To compare the peri-operative outcomes of females undergoing laparoscopic intracorporeal urinary diversions (ICUD) and extracorporeal urinary diversions (ECUD) after laparoscopic radical cystectomies (LRC).Thirty-eight females who underwent LRCs and urinary diversions from February 2008 to October 2018 were divided into two groups: the ECUD group (19 patients) and the ICUD group (19 patients). We retrospectively analysed the patients in terms of patients’ demographics, peri-operative outcomes, and oncological follow-ups.p = 0.007), transfusion rates , time to flatus , time to ambulation , and duration of postoperative hospital stays . The mean lymph node yield was 12.9 in the ECUD group and 18.6 in the ICUD group (p = 0.140). Seven out of 19 patients (37%) in the ECUD group and 6 out of 19 patients (32%) in the ICUD group had positive lymph nodes (p > 0.9). Two out of 19 ECUD patients (11%) and 4 of 19 ICUD patients (21%) had positive surgical margins (p = 0.660). Although there were no differences in major complications at 30 days and in all complications at 90 days, the Clavien grade II complications were significantly different at 30 days . The mean follow-up times were 48.7 months (ECUD group) and 26.4 months (ICUD group). There were no statistically significant differences in estimated glomerular filtration rates postoperatively (p = 0.516). Seven patients had disease metastases  and 5 died .There were significant differences in the mean operative times between ECUDs and ICUDs (364.6 vs. 297.1 min, ICUDs benefit females by having smaller incisions, faster recoveries, and decreased complication rates. Primary bladder cancer is a serious worldwide health issue , with thFrom February 2008 to October 2018, 38 female patients with bladder cancer received LRCs with urinary diversions, of whom 19 patients underwent LRCs with ECUDs and 19 underwent LRCs with ICUDs. All operations were performed by an experienced surgeon in a single centre. Indications included muscle invasive bladder cancer, T1G3 and recurrent superficial bladder cancer, or extensive non-muscle-invasive bladder cancer (NMIBC) that could not be controlled by transurethral resection bladder cancer and intravesical treatments. All patients received pelvic magnetic resonance imaging or enhanced computed tomography examinations before their surgeries. No distant metastases were identified on bone scans, chest X-rays, and sonographies. The Clavien-Dindo classification was used to assess postoperative complications .Under intravenous anaesthesia, patients were placed in lithotomy positions. We used a five-port transperitoneal approach. The first 10-mm trocar (for the camera) was placed at the 2–4 cm upper level of the umbilicus. Two 12-mm trocars were placed at the bilateral external rectus line, and two 5-mm trocars were placed at the 3-cm interior bilateral anterior superior iliac spines, at the same level as the first trocar.TM . The bilateral ureters were then divided at the common iliac artery bifurcation and the umbilical arteries were dissected using Hem-O-Lok clips. The broad ligaments of the uterus were disassociated along the pelvic wall and the cardinal ligament of the uterus was cut off. The fornix of the vagina was incised transversely until reaching the posterior urethra, after lifting the uterus and bilateral attachments using forceps. Subsequently, the endopelvic fascia was dissected at both sides, and the dorsal vein complex (DVC) was ligated with 2-0 V-Loc sutures to avoid using instruments that caused heat damage, thereby preserving sexual function. The anterior urethra was separated along the bladder neck and removed using scissors in a ‘cone shape’ to protect the internal urethral sphincter. Hem-O-Lok clips were used to close the urethra. The ureters were also closed using Hem-O-Lok clips  and were then transected down the middle using scissors. Frozen section examinations of the ends of the urethra and the distal ureter were subsequently performed. The bladder and the female reproductive organs were placed into an EndoCatch bag and were removed together through the vagina, which was later closed with a running suture.Laparoscopic dissection began with generous mobilisation of the suspensory ligament of the ovary. The suspensory ligaments were transected with LigasureThe external iliac artery sheath was cut from the iliac artery branch to the distal end. Dissections of the internal iliac lymph nodes, pre-sacral lymph nodes, obturator fossa lymph nodes, and external iliac lymph nodes were then performed. Distinct area lymph nodes were marked and removed for pathological examination.For ECUDs, the ileum was extracted through the 10–15-cm incision below the umbilicus. For ileal conduits , a 15-cmt tests. Categorical data were analysed using medians and ranges and compared with the test. p values < 0.05 were considered statistically significant. Kaplan-Meier analysis was used to calculate survival probabilities. All statistics were performed using SPSS v. 21 .Continuous data were analysed using mean values with standard deviations and compared by Student’s There were no significant differences in baseline characteristics, body mass indices, Charlson comorbidity indices, American Society of Anaesthesiologists scores, pre-creatinine, and pre-operative stage distributions, etc. Table .Table 1p = 0.007), transfusion rates , time to flatus , time to ambulation , and duration of postoperative hospital stays . However, there were no statistical differences in estimated blood loss (EBL) , intensive care unit (ICU) stay rates post-surgery , onset of liquid diets , and length of time before Jackson-Pratt drains were removed . Overall, there were no significant differences in pathologic stages (p = 0.527). Mean lymph node yield was 12.9 in the ECUD group and 18.6 in the ICUD group (p = 0.140). Seven out of 19 patients (37%) in the ECUD group and 6 out of 19 patients (32%) in the ICUD group had positive lymph nodes (p > 0.9). Two out of 19 patients in the ECUD group (11%) and 4 of 19 patients in the ICUD group (21%) had positive surgical margins (p = 0.660).A total of 38 patients underwent LRCs with ICUDs or ECUDs: 19 had ECUDs (11 conduits and 8 neobladders), and 19 had ICUDs (13 conduits and 6 neobladders) Table . There wp = 0.048); however, there were no statistical differences in the mean operative times , EBLs , postoperative ICU stay rates , time to flatus , onset of liquid diets , time to ambulation , time before removal of the Jackson-Pratt drains , and duration of postoperative hospital stays  (Table p = 0.039). There were no statistical differences in any other categories  within 30 days. The most common complications in the ECUD group were haematological diseases, while infections were the most common in the ICUD group . Seven patients had disease metastases  and 5 died . There was no recurrence. There was no statistical differences in oncologic outcomes   and ECUDs (n = 1031) from 26 institutions since 2005. Patients having ICUDs showed shorter operative times , less blood loss , and fewer received blood transfusions , suggesting that the complete laparoscopic approach was technically more efficient. Similarly, in our study, the mean operative time between the ECUD and ICUD groups , transfusion rates , and EBLs  showed advantages for ICUDs to some extent. The time to flatus , ambulation , and durations of hospital stays  postoperatively in the ICUD group were shorter than in the ECUD group. It was suggested that ICUDs were also associated with quicker recoveries. This may be partially due to decreased intestinal exposures, shorter operative times, and smaller EBLs. Additionally, enhanced recovery programmes, which we began in 2014 [Hussein et al.  retrospe in 2014 , were id in 2014  that mayp = 0.07). The 90-day complication rate was not significant between the two groups  [p = 0.026) potentially indicating that the ICUD group was associated with decreased complication rates. Azzouni et al. studied 81 patients after robot-assisted intracorporeal ileal conduits  and reported postoperative complications in the first 90 days, 15 patients of whom had high-grade complications (15%). A total of 164 complications were recorded with the most common complication being urinary tract infections [Ahmed et al. reported on 935 patients in 18 international centres who had undergone ICUDs or ECUDs following robot-assisted radical cystectomies resulting in 43% in the ECUD group and 35% in the ICUD group having complications within 30 days of surgery (= 0.055) . In our fections . InfectiIn this group, orthotopic ileal neobladder reconstructions were performed in 14 cases, all of whom could urinate on their own 12 months postoperatively without catheterisation. The complete daytime continence rate was 88.9% and 77.8% at night. Orthotopic ileal neobladder reconstructions can maximally imitate the natural urination function and significantly improve the patients’ psychological acceptance of surgery. To some extent, it might ameliorate the postoperative quality of life. Our experience regarding orthotopic ileal neobladder reconstructions are as follows: (1) the procedure should comply with the principles of tumour resection, and the urethral autonomic nerve should be preserved to the greatest extent; (2) the bladder neck should be separated close to the bladder wall; and (3) the bilateral tissue of the anterior vaginal wall should be preserved. Overall, the patients were satisfied with their postoperative urinary continence based on the follow-up results.This study also had several limitations. First, the sample size was relatively small; thus, it was difficult to arrive at a definitive conclusion. Secondly, this was a cohort study and not a randomised trial; therefore, there were selection biases and limited information.ICUD after LRC in women is technically feasible. Understanding the female pelvic anatomy and mastering the techniques are helpful to optimise surgical procedures and greatly decrease complications. Compared with ECUDs, ICUDs are potentially beneficial due to smaller incisions, faster recoveries, and decreased complication rates.


