Dry eye and glaucoma are two frequently encountered ocular conditions, which can lead to substantial morbidity and decreased quality of life. Patients on topical glaucoma medications are known to be at greater risk for ocular surface symptoms. Veterans seen in the eye clinics at the Miami Veterans Affairs Hospital from January to July 2016 completed surveys assessing dry eye and ocular pain symptoms, including the five item Dry Eye Questionnaire (DEQ5). A total of 62 patients with glaucoma completed the survey. Of those, 52 were on glaucoma medications at the time of the survey, with the majority requiring more than one medication to control intraocular pressure. The frequency of mild or greater dry eye symptoms (defined as DEQ5 >6) tended to increase with increasing medication burden, and patients on brimonidine were more likely to report a DEQ5 >6. Patients on three or more glaucoma medications were more likely to report symptoms of shooting pain, dryness, and itchiness. Patients using timolol were more likely to report throbbing and pain by light, while those on latanoprost reported stinging. Our data support an association between increasing number of glaucoma medications and worsening of dry eye symptoms. Patient and medication-associated symptoms can be used to tailor individual medication regimens. Glaucoma is an optic neuropathy defined by optic disc cupping, characteristic visual field defects, and often an increase in intraocular pressure. It remains a leading cause of irreversible blindness, with an estimated 60.5 million people affected worldwide ,2. The bDry eye often presents with symptoms of discomfort and blurred vision. It is seen more commonly in the elderly population, with an estimated prevalence of approximately 19% in those over the age of 75 . As the Prior studies at the Miami Veterans Affairs Hospital have shown a high prevalence of dry eye in the veteran population . In thesThis is a single-center, cross-sectional study of patients evaluated at the Miami Veterans Affairs Hospital between January 2016 and July 2016. Patients seen in the ophthalmology and optometry clinics over the designated time period were invited to complete standardized eye questionnaires, including the DEQ5, OSDI, NPSI-Eye, and sf-MPQ, to assess their dry eye and ocular pain symptoms. These surveys were modified for the eye and are validated forms designed to evaluate dry eye and ocular pain symptoms. The DEQ5 questionnaire assesses the frequency and intensity of dry eye symptoms, with scores ranging from 0 (no symptoms) to 22 (severe symptoms), and a score of >6 indicating mild or greater dry eye symptoms. The OSDI survey is a 12 item questionnaire assessing dry eye symptoms  and the effect on vision. The sf-MPQ survey evaluates the severity of 15 pain and affective descriptors . Additional pain descriptors found in other DE questionnaires were added to the sf-MPQ survey, including dryness, itchiness, irritating, piercing, and stinging. The NPSI-Eye is a validated 10 item tool to assess neuropathic pain (including the symptom of pins and needles) . The queAfter administration of the surveys, the medical records of patients completing the questionnaires were retrospectively reviewed for baseline characteristics and demographics including age, sex, diagnosis of glaucoma, number and type of glaucoma medications used, and a history of glaucoma surgery or laser. The only combination glaucoma medication used at this institution was dorzolamide/timolol, which was recorded as the two separate components for the purposes of this study. Systemic comorbidities were also examined, including a history of post-traumatic stress disorder, depression, headaches, migraines, back pain, fibromyalgia, sleep apnea, diabetes, and hypertension. Exclusion criteria included current contact lens use, active infection, presence of pterygium or corneal edema, history of refractive surgery, eyelid pathology , and cataract surgery within the preceding 6 months. Systemic exclusion criteria included a diagnosis of Sjögrens syndrome, human immunodeficiency virus, sarcoidosis, graft-versus-host disease, or collagen vascular disease.® Excel Version 16.16 and SAS version 9.4 . Independent samples t-test, Mann–Whitney U, Jonckheere-Terpstra, chi square, Fisher’s exact tests, Spearman and Kendall correlations, and logistic regression were used as appropriate to compare variables of interest. A p-value < 0.05 was considered statistically significant. The project was started as a quality assurance study. The Bruce W. Carter VA Medical Center later approved the retrospective review of patient questionnaires and charts. The research adhered to the tenets of the Declaration of Helsinki and complied with the Health Insurance Portability and Accountability Act of 1996.Statistical analysis was performed using Microsoftn = 58, 93.5%) and the average age was 72 years old .A total of 151 patients were seen in the ophthalmology and optometry clinics at the Miami Veterans Affairs Hospital and completed the dry eye and ocular pain questionnaires over the designated time period. Sixty-two of these patients (41.1%) had a known diagnosis of glaucoma at the time of survey administration and met the inclusion criteria . The majn = 40), followed by latanoprost (n = 39), dorzolamide (n = 36), and brimonidine (n = 22). The majority of patients required more than one topical glaucoma medication to control intraocular pressure: 1 medication (n = 9), 2 medications (n = 11), 3 medications (n = 22), and 4 medications (n = 10). Of the 22 patients on brimonidine, none were on brimonidine alone, and all were on three or more glaucoma medications. Of the 40 patients on timolol, only one (2.5%) was on timolol alone, and of the 39 patients on latanoprost, eight (21%) were on latanoprost alone. A total of 18 patients had a history of prior incisional glaucoma surgery, with eight patients having undergone trabeculectomy and 13 patients having had tube shunt surgery. Eleven patients had a history of laser trabeculoplasty.Fifty-two patients were on glaucoma medications at the time of the survey administration (83.9%). The most commonly used medication was timolol (p = 0.004) (p = 0.004). Additionally, those patients on three or more glaucoma medications tended to report more severe dry symptoms, with an average DEQ5 score of 8.5 in patients on no medications, 7.4 in patients on 1–2 medications, and 9.9 in patients on 3–4 medications. Overall, individuals with a DEQ5 ≤6 (n = 16) were on an average of 1.7 medications, while those reporting a DEQ5 >6 (n = 46) were on an average of 2.5 medications (p = 0.03).All patients completed the DEQ5 questionnaire. Patients on three or more glaucoma medications at the time of survey administration were more likely to have a DEQ5 >6, indicating mild or greater dry eye symptoms: 50.0% on 0 medications, 44.4% on one medication, 45.5% on two medications, 86.4% on three medications, and 70.0% on four medications (= 0.004) . In totap = 0.03). There was a trend for those on brimonidine to more frequently report a DEQ5 >6 compared to those on other glaucoma eye medications: 81.8% on brimonidine, 72.5% on timolol, 69.4% on dorzolamide, 69.2% on latanoprost. When considering both each individual medication and number of medications in a forward stepwise multivariable analysis, only brimonidine remained significantly associated with mild or greater dry eye symptoms .Patients on brimonidine were more likely than those not on brimonidine to report mild or greater dry eye symptoms, as defined by a DEQ5 >6 , irritating (n = 29), dryness (n = 28), and aching (n = 21). Patients on three or more glaucoma medications were more likely than patients on fewer medications to report symptoms of shooting pain , dryness , and itchiness . Medication-specific ocular pain symptoms were also investigated (p = 0.03) and pain by light . Patients using latanoprost were more likely than those not using latanoprost to report stinging .Ocular pain surveys were reviewed to analyze symptom-specific complaints. Specifically, the results of the sf-MPQ, OSDI, and NPSI-Eye survey were used to evaluate pain and effective symptoms. The most common descriptors reported by surveyed glaucoma patients included itchiness (stigated . Those pp = 0.04). There was a moderately significant association between depression and latanoprost use, compared to those not on latanoprost . There was no association between specific glaucoma medication use and the concomitant use of antidepressant medication and anti-anxiety medications.The association between glaucoma medication use and the presence of certain systemic comorbidities  was investigated, and those comorbidities reaching statistical significance are presented in For each specific ocular pain and systemic comorbidity found to be statistically associated with one of the four glaucoma medications used in our series , a univaGlaucoma and ocular surface disease are two frequently encountered ocular conditions, which account for a substantial number of office visits and can lead to patient morbidity. While many studies have shown a correlation between the use of glaucoma medications and the incidence of dry eye disease, none have evaluated specific ocular pain descriptors to better quantify and understand medication-associated symptoms. The use of validated tests in this study  allowed for both the evaluation of dry eye symptoms and pain-specific descriptors.The majority of patients in our series required the use of topical pressure lowering eye medications for treatment of their glaucoma. The most commonly used eye medication was timolol, followed closely by latanoprost and dorzolamide. Fewer than half of patients were using brimonidine at the time of survey administration. These prescription patterns mirror other epidemiological studies, which have shown topical beta blockers and prostaglandin analogs to be the most commonly used glaucoma medications ,19,20. TThe DEQ5 survey was administered to all patients to better assess the frequency and intensity of their dry eye symptoms. Those patients on three or more glaucoma medications were more likely to report the presence of mild or greater dry eye symptoms (measured by a DEQ5 >6) and more severe symptoms (measured as a higher DEQ5 score) than those patients on a fewer number of mediations. This corroborates prior studies, which have shown a higher frequency of dry eye symptoms in patients on glaucoma medications, with increased incidence and severity amongst those using multiple medications ,8,16. AlInterestingly, patients using brimonidine at the time of survey administration were statistically more likely than those not on brimonidine to report a DEQ5 >6. Brimonidine, an alpha-2-adrenergic receptor agonist, is known to have a number of ocular side effects, including conjunctival hyperemia, allergic conjunctivitis, and ocular pruritis, which limits its use in some patients . As prevUnique to our study was the use of standardized surveys to investigate patient-specific descriptors of ocular pain. Patients with glaucoma in our series most commonly described symptoms of itching, irritation, dryness, and aching. Those patients on three or more glaucoma medications were statistically more likely to report symptoms of shooting pain, dryness, and itching compared to those on fewer topical medications. Interestingly, patients using timolol were more likely to report symptoms of throbbing and pain by light compared to those not on timolol. Timolol, a medication which has been used for decades in the treatment of glaucoma, is a non-selective beta-adrenergic blocker which lowers intraocular pressure by decreasing the production of aqueous humor in the eye. Known side effects include central nervous system changes , cardiovascular effects (bradycardia and hypotension), respiratory complications (bronchospasm), and ocular side effects, including deep orbital pain and burning ,30. ThouInterestingly, further investigation of these medication-associated pain descriptors in a bivariate model, which included brimonidine as the second explanatory variable, showed that brimonidine had an odds ratio of less than 1.00 for the descriptors analyzed (suggesting that use of brimonidine is associated with reduced odds of experiencing this ocular pain symptom). This was particularly true for pain by light and stinging, for which there were clinically significant decreased odds of approximately one-half in those patients on brimonidine. Therefore, while patients using brimonidine were at increased odds of dry eye symptoms (DEQ 5>6), they were less likely to report these specific pain descriptors. It is plausible that this may represent a case of reverse causality, with physicians being less likely to prescribe brimonidine to those patients with specific ocular pain symptoms.The relationship between multiple systemic comorbidities and glaucoma medication use was evaluated. Patients in our series on latanoprost tended to have a more frequent diagnosis of depression, which was of borderline significance. Traditionally, topical beta-blockers (timolol) have been associated with symptoms of depression, memory loss, and disorientation . While iPatients on three or more glaucoma medications are more likely to have dry eye symptoms compared to those patients on fewer medications. They are also more likely to report specific ocular surface symptoms of dryness, shooting pain, and itchiness. This is the first study to use validated ocular pain surveys to assess patient-specific symptoms. The use of brimonidine was shown to be associated with a higher frequency of dry eye symptoms and a more frequent history of headaches. Patients on timolol were more likely to report throbbing and pain by light, while those on latanoprost reported more stinging. Dorzolamide was not associated with any specific increase in ocular pain descriptors. Given the known association between glaucoma medications and ocular surface disease, providers should actively assess dry eye symptoms in their glaucoma patients, note patient-specific pain descriptors, and tailor a medication regimen based on a patient’s individual complaints. More research is needed to understand the associations between glaucoma medications and dry eye symptoms, including how dry eye symptoms and medication intolerability may accelerate the transition from medically treated to surgically treated glaucoma.


