In this study, we demonstrate the potential role of VNPP433-3β as molecular glue that induces physical proximity between the Androgen Receptor and MDM2 E3 ligase in prostate cancer cells. The interaction promotes MDM2-mediated ubiquitination of AR and its subsequent proteasomal degradation resulting in growth inhibition of prostate cancer cells.Targeted protein degradation is a fast-evolving therapeutic strategy to target even the traditionally undruggable target proteins. Contrary to the traditional small-molecule inhibitors of enzyme or receptor antagonists that bind the active site pockets in the target protein, molecular glue degraders facilitate interaction of target proteins with E3 ubiquitin ligases by stabilizing the ternary complex and induce physical proximity, thereby triggering ubiquitination and subsequent proteasomal degradation. AR plays a key role in all stages of prostate cancer. It is activated by the binding of androgenic hormones and transcriptionally regulates multiple genes including the ones that regulate cell cycle. Using HiBiT CRISPR cell line, biochemical methods, and RNA sequencing, we report the potential role of VNPP433-3β, the next generation galeterone analog as molecular glue that brings together AR, the key driver of prostate cancer and MDM2, an E3 ubiquitin ligase leading to ubiquitination and subsequent degradation of f-AR and AR-V7 in prostate cancer cells. Targeted protein degradation (TPD) is a much-celebrated approach in today’s drug discovery efforts. Lately, close to 15 targeted degraders ranging from heterobifunctional PROTACs to molecular glues are expected to reach the patients soon . PROTAC Androgenic hormone-regulated transcriptional activity of androgen receptor (AR) is vital for the normal development and function of the prostate but aberrant AR signaling is a major hallmark and driver of prostate cancer, the second highest cancer of men in the US and worldwide . CastratIn this study, using biochemical, molecular biology, and CRISPR-edited 22Rv1 HiBiT cell line that combines the power of CRISPR-mediated gene editing and bioluminescent reporter system, we demonstrate the molecular glue degrader role of VNPP433-3β that chemically induces proximity and brings together the target f-AR and E3 ubiquitin ligase MDM2, resulting in ubiquitination and subsequent proteasomal degradation of f-AR. Our findings of VNPP433-3β as a molecular glue degrader of f-AR/AR-V7 further reiterate the potential development of VNPP433-3β for treating advanced CRPC.2. Chemical synthesis of Galeterone  and VNPP433-3β was performed as described earlier and dissolved in cell culture-grade DMSO [Prostate cancer cell lines, CWR-R1, CWR22Rv1 and LNCaP were procured from ATCC  and cultured as recommended in RPMI-1640 media containing 10% heat-inactivated fetal bovine serum  and 1% penicillin-streptomycin  at 37 °C and 5% COade DMSO . The priThe cells were harvested, washed in PBS, and lysed in RIPA buffer containing 1× protease inhibitors , phosphatase inhibitors  and 1 mmol/L EDTA and 1 mmol/L PMSF . Immunoblotting was carried out as described earlier Nuclei were isolated from the cultured cells that were treated with the VNPP433-3β or androgen (DHT) using NE-PER Nuclear and Cytoplasmic Extraction Kit  following manufacturer’s instructions as previously described . SubsequThe crystalline structure of human E3 ligase MDM2 (amino acids 17–125) available in the protein databank PDB (PDB id 2AXI) was employed for docking the ligand VNPP433-3β using the algorithm Autodock VINA 1.1.2. The co-crystallized ligand and water molecules were removed and polar Hydrogens and Kollman charges were added to the protein prior to docking as described previously . VNPP433CWR-R1 cells were hormone-starved for 48 h, treated with 10 µM VNPP433-3β for 4 h and lysed with lysis buffer . Immunoprecipitation of full-length AR (fAR) was carried out using Dyna beads conjugated to Protein A following manufacturer’s instructions . Dyna beads conjugate was incubated with 3 μg antibody and the Dyna beads-Ab complex was washed in washing buffer and successively in binding buffer. The cell lysate of 1 mg protein was then incubated with Dyna beads-Ab complex for 10 min. The complex was resuspended in elution buffer after washing in washing buffer and immunoblotted. The blot was probed with antibodies anti-fAR and anti-MDM2. IgG served as negative control.® Endurazine™ Promega # N2570) prepared in CO2-independent medium (Gibco # 18045088). The plates were incubated at 37 °C and 5% CO2 for 2.5 h to allow luminescence to equilibrate. Specified concentration of VNPP433-3β was added to five wells each, luminescence was read every 10 min for 5 h in TECAN Spark multimode microplate reader . Relative luminescence unit (RLU) was plotted against time using Graphpad Prism .CRISPR-edited 22Rv1 cells that express endogenous AR labeled with HiBiT, a small 11 amino acid peptide is obtained from Promega Corp, Madison, WI, USA , grown in RPMI medium  supplemented with 10% FBS (Gibco) and 1× PenStrep (Gibco) in T25 cell culture flasks and assayed as described previously . BrieflyTotal RNA was isolated from 22Rv1 cells treated with 10 μM VNPP433-3β for 24 h in triplicates using RNAeasy Plus mini kit . The RNA was quantified, and the quality of preparation was assessed using Agilent 2100 Bioanalyzer. Only preparations with RNA Integrity Number (RIN) 8 or above was considered for the preparation of library using NEB Ultra II Directional RNA library prep kit. The libraries were quality-checked using Qubit and Agilent 2100 Bioanalyzer. RNA sequencing was carried out in Illumina NovaSeq S2 PE100 bp lane at Maryland Genomics, Institute for Genome Sciences, University of Maryland Baltimore. The quality of sequencing was measured by Phred quality score (Q score). Differential gene expression and Gene Set Enrichment analyses (GSEA) were carried out to reveal the genes and cellular metabolic and signaling pathways modulated by VNPP433-3β.p < 0.05, ** p < 0.01 and *** p < 0.001 were considered statistically significant. All experiments were performed three times independently.Statistical analysis of differentially expressed genes were carried out and volcano plot was generated using GSEA  and GraphPad Prism 9. A probability value with * Altered androgen signaling contributes significantly to PCa development and progression. Studies showed that activation of the AR suppresses eIF4E phosphorylation whereas antagonizing AR with anti-androgens stimulated eIF4E phosphorylation. As the degradation of AR triggers the increase in eIF4E phosphorylation by Mnk1/2, combination of AR antagonists and mTOR inhibitors was effective in suppressing tumor growth . In ordeThe f-AR belongs to the steroid receptor superfamily and is a ligand-dependent transcription factor. In the absence of androgens (the ligand), f-AR is localized largely in the cytoplasm. However, upon activation by binding of androgen ligands, f-AR is translocated to the nucleus where it mediates active transcription of the target genes, the androgen-responsive genes. But, in CRPC cells, f-AR remains active in the nucleus and mediates transcription of androgen-responsive genes even in the absence of androgens leading to tumor progression ,21. TherWe next investigated the effect of VNPP433-3β in proteasomal degradation of AR. MG132 is a potent proteasome inhibitor that decreases degradation of ubiquitinated proteins by the 26 S proteosome in mammalian cells. To study the role of 26S proteasome in VNPP433-3β-induced f-AR/AR-V7 degradation, we treated 22Rv1 or LNCaP cells with 10 µM VNPP433-3β for 4 h followed by MG132 for 8 h. Interestingly, treatment with MG132 abated VNPP433-3β-induced degradation of AR, leading to the accumulation of AR in 22Rv1 A and LNCUsing different biochemical approaches, we have demonstrated that VNPP433-3β enhances proteasomal degradation of AR thereby significantly decreasing its level in PCa cells. To further validate this finding and kinetic studies of AR degradation in real time in live cells, we employed CRISPR-edited CWR22Rv1 cells that express endogenous AR labeled with HiBiT, a small 11 amino acid peptide that binds with high affinity to another larger subunit LgBiT. LgBiT is a luciferase that is non-functional; but binding HiBiT renders it functional due to complementation. When the HiBiT cells are transfected with LgBiT expression vector, the protein forms a functional complex (HiBiT-LgBiT complex) that can produce luminescence in the presence of suitable substrate. The luminescence is proportional to the amount of AR in the PCa cell . InteresSeveral studies show that physiologically, AR is regulated partly by MDM2-mediated ubiquitination and subsequent proteasomal degradation ,25,26. SSince AR is a known transcriptional factor that mediates the transcription of AR-responsive genes, we next evaluated the transcriptional variation of several key target genes by RNA sequencing. Various studies have identified several genes that are transcriptional targets of AR. We specifically analyzed major genes that appear in more than five independent studies as targets of AR as reviewed . All genNearly all the natural and synthetic ‘molecular glue degrader’ small molecules are discovered serendipitously while the PROTACS are rationally designed and developed . Earlierf-AR is known to activate transcription of several genes, the androgen-responsive genes. Failure of f-AR translocation into the nucleus is further reflected as decreased transcription of f-AR target genes as revealed by transcriptome profiling. Nearly all prostate cancer patients express elevated levels of prostate specific antigen (PSA) encoded by the gene KLK3 and is often considered as indicative marker of prostate cancer and or anomalous functioning of the prostate gland . RNA seqVNPP433-3β inhibits nuclear translocation of f-AR and f-AR-mediated oncogenic transcription by chemically inducing proximity of f-AR and E3 ligase MDM2 triggering targeted degradation of f-AR rapidly thereby inhibiting development and progression of prostate cancer. Because targeted protein degradation has a few putative advantages, including the simultaneous destruction of the target’s scaffold and enzymatic/antagonistic activities, and the ability to catalytically turn over the target protein within a cell, the development of VNPP433-3β as a potential therapeutic for prostate cancer is well justified.


