As vessel diameter decreases, reperfusion after anastomosis becomes more difficult. When a blood vessel is sutured, its inner diameter becomes narrower owing to the thickness of the suture material and the number of sutures. To minimize this, we attempted replantation using a 2-point suture technique. We reviewed cases of arterial anastomosis in vessels with a diameter of less than 0.3 mm during replantation performed over a four-year period. In all cases, close observation was followed by absolute bed rest. If reperfusion was not achieved, a tie-over dressing was applied, and hyperbaric oxygen therapy was administered in the form of a composite graft. Of the 21 replantation cases, 19 were considered successful. Furthermore, the 2-point suture technique was performed in 12 cases, of which 11 survived. When three or four sutures were performed in nine patients, eight of these cases survived. Composite graft conversion was found in three cases in which the 2-point suture technique was used, and two of these cases survived. The survival rate was high in cases where 2-point sutures were used, and there were few cases of conversion to a composite graft. Reducing the number of sutures aids in optimizing reperfusion. Accurate and successful microvascular anastomosis is essential for free tissue transfer and limb replantation . DespiteFrom January 2017 to December 2021, the medical records of patients who underwent arterial anastomosis of vessels that were less than 0.3 mm in diameter during replantation at our institution were retrospectively reviewed. Electronic medical records, X-ray films, clinical photographs of the wounds, and demographic information were reviewed. Patient characteristics, preoperative assessments, and operative data  were recorded. The recorded patient data included age, sex, body mass index, level of the injury, the mechanism of the injury, comorbid medical conditions, anticoagulant use, and tobacco use. We categorized the mechanism of injury into either guillotine (cut) or crush injury. Comorbid medical conditions included hypertension, diabetes, cardiovascular disease, and peripheral artery disease. Postoperative data collected included the anesthesia method, operating time, length of hospital stay, use of hyperbaric oxygen therapy (HBOT), the total number of HBOT sessions, and follow-up duration. All patients included in this study were followed for at least 6 months. Postoperative complications, including arterial insufficiency, infection, tip necrosis, and replantation failure, were defined as complications occurring after anastomosis. We compared the survival rates between those who were treated using the 2-point suture technique and those who were treated with the 3 or 4 sutures.All study participants provided written informed consent for the storage of their medical information in the database and its use for research purposes. The study protocol was approved by the Institutional Review Board of the Kosin University Gospel Hospital of Korea (KUGH 2022-04-002). All procedures were performed in accordance with the ethical standards of the Institutional and National Research Committee and the 1964 Helsinki Declaration and its later amendments. This study was supported by a National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2020R1G1A1007678).p-value less than 0.05 was considered statistically significant.A biomedical statistician analyzed the collected data. Statistical analysis was performed using SPSS version 27.0 . Patients’ characteristics were summarized using means with SD or medians with interquartile ranges. Univariate analysis of patient characteristics and complications was conducted using a t-test and Kruskal-Wallis test for continuous variables, Pearson’s chi-square test for categorical variables, and Fisher’s exact test for variables with an expected frequency of less than 5. Odds ratios and 95% confidence intervals were obtained, and a Most of the replantations were performed under general anesthesia, and in some cases, nerve block and local anesthesia were performed. First, we found vessels that could be used in wounds and stumps, and vessel preparation for replantation followed standard techniques ,15. The In all the cases, close observation was followed by absolute bed rest for 3 days postoperatively. During monitoring, needle puncture exsanguination was performed if congestion occurred, and revision surgery was performed if arterial insufficiency occurred. If reperfusion was not achieved in the intraoperative field during revision surgery, a tie-over dressing was applied to the amputated part as a composite graft, and HBOT was performed to manage it in the form of a composite graft. By setting 2 atm and 100% oxygen in a hyperbaric chamber, HBOT was performed for 80 min every day for a week. The tie-over dressing for the composite graft was opened after 7 days. All patients were treated with 2 g of intravenous cefazedone sodium twice daily and prostaglandin E . Survival was assessed on postoperative day 7, and the patient data, survival rates, and complications were reviewed.We enrolled 21 patients  who underwent replantation surgery with arterial anastomosis of vessels with a diameter of less than 0.3 mm between January 2017 and December 2021. The average age of the patients was 44.2 ± 15.1 years . Among the patients, three had diabetes mellitus, three were active smokers, and one was a former smoker. The mechanisms of injury were crush (ten patients) and cut injuries (eleven patients). The injured lesions were on the forehead (one patient), thumb (two patients), index finger (six patients), middle finger (two patients), ring finger (four patients), small finger (five patients), and second toe (one patient). There were ten Tamai level I amputations and ten Tamai level II amputations . In totaOf the 21 replantation cases, 19 (90.5%) were successful. Further, the 2-point suture technique was performed in twelve cases, eleven of which survived. Three or four sutures were performed in nine cases, eight of whom survived. The two groups had no statistically significant differences with regard to age, sex, diabetes, or smoking history. Composite graft conversion was performed in three cases where the 2-point suture technique was used, and two of these cases survived. Composite graft conversion was performed in six cases where three or four sutures were used, five of which survived . The surTwo patients experienced arterial insufficiency. Wound exploration was performed immediately, and composite graft conversion was performed after re-anastomosis; however, replantation failed. After two weeks of dressing, surgical debridement and full-thickness skin grafting were performed.Case 1A 60-year-old woman amputated her left index finger in a plant while using a fish-cutting machine. One digital pulp artery could be found at the site of amputation after debridement of the stump tissue and was anastomosed using the 2-point suture technique. The fingertip survived successfully, and three months postoperatively, the patient did not have any complications or functional impairment .Case 2A 61-year-old woman amputated her right index finger in a plant while using an abalone-cutting machine. One digital pulp artery could be found at the site of amputation after debridement of the stump tissue and was anastomosed using the 2-point suture technique. However, the color of the flap became pale in the evening, and arterial insufficiency was noted, so a wound re-exploration was performed, but reperfusion was not achieved. Composite graft conversion was performed after arteriorrhaphy, and it was confirmed that the graft was engrafted seven days after surgery. The fingertip survived successfully, and nine months postoperatively, the patient did not have any complications or functional impairment .This review suggests that the 2-point suture technique is relatively safe and feasible for microvascular anastomosis. In this study, survival rates were compared between cases where the 2-point suture technique was used and cases where three or four sutures were used. In the 2-point suture group, 11 out of 12 cases survived, and the composite graft conversion rate was 25.0%. In contrast, eight out of nine cases in which three or four sutures were used survived, and the conversion rate was 66.7%. Hence, the outcomes of the 2-point suture technique were satisfactory. We thought that cases with three or four sutures could have poor outcomes due to occlusion of the lumen by the thickness of the suture material and the number of sutures.The first microscopic surgery was performed in 1921 by Carl Nylen, an otolaryngologist in Stockholm, Sweden . In 1960Various suture techniques have also been developed, including the simple interrupted microvascular suture, the 12 o’clock to 6 o’clock method, the 3 o’clock to 9 o’clock-side-side method, the triangulation method, and the posterior wall first ,27. The Amputation is one of the most common cases in emergency departments. Particularly in the case of distal fingertip amputations, microsurgical vascular anastomosis may not be possible, and composite grafts are often used in such nonreplantable fingertip amputations . However2 at high atmospheric pressure, and it is well known to have a positive effect on wound healing [HBOT is a treatment modality in which the patient inhales 100% O healing . Systemi healing . HBOT in healing ,37. Ford healing . Li et a healing . HBOT in healing . The art healing ,40. The A limitation of this study was the small sample size and the use of Nylon 10-0 sutures. Due to the small sample size, influencing factors such as age, comorbidities, level of injury, and mechanism of injury may not have been properly assessed. However, the authors’ study did not show a statistically significant difference, and when more samples are collected, the factors associated with the prognosis of anastomosed vessels will be studied. Sutures can also act as foreign bodies or obstacles; therefore, if thinner threads  were used, the outcomes of using three or four sutures may have improved . NowadayThe results of this study suggest that the 2-point suture technique is a feasible alternative to placing three or four sutures in microvascular anastomosis. This option may be useful in situations where supermicrosurgical tools are not available. Composite graft conversion and HBOT can be the second choice for reconstruction when replantation failure is suspected.


