The reversion of diabetes and the treatment of long-term obesity are difficult challenges. The failure mechanisms of rapid weight loss are mainly related to the wasting of lean mass. This single-arm study aims to evaluate the effects of a very low-calorie ketogenic diet (VLCKD) on body composition and resting energy expenditure in the short term reversal of diabetes mellitus Type 2. For eight weeks, subjects were administered a personalized VLCKD with protein intake based on lean mass and synthetic amino acidic protein supplementation. Each subject was assessed by anthropometry, Dual-energy X-ray Absorptiometry(DXA), bioimpedentiometric analysis (BIA), indirect calorimetry, and biochemical analysis. The main findings were the saving of lean mass, the reduction of abdominal fat mass, restored metabolic flexibility, the maintenance of resting energy expenditure, and the reversion of diabetes. These results highlight how the application of preventive, predictive, personalized, and participative medicine to nutrition may be promising for the prevention of diabetes and enhancement of obesity treatment. Obesity and poor nutrition are the main causes of the increase in chronic degenerative diseases that can be observed globally . A recenLimiting the incidence of diabetes and reducing the prevalence of subjects suffering from prediabetes and obesity would lead to a considerable improvement in the quality of life of patients and an economic savings governments. Paradoxically, although obesity is a cause of diabetes, the prescription of DMT2 drugs is significantly higher than those for anti-obesity, when it would be enough to treat obesity to reduce DMT2 onset . Even moFrom the observation that the diabetic condition of patients undergoing bariatric surgery was improved, a twin cycle in the pathogenesis of DMT2 was hypothesized. According to the hypothesis of Taylor et al., the excess of calories was responsible for liver and pancreas lipotoxicity, insulin resistance, and beta cell differentiation . FollowiFinally, the aim of this single-arm study was to explore the effects of a VLCKD with synthetic amino acid protein supplementation on BC and resting energy expenditure (REE) in the short term reversal of DMT2. We hypothesized that with a personalized prescription of proteins in a VLCKD it would be possible to obtain a savings of LM, a maintenance of REE, and a high compliance. The results obtained will provide the precautions to be followed in the future to treat obesity and DMT2 in the long term more successfully and prevent dramatic complications with nutritional intervention alone.This prospective, single-center longitudinal single-arm study concerned a VLCKD for eight weeks in patients with DMT2. Biochemical-clinical analyses at baseline and at the end of the treatment were performed. Instrumental evaluations were performed at baseline, at four weeks of treatment, and at the end of the eight weeks. Rather than a comparative clinical study of treatment, this study aimed only to evaluate changes in DMT2 parameters, body composition, and basal metabolism following a VLCKD.2. Exclusion criteria were as follows: duration of illness over 8 years; weight loss over 5 kg in the previous 6 months; treatment with thiazolidinediones, glucagon-like peptide-1 agonists, steroids, or atypical antipsychotic; untreated thyroidism; renal alteration (serum creatinine > 1.7 mg/dL or 150 µmol/L) and habitual alcohol consumption. To exclude diagnostic errors, the diagnosis and evaluation of illness duration were performed by a specialist in diabetology, and this was confirmed by medical records. In addition to the dietary treatment, enrolled patients were asked not to change lipid-lowering therapy and lifestyle, while dosages for hypertension drugs were changed or reduced according to clinical needs throughout the study. With reference to diabetes therapy, enrolled patients were asked to interrupt all medications before the beginning of the VLCKD, as per Steven et al. [At the Clinical Nutrition and Nutrigenomics section of the University of Rome “Tor Vergata”, 25 patients with DMT2 were enrolled. Inclusion criteria were as follows: age 25–75 years; DMT2 treated with diet and/or oral antidiabetics, dipeptidyl peptidase-4 inhibitors and/or insulin; and body mass index (BMI) between 18–45 kg/mBody height and weight were assessed by a stadiometer and scale  while the patient was standing and only wearing underwear Data were collected to the nearest 0.1 cm and 0.1 kg, respectively. BMI was calculated as follows:As done previously, four circumferences were measured: neck, abdomen, waist, and hip .Body composition evaluation was performed after a 12 h overnight fast. Subjects underwent Dual-energy X-ray Absorptiometry (DXA) , with a specific system software package , to measure fat mass (FM) kg and %, both segmental and whole; LM kg and %; both segmental and whole; and bone mass (BM) kg. Before each testing session, standard DXA quality control and calibration measures were carried out.Furthermore, each subject underwent a bioimpedentiometric analysis  to measure phase angle; resistance (Rz); reactance (Xc); total body water (TBW), L; extracellular body water (ECW), L; and body cell mass (BCM) kg ,28.An electronic dynamometer for measuring maximum handgrip strength was used  .2 and CO2 volumes (VO2 and VCO2), using a Vyntus CPX Canopy  with SentrySuiteTM Software . A gas mixture with 12.0% O2, 5.0% CO2, balanced with N2 was used. After a steady-state condition, when no variation over ± 5% occurred, VO2 and VCO2 values were recorded. According to the Weir equation, the REE was calculated without using urinary urea nitrogen levels. [Indirect calorimetry was performed to obtain REE, respiratory quotient (RQ), O levels. .Glycemia, insulinemia, HbA1c, hepatic transaminases, and creatinine at baseline and at eight weeks, after 12 hours of night fasting, were performed. The Homa Index was calculated to assess insulin resistance . The anaThe included subjects undertook a dietary treatment: VLCKD. This treatment provided a synthetic amino acid powder supplementation of 8 grams per bag as the source of protein; it contained whey protein (6.71 g/bag), carbohydrates (0.015 g/bag), fats (0.075 g/bag), isoleucine (0.155 g/bag), ornithine alpha-ketoglutarate 0.125 g/bag), L-citrulline (0.125 g/bag), taurine (0.125 g/bag), L-arginine (0.100 g/bag), L-tryptophan (0.0375 g/bag), potassium citrate (0.100 g/bag), and pantothenic acid (0.0015 g/bag) for a total of 29 kcal (122 kJ) . The powder was dissolved in water and taken in daily meals. The amount of synthetic amino acid powder supplementation administered to each patient was calculated considering a supply of 2 g of proteins per kg of whole lean mass, measured by DXA, at baseline and after four weeks [ g/bag, LIn addition, a quantity of vegetables equal to 600 g/day was administered, exclusively from non-starchy cooked and raw vegetables, subdivided into 2 or 3 portions during the day and a quantity of 20 mL of extra virgin olive oil per day, preferably raw. Finally, a minimum water intake of 2 L of mineral water per day was indicated. The average caloric content of the VLCKD was between 450–600 kcal/day for women and 650–800 kcal/day for men.In summary, the average daily distribution of macronutrients and micronutrients was as follows: 5–10% of carbohydrates (<25 g/day), derived mainly from vegetables; 60–70% of proteins, mainly from the protein supplement and minimally from vegetables; 25–30% of lipids, exclusively from extra-virgin olive oil of which polyunsaturated fatty acids (PUFA) was <10 %; Monounsaturated Fatty Acids (MUFA) was 10–20 %, saturated fat was <5 %; and sodium < 2000 mg/day. All patients were informed about the VLCKD protocol and were asked to maintain their daily physical activity levels. To improve compliance, operators contacted patients during the treatment on a weekly basis.t-test or Wilcoxon rank test (if nonparametric) were used to assess the presence or not of differences in the variables examined between the established times. For each study variable, in order to compare the trend over time, ∆% were calculated equal to the percentage variation of each parameter calculated as an absolute margin of variation from the base value. The analyses were performed using the SPSS software . All changes with p < 0.05 were considered significant.From the analysis of the literature of a previous work , it was 2. Fasting glycemia were 170.06 ± 38.18 mg/dL and glycated hemoglobin were 7.33 ± 1.13% (57.06 ± 13.00 mmol/L) . The neck circumference was significantly reduced (p < 0.001) in the first four weeks of treatment. The maximum force of the dominant hand did not show significant changes over time  in the three comparisons, except Arm FM, which was significantly reduced only between baseline and eight weeks (p = 0.01). Furthermore, a significant reduction (p < 0.001) of FM%, segmental and whole, with the exception of Leg and Gynoid FM%, which were significant between four weeks and eight weeks (p < 0.001), was observed (p < 0.001) of the lean mass (kg), segmental and whole, was shown only between baseline and four weeks, while no variations were shown for the arms’ lean mass (kg) (FM (kg), segmental and whole, showed a significant reduction (observed . A signiass (kg) . Finallyass (kg) .p < 0.001) between baseline and four weeks. Furthermore, TBW and ECW were significantly reduced (p < 0.001) between baseline and four weeks. Furthermore, no significant changes for BCM and phase angle (PA) were noted , while no significant changes were observed between four weeks and eight weeks. Overall, a significant variation (p < 0.001) between baseline and eight weeks for VCO2, RQ, and REE was observed. Finally, no variation was noted for VO2 between four weeks and eight weeks, nor between baseline and eight weeks . Indeed, this element, defined by Taylor, could correspond to the FM% evaluated by DXA and recognized as a parameter for the diagnosis of obesity ,40. The Regarding the saving of the LM, an initial loss was still observed between baseline and four weeks, but it stabilized by eight weeks. Despite this initial loss, our hypothesis on LM saving is supported by the maintenance of BCM and a significant decrease of ECW, thanks to a personalized protein prescription. The reduction of the water load is a known phenomenon in a low-calorie and ketogenic diet. In our study this is even more observable given the reduced sodium intake. The reduction in water content is due to the increase in diuresis due to urinary excretion of ketones, sodium, and the depletion of glucose reserves ,43. The 2 and an even bigger decrease in VCO2 with the restoration of the metabolic flexibility was observed. After four weeks and a weight loss >15% the REE and the gas volumes were not reduced further. Thanks to the BC assessment, we can state that the additional weight loss between four weeks and eight weeks was only due to the reduction in FM. Therefore, saving the LM also maintained the REE in the VLCKD. Metabolic adaptation can be attributed to the reduction of FM and related inflammatory mediators such as adipokines, and to the change of oxidized substrates. In addition, changes in leptin levels, thyroid hormones, sympathetic stimuli, and others not evaluated in this study may also be contributers [From the metabolic point of view, a reduction of RQ −12%) was observed corresponding to a change in the oxidized energy substrate, which moved towards fat, with a consequent increase in circulating fatty acids, as demonstrated by Hall et al. . All pat% was obsributers .Regarding the blood tests, this study led to a reduction in fasting glycemia of 39.7% and of glycated hemoglobin below 6.5%, corresponding to the return of subjects to within the normal ranges. These data confirm the results previously obtained in the Counterpoint  and CounMoreover, as already demonstrated by the Counterpoint study , a signiFinally, our single-center longitudinal single-arm study reinforced the hypothesis of the reversibility of diabetes and the twin cycle, adding the evaluation and saving of LM as fundamental in the process of reversion and therapeutic success. In the DiRECT study, Lean et al. achieved a one-year reversal of diabetes in 46% of treated patients and the maintenance of 15% weight loss in 24% of the treated . At yearTherefore, we hypothesize that saving the LM and maintaining the REE will allow us to obtain long-term success, especially after a treatment that attacks visceral fat. However, the study has numerous limitations represented by the number of patients, the duration of the study, and the lack of follow-ups. Another limitation is the absence of a control arm, and for this reason the current results must be considered with caution. In the future, longitudinal and randomized case-control studies will be performed to confirm the results obtained in this first exploratory study. These results highlight how the application of preventive, predictive, personalized, and participative medicine to nutrition may be promising to prevent diabetes and enhance obesity treatment.


