F. nucleatum in Alzheimer’s disease patients (adjusted p = 0.02), and its incidence was linked to C. rectus and P. gingivalis (adjusted HR = 1.22 (1.04–1.43), p = 0.012) as well as A. naeslundii (crude HR = 2.0 (1.1–3.8)). The presence of periodontitis at baseline was associated with a six-fold increase in the rate of cognitive decline over a 6-month follow-up period (ADAS-Cog mean change = 2.9 ± 6.6). The current review suggests an association between periodontal disease and Alzheimer’s disease. The treatment of periodontal disease could be a way to explore Alzheimer’s disease prevention.The hypothesis of an infectious connection from the oro-pharyngeal sphere to the brain underlines the interest in analyzing the link between periodontal disease and Alzheimer’s disease. The aim of this systematic review was to examine the link between Alzheimer’s disease and periodontal disease in patients aged 65 and over. Databases (PubMed (MEDLINE), the Cochrane Library, and Embase) were analyzed for relevant references up to 21 June 2021. The authors independently selected the studies and extracted the data. The quality of included studies was checked using the National Institutes of Health’s quality assessment tools. Five studies were included. The selected studies described in their results an increase in  Porphyromonas gingivalis (Pg), Prevotella intermedia (Pi), Treponema denticola (Td), Tannerella forsythensis (Tf), Campylobacter rectus (Cr), Aggregatibacter actinomycetemcomitans (Aa), and Fusobacterium nucleatum (Fn) release inflammation mediators and toxins, which go into the bloodstream and participate in systemic inflammation. Consequently, chronic periodontitis can contribute to the development of various pathologies [Around 770 microorganisms compose the human oral microbiota. This microbiota forms a biofilm or dental plaque on the surface of teeth. Its composition is dynamic and depends on the host environment. In a healthy state, with good dental hygiene, the composition of the microbiota remains stable . This echologies .Pg [Fn, Pi, H. pylori, and B. burgdorferi. In particular, Pg, the key pathogen of chronic periodontitis, is significantly identified in the brains of patients who have died from AD. Moreover, in mice models, an infection with Pg results in a colonization of the brain by this bacterium, and in an increased production of amyloid plaques within it [Alzheimer’s disease (AD) is the leading cause of neurocognitive disorders in the adult population, with nearly 47 million people affected worldwide. The estimated annual cost worldwide has exceeded 1000 billion US dollars , and excPg , Fn, Pi,ithin it .The composition of the oral microbiota in AD patients and its association with the severity of the disease remain largely unknown. In the absence of an effective disease-modifying treatment for AD, a great deal of research is being carried out to prevent its onset and/or progression. It is therefore necessary to describe and understand the link between PD and AD. The questions are therefore these: “Is there a link between PD and AD?”, and if so, "What would be the nature of this link?”We carried out a systematic review of the scientific literature and reported the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  supplem. The stuResearch questions were defined to answer the research objectives: “Is there a link between PD and AD?” and “What would be the nature of this link?” The PICO question was “Are people aged 65 and over (P) who have PD (I) compared with those without PD (C) at increased risk for AD (O)?”The primary goal was to determine if a link between PD and AD can be said to clinically exist based on periodontal clinical markers in people over 65 years of age.The secondary goal was to determine the microbiological pattern  in people over 65 years of age with AD.The conditions for eligibility were specified before the onset of screening.The inclusion criteria were as follows: (i) human studies in which participants over 65 years of age were at least a part of the study sample; (ii) the analysis of the link between PD and AD was one of the objectives of the study; (iii) the evaluation of the PD and/or the bacterial microbiota related to PD was clearly defined; (iv) the diagnosis criteria for AD diagnosis were clearly defined; (v) clinical studies, longitudinal studies , and transversal studies that evoked the link between periodontal disease and Alzheimer’s disease; (vi) studies published between 2010 and 21 June 2021; and (vii) studies written in English.Studies interested in other syndromes  and experimental studies on animals or on human tissues were excluded.The bibliographical research was performed through the following electronic databases: PubMed (MEDLINE)/the Cochrane database (Cochrane Library)/Embase.The keywords used were “Alzheimer”, “Alzheimer disease”, “periodontal disease”, “periodontitis”, “calculi”, “calculus”, and “dental plaque”. Keywords were mixed using Boolean operators, and MeSH terms (for MEDLINE and Cochrane) or Emtree (for Embase) were used depending on the database. For example, the search strategy used for PubMed (MEDLINE) database was (“Alzheimer’s disease” (MeSH) or “Alzheimer”) and  or “Periodontitis” (MeSH) or “dental plaque” (MeSH) or “calculi” (MeSH) or “calculus”).Two authors manually extracted data independently. First, duplicates were removed. Then, articles of interest were selected based on their titles and abstracts. The final selection of the articles to be included was based on reading the full texts, according to the PICO characteristics, as well as inclusion and exclusion criteria. Reasons for exclusion were documented at each stage. Any discrepancy regarding references, selection criteria of the subjects, sample characteristics , diagnosis criteria of AD, diagnosis criteria of PD, outcomes and relevant data, follow-up duration, and results were solved by discussion between the authors.For each eligible study, the following data were extracted by two members of the research team: first author, year of publication, study type, protocol, total number of patients, and covariates studied. The average age and the number of females were also extracted.The National Institutes of Health’s (NIH) study quality assessment tools for observational cohort and cross-sectional studies in addition to those of case–control studies were used to assess the quality of each eligible study . In the A total of 802 articles were identified. After elimination of duplicates, 533 articles were retained. We finally obtained 70 articles to read fully. Among them, five articles were finally included in the qualitative analysis .All the selected articles analyzed the link between PD and AD: three case–control studies ,28,29, oThe characteristics of the included studies are presented in the Only five studies met the inclusion criteria, and they provided data from populations in four countries: Italy , USA 2828,30, UKThree studies ,30,31 coThe tests used for AD diagnosis were the Mini-Mental State Examination (MMSE) test ,28,31, tThe results of the association between AD and periodontal indicators are presented in the Regarding bias, the quality of included studies was evaluated by the criteria of the NIH’s study quality assessment tools for observational cohort and cross-sectional studies in addition to those of case–control studies. Based on these criteria, two out of the five studies were qualified as good quality ,29, whilFour studies examined the association between periodontal bacterial pathogens and AD ,28,30,31Fn load in AD than in controls and a higher bacterial load of Td in persons with amnestic mild cognitive impairment than in AD [Pg antibodies and the rates of cognitive decline, but showed evidence of a relative increase in pro-inflammatory status and a decrease in anti-inflammatory status over a 6-month follow-up period in participants with AD and PD [A. naeslundii (An) serum immunoglobulin G (IgG) had a consistently higher risk for incident AD, whereas high antibody levels to E. nodatum (En) were significantly associated with a decreased risk of incident AD [One study found a significantly higher an in AD . Anotheran in AD . One stuD and PD . Anotherident AD .Four studies examined the association between clinical periodontal markers and AD. One study estimated the diagnosis of AD as predictive of tooth loss, especially in subjects aged 80 years or older . AnotherThis systematic review including five studies provides evidence of a relationship between AD and PD. However, these pieces of evidence on the relationship between PD and AD need to be further investigated.In the studies analyzed, the diagnosis of PD was based on clinical criteria , microbiThe initial examination leading to a probable diagnosis of AD, according to the DSM V, generally includes different aspects such as a cognitive assessment , a functional assessment , a behavioral assessment, a clinical examination, and para-clinical examinations ) , since oIf the MMSE test ,37 is usOne study  considerWe wished to study non-genetic forms, and because genetic aetiologias are considered rare after this age , we chosAll the studies analyzed chose to include covariates such as age ,29,30,31In AD, poor dental health, particularly the presence of PD, is associated with a marked increase in cognitive decline over a 6-month follow-up period . HoweverPg antibody serum levels and the rate of cognitive decline, while others have shown a link between AD and certain periodontal pathogens [Fn appears significantly higher in AD [An, and this appears to be even stronger when high levels of En are included in the model [Pg, Pi, P. nigrescens (Pn), Fn, Cr, S. intermedius (Si), C. ochracea (Co), and P. melaninogenica (Pm) could be related to increased AD mortality risk above 65 years of age, while the reverse could be true for Aa. S. oralis (So) was directly related to AD mortality risk among men. Pg and Cr were linked to an increased risk for incidence of AD over 65 years of age. So increased the risk of major NCD  in men, while E. corrodens (Ec) increased the risk of major NCD  in women. The reverse was true for Si, which appeared to be marginally and inversely associated with the risk of AD incidence in women [Pg, among others, could be an effective way to delay the onset of AD, pending randomized clinical trials [Whereas Ide et al.  showed tathogens ,28,30. Ter in AD . The incFurther multimodal exploration of the role of periodontal infections, other oral health markers, and systemic host response may elucidate a potential new causal pathway for cognitive impairment in the elderly .The NIH’s study quality assessment tools were used to assess the quality of each eligible study .One of the major limitations of all the studies found for this systematic review was the diagnosis criteria used to define AD patients. Indeed, criteria used in these studies allowed for the diagnosis of neurocognitive disorders associated with Alzheimer’s syndrome but, without a CSF sample, the proteinopathy related to AD could not be established. Thus, linking PD and AD on this basis could be controversial. The only conclusion possible is the association between PD and NCD. To confirm the hypotheses of an association between PD and AD, and to explore the possible physiopathological process underlying these two pathologies, future studies should include only well-phenotyping AD patients with a confirmed amyloïdopathy, according to the last National Institute on Aging and Alzheimer’s Association Research Framework .It is also worth noting the multiplicity of criteria used to define PD in the selected publications. Moreover, three studies ; patients exposed for a long time would then have 1.7 times more risk of developing AD than those with a healthy periodontium.In addition, other authors stress the importance of the duration of periodontal disease. Patients with chronic periodontitis are reported to be at greater risk of developing AD ,51. IndeThis may explain why some studies do not show a link between the two diseases, as it seems that cause precedes effect .Genetics does not appear to be a causal factor in the link between the two diseases .While there is currently no clinical evidence with which to describe a direct link between PD and AD, several studies propose indirect links. The two main hypotheses are inflammation and the bacteria involved. Periodontal pathogenic bacteria cause an inflammatory defense reaction in the host, leading to the production of inflammatory molecules such as IL-1B, IL-6, IL-8, and TNF. In advanced PD, the inflammatory cytokines are able to reach the central nervous system via the bloodstream, which is believed to influence the progression of AD ,55,56,57Pg, a highly periodontal pathogenic bacteria, was the first to be incriminated. Its presence is thought to be linked to an increase in cognitive decline in patients and its presence in saliva is statistically linked to lower MMSE (p < 0.05) and CDT (p = 0.056) scores [Research into bacteria involved in the onset and/or progression of AD has highlighted many risk associations. ) scores .Pi, An, Pn, Pm, Pg, Td, and Tf) with Helicobacter pylori and their impact on AD.Other periodontopathogenic bacteria have been the subject of studies aimed at gaining a better understanding of their link with the onset and/or progression of Alzheimer’s disease. The study by Beydoun et al.  reveals Pg in the etiopathogenesis of AD has also been highlighted by Poole et al. [Pg antibodies, and its lipopolysaccharides have been found in the brain and cerebrospinal fluid of patients with AD [Pg is able to bypass the immune system, reach the brain, and cross the brain barrier.The role of e et al.  