Deep venous thrombosis (DVT) is associated with significant morbidity and mortality. Studies on changes in the level of metabolites could have the potential to reveal biomarkers that can assist in the early detection, diagnosis, monitoring of DVT progression, response to treatment, or recurrence of DVT. In this scenario, the metabolomic analysis can provide a better understanding of the biochemical dysregulations of thrombosis. Using an untargeted metabolomic approach through magnetic resonance spectroscopy and multi- and univariate statistical analysis, we compared 40 patients with previous venous thrombosis and 40 healthy individuals, and we showed important serum differences between patients and controls, especially in the spectral regions that correspond to glucose, lipids, unsaturated lipids, and glycoprotein A. Considering the groups depending on risk factors and the local of the previous episode , we also noticed differences in metabolites linked to lipids and lactate. Comparative analyses pointed to altered ratios of glucose/lactate and branched-chain amino acids (BCAAs)/alanine, which might be associated with the fingerprints of thrombosis. Although samples for metabolomic analysis were collected months after the acute episode, these results highlighted that, alterations can still remain and may contribute to a better understanding of the complications of the disease. Deep venous thrombosis (DVT) is a common disease associated with significant morbidity and mortality, and represents the third most common cause of death, after cardiovascular disease and stroke ,2. AlthoDVT is a multifactorial disease and there are several risk factors that contribute to its development, including acquired and genetic factors ,7. ApproIn this sense, the search for biomarkers that could identify patients with a higher risk of recurrence is a challenge. Higher levels of D-dimer are considered a marker of an increased risk of recurrence, and this measurement is included in Vienna, DASH, and Herdoo2 scores . On the Magnetic resonance (NMR) spectroscopy, in an untargeted approach, provides information on metabolites in a given sample ; howeverThis work aimed to evaluate patients retrospectively, using a metabolomic point of view to find metabolic alterations, even months after an acute DVT episode. n = 5) or rivaroxaban (n = 1) at the moment of blood collection. For the time between blood collection and the thrombotic episode, see Among the 40 patients with a mean age of 38 years (18–78) at the time of thrombosis and enrolled in this study, 20 of them presented DVT in the lower limbs , 7 males, and 13 females), and 20 patients in the cerebral region , 1 male, and 19 females). Following the three years of observation, one patient presented PE and 12 were diagnosed with PTS in the DVT group. None of the patients in the CVT group presented recurrence. For detailed characteristics of the groups, see 2), 35% were overweight (mean 27.60 kg/m2), 15% presented obesity class I (mean 32.50 kg/m2), 10% obesity class II (mean 36.90 kg/m2), 5% morbid obesity (mean 51.15 kg/m2), and in 15%, BMI information was not available (2), 30% overweight (mean 27.79 kg/m2), 15% classified as obesity class I (mean 32.72 kg/m2), ≈3% as obesity class II (mean 35.75 kg/m2), and 5% as non-reported BMI (p = 0.038).The classification of patients according to BMI  showed tvailable . In the rted BMI . The ana1H-NMR CPMG data , alanine (δ 1.47), valine (δ 1.04), glutamine (δ 2.44), and glucose  were responsible for class separation in the thrombotic group, and all presented significant differences by the U test  , showed a sample clustering related to patients or controls B with R2 < 0.05) C. Addition model .The receiver operating characteristic (ROC) curves of the metabolites discussed pointed to an acceptable capacity to discriminate patients , with thIt is already known that thrombosis can be triggered by a known risk factor, called provoked thrombosis. In our cohort of patients, hormonal contraceptives (OAC) and obesity were the principally acquired known risk factors, especially OAC for CVT (75%) and obesity for DVT (35%) . The BMIAs mentioned previously, the multivariate analysis showed the dispersion of the thrombosis group B, and thThis analysis showed a sample clustering for DVT and CVT vs. controls A, and inResearch efforts are currently seeking alternative blood biomarkers that are capable of improving patient diagnosis, treatment, and stratification, identifying those patients that may benefit from different treatment schedules, and particularly in thrombosis, extended anticoagulation . In thisCommon variables, called confounders, such as age, sex, lifestyle, BMI, estrogen use, and others, might explain the alterations of lipids in thrombotic patients . HoweverAs the blood samples were collected months after the thrombotic episode, we can only speculate that if lipid alteration was present before the thrombosis, it could interfere with hemostasis and inflammation . This caLactate was also found to be important for the provoked thrombosis. This alteration was previously reported as caused by a number of conditions, including shock, cardiac arrest, trauma, ischemia, diabetic ketoacidosis, genetic disorders, and other conditions, which is an indicator of a non-specific factor unless thoughtfully coupled with the overall clinical picture . MaekawaAs mentioned above, in our cohort of patients, hormonal contraceptives and obesity were the principal acquired risk factors. Normally, obesity interacts with other environmental or genetic factors, increasing the risk of thrombosis . ParticuA comparison between thrombotic patients and controls showed differences in blood serum lipids  C, as wel1H-NMR spectral region that correspond to glycoprotein A (GlycA). Recently, glycoprotein profiles by NMR have emerged as a potential biomarker that reflects systemic inflammation in type 2 diabetes, obesity, cardiovascular events, and other pathological processes [N-acetyl sugar groups present on glycoproteins in circulating blood, which are involved in the acute phase response of different inflammatory disease states [Other metabolites’ alterations were identified and could be linked to energy or amino acids’ metabolism pathways. Alterations in glucose are associated with the VTE as a risk factor, given that hyperglycemia can activate coagulation . Howeverrocesses ,38,39,40e states . NeverthThe branched-chain amino acids (BCAAs) leucine, isoleucine, and valine are important resources for energy production and regulators of metabolic and nutrient signals. BCAA catabolism is a regulator of platelet activation, and BCAA dysfunction could be associated with arterial thrombosis risk . AlthougPrevious studies reported that aspirin, an anti-aggregating drug, can reduce the risk of recurrence of DVT by 30% . An elucStrengths of this study include a well characterized investigated cohort selected based on rigorous exclusion criteria—no DVT recurrence, APS, cancer, infection, renal, hepatic or inflammatory disease, as well as, the use of corticosteroids, and tobacco. The use of a homogenous cohort matched with a similar control group, and inclusion of a metabolomics analysis to highlight the alterations that remain after thrombotic episodes.The limitations of this study are the relatively small number of patients having in mind such a common disease, the lack of inflammatory or thrombotic markers at the time the blood samples were collected for the metabolomic analysis, as well as the design of the retrospective study. Although the data obtained herein provided important features in patients with previous venous thromboembolic disease that distinguish them from controls, future studies are still needed to confirm the findings in patients with acute DVT.Since the purpose of the current study was to identify metabolic alterations even months after acute DVT episode, the next step is a validation analysis including diverse populations and different disease subtypes.We studied 40 serum samples from patients with a previous history of thrombosis. The patients were assisted at the Outpatient Clinic of Hemocentro of Unicamp  between 2015 and 2018, and were selected according to the inclusion criteria: aged 18 to 80 years, a unique previously confirmed DVT of the lower limbs or CVT up to three years after acute thrombotic episode. The exclusion criteria were DVT recurrence, APS, cancer, infection, renal, hepatic, or inflammatory disease, as well as the use of corticosteroids and tobacco. Forty healthy subjects from the same geographic area, and workers from Hemocentro were used as controls. The exclusion criteria for the healthy individuals were the same as for the patients, including previous DVT. The diagnosis of lower-limb DVT was established by Doppler ultrasound, and the diagnosis of CVT was confirmed by cerebral magnetic resonance or cerebral angiotomography. The project was approved by the local medical research review board and ethics committee (file number 18501718.9.0000.5404).g for 15 min at room temperature. The serum was stored in aliquots at −80 °C until analysis.Blood was collected by venipuncture after minimal stasis from the antecubital vein in standard citrated tubes , and centrifuged at 1372 1H-NMR spectra, 250 μL of each serum sample was mixed with 250 μL of deuterium oxide solvent , and transferred into 5-mm NMR tubes. The 1H-NMR spectra were acquired using a Bruker AVANCE III 600 spectrometer  at 25 °C operating at 600.13 MHz and equipped with a TBI (Triple Resonance Broadband Inverse) probe. Regular one-dimensional 1H-NMR spectra with a T2 filter was recorded using the pulse sequence CPMG (Carr–Purcell–Meiboom–Gill) with ns = 128.For 1H-NMR spectra were manually processed to correct their phases and baselines. Chemical shifts were referenced to the TSP signal (δ 0.00), using MestReNova software (9.0.1-13254). The spectra were divided into regions with an equal width of 0.005 ppm. The HDO (δ 4.70–5.55) was excluded from the analysis. Samples were normalized by a reference sample for Probability Quotient Normalization (PQN). The metabolites were assigned based on chemical shifts, coupling constants, 2D NMR spectral characteristics, and in concordance with the Human Metabolome Database (HMDB) and BioMagResBank (BMRB) databases [All serum atabases ,45. Meta1H-NMR binned data were used as a data matrix and the multivariate analysis was performed using MATLAB software  and the MetaboAnalyst platform [1H-NMR CPMG, and for visualization data, we used pareto scaling (mean-centered and divided by the square root of the standard deviation of each