Dietary therapies play a crucial role in managing patients, especially those who have specific types of epilepsy, display adverse effects, or are not responding to pharmacological treatments. The ketogenic diet (KD) is a high-fat, restricted carbohydrate, and adequate protein regimen. The KD has proven to be an effective nonpharmacological treatment for drug-resistant epilepsy (DRE) by generating ketones that act as an alternative fuel source for the brain, thereby reducing the occurrence of seizures. The advantages of KD have been attributed to its universal availability, numerous administration techniques, and affordability.This article presents the KD algorithm developed by a multidisciplinary team of experts at the Children's Hospital, Ain Shams University, Egypt. The algorithm serves as a guide for implementing the KD in the treatment of DRE in children. The algorithm has been previously validated through a study.The algorithm consists of seven essential stages: (1) referral of patients to the Complex Epilepsy Committee, (2) pre-diet assessment of patients, (3) referral of patients to the Clinical Nutrition (CN) team, (4) diet selection and initiation, (5) seizure follow-up and diet fine-tuning, (6) diet reassessment after 3 months, and (7) evaluation of the KD journey after 24 months.The KD algorithm was systematically developed and proved highly influential in facilitating the implementation of the KD. The algorithm yielded significant health benefits in pediatric patients.The KD algorithm provides a systematic approach to implementing the ketogenic diet and has demonstrated positive health outcomes in pediatric patients. DRE The ketogenic diet (KD) is a well-established and effective nonpharmacological treatment for DRE and specific epilepsy syndromes. It is a high-fat, restricted carbohydrate, and adequate protein regimen that was first applied in treating epilepsy in the early 1920s –6. It waThe prevalence, epidemiology, and treatment gaps in epilepsy have been the study's focus in Egypt. Published reports indicate that in the largest district of Egypt , more than 61% of individuals diagnosed with active epilepsy, including men, women, and children, do not receive any treatment 39%) or are not provided with appropriate treatment (22%) . In anot% or are While the use of the KD as a treatment for drug-resistant epilepsy (DRE) has shown success in various parts of the world, there is limited information on its implementation and utilization in Egypt , 12. To 2.The clinical algorithm developed by the multidisciplinary expert faculty is called the ketogenic diet algorithm (KDA) . This alThe KDA was created by expert clinicians from Ain Shams University Children's Hospital, drawing upon their extensive experience of more than 12 years, opinions, and relevant published papers. The development process involved identifying performance requirements, addressing challenges, and finding suitable solutions. The team conducted a thorough review of the literature and studied published guidelines. Several drafts were created, tested, revised, edited, and refined to ensure the algorithm's accuracy and effectiveness. The resulting clinical algorithm provides a precise sequence of clinical decisions and provisions for appropriate feedback.2.1.The KDA is designed to encompass a series of steps involved in the non-pharmacological treatment of epilepsy, specifically using dietary therapy, primarily focusing on the KD.(A)(1)Patient referral to the Complex Epilepsy Committee.(2)Pre-diet assessment of patients.(3)Patient referral to the Clinical Nutrition (CN) team.(4)Diet selection and initiation.(5)Follow-up of seizures and fine-tuning of diets.(6)Reassessment of the diet after 3 months.(7)Evaluation of the KD journey after 24 months.The KDA consists of seven crucial stages, listed as follows:(B)The KDA is designed as a systematic and logical tool, providing valuable assistance in managing different KD treatment protocols. Furthermore, it offers alternative options at critical branching points, ensuring flexibility and tailored approaches to patient care.By incorporating these salient features, the KDA is a comprehensive and practical resource for healthcare professionals, facilitating the effective implementation and management of KD treatment for epilepsy.Key features of the KDA are as follows:In the initial evaluation phase, patients with epilepsy were assessed to determine their suitability for other medical or surgical management options in cases with focal structured defect (FSD), including curative resective epilepsy surgery to be performed. If surgery was not deemed appropriate or the family refused, the KD therapy recommendation was followed. The implementation and management of the KD is a complex process that requires the collaborative efforts of a multidisciplinary team of experts.At the Children's Hospital, Ain Shams University (Egypt), the core team responsible for overseeing the process is known as the Complex Epilepsy Committee. This team consists of expert consultants from the neurology and clinical nutrition departments, with additional input from neurosurgery consultants for patient enrollment. In cases where a patient was found unsuitable for KD, the expert team provided further guidance and advice based on the patient's condition, referring them back to the committee for vagal nervous stimulation (VNS) or palliative epilepsy surgery.Once a patient was enrolled in the KD program, a specialized nurse, psychologist, nutritional educator, and dedicated chef joined the team to provide their expertise. This approach aligns with previous reports, which recommend the involvement of a neurologist experienced in KD treatment, a skilled pediatric nutritionist, a specialist nurse, a nutritional educator, a social worker, and a chef knowledgeable in ketogenic diets , 14–17. 2.1.1.The algorithm begins with the first critical stage, which involves referring the patient to the Complex Epilepsy Committee at the Faculty of Medicine, Ain Shams University (Egypt). During the evaluation process, the committee confirms the diagnosis of drug-resistant epilepsy (DRE) and identifies the specific type of seizures experienced by the patient, such as focal with awareness, Focal with impaired awareness, motor onset, generalized epilepsy where epileptic spasm tonic-clonic, a tonic or Myoclonic and hyperkinetic motor seizure . Based oThe KD is chosen as the treatment for children diagnosed with DRE who are not eligible for curative surgery and fall within the age range of 0–18 years. Before being directed to the Keto Clinic, all patients approved for KD treatment by the Keto team undergo screening to ensure they do not have any contraindication for KD as fat metabolism-related disorders (such as β-oxidation defects and medium-chain 3-hydroxy acyl-CoA deficiency) or other conditions like porphyria. This screening is crucial as the KD primarily involves a high-fat diet, and patients with underlying fatty acid metabolism disorders placed on the KD may experience a potentially severe catabolic crisis .2.1.2.At the Keto Clinic, all patients underwent various evaluation programs to ensure their medical and nutritional suitability for the KD treatment, following the guidelines set by the algorithm. These evaluation programs included metabolic, nutritional, and laboratory tests, which were carried out to gather a comprehensive medical profile and assess the patient's health status before initiating the treatment.2.1.2.1.The patients underwent assessments to identify and exclude any metabolic disorders that could be contraindications for the diet , or a combination . Based o2.1.2.3.Several routine laboratory tests were conducted to gain insights into the patient's health. These tests encompassed a complete blood count with platelets, electrolyte analysis , liver and kidney function tests , fasting lipid profile, and urinalysis, including urine calcium and creatinine . If applFurthermore, specific comprehensive tests were conducted to assess the metabolic profile of the patients. These included blood ammonia and lactate levels, evaluation of cerebrospinal fluid , serum acylcarnitine profile, serum amino acids, and urine organic acids. Optional tests were also prescribed in cases where patients had pre-existing medical conditions. For instance, a renal ultrasound and nephrology consultation were recommended for patients with a history of kidney stones, recurrent urinary tract infections, or those taking topiramate or zonisamide. Additionally, an electrocardiogram was performed for patients with a history of heart disease .An extensive literature survey highlighted the importance and significance of conducting comprehensive testing , 19, 22.Patients who were deemed medically and nutritionally unfit for KD treatment were referred back to the Keto team (Complex Epilepsy Committee), with the option of considering vagal nerve stimulation therapy and/or palliative surgical treatment .2.1.2.4.The subsequent stage of the algorithm involved counseling the parents of patients who were deemed suitable candidates for KD treatment. The Keto team conducted individual counseling sessions with each patient and his family using the data gathered from the pre-diet evaluations . These sessions provided crucial information about the principles of KD and their role in meal preparation, diet maintenance, and monitoring ketosis. The significance of strict adherence to the diet and the need for vitamin and mineral supplementation were emphasized , 6. FollAfter the counseling sessions were completed, the subsequent step in the algorithm involved seeking guardian approval. The parents or caregivers of the patients were asked to provide informed and written consent. With their authorization, the patients could proceed with KD initiation. Patients whose parents rejected or withheld consent for the proposed KD treatment were referred back to the Complex Epilepsy Committee to explore alternative non-pharmacological treatment options.2.1.2.5.After obtaining parental approval, the next crucial step in the KD algorithm (KDA) entailed a comprehensive review of the laboratory evaluations by the Keto team. The tests conducted during the pre-diet evaluation phase Section  were tho2.1.3.Upon successfully completing the final inspection, the patients were referred to the Clinical Nutrition (CN) team, marking the transition to the next crucial stage of the algorithm. The CN team was responsible for stabilizing the patients and preparing them for diet selection. The patient data were thoroughly reviewed to develop a personalized nutritional plan that would address any existing malnutrition or undernutrition conditions before the initiation of the KD treatment. This step ensured that the patient’s nutritional needs were adequately met and optimized before commencing the KD.2.1.4.Diet formulation, selection, and construction were based on the specific circumstances of each child and their family rather than solely relying on the perceived efficiency of a particular type of KD. This approach allowed for customizing diets that best suited the individual patient, thereby achieving optimal treatment conditions.The decision regarding the type of KD to be implemented was made from four main types of diets , namely,2.1.5.The primary source of fat in the KD is predominantly derived from long-chain triglycerides obtained from standard traditional foods. There are no specific restrictions on calorie intake or fluid consumption . For inf2.1.6.The MCT KD is distinguished by its higher carbohydrate