Macrovipera lebetina  is a medically important snake species in the Middle East. Its nominate subspecies Macrovipera l. lebetina is confined to Cyprus, where it is the only dangerously venomous snake species and heavily pursued. Despite the viper’s large size, data on its body mass and sex-specific morphological differences are scarce. It is commonly believed that M. l. lebetina prefers freshwater proximity during summer. Hence, we aimed at investigating M. l. lebetina sex-specific morphological differences and its possible attraction to freshwater bodies in late summer.The blunt-nosed viper M. l. lebetina were investigated in Paphos district (Cyprus) in 2014, 2015 and 2017. Vipers were caught in different habitats, examined morphologically for metric and meristic characters, and released back into their habitat. Additionally, local people were interviewed about the conservation situation of the species.Morphometric characteristics, proximity to water and conservation status of Of 38 recorded blunt-nosed vipers, morphological characteristics were collected from 34 . Rounded total length (ToL) ranged from 23.5 cm to 133.0 cm and weight between 10 g and 1456 g. Adult males significantly exceeded adult females in tail length (TaL), ToL and head length (HL). No significant sex-specific differences were found in snout-vent length (SVL), head width (HW), weight or body condition index (BCI), nor for the ratios TaL / SVL, TaL / ToL, HL / SVL or HL / HW. Adult females from late summer (2015) had a significantly lower mean BCI than those from spring (2014).Distances of blunt-nosed vipers to the nearest water bodies  did not differ significantly between spring (2014) and late summer (2015). There was also no significant difference between the distances of vipers to natural and to artificial water bodies in spring (and late summer).Adult male blunt-nosed vipers exceed adult females in TaL, ToL and HL. Adult females are likely in a more vulnerable body condition in late summer than in spring. Periodic drying out of freshwater bodies in summer probably does not affect the species’ occurrence. Educational workshops and habitat conservation are recommended for reducing human-viper conflict. Macrovipera lebetina  for instance has been a cause of serious snakebite accidents from Cyprus and Eastern Anatolia to Northwest India [Macrovipera lebetina inhabits river valleys, slopes with rocky outcrops and shrubs as well as canyons, gorges, gullies, pine forests, orchards, vineyards, caves and ruins [Macrovipera lebetina lebetina (Cypriot blunt-nosed viper) is confined to Cyprus [M. l. obtusa) may even exceed 200 cm in ToL, with the published record being 230 cm [M. lebetina populations [M. l. turanica in Central Asia) reaches a ToL of 180 cm. The maximum weight of M. lebetina is 2700 g [M. l. lebetina within the European viper fauna, little information is available on the natural history of this subspecies. Furthermore, no body mass data have been published yet on the Cypriot blunt-nosed viper. Although snake body mass (or weight) is rarely reported in the literature, it is considered the best measure of body size in life history studies and often a more useful proxy than length [M. l. lebetina body weight and length [M. lebetina are scarce and sometimes contradictory, comparing different morphological characteristics between male and female blunt-nosed vipers can contribute to filling this knowledge gap. Based on the literature [In the Near and Middle East, true vipers (Viperinae) are of significant medical importance –5. The bst India –11, whilst India –16. Macrg 230 cm . Howeverulations . Accordid length , 22. As M. l. lebetina is frequently observed close to water [M. l. lebetina distribution patterns and habitat requirements can contribute to minimizing human-viper conflicts, little is known about the importance of water for the spatial ecology of this species. In this study we therefore also investigated the relationship between water occurrence and blunt-nosed viper presence in Cyprus, via analysis of distances of the vipers to the nearest body of artificial and (or) natural freshwater body.Reptiles in semi-arid regions are often confronted with annual droughts. The resulting periodic water scarcity affects their spatial distribution, foraging ecology and body condition. Water availability is an important factor for survival as it may also determine the presence or absence of prey species and shelter from overheating and natural enemies , 24. As to water , 25 and to water . AlthougM. l. lebetina were caught for the collection of biometric data. Body weight was measured to the nearest gram (mean of five measurements) using a Beurer digital scale. Snout-vent length, tail length (TaL) and ToL were measured to the nearest 0.5 cm in live individuals and to the nearest 1 mm in dead ones. For statistical purposes, SVL, TaL and ToL of dead specimens were later rounded to the nearest 0.5 cm. Head length (HL) and head width (HW) were measured to the nearest 1 mm. Ventral, subcaudal and dorsal scales were counted, the latter at mid-body. The sex was determined via examination of the tail base and cloaca in live specimens, and via probing of the hemipenes in dead individuals [M. l. lebetina were conducted with staff of Cypriot institutions and local people related to environmental management, outdoor labor and medicine.Data collection took place during three field surveys in northern Paphos district, Cyprus , from 24 March to 4 June 2014, 27 August to 29 September 2015 and 21 September to 3 October 2017. This coastal lowland area is characterized by agriculture in the Polis Chrysochous valley, bordering Akamas Peninsula in the west and the forested foothills of the Troodos Mountains in the east  logW = loga + bSVL, using the least squares method. The coefficient of determination (R2) was used as a measure of the fraction of weight variation that can be explained by SVL. The correlation coefficient R was used as a measure of the strength of the linear relationship between SVL and TaL, SVL and HL, SVL and HW, and between HL and HW. Morphometric properties and the BCI of adult males and females were compared using the unpaired t test for normally distributed variables or the Mann-Whitney U test for non-normally distributed variables. For all tests, results were considered to be significant when P < 0.05. All statistical analyses were performed using the software Statistica 13.2 .For all collected morphometric measurements, the mean, standard deviation (SD) and coefficient of variation (CV) were calculated. As a body condition index (BCI) for each snake, Fulton’s index (K) was calculated using the formula SVL3x105 , 22. Priconstant . The coeMacrovipera l. lebetina was observed at edges of agricultural plantations, grain fields, gardens and streambanks, on grassy slopes, and inside dried-out streambeds. Besides shrubs and thick grassy vegetation, habitats with confirmed blunt-nosed viper presence contained a variety of microstructures such as crevices and caves, animal dens, stone slabs, rock piles, rock walls, and ruins of buildings and other constructions. Ten blunt-nosed vipers were recorded in private gardens , two in a building next to a swimming pool (3 and 19 May 2014) and a killed (newborn) viper at a building entrance door (21 September 2015). An adult female was found inside a pickup truck into which it had crawled when the vehicle had briefly stopped on a dirt road (23 September 2015). Common plant species of surveyed M. l. lebetina habitats in Paphos district included oriental alder , giant reed (Arundo donax), common fig tree (Ficus carica), Phoenician juniper (Juniperus phoenicea), olive tree (Olea europaea), lentisk (Pistacia lentiscus), oriental plane , holy bramble (Rubus ulmifolius sanctus) and the exotic eucalypt .Anthus campestris). This snake was found killed on a country road (10 April 2014). A live adult female  caught on 1 May 2014 (11:07 AM) at the edge of a stream bank next to an olive tree plantation regurgitated a half-digested, adult brown rat (Rattus norvegicus) of 270 g after 5 h in captivity  was found in the stomach of a killed adult male viper  lying on a small village road (12 May 2014). A killed male found on 17 September 2015  contained remains from a rodent, most likely a brown rat.The stomach of an adult female blunt-nosed viper  contained remains of a tawny pipit  was found at the edge of an orange tree plantation and grazing pastures interspersed with almond trees. The slough was in the grass next to a pile of wooden debris. Two adult females (SVL = 65.5 and 93.0 cm) were later observed 33 m (6 May 2014) and 119 m (2 September 2015) away, respectively. The distance of the slough to the next water body  was 137 m. The slough remnant of another large adult blunt-nosed viper (including a 15.5 cm long tail section) was discovered inside a periodically dry streambed with several small water pools on 27 September 2015. In the same month (6 and 29 September), two large vipers were recorded 76 m and 67 m upstream from this shedding location. The individual of 6 September was an adult male .M. l. lebetina every year . In summer, bite accidents happen especially when goats and sheep concentrate around waterholes frequented by vipers , a woman was bitten on her foot by a juvenile blunt-nosed viper next to her swimming pool (S. Paphitis pers. comm. 17 September 2015). As a survey of snakebite epidemiology was beyond the scope of the present study, it is possible that additional people in the area might have been bitten by vipers during the study period. Livestock and hunting dogs are bitten by M. l. lebetina is feared and persecuted by local people both in populated areas and in the wild. Road traffic is another threat. People involved in outdoor activities  encounter vipers more often in comparison with other occupational groups. The widespread public aversion to M. l. lebetina has so far prevented legal protection of this species in Cyprus ([During the 2014 survey (between 3 April and 26 May), 13 blunt-nosed vipers were found killed on roads in Paphos district (Polis area) with injuries including smashed heads, necks and cloacae. In two cases, a string was attached to the body of the snake  ranged from 23.5 cm (10 g) for juveniles to 133.0 cm (1456 g) for a killed adult male (SNM-BS N-56085). The three largest males exceeded 130 cm ToL whereas the largest female (SNM-BS N-56086) had a rounded ToL of 124.0 cm. Rounded SVL ranged from 20.5 cm to 119.5 cm  and 10.80 ± 1.91% for adult females (n = 