Almost all students experienced at least one ACE , and more than half experienced four or more ACEs . A large majority of students experienced maltreatment, which often co-occurred with household challenges and community stressors. Additionally, 45.9% of the students experienced their first ACE before the age of 4. Students with EBD in SE who live in poverty or in single-parent households were more likely to report multiple ACEs. Knowledge of the prevalence of ACEs may help understand the severe problems and poor long-term outcomes of students with EBD in SE.Adverse childhood experiences (ACEs) are associated with an increased risk of developing severe emotional and behavioral problems; however, little research is published on ACEs for students with emotional and behavioral disorders (EBD) in special education (SE) schools. We therefore systematically explored the prevalence, type and timing of ACEs in these students from five urban SE schools in the Netherlands ( Adverse childhood experiences (ACEs), such as abuse and parental mental illness, are associated with an increased risk of developing emotional and behavioral problems ,2,3. MorAccording to the International Convention on the Rights of the Child, all children have the right to an education that enables their personalities, talents and mental and physical abilities to develop to their fullest potential . To fulfIn Western nations such as the USA and the UK, students with EBD comprise one of the largest groups that are educated along the continuum of SE support, totaling 0.5% to 2% of the general population of students aged 4–21 years ,18. EBD In the Netherlands, students with EBD can be characterized in line with the aforementioned international descriptions. Two-thirds of all students with EBD are ultimately placed in separate SE schools . For stuRecent studies showed that ACEs are an important factor for understanding well-being and lifelong health outcomes ,34. ACEsKnowledge of the prevalence of ACEs in the lives of students with EBD in SE schools is a crucial first step in better understanding the potential role of ACEs and the emotional, behavioral and school problems that these students encounter. An accumulation of ACEs can be expected for students with EBD in SE schools since vulnerable populations are particularly more at risk of experiencing ACEs ,43. MoreDespite the expected associations between ACEs and emotional and behavioral problems, in a previous systematic review, we showed that ACEs have hardly been assessed for students with EBD in SE schools . Based oDespite tentative indications on elevated prevalence rates for ACEs for students with EBD in SE schools, these indications are based on only a few studies, and various uncertainties remain. First, previous studies included a small range of ACEs, assessing primarily maltreatment, although the original ACE framework is broader than maltreatment only. In addition, the concept of ACEs evolved over recent decades from the original ten ACEs measured by Felitti and colleagues  towards Exploring the prevalence of ACEs is a first and important step in understanding the potential key role of ACEs in the severe and complex problems of students with EBD in SE. From a trauma-informed approach, understanding the effect of ACEs, trauma and toxic stress could help SE schools change the lens through which students’ emotional and behavioral difficulties are perceived and be more responsive to their complex needs. In this explorative study with a sample of 174 students with EBD in SE schools, we addressed the following questions: (1) What is the prevalence, type and timing of ACEs in students with EBD in SE schools from a multi-informant perspective? and (2) Does the prevalence of ACEs differ significantly between subgroups based on demographic characteristics  and DSM diagnoses?ageM = 11.58 years, 85.1% boys) in five urban primary and secondary separate SE schools. These schools operate under the auspices of a special education foundation in the Netherlands. The majority of students in the sample started their school careers in regular education schools (84.5%). Based on previous intelligence research reports in the students’ school files, we established that the IQ score of our sample was roughly estimated as normal to borderline intellectual functioning . However, there was a large variance in IQ scores of our sample (range 49 to 137). The school files demonstrated that in the assessment of the IQ, the WISC-III NL was predominantly used (74.5%), followed by the WPPSI-III-NL (11.8%).Our sample consisted of 174 students with EBD aged 8–18 years . More than half of the students used medication related to their DSM diagnoses. The majority of the students received some form of mental health support, either individually or family-oriented. The biological parents of the participating students represented more than 10 ethnic backgrounds, with Dutch, Surinamese, Moroccan, Antillean, Ghanaian and Turkish being the most common. The current study is part of an ongoing research project investigating factors that possibly influence the onset and maintenance of behavioral and emotional problems and mental illness of students in Dutch urban SE schools for EBD. We used a descriptive retrospective cross-sectional design and a multi-informant perspective.n = 169 for students and n = 95 for parents and had access to n = 172 school files.Data was collected between the years 2017 and 2020. The study was approved by the Ethics Review Board of the University of Amsterdam (2017-CDE-7603). We briefed primary caregivers, teachers and students about the project and asked for active and documented informed consent. The consent rate of parents for child participation was 35%. The flowchart  shows thTo ensure the most optimal number of participants and their degree of disclosure, we adapted the methods of ACE assessment to the specific needs of our sample. The questions had little jargon, and each student had an individual assessment supported by the presence of a professional with sufficient time to complete the questionnaire. Parents scored the questionnaire either online or on paper at home. In addition, based on a codebook developed by the authors, we scored the participating students’ school files. We used all available reports from previous and current schools settings and care settings, such as school progress reports, daily school journals, diagnostic reports, psychiatric reports and youth health care service reports. Research assistants were trained in how to use the codebook.ACEs in the student self-reports were measured by the Dutch version of the Life Events Checklist (LEC). The LEC is part of the Clinician-Administered PTSD Scale for Children and Adolescents interview (CAPS-CA) from 8 to 16 years old ,69,70. WACEs in the parent reports were also measured by the LEC , with scThe codebook used in the school file reports included 10 ACEs from the original Adverse Childhood Experiences Study , 12 ACEsEach item in the codebook was scored and substantiated with text from the school file. ACEs that were substantiated and ACEs that were reported in the school files according to the operationalization in the codebook (unsubstantiated ACEs) were scored as present (‘1′) ,92. If nsr = 0.18, p = 0.020) with self-reports and a moderate correlation  with parent reports. No significant correlation was found between students’ self-reports and parent reports), although the association was in the expected direction .Statistical Package for the Social Sciences  was used for all data analyses. Descriptive and inferential statistics were evaluated, including frequencies, means, standard deviations and bivariate associations. The data were not normally distributed; therefore, non-parametric tests were used in the present study . Bivariate associations between the number of ACEs reported by the three different informants were tested using the Spearman R correlation. School files showed a small correlation (n = 95) compared to self-reports (n = 169) and school files (n = 172), we firstly explored the potential bias between parents who completed their questionnaires and those who did not. We compared their demographic characteristics  and the present ACEs in the category household challenges  using the Mann–Whitney U test. There were no significant differences between the two parent groups for these variables. Furthermore, we did not find a significant difference in the number of ACEs between the students of which ACE scores of all informants  were available (n = 92) and the students whose parent’s reports were missing . Therefore, we ran all analyses for our full sample.Because of the difference in the number of parent reports , in the parent reports (89.5%) and in the school files (95.3%). Moreover, the majority of the students experienced four or more ACEs based on self-reports (74.4%), parent reports (52.7%) and school files (59.9%). Furthermore, a substantial proportion of students with EBD in SE schools experienced eight or more ACEs according to their self-reports (40.2%), parent reports (12.7%) and school files (20.3%). An overview of the prevalence of ACEs and the mean number of ACEs by the informant is presented in U = 1835, z = −0.11, p = 0.916; parent reports U = 577, z = −0.024, p = 0.809; school files U = 1575, z = −1.39, p = 0.165). Furthermore, no significant school type differences were found in the mean rank of ACEs for self-reports  and parent reports . However, in the school files the mean rank of ACEs for primary school students (mean rank = 98.46) was significantly higher than for secondary school students .We ran a Mann–Whitney U test to determine if there were differences in the mean rank of ACEs for each informant with regard to sex  and school type (primary or secondary SE school). No significant differences were found between the number of ACEs and sex for all informants  in relation to ‘the number of ACEs in school files’ (Mdn = 4.00), p < 0.001, as well as in ‘the quality of school files’ in relation to ‘school type’ (Mdn = 1.00), p < 0.0005 and in ‘school type’ in relation to ‘the number of ACEs in school files’, p < 0.001. Therefore, the median difference in the number of ACEs for primary and secondary school files could be attributed to the quality of school files, which was significantly lower in secondary schools. This median difference could therefore be disregarded in the analysis.A Friedman test was run to determine if there were differences between the quality of the school files, the school type (primary or secondary) and the total number of ACEs in school files. A significant difference was found, χ2(2) = 246.764, Prevalence rates of the various types of ACEs are reported separately for each informant in Co-occurrence of different types of ACEs was found