To assess the reliability of phase-sensitive inversion recovery (PSIR)magnetic resonance imaging (MRI) and its accuracy for determining thetopography of demyelinating cortical lesions in patients with multiplesclerosis (MS).This was a cross-sectional study conducted at a tertiary referral center forMS and other demyelinating disorders. We assessed the agreement among threeraters for the detection and topographic classification of cortical lesionson fluid-attenuated inversion recovery (FLAIR) and PSIR sequences inpatients with MS.FR) coefficient of 0.60, whereas the meanκFR for the topographic reclassification of thelesions was 0.57. On PSIR sequences, the raters reclassified 366 lesions(20% of the lesions detected on FLAIR sequences), with excellent interrateragreement. There was a significant correlation between the total number oflesions detected on PSIR sequences and the Expanded Disability Status Scalescore .We recruited 71 patients with MS. The PSIR sequences detected 50% morelesions than did the FLAIR sequences. For detecting cortical lesions, thelevel of interrater agreement was satisfactory, with a mean free-responsekappa (κIt seems that PSIR sequences perform better than do FLAIR sequences, withclinically satisfactory interrater agreement, for the detection andtopographic classification of cortical lesions. In our sample of patientswith MS, the PSIR MRI findings were significantly associated with thedisability status, which could influence decisions regarding the treatmentof such patients. Although theetiology of MS is unknown, the interaction between genetic and environmental factorsprobably plays a relevant role in its onset,2. In terms of theetiopathogenesis, autoreactive inflammatory cells cross the blood-brain barrier andinduce CNS damage, leading to the formation of demyelinating lesions-4.Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating degenerativedisease of the central nervous system (CNS) and has a markedly heterogeneousclinical course-9. Accurateassessment of gray matter damage has contributed significantly to the interpretationof the association that cortical lesions have with clinical and cognitive outcomesin MS,9. Depending on their location, cortical lesions can beclassified as leukocortical (type I), intracortical (type II), or subpial(subdivided into types III and IV). These diverse topographies suggest that theonset and growth of cortical lesions occur through various mechanisms, and theirdistinct locations probably account for the heterogeneous course of MS,4,9,10. Type I cortical lesions can be confused withjuxtacortical lesions, which are quite common, being found in 50% of patients withMS in autopsy studies,11.Historically, MS was considered as a disease of the white matter. However, variousmagnetic resonance imaging (MRI) studies of patients with MS have consistently shownthat demyelinating lesions are common in the gray matter of cortical and deep brainstructures of such patients and can be extensive,13. The standard MRI protocol for MSincludes volumetric fluid-attenuated inversion recovery (FLAIR), T1-weighted,gadolinium contrast-enhanced T1-weighted, and T2-weighted sequences. Thoseconventional sequences present low sensitivity for the detection of corticallesions, even if the images are acquired in high-power scanners. In contrast,non-conventional pulse sequences, such as those based on phase-sensitive inversionrecovery (PSIR) or double inversion recovery (DIR), substantially improve thesensitivity for the detection of cortical lesions,8.For the diagnosis and follow-up of patients with MS, it is essential to perform MRIexamination of the CNS. That examination can provide information regarding theactivity and progression of the disease, which are used as criteria for treatmentfailure, as well as being useful in screening for complications of MStreatment-16. Lesions identified as fullylocalized in gray matter on other sequences, such as FLAIR and DIR sequences, mightin fact be juxtacortical lesions or be totally located in the white matter. Theintrinsically low signal-to-noise ratio of DIR sequences, which are widely used inthe detection of cortical lesions, does not allow increases in resolution beyondthat achieved during the long periods required for the acquisition of clinicallyacceptable scans. In contrast, PSIR sequences can provide higher image resolutionwithin shorter, clinically feasible periods, the typical scan time beingapproximately 11 min,16. Some studies have demonstratedthat PSIR sequences have higher accuracy than do FLAIR sequences and are 3-4 timesmore sensitive than are DIR sequences for the detection of corticallesions,16,17. Inaddition, the PSIR findings have been shown to correlate significantly with physicaland cognitive function in patients with MS; therefore, given the clinical relevanceof cortical damage in MS, the PSIR findings could have important diagnostic andprognostic implications,18.A PSIR sequence is T1-weighted and presents a marked contrast between white and graymatter. It has a higher signal-to-noise ratio than does a DIR sequence, with fasteracquisition times, resulting in images with higher resolution. On a PSIR sequence,the distinct boundary between the cortical strip and adjacent white matter providesa more accurate differentiation between cortical lesions, juxtacortical lesions, andwhite matter lesions. This newparameter made it crucial to assess the accuracy of recently developed MRI sequencesused in order to detect these lesions. Therefore, we assessed the performance ofPSIR sequences and their accuracy for determining the topography of demyelinatingcortical lesions in patients with MS.The most recent revision of the diagnostic criteria for MS incorporated the presenceof cortical lesions as a discriminating criterion for the spatial dissemination ofthe disease and in the Guidelines for Reporting Reliabilityand Agreement Studies. Thestudy was approved by the local research ethics committee, and all participatingpatients gave written informed consent.This was a cross-sectional study of consecutive patients with MS who underwent MRI ofthe CNS within a 12-month period, based on the recommendations put forth in theStandards for Reporting of Diagnostic Accuracy Studies,15,17. Two neuroradiology interns, each with one year ofexperience, designated rater 1 and rater 2, respectively, evaluated images obtainedfrom the picture archiving and communication system, and their findings werecompared with those of a senior rater with 14 years of experience (six dedicated topatients with MS), designated rater 3, who evaluated the same images.The MRI sequences were acquired in a 3.0-T scanner , with a 32-channel head/neck coil. The image acquisition protocolconsisted of the following: unenhanced T1-weighted turbo spin-echo, 3D T1-weightedgradient-echo, and 3D FLAIR sampling perfection with application-optimized contrastsusing different flip angle evolution sequences, all in the sagittal plane;T2-weighted turbo spin-echo and diffusion-weighted echo-planar imaging sequences,both in the axial plane; intravenous infusion of gadolinium-based contrast, with dosing according topatient body weight; and acquisition of contrast-enhanced axialsusceptibility-weighted imaging and sagittal 3D T1-weighted gradient-echo sequences,together with axial T1-weighted fast spin-echo magnetization transfer contrast andaxial PSIR sequences. The main sequences of interest were 3D FLAIR and PSIR. Thefollowing parameters were used for 3D FLAIR: field of view, 260 mm; repetitiontime/echo time, 5,000/395 ms; matrix, 256 × 256; voxel size, 0.5 × 0.4× 1.0 mm; and acquisition time, 5 min 15 s. The parameters used for PSIR werefield of view, 220 mm; repetition time/echo time, 2,600/10 ms; matrix, 195 ×320; voxel size, 0.4 × 0.4 × 3.0 mm; and acquisition time, 3 min 47 s.Cortical lesions were identified on the basis of recommendations in theliteratureThe Expanded Disability Status Scale (EDSS) score, duration of disease, MS phenotype,sex, and age were extracted from patient electronic medical records. All of theraters were blinded to the patient clinical data and to the findings of their peers.Each rater identified and counted the juxtacortical and cortical lesions in thesupratentorial and infratentorial regions, first on the FLAIR sequences and then onthe PSIR sequences, which were considered the standard sequences to define thetopographic classification of the cortical lesions.The findings of each rater are presented as the means and standard deviations(SDs) of the lesion counts. After applying the Shapiro-Wilk test to verify thedistribution of the variables, we estimated the correlation coefficients for theassociations that the numbers of juxtacortical and cortical lesions had with theEDSS score, duration of disease, and patient age.FR) statistic. That was chosen because the traditionalassessment of interrater agreement can be misleading in situations in which onlypositive findings are computed, such as in imaging examinations. In suchexaminations, the lack of a specific number for negative observations (absenceof lesions) limits the use of the classical kappa statistic. In many cases, theimages must cover extensive areas of bulky organs. In addition, multipleabnormalities, such as MS plaques, make the measurement of agreement impracticalor biased by a free-response paradigm, leading to underestimation of kappacoefficients. Withthe κFR statistic, the agreement does not depend onunknown/negative data and can be estimated from positive results alone, which isparticularly useful in imaging studies. The classification of the κFRfollows the standard Fleiss ratings employed for the kappacoefficient,categorizing agreement as poor (< 0.40), satisfactory (0.40 <κFR < 0.75), or excellent (> 0.75). Intraclasscorrelation coefficients (ICCs), with two-way random effects for agreementbetween raters, which is appropriate for examiners with different levels ofexperience,25, were calculated for thetotal lesion counts on FLAIR and PSIR sequences, as well as for thereclassification of cortical lesions .To calculate the agreement between the findings of the two inexperienced ratersand those of rater 3, for the presence of lesions, their localization, andtopographic classification, we used the free-response kappa. To exclude a proportionbias, we performed regression analysis of the differences between the methods.On the basis of data in the literature, we established a prioria limit of seven lesions as a clinically relevant and acceptable differencebetween the sequences-29. The sample size wascalculated in order to provide clinically satisfactory coefficients ofagreement, at a significance level of p < 0.05 and a powerof 0.80. For the correlation analysis, Spearman’s rho (ρ) was calculated.The statistical analysis was performed using the Stata software, version 14.0.The concordance between FLAIR and PSIR images for the same rater (intrarateragreement) was assessed with a Bland-Altman plot, which represents therepeatability between different