By using DTI image segmentation algorithm investigate the effect of large plants Rhodiola injection on myocardial injury in patients with acute severe CO poisoning (ACOP), and to explore the clinical and CT delayed encephalopathy after ACOP.Seventy-two ACOP patients were randomly divided into control and observation group, 36 cases in each group from December 2015 – December 2017. The control group received hyperbaric oxygen, mannitol, dexamethasone, citicoline injection, gangliosides, dracone; observation group were large strain Rhodiola injection treatment group based on the once daily for two weeks of continuous treatment. The head CT, head MRI results were analyzed retrospectively.(1) hsCRP and ET-1 in the observation group were significantly lower than those in the control group, and VEGF was significantly higher than that in the control group (P<0.01). No, NOS, and iNOS were significantly lower than those of the control group (P<0.01); (2) CT images of 16 cases showed bilateral symmetrical fusion lesions with blurred edges, low density, and oval center around the ventricle; (3) MRI showed that the lesion was located in the cerebral cortex, white matter lateral ventricle and/or basal ganglia in 12 cases.Rhodiola can reduce myocardial vascular endothelial cell injury, improve cardiac function, and protect the damaged myocardium. Meanwhile, after acute CO poisoning delayed encephalopathy early for CT and MRI examination facilitate analysis and prognosis of the disease. Due to high morbidity, mortality and poor prognosis, acute severe CO poisoning (ACOP) has become a hot topic in the medical community.Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) after CO poisoning is easy to be ignored and cause serious consequences. Skull CT MRI can detect brain lesions after CO poisoning early.(1) Graph cutting in discrete scalar space. The graphic cutting method is an interactive image segmentation method. First, the designer selects some pixels as the target object and background. The category of the remaining pixels is unknown. Then the pixels are assigned as vertices. Finally, the minimum cut method of the graph is to segment the image into target objects and background two parts.G≤V,E>V is a set of nodes, E is a set of connection relations between pixels and neighborhoods, and the weight of edges is a function of the degree of similarity between two pixel-specific attributes. Eight neighborhood connections are selected. Image segmentation is a binary classification of nodes of unknown class in V. For the convenience of graph construction and segmentation calculation, two dummy points are added: the sending point and the receiving point . Construct the objective function:Suppose graph i,yix is the generic of node i,j; s(xi)E is the penalty of node i belongs to ix; dE is the penalty of node 0<α<1 belongs to i,yix respectively; α is the expansion factor, i,j. Assume that ioD , iBD is the distance from node i to the target and background set, B, O, and U are the background, target, and unknown pixel sets, respectively, and i,PjP is the segmentation attribute of i,j nodes. Then, s(xi)E, dE is defined as:In the formula: The first two penalties ensure that the target seed is segmented into the target set, and the background seed is segmented into the background set; the third penalty guarantees that general pixels are segmented into the closest set; the fourth term is a penalty for the segmentation boundary of the target set. Finally, the maximum flow algorithm is used to minimize to segment the target area.Graphic cutting of discrete tensor space. It needs to be extended in the following two aspects: First, the image element’s segmentation characteristic standard is mathematically extended from a scalar to a tensor. Define the similarity between two diffusion tensors:i, TjT and tensor, the greater the similarity between the diffusion characteristics between them, which is ∞ in the limit case; otherwise, the smaller the difference between the diffusion characteristics, the smaller the distance, and the distance i=TjT, in the limit case. Equal to 0. Starting from the definition of diffusion tensor similarity, the effective distance between the unknown generic node i to the target set and the background set is defined as the average value of the similarity between node i and each set:Equation (3) shows that the larger the difference between B is the number of elements in the background set, and O is the number of elements in the segmentation target set. The maximum flow algorithm is used to minimize E(G), and the carcass segmentation region is obtained.In the formula: Research objects. 72 ACOP patients were randomly divided into control and observation group, 36 cases in each group. The patients in December 2015 – December 2016 admitted to the control group; patients in January 2017 – December 2017 admitted to the observation group. 20 males and 16 females in the control group; age 38~65 years (49.3±5.6) years; coma is 2~10h (6.3±2.5)h; coronary heart disease 12 cases of cerebral infarction in three cases, seven cases of hypertension, diabetes eight cases. Observation group 19 males and 17 females; mean age was (50.2±5.5) years old, coma time is 2~11h (5.9±2.7)h, 11 cases with coronary heart disease, cerebral infarction in four cases, eight cases of hypertension, diabetes seven cases. General information on two groups of patients, the difference was not statistically significant (P>0.05). Both in the acute phase of coma, coma time 5h~9d. 16 cases of coma delayed encephalopathy clear from 4 hours to 30 days, an average of 17 days. There are eight cases of mental symptoms, incontinence five cases; grand mal seizures in two cases. four routine lumbar punctures, cerebrospinal fluid pressure, conventional, biochemical, immunological and cytological examination were normal. EEG 18 cases were treated: 15 cases of exception, where extensive severe abnormalities nine; five cases of moderately abnormal widely; broad mild abnormalities in one case. EEG abnormalities primarily for a wide range of irregular diffuse slow, continuous long-range, seriously appear flat waveform, individual performance spikes, sharp wave or spike and wave. Both met the GBZ 23-2002 “Diagnostic Criteria for Occupational Acute Carbon Monoxide Poisoning” . The patAfter admission, the control group was treated with hyperbaric oxygen, while mannitol, dexamethasone, citicoline injection, and ganglioside  were given intramuscularly, dracone  Intravenous drip. The observation group was given 10 ml of Rhodiola rosea injection  based on the control group, 250 ml of saline was added intravenously, once daily and the treatment was continued for 2 weeks. Patients in the two groups received the same drug lot number.Observation indicators. (1) fasting blood samples were collected, automatic biochemical analyzer serum CK-MB activity; troponin (of cTnI), myoglobin (Myo) Content. Using color Doppler ultrasound cardiac LVEF detecting a patient. (2) respectively detecting a hsCRP and VEGF levels using radioimmunoassay of endothelin (ET-1) was detected by the ELISA.2 test. Measurement data were expressed by x̅±s. Two groups were compared by t test. Multiple groups were compared by analysis of variance. P<0.05 was considered statistically significant.(5) Statistical processing. SPSS 17.0 statistical analysis was used. Count data comparison was performed by χCT results. Head CT examination showed no abnormality. The skull CT examination showed delayed encephalopathy 1 to 20 days after acute CO poisoning. The lesions were mostly located in the white matter of the brain, and the basal ganglia area mainly involved the pale bulbs.Ten cases of pure white matter involving the paraventricular or hemisphere center of the hemisphere side of the brain were involved, and five cases of basal ganglia or pale bulbous lesions were involved in the hemisphere side of the cerebral ventricle and hemisphere center, and 1 case had cerebral cortex damage.The lesions were basically symmetrically distributed, and the lesions ranged in size and divergent. The morphology was spot-shaped, spot-shaped, some melted into clumps, the edges were slightly fuzzy, and there was little strengthening, and no placeholder effect. five cases were only involved in the paraventricular or hemisphere center white matter of the cerebral hemisphere side. Involving the paraventricular side of the hemisphere side of the brain and the center of the hemi-ovum, 6 cases with basal ganglia or pale bulbous lesions, and one case with damaged cerebral cortex. The lesion morphology was basically consistent with the CT findings. It shows low signal or equal signal at T1, and high signal at T2 and T2flair. Some patients showed that the gray matter interface of brain tissue was unclear on T1-weighted images.All patients underwent hyperbaric oxygen therapy, 1 hour a day, 10 days as a course of treatment, given 2 to 4 courses or until the condition improved. In the early onset of delayed encephalopathy after acute CO poisoning, dexamethasone was administered intravenously at a dose of 10-20 mg daily, and it was gradually reduced to discontinuation after 5-7 days. After the above treatment, the clinical symptoms of all patients were improved.Heart function comparison. CKMB, cTnI, Myo were significantly lower than the control group, LVEF was significantly higher (P<0.01). Comparison of inflammatory factors and vascular endothelial function. HsCRP and ET-1 were significantly lower than the control group, of VEGF significantly higher (P<0.01). See NO, NOS, iNOS were significantly lower than the control group, the differences were statistically significant (P<0.01). See The clinical manifestations of ACOP are mainly mental retardation, mental symptoms, tremor, dystonia, incontinence and paralysis.The imaging data found that: (1) the lesions mainly affected the white matter around the bilateral ventricles and the semi-oval center; (2) the symmetry of the basal ganglia area , or combined with the aforementioned white matter damage; (3) early gray matter interface is not clear, brain atrophy and other non-characteristic changes. Therefore, CT and MRI can better reflect the scope and severity of brain damage of delayed encephalopathy ACOP. In this group, clinical symptoms and electroencephalogram were improved to varying degrees after treatment with hyperbaric oxygen, hormones, and energy.21 Other studies have shown that Rhodiola rosea can increase high density lipoprotein, reduce low density lipoprotein, and regulate the effect of blood lipids.17Animal experiments confirmed that Rhodiola rosea treatment of myocardial infarction rats increased rat VEGF, inhibited the production of inflammatory factors, improved blood viscosity, inhibited platelet aggregation, promoted angiogenesis, and improved blood circulation.Based on the above results, we can find that Rhodiola significantly improves cardiac function, reduces inflammatory factors, increases VEGF to repair damaged cells, inhibits the release of NO, thereby protecting myocardial cells. Rhodiola rosea injection can reduce inflammatory response, reduce myocardial vascular endothelial cell damage, promote new blood vessels, improve cardiac function, protect damaged myocardium. Patients after ACOP should be closely observed. Once symptoms occur, CT and MRI should be performed as soon as possible to detect and treat DEACMP early and help judge the prognosis.ICD-10: International Classification of Diseases-10.WHO: World Health Organization.SDQ: Strengths and difficulties questionnaire.CGI: Clinical global Impression Scale.LOS: length of stay.CAMHS: Child & Adolescent Mental HealthServices.LMIC: Low and Middle-Income countries.YG: Conceived the study, literature review, participated in its design, coordination, analyzed the data and helped to draft the manuscript and also the responsible and accountable for the accuracy or integrity of the workHC & WR: Helped in design, data collection, article drafting & critical revision.BH: Takes the responsibility and is 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.


