Second, for each subset, TPs representative of the new SC breeding lines were determined based on genetic relatedness using the ‘STPGA’ R package. Third, for each TP, phenotypic values and SNP data were incorporated into the ‘rrBLUP’ mixed models for generation of GEBVs of YLD, TW, HD and PH. Using a five-fold cross-validation strategy, an average accuracy of r = 0.42 was obtained for yield between all TPs. The validation performed with 58 SC elite breeding lines resulted in an accuracy of r = 0.62 when the TP included complete historical data. Lastly, QTL-by-environment interaction for 18 major effect genes across three geographic regions was examined. Lines harboring major QTL in the absence of disease could potentially underperform , whereas it is advantageous to express a major QTL under biotic pressure . This study highlights the importance of genomics-enabled breeding and multi-institutional partnerships to accelerate cultivar development.With the rapid generation and preservation of both genomic and phenotypic information for many genotypes within crops and across locations, emerging breeding programs have a valuable opportunity to leverage these resources to 1) establish the most appropriate genetic foundation at program inception and 2) implement robust genomic prediction platforms that can effectively select future breeding lines. Integrating genomics-enabled Triticum aestivum L.) is a major cereal crop worldwide as its production ranks third in the US (49.7 million tonnes) and globally (895.2 million tonnes) behind maize and soybean. Wheat has a high production value of US$8.7 billion in the United States and $188.1 billion globally (FAOSTAT 2022). The effects of climate change, including warming temperatures, variable precipitation and more frequent extreme weather events  is becoming a valuable technology for modern crop breeding programs, and its implementation for cultivar development has been shown to accelerate the rate of genetic gain by shortening the breeding cycle and/or increasing selection accuracy . Genomicr = 0.50 in France   , agronomce (FHB)  and qualce (FHB) . Lastly,ce (FHB) .This study was conducted to understand how new or reestablished breeding programs should leverage existing historical genomic, and multi-environment and multi-trait phenotype data of elite breeding lines. The Clemson University winter wheat breeding program was reestablished in 2017 and used as a case study to understand the foundational genetics and requirements to maximize predictive ability of genomic models to successfully develop cultivars adapted to a target population of environments. To accomplish this, historical genotypic and phenotypic information for advanced soft red winter (SRW) wheat breeding lines, evaluated as part of the Southeastern University small grains (SunGrains) breeding alliance, was used to predict YLD, TW, HD and PH using optimized TPs for a set of untested SC-derived breeding lines. Two validation strategies were completed to assess and compare fitted models’ prediction accuracy. Finally, QTL-by-environment (QE) interaction analysis was completed using 18 major effect QTL to identify whether there was a favorable effect on yield across three major testing regions. The use of comprehensive datasets and genomic models have great value to securing the needed increases in genetic gain and enhance the efficiency of cultivar development.Annually, advanced SRW wheat lines entered into the Gulf Atlantic wheat nursery (GAWN) and advanced wheat nursery (SunWheat) are evaluated across the greater southeastern US, which is coordinated by SunGrains and partnering public wheat breeding programs. The SunGrains cooperative includes seven land-grant university breeding programs  having very strong collaborations for field evaluation and unfettered distribution of adapted germplasm and data exchange. As part of this historical cooperative, a total of 1,285 lines were tested in 19 locations  from 200−1), TW (kg hl−1), HD (Julian days) and PH (cm) was 17,645, 14,942, 11,092 and 8,678, respectively. The number of replications ranged from one to three, depending on location-year combination.Historical phenotypic data consisted of a multi-location, multi-year and multi-trait dataset generated and maintained by SunGrains. A total of 1,285 elite SRW wheat breeding lines were tested in two regional nurseries (GAWN and SunWheat) in 19 trial locations in the southeastern US . The num‘princomp’, ‘cor’ and ‘corrplot’ packages in R; second, biplots showing the relationship among environments  plots from Pearson’s correlation matrix using the ronments  were obts , the following linear model  was fittage in R  to estimYijk represents the phenotypic observation of genotype i in environment j and replication k, µ is the overall mean; Gi is the effect of genotype i, Ej is the effect of environment (location-year combination) j; Rk(j) the effect of replication k nested in environment j; GEij the G × E interaction between genotype i and environment j; and eijk the residual effect associated with genotype i in environment j and replication k. All terms except genotype were set as random effects. Genotype was defined as fixed effect  with the ‘H2cal’ function of the ‘inti’ R package  new SC breeding lines were used to identify the best TP using each of the subsets of trial locations . The bes package  was utilt to 400 , and otht to 400 . The fir‘ggplot’ package in R (pheatmap’ package (prcomp’ package and plotted with ‘ggplot’.The frequency and percentage (%) of breeding lines by breeding program selected by STPGA was calculated for each TP and normalized by number of lines by program. A stacked barplot was displayed with age in R . A heatm package , and PCAGenomic best linear unbiased prediction (GBLUP) mixed models were fitted to estimate GEBVs for YLD, TW, TW and PH with the following equation:y represents the vector of BLUEs for each genotype; X and Z represent the design matrices for fixed and random effects, respectively; β is the vector of fixed effects; μ is the vector for random genotypic effects; and e is a vector of residuals  and B (lower-left) for correctly classified lines, and C (lower-right) and D (upper-left) for wrongly categorized genotypes.Two types of validation were implemented to assess and compare each model’s prediction ability using each TP for each trait. First, five-fold cross-validation (CV) is a procedure that randomly divides the TP into five groups of approximately equal size (20%). One random group is masked and GEBVs are calculated for the masked set using the remaining four folds (80% of lines) . After c‘mixed.solve’ function of the R ‘rrBLUP’ package as previously described. With the aim to select a subset of lines as the foundation for the breeding program as well as first year advanced field testing, one hundred and five superior lines were identified based on GEBVs for YLD, and 20 low-ranked lines were identified for comparison. Advanced field evaluation for these lines is in progress (data not shown).Furthermore, GBLUP mixed models were fitted to estimate GEBVs for the 998 breeding lines developed by the Clemson University breeding program. Using the EMMs and BLUPs of the TP with highest prediction accuracy, predictions of YLD, TW, HD and PH were performed with the Fusarium graminearum) resistance, leaf rust (Puccinia triticina) resistance, stem rust (P. graminis) resistance, stripe rust (P. striiformis) resistance, Hessian fly (Mayetiola destructor) resistance, powdery mildew (Blumeria graminis) resistance, septoria nodorum blotch (Parastagonospora nodorum) susceptibility, or photoperiod sensitivity  to generate composite calls for major effect genes at the Eastern Regional Genotyping Small Grains Laboratory . Over the course of 14 years (2008–2021), 4,426 breeding lines were tested for 75 molecular markers associated with disease/pest resistance, photoperiod, vernalization, dwarfing, grain texture and kernel color . For thisitivity . In addiHistorical phenotype data from 1,285 breeding lines was used to assess the effect on agronomic traits when the expression of a major effect QTL differs under different environmental pressure  across production locations . The his‘lmer’ of ‘lme4’ package in R:For each of the 18 major genes, only absent/present calls were considered for analysis by discarding heterozygous, null, and failed calls. The following linear mixed model was calculated to test the significance of QTL-by-environment (region/origin) interactions for YLD, TW and HD using the function Yijk represents the phenotypic observation of genotype i in environment j and replication k, µ the overall mean; Gi is the effect of genotype i, Ej is the effect of environment (location-year combination) j; Rk(j) the effect of replication k nested in environment j; GEij the G x E interaction between genotype i and environment j; QE the QTL-by-environment interaction effect; and eijk the residual effect associated with genotype i in environment j and replication k. QE effect was considered fixed and all the remaining effects were considered random.Where ‘emmeans’ function in R for the fixed effect of the interaction between major gene (absent/present) and region . To estimate the significant difference at 0.05, p-values were calculated using pairwise comparisons between groups with the option ‘pairwise’ and adjusted with the Tukey correction method. Plots for EMMs and p-values were displayed with ‘ggplot’ in R. The same analysis was performed for YLD using the classification of locations by origin to assess for genetic background bias.Using the mixed model, EMMs were calculated using the r = 1) between BLUPs calculated with ‘coef’ and ‘ranef’ R functions, hereinafter only results using BLUPs estimated with ‘coef’ function are presented.The historical phenotypic dataset was used to calculate biplots and PC plots showing the relationship among environments . These p2) using the Cullis method was moderate to high for YLD (r2= 0.56), TW (r2= 0.74), HD (r2= 0.85) and PH (r2= 0.83).Broad-sense heritability  where fewer lines were selected due to a lower number of available entries. The normalized frequency of lines selected by breeding program showed that overall representation of breeding programs within TPs was LA (µ = 13.9%), NC (µ = 13.8%), AR (µ = 13.3%), GA (µ = 13.2%), TX (µ = 12.9%), FL (µ = 12.5%), VA (µ = 11.7%), and SC (8.8%). After normalizing the number of lines included from each program by the total lines available from each program , it was apparent that STPGA included approximately one-third of individuals from every program, with a mean over all 22 sets ranging from a high of 36.3% (LA) to a low of 24% (SC)  . The hea24% (SC) . The Sun24% (SC) . STPGA s24% (SC) , in blueopheevii .r = 0.42 was observed across the 22 TPs when using EMMs as the observed data for YLD. When using BLUPs, the average prediction accuracy was reduced to r = 0.31. For TW, mean prediction accuracies ranged from r = 0.26 to 0.32 when using BLUPs and EMMs, respectively. Prediction accuracies oscillated from r = 0.42 to 0.45 for HD and PH  and EMMs of observed YLD data. The four-quadrant plot for this comparison, where 69% (40 of 58) of breeding lines were accurately categorized into the proper quadrant (A and B) and 31% of the breeding lines were categorized in quadrants C and D (r = 0.59 was obtained by comparing the GEBVs (predicted with the BLUPs of the combined TP), versus the EMMs of YLD. In this case, 74.1% of the breeding lines with high or low observed YLD were categorized in quadrants A and B, whereas 25.9% of the breeding lines fell into quadrants C and D  (−1) were selected for field testing. This set of lines had predicted values of 73.8–74.6 kg hl−1, 100–104 Julian days and 82.9–88.9 cm for TW, HD and PH, respectively (−1) were included for comparison. These lines had predicted values for TW, HD and PH of 72.6–73.5 kg hl−1, 103–105 Julian days and 84.9–86.8 cm, respectively   was used = 0.62) . Based oectively , in red.p-values  were also calculated based on origin of the breeding lines  , along wp-values  for nineng lines .For each of the studied QTL , lines tFive genes that are relevant for target population of environments across the southeastern US were more rigorously assessed individually for YLD trends within testing regions and by breeding program :The FHB resistance gene Fhb1 , which fFhb_1B , an addiThis third FHB resistance QTL under study  was deriVS:2A translocation segment derived from Aegilops ventricosa , and outperformed predictions made with TPs with reduced data. The complete dataset not only included more high-quality data for predictions, but also TPs selected from a historical pool of lines tested in multiple years and geographic regions aids in capturing a broader range of environmental conditions when compared to newly generated, population-specific TPs. In this case study, it was apparent that the historical phenotypic dataset using all data (combined GAWN + SunWheat over 14 years) effectively captured environments that were representative of the collection of locations in 2021 where the 58 SC breeding lines were tested. Specifically, grain yield GEBVs for 40 of the 58 lines (69%) used for validation correctly grouped with observed data  were observed when using training data of 318 lines collected over 11 years at six locations in France (r2 = 0.56) is highly affected by genotype-by-environment interactions  produced the highest prediction accuracy for grain yield  toxin contamination, with FHB not known to severely hinder yield unless present at epidemic levels . For H13, the QTL that confers strong resistance to the local biotype L Hessian fly, was present at much lower frequency (11%). Because of the tendency of Hessian fly biotype L to be more frequent and impactful along the Atlantic Coastal Plain  utilizing a combination of historical phenotype data and genome-wide SNP markers to build a reliable GS model for predicting best lines for a target population of environments, and 2) identifying major effect QTL using existing PCR-based marker reports that were favorable, within the context of region and biotic pressure. This study highlights the importance of cooperative efforts between breeding programs that share a target population of environments to not only perform extensive multi-environment field trials but also to compile genotypic and phenotypic datasets that are key to enhancing genetic gain through robust genomic prediction models.