variable). A principal component analysis (PCA) was performed for all samples to explore inherent groupings in the data and identify outliers. Data were modelled with the supervised method of orthogonal partial least squares discriminant analysis (OPLS-DA) to find the metabolite differences between the groups. Variable importance in projection (VIP) scores were estimated according to the PLS-DA model [The platform . The matDA model .1H-NMR bin data as dependent variables and, as independent variables, the subgroups of patients (by type of thrombosis) and the adjustment variables . The p-values < 0.05 were considered statistically significant. All analyses were performed using the R version 3.6.1 (5 July 2019), copyright (C) 2019, the R Foundation for Statistical Computing.Multivariate analysis was also performed using linear regression models, with the values of the There is a great need for low-cost, rapid, simple, and reliable methods that can be used as important point-of-care methods to evaluate the gravity and monitor common diseases’ progress such as venous thrombosis. To this end, the identification of biomarkers has appeal, and given the complex nature of thrombosis, it has been difficult to earmark potential ones. Here, we provided new insights into the importance of some serum metabolites, such as glucose, lactate, alanine, BCAAs, and lipids with important differences in VLDL fatty acid levels in thrombotic patients. Comparative analyses also pointed to altered ratios of glucose/lactate and BCAAs/alanine, which might be associated with the fingerprints of thrombosis, especially high VLDL for the DVT group, which might lead to a procoagulant state.1H-NMR as an important add-on to the clinical research.Although the data found are in agreement with similar studies, this is a retrospective study. This is, to our knowledge, one of the few articles carried out in patients with venous thrombosis. The results obtained can contribute to novel perspectives towards a better comprehension of the disease and might open up the possibility of including metabolomics by


In recent years, digital devices have been progressively introduced in rehabilitation programs and have affected skills training methods used with children and adolescents with intellectual disabilities (ID). The objective of this review is to assess the effects of the use of digital devices on the cognitive functions and behavioral skills in this population, and to acknowledge their potential as a therapeutic tool. Electronic databases were analyzed until February 2020 using search formulas with free terms related to ID and the use of digital systems with children or adolescents. The risk of bias in randomized controlled trials was assessed by means of the modified Cochrane Collaboration tool and the quality level of the non-randomized studies was assessed using the Newcastle-Ottawa Scale. Forty-four studies were analyzed, most of which were categorized as low quality. Of the executive function studies analyzed, 60% reported significant improvements, most commonly related to working memory. Within the cognitive skills, 47% of the studies analyzed reported significant improvements, 30% of them in language. Significant improvements in the social (50%) and behavioral domains (30%) were also reported. These results suggest that digital interventions are effective in improving working memory and academic skills, and positively affect both the social and behavioral domains. Little information has been published regarding the duration of the effects, which could be limited in time. Further research is necessary to assess long-term effectiveness, the influence of comorbidities, and the effects on subjects with severe ID. The inclusion of smartphones and special education centers is also necessary. The Diagnostic and Statistical Manual of the American Psychiatric Association, Fifth Edition DSM-5) , defines , defineIn the field of disability management, functional and psychosocial interventions are used most frequently, but cognitive interventions have also yielded positive results –28. CognDue to the number and diversity of skills training programs available through digital devices for people with ID, it is important to describe which digital interventions and media have been developed, as well as which are the most effective. Programs and devices have been used to support language learning and communication , 49, daiPrior to the literature search, we registered with the PROSPERO database (register number CRD42019121219) and created a detailed protocol in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P) .* retardation” OR “cognitive disability”) AND  AND (“child” OR “adolescent”).A systematic literature search of SCOPUS, the Web of Science and PsycINFO was carried out that ended in February 2020. The following search formula was created with the following free terms: . Participants were children and adolescents with ID (mild to profound) or with syndromes associated with ID. All studies included therapeutic interventions using digital devices such as virtual reality, computers (including laptops), touch screens, input devices and handheld devices .Outcome measures obtained using non-standardized or standardized tests were included if the dependent variables were related to either the cognitive, social, emotional or behavioral domains. The study designs included in our analysis were experimental studies, randomized and quasi-experimental (non-randomized or without control group). We included articles published in peer-reviewed journals in English or Spanish.We excluded studies whose participants were parents or professionals, or had mental illness, traumatic brain injury or sensorial affection. In addition, we excluded studies that did not meet the previously defined PICOS characteristics or which contained poor empirical data. Case studies, reviews, abstracts and communications from scientific meetings and qualitative studies were not considered.The inclusion of the studies was independently reviewed by two authors. A form with inclusion criteria was designed and reviewed by all authors. In the first round, titles and abstracts of articles were selected in accordance with the form. In the second round, we assessed the full-text articles for their selection based on the inclusion criteria. In some cases, we requested the full text from the authors. Duplicated articles were removed. When necessary, any disagreement was discussed with a third author. We created a PRISMA flow chart to track the studies we included and discarded ; Figure .Three reviewers independently assessed the risk of bias for each study using the modified Cochrane Collaboration tool  for randn = 535) and manual searches (n = 4), and then duplicates were removed (n = 33). The titles and abstracts of the remaining 506 publications were screened to select articles that met the inclusion criteria, and 306 articles were excluded. The remaining 200 full texts were carefully examined. Then the articles that did not report an intervention or that were beyond the scope of this systematic review were excluded (n = 156). In the end, a total of 44 articles were included in this review. The general characteristics are summarized in 4.The flow chart included as n = 10 to n = 95). Participant age ranged from 4 to 21. Most of the studies used randomized designs, except two [20%]: a quasi-experimental non-randomized study (n = 9) [75%]  [75%] , 59–64. 9) [75%] , 60, 61,9) [75%] , identif9) [75%] , 60, 64,9) [75%] , 47, 59 9) [75%] , 61, 63.9) [75%] . The dur9) [75%] , 63. Alm9) [75%] , 61, 64.9) [75%] , 64. Out9) [75%] –47, 50, 9) [75%] –64. Finan = 4 to n = 95). Subject age ranged between 1 and 22. Eleven [61%] studies had a randomized design, the rest were quasi-experimental non-randomized (n = 9) [45%], used standardized tests. Of the studies analyzed, 10 [55%] reported significant benefits [all in language (n = 7)], four [22%] obtained non-significant improvements, and in the remaining, improvements were similar between groups or no improvement was observed . Participant age ranged between 3 and 23 years. Regarding design of the studies, most of them (n = 5) [71%] were randomized design and two [28%] were quasi-experimental without control group (n = 5) [50%] used personal computer (n = 3) [30%]; and the remaining two [20%], used handheld (n = 6) [85%] (n = 6) [85%] had a duration ranged between 1 and 4 months. Four [57%] studies specify post-test assessments, from just at the end of the intervention to 2 months. Only three [42%] studies conducted long-term assessment, they were ranged between 10 weeks and 3 months (n = 5) [71%], and the rest (n = 2) [28%], used standardized tests. The outcomes reported from the studies analyzed, two [29%] showed significant improvements (n = 5) [71%] reported some improvements or non-significant changes. Six [85%] studies were categorized as low quality and one [15%], as moderate quality.As detailed in ol group , 81. Rescomputer , 80, 82,handheld , 81. Con (n = 5) % used pe6) [85%] , 80–82. 