16). The coefficient of variation was highest for the variable weight, ranging from 46% in adult females to 113% in juveniles.Morphometric data Table  were col2 amounted to 0.99. In comparison, Fig. 2 = 0.73) than in juveniles and adult males (R2 = 0.97 and R2 = 0.99 respectively) , average ToL (P = 0.047) and average HL (P = 0.016). No significant sex-specific differences were found for HL / SVL, HL / HW and BCI (Table P = 0.285) and TaL/ToL (P = 0.285). These results indicate that adult females did not have longer tails than adult males relative to their body length.According to the L P = 0.07 and aven = 5) had a significantly lower mean BCI than those found in the spring of 2014 (n = 11) (P = 0.0007). Among adult males, the mean BCI was significantly lower in the four longest individuals (SVL ≥ 100 cm) than in the six smaller ones (SVL < 100 cm) (P = 0.013).Adult females observed in the late summer of 2015  and in 2015 (n = 17) (Table n = 16). Out of the 36 observed vipers, 24 individuals could be captured for data collection whereas 11 vipers either escaped or were killed by local people. In one case, a viper slough was treated as a single individual. At the site where a large male was observed, another large viper was recorded 21 days later, as were remains of a slough belonging to a similarly sized individual. To exclude the possibility of double-counting, all three observations were treated as one individual. Assumption of normality was rejected for all distances of M. l. lebetina to the nearest water bodies. The Mann-Whitney U test showed no significant difference between the distances of M. l. lebetina to the nearest water bodies in the spring of 2014 and late summer of 2015 (P = 0.537). Likewise, the distances of M. l. lebetina to natural water bodies in the spring of 2014 did not vary significantly from those in the late summer of 2015 (P = 0.497). There was also no significant difference between the distances of M. l. lebetina to artificial water bodies in the spring of 2014 and in the late summer of 2015 (P = 0.635). Equally, the Wilcoxon matched pairs test could not prove a significant difference between the distances of M. l. lebetina to natural and artificial water bodies in the spring of 2014 (P = 0.295) and in the late summer of 2015 (P = 0.717).Of 38 total field observations, 36 blunt-nosed vipers were recorded with corresponding distances to the nearest body of artificial and (or) natural freshwater in 2014 , now considered a subspecies of M. lebetina [M. schweizeri was absent from biotopes without large bushes as well as from densely vegetated habitats [M. l. lebetina from inhabiting areas. However, droughts have become more frequent on Cyprus [The summer season is a critical period for populations of redators . Due to redators . Againstredators , 33, parredators . Water pbekistan . Howevern Cyprus , 35, 36,n Cyprus  and may n Cyprus . Besidesn Cyprus –41. Snakn Cyprus . Habitatfeatures . In our lebetina , found thabitats . Our finn Cyprus , and theM. l. lebetina throughout the year. Prior to molting, blunt-nosed vipers seek contact with water by bathing or lying in the rain to facilitate the sloughing of the old skin [M. l. lebetina in pre-shed condition and may influence the selection of shedding locations, together with other factors (e.g. prey availability) that are communicated via chemical cues. The two blunt-nosed viper sloughs recorded in early April 2014 and late September 2015 were situated in habitats with year-round water availability, diversity of microstructures and abundance of brown rats. Based on observations of North American rattlesnakes , Loughran et al. (2015) pointed out that different social interactions  occurred around shedding sites and that these places had a similar importance for the social structure of snakes as communal hibernacula [Shedding increases dehydration in snakes . As Cyprold skin . Water bernacula . This imM. l. lebetina movements are available, distances of 2–3 km to water bodies  may still fall within the home range of this species. Nilson et al. (1999) found that the home range of the smaller M. schweizeri was up to 20 ha, with one female covering a distance of 5 km within 12 months [M. l. lebetina habitat use.Even though no data on 2 months . A radioM. l. lebetina than natural pools during late summer, highlighting the importance of natural water bodies for blunt-nosed viper conservation. Since water bodies provide significant advantages for blunt-nosed vipers such as ambushing for prey [The annual drying-up of many natural water bodies in summer may imply that Cypriot blunt-nosed vipers prefer man-made, permanent water bodies during this season, but not necessarily during the rainier spring. Yet this study could neither confirm a preference for artificial over natural water bodies during late summer, nor could it provide evidence that vipers are found closer to artificial water bodies in late summer than in spring. These findings indicate that swimming pools are not more attractive for for prey , water ufor prey . The idefor prey .M. l. lebetina populations and increase the likelihood of human-viper confrontations in the future. Habitat loss due to land transformation for tourism is a general threat to snake species on Eastern Mediterranean islands [M. lebetina throughout the species’ range [The ongoing anthropogenic destruction of wild snake habitats for real-estate and industrial development in Cyprus  may thre islands . Wildfir islands . Road trs’ range .M. l. lebetina is listed in Appendix II of the Berne convention (which contains “strictly protected fauna species”), it is the only snake species not protected by law in Cyprus [Laudakia stellio and Dolichophis jugularis [M. schweizeri on Milos [M. l. lebetina should be investigated.Although n Cyprus , but at ugularis . Feral con Milos . ConsequM. l. lebetina should be placed under protection, with prohibition of land transformation , and strict regulations concerning further interventions by man . This could be achieved by designating new areas for the Natura 2000 network of the European Union. In all conservation areas, hunting should be prohibited. Wetlands are also important habitats of other endangered Cypriot reptiles such as Hierophis cypriensis (Cyprus whip snake), Natrix natrix cypriaca (grass snake) and Mauremys rivulata  [Workshops for mosquito control workers and other  outdoor groups such as hunters, shepherds, farmers, forestry employees and game wardens could help to raise awareness of non-lethal methods of preventing human-viper conflict such as snake deterrence or translocation. Workshops should also be offered to rural communities and schools. Public education could be further aided by the establishment of a national snakebite database for Cyprus, which so far is not available (E. Erotokritou pers. comm. 12 October 2017). Valuable snake habitats such as wild riparian areas and rocky slopes with confirmed populations of M. l. lebetina (n = 34) can be modelled as an exponential curve  may grow up to 218 cm [The allometric relationship between SVL and weight in rve Fig.  fitted to 218 cm ; howevero 218 cm , whereaso 218 cm .2 determination coefficient of the regression ln weight vs. ln SVL among adult female blunt-nosed vipers (0.73) shows that the body weight of females was not only influenced by their SVL but also by other factors. In line with our hypothesis, adult M. l. lebetina females caught in September were significantly thinner than those captured in spring (P = 0.001). This fluctuation of body mass might be explained by postpartum weight loss, provided that the females examined in late summer had reproduced in that year. After oviposition, blunt-nosed vipers (M. l. obtusa) may lose up to 52% of their weight (mean: 35%) [n = 10), the significantly lower body condition index of the four largest adult males compared to the six smaller ones was striking (P = 0.013), since it suggests that male blunt-nosed vipers may become thinner with age. This hypothesis would be consistent with the trend of the scatterplot of SVL vs. BCI  examined by Nasiri et al. (2014), 16 were infested with parasites [M. l. lebetina. However, a much larger dataset is needed to provide solid statistical evidence.The highest coefficient of variation among all variables in this study was determined for weight . It corresponds to the identified positive allometric relationship between weight and the linear measures of the blunt-nosed viper’s body. The relatively low Ran: 35%) . Snake ban: 35%) . HoweverBCI Fig.  showing et Union , while M. obtusa . Of 20 Iarasites . As our P-values of the respective t test amounted to 0.06 for SVL and 0.097 for weight), our results suggested that they were longer and heavier. This apparent dimorphism was further supported by the significantly longer TaL (P = 0.005), ToL (P = 0.047) and HL (P = 0.016) of adult males. This trend is also shown by the scatterplots of SVL vs. TaL . Larger sample sizes are required to obtain more powerful test results on sex-specific differences.Although we could not prove that adult male blunt-nosed vipers exceeded adult females in body size and weight , which is comparable to the body dimensions of large North American rattlesnake species  (Table C. atrox) are found in similar biomes  as M. lebetina. In the Mediterranean basin, Moorish vipers (Daboia mauritanica) and desert vipers (D. deserti) reach similar dimensions , whereas Palestine  and Ottoman vipers (Montivipera xanthina) commonly do not grow much larger than 1 m [D. palaestinae (S. Meiri pers. comm. 1 May 2017) and 143.5 cm ToL (1284 g body mass) in M. xanthina nilsoni  and 1800 g (128 cm ToL), respectively, the latter being a gravid female . As large viper species are primarily found in the Americas, Africa, the Middle East and South Asia, the enormous body dimensions of M. l. lebetina highlight its morphological and evolutionary uniqueness within the European viper fauna.The enormous differences in body size between blunt-nosed vipers from the Cyclades and Cyprus , 44, 60 .) Table . Some ofthan 1 m . Howevernilsoni (; A. CattM. l. lebetina exceed adult females in head length, tail length and total length. Adult female blunt-nosed vipers are probably in a more vulnerable physical condition in late summer than in spring. Old age possibly has an adverse effect on the body condition index of M. l. lebetina. The annual drying out of freshwater bodies in late summer most likely is not a decisive factor for the occurrence of the species on Cyprus. It must be assumed that prey availability and protective microhabitat structures such as large bushes and rocks are of crucial importance for preserving blunt-nosed viper populations in Cyprus. A radio-telemetry study would greatly improve the understanding of the spatial ecology of M. l. lebetina. Workshops should be conducted for rural communities, schools and outdoor groups to raise awareness of non-lethal ways of removing blunt-nosed vipers from areas inhabited or frequented by people. The establishment of a national snakebite database for Cyprus would contribute to improving public education. Wild snake habitats with confirmed populations of M. l. lebetina should be protected from anthropogenic modifications such as real-estate development, grazing and hunting.We conclude that adult males of