Residents of urban slums are at greater risk for disease than their non-slum dwelling urban counterparts. We sought to contrast the prevalences of selected non-communicable diseases (NCDs) between Brazilian adults living in a slum and the general population of the same city, by comparing the age and sex-standardized prevalences of selected NCDs from a 2010 survey in Pau da Lima, Salvador Brazil, with a 2010 national population-based telephone survey. NCD prevalences in both populations were similar for hypertension (23.6% (95% CI 20.9–26.4) and 22.9% (21.2–24.6), respectively) and for dyslipidemia (22.7% (19.8–25.5) and 21.5% (19.7–23.4)). Slum residents had higher prevalences of diabetes mellitus (10.1% (7.9–12.3)) and of overweight/obesity (46.5% (43.1–49.9)), compared to 5.2% (4.2–6.1) and 40.6% (38.5–42.8) of the general population in Salvador. Fourteen percent (14.5% (12.1–17.0)) of slum residents smoked cigarettes compared to 8.3% (7.1–9.5) of the general population in Salvador. The national telephone survey underestimated the prevalence of diabetes mellitus, overweight/obesity, and smoking in the slum population, likely in part due to differential sampling inside and outside of slums. Further research and targeted policies are needed to mitigate these inequalities, which could have significant economic and social impacts on slum residents and their communities. Over the course of the past 25 years, non-communicable diseases (NCDs)—including neoplasms, cardiovascular and circulatory diseases, chronic respiratory diseases, cirrhosis of the liver, digestive diseases, neurological disorders, mental and behavioral disorders, diabetes, and musculoskeletal disorders—have gradually displaced communicable diseases, maternal, neonatal, and nutritional disorders, and injuries, as the principal global causes of illness. In 1990, NCDs accounted for only 43% of global disability-adjusted life years (DALYs), whereas in 2013 they accounted for 54% of global DALYs [The United Nations Human Settlements Program estimates that roughly 863 million people live in urban slums in low- and middle-income countries . Access Existing surveys of NCDs and NCD risk factors in slums tend to focus on individual NCDs. Further, many studies done in urban areas do not disaggregate the population’s health data by slum and non-slums status to allow for the detection of intra-urban health disparities, or even sample from this population ,15,16,17favelas, to that in the general Brazilian population. Here we report the findings of a survey of the prevalences of NCDs and NCD risk factors among adults living in a favela in Salvador, Brazil and compare those prevalences with the prevalences of NCDs and NCD risk factors in the general population of the same city.Brazil is the largest country in South America, with an estimated 45.7 million (28.0%) of its residents residing in slums . It has favela in Salvador, to conduct surveillance for acute febrile illnesses and cohort studies of leptospirosis. Of the city’s estimated favela population of 882,204 people, 76,532 (8.7%) reside within Pau da Lima [2).In 2010, Salvador had the third largest population in Brazil , and the greatest proportion of its residents (33%) living in slums . In 2003 da Lima ,24. A de da Lima . Brieflyaglomerado subnormal to describe communities meeting the following criteria:(1)illegal occupation of the land characterized by construction on the property of others or receipt of land title in the previous 10 years, and(2)construction outside of existing municipal patterns, reflected by the presence of narrow and uneven roads, land parcels of inconsistent shape and size, and development not overseen by regulatory agencies, ora general scarcity of public services .one of the following:Pau da Lima meets both the United Nations’, and the Brazilian Census Bureau’s criteria for an urban slum . In the In 2010, during enrollment of individuals from randomly selected households for a leptospirosis survey ,24,25,262.Collaborating with the community’s Health District Office, researchers arranged appointments with physicians at the local health facility for those with abnormal laboratory results, a prior diagnosis of hypertension but not on treatment, or a body-mass index (BMI) greater than 25 mg/kg2), overweight (BMI ≥ 25 and < 30 kg/m2), or obese (BMI ≥ 30 kg/m2) [The BMI of all participants was calculated and categorized according to World Health Organization (WHO) guidelines as normal weight (BMI ≥ 18.5 and < 25 kg/m0 kg/m2) . Partici0 kg/m2) . HyperteLevels of low-density lipoprotein cholesterol (LDL-cholesterol), high-density lipoprotein cholesterol (HDL-cholesterol), and triglycerides were used to calculate total cholesterol per the Adult Treatment Panel (ATP) III report criteria. Dyslipidemia was defined as an LDL-cholesterol greater than 160 mg/dL, a total cholesterol above 240 mg/dL, or a self-reported previous diagnosis by a medical professional .To investigate how the prevalences of NCDs in Pau da Lima population differed from the prevalences of NCDs in the overall population of Salvador, we compared the prevalences of NCDs among residents of Pau da Lima with the prevalences of NCDs among all residents of Salvador who participated in the 2010 Vigitel survey. This annual telephone survey interviews at least 2000 adults (18 and older) in every Brazilian state capital. It has been conducted by the Ministry of Health since 2006 with the express purpose of monitoring NCD burden in Brazil . Samplin2010 Pau da Lima Leptospirosis Survey—Randomly selected households in Pau da Lima, Bahia, Brazil ,24,25,262010 Pau da Lima NCD Survey—Non-random subsample of leptospirosis survey respondents who chose to participate in supplemental NCD survey.2010 Vigitel Survey—Citywide telephone survey of residents of Salvador, Bahia, Brazil . Due to There are three datasets described in this manuscript:All analyses were performed in STATA Version 12.1 . To assess for selection bias between those who participated in the randomly selected leptospirosis study and those who chose to participate in the NCD survey, Pearson’s chi-squared test was used to assess for differences between leptospirosis cohort members who did and did not participate in NCD screening. Overall, age- and sex-specific prevalences for the surveyed population in the Pau da Lima community and the Vigitel survey were calculated as the proportion of participants who fulfilled clinical criteria for each condition. Measurements of glucose, triglyceride, cholesterol, and creatinine for those not fasting at least nine hours prior to blood draw were excluded from analyses . One parPrevalences of DM, hypertension, overweight, obesity, smoking, and dyslipidemia from both the Vigitel survey and the Pau da Lima survey were age- and sex-standardized to the age and sex distributions of the city of Salvador reported in the 2010 Census, to allow direct comparisons of NCD prevalence . Sex-speThe leptospirosis cohort study was approved by the ethics committee at the Oswaldo Cruz Foundation, the Brazilian National Committee for Ethics in Research (0021.0225.000-08), and the Yale Human Research Protection Program (1006006956). All participants provided written informed consent. The NCD and NCD risk factor survey data were not initially collected for research purposes, but as a service requested by community leaders and delivered by researchers at the Oswaldo Cruz Foundation. However, a 2014 protocol was approved by the ethics committee at the Oswaldo Cruz Foundation (11899212.1.0000.0040), granting a waiver for informed consent for the present use of these data.p <0.05)  participated in the NCD survey. These residents were similar to the initial cohort that did not participate in NCD screening in terms of race and education, yet had more females, and was older and significantly wealthier (p <0.05) . The PauSeven hundred and seventy-three (97.6%) people had data available on all conditions . The main reason for missing data was refusal to report . The number of residents reporting each condition varies due to differential rates of reporting and different numbers of individuals participating in laboratory testing.Of 783 participants in Pau da Lima, 69 (8.8%) reported a previous diagnosis of DM , or had a measured plasma glucose (PG) above 200 mg/dL at time of survey  . The ageOf the 792 participants in Pau da Lima, 189 (23.8%) reported a previous diagnosis of hypertension . The ageOf 781 participants living in Pau da Lima, 183 (23.4%) had dyslipidemia . In 2013Of 790 participants living in Pau da Lima, 387 (49.0%) were overweight or obese, and 137 (17.3%) were obese . The oveIn Pau da Lima, the prevalence of overweight or obesity, and obesity was higher among women (52.0% BMI ≥ 25 and 20.2% BMI ≥ 30) than among men (42.8% BMI ≥ 25 and 11.3% BMI ≥ 30) .Among the 792 participants living in Pau da Lima, 106 were smokers (13.4%) . In Pau favela in Salvador, Brazil, we found higher prevalences of DM, smoking, and being overweight or obese than among the general population of Salvador. These high prevalences were mirrored in most age- and sex-specific estimates as well, with the largest disparity among Pau da Lima’s women. Women in Pau da Lima had a much higher BMI than men in their community, who were also more obese and overweight than the general population of Salvador. Women in Pau da Lima also had a higher prevalence of hypertension than men in Pau da Lima, or women in the city of Salvador. There were almost twice as many active smokers living in Pau da Lima than in the city of Salvador.In this survey of a These results suggest that the prevalence of NCD in Pau da Lima is higher than in the city of Salvador, lending support to the hypothesis that slum residents have more NCD than their non-slum dwelling urban counterparts. The higher prevalence of NCD and cardiovascular risk factors in this slum population suggest that as it continues to age, it will be at greater risk for major cardiovascular events, such as heart attack or stroke, than the general population.Very few studies have investigated the prevalence of NCD among residents of urban slums. A 2012 survey in a Lima, Peru community found lower prevalences of hypertension and DM, but similar prevalences of overweight, obesity, and smoking to our survey . Serial In 2011, the World Health Organization estimated that 14.1% of the Brazilian population smoked, 40.0% had elevated blood pressure, and 18.8% were obese . These aThere were several limitations to this study. Both the Vigitel and the Pau da Lima surveys relied on self-reporting. In the Vigitel survey, every NCD was self-reported, whereas the Pau da Lima survey combined self-report and laboratory measures for DM and dyslipidemia, relying on self-report for hypertension, smoking, and overweight and obesity. Self-reporting can significantly underestimate NCD prevalence; however, this would likely be a differential bias, with wealthier (non-slum) residents more accurately reporting their disease status due to their higher level of education, and relatively better access to medical care.favelas are also located on rough or poor-quality terrain, such as mountain slopes, hindering travel and development of transportation infrastructure. Differential access to healthy food between these communities and wealthier regions also exists, given the elevated cost of fresh fruits and vegetables relative to more processed foods. The difference in disease burden between the general population of Salvador and the results of the Vigitel survey could be due to differences in survey methodology, but they may also be due to the well-documented and described physical and demographic differences between slum and non-slum areas. For example, residents of urban slums have limited access to healthcare, are less educated, and poorer compared with their non-slum dwelling urban counterparts ,39. ThisAnother limitation to this study is that it was done in only one community, and sampling was not random. Sampling in the initial leptospirosis cohort was random by household, but participants in the present survey were expected to report to the Pau da Lima RA. As such, it is possible that the study suffered from self-selection bias, but the Vigitel survey would also