Parachlorella beijerinckii has been used as a health food supplement for many years and contains carotenoids and vitamins that have antioxidant and anti-inflammatory effects. The aim of this study was to investigate whether Chlorella extract also has antiglycation activity. Antiglycation activity was measured using fluorescent AGEs, Nε-(carboxymethyl) lysine (CML), and Nε-(carboxymethyl) arginine (CMA) from glycated bovine serum albumin and type I collagen in vitro. A gel with a dermis-like structure consisting of collagen and a live fibroblast cell line was glycated with glyoxal. The content of fluorescent AGE, CML, and CMA, and the gel contraction activity were measured. In addition, to investigate the level of inflammation induced by the glycation of the collagen gel, the expression level of the receptor for AGEs and interleukin-8 were examined. Fat-solubleChlorella extract suppressed the formation of fluorescent AGEs, CML, and CMA in both models. These results indicated that Chlorella extract directly inhibited AGE formation. The collagen gel contracted over time during culturing, whereas contraction was inhibited in the glyoxal-treated collagen gel. Chlorella extract remarkably attenuated the glyoxal-induced gel contraction. Moreover, Chlorella extract substantially decreased the fluorescent AGEs, CML, and CMA in the collagen gels with glyoxal. Glyoxal exposure increased the expression levels of interleukin-8 and receptor for AGE proteins in collagen gels, while Chlorella extract inhibited this increase. This study showed that fat-solubleChlorella extract has a direct inhibitory effect on AGEs and decreases receptor expression for AGE-mediated inflammation by reducing AGEs. Chlorella may delay skin aging by inhibiting the formation and accumulation of AGEs.Advanced glycation end products (AGEs) are formed via a nonenzymatic glycosylation reaction called glycation. The formation and accumulation of AGEs increases in skin with age, contributing to the appearance of facial wrinkles and loss of skin elasticity. Therefore, inhibition of AGEs may delay skin aging. The microalgae  The Schiff base spontaneously rearranges into an Amadori product, which induces further oxidation, giving rise to advanced glycation end products (AGEs). In the skin, an increase in autofluorescence with age reflects the accumulation of fluorescent AGEs. Nical age , 2. Moreical age , 4.in vivo [Dermal extracellular proteins are considered major targets for glycation. Collagen is the main structural protein in the dermis, and its glycation induces the cross-linking of proteins. Accumulation of glycated collagen results in a long half-life and slow renewal of proteins in vivo . Moreovein vivo . For exain vivo , accelerin vivo –9, and iin vivo . These bin vivo . TherefoChlorella, a unicellular green alga, has been used as a health food supplement for many years and has been considered to be safe. It contains a wide variety of vitamins and carotenoids, which have recently been reported to have antioxidant, anti-inflammatory, and antidiabetic effects [Chlorella–a Parachlorella beijerinckii strain–has inhibitory effects against obesity, dementia, muscle atrophy, and inflammasome activation in rodent models [P. beijerinckii. These findings suggest that P. beijerinckii has the potential to suppress the formation and accumulation of AGEs and AGEs-induced inflammation. However, no studies have evaluated the antiglycation activity of P. beijerinckii.Synthetic inhibitors, such as aminoguanidine (AG), have been used to inhibit the formation of AGEs and to strongly inhibit glycation. However, prolonged use of AG has been reported to cause some side effects . Glycati effects –21. We ht models –25. ThesP. beijerinckii exhibit direct antiglycation activity by inhibiting the glycation of bovine serum albumin (BSA) and collagen by glucose and glyoxal using an in vitro model. We also determined the inhibitory effects of glyoxal-induced glycative stress in a dermis-like model constructed from collagen gel and live fibroblasts and evaluated its potential contribution to the suppression of skin aging.The purpose of this study is to examine whether the components of D-glucose, aminoguanidine hydrochloride (AGH), 40% glyoxal solution, chloroform, 2-propanol, and 70% ethanol were purchased from Wako Pure Chemical Corporation . BSA was purchased from Sigma-Aldrich . Acid-soluble bovine skin collagen type I was purchased from Nippi .Chlorella extract was prepared according to a previous method [Chlorella (Parachlorella beijerinckii) was cultured, dried, and powdered by Chlorella Industry Co. Ltd. Chlorella powder was extracted with methanol and chloroform (1 : 2) at 25°C overnight in the dark. The extract was filtered through a filter paper, evaporated under reduced pressure, and dissolved in ethanol. For saponification, 50% KOH (w/v) was added to the extracted solution for 2 h. After saponification, 3% NaCl (w/v), distilled water, and diethyl ether were added. The residue was extracted with diethyl ether three times. The upper layers were evaporated and dissolved in tetrahydrofuran, dimethyl sulfoxide, and ethanol (1 : 1 : 2) to prepare a stock solution. The stock solution was stored in the dark at −80°C. Carotenoids and tocopherol in Chlorella extracts were measured using high performance liquid chromatography (HPLC) as described in a previous method [β-carotene (97.7 mg/g extracts), zeaxanthin (40.3 mg/g extracts), α-tocopherol (27.8 mg/g extracts), and α-carotene (12.5 mg/g extracts). However, approximately 40% of the extract weight was unknown.s method . Brieflyμg/mL CE (each contained 1 and 10 μM of Lutein) were used for experimentation. AGH solution (1 mM) was used as a positive control [μg/mL) at 37°C for four weeks. For the glyoxal glycation test, collagen (1 mg/mL) was incubated with 1 mM glyoxal in phosphate buffer with or without CE (1.65 and 16.5 μg/mL) at 37°C for one week [BSA was dissolved in phosphate buffer  with glucose or glyoxal. Glyoxal is a physiological metabolite formed by lipid peroxidation, ascorbate autoxidation, oxidative degradation of glucose, and degradation of glycated proteins. It has also been identified as a reactive dicarbonyl formed during AGE generation and is far more reactive than D-glucose and most other reducing sugars . The gly control . Collage control , collageone week . GlucoseFluorescent AGEs, the irreversible products at the end stage of nonenzymatic glycation, were determined using a spectrofluorometer  at excitation and emission wavelengths of 355 and 460 nm, respectively.The OxiSelect CML competitive ELISA kit was purchased from CELL BIOLABS Inc. . The concentration of CML was determined using an enzyme-linked immunosorbent assay (ELISA) according to the manufacturer's instructions. The absorbance of the samples was compared with that of the CML-BSA standard provided in the assay kit.μL of type I collagen (3 mg/mL) dissolved in 5 mM acetic acid, 198 μL of 10× Hanks' solution, and 522 μL of 5 mM acetic acid. Then, NaOH was added dropwise to neutralize the solution. The gelation collagen solution  was mixed with fibroblasts (3.0 × 105), resuspended in 200 μL of fetal bovine serum and seeded into a 6-well culture plate, and the gels were detached from the rim of the wells and incubated at 37°C and 5% CO2 further for three days. The gels were photographed using a SONY DSC-WX350 camera . Gel areas were calculated using ImageJ software .Dermis-like structure collagen gels were prepared by modifying previously described methods –35 usingChlorella increased plasma lutein concentration to about 1.2 μM [μg/mL CE (1 μM lutein). To examine the effect of CE on contraction capacity, fibroblasts used for collagen gelation were pretreated with CE  or AGH  for three days. Following this, they were treated again with the same concentration of CE or AGH. Then, to induce glycation, glyoxal  was added and the cells were cultured for three days. In this experiment, AGH was examined at two concentrations, with the lowest concentration (50 μM) being the blood concentration when 0.3 g of AG was ingested [We previously reported that the ingestion of t 1.2 μM . Therefoingested . Thus, wβ-actin . Horseradish peroxidase-conjugated secondary antibodies  were used. Detection was performed by chemiluminescence using enhanced chemiluminescence (ECL) Western Blotting Detection Reagents  and Western Lightning Ultra . The detected CMA and RAGE band intensities were analyzed and quantified using the Image Studio™ analysis software .The sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS-PAGE)-separated proteins were electrophoretically transferred to a polyvinylidene difluoride (PVDF) membrane . The membranes were blocked  and then incubated with the following primary antibodies: anti-CMA , anti-RAGE , and anti-Collagen gels were cut into small pieces with scissors. HCl (0.01 M) was added to the fragmented collagen gel to make a 100 mg/mL collagen solution (w/v). The solution was incubated overnight at 37°C and centrifuged at 15000 rpm for 5 min. AGEs were recovered from the supernatant. CML, CMA, and RAGE in the supernatant samples were analyzed using CML ELISA and western blotting. Samples collected from incubation were loaded onto gels after heating with 4× SDS sample buffer at 96°C for 5 min. Electrophoresis was conducted using 10% gels.TM RT Reagent Kit , in accordance with the manufacturer's instructions. Additionally, qRT-PCR analysis was performed using specific primers . Relative quantification was performed using the ΔΔCt method in combination with reference genes for data normalization.To examine cell-mediated contraction, the gels were detached from the rim of the wells and incubated for up to 24 h. The gels were recovered and 1 mL ISOGEN  was added to glycated collagen gels. Then, the gel was cut with scissors and homogenized using a BioMasherII . Total RNA was extracted from cells in the glycated collagen gels using ISOGEN in accordance with the manufacturer's instructions. RNA samples were reverse transcribed using the PrimeScript primers  and TB Gp were calculated using unpaired two-tailed Student's t tests. Differences between the groups were considered statistically significant at p < 0.05.All experiments were performed in triplicate or greater. All graphs display the mean ± standard deviation (SD). Statistical analysis was performed using the Bell Curve for Excel . Values of Chlorella and investigated their inhibitory effects on fluorescent AGE formation in an in vitro system. The fat-soluble extract greatly inhibited fluorescent AGE formation, whereas the water-soluble extract resulted in slight inhibition   , the fluμM) . In addi Figures . These rIL-8), IL-6, and tumor necrosis factor alpha (TNF-α)). One day after glyoxal treatment of the collagen gel, the expression level of IL-8 mRNA was substantially increased in a dose-dependent manner  suppressed RAGE expression to the same level as that of the control group . These carotenoids may have synergistic effects that exhibited antiglycation activity in this study. However, given that approximately 40% of the components of fat-solubleChlorella extracts are unknown, further research is required to identify the ingredients of Chlorella that exert antiglycation activity.In many studies, redients –18. Usin Figures . Zheng eportions , which ilycation . BecauseChlorella suppressed the formation of CML and CMA, which passed the oxidation step during production. Furthermore, the Parachlorella beijerinckii strain that we used in this study has been shown to have antioxidant effects [Chlorella extract might contribute to the inhibition of AGE formation. In addition, collagen type I is the major structural component of the dermal extracellular matrix and accounts for >70% of skin dry weight, providing the dermis with tensile strength and stability [Chlorella are able to reach the skin tissue, glycation and aging in the skin may be reduced.The formation of AGEs involves molecular processes based on simple or complex multistep reactions, including an oxidative step . In this effects –25, suggtability . AGEs hatability , 2, 42. Chlorella, more specifically Parachlorella beijerinckii, has been used as a dietary supplement in Japan for about fifty years and no side effects have been observed. Its continuous ingestion for 6−16 months in animal experiments or for 1−5 months in