The over-secretion of monoclonal immunoglobulin light chains by clonal B cells followed by the aggregation and extracellular deposition of fibrillar deposits are responsible forthe clinical course AL amyloidosis. It is well documented that silica significantly increases the number of immunoglobulin-secreting cells. In the present paper, we report on a coal miner with silicosis and fast progressing primary amyloidosis with predominantly heart, kidney, and lung manifestations. Severeheart failure due to myocardial hypertrophy resulted in the patient’s death. We conclude that long-term environmental silica exposure and silica deposition may contribute to the development of monoclonal gammopathy and amyloidosis due to chronic stimulus and the dysregulation of the immune system. The correlation between dust exposure (silica) and silicosis has been well documented in medical literature. Acute silicosis involves a severe immunological reaction in lung tissue, which results in the destruction of its structure. However, chronic silicosis involves the formation ofgranuloma and lung tissue fibrosis. Chronic silicosis develops over an extended period of time and results in restrictive respiratory insufficiency. Symptoms may appear a long time after silica exposure. Studies show an association between chronic silicosis and autoimmune disease, such as systemic sclerosis, lupus erythematosus, rheumatoid arthritis, dermatomyositis, and vasculitis ,3,4,5,6.In the present paper, we report on a coal miner suffering from silicosis who developed fast progressive multisystem amyloidosis. We provide a detailed clinical history and complete histological microscope picture of the condition. To our knowledge, this is probably the first report that examines the link between silicosis and amyloidosis. In the 2) 5 months before and 3.3 mg/dL (eGFR (MDRD) 21 mL/min/1.73 m2) at the admission time.A 52-year-old male with a 9-year record of diagnosed silicosis  was admitted to the Nephrology Department because of proteinuria. Urine protein loss had been observed for two years, initially 50–150 mg per day and 3.5 g per day at the time of admission. In addition, the progressive impairment of kidney function was observed, with a creatinine level of 1.9 mg/dL (eGFR (MDRD) 40 mL/min/1.73 mHe had been treated for 12 years for hypertension. During the last few years, he developed paroxysmal atrial fibrillation. A year before his admission, he suffered a transient ischemic stroke. For 6 months, bilateral hydrothorax had been observed, with the right-side predominance, requiring repeated puncture.The patient was admitted with stable circulatory and respiratory functions and a good mental state. A clinical examination revealed bilateral hydrothorax and ankle swelling. Chest computer tomography (CT) confirmed the presence of mediastinal lymphadenopathy, multiple small pulmonary nodules accompanied by calcifications, hydrothorax in both pleural cavities A–C.The bronchoscopy revealed signs of chronic inflammation and restrictive ventilatory disorder in spirometry (volume capacity (VC) 34.0%, forced volume capacity (FVC) 32.1%, forced expiratory volume in 1 s (FEV1) 33.8%, FEV1/VC 97.8%). The transthoracic echocardiogram showed a normal left ventricle size with a good contractile function and mild mitral insufficiency. An abdominal ultrasonography revealed no abnormalities, except for a hyperechogenic kidney structure (right kidney 11.8 cm × 5.6 cm and left 11.9 cm × 5.6 cm).3; leukocytes—6000/mm3 with normal blood smear; serum creatinine—3.3 mg% (GFR MDR 21 mL/min/1.73 m2); serum urea—13.6 mmol/L; uric acid—8.5 mg/dL; total protein—61.9 g/L; albumin—30 g/L; cholesterol—3.6 mmol/L; HDL—1.04 mmol/L; triglyceride—1.49 mmol/L; C-reactive protein (CRP)—12.2 mg/dL; and erythrocyte sedimentation rate (ESR) 67/1 h. A urine examination revealed proteinuria from 150 to 2014 mg/dL (2.1 to 8.19 g/per day), erythrocyturia 6–8/hpf, and single hyaline-granular casts. Connective tissue disorder markers were negative . Complement hemolytic activity was normal. Protein electrophoresis showed immunoglobulin IgG concentration—−11.3 g/L (Norm: 8–17 g/L); Kappa light chain—−1.03 g/L (Norm: 1.7–3.7 g/L); Lambda light chain—−3.52 g/L (Norm: 0.9–2.1 g/L); and Kappa to Lambda ratio—0.29 (Norm 1.35–2.65). The serum immunofixation showed the presence of a monoclonal protein in the IgG class, the lambda-type light chain in the gamma globulin fraction. The microbiological examination of pleural exudative fluid was negative. Pulmonary tuberculosis was excluded by Ziehl–Neelsen sputum smear microscopy and the culture of sputum, pleural fluid and bronchial washings in a Mycobacterium Growth Indicator Tube (MGIT) , Franklin Lakes, NJ, USA). Conventional Lowenstein–Jensen cultures of these fluids were also negative.Laboratory testing showed hemoglobin—11.2 g%; hematocrit—33%; platelets—265,000/mmAn abdominal fat biopsy confirmed the diagnosis of primary amyloidosis AL with lambda light chains.Hemodialysis therapy was started because of the patient’s renal function deterioration and fluid overload. Despite daily hemodialysis, the patient’s clinical condition deteriorated as he developed severe cardiac insufficiency with pulmonary edema in addition to unresolved hydrothorax, although he remained normovolemic. A brain CT was carried out to evaluate the neurological manifestation of the patient as he lapsed into an altered level of consciousness; however, no evidence of stroke was demonstrated. The death of the patient was preceded with bradyarrhythmia followed by electro-mechanical dissociation. The patient died after cardiac arrest despite reanimation (3 months after the first admission to our clinic).An autopsy showed no single immediate cause of death. There were no signs of myocardial infarct or stroke. The examination revealed heart and liver hypertrophy, and bilateral hydrothorax. A high amount of amyloid deposits and birefringent particles were found in the small myocardial arteries A,B and iThe EnVision method was used in the immunohistochemical examination. The Examination showsthe expression of light chain lambda immunoglobulin and P protein , but no The development of the condition was typical neither for advanced silicosis nor for amyloidosis AL. It was characterized by an unusual dynamic of multiple organ disorders. Pathogenesis involved two factors—silica and amyloid deposition, as was shown by the typical symptoms. Recurrent hydrothorax that required frequent drainage can, in rare cases, be attributed to silicosis  as well Heart insufficiency and neurological disorders can be symptoms of both silicosis and amyloidosis. Only in exceptional cases can the rapid development of symptoms and their consequent amplified impact on our patient be attributed to a coincidence of two disorders.The disease developed in two stages. Stage one involved silicosis, hypertension, and mild proteinuria and was spread over many years. Stage two, which lasted for about 2 years, was linked to amyloidosis and increased proteinuria (over 3.5 g).The rapid development of symptoms took place during kidney function impairment. It progressed despite dialysis treatment, leading to the patient’s death. Clinical course and autopsy show that amyloidosis caused the last stage of disease, but coexisting silicosis may have played a double role: firstly, as an initiator of the process  and secondly as an accelerator of pathological fibril production and their tissue deposition.Silica particles are known to be an adjuvant factor; the substance activates the immunologic system . MacrophThe diagnosis of AL amyloidosis in our patient was based on the International Myeloma Working Group criteria  and inclThe exact mechanism of how advanced silicosis causes monoclonal immunoglobulin production is not entirely known; however, experimental data has shown that silica may have played an important role in lymphocyte B clone generation and immunoglobulin production . The chrAmyloidosis light chains can be created under laboratory conditions using proteolytic enzymes (pepsin). Souillact et al., using protein LEN (protein Bence Jones [BJ]κIV) in an amyloidogenesis model, proved that a high concentration of urea accelerates the process of fibril formation . AdditioOverall, the evidence exists to supportthe claim thatmetabolic acidosis and a high concentration of urea had a fundamental role in accelerating amyloid formation in our patient, despite dialysis treatment .Silica alone could have taken part in the acceleration of amyloidosis, as confirmed in the experimental research of Zhu et al. The authors demonstrated that fibril creation is more extensive on the surface. The study showed that mica, one of the granite components containing silica elements, provided a surface conducive to amyloid creation .It should be mentioned that, apart from generalized amyloidosis, there are also data showing that asbestos dust can be associated with amyloidosis limited to lung tissue in the form of solitary pulmonary nodule. Hiroshima et al. described a well-documented case of a patient in whom amyloid deposits were located at the site of asbestos fiber deposition . In addiIn the last stage of the disease, our patient developed symptoms of multiple organ dysfunctions. The autopsy presented no unequivocal cause of death. Our case study lends evidence that the patient’s death was caused by a cardiac arrest due to arrhythmia. The autopsy showed concentric myocardium hypertrophy and the significant narrowing of the small arteries due to amyloid deposition. This observation is consistent with other autopsy studies among patients with primary amyloidosis. Heart hypertrophy is caused by amyloid deposition in the myocardium, which leads to diastolic heart dysfunction and vasculopathy, which in turn leads to myocardial ischemia without atherosclerotic changes in coronary arteries ,30,31. TNaturally, we cannot rule out the independent development of AL amyloidosis in our patient, although the clinical data and the quoted laboratory data confirm this. We also cannot show with certainty the path of disease development in this patient and, therefore, our report rather opens the door to discussions and further research.Our study is probably the first case of primary amyloidosis triggered by silicon exposition. Long-term environmental silica exposure and silica deposition may contribute to the development of monoclonal gammopathy and amyloidosis due to chronic stimulus and the dysregulation of the immune system. Hopefully, it opens a debate on an important research problem that has grave implications for treatment.