Phrynocephalus are a clade of agamids, with all viviparous species restricted to the QTP and adjacent regions. The eastern part of the range of the viviparous taxa is occupied by three closely related but taxonomically controversial species, P. guinanensis, P. putjatia and P. vlangalii. Here, we combined genetic , morphological , and ecological (nine climatic variables) data to explore possible scenarios that may explain the discordance between genetic and morphological patterns, and to test whether morphological divergence is associated with local adaptation.The Qinghai-Tibetan Plateau (QTP) is the world’s highest and largest plateau, but the role of its uplift in the evolution of species or biotas still remains poorly known. Toad-headed lizards of the reproductively bimodal genus P. guinanensis and P. vlangalii. Genetically, the species boundary was not so clear between any species pair. Morphologically, the species boundary was clear between P. guinanensis and P. vlangalii but not between other two species pairs. Body size and scale characters accounted best for morphological divergence between species. Morphological divergence was related to habitat types that differ climatically.We found weak genetic differentiation but pronounced morphological divergence, especially between Phrynocephalus lizards, and supports the idea that natural selection in spatially heterogeneous environments can lead to population divergence even in the presence of gene flow. Our study supports the hypothesis that the evolutionary divergence between viviparous Phrynocephalus species was a consequence of environmental change after the uplift of the QTP.Our study provides evidence for genetic and morphological divergence among the three closely related viviparous species of The online version of this article (10.1186/s12862-019-1443-y) contains supplementary material, which is available to authorized users. Genetic divergence and speciation can occur in different parts of an ancestral species’ range and even within habitats . GeneticIntegrative analyses that combine molecular phylogeny, phylogenetic biogeography and phenotypic evolution represent a powerful approach to identify divergent clades with or without phenotypic differentiation, to detect population genetic structure, and to assess early stages of the speciation process , 11, 12.Phrynocephalus (Agamidae) inhabit desert, arid and semiarid regions in Central and West Asia and North-Northwest China, with all viviparous species restricted to the Qinghai-Tibetan Plateau (QTP) and adjacent regions  around Qinghai Lake, and P. guinanensis is the most narrowly distributed species restricted to sand dunes (2700–3500 m) in the south of Qinghai Lake  was 0.92 ± 0.01 in PG, 0.94 ± 0.01 in PP, and 0.86 ± 0.02 in PV; nucleotide diversity [(π ± SD) × 103] was 7.48 ± 4.04 in PG, 23.07 ± 11.44 in PP and 64.23 ± 31.19 in PV (Table We obtained a sequence of 684 base pairs (bp) of the mitochondrial ND4 gene, which contained nine singleton variable sites and 133 parsimony informative sites. Eight haplotypes were shared by two species , and only one haplotype was shared by all three species  northeast of Qinghai Lake, PV17 and the remaining haplotypes of the three species. Approximately 89% 25/28) of PG haplotypes formed a PG subclade , individuals from localities south of Qinghai Lake were still assigned to their respective clusters (green), but individuals from localities south of the lake and PG individuals were assigned to two groups with moderate probability (red and blue), PV individuals were assigned to a distinct, third cluster (blue)  differed significantly among the three species, while mean PC scores on the second axis did not . Overall, climatic differences were more evident between PP and PG than between any other pairs of species , and so was in females   was positively related to the first climate PC axis (C1) in males (01) Fig. . The sinPhrynocephalus species form a monophyletic lineage that diverged from the oviparous taxa 9.78 Ma, with the most recent common ancestor of viviparous species dated to 5.04 Ma  or ANCOVA  to examine morphological differences between sexes and among species. Prior to parametric analyses, data were tested for the homogeneity of variances using the Bartlett’s test, and for the normality of data using the Kolmogorov-Smirnov test. Tukey’s post hoc test was performed on the traits that differed among species. We performed a principal components analysis (PCA) on 22 morphological variables to show positions of three groups  at 30 arc-seconds resolution [r < 0.85) in subsequent analyses. We performed a PCA on the nine climatic variables to reduce the number of predictor variables in our data set, and plotted PC scores on a two-dimension plane. We used linear regression analysis to test if morphology PC scores were correlated with climate PC scores.In order to evaluate ecological distinctiveness among groups, we used ArcGIS 10.1 to extract values of the 19 climatic variables available in the WorldClim database Additional file 2:Table S2. Summary of genetic variation at nine microsatellite loci. Ho: observed heterozygosity; He: expected heterozygosity; Na: total number of alleles; Hs: genetic diversity; Ar: allelic richness; Fis: inbreeding coefficients. (DOC 111 kb)Additional file 3:Table S3. Loading of the first two axes of a principal components (PC) analysis on 22 morphological variables for both sexes. Size effects are removed in all cases by using residuals from the regressions on SVL. Variables with the main contribution to each factor are in bold. Species with different superscripts differ significantly . (XLSX 14 kb)Additional file 4:Table S4. Loading of the first two axes of a principal component (PC) analysis on nine climatic variables. (DOC 38 kb)Additional file 5:Figure S1. Median-joining network based on ND4 haplotypes. Red dots in network represent the corresponding mutation steps. Green: P. guinanensis; red: P. putjatia; blue: P. vlangalii. (TIF 5524 kb)Additional file 6:Figure S2. Position of three viviparous species of Phrynocephalus lizards in two-dimension space defined by the four principal component analysis according to the mensural and meristic data for both sexes. Green dots and lines: P. guinanensis; red dots and lines: P. putjatia; blue dots and lines: P. vlangalii. (TIF 3711 kb)


At present, repair methods for peripheral nerve injury often fail to get satisfactory result. Although various strategies have been adopted to investigate the microenvironment after peripheral nerve injury, the underlying molecular mechanisms of neurite outgrowth remain unclear. In this study, we evaluate the effects of exosomes from gingival mesenchymal stem cells (GMSCs) combined with biodegradable chitin conduits on peripheral nerve regeneration. GMSCs were isolated from human gingival tissue and characterized by surface antigen analysis and in vitro multipotent differentiation. The cell supernatant was collected to isolate the exosomes. The exosomes were characterized by transmission electron microscopy, Western blot, and size distribution analysis. The effects of exosomes on peripheral nerve regeneration in vitro were evaluated by coculture with Schwann cells and DRGs. The chitin conduit was prepared and combined with the exosomes to repair rat sciatic nerve defect. Histology, electrophysiology, and gait analysis were used to test the effects of exosomes on sciatic nerve function recovery in vivo. We have successfully cultured GMSCs and isolated exosomes. The exosomes from GMSCs could significantly promote Schwann cell proliferation and DRG axon growth. The in vivo studies showed that chitin conduit combined with exosomes from GMSCs could significantly increase the number and diameter of nerve fibers and promote myelin formation. In addition, muscle function, nerve conduction function, and motor function were also obviously recovered. In summary, this study suggests that GMSC-derived exosomes combined with biodegradable chitin conduits are a useful and novel therapeutic intervention in peripheral nerve repair. Every year, a large number of patients suffer from peripheral nerve injury worldwide, and the lack of effective treatments often leads to disability, which imposes a heavy burden on families and society –3. ThereThe repair of peripheral nerve injury is a very complicated pathological process, and it is difficult to obtain satisfactory results because of slow nerve regeneration, Wallerian degeneration, tissue adhesion, and muscle and motor endplate atrophy. Wallerian degeneration occurs after peripheral nerve injury, after which macrophages infiltrate the injured nerve and produce large amounts of inflammatory factors including CCL2, TNF-a, IL-1a, and IL-1beta , 8.The development of new therapeutic strategies to accelerate neurite outgrowth is of great importance . AccordiExosomes are extracellular vesicles that are secreted by living cells. They are released into the extracellular space through fusion of polyvesicular bodies and cytoplasmic membranes. The diameter of exosomes ranges from 30 to 150 nm, and their size is similar to that of viruses . FurtherVasculogenesis plays an important physiological role in tissue repair. Specifically, it can result in the transport of oxygen, nutrients, and immune cells to the injured site. Moreover, many studies have found that cytogenic exosomes can participate in signaling pathways involved in angiogenesis, affecting the development and maturation of blood vessels .Immunoinflammation plays an important role in coordinating a series of physiological processes involved in tissue repair and regeneration. However, it remains a challenge to control inflammation. Many studies have confirmed that MSC-derived exosomes can mimic the ability of MSCs to regulate immune cells including B cells, T cells, natural killer cells, dendritic cells, and macrophages , 24. Gin2 at 37°C for 24 hours in alpha-MEM medium containing 10% FBS and 100 U/mL penicillin/100 μg/mL streptomycin. The original culture medium was discarded, and the floating cells were removed. Fresh medium was added. The medium was then replaced every two days. When cell fusion reached 80%, cells were digested using trypsin for continuous passage. Passages from generations 3–5 were used for experiments.With the approval of the ethical committee of the Peking University Hospital of Stomatology, gingivae were collected from four healthy patients without a history of periodontal disease, such as upon wisdom tooth extraction. Human GMSCs were isolated as described in published protocols . The gin5) were incubated with a specific monoclonal