Supplemental Digital Content is available in the text Functional constipation is a chronic disease that is common in children and adults around the world. The treatments for functional constipation include diet and lifestyle interventions, medications, and surgery. The diet pattern plays an important role in the occurrence of constipation. We found in clinical practice that simple application of drugs cannot achieve long-term relief of constipation, and a large number of patients are not satisfied with the existing treatment. We have concluded that Qingjiang Tiaochang Recipe (QJTCR) and light vegetarian diet (LVD) can effectively improve constipation. However, there is no enough evidence for the description of the effect. This protocol aims at exploratorily investigating effectiveness and safety of LVD and QJTCR following a rigorous clinical trial.We will recruit 90 patients to participate in this prospective, placebo-controlled, randomized trial, and exploratory study at the China-Japan Friendship Hospital, including traditional Chinese medicine group, placebo + diet group, traditional Chinese medicine + diet group. Patients in the diet intervention group must strictly abide by LVD, and the study will continue for 28 days. During the intervention period, we need to record a designed diary to assess diet quality and defecation. The primary outcomes for this clinical study were weekly complete spontaneous bowel movements. The secondary outcomes were constipation-related symptom rating scale, traditional Chinese medicine syndrome scale, and 48-hour gastrointestinal transit time, high-resolution anorectal manometry, Bristol stool score, constipation quality of life assessment scale, constipation symptoms self-assessment scale, short-chain fatty acids in feces. In addition, the study will determine the safety of the intervention. FC does not threaten the life of the patient, but it seriously affects the patient's quality of life (QOL) and causes high medical expenses.Functional constipation (FC) is a common functional gastrointestinal disease and one of the most common gastrointestinal diseases of outpatients. The incidence of constipation in the world is about 15%, The occurrence of constipation is inversely related to the intake of dietary fiber . A low-fiber diet can induce constipation. The latest diagnosis of FC is based on the criteria of Rome IV Standard, including laborious defecation, dry or lumpy stool, incomplete defecation, anorectal obstruction, prolonged defecation cycle, and manually assisted defecation. Two or more of the above items need to be included with at least 25% frequency for each one. Meanwhile, loose stool is rarely present without laxative and irritable bowel syndrome should be excluded.Prolonged colonic transit time, pelvic floor muscle dysfunction, and their combined effects are recognized mechanisms for the development of FC. Gender, age, diet, education, and neurological diseases are the main influencing factors of FC. Therefore, it is necessary to find a safe and effective treatment. Reports show that out of 6318 Chinese constipation adults, only 25.1% choose laxatives, and 81.7% of them prefer lifestyle and eating habits as treatment options.The treatment of constipation should pay attention to comprehensive management. The routine management of adult functional constipation includes lifestyle intervention, pelvic floor intervention , and drug treatment. Currently, medical treatment is not satisfactory in continuously improving the symptoms and quality of life of FC patients, and side effects such as electrolyte disturbance, diarrhea, and nausea are often reported. These microbiome changes may be result from low-fiber diet. Different dietary habits, such as low intake of water, fruits and vegetables, and high intake of spicy and greasy foods, all contribute to the increased prevalence of FC. Similarly, increasing the intake of whole fruits can protect the health of the colon and gastrointestinal tract.,11,12 The report pointed out that 57% of the intestinal flora depends on the diet structure. Five days of dietary changes may quickly change the human intestinal flora. Therefore, diet is closely related to intestinal flora. Diet can cause constipation by affecting the flora. For example, a lack of isoflavones can cause intestinal flora imbalance, which can lead to constipation. Light vegetarian diet (LVD) is a healthy eating pattern summarized in clinical work. LVD is characterized by vegetarianism, avoiding high-temperature processing, and reducing flavoring.Studies have confirmed that the fecal microbiome of FC patients will change, such as the reduction of the number of Preobacterium strains and the decrease of the abundance of microflora.,16 Chinese herbal medicine can improve various chronic diseases, such as coronary heart disease, diabetes, obesity, depression, tumors, etc., by regulating the intestinal flora. Qingjiang Tiaochang Recipe (QJTCF) is a Chinese medicine prescription for treating functional constipation summarized in the clinical practice. The prescription does not contain drugs that can cause melanosis of the colon, such as rhubarb and aloe.Traditional Chinese medicine formula can effectively improve gastrointestinal symptoms and intestinal health of adults with digestive system diseases. The mechanism is to reduce intestinal permeability, enhance the richness of intestinal flora, and increase the number of probiotics.To date, there is no rigorous evidence to support the effectiveness and safety of LVD and QJTCR; thus, this needs authentication based on clinical trials in human subjects. In this protocol, we will design a randomized controlled trial (RCT) to systematically verify that point.22.1This exploratory research project aims to study the effectiveness of QJTCF and light vegetarian therapy for functional constipation and the changes of short-chain fatty acids in feces before and after treatment.2.2The protocol was drafted using the SPIRIT guidelines and the results will be reported following the checklist of the Consolidated Standards of Reporting Trials statement (see Supplementary Table 1). All participants will be informed of the purpose of the study and obtain their informed consent before participating in this parallel group study. According to the inclusion and exclusion criteria, a total of 90 patients with functional constipation are expected to be recruited. Then they were randomly assigned to the Chinese medicine group (group A), placebo + diet group (group B), Chinese medicine + diet group (group C) at the ratio of 1: 1: 1. The patient filled out the case report form (CRF) after confirming enrollment, and the researchers recorded the patient's symptoms, bowel movements, etc., on day 14 (phone follow-up) and day 28. Interventions were provided to subjects based on the enrollment number, but neither the patient nor the investigator knew whether the patient was receiving drug or placebo. The entire study design is shown in the figure .2.6Participants will be recruited from the outpatients and inpatients of Gastroenterology Department and traditional Chinese medicine (TCM) Gastroenterology Department in China-Japan Friendship Hospital in Beijing through roll-up banners, posters, Wechat, and the hospital official website. Two or more experts (at least 1 from Gastroenterology Department and 1 from TCM Gastroenterology Department) will decide the eligibility unanimously following the inclusion and exclusion criteria. It will be insured that both physicians and patients have no financial interests. All eligible recruiters will sign a written informed consent and those who accept the purpose, benefits, and adverse effects of the study will be enrolled.2.7The 2 interventions are light vegetarian diet  per week for the first 14 days, the average score of constipation symptoms and TCM syndrome. After 28 days of treatment, a second follow-up visit will be conducted to understand the condition of constipation (same as the first follow-up visit), and the patient will be required to complete the examination . The short-chain fatty acids of the patient 's fresh stool (<30 min) should also be checked and the diary should be retrieved. During the intervention, patients will keep in touch with the researchers. The patient's diet and stool diary will be filled out by the doctor. Keep in touch with each patient in the treatment period through mobile phone software (WeChat), ask the patient to send 3 meals to the doctor's mobile phone, ask the patient about the stool on the day at 7 o’clock every night, and urge patients in the diet intervention group to insist on light vegetarian diet.2.8Third parties not involved in the study will use Excel 2013 software  to generate 90 independent random numbers and divide them by 3. The rest will be 1 in group A, 2 in group A, and 0 in group C. A, B, and C are defined as Chinese medicine group, placebo + diet group, Chinese medicine + diet group. If the enrolled patients fall off, the total number of enrolled patients exceeds 90, and they will be randomly grouped again according to needs. Patient serial numbers will be generated in the order of enrollment. When distributing medicines, neither the doctor nor the patient can know what kind of medicine. The drug number information will be retained, encapsulated, and stored in an opaque envelope, and kept by a third party. When the patient is enrolled, the envelope based on their serial number will be delivered to the researcher. After the trial, the third party will expose blindness. Because dietary intervention is a set of dietary principles rather than specific foods, it is difficult to be blinded, so only drugs are double-blind to reduce information bias.2.9In case of any serious adverse events or emergency, the researcher will report to the supervisor and the main researcher to decide whether to open the emergency letter. Once opened, the case will be treated as exfoliated, excluded from the efficacy analysis, but will remain included in the adverse reaction analysis. Details of the unblinding cause, date, treatment situation, and results will be reported in the CRF and will be signed by the administrator.2.10Participants’ diet quality (DQ) will be assessed at the baseline and after the intervention. The foods involved are in LVD content.2.112.11.1Baseline information will include demographic data and clinical data from the participants. Demographic data includes gender, age, height, weight, nationality, occupation, and education level, etc. Clinical data includes past medical history, drug allergy history, the history of medications used to treat or induce constipation, dietary habits in the past year (see Supplementary Table 1), the primary outcome, and secondary outcomes.2.11.2The number of CSBM per week is the primary outcome. It is effective when the number before the intervention subtracted from the number after the intervention is more than or equal to 1.2.11.3Constipation-related symptom rating scale: The scale for constipation-related symptoms is used for investigating the degree and frequency of symptoms mentioned in Roman IV diagnostic criteria for FC. The degree of discomfort is assessed by visual analog scale, in which 0 represents no discomfort and 