The bact with AD ,54. ThisPg has the ability to secrete vesicles filled with proteases called gingipains. These have the function of breaking down cytokines to reduce inflammation. They use the tau protein present in the brain as a substrate. Its modification transforms the molecule into a neurotoxic product that contributes to the progression of AD. Gingipains can also be absorbed by neural cells to be detoxified. They will be transported from cell to cell throughout the neural system, spreading the infection that causes cognitive decline [Recent study has proven the ability of periodontopathogenic bacteria to hijack the immune system . They al decline ,60.It should be noted that the improvement in the PI favorably modifies the oral microbiological composition ,62,63 anFew studies currently have a high level of evidence on the link between AD and PD ,65. ThisMoreover, studies often have small numbers of staff ,52,66,67Most studies analyze the link only at a point in the patient’s life ,53,58,67Finally, as many risk factors have been established with AD, risks of confounding bias are often described by the authors ,46,51,58Pg, Fn, An, and Aa seem to be the key bacteria. Nevertheless, further studies are still needed to better understand the origin and mechanisms of this interaction, as there are not yet enough studies with a high level of evidence on the subject. Thus, new studies that are better constructed and more rigorous in the diagnostic criteria of the pathologies studied are essential to try to better understand the association between AD and PD.The literature currently seems to converge towards the affirmation of a link between periodontal diseases and Alzheimer’s disease. Indeed, AD patients seem to have a lower level of oral hygiene and a higher risk of PD. In this context, periodontopathogenic bacteria have been found in AD patients, either associated with a higher risk of AD incidence or mortality, or inversely associated with these risks. Among them, It seems fundamental to focus on this association, as a better understanding of it will allow the implementation of effective prevention and even treatment measures. Thus, the treatment of PD could represent a lever in a global strategy for the management of the prevalent and disabling disease that is AD.


Acute high altitude (HA) exposure elicits blood pressure (BP) responses in most subjects, and some of them suffer from acute mountain sickness (AMS). However, a 24-h ambulatory BP (ABP) change and the correlation with the occurrence of AMS in different sexes are still unclear.This prospective study aimed to investigate HA induced BP responses in males and females and the relationship between AMS and 24-h ABP.Forty-six subjects were matched according to demographic parameters by propensity score matching with a ratio of 1:1. All the subjects were monitored by a 24-h ABP device; the measurement was one period of 24 h BP. 2018 Lake Louise questionnaire was used to evaluate AMS.P = 0.007) and headache  were higher in females than in males. All subjects showed an elevated BP in the early morning . The elevation of morning SBP variation was more significant in females than in males , and a higher morning BP surge increase  was observed after acute HA exposure in the female group. The increase of morning SBP was associated with AMS occurrence  and AMS score . Among the AMS symptoms, we further revealed that the incidence  and the severity of headache  are closely correlated to morning SBP.Both the incidence of AMS (14 [60.9%] vs. 5 [21.7%], Our study demonstrates that females are more likely to suffer from AMS than males. AMS is closely associated with elevated BP in the early morning period, which may be correlated to higher headache incidence in subjects with higher morning SBP. High altitude (HA) is a hypobaric and hypoxic environment that imposes a formidable physiological challenge for humans. A series of responses in the cardiovascular system and alterations in ventilation allow the human body to acclimatize to hypoxic environments . Some inThe elevation of blood pressure (BP) during the day and its decrease at night is a normal physiological phenomenon. Subjects change their state from being asleep to being awake, and start activities in the early morning, which usually leads to an abrupt increase in BP, known as morning BP surge . ImportaTherefore, in our study, we matched demographic parameters to recruit 23 males and 23 females (1:1 ratio). The incidence of AMS and the changes in the 24-h ambulatory BP (ABP) after acute HA exposure were compared in both sexes. Correlation analysis was performed to demonstrate the relationship between changes in BP and AMS. Moreover, we wanted to investigate the potential mechanism of AMS and provide relevant evidence for the prevention and treatment of AMS.www.chictr.org.cn (ChiCTR-TRC-No.1900025728).This was a sub-study of a high-altitude prospective cohort study presented in 2019 in Chengdu, China . All subWe used an ABP measurement device  to record BP data. Two well-trained cardiovascular physicians were employed and same operators who adopted strict reading criteria and were blind to the subjects’ grouping information performed the examination of ABP monitoring. The BP cuff was applied to the non-dominant arm on a weekday morning and was removed after 24 h to gather the data. All participants were asked to remain still during the measurement. The subjects were instructed to avoid unusual physical activities, and follow a standard schedule at both locations, LA and HA. Day-time and night-time were defined as 6:00–22:00 and 22:00–6:00, respectively . The recPre-waking BP, morning BP, and evening BP were calculated by taking the average BP at 2 h just before the wake-up time (4:00–6:00), at 2 h after the wake-up time (6:00–8:00), and at 2 h before going to bed (22:00–24:00), respectively . The lowK ranges from 1 to N, and N denotes the number of valid BP measurements in the data corresponding to a given subject (where  subject . ARVs anSubjects ascended from locations at LA to locations at HA within 2 days. The latest Lake Louise questionnaire of AMS was used to assess AMS and was administered in the morning (around 8 h after arriving at HA). Participants completed a questionnaire of four items with the assistance of an experienced doctor. The items included headache, dizziness or lightheadedness, gastrointestinal symptoms, and fatigue. Each item comprised four alternative responses graded from 0 to 3, according to the severity of the symptom . AMS was defined as total scores ≥3, with at least 1 point from headache .T test, while the data that did not fit a normal distribution were analyzed by the Mann–Whitney U test. Changes in BP and other indexes from LA to HA were compared using a 2 × 2 mixed-model analysis of ANOVA. Categorical data were presented as percentage (%) and were compared by the chi-square test, continuity correction, or Fisher exact test, as appropriate. Spearman correlation coefficients were used to determine the correlation between the different BP index variations after acute HA exposure and AMS, as well as different AMS symptom severity. Statistical significance was assumed at P < 0.05. Statistical analyses were performed by SPSS software 26 . Statistical power calculations were performed using the PASS software, version 11 . Results suggested that 46 subjects would provide more than 75% power to detect morning systolic blood pressure (MSBP) and MSBPS differences between subgroups using a two-sided alpha of 0.05.Continuous variables were presented as mean ± standard deviation. Differences in measurements between males and females with normal distribution were tested using independent-sample There was no significant difference in age, BMI, race, HA living experience, and the history of alcohol and tobacco intake between males and females .2 at LA or at HA between the two sexes. The female group had a lower body water percent  compared with that of males at the LA location. However, the variation did not reveal a significant difference between the two groups after HA exposure , but variations of day-time BPs changed similarly. There was no obvious difference in nighttime BPs and ARV between the two groups both at LA and at HA  (P = 0.013) and morning DBP  but not in morning BP surge during the acute HA exposure period   (P = 0.005)  . All sub= 0.138) . Interes= 0.031) . As we f= 0.005) .P = 0.007), and AMS score was also significantly higher in the female group than in the male group . Furthermore, among the AMS symptoms, the incidence of headache was also higher in the female group than in the male group   .R = 0.584, P = 0.003), males , and all subjects . The variation of MSBP was also significantly correlated with AMS in females , males , and all subjects  , the female group , and the male group . The variation of morning SBP surge was significantly correlated with AMS score in the female group , male group  and all subjects . Furthermore, we demonstrated that MSBP and morning SBP surge have stronger correlations with the severity of headache in females  , males  , and all subjects  .The results of the correlation analysis indicated that there was a strong correlation between AMS and morning SBP surge variations in females (< 0.001) . BesidesTo our knowledge, this study was the first to investigate the changes of ABP in males and females after acute HA exposure. In this study, we showed the changes of ABP after acute HA exposure in both sexes and analyzed the correlation between ABP and AMS. Interestingly, we found that females exhibited a remarkable elevation in BP during the early morning period as well as an increase of the morning BP surge. However, morning BP surge declined in males, which may be attributed to an inapparent increase of MSBP after acute HA exposure. The BP readings of female participants were on average lower than those of the male participants. Furthermore, we found that there was a significant correlation between SBP in the early morning and AMS. Besides, in order to explain this phenomenon, we further revealed that MSBP was significantly correlated with the severity of headache among the AMS symptoms in males, females, and all subjects.Previous studies have demonstrated that 10–70% of travelers experience various degrees of AMS when ascending to elevation of ≥2500 m. The rate of AMS in our study was 41.5%, which is consistent with those reported previously . AMS wasIt is always a controversial topic to discuss the relationship