The duration and severity of CS/SE determine the extent of brain injury in survivors even after treating with medical countermeasures (MCM)/antidotes such as atropine, an oxime, and an anticonvulsant such as diazepam/midazolam. In this study, using a large mixed sex cohort of adult male and female rats, without pretreatment, we demonstrate severe SE lasting for >20 min in 82% of the animals in response to soman . Atropine sulfate  and HI-6  were administered immediately following soman, and midazolam  1 h post-exposure. Immediate MCM treatment is impractical in civilian exposure to civilians, but this approach reduces mortality in experimental models. Interestingly, female rats, irrespective of estrous stages, had an average of 44 min CS (stage ≥ 3), while males had an average of 32 min CS during SE, starting from soman exposure to midazolam treatment. However, in telemetry device implanted groups, there were no significant sex differences in SE severity; males had 40 min and females 43 min of continuous CS until midazolam was administered. No animals died prior to midazolam administration and less than 5% died in the first week after soman intoxication. In telemetered animals, there was a direct correlation between EEG changes and behavioral seizures in real-time. In the long-term, convulsive spontaneously recurring seizures (SRS) were observed in 85% of randomly chosen animals. At 4-months post-soman, the brain histology confirmed reactive gliosis and neurodegeneration. The novel findings of this study are that, in non-telemetered animals, the SE severity following soman intoxication was significantly greater in females compared to males and that the estrous cycle did not influence the response.Modeling a real-world scenario of organophosphate nerve agent (OPNA) exposure is challenging. Military personnel are premedicated with pyridostigmine, which led to the development of OPNA models with pyridostigmine/oxime pretreatment to investigate novel therapeutics for acute and chronic effects. However, civilians are not premedicated with pyridostigmine/oxime. Therefore, experimental models without pyridostigmine were developed by other laboratories though often only in males. Following OPNA exposure, prolonged convulsive seizures (CS) or  The current MCMs  control symptoms in experimental models but do not prevent long-term neurotoxicity, such as persistent neuroinflammation and neurodegeneration  are threats to both civilians and military personnel worldwide. The sarin attacks in Tokyo and Syria, VX attacks in Malaysia, and Novichok attacks in England demonstrate the real threat of OPNA to civilians . Currentneration . Thus, tNerve agents have been used to target both military and civilian populations . Therefo50) without PB/MCM pretreatment to better model a real-world scenario of OPNA exposure. We used wireless telemetry device to observe real-time responses of soman-induced SE in mixed-sex cohort. Further, to test whether the initial SE severity caused spontaneously recurring seizures (SRS) and brain pathology in the long-term, in a separate cohort of animals, telemetry devices were implanted 2 months after soman exposure and the animals were video-EEG monitored continuously (24/7) for 5 weeks. The novel findings from these experiments are discussed here.In this rigorous soman study, a mixed cohort of adult male and female rats were used to demonstrate the impact of sex on initial seizure severity in response to soman  used in this study were purchased from Charles River, United States. Male and female rats were housed individually in separate cages but in the same room. Animals had access to unlimited food and water in a 12 h day and night cycle and housed in an enriched environment. All experiments were conducted as per the approved IACUC protocols. Telemetry surgery was conducted at the Principal Investigator’s laboratory, Iowa State University, Ames, IA, United States. Soman exposure was done at MRIGlobal, Kansas City, MO, United States. All animals were euthanized at the end of the study with pentobarbital sodium  as per the American Veterinary Medical Associations Guidelines for the Euthanasia of Animals.The MRIGlobal, Kansas City, CA, United States purchased and administered soman (>95% pure) to the animals at their designated laboratory as per approved IACUC protocol. Soman was prepared in cold 0.1 M PBS just prior to administration. Atropine sulfate  and HI-6  were prepared fresh in saline at 5 and 50 mg/mL, respectively. All key chemicals, except soman, were authenticated, and purity was determined by LC-MS method at the Metabolomics Laboratory, Iowa State University, Ames, IA, United States. Midazolam  was supplied by MRI Global, and pentobarbital sodium for euthanasia was purchased from Iowa State University Lloyd Veterinary Medical Center Hospital Pharmacy.We used the following antibodies for immunohistochemistry (IHC) to determine gliosis and neurodegeneration: ionized calcium-binding adaptor molecule  for microglia and macrophages, cluster of differentiation 68  for phagocytic microglia/macrophages, glial fibrillary acidic protein  for astrocytes, and NeuN  for neurons. NeuN immunostaining followed by Fluoro-Jade B  staining was used to identify degenerating neurons. Secondary species antibodies such as Alexa Fluor conjugated (1:80), biotin-conjugated (1:400), and streptavidin-conjugated (1:300) were purchased from Jackson ImmunoResearch Laboratories West Gove, United States. All primary and secondary antibodies were diluted in PBS containing 2.5% donkey serum, 0.1% tritonX-100, and 0.25% sodium azide. Streptavidin conjugated antibodies were diluted in PBS without a detergent. FJB was diluted in 0.1% acetic acid. All antibodies were serially diluted to determine optimum concentration. In addition to primary antibody omission step during tissue processing for IHC, neutralizing antibody was used to determine the specificity of an antibody.2) and maintained at 1.0–1.5% during surgery. We used SomnoFlo anesthetic equipment from Kent Scientific . Artificial tears ointment was applied to prevent dry eyes and corneal ulceration during/after surgery. After drilling holes bilaterally, the electrodes were placed on the surface of the dura mater, overlying the cortical hemispheres, and the telemetry device was tunneled into a subcutaneous pouch. The electrodes were secured to the skull with dental cement  and the incision was closed with sterile surgical clips. Vetropolycin, a triple antibiotic ointment, was applied to the surgical site. Baytril  and 1 mL of normal dextrose saline were administered subcutaneously before the animals recovered. The animals were individually caged and placed on PhysioTel receivers (RPC-1) connected to the Data Exchange Matrix 2.0 (DSI) for continuous, integrated, video-EEG acquisition using the Ponemah Acquisition software. During the 3–4 weeks post-surgery prior to soman exposure, baseline EEG was recorded for 4 days to cover both day and night cycles to evaluate the impact of surgery on brain activity for each animal. The telemetry device has a sensor to record body temperature and locomotor activity in addition to EEG activity. In the nine male rats that received telemetry implant at 2-month post-soman, EEG data was acquired for 5 weeks continuously (24/7) to identify SRS.We used 44 rats for telemetry device implantation . All but nine male rats were implanted with a telemetry device 3–4 weeks before exposing to soman to determine real-time electrographic changes in the brain in response to soman injection. The nine male rats received the device implantation 2 months after the soman exposure to identify SRS. We used CTA-F40 PhysioTel™ telemetry device  for video-EEG acquisition. Implantation was performed as in our previous publications . Prior tAbout an hour before soman exposure, vaginal lavage and sampling were done, as described in our recent publication . Approxi50, 132 μg/kg, s.c.), followed immediately by HI-6  and atropine sulfate , and 1 h later by midazolam  from the same pool of reagents prepared fresh on the day of the experiment. The protocol is illustrated in We exposed 119 rats which included 44 females and 75 male rats  with PBS followed by 4% paraformaldehyde (PFA), and the brains were isolated . FollowiBefore the sections were processed for IHC, the brain sections were subjected to antigen retrieval by treating with citric acid solution  at 95°C for 23 min. After cooling, slides were placed into Shandon racks and washed with PBS for an hour and incubated in blocking buffer for an hour  followed by incubation with primary antibodies overnight at 4°C. The next day, slides were washed for an hour in PBS and incubated with FITC conjugated or biotin-conjugated secondary antibodies for an hour. Slides were washed again for an hour with PBS before incubating with streptavidin-conjugated antibodies for an hour followed by washing with PBS for another hour. Slides were then mounted with medium containing DAPI and used for imaging. For FJB staining, following staining with NeuN and washing with PBS, slides were washed three—four times with distilled water before placing in 0.006% potassium permanganate for 5 min . Slides The Leica DMi8 inverted fluorescence microscope  fitted with Leica K5 passive cooled sCMOS camera system was used to image the brain sections. Representative images of the amygdala from controls and soman-exposed animals were