antibody conjugated with either fluorescein isothiocyanate (FITC) or phycoerythrin (PE) in 200 μL PBS  for 30 min in the dark at 4°C. The cell surface antigens were then analyzed by flow cytometry. Antibodies against CD34 (PE) , CD45 (PE) , CD73 (FITC) , CD90 (FITC) , and CD146 (FITC)  were used. Mouse monoclonal IgG1  isotype was used as control.Cells  was added to resuspend the cells. Schwann cell was seeded in a cell culture flask. After 48 h, Schwann cell was digested and seeded in 96-well plates and 6-well plates cultured with exosomes (100 μg/mL). After culture for 1, 3, and 5 days, 10 μL of CCK solution was added to 96-well plates. The absorbance at 450 nm was measured with a microplate reader. Five days after culture, Schwann cell in 6-well plates was identified by immunofluorescence staining using rabbit anti-S100 antibody.Three-day-old Sprague-Dawley (SD) mice were used. The bilateral sciatic nerves were cut, and its epicardium was removed. Sciatic nerve was collected and digested with 0.2% NB4 collagenase for 10 min at 37°C. Schwann cell culture medium  was added. The supernatant was mixed via vortex oscillation for 1 minute, and then placed at 4°C for 2 h. The tube containing the mixture was removed and centrifuged for 60 minutes at 4°C and 10000×g; then, the supernatant was discarded, and the pellet was collected. The centrifugal sediment was beaten uniformly with 100 μL of PBS for mixing and transferred to a new 1.5 mL centrifugal tube. The 1.5 mL centrifugal tube containing exosome was centrifuged at 4°C for 2 min at 12000×g. The precipitation was discarded, and the supernatant was retained.GMSCs were cultured at 3 × 10The protein content of the exosomes was detected by the BCA Protein Assay Kit (Thermo). The morphology of the exosomes was analyzed by transmission electron microscopy (JEM-1400 Plus). The size of exosomes was measured by nanoparticle tracking analyses (ZetaView). The exosomal characteristic markers, CD9 and CD63, were analyzed by Western blot analysis.μg/mL) in MEM medium (Gibco) supplemented with B-27 (Gibco) and GlutaMAX (Gibco). The control had no exosomes.SD mice born within 24 hours were sacrificed. Then, 75% alcohol was used to sterilize the backs of mice; vertebrae were exposed and removed and then placed in DMEM-F12 medium containing 10% FBS. The vertebral body was cut centrally along the sagittal plane, and the DRG was extracted from the intervertebral foramen and placed in a new culture dish. The DRG epineurium was then peeled off and plated onto poly-lysine-coated glass coverslips in 6-well plates. The DRGs were cultured with exosomes  and rabbit anti-S100  were applied as the primary antibodies for overnight incubation at 4°C. Goat anti-mouse IgG  and goat anti-rabbit  secondary antibodies were then incubated with the samples in the dark for 1 hour. Three randomly selected DRG samples from each group were used for statistical analysis. The three longest axons per quadrant were measured and used to calculate the mean length of each DRG axon using the Image-Pro Plus 6.0 image analysis software.μL PBS was administered to the hollow chitin conduit group, retaining a 10 mm gap. The exosome group received 10 μL PBS containing 10 μg exosomes. Then, the muscle and skin were sutured. After waking, the rats were automatically fed food and drinking water and were housed with a 12-hour light/dark cycle and natural circulation.Chitin conduits (diameter: 1.2 mm) were patented by the Peking University and China Spinning and Weaving Institute, and these can retain structure for at least 6 weeks in vivo and undergo complete biodegradation . Eight-week-old SD rats were provided by Beijing Weitong Lihua Co. Ltd. We followed the guideline for ethical review of animal welfare of China (GB/T 35892-2018), and all experiments complied with the relevant regulations of the Medical Ethics Committee of Peking University People's Hospital . Twenty-four SD rats weighing 200–220 g were randomly divided into three groups, with eight rats in each, as follows: the hollow chitin conduit group, chitin conduit plus GMSC-derived exosome group, and autograft group. All rats were anesthetized with a sodium pentobarbital solution (30 mg/kg body weight), and then, the right hind limb was prepared. The sciatic nerve was cut and exposed, and 10 Twelve weeks after surgery, the regenerated nerve tissue samples were removed and fixed with 2.5% glutaraldehyde at 4°C for 2 hours. Samples were stained with 1% osmium acid, dehydrated with a gradient of acetone, embedded in Epon812 epoxy resin, and then cut into 700 nm thick semithin sections and 70 nm thick ultrathin sections. Uranyl acetate and lead citrate were used to stain the 70 nm thick ultrathin sections, which were observed by transmission electron microscopy (JEM-1400 Plus). Semithin sections were stained with 1% toluidine blue and observed by light microscopy. The number of regenerated axons was recorded based on five random images per animal. The diameter of myelinated axons and the thickness of the myelin sheath were measured using the Image-Pro Plus software. Five random axons were counted for each random sample of five random TEM images.Twelve weeks after the operation, bilateral gastrocnemius muscles were removed from each group and fixed with muscle tissue fixative mainly containing formaldehyde, glacial acetic acid, and absolute ethanol  for 24 hours, immediately after weighing. Paraffin-embedded tissues were cut into 7 mL thick sections and subjected to Masson's trichrome staining. Five random fields were imaged for each sample by optical microscopy and quantitatively analyzed using Image-Pro Plus.The CatWalk XT 9.0 gait analysis system  was used to evaluate rat motor function recovery at 4, 8, and 12 weeks after surgery. The sciatic functional index (SFI) is a quantitative measure of sciatic nerve function. The formula is as follows: SFI = 109.5(ETS − NTS)/NTS − 38.3(EPL − NPL)/NPL + 13.3(EIT − NIT)/NIT − 8.8.At 12 weeks after surgery, the regenerated sciatic nerves were exposed, while mice were under anesthesia. Parameters of the Medlec Synergy electrophysiological system  were set at a stimulus intensity of 0.09 mA and a duration of 0.1 ms. The stimulating electrode was placed proximal to the sciatic nerve; the recording electrode was placed proximal and distal to the gastrocnemius muscle, and the reference electrode was placed on the gluteus maximus. Then, the CMAP latency and peak amplitude were calculated separately.p value < 0.05.All numerical data are expressed as the mean ± standard deviation. Statistical analysis was performed by calculating the analysis of variance (ANOVA) followed by Tukey's post hoc multiple comparison test. All data were analyzed using SPSS 17.0. Differences were considered statistically significant with a Flow cytometry analysis showed that GMSCs were positive for MSC markers including CD73 (87.2%), CD90 (98.2%), and CD146 (63%) and were negative for hematopoietic stem cell markers, CD34 (1.8%) and CD45 (3.0%). Also, CD106 is a marker of mesenchymal stem cells with strong immunoregulatory function . ResultsThe ultrastructure of objects was observed by TEM. As shown in p < 0.05). On day 5, GMSC-derived exosomes were found to promote Schwann cell proliferation, and a statistical difference was noted between the two groups (p < 0.01) (p < 0.01)  . Immunof < 0.01) . Also, i < 0.01) . The len < 0.01) .p < 0.05) (p < 0.05)  ; further Figures . Howeverp < 0.05) (p < 0.05)  , and the < 0.05) , which wp < 0.01)  .p > 0.05) (p < 0.05) (p < 0.05)  . Eight w < 0.05) . Twelve  < 0.05) .Autologous nerve transplantation remains the gold standard for repairing peripheral nerve defects; however, it is necessary to uncover methods to replace this technique –34. The Stem cell-derived exosomes deliver various molecules including cytokines, growth factors, signaling lipids, mRNA, and microRNAs. Moreover, exosomes, as intercellular mediators of communication, transfer proteins, lipids, and RNA to regulate various physiological and pathological processes . In addiGingival tissue is known to heal very quickly after injury, and scarring is rare, due to the functions of GMSCs. These cells have many advantages, including the fact that they are homogeneous, nontumorigenic, easily separated, and phenotypically stable . In the GMSC transplantation for peripheral nerve regeneration after injury has been applied in several studies , 28, 38.DRG culture in vitro is usually used to evaluate peripheral nerve regeneration. Our results showed for the first time that GMSC-derived exosomes can significantly promote DRG axonal growth. Lopez-Verrilli et al. found that exosomes derived from Schwann cells can significantly promote axonal growth in vitro and in vivo . In the Using chitin conduits, we have performed different studies on small gap sutures in vivo –53. TypiTwelve weeks after the operation, GMSC-derived exosomes not only enhanced the density and diameter of regenerated axons but also increased the thickness of the regenerated myelin sheath, which was consistent with the results of in vitro studies.At the same time, electrophysiology results showed that the CMAP amplitude in the exosome group was significantly higher than that in the control group, whereas the CMAP latency was decreased in the exosome group compared to the control group. Gait analysis was also used to evaluate the restoration of neuromuscular function in rats. Our study showed that at 8 and 12 weeks after the operation, the SFI was improved in the GMSC-derived exosome group compared to the control group. This was consistent with histological and electrophysiological data. However, regenerated nerve grows into the muscle until 4 weeks, and there was no statistical difference between the groups at this time.In this study, 12 weeks after surgery, muscle histological data showed that the muscle wet weight and muscle fiber cross-sectional area were increased in the exosome group compared to the control group, indicating improved restoration of neuromuscular function, indirectly verifying the results of gait analysis.Although GMSC-derived exosomes in chitin conduits have achieved good results in the treatment of peripheral nerve injury, the extraction method of exosomes needed further optimization to get more exosomes. Also, one remaining question was how gingival stem cell-derived exosomes function. Kou et al. found  that GMSIn summary, the effect of exosomes on intercellular interactions is an exciting research area. Our results suggest that GMSC-derived exosomes combined with biodegradable chitin conduits represent a promising new approach for nerve regeneration.


