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Case report: Herbal treatment of neutropenic enterocolitis after chemotherapy for breast cancer

  • Peng Xu , Chaoxiong Cui , Yukun Liu , Kun Fang , Qitang Wang , Chao Liu EMAIL logo and Ruixia Tan EMAIL logo
Published/Copyright: October 24, 2023

Abstract

In this case report, a 53-year-old woman was diagnosed with severe NE after receiving chemotherapy for breast cancer. The patient with breast cancer was treated with a single cycle of docetaxel (140 mg) + epirubicin (130 mg) + cyclophosphamide (0.9 g) chemotherapy. However, the woman presented with symptoms of fatigue and diarrhea 5 days later accompanied with severe neutropenia according to the routine blood test. The computed tomography examination displayed the thickening and swelling of the colorectal wall. After the diagnosis of NE, the woman received antibiotics and supportive treatment, but her symptoms were not improved. The Chinese herbal medicine (CHM) diagnostic pattern was then designed for the patient. The patient was administered with two CHM decoctions. One decoction contained 24 kinds of herbal materials, and the other one was called pure ginseng decoction. These two decoctions were administered to the patient 2 or 3 times per day to tonify the spleen, nourish Qi and blood, and remove phlegm and damp heat symptoms. After the CHM treatment lasting for 10 days, the symptoms of the patient were improved, and she was discharged. In conclusion, CHM treatment played an indispensable role in curing the woman with chemotherapy-induced NE.

1 Introduction

Neutropenic enterocolitis (NE), also known as typhlitis, is a life-threatening inflammatory disorder of the intestine associated with neutropenia, which is characterized by an acute necrotizing process involving segments of the large and small intestines in the setting of agranulocytosis [1,2]. NE mainly occurs in immunosuppressed patients, and the mortality rate of NE is 30–50% [2].

NE is typically characterized by abdominal pain and fever in a neutropenic patient [3]. The entire intestine is usually affected, with the most impacted region occurring from the end of the ileum to the cecum and the ascending colon [4]. Laboratory test results include pancytopenia, hypoalbuminemia, and electrolyte imbalance such as hyponatremia, hypophosphatemia, and hypokalemia [1,5,6]. The diagnosis of NE depends on radiology. Computed tomography (CT) and ultrasonography are the best radiographic methods for NE early diagnosis at present [7,8]. Bowel wall thickening is regarded as a main diagnostic criterion, which can be determined through CT or ultrasonography [8]. The improvement of NE outcome relies upon the deep understanding of the risks for the condition, application of empiric therapy with broad-spectrum antimicrobial agents, systemic antifungal treatment, and meticulous attention to supportive care [9].

Natural killer (NK) cells, as important innate immune regulatory cells, play a key role in anticancer immunity and neutropenia [10,11,12]. The activation of NK cells is based on the balance of activating and inhibitory receptors expressed on the NK cell surface [10]. Upon activation, NK cells control the release of cytotoxic molecule and proinflammatory cytokines through immediate or short-lived immune response [12]. By transmitting signals from one cell type to another, cytokines are essential for communications between diverse cells in complex immune system responses [10]. The cytokines can eliminate target cells, for example, cancer cells, and activate other cells in the immune system such as T cells [12,13]. NK cells were previously reported to cooperate with neutrophils to damage the blood–brain barrier [14]. In the neoplastic process, NK cells and neutrophils have anti-tumor and pro-tumor functions because of high plasticity [15]. Neutrophils account for 40–70% of blood-nucleated cells in humans, and an increase in neutrophils in blood often is responsible for a sign of poor prognosis during cancer progression [15]. There exists a strong heterogeneity of the immune response between individuals, which may result from environmental and genetic factors, diet, lifestyle, or the interactions between these factors [16]. For example, vitamin D protects the innate immune system while inhibiting adaptive immunity, as evidenced by the stimulation of Th2 and Treg as well as the inhibition of Th1 and Th17, suggesting that diet is a variable factor affecting the function of the immune system [16]. Recently, many Chinese herbs or Chinese herb-derived compounds have been reported to affect immune cell populations in the immune (tumor) microenvironment. For example, solamargine was reported to alter dendritic cells, myeloid-derived suppressor cells, and T-cell populations by regulating macrophages and thus alleviate the immunosuppressive microenvironment in hepatocellular carcinoma [17]. The traditional Chinese medicine Yi-Yi-Fu-Zi-Bai-Jiang-San alters Tregs to hamper colorectal cancer cell growth [18].

In our case, a decoction containing 24 types of herbal materials and ginseng decoction were administered to a patient with breast cancer who was diagnosed with NE during chemotherapy. This case report revealed the protective role of Chinese herbal medicine (CHM) treatment against the alteration of neutrophils and white blood cell (WBC) counts in NE. Our report may provide more evidence supporting the function of CHM in immune system-related diseases such as NE.

2 Case presentation

A 53-year-old woman was admitted to the hospital with symptoms of diarrhea and fatigue. Five days before these symptoms, she had finished her first cycle of chemotherapy with docetaxel (140 mg) + epirubicin (130 mg) + cyclophosphamide (0.9 g) due to her left breast cancer (ycT2N1M0, stage IIB, Luminal B negative). She presented frequent diarrhea 2–3 times per day without the symptom of abdominal pain or distention, and the stools were loose and yellow.

