Adipose tissue, which is mainly composed of adipocytes, is a crucial component of the tumor microenvironment, particularly in breast cancer. Adipocytes surround breast cancer cells and may participate in cell‒cell interactions in the breast microenvironment. However, little is currently known about how adipocytes influence the biological behavior of the surrounding breast cancer cells. Hence, this study sought to investigate the role and underlying mechanisms of periostin in triple–negative breast cancer (TNBC) cells cocultured with adipogenic conditioned medium (ACM) and palmitic acid (PA).–related molecules were assessed by Western blotting and RT‒qPCR. The cellular viability was assessed using CCK‒8 assay. Plasmid transfection, RNA sequencing, and pathway inhibitor were used to explore the specific mechanisms of periostin.Human TNBC cell lines (MDA‒MB‒231 and SUM159PT) were treated with ACM and PA, then the expression of periostin, matrix metalloproteinases (MMPs) and stemness–related molecules in TNBCs. MMPs can promote tumor cell infiltration and migration by degrading the extracellular matrix, and stemness expression increases the development of tumor chemoresistance. Additionally, ACM and PA increased periostin expression, while inhibiting periostin disrupted the involvement of ACM and PA in promoting extracellular matrix degradation, stemness, and chemoresistance in TNBCs. Furthermore, this study found that periostin promoted TNBC progression by activating the MAPK/ERK signaling pathway and that inhibition of MAPK/ERK signaling reduced the phenotype caused by periostin upregulation in TNBCs treated with ACM or PA. Finally, the present results showed that the high expression of POSTN, which encodes periostin, was substantially related to worse survival in TNBC patients.ACM and PA elevated the expression of both MMPs and stemness–regulated tumor microenvironment, while periostin–neutralizing antibodies may serve as potential therapeutic agents in relation to TNBC progression.The results of the study elucidated for the first time how periostin is the key protein secreted in TNBCs in response to the adipocyteThe online version contains supplementary material available at 10.1186/s12944-023-01912-1. Triple–pression . Thus, tThe tumor microenvironment potentially plays a regulatory role in the development, progression, and metastasis of many malignancies. More specifically, different types of cells, including adipocytes, endothelial cells, and immune cells, within the tumor microenvironment continuously interact with cancer cells, thereby playing a significant role in tumor growth and progression , 5. Adip–mesenchymal transition, angiogenesis, and metastasis [Periostin, which is encoded by the POSTN gene, is both an extracellular matrix protein and a secreted protein . It has tastasis , 10. Clitastasis , 12.However, there have been no reports concerning the role and underlying molecular mechanisms of periostin in relation to communication between adipocytes and TNBC cells (TNBCs). Hence, in this study, we sought to examine the expression, role, and underlying mechanisms of periostin in TNBCs cocultured with adipogenic conditioned medium (ACM) and palmitic acid (PA) to gain insight into the mechanisms behind crosstalk between adipocytes and breast cancer cells as well as to identify effective targets for TNBC treatment.–MB–231 and SUM159PT) were purchased from American Type Culture Collection . Cells were cultured in RPMI 1640 medium  containing 10% fetal bovine serum  in a humidified incubator with 5% carbon dioxide and 37 °C.Human TNBC cell lines  were purchased from the indicated companies and administered at the indicated concentrations.For the in vitro experiments, PA , recombinant human periostin , periostin neutralizing antibodies , and U0126This study was approved by the Medical Ethics Committee of Affiliated Cancer Hospital & Institute of Guangzhou Medical University. Moreover, signed informed consent forms were obtained from each subject. We collected adipose tissue from the breast cancer mastectomy specimens of five TNBC patients. The participating patients’ clinical and pathological information is listed in Supplementary Table –derived adipocytes were prepared as previously described [–streptomycin  before being cultured in differentiation medium to obtain mature adipocytes, which were then cultured in maintenance medium for 24 h to collect the adipogenic conditioned medium. The differentiation medium contains the following ingredients: serum–free DMEM/F12, 2.5 mM glutamine, 15 mM HEPES, 1% antibiotic–antimycotic, 10 mg/ml transferrin, 33 µM biotin, 0.5 µM human insulin, 17 µM pantothenate, 0.1 µM dexamethasone, 2 nM T3, 540 µM IBMX, and 1 µM ciglitazone. The maintenance medium contained serum–free DMEM/F12, 2.5 mM glutamine, 15 mM HEPES, 1% antibiotic–antimycotic, 10 mg/ml transferrin, 33 µM biotin, and 0.5 µM human insulin. For the in vitro experiments, the TNBCs were treated with 100% ACM for 24 h, and the experiments were performed using at least three biological replicates.Mature human adipocytes were obtained from human adipose tissue within the breast cancer mastectomy specimens. Adipose tissueescribed . Briefly® Green Kit  in an ABI 7500 Real–Time PCR System . β–actin was used as an internal control. Relative mRNA expression was calculated using the 2−ΔΔCT method. The primer sequences are listed in Table Total RNA was extracted using TRIzol reagent  and reverse transcribed into cDNA with a PrimeScript kit  according to the manufacturer’s protocol. RT‒qPCR was performed with the SYBR–periostin , anti–ERK1/2 , anti–phospho ERK1/2 , anti–P38 , anti–phospho P38 , and anti–β–actin .Total protein was extracted from cells using RIPA buffer  in the presence of a protease inhibitor mixture  and quantified using a BCA protein assay kit . Western blotting was performed according to standard procedures. The following primary antibodies were used: antiThe conditioned medium (CM) of TNBCs cultured under different conditions was collected, and the concentration of periostin was determined with a human ELISA kit  according to the manufacturer’s protocols.–8 kit  according to the manufacturer’s instructions. In brief, the cells were seeded at a density of either 1 × 103 or 1 × 104 cells/well in a 96–well plate according to the specific experimental situation. The absorbance at 450 nm was determined using a BioTek Synergy 2 system, and the relative cell proliferation was calculated according to the formula included in the kit.To determine the proliferation of cells under different culture conditions, cell proliferation assays were performed using a CCK–LVRU6GP vectors containing specific shRNAs . The shRNA–POSTN sequence  was used for POSTN downregulation.To establish cells transfected with POSTN knockdown, Lipofectamine 3000  was used to transfect cells with psi–MB–231 cells treated with IgG antibody or rhPeriostin, and libraries were constructed using the VAHTS Stranded mRNA–seq Library Prep Kit for Illumina v2. The quality of the library was checked using Qubit 2100, and the concentrations were determined according to the analysis profiles. Genes expressed at a log2 (fold change) > 1 or < − 1 and a P < 0.05 were identified as differentially expressed genes and then subjected to Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses using DAVID Bioinformatic Resources 6.8.Total RNA was extracted from MDAhttp://ualcan.path.uab.edu/) is a comprehensive, interactive web resource for analyzing cancer omics data [http://kmplot.com) is capable of assessing the association between genes and survival in many types of cancer samples, including breast cancer, ovarian cancer, lung cancer, and gastric cancer samples. Kaplan‒Meier plotter was applied to illustrate the prognostic value of POSTN at the mRNA level based on cases enrolled from The Cancer Genome Atlas (TCGA). In terms of generating a Kaplan‒Meier curve, a convenient and widespread option for determining the cutoff is the median expression value [–low and POSTN–high groups based on the Kaplan‒Meier curve. Moreover, various prognostic values, including relapse–free survival (RFS), overall survival (OS), and distant metastasis–free survival (DMFS) of POSTN, were evaluated in TNBC.UALCAN  for multiple comparisons. In this study, the experiments were performed with at least three biological replicates, and a P value < 0.05 was considered statistically significant.All data were analyzed by SPSS v13.0 software and presented as the mean ± standard deviation (SD). Statistical significance was considered by the two–MB–231 and SUM159PT were cocultured with ACM for 24 h. Subsequently, the expression of matrix metalloproteinases (MMPs)  and stemness–related molecules  [–fat diets are rich in saturated fatty acids, including palmitic acid (PA), a 16–carbon long–chain saturated fatty acid commonly found in dietary fats. Therefore, we also sought to explore the role of PA in TNBCs. To accomplish this, the TNBCs were treated with 300 µM/mL PA for 24 h, and PA also significantly increased the expression of MMPs as well as stemness–related molecules in the TNBCs  –20 was dPOSTN mRNA and periostin protein was upregulated in TNBCs treated with ACM and PA  into MDA–MB–231 and SUM159PT cells. The results of the qPCR and Western blotting analyses showed that shRNA effectively inhibited periostin expression in both cell lines at the RNA and protein levels  [–related molecules were identified by qPCR analysis. Our experimental results demonstrated that periostin knockdown significantly reversed the PA–induced facilitation of MMPs and stemness–related molecule expression in TNBCs  , 22. SubBCs Fig. a–c. In ated Fig. d–f. Coll–8 assay to test the tolerance of TNBCs to the first-line chemotherapeutic agent paclitaxel (PTX) in MDA–MB–231 and SUM159PT cells transfected with shPOSTN or treated with rhPeriostin. The CCK–8 results showed that changes in periostin expression had no significant effect on the proliferation of TNBCs . The RNA–seq results showed that 400 genes were significantly upregulated and 1881 genes were significantly downregulated in the rhPeriostin group compared with the control IgG group  category and KEGG pathway enrichment analysis. The GO term mapping of the upregulated genes in the rhPeriostin group showed that proteolysis, the negative regulation of cell death, the regulation of protein ubiquitination, and the positive regulation of the tumor necrosis factor–mediated signaling pathway were upregulated  but a significant increase in the level of phosphorylation of ERK1/2 (p–ERK1/2) in rhPeriostin–treated MDA–MB–231 cells compared with the control IgG group , 95% confidence intervals, and computed log rank P value. The results indicated that TNBC patients with high POSTN expression had significantly shorter OS, RFS, and DMFS than those with low POSTN expression , as detailed in Supplementary Figure –positive and TNBC subtypes (Supplementary Figure Our results showed that periostin expression and secretion were significantly elevated in TNBCs treated with ACM and PA, while the inhibition of periostin expression or neutralization of periostin with periostin–related molecules to promote extracellular matrix degradation and enhance stemness. Importantly, upregulated periostin significantly attenuated the efficacy of PTX on TNBCs, suggesting that periostin has an impact on chemoresistance. Nevertheless, it is important to note that this study had several limitations. First, the ACM contained a complicated composition, including a wide range of secretory factors, such as cytokines, growth factors, hormones, and extracellular matrix–processing proteases, which are known as adipose–derived secreted factors or adipokines released by adipocytes [The mechanisms of periostin involved in the interaction between TNBCs and adipocytes are being for the first time in this study. The results demonstrated that ACM and PA upregulated the expression of periostin in TNBCs, leading to increased expression of MMPs and stemnessipocytes , 35. In – and PA–induced periostin expression promotes the extracellular matrix degradation, stemness, and chemoresistance of TNBCs by activating the MAPK/ERK signaling pathway. Targeting periostin can significantly suppress TNBC progression. Therefore, a better understanding of the underlying molecular mechanisms behind the interaction between adipocytes and breast cancer cells may lead to the identification of new molecular targeted agents. Moreover, targeting the tumor microenvironment may represent an attractive strategy for preventing breast cancer progression.This study clarifies the significance of the secreted protein periostin in mediating communication between TNBCs and the surrounding adipocytes within the tumor microenvironment. ACMBelow is the link to the electronic supplementary material.Supplementary Material 1