Due to the significant heterogeneity of renal cell carcinoma (RCC), immune checkpoints may express differently between primary and metastatic tumor. We aimed to evaluate the differential expression of TIM-3 between the primary and metastatic sites of RCC.Cases of RCC with metastases resected or biopsied at West China Hospital between January 2009 and November 2016 were included. Clinicopathological parameters were retrospectively extracted. SPPS 22.0, GraphPad Prism 6 and R statistical software were applied for data analysis.p = 0.002), with a poor consistency . Subsequent survival analysis suggested that TIM-3 expression either in the primary or metastatic tumor was associated with longer progression-free survival (PFS)  and overall survival (OS) . The expressions of TIM-3 in the primary, metastatic tumors and patients treated with targeted agents all played as favorable factors for PFS and OS. Further multivariate analysis showed that, in the whole cohort, TIM-3 expression in metastatic tumor increased the predicted accuracy (PA) of the whole model of PFS from 74.7 to 75.6% (P = 0.02). For OS, the PA of whole model was increased from 78.1 to 81.1% by adding TIM-3 expression in the metastasis (P = 0.005). The same trends were also observed in paired patients and patients treated with targeted agents. In conclusion, the expression difference between the primary and metastatic tumor of TIM-3 was significant. Biopsy or resection of the metastases may provide a more accurate biological information for clinician’s decision-making and the patient’s prognosis. What’s more, the role of TIM-3 in the RCC still remains controversy, further study are needed to verify the conclusion.A total of 163 cases were included. Immunohistochemical results showed that the overall detection rate of TIM-3 was 56.4% (92/163). The detection rate of TIM-3 in the primary  was numerically higher than that of the metastasis . Although the concordance rate of TIM-3 between the primary and metastasis was as high as 66.3% (55/83) in the paired cohort, a significant statistically difference of TIM-3 expression between the primary and metastasis was observed (χ2 = 4.664,  Of all patients with kidney cancer, 20–30% of them were diagnosed as metastatic renal cell carcinoma (RCC) at initial diagnosis, and about 20–40% of localized renal cell carcinoma would develop distant metastasis in spite of having been treated with radical nephrectomy . All aloRecent studies demonstrated that immune checkpoints have played key roles in the mechanism of immune escape –8. In thThrough analyzing the expression of immune checkpoints in tumor and the effect of checkpoints inhibitors, researchers found a positive correlation between immune checkpoints (such as PD-L1) over-expression and the treatment response in lung cancer and melanoma , 12. HowTIM-3 is an immune checkpoint  located in T-cell . DespiteTherefore, in the present study, we aimed to compare the differential expression of TIM-3 in the primary and metastatic sites of RCC, and additionally, to find the role of TIM-3 in predicting patient’s prognosis.Cases of RCC histologically diagnosed by focal resection or fine needle aspiration at West China Hospital from January 2009 to November 2016 were included. The inclusion criteria were metastatic disease at initial diagnosis with metastasis resected or biopsied, with or without companying specimens of the primary tumor. The exclusion criteria were metastases which were only suspected of deriving from kidney cancer, without screening of evidence of the primary tumor, or with a negative result in screening. All included cases were independently diagnosed by two urological pathologists (Ni Chen and Xiaoxue Yin), and the paraffin blocks of included cases were screened suitable for immunohistochemical staining.Clinicopathological parameters were retrospectively extracted, including age, gender, metastatic sites, T stage, Eastern Cooperative Oncology Group (ECOG) status, International Metastatic Renal-Cell Carcinoma Database Consortium (IMDC) classification, ISUP grade, histological type, treatment, nephrectomy status and tumor necrosis. The end-points were PFS and OS. PFS was defined as the time from diagnosis to progression of disease or death. OS was defined as the time from diagnosis to all-cause death.Expression of TIM-3 was detected by immunohistochemistry (IHC) by using anti-TIM-3 monoclonal antibody  at a 1:200 dilution. Positive signal of TIM-3 was on the cell membrane. Staining intensities were evaluated on a scale of 0(null), 1 + (weak), 2 + (moderate) and 3+ (strong) . PositivP < 0.05 was considered significant in all results. Predictive accuracy (PA) was calculated by using R software. Kaplan-Meier and Cox’s proportional hazards regression model were applied to analyze survival outcomes. Statistical significance was defined as P < 0.05. Predictive accuracy (PA) was calculated by using R software.SPPS 22.0, GraphPad Prism 6 and R statistical software were applied for data analysis. Continuous parameters were calculated as mean and SD and were analyzed by non-parametric test. Categorical parameters were calculated as proportions and were analyzed by chi-square test. Kappa test was applied to analyze the expression consistency between the primary and metastatic sites. The agreement was measured by Kappa coefficient: Kappa≤0.2 as indicating slight agreement, 0.4 < Kappa≤0.6 as fair, 0.6 < Kappa≤0.8 as substantial, > 0.8 as almost perfect agreement great. Kaplan-Meier and Cox’s proportional hazards regression model were applied to analyze PFS and OS. A total of 163 patients were included in this study from January, 2009 to November, 2016 in West China Hospital, Sichuan University. Patients’ characteristics were summarized in Table N = 163), the overall detection rate of TIM-3 was 56.4%(92/163). The associations between clinical pathological parameters and TIM-3 expression in the primary or metastatic tumor were shown in Table p = 0.03). After stratified by IMDC classification, a gradually decreasing trend of the detection rates was observed from favorable (69.7%), intermediate (61.3) to high risk (37.9%) groups .Figure as 56.4%9/163. Thep = 0.01). The expression rates of different metastatic sites were (from high to low): viscera without lung , ipsilateral adrenal gland , lung/lymph node , brain , others  and bone .As shown in Table N = 80), the concordance rate of TIM-3 between the primary and metastasis was 66.3% (55/83). However, TIM-3 was differentially expressed between the primary and metastasis, with a significant statistically difference  and poor consistency .In the paired cohort (P = 0.02) and OS . In the metastatic tumors, patients with TIM-3 expression experienced longer PFS  and OS  than that with negative expression , and the median OS was 36.0 month (IQR:16.0–70.0). In 64 patients with TKI therapy, the median PFS and OS were 21.0 and 52.0 months, respectively. Subsequent survival analysis, as shown in Fig. P = 0.254), except for OS . Furthermore, TIM-3 expressions in the primary and metastatic tumors were all associated with longer PFS and OS .Additionally, TIM-3 expression was also positively correlated with PFS and OS in patients treated with targeted agents Fig. . HoweverP = 0.02, Table P = 0.005, Table P < 0.001) and OS from 78.2 to 81%  and OS  models . Further multivariate analysis showed that, in the whole cohort, TIM-3 expression in metastatic tumor increased the predicted accuracy (PA) of the whole model of PFS from 74.7 to 75.6%  expression and treatment effect in lung cancer and melanoma , 12, butThe expressions of TIM-3 either in the primary or metastasis suggested a better prognosis for mRCC patients in our study, especially, its expression in metastases could more accurately predict the prognosis of patients . Interestingly, the results of TIM-3 expression in predicting better prognosis of mRCC were contradictory to other tumors –26. The In fact, the mechanism of TIM-3 in anti-tumor immune responses is complex. Some studies showed that TIM-3 could act as a co-stimulatory signal receptor and enhance the killing effect of cytotoxic T cells and other immune cells –19. OtheMultivariate analysis of the present study suggested that the expression of TIM-3 in metastases was significantly higher than that in primary tumors in predicting the prognosis of patients. It was further clarified that the expression of TIM-3 in metastatic tumors might be more indicative to patient’s prognosis. Therefore, more attention should be paid to the assessment of metastatic sites in clinical practice and research, to improve the efficacy of immunotherapy for mRCC and finally realize individualized treatment strategy.This study was the first to evaluate the differential expression of TIM-3 in primary and metastatic RCC tumors, and is the largest study to date. However, this study still has the following limitations: 1) retrospective study design, which may induce potential selection bias; 2) limited number of paired patients; 3) different types of samples were included . Therefore, subsequent studies should focus on the observation of differences between expression and prognosis on different types of tumor.The expression differences of TIM-3 were significant between the primary and metastatic tumors. The assessment of immunological checkpoint-related protein in primary tumor might not be able to provide adequate information for clinicians to evaluate or predict the patient’s treatment-related efficacy and prognosis. The expressions of immune check points in metastatic lesions of mRCC should be given more attention, and their accurate diagnosis might be one of the effective ways to realize individual treatment. What’s more, the role of TIM-3 plays in mRCC remains to be verified.


