Meningiomas are the most common group of primary intracranial tumors. While the majority are classified as WHO grade 1, WHO grade 2 and 3 meningiomas have poorer outcomes, even after gross total resection, and often require supplementary treatment. Long-term follow-up data regarding the progression-free survival (PFS) and overall survival (OS) for grade 2 and 3 tumors are scarce, and data evaluating the routine use of supplementary radiotherapy and radiosurgery have been inconclusive. Furthermore, few studies have reported data on the health-related quality of life (HRQoL), anxiety, and depression for these patients. In this population-based cohort study, we reviewed 51 cases of WHO grade 2 and 3 meningiomas. We found that the median OS was 13 years for grade 2 and 1.4 years for grade 3 meningiomas. Meningioma was the cause of death in 93% of the patients who passed away. The surviving patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked preoperatively returned to work after their treatment.p = 0.018, OR 1.12). The median PFS was significantly shorter for high-risk tumors compared to the low-risk group . The surviving meningioma patients showed HRQoL measures comparable to that of the general population, with the exception of significantly more anxiety and depression. All patients who worked before surgery returned to work after their treatment. In conclusion, we confirm dismal prognoses in patients with grade 2 and 3 meningiomas, with tumor-related deaths resulting in severely reduced OS. However, the cohort was heterogenous, and a large subgroup of both grade 2 and 3 meningiomas was alive at 10 years follow-up, suggesting that a cure is possible. In addition, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent and progressive diseases.Progression-free survival (PFS) and overall survival (OS) for WHO grade 2 and 3 intracranial meningiomas are poorly described, and long-term results and data evaluating the routine use of supplementary fractionated radiotherapy (RT) or stereotactic radiosurgery (SRS) has been inconclusive. The aim of this study was to determine the long-term PFS and OS at a center that does not employ routine adjuvant RT. For this purpose, a retrospective population-based cohort study was conducted of all WHO grade 2 and 3 meningiomas surgically treated between 2005 and 2013. The cohort was uniformly defined according to the WHO 2007 criteria to allow comparisons to previously published reports. Patient records were reviewed, and patients were then prospectively contacted for structured quality-of-life assessments. In total, 51 consecutive patients were included, of whom 43 were WHO grade 2 and 8 were grade 3. A Simpson grade 1–2 resection was achieved in 62%. The median PFS was 31 months for grade 2 tumors, and 3.4 months for grade 3. The median OS was 13 years for grade 2, and 1.4 years for grade 3. The MIB-1-index was significantly associated with an increased risk for recurrence ( Meningiomas are the most common intracranial tumors, accounting for 30–35%. In comparison, glioblastomas account for 15%, and gliomas of any grade account for 28% . The pooThis single-center cohort study aimed to evaluate and summarize the long-term clinical courses for patients with grade 2 and 3 meningiomas. In the first part, outcomes of surgical and nonsurgical treatments are evaluated, and in the second part, we provide an in-depth evaluation of HRQoL-measures in this patient group.The definitions of grade 2 and 3 meningiomas have changed with every version of the WHO grading system ,6,7,8. WThe treatment recommendations for grade 2 and 3 meningiomas frequently include conventional fractionated RT and intensified surveillance for recurrences. Several studies have sought to understand the benefit of RT ,13,14. HSRS is an important adjunct to the management of intracranial low-grade meningiomas, with low treatment-related morbidity and reported long-term (>5 y) tumor control rates ranging from 86–100% ,21,22. RDue to the lack of proven efficacy, chemotherapeutics do not have an established role in the treatment of meningiomas, and current recommendations suggest chemotherapy for progressive disease only when all other options have been exhausted . At the To shed light on these questions and improve external validity, this study aims to describe the long-term (>10 years) clinical courses, surgical and nonsurgical treatments, PFS and OS, and patient-reported outcomes in a cohort of grade 2 and 3 meningiomas, as classified according to the WHO 2007 classification.All adult patients (≥18 years) who were surgically treated for a grade 2 or 3 meningioma at the study hospital between 2005–2013 were eligible for inclusion. The study hospital is a publicly funded and owned tertiary care center serving a region of roughly 2.3 million inhabitants, the only neurosurgical center in the region, and the only center operating a Gamma-knife in the country. Patients were identified using the surgical management software Orbit . Medical records and imaging data from digital hospital charts were retrospectively reviewed using the health record software TakeCare .The details of the surgical technique are outside the scope of this manuscript. At the study center, patients with WHO grade 1 meningioma are followed with an outpatient visit at 3 months and routine MRI at 3 months, and 1, 3, 5, and 10 years after surgery. When a diagnosis of a WHO grade 2 or 3 meningiomas is made, radiological follow-ups are performed annually instead. In cases with residual tumors or recurrences, the patients are discussed at multidisciplinary conferences, where neurosurgeons, neuroradiologists, and neuro-oncologists participate. At the conferences, individual arrangements for follow-up and treatments, either surgical or supplementary radio- or chemotherapy, are discussed. In these cases, the patients are offered multiple outpatient visits or telephone contacts with members of their treatment team.Baseline data included demographic parameters, imaging findings, treatment data, tumor characteristics, and clinical parameters such as the Karnofsky Performance Status (KPS). Tumor growth was defined as the radiological growth of a tumor remnant following subtotal resection, while tumor recurrence was defined as the appearance of a new meningioma following gross total resection. To evaluate the effect of the number of treatments that a patient was subjected to during the course of the disease, the sum of surgeries, gamma-knife treatments, RT, and chemotherapy was calculated. In this context, a course of RT was counted once as was chemotherapy, which was typically given continuously if effective.While 15 patients had undergone their first meningioma resection prior to the study period, PFS and OS were calculated from the first operation performed during the study period (2005–2013). This was done because (i) the WHO grade was often uncertain for procedures performed before 2005, and (ii) not doing so would bias the data, as we were not able to include previously operated patients who did not undergo renewed surgery during the study period.All histopathological analyses were performed at the Department of Pathology, Karolinska University Hospital, Stockholm, Sweden. The MIB-1-indexes were analyzed manually. Patients were classified according to WHO criteria from 2007.All adult (>18 years) patients operated on for an intracranial meningioma at the Karolinska University Hospital during a period of 8 years (February 2005–June 2013), were identified. Patients with WHO grade 1 meningioma were excluded. All patients with WHO grade 2 or 3 meningioma at either index or reoperation were included. During the study period, 537 patients were operated on for a WHO grade 1 meningioma and 51 (8.6%) for either a primary or secondary WHO grade 2 or 3 meningioma. All 51 patients with a WHO grade 2 or 3 meningioma diagnosed at either index or reoperation were included in the baseline analysis for this study. Among these 51 patients, 36 underwent their first surgery between 2005–2013, while the remaining 15 were reoperations with the index surgery performed between 1974 and 2003 .p < 0.05.The Shapiro–Wilks test was used to evaluate the normality of the data. Parametric continuous data were presented as a mean (standard deviation), non-parametric continuous data as a median (Q1–Q3), and categorical data as numbers (proportion). The Wilcoxon matched-pairs signed-ranks test was used to determine if there was any significant change in Karnofsky Performance Status (KPS) before and after surgery. Tumor control and overall survival were plotted using Kaplan–Meier curves. Uni- and multivariable logistic regression was used to assess potential predictors of tumor growth/recurrence. All analyses were conducted using the statistical software programs R and SPSS. Statistical significance was set at The study was approved by the National Ethical Review Authority (registration numbers 2020-00192 and 2021-03623) who waived the need for informed consent regarding the retrospective part of the study. Signed informed consent was obtained from each participant in the prospective quality of life part of the study. Data from the Stockholm Public Health Survey was based on individuals who gave informed consent to participate and was anonymized when obtained.In total, 51 patients met the inclusion criteria and were included in the study. Of these, 15 (29%) had undergone at least one prior meningioma resection whereas 7 (47%) were WHO grade 1 at the most recent prior surgery. The median age was 64 years and 51% were female. A total of 84% (n = 43) of the tumors were WHO grade 2 and the remaining 8 (16%) were WHO grade 3 . The mosA Simpson grade 1 resection was achieved in 37% of cases, grade 2 in 25%, grade 3 in 3.9%, and grade 4 in 33% . A serioSupplementary fractionated RT was performed in 10 (20%) patients, with a total dose of 50–60 Gy. No patient underwent more than one session of fractionated RT. Gamma-knife treatment was performed in 32 (63%) patients, with residual or recurring meningiomas receiving 15–18 Gy to 50% isodose, with a maximum dose of 36–40 Gy. The median number of gamma-knife treatments was 2, although one patient underwent as many as 9 sessions . Chemotherapy was administered to 12 (24%) patients . The median survival following the start of chemotherapy was 14 months (range 1.9–67 months); none of the patients were alive in 2022 .p = 0.006). Two patients were unconscious at admission  but improved to KPS 50 and 60 at discharge, and KPS 70 and 90 at follow-up, respectively  . Surgeryectively .p = 0.018)  .p = 0.018, OR 1.12), but not for female sex, age, ASA class, reoperation, hotspots, or partial tumor resection. The MIB-1-index also showed independent risk association after adjusting for these parameters in the multivariable model , to help guide future treatments of these patients. The analyses included baseline data, postoperative complications, supplementary treatments, predictors of recurrence, PFS, OS, and cause of death.p = 0.018, OR 1.12) and remained an independent predictor even after confounder adjustment (p = 0.047). Surprisingly, the extent of tumor resection showed no significant association with PFS. These findings are, in part, different from a recent report where, in addition to the MIB-1-index, a larger tumor size, older age, and necrosis on MRI were identified as predictors of tumor recurrence [In the univariable logistic regression analysis, the MIB-1-index showed a significant association with tumor recurrence or growth . Barthelemy et al. studied a large cohort