We aimed to estimate the geographical distribution of periodontitis prevalence and risk based on sociodemographic and economic data. This study used sociodemographic, economic, and health services data obtained from a regional survey and governmental open data sources. Information was gathered for all 308 Portuguese municipalities and compiled in a large set of 52 variables. We employed principal component analysis (PCA), factor analysis (FA) and clustering techniques to model the Portuguese nationwide geographical distribution of the disease. Estimation of periodontitis risk for each municipality was achieved by calculation of a normalized score, obtained as an adjusted linear combination of six independent factors that were extracted through PCA/FA. The municipalities were also classified according to a quartile-based risk grade in each cluster. Additionally, linear regression was used to estimate the periodontitis prevalence within the peri-urban municipality clusters, accounting for 30.5% of the Portuguese population. A total of nine municipality clusters were obtained with the following characteristics: mainly rural/low populated, including small villages (one), partly rural, including small cities (two), mainly urban/peri-urban, including medium-sized to large cities (4), and urban/large cities (2). Within the clusters, a higher periodontitis risk was identified for municipalities with lower income, older populations. The estimated periodontitis prevalence for the 18 municipalities included in the four peri-urban clusters ranged from 41.2% to 69.0%. Periodontitis prevalence estimates range from 41.2% to 69.0% for the municipalities characterized as peri-urban and mainly urban, most of them located in the Lisbon Metropolitan Area, the tenth largest in Europe. Periodontitis is a disease caused by a dysbiotic polymicrobial community surrounding teeth ,2,3. WitTo date, the epidemiology of periodontal diseases in the Portuguese population has been inadequately reported. A single national epidemiological study, carried out in 2015, estimated a prevalence of 10.8% and 15.3% for the adult and elderly population, respectively . These rThe current gap of knowledge on periodontal status among the Portuguese population highlights the need for further studies. In our view, a comprehensive projection of risk trends for the disease at both national and regional levels based on current evidence is relevant. The geographical distribution of periodontitis prevalence and risk estimates are critical for understanding the burden of this disease for each specific region. This permits conducting a region-targeted adequate planning of the oral health policy in order to prevent and give early access to treatment for those in need. In this study, we aimed to develop a model able to estimate periodontitis risk for the Portuguese population at regional/territory level based on a multivariate approach using governmental sociodemographic, economic, and health services data along with epidemiological data.Secondary data were included to characterize and fingerprint the sociodemographic, economic, and health profiles at municipality level. Portugal is divided into 308 municipalities, also known as local administrative units, level 1 (LAU 1).The risk of periodontitis was considered the main outcome. It was estimated for each municipality by calculation of a numerical score, obtained as an adjusted linear combination of six independent factors that were extracted through a dimension reduction process. The normalized score, ranging from 0 to 25, was further used to categorize, within each cluster, the municipalities in a 4-level risk grade, identified by its quartile position (from Q1—higher risk to Q4—lower risk).A large set of 52 variables was considered and the correspondent values gathered for each municipality.The variables included data on the following areas: population, including sex, age and area distribution (population density); education; purchasing power; unemployment/employment; inactive/active population; longevity; aging; elderly dependence and health personnel .https://www.pordata.pt, accessed on 1 May 2022). Overall, data included comprised age, sex distribution, male/female ratio, population density from the 2021 CENSUS, number of doctors, dentist, nurses and pharmacists in 2019, illiterates in total, education , employment status, inactive and active population per 100, level of purchasing power in 2019, total population, dependence index of elderly from the 2021 census, aging index from the 2021 census, and longevity index from the 2021 census.All data were gathered from open public sources . Sociodemographic data were obtained from PORDATA, an official and certified statistics data website , factor analysis (FA), and cluster analysis (CA) were used to model the nationwide geographical distribution of the disease. Through the PCA/FA dimension reduction process, six factors were extracted from the original set of 52 variables. The factors were further used to categorize the municipalities through a CA procedure.Additionally, linear regression was used to estimate the periodontitis prevalence within the peri-urban municipality clusters , accounting for 30.5% of the total Portuguese population. The estimations were based on the calculated risk score and prevalence values previously obtained in the SoPHiAS, which was conducted in two peri-urban municipalities in the Lisbon Metropolitan Area . All anaUsing an online map-creator website (mapchart.net) we created a customized map for the risk of periodontitis on the Portuguese mainland and autonomous islands per region. To create this map, we categorized the risk per quartile as described in the Prior to the model development and to reduce the complexity of the dimension data, the 52 variables were grouped into six factors through a PCA/FA extraction procedure. The distribution of variables among the factors was as follows: factor 2—inactive and active population for female and male subjects, dependence index of elderly, and longevity index; factor 3—number of doctors and nurses, and level of purchasing power; factor 4—employment status for female and male subjects; factor 5—illiterates in total and male/female ratio; factor 6—unemployment ratio; factor 1—all variables except those mentioned in the remaining factors. The factors were used to categorize the municipalities in clusters.The developed model resulted in a 9-cluster based distribution . In thisWhen analyzing the map encompassing the predicted risk score for each cluster, the major population areas in Portugal, particularly the Lisbon and Porto metropolitan areas, have the largest population high-risk clusters for periodontitis . FurtherWhen forecasting the estimated periodontitis prevalence, the prevalence ranged between 41.4% and 69.0% . The lowThe present study was able to predict estimates for risk of periodontitis on the Portuguese mainland and autonomous regions (Azores and Madeira) based on sociodemographic/economic reference data from national governmental sources. Additionally, it was possible to produce estimates for periodontitis prevalence from secondary data previously obtained in a regional field study. The periodontitis prevalence estimates range from 41.2% to 69.0%, for the municipalities characterized as peri-urban and mainly urban, including some medium-sized to large cities. Most of them are located in the Lisbon Metropolitan Area , which is the largest urban area in the country and the tenth largest in Europe. However, it is worth noting that the highest prevalence (69.0%) was estimated for Funchal municipality, in the Madeira autonomous region. These findings contrast with those presented in the DGS oral health study in 2015. In other words, and according to DGS data, the prevalence of periodontitis in Madeira was 6.6% and 10.8% in those aged 35–44 and 65–74 years, respectively. Nevertheless, our results are similar for other regions, and ultimately confirm previous epidemiological studies conducted mainly in the Portuguese metropolitan areas (Lisbon and Porto) ,23,24. IA lack of financial support has often been a serious obstacle, in most countries, to permit adequate and sufficient dental care . In PortIn 2008, a “dental voucher” strategy was added to the program of the Portuguese National Health Service (NHS). Dental vouchers are awarded by primary care health centers to certain beneficiary patients, such as children, pregnant women followed in the NHS, receivers of specific social protection benefits, and people diagnosed with human immunodeficiency virus. This allows access to a range of preventive and curative treatments, free of charge, at any private dental surgery that has an agreement with the NHS . FinallyDespite the measures adopted, periodontitis remains one of the diseases that most affects the oral cavity in Portugal . It is tGiven this, the present study acquires extreme importance. It is an innovative study that has never been carried out before and that gives us information about periodontitis risk by county. Even so, this study presents some limitations due to the lack of information on sociodemographic and socioeconomic issues and the lack of information on oral health habits, such as tooth brushing per day and interproximal cleaning. In this way, this study was carried out by the county and not by the parish, as it had been initially planned. Analyzing the risk map, within each cluster, it is possible to identify the counties with the greatest risk for periodontitis based on a score from 1 to 4, where 4 represents the greatest risk.The values obtained in this study show a high prevalence of periodontitis in Portugal, the second most common disease concerning the oral cavity. Thus, the need for greater inclusion of dentistry in health centers is foreseen, with a greater interconnection between dentistry and the national health service, and a greater coverage of the treatments available.There are limitations worth mentioning. The results of these forecasts are always dependent on the availability, amount, and quality of data used to model the results. Although the data available could assemble a model, the amount is far from ideal, and requires further enhancement in the future. No prediction is entirely exact and possible variations or deviations from these forecasts are mandatory. Nevertheless, the periodontal data used were based on updated periodontal case definitions and high-quality epidemiological designs, hitherto confined to the Lisbon Metropolitan Area; therefore, national and regional studies should be carried out on a regular basis to allow consistent results and forecasting. Despite the abovementioned limitations and strengths, we developed a model to identify risk per municipality of periodontitis in Portugal. This geographical distribution of periodontitis risk allows region targeting for adequate planning of oral health policy. These findings provide important data to explore through regional/territory-level epidemiological studies.The periodontitis prevalence estimates range from 41.2% to 69.0% for the municipalities characterized as peri-urban and mainly urban, most of them located in the Lisbon Metropolitan Area, the tenth largest in Europe.