The EnSite Precision™ cardiac mapping system (Abbott) is a catheter navigation and mapping system capable of displaying the three-dimensional (3D) position of conventional and sensor-enabled electrophysiology catheters, as well as displaying cardiac electrical activity as waveform traces and dynamic 3D maps of cardiac chambers. The EnSite Precision™ Observational Study (NCT-03260244) was designed to quantify and characterize the use of the EnSite Precision™ cardiac mapping system for mapping and ablation of cardiac arrhythmias in a real-world environment and evaluate procedural outcomes.A total of 1065 patients were enrolled at 38 centers in the USA and Canada between 2017 and 2018 and were followed for 12 months post procedure for arrhythmia recurrence, medication use, and quality-of-life changes. Eligible subjects were adults undergoing a cardiac electrophysiology mapping and radiofrequency ablation procedure using the EnSite Precision™ System.n = 811/925, 87.4%) with fluoroscopy time of 11.0 min (IQR 6.0–18.0). Overall median procedure time was 101.0 min (IQR 59.0–152.0). Acute procedural success was high for both atrial fibrillation  and atrial flutter .A final cohort of 925 patients  were analyzed. The primary procedural indication was atrial flutter in 48.1% (445/925), atrial fibrillation in 46.5% (430/925), and other arrhythmias in 5% (50/925). Electroanatomic mapping was performed in 81.5% (754/925) of patients. Mapping was stable throughout 79.8% (738/925) of procedures with initial mapping time of 8.6 min (IQR 4.7–15.0). Average mapping efficiency created with AutoMap or TurboMap was 164.9 ± 365.7 used points per minute. Median number of mapping points collected and used was 1752.5 and 811.0, respectively. Only 335/925 (36.2%) required editing and 66.0% (221/335) of these patients required editing of less than 10 points. Fluoroscopy was utilized in most cases (In a real-world study analysis, use of the EnSite Precision™ mapping system was associated with high procedural stability, short mapping times, high point density requiring infrequent editing, low fluoroscopy time, and high prevalence of acute procedural success.The online version contains supplementary material available at 10.1007/s10840-022-01239-4. Electroanatomic mapping (EAM) has become an essential tool for effective ablation of cardiac arrhythmias with continued advancements in three-dimensional 3D) catheter tracking and high-resolution visualization to account for the increased case complexity and duration , 2. AvaiD catheteThe EnSite Precision™ Observational Study was designed to quantify and characterize the use of the EnSite Precision™ cardiac mapping system for mapping and ablation of cardiac arrhythmias in a real-world environment and evaluate procedural and subsequent clinical outcomes. In this report, we describe the performance of the system including mapping stability, mapping times, points collected, fluoroscopy times, and acute procedural success.The EnSite Precision™ Observational Study (NCT-03260244) was designed to quantify and characterize the use of the EnSite Precision™ cardiac mapping system for mapping and ablation of cardiac arrhythmias in a real-world environment and evaluate procedural and subsequent clinical outcomes. There was no randomization or blinding in this study.The study was designed and sponsored by Abbott Laboratories and approved by the appropriate Institutional Review Board or Ethics Committee at each site. Data monitoring, collection, and primary data analysis were performed by the sponsor in partnership with the publication committee. This clinical study was conducted in accordance with Abbott Standard Operating Procedures, ethical principles based on the Declaration of Helsinki, Good Clinical Practice, ISO 14155, and FDA 21 CFR 50, 54, 56, and 812.Eligible subjects were adults undergoing a cardiac electrophysiology mapping and radiofrequency (RF) ablation procedure using the EnSite Precision™ System. Subject enrollment in the EnSite Precision Observational Study began on September 12, 2017. The last subject was enrolled on December 6, 2018. The study enrolled 1065 subjects at 38 clinical sites in the USA and Canada. A subject was considered enrolled in the clinical study from the moment the subject provided a written informed consent. Subjects were followed for 12-months post procedure for arrhythmia recurrence, medication use, and quality-of-life changes. The last follow-up visit was completed on January 17, 2020.Patients with atrioventricular nodal reentrant tachycardia (AVNRT) or atrioventricular reentrant tachycardia (AVRT) as the only presenting rhythm and patients with planned cryoablation procedure were excluded. A full list of inclusion and exclusion criteria is included in Supplemental Table Subjects underwent a cardiac mapping and RF ablation procedure using the EnSite Precision™ cardiac mapping system per standard practice of the operating physician. Subjects were prepared according to the standard ablation procedures and standard practice of the center. All devices had proper regulatory clearance and were used according to their IFU, including anticoagulation and activated clotting time therapeutic requirements for multi-electrode catheters. Procedure data collection included overall procedure , fluoroscopy, and mapping times. EnSite NavX Surface Electrode (NavX patch) placement and associated skin preparation were recorded. Documented mapping characteristics included times to create and edit the initial map; number of mapping points collected, used, and edited; and EnSite™ Automap and AutoMark module software settings used. Editing included reannotating or deleting previously collected points. Time spent “shaving” was not specifically captured. The number of gaps in lesions identified that required further ablation (touch-ups) was also recorded. Operators were asked to note whether the mapping system was stable throughout the procedure (based on the opinion of the operator) and any factors affecting system stability. Mapping efficiency for a given map was characterized as the number of used points divided by the mapping time in minutes, resulting in used points per minute.Acute success was defined by the operator based upon their standard pre-defined endpoints for each type of procedure. Adverse events were not collected during this clinical study. Long-term follow-up up to 12-months will be reported in a separate analysis. Any complaints were managed via the sponsor’s standard post-market surveillance process.p-values presented are 2-sided, and p < 0.05 (not adjusted for multiplicity) was considered statistically significant.Continuous variables are summarized with number of observations, mean, standard deviation, min and max values, or median and interquartile range (IQR). Categorical variables are summarized with patient counts and percentages. All data available among the analysis population was used. Missing data was not imputed. No formal sample size calculation was performed. All analyses were performed using SAS software version 9.4 . The Of the 1065 enrolled subjects, 1053 met all inclusion/exclusion criteria. Of these, 69 were excluded due to a primary indication of persistent AF in the USA that was treated off-label. A total of 45 subjects withdrew prior to the procedure and an additional 14 subjects did not have an eligible procedure (no RF ablation performed).The final cohort of 925 subjects stratified by primary indication for ablation include the following: AF , AFL , or Other , as demonstrated in Fig. 2. The majority  did not have an implantable cardiac device at the time of procedure. Mean left ventricular ejection fraction was 54.2 ± 11.9. The most prevalent cardiovascular diseases included history of hypertension , valvular heart disease , coronary artery disease , and history of diabetes . Of the 430 PI-AF subjects, 102 (23.7%) had a prior ablation for AF. Only 40 (9.0%) of 445 PI-AFL subjects had a prior ablation for AFL.Baseline characteristics of the cohort are summarized in Table The standard patch kit  was used for almost all subjects in the analysis population  with older models used for the remaining three subjects. Patch size was reported to be appropriate for all but one subject. Standard patch placements were used in > 99% of subjects for all but the neck  and left leg  patches. Placement of the system reference surface electrode varied, with most placed on the lower back , followed by the upper back , abdomen , or other location . Positional reference sensors needed to be manually removed or repositioned in 2.8% (26/924) of subjects.For PI-AF subjects, Advisor™ FL Sensor Enabled™ , Advisor™ HD Grid 23.4%, 90/385), and Reflexion Spiral™  were used most often as the primary mapping catheter. In contrast, an ablation catheter  or other linear catheter  was used most often for mapping in PI-AFL subjects. In PI-O subjects, Advisor™ HD Grid  and Tacticath™  were used most frequently as the primary mapping catheter.Mapping was required in 81.5% 754/925) of subjects, with OneMap (simultaneous model and electroanatomic map creation) used in 96.3% (726/754) of subjects. AutoMap was used to create the initial map in 81.8% (315/385) of PI-AF subjects, 55.7% (180/323) of PI-AFL subjects, and 28.3% (13/46) of PI-O subjects, and a combination of AutoMap and manual mapping was also used in 10.6% (41/385), 24.1% (78/323), and 32.6% (15/46) of subjects in each cohort, respectively. Sinus rhythm , AFL , and sinus rhythm  were the most frequent cardiac rhythms during initial map creation in each cohort, respectively  and 1.0 IQR 1.0–2.0) minutes, respectively. Only 335/925 (36.2%) required editing and 66.0% (221/335) of those required editing of fewer than 10 points. Median number of mapping points collected and used was 1752.5 and 811.0, respectively. Table .0 minuten = 930 maps), which was significantly greater compared to 21.8 ± 30.3 used points per minute (n = 374 maps) for manual mapping alone (p < 0.001). Table In addition to 754 initial maps, 579 additional maps were created for a total of 1333 maps. Median time to create and edit any map was 6.0 (IQR 3.0–12.0) and 1.0 (IQR 0.5–2.0) minutes, respectively. Editing of the map was not required or not applicable for most maps created , and 30.2% (401/1327) required editing of fewer than 10 points. Median number of mapping points collected and used was 933.0 and 415.0, respectively. Average mapping efficiency for maps created with AutoMap or TurboMap was 164.9 ± 365.7 used points per minute (Redo AF ablation consisted of 40/430 (23.7%) of the PI-AF cohort and redo AFL ablation consisted of 40/445 (9.8%) of the PI-AFL cohort as shown in Supplemental Table p < 0.001), patient movement , and no difference in CS positional reference dislodgement . Between JET ventilation and non-JET ventilation, there were no differences in respiratory changes , patient movement , or CS positional reference dislodgement .The EnSite Precision™ System was stable throughout 79.8% 738/925) of procedures. Baseline patient and procedural characteristics, including fluoroscopy and procedure times were significantly longer when the mapping system was not stable throughout the procedure  of subjects. The available choices for the lesion color and size metrics are different in Canada and the USA (US); therefore, these settings are summarized by country in Fig. Table In this real-world, multi-center study including 925 patients undergoing mapping and ablation using the EnSite Precision™ cardiac mapping system for a variety of arrythmias, we demonstrated several key observations: (1) there was high procedural stability in nearly 80% of patients; (2) the system allows for high point density collection and short mapping times with the aid of AutoMap and TurboMap; (3) maps required editing in slightly over a third of patients with two-thirds requiring editing of fewer than 10 points; and (4) acute procedural success was high for all procedures.The automated 3D mapping system, EnSite