methods, analyzing the averages of thedifferences in the number of lesions found by one rater. To be clinicallyacceptable, 95% of the differences between the methods must remain within arange of the mean of the differences ± 1.96 SD, which would indicate thepotential for interchangeability between the methodsThe sample comprised 71 patients, all with the relapsing-remitting MS phenotype. Themean age was 47.3 ± 11.7 years. Among the 71 patients evaluated, 47 (62%)were female, the mean score on the EDSS was 2.4 ± 1.8, and the mean durationof disease was 12.9 ± 7.1 years. The raters detected 1,796 lesions on theFLAIR sequences (mean of 8.4 lesions/patient/rater), all of which were alsovisualized on the PSIR sequences . Onthe vs. 43.6 ± 11.8 years; p = 0.47) orthe mean of duration of disease . However, the mean EDSS score was 40%lower in the latter group (1.5 ± 0.9 vs. 2.5 ±1.8).There were 28 patients (39.4%) in whom no cortical lesions were detected on the FLAIRsequences. In 12 of those patients, the raters found cortical lesions on PSIR imagesthat were not apparent on FLAIR images. Therefore, the adjusted number oflesion-free individuals was 16 (22.5% of the sample). There was no significantdifference between the patients without cortical lesions on FLAIR images and thosewithout cortical lesions on PSIR images, in terms of mean age . For the reclassification of lesions, the meanagreement was 73.2%, with an κFR ranging from 0.56 to 0.58 .However, the total lesion count was not found to correlate significantly with any ofthe other variables assessed.The ICC demonstrated excellent interrater agreement for the number of lesionsreclassified and satisfactory agreement for the total lesion counts . Spearmap = 0.27), thus excluding a proportionbias in the differences between the FLAIR and PSIR sequences.As can be seen in the Bland-Altman plot , the mea,23,24. We found clinically satisfactorylevels of intrarater and interrater agreement for PSIR sequences, as well as showingthat PSIR MRI had better sensitivity for the detection of cortical and juxtacorticallesions (50% better than FLAIR MRI), with no loss of reliability, and for thetopographic reclassification of lesions.To our knowledge, this is the first study to assess the reliability of PSIR MRI amongraters with markedly different levels of experience, which rules out the influenceof training effects on the agreement coefficients-33. Therefore, MRIsequences that are more sensitive can help explain the variability in the course ofthe disease-33. Despite having incorporated the presence ofcortical lesions as a discriminating criterion for the spatial dissemination of MS,an expert panel concluded that conventional MRI sequences are incapable ofaccurately detecting and localizing cortical lesions and recommended the use ofadvanced sequences. Likewise,the current consensus guidelines issued by the Magnetic Resonance Imaging in MS(MAGNIMS) group suggest considering the number and location of cortical lesions as amarker of MS progression, as long as the rater has a high level of expertise in MRIanalysis. Therefore,the accurate detection of cortical lesions has gained greater relevance, given itsimpact on the diagnosis and prognosis of MS. Consequently, assessing the reliabilityof advanced MRI sequences has become essential, and the present study meets thatdemand.The heterogeneity of the course of MS seems to be multifactorial, and it is likelythat the topographic and volumetric characteristics of the demyelinating lesionscontribute to that heterogeneity,17.However, in those studies, the raters had more experience than did raters 1 and 2 inour study. Overall, the higher agreement coefficients in previous studies suggestthat training improves the rate of cortical lesion detection. However, our resultsindicate that a lack of training does not reduce the clinical efficacy of PSIRsequences.In our study, the raters detected higher numbers of lesions on PSIR images than onFLAIR images, with satisfactory interrater agreement for the detection andtopographic reclassification of the lesions. In our study, the interrater ICC wasmoderate for the total lesion count on PSIR sequences, which is in contrast with theexcellent agreement reported in some other studiesFR statistic showed only moderateinterrater agreement for lesion reclassification. One possible explanation for thisdiscrepancy is the difference in the size of the observed lesions. In the case ofsmall lesions, the exact topographic localization of cortical lesions can be achallenge for less experienced examiners. However, the size of the lesions does notseem so relevant for their counting. That might have also accounted for the factthat the ICC for the lesion counts was higher on FLAIR sequences than on PSIRsequences. Because larger lesions are easier to visualize, they are easier to count,leading to higher agreement coefficients. The fact that the FLAIR and PSIR sequencespresented good intrarater agreement and repeatability on the Bland-Altman plot, withmean differences close to zero, indicates a non-significant systematic bias betweenthe methods. The CIs and SDs of the mean differences in agreement remained at valueswithout clinical significance and within the parameters established apriori. The intrarater mean of differences ≤ 3.3 lesions  suggestedthe potential for interchangeability between the sequences.The ICC showed excellent interrater agreement for the total number of lesionsreclassified, whereas the κ,34-36. In our study,77.5% of the patients presented cortical lesions, which is higher than theproportions reported in studies that included patients in the early stages ofrelapsing-remitting MS or clinically isolated syndrome, all of which were around20%,37. In contrast, studies including patients withprogressive forms of MS showed higher proportions of patients with cortical lesions,ranging from 82% to 100%,13,15,16. These findingssuggest that the MS stage, which is directly associated with the EDSS score, as wellas being indirectly associated with the duration of disease and with patient age,correlates with an increased risk of cortical lesions. We detected a significantcorrelation between the number of lesions detected on PSIR sequences and the EDSSscores, which is in line with data in the literature. A previous study, conducted byNielsen et al., which usedadvanced 7.0-T MRI, found a significant association between cortical lesions and theEDSS score. A more recent study, conducted by Magliozzi et al., suggested that corticalpathology has a robust correlation with physical and cognitive disability in MS.These data should alert neuroradiologists to be aware of the clinical anddemographic features of individual patients and to look for red flags during an MRIanalysis.Cortical lesions constitute a common finding in MS, and the frequency of such lesionsin the present study was comparable to those reported in studies involving patientswith MS phenotypes similar to those identified in our sample,34,38,39. In the present study, thedetection of cortical lesions on PSIR sequences (lesions that were not detected onFLAIR sequences) decreased the number of lesion-free patients by 43%. Thisreclassification lead to a relevant 40% reduction in the mean EDSS score whencompared with the lesion-free group as determined on the FLAIR sequences. Thereclassification from negative to positive for cortical lesions can have asignificant influence on the prognosis of MS, given that the presence of corticallesions has been correlated with pronounced disease activity and predisposition toprogress to the advanced stages of the disease. Our results indicate that the use of PSIR MRI is crucialfor identifying patients with false-negative results for cortical lesions. Notably,20% of the lesions detected on FLAIR sequences were topographically reclassified onPSIR sequences, and > 90% of the reclassifications were from juxtacortical tocortical. Juxtacortical lesions can occur in natural aging and may or may not beassociated with progression of MS,11,13,40. Therefore, if the presence of cortical lesionsis considered a criterion for MS activity, their reclassification can influencedecisions regarding treatment. One concern of the MAGNIMS group is the need for ahigher level of expertise for the detection of cortical lesions in MRI analysis. Theclinically satisfactory agreement observed in the present study, even among raterswith limited experience, suggests that MRI protocols including PSIR sequences havean advantage over other MRI protocols, such as those including DIRsequences-18. Although the MAGNIMS grouprecommended using the presence of cortical lesions as a marker of MS progression,they emphasized the low sensitivity of traditional MRI sequences for the detectionof such lesions. However, our findings raise a question about using the emergence ofcortical lesions as a definition of MS progression. One concern is that standardizedadvanced MRI sequences for the accurate detection of cortical lesions are not alwaysavailable in some clinical settings.In various studies, the presence of cortical lesions has been shown to be a robustindependent predictor of the MS disability progressionOur study has some limitations. First, the fact that DIR sequences were not includedin the local MRI protocol impeded the comparison with some data in the literature.In addition, we did not assess the cognitive status of the patients, whichcorrelates significantly with cortical lesions in MS. However, we considered thatevaluation to be beyond the scope of our study, the main objective of which was toassess the reliability of PSIR MRI, although such evaluation could be valuable infuture studies of the validity of the PSIR protocol. Finally, the differencesbetween PSIR sequences without volumetric acquisition and volumetric FLAIRsequences, in terms of spatial resolution and slice thickness  should be taken into consideration. Those differences might even haveinfluenced the detection and reclassification of some lesions, possibly leading tolower agreement coefficients, in our patient sample.Cortical and juxtacortical lesions have taken on greater relevance after beingincorporated into the diagnostic criteria for MS. New, advanced MRI sequences, suchas PSIR, with a higher sensitivity to detect such lesions, have been gainingimportance in investigative protocols, which creates the need to assess theiraccuracy in the clinical context. Our results indicate that PSIR sequences performbetter in the detection and topographic localization of cortical lesions than doconventional MRI sequences, such as FLAIR sequences. In addition, our data show thatthe detection of cortical lesions by PSIR MRI affects the EDSS scores, which couldinfluence decisions regarding the treatment of MS. Future prospective studies aimedat determining whether and to what extent the findings on PSIR MRI correlate withphysical and cognitive function over time in patients with MS could consolidatesupport for its incorporation into the routine MRI protocol for such patients.


