Serum uric acid (SUA) has been proven to be closely associated with metabolic abnormalities, including obesity. This study aimed to investigate the detailed relationship between total percent fat (TPF) and SUA among adults.Briefly, 23,715 adults aged 18–59 years in the National Health and Nutrition Examination Survey (NHANES) 1999–2018 were included in this study. Multivariable linear regression models were used to examine the association between TPF and SUA. Subgroup analyses stratified by sex and obesity status were also performed by multivariable linear regression. Then, fitted smoothing curves and generalized additive models were also applied to address the non-linear relationship between TPF and SUA. Finally, a recursive algorithm was used to calculate the inflection point in the non-linear relationship and a two-segment piecewise linear regression model was used to analyze the relationship between TPF and SUA on both sides of the inflection point.There were 15,808 (66.7%) obese individuals in all 23,715 participants. In the fully adjusted model, there was a positive association between TPF and SUA . Besides, this positive association remained statistically significant in subgroup analyses stratified by sex and obesity status. Interestingly, in males, the association of TPF and SUA was an inverted U-shaped curve (inflection point: 34.3%).Our study revealed a significant positive relationship between TPF and SUA among adults and this association remained statistically significant when stratified by sex and obesity status, but the shape of the smoothing curve in males differed from that in females. Obesity has gradually become a major public health concern owing to its increased risk of various diseases. The negative impacts on quality of life and overall life expectancy in the obese populations, as well as the extra healthcare expenditures on obesity-related comorbidities, emphasize the need for a more detailed clinical assessment to allow effective obesity management , 2. CharHyperuricemia (HUA), defined as serum uric acid (SUA) levels >415 μmol/L in males and >340 μmol/L in females , is assoThe purpose of this study is to evaluate the detailed relationship between TPF and SUA using a large nationally representative sample of US adults. Furthermore, due to the male-female differences in TPF and SUA, subgroup analyses were carried out following the STROBE guidelines  to illusn = 16,402), participants with complete TPF and SUA data were included in our subsequent analyses . The NHANES was reviewed and approved by the National Centre for Health Statistics Research Ethics Review Board and the informed consents were obtained from all participants in each year’s survey.Data were from the 1999–2018 National Health and Nutrition Examination Survey (NHANES), a continuous surveillance survey to assess the health and nutritional status of a representative sample of the United States civilians. Data of 40,117 participants aged 18–59 years were retrieved from the database. After excluding participants with incomplete TPF and SUA data  in 2017 and 2018.The exposure variable, TPF, was measured by whole body DXA scan using QDR-4500 Hologic Scanner . The outcome variable, SUA, was measured by 704 Multichannel Analyzer or Roche Hitachi Model 917 from 1999 to 2001, Beckman Synchron LX20 from 2002 to 2007, Beckman Coulter UniCel2) , prescription medication use, smoking status (whether smoked at least 100 cigarettes in life), heavy alcohol consumption (ever had 4/5 or more drinks every day), hypertension  , 20, dia2) , vigorou2 and EmpowerStats,3p-values less than 0.05 were considered to indicate statistical significance.The baseline characteristics were shown as means ± SDs (standard deviation) and percentages for continuous variables and categorical variables, respectively. In our study, obesity was defined as TPF >25% in males and >35% in females according to the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) . MultivaThe weighted characteristics of study samples based on obesity status are shown in Males, model 1: β = 3.35, 95% CI: 3.15–3.56; model 2: β = 3.73, 95% CI: 3.52–3.93; model 3: β = 1.72, 95% CI: 1.32–2.12. Females, model 1: β = 3.40, 95% CI: 3.23–3.57; model 2: β = 3.40, 95% CI: 3.23–3.57; model 3: β = 0.38, 95% CI: 0.03–0.72). When stratified by obesity status, the positive association remained statistically significant in the adjusted models. The results of these models are presented in In model 1 with no covariate adjusted and model 2 with age, sex, and race adjusted, TPF was positively associated with SUA . When fully adjusted for age, sex, race, health-related behaviors , hypertension, diabetes, weak/failing kidneys, BMI, blood urea nitrogen, cholesterol, triglycerides, education level, ratio of family income to poverty, dietary intakes of energy and nutrients, and prescription medication use, TPF was still positively associated with SUA , suggesting a 1% increase in TPF was accompanied by a 0.99 μmol/L increase in SUA. Additionally, subgroup analyses stratified by sex in these three models showed the same trend in both males and females . The results are shown in The non-linear relationship between TPF and SUA was further captured by smooth curve fittings and generalized additive models . In the Our study demonstrated that TPF was positively and significantly related to SUA in adults aged 18–59 years in all three models analyzing the NHANES 1999–2018 data. Sex- and obesity-stratified analyses revealed that TPF was still positively and significantly associated with SUA in the adjusted models. Additionally, the inverted U-shaped non-linear relationship between TPF and SUA was identified in males with the inflection point at 34.3% TPF.In the past few decades, several epidemiological studies have shown the positive association between obesity and SUA. However, the majority of them used the BMI approach to measure obesity, and very few of them focused on the association between TPF and SUA. For example, Chen et al. , Dai et in vivo study further showed that an SUA-lowering drug  can both prevent HUA and weight gain in rats  in obese individuals . AdditioInterestingly, an earlier study showed that estrogen can lower SUA in postmenopausal women  and trann = 23,715), which made it possible for us to conduct subgroup analysis to further illustrate the different patterns of association between TPF and SUA in males and females. Second, the TPF data in our study were measured by DXA, which offered a more accurate measurement of adipose tissue compared with the traditional BMI-based approach. The limitations of this study are also worthy of note. First and foremost, it was the nature of cross-sectional study that the outcomes and exposures were ascertained at the same time that limited the inference of a causal relationship between TPF and SUA. Thus, large-sample prospective studies are further needed to explore this causality. Second, the TPF data of participants ineligible for DXA scan  were not included in the original survey. Thus, the selection bias cannot be avoided. Third, some covariates in our study such as hypertension and diabetes status, smoking and drinking status, as well as physical activity level were all based on self-report data, which may introduce the recall bias. Finally, little was known about the potential biases caused by other unrecognized confounding factors, leaving them unadjusted in this study.There are some strengths and limitations of our study. First, it was a large-scale study involving nationally representative American adults with complete TPF and SUA data (In conclusion, our results supported a significant positive association between TPF and SUA, even after the adjustment for a wide range of potential confounders. And this association remained statistically significant when stratified by sex and obesity status. However, the underlying mechanisms of the different patterns of this relationship in males and females still need further investigation.http://www.cdc.gov/nchs/nhanes.Publicly available datasets were analyzed in this study. These data can be found here: JS and CY contributed to data collection, statistical analysis, and writing of the manuscript. ZL and JL contributed to data collection and statistical analysis. WK supervised the study and contributed to polishing and reviewing 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.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.


The intake of antioxidant vitamins can scavenge free radicals and reduce oxidative stress, which may be beneficial for stroke. However, the relationship between total antioxidant capacity (TAC) of antioxidant vitamins and stroke is controversial. This study aims to investigate the association between dietary TAC and the risk of stroke in US adults. This study included participants over 20 years old from the 2001–2018 National Health and Nutrition Examination Survey (NHANES). Data from two 24 h dietary recalls were used to estimate the usual intake of antioxidant vitamins. TAC was calculated by the vitamin C equivalent antioxidant capacity reference values of individual antioxidant vitamins. Survey-weighted generalized linear models were performed to evaluate the relationship between TAC and the risk of stroke. A restricted cubic spline regression model was used to investigate the dose–response association. A total of 37,045 participants was involved, of whom 1391 suffered a stroke. Compared with the first tertile, the participants in the second tertile of TAC showed a lower risk of stroke  after adjusting for potential risk factors. The dose–response analysis showed a gradual increase in the risk of stroke as TAC decreases. Subgroups analyses indicated that this association was primarily in the population of those aged over 60 years old, who were female, consumed alcohol, were a former smoker and inactive. The sensitivity analysis presented consistent results. These results suggest that deficiency of dietary TAC was associated with an increased risk of stroke, particularly in populations with underlying oxidative stress injury. Stroke has become a global public-health issue. According to the global burden of disease, age-standardized prevalence of stroke diminished by 6.0% from 1990 to 2019, while stroke remained the second-leading cause of death  and the third-leading cause of death and disability combined  in 2019 . Thus, tHealthy lifestyle, such as dietary changes, is encouraged as primary stroke prevention measures . A serieThis study aimed to investigate the association between dietary TAC of antioxidant vitamins and the risk of stroke in US adults based on the National Health and Nutrition Examination Survey (NHANES), after adjusting for potential risk factors.NHANES is designed to obtain nationally representative information on the health and nutritional status of the US population conducted by the National Center for Health Statistics . This sun = 59,433). We excluded 22,388 participants (n = 90); (2) without 24 h dietary recall (DR) or missing antioxidative vitamins intake data ; (3) no information of covariables (n = 7400). We selected participants in NHANES from 2001 to 2018 who were 20 years of age or older (icipants : (1) notThe medical conditions questionnaire provided self-reported personal interview data that could be used to obtain the status of stroke. Stroke was defined as a self-report of “a doctor or other health professional ever told you that had a stroke”.Dietary data were collected by 2 24 h DRs, including the first day (Day 1) and second day (Day 2) which were collected in via the MEC and telephone, respectively. The in-person interview was conducted in the MEC dietary interview room, reporting amounts of foods by a set of measuring guides . Telephone dietary interviews were self-reporting