To investigate clinical efficacy analysis of fast rehabilitation nursing on pain mitigation after lumbar discectomy and bone graft fusion and internal fixation. n = 30) or rehabilitation group (n = 30) via the random number table method. The patients in the routine group were intervened with the routine postoperative nursing mode, and the patients in the rehabilitation group were intervened with the fast rehabilitation nursing mode on the basis of the nursing of the patients in the routine group. The rehabilitation effect, self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores, postoperative pain improvement, and nursing satisfaction were compared between the two groups.  A total of 60 patients with lumbar disc herniation who underwent lumbar discectomy and bone graft fusion and internal fixation in our hospital from January 2021 to December 2021 were randomized either into routine group (P < 0.05). The fast rehabilitation nursing resulted in a notably lower postoperative SAS and SDS scores versus the routine nursing (P < 0.001). The postoperative pain was significantly mitigated in the rehabilitation group when compared with the routine group (P < 0.001). The fast rehabilitation nursing implemented in the rehabilitation group led to a remarkably higher nursing satisfaction of the patients (P < 0.001).  The postoperative rehabilitation effect of the rehabilitation group was significantly better than that of the routine group ( The fast rehabilitation nursing mode intervention for lumbar disc herniation patients undergoing lumbar discectomy and bone graft fusion and internal fixation is a promising approach to improve the postoperative rehabilitation, mitigate postoperative pain, and relieve anxiety, depression, and other negative emotions, with higher clinical nursing satisfaction. Lumbar intervertebral disc herniation is a common lumbar intervertebral disc rupture disease in clinical orthopaedics. It is the result of the rupture of the annulus fibrosus, which causes the nerve root of the patient to be compressed by the nucleus pulposus and then leads to the occurrence of lumbar intervertebral disc herniation . With thIn the context of the continuous transformation of biomedical models, perioperative care for lumbar spine diseases is not limited to the regulation and implementation of the nursing work system, but also involves how to promote the speed of postoperative recovery and improve the quality of life of patients. Simultaneously, with the continuous improvement of people's living standards and the level of medical and health knowledge, people's requirements for medical services are getting higher and higher. The fast recovery surgery nursing model is an emerging type of nursing method. On the basis of evidence-based medicine, patients are given perioperative optimization nursing intervention. Through the discussion of the nursing team, the routine perioperative nursing measures are improved, optimized to reduce the patient's stress response and maintain the balance of the patient's body indicators , 7. Addin = 30) or rehabilitation group (n = 30) via the random number table method. There were 27 males and 13 females in the routine group; the mean age was (52.43 ± 2.35) years; the mean disease duration was (10.53 ± 1.26) months. There were 28 males and 12 females in the rehabilitation group; the average age was (52.51 ± 2.36) years; the average disease duration was (10.48 ± 1.32) months. The two group patients presented similar baseline data. This study has been reviewed and approved by the Medical Ethics Committee of the Lu'an Hospital of Anhui Medical University .A total of 60 patients with lumbar disc herniation who underwent lumbar discectomy and bone graft fusion and internal fixation in our hospital from January 2021 to December 2021 were randomized either into routine group (Inclusion criteria: (1) the patients were diagnosed with lumbar disc herniation by clinical examination; (2) the cognitive and communication ability of the patients were normal; (3) all patients were informed of the study and signed an informed consent. Exclusion criteria: (1) patients with severe heart, liver, and other organic dysfunction; (2) patients with abnormal coagulation function; (3) patients with severe neurological diseases or cognitive impairment.Patients in the routine group were given routine nursing intervention, including life guidance, dietary guidance, psychological counseling, and health education. The patients in the rehabilitation group were combined with the nursing intervention of fast rehabilitation on the basis of the nursing of the patients in the routine group, while integrating traditional Chinese medicine intervention. (1) Pain care: in the postoperative care of the patients, the degree of pain of the patients should be evaluated first. At the same time, it is necessary to ensure that the environment of the ward is clean and comfortable, so as to improve the feeling of comfort of the patient, which is conducive to reducing pain; moreover; it is necessary to play light music for the patient, chat with the patient, and give the patient psychological support and counseling to distract the patient's attention to achieve the purpose of pain relief . (2) Str(1) Rehabilitation effect: markedly effective: the patient's activities returned to normal after nursing, and the clinical symptoms disappeared; effective: the patient's daily life basically resumed after nursing, and the clinical symptoms were greatly mitigated; ineffective: the patient's living ability did not improve after treatment, and the clinical symptoms did not mitigate or even aggravated. Total effective rate = (markedly effective + effective)/total number of cases × 100%. (2) Self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores: SAS and SDS were used to evaluate the psychological state of patients. 50–59 points were classified into mild anxiety, 60–69 points into moderate anxiety, and >70 points into severe anxiety. SDS score <53 was rated as no depression, 53–62 as mild depression, 63–72 as moderate depression, and >73 as severe depression. The lower the scores of the above indicators, the better the patient's psychological state. (3) Postoperative pain mitigation: the self-designed low back pain score scale of our hospital was used to detect the preoperative and postoperative pain of the patients. The full score of the scale was 100 points. The higher the score, the better the pain mitigation. (4) Nursing satisfaction: the “Nursing Satisfaction Questionnaire” designed by our hospital was used to score the patients. There are 20 questions in total, and the responses are summed to yield a total score ranged from 0–100 points <70 points are dissatisfied, 70–89 points are satisfied, and ≥90 points are very satisfied. Satisfaction = (very satisfied + satisfied)/total number of cases × 100%.t test was performed to compare the differences in measurement data, while the chi-square test was performed to compare the differences in count data. All statistical significance levels were set at a P value of less than 0.05.Statistical analysis was performed using SPSS/ Statistics 18.0 software for Windows . The paired P < 0.05), The postoperative rehabilitation effect of the rehabilitation group was significantly better than that of the routine group (P < 0.001), The fast rehabilitation nursing resulted in a notably lower postoperative SAS and SDS scores versus the routine nursing (P < 0.001), The postoperative pain was significantly mitigated in the rehabilitation group when compared with the routine group (P < 0.001), The fast rehabilitation nursing implemented in the rehabilitation group led to a remarkably higher nursing satisfaction of the patients (Lumbar intervertebral disc herniation is a common clinical disease in orthopaedics, and the contributors of this disease include heredity, congenital developmental abnormalities, external force injuries, and overwork . The cliIn this study, we first compared the postoperative rehabilitation effect of the two groups of patients. The results showed that the postoperative rehabilitation effect of the patients in the rehabilitation group was significantly better than that of the patients in the routine group. Fast rehabilitation nursing for patients with lumbar intervertebral disc herniation can effectively improve the postoperative rehabilitation effect of patients. It is attributed to the fact that fast rehabilitation nursing will provide accurate and detailed rehabilitation guidance for patients after operation and help guide patients to carry out rehabilitation training; thereby, the rehabilitation effect can be improved , becauseFast rehabilitation nursing mode intervention for lumbar disc herniation patients undergoing lumbar discectomy and bone graft fusion and internal fixation is a promising approach to improve the postoperative rehabilitation, mitigate postoperative pain, and minimize the occurrence of adverse reactions, with higher clinical nursing satisfaction. However, the number of patients included in this study was small, and a randomized multicenter study was not conducted. In the future, the number of patients included in the study will be expanded and the observation duration will be extended to obtain long-term clinical efficacy data to further verify the results.


The type, timing, and extent of provision of rehabilitation for lumbar discectomy patients in the UK are currently unknown. The aim of this study was to determine the provision and type of rehabilitation for patients undergoing lumbar discectomy in UK neurosurgical centers.Physical therapists involved in treating lumbar discectomy patients in UK neurosurgery centers were invited to complete an online survey that asked about the type, timing , and rehabilitation content for patients undergoing lumbar discectomy.n = 6 (35%) centers, postoperatively as an inpatient in all centers, and postoperatively as an outpatient in n = 14 (82%) centers. Factors that influenced the decision to provide rehabilitation included both external and internal or patient-related factors. Preoperative rehabilitation focused mainly on education, whilst postoperative outpatient rehabilitation focused more on exercises. Rehabilitation consistently included mobility, functional task training, and exercise prescription.Seventeen UK neurosurgery centers completed the survey. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. All participating centers provided a rehabilitation service for lumbar discectomy patients. Rehabilitation was provided preoperatively in Whilst all neurosurgical centers in this survey provided some form of rehabilitation for patients undergoing LD surgery, the approach remains inconsistent. Rehabilitation was delivered most frequently postoperatively, with one in three centers providing it preoperatively. Rehabilitation content also varied depending on when it was provided. Further research is needed to determine the optimum timing, contents, and target of rehabilitation for patients undergoing LD surgery.The online version contains supplementary material available at 10.1186/s12891-022-05346-1. Low back pain (LBP) is one of the leading causes of disability globally, affecting up to 80% of the world’s population at some time during their lives . Lumbar There are no current UK guidelines for LD rehabilitation. The American Physical Therapy Association (APTA) recommendations are to provide postsurgical general education, precautions, exercise, and resuming physical activity for patients with LBP following surgery . GeneralNational and international surveys , 12 havewww.SelectSurvey.net). Ethical approval was obtained from the University of Manchester .The design was a cross-sectional online survey. The survey was created and distributed using Select Survey tools  were identified by the Brain and Spine Foundation listed on the Royal College of Surgeons website.Recruitment took place between August 2019 to March 2020. The centers were approached firstly by posting the survey on the iCSP Network; secondly, by contacting centers by phone/email; thirdly, social media . For those who expressed an interest in taking part, a reminder email was sent after 3 weeks if the survey had not been completed.This study was descriptive, targeting all centers; therefore, no sample size calculation was undertaken.The survey questionnaire . Descriptive statistics were used to characterize the study population and questionnaire responses.The results of the study have been reported according to the STrengthening the Reporting of OBservational Studies in Epidemiology checklist (STROBE)  and the Responses were received from a total of 17 neurosurgery centers in the UK. Twelve (36%) responded from the 33 centers targeted as well as an additional five private centers. The completion rate, i.e., the percentage of users who finished the survey compared to those who started it, was (54%). The geographical distribution of the centers included the East Midlands, Northeast and Yorkshire, Northwest, Southeast, Southwest, and Wales  indicated that they were part of an ICP or healthcare protocol, 8 (47%) were not, and 2 (12%) were unsure.All seventeen centers provided postoperative inpatient rehabilitation for patients undergoing LD, and 14 (82%) provided postoperative outpatient rehabilitation. Six (35%) reported delivering rehabilitation preoperatively. Eight (47%) provided both postoperative inpatient and outpatient rehabilitation, while 3 (18%) provided only inpatient rehabilitation.Of the six centers providing preoperative rehabilitation, three centers invited all patients, while the other three invited only some patients. Of the 17 centers providing postoperative inpatient rehabilitation, fifteen offered rehabilitation to all patients, while two invited only a proportion. Of the fourteen centers providing postoperative outpatient rehabilitation, nine invited all patients after discharge, while in five, it was arranged if considered necessary.Factors influencing when to provide services included external factors, such as therapist experience about the required rehabilitation, surgeon protocols or preferences, or patient related factors such as functional or mobility status. Additional factors influencing the provision of preoperative rehabilitation included time limitations, staffing, and distance for patients to travel. For inpatient postoperative rehabilitation, it included multilevel surgery, and for outpatient postoperative rehabilitation, it included lack of current evidence, preadmission or admission processes, pain intensity, multilevel surgery, and comorbidities.There were differences between preoperative and postoperative inpatient and outpatient rehabilitation goals Fig. . Preopern = 2), whereas those who delivered this following admission used a one-to-one format (n = 4). All centers offering preoperative rehabilitation provided verbal and written patient education, while two centers provided additional online information.Of the six centers providing preoperative rehabilitation, those who delivered this prior to hospital admission used a class format (n = 12) delivered postoperative inpatient rehabilitation the day following surgery, while 5 delivered it on the same day. The frequency of sessions varied between centers from once a day (n = 14), twice a day (n = 2), and twice if the patient stayed a second night (n = 1). Postoperative patient education was provided using verbal and written information in n = 13 centers, while n = 4 provided only verbal information.The majority of centers (n = 6), 2 to 6 weeks following discharge (n = 5), while in 3 centers, rehabilitation was arranged depending on patient needs. Outpatient appointments were provided once a week (n = 9), three or more/week (n = 2), once every 2 weeks (n = 2), and dependent on patient needs (n = 1). Outpatient services were provided most commonly as one to one (n = 11), class (n = 1), or both (n = 2). Outpatients were provided with verbal information (n = 12), written information (n = 9), online information (n = 2), and video information (n = 1).Postoperative outpatient rehabilitation usually started within 2 weeks following discharge  followed an ICP. The content varied by service in terms of the type of exercise recommended, information provision, and advice on restrictions post-therapy.The strengths of our survey were that it was the first to evaluate preoperative rehabilitation following LD in the UK. Our questions reflect that of Gilmore et al. (2016) so a comparison between the UK and Australia can be made. Private and NHS centers have been included, providing a more reflective picture of practice.The limitations of our survey include response rate. Some researchers consider an acceptable response rate of between 60 to 75% , 20. On Information about rehabilitation and its timing was obtained by self-report and could have been subject to potential recall errors. Additionally, different teams may be responsible for preoperative and postoperative rehabilitation in each center; it is difficult to determine whether all teams were involved in responding. Finally, whilst most regions of England and Wales were represented, there may be differences between centers in terms of population, number, and type of surgery; caution is needed when generalizing the findings to the whole of the UK.In comparison to previous surveys, our findings showed that 9 (53%) of centers provided routine postoperative outpatient rehabilitation, compared to (44%) in a UK survey undertaken 14 years ago ; similarSimilarly, in the current survey, of the six UK centers that provided a preoperative service, about half invited all patients, others based decisions about invitation on a combination of factors external to the patient, including staffing, time limitation, and staff experience, and factors internal to the patient, including functional status, mobility, and distance to travel. Patients living far away from neurosurgery centers are not always invited or can travel to the appointment, and it is not clear whether they have access to local services. Although there are programs helping to improve access to specialist rehabilitation services, such as the UK Rehabilitation Outcomes Collaborative (UKROC), patients in some areas cannot access the right rehabilitation services .In the Australian survey, Gilmore et al. (2016) reported that preoperative rehabilitation was provided at 39% (25/64) of hospitals either in a preadmission clinic 46%, 12/25) or following admission to hospital  and that the most common reason for not providing preoperative rehabilitation was a lack of opportunity due to the patient preadmission or admission process [/25 or foPreoperative rehabilitation has been shown to be effective in other settings, including intra-abdominal surgery –25; cardEvidence showed that preoperative rehabilitation is provided for other back surgery. Current practice in the UK for lumbar fusion surgery showed that 94% of surgeons reported that their patients were seen preoperatively . Almost In our survey, just under half of the centers followed ICPs or a healthcare protocol. We did not ask about details of individual ICPs. However, there is evidence of variation in the composition and application of ICPs in spinal surgery . The NatThe APTA guidelines recommend general postoperative exercises . AdherenThere was a difference in preoperative and postoperative rehabilitation. Education alone dominated preoperative rehabilitation, whereas exercise and education together focused more during postoperative inpatient, and exercise dominated postoperative outpatient rehabilitation. As outlined, the evidence base to inform the content of lumbar surgery rehabilitation is weak, and it remains unclear which interventions, or combination of interventions, impact the outcome. Studies have shown that including education in a rehabilitation program for lumbar surgery patients reduces anxiety, increases patient empowerment and satisfaction, and results in positive outcomes –44. APTAIncreasing patient knowledge is an important component of management . In our Although described as rehabilitation, we found that preoperative rehabilitation tends to focus on providing information and preparing the patients for postoperative events. This reflects the fact that the majority of patients who have been listed for surgery have already received rehabilitation as part of conservative management of their back pain. Therefore, preoperative rehabilitation tends to focus on education for the postoperative period, including mobility and functional training. There is also no evidence to suggest how the content of the preoperative education should be provided.As expected, all centers reported providing advice about postoperative restrictions. Advice provided preoperatively and as an inpatient, postoperatively, was generally broad; however, advice during outpatient rehabilitation was less consistent and possibly more specific and targeted to individual patient needs. A lack of information about what to expect during postoperative recovery has been linked with patient anxiety and depression symptoms both before and after surgery . This isThis study provides an insight into current practice. More evidence is needed to provide clearer and more detailed guidelines, including those relevant to the UK. Future research should aim to identify and evaluate the optimal timing, content, frequency, and format of LD surgery rehabilitation. Barriers and facilitators to guideline implementation would also facilitate standardization of care.This study has provided descriptive data on the current rehabilitation for patients undergoing LD in the UK. The survey findings highlight inequity in the provision and add to the global picture of current practice. All neurosurgical centers in this survey provided rehabilitation for patients with LD surgery with therapy primarily delivered postoperatively. One in three centers provided preoperative rehabilitation. Preoperative therapy tended to include more general advice, whereas this was probably more targeted to patient needs in the postoperative setting. There was evidence of variability in the type of exercises prescribed in different centers. Further research is needed to determine the optimum timing, content, frequency and format and of rehabilitation for patients undergoing LD surgery.Additional file 1. Survey questionnaire.


Activating FLT3 mutations are the most common mutations in acute myeloid leukemia (AML), but the optimal threshold of FLT3/ITD allelic ratio (AR) among pediatric AML patients remains controversial. Here, we present the outcome and prognostic significance of FLT3/ITD AR analysis among pediatric patients with AML from the TARGET dataset. Applying fitting curve models and threshold effect analysis using the restrictive cubic spline function following Cox proportional hazards models identifies the cut-off value of 0.5 on FLT3/ITD AR. Moreover, we observe that high FLT3/ITD AR patients have an inferior outcome when compared to low AR patients. Our study also demonstrates that stem cell transplantation may improve the outcome in pediatric AML patients with high FLT3/ITD AR and may be further improved when combined with additional therapies such as Gemtuzumab Ozogamicin. These findings underline the importance of individualized treatment of pediatric AML. Activating FLT3 mutations are the most common mutations in AML. Here, the authors explore the relationship between the FLT3/ITD allelic ratio and prognosis in pediatric AML patients and identify an optimal threshold to stratify patients. It has been reported that the incidence of FLT3/ITD in adult AML is about 20–35%, whereas pediatric AML has a reported prevalence of 15% for FLT3/ITD, which was lower than in adults12. Previous reports demonstrated that childhood patients who harbored mutant FLT3/ITD had poor AML prognosis in certain large-scale studies15. Moreover, a high allelic ratio (AR) among patients with mutant FLT3/ITD to wild-type alleles revealed poor prognosis among pediatric and adult AML patients21. It is known that different ARs of FLT3/ITD demonstrated uneven prognostic significance, and a crucial cut-off value of 0.5 for FLT3/ITD AR has been well established in