clinical trials was also not associated with adverse effects [Chlorella may be used as a long-term ingestible antiglycation supplement as it has no reports about side effects. As a high CE concentration was shown to be as effective as or better than a low AG concentration in all experiments using collagen gel, it may show the same inhibitory effect on glycation as AG in vivo. However, because these experiments were conducted in vitro, further in vivo studies are warranted.In this study, we used aminoguanidine (AG) as a positive control for assessing antiglycation activity. AG is known to have strong antiglycation activity  and show effects , 44–47. Chlorella attenuated AGE-induced dysfunction in gels composed of skin fibroblasts and collagen (Chlorella, as shown in Figures Chlorella on glycation inhibition was not stronger than that of AG, Chlorella showed the same effect as AG in the experiments using collagen gel. This suggests that Chlorella has a mechanism to suppress the adverse effects induced by AGEs other than the direct inhibition of glycation. Owing to the fact that the lipophilic extract of Chlorella exhibits anti-inflammatory effects [Chlorella may suppress inflammatory signals in the fibroblasts contained in the collagen gels. Additionally, IL-8 expression was reported to be induced via signaling pathways activated by RAGE ligand recognition in normal skin fibroblasts [Chlorella reduced the mRNA expression level of IL-8. These results suggest that Chlorella has at least two mechanisms for alleviating the adverse effects of AGEs. The first is direct AGE inhibition, and the second is suppression of the inflammatory pathway initiated by RAGE activation. RAGE gene and protein expression are upregulated by AGEs [Chlorella not only suppresses inflammation but also suppresses the expression of RAGE. These results indicate that Chlorella may delay skin aging by suppressing chronic inflammation. However, our study did not clearly indicate whether the antiglycation and anti-inflammatory effects of Chlorella inhibit skin wrinkles and loss of elasticity; therefore, further research is required regarding the inhibitory effects of Chlorella on these processes.AGEs not only alter the physicochemical properties of biomolecules, such as proteins, lipids, and nucleic acids, but also bind to RAGE, initiating a cascade of signals that influence the cell cycle and proliferation, gene expression, inflammation, and ECM synthesis . In thiscollagen . These r effects , Chlorelroblasts . We foun by AGEs , 49, and by AGEs . TherefoParachlorella beijerinckii, which has been used as a safe supplement for many years–directly inhibit the glycation of BSA and collagen, as well as maintain the normal contraction of derma-like collagen gel by suppressing the accumulation of AGEs and RAGE-mediated inflammation. These results suggest that Parachlorella beijerinckii inhibits glycation stress and may slow age-related skin wrinkles and elasticity loss that occurs with an increase in age.In this study, we demonstrated that carotenoids–the major fat-soluble extract of


The rats trained three times a week for 12 weeks on a climbing ladder. An echocardiogram was performed before and after training. Protein expression of the insulin-like growth factor (IGF)-1/protein kinase B (Akt)/rapamycin target complex (mTOR) pathway was analyzed by Western blot. Results: Mortality rate was higher in MI than Sham; in the R-MI group, mortality rate was between that in MI and Sham and did not differ significantly from either group. Exercise increased maximal load capacity without changing cardiac structure and left ventricular function in infarcted rats. Infarction size did not differ between infarcted groups. Catalase activity was lower in MI than Sham and glutathione peroxidase lower in MI than Sham and R-MI. Protein expression of p70S6K was lower in MI than Sham and p-FoxO3 was lower in MI than Sham and R-MI. Energy metabolism did not differ between groups, except for higher phosphofrutokinase activity in R-MI than MI. Conclusion: Resistance exercise is safe and increases muscle strength regardless structural and functional cardiac changes in myocardial-infarcted rats. This exercise modality attenuates soleus glycolytic metabolism changes and improves the expression of proteins required for protein turnover and antioxidant response.Although current guidelines recommend resistance exercise in combination with aerobic training to increase muscle strength and prevent skeletal muscle loss during cardiac remodeling, its effects are not clear. In this study, we evaluated the effects of resistance training on cardiac remodeling and the soleus muscle in long-term myocardial infarction (MI) rats. Methods: Three months after MI induction, male Wistar rats were assigned to Sham ( Cardiovascular disease is an important worldwide cause of morbidity and mortality . MyocardIn addition to affecting the heart, MI also induces changes in organs such as the liver and kidneys, and skeletal muscles. Alterations in skeletal muscles mainly occur in advanced heart failure and contribute to a reduced functional capacity and ability to perform physical activities ,6,7. SkePhysical exercise has displayed beneficial effects in experimental studies ,17,18,19Current guidelines recommend resistance exercise in combination with aerobic training to improve functional capacity, increase muscle strength, and prevent or reverse skeletal muscle loss ,34. HoweIn a previous study, we analyzed the effects of aerobic and resistance exercise on the gastrocnemius of infarcted rats . DespiteMale Wistar rats weighing between 200–250 g were purchased from the Central Animal Center of Botucatu Medical School, UNESP. The animals were kept in collective cages with three animals each in a temperature-controlled room with a 12-h light–dark cycle. The experiments and procedures were approved by the Animal Experimentation Ethics Committee of Botucatu Medical School, UNESP, SP, Brazil, in accordance with the rules of the Brazilian College of Animal Experimentation.n = 14), MI (n = 26), and resistance exercised MI . Physical training was maintained for 3 months. At the end of the experimental period, rats were subjected to transthoracic echocardiogram, exercise testing, and euthanized the next day. All surviving rats were included in the anatomical analyzes. One rat from Sham and one from R-MI group had a poor echocardiographic window and were excluded from this evaluation. Six to eight rat muscle samples were randomly chosen for biochemical and molecular analyzes.MI was induced by ligating the left anterior descending coronary artery as previously described . Three mMaximum carrying load capacity was assessed on a vertical ladder . Adaptive training consisted of rats performing three climbs from different points on the ladder: near the top, in the middle, and the bottom; these were repeated over three consecutive days . MaximumRats were subjected to the training protocol three non-consecutive days per week for 12 weeks. In the first week, the rats performed three climbs with gradually increasing loads: no load on the first day, 15% of rat body weight on the second day, and 30% of rat body weight on the third day. From the second week on, the protocol consisted of four climbs. The climbs consisted of each rat carrying progressive loads of 50%, 75%, 90%, and 100% of its maximal carrying load capacity with a 2-min rest between climbs in the housing chamber at the top of the ladder ,41. RatsAfter anesthesia by intramuscular injection with a mixture of ketamine (50 mg/kg) and xylazine (1 mg/kg), an echocardiogram was performed using an apparatus  equipped with a 5–11.5 MHz multifrequency probe, as previously described ,43,44,45Rats were anesthetized with intraperitoneal sodium thiopental (50 mg/kg) and euthanized. After blood collection, hearts were removed by thoracotomy. Atria and ventricles were dissected and weighed. Soleus muscles from the right and left hind limbs were dissected, weighed, frozen in liquid nitrogen, and stored at −80 °C.Samples from LV were fixed in a 10% buffered formalin solution for 24 h, then washed in water and transferred to a solution with ethanol, according to a previously described method . To calcSerial transverse sections of the soleus muscles were cut at a 10-µm thickness in a cryostat cooled to −20 °C. The general morphology was evaluated in sections stained with hematoxylin and eosin. At least 150 cross-sectional fiber areas were measured from each soleus muscle .Soleus samples (∼100 mg) were homogenized in 2 mL of cold 0.1 M phosphate buffer, pH 7.0. Tissue homogenates were prepared in a motor-driven Teflonglass Potter-Elvehjem, tissue homogenizer. The homogenate was centrifuged at 10,000× g for 15 min at 4 °C, and the supernatant was assayed for total protein, lipid hydroperoxide, and glutathione peroxidase , catalase (E.C.1.11.1.6.), and superoxide dismutase  activities by spectrophotometry . Enzyme Soleus samples (~20 mg) were used to determine the maximum activity of enzymes that participate in glucose metabolism: phosphofructokinase (PFK), pyruvate kinase (PK), lactate dehydrogenase (LDH), citrate synthase (CS), and carnitine palmitoyltransferase-1 (CPT-1), as previously described ,51,52,53® homogenizer . The lysate was centrifuged at 12,000 rpm for 10 min at 4 °C and supernatant protein content was quantified by the Bradford assay. Samples were separated on a polyacrylamide gel and transferred to a nitrocellulose membrane. After 1 h blockade, membrane was incubated with the primary antibodies (overnight at 4 °C), washed with TBS and Tween 20, and incubated with secondary peroxidase-conjugated antibodies for 90 min at room temperature. Immobilon® Classico Western HRP Substrate  and an Image Quant LAS 4000 image analyzer  were used to detect bound antibodies, which were quantified by densitometry using Gel Pro 3.1.Western blotting was performed as previously described ,54. The t test. Mortality was compared using the Goodman test. Statistical analyses were performed using SigmaStat 12.0. The significance level was set at 5%.Data normality was evaluated by the Shapiro–Wilk test. Comparisons between groups were performed by one-way analysis of variance (ANOVA) followed by the Bonferroni test for parametric variables and expressed as means ± standard deviation. Non-parametric parameters were compared using the Kruskal–Wallis test followed by Dunn’s test and expressed as medians and percentiles. Infarction size was compared by unpaired Student’s Mortality rate from three days after infarction induction through to the end of the experiment was significantly higher in MI than Sham; in the R-MI group, mortality rate was between that in MI and Sham and did not differ significantly from either group A. We nexSystemic manifestations induced by cardiac remodeling are only observed when MI size is bigger than 30% of total LV area . Thus, rAdvanced post-infarction-induced cardiac remodeling is often associated with skeletal muscle atrophy ,38. ReduSkeletal muscle strength can be regulated by various molecular mechanisms, including protein turnover . Thus, wp < 0.07; Myocardial infarction-induced cardiac remodeling is associated with increased reactive oxygen species (ROS) generation and reduced antioxidant enzyme activity in skeletal muscles ,62. We op = 0.06) to be higher in MI than Sham , showing that exercise prevented changes in its activity.Increased oxidative stress is often observed in cardiovascular disease; this is driven by excessive ROS production and/or decreased antioxidant capacity ,46. We oThe unchanged muscle trophism in our infarcted rats is probably related to the fact that, despite severely impaired LV function, evaluation was performed in an early phase of heart failure. Body weight and skeletal muscle loss are late events in cardiac remodeling and heart failure . We haveA limitation of this work is the fact that only male rats were included. Although studies have evaluated the effects of physical exercise in female rats after cardiac injury ,80, its Resistance exercise is safe and increases muscle strength regardless of changes in cardiac structure and function in myocardial-infarcted rats. This exercise modality attenuates soleus glycolytic metabolism changes and improves expression of the proteins required for protein turnover and antioxidant response.


