Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPDs) are one of the most important clinical aspects of the disease, and when requiring hospital admission, they significantly contribute to mortality among COPD patients. Our aim was to assess the role of eosinopenia and neutrophil-to-lymphocyte count (NLR) as markers of in-hospital mortality and length of hospitalization (LoH) among patients with ECOPD requiring hospitalization. We included 275 patients. Eosinopenia was associated with in-hospital deaths only when coexisted with lymphocytopenia, with the specificity of 84.4% (95% CI 79.6–88.6%) and the sensitivity of 100% (95% CI 35.9–100%). Also, survivors presented longer LoH (P < 0.0001). NLR ≥ 13.2 predicted in-hospital death with the sensitivity of 100% (95% CI 35.9–100%) and specificity of 92.6% (95% CI 88.8–95.4%), however, comparison of LoH among survivors did not reach statistical significance (P = 0.05). Additionally, when we assessed the presence of coexistence of eosinopenia and lymphocytopenia first, and then apply NLR, sensitivity and specificity in prediction of in-hospital death was 100% (95% CI 35.9–100) and 93.7% (95% CI 90.1–96.3), respectively. Moreover, among survivors, the occurrence of such pattern was associated with significantly longer LoH: 11 (7–14) vs 7 (5–10) days (P = 0.01). The best profile of sensitivity and specificity in the prediction of in-hospital mortality in ECOPD can be obtained by combined analysis of coexistence of eosinopenia and lymphocytopenia with elevated NLR. The occurrence of a such pattern is also associated with significantly longer LoH among survivors. AECOPDs requiring hospital admission are the leading cause of hospitalization and significantly contribute to mortality among COPD patients4. Therefore, research on prognostic factors in this group is of special interest.Exacerbations of chronic obstructive pulmonary disease (AECOPDs) are one of the most important clinical aspects to the disease. The clinical manifestations of COPD exacerbations are highly variable and reflect broad heterogeneity in the pathobiology of the disease. Regardless of its variability, exacerbations are clearly associated with negative impact on the health status, increasing rates of hospitalization, readmission, and disease progression5. Eosinopenia was also proposed to be a predictor of a short or long-term survival in some diseases, including AECOPD10. Thus, we reanalyzed the problem of eosinopenia in AECOPD patients. Additionally, we assessed another previously discussed, and logically linked with eosinopenia, prognostic factor—neutrophil-to-lymphocyte count (NLR). This parameter has also been studied as a marker of sepsis and predictor of bacteriemia5. The roles of both these parameters in AECOPD still remain ambiguous and controversial. The aim of this study was to assess the role of eosinopenia and NLR as markers of in-hospital mortality and length of hospitalization. The relationships between both parameters and their possible pathophysiological background were analyzed as well.With a great deal of reasonable criticism, eosinopenia was already proposed as a marker of infection, in differentiating infectious from non-infectious causes of elevated C-reactive protein (CRP) and identifying sepsis or bacteremiaThis study is a retrospective analysis of the data collected in the digital base of the Barlicki Memorial Teaching Hospital of the Medical University of Lodz. The protocol of the study was approved by the institutional ethics committee. Also, due to retrospective character of the study, in which consent would be impossible to obtain, concordantly with the Declaration of Helsinki, the Committee waived the need of such consent.All methods in the study were performed in accordance with the relevant guidelines and regulations.3. We included only exacerbations that required hospital admission, both of infectious and non-infectious character. Full blood count and white blood cell differentiation were examined in these patients, which was performed on the hospital admission. Venous blood was collected by venipuncture into tubes with ethylenediaminetetraacetic acid as an anticoagulant. The samples were examined with the automated hematology analyzer. Cell counting was performed using electrical impedance method. Arterial blood gases parameters were analyzed using automated analyzer.Enrollment of our study included only adult Caucasians with the exacerbation of COPD, diagnosed concordantly with current GOLD recommendationsThe exclusion criteria were any other known chronic lung disease, any hematological disorder—active, or in the past medical history, any active malignancy, exacerbation of respiratory symptoms associated with other acute causes. We also excluded patients with clinically and radiologically proven pneumonia and those, who received any dose of systemic corticosteroids prior to the admission. Additionally, we excluded all patients who were transferred to the hospital by an ambulance, because retrospective character of the study would preclude reliable verification that these patients did not receive corticosteroids prior to the hospital admission.AECOPD was defined as an event characterized by a rapid decline in the patient’s respiratory symptoms that is beyond normal day-to-day variations and lead to changes in medication. In-hospital mortality was defined as any AECOPD-related death after the hospital admission.NLR was calculated as a ratio of absolute counts of peripheral blood neutrophils to lymphocytes.Length of hospitalization was assessed among survivors to avoid false shortage of hospitalization time in case of early in-hospital death.11.Continuous data was presented as the mean with SD or median with interquartile range (IQR), depending on the distribution of data. In comparing multiple groups, one-way ANOVA with pairwise comparisons using t tests with pooled SD or Kruskal–Wallis rank sum test with pairwise comparisons using Mann–Whitney U test was used according to tests assumptions. Bonferroni method was used for P value adjustment. Receiver operating characteristics (ROC) with area under the ROC curve (AUROC) analyses were preformed to measure the accuracy of absolute eosinophil count and NLR in prediction of in-hospital mortality and to identify its cut-off values for further analysis. Variables were compared using the unpaired Student’s t-test, Welch t-test or the Wilcoxon rank sum test with continuity correction, depending on data normality and homogeneity of variance. Categorical data were presented as absolute value and percentage. Such data were compared using Chi-square test or Fisher’s exact test according to test assumptions. Correlation analysis was performed using Kendall's rank correlation tau. Statistical analysis was performed using R softwareP = 0.09]. However, in infectious AECOPD we observed significantly higher NLR values .We included 275 patients. Five patients 1.82%) died in hospital. Baseline population data are presented in Table .82% diedThe ROC curves for absolute counts of eosinophils and NLR in peripheral blood in prediction of in-hospital death are presented in Fig. 3/μl as a cut-off value and 0.77 for neutrophil count with cut off value of 7.3 × 103/μl.We also analyzed AUROC for the components of NLR, however its values were lower—0.92 for lymphocyte count, identifying 1 × 10P = 0.006 for the Fisher's Exact Test). This value was characterized by sensitivity of 100% (95% CI 35.9–100%), however specificity of 65.2% (95% CI 59.2–70.9%). The diagnostic accuracy was 0.66 (95% CI 0.6–0.71).In ROC analysis, an absolute number of eosinophils ≤ 0.04 × 103/µl was identified as an optimal cut-off point for eosinopenia. Using this cut-off value, eosinopenia was diagnosed in 99 (36%) patients. All five patients who died presented on hospital admission with eosinopenia (Comparison of study parameters upon stratification by presence of EP is presented in Table P = 0.008), CRP ; WBC  and BE .We found a significant negative correlation between eosinophil count and length of hospitalization  patients, including all five patients who died during hospitalization. This cut-off point was characterized by sensitivity of 100% (95% CI 35.9–100%) and specificity estimated for 92.6% (95% CI 88.8–95.4%). The diagnostic accuracy was 0.93 (95% CI 0.9–0.96). Comparison of study parameters upon stratification by NLR value is presented in Table 2 and NLR .Kendall's test did not detect significant correlation between SaOP < 0.0001. We observed parallel situation when we analyzed results from Table 3/μl vs 0.1 (0.03–0.21) × 103/μl; P < 0.0001.In Table P < 0.0001) and negative correlation with NLR: τ = − 0.38 (P < 0.0001).Kendall's rank correlation tau revealed significant correlation between eosinophil and lymphocyte count: τ = 0.28 (3/μl) was observed in 47 (17.09%) patients and only such pattern was associated with in-hospital deaths in the analyzed group. There were no deaths in patients who presented with eosinopenia without lymphocytopenia (P = 0.0001 for the Fisher's Exact Test). The coexistence of eosinopenia with lymphocytopenia was characterized by higher specificity than previously analyzed eosinopenia [84.4% (95% CI 79.6–88.6%) vs 65.2% (95% CI 59.2–70.9%) and the same sensitivity of 100% (95% CI 35.9–100%). The diagnostic accuracy was 0.84 (95% CI 0.8–0.89).The coexistence of eosinopenia with lymphocytopenia . Length of hospitalization in isolated eosinopenia or lymphocytopenia subgroups was not significantly different than in patients with normal counts of these cells (P = 1.0 and P = 0.12 respectively)—Fig. Taking into account above findings, we reanalyzed the eosinopenia group in the context of previously analyzed study parameters. Results of additional analyses are presented in Table When we first assess the presence of coexistence of eosinopenia and lymphocytopenia, and then apply NLR, we can achieve the best sensitivity and specificity compared to the situation when these parameters are used individually: 100% (95% CI 35.9–100) and 93.7% (95% CI 90.1–96.3), respectively. The diagnostic accuracy for such approach was 0.94 (95% CI 0.90–0.96).Also, among survivors, occurrence of such pattern was associated with significantly longer hospital stay: 11 (7–14) vs 7 (5–10) days, P = 0.01.Our aim was to assess the role of eosinopenia, lymphocytopenia and NLR as markers of in-hospital mortality and length of hospitalization (LoH) among patients with AECOPD requiring hospitalization.12. Also, Zurfluh et al. reported a time-dependent effect with higher levels pointing towards higher mortality at short term associated with activation of stress hormones (particularly cortisol and cortisone)13.Such approach seems to be justified by pathophysiological background. Namely, we would analyze eosinopenia in the context of considering AECOPD as a state of an acute stress. Undoubtedly, COPD is associated with both physical and emotional stress. Extremal, but pictorial evidence for possible levels of stress which can be released in this condition may be presented in context of relatively frequent association between COPD and Tako-Tsubo cardiomyopathy, which is linked with a rapid elevation of circulating catecholamine, triggered by emotional and/or physical stress, as a key mechanism15.We should also remember that acute stress, and associated role of adrenal glucocorticoids in this process, is not the only cause of eosinopenia in peripheral blood. There are other contributing mechanisms including migration of eosinophils to the site of inflammation, rapid peripheral sequestration, suppression of egress of mature eosinophils from the bone marrow, and suppression of eosinophils production6 reported that patients with eosinopenia had a longer hospital stay and were more likely to die in hospital. Additionally, Rahimi-Rad et al. found an association between eosinopenia and an unfavorable prognosis within 30-day after discharge7. Both Holland et al. and Rahimi-Rad et al. used cut-off value of 40 cells/mm3 to diagnose eosinopenia. In the past, we also reported that eosinopenia would be a prognostic factor of in-hospital mortality in ECOPD16, however, in the present study, we used the analysis which was not applied by above mentioned authors, therefore ROC curve assessment. From one hand, AUROC analysis may still justify such statement, but from the other hand, relatively low specificity 