The liver of farm animals contained more Al, Cu, K, Mg, Na, Cr, and Sn, while the content of the remaining elements was higher in wild animals. An analysis of correlations between element content and age in wild animals (boar) showed that Pb and Al content increases with age, while Na and Cr contents decrease significantly. Comparisons between the test results and the maximum limits allowed by law showed that, in the case of wild animals, the regulatory limits were exceeded in 18% (for Cd and Cu) and 9% (for Hg) of the liver samples analyzed. In the case of farm animals, the limits for micro- and macroelement contents were not exceeded. The hazard index (HI) values for farm animals were lower than for wild animals, with regard to consumption by both children and adults. Based on the HI values calculated, it seems recommendable that consumption of the liver  by children be limited to once weekly. For adults, the liver can be a valuable source of elements such as Zn, Fe, and Cr, which may be an indication for more frequent consumption.The paper presents the macroelement  and microelement  contents found in the liver of wild animals (boar and deer) and farm animals . Statistically, the differences in element contents between the two groups were not significant (at  The content of particular elements in various parts of the environment typically attracts much attention, and may even stir up emotion when viewed in the context of potential impact on living organisms, and especially on human health Kicińska . Health The liver acts as a filter, or a chemical shield, that detoxifies the body by removing ingested toxins, physiological metabolites, or absorbed toxic chemicals. Its cells, called hepatocytes, absorb and deactivate dead, degenerated, or damaged cells that are no longer needed in the body, viruses and bacteria, and harmful substances ingested with food. These substances are neutralized by biochemical reactions and then excreted with bile. All kinds of the animal liver  are rich in minerals, including highly absorbable Fe, Cu, Zn, and Sn (Kabata-Pendias and Szteke n = 11) and farm animals (n = 22). The collected material was used to:determine the total content of the selected macroelements  and microelements ;identify differences in the content of these elements between wild and farm animals, as well as between the studied species ;compare the test results with the regulatory limits for food and with data reported by other authors; andcalculate the health risk involved in eating liver from both animal groups, associated with the content of selected elements , for children and adults.But is eating the liver really good for human health? We attempted to verify this by testing 33 liver samples from wild animals . Fresh liver samples, 100 g or more per sample, were obtained at two livestock buying stations. At the same time, surveys were used to collect information on the animals’ age, breeding and raising methods, and nutrition . For wild animals, the samples were obtained from three hunting clubs, and information on the animals’ age, sex, and body weight was provided by the hunters.n = 22 samples), including 11 chickens (mostly aged 1–2 months), 4 rabbits (3–12 months), 2 cows (2 and 18 months), 2 goats (2 and 36 months), 1 pig (6 months), 1 duck (8 months), and 1 turkey (18 months).Fresh, raw liver samples were placed in plastic bags and frozen until completion of the material collection stage. The total number of samples was 33, including 11 samples from wild animals . The animals were aged between 6 months and 5 years. Most material was collected from farm animals  at a 1:10 ratio of solids to solution. Additionally, mineralization was performed using a 30% H2O2 solution at 105 °C for 2 h. The solution was then cooled and poured into test tubes. The concentrations of Al, As, Ca, Cd, Co, Cr, Cu, Fe, Hg, K, Mg, Mn, Mo, Na, Ni, P, Pb, S, Sn, and Zn in the extracts were determined by ICP-MS using an Elan 6100 system at the accredited AGH UST geo-hydrochemical laboratory in Kraków (certificate No. AB1050), with a precision of 10−5 mg/dm3. LOD and LOQ values were calculated using formulas presented in Kicińska content of the metal (Me) in a dry sample (mg kgMe-mwC−1)content of the metal (Me) in a fresh sample (mg kgXmoisture (water) content in the sampleTo standardize the values published by other authors, we decided to report the test results in milligrams per kilogram of dry weight (DW), and fresh weight (FW) values reported in literature were converted to DW using formula  below, wRfDreference dose according to US EPA EDI−1 bw day−1), calculated using formula (estimated daily intake (mg kg formula :C−1)element content (mg kgEF−1)exposure frequency IRF−1 day−1, calculated in mg)liver consumption  US EPA ATaverage exposure time (365∙ED), while in the case of carcinogens the value is 25,550 (days)CF1−6unit conversion factor of 10To assess the potential health risk (HQ) for consumers, according to the US EPA methodology , 2007, w> 1, adverse effects are probable, while values of HI > 10 indicate high exposure and high chronic health risk associated with toxicity. To establish a level of the cancer Risk for carcinogens, the HQ doses were multiplied by the respective slope factors (US EPA Hazard index (HI) was calculated as the sum of HQ values. At HI ≤ 1, the probability of adverse health effects is low, at HI s US EPA .−1 DW (dry weight) for P and 8108–12,731 mg kg−1 DW for S (Table −1 DW), respectively. As to highly absorbable elements, which included Fe, Ca, Cu, Mg, and Zn, the respective contents were 79–3144, 144–769, 4–139, 356–596, and 43–200 mg kg−1 DW. Small amounts of Mn were also found (3–12 mg kg−1 DW).Out of all elements tested for, P and S dominated in the chemical composition, with values of 13,223–20,216 mg kgp = 0.05), except in the case of Fe, K, and Mg. In the studied population of wild animals, the respective levels of these elements were 448, 6141, and 1761 mg kg−1 DW, while in the population of farm animals, the respective values were 408, 6731, and 498 mg kg−1 DW : As 0.16, Cd 1.15, Co 0.07, Cr 2.81, Hg 0.07, Mo 2.67, Ni 2.29, Pb 0.45, and Sn 1.35. For farm animals, the calculated means were slightly higher in two cases : for Cr the mean was 2.99 , and for Sn, it was 1.44 (approx. 7% higher). The mean levels of the remaining elements were between 4 and 70% lower than in wild animals. The values (in mg kg−1 DW) were as follows: As 0.10, Cd 0.34, Co 0.06, Hg 0.02, Mo 2.04, Ni 2.09, and Pb 0.21  were only found for Cd, Hg, Mo, and Pb.The microelement group included, As, Cd, Co, Cr, Hg, Mo, Ni, Pb, and Sn, and the content of these elements in the samples was 0.04–0.56, 0.03–4.02, 0.01–0.12, 2.34–8.07, 0.01–0.40, 1.2–4.61, 1.81–3.09, 0.08–1.01, and 1.13–1.77 mg kgThe highest variability in the entire material was found for the concentrations of Hg (V = 30), Cu (V = 26), Fe (V = 22), Al V = 21), and Cd (V = 20). In this group, the so-called extreme values were also found , Co (0.10 mg kg−1 DW), and Cu (61.60 mg kg−1 DW)—in the boar liver, the levels of these elements were 0.16, 0.06, and 14.48 mg kg−1 DW, respectively. Mg and Mn contents were similar between the two species , while in the present study, the mean Cu content was 14.48 mg∙kg−1 DW, and the range was 8.03–43.95 mg kg−1 DW; andthe obtained results for Cd, Cu, Pb, and Zn were similar to those reported by Neila et al.  in the ba et al. ; the meawith regard to the deer liver, we found considerably higher levels of Al, As, Ca, Cr, Mn, and Ni; comparable levels of Cd, Co, and Mn; and considerably lower levels of Cu, Fe, Mg, Pb, and Zn than those reported for the deer liver samples by Khan et al.  and DługComparisons between the obtained results and values reported by other authors show that:−1 DW, respectively), compared to samples from females . The opposite was found for Cu, with slightly higher concentration of this metal found in female boars (23.83 mg kg−1 DW) than in males (23.08 mg kg−1 DW).In the boar population, samples were collected both from males and females. The calculated means and standard deviations indicate that the levels of Al, As, Hg, K, Mg, Pb, and Zn are higher in male boars Table . The livp = 0.05, the calculated differences in levels of the analyzed elements between the livers from male and female boars were not significant.With a significance threshold set at p = 0.05, p = 0.01, and p = 0.001) in the wild animal population (Table r < 0.7) was found for the following combinations: Mg–K, Mg–S, S–Mn, Fe–Cd, Cd–P, Co–Cu, Cr–Al, Cr–Na, Ni–Na, Pb–Na, Pb–As, and Pb–Hg. Similarly high inverse correlation was found for Na–Al, Cu–Fe, Zn–Cu, and Pb–Al. Very high correlation (0.7 ≤ r < 0.9) was found for P–Mg, Mn–Al, Zn–K, Mo–Cd, and Ni–Ca. Almost full correlation (0.9 ≤ r < 1) was only found for the Hg–As pair.Correlation coefficients were calculated for element content and animal age  and Al (r = 0.62) contents increase with age, while Na (r = − 0.84) and Cr (r = − 0.65) contents decrease significantly. For the remaining elements, no statistically significant correlations were found. Similar findings were reported by Khan et al. (p < 0.05) for Cd, Co, Cu, and Zn.An analysis of correlations between element content and age in wild animals showed that Pb , with slightly lower values in the pig  and chicken livers . The lowest P content was found in the rooster liver . These results are considerably higher than the P content listed in the basic report from USDA . For S, the highest levels were found in the duck liver , the lowest in the rabbit liver (9698 mg kg−1 DW) which also contained the least K . The highest K content was found in the chicken liver (7214 mg kg−1 DW). Na levels were the highest (2709 mg kg−1 DW) in the rooster liver and the lowest (1506 mg kg−1 DW) in the cow liver.The other, much larger, group studied included farm animals, and specifically, chicken, duck, goat, turkey, rabbit, and cow . Comparisons for such a large number of elements are rather difficult, mainly due to the wide variance in their concentrations. Therefore, the analyzed elements were divided into four groups Fig. . Group 1−1 DW) in the following: rabbit (495), turkey (3144!!), cow (534), pig (164), and goat livers (64). The lowest Ca, Fe, Al, Zn, and Cu levels were found  in the following: duck (370), cow (89), turkey (18), rooster (54), and chicken livers (8.6). The Ca values found in the duck, pig, cow, and chicken livers are considerably higher than those published by the USDA . The Cu levels found in the present study are considerably higher than those reported by Oyaro et al. , pig 14, and go−1 DW); Cr and Sn—in the chicken liver ; Mo—in the pig liver (2.78 mg kg−1 DW); and Ni—in the goat liver (2.21 mg kg−1 DW). The lowest mean Mn, Cr, Mo, Ni, and Sn contents were found  in the following: chicken (6.42), duck (2.48), rooster (1.45), turkey (1.90), and pig livers (1.23).Group 3 included elements found in concentrations of several ppm: Mn, Cr, Mo, Ni, and Sn Fig. c. Some o−1 DW) in the following: rooster (0.896), duck (0.650), pig (0.163), and turkey livers (0.051 and 0.100)  in the following: chicken (0.191), duck (0.125), rooster (0.043), turkey (0.018), and pig livers (0.033).Group 4 included those microelements that are considered as having no benefit with regard to growth and development: Cd, Pb, As, Hg, and Co. In high concentrations, these elements can be highly toxic or even carcinogenic. The highest Cd, Pb, As, Hg, and Co contents were found  Fig. d. The loThese results were higher than those reported by Szkoda and Żmudzki  for pigsIn the studied farm animal population, statistical analyses of age-related differences in element content would be pointless, as the groups were small and did not differ greatly in terms of age.