The association between BIN1 rs744373 variant and Alzheimer’s disease (AD) had been identified by genome-wide association studies (GWASs) as well as candidate gene studies in Caucasian populations. But in East Asian populations, both positive and negative results had been identified by association studies. Considering the smaller sample sizes of the studies in East Asian, we believe that the results did not have enough statistical power.P = 5 × 10− 07, odds ratio (OR) = 1.12, and 95% confidence interval (CI) 1.07–1.17) and in Caucasian populations . But in the East Asian populations, the association was not identified . Besides, the regression analysis suggested no significant publication bias. The results for sensitivity analysis as well as meta-analysis under the dominant model and recessive model remained consistent, which demonstrated the reliability of our finding.We conducted a meta-analysis with 71,168 samples . Based on the additive model, we observed significant genetic heterogeneities in pooled populations as well as Caucasians and East Asians. We identified a significant association between rs744373 polymorphism with AD in pooled populations (The large-scale meta-analysis highlighted the significant association between rs744373 polymorphism and AD risk in Caucasian populations but not in the East Asian populations. Alzheimer’s disease (AD) is the preeminent cause for dementia in the elderly and causes 50–75% dementia types –3. In thP = 3.16 × 10 − 10 [P = 2.6 × 10 − 14 [P = 2.13 × 10 − 09 [P = 2.9 × 10 − 07 [P = 1.1 × 10 − 04 [P = 0.217) and genotype test  [P = 0.038), but not southwest China (P = 0.874). When combining the two parts of populations, they still did not identify any significant association (P = 0.187) [P = 0.660 for dominant model and P = 0.547 for recessive model) [P = 0.06 for additive model) when analyzed 825 AD cases and 2934 controls from Japan [P = 1.19 × 10 − 02, 7.08 × 10 − 03 and 5.75 × 10 − 03 for the dominant model, recessive model and additive model) [Rs744373 is a single nucleotide polymorphism (SNP) that locates upstream of BIN1 gene. In populations of Caucasian ancestry, rs744373 polymorphism was consistently confirmed to be significantly associated with AD risk with  10 − 10 , P = 2.6 10 − 09 , P = 2.9 10 − 07  and P =  10 − 04 . Recentl models) . The res= 0.187) . In Braze model) . Ohara ee model) . AnotherGiven the inconsistent findings in East Asian populations, we believe that the relatively small sample sizes, as well as the genetic heterogeneity of AD susceptibility loci among different populations, may be important factors in the untrustworthiness of the results. In this study, we aimed to collect more studies and samples than before and obtain more statistically significant results by performing genetic heterogeneity test and meta-analysis of the rs744373 polymorphism in the Caucasians, East Asians, and pooled populations.https://www.ncbi.nlm.nih.gov/pubmed) and AlzGene database  with the Keywords “Alzheimer’s disease”, “Bridging Integrator 1” or “BIN1”. We also searched Google Scholar (http://scholar.google.com/) to acquire the articles citing the studies obtained in the PubMed and AlzGene databases. The literature acquisition was updated on December 12, 2017. In addition, we collected as much data as we could by directly contacting with authors. These datasets were not published due to not significant results, etc., and were not included in the previous meta-analysis of rs744373 polymorphism with AD.In order to find all available association studies, we searched the PubMed database  being a case-control study; (2) investigating the association between rs744373 polymorphism and AD; (3) being conducted in East Asian or Caucasian populations; (4) providing the numbers of rs744373 genotypes or sufficient data to calculate them or (5) providing an OR with 95% confidence interval (CI) and the The information was extracted from each study contained: (1) author names; (2) publication year; (3) the sample’s ethnicity; (4) the numbers of cases and controls; (5) the genotyping platform; (6) the frequencies of rs744373 genotypes or sufficient data to calculate them or (7) the OR with 95% CI or sufficient data to calculate them.Since not all studies provided exact genotype numbers, we investigated the association between rs744373 polymorphism and AD risk in this meta-analysis primarily using the additive genetic model. We selected allele C as effect allele and T as reference allele, the additive model can be described as C allele versus T allele .http://www.r-project.org/) to perform the t-test and calculate the OR and MAF values that not available in the original articles.We compared the minor allele frequency (MAF), which is the frequency of rs744373 allele C in this study, and the OR values between the Caucasian populations and East Asian populations. We used the t-test to investigate whether there were differences in the OR values and MAF values between these two populations. We used program R (k-1 (k represents the number of studies included in this studies). Statistics I2 can also use to measure the genetic heterogeneity, which is calculated as:We used the Cochran’s Q test to investigate genetic heterogeneity among different studies. Cochran’s Q test approximately follows a chi-square distribution and its degree of freedom is I2 is in the range of 0–100%, and we divided it into four parts: 0–25%, 26–50%, 51–75%, 76–100%, which respectively represent low, moderate, large and extreme heterogeneity [P-value and I2 value were completed using the program R (http://www.r-project.org/). We choose P < 0.05 or I2 > 50% as discriminant criterion for significant result of heterogeneity test.The statistics ogeneity . We condP-value of Cochran’s Q test was less than 0.05, and I2 value was greater than 50%, we selected the random effect model, otherwise we selected the fixed effect model. The signification of overall OR was measured by Z test.In the meta-analysis, we used fixed effect model (Mantel–Haenszel) or random effect model (DerSimonian–Laird) to calculate the overall OR. And which model to choose depends on whether the genetic heterogeneity is significant or not. If the http://www.r-project.org/).To further test the stability of our results, we conducted a sensitivity analysis by sequentially removing each study in the meta-analysis at a time. We used funnel plots to evaluate the potential publication bias. A symmetrical inverted funnel indicated the results were no bias, and an asymmetrical inverted funnel indicated bias results . Begg’s We obtained 126 articles by searching the PubMed database. Eighty-eight articles were excluded because they were (1) not Case-Control design, (2) not analyzed in East Asian or Caucasian populations, (3) not related with AD, (4) meta-analysis or (5) review articles. We further excluded 24 articles because they did not investigate the association between rs744373 polymorphism and AD or not provide sufficient data. The remaining 14 articles met the analysis requirements. According to the same criteria, we also obtained two articles from the AlzGene database. In addition, we had found one article by searching Google Scholar. We applied for two datasets of two articles (studies) by contacting the author directly. Finally, 37 studies in 19 articles, including 22,395 AD cases and 48,773 control samples, were included in this meta-analysis. More detailed information about selecting studies was described in Fig. t = 5.89 and P = 1.53 × 10− 6. However, the result of comparison of OR values did not indicate a very significant distinction between the two populations (t = 1.75 and P = 0.11).There were 11 studies belong to East Asian populations. The MAF values of rs744373, OR values and other information of these 11 studies listed in the top 11 rows in Table P = 0.001, I2 = 52.3%), East Asians  and pooled populations . Detailed results were described in Table We conducted heterogeneity test of rs744373 polymorphism in different populations, and identified significant genetic heterogeneity in Caucasians . Funnel diagram was described in Fig. Using sensitivity analysis, we identified that the results of meta-analysis remained largely unchanged by excluding any one study Table . The symGWASs showed that SNPs located in upstream of BIN1, particular rs744373, are strongly associated with AD risk . The expBased on the significant association between rs744373 polymorphism and AD risk identified by the GWASs in Caucasian populations, many recent studies had also explored this association in East Asian populations, as described in the introduction. However, the findings of the association studies in East Asian were always inconsistent. Considering a relatively small sample size may result in less statistical power, we collected 37 studies involving 22,395 AD cases and 48,773 controls for the meta-analysis. To the best of our knowledge, this was the largest sample size by far.P = 5 × 10− 07, OR = 1.12, and 95% CI 1.07–1.17) and also in Caucasian populations . The results were consistent with the previous studies. However, in East Asian populations, our results showed a significant genetic heterogeneity of rs744373 polymorphism  and the meta-analysis did not show a significant association between rs744373 polymorphism with AD risk by using a random effect model . The insignificant publication bias results and the consistent sensitivity analysis results showed that our results were reliable.By meta-analysis of the 37 studies, we obtained significant association between rs744373 polymorphism and AD risk in pooled populations , as well as in Caucasian populations . We also obtained negative results in East Asian populations . The consistent results among the three kinds of genetic models demonstrated the reliability of our results. The data was described in Additional file To confirm the findings that were obtained by additive genetic model, we further used the dominant model (CC + CT versus TT) and recessive model (CC versus CT + TT) to investigate the association of rs744373 polymorphism with AD risk based on genotype data of 33,184 samples . As same as the results of additive model, we obtained significant association between rs744373 and AD in pooled populations . The meta-analysis results under the additive, dominant and recessive model indicated a significant association between rs744373 and AD risk in Caucasian populations but not in East Asian populations. The consistent results of sensitivity analysis, as well as the negative results of publication bias analysis, demonstrated the reliability of our findings. We believe that the greater statistically powerful results are helpful for the understanding of AD genetic risk factors in East Asian populations.Additional file 1. Meta-analysis under dominant and recessive model. Table S1. The selected studies investigating the association between rs744373 and AD using dominant model and recessive model Figure S1. Funnel plot of the publication bias analysis under dominant model. Figure S2. Funnel plot of the publication bias analysis under recessive model.