Escherichia coli isolates is of great importance not only for understanding the populations of E. coli but also for clarifying the relationship between strains and diseases. The present study aimed to evaluate the prevalence of phylogenetic groups, antibiotic susceptibility pattern, and virulence genes among uropathogenic E. coli (UPEC) isolated from different parts of Iran through a systematic review and meta-analysis. Several international electronic sources, including Web of Science, PubMed, Scopus, and Embase, were searched (2000–2020) in order to identify the studies compatible with our inclusion criteria. The meta-analysis was performed using the metaprop program in the STATA (version 11) software. Based on our comprehensive search, 28 studies meeting the eligibility criteria were included in the meta-analysis. The pooled prevalence of phylogroups B2, D, B1, and A was 39%, 26%, 18%, and 8%, respectively. In addition, there was a significant heterogeneity among different phylogroups. However, according to the results of Begg’s and Egger’s tests, there were no significant publication bias in phylogroups B2, D, B1, and A. This research provided the first comprehensive study on phylogroups of UPEC isolated in Iran. Our findings indicated that phylogroup B2 and group D were the most predominant phylogenetic groups among UPEC isolates in various regions of Iran. In addition, we observed that certain phylogenetic groups are more antibiotic resistant than the others. It was also observed that the dissemination of virulent phylogroup B2 and D should be controlled via comprehensive infection control measures. Additionally, certain strategies should be developed for monitoring the antibiotic therapy.The phylogenetic classification of  Escherichia coli (UPEC) is the main factor causing UTIs (Urinary tract infections (UTI), as one of the most prevalent pathological disorders, are the most problematic infectious diseases worldwide in both community and hospital settings . UTI pating UTIs . The priing UTIs . Antibioing UTIs . Excessiing UTIs .The major etiological agents associated with UTI are UPECs with the ability to successfully colonize the urinary tract. UPEC pathogenesis during UTIs occurs in an ascending manner as the following order: from the urethra to bladder to ureter to kidney to bloodstream . A broadE. coli strains into one of the major phylogenetic classes of A, B1, B2, or D, a rapid and easy phylogenetic grouping technique based on triplex PCR has been developed to detect the genes chuA, yjaA, and TspE4. To improve the accuracy of their system, an extra gene target, arpA, has been added. This new quadruplex PCR is able to correctly assign E. coli strains in eight phylogroups, namely A, B1, B2, C, D, E, F, and one Escherichia cryptic clade I  is considered an important emerging pathogen among B2 strains, harboring multiple genes for resistance and virulence factors (VFs). The strains belonging to this group are mediated by the production of extended spectrum β-lactamases (ESBLs) and are resistant against most β-lactam antibiotics  guidelines (E. coli isolates collected from the urine of patients with UTI and (2) those published worldwide with available English abstracts. Review articles, meta-analysis, or systematic articles, editorials, case report studies, letters to the editors, congress and meeting abstracts, studies where the sample size contains less than 10 isolates, studies with samples from environmental or nonclinical sources, articles without full text, duplicate publications, and articles with unclear and missing data were excluded.To determine the articles meeting the inclusion criteria and reduce the risk of error, two reviewers screened independently the databases with the related keywords and reviewed the titles, abstracts, and full texts, and any discrepancies were resolved by consensus. The articles with the following criteria were included in the study: (1) cross-sectional, retrospective, and cohort studies indexed in the Web of Science or PubMed or Scopus database and reporting the prevalence of phylogenetic groups in Five eligibility and quality assessment criteria were retrieved based on the Joanna Briggs Institute guidelines, and any disagreements were resolved by consensus. The following data were extracted for eligible studies: authors’ names, publication year, performed time, study location, characterization of the studied population, sample size, prevalence of phylogroups, virulence factor, and antibiotic resistance pattern.I2. The funnel plot, Begg’s rank correlation test, and Egger’s weighted regression tests were conducted to evaluate possible publication bias and any asymmetry appearing in the funnel plot, or p < 0.05 in the test was indicative of statistically significant publication bias  . The pooion bias . Possiblion bias . MoreoveBased on our comprehensive search, 28 studies with eligibility criteria Figure 12 among 28 studies was 39% (95% CI: 33–47) . The funnel plot for publication bias did not show any evidence of asymmetry  and Egger’s tests , there was no significant publication bias  Figure 22 was 52% and 18% in the north and southwest regions, respectively . The funnel plot for publication bias in the four phylogroups did not show any evidence of asymmetry  and Egger’s tests  showed no significant publication bias in phylogroup D  Figure 4The subgroup analysis results based on region indicated that the highest and lowest overall prevalence of phylogroup D was in the southwest (58%) and south (12%) regions, respectively Table 2.The subgroup analysis results based on source of patients indicated that the overall prevalence of phylogroup D was 21% in hospitalized and 31% in community patients Table 2.χ2 = 341.53; p < 0.001; I2 = 92.68%). The funnel plot for publication bias in the four phylogroups did not show any evidence of asymmetry  and Egger’s tests , there was no significant publication bias  Figure 51 was 8% (95% CI: 6–10) . According to the results of Begg’s  and Egger’s tests  for phylogroup B1, there was no significant publication bias  Figure 61 was 8% and 7% in the hospitalized and community patients, respectively , 0.005076 , and −0.00513 , respectively. Furthermore, no significant increasing trend was observed over time on the estimated pooled prevalence of phylogroups B2, D, and B1 in the included studies . Furthermore, significant decreasing trend was observed over time on the estimated pooled prevalence of phylogroup A in the included studies ].Moreover, the results of the influence analysis demonstrating that none of the studies affect the estimated pooled prevalence of phylogroups B2, ampicillin had the highest antibiotic resistance rate at 76% , followed by cefixime at 70% , while nitrofurantoin and imipenem had the lowest resistance rates at 2%  and 7% , respectively , followed by ampicillin with 64% , while amikacin 5%  and ceftriaxone 17%  had the lowest antibiotic resistance rate. Also, in this group, there was no resistance to nitrofurantoin , followed by nalidixic acid at 58% , while imipenem and amikacin were the most effective antibiotics with resistance rates of 1%  and 3% , respectively. Also, there was no resistance to nitrofurantoin in this group , followed by ciprofloxacin with 30% , while nalidixic acid 1%  and gentamicin 2%  had the lowest antibiotic resistance rates. Also, in this group, there was no resistance to imipenem, cefotaxime, amikacin, nitrofurantoin, and ceftazidime , followed by group D (26%), group A, and group B1, which is in agreement with the study conducted by 2 (33.8%) was the dominant phylogroup followed by D (28.4%), A (19.6%), and B1 (18.2%).Phylogenetic analysis indicated that the majority of UPEC isolates belonged to phylogroup BE. coli predominantly belong to phylogenetic group B2. In this systematic review, we noted a high prevalence of phylogroup B2 in UPEC isolates, reflecting the importance of investigating and addressing the prevalence of isolates belonging to this group since they revealed a partially high level of antibiotic resistance and virulence factors.The majority of the studies on the phylogenetic grouping among UPEC have reported a similar distribution, such as studies conducted in China , South KE. coli include stable genetic isolates with far lower recombination rates, resulting in a clonal population structure and allowing characterization of the main phylogenetic groups  and meta-regression for controlling this heterogeneity.2, D, A, and B1 had a frequency of 52%, 58%, 32%, and 10% in the north, southwest, northwest, and west of Iran, respectively.The geographical distribution of phylogenetic groups is variable in different regions of Iran. Accordingly, the subgroup analysis of the geographical distribution indicated that the predominant prevalence of phylogroups BMoreover, based on our findings, the high prevalence of phylogroup D was found among the isolates obtained from hospital-acquired infection rather than community-acquired infection. However, several reports have indicated a discrepancy in the prevalence of these phylogroups in both community and hospital infections. Meanwhile, our results revealed no significant differences on pooled prevalence of phylogroups neither in community-acquired nor hospital-acquired infections.2 incidence increased gradually from 20% in 2014 up to 83% in 2020. This increasing trend seems to be directly linked to the increased UPEC infections in phylogroup B2.According to meta-regression, it seems as though the trend of phylogroup BInvestigations have shown that we have been experiencing an increase in the frequency of members of virulent phylogroups from clinical samples since 2009 to date.Once rank correlation approaches show bias, there are possibly minor study effects. Meanwhile, according to the meta-regression analysis, the weight of the studies should not be regarded as a confounding factor. In addition, based on the sensitivity analysis, the exclusion of any works does not have any considerable impacts on the approximated pooled prevalence.2 isolates taken from the patients’ urine compared with the other phylogenetic groups. This is consistent with former studies performed in South Korea (Furthermore, a superior characteristic is presented by these phylogenetic groups due to their partially higher content of virulence factors, which makes them virulent clinical isolates and harder to treat. In