and protein content compared to the classic KD. This is because MCT oils offer a higher yield of ketones  and are better absorbed by the liver. As a result, less fat is required in the diet, allowing for increased quantities of carbohydrates and proteins , 15, 16.At the Children's Hospital, a modified MCT KD was implemented using 30% MCT oil and, if necessary, 30% long-chain fats. This approach was chosen to address previous reports of gastrointestinal discomfort associated with a 60% MCT composition. MCT oil was administered in the diet as coconut oil or emulsion , 6. The 2.1.7.The MAD is a high-fat, low-carbohydrate therapy like the classic KD regarding food choices. It does not restrict protein, fluid, or calorie intake , 5. The The MAD generally provides a ketogenic ratio ranging from 1:1 to 1.5:1, although no fixed ratio is mandated. Initially, the daily carbohydrate consumption on the MAD is typically around 10–15 g, which is comparable to the strict initiation phase of the Atkins diet used for weight loss. After 1–3 months, there may be a possibility of increasing the daily carbohydrate intake to 20 g .2.1.8.The LGIT diet allows for a higher daily intake of carbohydrates, ranging from 40 to 60 g per day. However, there is strict regulation regarding the type of carbohydrates consumed, with a preference for those that have minimal impact on blood glucose levels, such as carbohydrates with low glycemic indexes below 50 . It is w2.1.8.1.Before starting a diet, the last step is to calculate each patient's specific dietary needs, such as their ketogenic ratio, protein levels, and fluid intake, tailored to their diet plan.i.Assessment of calorie requirements2 : 1.5 g/kg/day,✓Age 1–3 years: 1.1 g/kg/day,✓Age 4–13 years: 0.95 g/kg/day,✓Age 14–18 years: 0.85 g/kg/day, and✓Age 18 years and above (adults): 0.8 g/kg/day.The standard advice for the classic KD is 1 g protein/body weight for older children and 1.5 g/kg for rapidly growing younger children . The foliii.Assessment of fluid requirementsTo calculate the necessary fluid intake, we followed the Holliday–Segar method. Based on a weight of 20 kg, we determined that around 1500 ml of fluid was required to replace lost water and address renal loss. For every additional kilogram above 20 kg, an additional 20 ml of fluid was needed .ivDetermination of the appropriate ketogenic ratioThe ketogenic ratio was calculated as grams of fat to the sum of grams of protein and carbohydrate, represented as follows:Ketogenic ratio = fat (g): protein (g) + carbohydrates (g)The typical ketogenic ratio used in the Keto Clinic ranges from 2:1 to 4:1 . HoweverDue to the restriction of fruits, vegetables, and other foods in the ketogenic diet, special attention was given to supplementing the diet with appropriate quantities of minerals and vitamins , 16, 18.Prior to initiating the diet, the Keto team reviewed the anticonvulsants and other medications used by the patients to determine their carbohydrate content . It was 2.1.8.2.According to the algorithm, diet initiation was done gradually and stepwise, without fasting. Studies have shown that the no-fasting initiation method reduces the incidence of complications associated with the ketogenic diet , 32. HowFor infants below 1 year or who need special medical care, the classic KD was initiated in a hospital setting to ensure close observation of the child and prompt medical intervention if any complications arose. This approach allowed caregivers to receive training on food calculation and weighing, ketosis monitoring, and KD management before the patient was discharged from the hospital. Parents and caregivers were also taught about the symptoms and management of acidosis and hypoglycemia . Alterna2.1.9.During the early stages of diet initiation, the algorithm included regular follow-up visits and diet reassessments as the final critical stages. After discharge, patients were initially seen every week for the first month and then had monthly follow-ups, particularly if expected urinary ketosis was not maintained. These frequent follow-ups allowed for tracking seizure reductions and making necessary diet adjustments. The Keto team maintained continuous communication with patients through platforms like WhatsApp and provided round-the-clock telephone support. Under optimal conditions, follow-up visits were scheduled every 3 months during the first year , 34.During each follow-up visit, nutritional and laboratory evaluations were conducted to monitor the progress of the ketogenic diet in treating drug resistant epilepsy. Blood ketones were checked to ensure the diet's efficacy and compliance. Patients taking carbonic anhydrase inhibitors were closely monitored for an increased risk of kidney stones, considering that the ketogenic diet may exacerbate pre-existing metabolic acidosis, especially in the early stages of diet initiation. Blood pH and bicarbonate levels were monitored, and if a patient experienced symptoms such as vomiting or lethargy, bicarbonate supplements were initiated. Additionally, dietary requirements and supplement levels were reviewed, compliance with therapy was assessed, and minor adjustments were made to improve compliance and fine-tune the diets , 6, 7.2.1.10.According to the algorithm, the ketogenic diet was reassessed after 3 months of initiation. Research has shown that most patients (75%) responded to the diet within 14 days, while some took longer, up to 8–10 weeks. Nonresponders, who had less than 50% seizure reduction, were recommended for diet discontinuation and gradually tapered off the ketogenic diet. They were then referred back to the Keto team for further evaluation. Responders, who had more than 50% seizure reduction, continued the diet for 2 years if it was deemed completely successful in reducing seizures , febrile infection-related epilepsy syndrome, formula-fed infants, Ohtahara syndrome, and super-refractory status epilepticus , 6.2.1.11.At the end of the algorithm, the Complex Epilepsy Committee evaluated the outcomes of successful cases and decided whether to discontinue the diet after 2 years or continue it indefinitely. Nevertheless, patients who wished to extend the diet beyond the initial 2-year period for additional cognitive benefits and improved quality of life were provided with that option.2.1.11.1.Before discontinuing the diet in seizure-free children, a routine electroencephalogram and a review of clinical data were conducted. This allowed for counseling of families regarding the risk of seizure recurrence, which was estimated to be around 20%. However, studies on this topic indicated that 80% of individuals who had achieved seizure freedom on the ketogenic diet would remain seizure-free even after diet discontinuation . AdditioThe process of diet discontinuation involved a gradual tapering off, resembling the weaning off of anti-seizure medications, thereby minimizing the risk of increased seizures. Ideally, the diet should be discontinued for 1 year unless urgent discontinuation is necessary. The weaning process (over a period of 2–3 months) involved gradually lowering the ketogenic ratio from 4:1 to 3:1 to 2:1. Following this, the ketogenic foods were continued while increasing calorie and fluid intake. High-carbohydrate foods were reintroduced only after urinary ketosis was lost , 16.3.Implementing the KDA in our hospital has proven effective in identifying children who can benefit from the ketogenic diet and those who may not. The KDA offers a personalized and individualized nutrition plan tailored to specific needs, considering factors such as age, weight, height, gender, activity level, and overall health status. With the KDA, accurate calculations of macronutrient ratios and caloric intake can be made, ensuring that the ketogenic diet provides the desired amounts of carbohydrates, proteins, and fats for each patient. This standardized approach allows for easy accessibility to a well-defined ketogenic diet for all patients.Moreover, the KDA facilitates strict monitoring and tracking of a patient's condition, food intake, and macronutrient ratios. This level of monitoring enhances compliance and adherence to the diet, which, in turn, leads to improved outcomes. By following a personalized KDA, individuals may experience faster epilepsy control and improvements in other health markers. Additionally, the KDA helps prevent nutrient deficiencies and ensures that patients meet their daily nutritional requirements.Furthermore, the KDA simplifies the management of complex ketogenic diet treatment modules, making it easier for junior healthcare professionals to administer. It also aids in the early detection of potential complications and provides alternative options when necessary. Implementing the KDA has also contributed to cost reduction, minimizing long-term food and healthcare expenses while reducing the risk of chronic diseases such as diabetes and heart disease, which come with their costs.Finally, the KDA enables the collection and analysis of data on individuals’ progress and outcomes, offering valuable insights into the effectiveness of the ketogenic diet and identifying areas for improvement or optimization. It is important to note that the efficacy of the KDA may vary from person to person. For more information, please refer to our previously published work on using the DKA .4.Applying the KDA in patients with drug resistant epilepsy holds promise as an approach to ensure the precise and personalized implementation of the ketogenic diet, thereby enhancing the likelihood of success in reducing seizure frequency and severity. One notable advantage of the ketogenic diet is its universal availability at affordable prices compared to novel anti-seizure medications . FurtherAlgorithms, in general, play a significant role in managing medical disorders by assisting healthcare professionals in making precise and efficient diagnoses, developing customized treatment plans, and monitoring patient progress over time . For pat4.1.While the KDA has demonstrated promise in managing drug resistant epilepsy, it is essential to acknowledge its limitations. Strict adherence to the ketogenic diet can be challenging for certain patients, particularly children or individuals with specific dietary restrictions or food preferences, making it difficult to maintain the prescribed macronutrient ratios. Nutritional deficiencies are common complications, mainly when strict adherence to the diet is not achieved. Side effects such as constipation, nausea, vomiting, and diarrhea may also occur. It is important to note that our experience with the DKA is based on a single-center setting, representing a significant limitation. Further research and multicenter studies are needed to expand our understanding and validate the effectiveness of the KDA across different clinical settings.5.The limited information available on the use and implementation of the ketogenic diet (KD) as a treatment for drug-resistant epilepsy (DRE) in low-resource countries like Egypt prompted the development of a clinical algorithm. Expert faculty members collaborated to formulate the KDA, which provides a precise sequence of clinical decisions and offers alternative pathways to guide medical professionals in decision-making and monitoring patients’ progress. The KDA was successfully implemented at the Children's Hospital, Faculty of Medicine, Ain Shams University, Egypt, and has played a significant role in simplifying the implementation of the ketogenic diet, making it more accessible and manageable for medical professionals.