Insomnia is a common source of distress in adults with autism spectrum disorder (ASD). Two characteristics of ASD could be relevant to insomnia complaints by hampering the entrainment of a circadian sleep-wake rhythm. First, sensory hyper-reactivity could lead to bright light avoidance and thus affect photoperiodic input to the circadian system. Second, impaired social skills complicate the establishment of a social interactions and thus affect scheduled social-behavioral input to the circadian system. We investigated the association of insomnia severity with sensory reactivity and social skills in 631 adults (18–65 years) with ASD. Results revealed positive associations of insomnia severity with general and visual sensory hyper-reactivity and with impairment of social skills. The findings warrant further studies which (1) directly assess whether a suboptimal functioning of the biological clock underlies these associations and (2) identify other factors that could contribute to observed sleep problems. Autism spectrum disorder (ASD) is a lifelong neurodevelopmental disorder affecting around 0.6–1.7% of the population worldwide , which functions as an internal biological clock. The activity of the SCN synchronizes to several types of environmental and behavioral 24-h rhythms which is referred to as entrainment. The environmental light-dark cycle has the strongest entraining effect. Even without a functional SCN, light-dark cycles can induce a rhythm in core body temperature , which is a longitudinal register including approximately 2000 individuals with ASD. The NAR has been established by the Dutch Association for Autism  in collaboration with the Vrije Universiteit Amsterdam (VU) and operates primarily through online questionnaires covering various domains of functioning as well as demographical data. The Medical Ethical Committee of the Vrije Universiteit Amsterdam approved this research. For the present study, individual responses given to three measures of interest during an online survey in 2015 were analyzed.age = [42.62(12.21)], 48% males). Men from this sample were older than women  = 5.81, p < .001). With respect to the presence of sleep problems, the mean score obtained on the Insomnia Severity Index , which is indicative of subthreshold insomnia. For an overview of the sample composition with respect to other variables of interest see Tables The age range was restricted to 18 through 65 years during the respective time point resulting in the following sample characteristics: Data were obtained from 631 individuals with autism  were applied to examine the relationship between the two predictors, i.e. sensory responsivity and social skills, and sleep problems while controlling for confounding effects of covariates. Significant covariates identified during the primary analyses were entered in the first block, followed by the predictors. While a first HMLR examined the influence of the total SPQ score, the five subscale values representing the main sensory modalities were entered into a second HMLR model. Alpha was set to 0.05.SD = 6.01), which is indicative of subthreshold insomnia and higher than means reported for the general population ranging between 1 and 7  = − 3.51, p < .001; intake of medication: t(621) = 1.76, p = .08; age: r(623) = − .01, p = .10; IQ score r(623) = − .10, p = .02)  scored higher than men  as did participants with medication  compared to those without . Hence, all covariates were retained and entered into the first block of the HMLR models.Primary analyses revealed that each of the covariates had a significant impact on the ISI total score at R2 = .08, F = 7.49, p < .001). Squared partial correlation coefficients obtained for the first block including the covariates suggested the biggest contribution of sex  = 3.49, p = .001, sr2 = .02) followed by IQ  = − 2.08, p = .04, sr2 = .01), whereas the other covariates did not reach significance. Introducing SPQ total and AQ social skill scores into the model led to an 4% increase in the amount of variance explained, which was statistically significant  = 12.18, p < .001). Both main scores uniquely explained 2% of the variance in ISI scores. Obtained beta weights indicated higher insomnia symptom severity in individuals with higher sensory reactivity  = − 3.18, p = .002, sr2 = .02) and lower social skills  = 3.32, p = .001, sr2 = .02).The combination of covariates and predictors specified in the first HMLR model presented in Table R2∆ = .07, F = 6.89, p < .001), resulting in to a total R2 of .11  = 6.24, p < .001). Note, that this is slightly higher than the value of the first HMLR model, which was only able to account for 8% of the variance in insomnia scores. In line with our hypotheses, visual reactivity significantly predicted insomnia severity with higher insomnia scores in individuals with higher visual reactivity  = − 4.34, p < .001, sr2 = .03). This factor could uniquely account for 3% of the variance observed. Further, the effect of social skills remained significant  = 2.96, p = .003, sr2 = .02). None of the other sensory modalities reached significance.Based on the finding of a significant effect of overall sensory reactivity on insomnia symptom severity, a second HMLR model aimed at disentangling the individual contribution of the five main sensory modalities. Replacing the SPQ total score by subscale values for smell, vision, hearing, touch, and taste  appropriate control group(s) including typically developing individuals and/or other clinical populations. Thus, the question whether the patterns revealed are ASD specific or a common feature shared, for example, with other developmental disorders remains unexplored and an important area for future inquiries. With respect to the measures applied, the usage of online questionnaires may introduce a bias by impeding the participation of non-verbal and non-literate adults. Furthermore, the lack of objective sleep assessment instruments such as actigraphy and polysomnography may be criticized. To date, studies investigating the ASD sleep phenotype by means of these measures have, however, produced rather mixed results with respect to discrepancies from typically developing populations despite elevated subjective complaints in subjects with ASD (Tani et al. Overall, the present study showed that insomnia severity in ASD is associated with sensory reactivity, especially in the visual domain, and impaired social skills. The findings are indirectly compatible with the notion that limited entrainment of the circadian system caused by reduced sensory and social input could contribute to poor sleep in adults with ASD. Consequently, interventions targeting sensory reactivity, social skills and scheduled entrainment could attenuate the observed problems. Other options include behavioral interventions involving sleep timing as well as the administration of melatonin for which favorable effects have been demonstrated in children with ASD (Cortesi et al.


To investigate disk halo size changes produced by a glare source after surgical insertion of an implantable collamer lens with a central hole (ICL V4c) for myopia correction.  In this prospective study, disk halo size and pupillary light response with a vision monitor were measured preoperatively and at 1 week, 1 month, and 3 months postoperatively. Pupillary light response parameters included contraction amplitude, latency, duration, and velocity; dilation latency, duration, and velocity; and initial, maximum, minimum, and average pupil diameters. P > 0.05) and then decreased significantly at 1 and 3 months postoperatively (both P < 0.001). Contraction amplitude and velocity, as well as dilation velocity, decreased significantly at all postoperative time points . Disk halo size at 3 months postoperatively was significantly correlated with initial , maximum , minimum , and average pupil diameters .  Forty-two right eyes of 42 patients were enrolled. Postoperative uncorrected distance visual acuity was better than or equal to 20/20 in all eyes. Compared to preoperative values, disk halo size showed no significant difference at 1 week postoperatively ( After ICL V4c implantation, disk halo size was reduced in the short term. Patients with smaller pupil sizes during pupillary response to light experienced smaller halos after ICL V4c implantation. Although the ICL V4c has shown excellent clinical and refractive results when used for the treatment of myopia [The implantable collamer lens with a central hole  is a new posterior chamber intraocular lens (IOL) that is designed to allow natural flow of the aqueous humor from the posterior chamber to the anterior chamber through a 360 f myopia –5, some A previous study showed that in myopic patients, the minimum pupil size achieved within the dynamic pupillary light response was correlated with disk halo size . ConsideThe present study was performed to investigate disk halo size changes using a visual monitor with good repeatability , as wellThis study was approved by the Ethics Committee of the Eye and ENT Hospital of Fudan University and complied with tenets of the Declaration of Helsinki. Informed written consent was obtained from all patients after the possible consequences of the study were explained.2. Corrected distance visual acuity was better than or equal to 20/20 in all patients. Because age is associated with both the pupillary response to light and disk halo size [This prospective study enrolled consecutive patients who underwent routine preoperative ophthalmic examinations at the Refractive Surgery Centre in the Department of Ophthalmology of the Eye and ENT Hospital of Fudan University. The inclusion criteria were as follows: age between 20 and 35 years, stable refraction, anterior chamber depth ≥2.8 mm, and endothelial cell density ≥2,000 cells/mmalo size , and patalo size , the criICL V4c implantation procedures were performed by two experienced surgeons (X. Y. W. and X. T. Z.). As described in a previous study , the vis2. In preoperative measurements, a lens was used to achieve full correction of refractive error. Three radial lines of 10 letters appeared from the periphery toward the light source on the screen, such that the 10 letters formed 10 rings at 30 min arc intervals (arcmin). The average distance to the letter nearest to the light source was measured for each line, and then the visual angle formed by the radius of the halo was calculated in arcmin. The pupillary contour was automatically traced by the pupillometer with an accuracy of ±0.1 mm. The software then performed an analysis of responses to successive visual stimuli with automated quantification of the following parameters: contraction amplitude, latency, duration, and velocity; dilation latency, duration, and velocity; and initial, maximum, minimum, and average pupil diameters. Each parameter was measured at least five times and the mean values were recorded.Disk halo size and pupillary light response were evaluated by an experienced technician preoperatively and at 1 week, 1 month, and 3 months postoperatively with monocular dynamic pupillometry . As described in previous studies , 13, allP value < 0.05 was considered to be statistically significant.All statistical analyses were performed using the Statistical Package for Social Sciences . All data were tested for normality using the Kolmogorov–Smirnov test. A repeated-measures analysis of variance with least significant difference post hoc comparisons and the Friedman test were performed to evaluate temporal changes in disk halo size and pupillary response to light. Pearson's and Spearman's correlation analyses were applied to detect potential correlations between these variables. A Forty-two consecutive patients  were enrolled; these patients had a mean age of 24.76 ± 5.16 years and mean spherical equivalent (SE) of −10.42 ± 2.54 diopters. P < 0.001), but showed no significant difference at 1 week postoperatively (P > 0.05). Contraction amplitude and velocity, as well as dilation velocity, decreased significantly at all postoperative time points, compared to preoperative values ; there were no differences among postoperative time points  (P > 0.05).Preoperative and postoperative disk halo size and pupillary response to light measurements are shown in  > 0.05) . No signP < 0.01) and then returned to baseline at 3 months postoperatively (P=0.086). Compared to preoperative values, no differences in maximum pupil diameter were found at 1 week or 1 month postoperatively ; however, maximum pupil diameter significantly decreased at 3 months postoperatively (P=0.01). There were significant decreases in initial pupil diameter at 1 week (P=0.037), 1 month (P=0.001), and 3 months postoperatively (P < 0.001), compared to preoperative values.r = −0.407, P=0.008). Disk halo size at 1 week postoperatively was significantly correlated with maximum pupil diameter . Disk halo size at 1 month postoperatively was significantly correlated with dilation velocity , as well as initial , maximum , minimum , and average pupil diameters . Disk halo size at 3 months postoperatively correlated significantly with initial , maximum , minimum , and average pupil diameters   .The presence of a halo is a common phenomenon after ophthalmic surgeries. Changes in the presence of a halo must be clearly communicated in discussions of the complications of ICL V4c implantation in clinical practice. In the present study, we examined changes in disk halo size after ICL V4c implantation, as well as factors that influenced halo size.Disk halo size showed a decreasing trend, but the difference between preoperative and 1-week postoperative values was not statistically significant. This result might be related to postoperative recovery in the early period. Disk halo size decreased significantly at 1 and 3 months after the procedures. Moreover, as in a previous study, preoperative disk halo size was related to the SE . This suAt 3 months postoperatively, the average disk halo size was 104.76 ± 36.11 arcmin, which is consistent with the reported baseline value of 111.6 ± 39.8 arcmin in healthy subjects , 20.Reductions in postoperative contraction amplitude, contraction velocity, and dilation velocity were observed in this study. The changes in contraction amplitude were consistent with previous studies , 9. In tIn the present study, the postoperative initial and maximum pupil diameters were significantly smaller than the corresponding preoperative values, and the minimum pupil size returned to the preoperative value at 3 months postoperatively. Totsuka et al. found no significant changes in the pupil diameters of patients aged 31.1 ± 6.8 years, preoperatively and at 1, 3, and 6 months after ICL V4c implantation . Kamiya Postoperative disk halo size was significantly correlated with pupil sizes from the pupillary response to light. Patients with smaller pupil sizes from the pupillary response to light experienced smaller halos. In a previous study, the disk halo size of myopic eyes demonstrated a relationship with the minimum pupil size from the pupillary response to light . SignifiFurthermore, this study was limited in that it would have been better to record subjective changes in halo phenomena in the form of a questionnaire at each follow-up examination.In conclusion, after ICL V4c implantation, disk halo size was reduced in the short term. Patients with smaller pupil sizes during pupillary response to light experienced smaller halos after ICL V4c implantation. For patients with large pupils, adequate preoperative communication is particularly important.


