Tuberculosis (TB)‐related death has increased for the first time in a decade due to the coronavirus disease 2019 (COVID‐19), globally. People living with HIV (PLWHIV) might be at a higher risk of developing COVID‐19‐related complications. Herein, we describe the first case of a patient surviving from SARS‐CoV‐2‐TB‐HIV triple co‐infection in Cameroon. A 36‐year‐old Cameroonian woman presented at the emergency unit of the Jamot Hospital, Yaoundé with symptoms of anorexia, productive cough, weight loss, and fever. The SARS‐CoV‐2 rapid antigen test on nasopharyngeal sample was positive. Chest X‐ray showed bilateral parenchymal and tracheal calcifications most consistent with prior pulmonary histoplasmosis, varicella, or TB. She was tested HIV positive, and the sputum sample tested positive for TB on auramine staining. TB therapy  and COVID‐19 treatment were initiated, and the symptoms improved after 2 weeks of treatment. The SARS‐CoV‐2 rapid antigen and real‐time polymerase chain reaction tests were negative after 2 weeks. She was discharged home on antiretroviral therapy and TB therapy. Coinfection with both TB, HIV, and SARS‐CoV‐2 may be common in Cameroon but not reported. The similar clinical features of COVID‐19 and TB usually lead to misdiagnosis. Early diagnosis and initiation of appropriate treatment improve outcome. COVID‐19, TB, and HIV are infectious diseases of global public health concern. Triple Co‐infection with these diseases can create a diagnostic and therapeutic dilemma. We present a 36‐year‐old Cameroonian woman who survived SARS‐CoV‐2 – HIV‐TB triple co‐infection. Timely diagnosis and appropriate management of these infections may improve outcomes and prevent complications. These were associated with frontal headaches and night sweats. She received home‐based management for COVID‐19 following a positive rapid antigen test for SARS‐CoV‐2. Her symptoms relapsed 2 weeks after completion of the COVID‐19 treatment, with recurrence of symptoms of fever, cough, with associated constitutional symptoms. However, the symptoms were much severe. She had no contributory past medical history.Her oxygen saturation was 96%, and the blood pressure was 120 and 80 mmHg for systolic pressure and diastolic pressure, respectively. She had no conjunctival pallor, jaundice, cyanosis, peripheral lymphadenopathy, or digital clubbing. Chest examination revealed bilateral versicular breath sounds with added coarse crepitations. Other systemic examinations were unremarkable.A possible diagnosis of SARS‐COV‐2 persistence or re‐infection was made. Differential diagnosis included post‐acute COVID‐19 syndrome, malaria, sepsis, bacterial pneumonia, TB, histoplasmosis, and other HIV‐related opportunistic infection.Both SARS‐CoV‐2 antigen and real‐time polymerase chain reaction (RT PCR) tests were positive. Chest X‐ray performed showed bilateral dots of calcification most consistent with prior histoplasmosis, varicella, or tuberculous infection; enlargement of the left hilum with calcified bronchi and also some tracheal calcification; small areas of patchy calcification posteriorly in the left base, visible on the lateral view, normal bones, and heart outline Figure . The spuA standard TB therapy regimen was initiated, that is, RHEZ . After 8 days of both COVID‐19 treatment and TB treatment, we had amelioration of the symptoms. After 2 weeks of treatment, both SARS‐CoV‐2 rapid antigen tests and RT‐PCR for COVID‐19 came out negative, the protocol for COVID‐19 was discontinued. In the 3rd week, she was initiated on antiretroviral therapy (ART) and allowed home.3In this report, we described a case of TB‐SARS‐CoV‐2 co‐infection in a young Cameroonian woman newly diagnosed with HIV, without previous ART experience. Literature on COVID‐19 and moreover co‐infection with chronic infectious diseases, such as HIV and TB, is rare in Cameroon. However, a study revealed that male gender, diabetes mellitus, and hypertension are the most important risk factors for severe COVID‐19 and mortality in Cameroon.HIV and TB interaction with COVID‐19 is poorly understood. However, it is recognized that persons living with HIV are immunocompromised and are more susceptible to TB and, possibly COVID‐19.The diagnosis and management of COVID‐19 is more challenging when co‐infected with TB due to the similarity of their clinical features or when there are existing lung lesions due to previous lung diseases. The main chest imaging findings for severe COVID‐19 are pulmonary opacities with a diffuse distribution, even with complete opacification of both lungs.4There are several complications associated with acute and post‐acute COVID‐19 syndromes. Immunosuppression associated with COVID‐19‐HIV co‐infection may significantly promote the development of active TB. The co‐infection with both TB, HIV, and SARS‐CoV‐2 may be common in Cameroon but not reported and published. Moreover, the similar clinical features of COVID‐19 and TB usually lead to misdiagnosis. The immunocompromising disease, HIV, can triple the risk of fatality when co‐infected with COVID‐19. However, this case shows that early diagnosis and management improves outcomes in co‐infected individuals.Marius P. Ngouanom Kuate involved in data collection, wrote the first draft, and read and approved the final draft. Felix Bongomin revised the first draft, and read and approved the final draft. Roland Ndip Ndip supervised the work, and read and approved the final draft.None.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Community‐acquired pneumonia (CAP) is the major cause of infection‐related mortality worldwide. Patients with CAP frequently present with admission hyperglycemia.The aim of this study was to evaluate the association between admission blood glucose (ABG) level and clinical outcomes in elderly CAP patients (≥80 years of age) with or without diabetes.In this single center retrospective study, 290 elderly patients diagnosed with CAP were included. Demographic and clinical information were collected and compared. The associations between admission blood glucose level and the 30‐day mortality as well as intensive care unit (ICU) admission and invasive mechanical ventilation (IMV) in elderly CAP patients with or without diabetes were assessed.P < 0.001).Of the 290 eligible patients with CAP, 159 (66.5%) patients were male, and 64 (22.1%) had a known history of diabetes at hospital admission. After adjusting for age and sex, the logistic regression analysis had identified several risk factors that might be associated with clinical outcomes in elderly patients with CAP. Multivariable logistic regression analysis revealed that admission glucose level > 11.1 mmol/L was significant associated with ICU admission, IMV, and 30‐day mortality both in non‐diabetic and diabetic patients. Furthermore, Kaplan–Meier analysis indicated that patients with higher admission glucose level were correlated statistically significantly with 30‐day mortality in patients with CAP (Admission blood glucose is correlated with 30‐day hospital mortality, ICU admission, and IMV of CAP in elderly patients with and without diabetes. Specially, admission glucose > 11.1 mmol/L was a significant risk factor for 30‐day hospital mortality. This study aimed to investigate the association between admission blood glucose level and clinical outcomes, including 30‐day mortality, ICU admission, and invasive mechanical ventilation, in elderly CAP patients with or without diabetes. The results showed that higher admission blood glucose is correlated with 30‐day hospital mortality, ICU admission, and IMV of elderly CAP patients with and without diabetes. Specially, admission glucose > 11.1 mmol/L were correlated statistically significantly with 30‐day hospital mortality in elderly CAP patients. We observed 2142 consecutive hospitalized CAP patients that were admitted to Meizhou People's hospital from January 2016 to December 2020. The inclusion criterion was the patient discharged with a confirmed diagnosis of CAP according to the 2016 CAP clinical practice guidelines by the Chinese Thoracic Society.2.2CAP was defined as the presence of acute illness with features of lower respiratory tract infection and the presence of consolidation in the chest CT or radiography radiograph. The patients were classified into diabetes and non‐diabetes groups according to known diabetes status on admission only. All patients that had admission blood glucose measured were also assigned to three groups in terms of admission glucose level  for analysis. Elderly patients were defined as those aged 80 years and above.2.3Initial data after admission contained demographic, baseline clinical characteristics, and laboratory findings were extracted from the electronic medical record system. For the examination of admission plasma glucose, blood samples were collected within the within 3 h once their admission. The primary outcome was defined as 30‐day hospital mortality. The secondary outcomes were consisting of intensive care unit (ICU) admission and/or need for invasive mechanical ventilation (IMV). All patients included in this study were followed up for discharge status  or death within 30 days.2.4U test, and Kruskal–Wallis test was used to compare more than two groups. Categorical variables were presented as numbers and percentages, and χ2 test or Fisher's exact test was utilized to compare their difference, as appropriate. Multivariate logistic analysis for clinical outcomes was performed. The model was adjusted for age and sex. Survival was estimated by the Kaplan–Meier method, and the differences in survival rates were evaluated with a log‐rank test. A P value of <0.01 was considered statistical significance.Statistical Packages for Social Sciences (SPSS) software version 20.0.  was used for the statistical analysis. Continuous variables are described as medians and interquartile ranges (IQRs). Two‐group comparisons were analyzed by Mann–Whitney 33.1Out of 2142 patients who presented with CAP from January 2016 to December 2020, a total of 1826 patients including age <80 years old, outpatients, with active tuberculosis, and death in the first 12 h of admission were therefore excluded. Another, 26 patients without complete clinical data were also ruled out. Finally, 290 elderly patients with CAP were included in the analysis, as shown in Figure P < 0.001). However, there were no obvious differences in the incidences of IMV, ICU admission, hospital length of stay, and 30‐day mortality between patients with and without diabetes . Additionally, patients were divided into 3 groups according to the admission blood glucose level ranging from <6.1, 6.1–11.1, and >11.1 mmol/L, respectively. The percentages of chronic kidney disease and chronic liver disease, as well as the incidences of fatigue and impaired consciousness, and CURB‐65 score show differences among the three groups. Moreover, significant differences in the severe CAP on admission, IMV, ICU admission, and 30‐day mortality were also found among the three groups (P < 0.01).The demographic and clinical characteristics of the study population are summarized in Table 3.2P < 0.01). Furthermore, patients with blood glucose levels 6.1–11.1 or >11.1 mmol/L had a trend towards higher white blood cell count, neutrophil count, higher level of uric acid, urea nitrogen, procalcitonin, C‐reactive protein (CRP), and D‐dimer compared with patients with blood glucose levels <6.1 mmol/L.As shown in Table 3.32 on arrival, and 43 (14.8%) patients needed IMV. The