Salmonella Typhi isolates from the Brazilian North region. Bacterial isolates were recovered from blood and a rectal swab of patients in the states of Acre and Pará, Brazilian North region, in the period of 1995 to 2013, and were submitted to genotyping by applying Multilocus sequence typing (MLST) and Pulsed Field Gel Electrophoresis (PFGE) reference methods. MLST genotyping revealed the presence of epidemic clones ST1 and ST2, and 20 pulsotypes were identified by PFGE, including four distinct clusters (A–D), and six subclusters (A1–D1) with indistinguishable strains in different periods and locations. To conclude, the obtained data demonstrates the temporal stability, adaptation, and transmission of outbreak-related and sporadic S. Typhi strains over time, contributing to the transmission chain in the region.Typhoidal salmonellosis is a global public health problem occurring in developing endemic regions. In Brazil, cases are mostly registered in the North and Northeast regions. Molecular characterization of the strains is important to understand the epidemiology of disease infections and to design control strategies. The present study retrospectively evaluates the genotyping features of sporadic and outbreak-related  Typhoidal salmonellosis is a global public health problem associated with deficient socioeconomic levels in developing areas of Africa, the Americas, South-East Asia, and the Western Pacific regions, reaching a burden of 11–20 million cases annually, resulting in about 128,000–161,000 deaths per year [Salmonella Typhi, the etiologic agent of typhoid fever, causes a high fever and severe gastrointestinal issues, including life-threatening intestinal perforations, and is usually spread via contaminated food and water [Salmonella species, S. Typhi is man-restricted [nd water ,4,5,6. Istricted .S. Typhi is important for disease control, such as during a disease outbreak, to trace the potential sources. Therefore, the present study proposed to retrospectively evaluate the genetic relatedness of sporadic and outbreak-related S. Typhi isolates from two states in the Brazilian North region in the period of 1995 to 2013. The epidemiological investigation supported by molecular methods for S. Typhi isolates collected in the Bacteriology and Mycology Section of the Evandro Chagas Institute (IEC), Ananindeua, Pará, Brazil, were evaluated. The IEC is a regional referral center for typhoid fever diagnosis, and one of the few centers in Brazil, and perhaps in Latin America, that maintains a clinical and laboratory surveillance program for typhoid fever, operating since the 1980s in the investigation of sporadic cases and outbreaks that occurred in different locations in the region. Thirty-eight S. Typhi, were selected and inoculated in TSI (Triple Sugar Iron) medium to the definition of the biochemical profile, then incubated at 37 °C for 24 h. Subsequently, they were directed to biochemical identification using the VITEK-2 automated system, according to the manufacturer’s instructions.Bacterial isolates were recovered from blood and rectal swabs from patients in the states of Acre and Pará, Brazilian North region, in the period of 1995 to 2013. Isolates were reactivated to confirm identification, viability, and purity by the first growth in TSB broth (Tryptic Soy Broth) at 35 °C for 24 h, followed by plating on salmonella shigella agar (SSA) at 35 °C for 24 h. Colonies that did not ferment lactose, characteristic of aroC, dnaN, hemD, hisD, purE, sucA and thrA) were amplified by PCR on the Veriti thermocycler . PCR products were separated by electrophoresis in 1.5% agarose 1X TAE gel stained with SYBR Safe (Invitrogen) and bidirectionally sequenced using Big Dye Terminator v3.1 chemistry on an ABI Prism 3130 Genetic Analyzer . The results obtained were analyzed according to the PubMLST database  for the determination of sequence types (STs).MLST was performed as previously described by Harbottle et al. , with moS. Typhi isolates was digested using restriction endonuclease XbaI enzyme for 24 h. An electrophoretic run was performed using the CHEF-DR III (Bio-Rad) system for 24 h at 160 V, followed by band patterns analysis and dendrogram construction applying the Dice coefficient with 3% tolerance, 80% cut-off, and UPGMA using the software BioNumerics 6.5 (Applied Maths).PFGE was performed according to the Gautom , with slS. Typhi strains with similar genetic signatures by PFGE were detected in distinct periods and locations: Strains in cluster A were demonstrated to be genetically related with isolates from 1995–2012 in Acre and Pará States, also being associated with epidemic clones ST1 and ST2; ST1 strains were mostly detected at Acre State in 1995, including three clonally related isolated as verified on subcluster A1. In contrast, ST2 strains were predominant in cluster B, including subclusters B1 with strains from Pará in 2012–2013 and subclusters B2 with strains from Acre and Pará in 1995, 2012, and 2013. Finally, clusters C and D were mostly composed of ST2 strains from 2006 in Pará State.MLST genotyping revealed the presence of epidemic clones ST2 (32/84.2%) and ST1 (6/15.8%). Through the PFGE analysis, 20 pulsotypes were identified, including four distinct clusters (A–D), six subclusters (A1–D1) with indistinguishable strains, and one unrelated strain . S. TyphS. Typhi strains in the Brazilian North/Amazon region from 1995 to 2013. The Brazilian North region is an endemic area for typhoid fever, especially the state of Pará, which has historically registered cases and outbreaks of typhoid fever since the 1980s. The identification of circulating clones and understanding of transmission by applying reference molecular epidemiology tools, such as PFGE and MLST, are of high value to control strategies and the comprehension of transmission dynamics in this region. Through a retrospective approach, the present report provides data on the molecular epidemiology of sporadic cases and outbreak-related The most globally spread MLST lineages ST1 and ST2 were the only detected clones in the analysis period and locations, demonstrating a low genetic diversity of MLST clones in the region, likewise reported in Bangladesh, Angola, Zambia, India, Malaysia, Chile, and Papua New Guinea ,13,14,15S. Typhi strains, with the presence of 20 distinct pulsotypes, and clonally related isolates causing infection in different locations and periods, also supporting the hypothesis of a localized and restricted clonal expansion [The PFGE typing revealed a higher genetic diversity of xpansion ,11. Suchxpansion  evaluatiS. Typhi strains over time and suggest the role of asymptomatic human hosts, who usually develop chronic infection, eliminating the pathogen through feces that contaminate water and food and contribute to the transmission chain in the region. Finally, further studies evaluating S. Typhi isolates from recent periods allow comparison with the data present in this report, in addition to the study of antimicrobial resistance patterns, virulence features, and genetic diversity that are of high value to the comprehension of epidemiology and dynamics of typhoidal salmonellosis in this endemic region.The present data demonstrate the temporal stability, adaptation, and transmission of outbreak-related and sporadic


Predicting the potential risk factors of high blood pressure (HBP) among children and adolescents is still a knowledge gap. Our study aimed to establish and validate a nomogram-based model for identifying youths at risk of developing HBP.HBP was defined as systolic blood pressure or diastolic blood pressure above the 95th percentile, using age, gender, and height-specific cut-off points. Penalized regression with Lasso was used to identify the strongest predictors of HBP. Internal validation was conducted by a 5-fold cross-validation and bootstrapping approach. The predictive variables and the advanced nomogram plot were identified by conducting univariate and multivariate logistic regression analyses. A nomogram was constructed by a training group comprised of 239,546 (69.9%) participants and subsequently validated by an external group with 103,190 (30.1%) participants.P > 0.05) were observed in our models. An available web-based nomogram was built online on https://hbpnomogram.shinyapps.io/Dyn_Nomo_HBP/.Of 342,736 children and adolescents, 55,480 (16.2%) youths were identified with HBP with mean age 11.51 ± 1.45 years and 183,487 were boys (53.5%). Nine significant relevant predictors were identified including: age, gender, weight status, birth weight, breastfeeding, gestational hypertension, family history of obesity and hypertension, and physical activity. Acceptable discrimination  and good calibration (Hosmer and Lemeshow statistics, This model composed of age, gender, early life factors, family history of the disease, and lifestyle factors may predict the risk of HBP among youths, which has developed a promising nomogram that may aid in more accurately identifying HBP among youths in primary care. High blood pressure (HBP), whether primary or secondary, occurs with 2–3% incidence in the general children population , 2 and iGiven the increasing evidence base, recommendations of identification regarding BP in children from multiple guidelines vary somewhat –14, probAnd another concern is that previous studies yielded contradictory results on the risk factors for HBP in children. For example, some studies indicated that childhood exposure to smoking, whether active or passive, was associated with an increased risk of HBP –17. At tConsequently, in this study, based on the ongoing successive sectional study conducted in Guangzhou  in 2020 with a total of 1,594,048 participants, our study aims at assessing the association of numerous predictions and HBP, and to build the first-ever statistical nomogram tool to identify the precise long-term effect modifiers of HBP in children and adolescents both by developing and internally validating the dataset.The survey is not publicly available and participants were protected under a certificate of confidentiality issued by the Government of Guangzhou due to the sensitive nature of data collected from all student groups in Guangzhou city.Our study was performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines . RelevanThis survey was approved by the Ethics and Human Subject Committee of Sun Yat-sen University and any uncertainties were corrected before the consent forms were signed. Data were obtained from the GSSCH, a sequential cross-sectional investigation carried out annually, comprising approximately 1,600 primary and middle schools in Guangzhou city, which was completed and supported by Sun-Yat Sen University, Guangzhou school-health promotion center, and Guangzhou Education Bureau. The GSSCH has been conducted for 4 consecutive years, and a battery of relevant measures was undertaken during September and October, the first 2 months of a new school year.N = 239,546) for training and the remaining 30.1%  for validation.The dataset was independently divided by the cross-sectional study conducted in 2020 for identifying the first-ever incidence of HBP among children and adolescents. All participants were students aged from 5 to 25 years old, and trained investigators or practitioners conducted questionnaires on health-related behaviors, administered regular physical examinations, and collected objective anthropometric data measurements. A total of 1,102,462 children were removed due to missing data, incomplete data, or extreme values respecting the demographic variables or relevant BP variables based on the four