On July 29, her blood test showed severe myelosuppression. The WBC count was 0.65 × 109/l, and the neutrophil count was 0.02 × 109/l. The concentration of C-reactive protein (CRP) was 239.65 mg/l, and that of procalcitonin (PCT) was 0.32 ng/ml. Considering the severe myelosuppression after chemotherapy, the patient was primarily diagnosed with acute agranulocytosis. The recombinant human granulocyte colony-stimulating factor (200 μg, hypodermic injection, qd) was intramuscularly administered to the patient for 3 days to increase the number of WBC and neutrophils. Cefoperazone/sulbactam (3 g + 100 ml in 0.9% sodium chloride injection, intravenous injection, q12h) was intravenously administered to the patient for 6 days to prevent severe bacterial infection. On August 1, she complained of a fever of 40℃. The frequency of diarrhea increased to 5–6 times per day. Blood cultures for the diagnosis of bacterial and fungal infections were negative. There exist no abnormalities in the results of the stool examination, while the occult blood test was positive. The results of fecal flora analysis were as follows: (1) 70% of Gram-negative bacilli, (2) 20% of Gram-positive cocci, (3) 10% of Gram-positive bacilli, and (4) occasional Gram-stained fungi. We increased the use of antidiarrheals and administered Peifeikang (Shanghai Xinyi Pharmaceutical Co., Ltd.) to her. Peifeikang are probiotics that can replace the pathogenic flora in the intestine. The above-mentioned treatment was continued. On August 2, the results of blood tests were as follows: WBC count: 3.10 × 109/l, neutrophil count: 1.90 × 109/l, CRP concentration: 216.6 mg/l, and PCT concentration: 1.37 ng/ml. On August 4 and 5, the WBC count was 13.36 × 109/l and 24.46 × 109/l, and the neutrophil count was 11.06 × 109/l and 21.96 × 109/l, respectively. The number of WBC and neutrophils in her blood samples was increased rapidly, while the value of CRP suggested that there may exist a serious infection. Thus, we administered vancomycin (1.0 g + 250 ml in sodium chloride injection, iv, q12h) to her for the following 13 days. On August 7, the patient still suffered from fever, and the frequency of diarrhea increased to 6–12 times per day. The results of fecal floral analysis were as follows: (1) 90% of Gram-negative bacilli, (2) 10% of Gram-positive cocci, and (3) negative Gram-stained fungi. The results of blood tests showed that the number of WBC and neutrophils was 46.47 × 109/l and 41.87 × 109/l, respectively. Despite the use of antimicrobials, WBC and granulocyte counts were continuously elevated. Meanwhile, the symptoms of fever and diarrhea were not improved in the context of intestinal dysbiosis. A CT scan was then performed, and the scan image showed that the colorectal wall was thickened and swelled; there was effusion in abdomen and pelvis, and abdominal fat space was blur (Figure 1). After a multidisciplinary consultation with the CT report, she was diagnosed with NE.

Figure 1 
               CT scan findings on August 7, 2022. These scan images showed thickening and swelling of the colorectal wall, abdominal and pelvic effusion, and a blurred abdominal fat space.
Figure 1

CT scan findings on August 7, 2022. These scan images showed thickening and swelling of the colorectal wall, abdominal and pelvic effusion, and a blurred abdominal fat space.

After that, human albumin and plasma were infused to the patient for improvement of coagulation, osmotic pressure, and hemodynamics. Additional tests for pathogen detection were negative. On August 24, the blood parameters were not significantly improved. The fecal flora analysis indicated that the intestinal flora was significantly reduced, while bacterial cultures of specimens obtained from blood, pleura, and peritoneum were negative. Further application of antibacterial drugs may further aggravate intestinal dysbiosis, which is unbeneficial for recovery. Subsequently, we decided to use CHM for the following treatment. After our consultation with the CHM department, her diagnostic pattern was considered “phlegm-dampness due to spleen and stomach deficiency as well as asthenia of Qi and blood.” A therapy should be designed to tonify the spleen, nourish Qi and blood, and remove phlegm and damp heat.

Therefore, a traditional Chinese medicine decoction including 24 types of Chinese medicinal herbs was prepared. The names and gram weight of these Chinese medicinal herbs are summarized in Table 1. These herbal materials were prepared in three doses, and each dose was decocted and administered to the patient 2 or 3 times per day. A pure ginseng decoction, with ginseng being decocted with red sugar and water, was also administered to her. Three days after CHM treatment and enteral nutrition, the frequency of diarrhea was reduced from 12 times to 5–6 times per day. The symptoms of fever, chills, and stool consistency were ameliorated, and the patient was more energetic than before. The decoctions were administered to her until recovery. On September 7, the results of blood tests showed that WBC and neutrophil counts were 7.81 × 109/l and 4.76 × 109/l, respectively. The results of the CT examination showed an edematous thickening of the ascending and transverse colon. The cecum and descending colon were normal, while there was a small effusion of blood in the abdominal cavity (Figure 2). The changes in WBC and neutrophil counts before and after CHM treatment are shown in Figure 3. On September 8, 10 days after the CHM treatment, the patient was in good condition and she was discharged from our hospital.

Table 1

The Chinese medicinal herbs used in this study

Name of Chinese medicinal herbs Gram weight
Decoction 1 (24 herbal materials)
Codonopsis pilosula 30 g
Poria cocos 20 g
Atractylodes macrocephala 12 g
Amomum villosum 10 g
Cyperus tuberose 12 g
Ginger Pinellia ternata 15 g
Pericarpium citri 12 g
Bamboo shavings 15 g
Astragalus membranaceus 50 g
Radix Rehmanniae 30 g
Ginseng psammophila 30 g
Ophiopogon japonicus 20 g
Trichosanthin 30 g
Dendrobium Nobile 15 g
Honeysuckle 20 g
Fritillaria thunbergii 10 g after mixing with water
Fructus Tritici Levis 30 g
Ephedra root 15 g
Coix Jobi 30 g
Chinese yam 30 g
Gorgon fruit 30 g
Semen dolichoris album 30 g
Fried hawthorn 20 g
Fried malt 20 g
Decoction 2
Pure ginseng
Figure 2 
               CT scan images on September 7, 2022. After CHM treatment, the cecum and descending colon were normal, while there was a small effusion of blood in the abdominal cavity. There is an edematous thickening of the ascending and transverse colon.
Figure 2

CT scan images on September 7, 2022. After CHM treatment, the cecum and descending colon were normal, while there was a small effusion of blood in the abdominal cavity. There is an edematous thickening of the ascending and transverse colon.