experience this same bias. Further, a large proportion of the world’s and Brazil’s slum populations live in similar tropical climates, with comparable rates of poverty and environmental degradation . It is also important to highlight that citywide surveys conducted by telephone, such as Vigitel, likely do not generate viable sampling frames in slums. Only 40% of the 764 surveyed households in Pau da Lima had landlines in 2010. Consequently, the general population of Salvador represented by this survey may not have proportionally included slum residents, and would have likely underestimated the true burden of NCD in the overall population. On the other hand, because we did not compare the Pau da Lima population with the non-slum population of Salvador, but with the general Salvador population, the differences between the prevalences of NCD between slum and non-slum populations may even be conservatively low. There may also have been differential misclassification in identification of DM and dyslipidemia because poverty and education can confound the accuracy of self-reported medical information .Further, we only used one PG reading to identify DM (cross-referencing with self-reported previous diagnosis). This would overestimate the DM prevalence were fasting incorrectly reported. However, in doing so, we identified 13 people who had not been told by a physician that they were diabetic. Active tobacco smoking was only reported as binomial (yes or no), not allowing for thorough definition as a risk factor. Cardiovascular risk is usually measured using scales such as the Framingham Risk Score, but due to lack of data availability, we were unable to calculate this score in these populations . Furtherfavelas is also the most active economically (those aged 25–60) [This differential NCD burden among slum residents imposes an enormous economic cost on the state, not only in terms of mounting healthcare costs from sequelae and mortality, but also in the form of an acute loss of labor from low-income workers and the informal economy when they become too sick to work. The informal economy is estimated to comprise roughly 40% of the economy in middle- and low-income countries, where the majority of the global slum population resides ,47, and d 25–60) , NCD seqd 25–60) , perpetud 25–60) .This work must also be situated within the broader context of social determinants of health and neighborhood-specific risk factors for disease. This eco-social theory highlights the role of structural and group-level conditions, such as education, wealth, class, sanitation and habitation infrastructure, and many more in the health-disease process.  The compLong-term severe sequelae due to these NCDs can be prevented with early, direct social interventions that facilitate access to healthy food and exercise, while also offering competitive economic opportunities . As the


The surgical approach  for patients with Siewert type II adenocarcinoma of the esophagogastric junction (AEG) still remains controversial. We made a bold attempt to adopt the modified Ivor-Lewis surgery, No turning over, thoraco-laparoscopic esophagogastrectomy, two-field lymphadenectomy and intrathoracic anastomosis, to observe the clinical application and effect.Data of patients with Siewert type II AEG were collected in the Hebei General Hospital from June 2017 to February 2019. The operation time, surgical blood loss, the number of dissected lymph nodes, duration of drainage tube, postoperative complications, the length of postoperative hospital stay were collected to assess the safety and feasibility of modified Ivor-Lewis surgery.A total of 20 patients with Siewert type II AEG were analyzed in our research, there was no case of turning to thoracotomy, laparotomy or death during the operation.The average operation time, surgical blood loss, amount of dissected lymph nodes, duration of drainage tube, postoperative hospital stay of all enrolled patients was 4.67, 0.57 h, 156, 56.80 ml, 22.55, 3.91, 8.6, 2.21 days, 12.85, 2.5 days respectively. Among all the enrolled patients, one patient(5%) developed anastomotic fistula and one patient(5%) developed hematemesis after operation, eventually, these two patients were discharged successfully.For patients with Siewert type II AEG, The modified Ivor-Lewis surgery, No turning over, thoraco-laparoscopic esophagogastrectomy, two-field lymphadenectomy and intrathoracic anastomosis, is safe and feasible. The feasibility and safety could be further and better investigated with a RCT to achieve more conclusive results. In the last two decades, the incidence of adenocarcinoma of the esophagogastric junction (AEG) has been increasing rapidly . Surgica2; As for comorbidities, 7 patients with hypertension,6 patients with type 2 diabetes disease, and 3 patients with coronary heart disease. The characteristics of the enrolled patients were shown in Table 20 patients with Siewert type II AEG were enrolled into our research from June 2017 to February 2019, all of whom had underwent modified Ivor-Lewis Surgery:No turning over, thoraco-laparoscopic esophagogastrectomy, two-field lymphadenectomy and intrathoracic anastomosis, in our department in Hebei General Hospital. 14 male and 6 female, age from 52 to 74, average age 64.5, 4.7. 10 patients had a history of smoking;The average BMI of enrolled patients was 24.12 ± 2.70 kg/mThe inclusion criteria were as follows criteria: 1. Studied patients with AEG were pathological examination confirmed;2. The staging was limited to IIA or IIB according to TNM classification of gastric cancer as described in the 7th edition of the American Joint Committee on Cancer (AJCC);3. Siewert type II AEG; 4.The lesion length is less than 4 cm;5.The KPS score ≥ 90 points.The exclusion criteria were; 1.The staging was III or IV according to TNM classification;2. Siewert type I, III AEG;3.Neoadjuvant chemo−/ chemoradio-therapy before surgery;4.The KPS score, 90 points;5.Previous history of chest or abdominal surgery;6.Patients with sereve cardiac, pulmonary, brain, renal complications cannot tolerate surgery.The study was approved by the local Ethical Committee of the Hebei General Hospital and was conducted in accordance with the ethical principles of the Declaration of Helsinki. All patients provided written informed consent.Single lumen endotracheal tube was intubated after successfully anesthesia, Patients in the study were placed in the left supine position at 45 degrees, the upper abdomen and the right chest were disinfected and drapped at the same time after properly fixed.Transabdominal surgery: Tilt the operating bed 45 degrees to the right, so that the patient is supine, mobilization of stomach and the lower esophagus, division of the diaphragm and abdominal lymphadenectomy was performed in the video-assisted laparoscopy.The lower esophagus was dissected by linear cut stapler. Make a 5 cm vertical abdominal incision in the upper epigastrium, take out the stomach and resect the tumor and than make a gastric tube along the greater curvature by linear cut staplers, oversuture the incision edge. After mobilization of the stomach, division of the left gastric artery at its origin, the lymphadenectomy along the celiac axis and suprapancreatic region was performed (according to a D2-lymphadenectomy for gastric carcinoma). The abdomen was closed.Transthoracic surgery: Tilt the operating bed 45 degrees to the left, so that the patients is in lateral position. Mobilization of the esophagus, thoracic lymphadenectomy and intrathoracic anastomosis in the video-assisted thoracoscopy. The gastric tube was pulled into the thorax through the hiatus. The reconstruction of the digestive tract was performed with an esophagogastrostomy (side-to-side) in the tip of the right pleural cavity by a linear cut stapler. The closure of the gastric tube and esophagus was achieved by a linear cut stapler. By oversuturing the anastomosis and the blind end of the esophagus and gastric tube, a functional anastomosis was created. The chest was drained with one tube parallel to the gastric tube in the posterior mediastinum with its superior tip at the anastomosis and one tube in the recessus of the diaphragm.The thorax was closed.The operation time, surgical blood loss, the number of dissected lymph nodes, duration of drainage tube, postoperative complications, the length of postoperative hospital stay were collected by the third author.All the enrolled patients successfully completed surgery, there was no case of turning to thoracotomy, laparotomy or death during the operation.Data collection and statistical analysis were performed on all enrolled patients. All quantitative data are expressed as mean, standard deviation (SD).The postoperative data of the enrolled patients were shown in Table Operation time; The average operation time of all included subjects was 4.67, 0.57 h, the minimum was 3.4 h and the maximum is 5.5 h.Surgical blood loss; The average surgical blood loss of all enrolled patients was 156, 56.80 ml, the minimum amount of blood loss was 60 ml, the maximum amount of blood loss was 250 ml.The number of dissected lymph nodes; In all enrolled patients, the average amount of dissected lymph nodes was 22.55 ± 3.91, the minimum was 16 and the maximum was 31.Duration of drainage tube; The average duration of drainage tube of all enrolled patients was 8.6, 2.21 days, the minimum duration of drainage tube was 6 days, the maximum duration was 13 days.The length of postoperative hospital stay; the mean postoperative hospital stay was 12.85 ± 2.5 days, the minimum postoperative hospital stay was 9 days, the maximum postoperative hospital stay was 17 days.Postoperative complications; Among all the enrolled patients, one patient(5%) developed anastomotic fistula on the third day after surgery. Postoperative hematemesis occurred in one patient in the seventh day after operation, eventually, these two patients were discharged successfully. No other serious complications occurred in the remaining patients. Perioperative complications were shown in Table After decades of research progress, the operation methods of AEG include transthoracic approach, transabdominal approach and combined thoracoabdominal approach. However, different surgical methods still have different advantages and disadvantages. According to NCCN guideline, the therapeutics of Siewert type I/II AEG has been classified as to that of esophageal carcinoma, the transthoracic approach is considered as the recommended surgical procedure . SiewertCompared to traditional open Ivor-Lewis surgery, The modified Ivor-Lewis surgery, No turning over, thoraco-laparoscopic esophagogastrectomy, two-field lymphadenectomy and intrathoracic anastomosis, carried out in our department has advantages in the following aspects. First, all enrolled patients were placed in the left supine position at 45 degrees before the operation, we changed the position of the patients by adjusting the angle of the operating bed during the operation, avoiding the process of intraoperative turning over and disinfection, shortening the unnecessary operative time. Second, the modified Ivor-Lewis surgery is able to mobilize longer esophagus and make a longer gastric tube, achieve thoracic and abdominal lymphadenectomy through the combination between thoracoscopy and laparoscopy. These ensure no residual cancer cells on the stump, realize the goal of radical cure. Third, the combination between thoracoscopy and laparoscopy can relieve surgical trauma and postoperative pain, accelerate postoperative rehabilitation, reduce postoperative complications compared to traditional thoracotomy and laparotomy.Some limitations have to addressed in our study. First, the enrolled patients were limited, which inevitably contributed to some bias. Second, It was a challenge for operator and assistant that the patient’s position couldn’t completely meet conventional anatomical position.In conclusion, Compared to traditional open Ivor-Lewis surgery, The modified Ivor-Lewis surgery, No turning over, thoraco-laparoscopic esophagogastrectomy, two-field lymphadenectomy and intrathoracic anastomosis, is safe and feasible. The feasibility and safety could be further and better investigated with a RCT to achieve more conclusive results.


Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) are chronic autoimmune diseases leading to joint damage, functional limitation, and disability and are typically associated with several comorbidities. Alexithymia is a personality trait characterized by a disregulation of emotion processing and regulation of emotions that involves a dissociation of emotional and physical responses to life events. A broad association between alexithymia and symptoms as depression, inflammation, and pain has been demonstrated. We aimed at evaluate an association among inflammatory arthritis, as RA and PsA, and alexithymia, and a possible link with clinical characteristics and disease activity.In this cross-sectional study, we enrolled, from January to December 2017, patients affected by RA or PsA referring to the outpatient's clinic of the Rheumatology Unit of the University of Rome Tor Vergata. The 20-item Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. Disease activity, function, quality of life, and clinimetric indexes were assessed.P = .029, CRP: P = .043) and between alexithymia and clinimetric parameters . A significant trend of association has been demonstrated between alexithymia and female gender and concomitant steroid therapy. No correlations among variables such as age, duration of disease, and comorbidities and alexithymia status were observed.A total of 50 RA patients and 51 PsA patients were enrolled. The TAS-20 score showed 38.6% (39/101) patients had alexithymia, 26.7% (27/101) patients were in the borderline of alexithymia and 34.7% (35/101) patients did not have alexithymia. A statistical significant association was observed between alexithymia and inflammatory indices (ESR: This study suggests that alexithymia assessment should be a part of the comprehensive management of RA and PsA patients. Both are characterized by the presence of a significantly high prevalence of comorbidities, which can involve different organs and tissues, even the psychiatric sphere. The presence of comorbidities should be taken in consideration by physician in order to guarantee an improvement in quality of life and a major adherence to therapies. The presence of psychological distress, especially depression and anxiety, is a well-known aspect of inflammatory arthritis and has been reported as a common comorbidity. In fact, as underlined in the COMORA study, depression is one of the most frequent ones. Moreover, the activation of the innate and acquired immune response not only leads to inflammation in affected organs, but also mediates behavior abnormalities, including fatigue and depression-like symptoms. Arthritis negatively affects not only the physical and social aspects of patients with RA or PsA, but also their psychological well-being.Rheumatoid arthritis (RA) is a chronic autoimmune inflammatory disease characterized by synovitis that leads to destruction of cartilage and bone, functional limitation, and disability.,8,9 Sifneos coined the term alexithymia, literally “absence of words for emotion” , to describe people who lack the ability to communicate their feelings or have limited imagination.,11 Kokkonen and collaborators examined the prevalence of alexithymia and its associations with sociodemographic factors in a population cohort of the Northern Finland. The population consisted of all 12,058 live-born children in the provinces of Lapland and Oulu in Finland and the prevalence of alexithymia was 9.4% in male and 5.2% in female subjects. Due to the strong correlation between altered emotions and chronic diseases, alexithymia has been assessed in patient affected by inflammatory bowel disease or plaque psoriasis, whereas it has been minimally explored in arthritis.Alexithymia is conceptualized as a disorder of emotion regulation mechanisms, which involves a dissociation of emotional and physical responses to life events and bodily sensations.The aim of this cross-sectional observational study was to assess the prevalence of alexithymia in patients with inflammatory arthritis, as RA and PsA, and potential association with demographic variables, clinimetric values, and concomitant treatments.22.1 or a diagnosis of PsA made according to the CASPAR criteria. Exclusion criteria were: treatment with more than 7.5 mg per die of prednisone or its equivalents, treatment with Apremilast, patient affected by fibromyalgia, psychiatric disorders, central nervous system (CNS) or peripheral nervous system (PNS) diseases or patients who received or were receiving any systemic treatment with psychotropic drugs or cytotoxic medications. For each patient, demographic, clinical data, and treatments performed were collected. The clinical evaluation of joint disease was assessed using tender and swollen joint count and clinimetric values such as pain-visual analog scale (pVAS), patient-visual analog scale (ptVAS), Global Health index (GH), DAS28 (Disease Activity Score 28) for RA and DAPSA (Disease Activity Index for Psoriatic Arthritis) for PsA. Laboratory values of erythrocytes sedimentation rate  and C-reactive protein  were evaluated.We enrolled, from January to December 2017, patients affected by RA or PsA, referred to the outpatients’ clinic of the Rheumatology Unit of the University of Rome Tor Vergata, Rome, Italy. Inclusion criteria were ≥18 years of age and a diagnosis of RA made according to the ACR revised criteria for RA2.2 Questionnaires were fulfilled in a dedicate room were privacy was guaranteed. All subjects were instructed from a psychiatrist and completed the Italian translation of the revised 20-item Toronto Alexithymia Scale (TAS-20),–20 developed by the usual method of back-translation and cross-validated using confirmatory factor analysis.The Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia. The TAS-20 is a self-report questionnaire which consists of 20 questions inherent emotional items. Each question is rated on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Patients can obtain a score that comes from 20 points to 100 points. Internationally accepted cut-off values allow to classify patients in 3 different categories, as follows: from 20 to 50 points—nonalexithymic patients, from 51 to 60 points—borderline alexithymic patients and from 61 to 100 points—alexithymic patients.The study was carried out according to the Declaration of Helsinki and conducted in accordance with the International Conference on Harmonisation Good Clinical Practice Guidelines. The study protocol was approved by ethic committee of the University of Rome Tor Vergata. All patients provided written informed consent before participating in study-related activities.2.3T test or the nonparametric Mann–Whitney U test when appropriate. Categorical variables were presented with absolute frequencies and percentages and were compared using the Chi-squared test or Fisher’ exact test when appropriate. The significance of any correlation was determined by Pearson correlation test or Spearman's rank correlation coefficient where appropriate. P values <.05 were considered significant. All statistical analyses were performed using GraphPad Prism version 7 (GraphPad software).Continuous variables were presented as means ± standard deviation and were compared using the parametric unpaired 3Around 101 patients, 29 men and 72 women, with a diagnosis of RA (9 men and 41 women) and PsA (20 men and 31 women) were included in this study. The mean age ± SD of RA patients and PsA patients was 59.5 ± 11.5 years (range 22–79) and 52.6 ± 12.8 years (range 27–79), respectively. The disease duration was 6.19 ± 3.82 years for RA and 6.29 ± 3.96 years for PsA. 62 patients (61%) of all the enrolled patients were affected by comorbidities, such as hypertension , obesity  diabetes mellitus , and osteoporosis . Demographics and clinical characteristics are summarized in Table In the total study population, the TAS-20 score showed that 38.6% (39/101) patients had alexithymia, 26.7% (27/101) patients were in the borderline of alexithymia and 34.7% (35/101) patients did not have alexithymia.In RA patients’ population, TAS-20 scores showed that 42% (21/50) patients had alexithymia, 24% (12/50) patients were in the borderline area of alexithymia, and 34% (17/50) patients did not have alexithymia.In PsA patients’ population, TAS-20 score showed that 33.3% (17/51) patients had alexithymia, 29.4% (15/51) patients were in the borderline area of alexithymia and 37.3% (19/51) patients did not have alexithymia.P = .023)    (23) Fig. . SimilarFinally, a trend of statistically significance was observed between concomitant steroid therapy and high TAS-20 score and between female sex and high TAS-20 score. No correlations among variables such as age, duration of disease, and comorbidities and alexithymia status were observed in our cohort.4,22 The present study focused on an aspect of these disorders such as alexithymia that manifests itself as an inability to describe and identify emotions and may have an impact on disease activity and treatment efficacy.Inflammatory arthritis are chronic rheumatologic disorders with both social and psychiatric burden in addition to joint involvement. Moreover, the presence of comorbidities, involving also the psychiatric sphere, has been frequently associated to RA and PsA. Few studies have been published in the field of alexithymia in inflammatory arthritis and its possible causes. A study conducted by Velasco and collaborators evaluated alexithymia, anxiety, depression, and emotional awareness, underling how all these parameters were more frequent and severe in patient with chronic rheumatological diseases than in healthy control. However, a limit of this study was that patient affected by fibromyalgia were included. Taylor and collaborators evaluated 2795 patients with RA in order to measure patients’ perceptions and pain management in RA. The majority of patients reported their RA as being somewhat-to-completely controlled, while only 12% in Europe and 15% in the United States reported not at all controlled or poorly controlled. As expected, patients with all levels of RA severity reported pain, the level of pain  corresponding