Interference of dietary fibres with the enterohepatic circulation of bile acids is proposed as a mechanism for lowering cholesterol. We investigated how lupin hull and cotyledon dietary fibres interact with primary bile acids using an in vitro model under simulated upper gastrointestinal conditions. Cell wall polysaccharides were isolated and extracted to separate pectin-like, hemicellulosic, and lignocellulosic structures. Lupin hull consisted mainly of structural components rich in cellulose. The viscosity of the in vitro digesta of lupin hull was low, showing predominantly liquid-like viscoelastic properties. On the other hand, lupin cotyledon fibre retarded bile acid release due to increased viscosity of the in vitro digesta, which was linked with high contents of pectic polymers forming an entangled network. Molecular interactions with bile acids were not measured for the hull but for the cotyledon, as follows: A total of 1.29 µmol/100 mg DM of chenodesoxycholic acids were adsorbed. Molecular interactions of cholic and chenodesoxycholic acids were evident for lignin reference material but did not account for the adsorption of the lupin cotyledon. Furthermore, none of the isolated and fractionated cell wall materials showed a significant adsorptive capacity, thus disproving a major role of lupin cell wall polysaccharides in bile acid adsorption. As a sustainable alternative to soybean products, interest in the inclusion of sweet lupins in food is growing . Next toLegume seed fibres are derived from two main tissues, as follows: The hull (seed coat) and the cotyledons (kernels), which are therefore often referred to as outer and inner fibre. Legume hulls are rich in fibre, contain high amounts of cellulose and insoluble hemicelluloses and vary in lignin contents. Cotyledons contain less dietary fibre and are poorer in structural components (cellulose and lignin). A special feature of lupin cotyledons is the storage of high amounts of non-cellulose non-starch polysaccharides in their cell walls . DietaryThere is clear evidence that a diet rich in dietary fibre provides protection against diet-related disorders such as obesity, type 2 diabetes, cardiovascular disease, and colon cancer ,10. AccoOur recent in vitro findings suggest that the interaction of lupin kernel fibres with primary bile acids may contribute to the cholesterol-lowering properties of lupins . PrimaryInteractions of dietary fibre with bile acids can be differentiated in adsorptive effects and the entrapment of bile acids in viscous chyme matrices using an in vitro model based on in vitro digestion, dialysis and kinetic analysis . For a lWhile there is a broad agreement on the contribution of dietary fibre to viscosity formation, data regarding adsorptive capacities of individual dietary fibre structures are contradictory. As recently reviewed by Singh et al. , bile acIn our previous study, we positively correlated bile acid adsorption with bile acid hydrophobicity, which indicates an underlying mechanism based on hydrophobic interactions . The maiWe hypothesize that bile acid retardation by dietary fibres is a synergic effect of viscosity formation and hydrophobic interactions of dietary fibres with bile acids ,18,19,36The aim of this study was to evaluate whether and to what extent lupin dietary fibres contribute to the viscous and adsorptive interactions with primary bile acids. Cell wall components were isolated from lupin cotyledon and hull and sequentially extracted to separate pectin-like hemicellulosic and lignocellulosic structures. Cellulose and lignin were used as references for bile acid interaction studies. The assessment of in vitro bile acid interactions was combined with rheological and dietary fibre characterisations to obtain a profound knowledge about the fractions of the fibre responsible for interactions with specific bile acids.® (L 600-30) was supplied by J. Rettenmaier & Soehne GmbH & Co. KG . Taurocholic acid sodium salt hydrate (CAS 345909-26-4), sodium taurochenodeoxycholate (CAS 6009-98-9), sodium glycocholate hydrate (CAS 338950-81-5), sodium glycochenodeoxycholate (CAS 16564-43-5), PRONASE® , lignin alkali (CAS 8068-05-1), L-α-lecithin , pancreatin from porcine pancreas (8 × USP specifications), and pepsin from porcine gastric mucosa (3200–4500 units/mg protein) were purchased from Merck KGaA . All other reagents and chemicals used were of analytical grade and supplied by VWR .Cellulose VITACELL. angustifolius L. Boregine (harvest 2016) were provided by Saatzucht Steinach GmbH & Co. KG . The cleaned lupin seeds were de-hulled using an underrunner disc sheller . The cotyledons were separated from the hulls using a zigzag air-classifier . Remaining hull material was removed manually and the germ was discarded. Subsequently, the kernels were flaked using a flaking mill . The obtained yellow flakes were de-oiled by Soxhlet extraction using n-hexane (‘white flakes’), which was evaporated in a cold air stream after oil removal. Hulls were sieved to remove adherent residues of the cotyledons. Finally, the hulls and de-oiled white flakes were milled using a Retsch ZM-200 mill  to fit through a 500 µm screen.Dry-matter and ash contents were analysed on a thermogravimetric basis at 105 °C and 550 °C using a TGA 601 analyser  following the official methods, L 18.00-12 and L 15.00-7, respectively . NitrogeThe soluble and insoluble dietary fibre content was determined on an enzymatic-gravimetric basis . NeutraCell walls were hydrolysed by Saeman procedure  and monosaccharides  were determined by high performance anion exchange chromatography with pulsed amperometric detection. The total uronic acid was determined by spectrophotometric quantification .Hull flour and de-oiled cotyledon flour were obtained as described in w/v)) was homogenised in phosphate buffer  using an Ultra-Turrax blender . Pronase (5000 IU/100 g lupin flour) was added and incubated at 30 °C for 5 h, followed by centrifugation at 5000× g for 15 min. The residue was washed five times with excess water and recovered by centrifugation [De-oiled lupin cotyledon flour (5% (fugation .w/v)) and extracted in boiling ethanol (80% (v/v)) for 1 h under permanent mixing. The solid fraction was isolated from the alcohol phase by filtration using a Büchner funnel and blue ribbon filter paper. The extraction was repeated until the alcohol phase was clear, which was achieved after three repetitions for cotyledon residue and six repetitions for hull flour. The residue was stirred overnight in acetone and then filtered using a G3 glass sinter filter. The solids were transferred into a tared glass vessel and dried at 40 °C for 24 h. The yield of CWM was determined gravimetrically (n = 3) [The residue of cotyledon Pronase hydrolysis  and the  (n = 3) .g, 25 min) with subsequent filtration of the supernatant using a Büchner funnel and black ribbon filtration paper was used to separate the liquid phase from the residue, which was further extracted afterwards. Filtrates were pooled, concentrated using a rotary evaporator, dialysed  for three days against demineralized water and lyophilized.The sequential extraction was adapted from Schieber et al. . Extractw/v)) in alkaline EDTA solution  and extracted twice at 30 °C for 1h. After washing twice with demineralized water, the OHEP fraction was obtained. Aqueous sodium hydroxide (16% (w/w)) was used to extract the hemicelluloses (HC) at 30 °C for 5 h. The pellet was rinsed twice and the pH of the resulting fraction was adjusted to 6.5 using hydrocholic acid (37%). The residue was defined as cellulose-lignin fraction (CL). The proportions of the single fractions were determined gravimetrically by repeated fractionation of 1 g CWM (n = 3). In order to obtain material for further analyses, a larger extraction of 100 g CWM was additionally carried out.CWM  was suspReference materials (cellulose and lignin) and lupin fractions were diluted with demineralized water to obtain a constant dietary fibre concentration of 5% in the final digestion mixture. The in vitro digestion was performed according to the harmonized INFOGEST protocol ,47 with ® 12–14 kDa cut-off dialysis tubings ) against 36 mL of phosphate buffer  using a shaking water bath at 150 rpm and 37 °C. At 1, 2, 4, 8, 12, 24, and 48 h dialysis time, 100 μL-aliquots of dialysate were analysed for permeated bile acids by high performance liquid chromatography as described in detail in Naumann et al. [®, version 12.5 .A total of 4 g of in vitro digesta , with 10Viscoelastic and viscosity measurements were conducted using a rotational rheometer . Triple determinations were performed using a parallel plate geometry   at constant temperature of 37 ± 0.1 °C.−1 for 20 s and allowed to rest for 20 s. The viscosity η was monitored as a function of the shear rate, which was analysed in a logarithmic scale ranging from 1–1000 s−1.Before starting the measurement, samples were sheared at a shear rate of 5 s−1 and a strain ramp in a logarithmic scale ranging from 0.01% to 100% deformation of the sample. Based on the results for linear viscoelastic ranges, a constant strain of 0.5% sample deformation was set for the frequency sweep tests. Frequency sweep tests were performed with a logarithmic decreasing angular frequency ranging from 100 to 0.001 s−1. Storage (G′) and loss modulus (G″) were calculated and used to evaluate the viscoelastic properties of the samples.The linear viscoelastic range was determined using strain sweep tests prior to the analysis of the viscoelastic behaviour by frequency sweep tests. Strain sweep tests were performed at an angular frequency of 10 swww.r-project.org). In all analyses, p ≤ 0.05 was considered significant. After testing for homogeneity of variance (Bartlett test) and normal distribution (Shapiro–Wilk test), one-way ANOVA with a post-hoc Tukey test was applied to separate significant means.The results were evaluated statistically using R version 3.2.4 (L. angustifolius L. Boregine (n = 10).Lupin seeds of Boregine  had an aL. angustifolius L. Boregine are given in The chemical and dietary fibre compositions of the cotyledon and the hull of Protein (40.13 g/100 g DM), dietary fibre (37.77 g/100 g DM), and fat (9.47 g/100 g DM) represented the main components of lupin cotyledon; the compositional data was within the range reported in the literature ,49,50. SL. angustifolius L. Boregine was comparable with values reported by Evans et al. [L. angustifolius L. Boregine contained high amounts of dietary fibre (37.77 g/100 g DM), which was predominantly water-insoluble (34.59 g/100 g DM). Water-insoluble fibre determined by detergent-extraction (NDF) was 11.34 g/100 g DM. This underestimation in comparison to the enzymatic-gravimetric analysis of insoluble dietary fibre is probably due to a high content of water-insoluble pectin-like substances, which are lost during the NDF procedure [Dietary fibre composition detected for cotyledon and hull of s et al.  for threrocedure . Detergerocedure  and may rocedure . As experocedure . Hull fiCWM constituted of 32.6 ± 0.3 g/100 g DM for lupin cotyledon and 93.1 ± 0.7 g/100 g DM for lupin hull. Recovery of the CWM after