We describe a three-year-old male child who presented to the pediatrics out-patient department with a history of decrease in appetite, generalized weakness, on and off loose motions for one year, inability to walk and sit for eight months with a loss of neck holding for 14 days. On examination, the patient had a classic frog-shaped leg posture. X-rays of chest, skull, pelvis and long bones were performed which showed osteopenic bones, frontal bossing and multiple microfractures, which were classic for osteogenesis Imperfecta but the child did not have other salient features such as blue sclera, otosclerosis, and respiratory difficulty. The patient also had urinary complaints due to which ultrasound of kidney ureters and bladder (KUB) was performed, which showed bilateral renal calculi and grade 2 renal parenchymal changes. This case report illustrates the evaluation of the child with osteogenesis imperfecta, as well as the unique association of renal osteodystrophy and gastroenteritis with it. Osteogenesis imperfecta (OI), also known as brittle bone disease, is a group of inherited connective tissue disorders, which happens due to mutations that affect collagen in the connective tissue of the body resulting in fragile bones. Therefore, people with this condition have bones that break easily, often due to a mild trauma or with no apparent cause. There are eight recognized forms of osteogenesis imperfecta, type I to type VIII. The types can be differentiated by their clinical presentations, although, some of their characteristic features overlap. Type I is the mildest form, while type II is the most severe form and the remaining types have signs and symptoms that range between these two extremes .Collagen is the major protein of the body’s connective tissue and plays an essential role in building strong bones. OI is caused by genetic defects that mainly affects collagen synthesis or quality of collagen resulting in weak, fragile bones. Most cases of OI have an autosomal dominant pattern of inheritance, which is caused by a mutation in one of the type 1 collagen genes (COL1A1 and COL1A2); therefore, a person has either too little type 1 collagen or poor quality of type 1 collagen. In recessive OI, the mutation does not affect the main collagen genes and results from mutations in other genes which interfere with the collagen production. The result in all cases is weak bones that break easily .A three-year-old male child was admitted to the pediatric ward of Dr. Ruth KM Pfau, Civil Hospital Karachi (CHK) with a one-year history of generalized weakness, loose motions, decreased appetite and intermittent fever not associated with rigors, chills or night sweats, an eight-month history of inability to walk and sit, polydipsia, polyurea, abdominal distention and loss of neck holding for 14 days. He had a previous history of hospitalization six months ago due to the same complaints. The patient was accompanied by his mother. He weighed 6 kg, is the 7th born child to his parents and was delivered at term to a 37-year-old G7P7 mother via normal vaginal delivery. The mother did not report any complications or illnesses during pregnancy. He cried immediately after birth, and there were no complications during or after birth. There is no consanguinity between mother and father. The child was vaccinated but was malnourished, with an unremarkable family history.The patient also developed diarrhea which was bulky in consistency, green in color with seven episodes per day after every meal intake. Diarrhea was associated with abdominal distention and vomiting. The mother then started giving him a combination of trimethoprim-sulfamethoxazole, after which diarrhea subsided. The child developed neck holding at four years of age, he started sitting at eight months and started walking with support at 12 months of age. The child was first breastfed within three hours of delivery and was exclusively breastfed up to six months. Complimentary feeding was started after six months with pulses, mashed potatoes, porridge and chicken. Breastfeeding was continued up to two years. Currently, the child takes 1-2 feeds per day. The personal history revealed that the patient was sleeping normally, but the appetite was decreased. The mother also noticed a weight loss, altered bowel habits, and micturition was normal.On examination (O/E), the patient was lying on the bed irritated, severely wasted and emaciated with visible bony deformities. Initial vitals included blood pressure (BP) 110/70 mmHg, a regular pulse of 90 beats/min, a respiratory rate of 20 breaths/min, and a low-grade fever of 100° F. The patient was anemic and dehydrated, while, there was no presence of edema, clubbing, cyanosis, and lymphadenopathy. On further examination, parietal and frontal bossing, rachitic rosary  and height for age = 72.5/94.6*100 = 76.6 (severely low).9/L, including 39% neutrophils and 48% lymphocytes. His inflammatory markers were raised with a C-reactive protein (CRP) of 23 mg/L [Normal (N) = 3] and an elevated erythrocyte sedimentation rate (ESR) of 115 mm/hr (N = 0-22) for men and (N = 0-29) for women. The clotting profile showed an international normalized ratio (INR) of 1.01, while prothrombin time (PT) was 10.6 seconds.On investigations performed, complete blood count (CBC) showed a hemoglobin (Hb) of 5.4 gm/dl, mean corpuscular volume (MCV) of 82 fl and a platelet count of 187,000/mL. The total leukocyte count (TLC) was 10.6 x 10The urea creatinine electrolytes (UCE) were within normal range except decreased potassium levels of 2.8 mEq/L. The levels of calcium, magnesium and phosphate in blood were 15.1, 1.9 and 4 mg/dL, respectively. The blood culture showed a growth of Burkholderia species. The urinalysis showed a pH of 5.0, specific gravity of 1.025, with the presence of protein and blood. Additionally, numerous red cells were seen along with yeast and 4-6 pus cells per high power field (HPF). The urine culture showed growth of Candida species. The stool analysis showed that the stool was hard, acidic, brown in color with 1-2 pus cells per HPF. His vitamin D levels came out to be 54.29 ng/mL, and parathyroid levels were 8.36 pg/ml. Liver function tests showed a total bilirubin of 0.28 mg/dL, direct bilirubin of 0.21 mg/dL and levels of alkaline phosphate alanine aminotransferase were 368 and 3 units per liter, respectively.The X-rays of the chest Figure , skull  and femuConsidering the diagnosis of OI, an ophthalmology review was done to look for lens dislocation and blue sclera, but neither was present in both eyes. However, the left eye showed a corneal thinning nasally, temporally and inferiorly.During the hospital stay, the patient was intravenously given cefotaxime 220 mg, piperacillin-tazobactam 700 mg, and meropenem three times a day. Additionally, linezolid 70 mg was injected every eight hours, along with injections of bisphosphonate 7 mg for three days, amikacin 55 mg twice a day for 14 days and fluconazole 85 mg loading dose, 45 mg once a day for 10 days. The patient was also given a teaspoon of the combination (artemether and lumefantrine) once a day. Three pints of red blood cells were transfused as well, after which his Hb became 10.6 mg/dL. During the stay, the child had a prolonged course of fever with pancytopenia, which improved on injections of meropenem, amikacin, and fluconazole.OI is a genetic disorder characterized by a varying group of diseases. The hallmark of OI is an increased vulnerability to fractures ranging from slight to pre-natal. Other common features include a distinct blue sclera, hyper-elastic skin and ligaments, impaired hearing, bone deformities, short statures and dentinogenesis imperfecta (DI) . With anOI was designated a widely accepted classification in 1979 by Seillence et al. The disorder was classified into four types depending on symptoms and presentation: Type I; blue sclera and dominant inheritance, Type II; perinatally lethal with crumpled femora, Type III; progressively deforming and no discoloration of the sclera and Type IV; no discoloration of sclera with dominant inheritance. Type I and II defer in that the former is mild and has two subtypes, A and B, depending on the presence of DI while the latter is lethal and inherited autosomal recessively. Type III and IV have intermediate presentations with Type III being the most severe form that is non-lethal while Type IV also has two subtypes similar to Type I. Since then, five more types have been classified depending on histological findings .The various phenotypic variations all result from mutations in one of two genes, COL1A1 and COL1A2 which encode for pro-α1(I) or pro-α2(I) chains of type I collagen  which reIn the present case, the diagnosis was made based on the multiple micro-fractures, frontal bossing and the osteopenic bones exhibited by the patient during X-ray imaging. While such a presentation is classic for OI, the presence of multiple other features such as blue sclera, perinatal lethality, and respiratory problems makes diagnosis and classification easier, which were not noted in this case. Physical examination only revealed an emaciated, malnourished child with visible bony deformities without the presence of DI or other classically associated features but parietal and frontal bossing, Rachitic rosary, widening of wrists and knock knees were observed which aided the diagnosis ,7. The pFurthermore, the most unique feature of this case, besides the lack of other OI identifying associations, was what ultrasound KUB revealed. We observed that the patient had renal calculi and grade II renal parenchymal changes. While chronic renal failure from renal artery occlusion in OI owing to pelvic deformities has been rarely documented , the preThe treatment regimen involved administration of multiple antibiotics, antifungals, and antimalarials to treat the infection, fever, and diarrhea as it presented a more immediate threat followed by blood transfusions .While OI results in a multitude of complications, to date there is no surgery or known treatment that will effectively treat and cure OI. The mainstay of therapy is care of fractures, physiotherapy and the use of bisphosphonates to maintain bone mineral density by inhibiting osteoclastic activity and therefore reducing bone resorption  and treaThe therapeutic goal we developed was based on curing the infection and diarrhea and anemia followed by helping to manage the renal parenchymal disease found in the patient and helping to manage the osteopenia demonstrated.While the treatment therapies mentioned previously form the current gold standard of OI management, new pharmacological interventions such as antibodies to sclerostin, mesenchymal stem cell transplantation, and gene therapy with specific allele silencing , might pThe present case report, in conjunction with previous literature, albeit scarce, suggests that renal manifestations of OI need to be considered as a grave complication or association. While the renal parenchymal disease has been documented to some extent, the presence of renal calculi is a perhaps novel finding in OI patients. Therefore, we recommend that suspecting renal disease in patients of OI should be suspected and physicians should be aware of its possible existence. Complete workup for the renal function should be carried out, and preemptive strategies to combat chronic renal failure in OI should be specified and fine-tuned.


