According to the World Health Organization, obesity has nearly tripled since the 1970s. Obesity and overweight are major risk factors for cardiovascular diseases, diabetes, inflammatory-mediated diseases, and other serious medical conditions. Moreover, recent data suggest that obesity, overweight, diabetes, and cardiovascular diseases are risk factors for COVID-19-related mortality. Different strategies for weight control have been introduced over the last two decades. Unfortunately, these strategies have shown little effect. At the same time, many studies show that plants might be the key to a successful strategy for weight control. Following the PRISMA guidelines for conducting systematic reviews, a search was conducted in PubMed, Web of Science, Scopus, and Embase using the following keywords: obesity, globesity, vegan, plant-based diet, etc. Our results show that vegan diets are associated with improved gut microbiota symbiosis, increased insulin sensitivity, activation of peroxisome proliferator-activated receptors, and over-expression of mitochondrial uncoupling proteins. The key features of this diet are reduced calorie density and reduced cholesterol intake. The combination of these two factors is the essence of the efficiency of this approach to weight control. Our data suggest that plant-based/vegan diets might play a significant role in future strategies for reducing body weight. According to the World Health Organization (WHO), obesity has nearly tripled since the 1970s ,7,8,9,10Although obesity is considered to be preventable, to date, there is no reduction in the prevalence of individuals with overweight/obesity .2. Adults with a BMI equal to/greater than 30 kg/m2 are considered obese.Obesity and overweight have huge impacts on health ,7,8,9,10Some of the complications associated with obesity/overweight are hypertension, atherosclerosis, diabetes, sleep apnea, osteoarthritis, and cancer ,4,5,6,9.2 [2, the relative risk increases 40-fold [Diabetes mellitus, insulin resistance, and metabolic syndrome are considered to result from enlarged fat cells. The risk of diabetes is considered lowest in individuals with a BMI less than 22 kg/m2 . The risThe COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out at a time when about 20% of humanity was overweight or obese. The number of obese or overweight individuals is increasing .The COVID-19 pandemic has resulted in restriction of movement, the implementation of social distancing, and the interruption of many different sports activities. These adjustments have affected populations almost everywhere in the world by causing changes in food consumption and reduced physical activity . MoreoveThe relationship between overweight/obesity and morbidity and mortality has been known since antiquity. The Greek physician Hippocrates said, “Sudden death is more common in those who are naturally fat than in the lean” . ResearcThe key factors for this epidemic of overweight and obese individuals are: increased consumption of high-energy foods, decreased physical activity, and genetic susceptibility ,9. ThereNowadays, humanity needs to find an urgent solution for the global prevalence of obesity and overweight. The current trends in the treatment of obesity/overweight include: pharmacotherapy , surgery, food supplements intake, diets , and physical activity. ,13,14,15The best strategy for reducing the number of obese/overweight individuals is the prevention of these conditions. Unfortunately, the correct formula has not yet been found.Something relatively new in treating and preventing obesity and cardiovascular diseases is vegan and plant-based diets ,21,22,23In the last decade, vegan and plant-based diets have been consistently associated with reduced body weight and other health benefits ,64,65,66Vegan diets are dietary patterns that exclude all animals, while plant-based diets (vegetarian) do not necessarily eliminate all animal products but focus on eating mostly plants, such as fruits, vegetables, and nuts. ,23,28,45Compared to a plant-based diet, a vegan diet provides almost no cholesterol intake ,67. AnotEnterobacteriaceae [F. prausnitzii [Vegan diets are also associated with improved gut microbiota symbiosis, increased insulin sensitivity, reduced trimethylamine-N-oxide (TMAO), activation of peroxisome proliferator-activated receptors (PPARs), and overexpression of mitochondrial uncoupling proteins ,24,48. Teriaceae ,26, and usnitzii .Recent data suggest that vegan and plant-based diets are also associated with decreased all-cause mortality ,29,31. IIt is very important for these diets to exclude processed food and food containing added sugar in order to be very well balanced; otherwise, deficiencies in proteins, ω-3 fatty acids, vitamins, and minerals can occur ,53.Over the past few years, the interest in vegan diets and plant-based diets has increased not only in the general population but also in the scientific community. Although current scientific data suggest that limiting the consumption of meat and dairy products may contribute to better overall health, randomized clinical trials investigating the link between plant-based diets and human well-being are limited. However, plant-based diets, and especially vegan diets, may provide many benefits not only for overweight and obese individuals but also for individuals with type 2 diabetes, CHD, or arthritis ,64,65,66Following the PRISMA guidelines for conducting systematic reviews, a search was conducted in PubMed, Web of Science, and Scopus using the following search terms: “obesity”, “globesity”, “vegan”, “plant-based diet”, “vegetarian”, “weight control”, “weight loss”, and “obesity management”. The full search strategy is reported in Results were limited to original English-language articles published in full-text format in peer-reviewed journals until June 2021, assessing the direct relationship between plant-based diet and/or vegan diet and weight loss/obesity control in adults. Only clinical trials, randomized controlled trials, and prospective cohort studies were included in the results. The study selection included the screening of titles, abstracts, and full-texts and conducting a forward and backward search. All the studies selected showed a relationship between index terms “plant-based diet”, “vegetarian diet”, “vegan diet”, “obesity management”, “overweight”, and/or “weight loss”. The exclusion criteria were articles written in a language other than English, reviews, webinars, studies involving children or pregnant women, animal studies, articles with irrelevant topics, and lack of data. Inclusion criteria were human studies that investigate the relationship between obesity and vegan/plant-based diets and only adult participants.The full search strategy is reported in In total, 8014 articles were found. After removing review articles, 4054 articles remained. After removing duplicates, 1058 articles remained. A total of 442 articles were removed for other reasons. The titles, abstracts, and full texts of 616 articles were screened for eligibility. Of the 86 articles that remained after screening, 30 references met the inclusion criteria. However, these 30 references only referred to 27 studies because two of the studies are presented in more than one article.n = 762)/vegetarian diet (n = 876).These studies involved a total of 2890 participants. A total of 1638 of the participants had a nutritional intervention that included a plant-based diet: vegan diet  studies presented in  are randAlthough many researchers have tried to explain how these nutritional regimes impact different health conditions, many other further investigations are necessary.A total of 17 studies investigated the relationship between a vegan diet and weight management. Most of these 17 studies were randomized trials (94%), and one study did not have a control group. A total of 14 (82.3%) studies out of the 17 vegan-trials reported body weight reduction after a vegan diet intervention ,51,53,56According to data obtained from these trials, vegan diets, as compared to omnivorous diets, may significantly reduce body weight ,47,50,53Neal Barnard and his colleagues are among the researchers who have investigated the relationship between consumption of vegan diets and human health in many trials ,47,48,49In one of these trials, they compared the effects of a vegan diet to an ADA diet for 22 weeks . The resp = 0.01); LDL cholesterol decreased by 13.5 mg/dL in the vegan group compared to 3.4 mg/dL in the other group (p = 0.03) [In another study, Barnard and his team compared the vegan diet to the ADA diet for a longer period—74 weeks. The number of participants was the same as the previous study. The