Myxosarcomas are known to be classified as soft tissue sarcomas. However, there is limited clinical characterization pertaining specifically to canine cutaneous myxosarcomas in the literature. The objective of this study is to evaluate the local recurrence rate, metastatic rate and prognosis of canine myxosarcoma.A total of 32 dogs diagnosed with myxosarcoma via histopathology were included in this retrospective study. All dogs had surgical resection. No adjunct treatments were performed in 9 dogs, while 22 dogs also received either radiation therapy or chemotherapy, or a combination of both. One dog received only NSAID after surgery. Overall median survival time (MST) was 730 days (range 20–2345 days). The MST of dogs with a tumor mitotic count < 10/10 HPF was 1393 days (range 20–2345 days). The dogs with a tumor mitotic count of 10 or greater/10 HPF had a MST of 433 days (range 169–831 days). There was no significant difference of MST among different treatment modalities. Local recurrence was noted in 13 cases (40.6%) and the median time to recurrence was 115.5 days (range 50–1610 days). The median time to local recurrence in dogs with mitotic count of < 10/10 HPF was 339 days (range 68–1610 days) and in dogs with mitotic count of 10 or greater/10 HPF was 119 days (range 50–378). Metastasis to local lymph node or lung was noted in 8 cases (25%) with median time to metastasis of 158.5 days (range 0–643 days).Based on the results of this retrospective study, myxosarcoma may have a higher local recurrence rate and risk of metastasis to the local lymph nodes compared to other soft tissue sarcomas. Soft tissue sarcomas (STSs) are a heterogeneous group of tumors that arise from mesenchymal tissues, including muscle, adipose, neurovascular, fascial, and fibrous tissue. They account for 15% of all skin and subcutaneous tumors in the dog , 3. STSsMyxosarcomas are classified as soft tissue sarcomas. This neoplasm is of fibroblast origin with an abundant myxoid matrix composed of mucopolysaccharides . The mosIn humans myxofibrosarcoma represents about 5% of all soft tissue sarcomas. It affects older patients with the most common sites of presentation being the extremities (77%), followed by trunk (12%) and head and neck region (3%) . MyxofibTo the authors’ knowledge, no large data set of canine myxosarcoma has been published. The purpose of this study was to evaluate the local recurrence rate, metastatic rate and prognosis of canine myxosarcomas.n = 10), mixed breed dog (n = 6), Australian shepherd (n = 3), beagle (n = 2), golden retriever (n = 2), miniature dachshund (n = 2), and one each of border collie, English bull dog, German shorthair pointer, mastiff, Staffordshire terrier and toy poodle. Tumors were located on the head for 7 dogs, trunk for 18 dogs, and limbs for 7 dogs (thoracic limb in 2 dogs and pelvic limb in 5 dogs). The tumor size was available in 20 dogs and the median size of the longest axis was 7.45 cm (range 1–31 cm). The duration of clinical signs, which was available for 28 dogs, ranged from 1 week to 4 years with a median of 1.5 months.Thirty two dogs were included in this study. Median age was 10 years (range 3.5–14 years) and median body weight was 25.0 kg (range 5.8–58 kg). Gender distribution included 20 spayed females and 12 castrated males. Breeds included Labrador retriever (n = 7). Mildly elevated blood urea nitrogen was noted in 1 dog and mild anemia was noted in 1 dog. Thoracic radiographs were performed in 24 cases and thoracic CT scans were performed in 5 cases. No pulmonary metastasis was noted in any dogs with thoracic imaging. Abdominal ultrasound was performed in 10 dogs. The abnormal findings included enlarged adrenal glands (n = 3), hyper- or hypo-echoic liver nodules (n = 2), splenic nodule (n = 2), renal cysts (n = 2), enlarged medial iliac lymph nodes (n = 2), and bilateral nephrocalcinosis (n = 1). Fine needle aspirations of enlarged medial iliac lymph nodes were performed, however, the samples were non-diagnostic in both dogs.Hematological and serum biochemical analysis were available in 30 dogs. Common abnormal clinicopathologic parameters included mild increased liver enzymes (All dogs received surgery. The median number of surgeries was 1 (range 1–5). A complete margin was achieved in 12 dogs, and 15 dogs had incomplete margins. Margin status was not reported in 5 dogs. Grades were available in 11 cases; of these, 4 tumors were classified as grade I, 2 tumors as grade II, 1 tumor as grade III, and 4 tumors as low grade. Mitotic counts were available in 29 cases; of these, 20 tumors had a mitotic count of less than 10/10 high-power fields (HPF), 3 tumors had 10–19/10 HPF, and 6 tumors had more than 19/10 HPF. There was no correlation between margin status and mitotic count , doxorubicin (n = 6), Palladia (n = 4), Mastinib (n = 2), Rapamycin (n = 1), and CCNU (n = 1). The median dose of cyclophosphamide was 15 mg/m2 once a day (range 8.4 to 25 mg/m2). Chlorambucil was given 0.1 mg/kg once a day, and 0.15 mg/kg once a day for each dog. Melphalan was given 0.076 mg/kg once a day. Doxorubicin was given 30 mg/m2 (> 10 kg dogs) or 1 mg/kg (< 10 kg dogs) once every 3 weeks. The median dose of Palladia was 2.4 mg/kg on Monday, Wednesday, and Friday (range 2.3 to 2.6 mg/kg). Mastinib was given 9 mg/kg every other day. Rapamycin was given 0.1 mg/kg on Monday, Wednesday, and Friday. CCNU was given 60 mg/m2 once every 3 weeks. Seven dogs received multiple chemotherapy drugs due to disease progression. The relationship between mitotic count and treatments are summarized in Table Nine dogs did not receive any treatment after surgery. Pre-operative radiation therapy was performed in one dog and intra-operative radiation therapy was done in one dog. Five dogs received post-operative radiation therapy, 8 dogs received post-operative chemotherapy, and 7 dogs received a combination of both. One dog received only a non-steroidal anti-inflammatory drug following surgery. Margin status for each group were summarized in Table Fifteen cases were censored; 8 dogs were lost to follow-up . Of these 8 dogs, 3 dogs had progressive disease at the time of last contact. This included metastasis to medial iliac lymph node at day 77, local recurrence and metastasis to sternal lymph node, aortic lymph node, lungs, and subcutaneous tissue at day 170, and local recurrence at day 566. Seven dogs were still alive at the time of data collection .p = 0.109) between these two median survival times. When comparing the use of adjuvant therapy, no significant difference was noted in the MST between dogs receiving no adjuvant therapy, chemotherapy alone, radiation therapy alone, or a combination of chemotherapy and radiation therapy . The MST of dogs with a tumor mitotic count < 10/10 HPF was 1393 days (range 20–2345 days). The dogs with a tumor mitotic count of 10 or greater/10 HPF had a MST of 433 days (range 169–831 days)  with the median time to recurrence of 115.5 days in this study. Two of these cases had complete surgical margins as assessed on histopathology. In the current study, 20% of myxosarcoma with mitotic count < 10/10 HPF recurred and 77.8% of the tumors with mitotic count ≥10/10 HPF had local recurrence. Reported median time to local recurrence ranges from approximately 6 months to 26 months when soft tissue sarcomas are treated with surgery, or combination of surgery, radiation therapy, and chemotherapy –32. It iEight dogs in this study developed metastatic disease with an overall metastatic rate of 25%. This study is a multi-institutional study and not all the patients were regularly screened for disease progression; thus this metastatic rate could be higher. In a previous study of 75 dogs with soft tissue sarcomas treated with surgery alone, the reported overall metastatic rate was 17% . While tNo significant difference was noted between survival times of dogs when separated out into treatment groups. The reason for this may be inherent clinician bias for treatment plans with no adjuvant treatment chosen mostly for dogs with lower mitotic count tumors and complete surgical margins. On the other hand, dogs with higher mitotic count tumors and/or incomplete surgical margins tended to have adjuvant treatments after the surgery.The limitations of the current study are inherent to its retrospective nature and small sample size. The initial staging tests were not completed in all cases. Histopathology reports for initial surgical procedures and previous treatment information before referral to a specialty hospital were missing for some cases. Necropsy data was available only one patient. Additionally this is a multi-institutional study; thus different pathologists read the histopathology, and treatment protocols varied and were dependent on multiple clinicians’ preferences.Myxosarcoma has been classified into the broad category of soft tissue sarcomas, and its clinical behavior in the past has not been separately evaluated. This study indicates that myxosarcoma may have a higher local recurrence rate and shorter time to recurrence even with adjuvant treatments. Additionally, the risk of metastasis to lymph nodes appears to be higher as compared to previous reports for soft tissue sarcomas as a whole.The medical records of dogs diagnosed with histologically confirmed myxosarcoma at five institutions  between June 2003 and January 2018 were retrospectively reviewed. The following data were retrieved from medical records: age, sex, breed, body weight at the first visit, blood work results, results of diagnostic staging tests, location and size of tumor, date of surgery, histopathology results, treatments after surgery, follow-up staging tests, date of local recurrence and metastasis, date and cause of death or euthanasia, and availability of necropsy findings. Anemia was graded by hematocrit . The elevation of liver enzyme was graded as mild if it was less than 5 times of upper reference range, moderate if it was 5–10 times of upper reference range, and markedly if it was more than 10 times of upper reference range.P value of < 0.05 was considered to be statistically significant. Commercially available software was used for all statistical calculations.1Overall survival time was defined as the time from the date of diagnosis to the date of death/euthanasia. Dogs that were still alive or lost to follow-up at the time of the analysis were censored from the overall survival analysis. The time to local recurrence was defined as the time from the date of surgery to the date of recurrence. Metastasis free interval was defined as the interval between surgery and evidence of metastasis. The Kaplan-Meier method was used to calculate median survival time. The Log rank test was used to investigate survival distribution between dogs with lower- and higher-mitotic count and dogs with different treatments. A