This study aimed to assess the prognostic value regarding neurologic outcome of CT neuroimaging based Gray-White-Matter-Ratio measurement in patients after resuscitation from cardiac arrest.We retrospectively evaluated CT neuroimaging studies of 91 comatose patients resuscitated from cardiac arrest and 46 non-comatose controls. We tested the diagnostic performance of Gray-White-Matter-Ratio compared with established morphologic signs of hypoxic-ischaemic brain injury, e. g. loss of distinction between gray and white matter, and laboratory parameters, i. e. neuron-specific enolase, for the prediction of poor neurologic outcomes after resuscitated cardiac arrest. Primary endpoint was neurologic function assessed with cerebral performance category score 30 days after the index event.Gray-White-Matter-Ratio showed encouraging interobserver variability (ICC 0.670 [95% CI: 0.592–0.741] compared to assessment of established morphologic signs of hypoxic-ischaemic brain injury (Fleiss kappa 0.389 [95% CI: 0.320–0.457]) in CT neuroimaging studies. It correlated with cerebral performance category score with lower Gray-White-Matter-Ratios associated with unfavourable neurologic outcomes. A cut-off of 1.17 derived from the control population predicted unfavourable neurologic outcomes in adult survivors of cardiac arrest with 100% specificity, 50.3% sensitivity, 100% positive predictive value, and 39.3% negative predictive value. Gray-White-Matter-Ratio prognostic power depended on the time interval between circulatory arrest and CT imaging, with increasing sensitivity the later the image acquisition was executed.A reduced Gray-White-Matter-Ratio is a highly specific prognostic marker of poor neurologic outcomes early after resuscitation from cardiac arrest. Sensitivity seems to be dependent on the time interval between circulatory arrest and image acquisition, with limited value within the first 12 h. Sudden cardiac arrest is among the leading causes of death in industrialized countries, incidence of out of hospital cardiac arrest (OHCA) with attempted cardiopulmonary resuscitation (CPR) is estimated to be as high as approximately 50 to 60 per 100.000 population per year . HypoxicVarious methods of prognostication are hampered by the effects of therapeutic interventions, primarily hypothermia in the course of targeted temperature management, sedative and neuromuscular blocking agents, and their potentially altered metabolism in the setting of post-resuscitation syndrome. International guidelines recommend prognostication of outcome not before 72 h after cardiac arrest or regaining normothermia in patients in whom targeted temperature management with hypothermia was applied, respectively , 7. ValiConcerning imaging-based parameters, CT is feasible in intensive care patients, widely available, and rapidly performed. In CT neuroimaging decreased attenuation of gray matter, subsequent loss of distinction of the junction between gray and white matter, and diminished cerebrospinal fluid spaces are the morphologic features of generalised cerebral oedema , the patIn this retrospective observational investigation, CT neuroimaging studies of patients resuscitated from cardiac arrest were assessed concerning morphologic features and GWR by a set of two independent neuroradiologists and two neurologists. Furthermore, demographic, clinical, and laboratory data were obtained. The study protocol was approved by the institution’s ethics committee .This study was conducted at the University Hospital Jena, which serves as a tertiary referral centre for a population of approximately 1.5 million people. At our institution all patients admitted to the medical intensive care unit (ICU) for post-reanimation treatment are entered into a CPR registry. Using this registry we identified 92 patients admitted to the medical ICU between March 2004 and September 2012 after successful resuscitation from cardiac arrest, who remained comatose after return of spontaneous circulation (ROSC) and underwent neuroimaging with non-contrast enhanced computed tomography (CT) within 3 days of admission. In addition to this patient cohort we included 46 age-matched patients, who underwent cranial CT imaging in the Emergency Department of our institution for evaluation of head injury after syncope or falls, as a control population. In this control population GWR was calculated and its distribution assessed, in order to a priori define a lower limit of normal, whose prognostic usefulness would be tested in the group of comatose patients.Each patient’s medical record in the hospital information system and the ICU-specific patient data management system was reviewed and relevant demographic, clinical, and laboratory data obtained.The indication, choice of modality and timing of neuroimaging were made at discretion of the treating physicians. CT scans were obtained on a GE LightSpeed 16 scanner until October 2007, and on a GE LightSpeed VCT scanner thereafter  using imaging protocols established in routine clinical care. The CT images relevant for our study were exported in DICOM format from the Picture Archiving and Communication System (PACS) of our institution and reviewed by four independent investigators (two neuroradiologists and two neurologists), blinded for history, group assignment and outcome. The workstation and software used were left at the investigator’s discretion. The evaluation protocol required assessment of morphologic features of hypoxic-ischaemic brain injury, i. e. diffuse cerebral oedema, effacement of the junction between gray and white matter, and diffuse hypodensity of cerebral parenchyma. Furthermore, readers measured radiodensity of the caudate nucleus and the posterior limb of the internal capsule bilaterally. Findings of Gentsch et al.  indicateNeurological outcome was determined by review of the electronical patient record using the cerebral performance category (CPC) score , 14 at dΧ2 tests. Different ROC curves were compared with DeLong’s method. Tests were two-sided and a p-value < 0.05 was considered as statistically significant.Statistical analyses were performed using SPSS Statistics version 24.0  and MedCalc Statistical Software version 19.1.7 . Categorical variables were expressed as numbers of patients (percentages) and continuous variables were expressed as median (IQR) or mean . Comparison of continuous variables was carried out using t-test or Welch test if normally distributed, or Mann-Whitney-U-Test if non-normally distributed, as assessed with Shapiro-Wilk normality test. In case of comparison of more than two groups, Kruskal-Wallis-Test was used. Categorical variables were tested with p = 0.728), respectively. Regarding sex the groups were not balanced, proportion of females in the control group 52%, and in the patient cohort 25% (p = 0.002). 24% of patients had a favourable neurologic outcome after 30 days of admission, all-cause mortality was 64, 12% of patients remained in a persistent vegetative state (CPC 4). Baseline characteristics of patients with favourable neurologic outcome and patients with poor outcome were similar with respect to age, sex, setting of cardiac arrest, targeted temperature management with hypothermia, mechanical circulatory support, renal function, and APACHE II and SAPS II scores. Patients with a favourable outcome had significantly lower levels of lactate at admission and neuron-specific enolase at three days of admission, showed a shockable rhythm at first medical contact more frequently, and had shorter times to ROSC , with marked dispersion of diagnostic accuracy for the prediction of worse neurologic outcomes; sensitivity ranged from 69.6 to 89.9%, and specificity from 46.3 to 91.2%, respectively (Table p < 0.001).Measurement of GWR at basal ganglia showed good absolute interobserver agreement, intraclass correlation coefficient 0.670 (95% CI: 0.592–0.741). Differences in GWR were based on a decreased attenuation of gray matter, as well as an increased attenuation of white matter. Furthermore, the magnitude of this effect seemed to depend on the time interval between the circulatory arrest and acquisition of CT images  vs. 1.32 , respectively. As mentioned above, difference in GWR markedly increased with time interval between cardiac arrest and CT imaging, becoming significant in CT studies obtained after 12 h of admission to the ICU , and later than 12 h  after admission. GWR correlated with neurologic outcome at 30 days of admission or hospital discharge, Spearman’s rank correlation coefficient 0.624 (p < 0.001). GWR was significantly lower in all comatose patients irrespective of timing of imaging, than in non-comatose controls, 1.20 (95% CI: 1.16–1.24) and 1.42 , respectively. In the subgroup of patients with delayed CT imaging there was a significant difference in mean GWR with respect to neurologic outcome, 1.09 (95% CI: 1.04–1.15) for a poor outcome, and 1.29  for a favourable outcome, respectively. Patients, who survived with no neurological residues, showed no significant difference in GWR after 12 h compared to controls, 1.35 (95% CI: 1.23–1.47) vs. 1.42 .Therefore, in a post hoc analysis the patient cohort was divided into two subgroups based on the timing of CT imaging: less than or equal 12 h . This also applies to patients with favourable neurologic outcome (p = 0.371).Targeted temperature management with mild hypothermia seemed to have no relevant influence on GWR, as tested with correlation ratio (Eta coefficient 0.192). Patients with poor outcome who underwent targeted temperature management with hypothermia showed no difference in GWR compared to patients in normothermia . Based on a mean GWR in healthy controls of 1.42 (SD 0.10) we assumed a normal range of 2.5 standard deviations around the mean, resulting in a lower limit of normal of 1.17. Applying this threshold to the subgroup of patients with delayed neuroimaging resulted in 67.4% sensitivity (95% CI: 52.0–80.5), 100% specificity (95% CI: 66.4–100.0), 100% positive predictive value (95% CI: 82.7–100.0), and 37.5% negative predictive value (95% CI: 27.4–48.8) for prediction of a poor neurologic outcome (Table p = 0.001). Diagnostic power of GWR for prediction of a poor neurologic outcome as measured by AUC was comparable to NSE at day 3 of ICU treatment  and significantly better than serum lactate level on admission . NSE levels on day 3 were available for 89 of 91 patients, and absolute cut-offs for poor