This study is oriented to study the correlation between different vestibular symptoms and migraine and non-migraine headaches.A questionnaire containing factors related to vestibular symptoms and migraine was designed to survey nurses in a tertiary hospital. Then, all study subjects were divided into three groups: no headache, migraine, and non-migraine headache, and the general physical condition and incidence of different vestibular symptoms were compared among the three groups.Among all the 708 subjects, 233 had headaches. The incidence of migraine was 13.3%. There were 235 cases had vestibular symptoms. Dizziness and vertigo are independent factors related to headaches, especially migraine. The risk of migraine and other types of headaches in the vertigo group is 2.808 and 2.526 times of those without vertigo, while in the dizziness group, the risk is 8.248 and 5.732 times of those without dizziness.Different vestibular symptoms were all related to migraine. And different vestibular symptoms and non-migraine headaches also showed a clear correlation. In 2012, the Bárány Society first proposed and formulated the definition and diagnostic criteria of vestibular migraine and probable vestibular migraine (VM) , in whicMeanwhile, the 2009 International Classification of Vestibular Diseases defines vestibular symptoms as vertigo, dizziness, vestibulo-visual, and postural symptoms . A few sThis is a cross-sectional study conducted through a self-designed questionnaire among the nurses from a tertiary A hospital in Beijing. Researchers have undergone uniform training to be familiar with the contents of the questionnaire. The electronic questionnaire was distributed through the WeChat platform. Before distributing the questionnaire, researchers went to each department to conduct training for filling the questionnaire, clarifying the purpose, significance, and filling requirements of the survey to ensure its quality. The questionnaires are filled out voluntarily by the respondents. It takes about 20 min to complete each questionnaire. Complete and effective questionnaires are selected by researchers in the end.The nurses were on-the-job from January to June 2019. Inclusion criteria were as follows: (1) Registered nurses in tertiary A hospitals; (2) Female; (3) Engaged in ward nursing work with working experience no less than 3 years; (4) Can answer questions independently; (5) Volunteer to participate in the survey; (6) Vestibular dysfunctions such as Meniere’s disease and vestibular neuritis were excluded; (7) Organic lesions, such as acoustic neuroma, were excluded. Exclusion criteria were as follows: severe physical and mental illness and those who cannot complete the survey due to various reasons. A total of 1,052 questionnaires were distributed by the WeChat platform, 722 were recovered, and finally, 708 valid questionnaires were collected with 14 questionnaires deleted for missing Information .This study used a self-designed questionnaire, including the contents as following:Age, department , professional title , BMI, whether to work the night shift, addiction to tobacco or alcohol (yes or no), and exercise status. The exercise status includes the following: (1) Daily pedometer steps ; (2) Is it possible to guarantee moderate-intensity exercises more than 30 min at least twice a week? Chronic disease history includes the following: hypertension, hyperglycemia, hyperlipidemia, ototoxic drug, noise exposure which refers to an 8 h average exposure of greater than 83 dBA , and lonInclude the following: (1) headache history and (2) the modified ID-migraine: ① Your headaches limited your ability to work, study, or do what you needed to do for at least one day (Yes or No). ② You felt nauseated or sick to your stomach (Yes or No). ③ Light bothered you a lot more than when you do not have headaches (Yes or No). When ID-migraine was initially proposed, it only required to record headaches during the last 3 months. Individuals who indicated that they had two or three of these features were said to screen positive for migraine . HoweverIncluding (1) history of vestibular symptoms and (2) classification of vestibular symptoms, such as vertigo, dizziness, and postural symptoms. These three vestibular symptoms are defined as follows: vertigo is the sensation of self-motion when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement; dizziness is the sensation of disturbed or impaired spatial orientation without a false or distorted sense of motion; postural symptoms are balance symptoms related to maintenance of postural stability, occurring only while upright  ; (3) if The Peking University People’s Hospital Ethical permission committee approved the study (2019PHB099-01) and all subjects provided their informed consent.p values are bidirectional, and p < 0.05 values are considered statistically significant.SPSS 23.0 statistical software was used for statistical analysis. Frequency and percentage are used to describe the distribution, while the means are used to describe the average level. The Chi-square test and ANOVA are used to compare categorical and continuous variables, respectively. According to whether migraine was combined, all participants were divided into no headache group, migraine group, and non-migraine headache group. First, univariate analysis was used to screen statistically significant influencing factors, then multivariate analysis was used to explore the independent correlation factors between migraine and other types of headaches. All A total of 708 women nurses were enrolled in this study, with an average age of 32.39 ± 8.924 years old (23–57 years old), and an average BMI of 21.667 ± 3.08 (13.521–30.819). Among the nurses, 454 were in internal medicine and 254 were in surgery. Junior, middle level, and senior professional titles are 342, 225, and 141, respectively. The general physical condition was well, subjects with high blood pressure, diabetes, and hyperlipidemia were 53, 26, and 45, respectively. Subjects with smoking and drinking history were 4 and 15, respectively. The specific description of its epidemiological characteristics is shown in Among all the 708 subjects, 233 (28.7%) had headaches, with an average history of 7.91 ± 7.642 years, of which 94 cases were consistent with the diagnosis of migraine , accounting for about 13.3% of all subjects, and 40.3% of headache population. According to whether migraine was companied, headache patients were divided into migraine group (94 cases) and non-migraine headache group (139 cases) and included in the follow-up statistical analysis. The positive response rate of each question in ID-migraine is shown in Among all the 708 subjects, 235 (33.2%) complained of multiple vestibular symptoms, with an average history of 5.91 ± 6.551 years. Among them, 155 cases had only one single vestibular symptom, and 80 cases had multiple vestibular symptoms. According to the 2019 Bárány Association’s classification criteria for vestibular symptoms, this study divided vestibular symptoms into vertigo, dizziness, and postural symptoms, of which 96 cases were combined with vertigo, 173 cases were combined with dizziness, and 66 cases were combined with postural symptoms. The clinical characteristics of the vestibular symptoms are shown in According to whether migraine is accompanied, all the subjects were divided into three groups: no headache, migraine, and non-migraine headache group. Univariate analysis was used to screen out the statistically significant factors: age, professional title, whether to work night shifts, dizziness, vertigo, and postural symptoms, then all these factors were included in the following multiple logistic regression. The results showed that: different vestibular symptoms all showed a certain correlation with migraine, among which dizziness and vertigo were independent related factors of migraine and non-migraine headaches. The incidence of combining migraine and non-migraine headaches were 2.808 and 2.526 times that in the non-vertigo group, respectively. The incidence of combining migraine and non-migraine headaches was 8.248 and 5.732 times that in the non-dizziness group, respectively .Among all the 708 subjects admitted in this study, the incidence of headache and migraine were 28.7 and 13.3%, respectively. It has been reported that the incidence of idiopathic headaches in mainland China is about 23.8%, of which the incidence among women is around 36.8% . ResearcIn this study, the incidence of dizziness, vertigo, and postural symptoms were 24.44, 13.56, and 9.32%, respectively. About 1/3 of the subjects had complained about vestibular symptoms, which was close to the lifetime prevalence of dizziness and balance instability among American adults . Among aWe further found that different vestibular symptoms also correlated significantly with non-migraine headaches. Compared with vertigo group patients, the dizziness group patients were more likely to suffer from non-migraine headaches (5.732 vs. 2.526). These suggested that similar to migraine, non-migraine headaches could also be accompanied with vestibular symptoms. Migraine and tension-type headaches, the current most common primary headaches, were thought to be independent diseases according to the Similar to several epidemiological studies, this study had some limitations that need to be addressed. The first was the self-misclassification of study subjects, including (1) patients were given certain options to describe their subjective symptoms, and had to choose from them; (2) patients were not provided with sufficient options which could cover all specific subcategories, leading to wrong classification of their symptoms. Second, the age distribution of study subjects is not regular, which may cause some bias in the results. Third, the view that vestibular dysfunction may induce visual impairment is not commonly accepted by patients, and we focused mainly on the correlations between vestibular symptoms and headache. Therefore, the vestibular visual symptoms were not included in this study. Finally, we did not provide relevant questions about the diagnostic criteria of tension headache. Although a great portion of non-migraine headaches might be tension headaches, without accurate diagnoses, we could not explore the relationship between dizziness and tension headaches, which will be further explored in our future studies.Different vestibular symptoms were all closely related to migraine, among which dizziness and vertigo were both significantly related. Compared with patients with vertigo, patients with dizziness were more likely to be accompanied by migraine. This suggested that when diagnosing vestibular migraine according to current criteria, some patients with non-vertigo vestibular symptoms might be missed. On the other hand, different vestibular symptoms also showed a clear correlation with non-migraine headaches.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The Peking University People’s Hospital Ethical Permission Committee (2019PHB099-01). The patients/participants provided their written informed consent to participate in this study.XM, TD, and JZ supervised this research. XM and TD contributed to the analysis and interpretation of data and wrote the first draft of the manuscript. XM and LY made critical revision for important intellectual content. All authors contributed to the study conception and design, material preparation, and data collection, 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.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.


