Acute pancreatitis (AP) is a sudden inflammatory process in the pancreas with variable involvement of nearby organs or other organ systems, and it is a common cause for hospitalization of gastrointestinal origin. Early prediction of the prognosis of patients with AP is important to help physicians triage the patients and decrease mortality. Red cell distribution width (RDW) and total serum calcium (TSC) have been reported to be useful predictors of the severity of AP, but if these parameters are associated with the prognosis of AP is unknown. The objective of the study was to evaluate whether RDW/TSC can be used to predict the prognosis of patients with AP at an early stage.  We retrospectively enrolled AP patients admitted to the emergency department of West China Hospital of Sichuan University from January 1, 2016, to June 30, 2016. According to the prognosis, AP patients were divided into ICU group and non-ICU group, surgery group and nonsurgery group, and hospital survival group and hospital death group. Demographic information and clinical and laboratory parameters of all enrolled patients after being admitted to ED were compared between the groups. The receiver operator characteristic (ROC) curves were used to evaluate the prognostic values of RDW, TSC, and RDW/TSC in patients with AP.  A total of 666 AP patients were enrolled in this study, with an average age of 47.99 ± 14.11 years, including 633 patients who survived to discharge and 33 patients who died during hospitalization. The areas under the curve (AUC) of RDW and RDW/TSC predict that patients need to be admitted to ICU (0.773 vs. 0.824 vs. 0.723), patients need surgery treatment (0.744 vs. 0.768 vs. 0.690), and patients survived to hospital discharge (0.809 vs. 0.855 vs. 0.780) were greater than that of TSC, with RDW/TSC being the greatest.  RDW/TSC may be a new method to identify the AP patients who need to be transferred to the ICU, accompanying complications which need surgery treatment, or may be died in hospital at an early stage, and we should pay more attention to RDW/TSC in patients with AP, for they may have a worse prognosis. Acute pancreatitis (AP) is one of the leading causes of hospitalization among gastrointestinal diseases worldwide . PancreaCurrently, there are many scoring systems and biomarkers used to predict the prognosis of AP, such as the Ranson criteria , Acute PRed cell distribution width (RDW) is a routine parameter of the complete blood count test, described as simple, easy, inexpensive, and quantitative that measures the size heterogeneity of peripheral red blood cell (RBC) –17. StudAdult patients diagnosed with AP admitted to the emergency department of West China Hospital of Sichuan University from January 1, 2016, to June 30, 2016, were enrolled. AP was diagnosed and stratified according to the 2012 Atlanta classification criteria [Demographic information and clinical and laboratory parameters of all enrolled patients after admission to the emergency department were collected. Patients with AP were followed up, and the rate of admission to ICU and rate of complications which require surgical treatments and hospital mortality were recorded. The data recording was supervised by the medical team leader, and the data were double-checked to ensure the accuracy. Wrong telephone numbers, three unanswered calls at different times, or not being amenable to follow-up was defined as lost to follow-up. The retrospective cohort study complied with the Declaration of Helsinki and was approved by the Institutional Review Board and Medical Ethics Committee of West China Hospital . The requirement for written informed consent was waived because of the retrospective design of this study.t-tests for the normally distributed data. For skewed distributions, the data are presented as the median (interquartile range) and compared using Mann–Whitney U nonparametric test. Categorical variables were presented as frequencies (proportions) and compared using the chi-squared or Fisher's exact test as appropriate. The receiver operating characteristic (ROC) curves were used to evaluate the predictive values of RDW, total serum calcium (TSC), and RDW/TSC for the prognosis of patients with AP. The area under the curve (AUC) >0.75 was defined as a good predictive value. Statistical significance was considered when the P value < 0.05.All analyses were performed using the SPSS statistical software version 26.0 . Continuous variables were presented as the mean ± standard deviation and compared using independent-sample A total of 666 AP patients were enrolled in this study, with an average age of 47.99 ± 14.11 years, including 431 males (64.7%), and 518 patients with MAP, and 148 patients with MSAP or SAP. Baseline characteristics and clinical features of the two group patients are shown in The RDW, TSC, and RDW/TSC of patients with poorer prognosis who need be admitted to ICU, surgery, or died in hospital were higher than that of patients with better prognosis who need not be admitted to ICU, surgery, or survived to hospital, respectively .n = 66) and non-ICU group (n = 600), according to whether the patient was admitted to ICU. The AUCs of RDW, TSC, and RDE/TSC for predicting admission to ICU were 0.723, 0.773, and 0.824, respectively (n = 49) and nonsurgery group (n = 617). The AUCs of RDW, TSC, and RDW/TSC for predicting the complications which need surgery treatment were 0.744, 0.690, and 0.768, respectively (n = 633) and nonsurviving group (n = 33), according to whether the patient survived or died. The AUC of RDW, TSC, and RDE/TSC for predicting hospital mortality were 0.780, 0.809, and 0.855, respectively  is critical, not only for improving clinical outcomes but also for decreasing hospitalisation cost . Over yeRed cell distribution width (RDW) is a routine parameter of the complete blood count test, described as simple, easy, inexpensive, and quantitative that measures the size heterogeneity of peripheral red blood cell (RBC) –17. ManyDifference from other studies on the relationship between RDW and AP, we added serum calcium to evaluate the severity of acute pancreatitis. Studies have shown that hypocalcemia could be a poor prognostic indicator in acute pancreatitis. Currently, the development of hypocalcemia has been included in the prognostic scoring system for AP . DisturbHowever, our study also has several limitations: First, it was a retrospective study in which selection bias potentially existed, and some details regarding clinical or laboratory information might not have been well documented. Second, as a retrospective study, we did not study the changes in these biomarkers at different time points, which may be more predictive for prognosis were deficient. In addition, it was based on a single-center design in our hospital, and it may have some sources of bias and confusion. For a more robust conclusion and to define a precise cut-off value of RDW/TSC, we recommend further multicenter prospective trials with a larger sample size.In conclusion, RDW/TSC may be an easily obtained, inexpensive, and useful indicator which can be used to identify the AP patients who need to be transferred to the ICU, accompanying complications which need surgery treatment, or may be died in hospital at an early stage and we should pay more attention to the patient with AP who has an increased RDW/TSC, for they may have a worse prognosis. However, more multicenter prospective studies with a larger sample size are warranted to validate our results.


