In children with ADHD/ODD, mean effects were d = 0.64 (95% CI 0.31–0.96) for WM and d = 0.46 (95% CI 0.07–0.84) for IC. Studies on reward-related IC and FL were lacking. Effects on ODD and ADHD symptoms were d = 0.40 (95% CI − 0.23 to 1.03) and d = 0.28 (95% CI − 0.08 to 0.64), respectively. Interventions targeting multiple EFs and using interpersonal cognitive scaffolding approaches showed large and statistically significant effects on ADHD and ODD symptoms. In preschool children of the general population and in those with ADHD/ODD (symptoms), interventions led to an improvement of EF performance. In children with ADHD and ODD, cognitive scaffolding interventions were most effective in terms of reducing ADHD and ODD symptoms. However, more well-controlled studies need to be conducted before any firm conclusions can be drawn.Many interventions targeting executive function (EF) development in the preschool period, where malleability might be particularly high, have been created and evaluated. We conducted a meta-analysis of randomized controlled trials (RCTs) on the effects of these interventions on (a) EFs in preschool children from the general population as well as preschool children with (symptoms of) attention-deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), and (b) ADHD and ODD symptoms in preschool children with ADHD/ODD (symptoms). Literature search yielded 35 RCTs. Risk of bias of the individual studies was assessed. A random-effects model was used. Moderator effects were tested using mixed model analyses. The overall effects on EFs were:  From the preschool years onwards, children with attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD) have consistently been found to show deficits in executive functions (EFs). Specifically, studies demonstrated reduced inhibitory control (IC) capacity in the “cool”, non-reward-related context and in the “hot”, reward-related context, a low working memory capacity, and low set-shifting ability , 2. ThesEFs are regarded as complex cognitive processes that serve purposes of behavioral regulation and goal-directed action . TheoretEFs involve the so-called executive control network, i.e. a set of frontal and parietal brain structures including regions of the prefrontal cortex (PFC), the insula, parts of the supplementary motor area and the anterior cingulate, the intraparietal sulcus, and other areas , 13. In In recent years, many intervention programs targeting EFs have been developed and evaluated. Several years ago, Diamond and Lee  reviewedd = 0.79, p < 0.001) and a medium effect on visuospatial WM . In children younger than 10 years, effect sizes for verbal and visuospatial WM were d = 1.41 (p < 0.01) and d = 0.46 (p < 0.01), respectively. Transfer effects to the Stroop measure (interference control) and to other cognitive abilities were small. Two further meta-analyses analyzed training effects on EFs in children with ADHD and high ADHD symptoms. Rapport et al. [d = 0.63, p < 0.05), and the training of mixed EFs (three studies) showed no noteworthy effect (d = 0.06). Far transfer effects on objective outcomes (e.g. cognitive tests) were modest. Wass et al. [Meta-analyses of the interventions for preschool children have not yet been performed. However, several meta-analyses on WM training (targeting the short-term memory component of WM) have been conducted. Melby-Lervåg and Hulme  analyzedt et al.  includeds et al.  analyzedd = 0.64 (p < 0.05). To control for the influences of expectancy effects of patients, parents, and researchers (i.e. more favorable ratings of responses to treatment by those who were invested in the therapy), mean effect sizes were estimated exclusively for studies with (probably) blinded assessments of ADHD symptom outcomes . The weighted mean effect size of the five respective studies was d = 0.24 and did not reach statistical significance. The meta-analysis by Rapport et al. [d = 0.48 (p < 0.05) and d = 0.12 (not significant), respectively. Comparably, Cortese et al. [d = 0.37, p < 0.05) on ADHD symptoms in children with ADHD and a decrease to d = 0.20 (p < 0.05) when exclusively blinded studies were considered. These authors suggested a possible advantage of programs targeting multiple EF deficits.Three recent meta-analyses studied the effects of cognitive training on ADHD symptoms in ADHD patients. Sonuga-Barke et al.  includedt et al.  analyzede et al.  found a Taken together, there is broad evidence regarding the significance of EFs in social adjustment development and psychopathology. In children with ADHD and externalizing symptoms, poor EF development has frequently been found, and has been assumed to be involved in the development of ADHD and ODD symptoms. Cognitive training of EFs in the preschool period was expected to be particularly effective, including the reduction of ADHD and externalizing symptoms. In recent years, specific intervention programs tailored to preschool children have been developed and evaluated (see description/definition of interventions below). In many cases, these programs focus on multiple core EFs and contain elements which target the facilitation of transfer. However, a meta-analysis summarizing the current results of this research has not yet been conducted.In the present meta-analysis, we, therefore, examined the following hypotheses: (1) cognitive interventions targeted at EFs (as defined by Diamond and Lee ) in presTo be included in the meta-analysis, a study had to fulfill the following criteria: (1) the study tested the effectiveness of an intervention which was developed to improve EFs in preschool and kindergarten children using a mainly cognitive approach . (2) ThThe meta-analysis follows the suggestions of the PRISMA statement . A literk = 8) of the studies were coded independently by the two coders to assess inter-coder agreement. Kappa coefficients for the categorical variables ranged between 0.74 and 1.0, and Kendall’s Tau-b correlations for the continuous variables ranged between 0.79 and 1.0, indicating excellent inter-coder reliability. Statistics necessary for effect size calculation were extracted by the second author (C.M.) and independently checked by the first author (U.P.-P.) in all cases. Divergence was solved by renewed inspection and discussion where necessary.Besides information necessary for effect size calculations (see below), the variables listed below (moderator variables section) were coded. For this purpose, a standardized coding sheet was developed. Coding was carried out by two psychologists (first and second author). 20% , ADHD, and ODD/externalizing symptoms measured at the first post-intervention assessment. In most instances (32 of 35 studies), a pretest–posttest control group design was used. To take advantage of the strengths of this design, the difference between the standardized mean change for the treatment and control group was used as primary effect size (see statistics section for further details).Several studies used more than one single task to assess one EF or symptom domain to increase the reliability of measurement. In some of the studies, composite scores had already been computed and listed in the article. Otherwise, we calculated the weighted mean effect size of the multiple tests per outcome domain. In cases where multiple scores were reported for a single test (e.g. error and accuracy scores), we used the score which most precisely reflected the outcome domain. If more than one independent study was reported in one article, all eligible studies were coded separately  dirIn cases of significant heterogeneity of effect sizes, we analyzed potential influences of sample and intervention characteristics. We considered the following sample characteristics: (a) mean age of the sample and (b) percentage of boys. The following intervention characteristics were considered: (a) duration of the intervention in weeks, (b) the intensity of the intervention in minutes per week, (c) the setting (group vs. single child), and (d) the delivery of the intervention by teacher (classroom curriculum) vs. trainer/therapist.Regarding risk of bias, the meta-analysis follows the suggestions of the Cochrane Collaboration’s tool  as well For the assessment of publication bias, we used funnel plots and Egger’s test for funnel plot asymmetry. As funnel plot asymmetry can be caused by heterogeneity of effect sizes , we contd coefficient) was used as the primary effect size metric. According to Morris [The difference between the standardized mean change for the treatment and control group  and on ADHD and ODD/externalizing symptoms, random effects models were used because between-studies variability of effect sizes is assumed. The amount of heterogeneity was estimated with the restricted maximum-likelihood estimator and tested by Cochran’s Q test .To explore differences between the four approaches, we used mixed effects analyses. For the analyses of other moderator effects, mixed effects analyses also were performed. Calculations were carried out with “metafor” version 1.9–2 of R version 3.1.0 .The procedure was as follows: hypothesis 1: (1) for each of the EF outcome domains , the overall weighted mean effect size of the interventions was estimated. Heterogeneity of effect sizes was tested. (2) The weighted mean effect size for the studies with ADHD/ODD samples was estimated and compared with the mean effect in the general population samples. (3) The weighted mean effect size for the internally valid studies was estimated. (4) Differences between intervention approaches were explored. (5) Further moderator effects were tested if heterogeneity of the overall weighted mean effect size was significant. Hypothesis 2: (1) for the two outcome domains , the overall weighted mean effect sizes in the studies with ADHD/ODD samples were estimated. Heterogeneity of effect sizes was tested. (2) The weighted mean effect size for the internally valid studies was estimated. (3) Differences between intervention approaches were explored. (4) The moderator effects were tested if heterogeneity was significant.k = 35 independent RCTs (k = 35) reported in 29 