sex and age-specific standard deviations (SDs). Overall, 148,850 participants were aged above 18. And a total of 342,736 subjects were included in our analysis after the eliminations mentioned above. The subject group was split into training and validation sets by taking a random sample of 69.9% , lifestyle-associated factors , and health-related information  for HBP was assessed in 2020 as the training cohort and validation database, through matching individuals' identifications. Body mass index (BMI) was calculated as the individual's body weight in kilograms divided by the square of height in meters and further divided into four categories  adjusted for age and gender. Parental education level was defined as the highest level of education reported for either parents, divided into primary school or below, secondary school, senior high school or junior school, junior college or university, and graduate or above. Parental smoking status separately for the father and mother was combined with three categories: never smoked (both parents had never smoked), and former or current smokers (either of the parents were former or current smokers). The family history of obesity and hypertension was defined by the reported history of obesity and hypertension in immediate family members, while gestational hypertension was defined as new-onset hypertension after 20 weeks gestation.The children were asked to sit comfortably for at least 10 min before BP measurement, which was conducted in a quiet area. A standard BP cuff was positioned near the right elbow, 2 cm below the antecubital fossa. BP for each child was recorded three consecutive times in a seated position on their right arm by a calibrated electronic sphygmomanometer  on a single occasion. The diagnosis of HBP was in accordance with the updated BP diagnostic criteria for Chinese children and adolescents that have an average systolic blood pressure (SBP) or diastolic blood pressure (DBP) ≥95th percentile for the corresponding child's age, sex, and height .t-test or Mann-Whitney test and Chi-Square test were applied, as appropriate. We first used least absolute shrinkage and selection operator (Lasso)-penalized logistic regression to identify significant predictors by presenting the significance with α = 0.05 with over 1,000 bootstrap iterations  with several packages including “Foreign,” “Hmisc,” “Glmnet,” “Caret,” “Rms,” and “pROC.” The bilateral P < 0.05 was recognized as statistically significant.The continuous variables of participants were presented as mean with standard deviation and interquartile range (IQR), whereas categorical data were revealed as absolute frequencies with percentages. For differences between groups of continuous and categorical variables, the two-sample erations . The odde manner . Along wN = 239,546) of students were randomly assigned to the derivation group and 30.1%  to the internal validation group. Of the development group, the average age of children and adolescents was 11.51 years (2.73) with a range from 6 to 18, and 11.51 years (2.74) with a range from 7 to 18 in the validation group. More than half of the children were boys . Of 342,736 participants, 287,256 (83.8%) and 55,480 (16.2%) children were identified as having non-HBP and HBP, respectively.As displayed in P < 0.001), such as age, gender, birth weight, and so on. We found no significant differences in one parental education level only. The demographic characteristics of the subjects are listed in There was a statistically significant difference among the majority of demographic variables in either the HBP group or non-HBP group , validation group: 16.16% ] judged by the 95th percentile for gender, age, and height. The mean SBP and DBP were 104.10 ± 10.17 mmHg and 64.95 ± 6.88 mmHg in total participants.The prevalence of HBP was 16.19% [development group: 16.20%  to present the diagnostic probability for helping guardians and physicians to identify HBP among children and adolescents in a user-friendly way.An available web-based nomogram calculator of HBP was built  in our study was higher than the reported incidence in the general youth population (4.0%) , which mIn this study, a feasible nomogram was derived from the ongoing study to visually predict the probability of HBP in children and adolescents for clinicians, policymakers, and even family members to enhance the screening and subsequent diagnosis.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This survey was approved by the Ethics and Human Subject Committee of Sun Yat-sen University. All participants' parents or legal guardian gave written informed consent which was collected according to the guidelines of the Declaration of Helsinki.J-HL conducted the database search, screened and extracted data for the manuscript, and had primary responsibility in writing this article. YZ, Y-CC, SH, S-XZ, NJ, and AK interpretation of data and drafted the initial manuscript and contributed to the discussion and editing. Y-JC supervised data collection and critically edited the final manuscript. All authors approved the final manuscript as submitted, agree to be accountable for all aspects of the work, and read and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (No. 81673193).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


U (103 ± 91 Bq kg−1), ATh (78 ± 19 Bq kg−1), and AK (1484 ± 334 Bq kg−1) in the monzogranite samples were higher than the recommended worldwide average. The change in radioactive-transporting minerals found inside granite faults caused the high amounts of radioactivity seen in the samples. Due to the monzogranites being applied in building materials, the radiological hazards were assessed by calculating risk indices such as annual effective dose (AED) and excess lifetime cancer risk (ELCR). The acceptable limit for the ELCR readings was surpassed. As a result, the investigated monzogranite samples are not suitable for use in infrastructure materials.The present work is concerned with assessing the cancer risk contributed by the studied granite types including valuable metals, such as Cu, Au, and Ba mineralization, as well as radioactive-bearing mineralization, such as monazite and zircon, in south Monqul at Wadi Makhrag El Ebel, north Eastern Desert, Egypt. The mineralization analyses illustrated that copper mineralization containing chrysocolla and tenorite minerals were restricted to the alteration zone, especially  in monzogranite. However, barite veinlets had an ENE–WSW trend, while gold mineralization was confined to quartz veins having NE–SW trends. Monazite and zircon are radioactive-bearing minerals recorded in monzogranite causing high radioactive zones in south Monqul. The radionuclide activity concentrations were detected in the studied monzogranites. The mean values of A These rocks carry radionuclides by their very nature. The most important sources of natural radioactivity in the environment are terrestrial and cosmic radiation. Ionizing radiation in naturally occurring radioactive elements (NORMs) makes the human body uneasy. External strategy exposure from the emitted gamma rays of terrestrial radionuclides such as exposure ,2,3. In recent years, numerous evaluations of high natural background zones around the world have gained increased attention for risk assessment due to whole-body exposures to long-term, low-level radiation of populations. Previous research has shown that high radiation levels are caused by the presence of radionuclides in high concentrations in granite rocks, sediments, and soils, among other things. Granite and sediments, among other geological items, serve an important role in building materials and other infrastructure applications, as well as accumulating and transporting radionuclides from one zone to another ,5. As a Furthermore, the general population’s radiological impact is a prominent research area in radioecology, where data provide crucial and necessary information in the monitoring environmental contamination, allowing the public to receive more appropriate and effective protective recommendations ,11. To pThe Eastern Desert (ED) massif of Egypt is considered a part of the Arabian–Nubian Shield (ANS) that was formed around the end of the Precambrian time. These rocks are well-exposed all over the Red Sea Hills in Egypt, Sudan, Ethiopia, Eritrea, Somalia, Saudi Arabia, Jordan, Oman, and Yemen  Figure a,b. TheyThe East African Orogen (EAO) hosts many sites of gold mineralization. Gold has a strong exploration program, especially in Egypt, Tanzania, Malawi, Eritrea, Ethiopia, Kenya, and Mozambique . Gold prIt has been recognized that granite, related to pegmatite and acidic volcanics, is a good potential source of uranium, thorium, and other rare metal mineralization ,32,33,34It is well known that porphyry copper mineralization is derived largely from the fractionation process associated with igneous rocks of calc-alkaline affinities ,56. Thes238U, 232Th, and 40K) contained in the granites. Various radioactive hazard factors are calculated, including radium equivalent activity (Raeq), absorbed dose rate (Dair), and annual effective dose (AED). In addition, the effective dose due to the organs (Do) and the excess lifetime cancer risk (ELCR) are calculated.The novelty of this study is that it evaluates the radioactive risk of using monzogranites in construction materials and infrastructure applications. As a result, the assessment is based on determining the public’s exposure to ionizing radiation emitted by radionuclides  occur as small, scattered masses in the northern part of the mapped area. They are characterized by low-to-moderate relief and medium-to-coarse grains, and they are fractured, weathered, and vary in colors from whitish-grey to a greenish-grey, as well as porphyritic in texture. They are composed mainly of plagioclase quartz and mafic minerals and are set in a relatively finer groundmass.Dokhan volcanics are mainly composed of stratified lava flows interbedded with subordinate pyroclastics. They consist of thick flows of andesite and, to a lesser extent, of basalt, and they range from buff to reddish colors of rhyolite, dacite, and rhyodacite. These rocks are hard, massive, fine-grained, and vary in color from whitish to reddish-pink, buff, pale red, and red, as well as dark green to grey and black. Pyroclastics are well-characterized by bands and include ash tuffs, lapilli tuffs, and lithic tuffs, as well as ignimbrite and imperial porphyries. The studied Dokhan volcanics were nonconformably followed upward by thick sequences of Hammamat sediments. Hammamat sediments are composed mainly of conglomerates, sandstone greywacke, and siltstone and are intruded by monzogranite a.The Dokhan volcanics in the studied area intruded on granitoids with sharp contact. The studied rocks were extruded by Dokhan volcanics with sharp contact and were intruded by younger granite.The younger granites are well-represented in the southern and northern parts of the studied area . They ha238U, 232Th, and 40K, as well as the mathematical formulas.Ground gamma ray spectrometric measurements were conducted on Monqul monzogranites using a Geophysica Brno GS-256 spectrometer. The instrument is manufactured by Radiation Solution Inc in Sugar City, ID, USA. It had a 0.35 L sodium iodide (NaI) thallium-activated detector. A measuring interval of 120 s was maintained in order to allow sufficient time to establish a stable spectrum. The ground spectrometry survey sites were selected to cover granitoid exposures in the study area. The radioelement measurements were obtained using a single measurement from each