Psoriasis has been reported as a high-risk factor for quality of life and survival rate in patients with metabolic disorder. However, there is no animal model for studying this disease. This study aimed to establish and evaluate mouse models of psoriasis with blood stasis syndrome  complicated with metabolic disorders. n = 9 mice/group). Psoriasis lesions were induced using IMQ cream . Mice of the IMQ + BSS group were fed a half-fat, high-sugar diet and stimulated with ice-water swimming every day. Mice of the IMQ + STZ group were fed a half-fat, high-sugar diet and injected with STZ. Mice of the IMQ + STZ + BSS group were subjected to the same treatments as the IMQ + STZ and IMQ + BSS groups. After induction, the mice in each group were observed for vital signs, ear thickness, body weight, and psoriasis area and severity index (PASI) score. The mice were fasted for 12 h before determination of related laboratory serum indexes. Dorsal skin lesions, aortic arch pathology sections, and signal transducer and activator of transcription 3 (STAT3) were examined by H&E staining and immunohistochemistry.  Forty-five C57BL/6 mice were randomly divided into the blank control (Control), psoriasis (Imiquimod (IMQ)), psoriasis with metabolic disorders (IMQ + streptozotocin (STZ)), psoriasis with blood stasis syndrome (BSS) (IMQ + BSS), and psoriasis with blood stasis syndrome complicated with metabolic disorders (IMQ + STZ + BSS) groups (p < 0.01); indicators of the IMQ + STZ, IMQ + BSS, and IMQ + STZ + BSS groups showed varying degrees of difference from those of the IMQ group.  Laboratory indexes in the four model groups were significantly different from those in the Control group ( The established mouse models of psoriasis blood stasis syndrome complicated with glucose and lipid metabolism disorders met the clinical and Chinese Medicine characteristics, and thus they could be used as animal models in future studies of psoriasis complicated with glucose and lipid metabolism disorders. Psoriasis is a clinically common chronic relapsing inflammatory skin disease, and it is called “Baibi” or “Songpixian” in Chinese Medicine (CM). A previous study  has showIn CM, blood is believed to be the disease location of psoriasis, given that the classic CM syndromes of psoriasis include “blood heat,” “blood stasis,” and “blood deficiency” . MoreoveForty-five male C57BL/6 mice weighing 25 ± 3 g were provided by Shanghai Medical Experimental Animal Center . The animals were maintained under a standard temperature of 23 ± 2°C and 12-h light-dark cycle. The mice were grouped into three mice per cage with free access to standard diet and water. All procedures were reviewed and approved by the Scientific Research Department of Yueyang Hospital affiliated to Shanghai University of Traditional Chinese Medicine . All procedures were reviewed and approved by the Ethics Committee of Yueyang Hospital affiliated to Shanghai University of Traditional Chinese Medicine (no. 17772).All mice were randomly divided into five groups: blank control group (Control group), psoriasis group (IMQ group), psoriasis with metabolic disorders group (IMQ + STZ group), psoriasis with blood stasis syndrome (BSS) group (IMQ + BSS group), and psoriasis with blood stasis syndrome complicated with metabolic disorders group (IMQ + STZ + BSS group), with nine mice in each group.Low-density lipoprotein-cholesterol (LDL-C) and total cholesterol testing kits were purchased from Nanjing Jiancheng Institute of Biological Engineering . Vascular endothelial growth factor (VEGF), endothelin-1 (ET-1), insulin, and mouse C-peptide testing kits were obtained from Shanghai Xinyu Biotechnology Co., Ltd. , and the rapid glucose meter was purchased from Bayer .IMQ cream was purchased from Sichuan Mingxin Pharmaceutical Co., Ltd. . Norepinephrine (NE) adjusted to 0.1 g/l was obtained from Shanghai Wellhope Pharmaceutical Co., Ltd. . STZ powder (batch number: Cas18883-66-4) was purchased from Beijing Boai Port Trade Center . STZ buffer was configured from liquid A  and liquid B  at 4°C, avoiding light preservation, to 10 mg/ml solution configured to STZ before use. Rabbit antiphosphorylation signal transducers and activators of transcription-3 (STAT3) antibodies (batch number: GR287047-7) were purchased from Abcam Co. .The model establishment methods are shown in 2 of skin; 0.01 g IMQ cream was applied evenly using a rubber hose) once a day for seven days [The back hair of the mice was shaved, and IMQ cream was applied to the skin on their ears and back  for one week. STZ solution was administered via intraperitoneal injection to mice at a dose of 100 mg/kg once daily for two days, and blood glucose level was measured on the fifth day. An obvious increase in blood glucose level indicated successful model establishment. Otherwise, the dose was administered again on the fifth day until blood glucose level reached >14.9 mmol/l. The day after blood glucose level reached >14.9 mmol/l, and IMQ cream was applied to the skin of the ears and back of the mice, with the same method as for the IMQ group. Starting from the first day of IMQ cream application, the skin lesions were photographed and recorded daily, ear thickness was measured, and body weights were recorded.Mice were fed a half-fat and high-sugar diet  for one week. NE was administered via intraperitoneal injection in mice at a dose of 0.1 ml/100 g . After 15 to 20 min, the mice were induced to swim in ice water at 4°C for 5 min once a day for 8 days. On the second day of ice-water swimming, IMQ cream was applied to the skin of the ears and back of the mice, using the same method as for the IMQ group. Starting from the first day of IMQ cream application, skin lesions were photographed and recorded daily, ear thickness was measured, body weights were recorded, and changes in mouse hair color, nails, tongue, and activity were observed every day.The psoriasis induction method was the same as for the IMQ group, and the induction methods of blood stasis syndrome and metabolic disorder were the same as for the IMQ + BSS and IMQ + STZ groups, respectively. During the eight consecutive days of model induction, skin lesions were photographed and recorded daily, ear thickness was measured, and body weights were recorded.2 into the box maintained at 20% volume of the box per minute. Specimens of the bilateral ears, back skin, and aortic arch were collected using surgical scissors and fixed in 100 ml/l paraformaldehyde solution. Paraffin blocks of specimens were then prepared routinely for analysis.The experimental cycle was approximately 15 days. The mice were fasted but allowed water for 12 h before specimen collection. At 8 a.m. on the next day, 2 ml blood was extracted via the eyeball: 1 ml was injected into an anticoagulant test tube, and the other 1 ml was injected into a coagulant test tube. Blood samples were allowed to stand for 4°C for 1 h and then centrifuged in a refrigerated centrifuge at 4°C and 1800 rpm/min for 5 min. The supernatant was then collected and stored in a refrigerator at −80°C until analysis. The mice were sacrificed in a euthanasia box with the flow rate of COx̄ ± s). Values of p < 0.05 indicated a statistical difference, and p < 0.01 indicated a significant difference. A group sample t-test was used for comparison between groups.The data were analyzed by using the SPSS.21.0 statistical software . The data were expressed as .The PASI score showed similar results . The PASp < 0.01). Thickening of the mouse ears was the fastest in the IMQ + STZ + BSS group, followed by the IMQ + STZ group. The ears of the IMQ + BSS group were slightly thicker than those of the IMQ group, suggesting the same conclusion as that suggested by the PASI score.IMQ cream was applied to the mouse ears, and mouse ear thickness was measured on the first to seventh day . We founp < 0.01; Mouse back skin collected on day 7 was stained with H&E and observed at 100× magnification , left. Tp < 0.01; p < 0.05), suggesting that glucose and lipid metabolism disorders and blood stasis syndrome promoted the proliferation and differentiation of keratinocytes (KCs), and that the expression of STAT3 was positively correlated with PASI score.Using immunohistochemical staining and microscopy at 200x magnification , right, p < 0.01), but significantly decreased in the IMQ + BSS group (p < 0.01). Compared with those in the Control group, serum C-peptide levels significantly decreased in the IMQ + STZ, IMQ + BSS, and IMQ + STZ + BSS groups (p < 0.01), suggesting that islet dysfunction occurred in varying degrees in each model group after induction. Compared with those of the IMQ group, blood glucose levels significantly increased in the IMQ + STZ and IMQ + STZ + BSS groups (p < 0.01), but significantly decreased in the IMQ + BSS group (p < 0.01), suggesting that STZ induction increased blood glucose level. Moreover, blood glucose level in the IMQ + BSS group might have been too low owing to insufficient insulin secretion , IMQ + BSS (p < 0.05), and IMQ + STZ + BSS (p < 0.01) groups, and insignificantly decreased in the IMQ + STZ group. Mouse body weights in the IMQ, IMQ + STZ, IMQ + BSS, and IMQ + STZ + BSS groups slightly increased at the fifth and sixth days of induction, which may be related to the induction treatments. At the end of the induction period, weight loss was the most obvious in the IMQ + BSS group, followed by the IMQ + STZ + BSS and IMQ + STZ groups, and the least obvious in the IMQ group , whereas the levels of HDL were significantly decreased in each model group (p < 0.01), indicating that lipid metabolism disorders were prevalent in each model group (p < 0.01), accompanied by decreased HDL levels (p < 0.01). This result suggested that compared with the Control group, the IMQ group had a certain degree of lipid metabolism disorder, and the model groups induced with STZ showed more severe lipid metabolism disorder than the IMQ group.Compared with those in the Control group at the end of induction, the levels of total cholesterol, triglycerides, and LDL significantly increased in each model group (el group . Howeverp < 0.01). The high-shear whole blood viscosity level significantly increased in the IMQ + STZ and IMQ + BSS groups (p < 0.05), indicating that blood stasis syndrome as well as glucose and lipid metabolism disorders helped increase blood viscosity index , especially in the IMQ + STZ and IMQ + STZ + BSS groups, suggesting that the three interventions  caused different degrees of microcirculation disorders. In addition, compared with that in the IMQ group, VEGF level in the IMQ + STZ, IMQ + BSS, and IMQ + STZ + BSS groups increased significantly (p < 0.01). The levels of ET-1 in the IMQ + STZ and IMQ + STZ + BSS groups significantly increased, further suggesting that glucose and lipid metabolism disorders and blood stasis syndrome aggravated psoriasis (Compared with those in the control group, VEGF and ET-1 levels were significantly increased in each model group at the end of induction (soriasis .On the seventh day of induction, the aortic arch was dissected from the mice and stained with H&E . MicrocoThe idea of combining diseases and syndromes of CM has been used to study psoriasis animal model induction. At present, there are two published Chinese studies on the induction of blood stasis in psoriasis , 15, botModern clinical research has demonstrated the existence of glucose and lipid metabolism disorders in patients with psoriasis, which is more likely to be complicated with fatty liver and diabetes , 17. In β cells in the mice [β cells are destroyed, leading to islet dysfunction and insufficient insulin secretion. In our study, insulin levels in the non-STZ groups were slightly lower than those in the STZ groups, and blood glucose levels of STZ mice were elevated significantly, which led to insulin resistance and induce type II diabetes. These results may indicate that our IMQ-STZ models were undergoing a transition from an insulin-resistant state to induce type II diabetes [Our results showed that, compared with the Control group, thickening of mouse dorsal skin, increased erythema and scaling, and increased PASI score were observed in the groups treated with IMQ cream, indicating successful establishment of psoriasis models. Half-fat diet was used to induce obesity and insulin resistance in mice , and intthe mice , thus gediabetes . The blodiabetes .From the microscopic perspective, increased VEGF and ET-1 indexes verified that the internal environment of the IMQ, IMQ + STZ, IMQ + BSS, and IMQ + STZ + BSS groups all presented different degrees of microcirculation disorders. The pathological sections of the dorsal skin showed thickening of the spinous layer, and inflammatory infiltration was most significant in the IMQ + STZ + BSS group, whereas the IMQ + STZ and IMQ + BSS groups showed the same trend of thickening and infiltration, suggesting that both blood stasis syndrome and glucose and lipid metabolism disorders aggravated the skin lesions of psoriasis. Pathological sections showed that the intima of the aortic arch in the IMQ + STZ and IMQ + STZ + BSS groups presented lipid droplet aggregation, accompanied by narrowing of the vascular lumen and hyperplasia of connective tissue on the outside of the arch wall, whereas the intima of the aortic arch in the IMQ + BSS group showed lipid deposition and scattered calcification points, suggesting that both blood stasis syndrome and glucose and lipid metabolism disorders induced aortic blood flow obstruction.STAT3, a specific index of psoriatic KC proliferation , is mainFrom the perspective of CM, blood stasis is a key to the pathogenesis of psoriasis , 27. BloWe established mouse models of psoriasis with blood stasis syndrome complicated with glucose and lipid metabolism disorders, which presented the clinical characteristics specified in CM. Thus, our models could be used in studies investigating psoriasis complicated with glucose and lipid metabolism disorders.