This multicenter cohort study retrospectively assessed the association between polar vasculosis and the progression of diabetic kidney disease (DKD) in type 2 diabetes.We enrolled 811 patients with type 2 diabetes, biopsy‐proven DKD, and proteinuria (≥0.15 g/g creatinine [g/day]). The association between polar vasculosis and other kidney lesions was explored. The outcome was DKD progression defined as a composite of renal replacement therapy initiation or 50% decline in estimated glomerular filtration rate (eGFR) from baseline.Of the 811 cases, 677 (83.5%) had polar vasculosis. In multivariate logistic regression analysis, subendothelial widening of the glomerular basement membrane, glomerulomegaly, glomerular class in the Renal Pathology Society classification ≥IIb, vascular lesions, age, eGFR, and hemoglobin A1c were positively associated with polar vasculosis, whereas interstitial fibrosis and tubular atrophy (IFTA) was negatively associated with polar vasculosis. During a median follow‐up of 5.2 years, progression of DKD occurred in 322 of 677 (7.4 events/100 person‐years) and 79 of 134 (11.4 events/100 person‐years) cases with and without polar vasculosis, respectively. Kaplan–Meier analysis showed that polar vasculosis was associated with lower cumulative incidences of DKD progression. Multivariate Cox regression analyses showed that polar vasculosis was associated with a lower risk of DKD progression, regardless of eGFR or proteinuria subgroups. These associations between polar vasculosis and better kidney outcome were unchanged considering all‐cause mortality before DKD progression as a competing event.This study showed that polar vasculosis of DKD was associated with less advanced IFTA and a better kidney outcome in type 2 diabetes with proteinuria. This multicenter cohort study retrospectively assessed 811 proteinuric patients with type 2 diabetes and biopsy‐proven diabetic kidney disease (DKD) in Japan to investigate the association between polar vasculosis and DKD progression. This study showed that polar vasculosis of DKD was associated with less advanced interstitial fibrosis and tubular atrophy and a better kidney outcome in type 2 diabetes patients with proteinuria. The clinical course and outcomes in diabetic kidney disease (DKD) are heterogeneous and various phenotypes of DKD exist, but DKD is the leading cause of end‐stage kidney disease globally, including JapanAbnormal angiogenesis is involved in the pathogenesis of DKD, and the development of extra vessels, termed polar vasculosis (perihilar neovascularization), is noted as an early kidney lesion in DKDAlthough the function of polar vasculosis is also unknown, it has been speculated that the formation of polar vasculosis may decrease the intraglomerular pressureThis is a retrospective study of patients who underwent clinical kidney biopsy after obtaining informed consent and had a pathological diagnosis of DKD between June 1981 and January 2020 at the following 14 hospitals in Japan: Kanazawa University Hospital , Kanazawa Medical University Hospital , Toranomon Hospital , Fujita Health University Hospital , National Hospital Organization Chiba‐East National Hospital , Tohoku University Hospital , St Marianna University School of Medicine Hospital , Niigata University Hospital , University of Tsukuba Hospital , Nara Medical University Hospital , Kobe University Hospital , Nagasaki University Hospital , Okayama University Hospital , and Nagoya University Hospital . Kidney biopsy was performed on patients with type 2 diabetes in whom it was necessary to confirm clinically precise pathological findings. The exclusion criterion was patients with other kidney diseases, except for nephrosclerosis coexisting with DKD. Among 1,050 patients with type 2 diabetes and biopsy‐proven DKD, 93, 30, 30, and 86 patients were excluded for lack of data on urinary protein excretion, lack of data on the presence or absence of polar vasculosis, lack of data on kidney outcome, and baseline proteinuria <0.15 g/g creatinine [g/day], respectively. Thus, 811 patients were included in the final analysis. This study was approved by the Kanazawa University Ethics Committee [No. 2016‐460 (1204)] and all participating institutions.2) and G3a–G5 (<60 mL/min/1.73 m2) for categorical analysesThe following parameters at the time of kidney biopsy (baseline) were collected by manual chart review: age, sex, serum creatinine, eGFR, urine protein‐to‐creatinine ratio, 24 h urinary protein excretion, hemoglobin A1c, systolic and diastolic blood pressure, total cholesterol, use of antihyperglycemic medications, use of RAAS inhibitors, use of calcium channel blockers, and use of lipid‐lowering agents. eGFR was calculated based on the equation established by the Japanese Society of NephrologyBiopsy samples were stained using periodic acid–Schiff, periodic acid methenamine–silver, hematoxylin–eosin, and Mallory–Azan (or Masson's trichrome), and subsequently examined under a light microscope. The definition and scoring of all pathological lesions were agreed upon after reviewing previous pathological studies on diabetic nephropathy and after more than 2 years of meetings among the authors. Furthermore, we published the “Manual for pathological diagnosis of diabetic nephropathy and hypertensive nephrosclerosis”, focusing on the characteristic lesions of diabetic nephropathy/DKD and the common lesions of diabetic nephropathy/DKD and hypertensive nephrosclerosis in 2014The outcome was the progression of DKD, defined as a composite of renal replacement therapy initiation or 50% decline in eGFR from baseline. Data were obtained from the medical records of all participating institutions. Cases that did not achieve these outcomes or were lost to follow‐up were censored at the last follow‐up visit.U test and Fisher's exact test, respectively. To determine the factors associated with the presence of polar vasculosis, univariate and multivariate logistic regression analyses were performed including 12 pathological variables in the Japanese classificationP <0.05 were considered statistically significant. All analyses were performed using Stata version 17.0 software  and R version 4.2.3.Data are expressed as median and interquartile ranges for continuous variables and percentages for categorical variables, which were compared using the Mann–Whitney 2, and 1.9 (0.6–4.5) g/g creatinine or g/day, respectively. The proportions of G1, G2, G3a, G3b, G4, and G5 in the GFR categories were 10.7% (87/811), 24.2% (196/811), 21.7% (176/811), 24.2% (196/811), 15.2% (123/811), and 4.1% (33/811), respectively. The proportions of 0.15–0.49 g/g creatinine (g/day) and ≥0.5 g/g creatinine (g/day) in proteinuria categories were 20.5% (166/811) and 79.5% (645/811), respectively.The baseline characteristics of the 811 patients included in this study are shown in Table Polar vasculosis was present in 677 (83.5%) patients. Table P < 0.001), nodular sclerosis , subendothelial widening of GBM , exudative lesion , mesangiolysis , glomerulomegaly , glomerular class by the RPS classification ≥IIb , arteriolar hyalinosis , and arteriosclerosis  were positively associated with the presence of polar vasculosis, whereas the use of RAAS inhibitors was negatively associated with the presence of polar vasculosis . In the multivariate analysis of pathological variables, subendothelial widening of GBM , glomerulomegaly , glomerular class by the RPS classification ≥IIb , arteriolar hyalinosis , and arteriosclerosis  were positively associated with the presence of polar vasculosis, whereas IFTA was negatively associated with the presence of polar vasculosis . In the multivariate analysis of clinical variables, age , eGFR , and hemoglobin A1c  were positively associated with the presence of polar vasculosis.To investigate the associations between polar vasculosis and other kidney lesions and baseline clinical variables, we used univariate and multivariate logistic regression analyses Table . In the P = 0.006).During the median follow‐up of 5.2 years , DKD progression occurred in 322 of 677  and 79 of 134  patients with and without polar vasculosis, respectively. The cumulative incidences of DKD progression stratified by polar vasculosis are shown in Figure P = 0.005).In the cumulative incidence functions for DKD progression by the presence of polar vasculosis in consideration of all‐cause mortality before DKD progression as a competing event, the cumulative incidence of DKD progression was lower than that of the Kaplan–Meier analysis Figure . There wP = 0.003) and G3a–G5 categories  and G3a–G5 categories  and G3a–G5 categories  and G3a–G5 categories  among the G1–G2 and G3a–G5 categories. In the Cox model including 13‐pathological variables in the Japanese classification, the presence of polar vasculosis was associated with a lower risk of DKD progression among the G1–G2  and urinary protein excretion ≥0.5 g/g creatinine (g/day) categories  and urinary protein excretion ≥0.5 g/g creatinine (g/day) categories  and urinary protein excretion ≥0.5 g/g creatinine (g/day) categories  and urinary protein excretion ≥0.5 g/g creatinine (g/day) categories  among urinary protein excretion 0.15–0.49 g/g creatinine (g/day) and ≥0.5 g/g creatinine (g/day) categories. In the Cox model including the 13 pathological variables in the Japanese classification, the presence of polar vasculosis was associated with a lower risk of DKD progression among urinary protein excretion 0.15–0.49 g/g creatinine (g/day)  categories Tables  and 4, sThis multicenter study investigated a large cohort of patients with type 2 diabetes and biopsy‐proven DKD and showed two findings: (i) the presence of polar vasculosis was related to less advanced IFTA in contrast to more advanced glomerular lesions  and vascular lesions, and (ii) the presence of polar vasculosis was associated with a better kidney outcome in patients with proteinuria regardless of the subgroups stratified by GFR and proteinuria categories. We have previously shown that polar vasculosis was associated with preserved eGFR for 3 years after kidney biopsyet al.First, we explored the association between polar vasculosis and other kidney lesions and clinical variables. In the multivariate logistic regression analysis, IFTA was negatively associated with polar vasculosis, whereas subendothelial widening of GBM, glomerulomegaly, glomerular class by the RPS classification ≥IIb, vascular lesions, age, eGFR, and hemoglobin A1c were positively associated with polar vasculosis. Previous several studies have shown the relationships between polar vasculosis and more advanced mesangial expansion, glomerulomegaly, and arteriolar hyalinosis in human DKD, consistent with this studyNext, we showed that the presence of polar vasculosis positively correlated with eGFR and was associated with a better kidney outcome of DKD in type 2 diabetes with proteinuria. Kaplan–Meier analyses showed that polar vasculosis was associated with lower cumulative incidences of DKD progression. Cox regression analyses showed that polar vasculosis was associated with a lower risk of DKD progression in multivariate analyses, regardless of subgroups stratified by GFR and proteinuria categories. When we conducted the cumulative incidence function and the multivariate Fine‐Gray regression model in consideration of all‐cause mortality before DKD progression as a competing event, these results were unchanged. As many studies have suggested, we also identified that more advanced IFTA was associated with a poor kidney outcome in type 2 diabetes with DKD in this studyet al.In this study, hemoglobin A1c was positively associated with the presence of polar vasculosis in multivariate logistic regression analysis. Nyumura Furthermore, vascular lesions and age were also positively associated with polar vasculosis by multivariate logistic regression analysis in this study. Pathologically, DKD can be complicated by nephrosclerosis as well as by traditional diabetic kidney lesionsThere are several limitations in this study. First, this retrospective study included only cases that underwent kidney biopsy, which may have resulted in bias. Particularly, we included patients who underwent kidney biopsy in clinical settings, rather than using research biopsies. Therefore, there is a possibility that biases in the indications for kidney biopsy existed among participating institutions. Second, patients without proteinuria were excluded from this study because the number of observed outcomes was insufficient to perform a survival analysis. Third, we did not quantitate polar vasculosis. To understand the importance of polar vasculosis in the progression of DKD, quantitative assessment  is also needed. Because the quantitative analysis of renal pathology is complex and time‐consuming, we were unable to investigate quantitative assessment in this study, which deals with a relatively large number of cases. Fourth, we have tried to reduce inter‐observer and inter‐institutional variability in the pathological diagnosis including polar vasculosis as a collaborative study, but the current study did not assess them in detail. Fifth, we used only baseline clinical variables in our analyses, although the changes in clinical variables and the use of RAAS inhibitors during follow‐up may affect kidney outcome. However, the study has several strengths, including biopsy‐proven DKD of a large sample collected from multiple institutions in Japan and long duration follow‐up of a maximum of approximately 30 years.In summary, this multicenter cohort study showed that polar vasculosis of DKD was associated with less advanced IFTA and a long‐term better kidney outcome in patients with type 2 diabetes and proteinuria.The authors declare no conflict of interest.Approval of the research protocol: This study was approved by the Kanazawa University Ethics Committee [No. 2016‐460 (1204)] and all participating institutions.Informed consent: Not required, because de‐identified data were used; patients could ‘opt out’ of participation.Registry and the registration no. of the study/trial: N/A.Animal studies: N/A.Table S1| Multivariate Cox and Fine‐Gray regression results for diabetic kidney disease progression including 6‐pathological variables among subgroups stratified by glomerular filtration rate categoriesTable S2 | Multivariate Cox and Fine‐Gray regression results for diabetic kidney disease progression including 6‐pathological variables among subgroups stratified by proteinuria categoriesClick here for additional data file.