site for equivalent thorium , equivalent uranium , and potassium percent . The GS integrated a horizontal area of about 1 m diameter with nearly 25 cm of depth when in direct contact with the granitoid outcrops. The spectrometer was well-calibrated on artificial concrete pads at the Nuclear Materials Authority of Egypt before the field survey. The pads contain known concentrations of potassium, uranium, and thorium, as described by Grasty et al. . An erroIn this work, there was an identification of the important minerals in the mineralized zone to the south of the area at an old Roman mine (Wadi Makhrag El Ebel). The collected mineralized samples were separated by the operation of shaking tables using water and heavy liquid  to separate the light fractions from heavy minerals. Magnetite was separated from the heavy fraction using a hand magnet. The heavy mineral fractions were separated into magnetic and nonmagnetic fractions using a high-intensity, left-type magnetic separator  111-5). Then, the heavy minerals were easily picked as individual minerals with a binocular microscope.The separated minerals were analyzed using an environmental scanning electron microscope (ESEM) supported by an energy dispersive spectrometer (EDS) unit (model Philips XL 30 ESEM) at the laboratories of the ENMA. The analytical conditions were 25–30 Kv accelerating voltages, 1–2 mm beam diameters, and 60–120 s counting times. The minimum detection limit varied from 0.1 to 1 wt%. The precision was well below 1%, and the relative accuracy of the quantitative results was 2–10% for elements with Z > 9 (F) and 10–20% for light elements . Copper minerals were also confirmed with an X-ray diffraction (XRD) technique using American Society of Testing Materials (ASTM) cards no. (5-0661) and (5-0490) for tenorite and quartz, respectively.A Pearson correlation matrix (PCM), a principal component analysis (PCA), and a hierarchical cluster analysis are examples of the MSA used in this study (HCA). These analyses were used to highlight and reveal the relationships between radioactive variables, notably the impact of projected radiological danger factors on the distribution of radionuclide concentrations in beach sand. A PCA was used to discover how strong the connection between the radioactive variables was. PCA is a standard method for summarizing a collection of patterns among the analyzed variables of a dataset and for demonstrating their similarities and differences. For the PCA evaluation, the data were processed using varimax normalized technique. PCA has the advantage of compressing data by reducing the number of dimensions while retaining as much information as feasible. EMB-SPSS Version 21.0 was used for the statistical analysis of the data.The investigated mineralization associated with monzogranites included radioactive-bearing minerals such as monazite and zircon, as well as copper and barite. On the other hand, gold and pyrite were the most important minerals separated from the quartz samples of the old Roman mine in south Monqul at Wadi Makhrag El Ebel.Monazite is a light, rare, earth phosphate that was determined using an EDS  (to green c or stee and Ni) d. Additi and Ni)  and  .On the other hand, Botros and Wetait  stated tBarite is considered an important commercial mineral and is widely used as a pigment in the preparation of lithopone and as a filter for paper and cloth. Barite mud is poured into deep oil wells to buoy up drilling tools. It is the principal ore of barium, and it is used in paint and as radiation isolated material in the nuclear industry. The barite veins in the Monqul area cut through the younger granite (monzogranite) and range from minute veinlets to a size of 2 m in width. These veins are associated with the silicification of monzogranite in the form of secondary quartz, kaolinitization, and the sericitization of plagioclase.Barite minerals are fine-to-medium-grained; colorless, white, red or brown; and show a glassy luster e. BariteGold occurs as disseminated specks associated with sulphides that are altered by goethite [goethite . It is aPyrite is used as a source of sulphur for the manufacture of sulphuric acid. It is characterized by its yellow, brass-yellow, and reddish colors due to the effect of oxidation , rTh 50-174 78 ± 19), and rK 657-3098 (1484 ± 334) Bq kg−1, respectively. The natural radioactivity rates vary widely due to variations in the activity concentration values for 238U, 232Th, and 40K in geological formations, as well as their physical, chemical, and geochemical characteristics [238U, 232Th, and 40K were three, two, and four times greater than the worldwide data of 33, 45, and 412 Bq kg−1, respectively [238U, 232Th, and 40K in high concentrations in the monzogranite samples was due to the accumulation of radioactive minerals, including thorite and uranothorite, as well as zircon, monazite, allanite, clay, feldspar, etc [238U, 232Th, and 40K and are presented in The eristics . The achpar, etc . Descrip238U, 232Th, and 40K in the monzogranite samples. The asymmetry distribution and the peakness of probability were controlled by the skewness and the kurtosis, respectively. It can be clarified in 238U, 232Th, and 40K were positive. Therefore, the natures of 238U, 232Th, and 40K were asymmetric in distribution. Moreover, the positive values of the kurtosis factor illustrated the peak probability distribution. The variation coefficient  values were high for 238U (88%) and moderate for 232Th (24%) and 40K (22%). The variation was explained by the monzogranite samples containing radioactive minerals of the radioactive elements. The frequency distributions of the 238U, 232Th, and 40K activity concentrations of the monzogranite samples are shown in It was clarified that the standard deviation (SD) values of the radionuclide concentrations were lower than their mean values. This demonstrated a significant amount of symmetry for 238U, 232Th, and 40K distribution was estimated using IBM-SPSS version 21.0  and applied based on the Kolmogorov–Smirnov (KS) test and presented in A normal distribution was achieved for the thorium activity concentration, where the distribution of uranium and potassium was characterized by multimodality. The modality feature was due to the complexity of the heavy radioactive minerals in the monzogranite samples. The normality analysis of p–value of thorium concentration as greater than 5%, revealing that the 232Th distribution was normal. The activity concentrations of 238U, 232Th, and 40K in the studied monzogranites were compared with various previous investigations in other countries (see The KS test depicted the ries see .eq) values alternated from 177 to 971 Bq kg−1 with a mean value of 330 Bq kg−1, which was lower than the permissible limit of 370 Bq kg−1 [eq values were recorded in 19% of the monzogranite samples. The probability of the application of monzogranites in construction materials is governed by the effectiveness of the emitted gamma radiation. Therefore, sundry radiological variables were estimated and are presented in  Bq kg−1 . This reair) and the annual effective dose (AEDout and AEDin). The Dair is predicated by the interaction of the emitted gamma photon energy with the human body 1 m above the ground. air, which ranged between 84 and 452 nGy/h with a mean value of 156 nGy/h, which was less than the UNSCEAR recommended value (59 nGy/h) [out and AEDin were 0.19 and 0.77 mSv/y, respectively, which were higher than the permissible levels of 0.07 mSv/y (outdoor) and 0.41 (indoor) mSv/y [out and AEDin values exceeded the permissible level, where the AEDout min–max was 0.10–0.55 mSv/y and the AEDin min–max was 0.41–2.2 mSv/y. The effectiveness of the released gamma photon energy on the public is described by the absorbed dose rate (D9 nGy/h) . Thus, tr) mSv/y . This imt was observed to be expanded from 1.79 × 10−6 to 9.69 × 10−6 with a mean value of 3.35 × 10−6. The mean value was much higher than the permissible limit of 0.29 × 10−6 [Due to exposure to the released gamma radiation from the monzogranites, the ELCR9 × 10−6 . Low dos9 × 10−6 . It also9 × 10−6 .o computes how much radiation is retained in different human organs over a year of exposure, as shown in o mean values for all the examined organs, ranging from 0.35 mSv/y (liver) to 0.63 mSv/y (testes), while the Do were predicted with low values for outdoor exposure to gamma radiation and varied from 0.09 mSv/y (liver) to 0.16 mSv/y (testes). The registered results of Do illustrated that the mean values were lower than the permissible threshold dose of 1.0 mSv/y. The liver contributed the lowest dose due to the rate of absorption of nutrients from the diet [The Dthe diet . This in238U, 232Th, and 40K activity concentrations and radiological danger indicators in the monzogranite samples. The PC analysis describes the correlation strength of linear relations, which it divides into four groups: weak (0.3–0.49), moderate (0.5–0.69), strong (0.7–0.9), and very strong (>0.9) correlations [238U with 232Th (R2 = 0.34) and a moderate correlation with 40K (R2 = 0.54). This was explained by the investigated monzogranites enriched with uranium and potassium minerals. It can be observed in 238U and 40K with the radiological variables were very strong and strong, respectively. Therefore, uranium and potassium were considered the main contributors to adverse health effects linked to the released gamma radiation from monzogranite. Pearson correlation (PC) was used in this investigation to reveal strong links and linear relationships between elations . The cor238U, 40K, and the radiological parameters, while Cluster II contains the rest of the radiological parameters and 40K. The HCA defined the radioactivity of granite as being linked to the activity of radioactive concentrations, especially radium and thorium. The HCA data of the Pearson correlation were observed to correspond.Due to a large number of parameters, correlation analysis data were deemed difficult. Nevertheless, hierarchical cluster analysis was used to uncover and expose the correlations between the radioactive properties informally (HCA). HCA is a data classification system that identifies real-world data types using multivariate algorithms. Objects are grouped in such a way that they all belong to the same category. The data with the highest level of similarity are grouped first, followed by the data with the next best fit in hierarchical clustering. This process is repeated until all of the data have been classified. The degrees of similarity between the data are used to generate a dendrogram. A similarity of 100 percent means that the clusters are separated by zero distance from comparable sample measures, whereas a similarity of 0 percent suggests that the clustering areas are as dissimilar as the least similar location. In this work, Ward’s technique was employed to perform cluster analysis. Ward’s method connects radioactive activity concentrations with radiological variables to calculate their Euclidean distances . Figure 238U and 40K were the most common gamma-emitting sources in all the monzogranites in the study area. Furthermore, as previously stated, the mineral analysis revealed the presence of radioactive-carrying minerals in the studied monzogranites. An amount of 86.08% of the variation can be explained. As a result, 238U and 40K were the predominant natural radioactive contributors to the monzogranite in the study area. 232Th, on the other hand, displayed a negative loading in the PC2 load. The amount of variance that could be explained was 8.24%. The loading contrast that thorium saw did not affect the exposure phase. According to the PC analysis, the overall explained variance in the radioactive data was 94.32 percent; as a result, the data appeared to be good [A PCA was utilized to find the matrix correlations between multiple components using varimax rotations in this study.  be good ,86. −1, respectively, which were greater than the allowed global values of 33, 45, and 412 Bq kg−1. The radium equivalent content, the absorbed dose rate, the annual effective dose, and many other radiological hazard factors were evaluated. Furthermore, the mean values of lifetime cancer risk (3.35 × 10−6) were calculated. The radioactivity of monzogranites was mostly contributed to and dominated by 238U and 40K according to multivariate statistical techniques. Zircon, monazite, thorite, uranothorite, and other radioactive minerals were found in the granites. As a result, the Monqul granites are one of Egypt’s highest U favorability areas, and employing the granites in building materials is a public health risk.The monzogranite of Wadi Makhrag El Ebel was influenced by substantial hydrothermal alteration with copper minerals (chrysocolla and tenorite) and was restricted to argillic, phyllic, and propylitic alterations. The NE–SW and ENE–WSW patterns were seen in gold-bearing quartz and barite veins, respectively. The monzogranites were rich in heavy, radioactive-bearing minerals, particularly monazite and zircon, which were responsible for the increased radioactivity in the south Monqul area. The acquired results revealed that the activity concentration means of 238U, 232Th, and 40K were 103 ± 91, 78 ± 19, and 1484 ± 334 Bq kg


