Background: Stroke-associated pneumonia (SAP) is one of the common complications of stroke patients. Higher lactic dehydrogenase (LDH) and lower albumin levels were associated with SAP, but the contribution of the LDH to albumin ratio (LAR) to the risk of SAP in acute ischemic stroke (AIS) patients remained unclear.Methods: A total of 3173 AIS patients were included in this study, divided into SAP (n = 417) and non-SAP groups (n = 2756). Characteristics were compared between these two groups. The receiver operating characteristic curves (ROC) were used to evaluate the discrimination ability of the LAR, LDH, and albumin levels in predicting SAP. Logistic regression analysis was furtherly adopted to estimate the association between LAR and SAP. We also used the restricted cubic spline (RCS) to clarify the relationship between LAR and the risk of SAP.Results: LAR in the SAP group was significantly higher than that of the non-SAP group . According to the results of ROC, LAR had the highest prognostic accuracy compared to LDH and albumin (P < 0.05). Besides, the logistic regression model showed that higher LAR (LAR > 6.75) were more vulnerable to SAP , controlling the confounders. The RCS model showed that there was a non-linear relationship between LAR and the risk of SAP.Conclusion: High LAR was associated with an increased risk of SAP in patients with AIS. LAR may be a potential predictor for the incidence of SAP. Appropriate prevention measures were needed in patients with high LAR (LAR > 6.75). Acute ischemic stroke (AIS) caused by the interruption of blood flow to specific areas of the brain is a common type of stroke with high mortality, accounting for approximately 85% of acute stroke patients . These pLDH and albumin are two non-specific inflammatory biomarkers . AlbuminIn recent studies, LDH to albumin ratio (LAR) was found to be related to lung diseases, including pulmonary thromboembolism  and commThis was a retrospective study, and patients were recruited from the First Affiliated Hospital of Wenzhou Medical University between February 2013 and March 2021 . The incThe exclusion criteria were as follows: (1) fever or infectious diseases within two weeks before admission; (2) severe diseases including cancer, heart failure, renal insufficiency, acute myocardial infarction or liver dysfunction; (3) pneumonia before stroke; (4) transient ischemic attack; (5) administered with albumin during hospitalization; (6) incomplete information.n = 417) and Non-SAP group (n = 2756).As shown in The study was approved by the Ethics Committee of the First Affiliated Hospital of Wenzhou Medical University. All patient data included in the study was anonymous, so informed consent could be exempted .We obtained clinical features and demographic characteristics from self-reported electronic medical records at the time of hospital admission, which included age, gender, body mass index (BMI), hypertension, diabetes, liver disease, atrial fibrillation, smoking and drinking history, duration of hospitalization, National Institutes of Health Stroke Scale (NIHSS) score, stroke classification (TOAST criteria), dysphagia, and laboratory parameters . SAP was diagnosed according to the modified Centers for Disease Control and Prevention criteria of hospital-acquired pneumonia  during tThe National Institutes of Health Stroke Scale (NIHSS) score and dysphagia were evaluated by trained neurologists within 24 hours after admission. NIHSS score was used to assess stroke severity: 0–4, mild; 5–15, moderate; and ≥16, severe. According to the results of the dysphagia assessment, patients were managed with different diets . The LAR was calculated by dividing the LDH concentration by the albumin concentration. On the second day after admission, fasting blood samples were collected at 8:00–10:00 to measure biochemical indicators.t-test (continuous variable), and chi-square test or the Fisher's exact test . The receiver operating characteristic (ROC) curves were used to evaluate the discrimination ability of LAR, LDH, and albumin levels in predicting SAP. Multivariable logistic regression analysis was adopted to estimate the association between LAR and SAP, and the results were visualized as a forest plot. Significant variables (P < 0.05) in the univariate analysis were considered as confounders and were included in the multivariable logistic regression analysis. We also used the restricted cubic spline (RCS) to clarify the relationship between LAR and the risk of SAP. The spline was defined using 4 knots at prespecified locations according to the percentiles of the distribution of LAR, 5th, 35th, 65th, and 95th percentiles. All statistical analyses were conducted by using R v3.5.1 with P < 0.05 as the significance threshold.Descriptive statistics were used to summarize baseline characteristics. Continuous variables were expressed as median (interquartile) and mean (standard deviation). Categorical variables were evaluated by calculating frequencies or percentages. Univariate analyses were conducted to analyze differences between two groups comparison were analyzed by Mann-Whitney U test, P < 0.001). Patients in the SAP group were elder and presented longer hospitalizations, more severe dysphagia, higher NIHSS score, lower albumin, and higher levels of leukocytes, as well as LDH. Furthermore, the SAP group had a higher proportion of patients with atrial fibrillation. All the differences mentioned above were statistically significant (P < 0.05). The proportion of large artery atherosclerosis, hypertension, diabetes, kidney disease, liver disease, smoking, and drinking history did not differ between SAP and non-SAP groups  were included in this study, of which SAP patients accounted for 13.14% , and non-SAP 86.86% . The LAR of the SAP group was significantly higher than that of the non-SAP group .As was shown in P < 0.001). As was shown in P < 0.001).Based on the best cut-off value of ROC, patients were divided into high-LAR (LAR > 6.75) and low-LAR groups (LAR ≤ 6.75). The following logistic regression analysis showed that the high-LAR group (LAR > 6.75) was more susceptible to the development of SAP  and adjusted model . An OR > 1 meant LAR was a risk factor for SAP and an OR <1 meant the opposite.In addition, when LAR was included in the regression model as a continuous variable, the results remained significant in both unadjusted  LAR was strongly associated with the incidence of SAP. Patients with higher LAR (>6.75) had a nearly three-fold higher risk of SAP. (2)There was a non-linear relationship between LAR and the incidence of SAP. (3) LAR might be a potential predictor for SAP in AIS patients.LDH and albumin are both easily obtained in routine clinical practice, and both of them were related to pneumonia. Our study indicated that LAR combining LDH and albumin was associated with the risk of pneumonia in AIS patients. Patients with higher LAR (>6.75) had a nearly three-fold higher risk of SAP. Furthermore, the risk of SAP increased rapidly with the elevation of LAR when the value of LAR ranged from 6–10; while the rising trend of SAP development was relatively flat with the value of LAR <6 or > 10. There are several possible explanations for the close relationship between the LAR and SAP. The first explanation may be that both albumin and LDH can affect the immune system. Low albumin levels can lead to poor nutritional reserves and a weak immune system, which may increase the risk of pneumonia . BesidesIt is known that LDH and albumin have the potential to be affected by a variety of other non-inflammatory factors such as tumors, and these uncertainty biases may be decreased by the LAR . For anoThis study had several limitations. (1) this was a retrospective study, and we were unable to draw a causal relationship between LAR and SAP; (2) patients were recruited in a single center in China, whether the results could be applied to other regions needed further validation. (3) we only measured blood samples on admission, and we could not detect the fluctuations of LDH and albumin during hospitalization. Future studies are needed to address this issue, which will be of high value.High LAR level was associated with an increased risk of SAP in AIS patients. Patients with high LAR level (LAR > 6.75) should be alert to SAP, and more appropriate measures should be taken to reduce the risk of SAP.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 the First Affiliated Hospital of Wenzhou Medical University. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SC and WR contributed to the conception and design of the study. QH and CD collected the clinical data. QH contributed significantly to manuscript preparation. DY, QH, and CD wrote the manuscript and performed the analysis with constructive discussions. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


To develop a risk prediction tool for acute ischemic stroke (AIS) for patients presenting to the emergency department (ED) with acute dizziness/vertigo or imbalance.A prospective, multicenter cohort study was designed, and adult patients presenting with dizziness/vertigo or imbalance within 14 days were consecutively enrolled from the EDs of 4 tertiary hospitals between August 10, 2020, and June 10, 2021. Stroke was diagnosed by CT or MRI performed within 14 days of symptom onset. Participants were followed-up for 30 days. The least absolute shrinkage and selection operator (LASSO) logistic regression analysis was conducted to extract predictive factors that best identified patients at high risk of stroke to establish a prediction model. Model discrimination and calibration were assessed and its prediction performance was compared with the age, blood pressure, clinical features, duration, and diabetes (ABCD2) score, nystagmus scheme, and finger to nose test.https://neuroby.shinyapps.io/dynnomapp/) was developed for stroke risk prediction, including the variables of sex, trigger, isolated symptom, nausea, history of brief dizziness, high blood pressure, finger to nose test, and tandem gait test. The model exhibited excellent discrimination with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.889 (95% CI: 0.855–0.923), compared with the ABCD2 score, nystagmus scheme, and finger to nose test .In this study, 790 out of 2,360 patients were enrolled {median age, 60.0 years ; 354 (44.8%) men}, with complete follow-up data available. AIS was identified in 80 patients. An online web service tool (Our new prediction model exhibited good performance and could be useful for stroke identification in patients presenting with dizziness, vertigo, or imbalance. Further externally validation study is needed to increase the strength of our findings. It has been established that stroke accounts for 2–13.4% of patients presenting to the emergency department (ED) with