{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T02:49:01Z","timestamp":1791600541197,"version":"4.3.4"},"reference-count":50,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T00:00:00Z","timestamp":1791417600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T00:00:00Z","timestamp":1791417600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: A Branch-duct intraductal papillary mucinous neoplasms (BD-IPMNs) are common pancreatic precursor lesions requiring varying duration of surveillance because of their potential for malignant transformation. Current risk stratification relies predominantly on imaging-based criteria defined by the Kyoto guidelines, while reliable blood-based biomarkers are lacking. The neutrophil-to-lymphocyte ratio (NLR) has been associated with invasive IPMN in surgical resected cases, but its role in routine BD-IPMN surveillance has not been investigated. This study investigated the association between NLR and disease progression in a large surveillance cohort of patients with BD-IPMN. Methods: This retrospective two-center study included patients with image-based diagnosis of BD-IPMN who underwent at least one further follow-up endoscopic ultrasound (EUS) examination between 2006 and 2026 and had an available differential blood count. Disease progression was defined as the development of new worrisome features (WFs), high-risk stigmata (HRS), pancreatic resection for progressive disease, or IPMN-associated carcinoma. Results: A total of 285 patients undergoing 2207 EUS examinations were included, with a mean EUS surveillance duration of 4.8 years. During follow-up, 63 patients (22.1%) developed at least one WF, 4 (1.4%) developed HRS, 11 (3.9%) underwent pancreatic resection, and 2 (0.7%) developed IPMN-associated carcinoma. NLR was significantly elevated in patients who developed WFs (p = 0.0023), HRS (p &lt; 0.0001), underwent pancreatic resection (p = 0.0006), or had high-grade dysplasia (p = 0.0002). Baseline continuous NLR showed no significant discriminatory ability for subsequent disease progression (AUC, 0.563; 95% CI, 0.482\u20130.635; p = 0.136). Patients with an NLR above the cohort median (&gt;2.36) had approximately twofold higher odds of subsequent disease progression (OR, 2.02; 95% CI, 1.02\u20133.98). Longitudinal analyses demonstrated significant increases in NLR preceding the development of WFs (p &lt; 0.0001), HRS (p = 0.0265), and pancreatic resection (p = 0.0272). Rising NLR was particularly associated with cyst growth, cyst size \u226530 mm, and main pancreatic duct dilation. Conclusions: Elevated and increasing NLR was associated with BD-IPMN progression and correlated with established markers of higher-risk disease. Longitudinal NLR assessment may represent a simple and widely available complementary biomarker for surveillance; however, its modest discriminatory performance warrants prospective validation before clinical implementation.<\/jats:p>","DOI":"10.3390\/jcm15197758","type":"journal-article","created":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T01:40:17Z","timestamp":1791596417000},"page":"7758","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Neutrophil-to-Lymphocyte Ratio Is Associated with Disease Progression in a Surveillance Cohort of Patients with Branch-Duct IPMN"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7452-1189","authenticated-orcid":false,"given":"Frederik J.","family":"Hansen","sequence":"first","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"formal-analysis","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"}]},{"given":"Peter","family":"Ewald","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Luis","family":"Sorncharoen","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"investigation","vocabulary":"credit"},{"role":"formal-analysis","vocabulary":"credit"}]},{"given":"Daniel R.","family":"Quast","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Maximilian","family":"St\u00f6gbauer","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Christian Torres","family":"Reyes","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Renate","family":"Schlottmann","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Christoph","family":"Zeidler","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Mousa","family":"Ayoub","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Bernadette","family":"Kaup","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Anne","family":"Koch","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Sarah","family":"Schellen","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Lisa","family":"Weckheuer","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"given":"Oscar","family":"Cahyadi","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Alanna","family":"Ebigbo","sequence":"additional","affiliation":[{"name":"Medizinische Klinik I, Gastroenterology, St. Josef\u2013Hospital Bochum, Hospital of the Ruhr-University Bochum, Gudrunstra\u00dfe 56, 44791 Bochum, Germany"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"conceptualization","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,10,8]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1182","DOI":"10.1016\/S0140-6736(25)00261-2","article-title":"Pancreatic cancer","volume":"405","author":"Stoop","year":"2025","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"851","DOI":"10.1001\/jama.2021.13027","article-title":"Pancreatic Cancer: A Review","volume":"326","author":"Park","year":"2021","journal-title":"JAMA"},{"key":"ref_3","first-page":"e70035","article-title":"Advances in pancreatic cancer early diagnosis, prevention, and treatment: The past, the present, and the future","volume":"76","author":"Mannucci","year":"2026","journal-title":"CA Cancer J. Clin."