Co-existence of iron deficiency and obesity in adults has been reported in many countries. However, little is known on the association between obesity and iron deficiency in Qatar. This study aimed to investigate the link between abdominal obesity indices and iron status among adults in Qatar. A random sample of 1000 healthy Qatari adults, aged 20–50 years, was obtained from Qatar Biobank study. Body weight, waist circumference, dual x-ray absorptiometry (DXA) parameters and iron status indicators were measured using standard techniques. Multiple regression analysis was used to examine the associations. The prevalence of iron deficiency and anaemia were 35.4 and 25%, respectively. Of the participants with a large waist circumference, 31.7% had anaemia. Ferritin significantly increased with the increase in the android fat to gynoid fat ratio and visceral fat in both genders. Serum iron and transferring saturation decreased significantly with the increase in waist circumference in women. In both genders, C-reactive protein increased with the increase in all obesity indices. Standardized values of waist circumference, android fat, gynoid fat ratio and visceral fat were significantly associated with log transformed ferritin in men and women. Waist circumference was inversely related to serum iron  and transferrin saturation  in women. In men, waist circumference was positively associated with haemoglobin level . Central obesity coexists with anaemia among the study population. Elevated central obesity indices were associated with an increase in ferritin concentration. The increased ferritin concentration may be attributed to the increase in inflammatory status as a result of an increase in c-reactive protein concentration associated with central obesity. Obesity and iron deficiency (ID) continue to be a worldwide public health problem . In QataObesity is known as an accumulation of fat in the adipose tissue . Most of the studies that were conducted to elucidate the relationship between obesity and ID used body mass index (BMI) as an indicator of obesity. However, BMI is not considered to be a direct measure of adiposity. The effect of fat distribution, especially in CO, on iron status remains controversial –23. It iThis study is a population-based, cross-sectional survey of adults aged 20–50 years who are either Qatari or long-term residents of Qatar (≥15 years). This study was conducted within the framework of Qatar Biobank (QBB). It is the first national, Qatar, population-based prospective cohort study that includes the collection of biological samples with long-term storage of data and samples for future research . In thisThe study was approved by the Institutional Review Board of QBB (EX-2018-RES-ACC-0118-0060) and was carried out in accordance with the Declaration of Helsinki, as revised in 2008. An informed written consent form was signed by each participant.2 and obesity (OB) as BMI ≥ 30 kg/m2 [Trained staff in QBB clinics measured the anthropometric indicators using standard methods. Body weight (kg) and height (cm) were measured with a calibrated scale and a wall-mounted stadiometer, respectively, in patients wearing light clothing and no shoes. Waist circumference (WC) was determined at the midpoint between the last rib and the top of the iliac crest using a stretch-resistant tape. Overall adiposity, total body fat (TBF), VF and regional fat distribution  were measured using Lunar iDXA . DXA-derived parameters were used to calculate the AF/GF ratio. CO was defined as WC ≥ 102 cm for men and WC ≥ 88 cm for women. OW was defined as BMI = 25–29.9 kg/m30 kg/m2 . Blood p3+ ions are reduced to Fe2+ions by ascorbate. Ferrous ions (Fe2+) form a coloured complex with Ferrozine. The color intensity is proportional to the iron concentration in the sample. The iron concentration was determined using the Cobas C701 module . Ferritin was determined by electrochemiluminescence immunoassay (ECLIA), based on the sandwich principle using the Reagent . The combination of ten μL of the sample with a biotinylated monoclonal ferritin-specific antibody, and a monoclonal ferritin- specific antibody labeled with a ruthenium complex- forms a sandwich complex. After the addition of streptavidin-coated microparticles, the complex becomes bound to the solid phase via the interaction of biotin and streptavidin. The reaction mixture is aspirated into the measuring cell, where the microparticles are magnetically captured onto the surface of the electrode. Unbound substances are then removed with ProCell/ProCell M. Application of a voltage to the electrode then induces chemiluminescent emission, measured by the Cobas 8000–1 modular platform . Transferrin was analysed by an immunoturbidimetric assay . This procedure measures the increasing turbidity caused by the precipitate formed by adding a specific antibody to transferrin. The transferrin concentration was measured as a function of turbidity using the Cobas 8000 module . Total iron-binding capacity (TIBC) was assessed using the unsaturated iron-binding capacity (UIBC) method . Excess of ferrous iron was added to the sample to saturate the transferrin. The remaining unbound iron ferrous ions were determined by the FerroZine method. The color intensity is directly proportional to the unbound excess iron concentration and indirectly to the unsaturated iron binding capacity. It was determined by measuring the increase in the absorbance using the Cobas 710 . TIBC represents the sum of iron serum and UIBC (TIBC = Iron serum + UIBC). The percentage of TS (%TS) was calculated by the formula %TS = serum iron ÷ TIBC. The Hb was assessed by cyanide-free sodium lauryl sulphate (SLS) method . The reagent lyses red blood cells and white blood cells in the sample. The chemical reaction begins by altering the globin and then oxidizing the haeme group. SLS’ hydrophilic groups can bind to the haeme group and form a stable, colored complex (SLS-Hb), and the concentration was measured using Sysmex XN Series (XN3100 and XN1000) .Fasting blood samples were immediately collected from participants at the time of their visit. Blood samples were collected by a registered nurse at a QBB clinic. All biochemical assays were performed at the Medical Central laboratory of Hamad General Hospital in Doha, Qatar. Serum iron concentration was measured using the ferrozine method without deproteinization according to the manufacturer’s protocol provided with the Reagent . In a weak acid buffer, iron is dissociated from the transferrin-iron complex. The released FeThe education level, age, smoking status and physical activity of the participants were obtained using a self-administered health and lifestyle questionnaire. Education was divided into three levels namely low education (up to secondary school), medium education  and high education (university and above). Physical activity levels, expressed as metabolic equivalents (METs) in hours per week, were calculated based on the frequency and duration of the different types of physical activity. Only physical activity that was done during the patients’ leisure time was considered as physical activity in the calculation. Participants were divided in subgroups (tertiles) based on their METs. Participants were divided into groups based on their smoking status. These groups were current smokers, those with a history of smoking (ex-smokers) and non-smokers. Face-to-face interviews were done by a professional nurse to collect information on the patients’ health status, family history of disease and current medications.2) were used to compare body adiposity and iron status parameters by gender, obesity indicators . WC, VF and AF/GF ratio were converted to a z-score. Serum ferritin was logarithmically transformed. Multiple regression was performed to assess the association between the independent factors, zWC, zAF/GF ratio and z-VF, and iron status indicators, log ferritin, Hb, iron, TS and TIBC. Values were adjusted for age, education level, smoking and leisure-time physical activity . Anaemia was defined as Hb < 12 g/100 ml for women and Hb < 13 g/100 ml for men. ID was defined as serum ferritin <15 μg/L [Data were analysed using Stata 15.1. Results were presented as mean and standard deviations (SD) for continuous variables and percentages for categorical variables, to summarise the characteristics of the study population. The t test and chi-square test , anaemia (25%) and ID 35%) in the study population, with significant differences between the genders (34.9% in women and 3.4% in men). Similar results have been reported in KSA, Egypt and Tunisia with 40, 38.1 and 47.2% of women being anaemic, respectively , 33, 34.% in the This study revealed a high prevalence of ID and anaemia in adults with CO. The incidence of anaemia and ID were higher in women than in men. The incidence of anaemia in women with CO was higher in Qatar than in Tunisia and Morocco. Gartner et al. reported that 18.3 and 30.1% of women with a large WC had ID in Tunisia and Morocco, respectively. The same study also indicated the co-existence of anaemia and CO in women, 27.2% in Tunisia and 10.1% in Morocco . It has Most studies have explored the relationship between iron status and obesity, determined by BMI, while limited studies have been done on the relationship between ID and anaemia using other obesity indicators such as WC, body fat and fat distribution. The results of this study indicated a significant decrease in iron and TS with an increase in WC in women, but not in men. This supports the results reported by Jordaan et al. who showed a significant increase in TS in women as WC increases . In contHowever, Shim et al. reported a significant increase in ferritin, in both men and women, as WC increased . Aderibird tertile of VS had a higher level of ferritin when compared with those in the lowest tertile. This is consistent with the study of Iwasaski et al., who found a significant positive correlation between ferritin and VS  [Recent studies have elucidated the relationship between fat distribution and iron status indicators , 49–52.  0.0001) . In contThe results of linear regression showed slight differences between the genders. In women, serum iron and TS were inversely associated with zWC, while in men, zWC was only positively associated with Hb. There was no gender–zWC interaction in relation to Hb. Log ferritin was positively related to all obesity indices  in both genders. In contrast to our study, Choma et al. showed a positive relationship between WC and ferritin only in women. They also reported a positive and a negative relationship between WC and Hb for women and men, respectively . In lineDifferent mechanisms have been proposed to elucidate the relationship between obesity and ID, including an iron-poor diet and an increased iron requirement due to an increase in blood volume, body fat and low-grade inflammation . Recent This study has some limitations. First, in this study, we recognise the lack of sensitive inflammatory biomarker measures, which would have been useful in characterising the relationship between obesity and iron status. We used CRP as an indicator of possible inflammation. This study did not assess thalassaemia, a common disease in the region. Another limitation is due to the cross-sectional design of the study and therefore, no conclusions regarding the relationship between obesity and iron status could be drawn. The strengths of the study include the sample size, the body composition parameters gathered using DXA and the iron status variables.Central obesity coexists with anaemia among the study population. Waist circumference was inversely related to serum iron and transferrin saturation in women. Elevated central obesity indices were associated with an increase in ferritin concentration. The increase in the ferritin concentration may be attributed to the high inflammatory status, reflected by an increase in CRP concentration with CO.S1 Checklist(DOC)Click here for additional data file.