Precision™, uses a hybrid magnetic and impedance-based catheter technology to accurately locate ablation catheters and create electroanatomic maps. A high-frequency (8 kHz) signal is sent through the three pairs of surface electrodes to interact with the sensor-enabled catheters to create a voltage gradient in three axes of space. A catheter is used as reference  and after analysis of the voltages and impedance gradient, the localizations of catheters are determined within the cardiac chamber. To increase accuracy to less than 1 mm, a weak magnetic field is generated by a field frame attached under the table that is employed to enhance the impedance-based tracking , 5. TakeThe Ensite Precision system is an open-platform system that permits catheters from different manufacturers to be used to generate a map. For AF, the most used mapping catheter was the Advisor FL Sensor Enabled 33.2%), followed by the Advisor HD Grid (23.4%), while a more variable selection was observed for AFL with “Other” encompassing 25.4% of the catheters use, likely mostly catheters from other manufacturers. Further advancements in mapping technology allow for collection of multiple points simultaneously to rapidly build EAMs. The AutoMap feature allows for rapid signal discrimination without the need for operator discretion allowing for nearly continuous movement of the catheter for EAM creation. The use of the AutoMap feature has been shown to result in significantly faster mapping times with higher point density than manual, point-by-point mapping [3.2%, foln = 22) and Rhythmia (Boston Scientific) (n = 48) mapping systems, Kellnar et al. observed significantly higher success rates in the Rhythmia cohort  [Lastly, there was high acute procedural success across the indications, including approximately 98% for AF and AFL. There currently exist no randomized trials comparing mapping systems with respect to success rates of specific arrhythmias, although a few prior observational studies have described acute procedural success with other mapping systems in various arrhythmias. In 1,070 consecutive patients referred for RF catheter ablation for all arrhythmias, Romero et al. observed no difference in acute procedural success between CARTO  (88.2%) and Ensite NavX (91.1%) [ = 0.03) –13. In oThe present study must be interpreted in the context of several limitations inherent to its design. First, as an observational study including only one mapping system, comparisons to other systems cannot be made. Rather, these results validate the efficacy of the EnSite Precision™ mapping system. Second, the cohort consisted of ablation for various types of arrhythmias producing significant heterogeneity in some findings. We believe this accurately reflects clinical practice and allows for generalizability of our observations. Still, efforts were made to stratify according to arrhythmia type, although other unmeasured factors likely influence the outcomes studied, such as use of intracardiac ultrasound, provider experience, and need for additional ablation lesions. Third, adverse outcomes during the procedure were not recorded. Fourth, utilization of general anesthesia and jet ventilation continues to increase, and the present study may underestimate system stability in practice today. Finally, these data represent outcomes from a single mapping system that has undergone engineering and user improvements. The newer generation system, EnSite™ X EP System, will aim to broaden the range of mapping capabilities with further improvements on procedural efficiency and success.This real-world study demonstrates that use of the open-platform EnSite Precision™ mapping system results in high procedural stability, short mapping times, high point density with the use of Auto/Turbo map requiring infrequent editing, low fluoroscopy time, and high prevalence of acute procedural success.*Three (3) subjects were enrolled in the Primary Indication Atrial Fibrillation cohort without the study site confirming history of atrial fibrillation. Of these, 1 subject received ablation for atrial fibrillation and atrial flutter, 1 subject received ablation for atrial fibrillation, and 1 subject received ablation for atrial flutter.Supplementary file1 (DOCX 55 kb)Below is the link to the electronic supplementary material.


Sodium-Glucose-Co-Transporter 2 (SGLT2) inhibitor (Empagliflozin) is an effective drug in controlling blood glucose through predominantly glycosuria. Glycosuria increases the risk of genitourinary infections in diabetes. This study was aimed to establish the safety and efficacy of Empagliflozin (Group-A) versus standard care (Group-B) in Pakistani Muslim individuals with type 2 diabetes.2, glycosylated hemoglobin (HbA1c) 7–10% (53 mmol/mol to 86 mmol/mol) and treatment-naive to Empagliflozin were included. Treatment was given for 24 weeks, and allocation was done through randomization.A multicenter, randomized clinical trial was conducted in five cities across Pakistan from July 2019 to August 2020. Patients of both genders aged 18–75 years, body mass index (BMI) ≤ 45 kg/mp < 0.001 vs. Group-B2: 0.79 ± 0.14; p < 0.001). Efficacy comparison at 6 months revealed a significant reduction in weight and systolic blood pressure (SBP) in Group A only , .Out of 745 screened patients, 333 met the eligibility criteria, and a total of 244 (73.3%) patients were enrolled. More hypoglycemic events were reported in the standard care group, whereas positive urine culture, fungal infection, dehydration, and hypotension occurrence were comparable between the two groups. The 6 months mean HbA1c reduction was significant in both groups; (Group-A: 0.91 ± 0.15; Empagliflozin was a safe drug compared to standard care in Pakistani Muslim patients with diabetes. It was as effective as standard care in the clinical setting but achieved glycemic control by reducing weight and SBP in type 2 diabetes patients.This study was registered in the NIH US National Library of Medicine clinical trials registry at Clinicaltrials.gov with the registration number: NCT04665284 on 11/12/2020. Diabetes is one of the most common non-communicable diseases affecting 463 million adults worldwide. This figure is expected to rise by 2030 to 578 million and 700 million by 2045 . Type 2 Sodium-Glucose-Co-Transporter 2 (SGLT2) inhibitor, Empagliflozin, with its novel mechanism of action for treating patients with T2DM, has its own set of side effects. Increased urinary glucose losses lead to a higher proportion of urinary tract infections and genital tract mycotic infections, and this has been evident from various studies . Also, tEmpagliflozin, however, has not been studied in the Pakistani population yet. The main aim of this study was to establish the efficacy and safety of Empagliflozin in the optimum control of blood glucose in T2DM. This is the first study of its kind being performed in the Pakistani population. Roughly 24% of the world population and 96% of the Pakistani population is Muslim. We postulate that as Muslims make ablution five times a day, there is a probability of lesser genital infections due to wet hygiene practices compared to the data we already have from the western world. Furthermore, due to intense hot weather in this part of the world, the safety in terms of dehydration was also evaluated.2 and HbA1c 7 to ≤10% were enrolled from July 2019 to August 2020, from 12 clinical sites spread across 5 cities of Pakistan, including Karachi (n = 2), Lahore (n = 3), Islamabad (n = 2), Peshawar (n = 3), Multan (n = 1) and Quetta (n = 1) with the primary coordinating site at Peshawar. Most patients appeared for follow-up visits . After obtaining informed consent from all participants’, data was collected.We conducted a multicenter open-label randomized clinical trial to evaluate the safety and Efficacy of Empagliflozin  along with standard care as intervention (Group A) versus standard care group without Empagliflozin as control (Group B) in the Pakistani Muslim population with T2DM. Further titration and addition of medications in both groups were at the clinician’s discretion. All consenting Pakistani Muslim male and female, type 2 diabetic patients aged between 18 to 75 years, BMI ≤ 45 kg/mThe purposive sampling technique followed a meticulous patient selection process; all potential participants underwent screening. Those who were eligible for this study were asked to provide informed consent. Those who agreed to participate in the study were then provided a computer-generated random allocation number. MS Excel was used to assign patients to either treatment groups, i.e. (Group A or Group B).2) as per WHO classification criteria normal weight (BMI 18.5 to < 25.0), overweight (BMI 25.0 to < 30), obesity (BMI ≥ 30.0) [Primary outcome measures for safety included hypoglycemia (self-reported), hypotension, nocturnal hypoglycemia, as per ADA guidelines , dehydran = 328) was calculated using Open Epi sample size estimation for Clinical trials in health studies with 80% power of the test and 95% confidence interval, and proportion of adverse events (45%) [n = 139), non-muslims (n = 6), age below 18, and above 75 (n = 7), and medical history (n = 55). The rest of the patients were assessed for their eligibility based on laboratory test cutoff values-based. Further 205 patients were ineligible to participate, details of which are given in Fig. n = 129) and Group B (n = 115) by statistician. The investigators enrolled the participants and assigned them to interventions. After screening and baseline visit, participants recruited in the groups were followed up at 6, 12, and 24 weeks’ time points. This study included the Holy month of Ramadan, and patients who fasted, were also asked to keep the data during Ramadan. The sample size was not achieved as physical follow-ups were suspended during the Covid-19 lockdown period and were conducted via teleclinics.The sample size  for recording and reporting of safety data on drug compliance, self-monitoring blood glucose, hypoglycemia, dehydration, hypotension, dietary habits, physical activities and hygiene practices, and other adverse events. The diaries were reviewed at visit 2 (6 weeks), visit 3 (12 weeks) and visit 4 (24 weeks). Patients were told to monitor their symptoms related to hypoglycemia like sweating, headache, trembling, etc. (described in the diary) if they found blood glucose level < 70 mg/dL. Similarly, they were briefed on monitoring symptoms of hypotension like dizziness, fainting, inability to concentrate, discomfort, SBP (less than 90 mmHg) and Diastolic blood pressure (DBP) (less than 60 mmHg) etc. Urinary tract infections were assessed by culture and sensitivity of the urine and Genital fungal infections were assessed after appropriate history and self-reported examination by the patient.The physical activity index was also measured at visit 1 (baseline), which included evaluating the current exercise program by selecting the most appropriate score under each intensity, duration, and frequency category.Diabetes Mellitus Quality of Life (DMQoL15) Satisfaction with Diabetes Control & adherence with self-care regimen questionnaire was used to collect data on Quality of life and satisfaction of all the participants ; the toop-value of < 0.05 was considered as a cut-off for a significant difference between the two groups.The study followed per-protocol analysis. Data were analyzed using SPSS version 15.0. Clinical characteristics, comorbid conditions, and laboratory results were compared between Group A and B at baseline. The normality of continuous variables was assessed using Shapiro Wilk tests. Mean with standard deviation and median with interquartile range is reported according to the distribution. The student’s t-test or Mann Whitney U test assessed the significant difference between two specific visits. We analyzed the changes of dependent variables from baseline to 6 months in HbA1c, FBG, weight, BMI, SBP, Alanine aminotransferase (ALT), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) using