Dogs are a breed of animals that play important roles in security service, companionship, hunting, guard, work and models of research for application in humans. Intelligence is the key factor to success in life, most especially for dogs that are used for security purposes at the airports, seaports, public places, houses, schools and farms. However, it has been reported that there is correlation between intelligence, body weight, height and craniometry in human. In view of this, literatures were searched on body weight, height and body surface areas of ten dogs with intent to determining their comparative level of intelligence using encephalization quotient.Findings revealed that dogs have relationship of brain allometry with human as proven by encephalization quotient and Brain Mass (E)  =  kpβ, where p is the body weight; k  =  0.14 and β = 0.528, respectively. Saganuwa’s formula yielded better results as compared with the other formulas. Dogs with body surface area (BSA), weight and height similar to that of human are the most intelligent. Doberman pinscher is the most intelligent followed by German shepherd, Labrador retriever, Golden retriever, respectively. The neural basis of human intelligence in relation to brain weight and head circumference has been identified by computed tomography (CT) and magnetic resonance imaging (MRI). The value range of 0–0.6 with verbal ability correlating with cerebral volume has been reported for each hemi-sphere in women, and in right handed men accounting for 36% of the variation in verbal intelligence . Body teAll the mathematical equations used in the present study have relationship between brain mass and body height of man. The formulas are presented as follow: Brain Mass  = 920 g(± 113) + 2.70 (± 0.65)  ×  body height of man; Brain Mass = 748 g(± 104) + 3.10 (± 0.64)  ×  body height of woman . Animal 10 (B)  =  3.015 + 0.986 log10(C), where B  and C  is expressed as y = 0.39x0.27, where 0.39 , X (body weight mean) and 0.27 .These parameters are potentially associated with intraspecies ratio of body weight and body weight means [weight23 , modifiementclasspt{minimaht means . Also brht means . Whereasht means . Howeverht means . The intht means  in decreht means . One-yeaand dogs .The body weight, brain weight, body surface area, height and encephalization quotient of the ten dogs are presented in Table The intelligence quotient of 1.0–3.1 reported for the dogs used in the present study disagrees with the report indicating that, the EQ for dogs was 1.2 –10. EQs Body weight, height and body surface area can be used to estimate encephalization qotient of dogs, which can vary according to formulas, nutrition, environment and diseased conditions. The calculated parameters showed that Doberman pinscher is the most intelligent followed by German shepherd, Labrador retriever, Golden retriever, Australian Cattle Dog, Rottweiler, Border collie, Standard Poodle, Shetland Sheep Dog and Papilon, respectively.The calculations were based on different formulas generated for different or similar purposes in dog and human. Intelligence in dogs and human is used for different assignments even within canine species. More so difference in physiology, anatomy and biochemistry count for differences in the calculated values.


Orthostatic hypotension (OH) and orthostatic hypertension (OHT) are often unrecognized in clinical care for diabetic individuals, yet they are associated with increased risk for adverse cardiovascular outcomes. We aimed to determine the prevalence of the abnormal orthostatic blood pressure (BP) responses, and associated factors among diabetic individuals in ambulatory care for diabetes in southwestern Uganda.We conducted a cross-sectional study among diabetic individuals aged 18–65 years at Mbarara Regional Referral Hospital, southwestern Uganda from November 2018 to April 2019. We obtained demographic and clinical data including a detailed medical history, and glycemic profile. BP measurements were taken in supine position and within 3 min of standing. We defined OH in participants with either ≥ 20 mmHg drop in systolic BP (SBP) or ≥ 10 mmHg drop in diastolic BP (DBP) after assuming an upright position. OHT was defined in participants with either a ≥ 20 mmHg rise in SBP, or ≥ 10 mmHg rise in DBP after assuming an upright position. Multivariate logistic regression was used to identify factors associated with OH and OHT.P = 0.046), diabetic retinopathy , higher resting SBP ≥ 140 mmHg , and history of palpitations . Self-report of palpitations , and higher resting SBP ≥ 140 mmHg  were associated with OHT.We enrolled 299 participants, with a mean age of 50 years (SD ± 9.8), and mean HbA1c of 9.7% (SD ± 2.6); 70% were female. Of the 299 participants, 52  met the definition of OH and 43  were classified as having OHT. In multivariable models, factors associated with diabetic OH were older age (OR = 2.40 for 51–65 years vs 18–50 years, 95% CI 1.02–5.67, OH and OHT are common among diabetic individuals in ambulatory diabetes care in southwestern Uganda. Orthostatic BP measurements should be considered as part of routine physical examination to improve detection of OH and OHT, especially among older diabetics with complications of the disease. Future studies to assess the health and prognostic implications of OH and OHT among diabetics in the region are warranted. Orthostatic hypotension (OH) is a hemodynamic disorder that is characterized by a sustained drop in blood pressure (BP) from supine position to standing . OrthostOH is recognized as the among most disabling features of autonomic dysfunction , and is In addition, some complications such as supine hypertension, usually observed in more than half of diabetics with OH, are challenging to manage and often require expertise of a cardiovascular specialist , 21. FurHowever, there are very few data on the epidemiology of OH and OHT outside of resource-rich settings. Given the growing evidence of deleterious cardiovascular outcomes for individuals with abnormal orthostatic BP responses and DM , 21, it Most earlier studies on abnormal postural changes in BP in diabetic populations have mainly focused on elderly individuals ≥ 70 years, and have taken place outside sub-Saharan Africa (SSA). Data on the burden and correlates of abnormal postural changes in BP in diabetic populations in SSA are limited. We aimed to respond to this gap in the literature by characterizing the prevalence of abnormal orthostatic BP responses, both OH and OHT, and to identify factors associated with these conditions in a relatively younger population of diabetic individuals (18–65 years) in ambulatory DM care in Uganda.This was a cross-sectional study, conducted at the Diabetes and Endocrinology Clinic of Mbarara Regional Referral Hospital (MRRH) from November 2018 to April 2019. The detailed methods for the parent study that assessed the overall burden of cardiovascular autonomic neuropathy among individuals with diabetes in ambulatory care, and a detailed description of the study population at inclusion, have been published previously . In brie2). Measurements for glycosylated hemoglobin (HbA1c) were performed using an automated high performance liquid chromatography analyzer , at Lancet laboratories. Measurements of fasting blood glucose were obtained under aseptic technique, using a Freestyle Glucometer  after at least 8 h of fasting, by means of capillary blood obtained by finger prick. Diabetes was defined in participants with fasting capillary glucose of ≥ 7.0 mmol/L or those who were already on medication for diabetes mellitus, as per recognized criteria [We collected clinical and demographic data, using an interviewer administered structured questionnaire. Waist circumference was measured at the level of umbilicus with inelastic tapeline (to the nearest 0.1 cm), at the end of normal expiration. Height and weight of study participants were measured to the nearest 0.1 cm and 0.1 kg respectively. We calculated body mass index as the weight (kg) divided by the square of height  on study participants, and measured the QT interval from the beginning of the earliest onset of the QRS complex to the end of the T wave, where it crosses the isoelectric line. We used the Bazette’s formula to calculate a heart rate–corrected QT (QTc) . We consAll BP recordings were done using an automatic sphygmomanometer in the upper arm . The protocol for assessment of OH and OHT included supine BP and standing BP measurements. Supine BP was recorded after 5 min of rest. Standing BP was measured within 3 min of assuming upright standing position. We defined OH in participants with either a ≥ 20 mmHg drop in systolic BP (SBP) or ≥ 10 mmHg drop in diastolic BP (DBP) when assuming an upright position . To defiConventional BP measurements were done with participants in sitting positions. We defined hypertension in participants whose BP values were ≥ 140/90 mmHg or who were already on medications for high BP . We calc. We used Stata, version 13  for all statistical analyses.For the parent study, which was designed to estimate the prevalence of autonomic neuropathy, we estimated a sample size of 296 participants around a prevalence estimate of cardiovascular autonomic neuropathy (CAN) of 20% [t-test; while continuous non-normally distributed data (presented as median ± inter-quartile range) were compared using Wilcoxon rank-sum test. We compared categorical variables using the chi-squared test. Finally, we performed univariate and multivariate logistic regression analyses to identify factors associated with OH and OHT. All variables with a P-value less than 0.1, were included in the multivariate models and adjusted for sex, age, BMI, HbA1c, QTc interval, and duration of diabetes, based on biological plausibility. Pulse pressure—derived from SBP and DPB— and history of hypertension, were eliminated from the final multivariate model because of collinearity. We considered statistical significance at a threshold of P < 0.05.Our primary outcomes were OH and OHT. First, we determined the prevalence of OH and OHT, as the proportion of participants that met their definitions. Next, we compared differences in clinical and demographic characteristics between participants with OH and OHT and those without. Continuous normally distributed data (presented as mean ± standard deviation) were compared using a two-tailed independent The clinical and demographic characteristics of the total cohort have been described previously . In brieOverall, abnormal postural changes in BP were detected in 66 participants 22.1%). Of the 299 participants assessed orthostatic BP responses, 52  met the definition of OH; 43  were classified as having OHT (Table %. Of theDiastolic hypertension was found in 38 participants 12.7%), systolic hypotension in 23 participants (7.7%), while diastolic hypotension and systolic hypertension were found in 10 participants (3.3%) each. The differences between blood pressures from supine to standing followed a normal distribution pattern for both systolic and diastolic BP measurements are shown in Fig. 2.7%, sysP = 0.002), history of hypertension (P = 0.002), history of palpitations (P = 0.002), diabetic retinopathy (P < 0.001), mean QTc interval (P = 0.006) and median duration of diabetes (P = 0.031) between those with and without OH. Participants with OH also had significantly higher mean resting systolic BP (P < 0.001), higher mean resting diastolic BP (P = 0.004) and higher mean pulse pressure (P < 0.001) compared with their counterparts with no OH.We found crude differences in the mean age (P = 0.011) and those who reported history of palpitations (P < 0.001) was significantly higher in the OHT group than in the group without OHT, as shown in Table The proportion of female participants (P = 0.015), higher mean waist circumference (P = 0.019), higher mean pulse pressure (P < 0.001), higher mean resting systolic BP (P = 0.001), and higher mean QTc (P = 0.049) than their counterparts (Table Participants with OHT had significantly higher mean BMI (ts Table .P = 0.046), presence of diabetic retinopathy , history of palpitations , and higher resting systolic BP of ≥ 140 mmHg .In multivariate analysis Table , the facP = 0.005) and higher resting SBP ≥ 140 mmHg  were associated with presence of OHT in the multivariate analysis  had higher odds of OH, and OHT. This is in agreement with previous studies that have reported association between resting SBP and abnormal orthostatic BP responses , 36–40.  