Laminin, a non-collagenous glycoprotein present in the brain extracellular matrix, helps to maintain blood–brain barrier (BBB) integrity and regulation. Neuroinflammation can compromise laminin structure and function, increasing BBB permeability. The aim of this paper is to determine if neuroinflammation-induced laminin functional changes may serve as a potential biomarker of alterations in the BBB. The 38 publications included evaluated neuroinflammation, BBB disruption, and laminin, and were assessed for quality and risk of bias . We found that laminin may be a good indicator of BBB overall structural integrity, although changes in expression are dependent on the pathologic or experimental model used. In ischemic stroke, permanent vascular damage correlates with increased laminin expression (β and γ subunits), while transient damage correlates with reduced laminin expression (α subunits). Laminin was reduced in traumatic brain injury and cerebral hemorrhage studies but increased in multiple sclerosis and status epilepticus studies. Despite these observations, there is limited knowledge about the role played by different subunits or isoforms (such as 411 or 511) of laminin in maintaining structural architecture of the BBB under neuroinflammation. Further studies may clarify this aspect and the possibility of using laminin as a biomarker in different pathologies, which have alterations in BBB function in common. Neuroinflammation, defined as an inflammatory response within the brain or spinal cord , is a prNeuroinflammation can appear in both acute and chronic central nervous system (CNS) responses . Acute nBBB alterations are a common feature of CNS-related pathologies or injuries, mainly associated with a neuroinflammatory process leading to disruptive and nondisruptive changes. Disruptive alterations produce visible changes in the anatomy of the BBB, such as glia limitans collapse, astrocytopathy, glycocalyx degradation, and an increase in vesicular traffic . In contFurthermore, a persistent neuroinflammatory state is associated with alterations in the expression of extracellular matrix (ECM) receptors and ligands, basal lamina proteins, membrane receptors, and tight junctions (TJ) of endothelial cells ,14,15. CLaminins are heterotrimeric glycoproteins that constitute the major non-collagenous component of basement membranes (BM) ,19,20. SThe present systematic review collects, describes, and evaluates published evidence regarding the effects of neuroinflammation on laminin and the BBB in different animal models. This review is driven by our interest to evaluate laminin as a potential biomarker and is focused on analyzing functional changes in laminin induced by neuroinflammation, which could serve as a tool to assess BBB alterations.https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020212547 accessed on 13 June 2022), and it was carried out adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for reporting [The protocol for this systematic review was registered on 16 November 2020, in PROSPERO as PROSPERO 2020 CRD42020212547 . These databases were explored without date limits for articles published up to 16 September 2020. We used a combination of the following key search criteria (SC):We included experimental studies written in English, which were fully available (full text), and performed in vivo . No in vitro, in silico, or human studies were included. Moreover, literature reviews, conference abstracts, editorials, and theses were excluded. We considered the following interventions in the CNS to be included in the review: animal models of neurodegenerative diseases with neuroinflammatory effects, models of stroke, injections of proinflammatory substances such as lipopolysaccharide (LPS), or infections induced by pathogens; all of these, should have reported damage to the BBB due to neuroinflammation and measured changes in laminin. Therefore, studies included in this systematic review evaluated neuroinflammation, BBB disruption, and laminin. Articles were excluded if the interventions were performed only on one or two of the aforementioned criteria. Lastly, we excluded studies without a control group or any comparative criteria see .All studies that met the SC were obtained from the three databases explored. Duplicated or triplicated articles were excluded, and the remaining papers had the titles and abstracts screened in order to evaluate if eligibility criteria were met. Two different authors independently evaluated the titles and abstracts of all the selected papers and compared results. A third author was consulted if a discrepancy or doubt was present. Articles which met eligibility criteria were reviewed in full text and evaluated for biases using the Systematic Review Center for Laboratory Animal Experimentation (SYRCLE) risk of bias (RoB) tool, and for quality assessment using the Collaborative Approach to Meta Analyses and Review of Animal Data from Experimental Studies (CAMARADES) format, for in vivo studies, with slight modifications. The review and study selection processes are illustrated in a flow diagram , showingThe data were extracted according to (a) the type of experimental model, including neurological, neurodegenerative, cerebrovascular diseases, pharmacological interventions, physical interventions, or any other type of pathological model which induced brain parenchymal disorders, (b) alterations in BBB, (c) laminin measurements, (d) measurements of neuroinflammation markers, (e) time of the intervention and the method of neuroinflammation induction, (f) relationship among neuroinflammatory markers, BBB alterations, and changes in laminin, and (g) general aspects of experimental design .The in vivo results were organized according to the different experimental models, and evidence regarding laminin changes in the BBB due to neuroinflammation was analyzed.www.camarades.info; www.dcn.ed.ac.uk/camarades/research.html#protocols accessed on 10 December 2020). Both the RoB and the quality assessment were performed by two different authors independently for each paper. In case of doubt or disagreement, a third author was consulted.We used the SYRCLE RoB tool as described by Hooijmans et al.  to estimA total of 180 articles were screened for the inclusion criteria. The search was performed in the scientific databases PubMed, Scopus, and Web of Science (WoS). After the abstract and title screening phase, 76 studies were eligible for full-text analysis. Finally, after the full-text screening, 38 articles were included for qualitative analysis . These 3+/− knockout model [The distribution of the studies, according to the pathological model, was as follows: eight studies on cerebral ischemia, mostly induced by cerebral artery occlusion ,37,38,39ut model . The thr+/− mice, two in matrix metallopeptidase 9 (MMP-9) knockout mice, one in MMP-3 knockout mice, one in cyclooxygenase-2 (COX-2) knockout mice, one in agrin knockout mice, one in NG2 knockout mice, and one in F7 mice. According to sex distribution, 16 studies used male rats, but only one used female rats; 10 studies used male mice, three used female mice, two mouse studies were performed in both sexes, and six failed to report the sex of the animals.A diverse range of animal models were used in the included studies. Fourteen studies were conducted in Sprague-Dawley rats, three in Wistar rats, one in Fisher F344 rats, one in Dark Agouti rats, 10 in C57BL/6J mice, one in CD1 mice, two in BALB/c mice, one in 3xTg mice , one in EFAD mice (which express human apolipoproteins E (APOE) 3 or APOE4, and overproduce human Aβ via the expression of five familial AD (5xFAD) mutations), one in the β4 integrin flox/flox transgenic mice, one in C57BL/10 RIII H2 mice, one in Swiss Webster mice, one in PDGFRβThe assessment of study quality and RoB for all the included studies is presented in n number) to obtain statistical power . Almost all (97%) of the included articles mentioned that their experiments had ethical approval by an institutional animal care and use committee (IACUC), while only 18% did not report any information about conflicts of interest. Furthermore, 29% of experiments had randomization at any level, but only 13% of studies reported randomization to treatment or control, while 42% of experiments mentioned blinding at any level. Lastly, 61% of the studies included temperature control statements, and all the articles were published in a peer-reviewed journal.Approximately 97% of our included studies described statistical analyses, but only 53% of the studies had a large enough sample size  or damaged enough to allow bleeding (hemorrhagic stroke). During ischemic stroke (the most common type of stroke representing 85% of cases), the stationary blood promotes an inflammatory response, involving the activation of intravascular leukocytes, the appearance of oxidative stress and excitotoxicity, and the release of proinflammatory cytokines, which have the potential to increase cellular damage . Stroke Eight studies conducted on different stroke or ischemia animal models met the inclusion criteria and were incorporated in this systematic review. Two articles used a permanent middle cerebral artery occlusion (MCAO) model  in the middle cerebral artery. The bilateral carotid experiment was also the one with the shortest blood interruption time (15 min), while the other studies had interruption times of 30 min (two studies), 60 min, and 90 min. Similarly, only one study used a chronic hypoxia model, placing mice in a chamber with 8% oxygen for 14 days, followed by 7 or 14 days at normal oxygen levels. Although low, this level of oxygen is not enough to cause permanent pathological changes in the animals. The study by McColl and colleagues  reportedThe paragraphs below describe the changes in laminin, together with relevant inflammatory and BBB markers, present in studies involving stroke with a transient occlusion. Laminin expression and staining were