Cerebral palsy (CP) is the most common motor disability in childhood, but its causes are only partly known. Early-life exposure to toxic metals and inadequate or excess amounts of essential elements can adversely affect brain and nervous system development. However, little is still known about these as perinatal risk factors for CP. This study aims to investigate the associations between second trimester maternal blood levels of toxic metals, essential elements, and mixtures thereof, with CP diagnoses in children.In a large, population-based prospective birth cohort , children with CP diagnoses were identified through The Norwegian Patient Registry and Cerebral Palsy Registry of Norway. One hundred forty-four children with CP and 1,082 controls were included. The relationship between maternal blood concentrations of five toxic metals and six essential elements and CP diagnoses were investigated using mixture approaches: elastic net with stability selection to identify important metals/elements in the mixture in relation to CP; then logistic regressions of the selected metals/elements to estimate odds ratio (OR) of CP and two-way interactions among metals/elements and with child sex and maternal education. Finally, the joint effects of the mixtures on CP diagnoses were estimated using quantile-based g-computation analyses.The essential elements manganese and copper, as well as the toxic metal Hg, were the most important in relation to CP. Elevated maternal levels of copper (OR = 1.40) and manganese (OR = 1.20) were associated with increased risk of CP, while Hg levels were, counterintuitively, inversely related to CP. Metal/element interactions that were associated with CP were observed, and that sex and maternal education influenced the relationships between metals/elements and CP. In the joint mixture approach no significant association between the mixture of metals/elements and CP  was identified.Using mixture approaches, elevated levels of copper and manganese measured in maternal blood during the second trimester could be related to increased risk of CP in children. The inverse associations between maternal Hg and CP could reflect Hg as a marker of maternal fish intake and thus nutrients beneficial for foetal brain development. CerebraGenetic causes of CP are rare, but genetic factors may interact with risk factors, as the prevalence of CP is elevated among close relatives . Rather In utero exposure to chemicals may alone, or interacting with other factors, interfere with normal brain development leading to an early brain insult and CP. Earlier studies have found increased risk of CP diagnosis in children prenatally exposed to pharmaceuticals such as paracetamol or aspirin, as well as environmental toxicants such as pesticides and perfluoroalkyl substances (PFASs), which are known or suspected to adversely affect brain development  and lead (Pb), can contribute to neurodevelopmental disorders, and neurological and motor impairments in children . ChildreIn contrast to toxic  metals, essential elements, such as copper (Cu), cobalt (Co), selenium (Se), zinc (Zn), magnesium (Mg), and manganese (Mn), are important in human physiological and biochemical processes . A healtAlthough there are uncertainties as to whether gestational exposure to toxic metals and essential elements are associated with risk of neurological disorders like CP in the child, there is some evidence that elevated exposure to the toxic metals Pb, Hg, arsenic (As) and the essential element Mn can impair motor function in children and adolescents . For exaStudies of CP diagnoses requires very large sample sizes, due to the heterogeneity and the low prevalence of CP. The present study aims to address this question by using data from a large population-based cohort, the Norwegian Mother, Father, and Child Cohort Study . Most sThe aim of the present study is to investigate the associations between gestational levels of toxic metals and essential elements, individually and as mixtures, and risk of CP diagnoses in children using a prospective, population-based birth cohort.2.2.1.2.1.1.Participants in the current study were selected from NeuroTox, a sub-study to MoBa aimed at investigating the association of prenatal exposure to environmental toxicants and risk for neurodevelopmental and neurological disorders in children. MoBa is a population-based pregnancy cohort study conducted by the Norwegian Institute of Public Health. Participants were recruited from all over Norway during 1999–2008. The women consented to participation in 41% of the pregnancies. The cohort now includes 114,500 children, 95,200 mothers and 75,200 fathers . Blood s2.1.2.In total, 247 MoBa children with CP diagnoses , attention deficit/hyperactivity disorder (ADHD), and epilepsy. This control group was randomly sampled from the eligible MoBa sample, frequency matched with birth year and child sex to all diagnostic cases in NeuroTox applying the same inclusion criteria as for the cases. Since CP, and especially ADHD and ASD, are more prevalent among boys , more maThe current study was approved by The Regional Committees for Medical and Health Research Ethics (ref. no. 2012/985-1). Parents enrolled in MoBa gave written consent for the use of this data.2.2.n = 1,121) were analysed at ALS laboratory group’s lab in Sweden, and some (n = 105) were analysed at the University of Lund (Sweden). Internal quality control samples and procedure blanks were analysed along with each batch of samples to ensure high quality of the determinations throughout the project. Additionally, reference samples were included  that were used as project-specific quality control (QC) samples. Case, control, and QC samples were randomized to batch and blinded to the analysist. Details on analytical procedures, limits of detection (LOD), limits of quantification (LOQ) and quality control are presented in The present study used maternal blood samples from around gestation week 18. Details about the sampling procedure and handling and storage in the MoBa biobank are described in detail elsewhere . Eleven M be the measured metal/element concentration i for each participant j. M*ij is then the analytical round adjusted metal/element concentration, and is calculated as .where meanQCl represents the geometric mean of metal/element 2.3.+), maternal age at delivery (in years), gestational age, and birth weight. A minimal adjustment set was identified using directed acyclic graphs made at dagitty.net [DAGs; Textor et al.  was used to replace missing values with Amelia II in R  were selected for further analyses and entered into multivariable, adjusted logistic regression models (co-adjusted for other selected exposures) in order to obtain odds ratios (ORs) for CP. The regression model was run in each imputed dataset, and resulting ORs  were combined using Rubin’s rules  tests.2.4.2.p-value ≤0.1 and high selection probability) were included in a logistic regression model and visualized using line graphs.In order to detect possible multiplicative two-way interactions between individual metals/elements, we performed the elastic net stability selection described above. Previous studies have found associations with CP for sex and parental education , 54, 55.2.4.3.g-computation (qgcomp) analyses with the R package qgcomp  or above (N = 613) the median. Analyses were restricted to children born to term , children not born small for gestational age [SGA; Maršál et al. . The main analysis was also done without winsorizing  and on complete cases . In addition, due to multiple comparison, the results from the elastic net stability selection were assessed controlling the false discovery rate (fdr) at α = 0.05 (α = 0.1 for the interactions), according to a method proposed by Ahmed et al. , compliance with the EU General Data Protection Regulation (GDPR) and approval from the data owners. The consent given by the participants does not open for storage of data on an individual level in repositories or journals. Researchers who want access to data sets for replication should apply through helsedata.no. Access to data sets requires approval from The Regional Committee for Medical and Health Research Ethics in Norway and an agreement with MoBa.All analyses were done in R version 4.0 , using tglmnet , qgcomp   and Mg and Zn (r = 0.53).Spearman correlations between the log-transformed concentrations of the metals and elements showed low to moderate correlations , with thp = 0.018, Psel = 0.88), Hg  and Mn ; had the strongest associations with odds of CP in children. These associations did not remain when comparing with p-values adjusted for multiple comparisons , Cd*Cu , Maternal education*Cu , Hg*Mg , Maternal education*Hg , Cd*Pb , Child sex*Cu , Cu*Mn , and Co*Hg   are visualized using stratified, linear regression plots in Several two-way interactions were identified: Cu*Pb ( = 0.70) . None ofUsing qgcomp, there was no significant association between the metal/element mixture [MixAll—OR = 1.00, 95% CI = , 4.The present study is among the first to investigate the associations between multiple toxic metals and essential elements and their mixtures measured in maternal blood during pregnancy and risk of CP diagnosis in the child within a population-based birth cohort. As a first mixture approach, a penalized regression analysis was used to identify potentially important elements in the mixture in relation to risk of CP. Mn, Cu, and Hg appeared the most important. Follow-up logistic regression models of these individual elements indicated an increased risk of CP in the child associated with increased maternal levels Cu and Mn. In addition, maternal level of Hg was inversely related to CP. Using a similar approach, several two-way interactions were identified among metals/elements that appeared important for risk of CP, as well as effect measure modification by child sex and SES. The second mixture approach, investigating the joint effect of the mixture(s), revealed no significant effect for the metal/element mixture, but the mixture containing toxic metals revealed an inverse association with CP, in which Hg appeared to have the most influential, though it must be noted that since it will be missing co-confounding or co-exposure effects, it might not be very reliable. The discrepancy between the effects of the overall (MixAll) and toxic (MixTox) mixtures could point to antagonism between essential and toxic metals. None of the associations for selected metals/elements, two-way interactions or the joint mixture effect remained after adjusting for multiple comparisons. Therefore, the results must be interpreted with caution. Still, highlighted exposures herein should be considered important candidates for further studies of metal/element exposure and risk of CP in children, especially since very little knowledge exists to date on associations between toxicant and micronutrient levels during perinatal development and risk of CP.The main source of Cu exposure in humans is food, and in some cases, drinking water . Cu is aSince preterm birth is an important predictor of CP , it was The maternal blood concentration of Cu in the present study  was comparable to those in other studies, such as studies of pregnant women from Northern Norway , Poland , and Republic of Korea  . Thus, tFor the trace element Mn measured in pregnancy, a positive association (increased risk) was identified with CP in the child. The main source of Mn exposure in humans is diet, and some industrial occupations  also represent a risk for increased Mn exposure by inhalation . As for In adults, inhalation of Mn can lead to a condition called manganism, which is characterized by tremors, difficulties walking, and facial spasms. There is limited knowledge about early-life Mn exposure and neurological outcomes, but there is some evidence of adverse impact on cognition and behaviour , 89. PreThe effect size of Cu and Mn found in the present study (OR for an increase in interquartile range = 1.40 and 1.20) is comparable to effect sizes of other reported risk factors for CP, such as low and high maternal age, low SES, and maternal hypertension during pregnancy .in utero, also displayed various adverse neurological effects, some similar to symptoms of CP. The Hg concentrations in Minamata were, however, much higher  than in the present study  was inversely associated with risk of CP. This was mainly due to the inverse association between Hg and CP, reflected in the large negative weight for Hg . There wThis study has several strengths. First, it is among the first and largest studies of the association between prenatal exposure to toxic metals and essential elements, and CP diagnoses in children. Since only a relatively small percentage of children are diagnosed with CP , large sOur study has some limitations. One limitation concerns self-selection bias into MoBa, resulting in larger proportion of older mothers with high education and healthier lifestyle than the general population . A secon5.When investigating the associations between gestational levels of 11 toxic metals and essential elements, within normal population ranges, Cu, Hg, and Mn were found to be associated with CP in children. Higher maternal levels of the essential elements Cu and Mn were associated with increased risk of CP in the child. While the total mixture effect was not found to be significant, counterintuitively, an inverse association between maternal Hg levels and risk of CP was also observed, and this association was mainly found in the lower SES strata. However, the inverse association reported herein should not be interpreted as a protective effect of Hg, but rather that Hg could be acting as a marker of seafood intake and nutrients that are beneficial for brain development. Disentangling adverse neurodevelopment of Hg or other contaminants originating from seafood intake and SES remains a great challenge within environmental epidemiology. The etiology of CP is a complex and multifactorial disease. Considerable research effort remains to elucidate the role of toxicants and micronutrients and their interactions during perinatal development in the etiology of CP in children, including increased attention to Cu and Mn. Consortium studies would be preferred, in order to produce larger case groups.service@helsedata.no.The data analyzed in this study is subject to the following licenses/restrictions: data from the Norwegian Mother, Father and Child Cohort Study (MoBa) and the Medical Birth Registry of Norway (MBRN) used in this study are managed by Norwegian Institute of Public Health and can be made available to researchers, provided approval from the Regional Committees for Medical and Health Research Ethics (REC), compliance with the EU General Data Protection Regulation (GDPR) and approval from the data owners. The consent given by the participants does not allow for storage of data on an individual level in repositories or journals. Researchers who want access to data sets for replication should apply through helsedata.no. Access to data sets requires approval from the Regional Committees for Medical and Health Research Ethics in Norway and an agreement with MoBa. Requests to access these datasets should be directed to helsedata.no, The studies involving human participants were reviewed and approved by The Regional Committees for Medical and Health Research Ethics. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.KW: writing—original draft, formal analysis, and methodology. AW: writing—second draft, review, formal analysis, and editing. PS, GA, TV, HK, CT, HM, and TS: writing—review and editing. GB and SE: writing—review and editing and methodology. HA: writing—review and editing and PI NeuroTox. GV: conceptualization, supervision, writing—review and editing, and methodology. All authors contributed to the article and approved the submitted version.This study was funded by the Research Council of Norway’s “NeuroTox” project (grant no. 267984/E50). The research is also conducted as part of the project Center for Global Health Inequalities Research (CHAIN) at the Norwegian University for Science and Technology (NTNU) financed by the Research Council of Norway (project no. 288638). The Norwegian Mother, Father, and Child Cohort Study (MoBa) is supported by the Norwegian Ministry of Health and Care Services and the Ministry of Education and Research, NIH/NINDS (grant nos. 1 UO1 NS 047537-01 and 2 UO1 NS 047537-06A1).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.


Signet-ring cell gastric carcinoma is a highly malignant tumor, with the characteristics of strong invasiveness, rapid progression, a high degree of malignancy, and generally poor prognosis. The most common site of metastases is the abdominal organs, especially the liver, while delayed cutaneous metastases are rare.We report a case of cutaneous metastases on the head, groin, and thigh, which recurred 7 years after signet-ring cell gastric carcinoma surgery. The patient was diagnosed with a 2.0×1.5×1.0cm tumor at the angle of stomach, and treated with Billroth II distal gastrectomy accompanied with D2 lymph node dissection. According the pathology, the stage was pT1N3M0. Then the patient received two cycles of oxaliplatin and tegafur chemotherapy, which was discontinued due to the inability to tolerate the side effects of chemotherapy. Seven years after the surgery, the patient initially presented with a fleshy mass on the head and beaded nodules in the groin; then, the mass gradually became larger, along with the thighs turning red, swollen, and crusty. Firstly, the patient was diagnosed with “lower extremity lymphangitis” and treated mostly with anti-inflammatory, promote lymphatic return, detumescence and elastic force cannula in vascular surgery department. However, the symptoms relieved insufficient. Finally, the skin biopsy indicates a signet-ring cell gastric carcinoma cutaneous metastasis. The whole-body PET-CT examination showed multiple nodules with increased metabolism. Then the patient was transferred to The Department of Oncology for further chemotherapy.Our case highlights that gastric tumor recurrence and metastasis should be highly suspected when skin lesions appear in patients with signet-ring cell gastric carcinoma. At the same time, multidisciplinary consultation and close cooperation between surgeons, oncologists, and dermatologists are of great significance to the diagnosis and treatment of this disease. Cutaneous metastases of gastric carcinoma are extremely rare. Multiple studies have reported the prevalence of cutaneous metastases ranging from 0.2% to 2.2% , predomiA 61-year-old man was admitted to our hospital in May 2022 for three progressively enlarging masses in the left groin area and head, along with redness and swelling of the left thigh for more than half a year. He had a history of a major gastrectomy in 2015 after being diagnosed with gastric carcinoma. The patient was diagnosed with a 2.0×1.5×1.0cm tumor at the angle of stomach, and treated with Billroth II distal gastrectomy accompanied with D2 lymph node dissection. The postoperative histopathology of the primary lesion was mixed invasive adenocarcinoma, of which signet-ring cell carcinoma accounted for 80%, and tubular adenocarcinoma accounted for 20% Figure 1However, after 6 years, the patient developed a beaded nodular tumor in the left groin area and two fleshy nodules on the scalp, accompanied by redness and swelling from the upper left thigh to the groin area; there was no obvious fever or pain. This patient was diagnosed with “lymphangitis of lower limbs” in several major hospitals and was prescribed anti-inflammatory and detumescence treatment. After repeated treatment, the tumor in the left groin area and scalp gradually increased, and the skin of the left lower extremity was red, swollen, and scleroderma-like. Finally, he came to our hospital for treatment.A physical examination revealed moderate pitting edema of the left lower extremity, redness and swelling of the thigh with scleroderma-like changes, bead-like nodules of about 5*20cm in the groin area Figure 3Cutaneous metastases usually develop from breast cancer, lung cancer, colorectal cancer, ovarian cancer, and other tumors , while mThe pathogenesis of cutaneous metastases is still unclear. According to previous observations, poorly differentiated adenocarcinomas with signet-ring cell characteristics are closely related to the occurrence of cutaneous metastases. The proportion of SRC is inversely related to aggressive behavior, higher risk of metastases and poor prognosis in mixed-type gastric cancer . Some ofin situ hybridization, suggest that SRCCS harbor a similar molecular profile, regardless of the tumor location, means tailored therapy may become available for these patients in the future (Cutaneous metastasis of gastric cancer is one of the markers of an advanced tumor stage, suggesting a poor prognosis for patients, but about 61% of patients still receive active treatment with surgery, chemotherapy, or radiation therapy . Althouge future . Liu Shue future . Among tConsequently, Signet-ring cell gastric cancer has a higher incidence of long-term cutaneous metastasis than other types of gastric cancer, and the possibility of tumor recurrence and metastasis should be highly suspected when skin lesions appear in patients with a clinical history of gastric cancer. Therefore, early diagnosis and treatment is extremely important. At the same time, multidisciplinary consultation and close cooperation between surgeons, oncologists, and dermatologists are of great significance to the diagnosis and treatment of this disease.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 Ethics Committee of Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the patient for the publication of the case report and the accompanying images.QL and YL made substantial contributions to design the research work. SY and PZ made substantial contributions to collecting the clinical data. SY and PZ wrote the initial draft of the manuscript. QL and YL revised the paper for important intellectual content. All authors contributed to the article and approved the submitted version.