sequential extraction was 97.2 ± 1.4 % and 89.7 ± 0.5 % for cotyledon and hull, respectively. In a first step solubilisation of pectin-like substances from the isolated CWM was enhanced by EDTA in dilute alkaline solution (OHEP). Hemicelluloses were extracted with increasing alkali concentrations (HC), whereas the remaining alkali-insoluble residue predominantly consisted of cellulose and low amounts of lignin (CL) . SequentL. angustifolius L. Boregine is given in HC represented the main fraction of lupin cotyledon (21.4 g/100 g DM), followed by OHEP (5.2 g/100 g DM) and small amounts of CL (2.1 g/100 g DM). CL was predominant in lupin hull (80.8 g/100 g DM), while HC (8.4 g/100 g DM) and OHEP (2.0 g/100 g DM) was low. The monosaccharide composition of the cotyledon, hull and isolated pectin-like fraction (OHEP), hemicellulose fraction (HC), and cellulose-lignin fraction (CL) of L. angustifolius L. [The cell wall composition of the cotyledon  is in agolius L. ,51,52. Tolius L.  proposedolius L.  and EvanL. angustifolius L. and other lupin species [As expected for legume seed hulls , the lup species ,57. This species . OHEP, w species . The domThe viscosity of in vitro digested samples was tested for logarithmically increasing shear rates and which are reported in −1) are most relevant with regard to bile acid release [−1) and showed no significant deviation from blank digestion (p = 0.3).The digested HC fractions of hull revealed nearly true viscous flow behaviour (viscosity independent of changes in shear rate). All other samples showed a similar pattern of shear thinning at high shear rates, which is typical for insoluble fibre suspensions. The flow curve of the digesta containing lupin hull and its CL fraction tended to a plateau value at high shear rates. This newton-like flow behaviour at high shear rates is typical of polymers without crosslinks or entanglements. As only low shear forces occur in the gastrointestinal tract, viscosity values at low shear rates (approximately 15 s release . At low The frequency spectra of storage (G′) and loss (G″) moduli of in vitro digesta containing fractionated dietary fibre derived from lupin cotyledon (a) and hull (b) are shown in For the whole cotyledon as well as its OHEP and CL fraction a, both mAlthough HC was the largest fibre fraction of lupin cotyledon , the rheAs expected, the hull digesta showed rheological properties similar to the CL fraction, which was by far the largest hull fraction . In agref) and the apparent permeability rate constant (k) were calculated following the first-order kinetic described in Equation (1) [Bile acid release kinetics were investigated for the primary bile acids glycocholic acid (GCA), taurocholic acid (TCA), glycochenodesoxycholic acid (GCDC), and taurochenodesoxycholic acid (TCDC). The concentration of primary bile acids after reaching equilibrium (Ction (1) ,59.Correlation coefficients for non-linear regression of bile acid release ranged between 0.977 and 0.999, which showed the high agreement of the kinetic fitting with the experimental data.If bile acid release studies are combined with rheological investigations after in vitro digestion, viscous and adsorptive interactions of samples with specific bile acid species can be differentiated by the parameters of the kinetic analysis . The efff (Equation (1)), in comparison to the blank digestion. In In case that bile acids are adsorbed to sample components, less bile acids are available for diffusion, resulting in a decrease of the equilibrium concentration, CApparent permeability rates (k) of fractionated CWM derived from lupin cotyledon and hull and the references, cellulose and lignin, are given in p < 0.001). Release rates decreased following the order GCA > TCA > GCDC > TCDC, which can be explained by the micellar properties  of the different bile acids, as described in detail in Naumann et al. [The apparent permeability rate constants described in n et al. .In vitro digested cotyledon and its dietary fibre fractions showed a retarded release of primary bile acids in comparison to the blank digestion . The extLupin hulls also caused a retarded release of all primary bile acids, but it was significantly lower than that observed for the cotyledon. In agreement with its different composition and rheological behaviour, OHEP showed an extended retardation. The decrease in release rate was similar for hull, as well as for the HC and CL fractions. The retarded release for lupin hull can thus mainly be ascribed to these fractions. Since lignin did not show a significant increase in viscosity after in vitro digestion , the redf, Equation (1)), bile acid adsorption of fractionated CWM derived from lupin cotyledon and hull, as well as from the references, cellulose and lignin, were calculated with respect to dry matter concentration in the in vitro digesta. Conjugation of bile acids had no significant effect on the adsorption . Therefore, the data for glyco- and tauroconjugated cholic acids and chenodesoxycholic acids are given and summarized in Based on the equilibrium concentrations  and chenodesoxycholic acids  deviated strongly from the release curve of the whole cotyledon . No signThe adsorptive capacity observed for lupin fibre preparation  indicatAdsorptive capacities have also been suggested for dietary fibre sources with a low protein contents, such as described for a number of fruits by Kahlon and Smith . The autIn our study, we investigated how bile acid interactions were influenced by the cell wall polysaccharides of lupin hull and cotyledon. Lupin hull mostly consisted of cellulosic polymers, which is in line with low bile acid retardation induced by viscosity. Bile acid adsorption observed for a lignin reference material was not evident in hull or cotyledon due to low lignification. Sequential extraction revealed that pectin-like substances are mainly responsible for viscosity in lupin cotyledon digesta. We suggest that the formation of entangled networks, causing predominantly elastic properties, majorly contributes to the increase of viscosity. Due to the characterization of components accountable for the viscous effects on bile acid reabsorption, our results could contribute to the elucidation of cholesterol-reducing mechanisms of lupin dietary fibres. In future studies, the effects of food processing on the composition and rheological properties of lupin dietary fibre should be addressed to ensure to transferability of the in vitro results to complex food matrices.Our results indicate that bile acid adsorption of lupin cotyledon is not directly attributable to the cell wall polysaccharides. The contribution of dietary fibre polysaccharides to bile acid adsorption, as frequently reported for a variety of dietary fibre sources , should


Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality all over the world. Acute exacerbation of COPD (AECOPD) not only accelerates the progression of disease, but also causes hospital administration and death events. Epidemiologic studies have shown air pollution is a high risk factor of AECOPD. However, there are rare technics or treatment strategies recommended to reduce severe air pollution related AECOPD.This is a multi-center, prospective, randomized and standard treatment parallel control clinical trial. Seven hundred sixty-four stable COPD patients in group B, C and D according to GOLD 2017 will be recruited and equally divided into two parallel groups, salvational intervention (SI group) and control group (CT group). Original treatments for participants include tiotropium (18μg once q.d), budesonide/formoterol (160μg/4.5μg once or twice b.i.d) or budesonide/formoterol (160μg/4.5μg once or twice b.i.d) with tiotropium (18μg once q.d). The savational intervention for SI group is routine treatment plus budesonide/formoterol (160μg/4.5μg once b.i.d) from the first day after severe air pollution  to the third day after AQI < 200. CT group will maintain the original treatment. The intervention will last for 2 years. Primary outcome is the frequency of AECOPD per year and the secondary outcomes include the incidence of unplanned outpatient visits, emergency visits, hospitalization, medical cost and mortality associated with AECOPD per year.The salvational intervention is a novel strategy for COPD management under severe air pollution. Results of the present study will provide reference information to guide clinical practice in reducing the air pollution related exacerbation of COPD.NCT03083067) in 17 March, 2017.This study has been registered at www.ClinicalTrials.gov (registration identifier:  PM10 is the particulate matter with a diameter of 10 μm or less and PM2.5 is with a diameter of 2.5 μm or less. Once inhaled, PM2.5 deposits in lung tissues and diffuses in blood causing airway and systematic inflammation [2.5 and PM10 was associated with 15.8 and 15.8 years of life lost increase, respectively [Air pollution has become a serious public health issue in many regions, especially in China and other developing countries. Beijing is one of the most polluted cities in China, in which main pollutants are inhalable particulate matter PM0 and finmatter PM.5. PM10 3 increase in PM2.5 was associated with a 2.36% (95% CI 1.00 to 3.73%) increase in the risk of COPD associated admissions [, 1 and 6% in China, the European Union and the United States respectively, and a long-term exposure increased the mortality rate by 10% [3 of PM10, COPD related hospitalization and mortality would increase 29.69 and 46.35%, respectively [Although preventable and curable, chronic obstructive pulmonary disease (COPD) is still a major cause of morbidity and mortality all over the world, and best characterized by persistent airway inflammation and progressive airflow limitation . Acute emissions . A shortThus, there is an urgent need for effective interventions to reduce AECOPD associated with severe air pollution exposure. Many issues must be taken into account: 1) geographic variation of air pollution, 2) measurement of air pollution exposure level, and 3) safety and effectiveness of the intervention.2), nitrogen dioxide (NO2), carbon monoxide (CO), ozone (O3), inhalable particulate matter (PM10) and fine particulate matter (PM2.5) are monitored in each site. According to the 24-h mean concentration of PM10 and PM2.5, the air quality index (AQI) was calculated [In Beijing, air quality has been reported every hour automatically and summarized every 24 h since 2016 by Air Quality Automatic Monitoring System. In this system, there are 35 monitoring sites located in different districts of Beijing, and the monitoring area covers almost every corner in urban and main area in suburbs. Sulfur dioxide (SOlculated . AQI of lculated . Grades lculated . After elculated . At pres2-agonists stimulate beta2-adrenergic receptors in order to relax airway smooth muscle. Combination of ICS and long-acting beta2-agonists (LABA) such as budesonide/formoterol and fluticasone/ salmeterol has effective synergistic action on improving symptoms, lung function, and life quality, as well as reducing exacerbation of COPD [Inhaled corticosteroids (ICS) play an essential role on