Few data is available on the association between body mass index (BMI), serum uric acid (SUA) levels and blood pressure (BP) categories in the disease continuum, when efforts for its prevention may be applicable.We performed a cross-sectional study to examine the association between BMI, SUA and BP in a community-dwelling sample of Japanese men. Individuals not on antihypertensive and uric acid lowering medications, and aged 50 to 90 years [817men aged 66 ± 9 (mean ± standard deviation) years] were recruited for the survey during a community based annual medical check-up. The main outcome was the presence of prehypertension [systolic BP (SBP) 120-139 mmHg and/or diastolic BP (DBP) 80-89 mmHg] and hypertension [SBP ≥ 140 and /or DBP ≥ 90].2, increased SUA levels were positively associated with SBP and DBP, but in those with a BMI of ≥ 21.0 kg/m2, increased SUA levels were negatively associated with SBP and DBP. The interaction between BMI and SUA as well as BMI and SUA was a significant and independent determinant for both SBP  and DBP . Among participants, the respective prevalence of normotension, prehypertension, and hypertension was 19.5% and 53.7%, and 19.8%. The prevalence of normotension and prehypertension decreased with increasing BMI and the prevalence of hypertension increased with increasing BMI. In participants with a BMI ≥ 21.0 kg/m2, the adjusted-odds ratio of SUA for hypertension was 0.75  compared with normotension and 0.82 (0.70-0.96) compared with prehypertension. In those with a BMI of < 21.0 kg/m2, these associations were not shown.In participants with a BMI of < 21.0 kg/mBMI may modify the association between SUA and blood pressure status among community-dwelling men. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure JNC 7) defined a systolic blood pressure (SBP) of 120 to 139 mmHg and/or diastolic blood pressure (DBP) 80 to 89 mmHg as prehypertension . The Jic defined Serum uric acid (SUA) is the end product of endogenous and dietary purine metabolism in humans, and is catalyzed by the enzyme xanthine oxidase, which is involved in producing reactive-oxygen species (ROS). Its excess accumulation can lead to various diseases . SUA is ≥50 years.The aim of this study was to evaluate the prevalence of prehypertension and hypertension, and its association with BMI, SUA and other confounding factors {e.g., age, habits, lipid, fasting plasma glucose (FPG), renal function, and liver function} using cross-sectional data from community-dwelling Japanese men aged of The present study was designed as a part of the Nomura study . Partici–0.411 × 0.993 age × 0.813; Cr > 0.9 mg/dl, 141 × (Cr/0.9) –1.209 × 0.993 age × 0.813 [Information on demographic characteristics and risk factors was collected using clinical files. BMI was calculated by dividing weight (in kilograms) by the square of height (in meters). Smoking status was defined as the number of cigarette packs per day multiplied by the number of years smoked (pack year), and the participants were classified into never smokers, past smokers, light smokers (< 30 pack・year) and heavy smokers (≥30 pack・year). Daily alcohol consumption was measured using the Japanese liquor unit in which a unit corresponds to 22.9 g of ethanol, and the participants were classified into never drinkers, occasional drinkers (< 1 unit/day), light drinkers (< 2 unit/day), and heavy drinkers (≥2 unit/day). We measured SBP and DBP in the right upper arm of participants in the sedentary position using an automatic oscillometric blood pressure recorder while the participants were seated after having rested for at least 5 min. Appropriate cuff bladder size was determined at each visit based on arm circumference. Normotension was defined as not being on antihypertensive medication and having a SBP < 120 mmHg and DBP < 80 mmHg. Prehypertension was defined as not being on antihypertensive medication and having a SBP of 120 to 139 mmHg and/or DBP of 80 to 89 mmHg. Hypertension was defined as SBP ≥140 mmHg and/or DBP ≥90 mmHg (9). Total cholesterol (T-C), TG, HDL-C, FPG, creatinine (enzymatic method), SUA, aspartate transaminase (ALT), and γ-glutamyl transpeptidase (GGT) were measured during fasting. LDL-C levels were calculated by the Friedewald formula (14). Participants with TG levels ≥400 mg/dL were excluded. The presence of diabetes and CVD was defined as a history of treatment for diabetes and CVD. Estimated glomerular filtration ratio (eGFR) was calculated using CKD-EPI equations modified by a Japanese coefficient: Male, Cr ≤0.9 mg/dl, 141 × (Cr/0.9) 2 test for categorical data. Correlations between various characteristics and BP were determined using age-adjusted partial Pearson’s correlation test and multiple linear regression analysis. Logistic regression analyses were used to test significant factors of prehypertension and hypertension (versus normotension), with prehypertension and hypertension serving as the dichotomous outcome variables, and age, BMI, alcohol consumption, smoking status, history of CVD, lipids, antilipidemic medication, FPG, antidiabetic medication, SUA, eGFR, ALT, and GGT as the confounding factors. The synergistic effect of BMI and SUA levels on blood pressure was evaluated using a general linear model. A value of p < 0.05 was considered significant.Statistical analysis was performed using IBM SPSS Statistics Version 20 . All values are expressed as mean ± standard deviation (SD), unless otherwise specified. Data for TG, FPG, ALT, and GGT were skewed, and are presented as median (interquartile range) values, and were log-transformed for analysis. Differences in means and prevalence among the groups were analyzed by Student’s t-test for continuous data and χ2 , with 26.4% being underweight (BMI < 21.0 kg/m2), 53.7% normal weight , 19.8% overweight or obese (BMI ≥25 kg/m2). Table The participants comprised 817 men aged 66 ± 9 years  who do not take antihypertensive and UA lowering medications. Mean BMI in the study sample was 22.9 kg/mAmong them, the respective prevalence of normotension, prehypertension, and hypertension was 19.5% and 53.7%, and 19.8%. The prevalence of normotension and prehypertension decreased with increasing BMI and the prevalence of hypertension increased with increasing BMI , but in BMI ≥25.0 kg/m2, SUA correlated negatively with both SBP and DBP . Analysis of covariance showed that three regression lines in each graph were significantly different .In addition to their direct associations, we observed a synergistic effect between BMI category and SUA levels on BP status in Fig. 2 and ≥21.0 kg/m2) and blood pressure status. In hypertensive group with a BMI < 21.0 kg/m2, prevalence of smoking status and GGT were significantly higher than normotensive group. In hypertensive group with a BMI ≥21.0 kg/m2, age and BMI as well as smoking status and GGT were also significantly higher, but SUA was significantly lower than normotensive group.Table 2 but correlated negatively with SBP in participants with a BMI ≥21.0 kg/m2.Table 2, but negatively associated with both SBP and DBP in participants with a BMI ≥21.0 kg/m2, independently of other confounding factors.Table p = 0.001) and DBP , independently of other confounding factors.We assessed the statistical significance of the synergistic relationship using a general linear model with the following confounding factors: age, BMI, alcohol consumption, smoking status, history of CVD, TG, HDL-C, LDL-C, prevalence of antilipidemic medication, FPG, prevalence of antidiabetic medication, SUA, eGFR, ALT, GGT, and the interaction between BMI and SUA Table . The int2, the odds ratio of SUA for hypertension was 0.75  compared with normotension, and 0.82 (0.70-0.96) for hypertension compared with prehypertension. In subjects with a BMI < 21.0 kg/m2, these associations were not shown.Table 2, but negatively in those with a BMI ≥21.0 kg/m2. The effect of significant interaction between BMI and SUA on blood pressure indicated that increased SUA was a risk factor for elevated blood pressure in underweight participants, but was not a predictor among normal- or overweight participants. To our knowledge, few studies have indicated that BMI may modify the association between SUA and blood pressure status.In this cross-sectional, population-based study of 817 middle-aged and elderly men, we set out to determine the prevalence of prehypertension and hypertension, as defined by the JNC-7 criteria [p = 0.002) and DBP  after adjustment for age, diabetes, dyslipidemia, BMI, and eGFR, but the association was not significant in those ≥60 years [In men aged < 40 years, SUA was significantly associated with SBP  synthetase  and dire2. We suggest that SUA may be more important in participants with a BMI < 21.0 kg. It has been demonstrated that increased SUA induces increased BP that is initially reversible but leads to an irreversible salt-sensitive hypertension over time [Moreover, SUA also reflects systemic inflammation , oxidativer time . Thus, S2. The beneficial antioxidant actions of SUA may partially counter its potential detrimental effects. It is interesting that almost all studies examining the relation of SUA levels with CVD events show a J-shaped curve with the nadir of risk in the second quartile [An important observation was that UA may function as an antioxidant, and possibly one of the most important antioxidants in plasma. Increased SUA in subjects with CVD might therefore reflect a compensatory mechanism to counter the oxidative stress that occurs in these conditions . In our quartile , 40.Some limitations of this study must be considered. First, our cross-sectional study design does not eliminate potential causal relationships between BMI, SUA, and blood pressure status. Second, the prevalence of blood pressure categories is based on single blood pressure measurement. Third, confounding factors are based on a single assessment of blood, which may introduce a misclassification bias. Fourth, we could not eliminate the possible effects of underlying diseases and medications for diabetes and dyslipidemia on the present findings. We could not rule out one-time prehypertension and white-coat prehypertension. Finally, in this study, the demographics and referral source may limit the generalization of the results.The present study showed that BMI may modify the association between SUA, SBP, and DBP. The underlying mechanism seems to be independent from traditional cardiovascular risk factors such as age, BMI, alcohol consumption, smoking status, history of CVD, lipids, diabetes, renal function, and liver function. For community-dwelling healthy persons, prospective population-based studies are needed to investigate the mechanisms underlying this association to determine whether intervention, such as effective lifestyle modifications that decrease BMI and SUA, in adult populations will decrease risks.