using Spearman’s R correlation, both within ACE categories, e.g., different types of maltreatment, and across ACE categories. Specifically for school files, where the most ACEs in the category household challenges were measured, we noted that maltreatment often co-occurred with parental mental health problems, parental physical illness, economic hardship and parental substance abuse. We found that many ACEs co-occurred with at least four other ACEs for all informants. In the school files, the timing of the first ACE of each student was registered, if available. We found that almost half of the students experienced their first ACE before the age of 4 (45.9%) .M = 2.41, SD = 1.95, range 0–7) showed that the majority of students (79.7%) experienced at least one ACE, and 24.4% experienced four or more.To improve the comparison of the prevalence rates in our study to previous ACE studies, we determined the prevalence of the 10 original ACEs from Felitti and colleagues  in our sU = 1685, z = −2.21, p = 0.027) and economic hardship  showed a significantly higher mean rank of ACEs compared to students who grew up in families without this risk factor. The relationship between an accumulation of risk factors and the mean rank of ACEs in the school files was not statistically significant (rs = 0.07). However, we found that students with ≥ 2 risk factors had a significantly higher mean rank of ACEs in the school files compared with students with 0–1 risk factors .p = 0.469; parent report χ2(2) = 7.918, p = 0.340, school files χ2(2) = 17.650, p = 0.014; comorbid diagnoses: χ2(2) = 2.042, p = 0.360; parent report χ2(2) = 0.985, p = 0.611, school file χ2(2) = 3.190, p = 0.203).Additionally, we examined the differences in ACE prevalence in students for the various DSM diagnoses outlined in In this study, we explored the prevalence, types and timing of ACEs in students with EBD in separate SE schools. We assessed ACEs from a broad ACEs framework and a multi-informant perspective  to address the following research questions: (1) What is the prevalence, type and timing of ACEs in students with EBD in SE schools from a multi-informant perspective? and (2) Does the prevalence of ACEs differ significantly between subgroups based on demographic characteristics  and DSM diagnoses? Our results showed that, from a multi-informant perspective, ACEs are very common in the lives of students with EBD in SE schools. Almost all students experienced at least one ACE , and many students experienced a strong accumulation of ACEs at a very young age. More than half of the students experienced four ACEs or more . Because of a possible selection bias in our sample, the fact that not all ACEs were assessed for all informants and the fact that the quality of school files was low-moderate, we expect our prevalence rates to be an underestimation.Concerning the types of ACEs, the majority of students experienced some form of maltreatment, with physical abuse  and emotional abuse  most frequently reported. ACEs often co-occurred with at least four other ACEs, both within and across categories. With regard to the timing of ACEs, almost half of the students with EBD in Dutch urban SE schools experienced their first ACE before the age of four.Although we expected our prevalence rates to be elevated compared to the general population, the number of ACEs in students with EBD in SE seems strikingly high. Comparing our findings to previous studies is difficult because our study is the first to systematically explore ACEs in these students with EBD in SE schools. Nevertheless, our results indicate that the number of students that experience at least one ACE in our sample  is high compared to previous ACEs studies in school-aged youth , which reported almost two-thirds of youth worldwide to experience at least one ACE (ranging from 41% to 97% in USA studies and 19% to 83% for studies outside of the USA) . MoreoveOur expectation that prevalence rates in our sample are much higher than in the general population is underlined by the fact that for many ACEs, specifically forms of maltreatment and household challenges, preliminary indications from previous studies  were conThe results of our study underline the need to increase awareness of ACEs in stakeholders such as the government, kindergarten, school boards, school referral systems and school professionals. Additionally, our findings of the timing of ACEs emphasize the need to work jointly towards interventions before children enter school (in the Netherlands at the age of four) to prevent ACEs or their further accumulation in order to reduce their potentially harmful effects. As a start, the assessment of ACEs should be included in each diagnostic evaluation when emotional and behavioral problems arise in students.When ACEs are assessed for students with EBD in SE, a broad framework should be considered. Our findings indicate that assessors should at least pay attention to household challenges and parental stress and well-being, in addition to maltreatment, as these are known to be associated ,103. FurFurthermore, we recommend exploring trauma-informed education as a promising contribution for students with EBD in SE schools. Trauma-informed education could change the lens through which students’ emotional and behavioral difficulties or disorders are perceived by professionals and can improve students’ ability to learn, which may contribute to the reduction of physical aggression, referrals, and trauma symptoms . TherefoThis study has a number of limitations that should be mentioned. We expect these limitations to contribute to an underestimation of our prevalence rates. First of all, our sample was possibly not representative of the full population of participating schools. Although additional efforts were made to reach all parents for active, informed consent, more than half of the parents did not respond. For those parents who actively refused participation, one of the main reasons was that participation was thought to be too stressful because the parent was overburdened or because of the trauma experiences/many diagnostic evaluations (often trauma-related) of their child. Secondly, although the LEC is a user-friendly questionnaire that is widely used in trauma-informed clinical practice where there is considerable variability in the temporal stability of self-reported trauma exposure , the LECDespite these limitations, our study could serve as a baseline in the Netherlands and internationally for research on ACEs in students with EBD in SE schools. As a next step, future research should focus on the assessment of ACEs in students with EBD receiving SE in larger and representative samples in the Netherlands and abroad. Just as in clinical work, it is recommended that a multi-informant perspective and a broad ACE framework be used. Furthermore, ACEs should be related to the specific problems students with EBD in SE have and to their short- and long term developmental outcomes. In this respect, not only the number of ACEs but also the type, timing, frequency and severity of ACEs should be taken into account, as the impact of ACEs can significantly differ because of these aspects ,34,108. Our study contributes to the literature in a number of ways. First, to the best of our knowledge, this study is the first to systematically explore the prevalence of ACEs in students with EBD in SE schools, a vulnerable, high-risk school population with poor short-term and long-term outcomes. Second, we used a broad framework that included ACEs associated with child maltreatment, household dysfunction, peer victimization and community stressors. Third, we used a multi-informant perspective, with students’ self-reports, parent reports and school files. Our results suggest that ACEs are highly prevalent in the lives of Dutch urban students with EBD in SE schools and start at a very young age. Awareness of the high prevalence of ACEs from a multi-informant perspective widens our perspective to look beyond current EBD symptoms and regard the students’ severe and persistent problems from a holistic and trauma-informed perspective. It urges us to address ACEs as early as possible to prevent accumulation and a long-lasting impact. Trauma-informed education could be a promising approach to tailor education to the needs of ACE-exposed students and to those who work with them and can therefore contribute to optimal future perspectives for students with EBD in SE schools.


Alzheimer disease (AD) is a common degenerative disease of the central nervous system that can be divided into 3 stages, according to the degree of cognitive impairment. The clinical manifestations are cognitive dysfunction and memory loss, impacting the daily activities of the affected individuals. In recent years, studies have demonstrated a relationship between intestinal flora and AD. However, no meta-analysis has documented the correlation between AD and intestinal flora, to the best of our knowledge. Herein, we sought to assess the correlation between different stages of AD and intestinal flora. A systematic and comprehensive understanding of this relationship is of great significance for developing prevention and treatment strategies against AD.A comprehensive search of the medical literature in Chinese and English language was performed in databases, such as PubMed, EBSCO, CNKI, web of science, WanFang, Cochrane Library, and CBM databases. Pre-defined search strategies were used to retrieve clinical studies of Alzheimer disease and gut microbiota. The included studies were independently analyzed by the 2 researchers who extracted the data. The quality of the data was evaluated according to the “Cochrane system evaluator manual.” Finally, Endnote and RevMan software were used for systematic regression and meta-analysis of evidence.We documented the intestinal flora changes in the 3 stages of Alzheimer disease, according to currently available clinical evidence, and revealed the correlation between the abundance and diversity of flora and treatment efficacy. These findings are essential for developing new strategies for the prevention and treatment of Alzheimer disease.INPLASY2021100093Since all data utilized in this systematic review and meta-analysis are published, ethical approval was not needed. Its main clinical manifestations include progressive cognitive dysfunction, memory loss, and amnesia. There are currently about 47.5 million AD patients worldwide, and it is expected to reach nearly 82 million in 2030 and surpass 152 million in 2050.AD can be divided into 3 stages according to National Institute on Aging-Alzheimer Association (NIA-AA) diagnostic criteria (2011): the preclinical or presymptom stage where patients exhibit mild memory loss and early hippocampal lesions, lasting for several years.The gut microbiota forms an important line of defense against GI pathogens and toxins in the human body. It is widely acknowledged that the dynamic balance of gut microbiota plays an important physiological and pathological role.Lactobacillus plantarum WCFS1, Escherichia coli Nissle, and Bifidobacterium infantis) have been documented to enhance the intestinal barrier function by enhancing the tight junction of intestinal epithelial cells, making it difficult for β-amyloid peptide (Aβ), endotoxin, and other substances in the gastrointestinal biological environment to activate the peripheral immune response, and delaying the onset of AD pathological features such as amyloid plaques and neuroinflammation.