NPC) includes both chemotherapy and definitive radiation. However, there are limited data on the optimal management of stage II NPC. We performed a retrospective analysis of the National Cancer Database to analyze the treatment patterns and role of chemotherapy in patients with stage II NPC. We identified 611 patients diagnosed with T1‐2, N0‐1, M0 NPC, from 2004 to 2013. Five‐year survival was calculated using Kaplan Meier (KM) analysis. Multivariable analysis and propensity matched analysis were performed to analyze the impact of chemotherapy on overall survival. Of the 611 patients, 527 underwent concurrent chemoradiation (CCRT) and 84 received radiation only. Unadjusted KM analysis showed improved 5‐year survival in the CCRT group compared to radiation only . Multivariable analysis also showed improved survival with the addition of chemotherapy . Propensity matched analysis confirmed a significant clinical benefit from the addition of chemotherapy to radiation. Age ≥ 65 years , Charlson‐Deyo comorbidity index >1  and positive lymph node status  were associated with worse survival. In this retrospective analysis, patients with stage II NPC had improved survival with CCRT compared to definitive radiation only. Elderly patients with comorbidities had worse outcomes.The standard of care treatment for locally advanced nasopharyngeal carcinoma ( The NCDB is a nationwide and facility‐based oncology dataset that currently captures 70% of all newly diagnosed malignancies in the US annually.The American Joint Committee on Cancer (AJCC) 6th and 7th editions were used for staging. From 2004 to 2013, we identified patients diagnosed with nasopharyngeal carcinoma with clinical stage T1N1, T2N0, T2N1 from the NCDB by using International Classification for Disease for Oncology (ICD‐O‐3) topographic and histology codes. Patients were identified by using following histology codes for NPC: 8052, 8070, 8071, 8072, 8073, 8074, 8083 which corresponded to papillary squamous cell carcinoma, squamous cell carcinoma not otherwise specified (NOS), keratinizing squamous cell carcinoma NOS, nonkeratinizing squamous cell carcinoma (large cell), nonkeratinizing squamous cell carcinoma , squamous cell carcinoma (spindle cell), basaloid squamous cell carcinoma, respectively. We excluded nonsquamous and unknown tumor histology. The following topographic codes were used: C11.0, C11.1, C11.2, C11.3, C11.8, and C11.9 which corresponded to superior wall of nasopharynx, posterior wall of nasopharynx, lateral wall of nasopharynx, anterior wall of nasopharynx, overlapping lesion of nasopharynx, nasopharynx (NOS), respectively. Concurrent chemoradiation was defined as chemotherapy start date occurring ≤14 days before or after the start date of radiation similar to a previously published study evaluating radiation treatments in patients with head and neck squamous cell carcinoma.t‐test and chi‐square tests for univariate associations. Significance was defined as a P value < 0.05. To isolate the effect of chemotherapy on mortality, we performed a multivariable proportional hazards model adjusted for: age, gender, ethnicity, tumor grade, zip‐code income, zip‐code education, Charlson‐Deyo comorbidity index, treatment center, nodal status , clinical T stage, IMRT, and radiation dose. The results were reported as hazard ratios (HR) with 95% confidence intervals (CI). Five‐year survival between the CCRT and RT alone groups were calculated using Kaplan Meier (KM) analysis. Since selection bias is a significant limiting factor in retrospective cohort analysis, we performed a propensity matched pair analysis to compare 5‐year survival between CCRT and RT. To control for immortal time bias, we performed a 6‐month landmark analysis for all survival estimates. All analyses were performed with SAS 9.4 .Patient demographics included age at the time of diagnosis, gender, race, insurance status, income, education status, Charlson‐Deyo comorbidity index (CDCI), and radiation dose (Gy) are shown in Table 3P < 0.0001). In addition, patients with private insurance  and lymph node positive disease  were more likely to receive CCRT (Table P = 0.2314).We identified 611 patients with NPC who met our pre‐specified inclusion and exclusion criteria . Asian patients showed a trend toward improved overall survival compared to whites, but it did not reach statistical significance . Grade 3 and 4 tumors had improved overall survival compared to grade 1 tumors .Eighty‐four patients 13.8%) received radiotherapy alone and 527 (86.2%) received CCRT. The median follow up time was 4.2 years. Four hundred fifty‐four (74.3%) patients were alive at the time of analysis, 58.3% in radiation alone group and 76.9% in CCRT group. Unadjusted KM analysis showed improved 5‐year survival in the CCRT group as compared to RT only , Charlson‐Deyo comorbidity index >1  and patients with positive lymph node status  were associated with poor overall survival. CCRT still showed improved 5‐year survival in older patients with age ≥65 years , patients with Charlson‐Deyo comorbidity index >1  and N1 status  compared to RT alone. Other factors including ethnicity, insurance status, education level, facility type, tumor grade 1, clinical T stage, use of IMRT, and radiation dose did not affect the overall survival significantly  and distant metastasis‐free survival  were all significantly improved in the CCRT arm than in the RT arm. The number of chemotherapy cycles was the only independent factor that was associated with overall survival (OS), progression free survival (PFS) and distant control.P = 0.048) and distant metastasis‐free rates  in early stage NPC  compared to radiation alone.,This finding is consistent with majority of the Asian studies that showed benefit from the addition of chemotherapy.Multivariable Cox proportional hazards model for predictors of overall survival identified that older patients (age ≥ 65 years), Charlson‐Deyo index >1 and lymph node positive disease to be associated with increased risk for mortality Table . These fOur analysis shows that addition of chemotherapy to definitive radiation is associated with significant improvement in overall survival. Apart from the retrospective nature of this study, our analysis has other limitations as well. Patients receiving radiation alone were older than the CCRT cohort and more likely to be node negative. It is possible that the radiation only treatment cohort may have been selected based on other unknown confounding variables such as performance status which is not collected by the NCDB. But multivariable analysis confirmed benefit from chemotherapy after controlling for these potential confounding factors. To further confirm the benefit of CCRT over definitive RT, we performed a propensity score matched analysis. Furthermore, a 6‐month landmark analysis on all survival estimates was done to limit the effect of confounding factors related to retrospective analysis. Despite the rigorous analysis, the benefit from CCRT was confirmed in our study. Another limitation is that NCDB does not provide information on the type of chemotherapy agent, dose, and the number of cycles of treatment received. But taken together, our analysis clearly shows that CCRT is superior to RT alone in stage II NPC.In conclusion, our retrospective analysis of the NCDB demonstrated statistically significant improved overall survival with CCRT in stage II patients diagnosed with NPC in the United States. This is the only study to show benefit from the addition of chemotherapy to radiation in the US population. Even though older patients with high comorbidity scores and positive lymph node involvement had worse prognosis, our analysis suggests that even these groups did benefit from the addition of chemotherapy to radiation. A prospective randomized study would be the ideal solution to identify appropriate stage II NPC patients for CCRT, but such a study may not be feasible in the US population. In the absence of such data, results from our retrospective study could provide guidance to the practicing clinician when discussing the benefit of adding concurrent chemotherapy to radiation for patients with stage II NPC.Janakiraman Subramanian, M.D., M.P.H, Research Support—Biocept and Paradigm; Advisory Board—Alexion, Astra‐Zeneca, BMS, Boehringer‐Ingelheim Pfizer; Speaker Bureau—Astra‐Zeneca, Boehringer‐Ingelheim, Lilly; All other authors have no potential conflicts of interest to disclose


There was no significant difference in FA values between compressed lateral nerve roots and normal ones 90 days post-surgery (p > 0.05). DTI can be used for the accurate diagnosis of LDH, as well as for postoperative evaluation and prognosis, and it is thus useful for the selection of surgical timing.The purpose of this study was to evaluate the utility of diffusion tensor imaging (DTI) for guiding the treatment of lumbar disc herniation (LDH) by percutaneous transforaminal endoscopic discectomy (PTED). We collected the clinical data of a total of 19 patients: 10 with unilateral S1 nerve root injury, 6 with unilateral L5 nerve root injury, and 3 with unilateral L5 and S1 nerve root injury. All patients underwent DTI before surgery, 3 days post-surgery, 30 days post-surgery, and 90 days post-surgery. The comparison of the fractional anisotropy (FA) values of compressed lateral nerve roots before surgery and 3, 30, and 90 days post-surgery demonstrated the recovery of nerve roots to be a dynamic process. A significant difference was found in the FA values between compressed lateral nerve roots preoperatively and normal lateral nerve roots before surgery, 3 days post-surgery and 30 days post-surgery ( Patients are increasingly demanding minimally invasive treatment for LDH. Moreover, with the general aging of society, elderly patients with multiple systemic diseases and in poor physical condition who cannot tolerate open surgery have become highly frequent; therefore, precision has become increasingly important in minimally invasive treatments. In this context, clinicians mainly rely on tools such as the Visual analogue scale (VAS), Japanese orthopaedic association scores (JOA), and Oswestry disability index (ODI), along with other indicators to evaluate surgical effects. Nevertheless, these indicators are greatly affected by patients’ subjective feelings, and cannot objectively evaluate surgical effect and expected recovery.In recent years, percutaneous transforaminal endoscopic discectomy (PTED) has been widely used in the treatment of lumbar disc herniation (LDH), with very good clinical effects2. Magnetic resonance diffusion tensor imaging (DTI) is a non-invasive method for tracing nerve fiber tracts and evaluating nerve injury. It is also a method for indirectly observing the change process of nerve tissue6. DTI can be used to display peripheral nerve and the decrease of average FA value indicates the existence of demyelination injury6. A list of ‘Do’s and Don’ts’ was made by Jones et al.7 to make DTI better reflecting the actual neurological change. Thus, DTI can more accurately diagnose LDH, clarify the affected segment and the degree of nerve injury, and monitor postoperative nerve root recovery. The purpose of this study was to evaluate the utility of DTI for guiding the surgical treatment of LDH.Magnetic resonance imaging (MRI) is widely used to diagnose LDH, as it provides valuable