Left ventricular hypertrophy (LVH) regardless of other risk factors may be associated with an increased risk of mortality from cardiovascular diseases. Therefore, timely diagnosis for LVH is important in order to avoid possible complications. One of the simplest and cheapest methods to diagnose LVH is electrocardiography (ECG). Although a number of ECG criteria for LVH is known, their reliability varies in many studies.To evaluate the reliability of ECG criteria for LVH based on transthoracic echocardiography (TTE) data.The study included all consecutive patients in Kaunas Clinical Hospital Department of Cardiology from December 2019 until March 2020 and from September until October 2020, after applying the inclusion and exclusion criteria. The sensitivity and specificity of the ECG criteria for LVH were assessed based on TTE measurements performed during the same inpatient setting. The reliability of the ECG criteria for LVH was assessed using ROC curves. Reliability differences in gender, age and nutritional status groups were assessed using ANOVA statistical method.Data from 95 patients were analyzed (63.2% were women and 36.8% were men). The sensitivity, specificity and AUC of Sokolow–Lyon criterion were 9.38%, 85.71% and 0.44 (p = 0.034), R in aVL – 6.25%, 90.48% and 0.51 (p = 0.038), Cornell – 21.88%, 100 % and0.69 (p = 0.084), Cornell product – 31.25%, 95.24% and 0.72 (p = 0.070), Peguero–Lo Presti – 31.25%, 85.71% and 0.68 (p = 0.053), respectively. No statistically significant differences were observed among the individual gender, age and nutritional status groups.Sokolow–Lyon and RaVL criteria were not statistically significantly reliable in LVH diagnosis compared to TTE, unlike the Cornell, Cornell product, and Peguero–Lo Presti criteria. According to World Health Organization (WHO) data from year 2017, deaths from cardiovascular diseases account for about a third of all deaths every year . The aimA prospective study was performed that included all consecutive patients admitted to the Cardiology Department of Kaunas Clinical Hospital (KCH) from December 2019 until October 2020, excluding the period of quarantine for coronavirus disease 2019 (COVID-19) (from April 2020 until August 2020). Inclusion and exclusion criteria for entry were applied. Inclusion criteria: patient above 18 years of age, written consent for participation in the study, obtaining ECG recording and a scheduled TTE. Exclusion criteria: paced rhythm in ECG recording , preexitation, right or left bundle branch block.2), preobesity (25.0–29.9 kg/m2), obesity class I (30.0–34.9 kg/m2), obesity class II (35.0–39.9 kg/m2), obesity class III (≥ 40.0 kg/m2) [General data  and ECGs were collected from patients’ medical charts. In this study, the above-mentioned general data parameters are reported as mean ± standard deviation. According to the WHO classification, the subjects were divided into 2 groups based on age: young patients (< 65 years of age) and elderly (≥ 65 years of age) . PatientECG analysis was performed manually by a single person. The following LVH criteria were assessed:1)1 + RV5 or SV1 + RV6 ≥ 35 mm.Sokolow–Lyon: SV2)RaVL: R wave amplitude (mm) in lead aVL ≥ 11 mm.3)3 + RaVL > 28 mm for men and > 20 mm for women.Cornell voltage: SV4)3 + RaVL + 6) x QRS duration for women and (SV3 + RaVL) x QRS duration for men > 2440 mm x ms.Cornell product: (SV5)deepest + SV4 > 28 mm for men and > 23 mm for women, where Sdeepest is the deepest S wave in any lead.Peguero–Lo Presti: SDuring the same hospitalization, TTE data were collected from the same patients’ medical charts: MMI, relative wall thickness (RWT), interventricular septal thickness (IVSd), left ventricular posterior wall thickness at end-diastole (PWTd). Echocardiography was performed by the cardiologists who worked in the department. IVSd, left ventricular internal diameter at end-diastole (LVIDd), and PWTd were measured manually. The remaining parameters – left ventricular myocardial mass (LVMM), MMI, and RWT – were automatically calculated by echocardiograph .According to the European Association for Cardiovascular Imaging (EACVI), normal values of IVSd were considered to be 6–9 mm for women and 6–10 mm for men, and normal values of PWTd for women and men were considered to be 6–9 mm and 6–10 mm, respectively . Based o1)2 for men or 43–95 g/m2 for women with RWT ≤ 0.42.Normal LV structure: MMI 49–115 g/m2)2 for men or > 95 g/m2 for women with RWT > 0.42.Concentric LVH: MMI > 115 g/m3)2 for men or > 95 g/m2 for women with RWT ≤ 0.42.Eccentric LVH: MMI > 115 g/m4)2 for men or 43–95 g/m2 for women with RWT > 0.42.LV remodeling: MMI 49–115 g/mThe sensitivity and specificity of the ECG criteria were calculated and compared, as well as ROC curves were drawn to determine the reliability of the ECG criteria for the diagnosis of LVH:Using ROC curves, the area under the curve (AUC) of each ECG criterion was calculated. The sensitivity and specificity of TTE were assumed to be 100% (AUC = 1). Using Chi-Square test, the reference AUC = 1 was compared to each criterion’s AUC. In this way, the hypothesis that the reliability of the diagnostic ECG criterion did not differ from the reliability of TTE was tested. A 95% confidence interval (CI) was chosen, meaning that at p < 0.05, the reliability of ECG criterion was considered to be statistically significantly different from the TTE reliability.The reliabilities of the examined ECG criteria in different gender, nutritional status and age groups were calculated as well. The reliability of Cornell voltage, Cornell product and Peguero–Lo Presti criteria has not been assessed in terms of gender, as the Cornell voltage and Peguero–Lo Presti criteria already have separate thresholds depending on gender, and the Cornell product criterion is calculated differently for men and women. The reliability of the examined ECG criteria was calculated using generalized linear model. Analysis of variance (ANOVA) statistical method was used to test the hypothesis, whether there was a statistically significant difference between all the data of each ECG criterion and the data segregated by gender, nutritional status, and age groups. The hypothesis was accepted at p < 0.05  and rejected at p > 0.05.Sensitivity, specificity and other calculations of ECG criteria were performed using Microsoft Excel 2019 and R-Statistics programs. Graphs were made using the R-Statistics program.There were 95 participants in the study that met the study criteria. A total of 60 (63.2%) women and 35 (36.8%) men were included in the study. Patients had a mean age of 71.2 ± 11.4 years, with minimum and maximum age of 48 and 90 years, respectively. Patients aged < 65 years accounted for 29.5% and those ≥ 65 years old accounted for 70.5% of all subjects.2. Based on BMI, patients were divided into nutritional status groups . The percentage distribution of met and unmet ECG criteria is shown in 2, 0.47 ± 0.10, 10.3 ± 1.9 mm and 10.1 ± 1.8 mm, respectively. The calculated mean of MMI, RWT, IVSd and PWTd in men were 101.5 ± 32.5 g/m2, 0.48 ± 0.12, 11.5 ± 1.8 mm and 11.3 ± 1.6 mm, accordingly. 90.6% and 90.6% of subjects with LVH and 19.0% and 14.3% of subjects with normal LV structure had increased IVSd and PWTd, respectively. Based on MMI and RWT, patients were divided into four groups: normal LV structure, LV remodeling, concentric LVH, and eccentric LVH . The results show that there are no statistically significant differences between the mentioned groups (p > 0.05).The collected general patient data showed that the distribution of patients in gender as well as nutritional status groups in our study was unequal. Nearly twice as many women as men participated in the study, despite the fact that cardiovascular diseases are the leading cause of death among both women and men. Such gender distribution can be related to the fact that in Lithuania in 2012 more women than men were hospitalized with cardiovascular disease, although the duration of hospitalization was similar in both genders . AdditioIn the literature it is seen that patients often have the concentric type of LVH due to the high prevalence of arterial hypertension . As the 1)A part of patients with eccentric LVH had marginal RWT and MMI values possibly due to the onset of LV decompensation. A literature analysis which was conducted in the United Kingdom in 2020 has identified the type of eccentric LVH that develops from the concentric LVH type due to LV expansion at the onset of LV decompensation . This as2)Eccentric LVH may be a consequence of chronic myocardial ischemia (pre-infarction period) or prior myocardial infarction, as indicated by a study conducted in Lithuania in 2008 .A part of calculated sensitivity and specificity of ECG criteria differed from those that were seen in previous studies. RaVL criterion in our study was found to have lower sensitivity and specificity than was known from the previous studies , 15, 16.In this study, the reliability of Sokolow–Lyon and RaVL criteria for diagnosing LVH did not differ between both genders. This contradicts a study conducted in 2015 which found that RaVL criterion was more reliable among women than men . This diIn this study no statistically significant differences between age groups were observed. Similarly, in a study conducted in 2008 the reliability of Sokolow–Lyon criterion did not differ between different age groups . Neverth2 group [Our study identified no differences regarding the reliability of ECG criteria among the nutritional status groups. Our results are slightly different from the above-mentioned 2008 study where the sensitivity of Sokolow–Lyon criterion was lower in the obese group compared to the BMI < 30 kg/m2 group . The dif2 group .Our study showed that Sokolow–Lyon and RaVL criteria were not reliable in LVH diagnosis compared to TTE, while the Cornell voltage, Cornell product, and Peguero–Lo Presti criteria showed to be reliable. Therefore, the latter three criteria show potential to be used in everyday clinical practice. However, further studies with larger sample sizes are needed.Due to the fact that often patients with LVH have left or right branch block or paced rhythm in ECG recording, the sample size in our study is relatively small. In addition, there are only five ECG criteria analyzed. We excluded the ECG criteria that are not widely used and also do not have the potential to be used in everyday medical practice because of lower specificity or sensitivity. Furthermore, gender and nutritional status groups in this study were uneven. Therefore, further studies with larger sample sizes, more ECG criteria and even subgroups are needed in order to determine which ECG criterion is most suitable for LVH diagnosis.