mmHg hadAlthough the precise mechanism of OH is not well studied in this population, we postulate that OH may be a manifestation of autonomic neuropathy, given the high prevalence of cardiovascular autonomic dysfunction detected in this same population . This hyCurrent guidelines for care and management of diabetes in Uganda and other developing countries in sub-Saharan Africa do not routinely recommend screening for orthostatic BP abnormalities among individuals with diabetes in ambulatory care. Because routine measurement of BP is a non-invasive and low-cost procedure to identify individuals with abnormal orthostatic BP changes, our data suggest that routine comprehensive physical examinations in diabetic individuals could serve as a scalable mechanism to improve detection of OH and OHT. Future work should focus on how detection of OH and OHT with subsequent optimization of hemodynamics may improve quality of life and reduce the risk for excess cardiovascular morbidity and mortality associated with these complications.The findings from this study should be interpreted in consideration of our study limitations. First, our study population lacked individuals older than 65 years, based on the exclusion criteria of the parent study which assessed the overall burden of cardiovascular autonomic neuropathy among individuals with diabetes in ambulatory care. This may have led to underestimation of the prevalence of the OH and OHT, and biased our associations towards the null. Generalizability should be restricted similarly to those with diabetes and in ambulatory care in similar peri-urban African settings. Second, the cross-sectional study design limited us from assigning time causal directionally between our exposures and outcomes. Third, we did not comprehensively assess complications of OH and OHT including orthostatic intolerance and associated falls. Thus, we cannot evaluate the clinical implications of these abnormal orthostatic BP responses in the study population. Further studies are required to assess the prognostic and clinical implications of these orthostatic abnormalities in this patient population in the region. Despite these limitations, our study is among the first studies to provide useful epidemiological data on OH and OHT among diabetic individuals in sub-Saharan African region.OH and OHT are common among individuals with diabetes in ambulatory care in southwestern Uganda. Higher SBP, history of palpitations, coexistence of diabetic retinopathy, and older age were key correlates of the orthostatic BP abnormalities. Future work should elucidate how these conditions impact the health and quality of life of those with DM in this region. Given the ease and low cost of performing orthostatic BP measurements in clinical settings, we recommend that clinical guidelines for care of persons with diabetes consider including screening for orthostatic abnormalities in BP into routine physical examinations to improve detection and management of OH and OHT in the region, especially among diabetics with hypertension, older age, and coexisting microvascular complications. Timely management of OH and OHT may potentially minimize future adverse cardiovascular events in this patient population, given that co-existing DM and orthostatic abnormalities in BP portent a much poorer prognosis.


Mycobacterium tuberculosis (M.tb). In this study, RNA sequencing (transcriptome sequencing) was employed to investigate the global transcriptome changes in the macrophages during the different strains of M.tb infection. THP‐1 cells derived from macrophages were exposed to the virulent M.tb strain H37Rv (Rv) or the avirulent M.tb strain H37Ra (Ra), and the M.tb BCG vaccine strain was used as a control. The cDNA libraries were prepared from M.tb‐infected macrophages and then sequenced. To assess the transcriptional differences between the expressed genes, the bioinformatics analysis was performed using a standard pipeline of quality control, reference mapping, differential expression analysis, protein‐protein interaction (PPI) networks, gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis. Q‐PCR and Western blot assays were also performed to validate the data. Our findings indicated that, when compared to BCG or M.tb H37Ra infection, the transcriptome analysis identified 66 differentially expressed genes in the M.tb H37Rv‐infected macrophages, out of which 36 genes were up‐regulated, and 30 genes were down‐regulated. The up‐regulated genes were associated with immune response regulation, chemokine secretion, and leucocyte chemotaxis. In contrast, the down‐regulated genes were associated with amino acid biosynthetic and energy metabolism, connective tissue development and extracellular matrix organization. The Q‐PCR and Western blot assays confirmed increased expression of pro‐inflammatory factors, altered energy metabolic processes, enhanced activation of pro‐inflammatory signalling pathways and increased pyroptosis in H37Rv‐infected macrophage. Overall, our RNA sequencing‐based transcriptome study successfully identified a comprehensive, in‐depth gene expression/regulation profile in M.tb‐infected macrophages. The results demonstrated that virulent M.tb strain H37Rv infection triggers a more severe inflammatory immune response associated with increased tissue damage, which helps in understanding the host‐pathogen interaction dynamics and pathogenesis features in different strains of M.tb infection.Tuberculosis (TB) remains a worldwide healthcare concern, and the exploration of the host‐pathogen interaction is essential to develop therapeutic modalities and strategies to control  In the world's population, almost one‐third is infected with M.tb and 1.2 million TB‐related deaths, and 10 million new TB cases were estimated in the WHO global TB report in 2019.Tuberculosis (TB), caused by The macrophages serve as the main host cell niche for the persistence and intracellular growth of M.tb. As a pathogen transmitted through the respiratory route, M.tb was first identified to undergo phagocytosis through alveolar macrophages inside the lungs. The initial infection outcome is most often a latent status in healthy individuals, in whom the host immune response is holding the bacteria in check. Active TB develops in such individuals later in life when the immune response fails. Whereas, in a minority of infected individuals, when their immune system impaired, they can develop active TB by spreading the bacilli through infectious aerosols coughed out into the surroundings and inhaled by new hosts.Apart from the influence of the diverse immune response, the susceptibility and the consequence of M.tb infection are also due to the bacilli strains, which varied in virulence and transmissibility. Different M.tb strains provoke diverse responses from the host and ultimate results.Mycobacterium bovis, has been given to more than 3 billion people since 1921 and is the only M.tb vaccine available for human use.M.tb virulent strains H37Rv and avirulent strains H37Ra are two widely used laboratory reference strains, which were obtained by William Steenken in 1935 by performing a dissociation study after cultured clinical isolated M.tb H37 parent strain on glycerol‐egg media of different pH; these two strains of M.tb show different morphology, virulence as well as genetic variations. BCG , an attenuated strain of To address whether differential host responses or variances in the responses to the different strains of M.tb lead to differential disease severity, our current study aimed to investigate the immune responses induced by different genotypes strains of M.tb in macrophages by transcriptomic analysis. This will help to understand the underlying mechanisms of the virulence of this economically important pathogen.Our findings indicated that the gene expression profiles of H37RV, H37Ra and BCG infections were significantly different. In comparison with H37Ra and BCG infections, 66 unique genes were expressed in response to H37RV M.tb infection, with 36 genes up‐regulated and 30 genes down‐regulated. Increased expression of pro‐inflammatory cytokines and chemokines was observed in H37RV‐infected macrophages; these diverse gene expression profiles were associated with altered activation of inflammation‐related signalling pathways, including STAT1, NF‐kB and MAPK; additionally, we observed that, rather than inducing cell apoptosis, H37RV infection in macrophages induces a significantly higher level of pyroptosis.22.1Mycobacterium tuberculosis H37Rv, H37Ra and BCG strains were employed in all experiments. M.tb strains were grown routinely at 37ºC in 10 ml of 7H9 , supplemented with 10% of oleic acid albumin dextrose catalase (OADC) (Becton Dickinson Microbiology Systems), 0.5% Glycerol (Sigma) and 0.05% of Tyloxapol (Sigma). Growth was monitored daily by OD absorbance at 600 nm for 20 days.The axenic cultures of 2.2M. tuberculosis H37Rv, H37Ra and BCG were pelleted , washed twice with PBS  and re‐suspended in a THP‐1 culture medium. Differentiated THP‐1 cells were optimal conditions infected with Mycobacterium tuberculosis at a multiplicity of infection of 5 (MOI) for 24h.The THP‐1 cell line was maintained in medium 1640 supplemented with 10% (v/v) foetal calf serum, 2 mM glutamine, 1 mM sodium pyruvate and 0.05 mM 2‐mercaptoethanol in a humidified 5% carbon dioxide atmosphere at 37°C. The THP‐1 was differentiated for 24 h using a culture medium containing 40 ng/ml phorbol 12‐myristate 13‐acetate. The cells were then washed with fresh culture medium and incubated for 48 h. Rapidly grown 2.3The total RNA extraction was prepared from M.tb‐infected THP‐1 cells with RNA Miniprep kit reagent as described by the manufacturer Vazyme biotech. NGS analysis was performed on the BGISEQ‐500 platform by BGI Genomic Services, generating per sample on average about 6.86G reads. After filtering the reads, using HISAT clean reads were mapped to the reference genome. Averagely, 90.73% reads were mapped, and by using Bowtie2 (v2.2.5), clean reads were mapped to reference transcripts; then with RSEM (v1.2.12), the level of gene expression for each sample was measured.2.4p < 0.05. Standard bioinformatics analysis including PCA, gene expression, heat map, KEGG pathway, GO component, volcano plot and Venn diagram was performed by BGI.The raw data were defined as reads containing the low‐quality reads, high content of unknown bases and the sequence of the adaptor. To decrease data noise, these reads were removed before downstream analysis. The steps of filtering are as follow: The RNA‐seq libraries’ quality was first assessed using the Fast QC v0.11.5 software. Then, according to the following parameters, the reads were subjected to standard criteria of quality control (QC): (1) trimming and cleaning reads that aligned to primers and/or adaptors, (2) reads with over 50% of low‐quality bases  in one read, and (3) reads with over 10% unknown bases (N bases). After filtering, the remaining reads are called ‘clean reads’ and stored as FASTQ format. The present study used bioinformatics methods to identify overlapping differentially expressed genes (DEGs) in THP‐1‐derived macrophages infected by M. tb. The criteria for defining genes as DEGs were |log2 fold change| >1.0 and 2.5−ΔΔCt. In Western blot experiment, THP‐1 cell samples were homogenized in RIPA lysis buffer with 1% phosphatase and protease inhibitor cocktail (Sigma‐Aldrich). Furthermore, the supernatants were mixed with a 5× SDS/PAGE sample buffer. Equal amounts of proteins (20 μg) were separated by a 10% SDS/PAGE gel and then transferred to PVDF membranes (Merck Millipore). Then membranes were incubated at 4℃ overnight with specific primary antibodies p‐P65, p‐STAT1, p‐ERK, p‐JNK, Caspase‐1, Caspase‐1‐cleaved, Caspase‐3, Caspase‐3‐cleaved and GAPDH at a dilution of 1: 1000 . After washing with TBST three times, membranes were incubated with a secondary antibody . All membranes were incubated with the HRP substrate (Millipore) for the desired durations in order to visualize the bands. In each group, the relative density of the signalling band for the protein was compared with the band for the housekeeping gene GAPDH.Total RNA extraction was prepared from M.tb‐infected THP‐1 cells. The housekeeping gene GAPDH was used as an internal control. THP‐1 mRNA primer sequences for the target genes are listed in supplementary Table 2.6P‐values of 0.05 or less were considered statistically significant. All analyses were performed with Graph Pad Prism 7.0 software (version 6.07).All data were expressed as the mean ±SD from at least three independent experiments. When the distribution was normal and there was homogeneous variance, we used the ANOVA to compare amongst three or more groups. 