average length of stays from admission to discharge was 6 days. The average length of ICU stays in the hospital was 5 days, and the average duration of IMV was 4 days, respectively. Of these patients, there were 11 (3.8%) reported death in the patients with CAP, and the average time from admission to death was 2 days. These data are described in detail in Figure Of the 290 patients hospitalized with CAP, 185 (63.8%) were admitted to the general ward, and 105 (36.2%) were admitted to ICU, respectively. During the admission, 28 (9.7%) patients had a CURB‐65 score ≥ 4, 118 (40.7%) patients required O3.4P < 0.01). Meanwhile, we also found various risk factors associated with required IMV including chronic kidney disease, chronic liver disease, sepsis, neutrophil count > 6.3 × 10P < 0.01).As shown in Table 3.5P = 0.003) and 3.20  in the non‐diabetic patients. Furthermore, patients with admission glucose level > 11.1 mmol/L had a significantly higher ICU admission, IMV, and 30‐day mortality than in the patients with admission glucose level ≤ 11.1 mmol/L, regardless of whether there is a known history of diabetes.Among all patients, as is presented in Table P = 0.724). However, higher admission glucose level was correlated statistically significantly with 30‐day mortality in elderly patients with CAP (P < 0.001).The relationship between admission glucose level, diabetic status, and 30‐day mortality was also evaluated using a Kaplan–Meier analysis, as shown in Figure 4The incidence of CAP is increasing and is deemed to be the significant cause of infection‐related mortality worldwide. This study investigated the association between admission blood glucose level and clinical outcomes, including 30‐day mortality, ICU admission, and IMV, in elderly CAP patients with or without diabetes. Our results identified elevated blood glucose level on admission as significant predictors in all outcomes of interest . Further, Kaplan–Meier analysis revealed that the 30‐day mortality after admission for CAP was related to higher glucose level determined on admission, irrespective of diabetes status at presentation. Therefore, admission blood glucose level might serve as an independent highly significant parameter for the prognosis of elderly CAP patients and particular attention of clinicians should be paid to these patients.A large population‐based study reported that among patients hospitalized with pneumonia, of which 21% were admitted to ICU, 6% required IMV, and 2% died.Patients with infectious diseases frequently present with abnormal blood glucose level, especially in influenza and pneumonia.Importantly, there is also debate on the relationship between admission glucose fluctuation and CAP. For example, one earlier study found that admission hyperglycemia was a strong predictor of 30‐day mortality in both pneumonia patients with and without diabetes.The following limitations of the study have to be mentioned. Firstly, our study is a retrospective study with relatively small sample at a single center; therefore, our findings may not be broadly applicable. In addition, we measured only blood glucose at admission, not dynamic blood glucose during hospitalization non‐dynamic observation of blood glucose during hospitalization may be another reason for this result. Further clinical research of larger samples is still needed to confirm our results.In conclusion, we found that admission blood glucose is correlated with in‐hospital mortality, ICU admission, and IMV of CAP in elderly patients with and without diabetes. In addition, admission glucose > 11.1 mmol/L was a significant risk factor for death in elderly patients with CAP. Our study suggests that admission blood glucose may be used as an important and useful clinical tool for early and effective risk assessment of CAP in elderly patients, and further studies should be conducted to evaluate this possibility.The authors declare that they have no competing interests. No conflict of interest exits in the submission of this manuscript, and all the authors listed have approved the manuscript that is enclosed. The manuscript has been approved by all authors for publication.All procedures complied with the ethical guidelines outlined in the 1975 Helsinki Declaration and approved by the Ethics Committee of Meizhou People's Hospital  (number: 2020‐C‐118). Patients' consent was waived due to the retrospective nature and observational study design.Author WZ contributed to study design and interpretation of results and revised the final manuscript for publication. XH and WZ contributed to the analysis of results and wrote the manuscript. WL and MC supervised patients' recruitment and collected the clinical data. All authors read and approved the final manuscript.Table S1 Patients' demographic and clinical characteristics admission to the hospital.Table S2 Comparison of laboratory parameters among sub‐groups at admissionClick here for additional data file.


The aim of this paper is to present a freely accessible new instrument for the evaluation of cognition: the Global Examination of Mental State (GEMS).It is made up of 11 items tapping into a range of skills, such as Orientation in time and space, Memory, Working memory, Visuo‐spatial, Visuo‐constructional and Planning abilities, Perceptual and visual Attention, Language , and Pragmatics.The psychometric strengths of this screening are: (1) extensive and updated normative data on the adult Italian population (from 18 to 100 years old); (2) absence of ceiling effect in healthy individuals, which allows to better detect interindividual variability; (3) comparison of the global scores with normative data taking into account Cognitive Reserve rather than only education, thus increasing diagnostic accuracy; (4) thresholds for significant change over time and the possibility to use parallel versions (GEMS‐A/GEMS‐B) for test‐retest; (5) solid psychometric properties and data on discriminant validity; and (6) free access to all materials  on the web under a Creative Common License.With all these characteristics, GEMS could be a very useful paper‐and‐pencil instrument for cognitive screening. ‐ Another example is in the Montreal Cognitive Assessment (MoCA): 6 points are attributed to the Visuospatial/Executive section, while 3 points are attributed to the Naming section.Moreover, screening tests sometimes lack data on important psychometric properties, which limit their potential as assessment tools. A recent systematic review on Italian tests has shown that validity and reliability are often neglected properties, while thresholds for significant change are hardly ever reported  could be a way to share neuropsychological instruments with professionals and researchers.With this in mind, we present a new screening test, the Global Examination of Mental State (GEMS), which provides a fast measure of global cognition in approximately 10 min. This screening is easy to administer and takes into account many psychometric and methodological aspects often neglected in screening tests.22.1Healthy Italian volunteers  were recruited in different social groups, organizations, and in other environments without connections with clinical settings. Inclusion criteria were: age over 18, Italian mother tongue, and autonomy in principal daily living activities. Persons with neurological or psychiatric diseases were excluded.Mean age of the whole sample was 51.8 (SD = 21.57) ranging from 18 to 98 and mean education was 12.85 (SD = 4.91) ranging from 0 to 25 years . All participants underwent the administration of the Cognitive Reserve Index questionnaire (CRIq) in its digital form .Gruppo Veneto di Diagnostica e Riabilitazione . Mean age was 73.7 , mean education was 9.99 , and mean CRIq was 107.4 . These patients were also administered MMSE  recruited in the All participants took part voluntarily in this study, signed the informed consent, were aware they could stop and withdraw from the testing at any time. This study was approved by the Ethical Committee of the School of Psychology, University of Padua and it adheres to the Declaration of Helsinki.All participants were administered: (1) GEMS  for normative data collection and (2) CRIq  weighs as any other on the final score. The total score aims to represent a cognitive profile without a priori relevance in any functions. Thus, GEMS does not address any specific diagnosis or disorder.https://osf.io/4t5a8 with instructions and an Excel file to convert the raw scores and cut‐offs.GEMS‐A and GEMS‐B are freely available on the web at the OSF link: https://www.cognitivereserveindex.org/NewEdition/index.html) is a semistructured interview to measure a person's CR considering education, working activity, and leisure time activities during the lifespan.The Cognitive Reserve Index questionnaire  was assessed by Pearson's correlations. Internal consistency was calculated through a standardized Cronbach's alpha. Test‐retest and parallel‐form reliability were analyzed through Pearson's correlations. We also calculated significant change thresholds by means of a regression‐based approach  with GEMS, by a series of multiple regressions, entering total GEMS score as dependent variable . Based on the best fitting model, clinical cut‐offs were obtained following Crawford and Garthwaite's method . The distribution was left‐skewed, with no ceiling effect  and each item showed a high correlation with the global score: 0.80 for Orientation, 0.79 for Immediate Memory, 0.79 for Backward Months, 0.80 for Puzzle, 0.77 for Clock, 0.78 for Delayed Memory, 0.79 for Naming, 0.80 for Comprehension, 0.81 for Attention, 0.78 for Verbal Fluency, and 0.80 for Metaphor Comprehension.3.2r = 0.723, p < .001) and with ENB‐2 . To corroborate these results, we performed two additional regressions with GEMS total scores as dependent variable: in the first one, MoCA was the predictor , while in the second, ENB‐2 was the predictor . Both models strengthened a satisfactory construct validity.In order to verify GEMS capacity to measure global cognition, a subsample of 60 participants were further assessed with MoCA and ENB‐2. GEMS correlated with MoCA  ranging from good to excellent for each task, except for Verbal Comprehension. Table GEMS test‐retest reliability measured on 52 participants was very good  and in the GEMS total scores.Practice effect was calculated with a series of paired r = 0.774, p < .001). The correlation coefficients deriving from GEMS‐A/GEMS‐A and GEMS‐A/GEMS‐B were verified using the Fisher r‐to‐z transformation, and results showed no significant differences (two‐tailed p = .289).To account for practice effect, GEMS (hence GEMS‐A) was paired with a second form: GEMS‐B. A subsample of 59 participants was assessed with both versions and results showed good correlation . Results show that age, education, and CRI are significant predictors of GEMS, whereas sex has no effect. In particular, age has a negative relationship with GEMS, whereas education and CRI have a positive one. Interestingly, the main effect of CRI was stronger than that of education.R2 to select the best fitting model. Model 6, including age, sex, and CRI, and the quadratic terms for age (age2), education (education2), and CRI (CRI2) showed the minimum loss of information , showing a very good discriminant validity  2021 from University of Padua to SM.https://publons.com/publon/10.1002/brb3.2710The peer review history for this article is available at Supplementary materialClick here for additional data file.


