The loading content of nZVI in the filter paper reached 24.8%. The fabricated composite FP/PAA/nZVI was characterized by SEM, FT-IR and TGA respectively. Moreover, it was used for the removal of methyl blue and methylene blue as model anionic and cationic dyes. The effect of initial dye concentration on decolorization efficiency was investigated. The results showed that FP/PAA/nZVI enhanced the removal of dye from the simulated dye wastewater and the decolorization efficiency exceeded 95% for the dye solutions lower than 20 mg/L. More importantly, the filter paper supported nZVI realized the continuous treatment of simulated dye wastewater by a simple filtration process. This study hopes to serve as a basis for the application of nZVI in textile wastewater treatment.In this study, polyacrylic acid modified filter paper (FP/PAA) was synthesized by  However, the limitations of the respective methods restrict their application, i.e. flocculation and fenton oxidation produce sludge, photochemical forms by-products, electrochemical oxidation involves high cost of electricity and electrolytic precipitation needs long time11. Moreover, dye wastewater needs effective treatment to achieve complete mineralization, which is not possible with the available methods12. In recent years, the application of nanotechnology in environmental remediation has drawn the attention of researchers. Mohamed et al. investigated the adsorption of methyl green using multi-walled carbon nanotubes13. Liu et al. used 3D graphene to remove water-soluble dye14. Wang et al. reported the adsorption of azo dye on nanodiamond15. In addition, nano-titanium dioxide (nano-TiO2), nano-zinc oxide (nano-ZnO), nano-magnesium oxide (nano-MgO) and nano-scale zero valent iron (nZVI) were also studied for dye removal, respectively17. Compared to other nano-materials, nZVI is inexpensive, easy to prepare, has high reactivity and less toxic effect on humans18, and have received more focus in recent year. The application of nZVI in removing various contaminants, including nitrates, phenols, heavy metals and pesticides, had been reviewed by references20. However, nZVI easily aggregate, has rapid sedimentation and oxophilicity due to its magnetism and small size effect22, which leads to the decrease in the activity of nZVI, resulting in a decrease in the degradation rate of contaminants. Much effort has been made by researchers to solve these problems. Some studies used surfactants and coatings to stabilize nZVI via steric hindrance and electrostatic repulsion, such as sodium oleate and sodium dodecyl sulfate23, Tween and cetyltrimethylammonium bromide24, polyethylene glycol and polytetrahydrofuran25, rhamnolipid and carboxymethyl cellulose26. Other studies employed host materials to immobilize nZVI. The reported host materials included PAN28, cellulose29, calcium alginate31, modified clays33, clinoptilolite34, mesoporous molecular sieves35, and porous polymers36.In the textile dyeing industry, untreated dye wastewater undoubtedly causes serious environmental problems and deteriorates groundwater quality, which is associated with the health of human and other creatures. Thus, it is necessary to remove the dye from wastewater before they are discharged into the environment. In previous literatures, some methods, including flocculation37, copper nanoparticle38, gold nanoparticle39, titanium dioxide particle40 and nZVI41 had been fabricated for water treatment, dye removal, reaction monitoring and water-oil separation, respectively. However, all of them are intermittent and discontinuous. There are no reports about the continuous treatment of pollutions. In this study, nZVI was embedded in polyacrylic acid modified FP (FP/PAA) by a simple procedure and was proposed for dye (including methyl blue and methylene blue) decoloration. The introduction of PAA caused the ferric ion to be firmly anchored in FP. The study investigated the properties of the fabricated FP/PAA/nZVI and its effectiveness on targeted pollutants. Most importantly, the study realized the consecutive treatment of dyeing wastewater and is valuable for industrial application.Among all the reported stabilizers, cellulose-based materials were regarded as the best for their low cost, biodegradability and are environmentally benignant. Filter paper (FP), a common laboratory consumable, is composed of oxygen rich cellulose fibers with pores. The architectural structure of FP offers many anchoring sites and inner cavities for trapping nanoparticles. FP embedded with silver nanoparticle4)2S2O8, APS), Acrylic acid (AA), ethylene glycol (EG), Ferrous sulfate heptahydrate (FeSO4·7H2O) and Potassium borohydride (KBH4) were supplied by Sinopharm Chemical Reagent Co., Ltd. . Methyl blue (M100199-25 g) and Methylene blue (M134389-25 g) were supplied by Aladdin . All the reagents were used as received without further purification.Whatman qualitative filter paper with diameter 9 cm (525.4 ± 8 mg/piece) was purchased from General Electric Healthcare Company . Ammonium persulfate  via an in-situ polymerization of AA, which produced the carboxylic acid groups and chelates the ferric ion. The solution used for modification was prepared by mixing AA(86.0 g), APS (2.0 g), EG (6.4 g) and deionized water (105.6 g) in 500 ml beaker. FP was immersed in the solution for 20 mins and dried afterward in a vacuum oven at 60 °C for 5 h. APS initiates AA in a polymerization process and EG crosslinks PAA chains to