This study aimed to evaluate the predictive performance of end-tidal carbon monoxide corrected to ambient carbon monoxide (ETCOc) values phototherapy in neonates with significant hyperbilirubinemia.A prospective study was conducted on neonates with significant hyperbilirubinemia who received phototherapy between 3 and 7 days of life. The breath ETCOc and serum total bilirubin of the recruited infants were measured on admission.n = 87) and >72 h (n = 16) groups. Infants who received phototherapy for >72 h had significantly higher ETCOc . The cutoff value of ETCOc on admission for predicting longer phototherapy duration was 2.4 ppm, with a sensitivity of 62.5% and specificity of 88.5%, yielding a 50% positive predictive value and a 92.7% negative predictive value.The mean ETCOc at admission in 103 neonates with significant hyperbilirubinemia was 1.70 ppm. The neonates were categorized into two groups: phototherapy duration ≤72 h (ETCOc on admission can help predict the duration of phototherapy in neonates with hyperbilirubinemia, facilitate clinicians to judge disease severity, and make clinical communication easier and more efficient. Neonatal hyperbilirubinemia is a common disease with many etiologies that ultimately results in an imbalance between the production and elimination of bilirubin. Even in normal term neonates, bilirubin production is increased compared with adults because of neonates' shortened red blood cell (RBC) lifespan. Red cell breakdown and heme catabolism produce bilirubin and free carbon monoxide (CO) in equimolar ratios . Free COElevated ETCOc and carboxyhemoglobin levels were previously identified as clinical predictors of iso-immune hemolysis –7, such In some medical facilities, phototherapy usually requires hospitalization, which leads to the separation of the mother and baby. To reduce the inconvenience of this separation, both physicians and parents must have a preliminary estimate of the subsequent course, which is greatly beneficial for cases of both hemolytic and non-hemolytic jaundice.Clinically, neonates often undergo intermittent phototherapy. During early disease stages, a transient decrease in STB after phototherapy does not signify the end of the treatment course in neonates with rapidly increasing bilirubin levels. These patients often require multiple rounds of phototherapy before a steady, significant decrease in STB levels is achieved. Although some predictive tools have been developed for cases of rebound jaundice and are associated with an infant's gestational age (GA), age at phototherapy initiation, and STB level relative to the treatment threshold at phototherapy termination , 15, ETCThe aims of this study were to evaluate the performance of ETCOc values in predicting the duration of phototherapy in neonates with significant hyperbilirubinemia,and to investigate the risk factors of prolonged phototherapy.This study is written according the “STROBE guidelines" . This prThe inclusion criteria were as follows: GA ≥35 weeks and birth weight (BW) ≥ 2000g; postnatal age >3 days and <7 days; significant hyperbilirubinemia (STB level requiring phototherapy for the given age and risk category); and admission to the neonatology department for intensive phototherapy.via hood, tent, or cannula); had severe or life-threatening congenital anomalies; received phototherapy before admission; and needed blood exchange at admission were excluded.Infants who had pulmonary diseases and required respiratory assistance . The clinicians who managed the infants were unaware of the values of ETCOc. The STB was checked on admission and before discharge for each infant, and some infants (depending on the clinician's judgment) had their STB levels rechecked multiple times throughout their stay in hospital. STB was measured using the oxidizing method  on a Hitachi 7,600 autoanalyzer. The clinical variables considered were sex, BW, GA, age at admission, mode of delivery, presence of hemolytic diseases , G6PD deficiency (confirmed through a quantitative test using spectrophotometry), and presence of cephalhematoma.The study focused on the association between ETCOc values and the following phototherapy-related metrics: (1) duration of phototherapy; (2) age at which phototherapy was initiated; (3) time of phototherapy termination (STB ≤220 µmol/L); and (4) the study cohort was categorized into phototherapy > 72 h and ≤72 h groups. Statistical analysis was performed after grouping and receiver operating characteristic (ROC) curves were plotted.According to our pilot study, we set a sensitivity of 80%, a specificity of 80%, an alpha error of 0.05, and a tolerance error of 20%.The positive sample size needed is 16.χ2-test. Continuous variables are expressed as means (standard deviations [SD]) or medians (interquartile ranges [IQR]) and compared using a Student's t-test or nonparametric test, as appropriate. Two-sided P-values < 0.05 were considered statistically significant. Variables that reached P ≤ 0.1 in the difference analyses or clinically significant cases were subjected to a multivariable binary logistic analysis. A multivariable binary logistic regression model was developed using the clinical features of infants who received phototherapy for >72 h. Odds ratios (ORs) and 95% confidence intervals (CIs) were generated from this model, which included hemolytic diseases, male sex, BW, ETCOc, GA, and STB (at admission). ROC and AUC were built to assess the prognostic performance of ETCOc, STB alone, and a combination of both. All statistical analyses were performed using R software 3.0.Categorical variables are expressed as proportions (n/N (%)) and compared using the n = 19), 10 were excluded as their parents' did not provide written consent; 4 were excluded because of ETCOc measurement errors due to high hydrogen interference or ETCOc calculation errors; and 5 were excluded because ETCOc measurements were not available within 6 h of admission because of breath rates of <10 bpm or >50 bpm despite repeated tests (maximum of three attempts).A total of 122 infants with hyperbilirubinemia were eligible and enrolled in this study. Of the excluded infants  were recruited between 3 and 7 days after birth (mean 3.65 days),with mean GA and BW of 38.9 ± 1.07 weeks and 3255.73 ± 413.45 g, respectively. The cohort included 68 male and 36 female infants; 84 infants were born vaginally and 19 were born n = 87) group and >72 h (n = 16) groups. No differences were observed between the two groups with respect to the GW, delivery mode, admission age, presence of hemolytic diseases (blood type incompatibility and G6PD deficiency) and hemorrhagic diseases, and in laboratory tests including reticulocytes (RET), hematocrit (HCT) and hemoglobin levels. Male infants were more likely to receive longer phototherapy (P = 0.024). Infants who received phototherapy for >72 h had significantly higher ETCOc at admission (P = 0.001)  .p < 0.001). However, sex, GA, and STB at admission were not significant risk factors for a long phototherapy duration.Multivariate analysis of the risk factors associated with the two outcomes is shown in The ROC curves are shown in via spontaneous vaginal delivery with a BW of 3450 g. His ETCOc was 4.1 ppm and the STB was 299.8 µmol/L. After approximately 48 h of phototherapy, the STB decreased to 290.5 µmol/L (the rate of STB decrease was 0.19 µmol/L/h). After 144 h of phototherapy, STB reduced to 170.6 µmol/L. Patient 2 was born at a GA of 39 weeks and 5 days with a BW of 3450 g. He was admitted with an STB of 358.8 µmol/L and ETCOc of 1.6 ppm. After 21 h of phototherapy, the STB decreased to 235.5 µmol/L (rate of STB decrease was 5.87 µmol/L/h). After 48 h of phototherapy, the STB level decreased to 197.5 µmol/L. No hemolytic disease or cephalohematoma was observed in both cases. Two male infants were admitted with significant nonhemolytic hyperbilirubinemia on the third day of life. Patient 1 was a full-term infant  who was delivered ETCOc , 17, 18 As early as 20 years ago, ETCOc was used in clinical practice. Balaraman V et al.  reportedMost current studies use early ETCOc values to predict the occurrence of subsequent hyperbilirubinemia , 12, 20 We compared two patients with similar GA, BW, and age at admission, and found that patients with higher ETCOc on admission required a longer duration of phototherapy. This finding is consistent with our hypothesis. The reason that initial ETCOc but not STB measurements were a predictor of treatment duration is unclear. It is also unclear whether this conclusion necessarily extends to patients with mild hyperbilirubinemia. On the basis of our observations, we assumed that some cases of hyperbilirubinemia with mildly elevated ETCOc levels were due to insufficient bilirubin elimination. However, the decrease in bilirubin elimination might be transient, and STB could decrease in a relatively short time after phototherapy. In contrast, jaundice caused by increased bilirubin production has a remarkable increase in ETCOc, which cannot be compensated for by the restoration of bilirubin elimination capacity. Therefore, STB in the latter patients decreases slowly and requires a longer duration. Unfortunately, no technology is currently available to dynamically monitor the ability of a neonate to eliminate hepatic bilirubin. Given that ETCOc is a relatively non-invasive test that does not require blood sampling, it should likely be used in practice more widely, and it is particularly recommended for all patients receiving phototherapy prior to treatment.In a study by Butani on the use of ETCOc values to predict hemolytic diseases , it was Our results showed that prolonged phototherapy was significantly associated with a high initial ETCO value. ETCOc ≥2.4 ppm) on admission was a good predictor, with a sensitivity of 62.5% and specificity of 88.5%. Based on these findings, clinicians can inform parents of newborns with a high ETCOc, especially cases with ETCOc >2.4 ppm, to anticipate the possible need for a longer duration of phototherapy and stay in the neonatology department. Butani et al. ( ppm on aThis study had several limitations. Possible selection bias existed due to short trial duration and limited sample size. The present study focused on children between 3 and 7 days of age with the goal of reducing the impact of the physiological processes of red cell destruction that is prevalent in the early neonatal period. Further studies could incorporate more suitable neonates to understand the physiological and pathological processes of bilirubin production.In conclusion, the results of our study verified the effective role of ETCOc in the prediction of phototherapy duration in infants with hyperbilirubinemia, and indicated that the assessment of disease severity using ETCOc values is extremely meaningful, not only for physicians to make treatment plans but also to improve the adherence of the children's families to these plans.