European LeukemiaNet (ELN 2017)22, which has been reclassified as a favorable risk, but is only restricted to adult AML, whereas the threshold for pediatric AML remains controversial.Activating mutations of the FMS-related tyrosine kinase 3 (FLT3) receptor gene leads to constitutive activation of the FLT3 receptor tyrosine kinase and results in autonomous, cytokine-independent proliferation in vitro, which are the most common somatic mutations observed in acute myeloid leukemia (AML)In this present study, we report a comprehensive study among childhood AML to explore the characterization of FLT3-ITD AR and its influence on outcomes. Most importantly, our primary purpose was to determine an optimal cut-off value for FLT3-ITD AR in a large-scale study of 1857 pediatric AML patients from the Therapeutically Applicable Research to Generate Effective Treatments (TARGET) database in order to provide evidence for risk-stratified therapy and prognostic evaluation in the FLT3/ITD-positive pediatric patient population.P = 0.029). The median age of mutant FLT3/ITD was higher than that of wild-type  and mutant FLT3/ITD was far more common in older patients (å 10 years) . The initial median WBC of mutant FLT3/ITD patients was higher than that of wild-type patients , and was more common in patients with WBC > 50 × 109/L . Both peripheral blood (PB) blasts and bone marrow (BM) blasts among children harboring FLT3/ITD mutation were significantly higher than those harboring wild type .In total, 1857 pediatric AML patients were enrolled in this study. Among the TARGET group, 974 (52.5%) were male and 883 (47.5%) were female, and the median age in our cohort was 9.5 years old. The demographic, laboratory, and clinical characteristics of pediatric AML patients were compared based on the FLT3/ITD status (Table P < 0.001). FLT3/ITD mutation patients were mainly observed in the high-risk group (65.8%) and only 3.2% pediatric AML harbored wild-type in the high-risk group. The incidence of coexistence of mutant FLT3/ITD and WT1 mutation was 21.8%, which was higher than those which harbored wild-type and WT1 mutation (P < 0.001), where similar results also appeared in the coexistence of mutant FLT3/ITD and NPM1 mutation . Patients with mutant FLT3/ITD were more likely to have the FAB M1 phenotype than those with wild-type . None of the patients who harbored FLT3/ITD mutations had FAB M7 (Table P < 0.001).52.6% of childhood AML harbored mutant FLT3/ITD accompanied by normal karyotype, compared with 18.4% which harbored wild-type (P < 0.001). After course 2 of induction therapy, childhood AML with mutant FLT3/ITD had an inferior induction treatment response where 245 (77.8%) participants achieved CR, as opposed to 1285 (88.8%) cases with wild-type (Table P < 0.001).At the end of course 1 of induction therapy, 215 (64.6%) of the 341 participants with FLT3/ITD mutations achieved a CR compared with 1154 (77.2%) of 1516 participants with wild-type (P < 0.001). EFS(SD) at 5 years from study entry for pediatric AML patients which harbored mutant FLT3/ITD was 36.6% (11.6%) compared with 45.6% (5.5%) for the FLT3/ITD wild-type population  for childhood AML alive at last contact was 2.9 (0.1–10.9) years for patients with mutant FLT3/ITD and 3.6 (0.1–11.3) years for those with wild-type  can be converted to relative risk by pairing logarithms. After adjusting for factors that may be associated with all-cause mortality, including gender, chemotherapy protocol; risk group; BM blast; PB blasts; CNSL; FAB category; karyotype; WBC group; age group; CEBPA status; WT1 status; NPM1 status, FLT3/ITD AR was found to have a biphasic distribution Fig. , with anP = 0.057) for AR < 0.5 while 1.6  for AR ≥ 0.5  was 45.1 . Patients with high AR had a significantly higher BM and PB blast percentage of 85% and 73% compared with that of 69% and 49% for patients with low AR (both of P < 0.001), respectively. In addition, cases with high AR were more common to have FAB M1 than those with low AR . Those with high AR had a CR rate of 72.5% vs. 84% for those with low AR at the end of course 2 (P = 0.048). As expected, the proportion of pediatric AML with high AR who accepted SCT was significantly higher than those with low AR . Meanwhile, patients harboring high FLT3/ITD AR were more likely to appear in the high-risk group with a percentage of 65.8%, which was higher than those harboring low AR with only a percentage of 3.2% (P < 0.001). However, GO treatment seems to be similar in the distribution between high and low AR group .We compared the laboratory and clinical characteristics of patients with high and low FLT3/ITD AR  and 39.7% (17.1%) (n = 176) and chemotherapy-only (n = 1233). In FLT3/ITD wild-type patients, EFS at 5 years was 52.3% (21.4%) for the recipients of SCT versus 48.1% (5.9%) for those who received chemotherapy-only  with those treated with chemotherapy-only (n = 181). Within the cohort harboring FLT3/ITD mutations, SCT showed a favorable outcome on 5-year EFS (58.6% (18.1%) vs. 28.3% (15.1%); P < 0.001) and a better 5-year OS (64.3% (16.2%) vs. 45.7% (15%); P < 0.001) than those with chemotherapy-only  had mutant FLT3/ITD and the remaining 176 (59.7%) had wild-type. We initially compared outcomes directly between FLT3/ITD wild-type patients receiving SCT  vs. 70.5% (20.1%), P = 0.2; Fig. Among the 119 cases with mutant FLT3/ITD who received SCT, 76 had high and 43 had low FLT3/ITD AR, whereas of the 181 patients with FLT3/ITD who received conventional chemotherapy, 85 had high AR and 96 had low AR. In patients with chemotherapy-only who harbored high FLT3/ITD AR, 5-year EFS was 14.5% (18.3%), compared with 39.8% (21.8%) in low FLT3/ITD AR  vs. 54.5% (20.3%), P = 0.64; Fig. n = 161), SCT had a favorable impact on 5-year EFS (65.6% (22.5%) vs. 14.5% (18.3%), P < 0.001; Fig. P < 0.001; Fig. From further evaluation of the 139 childhood AML cases with low FLT3/ITD AR, survival analysis demonstrated that SCT conferred no impact on prognosis when compared with chemotherapy-only recipients (5-year EFS: 46% (18.9%) vs. 39.8% (11.4%), n = 16). The remaining 80 patients which were treated in the AAML0531 group (n = 77) and AAML03P1 (n = 3) received chemotherapy in the No-GO group only. When compared with the No-GO ARM, there were no significant differences in gender, CNSL, karyotype, WBC, PB blast, BM blast, and risk group in the GO group (Table P = 0.042). More children received GO therapy in AAML03P1 than in the NO-GO cohort . The median age of the No-GO ARM was higher than that of the GO cohort . No significant differences were found between high AR vs. low AR between the two treatment cohorts. Patients in the GO cohort accepted the initial dose of GO during induction course I, thus we evaluated the impact of GO on CR rates at the end of induction course. After the whole induction course, patients with GO had a CR rate of 80.5% vs. 73.4% for the No-GO cases (P = 0.396).A total of 836 patients with de novo AML treated with AOGAAML03P1 and AAML0531 were included in the evaluation, and we identified 169 FLT3/ITD-positive patients whose clinical outcome data were included in further analyses. Of these 169 patients with FLT3/ITD mutation, 89 patients received standard chemotherapy (GO group) and were treated with AAML0531 (n = 73) and AAML03P1 (up Table . There wP = 0.854) , had an inferior 5-year EFS (16.7% (37%) vs. 57.1% (55.1%), P = 0.023; Fig. P = 0.014; Fig. n = 14).Subsequently, we investigated the impact of GO in the high AR FLT3/ITD cohort. Among the high AR FLT3/ITD cohort, patients with GO had a similar CR rate of 68.9% vs. 67.5% for the No-GO group  and OS , instead of the FLT/ITD mutation  from the multivariable analysis. As expected, we showed that CEBPA and NPM1 mutations were also favorable independent prognostic factors for both EFS and OS, whereas WT1 was significantly associated with inferior EFS. Meanwhile, age (>10 years) exhibited a significantly negative influence on OS but not EFS. Conversely, WBC (>50 × 109/L) showed a strong association with an adverse EFS instead of OS. However, GO seemed to be not associated with EFS  or OS  , which was consistent with previous pediatric reports16. Several prior reports26 have demonstrated that FLT3/ITD mutation was significantly associated with higher WBC counts, higher PB blasts, higher BM blasts, older age, in addition to increasing probability to have FAB M1 phenotype and normal karyotype, where similar results could be found in this current study. Previous studies28 also illustrated the presence of FLT3/ITD as an independent risk factor contributing to disease evolution and poor prognosis among AML patients. In this study cohort, we observed that after induction therapy, the CR rates in childhood AML that harbored the FLT3/ITD mutation were inferior to patients with FLT3/ITD wild-type, which indicated that mutant FLT3/ITD patients had a poor early treatment response. Furthermore, our survival analysis showed that FLT3/ITD mutation was identified for inferior EFS and OS rates compared with FLT3/ITD wild-type. Unfortunately, our multivariable analysis subsequently validated that FLT3/ITD mutation was not an independent prognostic factor. Taken together, the presence of FLT3/ITD had no significant effect on prognosis.The TARGET program is a COG-National Cancer Institute (NCI) collaboration that can be used to effectively study the pediatric cancer cohort29. However, the use of an AR threshold of 0.5, as described in the previous report, was only in the adult AML cohort. In regards to pediatric studies, the cut-off value of FLT3/ITD AR was only reported by two large-scale collaboration groups, which were the Children’s Oncology Group (COG) with 630 childhood patients, and Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG) with a total of 369 samples. The former reported16 that AR > 0.4 was a significant and independent prognostic factor for relapse in pediatric AML, while the latter reported26 AR > 0.7 as the threshold for inferior EFS and OS. However, both of the studies were published several years ago and had much smaller sample sizes relative to the TARGET cohort (n = 1857), hence it was necessary to re-determine the optimal cut-off value of FLT3/ITD AR at present. Subsequently, we examined the relative risk for all-cause mortality of patients with different FLT3/ITD AR, which underwent a fitting curve analysis with the aim of confirming the optimal threshold of FLT3/ITD AR that was observed in such a large sample of FLT3/ITD-positive pediatric AML patients and finally the turning point was selected by using Cox proportional hazards models.Based on our findings, we hypothesize that FLT3/ITD AR may play an important role in prognosis. Both the National Comprehensive Cancer Network (NCCN) and ELN guidelines incorporated FLT3/ITD mutation in the risk stratification of patients based on the AR with a threshold of 0.530. Given the relationship between FLT3/ITD AR and prognosis, it has been reported that a high FLT3/ITD AR may suggest that the mutation occurred at an early stage and was a driving event for leukemogenesis, whereas a low AR suggests that the FLT3/ITD mutation was not a driving event for leukemia31.In this current study, those with high FLT3/ITD AR had a significantly higher WBC count, higher BM and PB blast, with inferior CR rates compared with those with low AR. Our survival analysis also showed that high FLT3/ITD AR had a strong impact on decreasing 5-year EFS and OS. From these results above, we suggested that the different FLT3/ITD allele ratios may represent an imbalance of FLT3/ITD alleles, ultimately reflecting the genetic heterogeneity and complexity of mutant FLT3/ITD AML33. When we focused on the impact of FLT3/ITD AR on the clinical outcome in pediatric AML, especially in the subgroup of chemotherapy-only patients, high FLT3/ITD AR was apparently associated with poorer EFS and OS when compared with low AR. In contrast, the 5-year EFS and OS of high FLT3/ITD AR could be significantly improved by SCT in our study. What’s more important, after adjusting for a number of potential confounders, the results were still consistent in our K–M