This study aims to investigate the potential association of peripheral inflammatory blood cell parameters with the incidence and progression of chronic kidney disease (CKD) in patients with diabetes.The cross‐sectional study included 1192 subjects with diabetes derived from one center. The cohort study included 2060 subjects with diabetes derived from another two centers followed up for 4 years. Logistic regression and Cox proportional hazards models were used to evaluate the association of peripheral inflammatory blood cell with CKD.9/L. In the cohort study, subjects were grouped based on tertile of neutrophil count and neutrophil‐to‐lymphocyte ratio. Cox regression analysis results showed that only neutrophil count was independently associated with CKD progression  after fully adjusting for potential confounders. The cumulative incidence of CKD progression in patients with diabetes gradually increased with increasing neutrophil count (53 (7.7%) subjects in the lowest group vs. 60 (8.2%) in the middle group vs. 78 (12.2%) in the highest group).In the cross‐sectional study, neutrophil count performed best as an independent risk factor for CKD  even after 1:1 case–control matching for age, gender, history of high blood pressure and duration of diabetes. Spline regression revealed a significant linear association of CKD incidence with continuous neutrophil count in excess of 3.6 × 10This study suggested that neutrophil count is an independent risk factor for progression of CKD in patients with diabetes. Highlights9/L, and increased neutrophil count could predict progression of CKD in patients with diabetes.Neutrophil count was an independent risk factor for CKD in patients with diabetes, especially when it exceeded 3.6 × 10 Approximately half of all affected patients will develop chronic kidney disease (CKD).An increasing number of studies has indicated that the pathogenesis of CKD in diabetes is multifactorial, and low‐grade chronic inflammation plays a crucial role.This study aimed to investigate the potential association of peripheral inflammatory blood cell parameters with the incidence and progression of CKD in patients with diabetes by cross‐sectional study of expanded sample size and cohort study. First, in the cross‐sectional study, WBC count, neutrophil count and NLR were all increased and lymphocyte count was decreased in patients with CKD. All were also associated with parameters of nephropathy including creatinine (Cr), estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR). Nonetheless neutrophil count was the best independent risk factor for and predictor of CKD. In addition, significant linear associations between continuous neutrophil count, NLR and the incidence of CKD were analyzed by spline regression. Finally, our cohort study further confirmed that an increased neutrophil count, not NLR, predicted onset of CKD in diabetes. Moreover, there was a linear relationship between increasing neutrophil count and cumulative incidence of CKD.22.1A total of 3582 patients with diabetes were screened, of whom 3252 entered the study. A total of 1192 patients with diabetes (291 with CKD and 901 without CKD [NCKD]) who attended the Metabolic Disease Care Center of Shanghai Fifth People's Hospital Fudan University from May 2017 to July 2019 served as the cross‐sectional study. Another 2060 patients with diabetes were recruited into the cohort study, who were followed up annually for 4 years from January 2016 to December 2019 at Maqiao and Gumei Community Hospitals in Minhang District, Shanghai. This analysis involving human participants was approved by the Independent Ethics Committee of the Fifth People's Hospital of Shanghai, Fudan University (2010–2024). Consent has been obtained from each patient or subject after full explanation of the purpose and nature of all procedures used. The study procedure is described in Figure 2.1.1Diagnosis of diabetes was based on the 2019 Chinese Diabetes Society criteria: (1) typical symptoms of diabetes  plus random plasma glucose ≥11.1 mmol/L, (2) fasting plasma glucose ≥7.0 mmol/L, or (3) oral glucose tolerance test 2hPG ≥ 11.1 mmol/L.2.1.22) or UACR ≥ 30 mg/g (two of three specimens of UACR collected within a 3‐ to 6‐ month period).Equations to estimate GFR use serum creatinine and a combination of age, gender, ethnicity, and body size as surrogates for the non‐GFR determinants of serum creatinine. We used the modified Modification of Diet in Renal Disease equations for use in individuals from China and Japan that have been reported previously. In cross‐sectional study, definition of CKD is based on the presence of decreased kidney function  presence of any infectious disease excluding by medical history collection and routine examination such as chest X‐ray, electrocardiogram, and biochemistry test; (2) presence of viral infection or positive carrier status ; (3) previous diagnosis of urinary tract infection, urolithiasis, or liver cirrhosis; and (4) other known renal disease: IgA nephropathy, nephrotic syndrome. All study subjects were of Han Chinese origin and lived in the same region at the time of the study.2.2All subjects underwent blood and urine sample analyses. After an overnight fast for 12 h, blood samples were collected for blood cell counts  and measurement of biochemical parameters . A urine sample was collected for assessment of UACR. Anthropometric parameters were used to calculate body mass index (BMI), and blood pressure was measured with a digital automatic blood pressure monitor . A patient questionnaire was completed and included information about history of high blood pressure (HBP) and duration of diabetes.2.3T‐test was used for between‐group comparisons of continuous variables and the χ2 test for categorical variables. Skewed variables are expressed as median (interquartile range), and rank sum test was used to compare the difference between two groups. To avoid potential bias due to uneven distribution of covariates between type 2 patients with or without CKD, a case–control matching method was employed to match variables that included gender, age, history of HBP and duration of diabetes. Matching tolerance was 0, 2, 0, and 0 respectively. Logistic regression analysis was performed to detect the predictability of WBC, neutrophil and lymphocyte count, and NLR for CKD. The covariates were prespecified for inclusion in multivariable models based on clinical and biologic importance. A continuous association of neutrophil count and NLR with CKD incidence was determined by spline regression analysis.Data are shown as mean ± SD, unless otherwise noted. 9/L), middle group (3.19–4.10 × 109/L), and highest group (>4.10 × 109/L); and NLR: lowest group (<1.58), middle group (1.58–2.16), and highest group (>2.16). Analysis of variance (ANOVA) and Student's t‐test were used to identify difference in mean between groups. Variables with a skewed distribution were analyzed by Wilcoxon tests. The cumulative incidence of CKD in relation to neutrophil tertile was assessed by Kaplan–Meier plots.In the retrospective cohort study, patients were divided into three groups based on tertile of neutrophil count: lowest group . All 33.1p < 0.001). Compared with those without CKD, patients with CKD were more likely to have hypertension, higher systolic blood pressure (SBP), diastolic blood pressure (DBP), uric acid (UA), and UACR . There was no significant difference in BMI, fasting glucose, glycosylated hemoglobin (HbA1c), total cholesterol (TC), high‐density lipoprotein cholesterol (HDL‐c), and low‐density lipoprotein cholesterol (LDL‐c) between the two groups (p > 0.05). The WBC count , neutrophil count , and NLR  were much higher in patients with CKD than those without, whereas the lymphocyte count was much lower in patients with CKD .Clinical characteristics of the patients were stratified according to their nephropathy status Table . A total9/L, p = 0.139), neutrophil count , and NLR  but lower lymphocyte count  in patients with CKD compared with those without  was performed to avoid the potential bias of covariates that were not evenly distributed between patients with and without CKD. After matching, patients with higher triglycerides (TG) were still more likely to develop nephropathy. Furthermore, there remained higher WBC count (6.59 ± 0.20 vs. 6.20 ± 0.16 × 103.2p < 0.05) and negatively associated with HDL (p < 0.05). There was also a strong association between UACR and age, SBP, UA, TC, TG, and LDL , whereas eGFR was negatively associated with age, SBP, DBP, BMI, and UA  (Table p < 0.001), but a negative association with eGFR . Additionally, lymphocyte count was negatively associated with Cr and positively associated with eGFR   Table . There w5) Table .3.3p = 0.030), neutrophil count  and NLR  were independently associated with CKD development but not lymphocyte count (Table p = 0.027) . We found that the mean value of neutrophils and NLR was relatively stable during the 4 years, and the CV were all less than 25% and 30% respectively Table .p = 0.024) and patients with HBP , as well as the level of TG, Cr, fasting glucose, and HbA1c  and a stepwise decrease in the eGFR and HDL level (both p < 0.05). Across the lowest, middle and highest groups of NLR, there was also a stepwise increase in the proportion of male patients , as well as age, level of fasting blood glucose, and Cr , and a stepwise decrease in eGFR (p = 0.046) and TC, LDL, and HDL level (p < 0.05) . After adjusting for age, gender, and BMI, HR of neutrophil count for eGFR decrease >30% in the highest group remained significantly different compared with the lowest group 1.651 . Finally, after fully adjusting for potential confounders, HR of neutrophil count for eGFR decrease >30% still showed a significant difference   subjects in the lowest group, 60 (8.2%) subjects in the middle group, and 78 (12.2%) subjects in the highest group over the 4‐year follow‐up period. The same applied to NLR: eGFR decreased by more than 30% in 55 (7.8%) subjects in the lowest group, 65 (9.4%) in the middle group, and 73 (10.6%) in the highest group. In the crude model of neutrophils, hazard ratio  for eGFR decrease >30% when comparing the highest group vs. the lowest group was 1.547  produced by neutrophils is a potential predictor of CKD and its progression,Our study also found that UA, advanced age, duration of diabetes, and history of hypertension were risk factors for CKD in patients with diabetes, consistent with previous studies.There were some limitations of this study. Although we have proved that among all white blood cells, neutrophils were the most predictive for CKD in patients with diabetes, the mechanism of the potentially pathophysiological role of neutrophils in the development of CKD has not been studied clinically. Further research in humans and in animal studies should be performed to clarify the function of neutrophil‐secreted proteins, especially NE and NGAL.9/L and increased neutrophil count could predict a faster decline of eGFR in patients with diabetes.In conclusion, our study is the first to demonstrate the close association of neutrophil count with CKD in patients with diabetes. Neutrophil count was an independent risk factor for CKD especially when it exceeded 3.6 × 10Natural Science Research Funds of Minhang District, Shanghai (2019MHZ066). Health Profession Clinical Funds of Shanghai Municipal Health Commission (201940295). Scientific Research Project funded by Shanghai Fifth People's Hospital, Fudan University (2018WYZD04). Medical Key Faculty Foundation of Shanghai (ZK2019B15). Minhang District Health Committee Project (2020MW38).No potential conflicts of interest relevant to this article were reported.FIGURE S1 Changes of neutrophils during 4 years among three groups categorized by tertile of neutrophil count in baseline. A for neutrophil count; B for neutrophil‐to‐lymphocyte ratio (NLR).Click here for additional data file.TABLE S1 Changes of neutrophils and neutrophil‐to‐lymphocyte ratio (NLR) during 4 years among three groups categorized by tertile of neutrophil count in baselineClick here for additional data file.