Rosai-Dorfman disease (RDD) is a rare non–Langerhans cell histiocytosis (non-LCH) in which an overabundance of activated histiocytes accumulate within tissues resulting in a clinical presentation that often includes massive bilateral cervical lymphadenopathy, fever, and leukocytosis.,Cutaneous RDD (CRDD) presents with slowly progressive papules, nodules, plaques, and/or tumors, typically on the torso or head and neck region. Epidemiologically, it is distinct from systemic RDD with a mean age of presentation at 43.5 years, compared to 20.6, and more common in Whites and Asians, compared to Blacks, with an inverse male/female ratio (1.4:1 in systemic RDD and 1:1.8 in CRDD).A)  . She hadA) . Both spB)  . She hadC)  . She hadD)  . She hadHere, we present 4 cases of cutaneous RDD at a single center. Each patient had variable response to treatment, demonstrating the clinical heterogeneity within this rare disease. The association between RDD and lymphoma has previously been described, and one patient in this series had her lymphoma at a distinct site and was in remission at the time of diagnosis.The value of Oct-2 as a helpful diagnostic marker in Rosai-Dorfman is also highlighted by our study in cases where the atypical histiocytes may have weak reactivity to histiocytic lineage markers.Additionally, the 2 patients who pursued treatment had disease that proved refractory to numerous therapies, and one patient did escalate to a biologic agent with rituximab infusions. The sample size is small, but given the rarity of the disease, it provides important evidence of the difficulty treating this disease.There have been recent advancements in our understanding of RDD and the molecular pathways that are impacted, such as the MAPK pathway.None disclosed.


Alzheimer’s disease (AD) is a progressive and degenerative disease producing the most common type of dementia worldwide. The main pathogenetic hypothesis in recent decades has been the well-known amyloidogenic hypothesis based on the involvement of two proteins in AD pathogenesis: amyloid β (Aβ) and tau. Amyloid deposition reported in all AD patients is nowadays considered an independent risk factor for cognitive decline. Vascular damage and blood–brain barrier (BBB) failure in AD is considered a pivotal mechanism for brain injury, with increased deposition of both immunoglobulins and fibrin. Furthermore, BBB dysfunction could be an early sign of cognitive decline and the early stages of clinical AD. Vascular damage generates hypoperfusion and relative hypoxia in areas with high energy demand. Long-term hypoxia and the accumulation within the brain parenchyma of neurotoxic molecules could be seeds of a self-sustaining pathological progression. Cellular dysfunction comprises all the elements of the neurovascular unit (NVU) and neuronal loss, which could be the result of energy failure and mitochondrial impairment. Brain glucose metabolism is compromised, showing a specific region distribution. This energy deficit worsens throughout aging. Mild cognitive impairment has been reported to be associated with a glucose deficit in the entorhinal cortex and in the parietal lobes. The current aim is to understand the complex interactions between amyloid β (Aβ) and tau and elements of the BBB and NVU in the brain. This new approach aimed at the study of metabolic mechanisms and energy insufficiency due to mitochondrial impairment would allow us to define therapies aimed at predicting and slowing down the progression of AD. Alzheimer’s disease (AD) is a progressive and degenerative disease that affects cognition and leads to the most common type of dementia worldwide. The number of people living with dementia—estimated to stand at 55 million in 2019—is expected to rise to 139 million in 2050, considering the overwhelming rate of estimated diagnosis (one every three seconds) and the increased lifespan . The amyAPOE4) (ε3/ε4 or ε4/ε4), an identified genetic risk factor for AD, show a higher BBB permeability in the medial temporal lobe and hippocampus compared with non-carriers, even when cognitively healthy [APOE regulates neurodegeneration predominantly by modulating activation of microglia, although a minor role for apoE in regulating the formation of tau and insoluble tau has also been identified regarding immunomodulatory function. Ptau (Ser202 and Thr205 epitopes) progression is therefore also determined by microglia [Moreover, amyloid deposition around cerebral vessels is related to cerebral amyloid angiopathy (CAA), which is observed almost in all AD patients to different degrees , and is  healthy . The BBB healthy . These picroglia , just asicroglia . Vasculaicroglia . Aβ actiicroglia . Long-teicroglia ,26. Cellicroglia . The cericroglia ,29. Evenicroglia . Underst2, lactate, Aβ, tau) [ApoE4 carriers, and E4 fails to suppress the CypA-MMP-9 pathway in pericytes leading to degradation of BBB tight junctions [APOE and the nuclear factor of activated T cells (NFAT) are selectively dysregulated in pericytes of APOE4 carriers, and inhibition of calcineurin–NFAT signaling reduces APOE4-associated CAA pathology in vitro and in vivo. Considering the role of pericytes in APOE4-mediated CAA calcineurin–NFAT signaling could be a therapeutic target in CAA and Alzheimer’s disease [2 supply in the active sites of the brain [apoE4 disrupting Aβ clearance compared to apoE3. This has been demonstrated by pharmacologic inhibition of LRP1 by an anti-LRP1 antibody. ApoE isoforms can be considered either protective (ApoE2) or a major risk for AD development (ApoE4), and, interestingly, ApoE4 homozygotes display, during asymptomatic stages even decades before the AD onset, a similar regional hypometabolism compared to AD patients, as observed with glucose tracers [ApoE4 isoform differently interacts with the metabolic receptor LRP1 seems a pivotal step in BBB regulation and AD pathophysiology [AQP4 and the integrity of perivascular AQP4 localization, correlated to sleep quality and cognitive functions in humans [AQP4 is exclusively astrocytic and the expression of perivascular astroglial gene products, such as dystroglycan, dystrobrevin, and alpha-syntrophin, were also associated with dementia and phosphorylated tau levels in the temporal cortex [AQP4 expression, hydrostatic pressure variation due to CSF decline or inflammatory processes) could justify regionally specific degeneration, based on microvascular dynamics not utterly clarified [LRP1 expression on smooth muscle cells surrounding the vessels could sequester Aβ, favoring vascular amyloidosis [The neurovascular unit (NVU) manages the metabolic supply of the brain . The NVUAβ, tau) . The intAβ, tau) . The cerAβ, tau) . The NVUAβ, tau) . Brain aAβ, tau) ,35,36; hAβ, tau) . DegenerAβ, tau) . They plAβ, tau) . The maiAβ, tau) . Pericytunctions . Dysfuncunctions . In the  disease . The ear disease . Vasculahe brain . LRP-1 ihe brain . Severalhe brain ,45. BBB- tracers . The preysiology . A possiysiology . The forysiology . Astrocyysiology ,51. Astrysiology ,53,54. Tysiology . In respysiology ,55. The ysiology . Thus, aysiology ,58. Alteysiology . Damage ysiology . The BBBysiology ,62. Precysiology . Differeysiology . The homysiology . The parysiology . These fysiology . During ysiology ,68. Inden humans ,70. Remal cortex . The redl cortex . The patlarified . Moreoveloidosis . Eventualoidosis ,75. Finaloidosis ,77.APOE*E4 alleles (which encode the E4 isoform of apolipoprotein E (ApoE4)) carriers have reduced glucose metabolism [JNK and SREBP which determine lipid synthesis. The synthesized lipids undergo the peroxidation process thanks to the presence of ROS. They are subsequently transferred to the pigment glia, where they are sequestered in the LDs [ABCA1, ABCA7, VLDLR, VPS26, VPS35, AP2A, PICALM, and CD2AP. APOE could be relevant as a risk factor for AD by mediating and modulating the transfer of lipids between neurons and the glia. Reduced transport capacities of APOE4 [APOE expression [APOE4 fly model. It has been shown to be able to restore glial LD formation. This could have a valid therapeutic potential for preventing ROS-induced neurotoxicity. In the future, it will be necessary to study therapeutic approaches aimed at inducing the glial uptake of lipids to reduce the levels of ROS and clear amyloids.The role of NVU in AD should be emphasized as a whole. Whenever there is damage to the NVU, it can trigger the breakdown of the BBB, decrease cerebral blood flow, and decrease the clearance of Aβ and its deposition. The result is a response that alters the different elements of the NVU: pericyte degeneration, activation of glial cells, metabolic imbalance, activation of the neuroinflammatory response, synaptic impairment, and neuronal loss . Followitabolism  and incrtabolism . Region-tabolism ,89. Pero the LDs . Activat the LDs . Therefo the LDs ,92. ROS  the LDs ,94. Nowa the LDs ,96 and b the LDs ,97. The of APOE4 ,98,99 coof APOE4 . In a mopression ,101, an Metabolism, through the production of ATP, regulates both the difference in electrochemical potential between mitochondria and the cell cytoplasm, and bioelectric activity, which propagates from the neuronal axons, and together they have a determining role in the transmission of the nerve impulse. Metabolism is considered as the core of destiny regulation, growth, death, or cell differentiation. Mathematical models are being developed to explain the connection between ROS and metabolism, as well as the importance of ROS-mitochondrial remodeling in neuron differentiation, neuroprotection, and antigliosis ,102,103.In conclusion, we can understand how saving brain energy improves neuronal integrity, synaptic plasticity, and interactions between neurons and glia, delaying the onset and progression of neurodegenerative diseases. Just as the neurocognitive development of the child requires an adequate energy supply, in the same way this energy supply is necessary during aging. To delay the onset and progression of neurodegenerative diseases, maintaining the brain’s energy state should therefore be a cornerstone for future experiments. Diet, body weight, diabetes, physical