The incidence of eclampsia and its adverse maternal outcomes are very high in developing countries, particularly in Subsaharan African Countries. Identifying predictors for adverse maternal outcomes of eclampsia has paramount importance for helping health care providers to optimize their management outcomes. Therefore, this study aimed to assess the incidence of adverse maternal outcomes of eclampsia and its determinant factors.A retrospective follow-up study design was applied. The data were extracted from patient charts using a structured, pre-tested, questionnaire. Descriptive analyses  were calculated, and bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. After the data were coded and entered into Epi-Info Version 7.2 Software, the data were analyzed using STATA Version 14 Statistical Software.3, AOR 34.9 ; platelet count between 50,000 and 99,000 cells/mm3, AOR 24.5 [95%CI = 5.4111.6]; and stillbirth of the current pregnancy, AOR 23.2 [95%CI = 2.1257.5] were strong predictors of adverse maternal outcomes in eclamptic mothers.The magnitude of eclampsia was 5.36 per 1000 pregnancies . The incidence of adverse maternal outcomes in eclamptic mothers was 53.7% . After adjusting for covariates maternal age 30–34, AOR 5.4 ; age above 34, AOR 10.5 ; gravidity 2–4, AOR 0.3 ; 10 or more convulsions, AOR 4.6 ; mild pyrexia, AOR 20.4 ; moderate pyrexia, AOR 14.6 [95% CI = 1.7125.1]; platelet count below 50,000 cells/mmThe incidence of adverse maternal outcomes of eclampsia was found to be high compared to similar studies discussed in this study. This study recommends early identification of patients with the risk factors , strengthening the referral system, and advocation of research on the area of adverse maternal outcomes and thereby encourage evidence-based medicine.The online version contains supplementary material available at 10.1186/s12884-021-04199-1. The overall global burden of eclampsia is 1.4% . HyperteAmong different characteristics, factors significantly associated with adverse maternal outcomes of eclampsia were gestational age, platelet count, the number of convulsions, birth weight, residence, maternal age, gravidity, and the presence of stillbirths –24.Essentially, morbidities and mortalities of eclamptic mothers can be prevented through the provision of early and effective medical treatments , 26. LesWe employed a retrospective follow-up study design to assess the incidence of adverse maternal outcomes of eclampsia and its determinants at the University of Gondar Compressive Specialized Hospital (UOGCSH), Gondar, Northwest Ethiopia. UOGCSH is one of the pioneer hospitals in the country and serving the population for more than 60 years. This teaching hospital provides more than 18 undergraduate and postgraduate programs in medicine and related sciences. Besides, it serves as a referral center for more than 7 million populations with varying climatic and geographical characteristics from related provinces, regions, and countries. Department of Obstetrics and Gynecology started a specialty program in 2010. There are now 50 residents and three subspecialty programs in three fields that have just opened. Every year, roughly 200,000 individuals visit the hospital, according to the Hospital Plan and Program Information Center. The total number of deliveries each year averages 8000. In this study, the data were collected from September 01, 2013, to August 31, 2020.All patients who were diagnosed with eclampsia during pregnancy or postpartum period and were admitted and managed as eclampsia at UOGCSH in the data collection period were included in the study. Patients with a previous history of epilepsy and patients with other causes for convulsions  were excluded from the study.The sample size was determined using the single population proportion formula by assuming a 95% level of confidence, 16% incidence , 5% margThe diagnosis and medical record number were searched from the morning presentation registry and all medical records/charts with eclampsia diagnosis were considered for data collection.A pretested and structured questionnaire was used for data collection. The data collection questionnaire was adapted from different literature , 30 and In the beginning, after the identification of eclamptic patient charts, all baseline data were collected. Then, all patient charts were followed to observe the status of the outcome. During the follow-up, all the necessary data were recorded . At the end of the follow-up, all outcome status, clinical management information, and maternal complications were also recorded meticulously.The adverse maternal outcomes of eclampsia were an outcome variable. It refers to maternal mortality or one or more serious complications of major organ morbidity. Eden’s criteria and WHO maternal near-miss criteria were employed for describing the severity of eclampsia. Adverse maternal outcomes are abruption placentae, DIC, maternal shock, HELLP, AKI, respiratory distress, neurologic complications, PPH, blood transfusion requirement, ICU admission, and maternal deaths.The explanatory variables are socio-demographic, clinical, laboratory, and management. These are maternal age, residency, parity, gestational age, number of gestation, the presence of antenatal care visit, place of antenatal care, eminent symptoms, the number of convulsions, duration of convulsions, referral system to our hospital, past obstetric history, history of self-chronic illness, history of family chronic illness, vital signs at admission, blood pressure at referral, labor initiation, duration of labor, place of delivery, mode of delivery, indication for cesarean section, antihypertensive requirement, anticonvulsant requirement, and laboratory/imaging findings.Definitions: Adverse maternal outcomes included maternal mortality or one or more serious complications of major organ morbidity. Hypertensive disease of pregnancy: Diastolic blood pressure (DBP) > 90 or systolic blood pressure (SBP) > 140 with two occasions at least 4 h apart and 1 week, after 20 weeks of pregnancy and 12 weeks of the postpartum period with ± proteinuria. Maternal death or maternal mortality is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. Maternal near-miss: The International Statistical Classification of Diseases and Related Health Problems 10th version defined a maternal near-miss case as a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy. Uncontrolled seizure: It is when there is a requirement of another anticonvulsant or reloading of Magnesium Sulfate after 15 min of an initial loading dose of Magnesium Sulfate to control recurrent seizures.After data extraction was completed, the data were checked for completeness and accuracy. Then, the data were coded and entered into Epi-Info Version 7.2 Software. Finally, the data were exported into STATA Version 14 Statistical Software for analysis.P-value < 0.2 were selected for multivariable analysis. A P-value < 0.05  was taken as a cut-off point for a statistically significant variable in multivariable logistic regression analysis. The goodness of fit was assessed by using the Hosmer and Lemeshow test.Univariate analyses were performed and presented as frequencies and percentages for categorical variables. Mean and Standard Deviation (SD) were reported for normally distributed data. The median and interquartile ranges were considered for non-normally distributed data. Bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. Bivariate analyses were made between independent variables and the outcome variable  and the variables with a A standardized data collection tool was employed, which is adopted and modified contextually. The data collection instrument was pretested for clarity and appropriateness before the actual data collection. To ensure the quality of data, the collected data were checked daily for completeness, accuracy, and clarity by the investigators. Data clean-up and crosschecking were done before analyses. The training was given to the data collectors for 3 days to equip them with the necessary skills. The investigators continuously supervised during the data collection process and the collected data were entered on the same day to address inconsistencies regarding wrong entries.Ethical clearance/approval was obtained from the ethics committee of the School of Medicine, University of Gondar. With this clearance, formal approval was sought and the permission for conducting the study  was secured from the administration of UOGCSH and the Department of Gynecology and Obstetrics before commencing the study. “Informed Consent waiver was obtained from the ethics committee of School of Medicine, University of Gondar”  and hospital directors . The confidentially of the data gathered was kept and handled during all phases of research activities. We confirm that all methods were performed following the relevant guidelines and regulations .The total deliveries in the study period were 46, 803, of which 251 patients were diagnosed with eclampsia and making the magnitude of eclampsia 5.36 per 1000 pregnancies . Of 251 eclamptic patients, 20 were excluded due to missing data/lost charts or not fulfilling the inclusion criteria, leaving 231 patients for analyses  of them had at least one antenatal care visit and the majority (147 patients) had antenatal care follow-up at a nearby health center , followed by the blurring of vision (38%) and vomiting (15%). Regarding the time of convulsion, 63.6, 13.4, and 22.9% were occurred in antepartum, intrapartum, and postpartum, respectively. Of all, about 34% arrived after 11 h of convulsion, 14.3% arrived after convulsion of more than 10 episodes, 83.5% experienced the first convulsion at home, and 11.7% experienced convulsion during transportation. In the present study, 86.6% of patients arrived after they were referred from one or two health facilities. Among the referrals (200 patients), 72% (144 patients) got anticonvulsants and the remaining 28% (56 patients) did not get anticonvulsants before referral. Among patients who were given anticonvulsants (144 patients), Magnesium Sulfate was given for 132 patients (91.7%) in which at least the loading or the loading and maintenance dose was administered and diazepam drip was given for 8.3% (12/144) of patients. The most common reason for referring eclampsia cases was due to inadequate setup and human power for managing eclampsia (76%) followed by the absence of basic workups for preeclampsia-eclampsia syndromes (47%). Of all eclamptic patients, 45% had spontaneous labor initiation, 3% had labor duration above 24 h, 12.5% (29 patients) had a history of home delivery, and 42.9% had a cesarean delivery. Of 99 cesarean deliveries, 78.8% (78 patients) were done at the intrapartum after labor initiation. The most common indication for cesarean delivery was failed induction (23.2%). Among the other six cases, cesarean sections were performed for cases of thick meconium in early labor, cord prolapse, antepartum hemorrhage with active bleeding and hemodynamic instability, and