To examine the potential mechanisms underlying social deficits in Turner Syndrome, we administered the empathic accuracy task (EAT) -a naturalistic social cognition task- and a (control) visual-motor line-tracking task to 14 girls with TS was compared to 12 age-matched typically developing girls . Empathic accuracy was compared across positive and negative emotionally valanced videos. We found that TS differs from TD on empathic accuracy ratings for negative videos; no differences were detected for the positive videos or for the control line tracking task. Thus, our findings suggest impaired detection of negatively valanced empathic interactions in TS and may help inform the future development of social-cognition treatment strategies for girls with TS. Turner syndrome (TS) is a disorder in human females in which part or all of the genetic material from one X-chromosome is absent. Girls with TS display a variety of physical, developmental and cognitive abnormalities. These include cardiovascular problems  difficulties may be present , ages 12 through 17 years of age were recruited from a larger study, which examined longitudinal brain changes associated with TS. Participants with TS were recruited nationally and TD participants were recruited from the San Francisco Bay area. Inclusion criteria for TS included genetic confirmation of Turner syndrome with a 45X karyotype. Controls with developmental delays and significant medical and/or psychiatric illness were excluded from participating in the study. Participant pubertal stage was assessed via self-report on the Tanner scale which includes ratings of breast and pubic hair development  for adolescents and administered it to all study participants. For the EAT, we selected our videos from a pool of stimuli and choose videos of late-adolescent female volunteers ages 18–19, who appeared younger than their age. Videos were between 90 and 150 s in duration and were presented as mp4 files embedded within the task stimuli, which were presented to participants by Psychtoolbox via MATLAB R2017b. We chose three positive and three negative videos that included topics applicable to adolescents. Positive video topics included telling a boyfriend or girlfriend “I love you” for the first time (Video 1), excelling at a sports competition (Video 3), and spending quality time with one’s family (Video 6). Negative video topics included death of a pet (Video 2), moving away from home for the first time (Video 4), and breaking up with a romantic partner (Video 5). We only presented videos of female volunteers since we were interested in learning how empathic accuracy may influence social relationships in girls with TS. Age related preferences for friends occur in girls, such that younger teen girls primarily have same sex friendships (85% of best friends are of the same sex in grades six through seven). With age, adolescents form more opposite sex friendships  using the right and left arrow keys on a keyboard. One line trial was shown prior to the six empathy videos and a second line trial was shown after the empathy videos.MATLAB R2017b was used to perform time series downsampling and calculations. Continuous empathy ratings obtained from participants were downsampled from 30 Hz to match the 10 Hz sampling frequency of the target’s ratings. Onsets for the participant and target ratings were aligned. Statistical procedures included calculating empathic accuracy by obtaining the Pearson’s correlation between the participant and targets’ continuous ratings for each task. Fisher’s r to z conversion was then used to convert correlation coefficients to z-scores See Fig. . Video 1p = 0.005) and intelligence  separately. To examine differences in group performance on each of the videos, we conducted a one-way MANOVA that included empathic accuracy z-scores for Videos 2–6 as dependent variables.To assess whether developmental stage and intelligence , Verbal Comprehension Index (VCI) and Perceptual Reasoning Index (PRI) should be included as a covariate within our primary analyses, separate Pearson correlations were used to examine the relationships between empathic accuracy (z-scores) with age and IQ scores. Separate Spearman’s rho correlations were used to examine the relationship between the empathic accuracy (z-scores) and the participant’s average Tanner score (the average of Tanner breast and pubic hair ratings were obtained). Significance across these correlations was determined by a Bonferroni correction, which was applied to control for multiple tests for developmental stage  and a Mann Whitney U test revealed no significant differences in groups on average Tanner stage  = 10.54, p = 0.00), PIC: F  = 11.63, p = 0.00); See Table p < 0.005). However, uncorrected p-values of p < 0.05 were observed for Video 3 for both age  and Tanner score  .The average r value for all participants on the empathic accuracy task prior to z-transformation was 0.65. SD = 0.29). A one way ANOVA revealed no significant differences between the two groups in age F1,24) = 1.97, ,24 = 1.9,24 = 1.99. A one 2 = 0.52). Between group effects revealed a significant difference for negative Video 5  = 4.26, p = 0.05, partial η2 = 0.15, TS mean = 0.90, SD = 0.21, TD mean = 1.11, SD = 0.30) and a trend towards significance and a medium effect size for negative Video 2  = 3.77, p = 0.064, partial η2 = 0.14, mean TS = 0.88, SD = 0.43, TD mean = 1.25, SD = 0.53). Significant between group differences were not found for positive Video 3  = 0.10, p = 0.75, partial η2 = 0.04, TS mean = 0.54, SD = 0.53, TD mean = 0.48, SD = 0.51), negative Video 4  = 0.23, p = 0.64, partial η2 = 0.01, TS mean = 0.95, SD = 0.58, TD mean = 0.85, SD = 0.46) or positive Video 6  = 0.31, p = 0.58, TS = 0.91, SD = 0.32, TD mean = 0.98, SD = 0.25).Figure p = 0.41, partial η2 = 0.08; Line 1 TS mean = 2.23, SD = 4.2; Line 1 TD mean = 2.49, SD = 3.8; Line 2 TS mean = 2.10, SD = 1.00; Line 2 TD mean = 2.40, SD = 0.77).Data were excluded from one TS participant who refused to complete the line-tracking task See Fig. . When exWe found evidence supporting our hypotheses that girls with TS differ from TD girls on empathic accuracy. Specifically, girls with TS as compared to TD controls demonstrated significantly lower empathy accuracy for the negative video about the death of the target’s dog, a trend towards lower accuracy for the negative video about moving away from one’s home for the first time. Though significant differences were not observed for the negative video about experiencing a breakup, girls with TS performed slightly better in comparison to TD controls. The positive video about being told “I love you” for the first time was excluded due to poor agreement across all participants. For the remaining positive videos, no group differences were found. However, for the positive video about excelling at a sports competition, girls with TS performed slightly better than TD controls and for the positive video about spending quality time with one’s family, TS participants performed slightly worse than the TD control participants See Fig. . TherefoOur results showing lower empathic accuracy for two of our three negatively valanced videos is consistent with the extant literature, which demonstrates impaired affect recognition for negative emotions in TS  than the positive videos . These results differ from a recent study in which participants rated empathic accuracy according to the video’s degree of emotional intensity  instead of valence; our study only examined emotional valence but not emotional intensity . Furthermore, they suggest that empathy accuracy differences could be associated with the emotional valence conveyed within the videos, although these findings are not definitive. Nonetheless, our empathy accuracy results in TS may contribute to the development of treatments aimed at improving social-emotional function in affected girls, such as the development of targeted empathy training. For example, if definitive deficits in empathy accuracy for negatively valanced stories is found in TS, then treatments aimed at helping girls with TS process their own negative emotions could be tested in order to determine whether this change in self emotion processing will impact empathy for negative emotions in another.Our study has several limitations. First, our sample size was small and we implemented a cross sectional design. Future studies should examine the impact of development by examining empathic accuracy longitudinally with larger samples. More study is needed in order to decipher the full extent of empathic deficits present in TS. Additionally, to further examine the full extent of empathy deficits in TS, the task should be pre-experimented to examine not only the valence but also the arousal, intensity and larger context of the stimuli. Results may be additionally influenced by the individual characteristics of study participants such as whether the participant can relate to the situation conveyed within the video and the participant’s own attachment style. They could also be influenced by the individual characteristics of the targets, such as the target’s sex, race, class and ethnicity, which would be important to examine in future studies. Specifically, one weakness of this study includes the potential generalisability of our stimuli to adolescent girls with TS. We chose to present videos of young looking targets who are just above 18 since they were old enough to consent to the use of their videos as research stimuli. However, because girls with TS tend to have friends who are either their age or younger, this may decrease the validity of how empathy influences friendships in girls with TS. Thus, future studies should examine empathy accuracy in girls with and without same age target stimuli. Moreover, another study weakness includes our limited range and number of stimuli, which should be increased for future replications of this study. We included only six videos, one of which was excluded due to poor agreement while another video was included despite it indicating moderate agreement. Therefore, further replication of this study should include a larger range of videos with good agreement.This is the first known study to examine empathic accuracy in girls with Turner syndrome as compared to age-matched controls. As hypothesized, we found between-group differences in empathic accuracy. Group differences did not appear to be due to visual-spatial deficits involved in rating the task, as demonstrated by intact accuracy for both groups on a visual moving line tracking task. Thus, our results suggest that the previously detected deficits for negative emotions may influence empathic accuracy abilities in TS during negatively valanced empathic interactions. However, more research is needed in order to identify the mechanisms underlying our findings. These deficits may help explain social cognition deficits and social anxiety in TS and could contribute to the development of novel treatments for the social deficits present in girls with this condition.