researchers reported no significant difference between the groups in terms of weight loss. However, weight loss was significant within each diet group: −4.4 kg in the vegan group and −3.0 kg in the other group. The lipid profile of the participants in the vegan group was reported to be better—the total cholesterol decreased by 20.4 mg/dL in the vegan group compared to 6.8 mg/dL in the other group ( = 0.03) ,44.A recent study, published in 2021, compared the vegan diet to the Mediterranean diet. In general, the Mediterranean diet is considered a “healthy nutrition regime”, but many varieties of it exist. For this study, this diet included a great variety of plant-based foods and low/moderate amounts of meat, dairy products, and eggs. The main source of fat was olive oil. The study involved 62 overweight adults and was performed by Barnard and his team . The stup < 0.01) and by −0.2% in the Korean Diabetes Association l diet group (p < 0.05). No significant differences in the changes in cholesterol levels were reported between the groups. However, a significant reduction in BMI and waist circumference was only reported for the vegan diet group [Yu-Mi Lee and colleagues compared the effects of a vegan diet to the diet recommended by the Korean Diabetes Association . The stuet group .One of the most important trials investigating the relationship between obesity/overweight lasted 2 years . The durCompared to conventional omnivorous diets, vegan diets seem to be much more effective for weight management ,47,48,49Turner-McGrievy and colleagues performed a five-arm, randomized controlled trial and reported that a vegan diet is much more effective for reducing body weight than other diets, including the vegetarian diet. The weight loss in the vegan group was not only the greatest, but was also significantly different from the other four groups .Kahleova and colleagues have also explored the relationship between a vegan diet and weight management by comparing vegan diet intervention to a conventional omnivorous diet. The researchers reported an average weight loss for the vegan group of 5.8 kg after 16 weeks compared to 3.8 kg for the omnivorous group ,46,47.2 for the vegan group (from 33.5 to 32 kg/m2). There was no reduction in BMI for the control group. The lipid profile of the vegan group was also reported to be better [Mishra and colleagues also compared the effects of an 18-week low-fat vegan diet intervention to an omnivorous diet . The rese better .Bacteroidetes to Firmicutes is associated with obesity [n = 84) and a control group (n = 84)). The vegan group lost, on average, 5.9 kg in body weight (including 3.9 kg of fat mass), compared to 0.5 kg for the control group. The researchers not only reported changes in body weight for the vegan group, but also changes in insulin sensitivity and changes in gut microbiota composition  [The role of the gut microbiota in human health is well known. It is understood that an imbalance in the microbiome may be associated with some serious pathological conditions. For example, a reduced ratio of  obesity . In anotcreased) . The autn = 20), overweight/obese adults (n = 20), and healthy adults (n = 20). Before the intervention, the participants had a fasting period of 10–12 h overnight. The participants with type 2 diabetes had to skip their diabetes medication in the evening and morning before the intervention. Measurements were taken at baseline (time 0) and then 180 min after the meal intake. The washout period between both test meals was 1 week. The researchers reported very interesting findings: the insulin secretion was higher after the vegan meal, compared to the meat meal, for the participants with diabetes. After the vegan meal, insulin sensitivity was the highest in overweight/obese adults compared with participants with diabetes and healthy adults. Compared to the meat meal, insulin sensitivity increased in all groups after the vegan meal by more than 40% [Kahleova and colleagues explored not only the effects of a long-term nutritional intervention, but also the direct effects of a vegan meal compared to the direct effects of a meat meal . The stuthan 40% .Compared to other diets, including vegetarian diets, the vegan diet seems to be much more beneficial in terms of weight control ,51,53,56Lower calorie density compared to other diets—individuals can eat bigger portions because plants have a lower calorie density than foods of animal origin .Antioxidants—vegan and plant-based diets, if well balanced, contain plentiful fruits and vegetables, which are rich in antioxidants. The consumption of raw fruits, vegetables, roots, nuts, and germinated seeds provides an intake of carotenoids, vitamin C, vitamin E, and other compounds that have an antioxidant effect.Lipid-lowering effects—the absence ,67 or liIn our view, the key points of the mechanism by which the vegan diet has a beneficial effect on conditions such as obesity and overweight are:Most obese/overweight adults are diagnosed with atherosclerosis, which is considered one of the most important risk factors for ischemic heart disease and ischemic stroke ,71,72,73However, the reduction in LDL levels is not the only key factor that reduces the risk of CVD. There is another mechanism by which plant-based/vegan diets might reduce the risk of major adverse cardiovascular events. This mechanism involves a reduction in the concentration of C-reactive protein, which is considered an important marker of inflammation . Not onln = 50) or the American Heart Association diet (n = 50). The study duration was 8 weeks. The researchers reported not only better anthropometric data for the participants in the vegan group  but also better glycemic markers, better lipid profile, and reduction in the concentrations of C-reactive protein. The total cholesterol decreased from 136 mg/dL  to 127 mg/dL  in the vegan group compared to a reduction from 146 mg/dL  to 142 mg/dL  in the American Heart Association group.Binita Shah and colleagues studied the anti-inflammatory effects of a vegan diet compared to the American Heart Association diet . The stuOverweight people suffer from a great variety of CVD, type 2 diabetes, joint pain (because of increased body mass), and other health problems. During our research for the link between plant-based diets and the prevention of obesity/overweight, we discovered studies that report that vegan diets are beneficial for recovery in patients with osteoarthritis. Kjeldsen-Kragh and colleagues performed a randomized, single-blind controlled trial of fasting and a one-year vegetarian diet in rheumatoid arthritis . The stuThe data from this research indicate that plant-based diets may benefit overweight individuals with joint problems. This study was not included in Other studies also provide evidence that plant-based diets may improve the signs and symptoms of rheumatoid arthritis ,35,36.Weight loss/obesity management should not only include strategies for reducing body mass but also for reaching a better overall health status, including reduced cholesterol levels, reduced triglyceride levels, and better glycemic control. That is why a vegan diet could be especially useful in the prevention/treatment of not only obesity/overweight but also CVD .However, a vegan diet should be well planned and balanced and should exclude processed foods. The intake of food supplements could support this type of diet to avoid the deficiency of some vitamins and minerals. It is important to include B12 supplementation because its deficiency is commonly associated with such nutritional regimes ,56,82,83We have included 11 studies that investigate the relationship between vegetarian diets and obesity/overweight management ,63,64,66n = 28) and a usual-care control group (no interventions) (n = 20). The results were in favor of the experimental group. The participants in the experimental group had a better lipid profile (LDL—3.93 mmol/L at baseline and 2.46 mmol/L at the first year) compared to the control group profile (LDL—4.32 mmol/L at baseline and 4.07 mmol/L at the first year). The average blood pressure also decreased in the experimental group (134/83 at baseline and 127/79 at first year). The participants in the experimental group reported a reduction in the frequency of chest pain by 91%, reduction in chest pain duration by 42%, and reduction in the severity of angina by 28%. However, these values worsened for the control group—chest pain frequency did not reduce but more than doubled, and the angina duration increased from 3.47 min to 6.97 min. The authors reported that the diameter of stenosis regressed significantly in the experimental group and progressed in the control