Schwannoma is a tumor of the peripheral nervous system originated in the Schwann cells of the neural sheath.A 43-years-old male complained of odynophagia, dysphagia and hemoptysis. The upper gastrointestinal endoscopy showed a smooth elevated lesion, 20 cm from the incisor teeth, occupying the entire lumen of the esophagus. The chest computed tomography (CT) scan showed a lesion of 7 cm and superior mediastinal, lower paraesophageal and cardiac enlarged lymph nodes. A posterolateral thoracotomy was performed with total esophagectomy without intraoperative complications. The anatomopathological analysis revealed fusocellular mesenchymal neoplasia of low malignancy potential. The immunohistochemical study showed positivity for S-100 protein and KI67 antibodies and absence of staining for CD117, CD34, ALK protein, SMA and Desmin. Thus, the morphological and immunohistochemical findings pointed to the diagnosis of esophageal Schwannoma.Although rare and indolent, Schwannoma occurs in the peripheral nervous system, being uncommon in the esophagus.The immunohistochemical study is essential for the diagnosis, which is based on the positivity for S-100 protein and absence of staining for CD34 and CD117. Schwann cell tumors of the peripheral nervous system were named Neurilemmoma by Stout and Carson in 1935 [Schwannoma or Neurilemmoma is a tumor of the peripheral nervous system originated in Schwann cells. Commonly, the term “Schwannoma” refers to a benign, slow-growing tumor. The rare cancerous cases should be called malignant Schwannoma of malignant nerve sheath tumor . This tyThe gastrointestinal schwannomas are uncommon and most of them originate in the stomach or intestines. The esophageal schwannomas are extremely rare. In the following study, we report a patient with esophageal schwannoma. Our work was described using the SCARE criteria of guidelines for consensus-based surgical case reports .2A search of the terms “schwannoma” and “esophagus” was performed using PubMed (NCBI) database. Only literature between 1989 and 2018 was included. A total of 120 studies were identified and analyzed. The inclusion criteria were studies with epidemiological, clinical, surgical, histopathological and immunohistochemical characteristics described and published in PubMed (NCBI) database. The data were arranged and the statistical analysis was performed by the SPSS software version 20.0. In the literature review, we analyzed the epidemiological, clinical, histopathological and immunohistochemical characteristics. In our analysis, patients complaining of discomfort or bad sensation during swallowing and difficulty of swallowing were gathered together and it was considered that they had the same symptom – dysphagia. We collected the information regarding the number of patients per study, sex, age, tumor size (mm), tumor location (cm) from the greater distance of the incisor teeth, clinical data and risk factors reported in the studies , surgical data reported in the studies  and pathological data concerning immunohistochemistry (Smooth Muscle Actin (SMA); Desmin; CD34; CD117; Protein S-100 (S-100); Vimentin; Neuron-specific enolase (NSE); DOG-1; Protein ALK-1 (ALK-1); Synaptophysin; Chromogranin; Glial fibrillary acidic protein (GFAP); Cytokeratin AE1/AE3 (AE1/AE3).3A 43-years-old male visited the hospital with complaints of odynophagia, evolving to sudden onset dysphagia to both solids and liquids, which relieved after hemoptysis. The patient presented a history of arterial hypertension and he reported frequent consumption of alcoholic beverages. An upper gastrointestinal endoscopy showed a smooth elevated lesion, 20 cm from the incisor teeth, preserving the continuity of the mucosa that obstructed all the lumen of the organ.A chest computed tomography (CT) scan showed a lesion of 7 cm and superior mediastinal, lower paraesophageal and cardiac enlarged lymph nodes. The patient presented grade I cardiac risk and he was referred to the surgical center. He underwent a thoracotomy via the fifth right intercostal space, with esophagctomy and anisoperistaltic gastric tube preparation. A mass  was founThe resected specimen (esophagus segment and celiac trunk lymph node) showed a globose lesion measuring 13.0 × 8.4 × 4.5 cm. The middle third of the segment was poorly delimited and elastic hard, forming a prominence on the outer surface. There was no capsule and it was covered by adventitia. A poorly delimited tumor measuring 7.0 × 7.0 × 4.0 was observed on one side, partially covered by smooth mucosa with erosion foci. That part of the tumor extended to the wall in depth and it was located 4.5 cm from the most distant margin and 1.5 cm from the nearest margin. The cut surface was fasciculated and almost uniformly yellowish-white. Additionally, there was an irregular tissue measuring 3.0 × 2.0 × 1.5 cm, from which celiac trunk lymph nodes were isolated.Histopathological examination revealed fusocellular mesenchymal neoplasm with low malignancy potential; solid and fasciculate pattern with trabecular areas; localization predominantly in submucosa, permeating own muscle and own lamina; extension of the lesion 7.0 × 7.0 cm; vessels with perivascular hyalinization; moderate intratumoral lymphomononuclear inflammatory infiltrate with lymphoid and peritumoral aggregates; mucosa with epithelial erosion and hemorrhagic foci; necrosis and non-mitotic cells; proximal, radial and distal free surgical margins. The celiac lymph nodes were free of neoplasia.Immunohistochemical studies were performed using the following antibodies: SMA (Smooth Muscle Actin), Desmin, CD34, CD117, S-100 protein, ALK protein and KI67. The analysis revealed positivity for the S-100 protein and KI67 and the absence of staining for SMA, Desmin, CD34, CD117 and ALK . Thus, t4After analyzing our case and the 48 studies that performed at least immunohistochemical test using S-100 protein antibodies, we observed that 54 patients were diagnosed with esophageal Schwannoma . The patAfter the arrangement of the 54 patients, we analyzed statistically all variables by means of the mean, median, mode, standard deviation and percentage of all patients . We obseWhen analyzing all the symptoms and risk factors of the 54 patients, we observed that dysphagia is reported in 53.7% of clinical complaints, dyspnea in 10.4%, cough/weight loss/chest pain/alcohol consumption in 4.4%, hemoptysis/palpitations/smoking/epigastric pain in 2.9% and odynophagia/hematemesis/back pain/left hand paresthesia in 1.4% of the patients . When an5The Schwannoma represents 0.2–1% of all gastrointestinal tumors and the stomach is the most common site of gastrointestinal schwannoma, while the colon and esophagus are relatively uncommon ,6,7,9,58th cranial nerve, in a condition called vestibular neuroma [The Schwannomas are commonly found involving the myelin-forming cells of the 8 neuroma . Symptom neuroma ,5,7,9. IThe initial evaluation is made by CT, nuclear magnetic resonance (NMR) and upper gastrointestinal endoscopy to determine the localization, size, density of the lesion and attempt to identify metastasis . The dia•Antoni A tissue pattern: the cells are spindle-shaped and compactly arranged. The pattern is characterized by palisades created by the alignment of nuclei that alternate with anucleated, rosy and homogenous or fibrillary zones (Verocay bodies). These bodies consist of cytoplasmic extensions, basement membranes, collagen and reticulin or small groups of fibrils surrounded by lines of palisade-shaped nuclei.•Antoni B tissue pattern: the Antoni B regions contain more loosely arranged. The extensions are not oriented and the nuclei are round, rather to elongated. Occasionally, the cells are starred, creating a resemblance to an astrocytoma. There may be abundant xanthomatous histiocytes. The immunohistochemical and structural features of Antoni B regions suggest that it results from degenerative processes.The Schwannoma is classified as a gastrointestinal mesenchymal tumor, together with GIST, leiomyoma, leiomyosarcoma, desmoid tumor, inflammatory myofibroblastic tumor and others . SchwannIn the histological character, the Schwannoma can present significant cellular pleomorphism, lymphoid follicles, rare mitotic figures and rare necrosis points. The fasciculate pattern makes differential diagnosis with GISC, leiomyomas and others. GIST may, on the other hand, have a high mitotic index, foci of necrosis and hemorrhage and there are no lymphoid follicles. Otherwise, leiomyoma does not present mitoses, nor necrosis, hemorrhage or lymphoid follicles ,7,66.In genetic issues, there are cytogenetic abnormalities in about half of the schwannomas, regardless of origin. These include loss of material on chromosome 22q, loss of sex chromosome and trisomy of chromosome 7 ,62. MostThe parameters of schwannoma immunohistochemistry are based on positivity for S-100 protein and on the absence of staining for CD117, CD34, Desmin and specific muscle actin. CD117 and CD34 are positive in GIST and muscle-specific proteins, such as actin, Desmin and caldesmon are positive in smooth muscle tumors such as leiomyoma and leiomyosarcoma. All these proteins are virtually negative in the schwannoma . In our The definition of malignant schwannoma is based on a combination of histopathological patterns, such as the presence of mitoses, invasion of muscle layers, cellularity, nuclear atypia and tumor necrosis . Tumor sThe therapeutic management of esophageal Schwannoma depends on several factors, such as clinical complaints, tumor size, complications due to tumor growth, pathological data . Thus, most of the studies advocate surgical resection as treatment ,72. The 61.The prognosis is determined by the degree of mitosis and the size of the tumor. Thus, the lower degree of mitosis and the smaller tumor, the better the prognosis. The prognosis and predictive factors for schwannoma are good since schwannoma is most often a benign tumor with a very low recurrence potential. Malignant transformation is exceptional and rare, and schwannomas tend to recur after incomplete removal6We reported an esophageal Schwannoma case, essentially benign, positive for S-100 protein and KI67 positive in 5% of tumor cells, which is part of the differential diagnosis of mesenchymal tumors. The tumor was treated with resection-surgical margins. The literature review shows the relevant statistical data of 54 patients with at least S-100 protein immunohistochemical marking  and dataThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.The author(s) received no financial support for the research, authorship, and/or publication of this article.CONEP and to the Research Ethics Committee of the Base Hospital Institute of the Federal District - IHBDF, with registration CAAE: 00,711,718. 00711718.0.0000.8153The case report was submitted to the National Council of Health - National Commission of Ethics in Research of Brazil - Written informed consent was obtained from the wife of the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Luiz Carlos de Araújo Souza was assigned to formal data analysis and statistical elaboration; Thiago David Alves Pinto and Hugo Oliveira de Figueiredo Cavalcanti were responsible for the methodology used in the pathological diagnosis; Alexandre Rezende Rezende was responsible for project management; Thiago David Alves Pinto and Luiz Carlos de Araújo Souza were responsible for the review and validation of the work; Ana Luiza Alves Nicoletti, Cinthia Mares Leão and Vinícius Carvalhêdo Cunha were responsible for the papers, writing and writing of the work.NA.Luiz Carlos de Araújo Souza.Not commissioned, externally peer-reviewed.