of 3611 grade 2 meningiomas from the National Cancer Database treated between 2008 and 2012 and considered their 78% 5-year survival to be acceptable [We identified a median OS of 13 years for WHO grade 2 and 1.4 years for grade 3 meningiomas. When dichotomized into low- or high-risk , low-risceptable . A systeceptable  reportedceptable ,36,37.Of note, previous studies did not address the causes of death. We found that meningioma was the cause of death in 93% of patients who died during the follow-up period.The evidence for radiotherapy is inconclusive but treatment guidelines typically recommend adjuvant radiotherapy (RT) after gross total removal for grade 2, grade 3, and “high-risk” meningiomas . SRS is The reported values for local control are 60% at 5 years for proton and 63–95% for carbon ion therapy at 2 years . In our We conclude that SRS is useful for the management of grade 2 and 3 meningiomas but did not provide cures.The impact of chemotherapy as supplementary treatment at the study center remains unclear as it was used as a last resort. All treated patients were dead at the time of the structured interview in 2022, and the median survival after starting treatment was 14 months.Taken together, we confirm dismal prognoses, with 93% of the mortality attributed to meningiomas. Yet, the cohort was heterogenous, and a large subgroup comprising both grades 2 and 3 was alive at 10 years follow-up after one operation or operations supplemented with radiosurgery, suggesting that a cure is possible. In contrast, fractionated radiotherapy and chemotherapy had little benefit when introduced for recurrent or progressive diseases.Currently, different combinations of surgery, radiation, and chemotherapy are used to combat grade 2 and 3 meningiomas. However, there are no internationally accepted treatment guidelines. In contrast to the treatment of grade 1 meningiomas, where a single surgery is often sufficient, higher-grade meningiomas frequently recur and require a series of treatments during the lifespan of the patient. Thus, it is of great importance to understand the effects of treatment choices on outcomes as well as the patients’ health-related quality of life (HRQoL).HRQoL measures can be viewed as self-perceived health . Only a In this part of the study, HRQoL and return to work among the patients alive in 2022 were systematically studied.Among the included 51 patients, 23 were still alive in 2022 and were contacted with a request for participation in a follow-up quality of life study. In total, 5 patients declined to participate or did not respond. Thus, 18 patients (15 WHO grade 2 and 3 WHO grade 3) were included in this part of the study, . Thus, the anonymized raw data of 39 individuals were included to represent the general population sample.For the multifactorial analysis of HRQoL a minimum of four aspects are needed: physical-, psychological- and social health or functioning and disease/treatment-related symptoms along with an additional global measure of health status . It is gVAS) [index, where 0 represents dead and 1 represents full health. Five dimensions within three answering levels give a total of 243 health profiles that can be elicited from the descriptive system. In this study, the United Kingdom (UK) value set was used to calculate the EQ-5Dindex [VAS, the respondents rate their current health between 0  and 100 . The recall period was the day of completion of the questionnaire.The EQ-5D-3L is a generic HRQoL measure and consists of two parts: a descriptive system where the respondents classify their health in five dimensions  within three severity levels , and a visual analog scale (EQVAS) . The res-5Dindex . On the FACT-Br was developed as a revalidation of the general version of FACT and a subscale for primary brain cancer patients by Weitzner et al. . FACT-BrHADS is a 14-item measure for detecting states of anxiety and depression, constructed by Zigmond and Snaith . The iteStructured interviews were conducted by the first author, either in a secluded room during a follow-up visit at the department of neurosurgery, or by telephone (according to the patients’ preferences). The interviews were conducted between nine and thirteen years postoperatively (index operation). During the interviews, neurological symptoms, subjective cognitive impairment, return to work, family relationships, and leisure activities were assessed. The questions that were asked were concerning the period before and immediately after surgery, the entire follow-up period, and patients’ current situation. The interviews were descriptive, and no formal scales were used. The first author has more than twenty years of experience working clinically with meningioma patients.index, and EQVAS were calculated. To analyze differences between groups, Fisher’s exact test and t-test were used. Moderate and severe levels on EQ-5D dimensions were collapsed before performing the chi-square statistics. All analyses were conducted using the statistical software program SPSS. Statistical significance was set at p < 0.05.The EQ-5D-3L data were compared between the meningioma sample and the general population sample. Descriptive statistics for the demographic and study-specific variables, EQ-5D dimensions, EQ-5DA total of 13 patients (6 men) chose to answer the EQ-5D-3L questionnaire. The median follow-up time was 12 years (IQR= 10–13) after the first meningioma surgery. The median age for both cases and controls was 66 years (IQR= 58–76).Of the possible 243 health profiles that can be elicited from the descriptive system, 8 profiles were selected in the meningioma sample, in comparison to 11 profiles in the general population sample. Full health  was rated by n = 2 (15%) in the meningioma sample and n = 17 (44%) in the general population sample. The best imaginable health  was rated by n = 5 (13%) in the general population sample, whereas the highest EQ VAS score in the meningioma sample was 93.The meningioma sample rated significantly more problems with anxiety/depression in comparison to the general population sample. No other significant differences were found within the EQ-5D-3L dimensions, EQ-5Dindex, or EQ VAS between the samples .A total of n = 12 participants  in the meningioma sample chose to answer the FACT-Br questionnaire, the results were not normally distributed. When comparing central tendency and dispersion with previously published reference samples, the meningioma sample scored similarly to US adult cancer patients on PWB, SWB, EWB, FWB subscales, and FACT-G total score , and higThe same twelve participants that answered FACT-Br in the meningioma sample also chose to answer the HADS questionnaire. When using the cut-off scores for cancer patients suggested by Singer et al. , a totalAll living patients were invited to a structured interview, of whom 16 chose to participate. Two patients refrained from participating in the interview, due to other health-related reasons, but were overall content following their previous surgery. The median follow-up time from index surgery for these 16 patients was 12 years (range 9.3–15 years). Two patients had undergone a reoperation for tumor recurrence after their index surgery, five underwent supplementary gamma-knife treatment, and one RT . Dependiindex values [Recently, systematic reviews have revealed that grade 1 meningiomas, although generally considered benign, cause a substantially reduced quality of life in affected patients compared to a normal population at short-term follow-up ,65. Neitx values ,67. The x values , who assindex (0.74 versus 0.77). Previous studies have shown that meningioma patients generally report a worse HRQoL than healthy controls [index between patients and controls could thus reflect this selection bias. In line with this, epilepsy, which is strongly associated with worse health after meningioma surgery [index could be that the randomized general population sample also reported high numbers of health problems due to high age or comorbidities [Surprisingly, the meningioma sample did not differ from the matched general population sample in the EQ-5Dcontrols . By nece surgery ,62, occubidities , or insubidities .p = 0.003). This high perceived anxiety/depression was also visible in the HADS scoring. The overall HADS scores were higher than reported by a randomized sample of the Swedish population [The EQ-5D-3L questionnaire showed significantly higher scores for the anxiety and depression dimension, where meningioma patients scored higher for moderate or severe problems than the matched general population sample (pulation . Our patpulation . The NorVAS (68 versus 72). One reason for not presenting the EQVAS as a general perception of HRQoL in studies may be that the measure is highly susceptible to response shift, i.e., a changed evaluation of a target construct as a result of the person’s internal standards of measurement or scale recalibration. For instance, patients may do upward- or downward comparisons (compare themselves with someone better or worse off), which sets the standard for their rating. To assess a possible response shift and its direction, comparisons of a baseline and a retrospective measure are needed [VAS values, thus the patients’ subjective perception of their current health is missing. However, interviews allowed further analyses of patients’ subjective health.The meningioma patients in our sample scored similarly to the general population sample on the EQThe HRQoL is also negatively affected by tumor recurrence which has a higher frequency than, for instance, spinal meningiomas where patients have an HRQoL similar to the general population ,74,75. TAll interviewed patients had some degree of perceived cognitive impairment. This is in contrast to previous findings on grade 1 meningiomas where, except for working memory, no differences in memory, visuo-constructive abilities, or executive functions could be seen compared to preoperative assessment, while an improvement in attentional functions was observed at 9 months after surgery . On the Despite reporting neurological deficits and impaired cognition, all interviewed patients had been able to return to work. Of the 13 patients working before surgery, all but one, who reached old-age pension, returned to work. This contrasts with previous reports on large populations that indicate that 17–33% of the patients operated on for meningioma were unable to return to work ,81.From a long-term follow-up perspective, our patients report an HRQoL comparable to that of meningioma grade 1 patients. The patients suffer some cognitive impairments and report emotional problems such as anxiety, depression, and fatigue as common symptoms after surgery ,78,80,82This study carries limitations inherent to its retrospective design. The study is also limited by the small number of patients fulfilling criteria for grades 2 and 3 with the 2007 classification. However, the use of that classification allows comparisons to similar cohorts [Patients with grade 2 and 3 meningiomas have a chronic disease requiring multiple surgeries and often supplementary treatments. Patients with high-risk tumors have a significantly shorter PFS compared to low-risk tumors. The MIB-1-index is an independent predictor of tumor recurrence or growth. Long-term surviving patients have a good HRQoL compared to the general population, with the exception of some degree of cognitive impairment, anxiety, and depression. This subgroup of patients needs fewer treatments, have a more benign clinical course, and returns to work at a high frequency.