our study, the occurrence of VFs was greater in within-group Bth Korea , Denmarkth Korea , Pakistath Korea , Ethiopith Korea , Mexico th Korea , and Polth Korea .2, D, B1, and A compared with that in the other VFs, including fimH papC and iucD. In this regard, iutA and papC are encoded on mobile elements or pathogenicity islands in uropathogenic strains.Based on the VF distribution in the phylogenetic groups, the existence of some genes had a high incidence in groups B2 had all the investigated PAI markers. Moreover, their findings revealed that B1, A, and D groups of UPEC isolates had fewer PAI markers (In this regard, some reports conducted in Iran revealed that the most frequent PAI marker belonged to PAIIV536. This PAI marker contains iron uptake system encoding genes and appears to be vital for successful colonization and wellness of UPEC strains throughout the urinary tract. However, previous studies have reported that there are a lot of differences concerning PAI markers among phylogenetic groups . Accordi markers .2 strains is mostly over the pathogenicity islands in the chromosome; however, virulence genes are often carried by group D strains, such as iutA, on plasmids. Nevertheless, group B2 is highly genetically diverse with at least nine subgroups (Therefore, the performance of virulence genes in group Bubgroups , some ofE. coli strain related to phylogroup B2 comprises a partially higher number of virulence genes compared with the E. coli related to the other phylogroups in other works on UPEC isolates.The differences concerning the host characteristics, geographical differences, and strain types are therefore responsible for variations in distributing such virulence factors in isolated UPEC. This result could be justified by the fact that the 2 isolates had high levels of resistance against ampicillin, cefepime, nalidixic acid, and ceftazidime and less resistance against nitrofurantoin and imipenem; meanwhile, a member of group D had a high resistance level against cefepime and ampicillin and less resistance against nitrofurantoin and amikacin. This finding is consistent with that of In our work, group B2, A, and B1.Moreover, regarding antibiotic resistance, high levels of resistance was observed in our work among the members of phylogroups D, followed by BPhylogenetic group D source was a considerable independent cause of antibiotic resistance, consistent with former studies, indicating that resistant genes could be achieved by isolates belonging to phylogenetic D.There were certain limitations in our systematic review; primarily, phylogroups of UPEC have not yet been examined in numerous areas of Iran. Therefore, the frequency of phylogroups could not be completely represented. Furthermore, considering the heterogeneity found within the considered studies, the findings should be cautiously interpreted.2 and group D were the most predominant phylogenetic groups among UPEC isolates in various regions of Iran, which is comparable with other parts of the world. Due to the relatively high frequency of phylogroup B2 and group D strains, it is necessary to pay attention to various groups involved in clinical care. Moreover, our results suggested that the members of phylogroup B2 strains may become reservoirs of genes encoding virulence factors. In addition, certain polygenetic groups were found to be more resistant than the others, which could be due to greater exposure of certain phylogenetic groups to antimicrobial agents. The dissemination of virulent phylogroups B2 and D could be suggested to be controlled through comprehensive infection control measures and through developing strategies for monitoring antibiotic therapy.The results of the present study provided beneficial epidemiological information about the distribution of phylogroups in UPEC from Iranian patients. Our findings shed light on the fact that phylogroup BConceived and designed the experiments: RR and MH. Performed the experiments: MH, AF, and DZ Analyzed the data: AF and DZ. Contributed reagents/materials/analysis tools: MR and MH. Contributed to the writing of the manuscript: RR, AF, and MH. Manuscript revision and English editing: AP and MR. All authors read and approved the final manuscript.This study was financially funded by the Babol University of Medical Sciences [Grant no. 724133882].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.


Measures of height, weight, and bioimpedance were used to calculate body mass index and percent body fat. Energy and nutrient intakes were assessed based on 7-day food records. The two groups had similar percentages of total body fat . The energy availability values for pre-teens were above the recommended values  69.38 ± 14.47 kcal/FFM/day, while those for the teens were much lower . The distribution of the daily energy intake across the macronutrients indicates that both groups ingested less than the recommended level of carbohydrates and more than the recommended level of fat. Very low intakes of calcium and vitamin D among other micronutrients were also noted. The main finding is that teenage gymnasts do not consume as much energy as they need each day, which explains their weight and development. Moreover, they are at a high risk of developing low energy availability that could negatively impact their performance and future health.The aim of this study was to analyze dietary intake and body composition in a group of elite-level competitive rhythmic gymnasts from Spain. We undertook body composition and nutritional analysis of 30 elite gymnasts, divided into two groups by age: pre-teen (9–12 years) ( Training and competing at professional levels require optimal body function, which relies on adequate dietary intake providing sufficient energy as well as macro- and micronutrients . It is wElite athletes’ health and performance are strongly affected by their dietary habits. Typically, they require above-average energy and macronutrient intakes to meet their daily energy expenditure and enable them to continue training, maintain their performance and recover from injury . In partNotably, several studies have indicated that many gymnasts aspire to attain a “perfect” body, characterized by specific body proportions with unrealistically low body weight and level of body fat ,18,19. An = 17) and teen  (n = 13). The age cut-off corresponds to the age of transition from primary to secondary education in our setting when patterns of training tend to change. All gymnasts and their parents were given information about the objectives of the study, and before inclusion in the study, the gymnasts assented, and their parents gave written informed consent. The Ethics Committee of the University of Leon approved all procedures, and the study was conducted in compliance with the principles for clinical research of the World Medical Association Declaration of Helsinki. The study population consisted of 30 elite gymnasts, whom we divided into two groups by age: pre-teen (9- to 12-year-olds: 10.51 ± 1.07 years) . During this event, the Royal Spanish Gymnastics Federation held technical tests, in front of an international panel of judges, as well as the technical director of the national team, for the gymnasts who were candidates to participate in upcoming international competitions. The anthropometry and body composition of elite gymnastics was measured before a routine training session in the middle of the competition season (January). Measurements were carried out after overnight fasting of at least 10 h and before the warm-up session. Body weight (BW) was measured to the nearest 0.01 kg using a digital scale  with participants wearing T-shirts and gym shorts. Height was determined to the nearest 0.1 cm with a portable stadiometer . Body mass index (BMI) and BMI z-scores were calculated using WHO reference data for 5- to 19-year-olds . Using aTo assess participants’ dietary intake, they and/or their parents completed a 7-day food diary using forms provided for that purpose on the day the anthropometric measurements were taken. These forms asked for information about what participants consumed each day: amounts, proportions of ingredients, methods of preparation, and so forth . Each ofThe information gathered about intake of foods, including quantities/portion sizes, and cooking processes as well as any dietary supplements  was processed using the Nutriber V.1.1.1.R5 software package  to calculate total energy and fat intakes, and intakes of specific fatty acids, cholesterol, vitamins, and minerals. Food diaries combined with 24 h recall met the condition of being a simple, rapid, and inexpensive method to analyze dietary intake. The recommended daily intakes for macronutrients were 1.6 to 2 g/kg/day of proteins and 6 to 10 g/kg/day of carbohydrates, and further, 20 to 35% of total energy intake should be from fat ,23. NutrParticipants were instructed in how to secure the ActiGraph accelerometer  under their clothing above their right hip, using an elastic waistband. They were asked to wear the accelerometer throughout their waking hours, except during water-based activities, and additionally to wear it during sleeping periods, unless they found that it was uncomfortable and interfered with their sleep. Further, participants were instructed to record any relevant incidents  on a sheet provided for that purpose. The accelerometer was used over 4 days (3 training days and 1 day off) . The totEnergy availability (EA) refers to the total energy available for physiological processes after the energy expended in exercise has been subtracted from the dietary intake . As descp-values < 0.05 were considered statistically significant.IBM SPSS version 20  was used for statistical analysis of the data and GraphPad Prism 6 software  for plotting the graphs. Descriptive statistics were calculated using the mean as a measure of central tendency and standard deviation as a measure of dispersion. Kolmogorov–Smirnov tests confirmed that the data were normally distributed in all groups. To assess whether differences between the two groups were significant, all the variables were analyzed using a univariate test using the category (pre-teen vs. teen) as a fixed factor. Finally, a chi-square test of prevalence was performed to examine the relation between LEA incidence and study group (pre-teen vs. teen). p < 0.05). Likewise, the teens showed significant more absolute