


The purpose of this study was to explore the efficacy and tolerability of poly ADP-ribose polymerase (PARP) inhibitors in patients with ovarian cancer.The meta-analysis searched the PubMed, Web of Science, EBSCO, and Cochrane libraries from inception to February 2020 to identify relevant studies. And the main results of this study were long-term prognosis and treatment-related adverse events.p < 0.001; HR, 0.79, 95% CI 0.65–0.94, p < 0.001, respectively). In the BRCA 1/2 mutation patients, the HR of PFS was 0.29 (p < 0.001), and the HR was 0.51 (p < 0.001) in the no BRCA 1/2 mutation patients. The HR of PFS was 0.40 (p < 0.001) in the homologous recombination deficiency (HRD) mutation patients, while the HR was 0.80 (p < 0.001) in the no HRD mutation patients. Moreover, the analysis found that the use of PARP inhibitors did not significantly increase the risk of all grade adverse events (AEs) . But the incidence of grade 3 or higher AEs was increased . In general, the AEs were mainly manifested in the blood system.The results showed that the addition of PARP inhibitors could significantly prolong progression-free survival (PFS) and overall survival (OS) for patients with ovarian cancer . Furthermore, PARP inhibitors were tolerable to patients when added to their current therapy, although it inevitably adds the grade 3 and higher AEs. Ovarian cancer was the fourth most common cause of cancer-related deaths in women, with an estimated 200,000 cases and 125,000 deaths worldwide each year . For theOn the other hand, studies have shown that PARP (poly ADP-ribose polymerase) was a key regulator of DNA damage repair, and PARP enzymes played a vital role in repairing single-strand breaks through base excision repair . In doubIn addition, studies have shown that PARP inhibitors can prevent cancer cells from repairing damaged DNA and leading to cancer cell death . Its rolovarian neoplasms,” “ovarian cancer,” “ovarian carcinoma,” “carcinoma of ovary,” or “ovary cancer.” Also, we manually search for references in the literature. In order to make the study more standardized and its conclusions more scientific, this meta-analysis was conducted following the guidelines of the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement [The meta-analysis searched the PubMed, Web of Science, EBSCO, and Cochrane libraries from the beginning to February 2020 to identify relevant studies. Because the authors have different calling habits for the same drug in the literatures, we choose a combination of free-text terms and medical subject heading terms which was used for topic search to ensure the integrity of the included literatures. Search terms included “PARP inhibitor,” “poly ADP-ribose polymerase inhibitor,” “olaparib,” “rucaparib,” “veliparib,” “niraparib,” “talazoparib,” “iniparib,” “Inclusion criteria: (1) included articles were English reports of completed clinical controlled trials evaluating the efficacy of PARP inhibitors to ensure the completeness of included studies. (2) The included articles were randomized controlled trials (RCTs) for PARP inhibitors in phase II and phase III for patients with ovarian cancer in order to increase the credibility of the research conclusion. (3) Included articles mentioned PFS  and/or OS  so that we could effectively analyze the results.Exclusion criteria: (1) research treatments that included neoadjuvant therapy. (2) The trial was not a phase II or phase III clinical trial. (3) Research data cannot be extracted. (4) In the event where the author has repeated publications or continuous updates, we would use the latest article.The main results of this study were long-term prognosis (including PFS and OS) and treatment-related adverse events (AEs), because these two types of indicators played a vital role in the prognosis of patients.The incidence of AEs was characterized based on all grades and grade 3 or higher as reported by each trial using the definitions of National Cancer Institute’s Common Terminology Criteria for Adverse Events (CTCAE) version 4. 