−1 FW for As, Cd, and Pb, and 0.05 mg kg−1 FW for Hg. Comparisons between the test results and the maximum content limits showed that, in the case of wild animals, the regulatory limits were exceeded in 18% (for Cd and Cu) and 9% (for Hg) of the liver samples analyzed. The results for farm animal liver samples are much better, as none of these elements exceeded the allowed limits  in a variety of food products (including the liver). Thus, the Polish Health Ministry Regulation of 2003 and the Commission Regulation  were somewhat better. RDI values were not exceeded for Sn, Co, Ni, Mo, Pb, Hg, As, or Zn. Cd content exceeded the limit in just 1 sample, Fe—in four samples, Cu—five, Al—eight, and P—nine samples.Results for farm animal liver samples , the RDI for Pb and Cd was exceeded. The RDI for Cu was exceeded in two liver samples, boar and deer, and the RDI for Fe was exceeded in seven boar liver samples. In the farm animal liver samples, RDI for Cd was exceeded in 1 case (turkey), Al—in three cases , Cu—in three , and Fe—in four .Cr levels were the most alarming, as they exceeded the RDI both for children and for adults in all the analyzed liver samples, collected from wild as well as farm animals.For the purpose of assessing the health risk involved in human consumption of animal products, we used 100 g as the daily animal liver consumption, based on the FAO/WHO expert committee report on veterinary drug residues EC No. 782/82/7 for ing) calculation. HQing was calculated for children and adults with an assumed FIR = 100 g  in the two sample groups.ing values calculated for children, we found HQing values > 1, which indicate a possible health risk, only for daily consumption of the liver from wild animals, due to Fe (2.23E+00), Cd (1.75E+00), and Cr (1.40E+00) content. With the farm animal liver, the only risks were related to Fe (2.03E+00) and Cr (1.50E+00) content. With once per week consumption of the liver, the HQing values for all the analyzed elements were below 1, which indicates no health risk. For adults, all HQing values were below 1, both for daily and weekly consumption of the liver and for wild and farm animals. This warrants the conclusion that the product does not pose a health risk.Based on the specific HQHFE gene. The health risk associated with high Cd and Cr content can be alarming.While the high Fe content in the animal liver is not problematic (indicating instead that the liver is an important source of highly absorbable Fe). Iron overload may occur but only when the element is delivered in supplements. With iron delivered in food, the organism carefully regulates its levels, assimilating this microelement according to the current needs. Any excess of this element is safely removed (it is not assimilated). The most frequent reason for elevated iron levels is a genetic predisposition for accumulation of iron, i.e., hemochromatosis. It is usually caused by a mutation of the Cd accumulates in the human body throughout the life, due to the element’s long half-life (10–33 years). Kabata-Pendias and Szteke  state thing > 1. It is needed for human and animal health, and has two forms: Cr3+ and Cr6+. Cr plays an important role in protein and lipid metabolism, as well as in the action of insulin. In food, it is mainly present as Cr3+, though this does not apply to the liver. Cr content in the body decreases with age, and the decrease is particularly marked in the liver. Therefore, the element is often included in the so-called geriatric supplements.Cr was another element with a HQing values calculated for children and adults, considering daily or weekly consumption, are shown in Table The final hazard index (HI) values, which are the sum of all HQThe HI for children  and for adults  is greater than 1, which may indicate a possible adverse health impact. No such risk was found for adults eating liver from wild or farm animals once weekly Table .The HI values for element content in the farm animal liver were lower than those for the wild animal liver, with regard to consumption by both children and adults. In the context of the analyzed macro- and microelement contents, this may indicate that the farm animal liver is “safer” for human consumption.With daily animal liver consumption in the case of children, the risk index was 3.21E−05 and 1.93E−05 for wild and farm animals, respectively. These values are close to the limit considered safe (10E−05). As for the scenario assuming animal liver consumption once weekly and once daily in the case of adults, the risk index ranged between 7.85E−07 and 9.18E−06. Since these values are below the permissible limit, this situation can be deemed satisfactory.No significant differences were found in the macroelement levels analyzed  between the livers from wild and farm animals. The farm animal liver contained more Al, Cu, K, Mg, and Na (the difference ranged between 9 and 23%). Mn and P levels were found to be nearly identical in these two animal groups. Slightly lower results were obtained for farm animals than for wild animals with regard to content of Zn, Ca, and Fe.With regard to microelements , farm animal liver had a higher mean content of Cr and Sn only. The mean levels of the remaining elements were between 4 and 70% lower than in wild animals.p = 0.05), with the exception of Fe, K, Mg, Cd, Hg, Mo, and Pb.Statistically, the differences in element contents between the livers from wild and farm animals were not significant  and 9% (for Hg) of the liver samples analyzed. The results for farm animal liver samples are much better, as none of these elements exceeded the allowed limits.The HI values for the liver from farm animals were lower than for wild animals, with regard to consumption by both children and adults. In the context of the analyzed macro- and microelement contents, this may indicate that the farm animal liver is “safer” for human consumption.Based on the HI values calculated, it seems recommendable that consumption of the liver  by children be limited to once weekly.For adults, the liver can be a valuable source of elements such as Zn, Fe, and Cr, which may warrant more frequent consumption.Based on our analysis of macro- and microelement contents in 33 liver samples collected from wild animals  and farm animals , the following conclusions can be formulated:


Kimura’s disease (KD) is a rare chronic inflammatory disorder with a high incidence of renal involvement. In this report, we present a case study of KD-associated nephrotic syndrome combined with minimal change disease (MCD) and acute renal tubular injury. Meanwhile, the clinical and histopathological characteristics of 26 patients with KD presenting with renal involvement were retrospectively evaluated.Here, we report a case study of a 59-year-old male patient with KD confirmed by a lymph node biopsy. He developed widespread edema and decreased urine output. A palpable swollen mobile and non-tender lymph node behind the left ear was observed upon admission. A renal biopsy revealed minimal-change lesions and acute renal tubular injury. The patient received hemodialysis because of the oliguria and renal insufficiency, and an initial dose of 40 mg/d methylprednisolone and then continued treatment with 40 mg/d prednisolone. He exhibited a good clinical response to the steroid after 6 weeks of treatment. Of the other 26 patients included in the review, 13 patients presented with mesangial proliferative glomerulonephritis, 4 with membranous nephropathy, 3 with MCD, 3 with focal segmental glomerulosclerosis, 2 with IgA nephropathy and 1 with acute tubular injury. With the exception of 2 patients who progressed to end-stage renal disease and received hemodialysis, the majority of patients responded well to treatment with corticosteroids alone.MCD combined with acute renal tubular injury is rare in patients with KD presenting with renal involvement. Corticosteroids may be a beneficial treatment for renal injury in patients with KD. Kimura’s disease (KD), a rare chronic inflammatory disorder whose etiology is unknown, was first reported by Kim and Szeto in 1937.The disease has a higher prevalence in Asians , 3. KD i2, and the ESR was 112 mm/h. The patient’s serum complement (C3 and C4) levels, antinuclear antibody titers, antistreptolysin O titers, and hepatitis screening results were normal. Hematology revealed a normal hemoglobin concentration and platelet count, a total white blood cell count of 6.98*10E9/L, and a percentage of eosinophils of 6.6%. The serum IgE concentration was elevated, as it was higher than 4000 IU/mL. A Mycobacterium tuberculosis γ-interferon release test was negative, and a bone marrow biopsy did not display obvious abnormalities. A neck CT showed that the cervical vascular sheath was surrounded by several small lymph nodes, and an ultrasound demonstrated the presence of bilateral pleural effusions and ascites. Pleural effusion examination revealed a karyocyte count of 76*10E6/L, a neutrophil count of 12%, a lymphocyte percentage of 85%, an Alb concentration of 1.8 g/L, a lactate dehydrogenase (LDH) concentration of 44 U/L, and an adenosine deaminase (ADA) concentration of 1.3 U/L.A 59-year-old male patient presented with widespread edema and decreased urine output. The patient had no history of active arthritis, hemoptysis, bleeding, purpura, fever, chills, weight loss, streptococcal infection or known tropical disease and had not suffered from asthma or any other atopic diseases. At the time of his visit to our hospital, his blood pressure was 136/93 mmHg, and his temperature was 36.9 °C. The physical examination showed that the patient was suffering from left-sided hearing loss and revealed the presence of a palpable swollen mobile and non-tender lymph node with a size of approximately 1.5*1 cm located behind the left ear. No other superficial lymph nodes were palpable. A urinalysis showed 3+ proteinuria and 3.68 g of proteinuria in 24 h.The serum albumin (Alb) concentration was 11.3 g/L, the serum creatinine concentration was 218.7 μmol/L, the BUN concentration was 25.33 mmol/L, the eGFR was 27.4 mL/min/mHistological sections of lymph nodes were examined in the department of pathology. The examinations revealed the presence of follicular and interfollicular hyperplasia and the proliferation of venules surrounded by infiltrating eosinophils, lymphocytes, plasma cells, and mast cells. An eosinophilic microabscess was detected in the cortical area of the lymph nodes Fig. . These fRenal biopsy showed that two glomeruli were sclerotic (13 glomeruli were assessed). The remaining glomerular mesangial cells and stromal cells showed signs of mild proliferation. No significant widening of the mesangial area was observed, and the basement membrane had no obvious lesions. The tubular epithelial cells displayed signs of vacuolization. Additionally, part of the renal tubular epithelium had flattened, and the bristles had fallen off. Small numbers of protein casts were present in the dilated tubules. No obvious interstitial inflammatory cell infiltration (including eosinophil infiltration) was present, and no IgG, IgA, IgM, C3, C1q, C4 or Fib deposition was noted in any of the glomeruli. Electron microscopy showed mild hyperplasia of mesangial cells and stromal cells, extensive fusing of the podocyte processes of the epithelial cells, and a lack of electron-dense deposits Fig. .These fi2, increased the serum albumin concentration to 15.6 g/L and significantly increased urine output compared with pre-treatment values. However, the patient’s proteinuria increased to7.02 g/day.The patient’s volume load did not respond to diuretics, and his urine output decreased. Furthermore, increases in the patient’s urea and creatinine levels were