6) [85%] , 80, mat (n = 5) % used pe6) [85%] , 73. In  (n = 5) % used pe3 months , 80. In ovements , 82 and n = 17) [77%]. Sample sizes were mostly small (range n = 3 to n = 87) and the age ranges were between 4 and 31 years old. In terms of the design of the studies analyzed, 12 [54%] had a randomized design, six [27%] a quasi-experimental design without CG (n = 13) [52%] and standardized tests (n = 12) [48%] were used about equally. The outcomes of the interventions reported indicate that almost half resulted in significant benefits (n = 10) [45%], and the remainder obtained no significant improvements (n = 11) [50%], or non-significant changes (n = 1) [5%]. Of the significant benefits reported, nine [50%] studies correspond to social skills and three [30%] to behavioral skills. Seventeen [77%] of the studies were categorized as low quality, four [18%] as moderate and one [5%] as high.The studies that assessed the effect of interventions on behavioral and social skills are described in thout CG , 83, 84 thout CG –88. The thout CG , 87–94 athout CG . The mosthout CG , 92 and thout CG –95. The thout CG , 87, 94,thout CG , 92, 95 thout CG . SessionThe main objective of this review was to assess the effects of digital interventions on trained skills in children and adolescents with ID. In general, the available evidence suggests that interventions undertaken with digital devices are potentially beneficial in executive function , basic cognition (as language and attention) and academic (concretely mathematics) training as well as in the social and behavioral domains. The increasing number of studies assessing the effectiveness of digital devices in the last years is noteworthy. Some studies assessed several functions at the same time, in these cases we included the same study in each of our function categories: executive functions, basic cognition skills, and behavioral and social skills , 63, 64.More than a half the studies we analyzed used randomized designs, albeit most of them evaluated a small number of participants. Studies were very heterogeneous in terms of the age range, tasks and devices used. Computers were the most frequently used device in the studies, followed by handheld devices. However, we noted a lack of studies comparing the same task administered on different devices. In fact, the choice of device seemed to be adapted to the subjects' requirements. Interestingly, it has been suggested that subjects with ID perform better using a mouse than a touch screen , which cNumerous tasks  were developed to train different functions. Although most studies used games, some used videos depicting different scenes and situations to train social skills , 86, 91.Because the lengths of the sessions and the duration of the interventions varied from study to study, we did not have enough data to draw a conclusion in this regard. Two studies described positive outcomes in the social and behavioral domains after a short intervention of 2 weeks , 86. TheSeveral studies did not specify the time at which the post-test evaluation was conducted, some did it immediately at the end of the program, while others assessed it between 1 week and 1 year after the training program ended. In general, all of the studies reported improvements when the subjects were evaluated within 1 week of training , 92, 94.Several studies comparing digital training with traditional  interventions suggest that digital methods may be more effective than traditional ones , 91, 94.It is important to emphasize that new technologies do not replace the work of professionals , but theIn agreement with a previous systematic review conducted by den Brok and Sterkenburg  includinThe main limitation of this review is related to the low quality of the studies analyzed, in part due to their small sample sizes. Our conclusions must be taken with caution, because monitoring the use of digital devices at home was not described and the complex characteristics of the sample could have influenced the study designs. The use of non-standardized tests and assessments rated by parents or teachers  was very common, and these carry a potential risk of bias due to the subjective component .For future lines of research, it would be interesting to conduct studies in special education centers were training variables in training programs may be easier to control than at home. It is also necessary observe effects in subjects with severe and profound ID. It is important to consider longer follow-up assessments and longer interventions  due to the lack of studies that make use of these longer formats, and because the improvements reported are probably not permanent , 78. TheDespite the limitations described at the methodological level, the data analyzed suggest that digital interventions have potential as a therapeutic tool to benefit working memory, academic skills, and the social and behavioral domains in children and adolescents with ID.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Designed form, data collection, and the inclusion analysis of the studies was independently reviewed by MC and MT. When it was necessary, any disagreement was discussed with JC. All authors contributed to the study conception and design, contributed to quality analysis, commented on previous versions of the manuscript, read, and approved the final 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.


Low-quality medicines and falsified medicines represent long-standing problems in developing countries. In Southeast Asia, the circulation of low-quality diabetes drugs (metformin) has been confirmed. It is possible that low-quality metformin has entered Japan via personal import through the Internet. This study evaluated the pharmaceutical quality and authenticity of metformin tablets obtained via the Internet in Japan.In total, 33 samples of 500-mg metformin tablets and 7 samples of extended-release/sustained-release tablets  were purchased via personal import in January 2017. Confirmation of a prescription was never requested purchase. The obtained samples were subjected to visual observations and authenticity investigations. Additionally, quantitative analysis, content uniformity and dissolution tests were performed using HPLC–PDA.Our authenticity investigations revealed that seven samples were genuine products, whereas the authenticity of the remaining 33 samples was unclear. Referring to United States Pharmacopeia 2014 for validation, four samples failed quality testing, five samples failed content uniformity testing, and two samples failed dissolution testing.Our findings illustrate that metformin tablets of poor-quantity and unregistered/unlicensed doses are available online and that it is important to increase consumer awareness about the presence of these medicines on the Internet to prevent the purchase of substandard medicines. Diabetes mellitus, a metabolic disorder characterized by hyperglycemia, seriously affects human health and quality of life . The WorMetformin  is a biguanide derivative and is the most commonly used treatment for type 2 diabetes (T2D) . VariousHowever, even if efficacious medicines are developed, patients may not benefit in some cases because of the existence of substandard and falsified medicines. For example, the active components of substandard medicines do not reach the therapeutic level, and falsified medicines may not contain therapeutic components. WHO defines “substandard and falsified medical products” as follows: “a) substandard : these are authorized medical products that fail to meet either their quality standards or specifications, or both; b) unregistered/unlicensed: medical products that have not undergone evaluation and/or approval by the National or Regional Regulatory Authority for the market in which they are marketed/distributed or used, subject to permitted conditions under national or regional regulation and legislation; c) falsified: medical products that deliberately/fraudulently misrepresent their identity, composition, or source” . It was To prevent the use of substandard and falsified medicines, this research examined the quality and authenticity of metformin tablets available online.We used Google Japan to identify purchase websites using the keyword search “Metformin personal import” in Japanese (メトホルミン 個人輸入). Among the purchase websites that could be identified using Google Japan, all sites that permitted payment via bank transfer were targeted. We performed Internet searches between October 27, 2016 and November 9, 2016.Based on the website search, 500-mg metformin tablets were sold on most websites. Therefore, 500-mg metformin tablets were purchased in this study. Additionally, we purchased sustained-released/extended-release tablets containing 500, 750, or 1,000 mg of metformin. The number of units purchased per site exceeded 60 tablets. Additionally, when different packaging types (boxes and bottles) were available on the same site, both were purchased  and three doses for sustained-release tablets/extended-release formulations .In the visual observation of the purchased products, abnormalities such as an inappropriate description, color, stain, or scratch on the packaging or tablets were recorded. The packaging and inserts were stored as scan data, and the press-through package (PTP) sheet and aluminum-plastic composite film package (APCFP) were stored as a photograph.We calculated the purchase price of each tablet from the Internet, excluding the shipping and import fees. The standard price for metformin prescribed under the Japanese Health Insurance System is 16.7 yen/tablet for the branded 500-mg product and 9.6–9.9 yen/tablet for generic products. The price of metformin per tablet in Japan  was compared with that online.A questionnaire with photographs of purchased products was sent to each manufacturer or distributor on August 14, 2017. The questionnaires contained the results of the appearance observations, authenticity tests, product names, active pharmaceutical ingredient (API), doses, forms, manufacturer name and address, batch/lot number, manufacturing license number, logo, manufacturing date, product expiration date, and a description of the outer box and instructions. We also asked whether the product was allowed to be manufactured or sold in the manufacturing country and if any countermeasures had been taken against falsified products.We recorded whether the website provided the following details required by the Act on Specified Commercial Transactions  for persAdditionally, we recorded the status of compliance with the following details required by the Act on Securing Quality, Efficacy and Safety of Products Including Pharmaceuticals and Medical Devices (Japanese Law Translation) : a stateMetformin hydrochloride, heptanesulfonate, acetonitrile, amoxicillin trihydrate, and methanol  were used for the analysis. We obtained potassium sodium chloride, phosphoric acid, potassium dihydrogen phosphate, and 0.2 N sodium hydroxide from Nacalai Tesque, Inc. . All other chemicals were commercially available and of analytic grade.Quantitative assay was conducted with reference to United States Pharmacopeia 37 (USP 37)  using thCU testing was conducted with reference to USP 37 . In the We performed dissolution testing using a dissolution apparatus  according to USP 37 . Six tabIn total, 40 samples were obtained from 24 websites. We purchased 33 normal 500-mg tablets and 7 extended/sustained-release tablets . Table Among the 500-mg tablets, one sample (No. 32) was from Singapore Table , but theFor another 500-mg sample (No. 12), the box indicated that the dose was 500 mg, but the insert stated a dose of 850 mg. From the measurement of the ingredient content, this product was considered a 500-mg tablet Table .The packaging form of the samples can be divided into four types Table , namely Among all 40 samples, only the manufacturing country was printed on a label for 29 samples and only the distributing country for one sample, whereas this information was not listed for the remaining 10 samples. The identified manufacturing countries included India, the United Kingdom, France, Thailand, Japan, and Canada, and the distribution country