activity, and other factors must be kept under control. We cannot cure dementia, but we do know how to decrease its risk. It is increasingly clear that it is not monocausal but a multi-cause syndrome. This changes the conceptual and practical approach to dementia: preventive measures are exploited, which act on the epigenesis of dementia. Now we can talk of the genetic and epigenetic nature of senile dementia. Metabolic connectivity is the key word for the future study of neurodegenerative diseases. It means the intertwining of the metabolic pathways for which the increase in the level of a certain metabolite may correspond to the increase (or the decrease) of other metabolites, depending on the metabolic pathway taken. Each disturbance of cell physiology will be characterized by having its own “metabolic fingerprint”, i.e., variations of metabolite levels in certain areas of metabolism, which will be strictly specific with respect to the physiological disturbance. Given the great level of connectivity of the metabolism, it will be difficult to analyze and interpret these metabolic changes without the use of mathematical models. According to Systems Biology, therefore, the functional properties of the cell result in emerging properties, directly determined by metabolism. Understanding how metabolism is regulated and how all other events occur, as well as how informational cells act on metabolism, and how metabolites act on other events of cellular life, is far from simple. A mosaic is not examined by concentrating attention on the individual tiles: the most detailed analysis of the parts cannot in fact provide an idea of the whole. Numerous future studies are needed to delve into this new fundamental view based on Systems Biology and metabolism. These approaches which will constitute the “systems metabolomics” studies will be the new cornerstones for the interpretation of biological processes.


Admission hyponatremia, frequent in patients hospitalized for COVID-19, has been associated with increased mortality. However, although euvolemic hyponatremia secondary to the Syndrome of Inappropriate Antidiuresis (SIAD) is the single most common cause of hyponatremia in community-acquired pneumonia (CAP), a thorough and rigorous assessment of the volemia of hyponatremic COVID-19 subjects has yet to be described. We sought to identify factors contributing to mortality and hospital length-of-stay (LOS) in hospitalized COVID-19 patients admitted with hyponatremia, taking volemia into account.Retrospective study of 247 patients admitted with COVID-19 to a tertiary hospital in Madrid, Spain from March 1st through March 30th, 2020, with a glycemia-corrected serum sodium level (SNa) < 135 mmol/L. Variables were collected at admission, at 2nd-3rd day of hospitalization, and ensuing days when hyponatremia persisted. Admission volemia , therapy, and its adequacy as a function of volemia, were determined.Age: 68 years [56-81]; 39.9% were female. Median admission SNa was 133 mmol/L [131- 134]. Hyponatremia was mild (SNa 131-134 mmol/L) in 188/247 (76%). Volemia was available in 208/247 patients; 57.2% were euvolemic and the rest (42.8%) hypovolemic. Hyponatremia was left untreated in 154/247 (62.3%) patients. Admission therapy was not concordant with volemia in 43/84 (51.2%). In fact, the majority of treated euvolemic patients received incorrect therapy with isotonic saline , whereas hypovolemics did not (p=0.001). The latter showed higher mortality rates than those receiving adequate or no therapy . The administration of isotonic saline to euvolemic hyponatremic subjects was independently associated with an elevation of in-hospital mortality .Hyponatremia in COVID-19 is predominantly euvolemic. Isotonic saline infusion therapy in euvolemic hyponatremic COVID-19 patients can lead to an increased mortality rate. Thus, an exhaustive and precise volemic assessment of the hyponatremic patient with CAP, particularly when due to COVID-19, is mandatory before instauration of therapy, even when hyponatremia is mild. The SARS-CoV-2 virus is still capable of inducing infection, severe disease and death, even when optimally treated. In fact, the WHO has reported 1.5 million new cases and 7300 deaths over a 28-day period following the end of the public health emergency, with countries such as Ireland and South Korea communicating an increase in the mortality rate of infected patients (The severe acute respiratory syndrome caused by coronavirus-2 (SARS-CoV-2), known as Coronavirus disease 2019 (COVID-19), has been affecting populations since the end of 2019. Although the Word Health Organization (WHO) announced on the 5Hyponatremia in COVID-19 is observed in 20.5% to 35.8% of cases at admission , 7. FurtLegionella pneumonia (Hyponatremia has long been recognized in patients with community—acquired pneumonia (CAP). In fact, Cuesta et al. detected hyponatremia (Na ≤130 mmol/L) in 8.3% of patients admitted with CAP in a prospective study conducted in a tertiary Dublin hospital. The Syndrome of Inappropriate Antidiuresis (SIAD) was identified as the most common cause of a low serum Sodium level (SNa) in this study . Others neumonia . Pressurneumonia –21.Inflammation itself could be contributing to the development of hyponatremia in COVID-19 patients. Prior to the pandemic, inflammatory cytokines such as Interleukin-6 (IL-6) and Interleukin-1β had been shown to stimulate non-osmotic secretion of AVP –25. In pBefore the etiology of a low SNa in a given patient can be identified, the volemia of the subject must be ascertained. Only once the hyponatremic patient has been classified as hypervolemic, hypovolemic, or euvolemic, can a diagnosis be made of the cause of the electrolyte disorder. And not only is a correct volemic classification of hyponatremia necessary for diagnosis, it is also an imperative for correct therapy. In fact, the approaches to COVID-19 hyponatremia that have been published by three scientific societies stress the importance of a correct assessment of volemia in the management of the hyponatremic patient with COVID-19 –31. Yet,The differentiation of euvolemia from hypovolemia has habitually been considered a pitfall in the approach to the patient with hyponatremia , 32. In Heretofore no study has applied a rigorous approach to the assertation of volemia in hyponatremic COVID-19 patients, based on the physical examination, and supported by laboratory findings. Nor has the response to therapy as a function of volemic status been investigated. Yet, as previously stated, a correct evaluation of volemia is essential to assure the hyponatremic patient is properly treated. The purpose of this study is to determine the rates of euvolemic, hypovolemic and hypervolemic hyponatremia in patients admitted with COVID-19 and analyze whether admission volemia and volemia-guided therapies are associated with in-hospital mortality, hospital length of stay (LOS), and the evolution of hyponatremic patients. We further sought to detect the prevalence and mortality rates in hyponatremic COVID-19 patients, and the factors related to the latter.2All adult (≥ 18 years of age) patients with confirmed COVID-19 and hyponatremia at admission, hospitalized at the Hospital Clínico San Carlos (HCSC) of Madrid, Spain, during the first wave of the COVID-19 pandemic in March of 2020, were analyzed. A total of 750 COVID-19 patients were attended during this period, and their clinical records were reviewed. Only patients with a positive reverse-transcriptase polymerase chain reaction test for SARS-COV2 were included. Hyponatremia was defined as a serum sodium level (SNa) < 135 mmol/L after correction for glycemia when appropriate . This stThe following variables were registered: age, sex, previously diagnosed comorbidities , chronic medication . Clinical parameters were collected at admission, the 2nd-3rd day of hospitalization, and at the patient’s discharge . Additionally, information on admission treatment for hyponatremia  and admissions volemic status was collected. In patients with persistent hyponatremia, SNa levels from additional days were registered, permitting the calculation of the total number of days on which SNa was measured, and days with hyponatremia during hospitalization.Volemia was categorized as hypovolemia, euvolemia or hypervolemia. Hypovolemia, based on the data recorded in the clinical records, was defined as a maximum height of the internal jugular pulse (HIJP) below 1 cm over the sternal angle with the patient reclined at 0-30°, plus at least two of the following: thirst, orthostatic symptoms, blood pressure ≤ 90/60 mmHg, heart rate ≥ 90 bpm, urinary sodium ≤ 30 mmol/L in the absence of polydipsia or a low sodium intake, and/or a rise in SC and/or SU accompanying the descent in SNa , 44, 45.Adequacy of treatment was categorized as “adequate” or “inadequate” as follows: “Adequate” when euvolemic hyponatremia patients had received therapy with FR, furosemide, urea, or tolvaptan, as well as when hypovolemic patients were administered ISI. Therapy was considered “Inadequate” when euvolemic hyponatremic patients received ISI, and when hypovolemic hyponatremic patients received furosemide, urea, tolvaptan, or if FR was indicated. The administration of NaCl tablets as sole therapy was considered inadequate in all cases, as isolated salt administration per se is not a therapy for hyponatremia .2.1Categorical variables are described in frequencies and percentages, and quantitative variables in median and interquartile range [IQR] when non-parametric or means and standard deviation (±) when parametric. The comparative analysis was performed with the Chi-squared or Fisher test for categorical variables, and with the Mann-Whitney U or Kruskal-Wallis tests (if non-parametric) and T-student or ANOVA tests (if parametric) for quantitative variables.Multivariate logistic and linear regression analyses were performed. The logistic model of the multivariable analysis included all variables with either a p significance < 0.1 in the univariate analysis or with clinical relevance. Forward steps methodology was used in both