The combined administration of intravenous (IV) and topical tranexamic acid (TXA) in primary total knee (TKA) knee remains controversial. The purpose of this meta-analysis was to assess the efficacy and safety of combined administration of IV and topical TXA in primary TKA.PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Web of Science, Google Search Engine and China National Knowledge Infrastructure databases were searched for randomized controlled trials (RCTs) were comparing the combined administration of IV and topical TXA following primary TKA. The primary outcomes were total blood loss, maximum hemoglobin drop, and deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The second outcomes were drainage volume and transfusion requirements. Data were analyzed using RevMan 5.3.P = 0.0003), drainage volume , maximum hemoglobin drop  than IV TXA alone. No significant difference were found in terms of transfusion requirements , DVT  and PE  between the two group. Subgroup analyses shows that the combined group was less total blood loss in non-tourniquet (P = 0.0008), topical TXA dose > 1.5 g (P <  0.00001) and number of IV TXA ≥ 2 doses (P = 0.005) of TXA compared with the IV group alone.A total of 6 RCTs involving 701 patients were included in the meta-analysis. The combined group provided lower total blood loss (MD − 156.34 mL, 95% CI, − 241.51 to − 71.18; The available evidence indicates combined group were associated with lower total blood loss, drainage volume, and maximum hemoglobin drop. A similar transfusion requirement was found in both groups. Subgroup analyses demonstrates that total blood loss was less in patients with non-tourniquet, topical TXA dose > 1.5 g and number of IV TXA ≥ 2 doses of TXA. There was no increase the rates of DVT and PE. Total knee arthroplasty (TKA) and total hip arthroplasty (THA) is an effective orthopedic procedure for patients with severe knee and hip diseases –4. HowevTranexamic acid (TXA) is a synthetic lysine analog, it can competitively inhibit the activation of plasminogen and plasmin binding protein , 8. SeveSeveral meta-analyses –21 were http://www.researchregistry.com).The method used for this meta-analysis is based on the recommended PRISMA checklist guidelines . The stuWe searched the following electronic databases: PubMed (1966 to December 2017), Embase (1974 to December 2017), Cochrane Central Register of Controlled Trials (December 2017) and Web of Science (1990 to December 2017). To identify additional potential studies, we also used the Google Search Engine (December 2017) and China National Knowledge Infrastructure (December 2017). We used the following keywords to search the database above:  AND (Tranexamic acid OR TXA OR TA). A search strategy with “PubMed” as an example in a manuscript: #1 Total Knee Arthroplasty; #2 Total Knee Replacement; #3 TKA; #4 TKR; #5 #1 OR #2 OR #3 OR #4; #6 Tranexamic Acid; #7 TXA; #8 TA; #9 #6 OR #7 OR #8; #10 #5 AND #9. There is no restriction on language and region.(2) patients were performed primary unilateral TKA; and (3) The outcomes of each RCTs included at least one of the following: blood loss, drainage volume, transfusion requirements, maximum hemoglobin drop, DVT, and PE. The studies were excluded if: (1) there were no sufficient outcomes; (2) revision or simultaneous bilateral total knee arthroplasty. All titles and abstracts were independently reviewed by two reviewers  to identify potential studies. These eligible studies were then obtained for inclusion based on the review of the full text. The differences were resolved by consensus after discussion, or a third reviewer was consulted if necessary.The inclusion criteria for these studies were performed as follows: (1) studies were RCTs that included combined IV and topical application of TXA, and IV application of TXA; Two reviewers  assessed independently the methodological quality as described by the Cochrane Collaboration for Systematic Reviews . The sixThe effectiveness and safety of combined IV and TA application of TXA versus single IV TXA after primary TKA in this meta-analysis were compared. The primary outcomes were total blood loss, maximum hemoglobin drop, and deep venous thrombosis (DVT) and/or pulmonary embolism (PE). The second outcomes were drainage volume and transfusion requirements. Furthermore, Subgroup analysis was also performed based on whether the use of tourniquet and drainage tube to compare the additional benefits for blood loss.If the study reported the same patient during the different follow-up period, we chose a longer follow-up time to avoid duplication of data.Two reviewers  independently extracted outcomes from the included studies. Their data includes authors, publication year, patients, age, and the intervention method of TXA, the method of DVT prophylaxis and screening, blood transfusion criterion. 2 < 50%, the fixed-effects model was chosen. Otherwise, a random-effects model was chosen. Publication bias was tested independently using funnel plots of total blood loss, drainage volume, maximum hemoglobin drop, transfusion requirements and DVT. If the funnel plot was symmetric, then there was a low potential for publication bias, or vice-versa.Statistical analyses of the meta-analysis were performed using RevMan 5 software . For continuous data, the mean differences (MD) and 95% confidence interval (CI) were calculated, such as total blood loss, drainage volume, and maximum hemoglobin drop. For dichotomous data, the risk ratio (RR) and 95% confidence interval (CI) were calculated, such as transfusion requirements, DVT or PE. The chi-squared test and I2 statistic were used to assess statistical heterogeneity. If the chi-squared test > 0.1 or the IThe flow chart in Fig. Table P = 0.0003) .A total of five studies , 22–24 rSubgroup analysis was performed base on the use of tourniquet or non-tourniquet, different topical (≤1.5 g or > 1.5 g) or number of IV TXA (single or ≥ 2 doses) of TXA. The outcome revealed that there was the significant difference between the two groups in terms of tourniquet or non-tourniquet, topical TXA dose or the number of IV TXA Table .Table 3RP = 0.0004) .A total of three studies , 24, 28 P = 0.003) . Similar results were received in subgroup analysis based on the application of tourniquet or non-tourniquet, topical TXA dose or the number of IV TXA (Table 4).A total of four studies , 23, 24 03) Fig. . A randoP = 0.19) . Similar results were received from subgroup analysis based on the application of the tourniquet or non-tourniquet, topical dose and number of IV TXA (Table 4).A total of five studies , 22–24 r19) Fig. . A FixedP = 0.99) . Thus, no significant differences were found in the two groups in terms of the incidence of DVT and PE. A fixed-effects model was used, since there was no significant heterogeneity among the studies .A total of six studies –24, 28 r99) Fig. . All butTranexamic acid, an analog of the amino acid lysine, successfully reduces perioperative blood loss and transfusion requirements in primary TKA , 29, 30.The main finding of this meta-analysis is that the combined application intravenous and topical of TXA can significantly reduce postoperative total blood loss, drainage volume, maximum hemoglobin drop compared to the application of intravenous TXA alone. Subgroup analyses showed that total blood loss was less in patients with non-tourniquet, topical TXA dose > 1.5 g and IV TXA ≥ 2 doses. No significant differences were found in the incidence of DVT and PE between the two groups.The administration of IV TXA in TKA has been well established in a lot of literature. Akgül et al.  reportedThe current meta-analysis shows that combined group could effectively reduce postoperative total blood loss by about 156.34 mL compared with IV TXA alone. Similarly, subgroup analysis suggested that there is also the significant difference between the two group in terms of the use of tourniquet or non-tourniquet, topical (≤1.5 g or > 1.5 g) and the number of IV TXA (single or ≥ 2 doses). Furthermore, the meta-analysis indicates that drainage volume found in the combined group significantly reduced drainage volume by a mean of 43.54 mL compared with the IV group. Thus, the combined administration of TXA could be a reasonable alternative to IV TXA alone for decreasing blood loss and drainage volume in primary TKA.P = 0.19). Subgroup analyses showed similar results for the tourniquet or non-tourniquet and different topical or the number of IV TXA. Huang et al. [P <  0.001), but no difference in blood transfusion rate . The result of our meta-analysis evaluating transfusion rates was consistent with these studies.In our meta-analysis, the rate of transfusion requirements was slightly less for the combined group (1.2%) than for the IV TXA group (2.8%), but the difference was not statistically significant . 1 PE was found in the IV TXA group. Our findings are consistent with those of RCT [Thromboembolic prophylaxis methods were performed in all of the studies and as follow: low-molecular-weight heparin, aspirin, and enoxaparin. As Anderson et al.  reportede of RCT , 23 or me of RCT , 39 whicThe current study had the following strengths. First, all of the included studies have been well-designed and satisfied the defined eligibility criteria comparing the efficacy of combined TXA versus intravenous administration of TXA during TKA. Second, subgroup analysis was performed based on the use of the tourniquet or non-tourniquet and different topical or the number of IV TXA. The results showed that combined administration of TXA in TKA can effectively reduce total blood loss and maximum hemoglobin drop compared with IV TXA alone. Third, this study independently used funnel plots to assess publication bias, the plots were generally symmetrical and shown a lower publication bias. However, the meta-analysis also has limitations. First, the reported blood loss methods are not consistent, which may lead to deviations in the clinical outcome of blood loss. In addition, the method for estimating displacement is not detailed, so it cannot exclude the result deviation caused by human factors measurement. Second, the number of RCTs included was limited. Thus, more carefully and scientifically designed RCTs are needed in the future to further confirm and compare the different results. Third, due to the limited sample size of the study, our meta-analysis failed to extract adequate data pertaining to some items from these studies, such as function outcomes, patient satisfaction, and other complications, etc. Last, there was substantial heterogeneity in the meta-analysis of several outcomes, including total blood loss and drainage volume. However, taking into account the effects of the tourniquet and different topical TXA dose (≤1.5 g or > 1.5 g) or number of IV TXA (single or ≥ 2 doses), thus subgroup analysis was performed to decrease heterogeneity.meta-analysis.This meta-analysis of currently available evidence indicates that combined administration of intravenous and topical TXA in primary TKA can significantly reduce total blood loss, drainage volume and maximum hemoglobin drop compared with IV TXA alone. The main finding, however, is that there is no significant difference in transfusion rates because this is the most clinically relevant point in this