stated for a sample was New Zealand. Approximately 48% of samples were shipped from Singapore, and the other shipping countries were Thailand, Taiwan, the United States, India, Hong Kong, and Malaysia. One sample (No. 17) included parcel posts for both Singapore and Hong Kong  and 31.4 ± 3.1 yen/tablet (n = 28), respectively. The online prices of the branded and generic 500-mg sustained-release tablets were 65 (n = 1) and 44.8 ± 9.4 yen/tablet (n = 4), respectively. The online prices of 750- and 1,000-mg sustained-release tablets were 54 (n = 1) and 62 yen/tablet (n = 1), respectively.Metformin is included in the National Health Insurance drug price list in Japan. Regarding price, the price of metformin 500-mg tablets was 16.7 yen/tablet for the branded product and 9.6–9.9 yen/tablet for the generic product at the time of purchase. The prices of metformin tablets purchased in this study are presented in Fig. A response was received from “CIPLA LTD” on August 21, 2017. We received an answer from Towa Pharmaceutical Co., Ltd. on October 24, 2017. A response was received from the “Apotex Pty Ltd” on September 8, 2017. Based on the responses, seven products were confirmed to be genuine. We sent reminders to other manufactures again in April 2018, but no response was received; thus, the authenticity of the other 33 products remains unknown.According to the Specified Commercial Transactions Law, certain details must be provided on commercial websites Table . HoweverTable In total, 35 samples (87.5%) passed CU testing Table . Among tTable In this study, we found that 4 of 24 websites (17%) for personal import agencies advertised the API, efficacy, and names of products (metformin hydrochloride sustained-release tablet) not approved in Japan, although article 68 of the Act on Securing Quality, Efficacy and Safety of Products Including Pharmaceuticals and Medical Devices prohibits advertising of unregistered/unlicensed medicines, and advertisements related to the name, manufacturing method, efficacy, effect, or performance of unregistered/unlicensed medicine are also prohibited .Additionally, it has become clear that unregistered/unlicensed medicines can be obtained without a prescription. Unregistered/unlicensed medicines available online have not been evaluated for safety in Japan, and thus, they are not eligible for the medicine side effects relief system . PersonaWe obtained one Japanese product (No. 32) among the products examined in this study Table . This isAlthough metformin is a prescription medicine in Japan, online wholesalers do not confirm prescriptions. Concerning the outer packaging Table , six boxVisual observation confirmed that several samples had physical cracks or stains. Although all of these samples passed quality testing, the cracks or stains may have been caused by lower-quality excipients or improper manufacturing practices, or may have been introduced during transportation because of defective packaging. These deficiencies might affect the health of consumers.Consumers who obtain medicines via personal import agencies without guidance from a doctor or pharmacist possibly refer to the package and instructions of the product when using the drugs. However, the packaging and insert for 98% of the purchased samples were not written in Japanese, and inserts and packaging materials written in foreign languages do not provide sufficient information to patients. Additionally, the dose described in the insert of one sample did not match the actual dose. Inappropriate drug use may result in side effects, which can threaten patients’ health.The online price of one 500-mg metformin tablet was higher than that from a regular Japanese medical institution Fig. . TherefoIn total, four and five samples failed quantitative analysis and CU testing, respectively Table . If the For the dissolution test, two samples (both extended-release/sustained-release tablets) failed specifications Table . The susOne limitation of the study was that we only tested 40 samples and evaluated 24 websites. The research object was only one drug, and the results do not reflect the quality of all medicines available online. Expanding the number of samples may provide more comprehensive information and permit more relevant discoveries. Another limitation was that most manufacturers did not complete the authenticity survey, and thus, we could not verify the authenticity of most products. However, the circulation of low-quality medicines on the Internet was confirmed. This study indicates the need for consumers to avoid purchasing medicines on the Internet. Additionally, the findings also revealed that active cooperation between manufacturers and regulatory authorities is necessary for improving the quality of medicines in circulation.This study clarified that metformin tablets of poor-quantity and unregistered/unlicensed doses can be personally imported into Japan without a prescription via the Internet. It is difficult to judge the quality of medicines based on the outer packaging. Because medicines can easily be imported via the Internet, consumers must be aware of the existence of falsified or poor-quantity medicines and the dangers of personal import. Additionally, relevant regulatory authorities should provide consumers with information and warnings to increase awareness of this issue. Moreover, it may be necessary to monitor or block illegal personal import agencies or senders to ensure the safety of consumers.


Determination of the levels of heavymetal ions would support assessmentof sources and pathways of water pollution. However, traditional spatialassessment by manual sampling and off-site detection in the laboratoryis expensive and time-consuming and requires trained personnel. Aimingto fill the gap between on-site automatic approaches and laboratorytechniques, we developed an autonomous sensing boat for on-site heavymetal detection using square-wave anodic stripping voltammetry. Afluidic sensing system was developed to integrate into the boat asthe critical sensing component and could detect ≤1 μg/LPb, ≤6 μg/L Cu, and ≤71 μg/L Cd simultaneouslyin the laboratory. Once its integration was completed, the autonomoussensing boat was tested in the field, demonstrating its ability todistinguish the highest concentration of Pb in an effluent of a galena-enrichedmine compared to those at other sites in the stream . An autonomoussensing boat for heavy metal spatial assessmentcan distinguish the highest concentration of Pb in an effluent ofa galena-enriched mine compared with those of other sites in the stream. Accordingto the World Health Organization (WHO) guidelines, Pb, Cd, Cr, andother heavy metals must be controlled in food sources to ensure publicsafety.3 The maximum permitted concentrationsof Pb, Cd, and Cu are 10 μg/L, 3 μg/L, and 2 mg/L, respectively.3 Monitoring HM pollutants in natural waters belowthese low concentrations is an urgent need.Freshwater, a necessityfor humans and other life forms, has beencontinuously compromised by inclusion of heavy metal (HM) pollutantsfrom various natural and anthropogenic processes.4 inductivelycoupled plasma mass spectrometry (ICP-MS),5 inductively coupled plasma atomic emission spectrometry (ICP-AES),6 etc. They are highly accurate and quite costlyand have complicated sample handling that requires bulky equipmentwith specialized personnel.Various techniquescan determine HMs quantitatively such as atomicabsorption spectrometry (AAS),8 Square-waveanodic stripping voltammetry (SWASV) is one of the most typical techniquesfor HM detection. Herein, first the HM cations (Mn+) are concentrated and reduced on the electrode surface (toM0) by applying a negative potential. Then, they are reoxidized(to Mn+) by applying a reverse potentialin square-wave pulses; in the meantime, the current and potentialduring the reoxidation process are recorded as a voltammogram. Consequently,the HM species and concentration could be known by the peak potentialand current intensity, respectively.9On the contrary, electrochemicaltechniques are promising due toportability, simplicity, and fast detection.15 To further decrease the labor errors and cost from on-site HM measurements,several automatic sensing probes based on anodic stripping voltammetryhave been reported; however, they still suffer from the low portabilitycaused by the large size and lack of remote operation and automation,requiring humans on deck to control the movements of sensing probesbetween different testing sites, which induces a high cost especiallyin large lakes and rivers.19 A fully autonomous sensing tool for on-site HM measurementsin natural waters has rarely been reported.On-site HM detection in a body of water, avoiding any pretreatmentand maintaining the most original characteristics of HMs, has shownthe advantages compared to the traditional approaches for HM distributionassessment in waters involving manual sampling, off-site detection,and possible contamination.To fill this gap,we developed an autonomous sensing boat witha programmable data collection campaign to assess the spatial distributionof HM pollutants in natural waters. With the aim of automatic samplingand detection, a low-cost fluidic HM sensing system (FSS), as thekey sensing component, was fabricated. The autonomous boat was constructedon the basis of the commercial vehicle and adapted for the integrationof the FSS and the corresponding electronic controlling unit. Then,the sensing performance with respect to Cd, Pb, and Cu of the FSSwas investigated in both deionized water and river water in the laboratory.Finally, the autonomous sensing boat was examined in a mine effluent.20 Bluebox (BlueboxT4) was developedby GO Systemelektronik. The software for HM analysis is PStrace 5.8.Hydrochloric acid and standard heavy metal solutions  were acquired from Sigma-Aldrich. Degassers (bubble trap),tubings (three-stop tygon), and connectors were from Darwin Microfluidics.The peristaltic pump was a model Perimax12 pump from SPETEC. The mini-potentiostatwas a model EmStatBlue instrument from Palmsens. The autonomous surfacevehicle  powered by a lithiumpolymer battery  was acquired from PlatypusLLC.Deionized water  was mixed with 37% HCl to prepare HCl dilutions. An individualHM solution was prepared by mixing deionized water with a single HMstandard solution (1000 ppm). Mixed HM solutions were prepared withthe addition of Cd, Pb, and Cu simultaneously in deionized water.9 PET as the substrate was first cleaned with deionizedwater, ethanol spraying, and nitrogen purging. They were then preheatedat 110 °C for 30 min to evaporate solvents and prevent deformationin