Visual impairment (VI) is a strong predictor of depression in middle-aged and older adults. However, the underlying mechanisms and pathways have not been well characterized. The purpose of this study was to determine whether Internet use and social participation mediate the effects of self-reported VI on depression.The study used the fourth wave of cross-sectional data from the China Health and Retirement Longitudinal Study, including 19,766 Chinese adults. Depression was assessed according to the CES-D 10 International Scale. Logistic regression models were used to examine the relationship between self-reported VI and depression. While adjusting for relevant covariates, the PROCESS macro (model nos. 6 and 91) was used to assess the chain-mediating effects of Internet use and social participation.A total of 17,433 respondents were included in this study. The CES-D 10 results showed that 7,327 middle-aged and older adults had depressive symptoms, of whom 39.5% were male and 10.2% were ≥75 years old. 32.1% of respondents self-reported VI. Regression analysis showed a positive association between VI and depression, while Internet use and social participation had a negative predictive effect on depression. In the mediation analysis, the social participation pathway contributed the most to the total effect, accounting for 52.69% of it. The proportion of Internet use is 37.72%. When these two mediators were considered together in the full model, they accounted for 9.58% of the total effect of VI on depression.Internet use and social participation were important mediators that mitigated the effects of VI on depression. Combined with previous evidence, online activities such as e-health and m-health can effectively promote disease monitoring and diagnosis, and various offline social participation activities can also play a role in regulating emotions. Therefore, Internet use and social participation factors may serve as relevant entry points for the development of intervention programs that may further improve the mental health of the visually impaired. The term visual impairment (VI) refers to self-reported blindness or difficulty with distance/near vision. According to the definition proposed by the World Health Organization, which used the International Classification of Diseases 11 (ICD-11) definition of VI and blindness, a person is said to be visually impaired if he or she presents with worse than 3/60 of the visual acuity (VA) of the better eye. In this revised definition, near VI is also included; it is defined as presenting with poorer near VA than N6 with the available correction . VI affevia effective Internet use and adherence . In brief, the CHARLS is a longitudinal study assessing the health, social, and economic status of a nationally representative sample covering 450 villages and 150 counties in 28 provinces in China . The CHAIn the Chinese population, uncorrected refractive error was relatively less affected by population aging, and the populations affected are becoming younger . TherefoWe excluded participants who were aged < 45 years; those with or who had intellectual disabilities, malignancies, and memory-related disorders, as this group may have experienced recall bias due to poor physical or mental status during data collection, thus becoming a confounding factor in the study results ; and thoIn the CHARLS, respondents were asked about vision . In this study, if middle-aged and older adults reported one of “blindness, poor-looking far away, poor-looking near, cataracts, and glaucoma,” they were judged to have VI . In ordeRespondents were asked whether they had used the Internet in the last month (Yes = 1 and No = 0) and frequency of Internet use . At the same time, we judge the specific situation of their Internet use through the analysis of several common Internet behaviors, including online chatting, mobile payments, reading news, watching videos, playing games, financial management, and others. Each type of network function usage is assigned a value of 1, and Internet use as a continuous variable was assigned a score range of 0–7.The score of depression was measured with 10 questions from the Center for Epidemiologic Studies Depression Scale (CES-D10), 34. TheIn the CHARLS, respondents were asked to choose which social activities they participated in during the past month, including (1) interacting with friends, (2) playing Ma-Jong, playing chess, playing cards, or going to the community club, (3) providing help to family, friends, or neighbors who do not live with you and did not pay you for the help, (4) going to a sport, social, or other kinds of the club, (5) taking part in a community-related organization, (6) doing voluntary or charity work, (7) caring for a sick or disabled adult who does not live with you and who did not pay you for the help, and (8) attending an educational or training course. We generated social participation as a binary variable (participating in at least one of these activities in the past month = “1” vs. no participation = “0”). Those who reported any of these activities were then asked a follow-up question about how often in the last month did they do . We multiply the number and frequency of social participation to generate a multi-categorical variable for the social participation intensity . Previous research has verified the reliability of this evaluation index .A parsimonious set of sociodemographic factors were included: (1) gender, (2) age , (3) area , (4) education level , (5) marital status , (6) health status , and (7) the chronic disease information of respondents that can be obtained by asking: have you been diagnosed with hypertension/dyslipidemia/diabetes or high blood sugar/chronic lung diseases/liver disease/heart problems/stroke/kidney disease/stomach or other digestive diseases/arthritis or rheumatism/asthma by a doctor? If the respondents were informed by the doctor and know that he/she has one of these chronic diseases, the value is “1”; otherwise, it is “0”.Statistical analyses were performed using the SPSS Statistics 22.0 . We performed a listwise deletion of the data with missing key variables. Some covariates contained missing values, and the proportion of missing values was < 5%. To ensure the completeness of the sample of key variables, we replaced the missing data with the mean of their integrity items (39). Frequency and case percentages were calculated to describe sociodemographic parameters and level distributions among participants.P < 0.05 using a two-sided test.Differences in characteristics between groups were investigated with chi-square tests for dichotomous variables. One-way between-group analyses of variance were employed to examine differences between depression subgroups and continuous variables . To fully appreciate the relationship between VI and depressive symptoms, the CES-D 10 was both dichotomized and continuous variable (CES-D10 cut-off ≥10) , 39. We n = 5,589) reported that they had VI.Among the 19,766 adult respondents in the fourth wave of the CHARLS, 17,433 respondents over the age of 45 years were selected. Of them, 42.0%  of the respondents had depressive symptoms and 32.1%  of the effect of VI on depression was mediated by two sets of explanatory factors. In the chain-mediated analysis, social participation had the largest effect on the VI–depression association, with an indirect effect of 1.85%, followed by Internet use (0.63%) and a chain mix of both factors (0.27%). Furthermore, this study examined the moderating mediating effect of Internet use frequency and found it to be not statistically significant.Our findings have shown that VI is strongly associated with depression, which is consistent with other research in different regions. Several reports showed a relatively consistent association between VI and mental health among different age populations. Cosh  surveyedOur results also provided support for the hypothesized mediation model in which increased levels of Internet use and social participation lead to lower levels of depression, which we found to be partially mediated—populations with VI who are accompanied by some level of Internet use and social participation have a correspondingly mitigated risk of depression. Dovetailing with the research about how both Internet and social factors are important significant control factors of depression , 47, ourAging highlights the revelation that more older adults suffer from depression and social isolation, and both online and offline social engagement activities provide us with effective alternatives. On the one hand, our findings suggested that measures to encourage appropriate Internet use among older adults, especially those with VI, may prevent depression in this population. Contrary to previously published studies, Banjanin et al. believed that Internet use was positively correlated with depressive symptoms in adolescents . The reaOn the other hand, we found that a range of offline social participation may also be a key variable in mitigating the negative association between VI and depression. The study showed that older adults involved in social activities, volunteer work, and donations had a reduced risk of depressive symptoms, while more frequent and diverse participation activities further reduced the risk . FurtherFurthermore, while Internet use and social participation may alleviate depression in VI, it is important to note that only 50.1% of the Chinese middle-aged and older adults reported engaging in offline social engagement and only 13.8% had Internet use habits. These results appear to be consistent with several other studies focusing on different populations , 56. ThuThe study has a few limitations. First, VI was self-reported, with no data on the timing of onset or further disease progression, while depression was based on CES-D10 judgment rather than a medical diagnosis. Therefore, we do not know the trends in VI and depression over time. Second, only cross-sectional data on Internet use were collected in this study, and the cross-sectional study design does not allow for the establishment of causal relationships and restricts chronological order, which means that the findings need to be interpreted with caution. Third, there are still untested mediators.Both online and offline social participation has shown a mitigating effect on improving depression in middle-aged and older adults, especially in the population with VI. As more and more daily social activities  and medical care services require the use of the Internet, it is becoming increasingly important to promote Web-based technology for social engagement behaviors and medical care behaviors between middle-aged and older adults. Based on a large nationwide cohort in China, Internet use and social engagement were found to play a mediating utility in the effect of VI on depression. Therefore, targeted Internet services and social engagement promotion services should be designated for middle-aged and older adults, especially those with VI, and the inequities caused by other social determinants for those with VI should be considered.The original contributions presented in the study are included in the article/The China Health and Retirement Longitudinal Study (CHARLS) was a survey approved by the Ethical Review Committee of Beijing University, and all participants signed informed consent at the time of participation. There is no need for additional ethics approval for the approved data users.WH and WZ conceptualized the study. WH, PL, YG, and XQ collected and analyzed the data. WH and PL wrote the manuscript. WZ, JC, and JY revised and finalized the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by the National Science Foundation of China (Grant No. 81871061), 1·3·5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (No. ZYJC21004), and Clinical Research Innovation Project from West China Hospital, Sichuan University (Grant No. 2019HXCX03).