There is a dearth of comprehensive studies on the association between serum electrolyte and adverse short-term prognosis of Chinese patients with acute decompensated heart failure (ADHF).n = 5145), sodium (n = 5135), chloride (n = 4966), serum total calcium (STC) (n = 4143)) under corresponding exclusions. Different logistic regression models were utilized to gauge the association between these electrolytes or the number of electrolyte abnormalities and the risk of a composite of all-cause mortality or 30-day heart failure (HF) readmission.A total of 5166 patients with ADHF were divided into four serum electrolyte-related study populations (potassium (p for trend < 0.001) in comparison with sodium at 141–145 mmol/L. Chloride < 95 mmol/L corresponded to a higher risk of a composite outcome with an OR of 1.65  in contrast to chloride levels at 101–105 mmol/L. In addition, the adjusted ORs (95% CI) for a composite outcome comparing the STC < 2.00 and 2.00–2.24 vs. 2.25–2.58 mmol/L were 0.98 (0.69–1.43) and 1.13 (0.89–1.44), respectively. Besides that, the number of electrolyte abnormalities was positively related to the risk of a composite outcome  in comparison with N = 0.In multivariable adjusted analysis, patients with potassium below 3.5 mmol/L (odds ratios (ORs) 1.45; 95% confidence interval (CI):1.07–1.95), 4.01–4.50 mmol/L , 4.51–5.00 mmol/L  and above 5.00 mmol/L  had an increased risk of outcome when compared with potassium at 3.50–4.00 mmol/L. Sodium levels were inversely related to the risk of a composite outcome ; 130–134 mmol/L: OR, 1.97 ; 135–140 mmol/L: OR, 1.45 ; ADHF patients with baseline serum potassium at first half part of normal range (3.50–4.00 mmol/L) may herald the lowest risk of recent cardiovascular events.Serum sodium and chloride levels exhibit discrepancies in terms of risk of short-term adverse events of ADHF patients.The number of electrolyte abnormalities is a significant predictor of poor short-term prognosis in patients with ADHF.A deviation of potassium levels from 3.50 to 4.00 mmol/L, lower sodium levels and hypochloremia were associated with poorer short-term prognosis of ADHF. Furthermore, the number of electrolyte abnormalities positively correlated with adverse short-term prognosis of patients with ADHF. http://www.chictr.org.cn/showproj.aspx?proj=23139. Unique identifier: ChiCTR-POC-17014020. Acute decompensated heart failure (ADHF) is defined as the new onset or recurrence of deteriorating signs or symptoms of heart failure (HF) requiring unscheduled medical care or hospitalization, which renders it as one of the most common causes for hospitalization in older patients globally. In China, the epidemiologic data indicate that about 13.7 million people are living with HF, with its incidence still on an upward trend . AccordiIn general, patients with ADHF are prone to face electrolyte disorders, which result due to variations in levels of potassium , sodium  and calcium . This may be caused due to a disturbance of renin–angiotensin–aldosterone and sympathetic nervous system, as well as a consequence of diuretic therapy and comorbidity burden . Furthermore, ion disturbances play a significant role in the development of HF, thereby imposing a considerable influence on the medical therapies and prognosis of patients with ADHF. Recent studies have shown a U-shaped relationship between potassium levels and mortality in both patients with AHF and chronic heart failure (CHF) ,11. AccoTherefore, we performed a retrospective analysis to gauge the relevance of four common electrolytes  together with the number of electrolyte abnormalities in the poor short-term prognosis of patients with ADHF.The Heb-ADHF (Hebei-acute decompensated heart failure) study (ChiCTR-POC-17014020) is a prospective, multicentre and observational study, conducted on patients discharged from hospitals with a main diagnosis of HF in accordance with the Chinese HF guideline [Verbal informed consents were obtained from all patients included in the study.We have obtained consent to publish from the participant to report individual patient data.ADHF was defined as a de novo AHF or decompensation of CHF. Inclusion criteria for the study were: (1) age ≥18 y; (2) unplanned admission; (3) typical symptoms or signs of ADHF; and (4) brain natriuretic peptide (BNP) levels > 100 pg/mL or N-terminal pro-brain natriuretic peptide (NT-proBNP) levels > 300 pg/mL. Exclusion criteria for the study were: (1) hospitalization < 24 h; (2) heart transplantation; (3) ongoing renal replacement therapy; (4) massive stroke; (5) concomitant terminal disease; or (6) patients lost to follow-up. Furthermore, patients with history of parathyroid disease or vitamin D-related disorders were excluded from the study.We gathered data on the baseline characteristics of the patients as follows: age, sex, body mass index  by height (in m) squared), details of first admission, smoking and drinking status, New York Heart Association (NYHA) or Killip functional class ; the more severe one was chosen), comorbidities compromising coronary artery disease (CAD), AMI, hypertension, valvular heart disease (VHD), dilated cardiomyopathy (DCM), diabetes mellitus (DM), stroke/transient ischemic attack (TIA), atrial fibrillation/atrial flutter (A fib/A flutter), chronic kidney disease (CKD) as well as records of physical examinations, laboratory tests and baseline medications. Each variable was based on the strength of the European Society of Cardiology (ESC) recommendations on HF initial evaluation .–-related study population was used to gauge the association between the number of electrolyte disorders and the adverse prognosis of ADHF. A flowchart describing further details of patient selection is shown in In order to explore the correlation between serum electrolyte levels and adverse events in patients with ADHF, participants were chosen as the four serum electrolyte-related study populations via corresponding exclusions from the Heb-ADHF Registry. Furthermore, the Cl+<3.5 or >5.0, Na+<135 and Cl–<95 mmol/L; Therefore, the maximal number of electrolyte abnormalities was 3, in terms of each individual participant.Blood samples were collected at the time of admission and analysed immediately. The normal ranges for serum electrolyte concentrations , were considered in accordance with the latest guidelines . In the Each recruited patient was followed up at 30 days after discharge via telephonic interview by trained staff. Information on events of readmission or death was gathered at each follow-up. The loss ratio of follow-up was around 2.7%. The primary outcome was a composite of short-term (in-patient or within 30 days after discharge) all-cause mortality or 30-day HF readmission.n ≥ 5000) or Shapiro–Wilk (n < 5000) test was performed to assess the distribution of quantitative variables. The normally distributed and homogenous data were reported as mean ± standard deviation (SD), followed by evaluation of differences among the distinct groups in each study population by one-way analysis of variance (ANOVA). Contrarily, variables were described as medium and interquartile range (IQR). In addition, the Kruskal–Wallis test was applied for the assessment of discrepancies in measurement data among the different groups. Categorical variables were presented as numbers and percentages (%) and analysed by Pearson’s Chi-square test or Fisher’s exact test. Pairwise comparisons were performed through Bonferroni’s corrections.Baseline characteristics were presented in each interval of electrolytes. The Kolmogorov–Smirnov . Variables for inclusion were deliberately chosen, considering the number of events available, to ensure parsimony of the final models.Baseline variables that were deemed clinically related or that displayed a univariable relevance to the risk of a composite outcome with a Multivariable logistic regression models were performed to eliminate the impact of confounding factors; while sensitivity analyses were implemented to ensure data robustness. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for determining the association between serum electrolyte levels and the risk of a primary composite outcome via logistic regression models. Each quantitative variable was verified to have a linear relationship with logit transformation on outcome by means of the Box–Tidwell method. Based on the results of the variance inflation factors, multi-collinearity did not exist among all the confounders . Multivariable models were first adjusted for age and sex (model 1), and were then further adjusted for first admission, smoking, drinking, NYHA or Killip functional class, comorbidities including CAD, AMI, hypertension, DCM, A fib/A flutter, CKD and corresponding variables among the four study populations (model 2). The models were further adjusted for confounders with respect to physical examinations , and laboratory tests, as well as baseline medications . Additionally, we conducted tests for analysing the linear trends by entering the median value of each interval of electrolyte concentration as a continuous variable in the models.Supplementary online resource Table 2 gives additional details of the statistical analyses.To maximize the statistical power and minimize bias, patients with missing data were not excluded from analyses. We used multiple imputation (MI), based on five replications and the Markov Chain Monte Carlo method in the SPSS MI procedure, to account for the missing data on serum albumin, left ventricular ejection fraction (LVEF) and estimated glomerular filtration rate (eGFR) . BNP andp value <0.2. Additionally, patients with NYHA II were excluded. The data of the remaining participants were used in the aforementioned models for reassessment. Multivariable logistic regression models were identically implemented in sensitivity analyses.We did subgroup analyses by perfusion status which provides important information on the HF management according to previous studies ,24. The p value < 0.05 was considered to be statistically significant.All analyses were performed using the SPSS version 25 . A two-sided A total of 5145 participants  comprised the potassium-related study population, with 631, 1784, 1726, 720 and 284 patients classified as internal 1 (K: <3.50 mmol/L), internal 2 (K: 3.50–4.00 mmol/L), interval 3 (K: 4.01–4.50 mmol/L), interval 4 (K: 4.51–5.00 mmol/L) and interval 5 (K: >5.00 mmol/L), respectively. Meanwhile, the sodium-related study population  included 5135 participants categorized into five groups according to their serum sodium levels. Furthermore, 4966 patients from the chloride-related study population  were divided into four different groups based on their serum chloride concentrations. Finally, differing from the above, the STC-related study population  was composed of 4143 patients stratified into three groups on the basis of their STC levels.Supplementary online resource Tables 3–6.On the whole, patients without electrolyte abnormalities tended to be younger and had a higher proportion of male and first admission, lower prevalence of AMI, DM and CKD, increased level of SBP, DBP and serum albumin, decreased concentration of BNP or NT-pro BNP, as well as more frequency usage of angiotensin converting enzyme-1/angiotensin receptor blockers (ACEI/ARBs) or β-blockers than participants with electrolyte disturbances. Further details and other baseline characteristics of different study populations are summarized in During a 30-day follow-up on each discharged patient, the number of outcome events spotted in the potassium, sodium, chloride and STC-linked populations was 562, 561, 549 and 444, respectively. The in-patient all-cause mortality of each study population reached an estimate of 4.2%, slightly higher than that of 3% reported in a previous study . MeanwhiSupplementary online resource Table 7) showed the OR (95% CI) for the risk of composite outcome according to changes in serum electrolytes when each one was a categorical  or a continuous variable . For the potassium-linked study population, patients with a potassium level below 3.5 mmol/L , 4.01–4.50 mmol/L , 4.51–5.00 mmol/L  and above 5.00 mmol/L  had a greater risk of a primary composite outcome as compared to those with a potassium concentrations of 3.50–4.00 mmol/L following full adjustment for potential confounding factors with respect to sex, age, first admission and NYHA or Killip functional class. In contrast, in terms of the sodium-linked study population, compared to participants with sodium at 141–145 mmol/L, sodium levels were inversely related