repeated measure ANOVA. Frequency and percentages were reported for categorical variables using Chi-square or Fisher’s exact test depending upon cell count assumption. A The study was approved by the institutional review boards from Postgraduate Medical Institute Hayatabad Medical Complex Peshawar (ERC No. 5579/Dy.Reg./PGMI) and the National Institute of Cardiovascular Diseases (ERC-56/2019), Karachi. Informed consent was obtained from all participants at the time of enrolment after a thorough explanation of the study. This study was performed in accordance with all relevant and applicable guidelines and regulations.Out of 244 participants recruited in the trial, 129 (52.8%) were randomized to the Empagliflozin arm (Group A) and 115 (47.2%) in the standard care arm (Group B)  in Group A and 16 (15.8%) in Group B as part of drug safety analysis  BMI , systolic blood pressure , ALT levels , HDL  but LDL  was statistically insignificant as compared to Group B  and 27.5% vs 19%  respectively.Similarly, in patients with FBG > 100 mg/dl at baseline achieved FBG 100–120 mg/dl at follow up visit 2 and 3 were higher in Group A as compare to Group B 22.5% vs. 20% . The rest of the biochemical profile is shown in Table There were only 5 patients who fasted during Ramadan, so analysis of those was not possible. There was a slight increase in Urea Nitrogen which was clinically significant  in the drug naïve patients with T2DM. Events consistent with urinary tract infections were reported in a similar proportion of patients in each treatment group. Urinary tract infections were mild or moderate in intensity except in one patient on Empagliflozin 25 mg and one on sitagliptin. In line with previous studies of Empagliflozin , there wDespite having a higher proportion of the overweight and obese population, Empagliflozin performed better and produced favorable results for controlling glycemia, reducing weight, and overall cardio-physiological profile compared to the standard care group. The findings of our study are comparable to the other regional populations .Empagliflozin has previously been reported to significantly reduce 24-hour ambulatory systolic BP versus placebo by weeks 12 and 24. With a reduction in diastolic blood pressure in black patients with type 2 diabetes mellitus, Empagliflozin reduced glycohemoglobin, body weight, and blood pressure. The effect of Empagliflozin on blood pressure was favorable from 12 to 24 weeks, suggesting that Empagliflozin may be beneficial for this high-risk population . SGLT2 iAnother landmark study has shown a definitive protective effect of Empagliflozin with reduced hospitalization and death due to cardiac events . CompariThe safety and efficacy of Empagliflozin demonstrated by our study with lower Urinary tract infection (UTI) events might be due to wet hygiene practices among Pakistani Muslim population. Furthermore, higher patient satisfaction, and Quality of life in patients compared to the standard care are the strengths of this nationwide multicenter randomized controlled trial covering wide variety of subjects in terms of demographics and climatic variations. There was also a high adherence to Empagliflozin regimen among patients from baseline to 24 weeks, despite ongoing pandemic and challenges in patient follow-up during national COVID restrictive protocols (more than 80% follow up at 6-week visit) leading to early closure of enrollments.The first limitation of our study is the use of Empagliflozin if given in variable doses such as 10 and 25 mg to compare the dose-response relationship for safety, efficacy, and factors related to patient experience. Secondly, as the study follow-up period included the Holy month of Ramadan, due to a small number of patients who fasted, analysis was not conclusive. Likewise, important data on the possible risk of Diabetic ketoacidosis could not be ascertained in safety. Thirdly, education on wet and dry hygiene was provided to the participants in this trial , which might have reduced the frequency of fungal infections and UTIs, but this factor was not gauged in the present study. Finally, due to the short course of the study, we could not record microalbuminuria data which was another limitation.Empagliflozin was found to be a safe drug as compared to standard of care in Pakistani Muslim T2DM individuals. Empagliflozin is as effective as standard care but achieves glycemic control with weight loss and significant blood pressure-lowering effect, especially systolic blood pressure, compared to standard care.


There have been major improvements in the trauma system and injury prevention in Al-Ain City. We aimed to study the impact of these changes on the incidence, pattern, injury severity, and outcome of hospitalized motorcycle-related injured patients in Al-Ain City, United Arab Emirates.This is a retrospective analysis of two separate periods of prospectively collected data which were retrieved from Al-Ain Hospital Trauma Registry (March 2003 to March 2006 compared with January 2014 to December 2017). All motorcycle-injured patients who were admitted to Al-Ain Hospital for more than 24 h or died in the Emergency Department or after hospitalization were studied.p = 0.02, Fisher's exact test), with fewer injuries occurring at streets/highways in the second period (69.1% compared with 85.3%). The anatomical injury severity of the head significantly increased over time (p = 0.03), while GCS on arrival significantly improved (p < 0.0001), indicating improvements in both prehospital and in-hospital trauma care. The mortality of the patients significantly decreased .The incidence of motorcycle injuries dropped by 37.1% over the studied period. The location of injury was significantly different between the two periods (The incidence of motorcycle injuries in our city dropped by almost 40% over the last 15 years. There was a significant reduction in the mortality of hospitalized motorcycle-injured patients despite increased anatomical severity of the head injuries. This is attributed to improvements in the trauma care system, including injury prevention, and both prehospital and in-hospital trauma care. Road traffic collisions (RTCs) are a major persistent public health problem. Out of 1.35 million deaths worldwide, 28% were caused by motorized 2–3 wheelers . This caAl-Ain City is growing rapidly (65% growth over the last 15 years). It currently has a population of around three quarters of a million –11. Its We have previously shown that the maturity of our trauma system reduced trauma death , but we Ethical approval was obtained from the Human Research Ethics Committee of Al-Ain Hospital, Al-Ain, United Arab Emirates (AAHEC-03-20-008). Written informed consent was obtained from the patients or their caregivers to use the data for this study.This is a retrospective analysis of prospectively collected data which were retrieved from Al-Ain Hospital Trauma Registry. Data were collected, coded, and entered by full-time trained research fellows and nurses.We studied all motorcycle-related injured patients who were admitted for more than 24 h or who died on arrival at the Emergency Department or after hospitalization from March 2003 to March 2006  and January 2014 to December 2017 .Studied variables included demography, location of injury, mode of arrival, vital signs and Glasgow Coma Scale (GCS) on arrival, severity of the injury of regions by Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), New Injury Severity Score (NISS), length of ICU stay, length of ventilation days, length of hospital stay, and clinical outcome.Al-Ain City is the second largest city in the Abu Dhabi Emirate, UAE. The city had about 463,000 residents during the first period , 11 and Since Al-Ain Hospital treated 80% of the RTC injured patients in Al-Ain City during the studied periods , the corU test was used to compare continuous or ordinal data of two independent groups. Data were analyzed with the IBM SPSS Statistics version 26 . A p value of less than 0.05 was accepted as statistically significant.Data are presented as numbers (percentage) for categorical data or median (range) for continuous or ordinal data. Fisher's exact test was used to compare categorical data for two independent groups, while Mann–Whitney p = 0.02, Fisher's exact test). There were relatively fewer street/highway injuries during the second period (69.1% compared with 85.3%), while other areas of less speed limits increased like homes (7.4% compared with 0%), workplace (3.2% compared with 0%), and public areas (4.3% compared with 0%).There were 68 patients during the first period and 94 patients during the second period. This gives an annual incidence of 6.2/100,000 population for the first period compared with 3.9/100,000 population for the second period, a reduction of 37.1%. Table p < 0.0001) , and NISS (median (range): 9 (1–41) compared with 5.5 (1–41), p = 0.01. The length of ICU and length of ventilation days significantly decreased in the second period (median (range): 0 (0–32) days compared with 4 (1–19) days, p < 0.0001; 0 (0–32) days compared with 1.5 (0–12) days, p < 0.0001, respectively) (Table p = 0.12).Table e): 0 0–3 days comp = 0.03, Fisher's exact test) and a significantly higher percentage of neck injuries . The AIS was significantly higher in both the head and upper extremities during the second period (median (range: 3 (1–5) compared with 1.5 (1–4), p = 0.03), and median (range): 2 (1–3) compared with 1 (1–2), p < 0.0001, respectively). The mortality significantly decreased during the second period  , use of safety devices (like helmet usage), installation of road speed cameras, penalties on speeding violations, and educational programs , 32–34. It may be surprising to notice that around 7% of motorcycle-related injuries in our city occurred at homes in the second period. Al-Ain City is very unique. It spreads horizontally over a very wide region of 30 × 20 kilometers despite the small number of its population. Houses of residential areas are not allowed to be higher than four floors and they have wide fenced areas around them. These are not public areas and considered legally as part of the homes. Motorcycles which are used for sport activity or food delivery enter within these fences and may cause injuries. Understandably, developing an injury prevention strategy for these specific injuries needs special educational and legal considerations.Our study has certain limitations. First, it is from a single hospital which limits its generalizability in all the UAE. Second, there was a gap in our registry from 2007 to 2014 due to a lack of research funding. Third, data on helmet use and clothing (including boots) on the incident and circumstance that led to the crash were missing in our trauma registry. We did not evaluate other important factors such as rider's behavior, riding experience, motorcycle safety technology (like Anti-Lock Brake systems), biomechanism of injury, and road characteristics to give us more insights into the cause of reduced mortality. Fourth, our study had a small sample size which may cause type II statistical error. Nevertheless, these patients represent the majority of those treated over seven years in a city of three quarter of a million population. Furthermore, this small sample enabled us to collect high-quality prospective accurate data with minimum missing data. Finally, our study did not include patients treated at the emergency department who were discharged home, those with minor injuries who did not seek medical advice, and those who died on the streets; which has the risk of selection bias.The incidence of motorcycle injuries in our city dropped by almost 40% over the last 15 years. There was a significant reduction in the mortality of hospitalized motorcycle-injured patients despite increased anatomical severity of the head injuries. This is attributed to improvements in the trauma care system, including injury prevention, and both prehospital and in-hospital trauma care.


