Growth charts constitute an essential tool for monitoring adolescents’ development. The percentile growth charts currently used are based on Basque Country population. Considering socioeconomic differences between Spanish regions, growth chart data could be inappropriate. Thus, a descriptive cross-sectional study with 4130 adolescents was conducted to describe the percentile distribution of adolescents from Extremadura and compares these percentiles with those used as reference. Bodyweight, height and BMI of Extremadura adolescents differ from the reference values currently applied. Thus, the need to use new indicators should be considered, adapted to the physical and anthropometric reality of children and young people to avoid the possible normalization of situations of thinness, overweight or obesity.Background: Growth charts constitute an essential tool for monitoring adolescents’ development. In Extremadura, the percentile growth charts by Faustino Orbegozo Foundation are used. However, they are based on Basque Country population data. Considering socioeconomic differences between Spanish regions, growth chart data could not be appropriate. Aims: to describe the percentile distribution of adolescents from Extremadura and compare these percentiles with those proposed by the Faustino Orbegozo Eizaguirre Foundation that are currently applied in the Extremadura Health Service. Methods: A descriptive cross-sectional study was conducted. A total of 4130 adolescents (12–17 years) participated into the study. Bodyweight and height were assessed. Results: Significant differences were found comparing real measured values with commonly used reference tables for bodyweight at all ages between 12 and 13 years and at 14 years in both gender (p < 0.05). Differences were also found in boys at 15, 16.5 and 17 years (p < 0.05). Regarding height, significant differences were reported at 12, 13, 14.5, 15, 16.5 and 17 years old (p < 0.05) in males; while females’ results only revealed differences at 12, 12.5, 14.5 and 15.5 years (p < 0.05). BMI outcomes showed differences in both gender at 12, 12.5, 13, 14 and 15 years old (p < 0.05). Differences were also found at 16 and 14.5 years for boys and girls, respectively (p < 0.05). Conclusion: Bodyweight, height and BMI of adolescents from Extremadura differ of the reference values currently applied. Hence, this study’s outcomes suggest the need to use new indicators, adapted to the physical and anthropometric reality of children and young people to avoid the possible normalisation of situations of thinness, overweight or obesity. Intergenerational changes in bodyweight, height, and body mass index (BMI) have been exposed in different long-term trend studies on physical characteristics of children and adolescents ,2. TheseFocusing in Spain, the 2008 data  show a cGrowth charts constitute an essential tool for monitoring children’s and adolescents’ development and are commonly used to diagnose and control changes in height, bodyweight and BMI . In ExtrIt should be noted that the monitoring of child and adolescent growth in Extremadura is being carried out by means of tables based on anthropometric data from children living in the Basque Country. Considering that differences have been found in the Human Development Index (HDI) between the most developed territories in Spain, such as Basque Country, and others least developed, such as Extremadura , the genNo studies have analysed the percentile distribution of height, bodyweight and BMI of adolescents from Extremadura. Considering that percentiles are useful to compare several population subgroups based on an average, if these populations show differences, such comparison might be biased and inappropriate.Furthermore, it is important to consider that growth charts are based on BMI. Although the BMI has been widely used as the standard clinic tool for determining the bodyweight status in young people ,17, the Therefore, this study aims to (1) describe the percentile distribution of adolescents from Extremadura and (2) compare these percentiles with those proposed by the Faustino Orbegozo Eizaguirre Foundation that are currently applied in the Extremadura Health Service.A descriptive cross-sectional study with a 14 month cut-off period was conducted (October 2007 to December 2008). A stratified multistage sampling was used. The units of the successive stages were provinces, healthcare areas, city typology , educational centres (IESO), academic year (classes where the survey is carried out), gender and pupils (surveyable persons).A favourable report was obtained from the Bioethics Committee of the University of Extremadura, considering that it complied with all the relevant regulations (reference code 11/2006).Thirty-nine secondary schools from Extremadura were contacted to participate in this study. A total of 4130 adolescents , aged between 12 and 17 years, participated into this study. Participants had to meet the following eligibility criteria to be included in this project: (1) age: 12 to 17 years; (2) registered and/or resident in the autonomous community of Extremadura; (3) authorised by parents or legal guardians; (5) acceptance of the adolescents to participate in the study.www.ine.es, accessed on 16 June 2021) [To provide estimates with a certain degree of reliability of the survey at Autonomous Community level, a sample of 4130 individuals between 12 and 17 years of age has been selected. Based on data from the National Institute of Statistics of Spain (ne 2021) , the popSections are made within each stratum with probability proportional to its size. Proportional allocation between strata  was used. Within each stratum, the size of each sub-stratum  was used. The type of sampling was proportional in age and gender quotas, randomly selected within the educational centre of the determined populations.Childhood Obesity Surveillance Initiative (COSI) [2).Data collection was carried out in their respective educational institutions by trained and standardised health personnel. The measurements were performed under standardized conditions, following the protocol established in the Data Collection Procedure Manual, developed specifically for e (COSI) . For meaAll information collected was tabulated in a database specifically designed for this purpose. Statistical analyses were carried out using IBM SPSS Statistics software, version 25. Descriptive statistics were performed for all parameters, including as measures of central tendency the mean and standard deviation (SD) for the dispersion of quantitative variables and percentiles  as measures of position.p ≤ 0.05. Hedge’s g effect size  was calculated to determine the magnitude of between reference methods comparisons. Effect size thresholds were interpreted, as follow [Normality and homogeneity of data was checked applying Kolmogorov–Smirnov and Levene’s test, respectively. Then, differences between the Extremadura data and the reference study by Faustino Orbegozo Eizaguirre  were examined by applying an Independent samples T-Test adjusted by age and gender. Alpha level was set at s follow : >0.2, sp < 0.001; girls: p < 0.001 to 0.003) and at 14 years old . A meaningful difference was also found in boys at 15 (p < 0.001), 16.5 (p = 0.001) and 17 years (p < 0.001). Regarding height, significant differences were reported in boys at 12 (p < 0.001), 13 (p < 0.001), 14.5 (p = 0.027), 15 (p = 0.005), 16.5 (p < 0.001) and 17 (p < 0.001) years, while girls’ outcomes only revealed differences at 12 (p < 0.001), 12.5 (p < 0.001), 14.5 (p < 0.001) and 15.5 (p = 0.009) years. Likewise, BMI comparisons also showed differences between studies. Coincidently, there were significant differences for BMI in both gender at 12 , 12.5 , 13 , 14  and 15 years old . Moreover, meaningful differences were found at 16 (p = 0.034) and 14.5 years (p = 0.012) for boys and girls, respectively.The main findings of the present study show significant differences in bodyweight, height and BMI growth charts between the studied population and the reference parameters applied in the Extremadura Health System , for numMore specifically, when comparing our study with the two previous studies ,11, resuRegarding height, both genders experienced a progressive increase with age, reaching a maximum value at 16 years old. Female results agree with those reported by previous studies ,11. In c2, like previous studies [As well as bodyweight and height, BMI increased progressively with age, in line with the findings previously presented by Sobradillo et al. , with a  studies ,11. Furt studies , as happThe differences and similarities found with the studies by Sobradillo et al. , and LezIt should be known that there are socio-demographic variables, such as socio-economic level or region , as wellAccording to Eurostat 2008 , the GroFurthermore, these differences between regions could also be conditioned by the classification of urban (Basque Country) and rural (Extremadura) environments. In urban environments, the access to sports facilities, team-programmed activities, transport networks, etc., can directly influence adherence to a lifestyle and affect physical activity practices or the following of healthy diets ,31. The There is also evidence of a direct relationship between long-term acceleration of growth and more favourable socio-economic and health conditions (nutrition and/or absence of disease). Thus, these allow the phenotypic expression of the maximum genetic potential for growth in the child and adolescent population . For exaIn summary, the comparison of anthropometric parameters of children and young people with specific graphs from other communities that do not correspond to their own, can lead to mistakes when these children grow by percentiles higher or lower than those stipulated as maximum or minimum . MoreoveOne of the strengths of this study is the representativeness of the sample, as it was 4130 children and young people from Extremadura between 12 and 17 years old, compared to the sample of the study used to elaborate the reference tables by Sobradillo et al.  (6443 chThe findings of this study showed that bodyweight, height and BMI of children and young people from Extremadura differ from the reference values proposed by the Faustino Orbegozo Eizaguirre Foundation that are currently used in the Extremadura Health Service. Moreover, the development-associated changes of children and young people from Extremadura compared to those from Basque Country raise the question of which values should be considered to define the levels of development and growth in the current population. Thus, we conclude that the reference values used by Extremadura Health Service may not be applicable to children and adolescents from Extremadura due to the different contexts of regions.Hence, this study presents growth tables and graphs adapted to the physical and anthropometric reality of Extremadura adolescents. Therefore, the results presented in this study could be an important contribution to the need to use new indicators, adapted to the physical and anthropometric reality of children and young people to avoid the possible normalisation of situations of thinness, overweight or obesity.