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Respiratory muscle weakness often occurs after stroke, which can lead to pulmonary dysfunction (PD). Pulmonary dysfunction prolongs the length of hospital stay and increases the risk of death. In a prospective, randomized, case-control study, we used musculoskeletal ultrasonography (MSUS), and pulmonary function tester to objectively evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) combined with respiratory muscle training (RMT) in the treatment of PD in patients with acute ischemic stroke. Sixty-two stroke patients with PD were recruited and eventually 60 patients participated in this study. The control group was treated with RMT, and the treatment group was treated with rTMS on the basis of RMT. Treatment occurred five times a week for 8 weeks. Before and after treatment, diaphragmatic thickness (DT), diaphragmatic thickening fraction (DTF) and diaphragmatic mobility (DM) in patients, bilateral chest wall were measured by MSUS. Meanwhile, FVC, FEV1, FEV1/FVC, PEF, and MVV tested by pulmonary function tester was used to evaluate the improvement of lung functional. activities of daily living (ADL) was used as an objective criterion to evaluate the overall functional recovery of patients before and after treatment. After treatment, DT, DTF, and DM values improved significantly in both the affected and unaffected sides. The FVC, FEV1, FEV1/FVC, PEF, MVV, and ADL were all increased after the treatment. Combined treatment showed a stronger increase than that by RMT treatment alone. The study preliminarily shows that rTMS and RMT could improve lung functional after acute ischemic stroke. Stroke can cause severe dysfunction . Up to 5Respiratory muscle training (RMT) can improve the lung function of stroke survivors . A reviein vitro neuromodulation technique, rTMS has received much attention from researchers since its birth in 1985  The first incidence of ischemic stroke with the lesion at the anterior cerebral circulation confirmed by the head MRI scan. (2) Presence of pulmonary dysfunction  assessed by spirometry. (3) Without aphasia or cognitive dysfunction. (4) Vital signs stable. Exclusion criteria: (1) History of lung, chest and abdominal disease. (2) History of smoking. (3) Combined with myasthenia gravis or phrenic nerve palsy. (4) Combined with severe heart disease, liver cirrhosis, renal failure, severe systemic illness and history of malignant disease. (5) Metallic implants in the body.The study is a prospective, randomized, case-control study. The subjects were numbered in the order of inclusion and divided into control and treatment groups by random number tables. Patients voluntarily participated in the experiment and signed informed consent. The study was approved by the ethics committee of the Dushu Lake Hospital of Soochow University. Collect basic information of patients, including age, gender, stroke duration and affected side. Assess the patient’s ADL score. The above work is collected and analyzed by the same person.®, International Ltd., Warwickshire, UK) twice a day, 10 min each time in the morning and afternoon, with an interval of 3 h. The initial intensity was 30% of the maximum inspiratory pressure (MIP) and increased by 5% every week until the training intensity reached 60% MIP. Continue to practice with 60% MIP for 2 weeks.Both groups received conventional rehabilitation and treated by one therapist. Conventional rehabilitation training includes respiratory training and limb function training. Each time, for 40 min. Breathing training is to blow balloons and blow bubbles. Limb function training, such as muscle strength training, body position transfer, walking training, activities of daily life training, etc. The control group received threshold RMT  connected with a 75 mm figure-of-eight water-cooled coil (MCF-B65) for stimulation. The patient wore an International 10–20 system positioning cap. The stimulation site was located 3 cm lateral to the midline and 2–3 cm anterior to the auricular plane. The frequency of 5 Hz with the stimulus intensity was set at 30% above the unaffected side diaphragmatic motor threshold applied . PatientA portable diagnostic ultrasound system  connected with a 6–13 MHz linear array transducer was used to assess DT, DTF and with a 3.0–5.5 MHz transducer was used to assess DM in patients, bilateral chest wall.The participants in a supine position with spontaneous breathing. Take the linear array probe and place it on the right anterior axillary line. The probe is perpendicular to the 8th–9th intercostal space. If the diaphragm cannot be seen at this position, the probe can be moved up to the 7th–8th intercostal space. The diaphragm is a 3-layer structure under diagnostic sonography. The three-layer structure includes the hyperechoic area of the upper and lower layer , and the hypochoechoic middle muscular layer (composed of anechoic diaphragmatic muscle tissue and hyperechoic fascia). Move the cursor to measure the calm end-expiratory diaphragm thickness and the maximum end-inspiratory diaphragm thickness. Values were measured for 3 breathing cycles and averaged . The chaThe participants in a supine position with spontaneous breathing. A 2D mode was used to find the best exploration line for each hemidiaphragm. The right used liver as a window, while the spleen was used on the left hemidiaphragm. For right hemidiaphragm, the ultrasound probe was placed at the lower costal margin between the midclavicular and anterior axillary lines. Diaphragm movements were recorded in M-mode and the sampling line should be perpendicular to the diaphragm. Diaphragm movements were recorded during quiet breathing (QB) and deep breathing (DB) . The meaPulmonary function tests by standard spirometry. The Participants take seats. The main indicators of observation including FVC, FEV1, FEV1/FVC, PEF, and MVV using an Master-Screen spirometer .t-test was used for those that conformed to the normal distribution, and the non-parametric Wilcoxon rank-sum test was used for the data that did not conform to the normal distribution. The data before and after treatment in the two groups were compared, and the independent samples t-test was used for those that conformed to the normal distribution, and the non-parametric Wilcoxon rank-sum test was used for those that did not conform to the normal distribution. P < 0.05 representatives have significant differences.Used Spss20.0 for statistical analysis of all experimental data, values are presented as mean ± standard deviation (X ± SD). For the comparison of data before and after treatment within the group, the paired sample P > 0.05) , age, duration, affected side, ADL score, FVC, FEV1, FEV1 \/FVC, PEF, and MVV between the two groups (.05) see .P > 0.05).Before treatments, the DT, DTF, and DM were not significantly different between the two groups . Lung function was improved in both groups after treatment. After 8-week treatment, compared with the control group, the pulmonary function test indicators increased more significantly in the treatment group  can improve the lung function in hemiplegic patients with acute ischemic stroke. Cohen found that diaphragm deviation was significantly positively associated with inspiratory volume in hemiplegic patients . In our Volitional breathing is controlled by the brain center and located on both sides of the primary motor cortex . StudiesPulmonary rehabilitation is a central part of the treatment of patients with chronic respiratory diseases . Stroke RMT mainly improves the lung function by strengthening peripheral respiratory muscle strength. Transcranial magnetic stimulation can act on the central nervous system and has been widely used. In our paper, we adopted the central plus peripheral mode of respiratory function training to treat stroke patients. The results showed that RMT combined with rTMS could obtain better therapeutic effect.Ultrasonography can dynamically observe the respiratory muscle function in real time. Ultrasonic probes with different shapes and resolutions can be used to observe the shape and contraction of diaphragm and auxiliary respiratory muscles during calm and deep breathing, including the position, shape, motion amplitude, motion time, acceleration of diaphragm and the thickness changes before and after contraction of diaphragm. Therefore, Ultrasonography was used for evaluation and measurement in this study.Study has shown that the critical time to begin recovery after stroke is in the first 30 days after stroke , with thThis study also has some limitations. On the one hand, the sample size is not large enough and the research cycle is not long enough. On the other hand, whether rTMS is effective for PD in patients with chronic hemiplegia has not been verified. In the future, we can further study the therapeutic effect of rTMS on patients with chronic hemiplegia. However, this study confirms the therapeutic role of rTMS, which can be used for the rehabilitation of lung function.The rTMS combined with RMT can effectively improve the lung function in early hemiplegia patients, which is more effective than RMT alone. Improvement of lung function may be attributed to increased local blood flow during stimulation. Meanwhile, the changes both before and after treatment in DT, DTF, and DM measured by musculoskeletal ultrasonography (MSUS) are consistent with the lung function and can be used as objective indicators in response to lung function. At the same time, the changes of ultrasound index, such as DT, DTF, and DM, as well as lung function index FVC, FEV1, FEV1/FVC, and PEF were consistent with the improvement of patients, activity of daily living. Therefore, we believe that the improvement of pulmonary function can further improve the activity of daily living of stroke patients.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Department of Physical Medicine and Rehabilitation Dushu Lake Hospital of Soochow University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Accuracy, Recall and F-measure were: (1) 95%, 95% and 0.95 for E. coli; (2) 91%, 91% and 0.90 for P. aeruginosa; and (3) 84%, 86% and 0.85 for S. aureus. Conclusions: Evidence related to the time-saving potential of the system was achieved; the time spent on quantification tasks of plates with a high number of colonies might be reduced to a half and occasionally to a third.Background: Accurate quantitative analysis of microorganisms is recognized as an essential tool for gauging safety and quality in microbiology settings in a wide range of fields. The enumeration process of viable microorganisms via traditional culturing techniques are methodically convenient and cost-effective, conferring high applicability worldwide. However, manual counting can be time-consuming, laborious and imprecise. Furthermore, particular cases require an urgent and accurate response for effective processing. Methods: To reduce time limitations and discrepancies, this work introduces an image processing method capable of semi-automatically quantifying the number of colony forming units (CFUs). This rapid enumeration technique enables the technician to provide an expeditious assessment of the microbial load of a given sample. To test and validate the system, three bacterial species were cultured, and a labeled database was created, with subsequent image acquisition. Results: The system demonstrated acceptable classification measures; the mean values of  The assessment of bacterial growth (enumeration) is one of the main, basic and frequent requisites when addressing studies on microorganisms. Evaluation of food and drug safety and the control of environmental quality are examples of fields that rely on the measurement of microorganism survival and proliferation rates. Due to its importance, this evaluation has been and will continue to be widely employed worldwide on a daily basis. Therefore, the improvement of the available techniques and practices is appreciated. The abovementioned processes often require the counting of bacteria in a unit volume of bacterial broth, and there are several methods available that can achieve it in a direct or indirect way: membrane filtration, turbidity, metabolic activity, dry weight and the viable cell counting as indirect measures, and microscopic counts and cytometry, as direct measures.Of these methods, the viable cell counting method is the most cost-effective, easily-accessed method to evaluate culturable microbial loads. When performing this method, the viable number of bacteria can be obtained by counting the number of colonies on the plate. However, the manual counting of colonies is laborious, time-consuming and error-prone. In addition, it is not immediate, requiring the incubation period for colony growth. Automated bacterial counters are also available as fully automated counting systems but can be highly expensive and not affordable for small labs, or multiple instruments may be required for large facilities and research centers ,2.Image processing techniques are thus seen as a potential option for performing the counting tasks. Several reported studies do exist in the literature reporting image analysis in microbiology. Some use computer image analysis (CDIA) as one of the operations for a more general procedure called computer digital image processing (CDIP) . AccordiSome of the outlined existent solutions exhibit excellent accuracy results and are seen as potential solutions that contribute to the laboratory automation and efficiency. However, most of them reveal one of two flaws: excessive user-provided action or information, and statistical relevance, expressing the need of being tested in larger and significant databases, resembling the actual and demanding laboratory environment. Furthermore, caution should be taken when interpreting the results of colony-forming units (CFU) in Petri plates, making sure the microbial species under study grow as individual cells and do not form aggregates in natural conditions. However, even in such cases, partial aggregation may be induced by laboratory practices and manipulations . MoreoveWith this work, we intended to complement the knowledge by developing a fast software capable of semi-automatically quantifying the number of colonies in Petri plates with very low user-provided action and with high levels of classification indexes for a selected set of bacterial species.In terms of structure, this paper is organized in four main sections. In In this section, all developed procedures are described. Primarily, the microbiology methods performed to acquire the image database are detailed, and subsequently the flowchart of the enumeration process is presented step-step.Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus, were used for the image database attainment. These were provided from the internal collection of CINATE  and were cultivated aerobically at 37 °C.Three bacterial species, ™ and Trypto-Casein Soy Agar™, both from BIOKAR Diagnostics©, Allonne, France.Two general-purpose media were used to grow the 3 bacterial species, Brain-Hearth Infusion BrothFrozen cultures of the 3 bacterial species cryopreserved in mini-cryovials at −80 °C, were thawed via gentle agitation in a water bath that was set to the normal growth temperature of each bacterial species, with prior decontamination of the outer surface using 70% ethanol. The entire content of each vial was transferred to sterilized test tubes containing the growth media. The 3 cultures were incubated overnight at 37 °C. Cultures were then streaked onto agar plates to produce isolated/purified colonies. With evidence of isolated and pure colonies and using the inoculation loop, a single colony was collected and transferred to a sterilized test tube containing 10 mL of fresh media. The new pre-inoculum was incubated overnight under 37 °C. Subsequently, 100 μL were transferred from the preceding solution to a 10 mL test tube containing fresh media and allowed to grow overnight at 37 °C—the final inoculum was achieved.g, each time resuspended in 1 mL of a Ringer solution previously prepared. The content of the 3 microorganism solutions was then transferred to sterilized test tubes containing 9 mL of Ringer, and serial decimal dilutions were made.After mixing, 1 mL of the inoculum was added to a sterilized eppendorf and a centrifugation step was performed. The solutions were centrifuged twice for 10 min at 5000× For enumeration; the spread plate method was employed; 100 μL of each dilution were pipetted onto the center of the surface of the sterilized agar plate and spread. All samples used were plated in triplicate; the plates were then incubated overnight at 37 °C . The developed algorithm performs three major steps: (1) preprocessing; (2) processing; and (3) enumeration. Before the preprocessing begins, the user is asked to input a parameter, i.e., the minimum size of a colony. This action is performed by an interactive placement of an ellipse around the minimum-sized colony of the plate. It is worth acknowledging that during the overall process, this is the only occasion when the user is asked to input information. Therefore, the computed result is compared with the real labels from each image, and consequently a set of classification indexes are computed. The process is outlined in The database was first loaded in MATLABThis task aims to produce the most satisfactory and noise-free images possible to further the segmentation in the following stage see .RGB  images to grayscale images:All database raw RGB color images have been converted to grayscale images by using the National Television System Committee (NTSC) formula : 0.299 *Median Filtering:This technique is widely applied in image processing algorithms for reducing the noise without a contrast loss ; a 9 × 9Top-Hat Filtering:To correct possible uneven illumination, which leads to uneven contrast, a top-hat transform with a 200-pixel radius and disk-shaped single structuring element was performed. This morphological filter computes the image opening and then subtracts the image result from the input image , in thisContrast Adjustment:p the current pixel value, In this step , the imahe image .(1)∑pnpExtended-Maxima Transform:Another normalization process occurred; the extended-maxima transform was applied, where the intensities of points inside the foreground regions were changed to show the distance to the closest boundary from each point. First the regional maxima were found; objectively, 80 pixel-region maxima were computed and with 8-connected pixels, i.e., the neighborhood of a pixel is the adjacent pixels in the horizontal, vertical or diagonal direction; subsequently, the transformation is performed see .Area Opening:The intent of this stage was the removal of small objects from the image  the pointwise minimum between the input image and the marker image is computed: -Watershed TransformFinally, the watershed transform is performed using the watershed function, and an image with the segmented colonies is exhibited .Area FilteringAt this stage, it is necessary to remove artifacts and outliers , it is considered 100% precise even if the plate itself contains more than 326 colonies .0 to 300 , thus plE. coli, P. aeruginosa and S. aureus images were separately analyzed to evaluate the accuracy of the process concerning each species. To access the overall accuracy, the respective data was divided into two major classes: [0–300] and more than 300.In accuracy on the “more than 300” group. From E. coli should be highlighted, evidencing values of 95%. In addition, From the analysis of accuracy and recall obviously affect statistical results, where a large number of false positives and false negatives will lower accuracy and recall, respectively. In particular in this work, the false positives resulted from: condensation droplets on the plates’ walls, clumps derived from less effective spreading, agar defects in the Petri-plates, a small round-shaped mark inherent on each plate and residual noise resulting from incomplete elimination during the processing. The causes for the false negative cases are due to colonies located exactly on the rim of the plate which are eliminated during processing, and concatenated colonies are sometimes wrongly excluded because of their non-circularity or exaggerated area. Additionally, during the process the only input required of the user, i.e., selection of the minimum colony size, (at the beginning of the computation). If the colony is missed or wrongly selected, inconsistencies could occur in specific situations. Summarily, the enumeration system displays consistent accuracy which can be further reinforced by overcoming the abovementioned limitations.The parameters As can be seen in ® i5 CPU running at 2.4 GHz. The execution times of the overall process ranges from 36 s to 44 s in 30 and 300 colonies, respectively. Moreover, the speed of the developed algorithm hinges on the processing capacity of the computer used and on colony size. However, the below-presented estimation was obtained based on average values between minor and major computation time intervals. Speed tests were executed on an IntelBased on As can be seen in E. coli, P. aeruginosa and S. aureus within acceptable rates of accuracy. Regarding values of accuracy, recall and F-measure for: (1) E. coli, the mean were 95%, 95% and 0.95, respectively; (2) P. aeruginosa were 91%, 91% and 0.90, respectively; and (3) S. aureus were 84%, 86% and 0.85, respectively. Thus, according to the results, E. coli is the most-efficiently-detected strain. The overall and mean values of accuracy, recall and F-measure were 91%, 92% and 0.92; 88%, 90% and 0.89, as well as 82%, 86% and 0.84, categorically split in ,  and  intervals. The results of the more than 300 colonies category were very satisfactory with a mean accuracy value of 94%. In addition, E. coli, P. aeruginosa and S. aureus are round in shape; therefore, the proposed counting approach can be applied to any bacterial strain that develops round-shaped colonies. Dry cracks in the agar, poorly performed spreading techniques and illumination inconsistencies might lead to difficulties in the processing of the images and should therefore be avoided during culturing and image acquisition. However, since during image acquisition the Petri-plate was illuminated using back-lighting, images acquired from plates with non-transparent media might not be easily captured by the employed apparatus. Furthermore, the image processing procedures were developed based on features of colonies with transparent media; therefore media with diverse colors and opacity might yield unsatisfactory outcomes.There are numerous commercially available instruments that perform plate enumeration with various advantages: saving costs by reducing enumeration time, automatic documentation, reproducibility, and operator independence. However, despite the advantages of automated image analysis, it is still necessary to invest in an expensive, high performance commercial system, or to acquire expert knowledge in image processing. So, this work proposed and validated a semi-automated colony-counting low-cost system with low user-provided action. It was demonstrated to be capable of counting the number of


The purpose of this study is to investigate pesticide residues in the imported and domestic tea sold in Turkey and to detect their compliance with maximum residue limits (MRL) and Acceptable Daily Intake (ADI). A total of 79 samples were analyzed by using LC-MS/MS and GC-MS devices with AOAC 2007.01 method to investigate 603 pesticide residues. According to the results, pesticide residues were found in a total of 28 tea samples. Pesticide residues were found in the countries of origin at the rates as follows: Iran (100%), India (33.3%) and Sri Lanka (17.3%). No pesticide residue was detected in the tea produced in Turkey. The compounds such as Diuron, Ethion, Cypermethrin, Thiacloprid, Thiamethoxam, Fenpyroximate, Acetamiprid, Imidacloprid, Flubendiamide, Deltamethrin and Hexythiazox were detected in positive samples. Seven types of pesticide residues exceeded the MRL determined by the Turkish Food Codex for 15 types (53.57%) for 28 samples with pesticide residue detected. Additionally, 4 types of pesticide residues were determined to exceed the ADI determined by the Codex Alimentarius for 13 (46.42%) of 28 samples with pesticide residue detected. These results have showed that the imported tea entering Turkey was not adequately analyzed in the customs control laboratories or the maximum residual limits were not clearly determined. Camellia sinensis. Tea, which is one of the most important beverages beside water, has a history of 5000 years. Approximately two-thirds of the world’s population consume tea [Tea is obtained from the leaves of the plant known as sume tea ,2. Tea, sume tea . The teasume tea . India, sume tea .Tea growing countries are generally located in the equatorial and near-equatorial regions. The lack of winter season and the humid and hot weather of these regions may lead to infestation, bacterial and fungal diseases in the tea plant. Tea manufacturers use pesticides and herbicides to kill pests, prevent diseases, remove weeds in the tea plantation to supply high quality tea products . Insect The tea plant has benefits such as antioxidant, antimicrobial, anticancer and anti-inflammatory effects on human health, lowering cholesterol and blood pressure and reducing the risk of cardiovascular disease ,9. HowevVarious methods are used to determine pesticide residue in foods. However, recently the QuEChERS method (Fast Easy Cheap Effective Robust and Safe) is fast becoming one of the most popular dispersive solid phase extractions (d-SPE) methods in food safety. The QuEChERS approach for ultra-trace identification of pesticides, mycotoxins, and other organic chemicals in food matrices has been widely recognized as accurate and highly efficient ,15. TherNot all pesticides that contaminate the tea plant may pass