Night shift workers might not eat due to their busy schedules during the night shift. However, food may not only satisfy hunger, but also affect performance and errors. The aim of this study was to clarify the effect of a snack on performance and errors during 2-day, 16-h, simulated night shifts.A randomized, repeated-measure, crossover study was performed to investigate subjective and cognitive performance in 15 healthy female adults  after they consumed a snack  during a simulated night shift (16:00 to 09:00) from October to November 2018. The participants were kept awake from waking up in the morning to the next day at 09:00. Subjects were tested for performance on the Uchida-Kraepelin test, as well as for subjective feeling, body temperature, psychomotor vigilance test, and heart rate variability, before and after they consumed the snack. One day before the experiment, all participants wore an actigraphy monitoring device to determine their sleep state.There was no difference between having (Snack condition) and not having (Skipping condition) the snack in sleep states the day before the experiment. On the day of the experiment, between 16:00 and 09:00, subjective sleepiness, fatigue, and body temperature were not different between the two conditions. Subjects maintained performance on the Uchida-Kraepelin test and showed a significant improvement in false starts on the psychomotor vigilance test, the primary outcome measure, in the Snack condition compared with the Skipping condition. The Snack condition was also associated with decreased high-frequency power, a decreased low-frequency power/high-frequency power ratio, and increased heart rate in the vagally mediated heart rate variability indices, which may reflect a higher ability to modulate cognitive and behavioral processes.These results suggest that providing a snack to shift workers during night shifts might improve work safety and efficiency. As Japan is increasingly becoming a 24-h society , rotatinThe activities of many organisms on earth have a circadian rhythm with a cycle of about 24 h, the same as the rotation of earth. In addition, the activities of the endocrine system and nervous system are synchronized with activity during the day and the rhythm of rest and sleep at night . The souIn addition, regarding dietary patterns during night shifts, avoiding eating altogether has been investigated as a strategy to maintain alertness . A previTherefore, this study aimed to investigate the impact of eating (the Snack condition) compared with not eating (the Skipping condition) at night on performance, sleepiness, fatigue, and other physiological measures during 16-h simulated night shifts. We hypothesized that, under the conditions of extended wakefulness during the “biological night,” eating a snack would lead to decreased errors and maintain performance until the morning. To test this hypothesis, sleepiness, hunger, vigilant attention, cognitive processing, and other physiological measures were assessed under both Snack and Skipping conditions during consecutive, 2-day, 16-h, simulated shifts throughout the night.2) recruited between October and November 2018. None of the subjects had any previous night shift experience, and none was identified as morning type or evening type according to the morningness–eveningness questionnaire [The participants in this randomized, crossover study were 15 healthy adult females  at 19:30 (not eating at night), and under the Snack condition only, participants ate a snack at 03:30 (eating at night). The meal provided at 03:30 consisted of two rice balls  and two slices of yellow pickled radish. Many night shift workers prefer a high-energy diet rich in carbohydrates [The protocol and experimental schedule of this study are shown in On the day of the experiment, all participants arrived at the laboratory at 15:00. Until 16:00, they carried out practice assessments, including the Uchida-Kraepelin test (UKT) and the psychomotor vigilance test (PVT). The Snack condition involved consuming a meal and a snack at 19:30 and 03:30, respectively, whereas the Skipping condition involved consuming a meal at 19:30 only. At the start of each experiment, the participants were fitted with a heart rate variability (HRV) sensor . For each hour throughout the experiment, they were given 10 min to record their sublingual temperature once and complete the visual analog scale for sleepiness, fatigue, and hunger, 10 min to perform the UKT, and 10 min to measure the PVT. The next 20 min were considered free time, and the remaining 10 min were considered a rest period. The participants spent their free time reading, drawing, or drinking water. During the 10-min rest period, they sat on chairs and chatted with the other participants. The same meal amounts and contents were given to the participants between 19:30 and 19:50 in each experimental period. The HRV sensor was removed at the end of each experiment, but the participants were asked to continue wearing the actigraphy monitoring device until they woke up the next day. During all waking times, the participants remained awake in the laboratory and were continuously monitored by the researchers.All participants stayed in a windowless and sound-insulated laboratory for 2 consecutive days (1 night). The laboratory environment was maintained at 26 ± 2°C  and 50% The sleep parameters measured were total sleep time, sleep efficiency , sleep onset latency, and wake after sleep onset. All parameters were measured using the actigraphy monitoring device, and they were analyzed using the AW2 software package (Ambulatory Monitoring Inc.).The circadian rhythm of body temperature is one of the most frequently used indicators of circadian rhythmicity , and bodA visual analog scale was used for the subjective assessment of sleepiness, fatigue, and hunger . The parThe UKT , a serial mental arithmetic task, was used to measure cognitive performance. This test is a questionnaire that requires intense concentration and effort, and it has been used as a tool to induce mental stress . The tesThe PVT is a reaction time task considered to be a sensitive measure for assessing the effects of sleep loss . In thisFor the purposes of the present study, HRV was obtained through autoregressive analysis of R–R intervals measured between 16:00 and 09:00. All data were analyzed offline after analog-to-digital conversion of 250-Hz R–R waves. HRV was measured every 5 min during each hour and then averaged; these measurements were used to monitor autonomic nervous system activity throughout the night . High-frt-test.All results are shown as means ± SD or standard error of the mean. All sleep variables measured the day before the experiment were analyzed using the To test the effects of consuming a snack on neurobehavioral and physiological outcomes during the early morning measurement periods, a fully saturated, linear mixed-effects analysis of variance was carried out , with a To assess the postprandial effect of the meal throughout the testing time, the net incremental area under the curve (niAUC), calculated from pre- (at 03:00) and postprandial time points, was tested.Correlations were used to assess the relationships of performance with temperature and autonomic nervous system activity. The performance outcome measure used in the analysis was the change from after eating (04:00 to 09:00). The performance variables of interest were PVT and UKT.p < .05, and a notable trend was set at p < .1.All statistical analyses were conducted using SPSS . The hypothesis rejection level for all tests was set at This study was approved by the Center for Integrated Medical Research of Hiroshima University  and the University Hospital Medical Information Network (UMIN)-Clinical Trials Registry (CTR) in the Japan Primary Registries Network (JPRN) registry . Written, informed consent was obtained from all participants before the first examination. The study protocol conformed to the Declaration of Helsinki guidelines. The authors confirm that all ongoing and related trials for this intervention have been registered.Total sleep time, sleep efficiency, sleep onset latency, go to bed time, and wake up time, assessed by the ActiGraph, were not different between phases See .Outcomes regarding the participants’ physiological parameters, cognitive performance, and autonomic nervous system activity from 16:00 to 09:00 are shown in Figs The interaction between condition and time of measure was not significant for sleepiness and fatigue, such that sleepiness and fatigue increased in the two conditions from 03:00 to 09:00; a similar trend was seen across the night to early morning  from 04:00 to 09:00. In The interaction between eating condition and time of measurement was significant for hunger (p < .001).The results of the correct answers and the rate of errors on the UKT are shown in p = .037); false starts were significantly fewer under the Snack condition than under the Skipping condition  and their interaction were observed (p = .029). Under the Snack condition, heart rate increased significantly at 04:00 (p = .028), 05:00 (p = .046), and 06:00 (p = .028) compared with the Skipping condition, and showed an increasing tendency at 07:00 (p = .078).Electrocardiogram data could not be obtained from one participant during the experiment; therefore, data were analyzed for 14 participants. p = .001). In addition, there was a significant main effect of time (p = .007), and a marginally significant condition * time interaction (p = .081) was seen for the low-frequency/high-frequency ratio (p = .041), 04:00 (p = .038), 06:00 (p < .001), 07:00 (p < .001), and 08:00 (p < .001) after eating than at 02:00 before eating.A significant main effect of condition was observed for high-frequency power , which tcy ratio . In the p < .001), higher HR , and less HF  ( < .001) .The present study investigated the effects of nighttime eating during night shifts on temperature, subjective sleepiness, fatigue, hunger, vigilant attention, processing speed, and autonomic nervous system activity during testing between 16:00 and 09:00. Increasing perceptions of hunger across night shifts have been reported by shift workers, who have described hunger as a factor that influences their decision to eat during the night shift . In the Regardless of the Snack condition, the greatest impairments in subjective sleepiness and fatigue, vigilant attention, and performance increased toward morning. This could explain the increases in circadian sleep pressure and decreased alertness throughout the night . ConsistAccording to recent reviews, eating breakfast may result in acute improvements of memory, attention, and motor and executive function, although no conclusion about the effect of macronutrients on cognitive function has been reached . The preGiven recent studies highlighting the potential metabolic consequences of consuming a large nighttime meal , 43, a sThese findings indicate that the subjects who ate a small meal felt less hungry for 5 h , and that those who did not eat at night perceived greater hunger toward morning. Although these findings may predominantly reflect a longer inter-meal interval, hunger is known to display a circadian rhythm and be increased during the night. Restricted sleep also increases hunger and appetite, and it results in a preference for a high-energy diet rich in carbohydrates . Night wIn the present study, the heart rate was significantly higher under the Snack condition than under the Skipping condition from 04:00 to 06:00. When eating a meal, visceral circulating blood volume increases to support the process of digestion and absorption, the sympathetic nervous system supports it, and the heart rate increases . The conIn the case of long night shifts, the time for taking meals is restricted, and it is difficult to eat freely. We recommend a small snack to maintain performance and stop the increase in errors regardless of time. Rice balls, which can be easily eaten even when busy, may be one of the options for meals during night shifts.This study has several limitations. First, it was conducted under laboratory conditions; therefore, the degree of change in performance and sleepiness could vary from that under actual working conditions, depending greatly on differences in workload due to the nature of the work or the timing of busy work periods. To confirm effective measures for reducing sleepiness and fatigue tailored to the conditions of specific professions and workplaces, intervention studies need to be conducted in actual workplaces. It is possible that the present results would be different if actual shift workers had been studied; therefore, caution is needed when interpreting the results. Second, the data were obtained under the condition that everyone was served the same meal at the same time, and that meals were standardized and not designed for each individual. It is plausible that variability in meal timing  could be triggering the misalignment between peripheral and central clocks . Third, A previous study reported that taking a nap during a night shift helped nurses recover from night shift fatigue . TherefoThis study investigated the effects of eating a meal at night during night shifts on subjective sleepiness, vigilant attention, processing speed, hunger, and autonomic nervous system activity between 16:00 and 09:00. The results showed that consuming a small meal  at 03:30 during the night shift reduced hunger and helped sustain performance until morning. To the best of our knowledge, this is the first study to explore the effects of consuming a small meal at night on 16-h performance in a controlled laboratory environment.S1 Checklist(PDF)Click here for additional data file.S1 Protocolhttps://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000039151.(PDF)Click here for additional data file.S1 Appendix(CSV)Click here for additional data file.