BACKGROUND: There is little known about epidemiologic evidence on periodic leg movements during sleep (PLMS) for the Japanese. The present study was a cross-sectional epidemiologic study to estimate the prevalence of PLMS and examine the associated factors of PLMS in Japanese community-dwelling adults.METHODS: The subjects were 884 with bed partners or bedroom mates of 1,889 Japanese adults aged 20 years and over randomly selected from the general population. The case ascertainment of PLMS was based on the assessments of their bed partners or bedroom mates using the Pittsburgh Sleep Quality Index. Multiple logistic regression analyses were used for investigating the associated factors.RESULTS: The age-adjusted prevalences  were 5.8% (4.7-6.8%) and 1.3% (0.8-1.9%) for 1 to 2-times, and 3-times or greater of PLMS per week during the preceding month, respectively. Those with PLMS were more likely to experience difficulty in initiating sleep, snore during sleep, be depressed, and suffer from peptic ulcer. Sex, age, difficulty in maintaining sleep, excessive daytime sleepiness, medication use to aid sleep, and any psychoactive substances  were not identified as significant associated factors of PLMS.CONCLUSIONS: The results suggest that the prevalence of PLMS in Japanese community-dwelling adults is not so high as those reported from Western countries, and that PLMS is correlated with some sleep and health disturbances. The movements usually occur in the legs and similar movements can occur in the upper limbs.6,7 The periodic leg movements during sleep (PLMS) are a characteristic feature of periodic limb movement disorder.8 The periodic limb movement disorder is a relatively new clinical entity, and the prevalence and predisposing factors still remain to be investigated.Periodic limb movements during sleep, which was originally described as nocturnal myoclonus by Symonds,9,10 11%  in healthy adults,11 10-16% in randomly selected elders and 45% in elderly volunteers willing to have their sleep recorded,12 and 2-12% in adult community residents.13,14 They also examined the associations with age, sex, sleep disturbances, daytime sleepiness, napping, sleep apnea or breathing problems, hypertension, mood or affective disorders, psychoactive substances , occupation, and low household income,9-22 but the findings obtained across studies were not consistent.Previous studies on periodic limb movements during sleep reported a prevalence of 11-13% in sleep disorder patients,The findings of most previous studies came from those who were clinically referred or willing to be tested. More epidemiologic research on periodic limb movement disorder was needed for the non-referred subjects of a target study population. For one reason, we wanted to know how prevalent it was among the non-referred subjects from the viewpoints of public health and health education, because it was not known well in society and those with periodic limb movement disorder accordingly might not be identified or treated appropriately. We also wanted to make a part of the investigations on its risk factors for further research on the etiology. The purpose of the present study was to estimate the prevalence of PLMS, a characteristic feature of period limb movement disorder, and examine its associated factors in Japanese community-dwelling adults based on the assessments of their bed partners or bedroom mates.23A nationwide epidemiologic study on sleep and health was conducted for 2,800 Japanese adults aged 20+ years randomly selected from the residential registries based on the 1995 Census. A self-administered questionnaire was mailed to each subject in autumn, 1997. Two reminders were sent at intervals of a few weeks to subjects who had not replied within two weeks. The participants for the study were 1,889 respondents who basically agreed with voluntary and anonymous participation in this study (response rate: 67.5%). The method used for this survey was previously reported in detail elsewhere.The subjects used for analyses were 884 with bed partners or bedroom mates: sex, 441 males and 443 females; age, 59, 178, 174, 155, 138, 113, and 67 for the age groups of 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80+ years, respectively; marital status, 830 married, 50 unmarried, and 4 unascertained; educational status, 249 junior high school graduates, 629 university, college, technical school or high school graduates, and 6 unascertained; employment status, 546 employed, 333 unemployed, and 5 unascertained.24-26 (4) sleep habit and sleep problems using the Japanese version of Pittsburgh Sleep Quality Index,27,28 (5) the environmental conditions of noise, light, temperature, moisture, and space in a bedroom, and (6) psychoactive substance use affecting sleep .A self-administered questionnaire used for the present study consisted of 60 items on (1) sociodemographic information , (2) physical health status on present medical illnesses , utilization of medical services or consultations, and activities of everyday life, (3) mental health status using the Japanese version of the 12-item General Health Questionnaire,PLMS and sleep-related complaints were assessed with the following respective items drawn from the Pittsburgh Sleep Quality Iindex.1) PLMS: if you have a bed partner or bedroom mate, ask him/her how often you have had legs twitching or jerking while you sleep.2) Difficulty in initiating sleep; how often have you had trouble sleeping because you cannot get to sleep within 30 minutes?3) Difficulty in maintaining sleep: how often have you had trouble sleeping because you wake up in the middle of the night or early morning?4) Excessive daytime sleepiness: how often have you had trouble staying awake while driving, eating meals, or engaging in social activity?The subjects were asked to choose one response from the following four answers: (1) not at all in one week, (2) less than once a week, (3) once or twice a week, and (4) three or more times a week in the previous month. Those who replied not at all per week in the past month to all of the above items were judged not to suffer from PLMS or sleep-related complaints. The rest were categorized as those with PLMS, the difficulty in initiation sleep, difficulty in maintaining sleep, and the excessive daytime steepness.27 in the steep laboratory could not be incorporated into a large-scale community-based epidemiologic study.The case ascertainment applied for this study was based on symptoms alone. Clinical diagnoses including polysomnographic and electromyographic recordings,Statistical analysis was performed for the subjects with bed partners or bedroom mates. The age-adjusted prevalence with a 95% confidence interval (CI) of PLMS and sleep-related complaints  were estimated, after being weighted according to the proportion of each age group in the total adult population determined by the 1995 Census. The number of those with PLMS was so small that the age-adjusted prevalence of PLMS was calculated for the combined data of males and females. Sex difference in PLMS was investigated using logistic regression models.29 A univariate analysis was performed to detect the association of PLMS with each of the variables, and then the variables were analyzed using the forward selection stepwise procedure (P≦0.05 as inclusion and P≧0.10 as exclusion). Strong intercorrelations between variables were checked and excluded from a multiple logistic regression model. The variables entered in the models (the reference groups) were determined based on the previously reported studies;9-22 (1) sociodemographic variables: sex , age group (20-29 years old), marital status (unmarried), educational status , and job status (employed), (2) sleep-related complaints: difficulty in initiating sleep, difficulty in maintaining sleep, excessive daytime sleepness, and snoring , (3) medication use to help sleep , (4) physical health variables: present medical illnesses (absent), (5) mental health variables: each item of the 12-item General Health Questionnaire excluding the item on insomnia (absent), and (6) psychoactive substance use affecting sleep: smoking (never), alcohol drinking (never) and caffeine drinking (never).To examine the associated factors with PLMS, a multiple logistic regression analysis was used.30 All the analyses were run with SPSS® version 10.0J.31Subjects with missing values were eliminated from the analyses (listwise exclusion). Two-tailed P values less than 0.05 were considered as significant. Hosmer-Lemeshow’s test was used to evaluate the goodness of fit for a multiple logistic regression model.Associated factors with PLMS were explored in the main contexts of age and sex, sleep-related complaints and medication use to aid sleep, physical and mental health status, and psychoactive substances affecting sleep. In univariate analyses, significant associations of PLMS were identified with the difficulty in initiating sleep, the difficulty in maintaining sleep, the excessive daytime sleepness, and snoring, physical health status , and mental health status . As shown in The present study was the nationwide epidemiologic study to explore the prevalence and associated factors of PLMS for Japanese adults in a community setting. Among the subjects with bed partners or bedroom mates, the prevalences of PLMS were 5.8%  and 1.3%  for 1 to 2-times, and 3-times or greater per week in the previous month, respectively. Examining the associated factors of PLMS, the multivariate analysis revealed that difficulty in initiating sleep, snoring, depressed mood, and peptic ulcer were significantly associated with PLMS.13 the prevalence was 2-5% for females and 8-12% for males among 4,612 community residents  in the geographically limited areas of Japan. A case definition of PLMS used in their study was based on a self-report using a self-administered questionnaire; Have you ever been told you jerk your legs or kick during sleep? (Yes/No/Sometimes). The answer of yes to the question was considered as representing PLMS. Male preponderance of PLMS was identified for the age group of 30-69 years. No age effect on prevalence of PLMS was found.We found only a few community-based epidemiologic studies on PLMS or periodic limb movement disorder for comparison with the findings in the present study. According to a brief report by Kageyama et al.,14 conducted a telephone interview survey for a representative sample of 18,980 subjects aged 15 years and above in the general population of five European countries. They asked the following question; according to you or your bed partner, do you move your limbs a lot during your sleep? The prevalences were 5.9%, 5.5% and 7.8% for several times per month, one night per week, and 2 nights or more per week, respectively. They also reported 3.9% as a prevalence of periodic limb movement disorder using the minimal criteria according to the International Classification of Sleep Disorders.7Ohayon and Roth12 conducted telephone interviews to 1,865 elderly community residents in San Diego, USA. The subjects were asked whether their legs often twitch or kick during the night while they are asleep. The prevalence was 16% vs. 10% for those with and without sleep recordings. Of 420 elderly volunteers willing to have their sleep recorded, 45% showed that a myoclonus index was 5 or higher.Ancoli-Israel et al.12-14 Although these findings derived from different study subjects and case ascertainments could not be strictly compared, it was implied that the prevalence of PLMS in Japanese community-dwelling adults was not so high as those