[Probiotics are considered a promising approach to treating AD based on the relationships among the microbiota, gut, and brain.To the best of our knowledge, no systematic review or meta-analysis has reported intestinal flora changes at different AD stages. We sought to explore the relationship between intestinal microflora and preclinical stage, mild cognitive impairment and dementia, and identify potential disease prevention or treatment targets.2The study was registered with the International Platform of Registered Systematic Review and Meta-Analysis . We designed this systematic review and meta-analysis according to the preferred reporting items of the systematic review and meta-analysis program statement.[2.1The inclusion and exclusion criteria in this study were defined based on the population-intervention-comparison-outcome and study design (PICOS) criteria.2.22.2.1Studies on the correlation between Alzheimer disease and intestinal flora were included in the systematic review. The included literature was not limited to the language type, blinding method, or allocation concealment requirements. As long as the included studies are approved by the local institution, we will include this study in the scope of research, including clinical studies and case-control studies.2.2.2Patients with Alzheimer disease were diagnosed according to NIA-AA 2011) criteria.[1 criteri+(N)–, T+(N)+, T–(N)+ among A- individuals has not been established.Non-Alzheimer continuum profiles are not included in this table2.2.3The experimental group consisted of patients in the preclinical stage, mild cognitive impairment, and dementia stage of Alzheimer disease. Acetylcholinesterase inhibitors2.2.4Included studies on the changes in the gut microbiota of AD patients provided data on the fecal microbiota profile, composition of gut microbiota, changes in fecal fungal or bacterial microbiota, the abundance of opportunistic pathogens, the abundance of beneficial symbiotic bacteria, and diversity of gut microbiota.2.3AD patients with gastrointestinal diseases such as cancer or other major symptoms such as nausea. Studies where the full-text version was not available. Studies that did not provide clear efficacy evaluation criteria. Studies with no clear dosing or dosage form provided. Comments, brief investigations, case reports, and letters to the editor.2.4The search strategy was conducted by CXS and WHR, and points of disagreement were resolved by a discussion with a third reviewer (GMZ). Databases, including PubMed, EBSCO, CNKI, web of science, WanFang, Cochrane Library, CBM, were searched. Databases were searched from inception to January 10, 2022. The following search terms were used: “Alzheimer Disease,” “Preclinical AD,” “Cognitive Dysfunction,” “Dementia,” “Gastrointestinal Microbiome,” etc. For repetitive studies, the complete research report was selected. In cases where a complete report could not be obtained, or the data were incomplete, we contacted the corresponding author to ensure the comprehensiveness of the preliminary search work and prevent the loss of valuable research data. The search strategy of this study is shown in Table 2.5Based on the above retrieval strategy, 2 researchers (CXS and WHR) independently extracted the data from the included studies. Any points of disagreement were resolved by a discussion with a third reviewer (GMZ). The retrieved articles were imported into Endnote software  to delete duplicate studies, integrate the literature retrieval results of different databases, establish an information database and download the full texts. If necessary, the author of the original study was contacted by email and telephone to obtain very important information for this study. Then the data were extracted using a predefined data extraction form (such as Microsoft Excel), cross-checked and reviewed, and the reasons for each excluded study were recorded for preliminary screening. Finally, third-party researchers were invited to discuss and study, and opinions were put forward to make the final decision.[2.6The research methodology, which included the quality and bias risk assessment, was independently assessed by 2 researchers (CXS and WHR) using the Cochrane Risk of Bias tool. If the results were different, third-party researchers (GMZ) were invited to discuss and analyze the source of the bias. According to the quality assessment criteria of Cochrane Handbook for Systematic Reviews, RevMan  was used to evaluate the integrity of the methods, whether the random method was correct, whether the distribution of concealment, whether it was used for analysis, and whether the results were complete. Among them, randomized controlled trial studies used the appropriate standard of Cochrane risk bias assessment tool to divide the studies into low risk, high risk, and unknown risk[2.72.7.1I2 index. A fixed-effects model was used for meta-analysis in the absence of significant heterogeneity . If significant heterogeneity  was present, the source of heterogeneity was first analyzed to exclude the effects of clinical or methodological heterogeneity, and a meta-analysis was performed using a random-effects model. When the meta-analysis could not analyze the data provided by clinical trials, a descriptive analysis was performed.The choice of whether to conduct a meta-analysis and which model to use (fixed or random effects) will depend on the level of statistical heterogeneity assessed by the 2.7.2This study aimed to study intestinal flora changes in different stages of Alzheimer disease. Accordingly, Alzheimer disease was divided into early, middle, and late stages. To eliminate the effects of drugs on the intestinal flora, we analyzed the clinical manifestations of the 3 stages before and after treatment to improve our understanding of the intestinal flora changes more clearly, and identify probiotics or other factors that can improve the clinical manifestations of AD. The early, middle, and late stages of Alzheimer disease were used as subgroups and the intestinal flora before and after treatment as statistical effects. If there are enough data and outcome indicators in the included study to calculate the comprehensive effect, RevMan software was used for meta-analysis. If high heterogeneity was present in the study, a systematic review was performed to summarize the evidence related to intestinal flora changes during the early, middle, and late stages of Alzheimer disease.2.7.3The abundance of intestinal flora in the 3 groups was measured before drug treatment, and the average abundance of intestinal flora in each group was compared with that in the normal population. After treatment, the abundance of intestinal flora in each group was measured again, and the mean value was compared with the mean abundance of flora before treatment and normal flora. Criteria for early, middle, and late AD are based on diagnostic criteria, interventions, and outcomes. If substantial heterogeneity was detected, subgroup analysis and meta-regression analysis were performed to find potential causes. For each excluded study, meta-analysis was conducted again, and the results were compared with those before exclusion. If no significant change was observed during the comparative analysis, the results were stable, otherwise, the results were unstable.2.7.4According to Cochrane Handbook, if analysis of >10 studies was conducted, RevMan was used to analyze potential publication bias and generate a funnel plot. If the shape of the plot was a symmetrical inverted funnel, it indicated a small possibility of publication bias. If the funnel plot was asymmetric or incomplete, it indicated that the possibility of publication bias was large.2.8This study did not require ethical approval since it is a systematic review. The research results will be disseminated by publishing manuscripts in peer-reviewed journals and conducting domestic and international reports.3AD is a neurodegenerative disease with mounting prevalence worldwide during the aging world population. The cognitive dysfunction resulting from AD is a source of burden to patients and families and has a substantial impact on society. At present, the relationship between different stages of Alzheimer disease and intestinal flora remains poorly studied. Most studies only reported the relationship between a single stage of Alzheimer disease and intestinal flora, with no meta-analysis and systematic reviews published. The purpose of this study was to use an optimized methodology to evaluate the relationship between the 3 stages of AD  and the heterogeneity in the intestinal flora. Importantly, we analyzed the composition of the intestinal flora, the abundance of opportunistic pathogens, and the abundance of beneficial symbiotic bacteria. By incorporating the intestinal flora changes before and after treatment, probiotics or other reasons closely related to treatment efficacy were screened. According to the exponential effect, the indicators of intestinal bacteria in different AD stages were sorted, and compelling evidence on the relationship between AD stages and intestinal flora was obtained. Our study retrospectively studied the relationship between intestinal microflora and different stages of AD, explained the different effects of different stages of AD on intestinal microflora and vice versa. Our study provides new insights for altering the intestinal flora in AD patients as a therapeutic approach.The authors thank the editor and anonymous reviewers for their contributions to improving the quality of this article.Conceptualization: Lijin Ji.Data curation: Chenhao Bi, Xunshu Cheng, Haorui Wang.Formal analysis: Xunshu Cheng, Ke Feng, Lijin Ji, Haorui Wang, Mingzhou Gao.Funding acquisition: Lijin Ji, Mingzhou Gao.Investigation: Zhihuang Zheng, Ke Chen.Methodology: Chenhao Bi, Lijin Ji.Project administration: Lijin Ji.Resources: Mingzhou Gao, Lijin Ji.Software: Mingzhou Gao.Supervision: Saixue Tang, Mingzhou Gao.Validation: Yuanyuan Liu, Mingzhou Gao.Writing – original draft: Xunshu Cheng, Haorui Wang.Writing – review & editing: Xunshu Cheng, Mingzhou Gao.