Inborn errors of immunity (IEIs) are being recognized as an important cause of morbidity and mortality in communities with a high frequency of consanguinity, such as Oman, and thus recessively inherited conditions. Various monogenic causes of IEI have been recently discovered; however, the disease phenotype may be variable and does not always include infection at presentation, leading to a delay in diagnosis and a poor outcome. It is now well recognized that immune dysregulation manifestations are observed in a significant proportion of patients with IEI and occasionally precede infection.Here, we retrospectively report the epidemiological, clinical, immunological, and molecular findings and outcomes from 239 patients with IEI who were diagnosed and managed at the Royal Hospital, Oman, from January 2010 to October 2021.The estimated annual cumulative mean incidence of IEI was 25.5 per 100,000 Omani live births with a total prevalence of 15.5 per 100,000 Omani population. Both the high incidence and prevalence are attributed to the high rate of consanguinity (78.2%). Defects affecting cellular and humoral immunity including severe combined immunodeficiency (SCID), combined immunodeficiency (CID), and CID with syndromic features were the predominant defects in IEI (36%). Immune dysregulation was a prominent manifestation and occurred in approximately a third of all patients with IEI (32%), with a mean age of onset of 81 months and a mean diagnostic delay of 50.8 months. The largest percentage of patients who showed such clinical signs were in the category of diseases of immune dysregulation (41%), followed by predominantly antibody deficiency (18%). The overall mortality rate in our cohort was 25.1%, with higher death rates seen in CID including SCID and diseases of immune dysregulation.Immune dysregulation is a frequent manifestation of Omani patients with IEI. Early detection through raising awareness of signs of IEI including those of immune dysregulation and implementation of newborn screening programs will result in early intervention and improved overall outcome. Inborn errors of immunity (IEIs) are a heterogeneous group of more than 400 primary immunodeficiency (PID) disorders, which are classified into 10 groups based on the involved pathophysiology, clinical phenotype, and genotype . PrevaleIn a historical cohort study performed over a 31-year period using a public administrative healthcare database in the USA, the incidence rate of IEI was approximately 10.3/100,000 person-years, with predominantly antibody deficiency (PAD) accounting for 78% of all cases compared to 10.5% for combined immunodeficiency (CID) including severe combined immunodeficiency (SCID) . HoweverA previous report from Oman described recurrent and severe infections as the only main clinical presentation of IEI . InfectiThis study aimed to collect information on the frequency and manifestation of non-infectious phenotypes in the current extended cohort of pediatric and adult patients with IEI in Oman. Additionally, we provide more recent data on the incidence, prevalence, molecular diagnosis, and outcome of IEI in the Omani population.via Excel and GraphPad Prism-9 . The results are expressed as means and medians with ranges and frequency (%) for continuous and categorical variables, respectively. The study was approved by the Research and Ethics Review and Approval Committee in the Ministry of Health, Sultanate of Oman.Data were extracted from electronic medical records by International Statistical Classification of Diseases (ICD)-10 codes (D80–D89) and were filled into Google forms and then an Excel sheet. A manual selection of patients was also performed, as some patients were not linked to ICD-10 codes. Further analysis was performed We performed an analysis of a cohort of 239 children and adults with IEI, who were seen and managed at the Royal Hospital—the main governmental tertiary hospital in Oman—from January 2010 to October 2021. The epidemiological details included the annual incidence per Omani live birth and the prevalence among the Omani population. The cumulative incidence was calculated by defining the mean of the yearly new diagnoses of IEI from the annual population of Omani live births obtained from local registries for the last 11 years. Given that most of our cohort were from the pediatric age group, the Omani live birth group was considered a reasonable population at risk to extrapolate a relatively true incidence. However, prevalence included all patients with IEI who were diagnosed from the Omani population over the last 11 years. Additionally, other information such as demographics (sex and age), family history, and clinical manifestations of infection, immune dysregulation, and malignancy, as well as molecular diagnosis, long-term events, and outcomes were collected into an electronic database. The adopted diagnostic criteria were based on The European Society for Immunodeficiencies (ESID) Registry Working Definitions for the Clinical Diagnosis of IEI . The claThe age of onset and age of diagnosis were grouped into the following eight categories: 0–2, 3–5, 6–10, 11–15, 16–20, 21–30, 31–40, and >40 years. The phenotypic and genotypic classification was based on the main categories of IEI described in the IUIS  assay for neutrophil function, a functional complement assay for classical and alternative hemolytic pathways and a CD11/CD18 expression assay for adhesion defect when clinically indicated.The laboratory evaluation included full blood count , basic lymphocyte subsets  and total serum immunoglobulin levels . Moreover, we also utilized a specific antibody panel for tetanus, diphtheria toxin, in situ hybridization (FISH), or microarray. Confirmed genetic diagnosis was determined when patient had a positive pathogenic or likely pathogenic genetic change that could explain the clinical phenotype. A note was made on the proportion of positive mutations according to the results of a commercial lab, National Genetic Centre (NGC), in Oman or via the help of external expert research laboratories. The novelty of the mutation detected was confirmed by reviewing the query interface on the ClinVar database. Genetic workup for patients with Predominantly Antibody Deficiency (PAD) (IUIS class III) was not frequently requested due to limited resources.Molecular diagnosis was obtained through whole-exome sequencing, Sanger sequencing, targeted mutation analysis, fluorescent The patients’ clinical outcomes were determined after reviewing the medical record system, noting long-term infectious and non-infectious manifestations. We also reported on the treatment options received, and information on the recent status was defined as follows: alive and well, alive with complications, need for Intensive Care Unit (ICU) admission, defaulted patients, mortality, and the contributions to mortality.The Sultanate of Oman is the second largest territory in the Arabian Peninsula with an area of 120,000 square miles, a total coastal border of 3,165 km, and a total population of 4,471,148 in 2020. The geographical location has led to open access to immigration and trading from various ancient civilizations in Asia and North Africa. Oman has two major tertiary referral centers for IEI, and one bone marrow transplant unit, which is limited to four beds. The Bacillus Calmette–Guerin (BCG) vaccine is a routine immunization at birth for all newborns. There is currently no newborn screening program for T- and B-cell deficiencies, and referrals from primary physician to tertiary units are based on clinical suspicion and previous family history of IEI. Most patients were referred from government primary or secondary hospitals (68.6%). This is the first report to describe our IEI cohort over the last 11 years.Two hundred thirty-nine (n = 239) patients were diagnosed and managed at the Royal Hospital over a period of 11 years (January 2010–October 2021). The estimated annual cumulative mean incidence of IEI was 25.5 (range: 20.0–29.8) per 100,000 Omani live births, and combined with the Middle East and North Africa region (MENA) Omani cohort , the totMost patients presented with infection  at clinical presentation, among whom 40 of them (16.7%) also had symptoms of immune dysregulation. Five patients presented with malignancy (2%), and the remainder were asymptomatic  at clinical presentation as they were familial.Mycobacterium bovis, including BCG strain , Mycobacterium tuberculosis , and atypical mycobacterium . Of note, most patients  received BCG vaccination at birth before diagnosis. The lowest reported infection etiology was protozoal agents . In regard to the frequency of infectious etiology among patients with infections (n = 219), approximately half  had up to two etiologies, a third  had three etiologies, and a fifth have four or more etiologies . The most commonly reported infection site was the respiratory tract (41.1%), followed by gastrointestinal (12.2%), cutaneous (8.5%), bacteremia and septicemia (8.4%), and other infections. The frequency of clinical presentations is grouped under infections, and the involved sites are illustrated in The mean age of infection episode onset was 42.6 months (range: 1–480). The documented infectious etiology varied but mainly included Gram-negative  and Gram-positive  bacterial infections; this was followed by viral infections including the common viruses , cytomegalovirus , Epstein–Barr virus, , and adenovirus ; fungal infections, including non-filamentous , filamentous , and dimorphic fungi ; and mycobacterial infections with Immunodysregulatory manifestations were prominent in 77 patients (32.2%), among whom 27 patients (35%) died and 5 patients received hematopoietic stem cell transplantation (HSCT), as it was clinically indicated for their phenotype and genotype . The mean and median age of onset of immune dysregulation was 81 and 25 (range: 1–480) months, respectively. The mean and median diagnostic delay in patients with immunodysregulatory manifestations was 50.8 and 19 months, respectively. Thirty-two patients were categorized as IEI with immunodysregulation (13.4%) according to IUIS classification, among whom the genotype of 21 patients (8.8%) was identified. The recorded immunodysregulatory manifestations included Omenn’s syndrome, recurrent oral ulcers, autoimmune cytopenia, lymphoproliferation, autoimmune