observed. Therefore, hemodialysis was initiated to improve the patient’s edema and kidney function. The renal biopsy demonstrated the presence of MCD combined with acute renal tubular injury. The patient was ultimately diagnosed with KD associated with MCD and acute renal tubular injury. The patient subsequently received 40 mg/day methylprednisolone for 3 weeks. Urinary protein and renal function were monitored during treatment, which decreased the patient’s serum creatinine level to 62.3 μmol/L, increased the eGFR to 103 mL/min/m2. The changes in the patient’s laboratory indexes are shown in Fig. 3.The patient withdrew from hemodialysis and continued taking 40 mg/day prednisolone after discharge, but returned to our hospital after 6 weeks. At that time, urinalysis revealed 1+ proteinuria. The serum albumin concentration was 37.5 g/L, the serum creatinine concentration was 69.4 μmol/L, the BUN concentration was 12.55 mmol/L, and the eGFR was 97.8 mL/min/mSeveral databases, including PubMed, EMBASE, MEDLINE (Ovid), the Chinese National Knowledge Infrastructure (CNKI), the VIP Database for Chinese Technical Periodicals (VIP), and WanFang Data, were systematically searched from the date of database inception until Nov 01, 2017 to collect published international and domestic studies with the term “Kimura’s disease” and “Nephrotic syndrome”. The selection criteria were as follows: 1). studies including patients who were diagnosed with KD by lymph node or mass biopsy; 2). studies in which renal involvement was noted in all patients, and renal biopsy was used to define the pathology. The exclusion criteria were as follows: 1). studies which the patients were diagnosed with Kimura’s disease but with no renal involvement; 2). the data provided by the articles could not be accessed, or the full text could not be transformed. 3). the articles were reviews or abstracts. Ultimately, 18 studies , 7, 9–24Of the 26 patients included in the review, two were female and were from China and India, respectively, and the remaining patients were male. Thus, the male-to-female ratio was 12:1. Most of the patients presented with cervical lymphadenopathy or subcutaneous masses in the head or neck region. The mean age of these patients was 31.1 ± 14.2 years, the daily protein excretion level was 8.04 ± 4.62 g/24 h, the serum albumin concentration was 21.2 ± 8.57 g/L, the serum creatinine concentration was 170 ± 190 μmol/L, the blood eosinophil count was 23.7 ± 15.4%, and the IgE titer was 1285 ± 1223 IU/mL.Renal biopsy was performed in all patients. Most of the patients presented with mesangial proliferative glomerulonephritis (13 patients). Other patients presented with membranous nephropathy (4 patients), minimal change disease (3 patients), focal segmental glomerulosclerosis (3 patients), IgA nephropathy (2 patients) and acute tubular injury (1 patient).Tripterygium wilfordii, cyclophosphamide and leflunomide. With the exception of 2 patients who progressed to ESRD  and received hemodialysis, all other patients achieved remission with respect to their proteinuria. Simultaneously, the neck lymph nodes or masses became smaller. However, 5 patients experienced a proteinuria relapse during follow-up, including 4 patients with mesangial proliferative glomerulonephritis and one patient with membranous nephropathy.The majority of patients were treated with corticosteroids alone, while a small number of patients received corticosteroids combined with immunosuppressive agents, such as KD presents as a benign subcutaneous mass, and males are affected by KD more often than females. However, KD combined with kidney involvement is not rare. According to previous reports in the literature, kidney involvement often presents after the skin changes have been present for a few months. Regarding the patients who have kidney involvement associated with KD, 12–16% have proteinuria, and 59–78% have nephrotic syndrome , 26. TheWang et al.[27]analyzed the clinical presentations of 20 patients with KD-associated nephrotic syndrome in China and found that men were predominantly affected by the disease, as the male: female ratio in their study was 19:1. The average proteinuria level in these patients was 8.67 ± 4.73 g/day. Renal biopsy was performed in 13 patients and showed that various forms of renal pathology were present. 9 patients had mesangial proliferative glomerulonephritis, 2 had MCD, and 2 had membranous nephropathy. Although mesangial proliferative glomerulonephritis was the most common disease demonstrated by renal biopsy in the review, MCD combined with acute renal tubular injury was demonstrated by renal biopsy in this report.Although some patients with KD suffer from kidney disease, the pathogenesis of KD and its associated renal involvement is not very clear. Several studies of the immunopathogenic features of the disease found that the pathogenesis of KD with renal involvement may be related to high serum IgE levels and eosinophilia . In addiCorticosteroids are particularly applicable for the treatment of KD with renal involvement , as theyThis report is about a singular manifestation of KD. Our patient, a middle-aged male, presented with atypical KD with renal involvement that responded well to steroids. The patient did not experience recurrence of either his skin lesions or his nephrotic syndrome during the follow-up period. We used corticosteroids alone, which successfully restored the patient’s renal function to normal. However, our follow-up time was short, and the long-term efficacy of the above treatment needs confirmation. In summary, steroids are still the first-choice treatment for KD with renal involvement but can be combined with immunosuppressive drugs if proteinuria persists.MCD combined with acute renal tubular injury is rare in patients with KD presenting with renal involvement. Corticosteroids may be a beneficial treatment for renal injury in patients with KD.


Chrysomya pinguis   is an endemic Asiatic blow fly species of forensic importance. Chrysomya pinguis is one of the first species to colonize a corpse, especially in high altitude areas during spring and autumn when the ambient temperature is lower. Despite its potential for forensic investigations to estimate the minimum postmortem interval (PMImin), little is known about the development of C. pinguis. In this study, C. pinguis was collected from the Yangtze River Delta region of China and reared at seven constant temperatures between 16°C and 34°C to investigate the effect of temperature on development duration, accumulated degree hours and larval body length of C. pinguis. Isomorphen and isomegalen diagrams for C. pinguis were generated using the results, and equations describing the variation in larval body length during development and the temperature-induced variation in development time were also obtained. Chrysomya pinguis can complete its life cycle at 16–34°C. The mean (±s.d.) developmental durations of C. pinguis from egg to adult at 16°C, 19°C, 22°C, 25°C, 28°C, 31°C and 34°C were 811.0 ± 3.8, 544.8 ± 2.0, 379.8 ± 1.8, 306.7 ± 2.4, 250.0 ± 2.8, 203.2 ± 2.1 and 185.3 ± 1.6 h, respectively. The mean (±s.e.) developmental threshold temperature D0 and the thermal summation constant K of the whole developmental process of C. pinguis were estimated as 10.88 ± 0.21°C and 4256.50 ± 104.50 degree hours, respectively. This study provides fundamental development data for the use of C. pinguis to estimate PMImin. As theyng death –5. As blng death ,7, it ismin more easily, several developmental models have been proposed, and the thermal summation model and the isomorphen as well as the isomegalen diagrams have been the most commonly applied models in forensic entomology [Entomological methods to age the immature insects are generally achieved through identifying developmental landmarks, such as length, weight and developmental stages of the juvenile insect, depending on the ambient temperature . To estitomology .Chrysomya pinguis   is an important necrophagous species that is primarily distributed in Asian countries [C. pinguis often coexists with Chrysomya megacephala (Fabricius) [C. pinguis appears to be adapted to colder climates [C. pinguis migrates between low and high elevations depending on the season [C. pinguis colonizes human corpses in different areas of Asia, and is regarded as a forensically important species [ountries , such asountries . Insect bricius) , but C. climates  and is mclimates ,15. Somee season . It is w species ,17.FiguC. pinguis have been focused on its external morphology [C. pinguis under seven constant temperatures between 16–34°C. Using these data, developmental models were built to improve the use of this species for forensic investigations to estimate the PMImin.At present, the majority of studies on rphology ,18,19, srphology –22, karyrphology , geograprphology –27, myasrphology  and DNA-rphology ,29,30. Hrphology . Therefo2.2.1.C. megacephala. Flies with brilliant blue body colour and grey bucca with black hairs were picked out and caged (30 × 30 × 30 cm3) at room temperature (approx. 25°C) with natural humidity and light at the laboratory of Forensic Entomology, Suzhou. Adults were fed with fresh water and a 1 : 1 mixture of sugar and powdered milk. Fresh lean pork was provided to induce ovary development and reproduction. Eggs that were oviposited on the fresh lean pork were removed from the cage and reared in a separate insect-rearing box under controlled conditions until emergence. Newly emerged adults from each rearing box were caged separately. Adults were randomly selected from each cage and pinned specimens were made, all of which were subsequently identified as C. pinguis under stereomicroscope using external morphology and male genitalia based on Fan [Chrysomya pinguis is a large-sized species with high flight capability, therefore flies were combined into one larger cage (200 × 100 × 100 cm3) to provide more space for mating and oviposition. In May 2017, about 300 wandering larvae were collected from the same field environment and cultured as above. After eclosion, the adults identified as C. pinguis were supplemented into the established colony. The colony was cultured for three generations and maintained at a density of approximately 4000 adults per cage for subsequent experiments.In April 2016, about 20 fly adults were collected from pig cadavers put in a field of Suzhou, China . We obtained the permissions to carry out fieldwork by Forensic Autopsy Centre of Suzhou. Among the flies, eight adults  had very similar morphology as d on Fan . Chrysom2.2.3) that contained sandy soil at the bottom. The insect-rearing box was kept in the artificial climate incubator LHP-300H  at constant temperatures of 16°C, 19°C, 22°C, 25°C, 28°C, 31°C or 34°C, with 75% humidity and photoperiod of 12 L : 12 D  for 30 s and stored in 80% ethanol . Samples2.3.min, the relationship between larval body length and time after hatching was investigated through a polynomial regression analysis adopting ‘larval body length’ as an independent variable and ‘the time after hatching’ as a dependent variable. The equation was as follows: L = aT3 + bT2 + cT + d, where L = larval body length (mm), T = the time after hatching (d) and a, b, c, d are constants. As forensic investigators commonly use larval body length to determine developmental time, we also conducted a polynomial regression analysis adopting ‘the time after hatching’ as the independent variable and ‘larval body length’ as the dependent variable [T = aL3 + bL2 + cL + d, where T = the time after hatching (d), L = larval body length (mm) and a, b, c, d are constants.Data analysis was performed using Python 3.6.5 and R 3.5.1. In order to develop an equation to estimate