by telephone using measuring guides 3 to 10 days after the MEC dietary interview. Data of 2 24 h DRs were intended to estimate the usual dietary intake in the US.The intake of antioxidative vitamins in the NHANES dietary interview consisted of vitamin A, vitamin C, vitamin E, α-carotene, β-carotene, β-cryptoxanthin, lycopene and lutein-zeaxanthin. Floegel et al.  developeAntioxidant content represents the daily intake of each antioxidative vitamin, which was collected in NHANES dietary interview. Antioxidant capacity is the vitamin C equivalent antioxidant capacity of corresponding antioxidative vitamin, which was derived from TAC database of the US diet [ US diet . VCE meaSocial demography and lifestyle factors were collected by interview and questionnaires.The sociodemographic factors included age, sex  and race . Lifestyle consisted of alcohol (yes and no), smoking status  and activity , which was obtained from questionnaires .2), normal weight (18.5–24.9 kg/m2), overweight (25.0–29.9 kg/m2) and obesity (≥30.0 kg/m2). Neutrophil to lymphocyte ratio (NLR) is an easily accessible inflammatory marker from complete blood count for stroke [The risk factors for stroke included diabetes, hypertension, dyslipidemia, CVD, obesity and inflammation ,3. The dr stroke . NLR wasχ2 tests. The intake of antioxidative vitamins and TAC was reported as medians  and compared between groups based on Mann–Whitney U or Kruskal–Wallis H test.NHANES data were extracted and preprocessed by R “nhanesR package”. In our study, all analysis was based on sample weights to produce accurate nationwide estimates in US. If the missing data of covariates were less than 10%, the samples with missing data were deleted. The characteristics of sociodemographic, lifestyle and stroke risk factors were described by frequencies (unweighted) and percentages (weighted). The distribution of these characteristics in groups was assessed with Rao–Scott Survey-weighted generalized linear models were performed to evaluate the relationship between TAC and the risk of stroke, represented by odds ratio (OR) and 95% confidence interval (CI). The relationship between antioxidant vitamins and stroke was also estimated. We fitted three statistical models, of which TAC was log-transformed or categorized by tertiles (T1 as reference). Model 1 was adjusted for age, gender and race. Model 2 was further adjusted for lifestyle factors, including alcohol, smoking and activity. Model 3 included all variables of Model 2 and additionally adjusted for stroke risk factors . ROC curve was used to verify the discrimination of the model. Then, TAC was log-transformed and brought into model 3 as a continuous variable to estimate the dose–response relationship with stroke risk by restricted cubic spline.The subgroups analyses were conducted by age, gender, smoke, alcohol and activity. Sensitivity analyses were also performed to test the robustness of our findings. First, we exerted multiple interpolation of missing data. Second, we excluded participants who simultaneously have complications of diabetes, hypertension, dyslipidemia and CVD.https://cran.r-project.org/mirrors.html; accessed on 10 September 2022). Two-sided p < 0.05 was considered as statistically significant.All statistical analyses were performed using the R version 4.2.1 software . What‘s more, the proportion of T1 to T3 for TAC decreased gradually in the stroke group. The intake of antioxidant vitamins between participants with stroke and without stroke is shown in 2), diabetes, hypertension, hyperlipidemia, CVD and NLR ≥ 1.95 were higher in the stroke group than those of participants without stroke (p < 0.05). In the tertile groups of TAC, T1 had the highest weighted mean rate of stroke with 3.27%, while T2 and T3 were 2.58% and 2.43%, respectively. The distribution of characteristics between groups based on tertiles of TAC is displayed in A total of 37,045 participants, representing 179,355,225, US adults, was included in our study. Among them, 1391 participants (unweighted) suffered from stroke. TAC was lower in the stroke group than that of the no-stroke group (p < 0.001) (The ORs and 95% CI for stroke by survey tertiles (T1 to T3) of TAC level are shown in < 0.001) B. For th< 0.001) , whereas< 0.001) .We further conducted stratified analyses for the associations of TAC with the risk of stroke by age, gender, smoking status, alcohol and activity. In the population of the elderly (more than 60 years old), women, drinkers, former smokers and no activity, inadequate intake (T1) of TAC was associated with a higher risk of stroke .In sensitivity analyses, T1 of TAC showed a completely coherent risk of stroke by interpolation of missing data . The assBased on a large sample of nationally representative US adults, we found that deficiency in dietary TAC of antioxidant vitamins was associated with an increased risk of stroke after adjustment for relevant covariates, predominantly in the population of over 60 years, female, drinkers, former smoking and inactivity. The dose–response relationship showed that the risk of stroke increased with the decrease in TAC gradually. Sensitivity analyses demonstrated the robustness of our findings.The relationship between dietary TAC and stroke in our study is consistent with the previous studies in the population of Italian and Iranian adults ,10, wherOur study found that deficiency in dietary TAC was associated with an increased risk of stroke. Oxidative stress and chronic low-grade inflammation share a plethora of common molecular and cellular mechanisms in the pathogenesis of vascular aging and atherosclerosis, involved in atherosclerotic ischemic stroke ,28. OxidSubgroup analysis showed that the association of lower TAC with increased risk of stroke was mainly in the population of over 60 years old, women, drinkers, former smokers and no activity. It is indicated that the effect of the antioxidant diet on stroke is influenced by age, sex and lifestyle. With the increase in age in females, the level of lipid peroxidation levels in follicular fluid gradually increases, accompanied by a change in the antioxidant pattern in vivo that impaired reactive oxygen species (ROS) scavenging efficiency . In postOur study has several strengths. First, we applied TAC as a measurement of the overall antioxidant potential from the diet. In addition, potential confounders were adequately adjusted on the controversial issue of TAC and stroke, particularly in the factors of lifestyle and health status associated with stroke. Furthermore, survey-weighted generalized linear models were used to obtain an unbiased estimation.This study has some limitations. Firstly, data on stroke and 24 h DR may be subject to recall bias due to self-report. Secondly, as participants only reported “stroke” or “no”, we cannot evaluate the effect of TAC on ischemic stroke or hemorrhagic stroke. Thirdly, the intake of TAC did not include vitamin supplements in our study. Fourth, the bioavailability and in vivo activity of dietary antioxidant vitamins are not considered, because there is only one survey cycle (2003–2004) with complete data of serum antioxidant vitamins. The bioavailability displayed a high variability between individual diets , which mIn conclusion, deficiency of dietary TAC was associated with an increased risk of stroke, especially in the population of potential oxidative stress injury. Our findings support the hypothesis that a physiological dose of antioxidant vitamin diet is beneficial in reducing the risk of stroke.


There are a range of wearable transdermal alcohol sensors that are available and are being developed. These devices have the potential to monitor alcohol consumption continuously over extended periods in an objective manner, overcoming some of the limitations of other alcohol measurement methods .The objective of our systematic review was to assess wearable transdermal alcohol sensor accuracy.A systematic search of the CINAHL, Embase, Google Scholar, MEDLINE, PsycINFO, PubMed, and Scopus bibliographic databases was conducted in February 2021. In total, 2 team members (EB and SH) independently screened studies for inclusion, extracted data, and assessed the risk of bias. The methodological quality of each study was appraised using the Mixed Methods Appraisal Tool. The primary outcome was transdermal alcohol sensor accuracy. The data were presented as a narrative synthesis.We identified and analyzed 32 studies. Study designs included laboratory, ambulatory, and mixed designs, as well as randomized controlled trials; the length of time for which the device was worn ranged from days to weeks; and the analyzed sample sizes ranged from 1 to 250. The results for transdermal alcohol concentration data from various transdermal alcohol sensors were generally found to positively correlate with breath alcohol concentration, blood alcohol concentration, and self-report (moderate to large correlations). However, there were some discrepancies between study reports; for example, WrisTAS sensitivity ranged from 24% to 85.6%, and specificity ranged from 67.5% to 92.94%. Higher malfunctions were reported with the BACtrack prototype (16%-38%) and WrisTAS (8%) than with SCRAM (2%); however, the former devices also reported a reduced time lag for peak transdermal alcohol concentration values when compared with SCRAM. It was also found that many companies were developing new models of wearable transdermal alcohol sensors.As shown, there is a lack of consistency in the studies on wearable transdermal alcohol sensor accuracy regarding study procedures and analyses of findings, thus making it difficult to draw direct comparisons between them. This needs to be considered in future research, and there needs to be an increase in studies directly comparing different transdermal alcohol sensors. There is also a lack of research investigating the accuracy of transdermal alcohol sensors as a tool for monitoring alcohol consumption in clinical populations and use over extended periods. Although there is some preliminary evidence suggesting the accuracy of these devices, this needs to be further investigated in clinical populations.PROSPERO CRD42021231027; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=231027 Reporlow-Back  and the low-Back . In recelow-Back ,9. Thus,low-Back . These alow-Back -12. DataThere is a range of TAS brands in various stages of development and validation, some available directly to the public. The 2 devices that have been most widely validated and reported on are SCRAM and WrisTAS ,13-18. MThe accuracy of these devices is evaluated by comparing TAC output with self-reported alcohol consumption via Timeline Follow-Back or drinking diaries, blood tests , or breath alcohol concentration (BrAC). When comparing with self-report, the participant typically wears the device and notes how much alcohol they consume and when. This can allow for drinking in the participant’s own environment and for typically greater, self-dosing drinking to be recorded. However, there can be limits to self-report data, including accuracy of recall, adherence to recording, and social acceptability reporting bias, particularly in clinical populations -5. SensiThe data collected and calculated from TAC  can be compared with the measurements collected via breathalyzer or blood tests (BrAC or BAC). Although TAS devices can automatically take readings at predefined time points, owing to the need for frequent administration of breathalyzer readings or the need for blood tests, studies using these comparisons typically require laboratory settings. This means that there are typically fixed-dose amounts of alcohol given by a research team, and the data are taken during a limited period (a few hours). TAC, BrAC, and BAC data are then statistically