It is well known that hematologic and biochemical reference intervals (RIs) play a major role in defining the health state of an animal. China is home to over 50% of the world pig population, but the assessment of hematologic and biochemical parameters for healthy commercial pigs has not yet been well studied in China. Adopting hematologic and biochemical RIs from other regions may lead to misjudgments by clinicians or researchers. Therefore, the aim of this study was to evaluate the correlations between hematologic and biochemical parameters and to provide a basic reference for the establishment of blood RIs for commercial pigs in China. Since most hematologic and biochemical parameters were significantly different between nursery pigs and sows, we preliminarily established hematologic and biochemical RIs for nursery pigs and sows, respectively. Our results are useful for better assessing the health conditions of commercial pigs in China.9/L and 5.62–7.84 × 1012/L, respectively, for nursery pigs, but 9.34–23.84 × 109/L and 4.98–8.29 × 1012/L for sows. The 95% RIs of total protein and albumin were 43.16–61.23 g/dL and 19.35–37.86 g/dL, respectively, for nursery pigs, but 64.96–88.68 g/dL and 31.91–43.28 g/dL for sows. In conclusion, our study highlights the variability in blood parameters between nursery pigs and sows and provides fundamental data for the health monitoring of commercial pigs in China.Hematologic and biochemical data are useful for indicating disease diagnosis and growth performance in swine. However, the assessment of these parameters in healthy commercial pigs is rare in China. Thus, blood samples were collected from 107 nursery pigs and 87 sows and were analyzed for 25 hematologic and 14 biochemical variables. After the rejection of the outliers and the detection of the data distribution, the correlations between the blood parameters were analyzed and the hematologic/biochemical RIs were preliminarily established using the 95% percentile RI. Correlation analysis showed that albumin was the hub parameter among the blood parameters investigated, and genes overlapping with key correlated variables were discovered. Most of the hematologic and biochemical parameters were significantly different between nursery pigs and sows. The 95% RIs of white blood cells and red blood cells were 7.18–24.52 × 10 Hematologic and biochemical parameters are of great importance for clinicians and researchers when assessing the health status of both humans and animals. A reference interval (RI) is a range of values based on the results of a specific percentage usually 95%) of the healthy population . Accurat% of the Because blood sample collection is fairly easy to perform and repeat for the same individual during a response to a stimulus, blood sample analysis is especially useful in controlling for baseline variation in the study of porcine immune responses. Additionally, hematological characteristics are crucial traits that are associated with immune and metabolic status and diseases in pigs. Previous studies have reported that many blood parameters are heritable in swine ,11, and However, due to the high cost and extensive labor, there is a lack of information regarding hematologic and biochemical RIs for commercial pigs in China. So far, most information about hematologic and biochemical RIs for pigs pertain to European and North American swine breeds ,17,18. TIn the present study, we collected and examined blood samples from 194 commercial pigs in Hubei, China. Following with the bioinformatic analysis and difference determination, we established hematologic and biochemical RIs for both nursery pigs and adult sows.A total of 133 crossbred nursery pigs (Duroc × Landrace × Yorkshire) and 121 adult sows (Landrace) were stochastically selected from a pig farm in Hubei province. The nursery pigs were treated with iron dextran (200 mg) injections at 7 days old and vaccinated according to the regulations of the pig farm, and blood samples were stochastically selected from 23 nursery pigs to evaluate humoral immune responses to regular vaccinations . The detection was performed at Wuhan Animal Disease Diagnostic Center . Pigs were closely monitored regarding their diet, water intake, body temperature, behavior, and physical characteristics. All subjects were apparently healthy in this study.Blood samples were collected via the anterior vena cava using a winged infusion set (22G) connected to an EDTA-K2 blood collection tube . All blood samples were transported to the laboratory at a temperature of 2–8 °C within 2 h after sample collection.® 2120i Hematology System  according to the manufacturer’s instructions. The measurements included white blood cells (WBCs), red blood cells (RBCs), hemoglobin (HGB), hematocrit (HCT), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), cellular hemoglobin concentration mean (CHCM), corpuscular hemoglobin (CH), red cell distribution width (RDW), hemoglobin distribution width (HDW), platelets (PLT), mean platelet volume (MPV), absolute and percentage value of neutrophil , absolute and percentage value of lymphocyte , absolute and percentage value of monocytes , absolute and percentage value of eosinophil , absolute and percentage value of basophilic granulocyte , and absolute and percentage value of unstained large cells . Moreover, 2 mL of blood from each sample was centrifuged at 3000× g for 10 min at 4 °C to obtain plasma for biochemical studies. A total of 14 biochemical parameters, including total protein (TP), albumin (ALB), aspartate transaminase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), total cholesterol (TC), triglyceride (TG), glucose (GLU), creatinine (CREA), high-density lipoprotein (HDL), low-density lipoprotein (LDL), blood urea nitrogen (BUN), gamma-glutamyl transpeptidase (GGT), and creatine kinase (CK) were analyzed using an automated HITEC 7100  according to the manufacturer’s instructions.In total, 25 hematological parameters, including complete blood count (CBC) and white blood cell differential (WBC DIFF), were analyzed for each blood sample using an ADVIATo avoid potential adverse effects on data accuracy, both coagulated and hemolyzed blood samples were excluded. Thus, samples from 107 nursery pigs  and 87 sows were finally used for examination. All calculations and statistical analyses were carried out in R Studio 4.1.2 , unless otherwise stated. The Shapiro–Wilk test was used to assess the normal distribution of variables. Data with nonnormal distribution were transformed using the Box–Cox power function method. Outliers for the hematologic and biochemical parameters were identified as more than 3 standard deviations (SD) from the mean and were removed.After outlier removal, the descriptive statistics of the hematologic and biochemical parameters were analyzed using the ‘psych’ package. The descriptive statistics included unit, sample size, mean, standard deviation, median, trimmed mean, min, max, and standard error. The correlation analysis of hematologic and biochemical parameters was performed using the ‘psych’ package. A correlation heatmap of hematologic and biochemical parameters was generated using the ‘corrplot’ package.p-value < 0.05 was considered as the threshold value. Percentage and absolute values of the same blood parameter were not included for interaction analysis. After interaction analysis, quantitative trait loci (QTL) of ALB, HGB, HCT, #LYMPH, and %LYMPH were accessed from the Pig Quantitative Trait Locus Database (PigQTLdb) [http://asia.ensembl.org/index.html, accessed on 15 April 2022) using the ‘biomart’ tool. QTL and gene stacking maps were generated using GraphPad Prism 8.3.0  and a Venn diagram of the candidate genes in QTL regions was generated using RStudio 4.1.2 . The gene set enrichments of candidate genes were analyzed on the Kyoto Encyclopedia of Genes and Genomes (KEGG) website .Interaction networks of blood parameter correlations were generated using Cytoscape 3.9.0 software . A igQTLdb) . The actt-tests, and differences between nursery pigs at different ages were examined by one-way ANOVA, followed by a post hoc Duncan test.Differences between nursery pigs and sows were analyzed by two-tailed unpaired Student’s Hematologic and biochemical RIs were established using Analyze-It 5.30  according to guidelines of CLSI. Reference intervals were determined using the 95% reference intervals (2.5th and 97.5th percentile) for each hematological and biochemical parameter.Blood parameter data were analyzed after quality control. After outlier removal (more than 3 × SD), blood parameter data were used for the subsequent analysis. Details of the descriptive statistics of the 25 hematological parameters and 14 plasma biochemical parameters are presented in p < 0.05). Among these, 41 pairs of blood parameters had a strong correlation , with 31 pairs of blood parameters being positively correlated and 10 pairs negatively correlated  showed significant correlation  were further performed. The QTL results and actual genes correlated with theses parameters are presented in p > 0.05) in six hematologic parameters among nursery pigs at different ages (p < 0.05) between all nursery pigs at different ages. Furthermore, although age had a significant effect in nursery pigs, only TP and ALB were significantly different between all ages  between nursery pigs and sows , which was understandable. TC includes both LDL and HDL, and LDL is the main source of cholesterol buildup [r = 0.83) in this study. In regards to negative correlation, neutrophils and the percentage of lymphocytes were strongly correlated (r = −0.86). Neutrophils and lymphocytes make up the largest portion of white blood cells, so it is obvious why a higher number of neutrophils would decrease the percentage of lymphocytes in pigs. Interestingly, there were only two ALB-related QTLs located on chromosome 6 and only one correlated gene (GRHL3), while there were 