to the risk of a composite outcome after fully adjusting for confounders ; 130–134 mmol/L: OR, 1.97 (CI 1.45–2.68); 135–140 mmol/L: OR, 1.45 ; and p for trend <0.001). However, patients with hypernatremia  did not reach a statistical significance of a lower risk of outcome with OR 0.90 . Notably, we merely found hypochloremia (<95 mmol/L) presenting a higher risk of outcome with an OR of 1.65  in comparison to chloride levels at 101–105 mmol/L. More specifically, participants with serum chloride at 95–100 and >105 mmol/L did not correspond to a significantly increased risk of outcome, with ORs (95% CIs) reaching 1.19 (0.93–1.51) and 1.20 (0.93–1.55), respectively. In addition, the adjusted ORs (95% CI) that compared the STC < 2.00 and 2.00–2.24 vs. 2.25–2.58 mmol/L were 0.98 (0.69–1.43) and 1.13 (0.89–1.44) for a composite outcome, respectively. Furthermore, the number of electrolyte abnormalities was positively related to the risk of a composite outcome  in comparison with N = 0. The fully adjusted models were considered well-adjusted in the light of the Hosmer–Lemeshow test  and are shown in The univariable and multivariable analyses (Supplementary online resource Table 8).Clinical profiles (warm or cold) at admission provide important information for ADHF management according to previous studies. We therefore examined the associations between serum electrolyte and the risk of a composite outcome stratified by perfusion status. Similar trends were also observed in the subgroup analysis  into model 3 for further adjustment as described above. As expected, all the pooled results were nearly identical to those before the further adjustment in the four study populations. Moreover, similar upshots were observed after excluding the patients with NYHA II. Further information is presented in In this present study, we found significant relationships between three serum electrolytes and poor short-term prognosis in Chinese patients with ADHF. Patients with serum potassium levels at a narrow normal range (3.50–4.00 mmol/L) at admission may herald the lowest risk of recent cardiovascular events. A lower level of baseline serum sodium is associated with a poorer short-term prognosis in patients with ADHF. Notably, serum sodium and chloride levels exhibit discrepancies, in terms of poor short-term prognosis in ADHF. More importantly, this is the first comprehensive evaluation of the number of electrolyte abnormalities among ADHF patients. More specifically, we found that the number of electrolyte abnormalities positively correlates with a poor short-term prognosis of patients with ADHF. Similar trends were also detected in the subgroup analysis.The relevance of potassium levels to mortality in HF has been studied in previous studies ,27–29. GHyponatremia is a common electrolyte abnormity that occurs in hospitalized and non-hospitalized patients with HF. The frequency of hyponatremia was calculated to be approximately 12.7% in our study; a result that is within the range of 7.2–27% observed in early studies due to the distinct populations and subtle discrepancies in reference values ,36,37. AIn addition, the increase in risk for outcome was 65%  for participants with hypochloremia vs. with the upper half of the normal chloride range (101–105 mmol/L), which is in line with the results of previous investigations ,40. HoweSerum calcium, existing in two forms (bound or ionized) in the body, plays an essential role in myocardial contraction and relaxation . RecentlThe association between the number of electrolyte abnormalities and the prognosis of ADHF was seldom discussed in previous studies, in terms of patients with ADHF. In our present study, we found that greater number of electrolyte disorders was associated with a poorer short-term prognosis of ADHF, which may possibly be explained by the fact that patients with greater number of electrolyte disorders usually imply greater severity of HF stage and poorer nutrition status  .Our present study expands previous awareness by displaying different associations between baseline serum electrolyte levels and risk of short-term all-cause mortality or 30-day HF readmission, with several key strengths including prospective data, relatively large study population as well as detailed information on potential confounders,As this was an observational study, it was impossible to eliminate the residual confounding factors that could bias our results. However, potential confounders were attentively chosen, considering the number of events available, to ensure parsimony of the final models and none of these changed our findings as per the multivariable analyses. Moreover, the serum electrolyte levels were only measured at admission, therefore, time course of changes in ions was not available. Finally, we could barely confirm whether our findings were applicable to other ethnicities.In terms of baseline serum electrolyte levels, the deviation of potassium levels from 3.50 to 4.00 mmol/L, lower sodium levels and hypochloremia are associated to poorer short-term prognosis of patients with ADHF. However, there is no association of a higher or lower risk of adverse recent outcome with hypocalcaemia (STC < 2.25 mmol/L). Furthermore, the number of electrolyte abnormalities positively correlated with adverse short-term prognosis of patients with ADHF. These findings imply that electrolyte levels at admission may serve as a useful tool to identify patients with ADHF who are at a high risk of adverse events. Future investigations should fixate the ambulatory monitoring of serum ions and focus on patients with traditionally defined normal serum electrolyte ranges in order to launch more refined reference ranges of serum electrolytes for clinical practice.Click here for additional data file.


Indirect calorimetry was performed 4 (3–6) d after an ICU stay of 12 (7–16) d. The mEE was 1682 (1328–1975) kcal/d, corresponding to 22.9 (19.1–24.2) kcal/kg/day. The eEE values derived using HB and WB equations were significantly higher than mEE: 3048 (1805–3332) and 2220 (1890–2640) kcal/d, respectively (both p < 0.001). There was no significant difference between mEE and eEE using the PS equation: 1589 (1443–1809) kcal/d (p = 0.145). The PS equation tended to underestimate mEE with a bias of −61.88 kcal and a wide 95% limit of agreement . Using the PS equation, agreement within 15% of the mEE was found in 32/55 (58.2%) of the patients. In the present cohort of patients who survived a prolonged ICU stay, mEE was around 22–23 kcal/kg/day. In this post-ICU hospitalization context, none of the tested equations were accurate in predicting the EE measured by indirect calorimetry.Actual energy needs after a stay in intensive care units (ICUs) are unknown. The aims of this observational study were to measure the energy expenditure (mEE) of ICU survivors during their post-ICU hospitalization period, and to compare this to the estimations of predictive equations (eEE). Survivors of an ICU stay ≥ 7 days were enrolled in the general ward during the first 7 days after ICU discharge. EE was measured using the Q-NRG calorimeter in canopy mode. This measure was compared to the estimated EE using the Harris–Benedict (HB) equation multiplied by a 1.3 stress factor, the Penn–State (PS) equation or the 30 kcal weight-based (WB) equation. A total of 55 adults were included  y, body mass index 26.1 (22.2–29.7) kg/m After a stay in an intensive care unit (ICU), survivors are at high risk of malnutrition. Critical illness is associated with metabolic alterations as consequences of the systemic inflammation . On the Malnutrition has systemic repercussions for muscle mass and function, the gastrointestinal tract, mental health and the endocrine system ,7. DisorIndirect calorimetry is the most accurate way to measure energy expenditure, based on the measurement of inspired and expired oxygen and carbon dioxide concentrations. This technique is now recommended as the gold standard to determine energy needs in the critical care setting ,12. ThisThe definition of energy targets specifically for ICU survivors is a crucial step prior to prescribing adequate nutrition therapy and thus delivering optimal nutritional care. The primary aim of the present observational study was to measure the energy expenditure of ICU survivors during their post-ICU hospitalization period using indirect calorimetry. The secondary aim was to compare the measured and estimated energy expenditures, based on common predictive equations.Over 8 months in 2021 and 2022, all consecutive critically ill survivors who were discharged from our ICU after a stay ≥ 7 days were recruited in the present observational study. Patients were enrolled in the general ward, during the first 7 days following ICU discharge. Oxygen therapy , confusion or agitation, isolation for COVID-19 infection or multi-drug-resistant bacteria, and refusal to participate were considered as exclusion criteria. Patients discharged from our burn ICU were not included in the present cohort.ClinicalTrials.gov (NCT04500483). Informed consent was obtained from patients before enrollment.The study was conducted according to the guidelines of the Declaration of Helsinki (1964) and its later amendments, after approval by the local ethics committee of our university hospital  and registration on 2) concentration in the hood. Inspired and expired air samples are collected in an internal micro-mixing chamber. These samples are then analyzed with a chemical fuel cell O2 sensor and a non-dispersive infrared adsorption digital CO2 sensor. Mean values of oxygen consumption (VO2) and carbon dioxide production (VCO2) are reported every 20 s. Energy expenditure (EE) is calculated according to the Weir equation. The respiratory quotient (RQ) is also calculated.The measurements were performed using the Q-NRG indirect calorimeter in canopy mode . In canopy dilution mode, a digital turbine flowmeter operates in series with the internal blower to draw air at a constant flow rate through the canopy hood. The pumping rate is automatically calculated based on the patient’s weight and can be adjusted during the measurement to prevent too high or too low carbon dioxide  was considered as the expected weight for BMI 25 in overweight patients. In obese patients (BMI ≥ 30), the adjusted body weight was calculated as follows: IBW + 0.33 ×  [Demographic data ) were recorded. Actual weight was used for patients with BMI < 25 kg/mght-IBW) . Data abThe biological data were generated from one single laboratory  accredited by the ISO 15,189 Guideline. Blood levels of total protein were assayed using turbidimetry ; the reference range was 58–83 g/L. Blood levels of albumin were assayed by spectrophotometry . The reference ranges for ≤60 years were 35–52 and for >60 years, 32–46 g/L. Blood prealbumin and C-reactive protein concentrations were assayed using immunoturbidimetry . The reference ranges were 0.2–0.4 g/L and 0–5 mg/L.p value < 0.05 was considered statistically significant.Statistical analysis was performed using Graphpad Prism . Normality was assessed using the Shapiro–Wilk test. As some datasets did not pass the normality test, the results were expressed as medians with lower and upper quartiles (Q1–Q3) for quantitative parameters, or as counts and proportions for qualitative parameters. Comparisons between data were made using the Mann–Whitney test or the Wilcoxon matched-pairs signed rank test. Correlations between measured and estimated EE were tested using the Spearman test. Each formula was tested against the reference method (IC) for bias using Bland–Altman analysis for accuracy. Accuracy was defined as the percent of estimates falling within 85% and 115% of measured EE. A During the 8 months of recruitment, 359 patients were discharged alive from the ICU after a stay ≥ 7 days. About one-third of these patients were on oxygen supply, precluding IC. Finally, a total of 55 patients were analyzed .The characteristics of the patients are detailed in The anthropometric data are detailed in Their biological data are detailed in The measurement was performed 4 (3–6) days after ICU discharge and lasted 17.5 (15–20) mins. The recorded data are detailed in p = 0.145). On the contrary, the estimated EE values using the three other formulas were significantly higher than the measured EE (p < 0.001 for each test). All estimated EEs were significantly and positively correlated to the measured EE (p < 0.001 for each test): rS = 0.59  0.38–0.75) for the Harris–Benedict equations, rs = 0.65 (95%CI 0.46–0.78) for the