Nonsuicidal self-injury (NSSI) is a serious public health problem. The role of adverse childhood experiences (ACEs) and lifestyle on the risk for NSSI is still underexplored, especially among college students. We aimed to investigate the association of ACEs with the risk of NSSI, and effect modifications by lifestyle among college students.A total of 18,723 college students from six universities were recruited through a multistage, random cluster sampling method in Shaanxi province, China. The Adverse Childhood Experiences International Questionnaire was used to assess ACEs for each participant, and the Chinese version of the Ottawa Self-injury Inventory was used to assess the presence or absence of NSSI behaviors. Information about lifestyle was collected by a self-designed questionnaire. The associations of NSSI with ACEs and lifestyle were analyzed using logistic regression models. Furthermore, we constructed a combination score of multiple lifestyles and evaluated whether lifestyle modified the effect of ACEs on the risk of NSSI.The prevalence of NSSI for the past 1 month, 6 months, and 12 months was 3.8, 5.3, and 6.5%, respectively. 82.6% of participants have reported experiencing at least one type of ACEs, and participants with higher levels of ACEs (≥4) were more likely to have higher odds of developing NSSI during the past 1 month , 6 months , and 12 months , as compared with participants with low levels of ACEs (0–1). There were additive interactions between ACEs and lifestyle. Compared with participants with low levels of ACEs and healthy lifestyle, participants with high levels of ACEs and unhealthy lifestyle had the highest odds of NSSI during the past 1 month , 6 months , and 12 months .These results suggest that ACEs play an important role in the occurrence of NSSI among college students, especially in those with unhealthy lifestyle. Our findings may help develop targeted intervention strategies for the prevention of NSSI. Globally, more than 700 thousands people die by suicide every year , accountNonsuicidal self-injury (NSSI) is defined as the deliberate direct destruction or alteration of body tissue without a conscious suicidal intent, which was regarded as a gateway of suicide behavior , 6. RepeMultiple factors were identified as potential causes of NSSI, which involved genetic, biological, psychological, physiological, and other factors . NotablyTherefore, we conducted this study to address the associations of NSSI with ACEs and lifestyle risk index  among college students, and to further explore the joint effect of the lifestyle and ACEs on the risk of NSSI.2.2.1.Through a multistage, random cluster sampling method, participants were recruited from universities from October to November 2022. Specifically, we randomly selected a total of 6 universities from 57 universities in Shaanxi province, China. Then, we selected approximately 2–4 classes from all the colleges and grades in each sampled university, resulting in a total of 20,165 undergraduates in 559 selected classes were invited to participate in the baseline survey and planned to follow up every semester. Before conducting surveys, each selected class has two class cadres who have received standardized training to guide other classmates to fill out the structured questionnaire using a Quick Response code (QR Code). We also set a calculation question and a choice question in the structured questionnaire for quality control. Finally, a total of 19,622 students submitted their online questionnaires. For the present study, we excluded students who failed to fill the questionnaire completely, completed in a short time , and have invalid questionnaire assessed by logic questions, leaving a total of 18,723 students included for the final analyses. All participants gave their electronic informed consent prior to participate in the study. The study was approved by the Ethics Committee of The Second Affiliated Hospital of Xi’an Jiaotong University  and conducted in accordance with the principles of the Declaration of Helsinki.2.2.2.2.1.Socio-demographic characteristics including birthdate, gender, grade, registered permanent residence, sibship, parental educational attainment, lifestyle , height, and weight were collected by a self-designed general information questionnaire.2.2.2.The Adverse Childhood Experiences International Questionnaire (ACE-IQ) developed by the WHO was used to assess ACEs in participants. Briefly, a total of 13 domains of adverse experiences during the first 18 years of their life were asked. There 13 domains include physical abuse, emotional abuse, sexual abuse, family substance use, family incarceration, family mental illness, domestic violence, parental death or separation, emotional neglect, physical neglect, bullying, community violence, and collective violence. Ho et al. translated the ACE-IQ and applied it to the Chinese population, suggesting a good reliability and validity , 20, we 2.2.3.The Chinese version of the Ottawa Self-injury Inventory was used to assess the presence or absence of NSSI behaviors. This scale was widely used to evaluate the participants’ frequency of 10 items of NSSI  during the past 1 month, 6 months, and 12 months without suicidal intent. If a participant gives an affirmative answer to whether they exhibited one or more abovementioned self-injury behaviors over the past 1 month, 6 months, or 12 months, he/she was regarded as having NSSI behaviors within a specific period of time . Zhang e2.2.4.2, and higher than 28 kg/m2, respectively. In consistent with previous studies, unhealthy diet was defined as participants who ate red meat every day or vegetables/fruits less than daily . Ac. Ac2, anan daily , 28, par2.2.5.We additionally assessed the depressive symptoms using the self-rating depression scale (SDS). The SDS includes 20 items which are scored between 1 (never or very infrequency) and 4  and reflects their recent feelings for nearly 1 week. We then converted the summed score of the SDS for each participant to a standard score by multiplying it by 1.25, and the presence of depressive symptoms was defined as a standard score higher than 50 . The Pit2.3.11-RERI10-RERI01 + 1; AP = RERI/RR11. The 95% CIs for the RERI and AP were computed by simulating 5,000 bootstrap samples from the dataset used for estimation  were conducted in college students, researchers are needed to further consider the adverse effects of childhood adversities and the potential interactions between childhood adversities and lifestyle. Notably, as revealed by a recent randomized controlled trial in Netherland, participants with a history of childhood adversity modified the effect of a lifestyle intervention on women’s body composition , which mSome limitations of this study should be noted. First, although most available individual/parental demographic and lifestyle variables were incorporated into the model for adjustment, some residual or unmeasured confounding parameters could have affected the results. For instance, the confounding effect of the timing of childhood adversities may vary depending on sensitive period . Second,5.In conclusion, this study provides evidence suggesting that ACEs and lifestyle play an important role in the occurrence of NSSI among college students. Such findings may help develop targeted intervention strategies for the prevention of NSSI.The original contributions presented in the study are included in the article/This study was approved by the Ethics Committee of The Second Affiliated Hospital of Xi’an Jiaotong University . All participants gave written informed consent before enrolment in the study, which was conducted in accordance with the principles of the Declaration of Helsinki.LZ contributed to the conception or design of the paper and drafted the manuscript. LZ, WW, YC, AA, XW, XY, YL, MW, and LM contributed to the acquisition, analysis, or interpretation of data for the work. LZ, MW, and LM provided a critical review of the manuscript. All authors contributed to the article and approved the submitted version.This research was funded by the Medical Research Foundation of Shaanxi Medical Association (MRFSMA2022001), the Natural Science Foundation of Changsha (kq2208302), and the Open Project of Key Laboratory of Environment and Health, Ministry of Education (2022GWKFJJ02).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.https://www.frontiersin.org/articles/10.3389/fpubh.2023.1199882/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.


The multivariate logistic regression analysis showed that UC patients with malnutrition had a 1.7-fold increased risk of readmission. (4) Conclusions: Nutritional problems deserve more attention in hospitalized UC patients. Malnutrition identified through the GLIM criteria was associated with opportunistic infection, tended to be associated with surgical treatment, and showed a prognosis value for readmission.(1) Background: The Global Leadership Initiative on Malnutrition (GLIM) was published in 2019, and its application has been explored in several diseases. However, the data on malnutrition based on the GLIM in ulcerative colitis (UC) patients are sparse. (2) Methods: This single-center, retrospective cohort study included 605 hospitalized UC patients. Demographics and clinical data were collected from electronic medical records. Nutritional Risk Screening 2002 (NRS 2002) was used as a screening tool, and malnutrition was diagnosed according to the GLIM criteria. The skeletal muscle area of the third lumber cross-section in abdominal computed tomography was used to evaluate muscle mass within one week before or after admission. (3) Results: The prevalence of malnutrition was 64.1% in this cohort, and the prevalences were 34.2, 57.7, and 86.7% in UC patients with mild, moderate, and severe disease activity, respectively. Malnourished patients tended to need surgical treatment ( Inflammatory bowel disease (IBD) is an idiopathic immune-mediated inflammatory disorder, mainly represented by ulcerative colitis (UC) and Crohn’s disease (CD). The incidence of IBD has gradually increased in China during the last three decades, reaching 3.01/100,000 person-years, with a prevalence of 47.06/100,000 . The rep2 . After adjusting for disease activity, patients with malnutrition tended to need surgery more than those without, but no statistical significance was detected (p = 0.080).The proportion of patients treated with surgery was significantly higher in the malnutrition group compared to the non-malnutrition group . Specifically, in patients with mild and moderate disease activity, the length of stay was significantly longer in malnourished patients compared to well-nourished patients . The length of stay tended to be longer in malnourished patients with severe UC, yet this difference did not reach statistical significance .The length of stay was significantly longer in patients with malnutrition compared to those without malnutrition . Univariate analysis was performed on the data at the first admission, showing that the disease activity and the prevalence of malnutrition were significantly higher (both p < 0.001) in patients with readmission, and the proportion of patients with extra-intestinal manifestations tended to be higher (p = 0.066) in patients with readmission. In contrast, the differences in disease extent and the proportion of patients suffering from opportunistic infection were insignificant  days vs. 374  days, nificant . Then, mnificant .p < 0.001). However, the results were inconsistent among patients with different disease activity levels. In the 114 patients with mild disease activity, HGB, ALB, and PA were significantly lower in patients with malnutrition , whereas the hsCRP did not differ (p = 0.256). In the 265 patients with moderate disease activity, HGB, ALB, and PA were significantly lower , while hsCRP was significantly higher (p < 0.001) in patients with malnutrition. Among the 226 patients with severe disease activity, HGB, ALB, and PA were significantly lower  in patients