articles. In all, n = 3068 children participated in these studies. Table Figure In 23 studies, the effect of a cognitive training intervention on WM was analyzed. Fourteen studies focused on direct WM training, seven on cognitive scaffolding, no study on attention-directing strategies, and two studies analyzed programs with a minor EF component . Inter-study heterogeneity of effect sizes was significant . The mean effect size of these studies did not differ from that in studies of children from the general population . The moderator effects by internal validity was statistically significant (Q(1) = 4.94; p = 0.026; k = 23), indicating a higher mean effect size of the more rigorously controlled studies. Intervention approaches did not significantly differ  = 0.04, k = 22) or mean age of sample (Q(1) = 0.21, k = 23). Among the characteristics of the intervention, there were also no significant moderator effects (delivery by trainer/therapist vs. teacher: Q(1) = 2.17, k = 23, duration of intervention in weeks: Q(1) = 2.71, k = 23, intensity: Q(1) = 0.42, k = 21, group vs. single-child setting: Q(1) = 0.00, k = 23). The funnel plot for the mixed model meta-analysis  did not show significant asymmetry . Seven of the 26 studies were classified as highly valid.d = 0.30 (p < 0.001), with no significant inter-study heterogeneity of effect sizes (Table d = 0.46 (p = 0.015). In the highly valid studies, the mean weighted effect size was d = 0.39 (p < 0.001). Moderator effects by study sample (Q(1) = 0.69) and validity (Q(1) = 0.72) were not significant. Effect sizes of the three intervention approach categories (with more than one study) did not significantly differ . Between-study heterogeneity of effect sizes was significant  = 0.21; percentage of boys: Q(1) = 0.76; duration of intervention: Q(1) = 0.85; doses/intensity: Q(1) = 0.01; delivery (teacher vs. trainer/therapist): Q(1) = 0.09; all interventions used a group setting). An analysis of funnel plot asymmetry was not appropriate due to the low number of studies.Further moderator analyses yielded no significant results . Heterogeneity was statistically significant (Table d = 0.84 (p < 0.001). The moderator effect by validity of the study design was significant (Q(1) = 9.40, p < 0.01), indicating larger effects of the more rigorously controlled studies. No significant differences emerged between the intervention approaches  = 1.17; percentage of boys: Q(1) = 0.59; duration of intervention Q(1) = 2.02; intensity of intervention: Q(1) = 0.03; setting: Q(1) = 0.26; delivery: Q(1) = 0.15). When controlling for the significant moderator effect by study validity, the Egger test for funnel plot asymmetry was significant . The other RCT analyzed a program with a minor EF component. The effect was not significant . There was no significant heterogeneity of the effect sizes of the studies. No study fulfilled all validity criteria. However, one study used a blinded assessment of the ADHD outcome and another study used an active control condition  while the mean effect size of the three RCTs on direct EF training was d = 0.17 (not significant). Analysis of funnel plot asymmetry was inappropriate due to the low number of studies.In four studies, the effect of a cognitive training intervention  on the ADHD symptoms of preschoolers with high symptoms or a diagnosis of ADHD, ODD, or externalizing disorders was analyzed Table . Two stu28 p = 0.3. There EFs have been found to predict social adjustment development in childhood and adolescence and are assumed to be causally involved in the pathogenesis of ADHD and ODD. The core EFs of WM, IC, and FL show major normative developmental improvements in preschool years. They are presumed to be particularly malleable by cognitive training interventions in this developmental period. The number of studies analyzing this hypothesis has increased considerably in recent years. However, this research has not yet been systematically reviewed and summarized by means of a meta-analysis.We analyzed the effectiveness of EF training interventions developed specifically for preschool children regarding the improvement of core EFs and the reduction of ADHD and ODD symptoms. The main findings were as follows: based on the RCTs with the lowest risk of bias , we found a significant, medium effect on WM, and a significant small to medium effect on cool IC. There were no highly valid studies on hot IC and only four on FL. In preschoolers with ADHD/ODD (symptoms), significant  medium-sized effects on WM and cool IC emerged. With the exception of hot IC, there were no differences between the intervention approaches. Hot IC, however, showed greater improvements from interventions focusing on attention-directing strategies and cognitive scaffolding. In children with ADHD/ODD (symptoms), overall small to medium sized, not statistically significant effects on ODD and ADHD symptoms emerged. Effects of cognitive scaffolding programs were large, while the effects of programs using direct training of EFs or programs with a minor EF component were negligible.d = 0.30 (cool IC) and d = 0.47 (FL). The effect on WM  is comparable with the findings of meta-analyses on WM/attention training by Cortese et al. [d = 0.51, p < 0.05; visual WM: d = 0.47, p < 0.05) in children/adolescents with ADHD and by Melby-Lervåg and Hulme [d = 0.46, p < 0.01) in children from diverse populations. In the present meta-analysis, in all instances, the mean effect size was larger in the trials with the highest internal validity (low risk of bias). In the domains of WM and FL, the moderator effect by study validity reached statistical significance. This finding is unsurprising given that controlling for unsystematic errors leads to a closer link between the experimental conditions and the outcome variable. Moreover, the finding underscores the methodological quality (i.e. no systematic biases in favor of the interventions) of the included studies. This latter aspect is probably due to the use of neuropsychological tests (i.e. no subjective ratings) for the assessment of the outcomes. Overall, it can be concluded that the interventions lead to a substantial improvement in preschoolers’ WM and cool IC. Due to publication bias, however, the effect on FL should be interpreted with caution.The overall weighted mean effect sizes in the four EF domains ranged between e et al.  . NevertIn previous research, transfer effects of improvements in EFs after direct (often computerized) cognitive training were rather low. Even if participants increased, for instance, their WM capacity, generalization to other EFs and cognitive abilities (near transfer effects) or to academic skills and subjective ratings of e.g. ADHD symptoms (far transfer effects) were poor , 22. ManIn the preschool period, during which ADHD and ODD symptoms emerge, the not yet full-blown disorders are hard to distinguish. ADHD and ODD symptoms often occur together and only over the course of time do they differentiate into the subtypes of ADHD, ODD, and the combination thereof . For thiIn samples of children with ADHD and ODD/externalizing symptoms, the overall effects on the ADHD symptoms (four RCTs) and the ODD/externalizing symptoms (two RCTs) were not statistically significant. In both domains, a RCT on a cognitive scaffolding program showed significant, large effects, while effects of direct (computerized) training of EFs or a program with a minor EF component were negligible and not statistically significant. Cognitive scaffolding programs usually aim at multiple EFs, comprise elements which target the facilitation of transfer to everyday life, and take place in everyday interpersonal contexts. These programs might, therefore, be better tailored to the probably multiple EF deficits of children with ADHD and ODD, and might better represent the everyday context in which the symptoms appear.Nevertheless, these conclusions need to be seen as tentative. Of the six RCTs, only two RCTs on ADHD samples showed good internal validity . Even though these two well-controlled studies showed an almost medium effect size on average, statistical significance was not reached due to large differences in the single effects. More research is needed in this area. Based on our results, RCTs on cognitive scaffolding programs with blinded assessments of the ADHD and ODD outcomes would be particularly worthwhile.As mentioned above, some findings of the meta-analysis are limited by the insufficient number of eligible studies. Specifically, more studies are needed which use blinded assessments of subjective ratings of ADHD and ODD symptoms, and analyze the effects on hot IC. Moreover, it is necessary to analyze the mediation effects by the core EFs on the ADHD and ODD/externalizing outcomes on the level of single studies. As the number of studies on this topic is insufficient, the question of whether the improved EFs actually lead to a reduction of the ExtD symptoms must remain unanswered. The results of the current meta-analysis are compatible with such mediation processes (as effect sizes on EFs and ADHD symptoms were significant) but, as mentioned, they do not prove mediation. Regarding FL, we found indications of publication bias. As shown by the funnel plot (Appendix), there were relatively few small studies reporting small, non-significant effects. The finding points to the need for the publication of well-controlled trials with FL outcome measures, irrespective of the significance of the results.To conclude, although we found many well-controlled RCTs on the effectiveness of preschool interventions aiming at EFs, more research is needed. The meta-analysis revealed significant, mostly medium-sized effects of the preschool interventions on core EFs in studies showing a low risk of bias. In children with ADHD and ODD, cognitive scaffolding interventions were most effective in terms of reducing ADHD and ODD symptoms. However, these findings need to be confirmed in future research. Such research appears to be worthwhile given the indications that these interventions could adequately support preschool children who show ADHD/ODD (symptoms).


