In this work, chitosan (CS)/poly  (PVA) nanofibers were prepared by using the electrospinning method. Different CS concentrations , maintaining the PVA concentration at 8 wt %, were tested. Likewise, the studied electrospinning experimental parameters were: syringe/collector distance, solution flow and voltage. Subsequently, the electrospun fibers were collected on a reticulated vitreous carbon (RVC) support for 0.25, 0.5, 1, 1.5, and 2 h. The morphology and diameter of the CS/PVA nanofibers were characterized by scanning electron microscopy (SEM), finding diameters in the order of 132 and 212 nm; the best results (uniform fibers) were obtained from the solution with 2 wt % of chitosan and a voltage, distance, and flow rate of 16 kV, 20 cm, and 0.13 mL/h, respectively. Afterwards, a treatment with an ethanolic NaOH solution was performed, observing a change in the fiber morphology and a diameter decrease (117 ± 9 nm). The electrospinning technique is an efficient method for the manufacture of micro- and nanofibers; it is also an efficient and simple method to produce homogenous fibers for various applications. This technique relies on multiple operating parameters such as applied voltage, collector type, temperature, relative humidity, flow rate, etc., as well as on intrinsic solution parameters like molecular weight, polymeric concentration, viscosity, surface tension, electrical conductivity, among others. The electrospinning process uses electrostatic forces to produce polymeric fibers. When high voltage is applied, polymer drops are subjected to instability, forming fibers when the surface tension of the polymer solution drop at the tip of the needle is overcome. A series of parameters must be optimized in order to produce fibers instead of drops ,2,3.Chitosan (CS) is a biopolymer derived from chitin, often obtained from the exoskeleton of crustaceans. It has very useful properties such as biocompatibility, biodegradability, and antimicrobial activity; however, the production of fibers of this polymer is very difficult due to its insolubility in organic solvents, its ionic character in solution and the formation of three-dimensional networks by strong hydrogen bonds ,5,6.In this sense, Li and Hsieh (2006) found that by combining an anionic polymer such as poly  (PVA) and chitosan, which is a cationic polymer, the formation of fibers was improved, which is in contrast with the combination of polymers having the same charge . PVA is Although CS and PVA can improve the production of fibers, the right proportion to have a stable solution has to be established. In this sense, several works studying different CS/PVA ratios have been reported ,12,13. TPaipitak et al.  used theAccording to the points described above and in order to improve the efficiency of the electrospinning method and morphology of the obtained CS/PVA nanofibers, in the present work, reticulated vitreous carbon (RVC) was used as a collector due to its high electrical conductivity and minimal reactivity. RVC is currently used in electrochemical systems such as battery and fuel cells, metal ion removal, electroanalytical analysis, sensors and synthesis of organic compounds. As it can be seen, these applications are related to the promotion of turbulence aimed at increasing the mass transfer phenomena in reactors. To the best of our knowledge, in the present research work, RVC has been used for the first time as a fiber collector in the electrospinning process. The ultimate goal, after fundamental studies, is to produce CS/PVA nanofibers, establishing the best parameters of the electrospinning technique , on a highly porous support to generate turbulence and adequate contact between the materials and a solution. The obtained results encouraged us to consider the experimental procedure featured in this work for its application in the reduction of sulfur compounds in FCC  gasoline, where the chitosan fibers could work as adsorbents of metals such as nickel and molybdenum in an oxidative desulfurization process. The results of this study will be part of a forthcoming paper.Preliminary electrospinning processes were carried out using different operation parameters. Not all the analyzed electrospinning parameters showed good results since in some cases, the fibers were not uniform with large nodules incorporated into them or simply no fibers were observed.The operation parameters used to produce fibers are shown in Zargarian and Haddadi  indicateAs for RVC, it is a macroporous polymeric carbon form as it can be seen in For the diameter frequency histograms, about 100 electrospun fibers were analyzed with particle counting. The viscosity of the CS/PVA solution decreased with time (weeks) from 10,500 to 410 cP, which was due to the hydrolysis of chitosan, as stated elsewhere ,20. BaseCS from crab shells with deacetylation degree of 85% (lot number 91k1265) was used as received from Sigma Aldrich. Medium molecular weight PVA was purchased from Sigma Aldrich and used as received. Acetic acid (99.7%) was acquired from J.T Baker. RVC 60 ppi  was obtained from Electrosynthesis, Co. Inc., Lancaster, NY, USA.The electrospinning solutions were prepared by dissolving a maximum of 3 wt % of CS in acetic acid at 2 wt %. This solution was magnetically stirred until complete dissolution at room temperature. PVA powder was dissolved in deionized water at 8 wt % near its boiling point to facilitate complete dissolution. Subsequently, both solutions were homogenized by magnetic stirring.In order to study the component ratio effect on the electrospinning process, the CS concentration was varied using 0.5, 1, 2, and 3 wt % while the PVA concentration remained at 8 wt % for each prepared solution.Electrospinning solutions were pumped using a 5 mL commercial plastic syringe and a Programmable Syringe Pump NE-1600. The studied flow rates were adjusted to 0.10, 0.12, 0.13, 0.15, and 0.20 mL/h at three different working voltages: 14, 15, and 16 kV, controlled by a high DC (Direct Current) voltage supply (Glassman High Voltage EH60). A glass plate or RVC was used as a collector, and the tip-to-collector distanceswere set at 15, 20, and 25 cm. All electrospinning procedures were carried out at room temperature . As the solution viscosity is a very important parameter, all the electrospinning experiments were carried out with recently prepared CS/PVA solutions (no more than 1 week old).The as-obtained electrospun nanofibers were immersed overnight in a saturated NaOH ethanolic solution in order to analyze the alkaline treatment effect. The treated samples were then rinsed with water and dried in air to be observed by SEM.The solution viscosity was measured in a rheometer  with cone and plate geometry, varying the shear rate between 1 and 100 rad/s. The measurements were carried out after 1, 2, 3, 11, and 13 weeks of their preparation. The storage temperature was 25 °C.In the present study, CS/PVA nanofibers were manufactured by the electrospinning technique. The use of RVC allowed the formation of homogeneous fibers, compared to the fibers collected on a glass plate, with diameters ranging from 132 to 212 nm, making RVC a suitable substrate to obtain thin fibers. However, the deposit of fibers occurred only on the substrate surface. After testing CS concentrations of 0.5, 1, 2, and 3 wt %, it was found that the best solution to produce fibers was that containing 2 wt % CS and 8 wt % PVA. After evaluating electrospinning parameters such as flow rate, tip-to-collector distance, and voltage on either glass or RVC substrates, the optimum parameters for producing CS/PVA electrospun nanofibers were a voltage, distance, and flow rate of 16 kV, 20 cm, and 0.13 mL/h, respectively. , which allowed the manufacture of uniform fibers that were observed by SEM. The use of RVC improved the formation of homogeneous fibers compared to the fibers collected on the glass plate, with diameters ranging from 132 to 212 nm. In order to obtain chemically stable CS/PVA nanofibers, it was necessary to treat the nanofibers with an ethanolic NaOH solution.