analyzed to determine the correlation. It would be optimal for TAS devices to perform with high accuracy in both laboratory and natural, real-world drinking situations.van Egmond et al  conducteThis systematic review aims to investigate the current knowledge by systematically identifying and evaluating the existing literature on the use of TAS devices in clinical and nonclinical populations, alone or in conjunction with a psychosocial intervention. The primary objective is to assess the level of accuracy of TAS devices. There is a linked review paper investigating the acceptability and feasibility of the devices .This systematic review was conducted according to the PRISMA-P  guidelines . This prStudies meeting all criteria were included: full-text original studies published in peer-reviewed journals, written in English, and using a wearable transdermal sensor device reporting accuracy outcomes. For the purpose of this review, a wearable TAS is defined as a wearable device that can measure alcohol consumption from alcohol vapors excreted via the skin. There were no restrictions on publication year or participant clinical and demographic characteristics. Data based on conference abstracts, dissertations, and gray literature were not included.Bibliographic databases included CINAHL, Embase, Google Scholar, MEDLINE, PsycINFO, PubMed, and Scopus. Searches were carried out between February 1, 2021, and February 8, 2021 . The seaAll identified titles and abstracts were screened in Covidence (Veritas Innovation Ltd) to identify studies that potentially met the inclusion criteria. From this list, the full text was retrieved and assessed by a reviewer (EB); any doubts were discussed with a second reviewer (SH). Any disagreement was discussed with a third reviewer (PD). A data extraction form was created and pilot-tested with the first 5 included studies and refined as necessary . EB extrAll outcome measures reported, both objective and self-reported, were extracted. The primary outcome was the accuracy of wearable TAS devices for measuring alcohol consumption compared with other methods  as it is designed for appraisal in reviews that include a range of designs  . EB compTo draw conclusions about the included studies, we developed a synthesis of study characteristics. The data are summarized using a structured narrative description for accuracy measures, and we report the available data reported for correlations, sensitivity and specificity, failure rates, and time lag on SCRAM, WrisTAS, and BACtrack, with a separate section for other TAS model studies (with only 1 study on each of these). Not all studies reported accuracy data on all these measures. A meta-analysis was not possible because of the methodological heterogeneity.After removing duplicates, a total of 125 papers were screened; 31 (24.8%) were excluded at the title and abstract screening, and 94 (75.2%) full-text papers were assessed. Of those 94 papers, a total of 64 (68%) were then excluded  used a SCRAM device ,23-40, 7A large proportion of studies  were conducted with adults in good health. Only 9% (3/32) of the studies included participants who were diagnosed alcohol-dependent clinical populations. Most of this research was conducted in the United States, with 94% (30/32) of the studies located there. The earliest paper included was from 1992, but most studies  were published as of 2015 .There were 1228 participants enrolled in total in the included studies, with 1147 included in the procedure or analysis. Therefore, 81 participants who were enrolled were not included in the results (for reasons such as withdrawing or missing data). In total, 1 paper  was still in the early stages of data collection for one of their studies and so these participant numbers were unknown . Not allAll studies apart from 2 30/32, 94%) met a minimum of 3 out of 5 criteria ,23 Tabl. This is/32, 94% Of the 32 studies, 19 (59%) explored the accuracy of SCRAM in laboratory or ambulatory settings ,23-40, 7r=0.79 and P<.001 [r=0.79-0.94 and P<.01 [r=0.68 and P<.001 [29=2.05; P=.04). Most studies that reported on the correlation between TAC and BAC or BrAC data found moderate to strong correlations (weighted correlations between TAC and estimated BAC (eBAC) [r=0.54 and P<.001; Pearson correlation coefficient range for peak TAC and BrAC [r=0.56 and P=.001; TAC and BrAC [r=0.60 and P<.001; correlation between peak TAC and peak BrAC [F1,73=160.03 and P<.001). However, Sakai et al [Approximately 6% 2/32) of the studies reported discrepancies between SCRAM TAC and self-report ,39, wherd P<.001 ; r=0.79-nd P<.01 ; r=0.68 d P<.001 ). Karns- of the sC (eBAC) : r=0.54 and BrAC : 0.700-0eak BrAC : F1,73=1P=.04 for the difference between correlation coefficient estimates). A low correlation was reported between WrisTAS TAC and BAC  [r=0.61 and P<.02; AUCs of BAC and TAS: r=0.91 and P<.001) [Bond et al  found th P<.001) . However P<.001)  found th P<.001) , whereas P<.001) .r=0.90 and P<.001; AUC for drinking event: r=0.7 and P=.008) [r=0.77; P<.001) [An overall high correlation between self-report and TAC was found (correlation for drinking start time:  P=.008) . BACtrac P<.001) . For the P<.001) , data co P<.001)  used SCRStudies found that the ability of SCRAM to predict or distinguish levels of alcohol consumption had a significant positive relationship with the amount consumed ,33,37,39Bond et al  found thThe failure rate for SCRAM was reported to be low at 2%  and, in χ2=−18.4; P<.001). WrisTAS data files were often found to have spikes despite the participants not reporting a drinking event. For some of these, it was most likely an environmental alcohol (perfume or hand sanitizer). However, other spikes may have been due to unreported alcohol consumption based on the data interpretation [Croff et al  found thretation .noisy patterns. However, Swift et al [Marques and McKnight  found a ft et al  reportednoise thought to be due to the rapid increase or decrease of the TAC signal [The BACtrack prototype was found to have a higher failure rate between 16% and 38% ,30. MissC signal .P<.001). Approximately 9% (3/32) of the studies found a delay in SCRAM data behind alcohol consumption and BrAC data of approximately 2-3 hours [The peak TAC measured by SCRAM was 120 minutes after the peak BrAC . Across -3 hours ,35,39 or-3 hours .P<.02). In the controlled consumption experiment, the peak values of the TAS concentration-time curves lagged by approximately 30 minutes behind the breathalyzer time curves. In intoxicated participants, the peak TAS signal lagged up to 120 minutes behind the BAC.The mean time to peak for WrisTAS was 71 (SE 7) minutes, and the mean time for the BAC curve was 107 (SE 12) minutes; for the TAS curve, the mean difference in onset times was significantly different (P<.001) [BACtrack measurements lagged the peak BrAC by 24 minutes (P<.001) . RosenbeP<.001)  found a P<.001) .A PEM fuel cell–based wearable alcohol-sensing device was used in a human volunteer pilot study . The meaLansdorp et al  used theInvestigation of a MOX sensor found that the TAC curve was right-shifted from the BAC and BrAC curves and there was a time delay for the peak of approximately 80 minutes. The 2 different concentrations of ethanol (0.5 g/L and 0.8 g/L) absorbed by the participants could be discriminated .The Quantac Tally was explored before Quantac Co. ceased its business operations. TAC measurements peaked on average 115 minutes after drinking onset, with a gradual increase to peak concentration .The use of a wearable IoT sensor  found thr=0.092 and P<.001; dose 3: r=0.88 and P<.001) than TAC compared with BrAC  and BAC . There was also a time lag for TAC output, which was affected by noise.Davidson et al  exploredThe aim of this review was to assess the current knowledge on the accuracy of TAS devices. We identified 32 papers, few of which reported the use of this technology in clinical populations. Of the 32 papers, we identified only 3 (9%) studies that used alcohol-dependent participants. Most studies used either SCRAM  or WrisTAS . However, there were some studies that investigated BACtrack Skyn  and others . This is a growing field, and the production and investigation of additional TAS devices supports this. This review found that wearable TAS devices could detect alcohol consumption with moderate to strong accuracy over various periods. However, factors such as the amount of alcohol consumed, the environment , age, and where the device is worn must be considered. The findings differed across the TAS brands included, and studies on each brand reported different limitations; for example, time lag compared with BrAC or BAC, data file errors, or device failure.The SCRAM, WrisTAS, and BACtrack studies showed reasonably high data capture rates but demonstrate that this is <100% ,41,42,44SCRAM devices had the lowest amount of recorded failure rates of the included devices ,30,34,42Approximately 3% (1/32) of the studies compared SCRAM and WrisTAS in laboratory and ambulatory settings. When the participants self-dosed, the true positive rates for both devices increased and, the higher the peak BAC level, the higher the rate of true positive TAC . AlthougOur findings relating to SCRAM, WrisTAS, and BACtrack were largely in line with the review findings of van Egmond . Data frThere was 1 individual paper  on each of the other 6 wearable TAS devices ,11,48-51This review highlights the small but growing number of studies investigating the accuracy of wearable TAS devices. With only a small number of studies testing more than one brand or even the same setting, intervention, or population, it is difficult to draw direct comparisons. Most studies  included healthy adults, and the length of time studied ranged from a day to a few months. If the ultimate objective is for these devices to be used within the clinical population or the criminal justice system for extended periods, this manner of use needs to be explored further. No included study was conducted in a criminal justice setting with offenders. However, there is a growing appeal for this technology to be used in this environment; for example, the use of SCRAM in the UK criminal justice system for alcohol-related offenses .A mix of study designs was included in both the ambulatory and laboratory settings. Although it is useful to conduct studies in controlled laboratory environments to investigate validity, reliability, and accuracy, the target use is not necessarily a laboratory environment. Hence, how the devices perform in vivo with populations other than those studied must be investigated. This would then be able to inform the devices’ long-term effectiveness in future treatment, interventions, research, and policy.There are currently a small number of studies in this area, but research on the use of this technology is growing and, owing to technological advancements, the accuracy and ability of these devices is improving considerably. What is needed is for research to expand into other populations, such as clinical populations and offenders within the criminal justice system, to examine their accuracy and reliability in the intended target populations and contexts. Although the accuracy outcomes for this technology are promising, there is a limit to this research because of the mostly laboratory and short-duration study design.The use of wearable TAS devices is becoming more accepted and appealing to society, as evidenced by their increasing implementation in the criminal justice system and increasing research. The implications of this review are that we need to investigate the engagement in real-world settings, where transdermal sensors are intended to be implemented, with the target populations. This can then inform clinical interventions, treatment, research, and use.