Clostridium difficile infection (CDI) in patients with underlying diseases is important because use of prophylactic antibiotics makes them prone to CDI. Epidemiology of CDI in this high-risk population is poorly understood. A study was conducted to evaluate the impact of CDI in patients with specific underlying co-morbidities.Surveillance of C. difficile toxin A and B assay by ELISA formed the basis of study. Patients with underlying diseases were classified based on the organ/kind of disease as pancreatic (n = 340), renal (n = 408), hepatic (n = 245), malignant (n = 517) and miscellaneous disease (n = 526). Laboratory records of clinical and demographic details were reviewed. The association of CDI with age, gender, antibiotic receipt, clinical symptoms and underlying co-morbidities was analyzed. Variation in CDI cases based on age groups was also investigated.A total of 2036 patients, whose fecal samples were processed for Clostridium difficile toxin positivity was 21.6% in general, whereas it was 30.6% in the pancreatic, 17.9% in the renal, 19.6%, in the hepatic, 21.3% in the malignancy and 20.0% in the miscellaneous disease groups. Toxin positivity was the lowest (14.8%) for female gender under renal disease and the highest (31.8%) for patients aged 40 to < 60 years, under pancreatic disease. Bloody diarrhea was a significant predictor for C. difficile toxin positivity. C. difficile toxin status irrespective to the underlying diseases was neither dependent on gender, age-groups or the number of antibiotics used. Association between patients’ gender, age and antibiotics receipt with underlying disease conditions, respective to C. difficile toxin status showed significance in relation to male gender (p < 0.05), age 40 to < 60 years (p = 0.03) and those receiving single (p = 0.09) or multiple antibiotics (p = 0.07).Pancreatic disease patients are at a higher risk for developing CDI, and particularly male gender, age 40 to < 60 years and those receiving antibiotics are at significant risk. Clostridium difficile is the causative microbe for almost all cases of pseudomembranous colitis and 15–25% of antibiotic associated diarrhea [C. difficile infection (CDI) has been increasing in occurrence and severity leading to considerable morbidity and mortality in hospitalized patients [C. difficile produces two potent toxins (A and B), which are responsible for the pathogenicity of the disease. Common clinical symptoms are fever, abdominal cramping, diarrhea with increased fecal leukocytes and resultant dehydration. CDI is a mounting public health challenge due to acquisition of the organism both nosocomially [comially  and fromcomially . VaishnaClostridium difficile infection is believed to be predominantly due to the broad-spectrum use of antimicrobials. Patients with underlying diseases generally receive prophylactic antibiotics, making them prone to acquire CDI. The epidemiology of CDI in this high-risk population is poorly understood. Due to global increase, the surveillance of CDI precipitated by underlying diseases is important as there is very little literature investigating the same. Early detection of patients with high CDI risk, particularly those with comorbidities, might help in the appropriate clinical management of the disease. In a recent study, the association of CDI in patients with inflammatory bowel diseases (IBD) was investigated to assess the role of IBD as a risk factor [k factor . HoweverAs this study was based on secondary data recorded in the laboratory on pre-printed proformae, informed consent from patients was not required. This project was cleared ethically by the Institute Ethical Committee, which operates according to the Declaration of Helsinki.C. difficile toxin assay, formed the basis of investigation. Samples were received in the Microbiology Division of the Department of Gastroenterology from October 2009 to September 2016. Fresh samples were processed daily as a matter of routine for CDI diagnostic purposes. However patients with IBD were analyzed earlier [This 2100 bedded tertiary care hospital is associated with premier medical institute of the country, known for medical education and research. This hospital caters to patients from large regions of North India inclusive of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir, and some parts of Uttar Pradesh and Rajasthan. Consecutive patients, whose fecal samples were received with specific request by the clinicians for Consecutive patients of age group more than 2 years and with different underlying diseases, except IBD were included in the study. Patients less than 2 years and pregnant women were excluded from the study.i.Pancreatic disease patients: This group comprised of 340 patients with pancreatic diseases, excluding pancreatic malignancy.ii.Renal disease patients: This group comprised of 408 patients with all kinds of renal diseases, including post-renal transplants. Renal malignancies were excluded from this group.iii.Hepatic disease patients: In this group 245 patients with all kinds of liver diseases except liver malignancies were included.iv.Malignancy group patients: A total of 517 patients with all kinds of malignancies inclusive of hematologic, pancreatic, renal and liver malignancies were included in this group.v.C. difficile toxin investigation. None of the patients in this group had IBD or any of the above mentioned co-morbidities.Miscellaneous disease patients: This group integrated 526 consecutive patients sent by the clinicians for During analysis, the patients were divided into the following groups based on their co-morbidities:C. difficile toxin status of the patient. Clinical symptoms suggestive of CDI, such as watery diarrhea, bloody diarrhea, presence of mucus in stool, abdominal pain, fever, frequency and duration of diarrhea were analyzed. Patient demographics, pertinent clinical aspects, diagnosis, therapy, antibiotic exposure and hospitalizations were taken into consideration along with the data of fecal C. difficile toxin A and B assay carried out as described earlier [C. difficile toxins A and B respectively. An aliquot of fecal suspension was added to the wells and incubated; the non-bound material was removed by washing the wells three times with wash buffer. Another incubation was carried out with biotinylated polyclonal anti-toxin A and monoclonal anti-toxin B antibodies. Non-bound material was again removed by a washing step. During the next incubation period horseradish peroxidase-conjugated streptavidin was added which reacted with the bound biotinylated antibodies. Unbound conjugate was removed by a washing step and the reaction was terminated by sulfuric acid dispensed into the wells. The intensity of the developed color, which was directly proportional to the specifically bound amount of C. difficile toxin A and B, was measured in an ELISA reader  at 450 nm. After consideration of the cut-off value, results were interpreted as positive or negative.Laboratory data of all the included eligible patients using pre-designed specific data-format, maintained in the Department, were reviewed. The primary and secondary outcome was based on the  earlier  using ELC. difficile toxin status with underlying disease were shown by “n” and percent (%) and their association was tested using Chi-square test statistics. When required, post hoc analysis based on Chi-square test was also performed. The distribution of underlying co-morbidities were summarized and similarly tested. If the association between the above said cases turned out to be significant, then association profiling was done by stratification of the data based on patients’ characteristics, antibiotic used, and clinical symptoms. Association of CDI was obtained in percent (%).The data were entered in MS Excel 2007 on 32-bit Microsoft Window Operating system and analysis was performed on R-Gui Version 3.4 statistical software on the same machine. Kruskal–Wallis and Chi-square test were employed for comparative analysis of the different groups. The Chi-square statistical test was based on p-value less than or equal to 0.05 criteria. Distributions of C. difficile toxin assay. The study retrospectively looked if specific underlying diseases had any bearing on C. difficile toxin positivity. We thus accessed 2036 patients’ record data scrutinized on the basis of eligibility criteria. CDI was positive in 440 (21.6%) of the 2036 samples tested. Statistically adequate sample power was provided by this large number of patients available and even disease-wise the sample size is ≥ 245. Estimation of sample size was also done considering the association of 50%, 10% error and 95% CI and adjusted for design effect. The estimated sample size thus obtained for this extreme condition is 192. Therapies received by the patients were also reviewed.During the study period of 7 years, 307,299 patients were admitted to the various wards of the hospital. Of these stool samples from patients suspected to have CDI by the treating team were sent to our laboratory for n = 107), penicillins (n = 88), carbapenems (n = 87), fluoroquinolones (n = 24), cephalosporins (n = 22), polymyxins (n = 11), aminoglycosides (n = 10), oxazolidinones (n = 8) and lincosamides (n = 6). Antifungals and proton pump inhibitors (PPI) were received by 5 each of the patients. However no patient received any form of immunosuppressant drugs or steroid treatment.Of the 340 pancreatic disease patients analyzed in the study, 232 (68.2%) were males and 108 (31.8%) females. The age range of the patients was 10–85 years (mean ± SD: 41 ± 14). There were 327 (96.2%) hospitalized patients, 6 (1.8%) outpatients and 7 (2.0%) patients with hospitalization status unknown. Major antibiotics received by these patients were nitroimidazoles  the age ranged from 9 to 83 years (mean ± SD: 45 ± 14). There were 233 (95%) hospitalized patients, 6 (2.5%) outpatients and 6 (2.5%) patients whose hospitalization status was not known. Major antibiotics received by these patients were penicillins (n = 35), cephalosporins (n = 19), nitroimidazoles (n = 17), polymyxins (n = 11), carbapenems (n = 10), fluoroquinolones (n = 9), oxazolidinones (n = 2) and lincosamides (n = 2). Ten patients received PPI and 4 received immunosuppressants. But no patient received any form of steroid treatment.In the patients with liver diseases  the age ranged from 10 to 90 years (mean ± SD: 42 ± 16). There were 318 (77.9%) hospitalized patients, 73 (17.9%) outpatients and 17 (4.2%) patients with unknown hospitalization status. Major antibiotic received by these patients were penicillins (n = 107), nitroimidazoles (n = 98), fluoroquinolones (n = 79), glycopeptides (n = 44), cephalosporins (n = 39), carbapenems (n = 29), aminoglycosides (n = 8), lincosamides and polymyxins (n = 5 each) and oxazolidinones (n = 2). Patients receiving antifungals were 3, antivirals 2 and antiprotozoal 1. Immunosuppressants were received by 19 and steroid treatment by 9 of the patients.In the patients with renal disorders  the age ranged from 3 to 86 years (mean ± SD: 34 ± 23). There were 487 (94.2%) hospitalized patients, 20 (3.9%) outpatients and 10 (1.9%) patients with hospitalization status unknown. Major antibiotics received by these patients were carbapenems (n = 42), cephalosporins (n = 38), glycopeptides (n = 24), penicillins (n = 22), nitroimidazoles (n = 16), fluoroquinolones and aminoglycosides (n = 13 each), polymyxins (n = 10), oxazolidinones and lincosamides (n = 2 each). Antifungals were received by 5, antiviral by 13, steroids by 7 and immunosuppressant by a lone patient.In the patients with malignancies (n = 55), glycopeptides (n = 53), nitroimidazole (n = 51), cephalosporins (n = 49), fluoroquinolones (n = 26), carbapenems (n = 18), aminoglycosides (n = 16), lincosamides and polymyxins (n = 4) and oxazolidinones (n = 3). Other drugs received by the