Plant-based diets rich in bioactive compounds such as polyphenols have been shown to positively modulate the risk of cardiometabolic (CM) diseases. The inter-individual variability in the response to these bioactives may affect the findings. This systematic review aimed to summarize findings from existing randomized clinical trials (RCTs) evaluating the effect of hydroxycinnamic acids (HCAs) on markers of CM health in humans. Literature searches were performed in PubMed and the Web of Science. RCTs on acute and chronic supplementation of HCA-rich foods/extracts on CM biomarkers were included. Forty-four RCTs (21 acute and 23 chronic) met inclusion criteria. Comparisons were made between RCTs, including assessments based on population health status. Of the 44 RCTs, only seven performed analyses on a factor exploring inter-individual response to HCA consumption. Results demonstrated that health status is a potentially important effect modifier as RCTs with higher baseline cholesterol, blood pressure and glycaemia demonstrated greater overall effectiveness, which was also found in studies where specific subgroup analyses were performed. Thus, the effect of HCAs on CM risk factors may be greater in individuals at higher CM risk, although future studies in these populations are needed, including those on other potential determinants of inter-individual variability. PROSPERO, registration number CRD42016050790. Recently, the Global Burden of Disease study stated that CM diseases are the leading causes of death worldwide, mainly triggered by the rise in biomarkers of metabolic syndrome (MetS), such as waist circumference (WC), fasting blood glucose, triglycerides (TG) and blood pressure (BP) . A diet s (CGAs) ,7,8.HCAs are present in several food sources, including coffee, cereals, potatoes and artichokes and, for this reason, they are generally ingested daily in high amounts with an estimated intake of ~200 mg/day in adults ,10. OnceAn increasing number of studies investigating the health effects of plant food bioactives have indeed shown that the response to the consumption of phenolic compounds may vary among different individuals ,17,18,19However, the inter-individual variability in the efficacy of the main dietary phenolic acids, namely HCAs, which are consumed in abundance in coffee and cereals, has not been fully explored. Therefore, the aim of this systematic review was to provide an overview of the randomized controlled trials (RCTs) evaluating the effect of HCAs on markers of CM health, in order to increase the knowledge about the impact of the inter-individual variability in the responsiveness to the consumption of this class of phenolic compounds.This systematic review was conducted following the Cochrane Handbook for Systematic Reviews of Interventions  and the http://www.ncbi.nlm.nih.gov/pubmed) and the Web of Science (http://apps.webofknowledge.com) databases on December 2016 (updated December 2018), using the syntaxes reported in The systematic literature search was conducted using PubMed (Exclusion criteria included (i) the presence of a co-intervention  or other confounding factors; and (ii) not reported in a European language. No restrictions for the characteristics of study participants  were applied.Two author-pairs independently assessed the studies for their inclusion. Disagreement between authors was resolved through consultation with a third author (PM) who performed an independent assessment to reach a consensus. Data were extracted from each identified study using a standardized form and the following information was collected: Name of first author; year of publication; study location; number of participants/controls; characteristics of intervention and placebo/control arms; characteristics of test food ; potential factors  influencing the heterogeneity in the responses to the supplementation with HCA-rich food/extracts ; outcomeData were then summarized by a qualitative assessment based on the results reported in individual studies. For each outcome assessed, studies were grouped by those significant or not and baseline levels of the outcome were used to compare studies. For studies that explored inter-individual variability in their own analyses, the results for each subgroup were assessed and summarized.Risk of bias of the individual studies was assessed independently by two authors following the Cochrane Risk of Bias Tool . The folThe study selection process is shown in The main characteristics of the included studies are reported in n = 11), followed by the United States of America and the United Kingdom (n = 5), Australia and Iran (n = 4), Italy (n = 3) and Germany, Denmark, Norway, Sweden, Finland, Greece, Thailand, Colombia, Mexico, Switzerland, Spain and Austria (n = 1).Most of the RCTs were performed in Japan (n = 27), coffee polyphenols (n = 2) or as a green coffee extract . Conversely, artichokes (n = 3), cereals  and potatoes (n = 2) were the least used sources of HCA. Pure compounds were also tested (n = 6), including both 3- and 5-CQA, ferulic acid or a mix of CGAs.For either acute or chronic studies, coffee was the most commonly investigated product, used as the HCA-source in 30 RCTs either as a beverage  rated as high.n = 11), while only few studies were focused on phenolic-rich extracts from coffee (n = 4), as well as on rye (n = 2), potatoes (n = 1) and pure CGAs (n = 3). Total doses of CGAs ranged from ~3 mg [n = 9 [n = 41 [om ~3 mg  to 600 mom ~3 mg ,31 for tom ~3 mg  to 900 mom ~3 mg  for pureg [n = 9  to n = 4 [n = 41 , while m [n = 41 ,29,36 to [n = 41 ,37. Over [n = 41  and on i [n = 41  and one  [n = 41 .n = 16), followed by BP (n = 8) and markers of endothelial function . There were no studies focused on platelet aggregation or exercise capacity. For acute glucose metabolism, 16 studies reported a measure of postprandial glucose, 13 of which calculated an incremental area under the curve (IAUC) [Among the outcomes, markers of blood glucose metabolism  were most often considered (e (IAUC) ,43,44,45e (IAUC) ,39,46. Oe (IAUC) ,44, where (IAUC) , conducte (IAUC) . The sece (IAUC) .Of the three studies that only reported differences in postprandial glucose at various time points, one demonstrated a reduction at the peak glucose (30 min) after the ingestion of a coffee polyphenol extract providing 355 mg CQAs consumed with a meal compared to when the meal was consumed without the polyphenol extract in healthy men . The othTwelve studies reported a measure of acute postprandial insulin, ten of which calculated an IAUC ,41,42,43Nine acute studies reported effects of HCA on BP ,33,39,492) and an average age of 45 y. Of the six studies that found some significant effects, four were conducted solely in men, with the other two having 67% and 38% men, in contrast to the two studies without significant effects, which had 58% and 17% men. Thus, these results may be indicative of a possible effect in men, although more studies assessing this are needed, specifically including women, with longer follow up for assessments (>2 h), and in higher risk populations.Eight studies reported effects of HCAs on FMD with 50% (four studies) demonstrating a significant increase in FMD compared to control ,30,46, aIn general, the acute studies demonstrated no effect of HCAs on glycaemia or BP, with some potential effects on FMD. Limitations of the comparability of these studies include the wide variability in terms of study design and methods of outcome assessment. Due to the vast majority of studies being conducted in healthy participants and with HCA coming mainly from coffee consumed alone, generalizability and applicability is also limited. From these studies it is unknown what the effects may be in higher risk populations, including those with impaired glucose tolerance or diabetes, and when HCAs are consumed as part of meals, which may be more common in real-world consumption.n = 15), followed by artichokes (n = 3), wheat (n = 1) and potatoes (n = 1), while extracts or pure compounds were the subjects of three studies. The HCA dose was sometimes difficult to identify  but it generally ranged from 25 mg CGAs [n = 11), and sometimes with pathophysiological conditions such as mild hypertension or hypertension (n = 4), non-alcoholic fatty liver disease , MetS (n = 2), impaired glucose tolerance , impaired fasting glucose , hyperlipidemia or hypercholesterolemia (n = 3). Three studies recruited solely individuals with overweight or obesity. The duration of the studies ranged from two weeks [n = 17) were 4–8 weeks long.The main findings associated with the 23 chronic studies investigating the effects of HCA-rich foods on cardiometabolic markers are reported in  mg CGAs  up to 12 mg CGAs . The num mg CGAs  to 183 [ mg CGAs  while me mg CGAs  to 54 yewo weeks  to four wo weeks , althougn = 22), blood glucose (n = 14) and BP (n = 13) were the CM outcomes most often considered. There were no studies assessing platelet aggregation or exercise capacity. As already observed in acute studies, results from the different investigations were often contrasting. Regarding blood lipids, 55% of the studies (12/22 studies) demonstrated a significant effect on at least one measure of the lipid profile  following HCA consumption [2 vs. 26.4 kg/m2). The average of the mean ages in each study was similar between these groups (~43 y) and the ratio of men to women in each study was ~37% in those studies that found an effect compared to 49% in those that did not. However, only