The preoperative LN (lymph node) status of patients with LUAD (lung adenocarcinoma) is a key factor for determining if systemic nodal dissection is required, which is usually confirmed after surgery. This study aimed to develop and validate a nomogram for preoperative prediction of LN metastasis in LUAD based on a radiomics signature and deep learning signature.This retrospective study included a training cohort of 200 patients, an internal validation cohort of 40 patients, and an external validation cohort of 60 patients. Radiomics features were extracted from conventional CT (computed tomography) images. T-test and Extra-trees were performed for feature selection, and the selected features were combined using logistic regression to build the radiomics signature. The features and weights of the last fully connected layer of a CNN  were combined to obtain a deep learning signature. By incorporating clinical risk factors, the prediction model was developed using a multivariable logistic regression analysis, based on which the nomogram was developed. The calibration, discrimination and clinical values of the nomogram were evaluated.P=0.193) capabilities for the training cohort. Additionally, the model achieved satisfactory discrimination  and calibration  when applied to the external validation cohort. An analysis of the decision curve showed that the nomogram had potential for clinical application.Multivariate logistic regression analysis showed that the radiomics signature, deep learning signature, and CT-reported LN status were independent predictors. The prediction model developed by all the independent predictors showed good discrimination  and calibration (Hosmer-Lemeshow test, This study presents a prediction model based on radiomics signature, deep learning signature, and CT-reported LN status that can be used to predict preoperative LN metastasis in patients with LUAD. Lung cancer is the most common cancer worldwide and the leading cause of cancer-related death . NSCLC , 3. StudImaging methods, such as CT and PET (positron emission tomography), are commonly used in clinical LN diagnosis. CT can diagnose lymph nodes based on their size, but it cannot detect small LN metastasis. In PET imaging, LN metastasis usually shows increased FDG (Fludeoxyglucose) uptake, but inflammation and infection can also contribute to this. Compared with imaging methods, imaging-guided biopsy has better sensitivity and specificity in identifying LN metastasis, but it may lead to complications such as pneumothorax and bleeding –10. In rTherefore, the purpose of this study is to develop and validate the effectiveness of a nomogram  with a rWe retrospectively collected the data of 300 patients with LUAD from the Liaoning Cancer Hospital over the period of April 2015 to July 2019. We randomly divided 300 patients into the training cohort, internal validation cohort, and external validation cohort in equal proportions. In total, the training cohort included 200 patients: 99 males and 101 females; mean age, 63.21 ± 6.82. Internal validation cohort included 40 patients . External validation cohort included 60 patients . The baseline clinicopathological data included age, sex, CT-reported LN status, and CEA (carcinoembryonic antigen). However, owing to the lack of CEA data in more than half of the patients, CEA was abandoned. The inclusion and exclusion criteria of the data were as follows. Inclusion criteria: (a) the LN status was confirmed by operation and pathology reports, (b) the focus was single nodal mass type, (c) the time interval between CT scan and operation was no more than 1 month, (d) the slice thickness of CT plain scan image was 5 mm. Exclusion criteria: (a) preoperative radiotherapy or chemotherapy, (b) central lesions in the lung, (c) atelectasis and consolidation, (d) history of other tumors. The workflow of the study is illustrated in Before CT scanning, foreign metal bodies were removed from the upper body of the patient to avoid the problem of artifacts. The patient was asked to raise his/her arms across the top of his/her head in the supine position and remain fixated in this position. The scanning was performed from the entrance of the chest to the diaphragm, when both the body and mind of the patient were in a relaxed state. The scanning machine used was Philips iCT 256 (Netherlands), and it had the following parameters: tube voltage of 120 kVp; 3D tube current in the range 110–325 mAs; layer thickness of 5.0 mm; acquisition matrix of 512 × 512; and, the FOV (field of view) was affected by the body fat and adjusted for thickness. The CT-reported LN status was determined by the radiologists based on the clinical radiological report of the preoperative CT. The presence of either regional LN of >1 cm and/or clusters of ≥3 lymph nodes was scored as LN-positive, and otherwise as LN-negative. The ROI (region of interest) was delineated by the radiologist according to the maximum cross-sectional area of the tumor boundary. CEA was obtained by a routine blood test and laboratory analysis within one week before operation. A CEA <5 ng/mL was recorded as normal, and otherwise as abnormal.For determining the differences in the distribution of variables between cohorts, we used Kruskal-Wallis rank sum test to analyze the continuous variables  and chi-square test to analyze the discrete variables . Furthermore, for determining the correlation between variables and LN status within the cohort, we used Wilcoxon rank sum test to analyze the continuous variables and chi-square test or Fisher exact test to analyze the discrete variables. All the statistical tests in the study were two-sided with a significance level of 0.05.P <0.05, and Extra-trees was used to further select features with rich information from the training cohort. Then, logistic regression . Furthermore, there was no significant difference observed with regard to gender among all the cohorts (P= 0.763), as was the case with the CT-reported LN status (P= 0.475) and age (P= 0.551). This indicated that the division of data was effective. Radiomics signature (P= 0.996) and deep learning signature (P= 0.869) also showed good reproducibility in all the cohorts  with good statistical significance. Next, Extra-trees was used to further select 8 features with rich information. The first eight features were selected because the eighth feature was a breakpoint, in other words, the value of the eighth feature was significantly different from that of the ninth feature. After the ninth feature, the importance of the features changed slightly , indicating no deviation from the perfect fit. The nomogram also showed good agreement in the internal (P= 0.468) as well as the external (P= 0.824) validation cohorts. Furthermore, it showed good discrimination capability for all the cohorts, and the C-index of nomogram in the training cohort, internal validation cohort and external validation cohort was 0.820 , 0.830  and 0.861  respectively.The calibration curve Figure 5P= 0.022; NRI , 0.033 and NRI (Continuous), 0.667), only deep learning signature , 0.133 and NRI (Continuous), 1.133), and only CT-reported LN status , 0.267 and NRI (Continuous), 1.067). The NRI results of an additional 5-fold cross-validation also showed that the multi-factor model was significantly improved compared to the single-factor model  was reduced to 528 using the T-test, and then 8 features with rich information were selected using Extra-trees. Extra-trees is an ensemble learning method, which is composed of multiple decision tree. Extra-trees reduces the risk of overfitting a single model. Therefore, the features selected by Extra-trees are robust. Then, we used logistic regression to combine features to obtain the radiomics signature.Considering that deep learning achieves better results than traditional machine learning methods in ImageNet large-scale Visual recognition Challenge, this study also used deep learning method. The difference between radiomics method and deep learning method is that the extracted features are different. The features extracted by the deep learning method are automatically learned by the model from the data, while the features extracted by the radiomics method are artificially defined. These two approaches have their own advantages and disadvantages. For the deep learning method, if the amount of data is large enough, the features it learns can explain the data well, but when the amount of data is small, the features it learns can’t explain the data well. For the radiomics method, the features extracted by it are not affected by the amount of data, but by artificial experience. Limited artificial experience makes it difficult for radiomics method to achieve very good diagnostic results. The combination of radiomics features and deep learning features can integrate the advantages of both. Therefore, in this study, both deep learning features and radiomics features were used to predict LN metastasis of lung adenocarcinoma. However, different from some studies, we didn’t directly output thousands of features of the last fully connected layer, but combined the features with its weights and biases to get a deep learning signature , 31. ThiBecause the amount of data is relatively small, this study used data augmentation technology and transfer learning technology in deep learning. Data augmentation technology expanded the amount of data. Transfer learning technology made the training of VGG-16 easier. Specifically, we took the pretraining weights of VGG-16 on ImageNet as the initial weights of the model, and then used our data to fine-tune the model.Multivariate logistic regression analysis showed that radiomics signature, deep learning signature and CT-reported LN status were independent and effective predictors. The c-index of the nomogram constructed with these three features in the training cohort, the internal validation cohort and the external validation cohort was respectively 0.820 , 0.830 , 0.861 , which was better than any single-factor model. The results of NRI showed that nomogram was significantly improved compared with the single-factor model.The limitations of this study mainly include the following: (a) No enough clinical information. Smoking history and CEA have been proved to be effective predictors of LN metastasis , 15; (b)In summary, this study proposes a nomogram based on radiomics signature, deep learning signature, and CT-reported LN status that can be conveniently used to predict preoperative LN metastasis in patients with LUAD.The data analyzed in this study is subject to the following licenses/restrictions: The datasets are privately owned by Liaoning Cancer Hospital and are not made public. Requests to access these datasets should be directed to DZ, zhaodan777@126.com.The studies involving human participants were reviewed and approved by Medical Ethics Committee of Cancer Hospital of Liaoning Province, China. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.JR, RC, JC, DZ, and ZW conceived and designed the concept. JC, TY, and DZ collected the data. JR and RC analyzed the data. All authors contributed to the article and approved the submitted version.This study was supported by the National Key Research and Development Program of China (Nos. 2017YFC1309100), and the Science and Technology Program of Liaoning Province (No. 2018225038).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.