the PMIvariable , and they = K + D0x, where D0 and K are constants, and D0 = developmental threshold temperature and K = thermal summation constant.The regression model revised by Ikemoto & Takai  was used3.3.1.C. pinguis from egg to adult can be completed between 16°C and 34°C. The raw data of life stages related to sample ages were shown in electronic supplementary material, table S1, and the portions of individuals observed in different life stages were given. The data on development time were used to generate isomorphen diagrams of duration by different developmental events at different constant temperatures  and thermal summation constants (K) of C. pinguis were calculated for each developmental stage and the whole developmental process (R2) of the other stages was above 0.98, indicating that the fit of the model was high. The developmental threshold temperature (D0) and the thermal summation constant (K) of the duration from first ecdysis to pupariation were 11.06°C and 1931.10 degree hours, and D0 and K of the whole developmental process of C. pinguis were 10.88°C and 4256.50 degree hours, respectively.Next, thermal summation models were established through linear regression analyses of the relationship between ADH, the duration of six developmental stages and the total developmental process . Using t process . With th3.2.The variation curve of larval body length from hatching to the wandering stage is shown in 4.C. pinguis, but the data on its development had not yet been reported. This study provides the basic developmental data of C. pinguis and development models including thermal summation model, and isomorphen and isomegalen diagrams for a range of seven temperatures between 16°C and 34°C. These developmental models facilitate the estimation of PMImin. Sang et al. [C. pinguis collected from corpse were in the third instar stage. Larval body length was not mentioned but the specimens had an emptied crop, which indicated that the larvae had entered the wandering stage. Based on this information, our isomorphen diagram estimates that the time required for C. pinguis from egg development to third instar at 21.76°C would be 6.8 days and the time from egg development to pupariation would be 8.9 days, indicating that the age of the oldest larvae in the wandering stage collected from the scene or the PMImin was 6.8–8.9 days. The investigators identified that the person had been decreased 10 days before the discovery of its corpse. Our PMImin estimate based on the basic morphological data presented in this past study suggests that our model is capable of identifying relatively good estimates of PMImin.Many studies have highlighted the forensic value of g et al.  reportedC. pinguis was able to complete development at 16°C to 34°C, which is consistent with a laboratory study of temperature adaptation in C. pinguis by Yang & Shiao [C. pinguis is able to complete its development at 15–35°C. However, at 38°C, C. pinguis did not complete development, indicating that the maximum resistance temperature of this species is between 35°C and 38°C. Our field studies have shown that C. pinguis is a dominant species in cooler seasons, and similar findings have been obtained in other studies. Kano et al. [C. pinguis has a preference for areas and seasons with low temperature, and its peak population is always in spring and autumn. In Japan, C. pinguis adults have been found in mountainous areas during the summer and they may migrate from the highlands to the lowlands in spring and autumn as the temperature cools down [C. pinguis may be of high value for estimating PMImin in cooler environments, or may be used to determine whether a corpse was exposed during the summer according to the occurrence of this species.In our study,  & Shiao , who fouo et al.  and TachC. pinguis. An evaluation of sampling methods study by Wells et al. [In forensic entomology development study, in order to record the body length and/or instar of a species, their larvae were usually reared at different temperatures, and individuals were removed periodically  –40. Thers et al.  revealedCalliphora vicina Robineau-Desvoidy, 1830 and Lucilia sericata   from geographically separate populations [L. sericata from the Michigan strain developed fastest, whereas L. sericata from the California strain took the longest to mature. Differences between the findings for the same species could be a result of geographically separate populations. Therefore, it is important to collect precise development data in different geographical regions of the world so as to provide developmental data of the species in or around the particular crime scene when estimating the PMImin [Recent studies have shown that geographically distinct populations can vary in developmental time ,38,42. Dulations –45. For e PMImin ,47.


Vaginal bulging is considered the key symptom for genital organ prolapse. The aim was to investigate the age-related prevalence and frequency of symptomatic pelvic organ prolapse (sPOP) and other pelvic floor symptoms in nonpregnant nullipara aged 25–64 years.This national postal and web-based questionnaire survey was conducted in 2014 and included four independent random samples of women aged 25–34, 35–44, 45–54, and 55–64 years. The association of sPOP with demographics and with other pelvic floor conditions and with clustering to other pelvic floor conditions, was presented in women with and without sPOP. Logistic regression was used to identify and rank variables associated with symptomatic prolapse.n = 10,187) and 726 nullipara confirmed sPOP. Women with sPOP were younger (p < 0.001), shorter (p < 0.001), and more often overweight and obese (p < 0.01) compared with asymptomatic women. Previous surgery for prolapse was reported by 15 women only (0.16%). Symptomatic POP decreased from 9.8% in the youngest age group (25–34 years) to 6.1% in the oldest (55–64 years) (p < 0.0001). Symptomatic POP was more often experienced as bothersome (p = 0.012), and aggravated by straining and heavy lifting (p = 0.003), in older women. Vaginal/vulval chafing/rubbing feeling was most prevalent among the youngest 14.2%, decreasing to 7.8% among the oldest (<0.0001). This symptom occurred three to five times more often in those with sPOP (p < 0.0001). Clustering of pelvic floor symptoms was four times more prevalent in women with sPOP (23.2% versus 6.1%) (p < 0.0001).The response rate was 52%  contains supplementary material, which is available to authorized users Childbirth is the dominant etiological factor for the development of pelvic organ prolapse (POP) , 2, resun = 396) was 0.6% [n = 1,484) and Sweden (n = 656), the prevalence sPOP was 1.1–2.4% [However, clinical examination is not considered feasible for large studies because of its workload, costs, and potential sampling bias . Screeniwas 0.6% . In ques1.1–2.4% , 15. The1.1–2.4% . This coTegerstedt et al. have validated the reliability of the question “Do you have a sensation of tissue protrusion  from your vagina?” to identify genital organ prolapse in a randomly selected population of women aged 30–79 years with mixed parity . The priEthical approval for the study was obtained from the Regional Ethical Review Board . All women gave their written consent before participation.n = 525) was related to immigration in 337 women.This national postal and web-based questionnaire survey was conducted in 2014. The potential study population was identified by Statistics Sweden from the Total Population Register (TPR) and comprised women who had not given birth and who were 25–64 years of age. The TPR includes data on name, place of residence, gender, age, civil status, place of birth, citizenship, immigration, biological and adopted children, etc., and is updated every 6th week. Out of 625,810 eligible women, 20,000 were invited to participate. The participants comprised four, independent, random samples, stratified by decades of age (25–34 to 55–64 years). An introductory letter about the study, which included login credentials to a web-form, was sent to all women and was followed by a postal questionnaire. After three mailing cycles during a 4-month period, 10,187 women had responded. The web-form was used by 52% of the responders. Questionnaire data showed that 194 women were pregnant, 525 were parous, 7 lacked information about parity, and 264 declined participation or returned an unusable form. These 990 women were excluded. The final study population comprised 9,197 women. Misdiagnosis of parity  was calculated from the weight and height given in the questionnaire.Urinary incontinence (UI), subtypes of UI, urgency/overactive bladder (OAB), and nocturia were defined according to the International Urogynecological Association (IUGA)/International Continence Society (ICS) definition . UI was  t test to compare continuous variables. Crude and adjusted prevalence and proportion and 95% confidence intervals (CI) for all outcomes were calculated for each 10-year category. Adjusted prevalence and odds ratio (OR) were calculated from the logistic regression model, taking age and BMI into account. Age- and BMI-dependent differences for various aspects of vulvar/vaginal symptoms were analyzed, with the youngest group (25–34 years) as reference. A p value of <0.05 was considered statistically significant. A logistic regression model was used to assess predictors for sPOP presented as OR and 95% confidence interval (95%CI). Potential predictors used in the analysis were: age < 35 years, BMI ≥ 30 kg/m2, childhood nocturnal enuresis, chafing, OAB, FI, and UI.Statistical analyses were performed using SPSS software . Chi-squared test was used to compare categorical and Student’sn = 10,187), increasing from 44.7% among the youngest (25–34 years), to 62.4% among the oldest women (55–64 years). The number of eligible women was 9,923 of which 9,136 women answered the question about sPOP. Women with sPOP (n = 726) were younger, shorter, more often overweight and obese, compared with those without sPOP  and occurred three times more often  in the youngest age group , but not with obesity (BMI ≥ 30) or UI. Chafing was the strongest predictor for sPOP , whereas OAB was a significant but weak predictor , and were more likely to be immigrants (63.7%), non-Swedish citizens (67.8%), unmarried (51.2%), living in suburban or commuting municipalities (53.7%), and having a lower income and lower level of education (59.1% of those with ≤3 years of secondary education compared with 40.9% of those with >3 years secondary education and higher) .The prevalence of sPOP in this study was high, and highest in the youngest women, decreasing with age. Conversely, surgery for prolapse was negligible in this cohort of nulliparous women aged 25–64 years of age. Nulliparous women with sPOP were shorter, more often overweight and obese, and more often reported childhood nocturnal enuresis and a family history of sPOP. The cut-off point of symptom frequency to define a positive response had a decisive influence on prevalence rates, decreasing drastically with higher frequencies. In addition, the symptom of “bulging” was strongly associated with “chafing” as a symptom and also, but somewhat weaker, with co-occurring FI and urgency/OAB. The proportion of co-occurring symptoms increased linearly with increased frequency of “bulging.”In contrast to our results, an sPOP prevalence of 0.6% was reported in subgroups of nulliparous women from two cross-sectional studies on randomly selected US women aged ≥20 years . In the In contrast to studies based on self-reporting, the prevalence of prolapse based on clinical investigations has produced more consistent results. In a few studies, mainly of convenient samples of women seeking care at outpatient clinics, the distribution of POPQ stages in nulliparous women of different ages has been described. In four studies on a total of 607 nullipara, 3 women aged <60 years had POPQ stage ≥3 (0.5%) and 20–25% had a stage 2 prolapse –11, 22. Case reports on rare causes of prolapse have also been reported in nulliparous women. They form a heterogeneous group with diverse pathogenic factors, such as connective tissue disorders, previous pelvic surgery, previous pelvic fractures, spinal cord injury, prolonged severe constipation, and excessive strenuous physical activity –7. We han = 33,124) were performed on women who claimed to be nulliparous. The study of Lo et al. reported on 1,275 surgically managed women with a prolapse of POPQ stage ≥3. In this large sample from one Taiwanese center, collected between 2005 and 2015, 8 women were nulliparous (0.55%) [The rarity of prolapse in nullipara is supported by register data regarding prolapse surgery. According to the Swedish GynOp Register , 278