taken to demonstrate soman-induced reactive gliosis and neurodegeneration. Experimenters were blind to the treatment groups while compiling the data. At least four sections from each animal were imaged and quantified for each staining. Only controls (not treated with soman) and animals with severe SE (>30 min) were considered in the analysis. IBA1, GFAP, and NeuN were quantified using cell profiler; the individual pipelines for each marker are described in The mixed cohort of male and female animals were randomized, ignoring sex, and the experimental groups were blinded until the data were completely analyzed. The normality of the data was evaluated with Shapiro–Wilk test. Data was graphed and statistics were performed by Graphpad version 9.0; specific tests are outlined in the corresponding figure legends. We had taken measures to minimize variables: (i) seizure severity during the SE was quantified by both direct observation and offline video analysis by at least two independent observers; (ii) authentication of the identity and purity of key MCMs by LC-MS; (iii) SRS events on EEG were also manually verified with integrated video module for behavior and power spectrum in NeuroScore; and, (iv) determination of the optimum concentration of the primary antibodies by serial dilution and their identify was confirmed by using neutralizing primary antibodies.The experimental design for soman exposure is illustrated in n = 27), there were 11.1% of animals in metestrus, 33.3% of animal in diestrus, 25.9% of animals in proestrus, and 29.6% of animals in estrus. In the telemetry group (n = 18), there were 23.5% of animals in metestrus, 41.2% of animals in diestrus, 35.3% of animals in estrus, and no animals were in proestrus at the time of exposure to soman . All animals in each group were housed in the same room, male and female side-by-side but in separate cages. Each mixed-sex cohort was treated with soman , atropine sulfate , HI-6 (125 mg/kg), and 1 h later midazolam (3 mg/kg. i.m.) from the same reconstituted drug pools. Unlike some other soman models, the animals were not pretreated with PB or an oxime.Surprisingly, in contrast to a general perception that female rats respond differently and inconsistently to soman/chemoconvulsants than males, in this study, female rats responded to soman more consistently, irrespective of their estrous stages, in both telemetered and non-telemetered groups , 2. SeizFor the male-only cohort (1), out of 24 animals, 3 (12%) animals did not respond to Soman, 5 (20%) had <10 min CS, 2 (8%) had 10–20 min CS, and 14 (60%) had >20 min CS. In the mixed sex cohort of non-telemetry animals (cohorts 2 and 3), out of 33 males, 5 (15%) did not respond to soman, 4 (12%) had <10 min of seizures, 1 (3%) had 10–20 min, and the 23 (70%) had ≥20 min of seizures. In contrast, all non-telemetered females had ≥20 min of seizures. In telemetry animals (mixed cohort 3), all 18 males had ≥20 min, and 16 females had ≥20 min of seizures . No animals died prior to midazolam administration and <5% of animals died within 1 week of soman administration.via EEG during 1h between soman and midazolam administration. Representative EEG traces and the corresponding images captured from integrated video-EEG system, and the power spectrum are illustrated from both male and female rats (Seizure severity determines the extent of brain injury and the onset of spontaneously recurring seizures (SRS) , 2016. Hale rats . BehavioSeizures detected on EEG and spike rate during SE were compared between male and female rats. There were no significant differences between male and female rats in the overall CS duration and rate of epileptiform spikes during SE . We alsoIt is important to note that there was no significant difference in SE severity between male and females in telemetered animals, unlike in non-telemetered animals . KnowingImmunohistochemical analysis in the amygdala for microglia/macrophages (IBA1), astrocytes (GFAP), and neurodegeneration (NeuN + FJB/NeuN) confirmed that the epileptic brains, compared to controls, had increased gliosis and neurodegeneration. Soman treated animals, compared to controls, had more IBA1 and CD68 positive cells as well as IBA1 positive cells with reactive morphology . ExampleTraditionally, chemical, biological, radiological, and nuclear agents were viewed as threats to only the military until the events of September 11, 2001, and the anthrax mailing incidents in October 2001. These incidents, as well as the sarin attacks in Tokyo and Syria, VX attacks in Malaysia, and Novichok attacks in England revealed the vulnerability of civilians to unconventional terrorism threats such as nerve agents . Until rSeveral experimental models have been developed, tested, and refined over the years to more closely approximate real-world scenarios of OPNA exposure to military and public . For exa50) of soman determines SE severity and mortality if no MCMs were administered. Several soman studies have tried to balance both mortality and seizure severity even at higher LD50 by utilizing a pretreatment approach. A summary of different soman models and the source is tabulated in Apart from pretreatment, the lethal dose (LD50 soman (instead of 1.2 LD50), however, the mortality details were not reported  than weight-matched male rats (92 μg/kg) (50 (132 μg/kg) soman, irrespective of the stages of estrous cycle. However, in telemetry implanted female and male rats, there were no significant differences in SE severity. In the rat and mouse kainate models of epilepsy, we had previously shown that surgery reduces the threshold for SE onset in males  in response to the same dose of soman used in age-matched male rats (132 μg/kg). This contradicts our previous study using DFP, which showed an increased resistivity in females compared to males . In our  estrous . These s2 μg/kg) . The behin males . In thisin males . In cont50 of soman compared to the females in proestrus or with males  in response to soman when compared between telemetered and non-telemetered animals. There were also no sex differences in SE severity in telemetered male and female animals. The stage of the estrous cycle had no impact on SE severity in both telemetry and non-telemetry groups. Long-term continuous video-EEG recordings and brain histology confirmed that soman-induced severe SE without pretreatment can promotes epileptogenesis as evidenced by SRS occurrence, reactive gliosis, and neurodegeneration. This study demonstrates, similar to previous work by others, that soman exposure without pretreatment can lead to severe SE and the development of SRS and neuropathology. The other advantage of the model in this study is the low mortality (<5%). Considering these advantages, this model can be used in the future studies to evaluate the efficacy of potential disease modifying agents.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation, to any qualified researcher.The animal study was reviewed and approved by the Iowa State University and the MRI Global Animal care and use committees.TT conceptualized the idea, secured funding for the project, designed the study, and wrote the manuscript. All co-authors conducted the experiments, acquired and analyzed the data, and edited the manuscript. MG, MP, NR, SV, and CM conducted surgery to implant telemetry devices and quantified behavioral SE. SV contributed 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.


Chronic pain (CP) has been a major area of interest in the field of knee osteoarthritis (KOA), further aggravating the dysthymia, stiffness, and dysfunction of KOA patients. As an important part of complementary and alternative medicine, Tai Chi has a positive effect on KOA patients. The systematic review is to evaluate the effectiveness and safety of Tai Chi for KOA patients with CP.A systematic search will be performed in the following electronic databases for randomized controlled trials to evaluate the effectiveness and safety of Tai Chi in treating chronic pain of knee osteoarthritis: the Cochrane Library, PubMed, EMBASE, OVID-MEDLINE, and four Chinese databases . Each database will be searched from inception to Dec. 2021. The process will include study selection, data extraction, risk of bias assessment and meta-analysis.This proposed study will evaluate the effectiveness and safety of Tai Chi for KOA patients with CP. Improvement in pain and adverse effects of KOA will be included in our measure.This proposed systematic review and meta-analysis will evaluate the existing evidence on the effectiveness and safety of Tai Chi for KOA patients with CP.The results of this review will be disseminated through peer-reviewed publication. This review does not require ethical approval because all of the data used in this systematic review and meta-analysis have already been published. Furthermore, all of these data will be analyzed anonymously during the review process.INPLASY2021120020. CP in KOA patients results in decreased physical mobility, muscle atrophy, anxiety, and depression.,8 Long-term CP can respectively induce plasticity of the central nervous system and seriously affect the physical and mental health of KOA patients.,10 Unfortunately, there is still no cure for the progress of CPKOA. Current mainstream therapies have some limitations, such as long-term use of drugs maybe lead to side effects, and surgical treatments can cause greater trauma. A study