0.ClinicalTrials.gov, the phase of clinical trials, the regimen of the experimental group of using a PARP inhibitor and control group, the number of participants, tumor mutation, first-line or non-first-line treatment, and survival benefit indicators including PFS, OS, and AEs. If different studies contain different chemotherapy regimens, we can try to conduct a subgroup analysis when the sample size is sufficient. However, if the chemotherapy regimens are variable and the samples are insufficient, we carefully combine the corresponding results.We assessed the potential risks of bias in trials by using the Cochrane Collaboration Risk of Bias Assessment tool . In ordeP < 0.1 to evaluate publication bias and the Stata 12.0 Software to perform the sensitivity bias [We compared the PFS and OS of the experimental group of using a PARP inhibitor and the control group, expressed as hazard ratio (HR) and 95% confidence interval (CI), and the AEs involved were also expressed as risk ratio (RR) and 95% CI. All pooled results are displayed using the forest plots. We used Begg’s and Egger’s test with a level of significance set at ity bias . BecauseAfter rigorous searching and selection, including manual searching, we have identified 1247 potentially relevant articles. In the excluding neoadjuvant therapy, not a PARP inhibitor compared to other, non-phase II or III studies and data unavailable after, the study included ten related articles ultimately , 24–30. p < 0.001; Fig. p < 0.001; Fig. p < 0.001; Fig. p < 0.001; Fig. In this included study, all of them reported on PFS, which the results showed that the use of PARP inhibitors could significantly prolong PFS  for anemia and 3.59  for thrombocytopenia. The other AEs were different such as decreased appetite (RR = 1.45), diarrhea (RR = 1.23), dizziness (RR = 1.46), fatigue (RR = 1.36), headache (RR = 1.35), nausea (RR = 1.71), neutropenia (RR = 1.88), and vomiting (RR = 1.82). Among grade 3 and higher AEs, the overall risk increased . Among the various AEs, anemia and thrombocytopenia were the more significant increase, and their risk values were 9.94  for anemia and 4.46  for thrombocytopenia. The other AEs were fatigue (RR = 2.39), nausea (RR = 2.57), and neutropenia (RR = 2.42). In general, the AEs were mainly manifested in the blood system. Detailed data are shown in Tables The analysis found that the use of PARP inhibitors did not significantly increase the overall risk of AEs . Anemia and thrombocytopenia were the most common AEs, with risk values of 3.40 , we performed a publication bias test on the relationship between PFS and PARP inhibitors, which was no significant publication bias . Through the sensitivity analysis of PFS, it was found that removing each group showed excellent stability in turn , but in specific AEs, anemia and thrombocytopenia were the most common AEs, and their risk values were 3.40  for anemia and 3.59  for thrombocytopenia. Other AEs included decreased appetite (RR = 1.45), diarrhea (RR = 1.23), and dizziness (RR = 1.46). Among grade 3 and higher AEs, the overall risk of AEs increased . Among the various AEs, the more significant increase was anemia and thrombocytopenia, and their risk values were 9.94  and 4.46 , respectively. Other AEs were fatigue (RR = 2.39), nausea (RR = 2.57), and neutropenia (RR = 2.42). Overall, its AEs were mainly manifested in the blood system. Such AEs tended to occur early after the start of treatment and recovered after a few months. Among patients receiving niraparib, hematological of AEs accounted for the majority of grade 3 and grade 4, which were the most common cause of dose adjustment, interruption, and discontinuation [In terms of AEs, the use of PARP inhibitors did not significantly increase the overall risk of AEs , but also prolong the prognosis of ovarian cancer patients of no gene mutation. Furthermore, PARP inhibitors were tolerable to patients when added to their current therapy, although it inevitably adds the grade 3 and higher AEs.Additional file 1: Supplementary Fig. 1. Flow diagram of study inclusion and exclusion.Additional file 2: Supplementary Fig. 2. Publication bias of the progression-free survival (PFS) for additional PARP inhibitors. (Egger’s) p = 0.241; (Begg’s) p = 1.0.Additional file 3: Supplementary Fig. 3. Sensitivity analysis of the progression-free survival (PFS) for additional PARP inhibitors.Additional file 4: Supplementary Table 1. Characteristics of included clinical trials in the meta-analysis.