Context: Antibiotic resistance is a serious problem worldwide. Searching for new potential agents is, therefore, essential. The bark of Sesbania grandiflora (L.) Pers. (Fabaceae) has been used in folk medicine against various diseases.Objective: To investigate the antibacterial activity of S. grandiflora bark and explore the therapeutic effect of the highest potent fraction.Materials and methods: Bacteria and healthy silkworms were exposed to three fractionated extracts (3.1–400 mg/mL) of S. grandiflora bark from hexane (HXF), chloroform (CFF), and ethyl acetate (EAF). The sets of bacteria were incubated at 37 °C while silkworms were kept at 27 °C for 24 h. To evaluate the therapeutic effect, silkworms infected with bacteria were exposed to the extracts (0.5–60 mg/mL) and incubated at 27 °C for 52 h. Qualitative analysis of the most potent extract was done using HPLC.Results: EAF showed the highest activity with MIC against methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci (VRE) of 1.6 and 0.4 mg/mL, respectively, and against Gram-negative Escherichia coli and Pseudomonas aeruginosa of 6.2 and 3.1 mg/mL, respectively. It is nontoxic to silkworms with LC50 >400 mg/mL and has high therapeutic effect on infected silkworms with EC50 of 1.9 mg/mL. EAF consists of at least five major compounds, one of them is gallic acid. The activity of EAF is higher than the sum of individual activities of separated compounds.Discussion and conclusion: These results suggest that EAF is a promising antibacterial extract, suitable for further investigation in rodents infected with drug resistant bacteria. Papaver somniferum L. (Papaveraceae) for pain treatment  for treatment of pericardial disease  Pers. (Fabaceae) is commonly found in Thailand and other Asian countries. The aerial part of this plant are edible and have been used as folk medicine in the treatment of various diseases related to bacterial infection such as skin disorders, ulcers, and wounds  were purchased from Sigma-Aldrich . Vancomycin was from Shionogi & Co., Ltd. . Gentamicin was from Sankyo Co., Ltd. . Organic solvents were from Merck  and Wako Pure Chemicals . Cation-adjusted Muller-Hinton broth (MHB) was from DIFCO . All other chemicals were of the highest quality grade available.S. grandiflora was collected in February 2014 from Chiang Mai province, a northern area of Thailand. The plant species was identified by the botanist of the Biomedical Engineering Center, Chiang Mai University, Chiang Mai, Thailand. A voucher specimen (no. 023207) was deposited at the Herbarium of the Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand. The bark was dried at 50 °C for 48 h and ground into powder.Bark sample of Bombyx mori L.) of Japanese breeding at the state of the fifth-instar larvae having body weight of 1.7 ± 0.1 g were used. Preparation of silkworms prior to the tests was done as in a previous report with some modification , chloroform (CFF), and ethyl acetate (EAF) were kept in tight containers in the refrigerator for further studies.Three different extracts of in vitro antibacterial activity of the extracts was investigated by broth micro-dilution assays in order to determine the minimum inhibitory concentration (MIC). The bacteria used in this study were clinical pathogenic sensitive and resistant strains of Gram-positive and Gram-negative bacteria as shown in S. aureus were isolated in Kyushu University Hospital, Fukuoka, Japan. Streptococcus species were isolated at the University of Tokyo Hospital, Tokyo, Japan. Listeria monocytogenes and Enterococcus faecalis were received from the National Institute of Infectious Diseases, Tokyo, Japan. All other strains were obtained from our laboratory stocks. The extracts were dissolved in MHB containing 10% DMSO to a concentration of 400 mg/mL for aerobic or facultative organisms, and that containing 2.5% lysed horse blood for fastidious organisms. The stock solutions of the tested extracts were centrifuged at 14,000 rpm for 1 min to remove some undissolved particles. The supernatant was diluted with MHB into 2-fold serial dilutions and added with an equal volume of the bacterial suspension having a concentration equal to 100-fold dilution of McFarland No. 0.5, and then incubated at 37 °C for 24 h. The final concentrations of the extracts exposed to bacteria were 0.1, 0.2, 0.4, 0.8, 1.6, 3.1, 6.2, 12.5, 25, 50, 100, and 200 mg/mL. The minimum concentration of the samples which could inhibit the bacterial growth was recorded as MIC. Vancomycin and gentamicin were used as standard antibacterial controls. The final concentrations of these drugs were 0.06, 0.1, 0.3, 0.5, 1, 2, 4, 8, 16, 32, 64, and 128 μg/mL.The This test was performed and evaluated according to the previous report  sub-cultured in MHB was incubated overnight at 37 °C. The bacterial suspension was prepared by diluting the cells with NSS to a desired concentration of McFarland turbidity standard No. 0.5. Freshly prepared suspension was used throughout the test. Silkworms were divided into five batches, two batches for two controls (vehicle and antibiotic), and three batches for the three different test extracts . Each batch of the test extracts was divided into eight groups according to the eight different extract concentrations, each group consisting of 10 silkworms. The exact volume of 0.05 mL of bacterial suspension was injected into the silkworm hemolymph and incubated at 27 °C for 1 h. The bacterial infected silkworms were then injected into the hemolymph with the tested extracts at concentrations of 0.5, 0.9, 1.9, 3.8, 7.5, 15, 30, and 60 mg/mL, prepared same procedure as in toxicity test  and gradient eluent of solvent A  and solvent B (methanol). The eluent gradient program was started with 100% of solvent A for 1 min, and then changed to 70% and 40% at 10 and 20 min, respectively. Finally, the eluent composition was brought back to 100% of solvent A in 5 min for the next run. The eluent was detected by an UV/VIS detector at wavelengths of 280 nm using a flow rate of 1 mL/min. The chromatogram of the extract was compared with that of a standard of gallic acid injected in the same HPLC conditions.In this experiment, the most potent extract was dissolved in methanol and then subjected to preparative HPLC using a Senshu Pak PEGASIL ODS SP100 column (20 i.d. × 250 mm). The ambient temperature of the ODS column was maintained at 40 °C. The mobile phase was a linear gradient from 10% to 100% of methanol after 30 min, and was eluted with 100% methanol for 15 min at a flow rate of 9 mL/min. The eluent of each fraction was examined by a photodiode array detector (PDA) and collected every 2 min. Each eluent was evaluated for antimicrobial activity in comparison with the unseparated extract before injection.in vitro antibacterial activity and the silkworm toxicity tests were analyzed statistically using the Student's t-test as performed by SPSS statistic 17.0 software. For therapeutic effect evaluation, the Log-rank test as performed by Prism5 for Mac OS X  was used. Differences at p < 0.05 were considered significant.The obtained data of E. coli w3110 and P. aeruginosa PA01 with the MIC of only 0.5 and 8 μg/mL but did not show good activity against Gram-positive bacteria, particularly most of the drug resistant strains like MRSA and VRE.All bacterial strains used in this study were human pathogens including drug-sensitive and drug-resistant bacteria. It was found that HXF, CFF, and EAF possessed inhibitory activity against all tested pathogenic microorganisms but at different levels . Among t50). The results revealed that LC50 of CFF was 65.9 mg/mL, significantly different from those of HXF and EAF which were higher than 400 mg/mL as shown in 50 of CFF. All infected silkworms injected with NSS gradually died during 52 h (50) of EAF was considered to be 1.9 mg/mL.In the toxicity study, the aqueous dispersion containing the tested extract of 3.1, 6.3, 12.5, 25, 50, 100, 200, 400 mg/mL was used in order to investigate the concentration at which 50% of silkworms were killed (LCing 52 h . All infS. aureus (MSSA1) as a test strain. The results demonstrated that EAF consisted of many weak antibacterial compounds as shown in EAF was selected for qualification because it presented the highest antibacterial activity. The HPLC fingerprint of EAF as shown in S. aureus and enterococcus were reported to habituate to gentamicin, so these pathogens also showed a proportional increase in resistance to gentamicin (Dawson Punica granatum L. (Lythraceae) (Voravuthikunchai & Kitpipit Quercus infectoria Oliv. (Fagaceae) (Voravuthikunchai & Mitchell Garcinia mangostana L. (Clusiaceae) ] which its dichloromethane extract, which showed MIC against MRS and VRE of 6.25 mg/mL and its methanolic extract showed MIC against these two pathogens of 3.125 and 6.25 mg/mL, respectively . The MIC of EAF against drug resistant bacteria, MRSA and VRE, are 1.6 and 0.4 mg/mL, respectively. EAF also inhibits Gram-negative E. coli and P. aeruginosa with MIC of 6.2 and 3.1 mg/mL, respectively. EAF and HXF are nontoxic (LC50 >400 mg/mL) to the silkworms in comparison with CFF (LC50 = 65.9 mg/mL). HXF and CFF have no therapeutic effect whereas EAF has a significant (p < 0.05) therapeutic effect on infected silkworms with EC50 of 1.9 mg/mL. EAF consists of at least five compounds, one of them being gallic acid. Preparative HPLC indicates that a synergistic effect of several compounds in EAF results (p < 0.05) in antibacterial activity higher than the sum of individual activities. These results suggest that EAF is a promising antibacterial extract and suitable for further investigation in rodents infected with drug resistant bacteria.Among three fractionated extracts of