with reported RA severity. Patient satisfaction with arthritis pain was significantly correlated with satisfaction with other areas of health, as social activity, tension, mood and fatigue, underlining how relevant is a good manage of physical symptoms influences the psychological sphere.Chronic pain, defined as pain lasting at least 3 months, is more complicated than acute pain, since it occurs in neurobiological, psychological, and social changes. The nosology of persistent pain is inconsistent and evolving. Some types of pain are tied to disease processes in specific tissues, including joint degeneration (osteoarthritis), inflammation , tumor growth (cancer pain), damaged nerves (neuropathic pain), or tissue anoxia (sickle cell disease).To the best of our knowledge, no studies have been conducted evaluating the presence of alexithymia in patient affected by PsA or by RA, in the absence of fibromyalgia.In the present study, high TAS-20 scores were observed in patient with an active disease, typically characterized by the presence of inflammation and pain at joint level. As a matter of fact, clinimetric parameters such as GH index, pain-VAS, and patient-VAS have been statistically significantly associated to the presence of alexithymia. Furthermore, patient with high ESR and CRP values resulted positive to the presence of alexithymia, showing how a chronic condition of inflammation and pain, as in RA and in PsA, can conduce to an alteration of the psychiatric sphere. This cytokine, strongly associated with the pathogenesis of RA and PsA, is able to interact with receptors expressed on the surface of the astrocytes, inducing them in a pro-inflammatory condition. TNF is also involved in some central nervous system pathologies such as Alzheimer. At the same time, TNF has a role in influencing the circadian clock, mediated by the clock genes (Cry1 and Tef), with a direct action on these genes. In particular, the abnormal expression of these genes, altered in cells stimulated by TNF, is associated with depression.Concerning gender, higher prevalence of alexithymia in female patients was expected, being women more susceptible to mood and personality changes. In this study, a trend of correlation among TAS-20 scores and female gender was found. Data concerning the presence of alexithymia in patients affected by RA and PsA are few in the literature, but the relation between inflammatory arthritis and central nervous system disorders has been well known; however, how they can influence each other is still unknown. A hypothesis takes in consideration the role of TNF (tumor necrosis factor) in the inflammatory process.The main limits of our study were: the lack of a control group for the detection of alexithymia in healthy controls; however its prevalence in healthy people is well known in the literature; the relative small sample size of patients included in the single-group analysis when divided according to other variables as the presence of comorbidities or gender; further investigations on a larger cohort of patients affected by spondyloarthritis are awaited.In conclusion, our study focused on the opportunity and the necessity to evaluate patient affected by rheumatological diseases, as RA and PsA, in a more comprehensive way, taking into consideration the presence of comorbidities and choosing a more appropriate treatment, which must include the control of all physical and psychological symptoms.Further studies are needed, involving a more complete psychiatric assessment, with personality tests, in order to better understand how TAS-20 can be used in daily clinical practice for the detection of mood changes in patients affected by RA and PsA and the impact of alexithymia in patients’ outcomes and treatment efficacy.4.1Inflammatory arthritis, as RA and PsA, are chronic rheumatologic disorders with both social and psychiatric burden.There is a strong relationship between inflammatory arthritis and central nervous system disorders.Alexithymia is a personality trait characterized by deficits in cognitive processing and regulation of emotions, related to the inflammatory status in RA and PsA patients.Alexithymia was also associated to pain and functional status indices in RA and PsA patients.Evaluate patients affected by RA and PsA in a more comprehensive way, including the psychiatric sphere may be useful for a more complete therapeutical management.Conceptualization: Maria Sole Chimenti, Elisabetta Greco, Roberto Perricone.Data curation: Juna Hithj, Barbara Kroegler, Marina Talamonti.Formal analysis: Paola Conigliaro.Methodology: Paola Conigliaro, Paola Triggianese, Miriam Teoli, Marco Galluzzo, Barbara Kroegler.Project administration: Giulia Lavinia Fonti, Elisabetta Greco.Resources: Paola Triggianese, Miriam Teoli, Marco Galluzzo.Supervision: Roberto Perricone.Writing – original draft: Maria Sole Chimenti, Giulia Lavinia Fonti.Writing – review & editing: Marina Talamonti, Roberto Perricone.


Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure . Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk. Lower extremity amputation (LEA) is one of the most serious surgical procedures performed in patients with diabetes . PatientAmputations in people with diabetes are a result of the combination of several conditions that include as key contributory factors, peripheral vascular disease (PVD), neuropathy , and infection. Neuropathy and PVD often co-exist and may lead to neuro-ischemic ulceration ,5,6.PVD independently increases the risk of major non-traumatic LEAs and failure to diagnose and adequately treat underlying PVD is a major cause of amputations in people with diabetes . The preSeveral other conditions are known to be associated with an increased risk of foot ulceration. All stages of nephropathy increase the risk of ulceration, with the highest risk found in the dialysis population. Dialysis treatment is an independent risk factor for foot ulceration ,5. Any dFor people with diabetes, diabetic foot infections (DFIs) are the most common diabetes-related reason for hospitalizations and for lower extremity amputations . It is eLEA is accompanied by a high risk of reulceration, reamputation, and death . In patiDiabetes increases the risk of death in the longer term following amputation compared with patients without diabetes . In the Another important factor associated with life expectancy is the level of amputation . Lopez-VDespite the relevance of this complication associated with diabetes, little information is available on long-term outcomes following diabetes-related LEAs in Spain .The aims of our study were to assess the trend in the incidence of LEA among T2DM patients living in the Autonomous Community of Madrid from 2006 to 2015, and to compare the mortality risk in diabetic individuals who underwent LEA with that of age and sex-matched diabetic individuals who did not undergo LEA.We conducted a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients.In Spain, the National Health System (NHS) is a public health care insurance system with universal coverage and is fully financed by the general tax fund . RegardiData were obtained from the Hospital Discharge Database (HDD) for the Autonomous Community of Madrid (ACM). The HDD contains administrative and clinical data regarding all yearly admissions to public hospitals in the ACM. For each hospitalization, information available from the database and used in the present study included the hospital code; patient code, age, sex, admission and discharge dates; discharge status ; main discharge diagnosis; up to 14 additional diagnoses; and up to 20 diagnostic and therapeutic procedures. The International Classification of Diseases—Clinical Modification, 9th edition (ICD-9-CM) is used for coding. The databases provided to us by the Health Authorities of the ACM were anonymous, but the individual patient code allowed us to link the records for the same patient over different years. Details on the HDD can be found elsewhere .We analyzed hospital admissions from 1 January 2006 to 31 December 2015. The ACM is one of the 17 Autonomous Communities in Spain and had a population of 6,008,183 in 2006, which increased to 6,436,996 in 2015 .In this study, only admissions of persons aged 40 years or over with ICD-9 codes for T2DM (250.x0 and 250.x2) in any of the 14 diagnostic positions were included. Those with a code for type 1 diabetes mellitus (250.x1 and 250.x3) were excluded.The main study outcome measures were the incidence of LEA and mortality after LEA among T2DM patients compared with age and sex-matched T2DM individuals without LEA.All hospital discharge records with an LEA code (ICD-9 codes: 84.10–84.19) in any of the 20 procedures’ fields were identified. We classified LEA, as proposed by Tseng et al. , into thTo increase the probability of identifying the first LEA for each T2DM patient, those who had any of these codes in any diagnosis field of the HDD from 1 January 2003 to 31 December 2005 were excluded. All LEAs performed on a person with diabetes were considered diabetes-related.If two or more amputations were coded during the same hospitalization, these were considered a single amputation because there are no variables in the HDD to enable us to assess whether the amputations were bilateral or contralateral and if the second or later amputations were a review of the previous. In this case, the highest anatomic level was assigned as a single procedure.Patients were excluded if traumatic (895–897) or tumor-related peripheral amputations  were codified.The vital status of every patient up to 31 December 2015 and the date of death were obtained from the Spanish National Statistics Institute. Survival time was calculated from the date of the first amputation coded until the date of death or the end of the study period, whichever came first.We defined an exposed cohort for each year as all persons with T2DM who had a hospital discharge with LEA.If the same patient had more than one discharge with LEA, we selected the first one as the level of amputation.To create the unexposed cohort, for each subject in the exposed cohort, we selected a matched T2DM patient