Figure 3 
               Changes in WBC and neutrophil counts before and after CHM treatment. A line graph was drawn to illustrate the changes of cell counts before and after therapy. Severe myelosuppression was found on July 29. From August 2 to August 7, the cell counts increased rapidly and reached the peak on August 7; however, the symptoms of fever and diarrhea were not improved. After CHM treatment, the cell counts recovered on September 7.
Figure 3

Changes in WBC and neutrophil counts before and after CHM treatment. A line graph was drawn to illustrate the changes of cell counts before and after therapy. Severe myelosuppression was found on July 29. From August 2 to August 7, the cell counts increased rapidly and reached the peak on August 7; however, the symptoms of fever and diarrhea were not improved. After CHM treatment, the cell counts recovered on September 7.

On October 13, 35 days after the discharge, the patient’s blood routine as well as liver and kidney functions were basically normal. Then, the patient underwent modified radical surgery for left breast cancer under general anesthesia. Afterwards, the patient underwent an EC sequential T chemotherapy regimen after the surgery. By the time of finishing this article, the patient had received 4 cycles of epirubicin (150 mg), cyclophosphamide (1 g), and docetaxel (400 mg).

  1. Informed consent: Informed consent has been obtained from all individuals included in this study.

  2. Ethical approval: The research related to human use has been complied with all the relevant national regulations, institutional policies, and in accordance with the tenets of the Helsinki Declaration and has been approved by the Institutional Ethics Committee of Affiliated Qingdao Central Hospital of Qingdao University, Qingdao Cancer Hospital (protocol code [Y]KY202305701 and date of approval: March 30, 2023).

3 Discussion

NE is a life-threatening digestive complication often reported in children with leukemia and is rare in adults [3,19]. A few articles reported that adult patients with breast cancer were diagnosed with NE after receiving chemotherapy [20,21]. For example, a 22-year-old woman developed NE despite the use of granulocyte colony-stimulating factor after chemotherapy for breast cancer, and the patient underwent surgery for severe abdominal pain [20]. After receiving neoadjuvant chemotherapy for epidermal growth factor receptor 2 positive left breast cancer, a 48-year-old woman was found to have neutropenia and was treated for neutropenic sepsis in the emergency department [21]. Cherri et al. concluded that taxanes seem to be the most involved chemotherapy drugs for the induction of NE in solid tumor treatment, although the exact incidence is unknown [20]. In this case report, the patient presented a severe lack of granulocytes in the blood test and had frequent diarrhea with a high fever. Moreover, the CT scan images displayed the thickening and swelling of the colorectal wall, abdominal and pelvic effusion, and a blurred abdominal fat space, and therefore, the diagnosis of NE was confirmed. Currently, NE is diagnosed when the thickness of the intestinal wall equals to or more than 4 mm at the onset of at least one of the following symptoms: (1) axillary temperature ≥38°C, (2) abdominal pain, and (3) diarrhea defined as more than three liquid stools per 24 h in the presence of neutropenia (absolute neutrophils count <0.5 × 109/l) [4].

There is no unified treatment standard for NE at present and the pathogenesis is not fully understood [22]. Early recognition, appropriate risk-stratified management, and symptomatic and supportive treatment can prevent the application of surgery and unnecessary antibiotics and can avoid complications and mortality [23]. The duration of antibiotic therapy for NE is controversial [4], and surgery has a high risk of bleeding, postsurgical infections, and damaged wound healing, which only suits the NE patients with complications [23]. The most common microbiologically proven complication of NE is bloodstream infection (BSI) can be induced by bacteria such as Escherichia coli [24]. Prompt administration of broad-spectrum empiric antibiotics is critical to prevent progressive disease, severe sepsis, and even death [25,26]. The incidence of BSI in adults is higher than in children, which is the leading cause of death [27]. To prevent BSI and sepsis, the patient in our study was given cefoperazone sulbactam for 6 days and vancomycin for the next 13 days. Although the blood culture showed negative results, the imbalance of intestinal flora was further aggravated, and her symptoms were not improved at all. The clinicians must balance the relationship between the risk of follow-up NE treatment (e.g., antibiotic resistance and metronidazole-neurotoxicity) and the patient’s total benefits. Shane reported that the rapid recovery of neutrophils usually turned into a good outcome of NE [4]. Unfortunately, in the present study, even though the WBC and neutrophil counts in blood samples of the patient reached the panic value of 46.47 × 109/l and 41.87 × 109/l, the patient’s symptoms of fever and diarrhea were still out of remission. Finally, human albumins were given to improve blood coagulation, osmotic pressure, and hemodynamics. However, the unsatisfied outcome and long-term treatment highly consumed the patient’s and attending physicians’ patience.

The balance of intestinal flora plays an essential role in human immunity [7]. NE seems to start with intestinal mucosal injury together with neutropenia and the weakened immune system of the afflicted patients [20,21,28]. The factors leading to NE are mucosal injury, cecal distension with resultant ischemia, cytotoxic drugs, and microbiological agents. Blocking these injuries would be the key to NE treatment and rehabilitation of intestine.

The improvement of her symptoms was brought about by the tentative use of CHM. Previous studies validate that the adjunctive use of CHM with chemotherapy may reduce the adverse events induced by chemotherapeutic agents, including nausea and vomiting, diarrhea, alopecia, myelosuppression, and impaired immune function [29]. Different natural products derived from CHM were identified with various anti-cancer properties, such as anti-proliferative, pro-apoptotic, anti-metastatic, and anti-angiogenic effects; the natural compounds can also regulate autophagy, reverse multidrug resistance, maintain the immunity balance, and improve the efficiency of chemotherapy [30,31,32]. Many studies found that CHM could effectively alleviate adverse gastrointestinal reactions (including diarrhea, nausea, and vomiting) to this anti-cancer chemotherapy-related therapy and decrease the incidence of bone marrow suppression [33]. Our case suggested a way to treat NE after chemotherapy with CHM. Moreover, some herbal materials mentioned in our medicine decoction have previously been investigated and the mechanisms underlying their spleen-invigorating function and regulatory role in gut microbiota are partly explained. For example, Codonopsis pilosula polysaccharide contained in Codonopsis Radix was reported to improve spleen deficiency by attenuating gut microbial dysbiosis [34]. Pori cocos oligosaccharides, a component in Pori cocos, have been revealed to alleviate dextran sodium sulfate (DSS)-induced colitis by modulating gut microbiota dysbiosis [35]. A new polysaccharide named CYP-1 isolated from Chinese yam has a therapeutic effect on gut microbiota dysbiosis by reducing the abundances of Alistipes, Helicobacter, and an unidentified Enterobacteriaceae in DSS-induced colitis [36]. CHMs also exert therapeutic impacts on other bacterium infections. For example, Ginseng treatment can reduce bacteria including Deferribacters, Lactobacillus, and Helicobacter against various diseases [37]. CHM is effective against the infection of human respiratory syncytial virus by stimulating IFN-β secretion [38]. Therefore, it can be concluded that the auxiliary therapeutic effect of CHM on NE is beyond doubt and of great potential.