Citrullus lanatus), mint (Mintha spicata), and pitaya (Hylocereus costaricensis). In this study, fresh pitaya, watermelon, and mint leaves were fermented using Saccharomyces cerevisiae. Juice extracts underwent fermentation at room temperature for 7 days under dark conditions. Physicochemical changes, such as pH, sugar content, specific gravity, and alcohol content, were observed daily. The antioxidant activities were measured by the 2,2‐diphenyl‐1‐picrylhydrazyl (DPPH) assay, the ferric reducing antioxidant power (FRAP) assay, and total phenolic contents (TPCs). After 14 days of fermentation, the alcohol contents of mixed and pitaya wine were 11.22% (v/v) and 11.25%, respectively. The total sugar content of the mixed wine was 8.0 °Brix, while that of pitaya wine was 7.0 °Brix. Moreover, pitaya wine exhibited a higher TPC (22.7 mg GAE/100 g D.W.), and better FRAP (3578 μmole/L) and DPPH scavenging ability (80.2%) compared to the mixed wine with a TPC of 21.4 mg GAE/100 g D.W., FRAP of 2528 μmole/L, and DPPH of 75.6%., while the addition of watermelon and mint did not change the alcohol percentage contents of wine.Fermentation of fruits offers a diverse range of flavors, smells, and colors. Colored fruits are rich in naturally occurring pigments, such as betacyanin. Hence, they are considered to possess powerful antioxidant activities. However, in wine production, such pigments often diversify the flavor and color of the wine. The objective of this study was to compare the quality of two types of wines: a single‐fruit (pitaya) wine and a mixed‐fruit wine that contains watermelon ( This is the first paper to demonstrate the anti‐oxidative ability and sensory evaluation in different types of pitaya wines. During fermentation, the sugar present in the juice will react with the yeast to produce alcohol and carbon dioxide as a by‐product. Nowadays, colored and non‐colored wines (white wine) are popularly available all over the world because of their taste, color, and alcohol volume Ali, . Most ofThe pitaya fruit, a Cactaceae family member, is native to Mexico and widely cultivated in tropical and subtropical areas. According to previous study, pitaya fruit is rich in vitamins, dietary fiber, betacyanin, organic acids, amino acids, and sugars. Studies suggest that pitaya betacyanins exhibit antidiabetic effects and modulate glycemic response  with wine produced from pitaya only. The oenological and physical properties analyzed were based on pH, sugar content, alcohol content, color, and specific gravity (SG). The antioxidant abilities of the wines were also analyzed and compared.22.1Pitaya and watermelon were purchased at a local market in Neipu, Pingtung County, Taiwan. Mint was grown in the Department of Food Science at the National Pingtung University of Science and Technology. Fruits were properly washed, peeled, and cut into cubes. The ratio of pitaya, watermelon, and mint for the mixed‐fruit wine was 50%, 40%, and 10%, respectively. Only pitaya was used for the single‐fruit pitaya wine. All fruit materials were blended and the juice was filtered through a cotton cloth  were then added and allowed to ferment at room temperature for 7–14 days under dark conditions between 25 and 30°C , a* (red to green), and b* (blue to yellowness) were measured using a spectrophotometer. The chroma and hue angles were also calculated to express the purity and color of wine according to the following formula  of pitaya and mixed wine was conducted according to the Folin–Ciocalteu method with slight adaptations  at 6 different concentrations  was also prepared. Samples of fresh wine were also prepared at the same concentrations as those of BHT. Ethanol was used as a control. Then, 100 μL of samples at different concentrations (experiment group) were added to 50 μL of DPPH solution in a 96‐well plate where the absorbance was measured at 515 nm. As for the background group, 100 μL of sample at different concentrations was added with 50 μL of ethanol  and were statistically analyzed by one‐way analysis of variance (ANOVA) with IBM, SPSS Windows 10. Duncan's multiple‐range test was utilized to compare the significant difference between treatments at 0.05 level. In addition, tables were analyzed by Student's independent 33.1Pitaya and mixed wines were produced successfully. Sugar content in food plays an important role, especially in the fermentation of fruits. The change of °Brix during the fermentation process is shown in Table As evident in Table 3.2This study used TPC and radical scavenging tests (FRAP and DPPH) to evaluate the antioxidant activity of mixed and pitaya wines. According to Figure In Figure 3.3Wine color is an important parameter to identify its quality characteristics such as age, type and sort, and composition. Nonetheless, color has been closely linked to pH and temperature. Based on the calculation shown in Table 3.4Lippia javanica extracts ; supervision . Mohsen Gavahian: Investigation (lead); supervision ; writing – review and editing (lead). Rojina Pradhan: Data curation (lead). Si Yu Lu: Data curation ; formal analysis (lead). Yung‐Lin Chu: Conceptualization (lead); funding acquisition ; supervision (lead); writing – original draft (lead).The authors declare no competing financial interest.


Helicobacter pylori (H. pylori).To estimate the effectiveness and safety of triple therapy containing berberine, amoxicillin, and rabeprazole in the eradication of H. pylori infection who were randomly allocated at a ratio of 1:1 into the berberine triple therapy group  or standard bismuth‐containing quadruple therapy group  for 14 days. Negative 13C/14C‐urea breath test at 4 weeks after completion of the therapy was regarded as successful eradication.This prospective, randomized controlled, open‐label, noninferiority trial included treatment‐naive patients with P = 0.742) and per‐protocol analyses  showed comparable eradication rate between the two groups, indicating a noninferior eradication rate . Adverse events more commonly occurred in the bismuth‐containing quadruple‐therapy group , while patient compliance and symptom improvement of the two regimens were comparable.Altogether 262 and 262 patients received berberine triple therapy and bismuth‐containing quadruple therapy, respectively. Both intention‐to‐treat  infection. Abbreviation: UBT, urea breath testWe demonstrated in a prospective randomized controlled trial that triple therapy containing berberine, amoxicillin, and rabeprazole can be used as the first‐line treatment for patients with primary  In addition, H. pylori infection is related to extra‐GI diseases including diabetes mellitus, coronary heart disease, and hypertension, etc.H. pylori eradication is also important for a complete remission of low‐grade gastric MALT lymphoma at an early stage.H. pylori gastritis as an infectious disease, and recommended eradication therapy for all adult patients infected with H. pylori. Theoretically, the eradication rate of should reach 80% or higher, and that of the optimal treatment scheme should be over 95%.H. pylori eradication therapy shows a gradual downward trend globally. Eradication failure is mainly attributed to antibiotic resistance, variation among bacterial strains and hosts, as well as ineffective treatments.H. pylori eradication.Due to the increasing antibiotic resistance, it is difficult to achieve an eradication rate of 80% by using triple therapy.H. pylori strains.H. pylori effectively, but decrease the adverse events (AEs) to a certain extent, leading to a good patient compliance.H. pylori eradication therapy were reported to be mainly linked to the use of antibiotics and bismuth. Bismuth can promote the efficacy of H. pylori eradication by protecting the mucosal tissue against damage and increase H. pylori susceptibility to antibiotics.H. pylori‐sensitive antibiotics cannot be generally enhanced by the addition of bismuth.Berberine, a traditional Chinese medicine, has long been used in clinical practice as an antibacterial and anti‐inflammatory drug in China, which also has a good inhibitory effect on multidrug‐resistant H. pylori eradication. In this this single‐center, randomized controlled, noninferiority study, we aimed to discriminate the effectiveness and safety of the triple regimen composed of berberine hydrochloride, PPI, and amoxicillin as the first‐line eradication therapy for H. pylori infection.Considering a high susceptibility to amoxicillin and almost no resistance to berberine hydrochloride, we speculate that in the bismuth‐based quadruple regimen containing berberine hydrochloride and amoxicillin, bismuth may not improve the susceptibility to amoxicillin and berberine hydrochloride. The triple regimen including berberine hydrochloride combined with amoxicillin and a proton pump inhibitor (PPI) may obtain an equivalent effectiveness to that of the bismuth‐containing quadruple therapy in 2This open‐label, randomized controlled, prospective, noninferiority study was conducted at the Xijing Hospital  from January 2021 to July 2021. The study was approved by the Ethics Committee of Xijing Hospital (no. KY20202119) and followed the CONSORT Statement of Randomized Controlled Studies and the Declaration of Helsinki . Written informed consent was obtained from each patient before their enrollment. The study was registered on ClinicalTrials.gov (registration no. NCT04697186).2.1H. pylori infection, dyspepsia, and had never received eradication therapy were recruited in this study. Exclusion criteria were: (a) hypersensitivity to study drug; (b) administration of antibiotics within 1 month or thrice a week and/or PPI within 2 weeks before 13C‐urea breath test (UBT); (c) with severe comorbidities; (d) with dysphagia, gastroduodenal ulcer, MALT lymphoma, or malignancy; (e) with pathologically confirmed high‐grade intraepithelial neoplasia; (f) with coagulation dysfunction, evident bleeding or iron deficiency anemia; (g) sustained use of hormones or nonsteroidal, anti‐inflammatory drugs (NSAIDs), anticoagulants or platelet aggregation inhibitors (except aspirin use <100 