group. The mean weight loss of the experimental group was 10 kg. The mean weight of the control group was 80.4 kg at the beginning of the study and 81.8 kg at the end of the study. This study demonstrated the strength of the relationship between plant-based diets, healthy lifestyles, and CVD management.D. Ornish and colleagues performed one of the earliest clinical trials investigating if lifestyle changes  can affect coronary atherosclerosis . The stuThe researchers made an important statement—lifestyle changes may cause not only significant weight loss but also a regression of even severe coronary atherosclerosis without the use of lipid-lowering drugs after only one year . Therefo−1 in the intervention group and by 2.2 mg dL−1 in the control group. LDL cholesterol declined by 7.8 mg dL−1 in the intervention group and increased by 0.4 mg dL−1 in the control group. The average body weight decreased by 7 kg for the plant-based group, compared to 0.6 kg for the control group [Another very important study reported on the relationship between the plant-based diets and s better lipid profile . Bunner ol group .However, the vegan diet seems to be much more beneficial in terms of cholesterol reduction. Vegetarian diets were not always able to provide a significant reduction in cholesterol levels .Some other beneficial changes in health status, which were associated with vegan diets, were also associated with vegetarian diets including but not limited to: healthier microbiota composition , a signiThe relationship between overweight/obesity, CVD, and diabetes is well known and extensively discussed. Current scientific data suggest that limiting the consumption of meat and dairy products may contribute to better overall health. However, randomized clinical trials investigating the link between plant-based diets and human well-being are limited. Plant-based diets, and especially vegan diets, may provide many benefits not only for overweight and obese individuals but also for individuals with type 2 diabetes, CVD, and arthritis.It is very important for the nutritional management of overweight/obesity to provide not only a reduction in body mass but also a better overall health status, including reduced cholesterol levels, reduced triglyceride levels, and better glycemic control.For that reason, a plant-based diet could become a novel successful instrument to fight the pandemic of “globesity”. However, long-term clinical studies should be carried out to establish the relationships between vegan diets, the prevention and treatment of obesity, and certain chronic non-communicable degenerative diseases. It is highly likely that, in the near future, these diets will be included in the therapy guidelines for of type 2 diabetes, CVD, obesity, and overweight.


Objective: To summarize the clinical features, hematology and imaging features of Takotsubo syndrome.Methods: The hospitalization data of Takotsubo syndrome patients in the First Affiliated Hospital of Xinjiang Medical University from January 2015 to December 2020 were collected, and their clinical characteristics were summarized. Patient outcomes were clarified through follow-up visits, and relevant objective indicators were statistically analyzed before and after admission. The characteristics of TTS incidence in Chinese population were summarized by searching three  major databases in China (PRISMA).Results: A total of 9 patients were enrolled, including 6 females (66.7%). The mean age of onset was 46.4 years old, the median time from onset to treatment was 1 day. The main symptom of 8 cases (88.9%) was chest pain, 1 case had a main symptom of syncope, and 7 cases (77.8%) had mood fluctuations or mental stimulation as the main symptom of the disease. Paired T-tests were conducted on routine blood, biochemical, coagulation, myocardial markers, inflammatory indicators and objective indicators of ECG before and after admission. The study found that the counts of white blood cells and neutrophils were statistically significant (P < 0.05). Prolongation of the QT interval was observed in all 9 patients. After a mean follow-up of 24 ± 28 months, no adverse cardiovascular events or recurrence occurred.Conclusion: Takotsubo syndrome is a group of clinical syndromes with emotional or somatic stimulation and chest pain as the main symptoms, partly accompanied by an increase in white blood cells, neutrophilic granulocyte count, creatine kinase, and troponin and is characterized by a prolonged QT interval and no obvious coronary stenosis. The prognosis is generally good, with few serious complications. Takotsubo syndrome (TTS) is also known as stress cardiomyopathy, apex spherical syndrome, octopus pot cardiomyopathy, broken heart syndrome, stress-induced cardiomyopathy, and Holy Bottle syndrome. Due to the continuous development of society, people's pressure is increasing, which is easy to induce Takotsubo syndrome. The clinical symptoms and electrocardiographic manifestations of this syndrome are similar to those of acute coronary syndrome. The main characteristic of this syndrome is regional abnormal left ventricular wall motion accompanied by abnormal left ventricular dilation during the systolic period. After the removal of the related inducements, the cardiac function of the patient returns to normal, and the prognosis is generally good. By retrospectively collecting the baseline data, clinical data and follow-up of patients with Takotsubo syndrome, we summarized the relevant clinical features of Takotsubo syndrome to facilitate more medical personnel to understand Takotsubo syndrome and to provide clinical guidance, since the current diagnostic method is mainly by a diagnosis by exclusion.Inclusion criteria were mainly based on the criteria for Takotsubo syndrome published by the Mayo Clinic; the main contents are as follows: 1) transient hypokinesia or abnormal movement in the middle segment of the left ventricle with or without apical involvement. Abnormal regional wall movement exceeds the distribution of single epicardial vessels. Triggers of stress are often present, but not always. (2) No angiographic evidence of obstructive coronary artery disease or acute plaque rupture. (3) New ECG abnormalities (ST-segment elevation and/or T-wave inversion) or mild myocardial troponin elevation , previous medical history, admission vital signs, height and weight of all patients were recorded. Serological examination results , auxiliary examination  and follow-up to observe whether the patient has recurrence or aggravation were also recorded.T-tests were used for the same patient from admission to discharge. The factors that did not follow a normal distribution are represented by the median , and the comparison between the two groups was performed by the Mann-Whitney test. For the enumeration data, we described the composition of the index by calculating its constituent ratio (%). A mean follow-up of 24 ± 28 months was followed for recurrence or exacerbation.This study was a retrospective, non-case-control follow-up study. The clinical data of Takotsubo syndrome patients in the First Affiliated Hospital of Xinjiang Medical University from January 2015 to December 2020 were collected, and the descriptive statistical analysis was conducted using Excel and SPSS 21.0. For measurement data, a normal test was carried out first, and the means plus standard deviations was used to describe those data following a normal distribution. Paired By searching three major databases: Wanfang, CNKI and China's VIP database. The search terms were “stress cardiomyopathy” or “Takotsubo syndrome” or “broken heart syndrome” or “apical spherical syndrome” or “octopus pot cardiomyopathy” or “stress-induced cardiomyopathy” or “Holy Bottle syndrome.” Chinese literatures published before April 31, 2021 were selected for reading, and their references were supplemented for reading. Inclusion criteria were consistent with the diagnostic criteria published by the Mayo Clinic. Exclusion criteria patients also had other diseases, and its influence on stress cardiomyopathy could not be excluded; Exclusion case report; Exclusion of cases ≤5; Exclude by title and abstract. From 8 dimensions of “gender, age, risk factors, symptoms, ECG, UCG, LVG, and follow-up” through literature retrieval, the clinical characteristics in each dimension were statistically summarized. A total of 154 literatures were initially examined. According to the inclusion and exclusion criteria, 18 literatures were finally included, including 264 cases, as shown in Among the 9 patients with a definite diagnosis of Takotsubo syndrome, 3 cases (33.3%) were male, and 6 cases (66.7%) were female. In this study, the mean