without LEA in the period 2003–2015 and an identical year of discharge, sex, age, and hospital of admission.We analyzed age, sex, and the presence of the following clinical conditions in the hospital discharge data: myocardial infarction, congestive heart failure, cerebrovascular disease, dementia, chronic obstructive pulmonary disease (COPD), rheumatic disease, renal disease, any malignancy—including lymphomas, liver disease, PVD, and a metastatic solid tumor. We also calculated the number of conditions included in the Charlson comorbidity index (CCI) codified for each subject and categorized this variable in those with 1, 2, 3, or 4 or more conditions. The ICD-9 codes used to identify these clinical conditions and to calculate the CCI were those described by Quan et al. . We alsoFor each year, the incidence rate was calculated as the ratio of the number of LEAs to Madrid´s resident population with T2DM. As a consequence, a patient could be included several times in the statistics if he/she had LEA two different times within one or subsequent years. The estimated population with T2DM per year was calculated using the Spanish National Health Surveys and the Di@bet.es study, as previously described by our group ,28,29.To test the incidence time trends, Poisson regression models were used separately for the three amputation levels, with sex and age being included in the model as independent variables.t-tests for means.Descriptive analysis was performed, with the distributions of variables compared among the exposed and unexposed cohorts and summarized using frequencies and means (SD). Comparisons were performed using the chi-squared statistic for proportions and Student’s We assessed survival with the Kaplan–Meier method, stratified for LEA status and according to the level of amputation. The log-rank test was used to compare the survival distributions.p < 0.05 was considered statistically significant. All statistical analyses were performed with Stata version 10.1 .After excluding patients who died within the first 30 days , multivariable Cox proportional hazards models for all-cause of death were performed, and hazard ratios (HRs) with 95% confidence intervals were estimated. A two-sided In the ACM from 2006 to 2015, the number of hospital discharges of patients aged 40 years or over with T2DM was 764,736. A code for LEA was found for 7945 (1.04%) hospitalizations, with 5245 (66.02%) being minor, 731 (9.20%) MBK and 1969 (24.78%) MAK.p = 0.007) after a Poisson regression analysis adjusted by sex and age was conducted.p < 0.001). The same trend was observed for MAK, with the incidence decreasing from 63.9 to 48.2 per 100,000 T2DM individuals from 2006 to 2015 (p < 0.001).The incidence rates of MBK decreased significantly from 24.9 to 17.1 per 100,000 T2DM individuals over time (p = 0.063).The total number of LEAs rose from 693 in 2006 to 834 in 2015, but after Poisson regression analysis, the change over time was not significant  and renal disease (20.79%). COPD (18.20%) and congestive heart failure (13.73%) were the two most frequent diseases among those without LEA.p < 0.05). On the other hand, those who underwent LEA had higher prevalences of rheumatic disease, renal disease, and PVD.Compared with the exposed cohort, those who were unexposed had higher prevalences of myocardial infarction, congestive heart failure, cerebrovascular disease, dementia, COPD, any malignancy—including lymphomas, liver disease, and metastatic solid tumors .The proportion of T2DM patients with LEA who had a CCI of 3 or more was 34.93% compared with 25.58% among the unexposed cohort (p < 0.001). However, the proportion that died within the first 30 days was higher among those without LEA (324/5325 (6.08%) versus 216/5325 (4.05%); p < 0.001).Over the follow-up period, 48.58% of T2DM patients who underwent LEA died, compared with 34.05% of those without LEA (p < 0.001). Furthermore, when we conducted a Cox regression analysis including the CCI as a covariate, we obtained an adjusted HR for mortality of 1.75 (95% CI 1.65–1.87) for T2DM patients who underwent LEA.The Kaplan–Meier survival curves, stratified by LEA status, are shown in p = 0.795) amputations, but did show a significant difference between minor and MAK (p < 0.001) amputations.When only patients who underwent LEA were analyzed with a Cox regression model, we found that males had a significantly higher risk of dying than females , and the risk increased as the CCI increased . Finally, using minor LEA as the reference category, the mortality was not significantly different for those with MBK amputations but was 1.34 times higher for those who underwent MAK amputations (95% CI 1.22–1.46) .Shown in The results of the Cox regression models, including the clinical conditions that were identified in the pathogenesis of LEA in T2DM patients and the amputation level, are shown in In our investigation, we found different trends over the last 10 years in the incidence rates of LEA among T2DM patients. There has been an increase in the number of T2DM patients undergoing minor LEA; however, a significant decrease was observed in MBK and MAK LEAs. For all LEAs, the trend was stable over the study period. These trends agree with the findings of previous studies conducted in Spain ,12, and Several studies have been published analyzing the incidence of amputations in different countries ,34,35,36Besides the characteristics of the health systems, studies conducted in several countries have found that different systems of diabetic care affect the incidence of LEA ,39,40,41In Spain, the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease, was associated with a reduction in the incidence of major amputations in patients with diabetes . These reports agree that the successful introduction of service improvements reduces the incidence rates of diabetic foot ulcers and prevents avoidable amputations, thus recommending the integration of all diabetes foot care services.A remarkable result of our study is the relative increase in the number of minor LEAs and the decrease in major LEAs. Different studies have reported that the suspected drivers behind this shift from major to minor amputations are improvements in preventive health care structures associated with the performance of more conservative limb-salvaging procedures and increasingly more aggressive treatment of PVD in these patients ,43. FurtIn our study, the presence of comorbidities in T2DM patients who underwent LEA, including PVD and renal disease, was more common than in those who were unexposed. A recent meta-analysis of risk factors for amputation in patients with diabetic foot infections reported that PVD was associated with a 2.35-fold increase in the risk of amputation . Other comorbidities, such as hypertension, cerebrovascular disease, coronary artery disease, and chronic renal failure, showed no statistically significant predictive ability for amputations in patients with diabetic foot infections . HoweverWe found that undergoing LEA increases the risk of death by 75%. However, the early mortality within 30 days) was higher in non-LEA patients, which indicates that patients who underwent LEA might have had better surgical and perioperative health care and a better control over their diabetes via strict glycemic control  days was, althougThe amputation level is also an important factor in predicting the mortality of amputees. Most of the previous studies agreed that major amputees have higher mortality than do minor amputees ,49. In oDifferent studies found that the rate of amputation was higher in men than in women ; howeverOur data indicate that older age and comorbidities were independently associated with higher mortality after LEA in patients with diabetes. These findings are similar to those reported in other studies that observed differences in postamputation mortality outcomes between younger and older patients , indicatComorbid conditions, especially macrovascular disease, are more common among patients undergoing amputation . The leaPrevious studies identified diabetic nephropathy as a risk factor for significantly lower long-term survival after LEA. Hoffmann et al.  found thIn our investigation obesity was not associated with mortality after LEA, even if the hazard ratios were bellow one (suggesting a protective effect) in all levels of amputation. Some authors have suggested that the “obesity paradox” may exist for LEAs in the diabetic population .Future research should include understanding the factors driving changes in trends in the incidence of LEA. These factors include, at the individual-level, clinical conditions and health policies, and organizational characteristics. Identifying those variables would help to prioritize preventive approaches ,36. It iIn Spain, investigation is needed to ascertain the position of diabetes in the Spanish national health care system. This will require improved data collection to monitor incidence, prevalence, expenditure, and outcomes. Studies are also needed to understand the disparities in access to care; in particular, the access to revascularization procedures, diabetic foot units, podiatrist care, diabetes care planning, and educational provisions . FinallyAs with all epidemiological studies, our study has several potential limitations. We used the HDD, which is an administrative database rather than a clinical database . TherefoOur data show a decrease in the incidences of major below-knee and major above-knee amputations in patients with T2DM; however, an increase was found in those undergoing minor LEAs. Undergoing LEA increases the risk of death by 75%. Older age, male sex, and comorbidities are responsible for mortality in in patients with T2DM who have undergone LEA. Long-term survival was worse in patients who underwent major above-knee LEAs than in those who underwent other types of LEA. These results may suggest an improvement in the quality of diabetic foot care in recent years, but additional improvements in preventive care and early treatment for patients with diabetes, and the aggressive treatment of comorbidities, are needed to reduce LEA further.