10 represents very strong discomfort. The final scores are obtained with the multiplication of the 2 and then divided by the average number of defecations per week (see Supplementary Table 2). Percent improvement will be calculated as follows: Recovery means symptoms disappeared; Marked improvement means percent improvement is more than or equal to 80%; Progress means percent improvement is more than or equal to 50% but less than 80%; Ineffective means percent improvement is less than 50%.Traditional Chinese medicine syndrome scale (TCMSS): The TCMSS is established by collecting information about effects of relevant syndromes of TCM constipation, which are assigned 0, 1, 2, and 3 points representing normal, mild, moderate, and severe degrees, respectively. Normal refers to the absence of this syndrome, mild refers to a slight impact on life, moderate means a significant impact on life, and severe refers to the serious impact on life (see Supplementary Table 3). Nimodipine method is used for evaluating the effects of relevant syndromes of TCM constipation. Symptoms, signs disappeared or basically disappeared and syndrome integral reduced more than or equal to 95% is considered clinical cure; Significantly effective means that symptoms, signs significantly have improved, and syndrome integral has reduced more than or equal to 70%; Effective means that symptoms, signs have improved and syndrome integral has reduced more than or equal to 30%; Ineffective means that symptoms, signs have no improved or have even aggravated and syndrome score has reduced less than 30%.Forty-eight hours GITT: 48-hour GITT is a simple method for evaluating the function of gastrointestinal motility. The barium residue rate is the ratio of the number of barium remaining in the body 48 hours after swallowing 20 barium bars with a standard meal. Higher residue rate indicates the worse gastrointestinal transport function. The parameters include barium excretion rate after 48 hours, residue rate above rectosigmoid colon and residue rate within rectosigmoid colon. The barium excretion rate in normal people is more than or equal to 90%.HRAM: HRAM is used to estimate the function of anal sphincter, rectal sensation, and anorectal reflex for diagnosing the defecation disorder constipation. The parameters include mean pressure of resting anal sphincter, maximum contraction pressure of resting anal sphincter, anal relaxation rate during analog defecation, first sensory value, defecation sensory value, and maximum tolerance.BSFS: The Bristol stool score is used to assess fecal traits under the naked eye. 1 point: scattered hard lumps, like nuts; 2 points: sausage-like, but agglomerate; 3 points: sausage-like, but with cracks on the surface; 4 points: sausage-like or snake-like, smooth, and soft; 5 points: soft balls, clear edges; 6 points: unclear edges, mushy stools; 7 points: watery, no solids.PAC-QOL: The quality of life assessment scale for patients with constipation includes 4 parts, including physiological, psychological, constipation's impact on life and treatment satisfaction, a total of 28 items, using Linker 5 grade. The higher the total score, the lower the quality of life, which means the more dissatisfied with the current state of life (see Supplementary Table 4).PAC-SYM: The symptom self-assessment scale for patients with constipation includes 3 dimensions  and 12 items. The Linker 5 scale is used. The higher the score, the more severe the constipation symptoms (see Supplementary Table 5).F-SCFAs: Detection of short-chain fatty acids in feces contains acetic acid, propionic acid, butyric acid, isobutyric acid, valeric acid, isovaleric acid, and caproic acid. Feces samples were collected before and after the intervention and stored in the −80°C refrigerator in the biological sample bank of the China-Japan Friendship Hospital. Inspection and analysis after the test.2.11.4Safety parameters include AEs and laboratory examinations .2.11.5After the test, the proportion of qualified diets and the frequency of various food intakes will be calculated. The diet intervention group should strictly follow the requirements of light vegetarian diet, while the nondiet intervention group does not need to observe the light vegetarian diet. Dietary compliance rate (DCR) means the ratio of qualified meals to total meals times 100. When DCR is greater than or equal to 80%, high compliance is achieved, while low DCR is less than 80%.2.12Adverse events refer to the negative effects caused by the intervention. During the trial, any abnormal reactions of the participants will be reported to the researchers. The time of onset, symptoms, degree, duration, and mitigation measures will be recorded in the CRF.2.13Researchers will be trained in a unified way before the study to ensure it is performed correctly. Data will be locked in the airtight cabinet and will be entered and checked by double entry into the database established by data administrator using Excel 2019 edition  for management after completion of the study. An independent statistician will analyze the data while the procedure will be monitored by a third individual. The data of the patients involved in the trial will be confidential and will be used only by scientific research institutes. The publication or reporting of any research findings will not reveal the individual identity.2.14χ2 test or Fisher exact test. Wilcoxon rank sum test or Kruskal–Wallis H test will be used for the number of CSBM per week in primary outcome. χ2 test or Fisher exact test will be used for percent improvement of each symptom scale score in secondary outcome indicators. The result of 48-hour GITT will be analyzed using χ2 or Fisher test. Wilcoxon rank sum test or Kruskal–Wallis H test will be used for measurement data in HRAM, while χ2 test or Fisher exact test will be used for counting data. Safety, dietary quality, compliance indicators will be tested by χ2 test or Fisher exact test. Complying with the intent-to-treat and per-protocol principle, all data of the patients randomized and at least 1 assessment (include baseline assessment) will be analyzed. For dropouts and terminations, their missing data will be obtained by last-observation-carried-forward method. All statistical analyses will be performed by SPSS23 software , and P value <.5 will be considered statistically significant.Continuous variables will be described as the mean ± standard deviation, median, or interquartile range. The number of cases, frequency, the rate, and the constituent ratio will be described by categorical variables. Variance analysis will be used for continuous variables in the baseline data having normal distribution and same variance. Wilcoxon rank sum test or Kruskal–Wallis H test will be used for the comparison of differences between groups that are not normally distributed or have uneven variance. Categorical variables will be tested by 2.15This study has been approved by China-Japan Friendship Hospital clinical research ethics committee (No. 2017-46-1). Participants will need to sign the informed consent before the entering the study. During the intervention, patients have the right to withdraw at any condition and will not affect subsequent treatment . We must submit a written application to the ethics committee if the protocol needs to be modified. The committee members will decide whether to modify it. The results of the study will be sent to researchers, participants, and disseminated to the public through academic conferences and journals. This is an open access article, which permits unrestricted use when the original work is correctly cited.3–20 kidney diseases,,22 and even sudden death. At present, traditional Chinese and Western medicines used to treat functional constipation can only temporarily improve constipation. Constipation can easily recur after stopping the medication. Some traditional Chinese medicines also cause damage to the intestinal tract (melanosis coli).,24 Long-term improvement of constipation can be achieved through the management of patients’ cognitive behavioral patterns. Studies have shown that dietary fiber supplementation can improve chronic constipation, but there is no intervention study on constipation with a vegan diet.–27 In clinical practice, maintenance of FC improvement has been observed in patients who persist in LVD for a period of time without any drug use. TCM is a national medicine in China.,29 It has been caring for the health of Chinese people from ancient times to present. TCM has mature experience in the treatment of constipation. Qing Jiang Tiao Chang Fang is a safe and effective prescription. However, these are only the results of clinical observations and need to be scientifically validated in clinical trials. This RCT aims to clarify the efficacy and safety of LVD and QJTCF on FC by designing rigorous trials. The results of the study can provide more evidence for dietary intervention and TCM intervention on FC, and to some extent, clarify the complementary effect of diet on drugs. There are still some limitations in this study:FC is a common disease of the digestive system and is characterized by persistent or recurrent difficulty in defecation. Constipation can cause digestive symptoms such as loss of appetite, abdominal distension, hemorrhoids, and colon polyps. It can also lead to cardiovascular and cerebrovascular diseases,1.Dietary intervention is a cognitive behavioral therapy, and there are many objective factors that will hinder the practice of light vegetarian diet and affect the experimental results.2.The experiment explored the metabolic effects of vegetarian diet and traditional Chinese medicine on fecal short-chain fatty acids, but no other metabolites were studied.3.The current study belongs to exploratory study with small sample size.Therefore, based on this study, a large sample size, multicenter RCT should be designed in the future to verify the effectiveness and safety of LVD and QJTCF on FC. In terms of mechanism, if intestinal flora, metabolism, power, and other angles can be integrated to study, it can be more convincing.The authors thank the doctors and other staff in the Department of Gastroenterology and Gastroenterology of Chinese Medicine of China-Japan Friendship Hospital for their assistance. LX is the first author. The authors thank MB of the Pharmacy Department of China-Japan Friendship Hospital for assisting in the packaging of drugs and placebos. They thank Sun Ruihua, Clinical Research Institute of China-Japan Friendship Hospital, for providing statistical guidance.Conceptualization: Xinyuan Liu, Yu Liu, Shukun Yao.Data curation: Xinyuan Liu, Yu Liu, Jialiang Chen, Huijing Wang.Formal analysis: Xinyuan Liu.Funding acquisition: Shukun Yao.Investigation: Yuehua Ding, Yuanchen Zhou, Xinyuan Liu, Huijing Wang, Qianqian Wang, Zuohu Niu, Zhangjun Yun.Methodology: Xinyuan Liu, Yu Liu, Jialiang Chen, Qianqian Wang, Bingzhi Ma, Shukun Yao.Project administration: Xinyuan Liu, Shukun Yao.Resources: Shukun Yao.Software: Xinyuan Liu, Jialiang Chen, Shukun Yao, Zuohu Niu, Zhangjun Yun.Supervision: Shukun Yao.Visualization: Xinyuan Liu, Bingzhi Ma.Writing – original draft: Xinyuan Liu, Yu LiuWriting – review & editing: Xinyuan Liu, Shukun Yao.