age of onset was 46.4 years old, the median age was 42 years old, 6 patients (66.7%) were ≤42 years old, 3 patients (33.3%) were 42 years old, and 2 patients (22.2%) were elderly (≥60 years). The median time from onset to treatment was 1 day, the shortest time was 4 h, and the longest time was 5 years. All patients were treated in the emergency department. There were 2 cases of hypertension, 1 case of diabetes, 1 case of abnormal glucose tolerance, and no patients with related medical history. There were 5 cases in spring, 1 case in summer and 1 case in autumn, and 2 cases in winter. Two patients lived in rural areas, and seven lived in urban areas. None of the above patients had a genetic history of related diseases.All patients came to the hospital on emergency. The main symptom was chest pain for 8 patients (88.9%) who came to the hospital, and 1 patient went to the hospital because of syncope. Among them, 7 cases (77.8%) were mainly caused by emotional fluctuations or mental stimulation. Among the remaining 2 cases, 1 case developed chest pain without a known cause, and the other case was admitted to the hospital for syncope without a known cause. Seven cases (77.8%) had pain mainly in the precardiac area, one case had pain in the shoulder area, and one case was admitted to the hospital due to syncope, the cause of which was not known. In patients with chest pain symptoms, the nature of chest pain was compression, needle or contraction like, with a median duration of 1 h. The longest duration of symptoms was that the pain was never relieved, and the shortest duration of pain was 3–5 min. Among the alleviating and aggravating factors, 2 cases (22.2%) reported that their symptoms were relieved after oral administration of suxiaojiuxin pills or nitroglycerin and other vasodilators, and 2 cases reported that their symptoms were relieved after rest. Among the accompanying symptoms, 2 patients developed shortness of breath, 3 patients developed nausea and vomiting, 3 patients developed dizziness and headache, and 1 patient developed shock. In the course of diagnosis and treatment, 6 patients visited our emergency department for the first time because of the disease, and the remaining 3 patients were transferred to our emergency department after visiting a local hospital. Regarding surgical history of the patients, 7 cases (77.8%) had no previous operations, 1 case received surgical treatment for a hepatic hydatid, and 1 case received surgical treatment for gallstones. One patient had a history of a tuberculosis infection and has now been cured. Among the 9 patients, 3 patients (33.3%) smoked, including 2 males and 1 female. A total of 2 people drank alcohol, all of them were male, and all of them drank alcohol occasionally. Among the vital signs, 9 patients had normal body temperatures and respiratory rates, 2 had rapid heart rates, 1 had shock, 7 were overweight with a high body mass index, 1 was a woman with a low body weight, and 1 was a woman with normal weight, as shown in T-test was performed on the routine blood tests before and after admission, and only the counts of the white blood cells and the neutrophils were statistically significant in the comparison . After characteristic analysis of the 9 cases of patients, we found that in cases 1 and 7 the ST was prolonged, in case 5, the ST segment was decreased and in cases 4, 8, 2, and 9, there was an ST -T change. There were 9 cases of paroxysmal atrial flutter and paroxysmal atrial fibrillation. Patients 2, 3, 4, and 9 showed prolonged QTc interval in ECG examination, while the rest of the patients were normal. Objective indicators of ECG are shown in In the ECG examination, a paired t P > 0.0. After cDuring the cardiac color ultrasound examination, the LVEF of Case 1 was significantly impaired with a weakened ventricular wall motion, but the ejection fraction returned to normal upon discharge. Aortic insufficiency was observed in case 4. Minor aortic regurgitation occurred in case 7. In case 9, there was left atrium enlargement, reduced left ventricular muscle segmental motion, mitral valve insufficiency, aortic valve insufficiency, and mild pulmonary hypertension. Other patients showed different degrees of ventricular wall motion reduction. The ventricular wall movement gradually returned to normal during out-of-hospital follow-up. See In the 9 patients, we found that, except for patients 1, 2, and 7 who did not receive cervical artery ultrasound, all the other patients had plaques located in the bifurcation of the innaminate artery and the right subclavicular artery to varying degrees, and the maximum plaques were ~11.1 × 1.8 mm. See For patients admitted to hospital for treatment of chest pain, the rise of the dynamic changes, the electrocardiogram (ECG) changes and rise in heart markers, the emergency department considered the possibility of coronary heart disease (CHD). Hence, the emergency departments considered performing emergency coronary angiography examinations, hospitalization and nutrition to improve myocardial blood flow, reduce myocardial oxygen consumption, and secondarily prevent coronary heart disease, and they performed other comprehensive treatments, The patient's symptoms were significantly improved at discharge from the hospital compared with those on admission. Of course, Takotsubo syndrome may also cause serious complications, such as heart failure, malignant arrhythmia, hemodynamics and other complications. Case 1 developed shock combined with acute renal failure, and Case 9 developed acute left heart failure accompanied by paroxytic atrial fibrillation, which improved after symptomatic treatment and was discharged. None of the 9 patients had any related complications or recurrence during the out-of-hospital follow-up. After discharge, due to the poor compliance of some patients, the patients stopped taking the medications, while some patients underwent medication adjustments under the guidance of doctors.TTS was first described in 1990. Japanese scholar Dote et al.  reportedAs research on TTS continues, an epidemiological study by Murugiah et al.  found thThe main causes of TTS are emotional stress or physical stress, and it has been found that pheochromocytoma, subarachnoid hemorrhage and other diseases can cause TTS. Sharkey et al.  followedFurthermore, we found that the main clinical symptoms of TTS patients were chest pain, including chest tightness, palpitations, dyspnea, syncope, fatigue and other symptoms. One reason for the symptoms of chest pain in patients includes the spasm of multiple coronary arteries. Dote et al.  believedT-tests were performed on routine blood, biochemical, myocardial markers, and inflammatory indicators before and after admission. Only the counts of white blood cells and neutrophils were statistically significant. Morel et al. , and the results showed that 1 case with left ventricular wall motion was abated, and was accompanied by a significantly lower ejection fraction. There were different degrees of blood flow deficiencies in the left ventricle and apex. Some foreign studies have found that TTS patients may have abnormal perfusion or low and normal coronary blood flow reserve –39. YoshTTS is a group of clinical syndromes induced by mental or physical stimulation, with chest pain as the main symptom, partly accompanied by an increase in white blood cells, neutrophils, creatine kinase, troponin, prolonged QTC interval, and no obvious coronary stenosis. The prognosis is generally good, with few serious complications. In clinical practice, since the symptoms of this disease are similar to those of acute coronary syndrome, careful attention should be given to improving the diagnostic efficiency of TTS to reduce the symptoms.The limitations of this study were that the sample size was small, the average follow-up time was short, and typical left ventricular angiography images of patients with Takotsubo syndrome were not obtained due to posture or technical problems at that time, or because the possibility of this disease was not considered at that time. The next step of our research plan is to strengthen the research on the pathophysiological and other potential mechanisms of Takotsubo syndrome as well as the research on hematological biomarkers, and focuses on establishing a multi-center, large-sample, long-follow-up case study bank.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.YM and XX supervised the project and designed the study. JY was responsible for analyzing and interpreting the data and wrote the manuscript. CD and QY were responsible for collecting, collating, and statistical data. SC and MM participated in part of revising work. All authors have read and approved the manuscript.This research was funded by the National Natural Science Foundation of China , State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia Fund (SKL-HIDCA-2019-4), and Prevention and control of major chronic Non-communicable disease Project (2018YFC1311505).