one study [Lipid profile components . The average of the mean ages in each study was similar between these groups (~41 y) and the ratio of men to women at ~45%. Of the nine studies that reported results for insulin, none demonstrated a significant reduction, with one that found a significant increase [2), age (45 vs. 44 y) and ratio of men to women (35% vs. 41%). Furthermore, those four studies all used HCAs consumed in the form of capsules (ranging from 372 mg to 600 mg/d CGAs from GCE or artichoke) [N-methylpyridinium (NMP)). Additionally, one of the two studies that did not find an effect of HOMA-IR [For markers related to glucose metabolism, ~30% of the studies demonstrated a significant effect on fasting glucose (6/19 studies) ,62,67,69increase . For homincrease ,60,62,67increase . In comptichoke) ,60,62,67tichoke) , had a mtichoke) , thus th HOMA-IR , conductThe beneficial effects predominating in higher risk groups are further supported if we look at those studies that were done in higher risk groups. For instance, the consumption of HCA-rich foods provided beneficial effects to study participants with impaired glucose metabolism, who are at a higher risk of type 2 diabetes mellitus. In fact, the oral consumption of 1200 mg CGA by 30 study participants with IGT for 12 weeks , or 600 2 vs. 27.8 kg/m2) with similar mean ages (~45 y) and ratio of men to women (~46 vs. 43%). No study completed subgroup analyses by BP status or by sex.Regarding BP, most studies  demonstrated a significant effect on either SBP or DBP resulting from the consumption of HCA-rich foods ,66,67,732 vs. 27.0 kg/m2) and greater baseline waist circumference (106.2 cm vs. 97.7 cm). Those studies that did find a significant reduction had similar mean ages  and lower ratio of men to women (~30% vs. 54%). Interestingly the populations of those studies that found a reduction included (n = 1) mild hypertension, (n = 1) obese, (n = 2) impaired glucose tolerance and (n = 1) metabolic syndrome.With regard to measures of adiposity, 29% (5/17 studies) demonstrated a significant reduction in BMI, body weight or waist circumference ,61,62,67Overall, the results from each of the outcomes assessed in the chronic studies consistently demonstrate there is a significant effect in those studies with participants with higher baseline levels of each risk factor for CVD. Therefore, HCAs may be more effective in those at higher CVD risk. n = 4), sex (n = 2), dietary patterns (n = 1) or specific polymorphisms (n = 1). The main findings of these studies are reported in Only seven out of the 45 studies took into account one or more determinants that might explain inter-individual variability, such as pathophysiological status (p < 0.05) after 30 min and FMD response after 60 min compared to the same meal without the coffee polyphenol extract. However, when study participants were stratified by insulinogenic index, those with an index <0.88 had significantly lower postprandial blood glucose concentration at 30 min (p < 0.01) compared to control, whereas there was no effect in those with an index ≥0.88. Thus in those with lower β-cell function, and thus at greater risk of chronic disease such as diabetes, there was an effect of HCA. With regards to the assessment of FMD, the response seemed not to be influenced by the insulinogenic index, being significantly higher at 120 min in both strata compared to control.Among the studies investigating the putative role of pathophysiological status in the effects of HCA-rich sources, two acute studies stratified results based on the glycemic response  or the iThe role of background lipid status in determining the effect of HCA-rich foods on CM markers was considered in one chronic study  in wRegarding sex differences, the eight-week supplementation of a CQA-rich artichoke leaf extract significantly increased HDL-C in primary mild hypercholesterolemic study participants (0.207 mmol/L) . HoweverThe inter-individual variability associated with the dietary pattern was taken into account by Ioakeimidis and colleagues  in an acThere is a clear interest in the exploitation of phenolic-rich foods as potential modulators of markers of CM health, and the present review aimed at summarizing the main findings from RCTs focused on HCA-rich foods. The observed intervention effects had clinical relevance mostly in study participants at high CVD risk. Conversely, many studies performed on self-reported healthy individuals failed to find any effect of HCAs, increasing the heterogeneity of the results and making it difficult to draw any clear conclusion.In the present review, only seven studies out of the 45 included publications considered one or more determinants of inter-individual variability in response to HCAs, while the remaining studies did not stratify results based on these parameters. This hinders our understanding of the role played by these determinants in the individual response to HCA-rich foods.Despite limited, results from these seven studies suggest that some individual characteristics may influence the beneficial effect of HCAs. Firstly, determinants of health or pathophysiological status, like baseline cholesterol levels ,28, insuRegarding sex differences, the response to HCAs has been shown to be different between men and women following artichoke leaf extract consumption . So far,Genetic polymorphisms have also been shown to impact the effect of plant compounds from different sources , since tAn additional determinant, not explored in any of the studies included in the present review, may likely be age, which is the strongest independent cardiovascular risk factor. Overall, the impact of age on the response to the consumption of plant food bioactives has received very limited attention . DiffereThe inter-individual variability in the biological response to the consumption of phenolic compounds, such as HCAs, may be partially related to the inter-individual variation in the bioavailability and metabolism of these compounds . SeveralThis long and complex physiological mechanism and the influence of gut microbiota composition form the pathway through which different types and levels of metabolites enter circulation where they may have metabolic effects. This is supported by the work by Stalmach and colleagues who assessed the metabolic fate of CGAs from coffee  and demoIn the framework of an intervention study, these aspects are further complicated by considering that the same colonic metabolites can be produced after the consumption of different classes of phenolic-rich foods. For example, in vitro and in vivo studies have shown that after berry, coffee, cocoa or orange consumption, the phenolic metabolic degradation pathways reach some common intermediates, most of them HCA or hydroxybenzoic acid derivatives, which can be further metabolized into smaller compounds ,88,89. Tn = 7), which explored potential determinants of inter-individual variability, thus there may be other variables that may influence the effectiveness of HCAs on CM biomarkers. Additionally, of those included studies, there was a wide range of methods by which HCAs were delivered, as well as ranges of doses, including those coming from coffee ) and foods , which may also influence the effect of HCAs. Furthermore, some studies controlled for caffeine whereas others did not, and considering the majority of studies focused on coffee, this also potentially confounds the ability to determine the effect of HCAs. In addition, further efforts should be paid on the contribution of other phytochemicals to the observed effects when dealing with food products rich in different bioactive compounds. A good example may be coffee, where the presence and amount of some compounds like caffeine, trigonelline and HHQ may affect the response to the intervention [The limitations of the present systematic review include that there were relatively few studies  and the dose of HCAs, which broadly ranged in both acute and chronic studies. It is worth noting that, even when the same HCA-food source was used as test food  in different investigations, a high variability in terms of phenolic content was observed. This further supports the importance of an in-depth characterization of the phenolic profile of the test items and, when possible, taking into account the actual phenolic amount provided by a single serving ,91. In aThe present review summarized the main findings of RCTs investigating the effect of HCA-rich foods on CM health, with a particular focus on the determinants of inter-individual variability such as pathophysiological status, sex or specific polymorphisms. Generally, there are limited studies that conduct stratified analyses to explore factors leading to inter-individual variation in the effect of HCAs to modulate CM outcomes, thus limiting the ability to conclude which factors may modulate the effectiveness of HCAs. However, the present systematic review demonstrates that overall, HCAs have greater effectiveness, regardless of the variation in the source of HCAs, in those subjects with greater baseline levels of cardiovascular risk factors such as cholesterol, BP and glycaemia. Further high quality, well powered RCTs with a low risk of bias should be performed, reporting all characteristics that may influence the individual response to these compounds, including but not limited to sex, age, BMI, pathophysiological status, presence of genetic polymorphisms, smoking habits, physical activity level and dietary patterns.