based on the data from the UK General Practice Research Database showed that TKR's lifetime risk increased from 2.9% to 10.6% and from 1.8% to 7.7% for men between 1991 and 2006. Therefore, it is particularly important to find effective and safe treatment methods to relieve the pain of CPKOA and reduce the medical burden.Chronic pain (CP) is one of the most important symptoms of knee osteoarthritis (KOA), further leading to the gradual deterioration of the stiffness, dysfunction, emotional disorder and poor quality of life. As an important part of complementary and alternative medicine, Tai Chi is easier accepted by KOA patients with its advantages of simple, safe, convenient and economical, small space occupation and less load on joints. Tai Chi is widely used to treat CP conditions, Tai Chi is widely used to treat CP diseases, such as knee osteoarthritis and fibromyalgia syndrome. Studies have shown that Tai Chi has produced beneficial effects for treating KOA, such as reducing pain, improving physical function, reducing depressed mood and improving quality of life.,15–17 The analgesic effect of Tai Chi on CPKOA has been confirmed by an increasing number of reports. The analgesic effect of Tai Chi on CPKOA has been confirmed by more and more reports,,18 thus showing the application prospect of Tai Chi in the clinical practice of CPKOA.According to the Guideline of Osteoarthritis Research Society International (OARSI), physical exercise is positive for individuals with KOA. To date, there is no valid evidence on the follow-up effects of Tai Chi for CPKOA. Compared with other active therapies, there is still insufficient evidence to support or refute the value of Tai Chi in the treatment of CPKOA. Despite the advantages of non-invasive and relatively low cost and the growing popularity of Tai Chi compared to other therapies, discussions continue regarding the effectiveness of Tai Chi in complementary and alternative medicine.,20 Therefore, we perform this protocol to comprehensively evaluate the effect of Tai Chi on CPKOA.Meta-analysis, an important tool for evidence-based medicine, is a powerful widely accepted statistical technique.22.1This protocol was registered on the International Platform of Registered Systematic Review and Meta-analysis Protocols on Dec. 14, 2021 (registration number:). We will strictly perform this protocol by following the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocol statement guidelines.2.22.2.1Only randomized controlled trials about Tai Chi for CPKOA will be included, with language restrictions in English or Chinese. Case report, experience report, and laboratory studies will not be included.2.2.2All patients with CPKOA will be included without limitation of age, race, gender, economic level, and severity. CPKOA patients have pain that lasts longer than 3 months.2.2.32.2.3.1The intervention in the experimental group included Tai Chi exercise compared with the control group. There will be no limitation on the methods, duration, and frequency of Tai Chi training.2.2.3.2The interventions of control group will involve any therapy other than Tai Chi .2.2.42.2.4.1Primary outcomes include pain, such as visual analog scale, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain etc..2.2.4.2(1)WOMAC stiffness;(2)WOMAC physical function;(3)A 12-item Short-Form Health Survey (SF-12);(4)Pressure pain threshold;(5)Adverse events.2.3We will perform a comprehensive search in the Cochrane Library, PubMed, EMBASE, OVID-MEDLINE, and four Chinese databases  for articles published before Dec. 2021. Only randomized controlled trials that used Tai Chi as the main treatment for adults with CPKOA will be included. The Chinese and English search strategies in PubMed database are shown in Table 2.4All the search results will be imported into EndNote software (V.x9) for management. Two reviewers (SX and BW) will independently screen all potentially eligible studies. Titles and abstracts will be screened first to exclude irrelevant citations. Full text of all the articles with potentially relevant abstracts will be retrieved and screened according to the study eligibility criteria. Disagreements will be resolved by consensus or discussion with a third reviewer (GG). The research flow chart is shown in Figure 2.5Two reviewers will extract data from the included literature through Microsoft Excel 2010 , mainly including the following information (Table (1)General information about the study, such as authors, year of publication, country, groups, sample size, age, and gender;(2)Detailed treatment information, such as diagnostic criteria and parameters of intervention;(3)Pain scores. Other outcome measurements, such as SF-12 or WOMAC stiffness, WOMAC physical function etc., will be extracted if they are mentioned in the study.2.6 In addition, we will use the online guide development tool to carry out this process. Any differences will be resolved by obtaining the consensus of all reviewers.Based on Grading of Recommendations Assessment Development and Evaluation, we will assess the quality of evidence as 4 grades: high quality, moderate quality, low quality and very low quality.2.7 using the Cochrane risk of bias tool. The risk of bias for each of the following domains will be assessed for each study: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of outcome assessments, (5) incomplete outcome data, (6) selective reporting, and (7) other bias. Each study included will be rated as having a high, low, or unclear risk of bias. Two reviewers (SX and BW) will evaluate the consistency of all the extracted data and quality ratings. Disagreements will be resolved by discussion with a third reviewer (GG).Study quality will be assessed in RevMan V5.4 2.8P > .1 or I2 < 50%). If there is a significant heterogeneity (P > .1 or I2 < 50%), we will conduct subgroup analysis or sensitivity analysis to identify possible causes of heterogeneity among populations.Revman 5.4 software will be used to perform statistical analysis. For discontinuous variables, the risk ratio with 95% confidence interval (CI) will be selected. For continuous variables, the weighted mean difference with 95% CI will be selected when the measuring instruments are the same, and the standardized mean difference with 95% CI will be selected when the measuring instruments are different. We will use the fixed-effect model if there is no significant heterogeneity The treatment period;(2)Different styles of Tai Chi .2.10To identify the robustness of the meta-analysis, low-quality trials, with high risks of bias or outcomes that are seriously distant from the rest of the data, will be excluded.2.11Ethical approval will not be in need because the data used in this systematic review will not be individual patient data, and there will be no concerns regarding privacy.3CP is a major symptom of KOA, and CPKOA patients often require long-term use of non-steroidal anti-inflammatory drugs, other drugs, and even choose surgery for pain relief. However, the pain of CPKOA is still not completely resolved for a long time.–27 Tai Chi has a holistic view consistent with the TCM diagnosis and treatment thinking, focusing on the overall recuperation and function recovery of the human body.,28,29 A study found that long-term regular Tai Chi exercise can restore the senesthesia sensitivity of the elderly, and the improvement effect of knee joint and ankle joint proprioception is better than running and swimming. Some studies strongly recommend 20-weeks Sun style Tai Chi exercise program  to relieve the pain and improve physical function of KOA.,31 Among them, the relief of bone pain may be related to the exercise intervention of bone stimulation, often accompanied by the participation of some cytokines or minerals.,33 A study based on the fNIRS system found that an exercise program 3 times a week for 6 weeks significantly reduced functional activity in the dorsolateral prefrontal cortex (DLPFC) in patients with CPKOA, and provided evidence about the pain modulatory effects of exercise at DLPFC level which is correlated with clinical improvements in CPKOA patients. Long-term Tai Chi practice is also benefit to the brain white matter.Tai Chi can improve balance, muscle strength, cardiopulmonary function and sleep quality, relieve depression, anxiety and tension and other psychological problems, bringing beneficial effects to KOA individuals.Although many studies have reported the effectiveness of these supplementary interventions, there is a general lack of determination of the most effective therapeutic Tai Chi methods in the field of CPKOA. Therefore, this online meta-analysis will provide a detailed summary and analysis of the latest evidence, with a focus on available Tai Chi methods. We hope that our findings will help patients, clinicians, and healthcare policy makers make better treatment choices for CPKOA.GG, SX, and BW conceived the study. JX, XZ, GW and PL provided general guidance to the drafting of the protocol. SX and GG drafted the protocol. SX designed the search strategy. GG and SX drafted the manuscript. JX, XZ, BW, GW and PL reviewed and revised the manuscript. All authors have read and approved the final version of the manuscript.Funding acquisition: Guangxin Guo, Ping Lu.Writing – original draft: Guangxin Guo, Boyi Wu, Shengji Xie, Jianghan Xu, Xu Zhou, Guanghui Wu, Ping Lu.Writing – review & editing: Guangxin Guo, Ping Lu.