muscle mass, fat mass, FFM, bone mineral content, and intracellular and extracellular water content (p < 0.005). On the other hand, there were no significant differences in the percentage of fat mass, FFM, or bone mineral content (p > 0.05).The comparisons made between the mean weight and height of the gymnasts and the WHO reference data  indicateThe results concerning participants’ nutrient intake indicate significant differences with respect to Spanish recommendations for pre-teens and teens. Specifically, the average energy intake was lower than the recommendations for their age in both groups , and notn = 17, 100%) intake was above the recommended value of 40 kcal/kg/day , while that of the teens was markedly lower  (FFM/day) . Among tThe distribution of the daily energy intake across the macronutrients indicates that both groups consume less than the recommended amount of carbohydrates  and more than the recommended amount of fat ; no significant differences being observed between the two groups of gymnasts in this regard. On the other hand, the carbohydrate intake according to BW was 7.4 ± 1.5 g/kg BW/day in the pre-teens and 3.7 ± 1.3 g/kg BW/day in the teens , this suGiven that the study participants are athletes who are still growing, their recommended protein intake is 2 g/kg BW/day. The pre-teen group consumed an average of 2.5 g/kg BW/day, whereas the teen group had an intake of 1.5 g/kg BW/day. Fiber intake was similar in the two groups (13.1 ± 4.1 g vs. 10.9 ± 1.7 g), but only covered the recommended minimum amount of 10 g/1000 kcal in the younger group.The mineral and vitamin content of participants’ diets, shown in p < 0.001).p = 0.005). While EA was sub-clinical in the pre-teens in 70.6% of cases, it was not adequate in any of the teens. Moreover, 100% of the teens group and 29.4% of the pre-teens were classified as having severe LEA  [Relatively few studies have focused on anthropometric parameters and body composition in rhythmic gymnasts ,41,42,43centile) , indicatcentile) ,46. ThisSome authors have indicated that gymnasts have decreased adipose tissue and delayed skeletal maturation and pubertal development ,47. ThisThe energy intakes of the gymnasts in our study were lower than the Spanish energy intake recommendations. An energy deficit is commonly reported in athletes ,49, but Inadequate energy consumption represents a powerful stimulus to the endocrine system, leading to detrimental effects that predominantly involve the reproductive system  and, subsequently, bone metabolism and bone mass (osteopenia and osteoporosis) ,51,52. IFurther, female athletes with insufficient energy intake to balance the energy that they expend during exercise are at risk of LEA, which is the cornerstone of a condition called the relative energy deficiency in sport (RED-S) ,55,56,57Concerning specific dietary components, numerous researchers and scientific societies ,23 have In assessing protein requirements, total energy intake is also an important consideration, since an inadequate energy intake will cause proteins to be used as a substrate for energy, potentially reducing its availability for its primary functions . ProteinRegarding minerals and vitamins, our gymnasts did not meet the micronutrient recommendations in most cases respect to RDA for the general population in Spain for girls 10–12 years (pre-teens) and 13–19 years (teens) . NotablySpecifically, iron and folate were identified among nutrients whose intakes often did not meet the RDA in the teen group. Deficiencies in either of these nutrients can promote anemia, which can cause fatigue and suboptimal athletic performance . In geneIn addition, very low intakes of calcium and vitamin D were observed. Gymnasts in both groups failed to meet RDAs for both of these micronutrients, which is in agreement with previous studies conducted on elite gymnasts ,61,68. VTo achieve optimal nutritional support for physiological function and performance, it is important to consider the macronutrient content of the diet. Indeed, low carbohydrate availability has been linked to poorer performance . LEA incIn this context, it has been suggested that, in line with annual training programs for athletes, their dietary intake should be varied over time, a strategy called “nutrition periodization”, to optimize their condition and performance. That is, even though optimal EA is crucial for good health and optimal performance, periods of subclinical LEA may be required to reach the physique desired .The potential negative effects of LEA and associated conditions on sporting performance ,75 and tThe first study to provide career-long data on the periodization of body composition and nutrition of a female Olympic-level athlete, a middle-distance runner, was reported recently . In the The main limitation of the study is the relatively small size of the sample. Nonetheless, considering the high level of performance of the athletes, it is not easy to find large samples to carry out this kind of study. The use of self-report questionnaires is another limitation, as they could limit the accuracy and validity of the dietary assessment method, in particular, for measuring micronutrient intake. Likewise, no parameter was included to determine the degree of development of the gymnasts, including the control of the menstrual cycle in teenage gymnasts. The main strength of this study is the inclusion of only elite gymnasts, all of whom are members of a team that competes in national and international tournaments. Our research is novel in that, to our knowledge, it provides the first assessment of body composition and dietary intakes and the risk of LEA in elite-level competitive rhythmic gymnasts in Spanish preadolescent and adolescent elite rhythmic gymnasts. The main conclusion of our work is that teenage gymnasts do not consume as much energy as they need each day, which explains their body weight, as well as putting them at a higher risk of developing LEA that may negatively impact their future health and performance. In particular, athlete support staff should underline the need for an appropriate carbohydrate intake to balance exhaustion against excessive consumption, since low carbohydrate consumption can compromise performance both in training and in competition. They should also encourage the intake of dietary sources of vitamin D and calcium.


Psoriasis, a chronic disease, is associated with a higher prevalence of comorbidities and has negative impact on health-related quality of life (HRQOL). The objective was to investigate the effect of comorbidities on HRQOL, and psoriasis severity measured appropriately by the dermatology life quality index (DLQI) and the psoriasis area severity index (PASI) before, and after a 3-month treatment and the median DLQI or PASI reduction from baseline in the adult psoriatic patients receiving various types of treatment. The study included 184 adult plaque psoriatic patients. DLQI and PASI scores were assessed in the studied patients before the therapy (a baseline visit) and after a 3-month treatment (a control visit) depending on the presence of comorbidities. Psoriatic patients with comorbidities had worse HRQOL and more severe skin lesions. The presence of comorbidities had a negative effect on the outcome of treatment with the use of conventional therapy. The outcome of therapy with biological agents was independent of each of the analyzed factors. Biological treatment had a high effectiveness on the psoriatic skin lesions improvement despite the presence of comorbidities, whereas methotrexate was effective even if the patients had co-existing hypertension. In psoriatic patients receiving systemic conventional treatment but not biological treatment, comorbidities had a negative impact on HRQOL and psoriasis severity. Psoriasis is a chronic autoinflammatory skin disease affecting about 1–4% of the world population ,3,4. TheIn order to measure the severity of psoriasis, psoriasis area and severity index (PASI), body surface area (BSA) and dermatology life quality of index (DLQI) are used. The psoriasis area and severity index score is a measurement of the erythema, thickness, scaling and coverage of the plaques. The body surface area is the factor which measures the area of the skin is covered by psoriasis. The result is given as a percentage . On the More often than not, psoriatic patients suffer from cardiovascular diseases, metabolic disorders, i.e., diabetes, overweight/obesity and lipid disturbances ,12. UndoThe aim of the study was to investigate the impact of comorbidities, overweight/obesity and nicotine dependence on HRQOL measured by the DLQI prior to and after a 3-month treatment. The study also aimed at assessing the median DLQI reduction from baseline in the adult psoriatic patients receiving various types of systemic treatment, both conventional and biological, and investigating PASI prior to and after a 3-month treatment as well as the median PASI reduction from baseline and PASI score improvement in the psoriatic patients with comorbidities, overweight/obesity and nicotine dependence treated either conventionally or biologically ,15.The study was conducted between May 2019 and October 2020, and it included 184 patients with plaque psoriasis , mean age 46 ± 12 years (range 20–80 years). The duration of the disease was15 ± 10 years, on average.The exclusion criterion was the age under 18 years. All the patients fulfilled the criteria of moderate to severe plaque psoriasis, i.e., in all of them, at least one of the indices  was 10 or higher.All the studied subjects were treated with either conventional systemic drugs, i.e., methotrexate (42.9% of the patients), cyclosporine (22.8% of the patients), retinoids (23.4% of the patients), or biological agents, i.e., adalimumab, ustekinumab and secukinumab (10.9% of the patients). Hypertension, diabetes and lipid disorders were diagnosed in 62, 40 and 60 of the studied patients, respectively. Out of the total number of the studied subjects, 65 of them were smokers. The detailed clinical and demographic characteristics of the studied patients are presented in All the studied psoriatic patients were interviewed, their medical history was taken, and they underwent physical examination. Severity of psoriasis was assessed with the use of the psoriasis area severity index (PASI), body surface area (BSA) and the dermatology life quality index (DLQI) ,17,18,19The DLQI and PASI scores were assessed prior to launching therapy (a baseline visit) and after a 3-month treatment (a control visit) in all of the studied psoriatic patients, and in the patients treated with different therapy regimens depending on the presence or absence of comorbidities, BMI score and smoking status.A 3-month treatment is a period long enough to evaluate the first effect of treatment and improvement in quality of life. Many conventional and biological drugs are evaluated after a 3-month period.The median DLQI and PASI reductions from baseline were also calculated. The numbers and percentages of the patients achieving improvement in the PASI score, i.e., PASI50, PASI75, PASI90, after a 3-month treatment were analyzed with reference to the presence or absence of comorbidities, BMI score and smoking status.p < 0.05) therefore, non-parametric tests were applied in the further analysis. Multiple regression analysis for the clinical-demographic features of the studied individuals was applied to avoid the potential confounding effects on the results. None of the demographic factors affected either DLQI or PASI score, thus the whole studied group underwent non-parametric testing. Values of the studied factors in the subgroups of patients treated with different therapy regimens were expressed by the median (Me) and interquartile range (IQR). Differences in the values of the studied parameters among the patients in regard to the presence of comorbidities, BMI score and smoking status were tested by the Mann–Whitney U test. The results presenting p values below 0.05 were considered as statistically significant.Statistical analysis was conducted with the use of the MedCalc computer software, version 18.2.1 . Data distribution in the studied population was examined by the Shapiro–Wilk test. All the studied parameters demonstrated abnormal distribution of the data , BMI score and smoking status is presented in 2 or smokers and the studied psoriatic patients presenting no aforementioned comorbidities, whose BMI was below 25 kg/m2, and also in non-smokers. The psoriatic patients with comorbidities  or individuals with BMI ≥ 25 kg/m2 as well as smokers had significantly higher DLQI scores in comparison to the patients without comorbidities, whose BMI was below 25 kg/m2, and also in non-smokers . Before the methotrexate therapy, the median DLQI scores were significantly higher in the patients with comorbidities, with BMI ≥ 25 kg/m2 and in smokers in comparison to the patients without comorbidities, with BMI < 25 kg/m2, and in non-smokers . In addition, before the treatment with cyclosporine or retinoids, the median DLQI scores were significantly higher in the patients suffering from diabetes .Prior to launching any of the applied therapies, the median DLQI scores at baseline were significantly different between the studied subjects with comorbidities, BMI ≥ 25 kg/m2 or smokers and the studied psoriatic patients presenting no comorbidities, whose BMI was below 25 kg/m2 as well as in non-smokers. However, they were lower in comparison with the median DLQI scores from before the treatment. As for the methotrexate therapy, after a 3-month treatment the differences were still significant (p < 0.001). In the case of cyclosporine therapy, the presence of diabetes and BMI ≥ 25 kg/m2 negatively affected the median DLQI scores, while in the patients without diabetes and with BMI < 25 kg/m2 the median DLQI scores were significantly lower . In the patients treated with retinoids for 3 months, the median DLQI scores were significantly higher in the studied subjects with hypertension or diabetes as well as in smokers in comparison to the psoriatic patients without hypertension or diabetes as well as in non-smokers. None of the studied factors influenced the median DLQI scores in the patients receiving a 3-month treatment with biological agents.After a 3-month treatment, significant differences were still observed in the median DLQI scores between the studied subjects with comorbidities, BMI ≥ 25 kg/mp = 0.021) as well as in the patients with BMI < 25 kg/m2 in whom the median DLQI score decreased by 18.0 points compared to the overweight/obese individuals who achieved the median DLQI reduction equal to 14.0 points (p = 0.023). Interestingly, in the patients with lipid disorders treated with biological agents, the median DLQI reduction from baseline was greater than in the patients without lipid disorders . When cyclosporine therapy was applied, a greater reduction of the median DLQI score was observed in the patients with BMI ≥ 25 kg/m2 in comparison to those with BMI < 25 kg/m2 .The median DLQI reduction from baseline  was analyzed in the studied psoriatic patients who received different treatment depending on the presence of comorbidities , BMI score and their smoking status. The most significant differences were observed in the patients treated with biological agents. The median DLQI reduction was significantly higher in the non-smokers (14.0 points) compared to the smokers (9.0 points) , BMI score and smoking status is presented in 2 as well in smokers in comparison to the studied psoriatic patients presenting none of comorbidities mentioned above, whose BMI was below 25 kg/m2, also in non-smokers (p < 0.001). Before treatment with methotrexate, the median PASI scores were significantly higher in the patients with comorbidities and with BMI ≥ 25 kg/m2 than in the patients without comorbidities and with BMI < 25 kg/m2 (p < 0.001) as well as in smokers than in -non-smokers (p < 0.008).Prior to launching any of the therapies, the median PASI scores at baseline were significantly different between the studied subjects with comorbidities, BMI ≥ 25 kg/m2 than in patients without the above named comorbidities and with BMI < 25 kg/m2 , whereas before treatment with retinoids, it was significantly higher in the studied patients with hypertension, diabetes, BMI ≥ 25 kg/m2, and also in smokers in comparison to the patients without hypertension, diabetes, with BMI < 25 kg/m2, also in non-smokers . No significant differences in the median PASI scores were noted in the patients treated with biological agents (p > 0.05).In addition, before the treatment with cyclosporine was launched, the median PASI score was significantly higher in the psoriatic patients with diabetes, lipid disorders and with BMI ≥ 25 kg/m2 or in smokers and the studied psoriatic patients presenting no comorbidities, whose BMI was below 25 kg/m2 as well as in non-smokers (p < 0.001). However, they were lower in comparison with the median PASI scores from before the treatment. As for the methotrexate therapy, after a 3-month treatment, the differences were still significant (p < 0.001). As for cyclosporine therapy, the presence of diabetes, lipid disorders, BMI ≥ 25 kg/m2 and cigarette smoking negatively affected the median PASI scores, while in the patients without diabetes, lipid disorders, with BMI < 25 kg/m2 and in non-smokers the median PASI scores were significantly lower . In the patients treated with retinoids for 3 months, the median PASI scores were significantly higher in the studied subjects with hypertension, diabetes, BMI ≥ 25 kg/m2 and in the smokers . None of the studied factors influenced the median PASI scores in the patients receiving a 3-month treatment with biological agents (p > 0.05).After a 3-month treatment with any of the agents, significant differences were still observed in the median PASI scores between the studied subjects with comorbidities, BMI ≥ 25 kg/mp = 0.045). Interestingly, in the patients treated with cyclosporine, a greater reduction of the median PASI score was observed in the patients with lipid disorders and with BMI ≥ 25 kg/m2 than in those without lipid disorders, with BMI < 25 kg/m2 and in non-smokers . When treatment with methotrexate was applied, the psoriatic patients also suffering from hypertension achieved greater median PASI score reduction from baseline than the patients who did not have this comorbidity (p = 0.025).The median PASI reduction from baseline to the control visit following a 3-month treatment was analyzed in regard to the type of therapy the studied patients received depending on the presence or absence of comorbidities , BMI score and their smoking status. In the cyclosporine treated subgroup, the median reduction of PASI score was significantly higher in non-smokers (10.4 points) in comparison to smokers in whom it was 8.2 points . Moreover, in the patients treated with methotrexate, the presence of analyzed comorbidities, BMI ≥ 25 kg/m2 and cigarette smoking had a significant negative effect on the number and percentages of patients achieving PASI75. The presence of diabetes, BMI ≥ 25 kg/m2 and smoking had a negative effect on achieving PASI75 in the patients treated with cyclosporine .PASI90 was achieved independently of the presence or absence of the analyzed comorbidities, BMI score and smoking status in all the studied patients as well as in those undergoing individual therapies, i.e., therapies with methotrexate, cyclosporine, retinoids or biological agents. However, achieving PASI75 and PASI50 depended on the presence or absence of the analyzed factors. In the whole studied group, the number and percentages of patients achieving PASI75 were significantly higher in the absence of hypertension, diabetes, lipid disorders, also in those patients whose BMI was below 25 kg/m2 as well as in the non-smokers in comparison to the patients with hypertension, diabetes, BMI ≥ 25 kg/m2, and in those studied subjects who smoked cigarettes (p < 0.001). In the patients treated with methotrexate, the presence of analyzed comorbidities, BMI ≥ 25 kg/m2 and cigarette smoking had a significant negative effect on the number and percentages of patients achieving PASI50. Moreover, in the cyclosporine treated patients, a negative effect on achieving PASI50 was observed in the presence of diabetes, when BMI was equal or above 25 kg/m2 and in the smoking patients.The number and percentages of patients achieving PASI50 were significantly higher in the absence of hypertension, diabetes, also when BMI < 25 kg/mNo significant differences in achieving PASI50, PASI75 and PASI90 depending on the presence or absence of comorbidities, BMI score and smoking status were found with regard to the number and percentages of psoriatic patients treated with retinoids