multivariate analyses. A two-tailed p value < 0.05 was considered statistically significant. Ninety-five percent confidence intervals (95% CI) were calculated for determination of the Odds Ratio (OR) and coefficient B (B). Statistical analysis was performed using SPSS version 25 .3Two hundred forty-seven (32.9%) of the 750 Covid-19 patients admitted presented with hyponatremia and were included in the current study. The median age was 68 years [56-81], and 99/247 (39.9%) were female. An admission SNa ranging from 131-134 mmol/L was found in 188/247 (76%) patients, a SNa ≤130 mmol/L in 52 (21.1%), with SNa ≤125 mmol/L detected in only 7 (2.8%). In our cohort, 53 (21.5%) patients died during hospitalization. Baseline characteristics and admission factors associated with hospital mortality in the studied cohort are displayed in 3.1Volemic status data was available in 208 patients, 89 of whom (42.8%) were classified as hypovolemic and 119/208 (57.2%) as euvolemic. No patient was found to be hypervolemic. The factors associated with hypovolemia or euvolemia at admission are described in Patients with hypovolemia were more likely to present an admission SNa ≤ 130 mmol/L than those euvolemic , while similar rates of a SNa ≤ 125 mmol/L were found in hypovolemia and euvolemia .We did not find any impact of admission volemic status on mortality, LOS, persistence of hyponatremia at 2nd-3rd day, nor on the number of days of hospitalization with hyponatremia Table 3.3.2No therapy for hyponatremia was ordered in a majority of patients: 154/247 (62.3%). 74/247 (30%) patients were treated with ISI, 4/247 (1.6%) with furosemide plus NaCl tablets, and 11/247 (4.5%) solely with NaCl tablets. Chronic, rather than acute treatment with a loop diuretic, was not considered to be a treatment of hyponatremia . No patiWhen identifying patients who received specific therapy for hyponatremia in whom volemic status had been ascertained, 84 subjects remained (43 hypovolemic and 41 euvolemic). In these, we analyzed the adequacy of their treatment as a function of volemic status. Therapy was not in accordance with volemic status in a total of 43/84 (51.2%) of treated subjects. The treatment ordered was more frequently incorrect for volemic status in euvolemics, with 37/41 (90.2%) administered an inadequate treatment, whereas only 6/43 (14%) hypovolemics were incorrectly treated. The difference between the two groups was statistically significant (p<0.001).3.3Factors associated with in-hospital mortality in the univariate analysis are displayed in The mortality rate was similar when comparing those adequately and inadequately treated . Yet, analysis of the entire cohort detected a higher mortality rate in those treated when compared with those not receiving therapy .Upon further analysis, when classifying patients by volemic status, the mortality rate of treated euvolemic subjects was significantly higher than that of euvolemics not receiving therapy , whereas this difference was not observed in the case of hypovolemics  , and an oncological history  were independently associated with mortality. Given that the registry of an oncological history was available only in the 23.8% of the cohort, thereby affecting the potency of the analysis, we excluded this variable in the following model. Thus, in the second multivariate analysis, age , OSat levels , SC levels  and the presence of treatment for hyponatremia (OR: 2.257. 95%CI: 1.06-4.81) were independently associated with mortality. However, when in a third analysis, we replaced the presence of any treatment of hyponatremia with the adequacy of therapy, only age  and OSat levels  remained associated with mortality in the entire cohort.We performed another multivariate analysis  assessing the effect of therapy as a function of volemic status. We found that the incorrect therapy of euvolemic subjects with ISI to be independently associated with mortality (OR: 3.877. 95%CI: 1.25-12.03). In hypovolemic subjects, this was not the case.Additionally, we compared the medians of SNa, glycemia, SC, SK, urea, and SAlb at the 2nd-3rd hospitalization day of the patients who died and those who survived Figure 2However, we found that the patients who died had a higher median rate of hospitalization days with hyponatremia , as well as a lower median LOS than survivors . Thus, in patients who died, there was also a higher median rate of SNa measurements with hyponatremia . A univariate logistic regression showed that the higher the rate of hospitalization days with hyponatremia, the higher the risk for mortality .3.4SNa values at the 2nd-3rd day of hospitalization were available in 210 patients of the entire cohort, and a mean increment in SNa of 4 ± 3.2 mmol/L was observed. SNa decreased at the 2nd-3rd day of hospitalization in 16 (7.6%). Hyponatremia persisted in 72/210 (34.3%) patients. Initial admission treatment or non-treatment of hyponatremia did not modify the rate of patients showing a SNa descent , nor did the presence or absence of inadequate therapy , upon analyzing the entire cohort.Although the difference were not statistically significant, we did observe in the entire cohort that patients adequately treated were less prone to remained hyponatremic at the 2nd-3rd day than those receiving inadequate therapy  and had a slightly higher median SNa  as well as a higher increment of SNa levels  at 2nd-3rd day than those incorrectly treated. These differences disappeared upon analyzing euvolemic and hypovolemic subjects independently.The median LOS , days with hyponatremia during hospitalization , and the mean nadir SNa values  were similar when comparing adequately and inadequately treated patients.4Close to a third (32.9%) of the patients hospitalized for COVID-19 during the first wave presented with hyponatremia at admission in the current study. Their mean age was 68, and they were predominantly male (over 60%). In the vast majority 76%), hyponatremia was mild, with glycemia-corrected SNa levels of 131-134 mmol/L. A SNa ≤125 mmol/L was found in only 2.8% of the patients studied. These findings are in accordance with prior studies of COVID-19 patients , and the remaining subjects hypovolemic (42.8%). No hyponatremic patient was hypervolemic. To our knowledge, this report is the first to describe the volemia of hyponatremic COVID-19 patients with a rigorous approach that includes the physical examination, as well as biochemical data, and the evolution of the latter during hospitalization.The volemic classification of patients with hyponatremia remains a challenge for clinicians, and error is frequent . One reaOf greater use in the differential diagnosis of hypovolemic from euvolemic hyponatremia, among indirect measurements, could be the evaluation of the changes in serum creatinine levels in relation to modifications in serum sodium levels, since in hypovolemia, creatinine levels rise as SNa descends. This method, long used in clinical settings, has been recently validated by Ruiz- Sanchez et al, although its generalized use warrants further investigation , 44, 45.To our knowledge, only 3 reports have attempted to classify volemia in COVID-19 hyponatremia, all exclusively using one or more of the aforementioned biochemical parameters as guides , 27, 50.The other 2 studies , 50 usedOur results in terms of the predominance of euvolemia, however, are in line with those of Cuesta et al., in a prospective study with a rigorous approach to volemic classification, in patients with non-COVID-19 CAP . The afoAlthough an initial analysis detected that patients who received any treatment for hyponatremia died at a higher rate than those who did not, further analysis indicated that this finding was due to the high rate of administration of inadequate therapy: a full 51.2% of patients did not receive treatment in accordance with their volemia. In fact, error was practically a constant in the therapy of euvolemics, 90% of whom were incorrectly treated, specifically with isotonic saline infusion (ISI). Thus, an increased mortality rate was observed in treated euvolemics versus those euvolemics not receiving any therapy at all. Of greater importance was the finding that the patients with euvolemic hyponatremia at admission who had received therapy with ISI had a significantly higher mortality rate than those receiving no treatment whatsoever. In fact, ISI therapy was independently associated in euvolemics with an OR for a fatal outcome of 3.87. This is in contrast with the use of ISI in patients with hypovolemic hyponatremia, in whom ISI is indicated, and its administration did not induce a negative response. Thus, the finding that therapy was associated with a worse outcome should not be misconstrued as an attestation that hyponatremia should not be treated. Rather, it illustrates the importance of the administration of a correct therapy. And for the latter to be possible, an accurate volemic classification of the hyponatremic patient is essential.In the previously cited article by Cuesta et al. the authors, in concordance with our results, detected no significant differences in the mortality rates of euvolemic versus hypovolemic subjects with hyponatremia and CAP . Nor didIsotonic saline should not be administered to patients with euvolemic hyponatremia. It may not only fail to correct hyponatremia, but can even worsen it , 52 by iTreatment errors in the management of hyponatremia have been associated with a higher mortality rate , but in The high rate of incorrect therapy observed in the current study could be related to the specialties of the attending physicians during the initial COVID-19 crisis, that included surgeons, and ophthalmologists, many of whom had no prior experience in emergency medicine. Additionally, the extraordinary burden placed on Emergency Room personnel during the first wave of COVID-19 could also have had an impact on the assessment of hyponatremia, particularly when mild, and scant attention paid to it. In any event, our findings highlight the importance of a correct volemic assessment in the approach to the patient with hyponatremia, as incorrect therapy was related with