65.2% of this marker decreased our enthusiasm significantly.Eosinopenia in AECOPD was concluded to have some clinical implications in already published studies. Namely, Holland et al.17, and regulation of T-helper-1 and Th2 immunity18. However, paradoxical to their physiological effects, evidence suggests that a reduction of eosinophils appears to have no negative effect on normal health. This statement is based not only on animal studies, but also on humans who received monoclonal antibodies reducing eosinophil count19. Therefore, even if we conclude that we indirectly assessed the exacerbation of stress or other contributing mechanisms, the occurrence of eosinopenia itself probably has no further significant clinical importance.Also, for further evaluation of the clinical implications of eosinopenia, discussion of its eventual consequences should be taken into account. First, we should start with the physiological role of these cells in the immune response. Among others, eosinophils promote humoral immunity by priming of B cells and have a role in the maintenance of type-2 immunity21 we decided to evaluate eosinopenia in a broader context, by adding the assessment of lymphocytopenia and NLR into analysis. The relation between NLR and in-hospital mortality also was previously reported in patients with AECOPD22. Yao et al. presented ROC curve analysis for using NLR to predict in-hospital mortality—AUROC was 0.803, and an optimal cut-off value was 6.24. Authors reported the sensitivity of 81.08%, and specificity of 69.17%. We observed both better sensitivity and specificity for NLR, however we obtained higher cut-off value in ROC curve analysis. In our study, NLR presented much better accuracy parameters and higher value of AUROC than obtained for eosinopenia. Moreover, we have observed that these parameters are not fully independent and that there is a significant relationship between the values of eosinophil count and NLR. That is why we started to analyze these associations in the context of individual components of NLR, observing intriguing interplay between eosinophils and lymphocytes. Interestingly, patients who presented with the coexistence of eosinopenia and lymphocytopenia had the lowest counts of both eosinophils and lymphocytes. This is justified because these patients probably had the highest level of stress, which can suppress both types of cells. However, this relationship itself seems to also have interesting clinical implications.Taking into account all above mentioned, and the fact that glucocorticoids can reduce eosinophils, raise neutrophils and reduce lymphocytes+ T cells and type 2 innate lymphoid cells produce IL-5 that prompts eosinophil production24, while from the other hand, Th17 cells, CD8+ T cells, γδ T cells, and type 3 innate lymphoid cells secrete IL-17A, leading to neutrophil maturation26. Infection by different types of pathogens may lead to different effects—either eosinophil, or neutrophil accumulation27. Wiesner et al. reported that Rag2/IL-2Rγ−/− mice that lack lymphocytes, and observed that without lymphocytes, infected mice had significantly impaired eosinophilia compared with similarly infected wild-type mice, yet neutrophil accumulation remained unimpaired. Authors also concluded that singular elimination of Th cells  may result in a loss of eosinophils that can be replaced by IL-17A-dependent neutrophilia27.In turn, eosinophils and neutrophils are granulocytes that originate from the same myeloblast progenitor in the bone marrow, and upon differentiating, each of these granulocytes leaves the marrow and migrates to the inflamed tissues to enact their effector functions. From the other hand, lymphocytes, which originate from the different progenitor, secrete cytokines that coordinate eosinophil and neutrophil responses. From one hand, type 2 CD4+ and CD8+ T cells in peripheral blood during AECOPD. From the other hand, Ross et al. observed that exacerbated airway neutrophilia in cigarette smoke–exposed mice infected with nontypeable Haemophilus influenzae, large subgroup of bacterial AECOPD, was associated with an induction of IL-17A28. There is also evidence for a decrease in both total CD4+ and CD8+ T cell counts after infusion of cortisol. The effect started 90 min after infusion29.Focusing on COPD population, Freeman et al. observed decreased concentration of CD4+ T cells are major players involved in responses to infectious diseases, enabling B cells to differentiate into plasma cells, helping CD8+ T cells develop into cytotoxic cells, as well as are required for long-term CD8 memory generation. CD4+ T cells also mediate activation of macrophages, playing a critical role in the viral and bacterial control35. Therefore, decrease in this population of cells would result in catastrophic effects for homeostasis of the immune response.How would these issues contribute to an increase in mortality? Namely, CD4The above-mentioned evidence may partially and indirectly justify our observations and allow to draw a hypothetical pathway that lymphocytopenia would be a primary pathology, which leads to eosinopenia and neutrophilia. Playing together with stress response, which potentially aggravates such pattern, these factors may contribute to a significantly increased risk of in-hospital death. However, for confirmation of these hypotheses, there is a need for a prospective study which directly will analyze all above mentioned relationships: stress response, lymphocytes subpopulations assessment, eosinophil and neutrophil counts with broad profile of cytokines, including IL-17A.There are some major limitations of our study, which need to be considered. As a retrospective study, it is burdened by all limitations associated with this type of data collection, including an absence of data regarding potential confounding factors. As the most important we indicate above mentioned lack of measurement of stress hormones and inflammatory cytokines. It should be also worth to diagnose pathogens responsible for infectious AECOPDs. Taking into account the above-mentioned issues, the results of our study should be considered as hypothesis generating and should be furtherly confirmed in a sufficiently powered prospective analysis, designed taking into account above mentioned limitations.All analyzed parameters in our study have certain value as prognostic factors of in-hospital mortality in AECOPD. However, the best profile of sensitivity and specificity can be obtained by combined analysis of coexistence of eosinopenia and lymphocytopenia with elevated NLR. Occurrence of such pattern is also associated with significantly longer time of hospitalization among survivors.


We aimed to distinguish the preoperative radiological indicators to predict the application of assistant techniques during intubation for patients undergoing selective cervical surgery.n = 78) and Assistant technique group (n = 26). We measured patients’ radiographical data via their preoperative X-ray and MRI images, and compared the differences between two groups. Binary logistic regression model was applied to distinguish the meaningful predictors. Receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to describe the discrimination ability of indicators. The highest Youden’s index corresponded to an optimal cut-off value.A total of 104 patients were enrolled in this study. According to whether intubation was successfully accomplished by simple Macintosh laryngoscopy, patients were divided into Macintosh laryngoscopy group (P <  0.05). Based on logistic regression model, four further showed correlation with the application of assistant techniques, namely, perpendicular distance from hard palate to tip of upper incisor (X2), atlanto-occipital gap (X9), angle between a line passing through posterior-superior point of hard palate and the lowest point of the occipital bone and a line passing through the anterior-inferior point and the posterior-inferior point of the second cervical vertebral body (Angle E), and distance from skin to hyoid bone (MRI 7). Angle E owned the largest AUC (0.929), and its optimal cut-off value was 19.9° . the optimal cut-off value, sensitivity and specificity of other three variables were X2 , MRI7 , and X9 .Ten variables exhibited significant statistical differences between two groups (Four radiological variables possessed potential ability to predict the application of assistant intubation techniques. Anaesthesiologists are recommended to apply assistant techniques more positively once encountering the mentioned cut-off values. Airway management is regarded as the most important aspect in clinical anesthesia and a successful intubation remains crucial for surgical procedures . ClinicaA pre-planned induction strategy involves consideration of various interventions that are designed to facilitate intubation during difficult airway conditions. The interventions that are intended to manage difficult airway include, but are not limited to : (1) vidMany researchers have attempted to predict difficult of intubation by preoperative radiologic data, but very few studies have specifically targeted at the necessity and possibility of the application of assistant techniques for intubation. Hence, in the present study, this prediction was carried out based on radiological indicators of patients who underwent cervical surgery. Our study findings could provide valuable information for airway management practice, especially for patients with special conditions where traditional assessment methods such as thyromental distance, mouth opening, cervical mobility and Mallampati classification are difficult to be obtained.From June 2019 to December 2019, patients who underwent elective cervical spine surgery under general anesthesia were recruited in this cohort study. Inclusion criteria of patients were as follows: (1) age ranging from 20 to 70 years; (2) with good mental health; and (3) complete radiographic and clinical materials. Exclusion criteria were as follows: patients (1) with airway tumor or foreign body; (2) severe cervical trauma; (3) cervical spine instability; (4) poor physical conditions (ASA IV or V); and (5) anticipated difficult mask ventilation. The clinical and radiological data of patients were acquired by reviewing their medical history and measuring the values on the Picture Archiving and Communication Systems (PACS). This study was approved by Medical Ethics Committee of Peking University Third Hospital, Peking University Health Science Center, Beijing (IRB00006761–2015021). Informed consents were obtained from the patients.Radiological data were obtained by cervical X-ray examination and neck MRI . X-ray examination was performed by informing patients to maintain standing position and MRI scan was completed in the supine position. All X-ray and MRI data were evaluated using radiography information system  of the Peking University Third Hospital. All distance and angle indicators on cervical lateral X-rays were measured in the neutral position Figs.  and 2, wRoutine preoperative monitoring of non-invasive blood pressure, heart rate, pulse oximetry, and electrocardiography were performed. Anesthesia was induced with sufentanil (0.3 μg/kg) and propofol (2 mg/kg). For patients who lost consciousness, neuromuscular blockade was injected by rocuronium (0.6 mg/kg). The Macintosh laryngoscope was applied by senior anesthesiologists who were not involved in the preoperative radiologic assessment. Patients who were successfully intubated with Macintosh laryngoscope were assigned to the Macintosh group, and those unsuccessfully intubated with Macintosh laryngoscope were settled according to the Difficult Airway Society 2015 guidelines .Patients who were unsuccessfully intubated with Macintosh laryngoscope were further dealt with assistant techniques in this study. In this study, unsuccessful intubation was defined as the clinical situation in which a conventionally trained anesthesiologist (working more than 5 years) could not successfully complete tracheal intubation less than three attempts with Macintosh laryngoscope. The video-assisted laryngoscopy is the first choice as it is easy to handle, and can be inserted into the patient’s mouth. If failed, shikani or fiberoptic-guided intubation was considered as alternative techniques. If the patient has poor oxygenation, then the intubating laryngeal mask airway