Background: Crosstalk of circular RNAs (circRNAs) and microRNAs (miRNAs) refers to the communication and co-regulation between them. circRNAs can act as miRNAs sponges, and miRNAs can mediate circRNAs. They interact to regulate gene expression and participate in the occurrence and development of various human diseases.Methods: Publications on the crosstalk between miRNAs and circRNAs in human diseases were collected from Web of Science. The collected material was limited to English articles and reviews. CiteSpace and Microsoft Excel were used for bibliographic analysis.Results: A total of 1,013 papers satisfied the inclusion criteria. The publication outputs and types of researched diseases were analyzed, and bibliographic analysis was used to characterize the most active journals, countries, institutions, keywords, and references. The annual number of publications remarkably increased from 2011 to 2020. Neoplasm was the main research hotspot (n = 750 publications), and Biochemical and Biophysical Research Communications published the largest number of papers (n = 64) on this topic. Nanjing Medical University ranked first among institutions actively engaged in this field by publishing 72 papers, and China contributed 96.84% of the 1,013 papers (n = 981 publications) analyzed. Burst keywords in recent years included glioblastoma, miR-7, skeletal muscle, and non-coding RNA.Conclusion: Crosstalk between miRNAs and circRNAs in human diseases is a popular research topic. This study provides important clues on research trends and frontiers. Caenorhabditis elegans. miRNAs are crucial post-transcriptional regulators of gene expression and known to pair with the 3′UTR of target mRNAs to either induce mRNA degradation or inhibit translation (MicroRNAs (miRNAs) are endogenous non-coding RNAs (ncRNAs) measuring ∼22 nucleotides in length; they were first discovered in 1993 . Lee et nslation . Moreovenslation , chronicnslation , and carnslation .Circular RNAs (circRNAs) are endogenous ncRNAs with covalent closed-loop structures that were first discovered in viral RNA by Crosstalk of circRNAs and miRNAs refers to the communication and co-regulation between them. As two important gene-expression regulators, circRNAs interact with miRNAs and participate in regulating mRNA expression in various human diseases . CrosstaCrosstalk between circRNAs and miRNAs may provide new avenues through which the mechanisms, diagnosis, and treatment of human diseases could be explored. Thus, in the present work, we provide a bibliographic analysis of the related literature to identify current global research trends and emerging topics in this field.∗ or “circ RNA∗” OR “circular RNA∗” OR circularRNA∗) AND TI = .This bibliographic analysis included published articles and reviews that related to research on the crosstalk between circRNAs and miRNAs, and these publications focused on the occurrence and development of human diseases or might be beneficial for studying human diseases. Data were extracted from Science Citation Index Expanded (SCI-Expanded) of Web of Science (WoS) in March 2021. Searches were conducted using the following keywords: TI =  were used for bibliographic analysis, and SPSS 22.0  was used for statistical analysis. CiteSpace is often used for bibliographic analysis with data derived from WoS . Internah, the researcher published at least h papers and each of these papers was cited at least h times , h-index, category and JIF quartile were collected from WoS. The productivity of an individual or group was reflected by the number of articles published. The number of citations, IF and h-index were collected to assess the impact of individuals or groups on publications in this filed. IF values were acquired from  h times . Each jo h times .t = 3.376, P = 0.01 < 0.05, data of 2021 were not included because they are incomplete) and citations  increased remarkably each year from 2011 to 2020.A total of 1,013 papers were included in our study. n = 750 publications; 74.04% of the total number of publications) and had an h-index of 56; this topic was followed by diseases of the circulatory system  and musculoskeletal system or connective tissue .The research directions of the 1,013 papers were classified and summarized according to ICD-11. Biochemical and Biophysical Research Communications contributed the greatest number of publications (n = 64) and had the highest h-index (33), followed by European Review for Medical and Pharmacological Sciences (n = 43 publications) and Journal of Cellular Biochemistry (n = 38 publications). The IF of the top 10 journals ranged from 2.886 to 15.302 (mean = 5.4113). Among the journals contributing publications on the crosstalk between miRNAs and circRNAs in human diseases, Molecular Cancer (n = 26 publications) had the highest IF (IF 2019 = 15.302), followed by Molecular Therapy-Nucleic Acids  and Cell Death and Disease . Among the top 10 journals, 33.33% JIF quartile were Q1, 46.67% were Q2 and 20% were Q3.A total of 244 journals contributed the 1,013 papers included in this study. Among the top 10 journals ranked by number of publications , BiochemA dual map of journals presenting contributions and connections between disciplines is shown in n = 981 publications), with a high centrality of 0.57. The United States revealed the highest centrality (0.59) and contributed the second highest number of publications (n = 42).In total, 30 countries and 748 institutions contributed to the related research, and the details of each item can be found in n = 72 publications), followed by Zhengzhou University (n = 43 publications) and Sun Yat-sen University (n = 41 publications).The top 10 institutions ranked by number of publications were all universities in China . Among tThe top 20 keywords with the strongest citation bursts at different time periods are shown in References are an indispensable part of publications. In this study, we performed a bibliographic analysis of studies on the crosstalk between miRNAs and circRNAs and found that research on this topic is well underway. circRNAs can communicate and co-regulate with miRNAs to regulate gene expression. Hansen and his colleagues published the first paper on the crosstalk between ciRS-7 and miR-671 in 2011 . HoweverThe mechanisms of crosstalk between miRNAs and circRNAs are incompletely understood. miRNAs and circRNAs have been proven to interact in the pathological process of many human diseases, including cancer, osteoarthritis (OA) and neuropathic pain (NP). circRNAs sponging miRNAs was a frequently mentioned mechanism of the crosstalk between circRNAs and miRNAs in human diseases. Molecular Cancer, which had the highest IF among the top 10 journals ranked by number of publications. Interactions between miRNAs and circRNAs have also been explored in other types of neoplasms, such as gastric cancer, breast cancer . Han and his colleagues revealed that circMTO1 inhibits the process of hepatocellular carcinoma by sponging miR-9 . Zhang at cancer  and gliot cancer . Most ofBiochemical and Biophysical Research Communications contributed the most to research on the crosstalk between miRNAs and circRNAs by publishing 64 articles with the highest h-index (33). However, in terms of IF, this journal placed ninth among the top 10 journals ranked by number of publications. Molecular Cancer, the IF of which was 15.302, was the only journal with an IF greater than 10 among the top 10 journals. Although the IF of the top 10 journals was not high, JIF Quartile shown that these journals ranked well in corresponding categories (33.33% of Q1 and 46.67% of Q2). These results suggest that the quality of most publications was reliable, but more high quality and ground-breaking researches are needed in this field. Furthermore, the crosstalk between circRNAs and miRNAs is a relatively new field, and it may be a possible reason for these results.China is the major country contributing research on the crosstalk between miRNAs and circRNAs in human diseases. The country published 981 papers  and showed fairly high centrality (0.57). The United States ranked second in terms of countries with the greatest number of publications; the country published 42 papers and demonstrated the highest centrality (0.59) among the countries compared. Interestingly, China noticeably contributed more publications than the United States, but the centrality of the former was lower than that of the latter. This finding may be explained by the vast number of articles published by China alone, which could result in low centrality. The top 10 institutions ranked by number of publications were all Chinese universities, among which Nanjing Medical University ranked first, with 72 publications. Therefore, China is the leading country in research on the crosstalk between miRNAs and circRNAs in human diseases, and universities are the main institutional form in this field.According to CiteSpace V, “glioblastoma,” “miR-7,” “skeletal muscle,” and “non-coding RNA” are the most popular keywords in the related research; these terms indicate potential research hotspots and frontiers. The four potential frontiers of research on the crosstalk between miRNAs and circRNAs in human diseases are as follows:(1)Glioblastoma: Glioblastoma multiforme (GBM), the most common type of brain cancer, is also known as grade IV glioma; the disease has a short overall survival time and high malignancy . Althoug(2)MiR-7: miR-7 can modulate the expression of several oncogenes, and changes in miR-7 activity can affect the progression of cancer . The mec(3)Skeletal muscle: Skeletal muscle, which contains 50–75% of all proteins in the human body, accounts for approximately 40% of the human body weight. Skeletal muscle is closely related to human locomotion and metabolism, and skeletal muscle diseases can severely affect a patient’s quality of life . circRNA(4)Non-coding RNA: Research conducted over the last decade has reported that ncRNAs are involved in several physiological and pathological processes. circRNAs and miRNAs are two types of ncRNAs that do not code proteins but can regulate gene expression. The effect of crosstalk between circRNAs and miRNAs on the complex and unknown regulatory networks of ncRNA must be further investigated .According to our analysis of keywords and references, research on the crosstalk between circRNAs and miRNAs mainly focuses on cancer, including glioma, gastric cancer, and ovarian cancer, and the related sponge mechanism. Journals in molecular, biology and genetics field were the main source of references for the published research. Most publications were published in journals dedicated to molecular, biology and immunology field.To the best of our knowledge, this study is the first to use CiteSpace to perform a bibliographic analysis of publications on the crosstalk between miRNAs and circRNAs. However, this study presents some limitations. First, SCI-E of WoS, although an authoritative and comprehensive database in the medical field, was the only resource we selected for data acquisition; thus, some important findings published in other databases may have been missed. Second, the contributions and collaborations of authors were not analyzed because most of the authors were from China and different Chinese names could be translated to the same English name. Third, this study lacked an assessment of the overall quality of publications.Biochemical and Biophysical Research Communications contributed the most to this field in terms of number of publications, and China produced the largest amount of research on this topic. In terms of institution, Nanjing Medical University published the largest number of related articles. At present, cancer is the most popular research area related to the crosstalk between miRNAs and circRNAs in human diseases. The latest burst keywords are “glioblastoma,” “miR-7,” “skeletal muscle,” and “non-coding RNA.” As far as we know, no bibliographic analysis has been conducted for publications on the crosstalk between circRNAs and miRNAs before. This study may provide researchers important clues on research trends and frontiers in this field.A total of 1,013 papers on the crosstalk between miRNAs and circRNAs in human diseases were published. The first paper was published in 2011 and initiated research in this field. The quality of most publications was relatively well in this field, but high-impact researches were needed. The original contributions presented in the study are included in the article/Y-MC and X-QW: conceptualization and visualization. Y-MC: data curation, formal analysis, methodology, and writing – original draft. X-QW: funding acquisition and supervision. Y-MC, Y-LZ, XS, and X-QW: validation. Y-MC, Y-LZ, and XS: writing, review, and editing. 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.