Asthma is a complex disease associated with many factors such as immunologic, environmental, genetic, and other factors. Common medicines used to treat asthma include β-agonist and glucocorticoid. However, in the long-term treatment, the effect of the above-mentioned drugs is not satisfactory, so many patients choose oral Chinese medicines instead of western medicines. The introduction of Chinese medicines therapies, a rapid proliferation of the literature on management of asthma in general, call for novel ways of evidence synthesis in this area. This systematic review is to systematically summarize and evaluate a large number of evidences for Chinese herbal interventions for asthma. Evaluate the efficacy and safety of Chinese medicines in the treatment of asthma and inform a decision aid for the clinical encounter between patients and clinicians. In addition, it helps to establish a future research agenda.Five English databases  and 4 Chinese databases  will be searched normatively according to the rule of each database from the inception to the present. The literature screening, data extraction, and quality assessment will be conducted by 2 researchers independently. Data will be synthesized by either the fixed-effects or random-effects model according to a heterogeneity test. Asthma control test symptom score will be assessed as the primary outcome. The curative effect of single symptom and sign; Withdrawal and reduction of western medicines in a course of treatment, including: time, type, and quantity; Maintenance of western medicines after the course of treatment, including: type, quantity; Asthma Quality of Life Questionnaire; laboratory efficacy indexes as the secondary outcome. General physical examination; routine examination of blood, urine, and stool; electrocardiogram; liver and kidney function examination; possible adverse reactions and related detection indicators as the security indexes. Meta-analysis will be performed using RevMan5.3.5 software provided by the Cochrane Collaboration.This study will provide high-quality synthesis based on current evidence of Chinese medicines treatment for asthma in several aspects, including asthma control score, side effects and laboratory examination such as lung-function test, serum total immunoglobulin, and so on.The results of this study will provide updated evidence for whether Chinese medicines is an effective and safe intervention for asthma.PROSPERO CRD42019136074. Eosinophils (EOS) is one of the most important cells involved in the pathogenesis of chronic airway inflammation in asthma.Asthma, affecting 1% to 18% of the population in different countries, is a complex disease associated with many factors such as immunologic, environmental, genetic, and other factors. It usually characterized by chronic airway inflammation and defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation. monoclonal antibodies,,6 corticosteroids,,8 the combination of inhaled corticosteroid and long-acting β2-agonist, and others), even bronchial thermoplasty symptomatic supportive treatment to relieve symptoms. Most patients may benefit from these treatments. Nonacute attack period, also known as chronic duration, refers to the patient although there is no acute attack of asthma, but in a considerable period of time still have different frequency and different degrees of wheezing, coughing, chest tightness, and other symptoms. Thus, due to the persistence of symptoms in chronic duration asthma, and the above-mentioned drugs treatment is not satisfactory, Patients’ conditions were not effectively controlled and their quality of life was not improved. In addition, some patients were unable to tolerate the above drugs–14 or show side effects, such as gastrointestinal, cardiovascular, metabolic, and bone-related complications that have been reported from long-term use of the above-mentioned medications.–17 Therefore, many patients choose Chinese medicines, with relatively few side effects, to treat asthma. Traditional Chinese medicine  is widely applied for asthma.Asthma can be divided into acute and nonacute attack period. Acute attack period, clinicians advocate the use of Western medicines  and has been reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.The protocol of this review has been registered with the International Prospective Register of Systematic Reviews  published in English or Chinese for the treatment of asthma. The current clinical trial results will be objectively integrated, which is conducive to the evaluation of the efficacy and safety of Chinese medicines in the treatment of asthma.Non-RCTs, cohort studies, reviews, case reports, experimental studies, expert experience, the data of the included study is missing or incomplete, and duplicate publications will be excluded.2.2.2Asthma participants of all ages will be included in the study regardless of nationality, gender, race, occupation, or education level.Patients with drug-induced asthma, aspirin intolerance triad, asthma with fixed airflow limitation, asthma with obesity, late-onset asthma will be excluded.2.2.3This study focuses on the clinical trial (RCTs) of asthma with the therapy of Chinese medicines, and the results will provide advice and consultation for clinicians. Therefore, patients in the experimental group were only treated with Chinese medicines, and the types and dosage forms of Chinese medicines prescriptions were not limited. In addition, western medicines and other treatment methods were not combined . Studies that with combination therapy fail to objectively evaluate the efficacy and safety of Chinese medicines will be excluded.Studies of control groups were treated with western medicines or placebo and other interventions .2.2.42.2.4.1 symptom score was assessed as the primary outcome. Symptom score: Step 1: accurately record the score of each question; Step 2: add up the scores of each question to get the total score; Step 3: find the meaning of the total score .Asthma control test2.2.4.2The secondary outcomes of this review mainly include the following aspects:(1)The curative effect of single symptom and sign.(2)Withdrawal and reduction of western medicines in a course of treatment, including: time, type and quantity; maintenance of western medicines after the course of treatment, including: type, quantity.(3),30Asthma Quality of Life Questionnaire.(4)Laboratory efficacy indexes.(1)+, CD8+ levels, and CD4+/CD8+ ratio.Serum CD4(2)The Th1, Th2.(3)Serum IgE.(4)Blood eosinophil count.(5)Skin prick test.2.2.4.3(1)General physical examination .(2)Routine examination of blood, urine, and stool.(3)Electrocardiogram.(4)Liver and kidney function examination.(5)Possible adverse reactions and related detection indicators.2.32.3.1Five English databases  and 4 Chinese databases  will be searched normatively according to the rule of each database from the inception to the present.2.3.2The search strategy for PubMed is listed in Table 2.42.4.1The basic process of the included literatures will be determined by referring to the Cochrane Collaboration System Evaluator's Manual 5.1.0). The study name, author, year, database, and whether the study met eligibility criteria and should be included in the review will be recorded using an excel spreadsheet. Reasons for inclusion and exclusion (PICOS) are documented in a spreadsheet during abstract screening and full-text evaluation. The records in this spreadsheet will be used to generate the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart ; participants characteristics ; Interventions ; comparators (western medicines); outcomes ; if funded, it will also be recorded. When the consensus on data extraction is not available through discussion, the third reviewer will make a decision.2.4.4I2 ≤ 50%); a random-effects model will be used if significant heterogeneity existed (I2 > 50%). The dichotomous data will be analyzed by risk ratio with 95% confidence intervals (CIs), while the continuous data will be analyzed by mean difference (MD) or standard MD with 95% CIs. The meaningful heterogeneity will be explained by any additional assessment included sensitivity analysis or subgroup analysis depended on the data.RevMan5.3.5 will be used for all statistical analyses. Based on the heterogeneity levels of the included studies, a fixed-effects model will be used if there is no significant heterogeneity of the data  of the Cochrane Collaborative Network System, and high, low, unclear evaluations will be performed for each item. Meanwhile, the STRICTA checklist will be completed. When 2 quality assessors are unable to reach a consensus on the risk assessment by negotiation, the third the third reviewer will make a decision.2.4.6When 10 or more studies are included in a meta-analysis, we will assess the reporting bias. The trim and fill method will be used to identify and correct for funnel plot asymmetry arising from publication bias, if appropriate.2.4.7I2 value will be applied to calculate and present the heterogeneity degree. When P > .1, I2 < 50%, it is considered that there is no heterogeneity between the trials, and the fixed effect model will be used for statistics, otherwise, the random effect model will be adopted to analyze.Data analysis will be performed using RevMan5.3.5 software provided by the Cochrane Collaboration. Using the software to obtain forest plots and test the heterogeneity between the included studies. Chi-square test and 2.4.8When heterogeneity is detected, we will judge the source of heterogeneity through subgroup analysis . In addition, we can also observe the relationship between effect values and grouping variables.2.4.9In the case of sufficient trials data, sensitivity analysis is mainly carried out for research characteristics or types such as methodological quality, and the effect on total effects is examined by excluding certain low-quality studies or small-sample sizes of studies. When heterogeneity occurs, we may perform sensitivity analysis by excluding the data one by one.3Asthma can be divided into acute and nonacute attack period. In the acute exacerbation period, β-agonist and glucocorticoid are used to symptomatic treatment. Non-acute attack period, due to the persistence of symptoms, and the above-mentioned drugs treatment is not satisfactory. Patients’ conditions were not effectively controlled and their quality of life was not improved. Furthermore, many patients were unable to tolerate the above drugs or show side effects. Therefore, many patients choose oral Chinese medicines instead of western medicines. Although Chinese medicines have a certain unique therapeutic effect on asthma. However, due to the complex composition of Chinese medicines, potential safety hazards may exist. The purpose of this systematic review is to systematically summarize and evaluate a large number of evidences for Chinese herbal interventions for asthma. Evaluate the efficacy and safety of Chinese medicines in the treatment of asthma and inform a decision aid for the clinical encounter between patients and clinicians. In addition, it helps to establish a future research agenda.Conceptualization: Qi Shi, Dongxu Si, Youlin Li.Data curation: Haipeng Bao, Wenfeng He, Dashzeveg Damchaaperenlei, Mingxia Yu.Formal analysis: Dongxu Si, Haipeng Bao.Project administration: Qi Shi, Dongxu Si, Haipeng Bao.Supervision: Qi Shi, Yue Yan, Yanhua Kong, Chunlei Li.Writing – original draft: Qi Shi, Dongxu Si.Writing – review and editing: Qi Shi, Youlin Li.