33.1The quality distribution of bases reflects the accuracy of sequencing reads. We first assessed the RNA sequencing Quality Control parameters including, sequencing yield, Q20 and Q30 , Total Raw reads, Total Clean reads and Total clean bases. Overall, we can see that the ratio of bases with low quality  is low, indicating the good quality of sequencing  revealed that the samples from uninfected macrophages clustered separately from the infected cells and the samples collected from the BCG‐infected cells as well. The samples collected from infected H37Rv and H37Ra cells were different and segregated from each other  enrichment analysis was used. The DEGs were classified into three categories: biological process, cellular component and molecular function. When examining the most enriched GO terms, most of the identified DEGs were involved in the biological process category Figure . The topKEGG pathway enrichment analysis is useful to identify the DEGs involved in major biochemical and signal transduction pathways. Enrichment analysis of the DEGs in the M.tb H37RV‐infected versus the control groups’ pairs was performed by using the KEGG database, where the pathways that play an important role in the infection process can be further explored Figure . There wThe protein‐protein interaction (PPI) network analysis using the Search Tool for the Retrieval of Interacting Genes (STRING) database identified an interaction network of up‐ and down‐regulated genes. In response to H37Rv infection, 322 up‐regulated genes were identified and then analysed according to node and interaction intensity. As shown in Figure 3.4In response to M.tb H37Ra infection, we identified a total of 1041 DEGs compared with the untreated control, which included 515 up‐regulated genes and 526 down‐regulated genes in the Transcriptomic Profile analysis Figure . The volGene Ontology (GO) analysis was performed for the whole 289 DEGs; the DEGs from selected 20 pathways were examined through the GO analysis Figure . In the Following that, a KEGG pathway enrichment analysis was performed; 193 of the 1041 DEGs were mapped into 20 pathways Figure . Based oFinally, we performed PPI network analysis of DEGs in the M.tb H37Ra‐infected macrophage, versus the mock infection control, to identify hub nodes. We analysed 515 up‐ and 526 down‐regulated genes by PPI and then analysed them according to node and interaction intensity. As shown in Figure 3.5p‐value of <0.05 after infection and an absolute fold change of >1 , cell adhesion (GO:0007155), response to the virus (GO:0009615), regulation of ion transmembrane transport (GO:0034765) and nervous system development (GO:0007399). In BCG‐infected groups, the 20 enriched GO terms under each category are shown in Figure DEGs in the BCG infected macrophages were next subjected to pathway analysis. The KEGG pathway assigned 217 out of 1052 DEGs (20.62%) to 20 pathways in the KEGG database. The top enriched pathways are shown in Figure To identify coherently modulated genes within the global cell signalling network, we performed a PPI network analysis of 649 up‐regulated, and 403 down‐regulated DEGs in the BCG‐infected group versus the mock control. PPI network analysis helps to reveal the flow and crosstalk between different KEGG pathways. As displaced in Figure 3.6To assess the virulent‐related factors during M.tb infection, the DEGs induced by virulent strain H37Rv infection were compared with the attenuated strain H37Ra and BCG. We performed a Venn diagram analysis of the DEGs in the various strains of M.tb‐infected groups Figure . Venn anNotably, there were 66 unique DEGs identified in the highly violent strain H37Rv‐infected group  consists of more than 10 different mycobacterial species that are the pathogens of tuberculosis (TB) both in humans and other species.The in vitro studies include the primary macrophages, mainly the mouse bone marrow‐derived macrophages (BMDMs), or the human monocyte‐derived macrophages (hMDMs) and cell lines, such as the murine J774 and RAW 264.7 or the human THP‐1 and U937. Since the primary healthy alveolar macrophages are relatively difficult to obtain due to the limited supply from the clinic, also concerning the ethical issues of human biological samples and the variation of genes that disturb the result interpretation. The use of the cell line to substitute the primary macrophages provides a promising approach for investigating the immune response and pathogenesis of TB infection in vitro. Murine cell lines have been found to trigger different immune responses compared with primary macrophagesin vitro experiments of M.tb infection.Macrophages play a crucial role in the immune defence against M.tb infection and are the major cell type favourably infected by M.tb. Generally, practised infection models for Macrophage polarization is increasingly known as an influential pathogenesis factor in multiple types of infectious and inflammatory diseases. Classical M1 and alternative M2 polarization are the two extremes of macrophage phenotype transformation.Mycobacterium tuberculosis infection in macrophages could trigger plasma membrane damage which caused NLRP3 activation and pyroptosis.Pathogen‐induced cell death is another concern associated with the pathogenesis of the disease. In macrophages, M.tb infection was the extensive activator of all currently known programme cell death (PCD) pathways, including the following: apoptosis, pyroptosis, necrosis, necroptosis, pyronecrosis, NETosis and autophagy. M.tb‐infected cells produce a potent adenylate cyclase toxin to prevent phagocytic killing, which can disrupt cell signalling in macrophages and ultimately induce apoptosis. A previous study indicated that Mtb infection could induce apoptosis via the TLR2/TLR4/MyD88/p38/ERK/PI‐3K/NF‐kB pathway. In contrast, necrosis was favoured in the absence of TLR4 signalling independently of p38, ERK1/2, PI‐3K or NF‐κB activity.Innate immune recognition, which relies on various types of pattern recognition receptors (PRRs), such as Nod‐like receptors (NLRs), Toll‐like receptors (TLRs) and C‐type lectin receptors (CLRs), plays a crucial role in recognition of M.tb. As expected, several molecules are involved in innate immune molecular recognition that has been altered or expressed in response to the various strains of M.tb infection; these include CD14, FN1 and TLR4. CD14 is an essential pattern recognition receptor protein in innate immunity, especially during M.tb infection. M.tb interacts with macrophages through cell surface receptors including CD14, and a CD14 polymorphism has been associated with M.tb infection susceptibility. FN1, which encodes fibronectin (FN), was found to be constitutively expressed in lung macrophages.As for the H37RV‐specific DEGs associated with pattern recognition, we detected increased expression of NOD‐like receptor in response to H37RV infection. NOD‐like receptors (NLRs), including NOD1, NOD2, NLRP3 and NLRC4, are a group of pattern recognition receptors expressed in the cell cytosol that are involved in the activation of inflammatory pathways and the recognition of microbial components that protect against invading pathogens. Its function in M.tb infection contains two aspects: the first one is its immune defence functions, as the NOD1/2 has been found to recognize and defend against M.tb infection; the second function is the activation of the inflammasome. ESAT‐6 derived from M.tb has been shown to strongly activate the NLRP3/ASC inflammasome in macrophages, correlating with airway inflammation. The increased activation of NLRs indicated that the M.tb H37RV violence strain is likely to elicit a number of severe anti‐bacterial immune responses when it infects macrophage. AGO2 is another critical gene involved in anti‐M.tb infection. Immune defence is mediated by RNA interference (RNAi); AGO2 was recently implicated in mammalian anti‐infection defence as a result of its role in miRNA biogenesis and function.Leishmania‐infected macrophages to establish an anti‐inflammatory response, the expression and phosphorylated status of Ago2 protein regulated miRNA‐targeted pro‐inflammatory cytokines.In Altered expression of metabolic function genes is another feature of M.tb infection. We found several common metabolic‐associated genes with HOMX. Induction of HO1 through M.tb infection has been found to be associated with inflammation and bacterial growth. HO1 is an enzyme that regulates the expression of carbon monoxide, which was sensed by M.tb. HO1 catalyses the breakdown of haeme into carbon monoxide, biliverdin and iron. In the M.tb‐infected animal model, mice deficient in HO1 are more vulnerable to the infection of M.tb compared with wild‐type mice, which is likely due to the cytotoxic effects of free haeme accumulation.CD36 is a scavenger receptor expressed in multiple cell types, including macrophages. Its function involves lipid metabolism, immune responses, molecular adhesion and apoptosis. Since Mtb could utilize host‐derived lipids as a source of nutrition during infection, patients with Mtb infection develop pronounced disorders of lipid metabolism.The ATP10A gene belongs to the family of P‐type cation transport ATPases. Its functions include the translocation of phosphatidylcholine, and it is involved in plasma membrane dynamics. Its function in M.tb infection is not fully known. However, it has been identified as a novel biomarker for the discrimination of TB from latent TB infection individuals (LTBI).In conclusion, with a comparison of the responses of different strains of M.tb infection in macrophages, we could identify the functionally characterized genes which were uniquely expressed during the process of virulent strain of M.tb infection. In contrast to H37RA or BCG, H37RV infection showed a richer transcriptional pattern of virulence factors which were linked with severe inflammatory immune response and altered metabolic pattern.The authors declare no conflict of interest.Wenyuan Pu: Conceptualization ; Data curation ; Formal analysis ; Investigation ; Methodology ; Validation ; Visualization ; Writing‐original draft ; Writing‐review & editing . Chen Zhao: Data curation ; Formal analysis . Junaid Wazir: Writing‐review & editing (supporting). Mengyuan Niu: Data curation (supporting); Formal analysis (supporting). Zhonglan Su: Data curation (supporting). Shiyu Song: Conceptualization (supporting); Data curation (supporting); Formal analysis (supporting); Methodology (supporting). Lulu Wei: Software (supporting). Li Li: Methodology (supporting). Xia Zhang: Supervision (supporting). Xudong Shi: Supervision (supporting). Hong‐wei Wang: Conceptualization (lead); Funding acquisition (lead); Project administration (lead); Supervision (lead); Writing‐review & editing (lead).Fig S1Click here for additional data file.Fig S2Click here for additional data file.Table S1‐S6Click here for additional data file.