4 Conclusions

This case report may strengthen the existing knowledge about CHM treatments for NE, especially for the refractory cases with poor therapeutic effects, and CHM may be another option after all efforts.

Acknowledgments

We would like to express our gratitude to Dr. Peng Xu, Dr. Chaoxiong Cui, Dr. Yukun Liu, Dr. Kun Fang, Dr. Qitang Wang, Dr. Chao Liu, and Dr. Ruixia Tan for their devoted work. Also, we would like to thank Dr. Qitang Wang for his professional guidance and advice. All authors have put much effort into writing, reviewing, and submitting this article.

  1. Funding information: This research was supported by The Medical and Health Research Guidance Project of Qingdao (2022-WJZD084).

  2. Author contributions: Dr. Peng Xu designed the study. Dr. Peng Xu and Dr. Chaoxiong Cui wrote the main manuscript text. Dr. Yukun Liu, Dr. Kun Fang, Dr. Chao Liu, and Dr. Ruixia Tan reviewed the article. Dr. Qitang Wang gave professional guidance. All authors read and approved the final manuscript.

  3. Conflict of interest: Authors state no conflict of interest.

  4. Data availability statement: The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Received: 2023-06-30
Revised: 2023-09-01
Accepted: 2023-09-11
Published Online: 2023-10-24

© 2023 the author(s), published by De Gruyter

This work is licensed under the Creative Commons Attribution 4.0 International License.