285 HCT-related QTLs and 232 correlated genes. GRHL3 encodes a number of transcription factors that are involved in neural tube closure and wound repair [We first evaluated all the data we collected before the assessment of the hematologic and biochemical RIs for commercial pigs in China. In total, 25 hematologic parameters and 14 biochemical parameters were analyzed after outlier removal. Among the blood parameters, the correlation between TC and LDL was the highest ( buildup . TC and d repair . HoweverNursery pigs undergo rapid changes in their bodies and immune systems, which may have an impact on the variation in their hematologic and biochemical parameters. Therefore, we compared the blood parameters in pigs from 20 to 50 days old. Unexpectedly, only 3 out of 39 blood parameters showed significant differences in all the nursery pigs between different ages. However, according to the Duncan’s multiple range tests, 23 out of 39 blood parameters were significantly different between 10-day-old nursery pigs and 40-day-old nursery pigs, indicating that these blood parameters changed significantly with a large enough age difference. Similar results regarding differences in the blood parameters of nursery pigs have been found in other publications , indicat9/L for nursery pigs and 9.34–23.84 × 109/L for sows. However, the reference interval of WBC is 6.0–21.7 × 109/L for Ontario piglets, 13.7–17.3 × 109/L for 5-week-old pigs in Wisconsin, and 5.6–18.5 × 109/L for 30-day-old piglets in Italy [9/L for Danish sows at mid-gestation [9/L for nursery pigs in our study. The reference interval of RBC is 4.8–7.3 × 1012/L for Ontario piglets and 4.08–8.17 × 1012/L for 30-day-old piglets in Italy [12/L for sows in our study, while the reference interval of RBC is 4.98–7.50 × 1012/L for Danish sows at mid-gestation [In the present study, the value of WBC was 7.18–24.52 × 10in Italy ,28. The estation . The valin Italy . The valestation ,29.ALB plays an important role in maintaining osmotic pressure and transporting numerous substances in the blood . The valTaken together, several blood parameters are subject to broad variations, indicating a dramatic physiological evolution in healthy pigs. According to the comparison analysis between our data and previously published data, region, age, and breed are essential factors that should be considered when assessing blood parameter RIs. China is a large country with highly diverse geographical and environmental features; thus, a limitation of this study was that we only included nursing pigs and sows from one region in China for RI assessment. Therefore, to establish more accurate blood parameter RIs for commercial pigs in China, studies with larger sample sizes from more commercial farms are necessary.To conclude, this preliminary study showed that ALB was a hub parameter among the blood variables, due to its correlation with most hematologic and biochemical parameters. We pointed out the significant differences in the hematologic and biochemical variables between nursery pigs and sows. Thus, the hematologic and biochemical RIs for nursery pigs and sows were assessed individually. Because China is home to over 50% of the world pig population, our data provide a basic reference for veterinarians and breeding researchers when assessing the health status of commercial pigs in China.


Vitamin D might participate in the pathogenesis of several immune-mediated diseases, but few related data are available for ANCA-associated vasculitis (AAV). In this study, we analysed the association between vitamin D status and disease in patients with AAV.2/3 were measured in 125 randomly selected patients with AAV  enrolled in the Vasculitis Clinical Research Consortium Longitudinal Studies at the time of enrolment and a subsequent relapse visit. Sufficient, insufficient and deficient vitamin D status were defined as 25(OH)D3 levels >30, 20–30 and ˂20 ng/ml, respectively.Serum levels of 25(OH)DP = 0.027) and disease activity (P = 0.047). In univariate and multivariate analyses, deficient vitamin D status was associated with disease activity (P = 0.015). Mean 25(OH)D status in the 21 patients with a subsequent relapse did not differ between baseline and relapse visit .Seventy of 125 patients (56%) were female, with a mean age of 51.5 (16) years at diagnosis; 84 (67%) were ANCA positive. Mean 25(OH)D was 37.6 (16) ng/ml, with vitamin D deficiency in 13 (10.4%) and insufficiency in 26 (20.8%). In univariate analysis, lower vitamin D status was associated with male sex (Most patients with AAV have sufficient 25(OH)D levels, although those with lower vitamin D status were more likely to be male and to have active disease. Whether optimization of vitamin D status alters disease manifestations or activity in AAV remains to be determined.https://clinicaltrials.gov/ct2/show/NCT00315380Vasculitis Clinical Research Consortium (VCRC) Longitudinal Study (LS), NCT00315380,  Key messagesOver one-third of patients with ANCA-associated vasculitis in this cohort had vitamin D insufficiency/deficiency.Lower 25(OH)D levels were associated with male sex and disease activity at the cohort level.The potential impact of vitamin D supplementation on ANCA-associated vasculitis disease activity remains uncertain.3)] is suspected to participate in the pathogenesis of several autoimmune conditions and to be a marker of inflammation or outcomes in some diseases  compared with females . Deficient vitamin D status (<20 ng/ml) was also correlated with disease activity in both univariate (P = 0.015) and multivariate analysis . The remaining variables analysed were not correlated with vitamin D level or age, diagnosis, geographical location, ANCA status, ethnicity, CRP, haemoglobin, WBC, platelets, glucocorticoid use, time from diagnosis to enrolment, kidney disease or history of relapse (Rheumatology Advances in Practice online).Univariate analysis found the vitamin D level to be lower in patients with active disease [33.9 (2) ng/ml] compared with patients in remission .In the 21 patients who relapsed after study enrolment [10.4 (6) months after study enrolment], there was no significant difference between the vitamin D status at enrolment [37.8 (16) ng/ml] and at the time of the relapse visit  were also seen more often in patients with Takayasu’s arteritis than in patients with Behçet’s disease [38.8 (20) nmol/l] and healthy controls [64.6 (22) nmol/l] [3 deficiency occurred in 13% of patients [3 status was comparable to that in both Canadian and American-based general populations [Few studies have been conducted on vitamin D levels in patients with vasculitis. Previous studies commonly found vitamin D deficiency to be prevalent in various vasculitides. A cohort from Istanbul (Turkey) of patients with AAV (patients . Likewis= 0.016) . Lower 2patients . In the ides n =  found vivs southern study sites, probably owing to limited differences in latitude with similar seasons at the locations of the study sites. As a surrogate of the duration taking vitamin D supplementation (common practice in AAV to prevent glucocorticoid-related osteoporosis), time from diagnosis to enrolment visit was analysed and showed no association with vitamin D status. Association of 25(OH)D3 levels with season was also not found to have a significant difference, probably owing to limited power in the present study because of small sample sizes for each subset and variation of exogenous vitamin D intake.In the present study, we found no significant differences in vitamin D status when comparing northern et al. [A numerically  greater proportion of patients with GPA had insufficient or deficient vitamin D status, when compared with MPA and EGPA. This might be related to disease-specific variations and/or possibly signal an interplay of vitamin D status and disease activity, and the higher incidence of disease relapse seen in GPA. No specific disease manifestations (including kidney) were associated with vitamin D status in the VCRC cohort, in contrast to Korkmaz et al. , who ideet al. . Diseaseet al. . Likwieset al. .3 supplementation and adherence, small number of patients analysed at the time of disease relapse and/or the onset of flare did not always correspond to the relapse study visit (weeks to months between the flare and blood sampling). Prospective studies are needed to determine whether optimization of vitamin D status impacts disease activity and risk of relapse in AAV.Despite this association between lower vitamin D level and disease activity at enrolment for the entire study group, there was no significant association between vitamin D status at the individual patient level between enrolment and subsequent relapses. Several reasons might account for this lack of association, including seasonal variation, routine prescription of vitamin D3 ranges for sufficient, insufficient and deficient values were established decades ago, are controversial and might not apply uniformly to all countries, ethnicities and ages [The strengths of this study include standardized data collection from a large cohort of patients with AAV, across multiple centres in the USA and Canada. Limitations of this study include the retrospective design, the lack of information on vitamin D supplementation, dietary intake of vitamin D, sun exposure or use of sun protection. The dose of immunomodulatory medications (including glucocorticoid doses) at the time of sera collection was also not recorded. Finally, as a recurrent, general and unsettled debate, 25(OH)Dand ages .The findings of the present study support the potential role of vitamin D in the pathophysiology of autoimmune diseases, including AAV. In the last two decades, vitamin D has been found to interplay with immunomodulation at multiple levels. Vitamin D receptors were, for example, found to be expressed in almost all immune cells, except B cells . Studiesrkad021_Supplementary_DataClick here for additional data file.