Brugmansia suaveolens Bercht. & J. Presl has been widely used due to the presence of different bioactive compounds. This review summarizes the latest advances and perspectives of the B. suaveolens plant species; it is a systematic literature review on aspects of botany, traditional uses, phytochemistry, pharmacology, and toxicology as therapeutic potential. In addition, 120 compounds are described, including alkaloids, flavonoids, terpenoids, steroids, amino acids, aromatics, and aliphatics. As for the therapeutic potential, it is described in extracts and compounds in the antitumor, anti-inflammatory, antioxidant, antimicrobial, antispasmodic, anticoagulant, and analgesic aspects, as well as the effects on the central nervous system. The toxicity of the genus stands out, especially the potential for organ toxicity. Therefore, this review evidenced the knowledge related to the traditional use based on the scientific research of Brugmansia suaveolens, highlighting an overview of bioactive compounds and biological and toxicological activities in order to provide a scientific basis for future studies on the value of this species for the development of new natural products. Medicinal plants have been used as inexhaustible sources of new substances with potential therapeutic effects. Chemical and pharmacological studies of natural products have been the focus of many surveys in the scientific world, aiming at the discovery of new compounds with therapeutic activity due to the high costs of research and the elaboration of synthetic medications. There are several plant species capable of generating research and development based on the claim of a given therapeutic effect, which can become a valuable tool for the discovery of new drugs ,2.Solanum lycopersicum), with major importance in agriculture, and, for the pharmaceutical industry, Atropa belladonna stands out, among others [The Solanaceae family has approximately 150 genera and 300 cataloged species. This family holds species of great economic importance worldwide; most of its species are found in tropaneal areas such as Brazil. It is considered the third most economically important plant family and the first among vegetables. Some examples of these species are tomato (g others .Brugmansia suaveolens Bercht. & J. Presl), widely cultivated as an ornamental piece due to its characteristic odor and the beauty of its flowers. Within the research scope, plants belonging to the Solanaceae family are known to produce tropane alkaloids, a group of commonly toxic secondary metabolites used as plant defense [The species from this family can be easily found in homes and gardens, such as the “trumpet tree”  and initially presented through a flowchart recommended by PRISMA ScR to indicate the evidence search flow. Subsequently, tables will be presented with information extracted from the articles included, taking into account the population, concept, and context. From the analysis of the tables, graphs will be prepared to present the correlations obtained in a didactic way. After presenting the data, they will be discussed in depth in order to list future research gaps and the limitations of the studies that will serve as a basis for further research focused on the analysis of this review.After the selection process, 108 studies met the inclusion criteria. The study selection process is shown in a flow diagram , accordiCurrently, pharmaceutical products are considered a promising market that moves a large part of the world economy with constant product innovations. In this context, natural products have wide applicability in the pharmaceutical market, in the production of new drugs, and in other economic sectors . Nature Different methods can be used to synthesize secondary metabolites with therapeutic action. Plant species can be used in these processes. Many of these substances can be highly toxic and may even be carcinogenic ,16,17.Secondary metabolites play an important role in the interaction between the environment and its defense against invaders. Vegetation has a wide variety of secondary metabolites, which are synthesized from primary metabolites . These compounds are necessary in the defense against herbivores, pathogens, and environmental stresses . They alThese substances have numerous applications, such as food additives, flavors, and industrially important products such as the development of new drugs . Some ofMedicinal plants are considered a great source of phytochemical compounds given their therapeutic activity, which enables the development of new drugs. Most natural compounds are of plant origin, such as phenolic substances and flavonoids, which are used in cancer treatment and prevention as well as for their antioxidant activity .The interest in using natural sources in the development and formulation of skin care products such as antioxidant, photoprotective, and anti-aging products is considered an alternative to conventional cosmetic products and phytomedications, contributing to the increasing interest in research and industrial application of medicinal plants ,24,25. TIn the context of discovering new herbal substances, an advantageous approach is essential when applied to samples from regions marked by high biodiversity and endemism, as the chemical diversity of natural products can reflect the biodiversity of their organisms of origin ,50.The ethnopharmacological approach is a study where the use of traditional medicine with medicinal plants constitutes the basis for the selection of test materials and pharmacological assays. Ethnopharmacology involves the observation, description, and experimental investigation of traditionally used drugs and their bioactivities. It represents a transdisciplinary concept based on botany, chemistry, biochemistry, and pharmacology ,51,52.The Solanaceae family has approximately 100 genera and 2300 cataloged species. As a holder of species of world economic importance, most of its species are found in tropaneal areas such as Brazil, where it occupies a prominent place among economically important plants. Some examples of these species are tomato (Solanum lycopersicum) and, for the pharmaceutical industry, Atropa belladonna [Brugmansia suaveolens Bercht. & J. Presl (Humb. & Bonpl. ex Willd.), considered a botanical synonym of Datura suaveolens (Humb. & Bonpl. ex Willd.), is a plant mainly used by indigenous peoples and credited with having originated in the Andes. It grows in Peru, Bolivia, and Ecuador in the Solanaceae family, genus Brugmansia, and species suaveolens; its growth is in the form of shrubs, reaching approximately 3–9 m in height, or even more in favorable conditions. It has white or pink flowers but presents color variations; it is aromatic, in the shape of a trombette, and can measure up to 15–50 cm, from where its popular name arises, “Trompete”, as well as other popular names such as “Saia Branca”, “Cartuchiller”, “Canudo”, or “Zabumba” [Zabumba” .Its leaves vary from 15–30 cm in length and approximately 10 cm in width; the best type of soil for its cultivation is in humid places, it is easily found near rivers, and the time of year for its harvest and the intensity of exposure to sunlight can significantly interfere with greater or lesser yields of tropane alkaloids [The Brugmansia species is native to South America. Previously, this species was considered a subgenus of Datura; however, more recent research shows that it should be classified within a genus of its own. Its popular use and wide distribution in the Americas demonstrate its relationship with men .Tropane alkaloids are named after nightshades and feature a tropane ring consisting of the pyrrolidine and piperidine rings. Tropanes have a bicyclic structure called the tropane ring. Nearly 150 tropane alkaloids are known, most of which are pyrrolidine derivatives such as hygrine and cuscohygrine, and the main ones are atropine, hyoscyamine, scopolamine, and cocaine. Atropine and scopolamine are potent anticholinergic agents used in therapy in the form of sulfate salts for ophthalmic use and as gastrointestinal relaxants ,55,56.®, usually in soft capsules or coated tablets of 10 mg manufactured by Boehringer Ingelheim) with indications for problems of the intestinal tract, particularly as an antispasmodic agent [Among the active pharmaceutical ingredients that have the tropane portion in their structure, the most significant in terms of volume and production value are those of natural origin, including atropine, hyoscyamine, and scopolamine. It is a group of its semi-synthetic derivatives that can be obtained by a single or more chemical steps, which can result in the formation of quaternary ammonium salts or undergo other chemical modifications or substitutions of functional groups. The biggest product in terms of production of this tropane active ingredient is scopolamine butylbromide  is presented based on the total number of studies analyzed in this review . Thus, iBrugmansia, as well as other Solanaceae, have alkaloids with wide therapeutic applications. Scopolamine and its derivatives have parasympatholytic, anticholinergic, antiemetic, and sedative actions; these substances are mainly used as pre-anesthetics. Due to their action, they become mydriatic and cycloplegic agents, with a mechanism similar to atropine [Plants from the genus atropine ,4,12.Brugmansia species differ in the concentration of atropine and scopolamine, both CNS depressants with sedative and tranquilizing properties, relevant ophthalmic action, and in the salivary, bronchial, and sweat glands. One of the adverse effects of scopolamine is drowsiness, which can also produce excitement and hallucinations. These effects are similar to those caused by toxic doses [ic doses ,12, althRegarding pharmacodynamics, scopolamine differs only quantitatively from atropine. While atropine has almost no detectable CNS effects at clinically applicable doses, scopolamine exerts prominent CNS effects at low therapeutic doses. This difference can be explained by better penetration of scopolamine into the blood–brain barrier ,12.The medicinal properties of plants can be based on phytochemical effects such as antioxidant, antimicrobial, and antipyretic activity. In this way, medicinal plants can be considered potent and promising therapeutic agents for the improvement of processes such as wound healing based on their variety of active and effective components, including flavonoids, alkaloids, phenolic compounds, and terpenoids. These metabolites can be adhered to as modern therapy due to their low cost, limited adverse effects, bioavailability, and efficacy. The emergence and development of nanoscience and technology can help improve the effectiveness of different therapies. Thus, nanoformulations have advantages over conventional therapy, providing a unique opportunity to ease the treatment of skin lesions, even for chronic wounds, and providing an efficient and fast healing process, resulting in reduced hospitalization costs .Brugmansia and bioactive compounds have led to improved validation of the species’ therapeutic potential. These extracts have been shown to have a wide range of pharmacological properties. B. suaveolens Bercht. & J. Presl species.Traditional uses of Brugmansia has different pharmacological properties, there is little research directing the proven biological activities to support these traditional uses. Recently, the anti-inflammatory activities of extracts from B. suaveolens flowers and leaves were evaluated through cellular electrophoretic analysis of NF-kB, p38α, TNFα and elastase. The data showed that the ethanol extract (100 μg/mL) from B. suaveolens inhibited NF-kB binding to DNA. The extract also shows inhibition of the p38α action with a value of 54.86 ± 2.82 μg/mL. These extracts directly altered elastase activity, with a value of 51.35 ± 0.69 μg/mL. In the elastase assay by human neutrophils, they showed release (65.98 ± 1.84 μg/mL) [B. suaveolens, further pharmacological and phytochemical studies are required to precisely identify which isolated compound is responsible for the anti-inflammatory effect.Although many traditional use reports mention that the genus 4 μg/mL) . AlthougB. suaveolens leaves and flowers was analyzed by colometry assay through reaction with -2,5-diphenyltetrazolium bromide (MTT). The results suggest that extracts (100 μg/mL) from the plants show cytotoxic effects with a value of 92 ± 0.7 μg/mL [B. suaveolens leaves led to the isolation of a new monoterpenoid with immunomodulator-mediated antitumor activity. The results showed that this monoterpenoid increased the secretion of IFN-γ, an immunological marker, and of IL-2 from peripheral blood mononuclear cells. They therefore observed an increase in the number of cell deaths in the A549 and MCF7 cell lines and showed an increase in ROS production and mitochondrial membrane disruption leading to apoptosis [The evaluation of the cytotoxicity of extracts from .7 μg/mL . Howeverpoptosis ,80.B. suaveolens was evaluated on smooth muscle contraction in rabbits. The results showed that the extract (71.5 μg/mL) had a significant antispasmodic effect [The antispasmodic activity of stem and leaf extracts from c effect . TogetheB. suaveolens stem, leaves, and flowers was evaluated by means of the disk diffusion test. The result showed that extracts from the stem of the plant exerted mild antibacterial activity, while extracts from the leaves and flowers had no antibacterial activity [The antibacterial activity of methanolic extracts from activity ,108.B. suaveolens leaves. Vogel’s method was used to record breathing patterns, and the aqueous extract was administered orally after being dissolved in distilled water. The results showed that the dose of 40 mg/kg of body weight of the aqueous extract exerted a significant effect when compared to salbutamol sulfate at a dose of 0.16 mg/kg of body weight. The presence of tropane alkaloids in the plant extract may explain its antiasthmatic activity and corroborate its traditional use.Anisa et al.  performeB. suaveolens flower extract were investigated using hotplates, muscle contractions, a formalin assay, and tail movement experiments in murines. The extracts were dissolved and administered intraperitoneally. The extract doses (100 and 300 mg/Kg) showed an increase in latency by the hotplate method, inhibiting the abdominal constrictions induced by acetic acid and producing the hypnotic effect generated by pentobarbital