with malnutrition; similar to the mild group, hsCRP showed no significant difference (p = 0.110)  .To the best of our knowledge, this is the first study to explore the prevalence of malnutrition based on the GLIM criteria in hospitalized UC patients with a relatively large sample size in China. In the present cohort, 73.6% of UC patients had nutritional risk based on NRS-2002, and 64.1% of UC patients had malnutrition. In severe UC patients, the prevalence of malnutrition reached over 80%. Malnourished UC patients had a significantly longer length of stay, a 2.4 times greater risk of having an opportunistic infection, and tended to need surgical treatment, compared with well-nourished ones. Moreover, malnourished patients had a 1.7-fold times greater risk of readmission due to UC recurrence or exacerbation, and the period between the first and second hospitalization was significantly shorter in malnourished patients than in well-nourished patients.2 can be diagnosed with malnutrition by both the ESPEN and GLIM criteria. However, if the BMI is ≥18.5 kg/m2, the GLIM requires weight loss of over 5% or reduced muscle mass, which can be proved by any validated body composition measuring techniques, such as fat-free mass index (FFMI) measured by dual-energy absorptiometry (DXA)/bioelectrical impedance analysis (BIA), muscle mass evaluated by CT/MRI, and even calf circumference, while the ESPEN criteria require weight loss over 5%, combined with reduced FFMI or reduced BMI (lower than 20 kg/m2 for patients under 70 years or lower than 22 kg/m2 for patients over 70 years). Moreover, the acceptable weight loss phase is also longer in the GLIM than in the ESPEN criteria (6 months vs. 3 months). A study on geriatric rehabilitation patients demonstrated that the prevalence of malnutrition was 52.0% based on the GLIM, while it was only 12.6% based on the ESPEN criteria [The prevalence of malnutrition in UC has been investigated in several studies based on different diagnostic criteria. A small-sample-sized study (including 48 CD and 25 UC patients) by Zhang et al. showed that the prevalences of malnutrition were 58.90% in hospitalized IBD patients, and the prevalences of malnutrition in CD and UC were 60.42 and 56.00%, respectively, according to the GLIM criteria . A multicriteria . The higcriteria .2, 51.5% had malnutrition, suggesting that a considerable part of undernourished patients will be neglected if we only use the BMI as a nutritional indicator. In malnourished patients, 40.7% had low BMI, while 53.9% experienced drastic weight loss, though their BMI was still over 18.5 kg/m2, and these patients accounted for over 1/3 of all UC patients. It was reported that in newly diagnosed UC patients, 32.4% experienced a weight loss of more than 5% of the initial weight in the three months before UC diagnosis [BMI is always a marker of interest when evaluating nutrition status. The incidence of low BMI in UC inpatients was inconsistent in previous studies, with several studies reporting incidences as low as 10.3%  and 13.1iagnosis . Second,iagnosis  and the iagnosis , leadingiagnosis . On the iagnosis , and a Eiagnosis . The preiagnosis , indicatiagnosis ,27, and In this study, undernourished patients had a significantly shorter disease duration than well-nourished ones. Meanwhile, the prevalence of malnutrition was significantly higher in younger patients (18–50 years) compared to older ones. Considering that the prevalence of malnutrition increased with the disease activity, the significantly higher proportions of patients with severe disease activity in the population of 18–50-year-olds and in those with a disease duration of less than 3 years can be important contributors to the higher prevalence of malnutrition. A previous study also supported the shorter disease duration and younger age of malnourished IBD patients . Female Surgical intervention is indicated for UC when medical treatments are ineffective or intolerable because of side effects or when there is a life-threatening hemorrhage, toxic megacolon, or perforation . SeveralC. difficile infection are important clinical issues in IBD, especially in UC patients, which can aggravate the symptoms of patients and are sometimes difficult to identify [C. difficile infection on IBD [Moreover, CMV reactivation and identify ,34. Seven on IBD ,36. Neven on IBD , and theMost UC patients experience intermittent relapses in the first 3–7 years after diagnosis , while sFor UC patients with mild, moderate, or severe disease activity, HGB, ALB, and PA were significantly lower in patients with malnutrition. However, the difference in hsCRP between patients with and without malnutrition was only significant in the group with moderate disease activity, indicating that the inflammation level might be relatively even in patients with mild or severe disease activity, whether well-nourished or malnourished. Considering that the level of ALB can be affected by both nutrition and inflammation , the valThe present study has several limitations. The retrospective nature of this study might have limited the power of our analysis, and the data from a single center might not be representative enough for the whole population of hospitalized UC patients. For example, the high proportion of patients with severe disease activity in our cohort might have led to a relatively high estimated prevalence of malnutrition. Therefore, further cross-sectional or prognosis studies involving multiple centers are required to verify the value of the GLIM criteria in diagnosing malnutrition in UC patients. Additionally, the energy intake could not be evaluated because of the lack of exact food intake and accurate intake of enteral nutrition formula in the electronic medical records. Thus, this study could not investigate the association between energy intake and malnutrition. The detailed collection of data on food intake or nutritional support is necessary for a future study, and apart from clinical manifestations, the nutritional status of patients should also be followed up after discharge to clarify the relationship between nutrition and prognosis more comprehensively.The present findings suggested that a large part of hospitalized UC patients had malnutrition, according to the GLIM criteria, especially those with severe disease activity. Malnutrition was associated with opportunistic infections, tended to be associated with surgical treatment, and was a risk factor for readmission. Nutritional assessment deserves more attention in UC patients, and more studies are needed to confirm the prognostic value of malnutrition based on the GLIM criteria for UC in the future.


Tuberculosis (TB) was the leading infectious cause of mortality globally prior to COVID-19 and chest radiography has an important role in the detection, and subsequent diagnosis, of patients with this disease. The conventional experts reading has substantial within- and between-observer variability, indicating poor reliability of human readers. Substantial efforts have been made in utilizing various artificial intelligence–based algorithms to address the limitations of human reading of chest radiographs for diagnosing TB.This systematic literature review (SLR) aims to assess the performance of machine learning (ML) and deep learning (DL) in the detection of TB using chest radiography (chest x-ray [CXR]).In conducting and reporting the SLR, we followed the PRISMA  guidelines. A total of 309 records were identified from Scopus, PubMed, and IEEE  databases. We independently screened, reviewed, and assessed all available records and included 47 studies that met the inclusion criteria in this SLR. We also performed the risk of bias assessment using Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2) and meta-analysis of 10 included studies that provided confusion matrix results.Various CXR data sets have been used in the included studies, with 2 of the most popular ones being Montgomery County (n=29) and Shenzhen (n=36) data sets. DL (n=34) was more commonly used than ML (n=7) in the included studies. Most studies used human radiologist’s report as the reference standard. Support vector machine (n=5), k-nearest neighbors (n=3), and random forest (n=2) were the most popular ML approaches. Meanwhile, convolutional neural networks were the most commonly used DL techniques, with the 4 most popular applications being ResNet-50 (n=11), VGG-16 (n=8), VGG-19 (n=7), and AlexNet (n=6). Four performance metrics were popularly used, namely, accuracy (n=35), area under the curve , sensitivity (n=27), and specificity (n=23). In terms of the performance results, ML showed higher accuracy (mean ~93.71%) and sensitivity (mean ~92.55%), while on average DL models achieved better AUC (mean ~92.12%) and specificity (mean ~91.54%). Based on data from 10 studies that provided confusion matrix results, we estimated the pooled sensitivity and specificity of ML and DL methods to be 0.9857 (95% CI 0.9477-1.00) and 0.9805 (95% CI 0.9255-1.00), respectively. From the risk of bias assessment, 17 studies were regarded as having unclear risks for the reference standard aspect and 6 studies were regarded as having unclear risks for the flow and timing aspect. Only 2 included studies had built applications based on the proposed solutions.Findings from this SLR confirm the high potential of both ML and DL for TB detection using CXR. Future studies need to pay a close attention on 2 aspects of risk of bias, namely, the reference standard and the flow and timing aspects.PROSPERO CRD42021277155; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=277155 Prior to the COVID-19 pandemic, tuberculosis (TB) was the leading infectious cause of mortality globally . Many peConsidered as the most important subdomain in AI, machine learning (ML) has gained increasing popularity in the last 2 decades, although it has been in use since the introduction of artificial neural network many years earlier . It can Liu et al , for exaAs a new form of AI, or more specifically ML, deep learning (DL) has gained traction recently due to the availability of increasing computation power and abundant data volume. DL originated from the NN concept that uses more hierarchical layers to segregate and manage the final output . It requLakhani and Sundaram  conducteIn our previous review of the literature with a focus on AI-based TB detection, from 33 included studies, most (n=20) used radiographic biomarkers rather than physiological and molecular biomarkers. Moreover, most of the included studies used DL approaches (n=21) rather than ML approaches, with the most applied DL architectures being AlexNet, ResNet-50, VGG-16, and GoogLeNet. One interesting finding is that ML approaches have better overall accuracy and specificity than the DL. By contrast, the DL approaches have better AUC and sensitivity than the ML approaches. This might be rooted in the data volume and quality available when implementing the former. Furthermore, from the systematic review, we also found that AI-based algorithms have moderate to high specificity and sensitivity for TB detection. This confirms the potential value of AI-based algorithms for TB detection. However, very few studies have focused on implementing AI-based algorithms for early detection of TB, and this warrants further study.In this review, we aim to evaluate the performance of available ML and DL algorithms developed to detect TB from CXR data. This was motivated by findings from previous reviews that many related studies used radiographic biomarkers, especially in the form of CXR images. However, in contrast to our previous review that took a broader focus on AI methods for TB detection and early TB detection, in this review, we put more focus on ML and DL efficacies for TB detection using CXR.There are several other review articles in this domain. Singh et al  performeIn the following section, we describe the methods applied in conducting this SLR. It consists of the following subsections: Information Sources, Search