dizziness . Stroke Many efforts have been made to differentiate stroke from other causes of dizziness. The age, blood pressure, clinical features, duration, and diabetes (ABCD2) score with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.79, and head impulse, nystagmus pattern, test of skew (HINTS) test with high sensitivity/specificity (100%/96%), are the two most widely acknowledged tools for stroke identification in patients with acute dizziness –17. The The present study sought to develop and validate a clinical prediction model based on easy-to-get predictors to identify patients with dizziness at risk of stroke in the ED.This was a multi-center, observational study that prospectively enrolled patients from August 10, 2020, to June 10, 2021. The study was conducted in the EDs at Wuhan Union Hospital, Wuhan Union Hospital West Campus, Wuhan Fourth Hospital , and Hubei Provincial Hospital of Integrated Chinese and Western Medicine. All study centers were teaching hospitals and home to the standardized resident training program. The four hospitals have a combined annual ED visit of ~200,000 patients, providing 24-h neurological consultation and emergency neuroimaging facilities.www.chictr.org.cn, ChiCTR2000037496). The research was conducted in accordance with the Declaration of Helsinki and written informed consent was obtained from all participants.The study was approved by the Ethics Committees of Tongji Medical College, Huazhong University of Science and Technology (S227) and was registered in the Chinese Clinical Trial Registry  and then sequentially with gaze directed ~30–40 degrees left, right, up, and down. In each position, the vector of the fast-beating component and the intensity of nystagmus were recorded. In addition, the nystagmus examinations were recorded by video and estimated by a third investigator. A positive result, central pattern of nystagmus, was identified when any of bidirectional gaze-evoked nystagmus (GEN), persistent vertical nystagmus scored in any position, or isolated torsional nystagmus was observed . BidirecFrom the electronic medical record system, we collected data on the arrival time, vital signs, such as body temperature, heart rate, and blood pressure, first laboratory tests of blood routine, kidney function, and coagulation parameters within 24 h after symptoms onset, and other routine laboratory parameters and administered medications by two investigators independently. Investigators were blinded to the neuroimaging findings and neurological exam abnormalities when they extracted the data.The outcome was an imaging-based definition of AIS according to the international diagnostic guidelines. All enrolled patients completed either CT or MRI with diffusion-weighted imaging (DWI) and apparent diffusion coefficient of the brain within 14 days after symptoms onset. Besides, the MRI was performed more than 48 h from symptom onset to reduce the missed diagnosis due to false-negative findings , 39. DifTo rule out the possibility of missed stroke diagnosis and avoid verification bias, all patients enrolled were followed-up by a structured telephone interview a month after onset. Participants were asked whether they had undergone any new neuroimaging test after discharge and were requested to provide imaging results once they had. Moreover, we checked for revisits to the ED or hospitalization using the electronic medical record system.We searched for predictors of stroke from keynote papers , 40–50. www.r-project.org) and SPSS . Multiple imputation was used to deal with missing data. Values of missing variates  were imputed by assuming that data were missing at random with 50 imputations. All candidate predictor variables and several relevant variables were included in the imputation model. Predictive mean matching and logistic regression were applied to impute continuous and binary variables, respectively. The normality test was performed using the Shapiro–Wilk test. Continuous variables with a normal distribution were reported as mean ± SD, and those with a non-normal distribution were reported as median . Categorical variables were presented as numbers and percentages. The t-test or Mann–Whitney U-test was conducted to compare continuous variables. Comparisons of categorical variables were performed using Fisher's exact test.Data analysis was conducted using R  of the chosen predictors.For the model development, the least absolute shrinkage and selection operator (LASSO) logistic regression was conducted to select variables that best identified patients at high risk of stroke through the selection of tuning parameter lambda (λ) , 52. Thehttp://www.shinyapps.io/).A nomogram was built to provide visualized risk prediction based on the multivariable analysis results using the “rms” R package. In the nomogram, the predicted probabilities were mapped into points on a scale from 0 to 100 in a user-friendly way. The point system works by ranking the effect estimates, regardless of the statistical significance, and it is influenced by the presence of other covariates in this model. The effect with the highest β  will be assigned 100 points on the scale, and the remaining variables are assigned a smaller number of points proportional to their effect size . The totp < 0.05 was considered statistically significant.To evaluate the stability of the model and to perform model validation, a bootstrap resampling approach was used with 1,000 iterations. Calibration of the models was evaluated using Hosmer–Lemeshow goodness-of-fit test and a calibration curve was plotted to compare the agreement between the actual stroke rates and the model predicted stroke probabilities. A 45 degrees diagonal reference line denoted the line of perfect calibration, whereas deviation above or below this line reflects underprediction or overprediction. The discrimination power of the model was assessed through an ROC curve. The AUC and Harrell's concordance index (C-index) were measured to assess the prediction performance of the model. AUCs for the prediction model and other existing methods of risk prediction were compared using the DeLong's test. To determine the clinical utility of the model, decision curve analysis (DCA) was performed to quantify the net benefits at different threshold probabilities. This method is based on the principle that the relative harm of false positives and false negatives can be represented by probability threshold. The net benefit is obtained by subtracting the proportion of patients showing false positive results from the proportion showing true positive results, and then weighing the relative harm of false positive and false negative results . A good The present study was conducted following the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) guidelines .n = 652), chronic recurrent symptoms (n = 519), history of multiple sclerosis (n = 3), patients with a history of trauma, orthostatic hypotension, medication intoxication, hypoglycemia, or a known medical or neurologic disorder (n = 316), CNS abnormalities with an NIHSS higher than 5 (n = 48), patient refusal or contraindicated for neuroimaging test (n = 17), and refusal to participate (n = 15)  . All pathttps://neuroby.shinyapps.io/dynnomapp/) based on the nomogram  = −3.907011, by applying the 1 SE of the minimum criteria (the 1-se criteria) . The mulnomogram .p of 0.769, suggesting good prediction accuracy. The calibration plot illustrated in CI) of 0.889 (95% CI: 0.855–0.923). The finger to nose test, which was a component of the nomogram, yielded a lower AUC value  than our nomogram. The AUC values of the ABCD2 score and nystagmus scheme were 0.712 (95% CI: 0.652–0.771) and 0.602 (95% CI: 0.556–0.648).The prediction accuracy of the nomogram was estimated using the Hosmer–Lemeshow goodness-of-fit test yielding a The DCA was applied to evaluate the clinical usefulness of the model. As illustrated in We developed a novel practical model to predict the risk of stroke in patients presented to the ED with dizziness/vertigo or imbalance. The model was internally validated and exhibited good discrimination and calibration power. The model incorporated eight components: sex, trigger, isolated symptom, nausea, history of brief dizziness, high blood pressure, finger to nose test, and tandem gait test. In addition, we developed a web-based calculator for efficient and individualized prediction, which could assist physicians during clinical decision-making. To the best of our knowledge, this is the first study to construct a nomogram and web-based calculator for predicting the stroke risk of individual patients with dizziness.Although many studies have been sought to explore novel approaches for early stroke recognition in patients with dizziness, few have been translated into the clinical practice. During the clinical practice, it has been established that misdiagnosis rates are high leading to treatment delay, especially in patients with posterior circulation stroke who exhibit non-specific symptoms and rarely present with unilateral weakness –59. It hThe acronym TiTrATE  is useful for targeting the examinations to help physicians make a specific diagnosis for patients with dizziness . The STAThe nomogram prediction model incorporated eight variables. Consisting with the literature, the variables of “isolated symptom” and “history of brief dizziness” were inversely associated with stroke onset while “male” and “high blood pressure” on admission were associated with a high risk of stroke in our study , 66, 67.The main strength of our study is that this study was a prospective multicenter observational study that enrolled participants from four different tertiary hospitals. Moreover, predictors incorporated in our nomogram are well defined and readily available. Then, we incorporated the prediction model into an online risk assessment calculator that could be convenient for clinical practice. Besides, our nomogram yielded significantly higher AUC values than previous models reported in the literature.Nonetheless, the present study has some limitations. First of all, although our model was internally validated by bootstrap resampling to demonstrate its applicability, external validation is essential to increase the robustness of our results. Furthermore, not all participants underwent DWI. Importantly, CT and a month of follow-up were conducted based on clinical guidelines to ensure that stroke cases were not missed, which could have significantly minimized the risk of misclassification bias . BesidesOur dynamic nomogram, which incorporates clinical data, symptoms, and physical examination, has significant value for estimating the probability of stroke in patients presenting to the ED with dizziness. If future validation is conducted, this tool may have huge prospects for helping EPs differentiate stroke from non-stroke dizziness and assist in therapeutic decision-making during clinical practice.