Suboptimal nutrition is a major cause of morbidity and mortality in the United Kingdom (UK). Although patients cite physicians as trusted information sources on diet and weight loss, studies suggest that the management of nutrition-related disorders is hindered by insufficient medical education and training. Objectives of this study were to: (1) Quantify nutrition-related learning objectives (NLOs) in UK postgraduate medical training curriculums and assess variation across specialties; (2) assess inclusion of nutrition-related modules; (3) assess the extent to which NLOs are knowledge-, skill-, or behaviour-based, and in which Good Medical Practice (GMP) Domain(s) they fall. 43 current postgraduate curriculums, approved by the General Medical Council (GMC) and representing a spectrum of patient-facing training pathways in the UK, were included. NLOs were identified using four keywords: ‘nutrition’, ‘diet’, ‘obesity’, and ‘lifestyle’. Where a keyword was used in a titled section followed by a number of objectives, this was designated as a ‘module’. Where possible, NLOs were coded with the information to address objective 3. A median of 15 NLOs (mean 24) were identified per curriculum. Eleven specialties (25.6%) had five or less NLOs identified, including General Practice. Surgical curriculums had a higher number of NLOs compared with medical , as well as a higher inclusion rate of nutrition-related modules . 52.9% of NLOs were knowledge-based, 34.9% skill-based, and 12.2% behaviour-based. The most common GMP Domain assigned to NLOs was Domain 1: Knowledge, Skills and Performance (53.0%), followed by Domain 2: Safety and Quality (20.6%), 3: Communication, Partnership and Teamwork (18.7%), and 4: Maintaining Trust (7.7%). This study demonstrates considerable variability in the number of nutrition-related learning objectives in UK postgraduate medical training. As insufficient nutrition education and training may underlie inadequate doctor-patient discussions, the results of this analysis suggest a need for further evaluation of nutrition-related competencies in postgraduate training. The Rs value was calculated using the following standard formula:Spearman’s Rank Correlation Coefficient .This section forms a descriptive analysis of the findings in this study. The testing of statistical significance was limited to Spearman’s Rank Correlation Coefficients (1); those in the upper quartile (Q3) had between 15 and 35 NLOs (interquartile range (IQR) = 30). The eleven curriculums in the lower quartile are listed in All 43 curriculums had at least one NLO identified, with a median of 15 NLOs (mean 24) per curriculum. There was considerable variation between curriculums in the number of NLOs identified , with a n = 11) had a higher number of identified NLOs  compared with medical curriculums , and the number of NLOs identified in the IMT curriculum (7 objectives) was lower than the CMT curriculum (39 objectives). Surgical curriculums , followed by ‘obesity’ (229), ‘lifestyle’ (166), and ‘diet’ (122) .In 22 specialties (51%) at least one nutrition-related module was identified, with a maximum of 13 modules in a single curriculum (Gastroenterology). Modules were identified in 100% of surgical curriculums (mean 2.7 modules per curriculum) compared with 34.4% of medical curriculums (mean 0.8 modules per curriculum). Shared peri-operative nutrition and obesity modules were present across all surgical curriculums, which likely contributes to the higher number of NLOs identified in surgical compared with medical curriculums. The most common keyword descriptor for modules was ‘nutrition’ (36 modules across curriculums), followed by ‘obesity’ (15 modules) and ‘lifestyle’ (4 modules). There were no ‘diet’ modules identified in any curriculum .84% of NLOs identified across curriculums were designated as knowledge-, skill-, or behaviour-based. 52.9% of these were knowledge-based, compared with 34.9% skill-based and 12.2% behaviour-based objectives .Over half of ‘nutrition’ and ‘obesity’ objectives were knowledge-based, with a small proportion of behaviour-based objectives  . In compAcross curriculums, 51.9% of NLOs identified were designated one or more GMP Domains. Twelve specialties did not include any clear GMP Domain designation to NLOs, and were not included in this sub-analysis , Paediatrics, Occupational Health, Public Health, and General Practice). The most commonly designated domain across curriculums was Domain 1: Knowledge, Skills and Performance (53.0%), followed by 2: Safety and Quality (20.6%), 3: Communication, Partnership and Teamwork (18.7%), and 4: Maintaining Trust (7.7%) . Rs(31) = 0.19, p = 0.30), and very weak negative correlations with Domain 2: Safety and Quality (Rs(31) = −0.06, p = 0.74), Domain 3 (Rs(31) = −0.06, p = 0.75), and Domain 4 (Rs(31) = −0.08, p = 0.69). There was a weak negative correlation between ‘diet’ NLOs and Domain 1 (Rs(31) = −0.22, p = 0.23) and very weak positive correlations with Domain 2 (Rs(31) = 0.13, p = 0.49) and Domain 4 (Rs(31) = 0.23, p = 0.22). There was a moderately strong positive correlation between ‘diet’ NLOs and Domain 3: Communication, Partnership and Teamwork (Rs(31) = 0.41, p = 0.02). There was a weak negative correlation between ‘obesity’ NLOs and Domain 1 (Rs(31) = −0.22, p = 0.23) and Domain 2 (Rs(31) = 0.30, p = 0.1), a weak positive correlation with Domain 3 (Rs(31) = 0.29, p = 0.17) and a very weak negative correlation with Domain 4 (Rs(31) = −0.06, p = 0.73). ‘Lifestyle’ NLOs had a very weak positive correlation with Domain 1 (Rs(31) = 0.03, p = 0.87) and Domain 4 (Rs(31) = 0.07, p = 0.70), a weak negative correlation with Domain 2 (Rs(31) = −0.20, p = 0.29) and a very weak negative correlation with Domain 3 (Rs(31) = −0.01, p = 0.94). Spearman’s Rank Correlations were used to assess the relationship between keywords and GMP Domains . These cA search for the stem “communicat-” across all objectives revealed only eight NLOs, outlining communication-based outcomes with either members of the multidisciplinary team or patients (0.008% of 1030 identified NLOs). The stem “counsel-” appeared in 3 NLOs (0.003%), and “modif-” appeared in 13 NLOs (0.01%). “Change” appeared in 59 NLOs (0.06%) and was associated with lifestyle change in all but one objective; the full term “behaviour change” was found in one objective (0.001% of objectives). This study provides a comprehensive critical synthesis of nutrition-related education in UK postgraduate medical training by identifying nutrition-related learning objectives (NLOs) and their designation within the GPC and GMP Domain frameworks. Using this standardised, quantitative approach we found that inclusion of NLOs is highly variable across curriculums, with a difference of 176 objectives between the highest and lowest scoring specialties . The resAlthough the median number of objectives was found to be close to the Nutrition Task Force standard, at 15 NLOs per curriculum, the considerable variability across training programmes suggests that further work is required to ensure consistency in nutrition-related education across specialties. In particular, unsubstantiated differences between surgical and medical curriculums—with surgical specialties incorporating a median of 30 NLOs compared with 8.5 NLOs in medical curriculums—highlight the need for further evaluation of nutrition-related competencies across medical training programmes. Surgical programmes were also ahead of their medical counterparts in the inclusion of modules. All surgical curriculums contained at least one nutrition-related module (with an average of 2.7 per curriculum), whilst only 34.4% of medical curriculums managed the same (with an average of 0.8 modules per curriculum). Shared peri-operative nutrition and obesity modules were present across all surgical curriculums, and suggest that incorporation of shared, generic modules across medical curriculums may facilitate the inclusion of a greater number of NLOs, as well as promoting a cohesive approach to nutrition education. Using the GPC and GMP Domain frameworks to understand the specific contexts in which nutrition-related objectives appear within curriculums, it is clear that there is a predominance of knowledge-based outcomes. Within the GPC framework, 52.9% of NLOs were knowledge-based , which wInterestingly, an analysis of the keywords used within NLOs suggests that their wording may be associated with their designation within both the GPC and GMP Domain frameworks. In the GPC framework, over half of the ‘nutrition’ NLOs were knowledge-based, with a small proportion of behaviour-based objectives (8.4%) . ‘Diet’ Learning objectives set out in postgraduate curriculums form the essential component upon which doctors will be taught, trained, and assessed throughout their training programme. Postgraduate programmes are required to ensure that doctors have sufficient experience, teaching, and training—including attending organised education sessions, training days, and courses—to meet the requirements of their GMC-approved curriculum . WorkplaFor trainees to be effectively taught, trained, and assessed on nutrition-related competencies, it seems clear that a sufficient number of nutrition-related learning objectives must be consistently incorporated into postgraduate curriculums. In light of the recognition that nutrition education is often waylaid by its sporadic and piecemeal inclusion throughout curriculums, objectives would ideally be integrated using a cohesive, modular approach, in order to facilitate learning and to champion the significance of nutrition in medical training. In looking to increase the representation of nutrition-related learning objectives across postgraduate curriculums in a meaningful way, it is also essential that we examine the contexts in which these objectives appear. For UK postgraduate curriculum development, this largely refers to three fundamental areas—professional knowledge, professional skills, and professional values and behaviours—that form the foundation of the Generic Professional Capabilities (GPC) Framework set out by the GMC . The GPCAll three of these GPC components are critical in nutrition-related training for doctors. Traditionally, however, acquisition of knowledge has formed the principal driving force of medical education. Despite the relationship between effective clinical communication and improved health outcomes being well established in the literature by the 1990s , communiAlthough a lack of nutrition knowledge is an identified barrier to nutrition counselling , knowledA second important GMC framework embedded into postgraduate curriculums is Good Medical Practice (GMP) . There aAs with the GPC Framework, all of these domains are important in nutrition-related clinical practice. Whilst maintaining a good standard of practice and keeping up to date with knowledge and skills are fundamental, training curriculums should also focus on protecting and promoting the health of patients and the public (Domain 2), communicating effectively with patients and supporting them in improving and maintaining their health (Domain 3), and never discriminating unfairly against patients (Domain 4), within their nutrition-related training and education. Professional values, such as building empathetic, trusting and respectful relationships with patients are integral to successful behaviour change . Weight The Nutrition Task Force and Intercollegiate Group on Nutrition recognised the need for nutrition-related education and training as a prerequisite to safe and competent clinical practice . To illuIndividuals with depression and schizophrenia have a higher level of obesity than the general population, and are disproportionately at risk of obesity-related conditions including cardiovascular disease and type 2 diabetes mellitus (T2DM) ,45. FurtThe National Institute of Mental Health identified obesity as a priority ,47; howeIn this study, we identified seven paediatric NLOs. ‘Nutrition’ objectives required trainees to “provide nutritional support for patients, including those with temporary or permanent intestinal failure, and manage services for home parenteral nutrition”, “manage all aspects of reversible and irreversible intestinal failure in children, and manage children with complex nutritional needs requiring nutritional support”, and “feeding and nutrition” in neonatal medicine. ‘Diet’, ‘obesity’ and ‘lifestyle’ objectives were to “work closely with…dieticians”, “liaise effectively with…specialist teams for managing paediatric inherited metabolic conditions, particularly...dieticians”, management of “endocrine-related obesity”, and playing “a vital role in planning and implementing local strategies to improve the health of all children in their area, including…targeted lifestyle programmes”. There are no competencies which specifically address diet and obesity counselling for children and parents—which have been shown to improve prevention and treatment of paediatric obesity —nor any The Royal College of Paediatrics and Child Health acknowledge that paediatricians have a role in the full breadth of child health. The management and prevention of childhood obesity is fundamental to a healthy lifestyle; overweight children are more likely to suffer psychosocial problems which affects educational attainment and interpersonal relationships and lead to persistent problems in adulthood ,52. In aWith the growing prevalence of non-communicable diseases (NCDs), General Practitioners (GPs) play an important role in the future trajectory of population health . Over 60The role of GPs in tackling the increasing burden of obesity and NCDs is recognised by the Royal College of GPs (RCGP) . This stIt is also crucial that GPs have skills and tools to manage obesity and diet with patients. The attendant COVID-19 (Severe Acute Respiratory Syndrome Coronavirus 2) crisis illustrates the importance of addressing malnutrition in primary care. A meta-analysis found substantial increases in morbidity and mortality associated with COVID-19 in patients with obesity, with 113% higher risk of hospitalisation, 74% higher risk for intensive care admission, and 48% increase in mortality . The rolTo our knowledge, this is the first study to quantitatively assess nutrition-related outcomes in postgraduate training in the UK. Using this study design, we were able to identify relevant NLOs and compare variation across specialties. We have built a database of all current nutrition-related outcomes that can be identified by ‘nutrition’, ‘diet’, ‘obesity’, and ‘lifestyle’ descriptors, which should provide the foundation for future qualitative work. In addition, we were able to assess the balance of knowledge-, skill-, and behaviour-based competencies, as well as Good Medical Practice Domains, to allow for continuing improvements toward GMC-aligned goals for excellence in postgraduate training programmes. Study limitations include the quantitative focus of this study design. Firstly, the number of NLOs in a curriculum bears no reflection on actual nutrition-related practice within an identified medical field, and we are therefore unable to comment on how variation in nutrition-related outcomes in curriculums translates into variation in practice. However, this data can serve as a starting point for further research seeking to understand the impact of curricular design on clinical practice. Secondly, a full thematic analysis of all objectives was outside the scope of this study. Future qualitative research into postgraduate training curriculums NLOs coupled with the findings in this study may help inform the development of new, high-level outcomes. Finally, in postgraduate training there is an assumption that all curricular competencies will be achieved, but recognised that not all may be specifically assessed, meaning that it is possible that, regardless of the number of NLOs in a curriculum, trainees may have evidenced competence in a smaller number of outcomes. In curriculums where NLOs constitute a very small proportion of total objectives, it may be possible for a trainee to progress through training without any demonstrated competence in this area. Given the concern regarding nutrition-related education and training for UK medical students and doctors, future research might look into the necessity for compulsory workplace-based assessments relating to nutrition-related outcomes. In addition, the exclusive inclusion of the current, GMC-approved curriculum for each specialty was necessary to ensure standardisation, but it should be recognised that some specialties, such as General Practice, also include detailed supplementary documents for trainees in which further reference to nutrition-related education may be present. However, the RCGP state “The core curriculum statement provides a full description of the knowledge, skills, attitudes and behaviours required of a GP in managing patients and their problems”, while the topic guides illustrate “key learning points with case scenarios, reflective questions, and advice for learning and teaching” , indicatPatient health and safety is at the core of the educational standards in postgraduate medical training, and should accordingly be the first priority of organisations that design and develop curriculums . Action-


Current evidence regarding the association of serum zonulin-related proteins (ZRP) levels with prevalent inflammatory bowel disease (IBD) is contradictory. Moreover, the association with the subsequent risk of incident IBD is still unexplored. This study aimed to investigate the association of serum ZRP levels with both prevalent and incident IBD.The study included a total of 130 women (51–61 years) from the Women’s Health in Lund Area (WHILA) study, which included 18 prevalent IBD (diagnosed before baseline) and 47 incident IBD diagnosed during the 17 years (median) follow-up and age- and sampling time-matched controls. Serum ZRP was tested in all participants by ELISA.p = 0.02), however, no evidence of a difference in ZRP levels was found between the women who developed IBD during the follow-up period and their matched controls . Using linear mixed models, we found that the association between serum ZRP levels and prevalent IBD , remained after adjusting for potential confounders. Conditional logistic regression models showed no evidence of an association between ZRP level and incident IBD .The serum ZRP levels were significantly higher in prevalent IBD compared to their matched controls (63.2 ng/ml vs 57.0 ng/ml, Higher serum ZRP levels were associated with prevalent IBD, but not with incident IBD in our study samples.The online version contains supplementary material available at 10.1186/s12876-021-02075-y. Inflammatory bowel disease (IBD), including Crohn’s disease (CD) and ulcerative colitis (UC), is characterised by chronic inflammation of the gastrointestinal (GI) tract. UC is an inflammation of the colon and rectum, whereas CD is characterised by mucosal inflammation in different areas of the GI tract . DiarrheZonulin was discovered and first described by Fasano approximately 20 years ago and it can increase permeability in the epithelial layer of the small intestine and contributes to intestinal innate immunity , 13. RecIn the present study, we aimed to investigate the potential association of serum ZRP levels with the prevalence and incidence of IBD in selected samples from a prospective study followed for 20 years.The study population was selected from the Women’s Health in Lund Area (WHILA) study. All women living in Lund, Sweden between 1995 and 2000, which were born between 1935 and 1945 , were invited to a health survey. In the WHILA study, a total of 6917 women (64.2%) completed the questionnaire and underwent a physical examination . In brieThe whole blood was collected into serum separate tubes (SST) and centrifuged at 2000 g for 10 min. Serum was harvested and stored at − 80 °C until the time of measurement.The serum ZRP concentration was measured by competitive ELISA method  according to the manufacturer's instructions. In brief, 20 ul serum was used for testing and optical density was read at 450 nm. The 4-parameter algorithm was used to set up the standard curve. The final ZRP concentration (ng/ml) was calculated based on the standard curve. The inter-assay coefficient of variance (CV) was 5.5% and intra-CV was 3.6%.Data were presented as the mean and standard deviation (SD) together with min and max for age, body mass index (BMI), systolic blood pressure (SBP), diastolic blood pressure (DBP), Triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C), whereas smoking and alcohol use were presented as numbers and percentages. ZRP levels were presented with mean and SD, median and IQR together with min and max.To examine the association between ZRP levels and subject characteristics we used linear mixed models with ZRP levels as outcome variables to take into account the correlation within matched pairs.Paired t-test and Wilcoxon signed-rank test were used to compare the ZRP levels between cases and controls, for all women as well as stratified by UC and CD . For the prevalent population, we used a linear mixed model with ZRP levels as outcome, estimating regression coefficients (β). We adjusted for BMI, smoking condition and alcohol use because these variables have been shown to be associated with both IBD and ZRP levels previously –31. STATAll the participants provided written consent according to the Declaration of Helsinki before enrollment in the study. The study was approved by the Ethics Committee in Lund, (2011/494 and 2015/6).A total of 130 women, 65 cases  and 65 matched controls were included in the analysis. The mean age of the study population was 55 years and the mean BMI was 24.6 at baseline. Most participants were non-smokers (78%) and low consumers of alcohol (68%). The mean serum ZRP level was 60.4 ng/ml (Table p = 0.02), higher DBP , higher TG , higher LDL-C  and a lower HDL-C  , systolic blood pressure (SBP), diastolic blood pressure (DBP), Triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), smoking condition, and alcohol use on serum ZRP levels indicated that ZRP levels were higher in subjects with a higher BMI , but there was no significant difference in ZRP levels between incident cases of IBD and controls  (Table p = 0.01) and that the results remained the same after adjusting for BMI, smoking condition, and alcohol (Table p = 0.34) , thus indicating that we may exclude the possibility that ZRP levels might predict short-term incident IBD.Previous studies reported that serum ZRP was related to metabolic risk markers, such as BMI, DBP, TG, LDL-C, and HDL-C , 36–39. The main limitation in the current study was the study sample size being relatively small and calls for further research with a larger population. Nonetheless, to our knowledge, this is the first clinical study to investigate serum ZRP as a predictor for IBD. This could be the starting point for further studies to examine the clinical role of serum ZRP in IBD. In addition, it is necessary to mention another important limitation; the serum measurements were based on a commercially available ELISA kit , 23. RecIn conclusion, we found an association of serum ZRP levels with prevalent IBD, but not with incident IBD in our study population. Therefore, the impaired intestinal permeability may be a consequence, rather than a cause of the chronic inflammatory response that characterizes both CD and UC. The results need further study in a large cohort to confirm.Additional file 1. Table S1. Zonulin levels in relation to various disease conditions.