Change in underweight status was significantly associated with a risk of hip fracture.Being underweight is associated with a high risk of hip fracture. However, the impact of change in underweight status on the risk of hip fracture is unknown. This study is performed to investigate the relationship between change in underweight status and risk of hip fracture. This study included 1,713,225 subjects aged ≥40 years who underwent two consecutive national health screenings between 2007 and 2009. We prospectively assessed the risk of hip fracture between 2010 and 2018 according to changes in underweight status. We divided the participants into four groups according to the change in underweight status: consistent non-underweight (non-underweight to non-underweight), became non-underweight (underweight to non-underweight), became underweight (non-underweight to underweight), and consistent underweight (underweight to underweight). Compared with the consistent non-underweight group, the became non-underweight (0.74/1000 person years (PY) increase in incidence rate (IR); adjusted hazard ratio (HR) 1.72; 95% confidence interval (CI) 1.42–2.07), became underweight , and consistent underweight  groups had a significantly increased risk of hip fracture ( The incidence of hip fractures is increasing with the aging of society worldwide ,2. ThereBeing underweight is a well-known risk factor for hip fracture. A cohort study of 24,691 Japanese participants aged ≥75 years found that the risk of hip fracture in people who were underweight was up to 1.74 times higher than that in participants of normal weight . In addiIn this paper, we examine the associations of changes in underweight status with risk of hip fracture using large population-based data from adults over 40 years of age with records of sociodemographic factors, health surveys, tests, and medical claims from the National Health Insurance Service (NHIS) of Korea.This nationwide population-based observational cohort study was conducted using claims data from the NHIS in Korea. NHIS is a quasi-governmental institution under the Ministry of Health and Welfare that has provided compulsory medical insurance services covering almost 99% of the Korean population since 1989. NHIS provides health checkups once every 2 years for adults with national health insurance. The NHIS database contains information on demographics, national health screening , medical treatment, and comorbidities . All data are anonymized, collected regularly, and carefully quality controlled. Since 2015, NHIS has been providing data to researchers whose research protocols have been approved by the official review committee.We enrolled participants of at least 40 years of age who underwent two consecutive biennial national health screenings provided by the NHIS between 2007 and 2009. The exclusion criteria were missing data, a prior fracture before the health check-up, and a 1-year lag period.We extracted demographic, socioeconomic, and clinical data from the NHIS database: sex, age, height, weight, smoking status , alcohol consumption , or heavy drinker (≥30 g/day)), regular exercise , low income (<20th percentile), blood glucose level, total cholesterol level, blood pressure, and estimated glomerular filtration rate.2.The definitions of comorbidities based on ICD codes were taken from those validated in previous studies ,13,14. D2). Underweight was defined as BMI < 18.5. We examined whether the participants were underweight by BMI measurements at two examinations (2007 and 2009), and then the study population was divided into four groups according to the change in underweight status: consistent non-underweight , became non-underweight , became underweight , and consistent underweight .Body mass index (BMI) was calculated by dividing body weight (kg) by height squared  was taken to indicate statistical significance. All statistical analyses were performed using SAS software .Baseline characteristics are presented as numbers with percentages for categorical variables and as numbers with standard deviations for continuous variables. The risk of hip fracture is presented as a hazard ratio (HR) with 95% confidence interval (CI) based on Cox regression analysis. The incidence rate (IR) was calculated as the number of hip fractures per 1000 person years (PY). Four proportional hazard models were constructed to investigate covariates potentially associated with hip fracture: model 1 was unadjusted; model 2 was adjusted for age and sex; model 3 was additionally adjusted for alcohol consumption, smoking status, regular exercise, and household income; and model 4 was further adjusted for comorbidities . We compared the cumulative incidence of hip fractures between groups using the Kaplan–Meier method. We also conducted subgroup analyses based on age (<65 and ≥65 years) and sex. In all analyses, A total of 1,984,497 adults over the age of 40 years who received consecutive health checkups provided by NHIS in 2007 and 2009 were initially included in the study. Among these participants, 33,262 with missing data, 216,463 with fractures before the medical examination, and 21,547 with fractures during the 1-year lag period were excluded. Therefore, 1,713,225 participants were included in the final analysis .p-values for all variables were <0.001. The BU group had the oldest average age of 57.7 years, followed by the CU group (56.1 years), CN group (55.2 years), and BN group (55.1 years). The CN group had a higher proportion of males than females , but there were fewer males than females in the BN , BU , and CU groups . The incidence of hip fracture was the highest in the BU group , followed by the CU group , BN group , and CN group .The 1,713,225 participants were divided into four groups according to the change in underweight status: CN group , BN group , BU group , and CU group . Comparisons of baseline characteristics among these groups using the change in underweight status are shown in After adjustments for multiple variables , the participants in the BU group , CU group , and BN group  had a significantly increased risk of hip fracture events compared with those in the CN group .The cumulative incidence was estimated using the Kaplan–Meier method in p = 0.012). In the subgroups according to sex, adjusted HRs for the BN, BU, and CU groups were 1.95, 2.84, and 2.83, respectively, in males, but 1.55, 1.75 and 1.73, respectively, in females (p < 0.001).We performed subgroup analyses by stratifying the study population according to age and sex. The adjusted hip fracture risks according to the change in underweight status in each subgroup are presented in Using a large national population-based database, we found real-world evidence that the change in underweight status was significantly correlated with hip fracture risk. In the data obtained through two consecutive health checkups, we confirmed that the BU group, in which the participants changed from non-underweight to underweight, had the highest risk of hip fracture. That is, even if the initial weight was normal, the risk of hip fracture can be rather high, if changed to become underweight at the re-examination after 2 years. Our results support that additional education on these risks may be beneficial even in normal weight patients. We also confirmed that the cumulative probability of hip fracture was the highest in the BU group at all time points.Well-known risk factors for hip fracture include age, sex, height, weight, race, prior fracture, cognitive dysfunction, low socioeconomic status, lack of physical activity, and health behaviors, such as smoking and alcohol consumption ,16. We aIn the present study, the BN group showed a 1.72 times greater hip fracture risk compared with the CN group. In general, when body weight is regained, body composition changes include more fat than muscle mass ,18. ThisIn our study, the association between a change in underweight status and hip fracture risk was greater in elderly subjects (≥65 years) than younger subjects (<65 years). Coin et al. reported that being underweight in the elderly was significantly associated with osteoporosis . In addiIn our study, the association between hip fracture risk and low body weight change was stronger in men than in women. According to a recent large-scale Norwegian cohort study, the risk of hip fracture in underweight individuals with a BMI ≤ 22 was higher in men than in women . The sexA notable strength of this study is that we used a large sample from a nationally representative database. In addition, we analyzed data from two consecutive national health examinations to explore the association between a change in underweight status and the risk of hip fracture. Our results mean that, even if there is an underweight classification at one point in time, the risk is not the same, and may vary according to the change in BMI over two consecutive years. It also shows that, even if the patient is of normal weight, they may be at greater risk if they become underweight in the future. Through this, clinicians may be able to screen and monitor patients more precisely. To our knowledge, there have been no previous reports of a relationship between a change in underweight status and the risk of hip fracture.However, this study had several limitations. First, there may have been selection bias due to the exclusion of subjects who did not undergo two consecutive health checkups. Although the NHIS provides mandatory national health insurance to all citizens in Korea, there is a possibility that people in certain socioeconomic status brackets may not be able to receive health checkups. Second, the incidence of hip fracture may be underestimated because the data from the NHIS can only identify patients who have received treatment in a hospital. Additionally, the change in BMI in each group may have been small. Third, caution is required in generalizing the results to other races. Race may also influence the relationship between BMI and fractures. BMD not only differs according to race, but has been reported to differ in the risk of fracture according to race even after excluding the effects of BMD ,32. FourWe found out that the change in underweight status was strongly related to the risk of hip fracture in Korean adults over 40 years old. Adults who became underweight from being non-underweight had the highest risk of hip fractures, followed by those who were consistently underweight.


ObjectiveTo evaluate crystallized phenol application and the Karydakis flap procedure in terms of treatment success, postoperative complications, and recurrence in the treatment of pilonidal sinus disease (PSD).Materials and methodsThe study included patients who underwent the Karydakis flap procedure and crystallized phenol application with the diagnosis of PSD in our clinic between June 2016 and January 2019. Age, gender, preoperative body mass index (BMI), sinus number, number of crystallized phenol administrations, postoperative length of hospital stay, postoperative complications, and recurrence rates were compared between the Karydakis and crystallized phenol groups.Results2. The median sinus number was 3 (2-3). There was no difference between the two groups in terms of age, BMI, sinus number, follow-up duration, gender, recurrence, wound infection, hematoma, wound dehiscence, and preoperative complaints (p > 0.05). A higher rate of drain requirement and more extended hospital stay were observed in the Karydakis group than in the crystallized phenol group, and the difference was statistically significant .Of the 88 patients included in the study, 29 (32.95%) were female, and 59 (67.05%) were male. The median age was 30 (27-33) years, and BMI was 29 (26-32) kg/mConclusionThe crucial advantages of crystallized phenol treatment in PSD are high wound healing rates, outpatient applicability, and no requirement of operating room conditions. Crystallized phenol application also has similar post-application complication rates to the Karydakis flap procedure. The results of our study support that crystallized phenol application is a less invasive alternative treatment method that can be applied before surgical treatment in selected patients. Pilonidal sinus is a common chronic disease of the sacrococcygeal region, first described in the Boston