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (S227). The patients/participants provided their written informed consent to participate in this study.YB contributed to the concept and design, data analysis and interpretation, and writing manuscript. FC performed data interpretation, writing, and final approval of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Montmorillonite (Mt) is a kind of 2:1 type layered phyllosilicate mineral with nanoscale structure, large surface area, high cation exchange capacity and excellent adsorption capacity. By virtue of such unique properties, many scholars have paid much attention to the further modification of Mt-based two-dimensional (2D) functional composite materials, such as Mt-metal hydroxides and Mt-carbon composites. In this review, we focus on two typical Mt-2D nanocomposite: Mt@layered double hydroxide (Mt@LDH) and Mt@graphene (Mt@GR) and their fabrication strategies, as well as their important applications in pollution adsorption, medical antibacterial, film thermal conduction and flame-retardant. In principle, the prospective trend of the composite preparation of Mt-2D nancomposites and promising fields are well addressed. Montmorillonite (Mt) is one of the most common 2:1 type clay minerals, which is rich in natural content and non-toxic , which cMt also exhibits promising advantages including high thermal stability, high modulus, high strength and low expansion coefficient. However, due to the hydrophilic and oleophobic properities of natural Mt, as well as poor compatibility with polymers, it fails to be widely applied. Therefore, many scholars have modified Mt and enhanced its adsorption and ion exchange properties via preparation with other two-dimensional materials , extendiEven though some researchers have made progress of the modification of Mt, the preparation of Mt@two-dimensional materials a systematic review on the composite preparation methods and applications of Mt and two-dimensional materials is still lacking . Thus, t2-xMgx)Si4O10(OH)2·(M·nH2O) . The isomorphic substitution in layers leads to insufficient charge (Fe2+ or Mg2+ replaces Al3+), and the charge is compensated by cations  absorbed in an interlayer space of Mt, which leads to its important cation exchange properties [The layer height of Mt is nearly 1 nm, and the interlayer distance is less than 1 nm, indicating Mt has a nanosized porous structure . Mt is noperties . Such a Highly depending on pH, the polymerization degree of Mt decreases as pH increases before reaching the isoelectric point. Moreover, the charge on edges and surfaces is different . The unin-isopropylacrylamide (NIPAm) to explore which chemical group was the driving force for AMPS adsorption in the surface of Mt, and finally revealed that it was the main interaction between AMPS and the clay [Currently, the modifications of Mt are mainly divided into three categories, including organic modification, inorganic modification, and organic-inorganic composite modification. For organic modification, cations in the interlayer space are exchanged by the ions with a functional group of surfactant molecules, which act as an interlayer opener . Organicthe clay . In 2015the clay  found th2+, Cd2+, Cu2+, Co2+, etc., it can quickly reach equilibrium within 10 min. Indeed, the performance of Mt, especially in terms of thermal stability and adsorption capacity of heavy metal ions, has been improved through inorganic modification.Inorganic modification is widely used for preparing Mt-based 2D composites. To enhance the adsorption capability of natural Mt for heavy metal ions, as early as the 1870s, inorganic methods were proposed to modify Mt, such as acid activation modification, inorganic salt modification and pillared modification. These methods can increase the interlayer distance and strengthen the thermal stability of Mt for using it as the adsorption material to remove heavy metal ions . Cheng eBesides, the organic-inorganic modification has also been used. Surfactant modification can greatly improve the adsorption selectivity of Mt for heavy metal ions, while it blocks the interlayer space of Mt, reducing the porosity and the adsorption capability of pollutants. However, pillared Mt can significantly increase the pore volume and surface area and has stronger tolerance to pH and coexisting inorganic ions. Therefore, preparing inorganic-organic composite modified Mt contributes to improving its adsorption capability for pollutants .The concept of two-dimensional materials was proposed in 2004, when scholars at the University of Manchester successfully prepared single-layer graphene by mechanical stripping method . Two-dim(1)Simple substances: graphene, graphdiyne, black phosphorus (BP), metals  and new boron, arsenic, germanium, silicon, bismuth, and so on.(2)3N4), boron carbon nitrogen, and various graphene derivatives.Inorganic compounds: hexagonal boron nitride (h-BN), graphite phase nitrogen carbide (g-C(3)3, metal halide, transition metal oxyhalide (MOX), III-VI layered semiconductor (MX).Metal compounds: transition metal disulfide (TMDs), Layered double hydroxide (LDH), transition metal oxide (TMOs), transition metal carbon/nitrogen/carbonitride (MXenes), metal phosphorus trisulfide APX(4)3) clay mineral .Salts: inorganic perovskite compound (AMX(5)Organic frameworks: layered metal-organic framework compounds (MOFs), layered covalent organic framework compounds (COFs) and polymers .According to the composition and structure of materials, the existing two-dimensional nanomaterials can be divided into five categories:(1)Ultra-high mechanical strength. Two-dimensional materials have strong fracture resistance, good toughness, and are ductile but not easy to break .(2)Good electrical properties. On the one hand, electrons are restricted to the limited domain of two-dimensional materials with no interlayer interaction, which can greatly stimulate the electronic properties; on the other hand, the large transverse dimension and ultra-thin thickness give them extremely high specific surface area, exposing more active sites on the surface to the greatest extent, thus they are widely used in catalysis or energy storage fields .Due to the limitation of electrons in two dimensions, two-dimensional features are unique and necessary for obtaining unprecedented physical, electronic and chemical properties . CompareAt present, many researchers have explored efficient preparation methods for two-dimensional nanomaterials . The recAmong two-dimensional nanomaterials, GR is the most powerful nanomaterial and has been widely used in many fields . MeanwhiLayered double hydroxide (LDH), also known as anionic clay or hydrotalcite-like, is a kind of mineral material composed of two or more metal elements, which is similar to the octahedral brucite layered structure. It has the characteristics of adjustable metal composition, interlayer anion, size and thickness of the laminate, etc. . The uniThe main content of intercalation assembly method is that LDH and Mt are exfoliated and intercalated to obtain composite materials. When the exfoliated LDH nanosheets are intercalated with Mt, the swelling property and high specific surface area of Mt in water can be used to increase the exposure of the inner space of LDH layer. In this way, the layered stacking structure of LDH can be changed to increase the specific surface area, and finally the composite material with chip assembly structure can be obtained. The process of synthesis of NiAl-LDH/Mt composites by Zhou et al.  is illusThere are two key challenges in the preparation of composite materials by intercalation methods. One is how to develop an effective method to peel off the laminated composite completely, and the other is how to adjust and control the assembly of nanosheets to obtain the nanocomposite with specific structure . Before Mt and LDH are closely aligned due to the interaction between interlayer ions and laminates, so stripping Mt and LDH to obtain stable sol is a prerequisite for preparing thin film materials . Most scAccording to the different stripping agents used, the LDH stripping methods can be divided into three types: stripping in short chain alcohols, stripping in formamide and stripping in water. Stripping in polar solvents such as formamide is considered to be one of the simplest and most efficient methods, which makes formamide one of the most common stripping agents .In addition, using chloroform as stripping agent is also common. Gong  and Dai However, the use of the above two stripping agents has certain limitations or potential hazards. The strong corrosive environment of the formamide stripping system limits the application of the stripped nanosheets, and the formamide solution is not volatile, which is not conducive to the synthesis of composite materials. Meanwhile, chloroform is sensitive to light. When exposed to light, it can react with oxygen in the air and gradually decompose into highly toxic phosgene, which is not only harmful to the environment but also dangerous in the preparation process. Therefore, some scholars put forward the stripping of LDH and Mt in water or other cheap degradable agents, to realize the economical and environment-friendly stripping.3-LDH by a hydrothermal method, Liang et al. [Due to the strong polarity of water molecules between LDH layers, interlayer anions with hydrophilic groups can improve the swelling performance of LDH in water. To achieve a more thorough stripping, it is necessary to balance the size of intercalated anions, as well as their relationship with hydrophilicity and hydrophobicity between laminates. Acetate, as a common short-chain carboxylate, can better meet the requirements for swelling and stripping of intercalated LDH in water . To syntg et al.  obtainedMa et al.  preparedKojima et al.  found thIn addition, some researchers used biodegradable materials such as polylactic acid (PLA) for lamellar peeling. Hu et al.  completeBecause Mt and hydrotalcite are similar in structure, the charges between layers are completely opposite. These characteristics provide natural conditions for the combination of Mt and hydrotalcite through electrostatic interaction, which have been used to combine Mt lamellae with LDH lamellae.Liang et al.  first diChen et al.  added a In-situ synthesis is a novel method to prepare composite materials. The basic principle is that different elements or compounds react chemically under certain conditions, and one or several ceramic phase particles are formed in the metal matrix, to improve the performance of single metal alloy. The reinforcement nucleates and grows spontaneously in the metal matrix, so there is no pollution on the surface of the