Trichomonas vaginalis strain G3, Tritrichomonas foetus strain D1, and Tritrichomonas foetus-like strain C1 that cause disease in humans and farm and domesticated animals. The increasing prevalence of antibiotic resistance requires development of new tools to enhance or replace medicinal antibiotics.We previously reported that the tomato glycoalkaloid tomatine inhibited the growth of Wild tomato plants were harvested and divided into leaves, stems, and fruit of different colors: green, yellow, and red. Samples were freeze dried and ground with a handheld mill. The resulting powders were evaluated for their potential anti-microbial effects on protozoan parasites, bacteria, and fungi. A concentration of 0.02% (w/v) was used for the inhibition of protozoan parasites. A high concentration of 10% (w/v) solution was tested for bacteria and fungi as an initial screen to evaluate potential anti-microbial activity and results using this high concentration limits its clinical relevance.S. enterica showed a minor susceptibility while B. cereus and C. albicans fungi both showed a significant growth inhibition with some of the test powders. The powders inhibited growth of the pathogens without affecting beneficial lactobacilli found in the normal flora of the vagina.Natural powders derived from various parts of tomato plants were all effective in inhibiting the growth of the three trichomonads to varying degrees. Test samples from leaves, stems, and immature ‘green’ tomato peels and fruit, all containing tomatine, were more effective as an inhibitor of the D1 strain than those prepared from yellow and red tomato peels which lack tomatine. Chlorogenic acid and quercetin glycosides were present in all parts of the plant and fruit, while caffeic acid was only found in the fruit peels. Any correlation between plant components and inhibition of the G3 and C1 strains was not apparent, although all the powders were variably effective. Tomato leaf was the most effective powder in all strains, and was also the highest in tomatine. The results suggest that powders prepared from tomato leaves, stems, and green tomato peels and to a lesser extent from peels from yellow and red tomatoes offer potential multiple health benefits against infections caused by pathogenic protozoa, bacteria, and fungi, without affecting beneficial lactobacilli that also reside in the normal flora of the vagina. Trichomonas vaginalis in humans causes the sexually transmitted disease (STD) trichomoniasis, reported to be the most common non-viral transmitted infection in the world [Tritrichomonas foetus are reported to cause the disease of trichomonosis in farm animals  [Infection by the parasitic protozoan he world , 2. Strand pigs) –6, as wend pigs) . In cowsBecause of increasing rates of clinical resistance to the widely used drug metronidazole, new treatments are needed to replace or to complement current available therapies. The need for new treatments is illustrated by a publication from the National Institute of Allergy and Infectious Diseases, National Institute of Health (NIH) that emphasizes the need for new therapeutics to help overcome the global epidemic of sexually transmitted infections, including trichomoniasis .As part of an effort to discover the efficacy of safe food extracts and their bioactive constituents against pathogenic trichomonads, we previously reported on the anti-trichomonad effects of potato and tomato glycoalkaloids, potato peels, and of black tea and other food-compatible compounds and extracts against three trichomonad parasites –12, reviTo help meet the need to develop new effective therapeutic agents, the objective of the present study is to evaluate anti-trichomonad, antibacterial, and anti-fungal properties of powders prepared from leaves, stems, and tomatoes harvested from a growing plant, and correlate this inhibitory activity to their composition of a separate set of test powders, as determined previously using high-performance-liquid chromatography/mass spectrometry (HPLC/MS). The results of the described efforts suggest that several tomato-plant-derived powders could potentially replace or enhance the therapeutic potency of metronidazole.S. lycopersicum) although it’s not likely to be a cultivar or variety per se. It may be a “weedy” or naturalized form. They are common in fields where tomatoes have been grown. Genomic analysis and typing of this plant have not been undertaken therefore this identification is preliminary. We plan a genetic analysis using newly grown plants. Materials will be stored in our laboratory, United States Department of Agriculture, Foodborne Toxin Detection and Prevention Research Unit at Albany, CA, 94710, USA.The wild, drought-resistant tomato plant was obtained from a residential garden in California with the permission of the owners. The plant and plant parts used in this study were harvested in the summer of 2018. This plant bears small fruit at different stages of maturity approximately the size of cherry tomatoes ranging from green (immature), yellow, then reddish colors. Informal determination via morphological identification by Prof. Dina St. Clair at the University of California, Davis indicates that “It looks like a small fruited version of cultivated tomato  from Stanley Marks, University of California at Davis, School of Veterinary Medicine, Davis, CA, USA. All of these protozoa were cultured according to methods previously described [escribed . The InsThe pathogenic and non-pathogenic bacteria and pathogenic fungi were obtained from the in-house United States Department of Agriculture (USDA) collection or from the American Type Culture Collection . The Institutional Biosafety Committee at the USDA approved the use of these non-pathogenic and pathogenic organisms.Trichomonas vaginalis G3, feline Tritrichomonas foetus-like C1, and bovine Tritrichomonas foetus D1); (b) four pathogenic bacteria ; (c) four nonpathogenic bacteria ; and (d) two pathogenic fungi , as described below.To demonstrate proof-of-principle, a tomato plant of unknown origin was randomly selected for this study from a garden of a private residence in Solano County, CA. Tomato leaves, stems, and green, yellow, and red tomatoes were harvested from the tomato plant as described previously . Brieflyp ≤ 0.5.The composition of the powders was determined by high-performance liquid chromatography (HPLC) and fast atom bombardment mass spetrometry (FAB-MS) using using a Hitachi 7000 liquid chromatography system with UV/vis detector and a JMS-700 double focusing mass spectrometer, as described in detail elsewhere . Each peT. vaginalis and C1 and D1 strains of T. foetus were grown and maintained in 11 mL of TYM Diamond medium of pH 6.2. Every 24 h, the cells from the C1, D1, and G3 strains were passed by inoculating 1000 μL of cells (approximately 1 × 106 cells) into a new 15 mL conical tube containing 10 mL of TYM Diamond medium. Then, the cells were incubated for 24 h at 37 °C. Inhibitory screens were carried out as previously described in several studies [Stock solutions of the plant powders (10% w/v) were prepared by solubilizing in a solution of 1:1 autoclaved water to DMSO (density of DMSO approximated to 1 g/mL) as follows. The powders were first dissolved or suspended in DMSO. The water was then added, and the powder was resuspended and used in bioassays immediately at 0.02% w/v. Cultures of the G3 strain of  studies , 9, 14.  studies .L. reuteri (ATCC 23272), L. acidophilus (ATCC 43560), and L. rhamnosus (ATCC 53103) were grown in Lactobacilli MRS at 37 °C under anaerobic conditions using the BD GasPak EZ anaerobic container system. Strains grown aerobically at 37 °C were: E. coli K-12 MG 1655 (USDA) in Luria Broth, S. enterica pGFP (USDA) in Luria Broth, L. monocytogenes RM2194 (USDA) in Brain Heart Infusion, B. cereus (USDA) in Brain Heart Infusion, and S. aureus (ATCC 6538) in Tryptic Soy. Empty BDL-sensi-discs (6 mm) were incubated with either vehicle control (50% DMSO:50% water) or tomato powders dissolved in DMSO:water for 30 min at room temperature. Discs containing vehicle control, compounds, or various antibiotic discs : levofloxacin (5 μg), gentamicin (10 μg), and gentamicin (120 μg), were placed onto the bacterial streaked agar plates and incubated overnight at 37 °C (18–24 h). Sensitivity to antibiotics or tomato powders was determined via measurement of zones of inhibition around each disc in millimeters (mm).Aspergillus fumigatus AF293, a causative agent for invasive aspergillosis, and C. albicans ATCC 10231. In both A. fumigatus and C. albicans tests, 5 μL of 10% tomato peel powders w/v (dissolved in water: dimethyl sulfoxide) were spotted onto the lawn of fungi (in duplicate), which were grown on Potato Dextrose Agar (PDA) or Yeast Peptone Dextrose   for A. fumigatus or C. albicans, respectively. Fungi were incubated at 35 °C and the formation of zones of inhibition in millimeters (mm) were monitored at 24 and 48 h.The antifungal activity of tomato peel extracts was examined in t-test to generate p values in the Prism 6 software . p values < 0.05 were considered statistically significant.All parasite screening trials were performed a minimum of three times on three separate days to a standard error of ≤0.10. Statistical significance was determined using the Student’s 50 of 0.00000822% w/v (0.72 μM) , 0.00000559% w/v (0.49 μM) (T. foetus D1), and 0.00000628% w/v (0.55 μM) (T. foetus C1) [Table t-test for these percent inhibitory values for the tomato leaves extract for all trichomonad strains, we found a statistical difference between the T. vaginalis G3 (human) vs the T. foetus C1 (feline) and the T. foetus D1 (bovine) strain . For the green tomato peel, it was found that there was a statistical difference between T. vaginalis G3 vs T. foetus D1(bovine) as denoted by the * and between T. foetus C1 (feline) vs T. foetus D1 (bovine) denoted by b), (Table p < 0.05). Similar to the green tomato peel, the yellow tomato peel powder was statistically significant with a p < 0.05 in Table T. vaginalis G3 vs T. foetus D1(bovine) and between T. foetus C1 (feline) vs T. foetus D1 (bovine). The red tomato peel was also shown to be statistically significant between the T. vaginalis G3 (human) vs the T. foetus C1 (feline) and the T. foetus D1 (bovine) strain . Last, the green tomato powder itself was only found to be statistically significant between the T. vaginalis G3 (human) vs the T. foetus D1 (bovine) strain .Using the Student’s 50 determination (concentration that inhibited 50% of the pathogens under the tesst conditions) for the three pathogens and determined to be approximately 0.02% (w/v) for strain G3, 0.01% (w/v) for strain C1, and 0.01% (w/v) for strain D1 when rounded to only one significant digit. Below we will discuss potential reasons for these differences in terms of the known composition of the test powders.Tomato leaves exhibited the highest activity across all strains, with nearly complete inhibition of strains C1 and D1 at values of 97.8 and 99.5%, respectively. This sample was then subjected to ICWe previously reported on the composition, as determined by high-performance liquid chromatography-mass spectrometry (HPLC-MS), of five of the test powders evaluated in the present study in terms of mg/g dry weight . Figure E. coli K12 (used as a model for other pathogenic E. coli) by the antibiotics levofloxacin and gentamycin (used as positive controls) and five plant powders in a 10% w/v solution as an initial screen for anti-microbial activity. Tomato stems, red tomato peels, and green tomato fruit showed no activity against any of the bacteria. Tomato leaves and green tomato peel, both high in tomatine, inhibited S. enterica to a minor extent. Most of the other bacteria were not affected by the treatments, with the exceptions that tomato leaves alone inhibited B. cereus, and green tomato peels alone inhibited E. coli K12. Either the tomatine was not responsible for the activity against these 2 bacteria, or some other compound, perhaps the high chlorogenic acid content of green peels, was acting antagonistically or synergistically with the tomatine. The inhibition of B. cereus by the tomato leaf powder was on par with the 10 μg gentamycin treatment.Table L. acidophilus, L. rhamnosus, and L. reuteri.Table Aspergillus fumigatus, an environmental filamentous fungus that can cause