Borrelia, originally described by Swellengrebel in 1907, contains tick- or louse-transmitted spirochetes belonging to the relapsing fever (RF) group of spirochetes, the Lyme borreliosis (LB) group of spirochetes and spirochetes that form intermittent clades. In 2014 it was proposed that the genus Borrelia should be separated into two genera; Borrelia Swellengrebel 1907 emend. Adeolu and Gupta 2014 containing RF spirochetes and Borreliella Adeolu and Gupta 2014 containing LB group of spirochetes. In this study we conducted an analysis based on a method that is suitable for bacterial genus demarcation, the percentage of conserved proteins (POCP). We included RF group species, LB group species and two species belonging to intermittent clades, Borrelia turcica Güner et al. 2004 and Candidatus Borrelia tachyglossi Loh et al. 2017. These analyses convincingly showed that all groups of spirochetes belong into one genus and we propose to emend, and re-unite all groups in, the genus Borrelia.The genus  Borrelia, named after the French biologist Amédée Borrel, was originally described in 1907 by Swellengrebel  hits were from well-defined group of Borrelia or which involved a large increase in E-values from the last hit belonging to a particular group of Borrelia to the first hit from any other group”. This methodology specifically identifies only CSIs and CSPs that are exclusive only to one Borrelia genogroup, and precludes the detection of CSIs or CSPs that may be shared non-exclusively between both genogroups (i.e. contests the hypothesis that LB and RF belong in different genera). This data presented in isolation misrepresents the extent of genomic divergence between LB and RF Borrelia and fails to consider widespread genomic similarities between these two groups. Additionally, although ANI has previously been used to investigate prokaryote taxonomy  x 100, where C1 and C2 are the number of conserved proteins between the genome pair, and T1 and T2 are the total number of proteins in each genome being compared [POCP analysis was performed according to Qin et al.  and as dcompared . ScriptsB. turcica and ‘Candidatus Borrelia tachyglossi’ to establish whether these molecular markers are useful for classifying their taxonomic relationships. To identify CSIs, the conserved amino acid sequences flanking the CSIs were searched against the proteomes of all 30 Borrelia genomes used here using BLASTP [Borrelia proteomes were aligned with MUSCLE [B. turcica, and ‘Candidatus Borrelia tachyglossi’ was determined using BLASTP searched as described in Adeolu and Gupta [The CSIs presented in Adeolu and Gupta  that areg BLASTP . Hits frh MUSCLE , and visnd Gupta .Borrelia, Brachyspira, Leptospira, Spirochaeta, and Treponema. Among all spirochete genomes investigated inter-genera POCP values ranged between 4.8% and 36.8% (mean 10.1%), indicating a low degree of protein conservation occurs between spirochete genera , while POCP values between RF species were generally lower and more variable, ranging between 65.3–93.1% (mean 81.1%) , B. americana , B. japonica , and B. mayonii . However, B. turcica and ‘Candidatus Borrelia tachyglossi’ genomes did have higher levels of protein conservation with B. anserina  and B. miyamotoi (‘Candidatus Borrelia tachyglossi’ only: 87.7% POCP) , and a maximum value of 88.8% (B. miyamotoi LB-2001 vs. B. chilensis VA1)   and 11/53 (20.8%) of the CSIs in B. turcica and ‘Candidatus Borrelia tachyglossi’, respectively, correspond to LB-specific forms  sharing a unique mixture of features from both RF and LB groups.The reptile- and echidna-associated B. afzelii and A14S for B. spielmanii. Previous data on multilocus sequence typing have shown that these two isolates are closely related to the type strain of the respective genospecies and fall into the same phylogenetic cluster [In our study we included as many type strains as possible, as type strains are the representatives of the species and can be obtained from microbial culture collections. However, for two of the species belonging to the LB group of spirochetes, genomic data of the type strains were not available to us. As a surrogate we used genomic data available for closely related strains of these species, i.e. PKo for  cluster , 25.Borreliella bavariensis  Adeolu and Gupta 2015, Borreliella burgdorferi  Adeolu and Gupta 2015, Borreliella carolinensis  Adeolu and Gupta 2015, Borreliella garinii  Adeolu and Gupta 2015, Borreliella japonica  Adeolu and Gupta 2015, Borreliella kurtenbachii  Adeolu and Gupta 2015, Borreliella sinica  Adeolu and Gupta 2015, Borreliella spielmanii  Adeolu and Gupta 2015 should be more appropriately placed in the genus Borrelia as Borrelia bavariensis Margos et al. 2013, Borrelia burgdorferi Johnson et al. 1984, Borrelia carolinensis Rudenko et. al 2011, Borrelia garinii Baranton et al. 1992, Borrelia japonica Kawabata et al. 1994, Borrelia kurtenbachii Margos et al. 2014, Borrelia sinica Masuzawa et al. 2001, Borrelia spielmanii Richter et al. 2006 which we consider to be the correct name of the taxon. Borreliella bavariensis  Adeolu and Gupta 2015, Borreliella carolinensis  Adeolu and Gupta 2015, Borreliella garinii  Adeolu and Gupta 2015, Borreliella japonica  Adeolu and Gupta 2015, Borreliella kurtenbachii  Adeolu and Gupta 2015, Borreliella sinica  Adeolu and Gupta 2015, Borreliella spielmanii  Adeolu and Gupta 2015 should be considered to be synonyms.We consider that Borrelia species belong to the same genus as values for POCP were consistently above the proposed threshold for genus delimitation. We propose to re-establish the genus Borrelia in its original form.The data presented in this study very clearly demonstrate that all groups investigated, i.e. RF group spirochetes, LB group spirochetes, reptile- and echnida-associated Emended description of the genus Borrelia (Swellengrebel 1907) (approved lists 1980)Organisms are helical (0.2–0.3 μm by 10–35 μm). Periplasmic flagella overlap in the central region of the cell. Cells are flexible and motile with rotational and forward/backwards movement. Organisms are host-associated and microaerophilic. They are vectored by argasid ticks, prostriate ixodid ticks, metastriate ixodid ticks and the human body louse. The genome is fragmented into a linear main chromosome, and linear or circular plasmids. The G/C content of the genomic DNA is 27–32 (mol%).Members of this genus are the causative agents of relapsing fever, Lyme borreliosis or of unknown pathogenicity.Borrelia anserina (Sakharoff 1891) Bergey et al. 1925(Approved Lists 1980).The type species is Borrelia afzeliiDescription of  Canica et al 1994rrs gene as well as reactivity of monoclonal antibodies differentiates B. afzelii from other Borrelia species [B. afzelii strains are also distinguishable from all other LB species by using Multilocus sequence analysis [The description is the same as in Canica et al 1994. DNA-DNA hybridization, RFLP of the  species , 27. B. analysis .T (= DSM 10508T = CIP 103469T)Type strain VS461Borrelia lusitaniaeDescription of  The description is the same as given in Le Fleche et al. 1997.T Type strain PotiB2 S1 TableTreponema.A distance matrix of POCP values is given for genera included and shows that the within genus percentages are generally higher than 50% except for (XLSX)Click here for additional data file.


Hepatocellular carcinoma in children with hepatitis B virus infection is rarely reported. Metastases to the vertebrae are an even more unusual phenomenon.We report on a case of a 10-year-old Ethiopian boy with hepatitis B infection presenting with paraplegia and incontinence of 10 days’ duration. A diagnosis of hepatocellular carcinoma with vertebral metastases was confirmed with serum α-fetoprotein, fine-needle aspirate cytology, and abdominal imaging.Surveillance of children not immunized against hepatitis B virus prevents infection and its complications, such as hepatocellular carcinoma. Among children in endemic countries prone to development of hepatocellular carcinoma, metastatic disease can present as sudden weakness of extremities with radiologic findings of vertebral body collapse. Hepatocellular carcinoma (HCC) is one of the top five most common cancers worldwide. A high incidence is seen in sub-Saharan Africa and South-East Asia. Among adults, male sex, advanced age, alcohol use, hemochromatosis, and aflatoxin exposure are potential risk factors. Superseding all risk factors, at any age, are chronic hepatitis B and C infection .Childhood hepatitis B infection is mostly acquired via the perinatal route. Sequelae of chronic infections such as cirrhosis and HCC have rarely been reported in children, with those few reports being notably of adolescents with genotype B infection from South-East Asia. Metastatic HCC occurs through direct, hematogenous, or lymphatic spread. Frequent sites of dissemination are lungs or lymph nodes. Vertebral metastases are infrequently reported . We repoA 10-year-old Ethiopian boy presented to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, with a sudden onset of weakness over his lower extremities. It had started 10 days earlier, accompanied by incontinence of urine and feces. He also had long-standing epigastric pain. He had no fever, diarrhea, cough, unconsciousness, abnormal body movements, or trauma. He had no close contact with a chronic cougher. He had received all scheduled vaccines during infancy, including four doses of oral polio vaccine, except hepatitis B vaccine, because he was born 1 year earlier than the incorporation of a routine three-dose series of hepatitis B vaccines into the national vaccination schedule. (He presented to our center in 2016.) Upon examination, he had an axillary temperature of 38.0 °C and tachycardia (115 beats per minute). He had a hard and tender hepatomegaly of 16-cm total span . Neurologic examination revealed a sensory level at T10, power of 0/5 of bilateral lower extremities, areflexia, and hypotonic anal tone.Investigations confirmed a normal complete blood count and erythrocyte sedimentation rate of 25 mm/hr. The patient’s liver enzymes were elevated: alanine aminotransferase 160 U/L and aspartate aminotransferase 136 U/L. Alkaline phosphatase was 761 U/L, and serum albumin was 3.4 mg/dl. His coagulation profile, renal function, serum electrolytes, blood and urine cultures, and human immunodeficiency virus and hepatitis C serologies were negative. His hepatitis B surface antigen was positive. Additional serologic testing to identify the state of his hepatitis B infection was not accessible.Thoracolumbar magnetic resonance imaging outlined a T9 vertebral body collapse with marrow signal change showing T1 isointensity and T2 heterogeneous hyperintensity. An epidural and paravertebral soft tissue swelling extending from T7 to T11 with postcontrast enhancement was seen to significantly compress the spinal cord. Differential diagnoses of tuberculosis spondylitis and metastases were considered.Workup for a primary malignancy showed elevated serum lactate dehydrogenase (599 U/L) but normal serum uric acid, chest x-ray, and abdominal ultrasound. Computed tomography of the abdomen Fig. a–d reveaSerum α-fetoprotein (AFP) was greater than 40,000 IU/L, and an ultrasound-guided fine needle aspirate showed moderately pleomorphic polygonal cells with round nuclei and ample granular eosinophilic cytoplasm. Thus, a diagnosis of HCC with vertebral metastases was confirmed. The boy’s parents were counseled on the prognosis of the illness, following which they decided against further medical care and opted for home palliative care.HCC is a rare complication of chronic hepatitis B infection in children. None of an Italian cohort of 108 children with hepatitis B infection aged 2–18 years who were observed for up to 24 years developed HCC. Affected children present with localized pain, nausea, vomiting, weight loss, and jaundice. Children diagnosed at an older age have a poor prognosis. Median age at diagnosis is 12 years .Elevated liver enzymes are seen in 40% of children with HCC. Raised serum AFP (higher sensitivity when more than 20 ng/ml) is seen in more than half of patients. Imaging and histology are the main diagnostic tools. Large pleomorphic tumor cells and tumor giant cells with different levels of differentiation are seen in histologic examination. Nervous system involvement in metastatic HCC is reported in 0.28% of cases. Of these, one-third involve the spine, making it an extremely rare observation. The thoracic and lumbar spine are commonly involved with collapse of vertebral bodies and extension into the spinal canal and severe cord compression. T1-weighted images show low-signal lesions [Complete surgical resection should be attempted. Chemotherapy with cisplatin and doxorubicin may be given following complete resection of small tumors (stages 1 or 2). If nonresectable, chemotherapy followed by resection with or without liver transplant may be offered. Chemotherapy has proved futile for stage 4 (metastatic) disease. Overall prognosis is good for stages 1 and 2 disease . Metastatic disease carries a poor prognosis . Early laminectomy prevents complete paralysis. Radiotherapy is recommended for vertebral metastases [Ultrasound surveillance for HCC every 6 months is indicated for hepatitis B surface antigen carrier children, especially those with cirrhosis or a family history of HCC. Our patient had not been vaccinated against hepatitis B. There was a delay in presentation for care for the metastatic HCC, hence aggravating his prognosis. Further serologies could not be tested to identify the stage of the child’s hepatitis B infection .In Ethiopia, screening of children born prior to 2007 and immunizing if a negative result is obtained effectively prevent acquisition of hepatitis B infection and its complications, such as HCC. Metastatic HCC should be considered in high-risk children residing in countries endemic for hepatitis B carriage, such as Ethiopia, and who have sudden onset of weakness of the extremities and imaging findings of vertebral body collapse.