SlADH gene plays a key role in environmental stress response. However, limited studies exist regarding the tomato SlADH gene. In this study, we identified 35 SlADH genes in tomato by genome-wide identification. Among the 12 chromosomes of tomato, SlADH gene is distributed on 10 chromosomes, among which the 7th and 10th chromosomes have no family members, while the 11th chromosome has the most members with 8 family members. Members of this gene family are characterized by long coding sequences, few amino acids, and introns that make up a large proportion of the genetic structure of most members of this family. Moreover, the molecular weight of the proteins of the family members was similar, and the basic proteins were mostly, and the overall distribution was relatively close to neutral (pI = 7). This may indicate that proteins in this family have a more conserved function. In addition, a total of four classes of cis-acting elements were detected in all 35 SlADH promoter regions, most of which were associated with biotic and abiotic stresses. The results indicate that SlADH gene had a certain response to cold stress, salt stress, ABA treatment and PEG stress. This study provides a new candidate gene for improving tomato stress resistance.The  ADH gene family is a large family, mainly divided into three subfamilies: Short-chain dehydrogenase/Reductase (SDR) -ADH (containing about 250 amino acid residues), medium-chain dehydrogenase/reductase (MDR) -ADH (containing about 350 amino acid residues), and long-chain dehydrogenase/reductase (LDR) -ADH (600–750 amino acid residues or about 385–900 amino acid residues) , a part of the dehydrogenase superfamily, is a zinc-binding enzyme that catalyzes the mutual conversion between acetaldehyde and ethanol as a dimer, relying on the NAD(P) cofactor . It is aesidues) . In planubfamily . These eubfamily .ADH is ubiquitously present in both animals and plants, though it is more commonly known in the latter. Plants require respiration at all times to energize their physiological functions. However, when there’s insufficient oxygen for normal respiration, the aerobic process transitions to anaerobic respiration. Plants produce large amounts of alcohol during anaerobic respiration, and alcohol dehydrogenase (ADH) is a key enzyme in the ethanol fermentation pathway and subsequent adaptive anaerobic metabolism of plant tissues  and is a good molecular marker candidate for cold stress. When maize seedlings were exposed to low temperature stress, the activity of ADH was also found to increase. Conversely, in the ADH1-ADH2 double deletion mutant, membrane lipid peroxidation intensified, leading to pronounced cellular damage , 22°C/18°C (day/night) with a humidity of 60%/50% (day/night). The leaves were collected when tomato seedlings grew to the five-leave stage after treatment at 0, 6, 12, 24, and 48 h, respectively.For the cold stress treatment, the temperature of the chamber was set at 4°C. For the drought stress treatment, tomato plants were subjected to a 10% polyethylene glycol (PEG) solution. For the salinity stress treatment, tomato plants were subjected to a 200 mM NaCl solution. For the ABA treatment, a 0.1 mM ABA solution was evenly sprayed on the surface of tomato seedlings until droplets began to form at the edges of the leaves.https://phytozome.jgi.doe.gov/pz/portal.html). The seed alignment files of the ADH domain (PF00107: ADH_zinc_N and PF08240: ADH_N) were downloaded from the Pfam (http://www.ebi.ac.uk/interpro/entry/pfam/#table) database. HMMER3 software was used to search the protein containing the ADH_N and ADH_zinc_N , containing the CDS (coding sequence) region, the UTR (untranslated region) region and the intron region.The MEME software was used to identify the conserved motifs among tomato et value , the lenSlADH genes were obtained from the genome sequence (version: SL4.0) by perl script. Meanwhile, PlantCARE (https://bioinformatics.psb.ugent.be/webtools/plantcare/html/) database was used to predict the cis-elements of the promoter regions of SlADH genes, and a Python script was used to stat the cis-elements data, a heatmap was used to show the distribution of cis-elements.The 1.5 kb upstream sequence of SlADH genes in tomato.The gene duplication events were analyzed by the One step MCScanX model of Comparative Genomics function of TBtools, and the Advanced Circos model was used to show the duplication events of A. thaliana, Solanum tuberosum and Zea mays were downloaded from Phytozome database, then the OneStepMCScanX model of TBtools was used to analyze the synteny relationship of orthologous ADH genes between the tomato and A. thaliana, S. tuberosum, Z. mays.In addition, the genome sequence file and the genome annotation file of SlADH gene expression.The transcriptome raw data with accession: PRJNA634438 was downloaded from the NCBI database, containing drought stress treatment and heat stress treatment were used in this study. The fastp (v0.23.3) software was used to filter the RNA-seq data , the hisSlADH family members to stress. Primer5 . Statistical analysis was carried out with one-way analysis of variance (ANOVA) in SPSS software . For all comparisons, SlADH genes were identified in tomato genome (SlADH17) to 14,237 bp (SlADH8). Only two of the SlADH genes had genome lengths less than 2,000 bp . The number of amino acids varies from 179 (SlADH17) to 511 (SlADH34), but most members have between 300 and 400 amino acids, except for SlADH17, SlADH15, and SlADH34. The genome length of SlADH family members is generally large, but the corresponding number of encoded amino acids is not particularly large, indicating that introns account for a large proportion of the genetic structure of the gene family. The molecular weight of SlADH protein ranges from 19.16 kDa (SlADH17) to 56.49 kDa (SlADH34), and the theoretical pI ranges from 6.01 (SlADH30) to 9.84 (SlADH8). Furthermore, out of the total, 21 SlADH proteins are anticipated to be alkaline (with a pI > 7.0), while 15 are predicted to be acidic (pI < 7.0).A total of 35 o genome . The SlASlADH genes were identified on 12 tomato chromosomes, and their distribution on the chromosomes was uneven. All chromosomes, except for the 7th and 10th, contain the SlADH gene, as depicted in SlADH family members are mainly distributed on chromosomes 4 and 11. Chromosome 11 contains the most SlADH family members, 8 in total, and the positions of these members on chromosome 11 are very close to each end. In general, the distribution of members of this family on chromosomes is found that most members of this family are distributed at both ends of chromosomes, only three members exist in the middle of chromosomes 2 and 6.A total of 35 SlADH gene superfamily, the sequences of a set of ADH family members from other plant species, including Solanum lycopersicum (Sl), Triticum urartu (Tu), Setaria italica (Si), Cucumis sativus (Cs), Vitis vinifera (Vv), Rosa chinensis (Rc), Prunus armeniaca (Pa), Prunus mume (Pm), and A. thaliana (At), were analyzed using a Neighbor-joining (NJ) phylogenetic tree. As shown in ADHs into three clades: short-chain ADHs, medium-chain ADHs and long-chain ADHs. Among the 35 SlADH family members of tomato, most belong to the medium-chain ADH branch (26 members), while the short-chain ADH branch contains the least SlADH family members, only two. It is not difficult to see from the evolutionary relationship that members of the SlADH family are closer to A. thaliana than other species, but far from masson pine, rose and other woody plants, so they contain the least members in the short-chain ADH branch.In order to understand the possible functional differences among individual members of tomato SlADH genes, all members contain introns. In addition, all except SlADH17 and SlADH27 contain UTRs , which reflected the functional specificity and diversity of the members of this family.Analyzing gene duplication is pivotal, as it often unravels insights into evolutionary processes and the functional diversification or redundancy of genes, potentially driving the adaptability and evolution of the species. Duplication events among analyzed . There wSlADH gene, we selected the 1,500 bp sequence upstream of the SlADH gene and submitted it to the PlantCARE database for promoter cis-element analysis , 11 SlADH genes responded to cold stress, 11 SlADH genes responded to drought stress(except SlADH20), and 12 SlADH genes responded to ABA treatment. Among them, SlADH6, SlADH26, SlADH24, SlADH32, SlADH12, SlADH9, and SlADH5 all responded to the four kinds of stress. Except for SlADH12, which showed no obvious trend, the expression levels of the other genes all showed a trend of gradual increase after stress. In addition, SlADH15 showed obvious response to cold stress, drought stress and ABA treatment except salt stress, and the expression level decreased gradually after a significant increase. However, SlADH20 was only responsive to salt stress, showing a trend of first increasing and then decreasing. SlADH16 and SlADH8 showed a good response to drought stress and ABA treatment, but no significant response to the other two stresses. These results suggest that the SlADH family members are responsive to a majority of stresses or treatments, underscoring their potential significance in plant reactions to diverse abiotic challenges. Concurrently, individual family members exhibit varied response patterns to distinct stresses, highlighting the functional diversity and specificity of these genes.Subsequently, tomato plants were treated with salt stress (NaCl), cold stress, drought stress (PEG) and ABA treatment, and a total of 16 genes from different subbranches of the phylogenetic tree were selected for response analysis . All 16 In recent years, extreme weather has occurred frequently around the world. Drought, waterlogging, salinity and freezing damage are all environmental factors that threaten plant growth. Adverse environmental conditions have a negative impact on agricultural production and reduce both the qualitative and quantitative yields of crops. Climate change is expected to pose serious challenges to agricultural production worldwide by causing rising temperatures and water shortages. Exploring the molecular responses of plants to abiotic stresses and using this knowledge to develop crop plants that can adapt to these adverse environmental conditions and maintain high yields under these adverse environmental conditions has been a major goal of molecular breeders . DespiteADH genes, and this work has greatly increased our understanding of plant responses to stress in many species. Many studies of ADH gene expression have linked it to both biotic and abiotic stresses. However, until now, the ADH gene family has not been reported in tomato, which has hindered the study on the function of tomato ADH gene to a certain extent. On this basis, we systematically analyzed the ADH gene family of tomato using bioinformatics. In this study, 35 ADH genes were identified from tomato, which had more ADH family members than maize (seven members) and grape (ten members)  among the 35 members, which indicated the functional diversity of the family members. In motif analysis, it is found that there are 10 motifs in this family, which are evenly distributed in different