enteropathy, autoimmune thyroid disease, autoimmune nephropathy, diabetes mellitus type 1, autoimmune arthritis, systemic lupus erythematosus, hemophagocytic lymphohistiocytosis, interstitial lung disease, autoimmune eye disease, and others. The features of the genotype, phenotype, and outcomes of patients with immune dysregulation are detailed in The mean and median age of malignancy episode onset was 54 and 36 months, respectively (range: 12–114). A malignant process was reported as Hodgkin’s lymphoma , non-Hodgkin’s lymphoma , and other malignancies .In more than a third of the patients, the basic immune workup revealed T-cell lymphopenia  and B-cell lymphopenia . Other observed cell line abnormalities excluding autoimmune cytopenia included anemia , neutropenia , thrombocytopenia , and eosinophilia . Various serum immunoglobulin abnormalities were detected including hypogammaglobulinemia , hypergammaglobulinemia , hyper-IgE , dysgammaglobulinemia , agammaglobulinemia , specific antibody deficiency , IgG subclass deficiency , IgA deficiency , and hyper-IgM . Other reported immunological findings were abnormal DHR123 assay , abnormal complement number and function assay , and abnormal expression of CD11/CD18 on flow cytometry .Genetic diagnosis was confirmed in 120 patients (50%), with a mean and median age of 59 and 21 months, respectively (range: 0.5–492). However, the median age (in months) of a delay in obtaining a genotype was 69 for class VI, 26.5 for class V, 21.5 for class III, 14 for class IV, 13.5 for class II, and 6 for class I. Homozygosity was paramount, as 90% of all genotypes were autosomal recessive in inheritance (n = 108). In addition to the known mutations associated with the described groups of IEI, we reported three mutations in genes described to cause IEI that are not yet classified into IUIS [LIFR , DIAPH1 One hundred thirty-one (54.8%) patients failed to gain adequate weight during their early life. Chronic lung disease constituted a major complication of IEI. Bronchiectasis , bronchial asthma , and interstitial lung disease  were the most commonly reported lung complications. End-organ damage  was recorded for the brain , hearing , liver , bone marrow , kidney , skin , and eye . In comparison to the overall median age of diagnostic delay (15 months), further delay was noted for patients with the following: bronchiectasis, 60 (2–453); combined end-organ damage, 32.5 (1–204); and bronchial asthma, 28.5 (1–396); and a lesser delay was observed for patients with ILD, 8.5 (2–84) months. Long-term enteropathy  was noted as one of the infectious and non-infections complications that contributed to morbidity.Management embraced frequent interaction with patients and their families. Extensive counseling was provided on nutrition, infection prevention, recognition of warning signs, adherence to action plans, and disease-specific treatment options. Proper assessment and follow-up of an individual clinical course for each patient were implemented. Most patients were evaluated by multidisciplinary teams for disease monitoring, complication prevention, and management. Management strategies included prophylactic antimicrobials , intravenous immunoglobulin (IVIG) reconstitution therapy , HSCT , targeted immune therapy , and biological therapy . One patient with complete 22q11.2 deletion syndrome received thymic transplantation. At the time of the study, 92 patients (38.5%) were alive and well, and 66 patients (27.6%) were alive but with complications and morbidity. Seventy-six patients (31.8%) had been admitted to the ICU at least once, and 21 patients defaulted (8.8%). The management of immune dysregulation involved high-dose immunoglobulin therapy and topical and/or systemic immunosuppressive therapy with corticosteroids, interleukin-1, and interleukin-6 receptor antagonists, calcineurin inhibitors, mammalian Target of Rapamycin (mTOR) inhibitors, Janus kinase (JAK) inhibitors, and anti-CD20 monoclonal antibody. All patients with Lipopolysaccharide-Responsive Beige-Like Anchor Protein (LRBA) deficiency received abatacept.The mean and median age of transplant was 32 and 19 months, respectively (range: 5–144). Among the 24 patients who received HSCT, 14 (58.3%) were reported to be in remission, 3 (12.5%) demonstrated rejection, and 2 (8.3%) had a relapse of original disease. Five patients are currently undergoing HSCT, with no conclusion of outcome at the time of this report. The donor source was a matched sibling in 12 patients (50%), haploidentical in 8 patients (33.3%), and a matched family donor in 4 patients (16.7%). More than half of the patients who received HSCT  were transplanted in centers abroad, while 10 patients (41.7%) received HSCT in Oman.The overall mortality rate was 25.1% (n = 60), with a mean and median age of 60 and 14 months, respectively (range: 1–408). The survival curve for patients with IEI is illustrated in The IUIS PID classification committee classified IEI into 10 major groups based on clinical and laboratory findings along with molecular diagnosis. The current study is the first to characterize 239 pediatric and adult patients with IEI in Oman and provides up-to-date detailed clinical and genetic data. The present results support a higher prevalence and incidence of IEI in such highly consanguineous community and poor survival. Early prevention and early management through screening programs for the classical T- and B-cell deficiencies as well as incorporating immunodysregulation as a warning sign for IEI are considered to represent effective approaches to improve survival.In this study, we analyzed the demographic, clinical, and molecular data and outcomes of 239 patients diagnosed with IEI at the Royal Hospital. In line with the previously reported high prevalence of consanguineous marriage rate in Oman (49%) , greaterAccording to a previous Omani study, Al-Tamemi et al.  describeSimilar to previously published literature, infection was found to be the predominant clinical presentation, followed by immune dysregulation and then malignancy. We also observed that symptomatic recurrent bacterial infections were the most common clinical presentation with the respiratory tract being the predominant site of infection. Failure to thrive, chronic lung diseases, infective lymphadenopathy, and enteropathy were major complications of IEI in our group. This is in agreement with previous studies conducted in Qatar, Kuwait, and Egypt , 6, 22.Interestingly, we found that immune dysregulation was prominent and occurred in approximately one-third of the patients (32%), which was a higher rate than that reported by previous studies from France 26%), Kuwait (20%), and ESID registries (18%) , 24. Dur%, KuwaitAnother relevant finding was that the prevalence of both CID and SCID exceeded the frequency of congenital functional phagocyte defects in this cohort. A similar pattern was observed by Barbouche et al.  in EgyptWe also found that 77% (n = 184) of this cohort had an attempt made toward obtaining molecular confirmation of their underlying IEI, with 50% n = 120/239) having their genetic defect identified. Compared to the global molecular diagnosis rate of 13.2%   and Kuwa%  and KuThis study is the largest in the country and addresses important factors that lead to poor outcome in patients with IEI. Our findings acknowledge the need to include immune dysregulation as one of the warning signs of primary immunodeficiency to avoid delayed diagnosis of patients with non-infectious manifestations. The higher mortality rate seen in patients with SCID/CID highlights the urgent need for proactive detection through the establishment of a national IEI newborn screening program. Finally, the development of a national IEI registry is a priority, as it will help to unify the national efforts and develop effective short- and long-term strategies. Addressing the above issues will pave the way for better disease ascertainment, phenotype characterization, early diagnosis, and early intervention, thereby improving the likelihood of positive health outcomes for Omani patients with IEI.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.TF: Conception of idea, research design, data collection, data management, analysis, report writing, and intellectual input. KA: Data collection and data management. JA: Critical reviewing and report writing. MK: Critical reviewing and report writing. MC: Critical reviewing. AH: Reviewing genotype. ZA: Data collection and data management. IN: Data collection and data management. NS: Conception of idea, research design, data collection, data management, analysis, report writing, and intellectual input. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To examine the efficacy of a complete nursing strategy during the perioperative phase for patients undergoing interventional treatment for hepatocellular cancer.  Sixty patients who were diagnosed with liver cancer and underwent interventional therapy in our hospital between February 2019 and December 2021 were recruited in this trial. All study subjects were numbered according to the time when the patients first came to our hospital, and were equally divided into a comprehensive group and a conventional group based on the odd and even number of the last number, with 30 cases in each group. Those in the conventional group received conventional nursing care, whereas patients in the comprehensive group received comprehensive nursing care. Before and after the nursing intervention, the quality of life, pain, and patient satisfaction in both groups were compared. P < 0.05); there was no statistically significant difference in numeric rating scales (NRS) scores between the two groups compared before treatment (P > 0.05). After treatment, the NRS scores of patients in the study group were significantly lower than those of patients in the control group (P < 0.05); before the intervention, the difference between the emotional state scores of patients in the two groups was not significant and not statistically significant (P > 0.05), while the emotional state of patients in both groups improved after the intervention, and the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) scores of patients in the comprehensive group were lower than those in the conventional group (P < 0.05); the total incidence of adverse reactions in the comprehensive group (10.00%) was significantly lower than that in the conventional group (46.67%) (P < 0.05); and the total satisfaction of patients in the comprehensive group (93.33%) was significantly higher than that of patients in the conventional group (73.33%) (P < 0.05).  