studied in the brains of animals that had either transient blood flow interruption or hypoxia. Results presented here refer to the ipsilateral or affected brain region. No changes in laminin were observed at 4, 8, or 12 h after transient MCAO. This was true even when the animals with transient MCAO were challenged with IL-1β . In addiChanges in laminin expression were related to changes in other proteins from the ECM or from NVU cells. Between 16 and 48 h after transient MCAO, laminin decrease affected other proteins of the basal lamina such as β1-integrin, β-DG, collagen-IV, and agrin. This decrease in laminin corresponded with an increased expression of matrix metalloproteinases (MMPs), cytokines, and proinflammatory chemokines in the injured regions ,37. At 1MMP-2 and MMP-9 are considered molecular biomarkers of neuroinflammation in stroke studies. These proteins showed an increased expression and proteolytic activity between 8 h and 7 days, for transient MCAO, and between 7 days and 14 days, for chronic hypoxia ,37,39. βIntracerebral hemorrhage (ICH) accounts for 10–15% of all strokes and is associated with a high incidence in elderly population . ICH canFive studies conducted on different cerebral hemorrhage animal models met the inclusion criteria and were incorporated in this systematic review. Three studies used a subarachnoid hemorrhage (SAH) model ,42,44. OThe paragraphs below describe the changes in laminin, together with relevant inflammatory and BBB markers, present in studies involving cerebral hemorrhage. Two studies explored the outcomes and changes of BBB permeability and laminin expression between 24 and 72 h post SAH ,44. It w+) from days 2 to 14 post ICH, due to the damage in the BBB [We also reviewed another study, which induced ICH with injected collagenase type VII-S into the striatum . In this the BBB .All these previous results showed that laminin is decreased in different cerebral hemorrhage animal models and at different timepoints, ranging from 24 h to 7 days. These laminin changes parallel a reduction in endothelial TJ proteins, pericyte function, and increased BBB permeability, with an increase in microglial and astrocytic activation.Traumatic brain injury (TBI) is a closed head injury which causes different degrees of damage to the brain, including inflammation and neuronal death in the injured areas. However, this focal inflammation can progress to secondary brain injury trough the exacerbation of brain edema and neuronal death, disseminating to other brain areas and causing complications that range from hyperthermia to brain death . LamininFive studies conducted on different traumatic brain injury (TBI) animal models met the inclusion criteria and were incorporated in this review. Two studies used PCI3000 PinPoint Precision equipment to produce a controlled cortical impact ,49, one The three studies of controlled cortical impact used either a PCI3000 PinPoint Precision Cortical Impactor in BALB/c mice ,49 or a Three studies conducted on different cerebral ischemia and AD animal models met the inclusion criteria and were incorporated in the present review. One study induced stroke by permanent MCAO in 3xTg mice , and theIn the 3xTg mice model, an increase in the expression of laminin and collagen IV in the neocortex, due to ischemic neuroinflammation and AD induction, was reported. This increase was observed 24 h after the permanent MCAO. Additionally, there was an increase in the number of activated microglia in the ischemic area. In the two experiments with Wistar rats ,51, therAPP, PSEN1, and PSEN2 [AD is a neurodegenerative disorder, which represents the most common cause of dementia worldwide. Most AD cases develop sporadically, associated with risk factors such as aging, the presence of ApoE allele ε4, diabetes, and metabolic syndrome, among others . Howevernd PSEN2 . The chand PSEN2 . Lamininnd PSEN2 , and altnd PSEN2 .Three studies conducted on different AD or aging animal models met the inclusion criteria and were incorporated in this systematic review. One study used 3 week old, 2 month old, and 18 month old Wistar rats , and injected IL-1β or TNF-α to induce neuroinflammation . A seconRegarding laminin, it was found that its expression was reduced in two of the studies associated with AD ,55, whilMicroinjections of IL-1β or TNF-α were applied in 3 week old juvenile and 18 month old aged rats, causing an increase in leucocyte recruitment and BBB breakdown . ImportaMS is a chronic CNS autoimmune disease, characterized by demyelination, neuro-axonal damage, inflammation, and reactive gliosis . The mosMycobacterium tuberculosis, and the mice received an i.p. injection of pertussis toxin. The clinical EAE status reached onset at days 12–14 after immunization, with clinical severity signs around 18–21 days (acute phase) and improvement without complete recovery at 32–35 days (chronic phase) [Two studies conducted in animal models of MS met the inclusion criteria and were incorporated in this systematic review. Both studies induced a model of MS onto 8 to 10 week old female C57BL/6 mice. Wesler’s study also used β4 integrin flox/flox transgenic mice), via immunization with MOG33–35 peptide ,57. The c phase) , NG2 KO + inflammatory leukocytes, as well as increased expression of the microglial/macrophage marker Mac-1 associated with leukocyte infiltration in the EAE model, was found. Moreover, the lack of endothelial β4 integrin also impaired the integrity of the BBB, which is represented by more fibrinogen leaky vessels and decreased expression of the TJ proteins, claudin-5, and ZO-1 during the acute stage of EAE.In the study of Welser et al. , the lam+ pericytes was found compared with wildtype mice.In the study by Girolamo et al. , an incrLastly, in EAE mice, the expression of several factors from the NVU was measured. For example, VEGF was expressed at the end-feet of perivascular astrocytes measured by immunostaining colocalization with GFAP. Fibroblast growth factor 2 (FGF2) and its receptor FGFR1 were colocalized on the endothelial cells, and PDGF-AA/PDGFRα and PDGF-AA/PDGFRβ were also colocalized on the endothelial cells and the astrocyte-like processes .These results indicated that laminin expression was increased in both studies associated with MS, although no additional information was given regarding specific laminin isoforms or subunits. In addition, β4 integrin, a laminin receptor, also showed increased expression. A lack of this receptor was accompanied by worsened clinical EAE outcome and augmented neuroinflammation. Moreover, the presence of NG2 seems to be important for laminin expression, as knockout animals for this marker showed reduced laminin expression, even under neuroinflammatory conditions.Epilepsy represents a group of neurological disorders characterized by recurrent seizures that can vary from brief absence episodes to continuous tonic–clonic motor activity. The seizures are a product of abnormal electrical activity of the brain, frequently caused by either excessive excitatory activity (glutamate) or reduced inhibitory control (GABA) . ContinuThree studies conducted on different SE animal models met the inclusion criteria and were incorporated in the review. One study induced SE in male 7 week old Sprague-Dawley rats, pretreated with an i.p. injection of LiCl (127 mg/kg i.p.) 24 h before receiving pilocarpine (30 mg/kg) . A seconIn the reviewed studies, laminin expression was significantly upregulated in the vessels recovered from 3 to 4 days post induction of SE in the striatum, hippocampus, and piriform cortex. Laminin expression returned to non-SE levels 1 to 4 weeks after SE ,59,60. FAstrocytes also presented changes after SE in the hippocampus and piriform cortex ,59. In tLaminin expression was found to be increased in all the studies associated with animal models of SE, but no information was given regarding the specificity of the studied isoforms or subunits. Furthermore, laminin returned to basal levels 1 to 4 weeks after the SE, which suggests a recovery in the ECM function. Increased microglia and BBB permeability were observed as a consequence of SE.To induce neurotoxic effects, MDMA, METH, and 3-chloro-1,2-propanediol (3-MCPD) were used in different animal models, leading to neuroinflammatory hallmarks. MDMA is recognized for causing microglial activation, IL-1 changes, and BBB dysfunction ,91,92. LFive studies, conducted on different pharmacological and toxicological interventions, which induced neuroinflammation and barrier breakdown in specific animal models, met the inclusion criteria and were incorporated in this systematic review. The first study used wildtype C57Bl/10 RIII H2 male mice , a seconIn a study using male Dark Agouti rats, it was found that the expression of laminin and collagen-IV decreased from 1 h to 6 h after MDMA induction (10 mg/kg) . In addiIn contrast, in a study that used male Fisher F344 rats, after 2 days of 3-MCPD administration (140 mg/kg), laminin immunoreactivity increased and became denser around vascular endothelial cells . GFAP imThe neurodegenerative disorder glutaric acidemia type I (GA-I) is characterized by striatal and cortical degeneration, BBB disruption, and gliosis . This diEscherichia coli serotype) on C57Bl/10 wildtype and MMP-3 KO mice [In another study, neuroinflammation was established with LPS  which significantly reduced the number of pericytes. This animal model showed a potent inflammatory response as recorded through an increase in the levels of the following agents: IL-1β, IL-6, TNF-α, CCL2, and ICAM-1. These alterations impacted the animal’s BBB structure, which presented a decrease in laminin levels and collagen type IV. In addition, BBB permeability was compromised with a reduction in the expression of the TJ proteins claudin-5, occludin and ZO-1, in PDGFRβ+/− mice and F7 mutants. Lastly, in vivo leakage of TMR-dextran was present on all PDGFRβ+/− mice [Only one study in this category met the inclusion criteria for this systematic review . Pericyt+/− mice .Only one study in this category met the inclusion criteria for this systematic review . This moIn this systematic review, we examined the relationship among neuroinflammation, changes in laminin, and BBB disruption. We found that changes in laminin are related to the specific conditions of the experimental model used in the included studies. Moreover, laminin changes are determined by the presence or absence of permanent damage, as well as by the acute or chronic nature of the induced insult .Stroke is a useful experimental model to evaluate changes in BBB and laminin due not only to the vascular and ECM damage but also to the strong ischemic and postischemic neuroinflammatory activity this model exhibits ,100. In Time is an essential element in experimental stroke models and in clinical practice, as longer occlusion times represent a greater damage on cells and tissues, together with poor prognosis and higher mortality. In animals which had permanent occlusion, laminin was found to be increased as early as 6 to 12 h, and remained increased up to 7 days after the injury ,34. It iStroke, as a model of BBB alterations and neuroinflammation, showed overall consistency in its results. All examined studies showed a significant neuroinflammatory response and subsequent laminin alterations, most of them with reduced expression levels after transient ischemia or hypoxia. This phenomenon may be explained as a result of the physical and functional changes in the brain after an ischemic event . The sevCOX-2 seems to play a role on laminin expression in permanent MCAO. COX-2 is