members of the family, forming a variety of different forms in the way of combination. We speculate that it is this relatively uniform combination distribution that causes the specificity and diversity among the members of this family, and they likely have more specific functions. The results of conserved motifs, gene characteristics and gene structure analysis of ADH family genes supported the classification results of phylogenetic analysis. We found that the signature of the ADH gene was similar within each subfamily and varied between different subfamilies.Over the past few decades, several studies have characterized members) . The memSlADH gene family, which were related to light response, phytohormone reponsive, stress response and plant growth and development. Among these elements, the types of elements related to phytohormone reponsive were the largest, but the total number of elements related to stress was the largest. Of these elements, MYC is the most numerous, with only three members without MYC element. MYC is one of the members of bHLH transcription factor superfamily, and MYC has been widely reported. MYC plays a very important role in plant growth and development, especially in stress resistance , cold stress, drought stress (PEG) and ABA treatment, and selected 16 SlADH family members for expression level detection. Through the above experiments, we once again verified that SlADH gene family has a certain degree of response to a variety of abiotic stresses, indicating that SlADH gene family members play a key role in the process of tomato abiotic stress. Studies have shown that there are three ADH genes in Pygmy cattle, and two of them are induced by hypoxia (ADHA of two ADH genes in cotton is induced by waterlogging (ADH gene family plays a vital role in plant resistance to waterlogging. Low temperature can cause lipid peroxidation of plant cell membrane, and even death of some plant cells sensitive to low temperature (ADH and PDC in rice seedlings, and enhance the ethanol fermentation pathway. Owing to its unique gene function, ADH not only holds significance in diverse biotic and abiotic stress responses but also assumes a pivotal role across various domains. ADH, a zinc-binding enzyme, is a key enzyme in the metabolic pathway of fatty acids, which can reversibly convert aldehydes into corresponding alcohols and may play an important role in the synthesis of volatile esters. So the gene also plays a crucial role in regulating fruit flavor. In ADH, not only the medium-chain ADH gene is associated with the production of aromatic volatiles (ADH may contribute to the biosynthesis of plant aroma (ADH genes are expressed in a developmentally regulated manner, especially during fruit ripening (LeADH2 is expressed in tomato fruits and its abundance increases during ripening, especially in late ripening (VvADH expression is noted during the late ripening phase of grapes (ADH6 and ADH7. The augmented transcriptional accumulation of ADH6 in ripe Nanguo Pear fruit correlates with heightened ADH activity, akin to the scenario with VvADH1 in grape (ADH, ADH activity and hexyl ester synthesis in Dangshansu pear and Nanguo pear fruits are related to the transcription of ADH6, indicating that ADH plays a decisive role in the volatiles of pear fruits (ADH gene, this paper reveals the important role of ADH gene on tomato stress resistance and fruit quality to some extent. It can provide a strong reference for further exploration of its function.Subsequently, we analyzed the expression level of tomato  hypoxia . Similarrlogging , indicatperature . Noguchiolatiles , the shont aroma . Other sripening . LeADH2 ripening . Similarf grapes . A similin grape . Qin et r fruits . Both stSlADH gene family members in tomato for the first time. Bioinformatics analysis and qRT-PCR analysis under abiotic stress revealed that tomato SlADH gene family members may play an important role in tomato growth and development and stress resistance. This investigation underscores the pivotal significance of the SlADH gene in tomato and establishes a foundational platform for subsequent inquiries into the broader role of the SlADH gene family in tomato breeding and augmenting resistance.In conclusion, this study identified


The utilization of biochar, derived from agricultural waste, has garnered attention as a valuable material for enhancing soil properties and serving as a substitute adsorbent for the elimination of hazardous heavy metals and organic contaminants from wastewater. In the present investigation, amide-modified biochar was synthesized via low-temperature pyrolysis of rice husk and was harnessed for the removal of Cr(VI) from wastewater. The resultant biochar was treated with 1-[3-(trimethoxysilyl) propyl] urea to incorporate an amide group. The amide-modified biochar was characterized by employing Fourier transform infrared (FTIR) spectroscopy, scanning electron microscopy (SEM), and X-ray diffraction (XRD) techniques. During batch experiments, the effect of various parameters, such as adsorbent dosage, metal concentration, time duration, and pH, on Cr(VI) removal was investigated. The optimal conditions for achieving maximum adsorption of Cr(VI) were observed at a pH 2, an adsorbent time of 60 min, an adsorbent dosage of 2 g/L, and a metal concentration of 100 mg/L. The percent removal efficiency of 97% was recorded for the removal of Cr(VI) under optimal conditions using amide-modified biochar. Freundlich, Langmuir, and Temkin isotherm models were utilized to calculate the adsorption data and determine the optimal fitting model. It was found that the adsorption data fitted well with the Langmuir isotherm model. A kinetics study revealed that the Cr(VI) adsorption onto ABC followed a pseudo-second-order kinetic model. The findings of this study indicate that amide-functionalized biochar has the potential to serve as an economically viable substitute adsorbent for the efficient removal of Cr(VI) from wastewater. With the increasing human population and industrialization of heavy metals (HM), pollution poses a serious threat to human and aquatic environments. Numerous industries, including fertilizer, tanneries, battery manufacturers, paper production plants, and pesticide manufacturing operations, release hazardous materials into the environment. Owing to the non-biodegradable nature of heavy metals, they remain in soil and water for a longer time, accumulate in the food chain, and thus enter human bodies via metal-contaminated food, drinking water, and air . Some HM–1100 µgL–1 and 50 µgL–1, respectively. On the other hand, 500–270,000 µgL–1 Cr has been reported in industrial wastewater  urea, which served to introduce an amide group onto its surface. The amide-modified biochar was characterized by scanning electron microscopy (SEM), FTIR, XRD, and thermo gravimetric analysis (TGA). The amide-modified biochar was utilized for the adsorptive removal of chromium VI from wastewater. Batch experiments were conducted to investigate the influence of metal concentration, adsorbent dosage, contact time, and pH values on the adsorption of Cr(VI). The Freundlich, Langmuir, and Temkin isotherm models were utilized in the analysis of experimental results in order to determine the optimal fit for the adsorption process of Cr(VI) onto ABC. Several kinetic models were examined to comprehend the interaction mechanism between chromium (VI) and biochar. The biochar was regenerated and reused several times for chromium (VI) removal from wastewater, and a discernible decrease in adsorption efficacy was observed.−1 and 2870 cm−1 are characteristic of the stretching vibration of O-–H and C–H bonds in the cellulose of rice husk biomass. The peaks in the same range can be seen in −1 is attributed to the CH stretching vibration of all hydrocarbon constituents in a material. A small peak located at 1690 cm−1 in −1 in 2) groups. The peak at 1510 cm−1 observed was due to the asymmetrical stretching of carboxyl (–COO−) groups  urea (97%), ferric sulfate (97%), hydrogen peroxide (35%), and NaOH (>98%), were bought from Sigma–Aldrich, Schnelldorf, Germany. A standardized solution of chromium (VI) with a concentration of 1000 parts per million (ppm) was diluted to prepare solutions with concentrations of 100, 200, 300, 500, 600, 700, and 800 ppm. Wastewater samples were collected from Pakistan Steel Re-Rolling Mills, Hattar industrial area, Haripur, Pakistan.The rice husks were obtained from a local farm situated in Swat, Khyber Pakhtunkhwa, Pakistan. The rice husks were subjected to washing and cutting, followed by drying in an oven at 70 °C for 5 h. The dried rice husks were pyrolyzed in a tubing furnace for 3 h at a temperature of 400 °C. After three hours, the biochar was taken out of the furnace and kept in a desiccator at room temperature.Raw biochar (100 g) was put in a round bottom flask of 500 mL capacity, and 2 % HCl solution (300 mL) was added. The mixture was then heated at a temperature of 80 °C for a period of 3 h. After acid hydrolysis, biochar was strained using cotton bags, rinsed with deionized water until it achieved a neutral pH, and placed in an oven at 70 °C for 6 h. Then, 100 g of acid-hydrolyzed biochar was dispersed in a mixture of 0.2 mL of hydrogen peroxide, 2 mL of 1-[3-(trimethoxysilyl) propyl] urea, and 0.3 mL of acetic acid in a conical flask. The flask was then placed in a water bath for 3 h at a temperature of 80 °C. The contents were filtered, cleansed with deionized water, and subjected to oven drying at 70 °C for a duration of 5 h.The biochar’s composition was ascertained by means of elemental analysis through an Elemental Analyzer . The BELSORP-Max  was used to measure the surface area, pore volume, and pore size of ABC. The pore volume of ABC was measured from the quantity of nitrogen gas absorbed at a particular pressure. The surface morphology of the biochar was evaluated with the S-4200 FE-SEM instrument made by HITACHI, Tokyo, Japan. The Fourier transform infrared spectroscopy (FTIR) was utilized to examine the surface functional groups of biochar. The analysis was conducted using the TENSOR II machine from Bruker, Billerica, MA, USA. The concentration of Cr(VI) in the filtrate was determined by an atomic absorption spectrometer using a 240 FS atomic absorption spectrometer (Agilent), Santa Carla, CA, USA.The adsorption of chromium VI onto amide-modified biochar was checked in batch experiments. To find out the optimum values of parameters such as pH, adsorbent dose, adsorption time, metal concentration, and temperature on Cr(VI) adsorption onto amide-modified biochar, batch adsorption experiments were conducted. A stock solution of chromium (500 ppm) was prepared and diluted into different concentrations (100–500 ppm), and these diluted solutions were used for further experiments. Then, 200 mL of each solution was added into a flask of 500 mL capacity, 0.1 g adsorbent (ABC) was added into it, and the flask was shaken at 25 °C for one hour in a water bath. After 1 h, the content was filtered, and the concentration of hexavalent chromium in the filtrate was determined using an atomic absorption spectrometer , Waltham, MA, USA, equipped with a 10 cm air/acetylene burner and a chromium hollow cathode lamp. The lamp current was 12 mA, the