Penn–State equation, and rs = 0.73 (95%CI 0.56–0.83) for the weight-based formula. The performances of the four predictive formulas are illustrated in Estimated EE values are detailed in Using the Penn–State equation, the predicted EE fell within 85% and 115% of the measured EE in 32/55 (58.2%) patients. The Penn–State equation led to an underestimation or an overestimation of EE in, respectively, 14/55 (25.4%) and 9/55 (16.4%) of the patients. With this equation, estimated EE represented −5.1% (−15.4–9.9%) of the measured EE.In the present cohort of survivors of a prolonged ICU stay, the resting EE measured by indirect calorimetry was around 22–23 kcal/kg/day during the week following ICU discharge, in a context of persistent low inflammation. This was significantly lower than the EE predicted by the 30 kcal/kg/day formula suggested by experts at this stage of the post-ICU trajectory . Energy In this study, the Penn–State equation was the only one to provide predicted EE statistically similar to the measured values, with a bias less than 100 kcal and an underestimation of about 5% compared to the measured EE. However, the performances of the Penn–State equations were weak: the limits of agreement in the Bland–Altman analysis were wide, and the predicted EE was found accurate in only 58% of the patients. This is not surprising, as several publications demonstrated that equations are generally inaccurate to predict EE in critically ill patients at almost all time points of their trajectory ,22,23,24The metabolism variability between patients and the subsequent inaccuracy of predictive equations are arguments for the use of indirect calorimetry as frequently as possible, or at least when any significant change in clinical condition occurs. Concerns were raised about the past generation of indirect calorimeters in relation to their availability, their accuracy, their calibration and maintenance protocols, and their practical use ,25. GiveIn the present study, a validated and scrupulously calibrated device was used to measure EE in the post-ICU phase. However, some limitations need to be acknowledged. First, the cohort, despite being the largest studied so far, was limited. The external validity of the present results should be confirmed in other larger cohorts. Second, indirect calorimetry was not performed in a fasting condition. This could have biased the comparison between measured and predicted EE. Most of the equations predict the resting EE only, theoretically not including diet-induced thermogenesis . The incIn the present cohort of patients who survived a prolonged ICU stay, energy expenditure measured by indirect calorimetry was around 22–23 kcal/kg/day. During the post-ICU hospitalization, none of the equations performed accurately in predicting the energy expenditure measured by indirect calorimetry. Further studies should confirm these findings and determine whether indirect calorimetry-guided nutrition in the post-ICU phase could improve outcomes.


The safety and feasibility of enhanced recovery after surgery (ERAS) for laparoscopic pancreaticoduodenectomy (LPD) are unclear. The aim of this retrospective clinical study was to evaluate the impact of ERAS protocols for LPD.Between March 2016 and December 2018, a total of 34 consecutive patients with ERAS for LPD were prospectively enrolled and compared with 68 consecutive patients previously treated for non-ERAS after LPD during an equal time frame. The intraoperative and postoperative data were collected and comparatively analyzed.P < 0.001) was reduced significantly in ER group than those in non-ER group. The operation time  and intraoperative blood loss  were similar in the two groups. The complications  and their severities  of patients with ERAS protocols were not increased. No difference in mortality and readmission rates was found. Finally, the total medical costs  in ER group were lower than those in non-ER group.The mean length of postoperative hospital stay (15.8 ± 3.4 and 23.1 ± 5.1 days, the ERAS is safe and effective in the perioperative period of LPD. It could effectively reduce the length of postoperative stay and medical costs, and does not increase the incidence of postoperative complications. Enhanced recovery after surgery (ERAS) protocols are referred to as “fast-track surgery”, which are multimodal, evidence-based approaches to the perioperative management of patients undergoing different types of operations that are designed to reduce the surgical stress response and accelerate recovery . The maiWith the increased publication of ERAS guidelines to optimize patient outcomes after more complex and high-risk surgical procedures, there is growing enthusiasm and interest among healthcare professionals for studies on ERAS programmes in patients after open pancreatoduodenectomy (OPD) , 6. EncoIn the present retrospective observational study, we primarily aimed to investigate the effect of ERAS protocols in patients after LPD, including length of postoperative hospital stay and medical costs. The secondary aims were to assess the postoperative recovery and outcomes of LPD in patients in an academic medical centre in China.This is a retrospective clinical study on a collected data base. Between March 2016 and December 2018, a total of 102 patients who underwent LPD were enrolled in this study according to the inclusion criteria: (1) tumors of pancreas, duodenum and lower bile duct; (2) biliary obstruction caused by benign tumors (3) all patients had complete laboratory test data; (4) no anticancer treatments before the operation; (5) curative resection of all tumor nodules; and (6) complete patient records and follow-up data. Patients who had tumour metastasis and other organ resection were not considered eligible for this study. These surgeries were performed by Dr. De-Wei Li and Dr. Xiong Yan, who are experienced laparoscopic surgical experts and have completed more than 50 cases of LPD. Among these cases, 34 patients were prospectively included in enhanced recovery (ERAS group). These patients were compared with 68 consecutive patients after LPD under the care of the same consultants previously receiving standard care during an equal time frame . The intra-abdominal drains were routinely placed at the site of the bilioenteric anastomosis and pancreaticojejunostomy.t-tests with a normal distribution or nonparametric Mann–Whitney U-tests with an irregular distribution. Count data were analysed using x2 test, Fisher's exact test and the rank sum test. A P value <0.05 was considered statistically significant.SPSS 24.0 statistical software was used to analyse the data. The continuous variable data are shown as the mean ± standard deviation. Continuous variables were compared using Student's P > 0.05). There was no difference in mean age, BMI, ASA score and Child-Pugh score between the ER and non-ER groups (P > 0.05). Common laboratory tests, including WBC, TB, DB, AST, ALT and albumin, did not differ significantly between the two groups (P > 0.05).Clinical characteristics between two groups were compared using the following risk factors: gender, age, body mass index (BMI), American Association of Anaesthesiologists (ASA) score, and Child-Pugh score as well as measurements of white blood cells (WBC), neutrophils, haemoglobin, albumin, total bilirubin (TB), direct bilirubin (DB), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) . This stP = 0.627), 537.5 (250–1500) ml (P = 0.800) and 11.8% (P = 0.746), respectively. The intravenous fluid infusion rate was 4.0 ml/kg/h. Usually, the ratio of crystalloid to colloid was from 2:1 to 3:1. The ER group had significantly lower total fluid and crystalloid volume than non-ER group (P < 0.01). There was no significant difference in the colloid volume between two groups. All patients used analgesic infusion pump in both groups.There were no statistically significant differences were observed between the ER and non-ER groups in duration of surgery, intraoperative blood loss and transfusion, which are presented in P = 1.000). Others were tumors including pancreatic cancer, cholangiocarcinoma and duodenal adenocarcinoma (P > 0.05). Compared with non-ER groups, patients with ERAS spent shorter time in nasogastric tube remove, urinary catheter remove, intra-abdominal drains remove, first bowel gas time, first diet time and off-bed activity . The mean length of postoperative hospital stay was 15.8 ± 3.4 and 23.1 ± 5.1 days (P < 0.001) in the ER group and non-ER group, respectively.Post-operative pathologic diagnosis found 3 and 6 benign lesions in ER group and non-ER group, respectively (P = 0.281). According to the clinical effect, postoperative pancreatic fistula has three grades  based primarily on the International Study Group on Pancreatic Fistula (ISGPF) (P = 0.903). There was one patient with biliary fistula, delayed gastric emptying and pleural effusions or ascites in each group (P = 0.615), respectively. One patient with postoperative haemorrhage in non-ER group underwent a second surgery. Two patients with postoperative haemorrhage in ER group received blood transfusion and hemostasis treatments other than surgery (P = 0.216). In ER group, there was no patient with abdominal, pulmonary or wound infection, thrombosis, unplanned reoperation and dead. Correspondingly in patients with non-ER, there was one patient producing abdominal, or wound infection, thrombosis and unplanned reoperation, respectively (P = 0.480). One patient was dead (P = 0.480), and three patients underwent pulmonary infection (P = 0.216). Except one unplanned reoperation, the other postoperative complications were treated conservatively. One patient with ER chose readmission in 30 days due to ascites. According to the Clavien–Dindo grade (P = 0.783). There was no difference in postoperative complications between the patients after LPD performed by Dr. Li and Dr. Yan. The median duration of postoperative fluid management was 9.5 days (range: 7.5–14 days) in the ER group and 14 days (range: 12.5–22 days) in the non-ER group (P < 0.01).The complications included pancreatic or biliary fistula, haemorrhage, abdominal or pulmonary infection, unplanned reoperation, mortality rate and readmission within 30 days of the operation . The ove (ISGPF) . There wdo grade , there w4 and $2.3 ± 0.7 × 104 in ER group were lower than those in non-ER group. in the ER and non-ER groups, respectively (P = 0.017). Postoperative mean costs per patient were $2.0 × 104 in the ER group and $2.2 × 104 in the non-ER group (P = 0.019). ERAS was significantly associated with lower costs for medication, housing, nursing care and disposable material costs (P < 0.05) in the ER group compared with the non-ER group. The surgical and anesthetic costs were similar in the two groups (P > 0.05). In the enhanced recovery group, these patients had some extra radiological examinations or laboratory examinations to prevent accidental complications due to the enhanced recovery. Other laboratory and radiologic examination costs had no significant difference (P > 0.05).The mean total medical costs per patient were $2.1 ± 0.7 × 10P < 0.001). In addition, oral elemental diet and targeted mobilization after surgery in the ER group also occurred much earlier than that those in the non-ER group (P < 0.001) . In addition, there were several patients deviating from the ERAS protocols. The nasogastric tube was removed on POD 1 in 26 (76.5%) patients, but four patients (11.8%) could not start oral intake of an elemental diet on POD 2. The overall compliance rates to protocol were 89.2% in ER group and 57.4.8% in non-ER group (P < 0.01), respectively. As shown in P < 0.001).The recovery indicators for patients with ERAS or non-ER were comparatively analysed. The retention time of nasogastric tubes, urinary catheters and intra-abdominal drains in the ER group were significantly shorter than that in the non-ER group (< 0.001) . In addiTo the best of our knowledge, this is the first clinical observational study in China to investigate the feasibility and safety of ERAS protocols in patients after LPD. The present study suggests that ERAS programmes may have benefits in facilitating earlier patient recovery, which included earlier first bowel gas time, first diet time, and off-bed activity time; shorter drainage tube retention time; shorter postoperative stay; and lower medical costs. Meanwhile, there was no significant difference in most postoperative complication rates and 30-day readmissions between the two treatments.Compared to OPD, LPD is a less invasive surgical