Using single-crystal synchrotron radiation X-ray experiments, the host–guest structure of the Ba IVb high-pressure phase has been solved for the first time. The proposed systematic analysis of possible host–guest structure models shows that the structure belongs to the incommensurately modulated type. This model reveals an atomic density wave and its pressure-dependent evolution between 16.5 and 19.6 GPa. The host–guest structures of elements at high pressure discovered a decade ago still leave many open questions due to the lack of precise models based on full exploitation of the diffraction data. This concerns in particular Ba IV, which is stable in the range 12–45 GPa. With the example of phase Ba IVb, which is characterized here for the first time, a systematic analysis is presented of possible host–guest structure models based on high-quality single-crystal diffraction data obtained with synchrotron radiation at six different pressures between 16.5 and 19.6 GPa. It is shown that a new incommensurately modulated (IM) structure model better fits the experimental data. Unlike the composite models which are commonly reported for the Ba IV phases, the IM model reveals a density wave and its pressure-dependent evolution. The crucial role played by the selected model in the interpretation of structure evolution under pressure is discussed. The findings give a new experimental basis for a better understanding of the nature of host–guest structures. In order to shed light on the unknown HP phase Ba IVb, we collected a sequence of single-crystal diffraction intensities at room temperature using synchrotron radiation in the pressure range between 16.5 and 21.8 GPa, where Ba IVb is stable. For each pressure, all reflections were indexed in terms of a single incommensurately modulated structure, thus leading to a structure solution within the (3+1)-dimensional superspace symmetry approach. [In the following, the terminology described by Janssen  al. 2007 will be 2.2.1.et al., 2012Small pieces of barium were cut from an ingot of high purity  and loaded into a BX90 type diamond anvil cell (DAC) equipped with Boehler–Almax diamonds (500 µm culettes)  were excluded from further consideration. Reflections with I > 2σ(I) were averaged according to symmetry. Structural analysis and all calculations were performed using the JANA2006 software system  and 21.8 (1) GPa. The phase described by Loa  al. 2012 as Ba IVStructure solutions of Ba IVb at 16.5 (1), 17.4 (1), 18.2 (1), 18.5 (1), 19.0 (1) and 19.6 (1) GPa are reported and discussed below.3.1.hklm with the wavevector H = ha*+ kb* + lc* + mq using lattice parameters a ≃ b ≃ 11.5 Å and c ≃ 4.6 Å and the incommensurately modulated vector q = βb* + γc* ≃ 0.1b* + 1.36c*. The strong hkl0 reflections are considered the main ones; all others hklm (m ≠ 0) are satellites. The index m = 1, 2 and 3 corresponds to three orders of satellites observed by diffraction  of the main reflections, the refined lattice parameters point to a lower symmetry . For all six measurements, averaging of the reflection intensities shows unacceptable reliabilities of Rint ≃ 0.55 for each group of symmetry-equivalent reflections. An improved reliability with Rint = 0.04–0.14 was obtained in the monoclinic system with the unique axis a. The pseudo-tetragonal appearance of the reciprocal-space patterns , the integration of experimental intensities was performed for the six diffraction data sets. For each pressure, about 18 000 reflections were used for the structure solution and refinement, of which 600–700 had I > 2σ(I).Using the refined lattice parameters and components of the modulation vector P21/b(0βγ)00 was derived from the observed systematic extinctions.The (3+1)-dimensional monoclinic superspace group 3.2.fr , and one site defines the channel atoms, Bach, . The principal distinction between IM and COMP concerns the c lattice parameter, which is different for H (cH ≃ 4.6 Å) and G (cG ≃ 3.4 Å) in COMP, while it is unique (c ≃ 4.6 Å) in IM. All details of the differences between the IM and COMP models are given in the supporting information. We have tested and refined both models for Ba IVb . The validity of and preference for IM are confirmed by the low reliability indices R , which were calculated for both COMP and IM for the six different pressures. For IM, Rmain = 0.043–0.056 and Rall = 0.091–0.099 for the main and all reflections, respectively, while essentially higher Rmain = 0.095–0.12 and Rall = 0.139–0.17 were obtained for COMP.Indexing of the diffraction reflections and the derived monoclinic superspace group are consistent with two different structure models: incommensurately modulated (IM) and modulated composite (COMP). In both models, two independent atomic sites describe the framework atoms, Ba3.3.ch—Bach distance variation in the channels . 70–85% of these distances are in the range 2.9–3.8 Å , forming dumb-bells and triplets along the channel . This results in dense and sparse arrangements of the Bach atoms, forming a wave in the bc layers . This wave changes with pressure, increasing from 16.5 to 19.6 GPa towards the formation of a more uniform chessboard-like distribution of the dense and sparse regions in the bulk of the crystal . The pressure dependence of the unit-cell parameters , and especially of the β component of the modulation vector , confirms this pressure-sensitive structural evolution appearing between 17.4 (1) and 18.2 (1) GPa.The IM model reveals an essential and specific feature of the Ba IVb phase, namely the presence of a density wave in the channels of the structure Fig. 3. This waor Fig. 2c, confi4.hklm reflections with l ≠ 0 and m ≠ 0 . The existence of these reflections was mentioned previously for Ba IV , are interpreted as satellites in our model. The difference concerns the hk0m (m ≠ 0) reflections, which are considered as main reflections for the G substructure in COMP. The reported scheme of the reflection distribution in Ba IVa  reflections for the COMP model  global, I, II, III, IV, V, VI. DOI: 10.1107/S2052252517000264/yu5011Isup2.hklStructure factors: contains datablock(s) I. DOI: 10.1107/S2052252517000264/yu5011IIsup3.hklStructure factors: contains datablock(s) II. DOI: 10.1107/S2052252517000264/yu5011IIIsup4.hklStructure factors: contains datablock(s) III. DOI: 10.1107/S2052252517000264/yu5011IVsup5.hklStructure factors: contains datablock(s) IV. DOI: 10.1107/S2052252517000264/yu5011Vsup6.hklStructure factors: contains datablock(s) V. DOI: 10.1107/S2052252517000264/yu5011VIsup7.hklStructure factors: contains datablock(s) VI. DOI: 10.1107/S2052252517000264/yu5011sup8.pdfAdditional information, figure and tables. DOI:


Microcystis blooms control but almost all the previous works have used Microcystis aeruginosa as the target organism to determine dosages. The aim of this study was to evaluate interspecific differences in the responses of various Microcystis species to varying Cu2+ concentrations . The half maximal effective concentration values for M. aeruginosa, M. wesenbergii, M. flos-aquae, and M. viridis were 0.16, 0.09, 0.49, and 0.45 mg L−1 Cu2+, respectively. This showed a species-dependent variation in the sensitivity of Microcystis species to copper sulfate. Malonaldehyde content did not decrease with increasing superoxide dismutase content induced by increasing Cu2+, suggesting that superoxide dismutase failed to reduce Cu2+ damage in Microcystis. Considering the risk of microcystin release when Microcystis membranes are destroyed as a result of Cu2+ treatment and the stimulation effects of a low level of Cu2+ on growth in various species, our results suggest that copper sulfate treatment for Microcystis control could be applied before midsummer when M. aeruginosa and M. viridis are not the dominant species and actual amount of Cu2+ used to control M. wesenbergii should be much greater than 0.10 mg L−1.Copper sulfate is a frequently used reagent for  Microcystis blooms are increasing in freshwater ecosystems as a result of eutrophication and global temperature increases, becoming a global environmental and ecological problem1Microcystis blooms that threatens public health through drinking water supply and fishingMicrocystis growth. However, most of these methods are impeded because they are expensive and slow to take effect, except for some chemical methods. Chemical methods can have serious negative effects on ecosystems, e.g., toxin release, persistence, and bioaccumulation9Microcystis bloomsMany methods, including biologicalMicrocystis was chosen to inhibit Microcystis growth. Hadjoudja et al.50 of Microcystis is 0.064 mg L−1 Cu2+. Tsai2+ concentration required to inhibit M. aeruginosa growth is 0.160 mg L−1. The 96-h-EC50 of M. aeruginosa was reported as 1.02 mg L−1 Cu2+ by Zhang et al.2+ doses are considered safe according to the World Health Organization recommendation (2 mg L−1)2+ concentration (0.16–0.64 mg L−1) would lyse Microcystis cells and release microcystins from the cells11212+ dose and more information on the effects of Cu2+ on growth, physiology, and cell integrity of both toxic and non-toxic Microcystis species is required.Copper sulfate is a frequently-used, low-cost chemical reagent for blooms control and the copper sulfate toxicity mechanisms have been well studied12M. aeruginosa as the target organism to determine the Cu2+ dose for Microcystis control1011Microcystis genusMicrocystis species varies greatlyMicrocystis species differs significantly25M. wesenbergii, M. flos-aquae, and M. viridis have been reported as the dominant species in lakes besides M. aeruginosa272+ dose determined from M. aeruginosa to control all Microcystis species in lakes.It is noteworthy that almost all of the previous studies used Microcystis species to varying Cu2+ concentrations. The efficiency of primary conversion of light energy of PS II (Fv:Fm), cell viability  reduction), superoxide dismutase (SOD), and malonaldehyde (MDA) were analyzed to assess the physiological status of various Microcystis species to varying Cu2+ concentrations since the mechanisms by which Cu2+ inhibits growth of Microcystis had been well studied1819Even though species-dependent variation in algal sensitivity to chemical compounds has been widely reported30Microcystis species were provided by the Freshwater Algae Culture Collection of the Institute of Hydrobiology, Chinese Academy of Sciences. The identification numbers and origins of the four species are listed in Four 2+ concentrations were 0.05, 0.10, 0.25, and 0.50 mg L−1. The culture without copper sulfate treatment was used as the control. The initial cell density of Microcystis was 100 × 104 cells mL−1. The light intensity was 50 μmol photons m−2s−1 and the culture time was 4 days. The cell density and efficiency of primary conversion of light energy of PS II (Fv:Fm) was analyzed daily. At the end of the experiment, cell viability  reduction), superoxide dismutase (SOD), and malonaldehyde (MDA) were analyzed.Each strain was batch-cultured axenically in triplicate in 150 mL sterilized liquid BG-11 medium in a 250-mL conical flask under a 12:12-h light:dark cycle. All cultures were prepared in triplicate. The medium was treated with varying amounts of copper sulfate and the CuThe cells were counted at least three times in a hemocytometer at 400× magnification with an optical microscope . Counting was stopped when three counts that differed by less than 10% had been obtained. The