anti-inflammation, and beta of COPD , 16. Com of COPD . COPD pa of COPD . In the  of COPD . Thus, bThe salvational intervention for COPD patients under severe air pollution (AQI ≥ 200) is a short-term treatment with budesonide/formoterol (160μg/4.5μg once b.i.d) from the first day after the exposure to the third day after the exposure end. We hypothesize that it may be beneficial on reducing AECOPD frequency per year and AECOPD related visits, hospitalization, mortality, costs and so on.This is a multi-center, prospective, randomized and standard treatment parallel control clinical trial. A total of 764 stable COPD patients diagnosed according to GOLD will be recruited and equally divided into two parallel groups, salvational intervention group (SI group) and control group (CT group). The Department of Respiratory and Critical Care Medicine in Peking University First Hospital is responsible for this research. Other 10 institutions participating in the study include Peking University Shougang Hospital, People’s Hospital of Beijing Daxing District, Beijing Jingmei Group General Hospital, Beijing Miyun Hospital, Beijing Changping Hospital, The Hospital of Shunyi District, Beijing Luhe Hospital capital medical university, Civil Aviation General Hospital, Beijing Jishuitan Hospital and Aerospace 731 Hospital. These 11 centers are located in the four corners and central of Beijing, covering area from urban to suburbs.Investigators or physicians will explain the trial in detail to potential COPD participants from outpatient visits of each center. Total 764 eligible COPD patients will be enrolled after signing consent forms.The inclusion criteria are 1) aged at 40–80 years old; 2) spirometry confirmed diagnose of COPD in group B, C and D according to GOLD 2017 with at least one acute exacerbation before and stable for at least 3 months; 3) quit smoking for more than 6 months; 4) be able to engage in daily activities; 5) have willing to participate in this study, follow the research program and have the ability to sign the informed consent; 6) Beijing residents; 7) can be contacted.The exclusion criteria are 1) history of asthma, lung cancer, active pulmonary tuberculosis, bronchiectasis, diffuse lung disease  and pleural disease; 2) history of lobectomy and / or lung transplantation; 3) predicted life expectancy less than 3 years; 4) history of severe psychiatric illnesses, mental disorders, neurological disorders, malignant tumors, chronic liver disease, heart failure, autoimmune diseases, chronic kidney disease; 5) never engage in outdoor activities; 6) plan to move out of Beijing in 3 years; 7) plan to carry out an indoor redecoration during the study; 8) alcoholism, drug abuse or abuse of toxic solvents; 9) allergic to the study drug or its ingredients, or have a clear contraindication of it; 10) participate in any other clinical trial; 11) cannot finish long term follow-up or be poor compliance; 12) do not provide consent.The information of demographic data, medical and medication history, smoking and exposure history, family history and main results of physical, laboratory, and lung function test  will be collected. Especially, region of daily activities like home or work address and the history of exacerbation of COPD in last 12 months will be recorded. Furthermore, such COPD assessment scales like the St. George’s Respiratory Questionnaire (SGRQ), COPD assessment test (CAT), Modified British Medical Research Council (mMRC) scale and BODE index will be noted.Inhaled tiotropium (18μg once q.d), budesonide/formoterol (160μg/4.5μg once or twice b.i.d) or the combination of budesonide/formoterol (160μg/4.5μg once or twice b.i.d) and tiotropium (18μg once q.d) will be used as routine treatment. Inhaled medication will be withdrawn from all potential subjects prior to randomization (shown in Table The randomization will be stratified by centers and the random code will be designed in a 1:1 ratio (SI group or CT group), with a block size of 4, using the SAS 9.2 software package . The randomization results will be sealed in the envelopes until the end of the study. The flowchart of this study is shown in Fig. After randomization, patients will be assigned to two groups, salvational intervention group (SI group) and control group (CT group). On the foundation of basic treatment strategies, inhaled budesonide/formoterol (160μg/4.5μg) will be used as an intervention drug for patients in SI group. When air quality index (AQI) is no less than 200, they will temporary add budesonide/formoterol (160μg/4.5μg once b.i.d) from the first day after exposure till the third day after AQI drops below 200. CT group maintains the original treatment. Intervention will be finished by telephone, message or E-mail. The intervention will last for 2 years. Daily AQI and whether the intervention is successfully accomplished during every intervention period will be recorded by investigators.Besides baseline, patients will be formally visited 4 or 5 times during this trial: before randomization  and every 6 months after randomization. Questionnaires of SGRQ, CAT, mMRC scale and BODE index will be filled out and assessment of AECOPD will be collected. Meanwhile, information of physical, laboratory, and lung function test  will be collected, too. The details are listed in Table What is more, all subjects have to complete diary cards during this study. Subjects are asked to record the daily dose of inhaled budesonide/formoterol (160μg/4.5μg) and score their status of cough, expectoration, dyspnea, physical activity and sleep on 5 points(from 0 = very well to 4 = very poor).Primary outcome is the frequency of AECOPD per year, which is defined as the incidence of AECOPD per patient per year.Secondary outcomes include the number of unplanned outpatient visits, emergency visits, hospitalization, medical cost and mortality caused by AECOPD per year.All baseline and follow-up data will be recorded on an online Case Report Form System. Project investigators of each center, study coordinators, investigators for intervention, investigators for follow-up visits and data managers will have accordingly authorized access to this system. Online data will be monitored carefully by two data managers every month. Complete online data will be exported into the EpiData3.10 database system.The study has no plan of data sharing.P < 0.01) or an obvious disadvantage(P ≤ 0.05), the research will be stopped after the discussion of all centers and the approval of the ethic committee.Adverse event is an unpredictable and infaust event that occurs during the study period, with or without the study intervention. Severe adverse event is an event that lead to death, threat of life, persistent disability or dysfunction, diagnose of tumor or other severe event during the study period. In our study, all drugs used for patients are routine medicine within recommended dosage. So our study will not produce additional risk on participants. However, adverse events may occur during daily use. All adverse events will be monitored carefully, managed promptly, and followed up until they are properly resolved, stabilized or recovered to normal. And occurrences of adverse events will be documented from the beginning to the end of the study including the time of occurrence, diagnosis, diagnosis time, management, duration of persistence, sequelae, and severity. The occurrences of severe adverse events will be reported to the Peking University First Hospital Institutional Review Board (IRB) as soon as possible. Severe adverse event will be analyzed every 6 months during the study. If there is a definite benefit  increase in the risk of COPD associated admissions [3 to 150 μg/m3 of PM10, and 52 μg/m3 to 150 μg/m3 of PM2.5 [According to previous studies, every increase of 55.89 μg/mof PM2.5 , suggestp values < 0.05 will be considered to have statistical significance (unless otherwise specified).Analysis will be performed on an intention-to-treat basis. All statistical analysis will be performed with SPSS 14.0 software . Two-tailed tests will be used in all statistical analysis, and A Poisson regression model will be used to calculate the rate ratio of frequency of exacerbation and the 95% confidence interval will be estimated. The influences associated with different centers or baseline data will be considered.Numeric variables will be presented as mean (standard deviation) or median  and categorical variables will be presented as number of cases (percentage). Accordingly, data will be analyzed with independent sample t test, Wilcoxon rank sum test, chi-square test, continuity correction Chi-squared test or Fisher’s exact test. Characteristics of baseline will be summarized with equilibrium test. Unplanned outpatient visits, emergency medical visits, hospitalization, medical cost and mortality caused by AECOPD per year will be compared between two groups.This study points out an idea about salvational intervention for COPD patients under severe air pollution, which is a novel strategy of adding budesonide/formoterol (160μg/4.5μg) twice a day from the first day after severe air population (AQI ≥ 200) till the third day after the population end (AQI < 200). This multi-center, prospective, randomized and standard treatment parallel control clinical trial is aiming to figure out whether the salvational intervention will reduce the air pollution related exacerbation of COPD.Airflow limitation, symptoms and exacerbation history are very important assessment for COPD pharmacological management. For patients with FEV1 < 80% of predicted value (after bronchodilator use), a history of exacerbations is a predictor of exacerbations, and exacerbations will become more frequent and more severe along with the progression of COPD . GOLD 20Long-acting muscarinic antagonist (LAMA) and LABA are highly recommended by GOLD for patient in group B, C and D . Althoug1 in 5 min after inhalation, and increases morning activities including getting washed, dried, dressed, eating breakfast and walking around the home [Budesonide/formoterol is believed to be an ideal salvational intervention drug. Firstly, budesonide/formoterol shows rapid-acting effects in COPD. Budesonide/formoterol significantly increases morning peak expiratory flow (PEF) and FEVthe home , 25. Secthe home . In our A limitation is that the study is not a double-blind design because both participants and researchers will know treatment which will be administered. To decrease the potential bias, investigators performing follow-up visits after randomization will be not informed of the administration of participants. Moreover, participants are asked to record daily dose of budesonide/formoterol (160μg/4.5μg) and investigators are asked to record daily AQI and whether the intervention is done.Conclusion, this is a multi-center, prospective, randomized and standard treatment parallel control study aiming at reducing air pollution related COPD exacerbations. Evidence of the study will provide effectiveness and safety for a novel and precise strategy called the salvational intervention.The trial is currently at the stage of patient recruitment and data collection.