primarily an inducible enzyme that promotes inflammation, although it is also constitutively expressed (in the absence of inflammation) in several organs including the kidneys, gastrointestinal tract, brain, and thymus . In addiICH is a major health problem resulting from the rupture of blood vessels in the brain, and it is related to other factors such as hypertension-related degenerative changes or cerebral amyloid angiopathy . PreviouTBI is an important cause of morbidity and mortality worldwide. The brain damage varies amply depending on the type and intensity of the traumatic force, ranging from localized small injuries to critical diffuse lesions leading to death . As TBI Previous studies have shown that endothelial cell dysfunction is an important risk factor for the deposition of Aβ peptides and the development of AD ,120. In Different studies have shown a chronic inflammatory response during AD development, due to the activation of astrocytes, microglia, and the release of numerous cytokines including IL-1β and IL-6, which in turn contribute to increased Aβ production and tau hyperphosphorylation ,123,124.EAE is the most commonly used experimental model for the study of MS ,56,57. PIn MS, leukocytes infiltrating into the cerebral parenchyma must first overcome the endothelial barrier and next cross the molecular layer of the endothelial BM, which allows them to reach the perivascular space. Finally, they must overcome the physical barrier given by the glial BM at the astrocyte’s end-feet ,142,143.SE is a life-threatening condition, which causes significant morbidity and mortality. SE develops when a seizure episode fails to spontaneously resolve, persistently overactivating brain cellular networks, and leading to neuronal death due to oxidative stress, excitotoxicity, and inflammation ,151. In An increased permeability of the BBB in SE facilitates the leakage of albumin from the blood into the brain tissue, stimulating neuroinflammation due to excessive activation of microglia and astrocytes ,158,159.This systematic review included five studies with different pharmacological and toxicological interventions that induced neuroinflammation ,63,64,65The effects on laminin of several pharmacological and toxicological agents were examined in our systematic review. In one of the included studies, it was reported that a single dose of MDMA reduced the expression of collagen IV and laminin, together with increased activity of MMP-3 and MMP-9 . AlthougLPS has also been used as a model of neuroinflammation based on different protocols, by single or multiple injections . It is kAfter administration of the food contaminant 3-chloropropanediol, a progressive increase in laminin immunoreactivity around endothelial vessels, accompanied by rapid loss of GFAP immunoreactivity in astrocytes, was observed ,175. TheNewborn rats that received an intracisternal administration of GA, developed striatal BBB leakage, NVU alterations, and reduction in the laminin associated with blood vessels . IncreasT. gondii has been recognized as an inductor of an impaired inflammatory response in the brain [T. gondii inoculation, an interaction between leukocytes and brain endothelial cells is evidenced [T. gondii infection in the cerebral cortex and hippocampus [T. gondii infection as a model of neuroinflammation was included, it seems the presence of this parasite in the brain may decrease laminin. More studies are needed to confirm the relationship between T. gondii and laminin in the brain and the influence on BBB function due to this infection.Infection with the intracellular parasite he brain . Followividenced . This invidenced ,184. Morpocampus . Therefopocampus . Angiogepocampus . In factpocampus . AltogetThe BBB breakdown can facilitate the entry of several pathogens, including HIV-1, into the CNS. The injection of the HIV-1 envelope glycoprotein Gp120 in the caudate-putamen of rats increased MMP-2 and MMP-9 levels and their gelatinolytic activity, leading to sustained vascular permeability . Gp120 a+/− mice resulted in severe neurovascular compromise, with reduced expression of TJ and BM proteins, including laminin. Laminin is of paramount importance for BBB, as mice knockout for laminin exhibited BBB disruption and increased permeability, similar to what occurs in increased laminin degradation [Our systematic review included one study that examined the critical role pericytes play in maintaining BBB barrier integrity during aging. In that study, it was found that deficient PDGFRβ signaling resulted in pericyte degeneration in the brain, leading to BBB breakdown and diminished brain microcirculation . This stradation . Furtherradation . These cradation . HoweverIn animal models of POCD, the surgical intervention seems to affect the MMP/TIMP balance in the hippocampus, suggesting BBB dysfunction due to surgical trauma ,195,196.The BBB integrity depends on numerous cellular and molecular factors, particularly astrocytes, brain endothelial cells, and pericytes. Laminin is a critical component for the stability of both ECM and BBB. Therefore, alterations in laminin expression or function can have a direct impact on the BBB. The results presented in this systematic review show changes in laminin due to various pathological models, which have BBB alterations and neuroinflammation in common. Specific variations in laminin, including changes in the three main subunits or in the different configurations, can be explored in diverse pathologies known to compromise the BBB. For instance, changes in laminin (or one of its subunits) at different timepoints may indicate if a pathological process is in a damaging or recovery phase, which may be of use for clinicians, particularly for diseases such as stroke or MS. In addition, laminin may also serve as an indicator of therapeutic success, as it may represent the functionality of the BBB after surgical or pharmacological treatment. Thus, we suggest laminin as a possible biomarker candidate for BBB changes in a diverse range of pathological conditions.There is limited knowledge about the role that the different isoforms of laminin play in maintaining the structural architecture of the BBB or its function as an immune cell mediator. However, certain studies highlighted the role of laminin-511 (α5-β1-γ1) and laminin-411 (α4-β1-γ1), which are differentially expressed in BBB under inflammatory conditions. In this aspect, a higher expression of laminin-511 has been reported to improve the BBB integrity by stabilizing the TJ and reducing leukocyte extravasation under neuroinflammatory conditions.When neuroinflammation is quickly established, the decrease in laminin expression is associated with a disruption of the BBB due to the degradation of TJ induced by the immunological activation of astrocytes, pericytes and microglia. However, in the case of a progressive neuroinflammatory process, laminin expression is increased over a time course. Likewise, in ischemic stroke, permanent vascular damage seems to correlate with increased laminin expression, while transient damage seems to correlate with reduced laminin expression. In addition, laminin was decreased in all the animal models of cerebral hemorrhage and in TBI.In different disease models it was observed that the communication between astrocytes and vascular endothelial cells could be altered, leading to an increased BBB permeability, which in turn is associated with an increased laminin expression. Once astrocytes and pericytes detect these changes in laminin expression, they can promote immune cell infiltration and BBB damage in a context of neuroinflammatory progression, which also induces a decrease in laminin expression and BBB disruption. Laminin seems to be closely related to the regulation and polarization of astrocytes, as they act as anchors for astrocytic end-feet and promote the expression of AQP4. Is not clear if these changes in laminin affect the function of the glymphatic system. Furthermore, laminin disruption may be an important precursor of the reactive gliosis seen in many pathological processes. These immunological changes, in turn, produce an increase in MMPs that will trigger a decrease in the expression of laminin, leading to TJ damage and BBB disruption. This can be evidenced both in a direct induction of neuroinflammation and in disease models.The reviewed studies showed that laminin may be a good indicator of the overall structural integrity of the BBB under neuroinflammation. This suggests that laminin expression could serve as a possible biomarker of BBB alterations.


Helicobacter pylori infection and tumor predisposition and/or immunodeficiency appears to contribute significantly to the risk of developing gastric carcinoma at a young age. In adolescents, these tumors are often diagnosed at an advanced stage of disease, which is associated with a poor prognosis and emphasizes the need for the development of new therapeutic strategies, such as molecular-targeted treatments.While gastric carcinoma is prevalent in adults and is one of the most common causes of cancer-related death, the disease is exceptionally rare in children. The aim of this analysis was to present peculiarities of gastric carcinoma in children and adolescents. A combination of CDH1 mutations and another was a patient with Peutz–Jeghers syndrome. Three patients were found to have distinctly decreased immunoglobulin concentrations. All four patients in whom complete resection was achieved remained in remission. Three of the other four patients died despite multimodal therapy. (4) Conclusions: A combination of Helicobacter pylori infection and tumor predisposition and/or immunodeficiency appears to promote the development of gastric carcinoma in childhood. While patients with localized disease stages have a good chance of achieving durable remission through complete resection, patients with stage IV carcinomas face a dismal prognosis, highlighting the need to develop new strategies such as mutation-guided treatments.