wavelength was 357.9 nm, the fuel flow rate was 1.5 L/min, the bandpass was 0.7 nm, and the sample suction rate was L1.9 mL/min. The adsorption capacity and % removal of chromium was calculated using Equations (9) and (10), respectively.An investigation of the adsorption isotherm was conducted in order to elucidate the mechanism underlying the transfer of metal ions from the solution to the adsorbent. The impact of concentration (Ce) on the adsorption capacity (qe) under constant temperature was measured in batch adsorption experiments. The isotherm study was carried out keeping the optimum pH (2), adsorbent dose (3 g/L), and time (60 min), while the kinetics study was also performed under optimum conditions  while changing the adsorption time. The adsorption data were computed by Langmuir, Freundlich, and Temkin isotherm models to check the fitness of adsorption data with these isotherm models. The data computation and linear regression analysis were performed utilizing the Origin Pro-8 software. Furthermore, an investigation into the kinetics of adsorption was conducted with the aim of determining the rate of transfer of the adsorbate from the solution onto the surface of the adsorbent material, as well as the time that the adsorbate remained on the adsorbent surface. Several kinetics models, including the pseudo 1st order, pseudo 2nd order, and intra-particle diffusion model, were utilized to compute the adsorption data of Cr(VI) onto ABC.In order to assess the efficacy of multiple batches of ABC with regard to Cr(VI) adsorption, three separate batches were synthesized utilizing identical methods of preparation. The aforementioned batches were subsequently employed to adsorb Cr(VI) utilizing equivalent optimized conditions with respect to pH, dose, time, and concentration. The adsorption efficacy of every batch of ABC for Cr(VI) removal was computed, and the results of each batch were compared. The findings indicate that the adsorption efficiency exhibited similar values across all three batches. The relative standard deviation of adsorption capacity for three batches was noted to be 0.8%. A calibration curve was constructed for the Cr(VI) solution, and the blank samples were utilized to assess any potential errors in the measurement. Marquardt’s %RSD was employed as an indicator of error in formulating calculations for the adsorption capacity of Cr(VI), as specified in Equation (11).The recycling of adsorbents plays a significant role in influencing the economic viability of the adsorption process, as well as its associated operational costs . In ordeThe present study describes the utilization of rice husk for the preparation of amide-modified biochar through the process of low-temperature pyrolysis. This modified biochar was utilized for the removal of Cr(VI) ions from wastewater. This study involved the treatment of biochar derived from rice husk biomass with a dilute hydrochloric acid solution, followed by subsequent treatment with hydrogen peroxide for the purpose of activating and oxidizing the surface functional groups of the biochar. The biochar that was produced underwent characterization by using scanning electron microscopy and thermo gravimetric analysis. This study revealed that the amide-modified biochar exhibited a significant removal efficiency of 97% for Cr(VI). The exceptional adsorption capacity observed in amide-modified biochar can be attributed to their porous nature and the presence of surface functional groups incorporated through chemical modification. The findings concerning the adsorption of Cr(VI) onto CMB were assessed through the application of the Friundlich, Langmuir, and Temkin isotherm models. The findings indicate that the utilization of CMB as an adsorbent exhibits promising potential for the efficient removal of Cr(VI) and other heavy metals from wastewater owing to its high removal efficiency and cost-effectiveness. In the foreseeable future, amide-modified biochar is expected to serve as a valuable tool for the removal of various heavy metals and dyes present in wastewater in fixed bed columns. The amide-modified biochar will be checked for multi-step adsorption in future work. Detail mechanism of Cr(VI) adsorption onto ABC will also be discussed in our future work.


The use of transcutaneous electrical nerve stimulation (TENS) to relieve labor pain remains controversial and existing evidence is neither strong nor consistent. This research was designed to compare TENS' effect with the injection of pethidine and promethazine in labor pain reduction.In this trial, for 45 pregnant women in the active phase of labor, TENS electrodes were placed  continuously for 120 minutes; and for another group 45 pregnant women, 100 milligrams of pethidine and 250 micrograms of promethazine were injected intramuscularly which could be repeated once at least one hour later. Labor pain and duration, need for labor induction/augmentation/other pain control methods/ instrumental delivery, delivery type, and maternal and newborn complications were measured in both groups.The baseline mean visual analog scale (VAS) score, in the TENS group was 8.51±0.62 and in the pethidine and promethazine groups was 8.37±0.61 (P=0.31). While in a 120min post-intervention, it was 6.29±1.50 and 5.73±1.46 in the TENS group and the pethidine and promethazine group, respectively with no statistically significant difference (P=0.07). The labor duration in the TENS group was 6.61±1.71 hours and in the pethidine and promethazine group was 6.17±2.07 hours, with no statistically significant difference (P=0.33). In addition, no complication was recorded neither in the mothers nor newborns.This study showed that applying TENS in the active labor phase can reduce at least two scores in patient labor pain with no significant complications. Labor pain, is an unavoidable part of a normal vaginal delivery (NVD). Notably, women who experience high levels of pain during their NVD are at higher risk for subsequent complications such as vaginal and/or anal sphincter injuries, fetal tachycardia, and fetal blood sample abnormality , 2. ConsAlthough these methods are used widely, there are important concerns about their side effects. For instance, pregnant women who experienced EA are more susceptible to having long-lasting first and second labor stages, maternal hypotension, motor neuron block, fever, urinary retention, and needing augmentation or induction by oxytocin as well as increasing risk of instrumental delivery , 7.In contrast, evidence showed that non-pharmacological pain relief approaches could be safe, non-invasive, inexpensive, and easily applicable. Furthermore, these approaches decline analgesic agent prescription during labor and constantly their adverse effects -10. One As mentioned, the application of TENS to reduce labor pain still remains controversial and existing evidence is neither strong nor consistent. On the other hand, there is no guarantee of the full effectiveness of existing painless approaches, hence, evaluation and replacement of new interventions especially noninvasive and non-pharmacological strategies such as TENS seem needed. Hence, this research was designed to compare TENS' effect with the injection of pethidine and promethazine in labor pain reduction.The study was conducted in compliance with the Helsinki Declaration. It was confirmed by Tehran University of Medical Sciences Ethics Committee (IR.TUMS.MEDICINE.REC.1398.013) and the IRCT registry number was IRCT20190208042655N1. All the pregnant women signed the informed consent prior to enrolling in the study. This non-blinding randomized controlled study was performed on 90 pregnant women (45 in TENS intervention group and 45 in pethidine and promethazine intervention group) in Yas Hospital, Tehran, Iran, 2021. The study included term  pregnant women at age of 16 to 40 years, with singleton pregnancy, cephalic presentation, and spontaneous vaginal delivery. Pregnant women with preeclampsia, gestational diabetes mellitus managed with insulin, intrauterine growth restriction, meconium staining, and history of previous cesarean section or previous transmural myomectomy or uterus rupture were excluded.A random allocation rule was used to assign participants to the study intervention groups; TENS and pethidine and promethazine groups. The study was non-blinded because of the nature of the interventions.In the first group of intervention, at the active phase of labor , two pairs of TENS electrodes were placed on participants’ both arms, and two electrodes over the participants’ low back. A TENS system  was set at 15 milliampere and 300 volts, continuously for 120 minutes. In the second group of intervention, 100 milligrams of pethidine  and 250 micrograms of promethazine  were injected intramuscularly at active phase of labor, if the pregnant woman was not responding to the primary dose; the second dose was applied at least one hour later.All pregnant women received routine obstetric care. Labor pain was measured by visual analog scale (VAS), from 0 (no pain) to 10 (worst imaginable pain) at baseline and 120min post-intervention. The secondary study outcomes were labor duration, the need for labor induction and augmentation, the need for other pain control methods, the need for instrumental delivery, delivery type, maternal complications, fifth minute neonatal Apgar, umbilical arterial pH, and the need to neonatal intensive care unit (NICU) admission. All data were analyzed with SPSS Version 24.0. A p-value of less than 0.05 was considered as the level of statistical significance. For continuous variables, mean ± standard deviation and for qualitative variables, frequency and percentage were used. In addition, the chi-square test was used to assess the differences in proportion. We assessed a total number of 129 pregnant women, 25 of them were excluded from the study (20 women due to not meeting the inclusion criteria and 5 women declined to participate). Then, 52 women were randomly assigned into TENS intervention group and 52 women into pethidine and promethazine intervention group. During the study, 14 women (7 from each group) left the study due to different causes. Finally, the study analysis was done on 90 pregnant women . The basThis study has shown that the use of TENS at the first time of active phase can be reduced at least two scores of VAS in labor pain measuring. In similar, recent studies , 14, 16 Njogu et al. trial  showed t In addition, Santana et al.  study shIn conclusion, this study has shown that the application of TENS at the first time of active labor phase can reduce at least two scores in patient labor pain with no complication neither in the mothers nor newborns. Future researches are needed to assess the application of TENS generalized to the whole population and evaluate the most effective dose of it. The strength of this study was to compare TENS with current pharmacological pain relief methods, instead of the non-intervention group. This study had some limitations; first, we could not match the groups for probable confounding factor such as anatomical, physiological, cultural, social factors, and anxiety and depression levels that might influence women’s pain level. The others were the small sample size, single-centered, and non-blinded intervention.