Differentiated thyroid cancer accounts for the majority of thyroid cancers and has a good prognosis after standard treatment. However, there are still some complex and refractory thyroid cancers, including locally advanced differentiated thyroid carcinoma and medullary carcinoma (MTC), poorly differentiated thyroid carcinoma (PDTC), and anaplastic thyroid carcinoma (ATC). Here, we report the therapeutic response of 2 advanced thyroid carcinoma patients treated with dabrafenib and trametinib.Two elderly females presented to the clinic with neck masses, dyspnea, and dysphagia. Signs of the trachea and esophageal compression were markedly visible in computed tomography (CT) scan and ultrasonography. Pathologic diagnoses of PDTC were confirmed for both patients through ultrasound-guided fine-needle aspiration (US-FNA). Both patients were significantly relieved from dyspnea and dysphagia after a course of treatment with dabrafenib and trametinib, and their tumors gradually shrank during the follow-up period.Overall, this treatment modality is rare, but effective. By sharing these 2 case reports, we hope to provide a reference for the treatment of clinically similar patients with advanced thyroid carcinoma. Locally advanced thyroid carcinoma is a type of thyroid cancer in which the tumor markedly invades surrounding organs and structures. Especially, poorly differentiated thyroid carcinoma is more aggressive and rapidly progresses to distant metastases. Poorly differentiated thyroid carcinoma is an aggressive form of follicular cell-derived thyroid carcinoma with a behavior, morphology, and prognosis that is intermediate between indolent differentiated thyroid carcinoma (DTC) and rapidly growing and often fatal ATC . PDTC isThis study was reported in agreement with principles of the CARE guidelines .BRAF V600E gene mutation . Because the patient’s nutritional status was poor, and she could not afford immunotherapy, she was discharged from the hospital and took 3 cycles of anlotinib 12 mg qd (taking the medication for 2 weeks and stopping for 1 week). After completing the 3 cycles, the patient had dysphagia, increased coughing, and expectoration accompanied by blood in the sputum, so she was re-admitted to Sichuan Cancer Hospital. During hospitalization, the patient was unable to eat and was completely supported by parenteral nutrition.In December 2021, a 72-year-old woman with a neck mass, dysphagia with a cough and expectoration was referred to the Department of Thyroid Surgery & Western Medicine, West China Hospital, Sichuan University. Before visiting our hospital, the patient found a hard mass on the left side of her neck, along with tenderness and poor mobility. At that time, there was no dyspnea or dysphagia. The patient was treated at Sichuan Cancer Hospital, underwent ultrasound examination and received FNA. Ultrasound showed morphological abnormalities in the thyroid, abnormal lymph nodes were found on both sides of the neck, and FNA cytology revealed PTC (occupying the right lobe of the thyroid). The results of immunohistochemical analysis were as follows: positive TTF-1, G-3, CK19, MC (HBME-1), CD56, Ki67 (10%), negative (TG), PD-L1: 22c3, CPS: 65, negative control: negative, and positive control: positive. Gene testing revealed a ). The patient had a personal history of 20 years of hypothyroidism and had taken 50 µg levothyroxine (Euthyrox) for a long time. There was no history of neck surgery, neck radiotherapy, parathyroid disease, or hereditary disease.Physical examination showed that she had a hoarse voice, clear consciousness and diffuse swelling of the neck, and was unable to touch her trachea because of the trachea was compressed by a huge mass. The thyroid mass was hard, and its size could not be measured. The laboratory examination revealed the following: FT3 1.64 pmol/L , FT4 9.53 pmol/L , TSH 7.34 mU/L , thyroglobulin (hTg) < 0.04 µg/l , anti-thyroglobulin antibodies (TGAb) > 4000 IU/ml , and tumor marker/carcinoembryonic antigen (CEA) 0.64 ng/ml . Ultrasound re-examination revealed that the thyroid gland contained giant nodules encircling the bilateral common carotid arteries. In addition, bilateral neck areas I-IV had multiple lymph node fusions, the left neck was approximately 12×10×16 mm, the right side was approximately 20×19×14 mm, and the corticomedullary demarcation was unclear. We showed on computed tomography (CT) that the thyroid gland was unclear and there were lymph node metastases in the neck and upper mediastinum  and trametinib (2 mg qd) on December 30, 2021. FDA recommends 150mg twice daily for the use of dabrafenib, but We had never used this scheme before in these two patients, so we could not evaluate the effectiveness and side effects. In addition, the patient’s condition was bad and the basic condition was poor, so we tried to use half a dose to observe the efficacy, and subsequently adjusted the scheme according to the patient’s condition. We sent the biopsy tissue for pathological re-examination, and the results of the cytology revealed malignant epithelial cells. Immunohistochemical staining of thyroid , which exhibited positive CK19, CD56 and G-3, and negative TTF-1, TG, HBME-1, CGA, SYN, p63, CD20. The Ki-67 positive rate was approximately 40%. Confirmed poorly differentiated thyroid carcinoma. After 13 days of treatment, the patient’s dyspnea and dysphagia symptoms had decreased, and she could sleep in a flat position and drink a small amount of liquid. Her neck circumference gradually decreased with daily measurements. However, she still had hoarseness and developed black stool (approximately 100-200 g/d) and hematuria on a daily basis. According to the patient’s condition, the patient’s above symptoms improved after treatment with proton pump inhibitor (PPI), somatostatin and oral Yunnan Baiyao. To clarify the cause of bleeding would require a gastroscope, after the patient’s condition has improved. The patient continued oral dabrafenib 75 mg and trametinib 2 mg maintenance therapy and underwent thyroid stimulating hormone (TSH) repression therapy with levothyroxine 50μg after discharge. We compared the imaging reports at 3 days, 19days, 50days and found that the tumors significantly decreased in size. The author’s department subsequently found that the tumor did not continue to grow or have any detectable distant metastasis through outpatient service and telephone. At the end of February 2022, the patient experienced fever and seizure. Moreover, a new mass was found in the right neck. After discontinuing dabrafenib and trametinib for 10 days, the mass grew rapidly, and blood culture suggested a serious infection. Therefore, after comprehensive consideration, we recommended that she continue to take dabrafenib and trametinib. The patient’s condition progressed rapidly, and she died on March 10.To solve the patient’s nutritional problems, the endoscopy center placed a jejunal nutrition tube. During this process, the patient had sudden dyspnea with a sharp drop in oxygen saturation and partial pressure of carbon dioxide of 164%, pH: 6.9. The anesthesiology department performed a successful emergency nasotracheal intubation, and the patient was transferred to the critical care medicine department. The multidisciplinary team (MDT) ruled out surgical treatment, because of the high risks involved, and because the tumor was poorly demarcated from surrounding tissues. dabrafenib and trametinib treatment was finally considered. dabrafenib and trametinib is approved by the FDA for the treatment of patients with ATC and . The laboratory examination upon admission revealed the following: FT3 2.08 pmol/L , FT4 9.39 pmol/L , TRAb 2.79 IU/l , WBC 12.99×10/L , Hb 99 g/L (115–150 g/L), and PLT 259×10/L (100–300 10^9/L); TSH, hTg, TGAb, and CEA were unremarkable. She had a 13-year history of papillary thyroid cancer (PTC) and had previously undergone total thyroidectomy, double central lymph node dissection, plus left cervical lymph node dissection in our hospital. Levothyroxine 75 µg in parallel with radioactive iodine [(131)I] therapy three times, were administered in after the operation. There was no personal or hereditary family history of cardiovascular or cerebrovascular disease. An appointment was set with a thyroid surgeon from our institution on the same day. After the completely treating the infection that emerged in the patient’s lungs during the consultation on February 7, 2022, she was admitted to the Thyroid and Parathyroid Surgery Center. A covered stent was used instead of tracheal intubation with the assistance of the Department of Otorhinolaryngology. Due to the patient was critically ill after admission and had obvious symptoms of neck compression. In an effort to strive for treatment time, while the patient underwent US-FNA, we communicated with the family and obtained the consent to empirically administer treatment with dabrafenib and trametinib (given the close similarity to that of case 1), and the final pathological results and genetic testing also confirmed the effectiveness of our medication. We selected a mass in the left lobe region of the thyroid gland by ultrasonographic localization, punctured the fine-needle into the interior of the nodule and multipoint aspiration was performed under the monitoring of ultrasound. Histological examination was performed postoperatively on fixed specimens with alcohol. Immunohistochemical analyses showed tissue positivity for the following markers: HBME-1, CK19, G-3, BRAF-VE, PCK, and PAX8. In addition, TERT promoter mutation (C288T) were identified by Molecular testing in the mass. Combined the morphology and all of the above findings led to a diagnosis of PTC with a mutation at position 228 of the TERT gene promoter . Under receiving comprehensive treatment from the nutrition, infection, and respiratory departments, the patient’s condition improved after 5 days of dabrafenib and trametinib, and her symptoms of dyspnea, dysphagia, and hoarseness disappeared. Unexpectedly, she was required dose reductions of dabrafenib and adds radiotherapy because of edema of both lower extremities with petechiae. Three months later, the patient developed a tracheoesophageal fistula, which improved after conservative treatment. After ∼8 months of treatment, numerous metastatic lesions had lessened on computed tomography. The survival time of the patient has reached 10 months since she diagnosis of PTC. At present, the patient is in a state of no recurrence and metastasis, and there is no obvious adverse reaction after taking dabrafenib and trametinib.A 73-year-old woman presented to the emergency department of West China Hospital, Sichuan University, on January 31, 2022, because of a neck mass with chest and airway tightness. Previously, FNA was performed at her local hospital, and the results showed metastatic, poorly differentiated squamous cell carcinoma. Upon arrival in the emergency room, the patient suddenly lost consciousness. The emergency physicians immediately diagnosed respiratory failure and intubated the patient. To comprehensively evaluate the condition of patient, CT was performed and showed that there was a mass (6.3×5.6 cm) located in the left lobe region of the thyroid gland, which wrapped and invaded the trachea and esophagus, both of which were compressed to varying degrees, resulting in stenosis. Nodules of varying size were scattered throughout both lungs, with the largest nodule measuring 1.8 cm in diameter, which we suspect to be metastatic lesions . The labBoth were approved by the ethics committee of the West China Hospital, Sichuan University, and written informed consent was provided by the patient for publication of this case publication.These cases give us great confidence and a new strategy for the clinical treatment of a advanced thyroid carcinoma. Our discussion will focus on the effects of treatment.BRAF kinase activity for the treatment of solid tumors , etc . In caseWe report 2 rare cases of advanced thyroid carcinoma and point out the effectiveness of the combination of the 2 targeted drugs. The conclusion that dabrafenib and trametinib contributes to the management of advanced thyroid carcinoma remains to be further confirmed. We hope that our treatment procedures and initial outcomes can serve as a reference for the diagnosis and treatment of similar patients.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by ethics committee of the West China Hospital, Sichuan University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XP managed the cases, collected patient data and images, and wrote the manuscript. JL, ZL and KZ conducted the study and revised the manuscript. All authors contributed to the article and approved the submitted version.