In the unadjusted analysis, the CNS had the strongest association with high CVD risk; in the adjusted analysis, the FLI score was most strongly associated with high CVD risk. Fatty liver is an important independent risk factor for CVD. Therefore, the available NAFLD scoring systems could be utilized to predict CVD.This study aimed to determine whether nonalcoholic fatty liver disease (NAFLD) is an independent risk factor for CVD and to identify the most useful NAFLD diagnostic tool for predicting CVD. Data from a total of 23,376 Korean adults without established CVD were analyzed. Cardiovascular risk was calculated using the Framingham Risk Score (FRS) 2008. The presence of NAFLD was defined as moderate-to-severe fatty liver disease diagnosed by ultrasonography. Scores for fatty liver were calculated using four NAFLD scoring systems , and were compared and analyzed according to cardiovascular risk group. Using the FRS, 67.4% of participants were considered to be at low risk of CVD, 21.5% at intermediate risk, and 11.1% at high risk. As the risk of CVD increased, both the prevalence of NAFLD and the score from each NAFLD scoring system increased significantly ( Nonalcoholic fatty liver disease (NAFLD) has become one of the most common liver diseases worldwide with a current estimated global prevalence of 30% in adults . NAFLD iNAFLD patients are at risk of cardiovascular disease (CVD); therefore, risk factors for NAFLD are also important risk factors in the development of CVD . RecentlThis association may result from processes involved in NAFLD pathogenesis. In NAFLD, oxidative stress and inflammation in the liver induce the progression of NAFLD from simple steatosis toward the more severe form of nonalcoholic steatohepatitis . The infLiver biopsy is the gold standard method for diagnosing NAFLD . HoweverThis study aimed to determine whether NAFLD is an independent risk factor for CVD and identify the most useful NAFLD diagnostic tool for predicting CVD.This study was approved by an Institutional Review Board (IRB) at a local hospital, Republic of Korea (protocol no. KNUH 2020-05-061). Anonymous and de-identified data were used for the analysis; therefore, informed consent was not obtained.A retrospective study was performed using data from 28,897 Korean patients who visited Kyungpook National University Hospital Health Promotion Center from January 2011 to August 2017. The inclusion criteria for this study were as follows: (1) subjects aged 30–74 who visited the hospital for health screening during the study period; (2) those who performed all examinations including abdominal ultrasonography and laboratory tests and completed questionnaires on socio-demographics and health-related characteristics; (3) those who had no previous history of any established CVD . Exclusion criteria were as follows: (1) significant consumption of alcohol ; (2) positive serologic markers for hepatitis B or C viruses, or human immunodeficiency virus; (3) abnormal ultrasonography liver findings ; (4) presence of thyroid disease, including thyroid cancer, hyperthyroidism, hypothyroidism, or thyroid hormone replacement therapy; (5) absence of questionnaire data or anthropometric measurements; and/or (6) patients with any history of taking drugs  or supplements that may influence liver enzymes or induce or reduce fatty liver changes. In total, 23,376 patients  were eligible for the analysis.Anthropometric measurements were taken with the participants wearing light clothing with bare feet after at least a 12 h fast. Height was measured by standing on the measuring instrument, matching the shape of the soles of the feet, keeping the knees straight, and looking straight ahead without leaning the back on the stand. A comfortable posture without applying any force to the body was maintained while measuring height and weight. Waist circumference was measured at the middle of the lowermost part of the ribs and the highest part of the pelvis while exhaling comfortably after spreading both feet about 25 to 30 cm to spread weight evenly. Body mass index (BMI) was calculated as the patient’s weight in kilograms divided by the patient’s height in meters squared. Blood pressure was measured after sitting on a chair for 5 min with validated electronic devices.Demographic characteristics, including past medical history, were obtained through a health screening questionnaire. Hypertension was recorded if the patient reported diagnosis of hypertension by a physician or treatment with antihypertensive medication, or if a blood pressure of ≥140/90 mmHg was measured. Diabetes was recorded if the patient reported diagnosis of diabetes by a physician or treatment with anti-diabetic drugs, or if a fasting plasma glucose level of ≥126 mg/dL was measured. Dyslipidemia was recorded if the patient reported treatment with cholesterol-lowering medication or if a total cholesterol level of ≥200 mg/dL, a high-density lipoprotein (HDL) cholesterol level of <45 mg/dL in males or <50 mg/dL in females, a low-density lipoprotein (LDL) cholesterol level of ≥130 mg/dL, or a triglyceride level of ≥150 mg/dL was measured [Laboratory parameters were measured after a minimum of a 12 h fast. Values outside extreme outliers were considered missing values. White blood cells, hemoglobin, erythrocyte sedimentation rates, and thyroid-stimulating hormone levels were measured, including blood sugar, triglycerides, and HDL cholesterol. Serum aspartate transaminase (AST), alanine transaminase (ALT), serum alkaline phosphatase, serum bilirubin, serum total protein, and albumin were measured. In addition, hepatitis B antigen, hepatitis C antibody, and human immunodeficiency virus antibodies were checked to diagnose infectious diseases such as hepatitis, and serum creatinine and glomerular filtration rate were measured for renal function evaluation.In all patients, liver ultrasonography was performed by a skilled radiologist after 12 h of fasting. The severity of fatty liver disease was assessed based on echogenicity, the echoic tissue amplitude of the liver and kidneys, the degree of echo penetration, and the degree to which the vascular structures of the liver were defined. Fatty liver was classified as mild, moderate, or severe based on standard criteria ,16. SteaThe FLI was calculated as reported by Bedongni and colleagues  using thFLI ranges from 0 to 100, with an FLI < 30 ruling out fatty liver disease (sensitivity 87%) and FLI ≥ 60 suggesting the presence of fatty liver disease (specificity 86%) with a good diagnostic accuracy of 0.84 (95% CI: 0.81–0.87) . In thisThe HSI was calculated based on the report by Lee and colleagues :HSI = 8 HSI values < 30 rule out fatty liver disease (sensitivity 93.1%) and HSI ≥ 36 suggests the presence of fatty liver disease (specificity 93.1%) with a good diagnostic accuracy of 0.93 (95% CI: 0.92–0.94) . In thisThe SNS was calculated using the formula as reported by Lee and colleagues ; detailsThe CNS was calculated using the formula reported by Lee and colleagues ; detailsFRS is a sex-specific CVD prediction tool that estimates the 10-year risk of CVD and was developed based on data from the Framingham Heart Study . Use of p-value of <0.05 was defined as statistically significant.All statistical analyses were performed according to the three CVD risk groups classified by the FRS. Categorical variables are presented as numbers with percentage, and continuous variables are presented as the mean ± standard deviation. Pearson’s chi-squared tests and ANOVAs were used for comparing groups. To determine the relationship between NAFLD diagnostic tools and CVD risk groups, multinomial logistic regression analysis was performed and adjusted for covariates. Each odds ratio (OR) was reported together with its 95% CI. In addition, receiver operating characteristic (ROC) curve analysis was performed to confirm the sensitivity and specificity of CVD risk prediction according to each NAFLD diagnostic tool and the AUC for each tool was calculated. ROC curve analysis was performed using MedCalc software version 19.2.1, and IBM SPSS statistics 25.0 was used for all other analysis. A Of 28,897 patients, 5521 were excluded, meaning 23,376 patients  were included in the analysis. Participants were classified according to CVD risk groups; baseline demographic, clinical, and biochemical characteristics of the study subjects are presented in p < 0.001). The FLI showed similar results: the proportion of FLI scores between 30 and 60 and ≥60 in the low-risk group for CVD were 18.7% and 4.7%, respectively; in the intermediate-risk group, 37.9% and 10.2%, respectively; and in the high-risk group, 42.6% and 15.4%, respectively. Similar results were found for other scoring systems: the proportion of HSI scores between 30 and 36 and ≥36 in the low-risk group were 45.4% and 16.3%, respectively; in the intermediate-risk group, 51.1% and 24.8%, respectively; and in the high-risk group, 50.0% and 29.7%, respectively. The proportion of participants with a SNS ≥ 8 in low, intermediate, and high-risk groups was 27.8%, 53.2%, and 66.7%, respectively. The proportion of participants with a CNS ≥ 40 in the low, intermediate, and high-risk groups for CVD was 33.8%, 65.3%, and 75.9%, respectively. Among 23,376 patents, 2343 (10%) had moderate-to-severe fatty liver when assessed by abdominal ultrasonography. Of this group, 1051 (6.7%) patients were in the low-risk group, 747 (14.9%) were in the intermediate-risk group, and 545 (21%) were in the high-risk group. In addition, the score of each NAFLD scoring system significantly increased with