Surgical site infection is a common complication in women undergoing Caesarean section and the second most common cause of maternal mortality in obstetrics. In Ethiopia, prevalence and root causes of surgical site infection post-Caesarean section are highly variable. This systematic review and meta-analysis estimate the overall prevalence of surgical site infection and its root causes among women undergoing Caesarean section in Ethiopia.Systematic review and meta-analysis were conducted to assess the prevalence and root causes of surgical site infection in Ethiopia. The articles were searched from the databases such as Medline, Google Scholar and Science Direct. A total of 13 studies from different regions of Ethiopia reporting the prevalence and root causes of surgical site infection among women undergoing Caesarean section were included. A random effect meta-analysis model was computed to estimate the overall prevalence. In addition, the association between risk factor variables and surgical site infection related to Caesarean section were examined.Thirteen studies in Ethiopia showed that the overall prevalence of surgical site infection among women undergoing Caesarean section was 8.81% (95% CI: 6.34–11.28). Prolonged labor, prolonged rupture of membrane, presence of anemia, presence of chorioamnionitis, presence of meconium, vertical skin incision, greater than 2 cm thickness of subcutaneous tissue, and general anesthesia were significantly associated with surgical site infection post-Caesarean section.Prevalence of surgical site infection among women undergoing Caesarean section was relatively higher in Ethiopians compared with the report of center of disease control guideline. Prolonged labor, prolonged rupture of membrane, presence of anemia, chorioamnionitis, presence of meconium, vertical skin incision, greater than 2 cm thickness of subcutaneous tissue and/or general anesthesia were significantly associated with surgical site infection post-Caesarean section. Caesarean section (C/S) is a surgical practice where a neonate is born via an incision through both the abdominal wall and uterus. It is the most frequent surgical procedure in obstetrics, occurring in approximately 15% of all deliveries, but ranges from approximately 3.5% across the African continent to 29.2% in Latin America  OR  OR “surgical site infection”[All Fields]) AND (“Caesarean section”[All Fields] OR “Cesarean section”[MeSH Terms] OR (“Cesarean”[All Fields] AND “section”[All Fields]) OR “Cesarean section”[All Fields]) AND (“ethiopia”[MeSH Terms] OR “ethiopia”[All Fields]). All the literatures accessible until March 15, 2019 were included in the present study. The systematic review and meta-analysis was guided with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [Studies reporting prevalence and causes of SSI among women undergoing C/S in Ethiopia were included.Only articles conducted in or including Ethiopian hospitals.All observational studies  that contain original (primary) data reporting of the prevalence and associated risk factors SSI among women undergoing C/S in Ethiopia were considered.Literature published in the English language only was included.Studies conducted among women undergoing C/S were considered.Both published articles and unpublished studies were considered.Non-accessible research whether published or unpublished if irretrievable from the internet or failures of reply to correspondences made by e-mail to the corresponding author within two weeks were excluded. Besides, research which did not report our outcome of interest, were excluded after reviewing  per our protocol described herein.All the necessary data were retrieved using a consistent data extraction format in Microsoft Excel™ by two authors (FA and AG). For the prevalence of SSI, the data extraction format included first author, the region where the study was conducted, and the hospital where the study was carried out, publication year, study design, sample size, and prevalence of SSI.For the root causes, the data extraction format was prepared for each specific potential cause . The researchers chose these variables because they are the most commonly reported associated risk factors in the studies included in this meta-analysis. In this systematic review and meta-analysis, the investigator considered variables as root causes if two or more studies mentioned them as risk factors (cause). For every root cause, to compute the odds ratio, the data from the primary studies were extracted in the form of two by two tables by the two authors (FA and AG).This systematic review and meta-analysis has two major outcomes. The primary outcome is to determine prevalence of SSI among women undergoing C/S in Ethiopia. The overall prevalence was calculated by dividing the number of mothers who develops SSI to the total number of mothers who delivered by C/S in the study period who have been included in the study (sample size) multiplied by 100. The second outcome of the study was to identify the root causes of surgical site infection.To evaluate the quality of the studies included in this review, two researchers (FA and AM) applied the Newcastle-Ottawa Scale tool as modified for cross-sectional studies’ quality assessment . The too2 test and the p-values [2 = 95.5%, p < 0.000). As a result, a random effects meta-analysis model was applied to estimate the Der Simonian and Laird’s pooled effect. In addition, univariate meta-regression model was conducted by taking publication year and sample size of the studies to assess the probable source of heterogeneity, but none was statistically significant. Possible publication bias was also evaluated objectively by using Egger’s correlation and Begg’s regression intercept tests at 5% significant level respectively [P < 0.059). Furthermore, to reduce the random discrepancies between the point estimates of the primary study, sub-group analysis was carried out based on region of studies.The required data were collected using a Microsoft Excel™ form and analyzed by using STATA Version 15.0 software. The original articles were presented using tables and forest plot. The researcher calculated the standard error of prevalence for each original article by the binomial distribution formula. Heterogeneity among the reported prevalence of studies was checked by using heterogeneity χ2 test, Ip-values . The aboectively , 22. TheA total of 164 articles regarding prevalence and root causes of surgical site infection in Ethiopia were retrieved from the databases of Medline (PubMed), EMBASE, HINARI, Google Scholar, Science Direct, Cochrane Library and other sources described above. From these preliminary records, 124 articles were excluded due to duplication. From the remaining 40 articles, 14 articles were excluded as they were found to be not eligible to this review after assessing their titles and abstracts. The remaining 26 full text articles were then accessed, and assessed for eligibility based on the preset criteria, which resulted in further exclusion of 13 articles primarily due to the study population and/or outcome of interest. Among these, four of the studies were conducted in countries other than Ethiopia: Nigeria , China  and EnglA total of 13 original studies that reported the prevalence of SSI among women undergoing C/S and its root causes were included in this systematic review and meta-analysis. The studies were conducted from 2010 to 2019. The study design for all included research was cross-sectional. In this study, 8496 study participants were included to estimate the pooled prevalence of SSI and its root causes in Ethiopia. The quality score of the research ranged from 6 to 8 out of 10 as assessed by the Newcastle-Ottawa tool described previously. The studies were conducted in Oromia Region –38, Sout2 statistic ; hence, a random effect model was used to estimate the pooled prevalence of SSI post-C/S in Ethiopia. A univariate meta-regression model was also carried out to identify the possible sources of heterogeneity, by considering factors, such as publication year and sample size although none of these variables was found to be statistically significant. Beggs’ and Eggers’ tests also indicated the absence of statistically significant publication bias (p > 0.05 for both).Thirteen studies across 5 regions of Ethiopia yielded an overall prevalence of SSI 8.81% (95% CI: 6.34–11.28) among mothers who delivered by C/S  followed by Amhara Region, 9.06 per 100 ;SNNP Region,8.28 per 100 ; Tigray Region, 6.38 per 100 and Addis Ababa, 4.92 per 100   (95% CI: 2.65–10.06), prolonged rupture of membrane (≥13 h) (95% CI: 3.33–8.29), presence of anemia (95% CI: 3.77–23.51), presence of chorioamnionitis (95% CI: 4.05–21.45), presence of meconium (95% CI: 1.41–9.99), vertical skin incision (95%CI 2.61–5.85), greater than 2 cm thickness of subcutaneous tissue  were significantly associated with surgical site infection.Mothers with prolonged labor (25 or more hours) at the time of the C/S had 5.16(95% CI: 2.65–10.06) times increased odds of SSI than their counterparts. The odds of SSI were also increased by 5.26(95% CI: 3.33–8.29) among mothers who had prolonged rupture of membrane (rupture of membranes for 13 or more hours). Mothers who had anemia, chorioamnionitis and/or meconium were9.41 (95% CI: 3.77–23.51), 9.32(95% CI: 4.05–21.45) and 3.76 (95% CI: 1.41–9.99) times more likely at high risk for SSIs as compared to those mothers with none of these conditions prior to C/S, respectively.Study subjects who underwent vertical skin incision were 3.91(95%CI: 2.61–5.85) times more likely to develop SSIs than those who had transverse skin incision. Mothers whose subcutaneous tissue thickness was greater than 2 cm were 2.82 (95%CI: 1.61–4.94) times more likely at risk for SSI than mothers whose subcutaneous tissue thickness was less than 2 cm.Finally, mothers who had C/S by general anesthesia were 2.69(95%CI: 2.02–5.85) times more likely to develop SSI as compare with mothers who had C/S by spinal anesthesia  and prolonged rupture of membrane (≥13 h) before operation had considerably increased risk of SSI than their counterparts. Studies carried out in Kenya , NigeriaIn our study, anemia was found to be predicative of SSIs showing women with anemia having 9.41 times more likelihood to develop SSIs as compared to non-anemic women. This finding was in line with previous studies conducted in Nigeria , India , and ChiIn the current study, women with chorioamnionitis were 9.32 times more likely to develop SSIs when compared to those women who had no chorioamnionitis. Similar findings have been reported in Sub-Saharan African countries, India, and United States of America –65. The In the present study, women with meconium were 3.76 times more likely to develop SSIs when compared to those women who had no meconium. This finding is in line with a previous study which reported that occurrence of thick meconium in amniotic fluid is strongly associated with SSIs .In addition, women who had vertical abdominal incisions were more likely to develop surgical site infections as compared to those women who had transverse incisions, which was also reflected in a study conducted in Nigeria . The ratThickness of subcutaneous tissue more than 2 cm was also one of the causes for surgical site infection in this study. Similar findings were reported in an American study . This riFinally, mothers for whom operations were under general anesthesia were more likely to have SSIs compared to mothers under spinal anesthesia. This finding is in agreement with the studies conducted in various African countries which indicated that C/S and use of general anesthesia increase the risk of accidental internal organs damage and internal bleeding because of uterine atony –71.All articles considered in this systematic review and meta-analysis were cross-sectional by design. As a result, temporal associations between the factors and the outcome variables cannot be established. Most of the studies included in this review had a relatively small sample size which may affect the final estimation. In addition, as this meta-analysis included available studies reported from a small number of hospitals in Ethiopia, there may be under-representation of the different regions in the country.The prevalence of SSI among women undergoing C/S was higher compared to the standard center of disease control (CDC) guidelines of SSI . The hig