uterine rupture after induction with oxytocin. From the referred patients (200 patients), the blood pressure of 178 was measured. Among cases that had SBP of 160–199 mmHg (69 patients), 36 patients did not get antihypertensive at primary care. Moreover, of four patients with SBP above 200 mmHg, one patient did not get an antihypertensive drug at primary care. At admission, of 231 patients, 26.4% had SBP < 140 mmHg and 47.2% had SBP between140 and 159 mmHg. After admission, 23% (14/61) of patients with SBP < 140 mmHg and 62.4% (68/109) of patients with SBP with 140–159 mmHg required anti-hypertensive for elevated blood pressure in the severe range. Of anti-hypertensive medication (143 required), the most common anti-hypertensive was Hydralazine (prescribed for 93% of patients) followed by Methyldopa (prescribed for 60.1%) and Nifedipine (prescribed for 25.2%). Of all patients, 229 took anticonvulsant drugs at admission, and Magnesium Sulfate was the first drug of choice. Furthermore, Diazepam, Phenobarbital, Phenytoin, Mannitol, and other anticonvulsants were either added or given as alternatives to Magnesium Sulfate in 30 patients : 95% CI: 47.02, 60.24%] developed serious maternal complications  .Consequently, maternal age, gravidity, the number of convulsions, rise in body temperature, low platelet count, stillbirths of current pregnancy, mode of delivery, and labor duration were significant predictors of adverse maternal outcomes of eclampsia in the outputs of binary logistic regression analyses , gravidity 2–4, the number of convulsions, maternal body temperature (mild pyrexia and moderate pyrexia), platelet count , and stillbirth of the current pregnancy  of eclamptic mothers. This finding is in line with the study done in Ethiopia, 53% . NeverthMaternal age, gravidity, multiple episodes of convulsions, rise in body temperature, low platelet count, and stillbirth of the current pregnancy were the factors associated with adverse maternal outcomes. In this study, the odds of developing complications after the onset of eclampsia were ten times more common in the age group above 34 years compared to ages below 20 years, AOR 10.5 . The age group 30–34 years had a five times risk of developing adverse maternal outcomes as compared to their counterparts, AOR 5.4 . However, for the age group 20–29 years, there was no significant difference in developing adverse maternal outcomes as compared to less than 20 years. Similar studies that were done in Pakistan, China, and Uganda are in line with our study findings –37. ThisIn this study, gravidity was significantly correlated with adverse maternal outcomes of eclampsia. Women with 2–4 pregnancies are 71% less likely to be affected by adverse maternal outcomes compared to primigravidas, AOR 0.29 . Nevertheless, there was no significant association between adverse maternal outcomes of eclampsia and the number of pregnancies above four. This finding is similar to the study conducted in Nigeria, Pakistan, Eastern Ethiopia, Egypt, Uganda, and Addis Ababa , 37–39. In our study, there was a delay in reaching tertiary level medical care after the onset of convulsions, about 14.3% of patients came to tertiary care after having more than ten convulsions. The number of convulsions before admission was significantly correlated with the development of adverse maternal outcomes. Thus, patients with more than ten convulsions had a five times greater risk of developing adverse maternal outcomes than patients with less than ten convulsions, AOR 4.6 . Similarly, in a study done in Nepal about adverse maternal outcomes and their associated factors in 2018, the number of convulsions played a significant role in the prognosis of the eclamptic mother . This stAnother finding from the clinical characteristics was the patient’s body temperature; it had a strong positive association with adverse maternal outcomes of eclampsia. In patients with mild-grade fever, the odd of developing adverse maternal outcomes were 20 times higher as compared to the patients with normal body temperature, AOR 20.4 . The odds of developing adverse maternal outcomes in patients with high-grade fever were 15 times more likely to occur as compared to their counterparts, AOR 14.6 . As Fugate et al. explained, this may be because the raised temperature indicates a significant dysfunction of the auto-regulatory capability of the brain. Meaning, the brain of eclamptic mothers may become unable to regulate the body temperature and indirectly could show severe neurologic sequelae is happening , 42. Alt3, AOR 34.9 . Besides, the odds of developing adverse maternal outcomes in patients with a platelet count of 50,000–99,000 cells/mm3 were 24 times higher as compared to their counterparts, AOR 24.5 . This study finding is strongly in line with other studies done in Zimbabwe  and Morocco  . This result is similar to the study done in Pakistan and Addis Ababa, Ethiopia , 37. BotAs a strength and limitation of the study: this study is a pioneer in conducting a retrospective chart review of 8 years at this center on the specified problem in this specified long time. Although we have done the study vigorously and meticulously to improve the accuracy of the data, because of its retrospective nature, some data or variables were difficult to get and were not analyzed at all. This is because they were not documented or they were missing data sets on the chart. Due to the limited resources, some measurements/laboratory investigations may not be available for all women. However, this had no greater impact on diagnosis and outcome since other clinical-based criteria were applied, and the findings found are crucial to provide evidence to plan and implement policies and programs to improve maternal morbidities and mortalities.Adverse maternal outcomes in eclamptic patients were found to be high. Determinants such as multiple episodes of convulsions, increased maternal body temperature, a decrease in platelet count, the presence of coexisting stillbirth, patient age group above 30 years, and having 2–4 number of pregnancies were independently associated with adverse maternal outcomes.It is important for the government to maintain a quick referral system to avoid delays, and the quality of antenatal care should be improved at all levels to discover high-risk patients early. Furthermore, health workers should be trained in the early detection and management of eclampsia-related adverse outcomes. To health care providers, identified high-risk groups (or identified risk factors) need special attention during pregnancy and delivery. Future studies using a multi-center and prospective design, to academicians/researchers, could enable a more comprehensive list of potential independent factors to be studied in order to improve evidence-based medicine and reduce poor care quality and outcomes.Additional file 1. English version questionnaire.


A 14-year-old neutered male British shorthair cat presented with a 21-day history of persistent erection and dysuria, along with overgrooming of the perineal region. Mild palpation induced pain and rigid corpora cavernosa with flaccid glans were observed during physical examination. Ultrasonography of the penis did not detect significant blood flow in the penile cavernosal artery. The drawing of aspirate blood from cavernosal bodies for gas analysis was impossible because of the anatomically small penis size of cats. Conservative management, including topical steroid ointment, lidocaine gel, gabapentin, and diazepam, was prescribed for supportive management. The clinical signs resolved, and ultrasonographic examination of the penis revealed no abnormalities. The cat remains clinically well without recurrence during the 6 months after treatment. To our knowledge, this is the first report of non-ischemic priapism in a cat. Priapism is a penile erection lasting more than 4 h in the absence of sexual stimulation and can be classified into non-ischemic , ischemic , and stuttering  subtypes ,2,3,4,5.2 < 30 mmHg and pCO2 > 60 mmHg, and a pH of 7.25) [In human medicine, the European Association of Urology (EAU) and the American Urology Association (AUA) have established a diagnosis and distinguished the subtypes ,2,3. A tof 7.25) ,5,10. Coof 7.25) . For refA total of 12 cats have been diagnosed with priapism since 1989; none of these studies reported non-ischemic priapism, and the treatment was mostly related to surgical options such as penile amputation and perineal urethrostomy, due to poor responses to conservative management ,15,16,17Non-ischemic priapism has been reported in humans and dogs, but not in cats ,5,6,8,18A 14-year-old male neutered British shorthair cat weighing 4.88 kg was referred to the Veterinary Medicine Teaching Animal Hospital of Chungnam National University with a history of persistent erection, dysuria, and perineum over-grooming for 21 days before admission. Despite 14 days of medical treatment with prednisolone (0.75 mg/kg q12h per os (PO)), metronidazole , and famotidine  at a local animal clinic, clinical signs did not improve. On referral to a veterinarian, the patient was bright, alert, and responsive, and blood examination was within the normal range and urethral patency was positive. An Elizabethan collar (EB collar) was used to hinder the over-grooming of the perineum, but the patient showed an immediate obsession with the penis after the removal of the EB collar.Moreover, the owner complained that the cat looked uncomfortable while urinating, and that the time taken to void urine had increased from 30 s to 2 min with a persistent erection. There was no history of mating, but interestingly, the patient was able to walk accompanied by its owner. Additionally, the patient had a history of cystitis treatment prior to the priapism.A general physical examination showed a persistent erection, and the penis was erect but not hard enough for penetration. The patient was slightly unsettled in the hospital and reacted aggressively to penis palpation. The surface of the penis was dry, and brown debris was detected at the glans . A soft 9 cells/L)  and mild eosinopenia (0.12 × 109 cells/L) (RI: 0.3–0.7). Serum electrolyte concentration, serum biochemistry, gas analysis, and total T4 revealed no abnormalities except for elevated Feline serum amyloid A (FSAA) level (23 μL/mL) (RI: 0–10) and mild hyperglycemia (171 mg/dL) (RI: 73–134). Urethral catheterization revealed complete patency. Urinary samples collected by ultrasound-guided cystocentesis showed no abnormal laboratory urine test results and a negative result on bacterial culture. Abdominal radiography  revealed edema of the perineal region. A cutaneous mass with fat opacity was also detected in the inguinal regions; this was later suspected to be a lipoma (Complete blood count (CBC) was normal except for mild lymphopenia , the cat was diagnosed with non-ischemic priapism.Conservative treatment was initiated with flushing of the penis with 0.9% normal saline as the surface was dry and showed brown debris