Strategy, Inclusion and Exclusion Criteria, Data Extracted, Outcomes Assessed, Strategy for Data Analysis and Synthesis, Potential for Publication Bias. Next, in the “Results” section, we describe the General Characteristics of the Included Studies, Risk of Bias Assessment Result, and the review Study Results. In the “Discussion” section, first we explain the Principal Findings, followed by Limitations and Conclusions from this SLR.In conducting this SLR, we followed the PRISMA  guidelines . We starIn this SLR, we collected the records from 3 major databases, namely, Scopus, PubMed, and IEEE . Those are recommended academic search systems for systematic reviews and meta-analyses . We checThere are several main keywords used for the search strategy, including “Artificial Intelligence,” “Tuberculosis,” “Detection,” and “Chest Radiograph*.” Moreover, several alternative synonyms for each keyword are included for the searching process in those databases. Using the keywords and alternative terms, we obtained results as shown in Artificial intelligence Tuberculosis Detection Chest radiograph* The * represents the wild-type character that can be used to represent any available characters in the search engine.Inclusion criteriaFull-text articles in peer-reviewed journals or proceedingsWritten in EnglishFocused on tuberculosis (TB) or pulmonary TB, chest radiograph, or chest x-rayApplied machine learning or deep learning algorithmsExclusion criteriaLiterature review, case reports, letters, corrigendum, editorial commentaryNot published in EnglishFocused on extrapulmonary TB, latent TB, and other types of dataApplied statistical methods, nonartificial intelligence methods, and general artificial intelligence methods not considered as machine learning or deep learningInformation extracted from each included study included the following: (1) title, (2) authors, (3) published year, (4) journal or proceeding’s title, (5) study objectives, (6) study findings, (7) data set characteristics and size, (8) parameters (metrics) used, (9) ML and DL methods applied, (10) best performance results, (11) comparison with other studies, (12) outcome types, (13) funding or sponsor sources, and (14) Google citation counts.The main outcome of this SLR is the list of various ML and DL methods for TB detection based on chest radiograph images. The secondary outcome is the summary statistics of diagnostic performance of various ML and DL methods for TB detection on chest radiograph, including accuracy, AUC, sensitivity, and specificity.A narrative synthesis was presented in the text based on extracted information from included studies. Descriptive statistics was performed mainly using box and whisker plots and other tables or figures to summarize and describe the characteristics and key findings of the included studies. The narrative synthesis was used to explore the relationship and findings both within and between the included studies.For the quantitative analysis, we performed the meta-analysis for diagnostic test accuracy. This particular meta-analysis differs from the meta-analysis of therapeutic or interventional studies as it is necessitated analyzing simultaneously a pair of outcome measures (sensitivity and specificity) instead of a single outcome . In thisTo assess the risk of bias within the included studies, we used a modified Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2) tool, which is recommended for evaluating the risk of bias and applicability of primary diagnostic accuracy studies in SLRs . There aFirst, 309 records were identified from 3 databases used in this SLR in the identification phase. After removing duplicates (n=112), 197 records remained and these were passed to the screening phase. The records’ titles, abstract, and keywords were examined in this phase using 3 main rejection reasons, namely, (1) not written in English (n=13); (2) being in the form of literature review, case reports, letters, corrigendum, or editorial commentary (n=12); and (3) not focused on ML or DL for detection of TB or PTB based on CXR (n=99). After these exclusions 73 records remained.Next, in the eligibility phase, the 73 remaining records were assessed by reading their full-text content. A total of 26 records were excluded for the following reasons: (1) has unclear data sets (n=6), (2) has unclear methodologies or method and evaluation (n=6), (3) has finding inconsistency (n=2), and (4) did not focus on ML or DL for TB or PTB detection based on CXR (n=12). After this phase, 47 records were passed to the included phase, which were checked for quality and data extraction. Of the 47 records, 10 were included in the quantitative analysis using data extracted from the confusion matrix results provided in the sources.Twenty-five of the included studies ,70,72-74In terms of “flow and timing,” 6 studies ,43,54,71Various ML and DL methods have been applied in the included studies: 7/47 (15%) studies ,43,63,67The most popular DL architectures used in the included studies were ResNet-50 (n=11), followed by VGG-16 (n=8), VGG-19 (n=7), and AlexNet (n=6). However, it is noteworthy that various DL ensemble (n=9) ,60-62,64In terms of performance measurements being used in the included studies, accuracy 35/47, 74%), AUC , sensitivity , and specificity  were the most used ones. Accuracy is the proportion of all cases that are either true positives or true negatives, while AUC is derived from the receiver operating characteristics curve and is another quantitative measure of model accuracy . Sensiti5/47, 74%The overall performance results of the methods reviewed in this study, in terms of accuracy, AUC, sensitivity, and specificity of all included studies, are shown as a box plot in We separately analyzed the performance results of ML and DL approaches. Among 11 (7+4) ,67,68,73In the meta-analysis phase, we analyzed 10 of the included studies ,63,66,70In this SLR, we reviewed available evidence related to the usage and performance of both ML and DL methods for TB detection, particularly on CXR images. Most included studies have recently been published, and only 2 studies ,43 were Various CXR data sets have been used in the included studies. Three of the most popular ones are SZ (n=36), MC (n=29), and ChestX-ray14 (n=4). Particularly, SZ and MC data sets are the most widely used as they are available to the public in Jaeger et al’s  publicatIn terms of the performance results, ML showed higher accuracy (mean ~93.71%) and sensitivity (~92.55%), while on average DL models achieved better AUC (~92.12%) and specificity (~91.54%). The ML methods tend to have better accuracy because the feature engineering phase is usually validated by experts. Moreover, they are carefully tuned with different parameters settings. By contrast, both feature engineering and parameter tuning in the DL are automatically done by the deep networks’ architecture without human intervention . HoweverFrom the grouped box plots shown in Both ML and DL have high sensitivity (ML ~92.55%/DL ~89.84%) and specificity (~87.01%/~91.54%). Further analysis on the 10 included studies that provided confusion matrix results confirms this finding. The pooled sensitivity is 0.9857 and the pooled specificity is 0.9805, which once again shows the potential value of ML and DL approaches for TB detection using CXR. A more complete data summary is provided in Another important factor that might influence the performance results of the DL approach is the data volume used in the learning phase. It is a well-known fact that a lot of data number is needed in the training phase for a DL method to work well ,88. HoweTransfer learning is another approach that can be utilized to handle insufficient data volume. It transfers the knowledge from source to target domain by relaxing the hypothesis that training data should be independent and identically distributed with test data ,94. UsinAnother interesting finding from this SLR is that the use of multiple input data types  could enhance the performance results of both ML and DL than using only 1 input type . The other input data types are clinical features , demograIt is worth noting that most of the included studies focused on the development of ML and DL models or architectures as the proposed solution. Only 2 studies ,55 have The absence of longitudinal  aspect of the data sets could not be ignored in this study. In practice, the diagnostic decision of TB detection by a medical practitioner or a radiologist using CXR is generally made by detecting change in a lesion compared with the previous observation. However, none of the included studies have considered the longitudinal dimension of the data sets used when building the model and making the decision. Hence, the proposed approaches are prone to false prediction, especially when used on an older age group and people with a history of TB.We also assessed the publication bias and applicability of the 47 included studies using the QUADAS-2 tool. Among 4 key aspects in the Risk of Bias assessment, namely, patient selection, index test, reference standard, and flow and timing, most included studies had low risks. However, it is important to note that 17 studies were regarded as having unclear risks for the reference standard aspect, and 6 studies as having unclear risks for the flow and timing aspect. This is mainly because no explicit and clear information was given about reference standards, time intervals, and any intervention being conducted in those studies. Hence, future studies should pay close attention to these 2 aspects of risk of bias because they could affect our confidence with the studies’ results.Particularly, the missing information about the reference standards’ procedure in determining the pulmonary TB (PTB) disease could really affect the confidence of the performance results achieved by various ML and DL methods. It is generally agreed that the mycobacterial culture is closest to a gold standard while the radiology, even under ideal circumstances, is an imperfect diagnostic tool. Therefore, a human radiologist’s diagnosis, even a consensus diagnosis, is an imperfect criterion. Comparing machine reading with this reference standard may tend to overestimate the “true” accuracy. By contrast, it is conceivable that machine reading might be better than human radiologists at detecting microbiologically confirmed PTB, if the algorithm is trained against microbiologically confirmed cases and controls. The use of a radiological reference standard would fail to detect this benefit.For the applicability concerns, 3 aspects were assessed for all 47 included studies. We conclude that all the included studies have low concerns regarding applicability. This means that the proposed solutions in the included studies are logically sound, feasible, and applicable in solving the task to detect TB based on CXR using ML and DL approaches.There are some limitations to this SLR. First, we only utilized 3 major databases in identifying and collecting all publications, namely, Scopus, PubMed, and IEEE. We argue that these databases adequately represent the domain of TB detection using ML and DL approaches on CXR. Next, we did not seek further information on reference standards used in each included study. As most included studies used publicly available CXR data sources, reference standards used in those studies were assumed to be the same. Lastly, we did not include any studies that focused on the use of various AI-powered technologies, such as CAD4TB -106, LunThese findings confirm the high potential of both ML and DL for TB detection using CXR. DL approaches, particularly the CNNs, dominantly applied than ML approaches. Besides, DL approaches tend to have more stable and consistent performance results than ML approaches. Data volume and quality were the main concerns of this review, where most of the included studies used relatively small data sets. Therefore, proper data curation and augmentation, transfer learning, and multimodal approaches could be considered in future studies.