Glioma is the most common central nervous system tumor with a poor survival rate and prognosis. Previous studies have found that long non-coding RNA (lncRNA) and competitive endogenous RNA (ceRNA) play important roles in regulating various tumor mechanisms. We obtained RNA-Seq data of glioma and normal brain tissue samples from TCGA and GTEx databases and extracted the lncRNA and mRNA expression data. Further, we analyzed these data using weighted gene co-expression network analysis and differential expression analysis, respectively. Differential expression analysis was also carried out on the mRNA data from the GEO database. Further, we predicted the interactions between lncRNA, miRNA, and targeted mRNA. Using the CGGA data to perform univariate and multivariate Cox regression analysis on mRNA.We constructed a Cox proportional hazard regression model containing four mRNAs and performed immune infiltration analysis. Moreover, we also constructed a ceRNA network including 21 lncRNAs, two miRNAs, and four mRNAs, and identified seven lncRNAs related to survival that have not been previously studied in gliomas. Through the gene set enrichment analysis, we found four lncRNAs that may have a significant role in tumors and should be explored further in the context of gliomas.In short, we identified four lncRNAs with research value for gliomas, constructed a ceRNA network in gliomas, and developed a prognostic prediction model. Our research enhances our understanding of the molecular mechanisms underlying gliomas, providing new insights for developing targeted therapies and efficiently evaluating the prognosis of gliomas.The online version contains supplementary material available at 10.1186/s12864-021-08035-w. Glioma is the most common intracranial primary malignant tumor, accounting for approximately 50% of all brain tumors, with a worldwide incidence rate of 4.67–5.73/100,000 . At presIn the human genome, about 90% of the genes get transcribed, about 2% encode proteins, and the remaining are transcribed into non-coding RNA (ncRNA) . Long noCompetitive endogenous RNAs (ceRNAs) play an important role in the molecular regulation of tumors by modulating mRNA expression via the development of a new type of regulatory relationship between lncRNA and miRNA . The lncIn this study, we carried out WGCNA and differential expression analysis based on The Cancer Genome Atlas (TCGA) and Genotype Tissue Expression (GTEx) databases to identify the differential lncRNAs and mRNAs that are highly correlated to glioma. The differential analysis was carried out using mRNA data from the Gene Expression Omnibus (GEO) database and the differential mRNAs obtained from the combined data of TCGA and GTEx were further screened. These mRNAs were used to perform a Cox regression analysis based on the Chinese Glioma Genome Atlas (CGGA) database and develop a prognostic prediction model for glioma patients. Finally, we constructed a ceRNA network and performed survival and functional analyses on the newly discovered lncRNA in relation to glioma using the network. Figure p < 0.05, |log2 fold change (FC)| ≥ 1).From the TCGA and GTEx combined dataset, we identified differentially expressed (DE) lncRNAs and mRNAs, including 194 upregulated and 280 downregulated lncRNAs, and 2223 upregulated and 2334 downregulated mRNAs. From the GEO combination dataset, we identified 2479 upregulated and 2056 downregulated mRNAs. We integrated DEmRNAs that overlapped between the aforementioned datasets and identified 828 upregulated and 716 downregulated mRNAs , and determined that the β value in the network was 3 . Finally, these eight mRNAs were used to analyze and screen the above information, and 25 lncRNAs and two miRNAs were obtained Fig. a.n = 668) was used to construct a regression model of glioma patients. Univariate Cox regression analysis was performed on the eight previously obtained mRNAs, and four mRNAs related to prognosis were identified (p < 0.001)  compared to those in the high-risk group  (p < 0.001) . The AUC values of the ROC curve for risk score, recurrence, and grade were 0.693, 0.658, and 0.759, respectively  Fig. a. Next, 01) Fig. b. Accordoup Fig. d. Univar01) Fig. e. Multiv01) Fig. f , macrophages (cor = − 0.452), dendritic cells (cor = 0.363); PGD is significantly related to B cells (cor = 0.523), dendritic cells (cor = 0.513), and neutrophils (cor = 0.427); CDK6 is related to B cells (cor = 0.309), CD8+ T cells (cor = 0.254) and dendritic cells (cor = 0.274); and GCC1 is related to CD4+ T cells (cor = 0.306), dendritic cells (cor = 0.343), and macrophages (cor = 0.365) . We found that they are associated with immune infiltration in GBM and LGG, and that the correlation is especially strong in LGG.The tumor microenvironment is mainly composed of the tumor, stromal, and immune cells. We analyzed and visualized the relationship between four kinds of mRNAs  and tumor purity and immune cell infiltration using the TIMER tool Fig. . In LGG,We used four mRNAs obtained from multiple Cox analysis to screen the ceRNA network and obtained two miRNAs and 25 lncRNAs. The CPAT online tool was used to verify lncRNA, 21 of which had no coding ability. Cytoscape was used to visualize the ceRNA network of 21 lncRNAs, two miRNAs, and four mRNAs Fig. b.n = 668), Kaplan–Meier analysis was used to verify the correlation between lncRNAs and the overall survival (OS) of glioma patients. In the Kaplan–Meier analysis of 21 lncRNAs, 12 lncRNAs were found to be closely related to the OS of glioma patients. Among these, there were six lncRNAs  that have not been studied in gliomas, and we visualize the Kaplan–Meier analysis results (p < 0.05) , we performed GSEA analysis on the six lncRNAs identified previously and showed that four were closely related to cancer. AC090425.1 shows potential effects on the p53 signaling pathway, small cell lung cancer, cell cycle, and other pathways involved in cancer  to access the RNA-Seq data from the GTEx and TCGA (LGG + GBM) databases. The former contains 702 samples, comprising 697 glioma and five adjacent tissue samples, and the latter contains 1146 normal brain tissue samples. We downloaded miRNA-Seq data of 530 glioma samples from TCGA databases. Next, we obtained two datasets, GSE33331  and GSE50161  from the GEO database (https://www.ncbi.nlm.nih.gov/geo/). The GSE50161 dataset was screened for glioma samples, and 95 glioma and 13 normal brain tissue samples were obtained. Finally, we downloaded the RNA-Seq and clinical data of 693 glioma samples from the CGGA database (http://cgga.org.cn/), of which 668 patients had survival information and 553 patients had complete clinical information.In this study, we comprehensively analyzed the data from four different databases. First, we used the UCSC Xena Browser (https://www.gencodegenes.org/human/). The R package oligo [The RNA-Seq data extracted from TCGA and GTEx databases were converted into gene symbols according to GENCODE  was used to predict the interactions between lncRNA and miRNA. We analyzed the predicted miRNA and the top 500 highly expressed miRNA data obtained from TCGA database to obtain the overlapping miRNAs. The miRTarBase (http://mirtarbase.mbc.nctu.edu.tw/), miRDB (http://www.mirdb.org/), and TargetScan (http://www.targetscan.org/) were used to predict the target mRNA of miRNA and were predicted by the three databases simultaneously. We analyzed the key mRNA modules obtained using WGCNA and predicted mRNA and DEmRNA to obtain overlapping mRNA. Finally, the prediction results were evaluated to obtain the ceRNA relationship of the lncRNA–miRNA–mRNA.The lncRNA key module and DElncRNA comprehensive analysis were used to screen for overlapping lncRNAs. The miRcode database  × exp.(β1x1 + β2x2 + … + βnxn). The clinical factors were then analyzed through univariate and multivariate Cox analyses, and the correlation between the prognostic characteristics and overall survival rate of the patient was calculated. Finally, we used the R package SurvivalROC to draw the ROC curve and calculated the area under the curve (AUC) to assess the performance of the prognostic prediction model.https://cistrome.shinyapps.io/timer/) [+ T cells, CD4+ T cells, macrophages, neutrophils, and dendritic cells.We used the online tool TIMER (/timer/)  to studyhttp://lilab.research.bcm.edu/cpat/index.php) was used to verify the coding ability of lncRNA, thereby constructing a ceRNA network. Cytoscape 3.8.0 software (https://cytoscape.org/) [Based on the mRNAs obtained from the multivariate Cox regression analysis and the predicted lncRNA–miRNA–mRNA relationship, the corresponding miRNAs and lncRNAs were screened, and the CPAT online tool (pe.org/)  was usedp < 0.05).Kaplan–Meier survival analysis of lncRNAs was performed based on the survival information of 668 patients obtained from the CGGA database. The Survival R package was used to draw the survival curve of the lncRNAs in the ceRNA network and perform a log-rank test (http://software.broadinstitute.org/gsea/index.jsp) [p < 0.05). The reference gene set “c2.cp.kegg.v7.2.symbol.gmt” was downloaded from MSigDB (https://www.gsea-msigdb.org/gsea/msigdb).The 693 glioma samples, whose data were obtained from the CGGA database, were divided into high and low expression groups based on the median expression levels of the target lncRNA. The lncRNAs related to patient survival in the ceRNA network were analyzed using the GSEA software (dex.jsp)  (p < 0.0Additional file 1: Table S1. In the context of WHO classification, Kaplan-Meier analysis data of 12 lncRNAs.Additional file 2: Table S2. DEmRNA related data.Additional file 3: Table S3. CPAT verifies the coding ability of lncRNA.Additional file 4: Table S4. Kaplan-Meier analysis data of 21 lncRNAs.Additional file 5: Table S5. GSEA analysis results.Additional file 6: Table S6. COX model related data.Additional file 7: Table S7. Figure


We studied the prevalence of atherosclerosis among ischaemic stroke patients ≤60 years and controls at the time of the index stroke, and its association with occurrence of new cardiovascular events (CVEs) and mortality at a 5-year follow-up.Prevalent atherosclerosis was assessed for 385 patients and 260 controls in seven vascular areas by electrocardiogram (ECG), ankle–arm index (AAI) and measurement of right and left carotid and femoral intima-media thickness (cIMT and fIMT) and abdominal aorta plaques (AAP). Clinical end-points were any new CVE  or death from any cause at 5-year follow-up. All results were sex- and age-adjusted; logistic regression and Cox proportional hazards models were applied.p = 0.024. Ischaemic ECG and mean cIMT were higher in young and middle-aged female patients . Mean fIMT was higher in middle-aged female patients (p <0.001). Cardiovascular events were associated with ischaemic ECG; AAI ≤0.9, fIMT ≥0.9 mm and increased number of areas with atherosclerosis (NAA) among patients, and with AAP, cIMT ≥0.9 mm, fIMT ≥0.9 mm and NAA among controls. Mortality was associated with higher age, ischaemic ECG and NAA among patients, and cIMT ≥0.9 mm among controls.Young patients ≤49 years had prevalent atherosclerosis in 1/2 of males and 1/3 of females. Compared with controls, young female patients showed significantly higher prevalent atherosclerosis, Atherosclerosis is highly prevalent even in young stroke patients. Some areas and increasing NAA are associated with CVEs and death. Several European long-term young stroke studies have shown high rates of recurrent CVEs, such as ischaemic stroke (IS), angina, myocardial infarction (MI), peripheral arterial disease (PAD) and mortality mainly due to coronary atherosclerosis (CA).3 Autopsy studies have also shown high prevalence of CA, predominantly in young healthy male populations.5The 15 cities young stroke study showed smoking, dyslipidemia and hypertension as the three most frequent risk factors (RF) for