information, such as the position and size of the herniation. However, in clinical practice, the degree of nerve root compression observed in MRI is often inconsistent with the patient’s symptoms. Therefore, MRI is unable to accurately identify the cause of symptoms and quantitatively evaluate nerve injuryThis study was approved by the ethics committee of The Third Hospital of Hebei Medical University (2017-019-1). All patients signed informed consent and allowed use of their clinical data for this study. All methods were performed in accordance with the relevant guidelines and regulations.The study subjects were patients with LDH who were treated with PTED in our hospital from June 2017 to April 2018. Patients initially included in this study met the following criteria: Patients with LDH (1) for whom conservative treatment had been ineffective and had typical symptoms of nerve root compression; (2) with protrusions confined to the L4-S1 segments; and (3) with no history of lumbosacral surgery of contraindications for MRI. Patients with bilateral symptoms were excluded from the study. All patients underwent DTI of lumbosacral nerve roots before surgery, as well as 3, 30 and 90 days post-surgery.2, bandwidth = 1396 Hz, echo spacing = 0.78 ms, and number of excitations = 5; the scanning range covered from the upper margin of L4 to the level of S3. We uploaded 3D STIR SPACE image and DTI tensor image to Siemens Verio Neuro 3D workstation to fuse the two. We used 3D STIR SPACE image to provide anatomical information for FA value measurement. The nerve root was divided into proximal, middle and distal segments by the entrance and exit of the intervertebral foramen. L5 nerve roots were measured and region of interests (ROIs) were performed at the three positions of “posterior superior margin of L5 vertebra”, “outlet of intervertebral foramen” and “anterior inferior margin of L5 vertebra”. The nerve roots of S1 were measured and ROIs were performed at the three positions of “posterior superior margin of S1 vertebra”, “posterior inferior margin of S1 vertebra” and “anterior inferior margin of S1 vertebra”. DTI parameters of nerve roots in ROIs were obtained. The FA threshold was set to 0.18, the maximum inversion angle was 30, and each ROI of L5-S1 nerve root accounted for 2–4 voxels. It ensured that each voxel had nerve passage, avoiding errors caused by manual depiction of ROI, and reduced the impact of partial volume effect, thus making the measured ROI data more reliable. The mean FA value of ROIs in the proximal, middle and distant position of each nerve was taken as the final FA value of the corresponding nerve. FA values of affected and contralateral nerve roots were recorded in each patient before surgery, and 3, 30, and 90 days post-surgery, respectively. The FA values were measured by two participants and the final result is averaged between the two. If there was a large difference between values measured by the two participants, the third participant measured again and the final result was averaged between correct two.This study used a German Siemens Verio 3.0 T superconducting MR instrument and an 8-channel Spine Matrix coil. The subjects were in supine position, and the subject’s head and upper body were in a magnetic resonance coil. The location center was set 3–5 cm below the umbilicus. Plain MRI scanning was performed for sagittal plane positioning. Sagittal plane T2WI settings: TR = 3000 ms, TE = 101 ms, scanning slice number = 11, slice thickness = 4 mm, FOV = 300.0 mm × 300.0 mm, voxel = 1.0 mm × 0.8 mm × 4.0 mm, and number of excitations = 2. Horizontal axis T2WI settings: TR = 3500 ms, TE = 112 ms, scanning slice number = 10, slice thickness = 3 mm, FOV = 220.0 mm × 220.0 mm, voxel = 0.9 mm × 0.7 mm × 3.0 mm, and number of excitations = 1. The settings for the 3D short-time inversion recovery fast spin echo (3D STIR SPACE) coronal scan were: TR = 3800 ms, TE = 309 ms, slice thickness = 1 mm, FOV = 250.0 mm × 250.0 mm, voxel = 0.8 mm × 0.8 mm × 1.0 mm, echo chain length = 167, and number of excitations = 1.5; no flow compensation. The scanning range covered from the upper margin of L2 to the lower margin of S3. The settings for the DTI cross-sectional scanning were: TR = 8000 ms, TE = 95 ms, slice thickness = 4 mm, scanning slice number = 40, FOV = 350.0 mm × 350.0 mm, voxel = 2.7 mm × 2.7 mm × 4.0 mm, diffusion direction = 12, b value = 0.800 s/mmp < 0.05 were considered statistically significant.SPSS v17.0 was used for statistical analysis. The normally distributed measurement data was expressed with mean ± standard deviation. Otherwise, they were represented with median (interquartile range). The paired sample t-test was used to compare the FA values of damaged nerve roots and contralateral undamaged nerve roots of patients in the two groups before surgery, and 3, 30, and 90 days post-surgery, respectively. ANOVA was used to compare dynamic changes in the FA values of the damaged nerve roots before surgery, and 3, 30, and 90 days post-surgery. We performed correlation analysis between duration of symptoms and FA values. Results with Demographic data for the patients was showed in Table p < 0.05). Preoperative lumbar disc MRI and lumbosacral nerve root DTI scan was showed in Fig. Comparison of FA values between the affected side and uninjured side nerve roots were shown in Table p < 0.05). Lumbar disc MRI and lumbosacral nerve root DTI scan was showed in Fig. The mean FA values of the affected side and the uninjured side nerve roots 3 days post-surgery in the S1 group were 0.367 ± 0.033 and 0.454 ± 0.039, respectively. In contrast, the mean FA values of the affected side and the uninjured side nerve roots 3 days post-surgery in the L5 group were 0.379 ± 0.029 and 0.479 ± 0.042, respectively. The mean FA values of the affected side were significantly lower than those of the uninjured side 3 days post-surgery (p < 0.05). Lumbar disc MRI and lumbosacral nerve root DTI scan was showed in Fig. Furthermore, the mean FA values of the affected side and the uninjured side nerve roots 30 days post-surgery in the S1 group were 0.383 ± 0.031 and 0.458 ± 0.040, respectively; whereas the mean FA values of the affected side and the uninjured side nerve roots 30 days post-surgery in the L5 group were 0.408 ± 0.035 and 0.462 ± 0.036, respectively. We found the mean FA values of the affected side were significantly lower than those of the uninjured side 30 days post-surgery (p = 0.134), respectively; while the mean FA values of affected side and the uninjured side nerve roots 90 days post-surgery in the L5 group were 0.421 ± 0.018 and 0.442 ± 0.034 (p = 0.38), respectively. No statistically significant difference was found between the FA values of the affected and uninjured sides 90 days post-surgery. Lumbar disc MRI and lumbosacral nerve root DTI scan was showed in Fig. Finally, the mean FA values of the affected side and the uninjured side nerve roots 90 days post-surgery in the S1 group were 0.437 ± 0.024 and 0.445 ± 0.025 (p < 0.001). On the other hand, the FA values of affected side in the L5 group between different time points were significantly different (p < 0.001). At 90 days post-surgery, the difference was statistically significant compared with the preoperative values and 3 days post-surgery, respectively . In summary, we demonstrated the recovery of nerve roots to be a gradual process .The differences in FA values of affected side in the S1 group were significantly different at pre-surgery, and 3, 30, and 90 days post-surgery Table . In part8. Furthermore, DTI is a method that can indirectly assess nerve tissue microstructure and noninvasively display nerve fiber bundle angiography6. Researches have shown that DTI can indirectly evaluate the degeneration and regeneration of peripheral nerves11. In addition, Oswestry disability index (ODI) scores and symptom duration have been negatively correlated with FA value and positively correlated with apparent diffusion coefficient (ADC) value of compressed nerve roots in patients with LDH12. correlation analysis in this study did not found significant correlation between duration of symptoms and FA values. This might be due to the small sample size of this study. This study focused on FA values, so no clinical symptoms evaluation was analyzed. The decrease in FA values in this context has been attributed to histological changes in the nerve root, including microstructure modifications such as demyelination of nerve fibers, loss of axons, neurofibrosis and degeneration, resulting in an increase of isotropic water volume15. The sensitivity and specificity of FA values for the detection of nerve injury have been reported to be higher than those of ADC values (73.3% and 100% vs. 13.4% and 80%). FA values appear to be superior to ADC values in the diagnosis of lumbosacral radiculopathy, with potential application for post-treatment evaluation19. Therefore, in this study, we used FA values for preoperative diagnosis, postoperative evaluation and prognosis of patients with LDH.Diffusion tensor imaging is a novel technique developed after the diffusion weighted imaging (DWI). DTI can detect the random movement of water molecules in nerve tissue, as well as measure their anisotropy, quantitatively analyze the diffusion of water molecules in nerve tissue with FA values, and evaluate the change of peripheral nerves20. However, when patients’ symptoms are inconsistent with imaging findings, or when MRI reveals multi-stage disc herniation, accurate diagnosis can reduce the degree of decompression, limit surgical trauma, and diminish the cost of hospitalization, while also ensuring the surgical effect. Recent studies have shown the application of MRI combined with DTI or paraspinal mapping (PM) can reduce false positives on MRI, and also replace invasive methods such as discography and selective nerve root block to further enhance diagnosis19. In this study, we applied DTI to improve diagnosis instead of selective nerve root closure, with good results. Preoperative routine MRI revealed the presence of single-segment LDH in 3 patients, yet FA values showed these patients had severe unilateral and bilateral nerve root damage. All 3 of these patients underwent PTED. After the procedure, symptoms disappeared, the DTI index of both nerve roots significantly improved, and no significant differences were observed between these and those on the uninjured side. Accurate diagnosis of LDH combined with minimally invasive treatment avoids extensive decompression in conventional open surgery, and reduces the complexity and risk of surgical procedures. Studies have shown FA values and patients’ symptoms do not appear to improve significantly after conservative treatment17. Likewise, a long duration of preoperative symptoms has been reported to be an important factor affecting patients’ quality of life and prognosis, and early surgical intervention is recommended24. Therefore, we believe DTI can be used for the accurate diagnosis of LDH. Thus, if conservative treatment fails and DTI examination indicates a significant decrease in FA value, early surgical treatment is recommended.When DTI is used to distinguish between intravertebral canal stenosis and intervertebral foramen stenosis, changes in DTI indexes are related to the location of the nerve root compression. The decrease in FA value indicates the presence