A 28-year-old woman with a past medical history significant for cervical cancer was diagnosed with a 2.5 cm adrenal tumor but was lost to follow-up. Two years later, she presented to the emergency room with worsening right upper abdominal and flank pain. The computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen and pelvis revealed that the right adrenal mass had nearly doubled in size (4.3 cm), was heterogeneous with calcifications, central necrosis and actively uptaking the intravenous (IV) contrast with a delayed washout. The biochemical workup was negative for hyperaldosteronism, hypercortisolism, and pheochromocytoma. She reported an unintentional body weight loss of 40 pounds. Adrenocortical carcinoma or a metastatic malignancy was high on the differential diagnoses list. She underwent a successful laparoscopic adrenalectomy, and final pathology revealed a benign extra-adrenal combined ganglioneurofibroma and schwannoma. These rare benign malignancies alone or in combination may closely mimic the clinical and imaging characteristics of adrenal malignancy and pose a diagnostic and therapeutic dilemma to surgeons as well as cause a significant distress to patients and their families. Thus, it is important to thoroughly document and report these cases in order to increase awareness and improve our understanding of the biology, natural history and management of these extremely rare tumors. The overall prevalence of incidentally found adrenal lesions is roughly 4.4%; however, this prevalence varies with the patient’s age, and incidentalomas occur in less than 1% of patients younger than 30 years old . The twoHere we present a case of benign combined ganglioneurofibroma and schwannoma, with clinical signs, pre-operative imaging, and intra-operative observations highly suggestive of a malignant adrenal mass.A 28-year-old woman with a history of cervical cancer was diagnosed with a 2.5-cm right adrenal mass; however, the patient was lost to follow up. Two years later, she presented to the emergency department complaining of knee pain, and worsening back and bilateral flank pain. She reported experiencing pain over the past two years, but it had worsened and become constant over the past two days. She also reported episodes of headaches, palpitations, hand tremors, and sweating, which had been increasing in frequency and severity over the past 2-3 years. She admitted to regular tobacco and marijuana use and a significant unintentional weight loss of about 40 pounds. She denied alcohol use. She had a past medical history significant for anemia and stage I cervical cancer, and she denied any history of hypertension. Her family history was noncontributory.ᵒF, pulse rate of 117 beat per minute, and hypertensive, with a blood pressure of 140/99. The abdominal exam revealed right-sided tenderness on palpation, and the musculoskeletal exam revealed bilateral lumbar tenderness and right lower leg pain with movement. There were normal bowel sounds on auscultation; no organomegaly, abdominal wall defects or abdominal distension. The remainder of the physical exam was unremarkable. The laboratory evaluation was significant for decreased red blood cell count of 3.64 x 106/µL, mild anemia of 11.2 g/dL, mild hypocalcemia of 8.4 mg/dL, hypoproteinemia of 6.1 g/dL, increased blood glucose of 117 mg/dL, and urine nitrite and bacteria.At initial evaluation, her body temperature was 98.5Computed tomography (CT) of the abdomen and pelvis revealed a 3.7 x 2.9 x 4.3 cm thick-walled and centrally necrotic mass on the right adrenal gland, which appeared to be exerting mass effect on the inferior vena cava (IVC) Figure , 1B. MagThe risks and benefits of laparoscopic versus open adrenalectomy were discussed in detail, and written informed consent was obtained from the patient. A successful laparoscopic right adrenalectomy was performed following the surgical oncological principles. Intraoperatively, ACC or metastasis remained the main differential diagnoses.Surgical pathology, however, revealed an extra-adrenal combined ganglioneurofibroma and schwannoma with no malignant features . The specimen was an intact adrenal gland, with a well circumscribed, encapsulated gray/tan mass measuring 27.6 g intimately attached to the adrenal cortex. The remaining adrenal gland, including the medulla, is intact and uninvolved. The tumor demonstrated a central nodule composed of spindle cells with wavy nuclei set in a collagenous background Figure . The cenThe patient tolerated and recovered from surgery well and was discharged to home on day 2 after surgery.It has been shown that isolated ganglioneuromas or schwannomas are rare and may be seen in approximately 1.4% of adrenal incidentalomas, respectively . A combiThe underlying pathophysiology of this specific form of adrenal mass has not been fully elucidated, especially in patients without neurofibromatosis type 2 (NF2). In patients with NF2, there is a mutation in the NF2 gene, located on chromosome 22, which normally produces a tumor-suppressor protein merlin . PatientAlthough benign adrenal masses account for the vast majority of adrenal incidentalomas, the prevalence is extremely low in patients less than 30 years old . AdditioIn this case, the diagnosis of a benign mass was the best possible outcome for the patient, that does not require follow-up or other treatments after surgery. However, it is important to note that cases can occur exactly opposite to this one - where all clinical signs and studies point to a benign mass, but malignancy is discovered on histological examination. Thus, this case highlights the importance of maintaining an open and dynamic differential diagnosis, which can ultimately lead to the best care and outcome for the patient.This case will contribute to increasing awareness and better understanding of the complexities that surround neuroendocrine tumors. Distinguishing between the various types of adrenal masses remains difficult and rather ambiguous pre-operatively, thus post-operative pathology is critical to determining the patient’s subsequent treatment plan, should they require one. Treatment decisions should be made through a collaborative team effort with surgeons, pathologists, radiologists, and oncologists to ensure the most favorable outcome for the patient.


Inoculations containing one of the following: 0.2 mL of 0.9% sterile saline (S), approximately 102 cells of Citrobacter freundii (CF), Citrobacter species (C2) or lactic acid bacteria mixture (L) were administered via in ovo into the amnion. Results showed that Enterobacteriaceae abundance was negatively correlated with aging, although its high population at day of hatch affected the microbiota composition, delaying mature microbiota establishment. L treatment increased colonization of butyrate-producing bacteria by 3 and 10 days, and segmented filamentous bacteria in the lower ileum by 10 days. On the other hand, L-probiotic decreased the population of Enterococcaceae. In addition, L and C2 microbial communities were less diverse at 10 than 3 days of age in the upper ileum. Importantly, these findings provide a valuable resource for a potential study model for interactions between microbial colonization and associated immune responses. In conclusion, our analysis demonstrates that intestinal pioneer colonizers play a critical role in driving the course of microbial community composition and diversity over time, in which early life exposure to L-based probiotic supported selection alongside greater colonization of symbiotic populations in the ileum of young broilers.Given that recent advances in metagenomics have highlighted the importance of intestinal microbes for poultry health, there has been a corresponding search for early manipulation strategies of intestinal microbiota in order to advance immune system development and optimize functional properties of growth. In this study, we used the  Enterobacteriaceae affect early microbiota are not yet clear, species from this family are typically GIT pioneer colonizers  microbiota, through its interactive metabolic dynamics and immune-inflammatory pathways, may influence both health status and disease susceptibility of the host . Since tlonizers . The higlonizers .Dynamics of the microbial establishment may also be affected by dietary supplementation of lactic acid bacteria (LAB). Several studies have shown that the addition of probiotics in the feed represents an effective method for improving growth performance, enhancing humoral immunity and accelerating the maturation of intestinal microbiota . Neverthin ovo techniques made it possible to manipulate the intestinal bacteria colonization before chicks have even been hatched or exposed to farm environments , suggesting that neonatal exposure to beneficial bacteria may be critical for influencing GIT populations throughout the life of poultry. Understanding how the introduction of pioneer species in the gut, regardless of long-term colonization, can lead to the modification of the microbiota toward beneficial bacterial growth has the potential to provide essential information about the development of the immune system, control of opportunistic bacteria and optimization of the functional properties of growth , which served as the control group, or approximately 102 cells of Citrobacter freundii (CF), Citrobacter spp. (C2) or LAB mixture (L) administered into the amnion. After inoculation, the eggs were allocated by treatments into three separate benchtop hatchers  per treatment, for a total of 12 hatchers, which had been disinfected with 10% bleach prior to use. Strains CF and C2 were selected from our previous study as non-pathogenic bacteria from the gut of healthy birds  before a small hole was aseptically punched into the shell with an inoculation needle hy birds , and thead libitum access to a standard corn-soy diet and water  the region proximal of Meckel’s diverticulum, denominated as upper ileum (UI) and (2) the region proximal to the ileocecal junction and distal to the Meckel’s diverticulum, designated as lower ileum (LI). Ileal contents were placed into 1.5 mL tubes, flash-frozen in liquid nitrogen at the time of collection, and stored at −80°C until further use.Immediately post-hatch, chicks were co-mingled on a treatment basis, and 128 chicks were placed into treatment-separated brooder battery cages with nd water . At 3 dan = 10). Ileal samples, collected at 10 days of age, were weighed in an equal volume of 0.25 g of digesta and placed directly into a single 2 mL tube (n = 12). Extraction of DNA was performed following the protocol of the Qiagen stool kit  as recommended by the manufacturer with modifications described previously by DNA was extracted from UI and LI samples following methods described by The generation of the PCR amplicon was achieved by amplification of the V4–V5 regions of the 16S rRNA gene using 515F and 806R primers . DNA samples were library prepared for NGS using the Illumina MiSeq platform  by The Ohio State University Molecular and Cellular Imaging Center (OSU MCIC).A sequence quality screen was performed to ensure high-quality sequences submitted to the analysis pipeline. Briefly stated, sequence quality was determined using the FASTQC and MultiQC toolkits. Sequence reads exhibiting a quality score of lower than 20 were removed. Further, low complexity reads, those shorter than 200 bp in length, and mismatched primers were removed. Additionally, reads exhibiting low sequence qualities on either end were trimmed. The pre-processed FASTQ files were then imported to the QIIME2 platform for analysis. The main analytical steps were as follows: firstly, reads were de-multiplexed and classified into their respective samples. Next, additional sequence quality control measures and feature table construction were performed by the DADA2 algorithm implementation in QIIME2. Quality control measures eliminated reads with barcode errors, reads with more than two nucleotides mismatches, and chimeras. Sampling depth was set to 800 sequences per sample. The high-quality sequences emanating from the afore-mentioned quality control measures were subsequently clustered together using the q2-feature-classifier plugin with the GreenGenes 13.8 reference database. The resulting feature table was used to calculate diversity metrics and create abundance infographics.in ovo treatment.Alpha-diversity was measured by Shannon’s diversity index, evenness, and richness. Richness was expressed as a number of observed OTUs. Beta-diversity was determined by applying unweighted and weighted UniFrac distance metric. Principal coordinate analysis (PCoA) was plotted to visualize similarities or dissimilarities along with the two sampling sites, age and between treatments. Relative abundance from the family to the genus-species levels was calculated for each P-values were adjusted with the Benjamini–Hochberg procedure, up to 1,000 permutations, and had a false discovery rate less than 0.05. The mean relative abundances of microbial communities, richness, and evenness were analyzed by ANOVA and compared with a Student’s t-test . Additionally, the Pearson correlation coefficient (r) was applied to identify correlations between bacterial colonization patterns and age (R software version 3.4.1).Kruskal–Wallis test was assessed to compare the differences in the microbial Shannon’s diversity index (H) across treatments and over time. To examine ileal microbiome beta-diversity variation among treatments at different ages and ileum sections, the permutational multivariate analysis of variance was conducted using distance matrices . All A total of 32,122,605 16S rRNA sequence reads was obtained. The number of mapped sequence reads of overall samples ranged from 842 to 384,833 with a mean of 111,536.82 .L. salivarius was significantly higher by 3 days in L compared to other treatments in UI. Similarly, it occurred in the LI, L. salivarius showed a meaningful reduction (P < 0.05) relative to S, CF, and C2 treatments by 10 days of age . Whereas, it remained lowly detectable in C2. By 10 days of age, Citrobacter was not found in CF or C2 treatments.Interestingly, inoculated strains did not remain in the GIT long-term. s of age . PediocoP = 0.101; To investigate whether different initial colonizers in the intestine could affect the ileal microbiome diversity, alpha-diversity was quantified by richness, evenness, and Shannon index, which relates both OTU richness and evenness by the total number of observed species. Biodiversity of microbial communities was defined at the two ileal sampling sites, where the overall alpha-diversity of samples within UI was similar to LI . At the same age, the LI bacterial communities in L, S, and CF treatments showed a dissimilarity between samples according to unweighted UniFrac distance analyses , although it was not evident in PCoA plots  in LI showed that there was a significant separation of the gut microbiome of broilers exposed to LAB-probiotic oA plots . Based oP < 0.05). The beta-diversity metrics also detected a larger variation in the community structure along with the two sampling sites in the ileum. Weighted pairwise PERMANOVA revealed that bacterial communities from L and CF were phylogenetically unrelated to each other among the two ileum sections at 3 and 10 days of age . Conversely, by 10 days of age, most of the sequences were taxonomically identified from the kingdom down to the genus. When we examined the OTUs that were generated at this age, less than 0.5% of relative bacterial abundance was not classified beyond the domain.In order to assess whether LAB-probiotic or Lactobacillaceae without significant differences among groups , CF (20.71%), and C2 (6.18%) relative to S (48.92%) in UI  and C2 (13.10%) compared to S (43.19%) and L (22.98%) by 3 days of age. While by 10 days of age, only in L treatment had Enterococcaceae abundance markedly decreased to 4.87%  in UI . Likewis; in ovo .Enterobacteriaceae abundance varied greatly, resulting in substantial population differences among the pioneer colonizers groups at 3 days of age  by 3 days in LI samples  in UI  than any other in ovo treatment  relative to S, CF, and C2  in samples from L treatment . In contrast, in UI, all relationships between Clostridiaceae relative abundance and age were negative . This issue highlights the complexity of microbe-microbe interactions in the intestinal ecosystem, and it might be worthwhile to explore further with metabolic and host function approaches to elucidate this assumption.In face of declining biodiversity, the host-microbiota may lose redundant species , which mEnterobacteriaceae in the different ileal sites. The predominance and endurance of most species of Enterobacteriaceae within the intestine is a standard marker of dysbiosis  abundance in ileal microbiota of LAB-probiotic treated broilers. The primary site for SFB in chickens, a avagella , is in tavagella . SFB hasavagella . Besidesavagella  and chicavagella .Clostridiaceae colonization patterns and time-course up to 10 days of age in L treatment .KW, WB, AD, and KC carried out the project. DR, EW, and KW performed the analyses. DR interpreted the results and wrote the manuscript in consultation with LB. All authors contributed to experimental design, discussed the results, and commented on the manuscript.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.