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  1. Biomedical Sciences
  2. Systemic investigation of inetetamab in combination with small molecules to treat HER2-overexpressing breast and gastric cancers
  3. Immunosuppressive treatment for idiopathic membranous nephropathy: An updated network meta-analysis
  4. Identifying two pathogenic variants in a patient with pigmented paravenous retinochoroidal atrophy
  5. Effects of phytoestrogens combined with cold stress on sperm parameters and testicular proteomics in rats
  6. A case of pulmonary embolism with bad warfarin anticoagulant effects caused by E. coli infection
  7. Neutrophilia with subclinical Cushing’s disease: A case report and literature review
  8. Isoimperatorin alleviates lipopolysaccharide-induced periodontitis by downregulating ERK1/2 and NF-κB pathways
  9. Immunoregulation of synovial macrophages for the treatment of osteoarthritis
  10. Novel CPLANE1 c.8948dupT (p.P2984Tfs*7) variant in a child patient with Joubert syndrome
  11. Antiphospholipid antibodies and the risk of thrombosis in myeloproliferative neoplasms
  12. Immunological responses of septic rats to combination therapy with thymosin α1 and vitamin C
  13. High glucose and high lipid induced mitochondrial dysfunction in JEG-3 cells through oxidative stress
  14. Pharmacological inhibition of the ubiquitin-specific protease 8 effectively suppresses glioblastoma cell growth
  15. Levocarnitine regulates the growth of angiotensin II-induced myocardial fibrosis cells via TIMP-1
  16. Age-related changes in peripheral T-cell subpopulations in elderly individuals: An observational study
  17. Single-cell transcription analysis reveals the tumor origin and heterogeneity of human bilateral renal clear cell carcinoma
  18. Identification of iron metabolism-related genes as diagnostic signatures in sepsis by blood transcriptomic analysis
  19. Long noncoding RNA ACART knockdown decreases 3T3-L1 preadipocyte proliferation and differentiation
  20. Surgery, adjuvant immunotherapy plus chemotherapy and radiotherapy for primary malignant melanoma of the parotid gland (PGMM): A case report
  21. Dosimetry comparison with helical tomotherapy, volumetric modulated arc therapy, and intensity-modulated radiotherapy for grade II gliomas: A single‑institution case series
  22. Soy isoflavone reduces LPS-induced acute lung injury via increasing aquaporin 1 and aquaporin 5 in rats
  23. Refractory hypokalemia with sexual dysplasia and infertility caused by 17α-hydroxylase deficiency and triple X syndrome: A case report
  24. Meta-analysis of cancer risk among end stage renal disease undergoing maintenance dialysis
  25. 6-Phosphogluconate dehydrogenase inhibition arrests growth and induces apoptosis in gastric cancer via AMPK activation and oxidative stress
  26. Experimental study on the optimization of ANM33 release in foam cells
  27. Primary retroperitoneal angiosarcoma: A case report
  28. Metabolomic analysis-identified 2-hydroxybutyric acid might be a key metabolite of severe preeclampsia
  29. Malignant pleural effusion diagnosis and therapy
  30. Effect of spaceflight on the phenotype and proteome of Escherichia coli
  31. Comparison of immunotherapy combined with stereotactic radiotherapy and targeted therapy for patients with brain metastases: A systemic review and meta-analysis
  32. Activation of hypermethylated P2RY1 mitigates gastric cancer by promoting apoptosis and inhibiting proliferation
  33. Association between the VEGFR-2 -604T/C polymorphism (rs2071559) and type 2 diabetic retinopathy
  34. The role of IL-31 and IL-34 in the diagnosis and treatment of chronic periodontitis
  35. Triple-negative mouse breast cancer initiating cells show high expression of beta1 integrin and increased malignant features
  36. mNGS facilitates the accurate diagnosis and antibiotic treatment of suspicious critical CNS infection in real practice: A retrospective study
  37. The apatinib and pemetrexed combination has antitumor and antiangiogenic effects against NSCLC
  38. Radiotherapy for primary thyroid adenoid cystic carcinoma
  39. Design and functional preliminary investigation of recombinant antigen EgG1Y162–EgG1Y162 against Echinococcus granulosus
  40. Effects of losartan in patients with NAFLD: A meta-analysis of randomized controlled trial
  41. Bibliometric analysis of METTL3: Current perspectives, highlights, and trending topics
  42. Performance comparison of three scaling algorithms in NMR-based metabolomics analysis
  43. PI3K/AKT/mTOR pathway and its related molecules participate in PROK1 silence-induced anti-tumor effects on pancreatic cancer
  44. The altered expression of cytoskeletal and synaptic remodeling proteins during epilepsy
  45. Effects of pegylated recombinant human granulocyte colony-stimulating factor on lymphocytes and white blood cells of patients with malignant tumor
  46. Prostatitis as initial manifestation of Chlamydia psittaci pneumonia diagnosed by metagenome next-generation sequencing: A case report
  47. NUDT21 relieves sevoflurane-induced neurological damage in rats by down-regulating LIMK2
  48. Association of interleukin-10 rs1800896, rs1800872, and interleukin-6 rs1800795 polymorphisms with squamous cell carcinoma risk: A meta-analysis
  49. Exosomal HBV-DNA for diagnosis and treatment monitoring of chronic hepatitis B
  50. Shear stress leads to the dysfunction of endothelial cells through the Cav-1-mediated KLF2/eNOS/ERK signaling pathway under physiological conditions
  51. Interaction between the PI3K/AKT pathway and mitochondrial autophagy in macrophages and the leukocyte count in rats with LPS-induced pulmonary infection
  52. Meta-analysis of the rs231775 locus polymorphism in the CTLA-4 gene and the susceptibility to Graves’ disease in children
  53. Cloning, subcellular localization and expression of phosphate transporter gene HvPT6 of hulless barley
  54. Coptisine mitigates diabetic nephropathy via repressing the NRLP3 inflammasome
  55. Significant elevated CXCL14 and decreased IL-39 levels in patients with tuberculosis
  56. Whole-exome sequencing applications in prenatal diagnosis of fetal bowel dilatation
  57. Gemella morbillorum infective endocarditis: A case report and literature review
  58. An unusual ectopic thymoma clonal evolution analysis: A case report
  59. Severe cumulative skin toxicity during toripalimab combined with vemurafenib following toripalimab alone
  60. Detection of V. vulnificus septic shock with ARDS using mNGS
  61. Novel rare genetic variants of familial and sporadic pulmonary atresia identified by whole-exome sequencing
  62. The influence and mechanistic action of sperm DNA fragmentation index on the outcomes of assisted reproduction technology
  63. Novel compound heterozygous mutations in TELO2 in an infant with You-Hoover-Fong syndrome: A case report and literature review
  64. ctDNA as a prognostic biomarker in resectable CLM: Systematic review and meta-analysis
  65. Diagnosis of primary amoebic meningoencephalitis by metagenomic next-generation sequencing: A case report
  66. Phylogenetic analysis of promoter regions of human Dolichol kinase (DOLK) and orthologous genes using bioinformatics tools
  67. Collagen changes in rabbit conjunctiva after conjunctival crosslinking
  68. Effects of NM23 transfection of human gastric carcinoma cells in mice