TP53 are associated with poor outcomes. In physiological situation, once activated by oncogenic stress or DNA damage, p53 induces either cell-cycle arrest or apoptosis depending on the cellular context. Its inactivation participates to drug resistance in MM. The frequency of TP53 alterations increases along with the progression of the disease, from 5 at diagnosis to 75% at late relapses. Multiple mechanisms of regulation lead to decreased expression of p53, such as deletion 17p, TP53 mutations, specific microRNAs overexpression, TP53 promoter methylations, and MDM2 overexpression. Several therapeutic approaches aim to target the p53 pathway, either by blocking its interaction with MDM2 or by restoring the function of the altered protein. In this review, we describe the mechanism of deregulation of TP53 in MM, its role in MM progression, and the therapeutic options to interact with the TP53 pathway.Multiple Myeloma (MM) is an incurable disease characterized by a clonal evolution across the course of the diseases and multiple lines of treatment. Among genomic drivers of the disease, alterations of the tumor suppressor  Multiple Myeloma (MM) is an incurable hematological malignancy developing as a result of clonal proliferation of plasma cells originating from post–germinal-center B cells . Age-adjOne of the distinguished characteristics of MM is the clonal progression of the disease, which is reflected through precursor stages, named monoclonal gammopathy of undetermined significance (MGUS), and smoldering multiple myeloma (SMM) –6. GenomTP53 gene is located at the chromosome 17p13.1, coding for p53 tumor suppressor protein, which is also known as guardian of the genome. The whole p53 signaling network is turned off under the normal physiological conditions, when p53 itself is expressed at low levels. In response to cellular stress, such as hypoxia, DNA damage, heat shock, p53 pathway becomes activated by means of protein stabilization through posttranslational mechanisms, which include phosphorylation and acetylation. The resulting accumulation of p53 protein in the nucleus triggers activation of various downstream pathways, which work in cooperation to keep the genomic integrity and homeostasis of the cell. This is achieved through several tumor suppressive mechanisms, including cell cycle arrest, apoptosis, and angiogenesis inhibition  within the DNA-binding domain , 26, 27.CDKN1A (coding for p21 protein), resulting in cell cycle arrest and senescence, and BAX, PUMA, and NOXA, triggering apoptosis (SLC7A11 gene) and upregulating expression of glutaminase 2 (GLS2 gene)  , 29.TP53 gene are usually monoallelic and associated with less favorable outcome in patients with MM  and serum lactate dehydrogenase (LDH) level, 17p deletion—together with t and t—is included in the revised International Staging System (R-ISS)  activities, making such gene an oncogene which is promoting tumor progression, rather than being a tumor suppressor  are detected in 3.7% of patients and represent a crucial marker of adverse prognosis for both PFS and OS, compared to wild-type or mono-allelic inactivation /TP53mut or del(17p)/TP53del were observed in 15% of the cases. Those patients had a worse outcome , and on restoring the function of protein product of the mutated in vitro and ex vivo, as well as in synergy with drugs such as melphalan, etoposide, and bortezomib  binds directly to the N-terminal domain of p53, which reduces its affinity for MDM2 as a consequence of conformational changes in the structure of p53 protein , althougherapies .MDM2 maintains low levels of p53, thus inhibiting its tumor suppressive functions , which is as a deubiquitinase removing ubiquitin specifically from MDM2. The inhibition of UPS7 results in the degradation of MDM2 and leads to re-activation of p53 . The smaTP53-deficient cells are highly sensitive to the inhibition of Ataxia-Telangiectasia Rad3-related (ATR), one of the kinases responsible for DNA damage response (DDR)  . Likewisapproach .MET, except restoring mutant p53, is also acting in a TP53-independent manner by inducing reactive oxygen species (ROS) in cancer cells, with a good efficacy in MM  has been introduced as therapeutic agent with aim of restoring the original function of mutant p53, through obtaining the wt conformation of the protein . The morcy in MM –81. In fe damage .in vitro. This compound is particularly effective in cancer cell lines with null or mutant p53 background (Other therapeutic approaches have been recently investigated , 84. A nckground . An innoTP53 alterations are of adverse prognosis in MM as in cancer in general. Recent publications of next generation sequencing on large cohort of patients with MM have enabled to better define the incidence of TP53 alteration across the course of the disease. In MM, TP53 is deregulated through different molecular mechanism, such as deletion17p, TP53 mutations, MDM2 overexpression, methylation of TP53 promoter, and deregulation of specific miRNAs. The knowledge of these molecular mechanisms of TP53 pathway alteration has helped the development of therapeutic strategies to target this pathway. Different approaches are currently tested: blocking the interaction between MDM2 and p53 with small molecules such as Nutlin or RITA, targeting MDM2 by inhibiting translation initiation with rocaglate or by blocking its deubiquitination by USP7 inhibitors, and restoring the function of altered p53 proteins. All these therapeutic strategies are currently being tested and need to be further validated for clinical use. Considering that TP53 alterations increase during progression of MM and induce drug resistance, it will be necessary to interact with TP53 pathway to be able to cure MM, or at least develop strategies that do not select TP53 subclones.KJ, GE, JD, AW, ZV, MF, PC, TF, BQ, and SM wrote the manuscript, generated the figures, and revised the review.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Neonatal sepsis (NS) is considered as the most common cause of neonatal deaths that newborns suffer from. Although numerous studies focus on gene biomarkers of NS, the predictive value of the gene biomarkers is low. NS pathogenesis is still needed to be investigated. U test, and coexpression network were used to estimate the weights of signaling pathway and hub genes.  After data preprocessing, we used KEGG enrichment method to identify the differentially expressed pathways between NS and normal controls. Then, functional principal component analysis (FPCA) was adopted to calculate gene values in NS. In order to further study the key signaling pathway of the NS, elastic-net regression model, Mann–Whitney F values of genes in the different pathways. The top 1000 genes were considered as the different genes and were further analyzed by elastic-net regression and MWU test. There were 7 key signaling pathways between the NS and controls, according to different sources. Among those genes involved in key pathways, 7 hub genes, PIK3CA, TGFBR2, CDKN1B, KRAS, E2F3, TRAF6, and CHUK, were determined based on the coexpression network. Most of them were cancer-related genes. PIK3CA was considered as the common marker, which is highly expressed in the lymphocyte group. Little was known about the correlation of PIK3CA with NS, which gives us a new enlightenment for NS study.  A total of 115 different pathways between NS and controls were first identified. FPCA made full use of time-series gene expression information and estimated  This research might provide the perspective information to explore the potential novel genes and pathways as NS therapy targets. Neonatal sepsis is the most prevalent cause of death of the neonates with few certainly reported biomarkers for many years. At least 35% neonatal deaths were caused by infections each year. The neonates have usually suffered from early-onset NS, which occurs within the first 72 hours after birth , 2. AccoDespite the numerous studies of NS pathogenesis based on genes, the valuable predictors have remained unveiled and contributed to being a major challenge to the research of NS. Gene transcriptomic profiles can be used to identify diagnostic and prognostic gene signatures in complex diseases and to reveal the pathogenesis of NS , 10. SevU (MWU) test was also applied for gene set-level inferences. Finally, hub genes were determined by the topological feature of coexpression networks [In this report, a method based on the functional principal component analysis (FPCA) was proposed to discover arbitrary nonconstant trends in time-course data analysis . After enetworks . Using tt = 0, t = 8, t = 24, and t = 72 h after admission to the paediatric intensive care unit), were studied, and key pathways and hub genes were also identified. Next, based on the RNA microarray, gene expressions isolated from whole blood, lymphocytes, and monocytes were also analyzed, respectively. According to the different sources of microarray data, we adopted different groups: The first, we named All Sources, contained all the 41 samples (10 controls and 31 patients). The second, we named Blood Source, contained the microarray data derived from blood (3 controls and 8 patients). The third, we named Lymphocyte Source, contained the microarray data derived from lymphocytes (4 controls and 12 patients). The fourth, we named Monocyte Source, contained the microarray data derived from monocytes (3 controls and 11 patients). In the following analyses, we conducted four parallel analyses based on different groups. The study was approved by the local medical ethics committee.Gene expression profiles of human peripheral blood cells at various time points from samples of meningococcal sepsis were deposited at Gene Expression Omnibus database with the data accession no. GSE11755, including NS patients and normal controls. These datasets were processed on Affymetrix Human Genome U133 Plus 2.0 Array platform. Totally, forty-one samples, which were drawn at four time points (http://cran.r-project.org/) was applied. GraphPad Prism 7.0 software was used to create images. And data preprocess of dataset was commenced with reading the data by the standard method carried out by Affy. Expressions of genes were normalized using the robust multiarray average (RMA) method, in order to eliminate the influence of nonspecific hybridization [For data preprocessing, a freely available R platform  . Fisher'In the present research, the FPCA model was used to identify temporally differentially expressed genes . The genlth eigenfunction, and The observed expression using the FPCA model is as follows:F-statistic to summarize the gene pattern information for each gene in the time points:i0 is the residual sum of squares of null hypotheses and RSSi1 is the residual sum of