Downregulation of key lipogenesis enzymes has been shown to activate apoptosis in cancerous cells. Epigallocatechin gallate (EGCG) inhibits cancer cell proliferation without causing cytotoxicity in healthy cells. The present study aimed to investigate the effects of EGCG on the promotion of apoptosis associated with the DNL pathway inhibition in cancer cells, both in vitro and in vivo. We observed that two colorectal cancer cell lines (HCT116 and HT‐29) had a higher cytotoxic response to EGCG treatment than hepatocellular carcinoma cells, including HepG2 and HuH‐7. EGCG treatment decreased cell viability and increased mitochondrial damage‐triggered apoptosis in both HCT116 and HT‐29 cancer cells. Additionally, we treated mice transplanted with HCT116 cells with 30 or 50 mg·kg−1 EGCG for 7 days to evaluate the apoptotic effects of EGCG treatment in a xenograft mouse model of cancer. We observed a decrease in intracellular fatty acid levels, which suggested that EGCG‐induced apoptosis was associated with a decrease in fatty acid levels in cancer. Suppression of ATP synthesis by EGCG indicated that cell death induction in cancer cells could be mediated by shared components of the DNL and energy metabolism pathways. In addition, EGCG‐induced apoptosis suppressed the expression of the phosphorylation protein kinase B and extracellular signal‐regulated kinase 1/2 signaling proteins in tumors from xenografted mice. Cytotoxic effects in unaffected organs and tissues of the mouse xenograft model were absent upon EGCG treatment.The  de novo lipogenesis and energy metabolism pathways are implicated in apoptosis. Furthermore, EGCG‐induced apoptosis reduced the expression of phosphorylated protein kinase B and extracellular signal‐regulated kinase 1/2 signaling proteins.Epigallocatechin gallate (EGCG) caused cytotoxicity and mitochondrial damage‐induced apoptosis in colorectal HCT116 cancer cells. A decrease in fatty acid levels was associated with EGCG‐induced apoptosis. Additionally, the reduction of ATP generation by EGCG revealed that components of the  As a result, effective new cancer therapy agents could be used as an alternative to improve the efficiency of clinical research. Colorectal cancer (CRC) is the third greatest cause of death from cancer, with an increasing incidence rate around the world . Surgeryde novo lipogenesis (DNL) pathway where they help provide precursors for ATP generation, cell membrane synthesis and various signaling pathways implicated in cancer growth and metastasis    at a dilution of 1 : 500; and rabbit anti‐phospho‐caspase 3 (Ser150)  at a dilution of 1 : 400. Consequently, a specific protein was conjugated with goat anti‐rabbit IgG (H+L) secondary antibody, horseradish peroxidase (HRP)  or goat anti‐mouse IgG (H+L), superclonal recombinant secondary antibody, HRP  at a dilution of 1 : 7000. Finally, LuminataTM Forte Western HRP Substrate (Merck KGaA) was added to visualize the protein bands, which were then detected via chemiluminescence western blotting . The molecular mass marker of proteins in membrane was identified using the BLUeye prestained protein ladder . Protein bands were calculated as a percentage of the relative expression level of protein/actin, and compared with the control using imagej, version 1.46 .Cells were trypsinized and lysed with lysis buffer , containing 1% protease inhibitors . Tumor tissues were homogenized in RIPA  secondary antibody, HRP  or goat anti‐mouse IgG (H+L), superclonal recombinant secondary antibody, HRP . Finally, the expression levels of proteins were detected using 3,3′‐diaminobenzidine substrate , counterstained with hematoxylin and visualized using a light microscope . The cytotoxic effect of EGCG on tumor tissues and internal organs of the xenograft host was investigated using hematoxylin and eosin staining. The morphological changes were visualized under a light microscope.g for 10 min. The lower phase of homogenized fatty acid was collected by vacuum‐dried chloroform for 30 min at 60 °C. Next, dried lipids were collected, and the free fatty acid level was detected by a microplate reader at an excitation wavelength of 535 nm and an emission wavelength of 590 nm. The calculated percentages of free fatty acids were compared with the control using prism, version 9.The level of free fatty acids was investigated using the Free Fatty Acid Quantification kits . Cells and tissues were homogenized in 1% Triton‐X in chloroform and centrifuged at 15 000 g for 5 min. The supernatant was then harvested and the level of ATP was measured by microplate reader at an excitation wavelength of 535 nm and an emission wavelength of 587 nm. The ATP level was calculated using prism, version 9.ATP levels were detected using ATP Quantification kits . Cells and tumor tissues were extracted in ATP assay buffer and centrifuged at 13 000 prism, version 9. All data were analyzed using one‐way analysis of variance (ANOVA) with Tukey’s post‐hoc test and are presented as the mean ± SD. The samples were analyzed in at least triplicate and compared with the control. P < 0.05 was considered statistically significant.All statistical analyses were conducted using m for 24 h and cell viability was evaluated by a MTT assay. As shown in Fig. 50) of 0.5 ± 0.05 mm and 0.8 ± 0.06 mm, respectively , suggesting a safe usage in normal cells. Conventional and effective chemotherapeutic drugs were used as positive controls; 0.2 mm 5FU treatment in HCT116 and HT‐29 CRC cells [m sorafenib treatment in HepG2 and Huh‐7 liver cancer cells [Cell lines, including HCT116, HT‐29, HepG2 and HuH‐7, were incubated with EGCG 0‐1 mely Fig. . EGCG, oion Fig. . TherefoRC cells  and 20 µer cells  signific50 values of 0.5 and 0.8 mm for 24 h, respectively, cancer cells underwent early and late stages of apoptosis  via an intraperitoneal injection for 7 days exerted similar level of suppressive effect on the growth rate of HCT116‐tumors by significantly decreasing tumor volume and weight compared to the vehicle control  causes hepatotoxicity and associated dyslipidemia in a dose‐ and route‐dependent manner [−1 trigger several adverse effects in human [−1. Maruyama et al. [−1 body weight by i.p. injection every other day over a 2‐week period for the treatment in liver metastases. Luo et al. [−1 EGCG, i.p. injected every day), EGCG medium‐dose group  and EGCG high‐dose (EGCG‐H) group . Kang et al. [−1 EGCG and 50 mg·kg−1 EGCG). Thus, the dose of EGCG that we used in the animal study was based on these previous studies.Many research groups have reported different concentrations of EGCG that effectively generates cytotoxic effect in HCT116 and HT‐29 cells. However, the clear intensive mechanism has not yet been identified. It has been reported by La et al.  that thes et al.  showed tll death . Haratif [et al.  reportedt manner . Doses oin human . In mosta et al.  used EGCo et al.  reportedg et al.  divided m palmitate completely rescued the FASN inhibition‐induced apoptotic effect after α‐mangostin treatment in 3T3‐L1 preadipocytes [et al. [de novo fatty acid biosynthesis is more important for cell proliferation than the fatty acid uptake from the circulation [The present study demonstrated that the rescue effect of palmitate on the EGCG‐induced suppression of fatty acid synthesis confirms that fatty acids control HCT116 cancer cell proliferation. Exogenous fatty acids have been reported to help rescue the cytotoxic effect of fatty acid synthesis inhibition in a variety of cancer cell types. According to one study, the addition of 100 μipocytes . Palmitaipocytes , as wellipocytes . It has ipocytes . Howeveripocytes . Hoppert [et al.  found noculation . HoweverSeveral agents that target specific metabolic pathways, including fatty acid synthesis, have been shown to have the therapeutic potential to improve cancer treatment efficacy. A reduction of key enzymes in the DNL pathway has been shown to cause a reduction in fatty acid products  and fattin vitro experiments revealed that EGCG induced apoptosis by decreasing ACC expression without changing FASN levels. ACC is the rate‐limiting enzyme in the DNL pathway. A decrease in fatty acid synthesis occurs when the ACC is suppressed, which promotes apoptosis. The phosphorylation of ACC by AMPK is essential for inhibiting the DNL pathway [The current  pathway , 84, 85. pathway . ND‐646  pathway . A simil pathway . Malonyl pathway , 90. Cel pathway . The apo pathway . Our finAlthough TVB‐3166 is a highly selective FASN inhibitor, it fails to suppress FASN expression in tumor cell line xenografts, and ACC phosphorylation is most likely one of the key causes . In A549It has