Eriocheir sinensis, which has resulted in large economic losses. However, the underlying cause of this disease remains unclear. To better understand the pathogenesis and pathogenic mechanism of HPND, we compared the transcriptome differences of the hepatopancreas of E. sinensis with and without HPND. The analysis yielded > 30 million reads for each sample of three test (with HPND) and three control groups (without HPND). We observed 978 downregulated genes and 644 upregulated genes. Among the gene ontology categories “biological process,” “cellular component,” and “molecular function”, the subcategories cellular process, single-organism process, biological regulation, metabolic process, cell part, organelle, organelle part, binding, and catalytic were enriched. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis showed that “metabolism of xenobiotics by cytochrome P450,” “drug metabolism—cytochrome P450,” “chemical carcinogenesis,” and “material metabolism” were the “five” most significantly enriched pathways in the hepatopancreas of E. sinensis with HPND. The results revealed that material metabolic abnormalities and drug effects from the external environment might be associated with HPND in the Chinese mitten crab. Considering the wide use of pyrethroids for pond cleaning in Xinghua city, we speculated that pyrethroids might cause HPND in the Chinese mitten crab. Our study provided useful information about the cause and pathogenetic mechanisms of HPND and could help to prevent this disease in production practice.Hepatopancreatic necrosis disease (HPND) is a newly emerging disease in the Chinese mitten crab,  Eriocheir sinensis, is one of the most important economic crustacean species in China, and techniques to rear its larvae and its culture facilities were developed in the early 1980s. The Chinese mitten crab is regarded as a delicious and nutritious crustacean by many Chinese consumers because of its nutritional ingredients and delicate flavor [E. sinensis is rapidly expanding. As a province hosting large scale E. sinensis farming, the annual output of E. sinensis in Jiangsu Province, China is worth approximately US$ 4 billion [E. sinensis is prevalent in Xinghua city, Jiangsu province, and has spread slowly to other main areas of crab rearing nationwide since 2015 [The Chinese mitten crab,  billion . With th billion , and treHepatospora eriocheir was the pathogen of HPND in the Chinese mitten crab [H. eriocheir starved its host by destroying the hepatopancreas by appropriating host resources, resulting in associated changes in crab metabolism and immunity [Hepatospora eriocheir was unlikely to be the cause of HPND in the Chinese mitten crab. They revealed that fatty acid metabolic abnormalities and high concentrations of propamocarb might be associated with HPND. Yang et al. [Despite intensive research into HPND, its etiology has not been elucidated clearly. Ding et al. first claimed that the microsporidian fungus ten crab . They primmunity . Howeverimmunity . Shen etimmunity  construcimmunity  used liqg et al.  sought tCrassostrea gigas [Litopenaeus vannamei [E. sinensis [Gene expression variations in response to external stimuli are sensitive and rapid, and such transcriptional responses might help to explain how an organism responds to a particular situation . Recentlea gigas , Litopenvannamei , and E. sinensis , 16.Litopenaeus setiferus and L. vannamei indicated that the hepatopancreas has a vital role in non-specific immunity, and a cDNA library prepared from the hepatopancreas is more representative than that of hemocytes [E. sinensis with and without HPND using Illumina sequencing and bioinformatic analysis. The objective of the study was to annotate functional genes identified using transcriptome analysis, and to evaluate the transcriptomic response of the Chinese mitten crab affected with HPND. Our study will help to understand the etiology and pathogenic mechanism of HPND in E. sinensis and will provide a reference for further research.In crustaceans, the hepatopancreas is a digestive gland and an immune organ, which plays an important role in the metabolism of xenobiotics and the innate immune system –19. Tranemocytes . For theThis study was carried out in strict accordance with the recommendations and guidelines on the care and use of animals for scientific purposes established by the Institutional Animal Care and Use Committee of Shanghai Ocean University, Shanghai, China. The study design and protocol were approved by the Ethics Committee of Shanghai Ocean University . The crabs were anesthetized and dissected on ice; all efforts were made to minimize their suffering.Healthy mature male crabs , with yellow hepatopancreas, and diseased mature male crabs , with clinical symptoms of HPND, were collected from the crab breeding base  of Tao Huadao AgriculturalDevelopment Co., Ltd. in Anfeng Town, Xinghua City, northern Jiangsu Province, China, in December 2016. These crabs were transported to the laboratory in polystyrene boxes filled with cultivation water, which was aerated during transportation using an aeration pump. Upon arrival, the crabs were anesthetized and dissected on ice to collect the hepatopancreas, which was stored in liquid nitrogen at −80°C for RNA extraction. Healthy crabs and diseased crabs were separated into three groups . Each group consisted of a mixed collection of ten crabs, and the test and control group consisted of three replicates, respectively. A total of 60 crabs were used.2O. The eluted RNA was stored in liquid nitrogen before the next step. A NanoDrop ND-1000 UV–vis Spectrophotometer  was used to check the RNA quality. RNA integrity was determined using an Agilent 2100 Bioanalyzer  and an RNA 6000 Nano LabChip kit (Agilent Technologies). Poly (A) mRNA was isolated using Oligotex mRNA kits (Qiagen) and oligo-dT beads. The mRNA was treated using fragmentation buffer, and the first-strand cDNA was synthesized using the cleaved RNA fragments as templates. RNase H and DNA polymerase I were used to synthesize the second-strand cDNA. A single “A” base was added to these double-stranded cDNA fragments using Klenow 3′–5′ exopolymerase, and the fragments were end-repaired using T4 polynucleotide kinase, T4 DNA polymerase, and the Klenow fragment. Then, the double-stranded fragments were ligated to an index adapter or adapter using T4 quick DNA ligase. Then, the adaptor-ligated fragments were screened out according to their size via agarose gel electrophoresis. The target cDNA fragments were excised from the gel and a PCR reaction was performed to amplify them. After validation using the ABI StepOnePlus Real-Time PCR System  and the Agilent 2100 Bioanalyzer, the cDNA libraries of the corresponding samples were sequenced on a flow cell with the high-throughput mode on an Illumina HiSeq 2500 unit  [According to the manufacturer’s instructions, total RNA was isolated from hepatopancreas using the TRIzol reagent . DNA contaminants were removed using RNase-free DNase I , and the total RNA was eluted in 100 μL of RNase-free MilliQ HCA, USA) .http://www.bioinformatics.babraham.ac.uk/projects/fastqc/) was used to clean the obtained reads and to evaluate the quality and content of the remaining clean reads. Then, we conducted a comparative analysis with the reference genome of the Chinese mitten crab. For every sample belonging to the control and test groups, sequence alignment with the reference genome sequences was performed using TopHat (version 2.0.12), with default parameters [Trim Galore was used to filter out the low-quality reads and remove 3′ adapter sequences. The FastQC software (rameters .2 (FPKM+1) and evaluated. The DESeq software (version 1.14.0) was used to screen out the DEGs and the fold-change of each transcript was calculated [p-value < 0.05 was considered statistically significant [The RSEM software with default parameter settings  was usedlculated . A two-fnificant .http://www.uniprot.org/). The Blast2GO suite (https://www.blast2go.com/) was used to obtain the GO annotations against gene ontology terms  [N is the number of genes with GO annotation added; n represents the number of DEGs included in N; M represents the number of genes that were annotated to the specific GO term; and m represents the number of DEGs included in M. The p-value was assigned to each gene and adjusted using the Benjamini and Hochberg’s approach to control the false discovery rate. The corrected p-value of 0.05 was used as the threshold to determine statistical significance. When the corrected p-value was < 0.05, the GO term was considered significantly enriched in the DEGs [To investigate the potential functions of these DEGs, the DEGs were firstly annotated using the UniProt database (ogy.org) . All DEGthe DEGs .http://nebc.nox.ac.uk/bioinformatics/docs/blastall.html) to annotate the pathways of DEGs based on the Kyoto Encyclopedia of Genes and Genomes (KEGG) database. The enriched KEGG pathways were identified using the same formula as that used for GO analysis. M is the number of certain genes annotated to the specific pathways; N is the number of genes that were added with KEGG annotation; m represents the number of DEGs included in M; and n is the number of DEGs included in N [We used blastall  was used to verify the expression levels of the DEGs identified by RNA-Seq analysis. The genes selected for validation by qRT-PCR were involved in enriched GO terms and enriched KEGG pathways. We designed the primers using Primer 5 software. The gene encoding β-actin of the Chinese mitten crab was selected as internal control to normalize the expression levels of the DEGs; all the experiments were conducted in triplicate. The PCR reaction was carried out in a 25 μL volume, comprising 0.5 μL of primers, 9.5 μL of RNase-free HT method .E. sinensis with HPND. In the test groups, 48,219,524; 44,950,578; and 46,421,300 raw reads were obtained; and in the control groups 31,060,184; 31,016,354; and 32,478,004 raw reads were obtained. After the raw sequence reads were filtered and checked, we obtained 46,485,186; 43,436,726; and 44,832,770 trimmed reads in the test groups, and 30,506,938; 30,453,508; and 31,904,838 in the control groups. The trim rates of test groups were 96.40, 96.63, and 96.58%, and in the control groups were 98.22, 98.19, and 98.24%. The average length of the reads was 150 bp  of each group. The x-axis was the change in gene expression multiple in the different groups, and the y-axis was the statistically significant changes in gene expression . We idenThe 1622 DEGs were classified into 65 GO terms belonging to the three domains: biological process, cellular component, and molecular function .Eriocheir sinensis was related to stress of some kind.Lipids are stored in droplets in crabs and represent the major component of the fat body and the main source of metabolic fuel . When etWe mapped the DEGs to the KEGG database to further explore their related biological functions and important pathways. We found that some genes participated in multiple pathways, whereas other genes were included in a single pathway. The first nine most-enriched KEGG pathways of the DEGs were metabolism of xenobiotics by cytochrome P450; glycine, serine and threonine metabolism; pentose and glucuronate interconversions; drug metabolism—cytochrome P450; retinol metabolism; tryptophan metabolism; ascorbate and aldarate metabolism; chemical carcinogenesis; and histidine metabolism . FurtherWe used qRT-PCR to verify the gene expression profiles of 10 DEGs selected randomly after the GO and KEGG analyses. All the primer sequences of the 10 examined genes are listed in Positive values indicate that the expression of the DEG is upregulated. Negative values indicate that the expression of the DEG is