in a dose-dependent manner. Furthermore, both doses inhibited the formalin test phase. Similarly, the Tail-flick test shows attenuation of the response. The results suggest that the extract from B. suaveolens flowers has antinociceptive activity related to popular reports of the plant species [The antinociceptive effects of the  species ,111,112.B. candida and B. suaveolens species was tested against Leishmania amazonensis promastigotes. The findings showed that extracts from B. suaveolens flowers (86.2 ± 9.5 μg/mL) and leaves (33.9 ± 2.3 μg/mL) exerted antileishmanial activity, while B. candida extracts showed no antiprotozoal activity [The in vitro antileishmanial activity of extracts from activity . The resBrugmansia are commonly associated with toxicity due to the presence of different alkaloids, among which the presence of atropine and scopolamine in different organs stands out [It is known that species from the genus ands out ,114. Theands out ,115. Theands out .B. suaveolens species represented one of the main ornamental plants responsible for poisoning in humans from 1992 to 2009, with the highest percentage rate (5.71%) among toxic species [The  species ,118. The species .B. suaveolens flowers are also made up of essential oil, presenting a different tonality according to time alteration: before fully opening, they are yellow; at dusk, they are already fully open and white; and the next day, they are pink. The study carried out with the white flowers revealed the presence of several essential oil constituents, with 1,8-cineole (72.1%), €-nerolidol (11.7%), and α-terpineol (5.3%) identified as the main compounds. The pink flowers showed megastigmatrienone II (24.5%), nonanal (17.4%), terpinen-4-ol (10.5%), and a series of long linear hydrocarbons. These hydrocarbons were also identified in the white flowers in low concentrations, but megastigmatrienone II was not identified.According to Antony et al. (2009), the Brugmansia [Consequently, there are numerous reports of accidental poisoning by species from the genus ugmansia . TherefoBrugmansia suaveolens Bercht. & J. Presl, capable of dazzling the promising therapeutic potential of this species and making it possible to establish scientific grounds to subsidize future studies on the species. Thus, this paper contributes to understanding current knowledge and gaps in the bioactive compounds found in Brugmansia suaveolens. It also points the way for the design of comprehensive studies to further explore the composition of active and relevant phytochemicals in this species.This review is a study focused on the traditional uses, secondary metabolites, biological activity, and toxicity of Brugmansia suaveolens Bercht. & J. Presl, highlighting an overview of bioactive compounds and biological and toxicological activities in order to provide the scientific grounds for future studies on the value of this species for the development of new therapeutic agents.Therefore, this review evidenced knowledge related to the traditional use based on fundamental scientific research about


After mutual adjustment, the association for HEI-2015 (p for trend = 0.03) but not for the aMed index (p for trend = 0.59) remained significant. Among the component food groups and nutrients, higher intakes of red and processed meat, sodium, and total saturated fatty acids were associated with a higher risk of prediabetes, while moderate alcohol consumption was associated with a lower risk. In conclusion, adherence to the 2015–2020 Dietary Guidelines for Americans, as compared with the Mediterranean Diet, appeared to be more strongly associated with a lower risk of prediabetes among adults in the United States.Prediabetes presents a high-risk state for the development of various diseases and is reversible by adhering to a healthy lifestyle. We conducted this analysis to explore the associations of the Healthy Eating Index-2015 (HEI-2015) and the Alternate Mediterranean Diet Index (aMed index) with the risk of prediabetes. The data were derived from the National Health and Nutrition Examination Survey, including 20,844 participants. Multivariable-adjusted odds ratios (OR) of prediabetes and 95% confidence intervals (CI) by tertile of diet quality scores were estimated using a weighted logistic regression. Compared to those in the lowest tertile, the multivariable-adjusted OR of prediabetes for the highest tertile was 0.82 (95% CI: 0.72, 0.94;  Prediabetes, which is characterized by impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) , represeDietary elements are considered to be an important factor for diabetes prevention, especially so for at-risk individuals , but theThe Healthy Eating Index-2015 (HEI-2015)  and AlteBoth HEI-2015 and the aMed index have been extensively studied for their associations with various health outcomes ,14,15. HNHANES is a program aimed at assessing the health and nutritional status of the U.S. population. The survey combines in-person interviews and physical examinations and uses a stratified, multistage probability approach to recruit a representative sample . Our stuIn our study, data from 2007 to 2016 surveys were considered due to the applicability to oral glucose tolerance test (OGTT) results during this period. Participants below 20 years of age were initially excluded. Subsequently, participants who self-reported pregnancy, had unreliable dietary recall data, did not meet the minimum criteria of NHANES dietary interview, or had a confirmed diagnosis of type 2 diabetes mellitus (T2DM) from a doctor or other health professional, insulin or oral hypoglycemic agent usage, fasting plasma glucose levels of 7.0 mmol/L or higher, 2 h postprandial plasma glucose levels of 11.1 mmol/L or higher, or glycosylated hemoglobin A1c (HbA1c) levels above 6.5% were also excluded. A total of 20,844 participants were included in the final analysis .The current study focused on the first 24 h of dietary recall data obtained through in-person interviews ,17. DietThe components and scoring criteria of the HEI-2015 and aMed index are summarized in Prediabetes was ascertained in accordance with the diagnostic criteria defined by the American Diabetes Association (ADA) . PrediabAt baseline, sociodemographic characteristics, lifestyle factors, and body mass index (BMI) were collected through self-reporting from the standardized questionnaire data in NHANES. Ethnicity was classified into Non-Hispanic White, Non-Hispanic Black, Mexican American, and other ethnicities. Education was grouped as less than high school, high school or equivalent, and college or above. Marital status was grouped as married, previously married, and never married. Based on Liu’s report, the family poverty income ratio (PIR) was classified into three groups: ≤1.0, >1.0–3.0, and >3.0 . SmokingAll statistical analyses were conducted using sample weights, strata, and primary sampling units to ensure accurate national estimates. The baseline characteristics of the study participants were reported based on their tertile of adherence to either the HEI-2015 or aMed index. Continuous variables with a normal distribution were compared among the three groups using one-way ANOVA tests, while continuous variables with a non-normal distribution were compared using the Kruskal–Wallis test. Categorical variables were analyzed using the chi-squared test. Multivariate logistic regression was employed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for prediabetes based on the tertile of the two diet quality scores and several dietary factors.Three adjusted models were constructed to account for potential confounders. The first model was adjusted for sociodemographic variables  and total energy intake . The second model further included smoking status, drinking status, and physical activity. The full model was additionally adjusted for BMI as it could be a potential mediator for the association between diet quality and prediabetes. To compare the two diet quality scores, we further adjusted them for each other in a separate exploratory model. Multiple imputation was conducted to minimize sample size reduction due to missing covariates.2, ≥25 kg/m2). The potential interactions were assessed by testing the corresponding multiplicative interaction terms.Stratified analyses were conducted by age , sex , ethnicity , PIR , smoking status , drinking status , physical activity , and BMI  were standardized to account for a total energy intake of 1000 kcal/day . The majWe performed a set of sensitivity analyses to assess the robustness of our findings. These included the exclusion of participants with extreme energy intake  , those wp-value of less than 0.05.All statistical analyses were performed using R software (version 4.2.1). Statistical significance was considered for a two-sided Across five cycles spanning from 2007 to 2016, a total of 20,844 individuals were included in our present study. The baseline characteristics of the participants, categorized according to tertiles of the two dietary scores, are presented in p for trend = 0.005) for HEI-2015 and 0.87  for the aMed index. In a separate exploratory model, we further adjusted for the mutual diet quality score to observe the stability of the two diet quality scores. The over-adjusted OR was 0.83  for HEI-2015 and 0.98  for the aMed index.Associations of the two diet quality scores with the risk of prediabetes are presented in p for interaction > 0.05, In stratified analyses, a protective effect against the risk of prediabetes was observed for the highest tertile of both dietary scores when compared to the lowest tertile across all subgroups . In contrast, a lower risk of prediabetes was observed in men with moderate and high alcohol consumption (p for trend = 0.003) and in women with moderate alcohol consumption (p for trend = 0.050). For food components, higher intakes of total saturated fatty acids  and sodium (p for trend = 0.045) were both associated with a higher risk of prediabetes.We further explored the association of major dietary components with the risk of prediabetes using data collected by the 24 h dietary recall in the NHANES . After cIn this cross-sectional study of nationally representative samples of U.S. adults, both HEI-2015 and the aMed index were significantly inversely associated with the risk of prediabetes. Notably, the risk of prediabetes associated with HEI-2015 was lower than that associated with the aMed index, and the associated risk remained significant for HEI-2015 but not for the aMed index in the separate exploratory analysis including both indices in the same model. This result highlights the stability of HEI-2015 in predicting the risk of prediabetes in U.S. adults. All stratified and additional analyses demonstrated the robustness of our study. Furthermore, red and processed meat, TSFAT, and sodium intake were positively correlated with the risk of prediabetes, while alcohol consumption showed the opposite relationship. Dietary patterns represent the diversity of diets, with HEI-2015 and the aMed index being widely recommended. The commonality of these two patterns focuses on a high intake of fruits, vegetables, whole grains, and dairy, as well as a lower intake of red and processed meat. Compared to unhealthy diets, adherence to recommended healthy dietary patterns is generally associated with reduced risks of many chronic diseases ,26,27. IN-oxide (TMAO), branched amino acids (BCAAs), and endocrine disruptor chemicals (EDCs), in red and processed meat may contribute to the development of type 2 diabetes [Individuals with diabetes often receive specialized dietary guidance from healthcare professionals and may adopt a rigorous approach to nutritional choices in their daily lives. Therefore, we focused on the population with prediabetes alone and investigated the association between dietary patterns and the risk of prediabetes. In contrast to our study, a small cross-sectional study involving 535 participants reported that neither the aMed index nor the aHEI dietary pattern was associated with the risk of prediabetes . The disdiabetes . The associations between individual food or nutrient intake and prediabetes have been evaluated previously. Studies have discovered that red meat and TSFAT are positively correlated with the risk of prediabetes ,38, whicOur study found that alcohol consumption was significantly associated with a lower risk of prediabetes, especially in men. In a Swedish cross-sectional study, high alcohol consumption was correlated with an elevated risk of prediabetes, while high wine consumption was associated with a decreased risk among women . Given tOur study has some strengths. To the best of our knowledge, it is the first study to investigate and compare the two commonly recommended dietary patterns (HEI-2015 and aMED) for their associations with risk of prediabetes, in a nationally representative sample (NHANES). In addition, we identified the key dietary components as major contributors to the benefits of the healthy dietary patterns. Furthermore, when assessing prediabetes, we employed multiple methods in combination, rather than relying solely on HbA1c, FBG, or OGTT criteria, which ensured a more accurate evaluation of prediabetes, minimizing potential ascertainment bias. However, several limitations of this study should be acknowledged. First, due to the observational nature of the NHANES study design, causal relationships cannot be established. Second, despite efforts to adjust for confounding factors, some residual or unknown confounding may still be present. Third, the dietary data from the questionnaire in NHANES may be subject to recall bias and may not accurately reflect long-term dietary habits. Lastly, the OGTT test was only performed in a subset of participants, preventing the distinction between IFG and IGT and limiting the ability to focus on subtypes of prediabetes.Our study demonstrated that adherence to either HEI-2015 or the aMed index was significantly associated with a reduced risk of prediabetes. Furthermore, our findings suggest that HEI-2015 may be a more robust and reliable indicator compared to the aMed index for assessing the risk of prediabetes. These findings underscore the critical role of promoting healthy eating patterns as a crucial component of public health strategies aimed at preventing prediabetes and mitigating the risk of type 2 diabetes. However, further validation of our results in other large populations is warranted in future research.