near the glans. Lidocaine gel was used for lubrication and topical anesthesia to reduce mild pain. Topical steroid cream was applied directly to the penis to reduce inflammation and irritation. For medical management, diazepam  and gabapentin  were prescribed for sedation and analgesia. With the exception of 10 min of grooming time for the cat, 24-h EB collar wearing was advised to prevent grooming of the perineal region, which could reduce the efficacy of topical ointment and cause further damage. Moreover, to prevent additional exposure and excoriation of the penis, the cat was not allowed to go for a walk. According to the owner, the persistent erection was resolved in 24 h, even though the cat continuously showed a swollen penis within the prepuce. Dysuria gradually improves over 3 days, and palpation-induced pain was resolved in 5 days.After 7 days, the cat was brought to the animal hospital for physical examination and urogenital ultrasound recheck. FSAA, which showed an elevation at the first presentation, declined to the normal reference range. Physical examination and urogenital ultrasonography revealed significant pain reduction and reduced swelling of the penis. The penis was no longer enlarged or, hard, and it retracted into the prepuce well . AccordiAfter 10 days of conservative medical management, the cat no longer showed perineal region grooming, and it has not experienced a recurrence during the six-month follow-up period.The diagnosis of each type of priapism reflects different pathophysiological processes ,20. In iTo the best of our knowledge, this is the first report, describing feline non-ischemic priapism. Non-ischemic priapism is rare and is a condition that is unfamiliar, even to many human urologists and andrologists ,21. Firs2 > 90 mmHg, pCO2 < 40 mmHg and pH 7.35–7.4, as cavernous tissue appears to be well-oxygenated in non-ischemic priapism [As priapism can be a urological emergency, it is important for veterinarians to quickly differentiate between the types . The diapriapism ,2,3,4,5.priapism ,27,28,29Color-flow Doppler ultrasound scanning is also an important diagnostic tool that enables clinicians to confirm cavernosal arterial blood flow and the existence of a fistula ,30. SonoConservative treatment and non-surgical management are recommended for non-ischemic priapism which is not an emergency and resolves naturally without any significant side effects . The appIn a review of the literature in human medicine, success rates of first intervention in non-ischemic priapism by blood clots 61.7%, gel foam 75%, EVOH/NBCA 77.3%, microcoil 80%, surgical 90%, and observation/conservative 46.9% have been reported ,32. As tSerum amyloid A (SAA) is a prominent constituent of acute phase proteins (APPs) that are elevated in various diseases . In catsA few single reports of non-ischemic priapism have been documented in canine veterinary medicine, but not in feline medicine ,18. PriaIn this case, the feline patient was uncomfortable but did not seem to be in acute pain, and the erection of the corpora was not completely rigid. In two human medicine reports, the diagnosis of non-ischemic priapism in an infant was based on history and physical examination due to difficulties of blood gas analysis and color-flow Doppler ultrasound scanning ,38. BaseTo our knowledge, this case describes the first reported case of feline non-ischemic priapism in a cat, a 14-year-old neutered male British Shorthair with a 21-day history of persistent erection and dysuria accompanied by perineal region overgrooming. The cat with non-ischemic priapism showed complete resolution of clinical signs with conservative and supportive management. No complications or side effects were observed during the 6-month follow-up period. Traditional methods of diagnosing non-ischemic priapism are not feasible in all cats due to anatomical limitation of feline penises. Therefore, thorough history taking and physical examinations are crucial in feline non-ischemic priapism.


Mild cognitive impairment (MCI), an identified prodromal stage of Alzheimer's Disease (AD), often evades detection in the early stages of the condition, when existing diagnostic methods are employed in the clinical setting. From an alternative perspective, smartphone interaction behavioral data, unobtrusively acquired in a non-clinical setting, can assist the screening and monitoring of MCI and its symptoms' progression. In this vein, the diagnostic ability of digital biomarkers, drawn from Fine Motor Impairment (FMI)- and Spontaneous Written Speech (SWS)-related data analysis, are examined here. In particular, keystroke dynamics derived from touchscreen typing activities, using Convolutional Neural Networks, along with linguistic features of SWS through Natural Language Processing (NLP), were used to distinguish amongst MCI patients and healthy controls (HC). Analytically, three indices of FMI  and nine NLP features, related with lexical richness, grammatical, syntactical complexity, and word deficits, formed the feature space. The proposed approach was tested on two demographically matched groups of 11 MCI patients and 12 HC, having undergone the same neuropsychological tests, producing 4,930 typing sessions and 78 short texts, within 6 months, for analysis. A cascaded-classifier scheme was realized under three different feature combinations and validated via a Leave-One-Subject-Out cross-validation scheme. The acquired results have shown: (a) keystroke features with a k-NN classifier achieved an Area Under Curve (AUC) of 0.78 , (b) NLP features with a Logistic regression classifier achieved an AUC of 0.76 , and (c) an ensemble model with the fusion of keystroke and NLP features resulted in AUC of 0.75 . The current findings indicate the potentiality of new digital biomarkers to capture early stages of cognitive decline, providing a highly specific remote screening tool in-the-wild. Mild Cognitive Impairment (MCI) , 2 affecThe production and comprehension of speech are correlated with the activation and coordination of diverse sensory and cognitive processes in regions of the cerebral cortex, including semantic storage and retrieval, executive functions and working memory . TherefoApart from the speech-related area, there are several indications that cognitive decline in MCI patients is associated, to a certain degree, with motor dysfunction in both lower  and uppeHaving reviewed separately studies regarding linguistic characteristics and keystroke dynamics, the potential diagnostic properties of the cognitive load, associated and partly overlapping with both written speech production and motor dysfunction remain to be examined. Vizer and Sears  use a stMotivated by the aforementioned, the aim of this study is to provide an automated method that can identify MCI individuals and distinguish them from HC, based on digital biomarkers, through their routine interaction with a smartphone keyboard in a non-clinical setting. Specifically, it is firstly assessed how cognitive decline is linked with the natural language processing (NLP) of linguistic features of spontaneous written speech (SWS) production and sequentially with the keystroke information regarding specific motor impairment symptoms. Then, their combination is examined with ensemble models, aiming to capture the interlinked dysfunctions in the respective brain regions associated with language and motor skills; thus, improving the overall classification performance. The promising results, when the proposed approach was tested on data from HC and MCI patients, show that such an analysis could provide with predictive analytics of early stages of cognitive impairment, taking into consideration the pragmatic conditions of everyday living. This will contribute in automatic, unobtrusive, remote monitoring, and recommendation of MCI and AD diagnosis.U-test for the age and Chi-squared test for the gender and the education levels (p > 0.05). The demographic information of all participants is also presented in The participants of this 6-month long study were recruited in the Day Center “Saint John” of the Greek Alzheimer Association and comprised two groups consisting of in total 12 HC, with the official diagnosis of Subjective Cognitive Impairment (SCI) related to the effects of normal aging and a group of 11 patients diagnosed with MCI. During the duration of the study, there was no clinical progression of the participants' condition. All participants had undergone the same clinical assessment for the official diagnosis within the last 3 years, that included as measures the Mini Mental State Examination-MMSE , the FunParticipants downloaded in their own smartphones the “Type of Mood” mobile application from Google Play store  and creaSimultaneously, participants were asked to type down on their phones up to 4 short texts, around a paragraph in length, to be used for the NLP analysis. To simulate SWS production the suggested topics included: (1) a message to a loved one or a good friend, (2) a description of one's day, (3) giving advice on someone, and (4) narrating a short story from a happy memory, as those were the things they usually text their social circle about. The participants typed the texts on their phones at home, based on their own availability and without a time limit, to simulate a non-clinical setting. They could not use the auto-correction feature of their phones and they sent afterwards the texts via email. In total, 10 MCI patients contributed 40 texts and 7 HC contributed 28 texts. From all the participants, 10 MCI patients and 5 HC, respectively contributed for the fused features analysis both texts and keystroke information through their typing activities with the custom keyboard.The texts were delivered by the participants as emails and saved as txt files with the equivalent user ID. The spelling mistakes and accidental punctuation marks were corrected, to avoid interference with the Part-Of-Speech (POS) Tagging process , given they do not represent studied measures in the following experiments. Using a POS-Tagger trained for the Greek language , each teThe timestamped sequences of the typing data, contained in the stored JSON files, were used to extract keystroke dynamics variables, namely the “hold time”  and “flight time” , as shown:where For each text, a set of nine features was extracted, using the Natural Language Toolkit suite of tools and libraries , along cW denotes the total number of words and V the total number of unique words, namely the vocabulary. The Brunet Index—“BI” indicates richer language with lower values, independently from the text's length . The average number of words per sentence is calculated as seen below:where w_sents denotes a list with the number of words per sentence as elements. The ratio of the meaningful vocabulary (words that are not part of the Greek stopwords from the NTLK corpus) is expressed as shown below:where content refers to the vocabulary words that are not considered stopwords based on the NLTK corpus. Features related