reinforcement. The compatibility between the matrix and the reinforcement is good, and the interfacial bonding strength is high. Compared with other composite materials, the complicated pretreatment process of reinforcement is omitted, and the preparation process is simplified.Zhou et al.  pointed 2/g) of the composite obtained by intercalation method was quite different from that obtained by in-situ method (168 m2/g), which indicated that the internal structure of the composite obtained by the two methods was different.They also discovered that the specific surface area , polystyrene (PS) and high impact polystyrene (HIPS). The tape casting process has the advantages of a convenient process, adjustable size and good film forming quality . It is nIn the process of compounding Mt with LDH, there are three existing routes: in-situ synthesis methods, intercalation methods and melting methods. Most scholars use intercalation methods to combine the two materials. These can be divided into two steps: delamination and composition. Formamide and chloroform are the most common stripping agents used in lamellar stripping, and their stripping steps are quite simple and efficient. However, in some cases, they have certain use restrictions or represent potential hazards. Therefore, some scholars have been working on the use of water as stripping agent, as well as other environmentally friendly degradable materials.Heavy metal pollution can affect human health through the food chain , so how LDH, with anion exchangeability, has attracted much attention due to its unique properties in the removal of pollutants from water . On the 2+ and other heavy metal ions in water were adsorbed and thus removed. The experimental results proved that the adsorption effect was improved with the increase of temperature and the prepared Mg-Zn-Al (LDH)@Mt had better adsorption effects than LDH and Mt alone. Shehap et al. [Bakr et al.  preparedp et al.  reached p et al.  also fouWang and Li  found thSeddighi et al.  synthesiDue to their remarkable chelate effect on heavy metal ions, hydrotalcite-like materials have potential applications and economic advantages as water purification agents, which is a new research direction in recent years. Therefore, it is meaningful to further optimize the properties of the hydrotalcite and expand its application fields.Most industrial chemical reactions are carried out under the action of catalysts. Because catalysts have different degrees of activity under different conditions, it is very important to choose appropriate and efficient catalysts in industrial production. Although some reactions are catalyzed by acid sites on the catalyst surface, the base sites play a synergistic role to some extent in reactions such as alkylamine decomposition, aldol condensation and the Knoevenagel reaction, etc. . This diPu et al.  and Li eDue to metal corrosion, discarded and unusable metals account for 15% of the output in the world, while the steel equipment scrapped due to corrosion is equivalent to about 30% of the annual output . To imprSome researchers found that ion selective coatings had high protective performance . Dong etDong et al.  added LDInterestingly, bipolar anti-corrosion materials have been gradually developed, which also provides new ideas for the further development of anti-corrosion materials. Besides, we can find that Mt@LDH may have the following promising applications:(i) Sustained drug release. Mt can prevent gastrointestinal discomfort caused by other drugs and has a very high positioning ability. After oral administration, Mt can evenly cover the whole surface of the intestinal lumen and last for 6 h. As Mt is not easily absorbed after oral administration, it does not enter the blood circulation, so it is very safe during the application period and has no toxic reactions. Magnesium aluminum hydrotalcite (MgAl-LDHs) has good biocompatibility. In summary, Mt and LDH with layered structure are two clay minerals that can accommodate a large amount of drugs between the layers, making them the perfect choice for preparing drug sustained-release carriers . Chen 9 has stud+, which reduced the uncharged PA (procainamide hydrochloride) species to below pH 4, destroying the environment. Hydrotalcite has a certain buffering performance.Kevadiya and Bajaj  have als(ii) Flame retardant effect. Mt and LDH combined with other materials respectively have the effect of improving thermal stability . When hyThe advantages and disadvantages of the two materials complement each other, and the composite material should show a greater improvement in flame retardancy. However, this field is currently less studied in academia, and it is worthy of further researches in the future.Graphene, also known as “single-layer graphite sheet”, refers to a dense layer of carbon atoms wrapped in a honeycomb crystal lattice . The car2/g) [As the thinnest substance known in the universe , graphen2/g) , ultra-h2/g) , outstan2/g) , electri2/g) ,102 and 2/g) . In addi2/g) . Based o2/g) .Although the synthesis of graphene faces huge challenges, considerable progress has been made in this field of research in the past ten years or so . Many scDry-freezing is a simple and environmentally friendly method to produce Mt@GR . Its bas2 solution, and then the GO-Mt/SA were repeatedly washed five times, and finally subjected to vacuum freezing for 14 h. Adsorption experiments indicated that the GO-Mt/SA showed a better adsorption capacity towards MB (150.66 mg/g).For example, Tao et al.  added a Impregnation methods use a carrier to contain a specific solution impregnation, relying on capillary pressure to add the components into the carrier, while adsorbing on its surface. The principle and operation of vacuum impregnation are basically the same, but the porous material needs to be evacuated first, and then the impregnation liquid was added. Compared with the traditional wet impregnation method, the vacuum impregnation method produces a more uniform and efficient material.Peng et al.  producedWith the continuous development of industrial economy, more and more wastewater containing heavy metal or organic pollutants is being discharged into natural waterbodies. Due to their high toxicity, the increasing discharge volume and the non-biodegradability, heavy metal pollution and organic pollutants in dye wastewater have become one of the main problems endangering human life . TherefoCompared with traditional chemical methods, physicochemical methods and biological methods, the adsorption method has attracted much attention because of its environmental protection, high efficiency, low cost, and high removal efficiency . RecentlDue to its unique physical and chemical properties, graphene has received widespread attention as a new type of adsorbent for various heavy metal and organic pollutants, and has become a highly potential adsorbent . However2+ in wastewater.Adsorption materials based on Mt-graphene composites have been extensively studied by scholars due to their high adsorption performance, low price, and simple preparation process. The composite material, which was made by freeze-drying, hydrazine hydrate reduction, and wet impregnation , had gooSome scholars have modified natural Mt through organic and inorganic methods to improve the adsorption capacity of composite materials. Wei et al.  used the2+ and PNP were 19.79 mg/g and 15.54 mg/g, respectively. Compared with Mt and GO, the total adsorption capacity of MG for the two pollutants was significantly improved. However, while preparing materials using metal-containing catalysts, a large amount of metal waste will inevitably occur. Therefore, it is necessary to find a sustainable method to achieve environmental friendliness by improving the recyclability of adsorbent materials. Xiao et al. [Zhang et al.  used meto et al.  first pr2/g and an adsorption capacity of 0.49 mmol/g for CO2, which was 42% higher than that of other materials. This showed that clay-based materials represented by Mt were high-efficiency CO2 adsorbents. In terms of the adsorption of the greenhouse gas carbon dioxide, Stanly et al.  first syOverall, the data illustrates that Mt, as a typical natural organic compounding agent, can be compounded with graphene to reduce the stacking of graphene layers and increase the actual adsorption capacity of the adsorbent, obtaining better adsorption performance at a lower cost.According to reports, the current infections caused by bacteria are still one of the biggest health problems in the world, afflicting millions of people every year . HoweverStaphylococcus aureus (99.43%) was significantly stronger than that on Escherichia coli (84.30%).Yan et al.  mixed grEscherichia coli and Staphylococcus aureus, the antibacterial rates of 10 mg/L GM-CPB were 92.3% and 99.9%, respectively. This indicated a great improvement of the antibacterial activity of the composite. In terms of the durability of antibacterial time, many scholars have also explored and tried to improve it. Yang et al. [2O) nanocomposite material.In order to further improve the antibacterial properties, Wu et al.  have sucg et al.  used ascThrough the above exploration, it is not difficult to find that, compared with traditional antibiotics, Mt@GR composite has great advantages and potential in the field of antimicrobial medicine.According to worldwide trends, all walks of life are pursuing the use of lighter, thinner, more reliable, and more durable materials, stimulating people’s strong interest in nanotechnology. However, harmful residual products may be produced during combustion, which are not easy to decompose and can cause toxic biological accumulation . TherefoInspired by the hierarchical structure of nacre, Ming et al.  found thMithilesh and Sharif  preparedIt can be seen that the flame retardancy of the abovementioned Mt-GO composite material has been greatly improved, laying the foundation for it to become a new generation of combustion-supporting substances, and also provides a new idea for the research of developing new flame retardant materials.2/PVA in the composite film was 2:1 and the mass fraction of binary filler was 12%, the thermal conductivity of the composite film reached 66.4 W/(m·K), which was at least 132 times higher than that of pure PVA. The improvement of the structure and composition of the composite film through Mt and rGO could significantly improve the thermal conductivity of the polymer, and it also provided an idea for the preparation of other high thermal conductivity polymer composite films. Liu et al. [Plastic has become one of the most widely used materials in the world, but its inherent structural characteristics determine its low thermal conductivity. Therefore, some studies had been done to enhance the thermal conductivity of plastics. Zhu et