life-threatening disease in immunocompromised individuals [C. albicans to a significant extent (63–74%) relative to the positive control octyl gallate.Table ividuals . By contTrichomonas vaginalis and found α-tomatine had an approximate IC50 of 25 μM, while dehydrotomatine had no observable effect on cell growth [Previous compositional studies have shown that dehydrotomatine is always present to a lesser degree than tomatine in tomato plants , 17. Whil growth .Other than an apparent correlation between tomatine content of the plant powders and inhibition of strain D1, there does not appear to be any obvious patterns of correlation between composition and activity, possibly because plant components could act additively, antagonistically, or synergistically in binding to the cell receptor sites and because the analytical samples might not be identical to the biological samples, although both sets were harvested at the same time from the same plants. It is nevertheless of interest to note that tomato leaves, which have a high content of tomatine and dehydrotomatine, showed the greatest potency against all three trichomonad strains. This finding is consistent with our previous report , on the These observations suggest that because the biosynthesis of secondary metabolites change during the growth cycle of the plant , and theThe results on the growth inhibition of the pathogenic bacteria in Table The results shown in Table C. albicans fungi shown in Table C. albicans can also occasionally cause more serious systemic infections in severely ill or immuno-compromised individuals [Candida. albicans, suggesting that the glycoalkaloids were either not responsible for the inhibition, or that another component in the green peels was interfering with activity. We do not know the reason for the differential susceptibilities of the two pathogenic fungi to growth inhibition. However, a similar phenomenon could be found with the antifungal agent fluconazole. The yeast pathogens Candida sp. and Cryptococcus sp. are susceptible to fluconazole whereas the filamentous fungal pathogen Aspergillus fumigatus whch was is not inactivated by any of the test substances is not, reviewed in [The inhibition of ividuals . It is niewed in . This naiewed in .This investigation has shown that powders prepared from different parts of a harvested tomato plant, especially high-tomatine content leaves, have in vitro anti-trichomonad, anti-bacterial, and anti-fungal properties, suggesting their possible value to ameliorate the severity of trichomoniasis, vaginosis, and vaginal yeast infections in infected humans and trichomonosis in infected farm and domestic animals. The results of the present study contribute to our knowledge about the biological properties of different parts of the tomato plant. Because the analytical data show that the tomato leaves and green tomatoes have the highest content of bioactive compounds compared to red tomatoes, future biomedical studies should consider evaluating health benefits of readily available and inexpensive tomato leaves from different tomato cultivars.Our wild, drought-resistant tomato plant has the morphological characteristics of a “cherry” tomato plant but this identification is informal and future studies need to validate this preliminary determination via genomic analysis leading to the typing of the taxonomy of this plant. The results of the present study complement and extend related observations on the inhibition of the parasitic trichomonds by cherry (grape) tomato peels . MoreoveWe are challenged to help ameliorate adverse effects of pathogen contamination in food and infection in animals and humans using extracts containing bioactive compounds present in different parts of the tomato plant. In vivo studies should include an assessment of the ratio of effective to toxic doses.


Regorafenib after sorafenib therapy improved survival in patients with advanced hepatocellular carcinoma in the RESORCE study. The aim of our retrospective study was to investigate the predictors of response and outcome of regorafenib therapy in patients with unresectable hepatocellular carcinoma in whom sorafenib therapy had failed. We demonstrated that albumin-bilirubin grade at the initiation of regorafenib therapy is an independent predictor of disease control, progression-free survival, and overall survival. Patients with albumin-bilirubin grade 2 and an alpha-fetoprotein level of ≥20 ng/mL had the worst progression-free survival (after regorafenib therapy) and overall survival (after regorafenib and sorafenib therapy). Thus, a combination of albumin-bilirubin grade and alpha-fetoprotein level can be used to stratify patients with unresectable hepatocellular carcinoma by progression-free survival and overall survival probability for sorafenib–regorafenib sequential therapy.p < 0.001) for regorafenib therapy, and OS for both regorafenib  and sorafenib–regorafenib sequential  therapy. A combination of ALBI grade and AFP level can be used to stratify patients with unresectable HCC by PFS and OS probability for sorafenib–regorafenib sequential therapy.In the RESORCE study, regorafenib after sorafenib therapy improved survival in patients with advanced hepatocellular carcinoma (HCC). In total, 88 patients with unresectable HCC who received sorafenib–regorafenib sequential therapy were enrolled. The objective response rate and disease control rate were 19.3% and 48.9%, respectively, for regorafenib therapy (median duration: 8.1 months). Median progression-free survival (PFS) after regorafenib therapy was 4.2 months (95% CI: 3.2–5.1). The median overall survival  was not reached in this cohort. According to multivariate Cox regression analyses, albumin-bilirubin (ALBI) grade at the initiation of regorafenib therapy is an independent predictor of disease control, PFS, and OS. Moreover, the combination of ALBI grade 2 and an alpha-fetoprotein (AFP) level of ≥20 ng/mL was an independent predictor of PFS (hazard ratio (HR): 3.088, 95% CI: 1.704–5.595;  Multiple lines of therapy can improve overall survival (OS) in cancer. For advanced hepatocellular carcinoma (HCC), the median OS increases from 11–14 months to 35 months after two or more lines of systemic therapy ,3. SeverLiver reserve may worsen during anticancer therapy, and preserving liver function is essential to achieving favorable outcomes of sequential systemic therapy . The albn = 90) of patients with unresectable HCC who did not receive regorafenib therapy after sorafenib treatment failure from September 2012 to September 2019 as an historical control group for comparing survival. Baseline and on-treatment clinical characteristics  stage), laboratory data , alanine aminotransferase (ALT), total bilirubin, and AFP levels; international normalized ratio, and platelet count), and imaging findings were collected. Contrast-enhanced dynamic computed tomography or magnetic resonance imaging was scheduled for patients every 2–3 months to assess treatment response. Tumor response to regorafenib therapy was evaluated with the modified Response Evaluation Criteria in Solid Tumors (mRECIST) [9/L] × ALT level [U/L]1/2) [10 bilirubin level (μmol/L) × 0.66] + [albumin level (g/L) × −0.085] [Our study was a retrospective cohort study of patients from a single tertiary care medical center in Taiwan. In total, 88 patients with unresectable HCC who had received sorafenib–regorafenib sequential therapy, were enrolled from September 2012 to July 2020. Furthermore, we enrolled another cohort (mRECIST) . The Fibp values were <0.25 in the univariate analyses. Statistical analyses were performed using SPSS version 26.0 . A p value of <0.05 was considered statistically significant.The categorical data of the two groups were compared using Fisher’s exact test, as applicable. Continuous data were evaluated for normality using the Kolmogorov–Smirnov test. Continuous data, which are expressed as medians and interquartile ranges, were analyzed using the Mann–Whitney U test. We used the area under the receiver operating characteristic curve (AUROC) to evaluate the performance of AFP values in predicting progression-free survival (PFS) and OS. The optimal cutoff value of AFP (17.3 ng/mL) was determined according to the Youden index. For convenience, we adopted the popular integer value (20 ng/mL) as the cutoff value of AFP for further analysis. OS and PFS were determined using Kaplan–Meier curves, and univariate analysis with the log-rank test was used to compare groups. Child–Pugh score and ALBI grade were used as covariates and were considered as confounding factors. Therefore, we adopted three models  for multivariate Cox regression or logistic regression analysis. The HRs for survival predictors were determined using univariate and multivariate Cox regression analyses. Odds ratios for predictors of treatment response were determined through univariate and multivariate logistic regression analyses. A stepwise multivariate analysis was performed with variables whose The median age of the study group before regorafenib therapy was 66 ± 14 years. Among all patients, 69 (78.4%) were men, 83 (94.3%) were classified as Child–Pugh class A (score: 5 or 6), and 64 (72.7%) had BCLC stage C disease. In total, 19 patients (21.6%) died during the follow-up period, which had median durations of 18 and 8.1 months for sorafenib–regorafenib sequential therapy and regorafenib therapy, respectively. The variables at baseline (before sorafenib therapy) and during treatment (before regorafenib therapy) are presented in p < 0.001). After propensity-score matching, patients receiving regorafenib sequential therapy exhibited significantly higher OS than those not receiving regorafenib therapy (p < 0.001). Furthermore, the median progression-free survival (PFS) for regorafenib therapy was 4.2 months : 3.2–5.1), and a median OS was not reached . The characteristics of these two cohorts were compared before and after propensity-score matching . Approxi reached c. A medi reached d.n = 88), the objective response rate and disease control rate (DCR) were 19.3% and 48.9%, respectively. p = 0.089). The subgroup with ALBI grade 1 exhibited a significantly higher DCR than did the subgroup with ALBI grade 2 .Treatment response was evaluated according to the mRECIST . For allp < 0.001). The combination of ALBI grade and AFP level could be used to stratify patients by the probability of 6-month PFS (p = 0.001). The median PFS was 2.3 (95% CI: 1.8–2.8) and 5.6 months (95% CI: 3.0–8.3), respectively, for patients with both ALBI grade 2 and an AFP level of ≥20 ng/mL and for all the other subgroups combined.We investigated factors before the initiation of regorafenib therapy that were predictive of PFS. According to the univariate Cox regression analyses, the Child–Pugh score (5 vs. 6), ALBI grade (1 vs. 2), combination of ALBI grade 2 and an AFP level of ≥20 ng/mL (yes vs. no), and AST level, were associated with PFS . Accordip = 0.014). The combination of ALBI grade and AFP level could be used to stratify patients by the probability of 6-month OS (p = 0.001). The 6-month OS rates for patients with both ALBI grade 2 and an AFP level of ≥20 ng/mL and for the other subgroups combined were 78.6% and 92.5%, respectively. The median OS for patients with ALBI grade 2 and an AFP level of ≥20 ng/mL was 10.0 months (95% CI: 7.1–12.9).We investigated factors before the initiation of regorafenib therapy that were predictive of OS. The multivariate Cox regression analysis revealed that the combination of ALBI grade 2 and an AFP level of ≥20 ng/mL independently predicted OS in the model based on the combination of ALBI grade and AFP level (p < 0.001).We explored whether factors before the initiation of regorafenib therapy were predictive of OS after sorafenib–regorafenib sequential therapy. Multivariate Cox regression analyses revealed ALBI grade (1 vs. 2), AFP level (<20 vs. ≥20 ng/mL), and the combination of ALBI grade and AFP level to be independent predictors in two models . Moreovep = 0.039 and 0.006, respectively). However, no factor was significantly predictive of objective response .Multivariate analysis identified sex and ALBI grade as predictors of disease control  after regorafenib therapy (n = 178) to investigate the predictors of OS. In the ALBI grade-based model, ALBI grade (1 vs. 2), AFP (<20 vs. ≥20 ng/mL), sequential