Blastocystis sp. in Brazilian studies over a period of years (2000-2020), as well as point out relevant aspects of this enigmatic organism.The present study aimed to evaluate the occurrence of We performed a literature search using six sources of international databases. The data were divided into diagnostic by parasitological and molecular techniques, and relevant aspects. After applying the inclusion and exclusion criteria, 52 studies were included in the final analysis.Blastocystis sp. in Brazil ranged from 0.5% to 86.6%, as determined using parasitological techniques. The highest occurrence was in the North (27.3%) and the lowest, in the Midwest region (13.4%). In Brazil, most studies have employed molecular techniques and are concentrated in the Southeast region. The Blastocystis sp. subtype ST3 had the highest average positivity, followed by ST1 and ST2.The occurrence of Blastocystis sp. Additionally, we emphasize the importance of further studies in the context of molecular epidemiology with regard to this genus. Blastocystis sp. is not well understood yet, and very little information regarding this genus is available; hence, further research regarding this genus is urgently needed. These findings represent a panorama that reflects the reality of Brazil; thus, we believe that the effectiveness of parasitological diagnosis should be considered with regard to making an appropriate choice of technique for detecting  Blastocystis sp. was discovered well before its first description in the literature (Blastocystis sp. was published by Alexeieff (Blastomyces (Greek ‘kystis’: cyst)  . Even 10Blastocystis is genetically diverse, with 17 subtypes (ST1-ST17) based on polymorphic regions of its small subunit of the ribosomal RNA gene (SSU-rDNA)  . Some ofSU-rDNA) ,10. HumaSU-rDNA) . Several and ST8 -14.Blastocystis sp. was carried out by Guimarães and Sogayar (Blastocystis sp. (Blastocystis sp. in Brazilian studies over a period of 20 years (2000-2020), as well as point out some relevant aspects of this mysterious organism.In Brazil, the first specific study of  Sogayar . In thisstis sp. -19. HoweBlastocystis sp. using parasitological and molecular techniques in Brazil. We performed a literature search in six international databases: US National Library Online (PubMed), Scientific Electronic Library Online (SciELO), Web of Science, Science Direct, Scopus, and Google Scholar, in order to obtain the maximum number of relevant studies for the scope of this review. The literature search process used the keywords terms: “parasite,” “intestinal parasite,” “Blastocystis” and “Brazil,” alone or in combination with “AND.” As inclusion criteria, we used original research papers or short communications reporting the occurrence of Blastocystis sp. from Brazil published online in English and Portuguese in the last 20 years (2000-2020). Studies published before 2000, those that did not report the occurrence of Blastocystis sp., and those that were not published in English or Portuguese were excluded.We conducted a comprehensive and descriptive literature search regarding the occurrence of Blastocystis sp. in each article included in this study were extracted and recorded using Excel software . The data were divided into diagnostic by parasitological and molecular techniques, and relevant aspects. Various characteristics, including first author, year of publication, region, state, population, diagnostic method, sample size, and positivity for Blastocystis sp. in Brazil between 2000 and 2020.After applying the inclusion and exclusion criteria, 52 studies were included in the final analysis to estimate the occurrence and molecular identification of Blastocystis sp. varied between the different regions of Brazil ,-64,BlastBlastocystis sp. in Brazil ranged from 0.5% to 86.6% , as per the use of parasitological techniques  of these studies was not greater considering the average occurrence rate of this organism in Brazil. However, we can consider the best visualization of the forms, which considerably facilitates the identification of this organism. Nevertheless, recent studies  that can infect human and non-human hosts (Blastocystis subtypes carried out in Brazil was by Malheiros et al. (Molecular methods are commonly used to identify and determine the distribution of different subtypes of stis sp. . As a rean hosts ,10. We hs et al. , who anaBlastocystis subtypes in Brazil is shown in The distribution of Blastocystis sp. DNA, considering the analysis of Blastocystis SSU-rDNA. Initially, specific primers were used for each subtype (Blastocystis barcode (Blastocystis subtypes in different studies (Different primers have been described for the detection of  subtype ,77, foll barcode . Althoug barcode ,40. Harm studies .Blastocystis subtypes that had not been described in Brazil have recently been identified. In this context, we can mention that ST4, which was considered to be restricted to Europe (Blastocystis infection (With the growing number of studies, o Europe , has reco Europe ,19,40,74nfection . In addinfection ,72,75 annfection ,19 have Although molecular PCR has clearly enabled further improvements in diagnostic and epidemiological studies, its successful application depends on understanding the limitations and assumptions associated with its use . In thisBlastocystis sp. present great genetic variability, it is not known whether this can influence factors related to the host (Blastocystis sp. in patients with chronic urticaria; however, the absence of a control group compromises the conclusions drawn.Although the subtypes of the host . This vathe host ,67,73. Athe host  reportedBlastocystis-related studies with regard to its presence in the intestinal microbiota and the possible pathological implications of this phenomenon (It is important to highlight the recent approach followed in enomenon ,81. HoweBlastocystis (The fecal-oral route of transmission and its survival capacity in different organisms, such as humans and animals, likely explains the global distribution of tocystis . In additocystis .Blastocystis in natural water sources (It is common to evaluate different environmental samples with the expectation of a transmission link between intestinal parasites and the environment. In studies carried out in Brazil, the high positivity rate of  sources  and in p sources  was noteBlastocystis sp. in samples of wild and domestic animals (Another pertinent issue when considering this organism is the possibility of zoonotic transmission. Research reinforces the need for the investigation of  animals ,85. Data animals ,75,86. WBlastocystis can help improve the knowledge about the pathogenicity of its infection.An interesting point to address is the different epidemiological patterns of the colonization and/or infection of this organism. Although there is evidence that some subtypes may be related to clinical manifestations, the studies presented in Brazil are still inconclusive , mainly Blastocystis sp. exposes much uncertainty regarding its biological and pathogenic aspects. This observation reflects the reality of Brazil; thus, we believe that the effectiveness of parasitological diagnosis should be considered with regard to making an appropriate choice of technique for detecting Blastocystis sp. Thus, based on our review, we suggest the use of fresh fecal smears, followed by permanent staining, to increase the effectiveness of the results. It should be remembered that Brazil is a country with wide regional and dimensional variations, in addition to socioeconomic factors that can directly affect the positivity rate of Blastocystis.The history of research regarding Blastocystis sp. This would improve the elucidation of the biological and pathological aspects regarding this genus that remain unclear. Blastocystis sp. is an important organism, and further studies will work toward answering the many questions that studies regarding this genus have brought about so far.Additionally, we emphasize the importance of further studies in the context of molecular epidemiology, particularly in increasing knowledge about the genetic diversity of Melo GB and Paula FM contributed to the conception and design of the study. Melo GB and Bosqui LR performed the literature search. Melo GB and Paula FM wrote the manuscript. Melo GB, Paula FM, Bosqui LR, Costa IN and Gryschek RCB reviewed and approved the final version of the manuscript.