We comprehensively searched electronic databases, namely, PubMed, Web of Science, EMBASE, Chinese National Knowledge Infrastructure (CNKI), and WanFang databases up to December 2019. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated to evaluate the association between PRDX1 protein expression and the survival of patients with solid tumors. Odds ratios (ORs) with 95% CIs were pooled to estimate the correlation between PRDX1 protein expression and clinicopathologic characteristics in the patients. P = 0.001) and disease-free survival . In addition, high PRDX1 expression was associated with large tumor size , advanced TNM stage , and poor tumor differentiation .  Seventeen cohort studies that involved 2,858 patients were included in this meta-analysis. The pooled results indicated that positive PRDX1 expression was related to poor overall survival (HR = 1.68, 95% CI: 1.24-2.27,  PRDX1 overexpression is associated with poor outcomes of cancers and may serve as a prognostic biomarker for malignant patients. Hence, PRDX1 could be a new target for antitumor therapy. Cancer is one of the leading contributors to morbidity and mortality, with approximately 1,735,350 new cancer cases and 609,640 cancer-related deaths reported in the United States in 2018 [Reactive oxygen species (ROS) is involved in various physiological and pathological reactions in mammalian cells and plays a critical role in some diseases, including certain cancers , 7. PeroκB), and then induces or inhibits cell death [Peroxiredoxin-1 (PRDX1) is an affiliate of the PRDX antioxidant protein superfamily . PRDX1 all death , 17, 18.ll death . An incrWe performed this meta-analysis in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The PubMed, Web of Science, EMBASE, Chinese National Knowledge Infrastructure (CNKI), and WanFang databases (up to November 2019) were systematically searched with the following keywords: (“peroxiredoxin-1” or “prdx1” or “prx1”), and (“tumor” or “cancer” or “carcinoma” or “neoplasm”), and . Manual searches were also conducted on the reference lists of the original articles to identify additional studies. Full-text articles published in English or Chinese were included.Studies were enrolled according to the following criteria: (1) solid tumors were diagnosed by histopathology; (2) studies assessed the relationship between PRDX1 and prognostic outcomes, including overall survival (OS) or disease-free survival (DFS); (3) PRDX1 protein expression was detected in cancer tissues by immunohistochemistry stain or reverse phase protein array (RPPA) analysis and categorized into “high” and “low” groups; and (4) hazard ratios (HRs) with corresponding 95% confidence intervals (95% CIs) can be extracted directly or estimated with sufficient information. Articles were excluded according to the following criteria: (1) letters, reviews, abstracts, case reports, editorials, expert opinions, or animal experiments; (2) studies without sufficient information for estimating HRs with corresponding 95% CIs; (3) participants were not divided into two groups according to PRDX1 expression; and (4) studies with a sample size of less than 50.Data from each study were evaluated and extracted independently by two investigators (JLH and WJ). Any disagreement was resolved by a consensus with a third investigator (ZCM). The following information was collected in this meta-analysis: first author's name, publication year, country, cancer type, TNM stage, sample size, follow-up time, OS and DFS, and HR estimation with 95% CI. In studies that reported univariate and multivariate HR estimations, only the latter was selected because it considers confounding factors and is more accurate.The quality of eligible studies was assessed independently by two authors (JLH and WJ) according to the Newcastle-Ottawa Scale (NOS). Any disagreement was resolved through discussion with another investigator (YJ). Each study was assigned an overall score ranging from 0 to 9 based on quality of selection, comparability, exposure, and outcome assessment. Investigations with scores higher than or equal to 6 were regarded as high-quality research.Q test and I-squared statistical test. When the results (I2 > 50% or P < 0.05) indicated heterogeneity, the random effects model was applied for the meta-analysis; otherwise, the fixed effects model was