Nonalcoholic fatty liver disease (NAFLD) is highly prevalent in people living with HIV (PLWH) and the expression of some microRNAs could be useful as biomarkers for the diagnosis of NAFLD. The aim of this study was to identify patterns of differential expression of microRNAs in PLWH and assess their diagnostic value for NALFD.A discovery case-control study with PLWH was carried out. The expression of miRNAs was determined using HTG EdgeSeq technology. Cases were defined as patients with severe NAFLD and controls as patients without NAFLD, characterized using the controlled attenuation parameter (CAP). Cases and controls were matched 1:1 for age, sex, BMI, CD4+ lymphocyte count, active HCV infection, and ART regimen.Serum 2,083 simultaneous microRNA transcripts were analyzed using HTG technology and compared between cases and controls. Forty-five patients, 23 cases, and 22 controls were included in the study. In the analysis of the expression pattern of the 2,083 microRNAs, no differential expression patterns were found between both groups of patients included in the study.Analysis of the microRNA transcriptome profile of nonobese PLWH with severe NAFLD did not appear to differ from that of patients without NAFLD. Thus, microRNA might not serve as a proper biomarker for predicting severe NALFD in this population. Simple The prevalence of NAFLD in people living with HIV (PLWH) is more frequent than in the general population, being approximately 34% according to a recent meta-analysis . In addi® , was introduced as a new technique to detect fatty liver disease. This method is a non-invasive technique, has low inter- and intraobserver variability (2) is lower  between January 2012 and December 2018. All patients included in this cohort had a valid baseline determination of CAP, defined as a measurement with a success rate greater than or equal to 60% and an IQR less than or equal to 30% . The CAP+ lymphocyte count, active HCV infection, and ART regimen. The inclusion criteria were: i) HIV infection, ii) being on ART, and iii) undetectable serum HIV viral load in the last 12 months. The exclusion criteria were: i) hepatitis B virus (HBV) infection, determined by the presence of surface antigen (HBAgS); ii) alcohol consumption equal to or greater than 20 grams/day; iii) BMI higher than 30 kg/m2; iv) liver cirrhosis; v) diabetes mellitus; and vi) use of lipid-lowering treatments.Cases and controls were matched 1:1 for age, sex, BMI, CD42.22), active HCV infection, and ART regimen. In addition, the percentage of absolute CD4+ lymphocytes (cells/mL), nadir CD4+ lymphocyte count (cells/mL), HIV viral load (IU/mL), and time with viral suppression of HIV (expressed in months) were also recorded.Variables collected included age (expressed in years), sex, BMI .2.3The expression of miRNAs was determined using HTG EdgeSeq technology . The HTG EdgeSeq system combines HTG’s proprietary quantitative nuclease protection assay (qNPA) chemistry with a Next Generation Sequencing (NGS) platform to enable the semiquantitative analysis of a panel of targeted genes in a single assay. qNPA chemistry does not require nucleic acid extraction from serum samples. Samples were processed in accordance with OP-00034, HTG EdgeSeq Processing (Instrument Method).To study the expression of miRNAs, the miRNA Whole Transcriptome Assay, Rev. 3 (23-August 2018) panel was used, in which the expression of 2,083 simultaneous miRNA transcripts was quantitatively measured. The analysis of the miRNAs was performed from 15 µL of serum using the HTG EdgeSeq processor. First, qNPA was used to identify and measure miRNA gene expression. The output of qNPA is protection probes corresponding to the expressed target miRNA. The results of the qNPA technique were subjected to PCR to amplify the material obtained using a pair of specific primers with barcoding for each patient. Once the amplification was carried out, the library was purified to subsequently perform quantitative PCR (qPCR) and determine the concentration of probes in each patient.® sequencer with sequencing-by-synthesis (SBS) technology, which uses in vitro clonal amplification by bridging PCR. Sequencing results were generated in FASTQ files, which were loaded into HTG Parser Software. The HTG EdgeSeq host software was used to align the FASTQ files to the probe list to collate the data. Data are provided as a data table of raw, QC raw, CPM (counts per million), and median normalized  added to each sample. The raw data obtained from sequencing were normalized by transforming the counts by fitting the total reads within each sample. Once the quantification was carried out, the library was normalized to ensure that the samples had a homogeneous input concentration to the sequencer. For this, the data obtained from the quantification were entered into the HTG EdgeSeq Library Calculator. Sequencing was performed using the Illumina MiSeq2.4The minimum sample size was calculated in a 1:1 ratio to ensure that significant differences in miRNA expression were obtained. For this purpose, a frequency of expression of each of the miRNAs of 10% in controls and 50% in cases, a statistical power of 80% and a safety level of 95% were considered. With these considerations, the minimum sample size was 38 patients (19 cases and 19 controls). Categorical variables are presented as absolute (number of cases [n]) and relative frequencies (%), while continuous variables are presented as medians (interquartile range [IQR]). The Mann-Whitney U test was performed to compare medians between the case and control patient groups.2.5Given the large number of miRNA attributes, to make the study feasible, feature selection using the Lasso technique was performed , conside2.6This study was designed and conducted in accordance with the Declaration of Helsinki. All patients signed informed consent that authorized the storage and processing of samples in routine diagnostic processes by the Biobank of the Public Health System of Andalusia. The study protocol was approved by the CEIC  with code PI18/00606.33.1Selection criteria were met by 379 patients. Of these, 45 patients (23 cases and 22 controls) were selected, achieving the minimum sample size needed. The main clinical characteristics of patients are shown in 3.2The graphical representation of the statistical process control and the quality control chart for ANT is shown in 3.3Dimensional reduction by principal component analysis revealed that both cases and controls are closely related in terms of their expression pattern of serum miRNAs Figure 1The exploratory analysis generated from the 44 study samples measured the expression of each miRNA, obtaining the raw data of the amount of expression of the miRNAs as count per million (CPM). Subsequently, the data obtained were normalized by means of transformation by the median, thus obtaining the normalized data Figure 23.4By means of the Lasso technique, the set of miRNA attributes was reduced to only 29, with the rest considered irrelevant. From this set of 29 attributes, the possible univariate correlation between each of them and the objective variable was calculated; no significant correlations were obtained in any case between any of the attributes and the group. Despite these poor univariate correlations, a second study aiming to obtain higher-level correlations among the 29 selected variables jointly and the group was performed through machine learning algorithms. These models obtained AUROC values between 0.5 and 0.61, demonstrating very poor performance; this indicates that no clear high-level correlations among the miRNA attributes and the patient group exist, since the classification methods were unable to correctly model such relationships. It should be noted that sub-analyses involving patients separated by sex and previous HCV infection yielded similar results, i.e., strong relationships are not found even when analyzing the patients by these groups independently.4Our study does not show differences in the expression pattern of serum miRNAs in PLWH patients who could be associated with the presence of NAFLD. Analysis of the normalized data did not reveal any pattern of differential expression of miRNAs between patients who had severe NAFLD and those who did not. Therefore, our results suggest that serum miRNAs are not useful as biomarkers for the diagnosis of severe NAFLD in PLWH patients.Although most of the studies that analyze the expression profiles of miRNAs in NAFLD have been carried out in the general population, the results of this study are contrary to what has been reported regarding some miRNAs linked to NAFLD , 25–27. 2) denotes another limitation of the study, since the determination of CAP in these patients may be biased, as the technique is not indicated for these patients  whose classification was not associated with the degree of NALFD Figure 2Our study has three limitations. First, patients were diagnosed with NAFLD through CAP and not using the gold standard technique, which is the histological study of liver biopsy. Second, although patients with an alcohol consumption greater than 20 grams/day were not included, this was collected on a self-reported basis. Last, our study did not include a healthy volunteer group. This aspect is of great interest to assess the possible influence of HIV infection itself on the difference in expression of miRNAs and its relationship with severe NAFLD.5This study shows that the miRNA transcriptome profile of nonobese patients with severe NAFLD do not differ from the profile of PLWH without NAFLD. Therefore, miRNAs are not ideal markers for the diagnosis of severe NALFD. Further studies are needed to determine other -omic biomarkers that could be linked to the development of severe NAFLD in this special population.The data presented in the study are deposited in public repository , with code E-MTAB-12974.The studies involving humans were approved by Clinical Trials and Ethics Committee of Hospital Universitario Ntra. Sra. de Valme. The study was approved with code PI18/00606. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.Conceptualization: FM, R-JA and RA; Data curation: FM, R-JA, MM and RA; Formal Analysis: FM, R-JA, MM and RA; Funding acquisition: RA; Investigation: FM, C-GJ, L-LP, ACG, DC-M, R-CI, C-JM, P-VI and RA; Methodology: FM, R-JA, MM, C-GJ, P-VI and AR; Supervision: R-JA and RA; Validation: FM, R-JA and RA; Visualization: FM, R-JA and RA; Writing-original draft: FM, R-JA and RA; Writing-review & edition: All authors. All authors contributed to the article and approved the submitted version.


Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the  outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA).A total of 239 patients  who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included.P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups . Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF.Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA.Level III, retrospective cohort study. Although an (inter)national algorithm for the surgical treatment of calcaneal fractures is still lacking, treatment options for calcaneal fractures have been widely described. For displaced intra-articular calcaneal fractures (DIACFs), operative fixation is considered the gold standard. The operative management of calcaneal fractures can be divided into 2 different groups: the open reduction internal fixation (ORIF) and percutaneous reduction internal fixation (PRIF). For ORIF different approaches are available, such as the extended lateral approach (ELA) and the sinus tarsi approach (STA), with each approach having its own advantages and disadvantages.18 In addition, the quality of the reconstruction via STA has proven to be similar to that of the calcaneal reconstructions performed through ELA.22In the last decade, for many indications, STA has proven to itself as an equal or even superior alternative to ELA. A postoperative wound complication rate of 5% via STA is described, which is significantly better than the 20% or more reported described for surgery performed via an ELA.16 there is a paucity comparing the surgical outcome of SF, PF, and APF while combining this with functional and quality of life patient-reported outcomes. Therefore, the aim of this study is to compare both the surgical, functional, and quality of life outcome of SF, PF, and APF via STA for DIACFs.Utilizing STA, different fixation methods can be used such as screw fixation (SF), plate fixation (PF), and more recently anatomic plate fixation (APF) specifically designed for the calcaneus and indicated for the sinus tarsi approach. Although there is literature available comparing the outcome of both SF and PF or APF,This study was granted a waiver waived by the Medical Research Ethics Committee of our hospital. Data were acquired from a database consisting of 311 consecutive patients who underwent surgical treatment via STA for a DIACF between August 2012 and January 2022. Included patients were aged 16 years or older. Patients who underwent a primary arthrodesis of the subtalar joint were excluded. After a patient was deemed eligible, written informed consent was obtained in accordance with the World Medical Association Declaration of Helsinki. Essex-Lopresti classification, and Sanders classification were determined.The following patient characteristics were collected: age, gender, affected side, smoking, length, weight, and a history of diabetes mellitus. In addition to this, fracture characteristics such as the Böhler angle (BA),BA was measured on a lateral radiograph at presentation, directly postsurgery, at 6 months and 1 year. Fracture classification and angle measurements were performed once by one of the 3 authors on the available radiographs and computed tomographic imaging. When a measurement was deemed inconclusive by one of the raters, it was discussed with the other raters in a consensus meeting and consensus was reached. Further data were collected retrospectively from the medical records in December 2022. Foot Function Index (FFI), EuroQOL-5D-3L (EQ5D-3L), and EuroQOL-5D-5L (EQ5D-5L).From 2014 onward, paper surveys were sent to the patients at approximately 18 months’ follow-up. In March 2022, an equivalent survey was sent using Castor EDC  to all patients who had a valid email address, including those who had already received a paper survey. The survey consisted of 4 different questionnaires: the American Orthopaedic Foot & Ankle Society ankle-hindfoot scale (AOFAS),The patient is positioned on a beanbag in a lateral decubitus position on the contralateral side of the injury. The injured leg is flexed at the knee and hip, and the contralateral leg is in a straight position. The beanbag is raised at the level of the ankle. As it supports the ankle, the foot is free, which allows for temporarily adding varus of the hindfoot during the procedure to visualize the subtalar joint.The STA is made from 5 mm below the tip of the distal fibula toward the base of the fourth metatarsal. The incision is usually between 3 and 4 cm in length and can be extended in the case of anterior process and/or calcaneocuboid joint involvement. The peroneal tendon sheath is preserved as much as possible, and tendons are held plantar-ward. The sural nerve is not routinely explored, but if encountered, it is freed up and protected. Following debridement, the subtalar joint and the crucial angle of Gissane are visualized. A subperiosteal lateral flap is created using a broad periosteal elevator and a No. 15 blade. Depending on the fracture type, different reduction techniques are used, which have been described previously.The primary outcomes were BA immediately postoperatively (BA post-OR) and decrease in BA after 1 year as compared to BA post-OR (∆BA).Secondary outcomes were surgical site infections (SSIs), secondary subtalar arthrodesis (SAD), implant removal, failed fixation, and patient-reported outcomes: AOFAS score, FFI score and EQ5D-index/VAS. Failed fixation was defined as a decrease in BA ≥10 degrees within 1 year (∆BA ≥ 10).P values for the patient-reported outcomes were omitted. At last, a post hoc power analysis was performed.Data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS) version 26.0 . When the test conditions were met, a chi-squared test, Fisher exact test, or Kruskal-Wallis 1-way analysis of variance was run to describe intergroup variability. A generalized linear model (GLM) was run to analyze continuous outcomes, which made it possible to adjust for significant differences in outcome predicting variables between groups. To overcome the problem of type I errors due to multiple testing, Patient characteristics are displayed in P = .352 and P = .852). Implant removal was performed significantly less in the APF group when compared to SF/PF (P = .015). Mean duration until implant removal  did not differ significantly between the groups (P = .171). Even though SF had a 2 to almost 3 times higher rate of failed fixation compared to the other groups, the amount of failed fixations did not differ significantly between groups (P = .251), given the current number of patients.In P = .788, P = .547, and P = .992), FFI , and EQ5D  scores.AOFAS, FFI, and EQ5D scores are displayed in Post hoc power analysis revealed learned that considering the common SD and primary outcomes (BA post-OR/∆BA), a minimum of 49 patients was necessary for BA post-OR and a minimum of 65 patients for ∆BA in order to have at least 80% power.Patient-reported outcomes , number of SSIs, SAD, and failed fixation were comparable between the 3 groups. A significant difference was seen in the BA post-OR, ∆BA, and number of implant removal procedures. and SF with APF7 are available for comparison.As mentioned earlier, literature comparing SF, PF, and APF for DIACFs via STA is currently not available. However, studies comparing SF with nonspecified PF who compared SF with nonspecified PF, found no significant differences in BA postoperatively, decrease in BA after approximately 1 year, and SSI between SF and PF/APF. On the other hand, Guo et al and Sato et al described results comparable to our study, despite a significantly higher implant removal rate for APF as compared to SF in the study of Guo et al. One of the possible explanations for the higher implant removal rate could be the longer follow-up (mean 44.2 months) for the APF group as compared to our study (median 29.8 months). In addition to this, Chotikkakamthorn et al showed that SF, in comparison to APF, provided inferior stability of the posterior facet fixation and calcaneal varus reduction with a lower complication rate. Finally, Kir et al described a significant difference in the amount of reinterventions, complex regional pain syndrome, and Maryland Foot Score in favor of APF when compared to SF.Unlike the results of our analysis, Pitts et al, concluded that SF is favored over PF, it has to be kept in mind that their study combined both radiologic and functional outcome of (randomized) prospective studies and retrospective studies while not mentioning the surgical approach and potential selection bias.Although the recent systematic review and meta-analysis of Wang et al15 significant differences between the groups in favor of SF and PF were expected. Despite these expectations, the opposite was seen. The results of APF were, if not favorable, at least comparable to SF and PF. Interestingly, after exclusion of bilateral fractures, BA at presentation, BA post-OR, and ∆BA did not predict outcome for the overall population based on the AOFAS , FFI , and EQ5D  scores debating the clinical importance of BA at the different stages of treatment.An interesting observation is that the preoperative BA was significantly lower and the Sanders classification significantly higher in the APF group when compared to the SF and PF groups. This suggests that in more complex injuries, treatment with APF was favored over SF and PF. As more complex injuries are associated with a poorer outcome,Another consequence of the heterogeneity between the groups, more specifically SF and PF being performed more often in less complex injuries, is that SF and PF might falsely be considered as reliable fixation methods because of selection bias. Additionally, post hoc power analysis showed that the study is underpowered in regard to the PF. The importance is debatable, as the results show clear significant differences with SF.As APF was introduced later on the market than the other implants, the follow-up was significantly lower in the APF group when compared to both the SF and PF groups. This did not affect the primary outcome of ∆BA although it might have affected the other outcomes such as the patient-reported outcomes, amount of SAD, and implant removal. Furthermore, the improvement in skills of the surgeon performing the surgeries might have influenced the outcome as APF was introduced later and the baseline skill of the surgeon might have been higher when compared to the other groups. Additionally, as mentioned in the Results section, the time after which implant removal was performed did not significantly differ between the groups. However, big differences in the mean duration after which implant removal was performed are seen, not taking away the risk of bias due to the difference in length of follow-up for the implant removal outcome.In our opinion, the results of this study can be considered reliable because of the large cohort, simultaneous comparison of the 3 main fixation techniques, homogeneity in surgeons performing the surgeries, and length of follow-up. The main limitations were the heterogeneity between groups and the retrospective design of the study. Finally, as it could have led to bias, the unavertable loss to follow-up of 35% of patient-reported outcomes has to be noted.In conclusion, for reconstruction via the STA, (anatomic) PF is favored over SF due to the higher Böhler angle measured directly postoperatively, the lower secondary loss of Böhler angle and, for APF, a lower implant removal rate while not affecting the rate of SSIs, need for secondary arthrodesis, number of failed fixations, and functional outcome scores. However, the differences between the groups were small, indicating that probably more important in dictating outcome is the severity of the initial injury and the quality of reduction, rather than the type of implant.Click here for additional data file.Supplemental material, sj-pdf-1-fai-10.1177_10711007231176276 for Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures by Robin Eelsing, Loran B. Aronius, Jens A. Halm and Tim Schepers in Foot & Ankle International