between sex difference and AMS as shown in previous studies. A cohort study showed that females developed AMS at a rate of 69.2%, which was consistent with our results . HoweverPrevious studies have demonstrated a correlation between exaggerated morning BP surge and adverse cardiovascular events in patients with hypertension . Higher Previous studies did not demonstrate a significant difference in early morning BP surge between men and women at LA . In our Our findings could be helpful and shed light on the prevention of AMS. Females could be more in need of preventive treatment compared with males. Moreover, treatments that specifically target the morning BP surge may be worthy of further investigation. Besides, previous studies point that the usage of diuretics, such as acetazolamide , to imprThere are several limitations in our present study. First, the number of subjects was relatively small; a larger cohort study needs to be performed to verify the results. Second, we did not examine parameters related to the biochemical and cerebral blood flow as well as some indexes, which could more thoroughly explore oxygen saturation, due to limitations of HA conditions in this study. The potential mechanism underlying this phenomenon remains to be studied. Moreover, age-related reference ranges for morning BP surges are not currently available. Furthermore, the classification of AMS was based on a self-report without immediate medical control, which did lead to possible classification bias especially in different genders. Besides, the study subjects were mostly young Chinese people from the Han population. With a narrow study population, the application of our findings might be limited.Our study demonstrated that morning BP surge increased more in females compared with males after acute exposure to HA, which may be related to an elevation of MSBP. AMS score strongly correlated with morning BP surge and MSBP in the correlational analyses. Furthermore, headache, a typical symptom of AMS, showed a higher correlation with morning BP surge and MSBP compared with other AMS symptoms. To our knowledge, this is the first study to investigate the relationship of ABP variations and AMS following acute exposure to HA, especially in males and females. However, the exact mechanisms involved need to be further elucidated, and larger cohort studies are also needed to verify the results.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Human Ethics Committee of the Xinqiao Hospital, Third Military Medical University . The patients/participants provided their written informed consent to participate in this study.ReC, JY, and LH worked on the conception of the study. ReC, MS, YY, YS, JK, FY, CH, RaC, and HL contributed to the data collection. CL and JY checked the data. RaC, YS, and MS performed the statistical analysis. JY and ReC drafted the manuscript. XG, CL, HT, JZ, and LH reviewed the manuscript. All authors read and approved the final version of the manuscript.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.


Primary liver cancer is the fifth most common malignancy and limits patients’ quality of life and working ability. Return to work after cancer treatment is an important step in social recovery. In addition, return to work represents the recovery of financial ability and improvements in self-confidence. The purpose of this article is to discuss the relationship between return to work and various covariables in workers with liver cancer.The national registry cohort study collected adult workers newly diagnosed with liver cancer from 2004 to 2010 in Taiwan. There were 2451 workers included in our study. Primary liver cancer was diagnosed by using the International Classification of Diseases for Oncology code. Return to work after liver cancer survival was determined as returning to the same work or reemployment within five years after cancer diagnosis. The associations between independent variables and return to work were analyzed by Cox proportional hazard models.p < 0.001) among all patients with liver cancer. The completely adjusted model identified that the rate of return to work was related to all-cause mortality with a hazard ratio of 0.244 .Workers who underwent surgery were more likely to return to work not only in the 2nd year but also in the 5th year. A lower survival rate was noted in the non-return-to-work group (Our study indicated the impacts of treatment on the return to work of liver cancer survivors. In addition, in patient with liver cancer, return to work had positive effect on the survival rate.The online version contains supplementary material available at 10.1186/s12889-021-11872-9. Cancer is a major cause of morbidity and mortality in twenty-first century. Cancer impacts not only physical capacity but also mental health of patients. Cancer decreases not only working capacity but also quality of life. Due to early detection and the development of treatment options, the prognosis and outcomes of cancer patients have improved, and the survival of cancer patients has increased . Recent Primary liver cancer is the fifth most common malignancy and one of the leading causes of cancer-related death worldwide . To our According to literature reviews, liver cancer and return to work was only a small part of study in cancer impact and employment status. Results of these studies concluded that liver cancer was one of barriers about return to work , 15. TheThe data for this study were from population databases in Taiwan and included data collected from adult patients diagnosed with liver cancer in the period 2004–2010. These data were collected by the National Health Insurance Research Database (NHIRD), Labor Insurance Database (LID), and the Taiwan Cancer Registry (TCR), and the data were connected by an encrypted number. All procedures were conducted in accordance with the regulations and guidelines of the Institutional Review Board (1–107–05-129) in Tri-service General Hospital (TSGH). First, pertinent information, which included the employee industry, employment data, and working district, were extracted from the LID. Next, we connected the identification number in the LID with the TCR and NHIRD databases.There were 2451 workers included in our study, and they were first diagnosed with liver cancer in the period of 2004–2010. The exclusion criteria for this analysis were being twenty years of age or younger, being unemployed at baseline, having liver cancer in combination with other cancers, and having a liver cancer diagnosis before 2004. In the 2nd year, there were 1504 workers who had gone back to work, 550 deaths, and 397 unemployed individuals; in the 5th year, there were 1123 workers who had gone back to work, 940 deaths, and 388 unemployed individuals. The demographic characteristics of workers, including age, gender, comorbidities, district of domicile, monthly income, corporation size, and the stages of liver cancer, are presented in Table Since the study used deidentified materials from National registry database. All protocols were executed by the Institutional Review Board (1–107–05-129) of TSGH.In accordance with the International Classification of Diseases for Oncology code (ICD-O-3: C22), we listed the primary site, staging, and histology of liver cancer. We used the American Joint Committee on Cancer (AJCC) 8th Edition staging system for hepatocellular carcinoma (HCC)  for analysis in the study. We considered two-sided 푃 values smaller than 0.05 as significant. Percentages, frequencies, means, and standard deviations were included in descriptive statistical analyses. Continuous variables were investigated with independent-sample t tests and Wilcoxon rank sum tests, and categorical variables were compared by chi-square tests. Return to work after liver cancer survival was determined to be returning to the same work or reemployment within five years after cancer diagnosis. In addition, we recorded survival time from diagnosis of liver cancer until death in the period of 2004–2010. The Cox regression model was defined as the influence of different variables on return to work and survival rate.p < 0.05). In addition, radiation therapy, chemotherapy, company size and pathological staging also presented statistical significance (p < 0.05).Table p < 0.05)   Fig. A. In the05) Fig. B. In terp < 0.05)   Fig. A. In the05) Fig. B. In terp < 0.001) in all patients with liver cancer , II (p = 0.0153), III (p < 0.001) and IV (p < 0.001) liver cancer   Fig. . All of In our study, we analyzed the independent effects of cancer treatment, comorbidities, financial status, social characteristics and cancer stage on return to work from the 1st to 5th year after liver cancer diagnosis in survivors. We demonstrated that surgical treatment had positive effect for patients with liver cancer and increased the rate of 5th-year return to work. In contrast, chemotherapy was associated with a lower rate of 2nd-year return to work. In social characteristics, the rate of return to work had no differences between industries but higher in large companies. Interestingly, our study noted that lower income group (< 28800NTD) had higher rate of return to work. In addition, we also found that the lower survival rate was noted in liver cancer patients who did not return to work.Based on the Barcelona Clinic Liver Cancer (BCLC) staging system, surgical treatment usually performed for patients with early stage (such as carcinoma in situ and Child-Pugh A) . In contComorbidities also play an important role in our study. The lower rate of 5th year return to work was associated with metastatic solid tumor, alcohol consumption and heart failure. The patients with metastatic solid tumor mean the patients at the end-stage of cancer. Alcohol consumption connected with liver cirrhosis increasing the severity of comorbidities such as portal hypertension, ascites, varices, infection and encephalopathy . Heart fThe work environment, culture, and resources are the main reasons for different work performances. A previous study demonstrated that lower educational level and poorer perceived financial status were related to delayed return to work in colorectal cancer survivors . In our Different from other research, in our study, the rate of return to work was higher in lower income range group. For these conflicting results, we established two hypotheses. First, lower income range group had more intent to return to work due to economic pressure. Second, compared the national health insurance system with other countries, Taiwan’s health insurance system covers nearly 100% of the population  and provThe survivors return to work has very significant meaning for patients and society. It is related to having a purpose of life, a stable income, and a sense of contributing . In otheThis study had both strengths and limitations. The strength of the current analysis was that a large population was included in our study. Moreover, we examined many confounders and discussed their connection with exposure and outcome. Unfortunately, there were still some limitations in our study. First, we did not include HBV and HCV infection data in our analysis. The impact of HBV and HCV infection on liver cancer has been examined in many studies. Second, educational level was not presented in this study, but educational level has been shown to strongly impact return to work . FinallyOur study identified the impacts of medical and sociodemographic factors on the return to work of liver cancer survivors. In addition, in patients with liver cancer, the return to work had a positive effect on the survival rate. Side effects of disease or treatment, including physical and psychological problems, also affected patients’ working abilities and the rate of return to work. In summary, disease, reemployment, treatment and survival rate were inseparable and interfered with each other for patients with liver cancer.Additional file 1: Supplement Table 1. ICD-9-CM codes of comorbidities listed from the NHIRD database.Additional file 2: Supplement Table 2. Associations between the return to work and all caused mortality.