mg/day); (h) previous history of drug or alcohol abuse; (i) pregnant or lactating; (j) with psychological disorders; (k) had participated in other clinical trials during the past 3 months before the enrollment; and (l) refused to sign informed consent.Subjects aged 18–70 years who were confirmed to have initial The enrolled patients were then randomly allocated to the berberine triple scheme (the observation group) or bismuth‐containing quadruple treatment (the control group) at a ratio of 1:1. The berberine triple therapy group were treated for 14 days with berberine hydrochloride  300 mg thrice daily, amoxicillin  1 g twice daily, and rabeprazole  10 mg twice daily. While the standard bismuth‐containing quadruple therapy group were treated for 14 days with rabeprazole (Eisai China) 10 mg twice daily, amoxicillin (Zhuhai United Laboratories) 1 g twice daily, clarithromycin  500 mg twice daily, and colloidal bismuth tartrate  200 mg twice daily. Rabeprazole and colloidal bismuth tartrate were both taken 30 minutes before meals, whereas amoxicillin, clarithromycin and berberine hydrochloride were administrated 30 minutes after meals.2.2H. pylori infection was confirmed when any one of the 13C/14C‐UBT, H. pylori stool antigen test (H. pylori SAT), and rapid urease test (RUT) were positive. Negative 13C/14C‐UBT at 4 weeks after the completion of H. pylori eradication therapy was regarded as a successful eradication.2.3H. pylori eradication rate at 4 weeks after the completion of 14‐day eradication treatment. Secondary outcomes included improvement of clinical symptoms, patient compliance, and AEs. The factors that affected H. pylori eradication rate were also investigated.The major patient outcome was Clinical symptoms of the patients at admission, including nausea, abdominal pain, bloating, diarrhea, constipation, belching, reflux, heartburn, were recorded. The severity and frequency of the symptoms were scored from 0 to 3 . The total score for each symptom was calculated using the following formula: total score = frequency score × severity score.All patients were followed up via telephone during the trial to improve treatment compliance and to record their clinical symptom scores and AEs. Symptom relief and a good patient compliance were defined as a 50% reduction in the total symptom score and at least 80% of medications were taken, respectively.2.4Based on 69%–91% eradication rates with the bismuth‐containing quadruple therapy, an 85% eradication rate was assumed to be achieved in the two groups.t‐test. While categorical variables were expressed as numbers or percentages or frequencies, and were evaluated using the Chi‐square or Fisher's exact test. To determine noninferiority in the per‐protocol (PP) population, 95% confidence interval (CI) of the rate difference (RD) between the two groups was estimated by Student's t‐test. Using the lower limit of the RD 95% CI over −10%, the berberine triple therapy was not inferior to bismuth‐containing quadruple therapy, the intention‐to‐treat (ITT) population was also defined as statistically significant (P < 0.05).Continuous data were expressed as mean ± standard deviation, and were evaluated using the Student's 33.1H. pylori eradication therapy, and three withdrew from the trial due to severe allergic phenomena. Finally, 499 patients completed the full course of the trial . Baseline characteristics of the two groups are presented in Table From January 2021 to July 2021, 524 patients were successfully recruited in the trial, among whom 17 were lost to follow‐up, four discontinued against medical advice, one did not receive retesting at 4 weeks after the completion of 3.2P =  0.742; PP analysis, P  =  0.636). Furthermore, the lower limit of RD 95% CI between the two groups was >−10% , indicating that the eradication rates were noninferior in both groups  in the ITT analysis and 83.6% (209/250) in the PP analysis, while that of the standard bismuth‐containing quadruple therapy group were 80.9% (212/262) and 85.1% (212/249), respectively. No significant differences were observed between the two groups  (Table P = 0.043). Differences were not observed in patient compliance and symptom relief between the two groups.All patients received telephone follow‐up during the trial to improve treatment compliance and to record their clinical symptom scores and AEs. Compared with the standard bismuth‐containing quadruple therapy group, The overall rate of AEs in the berberine triple therapy group was relatively low  Table . Common 2) Table . Compare4H. pylori is an infectious bacterium with a high global infection rate. It is closely related to both GI and extra‐GI diseases.H. pylori eradication may prevent the occurrence of GC.H. pylori cannot be eradicated, the infection will continue for life.H. pylori infection is detected, unless there are competing considerations, the initial therapy should achieve an ideal eradication success.H. pylori strains. As the prevalence of antibiotic resistance increases, treatment regimens for H. pylori eradication continue to escalate from the initial dual regimen (PPI plus amoxicillin), a 7‐day triple regimen (PPI plus two antibiotics), to the 14‐day bismuth‐containing quadruple regimen. An eradication rate below 80% using the triple therapy is no longer acceptable.H. pylori to clarithromycin (20%–55.2%), metronidazole (40%–90.6%), and levofloxacin (20%–50%) is high, while that to amoxicillin (0%–7.7%), tetracycline (0%–5%), and furazolidone (0%–0.91%) remains low.Recently, the easy availability and extensive application of antibiotics have become the direct factors for mutation, secondary, and multidrug resistance of H. pylori eradication. Increasing the drug dose without changing the dosing frequency of PPI–amoxicillin dual therapy has comparable efficacy and patient compliance for H. pylori eradication compared with conventional mainstream guidelines.H. pylori.High‐dose dual therapy with PPI and amoxicillin has been recommended as both initial and rescue therapies for Coptis chinensis and possesses various biological activities. It is widely used in clinical practice because of the unique antimicrobial, antibacterial, and anti‐inflammatory effects. The potency of berberine on reducing the activity of H. pylori is seldom affected by the internal and external environments, especially against multidrug‐resistant strains. This effect is significantly enhanced with clarithromycin, which may be due to a synergy between them.Berberine is an alkaloid derived from H. pylori eradication and cure rates in the treatment of H. pylori‐related gastritis and peptic ulcer. It also reduces the recurrence rate of ulcers.H. pylori strains when used in combination with other antibiotics.Clinical studies have found that berberine combined with traditional triple therapy or alternatives to antibiotics with high resistance rate in bismuth‐containing quadruple regimen shows higher H. pylori nomogram model has demonstrated that bismuth can enhance the eradication rate by at least 30%,The H. pylori in the PP analysis was above 80%, and there was no statistical difference between the berberine triple therapy and the bismuth‐containing quadruple therapy. Furthermore, the lower limit of the RD 95% CI between the two groups was >−10% , indicating that the eradication rate was noninferior in both the berberine triple therapy group and the standard bismuth‐containing quadruple therapy group. In addition, clinical symptom improvement and patient compliance were comparable between the two groups. However, the overall incidence of AEs in the berberine triple therapy group was relatively low . Among all AEs, compared to the standard bismuth‐containing quadruple therapy group, dysgeusia rarely occurred in the berberine triple therapy group . We speculate that this may be related to the combined use of bismuth and clarithromycin in the quadruple therapy. AEs in both groups were mild or moderate, which disappeared about 2 weeks after treatment was discontinued. Considering its eradication effectiveness, good safety, low medical cost and easy availability, we suggest a combined use of berberine hydrochloride, amoxicillin, and rabeprazole as a new triple regimen with excellent clinical prospects.The results of our study showed that eradication rate of H. pylori to clarithromycin in Gansu Province, China was 54.72%, and the dual, triple, and quadruple resistance rate exceeded 20%. Xie et al yielded similar results that exceeded 30% in northwest China.H. pylori is not resistant to berberine. As drug resistance rate to amoxicillin is low, the combination of berberine and amoxicillin is H. pylori‐sensitive.The study of Shang et alOur subgroup analysis of the factors affecting the eradication rate showed that the efficacy of both regimens was not affected by patient's age, sex, BMI, smoking, alcohol consumption, dietary habits, or AEs. It might be due to the small sample size of this study. Further confirmation of our results with studies with large sample sizes is needed.H. pylori in our patients were not assessed.There were some limitations to our study. First, the vast majority of subjects in the study were from northwest China, and further studies are required to verify whether the berberine triple regimen is feasible in other regions. Second, quadruple therapy of berberine, amoxicillin, rabeprazole, and bismuth was not used as an additional control, and the effect of bismuth could not have been fully excluded. Finally, gastric pH value, cytochrome P450 2C19 (CYP2C19) genotype, and antibiotic susceptibility of H. pylori, providing an innovative eradication regimen of H. pylori. Furthermore, 2‐week berberine triple regimen was well tolerated with an acceptable eradication rate and low AEs. This triple therapy can be considered for H. pylori eradication in the local region.In conclusion, our study preliminarily demonstrated the efficiency and safety of the new triple regimen including berberine hydrochloride, amoxicillin, and rabeprazole for initial eradication of The authors declared that they had no conflicts of interest.