procedure with higher risk that requires advanced laparoscopic skills for senior surgeons. The incidence of postoperative complications of LPD is still as high as 30%–50%, even when performed by an expert surgeon. Thus, it seems that ERAS programmes for LPD might not be widely accepted. In fact, implementation of ERAS is now expanding across a wide range of complex laparoscopic surgical procedures and specialties, such as colorectal resection , liver rIn this study, the postoperative stay was decreased significantly in ER group. This may be clinically important because early oral elemental diet and targeted mobilization lead to fast recovery and increased immunity of patients after surgery, and subsequently reducing the length of hospital stay. In the ER group, earlier first diet and off-bed activity after surgery were encouraged for patients following LPD, which may have resulted in earlier bowel gas. Currently, increasing studies have shown that long-term fasting may lead to slower recovery of intestinal peristalsis  and incrThe shorter retention time of urinary catheters, nasogastric tubes and intra-abdominal drains could reduce some related postoperative complications. Indwelling urinary catheters can increase the risk of postoperative lung and urinary tract infections , and indOur data suggest the efficiency of ERAS programmes for decreasing postoperative complications and morbidity, which is consistent with a previous RCT on ERAS protocols for OPD . Moreovevia ERAS programs.ERAS pathways showed reduced medical costs with LPD. Compared to non-ER, surgical and anaesthetic costs were not different, but the costs of wards and beds, laboratory and radiologic examinations, and medications were decreased significantly, which resulted in lower total medical cost. Other reasons for reduced medical costs may be attributed to the shorter postoperative hospitalization time and less postoperative complications, with no increase in the readmission rate. Consequently, the patients could benefit from the reduced healthcare costs of LPD Another important finding was that ERAS programmes did not increase the risk of postoperative haemorrhage and biliary or pancreatic fistula. Given the technically challenging nature of the LPD procedure, it requires higher laparoscopic skill with regard to accurate needle handling to prevent suture tangling in the biliary/pancreatic ducts and intestinal/pancreatic tissues. In our study, the two surgeons were experienced laparoscopic surgical experts and completed the initial learning curve, which could help to avoid technical bias. Moreover, we do not support the recommendation for routine preoperative endoscopic nasal biliary drainage for patients undergoing LPD.The main limitations of our study are the nature of the retrospective study and the small sample in a single medical centre. We have not compared the surgical effects between LPD and OPD during the same period. To date, there is no widely accepted guideline or recommendation for ERAS programmes for LPD. Therefore, all the basic components of the “fast-track” or ERAS programmes for LPD in our study are based on other protocols for OPD in other different laparoscopic surgical specialties. Some factors would produce some differences in the implementation of ERAS between LPD and OPD, such as the influences of surgical wound size, carbon dioxide pneumoperitoneum pressure, patient psychology status induced by different surgical methods and diet time. However, according to our results, the majority of OPD protocols could be implemented in the ERAS of LPD. A different selection of LPD patient population mainly comes from the requirements of laparoscopic surgery. Moreover, our results need to be validated by additional future studies or stratified analysis. Furthermore, compared to the west countries, the mean length of postoperative hospital stay was still longer in both groups. The difference may come from the eastern traditional culture of health care requiring long-term postoperative recuperation. On the other hand, Chinese medical insurance policy does not strictly control the length of the hospital stay and many Chinese patients did not strictly follow the doctor's discharge schedule. We believe it could be further shortened if Chinese patients are more able to follow the surgeons' guidance. In addition, the introduction of laparoscopic procedure perhaps led to clinicians challenging their traditional viewpoints of postoperative care which has been aided by the ERAS groups research. Therefore, a more evidence based postoperative care program should be introduced in the future.In summary, ERAS protocols for LPD can effectively reduce the length of postoperative stay and medical costs and do not increase the incidence of postoperative complications. However, individualized ERAS measures for LPD should be formulated in light of clinical practice and previous studies. In future studies, more intensive multimodal approaches should be optimized and improved to maximize patient benefit.


P.02). Patients diagnosed with mental disorder had 7.25 times higher risk of longer hospital stay compared to no mental health disorder . Amphetamine use disorder increased the risk of readmission. A secondary diagnosis of mental disorders among SUD patients increased length of hospital stay. As a targeted region of amphetamine smuggling in the world, policy and clinical decision-makers in Saudi Arabia and the Gulf States should consider taking proactive steps to minimize the future anticipated high demand for addiction treatment in the region.Substance use disorders (SUDs) patients have longer lengths of hospital stay, and more unplanned readmissions than other hospitalized patients. We aim to evaluate SUD-related rehospitalization and length of hospital stay in a major rehabilitation center that serves countries of the Gulf States. In a retrospective cohort study for 16-year data set in Al-Amal Hospital Electronic Health Record in the city of Dammam, Eastern region of Saudi Arabia, patients received services from the SUD treatment programs in the period of January 1, 2005, to December 31, 2021. We used cause-specific Cox proportional hazards regression model to estimate risk of readmission, and general linear model to examine the association between substance use disorders and length of hospital stay. Of the total cohort, 4398 (30.17%) were readmitted within 1 year of discharge date. More than half of the cohort were unemployed patients (52.93%). Patients diagnosed with amphetamine use disorder were 1.36 higher risk of readmission compared to no amphetamine disorder   Substance use disorders (SUDs) remain the leading cause of disability and premature mortality, impacting health, social care, welfare, and criminal justice systems worldwide . Diagnoses were extracted from the health record system using the International Classification of Diseases (ICD-9-CM and ICD-10-CM codes) for each admission and then confirmed with written clinical primary and secondary diagnoses.vs. no hospital readmission within the study period), given that the implemented treatment, the 12 Steps Program, at the hospital requires an average of 30 days of hospital stay. Patients with a history of at least one admission within the study period from 2005 to 2021 were categorized as readmitted, and those with no previous admission history within the study period from 2005 to 2021 were categorized as having no hospital readmission. The follow-up time started on the date of admission and ended on the last discharge date. The application of this follow-up plan allowed us to account for the longest potential follow-up duration covering the entire study period. Patients with missing discharge data were excluded from the study , pregabalin (Lyrica), and volatile inhalants. Specific ICD9 and 10 codes are assigned for polysubstance abuse disorders. Individuals diagnosed with polysubstance abuse disorders will not be diagnosed with other SUDs. Independent variables were dichotomized (yes vs. no). Each SUD was examined separately as an independent, mutually exclusive event.Herein, the main outcome variable was hospital readmission within 1 year of discharge date  to examine the association between SUDs and length of hospital stay in days adjusted for covariates. The assumptions of normality and homogeneity of variance were also assessed. All statistical tests were 2-sided, and the findings were considered statistically significant at P < 0.05. All analyses were conducted using the SAS statistical software .For data analyses, all patients with SUDs were classified into two groups: those with and without readmission within 1 year (365 days) after discharge. The demographic and hospital-related characteristics and SUD diagnoses were assessed across frequent SUD readmissions and non-readmission patients, using unadjusted chi-square, Fisher exact, and independent p 0.3) with mean of 3 readmission times during the study period. The cohort was predominantly Saudis 13,789 (94.59%) followed by Kuwait’s (1.78%), and Omani’s nationalities (1.56%) (Table p 0.03). About 1 out of 4 patients discharged with family request was readmitted to the hospital  were readmitted to the hospital within 1 year of discharge date. The cohort predominantly included males 14,535 (99.7%) with mean age of 39 years old, single 8961 (61.47%), and unemployed 7716 (52.93%) (Table P = 0.42) (Table P < 0.0001), opioid disorder (P < 0.001), amphetamine/methamphetamine dependence (P < 0.001), benzodiazepines (P < 0.04), and pregabalin use (P < 0.05). In addition, the admitted patient cohort presented with mental health disorders (12.5%) and comorbidities (0.8%) , followed by alcohol (31.29%) and opioid (15.2%) use disorders. However, we detected no significant difference in the readmission rate among patients diagnosed with cannabis use disorder  (Table P.02). Patients diagnosed with amphetamine/methamphetamine use disorder had a 1.36 higher risk of readmission than those with no amphetamine/methamphetamine use disorder (Table p = 0.017) , 1, 1.79, P = 0.03). The 41–60 age group had a 1.39-fold greater mean length of hospital stay than the 61–112 age group (Table P < 0.0001) (Table P < 0.0001). Patients diagnosed with mental health disorders had a 7.25-fold higher risk of longer hospital stay than those not diagnosed with mental health disorders  . As suggested in previous studies, patients with SUD tend to be younger (46 years old) than those admitted for conditions other than SUDs (60 to 80 years old) (Bursac et al., Our study has several limitations that need to be addressed. First, the retrospective nature of the study included an uncontrolled methodology with potential selection bias and a limited number of patients from a single cohort. Thus, our findings should be validated in a larger prospective study to better represent the Kingdom of Saudi Arabia and the Gulf States and minimize potential selection bias. Second, factors associated with readmission and length of hospital stay, such as a history of mental illness, were unavailable in the hospital data for the study period. These data would have allowed an additional evaluation of readmission and length of hospital stay. Third, the data included an extremely small sample of female participants, which might have induced a gender bias. However, it is important to note that the hospital was designed for male services only until 2012, following which a new female section was established.In the current retrospective cohort study, our results reinforce findings from previous studies in the West, considering factors associated with readmission and length of hospital stay in patients with SUD. We demonstrated that employment status is a significant predictor of SUD-related readmission. As reported previously, we found that patients with amphetamine use disorder are at a higher risk of readmission than patients with other SUD. A secondary diagnosis of mental health disorders among patients with SUD could increase the length of hospital stay. Identifying populations at risk of high healthcare utilization remains crucial. This can help inform discharge planning and develop programs and interventions designed to improve health outcomes among this population. As a targeted region for global amphetamine smuggling, policy and clinical decision-makers in Saudi Arabia and the Gulf States should consider taking proactive steps to develop programs that evaluate the current treatment programs and minimize the anticipated high demand of addiction treatment in the region.