patients were antifungals (n = 8), antivirals (n = 16), antiprotozoals (n = 2), PPI (n = 45), steroids (n = 38) and immunosuppressants (n = 16).There were 526 patients (M:F 325:201) who did not have IBD or any other above grouped co-morbidities. The age of the patients ranged from 3 to 103 years (mean ± SD: 41 ± 19). There were 432 (82.2%) hospitalized patients, 77 (14.6%) out patients and 17 (3.2%) patients with hospitalization status unknown. Major antibiotic received by these patients were penicillins  and 1.91 . In addition bloody diarrhea is also reported significant  irrespective to underlying diseases condition.We have also performed the logistic regression analysis to cross check and the result is not different as explained through stratified tabular results. Logistic regression with C. difficile toxin status and underlying disease conditions, irrespective to all observed factors is depicted in Table C. difficile toxin status and further post hoc analysis showed that pancreatic disease group was significant (p < 0.05) in association with the other underlying disease conditions. To comprehend the variation based on age groups, the patients were divided into four groups i.e. (i) < 20 years (ii) 20 to < 40 years (iii) 40 to < 60 years (iv) 60 years and above. Association of C. difficile toxin status with gender, age groups and antibiotic receipt, irrespective to underlying disease conditions , hepatic disorders (18.5%) and cancers (17.6%). In the present study C. difficile toxin status irrespective to the underlying diseases was neither dependent on gender, age-group or the number of antibiotics used.In general, male gender was found to be strongly associated with various underlying diseases compared to females. i et al.  found thC. difficile toxin status showed significance in relation to male gender (p < 0.05), in age 40 to < 60 years (p = 0.03) and receipt of single (p = 0.09) and multiple antibiotics (p = 0.07).The association of CDI based on 2036 patients’ data was computed 21.6% which is not the correct representation because the distribution of CDI prevalence depends on the underlying co-morbidities of the patients. The association of CDI stratified based on the underlying disease condition and further based on gender, age-groups and the number of antibiotics used showed highest association (30.6%) in pancreatic disease group and lowest in the renal disease group (17.9%). It was thus clear that pancreatic disease condition is a risk factor for CDI as compared to other underlying diseases. Similar condition was noted for association of CDI for pancreatic disease group when stratified by patients’ clinical symptoms. Association between patients’ gender, age and antibiotics received with underlying diseases condition, respective to Clostridium difficile infection is commonly reported as nosocomial [C. difficile toxin was positive in 19.6% of the hepatic patients and the use of antibiotics in this group was found to be highly significant compared to the control miscellaneous disease group.socomial  and commsocomial  with 22%socomial . The Cansocomial . Musa etsocomial  reportedsocomial  observedC. difficile toxin was positive in 17.9% of them and the duration of diarrhea was also significant compared to other co-morbid groups, except the miscellaneous disease group which was similar to the renal group.Keven et al.  in a 4 yC. difficile toxin positivity (30.6%) in the pancreatic disease group was found to be highly significant compared to all the other specific groups  as well as the control patients. The use of antibiotics was also found to be significant in the pancreatic disease patients compared to those in the renal disease group and the control miscellaneous disease patients.There is hardly any literature available relating CDI with pancreatic diseases. In the present study, C. difficile toxin positivity status.Patients with hematological malignancies , 24, 25,Antibiotics have been established as a risk factor for development of CDI , 32. BajC. difficile [Reduced gastric acid due to PPI use leads to survival of any ingested ifficile –37. Aparifficile . One stuifficile . Daniel ifficile  reportedImmunosuppressant medication is often required in certain patients with underlying diseases and is an important risk factor for CDI . In the The high association of CDI thus reported in patients with various underlying diseases, particularly the pancreatic group followed by malignancy group, and the considerable rate of severe cases, signifies the requirement for precautionary policies, such as antimicrobial stewardship programs, strict compliance with hand hygiene and environmental decontamination particularly involving this patient group. But despite the routine steps being taken to curb infection with a Hospital Infection Control Committee to constantly check the compliance, actually no decrease in the cases of CDI has been noted. Various factors may account for this. Our institute is a tertiary care hospital catering to the people of the northern region of India, inclusive of Chandigarh, Punjab, Haryana, Himachal Pradesh, Jammu and Kashmir, western parts of Uttar Pradesh and some parts of Rajasthan. Thus patients are referred from other lower centers where implementation of infection surveillance is not available. These patients are on antibiotics previously by the time they reach our hospital. Because of uncontrolled use of antibiotics, the difficulty in controlling antibiotic resistance occurs, despite adequate care being taken in our hospital.C. difficile organisms transiently present in other hospitalized individuals with no CDI, and thus lead to wrong CDI diagnosis.The strength of this study is that this is the first analysis of its kind investigating CDI in underlying disease patients. However there are some limitations of this study. Firstly, the use of ELISA has its own limitations in detecting the toxins, but this method is widely used the world over. Moreover the kits we used had sensitivity up to 98% and specificity up to 92% and the assay was performed by a dedicated trained medical technician and therefore was largely reliable. Though molecular tests can also detect and confirm cases, the use of polymerase chain reaction to detect toxin A or toxin B genes has a potential for false positive results, given its high sensitivity, as PCR will detect even low number of C. difficile toxin assay. If it was surveillance or screening for C. difficile toxin, then the total number of patients with different diseases would be important. But this would have also resulted in tremendous cost to the hospital, which was not feasible in a low budget country.Secondly, of all the admitted patients, we had access to only those referred to us for Thirdly, the cases were not classified according to severity as the data assessment was limited to laboratory details of the patients without access to details on further clinical complications. Thus we had no access to the mortality rate data also. Some data of the patients’ prescriptions could also have been lost due to some likely incomplete records. But, as it is a tertiary care hospital, every effort is routinely made to maintain the demographic and clinical records for future use. However, as this is a preliminary study, further study based on severity classification will be carried out for individual group of diseases.C. difficile toxin positivity. Among the underlying diseases, pancreatic disease patients are the most susceptible to CDI compared to those with non-pancreatic diseases in our setting. Male gender, age 40 to < 60 years and those patients receiving antibiotics were also more prone to CDI. However, further studies are required to investigate the association of CDI in underlying diseases within the groups analyzed due to their complex pathophysiology.The study looked retrospectively if specific underlying diseases had any bearing on


Background: Star fruit (SF) is a popular fruit, commonly cultivated in many tropical countries, that contains large amount of oxalate. Acute oxalate nephropathy and direct renal tubular damage through release of free radicals are the main mechanisms involved in SF-induced acute kidney injury (AKI). The aim of this study was to evaluate the protective effect of N-acetylcysteine (NAC) on SF-induced nephrotoxicity due to its potent antioxidant effect.Materials and methods: Male Wistar rats received SF juice (4 mL/100 g body weight) by gavage after a 12 h fasting and water deprivation. Fasting and water deprivation continued for 6 h thereafter to warrant juice absorption. Thereafter, animals were allocated to three experimental groups: SF (n = 6): received tap water; SF + NAC (n = 6): received NAC (4.8 g/L) in drinking water for 48 h after gavage; and Sham (n = 6): no interventions. After 48 h, inulin clearance studies were performed to determine glomerular filtration rate. In a second series of experiment, rats were housed in metabolic cages for additional assessments.Results: SF rats showed markedly reduced inulin clearance associated with hyperoxaluria, renal tubular damage, increased oxidative stress and inflammation. NAC treatment ameliorated all these alterations. Under polarized light microscopy, SF rats exhibited intense calcium oxalate birefringence crystals deposition, dilation of renal tubules and tubular epithelial degeneration, which were attenuate by NAC therapy.Conclusions: Our data show that therapeutic NAC attenuates renal dysfunction in a model of acute oxalate nephropathy following SF ingestion by reducing oxidative stress, oxaluria, and inflammation. This might represent a novel indication of NAC for the treatment of SF-induced AKI. Oxalidaceae family and can be classified into two categories: the sour type—richly flavored, commonly prepared as juice and with more oxalic acid; and the sweet type—mild flavored, usually consumed as fresh fruit and with less oxalic acid.Star fruit (SF) (Averrhoa carambola) is an attractive and popular fruit originated from Asia and cultivated throughout many tropical and subtropical zones. It is a member of the ,Since the neurotoxic effect of SF was first reported in 1980,,,In the past 15 years, SF nephrotoxicity has been described in several patients with normal renal function.N-acetylcysteine (NAC) is a pharmaceutical drug and nutritional supplement largely used as a mucolytic agent, in the management of paracetamol (acetaminophen) overdose and in the prevention of radiocontrast-induced nephropathy. NAC is an antioxidant thiol that can enter to the chain of glutathione synthesis and serves as a source of sulfhydryl groups for the cells, acting as a scavenger of reactive oxygen species (ROS).ad libitum. Room temperature was maintained at 23 °C. The study protocol was reviewed and approved by the local institutional ethics committee.The study was performed using adult male Wistar rats weighing between 230 and 400 g, obtained from the animal facilities of the University of São Paulo School of Medicine. Animals were housed under standard laboratory conditions, kept on a 12 h light/dark schedules and provided with food and water n = 6), fed with tap water; SF + NAC group (n = 6), treated with NAC (4.8 g/L) in drinking water; and Sham (n = 6): subjected to no interventions. After 48 h, inulin clearance studies were performed to determine renal function (glomerular filtration