Pancreatic cancer is increasingly treated with chemotherapy before surgery, but this does not improve prognosis for every patient. On a cellular level, pancreatic cancer tissue is usually mixed with a dense matrix called the stroma which interacts with the tumor and contains fibers, large molecules and cells. The role of this stroma in chemotherapy and subsequent surgical tumor resection is unclear, especially for current first-line chemotherapy regimens. We analyzed two of the main stromal components, activated fibroblasts and collagen, and found that treatment with gemcitabine + nab-paclitaxel reduced collagen content while FOLFIRINOX had no quantitative effect. Meanwhile, a higher number of activated fibroblasts was beneficial for prognosis after chemotherapy. These findings will serve to further elucidate mechanisms of response and chemoresistance in pancreatic cancer and potentially to stratify patients for different treatment pathways.n = 48 PDAC patients after neoadjuvant chemotherapy with FOLFIRINOX , gemcitabine + nab-paclitaxel  or combination treatment  was compared with upfront resected matched controls . Activated CAFs were assessed by immunohistochemistry for α-SMA, and collagen was stained with aniline blue; the stained area was then determined by computational imaging analysis and ASI was calculated. In GEM, ASI was significantly higher and collagen deposition lower than in controls and FOL. The lowest quartile of ASI values had significantly longer overall survival (OS) in RES, whereas in FOL, the highest quartile had the best prognosis. After NT, OS was significantly improved in the α-SMA-high group; in RES, however, survival was independent of α-SMA. Reversed prognostic association of ASI thus points to the differing significance of stromal composition after FOL, while improved prognosis with high CAF abundance suggests a synergistic effect of myofibroblasts with chemotherapy. These divergences impede usability of ASI after NT.Neoadjuvant therapy (NT) for advanced PDAC is an emerging concept, affecting both stroma and tumor. The Activated Stroma Index  to collagen deposition) is a prognostic marker in upfront resected pancreatic adenocarcinoma (PDAC). We assessed ASI and its prognostic relevance after NT. Tissue from resection specimens of  Pancreatic ductal adenocarcinoma (PDAC) is a disease with a dismal prognosis, largely due to late diagnosis and lack of screening options as well as relative chemoresistance. Only about 20% of diagnosed patients are in a surgically resectable stage and 5-year overall survival (OS) has seen only slight improvements in the past decades, reaching about 10% ,4,5,6. PGemcitabine monotherapy or radiochemotherapy used to be the first-line chemotherapeutic treatment in PDAC from 1997 , until iSince FOLFIRINOX—the combination chemotherapy containing fluorouracil, leucovorin, irinotecan and oxaliplatin—was shown to improve prognosis in palliative and adjuvant treatment of PDAC compared with gemcitabine alone in 2013 ,22; it iIn patients undergoing resection of PDAC after neoadjuvant treatment (NT), oftentimes the tumor mass appears more brittle and, though imaging might still suggest vascular contact, can be removed from visceral arteries by divestment . HypotheThe institutional prospectively maintained database was screened for all patients undergoing surgery for pancreatic cancer between 2013 and 2017 after previous NT with FOLFIRINOX or gemcitabine + nab-paclitaxel. A matched control group was then selected which had undergone upfront resection. Formalin-fixed, paraffin-embedded 3 µm tissue sections of sufficient quality along with complete clinical data were available from 48 NT patients and 69 matched upfront resection patients; demographic and clinicopathological data of patients were complemented retrospectively from electronic patient records. Survival time was calculated from date of diagnosis. Samples were provided by the tissue banks of the National Centre for Tumour Diseases  and the Pancobank of the European Pancreas Centre Heidelberg in accordance with institutional regulations and with the approval of the ethics committee of the University of Heidelberg.H&E stainings served for confirmation of PDAC diagnosis and to determine the area of interest. As described by Erkan et al. for analysis of ASI, collagen and α-SMA—originally for detection of activated PSC but recently discovered to be the main marker of the myCAF subtype—were then stained on separate slides . On two U and Kruskal–Wallis tests were used; multiple comparisons were adjusted by Bonferroni correction. Survival times were analyzed by the Kaplan–Meier-method, compared by log-rank test and reported as median with 95% confidence intervals (CI). To analyze survival according to differential tissue marker expression, ASI and its constituents were divided into statistical quartiles or high and low expression  and the resulting subgroups compared statistically. Two-sided p-values of ≤5% were considered statistically significant. Because of the exploratory study design and the descriptive character of the analyses performed, all results were interpreted cautiously, and p-values were used descriptively.All statistical testing was performed with SPSS Statistics software . Categorical variables were compared using chi-squared or Fisher′s exact test, depending on cell frequencies. Tissue parameters α-SMA, AB and the resulting ASI were not normally distributed in most subgroups, as assessed by the Shapiro–Wilk test (α = 0.05); thus, nonparametric Mann–Whitney n = 117 patients aged 40.0–86.9 years (median: 69.1) of whom n = 63 were male (53.8%). Overall, n = 69 had undergone upfront resection  and n = 48 had been resected after neoadjuvant treatment . Of the latter, n = 31 had received NT with FOLFIRINOX only , n = 10 a combination of neoadjuvant treatments  and n = 7 gemcitabine/nab-paclitaxel only . The COMB subgroup included patients who in addition to a median of six cycles of FOLFIRINOX had received partially overlapping gemcitabine/nab-paclitaxel (n = 4), radiochemotherapy (n = 4), gemcitabine mono (n = 3) and single cases with gemcitabine + erlotinib and FOLFOX. In line with our department′s treatment pathways, all patients undergoing NT had either locally advanced or disseminated stages at time of diagnosis, and the majority underwent extended resections. The treatment subgroups differed significantly in age (younger patients in COMB and FOL), ASA classification (lower score in FOL vs. RES) and extent of surgery  was significantly more frequent than in M0 . Other clinicopathological parameters were not statistically different.The overall cohort comprised p = 0.032 and 0.048, respectively; p = 0.015; 0.015; and 0.025) indicating lower collagen content after GEM treatment . In the treatment subgroups, however, ASI showed a distinct trend for higher values in GEM than in all other (sub)groups; this was statistically significant in the Mann–Whitney U tests of GEM vs. both RES and FOL  but not in (sub)group analyses. Of note, however, data for lymphatic, venous and perineural invasion were only available in n = 81 (69.2%) of all cases. Furthermore, AB values were significantly different between n stage categories in the overall cohort, (p = 0.021) with N1 significantly higher than N2 (p = 0.049) but not N0 (p = 0.055). In the NT group, AB values were significantly higher for the small subgroup with perineural invasion than without .Comparing tissue parameters between categories of patient characteristics, microscopic venous invasion pV was significantly associated with lower ASI values in the overall cohort , the M1 group  and the FOL subgroup , with a nonsignificant trend in the GEM subgroup as well (n = 4 vs. 3). Contrastingly, in the RES group, no significant associations of tissue parameters with sex nor trends were found . OS was calculated from date of diagnosis and was not different between RES and NT at a median of 20.3 months  vs. 24.1 . M1 patients had a significantly shorter OS at 16.6 months  than M0 at 23.8 . A trend for shorter median OS in female patients was observed within the NT group at a median of 34.4 months for males  vs. 17.2 for females . After exclusion of M1 patients due to the imbalanced distribution of sex and M status between types of NT, a significant association of female sex with worse OS was only found within the small M0 GEM subgroup .Four patients of the overall cohort had died of other causes than PDAC and were excluded from analysis of overall survival (OS), as were two patients with palliative resections, resulting in a subset of p = 0.040) in the RES as well as RES M0 group , the highest quartile of ASI values, than in Q1-3 of FOL patients at 38.4 vs. 22.0 months , however, which was only divided into high vs. low values due to the small group size, it was again low ASI, which was significantly associated with longer OS at 35.0 months (95% CI: 22.8–47.2) vs. 18.8  vs. 19.1 (13.2–25.0); p = 0.011), as well as in the NT M0 group (39.4 (35.2–43.5) vs. 18.8 (8.7–28.8); p = 0.010; p = 0.016; data not shown)  f. In thep = 0.042; data not shown). Despite a consistent trend for improved OS with higher AB values in the FOL and GEM patients, no further significant associations were found in NT and its subgroups. In the RES group, no trends nor associations of AB values with OS were observed.In the analysis of AB stainings, Q4 (representing the highest collagen content) was associated with significantly longer OS than Q1 in the NT group (22.1 (16.0–28.2) vs. 35.0 (33.4–36.5), n = 9) at 18.8 months (14.3–23.3) vs. both “fibrolytic” stroma = high/low at 24.1  and “fibrogenic” high/high at 40.5 . Congruent results were obtained in the NT M0 group with significantly shorter median OS in the low/low class at 16.9  vs. high/low at 24.1  and vs. high/high at 39.4 . For further survival statistics cf. As an alternative to the arithmetic ASI, we analyzed survival classified by combinations of high and low α-SMA and AB according to median expression, as described before , and agaLow ASI, signifying low myCAF density and/or high stromal collagen deposition, has earlier been shown to be a positive prognostic factor in upfront resected PDAC patients, and the results in our control group largely confirm these findings . Howevern = 11) than after gemcitabine-based therapy (n = 11) and in untreated samples but higher collagen in both NT groups compared with untreated. ASI was higher in FOLFIRINOX-treated patients than after gemcitabine-based therapy, but there was no correlation of ASI with survival [Interestingly, tissue parameters were not statistically different after NT compared to RES, and only the GEM subgroup revealed a distinct pattern with higher ASI rooted in lower collagen content but nondifferent α-SMA values. The small subgroup sizes, however, certainly need to be considered and represent one of the limitations of our study. Another relative limitation might be the lack of pretherapeutic tissue samples to investigate stromal marker changes over the course of neoadjuvant treatment, although our major findings pertain not to differential expression but instead differential association of tissue markers with prognosis between treatment cohorts. Other groups have reported controversial results on stromal markers after NT: Nakajima et al. found reduced collagen content for several collagen subtypes but not reduced α-SMA in 25 patients after NT; collagen reduction furthermore correlated with radiographic chemotherapy response . Howeversurvival ; howeversurvival ; possiblCollagen in PDAC appears to have ambiguous relevance for prognosis, which has been shown to correlate with abundance of its specific subtypes rather than overall content . AdditioTo our knowledge, the direct association of improved OS with greater myCAF abundance after current first-line NT regimens has not been previously reported in patient samples. As the complex dynamic interaction of CAFs in PDAC is still gradually being discovered ,11,15,37Although no direct connection has neither been proposed nor investigated thus far, available data seem to suggest a link of NT with myCAF for the improved prognosis we found most likely via their mutual—or potentially interdependent—immunomodulatory mechanisms: On the one hand, myCAFs have been shown to confer improved prognosis by immune modulation in preclinical and translational models , and strMany of the most comprehensive and distinguished recent publications on CAFs in PDAC did either not include investigations into response to NT or investigated chemotherapeutics with little relevance in current clinical standard treatments, leaving stromal interactions in modern NT regimens to be elucidated. Our data thus represent a stratified analysis of two of the most widely used stromal parameters for PDAC in a translational setting, correlating primary tissue markers with patient survival and adding real-world data to the numerous, and in part conflicting, recent reports on the significance of collagen and myCAFs in PDAC and NT.Our study shows distinct properties of the myCAF and collagen compartment in PDAC tumor stroma after NT with current first-line agents FOLFIRINOX and gemcitabine/nab-paclitaxel and their differential association with survival compared with stroma without NT. These results underline the importance of further research into chemoresistance and response mechanisms on stromal level. Prognostic significance of ASI in resection of PDAC is not retained after NT, and future studies reporting ASI after NT should provide stratification and analysis of primary tissue markers for comparability of results.