outcomes were 39.4 μg/l for patients treated with TTM, and 76.1 μg/l for patients not treated with TTM, respectively. Serum lactate levels on admission were available for all patients, the absolute cut-off for poor outcomes was 13 mmol/l.ROC curve analysis in patients with delayed CT imaging showed that a GWR threshold of 1.18 predicted a poor neurologic outcome with a false positive rate of 0% (AUC 0.855, 95% CI: 0.751–0.959, In the search for parameters with a prognostic value for the prediction of worse neurologic outcomes after successful resuscitation from cardiac arrest, i. e. death or persistent vegetative state, that are not influenced by sedation, we evaluated two methods based on CT neuroimaging. In contrast to most previous studies we a priori defined a cut-off for GWR derived from an age-matched non-comatose control population. Moreover, we expanded the considered time frame for CT imaging to 72 h after ROSC, on one hand in order to include as many clinically indicated imaging studies as possible, and on the other hand because most aforementioned validated predictors gain their prognostic potential only after this period.Qualitative assessment of signs of hypoxic-ischaemic brain injury in CT imaging studies established in clinical practice yielded high sensitivity in our study. Unfortunately, this was counterbalanced by unacceptable modest specificity and considerable interobserver variability, whereas determination of GWR proved robust in this respect. GWR showed excellent interobserver agreement, even when performed by non-radiologists, and satisfactory specificity. Regarding specificity of GWR we observed a dependency of GWR on timing of CT imaging after circulatory arrest, suggesting an interval of approximately 12 h with diminished sensitivity. This presumably reflects the time course of the underlying evolution of cerebral oedema . Our finUtilising the threshold of 1.17 derived from our control population demonstrated satisfactory diagnostic accuracy in predicting poor neurologic outcomes. Only few studies have reported prespecified GWR thresholds so far –23, rangConcerning potential effects of the routinely applied temperature management, we did not observe an effect of mild therapeutic hypothermia on the capability of GWR to indicate an unfavourable neurologic outcome, however the number of cases in this study was insufficient to reliably exclude such effect.The present study has some limitations that need to be considered. First, results of the neuroimaging studies were known to the requesting physicians and might have biased outcome through support of WLST decisions. Nevertheless, due to the retrospective design of our study GWR measurements were not available to the treating physicians and therefore had no influence on treatment decisions. Besides that, a recent neuropathology study by Endisch et al.  underscoA reduced GWR is associated with unfavourable neurologic outcomes in comatose patients after resuscitation of cardiac arrest. Sensitivity of GWR for predicting neurologic outcome seems limited within the first 12 h after cardiac arrest, pointing to a time window of 12 to 48 h after ROSC with a reasonable trade-off between diagnostic accuracy and the demand of the treating clinicians for early outcome prediction. We propose a threshold for GWR at caudate nucleus and internal capsule of 1.17. This threshold needs to be validated in a larger trial powered for confirming its prognostic value. In particular, it has to be demonstrated that GWR maintains its prognostic power after multivariate analysis of potentially confounding conditions and comorbidities. The design of this trial needs to exclude an interaction between calculated GWR and fundamental treatment decisions, especially premature withdrawal of life sustaining therapies. Additionally, further studies are needed to reliably exclude an impact of therapeutic hypothermia on GWR diagnostic power or specific thresholds.


Qualitative data show negative impacts of menstruation on health and education in many settings, but there are few longitudinal quantitative studies of the impact of menstruation. We analyse associations with menstrual anxiety and school attendance in a study of Ugandan secondary school students.Data were from a longitudinal pilot study of a menstrual health intervention (MENISCUS), conducted in two secondary schools in Entebbe sub-district, Uganda. Self-completed menstrual-related data, including menstrual anxiety, were collected from 232 participants pre- and post-intervention. A sub-cohort of 100 randomly-selected post-menarcheal girls were asked to self-complete daily diaries during 10 months of follow-up, with data on menstrual flow, pain, and school attendance. We used multivariable logistic regression to estimate associations with menstrual anxiety among all girls at baseline, and random-effects logistic regression to estimate associations of menstrual characteristics with school non-attendance for 3 months pre-intervention in the sub-cohort, adjusting for within-girl clustering.Overall, 130/222 (58.6%) of menstruating girls reported being anxious about their next period. Menstrual anxiety was higher in those not living with their mother (adjusted odds ratio (OR) = 1.91; 95% confidence interval (CI) 1.01–3.60), believing menstrual myths , lower menstrual confidence . Those with lower knowledge about menstruation were less likely to report anxiety . During the pre-intervention period of the sub-cohort, school non-attendance was associated with menstrual pain, with 21.7% of girls missing school on days when they reported pain vs. 8.3% on days when no pain was reported .Menstruation causes substantial anxiety in Ugandan schoolgirls, and menstrual pain is associated with missing school on period-days. Menstrual health interventions should address socio-cultural aspects of menstruation to reduce anxiety, and provide education on pain management strategies to support school attendance.The online version contains supplementary material available at 10.1186/s12905-021-01544-6. Menstruation is frequently experienced in a negative way, impacting adversely on mental and physical health , 2, educMost quantitative research describing menstrual cycles in girls has been cross-sectional –18. ManyThe aim of this paper is to understand characteristics of menstruation and examine associations with menstrual anxiety and school attendance in Ugandan secondary school students, using data from a recently-completed pilot trial of a school-based MH intervention , 23. ThiData were collected as part of a longitudinal pilot trial of a multi-component school-based MH intervention (“MENISCUS”) conducted in two secondary schools in the Entebbe Municipality in Uganda. The aim of the parent study was to pilot test the MENISCUS intervention to prepare for a future cluster-randomised trial which will evaluate impact on secondary school performance and attendance, mental health and well-being, and menstrual knowledge, practices and self-efficacy, in Uganda. EligiblThe parent study was prospective, with pre-post evaluation of the MENISCUS intervention. The intervention is shown in Fig. Data for the current analyses focus on menstrual experience in the absence of an intervention, so we analyse baseline survey data from the parent study (objective 1), the 10 months of longitudinal data from the diaries to characterise menstrual patterns and characteristics (objective 2); and the 3 months pre-intervention data from the diaries to assess associations of menstrual characteristics with school attendance (objective 3).Survey data captured electronically were stored on the LSHTM ODK secure server and transferred to Stata 15 for analysis. Diary data were paper-based and were double-entered using Microsoft Access and transferred to Stata 15 for data management and analysis.p < 0.1). We created a similar model for the next level of antecedents (level 2), which relate to behavioural expectations  and knowledge and beliefs around puberty and menstruation, retaining factors from this level independently associated with anxiety (p < 0.1). We then created a model assessing the association between anxiety and variables related to menstrual practices, individual menstrual factors, confidence around menstruation, and shame and distress around menstruation (level 3), retaining factors independently associated (p < 0.1). We present multivariable models containing (a) level 1 and 2 variables (model A); and (b) level 1, 2 and 3 variables (model B). In all analyses we allowed for clustering by school by including school as a fixed effect.Data from the baseline survey were used to examine the association between reported anxiety about next menstrual period (outcome) and menstrual factors (exposure) using logistic regression (objective 1). Measures are described in Additional file Diary data were used to describe menstrual cycles during the 10 months of follow-up (objective 2). Initial analyses were at menstrual period-level, to estimate menstrual patterns ); perceived menstrual flow; and pain. Repeated-measures linear regression with robust standard errors was used to compare duration of menstrual cycle and menstrual period, by age group  and years since starting menstruation . To capture differences in participants’ experience of menstruation, the following participant-level summary statistics  were calculated: (i) percentage of days of menstruation with self-reported heavy flow and (ii) percentage of days of menstruation with pain. Further analyses were at day-level, adjusting for clustering by participant using random-effects logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CI) for the association between pain (outcome variable) with flow (light/medium/heavy) and day of menstrual period (1st day vs. not 1st day).The relationship between menstrual cycle characteristics and school/class attendance (objective 3) was analysed using the diary data collected during the first term of data collection (October-December 2017) i.e. prior to implementation of the intervention, which began in February 2018. Non-school days (i.e. weekends and school holidays) were excluded. Outcomes were (i) school attendance (attended a full day of school—including if they missed some classes) and (ii) class attendance . Random-effects logistic regression (adjusting for within-participant clustering) was used to estimate ORs and 95%CI for associations of each outcome with: day of