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"171","DOI":"10.1001\/jamasurg.2025.5692","article-title":"Molecular Analysis of Mixed-Type and Branch-Duct Intraductal Papillary Mucinous Neoplasms","volume":"161","author":"Kannan","year":"2026","journal-title":"JAMA Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1177\/02841851251389575","article-title":"Pancreatic IPMN in clinical practice: Descriptive analysis of 1082 patients referred to multidisciplinary evaluation","volume":"67","author":"Abdolalizadeh","year":"2026","journal-title":"Acta Radiol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"226","DOI":"10.1053\/j.gastro.2019.08.032","article-title":"Long-term Risk of Malignancy in Branch-Duct Intraductal Papillary Mucinous Neoplasms","volume":"158","author":"Oyama","year":"2020","journal-title":"Gastroenterology"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"154","DOI":"10.1097\/SLA.0000000000006535","article-title":"Unraveling the Long-term Natural History of Branch Duct Intraductal Papillary Mucinous Neoplasm: Beyond 10 years","volume":"281","author":"Assawasirisin","year":"2025","journal-title":"Ann. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1087","DOI":"10.1002\/jso.27414","article-title":"Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features","volume":"128","author":"Lattimore","year":"2023","journal-title":"J. Surg. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2660","DOI":"10.1007\/s00261-024-04665-2","article-title":"Exploring the new Kyoto guidelines for managing pancreatic cysts: An overview and comparison with previous guidelines","volume":"50","author":"Rahmatullah","year":"2025","journal-title":"Abdom. Radiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1016\/j.pan.2023.12.009","article-title":"International evidence-based Kyoto guidelines for the management of intraductal papillary mucinous neoplasm of the pancreas","volume":"24","author":"Ohtsuka","year":"2024","journal-title":"Pancreatology"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"3545","DOI":"10.1245\/s10434-025-18890-6","article-title":"Evaluating the Kyoto Guidelines\u2019 Worrisome Features and High-Risk Stigmata to Predict High-Grade Dysplasia and Invasive Cancer in Intraductal Papillary Mucinous Neoplasms","volume":"33","author":"Levine","year":"2026","journal-title":"Ann. Surg. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"2413","DOI":"10.1016\/j.cgh.2024.05.043","article-title":"The Revised Kyoto Criteria and Risk of Malignancy Among Patients With Intraductal Papillary Mucinous Neoplasms","volume":"22","author":"Hamada","year":"2024","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Moris, D., Liapis, I., Gupta, P., Ziogas, I.A., Karachaliou, G.S., Dimitrokallis, N., Nguyen, B., and Radkani, P. (2024). An Overview for Clinicians on Intraductal Papillary Mucinous Neoplasms (IPMNs) of the Pancreas. Cancers, 16.","DOI":"10.3390\/cancers16223825"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1988","DOI":"10.1007\/s11605-022-05536-1","article-title":"A Clinical Guide to the Management of Intraductal Papillary Mucinous Neoplasms: The Need for a More Graded Approach in Clinical Decision-making","volume":"27","author":"Fong","year":"2023","journal-title":"J. Gastrointest. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"436","DOI":"10.1016\/j.pan.2026.03.003","article-title":"Re-evaluating routinely collected clinical and laboratory parameters in the preoperative risk assessment of intraductal papillary mucinous neoplasms: Model development and internal validation","volume":"26","author":"Grewal","year":"2026","journal-title":"Pancreatology"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e00856","DOI":"10.14309\/ctg.0000000000000856","article-title":"Risk Stratification for Malignant Potential of Intraductal Papillary Mucinous Neoplasms Using the Apolipoprotein-A2 Isoforms Blood Test","volume":"16","author":"Hasegawa","year":"2025","journal-title":"Clin. Transl. Gastroenterol."