al.  used Mt/u et al.  have sol2 nanocomposites, which provides the possibility to construct a new two-dimensional nanoelectrochemical hydrogen evolution composite material performance.Mt@GR can also be further compounded with other materials for anti-friction additives, lightweight fire-resistant conductors , or cata2, MoSe2, BiOCl, MnO2 nanosheets [In addition to LDH and GR, Mt can also be composited with two-dimensional materials, such as MoSnosheets , etc. AsHydrothermal synthesis is a simple synthesis method. Its advantages are high concentration, good dispersibility and easy control of particle size. In the process of hydrothermal synthesis, the samples in aqueous solution are mixed equally at a high reaction rate. In addition, it can form crystalline powder with high purity, so it has been widely used.2 by hydrothermal synthesis. Firstly, Mt nanosheets were prepared by ultrasonic exfoliation as the exfoliation of GO. Then Mt was added into deionized water, with stirring and centrifuging to remove coarse particles. Collecting supernatant, further ultrasonic stripping, and centrifuging to obtain supernatant. (NH4)6Mo7O24·4H2O and CH4N2S were dissolved in water and added to Mt nanosheet suspension. After halving, the suspension was added into a Teflon-lined autoclave for heat treatment. Finally, Mt@MoS2 was obtained via freeze-drying.Yang et al.  synthesi2SO4·2H2O, Se, NaBH4 were added to deionized water after ultrasonic treatment to produce a uniform solution. Then Mt was added to the above solution and stirred at room temperature. Then, the suspension was transferred to a stainless steel autoclave lined with Teflon-lined stainless-steel autoclave and treated at 200 °C for 24 h. After natural cooling, it was filtered, washed and dried to obtain Mt@MoSe2. Rhodamine B was selected for decolorization to evaluate the adsorption performance and photocatalytic ability of Mt@MoSe2. It is found that the total decolorization rate can reach 98.2% after 45 min of visible light irradiation.The research of Li and Peng  also useUltrasound-assisted chemical precipitation methods mainly use the propagation characteristics of ultrasonic waves, increasing the reaction rate. Ultrasonic waves can cause drastic changes in sound pressure, which leads to strong cavitation and emulsifying phenomena in liquids. In a very short time, a large number of tiny air bubbles are generated, and violent blasting occurs continuously. The impact force produced by blasting makes the reaction particles in full contact, achieving the purpose of accelerating the reaction rate.3)3·5H2O and KCl were dissolved in ethylene glycol, and magnetic stirring was carried out at normal temperature until the solution was clear. Under ultrasonic irradiation conditions, a certain amount of Mt was added to the clear solution to form a suspension. After ultrasonic treatment, distilled water was poured into the suspension system and reacted under magnetic stirring to form a milky white precipitate. The precipitate was filtered by suction, washed with ethanol and distilled water, and dried at 50 °C to obtain Mt@BiOCl. After illumination for 120 min, the degradation rates of catechol and p-aminobenzoic acid were 98% and 92.5%, respectively, indicating that Mt@BiOCl had good adsorption and photocatalysis properties.Mao et al.  studied With the expansion of industrialization, a large amount of organic dye wastewater is produced and discharged every year, which seriously threatens the ecological environment and human health. Photocatalysis with safety and environmental friendliness have been considered as a popular methods to treat organic dye wastewaters. By compounding Mt and other two-dimensional materials with photocatalytic properties, the active sites can be well increased and then the photocatalytic efficiency can be improved greatly.2 is an effective photocatalyst for degrading organic dyes, but its poor dispersion in water and easy aggregation of nanosheets limit its further applications. When MoSe2 is compounded with Mt, the aggregation of molybdenum disulfide can be inhibited, improving its dispersibility. Finally, the photocatalyst Mt@MoSe2, with high efficiency and low cost, can be obtained [2 photocatalytic reaction mechanism is shown in p-aminobenzoic acid. This reaction follows quasi-first-order reaction kinetics [MoSeobtained . The schkinetics . BesidesBased on the excellent photocatalytic performance of the composite, it is necessary and meaningful to protect the environment using pollution-free and sufficient light energy for sewage treatment. Hence, the combination of Mt and other two-dimensional materials with photocatalytic properties has great potential in catalysis and wastewater treatment.2, BiOCl and other two-dimensional materials is also introduced laterIn this review, we have summarized the preparation and applications of Mt and other two-dimensional materials, and focused on Mt@LDH and Mt@GR. Mt shows strong water absorption, adsorption and good cation exchange performance, but its hydrophobicity and poor compatibility with polymers limit its wider application. At the same time, two-dimensional materials, especially their own active sites, are under-exposed, which makes their functions not well reflected. If the two materials can be compounded, the deficiencies of the two single materials can be overcome. In the preparation of Mt@LDH, there are three general kinds of methods: intercalation methods, in-situ growth methods and tape casting methods. Herein, several methods of delamination are summarized according to the strippers used. Among them, polar solutions of formamide are considered to be the simplest and most effective way. However, because formamide has certain environmental issues, PLA and other environment-friendly stripping agents have been considered to be selected by some scholars. On the other hand, dry-freezing and impregnation methods are also used to prepare Mt@GR. The former is a simple and environmentally friendly method. In the latter method, a carrier containing a specific solution is impregnated, and components enter the carrier by capillary pressure and are adsorbed on its surface. The principle and operation of vacuum impregnation are basically the same, but porous materials need to be evacuated first, and then the impregnation liquid is added. Compared with the traditional wet impregnation method, the materials produced by vacuum aging methods are more uniform and efficient. The preparation of MoS


Susac syndrome (SS) is characterized by the triad of encephalopathy, branch retinal artery occlusion, and sensorineural hearing loss. However, the diagnosis of SS remains difficult because the clinical triad rarely occurs at disease onset, and symptom severity varies. SS symptoms often suggest other diseases, in particular multiple sclerosis (MS), which is more common. Misdiagnosing SS as MS may cause serious complications because MS drugs, such as interferon beta-1a, can worsen the course of SS. This case report confirms previous reports that the use of interferon beta-1a in the course of misdiagnosed MS may lead to exacerbation of SS. Moreover, our case report shows that glatiramer acetate may also exacerbate the course of SS. To the best of our knowledge, this is the first reported case of exacerbation of SS by glatiramer acetate.We present a case report of a patient with a primary diagnosis of MS who developed symptoms of SS during interferon beta-1a treatment for MS; these symptoms were resolved after the discontinuation of the treatment. Upon initiation of glatiramer acetate treatment, the patient developed the full clinical triad of SS. The diagnosis of MS was excluded, and glatiramer acetate therapy was discontinued. The patient’s neurological state improved only after the use of a combination of corticosteroids, intravenous immunoglobulins, and azathioprine.The coincidence of SS signs and symptoms with treatment for MS, first with interferon beta-1a and then with glatiramer acetate, suggests that these drugs may influence the course of SS. This case report indicates that treatment with glatiramer acetate may modulate or even exacerbate the course of SS. Susac syndrome (SS) is a rare autoimmune disease in which occlusion of the microvessels in the brain, retina and inner ear leads to a characteristic triad of clinical symptoms: encephalopathy, visual impairment related to branch retinal artery occlusion (BRAO) and hearing loss, respectively –3. SS isSS is rare, with an annual incidence of 0.024 per 100,000 people (95 % CI 0.010–0.047) .A definitive diagnosis of SS is made when a clinical or neuroimaging triad is present. Patients do not usually present with a complete clinical or neuroimaging triad initially, which makes diagnosis difficult . MoreoveMisdiagnosing SS as MS may not only leads to the delayed diagnosis that can worsen the prognosis but may also cause serious complications because MS drugs can worsen the course of SS –7. This A 20-year-old woman receiving interferon beta-1a for MS reported a visual field defect in the lower temporal quadrant of the left eye. Examination revealed a normal visual acuity of 20/20 in both eyes. Intraocular pressure was 15 mmHg in the right eye and 17 mmHg in the left eye. Anterior segment examinations were normal in both eyes. Pupils were equal, round and reactive to light with no relative afferent pupillary defect. Fundus examination of the left eye showed ischemic retinal whitening in the supra-nasal area, fluorescein angiography (FA) revealed BRAOs and subtle, segmental arteriolar wall hyperfluorescence (AWH) at the site of BRAO in the late phase , herpes simplex virus (HSV), cytomegalovirus (CMV), and factor V Leiden mutations. The results of laboratory studies  were suggestive of antiphospholipid syndrome or lupus; however, further biochemical tests excluded these causes. Performed again with an interval of 12 weeks, anti-cardiolipin antibodies in the IgG or IgM class, lupus anticoagulant and antibodies against β2-glycoprotein were negative. Moreover, IgM and IgG antibodies against CMV were detected. Transthoracic echocardiography and carotid artery ultrasonography were unremarkable.Treatment with glatiramer acetate was started 3 weeks after discontinuation of interferon beta-1a. After 2 weeks of glatiramer acetate therapy, we observed neurological worsening with fever, headache, impaired consciousness, left-sided weakness, and lower limb ataxia. Lumbar puncture revealed only a mild elevation of cerebrospinal fluid protein, no oligoclonal bands, and a negative encephalitis panel; meningitis was therefore ruled out. The brain MRI showed diffuse and limited hyperintense changes in fluid-attenuated inversion recovery (FLAIR) and T2 sequences located periventricularly in the subcortical white matter, mainly in the frontal and parietal