reported from Western countries.The prevalence across the above studies ranged 2-16%.13,14 including the present study did not suggest that PLMS or periodic limb movement disorder was more common in the elderly.11,12 Regarding sex, the present study did not show a significant relation between PLMS and sex, but some studies reported a male dominance of PLMS or periodic limb movement disorder.11-14 The inconsistent findings on age and sex across studies may be partly due to the different methods used in each study . Further well-controlled studies are needed to clarify how aging plays a role in a mechanism of causing or developing PLMS and whether or not there is sex difference in PLMS.Associated factors of PLMS or periodic limb movement disorder examined were not concordant among studies. For age, the recent epidemiologic community-based studies for the general population with a wide age range17 compared the frequencies of PLMS among 100 middle-aged subjects with various sleep-related disorders, and found no significant difference in PLMS among insomniacs, hypersomniacs, and healthy controls, suggesting that PLMS may not contribute to the complaints of insomnia and hypersomnia. Rather, they suggested much higher frequencies of PLMS among narcoleptic and restless leg syndrome patients. Youngstedt et al.15 reported no association of myoclonus index with subjective and objective sleep measures in 22 elderly volunteers with complaints of poor sleep or depression. Mendelson16 examined 67 periodic limb movement disorder patients and reported no significant correlation between the periodic leg movement arousal index and the measures of sleepiness. To our knowledge, there was no epidemiologic study investigating the associations of PLMS with sleep disturbances other than the present study. The present findings did not show that PLMS was significantly associated either with the difficulty in maintaining sleep or with the excessive daytime sleeping. In addition, there was no significant difference in medication use to help sleep between those with and without PLMS. Considering these findings with together, PLMS may not disrupt sleep too severely to cause nocturnal and early morning awakenings and daytime somnolence in the subjects of our study. A relation between PLMS and the difficulty in initiating sleep found in the present study may be caused by a possible coexistence of restless leg syndrome, which is often accompanied by PLMS and disturbs falling asleep.17,32The correlation between PLMS and sleep disturbances is of interest regarding the symptomatology of PLMS. Recently, Montplaisir et al.17-19,21,22,33,34 and depressed mood.15,21,22 In the current study, peptic ulcer appeared as a significant correlate with PLMS, which was not reported in any pervious studies. It is too early, however, to confirm this finding because the number of those with peptic ulcers was small. Further investigation is needed.The findings obtained in the present study on associations or co-morbidity of PLMS with some physical and mental conditions are in agreement with those reported from other studies, such as snoring or obstructive sleep apneasSome limitations should be taken into account in interpreting the findings of the present study. Firstly, as noted earlier, we did not have objective data on PLMS measured with polysomnograpies or electromyographies. A validation study about sensitivity and specificity using the assessments of observers  and electrophysiological tests  is considered to implement in the near future. Secondly, the subjects used for this study were targeted only to those who had bed partners or bedroom mates. We checked statistical significance in sociodemographic characteristics between the subjects with and without bed partners or bedroom mates. There was no sex difference, but the former were less likely to be younger or older, and more likely to be married, employed, and finish high school, college or university than the latter. Thus, there is a possibility of the present findings distorted due to such selection bias. Thirdly, the goodness-of-fit of the model was not satisfactory, because the data in each stratum of the model was so sparse that the model might not become stable. The larger number of subjects is necessary for the future study. Lastly, our cross-sectional study design could not refer to a cause-effect relation between PLMS and its risk factors.In summary, the present study provides us with the preliminary evidence on prevalence and associated factors of PLMS for Japanese adults with bed partners or bedroom mates in a community setting. The results in this study deserve emphasis for promoting further research of PLMS or periodic limb movement disorder with regard to its etiology and symptomatology.


Cardiorespiratory fitness was tested with a bicycle test, and adherence to the Mediterranean diet (MedDiet) was assessed with the MDS questionnaire. Our data strengthened previous results confirming that the higher a person’s adherence to MedDiet, the higher the cardiorespiratory fitness and the lower the body fat. Furthermore, our results showed that anemia in patients with CHF has an impact in terms of cardiorespiratory fitness, and functional outcomes by questionnaire. Since our data revealed gaps in iron supply (37.9% with iron deficiency), malnutrition (only 7.8% with high adherence to MedDiet), and both symptomatic and non-symptomatic study participants failed to meet reference values for physical performance, we encourage the enforcement of the guidelines in the treatment of CHF more strongly.In addition to drug therapy, lifestyle modification, including physical activity, and nutrition management are an integral part of current guidelines for patients with chronic heart failure (CHF). However, evidence on which clinical parameters are most influenced by nutritional behaviour, exercise capacity, or iron status is scarce. For a multicenter intervention study, we included participants with diagnosed CHF ( Chronic heart failure (CHF) is one of the most common diseases with a prevalence of 1–2% in adults in developed countries, disproportionately affecting the elderly . The cauDamage of the heart and chronic pressure and/or volume overload triggers cellular, structural, and neurohumoral adaptions . This caN-terminal natriuretic pro-B peptide (NT-proBNP) has emerged as an important diagnostic laboratory marker of cellular damage and CHF because blood concentrations increase as heart failure develops or worsens ,6,7. AccThe clinical severity of CHF is graded according to the New York Heart Association (NYHA) on the basis of clinical symptoms at various degrees of patients’ physical activity (PA) .Therapy of CHF is primarily based on consistent drug intervention to reduce the cardiac workload and improve comorbidities . FurtherA significant advantage of a specific diet for patients with CHF could not be proven so far, which is why the dietary recommendations for the general population of the German Society for Nutritional Medicine also apply to patients with CHF ,14. AlthExercise capacity in cardiopulmonary exercise tests correlates strongly with the degree of heart failure according to NYHA stages . So far,Heart failure, Individual exercise training, Telemonitoring, Selfmanagement”) at the study center Hannover Medical School, Germany. HITS is a partially ongoing multicenter, prospective, both therapeutic and diagnostic, randomized, and parallel-group study done as a collaborative project between Leipzig University, Hannover Medical School, Leipzig Heart Center, AOKplus health insurances, IGES institute, Diaventions GmbH, and the Clinical Centers in Wolfsburg, Chemnitz and Dresden (Germany). The study is registered under DRKS00019022 in the German Clinical Trials Register. The institutional review boards of Hannover Medical School (No. 8786) and medical faculty of Leipzig University (479/19-ek) approved the study’s ethics, and written informed consent was obtained prior to the inclusion of study participants.The objective of the presented data set refers to the baseline data from the “HITS” study  and control group (CG). The allocation to the NYHA stages I, II, or III was taken from existing diagnoses or was determined by the study physicians based on the severity of symptoms during PA  which were collected via a venous blood sample, further laboratory parameters were collected at Hannover Medical School .Anthropometric data  were assessed based on defined standard operation procedures (SOP), after a general medical examination by a physician . Body-mass index (BMI) was calculated with the formula bodyweight (kg) ÷ height (mn = 216), participants were divided into one of the following three groups: ID according to ESC guidelines included participants (n = 82) with a ferritin level < 100 ng/mL or a ferritin level < 300 ng/mL in conjunction with a transferrin saturation < 20% , the carbon dioxide production [VCO2(mL/min)], and ventilation. All parameters were continuously measured breath-by-breath [Exercise capacity (measured as peak power output in watts [W]) and maximum heart rate  . Scores The 23-item Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to quantify physical limitations, symptoms, self-efficacy, social interference, and HrQoL in patients with CHF ). A one-way analysis of variance (ANOVA) was used to test for group differences between normal iron status, ID, and anemia. The effect size is given by η². Significant differences were corrected with the Bonferoni post hoc test. The type-I-error was set to 5% (two-sided).A stepwise backward multivariate linear regression was performed to identify parameters associated with relative oxygen uptake . A priory case number calculation was performed to detect group differences of 10% in exercise capacity with the given number of cases with a statistical power of 0.85 and the mentioned significance.The combined data set consisted of 239 participants, 74 participants with NYHA 1 classification, and 165 participants with NYHA 2 & 3 classifications.In addition to the primary diagnoses according to the inclusion criteria of the study, the most frequent secondary diagnoses are listed in p = 0.005), TSF% , KCCQ total score , ferritin , waist-to-hip-ratio , wattmax , VO2max , FFM , hematocrit , but not with sTFR . In all participants, hemoglobin correlated with BMI , FFM  and by trend with wattmax/kg  and VO2max/kg . The sTFR correlated with BMI , KCCQ symptom scale , KCCQ functional score , clinical summery score  and KCCQ total score , wattmax/kg , and VO2max/kg .Ferritin correlates with BMI , NYHA level , KCCQ symptom scale , individual aerobic lactate threshold , and MDS total score  predicted VO2max/kg. The model explained 31.1% of the total variation in VO2max/kg.In a multivariate linear regression model including age, sex, WHR, NT-proBNP, ferritin, sTFR, tTSF(%), hemoglobin, hematocrit, VOn = 109), ID (n = 82), and anemia (n = 25). 