Oidiodendron maius FC (OmFC) or Lachnum pygmaeum ZL6 (LpZL6), well-watered (WW) and severe drought stress (SDS). The results showed that the mycelium of LpZL6 was denser than that of OmFC, and both ErM fungi significantly increased the biomass of lingonberry stems and roots. They also significantly increased the chlorophyll content by 65.6 and 97.8%, respectively. In addition, inoculation with LpZL6 fungi can improve drought resistance, promote root growth and increase root wet weight by 1157.6%. Drought reduced the chlorophyll content and soluble sugar content of lingonberry but increased significantly after inoculation with LpZL6. Inoculation with LpZL6 decreased lingonberry’s malondialdehyde (MDA) content but increased the superoxide dismutase (SOD) activity. Overall, these results indicated that the successful coexistence of ErM fungi and lingonberry alleviated the adverse effects of drought stress through higher secondary metabolites and photosynthetic pigment synthesis.The application of Ericoid mycorrhizal (ErM) fungi is considered to be an important strategy for increasing plant yield and drought resistance. In this study, we isolated and identified two ErM fungi that can promote the growth of lingonberry. We tried to understand the potential of these two ErM fungi to promote the growth of lingonberry and the strategies to help plants cope with water shortage. The use value of ErM fungi was evaluated by inoculating  Vaccinium vitis-idaea L.) is a low-shrub wild plant growing in the temperate and subtropical regions of the Northern Hemisphere. Its leaves and fruits have antibacterial, anticancer, and antioxidant effects  fungi  fungi . ErM funM) fungi .Oidiodendron maius is a member of Leotiomycetes and has been isolated from Rhododendron fortunei  and enough ddH2O to reach a total volume of 20 μL. Primers ITS1 and ITS4 are shown in ON032317.1 (OmFC) and ON007175.1 (LpZL6).Total DNA was extracted from fungi by the CTAB method . PCR use–1) and agar (9 g L–1). The seedlings grew at low light intensity (30 μmol m–2s–1) in the culture room at 22 ± 2°C  was added to 2% citric acid solution (0.4 ml) and vanadium ammonium molybdate solution (4 ml), with deionized water volume to 10 ml after mixing. After standing at room temperature for 20 min, the absorbance of the sample at 456 nm wavelength was measured by UV spectrophotometer, and the content of available phosphorus in the fermentation broth was calculated according to the phosphorus standard curve. Fermentation broth samples were taken every 48 h, with three replicates per group.–1. The indole-3-acetic acid (IAA) content in the fermentation broth was determined by Salkowski reagent. The operation was as follows: The supernatant was mixed with Salkowski reagent at a ratio of 1:2, and the sample was placed in the dark for 30 minutes. The absorbance of the sample at 530 nm was measured by a UV spectrophotometer, and the IAA content was calculated by an IAA standard curve. Fermentation broth samples were taken every 48 hours with 3 replicates per group.The fungi were inoculated into liquid medium containing tryptophan and cultured at 28°C for 5 days at 150 rpm minOmFC, LpZL6, and no fungi in a germ-free tissue culture bottle. The inoculation process was to bury the activated fungus piece at 0.5 cm deep in the middle of the aseptic seedlings of lingonberry . The lingonberry was inoculated with gonberry . DroughtMeasurements of chlorophyll content were performed according to the method described by –1) trichloroacetic acid (TCA), centrifuged at 11,500 × g for 10 min. One milliliter supernatant was mixed with 4 ml thiobarbituric acid (TBA) reagent (0.5% TBA in 20% TCA). The samples were heated at 95°C for 30 min, cooled rapidly in an ice bath and centrifuged at 11,500 × g for 15 min. The amount of MDA-TBA complex was measured by spectrophotometry at 532 and 600 nm, and the MDA content was calculated. SOD activity was measured by the method of –1 phosphate buffer (pH 7.8), 0.1 mmol L–1 EDTA, 75 lmol L–1 NBT, 2 lmol L–1 riboflavin, 13 mmol L–1 methionine, and tissue extract. The absorbance of the mixture was measured by a spectrophotometer at 560 nm. One unit of SOD activity was defined as the amount of enzyme required for 50% nitroblue tetrazole (NBT) photoreduction inhibition. SOD activity is expressed as the enzyme activity of fresh weight per gram leaf.Measurement of MDA content in leaves Referring to t-test to determine the significant difference . In root length measurements, we used six plants for counting. SPSS software v 19.0 was used to analyze the data.All experiments were completely randomized and repeated four times. In the weight measurement, the weight of 10 plants was counted randomly. The root and bud were separated, and the bud fresh weight (FW) was immediately reported. Then, the dry weight (DW) of branches was measured after drying in an oven . We conducted a OmFC was irregular in shape and gradually changed from white to gray-brown dull, and intact in the early stage. No aerial mycelium was produced within two weeks. LpZL6 showed regular white mycelium, no luster, transparent, and dry texture, and the edge of the mycelium was grainy (LpZL6 mycelium was denser than OmFC (OmFC belonged to the Oidiodendron maius evolutionary branch (NCBI accession number: ON032317.1), while LpZL6 belonged to Lachnum spp. evolutionary branch (NCBI accession number: ON007175.1). However, several characteristics between the two branches were different  performed better than those inoculated with LpZL6 (3.45 ± 0.2 cm), and the stem length increased by 54.8 and 27.8% compared with WT, respectively (OmFC (1.78 ± 0.05 mg g–1) and LpZL6 (1.49 ± 0.06 mg g–1) increased by 97.8 and 65.6% compared with WT, respectively  and LpZL6 (28.56 ± 0.76 mg) increased by 217.8 and 113.5%, respectively, compared with that of lingonberry without inoculation. The stem dry weight of lingonberry inoculated with OmFC (15.5 ± 1.29 mg) and LpZL6 (9.71 ± 0.78 mg) increased by 236.2 and 110.6%, respectively, compared with that of lingonberry without inoculation (OmFC (10.26 ± 1.18 mg) and LpZL6 (8.75 ± 0.49 mg) increased by 154.6 and 117.1%, respectively, compared with that of non-inoculated fungi. The root dry weight of lingonberry inoculated with OmFC and LpZL6 was 113.2 and 61.9% higher than that of non-inoculated fungi, respectively . SDS reduced stem dry weight and root dry weight by 8.6 and 741.7%, respectively, compared with WW . Compared with WW, the total chlorophyll concentration of non-inoculated plants (0.8 ± 0.06 mg g–1 FW) grown under SDS decreased by 38.8%, but inoculation with LpZL6 fungi (1.35 ± 0.08 mg g–1 FW) increased by 21.6%  for IAA synthesis through IPA (indole-3-pyruvate) and IAA to promote mycelium growth. IAA may also induce adventitious root formation in micro-cutting and promote IAA production in plants  can be found in the article/HL, LS, and JZ designed the experiments and wrote the manuscript. HL, CG, and BF analyzed these data. Others participated in the experiments. All authors read and approved the final manuscript.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. The reviewer AW declared a shared affiliation with the author HS to the handling editor at the time of review.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.


LEbirth increased with decreasing dog size group and increasing survey year 2013 to 2018 for all dog size groups and cats. Female dogs and cats had significantly higher LEbirth than males: 12.76 years (12.75–12.77) vs. 12.63 years (12.62–12.64), and 11.68 years (11.65–11.71) vs. 10.72 years (10.68–10.75), respectively. Obese dogs (BCS 5/5) had a significantly lower LEbirth [11.71 years (11.66–11.77)] than overweight dogs (BCS 4/5) [13.14 years (13.12–13.16)] and dogs with ideal BCS 3/5 [13.18 years (13.16–13.19)]. The LEbirth of cats with BCS 4/5 [13.67 years (13.62–13.71)] was significantly higher than cats with BCS 5/5 [12.56 years (12.45–12.66)] or BCS 3/5 [12.18 years (12.14–12.21)]. These LE tables provide valuable information for veterinarians and pet owners and a foundation for research hypotheses, as well as being a stepping-stone to disease-associated LE tables.There are few recent and methodologically robust life expectancy (LE) tables for dogs or cats. This study aimed to generate LE tables for these species with clinical records from >1,000 Banfield Pet hospitals in the USA. Using Sullivan's method, LE tables were generated across survey years 2013–2019, by survey year, and for subpopulations defined by sex, adult body size group , and median body condition score (BCS) over life. The deceased population for each survey year comprised animals with a recorded date of death in that year; survivors had no death date in that year and were confirmed living by a veterinary visit in a subsequent year. The dataset totaled 13,292,929 unique dogs and 2,390,078 unique cats. LE at birth (LE Human health metrics and life expectancy computations have been used for centuries. The first quantification of life expectancy was reported in England in the 19th century , 3. TheyAccurately calculating the life expectancy of dogs and cats would be of greatest interest in helping to understand the benefits of preventative care and the success of increasingly advanced medical interventions. However, there are relatively few studies on lifespan or all-cause mortality in either of these species, especially in cats. Four studies in dogs have compiled age of death statistics from surveys of owners belonging to the UK Kennel club , 5, the Survival data are analyzed in two ways: the life-table method divides time into intervals and calculates survival in each interval; the Kaplan-Meier method calculates survival each time an event occurs (death). Both methods produce a graph  that shows the cumulative probability (hazard ratio) of the event in the total period of observation. Kaplan-Meier survival analysis may be more appropriate for studies with longitudinal follow-up focused on the time until events occur. In contrast, the life-table methodology is a statistical technique that provides a summary of the mortality and life expectancy experiences of a large population of different ages. This study used life table methodology to analyze survival, in part to provide information equivalent to that for large human populations, and in part because of the high dropout rates of animals  due to discontinuity in veterinary visits in the clinical dataset.Life expectancy tables for pets have been reported previously from a total of four studies in Japan and one in the UK –16. The Other studies in dog populations comprising multiple breeds and both sexes have summarized overall ages of death without computing life expectancy tables –8. Age oThe more recent studies demonstrate the opportunities available in the current era of veterinary “big data”, which is giving researchers access to reliable and extensive high quality data over long periods of time . There iThe current study aimed to generate life expectancy tables for dogs and cats in the USA, computed for each survey year between 2013 and 2019, and across survey years according to breed size, sex, and body condition score (BCS). Clinical data were obtained from the electronic medical records (EMRs) of healthy and sick dogs and cats attending Banfield hospitals throughout the USA. Computations followed Sullivan's method for life expectancy tables, which can also account for health status assessed as a cross-sectional variable . This men2013 = 854; n2014 = 893; n2015 = 933; n2016 = 984; n2017 = 1,015; n2018 = 1,044; n2019 = 1,074; n2020 = 1,084; n2021 = 1,069; n2022 = 1,054). All hospitals were linked by a proprietary practice management system (PetWare®) and data from all visits were uploaded to a central database, resulting in a large amount of aggregated, structured data.The clinical dataset was derived from the EMRs of 1,152 different Banfield hospitals in the USA between January 1st, 2013, and July 31st, 2022. The number of hospitals varied between years due to the closure of some hospitals and the opening of new ones, however most hospitals contributed data for each of the 9 years of the study , a visit age >30 years, or incomplete data for sex, age or BCS. The resulting dataset is referred to as the cleaned dataset.A deceased and survivor population for each survey year was identified from the clinical dataset as outlined in UF = Q3 + 1.5*IQR) of 391 days for dogs and 443 days for cats. At least two full years of data after a survey year were needed for life table calculation. It was decided to analyze life expectancy in the dataset from January 1st, 2013 to December 31st, 2019. The last 2.5 years of data  were used to define if a pet without a death date could be confirmed as a survivor in any of the previous years.The return rate of animal visits across all study years was calculated to support the validity of the range of years selected for the analysis. On average, dogs returned in 111 days and cats in 146 days; median return rate was 70 days (IQR: 21–169) for dogs and 90 days (21–190) for cats. The Tukey's outlier detection method applied to the return rate in days yielded an upper fence , and median BCS was recorded for individuals between January 1st, 2013 and July 31st, 2022. The sterilization status was available in the clinical dataset, but it was not included in the study because of the way these data were collected. Pets that were sterilized at a certain age were identified as neutered from birth to death. This introduced a bias due to mortality in the first few months of life when pets were not yet spayed or neutered, which impacted the early mortality rate for entire animals. Body condition score was assessed on a 5-point scale between 2013 and 2018, and on a 9-point scale between 2018 and 2022. Data from the 9-point scale were converted to the 5-point scale . SeparatQ1 − 1.5*IQR; upper fence = Q3 + 1.5*IQR). The average adult bodyweight of each breed in the resulting dataset was calculated from dogs aged 2–5 years, and was used to assign a size group  in a 1-year age interval , and the study population size (dead plus living pets) at the mid-year point P(x). Central death rate was computed as x, x+1) had lived x complete years plus a fraction a(x) of the last year. It was assumed that deaths were uniformly distributed in each year interval, occurring on average midway in the age range ; therefore a(x) was uniformly taken to be 0.5  was calculated as x, denoted as l(x), was estimated from a hypothetical population of 100,000 pets at birth i.e., l(0) = 100, 000. As these pets were assumed to be subject throughout their lives to the conditional probability of death in the 1-year age interval , the calculation was l(x) = (1−q(x−1))*l(x−1). The number of pet years lived at age x , denoted as L(x), was the sum of pets surviving until age (x+1) and the fraction a(x) of pets surviving in age interval , so that L(x) = l(x+1)+a(x)*(l(x)−l(x+1)). Given that a(x) = 0.5, the equation was simplified to L(0) = 0.2*l(0)+0.8*l(1). For the last age interval ω, as no information was available after this age, it was calculated as x was x was birth) corresponded to life expectancy for animals in the 0–1 age interval. Uncertainties were calculated with Monte-Carlo methods, with n = 1.106 iterations, drawing d(x) from a parametrized binomial distribution where each sample was equal to the number of successes over n trials, the probability of success being P(x). Life expectancy e(x) was calculated n times, using the Monte-Carlo-derived d(x) in the previous equations. Confidence intervals (CIs) at the 95% level were calculated for each year using the mean e(x) and standard deviation [denoted as SLE(x)] for the n iterations: The conditional probability of death in a 1-year age interval (P(x) and d(x) specific to that subpopulation were used to recalculate the intermediate variables, m(x), q(x), l(x), L(x) and T(x). Only data for purebred dogs were used for life expectancy estimations by dog size group.Life tables were generated for each species across all survey years, for each survey year, for the global population and the subpopulations defined in Section 2.1. For each subpopulation, the variables ® database; there was no searching of free text entries. Software applications used for data processing and building life tables were Databricks  on Microsoft Azure, with Python 3.9.5 .Only structured data were extracted from the PetWare® visit records for 9.29 million unique dogs, and 9.85 million visits for 2.51 million unique cats. Of these animals, 1.74% dogs and 1.82% cats were removed to produce the cleaned dataset as described in the methods. The total population sizes (deceased and survivor combined) in the cleaned dataset are presented by survey year for each species in There were 64.76 million PetWareIn summary, the mean total dog population size (deceased and survivor populations) was 1,899,048 individual dogs per year . The mean deceased dog population was 85,651 per year, and a mean of 621,284 (25%) dogs were excluded each year on account of having no date of death and no additional visits in subsequent years . The meaThe mean total population size for cats was 314,823 individuals per year . The mean deceased cat population was 28,308 cats per year, and 172,523 (34%) cats per year were excluded according to the study methodology . The meaThe overall proportion of male dogs was 52.0%; for purebred dogs it was 51.9, 53.7, 51.1, 51.2, and 55.9% for toy, small, medium, large and giant sizes, respectively, and for mixed-breed dogs it was 48.3% . The proData were sparse for dogs and cats older than 17 years, and uncertainty in life expectancy calculations became unacceptably large. Therefore, dogs and cats living more than 17 years were grouped into an age interval of 17+ years. The median BCS was 3 for 72.7% of dogs  . The preIn summary, the study dataset for dogs covered all bodyweight size categories; the large and small dog sizes had the greatest representation. Less than 5% of dogs were of mixed breed, whereas in the cat dataset there were ~5 times more mixed-breed cats than purebred. For both cats and dogs the sex ratio was well-balanced between males and females, and the vast majority of both sexes in both species were sterilized. Median body condition was ideal for nearly three quarters of dogs and obese for 1.5%. In contrast, for cats, median body condition was ideal for slightly more than two thirds and obese for 3.6%.The global life expectancy table with intermediate variables is presented in birth of dogs across all survey years and dog sizes was 12.69 years (95% CI: 12.68–12.70) (birth of 12.71 years (12.67–12.76)  (The LE8–12.70) . Life ex8–12.70) . Mixed-b7–12.76) . The LEb6–11.20) . Life ex6–11.20) .birth increased progressively for survey years 2013–2018 for all dog size groups and for cats , 0.66 years (5.0%), 0.56 years (4.51%), 0.48 years (4.27%), 0.6 years (6.59%), and 0.83 years (6.81%) for toy, small, medium, large, giant and mixed-breed dogs, respectively, and by 1.01 years (9.31%) for purebred and 1.41 years (13.69%) for mixed-breed cats.The LEfor cats . A smallLife expectancy for each age interval by survey year is presented in birth than male dogs: 12.76 years (12.75–12.77) compared with 12.63 years (12.62–12.64) for males  vs. 13.32 years (13.28–13.35)]. There were no significant sex differences in the life expectancy of small dogs in any age interval; LEbirth was 13.52 years for males (13.5–13.55) and 13.55 years (13.52–13.57) for females. In all other dog-size groups, females' LEbirth was significantly higher than that of males: medium 12.8 years (12.77–12.83) vs. 12.6 years (12.57–12.63), large 11.74 years (11.72–11.76) vs. 11.28 years (11.26–11.3), giant 9.76 years (9.66–9.85) vs. 9.33 years (9.24–9.41). Female mixed-breed dogs also had a significantly higher LEbirth than their male counterparts-−12.81 years (12.27–12.87) compared with 12.61 years (12.54–12.67).Female dogs had a slightly but significantly higher LEor males . Life exor males . Male tobirth than male cats, by ~1 year [11.68 years (11.65–11.71) vs. 10.72 years (10.68–10.75)]  vs. 11.05 years (10.97–11.14), mixed breed 11.62 (11.58–11.65) vs. 10.66 (10.63–10.7) ] . Differe63–10.7) .birth of 13.18 years (13.16–13.19) and 13.14 years (13.12–13.16), respectively (birth [11.71 years (11.66–11.77)] than dogs with median BCS 3 or median BCS 4. This continued to be the case for life expectancies in subsequent age intervals until 15–16 years, when the difference between median BCS 5 and median BCS 4 was no longer significant, while the difference between median BCS 5 and median BCS 3 remained significant until the age interval 17+ years. Dogs with median BCS 1 or median BCS 2 had significantly lower life expectancies compared with dogs of all other median BCS at all age intervals; LEbirth was 1.54 years (1.49–1.60) and 3.91 years (3.86–3.97), respectively. The difference in life expectancy between dogs with median BCS 1 and those with median BCS 2 diminished progressively after the age of 2 years, but remained significant until the age of ≥17 years.Dogs with median BCS 3 and dogs with median BCS 4 had similar LEectively . Life exbirth than cats with median BCS 4 [13.67 years (13.62–13.71)] or median BCS 5 [12.56 years (12.45–12.66)] (Cats with median BCS 3 [12.18 years (12.14–12.21)] had a significantly lower LE–12.66)] . Life exbirth of dogs by year of survey for median BCS 3 was 13.73 years (13.68–13.78) in 2013. This was significantly higher than for subsequent years, during which LEbirth increased slightly from 13.04 years (13.0–13.08) in 2014 to 13.15 years (13.12–13.18) in 2019, with few significant differences between years in this range ] and 2014 [11.08 years (10.94–11.22)], but then increased by almost 1.5 to 12.57 years (12.42–12.72) in 2019. The mean LEbirth over all survey years for dogs with median BCS 1 was 1.51 years with no significant differences between years. For dogs with median BCS 3 or 4, the LEbirth was always significantly higher than that of dogs with BCS 5 regardless of the survey year.The LEis range . The LEbbirth for cats were similar to those of dogs. Cats had a mean LEbirth over all survey years of 1.04 years with no significant differences between years in the survey (birth for cats with median BCS 3 was 12.88 years (12.76–13.01) in 2013, dropping to 11.87 years (11.77–1.97) in 2014 before starting to increase slowly to 12.47 years (12.38–12.56) in 2018, falling back however to 12.19 years (12.1–12.27) in 2019. For cats with median BCS 5, there was an initial a drop in LEbirth from 12.12 years (11.85–12.39) in 2013 to 11.58 years (11.31–11.85) in 2014, followed by a 1.83 years increase in life expectancy between 2014 and 2019 [13.41 years (13.1–13.72)]. The LEbirth of cats with median BCS 4 was always significantly higher than that of cats with BCS 3 or 5 regardless of the survey year.The trends in LEe survey . The LEbThis study generated annual life expectancy tables over a period of 7 years for dogs and cats aged from <1 to >17 years in the USA. Life expectancy tables were computed by survey year and by age in 1-year increments for each sex and each of five median BCS values.birth for dogs reported here [12.69 years (12.68–12.7)] was higher than that computed from the UK VetCompass™ dataset [11.23 years (11.19–11.27)] (birth in another Japanese study of dogs that died between 1981 and 1982 was only 8.3 years (birth by survey year increased by 1.3 months (0.93%) in each successive sampling year ]  and lowe–11.27)] , 14. Theing year . A backwears 12.6–12.7] wabirth by size as observed in this study: small > toy > medium > large > giant  compared with 13.53 years (13.52–13.55), respectively, and for toy dogs was 13.34 years (13.32–13.36) in japanese study and 13.36 years (13.33–13.38) in our study. The inverse relationship between dog size and longevity is well-described  . Our stuThe concept of hybrid vigor has led to a perception that mixed-breed pets live longer than purebred pets, and indeed, this has been demonstrated for size-matched dogs . Our stubirth progressively increased except for a small decrease in 2019, which was significant for cats but not for dogs. This might be explained by the impact of the COVID-19 pandemic in 2020 and 2021. During this time in the USA, veterinary practices were subject to emergency regulations, and practice visits were curtailed in many areas to “essential” services only, while telemedicine was actively encouraged  and did not persist in older age groups. A 4-month difference was shown between the sexes in a UK dog population [LEbirth 11.41 years (11.35–11.47) for females vs. 11.07 years (11.01–11.13) for males], and this also declined with increasing age.Although female dogs had a significantly higher LEbirth for female cats was 1 year higher compared with that for male cats reflected a higher death rate for males between the ages of 1 and 9 years. It was hypothesized that these sex differences were due to the higher probability of infection with feline leukemia virus and feline immunodeficiency virus  is consistent with another primarily USA analysis that found overweight and obesity to be associated with a higher instantaneous risk of death and a reduced life span (Our finding that obese dogs (median BCS 5) had 1.5 years lower LEife span . In thatife span . We obseife span  and hearife span .birth, but since the database included both healthy and diseased animals it is feasible that it played an indirect role through disease association.Obesity in dogs is associated with a wide diversity of disease types, ranging for example from metabolic such as diabetes mellitus , to orthA further consideration is that we used the median BCS over a pet's medical history in the database to reflect its weight status over life. This approach could lead to misinterpretation in cases where an age-related disease affected BCS. For example, if an animal with a BCS of 5 in the first third of its life contracted a disease in the second third of its life that led to a reduction in BCS to BCS 3, and with disease progression this declined to BCS 1 in the last third of its life, the animal would nevertheless be analyzed in the median BCS 3 category.Less than ideal median BCS (1 and 2) was associated with much lower life expectancy than an ideal or obese median BCS. In adult dogs, underweight is a general signalment for serious illness or a poor prognostic factor for diagnosed disease. For example, low BCS in dogs with chronic enteropathy is a predictor for lack of response to treatment and death . Underwebirth than cats of ideal body condition (median BCS 3) as well as obese cats (Similar to dogs, overweight and obesity in cats are associated with a wide range of disorders, including endocrine and lipid metabolism disorders, neoplasia, lower urinary tract disease, gastrointestinal disease and dermatoses , 59. Howese cats ; the difese cats . The autese cats , while dese cats –63. FinaAs for dogs, underweight cats had a lower life expectancy at all ages than cats with ideal, overweight or obese median BCS. However, life expectancy in underweight cats did not decline; cats of median BCS 1 consistently had almost 1 year of life expectancy and cats of median BCS 2 consistently had ~2 years of life expectancy. A range of interacting factors might influence the life expectancy of cats with low median BCS in different ways. For example, weight loss is one sign of chronic kidney disease in cats ; it is obirth of animals with median BCS 3 was quite stable over survey years, while for animals with median BCS 5 a relatively large increase of LEbirth was observed between 2014 and 2019: 1.51 years for dogs and 1.93 years for cats. Although these findings may be related to advances in veterinary medicine that would allow obese dogs to live longer, they also raise new questions about potential changes in veterinarians' perception of, and attitudes toward obesity. It is possible that a dog considered to be BCS 5 in 2014 would be considered to be BCS 3 according to perceptions in 2019. Increasing awareness of obesity and its health implications in pets could also have driven greater proactivity in interventions to treat obesity-associated diseases.For both dogs and cats, the LEOur clinical dataset relied upon owners visiting a veterinarian, and the animal having a recorded BCS. There may be different thresholds of bodyweight loss or bodyweight gain that would prompt owners to seek veterinary advice. Delaying a visit until a dog or cat has reached an extreme BCS will worsen the prognosis for the underlying etiology. The decision of an owner to opt for the euthanasia of their dog or cat might also vary by BCS and thereby impact life expectancy. Pet lifestyle can impact survival for medical and non-medical reasons. An indoor lifestyle is associated with feline obesity at 1 year of age , and outbirth for cats with BCS 5, and life expectancy for dogs and cats with BCS 5 over the age interval 14–15 years, likely due to the small number of obese animals in these age intervals.This study benefited from a large dataset of 8.9 million dogs and 2.4 million cats, which is more than 10-fold greater than the dataset used to generate life expectancy tables for Japanese dogs  and 100-Limitations that should be considered include the retrospective nature of the study design, a degree of uncertainty of pet age for dogs and cats acquired as rescued animals or adopted from animal shelters, and the inherent limitations of body condition scoring. In clinical practice body condition scoring is routinely used to estimate adiposity and weight status, scoring systems have been validated against measurement of body fat by dual-energy X-ray absorptionmetry –72 and gThe intentional omission of some aspects of life expectancy in our analyses might be regarded as limitations. We decided not to analyze any effect of neuter status, because ~90% of owned dogs and cats in the USA are neutered, and this is reflected in the clinical Banfield population. Differences in life expectancies between breeds within body size were not captured. The intent was to maintain accuracy in life expectancy tables while recognizing the large size differences between breeds. As population numbers were low for many of the more than 300 breeds in our dataset, we favored statistical accuracy over breed differences. Parallel analyses of health status, recorded causality of death, or reason for euthanasia were beyond the scope of this study and this limited the interpretation of differences between subpopulations.Most pets that visit Banfield Pet Hospitals have veterinary care as part of an Optimal Wellness Plan, which is a suite of pre-paid services focused on preventive health care, routine diagnostic testing, comprehensive physical examination, and unlimited clinic visits. Wellness Plans could result in a pet being seen more frequently and having an earlier diagnosis and treatment of chronic conditions; they might also drive a proactive reduction in risk factors for disease and improvement in prognosis for disease at diagnosis. Conversely, the use of medical records results in missed visits by animals never presented to veterinary clinics.6 times. This mitigated the issue, but statistical significances were still high whatever significance level. A complementary strategy would have been to sample the mid-year population in the Monte Carlo simulation.A major statistical consideration with databases involving millions of individuals is that tests are often highly significant. A widely used method for assessing the standard error of life expectancy is to use the variance of the conditional probability of death. To address the issue of having such large populations, instead of implementing this method we used Monte Carlo simulations to sample dead populations and recalculated life expectancies 1.10The analyses presented do not extend to estimations of disability free life expectancy, healthy life expectancy or healthy life years lost. A method has been developed for this  and applbirth for both species between 2013 and 2018. Unexpected findings included the relatively constant life expectancy of underweight cats at all ages, and the higher life expectancy of overweight cats compared with cats that were ideal median BCS. Further study is needed to elucidate apparently complex, interrelated and dynamic relationships between median BCS and life expectancy.To our knowledge this is the first study to generate life expectancy tables for dogs and cats in the USA and the first study to present these by median BCS. Some of the main findings were expected based on direct and indirect evidence in the literature, namely decreased life expectancy for the largest sizes of dogs compared to the smallest, increased life expectancy of female versus male dogs and cats, significantly lower life expectancy at all ages for underweight dogs and cats compared to those with an ideal, overweight or obese median BCS, and a progressive increase in LEThe life expectancy tables presented provide valuable information for practicing veterinarians and a foundation for research hypotheses. A better knowledge of life expectancy is important at the population level as a broad indicator of the general health status of the pet population, reflecting owner attitudes, the accessibility of veterinary care, and advances in veterinary care including preventive medicine. At the level of the individual owner, these life expectancy tables may help inform the choice of species and breed size. Life expectancy tables are especially relevant for adopters of adult animals who need to understand the likely duration of their commitment. Quantification of the reduction in life expectancy associated with overweight and/or obesity is a vital step toward making proactive bodyweight management a healthcare priority for veterinarians and owners. Furthermore, this work is a stepping-stone to the generation of disease-associated life expectancy tables.mathieu.montoya@royalcanin.com.The data analyzed in this study is subject to the following licenses/restrictions: Raw data cannot be shared for legal and privacy restrictions. Requests to access these datasets should be directed to MM contributed to the study design, data processing and interpretation of the results, performed the statistical analyses, wrote the first draft of the manuscript, and revised the intellectual content of subsequent drafts. FA contributed substantially to the design of the study and the statistical analysis work and critically reviewed the intellectual content of the manuscript. JM, NS, VB, HC, and M-AH contributed to data processing and interpretation of the results and critically reviewed the intellectual content of the manuscript. All authors have approved the final content of the manuscript for publication.