analysis. All of the abovementioned results suggested that SCT was more particularly indicated for pediatric AML patients with high AR instead of chemotherapy only.In the entire study, our analysis showed that SCT recipients of mutant FLT3/ITD could significantly improve EFS and OS when compared with those who did not receive SCT. These findings were consistent with the concept that SCT was indicated for AML patients with FLT3/ITD mutation2) to standard chemotherapy did not improve the initial CR rate. Subsequently, we assessed the outcomes for high AR FLT3/ITD patients with or without GO, and finally found no statistical differences on EFS and OS. However, through subgroup analysis, the prognosis of high AR patients who received SCT plus GO was significantly better than those with chemotherapy plus GO, where the results were consistent with previous literature34. In total, our results showed that GO targeting with HCT consolidation might be a useful therapeutic strategy among high AR FLT3/ITD pediatric patients.As mentioned above, the prognosis of FLT3/ITD patients with chemotherapy-only is poor, especially those with high AR. While HCT increased the survival of patients in this cohort to approximately 65%, the use of alternative approaches such as GO is necessary to further improve outcomes. In this present study, we found that the addition of GO , 86 were unable to be evaluated , and finally, 1857 patients with childhood AML were enrolled in our research. The results published here were in whole or partly based upon data generated by the Therapeutically Applicable Research to Generate Effective Treatments (https://ocg.cancer.gov/programs/target) initiative, phs000218. Datasets from childhood patients with AML from 4 clinical trials were accessed through the TARGET database. These trials were registered as NCT0007017435, NCT0037259336, NCT0137198137, and NCT0000279838, respectively. The data used for this analysis are available at https://portal.gdc.cancer.gov/projects. The study was approved by the Ethics Committees of Office of Cancer Genomics (OCG). All the patient’s guardians signed informed consent forms.This study was approved by the ethics committee of National Cancer Institute’s Office of Cancer Genomics. We obtained demographic, clinical characteristics, and laboratory data of AML in children under the age of 18 from the TARGET dataset . From September 1996 to December 2016, 2064 pediatric AML (non-M3) cases were enrolled in the TARGET database: 121 were excluded /t or t, and high-risk patients were defined as those having monosomy 7 or del(5q). Patients with an accepted cytogenetic sample who did not meet the criteria for low or high risk were defined as standard risk. Stem cell transplantation (SCT) was performed in high-risk AML patients with first complete remission. Enrollment years were from 1996 to 2016, and the last follow-up years were 1997–2019, according to TARGET data.35, AAML053136, AAML103137, and CCG-296138, respectively (Table 2) administered once during induction course I on Day 6, then once more during the intensification course II on Day 7.The four therapeutic regimens included in this study differed in their basic composition of drugs. Tables ly Table . From thhttp://www.empowerstats.cn/). P < 0.05 was considered statistically significant.The baseline characteristics represent the classification variables as frequency (%) and the median as continuous variables. Chi-square test was used for categorical variables and analysis of variance and the Kruskal–Wallis test was used for continuous variables. The multivariable Cox proportional hazards model was used to determine the independent effect of prognostic factors on overall and event-free survival in AML patients. In order to explore whether there was a non-linear relationship between FLT3/ITD AR and all-cause mortality, after adjusting for all covariates, the correlation fitting curve between FLT3/ITD AR and all-cause mortality was drawn using the restrictive cubic spline function following the Cox proportional hazards models. Threshold levels  were determined by trial and error, which involves selecting turning points along a predetermined interval and then chosing turning points. In order to assess the clinical outcome, we used the following concepts: complete remission , event-free survival , and overall survival . EFS and OS were evaluated by the Kaplan-Meier method and compared by log-rank test. All statistical analysis by SPSS statistical software version 22.0 and EmpowerStats (Further information on research design is available in the Supplementary InformationPeer Review FileReporting Summary


Retarded AR ofeCs-KO sperm was enhanced by cyclic adenosine 3′,5′-monophosphate (cAMP) treatment. In conclusion, eCS regulates AR via a cAMP-dependent pathway, which presumably contributes to sperm metabolism.The sperm consumes adenosine triphosphate (ATP) to maintain the cellular function, viability, acrosome reaction (AR), and motility. Extra-mitochondrial citrate synthase (eCS) catalyzes citrate production in the sperm head, and thus regulates sperm function through ATP synthesis, similarly to CS. This study aimed to investigate how eCS regulates AR. Herein, acrosome-reacted (ARed) sperms were rarely detected on the zona pellucida, and spontaneous ARed sperm in Citrate synthase (CS) is localized in the mitochondrial matrix, where it catalyzes the reaction between acetyl coenzyme A and oxaloacetate to form citric acid (Surpin and Chory 1997). The extra-mitochondrial form of CS (eCS) is encoded by a separate gene in mice (citrate synthase like (Csl) MGI:1919082) and expressed by alternative splicing of the CSgene in humans . eCS also has CS activity, implying its involvement in ATP production which is related to sperm function in the extra-mitochondrial cytoplasm . Citrate serves as an essential substrate in the tricarboxylic acid (TCA) cycle, and its subsequent complete oxidation is the major source of cellular ATP production (Iacobazzi and Infantino 2014). Consequently, the activation of TCA cycle-related enzymes that regulate cellular ATP production may be involved in controlling sperm functions . Conceivably, eCS is involved in regulating AR in the sperm head, as citrate is an important substrate in cellular energy metabolism (Iacobazzi and Infantino 2014). However, the role of eCS in AR remains unclear.Sperm must undergo sequential and complex processes in the uterus and oviducts before fertilizing the eggs, including capacitation and acrosome reaction (AR) (Gervasi and Visconti 2016). Adenosine triphosphate (ATP) production through glycolysis and oxidative phosphorylation (OXPHO) is essential for maintaining sperm motility and completing AR . Anti-IZUMO1 monoclonal antibody (mAb) can react with the sperm head only after permeabilization because IZUMO1 is present in the inner acrosomal region before AR . However, in sperm that have undergone AR, anti-IZUMO1 mAb can react with the sperm head even without permeabilization . As depicted in Figure 1A, Hoechst 33342-stained sperm were incubated with cumulus-intact eggs for 10 min and subjected to immunostaining with an anti-IZUMO1 mAb without permeabilization of the sperm. Although the WT sperm underwent AR successfully, it failed to undergo AR in theeCs-deficient (eCs-KO) sperm  .We studied the influence of eCS deficiency on AR using IZUMO1, an integral membrane protein of the sperm that is essential for sperm-egg fusion , the elevation of intracellular calcium in the post-acrosomal region is essential and is thought to be induced by the cyclic adenosine 3′,5′-monophosphate (cAMP) signaling pathway (Breitbart 2002). To assess the involvement of the cAMP-dependent pathway in the AR ofeCs-KO sperm, we evaluated the AR ineCs-KO sperm after dibutyryl cAMP (dbcAMP), a cell-permeable synthetic analog of cAMP, treatment. As depicted in Figure 1D, sperm were collected from the cauda epididymis and incubated in dbcAMP  for 2 h without cumulus-intact eggs. The sperm were then immunostained with anti-IZUMO1 mAb and counterstained with 4’,6-diamidino-2-phenylindole (DAPI). AR is known to occur spontaneously, even when sperm are cultured without cumulus-intact eggs . The percentage of sperm that underwent AR among those incubated without cumulus-intact eggs was then evaluated. Consequently, without dbcAMP treatment, the percentage of acrosome-reacted (ARed)eCs-KO sperm was significantly lower than that of WT sperm . After treatment with 2 μM dbcAMP, the percentage of ARed WT sperm remained unaltered, while the percentage of ARedeCs-KO sperm was strikingly elevated and turned out to be comparable with that of the WT sperm . Similarly, when the sperm were treated with 3.5 and 5 μM dbcAMP, the percentage of ARed WT sperm remained unaltered, while the percentage of ARedeCs-KO sperm was strikingly elevated but comparable with that of the WT sperm . These results indicated that cAMP signaling plays an important role in the AR ofeCs-KO sperm.To induce sperm AR in both humans and mice . In particular, the regulation of sperm motility and AR is highly dependent on mitochondrial activity (Moraes and Meyers 2018). The activities of some mitochondrial enzymes such as CS and respiratory complexes showed a high correlation with sperm motility , and asthenozoospermia was the cause of the reduction in their activities. As reported earlier , mitochondrial metabolic activity is altered by reduced amounts of citrates ineCs-KO sperm, suggesting a possible role for eCS proteins in regulating mitochondrial activity. However,eCs-KO sperm exhibited normal motility, indicating no correlation between eCS and sperm motility.AR retardation inet al. 2016). As both glycolysis and OXPHO pathways can produce ATP in sperm , the activities of the enzymes involved in these pathways are important for ATP production. eCS is localized in the acrosome of the sperm head, while CS is localized inside the mitochondria of the sperm midpiece. Importantly, wheneCs-KO sperm were incubated in the presence of dbcAMP, ARed sperm levels were significantly increased, raising the possibility that cAMP plays a critical role ineCs-KO sperm function. The cAMP-dependent protein kinase (PKA) signaling pathway plays a central role in the regulation of energy balance and metabolism . Because of its location, eCS may be directly or indirectly involved in ATP-related induction of AR. It would be interesting to uncover the mechanism by which eCS regulates energy metabolism in sperm.It is well known that ATP is essential for sperm motility and AR , mutant mice were generated from C57BL/6-derived embryonic stem cell clones by injecting blastocysts from C57BL/6 mice with genetically deletedCsl(eCs) (Csltm1(KOMP)Vlcg;MGI:4842999) obtained from the knockout mouse project (KOMP) repository, an NCRR-NIH-supported strain suppository. C57BL/6J mice  were used as the controls.All the mice were housed under specific pathogen-free conditions. Food and water were providedad libitum. All animal experiments were approved by the Institutional Animal Care and Use Committee of the National Research Institute for Child Health and Development .Using the method reported in a previous study . Alexa 488- and 546-conjugated IgG were purchased from Molecular Probes  as secondary antibodies for immunohistochemistry. Nuclei were counterstained with DAPI . dbcAMP was purchased from Sigma-Aldrich .Sperm/cumulus penetration assay2. The capacitated sperm (150 sperm/µL) was mixed with the cumulus-oocyte complexes (COCs) in a 100-μL TYH drop and incubated for 10 min at 37 °C in 5 % CO2. The COCs and sperm were then transferred to a 100-μL drop of fresh TYH medium and fixed by treatment with 100-µL Hanks’ balanced salt solution containing 8% paraformaldehyde and 1% polyvinylpyrrolidone (PVP) for 15 min, followed by washing with HBS containing 0.5% PVP. COCs and sperm were immunostained with Alexa Fluor 488-labeled anti-IZUMO1 mAb. The COCs were lightly squashed to accommodate them within the 80-µm space between the glass slide and the coverslip and then observed under a fluorescent microscope . Fluorescent images were captured as vertical sections with 3-μm intervals and then stacked into a single picture using BZ-analyzer software (Keyence), as described previously .Cauda epididymal sperm were incubated in a 200-μL drop of TYH medium containing Hoechst 33342 (2.5 µg/mL) for 10 min at 37 °C and then capacitated by incubation in a 100-μL drop of TYH medium for 2 h at 37 °C under 5% COSpontaneous AR2. After 2 h of incubation in the absence and presence of 2, 3.5, and 5 mM dbcAMP, the sperm were transferred into a 1.5-mL microtube, washed with HBS, and fixed with 4% PFA in HBS on ice for 15 min. After fixation, the sperm were immunoreacted with an anti-IZUMO1 antibody, incubated with an Alexa Fluor 568-conjugated antibody against rabbit IgG, and counterstained with Hoechst 33342. Fluorescent images were obtained under a fluorescence microscope (KEYENCE BZ-X710).Cauda epididymal sperm were dispersed in a 200-µL drop of albumin-free TYH medium for 10 min and subsequently incubated in albumin-containing TYH medium at 37 °C under 5% COStatistical analysisU-test, or Fisher’s exact test. Statistical significance was defined asp< 0.05. The results are expressed as the mean ± standard error of the mean.Comparisons were made using one-way analysis of variance following Scheffe’s method, Mann–Whitney