BackgroundThe incidence and 30-day readmission rates of patients with infective endocarditis (IE) are not fully determined. We used the United States Nationwide Readmission Database (NRD) to assess national trends and predictors of 30-day readmission.MethodsWe queried the NRD from 2010 to 2014 and identified patients with index hospitalizations primarily for IE. Univariate and multivariate logistic regression analyses were conducted to identify predictors of 30-day readmission.ResultsA total of 48,500 patients  were admitted for IE. There was an annual decrease in hospitalization rates by 1.5%. With an exception for 2014, subsequent 30-day readmission rates remained relatively unchanged. All-cause 30-day readmission occurred in 25.4% of patients, 21.8% of which were due to acute or subacute bacterial endocarditis. Leaving against medical advice (odds ratio (OR): 3.46, 95% CI: 3.12 - 3.84; P <0.001), history of drug abuse and a cardiac implantable electronic device in situ , fungal IE , and uninsured patients  were the strongest independent predictors of 30-day readmission. Readmission cost  accounted for 14% of the total hospitalization cost.ConclusionsThe annual incidence of IE in the US decreased slightly from 2010 to 2014, but the 30-day readmission rates remained relatively unchanged. Addressing modifiable predictors of readmission may reduce the financial burden of IE on health care. Infective endocarditis (IE) is a lethal disease, with nearly 25% mortality at six months  and 18% Data sourceWe conducted a retrospective analysis of the NRD from January 1, 2010, to December 31, 2014. The NRD is the largest all-payer annual national database sponsored by the Agency for Healthcare Research and Quality under the Healthcare Cost and Utilization Project (HCUP) [The NRD provides deidentified patient demographic and clinical variables , variables to assist with a national estimate , and readmission information . For each hospitalization, admission diagnoses and procedures are provided using the International Classification of Diseases, Ninth Revision-Clinical Modification (ICD-9-CM) codes for admissions prior to October 1, 2015.Study populationWe identified all IE index admissions between January 1, 2010, and December 31, 2014, using ICD-9-CM codes 421.0, 421.1, 421.9, 036.42, 098.84, 112.81, 115.14, or 115.94 as primary admission diagnosis (DX1 only). The validity of these codes has been previously published  using thDescription of variablesIn the study sample, age was stratified into the following groups: 18 - 54, 55 - 64, 65 - 74, 75 - 84, and > 85 years, and ECI was categorized into four subgroups: 0, 1, 2, and > 3, which has been adopted in previous studies . HCUP idInfective endocarditis etiology and risk factorsThe causative organisms of IE were identified using primary or secondary ICD-9-CM codes during the index admission and are described in Table EndpointsThe primary endpoint of the study was to assess the annual trends in IE hospitalizations, 30-day readmission rates, and predictors of readmissions. Time to readmission was computed as the difference between index hospitalization discharge and subsequent hospitalization for any cause. If there were multiple readmissions during the 30-day period after the index hospitalization, then only the first readmission was considered. Secondary endpoints included identifying an etiological agent for IE, the top 10 reasons for readmission, and the cost of index and readmission hospitalization. Reasons for readmission were identified using primary diagnosis ICD-9 CM codes for readmission hospitalizations. All ICD-9 CM codes for similar diagnoses were pooled together. The costs associated with the index and readmission hospitalizations were computed in terms of 2014 dollars by using the consumer price index data for medical care released by the United States Department of Labor, Bureau of Labor Statistics [Statistical analysisCategorical variables are presented as weight values and percentages and compared between patients with versus without readmissions using the χ2 test. Continuous variables are presented as mean ± standard error and compared between patients with versus without readmissions using the Wilcoxon rank test. Multivariable logistic regression for age cluster, sex, ECI, mode of acquisition, etiology, LOS, disposition on index admission, and primary payer were conducted to assess independent predictors for 30-day readmission. A linear regression analysis was performed for continuous variables, as appropriate, to evaluate for the significance of trends. Statistical analyses were performed using IBM SPSS version 26.0 .The study cohort consisted of 21,076 unique patients admitted with a primary diagnosis of IE between January 1, 2010, and November 30, 2014, representing 48,500 observations, after applying discharge weights. Over the study period, there was a slow but steady decline in the number of IE hospitalizations  vs 9,331 (2014); p <0.001) with the incidence decreasing by 1.5% annually. Trends in IE hospitalization and associated 30-day readmissions are shown in Figure Table 30-day readmissionsAmong those who survived the initial hospitalization, the 30-day readmission rate for the total cohort was 25.4%. The annual readmission rate was mostly unchanged from 2010 to 2013 but decreased in 2014 by 11.5%  had valve surgeries during both hospitalizations.The demographics of patients stratified by 30-day readmission have been summarized in Table The identity of IE organisms remained relatively stable over the study period, except for the presence of Gram-negative bacilli, which decreased by 9.3% annually Table . The assThe top 10 most common reasons for readmission stratified by year are summarized in Table In a multivariate regression analysis Figure , the strCost of hospitalizationDuring the study period, the average cost per index hospitalization was $38,006, and per readmission, hospitalization cost was $23,535. The annual cost for index hospitalization was approximately $369 million while for readmission hospitalization, it was $58 million. Trends in annual index hospitalization costs and readmission hospitalization costs are summarized in Figure In this nationwide analysis of IE from the largest available readmission database in the United States, we report a slight decrease in the admission rates for IE and mostly stable 30-day readmission rates annually (except during 2014) from January 1, 2010, to November 30, 2014. The highest readmission rate was within 24 hours of the index hospitalization and nearly half of the patients were readmitted within 10 days after discharge. Acute and subacute bacterial endocarditis was the most common primary diagnoses upon readmission, followed by septicemia and heart failure. Patients leaving the hospital against medical advice and those with a history of drug use in association with implanted cardiac devices or valve prostheses were at the highest risk for readmission in multivariable analyses. Approximately, $58 million are spent annually in the US toward IE rehospitalization.Appropriate antibiotic therapy and removal of infected prostheses remain the cornerstone therapy in the management of IE. Practice guidelines are well-developed and regularly updated to assist clinicians in choosing the appropriate treatment for their patients -13. ContIE patients have higher all-cause 30-day readmission rate (25.4%) when compared to the all-cause readmission rate for total inpatient stays in 2014  . When coSepticemia (038.9) has remained the second most common primary reason for readmission, which most likely stems from uncontrolled and failed initial therapy from IE bacteremia. It is interesting that previous analyses from our group have shown that septicemia is also the second most common cause for readmission after CIED implantation. It is difficult to tease out, based on our study, if bacteremia leads to infection of the CIED or if IE was due to a poor sterile technique, leading to contamination of the pocket site, which caused septicemia. However, in light of our previous study  with a vIn the multivariate analysis, we demonstrate that patients at higher risk for readmission within 30 days were those who left the hospital AMA, had a history of drug abuse and CIED in situ, had a history of drug abuse and prosthetic valve, having fungal IE, higher comorbidity (ECI > 3), and those with a shorter LOS (< 2 days). Interestingly, our data demonstrate that it is the combination of risk factors  that is associated with higher rates of readmission, not each risk factor independently. This double hit finding makes physiological sense since the high-risk behavior leads to repetitive inoculation with infectious agents while the presence of a foreign device or prosthesis allows for the seeding of the infectious agent, leading to recurrence of IE even after adequate therapy.This study’s major advantage is that it is based on mandatory data reporting from all regions of the 22 states participating in the NRD. These collectively represent the real world of IE across the United States. With patient weights provided by the HCUP, this dataset provides accurate estimates of IE admissions, readmissions rate, predictors of readmissions, and associated costs.LimitationsHowever, our study is limited due to its retrospective nature and its reliance on administrative data. We are unable to validate the accuracy of ICD-9-CM code documentation, which was used to determine the clinical and procedural information pertaining to the disease of interest, however, these errors are expected to be very low . NRD lacIn the United States, there is a slight decrease in the incidence of IE hospitalizations between January 1, 2010, and November 30, 2014. One in four IE patients is readmitted to the hospital within 30 days. IE patients leaving AMA or having a history of drug abuse and CIED in-situ or prosthetic valve in-situ were at the highest risk for 30-day readmission. The annual cost of readmissions after IE is $58 million. Further research is needed to investigate the impact of clinical and social measures that could decrease patients’ readmissions after IE and curb the high associated costs.