We did not register deaths and severe complications; all cases evolved favorably under the instituted treatment. Laboratory abnormalities in transaminase levels 53.97% (ALT) and 61.9% (AST) were grades 1 or 2 and did not require discontinuation of the antiviral treatment, p < 0.05. RDV in children reduced the duration and evolution of COVID-19 and decreased the length of hospitalization in group-associated allergies; p < 0.05. This article summarizes RDV’s efficacy among children with COVID-19 and allergies when the clinical result was improved and reports positive effects on tolerability and reduced duration of hospitalization, especially in children with asthma, atopic dermatitis, and allergic rhinitis. More studies are needed to confirm our findings.In children, coronavirus disease 2019 (COVID-19) starts as a minor illness compared to adults, but during the ongoing COVID-19 pandemic, distinct SARS-CoV-2 variants and subvariants have changed options for therapies in both adults and children, especially for those with comorbidities such as allergies. On 25 April 2022, Remdesivir (RDV), a viral RNA-dependent RNA polymerase inhibitor, was approved by the Food and Drug Administration (FDA) for the treatment of pediatric patients 28 days and older, weighing ≥3 kg, hospitalized or non-hospitalized, who are at high risk of progression to severe forms of COVID-19. While RDV has been shown to have favorable effects in numerous types of research conducted on adults, such as shortening hospital stays, and has shown it has antiviral effects on various RNA viruses, there is a lack of findings regarding safety, tolerability, and efficacy of RDV in allergic pediatric patients since its initial FDA approval. This study aims to assess RDV’s efficacy and tolerability in treating pediatric patients with mild and severe forms of COVID-19-associated allergies such as asthma, allergic rhinitis, and atopic dermatitis and how RDV affects the duration of hospitalization, especially for these comorbidities. The most recent pandemic wave among children rose due to the high transmissibility of the Omicron variant, and this study analyzed changes between July 2020 and September 2022 at the National Institute of Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania. Our retrospective study included 250 children <18 years old, 42 (16.8%) had allergies, 132 were males (52.8%), age group 0–5 years old (80%), with a positive viral test for SARS-CoV-2. Severity was categorized as mild (43.6%), moderate (53.2%), and severe (1.6%) COVID-19, and treatment with RDV was administered in 50.4% (126/250) of children included in the study. The presence of comorbidities, asthma (7.2%), allergic rhinitis (4.4%), and atopic dermatitis (4.4%), was associated with an increased risk of developing severe COVID-19 infection in children,  Since the COVID-19 pandemic was initially reported in March 2020, it has been demonstrated that children have a much lower incidence of SARS-CoV-2 infection than adults and most infected children either experience mild sickness or no symptoms at all ,4. The eThe results of the pollen monitoring in Bucharest during the previous years revealed a sizable number of allergenic pollen. Pollen levels in Bucharest’s atmosphere grew from May to September, with peaks in June, July, and September as well, indicating a longer period than previously thought. Relevant observations included the seasonal new case rate increasing by 2.5–3 times over the past few years, with notable increases in the most recent year. Nearly all allergists indicated that 2–5 new verified cases were recorded each day. Seasonal allergic rhinitis, or rhino-conjunctivitis, was the most prevalent clinical kind of allergy, and 20% of patients had also recently developed asthma. Up to 90% of pediatric asthma cases have an allergic etiology, and children who have allergies have a 30% higher chance of getting asthma . Of the many recognized causes of asthma flare-ups and poorly managed asthma, respiratory viruses are the most clearly described. SARS-CoV-2 and other respiratory viral infections such as human rhinovirus, respiratory syncytial virus, and influenza virus are significant causes of morbidity and asthma exacerbations . To dateAs an antiviral medication, RDV is a nucleotide analogue that specifically inhibits the SARS-CoV-2 RdRP as well as the RdRP of other viruses and has been administered in children after the drug met the condition of approval. RDV is an antiviral drug developed by Gilead Sciences, and its primary prescription was for the Ebola virus infection with poor efficacy in a clinical trial of phase III ,18.Remdesivir, as an intravenous nucleotide prodrug that binds to viral RNA-dependent RNA polymerase and prevents viral replication, is the only antiviral medication against COVID-19 that has received approval to date ,21,22. TThus, we aimed to investigate the efficacy and safety of Remdesivir therapy in COVID-19 pediatric patients and how intravenous RDV reduced time to hospital recovery and improved their clinical status, especially in patients with allergies such as asthma, allergic rhinitis, and atopic dermatitis.A retrospective study was conducted at the Pediatric Clinical Section IX of the National Institute of Infectious Diseases “Prof. Dr. Matei Balș”, Bucharest, Romania, after approval from the institutional ethical review committee, C0033/10.01.2023. Consent was obtained from the patients and their parents as per the requirements of the ethics boards. The study included 250 pediatric patients aged <18 years old, admitted with COVID-19 in Clinical Section IX from July 2020 to September 2022. Nasopharyngeal swabs were taken from all patients who presented an acute illness at the National Institute for Infectious Diseases, Bucharest, Romania within 24 h of admission and tested using a reverse transcription-polymerase chain reaction (RT-PCR) kit (Thermo Scientific). We included pediatric patients eligible for a RDV regimen (intravenous) with allergies and compared them with the group with allergies on a standard regimen, except RDV. For children under 40 kg, a single dose of 5 mg/kg on day one was prescribed, followed by a daily dose of 2.5 mg/kg from day 2 up to 10 days of hospitalization. Children who were 40 kg or more at screening received a single 200 mg dose on day one, followed by a daily 100 mg dose for the next days (2–10). The severity of the disease was classified according to the national guidelines into mild, moderate, and severe disease. Allergic symptoms for all the children with allergies included in our study were evaluated and diagnosed in the past by specialist physicians. Skin prick testing, specific immunoglobulin E (IgE) levels, and spirometry results were completed in the medical record, along with demographic data regarding pediatric patients, comorbidities, clinical presentation, and laboratory parameters including details of infections, and the outcomes were saved in the medical records. The diagnosis of asthma in the study participants was collected from patient records, consisting of demographic data, asthma-related clinical history , and asthma severity. The history of exacerbations requiring the use of systemic corticosteroids; total IgE levels; eosinophil number; and allergic sensitization by skin prick test and/or specific IgEs to common perennial and seasonal allergens ; a mixture of grass and cereal pollens, Betulaceae pollen, weed pollen (Artemisia and Ambrosia); Alternaria alternata; cockroaches (Blattella germanica); and a mixture of feathers were all part of the test panel and comorbidity data . Two or more nasal symptoms, such as congestion, rhinorrhea, sneezing, and aeroallergen sensitivity detected on SPT or an allergen-specific IgE, were necessary for the diagnosis of allergic rhinitis (AR). The Hanifin–Rajka criteria were used to make the diagnosis of atopic dermatitis (AD).p-value of <0.05 was taken as statistically significant.Data were analyzed using GraphPad Prism Quantitative variables such as age and length of stay, and values of inflammatory markers were presented as a number and (%), median and interquartile range (IQR). Qualitative variables such as gender, comorbidities, clinical presentation, disease severity, details of infections, and outcomes were presented as median (IQR) depending on the distribution of the data. Univariate and multivariable logistic regression models were used to find independent predictors of mild, severe, or critical COVID-19. A three-way ANOVA test was used before and after RDV administration in children with allergies for clinical outcomes. A The monthly COVID-19-associated number of hospitalizations in children and adolescents during the week ending July 2022 was nearly five times (20 vs. 125) the number during the week ending July 2020. Hospitalizations for both vaccinated and unvaccinated children during July 2022–September 2022 for the mild and moderate forms among children aged 0–18 years was nearly 5.23 times compared with a similar period in 2020 (47 vs. 246) and 10 times higher for 2021 See .A total of 250 pediatric patients were enrolled in this study between 1 July 2020 and 30 September 2022 in our Pediatric Department. The median age of the pediatric population was 3 years old (IQR 2–16). There were 132 males, (52.8%), and 38.8% were in the 0–1 year old age category. In the first group, 126 pediatric patients received RDV and symptomatic therapy and in the second group, 124 pediatric patients received only symptomatic treatment (non-RDV group). While 43.6% of the total group were mild cases, 53.2% of cases had moderate forms of COVID-19 and 1.6% were in a severe category. p < 0.001). The rate of COVID-19 hospital admission was higher in children with poorly controlled asthma than in those with well-controlled asthma or without asthma. All cases progressed favorably; we recorded no deaths. We performed subgroup analyses by comorbidities and found that the total number of children with allergies was 42 16.8%). Based on the results of the medical records, in 250 pediatric patients hospitalized with COVID-19, 18 7.2%) had a history of asthma and 4.4% had atopic dermatitis and allergic rhinitis for each group. Of the 42 pediatric patients with allergies, 23 (9.2%) received RDV and 19 (7.6%) were included in the non-RDV group. Among the 23 children with RDV treatment, 43.5% had asthma See . The res.8%. Base.2% had aWe performed a multivariate analysis to assess the association between the demographic characteristics and the clinical outcomes. p = 0.001. 