lobes, in the pons, in the basal ganglia and in the corpus callosum. MRI revealed also post contrast leptomeningeal enhancement (Fig. The clinical manifestation of SS is highly variable. The complete triad is present in only 13 % of patients at disease onset. Any one of the triad components may initially be the only symptom, which can lead to a delayed or wrong diagnosis. Full manifestation of SS is observed within several months, and in some cases complete manifestation of SS lasted for more than two years . In our Significant progress has recently been made in understanding SS, making it easier to differentiate from MS and other entities –3. Egan According to previously published criteria, patients without a complete clinical triad but with central callosal lesions on MRI or AWH on FA would be diagnosed with probable SS . The newMisdiagnosis of SS as MS can cause serious complications. Drugs such as interferon beta-1a or natalizumab have been reported to worsen the course of SS –7. HowevAs in the case described by Laird et al. , our patIn the differential diagnostics of retinal artery occlusion in young persons, haematologic disorders, factor V Leiden, protein C and S and anti-thrombin deficiencies, prothrombin gene mutations, sickle cell anaemia, migraine secondary to vasospasm, vasculitis, systemic lupus, antiphospholipid syndrome, or use of oral contraceptives, as well as valve disorders, should also be taken into consideration , 12.In our case, the positive lupus anticoagulant test, together with other laboratory abnormalities, was suggestive of antiphospholipid syndrome or systemic lupus, however, further biochemical tests excluded these causes. Anticardiolipin antibodies and lupus anticoagulant have also been detected in patients with SS, but whether they are pathogenic is uncertain .During treatment with glatiramer acetate, BRAO and AWH were again detected on FA; this time, AWH was localized away from the site of BRAO, which is pathognomonic for SS. Our patient’s neurological condition deteriorated after the use of glatiramer acetate, and MRI showed changes in the central part of the corpus callosum, indicating SS. There was also hearing impairment. To our knowledge, we are the first to report that glatiramer acetate may affect the course of SS.We cannot rule out the possibility that this was the natural course of SS in this patient. Nevertheless, the coincidence of SS signs and symptoms with treatment for MS, first with interferon beta-1a and then with glatiramer acetate, suggests that these drugs may influenced the course of SS.This is an interesting report both due to the proposed mechanisms of action of glatiramer acetate and the recently described new model of SS pathogenesis , 14. TheAdditionally, both interferon beta-1a and glatiramer acetate modulate and interfere with the immune response, potentially increasing susceptibility to infection . One hypBased on their research, Gross et al. point out that, although it also induces CD8 + T cells, CMV is not a driving force in SS . NeverthIn conclusion, distinguishing SS from MS is a diagnostic challenge. The presented case is an example of how difficult it is to correctly diagnose SS in a patient with primary misdiagnosed MS who additionally has risk factors for BRAO and a positive CMV antibody. Misdiagnosis can lead to serious problems caused by inappropriate therapy. This case report suggests that treatment with glatiramer acetate may modulate or even exacerbate the course of SS. Further research is required to confirm this hypothesis.Our observations also raise awareness of the importance of the early and correct diagnosis of SS. This case also highlights the importance of interdisciplinary collaboration for the correct diagnosis of SS. Ophthalmological evaluation of patients with MS is essential for differential diagnosis and, in some cases, may be key to achieving a correct diagnosis of SS, which translates directly into improved prognosis.


The packaged foods sold in food stores may be “private-label” products (PL), when branded by the supermarket, and “branded” products (BR). PL products are generally cheaper than the BR counterparts, and this can be perceived as a sign of general low quality by consumers, when items are compared with their branded counterparts. Thus, the aim of the present study was to compare the nutrient content of BR and PL cereal-based foods, by evaluating the nutritional declaration reported on the food pack of products on the home-shopping website of major retailers present on the Italian market. A total of 3,775 items (~58% BR and ~42% PL), collected in the period from July 2018 to March 2019 and updated in March 2020, were included in the final analysis. Data were analyzed by means of the Mann–Whitney nonparametric test for two independent samples for differences between BR and PL categories and types. Overall, BR products showed higher contents of total and saturates than PL items. When products were grouped for categories and types, items only differed for the content of total fats, saturates, total carbohydrates, proteins, and salt. No differences were instead found for energy and sugar contents among any of the categories. However, we did not find any consistency in the direction of results. These results could be useful for future education activities aimed to help consumers in making informed food choices. Food labels are one of the main tools used by industries to deliver information about their products. Among the different information reported on the food pack, the brand name and/or logo is certainly one of the main aspects that majorly attracts the customer's interest during shopping time, linking the product to positive feelings, and in turn may influence purchasing behavior and consumption . RegardiPL products are constantly gaining market shares despite some signs of declining in the last years . HoweverFew studies have been performed investigating the potential difference between PL and BR products in terms of nutritional quality, focusing on specific food components such as sodium  or consiBased on these premises, the aim of the present study was to compare energy and nutrient contents of BR and PL cereal-based foods currently sold in Italy, by evaluating the nutritional declaration reported on the food pack. This work is part of the Food Labeling of Italian Products (FLIP), conceived by the Working Group SINU  Young with the purpose of systematically evaluating the nutritional quality of the different food categories sold on the Italian market –17 and oThe online search for information was conducted on the home-shopping website of the major retailers present on the Italian market . We included all the prepacked cereal-based foods for which, as stated in the Council Regulation (EC) no. 1169/2011 , mandatoThe exclusion criteria for product selection were as follows: (i) not prepacked, (ii) incomplete images of all the sides of the pack, (iii) unclear images of nutrition declaration or list of ingredients, and (iv) products marked as “product currently unavailable” in all the online stores which were selected throughout the data collection period. The online research was performed from July 2018 to March 2019 and updated on March 2020.Data from the complete images of all the sides of the pack were collected for all the selected products. As previously described, the following qualitative–quantitative and specifically regulated (mandatory) information was retrieved for each food item: company name, brand name, descriptive name, energy , total fat (g/100 g), saturated fatty acids , total carbohydrates (g/100 g), sugars (g/100 g), protein (g/100 g), and salt (g/100 g). Moreover, the number of nutrition claims (NC) and of health claims (HC), as listed in the Council Regulation (EC) No. 1924/2006 , and inaccuracies were resolved through secondary extractions made by a third researcher (DM).A dataset was created with all the collected data and items were subgrouped for specific comparisons by considering the descriptive name reported on the pack and the brand. Based on the brand, the food items were classified into (i) private-label foods for products branded by the supermarket and (ii) branded foods for food items produced by food manufacturers and labeled with their own brand. Based on the descriptive name, food items were further divided into the following categories and into related types, as previously reported , 15–17: p < 0.05 of significance level. The normality of data distribution was firstly verified through the Kolmogorov–Smirnov test and rejected. Therefore, variables were expressed as median and interquartile range. Data of energy and nutrient contents per 100 g of products for each item were analyzed by means of the Mann–Whitney non-parametric test for two independent samples for differences between BR and PL categories and types. Comparisons among product types of each category were shown graphically using Origin software .Statistical analysis was carried out using IBM SPSS Statistics®  and performed at n = 2 and 1, respectively)  .p = 0.025; SFA: 2.0 (0.9–5.2) vs. 1.9 (0.1–4.8) g/100 g, p = 0.025, in BR and PL, respectively]. As regards the seven categories, overall, no differences were found for energy content in any of the considered categories, while only small differences were observed in specific nutrient content for some products. More specifically, higher total fat and SFA contents were observed in BR compared with PL products for breakfast cereals , sweet snacks , and dried pasta , while BR and PL fresh pasta differed for total fat  but not for SFA. Regarding total carbohydrates, a lower content was observed in BR products than PL counterparts for breakfast cereals , sweet snacks , and dried pasta , while no differences were found for sugar content in any of the food category under study. Contrasting results were observed for protein, with a higher content in BR breakfast cereals  and dried pasta  compared with the PL counterparts, while a lower protein content in BR products compared with PL was found for fresh pasta . Similarly, a higher salt content was observed in BR compared with PL biscuits , fresh pasta , and dried pasta , while a lower content in BR products was observed for sweet snacks . Thus, no consistency in the direction of the results was observed, with some favorable results among PL products and others among BR ones.The values of energy, macronutrients, and salt content of branded and private-label food categories are summarized in These results are further confirmed by comparing the nutritional quality of PL and BR types of products within each category. Some differences indeed emerged for energy and nutrients between PL and BR products of some types in all the seven considered food categories, despite some contrasting results