The aim of this study was to identify phenolic compounds in walnut leaves from northern Iraq and evaluate their ability to act as antibacterial and antioxidant agents. Phenolic compounds were determined by reversed‐phase HPLC. Antibacterial activity was tested against various bacteria. Antioxidant properties were evaluated by various assays, including reducing power and DPPH radical scavenging activity. The HPLC profiles of walnut leaf fractions revealed quercetin, hydroquinone, 4‐hydroxybenzoic acid, and caffeic acid in three fractions. The inhibitory activity of DPPH was determined as 47.66, 32.41, and 51.90 μg/mL for fractions I, II, and III, respectively. For ferric reducing power activity, fraction II > fraction III > fraction I and the FRAP activity was observed as 64.43, 73.19, and 68.18 μg/mL for fractions I, II, and III, respectively. All extracted fractions had antibacterial properties against all bacterial strains tested. Observations showed that fraction I was able to produce similar zones of inhibition as streptomycin in most cases. These results suggest that the fractions of this plant extract are plausible natural antioxidants that could be used as prime candidates for the synthesis of antioxidant drugs that can be used for the treatment of many oxidative stress‐related diseases. Phenolic compounds of walnut leaves were determined by reversed‐phase HPLC. Antibacterial activity was tested against various bacteria. Antioxidant properties were evaluated by various assays, including reducing power and DPPH radical scavenging activity. In previous centuries, natural remedies, particularly medicinal plants, were considered the mainstay of treatment. In recent years, there has been a growing inclination toward natural therapies in both developed and developing countries  derivatives, and others . The weight of all extracts was measured after the solvent evaporation and stored in an airtight container for further analysis  of 2.3Juglans regia extract. The column used for this purpose was a vertical glass one, made of borosilicate material, and measured 40 mm in width and 60 mm in length. Before packing, the column was rinsed with acetone and left to dry. A piece of glass wool was placed at the bottom of the column, followed by sea sand (with a particle size ranging from 50 to 70) to a height of 1 cm. Then, hexane was poured into the column, and 200 g of silica gel (with a mesh size of 60–120) was used as the packing material. A silica slurry was prepared with hexane and poured into the column until it reached 2/3 of its height. The slurry was then rinsed with solvent. Sea sand was added on top of the silica slurry to a height of 1 cm, and the sand particles were rinsed with the solvent. To isolate the fractions from the EAE, 20 g of it was mixed with the minimum amount of hexane and poured down the sides of the column, followed by rinsing with solvent. Sea sand was added on top of the EAE to a height of 1 cm, and the solvent level was maintained at 6 cm above the extract to prevent drying. The separation of fractions from EAE was achieved through a gradient elution method, varying the ratio of solvents . The flow rate was adjusted to 5 mL/min, and 40 mL of solvent was collected for each fraction. The concentrated fractions were analyzed using HPLC, and only the fractions that contained ethyl acetate and ethanol were identified. This was due to the difficulty in separating the hexane and methanol fractions, which resulted in an unrefined sample  in double‐distilled water (A) and formic acid (0.1%) in acetonitrile (B). They used a gradient elution method, starting with 95% A for the first 15 min, followed by a decrease to 80% A for 5 min, then maintained at 70% A for 5 min, followed by a decrease to 10% A for 5 min, and then maintained at 10% A for 5 min, and finally increased to 95% A for the last 5 min. The injection amount was 5 μL, and the flow rate was 0.5 mL/min. They used a fraction collector with the RP‐HPLC system and after fractionation and concentration, each fraction was separately analyzed using a Nano‐ESI MS instrument (110–1500 m/z). They confirmed the identification of compounds by comparing retention times, fragmentation, and stepping methods using standard solutions and calibration curves  was used to estimate the phenolic compounds in the pure  Raafat, .2.5−5 mol/L). The mixture was shaken and left to stand in the dark until the absorption values stabilized. The decrease in absorption at 517 nm was continuously monitored to determine the reduction of the DPPH radical. The percentage of DPPH discoloration was calculated as the scavenging effect using the equation: % scavenging effect = [(ADPPH × AS)/ADPPH] × 100, where AS is the absorbance of the solution when the sample extract has been added at a particular level and ADPPH is the absorbance of the DPPH solution. BHA was used as reference compounds , yeast extract (0.5% w/v), NaCl (1% w/v), and agar (2% w/v), and the bacteria were regularly subcultured at a temperature of 37°C. An adaptation of the agar streak dilution method based on radial diffusion, as described by Sousa et al.  capable of inhibiting bacterial growth after 24 h at 37°C. The inhibition zone diameters were measured using a ruler with 0.5 mm accuracy, and the average radius of the inhibition zone in mm was calculated from three measurements on three different plates. Control plates inoculated with each sensitive indicator microorganism were also prepared , and all datasets obtained were statistically analyzed using statistical package for the social sciences (SPSS) software and the efficacy of plant extract fractions was analyzed using variance (ANOVA). The significant difference and the mean comparison were executed using Tukey's test with STATISTICA 13 (α = .05). Finally, the graph plots and results were analyzed using Microsoft Excel (2007) and BioStat software.The complete experiments were implemented with three replications (33.1Juglans regia L.) leaf extracts were analyzed for the detection of various phytochemical compounds. For this purpose, the HPLC profiles of walnut (Juglans regia L.) leaf fractions were analyzed. Following extraction, three fractions were collected. Fraction I was associated with ethyl acetate extraction, while fractions II and III were associated with ethanol extraction. The identified phenolic compounds present in each fraction are shown in Table Fractions obtained from silica gel column chromatography of walnut  leaves extracted with ethyl acetate solvent was quercetin (Fraction I). Also, hydroquinone, 4‐hydroxybenzoic acid, and caffeic acid were introduced as specific compounds in ethanol solvent extraction  leaves contain a variety of polyphenolic compounds that have antioxidant properties via diverse methods. In the present study, the antioxidant activity of fractions of walnut (Juglans regia L.) leaves was determined by the 2,2‐diphenyl‐1‐picrylhydrazyl (DPPH) radical scavenging assay  value, which corresponds to the highest antioxidant potential. The calculated half‐maximal inhibitory concentration (IC50) value was determined as 47.66, 32.41, and 51.90 μg/mL for fractions I, II, and III, respectively and it was higher compared to BHA, used as a positive control (10.73 μg/mL). The highest antioxidant potential was observed for fraction II (IC50 = 32.41 μg/mL), whereas the lowest was observed (IC50 = 51.90 μg/mL) for fraction III  were used. The antibacterial activity results of the extract and positive control are shown in Table P. aeruginosa. As can be seen in Table B. subtilis, S. aureus, P. aeruginosa, and E. coli, respectively. Fraction I at a concentration of 8 μg/mL showed corresponding zones of inhibition of 16 ± 1.25, 18 ± 1.27, 20 ± 1.28, and 16 ± 1.34 against the above bacteria, respectively. This observation indicated that fraction I could in most cases produce zones of inhibition similar to those of streptomycin.The antibacterial properties of walnut leaf fractions were also studied. Five Gram‐positive and Gram‐negative bacteria (Pseudomonas fluorescens (15 mm) and lower for B. subtilis and P. aeruginosa (8 mm). On the other hand, Sharma et al.  and the ethyl acetate extract was the most effective against Bacillus subtilis. To date, the antimicrobial activity of fractions of walnut leaf extracts has not been evaluated. It should also be noted that no statistical correlation was found between antimicrobial activity and chemical profile.Oliveira et al.  previousa et al.  examined4J. regia leaves. This study confirms that walnut leaves (Juglans regia L.) are a valuable source of quercetin derivatives, hydroquinone, 4‐hydroxybenzoic acid, and caffeic acid. This is reflected in its high antioxidant capacity. In addition, the fractions of the extract from the leaves of J. regia have shown antibacterial activity. The observations showed that some of its fractions were able to produce zones of inhibition similar to streptomycin in most cases. According to these findings, it can be concluded that fractions of this plant extract are plausible natural antioxidants that could be exploited as a lead contender for synthesizing antioxidant medicines for the treatment of numerous oxidative stress‐related disorders.In conclusion, the findings of this study fill a gap in scientific knowledge about fractions extracted from Ammar B. Altemimi: Conceptualization ; methodology ; writing – original draft . Siba Mouid Al‐haliem: Data curation ; formal analysis ; writing – original draft . Zina T. Alkanan: Data curation ; software ; visualization ; writing – original draft . Muthanna J. Mohammed: Writing – original draft . Mohammad Ali Hesarinejad: Conceptualization ; methodology ; writing – original draft ; writing – review and editing . Mazin A. A. Najm: Software ; writing – review and editing . Aziz Bouimayane: Writing – review and editing . Francesco Cacciola: Writing – review and editing . Tarek Gamal Abedelmaksoud: Conceptualization ; methodology ; writing – review and editing .This research did not receive any specific grant from funding agencies in the public, commercial, or not‐for‐profit sectors.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.This article does not contain any studies with human or animal subjects.All authors have read and agreed to the published version of the manuscript. All authors read and approved the final manuscript.