Medical-Surgical Journal in 1847 by Dr. Andersson . AlthougPatients aged 18-50 years who underwent the Karydakis flap procedure or crystallized phenol application with a diagnosis of primary PSD in the Ankara Numune Research and Training Hospital General Surgery Clinic between June 2016 and January 2019 were included in the study. The patients' age, gender, preoperative body mass index (BMI), sinus number, surgical method used, number of crystallized phenol administrations, postoperative length of hospital stay, postoperative complications , and postoperative recurrence were obtained by screening the hospital system and contacting the patients by phone. Patients who underwent recurrent operations due to PSD underwent surgery when infected, complicated PSD cases, patients with chronic diseases  or cancer history, and those who had received radiotherapy from the pelvic region were excluded from the study. The study's ethics committee approval was obtained from the Clinical Research Ethics Committee of Ankara City Hospital No. 1 . All the patients provided informed consent before the procedure.Statistical analysisData were transferred to the IBM SPSS Statistics v. 23  for statistical analyses. Non-parametric tests were used since numerical variables were not normally distributed according to the Kolmogorov-Smirnov test. Frequency distribution (number and percentages) was given for categorical variables and descriptive statistics (median and interquartile ranges) for numerical variables. The Mann-Whitney U-test was carried out to examine the differences in numerical variables between the two groups, and the chi-square test was used to investigate the relationship between two categorical variables.Crystalized phenol applicationAfter a sterile site was created and local anesthesia was induced, the sinus tract was cleaned from the sinus openings and curetted. Before the application, the surrounding normal skin tissue was protected with an antibiotic cream (Furacin cream) against pure crystallized phenol's irritating and burning effect. However, non-antibiotic creams can be used for this process. Debris and hair were removed entirely from the sinus Figure . CrystalKarydakis procedureFollowing local and/or spinal anesthesia, an elliptical incision with a vertical length of approximately 2 to 5 cm was made above the sinus and 2 cm lateral to the midline. The cyst was carefully excised without damaging the sinus structure and leaving no sinus extension behind. The skin, subcutaneous advancement flap was prepared from the medial side of the incision. The subcutaneous tissue was sutured to the presacral fascia at the base using 2/0 polyglactin (Vicryl) lateralized to the midline at the top. The skin was closed with 3-4/0 polypropylene (Prolene) , hospital stay was significantly longer in the Karydakis group compared to the phenol group (p < 0.05). No statistically significant correlation was observed between the type of treatment and gender, recurrence, wound infection, hematoma, wound dehiscence, and preoperative complaints (p > 0.05), but the rate of drain requirement was higher in the Karydakis group than in the phenol group (p < 0.05) Table .In the phenol group, no difference was detected between the genders in terms of length of hospital stay and follow-up duration (p > 0.05). There was also no statistically significant difference in the preoperative complaints and number of applications according to age, BMI, and sinus number (p > 0.05). Furthermore, there was no statistically significant difference between the genders concerning preoperative complaints and the number of applications (p > 0.05). The Spearman correlation analysis revealed that length of hospital stay had a statistically significant negative correlation with age and a statistically significant positive correlation with BMI (p < 0.05) Table .In the Karydakis group, no statistically significant difference was determined between the genders in terms of length of hospital stay and follow-up duration (p > 0.05), and preoperative complaints did not significantly differ according to age, BMI, and sinus number (p > 0.05). In addition, there was no significant correlation between gender and preoperative complaints and the number of procedures (p > 0.05). Lastly, as a result of the Spearman correlation analysis, no statistically significant relationship was found between length of hospital stay and follow-up duration and age, BMI, and sinus number (p > 0.05) Table .Although PSD is primarily seen in the sacrococcygeal region, it can also occur in other parts of our body, including the fingers and toes, navel, and ears . PSD is In PSD, removing free hair and debris from the sinus and from around the sinus orifice  is the most commonly used non-surgical treatment method. The other frequent procedure is followed by the injection of some chemical agents  into the sinus cavity to initiate destruction and promote scar development . On the In our study, we applied three treatment sessions to 60% of the patients and two sessions to 40% in the phenol group. In a study by Kayaalp et al., 30 patients who underwent single-session crystallized phenol application were evaluated, and 93% success was reported after 14 months of follow-up. Doğru et al. reported 95% success in their 24-month follow-up after 107 applications . AnotherThe Karydakis procedure, also known as the lateral flap technique, is widely used in PSD due to its easy application and low infection rates, the divergence of the suture line from the midline, and faster wound healing compared to other surgical methods . There aThe most important limitations of our study include the retrospective design, inclusion of only primary PSD cases, number of sinuses being restricted to three, small number of patients, and short follow-up duration. Also, patients could not be matched exactly in terms of etiological factors  for both groups and that risk matching could not be done in terms of drain use, especially in patients who underwent the Karidakis flap procedure. Since a smaller incision is used and the wound is left open in patients treated with crystallized phenol, there is no need for a drain compared to the Karydakis flap technique. This reduces the significance value of comparing both groups in terms of drain use in our study. Future studies with larger series and more homogenous paired groups will be useful in demonstrating the advantages of crystallized phenol application and Karydakis flap methods used in the treatment of PSD over each other and treatment success rates.We consider that crystallized phenol can be used safely in PSD treatment, especially in selected cases. Because it is a more conservative method than other surgical procedures with low recurrence rates and low costs, which also requires only local anesthesia, and allows the patient to return to daily activities earlier.


Background: A single measurement of grip strength (GS) could predict the incidence of cardiovascular disease (CVD). However, the long-term pattern of GS and its association with incident CVD are rarely studied. We aimed to characterize the GS trajectory and determine its association with the incidence of CVD .Methods: This study included 5,300 individuals without CVD from a British community-based cohort in 2012 (the baseline). GS was repeatedly measured in 2004, 2008, and 2012. Long-term GS patterns were identified by the group-based trajectory model. Cox proportional hazard models were used to examine the associations between GS trajectories and incident CVD. We identified three GS trajectories separately for men and women based on the 2012 GS measurement and change patterns during 2004–2012.Results: After a median follow-up of 6.1 years (during 2012–2019), 392 participants developed major CVD, including 114 myocardial infarction, 119 angina, 169 stroke, and 44 heart failure. Compared with the high stable group, participants with low stable GS was associated with a higher incidence of CVD incidence , myocardial infarction , stroke , and heart failure  in the fully adjusted models.Conclusions: The low GS trajectory pattern was associated with a higher risk of CVD. Continuous monitoring of GS values could help identify people at risk of CVD. Muscle dysfunction reduces the quality of life and increases healthcare budgets. Many studies suggest that muscle dysfunction predisposes to the development of diabetes , hyperteCVDs are known as the leading causes of non-communicable disease-related deaths and one of the most serious health problems worldwide , which cPrevious cohort , 14, 15 In view of these knowledge gaps, this study aimed to identify GS trajectories over 8 years among 5,300 English participants and to explore the relationship between long-term GS patterns and the subsequent CVD risk. We further investigated the association of GS trajectories with the components of the CVD events, including MI, angina, stroke, and heart failure. We hypothesized that (a) people have different GS patterns and (b) people with different GS patterns would be at different levels of risk for the incidence of CVD.Data were obtained from the English Longitudinal Study of Ageing (ELSA). ELSA is a nationally representative, biannual, ongoing, longitudinal cohort study based on community-dwelling adults living in England . The detn = 1,522) or if they already had a doctor-diagnosed CVD  at the baseline . In addition, we excluded participants who were lost to follow-up from wave 7 to wave 9 (n = 466). Finally, a total of 5,300 participants were included in 2012 (the baseline), with at least two repeat GS measures and at least one follow-up reassessment (during 2012–2019) for the current analysis of CVD risk. The participant selection flowchart is shown in The current study used data from wave 2 (2004/2005) to wave 9 (2018/2019). Every 4 years from 2004 (wave 2) through 2012 (wave 6), GS was measured by trained nurses. Participants were excluded if they did not have valid GS measurements between 2004 and 2008 , and all participants provided informed consents.The Smedley handheld dynamometer  was used to measure GS (kg) three times on each hand. The participant was asked to squeeze the device for a couple of seconds and to rest at least 30 s between each measurement. The overall GS value was computed as the average of maximum GS of the non-dominant and dominant hands.2) was calculated based on body weight and height measured in light clothing without shoes. Education level was classified as (1) equivalent or less than the general certificate of education (GCE) O-level, (2) equivalent or GCE O-level, and (3) higher than GCE A-level or equivalent. Smoking status was categorized as non-smokers (never smoked or ex-smokers) and current smokers. Physical activity was divided into two levels based on whether once or more times moderate or vigorous exercises a week. Sleep quality was grouped as good (score ≤ 2) or bad (score >2) using the Jenkins sleep scale. The level of depression was evaluated by the Centre for Epidemiological Studies Depression scale (CES-D). A score ≥4 denoted a higher level of depression. The BPs were measured three times using an electronic sphygmomanometer  after resting for more than 5 min, and the average value of the three consecutive readings was used in the analyses. Hypertension was diagnosed as individuals with a mean SBP ≥140 mmHg and/or mean DBP ≥90 mmHg, or individuals who reported hypertension or received antihypertensive treatment. Diabetes was defined as individuals who reported diabetes or use insulin/antidiabetic medications.Covariates shown by previous studies to be associated with both CVD and GS were selected for our study, including age, sex, body mass index (BMI), education, current smoking, physical activity, sleep quality, depression, hypertension, and diabetes. BMI  analysis –22 to caP-values]. All analyses are presented as the two models with adjustment of confounding factors in 2012. These confounders shown by previous studies to be associated with both CVD and GS were selected for our analyses. More specifically, the minimally adjusted model was adjusted for age and sex. The fully adjusted model was further adjusted for education, BMI, systolic blood pressure, smoking, physical activity, depression, and quality of sleep.Multivariable Cox