of intervertebral foramen stenosis and allows identification of the compressed nerve roots25. Indeed, DTI is widely used in the clinical evaluation of nerve root lesions. Although research has shown a significant negative correlation between the FA value of compressed nerve roots and ODI scores2, few studies have evaluated the relationship between the dynamic changes of postoperative DTI indicators and the improvement of clinical symptoms. Therefore, all the patients in this study underwent PTED, and DTI scanning was performed before surgery, as well as 3 days, 1 month, and 3 months post-surgery, respectively. At the time of DTI reexamination 3 days post-surgery in both groups, the protruding nucleus pulposus completely disappeared in the sagittal and axial MRI images. However, the preoperative DTT reconstruction of the compressed nerve roots showed significant microstructural changes, with no significant improvement in these changes or FA values in the DTT reconstruction 3 days post-surgery. This may be due to the fact that although the procedure relieves the nerve root compression, the edema response caused by intraoperative stimulation of the nerve root remains. We believe this phenomenon explains why patients’ symptoms do not disappear immediately after the procedure. Comparison of the FA values before surgery, and 3, 30, and 90 days post-surgery revealed the differences between the two groups were statistically significant (p < 0.001). Indeed, we found the postoperative recovery of the compressed nerve roots was a dynamic process of gradual recovery. Patient A experienced slight symptom relief post-surgery, mild symptoms at the 1-month reexamination, and complete improvement at the 3-month reexamination. The changes in the DTI indexes were consistent with the evolution of the symptoms. Patient B had mild residual symptoms at the 3-month reexamination post-surgery, which was consistent with the incomplete improvement seen in the DTI index. We suggested open surgery for patient B, but they declined open surgery and chose to continue to a follow-up observation. When PTED is applied in cases with complicated protrusion of intervertebral discs, sufficient decompression of nerve roots cannot be accomplished. Residual nucleus pulposus and intervertebral disc tissue may continue to compress or stimulate nerve roots, leading to incomplete symptom relief. The non-significant improvement of FA values in patients post-surgery reflects the persistence of nerve root injury, indicating a poor prognosis. Therefore, we suggest open surgery should be performed as soon as possible in cases where PTED fails in the treatment of LDH.Diffusion tensor imaging is a noninvasive method for effectively tracing nerve fiber bundles, as well as quantitatively evaluating nerve injury and axon regenerationThis study has limitations. First, the relatively small sample size, meaning a large number of clinical studies is required to confirm repeatability of our results. Second, there was no control group. Third, the shift point position identity of the DTI values was poor.In conclusion, we found DTI can be used for the accurate diagnosis, postoperative evaluation and progonosis of LDH, and is useful for guiding the selection of surgical timing.


Estimated glomerular filtration rate (eGFR) formulas are routinely used in human patients to provide a more accurate evaluation of GFR compared to serum creatinine concentration alone. Similar formulas do not exist for cats.To validate a prediction formula for eGFR in cats based on adjusting serum creatinine concentration.Client‐owned cats with various levels of renal function.The study was cross‐sectional. Glomerular filtration rate was determined by iohexol clearance. Variables including signalment, biochemical markers, and noninvasive measurements considered to represent surrogate markers of muscle mass were evaluated with the reciprocal of serum creatinine concentration in a multivariable regression model. The derived eGFR formula was subsequently tested in another group of cats and agreement with GFR assessed.−1) independently predicted GFR in the final multivariate model. The derived eGFR formula was 0.408 + (243.11 × creatinine−1 [μmol/L]) ‐ (0.014 × pelvic circumference [cm]). When the formula was tested in another 25 cats it was not found to offer any advantage over creatinine−1 alone in its relationship with GFR . Furthermore, agreement between eGFR and GFR was poor.The formula was developed in 55 cats. Only a single morphometric measurement (pelvic circumference) along with the reciprocal of serum creatinine concentration (creatinineAn eGFR formula for cats that adjusted serum creatinine concentration for a marker of muscle mass was developed. The formula did not provide a reliable estimate of GFR, and therefore, its routine use cannot be recommended. BCSbody condition scoreBLbody lengthBSAbody surface areaBWbody weightCKDchronic kidney diseaseCKD‐EPIchronic kidney diseases epidemiology collaborationeGFRestimated glomerular filtration rateECFVextracellular fluid volumeFFMfat free massFMfat massFLHforelimb heightGFRglomerular filtration rateHLHhindlimb heightLFLCleft forelimb circumferenceLHLCleft hindlimb circumferenceLPHLCleft proximal hindlimb circumferenceMDRDmodification of diet in renal diseasePCpelvic circumferenceRFLCright forelimb circumferenceRHLCright hindlimb circumferenceRPHLCright proximal hindlimb circumferenceTBWtotal body waterTCthoracic circumference1Detection of chronic kidney disease (CKD) before development of azotemia in cats is desirable because implementation of therapeutic interventions at this stage may delay or prevent progression of CKD. Limitations of serum creatinine and urea concentrations and urine specific gravity for assessing renal function, particularly in early stage CKD, are recognized.Estimated GFR (eGFR) formulas offer the advantage of more accurately reflecting actual GFR than serum creatinine concentration in human patients. By incorporating demographic and clinical variables that may affect physiological processes contributing to serum creatinine concentration, a more accurate measurement of renal function may be ascertained. Of most relevance are factors that contribute to muscle mass such as age, sex, and race. It is now mandatory for eGFR to be reported with every serum creatinine concentration measurement performed in human patients in several states in the United States, in the United Kingdom, and in Australia,J Vet Intern Med. 2010; 24: 1548 [abstract]).Identifying useful methods that correct serum creatinine concentration to account for muscle mass would be important in developing an eGFR formula for cats. Methods to directly measure muscle mass cannot be readily applied to clinical patients.No published eGFR formulas have been developed for veterinary species and such a formula may prove to be a more useful indicator of renal function than serum creatinine concentration alone. Our objectives were to develop an eGFR formula in cats with various levels of renal function based on noninvasive measurements including signalment, morphometric measurements, FFM, and predicted FFM by which to adjust serum creatinine concentration. A second objective was to test the formula in another group of cats.22.1Client‐owned cats with various levels of renal function were recruited into the study, but cats with evidence of concurrent medical disease such as hyperthyroidism were excluded. Only cats with stable renal function determined by at least 2 repeated serum creatinine concentration measurements within 12 months in nonazotemic cats and within 3 months in azotemic cats before GFR measurement were included in the study. Cats with evidence of acute kidney injury were excluded from the study. The cats were identified from an ongoing cohort study conducted at 2 London‐based first opinion practices . The cats in this study were presented for senior cat wellness screening. At each visit, a full medical history was obtained, physical examination performed, urine sample collected by cystocentesis, blood pressure measured by the Doppler technique and blood collected for hematology, biochemistry and total serum thyroxine concentration measurement. This approach allowed cats to be followed longitudinally during which time some develop azotemic CKD and some remained nonazotemic. Cats had no evidence of relevant clinical disease. Informed consent was obtained from the owners and the study was conducted with approval from the Royal Veterinary College's ethics and welfare committee.2.2Food was withheld for 12 hours before performing the measurements. Glomerular filtration rate was determined by a previously described iohexol clearance method.2.318O) dilution method . Briefly, baseline blood samples and samples collected after an equilibration period of 2 hours after administration of 18O (0.3 g/kg 10% solution H218O) were analyzed at an external laboratory  by isotope ratio mass spectrometry (IRMS). Dilution space of 18O was calculated by the standard equationThe following variables were considered for inclusion in a multivariable regression model to predict eGFR: age, sex , breed (categorized as either domestic short hair/long hair or pedigree), urea, albumin, total protein, BW, BCS, predicted muscle mass, various morphometric measurements, FFM, and predicted FFM. Body condition score was determined by a previously validated 9‐point scaling system.T is the mass of tap water diluent in which a is diluted, A is dose of 18O administered, a is portion of dose administered of 18O that was retained for mass spectrometer analysis, and δa, δt, δs, and δp are isotopic enrichment in delta units of the portion of dose administered, tap water diluent, postdose serum sample, and predose serum sample, respectively. Delta units express isotopic enrichment relative to 2 standard waters (standard mean ocean water and standard light arctic precipitate). Total body water then was calculated as:where Predicted muscle mass was determined by the equationMorphometric measurements were performed with a flexible tape measure and recorded to the nearest 0.1 cm. The same investigator performed the measurements in all cats to minimize interobserver variability. Cats stood in a standard position when measurements were obtained. The following morphometric measurements were recorded :Predicted FFM was calculated by the equation  + (0.054 × FLH) + (0.098 × RFLC) ‐ (0.028 × HLH)where BW is body weight (kg), FLH is forelimb height (cm), RFLC is right forelimb circumference (cm), and HLH is hindlimb height (cm).t test. Where assumptions of linearity and Gaussian distribution were not met, transformations were performed. Univariable linear regression analysis was performed for each individual variable initially. Variables with a P < .2 were entered into a manual forward stepwise linear regression model containing the reciprocal of the serum creatinine concentration to predict eGFR. The reciprocal of the serum creatinine concentration was selected because it displayed a linear relationship to GFR compared to that of serum creatinine concentration, which was nonlinear. Predicted GFR was expressed as mL/min/kg. Model assumptions and performance were evaluated by examining multicollinearity, standardized residuals, Cook's distances, leverage values, and by performing the Durbin‐Watson test. Significance was set at P < .05.Statistical analyses were performed by a statistical software package (SPSS version 17.0). Data were assessed for normality by the Kolmogorov‐Smirnov test and by visual inspection of graphical plots. Data between the population in which the formula was developed and that in which it was tested was compared by the Student's 2.4R2). Agreement was assessed by creating Bland‐Altman plots.The derived eGFR formula was subsequently applied to an additional 25 cats in which GFR assessed by iohexol clearance had been determined and performance tested by assessing the coefficient of determination (33.1P < .001), serum urea concentration (P < .001), left forelimb circumference (P = .019), and right proximal hindlimb circumference  ‐ (0.014 × PC [cm])eGFR = 0.408 + (243.11 × creatinineR2 was 0.67 (P < .001) and explained additional variation over the reciprocal of serum creatinine concentration alone .The model 3.2P = .141, 41.0 ± 7.1, and 38.5 ± 6.7 cm, respectively). Agreement between GFR and eGFR was considered poor based on the wide limits of agreement (−1.15‐0.57 mL/min/kg). The negative bias (−0.29 mL/min/kg) also indicated that eGFR underestimated GFR .Data regarding signalment, BW, and renal function are included in Table 4R2 = 0.67 vs R2 = 0.64). However, when the formula was tested in an additional 25 cats, it was not found to offer any improvement in predicting GFR than the reciprocal of the serum creatinine concentration alone (R2 = 0.44 vs R2 = 0.45). Agreement of the eGFR formula with GFR was considered poor based on the wide limits of agreement (−1.15‐0.57 mL/min/kg) and negative bias (−0.29 mL/min/kg).In our study, the morphometric measurement, PC, was the only significant measurement considered to be a surrogate marker of muscle mass for correcting the reciprocal of serum creatinine concentration to predict GFR in a multivariable regression model. This eGFR formula had a slightly stronger relationship to GFR (determined by iohexol clearance) than the reciprocal of serum creatinine concentration in cats in which the formula was developed (r) between GFR and eGFR predicted by the Cockcroft‐Gault formula was 0.83 and mean percentage error (expressed as a percentage of true GFR) was 35% in 95% of patients.R2 for true and predicted GFR was 0.9 and percentage error was 28.4% in 90% of the population.R2 was 0.79, but in normal patients the R2 was only 0.19.R2 was 0.8 (vs 0.9 for GFR and eGFR),Clinical concerns regarding accuracy of the eGFR formulas used in humans in all patient populations along with the sensitivity and specificity of the formulas have been expressed. The precision and accuracy of the formulas are questionable, particularly in elderly patients, patients with extremes of muscle mass, and in patients with unstable renal function. Furthermore, the earlier formulasThe primary source of creatinine generation is muscle mass. This factor is addressed in human patients by including coefficients in GFR prediction equations for factors affecting muscle mass such as age, sex, and race. It is likely that there are important differences in creatinine generation in cats. It has been reported that serum creatinine concentration is higher in Birman catsWhen using eGFR formulas it is important to ensure that identical methods of analysis and the same laboratory are employed as those used for deriving the formula. Differences in determination of serum creatinine concentration, for example, if a method that detected noncreatinine chromogens was used, would lead to errors in predicted GFR. In studies of humans, differences in creatinine assays at different clinical laboratories can cause errors in GFR estimation as high as 20%.J Vet Intern Med. 2010; 24: 1548 [abstract]). In pediatric patients, correcting serum creatinine concentration for body surface area or body mass index was not found to improve the accuracy of GFR prediction.The formula used to estimate FFM in our study does not predict muscle mass. Skeletal muscle mass is the largest component of FFM (reported to be 0.49 × FFM in human patients).Development of an eGFR formula for cats to correct creatinine for body composition in our study did not provide a reliable estimate of GFR in cats, and therefore its routine use cannot be recommended. Moreover, the formula does not appear to improve the accuracy of predicting GFR over serum creatinine concentration. Therefore, determination of GFR will remain important in the early identification and accurate assessment of the stage of CKD.Authors declare no conflict of interest.


Background data on parental language, eating habits, leisure‐time physical activity (LTPA) and sleep duration were included. Genotyping was performed with the Metabochip platform. Weighted, standardized GRSs were derived. Of the11‐year‐old children, 25.5% were at least overweight and 90.8% had Finnish speaking background. BMI‐GRS was associated with higher risk for overweight with odds ratio  of 1.39  and obesity 1.41 , but not with central obesity. BMI‐GRS was weakly and inversely associated with the changes in BMIz and WHtR in the 4‐year follow‐up. Waist‐to‐hip ratio‐GRS was not related to any obesity measures at baseline nor in the follow‐up. The effect of BMI‐GRS is similar to that of low LTPA on overweight. An interaction between parental language and BMI‐GRS was noted (P = .019): BMI‐GRS associated more strongly with overweight in Swedish than in Finnish speakers. We further identified two suggestive genetic variants near LOC101926977 and LOC105369677 associated with BMIz in preadolescents which were replicated in the adult population. In preadolescents, known genetic predisposing factors induce a risk for overweight comparable to low LTPA. However, the GRS was poor in predicting short‐term changes in BMI or WHtR.Common genetic variants predispose to obesity with varying contribution by age. We incorporated known genetic variants into genetic risk scores (GRSs) and investigated their associations with overweight/obesity and central obesity in preadolescents. Furthermore, we compared GRSs with lifestyle factors, and tested if they predict the change in body size and shape in a 4‐year follow‐up. We utilized 1142 subjects from the Finnish Health in Teens (Fin‐HIT) cohort. Overweight and obesity were defined with age‐ and gender‐specific body mass index (BMI)  BMIbody mass indexBMIzz‐scoreage‐ and gender‐specific body mass index GRSgenetic risk scoreGWASgenome‐wide association studyLTPAleisure‐time physical activityMAFminor allele frequencyPCprincipal componentQCquality controlSNPsingle nucleotide polymorphismWHRwaist‐to‐hip ratioWHtRwaist‐to‐height ratio1The world is in the midst of an epidemic of obesity, and the number of obese children worldwide has increased to 124 million in 2016.The aetiology of obesity is complex, with many factors involved in its development, for example, lifestyle factors, other environmental factors, genetic susceptibility, and likely their interactions. The era of genome‐wide association studies (GWASs) has increased our knowledge of common genetic variants together explaining about 6% of the variation in adult body mass index (BMI).BMI is a measure of body size reflecting fat accumulation and overall adiposity, while body shape in terms of waist circumference or waist‐to‐hip ratio (WHR) distinguishes fat distribution and serves as markers of central obesity. WHR is independently of BMI associated with an elevated risk for chronic diseases including type 2 diabetes and cardiovascular diseases.In the present study we investigated associations of genetic loci with body size and shape in 1142 Finnish preadolescents and created genetic risk scores (GRSs) for BMI and WHR based on the literature.22.1http://www.finhit.fi/data/). The material collection was conducted at school.Material collected in the Fin‐HIT cohort was utilized in the present study. The cohort is described elsewhere in detail.Households with a participating adult and child were invited to the first active follow‐up in 2015 to 2016 when the adolescents were 13‐ to 15‐year‐old. The follow‐up was conducted with an online questionnaire allowing participation at home. All participants gave written informed consent, and the Coordinating research Ethics Committee of the Hospital District of Helsinki and Uusimaa approved the study protocol.2.2Information on gender, date of birth and parental language spoken at home , was obtained from the consent forms or questionnaires and confirmed by linkage with the National Population Information System at the Population Register Centre. Parental language mirrors genetic substructure of the Finnish population. Genetically, the Swedish speakers resembles more closely to European population than Finnish speakers do.2.32), and it mirrors body size. BMI was derived into age‐ and gender‐specific BMI z‐score (BMIz) according to equations of the International Obesity Task Force (IOTF).At baseline, trained field workers measured subject's height to the nearest 0.1 cm with a portable stadiometer (Seca model 217) and weight to the nearest 0.01 kg with a portable digital scale (CAS model PB), as explained in detail elsewhere.Waist circumference was assessed midway between the hip bone and the ribs to the nearest 0.1 cm with a measuring tape as previously described.In the follow‐up, the child's height, weight and waist were self‐measured and ‐reported by a parent. We have previously reported the validity of the self‐reported anthropometry.2.42.4.1Subjects filled in a 16‐item food frequency questionnaire covering the preceding month. The selected food items were adopted from Health Behaviour in School‐Aged Children Study protocolBased on food item frequencies, eating habit variable was created utilizing a factor and cluster analyses as explained more in depth elsewhere.2.5Duration of leisure‐time physical activity (LTPA) was assessed with the question: “How many hours a week do you normally exercise or do sports during your free time?” with 10 response options ranging from “An hour a week or less” to “Around ten hours a week.” We categorized the responses into two categories, less than 7 hours per week or at least 7 hours per week, to mimic the adherence to current guidelines.2.6The subjects replied the time asleep on school nights with the question: “When do you usually fall asleep in the evenings on a school night?” with 12 response options. Correspondingly, the waking up on school days was asked: “When do you usually wake up on school days?” with seven response options. Sleep duration on school nights was calculated and categorized into three groups: (a) less than recommended, (b) recommended and (c) more than recommended according to the age‐specific Childhood Sleep Guidelines by the American Academy of Pediatrics2.7All participants of the Fin‐HIT study provided saliva samples using the Oragene DNA Self‐Collection Kit . DNA was extracted using an automated protocol with the chemagic DNA Saliva Kit . Altogether 1368 salivary DNA samples were then randomly selected from the Fin‐HIT cohort and genotyped with the Cardio‐Metabochip  at the Finnish Institute for Molecular Medicine (FIMM) Technology Centre . Of these 1368 samples, a total of 216 samples were removed after genotyping due to either low sample call rate (<95%) (n = 12), inconsistent gender information (n = 9), duplicate samples/twins (n = 14), relatedness (n = 8) or missing clinical