final cell density was calculated from the average of the three counts.et al.et al.et al.A 10-mL sample was injected into a 10-mL centrifugal tube. All of the tubes were left undisturbed in the dark at room temperature for 15 min. The sample was then analyzed by AquaPen-P 100  to determine the Fv:Fm value. TTC, SOD, and MDA were analyzed according to the methods described by Hong All of the data are presented as mean ± SD. The specific growth rate was calculated by Dt is the cell density at time t, D0 is the cell density in the initial logarithmic growth phase, and t is the duration of the logarithmic growth phase. In the current study, the value of t was 4.where 50) was determined on day 4 at the 50% inhibition rate according to the relationship between inhibition rate and concentration of Cu2+. The inhibition rate was calculated by The half maximal effective concentration  decreased along with increasing Cu2+ concentration . In the highest Cu2+ treatment, SOD content was 9.0, 8.5, 5.0, and 4.1 U (108 cells)−1, for M. wesenbergii, M. aeruginosa, M. flos-aquae, and M. viridis, respectively. MDA content also significantly increased with increasing Cu2+ concentration in all four species −1 for M. wesenbergii, M. flos-aquae, M. aeruginosa, and M. viridis, respectively.In the control, SOD content in  species . With inMicrocystis species to copper sulfate. The species-dependent variation in algal sensitivity to copper was also recently reported by Tsai50 value in Microcystis species to Cu2+ was in the order of M. flos-aquae > M. viridis > M. aeruginosa > M. wesenbergii and ranged from 0.09 to 0.49 mg L−1. The decrease in Fv:Fm ratio in the highest Cu2+ treatment in the current study was M. flos-aquae < M. viridis < M. aeruginosa < M. wesenbergii  release is another protective response against chemical compounds in algae including microcystins4445 results . TherefoM. flos-aquae and M. viridis exposed to 0.05 and 0.10 mg L−1 Cu2+ were higher even than control , 0.033–0.054 mg L−1 Cu2+ was used for over 58 years to control algal growth2+ to control cyanobacterial blooms in Canada was 0.05–0.125 mg L−1 2+ concentrations would stimulate M. flos-aquae and M. viridis growth. Therefore, the actual amount of Cu2+ used to control M. wesenbergii should be much greater than 0.10 mg L−1; while the correct dose for M. flos-aquae and M. viridis control requires investigation in lakes. In addition, the species of copper from different copper algaecides should also be consideredThe growth curves of  control . This waMicrocystis membranes are destroyed by Cu2+ treatment is an important concern in the application of copper sulfate to control Microcystis. Trace Cu2+ (0.16–0.50 mg L−1)1011M. wesenbergii, potentially produces microcystins and other toxins5759−1 Cu2+ would reduce M. wesenbergii growth without cell lysis and microcystin release. Additionally, this Cu2 + dose would not promote growth in other Microcystis species.The risk of microcystin release when M. aeruginosa and M. viridis colonies may produce large amounts of microcystins5850 values of these two species to Cu2+ in this study were 0.16 and 0.45 mg L−1, respectively. These concentrations may induce cell lysis and microcystin release. Reports of toxin production are rare in M. flos-aquae (sometimes identified as M. ichthyoblabe)25M. wesenbergii in midsummerM. flos-aquae growth would be inhibited by 1 mg L−1 Cu2+, which is safe for drinking water and there is no risk of microcystin release. Therefore, copper sulfate treatment for Microcystis control could be applied before midsummer when M. aeruginosa and M. viridis are not the dominant species. The dose of copper sulfate should be evaluated according to the dominant Microcystis species.50 value is also affected by initial cell density63Microcystis phenotype36Microcystis phenotype on EC50 were excluded. However, the EC50 values obtained in the current study should be re-evaluated because Microcystis always exists as colonies in lakes with varying cell densitiesMicrocystis should also be consideredThe ECMicrocystis species to copper sulfate. The 96-h-EC50 value of Microcystis species to Cu2+ was in the order of M. flos-aquae > M. viridis > M. aeruginosa > M. wesenbergii and ranged from 0.09 to 0.49 mg L−1. MDA content did not decrease with increasing SOD content induced by increasing Cu2+, suggesting that SOD failed to reduce Cu2+ damage to Microcystis in the current study. However, the species-dependent variation in the sensitivity of Microcystis species to copper sulfate may have resulted from variations in EPS content in different Microcystis species. M. flos-aquae and M. viridis growth were promoted when exposed to 0.05 and 0.10 mg L−1 Cu2+. Our results suggest that copper sulfate treatment for Microcystis control could be applied before midsummer when M. aeruginosa and M. viridis are not the dominant species and the actual amount of Cu2+ used to control M. wesenbergii should be much greater than 0.10 mg L−1, while M. flos-aquae and M. viridis control in lakes requires further investigation.Our results reveal species-dependent variation in the sensitivity of How to cite this article: Wu, H. et al. Species-dependent variation in sensitivity of Microcystis species to copper sulfate: implication in algal toxicity of copper and controls of blooms. Sci. Rep.7, 40393; doi: 10.1038/srep40393 (2017).Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


Nine AESD pediatric patients  admitted to Okayama University Hospital from 2010 to 2016 were compared with 10 control patients with febrile seizures (FS) . Mean PCT concentrations (ng/mL) in the AESD and FS groups were significantly different, at 9.8 ± 6.7 and 0.8 ± 0.9, respectively (p = 0.0006). CRP (mg/dL) were 0.79 ± 0.89 and 1.4 ± 1.0 (p = 0.94), respectively; IL-6 (pg/mL) were 449.7 ± 705.0 and 118.3 ± 145.4 (p = 0.20), respectively; TNF-α (pg/mL) were 18.6 ± 12.5 and 16.6 ± 6.0 (p = 0.67), respectively; and IFN-γ (pg/mL) were 79.6 ± 158.5 and 41.9 ± 63.7 (p = 0.56), respectively. Ratios of PCT to CRP were 27.5 ± 34.2 and 3.2 ± 6.8 (p < 0.0001), respectively. The sensitivity and specificity in the diagnosis of AESD using a cutoff of PCT/CRP ratio of 1.0 were 79% and 100%, respectively. These results suggest that PCT and the PCT/CRP ratio are useful in auxiliary diagnosis of the second stage of AESD, and in AESD, PCT is likely to increase through a different mechanism.Procalcitonin (PCT) is used as a biomarker in severe infections. Here, we retrospectively investigated levels of serum PCT, C-reactive protein (CRP), and inflammatory cytokines (IL-6, TNF- It is a more specific marker of microbial infections than C-reactive protein (CRP) and is used in the diagnosis and assessment of therapeutic effect in sepsis and other systemic infections . Acute eNine AESD patients  admitted to the Department of Pediatrics or the Department of Emergency and Critical Care Medicine, Okayama University Hospital, during the 7-year period from 2010 to 2016 were compared with 10 control patients with complex febrile seizures . The AESD criteria used were the characteristic clinical course which had secondary seizures within a week after febrile seizures, electroencephalogram (EEG) abnormalities characterized by generalized high voltage slow waves and high signal foci in the subcortical white matter on diffusion-weighted head MR images taken at the start of therapy or during follow-up. The criteria of the FS group were status epilepticus lasting ≥15 min plus a clinical course eliminating the diagnosis of encephalopathy.α, and IFN-γ, using a Human Cytokine/Chemokine-Magnetic Bead Panel  with a Luminex 100 system (Merck Millipore).Serum PCT, CRP, and cytokines were measured at the second phase of AESD (before treatment) and onset of complex febrile seizures. In AESD, the changes in PCT and CRP levels during the follow-up period were measured. The measured cytokines were IL-6, TNF-p < 0.05).Statistical analysis was performed using Prism 6.0 software. Wilcoxon's signed-rank test was used to evaluate the statistical significance of differences between the two groups .The average period from the first seizure to the second seizure in the AESD group was 5.3 days (range 4–7). Mean age at AESD onset was 13.9 (range 10–29) months, and pathogens of the preceding infection were influenza A virus (2 cases) and HHV-6 (7 cases). All blood cultures were negative in the AESD group. Mean age of FS onset was 26.6 (range 11–44) months, and causative agents were HHV-6 (2 cases), adenovirus (1 case), human metapneumovirus (1 case), hemolytic streptococcus (1 case), and unknown (6 cases).All patients were treated in accordance with the guidelines for the management of influenza-associated encephalopathy from the time they were diagnosed as AESD. They received pulse steroid therapy, immunoglobulin therapy, mannitol, and edaravone, and five of them received targeted temperature management .p = 0.0006), and 7 out of 9 patients had PCT levels exceeding the cutoff for severe sepsis (2 ng/mL). Similarly, CRP concentrations were 0.79 ± 0.89 mg/dL and 1.4 ± 1.0 mg/dL (p = 0.94), respectively; mean IL-6 concentrations were 449.7 ± 705.0 pg/mL and 118.3 ± 145.4 pg/mL (p = 0.20), respectively; TNF-α concentrations were 18.6 ± 12.5 pg/mL and 16.6 ± 6.0 pg/mL (p = 0.67), respectively; and IFN-γ concentrations were 79.6 ± 158.5 pg/mL and 41.9 ± 63.7 pg/mL (p = 0.56), respectively.Mean PCT concentrations were significantly higher in the AESD group than in the FS group . CRP levels often increase with elevation of PCT levels in sepsis [Elevation of CRP was less prominent compared with that of PCT in AESD, resulting in a significantly higher PCT/CRP ratio in the AESD group 27.5 ± 34.2) than in the FS group (3.2 ± 6.8) ; however, the peak of CRP was delayed (0–3 days after the start of therapy).There are three main categories in AE. The first group typically presents with cytokine storm and cerebral edema, the second with AE with status epilepticus, and the third with AE caused by metabolic derangement. The second group AESD has become the most common 29%) in recent years . The pat9% in recα. IFN-γ inhibits the synthesis of TNF-α, thereby suppressing PCT production. Generally, sepsis and severe sepsis are suspected when serum PCT levels exceed 0.5 and 2.0 ng/mL, respectively [PCT is a 13 kDa protein usually produced in the thyroid as a precursor of calcitonin, a hormone involved in calcium metabolism. However, in severe infections, it is produced in the lungs and liver upon induction by endotoxins, IL-6, and/or TNF-ectively . Howeverectively .In the present study, we found several AESD patients with significant increase of PCT in the second phase. In reports on the relationship between AE and PCT, Takasu et al. report that in a retrospective study of 7 cases of AESD and 8 cases of febrile status epilepticus, PCT on the first day was significantly higher in the AESD group , and Azuα are involved in the pathology of encephalopathy characterized by cytokine storm. In AESD, levels of inflammatory cytokines are increased in the cerebrospinal fluid but only slightly in blood [α, and IFN-γ, between the AESD and FS groups, suggesting that their effects are negligible. In AESD, PCT is likely to increase through a different mechanism from that obtained in sepsis, such as via the involvement of distinct PCT-producing cells.The present retrospective study comparing PCT levels between the AESD and FS groups revealed that PCT was significantly elevated in the second phase of AESD. Also, elevation of CRP was less prominent compared with that of PCT in AESD, resulting in a significantly higher PCT/CRP ratio in the AESD group than in the FS group. Discrepancies in concentration changes between PCT and CRP may be explained by (1) differences in cytokine kinetics and (2) differences in PCT-producing cells and in production mechanisms. Inflammatory cytokines such as IL-6 and TNF-in blood . The prePCT level and PCT/CRP ratio appear to be useful markers in the diagnosis of AESD: patients with a PCT/CRP ratio > 1.0 are likely to have developed AESD. Future studies with more cases will help further elucidate its clinical significance and response mechanisms, which presently remain unclear. AESD is difficult to diagnose in the early stage, and brain dysfunction has often already occurred when the disease is diagnosed.The measurement of PCT and PCT/CRP ratio are safer and easier than MRI or EEG for children, and they may lead to auxiliary diagnosis of AESD. If we can prove that PCT will rise before the second seizure attack, we can anticipate the onset of AESD and intervene at an early stage.α, and IFN-γ, between the AESD and FS groups. In AESD, PCT is likely to increase through a different mechanism from that obtained in sepsis.This study investigated PCT and CRP levels in the second stage of AESD. PCT level increased significantly, while CRP level did not increase in comparison. Furthermore, PCT/CRP ratio was extremely high in AESD compared with other conditions. There were no significant differences in levels of cytokines involved in PCT production, such as serum IL-6, TNF-