fatal outcomes.The precise mechanism by which the use of isotonic saline in the euvolemic hyponatremic patients we have studied was associated with a higher mortality rate is unclear. Although we did detect higher rates of persistence or worsening of hyponatremia, and lower levels of SNa at the 2nd-3rd day of hospitalization in patients treated inadequately, these differences did not attain statistical significance. The latter could perhaps be related to the fact that the rates of moderate and severe hyponatremia were low, and mild hyponatremia predominant. Another possible contributing factor to the negative outcome observed in ISI–treated euvolemic patients could have been the development of fluid overload, although pertinent clinical information was not registered.We detected a mortality rate of 21.5% in the entire group of COVID-19 patients. Our finding is within the range that has been described by other authors, from 20 to 30·% , 51, 60.We detected no relationship between mortality and admission SNa levels per se in the current study, nor with admission volemia, nor with the persistence of hyponatremia at the 2nd–3rd day of hospitalization. However, the rates in normonatremic subjects with COVID-19 were not studied, and thus differences attributable to the presence or absence of hyponatremia itself could not be evaluated. The adequacy of treatment in the whole cohort and in hypovolemic patients had no impact on mortality. Sustained hyponatremia during hospitalization, on the other hand, was associated with a higher mortality rate, as patients with a higher rate of days of hospitalization with hyponatremia showed an increased risk for in-hospital death (OR 3.583). Similar findings have been described in non-COVID-19 patients receiving parenteral nutrition . Thus, tOur study has several important limitations. It is a retrospective study, and therefore, some collection biases could have occurred. Data on normonatremic subjects was not available to compare with those hyponatremic, making the identification of a possible link of hyponatremia per se to mortality impossible. Furthermore, the management of patients could not be considered to be standard clinical practice, as patients were attended during the first wave of the pandemic in the setting of a public health crisis, in which the health system was overwhelmed. In fact, multivariable analyses showed an association of these variables with mortality Another important weakness is the lack of information regarding previous episodes of hyponatremia, as well as symptoms such as vomit, nausea or diarrhea, or other comorbidities at admission that can be a cause per se of hyponatremia. Another serious limitation of the study is that these data were not released in a timely manner, soon after the start of the pandemic and its first wave. However, given the continued presence of COVID-19 infection and the possible relevance of the results to the therapy of euvolemic hyponatremia in general, upon analysis of the data initially collected, we feel that the results have enough clinical relevance to merit their communication to the scientific community.The main strength of our study is the meticulous collection of volemic data and the assessment of the adequacy of the treatment of hyponatremia. Furthermore, all patients of the tertiary HCSC admitted during the time of study were included, permitting a sufficient number of subjects for statistical analysis. Another advantage is the homogeneity of the patients studied as regards the microbial origin of their CAP, as well as the setting in which they were hospitalized, perhaps facilitating the detection of the consequences of inappropriate therapy for hyponatremia.In conclusion, the majority of COVID-19 patients with hyponatremia are euvolemic, and the descent in serum sodium is mild. Furthermore, in most cases, eunatremia will be attained by the 2nd-3rd day on the wards, regardless of therapy. However, those patients who are euvolemic and receive iv isotonic saline infusion are at a higher risk for in-hospital mortality, as are hyponatremic patients of advanced age, those presenting with a reduced OSat, an increased SC, and/or an oncological history. Although COVID-19 is no longer a public health emergency, it is still a prevalent disease that will presumably remain with us for many years . We thusThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Research Ethics Committee of the HCSC (20/396-E_COVID). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.MP-G, JR-S, JM and IR-V contributed to conception and design ofthe study. MP-G and JR-S organized the database and performed the statistical analysis. MP-G, JR-S wrote the first draft of the manuscript. MP-G, JR-S, and IR-V wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.


The principal component analysis method was used to explore the overall differences in flavor spectra, and a total of 60 compounds were identified. The fingerprints of volatile organic compounds in the samples showed that the volatile organic compounds with doses of 60Co irradiation in about 0 kGy and 5 kGy are similar, while the 10 kGy samples are quite different. The PCA results showed that the similarity between 0 kGy and 5 kGy was slightly higher, and the difference between 10 kGy and other samples was greater. Therefore, it was determined that 60Co irradiation with a 10 kGy intensity has a significant influence on the content of volatile oils components, while 60Co irradiation with a 5 kGy intensity has little effect. Irradiation technology is demonstrated as a promising method of food sterilization, but the irradiation dose and chemical composition must be taken into consideration.In recent years, as the desire for a healthy lifestyle has become more widespread, consumers are gaining an increasing appreciation for safe, high-quality food. Researchers are constantly seeking new ways to protect foods from insect pests and fungi. This study used GC-IMS to analyze the volatile organic compounds and flavor characteristics of Finger Citron in response to different doses of  Citri Sarcodactylis Fructus) is the dried fruit of Citrus medica L. var. sarcodactylis Swingle. When the fruit turns yellow in autumn, it is collected and is distributed throughout Guangdong, Sichuan, and Zhejiang, China. It is widely used in Chinese food and as a traditional Chinese medicine, which is often used for regulating the liver’s and stomach’s qi flow and relieving pain [Escherichia coli, Bacillus subtilis, and Staphylococcus aureus; they also have an effect on antidepressants and inhibit the reproduction of cancer cells [Finger Citron  has a more efficient separation ability, and with its high selectivity, instrumental simplicity, analytical flexibility, portability, and quasi-real-time monitoring capacity, it can be widely used to analyze the differences in the volatile organic compounds of different products ,17,18,19In this study, the volatile flavor substances of Finger Citron volatile oils were analyzed using GC-IMS technology after irradiating at doses of 0, 5, and 10 kGy. Using fingerprint and principal component analyses, the differences and associations of volatile flavor substances under different irradiation doses were explored.We collected fresh finger citrons from Jinhua, Zhejiang, China, and Prof. Zhaoming Xie identified them at the Hunan Academy of Traditional Chinese Medicine. A voucher specimen (HNATCM2021-010) was deposited in the herbarium of the Hunan Academy of Traditional Chinese Medicine and stored at 4 °C.2SO4 and divided them into three equal parts for 60Co irradiation  with a radiation source intensity of 2.96 × 1016 Bq using the dynamic stepping irradiation method. The dose rates were 0, 5, and 10 kGy/min. The 60Co γ radiation source was located at Hunan Radiological Technology Application Research Center .We then dehydrated the Finger Citron EOs with anhydrous NaFirst, 0.5 kg of Finger Citron was placed in a round-bottomed flask (chopped up before the extraction), which was filled with 3300 mL of water to immerse the Finger Citron. This was extracted via steam distillation and slightly boiled (100 °C) for 5 h. Heating was stopped when the volume of the volatile oil no longer increased. We separated the volatile oils layer, preserved it in a sealed tube, and stored it at 4 °C for analysis.®-G.A.S., Dortmund, Germany). With the carrier gas, samples were introduced into the instrument: first through the gas chromatography column, then into the ion drift tube.The GC-IMS analysis was performed using a GC-IMS instrument , the column temperature was 60 °C, and NInitially, the carrier gas velocity program was set at 2.0 mL/min, which was maintained for 2 min and then increased linearly to 100.0 mL/min from 2 min to 20 min. After that, it was maintained at 100.0 mL/min from 20 min to 40 min. The flow was stopped after a 40 min runtime.2 was the drift gas, and its flow rate was 150 mL/min. Temperature kept at 45 °C.IMS conditions: NIn order to identify compounds, linear retention indices and mass spectra of GC-IMS data were compared with the NIST 17 database. Our analysis of GC-IMS data  was performed using Reporter, Gallery Plot, and GC-IMS Library Search. The detected Finger Citron volatile oils were determined by combining the retention index (RI) and drift time (Dt) using NIST Library and IMS database retrieval software from G.A.S (version 2.0.0). This plug-in was used for dynamic PCA, cluster analysis, and a rapid determination of known and unknown samples.60Co doses of 0 kGy, 5 kGy, and 10 kGy is shown in x, y, and z axes in the figure represent the drift time, gas chromatography retention time, and peak intensity, respectively. This shows that the peak signal distribution of each group is generally similar, and there is a certain difference in peak signal intensity, indicating that the VOs of Finger Citron volatile oils in each group are generally similar under different irradiation doses, and no new substances are generated. However, there are certain differences in content. By projecting the three-dimensional GC-IMS spectrum, we obtain a two-dimensional GC-IMS