(1) Background: Gastric carcinoma is an exceptionally rare tumor in childhood. Little is known about the etiology, epidemiology, and clinical features of pediatric gastric carcinomas. This analysis aimed to fill this gap by increasing knowledge about the occurrence of gastric carcinoma in childhood. (2) Material and methods: Data from gastric carcinoma cases diagnosed between 2000 and 2017/2018 were retrieved from the Surveillance, Epidemiology, and End Results Program (SEER) and the German Center for Cancer Registry Data. Data from patients <20 years of age were analyzed for patient- and tumor-related characteristics. In addition, clinical data from patients with gastric carcinoma registered in the German Registry for Rare Pediatric Tumors (STEP) were analyzed for diagnostics, therapy, and outcome. (3) Results: Ninety-one cases of gastric carcinoma, mainly in adolescents, were identified in the epidemiologic cancer registries. Among patients with recorded staging data, advanced tumor stages were common (66.7%). Within the follow-up period covered, 63.7% of patients with clinical follow-up data died. Eight pediatric patients with gastric carcinoma were enrolled in the STEP registry, among whom two were patients with hereditary  Helicobacter pylori (HP), exogenous factors such as diet, tobacco smoking, and salt consumption, and genetic predisposition . Aln = 31; SEER: n = 60). The characteristics of these patients are shown in n = 19), body (n = 12), and antrum (n = 13) of the stomach and only rarely in the curvature region. In terms of TNM staging, the T stage was relatively evenly distributed between T1 and T4. Lymph node metastases were detected in 51.2% of cases. Distant metastases were found in 61.1% of cases. Accordingly, advanced disease stages, especially stage IV, were common (66.7%). Tumors were also frequently poorly differentiated on pathologic examination. Most gastric carcinomas were classified as high-grade tumors (86.9%). While most of these observations were identical for ZfKD and SEER, certain differences were noted. In the SEER cases, more tumors were categorized as overlapping lesions, and we found a higher frequency of distant metastases and stage IV cancers . The ZfKD also had a slightly higher proportion of patients younger than 15 years of age . We identified 91 cases of gastric carcinoma in children and adolescents in the epidemiologic cancer registries , stool irregularity (n = 2), and anemia (n = 2). These symptoms were usually present between one and three months prior to diagnosis. The initial clinical diagnosis was made by gastroscopy (n = 7) or imaging (n = 1) and subsequently confirmed by histopathological analysis. All carcinomas were classified as adenocarcinomas, with signet ring cell carcinoma being the most common subtype (n = 3). Based on the Laurén classification, diffuse type (n = 3) and intestinal type (n = 2) carcinomas were present, as well as mixed type tumors (n = 3) [n = 2) and hyperplastic polyps with intestinal metaplasia (n = 1). One of the two patients with hereditary diffuse gastric cancer (HDGC) was found to have moderate foveolar hyperplasia consistent with in situ carcinoma. EBV was not detected in any tissue sample. Overexpression of HER2/neu and microsatellite instability were not found in all samples examined . Peutz–Jeghers syndrome was detected in one patient during a subsequent diagnostic workup after the diagnosis of gastric carcinoma. Two patients were diagnosed with a germline CDH1 mutation causing HDGC. In one of these patients, gastric carcinoma was detected at an early stage during a cancer screening gastroscopy. Immunoglobulin concentrations of IgA and IgG were significantly decreased at diagnosis in three patients. Two of these patients were diagnosed with type A gastritis. One patient already had a known autosomal recessive agammaglobulinemia. On histopathologic examination, seven patients showed evidence of chronic gastritis. Infection with HP was detected in gastric tissue samples in six patients. Advanced disease stages were frequently observed at diagnosis (5× stage IV). The peritoneum was the most common site of metastases. All patients in whom complete resection (CR) was achieved by gastrectomy were still in remission at their last follow-up (n = 4). In the other four cases, resection of the primary tumor was not reasonably feasible due to advanced metastatic spread. Three of these patients died within a short time, and the fourth patient showed progression on therapy at the last follow-up. The first-line chemotherapies included 5-fluorouracil, cisplatin/oxaliplatin, and docetaxel (n = 5). In addition to chemotherapy, immunotherapies and regional deep hyperthermia were also administered.Eight patients with gastric carcinoma were enrolled in the STEP registry, with a median age at diagnosis of 16.1 years (range 12.7–17.4 years). The characteristics of these patients are shown in  (n = 3) . Signet HP infection, salt intake, and alcohol consumption, proximal gastric cancer is more common in adults in North America and Western Europe and is linked with obesity and gastroesophageal reflux [HP positivity in pediatric gastric carcinomas (6/8 STEP patients). Although this characteristic is not recorded in the epidemiologic cancer registries and thus could not be verified in the larger cohorts, HP has been detected in many other published pediatric gastric cancers [HP is a proven risk factor for adult gastric carcinoma, and carcinogenesis involves a cascade from chronic inflammation to atrophy and sometimes intestinal metaplasia, this suggests that HP is also an important risk factor for the development of gastric cancer in childhood [HP infections in childhood are common, and the prevalence of HP infections in children varies from 10% in the US and Western Europe to as high as 80% in India, Africa, or Latin America [HP positivity in our patients was distinctly higher than expected in the German population. In a Turkish cohort of 750 pediatric patients undergoing upper gastrointestinal endoscopy, 52% were HP positive. Of these, 74% had chronic gastritis and 6.2% and 2.8% had already developed atrophy and intestinal metaplasia, respectively, but no cases of cancer were found [HP infection alone may not be sufficient to trigger carcinogenesis in childhood. While, in adulthood, the duration of chronic gastritis and atrophy contribute to the risk of cancer development, as do lifestyle and diet, these risk factors do not appear to play a comparably important role in carcinogenesis in childhood [CDH1 and CTNNA1 [HP infection and tumor predisposition and/or immunodeficiency contributes significantly to the risk of developing gastric carcinoma at a young age.Gastric carcinomas predominantly arise in older adulthood, with less than 10% of all gastric cancers occurring in patients younger than 45 years of age, although an increase in incidence has recently been noted in young adults ,21. Thesl reflux ,27. Alth cancers . Becausehildhood ,23,28,29 America . Notablyre found . This inhildhood . In chilhildhood . For gashildhood ,34,35,36d CTNNA1 . It is id CTNNA1 . In the d CTNNA1 ,41,42,43n = 6) had HER2/neu overexpression [HP status, it has been reported that HP-positive patients had a higher risk of non-response to PD-L1 inhibition [HP positivity was common in pediatric gastric carcinomas, this could affect the efficacy of this treatment. Currently, the treatment of gastric cancer in childhood should be based primarily on the evidence-based adult guidelines and should be undertaken in close collaboration with adult oncologists, particularly with regard to the treatment of microsatellite unstable cancers, which are associated with excellent long-term outcomes after PD-L1 inhibition [HP, HER2/neu, and PD-L1 status. Children and adolescents with a family history of gastric carcinoma, as well as those with already diagnosed cancer predisposition syndromes and immunodeficiencies associated with gastric cancer, should undergo regular endoscopic surveillance. This can detect gastric carcinoma at a localized stage of disease, as in one of our patients, leading to a significant improvement in survival. Furthermore, in these patients with cancer predisposition, HP eradication treatment should be considered in cases of confirmed chronic gastritis with detection of HP to reduce the risk of gastric cancer [Because symptoms of gastric carcinoma are usually nonspecific, a correct diagnosis is often delayed by several months, which has also been acknowledged in other reports ,14. Thispression ,46. PD-Lhibition ,47,48. Bhibition ,36. The c cancer . In addiHP infections, appear to promote early cancer development. Close collaboration with adult oncologists is needed to provide optimal treatment of pediatric patients with gastric carcinoma, in consideration of these characteristics of childhood gastric carcinoma and a greater impact of long-term therapy-associated morbidity [Our analysis provides a detailed picture of the characteristics of gastric carcinoma in childhood. Complete resection at a localized stage of disease provides a good chance of durable remission, whereas patients with stage IV carcinomas face a dismal prognosis. In contrast to carcinogenesis in adults, tumor predisposition syndromes and immunodeficiencies are much more common in childhood and, together with orbidity . Therefoorbidity .


Background and Objectives: Kawasaki Disease (KD) incidence has been on the rise globally throughout the years, particularly in the Asia Pacific region. KD can be diagnosed based on several clinical criteria. Due to its systemic inflammatory nature, multi-organ involvement has been observed, making the diagnosis of KD more challenging. Notably, several studies have reported KD patients presenting with hepatobiliary abnormalities. Nonetheless, comprehensive data regarding the hepatobiliary manifestations of KD are limited in Malaysia, justifying a more in-depth study of the disease in this country. Thus, in this article, we aim to discuss KD patients in Malaysia with hepatobiliary manifestations. Materials and Methods: A total of six KD patients with hepatobiliary findings who presented at Hospital Canselor Tuanku Muhriz (HCTM) from 2004 to 2021 were selected and included. Variables including the initial presenting signs and symptoms, clinical progress, laboratory investigations such as liver function test (LFT), and ultrasound findings of hepatobiliary system were reviewed and analyzed. Results: Out of these six KD patients, there were two patients complicated with hepatitis and one patient with gallbladder hydrops. Different clinical features including jaundice (n = 3) and hepatomegaly (n = 4) were also observed. All patients received both aspirin and intravenous immunoglobulin (IVIG) as their first-line treatment and all of them responded well to IVIG. The majority of them (n = 5) had a complete recovery and did not have any cardiovascular and hepatobiliary sequelae. Conclusions: Despite KD mostly being diagnosed with the classical clinical criteria, patients with atypical presentations should always alert physicians of KD as one of the possible differential diagnoses. This study discovered that hepatobiliary manifestations in KD patients were not uncommon. More awareness on the epidemiology, diagnosis, and management of KD patients with hepatobiliary manifestations are required to allow for the initiation of prompt treatment, thus preventing further complications. Kawasaki disease (KD) is an acute systemic vasculitis that was first reported in 1961 . KD is sThe search for KD cases with hepatobiliary manifestation was conducted at Hospital Canselor Tuanku Muhriz (HCTM), a tertiary medical center and a teaching hospital under the administration of Universiti Kebangsaan Malaysia (UKM). The study was conducted from October 2021 to October 2022. Ethical approval was obtained from the institute itself (HCTM) prior to the commencement of this study (JEP-2021-868).The study was conducted as a retrospective cohort study. A total of 103 patients who attended HCTM with the diagnosis of KD from 2004 to 2021 were initially retrieved from the HCTM Case Mix system by using the International Classification of Diseases (ICD) code, ICD-10 (M30.3), for mucocutaneous lymph node syndrome, which is another name for KD. From this cohort, a total of 6 KD cases with hepatobiliary manifestations, such as jaundice, hepatomegaly, hepatitis, or gallbladder hydrops, were identified and included in this study. Variables including the initial presenting signs and symptoms, clinical progress, laboratory investigations such as liver function tests, and ultrasound findings of the hepatobiliary system were reviewed and analyzed.All registered data of patients who were admitted to HCTM between 2004 and 2021 with the diagnosis of KD based on the health information system were retrieved. With this approach, there were two methodological limitations. The first limitation was the type I error, which happened when non-KD patients were coded as KD in the system. These patients did not meet the criteria to be diagnosed as complete or incomplete KD and were excluded from this study. The second limitation was the type II error, which happened when KD patients