All participants were evaluated for psychiatric, biochemical, and cardiovascular physiological effects. Patients were selected through Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV criteria and urine samples, exclusively for the evaluation of cannabis presence. Serum thyroid stimulating hormone (TSH), T3, and T4 levels were measured using the immunoassay technique. Patients were assessed for severity of depressive, schizophrenic, and manic symptoms using international ranking scales. Various quantifiable factors were also measured for the development of tolerance by cannabis. Among the patients of cannabis abuse, 47.5% were found with schizophrenia, 20% with schizoaffective symptoms, 10% with manic symptoms, and 22.5% with both manic and psychotic symptoms. In the group–group and within-group statistical analysis, the results of thyroid hormones and cardiovascular parameters were non-significant. The psychiatric assessment has shown highly significant (p < 0.001) difference of positive, negative, general psychopathology, and total scores [through Positive and Negative Syndrome Scale (PANSS) rating scales] in patients vs. the healthy control subjects. The study revealed that cannabis abuse did not significantly alter thyroid hormones and cardiovascular parameters due to the development of tolerance. However, the cannabis abuse might have a significant contributing role in the positive, negative, and manic symptoms in different psychiatric disorders.Cannabis abuse is a common public health issue and may lead to considerable adverse effects. Along with other effects, the dependence on cannabis consumption is a serious problem which has significant consequences on biochemical and clinical symptoms. This study intends to evaluate the harmful effects of the use of cannabis on thyroid hormonal levels, cardiovascular indicators, and psychotic symptoms in the included patients. This prospective multicenter study was conducted on cannabis-dependent patients with psychotic symptoms ( Substance-induced psychosis (SIPs) is a condition in which psychosis begins in the context of substance used and persists for days to weeks in the absence of that agent(s). The substances with psychoactive properties include cannabis, amphetamine, cocaine, lysergic acid diethylamide (LSD), phencyclidine, ketamine, benzodiazepines, and alcohol .Cannabis is a widely used addictive agent after tobacco and alcohol. It has a prevalence of 3.6% of the local population in Khyber Pakhtunkhwa, Pakistan . CannabiTetrahydrocannabinol (THC) is a major constituent present in cannabis, which can initiate psychotic-like symptoms in its users. The severity and frequency of these symptoms are closely related to its usage. THC can produce brief psychotic symptoms through dopaminergic dysfunction and memory impairment through stimulation of cannabinoid receptor-1 (CB1R) . ExperimTHC, the main psychoactive constituent present in cannabis, acutely alters several hormones including suppression of luteinizing hormone , testostAcute exposure to cannabis smoking in humans can cause unfavorable consequences on the functions of the cardiovascular (CV) system. It causes an increase in the heart rate (HR), an increase in cardiac output (CO), reduced peripheral vascular resistance, and an overall moderate increase in blood pressure (BP), and sometimes postural hypotension. These deviations are mediated centrally by the autonomic nervous system (ANS) and peripherally by cannabinoid receptors mediated by vasodilatation. For many psychoactive drugs, including cannabis, the development of dependence is usually related to the tolerance, which develops when people are exposed to high doses for a sustained period. Tolerance to the acute CV effects of cannabis smoking develops over several days to a few weeks, but it is quickly lost when cannabinoid administration is stopped . A recenIn view of the above-mentioned facts and considering the higher percentage of drug abuse, addiction, dependence, and development of related psychotic disorders, this study was designed not only to evaluate the variety, severity, and multiplicity of psychotic symptoms possibly contributed due to cannabis abuse but also to find out the significant role of cannabis dependence to alter the selected THs and CV parameters in human subjects/patients.via testament no: 08/EC-16/Pharm, dated July 12, 2015. This study was conducted in compliance with the principles of the declaration of Helsinki and its amendments  and healthy control subjects (n = 40). Both groups were assessed on the basis of psychiatric, biochemical, and CV parameters.Well-informed consent was obtained from the selected individuals  at the beginning of the study. Drug use was determined by urine screening test, and all the individuals went through clinical examination for diagnosis regarding psychiatric symptoms. These symptoms were positively diagnosed on the basis of Diagnostic and Statistical Manual of Mental Disorders (DSM) IV (adopted) criteria by professional psychiatrists. The included subjects were then categorized into patients/test group (n = 40) were selected after physical examination, clinical investigation, and previous medication history. Male patients of the age group ranging from 18 to 60 years, who used only cannabis during the preceding 30 days, were selected for the said study. Subjects with no family history of psychosis or any other psychotic disorders were also included in the study. However, those patients who were not willing to sign the informed consent form regarding participation in the study and patients having any history of serious illness like endocrinological, renal, neurological, hepatic, or thyroid abnormality were excluded from the study. Similarly, patients with a history of psychotic symptoms induced by drugs other than cannabis were also excluded from the study. In contrast, healthy control subjects were included if they had negative reports for cannabis abuse through urine screening/test; did not show any psychotic symptoms during assessment through Hamilton Depression Rating Scale (HAM-D-17), Positive and Negative Syndrome Scale (PANSS), and Young Mania Rating Scale (YMRS); and had normal thyroid hormonal levels and CV parameters. They were also not using any other kind of drug of abuse.According to the inclusion criteria, new cannabis-related psychosis or relapse cases (n = 40) with positive screening for cannabis were selected for the study. Patients with positive results for substances other than cannabis were excluded from the sample. The healthy control subjects (n = 40) were also screened to ensure that the selected sample was of non-cannabis users.Patients were screened to determine the active use of drugs  through multiple drug screening strips  . This meAbout 4–5 ml of blood was collected from subjects of the study and then transferred to gel clot-activator tubes. These were centrifuged at 4,500 rpm for 10 min, and the serum part was separated for analysis. Biochemical variables TSH, T3, and T4 were analyzed using the commercial Roche diagnostics test kits (Roche®) by ELECYS 2010, following the chemiluminescence method. The reference ranges for TSH, T3, and T4 were adopted according to the guidelines of the National Academy of Clinical Biochemistry NACB which were 0.27–4.2 U/ml, 80–200 ng/dl, and 5.1–14.1 μg/dl, respectively .Systolic and diastolic BP was measured by using a sphygmomanometer , and HR was calculated as beats per minute (bpm) using a stethoscope and stopwatch. According to the guidelines of the American Heart Association (AHA), BP values greater than 140/90 mmHg and <90/60 mmHg were considered hypertension and hypotension, respectively , 21. ForIncluded subjects were assessed for the severity of depressive, schizophrenic, and manic symptoms using HAM-D-17, PANSS, and YMRS, respectively, by professional psychiatrists.The development of tolerance for cannabis was assessed by considering various parameters including dose, frequency, duration, route, and cannabis alone or in combination with other substances. The amount of cannabis consumed was quantified as grams per day. The frequency was calculated based on the