cardiovascular events (CVEs), without regional differences in Europe.The 15 cities study found 39.6% stroke of undetermined cause (SUC) and 9.3% large-artery atherosclerosis (LAA) based on the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, requiring ≥50% artery stenosis. worst prognosis for patients with atherosclerosis, high rates of cryptogenic stroke among young patients, and knowledge showing that plaque instability is more important than the degree of stenosis for coronary and cerebral CVEs,11 we wanted to investigate the extent of atherosclerosis in young stroke patients. Staging of arterial vascular areas, with a more scrutineous detection of atherosclerosis, became a main pillar for the Norwegian Stroke in the Young Study (NOR-SYS). Our hypothesis is that atherosclerosis is far more present among young and middle-aged patients than the TOAST definition of atherosclerosis with at least 50% stenosis is able to show, and arterial staging is the first step to understand the extent of established artery wall disease. The aims of this study are the detailed presentation of seven predefined vascular areas at study inclusion, and their association with new CVEs and mortality at 5-year follow-up.Combining knowledge of the high rates of recurrent CVEs and mortality in young stroke patients, and methods and results of inclusion have been published. Verified acute ischaemic stroke diagnosis was done by magnetic resonance imaging (MRI) in 98.5% among patients or by computed tomography (CT) alone in case of contraindications. The majority of stroke patients were admitted within a few days after symptom onset  ≤0.9 indicated PAD. High quality measurements of mean carotid intima-media thickness (cIMT) and femoral intima-media thickness (fIMT) were obtained at predefined segments from the common carotid artery, carotid bifurcation, internal carotid artery, common femoral artery and superficial femoral artery. In the analyses, the maximum of any mean IMT segment value was used, and plaques were included in the IMT measurements. Mean IMT values ≥0.9 mm were considered pathological, and mean IMT values ≥1.5 mm were defined as atherosclerosis. The abdominal aorta was assessed by ultrasound for detection of abdominal aorta plaques (AAP).A 12-lead electrocardiogram (ECG) was verified by a cardiologist to identify signs of acute or previous myocardial ischaemia. Detailed information about the NOR-SYS ultrasound protocol has been published before.Atherosclerosis was defined prevalent at seven chosen areas by the following: presence of ischaemic ECG signs; AAI ≤0.9; right and left mean cIMT and fIMT Stroke aetiology was classified according to TOAST criteria, independent from the results of the ultrasound research protocol.st September 2015 to 31st December 2020 for a 5-year follow-up. Primary end-points were occurrence of any new CVE , and death of any cause. Study participants were interviewed about occurrence of any CVE during the follow-up period, and new CVEs were verified by medical records for those who attended the follow-up. ECG were performed. For mortality analysis, we chose the date of 31st August 2020. In Norway, mortality data appears in medical records, connected to each citizen’s 11-digit personal identification number.Patients and controls visited our outpatient clinic from 1The study complies with the Declaration of Helsinki and is approved by the Regional Ethics Committee (REK-Vest 2010/74). Written consent is present for all study participants. The Regional Ethics Committee did not allow to follow dropouts apart from the dead–alive state and causes of death.p-values ≤0.05 were considered significant. All statistical analyses were performed in Stata SE 16.0.The mean and standard deviation (SD) were used for descriptive statistics. Study participants were dichotomised into young (≤49 years) and middle-aged (≥50 years). Analyses were adjusted by age and sex. To avoid systematic bias, univariate comparisons of vascular areas between patients and controls were done within the four sex and age strata using the unpaired t-test and the Fisher’s exact test. For the unadjusted comparison of all patients to their controls, McNemar’s test of symmetry was used. Mean cIMT and fIMT values were compared between patients and controls by relative change (RC). The number of vascular areas affected by atherosclerosis was compared between TOAST subgroups using the Kruskal–Wallis rank test. To adjust for confounding and matching, logistic regression and Cox models were used to estimate the risk of new CVE and mortality, with respect to age, sex and vascular areas. The results were reported as odds ratios (OR) and hazard ratios (HR) with a 95% confidence interval (CI). Two-sided At inclusion, patients had a mean age of 49.5 years, and controls had a mean age of 50.3 years . The majp = 0.044 and p = 0.020) and higher mean cIMT (p = 0.023 and p < 0.001), as shown in p <0.001). Abdominal aorta plaques presence and pathological AAI did not differ in any comparisons between patients and controls. The prevalence of atherosclerosis among male patients and controls did not differ for clinical and ultrasonographic variables.Compared to controls, young aged and middle-aged female patients had higher prevalence of ischaemic ECG (Eight (5.1%) of 157 patients with fIMT ≥0.9 mm in their right femoral artery (FA) had previously performed percutaneous coronary intervention (PCI) with access from their right FA.Ultrasonography was not performed in two patients due to terminal unconsciousness at admission and morbid obesity causing insufficient imaging quality, respectively. Main reasons for other missing data  were artp = 0.024) compared with young female controls (p = 0.167), middle-aged male patients  and middle-aged female patients . The prevalence was higher in middle-aged patients than in younger patients  and higher in male patients than in female patients . Maximum number of affected vascular areas were six among patients and five among controls.The prevalence of atherosclerosis was higher in young female patients , LAA was found among 28 (7.3%) of patients according to the TOAST classification . Atherosp = 0.001), and occurrence of CVE was higher in young female patients than controls (p = 0.002). In total, 21 (5.5%) patients and 9 (3.5%) controls died (p = 0.524). No difference was found after adjustment for age and sex. Seven patients died within 1 month after hospital admission due to malign oedema (4), basilarisocclusion (2) and subarachnoidal haemorrhage (1). Regarding 14 patients who died after the first month after hospital admission, and within 31th August 2020, when dead–alive state was checked, the causes of deaths were recurrent stroke (1), coronary heart disease (1), lung embolism (1), cancer (4), infection (3), dementia (1) and unknown cause (3). The causes of death among controls were cancer (4), infection (1), respiratory failure after lung transplant (1) and unknown cause (3).The average duration of our outpatient clinical follow-up was 5.3 years for all participants. There were 323 (83.9%) patients and 219 (84.2%) controls participating in the 5-year follow-up. Three patients had telephone interviews. During follow-up, 44 patients (13.7%) and 9 controls (4.1%) experienced any CVE (p = 0.005), AAI ≤0.9 , fIMT ≥0.9 mm  and increased number of areas with atherosclerosis (NAA)  among patients, and with presence of AAP , cIMT ≥0.9 mm , fIMT ≥0.9 mm  and increased NAA  among controls (p = 0.036), ischaemic ECG  and increased NAA  among patients, and with cIMT ≥0.9 mm  among controls (p = 0.047) among patients, and with cIMT ≥0.9 mm  among controls.Adjusted for sex and age, occurrence of CVEs was associated with ischaemic ECG  for a median of 24 months and found that femoral plaques were independent predictors for CVEs. Giannoukas et al. reported that fIMT separately or in combination with cIMT was related to cardiovascular disease.Since atherosclerosis is regarded as a risk factor for CVEs and mortality, various non-invasive surrogate markers for atherosclerosis have been identified.27 In the ARIC (Atherosclerosis risk in communities) study, cIMT predicted CVEs or death in participants recruited from four communities in the United States. A meta-analysis has shown that increased cIMT by 0.10 mm is associated with an increased risk of 18% for stroke and 15% for myocardial infarction. Our study confirms that cIMT predicts increased risk of CVEs and mortality among controls and that AAI is strongly related to CVE among patients.CIMT and AAI are well-established surrogate markers for subclinical atherosclerosis and strong predictors of future CVEs and mortality. Furthermore, ECG findings revealing silent ischaemia has been a powerful and independent predictor for cardiac mortality in another study.Another important finding in our study is that ischaemic ECG predicts CVEs and mortality among patients, regardless of age and sex. Also, Bacquer et al. reported that major abnormalities in ECG are strongly associated with CVE and mortality in both sexes. In the Rotterdam study, AAP, measured by X-ray in 6389 subjects, was associated with MI.Regarding AAP, we found a positive association with CVEs among controls. Li et al. reported higher prevalence of AAP in patients with coronary artery disease (CAD), compared to those without CAD.32 and this is in line with our results.The TOAST classification is most widely used by date, but there is the problem of the big group of up to 33–40% of young stroke patients with SUC, PCI of the FA is associated with haematoma, intimal dissection or arterial occlusion. However, in our study, only few patients with increased fIMT on the right side had undergone PCI.The major strength of NOR-SYS is the population-based design with inclusion of consecutive acute IS patients and comprehensive vascular work-up based on a standardised protocol. The number of unobtainable IMT measurements was low. We used mean IMT measurements, which provide information on cardiovascular risk even in absence of plaques. We chose not to include intracranial arterial pathology analysis due to uncertainties in defining the cause and degree of stenosis by common imaging methods. Another limitation was the low number of outcome events, especially numbers of deaths.An important study limitation was inequality of sex group sizes, with a high number of male patients and relatively low number of male controls. Our controls were partners of included patients, selected as such to improve the three-generation design of NOR-SYS, and also including joint offspring. We expected higher risk factor matching between patients and partners compared with controls selected by random.Atherosclerosis is highly prevalent in our study population, being found in half of the young male patients and one third of the young female patients ≤49 years. Comprehensive investigation reveals a far higher prevalence of atherosclerosis than found by TOAST criteria.In oncology, staging of tumours has for decades been the first step to tailor individual treatment. Staging arteries of young stroke patients should be performed, accordingly. This would contribute to potential early individual-tailored secondary prophylaxis, and selection of patients to targeted and reasonable treatment, and future more targeted genetic diagnostics in order to search for why we do find serious early arterial disease (LAA) in some patients, while other patients are protected from development of atherosclerosis despite of a high number of risk factors. Ultrasound images of good quality were used in this study as teaching tool to explain interested patients the findings and importance of life-style changes, and to take and continue medication that we evaluate necessary for secondary prevention. Randomised future studies could show if this could contribute significantly to reach important treatment goals.