2max,VO2max/kg, KCCQ scores, and CRP  and VO2max/kg (p = 0.043). The MDS correlated with BMI , body fat , wattmax/kg , VO2max/kg , and WHR , but no correlation with the KCCQ subscores and the KCCQ overall score were found. A total of 154 participants completed the MDS questionnaire; 67 showed a low adherence to MedDiet and 87 showed a medium/high adherence. By this division, there are significant differences for body fat (n = 36) and 47.1% of the participants with anemia showed at least medium adherence to MedDiet. When comparing low adherence with medium/high adherence to MedDiet and ID and anemia classification, the chi2 test showed no significant differences (p = 0.476). In all, 62.1% of the participants with ID (n = 11) had increased sTFR. There were no significant differences between participants with increased sTFR and normal sTFR in physical performance, laboratory parameters, body composition, and MedDiet.Only 4.8% of all participants  and medium/high (≥6 points) adherence to MedDiet. This goes in line with the findings of a 12-month intervention study, in which, besides some positive effects on biomarkers of iron status, no overall effect on iron status was found . With reTuttolomondo et al. describe that there has been no review of evidence base assessing the impact of dietary intake on functional indices that impact HrQoL in persons over 65 years of age . To inve2max and endurance performance, due to the reduction of the oxygen-carrying capacity of blood [Iron deficiency is prevalent in up to 50% of patients with CHF, which is associated with reduced exercise capacity, impaired HrQoL, and increased risk of hospitalization and mortality, regardless of the presence or absence of anemia ,36. Thisof blood .2max and significant group differences between the three iron status groups  in terms of VO2max and VO2max/kg and KCCQ questionnaire as an expression of functional outcomes.Indeed, our analyses showed significant differences between anemic and non-anemic participants in terms of VOThe presence of ID or anemia are frequent co-occurrences in patients with CHF whereby an absolute ID with depleted iron stores can be distinguished from a functional ID caused by impaired iron utilization or misdistribution ,39. ThatThe current definition of ID for CHF patients is a ferritin level < 100 ng/mL, or ferritin levels from 100–299 ng/mL in the presence of TSF level < 20%, irrespectively of present anemia . These hAn alternative to ferritin determination could be the combined evaluation of low hepcidin and increased sTfR values. The sTfR value is expressed more abundantly in intracellular ID and indicates increased tissue demand even before low hemoglobin levels occur. Unlike ferritin and transferrin, it is not affected by inflammation or vigorous physical exercise . Jankowsn = 239) instead of the whole study population (n = 679), which would have resulted in a greater statistical power. Overall, not all of the study data collected, including medications or nutritional supplement, is yet available, as the examinations are still ongoing in some study centers.Our study has strengths and limitations. One limitation of our multicenter study that we have to state is that the technologies used to determine the body compositions, the exercise capacity, and the consulted laboratories were not the same for all study centers. In addition, not every parameter on which this analysis is based has been collected in every study center, which is why the present analysis included only participants of Hannover Medical School (For the diagnosis of ID, the current diagnostic criteria for clinical heart failure were also applied to NYHA 1 patients. Since these were often just patients at risk for developing heart failure, too many patients may have been diagnosed with ID, which could also explain the relatively good exercise performance in the group of patients with ID.Our results show that anemia in patients with CHF has an impact on both maximum oxygen uptake as a vital sign for cardiorespiratory fitness, and functional outcomes by questionnaire. Furthermore, our results show the higher a person’s adherence to MedDiet, the higher the relative cardiorespiratory fitness. The analysis of our baseline data show, that 10.9% of study participants are anemic and 37.9% showed an ID. In further studies, we suggest investigating whether or not the combined evaluation of low hepcidin and increased sTfR values could be an alternative to ferritin determination.Only 7.8% have stated a high adherence to the MedDiet. Both symptomatic and non-symptomatic study participants failed to meet reference values for physical performance during exercise testing . With ou


The concentrations of benzene and 1,3-butadiene in urban, suburban, and rural sites of the U.K. were investigated across 20 years (2000–2020) to assess the impacts of pollution control strategies. Given the known toxicity of these pollutants, it is necessary to investigate national long-term trends across a range of site types. We conclude that whilst legislative intervention has been successful in reducing benzene and 1,3-butadiene pollution from vehicular sources, previously overlooked sources must now be considered as they begin to dominate in contribution to ambient pollution. Benzene concentrations in urban areas were found to be ~5-fold greater than those in rural areas, whilst 1,3-butadiene concentrations were up to ~10-fold greater. The seasonal variation of pollutant concentration exhibited a maximum in the winter and a minimum in the summer with summer: winter ratios of 1:2.5 and 1:1.6 for benzene and 1,3-butadiene, respectively. Across the period investigated (2000–2020), the concentrations of benzene decreased by 85% and 1,3-butadiene concentrations by 91%. A notable difference could be seen between the two decades studied  with a significantly greater drop evident in the first decade than in the second, proving, whilst previously successful, legislative interventions are no longer sufficiently limiting ambient concentrations of these pollutants. The health impacts of these pollutants are discussed, and cancer impact indices were utilized allowing estimation of cancer impacts across the past 20 years for different site types. Those particularly vulnerable to the adverse health effects of benzene and 1,3-butadiene pollution are discussed.  Of the st toxic . Benzene pollution results from domestic heating, waste incineration, evaporation of petroleum, and incomplete combustion of fossil fuels, namely in road transport ,4,5,6. H−12 and 66.6 × 10−12 cm3 molecule−1 s−1, respectively [3 radicals (approx. 25%) is important [x environments, OH loss will dominate. The degradation occurs through OH addition across the double bonds for 1,3-butadiene and to the benzene ring to form an initial adduct, forming radicals, which subsequently undergo a series of reactions with O2 and/or NO forming a mixture of neutral products [Once released into the atmosphere, benzene and 1,3-butadiene degrade by OH oxidation with an associated rate constant at 298 K of 1.22 × 10mportant . Away frproducts . Pollutant damage can be acute, resulting from immediate exposure to high pollutant concentrations, or chronic, as a result of prolonged exposure to low 1,3-butadiene and benzene concentrations. Chronic damage is of increasing concern, affecting millions globally and having significant health consequences ,15,16. BOwing to the adverse health effects of these pollutants, their presence in the atmosphere has been well documented for years and the cancerous effects of 1,3-butadiene and benzene have been at the forefront of research ,30. AddiWith the World Health Organization (WHO) estimating 4.2 million premature deaths every year as a direct result of air pollution (with 6% attributed to cancer ), coupleDespite a reduction in UK emissions over the past two decades, these compounds remain genotoxic and no safe level of exposure can be defined ; therefohttps://uk-air.defra.gov.uk/data/ (accessed on 18 January 2022)) from the Department for Environment Food and Rural Affairs (DEFRA) [Mean daily averages for the concentrations of benzene and 1,3-butadiene (with uncertainty of 15%)  were obt (DEFRA) . Concent (DEFRA) . Measurement locations chosen included representations of varying environments in the UK including suburban , rural background , and urban traffic . Data coverage of the sites was inconsistent and individual sites selected were chosen to maximize data coverage for the specified time period and environment type .To illustrate the potential health impacts of concentration changes of these chemicals on cancer incidence, we have utilized recent research into risk indices of leukemias as a result of ambient benzene and 1,3-butadiene concentrations ,39,40,41The atmospheric concentrations of 1,3-butadiene are found to be significantly lower than those of benzene across all sites considered between 2000 and 2020. At suburban and urban traffic sites, 1,3-butadiene concentrations are just 13 and 24% of corresponding benzene concentrations, respectively. This decreases further for rural sites which see 1,3-butadiene concentrations at 12% of corresponding benzene concentrations. This is likely due to benzene’s additional sources of pollution  and lonp > 0.05, see Observing trends over the 20 years analyzed, all sites showed an overall decrease in concentration for both 1,3-butadiene and benzene  . Specifichnology . Furtherchnology ,48. Therchnology . With dichnology . As a reEven at the traffic site, LMR, a plateau in concentration reductions is seen post-2015 . SimilarConcentrations at urban traffic site LMR remained noticeably and expectedly greater throughout the period studied due to considerably higher volumes of traffic. Comparison of LMR with other site types showed that the yearly pollutant concentration was on average ~5- and ~10-fold greater for benzene and 1,3-butadiene across the period 2000–2020. Consequently, residents in urban areas are exposed to higher levels of pollution compared with those living in rural areas and are therefore at greater risk of developing associated diseases.By comparing the sites with data available for the entire 20-year analysis, LMR and LE, a smaller decline in benzene concentration, compared with that of 1,3-butadiene, can be seen. For LMR (2000–2020), benzene concentration declined 89% compared with 92% for 1,3-butadiene; likewise, the suburban site, LE showed 75% and 85% decrease for benzene and 1,3-butadiene, respectively. The greater decrease in 1,3-butadiene could be reflective of vehicle emissions having a higher contribution to overall 1,3-butadiene levels relative to benzene, which has additional sources of pollution, as mentioned previously. Moreover, with a 6% difference between pollutant decrease in the urban traffic site, compared with 10% in the suburban site, it could be reasoned that the slight disparity is partly due to the contribution of other sources of benzene found predominantly in residential areas. These sources have likely not been reduced and now may have a comparably higher contribution than previously. Findings from a study by the UK Health Protection Agency support this, showing that benzene pollution from vehicle emissions had decreased from 60% to 20% by 2004, contributing less than domestic sources, which made up the greatest source of benzene at 33% [Moving forwards, the seasonal variations of the pollutants were considered to indicate the variation of exposure. The seasonal variations in the concentration of benzene and 1,3-butadiene generally show similar trends across all sites, with the maximum concentrations occurring during the winter and the minimum concentrations occurring during the summer in agreement with previous studies ,9,54. ThThis trend was seen for all years for benzene and 1,3-butadiene, with the exception of 2008, 2009, 2012, and 2020, this was also the case. Records for 2008–2009 1,3-butadiene concentrations showed inversed results where higher levels were observed in summer than in winter. This is an unexpected trend as it does not align with previous observations for other years but could be due to increased tourism during those years or even increased use of