To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE).In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records.Twenty‐five children fulfilling LE criteria were identified, with median age of 11 years  and median follow‐up of 24 months . All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra‐limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti‐NMDAR Abs, and 2/15 positive for anti‐Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti‐GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second‐line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days . At last follow‐up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long‐term cognitive and epilepsy outcomes in those who received rituximab versus those who did not.A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort. Autoimmune limbic encephalitis (LE) is a rare but well‐recognized neuroinflammatory condition in which patients typically present with memory deficits, seizures, and psychiatric disturbances alongside radiologic changes in the medial temporal lobe.N‐methyl‐d‐aspartate receptor (anti‐NMDAR) encephalitis, the most frequently described pediatric autoimmune encephalitis (AE), in which the antibodies target the NR1 subunit of the receptor.Prior to current understanding of antibodies in LE, a retrospective multicenter study of 10 children with LE included antibodies that are no longer considered pathogenic.Outcomes in pediatric AE improve with prompt recognition and treatment.Little is known about the natural history of autoimmune LE, particularly in the pediatric population, with only single case reports and small case series published.3) or EEG with epileptic or slow‐wave activity involving the temporal lobes, and (4) exclusion of alternative causes . All cases were carefully evaluated for neurotropic viruses and had negative CSF PCR for HSV and enteroviruses. Additional CSF testing for neurotropic viral DNA or RNA often performed as a panel would include varicella‐zoster virus, Epstein–Barr virus, and HHV‐6. Cases included had a minimum of 6‐month follow‐up data.The British Paediatric Neurology Association (BPNA) hosts the UK Childhood Neuro‐Inflammatory Disorders (UK‐CIND). Twenty‐three pediatric neuroscience centers participate in the UK‐CIND which keeps a database of cases discussed. LE cases were identified through the database and through direct correspondence with the network participants. Case imaging were reviewed by the two neuroradiologists (K.M. and A.S.) along with clinical information by study clinicians . Diagnosis of LE was made and retrospectively confirmed again by the study team based on the following criteriaSix tertiary pediatric neurology centers contributed cases: Great Ormond Street Hospital (London), Evelina London Children's Hospital (London), Birmingham Women's and Children's Hospital, Addenbrooke's Hospital (Cambridge), Alder Hey Children's Hospital (Liverpool), and Children's University Hospital (Dublin).Clinical data including demographics, clinical findings and laboratory results, imaging and neurophysiology reports, and treatment information were retrospectively reviewed from medical records of patients and entered in a standardized case report form. Clinical notes reported deterioration in processing information separately from difficulties retaining information and was recorded as additional cognitive difficulties. Outcomes were assessed using the modified Rankin Scale (mRS) which emphasizes gross motor skills and disability impact on age‐expected activities.U and Kruskal Wallis tests) were used for continuous distributions, as appropriate, and χ2 or Fisher's exact test for nominal data to compare the demographic characteristics, presenting symptoms, and radiologic features across the age groups. Univariate logistic regression analysis was used to predict risk factors of; (1) mRS scores of 3 or more, (2) refractory seizures, and (3) cognitive impairment at last follow up. Predictors tested included age, sex, ethnicity, intensive care admission, epileptiform discharges on EEG, abnormal CSF at presentation (defined as raised white cell count and/or protein), rituximab therapy, time from initial presentation to steroid treatment and time from initial presentation to escalation of immune therapy (IVIG/PLEX). All results associated with a p < 0.05 were considered significant. Data were analyzed using GraphPad Prism 9 .Parametric or nonparametric statistical tests . Any data not published within the article will be shared upon request from any senior (tenured) investigator.A total of 25 patients were identified. Four patients have been reported previously elsewhere.n = 13), headache (n = 10), and vomiting (n = 4). Patients under the age of 12 years were more likely to present with fever . One patient was found to be SARS‐CoV‐2 positive on respiratory PCR when screened for admission and had positive SARS‐CoV‐2 IgG serology 3 weeks later. All cases presented with seizures, of which 15/25 (60%) required PICU admission for status epilepticus. The next most common presenting features were short‐term memory deficits , additional cognitive deficits , or behavioral change . Visual and auditory hallucinations occurred in 6/25 patients (24%). The median duration of hospital admission was 21 days   with most common symptoms being fever  Tables .MRI abnormalities are summarized in Table 6/L , and elevated CSF protein concentration in 4/23 (17%). Intrathecal oligoclonal bands were identified in 5/19 (26%) patients. All patients had serum anti‐NMDAR Ab and paraneoplastic antibody testing. Testing was performed for anti‐Yo/anti‐Ri (n = 15), LGI1 (n = 17), CASPR2 (n = 17), glycine (n = 10), and GABA(B)R‐ab (n = 13) antibodies but were negative. Serum antibodies against intracellular antigens (anti‐Hu) were identified in 2/15 children; one of these children had relapsing neuroblastoma and unfortunately died. The second patient had pre‐existing peripheral axonal neuropathy since infancy and whole‐body MRI did not identify an underlying malignancy. He remains under regular tumor surveillance. Two patients (tested n = 14) had GAD antibodies in both the serum and CSF; patient 17 had serum GAD antibodies >2000 IU/mL and CSF GAD antibodies >50,000 IU/mL; patient 25 had serum GAD antibodies >2000 IU/mL and CSF GAD antibodies >1,000,000 IU/mL. Two patients with clinical phenotype of anti‐NMDAR encephalitis were positive for anti‐NMDAR Ab in the serum . Four patients, out of 10 tested, had antibodies to thyroid peroxidase (anti‐TPO), ranging from 178 to 541 IU/mL . All were euthyroid at presentation.Initial CSF study showed lymphocytic pleocytosis in 7/24 (29%) patients, with median white cell count of 12.5 × 10First‐line immunotherapy was given to 24/25 (96%) patients: steroid treatment in 23/25 (92%), IVIg in 14/25 (56%) and plasma exchange in 7/25 (28%). High‐dose methylprednisolone for 3–5 days (17/25) was the most frequent steroid preparation. Pulsed dexamethasone was used in 5/15 (33%) children under the age of 12 years and was the only therapy used in one case. In 23/25 cases, the median time to first administration of steroids was 1 week . The late commencement of steroids was in a child with underlying neuroblastoma. Initial management was neuroblastoma treatment, but symptoms did not resolve, and intrathecal steroids were administered a year after presentation.Seventeen out of 25 (68%) cases received further immunotherapy, most frequently rituximab 15/25 (60%), which was administered at a median time of 24 weeks from presentation . Only one patient received rituximab within 4 weeks from symptom onset. Other therapies given were; mycophenolate mofetil in 4/25 (16%), cyclophosphamide in 3/25 (12%), alemtuzumab in 1/25 (4%), natalizumab in 1/25 (4%), and tocilizumab in 1/25 (4%).p = 0.04) and intensive care admission (p = 0.004). No significant association was detected between refractory seizures at last follow‐up and age, sex, epileptiform discharges on EEG, abnormal CSF at presentation, rituximab therapy, time from initial presentation to steroid treatment and time from initial presentation to escalation of immune therapy (IVIG/PLEX) (Table Regular anti‐seizure drugs (ASMs) were commenced during admission in 19/25 (76%) patients. Immune therapy was administered to 24 patients of which 4/24 (17%) had no further seizures. Seizures continued in 6/25 (24%) with re‐emergence of seizures in 15/25 (60%) at a median time of 12 weeks  Fig. ; initialX) Table .p = 0.03). No significant predictors were detected for mRS score of 3 or more at final follow‐up . At final follow‐up, memory impairment was reported in 16/25 (64%) and additional cognitive impairment in reasoning or processing was reported in 11/25 (44%); two children moved from mainstream to special schools. Six out of 25 (24%) children had mRS scores of 3 or more, with the main health burden being refractory seizures. In 19 cases with complete 2‐year follow‐up, the greatest reduction in the five main symptoms  and improvement in mRS scores occurred within the first 3 months Fig.  had progup Table .n = 9) compared to those with no claustrum changes (n = 16); there was no difference in memory impairment (p = 0.15), cognitive (p = 0.2), psychiatric (p = 0.35) or behavior symptoms (p = 0.63) at presentation, nor in mRS at last review . In those who had follow‐up MRI scans (range 3 weeks to 93 months), sclerosis or atrophy of the hippocampus was identified in 8/12 (66%) . Median time to first assessment was 12 months from presentation . Five cases had more than one assessment. Below average scores were identified in either memory, reasoning, or processing speed in 8/9 (89%) of cases. Very low scores (<5th percentile) in measures of memory were reported in 6/9 (67%) Table .n = 15) compared to those who did not (n = 10), there was no difference in mRS , memory impairment (p = 1.0), cognitive outcomes (p = 1.0), or refractory seizures (p = 1.0) at last review.A higher proportion of children with refractory seizures , memory impairment  and additional cognitive impairment  received rituximab. In patients who received rituximab , over half of patients had refractory seizures, over half had memory impairment and over 40% had additional cognitive difficulties in reasoning or processing speed. The poor outcomes are in keeping with follow‐up data in LE adult patients, reporting mRS score ≥3 in 35/80 (44%) at last follow‐up (median follow‐up of 22.5 months).Consistent with the literature in children,In this study, PICU admission was required (predominantly for seizure management) in 16/25 (64%) children, higher than up to 48% reported in pediatric anti‐NMDAR encephalitis.The involvement of extra‐limbic areas may occur in patients with LE, termed as “LE plus” in the adult literature.Cognitive impairment is not always apparent at disease onset in LE, which can result in potential treatment delayEarly initiation of immune therapy with rituximab  has been shown to result in a more favorable prognosis