Although parotid-sparing IMRT decreased the dose distribution of parotid, parotid region recurrence has been reported. Prophylactic irradiation in parotid area would be necessary in patients with high risk of parotid lymph node metastasis (PLNM). This study was to detect the high-risk factors of PLNM in nasopharyngeal carcinoma.This was a 1:2 case-control study. All patients in this study were newly diagnosed NPC with N2-3 classification from January 2005 to December 2012. Cases were 22 sides with ipsilateral PLNM. Controls were 44 patients who were randomly selected from N2-3 disease in database.vs. 3.6 cm, p = 0.003). Level II lymph node necrosis, level Va/b involvement, and rare neck areas involvement were more common in case group . RPN, level III, and level IV metastases showed no significant difference between the two groups. Multivariate analysis in logistic regression showed that only SLD ≥5 cm in II area  and rare neck areas involvement  were associated with PLNM in NPC patients.20/1096 (1.82 %) NPC patients were found PLNM. Sum of the longest diameter for multiple lymph nodes (SLD) in level II was larger in case group than that in control group (6.0 cm PLNM was an uncommon event in NPC patients. SLD ≥5 cm in level II and involvement in rare-neck areas may be potentially high-risk factors for PLNM. Sparing parotid in IMRT was not recommended for NPC patients with high risks of PLNM. Nasopharyngeal carcinoma (NPC) is usually presented with regional lymph node metastasis. And retropharyngeal nodes and level II were the most commonly involved regions, with the incidence of 69 % and 70 %, respectively . HoweverIn 2013, DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG consensus guidelines regarding the delineation of the neck node levels for head and neck tumors has defined the parotid lymph node group as level VIII, which included the subcutaneous pre-auricular nodes, the superficial and deep intraparotid nodes, and the subparotid nodes . Direct Radiotherapy is the mainstay of definitive treatment modality for nasopharyngeal carcinoma. In conventional two-dimensional treatment era (Ho’s technique), lateral opposing fields encompassed the parotids in the irradiation volume. Mean dose of parotid was 55.3Gy  and ≥ grAlthough parotid lymph node metastasis is an uncommon event in NPC patients, and the target definition and coverage for patients treated with IMRT for parotid sparing is adequate, questions remain pertaining to what high-risk factors would lead to parotid lymph node metastasis in NPC patients and whether the target definition of parotid sparing should be adjusted in patients with high risks. To address these issues, we conducted this case-control study.th edition of American Joint Committee on Cancer (AJCC) staging system, 19/20 (95.0 %) patients were N2-3 classification, which was significantly higher than 616/1096 (56.2 %) in whole NPC patients (p < 0.001). However, in the subset of the N2-3 NPC patients, the rate of PLNM was only 3.3 %. N classification alone was not enough to select the high-risk PLNM patients.We retrospectively reviewed the archives of 1096 patients with NPC who underwent IMRT in Cancer Hospital of Chinese Academy of Medical Science from January 2005 to December 2012. Twenty (1.8 %) patients were shown parotid lymph nodes metastasis when newly diagnosed. And 3 patients were found simultaneously bilateral parotid lymph node involvement. Of the 20 PLNM patients, 10 patients were diagnosed with fine needle aspiration (FNA) and cytological biopsy. And the other 10 patients were diagnosed with contrast-enhanced MR imaging and Doppler ultrasonography. According to the 7This was a 1:2 case-control study. All patients in this study were newly diagnosed NPC with N2-3 classification. One PLNM patients was removed because of the N1 disease. Case group was designed as the ipsilateral neck with PLNM, including 22 cases . 44 NPC patients were randomly selected from the N2-3 patients without PLNM. And the control group was designed as the ipsilateral neck with primary tumor center, or the side with heavier neck disease. This study was performed after approval by the institutional review board and ethics committee. And informed consents from each participant were obtained.rd echelon of draining nodes in NPC [MR imaging was performed in all patients. And the images were separately reevaluated by two radiologists and one radiation oncologist. The node level was divided according to the updated consensus guidelines in 2013 [s in NPC , includit test or Wilcoxon rank sum test for quantitative variables, and the chi-square test or Fisher exact test for categorical variables. Receiver operating characteristic (ROC) curve analysis was used to evaluate different cut-off points for SLD to discriminate case or control group. Binary logistic regression was used to estimate the correlation between multiple exposure factors and the PLNM. With a two-sided test, p value of <0.05 was considered statistically significant.SPSS 16.0 software package was used for statistical analysis. The distribution of exposure factors between case and control groups was evaluated using Median age of the patients in this study was 42  years. All patients had WHO type II or III disease. And 41/63 (65.1 %) patients were T3-4 disease. 47/63 (74.6 %) patients came to hospital because of a chief complaint of the mass in neck. Table Totally, there were 48 positive lymph nodes found in the 22 cases of PLNM. Of the 48 positive lymph nodes, 21 nodes were located in superficial intraparotid, 13 nodes in subparotid, 11 nodes in deep intraparotid, and 3 nodes in pre-auricular area, respectively. The median of largest transverse diameter of nodes in parotid was 1.0 cm . And the median of shortest transverse diameter in the largest plane of parotid node was 0.7 cm . There were 10 cases of ENS and 8 cases of necrosis in metastatic parotid nodes. Fig. Involvement of RPN was found in 53/66 (80.3 %) sides. ENS and necrosis in RPN were found in 43/66 (65.2 %) and 20/66 (30.3 %) sides, respectively. RPN involvement, ENS, necrosis, and SLD showed no significant difference in case and control group.vs. 56.8 %, p = 0.016). The median of SLD in level II was 4.5 cm  in the sets. And the SLD of level II in case group was larger than that in control group .Level II contained IIa and IIb subareas. All patients in this study were involved with level II. ENS and necrosis in level II were found in 59/66 (89.4 %) and 44/66 (66.7 %) sides. And level II necrosis in case group was significantly higher than that in control group , 33/66 (50.0 %), and 14/66 (21.2 %) sides in this study, respectively. The median of SLD in level III was 0.9 cm . And no significant difference in level III involvement, ENS, necrosis, and SLD was found in case and control groups.Level IV involvement, ENS, and necrosis were found in 21/66 (31.8 %), 15/66 (22.7 %), 4/66 (6.1 %) sides in this study, respectively. And no significant difference in level IV involvement, ENS, necrosis, and SLD was found in case and control groups.vs. 20.5 %, p = 0.034). There was no significant difference in ENS, necrosis, and SLD in level Va/b between the two groups.Level Va/b involvement was found in 19/66 (28.8 %) sides in this study. And the rate of level Va/b involvement was higher in case group than that in control group .Rare-neck areas in this study contained level Ia/b, Vc and VIa/b. And level Ia/b, Vc and VIa/b involvement were found in 6, 8, and 2 sides in case group, respectively. The rate of rare-neck areas involvement was higher in case group than that in control group (54.5 % p = 0.003). 5.0 cm (≥5.0 vs. <5.0) was selected as the cut-off point with sensitivity of 72.7 % and specificity of 72.7 %. Binary logistic regression model was used to analyze the high-risk factors of PLNM in multivariate analysis. When SLD ≥5.0 cm in level II, necrosis in level II, involvement in level Va/b, and involvement in rare-neck areas were included into analysis, only SLD ≥5.0 cm in level II  and rare-neck areas involvement  were associated with PLNM in NPC patients . 3.1–4.3 % cases with level Ib involvement has been reported in previous study and all patients were simultaneously accompanied with level II lymphadenopathy [Rare-neck areas in this study were defined as level Ia/b, Vc, and VIa/b, which all belonged to third-echelon of nodal metastases in NPC . The incenopathy . Wang rep = 0.030) and rare-neck areas involvement  were independent high-risk factors of PLNM. Any patients with extensive tumor invasion and suspected blockage of lymphatic drainage should be emphasized to conduct parotid detection. In 2008, Cannon reported two cases of periparotid recurrence in NPC patients after definitive IMRT [Multivariate analysis showed that SLD ≥5.0 cm in level II (OR = 4.11, ive IMRT . Both paive IMRT , but no High-risk factors of PLNM have been discussed for the first time in this study. However, the results of this study should be interpreted with caution, as this was a case-control study of a small sample size. Although periparotid failure was inferred to be related to parotid-sparing IMRT, failure analysis was hard to carry out. Further investigations of large sample from multiple centers may be warranted.To summarize, PLNM was an uncommon event and the incidence was 1.8 % in NPC patients. Any enlarged single lymph node of parotid with largest transverse diameter ≥ 0.5 cm or multiple nodes with borderline size in NPC patients who were simultaneously companied with extensive ipsilateral nodal disease should be further detected. SLD ≥5.0 cm in level II and involvement in rare-neck areas may be potentially high-risk factors for PLNM in NPC patients. Sparing parotid in IMRT was not recommended for NPC patients with high risks of PLNM.