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The number of children who declared low and high physical activity of more than 60 min per day declined from 41.2% and 18.6% to 31.1% and 6.2% (p = 0.03 and p < 0.001), respectively; sleep times over 8 h increased (46.9% vs. 60.4% p = 0.007); screen times over 5 h daily increased . Eating habits did not change significantly. Conclusions: Daily physical activity and sleep levels were affected by the pandemic leading to the increase of BMI, especially in obese patients with endocrine disorders. During the COVID-19 pandemic, forward-thinking strategies must be developed to prevent childhood obesity.Background: Home isolation during the coronavirus 2019 (COVID-19) pandemic lockdown strongly impacted everyday life, affecting, in particular, eating habits and everyday activity. The aim of this study was to analyze the impact of the pandemic on behaviors and subsequent changes in body mass index (BMI) in children from Southern Poland. Methods: The study included 206 participants  with a complete analysis of 177 participants  with a mean age of 12.8 ± 2.6 years admitted to three pediatric endocrinology clinics  due to simple obesity, type 1 diabetes mellitus, somatotropin pituitary deficiency on growth hormone replacement therapy, and other endocrine and metabolic disorders between June and September 2020. The study used a self-prepared questionnaire regarding eating habits, physical activity, screen time, and sleep before and during the lockdown. Anthropometric measurements were performed under clinical settings twice . Results: During the lockdown, BMI z-scores increased over the whole group, especially in obese children (0.073 ± 0.18,  On 4 March 2020, the first confirmed case of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was announced in Poland. On 16 March, schools and kindergartens closed and subsequent restrictions were introduced in Poland. Cultural establishments and shops in galleries were closed, parties and gatherings were banned, access to parks and beaches was limited, and playgrounds and sports fields were closed. Additionally, in early April, a temporary ban on access to forests was introduced. Studies conducted in many regions of the world affected by similar problems have shown that pandemic-related restrictions have been related unfavorably to movement behaviors of children and youth ,4. RegarThe aim of this study was to analyze the changes in physical activity, eating habits, sedentary behaviors, leisure screen time, and sleep in school-aged children and youth in Southern Poland during the pandemic and the impact of these changes on body mass.Study hypotheses are as follows:The pandemic has a negative impact on physical activity, eating habits, play, sedentary behaviors, leisure screen time, and sleep in school-aged children and youth with chronic endocrine disorders.The pandemic has a negative impact on body weight and BMI in school-aged children and youth with chronic endocrine disorders.The study was conducted in three tertiary pediatric endocrinology clinics in the south of Poland  among outpatients visiting endocrinology, diabetes, and metabolic disease units for treatment or management due to simple obesity, type 1 diabetes mellitus, somatotropin pituitary deficiency on growth hormone replacement therapy, and other endocrine and metabolic disorders .Consent to participate in the study.Availability of documented measurements of body weight and height.The inclusion criteria were as follows:Lack of consent to participate in the study.Lack of documented measurements of body weight and height.The exclusion criteria were as follows:The study used a questionnaire and anthropometric measurements. The anthropometric measurements were performed in all participants from January to March 2020 (before the pandemic) and again from June to September 2020 (during pandemic lockdown).There were 206 participants and complete data allowing for a full analysis were obtained from 177  with a mean age of 12.8 ± 2.6 years (range 5.7–18.5 years).The study used a self-prepared questionnaire containing questions about eating habits, physical activity, screen time, and sleep pertaining to the child and the family before the pandemic and during the lockdown see . The queAnthropometric measurements were performed in all participants from January to March 2020 (before the pandemic) and again from June to September 2020 (during pandemic lockdown). The mean period between the first and second measurements was 183 ± 24 days. Body weight was measured to the nearest 0.1 kg on a calibrated balance beam scale and body height was measured to the nearest 0.1 cm. BMI was calculated by dividing weight (in kilograms) by the square of height (in meters). The value of BMI was interpreted, and BMI z-scores were calculated according to World Health Organization standards. All measurements were performed by trained health care professionals (nurses/physicians) with professional, validated equipment.The study was conducted according to the Helsinki declaration and approved by the Ethics Committee of The Medical University of Silesia on 3 July 2020 (PCN/0022/KB1/117/20). p-value less than 0.05 was considered statistically significant.A statistical analysis was performed using Statistica 13.3 PL. The quantitative variables were described with the mean , and qualitative variables were defined by frequency (%) for descriptive statistics of the participants’ baseline and lockdown characteristics. Normal distribution of data was checked with the Kolmogorov–Smirnov test (K-S test). We used a chi-square test for qualitative data comparison of variables in relation to pandemic situation (before and during lockdown), and dependent sample Student’s t test for quantitative comparison of variables in relation to pandemic situation (before and during lockdown), as appropriate. A n = 120; 68.2%) with garden area availability .Descriptive data regarding children and their residential characteristics  are presented in p > 0.05). When we compared obese and non-obese subjects, an increase in the BMI z-score was present in both subgroups; however, only in obese children was there a significant increase (0.073 ± 0.18). The number of children with obesity increased from 76 (42.9%) prior to the pandemic to 80 (45.2%) during the lockdown (p > 0.05), whereas the number of children with BMI <85 percentile decreased from 81 (45.8%) to 76 (42.9%) subjects. Overweight was observed in similar number of children before and during lockdown , respectively.We observed that during lockdown, BMI z-scores of children increased significantly , but the reduction was greater for obese children ; the reduction was also greater in the obese subgroup. Before lockdown, 33 children (18.6%) engaged in high physical activity for more than 60 min per day, and this decreased during lockdown to only 11 children  and less slept less than 6 h ; The study revealed that during the pandemic, the length of sleep and screen time for children increased. During the lockdown, more children slept for more than 8 h than before (p > 0.05).There were no differences in the number of meals per day, nor in the amount of snacks, sweets, soda, juices, vegetables, fruits, and fast-foods meals consumed before and during the lockdown over the whole group studied . On the other hand, in a cross-sectional online survey of adult Polish citizens (n = 1097) conducted during the nationwide quarantine, found that increased BMI was associated with less frequent consumption of vegetables, fruit, and legumes and a higher consumption of meat, dairy, and fast-food meals [There were no differences in the number of meals per day, nor in the number of snacks, sweets, sodas, juices, vegetables, fruits and fast-food meals consumed before and during the lockdown over our studied group  that could be associated with obesity or abnormal eating habits requiring pharmacologic treatment. Due to the lack of available validated questionnaires dedicated to the assessment of the impact of a pandemic on children’s behavior at the time of designing the study, a self-prepared survey was used.Daily physical activity and sleep levels were affected by the pandemic leading to the increase of BMI, especially in obese patients with endocrine disorders. During the COVID-19 pandemic, forward-thinking strategies must be developed to prevent childhood obesity.