increasing cardiovascular risk (p < 0.001). The FLI score increased from 20.69 to 37.09, the HSI score from 31.80 to 33.83, the SNS from 5.94 to 8.61, and the CNS from 32.19 to 63.45. Using the FLI score ≥ 60 criteria, NAFLD was identified in 1656 (7.1%) of the 23,376 patients; using the HSI score ≥ 36 criteria, NAFLD was identified in 4581 (19.6%) patients; using the SNS ≥ 8 criteria, NAFLD was identified in 8781 (37.6%) patients; and using the CNS ≥ 40 criteria, NAFLD was identified in 10,570 (45.2%) patients. With all four diagnostic tools, the number of patients fulfilling NAFLD diagnostic criteria was higher as cardiovascular risk increased  using various fatty liver diagnostic tools (liver ultrasonography and four NAFLD scoring systems). We demonstrated that all tools were useful indicators of CVD risk and that fatty liver is an important independent risk factor for CVD; among the tools, ultrasonography, the FLI, and the CNS were found to be the most useful. We confirmed that both the severity of steatosis diagnosed by ultrasonography and the presence of fatty liver predicted through NAFLD scoring systems were associated with increased risk of CVD.NAFLD is not only prevalent in Western societies but is an emerging problem in many Asian countries . In WestIn this study, we assessed the relationship between ultrasonography, NAFLD diagnostic tools, and cardiovascular risk groups. For all tools, there was a correlation between score and cardiovascular risk even after adjusting for factors expected to influence the result, confirming NAFLD as an independent predictor of cardiovascular risk. Multinomial logistic regression, both before and after adjusting for covariates, showed that a higher degree of steatosis found via ultrasonography and a higher score from the FLI, HSI, SNS, and CNS were related to a higher risk of CVD. In both analyses, liver ultrasonography showed the strongest association. Among NAFLD diagnostic tools, ultrasonography, the FLI, and the CNS were most strongly associated with cardiovascular risk. Patients with moderate-to-severe fatty liver, diagnosed by ultrasonography, were 6.9 times more likely to be in the high-risk CVD group than patients with a normal liver ultrasound. If a patient’s FLI score was 60 or higher, the probability of being in the high-risk group for CVD was 6.3 times higher than a patient’s FLI score below 30; this association was significant after adjustment. However, the SNS and CNS showed lower OR values after adjustment in our analysis; this may be due to adjustment factors  being adjusted both in the multinomial logistic regression analysis and in the calculation of cardiovascular risk. Nevertheless, significant associations were continually confirmed. These results suggest that liver ultrasound, the FLI, and the CNS have the strongest associations with CVD and that NAFLD is an independent risk factor for CVD. In agreement with this, Cuenza and colleagues have also recently shown that ultrasound-based grading of NAFLD severity is associated with an increased risk of CVD . They suSeveral previous studies have assessed the association between NAFLD and CVD risk and have demonstrated that NAFLD is an independent predictor of cardiovascular risk . A previThe gold standard for diagnosing fatty liver disease is liver biopsy. However, due to its invasiveness, risk of complications, and high cost, it is not always feasible in the clinical setting. In this study, ROC analysis was used to confirm the usefulness of NAFLD in predicting CVD: we found that the FLI, HSI, SNS, and CNS were all useful. The CNS showed the highest AUC; the sensitivity and specificity for predicting high-risk CVD were 75.2% and 59.6%, respectively, based on >41.35 criterion. One drawback of ultrasound-based diagnosis of NAFLD is that it is highly operator-dependent, with significant inter- and intra-observer variability. In addition, ultrasonography is more expensive and takes more time than scoring systems , which uThis study has several limitations. First, we defined excessive alcohol consumption based on grams of drinks per week . These data are an approximation, since we could not access study participants’ complete data on the amount of alcohol consumed. Second, our study population included only healthy Koreans who were actively participating in the medical checkup program, which could lead to selection bias. Third, the study is based on patients from a single local tertiary center, so findings may not be a good representation of the general population. Fourth, the study was cross-sectional, meaning the data are retrospective and descriptive in nature, and cannot confirm causality. Finally, the FRS that was used in this study overestimates cardiovascular risk in cohorts with low background risk of CVD in the Asian population . FurtherNevertheless, strengths of the current study merit consideration. First, to the best of our knowledge, our study is the first to report on the association of multiple, validated NAFLD scoring systems with the risk of CVD in a large-scale population. Second, this study was designed to include individuals free of clinically-evident prior vascular disease or other chronic disorders at baseline to minimize the possibility of reverse-causation bias.In conclusion, our results demonstrate that higher scores on NAFLD scoring systems are associated with a higher risk of CVD; fatty liver is therefore an important, independent risk factor for CVD. Liver ultrasonography and the FLI and CNS scoring systems showed the strongest associations with cardiovascular risk. These widely-available NAFLD scoring systems could be a useful screening tool to identify patients who may benefit from lifestyle modification and appropriate CVD interventions in the long term. We believe that careful and routine screening for NAFLD and, simultaneously, prediction of cardiovascular risk, may lead to the early diagnosis and management of disease. By focusing on lifestyle modification and reducing risk factors, patients may demonstrate slower or no progression of liver disease and better cardiovascular outcomes. Further research is needed to determine whether NAFLD scoring systems could be a predictor of CVD in a clinical setting.


Evaluating the influence of vitamin D concentrations together with preoperative metabolic phenotypes on remission of chronic noncommunicable diseases (CNCDs) after 6 months of Roux-en-Y gastric bypass (RYGB). Cross-sectional analytical study comprising 30 adult individuals who were assessed preoperatively (T0) and 6 months (T1) after undergoing RYGB. Participants were distributed preoperatively into metabolically healthy obese (MHO) and metabolically unhealthy obese (MUHO) individuals according to HOMA-IR classification and to the adequacy and inadequacy of vitamin D concentrations in the form of 25(OH)D. All participants were assessed for anthropometric characteristics, biochemical variables, and presence of CNCDs. The statistical program used was the SPSS version 21. In face of vitamin D adequacy and regardless of the metabolic phenotype classification in the preoperative period, the means found for HOMA-IR allowed us to define them as metabolically healthy 6 months after RYGB. Only those with vitamin D inadequacy with the MUHO phenotype showed better results regarding the reduction of glucose that accompanied the shift in serum 25(OH)D concentrations from deficient to insufficient. It is possible that preoperative vitamin D adequacy, even in the presence of an unhealthy phenotype, may contribute to the reduction of dyslipidemia and improvement in cholesterol. It is suggested that preoperative vitamin D adequacy in both phenotypes may have a protective effect on metabolic health. Bariatric surgery aims to reduce the total body mass with consequent remission of chronic noncommunicable diseases (CNCDs), which can happen more intensely in the minimum period of 6 months after the procedure . SeveralThe scientific literature, when comparing metabolically healthy obese (MHO) or unhealthy obese (MUHO) individuals, shows that MUHO presents characteristics that can facilitate the onset of obesity-associated diseases, such as inadequate functionality of adipose tissue that, in turn, favors the appearance of lipotoxic products, presence of insulin resistance (IR), greater ectopic and visceral fat storage that contribute to the development of cardiometabolic diseases ,3,4,5.The weight loss process promoted by bariatric surgery may be related to lipolytic gene expression that correlates inversely with biomarkers of lipid and glucose metabolism . HoweverHowever, to date, there are no studies investigating the relationship between vitamin D and CNCD considering the metabolic phenotypes after bariatric surgery. Thus, the aim of the present study is to evaluate the influence of vitamin D concentrations together with the preoperative metabolic phenotypes on remission of CNCDs 6 months after Roux-en-Y Gastric Bypass (RYGB).This is a cross-sectional study of the analytical type consisting of 30 adult individuals with obesity who underwent RYGB, selected by convenience at the Multidisciplinary Center for Bariatric and Metabolic Surgery located in the city of Rio de Janeiro, Brazil, in the period from July 2019 to September 2020.2 and age ≥ 20 and <60 years preoperatively, who formally authorized their enrollment by signing the informed consent form. Exclusion criteria were: Previous disabsorptive and restrictive surgeries, intestinal disabsorptive syndromes, neoplasms, use of drugs for total body mass loss, alcohol consumption higher than 20 g/day