  69. Oral nifedipine and phytosterol, intravenous nicardipine, and oral nifedipine only: Three-arm, retrospective, cohort study for management of severe preeclampsia
  70. Case report of hepatic retiform hemangioendothelioma: A rare tumor treated with ultrasound-guided microwave ablation
  71. Curcumin induces apoptosis in human hepatocellular carcinoma cells by decreasing the expression of STAT3/VEGF/HIF-1α signaling
  72. Rare presentation of double-clonal Waldenström macroglobulinemia with pulmonary embolism: A case report
  73. Giant duplication of the transverse colon in an adult: A case report and literature review
  74. Ectopic thyroid tissue in the breast: A case report
  75. SDR16C5 promotes proliferation and migration and inhibits apoptosis in pancreatic cancer
  76. Vaginal metastasis from breast cancer: A case report
  77. Screening of the best time window for MSC transplantation to treat acute myocardial infarction with SDF-1α antibody-loaded targeted ultrasonic microbubbles: An in vivo study in miniswine
  78. Inhibition of TAZ impairs the migration ability of melanoma cells
  79. Molecular complexity analysis of the diagnosis of Gitelman syndrome in China
  80. Effects of maternal calcium and protein intake on the development and bone metabolism of offspring mice
  81. Identification of winter wheat pests and diseases based on improved convolutional neural network
  82. Ultra-multiplex PCR technique to guide treatment of Aspergillus-infected aortic valve prostheses
  83. Virtual high-throughput screening: Potential inhibitors targeting aminopeptidase N (CD13) and PIKfyve for SARS-CoV-2
  84. Immune checkpoint inhibitors in cancer patients with COVID-19
  85. Utility of methylene blue mixed with autologous blood in preoperative localization of pulmonary nodules and masses
  86. Integrated analysis of the microbiome and transcriptome in stomach adenocarcinoma
  87. Berberine suppressed sarcopenia insulin resistance through SIRT1-mediated mitophagy
  88. DUSP2 inhibits the progression of lupus nephritis in mice by regulating the STAT3 pathway
  89. Lung abscess by Fusobacterium nucleatum and Streptococcus spp. co-infection by mNGS: A case series
  90. Genetic alterations of KRAS and TP53 in intrahepatic cholangiocarcinoma associated with poor prognosis
  91. Granulomatous polyangiitis involving the fourth ventricle: Report of a rare case and a literature review
  92. Studying infant mortality: A demographic analysis based on data mining models
  93. Metaplastic breast carcinoma with osseous differentiation: A report of a rare case and literature review
  94. Protein Z modulates the metastasis of lung adenocarcinoma cells
  95. Inhibition of pyroptosis and apoptosis by capsaicin protects against LPS-induced acute kidney injury through TRPV1/UCP2 axis in vitro
  96. TAK-242, a toll-like receptor 4 antagonist, against brain injury by alleviates autophagy and inflammation in rats
  97. Primary mediastinum Ewing’s sarcoma with pleural effusion: A case report and literature review
  98. Association of ADRB2 gene polymorphisms and intestinal microbiota in Chinese Han adolescents
  99. Tanshinone IIA alleviates chondrocyte apoptosis and extracellular matrix degeneration by inhibiting ferroptosis
  100. Study on the cytokines related to SARS-Cov-2 in testicular cells and the interaction network between cells based on scRNA-seq data
  101. Effect of periostin on bone metabolic and autophagy factors during tooth eruption in mice
  102. HP1 induces ferroptosis of renal tubular epithelial cells through NRF2 pathway in diabetic nephropathy
  103. Intravaginal estrogen management in postmenopausal patients with vaginal squamous intraepithelial lesions along with CO2 laser ablation: A retrospective study
  104. Hepatocellular carcinoma cell differentiation trajectory predicts immunotherapy, potential therapeutic drugs, and prognosis of patients
  105. Effects of physical exercise on biomarkers of oxidative stress in healthy subjects: A meta-analysis of randomized controlled trials
  106. Identification of lysosome-related genes in connection with prognosis and immune cell infiltration for drug candidates in head and neck cancer
  107. Development of an instrument-free and low-cost ELISA dot-blot test to detect antibodies against SARS-CoV-2
  108. Research progress on gas signal molecular therapy for Parkinson’s disease
  109. Adiponectin inhibits TGF-β1-induced skin fibroblast proliferation and phenotype transformation via the p38 MAPK signaling pathway
  110. The G protein-coupled receptor-related gene signatures for predicting prognosis and immunotherapy response in bladder urothelial carcinoma
  111. α-Fetoprotein contributes to the malignant biological properties of AFP-producing gastric cancer
  112. CXCL12/CXCR4/CXCR7 axis in placenta tissues of patients with placenta previa
  113. Association between thyroid stimulating hormone levels and papillary thyroid cancer risk: A meta-analysis
  114. Significance of sTREM-1 and sST2 combined diagnosis for sepsis detection and prognosis prediction
  115. Diagnostic value of serum neuroactive substances in the acute exacerbation of chronic obstructive pulmonary disease complicated with depression
  116. Research progress of AMP-activated protein kinase and cardiac aging
  117. TRIM29 knockdown prevented the colon cancer progression through decreasing the ubiquitination levels of KRT5
  118. Cross-talk between gut microbiota and liver steatosis: Complications and therapeutic target
  119. Metastasis from small cell lung cancer to ovary: A case report
  120. The early diagnosis and pathogenic mechanisms of sepsis-related acute kidney injury
  121. The effect of NK cell therapy on sepsis secondary to lung cancer: A case report
  122. Erianin alleviates collagen-induced arthritis in mice by inhibiting Th17 cell differentiation
  123. Loss of ACOX1 in clear cell renal cell carcinoma and its correlation with clinical features
  124. Signalling pathways in the osteogenic differentiation of periodontal ligament stem cells
  125. Crosstalk between lactic acid and immune regulation and its value in the diagnosis and treatment of liver failure
  126. Clinicopathological features and differential diagnosis of gastric pleomorphic giant cell carcinoma
  127. Traumatic brain injury and rTMS-ERPs: Case report and literature review
  128. Extracellular fibrin promotes non-small cell lung cancer progression through integrin β1/PTEN/AKT signaling
  129. Knockdown of DLK4 inhibits non-small cell lung cancer tumor growth by downregulating CKS2
  130. The co-expression pattern of VEGFR-2 with indicators related to proliferation, apoptosis, and differentiation of anagen hair follicles
  131. Inflammation-related signaling pathways in tendinopathy
  132. CD4+ T cell count in HIV/TB co-infection and co-occurrence with HL: Case report and literature review
  133. Clinical analysis of severe Chlamydia psittaci pneumonia: Case series study
  134. Bioinformatics analysis to identify potential biomarkers for the pulmonary artery hypertension associated with the basement membrane
  135. Influence of MTHFR polymorphism, alone or in combination with smoking and alcohol consumption, on cancer susceptibility
  136. Catharanthus roseus (L.) G. Don counteracts the ampicillin resistance in multiple antibiotic-resistant Staphylococcus aureus by downregulation of PBP2a synthesis