The quality of survival scores, including physical, emotional, role, social, and cognitive function scores of patients in the comprehensive group, were significantly higher than those in the conventional group ( The intervention of a comprehensive nursing approach in the perioperative period for patients with liver cancer is remarkable as it can relieve patients' psychological burden and pain, ensure a smooth operation, improve patients' postoperative quality of life, and also help to reduce the risk of postoperative adverse reactions, effectively enhancing patients' satisfaction, and thus deserves to be promoted in clinical practice. Liver cancer , a maligAlthough the genesis and specific molecular processes of primary liver cancer remain unknown, the disease is thought to be a complicated process involving various causes and phases, including alcohol usage, viral hepatitis, moldy food ingestion, and genetics. Secondary liver cancer can be caused by different channels, such as blood, lymphatic migration, or direct penetration of the liver. Its symptoms are often asymptomatic in the early stage but more obvious in the middle and late stages, with common clinical manifestations such as liver pain, abdominal edema, anorexia, weakness, emaciation, progressive hepatomegaly, or epigastric mass. Years of clinical treatment data suggest that early-stage hepatocellular carcinoma is curable. However, therapy of medium and late-stage hepatocellular carcinoma is complex, with significant disparities in success. The key to improving efficacy is to provide tailored and complete therapy based on the stage of liver cancer. Liver cancer has become one of the most threatening diseases to society and human health, causing great pain and anxiety. Its clinical treatment methods include surgery, hepatic artery ligation, hepatic artery chemoembolization, radiofrequency, cryotherapy, laser, microwave, chemotherapy, and radiotherapy. According to the NCCN's American Cancer Treatment Guidelines, interventional therapy has been acknowledged as the preferred treatment for advanced liver cancer .Interventional Treatment of Hepatocellular Carcinoma (ITHC)  is a treNevertheless, with the development of the modern medical model, the theoretical system of modern nursing has deepened the connotation of nursing service and expanded the scope of nursing service. Under the new historical conditions, traditional Chinese medicine nursing has played a certain advantage. People have a new understanding of traditional Chinese medicine nursing technology and can rationally apply it to emergency treatment and psychological nursing of emergency patients. Therefore, traditional Chinese medicine nursing contributes greatly to the recovery of patients after surgery , 14. Acchttps://www.randomization.com).The participants included 60 patients who were diagnosed with liver cancer and underwent interventional therapy in our institution between February 2019 and December 2021, with 47 male patients and 13 female patients ranging in age from 39 to 84 years. All patients were numbered according to their first visit to our hospital and were equally divided into a comprehensive group and a conventional group according to their last number, both odd and even. Patients in both groups were treated with hepatocellular carcinoma intervention, with conventional nursing care for patients in the conventional group and comprehensive nursing care for patients in the comprehensive group. Thirty patients were enrolled in each group. Participants were randomly and equally allocated into two groups (placebo followed by ashwagandha or ashwagandha followed by placebo) using a randomization calculator , and all procedures were performed in compliance with the ethical guidelines in the Declaration of Helsinki.① Patients were examined accordingly and met the diagnostic criteria of liver cancer; ② patients had relevant treatment indications; and ③ patients and their families were informed of this study and voluntarily signed the consent form.① Combined with severe cardiopulmonary, hepatic and renal insufficiency; ② combined with psychiatric disease or unconsciousness; and ③ combined with coagulation dysfunction.All patients were treated with hepatic artery interventional chemoembolization, the Seldinger method: after puncturing the right femoral artery for hepatic arteriography, a catheter was delivered into the hepatic segmental artery; chemoembolization was then performed with cisplatin, doxorubicin, mitomycin, and 5-fluorouracil; after the procedure, symptomatic treatment with antibiotics was administered under the premise of protecting the liver.Patients in the conventional group were given conventional nursing modalities for intervention, including preoperative condition monitoring, control of blood pressure and blood glucose levels, assurance of stable vital functions, enhancement of nutrition and liver protection, monitoring of bleeding at the puncture site, explanation of the interventional procedure, preventive measures, complications, and patient predictability treatment measures.Patients in the comprehensive group were given a comprehensive nursing modality  for inteQuality of life: the Quality of Life Rating Scale (SF-36)  was usedPain condition: the Numeric Rating Scales (NRS) score was used to assess the patient's pain, the NRS score divided the pain into 10 levels, i.e., out of 10 points, where 0 points indicated no pain, 1–3 points indicated mild pain, 4–6 points indicated moderate pain, and 7–10 points indicated severe pain, with the score proportional to the patient's pain level, i.e., the higher the score, the more painful the patient was.Emotional status: the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS) , 18 wereAdverse reactions: the occurrence of adverse reactions, including fever, bleeding, urinary retention, gastrointestinal reactions, and liver and kidney function impairment, was recorded, and the total incidence of adverse reactions was calculated separately for the two groups and compared between groups.Satisfaction: our hospital's self-developed Nursing Satisfaction Questionnaire  was used and divided into four options  to understand the satisfaction of patients in both groups, so that the results could be used to analyze which of the two treatment modalities was more efficacious.s) and tested by the independent sample t-test. The count data were expressed as the number of cases (%) and tested by the chi-square test. P < 0.05 indicated that the comparison was statistically significant.The GraphPad Prism 8 software was used for graphics rendering, and SPSS 22.0 software was used for data analysis. The measurement data were expressed as (P > 0.05), The conventional group included 30 patients, 21 males and 9 females, with 24 instances of primary liver cancer and 6 cases of secondary liver cancer; the comprehensive group had 30 patients, 26 males and 4 females, with 18 cases of primary liver cancer and 12 cases of secondary liver cancer. The differences in general data between the two groups were not statistically significant (P < 0.05)  P > 0.05), and after treatment, the NRS scores of patients in the study group (2.99 ± 0.97) were significantly lower than those of patients in the control group (4.85 ± 1.11) (P < 0.05). The difference in NRS scores between the two groups before treatment was not statistically significant (P > 0.05). Both groups' emotional states improved after the intervention, and the SAS and SDS scores of the patients in the comprehensive group were lower than those of the conventional group (P < 0.05). Prior to the intervention, the difference in emotional state between the two groups was not statistically significant (P < 0.05). In the comprehensive group, there was 1 (3.33%) case of fever, 0 (0.00%) cases of bleeding, 1 (3.33%) case of urinary retention, 1 (3.33%) case of gastrointestinal reaction, and 0 (0.00%) cases of hepatic and renal impairment, all of which were lower than those of the conventional group (5 (16.67%) cases of fever, 3 (10.00%) cases of bleeding, 3 (10.00%) cases of urinary retention, 2 (6.67%) cases of gastrointestinal reaction, and 1 (3.33%) cases of hepatic and renal impairment). The overall incidence of adverse reactions in the comprehensive group (10.00%) was significantly lower than that in the conventional group (46.67%) (P < 0.05). The results showed that 10 (33.33%) patients in the conventional group were “very satisfied,” 12 (40.00%) were “satisfied,” 6 (20.00%) were “less satisfied,” and 2 (6.67%) were “dissatisfied”; 13 (43.33%) patients in the comprehensive group were “very satisfied,” 15 (50.00%) were “satisfied,” 1 (3.33%) was “less satisfied,” and 1 (3.33%) was “dissatisfied”; the total satisfaction of patients in the comprehensive group (93.33%) was significantly higher than that of patients in the conventional group (73.33%)  was significantly lower than that in the conventional group (46.67%). Although interventional therapy is less invasive, in the case of artificially invasive procedures, patients are infused with large amounts of chemotherapeutic drugs during embolization, making it prone to a certain degree of postoperative side effects and complications, and even adversely affecting the therapeutic outcome , 26. ConThe limitations of this study need to be addressed. First, this pilot study might not have a sufficient total sample size to confirm the efficacy. Future studies should endeavor to recruit larger sample sizes to compare and verify the treatment effects. Second, we did not conduct a long-term observation. Whether it has a long-standing efficacy of action will need to be investigated in the future.In conclusion, comprehensive nursing intervention in the perioperative period for patients with liver cancer is effective in reducing patients' psychological burden and pain, ensuring smooth surgery, improving patients' postoperative quality of life, and assisting in the reduction of the risk of postoperative adverse reactions, which can effectively elevate patients' satisfaction and is thus worthy of promotion in clinical practice.