following steps. The SPEs were fabricated in four steps. (1) Agpaste  was printed toform conductive connections. (2) Then the reference electrode wasprinted using Ag/AgCl paste . (3) Thecarbon paste was used for patterning working and counter electrodes. (4) Finally,the insulating layer was printed . The ink was cured at 110 °C for 30 min in an ovenafter every printing step.Screen-printed carbon electrodes(SPE) as a key sensing component were fabricated by a screen printingtechnique with a DEK248 printer machine .DetectingHM ions by SWASV included three steps, i.e., deposition, equilibrium,and stripping. During the deposition step, the peristaltic pump wasswitched on (range of flow rates of 1–7.5 mL/min), and a constantnegative potential  was applied to a working electrode for a depositionperiod (from 60 to 400 s). Then, during the equilibrium (20 s), theperistaltic pump was stopped. Afterward, the potential was scannedfrom −1 to 0 V in square-wave pulses in a stripping step witha frequency of 25 Hz, an amplitude of 30 mV, and a potential stepof 6 mV.A) of the HM peak was denoted as the output signal instead of thepeak intensity for the peak splitting that occurred when testing mixedheavy metal solutions. The limit of detection (LOD) was defined as3 times the standard deviation of the minimum concentration with measurableresults. Likewise, the limit of quantification (LOQ) was defined as10 times the standard deviation of the minimum concentration withmeasurable results.21The integral area . The performance of thissetup is shown in Movie S1, and one canobserve how two solutions with different colors (blue and pink) arecompletely mixed at the end of the process.To ensure a homogeneous mixture between the prestored electrolyteand the sample, we created a mixing system consisting of two syringesin series filled with PDMS particles whose diameters were approximately2 mm . After flowing out of the degasser,the injected air disappeared, showing the successful removal of allof the air inserted into the system.Due to the motiongenerated during the natural movement of theboat when sailing, bubbles that can significantly affect the measurementsare produced.Schematic 1a, inset, and Figure S2c,d). When SPE and the O-ring on the cover were compacted,a fixed cell was created (∼100 μL), providing stableconditions for the electrochemical reaction and preventing possibleleakage. The embedded electric contacts connected the SPE with thepotentiostat , transmittingthe obtained voltammogram to a data analyzer  by Bluetooth when the analysis had reached completion.A flow cell was customizedas a robust electrochemical cell forHM analysis. It was designed on the basis of the fluidic injectionsystem, mainly composed of two pieces of PMMA that encloses the SPEby four screws  reported in a previous study was used to equip this system.20 The boat was originally designed to be commandedby user via a tablet to navigate and monitor indicators in naturalwaters automatically  through correspondingsensors. It was constructed by adding a Bluebox  to the original boat control unit (BCU) of the commercialvehicle , which already includes a smartphoneproviding GPS data, an E-board for engine control, and operator interface(OI) software in the computer for programing the moving path. However,the proprietary E-board cannot communicate with the added Blueboxdirectly, interfering with the transmission of data from the sensorto the user. To overcome this, an Arduino Due was integrated on anE-board as the interface with Bluebox. To further accomplish automaticsampling and on-site HM analysis, we transformed this architecture by adding the developed FSSinside the upgraded one  is necessary. First , an application of a graphicuser interface (GUI), based on the open-source OI of a commercialboat, was transferred to the tablet. The smartphone read remote commandsemitted by GUI and transmitted them to the E-board for engine control,so that the GUI allowed users to directly program the data collectioncampaign . Simultaneously, the GUI also allowed the users to receivethe data from sensors and the status information from the batteryvia a smartphone and a boat control unit (BCU) even during a missionexecution, which strongly assisted operators in regulating the boatbehaviors promptly. Moreover, to improve the interaction of the userwith the obtained data in the database, a Web application (WAQUIN)and WASCO mobile application were developed to allow the user witha device using a connection to the Internet  access in real time, and the HM information on naturalwaters varying with different time and locations can be even visualizedby WAQUIN/WASCO software.In this way, the user can interactwith the sensing boat, programits data collection campaign, and instruct it to drive in the desiredarea to perform the required measurements. After any campaign, thecomplete set of data  can be transferred from the boat to users for detaileddata processing.Figures S6–S8. The optimum electrolyteis HCl for supporting the best signal for Cd compared with H2SO4 and HNO3. HCl also has shown better sensingperformance with respect to Cd, Pb, and Cu by graphite electrodesreported elsewhere.23 The concentrationis optimized as 0.05 M, the deposition potential −1.0 V, theflow time 200 s, and the flow rate 3 mL/min. More information is demonstratedin section 5 of the Supporting Information. All optimized parameters were applied in the following measurements.Compared with Bi-based electrodes, in our study thecarbon-based electrodes were selected for its inertness and robustnessduring deposition and less interference with many heavy metal species. To achieve the best sensing performance, key parameters of the FSS were optimized and are shownin Figure S9 shows that the FSS has linear responses toward varyingHM concentrations in the cases of Cd and Cu (R2 > 0.90). With regard to Pb, the linearity obtained wasnotas good as those of Cu and Cd [R2 = 0.90], which could be caused bythe inhomogeneous deposition of Pb onto a carbon paste electrode surface.24 The estimated LODs were all at the parts perbillion level: 7 μg/L for Cd, 1 μg/L for Pb, and 0.3 μg/Lfor Cu. The LOQs of Cd, Pb, and Cu were 23, 6, and 1 μg/L, respectively.The FSS was first tested with individual HM standard solutions with different concentrations. Figure S10). It could be attributed tothe more negative potential required for Cd deposition compared toPb and Cu, which induces substance loss on the working electrode duringthe competition with Pb and Cu.26 However, Pb and Cuwere negligibly affected showing LODs of 1 and 6 μg/L, respectively,both being below the minimum concentration required by WHO guidelines.To investigate the sensing performance in multi-HM contaminants,the FSS was tested in the standard solutions containing mixed Cd,Pb, and Cu. Compared with individual measurements, as expected, thesimultaneous detection did demonstrate the difference in sensitivityand LOD due to the mutual interference. The presence of Pb and Cudecreased the Cd sensitivity dramatically with a LOD of 71 μg/L as a standardaddition calibration. The FSS demonstrated good linear responses tothe varying concentration 2a–c. TheFigures S11–S13). In summary, the reproducibilities [relative standard deviation(RSD)] of nine different SPEs toward Cd, Pb, and Cu were 19.57%, 3.86%,and 4.73%, respectively, which are even comparable with those of commercialSPEs . In Figure S12, the repeatabilities toward Cd, Pb, and Cu areacceptable (RSD < 20%) in 28 continuous measurements. Moreover,the FSS also showed good stability within 2 h [RSD < 20% ].The robustness of the FSS is crucial for the sensingboat; therefore,the FSS was investigated in terms of repeatability, stability, andreproducibility .Finally, with the questionof how the automatic sensing boat performedin a natural environment, we conducted campaign experiments in a streamaffected by the input of an abandoned mine effluent . To further test the HM sensing ability, the automatic sensing boatwas instructed to drive into the mine effluent 2e, which28 Hence,the detected Pb with a higher concentration in mine effluent can beattributed to the drainage or leaching from Mine Osor to surface water,and Cu, not abundant in the mine, remains at the low concentrationlike the other sites. However, with regard to Cd, it is difficultto detect it not only because the concentration of Cd is relativelylow in the mine effluent but also because the high LOD toward Cd isaffected by mutual interference with the FSS. Moreover, Zn and Baas the interferents at high concentrations did not influence the detectionwithout showing any peaks in the voltammogram for their strippingpotentials were beyond the working potential (from 0 to −1 V).29The voltammogram2f, inset19 Simultaneous detection can berealized with one SPE sensor in the low-cost FSS (cost shown in Tables S1 and S2) without the need for photolithography,which may have a future impact in resource-limited regions.19These results suggest the autonomous sensing boat in our studyhas the ability to analyze the HMs with different concentrations incontaminated water. Compared to the reported studies of an automaticon-site sensing probe based on anodic stripping voltammetry, the autonomousboat has advantages in being fully automated and high portable becauseof its compact design and small size.30More detailed results about indoor and outdoor validationof thisautonomous sensing boat and quantitative analysis are shown in anotherwork, already submitted for publication.In this work, an autonomous sensing boatintegrated with a FSSwas fabricated for HM spatial monitoring in waters based on SWASV.The FSS, as the most important component in the automatic boat, wasfirst tested in the laboratory. The LODs toward Cd, Pb, and Cu wereat parts per billion levels in both individual and simultaneous measurements.It was then adapted into an engineered autonomous boat. To investigatethe performance, the autonomous sensing boat was tested during a campaign,and it could navigate under a programmable path automatically anddistinguish the highest concentration of Pb in the effluent of thegalena-enriched mine compared to other sites in the stream. Even thoughat this stage there are some issues , it is the first autonomous boat operating simultaneousmulti-HM detection by anodic stripping voltammetry, which may havea future impact in environmental control. Moreover, compared to thereported on-site and automatic sensing tools, it has the advantagesof being small, automated, portable, and cost efficient, which shedslight on HM pollution especially in resource-limited regions.