for children with conditions such as anti‐NMDAR encephalitis; a multicenter study of 144 children with autoimmune and inflammatory CNS disorders demonstrated that in 39 children with anti‐NMDAR encephalitis, 92% had mRS 0–2 at last follow‐up in the “early” treated group (those who received rituximab within 4 weeks of symptoms onset) compared to only 57% in the “late” treated group.Our study is limited by its retrospective design, with a small sample of patients given the rarity of the condition and a lack of standardized data collection as a “real‐world” observational cohort. Furthermore, despite the distinct clinical phenotype, LE is likely to represent many immuno‐pathobiological entities. In the current era of precision‐targeted therapies, future humoral and cellular biomarker identification are required to gain insight into the pathogenesis for early diagnosis and optimal treatment of LE.Cheryl Hemingway has received educational and travel grants from Merck Serono and Bayer and Biogen.Ming Lim receives research grants from Action Medical Research, the DES society, GOSH charity, National Institute for Health Research, MS Society, and SPARKS charity; receives research support grants from the London Clinical Research Network and Evelina Appeal; has received consultation fees from CSL Behring, Novartis and Octapharma; received travel grants from Merck Serono.Saraswathy Sabanathan and Omar Abdel‐Mannan: Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. Kshitij Mankad, Ata Siddiqui, and Krishna Das: Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data. Lucinda Carr, Christin Eltze, Jon Gadian, Cheryl Hemingway, Marios Kaliakatsos, Rachel Kneen, Deepa Krishnakumar, Bryan Lynch, Amitav Parida, Thomas Rossor, Micheal Taylor, and Evangeline Wassmer: Drafting/revision of the manuscript for content; major role in the acquisition of data. Michael Eyre: Drafting/revision of the manuscript for content, analysis, or interpretation of data, and drafting/revision of the manuscript for content, including medical writing for content. Sukhvir Wright: Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data. Ming Lim and Yael Hacohen: Drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; and analysis or interpretation of data.Tables S1–S4. Clinical history, demographics, treatment, and follow‐up information for 25 cases of limbic encephalitis.Click here for additional data file.Tables S5. Cognitive profile of nine cases of limbic encephalitis who had standardized tests administered.Click here for additional data file.Tables S6. Univariate analysis of risk factors for refractory seizures, cognitive impairment, and mRS score of 3 or more in 25 cases of limbic encephalitis.Click here for additional data file.


Impulse control behaviors (ICBs) in Parkinson's disease (PD) are thought to be caused by an overdose of dopaminergic therapy in the relatively spared ventral striatum, or by hypersensitivity of this region to dopamine. Alterations in brain networks are now also thought to contribute to the development of ICBs.To comprehensively assess white matter microstructures in PD patients with ICBs using advanced diffusion MRI and magnetization transfer saturation (MT‐sat) imaging.This study included 19 PD patients with ICBs (PD‐ICBs), 18 PD patients without ICBs (PD‐nICBs), and 20 healthy controls (HCs). Indices of diffusion tensor imaging (DTI), diffusion kurtosis imaging, neurite orientation dispersion and density imaging, and MT‐sat imaging were evaluated using tract‐based spatial statistics (TBSS), regions of interest (ROIs), and tract‐specific analysis (TSA).Compared with HCs, PD‐nICBs had significant alterations in many major white matter tracts in most parameters. In contrast, PD‐ICBs had only partial changes in several parameters. Compared with PD‐ICBs, TBSS, ROI, and TSA analyses revealed that PD‐nICBs had lower axial kurtosis, myelin volume fraction, and orientation dispersion index in the uncinate fasciculus and external capsule, as well as in the retrolenticular part of the internal capsule. These are components of the reward system and the visual and emotional perception areas, respectively.Myelin and axonal changes in fibers related to the reward system and visual emotional recognition might be more prominent in PD‐nICBs than in PD‐ICBs. Impulse control disorders (ICDs), including gambling disorders, compulsive shopping, compulsive sexual behaviors, and binge eating, occur in around 8%–40% of Parkinson's disease (PD) patients.Diffusion‐weighted magnetic resonance imaging (DW‐MRI) techniques have been developed to be able to detect intracerebral microstructural changes in PD.One conventional DTI study revealed that several areas, including orbitofrontal areas, the corpus callosum, and the internal capsule, are preserved in PD patients with ICDs compared with PD patients without ICDs.We used brain MRI to prospectively evaluate PD patients with ICBs (PD‐ICB), PD patients without ICBs (PD‐nICB), and healthy controls (HCs). All groups were approximately matched for age and sex. Patients with major abnormalities in the standard MRI, or those diagnosed with dementia with PD or dementia with Lewy bodies according to the Movement Disorders Society (MDS) criteria, were excluded.The study protocol complied with the Declaration of Helsinki and was approved by the ethics committee of Juntendo University (14–011). Written informed consent was given by all participants.b values of 1000 and 2000 s/mm2, completed with a b = 0 image with no diffusion gradients. PD patients were scanned during the “on” state. DWI data were acquired along 64 isotropic diffusion gradients in the anterior–posterior phase‐encoding direction. Standard and reverse phase‐encoded blipped images with no diffusion weighting (blip up and blip down) were acquired to correct for magnetic susceptibility‐induced distortions related to the echo‐planar imaging acquisitions.All participants were scanned on a 3‐T MRI scanner  using a 64‐channel head coil. Diffusion weighted imaging (DWI) was obtained using spin‐echo planar imaging consisting of two The 3D multi‐echo fast low‐angle shot sequences were performed with predominant T1‐, proton density‐, and MT‐weighting for calculating the MT‐sat index. Acquisition parameters for MT‐sat were as follows: MT‐off and MT‐on scanning = repetition time, 24 ms; echo time, 2.53 ms; flip angle, 5°; and T1‐weighted imaging = repetition time, 10 ms; echo time, 2.53 ms; flip angle, 13°; parallel imaging using GeneRalized Autocalibrating Partial Parallel Acquisition factor 2 in the phase‐encoding direction; 7/8 partial Fourier acquisition in the partition direction; bandwidth, 260 Hz/pixel; field of view, 224 × 224 mm; matrix size, 128 × 128; slice thickness, 1.8 mm; and acquisition time, 6 min 25 s.http://www.nitrc.org/projects/noddi_toolbox). Maps of intracellular volume fraction (ICVF) and orientation dispersion index (ODI) were acquired using accelerated microstructure imaging via convex optimization. The diffusion‐weighted data were then processed using the Diffusional Kurtosis Estimatorb = 0 and 1000 s/mm2. Maps of fractional anisotropy (FA) and mean diffusivity (MD) were calculated using the Diffusion Toolbox tool implemented in the FMRIB Software Library , based on standard formulae.All DWI datasets were corrected for susceptibility‐induced geometric distortions, eddy current distortions, and inter‐volume subject motion using EDDY and TOPUP toolboxes.MT‐sat data were used to calculate the MVF using an in‐house MATLAB script based on the theory described previously.Voxel‐wise statistical analysis was carried out using tract‐based spatial statistics (TBSS), which is part of FSLAny maps that showed significant clusters in the TBSS analyses were localized using the John Hopkins University ICBM‐DTI‐81 white matter labels and white matter tractography atlases.http://www.brain.org.au/software/). We estimated five white matter tracts in which significant differences were observed between PD‐ICBs and PD‐nICBs in the ROI analysis. The pathways were categorized in the ROI analysis  to validate the ROI analyses using the probabilistic Multi‐Shell Multi‐Tissue Constrained Spherical Deconvolution (MSMT‐CSD)is Table  using thhttp://www.kisnet.or.jp/nappa/software/star/freq/chisq_ixj.htm#).All statistical analyses were performed using JMP 13  and GraphPad Prism 8 , except for the general linear model (GLM) analyses, which were performed using FSL, and the chi‐squared test, which was performed using js‐STAR version 9.7.0j  was performed using LEDD as a covariate to evaluate the effect of LEDD. Spearman's rank correlation test was used for the correlation analysis between LEDD and each parameter. A p‐value of less than 0.05 was considered statistically significant.For the ROI analyses and TSA, we used the Kruskal–Wallis test for nonparametric parameters and one‐way analysis of variance for parametric parameters. False discovery rate controlling procedures were then applied to correct for multiple testing. For post hoc analyses, we used the Mann–Whitney p = 0.0320 and 0.0159, respectively), as expected. There were no significant differences in disease duration, H&Y stages, and MDS‐UPDRS part I and III scores between the PD‐ICB and PD‐nICB groups. The symptoms of ICBs are shown in the “QUIP” row in Table Table In TBSS, there were apparent diffuse changes in the white matter of PD‐nICBs compared with HCs, such as higher MD and lower MK, RK, AK, ICVF, and MVF. In contrast, areas with significant differences were restricted to a partial elevation of MD and reduction of AK in the PD‐ICBs compared with HCs Fig. . The sigSignificant differences in the MD, AK, ODI, and MVF of certain areas were found between the PD‐ICB and PD‐nICB groups in the TBSS analysis; thus, the ROIs of these values were evaluated. ROIs from left white matter structures were evaluated for ODI analysis because changes were almost always localized to the left side. For the analysis of other indices, the mean values of bilateral structures were evaluated. On the basis of the TBSS results, five areas each for MD and AK, three areas for ODI, and seven areas for MVF were analyzed. Among these areas, one area for MD, three areas for AK, one area for ODI, and three areas for MVF were significant. Of these areas, the splenium of the corpus callosum (SCC) for AK and the external capsule for MVF survived the multiple comparison adjustments Table . On the p < 0.0001, PD‐ICBs: p = 0.0298) and lower MVFs  in the inferior longitudinal fasciculus , uncinate fasciculus , and external capsule  (Table p = 0.0190). Only the ODI value was abnormal in the PD‐ICBs, with a significantly higher ODI in the retrolenticular part of the internal capsule (RLIC) compared with the PD‐nICBs (p = 0.0122); there was no difference between the PD‐nICBs and HCs.Compared with the PD‐ICBs and HCs, the PD‐nICBs showed notable alterations in most parameters, including a significantly lower AK  in the SCC (HCs: 6) Table , Fig. 2.TSA, which