Sacubitril/valsartan is a new cardiovascular agent characterized by its dual inhibition on the reninangiotensin system (RAS) and the neprilysin. As neprilysin also involved itself in the degradation of amyloid‐β, there is an ongoing concern about the effect of sacubitril/valsartan on cognition, especially in case of long‐term administration.2) were used to calculate the disproportionality.The FDA Adverse Event Reporting System (FAERS) was mined between 2015Q3 and 2022Q4 to analyze the association between sacubitril/valsartan and adverse events (AEs) involving dementia. Standardized Medical Dictionary for Regulatory Activities (MedDRA) Queries (SMQs) with “broad” and “narrow” preferred terms (PTs) relevant to dementia was applied to systematically search demented AE reports. The Empirical Bayes Geometric Mean (EBGM) from Multi‐Item Gamma Poisson Shrinker (MGPS) and proportional reporting ratio with Chi‐square  was 1.22 (2.40). Similarly, broad demented complications were not over‐reported in the heart failure patients administrated with sacubitril/valsartan .We filtered the query for indication and identified 80,316 reports with heart failure indication in FAERS during the analytical period. Among all the reports, sacubitril/valsartan was listed as primary suspected or secondary suspected drug in 29,269 cases. No significantly elevated reporting rates of narrow dementia were evident with sacubitril/valsartan. The EBGM05 for narrow dementia‐related AEs associated with sacubitril/valsartan was 0.88 and the PRR  involving dementia. Dementia‐related AEs were not over‐reported in the heart failure patients administrated with sacubitril/valsartan, suggesting that there is no safety signal generated attributable to sacubitril/valsartan for now. FAERS is a spontaneous database administered by the FDA and gathers information on AE reports that originate from different sources, including health‐care providers, patients, drug manufacturers, and others.2.2All reports reported to the FAERS database between July 1, 2015 and December 31, 2022 were downloaded and accessed. We managed the raw FAERS data in local by Microsoft Access software (version 2021). Deduplication was applied prior to conducting any analysis. Only reports with indication of heart failure were included in this study. Each report was classified based on the following binomial factors: (1) “with” or “without” exposure to the administration of sacubitril/valsartan, which was classified as “primary suspected” or “secondary suspected” drug. (2) “With” or “without” the development of an AE category of interest, which was defined by using Standardized MedDRA Queries (SMQs) with “narrow” or “broad” preferred terms (PTs) related to dementia‐like AEs in the MedDRA 25.0. The precise terms used are detailed in Appendix 2.32). Figure A population‐based pharmacovigilance study using a case/non‐case approach was applied to analyze the risk of dementia for sacubitril/valsartan. This approach is a common system used in pharmacovigilance studies to identify drugs safety signals.2). EBGM = a (a + b + c + d) / (a + c) / (a + b) in which a is the number of reports of dementia‐related AE for sacubitril/valsartan, b represents the reports for sacubitril/valsartan without reporting dementia, c is the number of the reports of dementia for all other drugs, d represents the number of the reports for all other drugs without reporting dementia. Signal was defined when the EBGM05 metric, a lower one‐sided 95% confidence limit of the EBGM ≥2.0.2 > 4.In our study, disproportionality was analyzed by calculating the Empirical Bayes Geometric Mean (EBGM) from MGPS and PRR  for nonnormally distributed data. Frequencies and percentages are reported for categorical variables. Statistical analyses were performed using SPSS (version 28.0).33.1Over the study period, a total of 12,245,295 AEs were available on FAERS database. Of these, 1,119,964 reports were excluded based on the exclusion criteria. We then filtered the query for indication with heart failure and identified 80,316 reports in FAERS during the analytical period, Overall, 29,269 AEs were found to be related to sacubitril/valsartan. Two hundred and forty reports related to narrow demented AEs and 5808 reports with broad demented AEs were documented. Among them, the sacubitril/valsartan was identified as the suspected drug causing narrow dementia in 99 reports and broad demented AEs in 2486 cases.3.2The demographic characteristics of the sacubitril/valsartan‐associated demented reports are presented in Table 3.32) was 1.22 (2.40) for narrow dementia‐related AEs associated with sacubitril/valsartan, demonstrating that no over‐reporting of narrow dementia‐related AEs was identified in sacubitril/valsartan within heart failure patients. Similarly, broad demented complications were not over‐reported in the heart failure patients administrated with sacubitril/valsartan . To further access the individual characteristics, separate sub‐analyses based on age and sex were conducted too  days for reports with narrow SMQs, and 87 (IQR 29–299.5) days for broad cases. The times to onset are summarized in Figure 4There is an ongoing concern about the risk of cognition impairment for the sacubitril/valsartan, an angiotensin–neprilysin inhibitor, especially under long‐term administration.Cannon and colleaguesThere is a known suggestion that a substantial proportion of heart failure patients have concomitant cognitive problems.Study limitations should be acknowledged. These limitations are mainly inherent to the nature characteristics of self‐reporting database. First of all, in most reports there is no demonstration of a causal relationship between the reported AE and drug exposure. The inability to make causal conformation is a limitation of all pharmacovigilance studies and cohort observational studies.In summary, our data indicated that in all reports from FAERS, no over‐reporting of dementia‐related AEs was identified in sacubitril/valsartan within heart failure patients. The number of dementia cases reported to FAERS did not generate a safety signal attributable to sacubitril/valsartan for now. Further long‐term studies are still warranted to follow up this question.Congqin Chen contributed to data analysis, interpretation, and writing. Lingqing Ding contributed to data analysis and revising. Fang Fu revised the manuscript. Jie Xiao conceived and designed this study.This work was partially supported by The Medical and Health Guidance Project of Xiamen (3502Z20214ZD1168).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To investigate the spontaneous brain activity alterations in survivors of cardiac arrest (CA) with good neurological outcome using resting-state functional magnetic resonance imaging (rs-fMRI) with amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) methods.Thirteen CA survivors with favorable neurological outcomes and 13 healthy controls (HCs) were recruited and underwent rs-fMRI scans. The ALFF and ReHo methods were applied to assess the regional intensity and synchronization of spontaneous brain activity. Correlation analyses were performed to explore the relationships between the mean ALFF and ReHo values in significant clusters and clinical parameters.p = 0.006) in the patient group.The survivors of CA showed significantly decreased ALFF values in the left postcentral gyrus and precentral gyrus and increased ALFF values in the left hippocampus and parahippocampal gyrus than HCs. Significantly decreased ReHo values were observed in the left inferior occipital gyrus and middle occipital gyrus in the patients. Mean ALFF values in the left hippocampus and parahippocampal gyrus were positively correlated with the time to return of spontaneous circulation (r = 0.794, Functional activity alterations in the brain areas corresponding to known cognitive and physical impairments were observed in CA survivors with preserved neurological function. Our results could advance the understanding of the neurological mechanisms underlying the residual deficits in those patients. The survival rate of cardiac arrest (CA) has improved in recent years, however, CA is still one of the leading causes of death worldwide . Neuron Several recent studies have shown that patients with CA possess structural and functional brain abnormalities . Koenig Resting-state functional magnetic resonance imaging (rs-fMRI) is a noninvasive brain imaging technique for evaluating hemodynamic changes induced by neural activity . The ampOur study aimed (1) to compare the functional brain activity differences between CA survivors and healthy controls (HCs) using ALFF and ReHo methods and (2) to examine the relationships between functional brain measures and clinical variables, especially cognitive performance, in the patient group.This study was approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University. Informed consent was obtained from all subjects. Between May 2020 and May 2021, we recruited 16 patients with CA according to the following criteria: (1) documented cardiopulmonary resuscitation for spontaneous CA, (2) 18 years or older, and (3) score 1 or 2 on the Cerebral Performance Categories (CPC). Criteria for exclusion were: (1) Glasgow Coma Scale (GCS) score < 8, (2) pre-existing neurologic or psychiatric disorders, (3) history of traumatic brain injury and brain surgery, (4) contraindication of MRI examination, or (5) abnormal brain parenchyma on brain MRI. Finally, 13 patients were enrolled in our study . The control group consisted of 13 age- and sex-matched healthy volunteers with no history of neurologic or psychiatric disorders or brain injury. All the participants were right-handed.Sample size was calculated according to the following formula:Where μ is the mean value for each group, σ is the standard deviation, and α is the type I error and β is the type II error, meaning 1 − β is power. The α was set at 0.05 and 1 − β at 0.9 for calculation. According to the results of the preliminary experiment, the calculated threshold sample size for each group was 10.Clinical data including time to return of spontaneous circulation (ROSC), CPC, modified Rankin Scale (mRS), etiology causes, and type of CA were collected. CPC is the predominant outcome measure for patients with CA and describes five levels of cerebral functioning . PatientMRI scanning was performed at an average of 14.85 ± 4.90 days after CA when the patient was in a stable condition, and the MRI-incompatible devices were no longer needed. The patients were monitored by an intensive care unit provider during transportation and scanning. All the patients and healthy participants were instructed to stay awake with their eyes closed and think about nothing during the scan.3; field of view (FOV) = 256 × 256 mm2; matrix size = 256 × 256; slice thickness = 1 mm; 176 slices. Functional images were obtained by an axial echo planar imaging sequence with the following parameters: TR = 2000 ms; TE = 30 ms; voxel size = 3.75 mm × 3.75 mm × 4 mm; FOV = 240 × 240 mm2; matrix size = 64 × 64; slice thickness = 4.0 mm; 35 slices. The scanning time was 12 min and 26 s in total. The images were promptly inspected for quality control after scanning. The subject was instructed to remain still and the procedure was repeated if the picture quality was subpar due to head movement.All subjects were scanned in a 3.0 T MR scanner  with a 20-channel head and neck coil. A sagittal 3D high-resolution T1-weighted imaging was acquired with magnetization-prepared rapid gradient echo sequence. The parameters were as follows: repetition time (TR) = 1900 ms; echo time (TE) = 2.45 ms; voxel size =1 × 1 × 1 mmhttp://www.restfmri.net) based on Statistical Parametric Mapping software  was used to conduct the rs-fMRI data preprocessing. Firstly, dicom data files were converted into nifti images and the first 10 time points were deleted. Then, slice timing and head motion correction were performed to make the remaining images slice-time-corrected and realigned to the first volume. Next, realigned images were spatially normalized to the Montreal Neurological Institute template (resampling voxel size = 3 mm × 3 mm × 3 mm). The images were then smoothed with a Gaussian kernel of 6 mm full-width at half-maximum (FWHM) and detrended to remove linear trends. Finally, the nuisance covariates, including head motion parameters as well as white matter and cerebrospinal fluid signals, were removed using linear regression. The head motion for each subject was checked, and subjects with head translation motion exceeding 3.0 mm or rotation over 3° would be discarded.A resting state fMRI data analysis toolkit . Two-sample t-test was conducted to compare the differences in the ALFF and ReHo values between patients with CA and HCs with age, sex, and years of education as covariates. Statistical significance was determined by the Gaussian Random Field (GRF) correction with a threshold of two-tailed voxel-level p < 0.001 and cluster-level p < 0.05.The between-group comparison of ALFF and ReHo values was performed by the statistical module of Data Processing & Analysis of Brain Imaging . The assumption of normality was assessed with Kolmogorov–Smirnov test. Two-sample p < 0.05/4 = 0.0125).The mean ALFF and ReHo values in each significant cluster were extracted for the following correlation analyses. Partial correlation analyses were performed to evaluate the relationships between the mean ALFF and ReHo values in significant clusters and clinical parameters after controlling for the effect of age, sex, and years of education. Multiple comparisons were corrected using the Bonferroni method (p = 0.713), sex (p > 0.999), and years of education (p = 0.895) between CA patients and HCs. The patient group showed significantly lower scores of MoCA than HCs (p = 0.030). The causes of CA included myocarditis , acute myocardial infarction , pulmonary embolism , kounis syndrome , and asphyxia . Twelve (92.3%) patients had in-hospital CA, and one patient (7.7%) had out-of-hospital CA. Five patients had a history of hypertension and three patients had a history of diabetes. After CA, the mean time for the patients to ROSC was 33.77 ± 23.87 min. The mean score for CPC was 1.08 ± 0.23 and mRS was 1.08 ± 0.95.p < 0.001 and cluster-level p < 0.05 with GRF correction). Furthermore, significantly decreased ReHo values were observed in the left inferior occipital gyrus and middle occipital gyrus in the patients compared with HCs (p < 0.001 and cluster-level p < 0.05 with GRF correction).The patients with CA showed significantly decreased ALFF values in the left postcentral gyrus and precentral gyrus and increased ALFF values in the left hippocampus and parahippocampal gyrus than HCs  would expand the current findings. Finally, hypertension and diabetes, which are common diseases in the elderly, may have a certain impact on cognitive function. Future subgroup analysis would further enable us to get a more comprehensive understanding of the brain changes in patients with In conclusion, our results provided insight into the mechanisms underlying the cognitive impairments in CA survivors with favorable neurological outcome. The study may be helpful in prompting new research areas to extend these findings to diagnostic and therapeutic benefits.