Bone deformities in the axial skeleton represent a frequent bone pathology in farmed salmonids, affecting the quality of life and even increasing mortality. Bone deformation can affect the formation, repair, and regeneration of inorganic-bone components and is associated with diet, culture conditions, and genetics. If diet and culture conditions are factors in the development of bone deformity, wild fish lack them and present fewer deformations than farmed fish. Hence, we studied mandibular bone microstructure using variable pressure scanning electron microscope (VP-SEM) coupled to EDS detector. Two groups of smolt rainbow trout were analyzed: Group 1, farmed fish with a control diet, and Group 2, wild fish without a control diet. We observed that serum protein levels remained within normal ranges. However, the calcium and phosphorus ratio was not the same in blood as in bone; phosphorus deficiency was more critical because it forms other structural molecules such as nucleic acid, phosphoproteins, phospholipids, and high-energy phosphates. Consequently, the microstructure in wild fish showed a more significant number of pores and microfractures per area, which was detrimental to the biomechanical properties of the bone.p < 0.05). Microstructural analyses indicated that farmed fish have a more robust mineral structure (p < 0.05), confirming the differences in mineralization and microstructure between both groups. However, the mechanisms regulating absorption and distribution in the organism and their effect on bone mineralization remain to be known. In our study, the combined use of techniques such as SEM-EDX and TGA-DSC allows a clearer assessment and detailed characterization beneficial to understanding the relationship between diet control and bone microstructure.Farmed salmonids show alterations in bone structure that result in skeletal deformities during formation, repair, and regeneration processes, with loss of mineralization at the level of the axial skeleton, mainly the head and spine, affecting their quality of life and even causing death. Despite improving factors, such as farming conditions, diets, and genetics, bone alterations appear more frequently in farmed fish than in wild fish. Thus, we used SEM-EDX, and TGA-DSC to study bone mineralization in farmed and wild rainbow trouts. As expected, we found significant differences in the nutritional parameters of farmed and wild fish ( Oncorhynchus mykiss) is a teleost fish with cellular bone [Rainbow trout 6(OH)2], a mineral component playing a key role in bone strength [Homeostasis between Ca and P at the systemic level is critical for HPA production [Castrength ,29,30. Tstrength ,31,32. Istrength ,9,26,31.strength ,34. Fe istrength . In addistrength ,36; or istrength ,37. Sevestrength ,38; (2) strength ,39; and strength .Oncorhynchus mykiss) with and without nutritional control (farmed vs. wild fish).Blood screening for clinical purposes in salmonids is frequently used to assess general physiological status, metabolism, and evaluation of changes or new diets and conditions, representing an important tool for evaluation, diagnosis, and prognosis of fish health status as previously described ,43,44,45Oncorhynchus mykiss), approximately 50 cm in size (maximum), were selected from fish farming and wildlife (considered the relevant difference was in the color of the skin and size). The capture of wild fish was carried out by personnel authorized for this by Servicio Nacional de Pesca y Acuicultura ; while the capture of farmed fish was realized by authorized fish farming personnel. In both cases, fly fishing to catch juvenile fish was used [Juvenile rainbow trout (was used . In totaw/v). The jaws were separated from the head and treated with deionized water at 60–70 °C for about 20 min to facilitate the removal of skin, muscle, connective tissue, and other organic components, leaving free the inorganic component without altering its structure. The jaws were fixed in buffered formalin  until analysis.We centrifuged blood samples at 1500 rpm; serum was separated from the cellular component and stored at −20 °C until further analysis. The euthanized specimens were decapitated and washed with physiological saline , and microelements , according to the protocol of the manufacturer  in a multimodal Synergy HT reader .The fixed mandibular bone samples were washed with distilled and deionized water three times and dried in an oven at 25 °C for 24 h. The dried sample was adhered to the sample holder with double-sided carbon tape. The separated sample was visualized in the middle area of the mandibular bone, including the teeth. Visualization was performed using a chemical contrast detector  in variable pressure without any further sputtering under the following parameters: 10 KV energy, 20 Pa pressure, WD 10 mm in Scanning Electron Microscope , and images were acquired and analyzed with Hitachi software controller and ImageJ 1.53k Java 1.8.0_172 Software .Bone porosity was determined using the ImageJ tool as follows: (1) chose an area of the control picture (farmed fish) with no borders or faults; (2) trimmed the section and adjusted the threshold to visualized regions, bright (bone), and dark (pores); (3) recorded the cut-off value on the dark areas and reproduced it to all photos to be analyzed; (4) chose the analyze particle tool (size and circularity); and, lastly, (5) began running and registering values in all photographs. ImageJ 1.53k Java 1.8.0 172 Software .® Detector 410 and Quantax Esprit 1.8.1 Software controller .The quantification and elemental distribution were coupled to the X-ray energy dispersive spectroscopy detector (EDS). We chose three quantification points for each region of interest (ROI). The acquisition was performed under the following parameters: applied energy 15KV, pressure 20 Pa, WD 10 mm using Scanning Electron Microscope  coupled to XFlashWhole mandibular bone samples, including teeth, were dried in an oven for 48 h at 40 °C. Subsequently, they were reduced to a fine powder by pulverization with a mortar and pestle. Approximately 20 mg of samples were subjected to two thermogravimetric analyses: first, from 25 °C to 850 °C (10 °C per minute rate) to evaluate bone sample stability in the air atmosphere by monitoring weight loss, and second, differential thermal behavior (DSC) from 25 °C to 850 °C (50 °C per minute rate) .p < 0.05 was considered statistically significant .The normality of the data was analyzed using the D’Agostino–Pearson test for descriptive statistics. Differences between groups were analyzed with the Mann–Whitney U test. The value p < 0.001 and 18.1 g/L; p < 0.001, respectively) than farmed fish (p = 0.053). Regarding enzymatic activities, all measurements in wild fish showed significant differences with farmed fish: creatine kinase , alkaline phosphatase , acid phosphatase , serum glucose .We analyzed blood samples for metabolites informative of the nutritional status  and microelements directly involved in promoting the bone mineralization. Regarding total protein and albumin content, we observed lower values for wild fish , and including the teeth .In terms of tooth morphology, there are no apparent differences between farmed and wild fish . Indeed,In the elemental microanalysis of the tooth samples, we observed differences between healthy vs. wild fish, mainly in calcium, phosphorous, and carbon percentages a,b.p = 0.001) and wild fish , and in the latter an increase in the percentage of C (p < 0.001), representing almost 46.8% of the total composition of the teeth in wild fish  , values that were higher than those observed in wild fish  .The EDS mapping in the mandibular bone showed microfractures, roughness, and pores in farmed and wild fish. These structure alterations were larger and more numerous in wild fish. We observed a more homogeneous elemental distribution pattern in farmed fish than in wild fish. The structure alterations affected P, C, and O but not Ca a,b.We performed a 3D projection of the mandibular bone surface microstructure and porosity analysis . FindingPorosity analysis in the images showed more pores of larger sizes that covered a higher percentage of the region of interest in wild fish than in farmed fish .The proximal thermogravimetric analysis  showed tThe differential scanning calorimetry or DSC analysis  describeMetabolic analysis in blood samples is essential to evaluate the physiological status at different stages of development. In addition, it is a minimally invasive procedure that allows assessing the effect of nutritional status and the incorporation of microelements, vitamins, or proteins in the diet, measuring toxicity, immune status, or stress related to fish culture management ,48. TotaGlucose level is an essential nutritional parameter. Although it varies with age, its importance lies as a marker of stress in animals due to its relation to corticoid production ,52. The Bone growth and metabolism is regulated by the quantity of microelements taken up from the water . The low availability of these microelements translates into bone mineralization alterations ,56,57,58Different studies show that systemic markers of bone mineralization are Ca and P  and, indThe microstructural analysis of the mandibular bone—including teeth—from farmed and wild fish involves the visualization of morphology, porosity, and roughness. Our data showed more microfractures, pores, and defects in wild fish , which mThe TGA-DSC analysis showed similar transitions indicating purity, referring to the same type of biomaterial, i.e., there is no significant difference in the type of crystal that forms the bone. The compositional results correlated directly with the SEM-EDX analysis since the microstructure having more surface alterations in wild fish showed lower ash percentage  and higher content of fixed carbon and volatiles in farmed fish . It shouTo understand the mechanisms involved in bone tissue formation and remodeling processes, sustained availability of nutrients and microelements—such as calcium and phosphorus—is required. However, our results do not clarify the role of Fe and Mg bioavailability on bone microstructure. The Ca/P ratio in serum is not the same as in bone because phosphorus is structural in bone and a structural part of nucleic acids, proteins, lipids, and other molecules, such as high-energy phosphates. Therefore, it is required to ensure enough quantity for all these functions. Incorporating destructive and non-destructive techniques for the analysis of the microstructure of bone tissue is highly useful for understanding how slight structural and mineralization differences impact the mechanical/physicochemical properties for the correct functioning of the bone.