W; wrist-worn weights). Although we found that HR was not significantly different between W6 and the two modes of AG, actual energy expenditure was consistently lower in AG and AGW compared to W6. We observed that playing AG with wrist-worn weights could be used as a means of increasing energy expenditure only at maximum game level, but ineffective otherwise. Our findings indicate that AG in an HMD may not provide a sufficient stimulus to meet recommended physical activity levels despite increased psychophysiological load. The differential outcomes of measures of HR and EE indicates that HR should not be used as an indicator of EE in AG. Yet, adding a simple constraint (wrist-worn weights) proved to be a simple and effective measure to increase EE during AG.Virtual reality using head-mounted displays (HMD) could provide enhanced physical load during active gaming (AG) compared to traditional displays. We aimed to compare the physical load elicited by conventional exercise and AG with an HMD. We measured energy expenditure (EE) and heart rate (HR) in nine healthy men (age: 27 ± 5 years) performing three testing components in a randomised order: walking at 6 km/h (W6), AG, and AG with an additional constraint (AG Insufficient physical activity is one of the main risk factors of non-communicable diseases  . More thWhile media usage such as video games do not provide adequate physical strain ,3, combiOne common feature of all aforementioned studies is that they have used TV or computer screens. Recent technological developments displaying virtual reality (VR) environments using head-mounted displays (HMD) with stereoscopic vision and large field of view have the potential to further increase feelings of immersion and sensory-motor experience compared with 2-D screens . For insHowever, despite the rapid development of commercially-available AG in HMD, no studies have evaluated whether the greater immersive feelings provided by HMD during AG elicit sufficient levels of physical activity. Therefore, the main purpose of this study was to quantify and compare the physiological load elicited by conventional walking exercise with a whole-body, to a commercially-available AG in an HMD. We sought to compare measures of EE, as a measure of true physiological load, to heart-rate (HR), as a general indicator of the total psycho-physiological load experienced by players, to determine whether AG in HMD truly increased energy expenditure or merely increased stress from a heightened emotional engagement in the game. To further highlight any potential discrepancy between EE and HR, we included an additional condition known to promote EE simply by adding weight at the wrists . FinallyNine healthy adult males  with a weekly exercise training time ranging <2.5 to 15 h/wk volunteered for this study. In accordance with the Helsinki Declaration of 1975, as revised in 2008, participants received an information sheet describing study procedures, risks associated with the testing, and were informed they could withdraw at any moment without comment or penalty. All participants gave their written consent prior to inclusion in the study, and their results were anonymised before analysis.All procedures were performed in a controlled laboratory environment . An initial habituation phase was implemented to control for the effects of gaming expertise. Participants were free to practice until they felt comfortable with the game and HMD (10–30 times) with the game used during testing. Following this habituation phase, participants reported to the laboratory for a single session lasting −2.5 h euhydrated and having abstained from alcohol and caffeine for 12 h.W). Prior to the first condition, a 5 min resting period (seating) was observed for baseline measurements, and all conditions were interspersed with resting periods ensuring full recovery .During this testing session, participants performed three tests in a randomized order: a submaximal walking test on a treadmill at 6 km/h for 15 min (W6), one bout of active gaming with HMD at body weight (AG), and one bout of active gaming with HMD and wrist-worn weights , which were continuously monitored by one of the investigators using a purpose-build software . The game ended when opponents entered through the main door of the castle.The virtual reality game used in this study was a free-to-play bow shooting game  for Vive VR headset OPJT100 . The purpose of the game is to defend the entrance of a castle by eliminating successive waves of opponents with increasing difficulty level (successive waves with increasing number of opponents and/or frequency), which determined the level of the game achieved. Difficulty and its evolution were internal parameters of the game, and no modification was made by experimenters. Performance in AG and AGW and recovery periods, using a portable 12-lead electrocardiogram . Individual age-predicted maximal HR (HRmax) was determined using Equation (1) [max using Equation (2):Heart rate (HR) was monitored continuously during W6, AG and AGtion (1)  and HR wW using an automated, breath-by-breath indirect calorimetry system . The metabolic cart was located outside of the reach of participants using a 1.5 m sampling hose, ensuring full range of movement and adding only trivial weight . Relative energy expenditure  was subsequently calculated in the standard manner using minute relative oxygen consumption (VO2) and respiratory exchange ratio (RER), based on the energy equivalent of oxygen (1 L of oxygen yielding 19.6–21.1 kJ for RER ranging 0.7–1.0), as described in Equation (3) [Expired gases at the mouth were continuously measured during W6, AG, and AGtion (3) :EE = VO2p < 0.05. A repeated-measures (RM) design was chosen for this study to capture the range of physical abilities in the participant sample. One-way, repeated measures ANOVAs with Bonferroni post hoc were used to assess the effect of mode  on HR% and EE. Two-way, repeated measures ANOVAs with Bonferroni post hoc tests were used to assess the effect of game level, added weight, and their interaction, on HR% and EE. Pairwise comparisons between AG and AGW  and between W6 and AG and W6 and AGW were tested for significant differences using Student’s t-test (using HR% and EE at maximum level attained).Data are expressed as mean ± standard deviation (SD), and were initially tested for normal distribution using the Shapiro–Wilk W-test. All statistical analyses were performed using the open-access statistical package jamovi , and thed < 0.5, moderate effect: 0.5 < d < 0.8, and large effect: d > 0.8). For ANOVAs, we reported effect sizes using partial eta-squared (η2p) interpreted according to Cohen’s scale .Effect sizes for pairwise comparisons were assessed using Cohen’s d, calculated in the standard manner and interpreted according to Cohen’s scale  induced significantly greater HR% values than rest (p < 0.001), a higher average HR% in AGW compared to AG (p = 0.004), and no significant differences between W6 and AG (p = 0.187), and between W6 and AGW (p = 0.739). There was also a significant main effect of mode with large effect size for average EE (W and W6) induced significantly greater EE values than rest (p < 0.001), and W6 inducing a greater average EE than both AG and AGW conditions (p < 0.001), with no significant difference between AG and AGW (p = 0.079).All participants completed the three components of the testing session. There was a significant main effect of mode with large practical effect for average HR% , with poerage EE , with poW: 14.7 ± 0.9 min; p = 0.807; d = 0.08) or number of actions performed . There were significant and large main effects of game level , added weights  and interaction  on HR% (W at level 4 and maximum level reached (p < 0.001) , added weights  and interaction  on EE (W only at maximum level reached (p < 0.001)  on HR% . Post ho< 0.001) . There w7) on EE . Post ho< 0.001) .p < 0.001, d = 1.749), as well as at maximum AGW level , with a total time spent above W6 longer in AGW than AG . There were no significant differences in EE at W6 and at maximum level during AG  or AGW , and no significant differences in total time spent above W6 between AGW and AG .There were significant differences in HR% at W6 and at maximum AG level  of conventional exercise and AG using HMD, and determine its usefulness as a tool to contribute fighting against the effects of physical inactivity on health.In this study, we observed that AG induced increases in relative heart rate similar to that of a brisk walk compared to rest. However, the main finding of this study was that average EE during the −15 min bout of AG was consistently inferior to walking EE. We initially sought to compare responses in EE and HR to determine whether AG in HMD truly increased physiological load, since, unlike EE, HR can be greatly influenced by both psychological and physiological factors. Therefore, from our findings, it may be inferred that AG in HMD resulted in a greater psycho-physiological strain without accompanying increases in relative energy expenditure. Similar results have been observed in sedentary video games played on 2-D displays with a strong cognitive load, for instance in a racing game raising HR without movement [More specifically, we found that the AG in HMD could elicit levels of physical activity typically found during conventional exercise such as walking, only very briefly, during AG at the maximum level attained. Overall, it is clear that the kind of AG used in this study did not elicit sufficient levels of physical activity, such as may be used to improve health outcomes compared to conventional exercise , and migW condition (+17% in EE and +14% in HR% on average) increased as a function of game level (from 16% to 22% increase in EE and from 11% to 16% increase in HR% from levels 1–4). However, adding weights at the wrists induced EE comparable to W6 only at higher AG levels, and further underscored the comparatively greater response in HR% than EE. Still, we observed that adding wrist-worn weights induced a large change in the time spent at or above walking EE, especially at the higher levels of the game, and thus, this simple physical constraint could be used increase the intensity of physical exercise during AG as is commonly done for conventional exercise [Surprisingly, we also found that playing AG with added weights provoked an increase in EE only at advanced game levels, but not on average: the additional physiological load induced by wearing weight on wrists in the AGexercise . TherefoFinally, although the AG we used was a whole-body exercise, it did not involve rhythmic activity from large muscle masses and required only quick shuffling to change positions. Following previous endeavours in AG with 2-D  or 3-D dThe findings of the current study indicate that the enhanced immersive feelings provided during active gaming in a head-mounted display were not sufficient to meet recommended physical activity levels. The differential outcomes of measures of relative heart rate and relative energy expenditure indicates that heart rate, as a global measure of psycho-physiological strain, should not be used as an indicator of energy expenditure in active gaming designed for increasing levels of physical activity. Surprisingly, adding a simple constraint (wrist-worn weights) during active gaming was effective to increase energy expenditure at levels comparable to conventional exercise only at the highest level of the game.