rate—GFR).After a 12 h overnight fasting and water deprivation, star fruit juice was administered via a metal oral-gastric tube at a dose of 4 mL/100 g body weight (BW). Fast and water deprivation were continued for another 6 h to warrant juice absorption. Thereafter, rats were allocated to three experimental groups: SF , and serum reduced glutathione (GSH). Serum TBARS and GSH were evaluated at 24 and 48 h after SF administration, using blood samples obtained from tail vein. On the day of the experiment, animals were anesthetized intraperitoneally with sodium thiopental (50 mg/kg BW). Trachea was cannulated with a PE-240 catheter, and spontaneous breathing was maintained. To control mean arterial pressure and allow blood sampling, a PE-60 catheter was inserted into the right carotid artery. For the infusion of inulin and fluids, another PE-60 catheter was inserted into the left jugular vein. In order to collect urine samples, a suprapubic incision was made, and the urinary bladder was cannulated with a PE-240 catheter. After the surgical procedure was completed, a loading dose of inulin  was administered through the jugular vein. Subsequently, a constant infusion of inulin  was started and was continued at 0.04 mL/minute throughout the experiment. Three urine and two blood samples were obtained during the experiment. Blood and urine inulin were determined using the anthrone method. GFR are expressed as mL/min/100 g BW.At the end of the inulin clearance studies, the kidneys were perfused with PBS solution . For histological examination, right kidney was dissected out, cleaned of connective tissue and a fragment was fixed in 10% neutral-buffered formalin solution. The kidney block was dehydrated in graded alcohol, embedded in paraffin, and cut at 4 μm sections.Plasma and urinary sodium and potassium were measured by flame photometry . The fractional excretion of sodium (FENa) and potassium (FEK) were calculated using the following formula:−1 cm −1.Serum levels of TBARS, which are markers of lipid peroxidation, were determined using the thiobarbituric acid assay. In brief, a 0.2 mL serum or urinary sample was diluted in 0.8 mL of distilled water. Immediately, 1 mL of 17.5% trichloroacetic acid was added. Following the addition of 1 mL of 0.6% thiobarbituric acid, pH 2, the sample was placed in a boiling water bath for 15 min, after which it was allowed to cool. Subsequently, 1 mL of 70% trichloroacetic acid was added, and the mixture was incubated for 20 min. The sample was then centrifuged for 15 min at 2000 rpm. The optical density of the supernatant was read at 534 nm against a reagent blank using a spectrophotometer. The quantity of TBARS was calculated using a molar extinction coefficient of 1.56 × 105 MReduced GSH, the major endogenous antioxidant in cells, was determined in total blood by the method of Sedlak and Lindsay.Urinary oxalate was measured by and enzymatic method using a kit provided by Trinity Biotech .2 were evaluated by graded scores according to the following criteria: (0), less than 5% of the field showing tubular epithelial swelling, vacuolar degeneration, necrosis, and desquamation; (I), 5–25% of the field presenting renal lesions; (II), involvement of 25–50% with renal damage; (III), 50–75% of damaged area; and (IV), more that 75% of the grid field presenting renal lesions. The morphometric examination was blinded to minimize observer bias, i.e., the observer was unaware of the treatment group from which the tissue originated. The mean score for each rat and the mean score for each group were calculated.Four micromiters histological sections of renal tissue were stained with hematoxylin-eosin and examined under light microscopy and polarized light microscopy. For the evaluation of renal damage, 40–60 grid fields (×400 magnification) measuring 0.245 mmx is the number of glomeruli in each grade of glomerulosclerosis.Hematoxylin-eosin stained sections were evaluated using a light microscope (×400 magnification). One hundred glomeruli per section were randomly selected and assessed by an investigator, who was blind to treatment groups. The degree of glomerular damage was evaluated according to a semi-quantitative scoring method: grade 0, normal glomeruli; grade 1, sclerotic area up to 25% ; grade 2, sclerotic area 25–50% (moderate sclerosis); grade 3, sclerotic area 50–75% (moderate-severe sclerosis); grade 4, sclerotic area 75–100% (severe sclerosis). The glomerulosclerotic index (GSI) was calculated as follows: GSI = (1 × n1)  + (2 × n2) + (3 × n3) + (4 × n4)/n0 + n1 + n2 + n3 + n4, where n2 field or per glomerulus and averaging the number of cells respectively per field or per glomerulus.We subjected 4-μ kidney tissue sections to immunohistochemical reaction using monoclonal antibody anti-CD68 (1:100 for 60 min at 20 °C) . Reaction products were detected by an avidin–biotin-peroxidase complex , and the color reaction was developed with 3,3-diaminobenzidine  in the presence of hydrogen peroxide. The sections were counterstained with the Harris hematoxylin. Using a computer coupled to a microscope  and a digital camera, we analyzed 30 renal cortex fields and 100 glomeruli, respectively, for assessments of interstitial and glomerular macrophage infiltration. The results of the immunoreactions were quantified by counting the number of positive cells per 0.087 mmTo evaluate the calcium oxalate deposition throughout the kidney samples, volume ratios of positive areas of renal tissue (%), determined by color difference of deposited crystals, were obtained by image analysis with the program Image-Pro Plus, version 4.1  on a computer coupled to a polarized light microscope and a digital camera.p < .05 were considered statistically significant. Data were analyzed using GraphPad Prism software 5.0 .All quantitative data were expressed as mean ± SEM. Differences among the means of multiple parameters were analyzed by one-way analysis of variance followed by the Student–Newman–Keuls test. Values of p = .4). No abnormal movements were observed after receiving SF juice. No rat from both groups died before being sacrificed after inulin experiments.To evaluate the efficacy of NAC therapy on SF-induced AKI, GFR was assessed by inulin clearance studies. Animals from the SF group showed markedly lower inulin clearance compared to the Sham rats. In contrast, SF + NAC group attenuated renal function deterioration following SF juice administration . There wTo determine whether the potent antioxidant effect of NAC could be the main factor involved in renal protection in the current experimental model, we assessed the serum TBARS (a byproduct of lipid peroxidation) and reduced GSH (a major endogenous antioxidant). Animals from the SF group exhibited significant increase in the plasma TBARS levels at 24 h after SF administration compared to Sham animals. NAC-treatment significantly reduced plasma TBARS levels, suggesting an improvement in the systemic oxidative stress conferred by NAC following SF-induced AKI. We found similar results, when TBARS was evaluated 48 h after SF administration. Accordingly, serum reduced GSH was lower in the SF rats compared to SF + NAC and Sham groups at 24 h and 48 h after SF juice administration. Animals from the SF group exhibited lower plasma sodium and potassium as compared with the SF + NAC and Sham groups. Fractional excretion of sodium (FENa) was higher in the animals that received SF juice compared to Sham. In addition, fractional excretion of potassium (FEK) was higher in the animals from the SF group compared to Sham rats. NAC-treatment reduced the potassium excretion in this animal model. We also assessed the urinary potassium/sodium ratio (UK/Na), a simple way to estimate potassium secretion in the distal tubules. According to the previous results, UK/Na was significantly higher in the SF group compared to Sham and SF + NAC groups. p < .001 versus SF group and p = NS versus SF + NAC.SF rats exhibit higher urinary oxalate excretion, which was normalized by NAC treatment, as illustrated in Renal histology showed acute tubular necrosis with tubular epithelium degeneration and flattening and intense dilatation of renal tubules in the SF group . Tubular+ (macrophages) cells in the SF group compared to Sham. Macrophage infiltration was significantly lower in the NAC-treated rats . SF animals exhibited a discrete overall increase in the degree of glomerulosclerosis compared to other groups . Moreoveted rats . Similarted rats .,,Since the first cases of SF nephrotoxicity have been reported,,In the present study, the rationale of using 4 mL/100 g BW of SF juice was based on a previous experimental model of oxalate nephropathy described by Fang et al.In vitro exposure of epithelial cells to oxalate leads to a dose-dependent severity of apoptosis.,Traditionally, acute oxalate nephropathy has been described secondary to substantial vitamin C ingestion, ethylene glycol intoxication and methoxyflurane anesthesia.Several studies have validate the FENa as a pivotal diagnostic tool in the AKI setting.− reabsorption with consequent tubular oxalate secretion along the nephron .,− delivery to the distal nephron and, consequently, increased chloride-oxalate exchange. In NAC-treated rats, more intact proximal tubules might be associated with lower Cl− delivery to the distal nephron, thus contributing to the lower oxaluria in the current experimental model. In addition, it has been demonstrated that damaged renal tubular cells can lead to tubular “back leak”,Regarding the protective effect of NAC reducing oxaluria, we found similar results compared with the study performed by Bijarnia et al.,We also showed a profound deposition of oxalate crystals in dilated renal tubules in the SF group. Thus, the lower urinary output encountered in the SF group might be due to the reduction in GFR associated with renal tubules obstruction by oxalate crystals. We believe that NAC treatment ameliorated AKI associated with CaOx crystals deposition and, consequently, renal tubular and glomerular injury. We showed more intense renal tubular lesion compared to the glomerular damage. In summary, we hypothesize that the reduction in GFR found in our study was mainly secondary to: (1) tubular obstruction due to CaOx crystals; (2) tubuloglomerular feedback, in which the higher distal tubular sodium chloride delivery leads to a reduction in GFR through a macula densa signaling; and (3) glomerulosclerosis.,Umekawa et al. have recently reported increased expression of monocyte chemoattractant protein-1 (MCP-1) following exposure of renal cells to CaOx-containing medium.Previous study using an animal model of acute oxalate nephropathy reported that NAC administration reduced calcium oxalate crystals in the urine.However, plasma oxalate levels occur at concentrations 100-fold less than urine, so detection itself can be difficult and a huge variation on the reported normal range of plasma has been described.In conclusion, our data show that NAC therapy attenuates renal dysfunction in a model of acute oxalate nephropathy following SF ingestion by reducing oxidative stress, decreasing oxaluria and inflammation. The present findings warrant further investigation regarding the beneficial effects of NAC in acute oxalate nephropathy or other hyperoxaluric conditions, given it is a low-cost and high safety profile medication.