Vitis vinifera L.), which were distributed on four different chromosomes with similar gene structures. Except for the closer relationship with PIF1 of citrus, PIFs of grape were distant from the other fruit species such as apple, pear, peach, and strawberry. The VvPIFs (except VvPIF4) were located in the syntenic block with those from Arabidopsisthaliana, Solanum lycopersicum, or Citrus sinensis. In addition to PIF1, all PIFs in grapevines have conserved active PHYB binding (APB) sequences. VvPIF1 has a conserved PIF1-specific active PHYA binding (APA) sequence, while amino acid mutations occurred in the specific APA sequence in VvPIF3. Interestingly, two specific motifs were found in the PIF4 amino acid sequence. The photoreceptor-related elements in the VvPIFs promoter region were the most abundant. PIF1, LONG HYPOCOTYL 5 (HY5) and PIF3, PIF4, GIBBERELLIC ACID INSENSITIVE 1 (GAI1) may interact with each other and participate together in light signal transduction. The relative expression levels of the VvPIFs showed diverse patterns in the various organs at different developmental stages, of which PIF4 was most highly expressed. Prior to maturation, the expression of PIF4 and PIF7 in the skin of the different cultivars increased, while the expression of all PIFs in the flesh decreased. The transcription level of PIFs in grape leaves was sensitive to changes in lighting and shading. Shading treatment was beneficial for enhancing the transcription level of VvPIFs, but the effect on VvPIF3 and VvPIF4 was time-controlled. We concluded that PIFs in grapevines are both conservative and species-specific. The identification and analysis of grape PIFs could provide a theoretical foundation for the further construction of grape light regulation networks.Phytochrome-interacting factors (PIFs), as the basic helix–loop–helix (bHLH) transcription factors, are the primary signaling partners for phytochromes (PHY) that play a key role in PHY-mediated light signal transduction. At present, there are few studies on PIFs in fruit trees. In order to clarify the status of PIFs in grapevines, we identified members of the grape PIFs family and conducted phylogenetic and expression analysis. We identified PIF1, PIF3, PIF4, and PIF7 in PIFs families of the grapevine ( PHYA, PHYB, PHYC, PHYD, and PHYE were reported in Arabidopsis thaliana, PHYA, PHYB, PHYC in Oryza sativa, PHYA1, PHYB1, PHYC1 and their homologous genes PHYA2, PHYB2, PHYC2 in Zea mays [r and Pfr forms. Red-light activates PHYs by converting the Pr form to the Pfr form, whereas far red-light inactivates Pfr by converting it back to the Pr form.Plants undergo the developmental program of photomorphogenesis in the presence of light . PhytochPhytochrome-interacting factors (PIFs), the primary signaling partners for phytochromes, are basic helix–loop–helix (bHLH) transcription factors that play a key role in PHY-mediated light signal transduction. Similar to phytochromes, PIFs have been discovered in a variety of plant lineages from bryophytes to angiosperms ,5. In vaArabidopsis, many PIFs have been identified and functionally characterized. PIF1 has been shown to play a major role in inhibiting light-dependent seed germination [CBF) genes [In mination , and regmination . PIF3 comination , negativmination ,11, and F) genes . PIF4 reF) genes ,14,15. AF) genes ,17. PIF5F) genes . PIF6 haF) genes . PIF7, aF) genes . In the F) genes  found thF) genes ,23. PIF1F) genes .Arabidopsis, tomato, maize, rice and other herbs [PIFs gene family in grapes have not yet been identified and their function in grapevine photomorphogenesis, fruit development, regulation of endogenous metabolism, and reaction to external environment remains to be studied.At present, PIFs have been widely studied in er herbs ,25,26,27PIF genes in the grape using AtPIFs as a template. Afterwards, we carried out the gene structure analysis of the PIFs in the grape, other five herbaceous plants and three woody plants, and analyzed the amino acid conserved functional domains and the cis-elements in the promoters. To further clarify the function of those genes in grapes, we also studied the transcriptional levels of PIFs in different organs of grapevines, the sensitivity of VvPIFs to different stresses in the berries and leaves. The results of our study can provide theoretical support for the further construction of regulation network of PIFs in grape and other fruit trees.In this study, we identified a total of four PIFs during grape berry development. Twenty vines of each variety were chosen and the berry samples  were collected at the following four developmental stages (DS): (i) DS1, the early stage of fruit enlargement (20 days after anthesis); (ii) DS2, pre-verasion (10% of the berries began to change color); (iii) DS3, post-verasion (90% of the berries completed the color changing); and (iv) DS4, maturity  and titratable acid (TA) tended to be stable). Samples were randomly collected, and the location of vines and clusters were also considered. Young leaves, young tendrils, young stems, young roots were also sampled for tissue-specific expression analysis. Mature berries were separated into the skin and flesh, and then were immediately frozen in liquid nitrogen individually. All samples were stored at −80 °C for the subsequent analysis.The 6-year-old grape varieties Summer black (SB) and Shine Muscat (SM) planted in the Jiangsu Academy of Agricultural Sciences were used as materials to study the transcription patterns of Potted 2-year-old Summer Black grapes were used for the experiment. The grape seedlings grew in an artificial climate chamber at 25 °C overnight before the treatment. Tinfoil paper with no light transmittance was used as the light-shielding material, and the leaves at the 4th to 6th nodes were selected for testing. Half the blades are treated with light and half are shaded along the dividing line of the main vein. One control ) and two treatments were set in the test. One treatment was a shading treatment, and the other was a light treatment after 6 h of shading. The sampling time started from shading and was set at 0 h, 2 h, 4 h, 6 h, 8 h, 10 h, 12 h after shading. The collected leaves were immediately frozen in liquid nitrogen and stored at −80 °C.The 6-year-old grape varieties Summer Black in Wuhu, Anhui Province, China were tested. 20 bunches of grape berries were shaded with tinfoil paper and another 20 bunches without shading. Fruit bagging was performed 30 days after fruit setting, and samples were taken at 0 days (d), 15 d, and 30 d after bagging. The berry sample was collected and stored as described above.Arabidopsis PIFs from the TAIR Arabidopsis database [PIFs genes, we searched and downloaded the annotated grapevine proteins from three public databases: the National Centre for Biotechnology Information , the Genoscope [PIF was based on the E-value (1e−5) and the highest similarity scores. All the obtained sequences were stored in the InterProScan database [Brassica napus, Nicotiana tabacum, Solanum lycopersicum, Prunus persica, Malus domestica, Pyrus bretschneideri, Citrus sinensis, Fragaria ananassa was also based on the E-value (1e−5) and the highest similarity scores to AtPIFs in NCBI.We downloaded the protein sequence of database  and thenenoscope  and the enoscope ,31. The database  and the database  to confidatabase ,35. The −30.Exon and intron structures of the VvPIFs were determined based on their coding sequence (CDS) and the correspondent full-length gene sequences in NCBI. The gene structures were thereafter illustrated by the online program Gene Structure Display Server . MEGA veVitis vinifera, A. thaliana, S. lycopersicum, and C. sinensis [−5 were filtered.MCscan X  was used to analyze the gene synteny and collinearity of PIFs among sinensis . The synsinensis  and thosPIFs were performed using the MEGA version 6 [PIFs genes of each species was used to perform cis-elements analysis in PlantCARE [https://string-db.org).Multiple sequence alignments of ersion 6 . The 150lantCARE . The prohttps://www.ncbi.nlm.nih.gov/geo/). Data code was GSE36128 and the chosen cultivar was Corvina. The short term abiotic stress data was from GSE31594, in which Cabernet Sauvignon was treated with 120 mM salt (10:1 NaCl:CaCl), Polyethylene Glycol, cold (5 °C) or unstressed. The long-term salt and water stress data was from GSE31677, where the potted Cabernet Sauvignon vines in the greenhouse were exposed to irrigated controls, non-irrigated water-deficits, and saline treatments for 16 days. The expression data were normalized according to Zhu et al. [The transcriptome data of organs such as roots, stems, leaves, flowers, berries, and tendrils are from Gene Expression Omnibus  and SuperscriptIII RNase H-RT kit from Invitrogen  according to the manufacturer’s instruction. The cDNA was diluted at 1:10 for RT-PCR.Total RNAs were isolated using a CTAB method according to Wang et al. . Then th−ΔCt method. Due to the low expression values of PIFs in some organs of the grape berries, expression levels in those cases were calculated based on the 2−ΔΔCt method with the first stage sample chosen as a reference for convenience of observation.Real time-PCR (RT-PCR) was carried out using the CFX96 Real-Time PCR Detection system . Reaction mixes volume was 10 μL, which included 5 μL of SYBR Green Supermix (Bio-Rad), 2 μL of diluted cDNA, and 0.2 μL of each primer. Each pair of quantitative real time PCR (qRT-PCR) primers were validated by cloning and sequencing of the RT-PCR product with this pair of primers. The efficiency of each primer pair was quantified using a PCR product serial dilution. All biological samples were assayed in technical triplicates. Ubiquitin and EF1γ were used as internal standards and for normalizing the expression. Expression levels were calculated based on the 2p < 0.05. Correlation network analysis was conducted in the Heml1.0.3.7 software  and the line chart was performed by Origin 2017 .Statistical analysis was performed with the software SAS 9.2 . Differences between genotypes and tissues for a giving sampling date were analyzed by a two-way analysis of variance (ANOVA) followed by the Duncan’s multiple comparison test at PIF1, PIF3, PIF4, and PIF7, respectively and their corresponding serial numbers are LOC100264869, LOC100247781, LOC100262490, and LOC100262138 in NCBI, VIT_07s0005g05100, VIT_14s0060g00260, VIT_12s0028g01110, and VIT_17s0000g06930 in CRIBI, and GSVIVT00028516001, GSVIVT00031338001, GSVIVT00020814001, and GSVIVT00007914001 in the 12X grapevine genome database. The basic information of the four genes was listed in PIFs varied from 3617 to 5463 bp, and the length of amino acids sequence ranged from 423 to 709. PIF3 and PIF7 have the largest or the smallest genomic DNA, number of amino acids and protein molecular weight individually. The predicted isoelectric point range of various proteins ranged from 5.32 to 8.94, indicating that those proteins might function in different subcellular compartments. What is more, each protein contains a bHLH domain.A total of 4 PIF members were identified in the three grape genome database ,30,31. TPIF4 and PIF1 (55%). But for the amino acid sequences, the similarity of each pair was low, ranging from 22% to 33%.As for the comparison among CDS , the simA. thaliana and B. napus were clustered together and other species were clustered in another class. But in the second class, VvPIF4 had a far kinship with other fruit species. In the PIF3, CsPIF3 diverged from other species at the earliest time, and VvPIF3 had a distant relationship with other species. In the PIF7, VvPIF7 was at the starting node of fruit species classification and has a distant relationship with others. PIF6 was only found in A. thaliana and B. napus. Overall, except for the closer relationship with citrus on PIF1, PIFs of grapes were far from the other fruit species such as apples, pears, peaches, and strawberries.According to the estimated divergence times for the molecular phylogenetic analysis by ML method (timetree) , the PIFPIF1  in  and Q48 ; of PIF1 and Q48 . From th and Q48 , whetherS. lycopersicum and N. tabacum, of which motif 1 and motif 2 existed in all fruit species, but others differed greatly among species. Above all, motif 1, 2, 7, 3, 6, 8 seem to be the conserved motifs of PIFs.After conservative motifs analysis of PIFs family, we obtained 10 conserved domains, of which the second domain contained APB conserved motifs . A totalPIFs, we amplified the 1500 bp upstream of the PIFs genes and analyzed their