Personality disorders are frequently associated with insomnia and depression, but little is known about the inter-relationships among these variables. Therefore, this study examined these inter-relationships and the possible mediating effect of insomnia on the association between specific personality pathologies and depression severity.There were 138 study participants, including 69 individuals with depression and 69 healthy controls. The main variables were measured by the Hamilton Depression Rating Scale-24 (HAMD-24), Athens Sleep Insomnia Scale (AIS), and the Personality Diagnostic Questionnaire (PDQ-4+). Multivariate linear regression and mediation analysis were conducted.p < 0.001). In the total sample, all personality pathology scores (p < 0.001), except the antisocial personality score, had significant positive correlations with the AIS scores and HAMD-24 scores, and the AIS scores and HAMD-24 scores were positively correlated . Regression analysis revealed that borderline personality, passive-aggressive personality, and insomnia positively predicted the severity of depression, after adjusting for sociodemographic covariates, and that insomnia partially mediated the associations of borderline personality and passive-aggressive personality with depression severity.With the exception of the antisocial personality score, all the PDQ-4+ scores and AIS scores were significantly higher in the depression group than in the healthy control group (Borderline personality, passive-aggressive personality, and insomnia tend to increase the severity of depression, and the effect of borderline and passive-aggressive personality on depression severity may be partially mediated by insomnia. This is the first study to report these findings in a Chinese sample, and they may help researchers to understand the pathways from specific personality pathologies to the psychopathology of depression better, which should be useful for designing interventions to relieve depression severity, as the impact of specific personality pathology and insomnia should be considered. Depression is a common mental disorder, with a lifetime prevalence of depression being 3–17% in the global population , and theDSM-IV Criteria, PDs include cluster A PDs , cluster B PDs , cluster C PDs , and passive-aggressive and depressive PDs (see the Appendix of DSM-IV). A survey of 13 countries showed that the estimated prevalence of having any personality disorder was 6.1%, and the prevalence in China was 4.1%  are defined as patterns of inner experience and behavior that obviously deviate from the expectations of an individual’s culture, have an onset in early life, and may lead to distress and impairment in individuals in the future . Accordiwas 4.1% . Personawas 4.1% , which awas 4.1% . Currentwas 4.1% . For inswas 4.1% . Anotherwas 4.1% . Even afwas 4.1% . The cluwas 4.1% . In addiwas 4.1% . A comorwas 4.1% . Personawas 4.1% . HoweverSleep difficulty is a crucial public health problem that involves daytime impairments and poor nighttime sleep. Insomnia is associated with brain function, cognitive and emotional effects, and physical health , and slePrevious studies have examined the relationship between personality disorders and depression—including research from the fields of epidemiology, epigenetics, and clinical treatments —and theiThe present study used a case-control design. Depressed patients between 18 and 60 years of age were consecutively recruited from the Inpatient Department of Mental Health of the Second Affiliated Hospital of Guangxi Medical University in Guangxi, China. A total of 69 inpatients with depression  were recruited. The diagnosis of depression was made by professional psychiatrists using the Structured Clinical Interview based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID for DSM-IV), and inpatients who had a Hamilton Depression Rating Scale-24 (HAMD-24) score ≥ 20 and a Hamilton Anxiety Rating Scale (HAMA-14) score ≤ 7 were included. Any inpatients who met one of the following criteria were excluded: (1) they had a current infection, somatic trauma, or an autoimmune disease; (2) they had another psychiatric Axis-I disorders (except depression) after SCID screening; (3) they had a family history of a genetic disorder or bipolar disorder; (4) they had an organic brain disorder, mental retardation, or a major physical illness; or (5) they were pregnant or lactating. Inpatients recently had transfusion therapy were also excluded.We also recruited 69 healthy controls  from the same hospital through posters placed in the Medical Examination Center. The control group was selected using a 1:1 age matching ratio (±3 years). The inclusion criteria for the control group were having a Hamilton Depression Rating Scale (HAMD-24) score < 8 and a HAMA-14 score ≤ 7. People with a current or past mental illness, any major physical illness, genetic disease, or a family history of mental illness were excluded.All the participants were given detailed information about the content and aims of the study, and the individuals then gave their written informed consent to participate in the study. The study was approved by the ethics committee of Guangxi Medical University .“Functioning  during the day.” Participants rated their insomnia on a scale from 0 to 3, with 0 corresponding to “no problem at all” and 3 corresponding to “very serious problem.” The total score ranged from 0 to 24, with higher scores indicating more severe insomnia , which is a psychometric instrument based on the Tenth Revision of the International Classification Diseases (ICD-10), was used to assess the severity of insomnia during the past month . This isinsomnia . A scoreinsomnia . The AISinsomnia , and theThe Personality Diagnostic Questionnaire (PDQ-4+)  was usedThe Hamilton Depression Rating Scale (HAMD)  was usedTrained clinical psychologists used the 14-item Hamilton Anxiety Scale (HAMA-14) to evaluate the severity of anxiety of all participants during the current or most recent week. This scale, which has 14 items, has good psychometric properties, and includes psychic anxiety and somatic anxiety domains . ParticiAll participants were personally interviewed by clinical psychologists from the Mental Health of the Second Affiliated Hospital of Guangxi Medical University in Guangxi, who were trained in a standard way to perform face-to-face interview. All participants were interviewed upon their consent, and those who could not read the questionnaire were assisted by the interviewer.t-test was used to analyze differences in insomnia (AIS scores), severity of depression (HAMD-24 scores) and each personality pathology  between the two groups, and Spearman’s rank correlation was used to measure the associations among the AIS, HAMD-24, and the scores for each type of personality pathology. Multivariate linear regression was used to analyze the degree to which insomnia and each type of personality pathology predicted the severity of depression severity, controlling for age, gender, ethnicity, education, income, and marital status. Finally, we conducted mediation analysis using AMOS 23.0, with HAMD-24 scores as the dependent variable, and AIS scores as the mediating variable; the analysis met the four criteria of Baron and Kenny’s method  between the depressed and control groups. Student’s s method . Bootstrp > 0.05).2 = −40.347, p < 0.001) and AIS scores  were significantly higher in the depression group than in the healthy control group. Significant group differences were found for all types of personality pathology scores, except antisocial personality: Compared to the healthy controls, inpatients had higher personality pathology scores (p < 0.001) (see HAMD-24 scores (χ001) see  and 2.r = 0.620, p < 0.001). With the exception of antisocial personality, all the other personality pathology scores were positively correlated with AIS scores and HAMD-24 scores , borderline personality scores , and passive-aggressive personality scores  significantly predicted HAMD-24 scores.The multivariate regression that was conducted to test the ability of insomnia (AIS scores) and each type of personality pathology  to predict depression severity (HAMD-24 scores) found insomnia, borderline personality, and passive-aggressive personality significantly predicted the severity of depression. We conducted a series of mediation analyses based on the results of correlation analyses and multivariate regression analysis. We found that insomnia had a significant partial mediating effect on the relationship of depression severity with borderline personality and passive-aggressive personality, based on 5,000 bootstrap samples. The standardized direct effects of borderline personality and passive-aggressive personality on depression severity were 0.553 and 0.548, respectively; the standardized indirect effects of borderline personality and passive-aggressive personality on depression severity through insomnia were 0.205 and 0.208, respectively see . FiguresThe main aim of this study was to explore the associations among each type of personality pathology, insomnia, and the severity of depression. Personality traits may develop into personality disorders under certain circumstances and conditions, leading to significantly decreased adaptation, affect, and social and professional functioning, and may even cause clinical problems . With thThe present study showed that in the entire sample, all types of personality pathologies but antisocial personality were positively correlated with depression severity, which is consistent with the findings of some prior studies. Personality pathology is frequently associated with internalized and externalized symptoms, social relationship problems, impulsive behavior, and comorbidities . Longitu2/D3 receptor binding in the nucleus accumbens (Interestingly, the results of the mediation analysis showed that insomnia partially mediated the relationships of borderline personality and passive-aggressive personality with the severity of depression, which may contribute to our understanding of the pathways from personality disorders to depression. These results suggest that borderline personality and passive-aggressive personality may promote insomnia, and this indirectly increases the negative influence of personality disorders on depression. This may be partly explained by a biologically plausible mechanism—the dopamine system. Several studies have shown that dopamine system dysfunction is associated with the symptoms and treatment of depression . For exaccumbens . Some stccumbens . Moreoveccumbens . At the ccumbens . Insomniccumbens  and haveccumbens . At presccumbens . A persoccumbens . And pooccumbens . Personaccumbens  that mayccumbens . Taken tAccording to our results and the previous evidence we reviewed, the presence of a personality disorder is not only associated with depression severity, but the comorbidity of a personality disorder can complicate treatment and worsen the prognosis of depression  and otheLike all studies, our study has some limitations. First, the cross-sectional design of our study is a limitation because it makes it impossible to determine the causal relationships among insomnia, personality pathology, and depression severity. Although the research evidence supporting our model was discussed in the introduction, the partial mediating effect of insomnia on the association between personality pathology and depression is a hypothesis that needs to be more thoroughly explored in prospective and longitudinal research in future. Second, it is common for a diagnosis of a personality disorder to co-occur with major depressive disorder . HoweverThese findings further demonstrate that borderline and passive-aggressive personality traits and insomnia are risk factors for depression severity, which should enable researchers to understand the risk factors of depression severity and clinicians to focus on evaluating specific personality disorders and sleep problems to provide optimal interventions and treatments to relieve the severity of depression in a timely way. In addition, to the best of our knowledge, this is the first study to examine the mediating role of insomnia on the relationships between personality disorders and depression in a Chinese sample, which may provide researchers with a way to understand the pathways from personality pathology to psychopathology. However, because our findings are based on cross-sectional data, causality remains unclear. Prospective studies are needed in the future to verify the mediating role of insomnia on the association between pathological personality and depression.10.7717/peerj.11061/supp-1Supplemental Information 1Click here for additional data file.