Objective: The aim of this study is to investigate the role of prophylactic anticoagulation regimens based on low molecular weight heparin (LMWH) or aspirin in thromboembolic events in patients with primary membranous nephropathy (PMN).Methods: A total of 717 patients with PMN were consecutively enrolled in this retrospective study. The propensity score matching method was utilized to adjust for the selection bias inherent in an analysis of outcomes, which was stratified by the anticoagulation prophylaxis regimen.Results: According to the anticoagulation prophylaxis regimen, patients were assigned into three groups: only LMWH therapy , only aspirin therapy , and no therapy of LMWH or aspirin . After performing 1:1 match, 37 patients were selected in the L + A − group and the L − A− group, respectively, and 94 patients were selected in the L − A+ group and the L − A− group, respectively. It showed that the prophylactic use of LMWH had no protective effects on arterial thromboembolic events (ATEs)  or venous thromboembolic events (VTEs) . The incidence of VTEs in the L − A+ group was lower than the L − A− group , while there were no significant differences in the incidences of ATEs between the L − A+ group and the L − A− group .Conclusions: The prophylactic use of LMWH showed no benefits on the incidence of ATEs or VTEs in patients with PMN. Aspirin effectively decreased the incidence of VTEs, without effects on the occurrence of ATEs. Primary membranous nephropathy (PMN) is associated with high risks of thromboembolism events, both arterial thromboembolic events (ATEs) and venous thromboembolic events (VTEs) . ATEs maTherefore, the aim of this study was to investigate the role of prophylactic anticoagulation regimens based on low molecular weight heparin (LMWH) or aspirin in thromboembolism events in patients with PMN. To our knowledge, this is the first study about anticoagulation prophylaxis in PMN.We retrospectively enrolled patients pathologically diagnosed as PMN by renal biopsy from January 2004 to June 2016 at the Peking Union Medical College Hospital. The exclusion criteria were (1) patients with malignant tumors, autoimmune diseases, serious mental diseases and hematological diseases; (2) patients with comorbidity of other pathological types of glomerular diseases; (3) patients who presented with arterial or venous thrombotic events at the time of diagnosis of PMN. This study was approved by the ethics committee of the Peking Union Medical College Hospital (No. S-K120).Clinical characteristics at the time of biopsy were collected, including gender, age, duration of the disease, history of smoking, history of diabetes, hypertension, and previous onset of ATEs, proteinuria (24 h-UP), serum albumin, serum creatinine, total cholesterol, triglycerides, and low density lipoprotein-cholesterol (LDL-C). The estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula . Prophylt-test, the Mann–Whitney U test, the Kruskal–Wallis test, or univariate ANOVA, depending on the normality of the data and levels of the outcome variable. Categorical variables were presented with percentages, and the differences were compared using chi-square test or Fisher’s test. Propensity score matching method was utilized to adjust for the selection bias inherent in an analysis of outcomes, which was stratified by the anticoagulation prophylaxis regimen. The following variables were selected to calculate the propensity score: age, sex, history of smoking, history of diabetes, hypertension, and previous onset of ATEs, proteinuria, serum albumin, cholesterol, and low density lipoprotein–cholesterol (LDL-C). In our propensity analyses, a 1:1 matching ratio was used. Subsequently, covariate balance between the matched groups was examined.Statistical analysis was performed by SPSS . Continuous variables were presented as mean ± SD or median with interquartile ranges (IQR), and the differences were evaluated by the Student n = 26, 55%) and IS .A total of 749 patients were pathologically diagnosed as PMN by renal biopsy from January 2004 to June 2016 at Peking Union Medical College Hospital. Thirty-two patients who presented with an arterial or venous thrombotic event at the time of diagnosis of PMN were excluded. Finally, 717 patients  were enrolled in the study. The mean age was 47.4 ± 14.8 years. Median observation period was 39.5  months. 84 patients (11.7%) experienced thromboembolic events during the observation period, of whom 47 had ATEs and 37 had VTEs. ATEs were consisted of CHD (n = 53), only aspirin therapy , and no therapy of LMWH or aspirin . Patients in the L + A − group were received LMWH 4000–6000 IU by subcutaneous injections, and then switched to warfarin therapy or not. For patients who were switched to warfarin, aiming to an international normalized ratio (INR) of 1.8–2.5. Patients in L − A+ group were received aspirin treatment with 75 mg or 100 mg daily. Baseline data showed that serum albumin level was the highest in the L − A− group (27.8 ± 6.5 g/L), while patients who had ever been received therapy of LMWH (L + A − group) had the relative lower serum albumin levels (22.0 ± 6.6 g/L)  .p = .21; 8.1% vs. 10.8%, p = .69)  .p = .02), while incidences of ATEs had no significant differences between the two groups   .Studies about prophylactic anticoagulation regimens with LMWH or aspirin in thromboembolism events were mainly in patients with tumors, surgical patients, and hospitalized internal patients . In nephp < .001), and hypoalbuminemia was the dominant independent risk factor for VTEs (p < .03). The propensity matching analyses in our present study showed that the prophylactic use of LMWH had no benefits on thromboembolic events in patients aged 49.2 ± 14.9 years and with the serum albumin level of 22.4 ± 6.4 g/L; in patients aged 52.3 ± 13.4 years and with the serum albumin level of 27.1 ± 5.8 g/L, the prophylactic use of aspirin decreased the incidence of VTEs, but had no effect on the incidence of ATEs.Our previous study  with theThromboembolism is one of the common complications of NS, especially in membranous nephropathy. However, the appropriate prophylactic anticoagulation treatment is still controversial . The 201There was a research constructing a Markov decision model from an inception cohort of 898 patients with PMN, evaluating the potential benefits of prophylactic anticoagulation (venous thromboembolic events prevented) relative to the risks (major bleeds), and then providing an approach to the decision of prophylactic anticoagulation personalized to the individual’s needs . BenefitOur study showed that, in patients aged 49.2 ± 14.9 years and presented with the serum albumin level of 22.4 ± 6.4 g/L, the prophylactic use of LMWH had no benefits on the ATEs or VTEs. This conclusion was not accordant with previous studies, which may be related to the following limitations: (1) patients with asymptomatic VTEs without routinely follow up, and patients with mild symptoms of ATEs were ignored; (2) the relative small sample size. After performing 1:1 matching, there were only 37 patients in L + A − group and L − A− group, respectively. (3) Variable usage of LMWH and warfarin, including dosage, course, and the maintenance.http://my.americanheart.org/cvriskcalculator   [The antiplatelet agent aspirin usage is associated with an increased risk of gastrointestinal bleeding . Guidelidence A) .Patients with PMN are also at high risk of cardiovascular events . We firsIn nephrotic syndrome, platelet hyperaggregability and platelet dysfunction were observed ,22. ClinHowever, there are several limitations in our study. It is a retrospective study, and the data of hemorrhagic complications is lacked. The anticoagulation prophylaxis regimens were not rigorously administrated. In summary, this study showed that, the prophylactic use of aspirin decreased the incidence of VTEs, but had no effects on the incidence of ATEs; LMWH had no benefits on the thromboembolic events. It provides valuable clinical evidence through a single center’s experience, but the limitations should also be recognized. Prophylactic anticoagulant therapy is still a clinical conundrum in nephrotic syndrome, and well-designed multi-center prospective studies were further needed.