should be chosen. In emergency situation or those in need for invasive airway access, tracheostomy could also be considered.No patients were involved in the radiological data measurements nor were they involved in developing plans for design and accomplishment of the present study. No patients were asked to advise on interpretation. The final results will be disseminated to investigators and patients through this publication.P <  0.05 was considered to be statistically significant.SPSS 22.0 software was used to execute statistical analysis. Kolmogorov-Smirnov test assists in determining whether the distribution was normal. Continuous variables that were normally distributed were analyzed by independent-samples T test, while non-normal variables were assessed by Mann-Whitney test. Categorical data were analyzed by Chi-square test. After that, binary logistic regression model was applied to distinguish multivariate predictors. Odds ratio (OR) and 95% confidence interval (95% CI) signifies the strength of association. The receiver operating characteristic (ROC) curve was used to describe the discrimination ability of the predictive indicators. Area under the curve (AUC) was used as a quantitative index. Youden’s index (= sensitivity + specificity - 1) was calculated and the highest score was considered as an optimal predictive cut-off value. P > 0.05). With regard to radiological measurement, ten indicators that showed significant differences between the two groups were found, namely, X2 (P <  0.001), X6 (P = 0.028), X7 (P = 0.001), X9 (P = 0.039), Angle B (P = 0.037), Angle E (P <  0.001), Angle F (P = 0.017), MRI 1 (P = 0.002), MRI 4 (P = 0.013), and MRI 7 (P <  0.001).A total of 104 patients were enrolled in this study. Based on whether assistant techniques were applied during intubation, patients were divided into Macintosh laryngoscopy group (78 cases) and Assistant technique group (26 cases). In the Assistant technique group, 4 patients underwent intubation with video-assisted laryngoscope successfully, 4 patients underwent intubation with shikani optical stylet, 15 patients with fiberoptic bronchoscopy, 2 patients with laryngeal mask airway, and 1 patient with tracheostomy tube. The average age of the patients was 51.77 years, and included 92 males and 12 females. Patients’ demographics and measurement data were displayed in Table P = 0.005, OR = 0.526), X9 , Angle E , and MRI 7 , and their 95% CI were (0.337 to 0.819), (1.213 to 8.309), (1.206 to 2.463), (1.058 to 1.796), respectively.Based on the binary logistic regression model (Forward: LR) presented in Table The ROC curve and the AUC were used to understand the predictive ability of the 4 radiological predictors established by the logistic regression model. As shown by Table Due to the existence of cervical degeneration, instability or spondylosis, difficult laryngoscopy has a higher incidence in patients undergoing elective cervical spine surgery. To reduce the unnecessary attempts and increase the efficiency and accuracy of the anaesthesiologist during application of assistant techniques during intubation, and based on patients’ preoperative cervical X-ray and MRI images, this study was conducted to distinguish radiological predictors that were reported in the previous literature in difficult conditions where assisted techniques should be prepared and applied in a more positive manner and where necessary. To our knowledge, only few studies have focused on the prediction of the application of assisted techniques according to the preoperative radiological measurements. Our findings would hold great value in providing references to clinical anesthesia.Angle E, which is the angle between a line passing through the posterior-superior point of hard palate and the lowest point of the occipital bone and a line passing through the anterior-inferior point and the posterior-inferior point of the second cervical vertebral body, could reflect the upper cervical spine mobility. Less Angle E seen in our study implied the limited flexion of upper cervical spine, which might result in difficult laryngoscopy. The occipitoatlantal junction contributes 23.0°–24.5° of flexion/extension of the skull and the atlantoaxial joint provides an additional 10.1°–22.4°  movementP < 0.001). In a sense, longer X2 distance caused by bucktooth and abnormal hard palate indicates shorter inter-incisor gap and smaller oral cavity space anatomically [X2, the perpendicular distance from hard palate to the tip of upper incisor, was also an effective radiological indicator in predicting the difficult laryngoscopy in this study (AUC = 0.819). The patients in Assistant technique group were detected with longer X2 distance . This result was consistent with some previous studies [MRI 7 is the distance from skin to hyoid bone. Adhikari et al.  have rep studies , 22, in P = 0.039). However, the AUC of X9 was 0.636, representing low accuracy and its optimal cut-off value was 7.3 mm with a sensitivity of 73.1% and specificity of 56.4%.X9 is the atlanto-occipital gap, and the distance between the occipital bone and first cervical vertebra in patients undergoing intubation in neutral position. Patients with atlantooccipital distance impairment had a higher prevalence of difficulty laryngoscopy , 24. X9 However, there are some limitations in our study. Firstly, the present study included a relatively small number of patients, and larger sample size and a multi-center study might make the results more convincing. Secondly, this was a retrospective study, and a prospective study for predicting the necessity and possibility of assistant technique application during intubation might have the potential to provide more references to clinical anesthesia. Additionally, some measurement errors might exist because the measurements were completed by a single surgeon.In summary, four radiological parameters were recognized to predict the application of assistant intubation techniques in this study. Based on the optimal cut-off values of each preoperative predictor, the possibility of difficult airway is warned, and the anaesthesiologist should then apply the assistant technique more positively before many attempts during intubation.


Animal models of viral disease are very important for understanding how viruses make people sick and for testing out drugs and vaccines to see if they can prevent disease. In this study, we identify the ferret as a model of encephalitis caused by Rift Valley fever virus (RVFV). This novel model will allow researchers to evaluate ways to prevent RVFV encephalitis. Mustela putorius furo (the ferret) following intradermal (i.d.) or intranasal (i.n.) infection. Infected ferrets developed hyperpyrexia, weight loss, lymphopenia, and hypoalbuminemia. Three of four ferrets inoculated intranasally with RVFV developed central nervous system (CNS) disease that manifested as seizure, ataxia, and/or hind limb weakness at 8 to 11 days postinfection (dpi). Animals with clinical CNS disease had transient viral RNAemia, high viral RNA loads in the brain, and histopathological evidence of encephalitis. The ferret model will facilitate our understanding of how RVFV accesses the CNS and has utility for the evaluation of vaccines and/or therapeutics in preventing RVFV CNS disease.Rift Valley fever virus (RVFV) is a pathogen of both humans and livestock in Africa and the Middle East. Severe human disease is associated with hepatitis and/or encephalitis. Current pathogenesis studies rely on rodents and nonhuman primates, which have advantages and disadvantages. We evaluated disease progression in IMPORTANCE Animal models of viral disease are very important for understanding how viruses make people sick and for testing out drugs and vaccines to see if they can prevent disease. In this study, we identify the ferret as a model of encephalitis caused by Rift Valley fever virus (RVFV). This novel model will allow researchers to evaluate ways to prevent RVFV encephalitis. Phenuiviridae. Transmission to humans can occur by mosquito bite or exposure to infected animal fluids  is a disease endemic to Africa and the Arabian Peninsula, affecting livestock and humans –3. Lives–l fluids . While tl fluids , 6. Thesl fluids . While sl fluids , 9, the l fluids . Our undCommonly used animal models for RVF include rodents and nonhuman primates (NHPs) , 12. Wil22–27–Mustela putorius furo) are a commercially available, outbred species that successfully models aspects of clinical disease for many viruses  or 1 × 106 (high dose) 50% tissue culture infective doses (TCID50) of recombinant WT (rWT) ZH501 RVFV via either the intradermal (i.d.) or intranasal (i.n.) route. The ferrets i.n. and i.d. infected at the high dose developed transient temperature elevation above the range of the controls in the first week of infection. Ferrets infected i.n. at both inoculation doses had temperature elevation above the range of the controls at 6 to 8 days postinfection (dpi)  . The clion (dpi) . Throughdoses TCI50 of recon (dpi) . Notablyght loss .10.1128/mSphere.00798-20.1FIG S1FIG S1, TIF file, 0.01 MB.Clinical scoring system. Download Copyright © 2020 Barbeau et al.2020Barbeau et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the 10.1128/mSphere.00798-20.2FIG S2FIG S2, TIF file, 0.9 MB.Weight and temperature change for each animal in the study. Weight change over time in control animals (A), animals that were inoculated intranasally (i.n.) (B), and animals that were inoculated intradermally (i.d.) (D) is shown. Temperature change over time in i.n. (C) and i.d. (E) inoculated animals is shown. Each animal is indicated by a unique color and shape. Gray shading indicates the range of temperatures observed in control animals. Open symbols in panel C represent animals that were euthanized for clinical disease. Individual weights are not shown for these animals since these data are depicted in Copyright © 2020 Barbeau et al.2020Barbeau et al.Creative Commons Attribution 4.0 International license.This content is distributed under the terms of the Serial complete blood counts CBCs) revealed a relative lymphocytopenia and neutrophilia during the first week of infection that resolved in all animals  to D. A Cs reveal10 copies per gram in the brains of the three animals that were euthanized for clinical neurologic disease  values of 640 or greater while the three animals that developed encephalitis had RVFV FRNT80 values of 40 to 640 on the day of euthanasia, which occurred between 8 and 11 dpi  obtained at euthanasia were analyzed for virus-specific cellular immunity by gamma interferon (IFN-γ) enzyme-linked immunosorbent spot (ELISPOT) assay. Virus-specific cells were detected in all animals from which viable PBMCs were obtained except in the animal euthanized at 8 dpi for CNS disease . This an6 TCID50 exhibited perivascular cuffing . No other animals had any pathologic lesions in the heart.An extensive necropsy was performed at the time of euthanasia. Mild splenic enlargement was noted in most of the infected animals. There were no obvious gross abnormalities of the pulmonary, urinary, or gastrointestinal tracts of any animal, with the exception of incidental renal cysts in 2 of 19 animals. In the animal that required euthanasia due to CNS disease at 8 dpi, the surface of the brain was grossly discolored, consistent with hyperemia and inflammation , and the cuffing , multifo cuffing , and enc cuffing , glial n cuffing , and lam cuffing . The samWhile several different animal models exist for studies of RVF disease, each of these models has some limitations. Most species of mice are exquisitely sensitive to RVFV infection and succumb rapidly to hepatitis. Nonhuman primates have shown promise and are excellent for later preclinical development studies but can be difficult to obtain and require significant resources. Rats have somewhat more diverse phenotypes but, as rodents, also do not meet the required FDA two-animal rule for the evaluation of therapeutics or vaccines for licensure. The two-animal rule would be a likely path of licensure of any RVFV vaccine or therapeutic given the difficulty of performing a clinical trial for a disease that exhibits sporadic emergence in wide geographic areas.The ferret model fills this gap in that it is a nonrodent animal species that is readily available and less resource-intensive than NHPs. Additionally, with wide