Health professionals working with older persons are not sufficiently aware of the sensory and functional difficulties experienced by older patients. Innovative educational activities, such as the aging-simulation experience, can facilitate this awareness. This study describes the effects of an aging-simulation experience on health professionals’ representations towards age-related limitations.306 health professionals, enrolled in university training in geriatrics/gerontology in the 2015–2016 and 2016–2017 academic years, experienced an aging-simulation session wearing a special suit according to a predefined scenario. Before and after the aging-simulation experience, participants completed free association tests, with the inductive words vision, hearing, movement, fine dexterity and balance. Semantic categories were created from participants’ free evocations using a correspondence table manually produced in Excel 2013 for Windows . Moreover, participants’ opinions on difficulties experienced by older people in relation to age-related limitations were studied using Likert scale questions.In total, 3060 free evocations were collected, and ten semantic categories were created. These categories were composed of participants’ geriatric knowledge, about age-related limitations, and participants’ feelings, about the experience of these limitations. These two aspects were impacted by the aging-simulation experience. Moreover, changes observed resulted in a better consideration of difficulties associated with age-related limitations.The aging-simulation experience is an effective educational tool to raise awareness among health professionals of age-related difficulties. This sensory activity allows health professionals to put themselves in the shoes of older patients and to feel age-related difficulties. With the aging process, age-related functional and sensory disabilities mainly affect people aged 70 and over. Decreased visual and aural acuity, difficulty with mobility, decreased fine dexterity and loss of balance are the principal manifestations of these limitations. Thus, among people aged 80 and over, 26.7% have three or more physical limitations, 6.6% have two physical limitations and 9.6% have one physical limitation . As a reOlder patients represent an important part of the population in care services , 9, 15. Changing health professionals’ viewpoint contributes to improve care for older persons. Lifelong learning plays an important role in enhancing representations toward older patients. Simulation-based medical teaching and learning has significantly expanded in recent years. The impact of procedural simulation techniques, on quality of care, in obstetrics  and emerThe aging-simulation experience is an innovative pedagogical device allowing health students and professionals to experience the functional and sensory limitations associated with aging. This sensory activity improves health students’ empathetic attitudes towards older adults , 18, 29 In this study, we deeply analyze the effects of the aging-simulation experience by focusing on its impact on health professionals’ representations towards age-related limitations. To our knowledge, this approach has never been realized until now.This quantitative study constituted the first part of a sequential explanatory research design (mixed methods); with a qualitative study, in the process of being published, compounding the second part. These two studies were included in a research program examining the impact of an aging-simulation experience on representations, attitudes and care practices towards older persons.We included healthcare professionals working in geriatrics. These professionals undertook geriatrics/gerontological teaching over two academic years (2015–2016 and 2016–2017). We excluded the participants who had already realized the sensory activity, those with back pain, and pregnant women.We conducted a before/after study asking participants to complete a questionnaire on social representations towards age-related limitations, before and after the sensory activity. This experience was conducted in three phases. First of all, we informed participants about the contents of the workshop and the trainer reminded them of the rules of this educational activity . During this step, participants completed the pre-test questionnaire. Secondly, we conducted the sensory activity. Each participant carried the aging suit for an average of 15 min and performed different actions according to a defined scenario: going up and down stairs, lying down on the floor and getting up, sitting and getting up from a chair, drinking a glass of water and eating. Thirdly, participants completed the post-test questionnaire at the end of the sensory activity. Finally, we held a debriefing allowing participants to share experiences and emotions generated by the simulation activity.Our questionnaire was constituted by five free association tests structured around five inductive words: vision, hearing, movement, fine dexterity and balance of older persons. The five inductive words were chosen because of the high prevalence of limitations affecting these functions. The five free association tests were worded as follows: “Could you indicate three words that you think best represent the vision of older people?” The pattern of these questions was the same for all the five inductive words vision/hearing/movement/fine dexterity and balance.To complete these free association tests, participants’ opinions on the difficulties experienced by older people, in relation to age-related limitations, were studied before and after the simulation using five Likert scale questions. These questions were worded as follows: “In your opinion, do older people experience difficulties related to visual decline in daily life? Yes severe/yes significant/yes moderate/yes mild/none/no answer”. The pattern of these questions was the same for the difficulties related to visual decline/to hearing decline/to movement disorders/ to alteration of fine dexterity and to balance disorders. To avoid restricting speech, we conducted free association tests before Likert scale questions.Several elements forming the GERT® age-simulation suit  were used in our study: overshoes reducing perception of the ground, knee and elbow pads limiting movement, weights on wrists and ankles reproducing muscle loss and making movements more difficult and less precise, a ballasted plastron (about 5 Kilograms) causing an arched posture and slowing movement, a cervical collar limiting neck mobility, a headset and glasses respectively simulating the presbycusis and the presbyopia, gloves limiting finger mobility and simulating loss of sensitivity.18 into Excel 2013 for Windows . We created semantic categories from these free evocations, using a correspondence table manually produced in Excel 2013. This table, enriched progressively, was the result of a consensus between two researchers. Using Excel 2013, we calculated the number and percentage of participants who cited each category before and after the aging-simulation experience. We retained the categories cited by at least 10% of participants before and after the experience. The categories cited by less than 10% of participants were not considered in further data analyses. For the analysis of the Likert scale questions, the number and percentage of each type of answer yes severe/yes significant/yes moderate/yes mild/none/no answer, were calculated in Excel 2013 before and after the aging-simulation experience.We transferred the participants’ free evocationsWe applied the McNemar test and the odds ratio calculation to compare participants’ free evocations before and after the sensory activity. We used the chi-square test to compare participants’ answers to the Likert scale questions. We performed these statistical tests using XLSTAT 2017.6 software for Windows .We informed all the participants about the study and we received their agreement to participate. We were careful to limit risk to participants by excluding pregnant women and individuals with back pain. In addition, we accompanied participants during the simulation experience to avoid any accidents. Data collected were handled and stored in accordance with the tenets of the Declaration of Helsinki (2008). According to the Jardé Law on research involving the human person, whose implementing decree came into force on 18 November 2016, such research does not require ethical approval. Verbal informed consent, sufficient for this type of research, according to current legislation, was obtained from all participants.n = 211) were female, 31% (n = 95) were male and the average age was 42 (18–68) years. Participants were working as physicians , nurses , occupational therapists , psychomotor therapists , health managers , psychologists , pharmacists , physical therapists , osteopaths , orderlies  and dieticians . In parallel with their professional activity, participants were enrolled in geriatrics/gerontology training including a university degree , a master’s degree  and a short two-day training session . Fifteen (5%) participants did not mention the training taken.We proposed the aging-simulation experience to 325 health professionals. Among them, 19 (6%) were excluded of the study due to eligibility criteria: 7 (2%) participants had already realized the sensory activity, 10 (3%) participants had back pain and 2 (1%) participants were pregnant women. Among the 306 health professionals included in the study, 69%  to 242 (79%), P = .002) and slowness (from 232 (76%) to 190 (62%), P < .001) after the simulation experience than before. Conversely, after the experience, more participants cited the categories stiffness (from 34 (11%) to 52 (17%), P = .02), loneliness (from 35 (11%) to 76 (25%), P < .001) and difficulties (from 129 (42%) to 183 (60%), P < .001). Secondly, looking independently at each free association test (Table decreased vision (from 272 (89%) to 280 (92%), OR 1.03 (0.60–1.76)) increased after the sensory activity; for the free association test 2 (inductive word “Hearing”), the number of participants citing the category decreased hearing (from 265 (87%) to 240 (78%), OR 0.91 (0.59–1.39)) declined after the sensory activity and this number increased for the category loneliness (from 32 (10%) to 76 (25%), OR 2.38 (1.52–3.72)); for the free association test 3 (inductive word “Movement”), the number of participants citing the categories slowness (from 217 (71%) to 183 (60%), OR 0.84 (0.60–1.18)), loss of balance (from 46 (15%) to 39 (13%), OR 0.85 (0.54–1.34)) and negative emotions (from 73 (24%) to 62 (20%), OR 0.85 (0.58–1.25)) declined after the sensory activity and this number increased for the category difficulties (from 54 (18%) to 105 (34%), OR 1.94 (1.33–2.83)); for the free association test 4 (inductive word “Fine dexterity”), the number of participants citing the categories slowness (from 47 (15%) to 54 (18%), OR 1.15 (0.75–1.76)), negative emotions (from 39 (13%) to 46 (15%), OR 1.18 (0.74–1.87)) and difficulties (from 61 (20%) to 104 (34%), OR 1.7 (1.18–2.46)) increased after the sensory activity; and, for the free association test 5 , the number of participants citing the categories loss of balance (from 241 (79%) to 250 (82%), OR 1.04 (0.7–1.55)) and fall (from 50 (16%) to 65 (21%), OR 1.3 (0.86–1.96)) increased after the sensory activity.We observed statistically significant changes in the categories quoted by participants before and after the aging-simulation experience. First of all, looking at the results for the whole of the five free association tests Table , we noten = 193 (63%) to n = 275 (90%), P < .001). The same pattern was observed for difficulties related to visual decline (from n = 165 (54%) to n = 248 (81%), P < .001), to hearing decline (from n = 193 (63%) to n = 263 (86%), P < .001), to alteration of fine dexterity (from n = 193 (63%) to n = 257 (84%), P < .001) and to balance disorders (from n = 162 (53%) to n = 242 (79%), P < .001). Thus, participants considered age-related difficulties to be more important after the sensory activity than before.Participants’ opinions on difficulties experienced by older people were impacted by the aging-simulation experience. Indeed, whatever the limitation questioned , we observed large differences in the distribution of participants’ answers pre- and post-sensory activity Fig. . ParticuIn this study we were interested in the impact of an aging-simulation experience on health professionals’ representations towards age-related limitations. We described that these representations were constituted by participants’ feelings and by participants’ geriatric knowledge about age-related limitations. We observed that these two aspects were impacted by the aging-simulation experience. Furthermore, after the sensory experience, participants’ opinions were oriented on a better understanding of difficulties experienced by older people. It is interesting to observe that, among a group of health professionals working with older patients, the aging-simulation experience impacted feelings and knowledge. We hypothesize that the strong emotional power  of this An original point of our study was using free association tests to explore representations of age-related limitations in geriatrics, these tests allowing a satisfactory investigation. The creation of a correspondence table, between participants’ free evocations and semantic categories, permitted to precisely describe these representations. The approach developed in this study is original and complementary to previous research focusing on the impact of this sensory experience on health students and professionals’ attitudes towards older persons. Indeed, earlier studies showed that the aging-simulation experience raised awareness of the importance of environmental adaptation to limit disabilities related to functional and sensory limitations  and imprHowever, this study had several notable limitations. Firstly, there is a selection bias due to the choice of our population of both health professionals and students. Indeed, the dual learner/health professional profile was relevant for our research because it allowed an easy recruitment and possibility to follow participants over time. However, persons enrolled in training have characteristics that do not attribute to the whole group of health professionals, such as reflexive posture, analytics abilities and motivation to learn . MoreoveThe investigation of social representations towards age-related limitations, located halfway between social representations of old age and social representations of health and disease, presents a real utility because it targets a large community of professionals and patients. For this work to be complete, an investigation into the long-term repercussions of the aging-simulation experience is required. Thus, our upcoming qualitative study, forming the second part of our sequential explanatory research design, will finalize this work.