for women and 40 g/day for men, pregnant or nursing women, kidney insufficiency and liver diseases, except nonalcoholic fatty liver disease, endocrinopathies , acute and chronic infections, use of anticonvulsant drugs or drugs that interfere with vitamin D metabolism, use of medication or supplement rich in vitamin D for 2 months prior to the first laboratory test. The instrument used for data collection was previously tested and consisted of a form filled out by a single interviewer through consultation of medical records. All the members of this study were evaluated for anthropometric variables and laboratory tests. Regarding the anthropometric variables, the total body mass (kg) and height (m) were measured to calculate the BMI in which the cutoff point adopted for class II and III obesity classification was ≥35 kg/m2, according to the WHO recommendation [Participants were evaluated preoperatively (T0) in relation to the inclusion and exclusion criteria established for the research and followed up for 6 months (T1) after undergoing RYGB. They were further distributed preoperatively into MHO  and MUHO  according to HOMA-IR classification, as well as to the adequacy and inadequacy of vitamin D concentrations (25(OH)D) according to the criteria of Holick et al. (2012) ,16,17. Iendation . BiochemVitamin D analysis was performed in the form of 25(OH)D and 1,25(OH)2D by means of High Efficiency Liquid Chromatography with an ultraviolet detector (HPLC-UV) . Thus, tThe overall technical requirements for adequately obtaining blood pressure (BP), as well as the definition of the cutoff point equal to or greater than 140/90 mmHg, which is considered hypertensive, followed the specifications of the VI Brazilian Guidelines on Hypertension .For diagnosing type II diabetes mellitus (2DM), the American Diabetes Association criterion was applied . Thus, 2p < 0.05).Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows version 21.0. The Kolmogorov–Smirnov test was performed to evaluate the normality of the sample. Measures of central tendency and dispersion (mean and standard deviation) were calculated for quantitative variables, and the Mann–Whitney or Kruskal–Wallis tests were used to compare the means. To test the homogeneity of proportions between categorical variables, the Pearson chi-square test, the Fisher’s exact test, and Linear Correlation (Spearman test) were applied between the non-parametric variables. The significance level adopted was 5% . Moreover, they presented similar means for almost all biochemical variables, except for 1,25(OH)2D, which was higher in the MUHO  and showed a strong correlation with HOMA-IR (0.982 p = 0.000). Nonetheless, such an increase in postoperative serum 1,25(OH)2D concentrations occurred only in the MUHO segment with preoperative 25(OH)D adequacy .The mean HOMA-IR values, 6 months after RYGB, allow including in the healthy phenotype the individuals who had vitamin D adequacy preoperatively, independent of the metabolic phenotype classification . Furtherp = 0.000). Patients with preoperative 25(OH)D ≥ 30 ng/mL maintained their means after surgery, and also had reduced HOMA-IR means, which allows classifying individuals as MHO .When the groups were only analyzed according to the preoperative adequacy/inadequacy of 25(OH)D, the means in the segment of adequacy of this nutrient were 37.32 ± 6.44 and in those with inadequacy were 19.57 ± 5.09 (p = 0.020). In addition, 1,25(OH)2D increased after bariatric surgery (In relation to the patients who had an adequacy of 25(OH)D with the MHO phenotype, there was a reduction in glycated hemoglobin and insulin in which the latter variable also had a strong negative correlation with the metabolic phenotype at T0 . Moreover, in this segment, 25(OH)D was strongly and negatively correlated with BMI , insulin  and positively correlated with 25(OH)D  6 months after RYGB. Furthermore, the presence of dyslipidemia was reduced, and there were no cases of MUHO after 6 months (The segment of participants who had preoperative 25(OH)D adequacy together with MUHO had reduced mean and percentage of cholesterol inadequacy after surgery , which i6 months .p = 0.004) and negative correlation with 25(OH)D , both assessed preoperatively. This nutrient also correlated negatively with glucose  and positively with HDL  at T0, as well as with postoperative 25(OH)D .When there was preoperative inadequacy of 25(OH)D with the MHO phenotype, a reduction in insulin, glycated hemoglobin, cholesterol, and LDL was observed postoperatively. Lower percentages of cholesterol inadequacy cases were also observed . Insulinp = 0.038) and HOMA-IR . Regarding preoperative 25(OH)D, there was a negative correlation with HOMA-BETA  at T0 and TG  at both times.In the segment of vitamin D inadequacy and MUHO, there was a reduction of insulin, glycated hemoglobin, cholesterol, LDL, glucose and increase in 25(OH)D shifting from deficient to insufficient, as well as a decrease in the percentage of inadequate insulin, cholesterol and MUHO cases . MoreoveIt is estimated that the inadequacy of 25(OH)D in the pre- and postoperative period is a recurring event and may reach up to 80% of this segment ,22,23. TIn this sense, some studies argue about the possibility of 25(OH)D being considered a clinical marker for a healthy metabolic profile, as well as whether this nutrient can predict the progression from the MHO status to the MUHO, considering that VDD may contribute to the increased risk of developing CNCDs ,32,33,34Thus, in the context of bariatric surgery, the presence of a healthy phenotype and preoperative adequacy of 25(OH)D could be related to more expressive metabolic benefits after bariatric surgery, however, there are no studies that address this issue. In this aspect, the present study found that when there is 25(OH)D adequacy, the means found for HOMA-IR, 6 months after RYGB, allow defining these individuals as metabolically healthy, regardless of the preoperative classification of the metabolic phenotype. Therefore, it is possible that preoperative 25(OH)D adequacy in both phenotypes may have a protective effect on metabolic health.Although no significant differences were found between the phenotypes regarding serum 25(OH)D concentrations after bariatric surgery, MUHO participants had higher mean 1,25(OH)2D, which, in turn, showed a strong correlation with HOMA-IR. However, this post-surgical increase occurred only in the MUHO segment with vitamin D adequacy (25(OH)D). Thus, it is suggested that the increased 1,25(OH)2D concentrations in MUHO with 25(OH)D adequacy found in the present study may indicate an increased need for it, which in turn may have contributed to metabolic protection of these patients after surgery. Even in this segment, there were no cases of MUHO 6 months after RYGB. Thus, it is possible that calcitriol may attenuate the action of preadipocytes in the basal release of IL-8 and IL-6 and in the action of macrophages, leading to a reduction in the production of MCP-1, which ratifies the anti-inflammatory effect, facilitating reduction of MUHO ,39,40. MIn the context of type 2 diabetes mellitus pathophysiology, it has been reported that vitamin D may exhibit some actions in pancreatic beta cells such as activation of the VDR; and binding of 1,25(OH)2D to the VDR, which promotes transcription of regulated genes to its active form. In addition, it is also responsible for the presence of the vitamin D responsive element (VDRE) in the promoter gene of insulin and the activation of the human insulin gene transcription caused by 1,25(OH)2D . AccordiRegarding the variables related to dyslipidemia, a reduction in cholesterol was observed. Besides, in the case of patients classified with vitamin D adequacy together with MUHO, there was also a reduction in dyslipidemia. In this sense, the literature indicates that vitamin D can reduce the accumulation of cholesterol in macrophages, as well as the uptake of LDL in atheroma plaques . FurtherIt is worth mentioning that this increase of vitamin D may present pleiotropic effects on cardiovascular health, such as nuclear receptor activation in cardiomyocytes, vascular endothelial cells, and regulation of the renin-angiotensin-aldosterone system. Thus, its deficiency in humans is associated with vascular dysfunction; arterial stiffness; left ventricular hypertrophy, SAH, and dyslipidemia ,52,53,54The present study has the limitation of sample size, however, nonparametric statistical analyses minimize this feature. Furthermore, this is the first study to assess, in a joint manner, the inherent results of vitamin D adequacy together with metabolic phenotypes on remission of CNCDs after RYGB. This fact may contribute to strategies to be implemented preoperatively to minimize the presence of CNCDs in the early postoperative period.Given the results, it was possible to observe that bariatric surgery can negatively influence the achievement of better metabolic profiles, including changes in serum 25(OH)D. These changes were more prominent in those with vitamin D adequacy in the preoperative period since it contributed to dyslipidemia reduction and cholesterol improvement after surgery in both metabolic phenotypes. Additionally, the postoperative increase in 25(OH)D was accompanied by a reduction in glucose in those with vitamin D inadequacy and presence of the MUHO phenotype. Therefore, it is suggested that further research on this topic should be conducted to identify whether adequate preoperative vitamin D in both metabolic phenotypes may contribute to a protective metabolic effect.