data (n = 173).P < 10−6; N = 514) or had a low minor allele frequency . Thus, the final analysis set consisted of 125 187 SNPs.After sample quality control (QC), we performed QC on the ~200 000 single nucleotide polymorphisms (SNPs) included on the Metabochip platform. Of these SNPs, we received 195 884 successfully genotyped SNPs from the FIMM Technology Centre. We further excluded 70 697 SNPs that were either mitochondrial or on X/Y chromosome (N = 250), had a low call rate , deviated from the Hardy‐Weinberg equilibrium  analysis was performed on the Metabochip SNPs that passed QC to identify ethnicity outliers and to compute PCs to adjust for population stratification. Before calculating PCs, we pruned the SNPs based linkage disequilibrium (LD) using a window size of 1000 kb and a pairwise The number of individuals and SNPs included in the final analysis after QC was thus 1142 and 125 187 with a total genotyping rate of 99.9%. Of these 1142 individuals, 573 (50.2%) were females and 569 males (49.8%). Follow‐up data on BMI and waist circumference was additionally available for 727 individuals (63.7%). QC was performed using plink v 1.09 and R software v 3.5.2.2.8r2 > 0.80, MAF > 5% or r2 = 1.00 if MAF < 5%). Proxy SNPs were derived using LDlink's LDproxy tool, and Finnish population data.We selected 32 SNPs for BMI and 32 SNPs for WHR based on the large GWASs performed on these traits at the time of study design in 2010, reflecting also the selection of SNPs to the Metabochip genotyping platform.P‐value, we used it solely in the further analyses.We created weighted GRSs using the score function in Plink v1.09, which calculates an average score per non‐missing SNP. This score is calculated by multiplying the weight of each SNP with the number of risk alleles for that SNP. As weights, we used the effect sizes from the original publications for BMI  in order to calculate the number of independent SNPs (n = 68 183). The P‐value threshold for a significant finding was thus 7.0 × 10−7, which is a 5% Bonferroni‐corrected threshold for 68 183 independent SNPs. We defined a suggestive hit as P < 1.0 × 10−4.We performed metabochip‐wide association studies for BMIz and standardized residuals of WHtR after adjusting for age and gender. The association was tested individually for each SNP with an additive model  for BMI and WHtR against the outcome variable using linear regression. The first two PCs mirroring the genetic substructure of the population were included as covariates in the model. The genetic associations were tested in Plink v.1.09. Power analyses were conducted in R using package “pwr.” To determine the 2.9.2t test in case of a continuous variable, and with chi‐square test for categorical variables.The normal distribution of variables was visually inspected, and transformations applied when needed. Comparison of baseline characteristics between two groups was performed with independent samples Logistic regression was used to study the association of GRSs with overweight (BMIz > +1), obesity (BMIz > +2) and central obesity (WHtR > 0.5) in two models: first GRS alone adjusted for PC1 and PC2, and a second multivariate model including GRS with all covariates, and adjusted for age, PC1 and PC2. Covariates in the analysis were gender, parental language, LTPA, sleep duration, and eating habits. Female gender, Finnish language, LTPA >7 hours per week, recommended sleep duration and healthy eating habit were considered as reference categories in the analysis. The associations were reported as odds ratio (OR) with 95% confidence interval (CI).We had missing values in several covariates: parental language (n = 33), LTPA (n = 11), eating habit (n = 109) and sleep (n = 59). The missing values were replaced in logistic regression analysis using the multiple imputation procedure in SPSS, in order to maintain the full sample size. The imputation method was “fully conditional specification,” which suits for arbitrary missing data. Multiple variables, for example, all covariates, GRSs and outcome measures in original scale, were included in the imputation process.t test or analysis of variance.Associations of covariates  with the two GRSs were tested with Association of GRSs with changes in BMIz and WHtR from baseline to 4‐year follow‐up were investigated with linear regression in a subgroup of 727 subjects. Model 1 was adjusted for gender, age, sleep duration, eating habit, LTPA, parental language, PC1 and PC2. Model 2 included an additional adjustment for baseline BMIz or WHtR.Interactions between covariates and GRSs were tested with log‐likelihood ratio comparing models with and without interaction terms.All statistical analyses were conducted using the IBM SPSS program for Windows, version 22 . The statistical significance level was set at 5%.33.1P = 0.001), while the prevalence did not differ by parental language: 25.2%, 30.8% and 20.8% with Finnish, Swedish and other language family background, respectively (P = .732). The subjects were recategorized into two groups combining under‐ and normal‐weight into “UW/NW” (BMIz ≤ +1) and overweight and obese into “OW/OB” (BMIz > +1)  were categorized as underweight, 843 (73.8%) normal weight, 230 (20.1%) overweight and 61 (5.3%) obese based on IOTF age‐ and gender‐specific BMIz. A combined prevalence of overweight and obesity was more common in boys than in girls  and waist circumference  were observed in UW/NW than in OW/OB group. BMIz increased among those in UW/NW group, while decreased in OW/OB group. In both groups, the WHtR decreased, but more so in OW/OB group.Follow‐up measurements were available from 727 subjects, and their baseline characteristics were similar to those of 1142 subjects . During 3.2P < .001), while no group difference was observed for WHR‐GRS (Table R2) of 1.0% and 95% power to detect R2 of 1.5%. The BMI‐GRS in our sample was associated with BMIz (P = 6.2 × 10−11) and it explained 3.7% of the variance in BMIz (after adjusting for PC1and PC2). Correspondingly, BMI‐GRS was associated with BMIz at follow‐up (P = .018) explaining 0.4% of the variance. The WHR‐GRS was not associated with WHtR at baseline or follow‐up .BMI‐GRS was higher in the OW/OB than in the UW/NW group P < .00, while n3.3Associations of GRSs with overweight (BMIz > +1), obesity BMIz > +2) and central obesity (WHtR ≥ 0.5) were tested with logistic regression in two models (Tables  and cent3.4P = .012) or in WHtR (P = .042) in the 4‐year follow‐up. However, the estimated effect sizes were relatively small, and the adjusted models were poor (R2 < 0.04). An additional adjustment for baseline BMIz or WHtR overruled the effects of BMI‐GRS. The WHR‐GRS was not associated with changes in BMIz or WHtR , parental language (P = .46 and P = .17), LTPA (P = .22 and P = .72), eating habits (P = .56 and P = .88) or sleep duration (P = .23 and P = .46).GRSs did not differ by gender (3.6P = .019) . In total, 12 SNPs reached P‐value of <1 × 10−4 for BMIz  in GWAS on BMI and WHR from the adult population was obtained for rs9882235  positive correlations were observed with SNP effects in the two adult population studies, while the effect sizes did not correlate with estimates for BMI in young children from the EGG Consortium  and rs1150442 near gene EYA2 (P = 1.4 × 10−6) in the recent study of Pulit et al.Of the 16 suggestive SNPs associated with WHtR, variants in or near 4Our study shows that a GRS based on well‐defined BMI‐related SNPs (BMI‐GRS) was associated with overweight and obesity in 1142 Finnish preadolescents. The classification of overweight and obesity was based on age‐ and sex‐specific BMIz according to IOTF guidelines.Recent GWAS studies have resulted in the identification of numerous common genetic variants, SNPs, which have been linked with BMI in large datasets. Recently, over 900 SNPs have been robustly associated with adult BMI.Besides body size, we were interested in body shape in terms of central obesity, which has been linked to cardiovascular diseases and diabetes more strongly than BMI.Fin‐HIT cohort is a well‐defined epidemiological cohort with multiple self‐reported lifestyle factors. Our analysis was adjusted for gender, parental language, eating habits, sleep duration during the week, and LTPA. In present study being a male bears a higher risk for excess weight than the genetic susceptibility. Male gender presented with a higher risk for overweight, obesity and central obesity compared with females, which is in accordance with previous results in this age groupExercising less than 7 hours per week led to a higher risk for overweight and central obesity in our children, which is in line with current physical activity guidelines.We observed an interaction between GRSs and parental language. In the present study, parental language mirrors socioeconomic status as previously suggested.We were able to incorporate follow‐up data of 727 subjects with an average follow‐up time of 4 years. Thus, if the subjects were considered preadolescent at the age of 11 years, they become adolescent at the age of 15. Several other studies in children have demonstrated that comparable BMI‐GRSs associate and predict adult weight reliably.P < 10−4 with BMIz and WHtR, respectively. Two BMI‐related SNPs (rs12680842 and rs10840674) were robustly replicated in adult population,Metabochip was utilized here to discover potential novel genetic variants for BMIz in preadolescents. Even though our metabochip‐wide association study was underpowered, we identified 12 + 16 suggestive SNPs associated with The study had several limitations. The sample size limited the power of metabochip‐wide association analysis, and only suggestive associations were identified. The Metabochip contained over 65 000 SNPs with MAF < 1% in this Finnish study, and those were excluded as rare SNPs were not of interest here. The Metabochip platform is not a fully genome‐wide genotyping platform as it contains markers only in some regions of the genome, for example, regions selected for fine‐mapping and replication based on GWASs on metabolic traits performed before 2012. Thus, it provides less data required for constructing the LD patterns, which is important for genotype imputation.We have demonstrated that BMI‐GRS is a significant risk factor for overweight and obesity in preadolescents, but is poor in predicting short‐term changes in body size and shape during puberty. The associations of BMI‐GRS and low physical activity with overweight/obesity were similar, but somewhat weaker than being a male. An interaction with socioeconomic status was observed, suggesting that predisposing genetic factors appear more strongly in Swedish than in Finnish speaking children, which still warrants further investigations.No conflict of interest was declared.Table S1. SNPs included in the BMI‐GRS used in the study.Table S2. SNPs included in the WHR‐GRS used in the study.Table S3. BMI‐GRS associations with BMI z‐score.Table S4. Background characteristics and change in anthropometric measures in 727 subjects by groups of under‐/normal‐weight (UN/NW) and overweight/obese (OW/OB) with mean (SD), if not indicated otherwise.Table S5. Associations of GRSs with change in BMI z‐score and change in waist‐to‐height ratio in 727 subjects.Figure S1. Manhattan plot of GWAS on BMI z‐score.Figure S2. Manhattan plot of GWAS on waist‐to‐height ratio.Click here for additional data file.