squares of alternative hypotheses. Fi can be viewed as a “signal-to-noise” ratio and revealed the importance of genes.When it applied to the time-course gene expression, we used functional In this study, we also took an approach with computationally efficient and highly flexible methods on the basis of an equivalent influence between the penalty function regression and a standard multivariate regression, in order to minimize optimization problem, which is known as the functional elastic-net regression problem . This prλ is the penalty coefficient and βi is the vector of the set of linear coefficients. When The main function of the model is as follows:A similar approach can be used to estimate the weights of genes.p value < 0.01 were considered significant in pathway enrichment analysis [MWU test is used to compare two independent samples. Given that two samples were exactly from the same groups, the mean was different. The aim of the MWU test was to analyze whether there was a significant difference between the means of the two groups. Recent reports showed that MWU test plays an important role in gene set enrichment analysis (GSEA) , 22. Theanalysis .Adjacency matrixes were firstly constructed based on the intergenomic relationships evaluated by Spearman correlation coefficient . Topologp < 0.05 and intersection gene count >1. p value.Gene expression profile of human NS with the series of GSE11755 was downloaded from Gene Expression Omnibus. After preprocessing the expression profile data of the dataset, we collected data from a total of 41 samples, including six children with meningococcal sepsis. Blood was drawn at four time points and matched with controls. Pathway enrichment analysis of NS and controls was conducted on the basis of the KEGG pathway database. A total of 286 pathways covering 6893 genes were obtained. After Fisher's exact test, 115 differential pathways covering 3532 genes met the thresholds of F value. Based on the 115 differential pathways (covering 3532 genes), we identified top 1000 gene signatures of NS using FPCA model, which were defined as dysregulated genes. FPCA narrowed the gene search range from 3532 to 1000. Greater F value means that the expression level differed greatly with others. Figures F value. Among the dysregulated genes, the top 12 genes from All Sources, Blood Source, Lymphocyte Source, and Monocyte Source were CDC37, NCOA2, P2RY12, RXRB, EDEM2, ACTN4, STX12, PPM1A, PRKACB, DUSP10, VEGFA, and SLC44A2. Since NS is mainly caused by infections, the dysregulated genes in NS should be immune response related. However, there were few genes in the list that were immune related. Activation of the cytokines in a specific infection might not be derived from all the regulated genes that can activate those genes. Therefore, it is important to find the pathways which are activated by infections in NS. FPCA could effectively utilize the time-series information and overcome the traditional control design deficiencies [F values would be used for the MWU test.In the present research, the FPCA model was used to identify temporally differentially expressed genes and each gene would get an ciencies . F valuew) of each gene would be used for the MWU test.Genes that exist in multiple pathways were considered as overlapping genes. These genes are thought to play multiple roles in hypothesis testing, where the weight coefficients were overestimated. In the present study, elastic-net regression model was used to decompose an overlapping gene between gene sets and eliminate the overlapping effects. After calculating the weight value of each gene and adding the weight values of the pathway genes, the total weight value of the pathways was obtained. t-test, pathways were ranked in the descending order. After the pathway data were tested by the MWU model, a total of 7 pathway terms met the condition p values < 0.05. There was no pathway met the conditions in the monocyte group. The resulting pathways are presented in Based on the KEGG pathway enrichment, 115 differential pathways were obtained. In order to more accurately find key pathways and molecules, FPCA and elastic-net regression were performed to eliminate overlapping gene effects. Combined with the MWU test, key molecular pathways in the gene transcription data of NS and controls were identified. Based on the p values < 0.05. We selected the top 3 significant pathways: hsa05220: Chronic myeloid leukemia; hsa04380: Osteoclast differentiation; and hsa05222: Small-cell lung cancer for further analysis. Besides, pathways including the proinflammatory cytokine genes were also studied, such as hsa05164: Influenza A ; hsa04620: Toll-like receptor signaling pathway ; hsa05168: Herpes simplex infection . Unfortunately, the MWU test showed that there was no difference between the controls and patients in those proinflammatory cytokines included pathways. For the obtained genes in the top 3 pathways, Helicobacter pylori infection from Blood Source after admission to the paediatric intensive care unit were significantly higher than control. Besides, the levels of hsa05222: Small-cell lung cancer from Lymphocyte Source were up at 72 h after admission to the paediatric intensive care unit.According to the MWU test, there were 7 pathways were screened based on the Networks provide effective models to study complex biological systems, such as gene and protein interaction networks. A weighted gene coexpression network was constructed using adjacency matrix based on superman coefficient. We further studied the topological features to find key nodes in the networks. Genes whose degree was greater than the average degree values were considered as hub genes. Based on the three networks of 7 pathways from All Sources, Blood Source, and Lymphocyte Source, we mapped a Venn diagram. α), interleukin-2 (IL-2), interleukin-6 (IL-6), interleukin-7 (IL-7), interleukin-10 (IL-10), and interferon alpha-1 (IFNA1). Besides, we examined expressions of housekeeping genes GAPDH and beta-catenin (not shown here) aiming at objectively reflecting the changes in hub genes. After analyzing the topological features of networks based on 7 pathways, 7 genes were considered as the hub genes which were described above. In order to investigate the relevance of the hub genes and NS, the expression levels of PIK3CA, TGFBR2, CDKN1B, KRAS, E2F3, TRAF6, and CHUK were further analyzed. As we all know that NS is mainly caused by infections, the levels of proinflammatory genes were also observed, such as tumor necrosis factor alpha , namely, PI3Kp110a. Approximately 4/5 of the mutations in PIK3CA occur in the two hot spots, exon 9 and exon 20. Its mutation not only can reduce the apoptosis of cells but also can promote the infiltration of tumors and increase the activity of its downstream kinase PI3Ks . Under pβ receptor type 2 signaling was able to limit hepatic stellate cells and fibrosis and attenuates tumor-associated inflammation [β acts as a key regulator of immune cells, epithelium, in inflammatory bowel disease [n, and further experimental verification should be conducted to verify our results. Besides, whether the workflow was suitable for other analysis or another database is a question.TGFBR2, transforming growth factor, beta receptor II, is a tumor suppressor gene. The encoded protein is a transmembrane protein that has a protein kinase domain, forms a heterodimeric complex with another receptor protein, and binds TGF-beta. Heterozygous mutations in TGFBR2 play an important role in Marfan syndrome, which is an extracellular matrix disorder with cardinal manifestations in the eye, skeleton, and cardiovascular systems . Severalammation . TGF-β a disease . Many stIn conclusion, a comprehensive process of data in datasets of NS was conducted in our research. Then, the function and signaling pathways of NS were presented systematically by the cutting edge models. Finally, based on the potential pathways and their topological characteristics of coexpression networks, several critical genes for NS were identified. PIK3CA was defined as the common marker of NS. However, the current study was based on the previous reports and more clinical evidence results were needed.


Supplemental Digital Content is available in the text. Magnetic resonance imaging may be useful to assess disease severity in cerebral small vessel disease (SVD), identify those individuals who are most likely to progress to dementia, monitor disease progression, and act as surrogate markers to test new therapies. Texture analysis extracts information on the relationship between signal intensities of neighboring voxels. A potential advantage over techniques, such as diffusion tensor imaging, is that it can be used on clinically obtained magnetic resonance sequences. We determined whether texture parameters (TP) were abnormal in SVD, correlated with cognitive impairment, predicted cognitive decline, or conversion to dementia.In the prospective SCANS study (St George’s Cognition and Neuroimaging in Stroke), we assessed TP in 121 individuals with symptomatic SVD at baseline, 99 of whom attended annual cognitive testing for 5 years. Conversion to dementia was recorded for all subjects during the 5-year period. Texture analysis was performed on fluid-attenuated inversion recovery and T1-weighted images. The TP obtained from the SVD cohort were cross-sectionally compared with 54 age-matched controls scanned on the same magnetic resonance imaging system.There were highly significant differences in several TP between SVD cases and controls. Within the SVD population, TP were highly correlated to other magnetic resonance imaging parameters . TP correlated with executive function and global function at baseline and predicted conversion to dementia, after controlling for age, sex, premorbid intelligence quotient, and magnetic resonance parameters.TP, which can be obtained from routine clinical images, are abnormal in SVD, and the degree of abnormality correlates with executive dysfunction and global cognition at baseline and decline during 5 years. TP may be useful to assess disease severity in clinically collected data. This needs testing in data clinically acquired across multiple sites. TA describes the relationship between the intensities of neighboring pixels and is particularly suited to tissue, such as NAWM, where there is only subtle disruption because of disease. This postprocessing technique has been used in T1- and T2-weighted images and magnetization transfer ratio maps.7 suggesting that NAWM damage is important in disease progression. Therefore, we applied gray-level co-occurrence (GLCM) matrix-based TA to conventional MR images of patients with symptomatic SVD and correlated the derived parameters with temporally equivalent neuropsychological