to word class deficits were extracted from the POS-Tagged texts. The nouns over verbs ratio is calculated as shown below:where nn denotes the number of nouns and vrb the number of verbs within the text. The noun ratio and word finding difficulties are expressed as seen below:where The pronoun ratio, which quantifies indirect referencing, is presented below:prn denotes the number of pronouns within the text. Lastly, a form of the Mean Dependency Distance—“MDD” was used  of the dependency parsed trees format of the sentences in the CONLL-U files. In where −3 for the mean squared error loss function) on a dataset of a relevant study of Parkinsonian screening , Rigidity (R), and Alternate Finger Tapping (AFT), the symptoms describing Fine Motor Impairment (FMI). Specifically, one dimensional CNN-based autoencoders, consisting of two sequentially connected convolutional layers  without max-pooling layers, took as inputs the HT and FT sequences of the typing data and were used to learn a neural network's encoding mechanism for representing efficiently the keystroke dynamics and reject the noise. The CNN was trained in an unsupervised manner , (4) the union of the first two datasets with 252,000 typing sessions with keystroke dynamics from 253 subjects (PD/HC: 67/186) The optimized scores produced indicators that can be used in-the-wild prediction of UPDRS scores 22/23/31, yielding correlation 0.66/0.73/0.58, respectively, in the validation set of 36,000 typing sessions. The trained models were used to infer based on the typing data from 11 MCI patients and 12 HC, and estimations for each symptom (R/B/AFT 0-4) were extracted for each typing session of each user  with keystroke dynamics from 33 demographically matched subjects [18 early Parkinson Diseases (PD) patients and 15 HC], whom underwent clinical examination by neurologists and their FMI was evaluated by their UPDRS Part III single-item scores 22/23/31, expressing rigidity of upper extremity/alternate finger tapping/general body bradykinesia-hypokinesia, respectively. Before being tested to our dataset, consisting of more than 3,000 typing sessions of MCI patients and HC, the models have also been tested in 4 in-the-wild datasets: (1) a dataset with 216,000 typing sessions with keystroke dynamics from clinically examined 214 subjects (PD vs. HC), with self-reported demographics, through the iPROGNOSIS app, (2) a dataset with 36,000 typing sessions with keystroke dynamics from 39 subjects (PD/HC:22/17), (3) a subset of the previous dataset with 7,600 typing sessions, drawn from ach user . All theIn order to address the study research questions, that is, the exploration of the classification performance between MCI and HC, using features drawn from the NLP, keystroke dynamics, and combined feature spaces, three experiments, i.e., EXP1, EXP2, and EXP3, with different feature sets and demographically matched sub-cohorts were conducted, accordingly. In each experiment, three different classifiers, Logistic Regression, Random Forest, and k-Nearest Neighbors are evaluated based on their accuracy and the receiver operating characteristic (ROC) analysis, after multiple rounds of LOSO cross-validation. ROC analysis is an iterative process of varying the discrimination threshold of a binary classifier and outputting the  pair for each threshold. The ROC curve is then formed by plotting the output pairs of . This analysis provides reliable insights into the performance of a classification model even when datasets are not completely balanced. To assess the statistical significance of classification results, sampling with replacement  is further used here to define a ROC curve distribution, by obtaining the average value (solid line in figures) and the confidence intervals (shadowed areas in the figures) of the area under the ROC curve (AUC). Where reported, specificity/sensitivity values correspond to the optimal ROC-based cut-off point (decision threshold), estimated by maximizing the Youden Index , for equIn particular, at EXP1, 78 texts from 10 MCI patients and 7 HC were used to extract NLP features and test the predictive potential of SWS production. In EXP2, 3,139 typing sessions from 11 MCI patients and 12 HC were used to extract the keystroke related features that quantify FMI symptoms and test their predictive potential linked to cognitive decline. In EXP3, NLP and keystroke feature sets, combined differently in 3 models , were used to assess the performance of fused feature sets against models with separate NLP and keystroke features , from 10 MCI patients and 5 HC contributing both texts and typing sessions. Model “A” concatenates the probabilities/predictions of the “Just NLP” model with keystroke features and feeds them into another Random Forest classifier, while model “B” concatenates the probabilities/predictions of the “Just Keys” model with NLP features and feeds them into another k-Nearest Neighbors classifier. Lastly, model “C” concatenates the probabilities/predictions of both the “Just Keys” and “Just NLP” models and feeds them into another Random Forest classifier. The cohorts and the chosen optimal feature sets of each experiment can be found in Combinations of the features “nonstop,” “dvrst,” “HS,” and “MDD,” comprising the optimal feature set, were used with the different classifiers. The Logistic Regression classifier has an AUC of 0.76, accuracy 76% and specificity/sensitivity of 0.80/0.71, respectively. The Random Forest Classifier has an AUC of 0.73, accuracy 71% and specificity/sensitivity of 0.83/0.43 respectively. The k-nn classifier with seven nearest neighbors has an AUC of 0.69, accuracy 71% and specificity/sensitivity of 0.80/0.57, respectively. The Logistic Regression classifier appears to have the best performance, whereas the Random Forest one, due to the small number of data wasn't able to perform that well. We observe higher specificity than sensitivity levels. The three ROC curve distributions of the first experiment can be found in Combinations of the “B” and “R” indices, comprising the optimal feature set, were used with the different classifiers. The Logistic Regression classifier has an AUC of 0.69, accuracy 70% and specificity/sensitivity of 0.54/0.83, respectively. The Random Forest Classifier has an AUC of 0.65, accuracy 66% and specificity/sensitivity of 0.55/0.75, respectively. The k-Nearest Neighbors classifier with seven nearest neighbors has an AUC of 0.78, accuracy 77% and specificity/sensitivity of 0.64/0.92, respectively. The k-Nearest Neighbors classifier appears to have the best performance and we observe higher sensitivity than specificity levels. The three ROC curve distributions of the second experiment can be found in The “Just NLP” model resulted in an AUC of 0.60, accuracy 67% and specificity/sensitivity of 0.80/0.40, respectively. The “Just Keys” model resulted in an AUC of 0.75, accuracy 80% and specificity/sensitivity of 0.90/0.60, respectively. Model “A,” resulted in an AUC of 0.68, accuracy 75% and specificity/sensitivity of 0.90/0.40, respectively . Model “Digital and Connected Health is an emerging field, encompassing novel, efficient, effective, and accessible technological tools, that could contribute greatly to early disease diagnosis and management. The aim of this study has been the development of an objective tool for the detection of MCI patients against HC, by exploiting linguistic characteristics and keystroke dynamics, during routine typing on mobile touchscreens. The adopted design reflects the natural spontaneous state of the users and its unobtrusive data collection fashion meets the need of long-adherence. Simultaneously, such a tool assists the longitudinal passive monitoring and diagnosis of the condition, in an interpretable way, facilitating physicians and medical interpretation, through high-frequency sampled data streams. Overall, the study further verifies the relationship between cognitive functions and motor dexterity, being consistent with the overlapping cognitive and motor neural circuitry in the brain, and paving the way toward new approaches for dementia risk screening.Nn) and when compared to verbs (NnVrb)], and higher mean number of pronouns (Prn) in MCI patients compared to HC, despite the fluctuation noticed in the number of words per sentence within subjects over successive text sessions (wrd_sent). The measures of the vocabulary size and lexical diversity  were decreased within the group of MCI patients as expected  with the MMSE clinical scores and the predictions of the NLP models significantly correlated  with the FUCAS clinical scores. These correlations tangibly showcase the connection of the FMI symptoms, like bradykinesia, with the clinically verified cognitive decline, aligned with the relevant literature , that provide a complete phenotype of MCI-related symptoms. The promising results presented here pave the way toward a holistic, objective patient-centric AD detection tool to be even successfully deployed in a non-clinical setting.leontios@auth.gr.The datasets presented in this article are not readily available because they cannot be publicly uploaded and accessed without a reasonable request. Requests to access the datasets should be directed to Leontios J. Hadjileontiadis, The studies involving human participants were reviewed and approved by the Bioethics Committee of the Aristotle University of Thessaloniki, Medical School, Thessaloniki, Greece (359/3.4.17). The patients/participants provided their written informed consent to participate in this study.AN, DI, and LH conceived the study protocol and contributed to the manuscript. AN, DI, SH, and VC developed the keyboard and the keystroke dynamics processing algorithms. AN developed the NLP feature extraction and processing algorithms and conducted all experiments. MT and Alzheimer Hellas center conducted the clinical evaluations. AN and DI analyzed the data, developed the participants demographic information, participant information and consent process, and handled the data governance procedures as well as the corresponding ethic approvals. All authors discussed the results. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A 23-year-old woman was admitted to the hospital with proteinuria and mildly elevated creatinine, and a renal biopsy confirmed the diagnosis of oligomeganephronia (OMN). OMN is an extremely rare bilateral renal hypoplastic disease, and its diagnosis mainly relies on the pathological results obtained from renal biopsy. At present, there is no effective treatment for OMN. Here, we report a case with mild renal insufficiency and proteinuria as the main symptom and present a summary of the clinical characteristics of ON along with a review of the literature on OMN. Oligomeganephronia (OMN) is a rare congenital bilateral renal hypoplasia disease, which was first reported by Royer et al. in 1962 . It is o2). The current patient should be in stage 3 chronic kidney disease. Other Biochemistry indexs were slightly changed or normal.The ultrasound of both kidneys showed enhanced cortical echogenicity, good blood flow in both kidneys, a left kidney cyst, and left and right kidney sizes of 9.6 × 3.7 × 3.5 cm and 9.4 × 3.5 × 3.6 cm, respectively. The electrocardiogram, cardiac Doppler ultrasound, and lung computed tomography did not reveal any significant abnormalities.Renal biopsy revealed . The patient was advised to take losartan 50 mg orally once daily.We used PubMed® and the China National Knowledge Infrastructure to retrieve reports on OMN from 1970 to 2020, and a total of 39 complete cases were included. The 39 cases were summarised and reviewed below, and all cases were shown in the Appendix in OMN can be broadly classified into two categories. One is a solitary sporadic form, in which the onset is often during adolescence. There were 30 patients in this category, with the age of onset ranging from 2 to 45 years and a mean age of (23.5 ± 9.5) years. There were 23 male and 7 female patients with OMN, with a male-to-female ratio between 3:1. We found that only a few patients were low-birth-weight infants or patients with previous chondrosarcoma, unexplained fever, and/or growth retardation; the rest of the patients were previously healthy. Most patients with the solitary sporadic form of OMN have an insidious onset, with a duration of disease ranging between 1 month and 15 years.The course of disease is more than 1 year in 50% of patients. Clinical manifestations often include proteinuria, elevated creatinine, dysuria, increased nocturia, and hypertension. In terms of extrarenal damage, four patients were found to have hypertension, and one patient had a large optic disc in both eyes. In terms of laboratory findings, 25 cases (83.3%) had elevated creatinine, and proteinuria was present in almost all the patients. As far as ultrasound findings were concerned, bilateral renal atrophy was present in 25 (83.3%) patients, and unilateral renal atrophy was present in 1 patient. In terms of pathological findings, the solitary sporadic form of OMN often manifests as sparse glomeruli with an increased glomerular diameter and with a mean glomerular diameter of 224.32 ± 67.62 μm. There were 9 patients with concomitant focal segmental glomerular sclerosis, 17 patients with IgM deposition, 1 patient with IgG deposition, and 16 patients with concomitant podocyte fusion. Mutation of the PAX2 gene was found in only one patient.In terms of treatment, 12 out of 30 patients were reported and followed up, 10 of whom used pharmacological treatment with the following regimens: angiotensin-converting-enzyme inhibitors (ACEIs) combined with angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), α receptor blocker, β receptor blocker, and aspirin; ACEI combined with ARB and CCB; sole treatment with ARB; sole treatment with ACEI; ACEI combined with statins; hormone therapy combined with ACEI; sodium bicarbonate combined with aluminium hydroxide gel and antibiotics; sole treatment with Chinese medicine; and haemodialysis combined with kidney transplantation, respectively. These patients were followed up for 2 months to 5 years. The creatinine increased three-fold within 5 years in the patient receiving Chinese medicine; two patients were solely treated with ARB-type drugs; creatinine did not change significantly in one patient after 1.5 years of follow-up, and creatinine was increased in one patient after 2 years of follow-up, considering that the latter may have been associated with a high 24-h urine protein result. Meanwhile, there were two patients with elevated 24-h urine protein >1 g. One of these patients with concomitant focal segmental glomerular sclerosis was treated with ACEI in combination with statins and had a 1.27-fold increase in creatinine at the 5-year follow-up, and the other patient was treated with hormones in combination with ACEI drugs and had no significant change in creatinine at the 1.5-year follow-up. The patient who was solely treated with Chinese medicine had a 3.37-fold increase in creatinine after 5 years. Renal transplant patients remained in good health within 2 years .The other form is associated with multiple congenital anomalies, with a total of nine cases in this summary presenting with symptoms at or shortly after birth. Patients with the second category were often associated with poor developmental growth and physical deformities, and nearly 55% of the patients had low birth weight. The clinical manifestations of OMN associated with congenital anomalies commonly include oliguria and proteinuria, and it is most often accompanied by extrarenal damage, such as facial deformities, limb deformities, respiratory failure, and cardiac failure. Elevated creatinine was reported in only three patients, and all the patients had small kidneys. Patients with congenital anomaly-related OMN are often associated with genetic mutations. Five patients had Wolf-Hirschhorn syndrome , and two patients were diagnosed with limbic renal syndrome. Moreover, this group of patients have a low survival rate and rapid disease progression. In neonatal-onset patients, the maximum follow-up survival time was 27 months. In two adolescent-onset patients, a two-fold increase in creatinine was reported 3–4 years after treatment with ACEI/ARB .We conducted the first systematic review of previous OMN cases and compared OMN patients into two groups, the solitary sporadic form of OMN and OMN associated with congenital anomalies. However, because this disease is relatively rare and related reports span a long period of time, the relevant information is not perfect. OMN is characterised by a decrease in the number of nephrons and a marked hypertrophy of the glomeruli. A maximum reduction of 80% in the number of nephrons and hypertrophy of the remaining nephrons with glomerular volume reaching 12–15 times the normal volume and tubular volume reaching 17 times the normal volume has been reported . Globle In 1997, Broyer et al. established strict diagnostic criteria for OMN : (1) theMost patients develop clinical manifestations, such as anorexia, vomiting and dehydration, polyuria, and polydipsia in the first 2 years of life. However, these clinical manifestations are often seen in patients with congenital anomalies related to OMN, and to date, only one patient with a solitary sporadic form of OMN presented with recurrent fever in infancy. As the sparse glomeruli become chronically overloaded, the glomerular volume increases, leading to glomerular basement membrane damage, which in turn results in hypertension, haematuria, proteinuria, and decreased renal function. Urinary protein levels also gradually increase with progressive renal failure. Approximately 62.5% of patients develop proteinuria with concomitant impaired renal tubular function before the age of 20 years ; 11 patiIn the solitary form of OMN, nearly 40% (12/30) of patients have developmental problems, including low BMI, low birth weight, and developmental delay. It is possible that even these patients may have other developmental malformations of organs or limbs, which may not be recognised because they do not have typical characteristics or have less impact on quality of life. Therefore, compared with patients with OMN associated with congenital anomalies, the early clinical manifestations of the solitary form of OMN are less and not easily detected, and the disease progresses more slowly.At present, there is no effective treatment for OMN, and the main clinical focus is on comprehensive symptomatic treatment. The usage of anti-hypertensive treatment with ACEI/ARB may help to reduce glomerular hyperfiltration, and, hence, delay OMN progression. However, for patients with high urinary protein and focal segmental glomerular sclerosis, the effect of treatment with ACEI/ARB drugs alone is limited, and combinational therapy with hormone or statins is recommended. However, it will eventually progress to end-stage renal disease, and long-term replacement therapy or early renal transplantation may be a better treatment modality.In summary, OMN is a congenitally dysplastic disease of both kidneys, and the diagnosis of which relies on pathological biopsy. Congenital anomaly-associated OMN often develops shortly after birth, with extrarenal damage, such as physical deformities, and is often associated with genetic mutations, poor drug treatment efficacy, and low survival rates. The clinical manifestations of the solitary sporadic form of OMN are non-specific and often overlooked. Some patients have hypertension and ocular changes, and the use of ACEI/ARB treatment may delay the progression of OMN, though it induces elevated urinary protein. Combinational therapy with drugs, such as hormones or statins, may be effective. Early renal transplantation may be a better treatment modality.X-HW and LP contributed to conception and design of the study. SH organized the database. X-HW and SH performed the statistical analysis. X-HW wrote the first draft of the manuscript. LP, SH, D-LK, and WW wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The purpose of this study was to identify the factors associated with poor glycemic control amongst rural residents with diabetes in Korea. (2) Methods: This cross-sectional analysis was conducted amongst a total of 522 participants who had completed baseline health examinations for the Korean Genome and Epidemiology Study (KoGES) Rural Cohort from 2005 to 2011. The subjects were divided into two groups: the good glycemic control group (GCG) (glycosylated hemoglobin (HbA1C) < 7%) and the poor GCG (HbA1C ≥ 7%). Logistic regression was used to examine the role of sociodemographics, health-related behavior, comorbidity and diabetes-related and clinical factors in poor glycemic control amongst rural residents with diabetes. (3) Results: In total, 48.1% of participants were in the poor GCG. Poor GCG was significantly associated with drinking (odds ratio (OR) = 0.42, 95% CI = 0.24–0.71), lack of regular physical activity , fasting blood glucose (FBG) > 130 mg/dL , diabetes for > 7 years , cholesterol ≥ 200 mg/dL  and positive urine glucose . (4) Conclusion: Intensive glucose control interventions should target individuals amongst rural residents with diabetes who do not engage in regular physical activity, have been diagnosed with diabetes for more than seven years and who have high fasting-blood glucose, high cholesterol levels and glucose-positive urine. Type 2 diabetes is a lifestyle-related disease and is gradually increasing due to inactivity, sedentary lifestyles, obesity and Westernised food intake. The number of people with diabetes worldwide has increased more than fourfold in 35 years, from 118 million people in 1980 to 422 million in 2014. In 2016, diabetes was estimated to be the seventh leading cause of death globally , 37% in Local socioeconomic levels affect the health of individuals living in the area, and social factors such as the community’s material resources play a decisive role in maintaining health-related behavior . Korean Some notable studies around the world have