Hair samples were extracted and analyzed by liquid chromatography high-resolution mass spectrometry detection. The percentage of photodegradation was calculated for each analyte . In parallel, photodegradation processes of standard molecules dissolved in aqueous and organic solutions were studied. In 20 hair samples positive for the targeted analytes, exposure to artificial sunlight induced an appreciable decrease in drug concentrations. The concentration ranges in the non-irradiated hair samples were 0.01–24 ng/mg, and 65% of samples exhibited a decrease in post-irradiation samples, with reduction from 3% to 100%. When more drugs were present in the same hair sample  the degradation yields were compound dependent. A degradation product induced by irradiation of ketamine in aqueous and methanol solutions was identified; it was also found to be present in a true positive hair sample after irradiation. Ketamine, amphetamines, and their metabolites incorporated in the hair of drug users undergo degradation when irradiated by artificial sunlight. Only for ketamine was a photoproduct identified in irradiated standard solutions and in true positive irradiated hair. When decisional cut-offs are applied to hair analysis, photodegradation must be taken into account since sunlight may produce false negative results. Moreover, new markers could be investigated as evidence of illicit drug use.Drugs incorporated into hair are exposed to the environment, and cosmetic and chemical treatments, with possible decreases in their content. Knowledge concerning the effect of sunlight on drug content in hair can be helpful to forensic toxicologists, in particular, when investigating drug concentrations above or below pre-determined cut-offs. Twenty authentic positive hair samples were selected which had previously tested positive for amphetamines and/or ketamine. Washed hair were divided into two identical strands, with the former exposed at 765 W/m The main advantage of hair as a testing matrix is the ability to provide information relating to historical drug exposure. Hair analysis has many applications within forensic , child protection) and clinical toxicology  ,2,3,4.The stability of drugs in hair, however, is affected by exposure to sunlight and weathering, cosmetic chemical treatments , and physical damage ,6,7. In Previous studies on this matter have been published by Skopp et al.  in whichIn order to better understand the role and underlying mechanisms of solar light exposure on decreasing concentrations of drugs in hair, and following our previous  photodegAmphetamine-based drugs are illegal synthetic stimulants that share a common structural backbone. The four amphetamines considered in the present work are the most used in Europe: amphetamine (AMF), methamphetamine (MA), 3,4-methylenedioxymethamphetamine (MDMA), and 3,4-methylenedioxyamphetamine (MDA).Amphetamine can be metabolized along two pathways: either by hydroxylation of the aromatic ring to 4-hydroxyamphetamine or by deamination of the side chain to benzyl methyl ketone, which can then be degraded to benzoic acid. Methamphetamine is metabolized by cytochrome P450 (CYP), mainly by the CYP2D and CYP3A subfamilies, leading to the production of 4-hydroxyamphetamine and AMF. The half-life of MA is about 10 h, and 35–45% of a dose is excreted unchanged in the urine over a period of several days. Other metabolites, such as 4-hydroxymethamphetamine, norephedrine, and 4-hydroxynorephedrine, can also be found in urine in substantial quantities ,12,13.O-demethylenation followed by catechol-O-methyltransferase (COMT) methylation and/or glucuronide/sulfate conjugation; and (2) N-dealkylation, deamination, and oxidation. MDMA N-demethylation gives rise to 3,4-methylenedioxyamphetamine (MDA). The elimination half-life of MDMA is about 8–9 h, lower than those reported for MA (10–12 h) or AMF (12–15 h) + ion at 238.0993 m/z (C13H17ClNO) was accompanied by a new ionic species at 220.0888 m/z (C13H15ClN), corresponding to the loss of H2O. In methanol, two species were observed at 220.0888 m/z and at 252.0786 m/z (C13H15ClNO2), with the latter corresponding to the loss of H2 and to the photo-addition of one oxygen atom. The proposed structures of KET photoproducts are shown in All the irradiated solutions in the solar simulator, including the control solutions kept in the dark, were diluted to 10+ ions at 224.0837 m/z (C12H15ClNO) were accompanied by a new species at 206.0731 m/z (C12H13ClN), corresponding to the loss of H2O. The proposed structure of NKET photoproducts formed in methanol is shown in In HRMS spectrum of the methanol solution of NKET irradiated in the solar simulator, [M+H]Vice versa, for all the other analytes , both in water and methanol solutions, no photoproducts were evidenced by direct HRMS analysis. To avoid ionization suppression phenomena that could occur in a mixture and shield the presence of less abundant species, irradiated solutions were also analyzed by HPLC-HRMS. The ratios of peak areas observed for samples upon irradiation vs those analogous samples kept in the dark were calculated as “percent degradation”. In As may be observed, AMF and MA in water show the highest photostability: the photodegradation was 1% and 4%, respectively, while in methanol it increased up to 15%. In addition, MDMA and MDA in methanol and water both presented similar photodegradation with a linear relationship with irradiation time: MDMA from 23% to 42% and MDA from 13% to 36%. For KET and NKET, the photodegradation yield was significantly higher in methanol  than in water  after 3 h.The main goal of the study was to observe the photo-induced degradation of drugs in hair. In In When comparing results from three poly-drug abusers, photodegradation of all the analytes was generally obtained, with the highest comparable photodegradation yields observed in sample Brown 3 see .From our results, a clearly different behavior of KET and NKET was evidenced when compared to all the other drugs and metabolites under study. Indeed, these drugs seem photo-unstable, both in solution and in hair matrix. In particular, for the experiments in solution, KET and NKET photo-induced products were identified; in hair samples their degradation was higher (average 42% and 29%) than all the other compounds (average 8–30%).No color effect seems to be present, although no fair hair samples were present in this study, and the number of samples was limited. It is well known that the color of hair depends on the relative amount of pheomelanin (red) and eumelanin (black), the first defense against UV in human hair and skin ,24,25,26Regarding MA and AMF, on the basis of the in vitro experiments, they were expected to photodegrade less readily than KET and NKET. Unexpectedly, the experiments in hair revealed an average degradation of 30% and 31% for MA and AMF, respectively, with a range of 13–47% and 25–35%.m/z, corresponding to the photoproduct of KET shown in The presence of photoproducts was also investigated in irradiated hair samples. In one sample, the species at 220.08750 The importance of this finding must be highlighted, since no previous study has identified stable photoproducts in hair for KET, nor for any other substance previously investigated  by a greater lability of the keratin matrix with consequent greater yield during the extraction of the analytes in the liquid acid phase with access to deeper layers of the hair structure.Amphetamine, MA MDA, MDMA, KET, and NKET incorporated in hair undergo degradation when irradiated by artificial sunlight, suggesting that they can suffer photodegradation under natural sunlight. With this work, for the first time, the presence of a photoproduct of KET was evidenced in one true positive sample.Since the detection of drugs in hair is often used as evidence of illegal acts with consequences on the freedom of persons, the UV-Vis effects on the integrity of the drugs and their metabolites should be considered when single administration needs to be evidenced. When decisional cut-offs are applied to hair analysis , it must be taken into account that hair exposed to sunlight may produce false negative results and lead to misjudgment. When possible, the detection of photoproducts of a drug under investigation can be a key factor in a case management.