use of ferrets for influenza studies, there is a wealth of knowledge already in place, and new immunologic reagents are being actively developed . The ferThe host determinants of RVF disease manifestations in humans are poorly understood. There are data to suggest that host innate immune responses modulate clinical disease manifestations; polymorphisms in Toll-like receptor 3 (TLR3), TLR7, TLR8, MyD88, TRIF, mitochondrial antiviral signaling protein (MAVS), and RIG-I genes were associated with severe hemorrhagic or encephalitic disease , 38. TheIt is also possible that the route of exposure plays an important role in modulation of disease manifestations. Humans become exposed either by an infected mosquito bite or by mucosal exposure to the blood or bodily fluids of infected animals . Given tThe ferret pathogenesis studies presented here recapitulate both routes of exposure to RVFV, mimicking a mosquito bite-delivered inoculation or a mucosal exposure that might occur from infected livestock. Both routes of exposure resulted in transient low-level viremia accompanied by mild and transient ALT elevation and hypoalbuminemia, indicating systemic spread and inflammation. This was most prominent in the high-dose i.n. infected group. While direct spread from i.n. inoculation across the cribriform plate cannot be ruled out, the detection of viremia also suggests that systemic spread could be another route of CNS invasion by RVFV in ferrets. A role for systemic spread is further supported by the histopathologic evidence of CNS involvement in one animal that received an i.d. inoculation. This ferret model utilizes rWT RVFV of the ZH501 strain, which has been used in many other studies of RVFV , 44–48 i44–Unlike most inbred rodent models , ferretsIn 1935, experimental exposure of ferrets to RVFV was reported  were all male due to size requirements to permit repeated phlebotomy. Animal ages ranged from 6 to 9 months at the time of infection, with weights from 1,123 to 1,837 g. Animals were implanted with an IPTT-300 temperature and i.d. transponder (BMDS) and were housed in an ABSL-3 laboratory in HEPA-filtered biocontainment caging. Animals were monitored twice daily for the first 2 weeks and daily thereafter. Daily weights, temperatures, and clinical observations were recorded. Animals were anesthetized using isoflurane for cranial vena cava phlebotomy at 0, 3, 6, 10, 14, 21, and 28 days postinfection (dpi). At each phlebotomy, blood was collected for complete blood counts (CBCs) and clinical chemistries (CHEM). CBC and CHEM data were analyzed using a VETSCAN HM5 hematology analyzer (Abaxis) and a VETSCAN VS2 chemistry analyzer (Abaxis) using the Preventative Care Profile Plus disc. At the end of the experiment or when indicated by clinical signs, animals were euthanized by intravenous injection of 2 milliequivalents (mEq)/kg of potassium chloride following terminal phlebotomy under anesthesia with inhaled isoflurane. During necropsy, various tissues were collected for virologic assays in phosphate-buffered saline (PBS) supplemented with antibiotics and antimycotic (Invitrogen). Samples of tissues were also fixed in 10% formalin for pathological analysis. Fixed tissues were processed and paraffin embedded. Sections (4 μm) were cut by microtomy and mounted on glass sides, and tissues were stained with hematoxylin and eosin (H&E).in vivo. Titers of viral stocks were determined using the TCID50 method  or intranasally (500 μl) distributed in both nares under isoflurane anesthesia.rWT ZH501 was generated using an established reverse-genetics system  and propTissues were homogenized using a D2400 homogenizer (Benchmark Scientific), and RNA was extracted from tissue homogenates or plasma samples using TRIzol reagent (Ambion) and a Direct-zol RNA purification protocol (Zymo Research). Viral RNA was detected using qRT-PCR targeting the RVFV large (L) segment as previously described . Data weRVFV-specific antibody titers were assessed using a previously described protocol  with the80. Graphs were generated using GraphPad Prism, version 8.Serum samples obtained from terminal phlebotomy were used in a focus reduction neutralization test (FRNT) as previously described . Foci we5 cells. Graphs were generated using GraphPad Prism, version 8.At terminal phlebotomy, blood was collected into cell preparation tubes (BD Biosciences), and peripheral blood mononuclear cells (PBMCs) were prepared and stored in liquid nitrogen until use. Cryopreserved PBMCs were thawed and washed in RPMI medium supplemented with 10% (vol/vol) fetal bovine serum (FBS). PBMCs were incubated with no stimulation (dimethyl sulfoxide [DMSO] control), with 1 μg/ml of staphylococcal enterotoxin B (positive control), or in duplicate with a pool of peptides that represented the entirety of the RVFV nucleocapsid (N) protein. There were a total of 59 peptides, each 15 amino acids (aa) in length with overlaps of 11 aa, suspended in DMSO. Final peptide concentration was 1 μg of each peptide/ml. Serial dilutions of PBMCs mixed with the various stimulation conditions were placed in a precoated ferret interferon gamma (IFN-γ) ELISPOT plate (Mabtech). PBMCs from uninfected ferrets were used as controls in all assays. Following overnight incubation, plates were processed according to the manufacturer’s instructions. Spots were counted using an ImmunoSpot Analyzer (CTL), and data were exported to Excel. The RVFV-specific spot count was determined by subtracting signal of the no-stimulation wells from signals of the RVFV N protein peptide pool wells, and the number of spots was recorded per 1 × 10


Glioblastoma (GBM), one of the most malignant types of human brain tumor, is resistant to conventional treatments and is associated with poor survival. Since the 3D extracellular matrix (ECM) of GBM microenvironment plays a significant role on the tumor behavior, the engineering of the ECM will help us to get more information on the tumor behavior and to define novel therapeutic strategies. In this study, polycaprolactone (PCL)/gelatin(Gel)/hyaluronic acid(HA) composite scaffolds with aligned and randomly oriented nanofibers were successfully fabricated by electrospinning for mimicking the extracellular matrix of GBM tumor. We investigated the effect of nanotopography and components of fibers on the mechanical, morphological, and hydrophilic properties of electrospun nanofiber as well as their biocompatibility properties. Fourier transform infrared spectroscopy (FTIR) and differential scanning calorimetry (DSC) have been used to investigate possible interactions between components. The mean fiber diameter in the nanofiber matrix was increased with the presence of HA at low collector rotation speed. Moreover, the rotational velocity of the collector affected the fiber diameters as well as their homogenous distribution. Water contact angle measurements confirmed that hyaluronic acid-incorporated aligned nanofibers were more hydrophilic than that of random nanofibers. In addition, PCL/Gel/HA nanofibrous scaffold (7.9 MPa) exhibited a significant decrease in tensile strength compared to PCL/Gel nanofibrous mat (19.2 MPa). In-vitro biocompatibilities of nanofiber scaffolds were tested with glioblastoma cells (U251), and the PCL/Gel/HA scaffolds with random nanofiber showed improved cell adhesion and proliferation. On the other hand, PCL/Gel/HA scaffolds with aligned nanofiber were found suitable for enhancing axon growth and elongation supporting intracellular communication. Based on these results, PCL/Gel/HA composite scaffolds are excellent candidates as a biomimetic matrix for GBM and the study of the tumor. Glioblastoma (GBM) is a highly malignant human primary brain tumor. Even with maximal surgical resection followed by adjuvant chemo-radiotherapy, median survival is still less than two years . It is nTo date, natural and synthetic polymers were used to produce 3D scaffolds by various fabrication techniques. Electrospinning is a simple and commonly used technique for constructing 3D scaffolds consisting of nanofibers or mostly sub-microfibers-structured scaffolds ,6,7 thatAnother natural anionic polymer using in tissue engineering is hyaluronic acid (HA), which is found in skin and cartilage, and is an essential component of brain ECM . Since tThe fiber diameter remained in the nanoscale range for all the studied scaffolds, which is crucial to mimic the extra-cellular matrix size, an essential requirement for satisfactory cell attachment and proliferation . Rao et v/v). To obtain the PCL/Gel mixture solution containing 9 wt % PCL and 6 wt % Gel, the prepared polymer solutions were blended in 3:2 (v/v) ratio. HA was added to the obtained PCL/Gel polymer solutions at 0.5 wt % concentration. The homogeneous solutions were prepared using a magnetic stirring overnight at room temperature. Electrospinning setup consists of a polymer mixture placed in 10 mL syringe with an 18-gauge needle and rotating collector. Composite nanofibers were fabricated for an optimum condition: voltage of 22–25 kV, flow rate of 200–250 μL/h, 13 cm distance between needle and collector. The collector was rotated with the rotation speed of 3000 rpm for producing aligned fibers or 100 rpm for fabricating random fibers. After electrospinning, each sample was stored at ambient for 24 h before characterization. The obtained random nanofiber scaffolds were named as PCL/Gel, PCL/Gel/HA, while aligned nanofiber scaffolds were named as PCL/Gelxy and PCL/Gel/HAxy.As shown in The conductivity, viscosity, and surface tension of prepared solutions were characterized at ambient temperature using an electroconductive meter , digital viscometer , and a surface tension meter (the du Nouy procedure with a platinum ring), respectively. Each measurement was performed three times; the average value and standard deviation were calculated.Scanning electron microscopy was used to determine the scaffold morphology . Fiber diameters were measured from randomly selected 100 fibers from SEM images (taken at 2000× magnification) with Image J software.The composite scaffolds were characterized by Fourier transform infrared spectrometer (FTIR) .Tensile properties of the scaffold were evaluated using a tensile test machine  to obtain tensile stress–strain curves for all samples. To analyze the tensile properties of the aligned scaffolds, the lengths of the samples were cut both along the orientation of fibers (PCL/Gelx and PCL/Gel/HAx) and perpendicular to the orientation of fibers (PCL/Gely and PCL/Gel/HAy). The samples were cut into 5 cm (length) × 1 cm (width). Young’s modulus and ultimate tensile strength values were calculated through these curves.For differential scanning calorimetry (DSC) analysis, samples (The wettability of the scaffolds was characterized by water contact angles (θ) (WCA) measurements using the sessile drop method  at ambient temperature. Water droplets (3 μL of deionized water) were automatically dropped on the sample surface, and its evolution after 2 s was recorded with a CCD camera connected to the equipment. Then the equipment software automatically measured the WCA.5 cells/well was cultured on scaffolds and incubated at 37 °C in 5% CO2 incubator.Cell culture on the scaffolds—U251 cells were used for all cell experiments in Dulbecco’s modified eagle’s medium (DMEM) supplemented with 10% fetal bovine serum (FBS) and 1% penicillin/streptomycin. The samples with circle pieces (0.02 mm in thickness and 16 mm in diameter) were placed into 24-well plates, followed by ultraviolet (UV) light sterilization for 2 h. A density of 1 × 103--2,5-diphenyl tetrazolium bromide (MTT) assay was used for the evaluation of cell viability. Cells were seeded on scaffolds as described above. After 1, 4, and 7 days of cell incubation, the cell-cultured scaffolds were washed with PBS and then incubated with 0.5 mL of 0.5 mg/mL MTT in PBS for 4 h at 37 °C with 5% CO2. The supernatant was removed gently, followed by the addition of 1.5 mL of dimethylsulfoxide (DMSO). Then, each sample was transferred to a 96-well plate to measure the absorbance at 590 nm (reference 660 nm) wavelength using a microplate reader.Viability—A Cell morphology—The cell–matrix interaction and cell morphology on scaffolds were evaluated by scanning electron microscope (SEM) and confocal laser scanning microscope. After 4 and 7 days of cell incubation, cell-laden scaffolds were fixed with 2.5% glutaraldehyde (Sigma) for 1 h and then dehydrated via ethanol dilutions  and dried in air. All samples were coated with gold and analyzed using SEM . For cell observation under a confocal laser scanning microscope (Zeiss LSM700), on day 7, the samples were washed with PBS, fixed with 4% formaldehyde for 1 h. Permeabilization was then performed with 0.1% Triton X-100 in PBS for 15 min, followed by washing with PBS. The samples were incubated with FITC–phalloidin (diluted 1:100) for 1 h at room temperature, followed by staining with DAPI. Confocal laser scanning microscope was used to obtain cell fluorescence images (20× immersion objective). The emission wavelengths were fixed at 500–540 nm for FITC and 461 nm for DAPI.v/v), on the other hand, gelatin, a natural polyelectrolyte, has several ionizable amino groups and carboxylic groups and can be generally hydrolyzed by either acidic condition or at neutral pH [As shown in utral pH . It was utral pH .