To explore the clinical implications of neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) for diagnosing frailty in patients with maintenance hemodialysis (MHD) and their correlations with patient prognosis.  A total of 185 patients with MHD admitted to the hemodialysis center of our hospital were selected, 72 of whom were diagnosed with frailty according to the Chinese version of Tilburg Frailty Indicator (TFI). The relevant data were collected, and the influencing factors of frailty in MHD patients were analyzed by one-way analysis of variance (ANOVA) and multivariate logistic regression. The value of NLR and PLR in diagnosing frailty in MHD patients was observed, and patients' all-cause mortality was compared during the 3-year follow-up. The influences of different levels of NLR and PLR on the survival of MHD patients were investigated. P < 0.05). The area under the receiver operating characteristic (ROC) curve of NLR and PLR in diagnosing frailty in MHD patients was 0.859 and 0.799, respectively. Compared with the nonfrailty group, the 3-year mortality was higher, and the 3-year survival rate assessed by survival analysis was lower in the frailty group (P < 0.05). Patients with high NLR and PLR levels showed a lower 3-year survival rate.  Multivariate regression analysis identified that serum albumin, dialysis adequacy, NLR, and PLR are independent risk factors for frailty in MHD patients ( Dialysis adequacy, serum albumin, NLR, and PLR are independently associated with frailty in MHD patients. NLR and PLR are of a certain diagnostic value for frailty in MHD patients. MHD patients with frailty have an unfavorable prognosis, as of those with high NLR and PLR levels. Currently, maintenance hemodialysis (MHD) is the most important renal replacement therapy for patients with end-stage renal disease (ESRD) . With thThe clinical data of 185 MHD patients  treated in the outpatient department of Nanjing Integrated Traditional Chinese and Western Medicine Hospital and Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine from July 2015 to October 2018 were collected for retrospective analysis. The Ethics Committee at the Nanjing Integrated Traditional Chinese and Western Medicine Hospital approved the study protocol without reserves . Inclusion criteria were as follows: meeting the diagnostic criteria of ESRD [α coefficient = 0.686) [The Chinese version of the Tilburg Frailty Indicator (TFI) (Cronbach's = 0.686) , with a The influencing factors of frailty in MHD patients were determined by one-way analysis of variance (ANOVA) and binary logistic regressionThe diagnostic value of PLR and NLR for frailty in MHD patients was observedThe 3-year mortality was observed and comparedThe effects of different levels of NLR and PLR on the survival of MHD patients were analyzedX ± SD), and the differences were analyzed by the t-test of independent samples (denoted by t). Nonnormally distributed measurement data were recorded as the median (lower and upper quartiles), and intergroup comparisons were performed by Mann–Whitney U-tests. The count data were tested by the Pearson chi-square test and expressed as χ2. Variables that differed in univariate analysis were screened, and the influencing factors of frailty in MHD patients were analyzed by multivariate binary logistic regression. After plotting the receiver operating characteristic (ROC) curves, the area under the ROC curves (AUROC) was calculated, with the values of 0.5–0.7 indicating small diagnostic utility, 0.7–0.9 indicating medium diagnostic utility, and >0.9 indicating high diagnostic utility. Patient survival was analyzed by the Kaplan–Meier method with the use of the log-rank test, and the multivariate analysis was performed using the Cox model. P values < 0.05 indicated that the differences were statistically significant.SPSS22.0 statistical software (Easy Bio (Beijing) Technology Co., Ltd., China) was used to analyze data. The normally distributed continuous variables were described as mean ± standard deviation (‾P < 0.05). In addition, there were no significant differences in sex, dialysis duration, education years, type 2 diabetes mellitus, coronary artery disease, hemoglobin, predialysis blood urea nitrogen, predialysis serum creatinine, uric acid, triglyceride, total cholesterol, high-density lipoprotein, low-density lipoprotein, blood potassium, blood calcium, blood phosphorus, body mass index, and upper arm circumference between the two groups (P > 0.05) as given in Among the 185 patients included, 72 patients had frailty, accounting for 38.92%. Patients in the frailty group were elder with higher NLR and PLR, while lower dialysis adequacy, serum albumin (SA), grip strength (GS), walking speed (WS), and midarm muscle circumference (MAMC) than the nonfrailty group , and the indicators which differed in the univariate analysis were selected for multivariate binary logistic regression analysis. It was found that dialysis adequacy, SA, NLR, and PLR were all risk factors leading to frailty in MHD patients as given in The AUROC of NLR for diagnosing frailty in MHD patients was 0.859. When the cutoff value of NLR was 2.98, its Youden index, specificity, and sensitivity were 0.666, 0.805, and 0.861, respectively. The AUROC of PLR for diagnosing frailty in MHD patients was 0.799, and when the cutoff of PLR was 118.98, its Youden index, specificity, and sensitivity were 0.642, 0.850, and 0.792, respectively, as shown in n = 84) and NLR low-expression group (n = 95). Survival analysis showed that the survival rate of the NLR high-expression group was lower than that of NLR low-expression, with a statistical difference . Similarly, the patients were assigned to high (n = 76) and low (n = 103) PLR expression groups, with the PLR diagnostic threshold of 118.98 as the dividing line. Survival analysis showed a significantly lower survival rate in patients with high PLR expression compared with those with low PLR expression , as shown in With the NLR diagnostic cutoff value of 2.98 as the dividing line, the patients were further assigned to the NLR high-expression group (P < 0.05). The survival analysis revealed that the 3-year survival rate of the frailty group was significantly lower than that of the nonfrailty group . Multivariate COX proportional risk model analysis identified that NLR was an independent risk factor affecting the prognosis of MHD patients, as given in Tables Six (1 in the frailty group and 5 in the nonfrailty group) of the 185 patients were lost to follow-up due to hospital referrals or other factors. Thirteen cases out of the 71 patients with frailty died within the 3 years of follow-up, with an incidence of 18.31%. While 9 cases among the 108 cases in the nonfrailty group died within 3 years, with an incidence of 8.33% (Frailty is a condition in which the decrease of physiological reserve and the dysfunction of multiple systems lead to the decline of the body's ability to cope with external conditions. In addition to the increase of vulnerability of the body, it can lead to an increase in the incidence of adverse events, resulting in adverse prognosis of patients . MHD patThe influencing factors of frailty in MHD patients were discussed in this study. The incidence of frailty increases with age and can reach 21.5% among the elderly in China . DialysiMicroinflammation is a common condition in patients with MHD. In this study, the diagnostic value of NLR and PLR for frailty in MHD patients was further studied. The results of ROC analysis determined that both NLR and PLR were of certain diagnostic value for frailty in MHD patients. At present, no study has explored the clinical implications of NLR and PLR for diagnosing frailty in MHD patients. Previous studies have shown a strong connection between inflammation and the occurrence and development of diseases such as sarcopenia, malnutrition, type 2 diabetes, and coronary heart disease , which mIn MHD patients with frailty, the risk of fracture, fall, hospitalization, and death increases significantly, leading to a decline in patients' quality of life and adversely affecting their prognosis . Due to With the extended life span of MHD patients, the incidence of experiencing frailty is also on the rise, which deserves more attention from the clinic. Clinical workers should pay attention to the monthly blood routine testing of MHD patients and evaluate whether the microinflammatory state in patients with elevated NLR and PLR is associated with frailty, so as to take intervention measures such as nutritional intake and dialysis adequacy as early as possible. Referring to the previous research, we began to carry out exercise combined with nutritional support intervention therapy for MHD patients with frailty, searched for exercises suitable for MHD patients such as resistance exercise and Baduanjin, and set up a special nutritional support group to evaluate the nutritional status of patients and give individualized diet intervention, all of which can reduce the microinflammatory factors in patients to a certain extent and correct the patients' frailty.The novelty of this study lies in that it not only confirmed the diagnostic and prognostic value of NLR and PLR in MHD but also proved the correlations of the two with the occurrence of frailty and the prognosis of MHD patients from multiple perspectives, such as related factors of frailty, diagnostic value in frailty, patient prognosis, and related influencing factors, which provides new clinical markers for the diagnosis and prognosis prediction of MHD patients and provides a new clinical reference for the prevention of frailty and poor prognosis in MHD patients.Shortcomings and prospects: the sample size of this study is small, which can be further expanded to observe the influence of NLR and PLR on the diagnosis and prognosis of MHD patients with frailty.To sum up, dialysis adequacy, SA, NLR, and PLR are independently associated with frailty in MHD patients. NLR and PLR are of certain clinical implications for diagnosing frailty in MHD patients. MHD patients combined with frailty are accompanied by poor prognosis, as of those with high NLR and PLR levels.