HNF1B) gene.Maturity-onset diabetes of the young 5 (MODY5), a rare diabetes syndrome of young adults, is associated with variants in hepatocyte nuclear factor 1B  was identified through Sanger sequencing.We reported a case of MODY5, which presented with diabetic ketosis, multiple renal cysts, and hypokalemia. In this case, the HNF1B mutations, and insufficient insulin secretion may be a potential cause of diabetic ketosis in MODY5.Multiple renal cysts and youth-onset diabetes are common manifestations in patients with  GCK, HNF1A, HNF1B, HNF4A, PDX1, NEUROD-1, KLF-11, CEL, PAX4, INS, BLK, ABCC8, KCNJ11, and APPL1 . Currently, at least 14 genes have been confirmed to be involved in the pathogenesis of MODY, including ariation . However2 in body mass index (BMI). Physical examination revealed no abnormalities except rapid pulse rate and malnutrition. Laboratory investigations revealed a random blood glucose (RBG) level of 28.9 mmol/L and glycated hemoglobin (HbA1c) value of 17.40%. The erythrocyte sedimentation rate (ESR) level was 10 mm/h and c-reactive protein was less than 3.11 mg/L, both within the normal range. Urine ketone bodies were positive and urine sugar was strongly positive. Therefore, the patient was diagnosed with diabetic ketosis and treated with insulin at a dose of 0.48 U/kg*d as a tentative pharmacotherapy. The patient’s hyperglycemia gradually improved and urine ketones were negative. After that, we performed the relevant examination for the patient  in 4 exon, leading to a nonsense change of amino acids 276, which changed the amino acid position 276 of the encoded protein from Arg to stop codon . The occurrence of diabetic ketosis might be related to insufficient insulin secretion, which was different from type 1 diabetes in that diabetes-related autoantibodies were negative. While previous reports suggested that pancreatic hypoplasia was often the cause of insufficient insulin secretion in MODY5 patients , and the possible reasons were as follows: First, there was obvious heterogeneity in MODY5 patients, and the clinical manifestations were different among different patients. Second, diabetic ketosis was a rare manifestation of MODY5  occurred in exon 4 and diabetic ketosis was the first manifestation. This was the first report of diabetic ketosis in patient with patients , no overpatients . Furtherof MODY5 , which mHNF1B mutations  occurred. Although some patients might be independent of insulin in the early stage  for the publication of any potentially identifiable images or data included in this article.SG: Data extraction, Data analysis, Essay writing, and Paper submission. MY, WG and WC: Data extraction. JD and LL: Critical revision and Paper submission. All authors contributed to the article and approved the submitted version.This work was funded by the National Natural Science Foundation of China (82170847).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.


Previous studies have attempted to elucidate the molecular mechanism of vitiligo; however, its pathogenesis remains unclear. This study aimed to explore biomarkers related to vitiligo through bioinformatic analysis. The microarray datasets GSE53146 and GSE65127 were downloaded from the Gene Expression Omnibus database. Firstly, differentially expressed genes (DEGs) in GSE53146 were screened, and then an enrichment analysis was performed. Secondly, the protein-protein interaction (PPI) network of DEGs was constructed using the STRING database, and the key genes were screened using the MCODE plugin in Cytoscape and verified using GSE65127. Finally, quantiseq was used to evaluate immune cell infiltration in vitiligo, then to observe the correlation between biomarkers and immune cells. In total, 544 DEGs were identified, including 342 upregulated and 202 downregulated genes. Gene Ontology (GO) enrichment showed that DEGs were related to inflammatory and immune responses, and Kyoto Encyclopedia of Genes and Genomes enrichment showed that DEGs were involved in many autoimmune diseases. In the PPI network, 7 key genes, CENPN, CKS2, PLK4, RRM2, TPX2, CCNA2, and CDC45 were identified by MCODE cluster and verified using the GSE65127 dataset. With an area under the curve (AUC) > 0.8 as the standard, 2 genes were screened, namely CKS2 and RRM2. Further immune infiltration analysis showed that M2 macrophages were involved in the pathogenesis of vitiligo, whereas CKS2 and RRM2 were both related to M2 macrophages. This study shows that CKS2 and RRM2 have potential as biomarkers of vitiligo and provides a theoretical basis for a better understanding of the pathogenesis of vitiligo. Vitiligo is less likely to be life-threatening, so it seems to belong to a low-priority medical area; however, because the rash easily occurs in significant parts, it usually causes negative effects such as shame, fear, anxiety, and discrimination. Studies have shown that the decline in quality of life caused by reduced self-esteem and social isolation in patients with vitiligo can be comparable to that of psoriasis, so we should be paid to this disease. The current treatment can reverse vitiligo by stimulating the regeneration of the melanocyte stem cell reservoir in the hair follicle and suppressing the immune response to repigment the skin lesions, but the risk of recurrence in the first year is approximately 40%. In addition, different patients and rashes in different parts have different sensitivities to treatment, and their efficacy is uneven. Therefore, it is very important to deeply understand the complex pathogenesis of vitiligo, develop new treatment methods, and meet the treatment needs of patients.Vitiligo is an autoimmune disease that affects the skin and is characterized by white patches caused by the loss of epidermal melanin. High-throughput sequencing and DNA microarrays can provide genome-wide expression data; therefore, they are widely used in the medical field. These data are stored in public databases, such as Gene Expression Omnibus (GEO), The Cancer Genome Atlas (TCGA), and Online Mendelian inheritance in humans (OMIM). In this study, we downloaded microarray data on vitiligo from the GEO database and screened key genes to explore the genes related to the pathogenesis of vitiligo through bioinformatics analysis and provide direction for disease prediction and accurate treatment.Bioinformatics has developed rapidly since the 21st century and has become a promising analytical method. The differentially expressed genes (DEGs) between the diseased population and healthy controls were screened, and the potential pathogenic pathways were verified, providing a theoretical basis for an in-depth understanding of the molecular mechanism of the disease, which can be further used for disease screening, prognosis, targeted therapy, and drug development.https://www.ncbi.nlm.nih.gov/geo). Taking “vitiligo” AND “Homo sapiens” as the inclusion criteria, taking the tissue source as “skin biopsy,” and the sample containing “healthy control and disease group” as the screening criteria, 2 datasets, GSE53146 and GSE65127, were obtained. The sequencing platforms were GPL14951 (Illumina HumanHT-12 WG-DASL V4.0 R2 expression beadchip) and GPL570 (Affymetrix Human Genome U133 Plus 2.0 Array). The sequencing type used was microarray. Basic information on the dataset is provided in Table All data were downloaded from the GEO database (https://www.r-project.org/) is a free and open-source programming language that can be run and compiled for different operating systems. The R package can be downloaded for statistical calculations and data visualization. RStudio (https://www.rstudio.com), as an editor of the R language, has the advantages of a simple page and convenient application.R (This study primarily used R (v4.0.4) and RStudio (v1.4.1106) to analyze the dataset. The GSE53146 dataset was preprocessed using the limma package of R and visualized using R’s boxplot function.Principal component analysis (PCA) is a statistical method used to study the relationships between multiple variables. It is one of the most widely used data dimensional-reduction algorithms. The basic principle is to reduce the dimensions of the dataset while retaining the characteristics that contribute the most to the difference in the dataset.In this study, PCA was used to observe the gene expression patterns of the 2 groups, the prcomp function of R was used for calculation, and the ggord package was used for visualization to evaluate the difference between the samples of the vitiligo and healthy control groups.P < .05 and |logFC| > 2. The results are presented in the form of a heatmap and volcano map that were drawn using the pheatmap package and ggplot2 package of R, respectively.In this study, the annotation file was obtained from the corresponding sequencing platform, and the dataset was probe-transformed using the dplyr and tidyr packages of R. The limma package of R was used for calculation based on the processed GSE53146 dataset, and DEGs were identified and screened. The screening threshold was https://david.ncifcrf.gov) is an online database that provides biological function annotation information for a large number of genes and proteins, helping researchers extract the most significant biological information from thousands of associated annotations. At present, it is mostly used for DEG function and pathway enrichment analyses.DAVID (Gene Ontology (GO) can define and describe the functions of genes and proteins. It divides functions into 3 parts: biological process (BP), cellular component (CC), and molecular function (MF). The Kyoto Encyclopedia of Genes and Genomes (KEGG) is a database that stores health information, such as the interaction between genomes and chemical substances, diseases, and drugs.P < .05. The obtained results were imported into R and visualized using the ggplot2 package.In this study, the DAVID database (v 6.8) was used for the GO and KEGG enrichment analyses of the screened DEGs. Statistical significance was set at https://cn.string-db.org, v 11.5) database was used to construct protein-protein interaction networks (PPI) of DEGs. The minimum interaction score was set to 0.7, the