even within the same category.p < 0.001], saturates , and protein  and lower values for total carbohydrates . Total carbohydrates were also lower in BR flakes compared with PL ones , while among bran cereals, sugar content was markedly lower in BR items , and among other cereals, protein was higher in BR compared with that in PL items . Energy and salt content did not differ for any of the types.Among breakfast cereals , cereal p = 0.047] and protein content . Compared with PL, BR wafer showed higher total carbohydrates  and salt content . Higher salt content in BR than in PL items was also shown for tea cookies  and covered/sandwich cookies .Among biscuits , BR and p = 0.026; plumcake and muffin: 19.4 (17.0–21.9) vs. 18.0 (14.0–21.0) g/100 g, p = 0.020; shortbread cake: 10.5 (10.0–14) vs. 17.0 (13.8–23.0) g/100 g, p < 0.001, in BR and PL, respectively], SFA , and total carbohydrates . Shortbread cake also differed for energy content   vs. 0.4 (0.3–0.4) g/100 g, p = 0.002].Regarding sweet snacks , the typctively]  and for p = 0.039, respectively], total fat , and salt contents , while no differences were found among rolls and sliced bread. Conversely, among bread substitutes  vs. 11.0 (11.0–11.1) g/100 g, p = 0.002], and salt  contents; breadsticks only for fat content ; “croutons, bruschetta, and frisella bread” for saturates ; and crackers for both total carbohydrates  and sugar . Finally, BR “rice and corn cakes” differed to the PL ones only for total carbohydrates  and protein .Comparing bread types , only BRstitutes , BR and p < 0.001], SFA , and protein  but higher total carbohydrates , while BR stuffed pasta showed higher total fat  and lower protein  compared with the PL counterparts. Among dried pasta, BR and PL semolina and egg pasta differed for total fat, total carbohydrates, protein, and salt, while saturates differed only in semolina pasta . Special pasta only differed for sugar  and protein contents , while no differences were found between BR and PL stuffed pasta.Finally, considering pasta , 7, amontout court as a marker of overall better nutrition quality compared with PL. In this scenario, it is noteworthy that BR did not show better nutritional values compared with PL although they bore a higher number of both nutrition and health claims compared with the related counterparts for almost all of the food categories under study.In the present study, we compared the nutrition declaration of over 3,700 cereal-based food items, belonging to seven different food categories, to investigate whether BR and PL products differ in terms of nutritional quality, by retrieving information from the food label. Overall, BR and PL products differed only for total fat and SFA contents. When considering the seven food categories, the main differences referred to the content of total fat, SFA, total carbohydrates, protein, and salt, while differences in terms of energy and sugars were not observed between BR and PL products of all categories. It is worth mentioning that these differences were often not relevant from a nutritional point of view, as the variation was generally lower than 4%. Moreover, some differences can be attributed to the ratios of BR and PL types of products belonging to the same categories. For instance, cereal bars represent ~9 and ~38% of total PL and BR breakfast cereals, respectively, while flakes ~46 and ~25%, respectively. With cereal bars and flakes very different in terms of total fat content , the difFor the abovementioned reasons and due to the heterogeneity of the characteristics of studies—in terms of considered nutrients and/or food categories—comparisons of our results with findings from previous studies are tricky. Moreover, studies were performed in different countries such as Australia , USA 1111, and SThe study has some limitations worthy to be highlighted. First, as done for other studies performed within the FLIP project –17, we dOverall, we found some contrasting results in terms of nutritional quality between BR and PL products; thus, we cannot conclude that PL items always have a lower nutritional quality than BR ones. Despite some differences among categories, this supports the theories of a net discrepancy from the perceived whole quality—nutritional, technological, and hedonistic—and effective food quality of PL foods , mainly The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors.DA was involved in the protocol design, data analyses, and in the interpretation of results and drafted the manuscript. CD was involved in the protocol design and in the interpretation of the results and contributed to the drafting of the manuscript. NP participated in the conceptualization of the study and critically reviewed the manuscript. DM conceived and designed the protocol of the study, was involved in the interpretation of the results, critically reviewed the manuscript, and had primary responsibility for the final content. Other members of the Italian Society of Human Nutrition (SINU) Young Working Group were involved in the protocol design and critically reviewed the final manuscript. All authors contributed to the article and approved the submitted version.The present publication has been conceived within the Italian Society of Human Nutrition (SINU) Young Group, and it has been made without any funding from food industries or other entities. DM has received a research grant from Despar Italia which is not related to the present study, so had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. The remaining 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. The reviewer GS declared past co-authorship with the author NP to the handling editor.


Introduction: The immediate impact of coronavirus 2019 (COVID-19) on morbidity and mortality has raised the need for accurate and real-time data monitoring and communication. The aim of this study is to document the initial observations from multiple digital services providers during the COVID-19 crisis, especially those related to mental health and well-being.Methods: We used email and social media to announce an urgent call for support. Digital mental health services providers (N = 46), financial services providers (N = 4), and other relevant digital data source providers (N = 3) responded with quantitative and/or qualitative data insights. People with lived experience of distress, as service users/consumers, and carers are included as co-authors.Results: This study provides proof-of-concept of the viability for researchers and private companies to work collaboratively toward a common good. Digital services providers reported a diverse range of mental health concerns. A recurring observation is that demand for digital mental health support has risen, and that the nature of this demand has also changed since COVID-19, with an apparent increased presentation of anxiety and loneliness.Conclusion: Following this study, we will continue to work with providers in more in-depth ways to capture follow-up insights at regular time points. We will also onboard new providers to address data representativeness. Looking ahead, we anticipate the need for a rigorous process to interpret insights from an even wider variety of sources in order to monitor and respond to mental health needs. During the coronavirus 2019 (COVID-19) pandemic, traditional mental health services and related activities declined, in part, due to outpatient clinics being closed to adhere to social distancing requirements, mental health staff redeployment, and inpatient beds being converted into COVID-19 units. As governments attempt to contain the virus, we must mitigate the mental health impact of the pandemic and economic crisis, especially given that pre-COVID-19 predictions already indicated that by 2030, depression will be the leading cause of disease burden globally (During the severe acute respiratory syndrome (SARS) 2002–2004) epidemic, social disengagement, mental stress, and anxiety were associated with increased suicide rates in the elderly population 002–2004 . Data frIn the current pandemic, frontline healthcare workers face the possibility of anxiety and burnout , 7 and mThere is a need to obtain more granular and real-time information to help us understand the nature and scale of the mental health crisis. A possible source of this information is the large number of digital mental health services providers used by millions of people globally. These include patient to clinician communication tools, digitally enabled treatments, self-managed care solutions, mental health and well-being apps, online forums, support networks, and digital communities. In addition to this, given the established links between health, social, and economic factors , insighTo investigate the impact of COVID-19 on mental health, we set out to collect observations from multiple digital services providers . To our via LinkedIn, Twitter, and Facebook. Additionally, we encouraged providers and co-authors to ensure that they sought the views of people in their own networks.We used email and social media to announce an urgent call for support to investigate the scale and nature of the mental health impact of COVID-19 N = 3). Respondents were asked to provide qualitative and/or quantitative insights with no exchange of data or identifiable information. A list of digital services providers can be found in We reached out directly to 55 digital services providers. We received confirmation of support to contribute from 53 providers , which consisted of 46 digital mental health services providers, four financial services providers, and three other digital data source providers  and the Data Protection Act 2018 if their users were within Europe. To set a good example of responsible innovation, this document only accepted data insights from providers with clear and accessible privacy policies. Other than these ethical grounds, there were no other exclusion criteria. There were no specific inclusion criteria, but many of the respondents had a pre-existing association with members of the study team, for example, through the annually run conference, DIMH, created by Dr. Becky InksterWe deliberately did not select a specific methodology for this study, and we did not test any specific hypotheses. Providers collected very different types of data and analyzed it in their own way using techniques that were appropriate for their data. Trying to develop some common methodologies is a future goal, which will require more time, and increased collaboration between different providers and other stakeholders.Data insights and draft versions of the paper were shared among all co-authors for feedback, including from people with a range of lived experiences of distress and service use.Given the anecdotal nature of many of the insights and the non-systematic way in which providers