Considering that high-heeled shoes are traditionally associated with femininity, body image, beauty, and charm, this research has important biopsychosocial implications that should be explored in detail in future studies.High-heeled shoes adversely affect spinal curvature, increase the risk of low back pain, and disturb the normal gait pattern. The purpose of this study was to examine, from a biopsychosocial point of view, the combined effect of wearing two different heel heights and of hormonal oscillation throughout different phases of the menstrual cycle on spinopelvic alignment. Notably, 70 females with an average age of 20.42 ± 1.51 years participated in this study, wearing each female two different heel heights as follows: low (2.5 cm) and high (7 cm). Spinopelvic alignment was evaluated by rasterstereography formetric 3D analysis during early follicular, ovulatory, and mid-luteal phases of the menstrual cycle. Statistical analysis showed that there was no significant difference ( High heels adversely affect the kinematics and kinetics of body structures from toes to the spine . FrequenThe menstrual cycle is characterized by oscillations of sex hormones, mainly estradiol and progesterone, in fertile females . CirculaAlthough several studies examined the effect of high heels on posture and gait , definitFor this reason, this study aimed to explore, from a biopsychosocial point of view, the combined effect of two different heel heights and hormonal oscillation throughout different menstrual cycle phases , in young adult women, on thoracic kyphosis, TI, and pelvic inclination. We hypothesized that spinopelvic alignment would be affected by the combined effect of wearing different heel heights and hormonal fluctuations that occurred across the menstrual cycle, with important biopsychosocial implications.This study was cross-sectional with a repeated measures design.2]. The written informed consent was given to each participant after clarifying the aim of this study to them and their right of withdrawing from this study at any time. All participants signed the informed consent. Ethical approval was obtained from the Institutional Review Board of the Faculty of Physical Therapy of Cairo University before initiating this study (No. P.T.REC/012/001884). This trial was prospectively registered at clinicaltrials.gov: (NCT03688750). This study was conducted between October 2018 and May 2019.Notably, 70 female students were recruited through a flyer distributed at the Faculty of Physical Therapy of Cairo University, in Egypt  through a computer-generated table of random numbers using Statistical Package for Social Sciences (SPSS) version 25 . Sequentially ordered cards were included in impermeable sealed envelopes and were opened by an assistant researcher blinded to the procedures, who allocated the participants to their shoes. The hair of females was bound up  to expose the neck and C7 vertebra prominence. Participant’s trunk was exposed till gluteal cleft. Rings, watches, and necklaces were removed to avoid any reflections. Each female stood in a relaxed position with a distance of nearly two meters from the system, and the position of the feet was marked on the floor to ensure that they stood in the same position in all trials.Each female was asked to keep the head in the neutral position and breathe normally and then stop breathing for a few seconds while the image was captured. Full back 3D analysis was performed four times, and the mean value for each parameter was recorded. These steps were repeated for low- and high-heeled shoes, and approximately 5 min rest was given between measurements. These measurements were performed during different menstrual phases .∗POWER statistical software  , and it indicated that the proper sample size for this study was N = 56. We collected a larger number than the calculated sample size to overcome the possibility of missing participants.Before beginning the testing procedures, a pilot study was conducted with 10 participants to identify the proper sample size. Test size estimation was performed preceding the investigation utilizing GReported data were analyzed using the SPSS version 25, with an intention-to-treat analysis. Descriptive statistics, including mean ± SD, were quantified for all variables. This study involved two independent variables. The first independent variable was the sports shoes with different heel heights (within-subject factor) with two levels as follows: low (2.5 cm) and high (7 cm). The second independent variable was the phases of the menstrual cycle (within-subject factor) with three levels as follows: early follicular, ovulatory, and mid-luteal phases. The three dependent variables were as follows: KA, TI, and pelvic inclination. Two-way repeated measures MANOVA was applied to the dataset among the two heel heights during the three phases of the menstrual cycle. The alpha level was set at 0.05.Of the initial 90 participants, six of them did not follow the inclusion criteria, as they had irregular menstrual cycles or spinal deformities, which would affect the testing procedure and its results. Other five participants performed the assessment procedure in only one phase of menstruation. Other six participants performed the assessment procedure during two phases of menstruation but did not complete the last measurement. The other three participants refused to participate in this study due to personal reasons. Therefore, only 70 participants were included and analyzed .F = 1.3, p = 0.34, and partial η2 = 0.08), sport shoes with different heel heights , and phases of menstrual cycle by sport shoes with different heel heights . Bonferroni multiple comparison tests (post hoc tests) indicated that there was no significant difference (p > 0.05) in KA, TI, and pelvic inclination among phases of the menstrual cycle at different heel heights. Also, there was no significant difference (p > 0.05) in KA, TI, and pelvic inclination between sports shoes with different heel heights at the three phases of the menstrual cycle  during early follicular, ovulatory, and mid-luteal phases of the menstrual cycle. Considering that high-heeled shoes are traditionally associated with femininity, body image, beauty, and charm, this research has important biopsychosocial implications that should be explored in detail in future studies.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by the Institutional Review Board of the Faculty of Physical Therapy of Cairo University (No. P.T.REC/012/001884). The participants provided their written informed consent to participate in this study.ME-S, AY, and HH contributed to the concept and design of the study, collected the data, and performed the statistical analysis and data interpretation. All authors collaborated in writing and critical revision of the study, and read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


Echinococcus granulosus sensu lato that causes economic losses by affecting livestock and also poses a public health threat worldwide. The present study is the first retrospective report on the seroprevalence of anti-E. granulosus antibodies in humans in Pakistan. The study used data from 93 blood analysis reports of patients suspected of having CE from different medical centers in Lahore, Pakistan. Out of 93 sera samples, 20 (21.5%) were seropositive, and higher seropositivity (17.2%) was recorded with the indirect hemagglutination test (IHA) than with enzyme-linked immunosorbent assay (ELISA). The findings indicated that age, gender, and year had no significant relationship with the seropositivity of CE. The current study provides directions towards the management of the disease in the near future in Pakistan.Human cystic echinococcosis (CE) is a zoonotic disease caused by the larval stage of  Echinococcus granulosus sensu lato [Cystic echinococcosis (CE) is an essential parasitic zoonotic disease in humans and livestock caused by larvae of the cestode parasite nsu lato . The lifnsu lato . Exposurnsu lato . Humans nsu lato ,5. The mnsu lato . Intermensu lato ,8.CE can be asymptomatic for months or years until a large cyst is formed. Cyst formation usually occurs in the liver and lungs but can develop in other organs . The WorE. granulosus presence and detecting asymptomatic cyst carriers. Hence, CE diagnosis is mainly based on imaging techniques, while serological tests are employed as confirmatory tests that detect E. granulosus antibodies such as IgG and IgM [On the other hand, serological tests are more readily available and helpful for providing data on  and IgM . With a  and IgM . Accordi and IgM .CE is a cosmopolitan helminthic disease that occurs worldwide over a wide range of geographic areas associated with livestock rearing, such as Australia, eastern and southern Europe, Asia, South America, and the Middle East, and is endemic in many parts of the world, including Pakistan. Multiple socio-cultural and economic factors, as well as poor hygiene practices, are associated with higher transmission and prevalence rates of CE ,18,19, fTo the best of our knowledge, no comprehensive sero-epidemiological study on human CE has been conducted in Pakistan, even though there are records of CE in several hospitals in the country. Therefore, this study aimed to evaluate the seropositivity of human CE in Pakistan.Out of the 93 cases included in this study, the majority  of the cases were recorded in 2018 and 20 (21.5%) were recorded in 2020. Concerning the distribution of cases according to age group, the highest number of cases  was observed in the age group 44–63 years, followed by the age group 24–43 years . Of the 93 patients, 52 (55.9%) were females and 41 (44.1%) were males. Further, 20 (21.5%) patients were found to be seropositive with a titer level of >12 and 71 (77.4%) were negative (<9), according to both the commercially available enzyme-linked immunosorbent assay (ELISA) and indirect hemagglutination (IHA) test results . The higE. granulosus antibodies was detected using ELISA and IHA testing. According to the results of ELISA, seroprevalence was the highest in the age group 24–43 years (n = 2) and, according to the IHA results, too, the highest seroprevalence was recorded in the age group 24–43 years (n = 3), followed by the age group 44–63 years (n = 2). However, the difference in seroprevalence between the age groups was not statistically significant  . Most cases were recorded in 2018, according to the results of both ELISA (n = 4) and IHA (n = 7) .The association of age, year, and gender with anti-= 0.811) . Gender- (n = 7) . HoweverCystic echinococcosis is an emerging disease with a worldwide geographic distribution and is endemic in many parts of world, including Pakistan. In Pakistan, limited studies are available on human CE by using serological tests (ELISA/IHA) to rule out the epidemiology of disease and its public health importance ,27,28,29In the current study, the overall seropositivity of human CE was calculated as 21.5%. In comparison, the seroprevalence recorded in the Mediterranean basin region of Greece by Sotiraki et al. (2003)  was highE. granulosus-contaminated environments. Another reason might be that CE remains asymptomatic for years and is considered to be a slow-growing chronic disease. The findings of this study are in accordance with previous studies, which have reported prevalence rates of 47.8% and 46.7% in the age group 20–40 years [CE affects people of almost all ages, from below 3 to above 80 years [40 years ,42. In c40 years ,35, and In this study, no sex-dependent, statistically significant difference was detected, as both males and females were found to be equally positive for CE. This is possible because most people in Pakistan reside in rural regions linked with the agricultural sector, where both males and females are equally active in farming and livestock raising and come into contact with dogs and infected food during production.The major limitation in our study is the small sample size, as only individuals who had specimens taken for histopathological examination and records available were included. Therefore, the current report’s data analysis probably underestimates the incidence of the CE seropositivity rate in Pakistan.The present study was conducted in Lahore, Punjab province, Pakistan. Punjab is one of the largest provinces by population, with fertile agricultural land and deserts in the southern part neighboring Rajasthan and the Sulaiman Range. Lahore is the capital city of Punjab and is a pivotal part of the country’s cultural diversity . AccordiEchinococcus granulosus antibodies in patients suspected of being infected from different serodiagnostic centers between 2018 and 2021 in Lahore, Pakistan. ELISA and IHA tests were used to detect anti-E. granulosus antibodies in the serum samples. The recorded data included the patient’s age, gender, and serum test performed for detecting anti-E. granulosus antibodies.The current study included 93 serological test reports of anti-Echinococcus antibodies were detected using the DRG Echinococcus IgG ELISA Kit (ECHG0130BA) as per manufacturer guidelines. Microtiter wells were coated with antigen as a solid phase. These wells were used for pipetting diluted patient samples and ready-to-use control samples. The color intensity was determined following the addition of primary and secondary antibodies, and it was shown to be directly related to the amount of echinococcus IgG antibodies in the sample . SimilarE. granulosus antibodies and each risk factor. The results were considered statistically significant when the p-value was below 0.05.Statistical analysis of the data was performed using SPSS 18.0 for Windows. The chi-square test with a 5% significance level was used to assess the association between seropositivity for anti-CE is widespread in Pakistan and is a significant health concern in the country. According to the current study’s research, the seropositivity of human CE in Pakistan exhibited no significant association with age, year, or gender. The current study is the first retrospective report on the seropositivity of human CE in a population-based setting. Furthermore, no prior investigation on this topic has been reported in Pakistan; hence, the current data serve as a baseline for future monitoring of human CE infection and may aid in designing control measures in Pakistan.