−1 and 1170 cm−1 associated with CH2 asymmetric and symmetric stretching vibrations, respectively; 1727 cm−1 indicated C=O stretching vibration in carbonyl groups; 2950 cm−1 and 2865 cm−1 corresponding to C–O–C asymmetric and symmetric stretching vibrations, respectively [−1, 1540 cm−1, and 3300 cm−1, which were associated with C=O stretching vibration, the coupling of the N—H in plane bending and the C—N stretching vibration, and the N—H stretching vibration, respectively [−1, 1044 cm−1, and 1614 cm−1 which were indicated to the hydrogen-bonded O–H stretching vibration, the C–O–C stretching vibration and the carbonyl group of the carboxylate (COO–) asymmetric stretching vibration, respectively [FTIR spectroscopy was used to determine the molecular structure of HA, Gel, PCL, PCL/Gel, and PCL/Gel/HA0.5. PCL-related infrared spectra were observed in the curves of PCL, PCL/Gel, and PCL/Gel/HA0.5 scaffolds, as shown in ectively ,44. Gelaectively ,35,45. Fectively . Accordiectively . The entThe stress–strain properties of scaffolds fabricated with two spinning parameters, including low and high collector rotation speed were characterized at 25 °C. The typical stress–strain curves are presented in As shown in The WCA measurement was used to evaluate the hydrophilic/hydrophobic properties of scaffolds which affect protein penetration and consequently cell adhesion and cell infiltration . StudiesCell survival, as well as cell distribution and morphology, is one of the parameters to be considered to evaluate the success of tissue engineering scaffolds . In thisThe SEM images in In this study, for the first time, composite nanofibrous scaffolds with random and aligned nanofiber consisting of polycaprolactone, gelatin, and hyaluronic acid were manufactured by electrospinning method, using a solvent mixture: formic acid/acetic acid. Fiber diameter and distribution affected by the addition of HA content into PCL/Gel solution and changing of spinning parameters. The aligned nanofiber production was achieved under the influence of two main forces, including electrostatic force and the stretching force and these forces resulted in a reduction of nanofiber diameter. PCL/Gel/HA nanofibrous scaffold (7.9 MPa) displayed a significant decrease in tensile strength compared to PCL/Gel nanofibrous mat (19.2 MPa). The presence of HA decreased the mechanical properties, but their nanotopography did not cause a significant difference. The aligned nanofibers with the presence of HA exhibited superhydrophilic properties. Still, the random nanofibers containing HA have the moderately hydrophilic characteristic that can assist in cell growth compared to aligned nanofibers. Biomaterial topography and surface chemistry played an important role in the biomechanical, proliferative, and morphological properties of GBM cells. Overall, aggregated cell formation and cell morphology on PCL/Gel/HA0.5 composite scaffold indicate that this 3D scaffold with random nanofibers can be a promising candidate for the biomimetic platform of GBM extracellular matrix.


The multivariate-adjusted PRs (95% CIs) for underweight and obesity were 1.08 (0.88–1.33) and 0.85 (0.68–1.06), respectively, in 2013 and 1.02 (0.82–1.26) and 0.87 (0.69–1.09), respectively, in 2014. The results of the present study showed that obesity may be a useful predictor for probable PTSD recovery. Obese victims with PTSD would require more intensive support and careful follow-up for recovery.Post-traumatic stress disorder (PTSD) and obesity share common risk factors; however, the effect of obesity on recovery from PTSD has not been assessed. We examined the association between body mass index (BMI) and recovery from PTSD after the Great East Japan Earthquake. We analyzed 4356 men and women with probable PTSD aged ≥ 16 years who were living in evacuation zones owing to the radiation accident in Fukushima, Japan. Recovery from probable PTSD was defined as Post-traumatic Stress Disorder Checklist-specific scores < 44. Using Poisson regression with robust error variance adjusted for confounders, we compared the prevalence ratios (PRs) and 95% confidence intervals (CIs) for this outcome in 2013 and 2014. Compared with point estimates for normal weight (BMI: 18.5–24.9 kg/m Previous studies also reported a high prevalence of posttraumatic stress disorder (PTSD) symptoms , defined as Post-traumatic Stress Disorder Checklist-specific (PCL-S) scores ≥ 44 in 2012, almost one year after the disaster4.On March 11, 2011, the Great East Japan earthquake (GEJE) caused a tsunami, as well as a radiation accident at the Fukushima Daiichi Nuclear Power Plant in Fukushima Prefecture, on the Pacific coast of northern Japan. Several studies have conducted to observe the effects of this complex disaster on the health of its victims. For example, the prevalence of overweight and obesity in this population, defined as body mass index (BMI) ≥ 25 kg/m8, biochemical values12, and personality17. Individuals with PTSD are likely to be obese and have an increased risk of weight gain18. However, to our knowledge, the effect of obesity on recovery from PTSD has not been reported. In this context, BMI may be a predictor for recovery from PTSD.Obesity and PTSD share several common risk and correlated factors such as dietTherefore, this study examined the association between BMI and recovery from PTSD by longitudinal data from evacuees who lived in the evacuation zone owing to the nuclear accidents in Fukushima in 2011.Table Table Table These associations remained consistent after excluding participants aged < 20 years , meat, and vegetable, is negatively associated with both obesity and PTSD8. PTSD is associated with low-density lipoprotein-cholesterol, cortisol, interleukin (IL)-2, IL-6, IL-8, leptin, insulin resistance, and tumor necrosis factor (TNF)-α12. PTSD is caused by neuroendocrine links, leading to the activation of the sympathetic-adrenergic nervous system together with the release of hormones via the endocrine hypothalamic–pituitary–adrenal (HPA) axis19. A previous study also showed HPA axis dysregulation, with decreased blood and urinary cortisol levels and enhanced HPA axis sensitivity to negative feedback20. Lipid metabolism is also affected by these alterations21. Additionally, microglial TNF-α was associated with sustained fear memory, which is a cause of PTSD22. A process of fear memory formation changes the proinflammatory cytokine production in the brain. It was observed that TNF-α increased in mice which retained fear memory, whereas it returned to basal levels in mice, which extinguished fear memory. Previous studies showed that pharmacological treatments that target inflammatory mechanisms are associated with decreased for having a diagnosis of PTSD and lower levels of PTSD symptoms in traumatized participants23. Interventions to improve obesity might also prevent from new onset and prolonged PTSD because obesity, especially the accumulation of visceral fat, increases the levels of the abovementioned metabolic substances12. Moreover, a certain personality is associated with both obesity and PTSD17. Odds Ratio and 95% CIs of PTSD increased in individuals with nervousness 13. A systematic review reported neuroticism as a risk factor for obesity16. Therefore, obese participants would find it difficult to recover from PTSD owing to the above factors mediating obesity and PTSD.Although no previous studies have examined the association between BMI and PTSD recovery, systematic reviews and meta-analyses have suggested the effect of PTSD on obesity and the risk of weight gain1. However, the victims received support for the recovery of their quality of health. The Fukushima Health Management Survey has conducted health checkups24, consultation meetings, and lecture presentations and has distributed informational health brochures. Not infrequently victims have decreased BMI and improved obesity owing to these interventions. Therefore, misclassification of BMI changes in the follow-up period might induce attenuation of the association between BMI and probable PTSD in these participants.Meanwhile, obesity in participants who did not recover from probable PTSD during 2012–2013 was not associated with recovery in 2014. BMI and the prevalence of obesity increased dramatically in victims after the disasterOur study had several limitations. First, information on probable PTSD before the disaster was not available. Some study participants might have had probable PTSD not associated with the disaster. Second, probable PTSD were assessed almost one year after the disaster. Thus, participants who developed and recovered from probable PTSD before this assessment were excluded. Therefore, this study included study participants limited by severe probable PTSD persisting for a long period after excluding potential participants with relatively mild probable PTSD. Third, the survey periods differed between the assessments of BMI and probable PTSD. Probable PTSD was assessed using the Mental Health and Lifestyle Survey from January to May in 2012, while BMI was measured as part of the Comprehensive Health Check from July 2011 to March 2012. Thus, the results might show weak associations because of underestimation owing to non-differential misclassification. The survey period did not depend on exposure and outcome. Fourth, respondents of the Mental Health and Lifestyle Survey comprised 41.2% of the target population. Therefore, the results of this study may be affected by a response bias. Individuals with PTSD were more likely to not respond. However, this response tendency was not associated with BMI; therefore, while the present results underestimated the absolute risk, this bias did not affect the relative risk. Fifth, the number of participants in the underweight and obesity is relatively small compared with that in the normal weight and overweight. The accuracy of the results might be unstable. Further larger studies are needs to clarify the association between BMI and recovery from probable PTSD.In conclusion, the results of this study showed that obesity may be useful as a predictor for probable PTSD recovery. After disasters, both physical and mental health are important public health concerns for victims. Therefore, considering BMI might be effective to improve mental health. The obese victims with PTSD might be required more intensive support and careful follow-up to recover it. Weight control has a possibility of benefit for PTSD.24. Briefly, the Mental Health and Lifestyle Survey was a self-administered questionnaire that annually assessed mental health and various lifestyle habits according to age category ; the first survey was delivered in January 2012 to all residents who lived in the evacuation zones owing to the radiation accident in Fukushima Prefecture on March 11, 2011. The evacuation zone was a government-designated area with a radius of 20 km around the nuclear power plant. PCL-S scores did not assess in participants aged 0–6 and 7–15 years. In those aged ≥ 16 years, PCL-S scores were not assessed after 2015. Among the target population of 180,604 individuals aged ≥ 16 years in 2012, 74,549 (41.2%) responded. The study participants included 38,273 respondents for whom information about body mass index (BMI) was available from the Comprehensive Health Check. The present analysis excluded participants with missing PCL-S data in 2012 and both 2013 and 2014 , with a history of mental illness (n = 1142), and with PCL-S scores < 44 in 2012 . Thus, we analyzed a total of 4356 participants (1614 men and 2742 women) . The questionnaires were described, and an explanation of the survey and handling of personal information was provided on a cover page. The participants subsequently provided their written informed consent to participate by returning the questionnaires. In participants aged < 18 years, their parents or representative also provided written informed consent. This study was conducted according to the Declaration of Helsinki. We followed the STROBE Statement to report our observational study.2 (underweight), 18.5–24.9 kg/m2 , 25.0–29.9 kg/m2 (overweight), and ≥ 30.0 kg/m2 (obese)25.BMI was calculated as the measured weight divided by the square of measured height. We divided the participants according to the following BMI categories: < 18.5 kg/m26.Probable PTSD were defined by PCL scores, which is used for screening PTSD, aiding in the diagnostic assessment of PTSD, and monitoring changes in probable PTSD. Among the three versions of PCL in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the present survey used PCL-S27. Participants responded to each item as follows: 1 , 2 (slightly), 3 (moderately), 4 (quite a lot), or 5 (very much) in the past month. Therefore, PCL-S scores < 44 were used to denote recovery from probable PTSD during the follow-up period.Probable PTSD were defined as PCL-S scores ≥ 44; the scores are derived from a 17-item self-report measure according to the recommendation for diagnostic efficiency28. The normal weight category was selected as the reference. The p-values for trends were calculated for continuous variables. All p-values were two-tailed, and p < 0.05 indicated statistically significant differences.We used Poisson regression with robust error variance to derive prevalence ratios (PRs) and 95% confidence intervals (CIs) for recovery from probable PTSD (PCL-S scores < 44) in 2013 and 2014, respectively, according to BMI categories and to adjust for potential confounding factors. This analysis was performed using SAS version 9.4We considered the following variables as potential confounding factors: sex, age , PCL-S scores in 2012 (continuous), smoking , drinking , exercise habit , sleeping habit , education level , activities of daily living (independent or dependent), history of cancer or heart disease (yes or not), house damage , lose someone close in disaster (yes or not), experience about tsunami following the GEJE (yes or no), and experience about nuclear reactor accident (heard the explosion) following the GEJE (yes or not). Multiple imputation using 20 iterations was applied for missing covariate information.Additionally, we repeated the above analysis to examine the association between BMI and recovery of probable PTSD in 2014 among participants who had probable PTSD until 2013.This analysis was also conducted after excluding participants aged < 20 years because the smoking and drinking statuses of all participants in this age group should be categorized as “never” and “almost never.”Supplementary Information


The main conclusion was that there were no adverse events. Strength and endurance training with a balanced, individualized hypocaloric diet was the most effective at reducing weight loss and fat mass in overweight subjects. Trial registration: NCT01116856.Studies with overweight people are a priority in order to observe the effect of the timing of intervention on pre-obesity people. The aim was to compare different physical activity programs plus an individualized hypocaloric diet on body composition in overweight subjects. A randomized controlled clinical trial was carried out in overweight adults with no history of relevant illness. Primary outcome was total fat mass (TFM). Participants were allocated into four activity programs with equal intensity and volume of exercise for 22 weeks: strength training (S), endurance training (E), strength + endurance training (SE), and ‘adhering to physical activity recommendations’ (C). Participants followed a diet with 25% less energy  measured by accelerometer. Variables were assessed at baseline and at the end of the intervention. Body composition was measured by dual-energy X-ray absorptiometry. One hundred nineteen from 205 subjects were randomized in the four exercise groups (S = 30/E = 30/SE = 30/C = 29) and 84 participants (36 men/48 women) ended the intervention (S = 19/E = 25/SE = 22/C = 18). At the end of the experiment, all groups except C increased their total physical activity . Using an ANOVA-test, improvements were observed in body weight (S = −4.6 ± 4.5; E = −6.6 ± 4.6; SE = −8.5 ± 2.8; C = −6.1 ± 5.6 kg,  This trial was retrospectively registered as NCT01116856 at The exercise training for S, E, and SE groups was 3 times/week. The intensity of (percentage of 15 repetition maximum (RM) in strength groups or percentage heart rate reserve (HRR) in endurance groups) and volume of exercise for these three groups was designed to be equal ,22. All The exercise training programs were designed taking into account each subject’s muscular strength (MS) and HRR. MS was measured in the S and SE subjects using the 15-RM testing method every other day during the week before the intervention period. The HRR was calculated to set the exercise intensity (50%–60% maximum heart rate-resting heart rate) for the E and SE subjects. The volume and intensity of the three training programs were equal and increased progressively during the study. In weeks 2–5, exercise was at an intensity of 50% of the 15-RM and HRR, and lasted an overall 51′ and 15″. In weeks 6–14, exercise was performed at an intensity of 60% of 15-RM and HRR, again with duration of 51′ and 15″. Finally, in weeks 15–22, exercise was performed at an intensity of 60% of 15-RM and HRR, with a duration of 60′. Each training session for the S, E, and SE subjects commenced with a 5′ aerobic warm-up, followed by the main session exercises, and concluded with 5′ of cooling down and stretching exercises. In all sessions, the exercise rhythm was controlled by instructions recorded on a compact disk. The energy expenditure during the training sessions was controlled by individualized heart rate vs. VO2 regression analysis. p < 0.001) [Balanced, hypocaloric diets  and 1850 kcal (7732 kJ)) were prescribed individually for all participants by expert nutritionists at the Department of Nutrition, HULP, Madrid. The diet was designed to provide 25% less energy than baseline total daily energy expenditure (DEE), as measured using a SenseWear Pro Armband accelerometer    and 20% < 0.001) . The hypThe following analyses and measurements were made at baseline and at the end of the intervention period. All data were collected by the Department of Nutrition, HULP.2)). Waist circumference (WC) was measured using a SECA 201 steel tape . Dual-energy X-ray absorptiometry (DXA) was used to measure the total fat mass (TFM), android fat (AF), android/gynoid fat ratio (AF/GF), and total lean mass (TLM), employing a GE Lunar Prodigy apparatus . All DXA scans were performed using GE Encore 2002 software v.6.10.029.Height was measured using a SECA stadiometer (range 80–200 cm). Body weight was measured using a TANITA BC-420MA balance . The BMI was calculated as (body weight (kg)/ when not. Queries about the diet daily fillings were resolved by a trained researcher (dietician). When questionnaires were returned by the subjects, they were reviewed by the trained dietician and the subject to identify possible filling mistakes and omissions . The food energy and nutritional content consumed were calculated using DIAL software . The Healthy Eating Index (HEI) was calculated according to Kennedy et al. , taking www.ipaq.ki.se). The questionnaire took approximately 8–10′ to complete; a trained researcher assisted participants with answering. The collected data were summarized to classify the subjects into high, moderate, and low physical activity groups. Time spent in vigorous, moderate, and walking activity was weighted by the energy expended for these categories of activity, to produce the total MET-minutes of physical activity per week (MET-min/week). In addition, the IPAQ-SF contained an indicator item of time spent in sedentary activity (item 7): “During the last 7 days, how much time did you usually spend sitting on a weekday?” Sitting time/week was estimated taking into account the answers supplied.Physical activity was assessed using seven items in the International Physical Activity Questionnaire-Short Form (IPAQ-SF), which asks about the frequency and duration of vigorous intensity activity (1 and 2 items), moderate intensity activity (3 and 4 items), and walking activity (5 and 6 items). The questionnaire was scored using established methods posted on the IPAQ website  × 100. Complete adherence = 100%; high values reflect greater dietary restriction to the estimated energy intake, lower values, lesser restriction. Those participants who failed to meet 80% adherence were excluded from further analysis. Adherence to exercise was calculated as the number of sessions completed with respect to the theoretical maximum  × 100. An adherence of 90% was demanded for continued inclusion.p < 0.05, assuming a correlation of 0.80 between repeated measures, and assuming an estimated drop out of 20%. The TFM was used to calculate the expected effect size: 1.96 for C group and 2.18 for the experimental groups. The sample size was calculated to detect the effect of training and diet on TFM as the primary outcome (TFM), with 80% statistical power, and with significance set at p < 0.05. All analyses were performed using SPSS v.17.0 software . Significance was set at The Kolmogorov–Smirnov test was used to determine whether data were normally distributed. Means and standard deviations (SD) were calculated for continuous variables. Two-way analysis of variance (ANOVA) with repeated measures was used to determine differences among the four interventions groups and between baseline and post-training values. Multiple ANOVA comparisons were made employing the Bonferroni post hoc correction. The Chi-squared test was used to examine the relationship between quantitative variables.The clinical study was carried out from January to June (2010). Of the 119 subjects randomized to the four interventions , 84 completed the clinical trial and were included in the statistical analysis . Participant withdrawals were mainly due to personal reasons or loss of interest . The baseline characteristics of the 84 participants  who completed the study were reported in a previous article . No signp < 0.01), with no significant differences between groups (p < 0.05) and decreasing significantly the percentage of energy provided by fat (p < 0.05). Cholesterol intake decreased significantly by the end of the intervention period in the C group (p < 0.05). At baseline, all subjects had a diet “needing improvement”, however at the end of the intervention all groups improved their HEI index (p < 0.05), approaching “good”.Adherence to diet was good . All groups significantly reduced their energy intake compared to baseline . Time spent sitting per week decreased significantly in all groups after intervention with no significant differences between groups . In addip < 0.001), with no significant differences between them (p < 0.05). Body weight changes in the SE group showed a trend towards significance with respect to the S group (p = 0.059). After 22 weeks, a significant reduction in BMI, WC, and TFM was detected in all groups  to 6.74% (group SE)  and wereIn recent years, interest has grown in the influence of lean mass (LM) on weight loss ,41. The A trial limitation is that we did not analyse the effects of an individualised, balanced, hypercaloric diet alone from the effects of diet plus exercise. However, the international recommendations suggest exercise and diet as the ideal treatment to control excess body weight.In conclusion, when keeping to an individualised, balanced, hypercaloric diet, some types of exercise may have a greater effect on weight loss and the reduction of body fat. The present results suggest that SE exercise in combination with a balanced, individualized hypocaloric diet may be the most recommendable protocol for the management of weight loss and fat mass in overweight subjects.