identified the following: education up to high school level only, residency in regions outside of Seoul, long-term diabetes, combined insulin and oral hypoglycemic treatment, hypertriglyceridemia, excessive sleep, hypertension, smoking and weight fluctuation were identified as contributing factors in uncontrolled blood glucose in Korean diabetic patients ,18,19. AAs such, several differences between countries are evident in the factors contributing to uncontrolled blood glucose in rural areas, but studies on blood glucose control that reflect the medical accessibility, environment and specificity of rural areas have been very limited. Due to the recent ageing of the global population, the prevalence of diabetes in rural areas has increased significantly; consequently, it may become more important for diabetic patients to control their blood glucose levels to prevent diabetes complications, save on medical expenses and improve their quality of life. Therefore, this study investigated the status of glycemic control and the demographic, lifestyle, diabetes-related and clinical factors associated with poor glycemic control amongst diabetic patients in rural areas of Korea. This study’s findings will guide the development of interventions aimed at preventing complications and reducing medical expenses and mortality in rural residents with diabetes.This study used secondary data from the Rural Cohort of the Korean Genome and Epidemiology Study (KoGES) to identify the factors affecting uncontrolled glycemic status in rural diabetic patients. KoGES has established a large-scale cohort for the prevention and management of cardiovascular disease for the general population aged between 40 and 69 years by the Korea Disease Control and Prevention Agency (KDCA). In this study, we used the baseline survey data of men and women aged between 40 and 69 years in six rural areas—Yangpyeong, Namwon, Goryeong, Wonju, Pyeongchang and Ganghwa—from 2005 to 2011. In compliance with KoGES’s confidentiality protection regulations and statistical laws, the KCDC provides only non-identifiable data. The data were obtained with the approval of Jeonbuk National University’s Institutional Review Board (IRB No. 2019-10-010).Of the 28,337 people who participated in the baseline survey of the Rural Cohort, 2656 diabetic patients answered “Yes” to the question of “diabetes diagnosis” according to an earlier study . After oParticipants with less than 7% HbA1C were classified as the “good glycemic control group” while those with over 7% were categorized as the “poor glycemic control group”, with the aim of reducing microvascular and macrovascular complications in diabetic patients according to the guidelines of the American Diabetes Association (2019) . In KoGEVariables related to glycemic control were classified into demographic, health-related behavior, disease-related, diabetes-related and clinical examination factors by selecting available variables from KoGES data based on earlier studies. General characteristics were grouped as follows: age (40–64 years old and 65 years or older), marital status , education level , monthly household income .2, overweight between 23 to 24.9 kg/m2 and obese at 25 kg/m2 or more [Health-related behavior and disease-related factors were included and classified as follows : drinkinUsing SPSS/Win 21.0, frequency, percentages, mean and standard deviations were obtained for general characteristics and disease-related characteristics. A Chi-square test was performed to determine the differences in poor glycemic control according to demographic, health behavior, disease factors, diabetes-related and clinical examination characteristics. A binary logistic regression analysis was performed to identify factors affecting poor glycemic control.The participants were 522 rural diabetic patients, of whom 57.9% were women. The 40–64 years age range accounted for 68.8% and the average age was 60.2 (±7.84) years old. It was found that 82% of the participants did not live with their spouses and 50.6% of participants were educated up to the primary school graduation or less. The monthly household income of 54.7% participants was less than 1 million won and 56% were currently employed. Diabetes duration of seven years or more was found in 38.1% of subjects; 25.9% used oral hypoglycemic agents or insulin injection treatment and 2.5% used diet or exercise therapy as non-drug treatments.p = 0.003); in those who did not engage in regular physical activity than those who regularly engaged in physical activity ; in those whose diabetes duration was >7 years as opposed to ≤7 years ; in those whose FBG > 130 mg/dL as opposed to 70–130 mg/dL ; in those whose cholesterol ≥ 200 mg/dL as opposed to < 200 mg/dL  and in those whose urine glucose was positive rather than negative   .Diabetes is increasing globally due to changes in ageing, diet and lifestyle, and diabetes management in rural areas is poor compared to that in cities due to the lack of medical access and medical information . SeveralThe rate of uncontrolled blood glucose of HbA1C of 7% or higher in this study was 48.1% compared with 35% in the United States , suggestAs a result of the logistic regression analysis carried out in this study, non-drinkers, those with diabetes duration > 7 years, those with FBG > 130 mg/dL, those with cholesterol ≥ 200 mg/dL and those who tested positive for urine sugar showed significantly higher poor glycemic control rates than their counterparts. Those who drank had 0.42 times lower blood glucose control than the non-drinking group. This echoes findings that drinkers have better blood glucose control than non-drinkers  but diffIn this study, the group who did not engage in regular physical activity had a poor glycemic control rate which was 1.68 times higher than that of their more active counterparts. This echoes findings that regular exercise positively affects uncontrolled blood glucose  but diffIn this study, the observed correlation between FBG levels and HbA1C was strong . When HbA1C data are unavailable, FBG can substitute as a guide for blood glucose management for rural residents. However, amongst this study’s participants, 31.2% of those with normal FBG at 70–130 mg/dL had poor blood glucose conditions according to the HbA1C standard, which indicates the degree of blood sugar management in the past three to four months. Therefore, it is recommended that diabetic patients regularly check their HbA1C—at least two to four times per year—and that they are provided with access to clinics for HbA1C blood tests.There are several ways to measure the level of glycemic control. HbA1C reflects the level of blood sugar during last 2–3 months. It can be measured regardless of fasting state, less susceptible to stress or infection than fasting blood glucose, and has little variation within individuals . Urine gWhen the patient had diabetes for longer than seven years, the rate of unregulated blood glucose was 1.79 times higher than that of patients who were diabetic for seven years or fewer. This corroborates the findings of previous studies ,18,19,20In this study, when the cholesterol level was 200 mg/dL or higher, poor glucose control was 1.73 times higher than cases in which the cholesterol level was 200 mg/dL. According to a Diabetes Fact Sheet from 2018 , 35% of In this study, no significant relationship was observed between triglyceride, HDL-C, LDL-C and uncontrolled blood glucose. However, triglycerides were 170.43 ± 14.90 mg/dL on average, which was higher than 150 mg/dL, the standard for diabetic patients. Insulin resistance in diabetic patients leads to increased fatty acid release from adipocytes and increased liver LDL and Triglycemia production and secretion, leading to hyperlipidemia , Yemen , and ChiThe level of LDL-C was high on average, at 118.73 ± 34.08 mg/dL, which was higher than the normal standard of 100 mg/dL, and the HDL-C results were also out of normal range for both men and women. It is important to manage blood lipid levels in people with diabetes, and comprehensive intervention programs should be initiated to provide education on the causes and outcomes of hyperlipidemia in addition to education on the importance of blood glucose management.Participants who tested positive for urine glucose had a 6.24-fold higher rate of poor glycemic control than participants with negative urine glucose. The presence of glucose in urine indicates that the blood consistently contains high levels of glucose, with the exception of glucose reabsorption due to dysfunction of the ureter . UrinaryCare managers  may take on an important role in the management of patients with diabetes by providing necessary information and helping the patients to maintain a healthy lifestyle, enhance self-efficacy to control blood glucose and achieve good compliance with their healthcare provider’s recommendations . In the The limitations of this study are as follows: First, this study has limitations in its ability to explain the causal relationship of factors affecting poor blood glucose control because of its characteristics as a cross-sectional study. There is an issue of cause versus results of glycemic control. For example, lack of physical activity can be a cause of poor glycemic control and albuminuria can be its result. Further cohort studies with different designs could overcome this limitation. Second, the diabetes diagnosis and income levels are self-reported, so their accuracy may be limited. Third, due to the limitations of secondary data, psychosocial variables, such as depression and stress, diabetes knowledge, access to healthcare service, barriers and self-efficacy, were not controlled. Fourth, the dataset used in this study does not include information on the kinds of OHA . However, this study makes a meaningful contribution in comprehensively identifying the demographic, lifestyle, diabetes-related and clinical factors affecting blood glucose control in rural residents with diabetes using large-scale secondary survey data provided by the country.This study analyzed the factors of poor glycemic control in 522 rural diabetic patients aged over 40 years using the Rural Cohort from the Korean Genome and Epidemiology Study (KoGES) of the KCDC. The rate of poor glycemic control was found to be 48.1% and the influencing factors were identified as alcohol consumption, physical activity, FBG, duration of diabetes, cholesterol and urine glucose. It is necessary to develop a comprehensive diabetes management program suitable for rural contexts. Furthermore, future studies should aim to identify factors that influence blood glucose control in consideration of the regional environment in addition to characteristics related to demography, health-related behavior and medical and diabetes-related factors. Multi-level analysis may be useful to reflect regional contexts like population density, local income tax, financial independence and health vulnerabilities, such as the ratios of elderly and the disabled and the number of doctors.