Metabolic syndrome is commonly associated with inflammation. The underlying factors of inflammation in metabolic syndrome are not fully understood. The objective of the study was to determine the association of dietary patterns, anthropometric measurements, and metabolic parameters with inflammatory markers in middle-aged and older adults with metabolic syndrome in Taiwan.A total of 26,016 subjects aged ≥35 y with metabolic syndrome were recruited from Mei Jau institution between 2004 and 2013 for a cross sectional study. Metabolic syndrome was defined by the International Diabetes Federation. Multivariate logistic regression was performed to evaluate the association of dietary patterns, anthropometric measurements, and metabolic parameters with C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) in men and women with metabolic syndrome. Crude and adjusted models were analyzed by gender.P < 0.01) or diastolic BP  and high TC  were significantly correlated with increased odds ratios of high NLR only in men.The western dietary pattern, obesity, high body fat, high waist or hip circumference, and high waist-to-hip ratio were significantly associated with increased odds ratios of high CRP and NLR in both genders. High systolic or diastolic blood pressure (BP), low high-density lipoprotein-cholesterol (HDL-C), high low-density lipoprotein-cholesterol (LDL-C), high total cholesterol (TC), high serum triglycerides (TG), and high fasting blood glucose (FBG) were significantly correlated with increased odds ratios of high CRP in both genders. Low HDL-C, high LDL-C, high serum TG, and high FBG were significantly associated with increased odds ratios of high NLR in both genders. However, high systolic (OR = 1.124, 95% CI 1.047–1.206, The western dietary pattern, obese-related anthropometric parameters, and most components of metabolic syndrome are positively associated with CRP levels and NLR in men and women with metabolic syndrome. Metabolic syndrome is defined by central obesity, increased systolic and diastolic blood pressure (BP), decreased high-density lipoprotein cholesterol (HDL-C), increased serum triglycerides (TG), and elevated fasting blood glucose (FBG). The International Diabetes Federation (IDF) declared that central obesity was strongly associated with metabolic syndrome and its components . The preDietary patterns are associated with inflammation. The previous study revealed that high intake of trans fatty acids had a positive correlation with inflammation . AdditioSeveral studies have investigated the effect of dietary patterns, anthropometric measurements, or metabolic parameters on inflammatory markers , 19. Hown = 23,377) who had renal dysfunction, liver problems, or all types of cancer, and those who  with missing data on food frequency questionnaire (FFQ), anthropometric measurements, or biochemical parameters, a total of 26,016 subjects were finally recruited for analysis in this study.The cross-sectional study was performed to examine data collected from a Mei Jau (MJ) Group, a private health management screening institution in Taiwan, from 2004 to 2013. The MJ Group’s four health screening centers in Taiwan in Taipei, Taoyuan, Taichung, and Kaohsiung (listed from north to south) were used to collect pertinent information for the study. Data collected included demographic data, lifestyle, diet, anthropometric data, biochemical parameters, and other health related data from the individuals who came to their health screening centers for a regular health check-up . A totalThe components of metabolic syndrome were proposed by the IDF in 2005 and defined as individuals who had central obesity (waist circumference ≥ 90 cm for men or ≥ 80 cm for women in Taiwan) with two of four factors: 1) systolic BP ≥ 130 mmHg, diastolic BP ≥ 85 mmHg or history of the therapy of hypertension, (2) HDL-C < 1.03 mmol/L for men, < 1.29 mmol/L for women or specific therapy for lipid abnormality, (3) serum TG ≥ 1.70 mmol/L or specific therapy for lipid abnormality, and (4) FBG ≥ 5.60 mmol/L or previously diagnosed type 2 diabetes mellitus  systolic or NLR ≥Dietary intake was analyzed using a validated FFQ collected by the MJ Group. All subjects were requested to complete the FFQ before they had health check-up. The FFQ included 22 food groups or food items referred to the characteristics of Taiwanese dietary patterns. The FFQ collected intake frequency data with the information of portion size and the corresponding pictures of measuring tools in each question. For instance, the description for milk consumption was “How much milk do you drink? ”, and the options for intake frequency were “none or < 1 cup a week, 1-3 cups a week, 4-6 cups a week, 1 cup a day, or ≥ 2 cups a day”. Each question had 5 options for intake frequency from the lowest to the highest. Food intake scores of 1 to 5 were assigned from the lowest to the highest frequency. Principal component analysis was performed to derive dietary patterns. We used the eigenvalues ≥2 in the orthogonal rotation to derive dietary patterns, and factor loading ≥0.30 to classify dietary patterns. The eigenvalues ≥2 have been used in the previous studies, and represented a strong correlation between each component and smaller variance compared with the eigenvalue < 2 , 24. The2), and classified as underweight, normal weight, overweight, or obesity  [The assessments of anthropometric data were carried out by the medical staff in the MJ health screening centers. Weight (kg), height (cm), and body fat (%) were measured by using a bioelectrical impedance analysis instrument . BMI was computed as weight (kg) divided by the square of height (mctively) . Body factively) –28. Waisctively) .Blood samples were collected after overnight fasting for 12–14 h. BP was measured in a sitting position using a sphygmomanometer. Blood HDL-C, TC, TG, FBG, and CRP levels were analyzed using the commercial reagents or kits, and LDL-C levels were calculated using Friedewald’s formula: LDL-C (mg/dL) = TC-(HDL-C + TG/5). The number of neutrophils and lymphocytes was determined, and NLR was calculated using the absolute neutrophil count divided by the absolute lymphocyte count. The IDF definition was used to define metabolic syndrome to categorize systolic BP (low < 130 mmHg and high ≥130 mmHg), diastolic BP (low < 85 mmHg and high ≥85 mmHg), HDL-C , TG (low < 1.70 mmol/L and high ≥1.70 mmol/L), and FBG (low < 5.60 mmol/L and high ≥5.60 mmol/L) [Demographic and lifestyle characteristics such as sex, age, marital status, education, occupation, current smoking or drinking status, and physical activity were collected using an administered questionnaire from the MJ Group. Education level was dichotomized as low (high school and below) and high (above high school). Physical activity was categorized as low (< 1 h a week), moderate (1–2 h a week), and high (> 2 h a week).P ≤ 0.05 was used for all analyses, and SPSS 24  software was used to analyze the data.Chi-square test and general linear model test were used to determine the differences of categorical and continuous variables, respectively, in the characteristics of the subjects with low or high CRP and NLR levels. Odds ratios (OR) with 95% confidence interval were derived using multivariate logistic regression analysis to compare the association of dietary patterns, anthropometric status, and metabolic parameters with CRP and NLR levels in men and women. Model 1 was unadjusted and model 2 was adjusted for age, marital status, education, occupation, smoking, drinking status, and physical activity. A significance level of Among 26,016 subjects with metabolic syndrome, 4639 (27.5%), 6650 (39.4%), 4089 (24.2%), 5687 (33.7%), 8933 (52.9%), and 11,903 (70.5%) subjects had high waist circumference (≥ 95.8 cm), high systolic BP, high diastolic BP, low HDL-C, high TG, and high FBG levels, respectively, among men, and 5131 (56.2%), 4139 (46.4%), 1658 (18.2%), 2785 (30.5%), 4155 (45%), and 6333 (69.4%) subjects had high waist circumference (≥ 85.2 cm), high systolic BP, high diastolic BP, low HDL-C, high TG, and high FBG levels, respectively, among women (data not shown).Two dietary patterns were derived from principal component analysis Table  and defi2), body fat (28.0 ± 4.7% and 27.6 ± 4.6%), waist circumference (94.4 ± 8.6 and 94.6 ± 8.1 cm), hip circumference (101.5 ± 6.7 and 101.3 ± 6.3 cm), and waist-to-hip ratio (0.93 ± 0.07 and 0.94 ± 8.13) than those who with low CRP or NLR. Additionally, subjects with high CRP or NLR had significantly higher systolic BP (124 ± 33 and 125 ± 32 mmHg), diastolic BP (75 ± 19 and 75 ± 19 mmHg), LDL-C (3.75 ± 0.87 and 3.73 ± 0.89 mmol/L), TC (5.29 ± 0.89 and 5.30 ± 0.92 mmol/L), TG (2.17 ± 1.34 and 2.09 ± 1.30 mmol/L), and FBG (6.76 ± 2.43 and 6.67 ± 2.29 mmol/L) but lower HDL-C (1.12 ± 0.31 and 1.15 ± 0.07 mmol/L) than those who with low CRP or NLR.The characteristics of subjects with low or high CRP and NLR in both genders are summarized in Table The results showed that regardless of gender, subjects who had higher tertiles T2 and T3) of the western dietary pattern, overweight or obesity, high body fat, high waist or hip circumference, high waist-to-hip ratio, high systolic or diastolic BP, low HDL-C, high LDL-C, high TC, high TG, or high FBG had significantly increased odds ratios of high CRP (≥ 28.6 nmol/L) in both models  of the western dietary pattern, obesity, high body fat, high waist or hip circumference, high waist-to-hip ratio, low HDL-C, high LDL-C, high TG, or high FBG had significantly increased odds ratios of high NLR (≥ 3.0) in men and women in both models Table . HoweverOur main findings are that dietary patterns, anthropometric measurements, and metabolic parameters were directly associated with CRP and NLR among Taiwanese men and women aged 35 and above with metabolic syndrome. Subjects who consumed more western dietary pattern were positively correlated with inflammation, while subjects who consumed more prudent dietary pattern were inversely associated with inflammation in both genders. Moreover, anthropometric measurements and metabolic parameters were strongly associated with CRP and NLR in both genders.The present study revealed that subjects with the high levels of inflammatory markers were more frequent in men and less active physically compared with those with low levels of inflammatory markers. The findings were consistent with the results in the previous studies , 31. TheOur results reported that the anthropometric measures such as BMI, body fat, waist or hip circumference, and waist-to-hip ratio were associated with inflammation in both men and women with metabolic syndrome. Some evidences supported our findings. BMI was independently correlated with certain markers related to inflammatory responses, including CRP, amylin, C-peptide, insulin, leptin, WBC, and NLR , 42. TheOur results found that both men and women with high consumption of the western dietary pattern, low consumption of the prudent dietary pattern, high values of anthropometric parameters or metabolic disorder increased the likelihood of being high CRP or NLR. However, there were gender differences in the effects of BP or TC on NLR values. Higher systolic or diastolic BP or TC was significantly associated with increased odds ratios of high NLR in men, but not in women. There is still a conflicting evidence regarding whether NLR is a good indicator of inflammation in a metabolic syndrome population. Neutrophil-to-lymphocyte ratio was not a better indicator of inflammation compared with CRP in obese subjects with metabolic syndrome , althougThis study has some strengths. This is the first study to discuss the association of dietary patterns, anthropometric measures and metabolic parameters with inflammatory markers in Taiwanese middle-aged and older adults with metabolic syndrome. In addition, the sample size was large from the population of interest. We defined metabolic syndrome by using the IDF definition, which uses central obesity as an essential component followed by other components of metabolic syndrome. This parameter was appropriate because the prevalence of central obesity or metabolic syndrome increases with age in both genders in Taiwan  and was Men and women have a similar association of dietary patterns and anthropometric measurements with inflammatory markers. The western dietary pattern is positively correlated with CRP and NLR. In contrast, the prudent dietary pattern is inversely associated with CRP and NLR. Furthermore, better BMI, body fat, waist or hip circumference, and waist-to-hip ratio improve CRP and NLR. Men and women have similar associations between metabolic parameters  and CRP. However, systolic or diastolic BP and TC show significantly positive correlations with NLR only in men.