therapy (yes vs. no) and locoregional therapy (yes vs. no) were independent predictors for OS after failure of sorafenib therapy (n = 78) was selected to analyze the effect of the sequential therapy. For OS after failure of sorafenib therapy, AFP (<20 vs. ≥20 ng/mL) and sequential therapy (yes vs. no) were independent predictors in the ALBI grade-based model. ALBI grade 2 and AFP ≥ 20 ng/mL (yes vs. no), sequential therapy (yes vs. no) were independent predictors in the combined ALBI and AFP-based model , patients who received regorafenib therapy had median PFS and OS of 3.7 and 13.2 months, respectively, which are consistent with the results of the RESORCE study [In the RESORCE study, regorafenib therapy demonstrated a DCR of 65.7% and improved survival (median OS of 26 months with sorafenib–regorafenib therapy) in patients with advanced HCC that progressed after sorafenib therapy . In an iCE study . Three rCE study ,22,23. Tp < 0.001) and OS  and can be implemented to predict treatment outcome in patients before regorafenib initiation.Although the Child–Pugh classification is the most common scoring system for liver function, the ALBI grade is more objective because its formula contains only two variables, which are easily measurable: serum albumin and total bilirubin. In the present study, we demonstrated that the on-treatment ALBI grade was a predictor of treatment response  and PFS The incidence of drug-related treatment-emergent adverse events (TEAEs), including HFSR, diarrhea, and hypertension, was similar for sorafenib and regorafenib. This finding is consistent with that of the phase 3 RESORCE trial . In our Our study is clinically relevant. First, it was a retrospective cohort study in a real-world setting, investigating the survival benefit of regorafenib therapy. Second, the combination of ALBI grade and AFP level at the initiation of regorafenib therapy can be used to stratify patients by their survival probability from receiving sequential therapy. Third, many patients received other therapy in real-world settings, such as locoregional therapy or radiotherapy, in addition to sequential therapy; such additional therapy might have partly accounted for the treatment efficacy. Nonetheless, similar proportions of patients from the entire cohort and from the propensity-score-matched cohort who did not receive regorafenib therapy after sorafenib failure received palliative locoregional therapy, suggesting the survival benefit of regorafenib therapy. Moreover, we demonstrated that sequential therapy was an independent predictor of OS not only for the entire cohort, but also for the subgroup, without receiving locoregional therapy after failure of sorafenib therapy . Fourth,The study has some limitations. First, this was a retrospective study with median follow-up periods of 18 and 8.1 months for sorafenib–regorafenib sequential therapy and regorafenib therapy, respectively. A longer follow-up was needed to determine the median OS in our cohort. Second, we could not guarantee the daily dose of regorafenib during treatment because adjustments of the TKI dose by patients might not have been accurately documented in the medical records. Third, the two cohorts were enrolled respectively before and after reimbursement of regorafenib therapy began in Taiwan. Although we compared these two cohorts after propensity-score matching, selection bias due to the Will Rogers phenomenon might have occurred .The ALBI grade at the initiation of regorafenib therapy is an independent predictor of disease control, PFS, and OS. A combination of ALBI grade and AFP level can be used to stratify patients with unresectable HCC by probability of PFS and OS for sorafenib–regorafenib sequential therapy. Our findings may provide a guide to clinicians in identifying the optimal candidates for regorafenib therapy after failure of sorafenib therapy in patients with unresectable HCC.


The effect of ambient temperature on allergic rhinitis (AR) remains unclear. Accordingly, this study aimed to explore the relationship between ambient temperature and the risk of AR outpatients in Xinxiang, China.2), and nitrogen dioxide (NO2) were controlled as covariates simultaneously.Daily data of outpatients for AR, meteorological conditions, and ambient air pollution in Xinxiang, China were collected from 2015 to 2018. The lag-exposure-response relationship between daily mean temperature and the number of hospital outpatient visits for AR was analyzed by distributed lag non-linear model (DLNM). Humidity, long-time trends, day of the week, public holidays, and air pollutants including sulfur dioxide  percentile, at lag of 0–7 days : 1.05–1.67), and at the 75th (25 °C) percentile at a lag of 0–3 days , respectively. Furthermore, men were more sensitive to temperature changes than women, and the younger groups appeared to be more influenced..Both mild cold and mild hot temperatures may significantly increase the risk of AR outpatients in Xinxiang, China. These findings could have important public health implications for the occurrence and prevention of ARThe online version contains supplementary material available at 10.1186/s12889-021-10671-6. Allergic rhinitis (AR) is triggered by a spectrum of environmental allergens and is considered an immunoglobulin E (IgE) mediated type 1 hypersensitivity illnesses . FurtherIncreasing evidence have revealed that both environmental and genetic factors play important roles in the etiology of allergic diseases, including AR , 12, 13.2) levels has been widely accepted over the past decades. Due to its very large population, even a minor temperature increase could potentially cause huge health losses in China. However, the potential effect of ambient temperatures on AR has not been directly examined in the Chinese population. Consequently, we performed a time-series study to explore the lag-exposure-response relationship between the prevalence of AR-related outpatient visits and ambient temperature.The development of climate change and global warming due to increased atmospheric carbon dioxide (CO2) was approximately 5.67 million at the end of 2014. The city is located in north of Henan province, on the north side of the Yellow River. Our research area was limited to the four traditional urban districts (422 km2). Xinxiang has a typical temperate continental monsoon climate, with prevailing northeasterly winds.The population of Xinxiang, China  and Sulfur dioxide (SO2) pollutants were measured at four fixed-site stations administrated by the Xinxiang Ministry of Ecology and Environment.Daily meteorological parameters, including relative humidity, maximum, minimum, and mean daily temperatures in Xinxiang from January 1, 2015 to December 31, 2018 were collected from the China Meteorological Data Sharing Service System (http//106.37.208.235.20035/). Additionally, daily mean concentrations of nitrogen dioxide  [A generalized additive model was adopted to link the outcome (daily AR outpatient visits) and exposure (daily mean ambient temperature). Additionally, several covariates were incorporated to control for potential confounding effects as previously described . Covaria for AR) . To optiThe 1st (− 2 °C), 25th (7 °C), 75th (25 °C), and 99th (32 °C) daily mean temperature percentiles relative to the median temperature were calculated for the relative risks (RR) and 95% confidence intervals (CIs) of the AR outpatient visits at cumulative lag effects from 0 to 28 days, respectively. These measurements were applied to analyze the effects of cold, mild cold, mild hot, and hot temperatures on AR outpatient visits. Moreover, we conducted sex and age  group stratification analyses to determine their effects on the risk of AR outpatient visits. The statistical significance of differences between effect estimates of the strata by calculating the 95% confidence intervals (CI) as d errors .p value of < 0.05 were considered statistically significant.All statistical analyses were completed by DLNM and MGCV packages in R software (Version 3.3.3). A 2 and SO2 were 48.0 μg/m3 and 33.0 μg/m3, respectively.Between January 1, 2015 and December 31, 2018, there were 14,965 hospital outpatient visits due to AR in Xinxiang, China. A total of 7912 male and 7050 female outpatients (3 records missing) were collected  over different lag times. Non-significant associations between cold temperatures  and AR outpatient visits were observed for all lag times. The heat temperature  had a negative effect on AR outpatient at a lag of 0–14 days, 0–21 days, and 0–28 days. The results show that either mild cold  or mild hot  temperatures could increase the risk for AR. Of note, mild cold temperatures had slightly longer lag times  and the mild hot temperatures had slightly shorter lag times .Table Figure The exposure-response curves of daily mean temperature on AR hospital outpatients at a lag of 0–7 and 0–3 days stratified by sex are presented in Fig. The sensitivity analysis results proved that the acute effects did not change substantially with the adjustment of smoothness of time using alternative df from 4 to 10 per year  may be more sensitive to ambient temperature. To our knowledge, this was one of the few studies to directly investigate the relationship between ambient temperature and AR outpatients among Asian population.2, NO2, and PM10 increased a higher AR risk in the warm season than that in the cold season [Many studies have found positive associations between hot temperatures and AR risk –37. Simid season . Howeverd season . In thisd season .2), may affect aeroallergens through plant distribution, pollen quantity, and season [Other studies have demonstrated that ambient temperature can alter vegetation patterns spatially and temporally, and is associated with allergic symptoms in several ways , 41–43. d season . Evidencd season . In addid season , 47. Neud season .Another noteworthy finding from our study is the significant relationship between AR outpatient visits and mild cold temperatures at a lag of 0–7 days, and also between AR visits and mild hot temperatures at a lag of 0–3 days. One study conducted in Guangzhou, China, also found that the effects of warmer temperatures appeared immediately, whereas the effects of colder temperatures were delayed but persisted longer . Warmer Stronger temperature effects on AR outpatient visits were observed in males than in females, at both mild hot and mild cold temperatures. One possible explanation is that males may have participated in more outdoor work resulting in greater exposure to higher temperatures. However, other studies have shown that females are more susceptible to temperature-related health hazards , 51. ClePrevious studies have observed that adverse effects of temperature on older adults and children are often higher than average . Our stuOur findings will contribute to understanding the influence of ambient temperature on AR, and to predict the impact of increased average temperatures due to climate change on the health of individuals with allergies. In addition, as global average temperatures and the incidence of allergies continue to increase, our results will provide a basis for future studies on the effects of increased temperature specifically on AR, and may also aid in the formulation of relevant health protection strategies.Nevertheless, there are some limitations in our study. First, ecological bias was inevitable. For instance, outdoor fixed-site monitoring data were used as surrogates for individual temperature exposure levels, which may have caused measurement errors since individuals stay indoors most of the time . AlthougIn summary, mild cold and mild hot temperatures both significantly increased the AR hospital outpatient visits in Xinxiang, China. This adverse effect was especially pronounced in males and in the younger population (< 15 years of age). As the global average temperature increases, individuals with AR or other allergies may develop heat-related health problems. Our study may have important public health implications for controlling and preventing adverse health effects associated with exposure to increased air temperature.Additional file 1: Figure S1. Relative risks of allergic rhinitis associated with daily mean temperature at 75th percentile relative to median temperature at lag02 day using different degrees of freedom per year.