Dendrobium huoshanense is an Orchidaceae perennial herb that is rich in polysaccharides and other secondary metabolites. By using D. huoshanense as the subject, we improved the method originated from CHAN and made it suitable for plants containing high amount of polysaccharides and polyphenols. The extracted total RNA was clear and non-dispersive, with good integrity and no obvious contamination with DNA and other impurities. And it was also evaluated by gel electrophoresis, nucleic acid quantitative detector and PCR assessment. Thus, as a simple approach, it is suitable and efficient in RNA isolation for plants rich in polysaccharides and polyphenols.Acquiring high quality RNA is the basis of plant molecular biology research, plant genetics and other physiological investigations. At present, a large number of nucleotide isolation methods have been exploited or modified, such as commercial kits, CTAB, SDS methods and so on. Due to the nature of different plants, extraction methods vary. Moreover, efficiency of certain approach cannot be guaranteed due to composition of different plants and extracting high quality RNA from plants rich in polysaccharides and polyphenols are often difficult. The physical and chemical properties of polysaccharides which are similar to nucleic acids and other secondary metabolites will be coprecipitated with RNA irreversibly. Therefore, how to remove polysaccharides and other secondary metabolites during RNA extraction is the primary challenge.  Dendrobium huoshanense C. Z. Tang et S. J. Cheng is a famous Orchidaceae perennial medicinal herb that has been used to remedy extensive symptoms, such as chronic superficial gastritis, throat phlegmonosis, to enhance immunity and so forth [D. huoshanense is a precious medicinal herb in China, and rare Daodi herb [D. huoshanense contains a variety of chemical components such as polysaccharides [D. huoshanense have the efficacy of enhancing immunity [D. huoshanense mainly focuses on germplasm resources, cultivation techniques and pharmacological effects.so forth . D. huosodi herb . Becauseodi herb . The govodi herb ,4–7. D. charides , alkaloicharides , amino acharides , flavonocharides  and so oimmunity , anti-oximmunity , anti-tuimmunity , cell apimmunity , lowerinimmunity , liver pimmunity  etc. At D. huoshanense is its high content of polysaccharides [D. huoshanense stem took up 36.23 per cent of its dry weight [D. huoshanense and other plants with similar traits. In this study, D. huoshanense was selected as the subject to extract total RNA from its stem, leaf and flower by applying modified CHAN method [Obtaining high quality RNA is the basis for many plant molecular biology researches . RT-PCR,charides –20. Studcharides  and totay weight . Howevery weight . TherefoN method –25. In aD. huoshanense C. Z. Tang et S. J. Cheng from Orchidaceae. Stems, leaves and flowers of D. huoshanense were washed with tap water, then sterilized with 75% ethanol for 45s, and then rinsed twice with sterile water. Subsequently, plant organs were placed on a sterile filter paper to remove water and finally ground rapidly in liquid nitrogen to obtain fine powder for RNA extraction.Subjects were collected from National Breeding Base of Seeds and Seedling of Medical Herbs for Essential Drugs (Anhui). Professor Nianjun Yu from Anhui University of Chinese Medicine identified the samples as Extraction buffer (EB) ; 20mM, EDTA; 1%(w/v) sodium dodecyl sulphate) was modified from the protocol proposed by CHAN  and PVP 75μL EB, 750μL CI and 30μL β-mercaptoethanol were mixed in a 2.0mL RNase-free microcentrifuge tube.D. huoshanense stem, leave and flower respectively in liquid nitrogen were added to tubes. Vortex vigorously. Place at 20°C for 5 minutes before centrifuging the samples at 4°C for 5 min at 12000×g. Note that the samples should not thaw when they were added to solutions prepared in step 1.50~100 mg of tissue powder made by grinding The supernatant (~700μL) was transferred to a new 2.0mL RNase-free microcentrifuge tube and 700μL of PCI was then added. Mix gently and centrifuge at 4°C for 5 min at 12000×g.The supernatant (~600μL) was transferred to a new 2.0mL RNase-free microcentrifuge tube. 600μL of PCI was added. Mix and centrifuge at 4°C for 5 min at 12000×g. This step resulted in ca 400 μL of supernatant.1/10 volume of 3M sodium acetate (pH = 5.2) and 2.5 volume of absolute ethanol were added to the supernatant. Mix gently and incubate at 4°C for 30 minutes.Centrifuge at 4°C for 10 min at 12000×g to recover the nucleic acids.200 μL of DEPC-treated water was added to dissolve the nucleic acids and 500μL of 10M LiCl was added to the solution. Mix gently and then place on ice for 60 minutes.Centrifuge at 4°C for 10 min at 12000×g. Discard the supernatant and wash the pellet with 800μL of 75% (V/V) ethanol. Air-dry in a ventilator for 5-10min.50 μL of DEPC-treated water was added to dissolve RNA. Incubate at 50°C for 5 minutes. RNA samples can be used immediately for downstream experiments or stored at -80°C for future use.D. huoshanense were collected and tested for integrity by 1.0% (w/v) agarose gel. A260/230 and A260/280 values for RNA samples were measured with an Analytic JENA Scandrop 200 to evaluate purity and yield.The total RNA extract of stem, leaf and flower of D. huoshanensis transcriptomic data. Primer 5.0 software was used to design primers for specific PCR amplification. Sangon Biotech synthesized the sequence. The forward primer of tubulin was 5’-TTC TGG GAG GTG ATC TGC GA-3’ and the reverse 5’-CGG GGG AAT GGA ATG AGG TT-3’. PCR reaction system: 33.5μL ddH2O, 5μL 10× Extaq buffer, 5μL 2.5mM dNTP Mix, 2μL cDNA, 2μL 10μM Forward Primer, 2μL 10μM Reverse Primer and 0.5μL Extaq enzyme. PCR reaction conditions: initial denaturation at 94°C, 2min; 30 cycles at 94°C for 30s, 52°C for 30s and 72°C for 2min. Later, 10μL of the PCR product was used for agarose electrophoresis using TBE buffer (1×) following the usual procedure. The remaining products were stored at -20°C.The first strand cDNA was synthesized using FastQuant RT kit  according to the manufacturer’s instructions. Through BLAST alignment, tubulin homologous sequences were searched in our D. huoshanense contains many polysaccharides, phenols, proteins and other secondary metabolites [D. huoshanense. By trying CHAN method [D. huoshanense RNA, the results were not ideal and the price for purchasing commercial kits was relatively high. Therefore, we set out to establish a simple, economical and efficient RNA extraction method in order to acquire high-quality RNA from plant rich in polysaccharides and polyphenols.Plant gene expression analysis, cloning, transcriptomic and other research often need to isolate and purify RNA from tissues and high purity, high concentration and good integrity RNA is always a must , 26. At abolites –11. ThesN method , Trizol,In this study, extracted total RNA was verified by gel electrophoresis, quantitative nucleic acid detection and PCR analysis. As a routine examination method –32, all 260 and A280 reveals seriousness of protein contamination. Likewise, A260/A230 provides clues for polysaccharides and other related metabolites contamination. Using the modified CHAN method, results from nucleic acid quantitative analyzer showed A260/A280 value of stem RNA at around 2.0, A260/A230 between 1.43 and 2.14 and the concentration ranged from 54.31 to 122.89 ng/μL Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


N = 44,110) published in 2001–2017. The standardized mean differences (SMD) in women who had GDM compared to pregnant women without were 0.25 µg/dL (95% CI: 0.001–0.50) for iron, 1.54 ng/mL (0.56–2.53) for ferritin, 1.05% (0.02 to 2.08) for transferrin saturation, and 0.81 g/dL (0.40–1.22) for hemoglobin. Adjusted odds ratio for GDM were 1.58 (95% CI: 1.20–2.08) for ferritin, 1.30 (1.01–1.67) for hemoglobin, and 1.48 (1.29–1.69) for dietary heme intake. We did not find any differences in TIBC or transferrin concentration in women with and without GDM. We also did not find any association of increased transferrin receptor or increased intake of total dietary iron, non-heme iron or supplemental iron, with increased odds ratios for GDM. Considerable heterogeneity was present among the studies (0–99%), but no evidence of publication bias. Accumulating evidence suggests that circulating and dietary iron biomarkers among pregnant women are associated with GDM, but the results should be interpreted with caution due to the high heterogeneity of analyses. Randomized trials investigating the benefits of iron reduction in women at high risk for GDM are warranted.A meta-analysis of the association of iron overload with gestational diabetes mellitus (GDM) may inform the health debate. We performed a meta-analysis investigating the association of iron biomarkers and dietary iron exposure with GDM. We identified 33 eligible studies ( Additional articles were captured by references and citations found in the original search and from the PubMed option “Similar Articles.” Exposure was defined as circulatory or dietary biomarkers of iron: hemoglobin (g/dL), ferritin (ng/mL), total iron binding capacity (TIBC) (µg/dL), transferrin (mg/dL), transferrin saturation (%), and transferrin receptor (mg/L). Dietary iron biomarkers included: total dietary iron with supplements, dietary iron without supplements, non-heme iron, heme iron, and supplemental iron. A diagnosis of gestational diabetes status was based either on oral glucose tolerance test (OGTT), medical record, and/or self-report. More specifically, the OGTT diagnosis cutoff values utilized depend on which criteria were used by the study . Specific criteria for each study are specified in Studies were selected if they reported an association of iron biomarkers and GDM. The following criteria were required for eligibility: (A) mean, standard deviation (SD), and N of the continuous exposures in pregnant women with vs. without GDM, or (B) unadjusted and/or adjusted odds ratio and 95% CI for the binary outcomes in pregnant women with vs. without GDM, or (C) raw N for the 2 × 2 tables to calculate the odds ratio and 95% CI for the binary outcomes in pregnant women with vs. without GDM.We excluded abstracts, reviews, commentaries, studies with inadequate data, and studies in languages other than English. “Inadequate data” is defined as data that were presented such that it was impossible to extract or calculate the necessary values for inclusion into a meta-analysis. One author (YK) first examined the study titles and abstracts. All studies identified as potentially relevant to the topic were eligible for a full-text review. The study selection process is shown in http://www.ohri.ca/programs/clinical_epidemiology/nosgen.pdf.The quality of each study was evaluated and scored using the nine-star Newcastle–Ottawa Scale (NOS), a tool used for quality assessment of nonrandomized studies . This waTwo authors (YK & YW) extracted information from the selected studies. The following variables were obtained from each study: author, size of study, year of publication, journal, name of study, assessment of GDM, GDM diagnosis criteria, assay type, the number of people with outcome/no outcome in exposed and non-exposed groups, odds ratio with 95% confidence interval (CI) or standard error (SE), mean and SD for continuous variables for exposed and non-exposed groups, and adjustment variables. Analysis was performed using STATA statistical software version 13.1. We combined summary estimates from all the studies in a meta-analysis. metan command to calculate random effects summary estimates in STATA. Comparing dietary and serum iron status to GDM vs. no GDM, we calculated weighted mean differences (WMD) and standardized mean differences (SMD) for continuous variables, and a pooled odds ratio for blood levels of ferritin, transferrin receptor, hemoglobin, and dietary iron intake. We meta-analyzed the unadjusted and adjusted data separately. If studies presented odds ratios parsed by tertiles or quartiles of iron status, we calculated a within-study fixed effect odds ratio for binary GDM status (yes/no) before we meta-analyzed the odds ratios across studies. Statistical heterogeneity was assessed by the I2 statistic, which is a measure of between study variance, and the corresponding Cochran’s Q-statistic p-value (p(het)). To investigate the validity and robustness of the meta-analysis of the mean differences in iron, ferritin, and hemoglobin, for which we had the most studies, we explored heterogeneity in sensitivity analyses by stratifying on study size, continent, and study design, and we performed leave-one-out analyses. Publication bias was measured by Begg’s test and Egger’s test and by visually assessing funnel plots. We used the After removing duplicates, 33 unique articles were identified . We inclThe studies were published from 2001 to 2017. In total, 44,110 pregnant women were included (age range 19 to 41 years). 2 = 83.4%, p(het) = 3.10 × 10−9) and 11.31 µg/dL  = 4.63 × 10−13), respectively  = 0) and 11.33 n/g/dL  = 1.39 × 10−25), respectively  = 1.1 × 10−1)  = 3.83 × 10−7)   and an a × 10−7) . 2 = 93.4%, p(het) = 8.0 × 10−10) and −28.14 µg/dL  = 1.39 × 10−25), respectively  in women who had GDM compared to pregnant women without were −0.47 µg/mL  = 1.73 × 10−7) and 8.30%  = 3.04 × 10−5), respectively  = 3.70 × 10−206)  = 1.11 × 10−2)   and an a × 10−2) . 2 = 95.9%, p(het) = 3.69 × 10−38) and 0.44 g/dL  = 2.33 × 10−24), respectively  = 2.71 × 10−1)  = 8.59 × 10−2)   and an a × 10−2) .2 = 78.6%, p(het) = 9.28 × 10−3)  = 3.58 × 10−2)   and the  × 10−2) .2 = 81.8%, p(het) = 9.00 × 10−4) and adjusted OR of 0.84  = 5.50 × 10−4)  . 2 = 0.0%, p(het) = 5.89 × 10−1) and adjusted OR of 1.48  = 2.09 × 10−1)  . 2 = 93.7%, p(het) = 2.26 × 10−10) and adjusted OR of 1.09 = 3.00 × 10−3)  .2 heterogeneity varied from 0–99% but there was no publication bias present in the meta-analyses (2: 0–99%) amongst all studies for mean differences in iron, ferritin, and hemoglobin levels . Heme and non-heme iron are derived from different food sources and have different absorption mechanisms. Heme iron is derived largely from hemoglobin and myoglobin in meat, poultry, and fish. On the contrary plants, dairy products, and supplements are sources of non-heme iron. Dietary heme iron was positively and significantly associated with GDM but total dietary iron and non-heme iron were not associated with GDM. This finding could be attributable to the different absorption rates of heme and non-heme iron. Additionally the absorption of heme iron is less influenced by other dietary factors compared to non-heme iron . The negIn support of our findings, a case-control study showed that the iron overload C282Y allele frequency is higher in women with GDM than in healthy pregnant women, suggesting a genetic susceptibility to the development of GDM . Our groOur meta-analysis is the most recent that comprehensively, critically, and quantitatively assesses the association between serum iron biomarkers and dietary biomarkers with gestational diabetes. Previous meta-analyses have either only qualitatively assessed the current data and/or are not comprehensive ,42,44,45The meta-analyses were based on observational studies, which are prone to confounding and reverse causation. Two previous randomized clinical trials (RCT) have been conducted investigating the effect of iron supplementation in healthy pregnant women and most with some degree of anemia, but did not find any association ,39. ThesIn conclusion, the meta-analysis suggested that mean differences in circulating iron, ferritin, hemoglobin, and transferrin saturation were higher in women with GDM compared to women without GDM, and increased ferritin, hemoglobin, and dietary heme intake were associated with increased odds ratios for GDM. Results should be interpreted with caution as the pooled estimates had high heterogeneity, potentially due to geographical location, GDM assessment, and selection of iron biomarkers and assays. The lack of association does not necessarily support the null hypothesis as some analyses included only a few studies and thus have wider confidence intervals. There is a clear need for larger and systematically conducted randomized controlled trials utilizing all the available iron biomarkers to elucidate the potential benefit and risk of iron repletion among replete pregnant women and in pregnant women at high risk of developing GDM.