downregulated.E. sinensis, and the expression levels of genes involved in these two pathways were mostly downregulated. The results indicated that abnormal lipid storage and mobilization occurred in crabs with HPND. In addition to lipid metabolism, DEGs that were enriched in pathways including glycine, serine and threonine metabolism and pentose and glucoronate interconversions were mainly downregulated. These results were consistent with the results of previous studies, in which nutrients metabolic abnormalities, especially fatty acid and carbohydrate metabolism, were proposed to be associated with HPND in the Chinese mitten crab [The GO annotation showed that compared with those in healthy crab, the expression levels of most DEGs involved in the lipid metabolic process and carbohydrate catabolic process in crabs with HPND were downregulated. Furthermore, the KEGG analysis showed that DEGs participating in the biosynthesis of unsaturated fatty acids were downregulated, and the DEGs involved in glycerolipid metabolism were also downregulated, except for two genes (VN_GLEAN_10001404 and VN_GLEAN_10006205). In the enrichment analysis of KEGG pathways, “glycerolipid metabolism” and “biosynthesis of unsaturated fatty acids” were the important pathways related to lipid metabolism in ten crab , 9.S-transferase (GST) [in vivo and in vitro [In the present study, the enriched drug metabolic pathways associated with HPND in the Chinese mitten crab were metabolism of xenobiotics by cytochrome P450, drug metabolism-other enzymes, drug metabolism-cytochrome P450, chemical carcinogenesis, and glutathione metabolism. Interestingly, all the DEGs associated with these pathways were downregulated. Furthermore, we found that the expression levels of carboxylesterase family genes were upregulated, and CYP450 family genes were downregulated. Previous studies have showed that the biodegradation of pyrethroids was mainly catalyzed by carboxylesterases, P450 enzymes, and glutathione-se (GST) . Carboxyse (GST) , CYP450 in vitro , and pyrin vitro . Considein vitro  in XinghOur study conducted a comparative transcriptome analysis between diseased crabs with HPND and healthy crabs. GO functional annotation analysis and KEGG pathway analysis showed that abnormal metabolism of nutrients occurred in the diseased crabs. Alterations in the expression levels of CYP450 and carboxylesterase family genes, which are involved in xenobiotics or drug associated pathways, suggested that pyrethroids or other drugs were related to HPND in crabs.In conclusion, our study revealed that under the stress effects of some as-yet-unidentified toxic substances, abnormalities in metabolism and absorption of nutrients appeared in crabs, which subsequently led to HPND. This hypothesis is consistent with that of Shen et al. . HoweverS1 FigThe x-axis represents the GO terms involved in the three main ontologies . The y-axis represents the percent of genes.(TIF)Click here for additional data file.S1 Table(XLS)Click here for additional data file.S2 Table(XLS)Click here for additional data file.S3 Table(XLS)Click here for additional data file.S4 Table(XLS)Click here for additional data file.S5 Table(XLS)Click here for additional data file.


Early-psychosis researchers have documented that duration of untreated psychosis (DUP) is an important predictor of outcomes in first-episode psychosis. Very few cross-national studies have been conducted, and none have been carried out involving patients from both Mexico and the U.S. We collaborated to answer three questions: (1)Are DUP estimates similar in two very different settings and samples? (2)Are demographic variables, premorbid adjustment, and symptom severity similarly related to DUP in the two different settings? (3)Does the same set of variables account for a similar proportion of variance in DUP in the two settings?Data on sociodemographic characteristics, premorbid adjustment, symptom severity, and DUP were available for 145 Mexican and 247 U.S. first-episode psychosis patients. DUP was compared, and bivariate analyses and multiple linear regressions were carried out in each sample.DUP estimates were similar (medians of 35 weeks in Mexico and 38 weeks in the U.S.). In the Mexican sample, DUP was associated with gender, employment status, premorbid social adjustment, and positive symptom severity (explaining 18% of variance). In the U.S. sample, DUP was associated with age, employment status, premorbid social adjustment, and positive symptom severity (but in the opposite direction of that observed in the Mexican sample), accounting for 25% of variance.Additional cross-national collaborations examining key facets of early-course psychotic disorders, including DUP, will clarify the extent of generalizability of findings, strengthen partnerships for more internationally relevant studies, and support the global movement to help young people struggling with first-episode psychosis and their families. Studies on first-episode psychosis from around the world have consistently shown duration of untreated psychosis (DUP)—often defined as the time interval from onset of frank psychotic symptoms  to the first contact with a psychiatric facility to receive adequate pharmacological treatment—to be an important predictor of clinical and social outcomes in patients with first-episode psychosis . A longecauses poor outcomes or if individuals at risk for poor outcome receive specialized treatment long after the onset of symptoms [The specific mechanisms underlying the association between DUP and outcome variables are not yet clearly identified. It is still unknown if DUP symptoms . It is csymptoms , and thasymptoms –10.Although longer DUP can be considered a risk factor for poorer outcomes in patients with psychosis, little is known about the determinants of a prolonged DUP . Some stLower premorbid adjustment is reflected by a poorer adaptation to school, lower academic performance, and limited social relationships during childhood and adolescence. If an insidious illness onset begins during this time, early manifestations of the disorder, such as predominant negative symptoms, are often misattributed to other circumstances rather than a serious mental illness, such as substance use, difficulties at school, or simply behaviors considered to be characteristic of adolescence , 20–22. In this study, we leveraged a collaboration between Mexican and U.S. early psychosis researchers to study two samples with regard to key variables pertaining to first-episode psychosis. We specifically sought to answer three research questions about DUP. First, are DUP estimates similar or different in the two very different settings and samples? Second, are basic demographic variables, premorbid adjustment scores, and symptom severity scores similarly related to DUP in the two settings and samples? Third, does the same set of variables account for a similar portion of variance in DUP in the two different settings and samples?Patients in Mexico were consecutively recruited from both the inpatient and outpatient services of the Instituto Nacional de Psiquiatría Ramón de la Fuente Muñíz (INPRFM), a highly specialized mental health center in Mexico City, dedicated to research, education, and treatment of psychiatric patients. A total of 145 patients, enrolled from the prospective Mexican First-Episode Psychotic Study  were incWith regard to the settings from which the U.S. participant were drawn, as part of a project examining the effects of premorbid marijuana use on early-course psychosis , consecuStructured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) [At both sites, after a clinical interview with the patient and his or her relatives, a trained clinical researcher made a diagnosis using the (SCID-I) , to confPremorbid Adjustment Scale (PAS) [childhood (≤11 years), early adolescence (12–15 years), late adolescence (16–18 years), and adulthood (≥19 years). Functioning in each of these age periods is assessed across five major psychosocial domains that are rated from 0  to6 (severe impairment): sociability and withdrawal, peer relationships, scholastic performance, adaptation to school, and social-sexual functioning. Social-sexual functioning is not included as a psychosocial domain during the childhood period, while scholastic performance and adaptation to school are not measured during the adulthood period. The adulthood period was not assessed in the present study. Thus, in childhood, academic functioning includes scholastic performance and adaptation to school, and the social functioning encompasses sociability and withdrawal and peer relationships. In both early adolescence and late adolescence, academic functioning is comprised of scholastic performance and adaptation to school, and social functioning includes sociability and withdrawal, peer relationships, and social-sexual functioning. At both the Mexican and U.S. sites, functioning was not rated in a respective age period if prodromal or psychotic symptoms began during or within one year of that period, as described previously [The le (PAS)  assessesle (PAS) –32. Funceviously .Positive and Negative Syndrome Scale (PANSS) [Positive and negative symptom severity was assessed at both sites with the commonly used  (PANSS) . The PAN (PANSS) . At the At the Mexican site, DUP was measured following the criteria proposed by Larsen  and was Symptom Onset in Schizophrenia (SOS) inventory [At the U.S. site, age at onset of psychosis and DUP  were determined using the nventory . The SOSnventory , 38–40.2 tests of association for categorical variables, independent samples Student’s t tests for continuous variables with approximately normal distributions (based on examination of descriptive statistics and the Kolmogorov-Smirnov test), and Mann-Whitney U tests for continuous variables that were not normally distributed. Correlations were computed using Pearson and Spearman correlation coefficients as appropriate.Bivariate analyses for comparisons between the Mexican and U.S. samples of first-episode psychosis patients were carried out using χTo assess the independent effects of correlates of DUP in both samples, we computed a log transformation of DUP, ln(DUP+1), which normalized the distribution to allow for multiple linear regression models.z=3.99, p<0.001) and more likely to be unemployed (at a trend level). Patients in the U.S. sample had completed more years of education , were more likely to be male , and were more likely to be single .We first compared our two first-episode psychosis samples in terms of basic demographic variables. As shown in z=0.02, p=0.99); the distributions of DUP are shown in In terms of PAS scores, patients in the Mexican sample had lower PAS academic adjustment scores (indicating better premorbid academic adjustment) across all three age groups. However, PAS social adjustment scores did not differ. Also shown in p<0.01) and in the moderate range (the average of the three correlations was 0.46 in the Mexican sample and 0.49 in the U.S. sample). Correlations between the three social adjustment scores were also statistically significant  and larger (the average of the three correlations was 0.68 in the Mexican sample and 0.58 in the U.S. sample). On the other hand, correlations between the three academic adjustment scores and the three social adjustment scores were only modest  and 0.17 in the U.S. sample ).Inter-correlations among PAS subscale scores, in both samples, are shown in r=0.15 in Mexican patients and r=0.23 in U.S. patients), and negative symptom and general psychopathology symptom subscale scores were most correlated .With regard to inter-correlations among the three PANSS symptom severity scores, findings were again consistent in the Mexican and U.S. samples