Guided by the models of health assessment and social determinants of health, we examined predictors of self-rated physical, mental, oral, and cognitive health of older Korean immigrants.N = 2,061, Mean age = 73.2). Multivariate regression models of self-ratings of health were tested with health indicators  and sociocultural factors .Data came from the Study of Older Korean Americans (SOKA; For self-rated physical, mental, and oral health, indicators specific to the targeted domain played a primary role, with those of other health domains playing a secondary role. Acculturation and social network were significant predictors of all four measures.Findings highlight the importance of holistic health assessment that considers a wide range of health domains as well as sociocultural contexts. In response to disparities in health and healthcare, increasing attention has been paid to older immigrants –3. In 20The present study focuses on the health of older Korean immigrants in the United Sates. With an estimated population of 1.8 million, Korean Americans represent the fifth largest Asian American subgroup . Becausephysical health (SRPH), a single item questioning “How would you rate your health?” has become well-established as an important health measure. SRPH is documented to predict older individuals’ general health and well-being and even mortality [Self-rated ortality ,15. Withortality –18.mental health (SRMH) has also gained its prominence, and studies demonstrate its close linkage to mental health symptoms, psychiatric diagnosis, and the use of mental health services [oral health [cognitive health [Self-rated services –21. The l health ,23 and ce health ,24. Howeexcellent to poor, the response to the single-item self-rating question is quick but reflects a complex process. Building on an earlier work on the cognitive flow of health [Typically ranging from f health , Jylhä [f health  proposedf health ,26. Partf health ,14. In tIn considering self-ratings of these health domains, it is important to keep in mind that more objective health indicators relevant to each specific domain have generally been the primary sources of personal assessment. For example, in Jylhä’s model , SRPH isBeyond health indicators, sociocultural factors are another set of critical variables that influence self-assessment of health. For this study, non-health-related variables such as acculturation, social network, and ethnic community social cohesion were anticipated to serve as critical determinants of health. Each of these variables represents individual-, interpersonal-, and community-level resources, and its selection was based on the literature on immigrants’ health and social capital. For example, acculturation is widely known as an important personal asset that enhances immigrants’ health and well-being . FurtherIn summary, we examined (1) how SRPH, SRMH, SROH, and SRCH might be associated with one another, and (2) how each of them might be predicted by health indicators  and sociocultural factors . We hypothesized that (1) the self-rated measures of physical, mental, oral, and cognitive health would be interrelated and that (2) the set of domain-specific health indicators, other health indicators, and sociocultural factors would make a unique contribution to explaining each measure.Data were drawn from the Study of Older Korean Americans (SOKA), a multi-state survey of Korean immigrants age 60 and older. In an effort to increase the generalizability of findings, sites were selected from states with differing proportions of the entire Korean population: California 29.3%), New York (8.0%), Texas (5.2%), Hawaii (2.7%), and Florida (2.2%) . In each9.3%, Newn = 111) or whose cognitive status suggested severe impairment , the final sample consisted of 2,061 participants.Study participants were recruited by a team of investigators who shared the language and culture of the target population. The project began with the compiling of a database of Korean-oriented resources, services, and amenities at each study location; this database not only facilitated the research team’s efforts for community engagement but also guided the selection of specific locations for data collection. In the development of these databases and in their use at each site, community advisors’ input was actively solicited. At each of the five geographic sites, surveys took place at multiple locations and events  from April 2017 to February 2018. The survey questionnaire was in Korean, developed through a back-translation and reconciliation method. The questionnaire was designed to be self-administered, but trained interviewers were onsite for anyone who needed assistance. Upon completion of the survey, each participant was assessed for cognitive function, using the Mini-Mental State Examination (MMSE), by trained research personnel. All participants were paid U.S. $20 each for participation. The project was approved by a university’s Institutional Review Board. All participants were informed of the study’s goals and signed an informed consent form. A total of 2,176 individuals participated in the survey. After removal of those who had more than 10% of data missing on variables used in the present analyses (poor), 2 (fair), 3 (good), 4 (very good), or 5 (excellent).Participants were asked to rate their overall status in four health domains: physical, mental, oral, and cognitive health. Each domain was rated using a 5-point scale: 1 (without help), 1 (with some help), or 2 (unable to do). Total scores could range from 0  to 32 . Internal consistency of the scale in the present sample was high (α = .89).As indicators specific to physical health, chronic disease and functional disability were used. The total count for a checklist of 10 chronic diseases and conditions common in older populations  was used as a continuous format. Functional disability was assessed with a composite measure  that incnone of the time) to 4 . Responses were summed to create a composite score, ranging from 0 to 24. The K6 has been translated into Korean, and its psychometric properties have been validated in samples of Koreans and Korean Americans [As the indicator specific to mental health, level of mental distress was measured by the Kessler Psychological Distress Scale-6 (K6) ,34. Partmericans . Cronbacno, 1 = yes). Cognitive function was indicated by MMSE [correct) or 0 (incorrect). Total scores could range from 0 to 30, with higher scores indicating better cognitive function. The psychometric properties of the Korean version of the MMSE have been validated [For the indicator specific to oral health, participants were asked whether they had any problems with teeth or gums  to 3 (very well/very often/very much). Total scores could range from 0 to 36, with higher scores indicating a greater level of acculturation to mainstream American culture. Internal consistency in the present sample was high (α = .91).Acculturation, social network, and ethnic community social cohesion were considered. The level of acculturation was assessed with a 12-item inventory of acculturation , addressnone) to 5 (nine or more). Total scores could range from 0 to 30, with higher scores indicating a stronger social tie. The scale has been translated into Korean, and it has been validated for psychometric properties [Social network was measured with the six items in Lubben’s Social Network Scale-6 (LSNS-6) ,39. Thesoperties . Internastrongly disagree) to 4 (strongly agree). Total scores could range from 0 to 20, with higher scores indicating a greater level of sense of cohesion. Internal consistency in the present sample was high (α = .92).Ethnic community social cohesion was measured with a five-item scale adapted from previous studies on social capital in general populations . Particimale, 1 = female), marital status , and education .Background information included age (in years), gender  demographic variables, (2) domain-specific health indicators, (3) other health indicators, and (4) sociocultural variables. This approach allowed assessment of how each set of predictors independently contributed to the variance of the self-rated measures of health. All analyses were performed using IBM SPSS Statistics 25.SD = 7.93), with a range from 60 to 100. Approximately 67% of the sample were women, and over half (60.8%) were married. About 40% had attained formal education beyond high school. The scores of chronic disease, functional disability, and mental distress averaged 1.57 (SD = 1.40), 1.67 (SD = 3.42), and 3.88 (SD = 4.05), respectively. Reflecting the nature of a community-dwelling volunteer sample, these scores were skewed to the healthy side. For multivariate analyses, the scores were log-transformed to approximate normal distributions. More than 20% reported a problem with teeth or gums, and MMSE scores averaged 26.7 (SD = 2.91).SD = 7.06), 15.5 (SD = 6.05), and 11.4 (SD = 4.11), respectively. Concerning self-rated health assessments, the average score for oral health was the lowest , followed by physical health , cognitive health , and mental health . The proportions of the sample reporting fair or poor status were 36.4% for SRPH, 21.3% for SRMH, 52.3% for SROH, and 33.2% for SRCH.With regard to sociocultural factors, the mean scores for acculturation, social network, and community cohesion were 12.2  and functional disability , SRMH with mental distress , SROH with problem with teeth or gums , and SRCH with cognitive function . Other health indicators non-specific to a given health measure also showed significant correlations. For example, chronic disease and functional disability were significantly correlated with a poorer rating of SRMH , SROH , and SRCH . It is noteworthy that the association of SRCH with mental distress was even greater  than that with cognitive function . Positive ratings of health were associated with high levels of acculturation  and large social networks . Community cohesion, however, had either non- significant or marginally significant correlations with the measures of self-rating. It is also worth noting that the self-rated measures of health were positively associated with one another. The strongest relationship was found between SRMH and SRCH . Similarly, the correlation coefficient between SRPH and SRMH exceeded .60. Because each measure was used as a separate outcome variable, there were no concerns about collinearity.A similar pattern was observed