and biological agents.Psoriasis is a multisystem autoinflammatory disease which affects not only the physical health, but it also has an extensive emotional and psychosocial effect on psoriatic patients. Since hypertension, diabetes, lipid disorders as well as overweight/obesity and nicotine dependence are more prevalent in psoriatic patients than in the general population, they were selected as representative comorbidities to investigate their impact on health-related quality of life (HRQOL) and psoriasis severity in psoriatic patients receiving systemic conventional treatment with methotrexate, cyclosporine, retinoids and biological treatment. In order to determine the efficacy of psoriasis treatment in the presence of the aforementioned comorbidities, the DLQI and PASI scores were assessed prior to launching a selected therapy and after 3 months of treatment.2 as well as in the smokers in comparison with the study subjects who had no comorbidities, whose BMI was below 25 kg/m2, and also in the non-smokers, which is reflective of the negative effect of the co-existing diseases, overweight/obesity and smoking on HRQOL and psoriasis severity. Analysis of all types of applied medical treatment revealed that after a 3-month treatment, the median DLQI and PASI scores were still significantly higher in the patients with comorbidities, BMI ≥ 25 kg/m2, and also in the smoking patients in comparison to those who did not have hypertension, diabetes or lipid disorders, and whose BMI was below 25 kg/m2 as well as in the non-smokers. After a 3-month treatment, similar data were observed for the patients treated with methotrexate, however, the median DLQI score in the patients treated with cyclosporine was significantly higher only in those who had diabetes, or were overweight/obese whereas in the patients treated with retinoids only when they had hypertension, diabetes or smoked cigarettes.Prior to the treatment, the median DLQI and PASI scores were significantly higher in the study subjects with comorbidities , the scores were also significantly higher in the patients with BMI ≥ 25 kg/mMichalska-Bańkowska et al., observed that concommitant diabetes and a metabolic syndrome did not affect the efficacy of cyclosporine in psoriasis treatment. However, in the study they included thirty-two patients with psoriasis vulgaris, of which seven had coexisting diabetes mellitus, seven patients had both diabetes and metabolic syndrome, and the remaining patients had no comorbidities .p = 0.028). The median PASI score was 5.9 for smokers compared to 2.3 in non-smokers (p = 0.003) [As for the analysis of the median PASI score after a 3-month treatment, it was significantly higher in those studied psoriatic patients treated with cyclosporine who also had diabetes, lipid disorders or who were overweight/obese as well as in those who were smokers. The median PASI score after a 3-month treatment was significantly higher in those psoriatic patients treated with retinoids who also suffered from hypertension, diabetes or who were overweight/obese, also in those who were smokers. In the study of Hayran Y. and Yalcin B., 67.6% of the psoriasis patients were smokers. The authors observed that smoking had a negative effect on psoriasis severity expressed by PASI. Among smokers, 29.3% of the patients had moderate/severe psoriasis (= 0.003) All the conventional treatment outcomes, i.e., methotrexate, cyclosporine and retinoids therapies, are indicative of the negative impact of the analyzed factors, i.e., comorbidities, overweight/obesity, nicotine dependence, on the DLQI and PASI scores both before launching the treatment and after a 3-month treatment. The DLQI score in the study of Sanchez-Carazo confirmed that patients with several comorbidities, such as obesity and arterial hypertension, had worse scores in the physical component of the quality-of-life questionnaire . Interes2. Interestingly, a greater reduction of PASI was also observed in the patients treated with cyclosporine who also had lipid disorders as well as in those patients who did not smoke in comparison to the patients who had no lipid disorders and in smokers. What is more, significant differences in the median DLQI reduction were observed in the patients treated with biological agents who had lipid disorders but who were not overweight/obese and did not smoke in comparison to the patients without lipid disorders, with BMI < 25kg/m2 and who were smokers. No differences in the median PASI reduction were observed in the patients treated with biological agents. These findings suggest that in the patients treated with biological agents the skin lesions’ improvement, but not quality of life, was independent of the presence or absence of comorbidities, BMI score and smoking status. However, these findings may be distorted by a small number of the studied psoriatic patients treated with biological agents who also suffered from hypertension (10%), had lipid disorders (10%), who were smokers (25%), and whose BMI was below 25 kg/m2 (10%). In the study of Prignano et al., all biological treatments significantly reduced PASI score. The authors included 471 patients with plaque psoriasis and psoriatic arthritis. In both psoriasis groups, the main comorbidity was hypertension, while hyperlipidaemia was frequently present in the patients treated with biologics [Having analyzed the DLQI and PASI scores prior to and after a 3-month treatment with conventional and biological agents, the median DLQI and PASI reduction from baseline was calculated. It was revealed that the medium PASI reduction from baseline in the patients with hypertension and treated with methotrexate was significantly higher than in those patients who did not have hypertension. However, the median PASI score prior to the treatment was nearly twice as high in comparison to the patients without hypertension. The result may prove that treatment with methotrexate is effective even if patients had co-existing hypertension. Moreover, the patients with overweight/obesity treated with cyclosporine presented a greater reduction in the DLQI and PASI scores than the patients with BMI < 25 kg/m2 as well as in those who did not smoke. Similar significant differences were observed in the psoriatic patients treated with methotrexate. However, in the patients treated with cyclosporine, the number and percentages of patients achieving PASI75 and PASI50 were significantly different and had a negative impact only in the patients with diabetes, overweight/obesity and in the smokers. Interestingly, in the psoriatic patients treated with either retinoids or biological agents, no significant differences in achieving PASI75 and PASI50 were found in the patients both with and without the analyzed factors. Petridis et al., in a multicentre, prospective, observational study which included 136 psoriatic patients treated with infliximab found out that the BMI score did not have any impact on the PASI75 or DLQI improvement rate [Analysis of all the studied psoriatic patients revealed that the number and percentages of the patients achieving PASI75 and PASI50 were significantly higher when the patients did not suffer from hypertension, diabetes, lipid disorders, when their BMI was below 25 kg/ment rate . Anzengrent rate . Warren ent rate . As for Psoriatic patients with comorbidities such as hypertension, diabetes, lipid disorders, overweight/obesity as well as those study subjects who were smokers had poorer HRQOL and presented more severe psoriatic skin lesions. The presence of comorbidities, overweight/obesity and nicotine dependence had a negative effect on the outcome of conventional treatment with methotrexate, cyclosporine, retinoids. The outcome of therapy with biological agents, however, was independent of each of the analyzed factors. Biological agents were highly effective in the treatment of psoriatic skin lesions despite the presence of comorbidities, whereas methotrexate was effective even if patients had co-existing hypertension.Limitations: A limitation to the study may be a different number of patients treated with conventional therapies, i.e., methotrexate, cyclosporine, retinoids, and biological agents. Most patients were treated with methotrexate (n = 79), and the number of patients treated with biological agents was much smaller (n = 20). The each of study group differed with regard to their sex, age, duration of psoriasis and different dosages of treatment. The studied patients came from different residential areas, had different marital, professional status and other previous treatment. The number and percentage of patients with comorbidities, overweight/obesity, and nicotine dependence varied among patients treated with methotrexate, cyclosporine, retinoids and biological agents.


Background: Among the determinants contributing to the pathogenesis of asthma, antioxidant genetic factors play a leading role. Glucose-6-phosphate dehydrogenase (G6PD) is an enzyme that is competent to detoxify free radicals. Although a relationship between G6PD deficiency and asthma has been previously reported, the literature is still scanty. In this study, we test this hypothesis in a large cohort of patients from Sardinia, Italy. Methods: A retrospective case–control study was performed using data from 11,829 clinical records of outpatients referred to a teaching hospital for a medical visit. In total, 455 cases (asthma-positive) and 11,374 controls (asthma-negative) were compared for G6PD status using multivariable analysis, adjusting for all covariates. Results: Overall, G6PD deficiency was detected in 11.2% of study participants and was associated with an increased risk of asthma (odds ratio (OR) 1.63; 95% confidence interval (CI) 1.27–2.10). Additional variables significantly associated with asthma were female sex , overweight/obesity , smoking , and high socioeconomic status , whereas age was inversely related with asthma . Conclusions: Our study shows that G6PD deficiency is an independent risk for asthma. These findings suggest that G6PD should be assessed in asthmatic patients for better risk stratification. Asthma is an inflammatory non-communicable disease of the small airways that affects more than 330 million people worldwide . The preApart from mucosal eosinophils, additional immune cells participate in long-lasting disease as well. Exposure to allergens triggers the production of specific