of first-episode patients . Specifip<0.001), though it was not associated with DUP in the Mexican sample . Also in the U.S. sample, employment status was associated with DUP at a trend level . In the Mexican sample, both gender  and employment status were associated with DUP .In terms of associations between DUP and the five demographic variables , and employment status), in the U.S. sample, age and employment status were associated with DUP. Age was directly correlated with DUP . In both samples, DUP was associated neither with negative symptom severity nor general psychopathology symptom severity. In the Mexican sample, longer DUP was associated with a lesser severity of positive symptoms , but in the U.S. sample, longer DUP was associated with a greater severity of positive symptoms .Correlations among DUP, PAS academic adjustment (an average score across the three age periods), PAS social adjustment , and PANSS scores are shown in . Similarly, in the model pertaining to the U.S. sample, the four independent variables  accounted for 25% of the variance in DUP .In each sample, multiple linear regressions were run, including variables found to be associated with DUP in the aforementioned bivariate tests. Results of these two models are shown in 4.social adjustment was related to DUP in both samples, though premorbid academic adjustment was not. Third, interestingly, positive symptom severity was associated with DUP in the two samples, but in contrasting ways. Fourth, we found that a similar set of four variables account for approximately one-fifth to one-quarter of the variance in DUP in the two different settings and samples.Several interesting findings emerged from this analysis, which represents one of the first cross-national comparisons of DUP and predictors/correlates of DUP, and the first to do so among first-episode samples in Mexico and the U.S. First, we found that the distributions of DUP—and the medians of DUP—were remarkably similar in these two very different settings and samples. Second, we observed similarities in variables associated with DUP; for example, premorbid With regard to the first of these findings, in our samples, the median DUP is around 8–9 months. This is consistent with findings in several other studies , 41. OneOur similarities in correlates of DUP add more evidence regarding the importance of poor premorbid social adjustment in understanding DUP. This variable may produce longer DUP as poor social adjustment is related to decreased social support –47 (incllesser severity of this kind of symptoms in the Mexican sample. However, a longer DUP was associated with greater positive symptom severity in the U.S. sample. This apparently contradictory finding could be explained by the exacerbation of stigma in the presence of positive symptoms [Regarding the relationship between DUP and positive symptoms, as expected due to the difficulty for the patient/family to recognize/accept a psychiatric disorder that needs to be evaluated and treated when positive symptoms are less severe or not present, a longer DUP was associated with symptoms  and conssymptoms . Additiosymptoms  pointed a priori that our two settings and samples were quite different; we view the findings as particularly informative in part because of this lack of similarity. In both samples, four predictors accounted for 18–25% of the variance in DUP.In comparing DUP estimates, predictors of DUP, and proportion of DUP explained by similar sets of predictors, we knew Several methodological limitations should be noted. First, this was a secondary analysis of two existing but similar datasets that were combined for the purposes of this collaborative analysis. As such, there were subtle differences in the exact measurement methods for key variables, including DUP. Second, as is true of any study of DUP, this is a difficult construct to measure as it inevitably relies on retrospective recall of patients and their family members. Third, and also related to the fact that this was a secondary analysis, there are a host of other variables that would have ideally been measured, and which could have explained more variance in DUP. Despite these limitations, our analysis reveals the value of cross-national collaborations in examining key facets of the early course of psychotic disorders, including DUP. Such studies will clarify the extent of broad generalizability of findings even in quite different samples; strengthen partnerships for more rigorous and internationally relevant studies; and support the now global movement to help young people struggling with early psychosis and their families, who must navigate complex systems of care while facing diverse social and psychological challenges.


The relationship between creativity and psychopathology has been a controversial research topic for decades. Specifically, it has been shown that people with schizophrenia have an impairment in creative performance. However, little is known about the brain correlates underlying this impairment. Therefore, the aim of this study was to analyze whole brain white matter (WM) correlates of several creativity dimensions in people with schizophrenia. Fifty-five patients with schizophrenia underwent diffusion-weighted imaging on a 3T magnetic resonance imaging machine as well as a clinical and a creativity assessment, including verbal and figural creativity measures. Tract-based spatial statistic, implemented in FMRIB Software Library (FSL), was used to assess whole brain WM correlates with different creativity dimensions, controlling for sex, age, premorbid IQ, and medication. Mean fractional anisotropy (FA) in frontal, temporal, subcortical, brain stem, and interhemispheric regions correlated positively with figural originality. The most significant clusters included the right corticospinal tract  and the right body of the corpus callosum. Verbal creativity did not show any significant correlation. As a whole, these findings suggest that widespread WM integrity is involved in creative performance of patients with schizophrenia. Many of these areas have also been related to creativity in healthy people. In addition, some of these regions have shown to be particularly impaired in schizophrenia, suggesting that these WM alterations could be underlying the worse creative performance found in this pathology. The relationship between creativity and schizophrenia has been a research topic of interest for centuries  since itThe study of the underlying neuroanatomical substrates of creativity in schizophrenia, nevertheless, is very scarce , and it Regarding structural brain correlates of creativity in healthy people, contradictory and inconclusive findings have been found . SpecifiInterestingly, brain regions identified by studies analyzing structural brain correlates of creativity in healthy individuals  are regiTaking into account the structural connectivity alterations as well as the creativity impairment shown in schizophrenia, it seems relevant to study the WM correlates of creativity in this disease. As far as the authors are aware, to date, none of the previous studies have investigated whole brain WM correlates with different dimensions of creativity  in schizophrenia. Therefore, the objective of this exploratory study was to assess whole brain WM correlates of several creativity dimensions in people with schizophrenia. Based on previous results from SD = 10.41)] diagnosed with schizophrenia and recruited from the Psychiatric Hospital of Álava and the Community Mental Health Services in Álava . All patients met the diagnostic criteria for schizophrenia according to the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision . All participants took part in the study voluntarily and provided their written informed consent. Participants did not receive any monetary reward for taking part in the study.Exclusion criteria consisted of: (a) clinical instability , (b) cognitive impairment secondary to another disease, (c) main diagnosis of a substance use disorder or presenting active drug consumption at the time of the study, (d) relevant modifications to the antipsychotic drug treatment in the previous 3 months, (e) diagnosis of an active major affective disorder, and (f) incompatibilities with magnetic resonance imaging: claustrophobia, metal implants in the body, or patients who were undergoing deep brain stimulation. The study protocol had the approval of the Clinical Research Ethics Committee of the Autonomous Region of the Basque Country (CEIC-E) in Spain (PI2017044). The trial was registered in Creativity was measured by means of two subtests from the Torrance Test of Creative Thinking . From thPsychopathology was assessed with the PANSS . PositivPremorbid IQ was calculated with the Accentuation Reading Test (TAP) , a SpaniHandedness was measured using the Edinburgh Handedness Inventory . In this2) and 1 b = 0 s/mm2.Diffusion-weighted images (DWIs) were obtained on a Philips 3T Achieva Dstream, in an axial orientation in an anterior–posterior phase direction using a single-shot EPI sequence  with diffusion weighting in 32 uniformly distributed directions  (The FMRIB Software Library (FSL)  version on Tool) , and theon Tool) . FNIRT ton Tool) , b was up < 0.05 corrected for family wise error (FWE), with an extent threshold of 100 voxels. Effect sizes for each cluster of the correlations were calculated according to Cohen’s d formula. Cohen’s d of 0.20, 0.50, and 0.80 were considered small, medium, and large, respectively . As creativity variables did not follow a normal distribution, these were log-transformed (LN) and all variables were then transformed into Z scores. To examine the relationship between WM indexes and creativity, permutation-based inferences  with the threshold-free cluster enhancement (TFCE) correction method for multiple comparisons, including the – – T2 option, were carried out using FSL’s Randomise Tool . Based oectively . The maxectively  as well Participants from the present study were assured that raw data would remain confidential and would not be shared. Therefore, data of the study are not available in the public domain.SD = 0.78) for verbal originality, −0.78 (SD = 0.61) for verbal fluency, −0.93 (SD = 0.69) for verbal flexibility, −0.19 (SD = 0.64) for figural originality, −0.20 (SD = 1.05) for figural fluency, −0.55 (SD = 0.81) for figural elaboration, −0.27 (SD = 0.99) for figural flexibility, −0.41 (SD = 1.02) for figural resistance to closure, −0.78 (SD = 0.74) for figural abstractness of titles, and −0.84 (SD = 0.57) for figural creative strengths.Sociodemographic and clinical characteristics of the sample as well as performance in verbal and figural creativity are shown in Significant positive correlations were found between mean WM FA and figural originality in two clusters . Signifip < 0.05) (d = 1.13 and Cohen’s d = 0.92). No significant correlations were found for MD, AD, RD, or MO in this variable.The subdomain of figural creativity that correlated positively with mean WM FA was originality. More specifically, WM fibers corresponding to the peak level of significance were located in the right corticospinal tract  for cluster 1 and the right body of the corpus callosum for cluster 2 . Other W < 0.05) . Effect The main objective of this study was to assess whole brain WM correlates of different creativity dimensions in people with schizophrenia. Our findings showed that creative performance was positively related to WM mean FA adjacent to multiple brain regions, including frontal, temporal, subcortical, and brain stem areas as well as to interhemispheric WM fibers. Significant positive correlations were specially found in figural originality but not in any verbal creativity dimension. As a whole, these