intake a number of times daily, duration in years/months, and the route by using either joint or bong. It was also considered whether they have used any other drug of abuse in the past along with cannabis or not.p ≤ 0.05, two tails). The relation between marijuana consumption and the development of tolerance was assessed on the basis of factors including dose, frequency, duration, route, or cannabis alone or in combination. Finally, the results were correlated with the development of psychotic symptoms, fluctuation of THs, and CV physiological parameters in included patients.Participant's data  were analyzed for the effect of cannabis on alteration of THs , CV physiological parameters , and to determine the severity of psychotic symptoms by using PANSS, YMRS, and HAM-D-17 scale. The parametric data from participants were further processed statistically using computer-based Prism Graph Pad (version 8). All results were expressed as mean ± SD. The non-paired analysis of variance (ANOVA) test was applied for the determination of the significance of the difference between means of respective parameters , representing that there was no impact on THs. Results regarding the biochemical evaluation for TH , showing no impact on CV physiological parameters  were also non-significant (rameters .p < 0.001) when compared with the score of healthy control subjects. However, within the same patient group, the results were statistically non-significant (p > 0.05) as shown in In case of psychiatric manifestations, the positive, negative, general psychopathology (GP), and total scores of PANSS for the patient group were found to be statistically highly significant  is the underlying cause for the development of tolerance to cannabinoids. These are organized along the central and peripheral TH axis and with greater magnitude in the hippocampus and cerebellum regions of the brain . The resBiochemically, the present results also revealed that 15% of the patients had lower T3 but normal TSH and T4 values, suggesting euthyroid sick syndrome. Furthermore, we have observed 10% sub-clinical hyperthyroidism and 5% sub-clinical hypothyroidism. Such dispersed results might be an indicator that the study sample had certain risk factors of thyroid dysfunction resulting from treatment provided to those included patients. Similar effects have also been reported in earlier studies, suggesting that in patients with psychiatric symptoms especially bipolar mania, treatment with lithium and haloperidol may have an alteration effect on serum TSH level .It is important to note that smoking tobacco may either have a weak stimulatory or no effect on thyroid function. According to earlier studies, nicotine-induced sympathetic activation could account for small increases in THs main serum T3 and TSH levels .Furthermore, statistically non-significant effects of cannabis dependence on CV physiological parameters  have been indicated by the results of the investigation. This might be due to the fact that the use of cannabis leads to dose-dependent increased HR, increased BP, and CO, but sometimes it causes reduced peripheral vascular resistance and postural hypotension. The CV effects are modulated centrally by ANS and peripherally by the cannabinoid receptor system .Moreover, the CV response to cannabis dose is biphasic in nature. A low to moderate dose of cannabis causes an increase in sympathetic activity with a reduction in parasympathetic activity. This results in marked tachycardia and an increase in CO (as much as 30%) and an overall increase in BP. On the other hand, high doses of cannabis lead to a decrease in sympathetic activity with increased parasympathetic activity. This results in bradycardia and hypotension –31. The Decrease in both systolic and diastolic BP due to chronic use of cannabis has been reported in various studies , 28, wheThe psychiatric assessment revealed overall higher intensity for positive symptoms in psychotic/schizophrenic patients. The results were similar for schizoaffective patients as well. However, when compared with schizophrenics, the results indicated lower scores for PANSS positive and negative symptoms.The patients suffering from mania and psychosis and who were cannabis abusers have shown high intensity of positive symptoms. However, the scores for positive, negative, and GP as well as of the total PANSS score were lower than that of schizophrenic and schizoaffective patients. Furthermore, some of the patients showed only the symptoms of mania and not psychosis.via CB1R activation provides a possible reason for the increase in positive psychotic symptoms induced by cannabis.D'Souza et al.  explaineThe CB1R activation in the PFC might be responsible for the cognitive deficits and negative symptoms of cannabis. Moreover, cannabinoids modulate the release of neurotransmitters such as dopamine, γ-aminobutyric acid (GABA), and glutamate. By suppressing GABAergic and dopaminergic inhibitory neurotransmission, cannabinoids contribute to worsen the working memory effects and negative symptoms as observed in schizophrenia .Moreover, it has also been reported that THC increases glutamate level in PFC which in turn leads to psychoactive and behavioral effects of marijuana consumption . Since tCannabis-related increased intensity for positive symptoms but low for negative symptoms in the case of schizophrenia has also been supported by studies , 37. HowAssessment of the patients by HAM-D-17 indicated mild depression in cannabis abuse subjects. Similarly, pre-clinical and clinical studies have suggested that cannabis causes an increase in 5-HT (serotonin) neurotransmission in the PFC due to the activation of CB1R which modifies the mood of those subjects , 41. FurAs cannabis abuse may aggravate both psychotic and manic symptoms, it is suggested to share genetic susceptibility to dysregulation of the dopaminergic system due to stress induced by cannabis . Brain iThe findings of the study were supported by previous studies conducted by Kumar et al.  and StonPrevious studies also revealed that THC might have significant psychotomimetic effects and perceptual alterations. These effects were dose-dependent and subjectively high as assessed through PANSS rating scale . It is lDespite strict inclusion and exclusion criteria and dedicated efforts to conduct this multicenter research, the study would be statistically more meaningful if executed on a relatively large population and included with both male and female genders. Similarly, it would have a great impact if the effects due to acute vs. chronic cannabis abuse were compared. Furthermore, follow-up evaluation of the subjects would have indicated more evident information regarding the exacerbation in the psychotic symptoms.Cannabis dependence had a non-significant impact on serum THs  and CV physiological parameters . This could be due to the development of tolerance resulting from the downregulation of CB1R. This study further revealed that cannabis might have association with the positive, negative, and manic symptoms in different schizophreniform, schizoaffective symptoms, manic disorders, and mild depression.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.via testament no: 08/EC-16/Pharm. Dated 12.07.2015. The patients/participants provided their written informed consent to participate in this study.The studies involving human participants were reviewed and approved by Institutional Review Board of the Lady Reading Hospital, Peshawar, Pakistan vide reference No: 10. Dated; 01.06.2015 and Department of Pharmacy, University of Peshawar AM performed all the experiments and wrote the manuscript. SU, FS, and ZN supervised the research team and edited the manuscript. SH, FK, and AKha participated in the data interpretation. AKhu, MUKS, and SA performed literature study and data compilation. AE-S and TE provided the technical assistance. BJ and JA reviewed and edited the manuscript. All authors have read and approved the manuscript.The current work was funded by Taif University Researchers Supporting Project Number (TURSP-2020/202), Taif University, Taif, Saudi Arabia.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.