Natural orifice specimen extraction surgery (NOSES) has been confirmed as an alternative approach without auxiliary incisions. The purpose of this study was to investigate the short-term and survival outcomes of NOSES versus conventional laparoscopic surgery (LAP) in treatment of sigmoid and high rectal cancer.The retrospective study was conducted at single centers between January 2017 to December 2021. Relevant data included clinical demographics, pathological features, operative parameters, postoperative complications and survival outcomes were collected and analyzed. All procedures were performed using either a NOSES or a conventional LAP approach. Propensity score matching (PSM) was conducted to balance clinical and pathological features between the two groups.P = 0.037), less pain and less analgesia required . In addition, the incidence of surgical site infection in the LAP group was significantly higher than that in the NOSES group , especially incision-related complications . After a median follow-up of 32  months, the two groups had similar 3-year overall survival rates  and disease-free survival rates .After PSM, a total of 288 patients were eventually included in this study, 144 in each group. Patients in the NOSES group experienced faster recovery of gastrointestinal function (2.6 ± 0.8 vs. 3.6 ± 0.9 day, The transrectal NOSES procedure is a well-established strategy with advantages in reducing postoperative pain, faster recovery of gastrointestinal function, and less incision-related complications. In addition, the long-term survival is similar between NOSES and conventional laparoscopic surgery. In the past 20 years, laparoscopic surgery (LAP) has been widely used in the treatment of colorectal cancer (CRC). Many studies have clarified that compared with open surgery, LAP has the advantages of less trauma and faster recovery while ensuring the same therapeutic effect, which is an important milestone in the development of modern surgery , 2. In tNatural orifice specimen extraction surgery (NOSES) can be easily combined with existing LAP skill without the need for additional specialized equipment. In the past few years, NOSES have been successfully promoted and developed in colorectal cancer treatment, and transrectal and transvaginal approaches are common natural method for extraction of specimens –8. HowevFrom January 2017 to December 2021, patients underwent laparoscopic radical resection in treatment for upper rectal cancer and sigmoid colon cancer at the National Cancer Center were reviewed. Patients who underwent laparoscopic surgery with natural orifice extraction were assigned to NOSES group while patients who performed conventional laparoscopic surgery with abdominal auxiliary incision were assigned to LAP group. The inclusion criteria were as follows: (1) aged between 18 and 75 years; (2) cT stage 1–3 (3) without distant metastasis. The exclusion criteria were: (1) complicated with other malignant tumors (2) emergency surgery for acute intestinal obstruction, perforation or bleeding. Finally, 186 patients who underwent NOSES and 274 who underwent LAP were enrolled. Propensity score matching (PSM) was used to balance the baseline data between the two groups. Propensity scores were matched 1:1 based on age, gender, body mass index (BMI), American Society of Anaesthesiologists (ASA) score, preoperative chemotherapy, tumor location, tumor differentiation, T stage, N stage, and tumor size. Finally, 144 patients were assigned to the NOSES group while 144 patients were assigned to the LAP group .Preoperative assessment for all patients included laboratory examination, colonoscopy with biopsy, abdominal CT scan and pelvic magnetic resonance imaging. Tumor staging was evaluated according to the American Joint Committee on Cancer  staging system. Patients with clinical stage II and III received preoperative chemoradiotherapy followed by surgery 6 weeks later. All patients received mechanical bowel preparation before surgery, and intravenous antibiotic profilaxis were administered during perioperative period. Postoperatively, patient-controlled analgesia (PCA) was administered to all patients for pain management, and additional nonsteroidal and opioid analgesics were administered intravenously as required. Pain scores were assessed once daily with a validated visual analogue scale (VAS), ranging from 0 to 10, with 0 representing no pain and 10 representing the worst conceivable pain. All patients signed the written informed consent and complied with the Declaration of Helsinki. This retrospective study was approved by the Institutional Review Board Committee of the Cancer Hospital at the Chinese Academy of Medical Sciences (No. 18-015/1617).The modified lithotomy position was taken, and all patients adopted the five trocar position with a pneumoperitoneum of 15 mmHg. One trocar was placed supraumbilical for the camera, while two trocars were placed on the right and left quadrant, respectively. After careful exploration, the patient was placed in the Trendelenburg position. The standard surgical technique was performed both in NOSES group and LAP group including separation and high ligation of the inferior mesenteric vessel, mobilization of the bowel, and dissection of the lymph nodes and and division of the distal rectum. Then the specimen extraction approach was different in two group. After the operation, both groups of patients will have 2 drainage tubes in the pelvic cavity, which are usually removed 5–7 days after the operation.For LAP group, an auxiliary abdominal incision 6–8 cm in length was made for specimen extraction. Then, the anastomosis was performed by a double-stapling technique under the direct visual observation.For NOSES group, after mobilization of the rectum and left colon, the distal rectum was transected below the tumor with a linear stapler. An incision was generated below the staple line of the rectal stump and a sterile plastic sleeve was placed into the abdominal cavity through the anus and rectal stump. Next, a long Babcock grasper was brought through the anus, and the specimen was extracted through the plastic sleeve . Then, aAccording to the guidelines of the NCCN, enrolled patients with T3/T4 or N+ received adjuvant therapy after operation if they did not receive preoperative treatment. All patients were scheduled to receive follow-up through outpatient visits every 6 months in the first 3 years. Physical exam, blood test (including CEA and CA19-9), and CT scans  were completed at each follow-up. Three years after surgery, the patients were followed up every 12 months by outpatient visits or telephone, the deadline for the follow-up was December 1, 2021. The survival endpoints of present study were 3-year overall survival (OS) and disease-free survival (DFS).t test or chi-square test, respectively. DFS and OS were calculated using the Kaplan-Meier method and the differences were compared by a log-rank test. A P value of <0.05 was considered statistically significant.Statistical data were processed using the SPSS software version 24.0 for Windows . Quantitative data are expressed as the mean ± standard deviation and categorical data are expressed as percentages. The differences in classification or quantitative variables were analyzed using Consecutive patients with sigmoid colon or upper rectal cancer undergoing laparoscopic radical resection were enrolled between January 2017 to December 2021. A total of 460 patients from our center were included in this study, including 274 in the LA group and 186 in the NOSES group.P < 0.001), BMI , ASA score, preoperative chemotherapy (P < 0.001), T stages (P < 0.001), N stage (P = 0.001), and tumor size . After PSM, the clinical variables, including age, gender, BMI, ASA category, preoperative chemoradiotherapy, tumour location, tumor differentiation, T stage, N stage and tumor size, were well balanced between the two groups .The baseline characteristic were presented in P = 0.153) and estimated blood loss were essentially identical . The mean numbers of retrieved lymph nodes were 20.8 ± 2.3 and 21.1 ± 8.0 in the NOSES group and LAP group, respectively (P = 0.577). Patients in the NOSES group suffered significantly less pain than those in the LAP group on day 1–3 (P < 0.05) and fewer patients in NOSES group required analgesia . Additionally, time to recovery of gastrointestinal functions was shorter in the NOSES group than in the LAP group . With regard to postoperative complications, 13 (9.0%) patients developed postoperative complications in NOSES group and 18 (12.5%) patients in LAP group (P = 0.342). However, the incidence of surgical site infection in the LAP group was significantly higher than that in the NOSES group , especially incision-related complications . There was one surgery-related deaths occurred in the NOSES group within 30 days after surgery while the mortality rates between the NOSES group and LAP group were not significantly different .The surgical details and postoperative outcomes are listed in P = 0.850) and DFS (P = 0.494) compared with the LAP group  months. During the follow-up period, 26 of the 288 patients died, and 42 patients had local recurrence or distant metastasis. There was no significant difference in tumour recurrence between the NOSES group and the LAP group. 5 patients developed local recurrence and 17 patients developed distant recurrence in the NOSES group after a median follow-up of 31  months. 6 patient developed local recurrence and 14 patients developed distant recurrence in the LAP group after a median follow-up of 33  months. The Kaplan curves showed that the NOSES group had similar OS . Moreover, there are a large number of superficial nerves in the abdominal wall, and the longer the incision, the more superficial nerve damage, and the more severe the postoperative pain. Excess length of incision will increase postoperative inflammatory reaction, and also limit the patient's respiration and movement, thus increasing postoperative complications such as pneumonia, bedsore, and thrombosis, and prolonging the length of hospital stay. Lu et al. reported that the time to first flatus , time to liquid diet , and the need for analgesics  were significantly lower for patients who underwent NOSES (P = 0.037). Moreover, patients in the NOSES group suffered significantly less pain than those in the LAP group on day 1–3, while fewer patients required analgesia .The characteristic of NOSES is that the specimen is extracted from the natural orifice, avoiding the auxiliary abdominal incision of 6–8 cm. It has been reported that the incidence of incision infection in traditional LAP surgery is about 5%–10% , while tP = 0.850) and DFS (P = 0.494) compared with the LAP group. Tang et al. reported on 186 patients who underwent total laparoscopic anterior resection with transrectal specimen extraction, and they found no difference in 5-year OS and DFS between NOSES and conventional laparoscopic surgery (P = 0.670), 3-yers DFS , and 3-years OS   patients developed local recurrences in the NOSES group and 6 (4.2%) patients developed local recurrence in the LAP group. The NOSES group had similar OS ( surgery . SimilarThe present study have several limitations. Firstly, the operations of 288 patients were performed by 5 different surgeons, which would lead to a certain technical imbalance. However, these 5 experts have at least 500 cases of laparoscopic experience of CRC treatment and completed the learning curve for NOSES before data collection. Secondly, this study is a retrospective study and there must have inherent selection bias. However, we conducted a case-matched design to minimize selection bias.In conclusion, the transrectal NOSES procedure is a well-established strategy with advantages in reducing postoperative pain, faster recovery of gastrointestinal function, and less incision-related complications. In addition, the long-term survival is similar between NOSES and conventional laparoscopic surgery.