was performed to validate the ROI analyses, revealed almost the same results: significantly lower MVFs in the uncinate fasciculus and external capsule in PD‐nICBs and a significantly higher ODI in the RLIC in PD‐ICBs compared with those in the other groups Figs.  and 4. Tp = 0.0468). To evaluate the effect of LEDD on ODI of RLIC, we performed an ANCOVA using LEDD as a covariate for both the ROI and TSA analyses. A significant difference in ODI‐RLIC was found in the TSA analysis after adjustment (p = 0.0335). The ROI analysis revealed the same tendency, although it did not reach significance (p = 0.0948).An additional analysis that included LEDD, age, and sex as covariates Fig.  revealedTo elucidate the pathological white matter microstructure changes that occur with ICBs in PD, we comprehensively evaluated cerebral white matter in HCs and in PD patients with and without ICBs using the latest MRI modalities: DTI, DKI, NODDI, and MT‐sat imaging. Table On the basis of our results, we detected five significant areas associated with ICBs: the uncinate fasciculus, external capsule, ILF, RLIC, and SCC.The uncinate fasciculus and the external capsule are both involved in the reward system.Impulsivity was associated with the relative preservation of mesolimbic connectivity in patients with PD. Consistent with our results, the preservation of connectivity between the substantia nigra and limbic network targets has been reported in PD patients with ICBs.The RLIC contains tracts that run from the pulvinar and lateral geniculate nuclei to the association and visual cortices (Fig. Our findings support a previous DTI studyOur study had several limitations. First, PD diagnoses were not determined pathologically, and the number of patients were relatively small. Second, pathological studies are needed to investigate the exact meaning of each MRI parameter in PD patients with and without ICBs. Third, the ICB diagnoses were only based on QUIP‐J scores. However, all cases with ICBs also had specific symptoms clinically confirmed. Although HCs were not assessed for ICBs using QUIP‐J, we recruited HCs without any neurological or psychiatric disorders based on detailed interviews of their medical history. Finally, in our cohort, there was a significant difference in LEDD and LEDD‐DA between the PD‐ICD and PD‐nICD groups. Additionally, the groups were not perfectly sex‐matched, although they were not significantly different. These factors may affect the results. However, the TBSS results were almost the same even when analyzed using age, sex, and LEDD as covariates Fig. . MoreoveIn conclusion, DKI and MT‐sat imaging revealed less change in white matter microstructures—especially those associated with the reward system and visual and emotional recognition—in PD‐ICBs than in PD‐nICBs, and NODDI was able to detect a characteristic change in the white matter of PD‐ICBs. PD patients with these preserved pathways may therefore be vulnerable to ICBs..The authors have no conflict of interest to reportTable S1 Seed and target ROIs for each pathway analyzed in tract‐specific analysis.Table S2. TBSS analysis of DTI, DKI, NODDI, and MT‐sat indices in PD patients with and without ICB vs. healthy controls, and in PD patients with ICB vs. PD patients without ICB.Table S3. ROI analysis of the indices with significant differences between PD patients with and without ICBs.Table S4. TBSS analysis of ODI and MVF in Parkinson's disease patients with and without impulsive‐compulsive behaviors adjusted for age, sex, and levodopa equivalent daily doseTable S5. Methods and parameters used in this studyClick here for additional data file.


Late presentation to HIV/AIDS care presents serious health concerns, like increased transmission and high healthcare costs, increased mortality, early development of opportunistic infection, increased risk of antiretroviral therapy drug resistance. Despite the effort to contain the HIV/AIDS epidemic, LP has remained an impediment to individual immune reconstitution and public health.This review aimed to estimate the prevalence and determine the factors associated with late presentation to HIV/AIDS care.I2 statistics and Q-test to estimate heterogeneity between studies. Random-effects meta-analysis models were used to calculate the aggregate odds ratio of late presentation to HIV/AIDS care.We searched PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Wanfang, and Weipu database for articles published from 2010 to 2020. We utilized OR = 2.19, 95% CI: 1.85–2.58; I2 = 97.44%), married , with heterosexual contact as risk factor for infection  and diagnosed in medical institutions . In middle or low HIV prevalence areas, patients ≥ 50 years old (P = 0.01), married (P < 0.01) and diagnosed in medical institutions (P = 0.01) were more likely to be presented late than in high prevalence areas. From 2016–2020, the OR of patients who were married and diagnosed in medical facilities were significantly lower than before (P < 0.01).Of 9563 titles and abstracts retrieved, 189 were identified as potentially eligible and 39 fulfilled the inclusion criteria. The pooled prevalence of late presentation to HIV/AIDS care was 43.26%. The major risk factors were patients ≥ 50 years old (Patients ≥ 50 years old, married, with heterosexual contact as risk factor for infection, and diagnosed in medical institutions were risk factors of LP. Gender had no significant relationship with LP. In middle or low prevalence areas, patients who were ≥ 50 years old, married, and diagnosed in medical institutions were more likely to be presented late than in other areas. Married patients and those diagnosed in medical institutions after 2015 have a lower risk of LP than before.The online version contains supplementary material available at 10.1186/s12981-021-00415-2. Late presentation (hereon in referred to as LP) to HIV care remains a challenge to HIV prevention and treatment in the world. In Guatemala from 2000 to 2015 . LP may Improving early presentation is of great importance for AIDS prevention and care. Early presentation means early entry to HIV care. Study evidence showed that patients shtarting early ART could have a near-normal life expectancy, provided that they start treatment before their CD4 count decreases below 200 cells/µl . Early ATo our knowledge, there is only two published systematic review and meta-analysis on HIV late presentation and its predictors , 16. In We searched PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Wanfang, and Weipu databases for articles published in English and Chinese from 2010 to 2020. Using the following Boolean term to search the databases: (TS = “HIV/AIDS” OR TS = “human immunodeficiency virus” OR TS = “Acquired immunodeficiency syndrome”) AND (TS = “late presentation” OR TS = “late diagnosis” OR TS = “late testing” OR TS = “delay presentation” OR TS = “delay diagnosis” OR TS = “delay testing”) in Chinese and (TS = "HIV/AIDS") AND (TS = "late entry" OR TS = "Advanced HIV disease" OR TS = "late presentation" OR TS = "late Diagnosed") in English. We also retrieved the studies referenced in all included studies to obtain further related studies. Our analyses followed the 2009 Preferred Reporting Items for Systematic reviews and Meta-Analyses(PRISMA) statement.Articles included met all the following criteria: (1) observational studies, including cross-sectional, case–control, and cohort studies; (2) studies reported the prevalence and associated factors of LP to HIV care in China from 2010 to 2020; (3) sufficient data present to estimate the odds ratios (ORs) with 95% confidence intervals (CIs); (4) studies defined late presentation of HIV/AIDS according to the European definition or other definitions recognized appropriate. Articles were excluded based on at least one of the following: (1) studies that do not meet the criteria above; (2) studies absence of original data, such as the number of patient with different factors; (3) studies published based on the same or overlapping data; (4) review, case report or meeting report.OR) and it's 95% CI. The Newcastle–Ottawa quality-assessment scale (NOS) was employed to assess the quality of those included studies. We evaluated the quality of evidence using the "grading of recommendations assessment, development, and evaluation" (GRADE) approach.The studies searched were managed by Endnote (version X9) and de-duplicated. The studies were first screened by title and abstracts independently by two investigators according to the inclusion and exclusion criteria. If there were any conflicts between the results, all three authors of this review would screen the full text to discuss and resolve it before reaching a consensus. Moreover, the references cited in all included studies were screened by two investigators independently. Information retrieved from each eligible study comprised of:- title, first author, publication year, study design, study period, study time, the definition of LP, geographical locations, source population, number of subjects in each category, the value of odds ratios. Otherwise, fixed-effect models were applied. Subgroup analysis focused on study region and period. The study regions were categorized into high prevalence regions  and others according to the proportion of HIV infected patients in the nationally reported cases [2 test was employed to estimate the proportion difference between the subgroups.We estimated heterogeneity between studies with ed cases . χ2 testP > 0.05 represented no publication bias). We conducted all statistical analysis with Stata 16.0 and SPSS 24.0.Sensitivity analysis was employed to assess the sensitivity of each included study. Publication bias was measured using the Harbord test and funnel plots . After the removal of duplicates, 6462(67.6%) remained. A total of 189 articles were eligible following titles and abstracts screening. After the full-text screening, 39 papers were finally included (36 Chinese and 3 English studies). The flowchart of studies identified by the search is in Fig. All of the 39 studies were case–control studies. According to the NOS assessment, the scores of all studies were ≥ 5, which denoted good quality. Included papers were from 2010 to 2020. The study regions covered 21 provinces or municipalities: Guangxi, Guangdong, Sichuan, Xinjiang, Yunnan, Jiangsu, Taiwan, Anhui, Beijing, Fujian, Gansu, Guizhou, Jiangxi, Liaoning, Shandong, Shaanxi, Shanxi, Tianjin, Zhejiang, Chongqing, and Hubei. We classified all study regions into high HIV prevalence or middle/low HIV prevalence groups based on HIV prevalence. Among these provinces and municipalities, Guangxi, Guangdong, Sichuan, Xinjiang, Yunnan are high HIV prevalence areas. Twenty-six (26) studies investigated the LP rate and evaluated the association between patients with age ≥ 50 and LP. The relationship between gender and LP was reported in 32 studies, and 38 publications researched the relationship between being married and LP. The number of studies that