67.89% had digestive symptoms , and 85.32% had respiratory symptoms,  , ely) See . Gastroep < 0.001). We observed a lower risk of serious adverse reactions in the RDV group [OR = 0.69 (95% CI 0.45–0.84)] than in the non-RDV group [OR = 0.39 (95% CI 0.25–0.60)]. Comorbidities associations between obesity and asthma and RDV administrations were found to have statistical significance  had allergic rhinitis and 11 were found with atopic dermatitis. Eighteen pediatric patients (7.2%) had asthma. We found patients with two comorbidities in 14.8% of cases and 16% with one comorbidity. The most common allergens were weeds pollens (Artemisia and Ambrosia), grass pollen, house dust and flour dust mites, tree pollen, cat and dog allergens, Dermatophagoides pteronyssinus, and Dermatophagoides farinae. There was a correlation between the proportion of diagnoses of asthma and allergic rhinitis and RDV administration. The performed statistical analysis allowed us to observe that patients with allergies and COVID-19 have symptoms such as fever, wheezing, and dyspnea and that these were statistically significant for asthmatic patients. The main symptoms related to asthma-associated COVID-19 are shown in When adjusted for SpO2, we found statistical improvements in the group with RDV for obesity, asthma, and CPD compared with the non-RDV group See .2), 13 patients were diagnosed with asthma and hypertension, and eight have asthma and chronic pulmonary disease . We performed a series of univariate and multivariate proportional odds ratio models for significant parameters such as body temperature, oxygen saturation, heart, respiratory rate, and the allergies, which were correlated with RDV administrations in the analysis. The adjusted OR showed significant results when including allergies  when correlated with fever and respiratory symptoms and gastroenteritis correlated with nausea, vomiting, and diarrhea   See . p = 0.05) by Wilcoxon rank sum test; the proportional odds assumption was met for this comparison). . See .Moreover, the subgroup analysis, based on treatment for pediatric cases with COVID-19, and the laboratory results indicated that there was a significant difference between the different categories in both groups with RDV and non-RDV See .p < 0.05). No important differences were apparent between the patients who received antibiotics, dexamethasone, and corticosteroids compared with patients who received RDV. Such analysis shows how the laboratory findings changed during the disease progression and whether they acquired a prognostic value. There was no statistical significance in groups in the use of corticosteroids and antibiotics. Of the total study group, 85 (34%) patients received dexamethasone. Additional antibiotic treatments were administered for 105 patients, (42%), as follows: 29 patients received cefotaxime, 34 patients received sulfamethoxazole /trimethoprim, 23 patients received sulbactam/ampicillin, and 19 received vancomycin.The laboratory findings show there is a significant relationship between antiviral treatment in COVID-19 patients. p = 0.032 and 0.001)  See . Overallp < 0.05). All asthma patients maintained the asthma symptoms and showed an improvement in days of hospitalizations after RDV administration, 8 days, IQR [We also found a correlation between RDV administration and no asthma exacerbation in the study group p < 0.0. All astays, IQR ,7,8,9,10ays, IQR ,14,15,16We performed gender analysis of the clinical variables in patients with allergies and groups with comorbidities when RDV was administered See .All patients in the study group recovered without any sequelae after RDV treatment.The results of our study suggest that RDV administration in children with SARS-CoV-2 is associated with clinical benefit compared with symptomatic therapy alone in hospitalized patients with mild, moderate, and severe forms of COVID-19 and especially for the group with allergies. In our study, COVID-19 predominated in males and the age group under five years old was predominant. The primary outcome of time to recovery was four days shorter in the RDV treatment groups. Additionally, we found differences in the treatment effects among clinical subgroups of patients with allergies and COVID-19. We found an increased number of patients with digestive manifestations in a group of children under 5 years and this was similar for infants . In older children and adolescents, the respiratory clinical picture predominates . Most of the cases also presented systemic symptoms  and were accompanied by highly elevated inflammatory markers. A decrease in inflammatory markers, as well as liver enzymes, was observed after RDV administration, probably due to recovery. The current study shows that RDV may be used safely for children and asthmatic pediatric patients with adequate treatment and good control of asthma, who had a lower risk of a severe manifestation of COVID-19. In this study group, all the patients recovered without invasive mechanical ventilation, with no mortality, even in the group with asthma, but we cannot be sure whether only RDV contributed to the recovery. Our asthmatic patients with COVID-19 reported mild and moderate symptoms and no one needed an intensive care unit or intubation. Most of our asthmatic patients had asthma 3 and 4 of the Global Initiative for Asthma (GINA), and their treatment included a moderate dose of corticosteroids  and long-acting bronchodilator inhalers (LABA). In this study, we found that wheezing and dyspnea associated with fever were frequent in the group with asthma, and their favorable evolution after RDV administration allowed us to assess the benefits of antiviral medication in this category. There were no differences in terms of spirometry parameters in children with asthma in the RDV and non-RDV groups. According to GINA, those with well-controlled asthma do not appear to be much more at risk of contracting SARS-CoV-2 or developing severe COVID-19, but those who recently required oral corticosteroids for their asthma have a higher risk of dying from COVID-19. To the best of our knowledge, it is the first study to focus on allergic diseases in children with COVID-19 in our country. We found some patients who developed mild to moderate liver dysfunction (elevations of transaminase levels), leukocytosis, lymphopenia, and high prothrombin time, but no serious adverse effects were reported. We had no patients with renal dysfunction, and serum creatinine levels were greater than the upper limit of the age-appropriate normal range in the group with RDV and did not necessitate the discontinuation of RDV. Previous clinical studies in children show that RDV may cause liver dysfunction among pediatric patients. ,27,30. AWe provide a comparative study designed for RDV administration in children, especially for the allergy group, where the effects of therapeutic interventions shortened the duration of hospitalization and improved clinical characteristics. These findings are similar to studies reported by the Centers for Disease Control and Prevention through surveillance of children hospitalized with different clinical forms of COVID-19 who are predisposed to severe evolution and moderate illness . Based oThe findings in this report are subject to a few limitations. First, COVID-19-associated hospitalizations might have been missed because vaccinated children were grouped with unvaccinated pediatric patients. We faced a small number of vaccinated patients, especially since, in the category of patients with allergies, parents were reluctant to vaccinate their children in our country. This led to a small number of patients vaccinated against COVID-19 and, consequently, the statistical significance was not relevant.Secondly, the use of antibiotics may be associated with the result of the safety and efficacy of RDV. The third limitation is the relatively short duration of follow-up for these patients (28 days). The fourth limitation is the clinical evolution of patients with asthma without correlation with RDV-associated asthma treatment. In conclusion, this single-center retrospective study shows that the use of RDV for COVID-19 in children led to no serious adverse events in children, no allergies, and reduced days of hospitalizations in patients with comorbidities and improved moderate and severe forms of COVID-19 associated with asthma, allergic rhinitis, and atopic dermatitis. Further studies should be conducted to determine whether RDV is safe and effective for children with COVID-19, especially those with allergies.


Among the myeloproliferative diseases, myelofibrosis is a widely heterogeneous entity characterized by a highly variable prognosis. In this context, several prognostic models have been proposed to categorize these patients appropriately. Identifying who deserves more invasive treatments, such as bone marrow transplantation, is a critical clinical need. Age, complete blood count , constitutional symptoms, driver mutations, and blast cells have always represented the milestones of the leading models still used worldwide . Recently, the advent of new diagnostic techniques  and the extensive use of JAK inhibitor drugs have allowed the development and validation of new models , which are continuously updated. Finally, the new frontier of artificial intelligence promises to build models capable of drawing an overall survival perspective for each patient. This review aims to collect and summarize the existing standard prognostic models in myelofibrosis and examine the setting where each of these finds its best application. Myelofibrosis (MF) is a rare and challenging type of bone marrow disorder that affects the ability to produce healthy blood cells. This myeloproliferative neoplasm (MPN) can arise de novo  or following another MPN . In both cases, the normal bone marrow is replaced by fibrous tissue, with the consequence of an impaired production of circulating blood cells. This impaired hematopoietic function can lead to the symptoms of MF, such as anemia, fatigue, night sweats, and weakness. Commonly, other manifestations are enlarged spleen and liver, abdominal discomfort, bleeding, and weight loss.JAK, CALR, and MPL genes, specific for uncontrolled cell proliferation, has been widely described. New analysis techniques, such as next-generation sequencing (NGS), play a key role in identifying mutations capable of conferring an increased risk of progression and worse outcomes [In brief, widely heterogeneous clinical manifestations characterize MF patients. Cytogenetic tests and CD34+ blast counts are routinely performed at the time of diagnosis and during follow-up to adequately study the patients ,2. From Treatment options for myelofibrosis range from supportive care  to stem cell transplants (HSCTs), which, at the moment, are the only potentially curative treatment. Nevertheless, a wide range of drugs have recently seen the light and have significantly changed the clinical and therapeutic approach to this disease. In recent years, JAK inhibitors (JAKi) have played a leading role, with the first-in-class ruxolitinib paving the way for others  with potential to reduce symptoms, improve quality of life, reduce spleen size , and pot9/L, absolute monocyte count > 1 × 109/L, presence of constitutional symptoms, platelet count < 100 × 109/L, and blast ≥ 1% were early prognostic hematological parameters on which the first models were based [However, despite the available treatments, we deal with a multifaceted disease characterized by a remarkably heterogeneous outcome. In fact, overall survival can range from fewer than two years to a life