form a stable 3D network structure. The modified FP was thoroughly washed with deionized water to remove unreacted monomers and non-anchored PAA polymers. The obtained FP samples were named as FP/PAA and its weight was increased by 38 mg compared with the original FP. Dried FP/PAA was soaked in 200 ml of 0.2 M FeSO4 solution for 12 h to chelate Fe2+ and rinsed with deionized water several times, followed by drying in a vacuum oven. The trapped Fe2+/ Fe3+ FP were reduced with 0.5 M KBH4 solution which resulted in the functional FP/PAA/nZVI. The resulting FP/PAA/nZVI was washed, vacuum dried and stored in a desiccator before characterization and decoloration experiments. The loaded nZVI is 185.8 mg, which is about 24.8% of the total weight of FP/PAA/nZVI.In accordance with the referenceMorphology of the FP samples were observed with S-4800 field emission scanning electron microscope  with an operating voltage of 5 kV. Fourier transform infrared spectra were obtained with Nicolet iS10 FT-IR  with attenuated total reflection (ATR) accessory. Thermal stability was recorded with 1100SF TGA  in a flowing nitrogen atmosphere between 50 and 750 °C at a heating rate of 10 °C/min.C0 is the initial concentration of SDW, Ct is the SDW concentration at time t.Methyl blue and methylene blue were selected to prepare the simulated dyeing wastewater (SDW). Decoloration experiments were conducted under room temperature in 500 ml beaker containing 200 ml SDW with different initial concentrations . A piece of FP/PAA/nZVI  was totally immersed in the beaker to initiate the reaction. The reactor was sealed with a plastic wrap and stirred under 200 rpm. At a certain time interval, 5 ml SDW was taken to analyze the absorbance using TU-1901 ultraviolet visible spectrophotometer  at maximum absorption wavelengths, which are 600 and 660 nm for methyl blue and methylene blue respectively. Moreover, the decoloration efficiency was calculated according to the following equation.27. That is because PAN membrane is hydrophobic. Although it was functionalized by hydrophilic modification, this modification is superficial and cannot penetrate the PAN matrix. This led to AA polymerization on the surface of PAN, resulting in PAA as a coating on the membrane. In this study, filter paper was used as a matrix, which is hydrophilic due to the hydroxyl groups and its porous structure. The AA aqueous solution can infiltrate the FP very well, resulting in a homogeneous FP/PAA matrix and surface, which is beneficial to the subsequent immobilization of nZVI. From the SEM image of FP/PAA/nZVI, it can be seen that a large amount of nZVI particles were anchored on the surface and embedded in the caves of FP. Which is ascribed to the strong chelation between -COOH of FP/PAA and ferric ion from FeSO4 solution. The nZVI particles presented a little aggregation, which resulted from the high loading of nZVI in FP/PAA/nZVI. According to the experiment section, the content of nZVI in FP/PAA/nZVI reached 24.8% (185.8 mg), which was determined by the weight method. Compared with other reports41, the loading content was very high. This ensued from the high concentration and large volume  of FeSO4 solution used to modify FP/PAA in the experiment. The loading content can be controlled by varying the concentration and volume of FeSO4 solution. Moreover, the high loading content guarantees an excellent decoloration efficiency for SDW.The surface morphology of FP, FP/PAA and FP/PAA/nZVI were observed with FESEM, as shown in Fig. −1, 2904 cm−1, 1636 cm−1 and 1032 cm−1, which are assigned to the -OH stretching, -CH2 stretching, H-O-H stretching and C-O, C-C stretching, respectively43, and are consistent with characteristic peaks for cellulose fibers. However, when PAA was incorporated into the FP matrix, the peak at 1636 cm−1 disappeared and a new peak at 1705 cm−1 appeared for FP/PAA, which is assigned to the asymmetric stretching of carboxyl groups28. This confirms that an abundant carboxylic acid groups were grafted onto the filter paper and FP was successfully functionalized by PAA, paving way for the next chelation of ferric ion. For FP/PAA/nZVI, the peak at 1705 cm−1 disappeared and a new peak at 1550 cm−1 appeared, which indicated the chelation between nZVI and carboxylic groups, confirming the loading of nZVI in FP/PAA matrix. It should be noted that, the chelation between nZVI and carboxyl is stronger than the general interaction between nanoparticles and matrix, which ensures the firm immobilization of nZVI in FP.To confirm the presences of carboxylic acid groups and chelation of ferric ion in FP matrix, FT-IR spectra of FP, FP/PAA and FP/PAA/nZVI were conducted. As shown in Fig. 45. Since the weight of nZVI was stable under nitrogen atmosphere during the TGA testing condition. The increase from 19.6% to 37.7% was mainly attributed to the development of nZVI on FP/PAA surface  of FP/PAA and nZVI in FP/PAA/nZVI, respectively. 