To investigate the factors of 30-day survival in ECMO patients, establish a nomogram model, and evaluate the predictive value of the model.A total of 105 patients with extracorporeal membrane oxygenation (ECMO) were admitted to the Department of Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, from January 2018 to March 2021. Cox regression analysis screened out the risk factors. Based on the results of multivariate analysis, the nomogram model was established by using R software, and the discrimination of the model was verified by bootstrap and calibration.The results showed that sex, acute physiology and chronic health evaluation (APACHE) II score, disseminated intravascular coagulation (DIC) score before ECMO initiation and average daily dose of norepinephrine were independent risk factors for prognosis. Verify that the nomogram model is verified by bootstrap internally, and the corrected C-index is C-index: 0.886, showing a good degree of discrimination. The calibration curve  showed that the nomogram model had good agreement. The decision curve analysis(DCA) curve shows good clinical validity above the two extreme curves. Kaplan–Meier curves were drawn for patients in the tertile and compared with the first and second groups. The third group predicted the worst 30-day prognosis for ECMO patients.The nomogram prediction model constructed based on the sex, APACHE II and DIC score, average daily dose of norepinephrine can effectively screen out the factors affecting the prognosis and provide a reference for individualized treatment of ECMO patients. Refractory respiratory and/or cardiogenic failure are the most critical cases in the Department of Critical Care, with higher mortality. Extracorporeal membrane oxygenation (ECMO) has been used exponentially increasing over the last decade and is considered a lifesaving modality . HoweverA nomogram is a popular prognostic tool with the ability to predict clinical events by integrating potential risk factors . NomograThe Respiratory ECMO Survival Prediction (RESP) score  and venoFrom January 2018 to March 2021, a total of 105 adult patients underwent ECMO at the First Affiliated Hospital of Anhui Medical University, People’s Republic of China. The indications for ECMO followed the Extracorporeal Life Support Organization (ELSO) guidelines  bridge tAccording to the exclusion criteria, 63 patients were recruited for this study . BaselinThe primary outcome was 30-day survival. The secondary outcomes included survival to ECMO weaning, ECMO duration, kidney injuries accepted continuous renal replacement therapy (CRRT), and ECMO-associated complications .t test or the rank-sum test, as appropriate. Categorical variables were compared by the 2χ test. Univariate Cox regression was used to screen for variables that were significantly associated with 30-day survival in the primary cohort. The proportional hazards assumption was checked based on the scaled Schoenfeld residuals using the survival package in the R tool. Potential prognostic factors that were significant in the univariate Cox regression model were entered into the multivariate Cox proportional hazard model, in which the HR, which was used to approximate the risk of an event, was also calculated. To avoid too many variables entering into the final model and influencing the practicality of the model, a strict cut-off value of 0.05 was chosen. The backwards stepwise process based on the Akaike information criterion was used to control the overfitting of the model.Continuous variables are expressed as the mean ± SD or median (IQR), as appropriate. Categorical data are expressed as numbers (percentages). Continuous variables were compared using Student’s p value <0.05 was considered statistically significant in our study. SPSS software  and R software  were used for statistical analysis.A two-tailed A nomogram based on the results of previous multivariable analyzes was established. The calibration, discrimination and clinical usefulness of the nomogram were calculated to evaluate its performance. The area under the receiver operating characteristic curve (AUC) and Harrell’s concordance index (C-index) were used to assess the predictive capacity of the prediction model . The calP>0.05) (p < 0.05).This study used multiple interpolations to fill in the missing data . A totalP>0.05) . Clinicap < 0.05)  .In univariate analysis, the APACHE II score before ECMO initiation, average daily dose of norepinephrine, and DIC score were statistically significant. In a nonlinear trend , within Because of the APACHE II score, so the age was not included separately in the multivariate analysis. Multiple epidemiologic studies have observed sex-related differences in admission into the ICU and ICU resources , 13. TheMultivariate Cox regression analysis was used to screen out the risk factors of prognosis, and was selected to establish a nomogram chart . The speThe nomogram demonstrated good specificity for predicting 30-day survival of ECMO patients. The AUC value of the nomogram was 0.999 , when compared with the NE, Sex, APACHE II and DIC scores, displayed an area under the receiver operating characteristic (AUROC) that was higher in both sets .) had a worst outcome (0.00%) than patients in tertile 1 and 2 (100.00 and 57.14%) (p < 0.001). Compared with actual survival based on Kaplan–Meier tables, the 10-day survival predicted by the nomogram revealed good estimations of 100.00, 76.19 and 33.33% in tertile 1, 2, 3, respectively (p < 0.001). Compared with actual survival based on Kaplan–Meier tables, the 20-day survival rate predicted by the nomogram revealed good estimations of 100.00, 61.90 and 9.52% in tertile 1, 2, 3, respectively (p < 0.001)  .In recent years, with the improvement of ECMO equipment and materials, as well as the advancement of technology and the enrichment of clinical experience, the indications for ECMO have been gradually relaxed, and the number of ECMO cases for acute cardiopulmonary failure has increased significantly , 15. Desp = 0.03).Some studies have shown that the severity of diseases in men and women is similar and even more severe in men, but women admitted to the Department of Critical Care Medicine –22. Few The APACHE scoring system is widely used in critically ill patients . The APAThe DIC scoring system is established based on conventional laboratory tests . AccordiSome studies have shown that the dose of norepinephrine is related to the prognosis , and beeThis study aims to establish a predictive model of survival in ECMO patients who can guide subsequent treatment in conjunction with a line diagram and decision-making curve to choose the best plan. The line diagram can provide a more personalized way to provide prognostic information that affects 30-day survival. First, this model can be quantified with simple, clinically applicable terms. Second, it can be used to compare several different models. The line diagram shows good discerning ability, predicting that the prognosis of the 30-day survival is 0.906, the nomogram C-Index: 0.886, AIC: 167.584. The modeling curve was above the two extreme curves, and the net gain was >0, indicating that the prognostic line diagram model has certain clinical guidance for evaluating and predicting 30-day survival.Several limitations include the following: 1) The confounding factors can occur with the inclusion of each variable, which can affect the results because this study is retrospective. 2) Our study only contains parameters related to the first day in the ICU, and it might have been better to have dynamic, continuous observational analysis data on indicators during the ICU stay. 3) Our database is only a single-center study. In the future, multicenter research can be performed in different countries and regions with different economic levels, and external databases can be used for validation. These are endeavors we will pursue in the future.The APACHE II and SOFA score before ECMO initiation, MAP, DIC score and average daily dose of NE were independent risk factors for 30-day survival. The 30-day prognosis line diagram prediction model provides a reference for individual therapy. The number of patients included in this study is limited, and it is also a single-center study. In the future, analyze the correlation maybe need more samples and multi-centers research.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The demographic, physiological and hospital-outcome data were obtained from electronic medical records (EMRs). This retrospective study did not modify the existing diagnostic or therapeutic strategies. This study was approved by the Ethics Committee of the First Affiliated Hospital of Anhui Medical University and granted this study exemption from informed consent due to its retrospective nature. Ethics Approval Number: Kuai-An the First Affiliated Hospital of Medical Sciences-P2021-04-17.LC and NL designed and drafted the paper. LC, YZ, CY, HR, MS, and NL were involved in the clinical care and management of the patients. CZ and HZ analyzed the data. All authors approved the final manuscript as submitted and agreed to accountable for all aspects of the work.This work was supported by the Anhui Province Natural Fund, China (1808085MH228).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.https://www.frontiersin.org/articles/10.3389/fmed.2023.1062918/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.Click here for additional data file.