plan. Each point represents a volatile oil; the closer the color is to red, the higher the concentration, while the closer it is to white, the lower the concentration. This allows for a more direct evaluation of the volatile species and concentration differences in each sample.A three-dimensional spectrum of volatile organic compounds at x-axis represents the GC drift time , the y-axis represents the retention time (s), and the z-axis represents the intensity of the peak. With blue as the background, the bright spot indicates a substance; the closer its color is to red, the greater the concentration.Note: The As shown in Using FS-1 as a reference to establish a difference comparison model, we obtain the results shown in In the GC-IMS 2D pattern, the three samples are reflected in the difference in the content of each volatile substance. On this basis, combined with the NIST and IMS databases built into the software, the volatile organic compounds were qualitatively analyzed, and the ion mobility spectrum of This study identified a total of 60 peak signals, including 10 aldehydes, 10 alcohols, 8 esters, 4 olefins, 4 ketones, 3 acids, and a few pyrazine, pyridine, and furan compounds. The qualitative analysis results of Finger Citron volatile organic compounds are shown in The peak volume of 60 volatile organic compounds of three irradiation doses of Finger Citron volatile oils was selected as the characteristic variable for principal component analysis, as demonstrated by The fingerprints of the volatile organic compounds of the three irradiated doses of Finger Citron are shown in 60Co doses of 0 kGy, 5 kGy, and 10 kGy, the volatile organic compounds of FS-1, FS-2, and FS-3 samples were qualitatively analyzed using GC-IMS, and no new chemical substances were produced after 60Co irradiation. Analyses of spectrograms and peak volume data revealed that irradiation can affect the content of volatile organic compounds, and different chemical substances will undergo different changes. For example, the content of Geranyl acetate, Ethyl cinnamate, Citral, alpha Terpineol, etc., increased with the increase in irradiation dose; Ethyl phenylacetate, Linalool, Z-Ocimene, and others had the highest content at a radiation dose of 5 kGy 60Co, followed by that of 10 kGy, but there was no significant difference between them and that of 0 kGy; Methylpyrazine, 2,3-Butanediol, Propyl acetate, etc., had the highest content at 0 kGy. Therefore, this study concludes that the chemical composition of Finger Citron volatile oils only changes in response to an irradiation dose of 10 kGy 60Co, and GC-IMS technology is suitable for a component analysis of volatile oils. As a widely used traditional Chinese medicine with multiple functions, Finger Citron will be subjected to more in-depth research on the specific changes in the content of its active ingredients to determine whether it will lead to changes in pharmacological effects, and the gradient selection of increased irradiation. We will explore this further in future research.As food and medicine with a high utilization value, Finger Citron volatile oils are an active ingredient . The com60Co irradiation dose has a greater effect on (E)-2-Pentenal, Pyridine, Ethyl propanoate, Propyl acetate, Acetic acid, Methylpyrazine, and other compounds, but less of an impact on terpenes. In summary, this study suggests that 60Co irradiation will affect the components of Finger Citron volatile oils, but the impact on its main components is small, and the moderate measurement of 60Co irradiation sterilization can be used in the sterilization of Finger Citron medicinal materials, providing a certain reference for the storage and processing of Chinese medicinal materials [In this study, GC-IMS was used to detect the volatile organic compounds of Finger Citron volatile oils after sterilization at irradiation doses of 0, 5, and 10 kGy. Based on the built-in NIST gas retention index database and the IMS drift time database, the volatile organic compounds of three volatile oils samples were qualitatively analyzed, and it was determined that the content of terpenes in Finger Citron volatile oils was the highest. By analyzing the GC-IMS fingerprint, PCA, and adjacent Euclidean distance map of the sample, and comparing the content differences of FS-1, FS-2, and FS-3, it can be concluded that irradiation does have a specific effect on the volatile organic compounds of Finger Citron volatile oils, and the larger the irradiation dose gap, the greater the impact on the content of the compound; however, no new compounds are generated. Comparing the fingerprints of the three irradiation doses of Finger Citron volatile oils, it can be observed that a 10kGy aterials .GC-IMS has a rapid response time and efficient separation capabilities ,31,32,33In today’s world, in which food safety issues are so highly valued, irradiation sterilization technology has undergone over one hundred years of development . It can


Work in heat affects millions of workers. Although kidney function in agricultural workers is increasingly researched, nonagricultural studies are scarce. In coastal salt pans, the absence of occupational exposures to pesticides and other toxicants allows assessment of heat stress alone.2) was computed. Heat-strain symptoms were assessed using questionnaires.Seven Indian salt pans were surveyed from 2017 to 2020. Job-specific workload was assessed. Heat stress was characterized as exceeding the wet bulb globe temperature (WBGT)-threshold limit value (TLV) for high and moderate workloads. Preshift and postshift heart rates (HRs), tympanic temperatures, and urine specific gravity (USG) were measured for 352 workers, as were sweat rates (SwR), serum creatinine (SCr), serum uric acid, and urine dipstick. Estimated glomerular filtration rate .The mean WBGT was 30.5 ± 1.3 °C (summer) and 27.8 ± 1.9 °C (winter). Water intake during the workday was low, median was one Litre, and most workers (87%) exceeded the TLV for heat stress. Dehydration-related symptoms were frequent in those with high-heat stress, as were cross-shift increases in temperature , a high USG , and a high SwR . An eGFR of 60 to 89 ml/min per 1.73 mWorkplace interventions to prevent heat stress and dehydration in the salt pans and other at-risk industries are urgently required. The findings strengthen the notion that high-heat stress and limited hydration is a risk factor for kidney dysfunction.  Page 1283See Commentary on ,13Climate change is expected to increase temperatures by at least 1.5 °C around the globe in the coming decades, with an increasing frequency and intensity of heat waves already here.Heat stress is defined as the net load resulting from the combined contributions of environmental heat, metabolic heat, and clothing.22The majority of epidemiologic research on CKDu has hitherto been done in agricultural settings, in line with the alternative theory that pesticides, agrichemicals, or other environmental toxins are the main culprits.,In many coastal areas around the world, salt pan work is a common occupation largely done in the informal sector where the workers do not have fixed employment terms and workplaces are not formally registered.We conducted a cross-sectional investigation among salt pan workers. After initial contacts and walk-through surveys by a certified industrial hygienist (author VV), we chose 7 salt pans, 4 in Marakkanam and 3 in Vedharanyam, Tamil Nadu, India . The stuam and 2 pm, with a lunch break of 30 minutes to 1 hour in the open air. The workers did not have any other breaks during active working hours. Apart from sparse vegetation, there were no shaded areas for the workers to rest. The workers brought water bottles from home and could refill them at the workplace, and the sanitation was poor with no toilet facilities. Whereas the salt pans in Vedharanyam were not run in an industrial way, the salt pans in Marakkanam were run in a partly industrial way with stricter production goals and piece rate wages. The laborers were largely locals who work in the salt pans on a seasonal basis. During the half-year long rainy period when the salt pan is idle, the workers hunt for other informal work.Work tasks in the salt pans included mud-border making, trampling the ground, salt crystal reshuffling, salt-scrapping, raw salt heaping, loading, packing, crushing, mill operations, and supervision. Working hours were between 6 On the days of workplace visits, we aimed to recruit workers who had more than 1 year of working experience in the salt pans. By this convenience sampling, approximately 20% of the daily workforce was included. Of the 380 salt pan workers who were initially recruited, 9% reported preexisting known medical disorders such as diabetes or hypertension and were therefore excluded, leaving a final sample group of 352 workers. We investigated 201 workers in the summers of 2017, 2018, and 2019; and 56 workers in the winter of 2018 in the salt pans in Vedharanyam. In Marakkanam, we investigated 53 workers during the summer of 2018, and 42 workers during the winter of 2020. All workers were acclimatized to the environmental conditions. The Institutional Ethics Committee at Sri Ramachandra Institute of Higher Education and Research (IEC-NI/17/APR/59/54) approved the study, and the workers gave their informed consent to participate.Trained field workers administered a questionnaire translated from the High Occupational Temperature Health and Productivity Suppression questionnaire.Using a structured interview, we gathered information about job history, socioeconomic characteristics, chemical and pesticide exposures, infections, snake bites, diabetes, hypertension, and heat stroke. Heat stress and heat strain symptoms such as excessive sweating, thirst, tiredness, cramps, headache, nausea, vomiting, fainting, or prickly heat/rashes, as well as urogenital issues such as burning sensations, rashes, and urinary tract infections were collected using a modified version of the “High Occupational Temperature Health and Productivity Suppression” questionnaiream to 2 pm). Assessment for each specific work