The structural appearance of each disabled athlete or the shape of their body, as determined by their individual genotype and influenced by the environment, considerably affects their technical and physical performance. This study sought to examine the morphological characteristics of elite track and field athletes with different disabilities, including their possible effects on physical and physiological performance.A total of 66 male elite athletes with cerebral palsy (n = 12), upper arm amputation (n = 12), short stature (n = 20), or intellectual disability (n = 22) were included. For each athlete, height, weight, sitting height, arm span and four skin folds were assessed; ape index, body mass index, body fat percentage, fat mass, fat mass index and fat-free mass values were calculated; and vertical jump, drop jump, countermovement jump, squat jump, repeated sprint ability and Yo-Yo Intermittent Recovery Level 1 tests were performed.Significant differences were noticed between short stature and the other groups concerning morphological characteristics, however, the best motor performance was observed in amputees and, to a lesser degree, in short stature. In the top performing athletes, physical performance was significantly correlated with body mass index and fat mass index for amputees, and with arm span, ape index, body fat percentage and fat mass index for short stature. Regression analysis revealed that regardless of disability type, physical and physiological performance (except maximum heart rate) were significantly influenced primarily by adipose tissue-specific variables. A significant effect of height, weight, fat free mass, arm span, sitting height, and ape index on drop jump performance with left leg, maximal oxygen consumption, and maximum heart rate was also noticed. The type of disability affects performance in the squat jump and vertical jump tests, and to a lesser extent in the countermovement jump test. Morphological characteristics; Physical and physiological performance; Cerebral palsy; Amputee; Short stature; Intellectual disability. It has Anthropometry and its effects on athletic prowess have been well documented in able-bodied participants in different types of sports . In manyGiven that variable anthropometric requirements in different disabilities would lead to differences in physical and physiological variables, a better understanding of the impact of anthropometric variables on physical and physiological performance and the effects of physiological variables on physical variables among athletes with different disabilities is of greater importance. Thus, the aims of this study were to (1) describe the anthropometrical and body composition profiles and evaluate the physical and physiological performance levels of elite Paralympic track and field athletes with certain characteristics; (2) analyze the between-group differences in anthropometry and physical and physiological performances; and (3) examine the relationships that may exist between anthropometric characteristics and the physical and physiological performance of these athletes.22.1In all, 66 athletes from the Tunisian Paralympic track and field team volunteered to participate in our study, aged 24.58 ± 3.33 years, and nine of them participated in the 2020 Paralympic games in Tokyo, Japan. All athletes eligible for inclusion compete in elite level sports for at least five years and had participated in the last three tournaments of the Tunisian Para Athletics Championship, with no smoking habit, no sensory or motor deficits, and no ergogenic aid or use of any medication known to affect cardiorespiratory function for six months prior to inclusion in the study. The study was conducted in accordance with the latest declaration of Helsinki , and app2.22.2.12); and the fat mass index was calculated as fat mass (kg)/height squared (m2)  . Partici2.2.2All tests were performed within two days of the clinical examination in the order described henceforth.2.2.2.1Details of the vertical jumping tests were previously described by 2.2.2.2This test was used to measure the athlete's ability to perform six maximal sprints back and forth along a 15-meter route, interspersed with 30-second episodes of recovery . Speed w2.2.2.3The protocol of the YYIR1 was previously described by 2, Rome, Italy), and was considered maximal (VO2max.) if 2 of the following 3 criteria were met: (a) the existence of a VO2 plateau despite increasing intensity of exercise (change lower than 100 mL/min in the last 30-s stages), (b) a respiratory exchange ratio ≥1.15, and (c) ±10 bpm of age-predicted HRmax, using equation 208 − 0.7 × age to predict the HRmax  = 99%, and a number of groups = 4. Considering a dropout rate of 20%, a minimum of 40 athletes should be selected for potential participation in this study at the rate of 10 participants/group.Using the software G∗Power version 3.1.9.7 , and based on the method described by Data were assessed for normality with the Shapiro-Wilk test and log-transformed where necessary. The between-group comparisons were performed using an analysis of variance (ANOVA), when the ANOVA p-value was significant, a Bonferroni's post-hoc comparison test was performed to determine the differences between groups. The specific correlations between morphological characteristics and physical and physiological parameters were conducted using Pearson's coefficient correlation, applying a Sidak's type I error correction to consider multiple comparisons. The results are represented graphically with a color-coded heat map. The linearity of the predictor variables was tested using scatter plots. The normality and homoscedasticity of the residuals were also verified, and the independent variables were checked for multicollinearity using the variance inflation factor (VIF): a value of VIF exceeding 10 indicated excessive multicollinearity. A principal components analysis was used to handle the collinearity between variables. In addition, a sequential multiple regression procedure was performed to determine the amount of variance in physical and physiological performance that could be explained throw the components derived from the principal components' analysis (Model 1) and the effect of the disability (Model 2). Data were analysed with SPSS version 26 for Windows , presented as mean ± standard deviation, and the statistical significance was set at α = 0.05.33.1Participants were classified according to their disability into the following four groups: (1) athletes with cerebral palsy (CP) , (2) athletes with upper arm amputation (amputees) ; (3) athletes with short stature (SS)  and (4) athletes with intellectual disability (ID) . All the athletes have completed all stages of the experiment.3.23.2.1Data related to anthropometric characteristics and physical and physiological performance in disabled elite track and field athletes are shown in 3.2.2The comparison of physical performances revealed significant differences in performance levels in tests of DJ-right, DJ-left, squat jump, countermovement jump, vertical jump, and repeated sprint ability tests in amputees relative to CP  and ID (p < 0.01 for repeated sprint ability and p < 0.001 for the rest). Significant differences were also observed in all physical variables between SS and ID (p < 0.001 for DJ-left and squat jump and p < 0.01 for the rest); in DJ-right, DJ-left, and repeated sprint ability performance level between SS and CP  and SS and ID (p < 0.05); and in DJ-right between amputees and SS (p < 0.05). The best motor performance was observed in amputees and SS. No significant difference in physiological performance was found among all groups .3.2.33.2.3.1The DJ-right performance was negatively correlated with the body fat percentage . A negative correlation was also noticed between the repeated sprint ability performance and the athlete's height  and fat-free mass . This parameter was also positively correlated with ape index , PBF , and fat mass index , the HRmax , and the % recovery . In addition, HRmax and % recovery was also correlated with the athlete's weight  and fat-free mass  and fat mass index . Negative correlations were noticed between BMI, fat mass, fat mass index, and MAS . The BMI, fat mass, and fat mass index affected also the VO3.2.3.3Pearson's correlation coefficient revealed that the ape index was positively correlated with results of the DJ-right , squat jump , and countermovement jump  tests. A significant correlation was also noticed between the arm span and performance level during the DJ-right , squat jump , countermovement jump , vertical jump , and repeated sprint ability  tests. However, the DJ-left, and repeated sprint ability were negatively correlated with the body fat percentage outcome , and with the fat mass index for the repeated sprint ability only , squat jump , countermovement jump , vertical jump  and repeated sprint ability  tests was also significantly correlated with BMI. In addition, the squat jump and vertical jump were negatively correlated with the body fat percentage  was observed on the performance at the squat jump test (R2 changes from 9.5% to 16.8%), and that at the vertical jump (R2 changes from 10.8% to 18%). A large, but statistically not significant, effect was also observed on the performance at the countermove jump test (R2 changes from 10% to 16.4%). No significant effects of the type of disability were noticed on the other physical and physiological performances  was significantly affected by the body fat percentage, fat mass and fat mass index. A significant effect of height, weight, fat-free mass, arm span, sitting height, and ape index on the performance at the DJ-left, MAS, VO2max and HRmax tests was also noticed. A negative effect of the type of disability was observed on performances at squat jump and vertical jump tests.Studies that focus on sports participation among people with disabilities are limited due to the limited total population of disabled athletes and the enormous variability in disabilities within the population itself, resulting in a wide territorial distribution for most studies . One mait status . SS also2max, and running speed ability. It is accepted that lower body fat is associated with greater muscle mass, which would give athletes an advantage in both jumping and running. Greater fat-free mass would imply greater economy in the movement of the weight both vertically and horizontally; however, fat mass is an extra load acting as a dead weight that must be moved , together their possible effects on physical and physiological performance. We were able to assess a wide variety of anthropometric, physical, and physiological characteristics specific to each group of elite athletes. Moreover, we were able to analyze the different relationships that may exist between all the variables, and thus to provide useful information to athletes and their coaches to better equip them to test their personal limits, improve training methods, and pursue their dreams and sporting goals . However5The current study demonstrates that certain morphological characteristics can enhance physical performances in track and field athletes with different disabilities, as has already been demonstrated by other authors . Data noReferring to previous data, we observed that the results recorded, especially during the jump tests, are not far from those of so-called “valid sportsmen” , and thiMoncef Cherif, Karim Bannour and Mounira Ben Chaifa: Conceived and designed the experiments; Performed the experiments; Contributed reagents, materials, analysis tools or data.Abdallah Aouidet: Conceived and designed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Majed M. Alhumaid: Conceived and designed the experiments; Contributed reagents, materials, analysis tools or data; Wrote the paper.Mohamed Ahmed Said: Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.Marwa Khammassi: Performed the experiments; Analyzed and interpreted the data; Contributed reagents, materials, analysis tools or data; Wrote the paper.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Data will be made available on request.The authors declare no conflict of interest.No additional information is available for this paper.