IgA nephropathy (IgAN) is the most frequent primary glomerulonephritis worldwide. Due to its heterogenicity, there is a need to establish robust biomarkers for IgAN, to support treatment decisions and evaluate the risk of progression to end-stage renal disease. Using both clinical and histopathological data, derived from renal biopsies, we aimed to find predictors of renal function deterioration and proteinuria reduction. Clinical and histopathological data of 80 patients with biopsy proven IgAN were analyzed. In a multivariate logarithmic regression model, the presence of endocapillary hypercellularity (E1) predicted a decline in estimated glomerular filtration rate (eGFR)of at least 50% with an odds ratio (OR) of 15.2, whereas serum albumin concentration had a negative influence on eGFR deterioration (OR 0.2). In the second multivariate model, the extent of interstitial fibrosis predicted the worsening of eGFR by 50% (OR 1.1) and serum albumin concentration had a protective impact (OR 0.1). In the univariate logarithmic regression, both the extent of interstitial fibrosis and the presence of endocapillary hypercellularity negatively correlated with the reduction in proteinuria below 1.0 g/24 h with an OR of 0.2 and 0.9, respectively. In our paper, we confirmed the utility of histopathological variables, especially endocapillary hypercellularity and interstitial fibrosis, and clinical parameters, particularly serum albumin concentration, in the prediction of both a decline in eGFR and a reduction in proteinuria in IgA nephropathy. IgA nephropathy (IgAN) is the most frequent primary glomerulonephritis worldwide , first dThere is a need for establishing robust biomarkers for IgA nephropathy to aid with diagnosis, treatment decisions, and risk prediction for progressive disease .The Oxford Classification of IgA Nephropathy (MEST score) offers an opportunity to use histology for the prediction of renal outcome, independently of proteinuria, blood pressure, and estimated glomerular filtration rate (eGFR) . The scaRecently, a new risk-prediction tool, including eGFR, blood pressure, use of immunosuppression, angiotensin system blockers (RAS), and proteinuria at the time of biopsy, while also incorporating MEST score, was proposed. It accurately predicted the risk of a 50% decline in eGFR or development of ESKD up to 7 years after biopsy .In this single-center, retrospective study, the clinical and pathological data of IgAN were analyzed to assess the predictability of both a decline in eGFR and a reduction in proteinuria.Eighty adult patients from a single center, with biopsy-proven IgA nephropathy, were enrolled in this retrospective study, from 1 January 2012 to 31 December 2019. The exclusion criteria were secondary causes of IgAN; in our center, this included hepatic cirrhosis and Crohn’s disease.The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Review Board of Wroclaw Medical University . Specimens obtained by renal biopsy were assessed by experienced pathologists (PD and AH), according to the Oxford classification of IgAN . AdditioThe following clinical parameters were assessed: age, gender, blood pressure (systolic (SBP), diastolic (DBP), and mean (MAP) calculated as ((2 × DBP) + SBP)/3), erythrocyturia in urinary sediment, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and serum concentrations of total cholesterol, triglycerides, uric acid, fasting glucose, serum creatinine, serum albumin, and total protein. The number of red blood cells (RBCs) in urinary sediment was calculated per high-power field (HPF). In the case of RBC/HPF ≤5, RBC/HPF of 6–20, and RBC/HPF >20, the extent of erythrocyturia was assessed as absent, moderate, and severe, respectively. The enzymatic method was used for urea, and Jaffe’s method was used for creatinine evaluation. Kidney function was expressed as eGFR using the MDRD equation . Renal fAll patients, with proteinuria greater than 1.0 g per day, were treated with angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers ARB (in the case of ACEI intolerance) at maximum tolerated doses, to obtain blood pressure below 125/75 mmHg. We did not include the ACEI or ARB doses in our analysis due to their variability. Patients who did not achieve a reduction in proteinuria below 1.0 g per day, after 6 months of treatment with ACEI or ARB, received corticosteroids according to the scheme proposed by Pozzi et al.   and percentage (%) values and compared using the χ2 test. To predict the values of decline in eGFR and reduction in proteinuria, logistic regression models were built. Firstly, univariate models were made to determine the best predictors. Then, multivariate regression was performed, including statistically significant parameters from univariate models. A p-value <0.05 was considered statistically significant.Statistical analysis was performed using Statistica ver. 13 software . Quantitative continuous data were expressed as the mean and standard deviation (SD). The distribution was tested with the use of the Kolmogorov–Smirnov test. Differences between the two groups were assessed with the use of a Eighty patients with primary IgA nephropathy were enrolled in the study, among them 35 women (44%) and 45 men (56%), aged 39 ± 14 years. Detailed patients’ characteristics at baseline are presented in MEST-C classification, the extent of interstitial fibrosis, and the degree of interstitial inflammation are presented in p = 0.34. Urinary protein excretion was assessed as urine protein-to-creatinine ratio (UPCR). Patients suffering from a decline in eGFR by at least 50% had statistically significantly higher PLR and lower concentrations of both serum albumin and total protein. They also had higher levels of proteinuria as assessed using UPCR. Furthermore, they used prednisone more frequently before biopsy.Seven patients (8.8%) suffered from a decline in eGFR of at least 50% during the observation period. Renal biopsies in the group with eGFR deterioration showed a higher degree of endocapillary hypercellularity (E1) and extent of interstitial fibrosis. Differences between both groups in terms of histopathological parameters are presented in Using nonlinear estimation, six parameters among those presented in Using the parameters selected by the univariate logistic regression model, we attempted to build a multivariate model, predicting 50% eGFR reduction. Only those consisting of two variables reached statistical significance. The best-fitting multivariate logistic regression models are presented in In the analyzed group, 38 (47.5%) patients presented urinary protein excretion higher than 1.0 g (as estimated by UPCR) at the time of biopsy. In 23 (61%) of them, daily protein loss was reduced below 1.0 g. The mean time to proteinuria reduction was 8 ± 12 months. In Patients in whom reduction in proteinuria was achieved presented a lower extent  of interstitial fibrosis and lack of endocapillary hypercellularity, compared to those in whom no reduction in proteinuria was achieved.A univariate logistic regression model was built  on the bOnly a univariate logistic regression model, including parameters influencing a decrease in proteinuria <1.0 g/24 h, was built. In contrary to 50% eGFR decline, the multivariate model did not reach statistical significance.A comparison of clinical parameters between patients based on endocapillary hypercellularity is presented in None of the clinical parameters differed between the groups on the basis of endocapillary hypercellularity.Patients with E1 presented higher mesangial hypercellularity, interstitial inflammation, and extent of interstitial fibrosis  and total protein  at baseline. It was accompanied by more severe protein loss, as expressed by UPCR . This finding is consistent with previous papers, pointing out the level of proteinuria as a crucial factor in the progression of renal insufficiency among IgAN patients [In our study, a significant correlation was found between the deterioration of renal function, as expressed by a decline in eGFR by 50%, compared to the baseline values, and the level of proteinuria. The group with a 50% decrease in eGFR had significantly lower concentrations of both serum albumin  and the risk of eGFR deterioration. In both univariate and multivariate logistic regression models, the presence of E1 increased the odds ratio of eGFR decline. On the one hand, this finding is in accordance with a study published by Edstrom et al., showing that the presence of endocapillary hypercellularity was associated with poor renal outcome, expressed by end-stage renal disease or eGFR reduction >50% . SimilarPlatelet-to-lymphocyte ratio (PLR) calculated as platelet count divided by lymphocyte count has been established as a novel marker of malignancies, cardiovascular diseases, and chronic obstructive pulmonary disease ,22,23. IIn our work, PLR was shown, in univariate analysis, to have a predictive influence on eGFR deterioration.2 per year in those with endocapillary lesions, compared with 2.6 ± 5.1 mL/min/1.73 m2 per year in those without endocapillary proliferation (p = 0.02) [It is also worth mentioning that patients with endocapillary lesions were more likely to receive immunosuppressive treatment. In our study, 18 patients were treated with prednisone already at the time of biopsy, and the number of these patients increased after the diagnosis. There are two studies in which no patient received immunosuppression, and both reported that E1 was independently associated with loss of renal function ,26. Amon = 0.02) . These s = 0.02) . In our Using multivariate analysis, we found an influence of E1 on eGFR decline, whereas serum albumin concentration had a protective impact. The second multivariate model involving serum albumin concentration and interstitial fibrosis had an impact on eGFR worsening.In our study, we also found that the presence of E1 influences blood pressure control. Although the number of patients with diagnosed hypertension did not differ between group E1 and E0, we observed a statistically significant difference in systolic blood pressure. Patients with the presence of E1 demonstrated a mean SBP of 137 ± 18 mmHg, in contrast to those with E0 who presented a mean SBP of 129 ± 15 mmHg. The higher values of blood pressure might be related to more active kidney disease, stimulating hormonal disorders responsible for blood pressure control, including activation of the renin–angiotensin–aldosterone system.It is worth mentioning that, although the presence of T lesions in our group did not reach statistical significance, both in the univariate and in the multivariate logistic regression models, we were able to prove that the extent of interstitial fibrosis, at the time of biopsy, influenced the deterioration of renal function. It is now a widely accepted paradigm that the degree of renal fibrosis correlates well with kidney function, both in native kidneys and in kidney grafts . The expSince the level of proteinuria, especially exceeding 1.0 g per day, is a key factor of renal insufficiency progression , we focuThe main limitation of this study was its small sample size. Although IgA nephropathy is the most common type of primary glomerulonephritis, it is generally a rare disease in the entire population. All available patients with biopsy-proven IgA nephropathy and at least 6 months of follow-up were included in the study, after excluding patients with secondary causes. The strength of the study is that we presented the results from one center that provides care for the large region of southwestern Poland and concerns an ethnically homogeneous group. Additionally, the same approach was used to treat all participants.In our paper, we confirmed the utility of the MEST-C score, especially endocapillary hypercellularity, in the prediction of renal function decline, expressed as a 50% decrease in eGFR. A similar conclusion was made for a reduction in proteinuria below 1.0 g/24 h. In addition to histopathological findings, the level of proteinuria expressed by initial serum albumin concentration was found to have an impact on final kidney function.