adapted. Metaregression and subgroup analyses were conducted on studies sorted into subgroups according to similar variables. Sensitivity analysis was performed to verify the stability of the synthesis results by sequentially omitting each individual study. Publication bias was also statistically evaluated using Egger's test and visually assessed with a funnel plot. In case of significant publication bias, the trim-and-fill method was applied to validate the robustness of the summary results.The Stata 12.0  software was used for all statistical analyses. The combined HRs and their 95% CIs were calculated to evaluate the relationship between PRDX1 expression and patient survival. For the overall results, HR and 95% CI greater than 1 indicated poor prognosis in patients with PRDX1 overexpression. Moreover, pooled odds ratio (OR) and their 95% CI were applied to assess the association between PRDX1 expression and the clinicopathological parameters of solid tumors. Heterogeneity among individual studies was analyzed using chi-squared A total of 227 records were retrieved from the PubMed, Web of Science, EMBASE, CNKI, and WanFang databases by using the above mentioned search strategy; of which, 94 studies were excluded because of duplicate records. And then 95 articles were removed because of obvious irrelevance. After screening the titles and abstracts, 27 papers were identified for full-text review. Finally, 15 articles met the inclusion criteria and were included in the meta-analysis. The study selection process is shown in The basic characteristics of each article are summarized in P = 0.025, random effects). Moreover, PRDX1 overexpression had a significant association with advanced TNM stage  and poor tumor differentiation . However, PRDX1 expression was not related to age , gender , depth of invasion , lymph node metastasis , and distant metastasis . The results are shown in To analyze the role of PRDX1 protein expression as a prognostic biomarker for solid tumors, we first investigated its correlation with clinicopathological features. Fifteen cohorts comprising 1,907 patients reported the relationship between PRDX1 expression and tumor size, and the pooled results indicated that high expression of PRDX1 was correlated with large tumor size . The pooled results indicated that PRDX1 overexpression was significantly related to poor OS .The main results of this meta-analysis are listed in Considering the significant heterogeneity among the studies, we conducted subgroup and meteregression analyses by focusing on study region, cancer type, TNM stage, sample size, and analysis method to explore sources of heterogeneity for OS .P = 0.002, random effects) but not in western countries . Subgroup analysis based on cancer type suggested that high PRDX1 expression predicted poor OS in patients with OC , OSC , GC , and others . Nevertheless, no significant relationship was observed between PRDX1 expression and OS in patients with CCA , ESCC , and BC . With regard to TNM stage, the results showed the predictive role of PRDX1 positive expression on unfavorable OS in patients with cancer of stages I-IV , and I , but not in those with stages I-III , and none reported . When the cohorts were grouped by sample size, high PRDX1 expression was associated with worse OS for small samples but better OS for large sample sizes. Finally, the subgroup analysis suggested the close association of PRDX1 overexpression with worse OS in the multivariate analysis  but not in the univariate analysis . Further metaregression analysis revealed that sample size (P = 0.010) and analysis method (P = 0.034) may be important factors for heterogeneity.Subgroup analysis of the study region indicated that PRDX1 overexpression was significantly related to worse OS in eastern countries  and Egger's test (P < 0.001). Furthermore, the funnel plot visually showed an apparent asymmetry (P = 0.023) but not by Begg's test (P = 0.107), which was also revealed by the asymmetrical funnel plot  and DFS . Hence, high PRDX1 expression could indicate poor prognosis in solid cancers. However, the combined results may be challenged because of significant heterogeneity. To explore the source of heterogeneity for OS, we conducted subgroup and metaregression analyses according to study region, cancer type, TNM stage, sample size, and analysis method. Sample size