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Pawlowski, W., Stefanski, M., Wlodarczyk, B., Durko, L., and Malecka-Wojciesko, E. (2025). Pancreatic Cancer Detection in Intraductal Papillary Mucinous Neoplasm (IPMN)\u2014New Insights. Cancers, 17.","DOI":"10.20944\/preprints202509.2404.v1"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1535","DOI":"10.1158\/1078-0432.CCR-22-2531","article-title":"Blood-Based Diagnosis and Risk Stratification of Patients with Pancreatic Intraductal Papillary Mucinous Neoplasm (IPMN)","volume":"29","author":"Zhang","year":"2023","journal-title":"Clin. Cancer Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"281","DOI":"10.1111\/prd.12612","article-title":"Inflammation indices in association with periodontitis and cancer","volume":"96","author":"Walther","year":"2024","journal-title":"Periodontology 2000"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"218","DOI":"10.1016\/j.critrevonc.2013.03.010","article-title":"The systemic inflammation-based neutrophil-lymphocyte ratio: Experience in patients with cancer","volume":"88","author":"Guthrie","year":"2013","journal-title":"Crit. Rev. Oncol. Hematol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1002\/jso.70039","article-title":"Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Melanoma: A Systematic Review and Meta-Analysis","volume":"132","author":"Yang","year":"2025","journal-title":"J. Surg. Oncol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1928","DOI":"10.1002\/hed.28101","article-title":"Neutrophil-to-Lymphocyte Ratio as a Predictor for PD-L1 Inhibitor Treatment in Recurrent or Metastatic Nasopharyngeal Carcinoma","volume":"47","author":"Gao","year":"2025","journal-title":"Head Neck"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1097\/SLA.0000000000001988","article-title":"Neutrophil-to-lymphocyte Ratio is a Predictive Marker for Invasive Malignancy in Intraductal Papillary Mucinous Neoplasms of the Pancreas","volume":"266","author":"Gemenetzis","year":"2017","journal-title":"Ann. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1623","DOI":"10.1016\/j.hpb.2021.04.001","article-title":"The diagnostic and prognostic values of inflammatory markers in intraductal papillary mucinous neoplasm","volume":"23","author":"Kim","year":"2021","journal-title":"HPB"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2171","DOI":"10.1007\/s11605-015-2973-2","article-title":"The Neutrophil-to-Lymphocyte Ratio Predicts Malignant Potential in Intraductal Papillary Mucinous Neoplasms","volume":"19","author":"Arima","year":"2015","journal-title":"J. Gastrointest. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1097\/MPA.0000000000001202","article-title":"Diagnostic and Prognostic Impact of Neutrophil-to-Lymphocyte Ratio for Intraductal Papillary Mucinous Neoplasms of the Pancreas With High-Grade Dysplasia and Associated Invasive Carcinoma","volume":"48","author":"Hata","year":"2019","journal-title":"Pancreas"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Wu, X., Zhu, W., Chen, W., and Ruan, L. (2026). Tumor-associated neutrophils in pancreatic ductal adenocarcinoma: Mechanisms and therapeutic targeting. Front. Immunol., 17.","DOI":"10.3389\/fimmu.2026.1806714"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"21164","DOI":"10.1038\/s41598-024-70916-3","article-title":"CD71 expressing circulating neutrophils serve as a novel prognostic biomarker for metastatic spread and reduced outcome in pancreatic ductal adenocarcinoma patients","volume":"14","author":"Hansen","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"485","DOI":"10.1038\/s41568-020-0281-y","article-title":"Neutrophil diversity and plasticity in tumour progression and therapy","volume":"20","author":"Jaillon","year":"2020","journal-title":"Nat. Rev. Cancer"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"258","DOI":"10.1186\/s13046-024-03178-6","article-title":"Tumor-associated neutrophils upregulate Nectin2 expression, creating the immunosuppressive microenvironment in pancreatic ductal adenocarcinoma","volume":"43","author":"Luo","year":"2024","journal-title":"J. Exp. Clin. Cancer Res."},{"key":"ref_31","doi-asserted-by":"crossref","unstructured":"Jiang, W., Li, X., Xiang, C., and Zhou, W. (2022). Neutrophils in pancreatic cancer: Potential therapeutic targets. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.1025805"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1002\/jso.24643","article-title":"The pancreatic cancer microenvironment: A true double agent","volume":"116","author":"Melstrom","year":"2017","journal-title":"J. Surg. Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"5161","DOI":"10.7150\/ijbs.133035","article-title":"Neutrophil Extracellular Traps in Pancreatic Ductal Adenocarcinoma: A Vicious Cycle in the Tumor Microenvironment and Targeted Interventions","volume":"22","author":"Zhao","year":"2026","journal-title":"Int. J. Biol. Sci."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Sturgeon, R., Goel, P., Molczyk, C., Bhola, R., Grandgenett, P.M., Hollingsworth, M.A., and Singh, R.K. (2025). Neutrophil Dynamics Contribute to Disease Progression and Poor Survival in Pancreatic Cancer. Cancers, 17.","DOI":"10.3390\/cancers17213541"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"178","DOI":"10.1038\/s41392-025-02242-7","article-title":"Therapeutic potential of tumor-associated neutrophils: Dual role and phenotypic plasticity","volume":"10","author":"Zhou","year":"2025","journal-title":"Signal Transduct. Target. Ther."