been proposed that the increased expression of proapoptotic proteins mediated by the induction of endoplasmic reticulum stress with inducing ceramide levels in pancreatic cancer cells is a result of the apoptosis‐facilitating effect of a decrease in fatty acid levels . Malonyl2 and acetyl CoA in each round by shortening fatty acids (two carbons per cycle) to enter the electron transport chain for ATP production [In addition to the enhanced proapoptotic expression that resulted from fatty acid suppression, a reduction in FAO has been reported as a consequence of the suppression of the ACC‐α expression in hepatocellular carcinoma cells. Both glycolysis and OXPHOS were suppressed by the knockdown of ACC‐α, leading to a decrease in tumor growth . Mitochooduction , 100. CPoduction . In addioduction  through oduction . Moreoveoduction . A similoduction . Therefoin vitro study, EGCG administration in tumor xenografts of mice did not result in weight loss in the current investigation. According to a previous study using in vivo A549 lung cancer xenografts demonstrated that EGCG, in contrast to C75, exerted no weight loss‐related effect on CPT‐1 activity [in vitro model [In addition to the activity . EGCG trro model . Thus, tIt has been reported that the antioxidant system of glioblastoma cancer cells was found to inhibit fatty acid oxidation‐induced apoptosis by increasing ROS‐induced oxidative stress and depletion of nicotinamide adenine dinucleotide phosphate‐reduced glutathione levels . The eleIn cancer cells, EGCG suppressed receptor tyrosine kinase activity, inhibiting cell proliferation. This included epidermal growth factor receptor  and human epidermal growth factor receptor‐2, as well as neu/erbB2. The inhibition of these protein targets resulted in the inhibition of downstream signaling cascades, leading to induction of apoptosis in colon cancer cells . EGCG haOf note, in addition to regulating apoptosis, the activation of Akt and ERK1/2 pathways has been found to regulate fatty acid synthesis in the DNL pathway. The induction of apoptosis in SK‐Br3 breast cancer cells has been reported to involve a suppression of the DNL pathway, which is controlled by the phosphorylated PI3K/Akt and MAPK/ERK1/2 pathways . The inhIn cancer cells, a reduction in ATP that results in an increase in ADP or AMP levels has been shown to activate AMPK. Glycogen, fatty acid and protein synthesis have all been demonstrated to be inhibited by active AMPK. AMPK activation has been found to suppress FASN activity in hepatoma cells , 114, asin vitro results, G28UCM, a synthetic FASN inhibitor, was found to induce apoptosis in breast carcinoma xenografts by decreasing FASN enzymatic activity but not total FASN levels. However, the mechanism underlying this was not addressed [In cancer cells, EGCG was reported to reduce FASN activity and free fatty acid levels without affecting protein expression , 118. EGddressed .in vivo model, we hypothesized that there may be an additional signaling mechanism and time‐dependent protein expression that regulate protein expression in fatty acid synthesis. In the present in vivo experiment, the phosphorylation of Akt and ERK was inhibited, although there was no alteration in the abundant expression of PI3K, mTOR and SREBP‐1c following EGCG treatment. This effect is more likely because the concentration of EGCG in the body varies over time. The phosphorylation of MAPK, c‐Jun N‐terminal kinase (JNK) and ERK in HT‐29 cells suggests that EGCG treatment affected signaling cascade in a time‐ and dose‐dependent manner. JNK activation occurred prior to an increase in ERK activation, and was followed by the inactivation of JNK during the late stages of cell death. In addition, ERK activation required a lower EGCG concentration than that of JNK. In response to cellular stress, the evidence revealed interactions among upstream signaling pathways that cross‐talk with one another [et al. [In the  another . Shimizu [et al.  reported [et al. .The protein expression pattern of 5FU treatment in the present study was similar to that of EGCG treatment, which was consistent with a previous study showing that the changes caused by 5FU injection in an orthotopic xenograft of human gastric cancer cells in the gastric submucosal layer from nude mice on the protein expression of the PI3K/Akt/mTOR pathway were small . Furtherin vitro and in vivo. This study provided the basis for further research into using EGCG to target the DNL pathway as a potential clinical approach for the treatment of CRC cells. To fully understand the signaling pathways that govern the DNL pathway in response to EGCG therapy, further research is required.The results of the present study demonstrated that EGCG inhibited fatty acid synthesis, resulting in the depletion of ATP, a regulator of the of fatty acid synthesis, and hence contributed to the induction of apoptosis in colon cancer cells, both The authors declare no conflict of interest.PK and PS were responsible for study conceptualization, data curation and formal analysis. PS was responsible for funding acquisition. PK, DS, MS, DP, SP, JS and PS were responsible for the conducting the investigation. PK, JS and PS were responsible for methodology. DS, MS, DP, SP, JS and PS were responsible for project administration. PK, DS, MS, LR, DP, SP, JS and PS were responsible for writing, review and editing.


Myxedema coma is a rare life-threatening presentation of severe hypothyroidism associated with a high mortality rate. Although most cases are due to primary thyroid failure, a minority have central hypothyroidism as the underlying cause. We report the case of a 69-year-old man who presented with obtundation, hypoglycemia, and hyponatremia. The patient's initial thyroid-stimulating hormone (TSH) was within normal limits. Subsequent evaluation revealed critical anterior pituitary insufficiency due to a macroprolactinoma and a diagnosis of myxedema coma after appropriate workup The finding of a normal serum TSH should not eliminate the possibility of myxedema coma. We report a very unusual case of myxedema coma (MC). Severe hypothyroidism meeting the definition of MC is associated with a significant mortality rate (30–50%), even with standard therapy , 2. The Following a rare series of three winter storms affecting Houston, TX, at the end of February 2021, there was widespread loss of power and water, and daily temperatures stayed below 0 degrees Celsius for 17 days. An estimated 250–700 Texans died from cold exposure during this period.A 69-year-old male was brought to the emergency department in early March 2021 for evaluation of deteriorating mental status leading to disorientation and unresponsiveness. Initial laboratory tests revealed a blood glucose of 45 mg/dl and a serum sodium of 120 mEq/L. His lactic acid level was elevated at 4.2 mmol/L. He was started on intravenous 10% dextrose with no improvement of mental status, though his serum glucose rose to 102 mg/dl. A chest CT revealed a large area of infiltration in the right upper lung consistent with pneumonia. A CT scan of the head revealed calcification of the basal ganglia, thalamus, and cerebral hemispheres bilaterally. A 2 cm mass arising from the sella turcica was also noted . AdditioHe also had a significant medical history of hypertension and iron deficiency anemia that required frequent erythropoietin injections. He also had a history of daily tobacco use but had discontinued that two years prior. There was no history of illicit drug use. His only home medication was lisinopril 20 mg daily. His family reported that he had been increasingly confused and lethargic for one week prior to his emergency room presentation. His family also reported that he had not complained of headaches, nausea, vomiting, or any visual impairment.Clinically, he was obtunded and only partially responsive to auditory stimuli. His skin was very dry and flaking off; he had generalized edema and macroglossia, but he did not have expressible galactorrhea or gynecomastia. He was variably hypothermic, with body temperature ranging from 94.8–96.1 degrees Fahrenheit. His heart rate ranged from 75 to 86 bpm. An ECG revealed a first-degree AV block. On 2 liters of nasal oxygen, his arterial pO2 was 95 mm·Hg, and his pCO2 was elevated at 48 mm·Hg. In previous medical visits, he had never been diagnosed with thyroid dysfunction, hyponatremia, or hypoglycemia. He had no prior brain imaging.Given the newly found pituitary lesion and the patient's clinical presentation, pituitary function labs were ordered for further evaluation. His prolactin level was 1,033 ng/ml (4–15 ng/ml); free