into the tea brewing. Actual exposure to pesticides depends on the number of residues that leach into the tea brew. Therefore, when determining the pesticides in the tea plant, the Brewing Factor should be considered to determine the amount that will pass to the consumer .Our aim in this study is to determine the risk assessment for consumer safety with maximum residue limits by determining the suitability of pesticide residues in Iran, Sri Lanka, India, Iraq, Syria, and Turkey teas sold and consumed by the public in Turkey. Scope of work: The answer to the question of "how reliable is the tea from different countries of origin consumed in the field?" will be sought in the sample from Turkey.Tea samples were obtained by buying from importing companies, from companies that package and wholesale imported teas for distribution, and from tea markets. It was obtained directly from the people living in the villages, especially in the Iran border region. The number of samples to be taken was adjusted according to the population density and consumption frequency of the provinces and the approximate share rates of the countries in the market. The number of samples collected was 79. Iran, Sri Lanka, India, and Turkey were the countries of origin of the samples. In addition, consisted of Sri Lankan origin the black tea that came to Turkey via touristic routes from Germany, Iraq, Syria, and Kuwait. A total of 79 collected samples were distributed by provinces as follows; Mardin; 7 samples, Sirnak; 3 samples, Van; 15 samples, Diyarbakir; 13 samples, Siirt; 9 samples, Batman; 4 samples, Gaziantep; 14 samples, Kilis; 4 samples, Sanliurfa; 10 samples. The number of samples collected was distributed by the countries of origin as follows; Sri Lanka; 52, Iran; 18, Turkey; 6 and India; 3. The samples were brought to the laboratory where the analysis was performed. Tea samples were extracted and made ready for LC-MS/MS and GC-MS within the same day. The analyses were carried out by Delta Laboratory Sist. Tezg. San. Tic. Sti. laboratory which is accredited by the European Union. The AOAC 2007.01 method was used for the analysis. The unit is based on mg/kg . Each sa®, Cirta Lab. SL, Madrid, Spain) for 7 minutes. Then, QuEChERS salt  was added and shaken in a shaker for 7 minutes. The extract was centrifuged at 3700 rpm for 5 min. After this process, 3 mL of the supernatant was taken, transferred to a 15 ml centrifuge tube containing 150 mg of anhydrous calcium chloride and 150 mg of PSA (primary secondary amine), and centrifuged again at 3700 rpm for 5 minutes. A total of 30 μL of 5% formic acid in acetonitrile was added to the extract. From the supernatant, 0.45 μL was taken and filtered, and then given to the device. Extraction of tea samples was performed by modifying the QuEChERS sample preparation procedure ,18. AfteThe analysis of pesticide compounds by LC-MS/MS was performed using a Nexera model Shimadzu HPLC attached to a dual MS (triple quadrupole-mass spectrometry) device. The LC-MS/MS system consists of a combination of UHPLC (Shimadzu Nexera model) device and LC-MS (Shimadzu 8040 model triple quadrupole mass spectrometer) device. The liquid chromatography system consists of the LC-30 AD model gradient pump, the DGU-20A3R model degasser, the CTO-10ASvp model column oven and the SIL-30AC model autosampler. Pesticide compounds were tried to be determined in the sample by using the MS Library (SANTE/11312/2021 identification kits were used according to the document) of the device and compared with the compounds registered in the library. The connected equipment and operating conditions are set as follows: Equipment: Two LC-20AD pumps, DGU-20A3R degasser, CTO-10ASVP column oven, SIL-20AC autosampler. Column Information: C-18 Intertsil ODS-4  analytical column temperature: 40 °C Mobile phase: A , B . The system delivered a constant solvent flow of 0.3 mL/min and the volume of injection was 2 μL. The elution gradient contains ultrapure water (mobile phase A) and acetonitrile (mobile phase B). To achieve a better chromatographic separation and to facilitate ionization, 10 mM ammonium formate and 0.1% formic acid were added to mobile phase A. The following UHPLC gradient elution program was applied for optimum separation: 5–20% B (0–10 min s), 20% B (10–21 min s), 20–50% B (22–35 min s), 95% B (35–40 min s), 5% B (40–50 min s). 10-C26 n-alkane series  and compared with the literature data.Some of the pesticides in the tea samples are polar and dissolve in water. Since some of them have non-polar structure, they are included in the class of solutes in non-polar solvents such as hexane and chloroform. Therefore, while LC-MS device is used to analyze polar pesticides, GC-MS device is preferred for nonpolar pesticides. Shimadzu GC-2010, QP-2010 system equipped with triple quadrupole system for separation of pesticide compounds, Shimadzu, Kyoto, Japan DB-FFAP capillary column  was used. The injection temperature of the device was set to 250 °C and the MS ion source to 200 °C. Mass spectrometry was used to scan between 33–650 mass/load (m/z) at 1 second intervals. The temperature program for separation was initiated at 40 °C for 2 minutes and then increased to 240 °C at the rate of 5 mL/min and adjusted for 6 minutes at this temperature. A flow of 1 mL/min was achieved in the column using He as the carrier gas. Wiley 7 and NIST 147 programs in the MS library were used to define the peaks. The retention indices of the defined peaks were determined using CFor the optimization process, in order to introduce each analytical standard to the devices, the optimized voltage values that provide the ion transitions and fragmentation conditions according to their molecular weights were determined and MS libraries were created in the devices . According to the "Turkish Food Codex Regulation on Maximum Residue Limits of Pesticides", the amount of pesticide residue in tea samples should not exceed the maximum residue limit (MRL) of 0.01 mg/kg . AccordiIt was determined that the pesticide residue in the tea samples which were produced in Sri Lanka and sold in Mardin was Diuron compound and that 2 of 4 samples with pesticide residue exceeded the maximum residue limits (MRLs). These pesticide residues were seen to be compatible with the Acceptable Daily Intake (ADI) of the Codex Alimentarius for pesticides. It was found that pesticide residues in the imported tea samples which were sold in Van and were all produced in Iran were Diuron, Ethion, Cypermethrin Thiacloprid, Thiamethoxam, Fenpyroximate, Acetamiprid, Imidacloprid and Flubendiamide compounds and that all the samples with pesticide residue exceeded the MRL levels. Moreover, the pesticide residues in eight samples were found to exceed the ADI levels. These pesticides were understood to be Acetamiprid, Cypermethrin, Thiacloprid and Thiamethoxam. Diuron compound was detected in one tea sample from Sri Lanka, packaged in Kuwait, brought into Sirnak province using touristic routes and sold in the stores there, and its amount was found to be at the MRL and ADI level limit. Deltamethrin, Thiacloprid and Thiamethoxam compounds were found to be present in one tea sample produced in Sri Lanka and sold in Siirt, and these residues were detected to be below the MRL and ADI level. Additionally, Diuron compound was observed in one tea sample produced in Iran and sold in Siirt and was found to exceed the MRL level. It was also found that a pesticide compound called Thiacloprid detected in one sample exceeded the ADI level.Deltamethrin, Thiacloprid and Thiamethoxam compounds were detected in one tea sample produced in Sri Lanka and sold in Diyarbakir and the amount of all compounds were found to be above the MRL level. Additionally, Hexythiazox, Thiacloprid and Thiamethoxam pesticides were found to be present in another tea sample produced in Iran and sold in Diyarbakir, and other two compounds, except Hexythiazox, were determined to exceed the MRL level. In addition, Thiacloprid and Thiamethoxam in two samples were found not to be compatible with the ADI levels.Ethion, Thiacloprid and Thiamethoxam compounds were detected in one tea sample produced in Iran and sold in Batman, and all the samples were found to be above the MRL level. Further, Thiacloprid and Thiamethoxam in one sample were found not to be compatible with the ADI levels. Ethion, Thiacloprid and Thiamethoxam residues were found in one tea sample produced in India and packaged in Gaziantep; Ethion and Thiamethoxam compounds were understood to exceed the MRL level. Additionally, Ethion compound was found in one tea sample produced in Sri Lanka and packaged in Gaziantep, and it was determined to be at the MRL level limit. In addition, Thiacloprid and Thiamethoxam in two samples were found not to be compatible with the ADI levels. Diuron compound was detected in one tea sample originating from Sri Lanka and purchased in Sanliurfa province. However, the amount of this compound was found to be below the MRL and ADI levels.We brought the analysis of pesticides in the imported tea consumed in Turkey into . LiteratDehghani et al.  conducteAccording to a report issued by the European Tea Committee on 4 January 1999, it was claimed that the exported Indian tea also contained important levels of pesticide residues . SeenivaAs a result of our analysis, the pesticide compounds in the positive samples were observed to be Ethion, Diuron, Cypermethrin, Thiacloprid, Thiamethoxam, Fenpyroximate, Acetamiprid, Imidacloprid, Flubendiamide, Deltamethrin and Hexythiazox. Many of these compounds were found to seriously threaten human life in literature studies ,24. As a"Ethion" compound, a pesticide prohibited for use by the Turkish Food Codex, which was found in 12.65% of the tea samples we collected from the field, was reported to be carcinogenic and lead to especially liver cancer and leads especially to liver hepatitis [epatitis ,26. Althepatitis ,28. Cypeepatitis ,30. FortThiamethoxam is a commercially important neonicotinoid insecticide that is absorbed and active against chewing pests. It has been reported that Thiamethoxam is not a mutagen and is not toxic to mammals and does not pose a carcinogenic risk to humans ,32. FenpAcetamiprid is a strong neonicotinoid insecticide. Animal studies showed that it had low toxicity to mammals. Despite its extensive use, human exposure leading to toxicity is extremely limited . HoweverDeltamethrin is a broad-spectrum synthetic pyrethroid insecticide and acaricide commonly used for agricultural and veterinary purposes. However, human and animal exposure have been reported to cause hepatonephrotoxicity , leadingIn 2013, the European Food Safety Authority (EFSA) announced the results of analysis of pesticide residues found in food in the European Union (EU). According to the report, 5.1% of the sampled tea, coffee and herbal infusions were above the accepted maximum residue limits . MRL valAccording to the Annex 4 of the Turkish Ethion is one of the prohibited pesticides . AlthougThere are also Ethion compounds under the prohibited pesticides for use in Turkey specified in Annex 4 of the Turkish Food Codex Regulation on Maximum Residue Limits of Pesticides. Although the use of Ethion is prohibited, this compound was found in 10 of 29 samples with pesticide residue according to the results of the analysis. The countries of origin where Ethion is found in the sample are Sri Lanka, India, and Iran. This result has showed that the imported tea entering Turkey was not adequately analyzed at the customs control points. In addition, Sri Lanka is the world’s largest tea producer and exporter country. Teas produced in Sri Lanka are consumed almost all over the world. The fact that a banned pesticide such as ethion was detected in the teas of this country; moreover, above the MRL limits, is a remarkably interesting result that should be considered. Considering this result, the relevant authorities in Sri Lanka should reconsider the trade of this pesticide. Compared with the samples of other countries, the individual maximum residue limit for each pesticide compound is determined in many countries. Still, it has been seen to be limited to a general limitation of 0.01 mg/kg in our country. Thus, the pesticide MRL in tea does not have a general limit of 0.01 mg/kg for all pesticides but needs to be individually determined for each compound. In addition, these results showed that teas originating in Iran contain serious amounts of pesticides. Therefore, its consumption can be dangerous for health. We consider this situation to be an important warning for both Iranian people and other people who consume Iranian tea.