menstrual period ; menstrual flow  and pain (yes/no).Of the 252 S2 female students at baseline, 232 (92%) consented/assented. At baseline, the mean age was 15.4 years . The majority  were Christian and 93 (42.7%) were of Ganda ethnicity. Relatively few participants  had running water at home, and 30 (12.9%) had a flush toilet in the home.Overall, 222 girls (95.7%) reported that they had started menstruating at baseline and were included in analyses of menstrual anxiety. At baseline, over half 58.6%; 130/222) of participants reported being anxious about their next period. Table 30/222 ofAnxiety about the next period was more common among those who disagreed that it is healthy for a girl to run, dance or cycle during her period (65.2% vs. 51.4%) and among those who agreed that when a girl has her period she is unclean (63.9% vs. 49.1%). Anxiety was less common among participants with poorer knowledge about menstrual biology (51.9% among those with ≤ 7/9 questions answered correctly vs. 68.5% among those with 8/9 questions answered correctly). These variables remained associated with anxiety after adjustment for each other and whether girls lived with their mother (Model A). There was no evidence of an association between anxiety and knowledge of the menstrual cycle, effective pain management methods or agreement that painkillers cause problems having children or sanitary pads can cause sickness or infection  during the last menstrual period (LMP), blood leaking through clothes at LMP or pain during LMP. However, anxiety was associated with variables that may represent lower confidence around menstruation. Those agreeing with the following statements were more likely to be anxious: during my period I feel less confident than on other days (63.7% vs. 41.2%); during my period I avoid doing physical activity (71.4% vs. 45.5%); I prefer staying at home during my period rather than going to school (74.5% vs. 53.3%); boys/girls tease me about my period (78.4% vs. 52.6%). Girls who didn’t report feeling comfortable talking to other girls at school about their period (63.9% vs. 52.4%) or reporting that they worry about being teased during their period were also more likely to report feeling anxious (68.5% vs. 45.3%). In a model containing all level 3 variables, girls who agreed with the following statements were more likely to be anxious: during my period I avoid doing physical activity and boys/girls tease me about my period. Girls reporting that they do not feel comfortable talking to another girl about their period or who reported worrying about being teased during their period were also more likely to report feeling anxious.In the multivariable model including variables from all levels (Model B), the following factors were associated with being more likely to report anxiety about their next period: not living with their mother (aOR = 1.91 [1.01–3.60]), not agreeing that it is healthy for a girl to run, dance or cycle during her period (aOR = 1.83 [0.95–3.50]), agreeing that when a girl has her period she is unclean (aOR = 1.97 [1.04–3.73]), avoiding physical activity during her period (aOR = 2.49 [1.33–4.65]), boys/girls teasing her during her period (aOR = 2.89 [1.28–6.54]) and worrying about being teased during her period (aOR = 2.27 [1.21–4.27]). Those with lower general knowledge about menstruation biology were less likely to report anxiety about their next period (aOR = 0.44 [0.23–0.84]). The association between avoiding physical activity and anxiety was weaker in this model adjusted for level 1 and 2 variables suggesting some confounding by these variables. Associations between disagreeing that it is healthy for a girl to run, dance or cycle during her period and not disagreeing that when a girl has her period she is unclean were also attenuated in the final model (Model B) suggesting that they were mediated through the level 3 variables.The Hennegan model suggests that menstrual experience impacts on psychological health. In our study, participants who reported being anxious about their next period had a higher mean SDQ score than those who did not report being anxious (11.0 (SD5.7) vs. 9.1 (SD5.5)) but there was no association after adjustment for level 1, 2 and 3 variables in the final model  implying that they have similar causal factors.All 100 post-menarcheal girls selected for the diary sub-study agreed to participate. Diaries were collected at least once from 99/100 girls, with complete diary data for 9 months of follow-up (6 diaries) available for 77 (77%) girls. Of the 22 girls with incomplete diary data, 13 submitted data from one diary, three from two diaries, three from three diaries and two from four diaries, although these diaries were not all complete. Missing diaries were due to students leaving schools rather than dropping out of diary completion. The mean age at enrolment was 16.5 years . The median age at menarche was 13 (IQR 12–14) and median years since menarche was 3 (IQR 2–4).p = 0.67) or by years since menarche . Overall, 739 complete menstrual cycles were reported by 94 of the 99 girls completing the diaries (i.e. those with data collected for at least 2 periods). The mean duration of menstrual cycles was 30.8 days  or by years since menarche .A total of 842 menstrual periods were reported by the 99 girls with diary data. The reported mean length of these menstrual periods was 4.1 days , participants reported no days of heavy flow. One day of heavy flow was reported for 22.0% of periods (185/842) and more than one day of heavy flow for 16.4% of periods (138/842). Participants were more likely to report a light flow on the first day of their period  than on subsequent days . Overall, 70.7% of girls reported at least one heavy flow day, with 24.2% reporting heavy flow on at least one-quarter of period-days , and on almost half of period-days . For one in six cycles , pain was reported on all period-days. Overall, few participants  reported no days of pain during follow-up, 18.2% reported pain on fewer than a quarter of period-days and 15.2% reported pain on at least three-quarters of period-days , menstruation was associated with reduced school attendance. Participants reported not attending a full day of school on 15.8% of period-days (70/443) vs. 8.6% of non-period days (235/2736) (OR = 2.36 [1.72–3.23]). Table The study showed that menstrual anxiety in our study population of secondary school girls in Uganda is associated with not living with their mother, other markers of lack of menstrual confidence and lack of self-efficacy, and that menstrual pain is a key factor in causing school absence on period-days.The majority of participants in our study 58.6%) reported feeling anxious about their next period. These findings align with Hennegan’s meta-synthesis which reported that worry and fear featured prominently in women and girls’ menstrual experience [% reporteWe observed lower anxiety in girls living with their mothers, and those who reported feeling comfortable to talk to other girls at school about their period but no differences in anxiety according to whether girls were living with their fathers. Other studies have highlighted the challenges of sharing information about menstruation with fathers . The assOur observed low levels of menstrual confidence among girls highlights the importance of addressing the socio-cultural context of menstruation. The importance of markers of social support and increased self-efficacy in managing anxiety around menstruation suggests that social cognitive theory (SCT) may be an appropriate framing for menstrual health interventions in schools . SCT assAccess to quality education, especially for girls, is a key sustainable development goal set by the United Nations in 2016 . In prevPrevious studies show inconsistent evidence for a relationship between menstruation and school absenteeism , 32–37. A limitation of our study is the relatively small number of participants with detailed menstrual cycle data (n = 99). However, the multiple datapoints per participant resulted in good power to detect associations of menstrual factors with school attendance. Further, this was a random sample of all post-menarcheal girls in the study, with a high response and retention rate, and was unlikely to have suffered substantially from selection bias due to high levels of participation. Girls were provided with information about how to manage menstrual pain during the study so this might have affected the reporting of pain in the diaries. In our study we asked girls about period pain generally and we do not know the site of the pain. For example, previous studies have reported headache as an important menstrual symptom, particularly as part of the pre-menstrual syndrome , 13. We Our analysis highlights the prevalence of menstrual anxiety and the key role of menstrual pain on girls’ education in our study in Uganda. The association between pain and missing school or individual classes suggests that menstrual health interventions in schools should include pain management. Further, to improve girls’ menstrual experience, it is essential to address the psychosocial aspects of menstruation in future interventions, in addition to the physical and biological aspects such as the provision of basic knowledge related to menstruation, access to menstrual hygiene products or access to WASH.Additional file 1. Measures used in the paper. A table of measures used in the paperAdditional file 2. Daily diary. An image of the diary self-completed by participants