proportional hazard models were used to analyze the association between GS patterns from 2004 to 2012 and the risk of CVD. The proportionality of hazards was checked by the Schoenfeld residuals method. Results of Cox models were presented as hazard ratios [HRs; 95% confidence intervals (CIs) and For the effects of sex or age, likelihood ratio tests were performed to explore statistical interactions between GS patterns and age ( ≤ 65 vs. >65) and GS patterns and sex of primary outcome, respectively, by comparison of the −2 logarithmic likelihood chi-square between the nested model with and without a product term. Stratified models by sex and age ( ≤ 65 vs. >65) were utilized to explore the associations between trajectories and CVD risks. We conducted all analyses with SAS version 9.4 .The model with three trajectories according to the change patterns of GS from 2004 to 2012 was identified as the fit by comparing the BIC and the proportion of the participants within each trajectory group . For womP <0.001) was greater in individuals with low stable GS compared with the high stable GS in age/sex-adjusted models. The association remained significant  after adjustment for further confounding factors. Compared with the stable high group, participants in the stable low GS group had a double significantly higher risk of CVD incidence.During a median follow-up of 6.1 years (interquartile range: 5.8–6.3 years), we recorded 392 CVD events, with 114 MI, 119 angina, 169 stroke, and 44 heart failure. In comparing high vs. low, low stable GS was associated with a higher risk of CVD incidence during 2012–2019. P-interaction = 0.572) and gender (P-interaction = 0.462). Besides, for individuals with older age (>65 years), low and moderate GS was associated with a more substantial increment of CVD risk (P = 0.572) in individuals aged ≤ 65 years.Results stratified by age and sex are shown in CVD risk , as compP = 0.083). Compared with the high stable GS group, individuals with stable low GS had a higher risk of MI , stroke , and heart failure , respectively.In addition, we have also added relevant data on the association between baseline grip strength and CVD risk in Muscles, as the main sites for protein storage and glucose processing, play an important role in maintaining the health of people , 24. GS The main finding of our study was that stable low GS was strongly associated with a wide range of CVD outcomes. Several studies , 26–28 hIn the analysis by age subgroup, the association between GS patterns and CVD incidence was more obvious among participants aged >65 years compared with those aged ≤ 65 years. However, the interaction between age and GS trajectories for CVD was not statistically significant. Previously, few studies have investigated whether the associations between CVD and GS are consistent across age groups. A systematic review  includinFurthermore, we examined the association of GS trajectories with the components of the CVD events. The predicted 6-year risk of MI and stroke increased substantially in the group of stable low GS. In the PURE study , a largeTo our knowledge, the current study was the first to investigate the association between GS trajectory and the risk of CVD among a nationally representative English population. The prospective design and high follow-up rate minimized the possibility of recall bias and follow-up loss, allowing the capture of a considerable number of CVD events. Our study design involved repeated GS measurements, which enabled us to create the trajectory of GS change and obtain the GS performance of participants in the years before CVD diagnosis. Because we excluded participants with diagnosed CVD at baseline and used longitudinal GS changes instead of one measurement of GS, reverse causality bias is unlikely in our study.Despite the strengths mentioned above, our study still has several limitations. First, the use of self-reported physician-diagnosed CVD could cause misclassifications of CVD events and might influence the results to a lesser extent. However, most CVD cases identified in our study were confirmed by ELSA researchers based on medical records. Second, the number of GS measurements is relatively less and the study may not acquire sufficient power to depict the full trajectories of GS. Defining the trajectory of GS changes based on three measurements within 8 years does not seem optimal. However, the systematic measurement of longitudinal GS data is already precious. Third, the use of data from the responders might have influenced our results, as non-responders might have a higher incidence of CVD and an accelerated rate of GS change compared with responders. Finally, although we have attempted to minimize potential confounding in the analyses, the findings might still be affected by the residual confounders from unknown and unmeasured factors .In summary, the long-term GS pattern was associated with the altered risk of CVD. People with stable low GS had twice the risk of developing CVD as those with stable high GS. When stratifying by age, the association was more pronounced in the older population. These results suggest that continuous GS values could be utilized to identifying people at risk of CVD, especially in the elderly. Furthermore, our research indicates that high stable muscle function may reduce the risk of CVD, which provides the potential to prevent and treat the condition.The original contributions generated for the study are included in the article/WL carried out the concepts, design, data analysis, and manuscript. RC, CY, and CW reviewed and polished the drafts. JH and CS provided assistance for data acquisition. The final manuscript was approved by all authors.The current study was funded by the National Key Research and Development Plan Project Tasks, Project No: 2020YFC1107902.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. 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The use of frozen embryo transfer (FET) cycles has dramatically risen. The optimal endometrial preparation method for women undergoing FET is of utmost importance to provide the optimal chances of pregnancy. For patients with abnormal ovulation in particular, there have been few studies on FET protocols; notably, most of these studies focus only on the clinical pregnancy rate or live birth rate (LBR) and pay little attention to the regimen’s safety for offspring.It was a retrospective cohort study. First FET cycle with a single blastocyst from whole embryo frozen IVF/ICSI at the Reproductive Center of Third Affiliated Hospital of Zhengzhou University between January 2016 and January 2020. The LBR was the primary outcome of interest. The secondary outcome measures were miscarriage rate and offspring safety, including preterm birth, low birthweight (LBW), small-for-gestational age (SGA), macrosomia and large-for-gestational age (LGA).In total, 2782 FET cycles met the eligibility criteria for analysis. Additionally, there were 1178 singleton births from FET cycles. The clinical pregnancy rate was 58.4% in the L-FET group and 54.5% in the HRT group, with no statistical significance (P=.116). The miscarriage rate was higher in the HRT group than in the L-FET group . The LBR was significantly higher in the L-FET group than in the HRT group . Neonatal outcomes were similar between the two groups. After adjustments for confounding factors, the LBR was higher in the L-FET group . The rate of miscarriage was lower in the L-FET group .For patients with abnormal ovulation, the L-FET regimen has a higher LBR and lower miscarriage rate than HRT. The neonatal outcomes were similar between the two groups. Currently, for every 2 embryos transferred, one is a FET  cycles has dramatically risen with the development of vitrification technology, and a rapid rise in single embryo transfer (ET), combined with the development of preimplantation genetic testing(PGT), has increased the number of embryos available for freezing –3. FET iis a FET . In someis a FET .The optimal endometrial preparation method for women undergoing FET is of utmost importance to provide the optimal chances of pregnancy. There are different FET cycle regimens used to prepare the endometrium, including natural cycles, hormone replacement therapy (HRT) with estrogen and progesterone, cycles in which ovulation is induced by drugs, and gonadotrophin-releasing hormone agonist (GnRH-a) cycles. Although there are many options for the preparation of the endometrium, there is still no uniform recommendation for the preparation of the FET endometrium for different groups of women to date –8. For pLetrozole is a third-generation aromatase inhibitor that is used mainly for the treatment of postmenopausal breast cancer. Recent studies have shown that letrozole can be used effectively for ovulation induction. Letrozole has a short half-life and has both peripheral and central effects , 13. SimHowever, there are few studies comparing the two regimens in women with ovulation disorders, and the existing ones focus mostly on clinical outcomes, such as the clinical pregnancy rate or LBR , 17. MorThis was a retrospective cohort study approved by the review board of the Third Affiliated Hospital of Zhengzhou University. All patients who initiated the first FET of whole-embryo-cycle transfer with first IVF/ICSI cycle at the Reproductive Center of Third Affiliated Hospital of Zhengzhou University between January 2016 and January 2020 were analyzed for potential inclusion. We included FET cycles of oligo-anovulation or anovulation with L-FET or HRT, and only single blastocyst transfer cycles were included. Cycles with maternal age >40 years were excluded, and cases with adenomyosis, uterine malformations, endometrial polyps, and PGT were excluded.Beginning on menstrual cycle day 3, 4 or 5, 2.5 mg of letrozole  was administered daily for 5 consecutive days. Then, follicle growth was monitored by vaginal ultrasound and, if necessary, combined with serum estradiol analysis on day 10. If the diameter of the dominant follicle was greater than 14 mm, there was no need to add HMG to the regimen; otherwise, HMG  37.5-75 IU daily was added according to the development of the follicle. When the diameter of the dominant follicle was greater than 18 mm, the endometrial thickness was greater than 7 mm, serum estradiol was >150 pg/ml and the occurrence of an LH surge was evident, 10 000 IU urinary hCG was injected . FET was cancelled for cycles with insufficient thickness (<7 mm) or insufficient follicle development .For HRT cycles, vaginal ultrasound examination was performed on the 3rd day of the menstrual cycle, 2-3 mg of estradiol valerate was taken orally three times daily (Bayer Co. Germany), and vaginal ultrasound examination was performed 7 days later. The drug dose was adjusted according to the thickness of the endometrium (up to 9 mg per day). When the medication was taken for > 12 days, the endometrial thickness was ≥7 mm, and the serum estrogen level was greater than 150 pg/ml, endometrial transformation was performed. FET was cancelled for Cycles with insufficient thickness (<7 mm).After the hCG injection in the L-FET cycle or after a medication time of > 12 days in the HRT cycle, an endometrial thickness of ≥7 mm was verified, and routine corpus luteum support, namely oral dydrogesterone  (Abbott Co. America) and intravaginal administration of 90 mg of a progesterone sustained-release vaginal gel (Merck Co. Germany), was given. Five days after endometrial development with corpus luteum support, single blastocyst transplantation was carried out by abdominal ultrasound. Corpus luteum support was performed at least until 55 days after transplantation if pregnancy occurred.The primary outcome measure was LBR, defined as at least one live birth after ≥ 28 gestational weeks.The secondary outcome measures were the miscarriage rate  and offspring safety, which was assessed by examining the neonatal birth weight of singleton live births as follows: low birthweight , small-for-gestational age  , macrosoAll statistical management and analyses were performed using SPSS software, version 22.0.The one-sample K-S test was used to check for normality. Continuous variables with abnormal distributions are expressed as the mean ± SD, and Student’s t test was used to assess between-group