cis-elements. The predicted cis-elements differed among species and genes, but the cis-elements related to photoreaction were the most abundant , which had the largest number in all species  was the largest except those related to photoreaction. In the promoter of PIF3 and PIF7, there was many elements for abscisic acid responsiveness (ABRE), but no for circadian control (circadian: CANNNNATC) in grapes when compared with other fruit species. The cis-elements in the VvPIF4 promoter were less diverse. Compared with other fruit trees, the upstream of VvPIF4 lacked the anaerobic induction (ARE), drought-inducibility (MBS) related elements, and had a seed-specific regulation class  element. Last but not least, there were no low-temperature-responsive elements detected in the promoters of VvPIFs.The number of PIF gene and grape growth, we also performed expression analysis.As we all know, PIFs are involved in the transduction of light signals in plants. However, the specific regulatory network of PIFs in grapes is still not clear. VvPIF1 could interact with PHYA, PHYE, and HY5 to participate in the regulation of diurnal growth and development of plants . VvPIF3 PIFs in grape organs . VvPIF3 was at higher transcriptional levels than VvPIF4 and VvPIF7 in most organs, such as the berries in stages before maturation , buds during sprouting and developing , the growing flower , leaves before senescence , the developing rachis , stems and tendril . Compared with the expression of other PIFs, PIF7 was only expressed higher at Bud-B, Leaf-Y, Leaf-FS and Tendril, and the transcription level of PIF1 was low in most organs.According to the transcriptome data of Corvina , the VvPPIFs between SB and Corvina, the transcriptional levels of PIF4 were similar and high in roots, mature leaves, and fruits (skin and flesh) of both varieties. But the relative level of PIF7 was a little different in the young stem, tendril and inflorescence of these two cultivars, and the transcription level of PIF7 in Corvina was not as high as that in SB. These differences may be related to the cultivar characteristic and developmental stage. Taken together, the transcription level of PIF4 was the highest in most organs of the grape, followed by PIF3 and PIF7.When comparing the transcriptional data of PIFs during fruit development showed a different pattern in different colored grape varieties  treatment did not change the trend of PIF7 at different periods but increased the expression of PIF7 at 1 and 24 h. The expression level of PIF4 gradually increased under PEG treatment. Under low temperature conditions, the transcriptional levels of PIF4 and PIF7 were down-regulated, but the latter decreased more significantly  as a direct target of PIF1, which acted downstream of PIF1 in the endodermis to repress photosynthetic genes and regulate plastid development.PIFs are important regulators of light signal transduction and each specific photoreaction can be regulated by several different PIFs ,6,52. PIcis-elements related to photoreaction in the promoter of PIFs is the most abundant, which corresponds to the role of PIFs in the light response process.To clarify the metabolic network of PIFs in grapes, we performed promoter analysis and functional prediction of PIFs. The number of ZmPIF1 promoter region was rich in drought response (MBS) and ABRE-related elements, and that the expression level of ZmPIF1 was significantly induced by drought and abscisic acid treatments [cis-elements related to ABA response and no cis-elements related to drought response. The response of VvPIF1 to ABA and drought signals may not be as sensitive as ZmPIF1.eatments . In grapVvPIF3, which indicated that grapes may react differently from Arabidopsis in response to ABA and ethylene stimulation. PIF4 is the main regulator promoting hypocotyl elongation and early flowering response under high temperature [VvPIF4. VvPIF4 was transcribed at low levels under the low temperature stress and might participate in the regulation of growth under high temperature. The transcription levels of VvPIF4 and VvPIF7 both increased under drought stress, but drought response elements were only detected in the promoter of VvPIF7, not in VvPIF4. VvPIF7 and VvPIF4 may respond to drought signals in different regulatory ways.AtPIF3 is the main regulator promoting hypocotyls elongation in response to ethylene  and therperature ,58. Thercis-element G-box to cope with light and temperature changes. In regulating photosynthetic pigment synthesis genes, HY5 and PIFs do not operate alone, but with the circadian clock [HY5 is a basic leucine zipper (bZIP) transcription factor that can form dynamic activation-suppression transcription module with PIFs, which directly act on the promoter an clock . Throughan clock , The funSlPIF1a were identified in tomatoes. Upon induction of ripening, PIF1a transcript levels increased approximately fivefold in red ripe fruit compared to green samples [PIF1 in the skin of SM was similar to SlPIF1a  were located at the syntenic block with those from A. thaliana, S. lycopersicum, or C. sinensis. PIF3, PIF4, and PIF7 in grapes have conserved APB sequences. VvPIF1 has a conserved PIF1-specific APA sequence, while amino acid mutations occur in the specific APA sequences in VvPIF3. What’s more, two specific motifs are found in the PIF4 amino sequence. The photoreceptor-related elements in the VvPIFs promoter region are the most abundant. VvPIF1 and VvHY5, VvPIF3, VvPIF4 and VvGAI1 may interact with each other and participate in light signal transduction together.We identified PIF1, PIF3, PIF4, and PIF7 in the grapevine. These members are distributed on four different chromosomes with similar gene structures. VvPIFs varied in different organs at different developmental stages, PIF4 was expressed at the highest level in most organs of grapevines. The transcriptional levels of PIF4 and PIF7 increased in the skin while the expression of all PIFs generally showed a downward trend in the flesh during the period before maturation. The transcription level of PIFs in grape leaves was sensitive to light/dark changes. Shading treatment was beneficial to enhance the transcription level of VvPIFs, but the effect is time-controlled on VvPIF3 and VvPIF4. These findings could lay the theoretical foundation for the function study of PIFs and the further construction of grape light regulation networks.The relative expression levels of


Infant dietary data, collected using a food diary at 6, 9 and 12 months of age, were used to estimate energy and nutrients intake using the Italian food composition database. Age-related trends were calculated using Page’s trend test. An increasing age-trend was observed in the percentages of contribution of macronutrients to total energy intake, with the exception of total lipids, which instead decreased over time. Most of the infants shared a low varied diet especially with regards to protein intake sources, represented mainly by dairy and meat products rather than pulses and fish. This could also account for the low intake of essential fatty acids (ω3) that play an important role in infant neurodevelopment. Moreover, non-commercial baby foods contributed more in terms of quantity, energy and macronutrients intake, compared with commercial products. Healthy eating habits should be encouraged during the first year of life, promoting a varied and well balanced diet at family level.Complementary feeding is recognized as an important predictor of health later in life and is likely to affect the development of food preferences. This paper describes age-related trends in terms of energy, nutrients intake and dietary habits of an Italian infant sub cohort ( The transition from exclusive breastfeeding or formula feeding to family foods, which is referred to as complementary feeding (CF), typically covers the period from 6 to 18–24 months of age of infants. This period has been shown to lay the foundations for health and growth . AlthougThe aim of this paper is to describe age-related trends in energy, macro and micronutrients intake and Body Mass Index (BMI), during the first year of life with a special focus on whether the dietary habits of this sub cohort privileged home-made versus commercial baby foods. The present study offers the opportunity to better understand how eating patterns change during this sensitive time and to identify critical aspects of feeding practices during CF, which should be monitored closely and addressed by recommendations, targeted to parents.We investigated age-related trends in nutritional and anthropometric data obtained from an ongoing prospective infant cohort study conducted in the north east of Italy (Trieste Infant Food cohort—TIF cohort). In this study, detailed data were collected from 400 healthy infants recruited at birth at the Institute for Maternal and Child Health—IRCCS “Burlo Garofolo” Trieste, between July 2007 and July 2008. The study, which started in 2006 as a part of the PHIME European research project , was conIn brief, infants were eligible if their birth weight was 2000 g or more, gestational age was 36 completed weeks or more, if they were not affected by severe diseases or congenital malformations that required hospital admission and if their mothers were resident in the province of Trieste. Dietary data were collected using a 3-day dietary (3-DD) record (food diary) provided to mothers during the first contact, with instructions on how to record type, quantity and method of feeding over a 24 h period on three separate non-consecutive days, including one at the weekend at 3, 6, 9, 12, 18, 24 and 36 months of age of the infants. Mothers were asked to report weight and length of their children as measured by their community paediatrician during periodic health checks at 1, 3, 5–6, 8, 12, 18, 24 and 36 months of age. In addition, demographic, educational, social and anthropometric data of the mothers and fathers were obtained from a validated questionnaire designed for the PHIME study .The present paper focuses on only 3  of the 7 collection points, because this is the period in which CF starts and the changes in the infant’s diet are greater and most rapid . Only suData extracted from food diaries were analysed using the Microdiet V2.8.6. software , which contains the Italian Food Composition database for Epidemiological Studies , integraThe nutritional analysis was performed on 28 food components: proteins , carbohydrates , lipids , minerals  and vitamins .Foods were classified into 21 food groups based on the methodology proposed by Talamini et al. (2006)  and modiBased on the methodology used by Noble and colleagues in the ALSPAC study , we alsoFor the analysis of CF practices and of the contribution of each food type in terms of energy and macronutrients intake, we considered three separate categories, two relating to complementary feeding (NCP and CP) and one to milk based feeding (BF plus FF).Furthermore, in order to highlight the age-related trends in daily intake of different food groups, we performed the analysis on the food groups that contributed the most to macronutrients intake: cereals, milk and dairy products, eggs, fruit and vegetables, pulses, fish and meat and cured meat.Categorical data are presented as absolute frequencies and percentages, while continuous data as medians and interquartile ranges (IQR: 1st-3rd quartiles). The mean daily intake of macro-, micronutrients and energy was calculated, for each infant, on a 3-day observation basis, excluding the use of supplements.p-value below 0.05.Differences in continuous variables were assessed using non-parametric rank-sum Mann–Whitney tests or signed-rank Wilcoxon test as appropriate, while differences between categorical variables were analysed with two-tailed Fisher exact tests. Trend analysis was performed using Page’s trend test. With regards to the repeated measures , the signed-rank test by Wilcoxon allowed us to test the significance of the difference between measures at different time points (i.e. 6 months vs. 9 months and 9 months vs. 12 months). Page’s trend test, instead, was used to verify if there was a significant trend (decreasing or increasing) taking into account the three measures simultaneously. Both tests (Wilcoxon’s and Page’s) are non-parametric rank tests, not imposing hypothesis on the distribution of the data analysed and on their residuals. Statistical significance for all tests was set at a z-scores [Anthropometric measures were compared with the WHO growth standards using WHO Anthro