Duchenne muscular dystrophy (DMD) is a severe rare progressive inherited neuromuscular disorder, leading to loss of ambulation (LOA) and premature mortality. The standard of care for patients with DMD has been treatment with corticosteroids for the past decade; however a synthesis of contemporary data describing the clinical course of DMD is lacking. The objective was to summarize age at key clinical milestones  in the corticosteroid-treatment-era.A systematic review was conducted using MEDLINE and EMBASE. The percentage experiencing key clinical milestones, and the mean or median age at those milestones, was synthesized from studies from North American populations, published between 2007 and 2018.From 5637 abstracts, 29 studies were included. Estimates of the percentage experiencing key clinical milestones, and age at those milestones, showed heterogeneity. Up to 30% of patients lost ambulation by age 10 years, and up to 90% by 15 years of age. The mean age at scoliosis onset was approximately 14 years. Ventilatory support began from 15 to 18 years, and up to half of patients required ventilation by 20 years of age. Registry-based estimates suggest that 70% had evidence of cardiomyopathy by 15 years and almost all by 20 years of age. Finally, mortality rates up to 16% by age 20 years were reported; among those surviving to adulthood mortality was up to 60% by age 30 years.Contemporary natural history studies from North America report that LOA on average occurs in the early teens, need for ventilation and cardiomyopathy in the late teens, and death in the third or fourth decade of life. Variability in rates may be due to differences in study design, treatment with corticosteroids or other disease-modifying agents, variations in clinical practices, and dystrophin mutations. Despite challenges in synthesizing estimates, these findings help characterize disease progression among contemporary North American DMD patients.The online version contains supplementary material available at 10.1186/s13023-021-01862-w. Duchenne muscular dystrophy (DMD) is a rare, progressive, life-limiting neuromuscular disorder  occurrinAlthough there is presently no cure for DMD, advancements to the standard of care, including the introduction of systemic corticosteroids in the 1990s, have helped slow disease progression and improve survival –12. HoweA comprehensive search of the Medline/Medline In-Process and EMBASE databases was performed . Scores on assessments of ambulatory, pulmonary, or cardiac function over a minimum of one year of follow-up were also included , pulmonary dysfunction, cardiomyopathy, and mortality. Relevant measures included the mean or median age at the outcome of interest, or the percentage experiencing the outcome over time or at a particular time  inhibitors, were also extracted where available.Data were extracted by two researchers; study characteristics extracted included authors, year, study duration, objective(s) and design, sample size, and inclusion and exclusion criteria. Patient characteristics included details of corticosteroid treatment and baseline demographics. Cohorts were classified as ‘corticosteroid-treated’ if all patients were so treated, ‘mixed corticosteroid use’ if the sample represented a mix of corticosteroid-treated and -untreated patients, and ‘likely corticosteroid-treated’ if the study was published after 2005 and did not state the sample was t by the original authors. Where available, scores on functional and clinical measures of interest over time were plotted using line graphs.For continuous variables, the mean, median, standard deviation (SD), confidence interval (CI), interquartile ranges (IQR), and range was extracted whenever available. For dichotomous and categorical variables, the number of patients and proportion was extracted. For studies reporting on the mean or median age at the outcome, the range of estimates was tabulated. The percentage of the sample who experienced the outcome at time of reporting was also described (where available). Data on the percentage experiencing the outcome at specific time points or over time were described using Kaplan–Meier (KM) curves, as well as presented as point estimates at time The strength of the available evidence was assessed using the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) Statement for observational studies and non-randomized clinical trials .The search strategy identified 5,637 potentially-relevant records; four < 1%) were removed after de-duplication and 5,213 (92.5%) were excluded on abstract review  was 14.2 (12.5–15.6) years among the 107 patients with scoliosis [One study reported the mean age at scoliosis , 2 studicoliosis . The percoliosis , 35, 37.coliosis .Fig. 3OcFour studies reported the mean or median age at ventilation , 39, 40,In terms of age at need for ventilation, one multicenter chart review of 324 mixed corticosteroid-treated DMD patients reported a median age at ‘any ventilation’ of 15 years  age at mortality , 44–46, In terms of the proportion surviving over time, up to 16.2% mortality was reported by age 20 years , and findings are consistent with those from large observational studies and registries from outside of North America. The Translational Research in Europe—Assessment and Treatment of Neuromuscular Diseases (TREAT-NMD) network of DMD registries have published studies documenting the clinical course of patients with DMD –52. In aThat longitudinal data describing survival specifically among North American DMD patients are few, was one of the major gaps identified in this review. However, mortality rates from included studies were consistent with findings of two important studies on mortality in dystrophin gene-related muscular dystrophy, which did not meet the inclusion criteria for the current review as they also included patients with Becker muscular dystrophy (BMD). The first study, which was based on vital statistics, estimated that 71% of mortality among those with BMD/DMD occurred between the ages of 15 and 29 years; the authors assumed it was most likely related to DMD . The secAccurately estimating the time of onset of gradually progressive manifestations of DMD can be difficult, and this along with changes in practice patterns and symptom detection, contribute to observed variability in estimates. For example, many studies reporting on scoliosis classify outcomes based on surgery, however with changing treatment patterns  the utilThere are several additional factors impacting the timing of key clinical milestones that require consideration. To capture the impact of corticosteroids in the management of DMD, only studies including patients from the corticosteroid treatment era were included. While details of corticosteroid treatment regimens were extracted and reviewed, there were important limitations that precluded analyzing outcomes according to regimen. First, details on the timing of initiation, duration, type, and dose varied within and between studies. Only a small number of studies reporting on LOA presented results according to agent; but the remainder of the studies for that outcome, and all of the studies for other outcomes of interest, did not stratify by corticosteroid regimen. However, variations in corticosteroid treatment patterns (in terms of duration and dosing) may have affected the timing when patients reached LOA , 62, 63,Variability in methodology and data sources may also have affected estimates. Data from the CINRG and MD STARnet registries, both large well-documented US cohorts that comprehensively collect longitudinal data on the clinical course of DMD, were used in ten studies within this review. Outside of those, most observational studies and treatment trials do not follow patients for a sufficient time to describe changes across the range of key clinical milestones , 30. OthSome limitations to the published data warrant mention. First, while time to event data using KM curves were presented in some studies, many reported the mean age at an occurrence where the entire sample had not experienced the event at the time of study reporting. As such, these values can be interpreted as the lower limit for when key clinical milestones will occur in DMD. Second, some measures may only be administered to individuals who still have some functional capacity (e.g. tests of ambulation), and patients unable to complete the test would have been excluded. This type of survival bias would result in an inflation of apparent functional status for cohorts as a whole. Third, mean scores on functional tests may reflect the inclusion criteria of each study, rather than the underlying distribution of scores on that functional test among the DMD population. Fourth, because of heterogeneity in designs employed, measures selected, and populations included across studies, meta-analysis was judged to be infeasible , 75; as This is the first systematic review of published estimates of the frequency and timing of important milestones that characterize the clinical course of DMD in the corticosteroid era. This review has also leant insight into a number of challenges in the interpretation and comparison of estimates of outcomes to characterize the clinical course of DMD. Additional studies on the ages at occurrence of other important DMD clinical milestones, and the relationships between short-term and long-term outcomes, will be valuable in the continuation of knowledge regarding disease progression in DMD.Additional file 1: Supplementary Table 1. Search strategy. Supplementary Table 2. Details of corticosteroid treatment, by study. Supplementary Table 3. Details of ACE inhibitor treatment, by study. Supplementary Table 4. STROBE assessments of included studies.