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1663","DOI":"10.21873\/anticanres.14929","article-title":"Neutrophil-to-lymphocyte Ratio as a Predictor of Malignancy of Intraductal Papillary Mucinous Neoplasms","volume":"41","author":"Sugimachi","year":"2021","journal-title":"Anticancer Res."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Heshmat-Ghahdarijani, K., Sarmadi, V., Heidari, A., Falahati Marvasti, A., Neshat, S., and Raeisi, S. (2023). The neutrophil-to-lymphocyte ratio as a new prognostic factor in cancers: A narrative review. Front. Oncol., 13.","DOI":"10.3389\/fonc.2023.1228076"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1016\/j.annepidem.2019.07.015","article-title":"Sociodemographic and lifestyle factors associated with the neutrophil-to-lymphocyte ratio","volume":"38","author":"Howard","year":"2019","journal-title":"Ann. Epidemiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"236","DOI":"10.1016\/1047-2797(94)90102-3","article-title":"Cigarette smoking and peripheral blood leukocyte differentials","volume":"4","author":"Schwartz","year":"1994","journal-title":"Ann. Epidemiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"3000605211019223","DOI":"10.1177\/03000605211019223","article-title":"Neutrophil\/lymphocyte ratio is correlated with levels of inflammatory markers and is significantly reduced by smoking cessation","volume":"49","author":"Komiyama","year":"2021","journal-title":"J. Int. Med. Res."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"8191254","DOI":"10.1155\/2016\/8191254","article-title":"Prognostic Significance of Neutrophil-to-Lymphocyte Ratio in Patients with Sepsis: A Prospective Observational Study","volume":"2016","author":"Liu","year":"2016","journal-title":"Mediat. Inflamm."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"104598","DOI":"10.1016\/j.mvr.2023.104598","article-title":"Neutrophil-to-lymphocyte ratio an inflammatory biomarker, and prognostic marker in heart failure, cardiovascular disease and chronic inflammatory diseases: New insights for a potential predictor of anti-cytokine therapy responsiveness","volume":"150","author":"Galeote","year":"2023","journal-title":"Microvasc. Res."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"e001019","DOI":"10.1136\/jitc-2020-001019","article-title":"Early changes in immune cell subsets with corticosteroids in patients with solid tumors: Implications for COVID-19 management","volume":"8","author":"Marte","year":"2020","journal-title":"J. Immunother. Cancer"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"6635594","DOI":"10.1155\/2021\/6635594","article-title":"Neutrophil-Lymphocyte Ratio as an Initial Screening Biomarker for Differential Diagnosis of Cushing\u2019s Syndrome from Nonfunctional Adenoma in Patients with an Adrenal Mass","volume":"2021","author":"Wang","year":"2021","journal-title":"BioMed Res. Int."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1111\/ejh.13560","article-title":"The hematologic consequences of obesity","volume":"106","author":"Purdy","year":"2021","journal-title":"Eur. J. Haematol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"342","DOI":"10.1016\/j.eprac.2021.11.083","article-title":"Is the Neutrophil-to-Lymphocyte Ratio an Exceptional Indicator for Metabolic Syndrome Disease and Outcomes?","volume":"28","author":"Neshat","year":"2022","journal-title":"Endocr. Pr."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1881","DOI":"10.1513\/AnnalsATS.202412-1265OC","article-title":"Neutrophil-to-Lymphocyte Ratio as a Biomarker in Clinically Stable Chronic Obstructive Pulmonary Disease: SPIROMICS Cohort","volume":"22","author":"Hoesterey","year":"2025","journal-title":"Ann. Am. Thorac. Soc."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1111\/imm.13747","article-title":"Circadian rhythm regulation in the immune system","volume":"171","author":"Ding","year":"2024","journal-title":"Immunology"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"917","DOI":"10.1111\/ijlh.13590","article-title":"Effects of circadian variation, lifestyle and environment on hematological parameters: A narrative review","volume":"43","author":"Feriel","year":"2021","journal-title":"Int. J. Lab. Hematol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1080\/07420528.2025.2511266","article-title":"Population-level analysis of circadian variations in blood cells","volume":"42","year":"2025","journal-title":"Chronobiol. Int."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7758\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T01:55:56Z","timestamp":1791597356000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/19\/7758"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,10,8]]},"references-count":50,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["jcm15197758"],"URL":"https:\/\/doi.org\/10.3390\/jcm15197758","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,10,8]]}}}