were chosen, we are reluctant to draw conclusions from the content provided in N = 11,033) taken in March 2020 compared with February 2020. Qualitative insights suggest that individuals are seeking practical resources and coping strategies. Participants in the It's Ok To Talk discussion raised questions about anxiety, strategies to manage work, studies, sleep, dealing with domestic violence, and difficult home relationships. Babylon reports that many patients are seeking advice on information about local council support services, seeking advice for activities to keep busy and how to remain healthy, and how to get support to access food and financial concerns. Ieso Digital Health reports up to a third of patients mentioning COVID-19 as a reason for presenting for mental health treatment and also reports a rise in patient worries about viruses, with up to 15% of in-session worries about COVID-19.Insights suggest changes in the type of information individuals are seeking or presenting. From Google Trends data, searches for “anxiety symptoms” doubled between the weeks beginning 8 March and 22 March 2020. In a similar timeframe, Mental Health America (MHA) witnessed a 22% increase in the numbers of Generalized Anxiety Disorder 7-item (GAD7) anxiety screens . Peer support specialists are being rapidly trained. Digital Peer Support trained 750 peer support specialists between 10 March and mid-April 2020. Wisdo reported a 283% increase in the numbers of people replying to other people's messages and an increase of 115% in the numbers of people signing up for roles to provide support for others. Mentally Aware Nigeria Initiative (MANI) trained over 200 psychosocial support team specialists/counselors on mental health.Many providers are experiencing increased support-seeking behaviors. For example, Ieso Digital Health reports an 84% increase in referrals. Vala Health reports a doubled volume of mental health-related consultations with general practitioners (GPs) during the period 10 March to 8 April 2020. By week 4 of the UK lockdown, general health enquiries had returned to almost pre-COVID levels, but mental health consultations continued to rise. National Alliance on Mental Illness (NAMI) reports a 41% increase in demand for HelpLine resources and information. Ieso Digital Health reported an 84% increase in referrals to their 1–1 online cognitive behavioral therapy (CBT) service in the weeks since the lockdown was announced in the UK, relative to the same period in 2019. Wysa witnessed a 77% increase in new users during February to March 2020, as compared with the same period in 2019. MANI recorded the highest number of emergency calls in the month of April. Qualitative insights from Orygen  revealed that young people report privacy concerns in having telehealth consults with family members in the background.N = 11,033) scored for severe anxiety. In a self-reported questionnaire to members of The Mighty, 89% of members reported that their daily life has been at least somewhat impacted by increased anxiety; 43% say that it has been extremely impacted. This is consistent with reports from Kooth demonstrating increases in sadness (up 161%), health anxiety (up 155%), sleep difficulties (up 90%), concerns over body image (up 43%), eating difficulties (up 31%), loneliness (up 23%), and bereavement (up 20%). The Mental Health Foundation survey reported that respondents felt increasingly lonely, and that this was most pronounced for people aged 18–24 (44%) and 25–34 (35%). Multiple providers report users mentioning their loss of access to care and human support .Many providers report observations suggesting increased anxiety, uncertainty, loneliness, and loss. MHA reports that 45% of people who took an anxiety screen in March .via telehealth , and increased activities on darknet markets mentioning psychiatric medications (The TellFinder Alliance).Other outcomes include increases in reporting of unsafe domestic settings , suicidal risk/ideation , and sleep disturbances . There have also been increased prescription of anti-depressant medications (Jasvinder Kandola), increased requests for pain killers Financial insights show an overarching theme of the interrelation between mental health and financial health worries. Three sub-themes emerged from the data: (1) uncertainty and a sense of loss of control particularly “at-risk” individuals and groups; (2) anger, anxiety, and concerns over access to financial support especially those who feel that they are “falling through the gaps”; and (3) negative mental health and/or physical health with financial health outcomes.N = 568) reported a range of concerns by respondents with lived experience of mental health problems about how changes, as a result of COVID-19, might affect their finances: 62% worried about having to access the benefits system, 57% worried about losing their job, and 56% worried about creditors chasing them for money. Tully and OpenWrks Group reported that 81% of self-employed customers (N = 650) have declared that they do not have any work coming in due to COVID-19. Furthermore, 50% of their wider sample  have had income reduced, and 19% have lost their income. The Turn2us survey showed that 70% of respondents  who have had employment affected are unable to afford rent or mortgages. An anonymous financial services provider also shared concerns that their on-site cashiers may be vulnerable and distressed by customer behaviors.The Money and Mental Health Policy Institute survey  to share their insights. We believe that our study provides a proof-of-concept for the viability of using this approach.The information that we have quickly compiled has been sourced from different geographies, demographics, and types of digital interactions and provides insights into the diversity of individual mental health needs. During our study, a paper  called fWe recognize that this study is not rigorous in terms of data collection and methodology. We did not choose these providers in a systematic way. Using data from digital services providers limits our population to people who have access to these digital platforms and many “hidden” populations are not registering in digital spaces. Furthermore, we do not know whether our demographic is representative of any larger population or whether whole-population impacts can be inferred from digital service impacts. In addition, we did not verify the insights shared by providers. This avoided privacy issues, but has the potential to have introduced inaccuracies or biases in the reported information. This study is also unable to characterize mental health problems at a clinical level because most digital providers did not report clinically-validated measurements. The use of digital measurements to monitor mental states and distress is still a developing space.Prior to this study, we did not know what the response rate would be or what types of insights we would be able to obtain. Developing new methodologies to combine such insights will be a substantial undertaking, which should involve many stakeholders. Developing such methodologies is a future goal, but it was not the purpose of this study.It is important to note that this study was conducted in the midst of the initial pandemic, a time of significant uncertainty. Between the time of the data gathering for and the publication of this study, there have been countless responses across countries announced and enacted. The insights discussed here capture an important moment in time during the initial pandemic phase and also offer a useful reference for on-going data monitoring and subsequent study follow-ups.Following this study, we will continue to work with providers to capture follow-up insights at later time pointsbecky@beckyinkster.com.The data analyzed in this study is subject to the following licenses/restrictions: we only had access to the data insights provided by digital services providers, we did not access the data. Requests to access these datasets should be directed to Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements. Digital services providers followed their own in house ethical procedures, terms and conditions and consent procedures for their own data sets.BI formulated the idea, operationalised and co-ordinated the response, inviting co-authors to join, all having different professional and/or lived experiences who have made important contributions in various ways, such as performing literature searches, writing, helping us to connect with digital providers, idea generation, editing, interpretation, etc.BI is an advisor to Wysa and TalkLife and has worked with the majority of these providers previously via either her Digital Innovation in Mental Health conferences and/or her FinHealthTech Consortium. KJ, JG, and MJ are employed by MindWave Ventures. AC, RC, TC, JB, VT, SB, and AB are employed by Ieso Digital Health. TP, KG, and ES are employed by Huma Therapuetics. PT is employed by Vala Health. DR and KS are employed by Ooca. AM and AS are employed by Kooth. DR, AE, and JP are employed by Silver Cloud Health and Trinity College Dublin. AB is employed by CBTClinics. EP is employed by Minddistrict. CL is employed by Big Health. FJ and LT are employed by Qare. DP is employed by Huma Therapeutics. AS and HB are employed by Unmind. KS is employed by Expert Self Care Ltd (distrACT app). TB, AM, and IA, Alpha Health, Telefonica Innovation Alpha. LA-P, RD, and SL work with ORCHA. JA RV, SJ, VS, and MK are employed by Wysa. CS is employed by Owlie. GI and AH are employed by Riliv. KC, AL, and KT are employed by Stop Blues. CR is employed by BeyondBlue. ML and CC are employed by Neurum Health. WA-M is employed by Spill. JR is employed by Mumsnet. SR and AC are employed by The Mighty. JR and JD are employed by TalkLife. BG is employed by Wisdo. SG and KC are employed by MeeTwo. SR is employed by MIELI Mental Health Finland Mental-chat & Mental Gaming, Finland. MC is employed by Teen Line, USA. AP is employed by Papa. KD and DG are employed by National Alliance on Mental Illness, USA. TN and MR are employed by Mental Health America, USA. VU and IW are employed by Mentally Aware Nigeria Initiative (MANI), Nigeria. CB, AF-E, GG, DK, KP-J, DJ, CS, CU, and LZ are part of the Young Leaders for the Lancet Commission on GlobalMental Health and Sustainable Development. GC and AF are employed by Qntfy, USA. MH, CD’A, and KA are employed by Money & Mental Health Policy Institute, UK. JK is employed by Turn2Us, UK. LH is employed by IncomeMax, UK. OB is employed by Tully and OpenWrks Group, the team behind Tully. AS is employed by Healthy Virtuoso, Italy. WV is employed by The Mind and Soul Foundation, UK. AT, DS, CD, and AS work for The TellFinder Alliance, USA. SV has received funding from iqvia for toolbox development. TI works for Humanest Care.