To evaluate renal function, the indices of estimated glomerular filtration rate (eGFR) obtained using several equations, including the Japanese versions of the serum creatinine-based MDRD equation (eGFRcreat), Chronic Kidney Disease Epidemiology Collaboration equation (eGFR-EPI), and serum cystatin C-based equation (eGFRcys), are utilized. This study prospectively examined the association between these eGFR values and all-cause mortality during a 12-year observational period in a community-based population. −1·1.73 m−2) were 81.5 for eGFRcreat, 78.1 for eGFR-EPI, and 76.6 for eGFRcys. There were 141 deaths during the observation period, and the area under the receiver operating characteristic curve for predicting mortality was 0.59 for eGFRcreat, 0.67 for eGFR-EPI, and 0.70 for eGFRcys . In the Cox proportional analysis adjusted for age and sex, eGFRcys, but not eGFRcreat and eGFR-EPI, showed a significant association with all-cause mortality .  The subjects of this study were 1312 participants undergoing a health checkup, aged ≥40 years. In the total population, the mean eGFR values (mL·min This study revealed that eGFRcys showed lower values than eGFRcreat and eGFR-EPI and was significantly associated with all-cause mortality in the Japanese community-based population. The association between renal dysfunction, cardiovascular diseases (CVDs), and total mortality in the general population has been reported previously . The sam−1·1.73 m−2), the CKD-EPI formula was developed in 2009 [In the calculation of eGFR, several equations including the serum creatinine-based Modification of Diet in Renal Disease (MDRD) equation, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, and serum cystatin C-based equation are utilized. The MDRD equation was developed in 1999, using the values of age, sex, and serum creatinine level . Thereaf in 2009 . Additio in 2009 . BecauseHowever, these formulas were developed for the Western population and showed a nonnegligible discrepancy between the eGFR and the actually measured GFR in Japanese subjects. Therefore, for the Japanese population, eGFR values calculated using the Japanese versions of the MDRD equation (eGFRcreat) , CKD-EPIIn recent years, it has been reported that the CKD-EPI equation is superior to the MDRD equation in predicting the development of CVD  and thatThe Yamagata (Takahata) study is a community-based cohort study that recruited participants undergoing an annual health checkup in Takahata town. In this study, 1312 subjects who underwent medical examination including testing for the serum concentration of creatinine and cystatin C between 2004 and 2006 agreed to participate and were followed up for 12 years . Details on the research design, recruitment procedures, and population profiles are described elsewhere . The insTo investigate the association between renal function and prognosis, a follow-up survey was performed annually until the end of 2015. The causes of death were determined by reviewing death certificates through the end of 2015. The death code  and the date and place of death were reviewed .2. Diabetes was defined as a fasting blood glucose level of ≥126 mg/dL and hemoglobin A1c of ≥6.5% or the use of a hypoglycemic drug. Hyperlipidemia was defined as a serum total cholesterol level of ≥220 mg/dL or the use of oral therapeutic agents for hyperlipidemia.At baseline, medical history and clinical symptoms were investigated using a self-answered questionnaire. Systolic blood pressure and diastolic blood pressure were measured in the sitting position after the subject had rested for 5 min or longer, using a mercury pressure gauge. Hypertension was defined as a systolic blood pressure of ≥140 mmHg or a diastolic blood pressure of ≥90 mmHg or the use of oral antihypertensive drugs. Obesity was defined as a body mass index of ≥25.0 kg/mSerum creatinine level was measured using the enzymatic method. Serum cystatin C level was measured using latex agglutination turbidimetry. eGFRs according to the serum creatinine level (eGFRcreat) and serum cystatin C level (eGFRcys) were obtained using the Japanese GFR calculation formulas prepared by the Japanese Society of Nephrology , 10. eGFeGFRcreat:eGFR-EPI:eGFRcys:http://www.r-project.org) was used. A significant difference was defined as P < 0.05.Data are expressed as mean ± standard deviation, unless otherwise indicated. Both unadjusted and age- and sex-adjusted Cox-proportional hazard model analyses were performed to examine the relationship between eGFRcreat, eGFR-EPI, and eGFRcys and all-cause death. All statistical analyses were performed using JMP version 10 . The area under a receiver operating characteristic (ROC) curve (AUC) for all-cause mortality was evaluated. To compare the AUC by using eGFR, eGFRcys, and eGFR-EPI, the DeLong test in the pROC version 1.10.0 package of R statistics . During the 12-year follow-up period, 141 all-cause deaths occurred.The baseline characters of all 1312 subjects  are shown in −1·1.73 m−2), 3B (eGFR 30–44 mL·min−1·1.73 m−2), and 4-5 (eGFR < 30 mL·min−1·1.73 m−2) were 6.1%, 0.3%, and 0.2%, respectively, for eGFRcreat; 4.6%, 1.6%, and 0.5%, respectively, for eGFR-EPI; and 12.2%, 1.8%, and 0.3%, respectively for eGFRcys (−1·1.73 m−2) was 6.6% for eGFRcreat, 6.7% for eGFR-EPI, and 14.3% for eGFRcys. The correlation between the eGFR values estimated using these equations was significantly positive, and the correlation coefficient was 0.808 between eGFRcreat and eGFR-EPI, 0.607 between eGFRcreat and eGFRcys, and 0.710 for eGFR-EPI and eGFRcys  (P = 0.02) and between eGFRcreat and eGFRcys (P < 0.01) but not between eGFR-EPI and eGFRcys (P = 0.679).Next, we examined the association between these eGFR values and mortality. The AUC for predicting all-cause mortality was 0.59 for eGFRcreat, 0.67 for eGFR-EPI, and 0.70 for eGFRcys  . In the −1·1.73 m−2 was 7.3, 8.8, 14.5, and 17.2, respectively, for eGFRcreat; 3.6, 8.1, 19.0, and 17.1, respectively, for eGFR-EPI; and 3.8, 6.7, 11.8, and 27.1, respectively, for eGFRcys  when eGFR ≥ 90, 75–89, 60–74, and <60 mL·min eGFRcys . The num−1·1.73 m−2 with eGFR ≥ 90 mL·min−1·1.73 m−2 as the reference was 1.04 (0.66–1.66), 1.37 (0.90–2.12), and 1.23 (0.66–2.22), respectively, for eGFRcreat; 0.82 (0.37–2.20), 1.07 (0.44–3.04), and 0.99 (0.37–2.98), respectively, for eGFR-EPI; and 0.94 (0.50–1.83), 1.28 (0.70–2.49), and 2.52 (1.33–5.08), respectively, for eGFRcys  but not for eGFRcreat  and eGFR-EPI  (P < 0.01) and that the age- and sex-adjusted mortality risk per 15 mL·min−1·1.73 m−2 decrease of baseline eGFR was significant , indicating that the predictive ability of the mean values of eGFRcreat and eGFRcys was not better than eGFRcys alone.In Cox proportional hazard analysis, the unadjusted risk for all-cause mortality was significantly increased with the decrease in eGFRcreat, eGFR-EPI, and eGFRcys. However, after the adjustment for age and sex, a significant association was observed for eGFRcys but not for eGFRcreat and eGFR-EPI. The hazard ratio (HR) ) of eGFR 75–89, 60–74, and <60 mL·min eGFRcys . Further94–1.38) . The ana−1·1.73 m−2 decreases of baseline eGFR were higher for eGFRcys than for eGFRcreat and eGFR-EPI in most subgroups  of eGFRcreat, eGFR-EPI, and eGFRcys was 1.9, 0.8, and 0.3, respectively, and their 30% accuracy was 75%, 75%, and 78%, respectively . This in1.73 m−2 . HoweverConcerning the association between eGFR and prognosis, some studies have examined eGFRcreat and eGFR-EPI. Matsushita et al. reported that the categorization by eGFR-EPI was more correlated with prognosis than that by eGFRcreat . Ohsawa −1·1.73 m−2, might be overlooked in health checkups. Furthermore, the association with all-cause mortality was stronger for eGFRcys than for eGFRcreat and eGFR-EPI. Although convenience of use and cost-effectiveness are other important issues to consider, eGFRcys may be a better marker for evaluating the risk for premature death in participants of health checkups.The findings of this study have important clinical implications. eGFRcreat is mainly used in clinical practice; however, this study suggested that a substantial number of subjects with borderline renal insufficiency, showing eGFRcys < 60 mL·min−1·1.73 m−2 was small in this study; therefore, it is unknown whether our findings can be applied to subjects with severe renal dysfunction. Fourth, there is a possibility that the small number of subjects with eGFR < 60 in eGFR-EPI and eGFRcreat causes an underestimation of the association between these eGFR values and all-cause mortality in this study.This study has several notable limitations. First, we did not perform the gold standard method for GFR measurement (inulin clearance method); therefore, we do not know the difference between the actual GFR values and the eGFR values obtained with each equation. Second, the number of events was not enough to perform an analysis according to the cause of deaths, and a multivariate analysis adjusted for other confounders such as diabetes mellitus and smoking. Third, the number of subjects with eGFR < 30 mL·minIn conclusion, this study revealed that eGFRcys showed lower values than eGFRcreat and eGFR-EPI and that the association with mortality was stronger for eGFRcys than for eGFRcreat and eGFR-EPI in the Japanese community-based population, suggesting that eGFRcys might be a better marker for health checkups.