Background: Previous evidence yielded contradictory findings on the relationship between metformin and anemia. This study aims to assess whether metformin use is associated with iron-deficiency anemia (IDA) risk in patients with type 2 diabetes (T2D) in Beijing, China. Methods: Overall, 60,327 newly diagnosed T2D patients were included based on a historical cohort study design. The information pertaining to these patients was gathered from the Beijing Medical Claim Data for Employees Database. These patients were then categorized into the metformin and non-metformin groups and matched on a 1:1 propensity score based on their initial antidiabetic prescription. The Cox proportional hazards models were utilized to calculate the incidences and the hazard ratios (HRs). Results: The study enrolled 27,960 patients with type 2 diabetes, with 13,980 patients in each of the initial glucose-lowering prescription groups: metformin and non-metformin. During a median follow-up period of 4.84 years, 4832 patients developed IDA. The incidence of IDA was significantly lower in the metformin group (26.08/1000 person-years) than in the non-metformin group (43.20/1000 person-years). Among the three groups divided by the proportion of days covered by metformin, we found a negative correlation between the proportion of days covered by metformin and the risk of IDA. The risk of IDA in patients with a proportion of days covered by metformin of <20%, 20–79%, and ≥80% was 0.43 , 0.37 , and 0.91 , respectively, compared to the non-metformin group. We also performed subgroup analyses and sensitivity analyses: the incidence of IDA in the metformin group was lower than that in the non-metformin group in all subgroups, and the protective effect was more significant in subgroups of patients aged ≥65, with Charlson comorbidity index (CCI) ≥2, and with gastric acid inhibitor use. Conclusions: In Chinese patients with T2DM, metformin treatment was associated with a decreased risk of IDA admission, and this risk responded positively to the proportion of days covered by metformin. These findings suggest that metformin may have a pleiotropic effect on IDA in patients with type 2 diabetes. Our study has important clinical implications for the management of patients with diabetes and other conditions that increase the risk of IDA. Iron deficiency anemia (IDA) is a prevalent form of nutritional deficiency that affects both the developed and developing world ,2,3. In 2+ levels [Metformin is a first-line antidiabetic drug used by more than half of T2D patients that has been found to have pleiotropic therapeutic effects on various diseases ,13,14. M+ levels . The incChina has the largest number of diabetes patients in the world, and it is a region representative of developing countries with rapid economic development and lifestyle changes that bear the heavy disease burden of diabetes and its complications. In addition, the medical insurance database in Beijing has been established for a long time, covers a wide range of people, and has detailed records of the diagnosis and medication of diabetes and IDA, thus providing us with an opportunity to explore the relationship between metformin and IDA based on long-term and large samples data. Therefore, in this study, we used a retrospective cohort design to investigate the incidence and risk of iron-deficiency anemia in T2D patients using metformin.This study was conducted in Beijing, the capital city of China, which has a high level of economic development and a high prevalence of diabetes in its population, as well as complete electronic medical records . Our stun = 60,327). Exclusion criteria consisted of patients with a T2D diagnosis before 1 January 2010 or after 30 September 2012, individuals with incomplete or missing electronic medical records (n = 858), who developed iron-deficiency anemia (IDA) within one year of follow-up (n = 2494), and with gastrointestinal bleeding (n = 1335), moderate-to-severe kidney diseases (n = 712), or malignant tumors (n = 1164) at baseline. The outcome measure of iron-deficiency anemia was defined as ICD-10 codes. We also excluded patients with a history of IDA before the diagnosis of type 2 diabetes (n = 3306). In addition, records of treatment for iron-deficiency anemia were collated to check for consistency with ICD-10 codes, such as the use of iron supplements. People who used iron supplements according to the defined daily dose for more than one month were identified as having cases of iron-deficiency anemia. Due to the rigor of our matching, the remaining cases that did not meet the match were also excluded. The included patients were divided into two groups: the treated group contained patients who had ever used metformin during follow-up, while the control group contained patients who had never used metformin during follow-up. In our study, to account for the effect of any drug’s use throughout the follow-up period after T2DM and make the basic characteristics of the treated and non-treated groups more consistent, we defined any metformin use after T2DM as the treatment group. To optimize the comparability of users and non-users in terms of confounding factors, they were matched at 1:1 within a caliper of 0.01 times the standard error of the logit propensity score for age, sex, first diagnosis date, hospital rank, medical resource utilization, comorbidities, and medication prescription. The standardized mean difference (SMD) of acceptable matching was less than 0.1. Follow-up began at the index date (control group was the same as the treated group) and lasted until the date of first diagnosis of IDA, death, loss to follow-up, or 31 December 2017, whichever came first.We included patients newly diagnosed with T2D , as well as those with a textual diagnosis between 1 January 2010 and 30 September 2012, as the baseline population for our study. We observed their outcomes from entry into the cohort until 31 December 2017. Patients with complete records in the BMCDE were considered eligible for inclusion . Sex and hypertension (yes/no) were analyzed as categorical variables, while age, and CCI were analyzed as continuous variables. The Cox proportional hazards regression model was further used to estimate the hazard ratio (HR) between the two groups to examine the relationship between metformin and IDA. The association between metformin and IDA was first compared between the metformin group and non-metformin groups to estimate correlation. Subgroup analysis was also conducted by stratifying for age, sex, and CCI. And, we also conducted a sensitivity analysis to confirm the robustness of our findings, and we further controlled age, sex, T2DM diagnosis date, comorbidity index, healthcare resource utilization, and Vitamin C supplementation in the models. Patients who developed IDA within one year of follow-up were excluded. Only patients using one type of hypoglycemic drugs were included. To ensure adherence to medication, we also calculated the metformin-compliance indicator, The formula was as follows: proportion of days covered by metformin = /follow-up days.2 test were used for comparisons between different groups. A two-tailed p value < 0.05 was considered statistically significant. PSM analysis was performed using R 4.3.0. All other analyses were conducted using SAS version 9.4.We utilized mean  or median  to represent continuous variables in patient characteristics, as well as quantity (and percentage) to represent categorical variables in patient characteristics. One-way analysis of variance (ANOVA), Wilcoxon test, or χThis study included a total of 27,960 newly diagnosed T2D patients, with 13,980 patients in each of the initial glucose-lowering prescription groups: metformin and non-metformin. Of these, 4832 diabetic patients had IDA during the follow-up period. The baseline demographic characteristics of T2DM patients before and after propensity score matching are presented in As shown in p-values of log-rank tests <0.001; Furthermore, the Kaplan–Meier incidence curves showed that patients treated with metformin had a lower long-term (>2 years of follow-up) risk of IDA than those who did not receive metformin treatment, with the group with a high proportion of days covered by metformin having the lowest risk (≥80%)  in subgroups of patients aged ≥65, with CCI ≥ 2, and with gastric acid inhibitor use. The incidence of IDA in the metformin group was lower than that in the non-metformin group in all subgroups  in the metformin group was lower than that in the non-metformin group in all subgroups. Furthermore, the protective effect of metformin against IDA was observed in subgroups of patients aged ≥65, with Charlson comorbidity index (CCI) ≥2, and with gastric acid inhibitor use. The GoDARTS study mentioned earlier also found that age and comorbidity influenced the association. Previous studies lacked exploration of the role of gastric acid inhibitors. Given the high prevalence of IDA and the potential for metformin use to prevent it, these results may have important implications for the management of patients with diabetes and other conditions that increase the risk of IDA. However, it is important to note that these findings are based on observational data and do not prove causality. Further research, including randomized controlled trials, will be needed to confirm these findings and determine the optimal dosing and duration of metformin therapy for preventing IDA. Our subgroup analysis further confirmed the stability of our main results, though future studies are needed to provide evidence for different populations.Based on the results of this study, it is clear that metformin therapy may be beneficial for T2D patients in reducing the risk of IDA. The negative correlation between the proportion of days covered by metformin and the risk of IDA is particularly noteworthy. The study’s subgroup analyses provide useful information for clinicians, highlighting the importance of considering patient age, comorbidities, and medication use when selecting appropriate glucose-lowering therapies. It is important to note that this study is observational and, therefore, cannot establish causality. Other factors that were not accounted for in this study may have influenced the results. Additionally, the study population consisted of newly diagnosed T2D patients, and the findings may not be generalizable to patients with other types of diabetes. Further research is warranted to confirm the results of this study and explore the underlying mechanisms behind the observed association between metformin and IDA risk. Nonetheless, the findings of this study are promising and suggest that metformin may have additional benefits for T2D patients beyond glucose control.2+ levels. This study found that metformin increased intracellular Fe2+ and lipid ROS levels by inhibiting its UFMylation process, which reduced the protein stability of SLC7A11, which is a key iron death regulator [In recent years, several studies have explored the potential mechanisms via which metformin affects the incidence of iron-deficiency anemia (IDA), though no direct evidence has been obtained. An experiment based on mice found that metformin improved the hematopoietic function of mice and delayed tumor formation . This stegulator . The potegulator . These rThe pleiotropic effects of metformin have important implications for the treatment of type 2 diabetes and other diseases. By targeting multiple pathways, metformin has the potential to provide broad-spectrum benefits beyond glycemic control. This observation has led to increased interest in the use of metformin for the prevention and treatment of other diseases, such as obesity , osteoarThis study has several strengths. To our knowledge, it is the largest study of its kind conducted in China. The dense population and long-term detailed medical records in Beijing provide us with a good opportunity to comprehensively analyze the relationship between metformin and IDA ,39. PrevIn conclusion, our study provides evidence of a protective effect of metformin against iron-deficiency anemia (IDA) in patients with diabetes. The incidence of IDA in the metformin group was lower than that in the non-metformin group in all subgroups, and the protective effect was more significant in subgroups of patients aged ≥65, with Charlson comorbidity index (CCI) of ≥2, and with gastric acid inhibitor use. Our study has important clinical implications for the management of patients with diabetes and other conditions that increase the risk of IDA. However, further research, including randomized controlled trials, is needed to confirm these findings and determine the optimal dosing and duration of metformin therapy for preventing IDA.