IntroductionThere needs to be more evidence about the tobacco products utilized by individuals who smoke and the primary determinants contributing to the development of smoking behavior. Our study aimed to assess the prevalence and factors associated with using one or more tobacco products among employees from various ministries in Kuwait.MethodsA cross-sectional study was conducted among employees in different ministries in Kuwait from December 27, 2018, to January 3, 2019. A questionnaire about smoking status and socio-demographic variables was used. Resultsp= 0.009) more likely to use at least one tobacco product if their monthly income in Kuwaiti Dinars ranged from 501-1000 KD  or 1501-2000 KD  compared to those who had monthly income range 500 KD or less.There was a total of 1057 participants in this study. Of the participants, 26% (n=275) reported using at least one tobacco product. The proportion of smoking of at least one tobacco product was higher among men  than women . Among smokers, 1.5%, 5.9%, and 18.6% reportedly use only three, two, and one tobacco products, respectively. Of the study participants, 26% were smokers, 20.3% were exclusively cigarette smokers, and 21.8% reportedly started cigarette smoking at the age of 15 years or less. Male compared to female workers had higher odds of being smokers of at least one tobacco product . Participants were significantly (ConclusionThe male gender and high income of the participants were significant predictors of the use of at least one tobacco product. Anti-smoking campaigns, mass media interventions, and increasing tobacco product taxes may minimize this population's tobacco consumption. Tobacco is the most important avoidable risk factor for non-communicable diseases. Annually, almost 6 million people worldwide die because of diseases attributed to tobacco use, and this number is expected to increase to 7.5 million by 2020, accounting for 10% of all deaths. In 2015, smoking caused more than one in ten deaths worldwide, killing more than 6 million people with a global loss of nearly 150 million disability-adjusted life-years [Nicotine is an active ingredient of tobacco smoke, affecting multiple body organ systems. In the central nervous system, nicotine reaches the brain within a few seconds of inhalation and changes one's mood. Smoking increases the atrophy of the optic nerve, which impairs vision . In the In the Middle East and Africa, cigarette consumption increased by 57% between 1990 and 2009 . FurtherThere is limited evidence about the range of tobacco products adults use and the leading factors to smoking habit in the Middle East, including Kuwait use. Cigarettes, cigars, pipe, and shisha are some of the most common modalities used in indulging in tobacco products used in Kuwait, with more females 69%) smoking shisha compared to males (57%) % smoking. HoweverUnderstanding the current tobacco smoking burden, including the prevalence of smoking and tobacco consumption through different smoking modalities among adults in Kuwait, may provide scientific evidence for effectively controlling and preventing tobacco-related diseases. Therefore, this study sought to i) assess the prevalence of tobacco smoking and concurrent use of multiple tobacco products in public sector workers and ii) examine the factors associated with the smoking status in the study population. Ethical approvalHealth Sciences Center Ethics Committee approved the study protocol and instrument for Students' Research under the Institutional Review Board (IRB reference number: 4051/2018). As noted above, written informed consent was obtained from all the participants. The participants were assured about the complete confidentiality of their personal information and the anonymity of their responses. It was explained to them that their participation was voluntary and they could withdraw from the study at any point.Study design, setting, and participants A cross-sectional study was conducted among workers in different ministries of the State of Kuwait from December 27, 2018, to January 3, 2019. The sampling frame comprised individuals of either gender, 21 years old or older, and employed full-time in one of the selected ministries, including the Ministry of Commerce and Industry, Ministry of Defense, Ministry of Foreign Affairs, Ministry of Interior, Ministry of Education, and Ministry of Health.Questionnaire validity and reliabilityA self-administered questionnaire comprising 39 items was used to collect data Table . The iteMeasuresSocio-demographic variables: Questions on self-reported age, gender, nationality, and income were included. Instruments for Tobacco use: Questions to assess the consumption of different tobacco products, including smoking onset and the amount consumed daily. Questions to assess the shift between using different tobacco products were also included, e.g., "What is the order of your smoking habits since the beginning?".Comorbidities: Questions about self-reported or physician-diagnosed tobacco-related morbidities were also included.Sampling, sample size, and data collection The data were collected from December 27, 2018, to January 03, 2019. A proportionate random sampling technique was used to recruit participants in the study. There was a total of 15 ministries in Kuwait with over 160,000 employees. A systemic random sampling was used to choose eight ministries. The total number of employees in those chosen ministries was around 60,000 employees. In order to calculate the sample size, Slovin's formula was used n = N/(1 + N e2), where n = number of samples, N = Total population, and e = margin of error, (0.03), which resulted in an n = 1090. Four data collection teams, comprising two medical students (one with three members), were constituted to accomplish the fieldwork. Workers were approached during their break periods. The objectives of our study were explained to them, and they were invited to participate. Consenting workers were requested to fill out the questionnaire and sign the consent form attached at the front of the questionnaire. Completed questionnaires were checked immediately to spot any oversight by the workers.Data AnalysisDescriptive statistics, including proportions (%), means, standard deviations, medians, and interquartile ranges, were computed as required to examine the distribution study variables, i.e., demographics, smoking practices, and comorbidities. Chi-square analysis was used to test for the statistical significance (p≤ 0.05) of the association between smoking status and socio-demographics and comorbidities. Multivariate logistic regression analysis was also used to identify the variables independently and significantly (p< 0.05) related to smoking status. The estimated adjusted odd ratio (OR) and their 95% confidence interval (CI) were used to interpret the final multivariate logistic regression model. Data were managed and analyzed using the SPSS statistical analysis software (version 25).Description of the study sampleA total of 1057 workers from different ministries of Kuwait participated in the current study, of whom 523 (49.5%) were males, and 534 (50.5%) were females. Of the study participant, 827 (78.4%) were Kuwaiti, 224 (21.2%) were non-Kuwaiti Arab, and 4 (0.4%) were non-Kuwaiti non-Arabs. It was found that 374 (36.5%) participants were in the age range of 21-30, and 394 (38.4%) were 31-40 years old. On enquiring about the monthly income in Kuwaiti Dinars (KD), 471 (44.6%) participants were earning 500-1000 KD, 286 (27.1%) had 1000-1500 KD, 68 (6.4%) had 1501-2000 KD, and 36 (3.4%) ranged of 2001 KD or more. Study participants were enrolled from various ministries, which included Commerce and Industry , Defense , Finance , Foreign Affairs , Interior , Education , Health , and Communication   were smokers of at least one product. Among smokers, 16 (1.5%) were using three tobacco products, 62 (5.9%) used two tobacco products, and 197(18.6%) reportedly used only one tobacco product. Of the smokers, 214 (20.3%) were exclusively cigarette smokers, and 46 (21.8%) of them started at the age of 15 years or less. Regarding the daily dose of cigarette smoking, reportedly 81 (38%) smoked less than one pack, 94 (44.1%) smoked one pack, 33 (15.5%) smoked two packs, and 5 (2.3%) more than two packs. Of the smokers, 94 (8.9%) participants used shisha, and 74 (82.2%) started at 25 years or less. Of the smokers, 61 (5.8%) smoke e-cigarettes, and 40 (66.8%) of them start at 30 years or younger. The frequency of using shisha and e-cigarettes among the participants is shown in Table Order of tobacco product used at the onset of smokingFigure Chi-square analysis of the association between socio-demographics, comorbidities, and smoking statusThe socio-demographic variables that were significantly associated with smoking of at least one product included: gender (p< 0.001), nationality (p= 0.049), total monthly income in KD (p= 0.003), and ministry of employment (p< 0.001). Age, marital status, time of work, hours of work per week, description of work as stressful, disturbed by work, description of home as stressful, heart disease, high blood pressure, diabetes, obesity, upper respiratory tract infection, peptic ulcer disease, and sleep disturbances were not significantly associated with smoking of at least one product Table , 6.Multivariable binary logistic regression model of factors associated with the smoking practice of any productMale compared to female workers had statistically significantly (p< 0.001) higher odds of being a smoker of at least one tobacco product . Participants were significantly (p= 0.009) more likely to use at least one tobacco product if their monthly income ranged from 501-1000 KD  or 1501-2000 KD  compared to those who had monthly income range 500 KD or less. Compared to the workers of the Ministry of Commerce and Industry, the Ministry of Interior's workers had statistically significantly (p= 0.009) higher odds of being a smoker of at least one tobacco product  Table .Prevalence of tobacco smokingOur study assessed the prevalence and factors associated with the use of tobacco  in both genders, 21 years old or older, public-sector workers of eight of 14 ministries  of Kuwait.In our study, the prevalence of current smoking was higher among males (46.5%) than females (6.0%) - evidence of substantial increase over the previously reported corresponding figures of (34.4%) and 1.9%) among males and females, respectively, in Kuwait % among m.In our Multivariate logistic regressionA significant and independent association existed between males and using one or