P, employing various computational approaches. Similarities and dissimilarities between experimental and computational logP were studied using principal component analysis, cluster analysis, and the sum of ranking differences. Furthermore, quantitative structure–retention relationship modeling was applied to understand the influences of sulfonamide’s molecular properties on lipophilicity and affinity to phospholipids.Sulfonamides are a classic group of chemotherapeutic drugs with a broad spectrum of pharmacological action, including anticancer activity. In this work, reversed-phase high-performance liquid chromatography and biomimetic chromatography were applied to characterize the lipophilicity of sulfonamide derivatives with proven anticancer activities against human colon cancer. Chromatographically determined lipophilicity parameters were compared with obtained log Due to inadequate pharmacokinetic properties, many drug candidates are rejected during clinical trials. Under those circumstances, besides biological activity, the physicochemical properties of putative drug molecules must be optimized at the early stage of drug development. These actions are carried out to achieve the desired in vivo drug metabolism and pharmacokinetics (DMPK) profile . Among aP. The International Union of Pure and Applied Chemistry (IUPAC) and the Organization for Economic Co-operation and Development (OECD) consider RP-HPLC an equivalent method to the traditional shake-flask approach for logP estimation. Generally, the chromatographic technique is low-cost, fast, and requires a small amount of target substances that do not need to be pure, as their impurities are readily separated during the chromatographic process. Furthermore, the chromatographic analyses are repeatable and robust. For these reasons, the solid–liquid partitioning methods are very convenient in the early steps of the drug discovery pipeline, when high throughput is more required than accuracy.The lipophilicity is a crucial physicochemical parameter of every molecule, affecting toxicity, absorption, distribution, metabolism, and drug elimination . RetentiAdditionally, the current chromatographic approach can be more similar to the biological partition process since available stationary phases are covered on even more similar or similar components of in vivo distribution media. Such an approach is called biomimetic chromatography. Generally, biomimetic chromatography combines the advantages of high throughput analysis, which are being user-friendly, rapid, reproducible, and compound sparing with the ability to reflect physiological conditions ,6,7. An Sulfonamides are a classic group of chemotherapeutic drugs with a broad spectrum of pharmacological action . HistoriN-acylsulfonamides have been clinically investigated as drug candidates with cytostatic activity against tumors: LY573636-sodium salt (Tasisulam) [Among the anticancer sulfonamides, the arylsulfonamides with clinical importance in the treatment of severe diseases are pazopanib  ,18, belisisulam) ,22, ABT-sisulam) , ABT-263sisulam) ,25 and Asisulam) ,24,25,26N-benzenesulfonamides, N-benzenesulfonamides and N-(heteroaryl)-4-(1H-pyrrol-1-yl)benzenesulfonamides has been proven for human colon cancer (HCT-116) cell [N-acylated benzenesulfonamides, which contained at the benzene ring the 1-naphthylmethylthio substituent and the sulfonamidic nitrogen atom bonded to acetic acid or cinnamic acid residues [P. Furthermore, Quantitative Structure–Retention Relationship (QSRR) models, which allow for predicting the retention or lipophilicity of these chemical compounds, have been proposed. Finally, we aimed to analyze which type of lipophilicity indices, computational or chromatographic, provided a better prediction of anticancer activity expressed as pIC50. The obtained models were used using the genetic algorithm partial least squares (GA-PLS) approach.Broad-spectrum antitumor activity depends on the substituents at the benzene ring of arylsulfonamide and the moieties attached to the nitrogen atom of the sulfonamide group. Recently, pro-apoptotic activity of 16) cell ,28,29. Aresidues . Similarresidues ,32. The P values for the same molecules using various theoretical approaches are the computational methods’ crucial limitations [It is well established that the computational approaches for lipophilicity estimation have several advantages over the experimental methods, including short calculation time and saving chemical reagents. Furthermore, it allows for lipophilicity prediction before synthesis; therefore, it can be applied to the design of potential drug candidates. These advantages make computational approaches desirable from economic and environmental points of view. Nevertheless, it should be emphasized that significant differences between the calculated logitations ,34,35,36P values for the investigated sulfonamides derivatives. As can be observed in P values are very diversified within a single substance. On average, within one molecule, the calculated logP values vary by four LogP units. It is most noticeable for molecule no. 21, where the difference between WLogP and iLogP states 7.3 clogP units. Indicated differences can be explained by the varied nature of the algorithms employed in the applied software programs [P values are achieved by the iLogP descriptor (in 16 cases), and the MLogP descriptor follows it in 10 cases. The iLogP descriptor is a physics-based algorithm established on free solvation energies, whereas the MLogP descriptor investigated the hydride algorithm of topological and molecular properties. Each compound has a logP with a value less than five for both mentioned algorithms and reached the Lipinski rule of five [P is observed for descriptor WLogP, based on purely atomistic methods.Similarly, this is also evident in the calculated logprograms . The low of five . On the 1. Nevertheless, selecting the most lipophilic substance based on calculated logP is difficult. According to the descriptors WLogP (atomistic method), Silicos-IT LogP , and Consensus LogP , the most lipophilic compound is no. 21. However, compounds 19, 27, and 11 are the most lipophilic accordingly to the descriptors iLogP, XLogP (atomistic and knowledge-based method), and KOWWIN LogP . Additionally, compound no. 27, in the case of the XlogP descriptor, is also the most lipophilic substance according to the MlogP descriptor.Among tested derivatives, the most hydrophilic substance, according to each algorithm, is compound no. kw value, so the retention factor was extrapolated to the pure water after calculation using a protocol based on two gradient measurements and DryLab software [18 chromatography, we applied protocols proposed by Valko and co-workers [kIAM [The obtained contradiction suggested that it is still worth using experimental methods to assess drug candidates’ lipophilicity. For this reason, the next step of our study concerns the characterization of investigated sulfonamide derivatives using a chromatographic approach. Generally, in RP-HPLC, the interactions between solutes and the stationary phase surface are mainly governed by lipophilicity ,39,40. Csoftware ,43. In t-workers ,45 and srs [kIAM  and CHI rs [kIAM  using thSince the biomimetic chromatography experiments are carried out at physiological pH to compare obtained results, all chromatographic experiments have been carried out at pH 7.4. Calculated pKa indicates that sulfonamide derivatives molecules are in a charged state. Consequently, the chromatography lipophilicity indices refer to the distribution coefficient (logD) values, which better reflect the lipophilicity of ionized substances under physiological conditions. The chromatographically obtained lipophilicity indices of sulfonamide derivatives are presented in 18, and C8 columns (r < 0.91). On the contrary, significantly lower correlation coefficients were achieved for the Ph and CN columns and the above-mentioned stationary phase (0.76 < r < 0.89), indicating a significant difference in the sulfonamide retention mechanism using these beds.As might be expected, the obtained chromatographic indexes are generally highly correlated . A high 1 turned out to be the least lipophilic substance. The calculation methods provided the same conclusion as experimental methods in selecting the least lipophilic drug candidate from tested sulfonamide derivatives. Contrarily, the most lipophilic properties are in compound no. 4, taking only the chromatographic experiments. However, none of the calculation algorithms selected this molecule as a highly lipophilic substance. Surprisingly, according to the calculation methods, it is one of the least lipophilic derivatives. These data indicate that experimental methods are still necessary for the drug development pipeline. Based on the experimental data, compound no. 1–4 and 26, can be recommended. Assessing the overall lipophilicity of the tested compounds, it can be said that it is at a reasonably high level. Compounds containing the 1-naphthyl substituent are especially more lipophilic. To obtain a lower, more desirable lipophilicity, the phenyl substituent should be more desirable because the analyzed compounds which comprise it, as a rule, had significantly lower lipophilicity.Considering the proportion of lipophilicity and anticancer activity, the assumption that the compound should be characterized by the lowest lipophilicity while maintaining pharmacological action for further tested molecules, Next, we aimed to analyze similarities and dissimilarities between chromatographic and computational lipophilicity indexes of the target molecules; therefore, the principal component analysis (PCA), cluster analysis (CA), and the sum of ranking differences (SRD) were performed. 1–7) and the second one where other derivatives are grouped. Our strategy also allows us to compare the similarity of anticancer activity expressed as pC50 concerning computational and experimental methods, determining lipophilicity. Interestingly, pIC50 is a group close to chromatographic that determines lipophilicity. Therefore, we cautiously conclude that chromatographic indices can be more effective for predicting anticancer activity than computational lipophilicity indices.The CA analysis results are presented in 2 it mainly affected the mainly chromatographic parameters, except IAM chromatography. Interestingly, the IAM stationary phase has a significant impact on both PCs. The surface of IAM is mostly zwitterionic at pH 7.4, and positively charged choline moieties are located in the outer part of the IAM layer. In contrast, the phosphate groups are negatively charged at the same pH and present in the phase’s inner part. This distinguishes the IAM phase from the rest tested RP-HPLC beds.Similar results are observed on the PCA , where tThe next step of our investigation concerned the application of SRD analysis to select the best and the worst approaches for lipophilicity measurement. The limitations of unsupervised chemometric tools such as PCA and CA are that these methods do not provide any information about statistical figures of performed analysis. Consequently, the SRD analysis was used to complete the data analysis and support the selection of the best lipophilicity indices. x-axis and left y-axis, while the right y-axis gives the cumulated relative frequencies for random ranking (black curve). The presented graph indicates the following facts: the Consensus LogP descriptor is placed closest to the reference ranking and can be considered the right choice for lipophilicity estimation of the studied series of compounds; the parameters logkwCN, CHI logDC18 and