results are quite consistent with findings from As expected, significant positive correlations were found between the figural originality subdomain of creativity and FA in the corpus callosum. This is congruent with findings from previous studies analyzing WM correlates of creativity . WM inteConsistent with our hypothesis, results also showed significant positive correlations between the figural originality subdomain of creativity and WM tracts traversing the frontal lobe, such as the uncinate fasciculus and WM adjacent to the prefrontal cortex. These findings were also in line with both structural WM studies  and fMRIIn addition to WM from the corpus callosum and frontal lobe, we also found a relationship between the figural originality subdomain of creativity and intrahemispheric WM fibers located in several association regions from the temporal lobe, specifically, the uncinate fasciculus and WM adjacent to the inferior temporal gyrus. This indicates that intrahemispheric communication may also be required for creative thinking through the integration of remote information belonging to multiple regions that are involved in different domains . BesidesWhite matter tracts located in subcortical regions were also associated with creativity. They included the fornix, internal capsule, external capsule, anterior thalamic radiation, and lenticular fasciculus. These regions could be involved in creativity due to their implication in the dopaminergic system . An incrFinally, a positive correlation was found between creativity and the corticospinal tract in its cerebral peduncle part. Although this region has not been related to creativity, the cerebral peduncle is a main component of the cortico-ponto-cerebello-thalamo-cortical loop and it is believed to connect the cerebellum with the neocortex . The cerAlthough we found some greater correlations in regions from the right hemisphere, in general, there were bilateral correlations with creativity. In fact, in spite of the long-held belief that the right hemisphere is mainly responsible for creative thinking , nowadayIt is worth mentioning that we did not find significant correlations with all dimensions and, specifically, with verbal creativity. The absence of significant correlations in various variables could be partially due to the sample size. In any case, several of the few studies that analyze WM FA correlates of creativity have not found significant correlations either in patients with schizophrenia  or in heTaken together, this study provides initial data for brain WM correlates of creativity in schizophrenia. Overall, results suggest that both intrahemispheric communication and interhemispheric communication seem to be required for creative thinking, allowing the integration of remote associations of ideas. Our findings support the role of the frontal lobe in creative thinking but also indicate the relevance of other brain regions such as the corticospinal tract. Results from this study are similar to those from The present study has several limitations that should be considered. First, we did not include healthy controls to check whether there was an impairment in WM integrity. However, our interpretations of the results were based on previous evidence, which has shown that people with schizophrenia have WM alterations in specific brain regions . Future As far as the authors are aware, this is the first study analyzing whole brain WM correlates of different creativity dimensions in schizophrenia. We consider that this study provides relevant preliminary data that could, on the one hand, shed light on the long-standing and controversial association between psychosis and creativity and, on the other hand, contribute to fill a gap in research on the neuroscience of human creativity. Results suggest that multiple brain regions are involved in creative thinking, which makes sense due to the complexity and multifaceted nature of this higher-order cognitive function. Yet more research is needed in order to understand the neural bases of creativity in both schizophrenia and healthy people. Understanding the brain correlates of creativity in schizophrenia has relevant implications for the treatment of mental disorders and for the enhancement of this ability that is essential for the survival and enrichment of humankind .The datasets for this article are not publicly available because participants from the present study were assured raw data would remain confidential and would not be shared.The studies involving human participants were reviewed and approved by Clinical Research Ethics Committee of the Autonomous Region of the Basque Country (CEIC-E) in Spain (PI2017044). The patients/participants provided their written informed consent to participate in this study.NO, NI-B, JP, and PS designed the study and wrote the protocol. AS, AC-Z, PS, NI-Y, and CP performed the clinical, neuropsychological, and neuroimaging assessments. AS and JP managed the literature searches. AS, JP, and AG-G undertook the statistical analysis. AS and JP wrote the first draft of the manuscript. All authors contributed to the writing and revision of the manuscript and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Burn injuries are one of the traumas seen in all parts of the world and children are usually one of the vulnerable groups. The aim of this study was to determine the factors related to unintentional burns in children, using data mining algorithms.In this hospital-based case-control study conducted in Kermanshah province, Iran, data were collected over a period of 15 months. Children under the age of 15 years old who were referred to the burn ward of Imam Khomeini Hospital, the only burn referral in Kermanshah province, were included as cases. For the control group, children who were admitted to Dr. Mohammad Kermanshahi Hospital, the only specialist and subspecialist pediatric center in this province, were included. Frequency matching was performed for age and sex. Support vector machine (SVM), artificial neural network (ANN), random forest (RF), and logistic regression (LR) were employed to determine the factors related to burns in children.The mean age of children with burn injuries was 4.29 ± 3.51 years and 58% of them were boys. The ANN algorithm had better performance than other algorithms. Body mass index (BMI), socioeconomic status, hours without a watchful, mother’s age, mother’s education, household size, father’s job, father’s age, having more than one watchful, and petroleum storage were the most important factors related to pediatric burns. The majority of the burn-related variables were related to individuals’ social welfare status and their environments. Lessening the effects of these factors could reduce the incidence of pediatric burns. Unintentional burns, Pediatric, Data mining


Vitreous hemorrhage (VH) is a common ophthalmic disease with a high rate of blindness, which will seriously affect the quality of life of patients and bring great burden to patients’ families and society. The treatment for VH contains medical therapy, lasers, and surgery. At present, there is no recognized western medicine with definite curative effect and little side effect for the treatment of VH. In most cases, PRP is not available to treat VH; intravitreal injection or surgical treatment is adopted as the primary therapy. However, in the long-term treatment, the effect of the above-mentioned treatment is not satisfactory, so many patients choose oral Chinese medicines, which has been widely used in China to treat VH. Numerous clinical trials have demonstrated that Chinese medicines can promote the absorption of VH and improve the visual function of patients. The purpose of this review is to evaluate the efficacy and safety of Chinese medicines in the treatment of VH and inform a decision aid for the clinical encounter between patients and clinicians. Besides, it is beneficial to establish a future research agenda.The systematic review will include all of the randomized controlled trials on the efficacy and safety of Chinese medicines for VH. Nine electronic databases, namely PubMed, Web of Science, EMBASE, the Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal database (VIP), and CBM, will be searched normatively on the basis of the rule of each database from the inception to August 31, 2019. We will also search registers of clinical trials, potential gray literature, and conference abstracts. There are no limits on language and publication status. The literature screening, data extraction, and quality assessment will be conducted by 2 reviewers independently. The reporting quality and risk of bias will be assessed by other 2 researchers. Standard of curative effect and total treatment efficacy rate were assessed as the primary outcome. The secondary outcomes will include the curative effect of single symptom and sign, the improvement rate of single auxiliary examination, withdrawal and reduction of western medicines in a course of treatment, maintenance of western medicines after the course of treatment, laboratory efficacy indexes. Meta-analysis will be performed using RevMan5.3 software provided by the Cochrane Collaboration.This study will provide a comprehensive review based on current evidence of Chinese medicines treatment for VH in several aspects, including standard of curative effect, total treatment efficacy rate, the curative effect of single symptom and sign, the improvement rate of single auxiliary examination, withdrawal and reduction of western medicines in a course of treatment, laboratory efficacy indexes, total treatment efficacy, and safety, among others.The conclusion of this study will provide evidence to determine whether Chinese medicines are an effective and safe intervention for patients with VH.It is not necessary to obtain ethical approval for this study. The systematic review will be published in a peer-reviewed journal, presented at conferences and will be shared on social media platforms.PROSPERO CRD42020152321. Fundus vascular diseases and ocular trauma, the leading cause in children and adolescents,,3 are the most common causes of VH.,5 The formation of retinal neovascularization (NV) plays a key role in the pathological mechanism of nontraumatic VH. Hypoxic ischemia of retinal tissue results in increased secretion of vascular endothelial growth factor (VEGF), insulin-like growth factor-1, and other cytokines.,8 Such angiogenic factors are present in the vitreous and whole retina of patients, which further forms NV between retinal-vitreous, leading to a VH. In adults, proliferative diabetic retinopathy (PDR) and age-related macular degeneration are the most common causes of retinal NV. Diabetic retinopathy (DR), the chief cause of severe vision loss in adults of working age, worldwide, accounted for 50.0%∼65.0% of the causes of nontraumatic VH.According to a recent survey of retina specialists, VH from PDR is one of the most common reasons for vitrectomy in the United States, which not only affects vision substantially but also can preclude performing panretinal photocoagulation (PRP), the standard treatment for PDR. China has the largest population of diabetic patients in the world, with >92 million diabetic patients older than 20 years. The prevalence of retinopathy in diabetic patients is up to 24.7% to 37.5%, among which the proportion of proliferative retinopathy is 3.3%∼7.4%. VH can be divided into 1 to 4 levels  is one of the common vitreoretinal diseases in ophthalmology. VH not only makes the refractive stroma cloudy, affecting the light to reach the retina, leading to vision loss, but also leads to vitreous degeneration, posterior detachment, and many serious complications such as macular edema, optic nerve atrophy, and so