Intravenous drug infusions in critically ill patients require accurate syringe infusion pumps (SIPs). This is particularly important during transportation of critically ill patients by helicopter emergency medical services (HEMS), where altitude may influence device performance. Because weight is a real concern in HEMS, new low-weight devices are very appealing.The aim of this study was to compare infusion flow rates delivered by low-weight versus standard SIP devices, in the prehospital emergency medicine setting, at different altitudes.We conducted a comparative bench study involving five SIP devices (two standard and three low-weight models) at 300, 1700 and 3000 m altitude. The primary endpoint was the flow rate delivered by SIPs for prespecified values. We used two methods to measure flow. The normative method consisted in measuring weight (method A) and the alternate method consisted in measuring instantaneous flow (method B).p for interaction< 0.001).Using method A, no significant differences were found in median flow rates and interquartile range depending on device and altitude for a prespecified 10-mL/h flow. However, method B showed that low-weight SIPs delivered multiple sequential boluses with substantial variations (1.2–15.8 mL/h) rather than a prespecified continuous 5-mL/h flow. At 1700 m altitude, the interquartile range of delivered flows increased only for low-weight devices (Despite satisfactory normative tests, low-weight SIPs deliver discontinuous flow with potential clinical implications for critically ill patients receiving vasoactive drugs. This study also highlights a thus far unknown negative impact of altitude on SIP function. We believe that normative requirements for SIP approval should be revised accordingly. Transporting critically ill patients by the air may greatly benefit patients by increasing rapid access to an adapted medical facility . Even ththe some extreme conditions related to the prehospital transportation, whenever possible meeting specific needs in terms of low weight, size and resistance.These devices have undergone high-level technological development. They allow constant delivery of flow in intravenous circulation by adapting the pushing power delivered into the syringe to the flow resistance in infusion lines  and to intravascular pressure prevailing at the injection site. They are part of the usual medical equipment for prehospital medical management of patients in a critical condition, in countries with physician-staffed services using ground ambulances, air ambulances or helicopter emergency medical services (HEMS), and for those with medical mountain rescue services. However, these devices must be adapted to A low-weight SIP model (0.22 kg), Micropump™ , which is ten times lighter than standard models, has been developed. Its low weight is highly advantageous, particularly for mountain rescue and HEMS. As for any electrical medical equipment, this device complies with the IEC 60601-2-24  standardThe aim of this study was to compare infusion flow delivered by low-weight versus standard SIP models, at different altitudes. We hypothesized that the flow delivered by SIPs differed depending on the model and altitude.We conducted an experimental, prospective and comparative bench study from February to April 2015 at Grenoble-Alps University Hospital , at the mountain rescue medical basecamp of l’Alpe d’Huez at 1700 m altitude and at the top of l’Alpe d’Huez ski resort . No institutional review board approval was required because neither patients nor volunteers were involved. Three Micropump models , one Agilia Injectomat® , and one DPS Orchestra®  were tested , which measures instantaneous flow rates (100 measures per second). It also calculates overshoot and possible boluses over the range. We took measurements over 2 h for two Micrel Micropump™ models and the two standard models (Agilia Injectomat® and DPS Orchestra®), with an infusion flow rate set at 5 mL/h, at 300 m and 1700 m, at 22 °C (71.6 °F). A sample of 1200 measurements was extracted during the 2nd h of infusion at steady state.For both methods, the test bed consisted of a half-filled 50-mL syringe ®, Franckin Lakes, NJ, USA), positioned in the SIP; an infusion line: Injectomat Line  connected to an 18-G catheter at the same height as the syringe’s outlet.For method A (weight method), catheters were placed directly in the measuring tubes. For method B (automatic flow), the circuit crossed the flow meter.®, Albuquerque, New Mexico, USA).For method A, the volumes delivered were weighed with a precision scale and entered into a Microsoft Excel spreadsheet ; cycle time (defined as the time between the beginning of a cycle and the beginning of the next one), representing the mean time between two modifications (increase/decrease/stop/start) of the flow detected by the flowmeter; maximum flow value exceeding the target set (expressed as a percentage of the target set) and calculated bolus volume (defined as the maximum overshoot “exceeding the set” during the infusion) were collected and processed using MATLAB® v R2014b software .Continuous variables with highly skewed distributions were reported as median along with 25th–75th percentiles and range . We performed median  and interquartile  regressions to examine whether median flow infusion rates and interquartile range differed depending on SIP device and altitude (300 versus 1700 m), respectively. A first-order interaction term was tested for statistical significance to examine whether the accuracy of the devices varied for the different altitudes.P-values less than 0.05 were considered statistically significant. All analyses were performed using Stata SE version 14.0 .Two-sided p = 0.83 and p = 0.27, respectively) and altitude . No significant first-order interaction was observed between devices and altitude levels for median flow rates (p = 0.32) and interquartile range (p = 0.66). There was no difference between devices when comparing median flow and interquartile range at 300 m (p = 0.25) or 1700 m (p = 0.16), as shown in Table For prespecified flow rate set at 10 mL/h , and for the Agilia Injectomat® .At 1700 m only, median flow was outside the specified variability range  for the DPS Orchestra® (9.66 ml/h).At 3000 m, due to poor weather conditions that prevented the investigation team from descending to 1700 m before the end of the experiment, only 20 measurements were taken at a prespecified flow rate set at 5 mL/h instead of 10 mL/h by mistake. All devices yielded a median flow lower than the target flow: Micrel Micropump™ 1 [4.54 (4.29–4.81)], Micrel Micropump™ 2 [4.55 (4.30–4.82)], Agilia Injectomat® [4.70 (4.54–4.80)] and DPS Orchestra® [4.68 (4.53–4.73)]. All of the devices tested needed at least 10 min to reach target flow at all altitudes, as shown in Fig. P for interaction < 0.001) and interquartile range (P <  0.001). While the accuracy of the Agilia Injectomat® and DPS Orchestra® devices was comparable at 300 and 1700 m of altitude, altitude change was associated with decreasing median flow rates and increasing interquartile ranges for the two Micrel Micropump™ devices. Low median flow-rate were observed with the two Micrel Micropump™ both at 300 m (4.4 and 4.0 mL/h) and 1700 m altitude (3.40 and 3.80 mL/h).For a prespecified flow rate set at 5 mL/h Table , the autMethod B allowed us to obtain the instant flow-rate profile delivered by each device. This is graphically displayed over a period of 20 min (1200 s at steady state) in the Fig. Starting time, cycle characteristics, and finally the boluses delivered after each mechanical push  are presented in Table The starting time increased at 1700 m for the Micrel Micropump™ devices (6–15 min and 3.8–14 min). The cycle time detected was higher at the higher altitudes for all devices. Maximum overshoot during infusion was > 30 μL for the Micrel devices and < 3 μL for the Agilia Injectomat® / DPS Orchestra®.The results of this study seem to indicate that SIP accuracy varies depending on altitude and the measurement method. It also highlights that compliance with IEC 60601-2-24 standards for electrical medical devices  may not When using the standard (weight) method, all five devices tested complied with the manufacturer’s requirements at 300 m altitude. Delivered flow rates were consistent with programmed flow rates and no significant difference was found depending on device and altitude. Notably, a previous study using the same measurement method reported significant differences between programmed and delivered volume depending on catheter diameter .The second method tested, which consisted in measuring the instantaneous flow rate with a flow meter, was used previously to assess the accuracy of check valves in SIPs . InteresAlthough speculative, the potential implications of this observation may include effects on hemodynamic stability, particularly when using vasoactive drugs such as noradrenaline or adrenaline. Indeed, Greau et al. demonstrated that manual changeover of noradrenaline SIPs had a clinical impact on patient hemodynamic status as compared with automatic changeover (modification of ≥20 mmHg). This effect was stronger for high-concentration solutions and low programmed flow. Manual changeover can be considered as a flow interruption followed by a bolus, very close to Micrel Micropump™ device performance. For this reason we consider that the use of these devices may compromise the clinical status of severely injured patients who may require hemodynamic support, particularly when managing acute severe head trauma . HoweverThese findings also suggest that altitude may impact mechanical compliance and modify delivered flow due to changes in pressure on devices. To our knowledge, this is the first study focusing on the effect of altitude on flow changes in mechanical infusion therapy. In a recent systematic review, Snijder et al.  noted meIn our experience, the average altitude for rotor-wing transportation is 1700 m, although some inter-hospital transfers may require flying above mountains more than 3000 m high. Because Micrel Micropump™ accuracy was significantly altered at 1700 m, we advocate the use of standard SIP devices during air transportation. Whether flying through valleys at 1700 m rather than passing above high-altitude mountains is a viable option remains unanswered: the potential impact of SIP inaccuracy when used over 3000 m altitude may be balanced by shorter transportation time.This exploratory study has several potential limitations. First, the weight measurement (method A) was close to the normative method proposed by the manufacturer in compliance with the IEC 60601–2-24  standardSecond, the prespecified infusion rate was set at 10 mL/h for method A (weight) and 5 mL/h for method B. Although unlikely, we cannot exclude that device accuracy differed according to flow infusion rate. In particular, low flow-rates can lead to increased start-up delays . Yet thiThird, only four devices were evaluated at 3000 m using the weight measurement method (method A), one of the Micrel having failed at 3000 m, and did not turn back on despite changing the batteries. Relatively few devices were evaluated at three altitudes, which may undermine the generalizability of the findings. Furthermore, the flow rate was set at 5 mL/h by mistake, and precluded any comparison with accuracy at 300 and 1700 m.Finally, measurements were made indoors, in order to control the ambient temperature. But we did not record the precise atmospheric pressure on the measurement days. The pressure variation related to the weather is about +/− 20 hPA outside of extreme events such as hurricanes. On a scale of altitude the weather variations could correspond to changes of less than 100 m to the highest altitude of measurement. We consider this variation not important enough to have changed our results. However, to be certain that the atmospheric pressure was responsible for the observed changes, a hypo / hyperbaric chamber study would be necessary.Low-weight SIPs (Micrel Micropump™), provide sequential boluses instead of continuous flow. Even though they are ten times heavier, standard devices appear to be most reliable, even at different altitudes. Only automatic measurement of instantaneous flow showed this very important difference across devices. We believe that existing norms regarding SIP accuracy may not be relevant for use in the prehospital setting. However, manufacturers should provide information on instantaneous flow.