The association of psychological factors with postoperative pain has been well documented. The incorporation of psychoeducational intervention into a standard analgesia protocol seems to be an attractive approach for the management of acute postoperative pain. Our study aimed to evaluate the impact of psychoeducational intervention on acute postoperative pain in pulmonary nodule (PN) patients treated with thoracoscopic surgery.In this study, 76 PN patients treated with thoracoscopic surgery and intravenous patient-controlled analgesia (IV-PCA) plus psychoeducational evaluation and intervention were selected as the psychoeducational intervention group (PG). Another 76 PN patients receiving IV-PCA without psychoeducational intervention after thoracoscopic surgery, treated as the control group (CG), were identified from the hospital database and matched pairwise with PG patients according to age, sex, preoperative body mass index (BMI), opioid medications used for IV-PCA and the educational attainment of patients.P < 0.001). Total opioid consumption for acute postoperative pain in the PG was 52.1 mg of morphine equivalent, which was significantly lower than that (67.8 mg) in the CG (P = 0.038). PG patients had a significantly lower incidence of rescue analgesia than CG patients . Nausea/vomiting was the most common side effect of opioid medications, recorded for 3 (3.9%) PG patients and 10 (13.2%) CG patients (P = 0.042). In addition, no significant difference was observed between PG and CG patients in terms of grade 2 or higher postoperative complications .The most common psychological disorders were anxiety and interpersonal sensitivity, which were recorded from 82.9% (63/76) and 63.2% (48/76) of PG patients. The numerical rating scale (NRS) pain scores of the PG patients were significantly lower than those of the CG patients at 2 and 24 h after surgery (Psychoeducational intervention for PN patients treated with thoracoscopic surgery resulted in reduced acute postoperative pain, less opioid consumption and fewer opioid-related side effects. Pulmonary nodules (PNs) are increasingly detected with extensive use of chest computed tomography (CT) scans . The staThe association of psychological factors with postoperative pain and surgical recovery has been well documented , 10, 11.In this matched-pair study, 152 PN patients who underwent thoracoscopic surgery and IV-PCA with or without psychoeducational intervention were retrospectively analysed. The aim of this work was to evaluate the impact of psychoeducational intervention on acute postoperative pain, opioid consumption, side effects of opioid medications and postoperative complications for PN patients treated by thoracoscopic surgery.Inclusion criteria: age 18 years or older; clinical diagnosis of PN with high probability of malignancy; treatment with single-port thoracoscopic wedge resection surgery; postoperative analgesia with IV-PCA; American Society of Anaesthesiologists physical status (ASA-PS) grade 1 or 2; no pain 72 h prior to the surgery.Exclusion criteria: incomplete medical documentation; multiport thoracoscopic surgery that might increase postoperative pain; intraoperative conversion to an open approach; presence of anxiety disorders or other significant alterations of cognitive impairment or mental status or visual and auditory deficits; history of antitumour therapy, psychopharmacological drug use, or chronic opioid use for any reason; concomitant malignant disease; considerable cardiopulmonary morbidity; hypohepatia or renal insufficiency.Seventy-six eligible patients with PN who underwent IV-PCA plus psychoeducational intervention after thoracoscopic surgery at the Affiliated Hospital of Jiangnan University between June 2018 and November 2019 were selected as the psychoeducational intervention group (PG). All PG patients provided written informed consent prior to IV-PCA and psychoeducational intervention. Another 76 PN patients receiving IV-PCA without psychoeducational intervention, included as the control group (CG), were identified from the electronic hospital database and matched pairwise with the PG according to age, sex, preoperative body mass index (BMI), opioid medications used for IV-PCA and the educational attainment of patients. Patient characteristics at baseline in both groups are detailed in Table All patients in both groups received general anaesthesia according to the following protocols. Briefly, intravenous administration of 1–3 mg of midazolam, 1.5–2.5 mg/kg propofol, 4 μg/kg fentanyl and 0.6 mg/kg rocuronium was performed for induction anaesthesia. Inhalation of sevoflurane (1.0%) and continuous infusion of remifentanil (4–18 μg/kg·h), propofol (2–5 mg/kg·h) and rocuronium (0.3 mg/kg·h) were performed for the maintenance of anaesthesia. The bispectral index (BIS) was used to guide the dose of anaesthetic for all patients. Other drugs affecting analgesia intraoperatively, such as magnesium, clonidine, paracetamol, and piritramide, were not administered to any patient.All patients received IV-PCA for postoperative pain management. An opioid agent  was administered at a total volume of 100 ml. The analgesic was infused basally at a rate of 2 ml/h with a bolus dose of 5 ml and a 2 ml bolus with 15-min lockout. Most patients used the total amount of IV-PCA within the first 2 postoperative days (PODs), and additional opioid analgesics  were prescribed by the anaesthesiologists or surgeons upon patient request. Intercostal block and infiltration with local anaesthetics of the surgical wound were not performed for all patients.Patients in the control group received general education support, including leaflets and behavioural instructions, regarding appropriate ways they could adhere to medical advice to support their recovery.In addition to general educational support, PG patients received psychological evaluations and interventions before surgery. First, the psychological symptoms of the PG patients were assessed with the symptom checklist-90 (SCL-90) questionnaire. In the SCL-90 inventory, 90 items are scored on a five-point scale to reflect the psychological symptom patterns of the patient. The items refer to the assessment of 10 indices, one each for somatization, obsessive-compulsive tendencies, depression, anxiety, phobia, interpersonal sensitivity, hostility, paranoid ideations, psychotic states, and other symptoms. Patients with any index scored above 1 were identified as having psychological disorders, and individualized psychological interventions were administered accordingly. Interventions included encouragement, verbal suggestion, relaxation training, guided imagery and audio or video recordings according to the patient’s individual situation. To ensure the outcome of the interventions, the procedure was performed by two trained nurses with 5 and 7 years of professional experience.The following data were collected for this study: acute postoperative pain scores during the first 3 PODs, opioid consumption for acute pain after surgery, the incidence of rescue analgesia, side effects of the opioid medications, and Grade 2 or higher postoperative complications.A numeric rating scale  was used to evaluate acute pain after surgery, which was measured at 2, 24, 48, and 72 h after surgery by registered nurses. The amount of opioid medication used for acute pain during the first 3 PODs, the incidence of rescue analgesia, and opioid-related side effects were collected by the anaesthesiologists. Opioid consumption was converted to morphine equivalents (mg) using a standard conversion ratio. Postoperative complications were assessed and recorded by the surgeons using the Clavien–Dindo grading system, in which Grade 2 or higher complications were defined as requiring pharmacological or surgical treatment and/or presentation with life-threatening complications or death.P value < 0.05 was accepted as statistically significant.The Pearson chi-squared test was used to compare categorical variables. Differences in continuous variables between the PG and CG groups were assessed using Student’s t test. All statistical analyses were performed using SPSS software, version 2.0.0 . A The psychological disorders of PG patients measured with SCL-90 (scored above 1) before surgery are listed in Table P < 0.001).Table P = 0.038). The results also demonstrated that PG patients had a significantly lower incidence of rescue analgesia than CG patients .As detailed in Table P = 0.042). In addition, dizziness was observed in 4 (5.3%) patients in the intervention group and 5 (6.6%) patients in the group that did not receive psychoeducational intervention, and the difference was not statistically significant (P = 0.731). We also found that the incorporation of psychoeducational intervention in our cohort showed significantly reduced total opioid-related adverse events compared with the CG .The opioid-related side effects recorded in the two groups are listed in Table P = 0.240), although there was a trend of reduction for atelectasis, recorded in 1 (1.3%) PG patient and 4 (5.3%) CG patients (P = 0.172).As shown in Table Postoperative pain management is an important component of patient care. In this study, the combined analgesia modality of IV-PCA plus psychoeducational intervention was retrospectively evaluated for patients with pulmonary nodules treated by thoracoscopic surgery. The results showed that the combined analgesia resulted in reduced acute postoperative pain, less opioid consumption and fewer opioid-related side effects than IV-PCA alone.The perception and severity of postoperative pain are influenced by various biological and psychosocial factors , 16. It P = 0.038) and fewer opioid-related side effects  than CG patients. These results, together with the pain relief data mentioned above, further indicate that IV-PCA plus psychoeducational intervention might be a promising method for the management of acute postoperative pain in patients with PN after thoracoscopic surgery.Opioids are the most commonly used analgesics during the postoperative period , 20. HowP = 0.240). Given the relatively small sample size and the selection bias in the patient population, further prospective studies are needed to verify these results.Notably, although the relationship between postoperative complications and pain intensity has been reported in several studies , 22, 23,This study has some limitations. The main limitation arose from the retrospective nature of the data, which were obtained through past records. Another drawback was the potential bias introduced by patient selection. Furthermore, the psychological symptoms of PG patients were not reassessed after psychoeducational intervention, so the outcomes of the intervention, whether it was truly beneficial or not, could not be analysed in the present study. Additionally, only intravenous analgesia was used, involving administration of three different opioids . Finally, observation bias, also known as the Hawthorne effect, which concerns research participation, the consequent awareness of being studied, and possible impact on behaviour, is a disadvantage of this study.Psychoeducational intervention for PN patients treated by thoracoscopic surgery resulted in reduced acute postoperative pain, less opioid consumption and fewer opioid-related side effects. Further clinical trials are needed to confirm these findings.