GCK) gene reported in the Human Gene Mutation Database (HGMD) and in the literature associated with GCK/MODY, and the other in the hepatocyte nuclear factor 1A (HNF1A) gene not previously described. The GCK variant was also identified in the hyperglycemic father, whereas the HNF1A variant was present in the mother. This new case of digenic GCK/HNF1A variants identified in a hyperglycemic subject, evidences the importance of NGS analysis in patients with suspected MD. In fact, this methodology will allow us to both increase the number of diagnoses and to identify mutations in more than one gene, with a better understanding of the genetic cause, and the clinical course, of the disease.Monogenic diabetes (MD) represents a heterogeneous group of disorders whose most frequent form is maturity-onset diabetes of the young (MODY). MD is predominantly caused by a mutation in a single gene. We report a case of a female patient with suspected MD and a positive family history for diabetes and obesity. In this patient, two gene variants have been identified by next-generation sequencing (NGS): one in the Glucokinase ( Monogenic diabetes (MD) accounts for 1–6% of all cases of diabetes in patients of pediatric-adolescent age, but its prevalence is probably underestimated . The mosHNF1A), and glucokinase (GCK) genes, representing ~70% of all MODY subtypes [Up to now, mutations in 14 genes involved in glucose homeostasis and pancreatic development have been associated with this form of diabetes . The mossubtypes ,7. The psubtypes ,9,10,11;Clinical manifestations of GCK/MODY are characterized by a slight increase in blood fasting glucose , which is often present at birth . AffecteHNF1A/MODY is characterized by a progressive reduction in insulin secretion and, consequently, hyperglycemia. This requires treatment with drugs, and is associated with a tendency to develop microvascular complications . The onsRecognition of GCK/ and HNF1A/MODY, particularly when the patient is of pediatric age, is of fundamental importance, because this allows us to select the appropriate clinical management and to conserve healthcare resources. In fact, diabetic patients with HNF1A/MODY can avoid insulin and be treated with oral hypoglycemic agents such as sulfonylureas, to which they are particularly sensitive, whereas GCK/MODY patients, due to their mild phenotype, require less frequent clinical monitoring than patients with other forms of diabetes ,15. TherHerein, we report a new case of a digenic variant, identified by next-generation sequence analysis (NGS), in a hyperglycemic pediatric patient with suspected MD.We report the case of a female patient, the only child of non-consanguineous parents. The family history showed fasting hyperglycemia (135 mg/dL-7.5 mmol/L) and elevated hemoglobin-glycosylated HbA1C (6.3%-45 mmol/mol) in the father, and similar values in the paternal grandmother. In both cases, the condition was not treated. In the maternal family, the great-grandparents had a history of type 2 diabetes mellitus (T2D). The father and mother were both obese, with a body mass index (BMI) of 36 and 39, respectively. The mother and the mother’s sisters had thrombophilia A.The patient came to our attention at 7 years of age, as a result of several episodes of fasting hyperglycemia  occasionally detected with a glucometer. Her medical history was characterized by birth at full-term from normal pregnancy, with her weight appropriate for gestational age (AGA). She did not present episodes of hypoglycemia at birth but she showed moderate to severe pulmonary valve stenosis, which was successfully treated with percutaneous valvuloplasty, and a speech delay that was diagnosed at 3 years of age.2 , according to the curves of the World Health Organization (WHO), adjusted for age and sex. The patient was not undergoing any drug therapy.Laboratory investigations showed glycemia 105 mg/dL (5.8 mmol/L), HbA1c 6.3% (45 mmol/mol). Her autoimmune diabetes autoantibodies  were negative and her thyroid hormones  with autoantibodies  were normal. An oral glucose tolerance test (OGTT) showed impaired glucose tolerance (IGT) without insulin resistance, and her liver and renal function tests were normal, with an adequate lipid profile: total cholesterol 167 mg/dL (4.32 mmol/L), LDL cholesterol 111 mg/dL (2.87 mmol/L), HDL cholesterol 50 mg/dL (1.29 mmol/L), triglycerides 91 mg/dL (1.03 mmol/L). Her BMI was 22.7 kg/mBased on the early onset of the diabetes, the absence of beta-cell autoantibodies, and on the family history of diabetes, genetic tests for MD were performed.Peripheral blood samples for DNA analysis were collected after obtaining written informed consent from both the patient and her parents. Genomic DNA was extracted from leukocytes with a QIAamp DNA Blood Mini Kit , according to the manufacturer’s instructions, and quantified by a NanoDrop ND-1000 spectrophotometer . A next-generation sequencing (NGS) analysis, including 42 genes associated with non-autoimmune diabetes, was performed . For eachttp://www.interactive-biosofware.com/alamut-visual/) Alamut Visual v2.11.0, accessed on 23 March 2021)) was used to determine the pathogenicity of all missense variants. Bioinformatic tools available online, such as Sorting Intolerant From Tolerant (SIFT)  and Polymorphism Phenotyping v2 (PolyPhen-2)  were utilized to classify identified variants. Further predictions were assessed with the Mutation Taster tool  [https://varsome.com/variant/hg38, accessed on 8 March 2021) [The Alamut software ch 2021)  and othe21  and o  and othch 2021) . GCK gene and in exon 4  of the HNF1A gene were identified. These variants were confirmed with standard Sanger sequencing. Molecular sequencing extended to the diabetic parents showed that the GCK variant was present in the father and the HNF1A variant was present in the mother  of the e mother B.Monogenic diabetes comprises a group of heterogeneous genetic disorders characterized by the early onset of diabetes, the absence of autoimmunity, and beta-cell dysfunction ,23.Recognition of these forms of diabetes is crucial for reducing both the complications and the treatment costs associated with the disease, and to improve glycemic control with the most appropriate treatment and follow-up for patients ,24. In pGCK and HNF1A genes. The GCK variant, reported in the Human Gene Mutation Database (HGMD)  and in the literature as associated with GCK/MODY [In this case report, we described an unusual molecular diagnosis performed by NGS analysis in a hyperglycemic child, which revealed two distinct genetic variants in the GCK/MODY , was alsHNF1A variant, not reported in HGMD or in any known genomic variants database, has been classified as novel and its pathogenicity has been evaluated. In particular, according to ACMG classification criteria [https://www.ncbi.nlm.nih.gov/, accessed on 8 March 2021) reports that the variant is likely pathogenic (PP5). Moreover, the variant is located in a conserved region among species, indicating its functional relevance, and wild-type amino acid Proline has physicochemical differences with respect to Arginine. Furthermore, because computational prediction tools were not all in accord, they were not considered as criteria for classifying the variant.The criteria , we addeThe p.Pro291Arg is also present in the mother (40 years) who has not shown glycemic alterations until now.HNF1A mutation carriers may be normoglycemic while their mutated siblings may be hyperglycemic, as reported by Miedzybrodzka et al. [HN1A gene that was not fully penetrant, because it was present in all diabetic family