differences. Categorical variables are represented as the number of cases (n) and percentage (%). The means from chi-square analyses were used to assess the differences between groups with Fisher’s exact test when necessary. For outcome measures , multiple logistic regression was used to adjust for the baseline characteristics. Unadjusted odds ratios and adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated. Statistical significance was set at p<0.05.From January 2016 to January 2020, a total of 2782 FET cycles, including 502 L-FET and 2280 HRT cycles, met the eligibility criteria for analysis. There were 1178 FET cycles with singleton births, including 245 cycles from L-FET cycles and 933 from HRT cycles.As shown in Regarding the main outcome measures, to adjust for the influence of confounding factors, we conducted a multiple logistic regression analysis. The included factors were maternal age, body mass index, duration of infertility, type of infertility (primary/secondary infertility), infertility diagnosis , basal antral follicle count, fertilization method (IVF/ICSI) and developmental stage of blastocysts (D5/D6). The unadjusted OR and adjusted OR value with their 95% CIs are presented in In summary, the results of this study demonstrate that the L-FET group has a higher LBR and lower miscarriage rate than the HRT group of patients with abnormal ovulation with a single blastocyst transfer. However, the offspring outcomes, including the rates of preterm birth, normal neonatal birthweight, LBW, SGA, macrosomia and LGA, were comparable between the two groups.Regarding clinical outcomes, to the best of our knowledge, few studies have explored L-FET and HRT for patients with abnormal ovulation, including polycystic ovary syndrome (PCOS). The first study was published in 2014 and included only 116 PCOS cycles  evaluateHowever, one randomized controlled trial of 177 infertile PCOS patients had a different result. After analysis, there were no significant between-group differences in the implantation rate; the chemical, ectopic, and clinical pregnancy rates; the miscarriage rate; or the ongoing pregnancy rate . CompareMoreover, the study did not limit the type of ET, including cleavage-stage or blastocyst-stage ET, or the number of transferred embryos. According to current research, there may be differences in clinical and neonatal outcomes between cleavage-stage and blastocyst-stage embryo transfers –24. MoreThere are two possible mechanisms underlying the significant increase in the LBR and decrease in the miscarriage rate. One is that letrozole is a specific third-generation aromatase inhibitor; when the aromatase is inhibited, the conversion of androgens to estrogens decreases, and the decrease in peripheral estrogen leads to increased expression of estrogen receptors and, thus, increased sensitivity to subsequently high estrogen levels, resulting in faster endometrial proliferation and increased blood flow in the uterus and endometrium, with positive effects on implantation , 27, 28.The strengths of this study are twofold. First, we included single-center cycles with full follow-up, cycles performed during the same period, and first transfer cycles, and this study included only the single blastocyst transfer cycle, to control the number of embryos transferred for the assessment of the pregnancy outcomes, as the consequent reduction in twin pregnancies had an impact on neonatal outcomes, which minimized potential bias. Second, our study explored not only the clinical outcomes of the two regimens but also their safety for the offspring, which has always been the focus of research and has always been of profound importance. Our study also has several limitations. First, it is limited by its retrospective nature, and thus, a further prospective study is needed. Second, we did not explore the relevant biological mechanism.In conclusion, for patients with abnormal ovulation, the L-FET regimen has a higher LBR and lower miscarriage rate than HRT. The neonatal outcomes, including the rates of preterm birth, normal neonatal birthweight, LBW, SGA, macrosomia and LGA, were similar between the two groups. Therefore, these findings imply that letrozole might be a better regimen for FET among women with abnormal ovulation, but further randomized controlled studies with large samples are needed.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 2020 Medical Ethics Review No. 126. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JZ and DM designed the study and selected the population to be included and excluded. JZ and ZL were involved in the data extraction and analysis. LS and YG reviewed the data. JZ was involved in drafting this article. 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.


However, CS was not related to fatigue. The MDF and MNF of muscle parameters were positively correlated with HbA1c and fasting plasma glucose (p < 0.05). In conclusion, we suggest that the duration of DM and glycemic control play important roles in muscle fatigue in patients with DN. Additionally, sEMG is useful for diagnosing muscle fatigue in patients with DN.Diabetic neuropathy (DN) is a major complication associated with diabetes mellitus (DM) and results in fatigue. We investigated whether type 2 diabetic patients with or without neuropathy experienced muscle fatigue and determined the most influencing factor on muscle fatigue. Overall, 15 out of 25 patients with type 2 DM were diagnosed with DN using a nerve conduction study in the upper and lower extremities, and the composite score (CS) was calculated. We obtained the duration of DM and body mass index (BMI) from subjects, and they underwent a series of laboratory tests including HbA1c, fasting plasma glucose, triglycerides, and high- and low-density lipoprotein. To qualify muscle fatigue, this study used surface electromyography (sEMG). Anode and cathode electrodes were attached to the medial gastrocnemius. After 100% isometric maximal voluntary contracture of plantarflexion, the root mean square, median frequency (MDF), and mean power frequency (MNF) were obtained. We showed a correlation among laboratory results, duration of DM, BMI, CS, and parameters of muscle fatigue. The duration of DM was related to fatigue of the muscle and CS ( Diabetic neuropathy (DN) is a peripheral nerve dysfunction, and one of the major complications associated with diabetic retinopathy and diabetic nephropathy ,2. DN haMuscle fatigue is considered a multifaceted phenomenon consisting of physical and chemical changes in muscles which are distinct from alterations in the nervous system efficiency underlying the symptoms, causes, and mechanisms. Muscle fatigue is defined as a decreased maximum capacity to produce force or power output . A rangeA previous study showed that weakness of the ankle plantar and dorsal flexors was progressive and contributed to the severity of neuropathy in patients with symptomatic diabetic neuropathy . The aimTwenty-five patients with type 2 DM who were not previously diagnosed with DN were enrolled in this study. Patients with liver disease, renal disease, chronic alcoholism, and a history of chemotherapy or spine surgery were excluded. Patients with suspected or diagnosed psychological factors related to fatigue , spine dPatients with type 2 DM were divided into two groups: with or without DN. Before NCS, all subjects had their history taken, including the duration of DM, and their BMI was assessed. Laboratory tests including HbA1c, fasting plasma glucose (FPG), albumin, creatinine, triglyceride (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL), were performed. DN examination was performed using NCS. The method of NCS was the same as that reported in a previous study , using KParticipants were placed in the prone position. We used the gastrocnemius medial (GCM) to evaluate muscle fatigue from a previous study . The skiί is the value of the ί-th sample point, and n is the total number of data points).The RMS, MDF, and MNF, by plantarflexion in the prone position, were measured using the sEMG system . The removal of noise generated by the electrocardiogram was performed using 50–500 Hz band-pass filtering, and sampling was set to 1,000 Hz. Using filtering techniques, artifacts were eliminated. To investigate fatigue, the RMS (unit: µV), MDF (unit: Hz) and MNF (unit: Hz) were calculated after the “Fourier transform” and were analyzed using filtered data. Distributions of RMS explain the action potential energies during the contractions, defined as below :RMS=∑ί=1The most representative valuable frequency-domain characteristics are MNF and MDF. For the evaluation of muscle fatigue in sEMG signals, MDF and MNF are defined as follows :∫0MDFP. The baseline characteristics in patients with and without DN were compared using an independent sample t-test after verification of a normal distribution using the Kolmogorov–Smirnov test. Subjects with DN had lower albumin levels (p < 0.05). Although the mean HbA1c and FPG were higher in patients with DN than in patients without DN, the difference was not statistically significant (p > 0.05).Among the 25 subjects with DM, 15 subjects were diagnosed with DN. The comparison between subjects with DN and subjects without DN was investigated using a p < 0.05). The mean MDF (p = 0.028) and MNF (p = 0.027) in subjects with DN were significantly lower than in the subjects without DN. However, the RMS between groups was not statistically significant  than those without DN  and serum creatinine level  but did not show a significant difference from fatigue parameters obtained using sEMG . The MDF and MNF were correlated with FPG, HbA1c, and duration. However, RMS was not associated with these measurements. The correlation coefficient between parameters of muscle fatigue  and duration was higher than between indicators of muscle fatigue and glycemic control (p < 0.05).The relationship between various parameters in subjects with DN was investigated using Pearson’s correlation coefficients after verification of a normal distribution using the Kolmogorov–Smirnov test. CS was correlated with duration (This study found that in patients with DN there was a high likelihood of muscle fatigue, and the duration of DM and glycemic control were responsible for muscle fatigue. However, there was no correlation between the severity of neuropathy and muscle fatigue. Additionally, the serum albumin level between patients with and without DN was significantly different. This is consistent with a previous study that indicated that albumin changes due to oxidative stress were a representative biomarker for DN .This study showed that CS in patients with DN was related to the duration of DM and serum creatinine level. Several studies have explained the high prevalence of neuropathy in patients as being dependent on age, glucose control, and duration of diabetes ,20. The This study quantified muscle fatigue using sEMG. MDF and MNF showed a significant decrease, but RMS was not significantly different between patients with and without DN. Muscle fatigue is a subjective symptom, which is defined as a decrease in objective performance, as well as a decreased maximum capacity to provoke force or power output, as measured by sEMG ,10. MuscTo the best of our knowledge, this is the first study to demonstrate that muscle fatigue, NCS, and parameters of DM are correlated in patients with DN. DN was associated with the duration of DM. Moreover, muscle fatigue and CS in DN patients were greater in those with a longer duration of DM, but CS was not directly related to muscle fatigue.There were some limitations in this study. Firstly, this study was a preliminary study, and a large-scale study is required to confirm the results. Secondly, as muscle atrophy in patients with DM contributes to protein degradation in the muscle and induces fatigue, a further study of the relationship between fatigue and muscle atrophy is required . ThirdlyWe investigated whether type 2 diabetic patients with or without neuropathy experienced muscle fatigue and determined the most influencing factor on muscle fatigue. In conclusion, we suggest that fatigue in patients with DN is related to the duration of DM and glucose control, and that sEMG is a useful tool to diagnose fatigue in patients with DN.