The number of patients who reached a glycated hemoglobin value of <7% increased statistically from 12% to 57% (p < 0.01), and there was a statistically significant decrease (p < 0.01) in the units of daily insulin (from 36.7± 14.9 IU to 28.9 ±9.1 IU) A reduction from 54% to 24% in clinical level 2 hypoglycemia episodes was reported. No cases of severe hypoglycemia or ketoacidosis were observed. The results of the study support that EVLCD in DM 1 seems safe and effective when adopted under tight medical supervision.A eucaloric very low carbohydrate diet (EVLCD) is a diet with a daily caloric intake equal to the total daily energy expenditure (TDEE) with a carbohydrate content of <50 g/day. The literature on very low carbohydrate diets (VLCD) in type 1 diabetes (DM 1) is limited, although recently published scientific studies have highlighted their safety and efficacy in managing DM 1. In this retrospective analysis, we report the clinical data of 33 patients affected by DM 1 carrying out insulin therapy who switched voluntarily from their usual diet  to an EVLCD. Our aim is to evaluate the glycemic control, the amount of insulin needed in order to maintain glycemic control and safety of EVLCD. The switch improved glycemic control (mean glycated hemoglobin decreased from 8.3% to 6.8% ( Type 1 diabetes (DM 1) is a chronic disease characterized by the immune mediated related destruction of pancreatic beta-cells; the destruction of the beta-cells leads to a substantially absolute insulin deficiency and to a scenario in which the residual pancreatic microsecretory activity is insufficient for glucose homeostasis . The disIn terms of complications, DM 1 remains one of the main risk factors for the development of microangiopathies —such as Although there is still no definitive consensus on their definition, low-carbohydrate diets are generally defined as diets with a carbohydrate content of less than 130 g per day . Very loCases of patients treated with insulin and low carbohydrate diets (LCD) have been reported since the 1970s  but tradRecently, however, several scientific studies have been published highlighting the safety and efficacy of low carb diets in the management of DM 1, showing better glycemic control and reductions in insulin requirement, hypoglycemia rates, and reductions in the incidence of diabetic ketoacidosis ,22,23,24Our aim is to evaluate glycemic control, the amount of insulin needed to maintain glycemic control and safety of an eucaloric very low-carb diet (EVLCD) in patients suffering from DM 1 who previously had a standard diet in a real-life contest. EVLCD is characterized by a carbohydrate content <50 g/die and by a caloric intake equal to the subject’s energy needs.This is a retrospective, real-life study on patients suffering from DM 1 belonging to hospitals of Azienda Sanitaria Locale of Udine  and taken in charge at the clinic of Dr. Kleiner.The case series concerns 33 patients with DM 1 regularly treated with insulin therapy, who decided, voluntarily, to switch from their usual diet rich in carb  to an EVLCD for a period of 12 months from December 2017.Data collected during the period of observation were personal and anthropometric data, the physical examination, the food anamnesis, and laboratory tests .Personal data, anthropometric data, the physical examination, and laboratory tests were collected at baseline and at the endline during outpatient practice using Excel.Self-measurement of blood glucose and of ketonemia were recorded by patients at home.The retrospective analysis of the data was approved by the individuals themselves through written consent and authorization.According to the medical recording, the following parameters were also evaluated: cardiovascular (CV) risk factors , CV events  and microvascular complications .Level 2 hypoglycemia was defined as blood sugar levels <54 mg/dL.Severe hypoglycemia was defined as a hypoglycemic value requiring assistance for the treatment. A flow chart of the study is shown in 2.Bodyweight was measured to the nearest 0.1 kg using an electronic scale (Seca srl), and height to 1 cm using a wall-mounted portable stadiometer (Seca srl). Body mass index (BMI) was calculated in kg/mAll laboratory tests were performed by a certified laboratory belonging to hospitals of Azienda Sanitaria Locale . The HbA1c was determined with immunoassay, using fasting venous samples collected by a hospital team. It was performed twice a year if glycemic values were at target, or every three months if not at target.Total cholesterol and HDL were determined with the enzymatic colorimetric assay in homogenous phase , triglycerides by an enzymatic colorimetric method . The glomerular filtration rate was estimated through the CKD-EPI formula, and low-density lipoprotein (LDL) cholesterol was calculated using the Friedewald formula.Moreover, strict blood glucose home monitoring was performed by patients through glucometers (Glucomen LX- Menarini Diagnostics) on fresh capillary whole blood by puncture with lancet, together with the use of a continuous glucose monitoring (CGM) sensors .The glucose measurement was performed before and after every meal . The dosage of blood beta-hydroxybutyrate with Glucomen ketostrips was suggested in order to exclude pathological values. Glycemia values were weekly communicated to the physicians (by telephone or messaging applications).The subjects included in this case series decided to switch from their usual diet high in carbohydrates (>200 gr/die) on average composed of 55% carbohydrates, 25% proteins and 20% fats to a EVLCD composed of an average of 70% fats, 25% proteins and 5% carbohydrates (carbohydrates intake <50 g/day).The characteristics of the eating patterns  in terms of percentages of macronutrients are shown in Total daily energy expenditure (TDEE) was valuated starting from the estimation of the basal metabolic rate (BMR) through the Mifflin formula and multiplying it by the presumed level of physical activity .The EVLCD, prescribed and calculated by a physician expert in nutrition, included mainly vegetables, olive oil, fish, white meat, eggs, nuts, butter and cheese. To maximize dietary variety and adherence to the diet, the diet was integrated with low-carb food products . The data about food assumption were collected by the patients themselves daily for the entire year and provided to the investigators monthly.At baseline, all patients were treated with multiple daily injections of insulin therapy: mean rapid-acting insulin at meals of 18 ± 9.5 IU 18.3 ± 8.0 IU of basal insulin. Basal insulin and rapid insulin were respectively 50% of total daily insulin, and rapid insulin was divided among breakfast, lunch and dinner. The mean units of insulin per kg at baseline were 0.54 ± 0.22 IU/kg/day. No patient at baseline was treated with oral antidiabetic therapy. No patient was treated with continuous subcutaneous insulin infusion.When patients switched to EVLCD, they were treated with multiple daily injections of insulin therapy, mean rapid- acting insulin of 10.3± 6.5 IU and 18.6± 5.1 IU of basal insulin. Basal insulin was set approximately at 70% of total daily insulin. Rapid insulin was set approximately at 30% of total daily insulin, divided among breakfast, lunch and dinner. The insulin regimen was prescribed at baseline exclusively on body weight 0.42 ± 0.12 .p values below 0.05 were considered significant.Two-tailed Statistical analysis was conducted using IBM SPSS Statistics, version 25.0  and R software version 4.2.0.Informed written consent for the use of personal data was obtained from patients.The study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee (register number CER Liguria: 365/2022-DB id 12515).Enrolled patients were, on average, young subjects (mean age 41.6 ± 15.0 years), predominantly females (69.7%), affected by long-term DM 1 (mean years 14.3 ± 11.3) .2; 72.7% of subjects were normal weight, 21.2% were overweight, and 6.1% were individuals with class I obesity. No cases of higher classes of obesity were present. At the endline, the mean BMI was 24.1 ± 3.1 kg/m2; 78.8% of subjects were normal weight, 18.2% were overweight and 3.0% had class I obesity. Two overweight subjects became normal weighted and one obese subject of type I became overweight.At baseline, the mean BMI was 23.9 ± 3.6 kg/mAt baseline, the mean systolic arterial pressure was 129.6 ± 7.8 mmHg, and the mean diastolic pressure was 79.1 ± 5.1 mmHg.At the endline, the mean systolic arterial pressure was 128.6 ± 10.1 mmHg, and the mean diastolic pressure was 79.0 ± 5.3 mmHg.At baseline, the mean LDL cholesterol level was 98.5 ± 36.1 mg/dL, the mean high-density lipoprotein (HDL) cholesterol was 67.0 ± 14.5 mg/dL, and the main triglyceride level was 74.2 ± 31.8 mg/dL. The glomerular filtration rate (GFR) was 95.7 ± 20.9 mL/min.At the endline, the mean LDL cholesterol level was 84.4 ± 26.2 mg/dL, the mean high-density lipoprotein (HDL) cholesterol was 71.3 ± 18.9 mg/dL, and the main triglyceride level was 70.4 ± 28.9 mg/dL. The glomerular filtration rate (GFR) was 94.2 ± 20.6 mL/min .p = 0.005).No significant improvements in any of the parameters considered above were observed, except for a significant improvement in LDL level  and the therapy prescription remained the same for the entire duration of the diet.At baseline, the mean glycated hemoglobin (HbA1c) was 8.34 ± 1.73%; 12% of the subjects had an HbA1c level <7%, 33% had an HbA1c level between 7 and 8% included, 33% had an HbA1c level between 8 and 9%, and 21% had an HbA1c level >9%.At the endline, the mean glycated hemoglobin was 6.8 ± 0.78%; 57% of subjects reached a value of HbA1c <7%, 40% a value of HbA1c between 7% and 8%, 3% a value of HbA1c between 8% and 9% included, and no patient had a value of HbA1c >9%. In only one case (3%), the value of glycated hemoglobin worsened from 7.3% to 7.6%.To highlight, the mean glycated hemoglobin (HbA1c) lowered from 8.3 ± 1.7% to 6.8 ± 0.8 1 subject worsened the HbA1c levels, 1 remained stable and the other 31 improved.Distribution of the different percentage classes of glycated hemoglobin of the patients before and after the diet are shown in p < 0.001. Consequently, even a reduction statistically significant (p < 0.001) in total daily insulin units was observed (from 36.7 ± 14.9 UI/day to 28.9 ± 9.1 UI/day).About insulin titration, the dosage of rapid-acting insulin lowered from 18.3 ± 9.5 UI/day to 10.3 ± 6.5 UI/day with a level of significance p < 0.001) increase in the basal units/total daily units ratio (from 51.0 ± 1.3% to 66.0 ± 1.2%).The basal total insulin dosage remained unchanged (from 18.3 ± 8.0 UI/day to 18.6 ± 5.1 UI/day) with a statistically significant (p < 0.001). No cases of severe hypoglycemia and diabetic ketoacidosis were recorded.At baseline, 54.5% of patients reported at least 1 episode of level 2 hypoglycemia while 30.3% reported at least 1 episode of severe hypoglycemia in the previous 12 months. At endline, seven patients (24.2%) reported one single episode of level 2 hypoglycemia during the diet, and this decrease was statistically significant (The characteristics of the patients in terms of metabolic control and therapeutic approach are summarized in TM with verified data).The estimation of diet adherence was performed through a dedicated application for food diary  from a standard deviation of 1.73% and a coefficient of variation of 21%, indicative of a relevant inhomogeneity in the glycemic control  insulin therapy, switched from their usual diet  to an EVLCD .Carbohydrate restriction required a concomitant reduction in the absolute number of insulin units, especially rapid insulin, which is more involved in the management of postprandial hyperglycemia; the low carbohydrate intake also led to a reduction in postprandial glycemic peaks, reducing the glycemic average, glycemic variability, and the insulinogenic stimulus at the level of residual beta cells. This has been shown to be in line with other studies on the subject ,23.In terms of clinical outcomes, dietary changes proved to be extremely effective in containing glycemic averages (mean glycemic hemoglobin went from 8.3% to 6.8%) and in reaching the therapeutic target, with an increase in patients with glycated hemoglobin <7% of about +475%. The drastic reduction of patients in very poor control (patients with glycated hemoglobin >8% went from 54.5% to 3%) is remarkable as well. This last result could be very impacting on DM1 considering the results of the DCCT-EDIC study, which demonstrated how the greater improvement in terms of microvascular complications occurs when passing from very poor to fairy control . It shouIn terms of safety, the reduction of insulin units required for a low-carb diet played an important role in containing hypoglycemic events, with a halving of level II hypoglycemia compared to the previous diet and a total absence of severe hypoglycemic events. Although the microsecretory beta-cellular activity of individual patients is not known, there is scientific evidence that this is present throughout the life of patients with DM1 , and thaAs shown by the recent literature, the use of many insulin units in DM1 management is linked to a cancer risk 4 times higher over time, with a lower risk when the insulin dosage is below 0.5 UI/kg/die . The redNo cases of diabetic ketoacidosis were observed; in the literature, in fact, ketoacidosis does not seem physiopathologically attributable to low carbohydrate diets but to severe hypoinsulinemia and hyperglycemia , which dFrom a physiopathological point of view, the effectiveness and safety of EVLCD could be explained as patients assumed too few carbohydrates to develop marked hyperglycemia and too few insulin units to develop marked hypoglycemia, achieving a satisfactory overall control of the disease through the limitations of the variables involved in the pathophysiology of the disease itself.The significant improvement in LDL observed appears to be due to the greater adherence to statin therapy than to diet itself. There were no significant changes in other parameters or biomarkers.The study has several limitations.First, the patients voluntarily decided to switch from their usual diet  to an EVLCD , motivated by the glycemic stability that this nutritional plan generally entails. It is therefore a group of highly motivated patients, willing to change their diet and maintain an EVLCD over time. Results may not be as good in less motivated patients.Secondly, although in the literature studies like this are very limited, and when present they are often case series, the number of patients is very small. Moreover, it is also a retrospective study, not a randomized one with a control group.Finally, unlike other experiences published in the literature, a very close telematic follow-up was performed here. Although in our clinical practice we perform the same monitoring in all our patients, regardless of the carbohydrate content of the diet, it is possible that, without such medical supervision, the results may be less satisfactory.Despite the obvious limitations, the results in terms of efficacy and safety seem very promising and we hope that these provide a starting point for further research on the nutritional plan adopted.Although nowadays (VLCD) are not routinely proposed to DM 1 patients as an alternative nutritional plan, this retrospective study has shown that they seem safe and effective if adopted under tight medical control with a proper adjustment in insulin therapy.Long-term outcomes of VLCD in patients affected by DM 1 are unknown and still debated. In light of the literature published today, our opinion is that randomized control trials on the topic are mandatory.