Aim: A network meta-analysis (NMA) was performed to determine the effects on the exercise capacity, measured by the 6 MWT, of patients with COPD of (i) different physical activity interventions and (ii) supervised or unsupervised programs. Methods: A literature search was carried out from inception to April 2022. Randomized controlled trials of the effectiveness of physical activity on exercise capacity in patients with COPD were included. The risk of bias was assessed using the Cochrane Risk of Bias (RoB 2.0) tool, and the Grading of Recommendations, Assessment, Development, and Evaluation tool (GRADE) was used to assess the quality of the evidence. A pairwise meta-analysis for direct and indirect effects was carried out. Results: A total of 41 studies were included in this NMA. The highest effects were for urban training pulmonary rehabilitation (PR) programs  versus the control group. For supervised and unsupervised PR and home-based PR programs, the highest effects were found for supervised PR  versus the control group. Conclusions: PR implemented with urban circuit training should be considered the most effective strategy to improve exercise capacity in patients with COPD. Supervision of the programs improves exercise capacity. Chronic obstructive pulmonary disease (COPD) is currently defined as a respiratory disease characterized by persistent symptoms and chronic airflow limitation, whose main cause is tobacco. Airflow limitation usually manifests as dyspnea and is usually progressive. COPD often occurs with other respiratory symptoms, such as chronic cough accompanied or not by expectoration and is characterized by the presence of exacerbations and the frequent presence of comorbidities that can contribute to the severity in some patients . In receSymptoms that characterize COPD include decreased exercise capacity and dyspnoea  as well In recent years, the evaluation of the exercise capacity of patients with COPD in clinical and research settings, including simple gait, has increased. The most widely used test, the 6 min walk test (6 MWT), measures the maximum distance covered at the highest possible intensity in 6 min ,14,15 anTo improve functional capacity and dyspnoea, physical training is considered an essential component of pulmonary rehabilitation (PR) in patients with COPD ,20. HoweThus, the main objective of this network meta-analysis (NMA) was to determine the effects of different physical activity interventions on the exercise capacity, as measured by the 6 MWT, of patients with COPD. In addition, we aimed to determine whether supervised or unsupervised programs could be more effective in improving exercise capacity in patients with COPD.The methodology of this NMA followed the Preferred Reporting Elements for Systematic Reviews that Incorporate Network Meta-Analysis  22] and and22] aTwo independent reviewers (S.P. J and C.A.-B.) conducted a literature search of PubMed, SCOPUS, WoS, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, the Cochrane Central Register of Systematic Reviews, and the Web of Science databases from inception to April 2022.The aim of the search was to identify published randomized clinical trials (RCTs) on the effect of physical activity programs on exercise capacity, measured as the 6 MWT, of patients with COPD. The search strategy included the following relevant terms combined using Boolean operators: “physical activity”, “pulmonary rehabilitation”, “yoga”, “active mind–body movement therapies”, “aerobic exercise”, “exercise capacity”, “6 MWT”, “COPD”, and “chronic obstructive pulmonary disease”. The full PubMed database search strategy is available in the This NMA included studies on the effectiveness of different types of exercise in improving the exercise capacity, as measured by the 6 MWT, of patients with COPD.For the selection of studies, the following inclusion criteria were defined: (a) type of studies: RCTs; (b) population: adults with COPD, at any stage of disease; (c) intervention: any type of physical activity intervention defined as repeated bouts of exercise over time aimed at improving physical fitness and involving multiple sessions over several weeks, months, or years of training; (d) outcome: change in exercise capacity, measured using 6 MWT. No language limitation was applied.Studies were excluded if they included (a) patients suffering from other respiratory pathologies, including COPD, where data from patients with COPD could not be extracted separately; (b) interventions where physical activity was combined with other health interventions; (c) studies with a lack of data to estimate the effect of the interventions. Finally, studies were excluded when they were not RCTs, as well as those RCTs with a lack of data to estimate the effect of the interventions.Data from the included RCTs were extracted using an ad hoc form, including information on the author, country, sample size, population characteristics , intervention characteristics , type of physical activity performed by the intervention group, and the activity performed by the control group.Two authors (S.P. J and C.A.-B.) independently conducted the literature search and data extraction. Discrepancies were resolved by a third reviewer who was responsible for resolving any disagreements (I.C.R.).The exercise interventions included in the selected studies were categorized as active mind–body movement therapies (AMBMT), combined training (COMB), endurance (END), pilates, PR, home-based pulmonary rehabilitation (HMPR), and urban training. (i) AMBMT includes interventions  supervised and performed as a form of the PR program. These interventions are based on strength and flexibility exercises combined with the patient’s deep and controlled breathing. (ii) COMB includes training programs that combine two interventions in the same session (strength and endurance training). (iii) END refers to aerobic training . (iv) Pilates intervention is a supervised pilates training program. (v) PR programs consist of comprehensive programs including different components, such as warm-up, strength exercises, aerobic exercise, breathing, and health education. (vi) Self-monitored HMPR is an alternative to outpatient rehabilitation ,25 in whIn addition, we categorized the interventions into supervised and unsupervised, where supervised referred to those programs implemented in a hospital under the supervision of health professionals; in the case of HMPR, programs that were supervised either by telephone or via home visits by the health professional, including booster sessions.The Cochrane Collaboration tool to assess the risk of bias (RoB2)  was usedTwo investigators (S.P. J and C.A.-B.) independently performed the risk of bias assessment of the included studies. Disagreements were resolved by consensus or discussion with a third reviewer, I.C.R.To evaluate the quality of the evidence as well as to make recommendations, the Rating of Recommendations, Evaluation, and Development evaluation (GRADE) tool was used . The ratTo carry out the analysis, we followed the detailed steps. We started to evaluate transitivity by testing whether the clinical characteristics of the included samples were similar at baseline. We assumed that the populations included in these studies were similar in their initial distribution of potential effect modifiers .To assess the distribution of the available evidence, we used a network geometry graph, with the size of the nodes representing the number of trials included for each intervention proportionally and the width of the continuous line connecting the nodes corresponding to the number of trials that compare directly the two interventions .Consistency was assessed by checking whether the intervention effects estimated from direct comparisons were consistent with those estimated from indirect comparisons.Finally, we used the relative rankings of the treatments to establish the ranking among the exercise interventions, which we graphically represented using rankograms. Additionally, we estimated the area under the cumulative ranking (SUCRA) for each intervention, in which each intervention could obtain a score for SUCRA between 0 and 1, 0 being assigned to the worst intervention and 1 to the best one ,29.2 statistic, which was considered not important (I2: 0–40%), moderate (I2: 30–60%), substantial (I2: 50–90%), or considerable (I2: 75–100%); likewise, the corresponding p-values were considered [2 statistic. An estimate of τ2 of 0.04 was interpreted as a low degree of clinical relevance of heterogeneity, 0.14 as moderate, and 0.40 as substantial [Subsequently, the DerSimonian–Laird random-effects method was used to compute standard paired meta-analyses for direct comparisons between the interventions and the control/no intervention . Furthernsidered . Finallystantial . A foresTo assess the robustness of the estimates and to detect whether any particular study accounted for a large proportion of the heterogeneity, we performed a sensitivity analysis. Finally, Egger’s regression asymmetry test was used to assess publication bias. For this purpose, the statistical software StataSE, version 16.0 , was used.Following similar procedures, we conducted a second NMA to determine whether the effectiveness of supervised and unsupervised PR and HMPR programs on the exercise capacity of patients with COPD was affected by the many differences between them.p-values, or t-statistics to calculate the SD.For all of the analyses, in cases where more than one study provided data referring to the same sample, the study reporting the most detailed data or with the largest sample size was included. Following the Cochrane Collaboration Handbook recommendations, when data on the standard deviation (SD) of change in the functional capacity from baseline were missing, estimates were based on standard error (SEs), 95% confidence intervals (CIs), The search strategy retrieved 14,177 studies, of which 41 were included in this network meta-analysis . The chaThirteen studies were assessed as having a low risk of bias, two as having some concerns, and twenty-six as having a high risk of bias. Considering each specific domain, the randomization process domain was scored as low risk in 68.3% of the studies and as some concern in 29.3%. The deviations from the intended interventions domain were scored as low risk in 90.2% of studies and as some concern in 9.8%. The missing outcome data domain was scored as low risk in 80.5% of studies and as high risk in 19.5%. The measurement of the outcome domain was scored as a high risk of bias in 53.7% of studies and as low risk in 46.3%. The selection of the reported result domain was scored as some concerns in 12.2% of studies and as low risk in 87.8% .Additionally, the GRADE results are available in After the evaluation of transitivity, the transitivity assumption was met for all comparisons, including participants with similar baseline characteristics  .The network diagrams showed the relative amount of evidence available for exercise interventions for exercise capacity measured by the 6 MWT among patients with COPD. The NMA involved 18 direct comparisons for exercise capacity. Most interventions had at least one direct comparison with a control.When analyses were limited to supervised and unsupervised PR and HMPR programs, the largest effects were found for supervised PR  and supervised HMPR  versus the control group .For the 6 MWT exercise capacity score, the highest SUCRA was observed for PR + URBAN (82.5%) and pilates (73.6%) .2 = 89.6, τ2 = 0.3080). Furthermore, AMBMT vs. control showed substantial heterogeneity . Direct comparisons for HMPR and PR vs. control showed substantial heterogeneity . All other direct comparisons showed no significant heterogeneity (p > 0.05) (AMBMT vs. HMPR showed considerable heterogeneity for exercise capacity (I > 0.05) .p = 0.526) and combined vs. control (p = 0.441) tests for exercise capacity  as well as distance walked when assessing an individual’s walking capacity .Several reasons could explain the effectiveness of exercise interventions on exercise function in patients with COPD. Previous research has associated decreased peripheral muscle strength  with reductions in ventilatory capacity, which independently contribute to reductions in exercise capacity . PeripheThis study has some limitations that must be acknowledged. First, it should be noted that we could not consider the intensity of the exercises analyzed because this information was missing in most of the studies. Second, this study cannot provide recommendations on the appropriateness of each type of exercise based on the duration, severity, and progression of the disease due to the heterogeneity among the studies reviewed. Third, the overall moderate risk of bias in the included studies was mainly due to the lack of information on the bias of the intended interventions . Fourth, the findings should be considered with caution due to the limited number of studies for some interventions, including some of the most effective ones, such as pilates and PR + URBAN. Fifth, within the pulmonary rehabilitation intervention, not all studies follow the quality standards according to the modern concept of pulmonary rehabilitation programs. Sixth, we could not determine the long-term effects of the interventions or adherence to the programs after the completion of the studies.In summary, PR programs implemented with urban circuit training seem to be the most effective type of intervention for improving exercise capacity as measured with the 6 MWT. In addition, pilates interventions have shown similar effects on exercise capacity when both interventions are supervised by physiotherapists. Comprehensive PR programs, preferably implemented within urban exercise training programs, should be considered a low-cost therapeutic strategy to improve exercise capacity in patients with COPD, improving their functional capacity. Our results are based on evidence from RCTs and represent a comprehensive research effort aiming to synthesize the best available evidence on the type of exercise intervention that is most effective in improving exercise capacity in these patients. However, more studies are needed to provide evidence on the effectiveness of exercise by disease severity as well as exercise intensity to improve the effectiveness of exercise recommendations for increasing the exercise capacity of COPD patients.