Bisphenol A (BPA) is a synthetic phenol extensively used in the manufacture of polycarbonate plastics and epoxy resins and a component of liquid and food storages. Among health disorders potentially attributed to BPA, the effects on metabolism have been especially studied. BPA represents a hazard in prenatal life because of its presence in tissues and fluids during pregnancy. Our recent study in rats fed with BPA showed a placental increase in glucose type 1 transporter (GLUT-1), suggesting a higher uptake of glucose. However, the role of BPA on GLUT transporters in pregnant women with metabolic dysfunction has not yet been investigated. In this study, placental tissue from 26 overweight (OW) women and 32 age-matched normal weight (NW) pregnant women were examined for expression of GLUT1 and GLUT4. Placental explants from OW and NW mothers were exposed to BPA 1 nM and 1 μM and tested for GLUTs expression. The data showed a different response of placental explants to BPA in GLUT1 expression with an increase in NW mothers and a decrease in OW ones. GLUT4 expression was lower in the explants from OW than NW mothers, while no difference was showed between OW and NW in placental biopsies for any of the transporters. Bisphenol A (BPA) is a synthetic phenol extensively used in the manufacture of polycarbonate plastics and epoxy resins and a component of many everyday products such as liquid and food storages , detergents, and medical and dental devices. Consequently, the human population is continuously exposed to BPA, as revealed by its presence in the environment and populations in general ,2,3,4. BObesity is a global health concern that has increased in the last decades . ObesityHowever, the role of maternal obesity in BPA response during pregnancy has not been elucidated. In this study, we examined healthy pregnant women with normal Body Mass Index (BMI)  (CTRL) and women with high BMI (overweight) (OW). Placental tissues after term delivery were examined for expression of glucose transporters (GLUT) 1 and 4 and for the in vitro response to BPA.This study was based on our previous data in rats fed with a diet containing BPA for a period of a month (virgin state) plus 20 days during pregnancy. The study showed changes in fetal and placental weight leading to higher fetal growth and an increased placental expression of GLUT-1. Upregulation of GLUT1 expression and glucose transfer was also shown in human trophoblast cells . GlucoseBased on the obesogenic effect of BPA and its impact on GLUT1 placental transport, we hypothesized that maternal metabolic dysfunction and exposure to BPA in a pregnant woman during human pregnancy could interfere with placental glucose transport via GLUTs modulation.n = 32) and OW (n = 26) pregnancies were comparable for maternal and gestational age at delivery. As expected, pre-pregnancy (p < 0.001) and delivery BMI (p < 0.001), plicometry (p < 0.001) and mid-upper arm circumference (p < 0.001) resulted significantly increased in OW compared to the CTRL pregnancies. In contrast, gestational weight increase was significantly reduced in OW compared to control patients (p < 0.001). The descriptive results of the pre-pregnancy BMI categories indicated that 51.8% and 48.2% of participants started pregnancy in an overweight and obese category, respectively. Before 14 weeks of gestation, triglycerides levels were significantly increased in OW compared to CTRL (p = 0.018), while during the third trimester, OW patients presented increased glycemia (p = 0.006) and systolic blood pressure values (p = 0.012) compared to the controls. Gestational Diabetes Mellitus (GDM) was more frequent in OW (37%) compared to CTRL (12.5%) (p = 0.027). Importantly, all GDM patients were treated with diet therapy. Even though no significant differences in birth and placental weights were reported between groups (p > 0.05), a significantly increased percentage of LGA fetuses was described in OW vs. CTRL (p = 0.024).The clinical features of the studied population are reported in p > 0.05, 1.61-Fold Decrease) and GLUT4  mRNA levels in placentae obtained from normal (NW) and overweight (OW) women  and GLUT4  did not reveal a significant difference between NW and OW placentae  women a,c. Theslacentae b,d.p = 0.0872; Fold Change 1.537).To focus on the expression of glucose transporters in the chorionic epithelium from NW and OW women, we cultured chorionic villous explants for 48 h in a medium containing a physiological concentration of glucose. qPCR and Western blot analysis for GLUT1 a,b showep = 0.0847; Fold Change 0.7383)  in placenta explants obtained by the women with high BMI compared to the normal ones  c. Moreovmal ones c,d.p < 0.05; Fold Change 2.200) in placenta explants by BPA treatment. Similarly, the effect was obtained at 1 nM, while 1 μM was ineffective. No significant changes were observed in GLUT1 mRNA nor in GLUT4 protein and gene expression . As we observed for the explant from normal weight women, the one from overweight pregnancy also did not demonstrate any evident alteration in the GLUT4 gene and protein expression.The placenta from women with a high BMI showed an altered metabolism . TherefoIn the present study, we demonstrated that, while no differences in GLUTs expression were detected between normal weight (NW) and overweight (OW) placentae, differences were observed in cultured placental explants and in response to BPA. In particular, GLUT1 was increased in BPA-treated NW villous explants and decreased in OW ones. GLUT4 was lower in OW than in NW villous explants and was not regulated by BPA.The placenta is the fundamental organ in maintaining pregnancy and assuring fetal development and growth. While the placenta has adapted, over the millennia, to protect the fetus from environmental threats , it is defenseless against chemicals that are increasingly produced by humans. Thus, the fetus is inevitably exposed to many of the chemicals that come from the environment and pass through the placenta, such as BPA. The placenta can also be adversely affected by these substances. Specifically, BPA alters the secretion of human chorionic gonadotropin (hCG) and reduces cell migration and invasion of the human trophoblast ,19. AccoA pregnant mother may have been exposed to BPA for long periods of her life and suffer from the effects of this chemical, including metabolic dysfunctions . These eAccording to the Developmental Origins of Health and Disease (DOhad), maternal diet, environmental insults, and lifestyle can interfere with the fetus-placental development, thus setting the conditions for future diseases later in life . In thisGlucose is the main source of nutrients and energy for the fetus and since the fetus is not able to carry out the gluconeogenesis process, the sugar is transported from the maternal to the fetal blood thanks to specific transporters in the placental barrier ,27. AlteAmong the characterized glucose transporters, GLUT1 and GLUT4 are the most important in regulating glucose exchange at the placental level. GLUT1 is considered the primary placental glucose transporter . Its expPre-pregnancy BMI is highly correlated with GDM onset ,34,35. CThe GDM patients included in the present study were well controlled by diet and, even if a significant increase in glycemic levels was detected during the third trimester in OW compared to NW women, they were within physiological ranges.Inconsistent results exist for GLUT expression and activity in GDM patients probably due to differences in criteria for GDM diagnosis as well as the complexity of the disease and the several factors that could impact placental function . For theAs previously described, BPA is an “obesogenic” factor. We, therefore, studied the expression of glucose transporters in BPA treated villous explants from NW and OW women. First of all, we observed, in explants obtained from NW women, an increase in GLUT1 expression as a result of exposure to BPA. The increase in GLUT1 levels was observed at low doses of the endocrine disrupter , confirming data by Benincasa et al. and Rajakumar et al. ,47. On tWhile supporting previous data on the effect of BPA in upregulating placental expression of GLUT1, our study shows for the first time to our knowledge that the placental response to BPA in mothers with metabolic dysfunction results in a reduction rather than an increase in GLUT1 physiological levels. Given the importance of glucose as a major source of nutrients and energy for the fetus, a worsening of its transport across the placenta as it occurs in overweight mothers can be detrimental to the fetal growth and development. On this basis, a maternal condition of overweight/obesity appears to be a risk factor for the protection of the fetus from contamination by environmental chemicals such as BPA.There is an increasing number of overweight/obese women of reproductive age. Maternal obesity is affecting the continuation of pregnancy, premature birth, abortion, congenital abnormalities, fetal macrosomia, and a higher incidence of cardiovascular metabolic disorders in their offspring. The obese maternal environment is characterized by hyperlipidemia and an excessive