LOX) family genes  plays important roles in extracellular matrix (ECM) reconstruction and has been investigated in terms of susceptibility to IA in a few populations. We aimed to determine whether polymorphisms in LOX family genes are associated with susceptibility to IA in a Chinese population.Intracranial aneurysms (IA) comprise a multifactorial disease with unclear physiological mechanisms. The lysyl oxidase  and 95% confidence intervals (CI) were evaluated using binary logistic regression analysis.This case-control study included 384 patients with IA and 384 healthy individuals without IA (controls). We genotyped 27 single nucleotide polymorphisms (SNPs) of LOX rs10519694 was associated with the risk of IA in recessive  and additive  models. Stratified analyses illustrated that LOX rs10519694 was associated with the risk of single IA in the recessive  and additive  models. The LOXL2 rs1010156 polymorphism was associated with multiple IA in the dominant model . No associations were observed between SNPs of LOXL1, LOXL3, and LOXL4 and risk of IA.The result showed that LOX and LOXL2 polymorphisms were associated with risk of single IA and multiple IA in a Chinese population, suggesting potential roles of these genes in IA. The effects of these genes on IA require further investigation. Intracranial aneurysms (IA) are cystic bulges caused by local defects or increased pressure in the intracranial artery wall . UnruptuEDNRA), alpha 1 type III collagen (COL3A1), transcription factor SOX-17 (SOX17), and lysyl oxidase-like 2 (LOXL2), which are mainly involved in ECM reconstruction, are associated with IA (LOXL2 gene belongs to the lysyl oxidase (LOX) family that comprises LOX and lysyl oxidase-like 1–4   . Lysyl od LOXL4) . Dysregud LOXL4) , which aLOX family genes and IA, and the results were inconsistent. For instance, associations between LOX gene polymorphisms and IA have not been found in Japanese, Central European, and South Indian populations  were significantly associated with IA   in Japan and found that rs1010156 of LOXL2 was associated with FIA . Using whole exome sequencing (WES), Wu et al. , is related to the FIA susceptibility in a Chinese population. Considering genetic heterogeneity among ethnic populations and that the genetic background of FIA might differ from that of sporadic intracranial aneurysms (SIA), we aimed to determine whether polymorphisms in LOX family genes are associated with susceptibility to IA in a Chinese population.So far, few population studies have explored associations between polymorphisms in ulations –24. Howe × 10–5) . Akagawa × 10–5)  examinedu et al.  also dishttp://grch37.ensembl.org/Homo_sapiens/Info/Index).We recruited 384 consecutive patients with IA at Xiangya Hospital of Central South University and the Hunan Provincial People’s Hospital  since January 2016. The diagnosis and phenotype information of IA  was confirmed by magnetic resonance imaging (MRI), computed tomography (CTA), or digital subtraction (DSA) angiography. Other neurological and vascular conditions such as arteriovenous malformation and Marfan syndrome were excluded. We also randomly selected 384 healthy individuals (control), who visited a district community health service center for routine annual health check-up and had no personal or family history of IA, SAH, or other known related vascular diseases. Demographic information and clinical data were collected using a questionnaire and from medical records. None of the participants were consanguineous. Peripheral venous blood sample was collected from all participants into 5 mL EDTA–K2 anticoagulant tubes . All participants provided written, informed consent before the study was initiated. The study was performed under the approval of the Ethics Committee at Central South University (Permit No: CTXY–150002–1). Furthermore, to test the robust of the association results identified in this study, an additional population control was adopted . The threshold of the LD parameter r2 was set at 0.8. The minor allele frequency (MAF) of all selected SNPs was > 5%. After tag SNP screening by gene name, priority was given to variants with a proven relationship to IA or SNPs located in the functional exonic region or that covered many other sites. We finally selected 27 SNPs of LOX family genes into this study  and their sequences are detailed in ®; Qiagen GmbH, Hilden, Germany). The amplification cycles were as follows: pre-denaturation for 2 min at 95°C, followed by 45 cycles of 30 sec at 9°C, 30 sec at 56°C, 60 sec at 72°C, and a final elongation step of 5 min at 72°C. The amplified products were stored at 25°C. When the PCR endpoint was reached, excess dNTPs were removed using shrimp alkaline phosphatase followed by single nucleotide extension and resin desalination steps. We identified SNP genotypes and alleles using MALDI–TOF–MS, mass spectrum peaks and MassArray TYPER 4.0 software. Finally, target genotypes were interpreted according to the peaks.Genomic DNA was extracted using TIANamp Blood Genomic DNA Isolation kits  and stored at -80°C. Primers were designed according to the SNP loci using Assign Design 3.1 software (2) and the standardized disequilibrium coefficient (D’) in Haploview v.4.2 (https://www.broadinstitute.org/haploview/haploview) . Continuous variables are described as means ± standard deviation (SD) and categorical variables are expressed as ratios (%). Pairs of normally distributed continuous variables were compared using Student t-tests, and distribution differences between two categorical variables were compared using chi-square or Fisher exact tests. The Hardy-Weinberg equilibrium of each SNP in the control group was assessed using chi-square tests. Pairwise LD was evaluated using the mean value of the squared correlation coefficient (rploview) . A pair n D’ = 1 . We calcP > 0.05). Among the patients, 48.7% had IA located in the internal carotid arteries and 64.5% and 35.5% had single and multiple IA, respectively. The distribution of gender and hypertension did not differ significantly between patients with single or multiple IA and the controls. The mean age was lower and smoking, diabetes, and hyperlipidemia were less frequent in the patients than in the controls (P < 0.05). In single or multiple IA groups, approximately 50% and 20% of aneurysms were located in the internal carotid and middle cerebral arteries, respectively. Females comprised 69.5% of the 384 patients with IA and the 384 controls and ~50% participants of both groups had hypertension  block of the targeted SNPs of the LOX family genes in all participants.The detection rate of all SNP genotypes was 100%. Except for the allele frequency and genotype distribution of LOX family genes and their associations with IA. The results of univariate logistic regression analyses associated LOX rs10519694, LOXL1 rs3825942, and LOXL3 rs715407 polymorphisms with risk of total IA  , which are copper-dependent oxidases with a conserved C-terminal region that corresponds to the catalytic domain and a different N-termini  with decreased risk of IA (P = 8.2 × 10-4) in Korean population, we also identified that this variant was associated with the decreased risk of single IA in Chinese, even a definite conclusion couldn’t be drawn considering the fact of that the statistical power was relatively low and the association was not replicated in the additional control. Hong et al. also found that the C allele of LOX rs3900446 and the G allele of rs763497 with increased risk of IA  in Korean population, respectively (LOX gene is not associated with IA in Japanese and Dutch (LOX (rs1800449) was associated with the susceptibility to coronary artery diseases in Chinese population (p.G473A) caused by rs1800449 could lead to loss tumor suppressor function of the LOX propeptide and thus accelerate carcinogen-induced tumor formation  domains . Even the result was not verified in the additional control, we thought that the previous analysis was more reasonable due to that we just performed univariate logistic regression analysis in the additional controls and potential confounders were not adjusted due to these informations was not available. Our findings were similar to the results obtained by Akagawa et al.  can increase susceptibility to FIA . The patients/participants provided their written informed consent to participate in this study.Conceptualization: CL, CH, and JY. Data curation: CL, BL, and JL. Formal analysis: CL and BL. Funding acquisition: JY. Investigation: CL, CH, BL, JL, LH, RD, XL, JZ, LX, SL, YL, DY, and WJ. Methodology: CH, CL, and JY. Project administration: CL, BL, and JY. Resources: CH, JL, WJ, and JY. Supervision: CL, CH, and JY. Writing—original draft preparation: CL. Writing—review and editing: JY. All authors contributed to the article and approved the submitted version.This work was supported by the National Nature Science Foundation, China [grant numbers: 81502881], and the Graduate Student Innovative Scientific Research Project of Central South University, China [grant numbers:1053320192459].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Impatiens mengtszeana is an endemic species in China. In this study, the complete chloroplast genome of I. mengtszeana was sequenced and analyzed. The total chloroplast genome size of I. mengtszeana is 152,928 bp, including a pair of inverted repeat regions  separated by a large single copy  region and a small single copy region . The whole chloroplast genome contains 89 protein-coding genes (PCGs), 37 transfer RNA genes (tRNAs), and eight ribosomal RNA genes (rRNAs). According to the phylogenetic topologies, I. mengtszeana was closely related to I. hawkeri. Impatiens is a large genus in the family Balsaminaceae, comprises over 1000 species, mainly distributed in tropical and subtropical regions  and DNA samples were stored in Guizhou Normal University (accession number: TR-010). Total DNA was extracted from fresh leaves by CTAB method and applied to 500-bp paired-end library construction using the TruSeq Nano DNA Sample Prep Kit for Illumina sequencing. Sequencing was carried out on the Illumina NovaSeq 6000 platform . Approximately 2.4 Gb of raw data from I. mengtszeana were generated with 150 bp paired-end read lengths. The low quality sequences of raw reads used Trimmomatic 0.39 for quality control  region of 83,722 bp and a small single-copy  region of 17,192 bp, which is separated by a pair of inverted repeat (IRa and IRb) regions of 26,007 bp. There are a total of 89 protein-coding genes, 37 tRNA genes, and eight rRNA genes. Among these, duplication events occurred with 19 genes .The complete cp genome sequence of I. mengtszeana, 20 cp genome sequences from Ericales were downloaded from GenBank. BioAider1.0 software was used for the alignment of cp genome sequences (Zhou et al. I. mengtszeana is closely related to Impatiens hawkeri with 100% bootstrap support (In order to further determine the phylogenetic location of  support .