Background and Purpose: Flow diverting stents are designed to divert blood flow from the aneurysm sac, allowing for eventual occlusion following endovascular therapy. This case series reports clinical experience using the Silk Vista Baby , a flow diverter (FD) designed to treat intracranial aneurysms in small, distal vessels.Methods: All patients who underwent treatment with SVB at the University Hospital “Santa Maria della Misericordia” of Udine between July 2018 and September 2020 were retrospectively identified. Baseline patient and aneurysm characteristics, intraprocedural technical outcomes, periprocedural complications, modified Rankin Scale (mRS) at discharge, magnetic resonance imaging (MRI) results at 3-month follow-up, and angiographic results at 6-month follow-up were collected.Results: A total of 18 patients  were retrospectively identified, receiving treatment for 22 aneurysms. Most patients were symptomatic  and approximately half had subarachnoid hemorrhage . Sufficient aneurysm coverage was achieved in 88.9% (16/18) of patients with a single device. Mortality did not occur ; adverse device-related events included side branch occlusion  and in-stent thrombosis . At discharge, 77.8% (14/18) had an mRS of 0. In most cases, patients showed complete occlusion  or a small aneurysmal remnant  upon MRI; upon angiography, most showed complete occlusion  or only a small aneurysmal remnant .Conclusion: This case series showed that the SVB FD is safe and feasible to use in patients with aneurysms in small, distal vessels. Additional randomized, prospective studies with larger cohorts are needed for the SVB. Flow diversion is a relatively recent development in endovascular treatment wherein a flow diverter (FD) stent is placed over an aneurysm to disrupt blood flow into the aneurysm sac, thus providing a scaffold for neo-endothelialization and eventual occlusion to occur , 2. FlowThe Silk Vista Baby , a newer iteration of the Silk Flow Diverter , is designed to treat aneurysms in vessels 1.5–3.5 mm in diameter , 9. The This was a single-center, single-arm, retrospective, observational study of consecutive patients treated with the SVB at University Hospital “Santa Maria della Misericordia” of Udine between July 2018 and September 2020. Patient selection for endovascular treatment was performed by a multidisciplinary team of interventional neuroradiologists, neurologists, and neurosurgeons. The treatment decision was based on the clinical status of the patient as well as aneurysm location, morphology, and size. Patients were informed regarding the risks and complications associated with the endovascular treatment; interventions were only performed after obtaining informed consent. For each patient, information was collected regarding demographic data, clinical presentation, aneurysm location and characteristics, intraprocedural outcomes, immediate angiographic and clinical results, and radiological follow-up results at 3- and 6-months post-procedure. All characteristics and outcomes are presented as frequencies and analyzed based on counts, rates, means, and ranges. Patients were considered “elective” if they were treated without using emergency procedures and prepared with standard dual antiplatelet therapy.Patients received mandatory dual antiplatelet therapy prior to implantation of FDs on a regimen of 100 mg aspirin and 75 mg clopidogrel twice daily for 5 days. In just one case, the patient with ruptured aneurysm, initially coiled and the next day treated with FD, was loaded with 300 mg of clopidogrel 12 h before the FD treatment and 500 mg of intravenous acetylsalicylated lysine 30 min before stent deployment. For ruptured aneurysms, depending upon the clinical state of the patient, pre-medication was also given immediately before the procedure. Patients were instructed to continue dual antiplatelet therapy for 6 months after the procedure; aspirin is typically continued indefinitely while clopidogrel may be stopped 3 months after the procedure.All endovascular treatment was performed with the patient under general anesthesia, via right common femoral artery approach, using a bi-axial access system. Interventionalists used a 7F Avanti femoral artery sheath , 6F Envoy guiding catheter , or 5F Sofia catheter . The Headway 17 soft microcatheter (MicroVention) was used for access to the parent vessel and placement of the SVB FD. The length and diameter of the stent were chosen based on pre- and intra-procedural imaging, which included magnetic resonance imaging (MRI) for evaluation of the aneurysm sac diameter and angiography for evaluation of the vessel diameter. The length of the stent was to be such that the stent extended at least 5 mm beyond both sides of the aneurysm neck, while the diameter of the stent was roughly the diameter of the parent vessel. In this case, interventionalists used SVB that had diameters of 2.25 or 2.75 mm and length of 15 or 20 mm.All procedures were performed under heparin anticoagulation, with a 5000 IU bolus dose at the start of the procedure and subsequent 1000 IU bolus doses every hour to maintain the activated clotting time at a level of 2–2.5 times the baseline. In addition, administration of nimodipine during the procedure was used to reduce the possibility of vasospasm-related complications . At the end of the endovascular procedure, patients with subarachnoid hemorrhage (SAH) were awakened after 24 h to assess for neurological deficiency, and elective patients were assessed at 72 h post-procedure. At discharge, patients were assessed for neurologic disability using the modified Rankin Scale (mRS) . PatientDuring the study period, a total of 18 patients  were treated for 22 aneurysms. Most patients were symptomatic ; they presented variously with unspecified headache , dysarthria, hemiplegia, or clonic seizure , and loss of consciousness . . Approximately half of the patients  had SAH and were treated within 90 days of SAH diagnosis. Patient characteristics at baseline are shown in Of the 22 aneurysms treated, 31.8% (7/22) were unruptured and 45.5% (10/22) were acutely ruptured. Additionally, 22.7% (5/22) were recurrent and previously ruptured; three of these recurrent aneurysms had been previously treated with coil embolization, and the other two with clip ligation. All aneurysms were saccular, and nearly all  arose from the anterior circulation. All aneurysms were located on small arteries; specifically, 4 aneurysms (18.2%) involved the anterior cerebral artery (ACA), another 4 aneurysms (18.2%) were located on the middle cerebral artery (MCA), 1 aneurysm (4.5%) was on the posterior cerebral artery (PCA), and 13 aneurysms (59.1%) involved the anterior communicating artery (ACoA). The mean aneurysm diameter was 8.9 mm, with diameters ranging from 5–25 mm. Patients with very small (5–7 mm) aneurysms were treated because they had SAH. A full list of aneurysm characteristics is in For endovascular treatment, a total of 20 FDs were used, all of which were SVB. Adequate aneurysm coverage was achieved with a single FD device in 88.9% (16/18) of patients, including in two patients who had two aneurysms each. Both patients had one aneurysm on the ACoA and the other on the right MCA; in these cases, a single stent was sufficient to cover both aneurysms and the entire dysplastic portion of the parent artery. Two patients  required multiple FDs; in these cases, each patient had two aneurysms on the ACoA involving the right and left A1-A2 segments. They were each treated with two stents placed with the kissing technique, demonstrated in Few technical or clinical complications were observed. Failure to catheterize the parent artery did not occur —though in one patient it was necessary to loop the sac with the microguide and catheter—nor did stent deployment failure occur . There were no instances of imprecise FD placement with incomplete neck covering, guidewire rupture, dissection of the artery wall, or aneurysm rupture. In all cases , slower flow and contrast stagnation were observed in the aneurysmal sac at the end of the procedure, indicating FD placement was technically successful.No patients experienced intracerebral bleeding or procedure-related death . A small minority of patients incurred adverse device-related events, including side branch occlusion  and in-stent thrombosis . In one patient with recurrent aneurysm involving the ACoA, acute thrombosis occurred in the middle of the stent following cross-stenting treatment (likely due to the progression of sac thrombosis), but this was fully resolved after administration of a half dose of abciximab calculated based on patient bodyweight. At discharge, 77.8% (14/18) of patients had an mRS of 0, indicating no disability; 11.1% (2/18) had an mRS of 1, indicating light disability; and 11.1% (2/18) had an mRS of 3, indicating moderate disability. Intraprocedural and clinical outcomes are presented in No patients  in this study were lost to follow-up; however, three patients  who were recently treated have not yet had their 3-month follow-up MRI visit, and a total of five patients  have not yet had their 6-month follow-up angiography visit. All follow-up imaging results are presented in Of the 15 patients who have had 3-month MRI follow-up, 66.7% (10/15) had complete occlusion of the aneurysm from the intracranial circulation. In one patient , MRI examination was indeterminate; angiography was then performed and confirmed complete occlusion of the aneurysm. In 20.0% (3/15) of patients, only a small remnant  was observed. MRI of the sole patient with a PCA aneurysm—who also had the largest aneurysm in the study (maximum diameter 25 mm)—showed a remnant ~30.0% of the original aneurysm sac, along with increased size of the aneurysm sac, trunk compression, and an associated mRS of 3. Example imaging of a patient with complete occlusion at 3-month follow-up is shown in As of submission for publication, 13 patients in this study have had 6-month angiographic follow-up.In 76.9% (10/13) of cases, angiography showed complete occlusion. In 15.4% (2/13) of cases, only a small remnant was observed. Angiography of the patient with the PCA aneurysm showed a remnant at least 40.0% of the original aneurysm sac, with the aneurysm sac further increased in size. No significant stenosis, proximal or distal stent profile deformation, or “fish mouth” effect were observed in any deployed stents in any patient at follow-up angiography. Imaging of a patient with complete occlusion at 6-month follow-up and of PCA aneurysm with a remnant of the original aneurysm sac are shown in This study showed high rates of technical success and aneurysm occlusion with no mortality and few instances of adverse events related to the SVB. Significantly, many of the aneurysms in this study had unfavorable circumstances based on their specific location or history of recurrence/rupture. Though this case series is limited in size, it demonstrates promising results for the SVB and broadens its evidence base in the literature.Other than a case report of two patients by Bhogal et al. , the preThe SVB is unique in its capability to be delivered via a 0.017-inch catheter; it shares this distinction with only one other FD, the Woven EndoBridge 17  . In two Delivery of an FD device through the smallest available catheters is crucial to treat aneurysms arising from distal, small-caliber vessels. While it is unclear whether flow diversion treatment in small vessels is more likely to result in clinical complications , evidencAdditionally, when using FDs in small vessels, it is imperative to understand and consider the effects of oversizing on the FD. Oversizing may result in lengthening of the device, subsequently increasing its porosity and likelihood of aneurysm persistence , 7. It sLimitations of this study include its retrospective, non-randomized design, limited sample size as a case series, and short follow-up period. Progressive aneurysm occlusion over time is common after flow diversion, so it is expected for occlusion rates to increase as more extensive follow-up is available. Larger, prospective, randomized studies with longer-term follow-ups are needed to corroborate the effectiveness of this treatment method and its comparison to other devices.This study demonstrated that the use of SVB for treatment of intracranial aneurysms is feasible and safe, with no procedural difficulties, no mortality, and few device-related adverse events. Future studies with larger samples and randomized treatment allocation will shed light on the comparative efficacy of SVB and other FDs.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.VG and AD validated the study, conducted the formal analysis and investigation, and participated in writing the original draft of the manuscript. VG conceptualized the study, designed the methodology, provided the necessary software, provided study resources, curated the data, reviewed and edited the manuscript, and provided study supervision and project administration. All authors contributed to study visualizations.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.