state of inflammation as well as oxidative stress compared to a pregnant woman of normal weight . MoreoveFurther studies will focus on elucidating the mechanisms and pathways involved in the different placental responses between OW and NW mothers. It will also be important to examine the different impacts of BPA on glucose transport in large or small for gestational age fetuses.This study was conducted according to the principles expressed in the Declaration of Helsinki. The study was approved by the Institutional Review Board of O.I.R.M. S. Anna Hospital and “Ordine Mauriziano di Torino”  . All patients were recruited at O.I.R.M S. Anna Hospital  and provided written informed consent for the collection of samples and subsequent analysis.n = 13) and NW (n = 12) dropouts were excluded, leaving 26 OW and 39 NW pregnant women for the statistical analysis. Before 14 weeks of gestation and after 27 weeks of gestation, maternal venous blood samples (5 mL) were collected into Vacutainer tubes with and without anticoagulant. Serum and plasma were separated by centrifugation (3000× g rpm at 4 °C for 20 min) and stored at −20 °C until assayed. For each woman, hemochrome, standard coagulation, glycemia, triglycerides, total cholesterol, High-Density Lipoprotein Cholesterol (HDL-C), Thyroid-Stimulating Hormone (TSH), Free Thyroid Hormones 4 (FT4), vitamin D, and homocysteine tests were measured using an autonomic analyzer.From June 2017 to June 2020, 39 overweight women (OW) and 44 age-matched normal weight women  with singleton spontaneous pregnancies were recruited and interviewed before 14 weeks of gestation. OW  or Pourcelot ratio, defined as peak systolic flow minus peak end diastolic flow divided by peak systolic flow. According to the literature, an abnormal uterine artery Doppler FVW was defined as a mean (of the two uterine arteries) RI of ≥0.58; a further, more restrictive cut-point (≥0.62) was also tested. Both cut-points are standardized references and are applied to gestational ages of at least 26 weeks. The uterine flows are not physiologically variable after the gestational age, and not age-adjusted . Umbilic2: underweight; BMI 18.5–24.9 kg/m2: normal weight; BMI 25.0–29.9 kg/m2: overweight; BMI 30.0–34.9 kg/m2: class I obesity; BMI 35.0–39.9 kg/m2: class II obesity; and BMI ≥ 40.0 kg/m2: class III obesity [Overweight and Obesity were diagnosed in categories of body mass index (BMI) as defined by the World Health Organization: BMI < 18.5 kg/m obesity .GDM diagnosis was performed as previously described by Nuzzo et al. . BrieflyAccording to the Italian neonatal anthropometric reference charts , newbornPregnancies with congenital malformations, chromosomal disorders (in number or structure), evident intra-uterine infections, as well as patients with diabetes, infections, chronic hypertension, kidney disease, or smoke and/or alcohol abuse were excluded.n = 6) and overweight placentae (n = 6) were processed. Amniotic membranes were mechanically removed, and placental specimens were washed in cold phosphate-buffered saline (PBS) solution to eliminate excess blood. Explants cultures were then performed as described by Caniggia et al. [2 to equilibrate overnight. Explants were then removed from the culture media and placed in 200 μL of medium with different BPA concentrations: 1 nM and 1 μM. Explants in basal culture medium were used as controls. Finally, control and treated explants were collected after 48 h and immediately frozen for RNA and protein isolation. The supernatants were centrifuged and used for lactate dehydrogenase activity (LDH). This model allowed us to determine the sequence of molecular events in tissues characterized by conserved physiological pathways, thus avoiding biases due to previous existing pathological anomalies.Biopsies from normal weight  according to the manufacturer instructions. Genomic DNA contamination was removed by DNase I digestion before RT-PCR. RNA was quantified using a NanoDrop Microvolume Spectrophotometer , and cDNA was generated from one µg of total RNA using a random hexamers approach and RevertAid H Minus First Strand cDNA Synthesis kit . qRT-PCR reactions were run in the StepOne™ Real-Time PCR System instrument . Gene expression levels of GLUT1  and GLUT4  were determined by Real-Time PCR using specific TaqMan commercially available inventoried primers and probes. mRNA levels were normalized using endogenous 18S  and GAPDH ,  as internal references. The expression level of the selected genes was calculated by the 2−ΔΔCt  .vol/vol) Triton X-100; 1% (wt/vol) sodium deoxycholate; 0.1% (wt/vol) SDS; 1 mM Na2VO3; 25 mM NaF; and protease inhibitors cocktail  and centrifuged at 15,000× g at 4 °C for 15 min. Protein concentrations of the supernatants were then determined using Bradford protein assay .Total proteins from placental biopsies or chorionic villous explants were homogenized in RIPA buffer  analyses were performed as previously described . Briefly®). HRP-conjugated secondary antibodies were obtained from BioRad (BioRad Laboratories Inc.) and used at a concentration of 1:3000.Primary antibodies employed in Western blotting include mouse monoclonal anti-beta Actin (ACTB) , mouse monoclonal anti-GLUT4 , rabbit polyclonal anti-GLUT1 , and the comparison between different groups was made with a Chi-Square Test. Statistical tests were carried out using SPSS Version 27 statistical software or GraphPad Prism 7.0 software . Significance was accepted at p < 0.05.Data are represented as mean ± ES for parametric and as median and range for non-parametric data. Comparison among groups was performed by analysis of variance. Bonferroni’s test was used for post hoc comparisons between two groups of parametric data, while Kruskal–Wallis test was used for non-parametric data. When two groups were compared, an Unpaired Student’s


Abnormal maternal lipid concentrations are associated with increased risk of preeclampsia. However, previous studies mainly focused on fasting lipid concentrations, scarce data have been published on the relationship between postprandial triglyceride (TG) concentrations in the second trimester and the risk of preeclampsia. Our aim is to evaluate the potential of triglyceride (TG) concentrations at the time of oral lipid tolerance test (OLTT) measurement in the second trimester to predict preeclampsia and to elucidate the lipid metabolic changes related to these diseases.This is a prospective cohort study of Pregnant women at 12–24 weeks of gestation undergone an OLTT in a university affiliated hospital between May 2019 and January 2020. Data were stratified into binaries according to the OLTT results. The receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off points of TG, HDL-C, LDL-C, sd-LDL, FFA, and BG for predicting preeclampsia.438 pregnant women were recruited to undergo an OLTT at 12–24 weeks of gestation. Among these, 24 women developed preeclampsia and 414 women remained normotensive. Women who subsequently developed preeclampsia had higher concentrations of 4-h postprandial TG than those who remained normotensive. In the linear logistic regression analyses of potential confounding factors, mid-trimester 4-h postprandial TG concentrations at the time of OLTT measurement were significantly higher in preeclamptic cases than in controls.Dyslipidemia in the second trimester of pregnancy, particularly postprandial hypertriglyceridemia, appears to be associated with an increased risk of preeclampsia. Mid-trimester 4-h postprandial TG concentration at the time of OLTT measurement may be a potential predictive marker of preeclampsia.Trial registration Data of registration: 2018/10/15. Date of initial participant enrollment: 2019/05/01. Clinical trial identification number: chiCTR1800018884. URL of the registration site: http://www.chictr.org.cn/showproj.aspx?proj=25526. Data sharing information: The data including individual participant data, detailed study protocols, statistical analysis plans will be shared upon request to the corresponding author.The online version contains supplementary material available at 10.1186/s12967-022-03261-6. Preeclampsia is a multifaceted condition, and its underlying etiologies are still poorly defined. Preeclampsia is associated with high morbidity and mortality; it affects 5%-7% of all pregnant women and is responsible for > 70,000 maternal and 500,000 fetal deaths annually worldwide . It is aThe increased risks of preeclampsia are associated with maternal obesity, polycystic ovarian syndrome, and pre-existing and gestational diabetes mellitus (GDM). These are all syndromes of maternal metabolic disturbance and, to varying degrees, abnormal maternal lipid concentrations . AccordiDuring pregnancy, the lipid concentrations increase gradually, resulting in a physiological hyperlipidemia state. Previous studies mainly focused on fasting lipid concentrations, neglected that we are in a postprandial state in most of the day , 7. PostThe postprandial response to an oral lipid tolerance test (OLTT) is a better metabolic challenge to emulate nutrient overload in comparison to an oral glucose tolerance test (OGTT). OLTT is used for screening dyslipidemia . AlthougThis prospective cohort study enrolled 506 pregnant women who attended the prenatal examination clinics in Shanghai General Hospital between May 2019 and January 2020. In the present analysis, we excluded one woman who had a miscarriage in the second trimester, and 67 women who met the following exclusion criteria: (1) multiple pregnancy; (2) unnatural pregnancy; (3) polycystic ovarian syndrome, thyroid disease, diabetes, heart disease, hypertension, or hyperlipidemia; (4) combined with autoimmune diseases; (5) combined with intrahepatic cholestasis of pregnancy or viral hepatitis; and (6) fasting TG concentrations > 5.6 (mmol/L). The remaining 439 women were included in the final analysis  < 2.4 mmol/L(median); 4 h TG < 3.47 mmol/L(median)] and high binary  groups. The women were also categorized into the following two groups according to the blood pressure levels and the presence or absence of proteinuria: normal and preeclampsia groups  concentrations were measured enzymatically. Fasting insulin (FINS) and serum lipid  concentrations were determined by chemiluminescent assays. Hemoglobin A1c was determined by high-performance liquid chromatography. Homeostasis model assessment for β cell function (HOMA-β) and homeostasis model assessment for insulin resistance index (HOMA-IR) were calculated to evaluate β cell function and insulin resistance using the following formulas: HOMA‐β = 20 × FINS(μU/mL) / FPG (mmol/L) − 3.5) and HOMA‐IR = FPG (mmol/L) × FINS (μU/mL) / 22.5.Data were expressed as the mean ± standard deviation for normally distributed variables and as the median with the interquartile range for skewed data. To determine the differences between the groups, we conducted an analysis of variance or the Kruskal–Wallis test for continuous variables and a chi-square test for categorical variables. Least significant difference tests were used to perform pairwise comparisons between two groups. The receiver operating characteristic (ROC) curve analysis was conducted to determine the optimal cut-off points of TG, HDL-C, LDL-C, sd-LDL, FFA, and BG for predicting preeclampsia. Each optimal cut-off point was assessed by searching for the maximum value of sensitivity + specificity–1 (Youden index). The area under curve (AUC) was calculated to evaluate the predictive powers. Logistic regression analysis was performed to determine whether the elevated postprandial TG concentrations during mid-gestation were independently associated with preeclampsia. Statistical significance was set at p < 0.05. Statistical analyses were performed using SPSS .2, p < 0.01), higher FPG concentrations , higher HOMA-IR (1.60 (1.14–2.23) versus 1.23 (1.01–1.66), p < 0.01), greater neonatal weight , and lower HDL-C concentrations  than the low fasting TG binary group (Table There were significant differences in the metabolic levels during pregnancy between the high and low fasting TG groups. The high fasting TG binary group had a higher pre-pregnancy body mass index (BMI) (22.39 ± 2.11 versus 20.82 ± 1.78 kg/mp < 0.01), higher FPG concentrations , and lower HDL-C concentrations , and lower LDL-C concentrations  than the low 4-h TG binary group  versus 1.23 (0.96–1.71), .23 versuAmong all enrolled 438 patients, 24 patients developed preeclampsia. Maternal plasma lipid and lipoprotein concentrations are shown in Table p = 0.045).Table p = 0.025) for the high TG binary group, and the adjusted OR was 5.561  when considering for age, gravidity, parity, pre-pregnancy BMI, and TC concentrations (Table p = 0.026) was a risk factor for preeclampsia. However, no association was found between other factors and preeclampsia.To determine whether the elevated 4-h postprandial TG concentrations during the second trimester of pregnancy was a predictive biomarker for preeclampsia, the odds ratios (ORs) for preeclampsia in women with different TG concentrations during the second trimester were calculated. First, compared to the low 4-h TG binary group at 12–24 gestational weeks, the crude OR for preeclampsia was 1.471  [Our findings are consistent with the results of the few available prospective cohort studies on maternal non-fasting plasma lipid and lipoprotein concentrations in preeclamptic and normotensive pregnancies , 16. We = 0.004) . The rea= 0.004) .Although, the temporality, wherein 4-h postprandial hypertriglyceridemia clearly precedes the onset of preeclampsia, leads us to generate the hypothesis that we may be able to change the natural history of the disease if we intervene early by lowering the postprandial TG concentrations. Maternal lipids offer a potential therapeutic target, and it is worth noting that the current treatments for diabetes in pregnancy, including dietary and lifestyle changes as well as pharmacotherapy, all alter not only maternal glucose but also maternal lipids , 18, 19.Women with elevated lipid concentrations are more likely to have preexisting endothelial dysfunction that worsens as a result of the physiological burden of pregnancy; this condition may be further exacerbated by increased maternal vascular inflammation . This waThe sensitivity of the prediction of preeclampsia using 4-h postprandial TG concentration at the time of OLTT measurement in this study (72.7%) was markedly higher than that of previously published prediction of preeclampsia based on clinical markers such as mean arterial pressure, maternal age, and uterine artery pulsatility index in a cohort of women at 11 + 0 to 13 + 6 gestational weeks (38.5%)  and in aThe link between postprandial hypertriglyceridemia and preeclampsia was still unclear. However, renin-angiotensin system (RAS) may play a role in this process. RAS has been recognized as a ubiquitous system for homeostasis and pathologies. The perturbation of RAS can cause hypertension and congestive heart failure, obesity, neural diseases, diabetes, and hepatic fibrosis , 25. AngIt has been reported gestational glucose intolerance can be classified into two subgroups as insulin resistant group and insulin sensitive group, which are at differential risk for adverse outcomes . SimilarThe major strength of our study was its prospective design with complete follow-up of 438 women with OLTT measurement. This study design more accurately reflects the predictive power of 4-h postprandial TG compared to a case–control design. Our high participation (86.6%) and follow-up (99.5%) rates minimized the likelihood of selection bias, which may affect the reported results. Second, the fasting and 4-h postprandial blood lipid concentrations obtained after a unified fat meal in the second trimester suggested that the disordered plasma lipid concentrations precede preeclampsia. The unified standard fat meal and blood sampling collection time can avoid lipid data deviation. Third, the exclusion of pregnant women with high risk factors for metabolic syndrome made the results more convincing. Fourth, compared to the fetus in the first trimester, the fetus in the second trimester grows rapidly and needs more energy. The mother gradually switches to a catabolic condition resulting in an increased breakdown of lipid. Therefore, detecting postprandial lipid concentration changes (the ability of lipid metabolism) in the second trimester is more sensitive. Finally, we used the logistic regression to adjust for a number of confounders to obtain a conclusion.Several important limitations must be considered when interpreting the results of our study. First, our study included a limited number of cases, which is difficult to overcome given the low incidence of these disorders. Our relatively small number of patients with preeclampsia hindered us from making inferences from some of our analyses. Further studies involving multiple centers and a larger number of patients are necessary in order to validate our findings. In addition, although we compared many potential confounders, we cannot exclude the possibility of the other confounding factors from unmeasured covariates.In conclusion, the results of our study served to highlight the importance of 4-h postprandial TG at the time of OLTT measurement in the second trimester as a possible predictive marker of preeclampsia. Moreover, dyslipidemia, particularly 4-h postprandial hypertriglyceridemia, may be of etiologic and pathophysiologic importance in women who developed preeclampsia. Our data may contribute to the development and evaluation of behavioral and medical interventions aimed at reducing the occurrence of these disorders. On the other hand, preeclampsia appears to be a multi-etiological syndrome with heterogeneous biologic pathways.Additional file 1: Table S1. Demographic and metabolic characteristics of all pregnant women at 12-24 gestational weeks who were categorized into binaries according to their fasting TG concentrations at the time of OLTT measurement (GDM cases removed). Table S2. Demographic and metabolic characteristics of all pregnant women at 12-24 gestational weeks who were categorized into binaries according to their 4-h postprandial TG concentrations at the time of OLTT measurement (GDM cases removed). Figure S1. ROC curve for FTG and 4h-TG to predict preeclampsia .