  137. Combination of a bronchogenic cyst in the thoracic spinal canal with chronic myelocytic leukemia
  138. Bacterial lipoprotein plays an important role in the macrophage autophagy and apoptosis induced by Salmonella typhimurium and Staphylococcus aureus
  139. TCL1A+ B cells predict prognosis in triple-negative breast cancer through integrative analysis of single-cell and bulk transcriptomic data
  140. Ezrin promotes esophageal squamous cell carcinoma progression via the Hippo signaling pathway
  141. Ferroptosis: A potential target of macrophages in plaque vulnerability
  142. Predicting pediatric Crohn's disease based on six mRNA-constructed risk signature using comprehensive bioinformatic approaches
  143. Applications of genetic code expansion and photosensitive UAAs in studying membrane proteins
  144. HK2 contributes to the proliferation, migration, and invasion of diffuse large B-cell lymphoma cells by enhancing the ERK1/2 signaling pathway
  145. IL-17 in osteoarthritis: A narrative review
  146. Circadian cycle and neuroinflammation
  147. Probiotic management and inflammatory factors as a novel treatment in cirrhosis: A systematic review and meta-analysis
  148. Hemorrhagic meningioma with pulmonary metastasis: Case report and literature review
  149. SPOP regulates the expression profiles and alternative splicing events in human hepatocytes
  150. Knockdown of SETD5 inhibited glycolysis and tumor growth in gastric cancer cells by down-regulating Akt signaling pathway
  151. PTX3 promotes IVIG resistance-induced endothelial injury in Kawasaki disease by regulating the NF-κB pathway
  152. Pancreatic ectopic thyroid tissue: A case report and analysis of literature
  153. The prognostic impact of body mass index on female breast cancer patients in underdeveloped regions of northern China differs by menopause status and tumor molecular subtype
  154. Report on a case of liver-originating malignant melanoma of unknown primary
  155. Case report: Herbal treatment of neutropenic enterocolitis after chemotherapy for breast cancer
  156. The fibroblast growth factor–Klotho axis at molecular level
  157. Characterization of amiodarone action on currents in hERG-T618 gain-of-function mutations
  158. A case report of diagnosis and dynamic monitoring of Listeria monocytogenes meningitis with NGS
  159. Effect of autologous platelet-rich plasma on new bone formation and viability of a Marburg bone graft
  160. Small breast epithelial mucin as a useful prognostic marker for breast cancer patients
  161. Continuous non-adherent culture promotes transdifferentiation of human adipose-derived stem cells into retinal lineage
  162. Nrf3 alleviates oxidative stress and promotes the survival of colon cancer cells by activating AKT/BCL-2 signal pathway
  163. Favorable response to surufatinib in a patient with necrolytic migratory erythema: A case report
  164. Case report of atypical undernutrition of hypoproteinemia type
  165. Down-regulation of COL1A1 inhibits tumor-associated fibroblast activation and mediates matrix remodeling in the tumor microenvironment of breast cancer
  166. Sarcoma protein kinase inhibition alleviates liver fibrosis by promoting hepatic stellate cells ferroptosis
  167. Research progress of serum eosinophil in chronic obstructive pulmonary disease and asthma
  168. Clinicopathological characteristics of co-existing or mixed colorectal cancer and neuroendocrine tumor: Report of five cases
  169. Role of menopausal hormone therapy in the prevention of postmenopausal osteoporosis
  170. Precisional detection of lymph node metastasis using tFCM in colorectal cancer
  171. Advances in diagnosis and treatment of perimenopausal syndrome
  172. A study of forensic genetics: ITO index distribution and kinship judgment between two individuals
  173. Acute lupus pneumonitis resembling miliary tuberculosis: A case-based review
  174. Plasma levels of CD36 and glutathione as biomarkers for ruptured intracranial aneurysm
  175. Fractalkine modulates pulmonary angiogenesis and tube formation by modulating CX3CR1 and growth factors in PVECs
  176. Novel risk prediction models for deep vein thrombosis after thoracotomy and thoracoscopic lung cancer resections, involving coagulation and immune function
  177. Exploring the diagnostic markers of essential tremor: A study based on machine learning algorithms
  178. Evaluation of effects of small-incision approach treatment on proximal tibia fracture by deep learning algorithm-based magnetic resonance imaging
  179. An online diagnosis method for cancer lesions based on intelligent imaging analysis
  180. Medical imaging in rheumatoid arthritis: A review on deep learning approach
  181. Predictive analytics in smart healthcare for child mortality prediction using a machine learning approach
  182. Utility of neutrophil–lymphocyte ratio and platelet–lymphocyte ratio in predicting acute-on-chronic liver failure survival
  183. A biomedical decision support system for meta-analysis of bilateral upper-limb training in stroke patients with hemiplegia
  184. TNF-α and IL-8 levels are positively correlated with hypobaric hypoxic pulmonary hypertension and pulmonary vascular remodeling in rats
  185. Stochastic gradient descent optimisation for convolutional neural network for medical image segmentation
  186. Comparison of the prognostic value of four different critical illness scores in patients with sepsis-induced coagulopathy
  187. Application and teaching of computer molecular simulation embedded technology and artificial intelligence in drug research and development
  188. Hepatobiliary surgery based on intelligent image segmentation technology
  189. Value of brain injury-related indicators based on neural network in the diagnosis of neonatal hypoxic-ischemic encephalopathy
  190. Analysis of early diagnosis methods for asymmetric dementia in brain MR images based on genetic medical technology
  191. Early diagnosis for the onset of peri-implantitis based on artificial neural network
  192. Clinical significance of the detection of serum IgG4 and IgG4/IgG ratio in patients with thyroid-associated ophthalmopathy
  193. Forecast of pain degree of lumbar disc herniation based on back propagation neural network
  194. SPA-UNet: A liver tumor segmentation network based on fused multi-scale features
  195. Systematic evaluation of clinical efficacy of CYP1B1 gene polymorphism in EGFR mutant non-small cell lung cancer observed by medical image
  196. Rehabilitation effect of intelligent rehabilitation training system on hemiplegic limb spasms after stroke
  197. A novel approach for minimising anti-aliasing effects in EEG data acquisition
  198. ErbB4 promotes M2 activation of macrophages in idiopathic pulmonary fibrosis
  199. Clinical role of CYP1B1 gene polymorphism in prediction of postoperative chemotherapy efficacy in NSCLC based on individualized health model
  200. Lung nodule segmentation via semi-residual multi-resolution neural networks
  201. Evaluation of brain nerve function in ICU patients with Delirium by deep learning algorithm-based resting state MRI
  202. A data mining technique for detecting malignant mesothelioma cancer using multiple regression analysis
  203. Markov model combined with MR diffusion tensor imaging for predicting the onset of Alzheimer’s disease