task was done in about 2 to 3 shifts, totaling 8 measurements across the 2 seasons. To determine the workers' attributed WBGT exposure during a work shift, we monitored the hourly ambient WBGT during normal shift hours and averaged the hourly data. To assess the risk of heat stress on the day of investigation (above or below TLV-WBGT), we categorized the workers using the corresponding attributed WBGT with the American Conference of Governmental Industrial Hygienists TLV of 27.5 °C for heavy workload and 28 °C for moderate workloadWe measured environmental climatic conditions according to the American Conference of Governmental Industrial Hygienists 2018 guidelines, using a calibrated portable heat stress WBGT monitor  with an accuracy level of 0.5 °C between 0 °C and 120 °C of dry bulb temperature and 5% relative humidity.,Experienced occupational hygienists (author VV) evaluated workloads while taking WBGT measures and classified each job type following the American Conference of Governmental Industrial Hygienists screening limits for work category.Each worker was examined twice, first in the morning before the start of work, then again during and at the end of the workday. The tympanic temperature, a proxy for core body temperature, was measured using an infrared ear thermometer (BRAUN ThermoScan IRT 6020). A temperature increase of more than 1 °C during the workday was deemed unfavorable.,,,Workers’ preshift weight was assessed once they reached the field, using a digital weighing scale . Midshift, usually after 2 to 5 hours, each participant’s weight was assessed before delivering their urine samples, and fluid consumption was reported. Thereafter, a urine spot sample was obtained. SwR was calculated by dividing the difference in preshift and midshift body weight plus self-reported fluid consumption by the observation time.Two different kinds of urine dipsticks (Dirui H10 and Siemens Multistix) were used to assess proteinuria, hematuria, pH, and leucocytes. The USG was determined using a refractometer, with USG ≥1.020 being considered excessive.P-value cut off of 0.05. To begin computing multivariate logistic regression, we performed the chi-square test to determine the significance of the independent variable in relation to covariates. The second stage involved calculating the adjusted odds ratios between the independent and dependent variables after controlling for major confounding variables (gender and age). In the second stage, the other nonsignificant confounders were excluded. Considering that the number of years of exposure is dependent on age, a correlation analysis was conducted. A Spearman correlation coefficient test shows age and years of exposure were moderately correlated (0.6); therefore, age (categorized) was used as one of the confounders in the main analysis. The multivariate logistic regression was not adjusted for smoking or alcohol intake, which exclusively occurred in men; however, correcting for gender eliminates this confounding factor. We utilized SPSS statistical program version 16.1  and Microsoft Excel for data analysis and for preparing the graphs.We used Microsoft Excel for data entry and consolidation. For demographic variables, heat exposure (WBGT °C), self-reported heat-related health symptoms, and physiological indicators, descriptive statistics were utilized. The dependent variables  were categorized according to the standard range. Chi-square tests were used to examine categorical variables. The Wilcoxon signed rank test was used to analyze comparisons between preshift and postshift physiological heat strain markers because it is continuous data. Multivariate logistic regression models employing a stepwise strategy for controlling probable confounders yielded adjusted odds ratios with a The median age was 47 years. The workers were aged 18 to 85 years. More than half of the workers had spent more than 15 years in the salt industry. The majority (85%) had heavy manual job tasks such as loading and unloading salt heaps, whereas 15% had moderate job task such as leveling the ground or constructing small mud walls for brine storage. There were no light-duty jobs. Less than half of the workers had completed primary school, and many were illiterate, particularly women . Unlike am  reported that they had experienced at least one of the self-reported heat-strain symptoms, here defined as excessive sweating, thirst, dizziness, muscle cramps, headache, nausea/vomiting, fainting, or prickly heat/rashes during the current season. The reported prevalence of each of these symptoms is given in Workers identified as having higher heat stress, or higher workload, more often reported more symptoms of dehydration than those with less demands . Heat st2) was seen in 56% (n = 101) of male workers and 38% (n = 66) of female workers, predominantly among workers with high-heat stress. eGFRs below 60 ml/min per 1.73 m2 were found in 7% of workers, of which 18 workers were males and 5 were females. The male workers had approximately 1.7-fold higher risk of eGFR (<90 ml/min per 1.73 m2) and approximately 3.1-fold higher risk of eGFR (<60 ml/min per 1.73 m2) compared to female workers after adjusting for years of exposure (>3 years and <3 years).The measured physiological responses are shown in Salt pan workers were exposed to high levels of occupational heat stress from the start of the workday. All participants had heavy or moderate workload, and 9 out of 10 workers were estimated to work above the limits of heat exposure (WBGT-TLVs) when, according to international regulations, frequent break periods should be imposed.Symptoms of dehydration were prevalent among workers, as were tiredness/weakness and other signs of heat strain. High USG levels observed before (10.1%) and after work (28%) and the average water intake of only 1 liter during the workday indicates a marked lack of rehydration. This likely depends not only on lack of access to palatable water during the workday but also indicates an adapted restricted fluid intake to avoid urination, a pattern which has been observed elsewhere in Indian settings without access to proper sanitation, especially among women.The strength of this salt pan study is the extensive WBGT monitoring, where variation in microclimate between locations and sampling days but limited variation within job tasks allowed the construction of job-exposure matrices for workload and heat stress based on WBGT-TLVs, which were then attributed to individual workers. The convenience sample can be seen as a limitation, but we have no reason to suspect that it was severely biased with respect to the outcomes of interest, being both self-reported and measured. The physiological measurements as well as the workload and heat stress classification represent a single day for the individual, but we presume that this day, at the group level, also is representative of labor over a longer period and thus work throughout a season, that is, the same time span as the questionnaire assessment of heat stress symptoms.Measurement of HR at work in a hot climate reflects the combination of the external heat load, the workload, and the resulting internal heat generation. The participants were assessed a short while after leaving their actual job tasks, therefore with an expected lower HR than during ongoing work. The assessment of sweat rate was limited by self-reported fluid intake, and lack of measurement of urine voids during the observation period. Continuous HR measurements during the workday would have strengthened the assessment of the actual workload and heat stress, but neither this, nor closely monitored fluid balance, was feasible during this investigation. Still, we find that the simple and cheap methods used, which are available in other low-resource settings, gave valuable information.,Heat, frequent dehydration, and intense labor have been linked to an increased risk of nephrolithiasis in other occupations.2, and 7% had an eGFR of less than 60 ml/min per 1.73 m2, all without proteinuria. The venous samples were taken once during the workday. Ideally, venipuncture in the morning to assess baseline S-Cr for estimation of eGFR at steady-state, and again at the end of the workday to assess cross-shift elevation and acute kidney injury should be performed, but this was beyond the scope of the present study. The validity of a creatinine-based Chronic Kidney Disease Epidemiology Collaboration equation in this disadvantaged Indian community may be called into question because a recent study from northern India found that all creatinine-based equations significantly overestimated glomerular filtration, whereas cystatin C equations were more accurate.Almost half of the workers had S-Cr values corresponding to eGFR of less than 90 ml/min per 1.73 m,,,In these heat-exposed manual workers, the finding of reduced eGFR in the absence of proteinuria and diabetes is similar to what has been reported in Mesoamerican sugarcane and construction workers.,The reported average intake of only 1 liter of water per day in bottles brought from home clearly speaks for workplace interventions to provide palatable water, safe sanitation, and education on the need to hydrate. Low technology workplace implementations focusing on regulated rests in shade, access to water and sanitation, and an understanding of why this is needed among employers and workers have been shown to reduce heat stress and kidney function loss in industrial agriculture,Our study performed with cheap and commonly available methods highlights the presence of high-heat exposure, workload, and physiological heat strain among these nonagricultural outdoor workers. In addition, a high prevalence of decreased kidney function was indicated. In a changing climate scenario, the expected rise in temperature will increase heat exposure and have negative health consequences for a large global workforce. Heat-exposed outdoor workers, especially from poorer areas, are among the most vulnerable populations. Even small increases in global temperature, as predicted by climate change,All the authors declared no competing interests.