Diabetic foot ulcers are a major complication of diabetes mellitus (DM), when heparin and heparin related substances may be potentially used as an adjuvant treatment. We aimed to evaluate the efficacy and safety of heparin and heparin related substances for the treatment of diabetic foot ulcers.We searched up to March 2021 in the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; EBSCO CINAHL; VIP Chinese Science and Technique Journals Database; China National Knowledge Infrastructure (CNKI) Database and Wan Fang Database investigating heparin or heparin-related substances in patients with diabetic foot ulcers. The primary outcomes included proportion of ulcers completely healed and time to complete ulcer healing. We assessed each included study with the Cochrane ‘Risk of bias’ tool and used the GRADE approach to assess the overall quality of the evidence.We included nine randomized studies involving 620 participants in the meta-analysis, involving two different heparin and heparin-related substances, low molecular weight heparin (LMWH) and hyaluronic acid. Our study did not show the benefits from LMWH on increasing chance of the ulcer healing  or shortening the time to complete ulcer healing . Hyaluronic acid may improve the complete ulcer healing  and shorten the time to complete ulcer healing . Hyaluronic acid and LMWH were generally well tolerated for treating diabetic foot ulcers in this review.Hyaluronic acid may improve diabetic foot ulcer with very low quality evidence but not LMWH. However, the benefits and harms need further validation in larger trials with different population.https://www.crd.york.ac.uk/prospero/], identifier .[ Heparin and related substances are glycosaminoglycans that exist naturally inside the cell and in the extracellular matrix , 2. TheyDiabetic foot ulcer is the most serious and costly complication of diabetes mellitus (DM). If the people with diabetic foot ulcer are insensitive to untreated sores and infection, it may lead to ulceration and subsequent limb amputation , 5. It oThis systematic review was written based on the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA). This systematic review was registered on International Prospective Register of Systematic Review .We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, VIP Chinese Science and Technique Journals Database, China National Knowledge Infrastructure (CNKI) Database, and Wan Fang Database, for articles published up to March 2021, using the keywords: “heparin and related substances”, “diabetic foot ulcers”. Medical Subject Heading (MeSH) was also used during the search when applicable (Studies were included if they met the following criteria: (1) Participants: participants with type 1 or type 2 DM with foot ulcers of any level of severity. Diagnosis of DM was according to the American Diabetes Association, Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus . OtherwiIndependently, two review authors  extracted data from the primary publications and from any associated online appendices using a standardized data extraction form. This extraction form included the following data: the last name of the first author, year of publication, sample size, duration of follow-up, intervention strategy, characteristics of participants , funding and outcome.Independently, two review authors  assessed each included study with the Cochrane ‘Risk of bias’ tool . This in2 test. Fixed-effect model was used to pool the data from the studies without significant statistical heterogeneity. If the heterogeneity was statistically significant, random-effect model was used and possible sources of heterogeneity were explored. Subgroup analyses according to the duration of follow-up, using that provided in each included study. We defined short-term follow-up as 1 to 12 weeks, long-term follow-up as from > 12 weeks to 24 weeks, and unknown follow-up.We reported estimates for dichotomous data  as risk ratios (RR) with 95% CI. We reported estimates for continuous data  as mean differences (MD) with 95% CI or, if different scales were used, standardized mean differences (SMD) with 95% CI. We considered clinical heterogeneity . Statistical heterogeneity was evaluated using the χ2 test . Heterogeneity across studies was evaluated using the IAll analyses were carried out using Review Manager 5.3.5 .Our study selection process is illustrated in The characteristics of the studies are shown in 2 and the maximum was 8.8 cm2 [Only one study did not report the age of participants , while tLow-molecular-weight heparin (LMWH) was used in two studies , 11, andSeven studies reported an adequate sequence generation and we judged them to have a low risk of bias for this domain , 21, 22,Two studies with a total of 155 participants  reported the proportion of ulcers completely healed , 11. We 2 = 0%, P = 0.46). We used the fixed-effect model in the analysis: RR 1.26, 95% CI 0.78 to 2.04; P=0.35.In a sensitivity analysis for one study , two parSubgroup analyses were carried out according to different duration of follow-up  reported data on time to complete ulcer healing . LMWH wa2 = 0%, P = 0.41), so used the fixed-effect model in the analysis. LMWH was not associated with a statistically significant reduction in the proportion of amputations   reported on amputation , 11. We  P=0.08) Figure 4Subgroup analyses were carried out according to different duration of follow-up  reported adverse events . The adv2 = 39%, P = 0.13), and a fixed-effect model was used in the analysis   reported the proportion of ulcers completely healed –22. Hyal0.00001) Figure 52 = 26%, P = 0.23), and a fixed-effect model was used in the analysis. Hyaluronic acid was associated with a statistically significant increase in the proportion of ulcers completely healed in the sensitivity analysis .We performed a sensitivity analysis for three studies in which there had been substantial dropouts , 19, 22.Subgroup analyses were carried out according to different duration of follow-up , and a fixed-effect model was used in the analysis. Hyaluronic acid was associated with a statistically significant reduction in the time to complete ulcer healing   reported the data on time to complete ulcer healing , 20, 22.0.00001) Figure 6Subgroup analyses were carried out according to different duration of follow-up  reported on amputation at the end of follow-up . HyaluroSubgroup analyses were carried out according to different duration of follow-up , and so we used the random-effects model for analysis. Hyaluronic acid was not associated with a statistically significant increase in adverse events . Three studies with a total of 265 participants  reported serious adverse events , and so we used a random-effects model in the analysis. Hyaluronic acid was not associated with a statistically significant increase in serious adverse events . We carried out a sensitivity analysis for three studies  compared with controls . But we LMWHs are a class of anticoagulants that includes enoxaparin, nadroparin, dalteparin, tinzaparin, bemiparin, and reviparin . StudiesAlthough there has been systematic review published before , this isOur research had several limitations. Firstly, we intended to include people with type 1 or type 2 diabetic foot ulcers according to the American diabetes association (ADA). However, only one study described participants with DM according to the diagnostic criteria of the ADA 1997; the remaining included studies did not describe the diagnostic criteria they used for DM. Secondly, although the studies used the Wagner grading system for ulcers , the staIn conclusion, Current evidence suggests that hyaluronic acid could be a potentially beneficial therapy that promotes the healing of diabetic foot ulcers compared with conventional therapy, and that better methods of administration would be to use dressings of an autologous fibroblast-hyaluronic acid complex and hyaluronic acid gel. However, the low, or very low, quality of the current evidence means that this conclusion may be substantially affected by any future studies. Meta-analysis of trials that compared treatment with LMWH to conventional ulcer therapy showed no significant improvement for either treatment regimen. Therefore, it is recommended that hyaluronic acid may be used for diabetic foot ulcer but not LMWH. In addition, high quality randomized controlled trials are needed to assess the effects of LMWH for diabetic foot ulcers.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/Design: NS and YZhao. Data curation: NS, HZ, and TX. Formal analysis: NS and XL. Methodology: BW and LD. Writing manuscript: NS, TX, XL, HZ, BW, SZ, YZhou, LD, and YZhao. All authors contributed to the article and approved the submitted version.NS was supported by grants from Health Commission Program (grant number 2020-111) and 1.3.5 Project for Disciplines of Excellence, West China Hospital, Sichuan University (grant number 2018HXFH048).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.


Lead poisoning is often considered a traditional disease; however, the specific mechanism of toxicity remains unclear. The study of Pb-induced alterations in cellular metabolic pathways is important to understand the biological response and disorders associated with environmental exposure to lead. Metabolomics studies have recently been paid considerable attention to understand in detail the biological response to lead exposure and the associated toxicity mechanisms. In the present study, wild rodents collected from an area contaminated with lead (N = 18) and a control area (N = 10) were investigated. This was the first ever experimental metabolomic study of wildlife exposed to lead in the field. While the levels of plasma phenylalanine and isoleucine were significantly higher in a lead-contaminated area versus the control area, hydroxybutyric acid was marginally significantly higher in the contaminated area, suggesting the possibility of enhancement of lipid metabolism. In the interregional least-absolute shrinkage and selection operator (lasso) regression model analysis, phenylalanine and isoleucine were identified as possible biomarkers, which is in agreement with the random forest model. In addition, in the random forest model, glutaric acid, glutamine, and hydroxybutyric acid were selected. In agreement with previous studies, enrichment analysis showed alterations in the urea cycle and ATP-binding cassette transporter pathways. Although regional rodent species bias was observed in this study, and the relatively small sample size should be taken into account, the present results are to some extent consistent with those of previous studies on humans and laboratory animals. Lead (Pb) has been and continues to be widely used in industrial activities, owing to its favorable characteristics including ease of smelting and processing, etc. However, it is well established that Pb is a toxic metal that enters the body through the environment, such as soil, dust, water, and food. Numerous previous studies have reported the toxicity of Pb at cellular, tissue or organ levels, which results in biochemical and physiological disorders ,2. Lead The study of Pb-induced alterations in cellular metabolic pathways is important to further understand the biological response and disorders associated with environmental exposure to Pb . MetabolThe town of Kabwe is the capital of the central province of the Republic of Zambia with a long history of Pb and zinc mining, which operated for nearly a century until its closure in 1994. Because of inadequate environmental pollution control during the period of mining activity, high levels of Pb have been reported in the environment , wild anWe aimed to elucidate the metabolic signatures in the affected biological systems induced by exposure to Pb. For this purpose, we selected the well-studied terrestrial animal model of wild rodents. This was the first study investigating the effect of exposure to Pb on metabolomics using field animals.g. Subsequently, the supernatants of plasma samples, as well as the liver, kidney, and remaining whole blood samples were stored at −20 °C. The samples were transported to Japan in cooler boxes for laboratory analysis in the Laboratory of Toxicology, Faculty of Veterinary Medicine, Hokkaido University , after an international sanitary certificate was obtained from the Zambian Ministry of Fisheries and Livestock (No. 20599).The sampling was performed with permission and strict adherence with the guidelines from the Zambian Ministry of Fisheries and Livestock, as well as the Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Japan . In September 2020, wild rodents were captured in two areas of Kabwe District including Mutwe Wansofu (N = 18) and Kang’omba (N = 10). The Mutwe Wansofu was considered polluted because the sample collection point of Mutwe Wansofu is located immediately south to the mine site (distance: ≤250 m). The Kang’omba area is located approximately 5 km from the mine site; therefore, it was included as the control site . Box-typ® Genomic DNA purification kit  for species identification through the cytochrome b  gene with accession number JX887164.1. The identification method was slightly modified from the original method [® PCR master mix  and 0.2 µM of each primer. The purification of the PCR products was performed using the QIAquick® PCR purification kit  according to the instructions provided by the manufacturer. Sequencing was performed by Fasmac Co., Ltd. . The