Plant-water relations have been of significant concern in forestry and ecology studies in recent years, yet studies investigating the annual differences in the characteristics of inter-class water consumption in trees are scarce.Schima superba plantation in subtropical South China into four ranks using diameter at breast height (DBH). The inter-class and whole-tree water use were compared based on three parameters: sap flux density, whole-tree transpiration and canopy transpiration over two years. Inter-class hydraulic parameters, such as leaf water potential, stomatal conductance, hydraulic conductance, and canopy conductance were also compared.We classified 15 trees from a −1, with a maximum of 1.39 mm d−1. (2) Isohydrodynamic behavior were found in S. superba. (3) Transpiration was regulated via both hydraulic conductance and stoma; however, there was an annual difference in which predominantly regulated transpiration.(1) Mean water consumption of the plantation was 287.6 mm over a year, 165.9 mm in the wet season, and 121.7 mm in the dry season. Annual mean daily water use was 0.79 mm dS. superba plantation and revealed the coordinated effect of stoma and hydraulic conductance on transpiration. These results provide information for large-scale afforestation and future water management.This study quantified annual and seasonal water use of a  Plantation species that are artificially planted in rows in intensively managed stands have different ecological functions to that of natural forests; in particular their water use is significantly higher . As sap China is the second largest plantation country in the world and has established extensive areas of plantations since the 1950s. The planting programs during the 1970s and 1980s mainly focused on fast-growing, high-yielding timber species, as well as ecosystem protection and rehabilitation . The rapSchima superba is a native tree species in south China, and plantations cover up to 1,236 hm2 in Guangdong Province  quantify water use for each tree rank and the plantation as a whole; (2) determine iso/anisohydry; (3) quantify inter-class canopy conductance and verify the possibility of a mean instantaneous conductance substitute for canopy conductance in the same canopy layer; and (4) determine if stomatal conductance determines water use more than hydraulic conductance.S. superba plantation  that was planted in the mid-1980s and located in the ecological observation station of the South China Botanical Garden, Chinese Academy of Sciences, Guangzhou. The study area had a subtropical monsoon climate, with an annual mean temperature of 21.8 °C, and mean temperature of 32.7  °C in the hottest month of July, and 9.8 °C in the coldest month of January. Annual mean rainfall was 1750 mm, with April to September tending to be wet, and October to March of the next year tending to be dry. In 2010, the annual mean rainfall was 2148.4 mm and in 2011, annual mean rainfall was 1421.2 mm  and DBH was established based on the above measures, which was used to calculate the As of the 15 trees in the plot. Similarly, leaf area (AL) was calculated using a log function , air temperature , relative humidity , and photosynthetically active radiation  above the S. superba forest canopies from an observation tower set up within the plantation. Soil moisture  was measured 30 cm below the ground surface from October 2010 until December 2011. Wind speed was measured using cup anemometers . TA and RH were measured using a temperature and humidity sensor . PAR was measured using a Li-Cor quantum sensor . SM was measured using three frequency domain sensors  at a depth of 30–40 cm, which were set in a triangle around trees 17–21. The output values were measured every 30 s, and 10-min mean values were logged using a DL2e Delta-T logger .We continuously monitored wind speed  combined with the parameters TA and RH was calculated using the following formula (The vapor pressure deficit ( formula : (1)\docJs) was continuously measured from 2010 until 2011 using a homemade thermal dissipation probe (TDP). The Grainer-type probes were inserted radially at a depth of 20 mm into the stem of 21 trees at 1.3 m aboveground, one pair for each tree. The upper heated probe was supplied with a constant DC current (120 mA). The unheated probe was installed 10–15 cm below the upper sensors. The temperature difference between the paired sensors was recorded using the same logger as environmental measurements. All probes were installed on the north-facing side of the trees and covered with a plastic case, and shielded using a radiation-insulating film in order to minimize the possible effect of direct sunshine.Sap flux density  was weighted using the following equation: J0−40 (Sap flux density at 0–40 mm) is calculated using the empirical equation proposed by λ are correction factors of 1.164, 1.128, and 1.096 for Ranks 1, and 3, respectively. J40 (sap flux density at ⩾40 mm) was calculated following Fs, g d−1) was calculated as: t is 600 s (data were averaged and stored every 10 min in the logger), A0−40 and A40 are the sapwood areas in the outer xylem (0–40 mm) and inner xylem (⩾40 mm), respectively, which were calculated as: As is the total sapwood area (m2), calculated using the regression equation relating it to DBH (m) as follows: Fs, g mon−1) was calculated as: EL, g m−2 mon−1) was calculated as: EL is canopy transpiration (g m−2 d−1), AL is the total leaf area (m2), which was calculated using a regression equation relating it to DBH (m) as follows  was calculated from ∑∑Fs per ground area over 1 year. ΔEL was the difference between predawn and midday ELSap flux density ( follows : (6)\docψL, MPa) was measured using a portable pressure chamber in two ways: at 1-hour intervals from 05:00–06:00 to 20:00 in Oct 2010, and point measuring at 05:00–06:00, 13:00, and 20:00 in the other time periods. This minimized the destructive sampling of tree branches. Predawn leaf water potential  and midday leaf water potential  referred to ψL at 05:00–06:00 and 13:00, respectively. Iso/anisohydraulic regimes during the time periods were determined using the linear framework of \docgs, m s−1) was simultaneously measured on trees 17–18 and 21 using a Li-6400 Portable Photosynthesis System, at the same time intervals and periods as ψL.Δgs represented the difference between predawn and midday gs. All measurements were taken three times.Instantaneous stomatal conductance  was calculated by inverting the following equation (λ is the latent heat of vaporization (2.39 MJ kg−1), Ec (mm h−1) is estimated from whole-tree transpiration divided by the projected canopy area of 3.96 m2, δ is the slope of the relationship between saturated vapor pressure and temperature (kPa °C−1), Rn isthe net radiation above the forest canopy (MJ m−2 h−1), Kt is a unit conversion equal to 3,600 s h−1, ρ is air density (1.29 kg m−3), Cp is the specific heat of air (1.013 MJ kg−1 °C −1), γ is the psychometric constant (0.066 kPa °C−1), and ga isaerodynamic conductance (m s−1), which was calculated using the method in Canopy conductance (equation : (8)\docKp and leaf-specific hydraulic conductance KL (g m−2 s−1 Mpa−1) were indirectly estimated following Jd and Jl are the difference in sap flux density of sapwood and leaf area between predawn and midday (g m−2 s−1), respectively. We ignored time lags between sap flux density and transpiration  and Origin 8.1 . The paired-samples Js, Fs, and EL varied month by month, although all were at their maximums in the wet season and at their minimums in the dry season. The inter-class daily maximum of Js followed weakly their size in 2010 and 2011 -wet season (four to nine months)-dry season (10–12 months)  –2B. The Es was 0.86 mm d −1 in 2010 and 0.72 mm d−1 in 2011. Moreover, Fs of all ranks declined to a certain extent, i.e., Ranks 1 and 2 declined from 40.2 and 15.8 g d−1 in 2010 to33.0 and 11.2 g d−1 in 2011, respectively, while Ranks 3 and 4 declined from 13.9 and 4.0 g d −1 in 2010 to 12.9 and 3.9 g d−1 in 2011, respectively.The total water use for Ranks 1, 2, 3, and 4 were 312.8, 185.9, and 126.9 mm in the wet season, and 262.4, 145.9 and 116.5 mm in the dry season in 2010. The mean daily Fs was determined mainly by soil moisture (SM) and rainfall, with the effect of SM greater than that of rainfall , only SM was significant in the linear regression. Of the remaining four factors, rainfall was more significant than WS in the linear regression. Of PAR, VPD, and WS, no significant relations were observed. However, ∑EL was determined mainly by SM, PAR, and rainfall, with the effect of SM >PAR >Rainfall >WS  was inversely proportional to the DBH , whereas no relation was found between the minimum ψL  and DBH. That is, bigger trees had more water available in the rhizosphere. However, the strongest potential capacity to access soil water may not have been related to tree size at the time of measuring. According to the model relating ψpd and ψmd proposed by σ > 1) was only found in Rank 3 in Jan and Rank 2 in Apr in 2011 .The maximum of gs  ranged from 0.011 to 0.151 m s−1. A linear relation between gs and PAR was observed in all five time periods. In contrast, a linear relation between gs andVPD, SM, and WS was only observed in Oct, Apr and Jul, Jan and Oct in 2011, respectively.Daytime hourly mean gc for the whole plantation ranged from 0.00058–0.034 mm s−1 in the wet season and 0.000092–0.070 mm s−1 in the dry season. Individually, the gc of trees ranked 1–4 ranged from 0–0.00069 mm s−1. Stomatal conductance of Rank 1 trees was positively related to gc in each of the five time periods , which was in agreement with  periods .Kp and KL did not vary with tree size. A proportional relationship between Kp or KL and DBH was observed in Oct 2011 . Moreover, both the maximums and minimums of Kp and KL occurred in Rank 2 and 3 trees.Daily Kp and KL for Rank 2 and 3 trees between 2010 and 2011 , Js showed high interspecific differences , which was possibly attributable to the combined effects of SM and rainfall. This was also shown in the decrease of 16.3% in Es between the two years, which was lower than 33.8% of precipitation.Many studies have reported that piration . Some stfficient . Even infficient . Neverthfficient . The incS. superba in 2010 and 2011 was approximately 14.6% and 18.5% of the average annual rainfall, respectively. The low level of water consumption was possible attributed to its growth near over-mature stage. From studies of broad-leaved plantations in south China, the total annual mean daily Es of 0.79 mm d−1 of S. superba (30–35a) was higher than the 0.59 mm d−1 of Acacia mangium (19a) at the Heshan experimental station in Guangdong Province , and lower than the 1.01 mm d−1 of Eucalyptus urophylla ×E. grandis (4–5a) at the Huangmian Forest Farm in Liuzhou, Guangxi Province , and 1.48 and 1.53 mm d−1 of E. urophylla at Hetou  and Jijia , respectively, in Leizhou Peninsula, Gouangdong Province , and larger values of VPD caused a large decline in gs (phase B), while minimal medium values of VPD increased transpiration (phase A). Although gs correlated well with VPD only in Oct 2011, our results followed Regulations of lagellin , and envntration . JohnsonS. superba, and that seemed to be a dynamic mechanism and varied with ranks and periods. However, it is doubtful that S. superba, which grew in South China, showed extreme anisohydry. σ > 1) in 102 species. Moreover, they noted that the phenomenon may occur in phreatophytes and drought-deciduous species. In our study, ψmd–ψpd was approximately maintained seasonally constant but ψpd was correlated with soil water availability, which be in consistent with an isohydrodynamic behavior proposed by SM and rainfall, because the latter had higher SM and rainfall. It is still suggested that a higher SM in the dry season (compared with Jan and Oct 2011) partially resulted in stomatal inverse control on leaf water potential , Scots s−1; −1; , Norway  −1; −1; , and Fagductance .S. superba trees showed no threat to the ground water balance. The annual and seasonal differences in water use were significantly affected by SM and rainfall. Stoma responsed to physical hydraulic factors, such as water potential, showed an isohydrodynamic behavior, and were positively linearly related with external environmental factors such as PAR.Plant-water relations of plantations have been increasingly studied, especially in south China, which has a large and growing proportion of plantation forests. The water consumption of 10.7717/peerj.5164/supp-1Data S1All data include sap flow data, leaf water potential and stomatal conductance and environmental data.Click here for additional data file.