IgE antibodies, leading to the overexpression of Th2 type T-cell response. The IgE bound to high-affinity receptors on dendritic cells facilitate allergen internalization; once inside the dendritic cell, the processing of allergens by cathepsin S and the subsequent selection of peptides loaded onto and presented by HLA molecules (MHC class II) are fundamental steps for these cells to act as antigen-presenting cells to T lymphocytes . PresentAmong the risk factors involved in the development of asthma, dietary, environmental, and genetic factors that are capable of reducing cell antioxidant capacity by increasing tissue vulnerability to oxidative stress raise the disease risk. For instance, selenium deficiency lowers red cell glutathione peroxidase activity and is associated with increased asthma risk . SimilarInterestingly, several years ago, a few studies reported an increased risk for developing asthma in subjects carrying a glucose-6-phosphate dehydrogenase (G6PD) defect ,18. HoweG6PD is known as the rate-limiting enzyme of the pentose phosphate pathway . The enzOn the Sardinian island in Italy, G6PD deficiency is very common, e.g., around 10–12% of the general population . On the Based on these premises, we attempted to evaluate the association between asthma and G6PD deficiency in a defined population of northern Sardinia.This was a retrospective case–control, single-center study that took advantage of the availability of the clinical records of adult outpatients referred to a teaching hospital of northern Sardinia , Italy, from January 2002 to December 2019. Patients were referred by their family physicians and/or specialists for any reason. Patients with asthma were considered, and the controls were patients without asthma.Records of personal information such as sex, age, smoking habits, socioeconomic status, anthropometric parameters (body height and weight), all signs and symptoms, treatments, and an accurate medical history were considered eligible for the analysis. More specifically, for the purpose of the study, the presence of asthma was retrieved from the computerized database among previously diagnosed conditions. Moreover, the diagnosis of asthma retrieved from patient’s chart was double-checked by matching the treatment , according to the Global Initiative for Asthma (GINA) consensus . AvailabIncomplete records or records belonging to patients younger than 18 years were not included in the analysis. In the case of multiple visits for the same patient within the given time period, only the most recent was considered for the analysis.G6PD status. Since Sardinia is a high-prevalence region for G6PD deficiency, the subjects are routinely assessed for G6PD status, especially before exposure to certain medications. The G6PD activity of whole blood was measured using a standard method, as previously described ,27. Less1) and forced vital capacity (FVC) less than 0.7 is the cut-off used to diagnose an obstructive respiratory pattern, while the GINA consensus suggests a cut-off of 0.8 [1 increases of 200 mL or FEV1 or FVC increases of 12% from the basal value [Asthma diagnosis. Asthma is a chronic obstructive condition characterized by both the inflammatory component and airway obstruction, which may be spontaneous or induced by different triggers, different from chronic obstructive pulmonary disease (COPD), which typically shows a fixed bronchial obstruction. The measure of pulmonary function assessed by spirometry is considered the gold standard to diagnose asthma . Accordif of 0.8 . To estaf of 0.8 ,28. The al value . A histoThe protocol was approved by the local Ethics Committee  .2), and overweight/obesity was defined as BMI > 25 kg/m2. In relation to smoking habits, patients were stratified as never or current/former smokers. Patients with total and partial G6PD deficiency were pooled together.Distributions of age, sex, socioeconomic status (SES), body mass index (BMI), and smoking habit were descriptively compared between cases and controls. More specifically, age was recoded into a binary variable by splitting at the age of 60 years. Socioeconomic status was estimated using current or past occupation and divided into four categories, from class I (the highest) to class IV (the lowest), as previously reported , and exp1±(β/SE). The main effect of variables was assessed first by entering the covariates one by one and then simultaneously (the adjusted model). In addition, patients with asthma were stratified according to the GINA classification, based on asthma symptoms and therapy, in order to ascertain the frequency of G6PD deficiency in each subgroup .Univariate and multivariable logistic regression was used to examine the association of asthma with G6PD status by calculating odds ratios (ORs) and their 95% confidence intervals (CI) using the Wald formula: 95% CI = ORp values lower than 0.05 were considered statistically significant.All statistical analyses were carried out using SPSS statistical software , and two-sided A total of 11,829 clinical records of patients  who underwent a medical visit were available for the analysis. Descriptive statistics of the studied population are reported in p < 0.0001). As expected, the prevalence of asthma was greater among females compared with males .The prevalence of asthma among study participants was 3.8%, according to a previous report . Asthmatp < 0.0001). Overweight/obesity (≥25 kg/m2) was more common among asthmatics, although this difference did not reach statistical significance (p = 0.003). Based on the laboratory data retrieved from the participants’ clinical records, 1319 patients (11.2%) were partially or totally deficient in G6PD, with greater frequency among females (13.4%) than among males (7.7%), in line with the sex-linked trait. Interestingly, the proportion of asthma sufferers was higher among G6PD-deficient patients than among patients with normal enzyme activity  in both males (6.4%) and females (4.3%).Individuals with a low SES were fewer in the asthmatic group .p < 0.0001)  .Remarkably, although the absolute risk of asthma was inversely related to age, in subjects with G6PD deficiency compared to normal subjects, the risk of asthma increased in an age-dependent manner  and reacSince steroids can inhibit G6PD activity, at least in animal models , there iIn the present study, conducted in a cohort of subjects referred to the Department of Medicine of Sassari, Italy, a significant association was found between inherited G6PD deficiency and the risk of asthma. This association, first reported over three decades ago ,18, for Med, S188F) in more than 95% of deficient subjects. The residual activity of G6PD Med is less than 10% in hemizygous males and homozygous females and between 10% and 50% in heterozygous females. Therefore, this population is an ideal model to test the hypothesis of the G6PD/asthma association with an adequate degree of statistical power.Among Sardinians, there is a prevalence of about 10–12% , essentiThe results obtained in this study provide compelling evidence that subjects with inherited G6PD deficiency are prone to develop asthma more frequently than subjects with normal enzyme activity, regardless of sex, SES, smoking habit, and excess weight. The increased risk was observed especially in older subjects, reaching statistical significance in the 60–79 years age group. The association probably persists in later ages as well, but the small number of older asthmatics in the examined sample cohort did not allow this hypothesis to be tested with sufficient statistical power. This finding suggests that G6PD-deficient individuals may experience progressively impaired antioxidant defense, putting them at increased risk to develop asthma in the presence of predisposing triggers, including aging. The same association may exist in children, although, in this study, it was not evaluated.The main pathogenetic mechanism of asthma is due to chronic inflammation, largely driven by the innate immune response. Reactive oxygen species (ROS) are powerful mediators of the inflammatory response, and the increased production or decreased neutralization level of ROS plays an important role in the pathogenesis of asthma.In a study aimed at identifying differentially expressed proteins in the serum of children with and without asthma, G6PD was found to be significantly downregulated in asthmatic children , suggestIn addition to infections, a key role in the pathogenesis of asthma is played by oxidative stress; this is supported by experimental and clinical studies, for example, those focused on exposure to strong oxidants such as ozone ,44. G6PDA major function of G6PD is to regenerate the reduced thiol GSH consumed during the neutralization of ROS . In expeFurthermore, G6PD deficiency causes the depletion of nitric oxide (NO) . This coFinally, G6PD deficiency is associated with a proinflammatory state or the exacerbation of a proinflammatory state . RecentlThe association of asthma with the G6PD gene, which maps on the X chromosome OMIM 305900), could theoretically be due to a linkage with a predisposing gene located near the G6PD locus. The most interesting candidate is probably the cysteinyl leukotriene receptor 1 (CYSLTR1) gene, located on chromosome Xq21.1 , which h00, couldSome limitations of this study need to be mentioned. First, being a retrospective study, we cannot exclude that potential confounders may be differently distributed between cases and controls. However, given the large number of participants, we are confident that the extent of such a bias would be minimized. An additional limitation of our study may be the lack of molecular genotyping for patients with biochemically identified G6PD deficiency, precluding the possibility, in the case of females, of distinguishing homozygotes and heterozygotes and, therefore, testing the association of asthma with total or partial G6PD deficiency separately. However, from a clinical standpoint, the lack of a more detailed analysis would not have changed the overall findings.In conclusion, in our study, we found that G6PD deficiency was associated with an increased risk of asthma, and this risk remained significant after adjusting for well-known traditional variables such as female gender, overweight/obesity, and high SES. These findings suggest that G6PD should be assessed in patients with asthma for better risk stratification.