cars, further investigations would need to be carried out to source the reason for this observation .These seasonal trends are driven by the oxidative capacity of the atmosphere which varies with OH radical concentration. Summer experiences increased insolation and sunlight intensity , leading3) and ozone (O3) [Interestingly, the seasonality of benzene concentration was more pronounced than that of 1,3-butadiene. In a few instances , winter levels of benzene were 2-fold higher than those observed in summer. UK Met. Office meteorological information shows that 2003–2005 had some turbulent weather with strong winds and high temperatures . These cone (O3) , which aObserved reductions in benzene and 1,3-butadiene pollution can be expected to correlate with a reduction in health impact over the same period. Results herein are discussed as additional deaths due to associated cancers of each pollutant, which correlates directly with pollutant concentration, according to risk factors detailed previously.Whilst benzene generally exhibits higher concentrations, due to 1,3-butadiene’s higher risk factor the cancer impacts of the two pollutants are generally comparable. For instance, LMR data showed, for 2000, an average of 5 additional deaths per 100,000 for ambient benzene pollution and 2 additional deaths per 100,000 for ambient 1,3-butadiene pollution. Compared with cancer death totals reported by the UK House of Commons Library , these vTo represent the upper and lower limit cancer impact of benzene and 1,3-butadiene in the U.K., the average cancer impact at urban and rural sites was paired with population data obtained from the Office for National Statistics (ONS)  and plotWhilst the impact per 100,000 is relatively small, it is by no means negligible. In fact, when additional deaths per region are considered, we see a concerning impact in 2000. This is particularly true when average urban concentrations are considered . Given tA shortcoming in our method comes from the fact that the general population spend the majority of their time indoors. However, recent studies have concluded that indoor ambient pollution of benzene and 1,3-butadiene is strongly associated with outdoor pollution ,64, and It is known that there are no safe levels of benzene nor 1,3-butadiene exposure [The seasonal trends in concentrations discussed previously suggest higher exposure is likely to be experienced in the winter; it is valuable to consider variational exposure of particularly vulnerable demographics. Particularly important is the consideration of fetal development in pregnant women. Maternal exposure to benzene and 1,3-butadiene emissions in the first trimester of pregnancy can increase incidences of genetic susceptibility to cancer for the fetus . Women pDecreasing trends in the ambient concentrations of benzene and 1,3-butadiene highlights the success of emission control strategies adopted in the U.K. in reducing benzene and 1,3-butadiene pollution. The large reduction in pollution observed at LMR, between 2000 and 2010, particularly emphasizes the decreasing influence of road traffic on these pollutants. A plateau in the reduction of benzene and 1,3-butadiene pollution from ~2015 implies that the contribution of road transport to emissions has gradually decreased over time and other sources have become dominant. Therefore, it will be beneficial to investigate the different U.K. sources of benzene and 1,3-butadiene in future, to identify the source of constant pollution levels observed since 2015 and determine the industry in which emission reduction initiatives should be targeted. Benzene and 1,3-butadiene pollution was notably higher in urban areas compared with rural areas by ~5-fold and ~10-fold, respectively, which highlights the need for geographically directed policies in future. Also, the upper and lower limit cancer impact from these species showed that despite the average rural (lower limit) concentrations of benzene and 1,3-butadiene meeting national air quality objectives, a measurable cancer impact is still likely. Therefore, although national pollution targets are often successful in cutting emissions, they are not effective in terms of protecting public health as no safe level of exposure to these pollutants can be clearly defined. It is important to note, the cancer impact indices utilized in this study are not without fault. Epidemiology and exposure relationships are complicated and undoubtedly the indices represent an over-simplification of the true relationship and many confounding factors are ignored. However, this study provides a good first approximation of the likely effect of these pollutants and such effects have varied as a result of legislative intervention. Conclusively, the analysis used in this work could be applied on a larger scale as a means to improve health data and direct future policy development.


Meloidogyne javanica, three domestic pistachio rootstocks, namely, Badami, Ghazvini and Sarakhs, and a wild pistachio, Baneh (Pistacia atlantica subsp. mutica), were selected. Their response to the nematode infection was evaluated based on different plant and nematode indexes, 120 days post-inoculation (dpi). The penetration and development rate of nematode in roots of these four pistachio rootstocks were evaluated at different time points by acid fuchsin staining. Based on the measured indexes, Badami, Ghazvini, Sarakhs, and Baneh rootstocks ranked as susceptible, moderately resistant, moderately resistant, and resistant, respectively. The penetration rate of second-stage nematode juveniles (J2) into four rootstocks was discussed. The first “midstage” or swollen juveniles appeared at 4 dpi but to a lesser extent in Ghazvini, Sarakhs, and Baneh cultivars. The first females were seen in Badami at 21 dpi, in Ghazvini and Sarakhs at 35 dpi, and in Baneh at 45 dpi. Three types of defense responses were distinguished and characterized in the examined pistachio rootstocks: (i) a hypersensitive response (HR)-like reaction in the cortex in Ghazvini, Sarakhs, and Baneh root tips at 4 dpi and 6 dpi; (ii) an HR response, degrading J2 which induce giant cells in the vascular cylinder of all rootstocks, at 6 dpi and 10 dpi; and (iii) an HR response, degrading females and giant cells in the vascular cylinder of all rootstocks at 15 dpi onward. These observations open new fields of study in breeding programs of this crop.Pistachio yield is annually reduced due to root-knot nematode infections. In order to evaluate its resistance to  Meloidogyne spp., are one of the most important pathogens of pistachio trees, dominating most pistachio-growing areas in Iran. They are sedentary obligate endoparasitic nematodes with a wide host range and can remarkably damage and reduce yield production. The second-stage juveniles (J2) nematode usually enter roots near the tip, behind the cap, and moves intercellularly between cortical cells downward to the root tip and enter the vascular cylinder. About five to seven parenchymatic root cells around the nematode head grow and form giant cells, after injecting the nematode effectors, triggering the reprogramming of the target cells. Meloidogyne spp. disrupt host physiology and reduce the quantity and quality of crops  Chitwood, 1949 and M. javanica  Chitwood, 1949, have been frequently detected from major pistachio-producing regions of Kerman, Yazd, Isfahan, and Semnan provinces  Rech.f. rootstocks from Geno of Iran had the highest resistance, and Badami was regarded as the most susceptible rootstock, but the defense responses of pistachio in pistachio–M. javanica pathosystem have not been investigated yet.M. javanica on three domestic pistachio cultivars  and a wild pistachio rootstock, Baneh; (ii) compare the resistance of the aforementioned rootstocks; and (iii) evaluate the resistance responses of the examined pistachio rootstocks.The objectives of the present study were to (i) evaluate penetration, development, and reproduction of Meloidogyne galls were collected from pistachio gardens in Kerman and Khorasan Razavi provinces, Iran. All root-knot nematode populations were cultured on Solanum lycopersicum L. cv. Early Urbana. Meloidogyne javanica populations were identified based on female perineal pattern  and the wild pistachio, Baneh (Pistacia atlantica), were obtained from the Pistachio Research Center, Horticultural Sciences Research Institute, Agricultural Research, Education and Extension Organization (AREEO), Rafsanjan, Iran. These were soaked in 0.5% sodium hypochlorite for 3 min, washed with sterile distilled water, placed between two layers of wet cotton tissue in plastic bags, maintained at 4°C for one week and four weeks for selected pistachio cultivars and Baneh, respectively. The seeds were maintained at room temperature till germination. Germinated seeds were planted in plastic pots containing 1 kg of autoclaved soil and maintained under greenhouse conditions (25–30°C) with a 16-h light and 8-h dark regime.Seeds of Badami, Ghazvini, and Sarakhs rootstocks  at the 8 to 10 leaf stage. The J2 were introduced into 3-cm-deep holes around the collar region of the plants. The inoculated pots were arranged in a complete randomized block design with six replications. They were irrigated and fertilized, as needed, and maintained under greenhouse conditions (25–30°C) with a 16-h light and 8-h dark regime. The pistachio seedlings were harvested at 120 dpi. The stem length and fresh root weight of pistachio seedlings, the nematode GI, EMI, and reproduction factor (RF) were measured. The roots were stained with Phloxine B and evaluated for GI or EMI, which had 1: 1 to 2 galls or egg masses; 2: 3 to 10 galls or egg masses; 3: 11 to 30 galls or egg masses; 4: 31 to 100 galls or egg masses; and 5: >100 galls or egg masses per root system . Eggs anFurthermore, the resistance index was measured according to Ten seedlings of each pistachio rootstock were inoculated, as mentioned in resistance assays. This experiment was conducted with two replicates. J2 were introduced into 3-cm-deep holes around the collar region of the plant. Distilled water without nematodes was added to the control plants. Roots were removed from the pots and were carefully washed with tap water at 2 dpi, 4 dpi, 6 dpi, 10 dpi, 15 dpi, 21 dpi, 28 dpi, 35 dpi, and 45 dpi. The roots were stained with acid fuchsin to detect J2 penetration, their localization, and subsequent development within the roots. The roots were immersed in 3% NaOCl solution for 5 min, followed by rinsing with tap water to remove excess NaOCl . The roots were then stained with 1 ml of 3.5% acid fuchsin stain . The mixStatistical analysis of the data obtained from different tests was performed using SPSS software (version 26), and the means were compared using Duncan’s multiple range test at a 95% confidence level.The stem length of the four non-inoculated pistachio rootstocks was not the same, and, Badami, Ghazvini, Sarakhs, and Baneh ranked from longest to shortest, respectively. All the treated rootstocks had a significant stem length reduction at 120 dpi compared to their controls .M. javanica in terms of fresh root weight; however, the root growth and development of all of the treated plants with nematode were reduced at 120 dpi compared to their controls (The fresh root weight differed between the tested plants. The highest fresh root weight in non-inoculated was found in Badami (2.25 g) and Ghazvini (2.07 g) rootstocks. Baneh had the least root weight in healthy controls (0.92 g). At 120 dpi, the fresh root weights of Badami, Ghazvini, Sarakhs, and Baneh