P < 0.05). In addition, the sensitivity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 80.0%, 86.7%, 80.0%, and 93.3%, respectively. The specificity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 86.7%, 93.3%, 60.0%, and 73.3%, respectively. The results showed that Munro microabscess and psoriasis-like hyperplasia had high sensitivity and specificity in all diagnostic items, which could be used as important features of skin lesion sites in the diagnosis of psoriasis in children. The research provides a basis for the clinical diagnosis of psoriasis in children, which is worthy of clinical promotion.This research was to explore the application value of three-dimensional computed tomography (CT) based on artificial intelligent algorithm in analyzing the characteristics of skin lesions in children with psoriasis. In this study, 15 children with psoriasis were selected as the observation group, and 15 children with other skin diseases were selected as the control group. The CT images were optimized, and the feature selection was carried out based on artificial intelligent algorithm. Firstly, the results were compared with the results of simple skin three-dimensional CT to determine the effectiveness. Then, the two groups of three-dimensional skin CT image features of skin psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium based on intelligent algorithms were compared. After comparison, the detection rate of psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium in the observation group was higher than that in the control group, with significant difference and statistical significance ( Psoriasis is characterized by a layer of easily exfoliated silver-white scales on the skin erythema, which is called “Bai Bi” in traditional Chinese medicine. Because its name is easily confused with “psoriasis” (neurodermatitis) in traditional Chinese medicine and is inconsistent with the actual disease, it is renamed “psoriasis.” Psoriasis has the characteristics of long course, easy recurrence, and difficult to cure, repeatedly, which causes pain to patients , 2. The Currently, psoriasis is mainly diagnosed by skin computed tomography- (CT-) confocal laser scanning microscopy (CLSM), dermatoscopy examination, blood examination, skin biopsy, and trace element examination –14. Due In recent years, with the development of computer-aided diagnosis (CAD) technology, the accuracy of diagnosis technology has made great progress by upgrading the traditional imaging technology. Dash et al.  pointed In order to improve the accuracy and efficiency of clinical diagnosis of pediatric psoriasis, three-dimensional skin CT based on artificial intelligent algorithm was innovatively applied to analyze the characteristics of skin lesions sites in children. In this study, 15 children with psoriasis in hospital were selected as the observation object, and 15 children with other skin diseases were selected as the control group. Moreover, CT image feature analysis based on artificial intelligence algorithm was used to diagnose the patients. By comparing the diagnostic information of the two groups, the diagnostic function of CT image feature analysis in psoriasis skin lesions sites was judged.In this study, 15 children with psoriasis diagnosed in hospital were collected as the observation group, including 8 males and 7 females aged from 6 to 12 years old, with an average age of 9.73 ± 2.24 years old, including 9 in progressive stage, 5 in stable stage, and 6 in regression stage. 15 children with other skin diseases were selected as the control group, including 8 males and 7 females, aged from 7 to 12 years, with an average age of 9.89 ± 2.14 years. There were 5 cases of pityriasis rosea, 5 cases of chronic eczema, 2 cases of lichen planus, 2 cases of seborrheic dermatitis, and 1 case of herpes zoster. This study was approved by the ethics committee of hospital. Patients and their families were aware of this study and signed informed consent.Inclusion criteria are as follows: (1) no other skin diseases in children with psoriasis. (2) The selected age is not more than 12 years old.Exclusion criteria are as follows: (1) family members and patients are unwilling to participate. (2) Children with poor dependence.μm × 500 μm. Three-dimensional imaging such as psoriasis-like hyperplasia of skin, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium should be judged. The results of the two groups were compared to determine the role of skin psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium in the diagnosis of psoriasis in children.Patients in both groups were examined by three-dimensional skin CT system. Appropriate postures should be selected for detection, and appropriate amount of tap water should be applied to the lesion. Three-dimensional skin CT examination should be carried out in the patient's affected area with B-ultrasound coupling agent as the medium, and the scanning area was 500 Diagnostic function will be judged by sensitivity and specificity, and the specific calculation method is as follows. M is sensitivity, T is specificity, TP is the number of true positive cases, FN is the number of false negative cases, TN is the number of true negative cases, and FP is the number of false positive cases. Equations   2) are gquations  and 4)  M is senX refers to pixel value, S denotes zoom ratio, and P represents deviation value. CT value is calculated by Equation CT=XA and B need to be calculated by deviation standardization Equation B=A−After the preprocessing, other interference is eliminated and 2-3-dimensional hybrid network is utilized to segment images. The backbone network 2-dimensional component is ResNet34, and the backbone network 3-dimensional component uses ResNet18. ResNet is an excellent image classification and segmentation model, and the residual structure in the model makes it easier to be optimized. The residual structure can address the problem of the disappearance of propagation gradient caused by reverse propagation in the propagation of neural network. In addition, gradient information is propagated easier in reverse propagation process with the residual structure. The networks added into residual modules will obtain higher recognition accuracy. The specific segmentation process of 2-3-dimensional hybrid network-based segmentation algorithm consists mainly of the next several steps. Firstly, the preprocessed images are reorganized. Secondly, 2-dimensional network input is transmitted into 2-dimensional model for the completion of extraction of 2-dimensional segmentation results and 2-dimensional features. Thirdly, 2-dimensional segmentation results are converted into 3-dimensional forms. Next, 3-dimensional network original input is combined to complete 3-dimensionl network input. After that, 2-dimensional features are converted into 3-dimensional features, and then, 3-dimensional features and 3-dimensional network input are transmitted into 3-dimensional model simultaneously to obtain the 3-dimensional segmentation results. Finally, maximum connected domain processing is performed for the 3-dimensional segmentation results to obtain the final segmentation results. J) is expressed by Equation J=∑xχ2. t-test was used. It was expressed as mean ± standard deviation , is a new dermatological examination method to scan and image the skin lesion sites through the probe and observe the lesions at the cellular level. Compared with traditional dermatological examination methods, skin three-dimensional CT not only has the characteristics of simple operation, real-time fast, dynamic response, no wound, high repeatability, and simultaneous examination of multiple lesions but also plays a more and more important role in the daily examination and diagnosis of dermatology. Li et al.  also conP < 0.05). The sensitivity and specificity of psoriasis-like hyperplasia, Munro mircroabscess, dermal papilla vascular dilation, and squamous epithelium were calculated, and the sensitivity was 80.0%, 86.7%, 80.0%, and 93.3%, respectively. The specificity was 86.7%, 93.3%, 60%, and 73.3%, respectively. For the combination of sensitivity and specificity, it can be obviously found that the sensitivity and specificity of Munro microabscess were among the top, which was the best analysis feature of the lesions' parts of psoriasis skin. The comprehensive data of psoriasis-like hyperplasia were slightly lower than those of Munro microabscess, but also higher than those of squamous epithelium and dermal papilla vascular dilation.In this study, 15 children with psoriasis diagnosed in clinic were selected. 15 cases of other common skin diseases that are easily confused with psoriasis, such as pityriasis rosea, herpes zoster, and chronic eczema, were selected as the control group and compared with psoriasis patients. Both groups underwent CT images based on the above artificial intelligent algorithm. In the final results, 12 cases of psoriasis-like hyperplasia, 13 cases of Munro microabscess, 12 cases of dermal papilla vascular dilation, and 14 cases of squamous epithelium were detected in 15 children with psoriasis. In the control group, there were 2 cases of psoriasis-like hyperplasia, 1 case of Munro microabscess, 6 cases of dermal papilla vascular dilation, and 4 cases of squamous epithelium. The data of the two groups were statistically analyzed, and there were significant differences (In this study, it is determined that CT images based on intelligent algorithm play a positive role in the analysis of the characteristics of psoriasis in children, especially the examination of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilation, and squamous epithelium. It is proved that these four types of features can be used as the diagnostic features of three-dimensional CT of psoriatic skin in children, especially Munro microabscess and psoriasis-like hyperplasia, which have high sensitivity and specificity, which is similar to the research results of Lv et al. .Qing et al.  found thIn this study, 15 children with psoriasis were selected as the observation object, and the characteristics of skin three-dimensional CT images based on artificial intelligence were analyzed and compared. The results show that the three-dimensional CT image of skin based on artificial intelligence has high sensitivity and specificity in four types of analysis features. It is proved that this detection method can be used in the clinical analysis of the characteristics of psoriasis in children and is worthy of popularization. Due to the small number of children with psoriasis and other skin diseases, this experiment cannot pass the validation experiment of a large amount of data. The experimental data may have some errors, but the results will not be too different. It is expected that relevant organizations or teams can select more patients for research in the future. In this study, the three-dimensional CT image of the skin is optimized to analyze the characteristics of the site of skin lesion, which provides certain research data and feature selection for the diagnosis of psoriasis in children and has certain significance for clinical experiment and diagnosis in the future.