T4 was 0.2 ng/dl (0.9–1.7 ng/dl); total T3 was low at 35 ng/dl (80–200 ng/dl) with an inappropriately normal thyroid-stimulating hormone (TSH) of 2.35 uIU/ml (0.27–4.2 uIU/ml). His initial (2 PM) serum cortisol was 5 ug/dl with an ACTH of 9.6 pg/ml (7.2–63.3 pg/ml). Following intravenous cosyntropin, his cortisol rose to 10 ug/dl at 30 minutes and 11 ug/dl at 60 minutes. There was no notable change in his mental status after the cosyntropin administration. His IGF-2 was normal at 206 ng/ml (180–580 ng/ml). His initial serum parathyroid hormone level was low at 9 pg/ml.The patient's serum follicle-stimulating hormone (FSH) was 1.0 mIU/mL (1.6–8.0 mIU/ml), and his serum luteinizing hormone (LH) was 0.3 mIU/ml (1.6–15.2 mIU/ml). An MRI of the brain confirmed a sellar and suprasellar enhancing mass, likely a pituitary adenoma, measuring 1.2 × 1.8 × 2.3 cm, with no sphenoid or cavernous sinus invasion.The patient's total score of 85 on the widely accepted Popoveniuc et al. diagnostic scoring system  confirmeWe report the case of a man who had underlying central hypopituitarism, including partial TSH deficiency, as the cause of his hypothyroidism. He then developed myxedema coma, possibly due to a combination of cold exposure and pneumonia. The cause of his hypopituitarism was most likely a macroprolactinoma. As far as we can determine, this is the first documented case of myxedema coma due in part to a macroprolactinoma. We found no other case reports of this phenomenon in our literature review.There are many potential underlying causes of MC. Two of the most common are autoimmune thyroid failure  and post-thyroidectomy hypothyroidism. Reports of MC due to hypopituitarism with secondary hypothyroidism are quite rare and have been estimated to account for much less than 5% of all MC cases . The earThe most common precipitating factors in MC are hypothermia, cessation of thyroid supplements, severe infections, anesthetics, tranquilizers, respiratory failure, and stroke , 7. In 2Several well-documented cases of MC associated with hypopituitarism have been reported in PubMed over the past 60 years –16. A caGiven that the vast majority (>95%) of MC cases are due to primary hypothyroidism, it can be difficult to diagnose MC when TSH is not elevated. In patients with MC due to central hypothyroidism, the TSH is typically low or normal, and these patients often have other features of hypopituitarism . AdditioAlthough patients with MC due to central hypothyroidism typically present with altered mental status as the first symptom, their neurological impairments may be more subtle than MC due to primary hypothyroidism, in part because there is some minimal TSH-independent T4 production in central hypothyroidism. However, the mortality rate for MC appears to be similar in both central and primary hypothyroidism , 20.Notably, patients with macroprolactinomas have various patterns of hypopituitarism. In a large retrospective review of men with macroprolactinomas (between 20–39 mm in size), 93% had central hypogonadism, 7% had central hypoadrenalism, and 18% had central hypothyroidism , 22. HypRegardless of the etiology of the MC, management with high-dose intravenous levothyroxine as a loading dose, followed by a weight-based daily dose, remains the gold standard for therapy to help reverse the severe hypometabolic state in MC patients. Intravenous hydrocortisone should also be administered initially or concurrently, as patients with MC often have relative adrenocortical deficiency, which can worsen as the replacement thyroid hormone increases the metabolic rate .Myxedema coma is an endocrine emergency that requires a high index of suspicion given its high mortality rate. Unusual underlying causes, such as tumoral hypopituitarism, can impede diagnosis due to the lack of elevated TSH levels. This can potentially delay time-sensitive management therapies. From our literature review and to the best of our knowledge, this is the first report of macroprolactinoma associated with MC and is worth noting, as it highlights the extensive range of complications that can arise from pituitary tumors. Overall, this case highlights the critical importance of careful and thorough clinical assessment in patients with seemingly incongruent clinical and laboratory findings.


Rhizobia or members of the SAR11 clade. Here we report on the microbiome of frost flowers sampled during the winter and polar night in the Barents Sea. There was a distinct difference in community profile between the extracted DNA and RNA, but both were dominated by members of the SAR11 clade (78% relative abundance and 41.5% relative activity). The data further suggested the abundance and activity of Cand. Nitrosopumilus, Nitrospinia, and Nitrosomonas. Combined with the inference of marker genes based on the 16S rRNA gene data, this indicates that sulfur and nitrogen cycling are likely the major metabolism in these ephemeral structures.Under very cold conditions, delicate ice‐crystal structures called frost flowers emerge on the surface of newly formed sea ice. These understudied, ephemeral structures include saline brine, organic material, inorganic nutrients, and bacterial and archaeal communities in their brine channels. Hitherto, only a few frost flowers have been studied during spring and these have been reported to be dominated by  Cand. Nitrosopumilus, Nitrospinia, and Nitrosomonas, indicating that sulfur and nitrogen cycling are likely the major metabolism in these ephemeral structures.Here we report on the microbiome of frost flowers sampled during the winter and polar night in the Barents Sea. There was a distinct difference in community profile between the extracted DNA and RNA, but both were dominated by members of the SAR11 clade (78% relative abundance and 41.5% relative activity). The data further suggested high abundance and activity by  Frost flowers from the central Arctic Ocean harbored even more cells with 3.46 × 106 mL−1 . Frost flowers can also contain high concentrations of sulfate (~50 µM), nitrate (~22 mM), dissolved organic carbon, and colored dissolved organic matter , from a cage, lowered to just above the ice surface, frost flowers were scooped into a sterilized bucket from two areas of about 5 m² size using a sterilized spade. The samples were thawed at 4°C, and the resulting 4.2 L were filtered on a 0.22 µm Sterivex filter, and stored at −80°C. 1.8 mL glutaraldehyde fixed thawed frost flowers were used to determine the cell abundance using a FACS Calibur (Becton Dickinson) flow cytometer according to Marie and coworkers  reads), followed by Roseibacillus (2.8%), Candidatus Nitrosopumilus (2.7%), members of the OM60/NOR5 clade (2.2%), and members of the SAR86 clade , LS‐NOB of the family Nitrospina (5.0%), and Nitrosomonas (2.8%) . In addition, the marker gene for nitrification, amoA, was inferred for Cand. Nitrosopumilus (0.003% and 0.002%) and Nitrosomonas (both 0.001%), while only nirS/nirK was inferred for all Nitrospina (0.002%). Other marker genes were not inferred or were in very low abundance. The carbohydrate‐active enzyme (CAZyme) classes glycosyl hydrolases (GH) and glycosyl transferases (GT) were inferred for nearly all ASVs, but specifically for Alpha‐, Gammaproteobacteria, Bacteroidia, and Verrucomicrobiae.Serendipitously, a frost flower sample was collected from black nilas ice within the pack ice in the Northern Barents Sea during the polar night. The cell abundance within the frost flower was 2.23 × 1045 mL−1, while at the other close by station, it was lower with 1.48 × 105 mL−1 . This is much lower than the numbers reported from summer samples by Bowman and Deming . The relative activity of all members of the SAR11 clade was lower than the relative abundance. The inference of the aprA gene is due to the abundance of members of SAR11 clades, which are suspected to perform sulfur oxidation for energy and detoxification of sulfite  sampled at one of the closest by stations (~50 km distance), was relatively similar to the cell abundance in the frost flower with 2.31 × 10d Deming . The difd Deming , the relStefan Thiele: data curation (lead); formal analysis (lead); investigation (lead); methodology (lead); software (lead); visualization (lead); writing – original draft (lead); writing – review and editing (lead). Anna Vader: conceptualization ; formal analysis (supporting); funding acquisition (supporting); writing – review and editing (supporting). Lise Øvreås: conceptualization (lead); formal analysis (supporting); funding acquisition (lead); investigation (lead); writing – review and editing (supporting).None declared.None required.