expectancy comparable to the general population and greater than 20 years . Startinre based ,7,8,9. TThe objective of this review is to collect all the currently available prognostic scores to explain in a clear, concise, and easily usable way which could be the most suitable model to apply at any time during patient follow-up, dwelling on the most recent proposals to have seen the light and that will probably be used shortly.One of the first prognostic scores created and validated in the primary MF setting is the so-called IPSS. A total of 1054 patients with a new diagnosis of MF referred in seven different centers in about 27 years of observation were included to develop the score . The dia9/L, and blood blast > 1% obtained a p-value < 0.001, without marked difference among them in the hazard ratio (HR). By assigning one point for each variable, four risk classes were identified , characterized by a mOS between 135 and 27 months. In this large cohort of patients, during a median survival of 69 months, 49% had died. The most frequent causes of death were leukemic transformation, MF progression, thrombosis and cardiovascular complications, and infections. Compared to the general population, the survival during the first five years is superimposable in low risk patients, while the difference is evident after three years in intermediate-1 risk patients and already at diagnosis in intermediate-2/high risk patients. IPSS is a globally used prognostic model based on simple variables easily accessible in every center and commonly collected at diagnosis in the clinical practice, giving the opportunity of roughly foreseeing the patient’s outcome. However, it remains a less accurate model than the newer ones as it does not consider increasingly impacting molecular and genetic variables.At the presentation of the disease, the risk factors associated with short survival were selected through a stepwise Cox regression model. Age greater than 65 years, presence of constitutional symptoms, hemoglobin < 10 g/dL, WBC count > 25 × 10If IPSS was validated only for MF diagnosis, Passamonti et al. deepened the score by evaluating data able to accurately predict the OS and outcome of the patients during follow-up . In totaTherefore, the main strength of the DIPSS is its applicability at any time during the PMF clinical course, emphasizing how anemia is often the earlier risk factor acquired during follow-up, manifesting myelodepletion and representative of disease progression.9/L were associated with lower OS. Through HR-weighted scoring, one point to each clinical variable and DIPSS intermediate-1, two points to DIPSS intermediate-2, and three points to the DIPSS high-risk class were assigned. This model, called DIPSS Plus, also established four risk classes: low risk , intermediate-1 risk , intermediate-2 risk , and high risk . Identifying potential prognostic factors for leukemic transformation is a plus of the score.Finally, a further refined version of DIPSS was presented a few years later based on a more extensive clinical data set . UnivariAs well as IPSS, the variables considered in DIPSS are easily obtainable, improving the accuracy even during the course of the disease and underlining the key role of anemia. However, new scores that consider molecular biology could be more suitable, especially in patients potentially eligible for transplantation. The DIPSS Plus model tries to take a step beyond this boundary, but its limitation lies in the need for a karyotype, which is not always easily obtainable due to the frequent occurrence of a dry tap in bone marrow aspiration secondary to the pathognomonic fibrous scar tissue.EZH2, ASXL1, IDH1/2, and SRSF2 mutations were found to confer a high risk (HRM) [9/L, and platelets < 100 × 109/L; one point to hemoglobin < 10 g/dL, blast > 2%, bone marrow fibrosis with grade ≥ 2, single HRM, and non-CALR type 1 presence. The patients were then stratified into three risk classes with different mOS.The progressive discovery and the better knowledge of the driver mutations  characterizing 85–90% of PMF patients, as well as the increasingly widespread availability of molecular biology study techniques, such as NGS , has allsk (HRM) . Two poiThe same working group has proposed a further implementation of this score, called MIPSS70+, where the cytogenetic alterations are weighted . In thisHere, for the first time, clinical, pathological, mutational, and cytogenetic parameters are incorporated and used to address most of the aspects that characterize MF heterogeneity. However, not all the necessary variables are always available in all patients, above all in elderly patients with follow-up in non-referral centers.ASXL1, SRSF2, or U2AF1 Q157 mutations. Based on the sum of these variables, four risk classes are identified, with an mOS ranging from 2.6 to 26.4 years. Through multivariate analysis, karyotype, SRSF2 mutations, ASXL1 mutations, platelet count <100 × 109/L, and circulating blasts ≥ 2% were significantly related to a leukemic transformation. Thus, AML remained the leading cause of death in this cohort, occurring in 73 out of 380 patients (59%).The importance of genetics has gradually been recognized in MF. In 2018, a score exclusively based on the patient’s genetic data was proposed . In thisAs well as MIPSS70, this score proves that genetic parameters could be enough to define the disease and its prognosis, but it also has the limitation of the difficulty of obtaining these data.PMF has been extensively studied and prognostically characterized over the years, while few studies focused only on MF secondary to essential thrombocythemia or polycythemia vera. Moreover, IPSS and DIPSS are less informative on secondary MF prognosis . Thus, ahttp://www.mysec-pm.eu/, accessed on 10 March 2023) is currently used to identify which of the four risk categories a patient belongs to: low risk (mOS not reached), intermediate-1 risk (mOS of 9.3 years), intermediate-2 risk (mOS of 4.5), and high risk (mOS of 2.0 years), based on six different variables. A CALR-unmutated genotype, blasts rate ≥ 3%, and hemoglobin < 11 g/dL were assigned two points; platelet count < 150 × 109/L and constitutional symptoms one point; and 0.15 per the patient’s years of age. Death occurred in 169 of 685 patients due to disease progression (38%), blast phase (32%), second malignancy (7%), and infection (9%). A visual nomogram . Among these, infections due to profound immunosuppression , graft-vASXL1 mutation), patient characteristics , and donor–recipient HLA matching grade are evaluated. One point is assigned to each of these characteristics, stratifying patients into four TRM risk classes  and guiding the physician to advise for transplant.Patients aged 70 or below with Intermediate-1 risk harboring an ASXL-1 mutation, Intermediate-2 risk, or high risk, based on DIPSS or MIPSS-70 models (depending on the availability of NGS data) for PMF and on MYSEC-PM for SMF, are to be considered for BMT upfront. Then, seven different variables related to the underlying disease .Therapy with JAKi has primarily revolutionized the management of MF patients. Ruxolitinib (a first-in-class inhibitor of JAK1 and 2) is widely used mainly to control these patients’ disabling signs and symptoms  ,28. SeveMachine learning (ML) is a subfield of artificial intelligence that allows a computer system to create accurate predictions and make decisions built on extrapolations based on historical data without humans explicitly programming. ML potentially plays a role yet to be fully exploited in medicine, opening new scenarios. In particular, in the context of MF, registry data of 1386 patients followed up in 60 different Spanish centers were analyzed by this computational approach  to creatDespite the limitations due to the registry-based data, and thus their quality depending on the local physician entering statistics, the performance of the AIPSS model was assessed using cross-validated, time-dependent AUCs, confirming that it outperformed the gold-standard scores (IPSS and DIPSS). A further strong point is the possibility of creating a personalized risk built for each individual patient without the need to use genomic data that are not always easily accessible, especially in small centers or low-income countries.A brief summary of all the above scores is reported in Myelofibrosis is a very heterogeneous disease; its prognosis is not always easy to determine, especially on a single-patient basis. Numerous prognostic scores have been produced and presented in the literature, with a wide choice for the clinician to make the best decision to start or modify the treatment. This has become even more important recently as the therapeutical armamentarium has widened.TP53, EZH2, CBL, U2AF1, SRSF2, IDH1/2, NRAS, or KRAS are generally considered high-risk mutations [ASXL1, instead, confirmed no definite role in prognostic outcome [Nowadays, at diagnosis, the presence of driver mutations should be investigated in all patients, adding a routine NGS study in transplant-eligible individuals . In factutations . The lat outcome . In the JAK2 V617F allele burden (with 50% as cut-off to dichotomize patients into two groups) represented a favorable marker of survival. Combined with an age lower than 65 years, the median OS was 126 months. Instead, those who carried a low allele burden reported an inferior OS, both in younger and elderly patients . The latter data was superimposable with that seen in triple-negative patients, known to have a worse prognosis [In this context, the evaluation of allele burden might also play a role. In a study at MD Anderson, a high rognosis .IDH1, ASXL1, and SRSF2), unfavorable karyotype, elderly age, male sex, rate of peripheral blood blasts ≥ 3%, moderate or severe anemia, and constitutional symptoms as variables correlated to a leukemic transformation within 5 years [Gene mutations are involved in the progression toward the blast phase. In all the developed models, its incidence is higher in patients categorized as high risk for OS, as expected. A study based on a large cohort of 1306 patients identified some mutations  should be performed in younger patients and based on these results, applying the MIPSS70, version 2.0 (preferred), or the GIPSS model, the patients with worse prognoses are identified. For elderly patients at diagnosis, the choice is IPSS for PMF and MYSEC-PM for SMF. During the course of the disease in PMF, DIPSS  performs better than IPSS, giving more weight to anemia, while MYSEC-PM has been validated to be also used in SMF follow-up. MTSS and RR6 should be reserved for specific subgroups of patients, those treated with ruxolitinib and those to be transplanted, respectively. A possible accepted flowchart is reported in Currently, several prognostic models can identify the patients with the worst outcome. The clinician’s challenge is to approach each patient in each phase of the disease carefully, extrapolating the results of the prognostic scores and thus obtaining critical information to guarantee the best therapeutic approach to best manage MF.