Escherichia coli was detected in the urine culture. Blood analysis revealed abnormal findings, including elevated WBC count  and C-reactive protein (0.28 mg/dl). Computed tomography (CT) of the abdomen demonstrated a defect of the right diaphragmatic crus containing a dilated right ureter with associated hydronephrosis. Retrograde pyelography showed hydronephrosis and dilated ureter loops through the defect of diaphragmatic crus, known as a “curlicue sign,” and the diagnosis was right ureteral diaphragmatic hernia. A ureteral stent was placed on her right side, and the ureter was reducted into the retroperitoneal space. After six months, the ureteral stent was removed, with no subsequent recurrence of the ureteral diaphragmatic hernia at seven months. We reviewed all cases in the literature published in English of ureteral diaphragmatic hernia. While the etiology of ureteral diaphragmatic hernia is unknown, our present case and previous reports suggest that a ureteral diaphragmatic hernia may occur due to hepatic atrophy and/or an elevated position of the right kidney.Ureteral diaphragmatic hernia through diaphragmatic defects is an exceptionally rare subset of ureteral hernia with only fourteen such cases reported in English manuscripts. An 85-year-old woman was introduced to our department with right flank pain, fever elevation, and nausea. Urinalysis showed bacteriuria, and  Ureteral hernias are a rare occurrence normally identified incidentally on imaging or during surgical hernia correction and can be a cause of ureteral obstruction . These hIn this report, we present a case of right ureteral diaphragmatic hernia containing an incarcerated right proximal ureter with subsequent obstructive pyelonephritis. We review all cases of ureteral diaphragmatic hernia published in the literature in English and discuss optimal treatment methods and the etiology.2, and suffered from kyphosis. The pharynx and bilateral tonsils were not swollen, and there was no evidence of rales of the lungs. However, right costovertebral angle tenderness was notable.An 85-year-old woman, with a medical history of hypertension, dyslipidemia, reflux esophagitis, osteoporosis, and kyphosis, was introduced to our department with right flank pain, fever elevation, and nausea. Her mental condition appeared stable. The patient's temperature was 37.7°C, pulse rate 72/min, and respiration 22/min. She was 148 cm in height, weighed 37.8 kg, with a BMI of 17.2 kg/mEscherichia coli and Streptococcus were detected in the urine culture. Abnormal findings of a complete blood count and laboratory examination included an elevated WBC count  and C-reactive protein (0.28 mg/dl) and serum creatinine of 0.98 mg/dl. Ultrasound examination revealed right hydronephrosis, and subsequent CT of the abdomen revealed a right diaphragmatic hernia of a part of the urinary tract, causing moderate to severe hydronephrosis .A CT done one year previously on our patient showed neither a right ureteral diaphragmatic hernia nor hydronephrosis; however, it did reveal the higher position of the right kidney due to hepatic atrophy , and a dFigure 3(b)Based on the diagnosis of pyelonephritis and the results of the urine culture, we administered antibiotics and placed an indwelling Foley catheter. Treatment resulted in reduced inflammation and hydronephrosis, and improvement of the ureteral diaphragmatic hernia was confirmed by CT. The stent was removed at six months after placement, and at seven months after removal, there had been no recurrence of pyelonephritis or right ureteral diaphragmatic hernia.It is a rarity to encounter a ureteral hernia. Pollack et al. reported that 120 reports of ureteral hernias had been confirmed at the time of their case-series publication in 1975 . While tWe conducted a retrospective review of reported cases, and published papers were retrieved from Medline, PubMed and Google Scholar. Literature review and a case report revealed 14 documented cases of ureteral diaphragmatic hernia , making,A majority of the reviewed 15 cases occurred in the elderly, with the diagnosis mean age being 75.6 years; 10 (66.6%) of the 15 were female. The right side was the diseased side in all cases; some ureteral hernias presented with symptoms attributable to the ureteral hernia/urinary tract obstruction while others were detected incidentally. Symptomatic cases presented with flank pain, renal dysfunction, gross hematuria, nausea, pyelonephritis, and urosepsis. Of the 15, 8 cases 53.3%) presented with right flank pain .3% prese, 12, 14,Ten of the cases were diagnosed by CT combined with pyelography  –14, 16, Of these 15 cases, 3 20.0%) were managed conservatively , 5, 10, 0.0% wereIn cases of obstruction and resultant pain or pyelonephritis, drainage becomes imperative. Attempt at retrograde ureteral stenting is reasonable and minimally invasive  and was Open surgery was done in 4 of the 15 cases, two of which underwent surgical repair via the retroperitoneal approach , 7. Lin In all 15 cases of ureteral diaphragmatic hernia, the herniation lateralized to the right-side; however, the etiology of this disorder characteristic is unknown .Bochdalek hernias in adults are thought to be more prevalent on the left side than the right. It has been postulated that the liver normally obstructs any right-sided defect . If therBased on the above results, we can speculate that since the right upper urinary tract was close to the defect of the right diaphragmatic crus, increased intra-abdominal pressure may have caused the right ureter to eventually herniate through the defect.Ureteral hernias are generally an exceptional occurrence, with ureteral diaphragmatic hernia being even more exceedingly rare in the literature. Imaging studies such as CT and/or pyelography are imperative for the diagnosis of ureteral diaphragmatic hernia. Management strategies depend on the clinical context. In cases of obstructive pyelonephritis or renal dysfunction, drainage is essential. A trial with retrograde ureteral stenting is reasonable and minimally invasive and has a notable success rate. While the etiology of ureteral diaphragmatic hernia remains unknown, our present case and previous reports suggest that the ureteral diaphragmatic hernia may be the result of hepatic atrophy and/or a high position of the right kidney.