test results. We also determined whether texture parameters (TP) were independent predictors of change in cognitive function in the same population and whether they could predict conversion to dementia.We hypothesized that TA might be sensitive to damage in the NAWM in SVD. Previous studies have shown correlations between NAWM DTI parameters and cognition,Because of subject confidentiality, the imaging data are not available to researchers. Summary data and analytical methods are available from the corresponding author on reasonable request.3 SVD was defined as a clinical lacunar stroke syndrome8 with an anatomically appropriate lacunar infarct on MRI, as well as confluent WMH (Fazekas grade ≥2) on MRI.9 The study was granted ethical approval by the Wandsworth research ethics committee (ref: 07/Q0803/82). All participants gave written informed consent. Participants were fluent English speakers, and MRI and cognitive tests were performed at least 3 months poststroke to minimize acute effects of stroke on cognition. Subjects underwent MRI and cognitive testing at baseline, then, of interest in this study, cognitive testing yearly for 5 years, 121 underwent MRI and cognitive tests at baseline; 99 of these attended for at least 1 follow-up visit, and details of the number of subjects at each time point can be found in the online-only Data Supplement.Symptomatic SVD patients recruited to the SCANS study (St George’s Cognition and Neuroimaging in Stroke) were used in this study. This prospective longitudinal study recruited patients from a geographically contiguous region served by 3 hospitals in South London, United Kingdom.3), comprised randomly selected community-dwelling subjects recruited to the GENIE study (St George’s Neuropsychology and Imaging in Elderly),10 these subjects had no history of psychiatric and central nervous system diseases (including stroke). There were data from 57 subjects available with mean±SD ; however, because of excessive movement or failure to tolerate the MRI protocol, data from 54 subjects were used.A control population, imaged on the same MR scanner using the same sequences , diabetes mellitus (on drug or insulin treatment), hypercholesterolemia , body mass index, and smoking history .11 including digit-span, logical-memory, visual-reproduction, BIRT memory and information processing battery, speed of information processing, digit-symbol, grooved pegboard, trail-making test, verbal fluency, and modified Wisconsin card-sorting test. The following cognitive indices were constructed: executive function (EF), processing speed (PS), working memory, and long-term memory. A Global Cognition (GC) index was produced, which summarized performance on all tasks. Premorbid intelligence quotient was estimated using the restandardized National Adult Reading Test.12 Measures for each task were transformed into z scores through psychometric standardization using age-scaled normative data and averaged to calculate cognitive index scores.Cognitive assessment was performed by a neuropsychologist using a battery of widely used tasks chosen to characterize the cognitive impairment seen in SVD,z scores of −3.33 and −3). Other missing data were excluded from the calculation of cognitive index scores.Missing data from tasks which the subject was unable to complete because of the effect of cognitive decline, as judged by the attendant neuropsychologist, were addressed by substituting the minimum scaled score for that task . The full MRI protocol has been described in detail.Sequences of interest to this study were as follows:2, matrix=256×192, 28 contiguous 5 mm slices.Axial fluid-attenuated inversion recovery (FLAIR): repetition time/echo time/inversion time=9000/130/2200 ms, field of view=240×240 mm2, matrix=256×192, flip angle=18°, 176 contiguous 1.1 mm slices.Coronal spoiled gradient recalled echo T1-weighted: repetition time/echo time=11.5/5 ms, field of view=240×240 mm15 The T1-weighted images were segmented using SPM8 , and the WM tissue probability map was lower thresholded at 90% to produce a WM segment. The T1-weighted images were registered to the FLAIR images using FLIRT,16 and the transformation applied to the WM segment. The lesion mask and WM segment were then applied to the FLAIR images to leave NAWM. The FLAIR images were registered to the T1-weighted images and the transform applied to the lesion masks to produce a T1-weighted NAWM map. For both registrations, 6 degrees-of-freedom were used to provide rigid-body transformation between the T1-weighted and FLAIR images.Lesions were marked on the FLAIR images by an experienced rater, using the semiautomated lesion marking tools in DispImage.17 in which 14 TP are defined based on the GLCM: angular second moment, contrast, correlation, variance, inverse difference moment, sum average, sum variance, sum entropy, entropy, difference variance, difference entropy, information measure of correlation 1, information measure of correlation 2, and maximal correlation coefficient .The FLAIR and T1-weighted NAWM images were analyzed using the method proposed by Haralick et al,Because of the anisotropic voxel dimensions of the FLAIR images and to maintain methodological consistency between the image types, 2-dimensional TA was performed. The NAWM maps were normalized to a specified number of gray levels using histogram equalization. Based on the number of voxels in the NAWM segments and the number of gray levels in the native images, and to avoid issues with sparsity in the GLCM, the FLAIR images were normalized to 64 gray levels and the T1-weighted images to 128 gray levels. The GLCM and TP were calculated for the NAWM.For analysis, the number of lacunes (nLAC) and number of microbleeds were log 10 transformed, and the T2-WMHL was expressed as a percentage of the total brain volume and log transformed.t test.Initially, TP from the NAWM were compared between the baseline SVD and control images using the Student unpaired 3Second, in the SVD cohort, the TP were correlated, using the Pearson correlation test, with normalized brain volume (NBV), WMHL, nLAC, number of microbleeds, and peak height from mean diffusivity NAWM (MDPH) histograms as determined previously to be the best MR-derived predictors of cognition.3 univariate regressions were run for the TP, including age, sex, and premorbid intelligence quotient as confounds. For each image type, the variable showing the greatest standardized β (with associated P≤0.05) was chosen to progress to the multivariate model. These were included in a multivariate regression with the parameters listed above. Initially, only parameters derived from conventional MR images were added, and then a further model including MDPH was run. The regression tests were then repeated using the rates of change of the cognitive measures during the 5-year follow-up period.A regression analysis was then performed to determine whether TP were independently predictive of the cognitive measures. As in ref,Finally, the ability of TA to distinguish those of the SVD subjects who developed dementia was determined. Initially, univariate Cox regression was used to determine those TP that best predicted conversion to dementia , and these were then included in multivariate analyses as above, with addition of binary parameters indicating whether new microbleeds or lacunes are seen in follow-up scans, which were acquired for the first 3 years of the follow-up, to assess whether they are independent markers of conversion. To counter the possibility of overfitting, the model bootstrapping with 1000 samples of the population was applied.Tissue segmentations were unreliable in 3 SVD subjects, and these were removed. Therefore, for the texture analyses, 118 subjects were included in the analysis. In a further 3 subjects, artifacts prevented reliable analysis of the DTI data, so for the regression, including the diffusion parameters, 115 subjects were included. Demographic details and MRI characteristics are shown in Table 11 but in summary, PS, EF, and GC scores declined significantly during the 5-year follow-up period. The annualized changes were −0.048±0.015 (P=0.001) for EF, −0.052±0.014 (P<0.001) for PS, and −0.029±0.009 (P<0.001) for GC. It was, therefore, decided to proceed with the analysis using only these cognitive parameters.Details of the cognitive changes during the 5 years have been previously described,P<0.0001 for both image types. The P values are not corrected for multiple comparisons because of shared variance between the measures. For reference, an uncorrected P value of 0.004 would give a Bonferroni-corrected P value of 0.05.There were highly significant differences between SVD cases and controls for many TP derived from both T1 and FLAIR sequences Table . The patThe TP were highly correlated to several MR measures Table , suggest3 only cognitive fields shown to change over the course of the study, and GC were included in the analysis.As with previous work,P=0.009) and the FLAIR-sum average  were the only significant regressors, only FLAIR-sum average significantly regressed with PS, and for GC, T1-MCC  and FLAIR-sum average  were the most significant regressors. Results of the multivariate regression are shown in Table For the univariate analysis in the EF, the T1-MCC , but this did not survive inclusion in the multivariate model. Again the addition of MDPH had little effect on the model.Only nLAC and NBV independently correlated with PS. For the univariate regressions, no T1-weighted texture parameter was significant, and FLAIR-sum average was the most significant texture parameter  and FLAIR-entropy  were significant regressors of EF, and the same parameters appeared for regression with GC ; no TP had a significant regression with PS. When the other MR parameters are included, none of the TP remains significant, the closest to significance is for the change in EF without the MDPH, where FLAIR-entropy, a standardized β of −0.208 and a P value of 0.058. In addition, nLAC and National Adult Reading Test are significant for the GC change, whereas nLAC is significant for EF change.For the univariate regressions of the TP with the rate of change of the cognitive fields during 5 years, T1-MCC . Several parameters from the FLAIR images predicted conversion to dementia, the best being FLAIR-sum average . In the multivariate bootstrapped model, the FLAIR-sum average retained significance  along with NBV , and when MDPH was also added, the same 2 parameters were significant in predicting dementia .Twenty of the 99 (20%) patients developed dementia during follow-up. Prediction of dementia was assessed by the Cox regression. On univariate regression, only 1 T1 image texture parameter was a significant predictor of conversion to dementia, the T1-MCC .11 Also, the small number of subjects who converted to dementia means that the Cox regression may still be optimistic despite the use of bootstrapping. Thus, these results should be treated accordingly.Although TP did correlate with cognition at baseline and predict decline in cognition, such correlations were only moderate and less strong than those with DTI parameters,These results suggest that TA may be less sensitive to changes in NAWM ultrastructure than DTI, in particular, those predicting cognitive decline. However, TA has an advantage, particularly for large clinically acquired data sets, in that it can be performed on standard MRI sequences acquired during routine clinical scanning. TA produces a large number of highly correlated parameters. In this study, we selected those which were most strongly associated on univariate analysis to take through to multivariate analysis. Further replication studies are required to confirm that the parameters which we prioritized are most strongly associated with cognitive function in SVD in other populations. The third criterion for diagnosing dementia is not as clinically definite as the former 2, and this may lead to a misdiagnosis of some subjects; however, in the absence of a definite diagnosis, it was considered that those subjects showing this significant level of impairment should be considered as having dementia.A major strength of this study is its longitudinal design with data on progression of cognitive decline during a 5-year period. A further strength is the inclusion not only of TP but also other MR parameters so that the independent contribution of TP to disease prediction could be determined. The SCANS cohort included patients with relatively homogenous SVD in that all had presented with lacunar stroke and all had confluent WMH. This is both a strength and a weakness of the study. However, further studies in cohorts of patients with different severity of SVD are required to determine whether these changes can be seen across the spectrum of SVD severity.21 This has led to increasing interest in the use of MRI techniques to both monitor disease progression and test new therapeutic approaches in smaller phase 2 studies before large phase 3 trials with clinical end points.22 MRI markers, particularly DTI, have been shown to be potential surrogate markers being both sensitive to change over short time periods and able to predict future cognitive decline and dementia.11 However, despite an increase in availability, DTI is not acquired in all clinical MRI settings and takes additional time and image processing and can present challenges in multicenter studies. As TA can be performed on conventional MRI data, it has potential advantages in these situations. Our results suggest that TP may be useful markers of disease in SVD, but further studies are required to replicate these results and determine how TA performs in cohorts with multicenter imaging.SVD presents a major health problem, and there are few proven treatments to prevent its progression. Recurrent stroke rates are relatively low, and it has been shown that neuropsychological testing is relatively insensitive to change both because of the slow rate of change and because of practice effects reducing the sensitivity to change.The SCANS study (St George’s Cognition and Neuroimaging in Stroke) was supported by a Wellcome Trust grant (081589). Recruitment was supported by the English National Institute of Health Research (NIHR) Clinical Stroke Research Network. Prof Markus is supported by an NIHR Senior Investigator award, and his and Dr Tozer’s work are supported by the Cambridge University Hospital Comprehensive NIHR Biomedical Research Unit. Dr Lawrence is supported by a project grant from Alzheimer’s Research UK (ARUK-PG2013-2).None.


The purpose of the present study was to compare patient-specific instrumentation (PSI) with standard instrumentation (SI) in patients undergoing total knee arthroplasty (TKA). PSI is hypothesized to have advantages with respect to component alignment; number of outliers ; operative time; perioperative blood loss; and length of hospital stay. This new surgical technique is expected to exhibit superior performance.A total of 23 randomized controlled trials (RCTs) involving 2058 knees that compared the clinical outcomes of TKA between PSI and SI were included in the present analysis; these RCTs were identified via a literature search of the PubMed, Embase, and Cochrane Library databases through March 1, 2018. The outcomes of interest included coronal, sagittal and axial component alignment (presented as the angle of deviation from the transcondylar line); number of outliers; operative time; perioperative blood loss; and length of hospital stay.p = 0.0004, I2 = 48%). PSI resulted in approximately 0.4° less deviation from the transcondylar line than SI. Based on our results, PSI reduced operative time by a mean of 7 min compared with SI . According to the included literature, PSI reduced perioperative blood loss by approximately 90 ml compared with SI . We did not find any differences between PSI and SI with respect to any other parameters.There was a significant difference in postoperative femoral axial alignment between PSI and SI patients , Level I. According to reports, the rate of component malpositioning can be 20% to 40% using standard instrumentation (SI) , 18, andA literature search was performed in the PubMed, Embase, and Cochrane Library databases following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The Cochrane Central Register of Controlled Trials was searched using the following terms: total knee arthroplasty, TKA, total knee replacement, TKR, standard instrumentation, conventional instrumentation, patient-specific instrumentation, PSI, patient-matched, customised instrumentation, and custom cutting block. The searches were restricted to the English language. Two independent reviewers (SG and RYW) selected the articles obtained from the PubMed, Embase, and Cochrane Library databases. Disagreements between the reviewers were resolved by consulting a superior (WHX) to reach a consensus.Studies of TKA comparing PSI with SI in terms of at least one of the following: coronal, sagittal and axial component alignment; number of outliers; operative time; perioperative blood loss; and length of hospital stay, were includedRandomized controlled trials (RCTs)Minimum of 40 patients in both the PSI and the SI TKA groupsPatients older than 18 yearsStudies with an Improved Jadad Rating Scale score of less than 3 were excludedFracture, deformity, tumour, animal and cadaver studies were excludedStudies exclusively reporting unicondylar knee component outcomes were excludedTo ensure a high-quality analysis, studies involving RCTs and a strict Improved Jadad Rating Scale score of at least 3 were included. The patients were required to be of legal age (at least 18 years old) to ensure that they had the right to sign the consent form for the surgery. Studies lacking any of the above-mentioned inclusion criteria or involving any of the above-mentioned exclusion criteria were excluded.Two reviewers (SG and ZJW) independently extracted the following data from each study: first author, country of origin, Improved Jadad Rating Scale score, number of patients, mean age, pre-imaging results, gender ratio, body mass index (BMI), PSI system, accuracy of component alignment, number of outliers, surgical time, perioperative blood loss, and length of hospital stay. Several of the initial articles contained some indicators of the means and 95% confidence intervals (CIs), which were converted to the means and standard deviations . The devp < 0.10; I2 > 25%). Otherwise, a fixed-effect model was used.The statistical analysis was performed using Review Manager version 5.3 . For each study, we calculated risk ratios (RRs) with 95% CIs for dichotomous data and mean differences with 95% CIs for continuous data. Where appropriate, we pooled the results of comparable groups of trials using a fixed-effect model (via the Mantel–Haenszel test) or a random-effect model (via the DerSimonian–Laird method). A random-effect model was used when significant heterogeneity was detected among studies (p values of the research parameters are shown in Table The initial searches produced 1388 studies, of which 370 were duplicates and 833 were excluded because the title and abstract were irrelevant. The remaining 185 studies were retrieved for evaluation of the materials and methods, and 159 of these articles were excluded because they did not include a comparison with SI or were not RCTs; furthermore, three full-text articles were excluded because they did not report an outcome of interest. The remaining 23 RCTs , 61, 64 Fifteen studies , 61, 64 Thirteen studies , 61, 64 Fourteen studies , 61, 64 Eight studies , 58, 64 Eight studies , 58, 64 Nine studies , 58, 61 Nine studies , 61, 64 The most important findings of the present study were that PSI resulted in approximately 0.4° less deviation from the transcondylar line, reduced perioperative blood loss by 90 ml and reduced the operative time by an average of 7 min compared to SI. No significant differences between PSI and SI were found with respect to alignment of the remaining components, number of outliers, and length of hospital stay.The effectiveness of PSI compared to that of SI is not completely clear, and the existing data are conflicting. The present study produced results that are consistent with some published studies showing that PSI and SI exhibited no significant difference in mechanical alignment , 49, 65.PSI showed approximately 0.4° less deviation from the transcondylar line than SI. Theoretically, the femoral axial alignment should be parallel to the transcondylar line. The clinical relevance of a 0.4° deviation is questionable despite the statistically significant difference. In the future, additional clinically relevant studies of femoral axial alignment should be conducted.PSI reduced the operative time by an average of 7 min compared to SI. Several published studies supported our opinions , 44, 50 There are some limitations to this study. First, the data showed large heterogeneity among the included studies, which may have affected the analysis of the results. Second, some of the data conversions in the articles may have affected the analysis of the results.PSI has advantages for axial alignment of the femoral component, operative time, and perioperative blood loss compared to SI. However, no significant differences were observed between PSI and SI with respect to the alignment of the remaining components, number of outliers, and length of hospital stay. High-quality, long-term RCTs are needed to determine whether PSI is superior to SI in other respects.