Duration of inpatient stay and weight at discharge were abstracted from medical records. Compared with controls, AN patients spent more time in very light-intensity physical activity (VLPA)  and light-intensity physical activity (LPA)  and less time in moderate-intensity physical activity (MPA)  and vigorous physical activity (VPA) . PA and BMI increase were not associated in a linear model, and BMI increase was mostly explained by lower admission BMI and longer inpatient stay. In a non-linear model, an influence of PA on BMI increase seemed probable . No direct association was observed between physical inactivity and BMI increase in AN. An altered PA pattern exists in AN patients compared to controls, yet the origin and consequences thereof deserve further investigation.Increased physical activity (PA) affects outcomes in patients with anorexia nervosa (AN). To objectively assess PA patterns of hospitalized AN patients in comparison with healthy, outpatient controls (HC), and to analyze the effect of PA on Body Mass Index (BMI) change in patients with AN, we measured PA in 50 female patients with AN (median age = 25 years, range = 18–52 years; mean BMI = 14.4 ± 2.0 kg/m The role of increased physical activity (PA) for the onset and maintenance of anorexia nervosa (AN) is increasingly recognized. Being associated with a longer duration of inpatient treatment  and highElevated levels of physical activity have been observed in 30–80% of patients suffering from AN ,7, with In a previous study , we focu2. Exclusion criteria were: age <18 years, current pregnancy or a diagnosed psychotic episode. Information about the duration of the illness, comorbidities as well as medication at the beginning and end of the treatment program were retrieved from anamnestic data and medical reports. Between 2015 and 2016, we also recruited 30 sex-matched and similar aged normal weight healthy controls (HC), consisting mostly of clinical staff and relatives thereof. A BMI between 18.5 and 25 kg/m2 served as inclusion criteria. Exclusion criteria were: Any known major medical or psychiatric disease and any condition with significant influence on PA. All participants gave written informed consent, and the study was approved by the institutional ethics committee of the Charité—Universitätsmedizin Berlin.We enrolled 50 female adults with AN who were admitted to the Department of Psychosomatic Medicine at Charité—Universitätsmedizin Berlin for inpatient treatment of AN between 2011 and 2016. Patient inclusion criteria were: A diagnosis of AN according to ICD-10 , restrictive, purging or atypical type, as well as a BMI < 17.5 kg/m2.Weight of all patients was measured to the nearest 0.1 kg via a digital scale  and height to the nearest 0.5 cm via a stadiometer  . MeasureWhole-body bioimpedance was measured by Nutriguard-M  as part of the patients’ clinical measurements. For bioimpedance analysis (BIA) of the normal-weight controls Biacorpus RX 4004  was used. Patients and controls were weighed after fasting for at least 2 h, voiding and an equilibration period in a supine position. The equilibration period of both AN patients and controls lasted at least 10 min. BIA was carried out in accordance to the manufacturer’s instructions, and body composition was calculated with Body Comp software .PA was measured in AN patients after inpatient admission and inclusion into the study. Using a portable armband device , PA was continuously detected over a 3-day period (Friday to Sunday). During the time of PA detection, the study population was not restricted regarding their daily physical activity . A day wA MET-value ≤1.0 was defined as the rate of energy expenditure while at rest .Activities with a MET-value ≤1.8 were considered as sedentary behavior .Thus, we concluded to form a new category ranging from ≥1.1 to ≤1.8 METs to describe very light-intensity physical activities (VLPA).Light-intensity physical activities (LPA) were defined as MET-values >1.8 and <3 .Moderate-intensity activities (MPA) were defined as ≥3 METs to <6 METs ,18.Vigorous-intensity activities (VPA) were divided firstly into MET-values ranging from ≥6 to ≤9, and secondly into values >9 METs .The Sensewear armband is a multi-sensor device worn on the upper dominant arm which enables a continuous physiological PA detection  by measup = 0.03) [n = 44) would be required to have sufficient power. For organizational purposes we capped HCs at n = 30 (assuming less heterogeneity among HCs); we increased the sample size of AN patients to n = 50.Based on a prior study of 11 AN patients and 10 HCs whose activity was measured with a shoe-based accelerometer at three time points: (I) while eating lunch, (II) filling out questionnaires, and (III) watching television for 1 h, power was sufficient with 19 analyzed individuals to demonstrate a significant difference in total PA levels  if following a normal distribution, otherwise as median (25th/75th percentile), or absolute frequency (relative frequency %). Quartiles were computed using R type 8 so that the resulting quantile estimates were approximately median-unbiased, regardless of the distribution. Data following a Gaussian distribution were analyzed by t-tests. Wilcoxon tests were applied for group differences for quantitative response variables not following a Gaussian distribution. Analyses for categories were performed by Fisher’s exact test. To test the relationship between BMI change and various potential predictors, univariate and multivariate linear models were computed. A regression tree was computed, as this approach does not make assumptions on distributions or linearity. This machine learning technique computes a series of prediction thresholds to split a data set. Given our relatively small sample, splitting the data set into learning and test sets was not feasible; therefore, we applied a jack-knife procedure, classifying each subject based on a tree build from the remaining patients. Statistical analyses were computed using R version 3.4.2, R Core Team 2017.A p = 0.057). Body weight, BMI, body fat, and lean mass were significantly lower in patients with AN compared to controls , episodes of depression (p < 0.001), and at least one comorbidity . No statistically significant differences existed for other medical disorders. In terms of medication, a significant difference between both groups existed only for psychopharmacological treatment, with none of the controls (C) but 16% of the AN patients receiving medication on admission (p = 0.021). No significant difference existed for oral contraceptives (p = 0.052), L-thyroxine (p = 0.632), or taking no medication .Medical details, comorbidities, and current medications of the study populations are summarized in a supplemental table . Forty-ep = 0.004) and low (p < 0.001) levels of PA than controls. Conversely, AN patients spent significantly less time in PA below the very low PA level (p < 0.001), in moderate (p = 0.022) as well as in 6–9 MET vigorous activity level  out of the 50 AN patients lost weight during their inpatient stay.r = 0.154; p < 0.001), phase angle  and BMI on admission  were significant predictors (presented in p < 0.001) and BMI on admission (p = 0.029) remained significant predictors and duration of sleep became significant  as well. In addition, for MPA a trend  towards becoming a significant positive predictor of BMI increase was observed.In an univariate regression analysis with BMI increase in % as the dependent variable and a range of potential predictive factors as independent variables , only length of inpatient stay . The importance score for length of inpatient stay was 1026, for admission BMI 822, and for number of steps 453, potentially suggesting at least a small effect of PA measured as steps on % BMI increase. Applying these statistical procedures also for LPA as a parameter for low level activity, data yielded a similar value for r2 for steps as well as an importance score of 562 for LPA, indicating also a slight effect of LPA on BMI change comparable in strength to that of steps.Furthermore, validation of this prediction model by jack-knife analysis was successful  Compared with healthy controls, AN patients spent more time engaging in light and less time engaging in vigorous intensity PA; (2) the patient’s BMI increase during inpatient treatment was largely predicted by low BMI on admission and longer duration of inpatient stay; (3) high step count and time in light-intensity PA only emerged as potential predictors of lower BMI increase in an exploratory and non-linear model; and (4) contrary to our assumption, the duration of sleep as a marker of physical inactivity was inversely associated with BMI increase.Few studies have objectively measured low intensity PA in AN inpatients compared with healthy controls. Our findings demonstrating increased low intensity PA are consistent with a previous study using a shoe-based monitor . Using tA better understanding of the origin of distinct PA patterns in AN patients is warranted. Increased light PA in AN might be a consequence of negative energy balance resulting in a foraging response to increase PA to find food ,20 or li2/min from both feet and BMI or rate of weight gain in AN patients admitted to an inpatient unit [A low admission BMI was identified as a major determinant for BMI increase in AN. Resting energy expenditure proportionally declines with BMI , physiolent unit , and (IIent unit . Howeverent unit . Interesent unit . These fIn the present study, no linear and direct associations between sleep duration and recumbency, conceptualized as physical inactivity parameters, and weight gain during AN treatment existed. Similarly, others could not find associations between sleep patterns and BMI , or betwWhile we used objective PA assessments at standardized time points close to hospital admission, which are different from other studies that assessed PA across various stages of AN treatment , our finIn conclusion, we found that AN patients spent more time engaging in light, and less time engaging in vigorous intensity PA than controls, and that the BMI increase during inpatient treatment was predicted by low admission BMI and longer inpatient treatment. Furthermore, high step count and time in light-intensity PA only emerged as potential predictors of lower BMI increase in an exploratory and non-linear model. This latter finding indicates that the effect of PA on the disease course of AN should be quantified and clarified further and that more complex models may need to be employed in future research on this topic. Since PA behavior is likely influenced by multiple factors including age, psychological and nutritional parameters, assessment of these potential modifiers in future studies may contribute to a better understanding of PA variability in AN.