more tobacco products. These results agree with the findings of a previous study, which reported that males were more likely to use tobacco products in Kuwait .In addition, the high income of the participants was a strong and significant predictor of using one or more tobacco products. Thus, participants with higher incomes, presumably, are more willing to buy and indulge in using one or multiple tobacco products. This result is congruent with a previous study, which found that people with relaxed budgets are more flexible in spending on purchasing tobacco products compared to those with a low income . AccordiChanging in smoking behaviors/modalities The present study showed that smokers usually shift between different tobacco products. This change in smoking behavior may be due to trying to quit smoking  or only to change the taste . Either way will probably lead to acquiring the habit of using more than one tobacco product. Interestingly, one participant reported that he smokes e-cigarettes secretly during official working hours (indoors), cigarettes with tea and coffee, and shisha when gathering with friends. In the present study, most smokers (47.6%) began with cigarettes and then shifted to shisha. This percentage is similar in the Gulf countries, especially Saudi Arabia .Similarly, in Iran, most university students still believe that shisha is the healthiest choice among tobacco products and is one of their traditional forms . Others Limitations and RecommendationsSome of the limitations of this study should be noted while interpreting the results. First, smoking status was self-reported; therefore, the true prevalence of smoking in Kuwait may be somewhat underestimated, particularly among females. This opinion may be attributed to cultural norms that dictate that smoking is morally unacceptable for women. As such, females may experience societal pressure to report their smoking status due to the perception of shame associated with this behavior. Second, the low prevalence of self-reported tobacco smoking among females precluded the stratified analysis for males and females to examine the gender-specific risk factors. Therefore, recall or information bias might have occurred as females who were smokers might be reluctant. This aspect warrants attention in future research to ensure the questionnaire's confidentiality, for instance, by incorporating anonymous data collection, private interviews, and non-judgmental language. Some examples of confidential questionnaires could be using coded identifiers instead of personal information, such as name or address, to maintain anonymity or providing the option for participants to complete the questionnaire online or through mail to avoid face-to-face interviews that might discourage candid responses.Another limitation of our study is that the cause-effect relationship cannot be drawn from the observed associations as the nature of this study is cross-sectional. In addition, our study found that individuals with high incomes had a higher likelihood of smoking. However, the specific type of tobacco product preferred by this group was not identified, as well as their costs. Additionally, there needs to be more knowledgeable concerning the tobacco product preferences of low-income employees. Lower-income individuals may prefer cigarettes over other types due to their lower cost. Therefore, future studies should aim to determine the preferred type of tobacco product for each group depending on their income better to understand the relationship between income and tobacco product preference. We also recommend that future studies incorporate nicotine, tar, and carbon monoxide measurements for each tobacco product to identify which types pose more significant health risks. Elevated levels of these substances can result in severe illnesses. Finally, future research endeavors in this field should consider the limitations of our study while also considering the recommendations presented above. Doing so will promote a more profound comprehension of smoking behavior across diverse socioeconomic strata.A higher prevalence of smoking among males (46.5%) and females (6.4%) was recorded than previously reported estimates in Kuwait. Among the participants, 18.6% used one tobacco product exclusively, while 7.4% used two or three. The high income of the participants was a significant predictor of the use of one or more multiple tobacco products. Anti-smoking campaigns through mass education using electronic and print media may help reduce the prevalence of tobacco smoking. Increasing taxes on tobacco products may discourage the purchase and use of tobacco products in this study population, particularly in low-income individuals.


Acinetobacter baumannii pneumonia, hoping to provide a reference for the treatment of children with extensively drug-resistant Acinetobacter baumannii pneumonia.Spinal muscular atrophy (SMA) is a neurodegenerative disease that results in progressive and symmetric muscle weakness and atrophy of the proximal limbs and trunk due to degeneration of spinal alpha-motor neurons. Children are classified into types 1–3, from severe to mild, according to the time of onset and motor ability. Children with type 1 are the most severe, are unable to sit independently, and experience a series of respiratory problems, such as hypoventilation, reduced cough, and sputum congestion. Respiratory failure is easily complicated by respiratory infections and is a major cause of death in children with SMA. Most type 1 children die within 2 years of age. Type 1 children with SMA usually require hospitalization for lower respiratory tract infections and invasive ventilator-assisted ventilation in severe cases. These children are frequently infected with drug-resistant bacteria due to repeated hospitalizations and require long hospital stays requiring invasive ventilation. In this paper, we report a case of nebulization combined with intravenous polymyxin B in a child with spinal muscular atrophy with extensively drug-resistant  Piperacillin sodium and tazobactam sodium, cefoperazone sulbactam sodium, tigecycline for anti-infection, fluconazole, and micafungin for antifungal infection were given successively. On the second day of hospitalization, the child’s dyspnea worsened. The dyspnea was relieved after the tracheal cannula was connected to an invasive ventilator for assisted ventilation. The child’s dyspnea worsened after removal of the tracheal cannula and ventilator twice, and the child was reintubated and connected to ventilator-assisted ventilation. The parents refused tracheotomy and transferred the child to our hospital. The child was admitted to the hospital with “bronchopneumonia and spinal muscular atrophy.”The child was a 4-year-old boy who was admitted to the hospital chiefly due to “postnatal hypotonia and intermittent asthmatic cough with dyspnea for 1 month.” The child, G1P1, was born by cesarean section at full term with postnatal hypotonia and delayed gross motor development and was diagnosed with spinal muscular atrophy (type I) at the age of 10 months after completion of genetic testing. One year prior, the child underwent tracheal intubation and was connected to an invasive ventilator for treatment for 26 days. The tracheal cannula was removed, and the child was discharged without a ventilator and was treated for the original disease with risdiplam orally for 8 months. One month before admission, the child developed a paroxysmal cough without obvious inducement, with more white mucous sputum aspirated, with fever, wheezing, and labored breathing. The child was hospitalized in a local tertiary hospital, and sputum culture showed The findings of the physical examination on admission were as follows: height 103 cm (P10–P25), weight 10 kg (<p3), respiration 40 bpm, heart rate 170 bpm, clear consciousness, slightly irritable, shortness of breath, positive nasal fan, and three depression signs. The patient had a bell-shaped thorax, coarse breath sounds in both lungs, scattered medium-fine moist rales, and wheezing sounds that were heard. There was no significant abnormalities in the cardiac and abdominal examinations; there was decreased muscle tone of the extremities, grade II muscle strength of the distal upper extremities, and grade I muscle strength of the proximal upper extremities and lower extremities. Tendon reflexes were not elicited, and both fingers were claw-shaped with contracture.9/l, N 36.1%, L 54%, HGB 110 g/l, PLT 557 × 109/l, CRP 2 mg/l. The blood gas analysis showed the following: P02 57.8 mmHg, PC02 44.1 mmHg, PH 7.413, HC03 27.6 mmol/l, S02 90.4%, and BE 3.1 mmol/l. The chest CT showed the following: there was a right lung upper lobe shadow, the bilateral lung lower lobe volume was decreased, a dense shadow was seen, a bronchial inflation phase was seen inside, there were bronchial gathering signs, there was an impression of pneumonia, and there was atelectasis of the bilateral lower lobes.The routine blood results were as follows: WBC 8.21 × 10A. baumannii, and sputum culture suggested a S. aureus and A. baumannii complex. Levofloxacin and tigecycline were added according to the drug susceptibility test. The child still had intermittent fever, and multiple bronchoalveolar lavage fluid and sputum bacterial cultures suggested the presence of the Acinetobacter baumannii complex, high- throughput gene detection tests on the bronchoalveolar lavage fluid suggested a high confidence level of the Acinetobacter baumannii. On the 44th day after admission, the child’s temperature was normal and his respiration was stable. Therefore, the tracheal cannula was removed, and the patient was changed to non-invasive ventilator-assisted ventilation. After maintenance for 4 days, the child was again fevered and intubated and connected to invasive ventilator-assisted ventilation due to dyspnea. The bacterial culture taken from the tip of the tracheal cannula on the 49th day of admission showed the following: A. baumannii complex, colistin-sensitive, cefoperazone, and sulbactam; the remaining isolates were resistant (including to tigecycline). Acinetobacter baumannii, with rechecked routine blood results as follows: WBC 4.89 × 109/l, N 25.1%, L 62.4%, HGB 109 g/l, PLT 498 × 109/l, CRP 0.46 mg/l; renal function results showed the following: BUN 5.83 mmol/l, Cr 12.2 µmol/l. The child was discharged uneventfully after a 75-day hospital stay. The child was admitted to the hospital with continuous invasive ventilator-assisted ventilation and was given cefoperazone sodium and sulbactam sodium ivgtt for anti-infection