and analysis method may significantly explain the heterogeneity for the combined HR of OS, and the heterogeneity mainly originated from the studies of O'Leary et al. [In our meta-analysis, we pooled 17 cohort studies involving 2,858 patients with solid cancer. Our overall pooled results indicated that high PRDX1 expression could predict poor OS /c-Jun NH2-terminal kinase (JNK) [First, as an endogenous product of aerobic respiration in all metazoan organisms, ROS is involved not only in tumor metastasis but also in tumorigenesis , 34. PRDse (JNK) , 36. In se (JNK) . Therefose (JNK) . The rolse (JNK) , 38. MorSecond, previous studies revealed that PRDX1 excessive expression enhances epithelial-mesenchymal transition (EMT) by inducing transforming growth factor beta 1; EMT is regarded as a critical process in tumor invasion and metastasis . During Third, the extracellular matrix (ECM) is a component of the tumor microenvironment, and its degradation is essential for tumor cells to escape from primary lesions. The matrix metalloproteinase (MMP) family can degrade the major components of the ECM and plays an important role in promoting tumor invasion and metastasis . Among MFourth, the invasion and metastasis of tumor cells are a complex series of pathophysiological processes accompanied by a complex regulatory network involving multiple molecules. In addition to the signaling pathways mentioned above, those related to PRDX1 are involved in the p53 signaling pathway, Akt/mTOR signaling pathway, PI3K/Akt signaling pathway, pathways in cancer, FoxO signaling pathway, cell cycle, and ubiquitin-mediated proteolysis , 20, 44.This meta-analysis presents certain limitations, and the results should be interpreted with caution. To begin with, the cut-off value of positive and negative PRDX1 expression was inconsistent among different studies, leading to bias in the results. Second, several individual HRs could not be directly achieved from the published data, resulting in some errors. Third, studies with positive results were more likely to be published than those with negative results. This phenomenon may lead to publication bias and exaggerate the overall results. Fourth, only published articles in English and Chinese were enrolled. Fifth, all included cohort studies were retrospective. Prospective studies are needed to assess the prognostic value of PRDX1 expression in patients with solid tumors. Finally, although we used the random effects model for the analysis, a considerable heterogeneity persisted in our study.Despite the limitations of this meta-analysis and the heterogeneity of the included studies, our results suggest that high PRDX1 expression is significantly associated with poor prognosis and may serve as a new biomarker for monitoring the development and progression of tumors. Hence, PRDX1 could be a new target for antitumor therapy. Large-scale prospective and standard investigations should be conducted in the future to confirm our results.


Alternative splicing (AS) modifies 92-94% human genes, abnormal splicing events might relate to tumor development and invasion. Glioblastoma Multiforme (GBM) is a fatal, invasive, and malignant tumor in nervous system. The recurrence and development leads to poor prognosis. However, few studies have focused on AS in GBM.RNA-seq and Alternative splicing events (ASEs) data of GBM samples were downloaded from The Cancer Genome Atlas (TCGA) and TCGASpliceSeq databases, respectively. Firstly, the Cox regression analysis was utilized to identify the overall survival splicing events (OS-SEs). Secondly, a multivariable model was applied to access the prognostic value of risk score. Then, we constructed a co-expressed network between splicing factors (SFs) and overall survival alternative splicing events (OS-SEs). Additionally, to explore the relationship between the potential prognostic signaling pathways and OS-SEs, we constructed a network between these pathways and OS-SEs. Ultimately, to better explain the results, validations from multi-dimension platforms were applied.In the first step, 1,062 OS-SEs were selected by Cox regression. Then, 11 OS-SEs were integrated in a multivariate model by Lasso regression. The area under the curve (AUC) of receiver operator characteristic (ROC) curve was 0.861. In addition, the risk score generated from the multivariate