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethics Committee of the First Affiliated Hospital of Nanjing Medical University. The patients/participants provided their written informed consent to participate in this study.QW: data curation, formal analysis, methodology, and writing original draft. G-NW: investigation, methodology, and writing original draft. HH: methodology and writing - review and editing. X-FC and X-QX: writing - review and editing. J-SZ and F-YW: conceptualization and writing - review and editing. All authors contributed to the article and approved the submitted version.Jiangsu Province Hospital  Clinical Capacity Enhancement Project JSPH-MC-2021-8 to X-QX.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Thymic epithelial tumors are rare and include thymomas and thymic carcinomas. There is scarce literature characterizing prognostic factors and long‐term outcomes in these tumors.This review aims to describe disease features of thymomas and thymic carcinomas and to report clinical differences among thymoma histological subtypes.p < .01). However, there was no significant difference in overall survival between histologic subtypes. Compared to females, males with thymomas had superior overall survival  despite presenting with larger tumors . Concomitant myasthenia gravis was associated with increased recurrence but not worsened mortality. Compared to thymomas, patients with thymic carcinoma presented with higher‐stage disease and had poorer 5‐year survival .A retrospective chart review was performed at the University of Florida Shands Hospital, a tertiary care academic medical center in Gainesville, Florida, USA. The review included clinical data of adults with thymic epithelial tumors diagnosed between 2001 and 2021. Significant associations among demographics, histology, stage, and outcomes were investigated. Thymoma subgroup analysis was performed using histological subtype and sex. Forty patients with thymoma and seven patients with thymic carcinoma were included in the final analysis. Among those with thymomas, patients with subtype B1, B2, or B3 tumors were younger, had larger tumors, and presented with higher stage disease when compared to those with subtypes A or AB. Tumor recurrence was most common in subtype B2 and B3 tumors (50.0% and 16.7% vs. 0%; This study affirmed pathologic stage and resectability as prognostic factors for thymic epithelial tumors. New findings include inferior overall survival in female patients and higher recurrence rates in those with thymomas and concomitant myasthenia gravis. These tumors comprise roughly one‐fifth of mediastinal masses and most commonly present between the ages of 40 and 60.Thymic epithelial tumors are histologically arranged according to the World Health Organization (WHO) classification scheme, which identifies type A and B tumors, defined by the presence of spindle‐oval versus stellate‐polygonal epithelial cells, respectively. These tumor types are further divided into subtypes: A, AB, B1, B2, and B3 epithelial thymomas based on organotypical features such as composition of tissue and pattern of growth.Thymic epithelial tumors are staged according to the tumor, node, and metastasis system of the American Joint Committee on Cancer (AJCC)/Union for International Cancer Control (UICC); however, the alternative Masaoka system stages thymic epithelial tumors by degree of macroscopic and microscopic tissue invasion and has been widely used in descriptive and investigative studies.With an incidence of 1–2 cases per 100 000 person‐years, thymic cancers are exceedingly rare with exceptionally diverse presentations.22.1Approval for this study was obtained from the University of Florida Institutional Review Board (IRB202102647). Patients were identified using the University of Florida Shands Hospital (UFHSH) integrated data repository. Patients were included if they had biopsy‐confirmed thymic epithelial malignancy treated between January 1, 2001, and January 1, 2021. Patients were then categorized according to whether they had a diagnosis of thymoma or thymic carcinoma. Thymomas were histologically classified according to the WHO scheme; this includes subtypes A (medullary thymoma), AB (mixed thymoma), B1 , B2 , and B3 (well‐differentiated thymic carcinoma), which are based on morphologic similarity to normal thymus tissue and percent of tumor‐invading lymphocytes.2.2χ2, Fisher's exact, and Wilcoxon tests. A 95% confidence interval with a p value of less than .05 was used as a cutoff for statistical significance. In addition, survival analysis was conducted using Kaplan Meier curves, log‐rank test, and Cox proportional hazards model. Multivariate analysis was not performed.Statistical analysis was performed with SPSS 28.0.1.0 (142) (IBM Corp). The significance of differences between expected and observed frequencies was assessed with 33.1p = .680) at time of diagnosis for thymoma versus thymic carcinoma. Additionally, no significant difference of incidence based on gender or a history of smoking  was identified between patients with thymoma versus those with thymic carcinoma. Patients with thymoma were more likely than patients with thymic carcinoma to have a history of autoimmune disease . The most prevalent autoimmune manifestation was myasthenia gravis; no instances of inflammatory myopathies or autoimmune bullous dermatoses‐autoimmune blistering diseases were noted.A total of 40‐seven patients diagnosed with epithelial thymic malignancies were treated at University of Florida over a 20‐year period. There were 20 patients diagnosed with a thymoma and seven patients diagnosed with thymic carcinoma. Baseline characteristics for these two groups are included in Table 3.2p = .157). Furthermore, patients with age greater than 65‐year‐old were more likely to have their tumors discovered incidentally . Among symptomatic patients in both groups, dyspnea and chest pain were the most common symptoms . Thymic carcinomas were more likely present at a higher stage (p = .024) and to be treated with chemotherapy  and radiation therapy . Patients with thymoma were more likely to undergo surgical resection via thymectomy  and, among patients who underwent surgery, were more likely to have microscopically negative margins . Tumor recurrence was more common in patients with myasthenia gravis , higher stage disease (p = .026), and positive surgical margins (p = .028). Detailed patient characteristics on the seven patients with thymic carcinomas are provided in Table Tumor characteristics are listed in Table 3.3n = 3; 7.5%), AB , B1 , B2 , and B3 , as reported in Table p = .031), had larger tumors (p = .012), and higher stage disease (p < .01). Tumor recurrence was most common in subtype B2 tumors (p < .01) and was not observed in any patients with subtype A, AB, or B1 tumors. There was no significant difference in overall survival in patients with different thymoma subtypes (p = .724).Among patients with thymoma, subtypes included: A (3.4p = .041). Overall survival was higher in males than in females .No differences were observed between male and female patients with thymoma in age, stage, thymoma subtype, frequency of myasthenia gravis, or rate of complete surgical resection Table . Thymoma3.5p = .630). Kaplan–Meier survival curves for patients with thymoma and thymic carcinoma, as well as survival curves based on patient stage (AJCC Staging) and sex, are provided in Supporting Information. Five‐year survival was higher in patients with thymoma than in patients with thymic carcinoma . Undergoing surgical intervention was associated with improved survival (p < .01), and higher stage disease was associated with a worse outcome (p < .01).The average follow‐up time for all patients was 84.8 months. Median survival was 72.5 months in patients with thymoma and 46.0 months in patients with thymic carcinoma (p > 0.25), as reported in Table p = .021; hazard ratio 95% confidence interval 7.357 [1.398–38.706]). Of the seven instances of disease recurrence in the thymoma cohort, four individuals were female.On univariate analysis of patients with thymoma, age at diagnosis, size ≥5 cm, negative surgical margins, and myasthenia gravis were not associated with significantly increased mortality  when compared to the next highest age (mean of 52 years in subtype B2). The impact of WHO histological subtype on prognosis has been less clear. In the largest analysis of thymomas, there was no significant association between subtype and outcome.Due to the rarity of thymomas, prognostic information is limited. A few investigations have independently identified complete resectability and stage as factors significantly associated with mortality in patients with thymomas as well as thymic carcinoma.The presence of concomitant autoimmune disease, namely myasthenia gravis, has also been proposed as a negative prognostic factor for thymomas. However, several studies, including a large investigation in 2020, have reported no significant association between the presence of myasthenia gravis and overall outcomes in patients with thymoma.Identification of risk factors significantly associated with onset of epithelial thymic cancer has also lacked clarity. Previously published literature has suggested that there are no known risk factors for developing thymic cancer. However, in 2019, Eriksson and colleagues investigated risk factors in 103 patients with thymoma when compared to population controls and reported that tobacco use was moderately related with diagnoses of thymoma .Data demonstrating the efficacy of various treatment modalities of thymomas and thymic carcinoma has been insufficient. Surgical resection remains the mainstay of treatment for epithelial thymic malignancies. All patients with thymoma in this study received surgical resection except one individual, who did not receive any treatment. The significance of postoperative radiotherapy and chemotherapy in thymoma remains controversial due to paucity of data.Thymic carcinoma is a more rare, understudied, and aggressive form of epithelial thymic malignancy. In our cohort, patients with thymic carcinoma presented with more advanced disease, which is consistent with the literature.Our study has several limitations. A large time‐span of 20 years was necessary to achieve even a modest sample size, and the retrospective nature of the data gathered limits the power of the associations we identified. For instance, while an association between myasthenia gravis and increased mortality was not demonstrated, this study is far too small to elicit definitive conclusions regarding this relationship; results should be interpreted with caution. Importantly, the cause of death in patients within this study was not documented. Of nine total patients with thymoma who died, including seven female patients, only one died within a year of diagnosis. Thus, no significant inferences regarding the impact of onset of thymoma and long‐term outcomes can be established.Ellery Altshuler: Conceptualization (lead); formal analysis (lead); investigation (lead); methodology (lead); writing – original draft (lead); writing – review and editing (lead). Akash Mathavan: Conceptualization ; investigation ; methodology ; writing – original draft ; writing – review and editing . Akshay Mathavan: Conceptualization ; investigation ; methodology ; writing – original draft ; writing – review and editing . Urszula Krekora: Investigation ; methodology ; writing – original draft ; writing – review and editing . Mohit Mathavan: Investigation ; methodology ; writing – original draft ; writing – review and editing . Keegan Hones: Investigation ; methodology ; writing – original draft ; writing – review and editing . Karen Daily: Supervision (lead); writing – original draft ; writing – review and editing .The authors have stated explicitly that there are no conflicts of interest in connection with this article.Approval for this study was obtained from the University of Florida Institutional Review Board (IRB202102647).Appendix S1: Supporting InformationClick here for additional data file.