However, the association between triglycerides and PSA remains unclear and complicated. Hence, we evaluated the correlation between triglycerides and PSA based on the U.S. National Health and Nutrition Examination Survey (NHANES) database. (2) Methods: A total of 2910 participants out of 41,156 participants fit into our study after conducting the screening from the 2003 to 2010 NHANES survey. Serum triglycerides were the independent variable of our study, and PSA was the dependent variable; (3) Results: In our study, the average age of chosen participants was 59.7 years (±12.7). After adjusting for covariates, the result indicated that for each additional unit of serum triglyceride (mg/dL), the PSA concentrations were reduced by 0.0043 ng/mL  with a statistical difference. Furthermore, we used machine learning of the XGBoost model to determine the relative importance of selected variables as well as constructed a smooth curve based on the fully adjusted model to investigate the possible linear relationship between the triglyceride and PSA concentrations. (4) Conclusions: The serum triglyceride is independently and negatively correlated with PSA among American males, which may make it hard to detect asymptomatic prostate cancer and diagnose at an advance stage with higher triglycerides due to detection bias. In 2020, prostate cancer (PCa) was recorded as the most common cancer diagnosed in men, accounting for 26%, and was the second cause of the estimated death of 34,130 cases in males ,6,7. InoAn increasing number of studies strongly indicate that lipid and glucose metabolism play a critical role in prostate cancer (PCa) development . Some stWe hypothesized that serum triglycerides may influence the PSA concentrations among men without diagnosis of prostate cancer in the U.S. population. The presence of possible association could create a detection bias in observational studies of the exposures and prostate cancer. To test the hypothesis, we investigated the U.S. National Health and Nutrition Examination Survey (NHANES) for secondary data analysis. After controlling a vast array of influencing factors, we attempted to clarify the association between serum triglycerides and PSA concentrations among U.S. men without prostate cancer as well as try to explain the conflicting resultswww.cdc.gov/nchs/nhanes, accessed on 7 October 2021). The National Center approved NHANES protocols for the Health Statistics research ethics review board.Since 1960, the National Health and Nutrition Examination Survey (NHANES) has been designed to estimate the health and nutritional status of adults and children in the United States, which is conducted by the National Centers for Disease Control (CDC) and Prevention National Health Statistics Center. Population and methodological details are available at the NHANES website ; (2) aged < 40 years ; (3) participant diagnosed with prostate cancer (n = 314); (4) factors affecting PSA concentrations: diagnosed with prostatitis, stain drug user, received prostate biopsy within one week and had urinary system surgery within one month (n = 76); (5) missing PSA (734); and (6) missing serum triglycerides (n = 3106) [Four cycles’ two-year data of the NHANES survey from 2003 to 2010 were integrated into our study. These data included PSA concentrations, sociodemographic data, laboratory data, medical examination–personal life history, dietary, and comorbidities data for the second analysis. According to the following exclusion criteria, participants were left out of our study as follows: (1) female participants ( = 3106) . There whttps://wwwn.cdc.gov/nchs/data/nhanes/2003–2004/labmethods/l11psa_c_met_total_psa.pdf, accessed on 7 October 2021). In this study, we used total serum PSA as the result variable connected to serum triglycerides and we selected the following covariates, based on the previous articles regarding the connection to triglycerides, PSA, or prostate cancer and other covariates [2), alcohol (gm), and triglycerides (mg/dL). Categorical variables contained race/ethnicity, education, marital status, physical activity (MET-based rank), smoked at least 100 cigarettes in life, hypertension history, coronary heart disease history, diabetes history, and stroke. More information about the details of variables is available on the NHANES official website.In our study, serum triglyceride was the target-independent variable downloaded from the NHANES website. Collaborative Laboratory Services periodically refines these laboratory methods. More detailed information on the test principles and clinical relevance can be found on the NHANES website and articles elsewhere ,24. PSA variates ,28,29,30https://www.cdc.gov/nchs/nhanes/index.htm, accessed on 7 October 2021). Serum triglyceride was expressed as the mean ± standard deviation as normally distributed. PSA concentrations and other continuous variables were expressed as the mean ± standard deviation . The categorical variables were expressed in percentage or frequency. Our aim was to research the potential relationship of particular participants between the serum triglycerides and PSA concentrations. First, we divided the continuous variables of serum triglycerides into four quartile concentrations. The weighted chi-square was used to calculate the categorical variable, and the weighted linear regression model was used to calculate the continuous variable between the quartile arrays which shown in the http://www.R-project.org, The R Foundation, accessed on 7 October 2021) [http://www.empowerstats.com, X&Y Solutions, Inc., Boston, MA, USA). In our study, a p-value < 0.05 was considered statistically significant.Following the criteria of the CDC guidelines, we conducted a statistical analysis between the serum triglycerides and PSA level (er 2021) . The sofp values > 0.05). Compared with the different groups in Weighted distribution of baseline characteristics is shown in p for a trend less than 0.05. In the minimally adjusted model, which adjusts for race/ethnicity, education level, poverty income ratio, and marital status, the PSA concentrations were reduced by 0.0013  for each additional unit of serum triglyceride with p for the trend <0.05. The fully adjusted model that adjusts for race/ethnicity, education level, poverty income ratio, marital status, VITD, LDL-C, total cholesterol, C-reactive protein, glycohemoglobin (%), physical activity (MET-based rank) (%), BMI (kg/m2), smoked at least 100 cigarettes in life, drinking alcohol (gm) first day, coronary heart disease, and stroke indicated that the PSA concentrations were reduced by 0.0043 ng/mL for each additional unit of serum triglyceride (mg/dL).The results of the univariate and multivariate analyses by the weighted linear model are shown in p for trend = 0.0036; p for trend = 0.0012; p for trend = 0.0004; and p for trend = 0.0002). In addition, we detected a significant difference by p for the interaction analyses. Variables of age and triglycerides may have an interaction effect associated with PSA concentrations (p for interaction < 0.0001).As shown in In the phase of model-development and validation, we used the machine learning of the XGBoost model to determine the relative importance of selected variables associated with the PSA. Variables included triglyceride, age, body mass index (BMI), LDL-cholesterol, total-cholesterol, C-relative protein, glycohemoglobin, vitamin-D, and alcohol. According to the results of each variables’ contribution by the XGBoost model, triglyceride, age, body mass index (BMI), LDL-cholesterol, and total-cholesterol were the top five most important variables of the dataset . Triglycp-value was calculated for trend. Surprisingly, the result of the categorical variable was consistent with the effect of the serum triglyceride as a continuous variable. To investigate the possible linear relationship between the serum triglycerides and PSA concentrations, we constructed a smooth curve based on the fully adjusted model. The relationship between the serum triglycerides and PSA concentrations was linear after adjusting for other covariates based on the fully adjusted model strategy  connections and is also the first to investigate this relationship in males without a history of malignant cancer in the United States based on the NHANES database. Up to now, there are no previous epidemiological studies that have reported on the association between triglyceride and PSA levels. Thus, after adjusting for the sociodemographic, laboratory, medical examination–personal life history, dietary, and comorbidities data, the serum triglyceride was negatively correlated with PSA. To avoid PSA detection bias in the process of diagnosis disease related to the prostate, it is necessary to understand that serum lipid may cause individual differences in PSA concentration and triglyceride is one aspect that needs further attention. Our study population was 2910 participants selected from the National Health and Nutrition Examination Survey (2003–2012). Machine learning of the XGBoost model was used to determine the relative importance of selected variables associated with the PSA, and triglyceride was the most relative variable. Our result shows that the PSA concentrations were reduced by 0.0043 ng/mL for each additional unit of serum triglyceride (mg/dL) and the result showed a statistical difference, which means that if 100 (mg/dL) of triglyceride is added, the PSA concentration will reduce by 4.3 ng/mL. Now, more and more of the population have dyslipidemia, which may aggravate PSA detection bias. Triglyceride, as the most relative variable, was included to construct smooth curve models to confirm the robustness of the result.Previously, some prospective studies have provided evidence showing a potential role for lipid metabolism in PCa development, which suggests that a higher serum total cholesterol may relate to a higher grade or more aggressive prostate cancer ,37,38,39The possible explanation of the inverse function of triglycerides with the PSA concentrations may be due to the detection bias between the process of prostate cancer, as shown in several recent studies ,42,43, rOur results support a negative association between triglycerides and PSA that may lead to detection bias, which can have implications for prostate cancer screening. Because triglycerides preferentially decrease PSA concentration in males without prostate cancer, the specificity of the PSA test for prostate cancer screening might be improved in males with high triglycerides. Thus, it is necessary to adjust the PSA threshold for further examination with various triglycerides if triglycerides can decrease PSA production by prostate tumor or change the ability of tumor-derived PSA to enter thee serum. Further studies are needed to explore the mechanism by which triglycerides influence PSA concentration and the influence on prostate cancer screening. Moreover, prospective cohort studies are still needed to confirm the causality, and serum triglyceride is involved in the occurrence and development of PCa, which needs to be verified via in vitro and in vivo experiments.This study had several advantages compared with previously published articles. First, a large sample with a total of 2910 participants was utilized in our research. Second, machine learning of the XGBoost algorithm model was used to assess each variable’s contribution to PSA. Then, we performed a sensitivity analysis that considered and evaluated the impact of other factors, which may influence the result. Finally, a smooth curve was constructed based on the fully adjusted model to investigate the possible linear relationship between the serum triglycerides and PSA concentrations. Nevertheless, our study had some limitations in interpreting the results, which need to be considered. First, in our study, it was hard to distinguish the causality because of the intrinsic limitations of the NHANES database as a cross-sectional survey. Therefore, prospective cohort studies are still needed to confirm the causality. Additionally, we excluded participants diagnosed with prostate cancer, with factors affecting PSA concentrations and missing data. Thus, our results cannot explain the aforementioned populations. Finally, our investigation was based on the NHANES database, which is limited to the American people. Therefore, generalizability is geographically restricted. All of the above points require further evaluation and investigation in the future.This nationally representative study showed that serum triglyceride is independently and negatively correlated with PSA among adult American males without a history of tumors. People with higher triglycerides would be more likely to be diagnosed with prostate cancer at an advanced stage in the future. This detection bias is unlikely to explain the inverse association between triglycerides and aggressive prostate cancer.