rootstocks were 1.32 g, 1.41 g, 0.99 g, and 0.69 g, respectively. The reaction of them was not the same after infection with controls .M. javanica. By contrast, Baneh with GI or EMI = 2 and RF ≤ 1 (RF = 0.25) is classified as resistant rootstock. In Ghazvini and Sarakhs, RF was >1 , and GI or EMI was 3, so they were considered moderately resistant (MR) to M. javanica -like reaction observed in moderately resistant (Ghazvini and Sarakhs) and resistant (Baneh) rootstocks at 4 dpi and 6 dpi, respectively. It was characterized by necrosis of cells directly affected by nematode in the cortex. This HR-like reaction led to death of the J2 ; howeverAnother early defense response observed in moderately resistant (Ghazvini and Sarakhs) and resistant (Baneh) rootstocks at 10 dpi and 6 dpi, was programmed cell death (HR), which occurred in the vascular cylinder during the formation of feeding sites. It prevents development of nematodes and feeding sites and has led to nematode death .Moreover, this reaction was more prevalent in Baneh than Ghazvini and Sarakhs. HR was not observed in Badami rootstock.The late defense reaction observed in all of the rootstocks was malformation and destruction of the giant cells occurred from 15 dpi onward. It was characterized by browning of feeding sites close to the nematode head, indicating necrosis of tissues. Also, no alive nematodes were found in these galls .Meloidogyne javanica for the first time in Iran. Shoot and root biomass have already been used to assess the reaction of rootstocks  and Sarakhs (relatively resistant) were less than those in Badami (susceptible) and Ghazvini (relatively resistant) at 6 dpi. Although the same penetration rate of J2 in different cultivars of host plant was observed in Myrobalan plum-M. arenaria  and Baneh (resistant). The delay in the life cycle of root-knot nematodes was observed in the resistant genotype of his spp. . The inh as well .M. javanica, occurred in all pistachio rootstock at 15 dpi onward in the present study and inhibited the development of feeding cells by forming a barrier between feeding cells and surrounding cells to block nutrition and water supply, yielding in the giant cell collapse. Based on Oryza glaberrima-resistant genotypes. Similarly, coffee genotypes resistant to M. exigua exhibited early and late HR, the latter in case of the J2 escaped from the first defense reaction (Gossypium spp. against M. incognita, reported all observed/discussed three types of HR responses in pistachio rootstocks and urged that the early HR reaction was the most common mechanism. The prevalence of the primary HR reaction has already documented (One of post-infection mechanisms of resistance is HR, a type of programmed cell death that is induced after the invasion of avirulent pathogens to prevent the spread of biotrophic pathogens . It has reaction . Lopes ecumented Meloidogyne javanica, so some of the penetrated J2 could reach the next generation, and the nematode inoculum remained in the soil. Therefore, the use of moderately resistant and resistant cultivars could be included in combination with other measures in an integrated root-knot nematode management. Desired features of moderately resistant or resistant rootstocks against M. javanica, as revealed herein, may be used in pistachio-breeding programs in future.The expression of HR-like reaction and early and late HR defense responses in infected roots could indicate that multiple genes are likely to be involved in the resistance of pistachio rootstocks. The two latter HR reactions triggered in susceptible Badami rootstock as well, but in a slow rate and to a less extent, compared to those in moderately resistant and resistant rootstocks. However, none of studied pistachio rootstock were completely resistant to M. javanica. The three latter rootstocks could be used in breeding programs of this economic crop.During the present study, both host pistachio plants and root-knot nematode-related indices were assessed in greenhouse experiments, and as the result, the Badami cultivar was proven to be susceptible, two cultivars Ghazvini and Sarakhs were proven as relatively resistant, and the wild pistachio, Baneh, was proven to be resistant against


In countries with a high incidence of tuberculosis, the typical clinical features of Crohn's disease (CD) may be covered up after tuberculosis infection, and the identification of atypical Crohn's disease and intestinal tuberculosis (ITB) is still a dilemma for clinicians. Least absolute shrinkage and selection operator (LASSO) regression has been applied to select variables in disease diagnosis. However, its value in discriminating ITB and atypical Crohn's disease remains unknown. A total of 400 patients were enrolled from January 2014 to January 2019 in second Xiangya hospital Central South University.Among them, 57 indicators including clinical manifestations, laboratory results, endoscopic findings, computed tomography enterography features were collected for further analysis. R software version 3.6.1 (glmnet package) was used to perform the LASSO logistic regression analysis. SPSS 20.0 was used to perform Pearson chi-square test and binary logistic regression analysis. In the variable selection step, LASSO regression and Pearson chi-square test were applied to select the most valuable variables as candidates for further logistic regression analysis. Secondly, variables identified from step 1 were applied to construct binary logistic regression analysis. Receiver operating characteristic (ROC) curve analysis was performed on these models to assess the ability and the optimal cutoff value for diagnosis. The area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy rate, together with their 95% confidence and intervals (CIs) were calculated. MedCalc software (Version 16.8) was applied to analyze the ROC curves of models. 332 patients were eventually enrolled to build a binary logistic regression model to discriminate CD (including comprehensive CD and tuberculosis infected CD) and ITB. However, we did not get a satisfactory diagnostic value via applying the binary logistic regression model of comprehensive CD and ITB to predict tuberculosis infected CD and ITB (accuracy rate:79.2%VS 65.1%). Therefore, we further established a binary logistic regression model to discriminate atypical CD from ITB, based on Pearsonchi-square test (model1) and LASSO regression (model 2). Model 1 showed 89.9% specificity, 65.9% sensitivity, 88.5% PPV, 68.9% NPV, 76.9% diagnostic accuracy, and an AUC value of 0.811, and model 2 showed 80.6% specificity, 84.4% sensitivity, 82.3% PPV, 82.9% NPV, 82.6% diagnostic accuracy, and an AUC value of 0.887. The comparison of AUCs between model1 and model2 was statistically different (P < 0.05). Tuberculosis infection increases the difficulty of discriminating CD from ITB. LASSO regression showed a more efficient ability than Pearson chi-square test based logistic regression on differential diagnosing atypical CD and ITB. China has the second highest incidence of tuberculosis (TB) in the world. As a TB highly endemic country and considering the increasing incidence of CD, TB infection may cover up the typical appearance of CD. So it is called atypical CD, which is more difficult to distinguish from tuberculosis and also the typical CD3.Crohn's disease (CD) is a transmural inflammatory disease, which can affect the entire digestive tract from the mouth to the anus. In the early years, Crohn's disease was prevalent in western countries. However, with ethnic migration and the improvement of people's living standards, the incidence of Crohn's disease in developing countries, especially China, with an incidence increased from 0.28/100,000 in 1950–2002 to 0.848/100,000 in 1950–20075. Acid fast bacilli (AFB) and granulomas with caseous necrosis are identified as golden criteria for diagnosing ITB, however, its value is limited with a positive rate at about 50%6. Generally, most of the studies report diarrhea, hematochezia, perianal disease, presence of longitudinal ulcers, aphthous ulcers, cobblestoning, and skip lesions are more common in CD, whereas presence of transverse ulcers and patulous ileocaecal valve are more common in ITB8. However, there is no gold standard for the diagnosis of CD. Clinicians make a decision largely relying on a comprehensive analysis of clinical, radiological, endoscopic manifestations. Nowadays, with the help of guide consensus, most Chinese patients with CD or ITB with typical disease characteristics obtain correctly and timely treatment. Gastroenterologists have also proposed multiple methods to improve the diagnostic value of the two diseases. He et al. applied random forest to screen variables and built two regression models based on 7 differential variables9. Wu et al. used t test and chi-square test to select variables and proposed a predictive model to discriminate CD and ITB10. Mao et al. established a model through univariate and multiple logistic regression analyses based on clinical and computed tomographic enterography (CTE) characteristics11. Models built via those methods were convenient and reliable for the differentiation of part of CD and ITB patients. Unfortunately, a study reported a misdiagnosis rate of the two disease was still at 50–70%12. Based on this, The methodology for the identification of these two diseases still needs to be further explored.Though CD and ITB have different etiologies, there are many clinical, radiological, endoscopic manifestations overlapped Fig. , especia13. Therefore, more comprehensive information need to be defined when come across analysis of clinical phenotypes.In clinical practice, anti-tuberculosis treatment was often used to discriminate the two disease. However, if patients with CD use anti-tuberculosis drugs, it will delay the course of the disease and bear the side effects of anti-tuberculosis drugs. Conversely, if ITB patients receive a treatment of CD, it will cause the spread of tuberculosis. In our previous study, a novel grouping strategy was already presented to separate CD into typical CD (TCD) and atypical CD (UCD). We proposed the phenotype of UCD is deeply influenced by TB infection history, which is also a major reason of misdiagnosis. we enrolled 141 atypical CD and ITB patients and built some predictive models based on clinical, radiological, endoscopic manifestations. However, we have not systematically and comprehensively explored the identification of CD and ITB, especially for the identification between atypical CD and ITB. Also, when identifying with ITB, we did not verify that different phenotypes of CD need to be discussed separately18. However, they have the disadvantage of overfitting19. LASSO (least absolute shrinkage and selection operator) is a variable selection method proposed by statistician Robert Tibshirani in 199620.Compared to traditional regression approaches, LASSO regression can handle a larger set of potential predictors, picking out the variables most associated with the disease. Based on this, LASSO has been utilized in the screening of disease risk factors and establishment of prediction models25.Few studies have used LASSO regression to explore risk factors for CD28. However, to our knowledge, in the identification of CD and ITB, especially in the identification of atypical CD and ITB, whether LASSO regression can help differentiate the two diseases remains unknown.Conventional methods, such as stepwise selection, are usually applied for variable selection in diseasesIn this study, we enrolled 332 CD and ITB patients, including 