At present, no predictive factor has been validated for the early efficacy of neoadjuvant chemotherapy (NACT) in osteosarcoma. The purpose of this study was to investigate the significance of the neutrophil-to-lymphocyte ratio (NLR) in predicting the response to NACT in extremity osteosarcoma.Pathological complete response (pCR) was used to assess the efficacy of NACT. Receiver operating characteristic (ROC) curves and the Youden index (sensitivity + specificity-1) were used to determine the optimal cut-off values of the NLR. Univariate and multivariate analyses using logistic regression models were conducted to confirm the independent factors affecting the efficacy of NACT.p = 0.02).The optimal NLR cut-off value was 2.36 . Univariate analysis revealed that patients with a smaller tumour volume, lower stage, lower NLR and lower PLR were more likely to achieve pCR. Multivariate analyses confirmed that the NLR before treatment was an independent risk factor for pCR. Compared to patients with a high NLR, those with a low NLR showed a more than 2-fold higher likelihood of achieving pCR (OR 2.82, 95% CI 1.36-5.17, The NLR is a novel and effective predictive factor for the response to NACT in extremity osteosarcoma patients. Patients with a higher NLR showed a lower percentage of pCR after NACT. Osteosarcoma, which originates from mesenchymal tissue and is mainly located in the long bones, is one of the most common primary malignant tumours in children and adolescents . Before 18F-FDG PET, have also been proposed as predictive indices [According to National Comprehensive Cancer Network (NCCN) recommendations, the curative effect of chemotherapy is a key index for assessing whether limb salvage is feasible . Hence,  indices . AlthougThe systemic inflammatory response (SIR) has been demonstrated to play a key role in tumorigenesis, metastasis, and even drug resistance . The neuThus, we conducted this multicentre retrospective study to determine whether the NLR or PLR can be used to predict pCR after NACT in osteosarcoma and therefore serve as a parameter to guide chemotherapy and surgical planning. To the best of our knowledge, this study is the first to explore the association of the response to NACT with the NLR and PLR in osteosarcoma.This multicentre study was conducted in three medical institutions. The medical records of patients diagnosed with osteosarcoma confirmed by postoperative pathology from September 2008 to December 2018 were retrospectively reviewed. The inclusion criteria were as follows: (1) patients diagnosed with osteosarcoma by postoperative histopathology; (2) patients who received standard neoadjuvant chemotherapy (NACT) before surgery; (3) patients with complete laboratory data before NACT; (4) patients who underwent tumour resection or amputation such that pathological complete response (pCR) was obtainable; and (5) patients with lesions located in the extremities. The exclusion criteria were as follows: (1) patients with infection, fever, or any blood disease; (2) patients with recurrence; and (3) patients with incomplete medical records.The clinical and pathological stages of the tumours were defined using the Enneking classification . InformeBlood samples were obtained when the patient was hospitalized to start the first cycle of chemotherapy. The NLR was calculated from routine peripheral blood examination results and defined as the absolute number of neutrophils divided by the lymphocyte count. The same formula was applied to determine the platelet-to-lymphocyte ratio (PLR). Other parameters, including white blood cell count (WBC), percentage of monocytes, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level and alkaline phosphatase (ALP) level, were also reviewed. Additionally, some clinical parameters, such as age, sex, lesion location, tumour size on imaging, and tumour subtype, were adjusted and analysed.After en block resection or amputation, pathologists evaluated the specimen and histopathologic information was obtained from the pathology report. The specimen was cut along the cross section with the largest area according to the preoperative imaging. The necrosis cell was observed by HE stain in tissue section. The necrosis rate was defined as necrotic area divided by total area. Patients whose rate were 90% or more had a pathological complete response (pCR) and patients whose rate less than 90% had a non-pCR.2 + cisplatin 75 ~ 100 mg/m2 and MAP: high-dose methotrexate 8 ~ 12 g/m2 + doxorubicin 45 mg/m2 + cisplatin 75 ~ 100 mg/m2.All patients received first-line NACT, and the detailed regimens were AP: doxorubicin 45 mg/mThe mean ± standard error and the median were used to present measurement data following a normal distribution and a skewed distribution, respectively. A receiver operating characteristic (ROC) curve and the Youden index (sensitivity + specificity-1) were used to determine the optimal cut-off values of the NLR due to the lack of a reference value in recent literature.p < 0.05. All data were assembled using Excel 2007, and data analyses were performed by SPSS 22.0 software.We used the chi-squared test and Fisher’s exact test to evaluate associations between the NLR, the PLR, other important clinical parameters, and pCR. Univariate and multivariate analyses by logistic regression models were conducted to confirm the independent factors that predict pCR. Statistical significance was considered when 3. According to the Enneking surgical staging criteria, 28 patients were classified as stage I, 46 as stage II, and 22 as stage III.A total of 403 patients histopathologically diagnosed with osteosarcoma of the extremities were identified. Ultimately, 96 patients met the inclusion/exclusion criteria and were included in this study. The baseline data are shown in Table p = 0.001) and 0.659 (p = 0.069), respectively. The optimal cut-off values of the NLR and PLR were 2.36  and 115 , respectively. Subsequently, according to the optimal cut-off values of the NLR, patients were divided into two groups: the low NLR group (LNLR <2.36) with 50 patients and the high NLR group (HNLR ≥2.36) with 46 patients. Similarly, 66 patients were included in the low PLR group (LPLR <115), and 30 patients were included in the high PLR group (HPLR≥115).As shown in Fig. 3 vs. 218.34 ± 11.24 cm3, p = 0.034). A similar result was found in the PLR group . Additionally, an advanced Enneking stage and elevated ALP were significantly associated with a high NLR, while the rates of these two parameters were not significantly different in the PLR group.To investigate the relationships of the NLR and PLR with clinical parameters in osteosarcoma patients, comparisons between the LNLR (LPLR) and HNLR (HPLR) groups were conducted Table . Our resp = 0.02).Thirty-six patients 37.5%) achieved pCR after NACT for osteosarcoma. Univariate analysis was conducted to determine the risk factors that influenced pCR Table . Our res7.5% achiIn this multicentre study, we explored the predictive value of the NLR for the effectiveness of NACT in patients with osteosarcoma of the extremities. Ninety-six patients undergoing NACT treatment were included, and the NLR and PLR were calculated. We found that a low pretreatment NLR (<2.36) was significantly associated with a higher rate of pCR and a better effect of NACT. However, other clinical parameters, including age, sex, tumour location, tumour size, clinical stage, tumour subtype, ALP, the ESR, CRP and the PLR, presented no relevance to pCR in our study.p = 0.018, 95% CI: 1.36–5.17). Kim et al. [Recently, many studies have demonstrated that the NLR plays a key role in predicting the treatment response to NACT and the survival rate in various cancers, such as colorectal cancer, rectal cancer, and breast cancer –21. In am et al. . Our obsMany oncologists and pathologists have suggested reasons for the association between a higher NLR in peripheral blood and tumour samples and higher-grade malignancy in cancer. Kk Liu et al. showed that an elevated NLR was significantly associated with higher pathological T stages and poor overall survival in bladder urothelial cancer cells . The assAlthough this is multicenter study, the sample size is still relatively small. Meanwhile, this is a retrospective analysis, which may bring potential bias to the results. Thus, future multicenter prospective studies are needed to validate our findings.Our findings suggest that the NLR is an important factor predicting the response to NACT in extremity osteosarcoma patients. Patients with a higher NLR showed a lower percentage of pCR after NACT.