To synthesize the published citations to determine the association between glucose metabolism tests and recurrent pregnancy loss (RPL).The electronic databases including PubMed, Scopus and Web of Science were searched for the original articles that evaluated the correlation between glucose metabolism tests including fasting blood glucose (FBG), fasting insulin (FI), homeostatic model assessment for insulin resistance (HOMA-IR), the rate of individuals with HOMA-IR  > 4.5, insulin resistance, fasting glucose/fasting insulin (FG/FI) and FG/FI  > 4.5.and recurrent pregnancy loss with a combination of proper keywords.The database search led to finding 390 articles. Detailed screening of titles and abstracts for potential eligibility was performed, and after excluding the duplicated and irrelevant citations, finally, 8 studies were selected to be included in this study, 7 observational studies and one controlled clinical trial. A significant difference in the amount of FI, HOMA-IR, the rate of HOMA-IR  > 4.5, the rate of individuals with insulin resistance, fasting glucose/fasting insulin (FG/FI), and the rate of FG/FI  > 4.5 were found among RPL patients compared to controls. There was no difference when comparing FBG between the groups.This study indicates an important link between abnormal glucose metabolism tests and a history of recurrent pregnancy loss. These data may encourage clinicians to request glucose metabolism tests other than FBG in women with recurrent pregnancy loss.The online version contains supplementary material available at 10.1186/s13098-022-00973-z. Recurrent pregnancy loss (RPL) is defined as the failure of two or more consecutive pregnancies before 20–24 weeks of gestation  and is eOne of the most critical questions that remain to be answered is if or how glucose metabolism affects pregnancy loss. Hence, we decided to carry out a systematic review and meta-analysis to improve our understanding of the relationship between glucose metabolism tests, including fasting blood glucose (FBG), fasting insulin (FI), homeostatic model assessment for insulin resistance (HOMA-IR), the rate of individuals with HOMA-IR  > 4.5, insulin resistance, fasting glucose/fasting insulin (FG/FI) and FG/FI  > 4.5 and RPL. This knowledge might contribute to understand the factors associated to RPL that can be the focus of prevention and management strategies.This study was conducted in accordance with the guidance presented in the Cochrane.Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement , fasting insulin (FI), homeostatic model assessment for insulin resistance (HOMA-IR), the rate of individuals with HOMA-IR  > 4.5, insulin resistance, fasting glucose/fasting insulin (FG/FI) and FG/FI  > 4.5 and RPL.Inclusion criteria based on PICOT acronyms were: (1) population: adult women; (2) exposure: patients with a history of two or more pregnancy losses defined as RPL; (3) control: patients with a history of at least one live birth as the control group; (4) outcome: evaluation of different glucose metabolism tests; (5) study design: all original articles which including observational cohorts and case–control studies. Only English articles were assessed. Exclusion criteria were as follows: pregnancy loss due to extrinsic causes, review articles, opinion pieces or guidelines, non-peer-reviewed papers, unpublished reports, and articles in which the date and location of the study were not specified.The initial search was undertaken in 3 main databases including PubMed, Scopus and Web of Science until 1 May 2022. For the search strategy, combinations of the following keywords  AND (Diabetes OR Glucose intolerance OR Impaired Glucose Tolerance OR Hyperglycemia OR Insulin Resistance OR Glucose Metabolism Disorders OR Insulin Sensitivity OR Hyperinsulinemia OR Metabolic Syndrome OR HOMA-IR OR Insulin Insufficiency or Fasting Blood Sugar OR Fasting Blood Glucose) as medical subject heading (Mesh) terms were used.The protocol of this study was registered and approved by the ethics review board of Tehran University of Medical Sciences.Titles and abstracts were independently retrieved and reviewed for eligibility by two authors (MG and AS) and non-relevant studies and studies that did not meet the inclusion criteria were excluded. After the initial screening, the remaining full texts were reviewed by SH; articles with not sufficient data and duplicates were identified. Eligibility of included studies and cases reported in case series were double checked at this stage.NS and AS independently assessed the quality of included studies using the National Institutes of Health (NHLBI/NIH) quality assessment tools for case–control, cross-sectional studies, and randomized controlled trials . StudiesNS extracted data from included studies to excel.We investigated 7 potential markers that were used to assess glucose metabolism test in the included studies: (1) fasting blood glucose (FBG); (2) fasting insulin (FI); (3) homeostatic model assessment for insulin resistance (HOMA-IR); (4) the rate of individuals with HOMA-IR > 4.5; (5) the rate of individuals with insulin resistance; (6) fasting glucose/fasting insulin (FG/FI); (7) the rate of individuals with FG/FI  > 4.5. The main outcome was to find the association between glucose metabolism tests and RPL.2 > 25% random effect model, and for outcomes with I2 < 25% fixed effect model was used for data pooling. For continuous outcomes, Standard mean difference (SMD) was used for reporting combined results. SMD is more generalizable than regular mean difference even when using similar units , P = 0.39 and SMD = 0.21 CI 95% = [− 0.28–0.71], P = 0.40. Inclusion or exclusion of pregnant women does not seem to have a significant effect (Test for between-subgroup differences P = 0.62)   level was reported in 7 studies including 889 participants (475 cases and 414 controls) and the results showed a significant increase in insulin level of patients with history of RPL  Fig. .Fig. 3FoHabets et al.  reportedThis outcome was reported in 4 studies including 462 patients (233 cases and 229 controls). This outcome was significantly lower among RPL patients compared to control SMD = − 0.52 , In three studies, number of patients with FG/FI < 4.5 were reported. Combining these two studies, we calculated the pooled odds ratio, the result is significant, OR = 3.26, CI 95% = 1.58, 6.74], P = 0.001 . HOMA-IR was significantly higher among patients with history of RPL, SMD = 0.73, CI 95% = [0.17–1.29], p = 0.01, I2 = 0% . Poold OR was 3.51, P = 0.0001, IZolghadri et al.  in a ranWe performed a sensitivity analysis by excluding the results of each study to assess how their findings have effect on the overall results. Table The present study, to our knowledge, was the first systematic review and meta-analysis to assess the relationship between recurrent pregnancy loss (RPL) and glucose intolerance. We found a significant difference in the amount of FI, HOMA-IR, the rate of HOMA-IR  > 4.5, the rate of individuals with insulin resistance, FG/FI, and the rate of FG/FI  > 4.5 among RPL patients compared to controls. There was no difference when comparing FBG between the groups.Several factors have been linked to the etiology of RPL. However, the incidence of unexplained RPL is about 40% in most studies , 15, 23.In the 9 studies included in this systematic review, 7 studies with 889 individuals reported the FBG in both patients with RPL and controls. We found a non-significant association between FBG and recurrent miscarriages. The majority of the reports on this topic are in line with our findings , 17, 18.Two studies by Crane et al.  and McCoOur findings suggest that there is a significant association between recurrent miscarriages and IR in patients with RPL by calculating the pooled SMD of HOMA-IR as a potential biomarker for assessing IR in patients. This finding was further confirmed by analyzing the odds of HOMA-IR  > 4.5 between the RPL and comparing group.Consistent with our results, Ispasoiu  and TianThe findings of our meta-analysis suggested that patients with RPL have significantly higher mean fasting insulin (FI) levels than controls. These results suggest that hyperinsulinemia may be present in women who experience recurrent miscarriages. Hyperinsulinemia is associated with decreased expression levels of glycodelin and insulin-like growth factor binding protein 1 (IGFBP-1), which are responsible for the immune response of the mother’s immune system towards the implanted embryo and facilitation of the adhesion process of blastocysts, respectively , 26, 27.Although the gold standard for identifying IR is the clamp technique , this teAlthough there is some debate about the exact biomarker alterations that occur in women who have had a history of RPL, the majority of studies agree that these women experience increased IR. The screening of pregnant mothers with a history of RPL in terms of metabolic status and blood sugar level should be prioritized to investigate possible IR states. FI, HOMA-IR, and FG/FI as IR indicators in these individuals need to be assessed in light of our findings.Our study has several strengths. We performed a comprehensive systematic review of three databases in line with the PRISMA statement with no date and language restrictions. To adjust serum levels of different markers for assessing IR, pooled effect sizes of relevant outcomes were calculated using the inverse variance method.Despite these strengths, we also faced number of limitations. The most important one lies in the fact that most of the included studies were observational, leading to the fact that these studies are limited-designed in nature and carry inherent biases. The majority of the studies included in the meta-analysis were of fair quality, which could result in weakening the strength of this meta-analysis. The paucity of studies in this field may contribute to publication bias.In conclusion, our study revealed a significant association between abnormal glucose metabolism tests and a history of recurrent pregnancy loss. These findings may persuade medical professionals to order further glucose metabolism tests in women who experience repeated miscarriages in addition to FBG.Additional file 1. Table S1. PRISMA 2020 checklist. Table S2. Quality assessment for each included study. Figure S1. Subgroup analysis based on the inclusion of pregnant women in the study population. Figure S2. Subgroup analysis based on the definition of recurrent pregnancy loss (RPL). Figure S3. Forest plot for patients with Fasting blood glucose (FG) / Fasting insulin (FI) <4.5. Figure S4. Forest plot for patients with Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) >4.5.