Despite recent advances in immunosuppressive therapy for patients with primary nephrotic syndrome, its effectiveness and safety have not been fully studied in recent nationwide real-world clinical data in Japan.A 5-year cohort study, the Japan Nephrotic Syndrome Cohort Study, enrolled 374 patients with primary nephrotic syndrome in 55 hospitals in Japan, including 155, 148, 38, and 33 patients with minimal change disease (MCD), membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), and other glomerulonephritides, respectively. The incidence rates of remission and relapse of proteinuria, 50% and 100% increases in serum creatinine, end-stage kidney disease (ESKD), all-cause mortality, and other major adverse outcomes were compared among glomerulonephritides using the Log-rank test. Incidence of hospitalization for infection, the most common cause of mortality, was compared using a multivariable-adjusted Cox proportional hazard model.Immunosuppressive therapy was administered in 339 (90.6%) patients. The cumulative probabilities of complete remission within 3 years of the baseline visit was ≥ 0.75 in patients with MCD, MN, and FSGS . Diabetes was the most common adverse events associated with immunosuppressive therapy . All-cause mortality (15.6 per 1000 person-years), mainly infection-related mortality (47.8%), was more common than ESKD (8.9 per 1000 person-years), especially in patients with MCD and MN. MCD was significantly associated with hospitalization for infection than MN.Patients with MCD and MN had a higher mortality, especially infection-related mortality, than ESKD. Nephrologists should pay more attention to infections in patients with primary nephrotic syndrome.The online version of this article (10.1007/s10157-020-01864-1) contains supplementary material, which is available to authorized users. Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminuria . EpidemiImmunosuppressive therapy is the main treatment modality for patients with primary nephrotic syndrome as suggested by the clinical guidelines of primary nephrotic syndromes , 13. SysThe aim of the present cohort study, the Japan Nephrotic Syndrome Cohort Study (JNSCS) , was to N = 20), kidney biopsy before or after the entry period (N = 32), no history of nephrotic syndrome (N = 1), diagnosis of secondary nephrotic syndrome (N = 13), sclerosing glomerulonephritis with unknown etiology (N = 1), incomplete informed consent (N = 7), duplicate registrations (N = 3) and unknown reason (N = 4), 374 patients with primary nephrotic syndrome in 55 hospitals were finally enrolled in JNSCS, including those with MCD (N = 155), MN (N = 148), FSGS (N = 38), IgA nephropathy (N = 15), membranoproliferative glomerulonephritis (N = 9), mesangial proliferative glomerulonephritis (N = 5), endocapillary proliferative glomerulonephritis (N = 2), and crescentic glomerulonephritis (N = 2). Because of the small number of patients with glomerulonephritides except those with MCD, MN, and FSGS, the patients were classified into four groups of glomerulonephritides: MCD, MN, FSGS, and other glomerulonephritides.The JNSCS is a 5-year multicenter cohort study of primary nephrotic syndrome to clarify the incidence rates of major clinical outcomes and assess the effectiveness of immunosuppressive therapy in Japan. Details of the study design was described elsewhere . BrieflyThe study protocol of JNSCS was approved by the ethics committee of Osaka University Hospital  and the institutional review board of each participating hospital. All procedures performed in the present study were in accordance with the World Medical Association Declaration of Helsinki.−0.287 × serum creatinine (mg/dL)−1.094 × 0.739  ), followed by malignancy (N = 7 [30.4%]), CVD (N = 2 [8.7%]) and others (N = 3 [13.0%]) . Although the incidence of hospitalization for infection was comparable among the four groups of glomerulonephritides  , P = 0.4) . A further adjustment for urinary protein confirmed their associations (Model 3).Compared with ESKD, all-cause mortality was more common in patients with MCD and MN  , foThe use of antidiabetic drugs was common especially among patients with MN and FSGS Fig. I. Their The present 5-year cohort study, which included 374 patients with primary nephrotic syndrome in 55 hospitals in Japan, clarified the incidence rate of major clinical outcomes and disclosed that the incidence of all-cause mortality was higher than that of ESKD in patients with two major glomerulonephritides, MCD and MN. Hospitalization for infection, the leading cause of all-cause mortality, was significantly more common in patients with MCD than those with MN, suggesting that patients with MCD were vulnerable to infection. Several advantages of the present study include the nature of the cohort study design, the inclusion of two major glomerulonephritides, MCD and MN, the measurements of a wide variety of major clinical outcomes, and the collection of recent real-world clinical data in the most recent decade between 2009 and 2015.Few studies have compared the incidence rates of ESKD and all-cause mortality among patients with primary nephrotic syndrome. A Korean single-center retrospective cohort study, including 187, 232, and 251 patients with MCD, MN, and FSGS, showed that all-cause mortality was more common than ESKD in MCD and MN during the median observational period of 7.5 years, whereas ESKD was more common than all-cause mortality in FSGS . A similComparable with the results of the present cohort study, previous retrospective cohort studies on MCD reported that infection was one of the most common adverse events –27 and oN = 22) and ESKD (N = 12) was small; thus, the findings of the present study might not be reproducible. The JNSCS is planning to extend the 5-year follow-up period to 10 years, providing more precise details regarding the clinical impacts of major outcomes in patients with primary nephrotic syndrome. Second, the small number of patents with FSGS and other glomerulonephritides hindered statistically meaningful analyses in JNSCS. The results of the present study suggested the cumulative probabilities of complete remission of proteinuria and an increase of serum creatinine of FSGS were comparable to those of MN Below is the link to the electronic supplementary material.


Musculoskeletal ultrasound (MSUS) and the multi-biomarker disease activity (MBDA) score are outcome measures that may aid in the management of rheumatoid arthritis (RA) patients. This study evaluated tofacitinib response by MSUS/MBDA scores and assessed whether baseline MSUS/MBDA scores or their early changes predict later clinical response.Twenty-five RA patients treated with tofacitinib were assessed at baseline, 2, 6 and 12-weeks. Power doppler (PDUS) and gray scale (GSUS) ultrasound scores, MBDA score, clinical disease activity index (CDAI), and disease activity score (DAS28) were obtained. Pearson correlations and multiple linear regression models were used to evaluate associations and identify predictors of response to therapy.p < 0.0001). Baseline MSUS and MBDA score correlated with each other, and with 12-week changes in CDAI/DAS28 , except for GSUS with DAS28. Two-week change in MSUS correlated significantly with 12-week changes in CDAI/DAS28 , except for early change in PDUS with 12-week change in CDAI. Regression analysis demonstrated significant independent associations between baseline PDUS/MBDA score and 6-week change in CDAI/DAS28, with adjustment for baseline CDAI/DAS28 ; and between baseline MBDA scores and 12-week change in DAS28 (p = 0.03).MSUS, MBDA scores, CDAI, and DAS28 improved significantly over 12 weeks .ClinicalTrials.gov  Early treatment and vigilant monitoring are important for preventing joint destruction, impaired function, and poor quality of life in patients with rheumatoid arthritis (RA). Numerous metrics are available to monitor disease activity and inform treatment decisions. Validated RA outcomes include questionnaire-based metrics , clinical metrics  and composites of clinical and laboratory-based metrics . While these measures have advanced RA patient care over the last few decades, concerns regarding their subjectivity indicate that objective, sensitive measures are still needed , 2.Musculoskeletal ultrasound (MSUS) and the multi-biomarker disease activity (MBDA) scores are measures that can aid in the management of RA patients. These measures are responsive to RA treatment and may provide additional information beyond that of standard disease activity RA metrics , 4. MSUSTofacitinib is a small-molecule oral Janus kinase (JAK) inhibitor that is approved for treatment of RA . The effExamining the relationship between early changes in MSUS/MBDA scores to later changes in DAS/CDAI is of interest, as it may potentially allow for earlier identification of individuals who benefit from therapy. Additionally, baseline values of MSUS/MBDA scores may aid in differentiating inflammatory disease amenable to treatment, in RA patients with comorbidities where components of DAS/CDAI may be falsely elevated , 17. Thiclinicaltrials.gov .This study was a single-center, open-label, single-arm trial of RA patients treated with oral tofacitinib. The study was conducted at the University of California, Los Angeles (UCLA) Rheumatology Clinics between February 2016 and August 2017. All participants provided written informed consent in person, prior to the conduct of any study procedures. The study was reviewed by the Institutional Review Board (IRB) (IRB# 14–001148) and registered with Inclusion criteria included meeting the ACR/EULAR 2010 RA classification criteria , baselinStudy participants were treated with tofacitinib 5 mg orally twice a day for a total of 12 weeks. Patient demographics were collected at the screening visit prior to treatment. Patients were assessed at baseline, 2 weeks, 6 weeks, and 12 weeks. At each visit, patients were assessed by the tender joint count 28 (TJC28), swollen joint count 28 (SJC28), acute phase reactants , physician and patient global assessments and HAQ. CDAI and DAS28-ESR (DAS28) were determined for each visit. Rheumatoid factor (RF) and anti-cyclic citrullinated peptide antibody (ACPA) were obtained at baseline.MSUS assessments (PDUS and GSUS) were obtained at screening, baseline, 2 weeks, and 12 weeks by the same sonographer, who had greater than 8 years of experience and is ACR certified in MSUS (RhMSUS certification) (VKR). MSUS assessment was blinded to patient clinical data. A 34-joint US scoring system was used, which assessed bilateral midline wrists , radio-ulnar joints , metacarpophalangeal joints 1–5 , proximal interphalangeal joints 2–5 , metatarsophalangeal joints 2–5 , and knees . The MSUS 34-joints were chosen based on commonly affected joints in RA and feasibility of acquiring images, and this protocol has been previously used , 20. MTPMBDA scores were determined for all patients at baseline, week 2 and week 12 from serum samples that were shipped on ice within few hours of phlebotomy to the CLIA-certified clinical laboratory of Crescendo Bioscience, Inc., in South San Francisco, CA, for testing. MBDA scores were determined with a validated algorithm based on serum concentrations of 12 protein biomarkers . The bioThe sample size for the study was calculated for the primary analysis of comparing PDUS between baseline and week 12. Based on unpublished data suggesting an effect size for change in PDUS over time of 1.03 (unpublished data), the planned sample size of 25 had 99% power for detecting differences in PDUS over 3 months, assuming a repeated measures ANOVA analysis plan with a 0.05 two-sided level of significance. Repeated measures ANOVA models were used to evaluate changes over time in MSUS, MBDA score and RA disease activity measurements. Each variable was examined for skewness and not found to be substantially skewed. Thus, Pearson correlations were computed for associations between MSUS or MBDA scores and CDAI or DAS28, which were evaluated cross-sectionally and as changes over time. In addition, correlations were calculated between MSUS/MBDA scores and individual components of DAS28/CDAI. Multiple linear regression models for the outcomes of change in CDAI and change in DAS28 were