  204. Effectiveness of the treatment of depression associated with cancer and neuroimaging changes in depression-related brain regions in patients treated with the mediator-deuterium acupuncture method
  205. Molecular mechanism of colorectal cancer and screening of molecular markers based on bioinformatics analysis
  206. Monitoring and evaluation of anesthesia depth status data based on neuroscience
  207. Exploring the conformational dynamics and thermodynamics of EGFR S768I and G719X + S768I mutations in non-small cell lung cancer: An in silico approaches
  208. Optimised feature selection-driven convolutional neural network using gray level co-occurrence matrix for detection of cervical cancer
  209. Incidence of different pressure patterns of spinal cerebellar ataxia and analysis of imaging and genetic diagnosis
  210. Pathogenic bacteria and treatment resistance in older cardiovascular disease patients with lung infection and risk prediction model
  211. Adoption value of support vector machine algorithm-based computed tomography imaging in the diagnosis of secondary pulmonary fungal infections in patients with malignant hematological disorders
  212. From slides to insights: Harnessing deep learning for prognostic survival prediction in human colorectal cancer histology
  213. Ecology and Environmental Science
  214. Monitoring of hourly carbon dioxide concentration under different land use types in arid ecosystem
  215. Comparing the differences of prokaryotic microbial community between pit walls and bottom from Chinese liquor revealed by 16S rRNA gene sequencing
  216. Effects of cadmium stress on fruits germination and growth of two herbage species
  217. Bamboo charcoal affects soil properties and bacterial community in tea plantations
  218. Optimization of biogas potential using kinetic models, response surface methodology, and instrumental evidence for biodegradation of tannery fleshings during anaerobic digestion
  219. Understory vegetation diversity patterns of Platycladus orientalis and Pinus elliottii communities in Central and Southern China
  220. Studies on macrofungi diversity and discovery of new species of Abortiporus from Baotianman World Biosphere Reserve
  221. Food Science
  222. Effect of berrycactus fruit (Myrtillocactus geometrizans) on glutamate, glutamine, and GABA levels in the frontal cortex of rats fed with a high-fat diet
  223. Guesstimate of thymoquinone diversity in Nigella sativa L. genotypes and elite varieties collected from Indian states using HPTLC technique
  224. Analysis of bacterial community structure of Fuzhuan tea with different processing techniques
  225. Untargeted metabolomics reveals sour jujube kernel benefiting the nutritional value and flavor of Morchella esculenta
  226. Mycobiota in Slovak wine grapes: A case study from the small Carpathians wine region
  227. Elemental analysis of Fadogia ancylantha leaves used as a nutraceutical in Mashonaland West Province, Zimbabwe
  228. Microbiological transglutaminase: Biotechnological application in the food industry
  229. Influence of solvent-free extraction of fish oil from catfish (Clarias magur) heads using a Taguchi orthogonal array design: A qualitative and quantitative approach
  230. Chromatographic analysis of the chemical composition and anticancer activities of Curcuma longa extract cultivated in Palestine
  231. The potential for the use of leghemoglobin and plant ferritin as sources of iron
  232. Investigating the association between dietary patterns and glycemic control among children and adolescents with T1DM
  233. Bioengineering and Biotechnology
  234. Biocompatibility and osteointegration capability of β-TCP manufactured by stereolithography 3D printing: In vitro study
  235. Clinical characteristics and the prognosis of diabetic foot in Tibet: A single center, retrospective study
  236. Agriculture
  237. Biofertilizer and NPSB fertilizer application effects on nodulation and productivity of common bean (Phaseolus vulgaris L.) at Sodo Zuria, Southern Ethiopia
  238. On correlation between canopy vegetation and growth indexes of maize varieties with different nitrogen efficiencies
  239. Exopolysaccharides from Pseudomonas tolaasii inhibit the growth of Pleurotus ostreatus mycelia
  240. A transcriptomic evaluation of the mechanism of programmed cell death of the replaceable bud in Chinese chestnut
  241. Melatonin enhances salt tolerance in sorghum by modulating photosynthetic performance, osmoregulation, antioxidant defense, and ion homeostasis
  242. Effects of plant density on alfalfa (Medicago sativa L.) seed yield in western Heilongjiang areas
  243. Identification of rice leaf diseases and deficiency disorders using a novel DeepBatch technique
  244. Artificial intelligence and internet of things oriented sustainable precision farming: Towards modern agriculture
  245. Animal Sciences
  246. Effect of ketogenic diet on exercise tolerance and transcriptome of gastrocnemius in mice
  247. Combined analysis of mRNA–miRNA from testis tissue in Tibetan sheep with different FecB genotypes
  248. Isolation, identification, and drug resistance of a partially isolated bacterium from the gill of Siniperca chuatsi
  249. Tracking behavioral changes of confined sows from the first mating to the third parity
  250. The sequencing of the key genes and end products in the TLR4 signaling pathway from the kidney of Rana dybowskii exposed to Aeromonas hydrophila
  251. Development of a new candidate vaccine against piglet diarrhea caused by Escherichia coli
  252. Plant Sciences
  253. Crown and diameter structure of pure Pinus massoniana Lamb. forest in Hunan province, China
  254. Genetic evaluation and germplasm identification analysis on ITS2, trnL-F, and psbA-trnH of alfalfa varieties germplasm resources
  255. Tissue culture and rapid propagation technology for Gentiana rhodantha
  256. Effects of cadmium on the synthesis of active ingredients in Salvia miltiorrhiza
  257. Cloning and expression analysis of VrNAC13 gene in mung bean
  258. Chlorate-induced molecular floral transition revealed by transcriptomes
  259. Effects of warming and drought on growth and development of soybean in Hailun region
  260. Effects of different light conditions on transient expression and biomass in Nicotiana benthamiana leaves
  261. Comparative analysis of the rhizosphere microbiome and medicinally active ingredients of Atractylodes lancea from different geographical origins
  262. Distinguish Dianthus species or varieties based on chloroplast genomes
  263. Comparative transcriptomes reveal molecular mechanisms of apple blossoms of different tolerance genotypes to chilling injury
  264. Study on fresh processing key technology and quality influence of Cut Ophiopogonis Radix based on multi-index evaluation
  265. An advanced approach for fig leaf disease detection and classification: Leveraging image processing and enhanced support vector machine methodology
  266. Erratum
  267. Erratum to “Protein Z modulates the metastasis of lung adenocarcinoma cells”
  268. Erratum to “BRCA1 subcellular localization regulated by PI3K signaling pathway in triple-negative breast cancer MDA-MB-231 cells and hormone-sensitive T47D cells”
  269. Retraction
  270. Retraction to “Protocatechuic acid attenuates cerebral aneurysm formation and progression by inhibiting TNF-alpha/Nrf-2/NF-kB-mediated inflammatory mechanisms in experimental rats”
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