members even if with considerable variations in severity and age of diagnosis (ranging from 16 to 67 years), and in two non-diabetic family members (aged 87 and 46) [HNF1A variants, some are sufficient for diabetes onset; however, not all carriers of these variants have early-onset diabetes and some do not have diabetes at all. It was hypothesized that multiple loci, inherited independently of diabetes, are modifiers of the HNF1A/MODY phenotype [HNF1A mutations; others may influence the onset of diabetes by affecting the amount of insulin that peripheral tissues require to maintain glycemia at the normal level [It is known that the clinical expression of HNF1A/MODY is highly variable, even within the same family ,25. In fa et al. . The aut and 46) . This cahenotype . Some ofThis phenotypic variability and incomplete penetrance have been also described in HNF4A/MODY ,29 and wHNF1A mutation, will develop a more severe phenotype later in life. However, studies on phenotypic effects in the general population of rare variants in MODY genes, previously reported as pathogenic, have provided evidence that the majority of variant carriers remain euglycemic through middle age, highlighting the limitations of disease variant databases, as well as bioinformatics criteria, in assigning pathogenicity to rare variants [HNF1A can have a spectrum of effects, ranging from weak effects, predisposing patients to T2D, to highly penetrant effects, causing MODY [As HNF1A/MODY is usually onset at a post-pubertal age, we could hypothesize that our patient, thus far showing a mild phenotype compatible with GCK/MODY, due to the progressive beta-cell function failure caused by the variants . Geneticing MODY ,31. HNF1A and GCK mutations in two patients of the same family with the coexistence of two phenotypes, GCK/MODY and HNF1A/MODY [Few reports are present in the literature describing individuals with digenic variants in different MODY genes ,34,35,36GCK/HNF1A variants, evidenced in a hyperglycemic pediatric patient by NGS analysis, confirms that the eventuality of two mutations in different MODY genes should not be excluded in patients with suspect of MD. In particular, in our proband, because we cannot exclude a possible evolution of the disease, a more careful clinical follow-up is necessary for accurate management and treatment. In addition, considering the relevance of HNF1A variants in the contribution of T2D risk, a greater attention to life style and a correction of the weight is strongly suggested for the mother carrier of the novel HNF1A variant.This new case of digenic


Objective: Diabetes mellitus (DM) has been critically associated with unfavorable outcomes in the general population. We aimed to investigate the association between type 2 DM and long-term survival outcomes for postoperative ischemic stroke in patients who underwent non-cardiac surgery.Research Design and Methods: This was a retrospective cohort study of patients with non-cardiac surgery who had suffered from postoperative ischemic stroke between January 2008 and August 2019. Diabetic individuals were included in postoperative ischemic stroke patients with the DM group. The outcome of interest was long-term overall survival (OS). We conducted propensity score matching (PSM) and inverse probability treatment weighting (IPTW) to adjust for baseline characteristic differences between groups. Multivariate Cox regression analysis with stepwise selection was used to calculate the adjusted hazard ratio (HR) of OS and type 2 DM.Results: During a median follow-up of 46.2 month , 200 of 408 patients (49.0%) died. The OS rates at 3, 5, and 10 years were significantly lower for postoperative ischemic stroke patients with DM than those without DM . All covariates were between-group balanced after using PSM or IPTW. The postoperative ischemic stroke patients with type 2 DM had a shortened OS in primary analysis , PSM analysis , and IPTW analysis .Conclusion: Type 2 DM was associated with an unfavorable survival outcome for postoperative ischemic stroke in patients who underwent non-cardiac surgery. When postoperative ischemic stroke co-occurred with type 2 DM, the potential synergies would have multiplicative mortality risk. Further research to assess the adverse effects of type 2 DM on long-term survival may be warranted. As the world population ages, surgical cases volume increases gradually. Postoperative ischemic stroke is a rare, under-recognized, and life-threatening neurological complication of surgery with high mortality and disability . CompareThe presence of type 2 diabetes mellitus (DM), which affected 11.2% of adults in China, has been critically linked to increased mortality . MeanwhiGiven the high prevalence and adverse effects of type 2 DM, we hypothesized that the potential risk of long-term survival outcomes attributable to type 2 DM could be substantial. Herein, we conducted a retrospective study to examine the association between type 2 DM and long-term survival outcomes in the patients with postoperative ischemic stroke.This retrospective cohort study was approved by the Medical Ethics Committee of Chinese PLA General Hospital (reference number: S2021-493-01), and the requirement for informed content was waived. The manuscript of the cohort study adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines .We identified the patients who had undergone non-cardiac surgery between January 1, 2008, and August 31, 2019, at Chinese PLA General Hospital, a tertiary academic hospital in Beijing, China. We excluded patients with (1) age < 18 years, (2) duration of surgery ≤ 60 min, (3) regional anesthesia, (4) American Society of Anesthesiologists (ASA) physical status ≥ IV, (5) type 1 DM, and (6) missing data for any confounders. For patients who underwent multiple surgeries within the study period, only the first eligible surgery was included. Additionally, we screened the patients who were diagnosed to have a postoperative ischemic stroke within 30 days after surgery, identified through ICD 9/ICD 10 diagnosis codes . If patiThe outcome of interest was overall survival (OS). The survival data after surgery were derived from hospital medical records, follow-up database, and confirmed by the Chinese Center for Disease Control and Prevention (CCDC). OS was defined as the period from the date of surgery to the day when the death occurred after surgery or the remainder were censored at the end of the follow-up point  .The exposure of interest was type 2 DM (hereafter simplified as DM) before the postoperative ischemic stroke event, identified through ICD 9/ICD 10 diagnosis codes .Covariates of interest included age, sex, body mass index (BMI), American Society of Anesthesiologists physical status, other comorbidities , use of preoperative medications , preoperative serological examination and index , surgery-related data , stroke severity , stroke laterality, stroke location, large hemispheric infarction (LHI), and thrombolysis.Postoperative ischemic stroke is defined as a brain infarction of ischemic etiology with motor, sensory, or cognitive dysfunction  30 days after surgery . Diagnosn (%). Kaplan-Meier method was performed to compare OS between groups.Baseline characteristics and outcomes of the patients were summarized through frequencies and descriptive statistics. Continuous variables are expressed as mean (SD), or median , and categorical variables are presented as To control the potential confounding effects, we performed multivariate Cox regression analysis with step-wise selection to evaluate the relationship between DM and OS. In Cox regression