in the regression models of the other three outcome measures. Each entry of demographic variables, domain-specific health indicators, other health indicators, and sociocultural factors made unique contributions to the predictive models. In the final model of SRMH, advanced age, lower education, higher levels of mental distress, greater numbers of chronic diseases, greater level of functional disability, having problems with teeth or gums, poorer cognitive function, lower acculturation, and smaller social networks were associated with more adverse ratings of SRMH. The full model accounted for 33% of the variance.In the final model of SROH, negative ratings were observed among those with male gender, lower education, and problems with teeth or gums. Among other health indicators, chronic disease and mental distress were predictive of negative ratings of SROH. All of the sociocultural factors reached statistical significance; those with greater levels of acculturation, social network, and community cohesion had more favorable SROH. The total variance explained by the model was 29%.Finally, in the model of SRCH, higher educational attainment was associated with positive ratings. In addition to the MMSE scores, all of the other health indicators were significant predictors of SRCH. Mental distress had a substantial negative impact on SROH, but higher levels of acculturation and social connectedness promoted positive ratings of SROH. The total variance explained by the model was 28%.In the present study, we examined factors associated with self-ratings of physical, mental, oral, and cognitive health in a sample of older Korean Americans. Based on the health assessment model posed by Jylhä  and the r = .62, p < .001) was anticipated because many studies have shown a close link between physical and mental health [r = .67, p < .001), and this finding is in line with literature demonstrating close connections between the symptoms of cognitive impairment  and those of mood disorders [As anticipated, all measures of health ratings were positively correlated, indicating intersectionality among different dimensions of health. Poor ratings of one dimension of health were likely to be linked to poor ratings of other dimensions of health. The close linkage between SRPH and SRMH  emerged as the most powerful driving factor of SRCH. Although this finding is in line with other studies [In all measures of self-ratings, the common finding was that domain-specific health indicators played a primary role and other health indicators played a secondary role. However, in the predictive model of self-rated cognitive health, the predictive power of the other health indicators exceeded that of the domain-specific health indicator. Although the MMSE score was a significant predictor of SRCH, it accounted for only 2% of the variance, whereas the amount of variance explained by other health indicators was over 13%. It was worthy to note that mental distress  would provide a stronger foundation for the validation of the self-reported measures. Furthermore, consideration should be given to broader levels of environmental variables such as neighborhood ethnic density and area health service availability.Despite these limitations, however, the findings of the study contributed to our understanding of the multi-faceted nature of health and the processes of self-evaluation. Confirming the inter-connectedness of health domains and the roles of social determinants, the study highlights the importance of holistic health assessment that considers a wide range of health domains as well as sociocultural contexts. As self-perceptions of health are linked with health behaviors, chronic disease management, health service use, and mortality ,15, poor


N6-methyladenosine (m6A) is the most common internal modification to eukaryotic mRNA, which is involved in the splicing, stability, export, and degradation of RNA metabolism. m6A methylated-related genes are divided into writers, erasers, and readers, and they are critical for the regulation of cell life. They play a significant role in various biological processes, such as virus replication and cell differentiation by controlling gene expression. Furthermore, a growing number of studies have indicated that m6A is associated with the occurrence of numerous diseases, such as lung cancer, bladder cancer, gastric cancer, acute myeloid leukemia, and hepatocellular carcinoma. In this review, we summarize the history of m6A research and recent progress on RA research concerning m6A enzymes. The relationship between m6A enzymes, immune cells, and RA suggests that m6A modification offers evidence for the pathogenesis of RA, which will help in the development of new therapies for RA.Rheumatoid arthritis (RA), one of the most common autoimmune diseases, is characterized by immune cell infiltration, fibroblast-like synovial cell hyperproliferation, and cartilage and bone destruction. To date, numerous studies have demonstrated that immune cells are one of the key targets for the treatment of RA.  Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by synovial hyperplasia and inflammation, progressive joint destruction, and significant disability . InitialN6-methyladenosine of RNA is a methylation modification of adenine (A) at the sixth N, catalyzed by methyltransferase from eukaryotes  contained m6A modifications  affects the binding of DGCR8 to pri-miRNAs, and the absence of METTL3 reduces this binding capacity .M6A, METTL3 has important functions, which include pre-mRNA splicing, nuclear export, translation regulation, mRNA decay, and miRNA processing; moreover, METTL3 also functions to influence epigenetics by regulating and initiating pluripotency , acute myelogenous leukemia (AML) cells, and pancreatic cancer  proteins, RBM15 combines with RNA through spliceosomes to regulate splicing, translation, and stability. At present, RBM15 has been studied widely in various blood diseases, such as chronic myelogenous leukemia (CML), acute megakaryocytic leukemia, and T−cell acute lymphoblastic leukemia. Yang et al. found that patients with chronic and accelerated-phase CML had a significantly lower mRNA expression level of RBM15 than that of patients with blast-crisis CML. Moreover, the RBM15 protein may affect the growth of RBPJ-mediated CML cells through Notch signaling , 74. Rbp6A demethylase called erasers, which remove the m6A methylated group from RNA. The most common erasers are the fat mass and obesity-associated protein (FTO) and alkylation repair homolog protein 5 (ALKBH5).The second type of protein is an m6A modification and modulates the stability of mRNA, which ultimately leads to the alteration of pathogenesis in various types of cancer  binding at splice sites . Howeverf cancer , 75. In f cancer . FTO andf cancer . In arsef cancer . Some obf cancer , 78, 79.6A modification and exerts its functions during the regulation of mRNA nucleation and other metabolic processes in the development of sperm. The functions of m6A modification are involved in the regulation of IncRNA to affect the development of cancers , and there was an increase in the number of naive T cells in the LNs. In non-small-cell lung cancer, circIGF2BP3 inactivated cocultured CD8+T cells and METTL3 depended on YTHDC1 to participate in the methylation modification of circIGF2BP3 -induced monocyte inflammation. In human monocyte PHT-1 cells, METTL3 and YTHDF2 jointly affect the state of mitochondria and energy metabolism, thereby enhancing the inflammatory response of monocyte-macrophage  is produced primarily by macrophages, and TNF inhibitors are effective for the treatment of RA . SecretiIn the early 1990s, macrophage gene expression was found to vary under different media stimulation (IL-4/IFN-γ/LPS). In 2000, Mills et al.  discoverNK cells are natural immune effector cells with a direct killing function and are particularly important in immune cells because they eliminate viral infections and secrete proinflammatory cytokines. Li et al. conducted an integrative pathway association analysis of RA using genome-wide association studies (GWAS) summary data of 25 RA-associated pathways for NK cells . In a moAutoreactive T cells play an important role in many autoimmune diseases. There are various types of T cells, such as the T helper cell and nonclassical T helper cell subsets, such as Th0, Th1, Th2, Th17, Th1/17, CCR4, CCR6, and CXCR3 . Yasuo eIn addition to autoantibody production, B cells are efficient APCs, which allow T cell activation. In some RA patients, B cells have been found to differentiate into plasma cells that produce rheumatoid factor and anticyclic citrullinated peptide antibodies . Rituxim6A has a potential function between DCs and RA.DCs are thought to play a crucial role in immunopathogenic responses, which result in the establishment of chronic proliferative synovitis and joint destruction in RA . FrancesMCs are important immune cells in the mammalian body and affect the pathogenesis of. MCs recognize and respond to various antigens, secrete various chemokines, recruit other immune cells, and cause local tissue inflammation, neovascularization, and tissue remodeling in the body . They exNumerous studies have shown that immune cells play a role in the pathogenesis of RA. First, some immune cells secrete chemokines and growth factors and subsequently, infiltration of other immune cells into synovial cells occurs. Second, immune cells can act as APCs to stimulate the production of various other immune cells. Third, in the early stage of RA, synovial cells have a small expansion area. Through the suppression of specific immune cells, combined with the patients’ age, sex, diet, constitution, and other factors to give appropriate treatment, it is a great approach to fully improve the treatment effect. Finally, whether immune cells promote angiogenesis in the synovium remains to be elucidated.6A methylation in RA has been poorly studied. Wang and colleagues showed that in RA patients, the expression of METTL3 is markedly increased in peripheral blood mononuclear cells (PBMCs); however, other RNA m6A methyltransferases have no obvious , China Postdoctoral Science Foundation (No. 2020M671839), Postdoctoral Science Foundation from Anhui Medical University (No. BSH201902), and Anhui Provincial Science and Technology Major Project (8212929035).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.