Intra-rater reliability ranged from good to excellent , whereas inter-rater reliability was good  in both groups. Ultrasonographic assessment of PT was found to be a reliable method to assess tendon thickness. The middle location of the PT (corresponding to 15 and 20 mm) can be considered the most reliable spot to measure PT thickness. The PT thickness was larger among track cyclists than soccer players, with larger differences over the distal location (15 mm). Ultrasonographic assessment of PT was found to be a reliable method to assess tendon thickness. The middle location of the PT corresponding to 15 mm and 20 mm can be considered the most reliable area to measure PT thickness.The goal of our study was to investigate the relative and absolute intra-rater and inter-rater reliability of ultrasound assessment of patellar tendon (PT) thickness assessed over four locations, in track cyclists and soccer players. Fifteen male elite track cyclists and 15 male elite soccer players participated. Tendon thickness was measured over 4 locations placed at 5-10-15-20 mm inferior to the apex of the patella by two experienced examiners. Each examiner took two US images for the test measurements with a 10-min rest period. After a 30-min period, the subjects underwent a retest measurements that were also repeated 1-week after. A two-way analysis of variance revealed a significant group x location interaction on PT thickness for Examiner 1 (p = .001, η Ultrasound (US) imaging is a clinical and research tool that is widely used for injury prevention and diagnosis , 2. RadiThe PT has a conical shape, where the proximal part is wider, and then narrows until the final attachment on tibial tuberosity. Moreover, the tendon is not homogenous along it entire length and may have a different structure, including collagen content, collagen type, and extracellular matrix density . From thPrevious studies have evaluated the reliability of US in assessing PT thickness in healthy volunteers –17, subjTrack cycling, especially sprint events, results in increased muscle tension and muscle soreness in the anterior thigh muscles –25. DecrGaining a better understanding of the reliability of PT thickness may be useful in diagnosing acute fatigue-induced overloading by US imaging. We aimed to assess PT thickness at different locations of the tendon structure to identify changes in PT thickness at specific areas of the tendon. Therefore, the primary aim of the current study was to investigate the relative and absolute intra-rater and inter-rater reliability of the assessment of PT thickness at multiple locations in line with the GRRAS recommendations . The sec2) and 15 male elite soccer players aged between 22 and 27 years (mean age (SD) of 24 (2.5) years, body height: 183.3 (4.5) cm, body mass: 83.2 (5.4) kg, BMI: 23.3 (0.5) kg/m2). The track cyclists were members of the national team specializing in sprint events, with a mean training experience of 12.2 (2.3) years. All cyclists were competing in international-level track races, including the World Cup, European Championship, and World Championship. The soccer-player group included elite high division soccer players. The inclusion criterion for both groups was having trained for ≥10 years, while the exclusion criteria for both groups included (1) current or previous PT injuries or symptoms and (2) a history of surgery in the lower extremity. Soccer players were recruited for this study as controls to assess the differences between individual and team sports and between sprint and mixed performance sports. In our study, we evaluated only PT thickness in athletes without knee pain or current injury, who were considered asymptomatic subjects.The population of the study included a group of 15 male elite track cyclists aged between 22 and 33 years (mean age (SD) of 26 (4) years, body height: 185.3 (8.6) cm, body mass: 85.5 (6.8) kg, body mass index (BMI): 25.3 (0.7) kg/mf) of 0.72, with the level of significance set to be a = 0.05, and a power of 0.90. The sample size calculation showed that at least 14 participants per group were necessary, but to account for potential dropouts, 15 participants were recruited. Furthermore, to estimate effect size for reliability analysis expressed by ICC, a sample size calculator performed by Arifin [a = 0.05, and a power of 0.90. The sample size calculation showed that at least 15 participants per group were necessary. A total of 30 participants were recruited, and none of the participants were excluded from further investigation.The expected effect size to assume differences in PT thickness in track cyclists and soccer player were estimated using G*Power software  . We calcy Arifin  was usedThe study was approved by the Ethical Committee of the University Research Ethics Committee at the Wrocław University of Health and Sport Science (project identification code: 26/2016) and it was conducted according to the Helsinki Declaration. All subjects signed the written informed consent before participation in the study.Ultrasonography was performed using a Honda HS-2200 ultrasound scanner  with a 7.5 (6.0 to 11.0) MHz and 40 mm linear array transducer  in grayscale B-mode. The settings of the US system were standardized for all participants and remained the same for all measurements .The participants were lying in a supine position with their right knee flexed at approximately 30°. A pillow was placed under the popliteal space during the examination. This knee position prevents errors in measurements related to the concave position of the posterior thigh muscles and PT extension. During the scans, the linear transducer was placed longitudinally distal to the patella . The thiUltrasound images of the PT were obtained by two sonographic examiners who specialized in musculoskeletal US and had ten (examiner 1) and twelve (examiner 2) years of clinical experience. Both examiners were physical therapists experienced (six and five years of experience) in lower extremity imaging. Examiners underwent 2 hours of training before conducting this study on the particular US settings and examination procedures (positioning of the subjects and transducer). The protocol was the same for all participants. All participants were asked to avoid physical activity for at least 2 days before the assessment. A screening evaluation of images of the PT was performed by an experienced orthopedic surgeon  to avoid signs of PT tendinopathy. The order in which the imaging locations were assessed was randomized, and the examiner was randomly selected for each assessment. The examiners were blinded to each other’s measurements and to the group of participants . Each examiner took two US images of the PT thickness within a 10-minute period (test). After 30-minutes, the same procedure was repeated to obtain two new US images of the PT thickness (retest). After 1-week, both examiners measured the PT thickness from the US images of the test and retest session. The average of the PT thickness measures from each of the two images at test and retest were used for the statistical analyses in line with previous studies , 31.The intra-rater reliability of PT thickness was calculated for each examiner and for each group . The inter-rater reliability of PT thickness was calculated for each group  from the images obtained by each examiner. The US images were randomly divided into blocks of 6 to decrease the potential learning effect. Maps of PT thickness were generated using inverse distance-weighted interpolation of the averaged values at each location (5-10-15-20 mm) to obtain a 3D graphical representation. The 3D images were obtained for graphical purposes using inversed distance interpolation by a factor of 2 with Franke and Nielson weightings . Each maStatistical analyses were performed using the statistical software SPSS 21 . Descriptive statistics (means ± standard deviation (SD) were calculated. Normality was evaluated using the Shapiro-Wilk normality test.2, k). The formula used was as follows:Intra- and inter-rater reliability was calculated according to the method described by Koo and Li  who esti2) was calculated to assess the effect size. P-values <0.05 were considered statistically significant.Reliability was classified as poor (ICC<0.5), moderate (0.5<ICC<0.69), good (0.7<ICC<0.89) or excellent (ICC>0.9) . The staF  = 11.7, p = 0.001, η2 = 0.81) and examiner 2  = 13.8, p = 0.001, η2 = 0.78). The post hoc analysis showed that the PT thickness was larger for track cyclists compared with soccer players at all locations (p<0.001). Moreover, the within-group analysis for examiner 2 showed that the track cyclists had different thicknesses at 10 and 15 mm than at 20 mm and across individuals (p<0.001) and that the soccer players had different thickness values at 15 and 20 mm (p<0.001) (p<0.001) , Fig 1C.2,k from 0.75 to 0.96) in both groups. The ICCs for examiner 1 were good and excellent at all locations among the track cyclists (0.77 (95% CI = 0.32 to 0.92)– 0.94 (95% CI = 0.58 to 0.96)) and soccer players (0.79 (95% CI = 0.42 to 0.90)– 0.92 (95% CI = 0.7 to 0.95)). The intra-rater ICCs for examiner 2 were slightly higher than those for examiner 1 among the track cyclists; the ICCs of examiner 2 ranged from 0.75 (95% CI = 0.45 to 0.94) to 0.96 (95% CI = 0.68 to 0.98). Among the soccer players, we found slightly lower ICCs for examiner 2 than for examiner 1, ranging from 0.79 (95% CI = 0.35 to 0.85) to 0.90 (95% CI = 0.69 to 0.92). Inter-rater reliability was good and excellent among the track cyclists (from 0.75 (95% CI = 0.49 to 0.92) to 0.9 (95% CI = 0.57 to 0.94)) and soccer players (from 0.76 (95% CI = 0.44 to 0.84) to 0.89 (95% CI = 0.63 to 0.90)) (Intra-rater reliability ranged from good to excellent (ICCo 0.90)) .In general, the intra-rater SEMs were higher among track cyclists than among soccer players, mostly due to larger thickness values. For examiner 1, the SEMs were below 0.05 mm among track cyclists and 0.04 mm among soccer players. Examiner 2 was more precise in measuring PT thickness in both groups. The inter-rater SEMs ranged from 0.03 to 0.04 mm in both groups. The intra-rater MDCs ranged from 0.05 mm to 0.12 mm, whereas the inter-rater MDCs ranged from 0.08 mm to 0.11 mm .The intra-rater LOA ranged from 0.6 mm to 1.5 mm, with the soccer player group showing lower values. The LOA for intra- and inter-rater reliability showed a mean difference that represented less than 1.5 mm of the corresponding thickness .The current study showed that the relative intra- and inter-rater reliability of measuring PT thickness with US imaging ranged from good to excellent at four different locations in track cyclists and soccer players. The reliability expressed in relative (ICC) and absolute terms (SEM and MDC) was highest at the area located 20 mm from the patellar apex. Moreover, the PT was thicker among track cyclists than among soccer players. Our study revealed the best location in relation to the apex of the patella enabling more reliable measurement of PT thickness. Moreover, this study was the first to report values in asymptomatic two groups of athletes enabling to compare findings with findings from clinical studies addressing PT injury mechanisms. These findings might be useful in monitoring PT thickness across several locations due to its conical structure.Previous studies reported good to excellent (ICC 0.7 to 0.93) relative inter-rater reliability for PT thickness –15 measuOnly one previous study investigated the absolute reliability  of measuring PT thickness . In the The changes in thickness and relative and absolute reliability were most likely related to the conical structure of the PT and the potential difficulty of clearly defining the tendon borders , 19, 21.Ultrasonography is commonly recommended for examination of the structure of the PT, including its stiffness in patients with tendinopathy and overloading injuries . InvestiFinally, we recognize that the current study has some limitations. First, since the PT can reach 45 mm, more distal points could be assessed in future studies. We decided to assess these four points since they are the most common sites of symptoms in patients with patellar tendinopathy. Second, we included asymptomatic track cyclists and sports players, i.e., individuals without symptoms in the knee. We do not currently know whether the PT reliability results would be similar in injured athletes or patients. Third, we could have reported the relative (%) measurement locations rather than the absolute location (mm). Future studies should include symptomatic adults  and larger sample sizes. Finally, US imaging is an operator-dependent measurement tool, as examiners with more experience yield higher reliability .In conclusion, US has been demonstrated to be a reliable method of assessing the thickness of the PT. The middle region of the PT (corresponding to 15 mm and 20 mm from inferior to the apex of the patella) was revealed to be the most reliable point to assess PT thickness. The PT was thicker among track cyclists than among soccer players, with larger differences at 15 mm from the apex. Of note, these differences were larger than the SEM and MDC, underlining the changes in PT thickness mostly related to training load and type of sport. Our findings on absolute and relative reliability provide important normative data that can be used in the future in longitudinal studies .