Depending on the serum sodium (Na+ level decreased to 82 mM/L, accompanied by pulmonary edema and lactic acidosis. The patient was strongly suspicious of OHIAS.A 53-year-old woman underwent hysteroscopic myomectomy for submucosal leiomyoma. Approximately 3 hours postoperatively, the serum Na+ level reached 120 mM/L, gradual correction was performed considering osmotic demyelination syndrome, and desmopressin was administered to prevent overcorrection caused by excessive water diuresis. Serum Na+ level normalized in 4 days and the patient recovered without any specific sequelae.A rapid correction was made using 3% NaCl to prevent brain edema as an initial response. After the serum NaThe detection of OHIAS may be delayed under general anesthesia, and prior vigilance is important if the operation time is prolonged. In severe hyponatremia with an apparently rapid onset, such as OHIAS, a two-step correction process may be safe and useful: rapid correction followed by more gradual correction. Although early detection is important, even obstetricians and anesthesiologists are often unaware of OHIAS. Once hyponatremia has occurred, it is important to determine the correction rate. A sharp overcorrection of serum Na+ level increases the risk of osmotic demyelinating syndrome (ODS). In contrast, life-threatening cerebral edema can occur if serum Na+ level does not rise to the target range within a period.,3Operative hysteroscopy intravascular absorption syndrome (OHIAS) refers to iatrogenic hypotonic hyponatremia caused by irrigation solution used in the surgical field. OHIAS is also called gynecological transurethral resection of the prostate (TURP) syndrome due to its similarity to TURP syndrome in pathogenesis, clinical picture, and treatment. It can cause seizures and respiratory arrest in postoperative patients, progressing rapidly to death or a permanent vegetative state.+ level of 82 mM/L after hysteroscopic surgery. It is a rare case where the sodium level suddenly dropped iatrogenically within 3 hours after surgery, and we performed a two-step correction with reference to several guidelines. Furthermore, we discuss the adopted initial correction rate and target values to minimize neurological sequelae and the subsequent occurrence of diluted urine and overcorrection.Here, we report the case of a female patient with a serum NaInformed consent was obtained from the patient for this study. A 53-year-old woman weighing 60 kg and 152 cm in height was diagnosed with submucosal leiomyoma. She decided to undergo a hysteroscopic myomectomy at the gynecology department of our hospital. She had been taking medications for hypertension and intermittent nonspecific angina.+, K+, and Cl– were 139, 4.1, and 106 mM/L, respectively). Furthermore, there were no abnormal findings on preoperative electrocardiography or echocardiography.Preoperative blood test results showed no abnormalities, and all electrolytes were within normal ranges , as well as acidosis , hypocalcemia (Ca2+ 0.75 mM/L), hypoglycemia (glucose 74 mg/dL), and anemia (hematocrit 19%). The total surgery time was 2 h 50 minute, during which 45 L of distension medium was used (15 × 3 L Urosol bags), and total urine output was 2400 mL.On the day of surgery, electrocardiogram, pulse oximetry, blood pressure, and body temperature were measured according to routine procedures in the operating room. Her blood pressure, heart rate, respiratory rate, and oxygen saturation were 136/84 mm Hg, 106 bpm, 15 breaths/minute, and 96%, respectively. Urosol , a hypotonic solution (190 mOsm) containing 540 mg of D-mannitol and 2.7 g of D-sorbitol per liter, was used as a distension medium for the hysteroscopic surgery.+, K+, and Cl– levels of 82, 4.4, and 62 mM/L, respectively. Lactate level increased to 8.7 mM/L. An anteroposterior chest radiograph revealed pulmonary edema in both the lungs , 289 mOsm/kg , 4 mM/L and 2.98 mg/dL , respectively. The patient was strongly suspicious of OHIAS.The patient was transferred to the surgical intensive care unit while maintaining intubation without emergence from anesthesia. Initial postoperative laboratory tests showed severe hyponatremia, with Nangs Fig. A. Serum + levels after approximately 1 and 3 h were 92 and 102 mM/L, respectively. Accordingly, the administration rate was lowered to 50 mL/h, and serum Na+ level was checked every 2 h and adjusted to 10–50 mL/h. Approximately 12 h after correction, the serum Na+ levels were 118 mM/L . Consequently, serum Na+ level elevation was somewhat stabilized, and urine output decreased . Gradually, urine concentrations of Na+ and creatinine increased to 25 mM/L and 40.51 mg/dL, respectively. The serum Na+ level increased steadily as planned and normalized at 4 days postoperatively (135 mM/L).The patient consistently excreted large amounts of dilute urine. During the first 10 h of transfer to the surgical intensive care unit, the fluid intake (2050 mL) and output (5040 mL) difference (I/O) was –2990 mL. The 24-h I/O measured the next day was –4190 mL . This caused the serum NaThe patient was transferred to the general ward on POD 4 and discharged on POD 8. Enhanced magnetic resonance imaging and angiography conducted on POD 7 revealed no remarkable abnormalities in the brain parenchyma, ventricular system, or extracerebral cerebrospinal fluid space. The patient complained of a mild headache after discharge and followed-up with a neurologist for consultation. The headache improved three months after discharge, and no other sequelae were reported. This suggests that sufficient attention should be paid to severe hyponatremia (serum Na+ <120 mm Hg) when using more than 2000 ml of irrigation solution. In our patient, 4500 ml of irrigation solution was used for 2 hours and 50 minutes of myomectomy.OHIAS is caused by systemic absorption of excessive irrigation solution in a closed space during hysteroscopic surgery. The irrigation solution used is typically a hypotonic, non-conductive fluid to avoid thermal burn. When absorbed systemically, it induces hyponatremia in proportion to the amount used. The major risk factors are use of large amounts of hypotonic fluid, prolonged operation time, operative procedures (not diagnostic), exposure of uterine venous sinus, and high irrigation fluid pressure (>10 mm Hg). In adult women, it has been reported that when 1000 ml of non-conductive solution is absorbed, there is a decrease of serum sodium of 10 mEq/L and that for 3000 ml is 30 mEq/L.Early detection and intervention are important for positive outcomes in cases of OHIAS; however, detection may be difficult or nearly impossible while the patient is under general anesthesia and cannot complain of symptoms. In severe hyponatremia, tachycardia, hypotension, and high airway pressure may occur, but they can be easily overlooked without careful attention. In our case, there was no significant change in vital signs or airway pressure, but a large amount of urine output (1800 mL) was the only clue to the impression.+ level was 82 mM/L, we planned a two-step calibration. The initial goal was rapid correction to 120 mM; then adjustment would proceed gradually to < 8 mM/day. Based on the above, we reduced the possibility of cerebral edema leading to brain herniation by aiming to reach a Na+ level of 120 mM/L within the first 24 h and then minimized the likelihood of ODS by performing subsequent gradual correction.After confirming that the serum Na Among other things, brain herniation, the most dangerous complication of hyponatremia, occurs almost exclusively in patients with acute hyponatremia. In the majority of OHIAS and TURP syndrome cases, a sharp decrease in serum Na+ level by electrolyte-free lavage did occur but was successfully reversed. In patients with severe postoperative hyponatremia (80–110 mM), use of 3% NaCl solution could increase serum Na+ level by 20–30 mM within 12–24 hours, and most of them were successfully treated without sequelae. This is supported by the fact that the rapid onset of hyponatremia is so short-lived that cerebral adaptation is insufficient; therefore, the risk of ODS is low. On the other hand, a relatively slow correction could potentially promote the risk of ODS by allowing sufficient time for cerebral adaptation.The US guidelines recommend 100 mL of 3% NaCl intravenous infusion over 10 minure 3 times as needed without limitation of the rate of correction in true acute hyponatremia. Patients with hyponatremia for less than 24 hours are highly unlikely to develop ODS.,9 Rapid correction is probably safe, but the risk of ODS is not completely ruled out. They suggest that an increase of 4–6 mM/L for the first few hours is sufficient to alleviate the symptoms and prevent brain herniation.Nevertheless, European and American colleges of obstetricians and gynecologists guidelines still recommend not exceeding 10 mEq/L and 12 mEq/L, respectively, during the first 24 hours. Although the US guidelines are more liberal, they also warn of the dangers of ODS for correction above 12 mM/L in the first 24 h.+ level after administration of hypertonic saline may be much higher than expected from the formula. In this case, the Na+ concentration increased from 82 to 118 mM/L during the first 12 h, and the required 3% NaCl concentration was calculated to be approximately 2105 mL using the classic formula. However, The actual amount of 3% saline administered to increase the Na+ level by 36 mM/L for this patient was approximately 400 mL , not 2105 mL. The patient was in a severe state, with excessive body fluid and a large amount of diluted urine (5400 mL) was simultaneously excreted.The increase in serum Na+ level reached 120 mM/L, 3% saline was replaced with normal saline for gradual correction, but the unexpected increase continued. Desmopressin effectively controlled the overcorrection that occurred rapidly during hyponatremia correction because of the excretion of large amount of diluted urine. Desmopressin (2 µg) was administered twice, and the 6-h urine output before and after administration rapidly decreased from 4100 to 1220 mL and from 2680 to 380 mL, respectively. The US and European guidelines recommend parenteral administration of 2–-4 µg of desmopressin to prevent water diuresis when overcorrection occurs, with repeated dosing every 8 hours based on a serial Na+ check. In addition, appropriate desmopressin can make hyponatremia correction more predictable by reducing excessive urine water.–13After the serum NaThe patient’s lowest serum sodium concentration and duration of hyponatremia should be considered in determining the correction rate. Although no consensus has been reached regarding the ideal initial correction rate, rapid correction will likely be safe in the event of obviously sharp hyponatremia, and the potential benefits outweigh the risks. Further studies related to ODS and brain adaptation time are needed, and based on this, a more detailed guideline on treatment strategies for iatrogenic acute severe hyponatremia such as OHIAS is required.Conceptualization: Jeongwoo Lee.Data curation: Yu Jin Oh.Formal analysis: Taehoon Kim.Visualization: Seonhwa Nam.Writing – original draft: Seon Woo Yoo.Writing – review & editing: Jeongwoo Lee, Min-Jong Ki.We would like to express our gratitude to the professors of nephrology and gynecology for their generous advice regarding the treatment of patients. In addition, this manuscript has been edited in English with the help of Editage.