Recently adopted mini-thoracotomy approach for surgical aortic valve replacement has shown benefits such as reduced pain and shorter recovery, compared to more conventional mini-sternotomy access. However, whether limited exposure of the heart and ascending aorta resulting from an incision in the second intercostal space may lead to increased intraoperative cerebral embolization and more prominent postoperative neurologic decline, remains inconclusive. The aim of our study was to assess potential neurological complications after two different minimal invasive surgical techniques for aortic valve replacement by measuring cerebral microembolic signal during surgery and by follow-up cognitive evaluation.Trans-cranial Doppler was used for microembolic signal detection during aortic valve replacement performed via mini-sternotomy and mini-thoracotomy. Patients were evaluated using Addenbrooke’s Cognitive Examination Revised Test before and 30 days after surgical procedure.p = 0.003), heavier  and had higher body surface area . Surgery duration was longer in mini-sternotomy group compared to mini-thoracotomy . There were no differences between groups in microembolic load, length of ICU or total hospital stay. Total microembolic signals count was correlated with cardiopulmonary bypass duration . Addenbrooke’s Cognitive Examination Revised Test score decreased equivalently in both groups (p = 0.630) .A total of 60 patients were recruited in the study. In 52 patients, transcranial Doppler was feasible. Of those, 25 underwent mini-sternotomy and 27 had mini-thoracotomy. There were no differences between groups with respect to sex, NYHA class distribution, Euroscore II or aortic valve area. Patients in mini-sternotomy group were younger (60.8 ± 14.4 vs.72 ± 5.84, There is no difference in microembolic load between the groups. Total intraoperative microembolic signals count was associated with cardiopulmonary bypass duration. Age, but not micorembolic signals load, was associated with postoperative neurologic decline.clinicaltrials.gov, NCT02697786 14.The online version contains supplementary material available at 10.1186/s13019-021-01509-8. Degenerative aortic valve stenosis is the most common valvular cardiac disease in developed countries and affects more than 4% of North American and European citizens , 2. SurgDuring the last decade, a conventional full sternotomy approach for surgical AVR has been widely replaced by a less aggressive mini-sternotomy (MS) access due to multiple benefits, such as reduced postoperative morbidity, mortality, and pain, while providing faster recovery, a shorter hospital stay, and better cosmetic results , 11. FurHowever, while such surgical approach is less invasive with better cosmetics results than MS, concerns have been raised by a number of clinicians that a limited exposure of the aorta and the heart achieved by an incision through a second intercostal space may potentially lead to incomplete heart and aorta de-airing at the end of the procedure, increasing the risk for cerebral microembolization .Since postoperative neurological complications due to microembolization can significantly influence patient’s general condition and postoperative quality life, the objectivization of the incidence of microembolization after MT AVR would be of outmost importance in order for the clinicians to offer their patients the best suited surgical AVR with an optimal ratio between minimally invasiveness and perioperative complications. Thus, the aim of our study was to compare intraoperative MES between well accepted MS approach and a novel, less aggressive MT access for surgical AVR and to test the relationship between intraoperative microembolic signals (MES) and postoperative cognitive decline in both groups of patients.ClinicalTrials.gov (NCT02697786) before patient recruitment was started.This was a prospective, observational; single-center clinical trial was carried out at the Clinical Department of Anesthesiology and Perioperative Intensive Therapy, Division of Cardiovascular Anaesthesia and Intensive therapy, and Clinical Department of Cardiovascular Surgery at the University Medical Centre in Ljubljana (Slovenia), between March, 2016 and December, 2018. Approval for the trial was obtained from the National Medical Ethics Committee  and a written informed consent was obtained from each patient before enrolment into the study. The trial was conducted in accordance with the Helsinki Declaration and registered at Power of study calculation was based on the assumption that the absolute number of MES would be around 100/procedure (SD ± 25 MES) [α) of 5%, the ClinCalc sample size calculator  defined our need as 25 patients per group, indicating a total of 50 patients across the two treatment groups. Considering an estimated 10% drop-out rate due to a poor trans-temporal window for transcranial Doppler (TCD), 60 patients were recruited to avoid risk of low power. 25 MES)  and any 2, mean gradient>_40 mmHg and indexed aortic valve area less than 0,6 cm2/m), who were referred to Clinical Department of Cardiovascular Surgery at the University Medical Centre in Ljubljana for mini-AVR, were eligible for recruitment.Patients> 18-years-old, II or III class according American Society of Anesthesiology (ASA) classification, diagnosed with isolated severe high-gradient aortic stenosis according to ESC/EACTS 2017 guidelines  of 70–75 mmHg in the perioperative and later throughout the postoperative course. In clinically stable condition, patients were transferred to the cardiovascular ICU, sedated and intubated on mechanical ventilation. Postoperative pain was treated with a catheter into the wound, filled with ropivacaine, as well as intravenous paracetamol and metamizole. Weaning from mechanical ventilation was performed when extubating criteria were fulfilled, meaning: an awake and cooperative patient, with end tidal CO2of 4–6 kPa, haemoglobin oxygen saturation > 96% and hemodynamically stabile with normal core temperature. When patients were without vasopressors/ inotropes, in good general condition, and without signs of delirium or infections, they were transferred to a step-down unit and sequentially discharged from the hospital. Patient follow-up after discharge from the hospital was conducted by telephone 30 days after surgery, with the focus on late postoperative morbidity and mortality.All patients in the OR received standard and extended hemodynamic monitoring, including electrocardiogram, arterial cannula for invasive hemodynamic measurements , and central venous catheter  in the jugular vein to monitor cardiac index, systemic vascular resistance index, and central venous pressure. Intraoperative neuromonitoring included near infrared spectroscopy (NIRS)  to follow cerebral oxygenation and bispectral index  to follow the depth of anaesthesia. Patients were intubated with fentanyl 5–10 μg/kg, propofol 1–2 mg/kg, and rocuronium bromide 0.6 mg/kg, and were mechanically ventilated with a tidal volume 6–8 mL/kg ideal body weight. Patients were operated on under total intravenous anaesthesia with propofol, according to bispectral index values, for the depth of anaesthesia, and remifentanil (0.3–0.6 μg/kg/min). After sedation, TCD probes were placed. After setting the baseline values on hemodynamic and cerebral monitoring tools, patient’s hemodynamic parameters were recorded continuously during surgery and acid base management was performed according to the pH stat regimen. An aortic valve was replaced during CPB with non-pulsatile flow of 2.2 to 2.4 L/mmax) through the middle cerebral artery during surgery was also recorded.Bilateral monitoring of the middle cerebral arteries was performed using multi-range, multifrequency 2 MHz TCD probes . Signals were analyzed on-line and recoded. The back scattered embolic high intensity transient signals (HITS) were counted –15. HITS2 was insufflated into the cardiothoracic wound through a gas diffuser  that provides an almost 100% CO2 atmosphere. CO2 was insufflated with flow set on 2 L/min. Selection of prosthetic valves was made according to patient age: in adults > 65 years we used biological valves and for younger than 65 years mechanical valves [All minimally invasive surgical procedures were performed by three experienced cardiac surgeons . Patients were divided into two groups, MS and MT groups. In the MS group, classical J-shaped upper mini-sternotomy into the third intercostal space was performed . In the l valves .g for 10 min) and aliquots were stored at − 20 °C until analysis. Serum IL-6 at base line and 6 h after surgery were measured by chemiluminescent immunometric assays using Immulite automated analyser .For all laboratory analyses, blood samples were collected without additive. Serum was separated from clotted blood by centrifugation (1500×Addenbrooke’s Cognitive Examination Revised Test (ACE-R) was performed in each patient before surgery and up to 30 days after. ACE-R is a diagnostic and screening instrument comprised of 5 domains: attention and orientation, memory, verbal fluency, language, and visuo-spatial abilities , 21.http://www.euroscore.org/calc.htmL). Furthermore, intraoperative data  and postoperative period , along with postoperative complications like bleeding, infections, hemodynamic instability, worsening of brain, kidney, respiratory, and liver function, including 30-day mortality were documented.Preoperative data was collected  from medical documentation. Surgical risk assessment was performed on the basis of EuroSCOREII  and IL − 6 levels.Other pre-specified outcome measures included duration of postoperative mechanical ventilation, length of ICU stay, use of inotropic/vasoactive drugs, length of in-hospital stay, and 30-day mortality.Demographic and clinical baseline data were summarized according to mean and standard deviation for metric variables, or to absolute value and frequency for categorical variables. Mann-Whitney U and Chi-square tests were used, respectively.p-value correction for multiple testing was not performed.Mixed model and repeated measures ANOVA were used to compare MES load between different time points and groups. Based on theoretical expectations, we created multivariable linear regression models for selected dependent variables: level of IL-6 tested 6 h after surgery, maximal deviation of NIRS oxygenation value from the baseline during surgical procedure, maximal median cerebral artery blood flow velocity during procedure, length of ICU stay (days), total duration of hospital stay (days), results of mental state examination after surgery, and the total intraoperative MES count. Binomial logistic regression was used to test the correlation of variables with postoperative incidence of delirium. The natural logof post-surgery IL-6 levels was used in all models to follow normality distribution, while IL-6 baseline levels were positive or negative. Because the nature of the study was the search for possible correlated indicators on selected dependent variables rather than hypothesis-driven, the P-values under 0.05 were considered statistically significant.The software package: A Language and Environment for Statistical Computing  for statistical computation was used. p = 0.458). There was also no difference in NYHA class distribution between the MS and MT groups . Compared to the MT group, patients in the MS group were younger , heavier , (Table p = 0.013).In total, 60 patients were recruited for the study, but eight patients were excluded due to poor trans-temporal window for TCD. We were left with 52 patients who underwent elective AVR, 25 assigned to the MS group and 27 to the MT group. Patient demographic characteristic and aortic valve pathology are presented in Table In the MS group, 11 mechanical valves and 14 bioprosthetic valves were implanted, while in the MT group, all implanted valves were bioprosthetic Table .Table 2p = 0.91167) . The total intraoperative MES count was associated with CPB duration , the 2nd period (from aortic cannulation until start of CPB) , the 3rd period  and during the 6th period .The cardiac index was lower in the MT compared to MS group at different periods of surgery: during the 1st period (from skin incision until aortic cannulation) (2.100 ± L/min/mp = 0.034) compared to the MS group, but no differences in lengths of ICU or in-hospital stays.There were no statistically significant differences in postoperative complications between the groups Table . Overallp < 0.05). There was no difference in change of ACE-R score between groups (p = 0.630); total ACE-R score decreased equivalently in the MS  and MT group .Compared to preoperative values, the total ACE-R score decreased postoperatively from 85.13 ± 5.41 to 82.11 ± 5.987 points , CPB duration (min), cell saver amount (L), CRP 6 h after surgery, and total number of MES during surgery, revealed that MES count was an independent predictor of IL-6 level 6 h after surgery  measured by TCD during surgery was an independent predictor of delirium development as measured by multiple linear regression including surgery duration, ACE-R after surgery, intraoperative NIRS deviation, and inclusion in MS/MT group , Surgery and CPB duration each independently predicted ICU stay , which was decreased during the MT procedure, probably due to reduced venous return from pulling the pericardium to visualize the aorta and the heart. The reduction of cardiac output during surgery had no impact on patient outcomes in our study.In our study, maximal peak systolic velocity in middle cerebral artery blood flow velocity during cardiopulmonary bypass was an independent predictor of postoperative delirium. Ina recent study, Thudium at al . clearlyPostoperative delirium is independently associated with long-term mortality  and neurWe found that age was associated with postoperative neurological decline, which is the most common adverse outcome following cardiac surgery . These tOn the other hand, an observational study of 131 patients that included a healthy control group and two groups of patients with coronary artery disease (managed with either CABG or percutaneous coronary intervention) failed to show any significant differences in neurocognitive performance after 1 year of follow-up . The stuWe have found an independent relationship between postsurgical proinflammatory IL-6 levels and MES counts during surgery, but IL-6 levels were also independently associated with surgery length. In open-heart surgery, the contact of blood with artificial surfaces of the circuits of the CPB machine has been shown to cause perioperative SIRS . In thisOur study had at least three major limitations. The first was that the study was observational, and patients were not randomized, so there were some age and weight differences between the MS and MT groups that could influence the results. However, previous studies have not shown any difference in age and weight between MS and conventional full sternotomy for AVR , 25, 27.To conclude with, our results indicate that MT represents a safe and efficient treatment strategy for surgical AVR yielding comparable results to MS approach in regards to intraoperative MES load. In our cohort of patients, MES load was namely associated only with CPB duration and not with surgical approach to the ascending aorta, clearly showing that less aggressive AVR performed through the second intercostal space can be safely performed even with limited exposure of the ascending aorta and the heart during the surgery. Since in our group of patients the postoperative neurologic decline was associated only with age, we were not able to confirm the relationship between postoperative neurological decline and intraoperative MES load.Additional file 1 Table S1. Microembolic signals, average maximal velocity in arteria cerebri media during surgery and values of serum IL 6. Table S2. Multiple linear regression model, showing predictors for total intraoperative count of microemboli as a dependent value. Table S3. Multiple linear regression with natural logarithm of IL 66 h after surgery as a dependent variable. Table S4. Binominal logistic regression with postoperative occurrence of delirium as a dependent variable. Estimates represent the log odds of “Delirium = 1” vs. “Delirium = 0”. Table S5. Multiple linear regression with ICU stay (days) as a dependent variable. Table S6. Result of postoperative cognitive function testing (number of points) as a depended variable in multiple linear regression model.