were not coded as KD in the system. These patients’ data could not be traced and subsequently were not included in this study. From the total of 103 KD patients’ data that were retrieved, those who had hepatobiliary manifestations, such as jaundice, hepatomegaly, hepatitis, or gallbladder hydrops, were identified and included in this study.Meanwhile, the exclusion criteria of this study are (i) patient data with repeated names and reference numbers and (ii) patient data that could not be accessed at all due to loss of information or the patient’s file. Repetitions of data were considered as a single entry. However, any incomplete dataset was accepted and reported as it is. After considering all the inclusion and exclusion criteria, the total of this study’s subject is 6.Out of the six KD patients, there were two patients diagnosed with hepatitis simultaneously with KD. Both patients presented with jaundice and abnormal liver function test. Patient 1 had incomplete KD, and serological investigation for hepatitis A immunoglobulin G (Ig G) tested positive, which led to the delayed diagnosis of KD. Meanwhile, Patient 2 had hepatomegaly with the typical presentations of KD, making an earlier diagnosis of KD complicated with hepatitis.9 L; neutrophil 92%), direct hyperbilirubinemia , and elevated alanine aminotransferase (ALT: 75 U/L). The patient was initially managed as viral hepatitis with concurrent G6PD hyperbilirubinemia. Serological investigations showed positive for Hepatitis A immunoglobulin G (IgG), indicating a previous history of infection. Kawasaki disease (KD) with atypical presentation was only diagnosed after the onset of edema and widespread rash over the extremities.Patient 1, with underlying glucose-6-phosphate dehydrogenase (G6PD) deficiency, presented with fever and cough for 3 days. Acute gastroenteritis (AGE) was diagnosed by a general practitioner and symptomatic treatment was given. On the next day, rashes started to develop over the chest, trunk, and upper limbs. Jaundice was also noted. Upon admission on day 4 of illness, examination revealed bilateral cervical and inguinal lymphadenopathy, injected throat, cracked red lips, desquamation of scrotal area, and mild hepatomegaly. Laboratory investigations showed neutrophilic leukocytosis (white cell count 16.4 × 109/L), hemoglobin of 11.1 g/dL, normal platelet count (230 × 109/L) and raised C-reactive protein (CRP) (30 mg/dL). Serum alkaline phosphatase (ALP: 447 U/L) and serum ALT (82 U/L) were elevated. Diagnosis of typical KD with mild hepatitis was considered, and echocardiographic (ECHO) examination was performed revealing a normal cardiac finding.Patient 2 was initially treated for tonsilitis and received antibiotics. However, the fever (average recorded temperature of 39 °C) and left-sided neck pain persisted. Referral to our hospital for further evaluation was only done on the 7th day of fever with rashes over the back, neck, and cubital and popliteal fossa; bilateral non-purulent conjunctivitis; unilateral lymphadenopathy; and jaundice. Upon admission, the patient’s liver was 3 cm palpable below the right subcostal margin, indicating the presence of hepatomegaly. Other systemic examinations were unremarkable. Laboratory studies revealed leukocytosis  2 g/kg with high-dose aspirin therapy followed by subsequent low-dose aspirin therapy. Both patients were subsequently on follow-ups at cardiology clinic and were later discharged with no complications.9 L, neutrophils 4.7 × 109) and hypoalbuminemia with normal ALT and ALP levels. Ultrasound of the abdomen was done, and gallbladder hydrops was confirmed, in which the gallbladder wall was distended without debris measured 4.9 cm in length . The echocardiography result was normal. Treatment with IVIG of 2 g/kg over 12 h and oral aspirin of 30 mg/kg/day for 6 days was given. The patient was then continued with low-dose aspirin of 4 mg/kg/day for 6 weeks and subsequently discharged with no complications.There was one KD patient within our cohort with the finding of gallbladder hydrops. Patient 3 presented with fever for 8 days with the highest temperature of 39 °C associated with rigors and rashes. Rashes started to develop on day 4 of illness and initially appeared around the perioral region, then radiated to the ear, scalp, trunk, and limbs within a few hours. However, these rashes subsided on day 6 of illness. Upon admission, there were red lips and tongue, bilateral conjunctival injection, left axillary lymphadenopathy, and flaring of the bacille Calmette-Guérin scar (BCGitis), hence the diagnosis of complete KD. Examinations of other systems were unremarkable. Laboratory investigations showed leukocytosis  had concurrent hepatitis and we described the patients in 9 with neutrophilia) and elevated CRP (20.78 mg/dL) with normal liver function test. The patient was tested to be rotavirus positive and was diagnosed with acute gastroenteritis (AGE). Ultrasound of the abdomen showed hepatomegaly with non-specific pericholecystic fluid. After 12 h of admission, pustular lesions developed and were noted to worsen especially around the thigh region, and the patient was started on intravenous antibiotics. On day 3 of admission, the patient was noted to have redness of both eyes and peeling of periungual region on his back eventually spreading to the abdomen and right upper limb. With this constellation of signs, the patient was eventually diagnosed with typical KD.The first patient, Patient 4, presented with 9 days of non-resolving low-grade fever (38 °C), which was temporarily relieved by tepid sponging. Maculopapular rashes developed on day 2 of illness and spread from both lower limbs towards the upper limbs, trunk, and face. Lips were dry; however, no classic KD mucosal lesions were noted. On systemic examination, other systems were normal, except the liver was 2 cm palpable . Blood investigations showed raised white cell count . Incomplete KD was subsequently considered, and treatment was initiated.In terms of management, both patients were treated well with IVIG at 2 g/kg over 12 h and high-dose oral aspirin. Echocardiography results of Patient 4 revealed right coronary artery ectasia of a 4 mm diameter, and the patient was prescribed low-dose aspirin (5 mg/kg/day) for 2 months. Meanwhile, Patient 5′s echocardiography result was normal, and the patient was only given low-dose aspirin (5 mg/kg/day) for 6 weeks.Our study found that cholestatic jaundice can also be one of the hepatobiliary manifestations of KD. Patient 6, with underlying G6PD deficiency, presented with 5 days history of fever associated with swollen lips and tongue, bilateral non-purulent conjunctivitis, and BCGitis with generalized macular rashes, as well as 1 day history of jaundice with passing of tea-colored urine. On examination, the patient appeared fretful and had jaundice with red and dry crack lips, generalized macular rash, and flaring of BCG scar. Cervical lymph nodes were palpable with the biggest measuring 1 cm × 1.5 cm. The throat was injected, and tonsils were enlarged. Systemic examinations were unremarkable.9/L) with neutrophilia. His CRP was elevated at 28.94 mg/dL. The total bilirubin was 142 µmol/L with the direct component of 112.8 µmol/L, indicating direct hyperbilirubinemia. The patient also had high levels of ALP (451 U/L), ALT (139 U/L), lactate dehydrogenase (LDH: 407 mmol/L), and Gamma-glutamyl transferase . However, ultrasound abdomen revealed no evidence of gallbladder hydrops.Laboratory investigations revealed leukocytosis (white cell count 21.5 × 10The patient was treated with IVIG2 g/kg over 16 h. After completion of IVIG, the patient remained afebrile. Oral aspirin of 30 mg/kg/day was given for 6 days and later tapered down to 4 mg/kg/day for 6 weeks. Upon discharge, the patient was well with improving liver function and no other complications noted.The cohort of KD patients reported in this series highlights the importance of the high level of suspicion that is required for KD to be diagnosed accurately, especially if patients come in with the atypical hepatobiliary presentations .The clinical manifestations of KD can be diverse. The diagnosis of KD can be difficult as not all the clinical features appear simultaneously. Hematological and biochemical investigations are not immensely helpful; however, these could exclude other diagnosis. Moreover, establishing the diagnosis of KD can be further complicated by the occurrence of other diseases, such as hepatitis and gallbladder hydrops, as seen in our cases. Our study reported six KD patients with hepatobiliary system manifestations, of which two had hepatitis, one had gallbladder hydrops, four had hepatomegaly, and three had jaundice, with one case manifested as cholestatic jaundice. All these patients presented with hepatobiliary manifestation simultaneously with the appearance of KD features, which further made the diagnosis of KD more challenging. In some cases, we reported a misdiagnosis in the first phase of the disease, causing delayed diagnosis of KD and late definitive treatment to be offered to the patients. This was similarly reported in previous study, where there was a delayed diagnosis of KD due to the initial misdiagnosis of viral hepatitis .There were four KD patients noted to have hepatomegaly, which is an uncommon feature in KD. This was suggested by the possible involvement of portal area inflammation during acute phase of KD . This clWe reported several KD patients with jaundice but without gallbladder hydrops, which was also observed by Taddio et.al . This haApart from atypical clinical manifestations of KD, laboratory and radiological investigations demonstrating hepatobiliary abnormalities could also assist in the confirmation of the diagnosis. Three patients were reported to have abnormal LFT with either elevated ALT, ALP, or both. The pathogenesis of LFT derangement in KD is incompletely understood but is thought to be multifactorial . ProposeBased on our study, although hepatobiliary manifestation is not one of the criteria to diagnose KD, it is important to remember such unusual presentations do not exclude KD. Diagnosing KD in those who presented with atypical presentations of KD remains a challenge for physicians. Undeniably, one of the reasons for delayed diagnosis of KD is due to the atypical presentations . InvestiBeing known as an X-linked recessive genetic disorder, certain variants of G6PD deficiency including Class I, II, and III will cause potentially life-threatening hemolytic anemia with exposure of triggers, such as infection, drugs, and fava beans . To dateOne of the major limitations of our study is the loss of patient’s data since this is a retrospective analysis of KD patients in HCTM. Therefore, some of the information, such as laboratory investigation and duration of follow-up and subsequent treatment, was missing and could not be reported completely.In this study, we discussed six KD patients who presented with hepatobiliary manifestations. Some of them initially had atypical presentations of KD, while others were misdiagnosed with other diseases before KD was considered. Therefore, abnormal results from laboratory investigations, such as LFT and imaging study including ultrasound of the hepatobiliary system, should always raise a suspicion of KD in patients who fulfilled only some of the classical clinical features of KD. KD with unusual presentations require for extreme alertness, rapid diagnosis, and prompt treatment to prevent progression to coronary artery lesions or potentially life-threatening disease with severe long-term consequences.