Weak-to-moderate correlations were also identified for the respiratory exchange rate at the anaerobic threshold (RER@AT), end-tidal carbon dioxide at the anaerobic threshold (PETCO2@AT), oxygen consumption at the anaerobic threshold (VO2@AT), carbon dioxide production at the anaerobic threshold (VCO2@AT), and metabolic equivalents at the anaerobic threshold . On multivariate analysis, the results showed that age, the BMI, and GLS are independent predictors for reduced exercise capacity in patients with IHD (p < 0.01). The area under the ROC curve value of GLS for identifying patients with a peak VO2 of <14 mL/kg/min was 0.73 (p = 0.000). Conclusion: As a sensitive echocardiographic assessment of patients with ischemic heart disease, global longitudinal strain is an independent predictor of reduced exercise capacity and has a sensitivity of 74.2% and a specificity of 66.7% to detect exercise intolerance.Objective: Global longitudinal strain (GLS) is a sensitive and reproducible predictive factor in patients with ischemic heart disease (IHD), although its correlation with exercise tolerance is unknown. We aimed to identify the correlation between global longitudinal strain (GLS) and cardiopulmonary exercise testing (CPX) parameters and assess the prognostic implications and accuracy of GLS in predicting exercise intolerance in populations with ischemic heart disease (IHD) using CPET criteria. Methods: Prospectively, 108 patients with IHD underwent CPX and 2D speckle-tracking echocardiography. Correlation between GLS and multiple CPX variables was assessed using Spearman’s correlation analysis and univariate regression analysis. A receiver operating characteristic (ROC) curve analysis was performed on GLS to detect exercise intolerance. Results: GLS was correlated with peak oxygen uptake (peak VO Catheter coronary angiography (CCA), the traditional gold standard for diagnosing coronary artery disease (CAD), identifies visual obstructive lesions . Despite2 pulse), peak oxygen uptake (peak VO2), peak carbon dioxide exertion (peak VCO2), anaerobic threshold (AT), VO2/WR, and respiratory equivalent during anaerobic threshold (VE/VCO2), provide more sensitive and specific information to detect the onset of ischemia, mortality, and hospitalization , where T is the time of incremental exercise and S is the slope of work rate incremental in watts per minute [All patients underwent symptom-limited CPX on a CARDIOVIT CS-200  on the same day before/after 2D-STE, and the procedure complied with the American Heart Association (AHA) statement concerning exercise Standards for Testing and Training ,16. The echnique ,19. The itations . The slor minute .Standardized transesophageal echocardiogram (TEE) examinations were performed using Vivid E9 Ultrasound systems  under the guidelines of the American Society of Echocardiography . The eleAs previously described, a strain specialist blind to the clinical data of the patients performed longitudinal strain assessments of the LV from three apical views  using EchoPAC  . The endt-test and the Mann–Whitney test were performed for quantitative variables, while Pearson’s chi-square test and Fisher’s exact test were performed for categorical variables to compare the differences between the two groups . Correlations between GLS and multiple CPX variables were performed using Spearman’s correlation analysis. The significant variables (p < 0.05) from the univariate analysis were included in the multiple stepwise regression analysis for assessing independent correlations to peak VO2. Receiver operating characteristic (ROC) curves were generated, and area under the curve (AUC) values were calculated to determine the discrimination value of GLS to predict a peak VO2 of <14 mL/kg/min. A p-value of <0.05 was considered statistically significant. All data were analyzed using SPSS Statistics software. .Continuous data were presented as the mean ± SD or the median . Categorical variables were expressed as numbers and percentages. Student’s n = 61) had impaired GLS (>−17.6), while 43.5% (n = 47) had normal GLS (≤−17.6). The baseline characteristics of the two groups are presented in Of the 108 patients included in the study, 56.5% @AT, VO2/kg@peak, VCO2/kg@peak, RER@peak, and %PPeak VO2, which indicated a better exercise capacity. TEE data were similar across both groups.ECG and CPX parameters between the two groups are shown in p < 001), VO2/kg@peak , METs@peak , VE/kg@peak , and %PPeak VO2 , and directly related to VE/VCO2slope ; see 2@AT, VO2/kg@AT, VCO2/kg@AT, and METs@AT (p < 0.01). The EF value showed no significant correlation with any of the analyzed CPET variables  and GLS (p < 0.01) appear to be associated with reduced exercise tolerance in subjects with IHD, while on multivariate analysis, age, the BMI, and GLS were independent predictors of reduced exercise capacity  0.6–0.86), with a sensitivity of 74.2% and a specificity of 66.7%, for a cut-off GLS value of −15.2% (p = 0.000); see The area under the ROC curve (AUC) value for GLS in the detection of peak VOTo the best of our knowledge, this is the first study to describe the relationship between GLS and CPX parameters in the population with IHD. The study highlights weak-to-moderate correlations between GLS and functional CPX parameters and further demonstrates that GLS can detect reduced exercise capacity in these patients.2 (<70% of predicted) on CPET. Furthermore, revascularization does not improve the peak VO2 for patients with multivessel disease, suggesting that CPET plays a vital role in characterizing the functional consequences of myocardial ischemia [The non-invasive detection of ischemia for non-obstructive CAD remains a clinical challenge. Previous studies have recognized GLS as one of the most sensitive and reproducible indicators of ischemia and have shown that GLS is superior to the EF in detecting an early reduction in contractile function . The LVEischemia . Hence, 2 and VE/VCO2 slope are critical parameters in the detection of obstructive CAD, and in this study, patients with normal GLS had a higher peak VO2 (19.19 ± 3.42 mL/kg/min vs. 17.01 ± 3.22 mL/kg/min), and compared with the resting EF, GLS showed a relationship with peak VO2  and the VE/VCO2 slope . Moreover, multivariable analysis demonstrated that GLS is independently associated with reduced peak VO2. Thus, reduced GLS may be an effective indicator of exercise intolerance in this group of patients.Patients with IHD frequently have reduced exercise capacity, even when the conventional parameters of left ventricular function, such as ejection fraction (LVEF), are within the normal range. In addition, the role of disability, particularly in the context of exercise intolerance, is not fully understood. GLS is associated with the extent of viable myocardial tissue in patients with chronic IHD, where the load has less of an impact. Since sub-endocardial fibers are more sensitive to ischemia, numerous studies have demonstrated that GLS is more accurate at detecting early myocardial disturbances caused by ischemia compared with the EF value ,25. Prev2, defined as cardiorespiratory fitness (CRF), is a vital clinical sign of all-cause and cardiovascular mortality in patients with cardiovascular diseases, as well as in healthy individuals [2 is recognized as an independent risk factor for adverse cardiovascular events in populations with IHD. The correlations between GLS and exercise capacity identified in this study further highlight the potential importance of early detection of LV dysfunction in individuals with IHD with exercise intolerance.Peak VOividuals . Reduced2 of <14 mL/min/kg was −15.2, with a sensitivity of 74.2% and a specificity of 66.7%. Collectively, these findings indicate the quantifiable and prognostic significance of GLS as a suitable alternative to evaluate patients with reduced exercise capacity.Ng et al. reported that GLS at rest was −16.3 ± 2.4 in patients with CAD vs. −19.1 ± 2.9 in patients with non-significant CAD . Similar2, the models are not specific enough to classify CRF as routine practice. Hence, determination of the relationship between GLS and exercise intolerance could potentially allow the prediction of CRF of patients with IHD based solely on ECG-derived GLS. The exercise intolerance prediction results from this study extend the findings of Maia et al. [2 of <14 mL/min/kg was −15.2. Therefore, GLS could be a valuable tool to discriminate patients with normal exercise capacity from those with reduced exercise capacity.The value of using CPX in detecting macrovascular ischemia has been previously reported . Howevera et al.  regardin2 in CPX. Further studies should be conducted on subjects using 3D STE.Despite the valuable findings of this study, there are several significant limitations that should also be considered. First, as a single-center study, the small size of the population in the study may limit the generalizability of the findings. Second, more than 50% of the participants in both experimental groups were taking β-receptor blocker medication, a primary treatment for IHD, which significantly lowers the peak VOThe study presented the value of GLS measured with 2D speckle-tracking echocardiograph in patients with IHD. The assessment of GLS was able to detect exercise intolerance and identify what has a poor prognosis.