constructed. These models included baseline MSUS or MBDA scores, adjusting for baseline CDAI and DAS28 as appropriate.Twenty-five RA patients were enrolled in the trial. Mean age was 52 (SD 9.9) years, mean duration of disease 10.4 years (SD 9.7); 88% of patients were female, 40% Caucasian, 88% were RF and/or ACPA positive (Table p < 0.0001)  and mean DAS28 of 6.3 (SD 1.2) (Table  and meanp < 0.01), 2 weeks  and 12 weeks ; and with GSUS at baseline  and 2 weeks  but not 12 weeks . These results show that correlations between MBDA score and ultrasound measures were strongest at baseline and remained statistically significant during treatment with tofacitinib.MBDA score demonstrated significant cross-sectional correlations with PDUS at baseline , with the exception of 12-week PDUS with 12-week CDAI  (Table p < 0.05) with the exception of 2-week mUS7 GSUS with 2-week DAS28, and 12-week mUS7 PDUS with 12-week CDAI. The magnitude of these correlations generally decreased over time. MBDA score correlated significantly with DAS28 at baseline , but not at weeks 2 or 12, and it did not correlate significantly with CDAI at any time point.Cross-sectional analyses demonstrated that PDUS and GSUS correlated significantly with CDAI and DAS28 at all study time points  , with the exception of 12-week changes in GSUS and DAS28 , with the exception of baseline GSUS and mUS7 GSUS with 12-week change in DAS28 (Table p < 0.05), with the exception of 2-week change in PDUS with 12-week change in CDAI . MSUS measures and the MBDA score correlated well with ESR at baseline . None of the MSUS measures or the MBDA score correlated with TJC28 at any time point.Cross-sectionally, MSUS measures correlated with SJC28 at baseline, and week 2 , with adjustment for baseline DAS28. Similarly, baseline PDUS was independently associated with change in CDAI from baseline to week 6 (p = 0.004), with adjustment for baseline CDAI. Baseline PDUS showed a trend toward positive association with changes in CDAI and DAS28 from baseline to week 12, . By contrast, GSUS was not associated with CDAI or with DAS28 responses from baseline to week 6 or week 12. The baseline CDAI and baseline DAS28 were not significantly associated with the 6-week or 12-week responses to therapy for CDAI or DAS28.Multiple linear regression demonstrated a positive independent association between baseline PDUS and change in DAS28 from baseline to week 6 (p = 0.006), with adjustment for baseline CDAI and DAS28, respectively. Baseline MBDA score was associated with 12-week change in DAS28 (p = 0.03), with adjustment for baseline DAS28, with a trend toward association with 12-week change in CDAI (p = 0.08), with adjustment for baseline CDAI.Multiple linear regression demonstrated a positive independent association between baseline MBDA score and change in CDAI or DAS28 from baseline to week 6 , and imaging and biomarker measures (MSUS and MBDA score). Our data is consistent with other studies of tofacitinib which demonstrated significant responses by CDAI and DAS28 , 16, 24 p < 0.05) [Several studies have demonstrated the ability of MSUS to monitor treatment response and predict radiographic progression in patients with RA, including patients in clinical remission , 25–28.  < 0.05) . Ellegaa < 0.05) . In a st < 0.05) , signifi < 0.05) . In addiThe present tofacitinib study found that higher baseline PDUS values were associated with larger CDAI and DAS28 responses at 6 weeks, with a trend observed at 12 weeks. Our study is distinct among imaging studies in that we included baseline clinical disease activity measures in the multiple regression analyses. Additionally, we found that early changes in PDUS,GSUS, and mUS7 scores, i.e., from baseline to 2 weeks, showed a significant correlation with 12-week changes in CDAI and DAS28.Prior studies have reported that baseline MBDA score can predict risk for radiographic progression , 32–34, The MSUS and MBDA scores, at baseline and their early changes, may be of clinical value for predicting outcomes in patients started on treatment with tofacitinib. In this RA cohort with high disease activity, MSUS/MBDA scores correlated fairly well with the clinical measures of CDAI/DAS28. In a more heterogeneous population , PDUS and MBDA score may help in the assessment of RA disease activity and stratify patients according to predicted response. If baseline measures or their early changes suggest possible treatment failure, an earlier change of treatment could be considered, potentially improving the clinical course and minimizing unnecessary healthcare utilization. In addition, elevated baseline MSUS and/or MBDA scores may provide value as inclusion criteria in randomized clinical trials allowing for a more homogenous group of RA patients with high disease activity and risk for joint damage .Interestingly, when assessing the correlations of MSUS measures and the MBDA score with the individual components of the CDAI and DAS28 , we found no significant correlations with TJC28 across any time point. In their review, Edwards et al. found that pain catastrophizing, or as they defined “the tendency to ruminate about and magnify pain”, and depression were frequently observed in patients with rheumatologic conditions, and adversely affect several outcomes . In a prLimitations of this study pertain to its sample size of twenty-five patients. Nevertheless, we did demonstrate significance in the primary end-points. The small sample size limited our ability to add other covariates into the linear regression model. The patient cohort had high baseline clinical disease activity , as well as long disease duration (10.4 years), which may limit the applicability of the data to other patient populations.The results of this open-label trial suggest that baseline PDUS and MBDA scores correlated with each other, tracked response to treatment with tofacitinib and, at baseline, predicted 6-week and 12-week clinical responses to therapy. In addition, the 2-week change in PDUS was found to be predictive of 12-week DAS28 response. Future studies could aim to further elucidate the utility of MSUS and the MBDA score in RA management, and investigate how early changes in these measures may help provide individualized RA patient care.


Rheumatoid Arthritis (RA) is a common inflammatory disorder affected by various factors, including fasting. The objective of the study was to establish the effect of Ramadan fasting on DAS 28 in Rheumatoid Arthritis patients.In this observational cohort study done in department of rheumatology, Mayo hospital, Lahore, between May 2019 to July 2019, 240 patients were divided in fasting (n=120) and non-fasting cohort (n=120) based on their own choice. Mean DAS-28 scores before and after Ramadan was compared in both cohorts with appropriate statistical analyses.Two hundred forty participants, , were recruited. Baseline DAS of fasting group was significantly low (4.35±0.9) as compared to non-fasting group (5.07±0.91). Paired t-test showed statistically significant improvement in fasting and non-fasting groups in total and in both genders (p=0.000). Mean improvement in DAS was numerically greater and statistically significant (p=0.000) in non-fasting group (1.08±0.62) as compared to fasting ones (0.86±0.61). Post-Ramadan DAS was, however, significantly low in fasting group (3.49±0.9) versus non-fasting group (3.98±1.0) (p=0.000).DAS 28 score decreased in both non-fasting as well as fasting patients of RA during the month of Ramadan. RA patients with moderate disease activity, who want to keep fast, can be allowed to do so without any fear of disease worsening. Rheumatoid arthritis is one of the most prevalent chronic inflammatory arthritic conditions with annual incidence of 0.5-1%, with more predilection for urban population. Prevalence of Rheumatoid arthritis is increasing in Pakistan. It is 26.9% as reported in 2015.6th lunar month of Ramadan.Fasting in Ramadan is one of five compulsory pillars in Islam, observed daily from day dawn to sunset for 29 or 30 days in 9This prospective cohort study was done in department of rheumatology in a large tertiary care hospital. A non-probability convenient sampling method was used to include the cases. Patients already diagnosed as having Rheumatoid Arthritis between 16 to 60 years of age who were consistently taking treatment were included in the study. Those patients with RA who were planning to fast throughout the month of Ramadan were included in Fasting group while others were kept in non-fasting group. Fasting was totally patients’ own choice and we did not enforce it. One hundred twenty patients were included in each group. RA patients who were pregnant, those who were lactating, with severe comorbidities and patients who were in induction phase (with biologic agents) of their treatment were not included in the study. Information like demographic factors as age, gender was also noted while collecting data. Both groups were assessed clinically for disease activity of RA using DAS 28 SCORE (disease activity score) using online calculator, both at the start of study and after Ramadan. All information was taken on a specially designed proforma after taking written and verbal informed consent from the patients.< 0.05 was taken as significant.Data was entered in SPSS 26. Quantitative variables like age were presented as mean+/- SD. Qualitative variables like gender were presented as frequency and percentages. Comparison of DAS before and after Ramadan was done by applying paired t-test in each group (fasting and non-fasting). Mean difference in DAS (before and after Ramadan) between both groups was compared by independent sample t-test. P value This study was approved by ethical committee of King Edward Medical University (KEMU), Lahore, on August 6,2019 via order no. 1000/RC/KEMU.A total of 240 participants, 74 males and 166 females, were included in study. Among females 90 (54.2%) opted for fasting as compared to males , but difference was not statistically significant. Mean age of study population was 37 years: that of fasting group was 39, and of non-fasting group was 36 years. Baseline DAS of fasting group was significantly low (4.35±0.9) as compared to non-fasting group (5.07±0.91). Paired t-test showed statistically significant improvement in both fasting and non-fasting groups and in both genders. Mean improvement in DAS was numerically greater and statistically significant in non-fasting group (1.08±0.62) as compared to fasting ones (0.86±0.61). Post-Ramadan DAS was, however, significantly low in fasting group (3.49±0.9) versus non-fasting group (3.98±1.0). Differential effect of fasting on mean DAS score was less pronounced and statistically insignificant in females. Age group stratified analysis was not done due to low numbers of subjects in some cells.Our study gives evidence about safety of Ramadan fasting in patients with Rheumatoid arthritis which is a very prevalent disease in Pakistan as shown by Syed Mahfooz Alam in a study done in Karachi which shows huge burden of RA at rheumatology clinic.New thing reported in our study was that non-fasting group showed numerically greater improvement as compared to fasting group. This trend was present in total as well as in males. However, although numerically similar, yet mean difference or improvement in DAS was less pronounced in females with and without fasting. It was contrary to that reported in previous studies where fasting group had greater reduction in DAS.18Because month of Ramadan brings important modifications in macronutrient composition of person’s diet, inability to monitor potential dietary changes was an important limitation in our study. We did not collect the diet data in our fasting patients. As high fat diet is known to worsen the inflammatory arthritis in miceFasting is safe in patients with rheumatoid arthritis who are in moderate disease activity and are stable on treatment. Further studies are needed to explore the effect of diet and disease duration on beneficial effects of fasting in these patients.SS conceived, designed and did statistical analysis, editing of manuscript, and responsible for integrity of research.UM did data collection and write manuscript.NA and YI did review and final approval of manuscript.