investigated the association of risk factor for infection and sample source with LP was 35. There are 12 articles with study time between 2010–2015, while four studies investigated the participants after 2015. The characteristics of the included publications are in Table OR = 2.19, 95% CI: 1.85–2.58; I2 = 97.44%), married , with heterosexual contact as risk factor for infection  and diagnosed in medical institutions  were more likely to be diagnosed late. While male was not a risk factor for LP . In high prevalence areas, patients ≥ 50 years old (P = 0.01), married (P < 0.01) and diagnosed in medical institutions (P = 0.01) were less likely to be presented late than in middle or low areas.Figure P < 0.01). For patients < 50 years old, ≥ 50 years old, male, female, married, with heterosexual contact as risk factor for infection, diagnosed in medical facilities and other institutions, the LP ratio decreased in 2016–2020 compare to 2010–2015 (P < 0.01). While in middle or low epidemic areas, the proportion of LP during 2016–2020 was high than before, and the difference was statistically significant (P = 0.015). As presented in Table OR = 1.67, 95% CI:1.35—2.07; I2 = 87.85%; P = 0.01), male , married  and diagnosed in medical institutions  were less likely to be presented late than in middle or low areas. There were no statistically significant group differences. The risk of LP from 2020 to 2015 was 1.81, , 3.00,  respectively for patients married and diagnosed in medical institutions, whereas from 2016 to 2020 was 0.94, , 1.57, . The observed differences in risk estimates between the groups were statistically significant (P < 0.01).As shown in Table The quality grade of age, infection routes, and sample sources were high. The grade score of gender and marital status was moderate. An additional file shows this in more detail   Table .We conducted 39 publications to identify the related factors of LP in China. It showed that the overall LP proportion from 2010 to 2020 in China was 43.26%. Patients ≥ 50 years old, married, with heterosexual contact as risk factor for infection, and diagnosed in medical institutions were risk factors of LP. Gender had no statistically significant relationship with LP. In high prevalence areas, patients who were ≥ 50 years old, married, and diagnosed in medical institutions were less likely to be presented late than in other areas. It suggested the need for targeted measures to reduce the occurrence of LP in different regions. Additionally, we have made some suggestions on prevention and policy making of LP to HIV care based on these data.In the general health environment, the elderly and female should be associated with reduced odds of LP because they have better health seeking behaviours. However, in our study the results were different. In China, partly of the HIV positive female did not realize the risk because they were infected by their husband. That might lead to the result after pooling the articles. Studies have shown that the elderly have limited access and ability to obtain and understand HIV/AIDS prevention information –59. AddiIn subgroup analysis, the proportion of LP in high epidemic areas is higher than in middle or low regions. When comparing the occurrence of LP in two time periods in middle or low epidemic areas, the latter period was significantly higher than the former. Action plan for AIDS containment and prevention in China in 12th Five-Year put forward measures to expand the coverage of publicity and education, comprehensive intervention, testing and treatment . Even thThere are some other findings in this study. Firstly, previous studies on the influencing factors of LP to HIV care mainly focused on social demographic determinants. There are still many other related factors to be explored, such as behavioral factors, AIDS knowledge level, access to testing and ART, policy, and social support. Secondly, there are few studies on the ART and immune reconstitution of LP patients. There are several limitations. The criteria for LP for the included publications were different, and the results may deviate from the real world. Therefore, there is an urgent need for a consensus definition of LP to facilitate full use of the actual material to reflect the problems and find solutions. Secondly, we included four articles in the 2016–2020 group, which may have led to bias in our results.Generally, LP remains an obstacle to the prevention and treatment of HIV/AIDS in China. Targeted public health interventions to improve early entry into HIV care are urgently needed. We still have a lot to do for HIV-related policy-making, testing strategy, and health education in the future.Patients ≥ 50 years old, married, with heterosexual contact as risk factor for infection, and diagnosed in medical institutions were risk factors of LP. Gender had no significant relationship with LP. Although the country have expanded the coverage of testing and treatment of HIV through great efforts, LP is still a pressing problem in high prevalence regions. In middle or low prevalence areas, patients who were ≥ 50 years old, married, and diagnosed in medical institutions were more likely to be presented late than in other areas. Patients married and diagnosed in medical institutions after 2015 have a lower risk of LP than before. Governments should also take measures to expand the coverage of education, testing, and treatment of HIV.Additional file 1. The quality grade of patients exposed to different factors with late presentation compare to non-late presentation.Additional file 2. The conventional funnel plots of different factors.


While six studies with 10 030 patients reported a lower risk of mortality in ACEIs/ARBs group hazard ratio (HR) of 0.53, 95% CI 0.34–0.84, p = .007, I2 = 68%. Similar association (for HR) was found in hypertension subgroup. There was no significant association for the secondary outcomes. Based on the available data, we concluded that ACEIs/ARBs is not associated with the risk of in‐hospital all‐cause mortality in COVID‐19 patients, but may be associated with a decreased risk of 30‐day all‐cause mortality. Patients with hypertension may benefit from using ACEIs/ARBs.Since the COVID‐19 pandemic, physicians concerned about the potential adverse effects of angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). To explore the relationship between ACEIs/ARBs and the risk of mortality and other clinical outcomes in COVID‐19 patients, the authors conducted a systemic review and meta‐analysis. An electronic search was performed from inception to November 12, 2020 in PubMed, Medline, EMBASE, ClinicalTrials, TRIP, the Cochrane Library, CNKI, Wanfang, and CBM database. Risk of bias was assessed using the Risk Of Bias In Non‐randomized Studies of Interventions tool. The primary outcome was in‐hospital all‐cause mortality. Secondary outcomes included all‐cause mortality measured at 30‐day or longer term, mechanical ventilation, length of hospital stay, readmission, and cardiac adverse events. A total of 28 studies with 73 465 patients was included. Twenty‐two studies with 19 871 patients reported the incidence of all‐cause mortality. Results showed no association between using ACEIs/ARBs and risk of mortality crude odds ratio （OR） of 1.02, 95% CI 0.71–1.46,  SARS‐Cov‐2 can bind angiotensin converting enzyme 2 (ACE2) and allows the virus to invade cells, which may lead to activate immune response and lung injury.In March 2020, a small sample study in China began to explore the impact of ACEIs/ARBs use on outcomes in patients with COVID‐19, with an increasing number of studies published subsequently. Most of these retrospective studies reported neutral results. Several cohort studies reported a significantly lower rate of short‐term death in ACEIs/ARBs group. To date, more than 10 published meta‐analyses have evaluated the effect of ACEIs/ARBs on mortality in patients with COVID‐19. The odds ratio (OR) showed the risk of mortality was similar for ACEIs/ARBs users and non‐users. However, these reports all included unpublished studies and most of them enrolled suspected cases. Unpublished studies did not undergo peer‐review process and may increase the risk of bias. A few of them distinguish the adjusted OR and hazard ratio (HR). Half of them only evaluated all‐cause mortality without other clinical outcomes. Therefore, we conducted a retrospective systematic review of studies evaluating patients with confirmed COVID‐19 treated with ACEIs/ARBs to further explore whether these medications influence mortality or other clinical outcomes.22.1This systematic review was carried out in accordance with the meta‐analysis of observational studies in epidemiology and preferred reporting items for systematic reviews and meta‐analyses statements. An electronic search was performed from PubMed, Medline, EMBASE, ClinicalTrials, TRIP, the Cochrane Library, Chinses National Knowledge Infrastructure (CNKI), Wanfang database and Chinese BioMedical (CBM) database. Drafts of protocol was developed and reviewed. The protocol was registered on PROSPERO on August 4, 2020 (CRD42020202402). Trials were identified through a comprehensive systematic search from inception to June 21, 2020 in PubMed, Medline, EMBASE, ClinicalTrials, TRIP, the Cochrane Library, CNKI, Wanfang and CBM database using the strategies presented in Appendix 1. No language restrictions were applied.2.2We included studies of patients with COVID‐19 confirmed by polymerase chain reaction (PCR) or genetic tests; ACEIs /ARBs use data were provided. The interventional group was ACEIs or ARBs user. The comparator was no use of ACEIs or ARBs, irrespective of combined use with other medications.Three reviewers  screened the search titles and abstracts. All potentially relevant citations were requested and inspected in detail using the full text version. Articles without full texts, duplicated publications, reports lacking data, and articles not reporting any outcomes of interest were excluded from the analysis. Disagreements were resolved by discussion with assistance from a forth reviewer (PZ).2.3Our primary outcome was in‐hospital all‐cause mortality. Secondary outcomes included all‐cause mortality measured at 30‐day or longer term, usage of mechanical ventilation, length of hospital stay, readmission and cardiac adverse events. Subgroup analysis was conducted to test the difference in effect size for the following subgroups: age (≥65‐years‐old versus  < 65‐years‐old); sex ; ACEIs or ARBs alone versus in combination with other medications; ACEIs and ARBs previously used versus ACEIs and ARBs used during hospitalization versus ACEIs and ARBs used continuously.2.4Two reviewers (SZ and WC) independently assessed the risk of bias based on methods endorsed by The Cochrane Collaboration. RoB2, the revised tool was used to assess the risk of bias in randomized trials. For cohort studies and case‐control studies, we used the Risk Of Bias In Non‐randomized Studies of Interventions (ROBINS‐I) tool to assess the risk of bias. The biases assessed include the biases associated with the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, selection of the reported result, confounding, selection of participants into the study and classification of interventions.2.5Data from each study was extracted independently by two separate reviewers (SD and WC) using a pre‐designed data extraction form. Any disagreements were resolved by discussion with assistance from a third reviewer (SZ). We extracted all relevant characteristics of all included studies including general study characteristics, participants' information, intervention, characteristics of outcome, ACEIs/ARBs‐related risk factors with reported estimates of association and corresponding crude and adjusted estimates.2.6I2 estimate greater than or equal to 50% accompanied by a statistically significant chi‐square statistic was interpreted as evidence of substantial levels of heterogeneity. If the number of studies more than 10, we conducted a funnel plot to test the reporting bias of one specific outcome. We synthesized data using a fixed‐effects method for all analyses. We explored the source of heterogeneity and conducted a subgroup analysis if the source of heterogeneity was identified. We synthesized data using a random‐effects model when we could not determine the source of heterogeneity. If heterogeneity was found and the source of heterogeneity was identified, a post‐hoc subgroup analysis according to the particular factor was conducted. All analyses were performed in Review Manager 5.1 .Meta‐analysis was performed for quantitative synthesis. In cases where data was not eligible for meta‐analysis, we narratively synthesized data. We summarized all dichotomous outcome data using odds ratios (ORs) or hazard ratios (HRs) and their 95% confidence intervals (CIs). We summarized all continuous outcome data using mean differences (MDs) and their 95% CIs. Heterogeneity in the study results included clinical heterogeneity, methodological heterogeneity, and statistical heterogeneity. When we suspected heterogeneity, we highlighted and fully discussed the reasons when this was possible. We visually inspected forest plots to investigate possible statistical heterogeneity; an 33.1Two thousand seven hundred sixty two records were identified and 2654 trials were rejected after title‐abstract screening. Of these, 117 full‐text articles were assessed for eligibility, with 89 studies excluded due to inadequate design, population, or outcome. From June 21, 2020 to November 12, 2020, we updated search results in PubMed and added an additional nine studies to the final analysis  was 0.4–42.1%. The majority of studies provided data on hospital deaths, and three studies provided mid‐term or long‐term death data. In most studies, groups of patients using either of ACEIs/ARBs were combined for statistical reasons, while a few studies performed separate statistical analyses. The methodological characteristics of the included studies are summarized in Table 3.2Risk of bias assessment was shown in Appendix 2. Three studies were assessed as having serious risk of bias, and 13 studies were found to be moderate risk of bias. Twelve studies were considered as having low risk of bias.3.3p =.89, 2 I= 89%). Seven studies with 6260 patients reported adjusted OR and produced a non‐significant association . Six studies with 10 030 patients reported a reduced risk of mortality  . Four studies reported adjusted OR with 1927 patients produced a non‐significant  .In the hypertension subgroup , 13 studies with 4887 patients reported a crude OR of mortality . Among them five studies with 2,572 patients reported an adjusted OR for ventilation, still without association with ACEIs/ARBs use . We narratively synthesized the results of duration of hospital stay, but did not show a significant difference. Only Richardson and coworkerp = .62, 2 I= 83%, Appendix 3, Figure 7), and an adjusted OR 1.34 , respectively. Ran and coworkerSeven studies with 4,576 patients reported the risk of ventilation and the result showed no association , 1.30 , and 1.28 , respectively .We preset the subgroup analysis for sex and age in the prior subgroup. However, only few individual studies were available. Soleimani and coworkern = 1791) yielded a crude OR of 0.83 . Only one study showed an adjusted OR 0.14 . Three studies with 3234 patients provided a HR of 0.86 . None of the results showed a significant difference between the groups. In the ARBs subgroup, five studies  showed a crude OR of 0.82 . Two studies (without sample size) had an adjusted OR of 1.11 . Four studies with 4357 patients indicated a lower risk of mortality in ARBs group .Analysis of the ACEIs and ARBs use as separate subgroups is shown in Figure 3.6p = .48, 2 I= 89%, and adjusted OR of 0.96, 95% CI 0.77–1.18, p = .68, I2 = 0%, respectively. While for HR, it is still significantly favored ACEIs/ARBs use . In the hypertension subgroup, the crude OR, adjusted OR showed non‐significant association  (Appendix 3).Additionally, three studies4The inconsistent conclusions about the use of ACEIs/ARBs call for more rigorous studies to demonstrate the effect of ACEIs/ARBs in different population. Several relevant systematic reviews and meta‐analysis summarized available evidence and suggested continue use of ACEIs/ARBs based on the lack of association of the treatment on the risk of mortality or severity of outcomes. By using strict paper inclusion criteria, and adjusting for confounding effect whenever possible, our systematic review provided relatively higher quality of evidence to increase the assurance of using ACEIs or ARBs on COVID‐19 patients. We identified 28 studies with 73 465 COVID‐19 patients and confirmed a non‐significant association between ACEIs/ARBs use and the risk of all‐cause mortality. Besides, our study found ACEIs/ARBs reduced the risk of 30‐day all‐cause mortality in both the entire population and the hypertension subgroup. Since SARS‐Cov‐2 can bind ACE2 and allows the virus to invade target cells, which may lead to activate immune response and cause lung injury, there still have discussion about using ARBs to replace ACEIs according to this mechanism. Our head to head comparison of ACEIs versus ARBs showed no difference in association with the risk of mortality. Furthermore, our study showed that ACEIs/ARBs use was not associated with other not fully addressed secondary outcomes such as long‐term mortality, ventilation, readmission, and cardiac adverse events.At present, there are more than 10 published meta‐analyses23,37,39 to reduce the risk of mortality, while more studies showed non‐significant associations between them.21,24,27,28,30,35 Among hypertensive patients, more studies supported lower risk of mortality in ACEIs/ARBs group,High heterogeneity was present in pooled crude OR. Some studiesOR was not significantly favor ACEIs/ARBs use, but HR showed an opposite result. In Ren 2020′s review, they observed a significant reduced severity of COVID‐19 infection and risk of mortality (measured by OR) and they suggested favor use of ACEIs/ARBs in hypertension groups. Since the data did not provide comparison between age group (≥65‐years‐old versus < 65‐years‐old), our study made three subgroup analyses according to the statistical difference of age variable in the original studies, for example, ‘p > .05′, ‘p≤.05′, and ``absent p value’’ , and produced crude ORs of 0.78 (95% CI 0.51–1.19), 1.30 (95% CI 0.74–2.30) and 1.28 (95% CI 0.64–2.56), respectively. Interestedly, from the data with p > .05 for age, it tends to favor ACEIs/ARBs use. So, age maybe an important factor causing heterogeneity and changing the direction of the association between ACEIs/ARBs and risk of mortality. However, longer term follow‐up study by Tirifiro 2020′sOur study conducted some subgroup analysis for the association of adverse outcomes and the use of ACEIs/ARBs according to our protocol. Hypertension was the most common comorbidities and ACEIs/ARBs user population. Our study showed that adjusted Since data are limited, we did not pool the studies about continue using and stop using ACEIs/ARBs after COVID‐19 infection. The study by Soleimani 2020 suggested that the death rate in patients who stopped using ACEIs/ARBs was higher than that of other groups. On the other side, a trail (NCT04338009) conducted in the USA comparing the mortality rate between discontinuation versus continuation using ACEIs/ARBs found that the mortality was 12.99% versus 14.67%, which suggested favor discontinuous use of ACEIs/ARBs. However, the reason for interrupting use of ACEIs/ARBs was not well explained.There are some limitations in this study. First, the original observational studies inherit high risk of bias and reduce the quality level of evidence. So using strict paper inclusion criteria, and adjusting for confounding effect whenever possible, we got our data have a moderate to low risk of bias (Appendix 2). Second, although we used adjusted OR and adjusted HR whenever possible to reduce the confounding effect, some bias still cannot be fully addressed. For example, patients with hypertension and other cardiovascular disease needed to be prescribed ACEIs or ARBs may have different disease risk and prognosis even though they did not have COVID‐19. Due to the limitation of data, this meta‐analysis cannot control the bias caused by different cardiovascular comorbidities. Third, although our study found using ACEIs/ARBs statistically significant reduced the risk of mortality evaluated by HR, it should be noticed that among the six studies reporting HR, four were conducted in Wuhan, China, and two were in Europe, which may influence the representativeness of population.5Based on the available data, we conclude that using ACEIs/ARBs is not associated with the risk of in‐hospital all‐cause mortality in COVID‐19 patients, but may be associated with a decreased risk of 30‐day all‐cause mortality. Patients with hypertension may benefit from using ACEIs/ARBs.Disciplines Construction Project of Peking Union Medical College (No.201920202102) initiated the study. CAMS Innovation Fund for Medical Science (No. 2018‐I2M‐1‐002) supported data extraction and the assessment of the risk of bias.There are no conflicts of interest to declare.Deping Liu and Zeng Ping conducted this study. Deping Liu, Ping Zeng, Na Jia, Yan Wang, Sai Zhao, Jun Xia developed the protocol. Na Jia, Xuelin Sun, Yan Wang screened the literatures. Ping Zeng made the final decision if there is disagreement. Wenjie Chi, Sitong Dong extracted the data. Sitong Dong and Sai Zhao did the risk of bias assessment. Guifang Zhang did additional search and the data analysis. Na Jia drafted the manuscript. Ping Zeng, Deping Liu, Sai Zhao, Sitong Dong revised the manuscript.Supporting materialClick here for additional data file.Supporting materialClick here for additional data file.Supporting materialClick here for additional data file.