118 typical CD, 109 atypical CD and 105 ITB patients. We wish to deepen the understanding of the identification between CD and ITB and reduce the rate of misdiagnosis of the disease.This retrospective study was approved by the Ethics Committee of second Xiangya hospital Central South University, Changsha, China. All subjects provided written informed consent. All methods were performed in accordance with the relevant guidelines and regulations.A total of 400 patients were enrolled from January 2014 to January 2019 in second Xiangya hospital Central South University. After a year-follow-up, 68 patients were excluded, including 14 patients with intestinal lymphomas, 12 patients with Behcet's disease, 14 patients with ulcerative colitis, 8 patients with unexplained intestinal ulcer, and 20 patients lost of follow up. Finally, we selected 332 patients to conduct our study, with 105 patients diagnosed with ITB and 227 patients diagnosed with CD. Among CD patients, 109 patients were defined as untypical CD (UCD), and 118 CD patients were defined as typical CD (TCD). UCD means the CD patient does not exclude tuberculosis; TCD means the CD patient excludes tuberculosis. Whether a patient with CD has tuberculosis infection is evaluated by a specialist. Detailed information was showed in Fig. The inclusion criteria were as follows: (1) Patients older than 18 years of age; (2) Patients were initially suspected of CD or ITB based on clinical data. The exclusion criteria were as follows: (1) ITB patients with caseous granuloma detected in pathological section when enrolled in the study; (2) Patients with HIV infection; (3) Patients diagnosed with other disease in the follow-up such as intestinal lymphomas, ulcerative colitis, Behcet's disease; (4) Patients lost of follow up.57 indexes were collected in this study, including demographic and clinical features, laboratory features, computed tomography enterography features, endoscopic features and site of involvement. All the continuous variables like albumin, platelets were changed into categorical variables. The detailed information was shown in supporting information Table . ComprehPatients diagnosed with ITB should meet the following criteria: Patients who received regular anti-tuberculosis treatment at least 3 months and diagnosed with ITB after a-year follow-up according to clinical, laboratory, radiological, endoscopic features. Patients diagnosed with CD should meet at least 1 of the following criteria: (1) Noncaseating granuloma detected in pathological section during follow-up; (2) Patients who received regular immunosuppressive or biological agents at least 3 months and diagnosed with CD after a- year follow-up according to clinical, laboratory, radiological, endoscopic features; (3) Patients who received anti-tuberculosis drug treatment for 3 months, but did not get better after re-examination, and got better after receiving immunosuppressive agents or biological agents after a- year follow-up according to clinical, laboratory, radiological, endoscopic features.P value of less than 0.05. All variables with statistical significance (P < 0.05) in Pearson chi-square test was taken as candidates for further binary logistic regression analyses. We also used the LASSO regression to select the most valuable variables. The feature selection step was performed on complete data. Secondly, variables identified from step 1 were applied to constructed a binary logistic regression model. The regression coeffcients of the predictive model were regarded as the weights for the respective variables, and the score for each patient was calculated. Receiver operating characteristic (ROC) curve analysis was performed on these models to assess the ability and the optimal cutoff value for diagnosis. The area under the ROC curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy rate, together with their 95% confidence and intervals (CIs) were calculated. MedCalc software (Version 16.8) was applied to analyze the ROC curves of models.SPSS 20.0 and R software version 3.6.1 and the “glmnet” package  were used for statistical analyses. The prediction model was developed using a 2-step approach. Firstly, Pearson chi-square test was used to compare enumeration data. Statistical significance was determined as a We performed univariate analysis of 57 indicators including demographic characteristics, clinical characteristics, laboratory findings, imaging characteristics, and endoscopic characteristics between comprehensive CD and ITB, which was evaluated by Pearson chi-square analysis on 332 CD and ITB patients. 29 indicators were statistically different . log(λ) =  − 3.662 (λ = 0.000217771) when the error of the model is minimized, and 26 variables were selected for further logistic regression analysis  and a validation set (30%). The training set comprised 236 cases (69 ITB patients and 167 CD patients), and the validation set comprised 96 cases (36 ITB patients and 60 CD patients). All variables with statistical significance (P < 0.05) selected by univariate analysis were taken as candidates for further logistic regression analyses. Based on binary logistic regression analysis, the regression was set asTo validate the diagnostic value of the predictive regression model, we applied a validation data set of UCD and ITB patients (27UCD and 36 ITB patients), which was selected from the 96 cases of mentioned validation set. With a cutoff value of 0.738, the sensitivity, specificity, PPV, NPV, and accuracy rate were 77.8%, 55.6%, 56.8%, 76.9% and 65.1% in differentiating ITB from UCD  and LASSO regression (for medel2) respectively. In the second step, 214 UCD and ITB patients were randomly divided into a training set (70%) and a validation set 30%). Two binary logistic regressions were established with the variables selected by Pearson chi-square test (for model 1) and LASSO regression (for model 2), using the same training set  could help discriminate the UCD and ITB, and if TB-IGRA ≥ 100 pg/ml, the possibility of ITB should be considered first, and diagnostic anti-TB treatment should be recommended. However, previous TB infection history may lead to false positives in TB-IGRA results. Due to the small sample size of this study, the conclusions need to be verified. Our previous research also explored the distinction between UCD and ITB. We enrolled 43 UCD and 56 UITB patients, and built 4 regression equations from clinical, laboratory, endoscopic, and radiological features, respectively13. Though AUC of clinical prediction model was 0.834, the model is not suitable for the application in clinical practice due to the subjectivity of its variable collection. Hence, in this study, we comprehensively analyzed the clinical, laboratory, endoscopic, and radiological features of UCD and ITB. We used Chi-square test and LASSO regression to filter variables. Results of the two methods revealed abdominal pain, perianal fistula, ileus, elevated CRP, cobblestone appearance, involvement of jejunum were favor of UCD, while T-SPOT positive were favor of ITB, which indicated these three indexes were reliable for the identification of the the two disease. We constructed two equations to predict the two disease, with the AUC over 80%. though these two equations had a partial missed diagnosis rate, they still provided a valuable method for the identification of UCD and ITB. It is worth mentioning that LASSO regression was considered to be a better method to choose variables when the size of predicted variables were relatively large33, our results showed the diagnostic value of training set in model 2 was prior to model 1, however, it is not much different when comparing the validation set, which may be related to the sample size.With the help of guidelines as well as the multivariate mathematical models, most typical CD patients could receive a correctly and timely treatment. However, there is still a high rate of misdiagnosis for CD when distinguishing from ITB. We speculated the reason is that previous studies did not consider typical CD and atypical CD separately. These methods were not applicable to the discrimination between ITB and atypical CD patients. To verify this, in this study, we substituted the UCD and ITB data into the previously established model, and found that the diagnostic deficiency was getting worse as we suspected, with accuracy rate decreased from 81.8 to 65.1%. This finding prompted us to look for ways to identify atypical CD and ITB. Until now, few studies were carried out to differentiate UCD from ITB. Zhao et al.36. We are not surprised because China is a country with a high incidence of tuberculosis, and the phenotype of UCD may be affected by tuberculosis infection to some extent. We further established the regression equation based on the indexes obtained by the multivariate regression analysis. Interestingly, we found that the two different subgroups of CD can be identified by the equation, with the AUC, sensitivity, specificity, PPV, NPV, and accuracy of the prediction model were 0.825, 80.5%, 70.7%, 78.4%, 73.3% and 75.6%, respectively. The diagnostic value was similar to that of the discrimination between UCD and ITB.This indicated that in the identification of ITB and CD, it is necessary to consider tuberculosis-infected CD separately,especially in areas where tuberculosis is epidemic.Our research further analyzed the characteristics of typical CD and atypical CD. Results showed that swollen ileocecal valve, involvement of ileum ulcer were favor of UCD, while intestinal surgery, intestinal wall edema, intestinal obstruction, blurred fat gap, shallow ulcer involvement of sigmoid colon were favor of TCD. Most of these indicators come from radiological examination, which suggested that when we diagnose CD, we should pay attention to the results of radiological examination, which may help reduce misdiagnosis. We also noticed that the indicators that support the diagnosis of UCD were similar to those of intestinal tuberculosis mentioned in previous studiesIn conclusion, there were several advantages in our study. Firstly, we proposed a new method to distinguish between CD and ITB, and we confirmed that identification of UCD and ITB required additional attention,especially in areas with a high incidence of tuberculosis,the existence of UCD affected the misdiagnosis rate of CD and ITB that should not be ignored. Secondly, we constructed two equations for the discrimination between UCD and ITB, and we were the first to apply LASSO regression to select variables and build a model for the identification of the two diseases. Thirdly, we constructed a equation to discriminate TCD and UCD, this validated that when discriminating between ITB and CD, we should consider UCD and TCD separately. Our research has enriched the identification methods of CD and ITB, and provided valuable guidance for clinical practice. However, there are also some limitations. This study is a single-center research and lack of an independent external dataset for testing the models. Although LASSO regression helps us to select and confirm some identification of parameters, these parameters may not be widely used due to geographical differences, multi-center data needs to be collected. In the future, to reduce the misdiagnosis rate of CD, new biomarker exploration is needed. Other methods such as neural networks and random forests can also be used in larger data sets to build predicted models. In epidemic ITB areas, efforts are still needed to increase the detection rate of Mycobacterium tuberculosis.Supplementary Information.