As x increases, the temperature span (ΔT) of NTE related with Γ5g antiferromagnetic (AFM) order is expanded and shifted to lower temperatures. At x = 0.1, NTE happens between 256 and 318 K (ΔT = 62 K) with an average linear coefficient of thermal expansion, αL = −46 ppm/K. The ΔT is expanded to 81 K (151–232 K) in x = 0.2 with αL = −22.6 ppm/K. Finally, NTE is no longer visible for x ≥ 0.3. Ferromagnetic order is introduced by Cr doping and continuously strengthened with increasing x, which may impede the AFM ordering and thus account for the broadening of NTE temperature window. Moreover, our specific heat measurement suggests the electronic density of states at the Fermi level is enhanced upon Cr doping, which favors the FM order rather than the AFM one.Negative thermal expansion (NTE) and magnetic properties were investigated for antiperovskite Ga The starting materials were mixed in the desired proportions, sealed in evacuated quartz tubes (10−3 Pa) and then annealed at 873–973 K for 5 days. After quenching the tubes to room temperature, the products were pulverized, mixed, pressed into pellets, and annealed again at 1,073–1,173 K for extra 8 days. The final samples were checked by X-ray diffraction (XRD) on a Bruker X-ray diffractometer (D8 Advance) with Cu Kα radiations at room temperature. The magnetization measurements were performed on a Superconducting Quantum Interference Device Magnetometer . By using a strain gauge, linear thermal expansion ΔL/L was measured on a Physical Property Measurement System  samples. All the samples are single-phase with a typical cubic antiperovskite structure (space group: Pm-3m), except for a very small amount of CrN detected in x = 0.4. The (111) peak shifts toward higher angles as x increases, which indicates the decrease of lattice constant with the increase of Cr content. Figure M(T) of Gax1−CrxN0.83Mn3 (0 ≤ x ≤ 0.3) measured at H = 100 Oe under both zero-field-cooling (ZFC) and field-cooling (FC) modes. As shown in Figure x = 0, indicating an AFM to PM transition as often observed in antiperovskite manganese nitrides. This value agrees well with the Neel temperature (TN) of GaN0.83Mn3 reported previously x1−MnxN0.8Mn3 s are featured by a clear peak in the ZFC curves, while the related FC M(T)s show a FM-like transition. This behavior was verified as a glassy transition  curves with an obvious divergence between them at lower temperatures. The absence of peak in ZFC M(T) curve is indicative of the emergence of long range FM order below 120 K. For x = 0.2, the FM-like transition is increased to 230 K. The kink on ZFC M(T) referring to TN is no longer visible. Instead, a drop of magnetization happens at 210 K in both ZFC and FC M(T) curves, similar to that observed in Gax1−MnxN0.8Mn3 with x = 0.3  curves for x = 0.3 display a FM transition at 322 K, though the FC curve deviates from the ZFC one at low temperatures. Figure M(H)s at 5 K for x = 0–0.3 samples. The magnetization at 45 kOe (M45kOe) increases quickly and linearly with increasing x  curves at high magnetic fields become smaller as x increases, indicating the FM component is enhanced at the expense of AFM component. For x = 0.3, a FM ground state is established.Figure L/L (380 K) for Gax1−CrxN0.83Mn3 (0.1 ≤ x ≤ 0.4). Because of the large volume change at TN which is above room temperature, the as-prepared GaN0.83Mn3 sample was brittle and thus not subjected to the strain gauge measurement. As shown in Figure x = 0.1, the lattice undergoes a continuous shrinkage upon heating between 256 and 318 K (ΔT = 62 K) with an average αL = −46 ppm/K. The onset temperature of NTE region is consistent with the broad AFM transition shown in Figure x = 0.2, The NTE temperature window shifts to 151–232 K (ΔT = 81 K), and the corresponding average αL is about ~ −22.6 ppm/K. The lattice contraction coincides well with the drop of magnetization displayed in both ZFC and FC M(T)s as shown in Figure x is further increased (≥0.3), no NTE was observed down to 5 K.Figure 5g-type AFM one is special because it adopts a larger lattice volume relative to the PM or FM state, which is considered as the prerequisite for the showing up of NTE  for GaN0.83Mn3 and Ga0.8Cr0.2N0.83Mn3 between 6 and 245 K. A broad peak was observed at 220 K for x = 0.2 compound, which is resulted from the structural transition  observed in Figure Cp(T)/T vs. T2 can be well-fitted linearly by using the expression, Cp(T)/T = γ+βT2, where γ  represents for the electronic contribution, the second term is the lattice contribution based on the Debye approximation  for GaN0.83Mn3 and Ga0.8Cr0.2N0.83Mn3, respectively. The value of γ corresponds to the density of the electronic DOS at EF in the ground state. The enhanced γ in the Cr-doped compound indicates an enhancement of DOS at EF. According the Stoner criterion, FM interactions are enhanced in Cr-doped compound compared with the parent compound  contribute a lot to the DOS at EF, while contribution from the face-center Mn atoms (MnII) is very similar to that in GaNMn3  are antiparallel to those at MnII (0.9 μB), leading to a ferrimagnetic ground state below 756 K  of the GaN0.83Mn3, their 3d orbitals will contribute to the DOS at EF. So the substitution of Cr for Ga introduces extra d electrons to the system, and thus increases the DOS at EF, leading to the enhanced FM interactions. A thorough theoretical study on the electronic band structures is needed in order to shed lights on the differences of magnetism and thermal expansion between Cr and Mn doped compounds.Although there are no theoretical reports on the electronic structure of Cr-doped GaNMnx1−CrxN0.83Mn3 (0 ≤ x ≤ 0.3). With increasing x, the NTE window was expanded and moved to lower temperatures quickly. For x = 0.1 and x = 0.2, the NTE occurs at 256–318 K (ΔT = 62 K) and 151–232 K (ΔT = 81 K) with an average αL of −46 and −22.6 ppm/K, respectively. Finally, for x ≥ 0.3, NTE was not observed down to 5 K. As revealed by the specific heat measurement, Cr doping increases the DOS at EF, which favors the emergence of FM order against the AFM background. The competing FM order was suggested to suppress the original AFM order and hinder its propagation upon cooling, leading to the NTE with wide ΔT.In summary, we report large NTE at low temperatures in antiperovskite compounds GaXG and PT designed the synthetic work; XG carried out the synthesis and characterization of all the compounds; JL, CY, KZ, and SL participated in characterization of structure and magnetism; WS and XG carried out the heat capacity; XG and PT analyzed the data and wrote the manuscript; PT revised the paper; YS did discussion for this work. All authors listed, have made substantial, direct, and intellectual contribution to the work, and approved it for publication.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.


Case reports suggest that patients with previous gastric bypass have an increased risk of severe hypocalcemia after total thyroidectomy, but there are no population-based studies. The prevalence of gastric bypass before thyroidectomy and the risk of hypocalcemia after thyroidectomy in patients with previous gastric bypass were investigated.By cross-linking The Scandinavian Quality Registry for Thyroid, Parathyroid and Adrenal Surgery with the Scandinavian Obesity Surgery Registry patients operated with total thyroidectomy without concurrent or previous surgery for hyperparathyroidism were identified and grouped according to previous gastric bypass. The risk of treatment with intravenous calcium during hospital stay, and with oral calcium and vitamin D at 6 weeks and 6 months postoperatively was calculated by using multiple logistic regression in the overall cohort and in a 1:1 nested case-control analysis.We identified 6115 patients treated with total thyroidectomy. Out of these, 25 (0.4 %) had undergone previous gastric bypass surgery. In logistic regression, previous gastric bypass was not associated with treatment with i.v. calcium , or calcium and/or vitamin D at 6 weeks (1.14 (0.39–3.35), 1.31 (0.39–4.42)) or 6 months after total thyroidectomy (1.71 (0.40–7.32), 2.28 (0.53–9.75)). In the nested case-control analysis, rates of treatment for hypocalcemia were similar in patients with and without previous gastric bypass.Previous gastric bypass surgery was infrequent in patients undergoing total thyroidectomy and was not associated with an increased risk of postoperative hypocalcemia.The online version of this article (doi:10.1007/s00423-016-1517-x) contains supplementary material, which is available to authorized users. Several case reports indicate that previous bariatric surgery for morbid obesity constitutes a risk factor for severe hypocalcemia after total thyroidectomy (TT) –3. GastrHypocalcemia after TT can cause unpleasant symptoms, leading to increased costs for sick leave, follow-up visits, and readmission  17]. Th. Th17]. Apart from case reports –3, thereThe Scandinavian Quality Registry for Thyroid, Parathyroid and Adrenal Surgery  started in 2004 and is recognized by the Swedish National Board for Health and Social Welfare as the national quality registry for endocrine surgical procedures in Sweden. Currently, 35 Swedish units report to the registry, covering 88 % of all procedures during the study period. Coverage is assessed by calculating the proportion of patients registered in the SQRTPA in relation to those registered in the Inpatient Register of the Swedish National Board of Health and Welfare. The quality of data for the registered patients is checked by external audit, comparing registered data to hospital medical records. The audit has demonstrated good data quality, with an error rate of <5 % , 19.The Swedish Obesity Registry, SOReg, started in May 2007. All Swedish bariatric units are affiliated with this register. The national coverage is 97 % and regular data quality evaluations have shown that >98 % of data are correct [Patients operated with TT between 1 January 2004 and 31 December 2015 were identified in the SQRTPA. Patients with concurrent or previous surgery for hyperparathyroidism were excluded, as were patients with missing information on postoperative hypocalcemia. By cross-linking with the SOReg, information on GBP was obtained.This study was approved by the research ethics committee at Lund University, DNR 2015/543 and 2016/83.Endpoint data concerning postoperative oral and intravenous (i.v.) calcium and vitamin D treatment during hospital stay, at discharge, and at 6 weeks and 6 months postoperatively were extracted from the SQRTPA. Further, data on age, sex, indication for thyroidectomy, and lymph node dissection were retrieved.The risk of hypocalcemia after TT in patients with and without previous GBP was investigated both in the whole cohort and in a 1:1 nested case-control subset. In the nested case-control group, patients with TT with previous GBP were randomly matched to patients without previous GBP, on the factors age, gender, lymph node dissection or not, and indication for surgery.Means and standard deviations (SD) were calculated for continuous variables except for age. Age is reported as median and range. Numbers and column percentages were calculated for categorical variables.p value of less than 0.05 was considered statistically significant.In the whole cohort, risk for treatment with calcium and vitamin D at different times of follow-up, in patients with and without GBP, was investigated with uni- and multivariate logistic regression, adjusting for possible confounding