model was confirmed to be an independent prognostic factor (P < 0.001). What's more, in the network of SFs and ASEs, CELF5 significantly regulated GSG1L|35696|AP and GSG1L|35698|AP . Additionally, GSG1L|35696|AP (P = 0.006) and GSG1L|35698|AP (P = 0.007) showed a significant relationship with cancer status. Eventually, KEGG pathways related to prognosis of GBM were selected by GSVA. The primary bile acid synthesis  was the significant pathway co-expressed with Germ Cell-Specific Gene 1-Like Protein (GSG1L).Based on the comprehensive bioinformatics analysis, we proposed that aberrant splicing factor CUGBP Elav-like family member 5 (CELF5) significantly, positively and negatively, regulated ASE of GSG1L, and the primary bile acid synthesis pathway might play an important role in tumorigenesis and prognosis of GBM. Alternative splicing (AS) is a common process for producing multiply mature RNA from pre-RNA, and it can contribute to the modification of 92-94% human genes . AlternaGlioblastoma multiforme (GBM) is the most fatal and invasive malignant tumor in the nervous system. The World Health Organization (WHO) defines GBM as the IV grade glioma. It is reported that there are three new cases of GBM per 100,000 people every year, and the two-year and five-year survival rate are 26-33% and 4-5%, respectively . GeneralIn the current study, we utilized a Cox regression analysis to identify the overall survival of splicing events (OS-SEs) and constructed a multivariate prognosis model. In addition, the risk score generated from the multivariate model was confirmed to be an independent prognostic factor. We constructed a co-expressed network between SFs and OS-SEs. Meanwhile, to explore the relationship between the potential prognostic signaling pathways and OS-SEs, we constructed a network between these pathways and OS-SEs. Ultimately, we found a regulatory network related to the cancer status and prognosis in GBM, in which the interaction SFs and ASEs were included.https://tcga-data.nci.nih.gov/tcga/). In addition, Percent Spliced In (PSI) values of ASEs more than 75% in primary GBM were downloaded from TCGASpliceSeq database (https://bioinformatics.mdanderson.org/TCGASpliceSeq/)  database (iceSeq/) . Then, aIn data preprocessing, the missing data in PSI values was supplemented by K-Nearest Neighbor algorithm . Next, the ASEs with percent spliced in (PSI) values were filtered. ASEs with mean PSI values of less than 0.05 and/or standard derivations of PSI values less than 0.01 were excluded. Samples from patients without demographic information and follow-up records were also excluded. Next, the rest data were analyzed by univariate Cox regression to identify the OS-SEs. The UpSet plot was applied to demonstrate the result. In the third step, a volcano plot was used to illustrate the prognostic of OS-SEs, and the x-axis and y-axis represented z-score and -log10  in the volcano plot, respectively. Moreover, the top 20 OS-SEs in each splicing pattern: Alternate acceptor site (AA), Alternate donor site (AD), Alternate promoter (AP), Alternate terminator (AT), Exon skip (ES), Mutually exons (ME), and Retained intron (RI) was selected and demonstrated in bubble plots.To avoid over fitness in the multivariate model, Lasso regression was utilized to screen the most significant OS-SEs in each splicing pattern. Then, the selected OS-SEs were integrated into the multivariate model. Receiver operator characteristic (ROC) curve was applied to access the efficiency of the prognosis model. The risk score of each sample for predicting the prognosis was calculated by the following formula:iRisk score” represented the risk score of No. “i” patient. Further, the median was selected to divide the risk score into high and low. Moreover, the Kaplan-Meier curve was utilized to evaluate the relationship between risk score and survival probability.In the formula, “n” represented the number of OS-SEs in the multivariate model, “β” represented the regression coefficient of each OS-SE from multivariate model, “The univariate and multivariable Cox regression analyses were utilized to access the prognostic value of risk score generated from the multivariate model. The demographics and clinical information including age, gender, and cancer status were used for model correction.Based on SpliceAid2 database , a datasThe