Actinopyga lecanora, is a valuable inshore fisheries resource which is famous for its high nutrition and pharmacological compounds. However, due to morphological plasticity and limited molecular phylogenetic studies, the taxonomic histories in the genus Actinopyga have not been completely resolved yet. Moreover, there remains a complex of cryptic species within Actinopyga, many of which are incorrectly assigned within the family Holothuriidae. In this study, we report the complete mitochondrial genome of A. lecanora. The mitogenome has 15,568 base pairs (63.40% A + T content) and is made up of a total of 37 genes , plus a putative control region. This study offers useful mitogenome data for future phylogenetic and taxonomic classification of Holothuriidae.The white-bottomed sea cucumber,  Actinopyga lecanora is a common edible sea cucumber widely distributed throughout the tropical Indo-west Pacific region and has been known as functional food for its relatively high protein and anti-oxidative component , commonly known as holothuroids, are a species-rich group of relatively large benthic invertebrates which only inhabit in marine environments  by local diving fishermen. And the whole body specimen (#GH0078) was deposited at Marine biological Museum, Guangxi Institute of Oceanology, Beihai, China . The total genomic DNA was extracted from the muscle of the specimen using an SQ Tissue DNA Kit  following the manufacturer’s protocol. DNA libraries (350 bp insert) were constructed with the TruSeq NanoTM kit  and were sequenced (2 × 150 bp paired-end) using HiSeq platform at BGI Company, China. Mitogenome assembly was performed with MITObim   is 15,568 bp in length and it contains a conserved set of 13 protein-coding genes (PCGs), 2 ribosomal RNA genes, 22 transfer RNA genes, and a putative control region. A total of 37 genes were annotated and 227 nucleotides were identified as putative control region. The overall base composition of the mitogenome is estimated to be A 34.64%, T 28.76%, C 21.47% and G 15.13%, with a high A + T content of 63.40%, which is similar, but slight higher than A. echinites (62.94%)  indicates that A. lecanora have very closely genetic relationship between these strains. These findings will be helpful for better resolving its taxonomic controversy and future conservation.The complete mitogenome of huriidae , which ihuriidae . The mit


Patients with alopecia areata (AA) may experience episodic disease flares characterized by increasing hair loss that follow a seasonal pattern. However, no studies have examined whether specific climate factors contribute to the seasonal pattern of AA flares. Using Spearman rank correlation analyses, we assessed the association between climate variables and AA flare frequency per month in 336 children with AA in Philadelphia, Pennsylvania. Region-specific monthly values for average ambient temperature, air pressure, cloudiness, hours of sunlight, relative humidity, number of days with sun, number of days with rain, volume of precipitation, wind gust, wind speed, and UV index from January 2015 to December 2017 were obtained from World Weather Online. We found significant (P < 0.05) correlations between AA flare frequency and UV index (R = − 0.66), precipitation (R = − 0.66), number of days with rain (R = − 0.70), number of days with sun (R = 0.62), and air pressure (R = 0.80). Stratified analyses showed even stronger associations with UV index and precipitation in patients with an atopic comorbidity. New significant correlations appeared with temperature, wind speed, and UV index of the prior month. However, in patients who did not have atopic comorbidities, we generally observed weaker and non-significant correlations between climate and AA flare frequency. This study suggests that certain climate factors may mediate the seasonal pattern of AA flares and may contribute to AA pathogenesis. Atopic AA patients may be more susceptible to the influence of climate compared to those with no history of atopy. Stratified analyses based on the presence of an atopic comorbidity suggest that the clinical course of AA differs between atopic patients and their counterparts1. We found that the greatest proportion of flares occurred during the winter in atopic AA patients. However, the greatest proportion of flares occurred during the fall in patients without atopy.We previously found that pediatric alopecia areata (AA) flares follow a seasonal pattern, with a greater proportion of flares occurring in the late fall and a smaller proportion towards the end of spring3. Meta-analyses suggest that serum levels of vitamin D are lower in patients with AA, supporting the potential role of vitamin D in the pathogenesis of AA2. However, only one included study was based on AA patients in the United States (US) suggesting lack of data in the US. Using UV index as an indirect surrogate of serum vitamin D levels, in the present study, we explore the association between AA flare frequency and various climate factors, including UV index.Whether climate factors contribute to the seasonal pattern of pediatric AA flares remains unknown. In the present study, we hypothesize that regional UV index, a standardized measure of the strength of sunburn-producing UV radiation, may partly contribute to this pattern, since UV-B irradiation of skin triggers vitamin D synthesisMedical charts of 457 children in Philadelphia, Pennsylvania with AA, alopecia totalis (AT) or alopecia universalis (AU) were reviewed. Of these, 336 children with dates of AA flare episodes in 2017 were included. Included episodes were the onset of hair loss, the first flare, and the second flare. Flares were defined as an increase in scalp hair loss noted by either patient or caregiver. Increased hair loss occurring immediately after a course of oral steroids was not included as a true flare episode to limit the confounding effect of steroids. Data from 518 episodes of flares were collected to calculate the frequency of flares during each month. The monthly values of climate variables in Philadelphia during 2015 to 2017 were obtained from World Weather Online, including average ambient temperature, UV index, air pressure, relative humidity, cloudiness, wind gust, wind speed, number of days with rain, volume of precipitation, number of days with sun, and hours of sunlight. Spearman rank correlation analyses were conducted using STATA version 15 to assess the correlations between these climate variables and AA flare frequency per month. To explore lag-time effects, UV index of the prior month was also analyzed.1. The male-to-female ratio was 1:1.5. The majority of our subjects self-identified as White (52.2%), followed by Black (19.6%), Hispanic or Latino (8.9%), Asian (4.1%), Indian (3.9%), Other (8.9%), and unknown (< 3%). The majority of our subjects had a documented atopic comorbidity (63.8%), with 87 cases of atopic dermatitis (AD), 47 allergic rhinitis, 35 asthma, 14 anaphylactic food allergy, and 2 eosinophilic esophagitis.Demographic information of the subjects was previously reportedThere were significant (P < 0.05) correlations between flare frequency and UV index (R = − 0.66), precipitation (R = − 0.66), number of days with rain (R = − 0.70), number of days with sun (R = 0.62), and air pressure (R = 0.80). Table . Stratif1. Furthermore, this correlation was stronger among atopic AA patients compared with patients without atopy.As predicted, we found a strong inverse correlation between UV index and AA flare frequency, which may partly explain the seasonal pattern of AA that we previously observed4. UV-induced immunosuppression may contribute to these findings as well5. We also found significant correlations between flare frequency and precipitation, number of days with rain, and air pressure. Since these three climate factors correlated with UV index during the 3-year period (R = − 0.80 to 0.65), UV index may partly account for their significant association with AA flare frequency. While UV index was strongly correlated with temperature (R = 0.92) and UV index of the prior month (R = 0.82), associations between these climate variables and flare frequency were only significant in atopic AA patients.Our findings regarding UV index may support the potential role of vitamin D in AA pathogenesis as vitamin D deficiency is more common in the fall and winter months when UV exposure is lower9. Several population studies based in the US10, Turkey11, Denmark8, and Norway12, but not others13, have suggested that there is an inverse relationship between temperature and AD. Lower temperatures correlated with increased AD prevalence10, more office visits12, more hospitalizations8, and more AD prescription medication utilization8. Prior studies have also found that some climate factors such as precipitation10, air pressure14, and UV index17, which were also the factors associated with AA in our study, were associated with AD. A meta-analysis based on nine individual studies found that AD was significantly associated with birth during the fall and winter seasons, compared with birth during spring18. One theory to explain the effects of season of birth on atopic conditions involves vitamin D produced by skin in response to UV-B radiation19. A recent systematic review supported the role of vitamin D in the pathogenesis of AD20.Stratified analyses based on comorbid atopy suggest that atopic AA patients may be more susceptible to the influence of climate compared to those with no history of atopy Table . This ma21. This would allow for more robust influence of UV exposure on flare frequency, if serum vitamin D levels truly mediate the correlation between UV index and AA flare frequency. However, we were not able to explore the relationship between atopic severity and that of AA due to lack of information on atopic severity, which is one limitation of this study. Previous research indicates that allergy may contribute to AA pathogenesis in a subset of patients22. In fact, atopic AA patients may benefit from antihistamines as adjunct therapy to support hair regrowth24. Thus, it is reasonable to wonder whether antihistamine use and atopy severity contribute to the seasonal AA flare pattern that is observed in atopic AA patients. Future research studies including multivariable analyses may be useful to further define the relationship between climate, atopic flares, and those of AA.Our study was based in a geographic region with four distinct seasons, which provides a wide range of climate variation. Our focus on a pediatric population may be advantageous, as high-dose supplemental vitamin D intake is less prevalent among children compared to adultsIn conclusion, UV exposure and other climate factors may be partially responsible for the seasonal pattern of AA flares and may contribute to AA pathogenesis. Physicians may counsel pediatric patients and their caregivers on these relationships between climate and AA flare frequency. A useful teaching analogy may be to think of the hair as leaves, with increased shedding during fall and more growth during spring. The seasonal patterns of AA flares should be documented in adults and pediatric populations in various geographic regions to better understand of the mechanisms.