variables: age, gender, indication for surgery, and lymph node dissection. In the nested case-control subset, ANOVA, chi-square, or Fisher’s exact tests were used to determine the association of primary endpoints with previous GBP. All analyses were performed with STATA 13 . A This study was performed and reported according to the Strengthening the Reporting of Observational Studies in Epidemiology statement .N = 1261). This left 6115 patients for analysis. By cross-linking with SOReg, 25 patients with GBP before TT were identified, corresponding to a rate of 25/6115 (0.4 %).There were 7600 patients who underwent TT. Of these, we excluded 217 patients due to prior or concurrent parathyroidectomy. Another seven patients lacked information on treatment for postoperative hypocalcemia. Patients that were operated before 1 May 2007 (start date of the SOReg) were also excluded (The median age in the cohort was 46 (33–59), male to female ratio was 1:4, and the indication for surgery was thyrotoxicosis in half of the patients. Mean (SD) postoperative total calcium was 2.13  and 641 (10.5 %), respectively.p = 0.977), male to female ratio  and postoperative total calcium  2.13 (±0.16) mmol/l vs 2.12 (±0.20) mmol/l; p = 0.997). However, there was a significant difference for the indication for thyroidectomy (p = 0.015). The most common indication for TT overall was thyreotoxicosis; in patients with previous GBP, it was compression symptoms.In the whole cohort, there were no statistically significant differences between patients with and without previous GBP regarding age ) 48 (41–52) vs 46 (33–59); Total serum calcium and rates of calcium and/or vitamin D substitution at 6-week and 6-month follow-up after thyroidectomy did not differ significantly between patients with and without previous GBP in the whole cohort Table .Table 2EIn the multivariate logistic regression analysis including age, gender, lymph node dissection, and indication for surgery, previous gastric bypass was not associated with in hospital treatment with i.v. or oral calcium (2.07 0.48–9.07); 0.89 0.37–2.11)), oral calcium, and/or vitamin D at discharge (0.75 (0.29–1.91); 1.37 (0.50–3.76)), at 6 weeks (1.11 (0.37–3.31); 1.25 (0.36–4.27)), or 6 months postoperatively (1.45 (0.33–6.36); 2.01 (0.46–8.77); Tables 7–2.11), 8–9.07; 0p = 0.450) mmol/l in patients without. Mean total serum calcium and rates of calcium and/or vitamin D substitution at 6-week and 6-month follow-up after thyroidectomy did not differ between patients with and without previous GBP  mmol/l in patients with previous GBP, vs 2.16


Dapp) as a quantitative imaging parameter, well-suited test fluids are essential. In this study, the previously proposed aqueous solutions of polyvinylpyrrolidone (PVP) were examined and temperature calibrations were obtained. For example, at a temperature of 20°C, Dapp ranged from 1.594  μm2/ms to 0.3326  μm2/ms for PVP-concentrations ranging from 10% (w/w) to 50% (w/w) using K30 polymer lengths. The temperature dependence of Dapp was found to be so strong that a negligence seems not advisable. The temperature dependence is descriptively modelled by an exponential function exp(c2 (T − 20°C)) and the determined c2 values are reported, which can be used for temperature calibration. For example, we find the value 0.02952 K-1 for 30% (w/w) PVP-concentration and K30 polymer length. In general, aqueous PVP solutions were found to be suitable to produce easily applicable and reliable Dapp-phantoms.To use the “apparent diffusion coefficient” ( Diffusion weighted imaging (DWI) is a magnetic resonance imaging (MRI) technique that finds widespread application today –4. By meAs DWI is a sensitive technique, several approaches for validation using ground truth phantoms have been proposed. On the one hand, phantoms mimicking anisotropic diffusion of neuronal tissue have been proposed. These phantoms are often made using thin fibers that make the diffusive motion of the fiber-embedding fluid anisotropic. Such phantoms have been used for multiple different methodological developments in the fields of diffusion tensor imaging –21, kurtStepping back from these advanced applications, an increased interest has recently sparked in finding good isotropic diffusion phantoms. While water has been used in a majority of cases –40, it hOne issue with all test fluids is that their diffusion properties depend on their temperature. One possibility is to fix the temperature, for example, by putting the test fluid in ice water thus maintaining a constant temperature of 0°C , 39, 51.cPVP of 10, 20, 30, 40, and 50% for K30 and 10, 20, and 30% for K90 (w/w). Concentrations of K90 of 40% and 50% were not used, since these concentrations resulted in fluids of high viscosity with trapped air bubbles. The tubes were immersed in a water-filled closed bin, which was placed in a surrounding water bath (Nine plastic tubes (volume 50 ml) were filled with aqueous solutions of polyvinylpyrrolidone (PVP)  with concentrations ter bath  to fill ter bath . The temter bath . The recMRI experiments were performed on a 1.5 T scanner  using a 20-channel head-coil and on a 3.0 T scanner  using a 64-channel head coil. A diffusion-weighted echo planar imaging sequence was used and data was acquired with two parameters sets:2, 20 slices, voxel size = 1 x 1 x 5 mm3, parallel imaging with GRAPPA and acceleration factor of 2, three orthogonal, monopolar diffusion weightings, strength of diffusion weighting b = 0, 100, 200, 300, 400, 500, 600, and 700 s/mm2 acquired with 1 average (b = 0 s/mm2), 2 averages (b = 100 to 500 s/mm2), or three averages (b = 600 and 700 s/mm2), magnitude images were averaged, the vendor-provided image filter was set to “strong” to suppress Gibbs ringing. Acquisition time was 5:52 min.High resolution parameter set: repetition time TR = 5000 ms, echo time TE = 144 ms, readout bandwidth = 1000 Hz/px, field of view = 200 x 200 mm3.Low resolution parameter set: Identical parameters as for the high resolution parameter set except for: TE = 86 ms, voxel size = 2 x 2 x 5 mmThe tubes were oriented perpendicular to the main magnetic field, i.e. along the anterior-posterior direction, and the image plane was coronal, i.e. perpendicular to the tubes. High and low resolution datasets were acquired alternatingly. A low duty cycle sequence of 8:22 min was inserted between them to avoid potential heating of the gradient system.Four data acquisition series were run at each scanner. Two times, the phantom was warmed up to about 30° and was let to cool down. Two times, the phantom was cooled to about 14°C and was let to warm up. Each of the series was acquired in an overnight scan lasting about 10 to 12 hours. One temperature recording file of a 3.0 T run was corrupted so that this run was excluded from the analysis.Dapp) were computed for each voxel using the equationS(b) is the signal intensity in dependence of the b-value with the free fit parameters S0 and Dapp [Dapp-values were computed for manually drawn volumes of interest (VOIs). The circular cross section was specified on the images within the tubes with a safety margin of roughly 3 mm to the tube boundary  in c1 and c2 in Here, c2 on cPVP was modelled by means of a linear fit according to the equationThe dependence of c2 with fitting weights equal to the inverse of the 95% confidence intervals. Additionally, aiming at a further increase of accuracy, the value for c2 at cPVP = 0 from Mill et al. [The coefficients l et al.  was inclAn estimate of the signal to noise ratio (SNR) was obtained by dividing the signal in the PVP solution by the signal in a region of interest outside the phantom. One has to note that this estimate has to be considered being far from accurate, in part due to the use of parallel imaging.b = 0 s/mm2  for K30 and -1 and −5 K-1/%(w/w) for K90. The data points do not lie perfectly on the interpolating straight line. If the assumption that the relation between c2 and cPVP is linear is correct, then the linear interpolation presumably averages out experimental errors and hence it would be more advisable to use the c2 values predicted by the interpolation. These values are stated in The here provided data can be used to calibrate measurements to the sample temperature. Measurements without temperature calibration or temperature fixation seem not advisable, because the observed temperature dependency appears too strong to be acceptable.c1 and c2 are in good keeping with published values. For example, using our measured c1 and c2 in 2/ms, 2.322 μm2/ms, and 2.963 μm2/ms. This matches, for example, closely to the values published by Mills, which are 1.777 μm2/ms, 2.299 μm2/ms and 2.919 μm2/ms [Dapp of approximately 0.852 μm2/ms at 21°C, and Pierpaoli et al. obtained approximately 0.955 μm2/ms at 22°C. Our values for c1 and c2 predict 0.960 μm2/ms at 21°C and 0.983 μm2/ms at 22°C taking into account the difference between (w/w) and (w/v) by means of linear interpolation and using calibration curves that we obtained (K30: cPVP(w/v) = 1.0955cPVP(w/w). K90: cPVP(w/v) = 1.0535cPVP(w/w)): We found that 30% (w/v) corresponds to 27.4% (w/w) for K30 , Keenan et al. report that Dapp ranges from 0.557 μm2/ms at 17.91°C to 0.640 μm2/ms at 22.11°C, while we find corresponding values of 0.512 μm2/ms to 0.584 μm2/ms. Thus at lower concentrations, a good agreement is observed, but at larger concentrations, the deviation becomes as large as 10%. One explanation might be that PVP is hygroscopic . Thus the weight of the powder can depend on its water content. Potentially, this must be accounted for when using PVP solutions as a DWI reference standard. Interestingly, however, the ratio between Dapp values at the largest and the smallest temperature is 0.640/0.557≈1.149 for Keenan et al.’s values and 0.584/0.512≈1.141 for our values indicating that the c2-based calibration by For the case of water, the obtained coefficients 9 μm2/ms . Pullenstrations . They usb and, sixth, it is independent of diffusion time [cPVP = 50%. Moreover, high PVP concentrations are more likely to contain air pockets. In particular, the K90 solutions with cPVP = 30% appear to us to be potentially outside the trustable range due their very high viscosity and thus difficult handling. One drawback of PVP solutions is their susceptibility to mold and bacteria growth, which they have in common with many gels [T1 time [In comparison to other proposed test fluids, aqueous solutions of PVP have several advantages: First, multiple image ghosts arising from chemical shifts are not observed in the echo planar data, which would be the case, e.g., using other proposed test fluids as ethanol or n-propanol . Second,ion time . Seventhany gels . This caany gels , 49. One[T1 time , 55.A recently proposed alternative test fluid is decamethylcyclopentasiloxane . It sharDapp values being correct. Only the relative change with temperature, i.e. c2, must be known.A drawback of the current study is that the calibration curves were obtained with systems that have, of course, their own systematic errors. This was partly overcome by using two systems and several acquisition series. However, in order to perform a temperature calibration, one does not necessarily have to rely on the absolute Dapp value shows little spatial variation and that ringing artifacts can be neglected Click here for additional data file.S2 File(DOCX)Click here for additional data file.S3 File(XLSX)Click here for additional data file.S4 File(DOCX)Click here for additional data file.