To investigate the expression of carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), CA19-9, CA724, and CA242 in serum and ascites of pseudomyxoma peritonei (PMP) patients and evaluate the predictive value of these elevated biomarkers in pathological grade, completeness of cytoreduction (CC), and survival.From May 2009 to October 2019, a total of 512 patients diagnosed with PMP through pathology in Aerospace Center Hospital were enrolled. The serum and ascites tumor biomarkers were obtained. The diagnostic values between serum and ascites biomarkers in pathology and CC were compared by the receiver operating characteristic (ROC) curves. The correlation between pathology, cytoreduction, and biomarkers was calculated by univariate and multivariate logistic regression. The associations between different numbers of elevated biomarkers and survival status were examined using univariate and multivariate backward Cox proportional hazard regression models.The results showed that the areas under the ROC curves (AUROC) in the diagnosis of CC were 0.798 (95% CI: 0.760–0.836) and 0.632 (95% CI: 0.588–0.676) in serum and ascites biomarkers, respectively. The elevated serum and ascites biomarkers were independent risk factors for both pathology and CC. The 1-year, 3-year, and 5-year survival rates were 89.07%, 73.22%, and 66.94%, respectively. Longer survival was observed in patients who had less than two elevated serum biomarkers compared with those with 2–3 and 4-5 elevated serum biomarkers (p < 0.001).CEA, CA125, CA19-9, CA724, and CA242 in serum and ascites can be used to judge the severity and predict the resectability. Furthermore, different numbers of elevated biomarkers can help determine the prognosis of PMP. Pseudomyxoma peritonei (PMP) is a syndrome characterized by mucinous effusion and mucoprotein tumor that diffusely implant in the abdominal cavity and peritoneal surface. The primary source is most often the appendix, but the source may also be colorectal, pancreatic, ovarian, or urachal. Most patients die of intestinal obstruction, perforation, malnutrition, etc., unless they undergo radical surgery , 2. Dr. The application of serum biomarkers carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), CA19-9, CA724, and CA242 in colorectal, ovarian, and pancreatic cancer has been widely reported in the literature and used in the clinic –8. Some This study aims to investigate the expression of CEA, CA125, CA19-9, CA724, and CA242 both in serum and ascites of PMP to evaluate the correlation between abnormal expression of these biomarkers and pathological grade, completeness of cytoreduction (CC), and survival prognosis.A prospective study was designed to find the diagnostic performance of serum and ascites biomarkers. The inclusion criteria were as follows: 1) patients were treated with CRS in Aerospace Center Hospital from May 2009 to October 2019. 2) Patients were diagnosed as having PMP by surgery and pathology. 3) Ascites and serum biomarkers were routinely collected. Patients without pathological results and serum or ascites biomarkers and those who were lost to follow-up were excluded. Eleven patients without ascites were excluded because of lack of ascites, and 94 patients whose ascites cannot be obtained were excluded due to the limitation of thick mucus jelly in the peritoneal cavity. Finally, 512 patients were enrolled in the study. The study was approved by the Aerospace Center Hospital Ethics Committee with approval no. 2009QN10. All the enrolled patients signed the informed consent.Patients were hospitalized with suspected PMP diagnosis by ultrasound (US) and computed tomography (CT) in our hospital and underwent core needle biopsy or local appendectomy in other hospitals. Biomarkers in serum and ascites were examined within 2 weeks before operation. The patients received CRS combined with HIPEC. After discharge, they received biomarkers and imaging reexamination once a half year, and those who failed to come to the hospital for reexamination were followed up by telephone. The enrolled patients were followed up to February 1, 2020.Here, 2–3 ml fasting venous blood and ascites were collected from all the patients, 3,000 R/min, centrifuged for 10 min, and the serum and ascites were stored at -20°C. CEA, CA125, CA19-9, CA724, and CA242 in serum and ascites of all subjects were determined by chemiluminescence method, and the automatic chemiluminescence immunity was performed by Abbott company ARCHITECT. The reagent, quantitative standard, and quality control materials used in the test are provided by the original manufacturer and operated in strict accordance with the instructions.The critical values of biomarkers used were all referred to the range given by the manufacturer, that is, CEA >5 ng/ml, CA125 >35 U/ml, CA19-9 >30 U/ml, CA724 >12 U/ml, CA242 >20 U/ml.The CC score is a score based on tumor distribution after CRS, which is considered an important prognostic indicator for patients with appendiceal mucinous tumors. No tumor or residual tumor less than 2.5 mm was scored CC 0–1, which was considered a complete CRS. The residual tumor larger than 2.5 mm was scored CC 2–3, which was considered the largest tumor removal operation , 9.According to the World Health Organization (WHO) 2019 digestive system tumor classification standard, the patients were divided into high-grade and low-grade .It was calculated that at least 72 patients with 0–1 elevated serum biomarkers and 168 patients with 4–5 elevated serum biomarkers per group would be required with alpha of 0.05, beta of 0.2, and survival rates of 80% and 60%, respectively. In this cohort study, the sample size was sufficient.Continuous variables were described using median [interquartile range (IQR)]. Categorical variables were described using frequency (percentage). The serum and ascites tumor biomarkers were described in both continuous and categorical variables. The receiver operating characteristic (ROC) curves and 95% confidence interval (95% CI) were used to show the differences between the number of elevated biomarkers. The optimal cutoff values were calculated with the criteria of Youden’s index. Sensitivities and specificities with 95% CI were also calculated with the optimal cutoff values. The relationship between pathology, CC, and biomarkers were calculated by univariate and multivariate logistic regression. The survival curves were plotted using the Kaplan–Meier method, and log-rank test was used for statistical analysis. The associations between biomarkers and survival status were examined using univariate and multivariate backward Cox proportional hazard regression models. All statistical tests were two-sided using a 0.05 significance level. The data analyses were performed using SAS version 9.4. The ROC curves and survival curves were drawn in MedCalc Statistical Software version 19.0.4 and GraphPad Prism version 5.0, respectively.In total, 512 patients were included in the final data analysis. The median age was 58 (IQR: 49–64.5) years old Table 1.As shown in The diagnostic performance of serum biomarkers for CC was better than that of ascites biomarkers Figure 1In The 1-, 3-, and 5-year survival rates were 89.07%, 73.22%, and 66.94% in 512 patients, respectively. As shown in The univariate and multivariate Cox regression model showed that the higher level of elevated serum and ascites biomarkers, the irregular treatment of HIPEC, the high grade of pathology and PCI were independently associated with shorter survival time Table 4.PMP develops from mucinous carcinomas that originate from appendix and/or ovary. The treatment consensus of CRS combined with HIPEC has been reached and become the first-line treatment of PMP .Due to the complexity of CRS, accurate preoperative evaluation is quite important to determine the indications and surgical procedures. As a convenient tool, CEA, CA125, CA19-9, CA724, and CA242 are commonly used to monitor tumor progression or remission. In the previous literature, preoperative serum CEA, CA19-9, and CA125 concentrations were found closely related to the survival time of PMP patients, and the higher the serum biomarker concentrations were when the disease relapsed, the shorter the survival time would be after secondary tumor reduction surgery and HIPEC , 16, 17.In our study, we tried to identify the pathological grade of PMP by abnormal biomarkers, which is an innovation compared with the previous studies. The results showed that the elevated abnormal biomarkers of serum and ascites were independent risk factors for pathology, the higher level of elevated biomarkers in serum and ascites, and the higher grade of pathology. In terms of cell heterogeneity in pathology, PMP was classified into high- and low-grade according to the WHO 2019 digestive system tumor classification standard . CompareRecent studies , 19 indiThe results showed that the elevated abnormal biomarkers of serum and ascites were independent risk factors for CC, the higher level of elevated biomarkers in serum and ascites, and the higher grade of CC. And the diagnostic performance of serum biomarkers for CC was better than that of ascites biomarkers.Some biomarkers play an important role in leukocyte adhesion and extravasation , 20. TheIt is worth mentioning that, from this study, male was an independent risk factor of a higher CC score. In fact, the effect of gender on the overall survival (OS) of PMP patients remains to be determined. Many scholars believe that gender has no effect on prognosis, yet others think male is an independent risk factor of OS –25. BaseIn our study, the patients with less than two elevated serum biomarkers had longer survival rates compared with patients with 2–3 and 4–5 elevated serum biomarkers. The similar trends were shown in ascites biomarkers.Biomarkers such as CEA and CA19-9 can inhibit the differentiation of cells and promote the formation of cell adhesion, thus inhibiting apoptosis after cell abscission and enhancing metastasis ability –29. SomeIn the present study, high-grade pathology, high surgical PCI, and no HIPEC were also identified as independent predictors for poorer survival rates in multivariate analysis, which were consistent with the reports .It has been confirmed that PMP is rarely transferred through blood; peritoneal dissemination and implantation are the main mechanisms of metastasis instead. It is the first time to study the correlation between these ascites biomarkers and pathological grade, CC, and prognosis of PMP. Nummela et al.  found thThe study was based on a prospective analysis of over 500 PMP patients from a single center database, potentially generating selection bias. Larger sample studies from multiple centers need to be included in future work.CEA, CA125, CA19-9, CA724, and CA242 in serum and ascites can be used to judge the severity, predict the resectability, and determine the prognosis of PMP, which will help oncologists to make a more comprehensive prediction and clinical treatment strategy before surgery.