logkwPh are places furthest from the reference ranking and therefore are depicted as the least suitable lipophilicity descriptors of sulfonamide derivatives; specific groupings of the parameters can be observed; WlogP, Silicos-IT LogP and XLogP3 have very close SRD values and the same stands for logkIAM and LogP KOWWIN descriptors as well as for logkwCN, CHI logDC18 and logkwPh parameters; looking globally, there are two clearly visible gaps  and 1b ; cluster #2 contains MLogP, XLogP3, Silicos-IT LogP, WLogP and Consensus LogP parameters. The groupings of the parameters suggested in the SRD graph and the dendrogram comply with each other.The SRD procedure was validated by 7-fold cross-validation. The results are presented in two ways in P parameter has the lowest median of the SRD data and is definitely depicted as the best lipophilicity parameter among the other calculated and experimentally determined parameters. There is a significant difference between the lipophilicity parameters separated by vertical dotted lines at the 5% level according to the Wilcoxon matched-pair test, which agrees with the separation of the parameters suggested in the SRD graph , polarizability (G2p), and geometrical properties (WHALES00_IR) significantly affect the anticancer activity of this class of chemicals. Nevertheless, comprehensive research is needed on a larger group of compounds to generalize this statement.Next, we aimed to analyze which type of lipophilicity indices, computational or chromatographic, provided a better prediction of anticancer activity expressed as pIC2R,2,Q and RMSECV) and show suitable predictive parameters (RMSEP). Additionally, the applicability domain assessment (AD) and the y-randomization tests were performed for each model.The statistical figures of the training and testing set indicated that obtained models are well fitted (x-axis) are plotted against standardized residuals (y-axis) on a so-called William’s plot. The leverages are calculated from the descriptor matrix and then compared to a critical h* value, represented by a vertical dashed line. Additionally, values of 3 (±σ) standardized residual units  define the cut-off value for acceptable predictions. The study revealed that in three models .Each developed model was additionally subjected to a y-randomization test to confirm their robustness and that the linear relationships are not derived by chance . The perH-pyrrole derivatives, 5-oxo-1,2,4-triazine derivatives, 1,2,4-triazine derivatives, and N-acylbenzenesulfonamides. All sulfonamide derivatives have confirmed in vitro anticancer activities against human colon cancer (HCT-116) expressed as pIC50 and shown in The chemical names and SMILES notation of the target sulfonamide derivatives are presented in IAM) and C18 (CHIC18). The analytical standards of acetaminophen, acetophenone, benzimidazole, colchicine, indole, and theophylline were purchased from Sigma-Aldrich . Octanonophenone, butyrophenone, and acetanilide were obtained from Alfa Aesar . Heptanophenone, hexanophenone, valerophenone, propiophenone, and acetophenone were bought from Acros Organic .The model substances were utilized to obtain the chromatographic hydrophobicity index of IAM (CHI−1) was purified and deionized in our laboratory via a Millipore Direct-Q 3 UV Water Purification System  to prepare the mobile phase. Ammonium acetate, disodium phosphate (Na2HPO4), and monosodium phosphate (NaH2PO4) were purchased from POCH . Dimethyl sulfoxide (DMSO), used as a solvent, was from Merck . Acetonitrile and 2-propanol (LiChrosolv®) gradient grade for liquid chromatography was purchased from Sigma-Aldrich . The water (18.2 MΩ × cmR) of investigated sulfonamides were collected, and their detection in all systems was performed at the wavelength characteristic for each compound, summarized in IAM and CHI18 indices of the target sulfonamides derivatives were obtained using the protocol proposed by Valko and co-workers [18 chromatography was performed on a Waters-C18 column , with a 1.5 mL/min flow rate. The mobile phase was ammonium acetate buffer (50 mM) at pH 7.4 and acetonitrile as an organic modifier. The linear gradient from 2 to 98% ACN was applied from 0 to 30 min. IAM chromatography was executed on an IAM.PC.DD2 column  additionally equipped with an IAM guard column with the same flow rate of 1.5 mL/min. The mobile phase was sodium phosphate buffer (10 mM) at pH 7.4 and acetonitrile as the organic phase. The linear gradient from 0 to 85% was applied within 5.25 min. All HPLC experiments were carried out using a Prominence-1 LC-2030C 3D HPLC system  equipped with a DAD detector and controlled by the LabSolution system . The stock solutions of solutes were diluted to obtain 100 μg/mL concentrations, and the injected volume was 10 μL. During this study, six different columns in terms of chemical modification of stationary phases were used. Retention times  were obtained. Two retention times for each system in two different gradients (short and long) were collected, and these data, as input, were introduced into DryLab 6.0 software . Dwell volume for these HPLC systems was measured at 0.780 mL, whereas the obtained dead times for used HPLC columns were equal to 1.530 min, 1.252 min, and 2.335 min for C8, SB-CN, and UK-Phenyl, respectively. The mobile phase was ammonium acetate buffer (50 mM) at pH 7.4 and acetonitrile as an organic modifier in each system. C8 chromatography was performed on Unison UK-C8 column  with 0.3 mL/min flow rate. Analyses were carried out in linear gradient from 30 to 100% within 15 min in short gradient and 30 min in long gradient. The Agilent SB-CN column  was used for the cyanopropyl chromatography. The CN chromatography analyses were carried out in linear gradient from 20 to 100%, which was applied from 0 to 20 min in short gradient, and from 0 to 40 min in long gradient. The flow rate was 1.5 mL/min. The column Unison UK-Phenyl  was used to perform phenyl chromatography. The flow rate was set to 0.2 mL/min. The phenyl analyses were carried out in linear gradient from 40 to 100%, which was applied from 0 to 20 min in short gradient, and from 0 to 40 min in long gradient. Each HPLC analysis was run in triplicate; in For C-workers ,43, apprhttps://xundrug.cn/molgpka, accessed on 1 March 2022). Finally, 3352 descriptors belonging to 31 classes were calculated.The theoretical descriptors were calculated applying alvaDesc software  and basehttp://www.swissadme.ch, accessed on 1 March 2022) and KOWWIN v. 1.68 software  were used for lipophilicity calculations based on the SMLIE notation. Calculated lipophilicity indexes are summarized in SwissADME software  and the testing group (n = 9). The training set always contains the molecule with the highest and lowest value of the modeled endpoint. The information on the belonging of each compound to a training or testing set is included in Descriptors selection was supported by a genetic algorithm (GA), whereas multiple linear regression (PLS) was employed as a regression method. The QSRR models were built using the retention data and the calculated descriptors as dependent and independent variables, respectively. The set of parameters applied to control GA was the size of the population (500) and the mutation rate (0.1). The models were built using three LVs and five structural descriptors in each variable. The optimization of the models was carried out based on R2R), external validation coefficients , root-mean-squared error of cross-validation (RMSECV), root-mean-square error in prediction (RMSEP) and concordance correlation coefficient (CCC). Applied statistics were calculated using the following formulas:The following statistical figures were used for assessment of model fitting and predictive abilities: the coefficient of determination (50 was used as the independent variable, and the dependent variables were lipophilicity parameters, both computational and chromatographic, and the remaining structural descriptors obtained.The same procedures were used to calculate the quantitative structure–activity relationship model, where the pICkIAM could be considered the best choice. Consequently, IAM-HPLC can be recommended as the most sustainable method for the lipophilicity characterization of this class of chemical compounds. From the practical point of view, considering the ratio between lipophilicity and anticancer activity, according to the assumption that the compound should be characterized by the lowest lipophilicity while maintaining pharmacological action for different tested molecules, compounds 1–4 and 26 can be recommended.Both PCA and CA showed significant differences between the chromatographically determined lipophilicity and calculated ones. Although the grouping results can be explained by ionization, since the calculation methods do not include information about the ionization of the compounds all the time, significant differences between the values calculated by different algorithms affect the credibility of the results obtained through the computational approach. SRD indicated that among the chromatographic lipophilicity parameters of the analyzed sulfonamide derivatives, log


IntroductionWhen COVID-19 vaccination started, there was little data on the safety of immunization against COVID-19 infection in pregnant women. Previous studies revealed no safety concerns for pregnant women or newborns who received a messenger ribonucleic acid (mRNA) COVID-19 vaccine during pregnancy. This study aimed to investigate the effects of COVID-19 vaccination on pregnant women and on perinatal outcomes.MethodsThis cross-sectional study was conducted in a maternity hospital in King Saud Medical City. It started in January 2022 and ended in June 2022. The questionnaire was developed and validated by experts. This study included all women admitted to the postpartum ward who were more than 18 years old and had received the COVID-19 vaccine. The study excluded women who had no proof of their vaccination status or who could not complete the questionnaire. The primary outcome was the effect of COVID-19 vaccination on gestational age and birth weight. The secondary outcomes included the development of polyhydramnios, oligohydramnios, mode of delivery, Apgar score, postpartum hemorrhage, and neonatal intensive care unit admission.ResultsA total of 365 pregnant women participated in this study. The mean gestational age of the unvaccinated women was 38.83 ± 1.62 weeks, which was significantly (p < 0.001) higher than that of vaccinated women (37.69 ± 2.9 weeks). In addition, the average birth weight for the unvaccinated women was 2.96 ± 0.4 kg, which did not differ significantly (p = 0.89) from that of vaccinated women (2.97 ± 0.66 kg).ConclusionCOVID-19 vaccination, regardless of the type of vaccine received before, during, or after pregnancy, is not associated with any unfavorable perinatal outcomes for pregnant women or neonates. COVID-19 was considered a devastating worldwide pandemic after it caused the deaths of millions of people worldwide -4 . CompThis cross-sectional study was conducted in a maternity hospital in King Saud Medical City (KSMC) from January 2022 to June 2022 after being approved by the KSMC’s institutional review board, with reference number H1RI-06-Feb22-01. The questionnaire was developed and validated by experts. A pilot study was conducted before starting the official study to test the validity of the questionnaire, and the pilot study participants were excluded from this study. All participants gave their written informed consent before they were included in the study. Each participant’s vaccination status was checked using the Tawakkalna , SAU) mobile application, which showed the vaccination status . This application is mandatory for all citizens, whether Saudi or non-Saudi. In this study, all women admitted to the postpartum ward who were more than 18 years old and who had received the COVID-19 vaccine  either before or during pregnancy were included as one arm and compared to unvaccinated women as a second arm. We excluded women who either did not have proof of their vaccination status or who refused to complete the questionnaire.The questionnaire was divided into two parts; the first part contains the participants’ demographic data such as their age, height, previous obstetrical history, smoking habits , and immunization status against COVID-19, including the number of COVID-19 vaccine doses they had already received and whether they were unvaccinated. Furthermore, the type of COVID-19 vaccine received  and the pregnancy trimesters when the COVID-19 vaccine doses were received were reported. The second part of the questionnaire contains the pregnant women’s medical history, such as the gestational age at delivery, chronic diseases, or any health conditions, including preeclampsia, premature birth, or gestational diabetes. Pregnancy-related hypertension illnesses, oligohydramnios, polyhydramnios, or amniotic fluid stained with meconium were other pregnancy issues that were investigated. In addition, delivery and postpartum were studied including the types of delivery  or any placental abruption that may have occurred during labor as well as postpartum hemorrhage or fever. Moreover, NB characteristics were recorded, such as birth weight, Apgar score, and neonatal intensive care unit (NICU) admission. After the sample was completed, the participants were divided into two groups, vaccinated and unvaccinated women, and thereafter the data was analyzed to show the differences. The primary outcome was the effect of the COVID-19 vaccine on gestational age and birth weight. The secondary outcomes included the development of polyhydramnios, oligohydramnios, mode of delivery, Apgar score, postpartum hemorrhage, and NICU admission. The mother and the NB were followed up until the time of discharge from the hospital. Data were collected, cleaned, and verified in an Excel sheet, after which they were coded and analyzed using Statistical Product and Service Solutions (SPSS) . Chi-square and analysis of variance (ANOVA) tests were used to compare the variables to each other.2, and the modal age range was 26-35 years. A total of 289 participants had taken the first dose of the COVID-19 vaccine, 266 had taken the second dose, and 102 had taken the third dose. Approximately 57% of the subjects had COVID-19 previously, either before or during pregnancy. It was noticed that some subjects had become infected with COVID-19 after vaccination, with 88 (24%) during pregnancy and 116 (32%) after delivery. We found that 32 women had gestational diabetes, 26 had hypertension, and 33 had preeclampsia.Data were collected by professionals from the postpartum ward. A total of 365 women filled out the questionnaire. The mean body mass index was 28.6 ± 5.1kg/mRegarding amniotic fluid changes, it was noticed that 14 participants had oligohydramnios and 14 had polyhydramnios. It was found that 197 women had a vaginal delivery, 166 underwent cesarean delivery, and only two NBs were delivered by vacuum. It was also found that 14 participants had placenta abruption and 26 experienced postpartum hemorrhage. These complications affected the length of hospitalization because it was found that 184 women were hospitalized for one day, 141 for two to three days, and 40 for more than three days, as shown in Table The main finding results showed that the mean gestational age for the unvaccinated women was 38.83 ± 1.62 weeks, which is considered significantly higher (p = 0.001) than that for vaccinated women (37.69 ± 2.9 weeks). However, the average gestational age of vaccinated women with the second and third doses was similar to that of vaccinated women with the first dose .Corresponding results showed that the mean birth weight for unvaccinated women was 2.96 ± 0.4 kg, which did not differ significantly (with p = 0.89) from the mean birth weight for vaccinated women (2.97 ± 0.66 kg). It increased after the second and third doses to 2.98 ± 0.68 kg and 3.11 ± 0.56 kg, respectively. None of these variations were statistically significant, as shown in Tables A comparison of the gestational age at delivery and birth weight between vaccinated and unvaccinated delivered women is shown in Figure Conversely, regarding the perinatal outcome for NBs, we found that 14 NBs had respiratory complications, two had a fever, and 24 NBs were admitted to the NICU, but we noticed that none tested positive for COVID-19 irrespective of whether the mothers were vaccinated or unvaccinated.The Saudi government offered free COVID-19 vaccines to all clients, irrespective of whether they were Saudi or non-Saudi citizens. The Saudi Minister of Health approved Pfizer-BioNTech, Moderna, Oxford-AstraZeneca, and Johnson & Johnson COVID-19 vaccines; however, the participants of this study received all types of vaccines except for the Johnson & Johnson vaccine. KSMC is a tertiary center in Riyadh with approximately 6000 deliveries annually, according to KSMC statistics. This study demonstrated that hypertension-related diseases occurred more in the vaccinated group than in the unvaccinated group, and this result is comparable to that of a previously published study, which showed that the COVID-19 vaccine might play a role in acute blood pressure elevation due to an imbalance between angiotensin II (overactivity) and angiotensin  . PreeclStrengthThis study examines women who received the COVID-19 vaccine before or during pregnancy with all the available types of vaccine at the time of the study.LimitationsIt is a single-center study that lacks extended follow-up of NBs.At the start of the pandemic, safety data on COVID-19 immunization in pregnant women and perinatal outcomes were scarce. However, later evidence demonstrated that the administration of COVID-19 vaccines to pregnant women had no harmful maternal or neonatal consequences. Our findings add to the growing body of evidence supporting the safety of COVID-19 vaccination for pregnant women prior to, during, and after pregnancy. Our study confirmed that the COVID-19 vaccine, regardless of the type received, has no adverse perinatal outcomes for pregnant women or NBs. Moreover, the vaccines from Pfizer, Moderna, and AstraZeneca were all safe, with only minor changes in gestational age and birth weight.


Plant protein sources, as a part of developing sustainable food systems, are currently of interest globally. Brewer’s spent grain (BSG) is the most plentiful by-product of the brewing industry, representing ~85% of the total side streams produced. Although nutritionally dense, there are very few methods of upcycling these materials. High in protein, BSG can serve as an ideal raw material for protein isolate production. This study details the nutritional and functional characteristics of BSG protein isolate, EverPro, and compares these with the technological performance of the current gold standard plant protein isolates, pea and soy. The compositional characteristics are determined, including amino acid analysis, protein solubility, and protein profile among others. Related physical properties are determined, including foaming characteristics, emulsifying properties, zeta potential, surface hydrophobicity, and rheological properties. Regarding nutrition, EverPro meets or exceeds the requirement of each essential amino acid per g protein, with the exception of lysine, while pea and soy are deficient in methionine and cysteine. EverPro has a similar protein content to the pea and soy isolates, but far exceeds them in terms of protein solubility, with a protein solubility of ~100% compared to 22% and 52% for pea and soy isolates, respectively. This increased solubility, in turn, affects other functional properties; EverPro displays the highest foaming capacity and exhibits low sedimentation activity, while also possessing minimal gelation properties and low emulsion stabilising activity when compared to pea and soy isolates. This study outlines the functional and nutritional properties of EverPro, a brewer’s spent grain protein, in comparison to commercial plant protein isolates, indicating the potential for the inclusion of new, sustainable plant-based protein sources in human nutrition, in particular dairy alternative applications. Protein ingredients isolated from plant sources are gaining popularity, in part due to the increasing emphasis by the consumer on health and ethics, as well as the worldwide movement towards sustainability and reducing the impact on the environment ,2. PopulAlongside this, the demand for plant-based dairy alternatives is on the increase. However, in many instances, the nutritional value of these products is sub-par when compared to their animal-based counterparts. In particular, plant-based milk substitutes are nutritionally lacking with regard to protein. A study by Jeske et al. (2017) evaluated commercially available plant-based milk alternatives and found that 50% of the analysed products had a low protein content, with 11 out of 17 containing <1% protein, compared to bovine milk ~3.5%). Only beverages prepared with soy protein could be described as comparable to bovine milk with regards to protein content [.5%. OnlyHordeum vulgare, vulgare L) is one of the most widely cultivated crops and is the main grain used in the production of alcoholic beverages worldwide [Barley  is one of the most commonly used and well-researched plant protein sources available to consumers and to food businesses looking to include plant proteins in their products. Several different brands are offering pea protein isolates and many products are formulated using pea protein ingredients, including milk alternatives, dried snacks, bars, meat alternatives, among many other food and beverage products. Pea protein is known for its high nutritional value, especially regarding amino acids composition, low allergenicity, and widespread availability, as well as its low cost [In contrast to this, pea  is another widely researched and commonly used source of plant-based protein, and has been in use since ancient times [Similarly to pea, soybean . Pea protein isolate (PPI) and soy protein isolate (SPI) were obtained from Naturz Organics . All chemicals were sourced from Sigma–Aldrich , unless otherwise stated.Compositional analysis was carried out using the following methods: protein was measured using the Kjeldahl method (AACC Method 46-12)  using a The quantification of mono-, di-, galactooligosaccharides, fructans, and polyols were conducted using high-performance anion-exchange chromatography coupled with pulsed amperometric detection (HPAEC-PAD), performed on a DionexTM ICS-5000+ system , as described by Ispiryan et al. (2019) . All carThe pH and TTA were determined using the method of Waters et al. , with mow/v) were prepared using distilled water. The pH was adjusted to pH 7 using HCl and NaOH  of varying concentrations and the samples were hydrated overnight at 4 °C. After equilibrating to room temperature and further pH adjustment, if necessary, the samples were frothed using an Ultra-Turrax equipped with a S10N-10G dispersing element , at maximum speed for 30 s. The height of the sample (foam phase only) was measured immediately and after 60 min. Foaming capacity was measured as % sample expansion at 0 min, while foam stability was measured as the