At slaughter, the content of the stomach, duodenum, jejunum, ileum, caecum, and colon was collected and analyzed by Next Generation 16S rRNA gene sequencing. Tissue samples of the same tracts were evaluated with histological and histochemical analysis. Ammonia and lactic acid in the caecum were also quantified. Twenty-nine operational taxonomic units (OTUs) were significantly different between groups. Groups receiving n-3 PUFAs supplementation showed an increase in Bacteroidetes and Lachnospiraceae in several gastrointestinal tracts, while Bacilli abundance, as well as Firmicutes/Bacteroidetes ratio, were reduced compared to the control group . Caecal ammonia was lower in the F than C group (p < 0.032), whereas no difference was found for lactic acid. Finally, histological evaluations revealed a mild hemorrhagic infiltration and vessels ectasia in the stomach mucosa of both F and O groups, but no effect of nutritional treatment was evidenced by the histochemical analyses. In conclusion, n-3 PUFAs supplementation could modify the rabbit gut microbiota and fermentation. The increase in beneficial bacterial populations may, at least partially, explain the positive effects of n-3 PUFAs diet supplementation on human and animals’ health, although the appropriate dosage should be established.The present study evaluated the effects of feed supplemented with two dietary sources of n-3 polyunsaturated fatty acids  on the gut microbiota, caecal fermentations, gastrointestinal histology, and histochemistry in rabbits. Fifteen male New Zealand White rabbits were divided into three groups ( The microbial community that colonizes a particular district of the body and lives in a symbiotic relationship with the host is defined as microbiota . The digThe rabbit is very sensitive to gastrointestinal diseases, not only when kept as a livestock species but also as a companion animal ,18. DiseIn recent decades, great attention has been paid to evaluate the role of dietary polyunsaturated fatty acids (PUFAs) on the health status as well as on the prevention and treatment of several humans and animals’ diseases ,39. MammIn this study, we hypothesize that n-3 PUFAs-enriched diets influence bacterial richness and diversity of rabbits’ digestive system. The aim was to evaluate the effect of flaxseed and fish oil supplemented diets on the gut microbiota composition in stomach, duodenum, jejunum, ileum, caecum, and colon of rabbits using next-generation 16S rRNA gene sequencing. In addition, histology and histochemistry were performed on the same sections of the digestive system. Finally, lactic acid and ammonia produced by the cecal bacterial fermentations were also quantified.The microbiota structure of the gastrointestinal tract of Control (C), Flaxseed (F), and Fish oil (O) groups was characterized by a total of 3,230,834, 3,056,689, and 3,201,736 high quality reads (after filtering), respectively, with a mean of about 130,000 ± 55,000 reads per group. The average reads loss due to filtering was 27%.Ruminococcaceae is the most abundant (between 33% and 42%), followed by Lachnospiraceae (11%–20%), Clostridiales vadinBB60 group, Muribaculaceae, Bacteroidaceae, and Bacillaceae . Lachnospiraceae were higher in F  and more or less similar in O (from 13.7% to 20.1%) and C (from 11.0% to 20.5%). At the genus level, relative abundances are clearly more spread across genera, with significant differences between treatments in 13 genera, among which Lachnospiraceae UCG-001 (p < 0.001), Acidovorax (p < 0.01), Campylobacter (p < 0.05), and Brevibacillus (p < 0.05). In total, 29 operational taxonomic units (OTUs) were significantly different between groups: these are reported in Phylum relative abundance distributions in the different gastrointestinal tracts of C, F, and O groups are shown in p = 0.0014), but with a large individual variation (p > 0.05).Regardless of the gastrointestinal tracts, the F/B ratio in the rabbit gut microbiota was consistently higher in the C group compared to F and O groups , as reported in Lactic acid quantification showed no statistically significant differences among groups, while there was a significant difference among C and F groups for the ammonia concentration  histochemical staining showed that intestinal goblet cells contained both neutral (pink color) and acid glycoconjugates (blue color). Acid glycoconjugates appeared to be predominant especially in the treated groups . Their proportions within the microbial population were, however, negligible.Regardless of the nutritional treatment, the main taxa detected were in accordance with previous studies evaluating the gut microbiota of both domesticated and wild rabbits ,53,54. TBacillales) were more abundant in control than in treated groups. The same result was found in other studies conducted on mice fecal microbiota, where diets enriched with n-3 PUFA significantly lowered the Bacilli relative abundance [Regardless of nutritional groups, the prevailing classes were Bacilli, Bacteroidia, and Clostridia, and the same pattern was followed at the level of order. Interestingly, Bacilli  butyrate, which has beneficial effects thanks to its anti-inflammatory and antiatherosclerotic properties [The dominant families were representative of the dominant orders and classes, with crobiota ,53. Impobundance ,42,44,49operties ,42.The importance of F/B ratio on several metabolic syndromes has been widely demonstrated both in humans and experimental animals ,42,48. IAs expected, the alpha diversity results showed a higher richness and diversity in bacterial composition in the hindgut compared to the foregut, independently from the group. These results are in agreement with another study performed in rabbits , and can-3 PUFA-enriched diets did not affect lactic acid production, whereas flaxseed supplementation decreased ammonia fermentation. Ammonia is one of the microbial products that is known to have negative health effects in animals, which is excreted in large quantities, especially in intensive production [Results about cecal bacterial fermentations indicate that both noduction ,62. Resuoduction , which iSurprisingly, the results concerning the histological analysis of the samples of the stomach collected by both F and O groups showed mild signs of hemorrhagic infiltration and vascular ectasia in the deepest part of the gastric mucosa compared to the control group. The same samples presented, however, a normal structural organization of the organ and no damage in the epithelium. Moreover, the samples obtained from the intestinal tracts did not show any kind of lesions in all the experimental groups. To date, there are no studies that report the same histological signs in the stomach of rabbits; there is indeed evidence that n-3 PUFA contained in fish oil does not induce negative effects on the histological structure of the liver and kidney . At commTo the best of our knowledge, this is the first study that shows the effect of dietary supplementation with flaxseed and fish oil on the gut microbiota composition of rabbits, albeit on a limited number of animals. These preliminary results could represent the starting point for future research to evaluate whether these changes in bacterial populations may also modify the cecal fermentative production of volatile fatty acids. The relationship and the connection pathways between the changes in the gut microbiota and the efficiency of the immune system of the host could be investigated. Moreover, bioactive components of flaxseed and fish oil other than PUFAs could intervene in this relationship, and further research should focus on their role in gut microbiota changes. For example, flaxseed contains phytochemicals, such as isoflavones and lignans ,76, whicn = 5/group) and fed three different diets . These diets have previously been used [The rabbits were reared in the experimental facility of the Department of Molecular and Developmental Medicine of University of Siena. At weaning, fifteen New Zealand White male rabbits were divided into three groups (nt diets  until sleen used  and theiThe rabbits were kept in a controlled environment for temperature (18–21 °C), relative humidity (60%), and light (16 h of day) in compliance with Directive 2010/63/EU related to the protection of animals kept for breeding purposes.At the end of the trial, the animals were slaughtered in an authorized slaughterhouse, and the stunning , bleeding, and skinning of the animals followed the European Union regulations, specifically the Council Regulation No 1099/2009 on the protection of animals at the time of the slaughter. The average body weights (± standard error) at weaning were 857 ± 105 g, 879 ± 115 g, and 898 ± 125, whereas at slaughtering, they were 2310 ± 82 g, 2410 ± 120 g, and 2375 ± 55 g in C, F, and O groups, respectively.The gastrointestinal tract was immediately removed from each animal. The luminal contents of the stomach, duodenum, jejunum, ileum, caecum, and colon were individually collected in a sterile 15 mL tube and stored in sterile tubes at −80 °C until analysis.DNA was extracted from each fecal sample while using a QIAamp PowerFecal Pro DNA Kit , according to the manufacturer’s protocol. DNA quality and quantity were assessed using a NanoDrop ND-1000 spectrophotometer . The isolated DNA was then stored at −20 °C until use.Bacterial DNA was amplified using the primers that were described in literature , which tDemultiplexed paired-end reads from 16S rRNA-gene sequencing were first checked for quality while using FastQC  for an iAfter joining, the reads were filtered for quality based on: (i) maximum three consecutive low-quality base calls (Phred <19) allowed; (ii) the fraction of consecutive high-quality base calls (Phred >19) in a read over total read length ≥0.75; and (iii) no “N”-labeled bases  allowed. Reads that did not match all the above criteria were filtered out. All the remaining reads were combined in a single FASTA file for the identification and quantification of OTUs . The reads were aligned against the SILVA closed reference sequence collection release 132, with 97% cluster identity ,81 applyThe microbial diversity of the different niches of the rabbit gastrointestinal tract was assessed within- and across-(beta diversity) samples. All the indices  were estimated from the OTU table (at the OTU level), filtered for OTUs with more than 50 total counts distributed in at least five samples. Besides the number of observed OTUs directly counted from the OTU table, within-sample microbial richness, diversity, and evenness were estimated using the following indices: Chao1 and ACE (abundance-based coverage estimator) for richness, Shannon, Simpson, and Fisher’s alpha for diversity ,86, and For the analysis of bacterial metabolites (lactic acid and ammonia), 1 g of cecal content was diluted in 1 mL of 1 M perchloric acid and 8 mL of distilled water. After homogenization, tubes were centrifuged for 10 min at 5000 rpm, and the supernatant was transferred to 2 mL eppendorf and frozen at −20 °C until metabolites quantification. The spectrophotometer  was set at 565 nm and 660 nm respectively. All chemicals were purchased from Sigma Chemical Co .The spectrophotometric method for biological fluids was used for lactic acid determination according to Pryce et al. . AmmoniaSamples of stomach body (fundic mucosa), proximal duodenum, jejunum, and ileum of 5 animals for each experimental group were collected, fixed in 10% formaldehyde in 0.01 M phosphate-buffered saline (PBS) pH 7.4 for 24 h at 4 °C, dehydrated, cleared with xylene, and embedded in paraffin. Microtome sections (4 µm thick) were stained with a) Hematoxylin–Eosin (HE) staining to establish structural details and b) Alcian blue 8GX- pH 2.5-periodic acid-Schiff (AB-PAS), which revealed neutral  and acid  glycoconjugates. This histochemical reaction selectively evidenced both the intestinal mucous cells and the adherent mucous gel, which is synthesized by the mucous cells and lies upon the mucosal epithelial layer.Lachnospiraceae while reducing Bacilli and the Firmicutes/Bacteroidetes ratio, usually associated with metabolic disease, opening interesting scenarios about the reduction in the use of antibiotics in rabbit farms. Further studies are warranted to investigate the mechanism of action of n-3 PUFAs and other bioactive components included in flaxseed and fish oil, which favor the modification of the gut microbiota. Targeting the gut microbiota populations composition and its metabolic activity with the diet could be a promising strategy, not only to maintain intestinal homeostasis, but also to control the immune as well as inflammatory response, and consequently, the incidence of gastrointestinal disorders of the rabbit. The appropriate quantity of flaxseed and fish oil to introduce with the diet to favor the right prebiotic action should be, however, optimized.This study provides novel evidence that the dietary supplementation of flaxseed and fish oil can have a beneficial impact on the composition of gut microbiota and cecal fermentation in rabbits. In particular, n-3 PUFAs supplementation increased some beneficial populations such as Bacteroidetes and