Individuals within the same species often differ in their metabolic rates, which may covary with behavioural traits (such as exploration), that are consistent across time and/or contexts, and morphological traits. Yet, despite the frequent occurrence of sexual dimorphisms in morphology and behaviour, few studies have assessed whether and how sexes differ in metabolic trait covariances.Carabus hortensis ground beetles.We investigated sex-specific relationships among resting or active metabolic rate  with exploratory behaviour, measured independently of metabolic rate in a novel environment, body size and body mass, in RMR, AMR and exploratory behaviour were repeatable among individuals across time, except for male RMR which was unrepeatable. Female RMR neither correlated with exploratory behaviour nor body size/body mass. In contrast, AMR was correlated with both body size and exploratory behaviour. Males with larger body sizes had higher AMR, whereas females with larger body sizes had lower AMR. Both male and female AMR were significantly related to exploratory behaviour, though the relationships between AMR and exploration were body mass-dependent in males and temperature-dependent in females.Differences between sexes exist in the covariances between metabolic rate, body size and exploratory behaviour. This suggests that selection acts differently on males and females to produce these trait covariances with potentially important consequences for individual fitness. Individuals within a species often display consistent differences in metabolic rate . Metabole.g., e.g., Intraspecific variation in metabolic rate may be associated with traits such as body mass e.g., , or linke.g., e.g., e.g., Three different hypotheses attempt to explain the relationship between resting metabolic rate (RMR) and personality differences: (1) the ‘performance hypothesis’ ; (2) the ‘allocation hypothesis’  , and; 3. Each ofe.g., e.g., e.g., e.g., Despite the increasing interest surrounding the relationships between metabolism, personality, and morphology, the majority of studies investigating metabolic trait covariances neglect one important factor: sex . This isCarabus hortensis Linnaeus, 1758. C. hortensis are flightless , exploratory behaviour in a novel environment, body size and body mass in both males and females of the predatory, nocturnal ground beetle ightless , obviatiightless . The bod success . Furtherss e.g., , which lss e.g., . If C. hWe measured metabolic rate and exploratory behaviour independently of one another to reduce the possibility that correlations between them are caused by immediate influences of one on the other. Such correlations could occur regardless of whether individuals consistently differ in behaviour and metabolism and hence could produce erroneous conclusions. We measured the repeatability of RMR, AMR, and exploratory behaviour in a novel environment over time across individuals, assessing the presence of consistent intraspecific differences in metabolism and personality. We first analysed the relationships between metabolic rates, exploratory behaviour, body mass and body size with both male and female combined data to assess whether the sexes differ in their average trait values. We then measured the relationships between traits using separate male and female data to determine sex-specific metabolic trait covariances.C. hortensis individuals show consistent personality differences in exploratory behaviour and consistent differences in metabolic rates; (2) C. hortensis metabolic rate scales with body size/body mass; (3) RMR and AMR are positively (‘performance hypothesis’) or negatively  correlated with exploratory behaviour (We hypothesise that: (1) ehaviour ; (4) if Carabus hortensis  Linnaeus, 1758, ground beetles were collected from the Lüneburger Heide, Lower Saxony, Germany   pupae ad libitum. The light and temperature at which individuals were stored was reduced in increments over time, once per week, to mimic daylight and temperature changes in the natural environment, thereby promoting natural behaviours and metabolic rates. The experiment lasted from October 2018 to February 2019 during which time the conditions in which the beetles were kept changed from a 12:12 h 13.8:6.6 °C light-dark regime to an 8.5:15.5 h light-dark regime at 5.8 °C. Prior to making behavioural and metabolic measurements, beetles were starved for 2 days to ensure that they were in a post-absorptive state.′08.06″) . In tota′08.06″) , using l′08.06″) . Traps w″) e.g., . CollectAll behavioural tests were conducted immediately before all metabolic measures. To measure individual exploratory behaviour, individuals were placed at the centre of an open white 37.5 (L) × 26 (W) cm plastic box with a 28 × square grid on the base . The num2 infra-red gas analyser , operating in differential mode at 2 Hz with two identical chambers was used to measure individual C. hortensis metabolic rates (2. Chambers were 115 (L) × 30 (W) mm, with a 50 ml capacity, allowing ample space for beetle movement. Air was pumped into the chambers using a SS4 Subsampler  through soda lime and Drierite  scrubbing columns, to remove CO2 and H2O, respectively, before it was split between two mass flow controllers  that maintained airflow into two chambers at 100 ml min−1. Temperature was recorded once every 10 min using Voltcraft DL-210TH data loggers , and ranged from 14.4–23.3 °C (mean = 18.1 ± 2.0 °C SD). Temperatures at which metabolic measurements and behavioural measurements were taken differed because metabolic and behavioural measurements were conducted in different rooms. Individuals were allowed to move freely throughout metabolic measurements. We filmed the metabolic rate chamber with a high-speed camera  operating at 72 frames per second to classify periods when beetles were stationary and when they were moving.A L1-7000 dual channel COic rates . One chaC. hortensis active period, after assessing individual exploratory behaviour. AMR trials took place over 12 h rather than 30 min due to difficulties with conducting multiple 30-min metabolic measurements throughout the night. A red lamp was used for illumination: ground beetles cannot see the wavelengths of red light  was used to replicate daylight. AMR was measured over 12 h and took place during the night (20:00–08:00), during the ht e.g., . All 88 2 μl min−1 production were calculated using Origin(Pro) 2016  software, from time periods when individuals were at rest or active, respectively. RMR was measured when beetles were at rest for 3 min or longer and was estimated from the last minute of inactivity. RMR was averaged across all periods of inactivity within a single 30-min trial. AMR was averaged across all periods of activity within a single 12-h trial. Volumes of CO2 μl min−1 for separate periods of activity and rest were converted to provide the total volume produced per hour.Videos of the beetles within chambers were analysed offline using JWatcher software (version 0.9) . MeasureC. hortensis beetles performed three different types of ventilation: continuous, discontinuous, and pulsatile  the length of time over which CO2 μl min−1 plateaued at 0 μl min−1 was almost equal to the time where CO2 μl min−1 was above 0 μl min−1; and (b) where there were obvious, individual peaks of CO2 output. Although some studies have shown that ventilation pattern has no significant effect on metabolic rate scaling , these breathing patterns were excluded from analysis.ulsatile . Ventilang e.g., , others ly e.g., . We therSample sizes available for different analyses differed. Twenty-one females and nine males were excluded from RMR analyses because they either: (a) remained active throughout both RMR trials ; (b) performed discontinuous or pulsatile respiration throughout both RMR trials ; (c) remained active throughout one RMR trial and performed discontinuous or pulsatile respiration throughout the other RMR trial ; or (d) remained active throughout one RMR trial and died before a second could be taken . RMR analyses were, therefore, conducted on 58 individuals .Nine females and two males were excluded from AMR analyses because they either: (a) remained inactive throughout the AMR trial ; (b) performed discontinuous or pulsatile respiration ; or (c) died shortly afterward . AMR analyses were therefore conducted on 32 individuals .We measured both body mass and pronotum width as a proxy for body size  to invesAll statistical analyses were carried out in R version 3.3.2 .Linear mixed effects models (LMMs) were used with the rptR package  to estimi.e., 17 individuals). From these tests, we determined that female RMR was repeatable in only 43% of cases in which the sample size was 17, suggesting that low sample size may explain why male RMR was unrepeatable.Male RMR was not repeatable over time, however, the sample size was considerably smaller than that of female RMR . To asses value was equal to or higher than 0.7.Body size and body mass are frequently correlated. To check for collinearity of body size (pronotum width) and body mass, we performed Spearman’s rank correlations on female data alone and male data alone, using data from only those individuals from which RMR and AMR measures were obtained. We reasoned that collinearity of traits was present if the Re.g., To assess whether relationships between metabolic rate and body size/mass, and metabolic rate and exploratory behaviour exist across combined male and female data, we performed an LMM using RMR as the response variable. The LMM was performed on collated male and female data, and sex was included as a fixed term. The temperature at which measurements of metabolic rate were made (hereafter: metabolic temperatures) was included as a fixed term because metabolic rates are influenced by temperature  using AMR as the response variable. We used a gamma error structure with a log link in our GLMM to account for increased AMR variability with increasing exploratory behaviour, such that the AMR data were log-transformed. Fixed and random terms for the GLMM with AMR as response were as described for the LMM, however, as beetles were tested for their AMR only once, beetle ID was not included as a random term.The sex-specificity of the effect of exploratory behaviour, body size and body mass on both RMR and AMR was determined by performing models as described above, on separate male and female datasets, with sex removed as an explanatory variable. Because male RMR was not repeatable, the effect of exploratory behaviour, body size and body mass on male RMR was not assessed.Stepwise model simplification was performed on LMMs and GLMMs; fixed terms were removed from these models in stages and compared to the previous model using likelihood ratio tests . At eachThe collection of beetles utilised in this study was carried out with a permit granted by the Lower Saxon State Department for Waterway, Coastal and Nature Conservation authorities (number: H72.2220212019).C. hortensis showed consistent differences in exploratory behaviour across 13–15 days, and in AMR across 4–8 h, for combined male and female data , but not in females . Average body size, body mass and their ranges are reported separately for males and females in Individual More exploratory individuals had lower RMR for all beetles , but theAMR was unrelated to body size or mass for all beetles . Howevere.g., e.g., Carabus hortensis AMR was related to body size/mass, though these relationships differed between sexes in terms of directionality for body size. Moreover, the relationship between AMR and exploratory behaviour depended upon behavioural temperature in females, but on body mass in males. Against our prediction, male RMR was not repeatable and hence its relationship with exploration or morphology was not assessed. Though repeatable, female RMR was unrelated to exploratory behaviour or body size/mass. Conversely, exploratory behaviour and AMR were repeatable in both sexes. Given the lack of female RMR trait covariances, and the lack of male RMR repeatability, we focus our discussion on AMR trait covariances.The relationships between metabolic rate and personality traits e.g., , and bete.g., e.g., e.g., The majority of studies of the relationships between metabolic rate, personality traits, body mass and size combine data from males and females e.g.,  or analyCarabus species are thought to search for females with whom to mate  our prediction that relationships between metabolic rate and body mass should be stronger in males in than in females; and (2) findings of the only comparable insect-based study, in which the relationship between AMR and body mass was stronger in male eucalyptus-boring beetles (Phoracantha semipunctata) than in females  to sustain increased bouts of movement and to increase chances of locating a potential mate. In contrast, female C. hortensis are more likely to store energy as lipids  to fuel egg production , body size, body mass and exploratory behaviour in he sexes . Our reshe sexes . Future 10.7717/peerj.12455/supp-1Supplemental Information 1Data includes only those individuals used in RMR LMM and AMR GLMM analysis.Click here for additional data file.10.7717/peerj.12455/supp-2Supplemental Information 2Temp; exploration (number of square visits in a novel environment), Expl.; metabolic temperature, MTemp; Variance of random terms, Var; number of individuals, N. Coefficients (Coeff.) in square brackets belong to non-significant terms just before dropping those terms from the model. Bold p-values denote significant terms.Behavioural temperature, BClick here for additional data file.10.7717/peerj.12455/supp-3Supplemental Information 32 ml/h. Individuals marked with an asterisk (*) died before a second exploration or RMR test could be made.The type of respiration performed (continuous (C) or discontinuous (D)) during AMR measurements (AMR_Type) and during RMR measurements (RMR_Type) by each individual in each trial, and the temperatures at which AMR (AMRTemp), RMR (RMRTemp), and exploration (ExplorationTemp) were measured are given in °C. NA denotes that data could not be obtained either because: (a) the individual was not measured for its AMR; (b) the beetle performed discontinuous respiration; or (c) the individual performed continuous respiration, but remained active throughout a RMR trial, or inactive throughout an AMR trial, meaning that a measure of RMR or AMR could not be obtained (denoted as C*). AMR and RMR are measured in COClick here for additional data file.10.7717/peerj.12455/supp-4Supplemental Information 42ml/h) were measured. ‘Type_MR’ denotes whether RMR or AMR was measured. Data was used for analysis only when individuals demonstrated continuous respiration. RMR was analysed only when individuals remained at rest for a period of 3 min or longer, and AMR was analysed from periods when individuals were active, as described in the ‘Metabolic Rate Analysis’ Methods section.The week during which the individual was measured for its active metabolic rate (AMR), resting metabolic rate (RMR), and exploratory behaviour , is given. The beetle ID, sex, body mass (g), and body size  of each individual is given. ExplorationTemp and MetabolicTemp describe the temperatures at which exploratory behaviour and metabolic rate (MR, COClick here for additional data file.