Irritable bowel syndrome is prevalent in the general population. This study investigates the association between dietary intake and irritable bowel syndrome in medical college students at King Saud University besides its prevalence.This is an analytical cross-sectional study of 426 students  from 5 academic levels of King Saud University Medical College. A self-reported questionnaire for Rome IV criteria was completed by each participant. They also filled out a food frequency questionnaire to assess their nutritional intake.P = .001). The irritable bowel syndrome group consumed significantly more energy, carbohydrates, and saturated fatty acids, while the non-irritable bowel syndrome group consumed significantly more fibers and niacin .The overall prevalence of irritable bowel syndrome was 17.8% without correlation to age and academic year in Medical School. However, the prevalence was higher in females than in males (40/115 vs. 36/235, About 17.8% of medical students had irritable bowel syndrome with a greater prevalence in females. The irritable bowel syndrome group consumed significantly more energy, carbohydrates, and saturated fatty acids, while the non-irritable bowel syndrome group consumed significantly more fibers and niacin. Our results did not show any significant association between irritable bowel syndrome and fermentable oligosaccharide, disaccharide, monosaccharide, and polyol intake. Overall, both groups were not adhering to the Saudi dietary recommended intake. Irritable bowel syndrome (IBS) is common among medical students. In our survey, 17.8% of medical students described symptoms of IBS according to Rome IV criteria, with greater prevalence among females.In our study, the IBS group reported to significantly consume more energy, carbohydrates, and Saturated fatty acids. Moreover, this group significantly consumed less fibers and niacin when compared to the non-IBS group.The findings shed light on the association between IBS and dietary intake among Saudi medical students. A large cohort study is recommended to give a better understanding of the relationship of IBS and Saudi diet.1 and ranges between 9.3% and 43.5% among medical institutions around the globe.2 The method of diagnosis utilized has an impact on this IBS prevalence.Irritable bowel syndrome (IBS) is one of the common disorders of gut–brain interactions , with a global prevalence of 9.2%, which varies between 0.2% and 29.2% according to country4 and its pathophysiology is complex and incompletely understood.5 The most common method for making a differential diagnosis based on these symptoms is the Rome IV criteria.6Irritable bowel syndrome is characterized by chronic or recurrent stomach pain that is relieved or made worse by defection or by a change in bowel habits,7 or would accept a hypothetical medication’s 99% chance of curing their symptoms in exchange for a median 1% risk of sudden death.8 In addition, there has been an overall increase in the length of physician visits associated with IBS,9 and the estimated direct care costs for IBS range from £45.6 to £200 million annually in the UKto €3.1 to €4.1 billion in Germany.7Irritable bowel syndrome negatively impacts the quality of life and work productivity, as it has been estimated that patients would give up 10-15 years of life expectancy for an immediate cure11 gender,13 anxiety, depression,15 smoking,16 and diet18 have been regarded as IBS risk factors. Particularly, the pathophysiology of IBS has been closely linked to diet or nutritional consumption.5 Despite the numerous IBS studies that have been conducted since the publication of the Rome IV criteria in 2016,6 there are limited studies that look at the prevalence of IBS in both the Saudi general population and medical students using the Rome IV criteria. Furthermore, there is also less research on the association between IBS and food.20Generally, genetics,We investigated the association between dietary intake and IBS among medical college students at King Saud University, Saudi Arabia. The prevalence of IBS was also reported.In this analytical cross-sectional study, a total of 426 students  at King Saud University, Medical College in Riyadh, Saudi Arabia, were studied from November 2020 to December 2020. A stratified sampling method was used to calculate the sample size. Stratification considered the gender and academic year; this stratification was done to eliminate any confounder related to gender and academic year. Medical students were randomly chosen from the students’ list provided by King Saud University Medical Students Council and were invited to complete an online self-reported questionnaire via email due to coronavirus-19 precautions, and all survey answers were collected anonymously without identification information. However, the excluded participants in this study involved the students who refused to give (online) informed consent for participation and those who self‐reported having the following criteria: diabetes mellitus, celiac disease, inflammatory bowel disease (Crohn and Ulcerative Colitis), cancer anywhere in the gastrointestinal tract, and current infection of the gastrointestinal tract. We obtained informed consent from all participants. Each analysis and questionnaire was completed in accordance with the rules and approval of the Institutional Review Board of King Saud University Medical City, Riyadh, Saudi Arabia (KSU-IRB 017E).16 so a proportion of 31% was taken with an alpha (α) of 0.05 and a precision of 5%. Thus, the estimated sample size was 329 participants. An additional 20% was added to compensate for any nonresponses or excluded participants. This resulted in a total sample size of 395.The sample size calculation was based on a recently published study on medical students, their sample size was 232, and the prevalence of IBS was 31%,The first part included informed consent and demographic details such as age, gender, academic year, and smoking habits.21 It also includes the presence and frequency of abdominal pain or discomfort, its onset, the connection between the pain and the frequency or type of stools, and whether the symptoms got better after defecation. The diagnosis of IBS required that students reported not only abdominal pain or discomfort at least 1 day a week during the past 3 months but also at least 2 of the following 3 symptoms: pain is related to defecation, onset is associated with a change in stool frequency, and a change in stool appearance. Criteria must be fulfilled for the last 3 months with symptom onset at least 6 months before diagnosis. The questionnaire also classifies subjects into the following subgroups: constipation-predominant IBS (IBS-C), diarrhea-predominant IBS (IBS-D), mixed IBS (IBS-M), or the subject never or rarely has abnormal stools (IBS-U), based on patient report of the usual consistency of abnormal stools by using a picture of the Bristol Stool Scale.The second part contains an English version of the Rome IV criteria questionnaire.22 The survey measures the consumption of food during the past year. The amount of food is what is consumed on average. Consisted of 140 food items developed to obtain the dietary habits of Saudis. This FFQ had been tested for its validity, internal consistency, test–retest reliability, and completeness of the food list. After that, the nutrient content of each item was calculated. These values included the amount of not only energy, proteins, fat, and carbohydrates but also of fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) , calcium, phosphate, iron, zinc, vitamin A, B1, B2, B,6, C, E, niacin, and folate. Dietary intake was calculated using the USDA software  program.The third part included a food frequency questionnaire (FFQ) to validate the dietary intake in the Arabic language.t-tests. Data were expressed as a frequency or mean with a SD. Two-tailed P <.05 were considered to indicate statistical significance. Statistical analyses were performed using Statistical Package of Social Sciences (SPSS) version 25 .We compared the gender, grade level, and food constituents between non-IBS and IBS groups, using the chi-square test and independent samples Of 445 responses collected, 19 were later excluded for meeting one of the exclusion criteria. The final analysis included 426 responses. The mean age of the included students was 21.21 ± 1.58 (range 18-27), and 271 (63.6%) were males. Seventy-six students  had symptoms of IBS. Therefore, the overall prevalence of IBS was 17.8% without correlation to age and academic year in Medical School. The female group showed a higher prevalence  than the male group . Prevalence of IBS during the 2 preclinical and 3 clinical years was 10.8%, 18.4%, 16.5%, 18.4%, and 25%, respectively, and showed no difference among each academic level. The IBS group was further subdivided into diarrhea-predominant (IBS-D), constipation-predominant (IBS-C), along with diarrhea and constipation (IBS-M), or undetermined categories (IBS-U). Among the 76 IBS students, the proportions of IBS-D, IBS-C, IBS-M, and IBS-U were 4.5%, 3.1%, 9.9%, and 0.5%, respectively .P = .001, odds ratio = 2.2705; 95% CI = 1.374, 3.753); hence being a female is a risk factor for IBS. Analysis of the smoking status  and the academic year  showed no significant differences . The IBS group also consumed significantly higher carbohydrates  and saturated fatty acids (SFA) . Furthermore, the IBS group consumed significantly less fibers than non-IBS group with a mean of 1.553 g and 1.909 g, respectively  and niacin with a mean of 1.158 mg and 1.337 mg, respectively .In the current study, the energy intake showed a significant difference between IBS and non-IBS groups with a mean of 2.158 kilocal and 1.820 kilocal, respectively . The consumption of the minerals calcium, potassium, phosphorus, iron, iodine, and zinc was also not significantly different between the 2 groups . They also had no significant difference in intake of vitamin A, vitamin B1, vitamin B2, vitamin B6, vitamin C, vitamin E, and folate . With regard to FODMAPs, there were no significant differences in the consumption of fructose, lactose, polyols, sorbitol, mannitol, fructans, galactans, raffinose, and stachyose   .Overall, on average, only 22.56% from the IBS group and 27.25% from the non-IBS group were following the Saudi recommended dietary allowance.1 and the overall prevalence of Saudi undergraduate students. However, it is lower than what has been reported by local studies among medical students.24In the current study, the overall prevalence rate of IBS among medical students was 17.8%, which is higher than the pooled global prevalence, which was 9.2%,1 It has been suggested that sex hormones and pain perception play a potential role in these gender differences.26 In our study, the prevalence of IBS was significantly higher among females, which is consistent with the literature.Many studies have observed that the prevalence of IBS is higher in females.28 On the other hand, a study conducted among medical students and interns from King Abdulaziz University Hospital, Jeddah, showed the prevalence is significantly higher among higher academic years and suggested that the reason is an increased study and work stressors.29 In contrast, a systemic review conducted in Iran concluded that IBS is more prevalent among the first and second years.30The prevalence of IBS appeared to be influenced by the academic year at college. However, a strong connection between the 2 has not yet been well established. Our study showed no significant difference between preclinical and clinical students, which is consistent with several international studies.31 our results showed that smoking status had no significant association with IBS prevalence. This could be due to the small number of smokers in our study for both IBS and non-IBS groups, which were 10 (13.16%) and 23 (6.6%), respectively. This result concedes with a study conducted in Jeddah29 and another study conducted in Malaysia,32 both among medical students. Nonetheless, a recent study among Saudi undergraduate students concluded that cigarette smoking is a risk factor for IBS.15Despite the adverse effects of smoking,34 Many studies associated worsening IBS symptoms with particular kinds of diet, such as high in fat and carbohydrates,37 spicy food,38 and caffeine.39 However, other studies associated improvement of symptoms and quality of life with a diet low in FODMAPs.44 In our region, a study conducted among nurses at King Abdulaziz University Hospital to determine the prevalence, severity, and predictors of IBS concluded that the first predictor of IBS was food hypersensitivity.18 Moreover, another study found that specific diets, especially garlic, onions, and coffee, were found to increase the IBS symptoms. On the other hand, decreasing carbohydrates and increasing fiber would enhance the patient’s health and decrease the symptoms.19It is well established that diet plays an essential role in the pathophysiology of IBS.45 Also, intake of carbohydrates, SFA, fiber, and niacin showed significant differences. Carbohydrates and SFA is linked to alterations in microbiota, inflamed microenvironment, and overgrowth of harmful bacterial species.47In the current study, medical students showing symptoms of IBS demonstrated significant differences in energy intake compared to the non-IBS group, which is consistent with a recent North American population-based study.48 Though both groups consumed more carbohydrates and SFA than the recommended dietary allowance (DRA), our results showed that the IBS group consumed them significantly more compared to the non-IBS group, which may be associated with their symptoms. On the other hand, dietary fiber appears to improve the global symptoms of IBS,49 as it acts as a prebiotic to intestinal microbiota that induces the growth of beneficial bacteria;50 however, our findings show that both study groups consumed dietary fiber below the DRA with the consumption among IBS group being significantly less. In regard to niacin, there is growing evidence that highlights the importance of niacin in neuronal health51 and the digestive system.52 The relationship between IBS and niacin should be further studied. Contrary to expectations, this research did not find any significant difference between FODMAPs intake and IBS. These effects on gut flora are important in the pathophysiology of IBS.This study has several limitations, which should be considered in future research. First, individuals with IBS were identified through Rome IV criteria and not through proper evaluation by a physician. Another potential limitation is recall bias. Finally, the study is done in only 1 of the 21 medical colleges in Saudi Arabia.In conclusion, 17.8% of medical students have IBS, with a greater prevalence in females. The IBS group consumed significantly more energy, carbohydrates, and SFA, while the non-IBS group consumed significantly more fibers and niacin. Our results did not show any significant association between IBS and FODMAP intake. Overall, both groups were not adhering to the Saudi DRA.More research utilizing the Rome IV criteria is required to assess the prevalence of IBS in the general Saudi population and in specific groups. Since Saudi food differs greatly from Western cultures, a large cohort study regarding the dietary or nutritional pattern and etiology of IBS is essential.