The surgical management and outcomes of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) have been reported in limited sample size, and there remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). The aim of the study was to analyze the outcomes of the patients with RCC with VTT in our institution and identify the independent prognostic factors.Patients with RCC with VTT were enrolled for the study from February 2015 to December 2018. All patients underwent RNTE. Clinical data were compared using Mann-Whitney U test and the chi-square test for continuous and categorical variables respectively. Survival analysis was estimated using the Kaplan-Meier method. Univariable and multivariable survival analyses were performed using Cox regression model.P = 0.016), metastasis at surgery (P = 0.034), tumor necrosis (P = 0.023) and sarcomatoid differentiation (P < 0.001) were demonstrated as independent significant risk factors on multivariable analysis.121 patients (91 men & 30 women) were identified with a median age of 60 years. VTT level was 0 in 25 patients, I in 20, II in 50, III in 12 and IV in 14. The median follow-up time was 24 months. During the follow-up period, 51 (42%) patients died and 69 (57%) patients experienced recurrence or metastasis. The 3-year and 5-year over-all survival (OS) were 58 and 39%. Among the several factors examined, positive lymph node (The OS was poor for patients with RCC with VTT. Rather than VTT level, positive lymph node, metastasis at surgery, tumor necrosis and sarcomatoid differentiation were independent prognostic predictors. One of the biological characteristics of renal cell carcinoma (RCC) is extending into the venous system, a so-called venous tumor thrombus (VTT). It has been observed that VTT occurs approximately in 4 to 10% patients with RCC , includiMany centers have reported their experience on the treatment of RCC with VTT, which may guide therapy and patient counseling. Kaplan et al.  reviewedThe records of 185 patients treated with radical nephrectomy and thrombectomy in our center from February 2015 to December 2018, were retrospectively evaluated. According to the inclusion criteria, only patients whose histopathology diagnosis were RCC were enrolled. The flow chart of patient enrollment was demonstrated in Fig. Clinical information, including patient demographics, anaesthesia and surgical situation, as well as cancer and pathological characteristics were obtained from respective medical records. Thrombus levels were classified according to the Mayo Clinic grading system . PatholoThe VTT above the hepatic veins was defined as high level, while VTT below the hepatic veins was defined as low level in this study. The cut-off values for age, body mass index (BMI), size, tumor thrombus (TT) length, TT width and surgery time were respectively determined based on their mean value. Distant metastasis was confirmed in all patients by imaging examination, including positron emission tomography-computed tomography (PET-CT), contrast enhanced computed tomography (CT) and/or magnetic resonance imaging (MRI), before surgery.After surgery, patients were followed up regularly according to the NCCN guidelines . Physicaχ2 test for categorical variables. And the Fisher exact test was used, only when the sample size was < 5 per cell. OS, PFS and CSS, as well as 3- and 5-year survival estimates were estimated by using the method of Kaplan-Meier. Prognostic and independent factors were determined by applying univariable and multivariable Cox regression models, respectively. The survival curves, stratified by various clinical parameters, were generated using the Kaplan–Meier method and statistically compared with one another using the log-rank test. All analyses were performed with SPSS version 20.0 , and P values < 0.05 were considered statistically significant.Patient demographics and clinical characteristics were examined for two distinct subgroups, Mayo 0–II and Mayo III–IV. Differences between these two subgroups were compared using the 2-tailed Mann-Whitney U test for continuous variables, while A total of 185 patients who received RNTE in less than 4 years were identified in our center. After excluding 64 patients who did not meet the inclusion criteria, 121 were available for analysis. Table No patients died during the operation. 87 (72%) patients were transferred to the intensive care unit (ICU) after surgery, but most of them (68/87) stayed in ICU for only 1 day. Complications occurred in 50 (41%) patients, of whom 17 had 2 or more complications. Major complications were detected in 17 (14%) patients, including lymphatic leakage infection in 1, acute renal insufficiency in 3, acute cardiac insufficiency in 2, ileus in 2, chylothorax and pleural effusion in 3, left heart failure in 1, deep venous thrombosis in 3, and death in 2. As to the cause of death, one was multiple organ failure associated with the bypass procedures, while another was cardiac arrest.The histological cell type was clear cell RCC (ccRCC) in 102 (84%) patients and non-clear-cell subtypes in 19 patients (16%). 93% of patients had sinus fat invasion, while 32% had perinephric fat invasion. 16% of patients had lymph node positive disease and 26% of patients had distant metastatic disease at the time of surgery, among which solitary distant metastases were detected in 23 (74%) cases, while multiple distant metastasis was found in 8 (26%) patients. Including these factors into the univariable Cox regression model analysis, lymph node metastasis and distant metastatic disease at surgery were associated with OS (Table P < 0.001), more median blood loss  and longer median length of hospital-stay  (Table P = 0.031) and higher ICU admission rate . In addition, progression is more likely to occur in patients with high level VTT .Compared with the patients with low VTT level, patients with high VTT level had longer median operative time .The median follow-up time after surgery was 24 months . During the follow-up period, 57 (47%) patients, including the 31 patients with metastasis at surgery, received postoperative adjuvant therapy, of which, 41 (72%), 14 (25%), 1 (1.8%) and 1 (1.8%) received targeted therapy, cytokine therapy, radiotherapy and targeted therapy plus radiotherapy, respectively. 51 (42%) died from all causes, among which 31 (26%) died from RCC, and 69 (57%) patients experienced progression. The median OS was 41 months (95%CI: 26.6–55.4). As demonstrates in Fig.P = 0.016, HR 2.30), metastasis at surgery , tumor necrosis  and sarcomatoid differentiation  were identified as independent significant risk factors. Among these four independent significant risk factors, sarcomatoid differentiation is highly correlated with metastasis at surgery (P = 0.017), as well as tumor necrosis (P = 0.001).In terms of independent prognostic factors for patients with RCC with VTT, 5 candidate risk factors were statistically significant in univariable Cox regression model analysis, and the 5 factors were affirmed in Kaplan–Meier survival analysis Fig. . In addiBecause VTT is not a common event in RCC patients, it is difficult to collect a large number of RCC patients with VTT in a short time for a single center. Thus, a long-time span and/or a limited sample size are the common problems of the existed studies on RCC with VTT. As one of the largest urology centers in China, we focused on the treatment of RCC with VTT in recent years and attracted a large number of patients. Here we aimed to report the outcomes of 121 patients enrolled in less than 4 years and determine the independent prognostic factors for these patients. To the best of our knowledge, it was rare that such a large number of cases was collected in such a short time span.The surgical treatment of patients with RCC with VTT remains challenging and technically demanding. Even for experienced urologist, perioperative complications cannot be avoided completely. However, popularization of the multidisciplinary collaboration improves the safety of the patients with RCC with VTT, and decreases mortality . In our Although surgical techniques and perioperative management have been improved a lot over time, the overall survival of patients with RCC and VTT remains poor, with 5-year OS varied from 37 to 71% , 13–18. Several patient characteristics and oncologic factors have been identified to be associated with poor oncologic outcomes for RCC with VTT, including BMI, tumor size, tumor necrosis, positive lymph node, metastasis at surgery, Fuhrman grade, and venous invasion –22. HoweP = 0.005); while for patients with and without sarcomatoid differentiation, it was 21 and 44% (P < 0.001).Histological tumor necrosis and sarcomatoid differentiation determine the biological potential and tumor aggressiveness . Many ceP = 0.342). Nevertheless, we did find that patients with high level VTT would be more likely experience tumor progress than patients with low level VTT.It remains controversial whether the VTT level could be used as a prognostic predictor in patients with RCC and VTT. Some studies suggested that the level of VTT is associated with long-term survival , while oMetastasis at surgery was generally reported as a poor prognostic indicator in patients with RCC with VTT , 27, witThere are several limitations to this current study. Firstly, this was a retrospective study from a single-institution. So, an inherent selection bias and some confounding factors may not be able to overcome. Secondly, some important variables, such as preoperative laboratory index, thrombus consistency, grafting and reconstruction, status of surgical margin and so on, were not available in the database. Hence, only several commonly available clinicopathologic parameters were included in the univariable and multivariable Cox regression model analyses; however, the results may vary with the different variables included. Thirdly, due to the low number of metastatic patients in our study, clinically non-metastatic and metastatic patients were mixed into the same cohort and analyzed in one group. Fourthly, many important information, such as the time of postoperative adjuvant treatment and side effects of adjuvant therapy, were not fully recorded, which made further analysis unable to be performed. At last, though the influences come from a long-time span were avoided, the median follow-up period of 24 months in this study was inadequate. Therefore, some important information cannot be documented and analyzed.We presently conclude that the OS was poor for RCC patients with VTT and rather than VTT level, positive lymph node, metastasis at surgery, tumor necrosis and sarcomatoid differentiation were independent prognostic predictors for RCC patients with VTT.