on. However, in most cases, PRP is not available to treat VH; vitrectomy is the primary treatment. Although vitrectomy has the advantages of one-time removal of cloudy vitreous and rapid recovery of impaired visual function, it cannot solve the problems of vascular tension and blood density, at the same time, surgical complications that can be fatal to vision remain including neovascular glaucoma, retinal detachment, endophthalmitis. In addition, recovery to normal activities following vitrectomy can take several days, weeks, or even months, thus affecting an individual's ability to function and work.Anti--VEGF treatment has also been used for VH in recent years, but currently there is no established guideline and its effect is ambiguous and NV tends to recur, and it may cause retinal atrophy, retinal pigment epithelium tears, systemic adverse effects, among others.The treatment for VH contains medical therapy, lasers, and surgery. At present, there is no recognized western medicine with definite curative effect and little side effect for the treatment of VH. PRP is used for the treatment of mild to moderate cases of VH when the refractive stroma permits. Formononetin, an active compound of Astragalus membranaceus (Fisch) Bunge, can ameliorate retinal NV via the HIF-1α/VEGF signaling pathway, and it may become a potential drug for the prevention and treatment of DR. “Stasis sanjie” method can effectively improve the absorption degree of VH, reduce its complications, and restore the visual function of patients.As a complementary and alternative therapy, Chinese medicines have a long history and great potential, which is widely used in the treatment of VH in China. The effectiveness of Chinese medicines in treating VH has been proved by many clinical and experimental studies. Samul-Tang significantly inhibited retinal NV by downregulating hypoxia inducible factor-1α (HIF-1α), stromal cell derived factor-1(SDF-1), CXCR4, and VEGF.Although the literature on Chinese medicines treatment of VH has increased rapidly in general, to our knowledge, there is a lack of critically designed systematic review to evaluate the effectiveness and safety of Chinese medicines for VH. In this study protocol, we will present the protocol and assess all of the clinical evidence on the effectiveness and safety of Chinese medicines for VH patients and inform a decision aid for the clinical encounter between patients and clinicians. Besides, it is beneficial to establish a future research agenda.2 Our protocol will follow the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) statement guidelines.,32The systematic review protocol has been registered on PROSPERO (registration number: CRD42020152321).2.12.1.1We will consider only clinical randomized controlled trials (RCTs) of Chinese medicines in the treatment of VH. The current clinical trial results will be objectively integrated, which is conducive to the evaluation of the efficacy and safety of Chinese medicines for VH. We will exclude non-RCTs, quasi- RCTs, uncontrolled trials, reviews, case reports, case-controlled studies, animal trials, and laboratory studies.2.1.2Patients diagnosed as having VH will be included in the study. There will also be no restrictions based on other conditions, such as age, sex, race, educational or economic status, disease duration, and disease severity.2.1.3This study focuses on the RCTs of VH with the therapy of Chinese medicines, and the results will provide advice and consultation for clinicians. Therefore, patients in the experimental group were only treated with Chinese medicines, and the types and dosage forms of Chinese medicines prescriptions were not limited. In addition, western medicines and other treatment methods were not combined. Studies that with combination therapy fail to objectively evaluate the efficacy and safety of Chinese medicines will be excluded. The control interventions will include placebo, western medicines, surgery and other therapies.2.1.42.1.4.1 and total treatment efficacy rate were assessed as the primary outcome. There are 4 levels about standard of curative effect on the basis of the grade of VH , and so on.The improvement rate of single auxiliary examination: visual field examination, optical coherence tomography, and ultrasound B-scan.Withdrawal and reduction of western medicines in a course of treatment, including: time, type and quantity; maintenance of western medicines after the course of treatment, including type and quantity.Laboratory efficacy indexes: VEGF, IGF-1.2.1.4.3The safety outcomes will be measured by the incidence and severity of side-effects. Any unexpected events that occurred during the studies will be recorded on an adverse event report form, including:General physical examination Routine examination of blood, urine and stoolLiver and kidney function examinationElectrocardiogramPossible complications adverse reactions and related detection indicators.2.22.2.1Nine electronic databases, namely PubMed, Web of Science, EMBASE, the Cochrane Library, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal database (VIP)and CBM, will be searched normatively according to the rule of each database from the inception to August 31, 2019 for reviews on Chinese medicines and VH. The search term will include two parts: that is, “Medicine, Chinese Traditional”  and VH. The equivalent search entries will be used while searching in the Chinese databases. The search strategy for PubMed is listed in Table 2.2.2Meanwhile, we will also search PROSPERO, the International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, dissertations, and gray literature to identify systematic reviews or clinical trials related to Chinese medicines and VH. Relevant journals and conference processes will be manual searched. We will also review articles and bibliographies included in the trials.2.32.3.1We will select studies involved any form of Chinese medicines as the sole treatment or as a major therapy. Chinese medicines will be classed as the major therapy when the literature suggests that the frequency of application of Chinese medicines is higher and the time is longer than other intervention methods. Studies only related to human subjects will be included. Two reviewers (MYH and ZQL) will independently browse the titles, abstracts, and keywords of all of the retrieved records to distinguish and exclude any obviously irrelevant articles. If these reviewers have disagreements, a third author (MJ) will make the final decision. The study selection procedure is presented in a PRISMA flow chart Fig. .2.3.2Based on the inclusion criteria, a standard data collection form will be produced before data extraction. EndNote X8 software will be used to manage the records we obtained from electronic databases and other resources. Two authors (MYH and ZQL) will extract the data of interest from the eligible study and enter the following information in the data extraction sheet: The basic characteristics of each study ; participants characteristics ; interventions ; comparators ; outcomes ; if funded, it will also be recorded. When the consensus on data extraction is not available through discussion, the third reviewer (MJ) will make a decision.2.3.3 The RevMan software program (V.5.3) will record the selected details of each study.Two authors (LQN and ZQL) will independently evaluate the risk and bias using the Cochrane risk of bias (ROB) assessment tool.2.3.4The risk ratio (RR) and 95% confidence interval (CI) will be used to analyze dichotomous data and measure the treatment effect. A weighted mean difference (WMD) or a standard mean difference (SMD) with 95% CIs will be used to analyze continuous outcomes.2.3.5st experimental period data of crossover trials to avoid carryover effects. Meanwhile, considering that there are multiple intervention groups in trials, we will combine all analogous groups into a single pairwise comparison to prevent a unit of analysis issue.We will only extract the 12.3.6If any details of the trial are incomplete, reviewer (HM) will contact the appropriate author of an article via email and telephone to obtain any missing data. The missing data will be deleted, if there is no response from the author. In this case, this will be addressed in the discussion.2.3.7χ2 test. To quantify the impact of the statistical heterogeneity on the systematic review, the I2 value will be applied to calculate and present the heterogeneity degree. When P > .1, I2 < 50%, it is considered that there is no heterogeneity between the trials, and the fixed-effect model will be used; otherwise, the random-effect model will be adopted. Data analysis will be performed using RevMan5.3 software provided by the Cochrane Collaboration. Using the software to obtain forest plots and test the heterogeneity between the included studies. The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) will be used to assess the meta-analysis findings and describe the strength of evidence. Narrative comprehensive synthesis will be adopted, if meta-analysis is not possible due to lack of clinical studies or heterogeneity.We will use the complete case data as the analysis data. Heterogeneity will be tested with a standard 2.3.8The funnel plot and statistic test will be adopted to evaluate reporting biases, when ≥10 studies are included in a meta-analysis.2.3.9When heterogeneity is detected, a subgroup analysis will be conducted to judge the source of heterogeneity. The criteria for a subgroup analysis are as follows:1.Type of Chinese medicines therapies2.Research quality3.Participation population4.Type of control interventions5.Intervention frequency and duration.2.3.10In the case of sufficient trials data, the ROB tool will be used to assess methodological quality. If low-quality articles are deleted, a second meta-analysis will be performed. The results and effect size of the 2 meta-analyses will be compared and discussed.3 But vitreous surgery equipment is expensive, the treatment cost is high, the technical level requirements are high, the basic hospital is not easy to carry out the operation, and vitrectomy has a series of complications, some patients even vitreous massive hemorrhage is not willing to receive surgery treatment. So how to treat the disease safely, cheaply, and effectively is an important topic. In today's world especially China, many patients choose oral Chinese medicines instead of other treatments. Chinese medicines have a certain unique therapeutic effect on VH. However, due to the complex composition of Chinese medicines, potential safety hazards may exist. The purpose of this systematic review is to systematically summarize and evaluate a great amount of evidences for Chinese medicines treatment for VH, and to evaluate the efficacy and safety of Chinese medicines in the treatment of VH and inform a decision aid for the clinical encounter between patients and clinicians. In addition, it helps to establish a future research agenda.VH is one of the most common diseases in ophthalmology, which has destructive impact on patients’ VA and negative effect on their quality of life and social development. Treatment for VH mainly includes medication, lasers, and surgery. At present, there is no recognized western medicine with definite curative effect and little side effect for the treatment of VH. In addition, in most cases, PRP is not available to treat VH, vitrectomy is the primary treatment.Conceptualization: Mengyu Han, Ziqiang Liu, Zhijun Wang, Ming Jin.Data curation: Mengyu Han, Ziqiang Liu, Luqi Nong, Huan Meng.Formal analysis: Mengyu Han, Ziqiang Liu.Project administration: Mengyu Han, Ziqiang Liu, Luqi Nong, Ming Jin.Supervision: Mengyu Han, Zhijun Wang, Ming Jin.Writing – review & editing: Mengyu Han, Ziqiang Liu, Luqi Nong.