Treatments with ethanol extracts at different doses could restore the levels of intracellular lipid, malondialdehyde, and antioxidant enzyme activities in oleic acid‐induced HepG2 cells. All these results suggested that mung beans and peas or their extracts may be utilized as good candidates of natural antioxidant agents.Hyperlipidemia is closely related to oxidative stress, and it has been proved that the intake of legumes can protect the body from chronic diseases related to oxidative stress. In this study, we investigated the protective effects of mung beans and peas against high‐fat‐diet‐induced rats. It was found that, with 50% addition of mung beans or peas, the intake of mung beans and peas could significantly restore the levels of serum total cholesterol, low‐density lipoprotein cholesterol, and high‐density lipoprotein cholesterol. Liver staining also showed that high‐fat diet (HFD) led to liver lesions, whereas whole‐grain intake could significantly relieve these symptoms. Compared with the HFD group, the antioxidant defense system and antioxidant gene expression in administered legume groups improved markedly. Furthermore, the antioxidant activities of the two legume extracts were determined. Characterization showed that the ethanol extracts of mung beans and peas possessed high antioxidant activities, for their ability to scavenge ABTS and DPPH, reduce Fe Intake of mung bean and pea could dramatically alleviate the serum and liver lipid profile of the high‐fat‐diet‐induced rats and markedly improved the antioxidant defense system and antioxidant gene expression. Characterization showed that the ethanol extracts of mung beans and peas possessed high antioxidant activities in vitro. Treatments with ethanol extracts at different doses could restore the levels of intracellular lipid, malondialdehyde, and antioxidant enzyme activities in oleic acid‐induced HepG2 cells.The main contribution of this paper is to validate the antioxidant capacity of mung beans and peas by animal experiments in vivo, chemical experiments in vitro, and HepG2 cell antioxidant experiments. In addition, the interaction between legumes and the rats fed with HFD was studied by HE staining and gene expression. Moreover, peas have high contents of antioxidant components mainly include phenols, tocopherols, and carotenoids. Duenas, Estrella, and Hernandez . The antioxidant components of mung bean and pea extracts were further validated in vitro or performed with HepG2 cell antioxidant experiments.22.1The mung beans and peas were obtained from a food company in Shanxi Province, China. Kits for catalase (CAT), TC, triglyceride (TG), low‐density lipoprotein cholesterol (LDL‐C), total antioxidant capacity (T‐AOC), and high‐density lipoprotein cholesterol (HDL‐C) were purchased from Jiancheng Bioengineering Institute, Nanjing, China. Kits for malondialdehyde (MDA), total superoxide dismutase (SOD), glutathione peroxidase (GSH‐Px), MTT Cell Proliferation and Cytotoxicity Assay Kit (MTT), Reactive Oxygen Species Assay Kit (ROS), TRIzol, and cDNA synthesis were purchased from Beyotime Biotechnology. Oil Red O was obtained from Sigma‐Aldrich. Potassium ferricyanide, trichloroacetic acid, thiobarbituric acid, 2,2′‐azino‐bis (3‐ethylbenzothiazoline‐6‐sulfonic acid) diammonium salt (ABTS), and 2,2‐diphenyl‐1‐picrylhydrazyl radical (DPPH) were purchased from Vita Co. Ltd. All chemicals and solvents were of corresponding grade required for the experiment.2.2Mung beans and peas were milled into flour and thoroughly mixed, and then stored at 4°C for further analysis. Nutritional components of mung beans and peas were provided by China Agricultural University Table . A portiThe extraction method was carried out based on a previously described method with slight modifications  were donated by Shanghai Slac Laboratory Animal Co. Ltd. The license number for using experimental animals was SCXK(SH)2017‐0005. All the rats were maintained under standard conditions . Surgery was performed under anesthesia to minimize suffering.After one‐week acclimatization phase, the rats were randomly separated into six groups (eight rats each): normal fat diet (NFD) group, high‐fat diet (HFD) group, HFD with 10% mung bean (HFDM‐L) group, high‐fat diet with 50% mung bean (HFDM‐H) group, high‐fat diet with 10% pea (HFDP‐L) group, and high‐fat diet with 50% pea (HFDP‐H) group. Feed was purchased from Jiangsu Xietong Pharmaceutical Bioengineering Co., Ltd. HFD included 15% lard, 10% sucrose, 1.2% cholesterol, 0.2% cholic acid, and basal diet. 10% and 50% (w/w) mung bean and pea flours were added into the HFD resulting in HFDM‐L, HFDP‐L, HFDM‐H, and HFDP‐H, respectively. The rats of each group were fed with the corresponding diet for 4 weeks. The body weight was measured every week. At the end of this experiment, the rats were deprived of food overnight and sacrificed. For the serum preparation, the rats were anesthetized, and blood samples were collected from the abdominal aorta. The livers were immediately dissected, weighed, and stored at −80°C for analysis.2.3.2TG, TC, LDL‐C, and HDL‐C levels in the serum were analyzed using a Multi‐Mode Microplate Reader  according to the manufacturer's instructions.The activities of SOD, MDA, GSH‐Px, CAT, and T‐AOC were tested in line with the kit's instructions. Liver homogenates were prepared in an ice bath with tissue homogenizers to determine the liver antioxidant enzyme activities, and the supernatants were obtained via centrifugation at 12,000 r/min for 10 min.2.3.3The livers were collected, fixed, stained with hematoxylin and eosin, and observed under a light microscope  in mung bean and pea was determined by a Folin–Ciocalteu assay with slight modifications  was evaluated using Dunnett's multiple comparisons test.At least three independent trials were conducted in all experiments, and the data were expressed as mean ± standard deviation. The results were analyzed for variance using the GraphPad Prism software , and statistical significance of differences (33.1p < .05), and there was no significant difference between legume supplementation groups and HFD group. Compared with the HFD group, the liver index of rats in NFD, HFDM‐L, and HFDM‐L groups decreased significantly (p < .05). In addition, there were no significant changes in the food intake of each experimental group (p > .05), indicating that different diets had no significant effect on the food intake of rats.Table 3.2p < .05). Treatments with mung beans and peas revealed significant decline in serum lipid profile in a dose‐dependent manner. With a higher dose, the levels of TC and LDL‐C did go lower, and bigger of the HDL‐C level. Interestingly, a higher dose of legumes did not have an effect on the levels of TG, though they were lower than the HFD ones.As shown in Figure 3.3H&E sections of rat livers in each group Figure a–f showe3.4p < .05). In HFDP‐H rats, the activities of serum GSH‐Px, SOD, and T‐AOC increased by 110.99%, 28.56%, and 45.64%, respectively, and serum MDA level reduced by 28.44%. Different from the data of serum enzymes and MDA, the effects on antioxidant status in livers were observed mainly in liver CAT and T‐AOC levels, which were increased by 28.82% and 71.45% for HFDM‐H rats and 31.27% and 69.41% for HFDP‐H rats, respectively.Lipid peroxidation and antioxidant enzymes both in serum and in liver were determined , respectively. The relative gene expression levels of Nrf2, NQO1, CAT, SOD, and HO‐1 in rats fed with HFDM‐H were 84.22%, 180.32%, 54.65%, 118.38%, and 79.35% higher than those in rats fed with HFD (p < .05), respectively. In HFDP‐H rats, the expression levels of Nrf2, NQO1, CAT, SOD, and HO‐1 were 80.11%, 165.92%, 53.57%, 97.54%, and 65.83% higher than those in the HFD group (p < .05).As shown in Figure 3.5The above results suggested that intact mung beans and peas can effectively improve oxidative stress injury induced by high‐fat diet in rats. However, the nutrients in these two kinds of legumes are complex, and it is difficult to determine which active ingredients play a key role in antioxidation. Therefore, in order to verify the main antioxidant components of mung beans and peas, these two kinds of legumes were extracted by sequential extraction methods, and the antioxidant activities of the extracts were studied in vitro and in cells. The antioxidant effects of water extracts were poor, and then, in this study, we focused on the antioxidant effects of ethanol extracts.Ethanol extracts exhibited DPPH scavenging capacity as shown in Figure As shown in Table 3.6p < .05) , whereas pea ethanol extracts were cytotoxic at 400 μg/ml  Figure a. Therefp < .05). However, the concentration of ethanol extracts at 100 μg/ml reveals no significant difference compared with OA group. Thus, ethanol extracts at 200 and 400 μg/ml were used for all the subsequent experiments. The TG and TC levels were significantly reduced at 200 or 400 μg/ml of ethanol extracts  (Wang, Shimada, Kato, Kusada, & Nagaoka, +. The previous study showed that the ABTS scavenging ability of the pea methanol extract was 6,155.37 μmol/g (Xu & Chang, DPPH scavenging assays are usually used for the evaluation of the free radical scavenging of plant extracts for its simple sensitive and reproducible procedures. The plant source of extracts, environmental factors, and the solvent applied in the extractions may account for the differences in the levels of DPPH scavenging activities (Duenas et al., Most of the reported studies were focused on the extraction procedures or the antioxidant abilities in vitro. However, there are few reports about the effects of the ethanol extracts of legumes on oleic acid‐induced HepG2 cells which could act as a good model for studying extract antioxidant capacity, and the results could be easily quantified by an Oil Red O colorimetric technique. There are abundant phenolic compounds in legumes, especially for the large number of polyphenols. In this study, the results showed that the main antioxidant components might be present in the ethanol extracts. A proper ethanol extracts with oleic acids in a combination mixture might lead to significant lipoapoptosis and intracellular lipid accumulation with minimal cellular damage.5Results showed that after intact mung bean and pea supplementation, the antioxidant defense system and gene expression of rats were improved in varying degrees compared with HDF group. The water and ethanol extracts of mung beans and peas have strong DPPH scavenging activity, a moderate ABTS scavenging activity, and high antilipid peroxidation ability and reducing power. Meanwhile, the ethanol extracts of mung beans and peas in HepG2 cells have also strong antioxidant activities. These results suggested that mung beans and peas have potent antioxidant activity, but the specific components of the extracts were not clear. Therefore, further research and discussion were needed. And this study is also worthy of further research and development in food and pharmaceutical industries.The authors declare no conflict of interest.The authors declare that there is no conflict of interest regarding the publication of this article. The research described herein was performed on male SD rats. This study was performed in strict accordance with protocols approved by Institutional Animal Care and Use Committee of University of Shanghai for Science and Technology, Shanghai, China.