nodes that had no connection with other nodes were hidden, and Cytoscape  was used for visualization.In this study, the STRING  curve is often used for disease diagnosis, tumor recurrence, and treatment target prediction. By comparing the area under the curve (AUC), we can determine the best diagnostic value.In this study, the hub genes were verified using the GSE65127 dataset. The pROC package of R was used for calculation and drawing, and genes with an AUC > 0.8 were selected.P < .05.Immune cells are important for the innate and adaptive immune responses of organisms. They are diverse and play important roles in the human body. Therefore, in this study, we further examined whether there were differences in the distribution of immune cells in samples from vitiligo patients and healthy controls. We used the immunedeconv package of R and the quantiseq method to evaluate immune infiltration and drew a bar graph using the ggplot2 package. The differences in the expression of immune cells in the 2 groups of samples were compared, the rank sum test analysis was performed using R, and the ggplot2 package was used to draw histograms. Statistical significance was set at The distribution and function of these molecules are inseparable from gene regulation. Therefore, this study further explored whether the screened genes (genes with an AUC > 0.8) were related to immune cells. The correlation was calculated using the psych package in R, and the ggcorrplot package was used to plot the correlation.The GSE53146 dataset used in this study was downloaded from the GEO database, including sequencing information of skin lesions of 5 vitiligo patients and 5 healthy controls. After standardization using the limma package in R, the data distribution between the 2 groups of samples was relatively consistent, and there was no obvious deviation, as shown in Figure DEGs analysis of GSE53146 was performed using the limma package, and a total of 544 significant DEGs were detected, including 342 upregulated genes (UP) and 202 downregulated genes (DOWN), as shown in Figure P < .05 was considered meaningful, and only the top ten were shown when there were many results). The results of GO analysis showed that in BP, upregulated DEGs were associated with inflammatory response, immune response, proteolysis, response to lipopolysaccharide, positive regulation of gene expression, cell surface receptor signaling pathway, T cell costimulation, T cell receptor signaling pathway, adaptive immune response, regulation of cell proliferation, and other processes; in CC, upregulated DEGs constituted membrane, extracellular region, Golgi apparatus, external side of plasma membrane, cell surface, immunological synapse, nucleosome, T cell receptor complex, dense core granule membrane, protein complex involved in cell adhesion, etc; in MF, upregulated DEGs were in the process of protein binding, receptor binding, serine-type endopeptidase activity, protein kinase binding, protease binding, and CXCR3 chemokine receptor binding , intestinal immune network for IgA production, T cell receptor signaling pathways, hematopoietic cell lineage, rheumatoid arthritis (RA), graft-versus-host disease, allograft rejection, type I diabetes mellitus, autoimmune thyroid disease, and primary immunodeficiency Fig. A. DownreThe screened DEGs were uploaded to the STRING database to obtain PPI information, and the results were visualized using Cytoscape Fig. A. The McTo analyze whether the screened hub genes were reliable, we used the GSE65127 dataset for verification, and 7 hub genes were selected using the pROC package in R , and no significant differences were found among the B cells, monocytes, NK cells, Tregs, and dendritic cell groups . Finally, in the GSE65127 dataset, we applied ROC to verify the above 7 genes, identified genes with AUC > 0.8, and obtained CKS2 and RRM2, so that they can be used as key genes of vitiligo for further research. CKS2 is highly conserved and can bind to the catalytic subunit of cyclin-dependent kinase (CDK), which is crucial for cell cycle regulation and is also closely related to embryonic development and somatic cell division. Previous studies have mostly focused on tumors and found that CKS2 is involved in biological processes such as DNA repair, the P53/P21 signaling pathway, and Akt phosphorylation.,12,13 Ji et al found that in hepatoma cells, the expression of CKS2 was negatively correlated with the content of PTEN protein, and PTEN, an important molecule of the P53 signaling pathway, was related to the activity of P53 protein. The results showed that high CKS2 expression could inhibit the activity of P53 and participate in the progression of liver cancer. In patients with vitiligo, Ultraviolet B (UVB) radiation is a commonly accepted treatment for patients with vitiligo. Su et al demonstrated that UVB activated p53, which caused the downregulation of transient receptor potential cation channel subfamily M member 1 (TRPM1); thus, the expression of microRNA (miR) -211, encoded by the intron of TRPM1, was downregulated. MiR-211 changed the ability of melanocyte migration ability by targeting matrix metalloproteinase 9; therefore, CKS2 may be a therapeutic target to improve repigmentation in vitiligo patients. Previous studies have found that with the upregulation of CKS2, the mRNA of CDK2/4/6 proteins inhibited by the P21 protein gradually increased, and CDK2 was involved in the development of melanoma by regulating the G1/S and G2 phases of the cell cycle. Similarly, melanocyte loss due to the abnormal expression of CDK2 was observed in vitiligo patients, but the exact mechanism is unclear.The CDC28 protein kinase regulatory subunit 2 (CKS2) is a member of the human CKS family. Akt can further promote IKK phosphorylation and activate the NF-κB pathway, which promotes the release of CXCL16 and IL-8 by keratinocytes, and an increase in CXCL16 can lead to the migration of CD8 + T cells in patients with vitiligo. We speculated that CKS2 might participate in the development of vitiligo through an immune response. Therefore, this study further analyzed the level of immune cell infiltration in the 2 groups, and the results showed that there was a significant difference between M2 macrophages. The correlation between screening genes and immune cells was evaluated, and CKS2 was found to be related to the abundance of B cells, M2 macrophages, and Tregs.Akt phosphorylation is closely associated with cell proliferation and apoptosis. Lin et al found that the protein expression of CKS2 was positively correlated with Akt phosphorylation.,19 It has been reported that RRM2 is involved in the pathogenesis of various cancers, such as breast cancer, glioma, multiple myeloma, retinoblastoma, etc.–22 Duxbury et al showed that overexpression of RRM2 activated the NF-κB pathway and increased the invasion of pancreatic cancer cells, while silencing the RRM2 gene could weaken NF-κB activity. In breast cancer, the NF-κB pathway is the main pathway affected by RRM2 overexpression, which could induce higher migration characteristics, while the NF-κB pathway is also involved in the pathogenesis of vitiligo. Chen et al found that NF-κB signaling in KCs promoted the expression of IL-15 and the transpresentation of IL-15, which in turn contributed to the activation of CD8 + T cells and induced adaptive immunity in vitiligo. Zhuang et al verified that NF-κB stimulates the production of IFN-β, which leads to the secretion of CXCL10, and that excess CXCL10 in the epidermis plays a key role in the transport of autoreactive CD8 + T cells, which further leads to the death of melanocytes in vitiligo. Therefore, we speculate that the upstream molecule, RRM2, of the NF-κB pathway plays an important role in the pathogenesis of vitiligo.Ribonucleoside diphosphate reductase subunit M2 (RRM2) is a catalytic subunit of ribonucleotide reductase and a rate-limiting enzyme for DNA repair and synthesis. It plays an important role in cellular processes such as proliferation, migration, and angiogenesis. RA is an autoimmune disease that is closely related to vitiligo. Such individuals have a higher risk of developing vitiligo. Therefore, we speculated that RRM2, as an effective treatment target for RA, is also important for vitiligo. MiR-211 is involved in many cellular processes such as pigmentation. Another study found that the expression of RRM2 was upregulated in the skin lesions of vitiligo, and its 3’-UTR region had an miR-211 binding site, further verifying that RRM2 could be used as an effective marker of vitiligo.In non-neoplastic diseases, researchers have also actively explored RRM2. Studies have shown that fibroblast-like synoviocytes (FLS) promote the development of RA through the production of proteases. When RRM2 containing small interfering RNA was sent to RA-FLS, they found that the level of apoptosis increased and the production of cell proliferation and proinflammatory factors decreased, indicating that silencing RRM2 improved the therapeutic effect of RA.However, there are still some limitations to this study. First of all, sample size we used is small, and the results may have limitations, so we verified them using another dataset. Secondly, this study is based on bioinformatics and obtains related disease-causing genes, then we will carry out experimental verification at the cellular and animal levels.This study briefly discussed the biological processes involved in CKS2 and RRM2. Some pathways and cellular activities overlap with the pathogenesis of vitiligo. Therefore, CKS2 and RRM2 could be used as potential markers for vitiligo.Feng Zhang conceived of and designed the experiments. Yu Miao, Dongqiang Su, Qian Fu, Taoyu Chen, and Yanqi Ji downloaded and analyzed the data. Yu Miao wrote the draft manuscript and all authors approved the manuscript for publication.Conceptualization: Feng Zhang.Data curation: Yu Miao, Dongqiang Su, Qian Fu, Taoyu Chen, Yanqi Ji.Formal analysis: Yu Miao, Dongqiang Su, Qian Fu, Taoyu Chen, Yanqi Ji.Funding acquisition: Feng Zhang.Validation: Yu Miao, Dongqiang Su, Qian Fu.Visualization: Yu Miao, Dongqiang Su, Qian Fu.Writing – original draft: Yu Miao, Feng Zhang.