Mann-Whitney-Wilcoxon test and Kruskal-Wallis test were applied to identify the relationship between OS-SEs and GBM status, and the Beeswarm plots were utilized to illustrate the significance of the relationship.Gene Set Variation Analysis (GSVA) was utilized to select the differential expression Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways in GBM. Then, prognostic KEGG pathways were identified by univariate Cox analysis based on GSVA. The Pearson analysis was applied to identify the correlation between cancer status-related OS-SEs and prognostic KEGG pathways. Based on the result, significantly co-expressing KEGG pathways and OS-SEs were selected.in silico analysis, multidimensional validation from other platforms was performed. Pathway Card (https://pathcards.genecards.org/) was utilized to find the top 5 genes related to the selected KEGG pathway. Then, The Human Protein Altas  .A two-tailed P-value < 0.05 was considered as statistically significant. In order to control the size of the SF regulation network, correlation coefficient > 0.400 and P < 0.001 in Pearson correlation analysis were selected as a more stringent screening criteria to screen for co-expression patterns between SFs and OS-SEs. All statistical analysis was performed by R version 3.6.1 , P < 0.001) , CELF5 significantly regulated GSG1L|35696|AP and GSG1L|35698|AP , and ELAVL3 significantly regulated ST3GAL4|19391|AP and ST3GAL4|19394|AP   protein and regulated its genome DNA synthesis . HCMV paGSG1L was inactive in the AMPA-type glutamate receptors (AMPARs) in cancer . In addiUp to now, there has been no publication focused on the direct regulation of CELF5 and GSG1L. We detected that they are all involved in the glutamate-related processes like cell apoptosis and tumor proliferation based on reports up to date.Some studies indicated that bile acid and its derivatives were related to several cancers, like multiple myeloma, hepatoma, GBM, and colon cancer, and bile acid could control the development of cancer by its cytotoxicity to cancer and by signaling to immune cells .Further, in bile acid synthesis, some products of bile acid regulated the PI3K dependent Bad pathway, causing apoptosis of neurons by glutamate. As we min silico analysis, it was limited by the sample size and support of the molecular mechanism. However, to minizine the systemic bias, we applied multidimension validation for CELF5, GSG1L, and primary bile acid synthesis based on multiple online databases, showing the stability of the results of this study.Overall, CELF5 was the remarkable SF and GSG1L was the remarkable OS-SE related to status. CELF5 significantly regulated GSG1L. Additionally, primary bile acid was the candidate pathway in the downstream of the regulation between CELF5 and GSG1L. However, because our analysis was only an With the aim of making our hypothesis more scientific, a convincing and high-level basic experimental verification will be launched in the future. Based on some studies devoted to ASEs, such as ASEs in pan-cancer, pancreatic cancer, and Renal Cancer . All genBased on the comprehensive bioinformatics analysis, we proposed that aberrant splicing factor CUGBP Elav-like family member 5 (CELF5) positively and negatively regulated ASE of GSG1L and the primary bile acid synthesis pathway might play an important role in tumorigenesis and prognosis of GBM. The scientific hypothesis might offer direction for subsequent biological experiments.All datasets used for this study are available from the TCGA-GBM program.This study was approved by the Ethics Committee of Tongji University School of Medicine.Conception/design: RH, ZL, CL, GW, PY, LP, JW, XZ, PH, JZ, ZC, ZH, LC, and JiZ. Provision of study material: ZH, LC, and JiZ. Collection and/or assembly of data: RH, ZL, CL, GW, PY, LP, JW, XZ, PH, JZ and ZC. Data analysis and interpretation: RH, ZL, CL, GW, PY, LP, JW, XZ, PH, JZ and ZC. Manuscript writing: RH, ZL, CL, GW, PY, LP, JW, XZ, PH, JZ, ZC, ZH, LC, and JiZ. Final approval of manuscript: RH, ZL, CL, GW, PY, LP, JW, XZ, PH, JZ, ZC, ZH, LC, and JiZ.This study was supported in part by the National Natural Science Foundation of China (No. 81501203), Shanghai Municipal Health Commission (No.201940306) and Henan medical science and technology research project (No. 201602031).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.