sample expansion at 60 min as a percentage of sample expansion at 0 min. Sample expansion was calculated using the following equations [Dispersions with a sample concentration of 2% (quations :(1)Foamig for 30 min. The oil was decanted from the tube carefully and the pellet was re-weighed. The FAC (%) was determined using the following equation [To determine fat absorption capacity (FAC), 1 g of sample powder and 6 g of sunflower oil were weighed into a 15 mL tube, dispersed using a vortex mixer  for 3 min at the highest speed and centrifuged at 4000× equation :(3)FAC was used to analyse the protein profile and estimate the molecular weights of the respective protein bands. Samples were prepared as described in Vogelsang et al. , with sow/v) protein dispersions were prepared using ultrapure water in 50 mL centrifuge tubes, adjusted to pH 7 using HCl and NaOH of varying concentrations, and shaken at 500 rpm overnight at 4 °C to hydrate. The samples were then allowed to equilibrate to 22 °C. The particle refractive index was set to 1.45 and the dispersant refractive index was set to 1.33. Sample dispersions were introduced into the dispersing unit using ultrapure water as a dispersant, until a laser obscuration of 12% (PPI and SPI) and 5% (EverPro) was achieved. For measurement on a dry basis, the same refractive parameters were used.Particle size distribution was measured using a static laser light diffraction unit  ,26,27, cThe minimum gelation concentration of each protein was determined as described by Vogelsang et al. , with slRheological tests were carried out using a controlled stress rheometer  equipped with a concentric cylinder measuring system , as described by Vogelsang et al. . Ingrediw/v). Then, 8-Anilino-1-naphthalenesulfonic acid ammonium salt (ANS) was mixed with 2 mL of diluted sample and stored in the dark for 15 min at room temperature. Fluorescence was measured  and corrected using blanks, sample dilutions measured without the addition of ANS. The results are presented as the slopes (R2 ≥ 0.98) of the absorbance versus protein concentration (% w/v).The surface hydrophobicity was measured using the method described by Vogelsang et al. . Proteinw/v) protein were prepared, and the pH was adjusted to pH 7 using HCl or NaOH. Dispersions were hydrated at 4 °C, shaking overnight. The temperatures of the samples were then readjusted to 22 °C while shaking, followed by a readjustment of the pH if necessary. Samples were centrifuged at 4893× g for 30 min and the protein contents of the resultant supernatants were measured using the Kjeldahl method (N × 6.25). Protein solubility was expressed as the % of protein remaining in the supernatant [For evaluation of protein solubility, dispersions of 1% (ernatant .w/v protein) were prepared using ultrapure water and adjusted to pH 7 using varying concentrations of HCl or NaOH. Samples were incubated by shaking at 4 °C overnight. Samples were then readjusted to room temperature and centrifuged at 2000× g for 10 min to remove any insoluble material. Automatic voltage selection was used for measurements and the zeta potential was calculated using the Smoluchowski model. A refractive index of 1.45 and an absorbance of 0.001 were used.The zeta potential of the ingredients in solution was determined using dynamic light scattering technology with the Zetasizer Nano-Z  according to the method described by Vogelsang et al. (2022) . Samplesw/v concentration were prepared, adjusted to pH 7 using varying concentrations of HCl and NaOH, and hydrated by shaking overnight at 4 °C. Emulsions were prepared by mixing ingredient dispersions with sunflower oil with a ratio of 90:10  in 50 mL centrifuge tubes. Samples were sheared using an Ultra-Turrax equipped with a S10N-10G dispersing element  at speed 5 for 2 min. Oil droplet size was measured using a static laser light diffraction unit  with a refractive index of 1.47 and 1.33 for sunflower oil and water, respectively. Stability was monitored using an analytical centrifuge  with parameters of 100 rcf for 15 min at 15 °C. The results are reported as separation rate (%/min) and transmission profiles over the entire measurement range.Emulsion stability was examined using the method described by Vogelsang et al. (2021) , with soThe sample colour was measured using the hand-held Minolta colour measuring system  ,30, withScanning electron microscopy (SEM) was used to image the ultrastructure of PPI, SPI and EverPro, according to the method reported by Atzler et al. . IngrediAll experiments were performed in triplicate. Data was analysed at a 5% level of significance using a one-way ANOVA, followed by Tukey’s post-hoc test in IBM SPSS version 26 .The nutritional characteristics of a protein isolate are key when considering the ideal protein ingredients for food application. Compositional AnalysisThe composition of the PPI, SPI and EverPro are presented in The amino acid compositions, free amino acids and the percentage of the recommended essential amino acid content per gram of protein are presented in The protein profiles of the three ingredients were analysed using the Bioanalyzer lab-on-a-chip technology under reducing and non-reducing conditions. Due to minimal observable differences, only reducing conditions are shown in The pH and total titratable acidity (TTA) are displayed in The protein solubility, surface hydrophobicity and zeta potential of PPI, SPI, and EverPro are presented in The colour values and images of PPI, SPI and EverPro are shown in The dry (A) and dispersed (B) particle sizes of PPI, SPI, and EverPro are shown in Fat absorption capacity is a characteristic that can be related to emulsifying capacity, and is therefore, important for consideration in fat-rich applications, such as sauces and dairy products. As shown in The foaming capacity and stability are displayed in The minimum gelation concentration for PPI and SPI were 14% and 8%, respectively. EverPro was trialled in concentrations of up to 22%, but gelling activity was not observed. During rheological analysis , PPI disThe separation profiles of PPI, SPI and EverPro oil-in-water emulsions are shown in The ultrastructure of PPI, SPI and EverPro was examined using scanning electron microscopy (SEM), at 50× and 1000× levels of magnification . EverProThe characterisation of novel protein ingredients, such as EverPro, is key to their introduction as new protein sources for their application in day-to-day products. A wide range of functionality, as well as a high content of essential amino acids, allow competition with currently used protein sources like pea and soy.The ingredient composition of the three samples is similar, with PPI, SPI, and EverPro containing 81%, 89% and 83% of protein, respectively. The only significant difference was observed in the fat content, whereby PPI contains significantly higher levels of lipids than SPI or EverPro. This relatively high lipid content could cause oxidation issues during storage, resulting in the formation of off-flavours . In contAnalysis of the total amino acid composition showed that EverPro has quite a similar profile to PPI and SPI, except for elevated levels of glutamine and proline. This is in agreement with a study conducted by Connolly et al., in which glutamine and proline were also found to be the most abundant amino acids in BSG protein extracts . In termLegumin, an albumin found in many pulses, is made up of six subunit pairs, engaged in non-covalent bonds. Each of these pairs consists of an acidic subunit of ~40 kDa and a basic subunit of ~20 kDa , which cIncreased volumes of small peptides and amino acids are the primary reason behind the increased solubility of EverPro, compared to PPI and SPI. Protein solubility has a direct effect on many important functional properties, including foaming characteristics and emulsion-forming capabilities, due to changing surfactant activity as a result of conformational changes . This ca0) is a quantification of the hydrophobic region on the surface of a protein molecule in a polar aqueous solution. Generally, proteins have a limited amount of these groups externally and this is increased by protein denaturation and unfolding, therefore exposing formerly buried hydrophobic groups. Following this, in theory, protein denaturation and degradation should increase S0. However, it is also known that excessive BSG protein degradation can cause a reduction in S0, simply due to a smaller number of hydrophobic regions being present in smaller peptides [0 appeared to be non-existent to the point of being unmeasurable. Generally, S0 can also be positively correlated with emulsifying characteristics, with SPI displaying the slowest separation rate, followed by PPI and EverPro, respectively. Further to this, increased protein solubility can indicate increased emulsifying abilities [Surface hydrophobicity  and 8% (w/w), respectively. The gelling properties of pea proteins are well studied, with pea proteins generally forming a strong gel network upon heating, although this depends on certain parameters, such as pH, ionic strength and heating temperature, as well as cultivar, protein fraction ratios and protein extraction method [In addition to foaming properties and emulsifying characteristics, the gelling behaviour of protein ingredients is of great importance when considering potential applications and processing conditions. The results show that EverPro displays no gelling characteristics at concentrations up to 22% n method ,54,55,56n method . During n method . HoweverEverPro has a much darker colour than PPI or SPI. This could be due to a variety of factors, including the browning reaction occurring during the brewing process, as well as during the protein extraction process. Colour is produced, via the Maillard reaction, during the malting process as a result of kilning . The degFor PPI and SPI, the ultrastructure images reflect what has been described and seen previously in the literature for these isolates, namely a variety in particle size with a generally spherical particle with a dimpled surface ,62,63. RThe increased consumption of novel plant-based proteins in the human diet is gaining momentum globally. In addition to this, the current climate crisis is driving interest in developing sustainable food systems. This study examined the properties of EverPro, a barley-rice protein isolated from brewer’s spent grain, in comparison to pea and soy protein isolates, and specifically aligns with the goals associated with SDG 12, Responsible Consumption and Production. Given its high solubility and high essential amino acid content, EverPro can be considered a highly functional protein ingredient suitable for use in a wide variety of food applications. EverPro exhibits a significant degree of protein degradation through a lack of visible bands during protein profile analysis, as along with increased levels of free amino acids. This perhaps makes it more similar in behaviour to a protein hydrolysate, instead of a typical protein isolate. This allows for some benefits, such as the near complete solubility, but means the ingredient lacks other functional properties, such as gelling and other network-forming capabilities. This property in particular highlights the potential for the application of EverPro in dairy-alternative beverages, where protein content and amino acid balance have shown a need to be improved upon.The first protein of its kind, EverPro offers a new opportunity for further study to enrich a wide variety of plant-based products with high-quality protein, while also representing the result of a bio-circular food process; a future food system approach.