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the ethics committee of the Aerospace Center Hospital. The committee’s reference number is 2009QN10. 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.LL, RM conceived and designed the experiments; XZ, XH, and YS provided study material or patients; XZ and YL collected and assembling data; QZ, JF, XH and LL analyzed and interpreted the data; LL and QZ contributed to the draft of the manuscript; JF, XH, XZ, YS, RM and YL revised the manuscript critically for important intellectual content. All authors approved the final version of the manuscript to be submitted. All authors agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors contributed to the article and approved the submitted version.This work was supported by Gold-Bridge Funds for Beijing (grant number ZZ21054), Aerospace Center Hospital Foundation (grant number YN201710), Beijing Talents Fund (grant number 2018000021469G198), and Natural Science Foundation of Beijing Municipal (grant number 7204249).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 analysis included data from 46 patients with 122 measurements of serum creatinine. Results: Among the 46 patients included in the analysis, kidney involvement was present in 37%, with 15% showing reduced eGFR and 22% abnormal UPE (63% of patients with available UPE data). No single predictor was associated with either eGFR values or its slope over time. Conclusions: Kidney involvement is quite common in patients with ATTRv regardless of the underlying genetic variant. In particular, abnormal UPE appears to be a common feature of the disease.Objective: Hereditary transthyretin amyloidosis (ATTRv) represents a diagnostic challenge considering the great variability of clinical presentation and multiorgan involvement. In the present study, we report the prevalence of kidney involvement and kidney function over time in a cohort of ATTRv patients with different transthyretin gene mutations. Patients and Methods: For this study, we systematically collected data from all patients with a diagnosis of ATTRv followed at the Neurology Unit of Fondazione Policlinico Universitario A. Gemelli IRCCS. Kidney involvement was defined as presence of estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m The term “amyloidosis” encompasses different disease entities deriving from conformational changes in native, soluble proteins that misfold and aggregate extracellularly into insoluble, highly ordered fibrils, leading to dysfunction of different organ and tissue . Kidney ATTRv is a rare disease due to mutations in the gene encoding TTR and is characterized by multisystem extracellular deposition of amyloid . More thATTRv amyloidosis represents a diagnostic challenge considering the great variability in clinical presentation and multiorgan involvement. Generally, patients present with polyneuropathy, but clinicians should also consider the frequent cardiac, ocular and gastro-intestinal impairment ,4,5,6. HKidney involvement in ATTRv, usually presenting as nephrotic syndrome and/or progressive renal failure, has been reported in about one-third of Portuguese/early-onset Val30Met patients , and in only 6% of sporadic/late-onset ATTRv cases ,9.Current therapeutic options include TTR tetramer stabilizers , agents designed to stabilize the normal circulating form of TTR, and, hence, to prevent the protein from dissociating and undergoing the conformational changes that lead to its aggregation as amyloid, and gene-silencers (patisiran and inotersen), able to decrease both variant and wild-type TTR hepatic production by targeting its mRNA ,11,12,13In the present study, we report the prevalence of kidney involvement and trajectories of kidney function over time in a cohort of ATTRv patients with different mutations coming from Italy, a non-endemic region.For this study, we systematically collected data from all patients with a diagnosis of ATTRv followed at the Neurology Unit of Fondazione Policlinico Universitario A. Gemelli IRCCS. Information was collected regarding the genetic variant, age at onset, age at examination, gender, presence of a polyneuropathy and/or a heart disease, Sudoscan measurements, as well as all the available data of urinary protein excretion and serum creatinine for each patient. Presence of polyneuropathy was defined based on nerve conduction studies, as previously described ,16. Sudo2, abnormal urinary protein excretion (UPE)  or both. An analysis of predictors of both eGFR values at any time and of eGFR slope  was performed in patients with at least two measurements of serum creatinine over time by random-intercept mixed models, with eGFR modelled as the continuous dependent variable and potential clinical and instrumental predictors as the independent variables. To determine whether predictors of interest were associated with the slope of eGFR, interaction terms for each predictor and time were included in the models. Time was modelled as a continuous variable, measuring months lapsed from the first measurement of serum creatinine.Heart disease was defined in the presence of a NYHA class > 1. All patients were genotyped; for statistical analysis patients were classified into the following genetic categories: “Val30Met”, “Phe64Leu” and “Other”. Estimated glomerular filtration rate (eGFR) was obtained with the CKD-EPI equation. Kidney involvement was defined as any eGFR < 60 mL/min/1.73 mp-value < 0.05 was considered as statistically significant. All statistical analyses were performed with Stata version 15.1 . This study was approved by the Ethics Committee of Fondazione Policlinico Universitario A. Gemelli IRCCS (ethic code number ID1493). All the patients who participated to the study gave an informed consent. This study was carried out according to the Declaration of Helsinki.A two-tailed Overall, 46 patients had at least one measurement of serum creatinine available . Of those 46 patients, 11 (24%) had 1 measurement, 12 (26%) had 2 measurements, 10 (22%) had 3 measurements, 9 (20%) had 4 measurements, 3 (7%) had 5 measurements and 1 (2%) had 6 measurements. Among those with at least 2 measurements, median follow-up time was 56 months . Sixteen patients (35%) had at least one measurement of urinary protein excretion. Baseline characteristics of the enrolled patients are reported in n = 18, 39%) or the Phe64Leu variant ; the remaining patients had the Glu89Gln variant , or other variants . Overall, the presence of kidney involvement was high: low eGFR during any time of follow-up was present in 7 patients (15%), abnormal UPE in 10 ; when considering a combination of low eGFR and/or abnormal UPE, 17 patients (37%) had kidney involvement. At baseline, only two patients presented low eGFR ; during follow-up, an additional 5 cases developed low eGFR . Conversely, abnormal UPE was found in 4 Val30Met patients, 3 Phe64Leu and 3 with other single mutations . Indeed, in one Val30Met patient a nephrotic syndrome represented the first sign of ATTRv.The majority of patients had the Val30Met variant  and age . However, in multivariate analysis eGFR was significantly associated only with age   .Focusing on the genetic variant, patients with the Phe64Leu mutation had nominally higher average eGFR values compared with the Val30Met ; however2 per year . No predictor was significantly associated with the slope of eGFR over time , revealed that the average change in eGFR was −1.00 mL/min/1.73 mver time .Kidney involvement is well-known in early-onset ATTRv, and it generally occurs in one third of patients ,5,10. CoIn our cohort of late-onset ATTRv, we reported the presence of kidney involvement in more than one third of patients, a much higher figure compared with that of the general population, suggesting that kidney involvement might be quite common and underestimated in ATTRv patients.Considering different mutations, we did not find significant differences at baseline. However, kidney involvement seems to be more frequent in Val30Met, being present in more than one third of cases, similar to what is described in early-onset Val30Met . On the Kidney disease may be one of the presenting manifestations in early-onset Val30Met . ConversOur study has several strengths, including the large number of patients for a rare disease, the longitudinal design with multiple measurements of serum creatinine for each patient, the presence of different genetic variants, and the statistical analysis performed with a gold-standard approach, useful for longitudinal data. Our study also has some limitations, including the observational design, the relatively small number of measurements for some variants, and the lack of UPE for most patients.In conclusion, ATTRv confirms to be a multisystemic disease that can frequently also involve the kidney, even in late onset cases. Serum and urinary biomarkers of renal damage  should be investigated early, both in diagnostic work-up, in follow-up, and in clinical trials.Future studies on a larger ATTRv cohort and on international registries, such as THAOS, will help clarify the real prevalence of renal disease in ATTRv. Furthermore, the role of therapies (including stabilizers and gene-silencers) on kidney function should be evaluated, as well as the role of prolonged survival of ATTRv patients in the occurrence of kidney disease, thus strengthening the role of the nephrologist in this disease.