This study aimed to explore the effect of retaining inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of proximal humerus fractures treated with a locking plate.Twelve Synbone prosthetic humeri  were used for a wedge osteotomy model at the proximal humerus, in four groups. In the cortex contact + screw fixation group and cortex contact group, the inferomedial cortical bone contact was retained. In the screw fixation group and control group, the inferomedial cortical bone contact was not retained. Calcar screw fixation was implemented only in the screw fixation groups. The dynamic and static mechanical stability of the models were tested with dynamic fatigue mechanics testing, quasi-static axial compression, three-point bending, and torsion testing.P < 0.01). The cortex contact + screw fixation group showed the best axial compressive stiffness, bending stiffness, and torsion stiffness; these were successively decreased in the other three groups (P < 0.01).The cortex contact + screw fixation group showed the longest fatigue life and the best stability. There was 35% difference in fatigue life between the cortex contact + screw fixation group and the cortex contact group, 43%between the cortex contact + screw fixation group and screw fixation group, and 63% between the cortex contact + screw fixation group and screw fixation group (Retaining inferomedial cortical bone contact and fixation with two calcar screws maintained fracture stability with the highest strength and minimum deformation. Of the two methods, restoration of the inferomedial cortical bone support showed better dynamic and static biomechanical properties than placement of calcar screws alone. Proximal humeral fractures commonly occur, often in elderly patients after a fall, where they are the third most common osteoporotic fracture . In mostIt is important during minimally invasive surgery to avoid iatrogenic radial nerve injury, and PHILP with a spiral plate is likely to achieve more satisfactory results . A spiraThere has been particular controversy over the treatment of comminuted fractures of the proximal medial humerus . These fSynbone prosthetic humeri  were used in this study. A total of 12 prosthetic humeri were randomized into four groups, each consisting of three prosthetic humeri: the cortex contact + screw fixation group  in the axial direction to test the dynamic fatigue properties. The finite fatigue life of each group was measured [All specimens were consistent in height, structure, load, and fixation method and underwent the same mechanical test method, to ensure experimental accuracy. Both ends of the Synbone prosthetic humerus were embedded with denture base resin  and fixed, and only the bone plate fixation area at the proximal end was exposed. Then, the fixtures at both ends were fixed in parallel to the Zwick/Roell dynamic mechanics tester . Via the center on the osteotomy section, the relative displacement was measured using a high-precision digital grating displacement sensor , with an accuracy of 5 um. After each specimen was carefully mounted, cyclic compression was applied with a loading of 500 N . In each experiment, the specimen was first pre-loaded with 100 N to eliminate bone relaxation, creep, and other rheological effects. For each loading, the measurement was repeated three times, and each measurement result was used to calculate the mechanical parameters of each group .P < 0.05 was considered statistically significant.Statistical analyses were performed using SPSS13.0 software . Data were analyzed using one-way analysis of variance (ANOVA), and intergroup comparisons were conducted using the Student–Newman–Keuls method. A difference with P < 0.01) of 35%, 43%, and 63% between cortex contact + screw fixation and cortex contact groups, cortex contact + screw fixation and screw fixation groups, as well as cortex contact + screw fixation and control groups, respectively.As can be seen in Table P < 0.01). In addition, the difference in fatigue life between the calcar screw fixation group and the control group was 35–37% (P < 0.01). These results showed that inferomedial cortical bone contact and fixation with two calcar screws for the treatment of humerus fracture had a very positive effect on the fatigue life, and the fracture instability gradually declined in the remaining three groups: cortex contact + screw fixation group > cortex contact group > screw fixation group > control group.The difference in fatigue life between the cortex contact group and the control group was 43–45%  N, (240.22 ± 14.46) N, (180.18 ± 12.26) N, and (114.35 ± 9.78) N, where the differences among the four groups were statistically significant, of which the cortex contact + screw fixation group showed the highest load  N/mm, (369.17 ± 23.97) N/mm, (214.73 ± 32.88) N/mm, and (139.98 ± 8.40) N/mm, where the differences among the four groups were statistically significant, of which the cortex contact + screw fixation group had the greatest axial compression stiffness. These results indicate that humeral inferomedial cortical bone contact and fixation with two calcar screws provided the best compressive strength and stiffness and presented the optimal curative effect . Meanwhile, the bending stiffness showed similar regularity with the bending moment, and the differences among the groups were statistically significant (P < 0.01), of which the cortex contact + screw fixation group showed greatest bending stiffness  N m, (4.21 ± 0.44) N m, (3.13 ± 0.19) N m, and (2.21 ± 0.13) N m. Further intergroup comparisons returned statistically significant differences (P > 0.05), while the maximum torsion moment of the cortex contact + screw fixation group showed a significant difference compared with those of the other three groups  N m, (6.33 ± 0.44) N m, (6.64 ± 0.38) N m, and (3.62 ± 0.18) N m, where the differences among the four groups were statistically significant. Further comparison between two groups showed that the difference between cortex contact and screw fixation groups was statistically insignificant P > 0.0, while tP < 0.01). Further comparison between two groups revealed that the difference between cortex contact group and screw fixation group was not statistically significant (P > 0.05), but the maximum torsion stiffness of the cortex contact + screw fixation group showed significant differences compared with those of the other three groups  N m/deg., (1.34 ± 0.06) N m/deg., (1.42 ± 0.07) N m/deg. and (1.02 ± 0.05) N m/deg., where the differences among the four groups were statistically significant ( ± 0.12 NThe aim of this study was to explore the use of PHILP for the treatment of proximal humerus fractures, in particular, to examine the effect of retaining inferomedial cortical bone contact and fixation with calcar screws on the dynamic and static mechanical stability of the fractures. The results showed that stability, axial compressive load and axial compressive stiffness, bending moment and bending stiffness, and torsion moment and torsion stiffness were all higher in the group that had both cortex contact and calcar screw fixation.The dynamic fatigue mechanical characteristics after fixation with the locking plate showed that the cortex contact + screw fixation group had the longest fatigue life and the best stability, while the fatigue life was decreased in the other three groups. Further comparison between two groups showed cortex contact + screw fixation group> cortex contact group> screw fixation group> control group. This result is supported by a previous study that also found that in humeri with normal alignment, calcar screws can provide additional stability; however, they also showed that this benefit is lost with varus deformity, but not when a medial deficiency exists .The quasi-static mechanics test revealed that the axial compressive load and axial compressive stiffness of the cortex contact + screw fixation group were 35%, 50%, and 70% higher than the other three groups. Meanwhile, the bending moment and bending stiffness of the cortex contact + screw fixation group were 37%, 53%, and 66% higher than those of the other three groups. The torsion moment and torsion stiffness of the cortex contact + screw fixation group were 37, 35%, and 64% higher than those of the other three groups. Comparison between two groups revealed cortex contact + screw fixation group > cortex contact group > screw fixation group > control group. These results compare well to the results of Zhang et al.  who showRestoring the inferomedial cortical bone support showed even more advantages in dynamic and static biomechanics compared with placing calcar screws alone for the treatment of humerus fractures. The presence or absence of inferomedial cortical bone contact and the static mechanical indicators accounted for respectively 44% and 40–50% in effect on stability. Meanwhile, placement of calcar screws accounted for 36% and 30% in effects on dynamic and static stabilities, respectively, which indicated that it was more important to restore the inferomedial cortical bone contact, similar to a previous study ..In case of comminuted inferomedial cortex and poor reduction, especially in case of the absence of inferomedial cortex support, the screws tend to shift, and even pierce the humeral head, which decreases the stability of the implants. In case of absence of inferomedial cortex support, the incidence of varus deformity cannot be prevented even with increased cement. Restoration of inferomedial cortex support could augment stability and strength of the locking plate and would be expected to reduce the incidence of complications . The preThis study has some limitations; as a synthetic model, the effect of surrounding tissues on these results could not be studied and we could not model the many different complex fractures that are seen clinically. The treatment of comminuted fractures needs further study.The results of this study show that proximal humerus fracture fixation retaining the inferomedial cortical bone contact with calcar screw fixation provided better biomechanical characteristics than retaining the inferomedial cortical bone contact or calcar screw fixation alone. Of the two methods, the most important from a biomechanical aspect is retaining inferomedial cortical bone contact.