A multicenter, randomized, double‐blind, placebo‐controlled trial was conducted to evaluate the efficacy, safety, and appropriate dose of ulipristal acetate (UPA) in Japanese women with symptomatic uterine fibroids (UFs).A total of 121 premenopausal women with UFs were enrolled to receive either placebo, UPA‐2.5 mg, UPA‐5 mg, UPA‐10 mg, or leuprorelin acetate (LEU), a reference drug, for 12 weeks. The primary end point was the rate of patients having achieved amenorrhea for 35 days at Week 12.The rates for amenorrhea were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% in the placebo, UPA‐2.5 mg, UPA‐5 mg, UPA‐10 mg, and LEU groups, respectively. The median times to amenorrhea were 20.0, 5.0, 5.0, and 23.0 days for treatment with UPA‐2.5 mg, UPA‐5 mg, UPA‐10 mg, and LEU, respectively. A significant dose‐response of UPA for the rate of amenorrhea was observed. The overall incidence rates of adverse events were 45.8% in the placebo group, 56.5%‐80.0% in the UPA groups, and 100.0% in the LEU group. There were no notable safety issues with UPA.Ulipristal acetate was effective and well tolerated in Japanese women with UFs. The recommended dose of UPA is considered to be 10 mg. UPA), leuprorelin (LEU) was used as a reference drug to evaluate the efficacy and safety of UPA. Patients were randomly assigned into five treatment groups. Patients were treated for 12 weeks and then followed up for 12 weeks. UPA and the placebo were administered in a double‐blind manner, and LEU, an injection drug, was administered in an open‐label manner. The median time to achieve amenorrhea for each group was 20.0, 5.0, 5.0, and 23.0 days for UPA‐2.5, UPA‐5, UPA‐10, and LEU, respectively.This is the study design. In addition to a placebo and ulipristal acetate ( In addition to a placebo and UPA, LEU was used as a reference drug to evaluate the efficacy and safety of UPA. Under a central registration, eligible patients were randomly assigned into five treatment groups—placebo, UPA 2.5 mg (UPA‐2.5), UPA 5 mg (UPA‐5), UPA 10 mg (UPA‐10), and LEU—using an allocating factor of the presence or absence of iron therapy , antifibrinolytic agents (tranexamic acid), and strong CYP3A4 inhibitors or inducers. Iron therapy was prohibited during the study for patients who had not received it at the time of giving informed consent, except when the investigator judged its necessity. For those patients who had received iron therapy for 4 weeks prior to giving informed consent, it was continued without a dose modification during the study.2.3The primary end point was defined as the rate of patients having achieved amenorrhea for 35 consecutive days (from Day 50 to Day 84) at Week 12. The bleeding status was evaluated according to four grades—none, spotting, bleeding, and heavy bleeding—and patients recorded daily bleeding status using electronic devices. Amenorrhea was defined as the absence of heavy bleeding or bleeding during the assessment period. Amenorrhea was also assessed from bleeding status, basal body temperature, and hormone levels by the Centralized Gynecological Assessment committee as an exploratory end point.®.Secondary end points were as follows: (a) time to achieve amenorrhea, (b) the proportion of patients achieving amenorrhea for 56 consecutive days (from Day 29 to Day 84) at Week 12, (c) the rate of patients with controlled uterine bleeding from Day 29 to Day 84 (bleeding 8 days or less and no heavy bleeding), (d) time to recovery of menstruation, (e) rate of change in total volume of three largest fibroids and uterine volume, (f) rate of change in Hb level, and (g) rate of change in anemia‐related items, visual analogue scale (VAS), and QOL status using health survey SF‐36v22.4The safety end points were as follows: (a) adverse events (AEs) coded using the Medical Dictionary for Regulatory Activities/Japanese (MedDRA/J) Ver. 19.1 and tabulated by System Organ Class and Preferred Terms, (b) E2 and progesterone levels, (c) change in endometrial thickness, (d) histological diagnosis of endometrium, (e) laboratory tests (hematology and biochemistry), (f) endocrine test (adrenocorticotropic hormone (ACTH), thyrotropin‐releasing hormone (TSH), follicle‐stimulating hormone (FSH), luteinizing hormone (LH), and prolactin), and (g) bone turnover markers .2.5Women with UFs who met the following inclusion criteria and did not exhibit any of the exclusion criteria were eligible for this study. Inclusion criteria were as follows: (a) Japanese premenopausal women aged 20‐50 years old, (b) menstrual cycle ranging from 22 to 35 days, (c) menorrhagia with heavy bleeding for more than 1 day within 8 days from the start of menstruation, (d) hemoglobin level between ≥6.0 g/dL and <11.5 g/dL, (e) patients with one or more myoma ≥3 cm and no myoma >12 cm by pelvic MRI diagnosis, and (f) patients scheduled for surgery (hysterectomy or myomectomy) after the treatment period. Exclusion criteria were as follows: (a) a history of uterine surgery affecting the evaluation of this study  or having undergone intrauterine curettage, arterial embolization, or microwave endometrial ablation, (b) cervical cancer, uterine cancer, ovarian cancer, breast cancer, endometrial hyperplasia, or a history or suspected of having these diseases, (c) calcified myoma nucleus, (d) hemoglobinopathy or severe coagulation disorder, (e) pregnant or breast‐feeding, positive pregnancy test at screening, or with the hope of a pregnancy during the study, (f) liver dysfunction, and (g) the possibility of the use of any of the prohibited drugs during the study.2.62.6.1Based on the results of a previous study,2.6.2Efficacy was evaluated using the full analysis set (FAS). The FAS was defined as the population excluding the following patients from the enrolled population: (a) patients who did not take study drugs, (b) ineligible patients, and (c) patients having no data for efficacy. Safety was assessed using the safety analysis set (SAF). The SAF was defined as the patient population who took at least one dose of study drug.2.6.3Descriptive statistics were expressed as n (%), mean ± SD, % [95% CI], and median [95% CI]. The dose‐response of UPA was evaluated using the Cochran‐Armitage test. Superiority of each UPA group to the placebo group was evaluated using Fisher's exact test under closed testing procedure. The time to achieve amenorrhea and the time to recovery of menstruation were estimated using the Kaplan‐Meier method, and comparisons between groups were performed using the log‐rank test. To evaluate the rate of change in total fibroid volume, uterine volume, and hemoglobin level, repeated measure analysis of variance was performed using group, time, and time and group interaction as explanatory variables. As LEU was reference drug, statistical test between UPA groups and LEU group were not performed. Alpha (α) was set to be 0.05 (both‐sided). For the Cochran‐Armitage test, α was set to 0.025 (one‐sided). Statistics were determined using SAS Release 9.3 (SAS Institute Inc).33.1Patient disposition is shown in Figure 3.2The rate of patients with 35 consecutive days of amenorrhea at Week 12 for each group were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% for the placebo, UPA‐2.5, UPA‐5, UPA‐10, and LEU groups, respectively, and were significantly higher in all of the UPA groups compared with the placebo group Table , change 3.3The incidence rates of AEs were 45.8%, 56.5%, 73.9%, 80.0%, and 100.0% for the placebo, UPA‐2.5, UPA‐5, UPA‐10, and LEU treatment groups, respectively  are shown in Table 4In the present study, the efficacy and safety of a dose range of 2.5‐10 mg of UPA for 12 weeks was evaluated in Japanese women with symptomatic UFs. The rate of achieving amenorrhea and controlled uterine bleeding were significantly higher in all UPA groups compared with the placebo group. Significant dose‐response of UPA was observed in the rate of amenorrhea, the time to amenorrhea, the rate of patients with controlled uterine bleeding, and the reduction rate of total volume of the three largest UFs. A dose range of 2.5‐10 mg of UPA appears to be safe and well tolerated.The rates of patients with amenorrhea for 35 days at Week 12 were 4.5%, 60.0%, 72.7%, 88.0%, and 76.2% for the placebo, UPA‐2.5, UPA‐5, UPA‐10, and LEU groups, respectively, and the median time of days to amenorrhea was 20.0, 5.0, 5.0, and 23.0 for the UPA‐2.5, UPA‐5, UPA‐10, and LEU groups, respectively. These results were comparable to the previous studies of UPA conducted in Europe.The mean reduction rates of total volume of the three largest UFs were −13.87% for UPA‐5, −25.06% for UPA‐10, and −34.40% for LEU. These reduction rates were less than those reported in the PEARL II, a phase III trial of UPA vs leuprolide, and similar to those reported in the PEARL I, a phase III trial of UPA vs placebo.The overall incidence rates of AEs were 56.5%, 73.9%, 80.0%, and 100.0% for the UPA‐2.5, UPA‐5, UPA‐10, and LEU groups, respectively. The most common AE in the UPA groups was nasopharyngitis , followed by constipation , endometrial hyperplasia , and hot flush . All cases of endometrial hyperplasia found in the UPA groups were judged by the Centralized Histopathological Assessment Committee to be benign endometrium. In the LEU group, the most common AE was metrorrhagia (41.7%), followed by hot flush (29.2%), nasopharyngitis (20.8%), headache (12.5%), menopause‐related conditions (12.5%), and hypermenorrhea (12.5%). The AEs in the LEU group were considered to be mainly associated with low estrogen levels or flare‐up.Endometrial modifications by SPRM are known as progesterone receptor modulator‐associated endometrial changes (PAEC).A recent post‐marketing report on UPA showed rare cases of serious liver injury and hepatic failure and a suspected relationship to UPA; thus, assessment of the benefits and safety of UPA is considered to be necessary.This study has the following limitations. This was a dose‐finding study and the number of patients was limited. The study was conducted only with patients scheduled for surgery, and the follow‐up data for efficacy were limited by surgery performed during the follow‐up period. This study consisted of a 12‐week treatment phase and a 12‐week follow‐up phase, and thus, long‐term efficacy and safety in Japanese women were not clarified.In the present study, UPA was effective and well tolerated and the rate of amenorrhea was significantly higher for all UPA groups compared with the placebo and a significant dose‐response was observed. There were no notable safety issues with UPA and no differences in the safety evaluations between the UPA groups. Therefore, the recommended dose of UPA for Japanese women with UFs was considered to be 10 mg. Ulipristal acetate does not reduce the estrogen level, unlike GnRH agonists, therefore, AEs due to hypoestrogen are unlikely to occur. Ulipristal acetate will be a new treatment option for Japanese women with uterine fibroids. Further confirmatory study to evaluate efficacy and safety of UPA is warranted. Currently, two UPA phase 3 studies are ongoing: one is a comparative study with LEU as a control, and the other is a long‐term study.Minoru Irahara, Yasuhiro Maejima, Yuji Yamauchi, Nobuhiro Shinbo and Hideki Mizunuma declare that he has no conflicts of interest.The study protocol was approved by the ethics committee at each institution.This study was carried out in compliance with the articles of the revised Declaration of Helsinki October 2013 and according to the Good Clinical Practices established by the Ministry of Health, Labor, and Welfare in Japan. The investigator provided an explanation sufficient to ensure that each patient clearly understood the study before obtaining written informed consent.The trial registration number is JapicCTI‐142718.Study organization, sites and investigators are shown in Table  Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file.