Chronic kidney disease is a worldwide public health issue, with increasing prevalence resulting in high morbidity and mortality. As a result, recognizing and treating it early can lead to improved outcomes. We hypothesized that some providers might be more comfortable making this diagnosis than others.Retrospective study of 380 patients with chronic kidney disease seen between 2012 and 2016 in an outpatient setting.p = 0.001; had lower GFR, 37  vs 57  ml/min/1.73 m2, p < 0.0001 and were more likely to be seen by a physician compared to an advanced practice provider: 272/316 (86%) vs 46/64 (71.8%), p = 0.008. In multivariate analyses, care by a physician, OR = 2.27 (1.13–4.58), p = 0.02 was associated with increased recognition of chronic kidney disease. On the other hand, higher GFR was associated with decreased diagnosis of chronic kidney disease, OR = 0.95 (0.93–0.96), p < 0.0001.Three hundred and sixteen patients were treated by physicians and sixty-four by advanced practice providers. Chronic kidney disease was identified by the primary care providers in 318 patients (83.6%). Patients recognized with chronic kidney disease were older, 76 ± 8.8 vs 72 ± 7.45 years, The odds of chronic kidney disease recognition were higher amongst physicians in comparison to non-physician providers. These patients tend to suffer from poorly controlled hypertension (HTN) and diabetes (DM) with low rates of statins, angiotensin converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARB) use despite their high cardiovascular risk. [Recent assessments of patients in the United States with estimated glomerular filtration rates (GFR) <60 mL/min/1.73 mHigher GFR, younger age, female sex, use of serum creatinine without adjusting for GFR and absence of hypertension or diabetes were previously identified as risk factors for missing the diagnosis of CKD in the outpatient setting. With the introduction of GFR, the recognition of CKD, proteinuria testing, prescription of ACEIs/ARBs and avoidance of nephrotoxins has modestly improved. This has led to an increase in Nephrology referrals, especially at earlier stages of CKD. Although there are plenty of studies describing the patient characteristics associated with under-recognition of renal disease, there is paucity of data studying the association of primary care provider characteristics with recognition of CKD. Identifying these factors when present can further increase the quality of care for these patients.We hypothesized that recognition of CKD can be influenced by factors independent of patient characteristics and that some primary care providers might be more comfortable making the diagnosis of CKD than others.This research was approved by the Institutional Review Board at Rice Memorial Hospital in Willmar Minnesota, protocol 10222014. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Three hundred and eighty patients with CKD seen between 2012 and 2016 in the outpatient setting were included.2 or proteinuria was obtained. The diagnosis of CKD was confirmed by manual revision of the charts.Initially, a computer-generated list of patients with GFR less than 60 mL/min/1.73 m2. Proteinuria was defined as urine protein to creatinine ratio ≥200 mg/g per day or urinary albumin excretion ≥300 mg/24 h.Chronic kidney disease was defined as evidence of structural or functional kidney abnormalities that persisted for at least 3 months, with or without a GFR of less than 60 mL/min/1.73 mTwo types of primary care providers were identified: physicians  and advanced practice providers (nurse practitioners or physician assistants). Each group of providers was solely responsible for delivering primary care to their patients. Each provider’s visit note over a period of 4 years in the medical chart was reviewed, looking for a documented diagnosis of chronic kidney disease or a corresponding ICD-9 or ICD-10 code.The ICD-9 or ICD-10 codes for proteinuria, chronic kidney disease, chronic renal insufficiency, chronic kidney insufficiency, kidney disease, renal disease, renal insufficiency, kidney stone, renal calculus, renal atrophy, renal sclerosis, kidney failure, renal failure, cystic kidney disease, kidney cyst, polycystic kidney, multicystic kidney, glomerulonephritis, nephritis, nephropathy, and hypertensive chronic kidney disease were used.Patients on renal replacement therapy or with a renal transplant; patients younger than 18 years of age or pregnant.t-test. For highly skewed data, the Wilcoxon–Mann–Whitney test was used.For parametric data, differences in the mean were compared by the Student’s Differences in proportions were assessed by the Chi- square or Fisher’s exact test.For multivariate analyses, logistic regression models were used for variables with P values < 0.1 in univariate analyses.P values ≤ 0.05 were considered statistically significant. All the analyses were performed using JMP statistical software version 14 .Three hundred and sixteen patients were cared by physicians and sixty-four by advanced practice providers. The baseline patient characteristics are described in Chronic kidney disease was identified in 318 patients (83.6%) and urinary protein excretion was measured in 321 patients (84.5%).2, seven (25.9%) were not recognized as having CKD. In those with GFR above 60 mL/min/1.73 m2, five patients (20%) were not diagnosed with CKD.In patients with proteinuria and GFR below 60 mL/min/1.73 mp = 0.40.One hundred and forty-three patients (45.1%) with recognized CKD were treated with ACEIs vs 33 patients (51.6%) with unrecognized CKD, p = 0.15.Angiotensin receptor blockers were prescribed in 63 patients (19.8%) with CKD diagnosed vs seven patients (11.2%) with undiagnosed CKD, p = 0.006.Non-steroidal anti-inflammatory drugs (NSAIDS) were prescribed in 19 patients (30.5%) not diagnosed with CKD vs 49 patients (15.4%) with CKD diagnosis, In univariate analyses, the characteristics associated with increased recognition of CKD included older age, lower GFR and care by a physician .In multivariate analyses, lower GFR and care by a physician were independently associated with increased CKD recognition .Chronic kidney disease is a worldwide public health issue, with increasing prevalence and high morbidity and mortality rates. As a result, recognizing CKD and treating it early can lead to improved outcomes.In the present study, the rate of CKD recognition was high, probably due to the fact that our population was older with a lower baseline GFR, with significant comorbidities and with the GFR automatically included in the electronic medical records. Proteinuria, as recommended in the current guidelines was measured in most patients, likely due to the high prevalence of HTN and DM.These findings are in line with prior studies which demonstrated that assessing renal function with GFR  translates into increased CKD diagnosis. , 122), HTN, proteinuria and DM were prevalent in this population, with increased risks of end- stage renal disease and cardiovascular events. Despite this, 15%–30% of the patients were not recognized as having CKD. Furthermore, 20%–25% of patients with proteinuria were not diagnosed with CKD.Stage 3 CKD . Similarly, the importance of following GFR trends and the recognition of proteinuria as a marker of adverse renal and cardiovascular outcomes needs to be disseminated among primary care providers.The above actions could lead to increased testing and diagnosis of CKD, better blood pressure control, timely referral to Nephrology and better renal outcomes. To the best of our knowledge this is the first study assessing the primary care provider characteristics associated with CKD recognition. Limitations of this study include being a retrospective, single center study in a rural setting with a relatively small number of patients. Other shortcomings include the lack of histology and ultrasonography assessment, along with reliance on ICD-9 or ICD-10 codes for diagnosis of some cases of CKD. At the same time, we did not compare treatment decisions or outcomes of care among different providers or specialties.In conclusion, we have found that in this high-risk population, the odds of CKD being recognized were higher with physicians in comparison to non-physician providers