Compare to non-obese children, the rates in obese children were higher for CO (odds ratio (OR) 3.54, 95% confidence interval (CI) 1.15 ~ 10.92); PM10  and PM2.5 . In obese children, correlations between higher concentrations of CO, PM10, PM2.5 and higher nasal discomfort (higher PRQLQ); and correlations between higher concentrations of CO, PM10, PM2.5, NMHC (non-methane hydrocarbon) and higher nasal mucosa inflammation (lower NPEF) were noted. Obesity negatively affected AR severity when AR children experienced higher concentrations of CO, PM10, and PM2.5. Increased nasal inflammation induced by air pollutants might be the underlying mechanism.The association between air pollution, allergic rhinitis (AR), and obesity has not been studied. From 2007 to 2011, 52 obese and 152 non-obese children (7–17 years old) with AR were recruited. Pediatric-Rhinoconjunctivitis-Quality-of-Life Questionnaire (PRQLQ) and nasal peak expiratory flow (NPEF) were tested. Association between the scores and rates of the two tests and mean air pollutant concentrations within 7 days before the tests were compared. When exposed to higher concentrations of CO, PM Therefore, determining the association between air pollution, obesity, and AR is crucial. However, this association has not been previously studied.Recently, more attention has focused on the impact of air pollution on individual health. Obesity2 and biological3 studies had find their association. Regarding the relationship between obesity and AR, epidemiological5 and biological6 studies also find their association. Air pollution can induce the recruitment of inflammatory cells and inflammatory cytokines7. AR and obesity are considered chronic inflammatory illnesses9. Studies also found that the aforementioned inflammatory cells and cytokines induced by air pollutants are also increased in people with obesity or AR10. It indicated that air pollution, AR, and obesity share the same immune and inflammatory effects on the human body.Regarding the relationship between air pollution and AR, epidemiological2; or AR and obesity5; or air pollution and obesity11 were studied. The combined associations between air pollution and obesity and AR were not studied. Therefore, a retrospective cross-sectional, case–control study was conducted to find the association. We aimed to investigate the influence of air pollutants on the severity of rhinitis  and degree of nasal obstruction and nasal mucosa inflammation among AR children when they are obese or non-obese.Therefore, it is reasonable to speculate that air pollutants might have a stronger adverse effect on the severity of AR when they are obese. However, only the separate relationship between air pollution and AR2), carbon monoxide (CO), particles ≤ 10 μm in diameter (PM10), particles ≤ 2.5 μm in diameter (PM2.5), nitric oxide (NO), nitric dioxide (NO2), and non-methane hydrocarbon (NMHC).The Environmental Protection Administration established five air pollution monitoring stations in Taichung, Taiwan. Concentrations of air pollutants, ambient temperature and relative humidity were measured continuously around the clock and reported hourly. Data on the mean daily levels of air pollutants, ambient temperature and relative humidity were supported and the data between 2007 and 2011 were gathered for the study. The following seven air pollutants were assessed: nitrogen dioxide  were measured and recorded in the chart, and the body mass index  was calculated. Based on the growth charts for Taiwanese children and adolescents13, these participants were classified into (1) obese AR children (BMI > 85th percentile) group and (2) non-obese AR children (BMI < 85th percentile) group.From chart review, children aged 7–17 years with AR residing in Taichung, Taiwan, were recruited from a teaching hospital in the same city, from January 1, 2007, to December 31, 2011. AR was diagnosed by two pediatric allergy specialists. Based on the AR and its Impact on Asthma guidelines14 and nasal peak expiratory flow 15 were tested on the same day and were done in the same setting for each patient. They were tested once and randomly on different days over the 5 years. NPEF was measured three times in the seated position using a Mini-Wright peak flow meter  connected to an anesthetic face mask. Subsequently, the highest value was eventually selected. The questionnaire was writ by children and under the assistance of their parents.In these AR children, the Pediatric Rhinoconjunctivitis Quality of Life Questionnaire The mean concentrations of each air pollutant within 7 days before the tests were calculated for the study. A higher PRQLQ indicates that patients suffer more discomfort from nasal symptoms . Correlations between PRQLQ scores and mean pollutant concentrations were compared to determine the influence of obesity on the quality of life of AR children when they attained higher air pollutant concentrations. A lower NPEF indicates that the patients suffered a higher degree of nasal obstruction and nasal mucosa inflammation. Correlations between NPEF rates and mean pollutant concentrations were also compared to determine the influence of obesity on nasal obstruction and inflammation when they exposed to higher air pollutant concentrations. Potential confounders were adjusted, including age, sex, second-hand smoke exposure, combined with asthma or not and parental occupation. Parental occupation included white-collar , blue-collar (company employee and others), and others . Mean ambient temperature and relative humidity within 7 days before the test were also adjusted.10 was divided to 34.0–67.2 μg/m3(low level) and 67.3–100.5 μg/m3 (high level); and PM2.5 was divided to 20.0–40.7 μg/m3(low level) and 40.8–61.5 μg/m3 (high level). PRQLQ contain 23 items and each item on a scale of 0 (not troubled) to 6 (extremely troubled)14. Scales euqal or higher then 4 (quite troubled) were equal to more severe AR symptoms in our clinical experience. Therefore, children whose PRQLQ scores were equal or higher than 92 (sceles 4 multiply by 23 items) were considered as those with obvious AR discomfort on the study day. When children are exposed to high pollutant level as mentioned above, the rates of subjects with obvious AR discomfort (higher PRQLQ scores) were compared between obese and non-obese groups. We aimed to determine the association between obesity and AR discomfort when children with AR are exposed to higher air pollutant concentrations.To find the association, mean air pollutant concentrations within 7 days before the tests were divided into low and high levels. For example, the concentration range of CO was divided to 0.35–0.60 ppm (low level) and 0.61–0.86 ppm (high level); PMt-test was used for continuous variables. Spearman’s rank correlations were used for the correlation test between PRQLQ scores, NPEF rates, and pollutant concentrations because the seven pollutant concentrations were not normally distributed. Multivariate regression and multivariate logistic regression analysis was used to adjust for the confounding factors. Statistical significance was set at p < 0.05 for a two-tailed test. We interpreted the correlation coefficient values with the method reported by Portney and Watkins16, as follows: (1) 0.00–0.25 and − 0.25–0.00, no relationship; (2) 0.25–0.5 and − 0.25 to − 0.5, fair relationship (3) 0.5–0.75 and − 0.5 to − 0.75, moderate-to-good relationship; and (4) < 0.75 and < − 0.75, good-to-excellent relationship. Statistical significance was set at p < 0.05 for a two-tailed test, and a correlation coefficient of > 0.25 or < − 0.25. This study was approved by the Institutional Review Board of Chung Shan Medical University Hospital, Taichung, Taiwan . All experiments were performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all subjects and/or their legal guardian(s).All analyses were performed using Statistical Analysis Software (SAS)  and PASW Statistics 18 . Chi-square tests were used for categorical variables, and the The flow diagram is presented in Fig. 10, and PM2.5 concentrations within 7 days before the test. The results were: CO Spearman’s ρ = 0.396, p = 0.026; PM10 Spearman’s ρ = 0.502, p = 0.025; PM2.5 Spearman’s ρ = 0.506, p = 0.022. In contrast, no correlation between PRQLQ scores and the seven pollutants was noted in non-obese AR children. Additionally, regardless of statistical significance, the correlations of the seven pollutants were stronger in obese AR children (with a higher correlation coefficient).The Spearman’s rank correlation test was used to calculate the Spearman’s rank correlation coefficient (Spearman’s ρ). Table 10, and PM2.5 concentrations were noted in non-obese AR children.When ambient temperature and relative humidity were not added for adjustment , a positive correlation between PRQLQ scores and CO, PM10, PM2.5, and NMHC concentrations within 7 days before the test. The results were: CO Spearman’s ρ = − 0.379, p = 0.048; PM10 Spearman’s ρ = − 0.429, p = 0.013; PM2.5 Spearman’s ρ = − 0.489, p = 0.005; NMHC Spearman’s ρ = − 0.415, p = 0.043. No correlation was observed between the NPEF rates and the seven air pollutants in non-obese AR children.Table 2, PM10, and PM2.5 concentrations. The results were: SO2 Spearman’s ρ = 0.290, p = 0.016; PM10 Spearman’s ρ = 0.540, p = 0.030; PM2.5 Spearman’s ρ = 0.517, p = 0.024. In boys with obesity, no correlations were found. In girls with obesity, the NPEF rates were statistically negatively correlated with PM10 and PM2.5 concentrations. The results were: PM10 Spearman’s ρ = − 0.532, p = 0.013; PM2.5 Spearman’s ρ = − 0.561, p = 0.016. In boys with obesity, no correlations were found. In non-obese AR children, and in both boys and girls, no correlation was observed between PRQLQ scores, NPEF rates, and air pollutant concentrations.Table p-value = 0.028; Odds Ratio (OR) 3.54, 95% confidence interval (CI) 1.15 ~ 10.92). The rates of obvious AR discomfort were also higher in obese children when they were exposed to higher PM10 and PM2.5 levels, compare to the rates in non-obese children.The results are presented in the Table 18. In obese AR children in our study, we find a relationship between higher CO, PM10, PM2.5, NMHC concentrations and higher degree of nasal obstruction/inflammation (lower NPEF rates). Our study results were compatible with other studies. These studies suggest that air pollution could induce nasal obstruction3 and nasal mucosa inflammation19. In obese AR children in our study, we also find a relationship between higher CO, PM10, PM2.5 concentrations and higher AR discomfort or symptoms (higher PRQLQ scores). Therefore, we speculate that, through the induction of nasal obstruction and mucosa inflammation, CO, PM10, and PM2.5 had a negative impact on nasal discomfort and symptoms in obese AR children. We also found that, in non-obese AR children, there were no correlations between air pollution