rodent species were identified from the obtained sequences through blast analysis using the National Center for Biotechnology Information website.Genomic DNA was extracted from liver samples using the Wizardl method . The useRattus rattus (R. rattus) and Mastomys natalensis  were estimated based on the weight of the desiccated eye lens using a slightly modified version of the methods originally described by Tanikawa [y is the age (in days), and x is the total weight of both lenses (in milligrams).The ages of Tanikawa  and FichTanikawa . After tTanikawa ,24:y = 13) and rinsed at least twice with distilled water. We confirmed that there was no metal contamination through the analytical procedures using the regent (digestion) blank measurement. Whole blood, liver, and kidney samples were digested for metal analysis using a method described in a previous study [All laboratory materials and instruments used in the heavy metal analysis were washed with 2% nitric acid . Replicate analysis of these reference materials showed good accuracy (relative standard deviation was <3%) and recoveries (95–105%). The instrument detection limit was 0.001 µg/L.The concentration of Pb in the extracted solutions was determined by using an inductively coupled plasma–mass spectrometer , following the procedure previously described by Nakata et al. . AnalytiThe imported plasma samples were transported to the Center for Preventive Medical Sciences, Chiba University  for the metabolome analysis. A solution containing methanol, ultrapure water, and chloroform (5:2:2 in volume ratio) was prepared. Methanol  and chloroform  were purchased from Wako Pure Chemical Industries , while ultrapure water was obtained using an RDF280NC system . Each plasma sample (10 µL) was mixed to prepare QC. Fifty microliters of plasma samples and QC were mixed with 250 µL of the solution and then mixed with 10 µL of internal standard solution containing 0.2 mg/mL of adonitol  in methanol and centrifuged . Subsequently, 200 µL of Milli-Q water was added to 250 µL of supernatant. The samples were centrifuged again . To remove ethanol, the supernatants were placed in a centrifugal evaporator  equipped with a vacuum system  for 2 h. Next, the residues were placed in a pre-cooled (at −80 °C) glass tube for overnight freeze-drying using FDS-1000 .®-5Sil MS column  was used for GC separation. For quality assurance, QC samples were analyzed at the beginning of the sequence and every seven samples, as well as a pyridine blank at the beginning. Additionally, a hydrocarbon mixture standard   was analyzed at the end of the sequence for the correction of retention time. Peak selection and annotation were performed using MS-DIAL version 4.36 with GC–MS DB-Public-KovatsRI-VS3.msp library [Methoxyamine hydrochloride  , which was dissolved in pyridine  immediately prior to use, was added to the freeze-dried samples for reconstitution. Subsequently, the reconstituted samples were incubated  for the first derivatization of methoxylation. For the second derivatization of trimethylsilylation, 40 µL of N-methyl-N-trimethylsilyl-trifluoroacetamide was added and centrifuged  after incubation . Finally, the supernatant was transferred to the gas chromatography–mass spectrometry (GC–MS) vial. Within 24 h after the completion of derivatization, the metabolome analysis was demonstrated using JMS-Q 1500GC  quadrupole mass spectrometer equipped with an Agilent 7890B gas chromatograph and a 7693 autosampler . An Rxi library . Peak het test, Mann–Whitney U test, and Shapiro–Wilk test were performed using the IBM SPSS Statistics version 26.0 software  to examine the differences in animal characteristics and levels of Pb between groups, as well as the data normality. The Shapiro–Wilk test revealed lack of data normality for the body weight, estimated age, and levels of Pb in blood, liver, and kidney. Thus, the data were log-transformed and subsequently confirmed for normal distribution using the Shapiro–Wilk test, except for body weight. For this reason, the differences between groups for body weight were examined using the Mann–Whitney U test without log-transformation, while the t test was used for the other parameters after log-transformation. A p value of <0.05 denoted statistically significant differences.The U test and Shapiro–Wilk test were used to investigate the differences in metabolites across sampling sites. Metabolomes were modeled through “least absolute shrinkage and selection operator” (lasso) [2) was used to further assess the lasso linear regression models. Parameters that optimized the R2 were determined numerically. Metabolites retained with variable importance of >0 in the linear and logistic regression with L1 regularization models were considered potential biomarkers. Furthermore, random-forest analysis for regression analysis was performed to distinguish the sampling location based on the metabolome profile and levels of Pb in blood, but the levels of Pb in the liver and kidney, species, and sex were excluded. Metabolites with a p value of <0.05, calculated using the permutation variable importance method [p values were adjusted by controlling the false discovery rate (FDR) [p value of <0.05 in random forest analysis .The R packages in R.4.0.5  were use (lasso)  using th (lasso)  and rand (lasso)  using th (lasso)  involvin (lasso)  in the R (lasso)  and the  (lasso)  in the R (lasso) . Logisti (lasso) . In all e method  and showe method  to distite (FDR) . A strinte (FDR) , the Humte (FDR) , and thete (FDR)  identifiR. rattus and one M. natalensis) collected from Mutwe Wansofu and 10 rodents  collected from Kang’omba were used for further analysis; notably, there was a species bias across the areas. The Mann–Whitney U test demonstrated the significantly greater body weight of rodents collected from the polluted site versus the control site. In contrast, the t test showed that the estimated age of animals was significantly higher in the control site versus the polluted site. The measured levels of Pb in blood, liver, and kidney showed significant elevation in the samples collected from the polluted site, confirming the pollution status.Data on the identified species, estimated age, body weight, as well as Pb levels in the blood, liver, and kidney, are summarized according to species and area in The GC–MS analysis detected a total of 25 target metabolites in >50% of plasma samples (<40% coefficient of variation). The clustering pattern of samples was visualized through PCA . The PCAp = 0.011) and phenylalanine (p = 0.031) in the polluted site versus the control site. A marginally significant increase in the levels of hydroxybutyric acid (p = 0.099) in the polluted site was also exhibited. The correlation matrix for the rodent characteristics and concentrations of Pb is shown in p = 0.07).p value of <0.05 . As a result, only two metabolites  were identified as important variables in the lasso for the regression model . In the of <0.05 . Of thesAnalysis using MBROLE2 at FDRs of <0.2 and at least two compounds per metabolic pathway revealed that the candidates were associated with various pathways  transporters) for both the lasso logistic regression model and random forest model. In the same analysis, the jasmonoyl-amino acid conjugates biosynthesis I; jasmonoyl-amino acid conjugates biosynthesis II; biosynthesis of alkaloids derived from ornithine, lysine and nicotinic acid; glucosinolate biosynthesis; and tropane, piperidine, and pyridine alkaloid biosynthesis pathways were recorded for the random forest model only .R. rattus and M. natalensis, respectively. Mastomys is the most widespread kind of rodent in the African continent [R. rattus is well investigated and widely used as a sentinel animal in environmental research. Anatomical and morphological differences between these two species of rodents have been reported [M. natalensis was recently published [M. natalensis will be investigated further in the near future; however, the currently available data are limited.In this study, we captured wild rodents from a Pb-contaminated site and a control site to verify the metabolomic alterations induced by environmental exposure to Pb. This was the first study to evaluate the relationship between environmental exposure to Pb and alteration of metabolomics in terrestrial wild animals. Eighteen and 10 rodents from the polluted and control sites, respectively, were used for metal and metabolomics analysis. An animal species bias was observed in the two areas. This is one of the limitations of this study; however, due to the nature of field research, it is often difficult to avoid. Most of the animals in the contaminated and control sites were ontinent , divergiontinent ,41. Howereported ,43. Neveublished . TherefoFor the above reasons, in the data analysis, we treated all animals as a single group in each site. Although there was a significant difference in body weight and estimated age between the two sites, it is unlikely that these had a significant effect on the patterns of Pb accumulation in tissues, according to the findings of previous studies ,19. The Danio rerio) [R. rattus and M. natalensis species. Our results implied that M. natalensis rodents could be more likely to use fatty acids as an energy source than carbohydrates. However, although species differences in lipid metabolism at the class level have been determined [Our study revealed a significant increase in isoleucine and phenylalanine in the plasma of rodents collected from the Pb-contaminated site. In the PCA, these two metabolites exhibited almost identical vectors in the same direction. The correlation matrix showed a marginally significant association between the levels of Pb and isoleucine in the liver, in agreement with the significant elevation observed in the polluted site. However, the correlation matrix did not demonstrate a significant correlation between the levels of Pb and phenylalanine. Similarly, there was a marginally significant difference in the concentration of hydroxybutyric acid between areas, but it was not correlated with the concentration of Pb. Hydroxybutyric acid is a major ketone body synthesized from acetyl-coenzyme A in the liver via the fatty acid metabolism. When the energy supply from carbohydrates is insufficient, the liver compensates by promoting the degradation of lipids to produce hydroxybutyric acid. In turn, hydroxybutyric acid is used by the body as an alternative energy source. Previous studies suggested that exposure to Pb induces disturbance of the lipid metabolism in smelter workers exposed to arsenic, cadmium, and Pb , as wello rerio) . Additioo rerio)  showed ttermined , there iThe significantly higher levels of phenylalanine detected in the plasma of animals collected from the Pb-contaminated areas in this study are consistent with those previously reported that suggested the disturbance of amino acid metabolism in smelter workers . IsoleucA random-forest model was also applied to distinct areas. The model identified some amino acids, including those  highlighted by the aforementioned analyses. The identification of hydroxybutyric acid was supportive of the possible effect of Pb exposure on lipid metabolism, as suggested by previous reports ,14,45; hEnrichment analysis of altered metabolic pathways in plasma highlighted several pathways related to the degradation and biosynthesis of amino acids, as well as some chemical compounds with an FDR of <0.2. Under the concept of “Toxicometabolomics”, metabolomic studies in toxicology have become increasingly important in recent years. Conversely, metabolomic knowledge is still insufficient not only for Pb, but also for other metals. Although in vivo studies have generally taken the lead, it is desirable to accumulate knowledge in the field as in this study. In our study, it was difficult to demonstrate the further analysis regarding other metals due to insufficient sample size and sample bias. In the future, it is expected to expand the target metals to other metals and to study the combined effects of multiple metals.This was the first metabolomics study of wild rodents environmentally exposed to Pb in the field. The blood, liver, and kidneys of animals captured in the contaminated area accumulated significantly higher concentrations of Pb than those of animals in the control area. Metabolomic analysis of plasma was carried out by GC-MS. The high levels of hydroxybutyric acid detected in the contaminated area suggest an enhanced lipid metabolism in animals; however, the possibility that this observation may be due to species bias or regional dietary differences should be considered. Phenylalanine and isoleucine were identified as possible biomarkers through comparison of regional differences, lasso analysis and random-forest model. In addition to the three compounds mentioned above, the random-forest model also identified glutaric acid and glutamine. Consistent with previous studies, the urea cycle and ABC transporters pathway were identified among the altered metabolic pathways. Although the relatively small sample size and the existence of animal species bias in different areas should be considered as study limitations, the results obtained in this study are extremely important for understanding Pb toxicity and its mechanisms. Importantly, a certain degree of commonality was found between previous studies on Pb-exposed humans and experimental animals and the present study on wild animals.