Dysthyroid optic neuropathy (DON) is a rare, severe form of thyroid eye disease, in which decreased visual acuity is accompanied by characteristic MRI findings. The treatment of DON has always been a challenge.In a patient in whom visual acuity deteriorated on the left eye, mannitol 20% 200 mL followed by furosemide 40 mg 6 h later, administered daily, were initiated on the day of admission. Visual function by ophthalmology methods, and orbital compartment volumes and water content by MRI were followed. Intravenous diuretics resulted in an immediate therapeutic response. Visual acuity improved from 20/50 to 20/25 after 2 days of treatment. MRI revealed decreasing water content of both the muscle and connective tissue compartments without any volume changes. Subsequently, corticosteroids and orbital irradiation were started. Orbital decompression surgery was not required.Edematous swelling of orbital tissues is an established contributor of local pressure increase in thyroid eye disease. Diuretics reduce orbital pressure and, if confirmed by others, may be useful additions to the standard of care in sight-threatening DON. For dysthyroid optic neuropathy, high-dose i.v. corticosteroids are the standard therapy. If visual acuity fails to improve, orbital decompression surgery has to be considered.Starting the treatment with diuretics alone resulted in immediate improvement of visual acuity. As evidenced by MRI, the mechanism is a decrease in the water content of orbital tissues. These findings suggest that the addition of diuretics to the standard of care might help to escape orbital surgery in dysthyroid optic neuropathy.Thyroid eye disease (TED) is an autoimmune inflammatory disease affecting the orbital connective tissue and extraocular muscles which represents a major challenge during the treatment of Graves’ disease. Sight-threatening compressive dysthyroid optic neuropathy (DON) is the most severe complication of TED. The main clinical finding is the progressive loss of visual acuity, which, if not treated appropriately, may result in the complete loss of vision. High-dose i.v. methylprednisolone pulses are the standard therapy for sight-threatening DON . If the Diuretics are an established treatment for cerebral edema and may have the potential to reduce the edematous swelling of orbital tissues. To clarify if diuresis is beneficial, in a patient with DON, corticosteroids were delayed and for the first 3 days only diuretics were administered. As of now, there have been no published cases on the therapeutic potential of diuretics in the management of DON.A 69-year-old man was referred to our Thyroid Eye Clinic for progressive TED. Graves’ hyperthyroidism and atrial fibrillation had been diagnosed 8 months earlier. He had become euthyroid on methimazole 10 mg per day; additional medications were propranolol, apixaban, and ramipril for pre-existing essential hypertension. He recalled that eyelid swelling, double vision, and excessive tearing were present for the last 4 months.On presentation, his main complaint was progressive sight loss on the left eye over the last 2 weeks. General physical examination was unremarkable except irregular pulse of 80 bpm; symmetric exophthalmos and symmetric periorbital edema were seen. Low thyroid-stimulating hormone (TSH)  was accompanied by normal free thyroxine and free triiodothyronine levels and elevated TSH receptor antibodies .Visual acuities were 20/20 on the right and 20/50 on the left eye. By slit-lamp examination, it was found that classical TED signs, periorbital and eyelid edema, exophthalmos, conjunctival hyperemia, chemosis, and swollen caruncles were present. No signs of corneal involvement were seen; the corneal epithelium was intact on both eyes with no fluorescein staining. Pupillary reactions were intact, direct and consensual on both eyes. Proptosis by Hertel exophthalmometry was 25 mm and 27 mm right and left, respectively. By kinetic perimetry, isopters were normal on the right eye, while concentric visual field angle reduction was observed on the left eye, especially in the temporal region 30°). Color visual fields were intact on the right eye; however, on the left eye, visual field and both red and green isopters were affected, and central color vision was deteriorated. By ophthalmoscopy, the optic nerve head did not show papillary edema on either side. No signs of optic nerve atrophy were present. The vascular structures showed mild signs of arteriosclerosis and hypertension. Critical flicker-fusion frequencies (CFF) were 34 Hz on the right and 29 Hz on the left . CFF is 0°. ColorMRI of the orbits has been performed in a conventional 3T MRI unit . Axial non-contrast 3D T1-weighted gradient echo  and short tau inversion recovery (STIR)  images were acquired. The extraocular muscles, optic nerve, intraorbital parts of the globe, and the lacrimal gland were manually segmented . Each mannitol infusion was followed by furosemide 40 mg 6 h later. Corticosteroids were started on day 4; 500 mg methylprednisolone was administered on alternate days , followed by 500 mg methylprednisolone weekly for 3 weeks and 250 mg methylprednisolone for 6 weeks. The protocol was approved by the Regional and Institutional Ethics Committee of the University of Debrecen. Consent was obtained from the patient after a full explanation of the purpose and nature of all procedures used.Immediate improvement of the CFF on day 2 was followed by improvement of visual acuity on day 3 . ImproveImproved visual acuity remained stable, and orbital decompression surgery was escaped. During the later course of the disease, orbital radiotherapy combined with i.v. glucocorticoids was effective  and F. TBased on current guidelines , the sugEdematous swelling of orbital tissues is a recognized phenomenon in active TED; water content estimated by MRI has been shown to be a corollary of disease activity . To clarAs no corticosteroids (only diuretics) were administered between day 1 and day 4 ophthalmology evaluations, the improvement seen on day 4 may entirely be attributed to the orbital effect of diuretics. Mannitol is an osmotic diuretic used for rapid volume depletion and water deprivation in focal brain diseases. The high hyaluronan content of the orbital tissues could be similarly deprived of a certain amount of water; hyaluronan retains a large amount of water, approximately 700 times its own weight . Indeed,In addition to being a single case report, another limitation of our work is that there is a mild chance that not the treatment but the natural course of TED, that is, coincidence with fluctuation in the disease activity, was responsible for the improvement. However, the course and timing of the changes argue against this. We did not experience any side effect of the diuretics, which, especially when co-administered with corticosteroids, may be of concern.Administration of mannitol resulted in immediate improvement of visual acuity. It seems feasible to add mannitol to i.v. corticosteroids in DON. The percentage of patients who may avoid decompression surgery by the combined use of diuretics and corticosteroids remains to be elucidated.The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of this case report.This work was supported by the Hungarian National Research, Development and Innovation Office Grants NKFIH K116419 and UNKP-21-4.2.The protocol was reviewed and approved by the Regional and Institutional Ethics Committee of the University of Debrecen, approval number 5952.Written consent was obtained from the patient after full explanation of the purpose and nature of all procedures used, for publication of the details of his medical case and accompanying images.All data related to this study will be made available on request by the corresponding author.Annamaria Erdei – diagnostic workup of the patient, treatment, follow-up, preparation of the mansucript. Annamaria Gazdag – treatment, follow-up, preparation of the manuscript. Bernadett Ujhelyi – ophthalmology examinations, preparation of the manuscript. Edit B Nagy – MRI examinations, preparation of the manuscript. Ervin Berenyi – MRI examinations, review of the manuscript. Eszter Berta – patient follow-up, literature review, manuscript preparation. Zita Steiber – ophthalmology examinations. Sandor Barna – patient follow-up, data management, literature review, manuscript preparation. Emese Mezosi – participated in the development of the new treatment modality. Miklos Bodor – patient follow-up, literature review, manuscript preparation. Endre V Nagy – development of the new treatment modality, study design, finalization and approval of the manuscript.