and AR discomfort/symptoms and nasal obstruction/mucosa inflammation.A lower NPEF rates indicates a higher degree of nasal obstruction and mucosa inflammation3. In our study, air pollution data were gathered within 7 days before the tests. Because of the short duration, the impact of air pollution on AR might have been caused by the neurogenic effects in our study. The trigeminal nerve innervates the nasal cavity. A study indicated that, through the activating of trigeminal nerve endings, air pollution exposure can trigger rhinitis20. Another study indicated that that obesity can increase the nociceptive activation of the trigeminal system under external stimulation21. The abovementioned findings might explain our result, which showed that air pollution had a more detrimental effect on AR when they were obese, compared to those without obesity.When exposed to pollutants, rhinitis symptoms can be exacerbated by immunological (long-term effect) and neurogenic (short-term effect) mechanisms22. Another study indicated that particles less than 100 nm were observed in human trigeminal ganglia capillaries23. This implies that PM could influences the trigeminal nerve and might result in the exacerbating of AR. In children with obesity in our study, we found a stronger correlation between PM10, PM2.5, PRQLQ (more severe AR symptoms), and NPEF . The two aforementioned studies by might explain the stronger correlation between PM10, PM2.5, and AR, compared to those of other air pollutants.A rats and mouse study found that airborne particulate matter (PM) can be transported via the trigeminal nerve. PM may also induce neurotoxicity, oxidative stress, and neuro-inflammation of nerves24. It was suggested that men have higher sympathetic tone and women have higher parasympathetic autonomic activity25. A study indicated that women appear to be more sensitive to intranasal trigeminal stimulation than men26. Another study reported a sex-differentiated electrophysiological response to intranasal trigeminal stimuli27. These findings could explain the stronger correlation observed between PRQLQ, NPEF, and air pollution  in female children with obesity and AR in our study, compared to male children.A reduction in the sympathetic tone can cause venous sinusoid dilatation, which can contribute to nasal obstruction symptomsTwo molecular mechanisms might explain our study results. First, air pollution could induce more nasal inflammation because obese children are in the chronic inflammatory states. Second, air pollution could induce more neuro-inflammation in obese children. Our study results  could explain the first speculation. However, the role of neuro-inflammation was not investigated in our study. Future study is necessary.28. Meteorological conditions including temperature and humidity were also report to be correlated with concentration of air pollutants29. Therefore, temperature and humidity could influence both the severity of AR and concentration of air pollutants, and should be adjusted when investigating the association between air pollution and AR. However, most studies investigating the relationship between air pollution and AR in children did not adjust for the two co-factors30. The two co-factors were adjusted in our study, so we can find the association between obesity, AR and air pollution more accurate.Ambient temperature and relative humidity was reported to influence the severity of ARFurthermore, our study had some limitations. First, the study was conducted at a single center. Therefore, it cannot reflect the general profile of the entire population owing to selection bias. Second, potential confounders  were not analyzed. Third, only children with moderate to severe AR were assessed in this study. Therefore, future studies including more children with AR from different clinics and areas, patients with mild AR, and gathering more confounding factors such as dietary habits, physical activity, and emotional factors are required.10, and PM2.5 negatively impacted discomfort and symptoms of rhinitis in obese AR children, rather than non-obese AR children. When obese AR children attain higher pollutant concentrations, increased nasal obstruction and inflammation might be the mechanism underlining the present study findings. This suggests that children with obesity and AR should avoid exposure to air pollutants, specifically CO, PM10, and PM2.5. Although we observed a significant correlation between air pollutants, obesity, and AR in Taiwan, regional differences in air pollution concentration, socioeconomic status, and race could have also altered the outcomes. Therefore, future studies should incorporate more diverse groups of participants with more significant variations in geographical location, socioeconomic status, race, and sex. Biological study to explain the association between AR, obesity and air pollution are required.The association between air pollution, AR, and obesity remain unclear to date. This study first demonstrated that air pollutant CO, PM


Musculoskeletal (MSK) disorders such as low back pain and osteoarthritis are a leading cause of disability and the leading contributor to the need for rehabilitation services globally. This need has surpassed the availability of trained clinicians; even in urban areas where services and providers are thought to be more abundant, access can be challenged by transportation options and financial costs associated with travel, care and lost time from work. However, continuing standard of fully in-person rehabilitation care for MSK-associated pain and disability may no longer be necessary. With increased ownership or access to even a basic mobile phone device, and evidence for remote management by trained clinicians, some individuals with MSK disorders may be able to continue their rehabilitation regimen predominantly from home after initial evaluation in primary care or an outpatient clinic.This manuscript describes application of a framework we used to culturally and contextually adapt an evidence-based approach for leveraging digital health technology using a mobile phone  to expand access to rehabilitation services for MSK-associated pain and disability. We then conducted a multi-level analysis of policies related to the adapted approach for rehabilitation service delivery to identify opportunities to support sustainability.Our study was conducted in Tanzania, a lower-middle income country with their first National Rehabilitation Strategic Plan released in 2021. Lessons learned can be applied even to countries with greater infrastructure or fewer barriers. The seven-step adaptation framework used can be applied in other regions to improve the likelihood of local mHealth adoption and implementation. Our practice and policy assessment for Tanzania can be applied in other regions and used collaboratively with government officials in support of building or implementing a national rehabilitation strategic plan.The work described, lessons learned and components of the plan are generalizable globally and can improve access to rehabilitation services using mHealth to address the significant and increasing burden of disability. Exercise is considered the cornerstone in management of MSK-associated problems and is sometimes best supported with other physical modalities, psychosocial treatment, and multidisciplinary rehabilitation  disorders—conditions that affect muscles, bones, joints and periarticular structures—are a leading cause of years lived with disability (YLDs) , 2. Theslitation . Exercislitation , 8.MSK disorders are the highest contributor to rehabilitation needs for every age group . UnfortuThe United Republic of Tanzania was one of many countries that committed to Rehabilitation 2,030 and in 2021 released their National Rehabilitation Strategic Plan . TanzaniIn Tanzania, we observed that individuals with MSK pain or reduced ability to complete daily activities initially see a general physician for medical guidance or pharmacist/medication dispensary to obtain pain relief medication. Direct access to physiotherapy is appropriate and possible but less common, due to a lack of awareness on the part of clinicians and clients that this practice is available . In 2021We used principles from implementation science to examine rehabilitation as a health care service in Tanzania, the gaps, and the needs and capacity for mHealth to manage MSK pain and activity limitations remotely to people's home or local community. Through a series of seven steps over 20 months from 2020 to 2022, we tailored evidence-based interventions to meet those needs. Although many frameworks exist for the adaptation of evidence-based interventions  and CardWe began with Williams et al.'s model  for cultStep 3, Selecting an Evidence-based Program, focuses on selecting an effective and suitable intervention. Suitable had to also consider most accessible to the general population. Coaching by telephone is the most common application of mHealth for MSK rehabilitation. We selected a home-based exercise program that included exercise counseling by phone that was tested with older adult Veterans with LBP in the United States . The appThis home-based model that was developed and tested in the United States was attractive for application in Tanzania as it did not require the rehabilitation patient and provider to meet frequently in person  and it extended the rehabilitation workforce by including someone trained in exercise and behavior change (a Tanzanian rehabilitation strategic plan priority). It was determined that the primary outcomes (TUG and PROMIS) and secondary outcomes  from the research in the United States  would beTelephone coaching as an alternative to in-person care can improve access to care for some people and for others can still be expensive and geographically out of range. Pay per use mobile phones can generate large expenses with per minute rates and roaming charges. This necessitates the evaluation of additional options. The next most accessible and low-cost approach was to consider text messaging. The feasibility, acceptability and effectiveness of SMS texts on simple  mobile phones in LMICs has been demonstrated for several populations and use cases. Examples include improved childhood immunization coverage , antiretText messages supporting exercise, physical activity or rehabilitation interventions for adults with MSK conditions –38 Tabl includedOur comparison of the US model to the standard of care in Tanzania (Step 6: Compare) using a framework for translation and adaptation demonstrated a rehabilitation care model that included mHealth would be feasible with some adaptations . Using ecological systems theory that views an individual's behavior as a component of multi-level relationships in a system, we identified policies at the interpersonal, organizational, community and public policy levels  39). Th. Th39). In Tanzania, several key policies are identified in the rehabilitation strategic plan that patients may not consider directly related to their care but are vitally important for building capacity and strengthening rehabilitation services as part of the healthcare and public health infrastructure. Obtaining a rehabilitation-specific budget line item in the Ministry's administrative structure is needed to support resourcing and sustaining any action of the national rehabilitation strategic plan. Related, integrating rehabilitation data in to the Health Management Information System is needed in order to establish national indicators and an evaluation plan for improvement. These same areas of budgeting and documenting need to be addressed at local levels. Many times local needs will need local solutions and data and finances to support change will be paramount.via mobile phones could expand the capacity for services and number of people with rehabilitation needs treated. International partnerships helped facilitate this work and could serve as a catalyst or accelerator in other regions. Timelines and priorities can change over time and communication between activities locally and nationally could help spread successful strategies. Data clearly illustrate that rehabilitation needs will only continue to escalate with the trends in population aging and activity limitations from long-COVID. Leveraging mHealth to expand access to rehabilitation could be an essential strategy for reducing the burden of disability.We propose that in conjunction with national rehabilitation strategic plan development and implementation, that an evaluation of local practice with best available evidence and consideration of policies at multiple levels could stimulate changes to improving access to rehabilitation. In our work, we found that adapting evidence-based approaches to support rehabilitation at home using telephone calls and SMS text messaging