software and are reported as BMI z-scores ,25.All the analyses were carried out using Stata/IC 14.2 .n = 152) are described in The number of food diaries available were 268 at 6 months, 179 at 9 months and 176 at 12 months of age but only for 152 infants completed food diaries were available at each collection points. The characteristics of the mothers and infants of the TIF sub cohort (Forty-five percent of mothers were 35 years old or more (mean age 34.4 ± 4.2), 92% were born in Italy, 91% were married or living with the father of the child, 88% had a medium-high level of education, 96% were in employment and 68% had a pre-pregnancy BMI that fell within the normal range. Most infants (94%) were born between 38 and 42 weeks of gestation, 83% by vaginal delivery. Infants were equally distributed by sex: 78 (52%) males and 73 (48%) females. The majority (94%) weighed between 2500 g and 4199 g at birth (mean weight 3432 ± 442 g) and 83% were between 46.0 and 52.9 cm long (mean length 50.5 ± 1.9 cm).n = 152) and the remaining TIF group (n = 248) shown a statistically significant difference in terms of level of education (p = 0.001), nationality (p = 0.041) and mean age at delivery (p = 0.004). More specifically, mothers belonging to the TIF sub cohort had a higher level of education (88% vs. 79%), were more likely to be Italian (92 vs. 85%) and had higher mean age at delivery (34.4 ± 4.2 vs. 33.0 ± 4.9), as compared with the remaining TIF cohort.A comparison between the mothers belonging to the TIF sub cohort  or in combination with breast milk (56%) or infant formula (36%) and only one infant (1%) was still exclusively breastfed. At 12 months of age, 39% of infants were still breastfeeding. A complete overview of the feeding practices in the TIF cohort, during the first 24 months of life of the infants is published elsewhere .Daily energy, macro- and micronutrients intake are shown in The intake of energy, total proteins, saturated fatty acids, starch, calcium, potassium, vitamin B2, vitamin B6 and vitamin E α-TE significantly increased between 6 and 12 months of age. In particular total proteins intake almost tripled, from 13.0  g/day at 6 months to 31.9  g/day at 12 months, while the intake of calcium and potassium almost doubled, from 313.5  mg/day and 610.3  mg/day at 6 months to 587.1  mg/day and 1232.7  mg/day at 12 months of age, respectively.Although the trend analysis shown a statistically significant increase in the intake of total lipids, monounsaturated fatty acids, oleic acid, cholesterol, available carbohydrates, fibre, iron, sodium, zinc, vitamin B1, retinol, retinol eq, niacin and folate between the ages of 6 and 12 months, this trend flattened between 9 and 12 months. The only exception was zinc intake for which no statistically significant difference was found between 6 and 9 months of age. Moreover, as shown in p < 0.001). Moreover, there was a statistically significant increase in CP consumption from 6 to 9 months (p < 0.001) followed by a statistically significant decrease between 9 and 12 months (p < 0.001). The only exceptions were soluble carbohydrates which continued to increase (p < 0.001), available carbohydrates and proteins which showed a non-significant decrease between 9 and 12 months of age (p = 0.0787). At 6 months, soluble carbohydrates were found not to contribute to energy intake from CP (0%E) but this was probably due to missing data in baby food labels [Overall, NCP contributed more, in terms of energy and macronutrients, compared to CP at each of the three collection points, with the exception of available carbohydrates at 6 months which were mainly from CP. In particular, for NCP consumption, the trend analysis revealed a statistically significant increase in energy and nutrients intake between the ages of 6 and 12 months . This can lead to negative short and long-term health consequences, as already reported in a previous paper on the same cohort .The assessment of the dietary intake of infants during the first year of life is generally recognized as difficult to accomplish. Only few national and international studies have analysed the dietary habits of infants in a period that is so crucial for child growth, development and health and is characterized by the transition from exclusive milk feeding to family foods. Among the few available studies, one of the most important is the DONALD study, a prospective cohort study conducted by the University of Bonn, Germany, to assess the relationship between diet, nutrition and development during childhood and adolescence . In partAs shown in Two studies have analysed the contribution of CP and NCP in terms of energy and macronutrients intake ,28. In tSince, only one infant in the TIF sub cohort classified as overweight, we decided not to study the influence of different complementary feeding habits  on infant BMI, as reported in another study . As repoThe strengths and limitations of our study need to be discussed. Among the major strengths are the frequent and detailed measurements of nutrition and growth, the adoption of a rigorous design (prospective cohort study) that allowed for accurate data collection, the use of a 3-day dietary (3-DD) record which is the gold standard for the assessment of dietary intake during infancy , the extThe data from our study demonstrate an increasing age-trend in the percentages of contribution of the main macronutrients to total energy intake, except for total lipids, during the first year of life. Most of the infants shared a low varied diet, as already reported in a previous paper , with enOverall, NCP contributed more, in terms of energy and macronutrients intake, compared to CP, during the CF period. However, there was a linear increase in CP consumption between 6 and 9 months of age.Our results suggest that, in order to promote healthy eating habits during the first year of life and encourage a varied and well-balanced diet at family level, a number of public health strategies should be implemented at national level. Among these the protection, promotion and support of breastfeeding during the first year of life and the development of evidence-based guidelines on infant feeding, endorsed by all health professionals and free from commercial interests.


This cohort study uses data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screen Trial to examine the associations among regular aspirin use, obesity, and all-cause and cancer mortality among older adults. Is aspirin use associated with reduced risk of mortality in older adults?This cohort study included 146 152 individuals from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and found that aspirin use 3 or more times per week was associated with reduced risk of all-cause, cancer, gastrointestinal cancer, and colorectal cancer mortality.These findings suggest that prophylactic aspirin use may reduce risk of mortality among older individuals. Aspirin use has been associated with reduced risk of cancer mortality, particularly of the colorectum. However, aspirin efficacy may be influenced by biological characteristics, such as obesity and age. With the increasing prevalence of obesity and conflicting data regarding the effect of aspirin in older adults, understanding the potential association of aspirin use with cancer mortality according to body mass index (BMI) and age is imperative.To investigate the association of aspirin use with risk of all-cause, any cancer, gastrointestinal (GI) cancer, and colorectal cancer (CRC) mortality among older adults and to perform an exploratory analysis of the association of aspirin use with mortality stratified by BMI.This cohort study evaluated aspirin use among participants aged 65 years and older in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial at baseline  and follow-up (2006-2008). Analysis began in late 2018 and was completed in September 2019.All-cause, any cancer, GI cancer, or CRC mortality. Multivariable hazard ratios (HRs) and 95% CIs were calculated using time-varying Cox proportional hazards regression modeling, adjusting for additional factors.P < .001) and cancer mortality . Aspirin use 3 or more times per week was associated with decreased risk of mortality of all causes , any cancer , GI cancer , and CRC . When stratified by BMI , aspirin use 3 or more times per week among individuals with BMI 20 to 24.9 was associated with reduced risk of all-cause mortality  and any cancer mortality . Among individuals with BMI 25 to 29.9, aspirin use 3 or more times per week was associated with reduced risk of all-cause mortality , any cancer mortality , GI cancer mortality , and CRC mortality .A total of 146 152 individuals  were included in analysis. The median (interquartile range) follow-up time was 12.5 (8.7-16.4) years, encompassing 1 822 164 person-years. Compared with no use, aspirin use 1 to 3 times per month was associated with reduced risk of all-cause mortality (HR, 0.84; 95% CI, 0.80-0.88; In this cohort study, aspirin use 3 or more times per week was associated with a reduction in all-cause, cancer, GI cancer and CRC mortality in older adults. This result has been additionally illustrated in a 2010 meta-analysis of randomized clinical trials.4 The association of aspirin with reduced cancer incidence and mortality has been consistently robust among GI cancers; however, there is limited evidence suggesting that aspirin use is associated with reduced mortality risk among other cancer types.11 The US Preventive Services Task Force (USPSTF) recommends low-dose aspirin use for the prevention of cardiovascular disease and CRC among average-risk individuals aged 50 to 59 years with a 10% or greater 10-year risk of cardiovascular disease; however, individuals aged 60 to 69 years should have an individualized approach, while evidence for use among individuals 70 years and older remains insufficient.12 It is important to note that a 2015 systematic review of the literature by the USPSTF11 found that individuals with daily aspirin dosing up to 1200 mg for a duration of 4 or more years exhibited a significant reduction in all-cause and cancer mortality, demonstrating a similar benefit of low-dose and standard aspirin.Aspirin use of 10 years or more is estimated to reduce cancer incidence and mortality.13 drew further attention of the potential cancer preventive effect of aspirin. The ASPREE study was a randomized clinical trial conducted in the United States and Australia investigating the efficacy of 100 mg of aspirin daily vs placebo in extending disability-free survival among elderly individuals (recruitment age 65 years or 70 years) during 4.7 years of follow-up.13 Unexpectedly, an increased risk of all-cause and cancer-related death was observed in the group randomized to aspirin.14Recently, the results of the Aspirin in Reducing Events in the Elderly (ASPREE) study1Thus, based on the results of the ASPREE randomized clinical trial that conflict with the preponderance of data showing a benefit of aspirin use, we examined the association of aspirin use with mortality risk among older adults enrolled in the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. In addition, given data suggesting that aspirin may be less effective among individuals who are overweight or obese, we conducted exploratory analyses stratified by body mass index (BMI), calculated as weight in kilograms divided by height in meters squared.STROBE) reporting guideline.This study is a post hoc analysis of PLCO study data. The original trial was approved by the institutional review boards at all study sites . All enrolled participants provided written informed consent. The use of their data for additional studies and analysis was included in the original informed consent. This study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology  or control arm at 10 screening centers in the United States between November 8, 1993, and July 2, 2001. Pertinent exclusion criteria for this study were individuals with a history of CRC or lung, prostate, or ovarian cancer, previous surgical removal of the colon, lung, or prostate, or, starting in 1995, individuals who had a colonoscopy, sigmoidoscopy, or barium enema in the 3 years prior to study randomization. This cohort included participants who were 65 years or older or survived until age 65, had a valid baseline questionnaire (BQ) after study enrollment, and had reported information on aspirin use at baseline. Completion of a follow-up supplemental questionnaire (SQ) by participants between 2006 and 2008 was not required for