Hypophosphatemia generally occurs in Intensive Care Units (ICUs), but its impact is often ignored. The aim of this study was to investigate whether hypophosphatemia can be a risk factor for ICU 28-day mortality.A single-center retrospective cohort study was conducted by collecting data from 1073 patients admitted to general ICU and then presented to the Sixth Affiliated Hospital, Sun Yat-sen University  from 1 January 2016 to 31 December 2017. The patients were divided into a normal control group (serum phosphate levels 0.80–1.60 mmol/L) and a hypophosphatemia group (serum phosphate levels < 0.80 mmol/L), based on the concentration of phosphorus at the time of ICU admission. The association between phosphate levels and ICU 28-day mortality was evaluated by binary logistic regression analysis. Multivariate logistic regression was employed to predict the ICU 28-day mortality.P < 0.05). Patients with hypophosphatemia had a longer ICU and hospital stays, and prolonged duration of mechanical ventilation . Hypophosphatemia was an independent risk factor for ICU 28-day mortality  in the multivariate logistic regression analysis.The cohort included 946 patients with a median phosphate concentration of 0.77 mmol/L (interquartile range 0.55–1.03 mmol/L). Patients with hypophosphatemia had a higher ICU 28-day mortality than the normal control group . No consent was given as the data were analyzed anonymously. Phosphate is a vital component of the lipid bilayer in the cell membrane, which has essential functions in many biological processes, such as adenosine triphosphate production, glycolysis, pH buffering, 2,3-diphosphoglycerate  synthesis, mitochondrial functions, enzyme regulation, signal transduction, and nucleotide metabolism –3. FurthPhosphate homeostasis is complex, and the phosphate ion may be influenced by other factors, such as decreased renal clearance, increased consumption in catabolic patients, intestinal losses, or clearance over a continuous renal replacement therapy (CRRT) membrane. Importantly, hypophosphatemia is among the most frequently encountered electrolyte metabolic disturbances in critically ill patients with an incidence and prevalence ranging within 2.4–100% , 14. UnlHypophosphatemia is often not diagnosed, because it remains asymptomatic, frequently presenting as fatigue and irritability. Reportedly, hypophosphatemia is associated with longer ICU and hospital stays , 15–17, Although many studies have discovered that episodes of hypophosphatemia during the ICU stay is associated with increased mortality, whether it directly leads to higher mortality or is merely a marker of disease severity in the general ICU still remains uncertain. Few studies have been carried out to investigate the association between the serum phosphorus levels at admission and the outcomes of general ICU population. We speculated that hypophosphatemia would have an unfavorable impact on ICU 28-day mortality and can be a marker of disease severity. To confirm this assumption, a single-center retrospective cohort study was conducted to determine whether patients with hypophosphatemia had higher mortality than patients with normal serum phosphate levels. Our primary study endpoint was patient mortality on the 28th day.The study was conducted from 1 January 2016 to 31 December 2017 after approval by the Institutional Ethics Committee of the Six Affiliated Hospital, Sun Yat-sen University. A waiver for informed consent was obtained for this retrospective cohort study as data were analyzed anonymously. The data can be accessed with permission from the Institutional Ethics Committee of the Six Affiliated Hospital, Sun Yat-sen University by contacting the corresponding author. A total number of 946 patients were included at ICU admission. The following inclusion criteria were used: (1) age ≥ 18 years; (2) patients with serum phosphate level measured at admission at ICU; (3) survival status for a follow-up period of 28 days after ICU admission. The criteria for exclusion were: (1) age below 18 years; (2) pregnancy; (3) patients with a hospital stay of > 180 days; (4) patients who could not be followed up; (5) patients without serum phosphate level measured at admission to ICU; (6) patients with hyperphosphatemia (serum phosphate levels > 1.60 mmol/L).A number of 1073 of patients were identified and screened, and 127 patients were excluded, resulting in a cohort of 946 patients finally included in our investigation.Variables were obtained from electronic medical records using the patient’s hospital admission number. The medical record of each patient who met the inclusion/exclusion criteria were reviewed to collect the following data: (1) age, (2) sex, (3) reason for ICU admission,(4) underlying disease,(5) medications, (6) nutrition, (7) Acute Physiology and Chronic Health Evaluation (APACHE II), levels of (8) phosphate, (9) potassium, (10) creatinine, (11) serum calcium, (12) serum albumin, and (13) glomerular filtration rate (GFR) patient admission to the ICU; the medical treatment included (14) mechanical ventilator time and (15) renal replacement therapy time. The parameters of the clinical outcomes included ICU’s length of stay, hospital’s length of stay, and ICU 28-day mortality. Parameters were obtained from electronic medical records by two independent, well-trained researchers. The data for the 28-day mortality in ICU was confirmed by telephone follow-up and inspection of the electronic medical data.All phosphate level data were collected by the Laboratory for Clinical Chemistry at the Sixth Affiliated Hospital of Sun Yat-sen University using phosphomolybdate method by Beckman AU 5800. The reference range of phosphate was 0.80–1.60 mmol/L.Phosphate concentrations at admission to the ICU were obtained, and the patients were divided into two groups. Patients with serum phosphate concentrations between 0.80 and 1.60 mmol/L were included in the normal control group, whereas those with phosphate concentrations lower than 0.8 mmol/L composed the hypophosphatemia group.t-test. The other variables were analyzed using the Mann-Whitney U-test; categorical variables were compared through the chi-square test. Binary logistic regression analysis was employed to assess the association of variables with ICU 28-day mortality. Multivariate logistic regression was utilized to identify the risk factors for 28-day ICU mortality. P < 0.05 was considered statistically significant.Statistical analysis was conducted by SPSS 20.0 software. Continuous variables are expressed as mean and SD or median with interquartile range, depending on the underlying data distribution. Categorical variables are reported as percentages and frequencies. The continuous variables for age were compared by the APACHE II scores using the Student’s A total number of 1073 of adult patients were admitted to the general ICU from 2015 to 2016, of which 946 patients met the inclusion criteria. Of the total cohort, 504/946 (53.27%) and 442/946 (46.73%) were classified into the hypophosphatemia group and the normal phosphate group, respectively  than the normal control group. Additionally, the patients in the hypophosphatemia group had a longer ICU stay with a median of 5.5  than those in the control group, the median of which was 1.7 , P < 0.05. Similar results were obtained for the length of hospital stay.As can be seen in Table P < 0.05). As illustrated in Fig. A total number of 526 of 946 (55.6%) patients received ventilation. Significantly higher mechanical ventilation was applied for the patients in the hypophosphatemia group as compared to those in the normal control group .The association of different laboratory parameters with ICU 28-day mortality is presented in Table Although previous studies have indicated that hypophosphatemia is associated with worse clinical outcomes in critically ill patients , 20, fewP = .0089). However, they defined hypophosphatemia as phosphate levels < 0.7 mmol/L and no phosphate levels > mmol/L during the ICU stay. A retrospective study was conducted by Yi Yang [P = 0.008). Renana Shor [P = 0.001). But unlike our study, they selected septic patients for study subjects, with a small population size. On the other hand, Dominik [Earlier evidence has revealed that episodes of hypophosphatemia during the ICU stay is associated with higher mortality in the ICU population , 15–17. ana Shor  reported Dominik  and Sato Dominik  found thWe found that male sex, APACHE II scores, serum albumin level and hypophosphatemia were associated with 28-day mortality in the general ICU population. Then, we examined whether the association between phosphorus levels and 28-day mortality were related to the illness severity and the nutritional status. Even after adjustment for APACHE II scores and serum albumin, and the gender, hypophosphatemia (< 0.80 mmol/L) was still associated with increased 28-day mortality. This indicates that hypophosphatemia (< 0.80 mmol/L) was associated with the 28-day mortality regardless of the illness severity and nutritional status in the general ICU.In the present investigation, we established that hypophosphatemia was associated with an increased duration of mechanical ventilation. As Christopher  reportedP = 0.00), and the former had a longer duration of RRT time. Renal replacement therapy (RRT) has been recommended for severe renal failure in critically-ill patients, such as those patients with sepsis shock and complicated with acute renal failure (ARF). RRT is also used in patient with chronic renal failure in the situation of hemodynamic instability. In our study population, although there was no difference between the two groups in the reasons for ICU admission, but the number of septic shock patients complicated with acute renal insufficiency and received RRT therapy in hypophosphatemia group is higher than that in the control group .Our study showed that the hypophosphatemia group had a higher proportion of RRT than that in the normophosphatemia group (8.8% VS 18.7%, Hypophosphatemia may lead to a multitude of complications in critically ill patients , 10 sincSome important limitations to our study should be acknowledged. First, this investigation was retrospective and performed at a single medical center. Second, we identified only the baseline measurements of the plasma phosphate level, which hindered the evaluation of plasma phosphate values over time. Phosphate replacement  is recomPhosphate abnormality is common in ICU, and hypophosphatemia is an independent indicator of 28-day mortality in the general ICU population. The development of hypophosphatemia should be diagnosed early to prevent its harmful effects.