Background. Limited studies and observations conducted on a too small number of patients prevent determining the actual clinical utility of pulmonary contrast-enhanced ultrasound (CEUS). The aim of the present study was to examine the efficacy of contrast enhancement (CE) arrival time (AT) and other dynamic CEUS findings for differentiating between malignant and benign peripheral lung lesions. Methods. 317 inpatients and outpatients  with peripheral pulmonary lesions were included in the study and underwent pulmonary CEUS. Patients were examined in a sitting position after receiving an intravenous injection of 4.8 mL of sulfur hexafluoride microbubbles stabilized by a phospholipid shell as ultrasound contrast agent . Each lesion was observed for at least 5 min in real-time and the following temporal characteristics of enhancement were detected: the arrival time (AT) of microbubbles in the target lesion; the enhancement pattern; the wash-out time (WOT) of microbubbles. Results were then compared in light of the definitive diagnosis of community acquired pneumonia (CAP) or malignancies, which was not known at the time of CEUS examination. All malignant cases were diagnosed by histological results, while pneumonia was diagnosed on the basis of clinical and radiological follow-up, laboratory findings and, in some cases, histology. Results. CE AT has not been shown to differ between benign and malignant peripheral pulmonary lesions. The overall diagnostic accuracy and sensibility of a CE AT cut-off value < 10 s in discriminating benign lesions were low . Poor results were also obtained in the sub-analysis of small (mean diameter < 3 cm) and large (mean diameter > 3 cm) lesions. No differences were recorded in the type of CE pattern showed between benign and malignant peripheral pulmonary lesions. In benign lesions we observed a higher frequency of delayed CE wash-out time (WOT) > 300 s. Anyhow, a CE WOT cut-off value > 300 s showed low diagnostic accuracy (53.6%) and sensibility (16.5%) in discriminating between pneumonias and malignancies. Similar results were also obtained in the sub-analysis by lesion size. Squamous cell carcinomas showed a more delayed CE AT compared to other histopathology subtypes. However, such a difference was statistically significant with undifferentiated lung carcinomas. Conclusions. Due to an overlap of CEUS timings and patterns, dynamic CEUS parameters cannot effectively differentiate between benign and malignant peripheral pulmonary lesions. Chest CT remains the gold standard for lesion characterization and the eventual identification of other pneumonic non-subpleural localizations. Furthermore, in the case of malignancy, a chest CT is always needed for staging purposes. Despite the fact that peripheral pulmonary consolidations adherent to the pleura can be easily detected by ultrasound, the correlation between the ultrasound pattern and a specific pathology is quite poor ,2,3. RecUltrasound contrast agents are composed of gas microbubbles stabilized in a phospholipid membrane, typically of about 6 µm in diameter (compared to a human erythrocyte measuring about 9 µm) . MicrobuGiven the advantage to allow a dynamic evaluation of tissue microvasculature and microperfusion in real time, CEUS has been successfully used in diagnostic imaging for a wide spectrum of pathological conditions. In Europe, CEUS use is currently approved for several cardiac and/or non-cardiac indications, including echocardiography, assessment of diseases in large vessels  and study of the microcirculation of parenchymatous organs  . PulmonaSome authors assessed dynamic CEUS parameters and their capability to distinguish malignant from benign peripheral pulmonary consolidations . In partOn this background, the aim of the present study was to evaluate the diagnostic accuracy of CE AT in discriminating between malignant and benign peripheral pulmonary lesions, as recently described in the literature. Discriminatory accuracy of other dynamic CEUS findings was also assessed for completeness.Between November 2021 and November 2022, we analyzed data of a total of 654 inpatients and outpatients scheduled for systematic TUS examination because of pulmonary consolidations on chest radiological imaging in our Unit of Interventional and Diagnostic Ultrasound of the Research Institute “Fondazione Casa Sollievo della Sofferenza Hospital” . All patients were in cardio-circulatory stability and showed no signs of respiratory distress.The inclusion criteria were: (1) age > 18 years; (2) presence of subpleural pulmonary lesions defined as lesions not only abutting the pleura but also having an accessible ultrasound window; (3) availability of confirmation chest radiological images; (4) an informed written consent to perform a CEUS study. The exclusion criteria included the following: (1) known history of allergic reaction to the ultrasound contrast agent; (2) severe cardiovascular disease, including right-to-left shunts, severe pulmonary hypertension  and uncontrolled systemic hypertension ; (3) pregnancy or breast-feeding; (4) massive pleural effusion ; (5) unsatisfactory ultrasound images; (6) failure to diagnose the lesion.A total of 317 patients  were finally included in the study. Their results were then compared in light of the definitive diagnosis of community acquired pneumonia (CAP) or malignancies, which was not known at the time of CEUS examination. Malignancies have been confirmed by biopsy and subsequent histological findings. CAP have been diagnosed on the basis of clinical and radiological follow-up, laboratory findings and, in some cases, histology.The study followed the amended Declaration of Helsinki, the institutional Ethical Review Board of the hospital approved the protocol  and all patients gave their informed consent to participate.Ultrasound examination was independently performed by two physicians with over 20 years of experience in lung ultrasonography using an Esaote MyLab Twice scanner or, alternatively, an ESAOTE Technos MPX scanner . For each exam we employed a multifrequency convex probe (3.5–5 MHz), the pre-setting for thoracic ultrasound in B-mode  and US contrast setting . Lungs were bilaterally explored, from the base to the apex, through all ventral, posterior and lateral intercostals spaces in order to identify consolidations. If more than one lesion was present, the largest and clearest one was selected. The maximal parallel and vertical diameters of the lesions were measured and the average diameter was recorded in cm.Once the consolidation was clearly individuated on B-mode TUS scan, the US instrument was adjusted to a low-mechanical-index contrast enhancement mode. In all patients, US scans were performed in the sitting position in order to exclude a variability in contrast uptake due to changes in decubitus, potentially influencing the results.Patients received then an intravenous injection of 4.8 mL of the new generation ultrasound contrast agent SonoVue , followed by 10 mL of regular saline and the chronometer included in the scanner allowed the assessment of temporal characteristics of flow enhancement. The lesion was observed for at least 5 min in real-time in order to obtain maximum diagnostic information on lesion vascularity. The following temporal characteristics of enhancement were detected: the contrast enhancement arrival time (CE AT) between injection and appearance of microbubbles in the target lesion; the contrast enhancement (CE) pattern; the contrast enhancement wash-out time (CE WOT) between injection and disappearance of microbubbles. CE pattern was simply categorized using a dichotomous visual score, defining lesions as homogeneous or non-homogeneous, according to the distribution of more or less than 50% within the lesion. CE AT was classified as “early” if contrast agent reached the target lesion within 10 s. CE WOT was defined as “delayed” if the disappearance of contrast agent from the target lesion occurred after 300 s. CEUS images were recorded and stored as an average of 3 dynamic videoclips, each lasting about 2 min.The clips were blindly reviewed by another operator with 35 years of experience. Cohen’s k values of the diagnostic results obtained for CE AT, CE pattern and CE WOT ranged from 0.81 to 1.00, indicating almost perfect agreement between operators.Data are presented as means ± standard deviation (SD) for continuous variables and as number (n) and percentage (%) for descriptive variables. Mann–Whitney U test was used for comparisons of continuous variables between patients with benign and malignant lesions and between patients with small  and large lesions . Continuous variables between patients with different histopathology subtypes of malignant lesions were compared using Kruskal–Wallis test. Dunn’s multiple comparison test was performed to determine whether there was a difference between the mean rank of all the possible pairs.p-value < 0.05. Dynamic CEUS parameters diagnostic accuracy, sensitivity, specificity, positive and negative predicted values were calculated with a 95% confidence interval (CI).Pearson’s chi-squared test was used to assess statistically significant difference in descriptive variables between patients with benign and malignant lesions, patients with small and large lesions and patients with different histopathology subtypes of malignant lesions. Significance was established at a p = 0.91) or smoking habit (p = 0.57). However, patients with benign consolidations were younger than those with malignancies (p < 0.0001). The average diameter of lesions measured on US was 3.2 ± 0.9 cm for community acquired pneumonia and 2.7 ± 0.5 cm for malignant lesions; malignancies were significantly smaller than benign consolidations (p = 0.0004). A mild to moderate pleural effusion was mostly associated to malignant lesions, despite with no statistically significant difference (p = 0.31)  .All 147 malignant cases were diagnosed by biopsy. Histological diagnoses of malignancies are shown in p = 0.39). No differences were recorded in the frequencies of lesions showing and “early” CE AT between the