analysis, multiple models were conducted with different covariates to calculate the hazard ratio (HR) of OS and DM .In sensitivity analyses, we conducted propensity score (PS) analysis, such as propensity score matching (PSM) and inverse probability treatment weighting (IPTW) to examine the OS associated with DM . For adj1c level, and the follow-up time were associated with shortened OS in several previous meta-analyses or studies  and R program , along with A two-sided From January 1, 2008, to August 31, 2019, at Chinese PLA General Hospital, a total of 2,21,541 patients who underwent non-cardiac surgery were included, of whom 484 (0.22%) patients were diagnosed to have an ischemic stroke within 30 days after surgery. After excluding 76 patients without follow-up data, 408 of 484 (84.3%) eligible patients with postoperative ischemic stroke remained in the cohort, of whom 113 (27.7%) had DM . During Baseline characteristics of the postoperative ischemic stroke patients with or without DM are summarized in After adjustment with PSM or IPTW method, most of the covariates were well balanced, with the standardized mean difference less than 0.10 for all covariates .In total, 200 patients with postoperative ischemic stroke had died during the follow-up period. In the analysis of causes of death, nine patients without specific causes of death were excluded. More than half of the postoperative ischemic stroke patients had subsequently died from cerebrovascular diseases and cardiovascular diseases. More patients with postoperative ischemic stroke had died from cerebrovascular diseases (35.1%) than from heart disease (22.5%). Meanwhile, the mortality rate of postoperative ischemic stroke patients with DM due to all cerebrovascular diseases was higher than that in those without DM . However, the mortality rate of postoperative ischemic stroke patients without DM due to cancer was much higher than that in those with DM  .p < 0.001). The median OS time and OS rates at 3, 5, and 10 years were significantly lower for the postoperative ischemic stroke patients with DM than those without DM . Additionally, the increased risk of unfavorable OS was noted among those who underwent malignant tumor surgery  and those who did not undergo malignant tumor surgery . The presence of DM was only significantly associated with increasing all-cause death in negative LHI group , whereas it was not significant in positive LHI group . The association between DM and OS was only significant for follow-up time > 18.5 months subgroup , whereas it was not significant for follow-up time ≤ 18.5 months subgroup  than those with HbA1c < 6.5% .Among 113 postoperative ischemic stroke patients with DM, 62 (54.9%) patients were aged ≥ 65 years, 55 (48.7%) underwent malignant tumor surgery, 12 (10.6%) presented with LHI, and 81 (71.7%) were with the follow-up time > 18.5 months. In this retrospective cohort study of 408 patients with postoperative ischemic stroke, we showed that type 2 diabetes was associated with a worsened prognosis for OS. After several statistical adjusting approaches for the difference between postoperative ischemic stroke patients with DM and those patients without DM, this finding remained consistent.Individually, evidence about the increased risk for cardiovascular disease, neuropathy, and mortality with DM or stroke are unequivocal . Patientp < 0.001, LHI vs. no LHI) and a shorten OS . Therefore, we speculated that the association between DM and OS was eliminated due to a faster progression and high severity of LHI. The subgroup analysis of HbA1c level in this study showed that postoperative ischemic stroke with DM with HbA1c ≥ 6.5% had a much higher risk of death, implying that strict glycemic control might help to improve survival.The major hurdle of the postoperative ischemic stroke study is the lower incidence, requiring a huge sample size. In the POISE trial of 8,351 patients who underwent non-cardiac surgery, 60 (0.7%) patients developed stroke within 30 days after surgery . A recenThis study has the following merits. First, as the postoperative ischemic stroke with lower incidence, we constructed a larger retrospective database with 3,76,933 surgical patients to screen the eligible patients with postoperative ischemic stroke as much as possible. Second, the survival data after surgery were derived from hospital medical records and a follow-up database. We validated the precision of survival data from the Chinese CCDC. Third, we made efforts to integrate preoperative, intraoperative, and postoperative data into this retrospective database. Thus, we included a variety of potential confounding factors, such as preoperative, intraoperative, and postoperative data, which allow for precise effect size evaluation. Fourth, we also assessed stroke laterality, stroke location, and especially LHI by CT or MRI imaging to reflect the difference in stroke status. Fifth, sensitivity analyses, such as PSM or IPTW analysis and subgroups analysis, were successfully applied to further validate the robustness of our findings. Last, to the best of our knowledge, this is the first study to evaluate the association between DM and long-term OS for patients with ischemic stroke after surgery.1c test among the surgeons, it is not a routine test for screening diabetes between the years 2008 and 2010 in our center. Thus, we did not have enough HbA1c data to evaluate overall glycemic control before the surgery. In the study, we only performed the HbA1c subgroup analyses of 339 patients with HbA1c data. Sixth, despite many efforts in obtaining more relevant data, we still lacked the preoperative data of antidiabetic medications, such as insulin and metformin, and long-term data of glycemic control. These potential confounders should be adjusted.Several potential limitations in our study deserve closer attention. First, we cannot draw conclusions regarding cause-effect relationships due to this retrospective study. Therefore, this causality between DM and long-term OS for patients with postoperative ischemic stroke will need to be validated with larger randomized clinical trials. Second, the results derived from a single-center study and thus the generalizability of our findings may be limited in other centers. Thus, multicenter, well-designed, and prospective trials are welcomed to further verify our hypothesis. Third, residual and unmeasured potential confounding cannot be completely ruled out in an observational study. Fourth, given the high specificity but low sensitivity of ICD codes, the true incidence may be underestimated with DM or peripheral vascular disease. Fifth, due to insufficient awareness of the HbAType 2 DM was associated with a unfavorable prognosis for OS in patients with postoperative ischemic stroke. When postoperative ischemic stroke co-occurred with Type 2 DM, the potential synergies would have multiplicative mortality risk. Future larger randomized clinical trials are required to confirm the adverse effects of type 2 DM on long-term survival.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Medical Ethics Committee of Chinese PLA General Hospital. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.WM, LW, and MN conceived and designed the study. FZ, MN, YM, YY, and MS contributed to the data extraction and acquisition. FZ, MN, and LW drafted the manuscript. YM, HL, and YL analyzed and interpreted the data. JL and JC supervised the study. FZ, MN, YM, WM, and LW critically revised the manuscript for important intellectual content. WM was the guarantor of this study and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.