and intensive airway management. On the fourth day after admission, the bronchial lavage fluid was positive for 1.2The search terms “Polymyxin B,” “Acinetobacter baumannii,” “Extensively drug-resistant,” and “Pneumonia” were searched in PubMed and Web of Science, and the search terms “Polymyxin B,” “Acinetobacter baumannii,” “Extensively drug-resistant,” and “Pneumonia in children” were searched in the CNKI, SinoMed, and Wanfang databases, with the searching time being from database establishment until 01/09/2022.The search did not include nebulization combined with intravenous polymyxin B for the treatment of childhood-associated pneumonia. Studies reporting nebulization of polymyxin B for the auxiliary treatment of pneumonia due to multidrug-resistant gram-negative infections have focused on adult patients. A recent prospective cohort study  and a re2Acinetobacter baumannii infection  is a severe neuromuscular disorder due to a defect in the survival motor neuron 1 (SMN1) gene . Childrenfection . Active Acinetobacter baumannii has a strong ability to acquire drug resistance and clonal transmission, and multidrug resistant, extensively drug-resistant, and fully resistant Acinetobacter baumannii is endemic worldwide and has become one of the most important pathogens of nosocomial infections in China , especially ventilator-associated pneumonia (VAP)  was 33.5% (382/1140) and the overall resistance rate to multiple antibiotics was > 60%. In the face of such serious drug resistance, there are very limited therapeutic drugs available in the clinic, and polymyxins with specific antibacterial mechanisms have returned to the clinic with renewed attention (in China . The mosia (VAP) . The resia (VAP)  suggest he ISPED  showed tttention . Polymyxttention .The Management of Adults With Hospital-acquired and Ventilator-associated Pneumonia: 2016 IDSA/ATS Clinical Practice Guideline  recommenCurrent studies on polymyxin B nebulization for the adjuvant treatment of pneumonia caused by multidrug-resistant gram-negative bacterial infections have mainly focused on adult patients. In the field of pediatrics, there are only a few clinical studies on the efficacy and safety of intravenous polymyxin B alone in the treatment of pneumonia in children with carbapenem-resistant gram-negative bacteria (CR-GNB), and there is a lack of data on the safety and efficacy of polymyxin B nebulization in pediatric patients. In addition to the guidelines and expert consensus, some studies have shown that nebulization of polymyxin B is effective and safe in pneumonia caused by infections due to resistant gram-negative bacilli for which intravenous administration is not effective . PolymyxAcinetobacter baumannii infection, the drug susceptibility results showed colistin sensitivity, and the remaining isolates were resistant (including tigecycline). After the clinicians and pharmacists codeveloped the treatment regimen, the dosage and administration that were recommended were according to the 2021 Multidisciplinary Expert Consensus on the Rational Clinical Use of Polymyxin Antibacterial Drugs in China. At present, there is no nebulization formulation of polymyxin B in China. In this case, the administration route of polymyxin B was nebulization in addition to an intravenous drip, and the treatment process went smoothly.The child in this case had an underlying disease of spinal muscular atrophy, recurrent pulmonary infections requiring tracheal intubation, and invasive ventilator support, and the child also had long-term hospitalizations with a variety of advanced antibiotic therapies. The current pulmonary lesions were serious, and it was difficult to withdraw the ventilator. The child had an extensively drug-resistant In this case, during there were no other complications, such as nephrotoxicity, hepatic damage, neurotoxicity, or skin damage, except for a mild decrease in transcutaneous oxygen saturation and increased heart rate at the initial stage of nebulization. The overall treatment was safe and effective, and the shortcoming of this case report is that the blood concentration of polymyxin B could not be monitored. The success of treatment in this case will provide a data reference for the optimal application of polymyxin B in pediatric patients with pulmonary infections. Please note that, since we only had one case, we were unable to confirm the effect of nebulization in the case, although the overall effect was good. Whether nebulization has an ideal effect remains to be discussed further.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Children’s Hospital, Capital Institute of Pediatrics, Beijing, China. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.BC reviewed the literature and analyzed the case. LC supervised the findings of this work. All authors discussed the results and contributed to the final manuscript.


Growing evidence suggests that micronutrient status may have some impact on the course of inflammatory bowel disease (IBD). However, micronutrient deficiencies are easily overlooked during the treatment of IBD patients. There have been many studies on micronutrient supplementation, in which several clinical trials have been conducted targeting vitamin D and iron, but the current research is still preliminary for other vitamins and minerals. This review provides an overview of the adjunctive therapeutic effects of micronutrient supplementation in IBD, to summarize the available evidence, draw the attention of clinicians to micronutrient monitoring and supplementation in patients with IBD, and also provide some perspectives for future research directions. Diarrhea, abdominal pain, bloody stools and weight loss are common clinical symptoms of IBD. As of 2017, the prevalence of IBD in many countries in North America and Europe has exceeded 0.3%, and in newly industrialized countries, the incidence of IBD is also rising, so it has become a global disease  showed that low vitamin D status was associated with increased disease activity, mucosal inflammation, poor quality of life (QOL) scores and future clinical relapse , but whepatients . This mapatients , but thi2.2There are a large variety of B vitamins, including thiamine , riboflavin (vitamin B2), folate (vitamin B9), and vitamin B12, among others. Folate and vitamin B12 deficiencies can lead to megaloblastic anemia, and monitoring of folate and vitamin B12 levels in IBD patients is necessary because deficiencies of these two B vitamins are common, especially in those with CD. A retrospective and comparative study that included 138 IBD patients found that 28.8% of CD patients and 8.6% of UC patients had folate deficiency, and 22.2% of CD patients and 7.5% of UC patients were vitamin B12 deficient, when deficiency of serum folate and vitamin B12 was defined as <3 ng/ml and <200 pg/ml, respectively . Since vThiamine may be associated with fatigue in IBD patients. A randomized controlled crossover trial conducted by Baker et al.  showed tThe anti-inflammatory effects of riboflavin have been demonstrated in animal studies, such as reducing the production of proinflammatory cytokines, TNF-α, and IL-6, but it is not clear whether riboflavin alleviates inflammation directly by modulating the immune system or indirectly by altering the composition of the gut microbiome . A prosp2.3in vitro and in vivo experiments to explore.No large-scale study has revealed the prevalence of vitamin K deficiency in the IBD population, and a cross-sectional study conducted in pediatric patients that enrolled 63 children with CD and 48 with UC showed that the prevalence of vitamin K deficiency was 54.0% in CD and 43.7% in UC, and was more likely to be present in CD patients with higher disease activity . Althoug2.4In vitro experiments by He et al.  scores in iron-deficient IBD patients . Moreove3.2Zinc deficiency is also common in the IBD population, and in an American cohort study of 773 patients with CD and 223 patients with UC, when serum zinc concentration <0.66 μg/ml was used as diagnostic criteria, the prevalence of zinc deficiency was 42.2% in CD and 38.6% in UC . Further3.3Lactobacillus paracasei (Previous experiments have shown that selenium has effects such as attenuating oxidative stress, modulating intestinal microbiota, and blocking possible pathways involved in the progression of colitis to colon cancer . Serum saracasei –80. Howe3.4Sodium, potassium, and chloride among the macroelements are often not easily deficient, so less research has been conducted on these three elements. However, excessive sodium intake may have adverse effects on IBD patients. Monteleone et al.  found thTrace elements in addition to the above-mentioned iron, zinc, and selenium, there are iodine, copper, manganese, chromium, cobalt, etc., among which less research has been carried out on iodine, chromium, and cobalt. In general, copper deficiency may occur in IBD patients with short bowel syndrome, which is mainly manifested as sequelae of the blood system and nervous system, while the sequelae of the nervous system are often irreversible . Moreove4The nutritional status of IBD patients tends to have some impact on the course of the disease, but the assessment of malnutrition risk and the monitoring of micronutrient levels are easily overlooked by clinicians during treatment. Clinical studies have demonstrated the benefits of micronutrient supplementation in IBD patients with specific micronutrient deficiencies. At present, micronutrients for which more clinical trials have been conducted in the IBD population are vitamin D and iron. Vitamin D supplementation in patients with IBD reduces inflammation and the risk of clinical relapse , 14, impIBD patients are also prone to deficiencies of other vitamins and minerals, such as vitamins B, K, A, C, and E, as well as zinc and selenium, due to impaired intestinal absorption, and restricted dietary intake . SupplemThis review summarizes the adjunctive therapeutic effects of micronutrient supplementation in IBD, but it is impractical to supplement all micronutrients in patients with IBD. Therefore, strengthening the nutritional management of IBD patients is the core, including a balanced diet, regular screening and assessment of nutritional status, and prompt supplementation when micronutrient deficiencies occur.YW performed the literature review and wrote the manuscript. CL reviewed the manuscript and provided critical comments. WD suggested the topic of the review and supervised, wrote, and critically reviewed the manuscript. All authors have read and agreed to the published version of the manuscript.