two groups . No differences were recorded in the number of lesions that showed an homogeneous CE pattern (76.5% vs. 72.8%) or a non-homogeneous CE pattern (23.5% vs. 27.2%) between the two groups (p = 0.52). Although without reaching statistical significance, an homogeneous CE pattern was the most frequent presenting feature compared to the non-homogeneous CE pattern for both benign (76.5% vs. 23.5%) and malignant (72.8% vs. 27.2%) lesions (p = 0.52). Malignant lesions showed statistical significance for an earlier CE WOT compared to benign lesions . In the group of benign lesions we observed a statistically higher frequency of consolidations showing a delayed CE WOT   .A CE AT cut-off of <10 s showed an overall diagnostic accuracy of 47.6% (95% CI: 42.0–53.3%), a sensitivity of 5.3% (95% CI: 2.5–9.8%), a specificity of 96.6% (95% CI: 92.2–98.9%), a positive predictive value of 64.3% (95% CI: 38.2–84.0%) and a negative predictive value of 46.9% (95% CI: 45.7–48.0%) in discriminating benign from malignant lesions . A CE WODepending on the average diameter, the participants were divided into two groups: the small lesion group (average diameter < 3 cm) and the large lesion group (average diameter ≥ 3 cm).p = 0.46) and the large lesion group . Lesions in the small lesion group showed earlier arrival times than lesions in the large lesion group. However, while this difference showed statistical significance for benign lesions , the same was not observed for malignant lesions . No differences were recorded in the number of lesions that showed an homogeneous CE pattern  or a non-homogeneous CE pattern  between benign and malignant lesions in the two groups. Benign lesions continued to show statistical significance for a delayed CE WOT compared to malignant lesions in both the small lesion group  and the large lesion group   .In the small lesion group, a CE cut-off of <10 s showed a diagnostic accuracy of 55.7% (95% CI: 48.0–63.2%), a sensitivity of 6.3% (95% CI: 2.0–14.0%), a specificity of 96.9% (95% CI: 91.1–99.4%), a positive predictive value of 62.5% (95% CI: 29.1–87.1%) and a negative predictive value of 55.4% (95% CI: 53.7–57.0%). In the large lesion group, a CE cut-off of <10 s showed a diagnostic accuracy of 37.6% (95% CI: 29.6–46.1%), a sensitivity of 4.4% (95% CI: 1.2–11.0%), a specificity of 96.1% (95% CI: 86.5–99.5%), a positive predictive value of 66.7% (95% CI: 27.5–91.3%) and a negative predictive value of 36.3% (95% CI: 34.7–38.0%). In the small lesion group, a CE WOT cut-off of >300 s showed an overall diagnostic accuracy of 60.8% (95% CI: 53.2–68.1%), a sensitivity of 17.5% (95% CI: 9.9–27.6%), a specificity of 97.0% (95% CI: 91.1–99.4%), a positive predictive value of 82.4% (95% CI: 58.2–94.0%) and a negative predictive value of 58.5% (95% CI: 55.9–61.1%). In the large lesion group, a CE WOT cut-off of >300 s showed an overall diagnostic accuracy of 44.7% (95% CI: 36.3–53.3%), a sensitivity of 15.6% (95% CI: 8.8–24.7%), a specificity of 96.1% (95% CI: 86.5–99.5%), a positive predictive value of 87.5% (95% CI: 62.4–96.7%) and a negative predictive value of 39.2% (95% CI: 36.7–41.7%).US and CEUS characteristics in the different histopathology subtypes of malignant subpleural lesions are detailed in p = 0.35). Squamous cell carcinoma showed a more delayed CE AT compared to other histopathology subtypes (p = 0.35). However, Dunn’s multiple comparison test assessed the existence of a statistically significant difference only between squamous cell carcinomas and undifferentiated lung carcinomas  (p = 0.75). No evidence for statistically significant differences in the CE WOT was found between different malignant histotypes (p = 0.24).No evidence for statistically significant differences in terms of average diameter of lesions measured on US was assessed between different histopathology subtypes of malignant lesions (= 0.004) . No diffResults of studies assessing CE AT values for the characterization of peripheral pulmonary lesions are controversial. While some authors have observed that CE AT allows to effectively distinguish between benign and malignant subpleural pulmonary lesions ,11,12, oTo date, a CE AT cut-off of 10 s has been included in the recommendations for the clinical practice of CEUS in non-hepatic applications proposed by the EFSUMB . ResultsThe lung is characterized by dual a blood circulation: the pulmonary arterial system and the bronchial arterial system. The pulmonary arterial system carries systemic deoxygenated blood from the right ventricle to the lungs. Branches of the pulmonary artery travel closely alongside the bronchial tree on their way to the alveoli. Here, the blood passes through a nest of small capillaries and becomes oxygenated. Oxygenated blood from the lungs is then circulated back to the heart through the pulmonary veins that drain into the left atrium . The broThe inflammatory process that characterizes pneumonia mainly affects the terminal alveoli and bronchioles, leading to the ectasia and permeabilization of the nest of the blood capillaries by which each alveolus is surrounded and that are supplied by small branches of the pulmonary artery. This explanation was given to justify the early CE AT that would characterize inflammatory lesions on CEUS study . On the Anyhow, previous studies on contrast-enhanced magnetic resonance (MR) have shown that in healthy individuals contrast enhancement appears in the right heart between 1 and 4.5 s after injection , and between 6 and 7.5 s in the left heart ,21. As ap = 0.67). A CE AT cut-off value ≤ 10 resulted in a diagnostic accuracy of 47.6% and a sensibility of only 5.3% in discriminating pneumonias from malignancies.In our study, none of the benign nor malignant lesions showed enhancement before 6 s. Furthermore, a CE AT ≤ 10 s was observed in nine cases (5.29%) of benign lesions and in 5 cases (3.40%) of malignant lesions, with no statistically significant difference . A homogeneous distribution of CE was found in 130/170 (76.5%) pneumonias and in 107/147 (72.8%) malignancies, whereas a non-homogeneous distribution was observed in 40/147 (23.5%) CAP lesions and 40/147 (27.2%) neoplasms. Probably, the lack of significant differences of CEUS features between CAP and malignancies could reflect some pathophysiological aspects shared by these conditions. For example, also local vasoconstriction due to hypoxic stimuli is usually present within the heterogeneous microenvironment of benign inflammatory processes and malignant lesions may be imaged as a defect in US contrast enhancement [Regarding other dynamic CEUS findings, the CE pattern did not differ significantly between benign peripheral pulmonary lesions and malignant ones  are strongly warranted. Anyway, in suspicious cases a chest CT remains necessary for staging purposes, while the histological examination of the lesions is always needed to confirm the diagnosis and to obtain immunohistochemical characterization. To this regard, US contrast media could be used to improve the diagnostic yield of percutaneous biopsy. In pneumonia cases, the possible addition of a simple ultrasound examination in B-mode could help to visualize the regression of the consolidation . Anyhow, a CT must still be done to exclude the possibility of further lesions.


Nowadays, suicide is a global public health problem thus detection of risk factors more specifically individual factors can be used as a method for prevention and intervention.The aims of our study were to assess the incidence of suicidal recurrence and its individual associated factors.th March 2009 to the 25th September 2020 for suicidal attempt. Sociodemographic and clinical data as well as suicidal attempts’ characteristics were assessed. The statistical analysis was executed on the software SPSS (20th edition).A retrospective descriptive and analytical study was undertaken including all patients consulting for the first time at Gabes psychiatry department (in southern Tunisia) from the 4-3) and low self-esteem (p=0.012).278 patients were collected including 217 female. The mean age was 26. Suicidal patients were unmarried (75.9%), childless (79.1%) and unemployed (47.5%). The common suicidal attempt method was voluntary drug intoxication (67.8%). Interference of individual factors was reported in 77% of cases, especially difficulties to cope with stress (46.4%), followed by low self-esteem (36.5%), personal psychiatric history (17.3%), personal medical history (8.3%) and alcohol or drug abuse (6.1%). A suicidal re-attempt was notedin 24.9 % of cases. Recurrence was associated with the female gender (72.4%), difficulties to cope with stress (<10After the first suicidal attempt, it’s crucial to identify the individual factors that seems to have an influence on subsequent suicidal behaviour in order to ensure a proper treatment.


In the original published version of this article, Figure 1 and its corresponding caption had been reused without reference to the original source. The corrected version of the caption for Figure 1 can be found below. The authors apologize for the error. Both the HTML and PDF versions of the article have been updated to correct the errors.https://doi.org/10.3390/ijms22052267).Figure 1. The role of NUDT5 in breast cancer metastasis. Model showing the multiple roles and indications for a key role of NUDT5 in aggressive breast cancer. (1) NUDT5 is elevated in tumor versus normal breast cancer tissue. (2) NUDT5 is essential for breast cancer stem cell (BCSC) generation and maintenance. (3) NUDT5 is highly expressed in circulating tumor cells (CTCs). (4 and 5) Elevated levels of NUDT5 are associated with increased levels of recurrence and metastasis in patients suggesting a role in mesenchyme to epithelial transition and secondary site colonization. And finally, (6) analysis of the gene expression changes occurring in BCSC in 3D cell culture suggests a role of NUDT5 in angiogenesis. (Figure and figure caption taken from Wright, R.H.G.; Beato, M. Role of the NUDT Enzymes in Breast Cancer. Int. J. Mol. Sci. 2021, 22, 2267. The authors declare no conflict of interest.