Dendrobium officinale. The two compatible fungi, i.e., Tulasnella SSCDO-5 and Sebacinales LQ, originally from different habitats, could persistently colonize seeds and form a large number of pelotons continuously in the basal cells, and both fungi promoted seed germination up to seedling with relative effectiveness. In contrast, the two incompatible fungi, i.e., Tulasnella FDd1 and Tulasnella AgP-1, could not persistently colonize seeds. No pelotons in the FDd1 treatment and only a few pelotons in the AgP-1 treatment were observed; moreover, no seedlings were developed at 120 days after incubation in either incompatible fungal treatment. The pattern of fungal hyphae colonizing seeds was well-matched with the morphological differentiation of seed germination and seedling development. In the fungal cocultural experiments, for both orchids of D. officinale and Dendrobium devonianum, cocultures had slightly negative effects on seed germination, protocorm formation, and seedling formation compared with the monocultures with compatible fungus. These results provide us with a better understanding of orchid mycorrhizal interactions; therefore, for orchid conservation based on symbiotic seed germination, it is recommended that a single, compatible, and ecological/habitat-specific fungus can be utilized for seed germination.Orchids highly rely on mycorrhizal fungi for seed germination, and compatible fungi could effectively promote germination up to seedlings, while incompatible fungi may stimulate germination but do not support subsequent seedling development. In this study, we compared the fungal colonization process among two compatible and two incompatible fungi during seed germination of  Orchids show a series of floral characteristics distinct from those of most other flowering plants. One of the characteristics is the large number of dust-like seeds, which are among the smallest seeds of all flowering plants and characterized by a small and undeveloped embryo not surrounded by an endosperm . Due to per se but did not support subsequent seedling development  What are the effects of cocultures on germination and seedling development in D. officinale and D. devonianum? and Do cocultures of two compatible fungi increase protocorm formation and seedling development and do cocultures of one compatible fungus with one incompatible fungus reduce protocorm formation and seedling development?Here, we presented our results concerning two aspects of symbiotic interaction, namely, (1) What are the differences of colonizing process to seeds between compatible and incompatible mycorrhizal fungi in Dendrobium species, D. officinale and D. devonianum, were used in this study. We conducted and assisted outcross-pollination trials on cultivated plants of two orchids during March and April 2017, and the close-to-dehiscent fruits of D. officinale and D. devonianum were harvested in November 2017 and April 2018, respectively. Seeds were dried and stored in the Orchid Seed Bank of Yunnan University using the same methods described by Seeds of two Tulasnella SSCDO-5, Sebacinales LQ, Tulasnella FDd1, and Tulasnella AgP-1, were used in this study to compare their effects on the seed germination of D. officinale and D. devonianum. The original source, compatibilities with D. officinale and D. devonianum based on our previous studies, and the related information about the four OMFs are summarized in Tulasnella sp. FDd1 was also deposited in the China General Microbiological Culture Collection Center (accession number: CGMCC No. 9551), and the strain of Sebacinales LQ was deposited in the China Center for Type Culture Collection (accession number: CCTCC No. M2019744).Four OMFs, namely, D. officinale were inoculated with compatible fungi  and incompatible fungi  to compare seed germination and the morphological differences in fungal hyphae colonizing seeds during the process of symbiosis. Seeds were sterilized with 1% (w/v) sodium hypochlorite solution (NaClO) for 5 min and washed with sterile distilled water 3–5 times. Using a pipette, ca. 30 seeds, suspended in 1 ml of agar solution, were transferred into a Petri dish containing 20 ml of sterile oatmeal agar  medium adjusted to a pH of 5.6 before autoclaving. Once the seed was transferred, each Petri dish was inoculated with 1 cm3 of fungal inocula placed in the center of the Petri dish for each of the SSCDO-5, LQ, FDd1, and AgP-1 treatments, and two control treatments without a fungal strain were carried out on OMA medium (nutrient-poor medium) and MS medium  were sampled and stained, following the methods described by D. officinale and D. devonianum were inoculated with one compatible fungus, one incompatible fungus, two compatible fungi, and one compatible fungus with one incompatible fungus. Approximately, 30 sterilized seeds were sown on OMA medium in each Petri dish, and each Petri dish was inoculated with two 1 cm3 pieces of fungal inocula. A total of six fungal treatments for D. officinale and five fungal treatments for D. devonianum were finally performed, and OMA and MS media without fungal inoculation were also used as nutrient-poor and nutrient-rich control treatments for two orchid species, respectively , germinated seeds (g), protocorms (p), and seedlings (s) were counted at 60 days after incubation. The percentages of germinated seeds (G), protocorms (P), and seedlings (S) were calculated as follows: G = 100 × (g + p + s)/t, P = 100 × p/t, and S = 100 × s/t, respectively.We used Stages 0, 1, 2 + 3, and 4 + 5 to determine no germination, seed germination, protocorm formation, and seedling development, respectively. Total seeds (p > 0.05).The one-sample Kolmogorov-Smirnov test, a non-parametric test, was used to test whether the data in each group obeyed a normal distribution. One-way ANOVA and least significant difference (LSD) in cases when data were subjected to a normal distribution, and generalized linear models (GLMs) when data did not meet normal distribution were used to test the effects of different fungal inoculations on seed germination, protocorm formation, and seedling development for the two orchid species, respectively. All statistical analyses were performed in SPSS (version 25.0). The results are expressed by mean ± standard error (SE), and the alpha-type I error was fixed at 5%  and shed seed coats, and a large number of pelotons in the basal cells of the protocorm could be observed . In the In the LQ treatment, protocorms had differentiated into seedlings with the first leaf (Stage 4), and a large number of pelotons occurred inside the cells of the protocorm staining black-blue . In the At this stage, seedlings with two leaves (Stage 5) were the common status in the LQ treatment, and pelotons occurred inside the most cells of the protocorm . The sitSeedlings continuously developed and bore 3–4 leaves (beyond Stage 5), and interestingly, the number of pelotons was observed to be obviously reduced in plant cells compared to 30 days earlier . In the At 60 days after incubation, seed germination, protocorm formation, and seedling development showed similar patterns for both orchid species. No seedlings were formed in incompatible fungal treatments or OMA treatments, and the cocultures of seeds with two compatible fungi and with one compatible fungus and one incompatible fungus had negative impacts on seedling development .p-values < 0.05), and the lowest seed germination (30.89 ± 4.73%) occurred in the FDd1 treatment (p < 0.01), while the percentages of seedlings in the two cocultural treatments were all significantly lower than those in the LQ treatment but significantly higher than those in the SSCDO-5 treatment. Interestingly, the percentage of seedlings in the cocultural LQ + FDd1 treatment with one compatible fungus and one incompatible fungus (30.11 ± 2.27%) was significantly higher than those in the two compatible fungi of LQ + SSCDO-5 treatment , while no seedlings were formed in the cocultural SSCDO-5 + FDd1 treatment (The percentage of seed germination was significantly higher in the SSCDO-5 treatment (53.00 ± 2.46%) than in the other treatments , but had no significant differences with the two cocultural treatments of FDd1 + SSCDO-5 (p = 0.33) and FDd1 + LQ (p = 0.48), respectively (p < 0.01). For the two cocultural treatments, the percentage of seedlings in the FDd1 + SSCDO-5 treatment with one compatible fungus and one incompatible fungus (63.56 ± 3.64%) was significantly lower than that in the two compatible fungi of the FDd1 + LQ treatment  and FDd1 treatment, respectively. Although the percentage of seedlings in the FDd1 + LQ treatment was lower than that in the FDd1 treatment, there was no significant difference between the two treatments (p = 0.21). The percentage of seedlings in the MS treatment was 7.56 ± 0.93%, which was significantly lower than that in the other four treatments (The percentage of seed germination was significantly higher in the FDd1 treatment (84.44 ± 2.70%) than in the LQ, SSCDO-5, and two control treatments  with a very long history in China , they showed great differences in subsequent development among treatments. In the LQ treatment, seeds could quickly germinate, form protocorms, and develop into seedlings accompanied by a large number of pelotons formed inside the cells of protocorms, while in the SSCDO-5 treatment, seed germination, protocorm formation, and seedling development were much slower than in the LQ treatment, and also fewer pelotons were obviously observed in different stages compared with the LQ treatment. In two incompatible fungal treatments, although most seeds reached the protocorm stage (Stage 3) and a few pelotons were also observed at 90 days after incubation, no seedlings were found even at 120 days after incubation in the AgP-1 treatment, while in the FDd1 treatment, only a few seeds started to germinate with seed coat broken (Stage 1), and no pelotons were observed at all 120 days after incubation.In this study, the process of fungal colonizing seeds during germination in The results showed that the pattern of fungal hyphae colonizing seeds was well-matched with the morphological differentiation of seed germination and seedling development, and compatible fungi could persistently colonize seeds and quickly promote the conversion of germinated seeds into seedlings. The number of pelotons in protocorms has been used as a proxy for successful symbiosis, and it can be positively correlated with protocorm growth in mycorrhizal symbioses in many orchids e.g., . It was Tulasnella strains differed greatly in colonization modes. Tulasnella SSCDO-5 is symbiotically compatible, while Tulasnella AgP-1 and FDd1 are symbiotically incompatible with D. officinale. The two compatible fungi, Tulasnella SSCDO-5 and Sebacinales LQ, were isolated from protocorms of D. officinale originally from different habitats, and both could promote seed germination up to seedling with relative effectiveness. Because OMFs have been recruited among endophytic fungi that colonize orchid ancestors  were cocultured with the host plant Metrosideros laurifolia, the biomass value was reduced when compared with the same inoculation treatment with only one species of Acaulospora (In the fungal cocultural experiments, for both orchids of  studies  and havecultures . In arbuulospora . Such reulospora .These results suggest that there is antagonism or competition between mycorrhizal fungi for the studied species, which may be caused by the environmental conditions of the habitat. An unexpected observation was that some rhizoctonia-associated epiphytic orchids displayed ectomycorrhizal taxa, and the surprising occurrence of ectomycorrhizal fungi on tree bark suggests that their ecological niche still hides some unknown aspects . OMFs haD. officinale, compatible fungi could persistently colonize seeds and quickly promote the conversion of germinated seeds into seedlings, and the pattern of fungal hyphae colonizing seeds was well-matched with the morphological differentiation of seed germination and seedling development. Two phylogenetically distant fungi, Tulasnella SSCDO-5 and Sebacinales LQ, originally from different habitats, were compatible with D. officinale, and both could promote seed germination up to seedling with relative effectiveness, indicating that the host-fungal compatibility could be influenced by environmental factors. Cocultures had slightly negative effects on seed germination, protocorm formation, and seedling development for D. officinale and D. devonianum. For orchid conservation based on symbiotic seed germination, it is recommended that a single, compatible, and ecological/habitat-specific fungus can be utilized for seed germination.During seed symbiotic germination of The original contributions presented in the study are included in the article/J-YG and G-HM designed the experiment and wrote the manuscript. G-HM and X-GC conducted the experiments. G-HM performed the analysis. J-YG and M-AS reviewed the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.