Background: The Naples prognostic score (NPS) is established according to nutritional or inflammatory state, which has been identified as a new prognostic score for various malignant tumors. However, its prognosis prediction effect on gastric cancer (GC) patients is still unknown so far. The present work aimed to examine the NPS function in the prediction of GC prognosis.Methods: In this study, patients undergoing surgery with no preoperative therapy were retrospectively examined from June 2011 to August 2019. Typically, the total cholesterol level, serum albumin content, neutrophil-to-lymphocyte ratio and lymphocyte-to-monocyte ratio were determined to calculate the NPS. Besides, the prognostic value of NPS was evaluated by survival analyses. Time-dependent receiver operating characteristic (t-ROC) curve analysis was also carried out to compare the prognostic value of the scoring systems.Results: Altogether 1,283 cases were enrolled into the present work. NPS was markedly related to age, gender, tumor size, body mass index, vascular invasion, perineural invasion, and pTNM stage. Upon multivariate analysis, NPS was identified as an independent prognostic factor for the prediction of overall survival (OS) (P < 0.001). In subgroup analyses stratified by adjuvant chemotherapy or surgery alone, NPS was still the independent prognostic factor for OS in both groups (both P < 0.001). Furthermore, NPS exhibited higher accuracy in the prediction of OS than additional prognostic factors, as revealed by the results of t-ROC curve analysis.Conclusions: NPS is a simple and useful scoring system that can be used to independently predict the survival of GC cases undergoing surgery. Gastric cancer (GC) ranks the 5th place in terms of its morbidity, which affects 1,033,701 people annually; meanwhile, it also ranks the 3rd place among the causes of cancer-related deaths, with around 782,685 GC-related death cases being reported annually . AccumulAs a result, the present retrospective cohort study was carried out aiming to determine the prognostic value of NPS among the GC patients and to investigate the relationships between NPS and additional clinicopathological characteristics.This retrospective study assessed the patients undergoing radical surgery due to GC from June 2011 to August 2019 at the Department of Pancreatic and Gastric Surgery, the National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. The patient inclusion criteria were as follows, those histologically or cytologically diagnosed with GC, those who were followed up for over 12 months, those with no inflammatory disorder or infection , and those with no malignant tumor at other site or multiple primary malignant tumors. Moreover, the demographic, histopathological and laboratory variables of all patients were retrospectively analyzed, and relevant data were extracted from the database and patient records at our hospital.Routine blood test was performed at a week before surgery. The results of blood tests conducted at a week before surgery were acquired from the Laboratory Database of National Cancer Center . The preoperative information was extracted from each patient, which included gender, age, body mass index (BMI), TC content, serum Alb content, tumor size, absolute monocyte count (AMC), absolute neutrophil count (ANC) and absolute lymphocyte count (ALC). According to galizia et al.'s method, the serum Alb content, TC content, NLR and LMR were determined to calculate NPS  Supplem. For patIn this study, overall survival (OS), which was defined as the time between surgery and all-cause death or the last follow-up. Deaths due to causes other than GC or survivals till the end of observation period  were considered as the censored observations of OS. The last follow-up was assessed in March 2020. Survival data were extracted from medical records or through telephone interviews during follow-up visits.t-tests were applied in analyzing the continuous variables. Survival curves were plotted by the Kaplan-Meier (KM) method, and log-rank test was utilized to analyze the differences. The significant variables identified from univariate analysis were incorporated in the multivariate Cox regression analysis. Concordance indices (C-indices) were calculated to evaluate the discriminatory power of the inflammation-based scores. And the time-dependent receiver operating characteristic (t-ROC) curves and the predicted values of area under the curve (AUC) were used to compare the prognostic value of NPS, SIS, CONUT and PNI , TC content (mg/dL) ≤ 180 (P < 0.001), LMR ≤ 4.44 (P < 0.001) and NLR > 2.96 (P < 0.001).P <0.001; statistic power >80%; P < 0.001; statistic power >80%; The OS curve was statistically analyzed, as shown in P < 0.001, respectively; P < 0.001). Additionally, the decreased BMI (<18.5 kg/m2) was related to dismal OS . In terms of the tumor characteristics, the undifferentiated , diffused-type , vascular invasion , lymphatic invasion  and perineural invasion  showed marked correlation with dismal prognostic outcomes. NPS was identified as the independent factor to predict the OS upon multivariate analysis (P = 0.001), LMR ≤ 4.44  and NLR> 2.96   showed markedly extended OS compared with that in groups 1 and 2  ; Table 2In this study, the prognostic value of NPS was compared with that of more prognostic factors . As suggested by results of t-ROC curve analysis to predict OS by different scoring systems, and the AUC value was high for NPS compared with those for other scoring systems . TypicalAs suggested by this work, the preoperative NPS was related to gender, age, BMI, tumor size, perineural invasion and vascular invasion in GC patients. NPS might serve as an independent factor to predict the OS for GC cases, and a large NPS was possibly related to the dismal prognosis. Additionally, NPS was more accurate than other prognostic scoring systems developed in previous studies  in predicting OS.The biological mechanism by which NPS affects patient prognosis is possibly dependent on the serum Alb content, serum TC content, neutrophil count, monocyte count and lymphocyte count, which are easily measured before surgery. Hypoalbuminemia suggests the low nutritional status along with the elevated inflammatory level, and it may negatively affect the surivval of GC patients. In addition, hypoalbuminemia can reduce the transport of substances like fatty acid and cholesterol as well as the scavenging of free oxygen radicals, and these show adverse effects on OS. The TC content is identified to be related to patient survival and tumor development in a variety of cancer types, such as GC, since the plasma TC content and calorie intake are reduced in tumor tissues0 . LMR is As for the SIS scoring system that developed on the basis of preoperative LMR and Alb contents, it is identified to be related to survival of a variety of cancers and can serve as a creditable inflammatory-based scoring system , 20. It Compared with the existing tools to target immunonutritional interventions, our system is superior in that, by combining the oncological, nutritional, and immunological parameters, it outperforms the other existing nutritional indices in predicting the postoperative adverse events. And it targets the immunonutritional intervention to patients who may benefit the most. The results of our study indicated that early inflammation control and nutritional support might improve the prognosis for cancer patients. Preoperative identification of patient status could have several uses in clinical practice, including prognostic stratification and treatment. Early detection and improvement of malnutrition and inflammation may result in better patient outcomes .Certain limitations should be noted in this study. Firstly, selection bias was inevitable due to the retrospective nature, even though the samples were strictly selected according to the inclusion and exclusion criteria. And the significance of NPS needs to be validated using other cohorts. Secondly, patients who received NACT were eliminated from this study, but it was difficult to guarantee the identical patient status prior to blood sample collection, and our findings did not apply to GC cases after NACT.To sum up, this work suggests that preoperative NPS can serve as a simple and useful predictor to predict the prognosis of GC. Besides, NPS is also utilized as one part of the preoperative prognosis stratification as well as postoperative follow-up for the development of individual treatment for GC.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Ethics Review Committee of National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College. The patients/participants provided their written informed consent to participate in this study.JX conceived the study and wrote the manuscript. WK, HH, and FM searched the database, reviewed the studies, and collected the data. HL and SM performed the statistical analyses. YL and PJ performed revision of the manuscript. YT arranged for and provided the funding for this work and is the guarantor for this study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.