Severe-to-profound hearing loss (STPHL) can affect a person negatively in many ways. Audiological rehabilitation is important for these patients. Patients receiving cochlear implants make up less than 10% of this group but have been studied extensively. In 2005, a national registry for adult patients with STPHL was introduced in Sweden. Its purpose was to evaluate and improve rehabilitation for all patients with STPHL. Data from the Swedish registry for adult patients with STPHL were used to evaluate variables affecting the audiological rehabilitation. Previous published data from the registry were reviewed, and new data from the follow-up questionnaire were presented. More than 90% of patients rehabilitated with hearing aids experienced a good or very good benefit of audiological rehabilitation. Tinnitus and vertigo affected quality of life negatively and were reported by many patients with STPHL (41% and 31%) at follow-up. To maintain the high number of patients who find audiological rehabilitation beneficial, individualized treatment plans and timely re-evaluations are crucial. Tinnitus and vertigo need to be addressed repeatedly in the rehabilitation process. Hearing loss in general and severe-to-profound hearing loss (STPHL), in particular, can result in major implications for a patient. It is well established that STPHL can lead to reduced quality of life (QoL), isolation, dependence, lack of energy, and frustration ,2. FurthSTPHL can be divided into purely sensorineural HL (SNHL), where the origin of the HL can be found in the cochlea or the vestibulocochlear nerve, and mixed HL (MHL), which is a combination of SNHL and conductive HL caused by damage to the outer and/or middle ear.Johnson points out that patients with hearing loss of a 60-dB air-conducted hearing level or less and with purely conductive hearing loss often are successfully rehabilitated with conventional HA. However, patients with MHL may have significant problems utilizing amplification . This deIn clinical practice, it is also well known that patients with conductive or mixed HL in general have less pronounced sensorineural damage, and they are often more successfully rehabilitated technically, especially with hearing aids, and hence could be believed to have a less marked negative impact on daily life.Technical rehabilitation is essential for patients with STPHL, and bilateral fitting of hearing aids (HAs), bilateral cochlear implants (CIs), or bimodal hearing are beneficial ,9,10. HoEvaluation of interventions for medical conditions is very important. Treatments administered to patients with STPHL have been extensively studied; however, they have also been overlooked. For instance, treatment with CIs and surgery for far-advanced otosclerosis have been studied thoroughly, and many studies have shown a positive impact on the QoL ,13. HoweA national registry for adults with STPHL was launched in 2005 to evaluate the rehabilitation provided to individuals with STPHL in Sweden . The regThe general aim of this study was to present a summary of previously published data on audiological rehabilitation from the Swedish registry for adult patients with STPHL and present new data from the follow-up questionnaires.(1)To present data on variables that could influence the outcomes of audiological rehabilitation.(2)To evaluate the influence of the type of HL (SNHL/MHL) and speech recognition on the outcomes of audiological rehabilitation.(3)To compare the outcomes of audiological rehabilitation over time between HA and CI users.The specific aims were as follows:All data used in this study were collected from the Swedish registry for adult patients with STPHL, henceforth referred to as the registry . The incA previous study by our group gathered information through a set of additional questions on the presence and severity of tinnitus and vertigo, together with the Hospital Anxiety and Depression Scale (HADS), from 1274 patients in the registry . The HADHealth care registries that aim to evaluate health care quality in Sweden are called ‘national quality registries’. Swedish law requires the validation of these registries. The Swedish registry for adult patients with STPHL is one of these ‘national quality registries’. The data were validated by manual random sampling and subsequent controls at the three registering clinics. Additionally, a structured validation was performed during 2021/2022 for the audiometric data, but the results have not yet been published.The registry started in 2005 using a general questionnaire. The content of this questionnaire has been described in detail in previous studies ,16. In 2The baseline questionnaire contained data on age, sex, PTA4, speech recognition, type of HL (SNHL or MHL), communication method, the use of HAs or CI, extended audiological rehabilitation, employment, and sick leave. The unaided speech recognition test was performed in a quiet environment with a fixed speech level; the scoring was presented as correctly identified speech stimuli. Aided speech recognition in the soundfield was optional to register. In addition, the patients were asked to grade the benefits of audiological rehabilitation on a four-level scale, ranging from no benefit to very good benefit, and to estimate the degree to which HL affects their daily life ). In the ES, the patient graded to what extent HL affects daily life on a scale ranging from 0 to 100. Similarly to previous studies based on the data from the registry, a threshold of ≥70 was used in this study to mark the point where HL caused a major negative effect on daily life . ExtendeDo you have tinnitus/vertigo? The alternatives were either yes or no. The subsequent questions were If yes, does tinnitus/vertigo affect your daily life? The response options were yes, always; yes, often; yes, sometimes; no, never.Furthermore, the baseline questionnaire contained questions regarding tinnitus and vertigo. The questions were as follows: Information on reasons why the patient did not receive a CI were registered. The reasons were divided into the following groups: medical ; hearing-related (the need for hearing rehabilitation is met by existing HA); patient-related (the patient has declined CI); communication (the patient uses sign language); unknown. Missing answers to this question were interpreted as unknown reasons in the baseline and follow-up questionnaires. Initiated CI investigations were also registered. The reasons why patients did not receive a CI were analyzed in the baseline and follow-up questionnaires between 2015 and 2021.The follow-up questionnaire contained questions from the baseline questionnaire and a supplemental question, where the patient was asked to rate how the influence of HL on their daily life had changed compared to one year earlier. The rehabilitation interventions introduced during the past year were registered by a professional. Rehabilitation interventions were divided into five categories: medical interventions , technical interventions , pedagogical interventions , psychosocial interventions , and other interventions . The present study focused on the degree to which patients had received extended audiological rehabilitation and the reported benefit of hearing health care. The development of these two parameters over time was studied among HA and CI users.Furthermore, the registry has a separate questionnaire evaluating CI surgery and the outcomes of rehabilitation with CI. This questionnaire was introduced in 2021 and is based on the International Outcome Inventory for Hearing Aids (IOI-HA) to enable comparisons. All questions were constructed according to the IOI-HA . HoweverIn this study, data were collected from all questionnaires of the registry , except for the recently introduced CI-questionnaire. With this model, we were able to utilize all collected data in the registry, including new and previously published data.Previously published data  are presp < 0.01. Overall, there were small differences between the crude and adjusted ORs, and therefore, only adjusted ORs are presented in the tables. In In In In It is very important to evaluate rehabilitation interventions in audiological rehabilitation, particularly in patients with STPHL. Since rehabilitation should be individualized, the evaluation is essential for all patients. Patients with STPHL rehabilitated with CI experienced a greater benefit from rehabilitation and completed the extended  audiological rehabilitation more often than patients without CI. However, more than 90% of patients rehabilitated with HA also experienced good or very good benefit of audiological rehabilitation .The present study focused on the follow-up questionnaire and measured different outcome variables one year after a new rehabilitation intervention was introduced.Previous studies on registry data have shown that the use of HA, CI, and extended audiological rehabilitation differs between groups of patients with STPHL ,18. MostTinnitus, vertigo, and deaf blindness are known to have a considerable negative impact on anxiety, depression, and daily life, while CI had a positive impact in the ES  3,23]. ,23. 3,23In a study of patients with STPHL, Turunen-Taheri et al. revealed variations in the benefits of audiological rehabilitation associated with different audiological interventions and professions. Patients participating in group rehabilitation and visiting a hearing rehabilitation educator experienced the greatest benefits of rehabilitation. That study showed no significant differences between visits to other professionals and the benefits of rehabilitation .In a previous study based on the general questionnaire, troublesome tinnitus and vertigo  were shown to affect 38% and 28%, respectively, of patients with STPHL [It is also important to remember that STPHL rehabilitation is not a static process. Re-evaluation must be performed at regular intervals. Turton et al. emphasized the need for a personalized treatment plan that must be adaptive and is updated continuously .The major prerequisite for a patient to receive a CI in Sweden is speech recognition of <50% when tested in a soundfield, wearing optimized HAs. Hearing-related reasons (aided speech recognition >50%) were the most common reasons for not receiving a CI at follow-up, meaning that the hearing needs were met by HAs . FurtherOnly small differences were observed between CI users and HA users with respect to the patient-reported benefits of hearing health care over time. Most patients (>90%) experienced good or very good benefits of hearing health care at follow-up . It is ip < 0.01. Additionally, in all types of questionnaires, it can be difficult for patients to choose between two options in a question; therefore, data are often dichotomized. This reduces the amount of information, but it is worth sacrificing some information for the sake of clarity. Robust and clear results are important when attempting to improve the rehabilitation process, which is the main purpose of the Swedish national registry for adults with STPHL. Based on a directive from the Swedish association of local authorities and regions, members from the registry board have contributed to the establishment of a national guideline for standardized care for patients with STPHL that has been approved and will be implemented later this year.In Sweden, the prevalence of adult patients with STPHL is 0.28%, which corresponds to 22,000 patients . A limit