The limited information available on mixed mycosis involving the lungs makes the understanding of mixed fungal diseases insufficient and affects prognosis. Our study aims to improve understanding by exploring experience in the successful management of mixed fungal infections.Patients who had two types of mycosis involving the lung at the same disease course were retrospectively enrolled.Mucor and Aspergillus, 4 cases were Cryptococcus and Aspergillus, 2 cases were Talaromyces marneffei and Cryptococcus, 2 cases were Talaromyces marneffei and Aspergillus, and 1 case was Candida and Aspergillus. Seven patients were diagnosed with mixed pulmonary mycosis at almost the same time. Among the remaining 10 patients, the initial treatment was ineffective in four cases, and six patients showed a partial response to the initial antifungal treatment, but the original fungal lesions became re-enlarged. Three patients were admitted to the intensive care unit during hospitalization, and one patient died. Another Mucor coinfection patient died due to treatment refusal.Between September 2011 and December 2019, 17 patients with proven mixed mycosis were enrolled. Four patients were immunocompromised, with one case each of lung transplantation, corticosteroid treatment, STAT3 hyper-IgE syndrome, and anti-IFN-γ autoantibody-associated immunodeficiency syndrome. Among 13 patients who were not immunocompromised, 9 had type 2 diabetes mellitus. Eight cases were coinfection with Mixed mycosis involving the lungs is not uncommon in patients without apparent immune deficiency diseases. During the management of mycosis, we recommend keeping mixed mycosis in mind for patients with a poor response to initial antifungal treatment, even in immunocompetent populations, and identifying the cause of illness through a rigorous procedure. Aspergillus, Candida, Cryptococcus species, and Pneumocystis jirovecii . Because this is a retrospective study, informed consent was not required.Inclusion criteria were the following: I. patients who had two types of fungal infections involving the lung at the same disease course; II. patients who had follow-up data in the outpatient medical records database; and III. patients who were HIV negative.Aspergillus was excluded) or yeast; or a positive test for cryptococcal antigen in cerebrospinal fluid or blood. The diagnosis of probable IFD should meet all three criteria, including host factors, clinical features and mycological evidence, with details in the referenced guideline (Mycosis was diagnosed based on the European Organization for Research and Treatment of Cancer and the Mycoses Study Group Education and Research Consortium (EORTC/MSGERC), which is a graded diagnostic standard, including the classifications of “proven,” “probable,” and “possible” invasive fungal disease (IFD) . The preuideline .Exclusion criteria included the following: I. two fungal infections did not occur at the same disease course, and the first mycosis was cured before the onset of the second mycosis; II. only one fungal infection was diagnosed; and III. there was incomplete information.Clinical features of enrolled patients were collected, including medical history, underlying diseases, use of corticosteroids and/or immunosuppressants before the onset of mycosis, clinical symptoms and signs, imaging and laboratory examination data, types of culture specimens, diagnosis procedure, treatment, and outcome. If the patient went to the outpatient clinic, the follow-up and results within 1 year were also collected from the database.Mucor mixed infection and non-Mucor mixed infection cases. All P values are two-sided tests, and P <0.05 means that the difference is statistically significant. Independent sample t-tests were used for continuous variables, and Fisher’s exact test and χ2 test were used for categorical variables.SPSS 25.0 software was used for data processing of the results of this study. Because the treatment drugs and prognosis of mucormycosis are different from those of other fungal infections, comparisons were made between Between September 2011 and December 2019, 17 cases of mixed fungal infection were confirmed in our hospital. The average age was 50.2 ± 16.9 years, ranging from 21 to 76, with 12 (70.6%) males. Four patients were immunocompromised, with one patient receiving bilateral lung transplantation for destructive pneumonophthisis, one patient receiving long-term corticosteroid therapy for nephrotic syndrome and hypoalbuminemia, one case of STAT3 hyper-IgE syndrome and one case of anti-IFN-γ autoantibody-associated immunodeficiency syndrome Table 1.Mucor and Aspergillus, 4 cases with Cryptococcus and Aspergillus, 2 cases with Talaromyces marneffei and Cryptococcus, 2 cases with Talaromyces marneffei and Aspergillus, and 1 case with Candida and Aspergillus. The lesions of all patients with mucormycosis were confined to the lungs, but some patients with Talaromyces marneffei infection and cryptococcosis had involvement of extra-pulmonary organs, including bone, skin, lymph nodes, and/or central nervous system (CNS)  Table 1.Cough, expectoration and fever were the most common symptoms. More than 40% of patients had hemoptysis or shortness of breath. Only 3 patients (17.6%) had an elevated white blood cell count. There were no decreased immunoglobulin G/M/A levels or CD4+ or CD8+ T lymphocyte cell counts in patients without apparent immune deficiency diseases Table 2.Aspergillus fumigatus in case 6 and case 7 and for Talaromyces marneffei in case 11. A galactomannan antigen test was positive in case 11. A cryptococcal antigen test was positive in case 14 and case 16. Biopsy was positive in all patients but case 16 , cavity , effusion or consolidation , multiple nodules  and pleural effusion , and the patients were diagnosed with mixed mycoses after review of the original biopsy from the hospital to which they were first admitted Figure 2Talaromyces marneffei infection even under the course of antifungal treatment. The remaining patient showed improvement in the CT scan with no recurrence.Three patients were admitted to the intensive care unit during hospitalization. However, patient 7 died even after treatment in the intensive care unit, and patient 6 died due to treatment refusal. Patient 2 showed a poor response to antifungal treatment, and pneumonectomy was conducted. Patients 5 and 11 suffered from a recurrence of disseminated Mucor, which has a poor prognosis, comparisons were made between patients with Mucor and without Mucor coinfection to discriminate the characteristics between these two groups. There were 8 cases with Mucor coinfection and 9 cases without Mucor coinfection. Patients with Mucor coinfection seemed to be older than patients without Mucor coinfection; however, the difference was not significant . Diabetes mellitus was more common in patients with Mucor coinfection than in patients without Mucor coinfection . Cavity, multiple nodule effusion/consolidation and enlarged mediastinal lymph nodes were more common in Mucor mixed infection than in non-Mucor mixed infection (P>0.05).Because voriconazole is ineffective for nfection Figure 3Candida, Aspergillus and Cryptococcus as the most common opportunistic fungi  in previously healthy adults . Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Conception and design: YZ, CL, and FY. Collection and assembly of data: YZ, CL, SL, JZ, ZL, and YG. Data analysis and interpretation: YZ. Manuscript writing: YZ, CL, and FY. Final approval of manuscript: YZ, CL, SL, JZ, ZL, YG, and FY. All authors contributed to the article and approved the submitted version.This research was funded by the ZHONGNANSHAN MEDICAL FOUNDATION OF GUANGDONG PROVINCE (ZNSA-2020003); Independent Fund of the State Key Laboratory of Respiratory Diseases (SKLRD-Z-202019); the Guangzhou Institute of Respiratory Health Open Project (2019GIRHZ06).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Objective: Few studies have been concerned with the combined influences of the presence of multiple risk factors on follow-up outcomes in AMI patients. Our study aimed to identify risk factor patterns that may be associated with 1-year survival in male patients with ST-segment elevation myocardial infarction (STEMI).Methods: Data were from the China STEMI Care Project Phase 2 (CSCAP-2) collected between 2015 and 2018. A total of 15,675 male STEMI patients were enrolled in this study. Risk factor patterns were characterized using latent class analysis (LCA) according to seven risk factors. Associations between risk factor patterns and follow-up outcomes, including the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death, were investigated by Cox proportional hazard regression analysis.Results: We obtained four risk factor patterns as “young and middle-aged with low levels of multimorbidity,” “middle-aged with overweight,” “middle-aged and elderly with normal weight,” and “elderly with high multimorbidity.” Four patterns had significant differences in event-free survival (P < 0.001). As compared with the patients of “young and middle-aged with low levels of multimorbidity” pattern, the risk of incidence of MACCE and all-cause death were increased in patients of “middle-aged with overweight” pattern , “middle-aged and elderly with normal weight” pattern , and “elderly with high multimorbidity” pattern .Conclusions: By adopting a Latent Class Analysis Approach, STEMI patients can be characterized into four risk factor patterns with significantly different prognosis. The data is useful for the improvement of community health management in each specific subgroup of patients, which indicates a particular risk factor pattern. Acute myocardial infarction (AMI) has high morbidity and acute onset and is one of the leading death causes among cardiovascular diseases. In China, the mortality of AMI increased sharply, from 15.46 cases per 100,000 persons in 2002 to 58.69 cases per 100,000 persons in 2016 in urban residents, and 12 cases per 100,000 persons in 2002 to 74.72 cases per 100,000 persons in 2016 in rural residents –5. For eIn this study, based on a national healthcare improvement project, we explored the association between risk factor patterns and follow-up outcomes of ST-segment elevation myocardial infarction (STEMI) that is the main type of AMI, with a latent class analysis (LCA) approach. Because that there's a sex difference among risk factors of a STEMI prognosis, we focused on the male participants in our study because of the limited female population included in the cohort.n = 409) or missing key variables, including age, body mass index (BMI), condition of current smoking, diagnosis of hypertension, diabetes, chronic renal disease, and cerebrovascular disease (n = 493). All female patients  were excluded. Finally, 15,675 patients were enrolled in the analysis.Our study is a prospective study based on a national healthcare improvement project named China STEMI Care Project Phase 2 (CSCAP-2) that was initiated in 2015 and includes three phases. More details about the project have been described previously  score provides an estimate for the probability of death within 6 months of hospital discharge in patients suffering from acute coronary syndrome (ACS). According to the information documented, we calculated the GRACE score in inpatient medical records. The GRACE score was stratified into three categories of low, intermediate, and high as scores of 49–125, 126–154, and 155–319 