Results: After eight weeks, exercise capacity increased significantly by 0.6 ± 0.77 MET (women) and by 1.0 ± 0.74 MET (men). The greatest benefit was observed in men, women under 55 years, women with LVEF 41–49%, and women with single-vessel CAD. An outpatient CR program appears less beneficial for women, especially those over 55 years, with two or three coronary vessels affected with atherosclerosis or with LVEF > 50%. In women with CAD, eight weeks of 45-min interval training, with sessions three times a week, is insufficient to improve exercise capacity to an extent that is considered a predictor of mortality risk reduction.This study evaluated the clinical outcomes of cardiac rehabilitation (CR) in women with coronary artery disease (CAD) in comparison to men. Methods: Patients after acute coronary syndrome or after revascularization procedures  were consecutively admitted to a comprehensive outpatient CR program, comprising of 45-min ergometer interval training three times a week for eight weeks. The training intensity was determined on the basis of training heart rate, calculated following an exercise test. Patients were divided into subgroups according to age , BMI (<25, ≥25 kg/m It is also associated with an improvement in quality of life and a reduction in mortality risk by up to 26% [Ischaemic heart disease (IHD) is the most common cause of death in the world . The devp to 26% ,4,5,6,7.p to 26% ,9,10,11.p to 26% ,13. The The study covered 286 patients, 106 female and 180 male, aged 31 to 85 years  after ACS, coronary artery bypass surgery (CABG), or percutaneous coronary interventions (PCI), who were prospectively and consecutively admitted to an outpatient comprehensive cardiac rehabilitation program for eight weeks. The mean time following PCI was 22.3 ± 9.1 days and CABG was 26.4 ± 8.5 days. The study was conducted in the Outpatient Rehabilitation Center of the Clinical University Hospital.All the patients enrolled to the study were treated with β-blockers, angiotensin converting enzyme inhibitors, or angiotensin receptor blockers, statins, and antiplatelet agents. All the examined patients had an optimal and stable pharmacological treatment. Any changes in pharmacotherapy during the rehabilitation program resulted in exclusion from the study. The statistical analysis included only patients who completed the entire eight-week program of CR.Three times a week for 45 min, the patients participated in interval trainings on cycle ergometers . Patients’ electrocardiographic values and blood pressure were continuously monitored during the training sessions. In the first part of the training session, the workloads were increasing, while in the second part they were decreasing, alternating a four-minute workload with two minutes of active restitution. The peak exercise intensity was determined on the basis of training heart rates (THR) and assessed according to the heart rate reserve (HRR), which was individually calculated as the difference between the resting HR and the highest heart rate achieved during the exercise test . The forThe training intensity was adjusted so that the patient’s heart rate achieved, but not exceeded, the calculated training heart rate and it ranged from 12 to 14 points on the Borg scale . In addiAt the beginning and after eight weeks of cardiac rehabilitation, all the participants underwent a physical examination, an exercise test, and fasting blood tests.2 (kg/m2). All the participants underwent an electrocardiogram at rest in the supine position and a physical examination including blood pressure (BP) measurements.Body weight rounded to the nearest 50 g and body height rounded to the nearest millimeter were determined with standard anthropometric methods: using a digital, medical scale (Radwag WPT 100/200) and a stadiometer , respectively. Waist circumference, with an accuracy of 10 mm, was measured at the midpoint between the iliac crest and the lowest rib. Body mass index (BMI) was calculated as weight/heightEach subject underwent a multistage, symptom-limited exercise test on the cycle ergometer Ergoselect II 100/200 with continuous 12-lead electrocardiographic monitoring using a Cardiovit CS-200 Ergo Spiro; Schiller, Switzerland. The exercise test began at 60 Watt, and the workload was gradually increased by 30 Watt every three minutes until exhaustion. When the exercise phase was completed, the participants were monitored for five minutes or longer, if necessary. The criteria for terminating the exercise tests included: clinical symptoms such as chest pain, breathing difficulties, dizziness or headache, abnormal ECG results, blood pressure values above 250/115 mmHg, or exhaustion .The rate pressure product (RPP) was calculated as heart rate (HR) x systolic BP. The resting RPP was calculated from resting values, while the RPP peak was based on the highest values obtained during the exercise test. The peak workload (Wpeak), expressed in Watt, was defined as the highest workload during exercise test. The patients’ exercise capacity was also expressed as the highest value in METs reached during exercise test. Also, at the last stage of the exercise test, the rating of perceived exertion was assessed according to the 20-point Borg scale .The serum glucose concentration, total cholesterol, triglycerides and high-density lipoprotein cholesterol (HDLc), and low-density lipoprotein cholesterol (LDLc) were assessed using the enzymatic calorimetric method with Cormay reagents.After the 8 weeks of the rehabilitation program, the M mode and two-dimensional echocardiography with Doppler technique using VIVID7  was performed by the same researcher. Data were obtained at rest using a 3.5-MHz linear transducer. The measurements were taken and analyzed according to the guidelines of the American Society of Echocardiography . In orde2), LVEF  [The data from echocardiography performed after eight weeks of cardiac rehabilitation were compared to the results of echocardiographic examination performed during the hospitalization that was connected with ACS, PCI, or CABG (which was an indication for CR). To assess whether all patients benefited from cardiac rehabilitation equally, they were divided into subgroups according to age , BMI . The study participants were not significantly different in terms of clinical history, cardiovascular risk factors, or frequency of coexisting diseases. Women more commonly had a single-vessel form of CAD, whereas a three-vessel CAD was more commonly found among men; these differences were statistically significant .Women admitted for the rehabilitation program had a higher value of LVEF, less frequent segmental systolic left ventricular dysfunction, left ventricular hypertrophy, and left ventricular enlargement in comparison to the group of men at the beginning of CR .The glucose serum concentrations and triglycerides were similar in groups of women and men, while the total cholesterol, LDL cholesterol, and HDL cholesterol were statistically significantly higher in women than in men at the beginning of CR program. Apart from the increase in triglycerides in the male group, none of the parameters changed within eight weeks of CR .Post-CR BMI was significantly higher in male patients when compared to their pre-CR BMI, while BMI in the female group remained unchanged. Waist circumference did not change in both examined groups after eight weeks of CR .Among hemodynamic parameters at rest, only resting heart rate in the female group did not significantly change after 8 weeks of CR. Resting heart rate among male patients and resting systolic and diastolic arterial blood pressure were significantly decreased in both groups after eight weeks of CR compared to the baseline measurements.Exercise capacity expressed in MET also improved significantly after 8 weeks of CR in both examined groups. The increase in exercise capacity by 0.6 ± 0.77 MET, (the median 0.0 MET) was observed in the female group, while in the male group, the mean increase in exercise capacity was 1.0 ± 0.74 MET, (the median 1.1 Met) .LVEF significantly improved and segmental systolic left ventricular dysfunction decreased after 8 weeks of CR in both examined groups. The other echocardiographic parameters remained unchanged .The results of the statistical analysis of changes in exercise capacity in the created subgroups according to age, BMI, LVEF, and the number of coronary vessels affected with atherosclerosis are presented in Only nine women under the age of 55 years participated in the study. There were significantly more men than women in this age group. The increase of exercise capacity was more pronounced in women under 55 years of age (by 1.03 MET) in comparison to women older than 55 years (by 0.03 MET). In the group of men, regardless of age, the improvement in exercise capacity was similar (by 1.17 and 1.12 MET respectively) .2 and ≥25 kg/m2, was slight, but still significant, . Greater improvement was shown in both men subgroups compared to women   .There were only seven women with reduced left ventricular ejection fraction (LVEF ≤ 40%), and the exercise capacity did not change after CR in this group. A significant increase of exercise capacity by 1.23 MET was recorded only in women with LVEF 41–49%, while in woman with LVEF≥ 50%, exercise capacity increased by 0.02 MET. In all three male subgroups, exercise capacity increased similarly from 1.1–1.17 MET .In the female subgroups the exercise capacity was found to have risen by 0.97 MET only in group with single-vessel CAD. A slight but significant increase was observed in women with two-vessel CAD and no statistical change in exercise capacity was seen in women with three-vessel disease. In the male subgroups, a significant increase in exercise capacity from 1.1–1.15 MET was identified, regardless of the number of coronary vessels involved .According to guidelines, regardless of gender, CR is a class I level A recommendation for patients after myocardial infarction, CABG, or PCI, and rehabilitation should be based on aerobic exercise training of moderate to high intensity for a minimum of 30 min at least 3 times a week ,5,6,7. TMany studies have shown that exercise capacity is a stronger predictor of mortality risk than traditional risk factors such as smoking, hypertension, hyperlipidemia, obesity, and type 2 diabetes. Moreover, exercise capacity is considered to be a more powerful predictor of risk than other exercise test variables, such as ST segment depression, exercise-related symptoms, and hemodynamic responses ,18. AccoIn our study, significantly more men than women participated in the CR program. Many studies showed that women are less likely to be referred and to participate in CR for various reasons, leading to higher mortality rates among women who are not referred to CR ,10,11,29p = 0.00052). There were fewer women than men in the under 55 age group. This may be due to the fact that in the premenopausal period, secreted estrogens reduce the risk of coronary heart disease [Moreover, our study involved women who were significantly older than men . BMI had no influence on the changes of exercise capacity in women. Previously published studies also showed no impact of BMI on the increase in exercise capacity after CR, regardless of gender .An increase in exercise capacity by more than 1 MET was observed only in women with LVEF 41–49% (median of increase was 1.23 MET) and by 0.97 MET in women with single-vessel CAD. In women with LVEF≥ 50%, and in women with two-vessels CAD, the increase of exercise capacity was slight ; in women with three-vessels CAD, the changes in exercise capacity were not significant. In previously published studies, left ventricular dysfunction has been found to be associated with an increased exercise capacity connected with a CR program ,40,41. TCR appears less beneficial for women over 55 years of age, with LVEF >50%, and with two or three coronary vessels affected with atherosclerosis.Eight weeks of aerobic training in a CR program might not have been sufficiently long to induce adequate changes in exercise capacity in the group of women with CAD because the origin of ischemia in the heart muscle is different in women than in men ,11. A loPrograms of cardiac rehabilitation vary around the world. Some cardiac rehabilitation programs have been shown to be ineffective in improving cardiovascular risk factors, morbidity, and mortality in patients with cardiovascular diseases. It seems that in order to obtain an improvement, women, especially those over 55 years of age, with LVEF ≥50% or two or three coronary vessels affected with atherosclerosis, should undergo cardiac rehabilitation based on physical training for a longer period of time, and exercise should be performed in a larger volume. Eight weeks of the 45-min training program completed three times a week improved blood pressure at rest, LVEF, and exercise capacity; however, it was not enough to improve exercise capacity by 1 MET or more in women with CAD. A larger volume of training might be more effective in achieving better outcomes of cardiac rehabilitation. The time spend on training should be at least 150 min per week, optimally about 300 min per week [The novel aspect of the present study is the comparison of the impact that physical training has on exercise capacity in women in comparison to men with regard to age, BMI, LVEF, and according to the number of coronary vessels affected with atherosclerosis. The limitation of our study is the lack of a matched control group. Unfortunately, it was not possible to create the control group because it would not be ethical to refuse CR to any patient with indications, and those who refuse to participate in the rehabilitation program are reluctant to attend control visits. We realize that our study is purely observational.An outpatient CR program based on regular aerobic interval training appears less beneficial for women, especially those over 55 years of age, with two or three coronary vessels affected with atherosclerosis, or with LVEF over 50%. In women with CAD, eight weeks of 45-min interval training, with sessions three times a week, is insufficient to improve exercise capacity to an extent that is considered a predictor of mortality risk reduction.