Methods. This was a single-blind clinical trial study in which patients with Parkinson's disease voluntarily participated based on the inclusion and exclusion criteria. The patients were randomly assigned to the case and control groups. The case group received 24 sessions of vestibular rehabilitation protocol, and conventional rehabilitation was performed in the control group . Both groups were also given fatigue management advice. Fatigue was measured by the Parkinson Fatigue Scale (PFS) and the Modified Fatigue Impact Scale (MFIS). ADL was measured by the Functional Independence Measure (FIM). All changes were measured from the baseline at the completion of the intervention. Results. Both fatigue (P ≤ 0.001) and ADL (P ≤ 0.001) improved significantly more in the vestibular intervention group than in the control one. Conclusion. Vestibular rehabilitation may improve fatigue and ADL and therefore can be used as an effective intervention for patients with Parkinson's disease, which was also found to be well tolerated.One of the most disabling nonmotor symptoms in persons with Parkinson's disease is fatigue, which can decrease the quality of life by restricting the function and activities of daily living (ADL). Nonetheless, sufficient evidence for treating fatigue, including drug or nondrug treatment, is not available. In this study, we evaluated the probable effects of vestibular rehabilitation on fatigue and ADL in patients with Parkinson's disease.  Fatigue is one of the most common nonmotor symptoms of Parkinson's disease (PD) , 2. It cThere are various types of fatigue. Krupp and Pollina noted that fatigue can be due to neurological, somatic, or mental dysfunction and is perceived as an excessive sense of exhaustion, frustration, or lack of energy by the patient . FatigueCentral sensory-motor integration  is important for efficient postural control and might be affected by the sense of fatigue in patients with Parkinson's disease , 9. SomaReviewing the literature, we saw no study to investigate the effect of vestibular rehabilitation exercises on fatigue in PD; however, Hebert et al. provided evidence about the effects of vestibular rehabilitation on multiple sclerosis-related fatigue and upright postural control . BesidesThis was an interventional pilot study using a single-blind clinical design. The eligible subjects of this study were a convenience sample of patients who had been referred to Rasoul-e-Akram and Imam Khomeini hospitals. Based on the pilot results and the inclusion and exclusion criteria, 24 patients were randomly assigned to two equal groups: twelve patients to the control group and twelve patients to the case group. All measures were performed in the first session and immediately after the last session by a senior occupational therapist (M. Sc. degree) who was blinded to the intervention; all investigations were performed in the medicine phase of “on” . The stIRCT201709123551N6) and the Ethical Committee of Tehran University of Medical Sciences (IR.TUMS.FNM.REC.1396.3210).Eligible subjects were enrolled after signing an informed consent form and the study was approved by the Iranian Registry Center of the Clinical Trials  stage 1–4. The stages are defined as follows: stage 1: the patients had unilateral involvement only, usually with minimal or no functional disability; stage 2: bilateral or midline involvement, without impairment of balance; stage 3: bilateral disease: mild to moderate disability with impaired postural reflexes and physically independent; and stage 4: severely disabling disease, still able to walk or stand unassisted . Also, tPatients with severe daytime sleepiness, depression, and apathy symptoms were excluded based on their historical medication . AdditioThe Parkinson Fatigue Scale (PFS) contains 16 questions: 7 questions related to tiredness and the effect of physical fatigue and 9 questions that evaluate the effect of fatigue on performance and daily activities. As mentioned, the questionnaire was completed by the subjects, and the score for each question ranged from 1 (definitely disagree) to 5 (definitely agree) , 22.As the Parkinson Fatigue Scale (PFS) Persian format has no related classification cutoff score, fatigue was measured by the Modified Fatigue Impact Scale (MFIS) as well. The MFIS is a valid measure with 21 self-report items and three subscales: physical (9 items), cognitive (10 items), and psychosocial (2 items); each item was scored from 0 (never) to 4 , and a total score is 84 , 23.The Functional Independent Measure (FIM) questionnaire is used to evaluate the daily activities. This questionnaire contains 18 items (13 items related to motor skills and 5 items related to the cognitive one). Each item has 7 ratings in which 7 means complete independence in activities and 1 means complete dependence, requiring maximum help in performing daily activities , 25.Vestibular rehabilitation exercises were performed for about 60 minutes at each of the 24 sessions, three days a week in the case group. The vestibular rehabilitation exercises included the following exercises: exercises on a trampoline; exercises on a firm surface, foam, and a balance board with open and closed eyes; head movements to the sides, upward, and downward; throwing and catching a ball in which alterations were made in the center of gravity; walking exercises and simultaneous movement of the head; and moving a ball in hands from side to side. Oculomotor exercises took about 10 minutes of the treatment session –28 , stretching exercises  for 15 minutes , body rot-test and chi-square tests were used to determine the significance level of data  about the inclusion criteria between the two groups . The paired t-test was used  for comparing the scores before and after the intervention in both case and control groups.All statistical analyses were performed by a senior biostatistician. Independent P ≤ 0.634) in terms of fatigue, the total score of FIM (P ≤ 0.402), and the MFIS at baseline (P=0.209).The complete information about the demography and inclusion criteria is listed in P < 0.001); the control group did not change significantly (P = 0.083). Total score of FIM, score of motor, and cognitive outcomes of FIM in the case group were respectively P < 0.001, P < 0.001, and P = 0.076. Also, FIM scores in the control group were P = 0.056, P = 0.089, and P = 0.339, respectively (The case group showed a significant difference in PFS (ectively .P < 0.001) compared with the control group. No significant difference was found in FIM cognitive outcome (P=0.106), but the motor outcome score and the total FIM differences were significant (P < 0.001 and P < 0.001) between the case group and the control group (The significant difference was found in PFS for the case group (ol group .This single-blind pilot study demonstrated significantly greater improvement in both fatigue and ADL in the case than in the control group.P < 0.001). To the best of our knowledge, no study has been published on the possible effects of vestibular rehabilitation on fatigue in patients with Parkinson's disease. Therefore, we cannot compare our results with other studies; however, Hebert et al. investigated the effects of vestibular rehabilitation on fatigue in multiple sclerosis patients. They found that vestibular rehabilitation produced significant improvement in fatigue MFIS (P < 0.001) [The primary outcome variable in this study was the change of fatigue which, in the case group, was improved by 12.58 in PFS compared to 1.58 in the control group (< 0.001) .Addressing the underlying mechanism of fatigue improvement was not the purpose of our study, but our findings may provide a theoretical insight into the probable role of neuroplasticity as an explanation for the beneficial effects . PreviouVestibular rehabilitation had significant benefits for the activities of daily living (FIM). Our findings agreed with Rossi-Izquierdo et al. who reported that vestibular exercise in patients with Parkinson's disease improved ADL, with faster walking, improved balance, and reduced the risk of falls . BalanceAs mentioned earlier in the Method section, the vestibular rehabilitation comprises oculomotor exercises which took about 10 minutes of each treatment session. Oculomotor exercises may play an important role in neuromuscular reorganization . As oculThe results of this study showed the benefits of vestibular rehabilitation for fatigue and activities of daily living in patients with Parkinson's disease. Why vestibular rehabilitation helped more than standard therapy is unclear but may involve novel neuromuscular reorganization mechanisms. Also, this type of intervention is low cost, safe, and practical in clinics and homes with minimal facilities and therefore can be recommended for both resource-poor and resource-rich societies.A small number of patients did not provide the possibility of generalization. Furthermore, for the future study, a follow-up phase may provide a reasonable outcome of the maintenance of the effects of vestibular rehabilitation exercises in patients with Parkinson's disease.