based on the in-hospital mortality risk for ST-elevation ACS patients.All enrolled subjects would answer a structured baseline questionnaire that was administered by a trained interviewer. The questionnaire collected various information, including age, sex, smoking habits, diagnosis of hypertension, diabetes, chronic renal disease, and cerebrovascular disease. According to international consensus and distribution tertiles of <45 years, 45–65 years, and ≥65 years, age was categorized as young, middle-aged, and elderly, respectively. The condition of current smoking was identified to be positive given being smoking within 1 month. The diagnosis of diabetes, hypertension, cerebrovascular disease, and chronic renal failure were based on clinical judgmental physical examination such as height and weight were measured based on a standard protocol. BMI was calculated as weight (Kg)/[height(m)]. According to Chinese classifications of normal weight, overweight, and obese, BMI was categorized as <24 kg/mAfter discharge from the hospital, patients were followed up from admission to 1 year. Follow-up outcomes included the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause death. MACCE includes death, myocardial infarction, stroke, and re-revascularization of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). The outcomes during the hospitalization period were collected at the time of discharge from hospital. After discharge from the hospital, patients were followed up for mortality status in 1 month, 3 months, 6 months, and 1 year through telephone. In the results, the observed maximum follow-up time was 365 days, and the average time was 225 days.All data represented a proportion for categorical variables. The chi-square test was performed for the comparison of the difference in categorical variables.LCA is an unsupervised learning method based on the latent class model (LCM) by maximum likelihood. The basic assumption is that the probability distribution of various responses of explicit variables can be explained by a few mutually exclusive potential category variables, and each category has a specific tendency to choose the response of each explicit variable. It has been generally applied for pattern identification. In our study, LCA latent class definitions were derived to identify the most common patterns of the seven variables for the range from 2 to 10 subgroups. We selected these variables based on their availability in cohorts and their potential prognostic value. The optimal number of subgroups for the risk factor pattern was determined by the first minima of the Bayesian information criterion with a condition to the percentage of patients in each cluster at least 15% of the total. Based on these criteria, the optimal number of clusters was four. The probabilities of membership in each subgroup for every LCA variable were applied to determine the most likely subgroup for each patient. Finally, patients were characterized into four risk-factor patterns by LCA.P-value of 0.05 was considered statistically significant.The differences in baseline characteristics among risk factor pattern clusters were summarized by conducting chi-squared tests. Then, variable time-to-event comparisons were performed by carrying out a log-rank test. Survival analysis was estimated by the Kaplan–Meier method. Furthermore, Cox proportional hazard regression models were adopted to assess the association between outcomes and risk factor patterns based on LCA subgroups so as to explore the association between risk factor patterns and follow-up outcomes. The result was illustrated by hazard ratio and 95% confidence interval . A two-sided All analyses were performed with R version 3.4.0.2), and 59.30% of them were currently smoking. The mortality of hypertension, diabetes, chronic renal disease, and cerebrovascular disease were 46.90, 9.72, 18.66, and 1.58%, respectively. Most patients have low Killip classification (78.4% of Level 1). Meanwhile, 93.92% of participates had a high risk of morbidity based on the GRACE score. More details were illustrated in A total of 15,675 subjects were included in the analysis. The mean age was 59.4(±13.1), and 33.56% were aged 65 and over, where 12.61% of them were obese ; class 2, an elderly with high multi-morbidity cluster ; class 3, a young and middle-aged with low levels of multi-morbidity cluster (consists of young and middle-aged with low levels of multi-morbidity patients); and class 4, a middle-aged and elderly with normal weight cluster . Multi-morbidity was defined as having two or over two kinds of disease at the same time. Class 2 has the highest possibility for patients experienced with hypertension and cerebrovascular disease. Class 1 has the highest possibility for patients with chronic renal disease and cerebrovascular disease. At the same time, there is a limited possibility for patients in class 3 to have diabetes and cerebrovascular disease. Patients in class 4 have the lowest potential of hypertension .The characteristics according to the classification showed a similar distribution with the probability calculated by the LCM. Patients in class 2 tended to be aged 65 years and over, with 99.88 vs. 8.98%, 0%, and 72.27%, respectively. The majority of their weights were at normal levels (61.57%). Patients in class 1 and class 3 had a higher prevalence of being obese (15.54 and 15.36% vs. 8.69 and 6.81%). Fewer patients in class 2 smoked currently . They also had a higher level of multi-morbidity than patients in the other three clusters .P < 0.001), ranked from high to low in order as 15.54% of class 2 patients, 10.76% of class 4 patients, 9.12% of class 1 patients, and 6.06% of class 3 patients. Compared with the patients in the class 3 pattern, the incidence risk of MACCE was significantly higher among class 1 pattern patients , class 4 pattern patients , and class 2 pattern patients . After adjusted for education, married status, family history of coronary heart disease, diabetes, hyperlipidemia, admission time, and early reperfusion therapy, the results were similar to the unadjusted model and the adjusted model (The incidence of MACCE among four-pattern patients had obvious differences (ed model .P < 0.001), ranked from high to low in order as 9.17% of class 2 patients, 4.87% of class 4 patients, 2.84% of class 1 patients, and 1.61% of class 3 patients. Compared with the patients of the class 3 pattern, the incidence risk of all-cause death was increased in class 1 pattern patients , class 4 pattern patients , and class 2 pattern patients . We obtained similar results in the adjusted model after being adjusted for education, married status, family history of coronary heart disease, diabetes, hyperlipidemia, admission time, and early reperfusion therapy .In this study, we discovered that STEMI patients can be divided into four patterns of risk factor from class 1 to class 4 as follows: “young and middle-aged with low levels of multi-morbidity,” “middle-aged with overweight,” “middle-aged and elderly with normal weight,” and “elderly with high multi-morbidity.” The risk of MACCE and death was significantly different between patients with different risk factor patterns from high to low in the order: class 2, class 4, class 1, and class 3 (We applied LCA to identify the pattern of risk factors. LCA was adopted to identify subgroups to approach the minimum within-subgroup variability and maximize among group variability. It can handle the interrelationship of multiple factors and can be adopted to explore the risk factor pattern for diseases. The external variables are independent in each level of latent classes . AccordiIn our study, we defined age, BMI, hypertension, diabetes, chronic renal disease, and cerebrovascular disease as the risk factors of STEMI mortality. Prior studies proved that aging , obesityThe characteristic of risk factors among the four risk factor patterns illustrated that more current smokers were in the pattern of “young, middle-aged with low levels of multi-morbidity” and “middle-aged with overweight,” accounting for 79.3 and 69.3%, respectively. Both of them had better prognoses than other patterns, indicating a smoker's paradox. Studies have examined that smoking was a protection factor of STEMI patients on prognosis . There wThe GRACE score is recommended in international guidelines for risk stratification in ACS. In our study, patients have a low Killip classification with a high risk of death. According to the GRACE score, class 2 and class 4 had a higher risk of death, which met the prediction results using the LCA class in the Cox proportional hazard regression analysis. However, risk score assessment focuses on risk stratification instead of presenting the characteristics of the patient. We could hardly recognize the characteristics of patients with similar risk scores. Understanding the risk factors pattern could exhibit the characteristic of patients directly, thus helping to set personalized interventions in community health management. Otherwise, personalized intervention for each person would cost lots of resources and works where several patterns of intervention suggestions could help. For example, according to the prognosis of each pattern, different follow-up periods were set, and according to the pattern's feature, personalized intervention and health education themes were applied. Patients in class 3 could have longer follow-up periods than patients in class 2 due to different prognoses. Diet management should implement in class 1 patients.There exist limitations in this study. First, seven risk factors were included in this study for the limitation of data accessibility. Otherwise, as for sex differences in risk factor distributions, we focused on the male patients' risk factor patterns. According to previous researches, the characteristics of STEMI-related risk factors, including smoking habits, BMI, and prevalence of multi-morbidity, had different distributions between males and females , 30. TheBy adopting an LCA approach, STEMI patients can be characterized into four risk factor patterns with significantly different prognoses. The data is useful for the improvement of community health management in each specific subgroup of patients, which indicates a particular risk factor pattern.dafangchen@bjmu.edu.cn.The dataset is not available for public use. Requests to access the datasets should be directed to Dafang Chen, This study was approved by the ethics committee of Peking University First Hospital, and each participant provided written informed consent. We adhered to the principles of the Declaration of Helsinki. The procedures followed were in accordance with institutional guidelines.SC takes responsibility for the statistical analysis and the reliability of our article interpretation. QC helped to complete the study aims and statistical analysis. QZ helped to complete the discussion part in the manuscript. YZ takes responsibility for all aspects of the reliability and freedom from bias of the data presented, who take charge of the data quality control in the China STEMI Care Project Phase 2. JJ helped with data collection. YW helped to revise and perfect the manuscript. YH was the major manager of the China STEMI Care Project Phase 2, who provided the data this manuscript used. DC takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation, who was the supervisor of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.