inclusion into the study cohort. All responses to the BQ and SQ were ascertained by self-report. The full content of both questionnaires has been published previously.18 Briefly, the BQ asked, “During the last 12 months, have you regularly used aspirin or aspirin-containing products, such as Bayer, Bufferin, or Anacin (Please do not include aspirin-free products such as Tylenol and Panadol).” If the respondent answered yes, the frequency categories were given as less than 2 per month, 2 to 3 per month, 1 per week, 2 per week, 3 to 4 per week, 1 per day, or 2 or more per day. The SQ asked, “During the last 12 months, about how often did you usually take aspirin ?” The frequency categories were given as none or less than once per month, 1 to 3 times per month, 1 to 2 times per week, 3 to 6 times per week, and 7 or more times per week. To allow for consistent values between BQs and SQs, we collapsed the aspirin use frequency variables into no aspirin use or less than once per month, 1 to 3 times per month, 1 to 2 times per week, and 3 or more times per week. Usual dose information was not available on the BQ; therefore, this analysis does not consider dose. We categorized BMI as less than 20, 20 to 24.9, 25 to 29.9, and 30 or higher.The design and methods of the PLCO Cancer Screening Trial have been previously described.15 Deaths were ascertained via annual study update questionnaire, individual reports, or death certificates. Beginning in 2011, participants were reconsented for follow-up. This allowed for linkage to the National Death Index, which extended mortality follow-up for up to 20 years after randomization.19 For those reconsenting, the end of mortality follow-up was December 31, 2015 or their date of death, whichever came first. For the approximately 15% of individuals who were alive in 2011 but who declined extended follow-up, the end of mortality follow-up was their declining date, which was generally in 2011.Initial analysis of the PLCO Cancer Screening Trial was completed after 13 years of follow-up or on December 31, 2009, whichever came first.The purpose of this analysis was to assess the associations among aspirin use, BMI, and mortality of all causes, any cancer, gastrointestinal (GI) cancer, and CRC among individuals in the PLCO Cancer Screening Trial who survived to age 65 years and older . ParticiFinally, as an exploratory assessment of longitudinal patterns of aspirin use, we examined risk of mortality only among participants who had completed aspirin frequency questions on the BQ and SQ. Follow-up for this cohort subset began at age 65 years or completion of the SQ, whichever occurred last. Participants were categorized according to baseline and follow-up aspirin use as (1) consistent nonusers (use >1 time per week or no use at baseline and follow-up), (2) users at baseline only (use ≥1 time per week at baseline only), (3) users at follow-up only (use ≥1 time per week at follow-up only), or (4) consistent users (use ≥1 time per week at baseline and follow-up). We used weekly aspirin use as our metric in this analysis for consistency with previous analyses and to include the maximum number of participants with BQ and SQ data. Supplemental questionnaire variables included in the model were randomization arm, sex , race/ethnicity , BMI, smoking status , history of myocardial infarction, history of stroke, history of hypertension, history of diabetes, and ibuprofen use 3 or more times per week.International Classification of Diseases, Ninth Revision (ICD-9) codes.20 All-cause mortality was defined as a reported death of any cause. Any cancer mortality was defined as a reported cause of death by cancer based on the official PLCO Cancer Screening Trial definitions, derived from standard ICD-9 groupings. Cause of death by GI cancer was determined by ICD-9 codes for esophagus (150), gastric (151), and colorectal (153 and 154) cancer, whereas CRC was determined by ICD-9 codes for CRC only (153 and 154). All statistical analyses were performed in SAS statistical software version 9.4 (SAS Institute). P values were 2-tailed, and statistical significance was set at less than .05.Causes of death were determined by The eligibility criteria for the study analysis are outlined in P < .001), 1 to 2 times per week , or 3 or more times per week . A similar association was noted for risk of cancer mortality and aspirin use 1 to 3 times per month  or 3 or more times per week . Use of aspirin 3 or more times per week was also associated with significantly reduced risk of GI cancer mortality  and CRC mortality . Data for the additional covariates included in the model are provided in the eTable in the The results of the Cox proportional hazards regression model are presented in P < .001; BMI 25-29.9: HR, 0.82; 95% CI, 0.78-0.93; P < .001; BMI ≥30: HR, 0.85; 95% CI, 0.78-0.93; P < .001), 1 to 2 times per week , or 3 or more times per week  (P < .001), BMI 25-29.9  or BMI 30 or higher  (P = .007) (P < .001) and CRC mortality   A. Reduce < .001) B. No sta = .007) B. Indivi < .001) C and D.P < .001), cancer mortality , and GI cancer mortality . Individuals who were consistent aspirin users were also associated with reduced risk of all-cause mortality , cancer mortality , and GI cancer mortality . Of particular interest, the HRs for CRC-associated mortality were 0.88  for users at baseline only, 0.62  for users at follow-up only, and 0.62  for consistent users, compared with nonusers of aspirin.We additionally examined the association between reported aspirin use at baseline and at the time of the SQ with risk of mortality. Participants who had reported aspirin use at follow-up only or consistent users were associated with a reduced risk of mortality . IndividThis cohort study found that aspirin use among individuals 65 years and older was associated with a lower risk of mortality. This observation was consistent across all causes of mortality ; however, the greatest reduction in risk was noted for CRC mortality among individuals who used aspirin 3 or more times per week. Additionally, our exploratory analyses investigating the potential associations among aspirin use, BMI, and mortality risk suggest that the efficacy of aspirin as a cancer preventive agent may be associated with BMI. Participants in the PLCO Cancer Screening Trial who were underweight  had no observable benefit associated with aspirin use, while those with BMI 20 or higher were associated with reduced mortality risk, particularly with aspirin use 3 or more times per week. reduced risk of CRC mortality was only associated with individuals with BMI 20 to 29.9 who reported aspirin use 3 or more times per week.21 found reduced CRC incidence 10 to 19 years after aspirin use initiation. This association persists among investigations of aspirin use and cancer mortality. A 2011 systematic analysis of 8 clinical trials22 found that daily aspirin use was associated with reduced risk of death of several cancers, with increased benefit associated with long-term use. A similar association was observed in a 2018 cohort study23 of veterans in which aspirin users were associated with reduced risk of CRC mortality compared with nonusers. This association was additionally examined in the Cancer Prevention Study-II Nutrition Cohort,24 in which daily aspirin use was associated with reduced overall cancer mortality. These observations are in contrast with data from the ASPREE trial.13 However, the interpretation of the ASPREE results is limited owing a lack of an association of aspirin with cancer and CRC incidence and the short duration of follow-up.25 With additional follow-up, an association of aspirin with lower cancer incidence and death may have emerged.26 In addition, a 2018 combined analysis of the NIH-AARP Diet and Health Study and the PLCO Cancer Screening Trial27 reported decreased risk of all-cause, cancer, and cardiovascular mortality associated with daily aspirin use. However, a dosage that exceeded 1 per day was associated with an increased risk of mortality. These data also did not account for effect modifications by BMI on mortality risk. Previous studies have also found that variables, such as BMI, are associated with the efficacy of prophylactic aspirin. In a 2012 study of the Cancer Prevention Study-II Nutrition Cohort,28 individuals with prediagnostic BMI 30 or higher were associated with increased risk of all-cause and CRC death. A similar association was demonstrated across several other cohort and case-control studies, cancers, and causes of death.31The efficacy of prophylactic aspirin use for prevention of cancer incidence and mortality has been debated; however, the most evidence from prospective cohorts and secondary analyses from clinical trials indicates a protective association with aspirin use. A 2016 systematic analysis of primary and secondary cardiovascular prevention trials32 Studies have suggested that aspirin has reduced effectiveness as a primary prevention modality among individuals who are obese owing to decreased bioavailability and antithrombotic efficacy; however, this study did not find an association of overweight or obesity with decreased efficacy.35 Therefore, although aspirin use is associated with benefit as a cancer preventive agent, the changing characteristics of the global population may alter its efficacy and must be considered along with age and risk of bleeding before recommending aspirin for cancer prevention.The observation that BMI may be associated with efficacy of aspirin in individuals 65 years and older is notable; however, our findings require further confirmation. Increasing rates of overweight and obesity globally may substantially alter the population-based efficacy of cancer prevention prophylatics.36 Additionally, our analysis was focused on individuals in the PLCO Cancer Screening Trial cohort who survived to and began follow-up at or after age 65 years. However, only a small percentage (5.5%) of the PLCO cohort was ineligible for our study.Our study has several limitations. First, this is a secondary analysis of a randomized intervention (screening) trial with self-reported data on aspirin use. When collecting self-reported data, one must be aware of the limitations to these data, such as underreporting parameters of interest and the potential effect of this error in the analyses, such as biasing toward the null. For example, it is possible that aspirin use was underreported if the participant was unaware that a given agent, based upon its trade name, was classified as aspirin. Next, the information on aspirin use may be subject to participant interpretation and measurement error. Regular use of aspirin was not defined in the BQ, so participants could then have interpreted regular aspirin use differently, which may have affected their categorization . Furthermore, the information collected regarding aspirin dosage was limited. These issues may, in addition to confounding by unmeasured covariates, help explain the lack of a dose-response association for mortality risk in the observed data. Though there is substantial evidence documenting the association of frequent aspirin use with cancer prevention, the biological effect of low frequency use  is uncertain. Therefore, the noted risk reduction associated with this group may be due to unmeasured confounders. Along similar lines, it remains possible that individuals who reported low or no use of aspirin were unable to tolerate aspirin use for an extended length of time, perhaps owing to risk of bleeding or gastrointestinal injury, and may be inherently different than those who reported aspirin use.Although this study had several limitations, the research questions investigated examining the associations among aspirin use, BMI, and mortality adds to our knowledge of modifiable factors associated with cancer prevention efficacy. We were able to explore this question in a large, prospective study with an extended follow-up period.In this cohort study, we found a significant association of aspirin use with reduced all-cause, any cancer, GI cancer, and CRC mortality among individuals 65 years and older in the PLCO Cancer Screening Trial. Aspirin use was associated with reduced risk of all-cause and any cancer mortality, and aspirin use 3 or more times per week was associated with reduced risk of GI cancer mortality and CRC mortality when stratified by BMI. Future studies should further examine the association of BMI with the efficacy of aspirin as a cancer preventive agent to adapt to the changing global obesity trends.