Dietary diversity is an important indicator of child malnutrition. However, little is known about the geographic variation of diet indicators across India, particularly within districts and across states. As such, the purpose of this paper was to elucidate the small area variations in diet indicators between clusters within districts of India. Overall, we found that clusters were the largest source of variation for children not eating grains, roots, and tubers, legumes and nuts, dairy, vitamin A-rich vegetables and fruits, and other vegetables and fruits. We also found positive correlations between the district percent and cluster standard deviations of children not breastfeeding or eating grains, roots, and tubers, but negative correlations between the district percent and cluster standard deviation for the remaining seven outcomes. These findings underscore the importance of targeting clusters to improve child dietary diversity. Dietary diversity is an important indicator of food consumption, and highlights the extent to which households have access to different food groups. Understanding dietary diversity is particularly important in the context of child health. Inadequate diets are an impediment to child survival, growth, and development . More spYet, child undernutrition is typically quantified by anthropometric measures, such as height-for-age, weight-for-age, or weight-for-height , 4. ThisThe Indian government's National Nutrition Strategy (NNS) was created as a response to the fact that child malnutrition remains a major public health problem throughout India. The NNS aims to improve nutrition outcomes by 2022 by targeting districts with a high prevalence of undernutrition . One issGiven the World Health Organization's emphasis on starting complementary feeding at six months, an emerging body of literature has also started examining the geographic variation of diet indicators, such as MDD, throughout India. The MDD is a binary indicator used to measure the micronutrient density of children between the ages of 6–23 months . The MDDThus, the purpose of this paper was to elucidate small area variations of MDD and each of the composite food groups  in India. We used the fourth round of the National Family Health Survey (NHFS-4) from 2015 to 2016 to conduct this analysis. This research is novel and significant because while prior research has examined small area variations in measures of anthropometric failure in India, small area variations in diet indicators have yet to be quantified. Doing so could help better inform policy design and implementation by demonstrating within district heterogeneity in children's dietary diversity.We used NFHS-4 for this analysis. Households were selected using a stratified two-stage cluster sampling strategy. Clusters were defined as groups of adjacent households, and were the primary sampling units (PSUs). Rural and urban clusters were selected in the first stage of sampling. Clusters with more than 300 households were divided in to smaller groups of 100 to 150 households. Therefore, clusters were either an entire PSU, or a part of a PSU, from which the final households were selected as part of the second stage of sampling. A maximum of 22 household were selected from any given PSU in final sample.Overall, the survey contained data from a total of 601,509 households from 28,522 rural and urban clusters, in all 640 districts, and all 36 states/union territories. As such, 699,686 women between the ages of 15–49 and 259,627 children under five were surveyed. However, the Demographic and Health Survey guidelines for calculating MDD are for mothers living with their youngest child between the ages of 6 and 23 months. As such, our final sample included 72,895 mothers currently living with their youngest child who was between 6 and 23 months old.We analyzed the small area variation of a child not meeting the minimum dietary diversity (MDD) throughout all 36 states/union territories, 640 districts, and 25,121 urban/rural clusters. The MDD is constructed from a score between zero and eight assigned to each child between 6 and 23 months . One poiIn addition to analyzing the small area variation of not meeting the MDD, we analyzed the small area variation for each of the component food groups that makes up the MDD. As such, we had a total of nine outcomes: (a) not meeting the MDD; (b) not currently breastfeeding; (c) did not eat grains, roots, and tubers; (d) did not eat legumes and nuts; (e) did not consume dairy; (f) did not eat flesh foods; (g) did not eat eggs; (h) did not eat vitamin A-rich fruits and vegetables; (i) did not eat other fruits and vegetables. Thus, we partitioned geographic variation in each outcome and elucidated the foods most needed by children in any given place .i in cluster j, district k, and state l not meeting the MDD or not eating each of the eight component food groups using equation (1) 0represents the constant, while the random effects are the residual differentials for clusters j (ujkl0), districts k (vkl0), and states l (fl0). Each of the residual differentials is assumed to be normally distributed , between-district (vkl0), and between-state (fl0) variation. The variance at level one (children) is assumed to be a constant in binary models ]/[1 + exp(β0 + (ujkl0 + vkl0 + fl0)]) * 100. We calculated the standard deviations of these cluster percentages by district, which would be used to elucidate the small area variation for each outcome. We also generated precision-weighted estimates specific to each district for each outcome. The percentage of each child in the district not meeting the MDD or eating the specific food group was calculated using equation (3) (exp[β0 + (vkl0 + fl0)]/[1 + exp(β0 + (vkl0 + fl0)]) * 100.Next, we generated precision-weighted estimates specific to each cluster for each outcome. The percentage of each child in the cluster not meeting the MDD or eating the specific food group was calculated using equation (2)  met the MDD, while 58,493 (80.2%) did not. Additionally, of the 72,895 children in our sample, a total of 10,603 children were not breastfed in the past 24-h and 22,364 children did not eat grains, roots, or tubers. Overall, 62,513 children from the whole sample did not eat legumes and nuts, 37,403 did not eat dairy, 64,403 did not eat flesh foods, and 62,323 did not eat eggs in the past day. Finally, of the total 72,895 children, 43,125 did not eat vitamin A-rich fruits and vegetables, while 55,424 did not eat other fruits and vegetables in the previous day.Overall, we found that clusters were the largest source of geographic variation for the following outcomes: (a) grains, roots, and tubers (55%); (b) legumes and nuts (47%); (c) dairy (49%); (d) vitamin A-rich vegetables and fruits (49%); (e) other vegetables and fruits (55%). States were the largest source of geographic variation for the following outcomes: (a) total MDD (46%); (b) breastfeeding (51%); (c) flesh foods (65%); (d) eggs (62%). Districts accounted for the lowest source of geographic variation for all nine outcomes. These values are presented in We computed the cluster standard deviations (SD) of the percentages of each outcome by district. These values quantified the within-district variation, or the small area variation, for each outcome. For the overall MDD, the SD ranged from 0.05 to 14.4 (median 5.7). For breastfeeding, the SD ranged from 0.08 to 5.3 (median 1.7). The SD for grains, roots, and tubers ranged from 1.4 to 9.6 (median 5.4), and the SD for legumes and nuts ranged from 0.02 to 16.7 (median 4.9). For dairy, the SD ranged from 2.8 to 12.5 (median 7.6) and for flesh foods it ranged from 0.02 to 15.5 (median 2.2). The SD for eggs ranged from 0.02 to 17.6 (median 3.3). Finally, the SD for vitamin A-rich fruits and vegetables ranged from 2.7 to 11.4 (median 6.7) and for other fruits and vegetables from 0.6 to 12.7 (median 6.2). The distribution of the SDs for each outcome is presented in p < 0.001), and grains, roots, and tubers . However, we found significant negative correlations for the district percentages and cluster SDs of the overall MDD , legumes and nuts , flesh foods , eggs , vitamin A–rich fruits/vegetables , and other fruits and vegetables . We did not find a significant correlation for the district percent and cluster SD of dairy consumption. These correlation plots are presented in We examined the correlations between the district percentage and cluster SDs for each outcome. We found a positive correlation between the district percentages and cluster SDs for breastfeeding , while the districts with the highest percentage of children of not eating other fruits and vegetables were clustered in the west and north . Furthermore, the percentage of children not eating flesh foods, eggs, and dairy were high across all 640 districts, each of which are food groups associated with improved child growth outcomes , 43–47.https://dhsprogram.com/.Publicly available datasets were analyzed in this study. This data can be found here: the Indian Demographic Health Survey can be downloaded from: Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.AJ, RK, and SS: conceptualization, design, and data interpretation. AJ and WW: data acquisition and analysis. AJ: drafting of the manuscript. AJ, WW, KJ, RS, RK, and SS: critical revisions to manuscript. RK and SS: overall supervision. All authors contributed to the article and approved the submitted version.This research was funded by Bill and Melinda Gates Foundation, INV-002992.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.