19.6% and 37.7% refer to the weight remains of FP/PAA and FP/PAA/nZVI at 750 °C, respectively.TGA was used to determine the thermal stability of FP, FP/PAA and FP/PAA/nZVI, the results are shown in Fig. The result shows that, the weight content of nZVI in FP/PAA/nZVI is 22.5%, which is consistent with the result for weight method 24.8%. The results from SEM, FT-IR and TGA proved that nano iron particles were immobilized on PAA modified FP by chelation between nZVI and carboxylic groups.46. The decoloration mechanism is shown in Fig. Methyl blue and methylene blue solutions were selected as the simulated dyeing wastewater (SDW) to evaluate the decoloration efficiency of FP/PAA/nZVI. Figure in-situ polymerization of acrylic acid. nZVI was firmly chelated on the surface and internal of FP by carboxyl group from PAA. The loading content of nZVI in FP reached 24.8%. The preparation approach was simple and environmentally benignant. Most importantly, the fabricated FP/PAA/nZVI exhibited high activity towards the removal of methyl blue and methylene blue. The decoloration efficiency exceeded 95% for 20 mg/L simulated dye solutions after 60 minutes treatment. The decoloration was performed under a filtration process to realize the continuous treatment. We believe that this study paves way for the application of nZVI in the textile industry for the treatment of effluents.In this work, a common filter paper (FP) was modified by Video 1Video 2


Introduction: This study aimed to evaluate the combination effect of voluntary exercise and garlic on oxidative markers, cholesterol level and histological alterations in streptozotocin (STZ)- induced diabetes in rat heart.Methods: Thirty-five male Wistar rats were randomly assigned into five experimental groups (n=7): Control, Diabetes, Diabetes+Garlic, Diabetes+Exercise, Diabetes+Garlic+Exercise groups. Diabetes was induced by STZ  in animals. Animals received garlic homogenate (250 mg/kg) by oral gavage or subjected to voluntary exercise alone or together for 6 weeks. At the end of intervention blood and heart tissue samples were obtained and used for measurement of glycosylated haemoglobin (HbA1c), cholesterol, total antioxidant capacity (TAC), malondialdehyde (MDA) levels and histological analysis.Results: Improved blood glucose, cholesterol, total antioxidant capacity, and MDA levels were established in both Diabetes+Garlic and Diabetes+Exercise groups. Additionally, staining with Hematoxylin and Eosin (H&E) revealed that voluntary exercise and garlic alone and together reduced interstitial edema, leukocyte infiltration, and myonecrosis. Furthermore, simultaneous treatment of diabetic rats with garlic and exercise training had an additive effect on these parameters.Conclusion: The findings indicated that combination therapy with garlic and voluntary exercise may present more beneficial effects in heart histological remodeling in diabetic rats than the use of garlic or voluntary exercise alone and that these beneficial effects might be associated with enhancement in cholesterol, total antioxidant capacity, and MDA levels. These pathways are stimulated or increased in order to mitochondrial superoxide overproduction.6 Furthermore, free radical overload and formation of oxidative stress lead to antioxidant defense system attenuation in tissues during diabetes.8 Diabetes-induced oxidative damage in different organs including the cardiovascular system, as manifested by increased MDA and also decreased antioxidant enzymes activities.9 Exercise training has been reported to reverse oxidative stress and provide alleviating effects on hyperglycemia and hyperlipidemia in the cardiomyocytes.10 Recently, Dietary plants, identified from herbal medicine are providing an opportunity for the apperance of new types of therapeutics.11 Among them, garlic (Allium sativum) has been utilized in herbal medicine for its unique antioxidant and anti-inflammatory properties.11 Garlic may markedly modulate antioxidants status in the blood and heart of type 1diabetic rats.6 Although the combination effect of voluntary exercise and garlic in diabetic heart related to oxidative stress and lipid parameters have not been elucidated yet. According to above, in this study, we decided to evaluate the combination effect of garlic and voluntary exercise performance on histological parameters, cholesterol level and oxidative markers in the blood and heart of type 1 diabetic rats.Diabetes mellitus (DM) is associated with an increased risk of cardiovascular disease.6Male Wistar rats (200-250 g) were housed under controlled environmental conditions and maintained on a 12h light-dark cycle in an air-conditioned room and stable temperature (22±1℃) room with food and water provided ad libitum. Thirty-five animals were randomly assigned to five experimental groups (n = 7).Control: Animals that received 0.4 mL of sodium citrate buffer, pH 4.5.Diabetes: Animals that received a single dosage of 50 mg/kg of STZ intraperitoneally (i.p).12Diabetes + Garlic: STZ  was administered to animals by a single injection. After confirmation of diabetes, 250 mg/kg of homogenized garlic was fed by oral gavage 6 days a week for a period of 6 weeks.Diabetes+Exercise: STZ  was administered to animals by a single injection. After confirmation of diabetes, voluntary running wheel exercise was performed for the animals for 6 weeks.Diabetes+Garlic+Exercise: Diabetic rats that received garlic homogenate (250 mg/kg ) 6 days a week by gavage and performed voluntary exercise simultaneously for 6 weeks.12Diabetes was induced with a single injection of STZ (50 mg/kg)  intraperitoneally. STZ dissolved in 0.4 mL of sodium citrate buffer, pH 4.5. To confirm the induction of diabetes, 72 hours later after the STZ injection, blood glucose level was measured by a glucometer . The fasting glucose concentration of more than 300 mg/dL was considered diabetic.Allium sativum) bulbs were obtained from a local market. Cloves were peeled, cut off, blend by a mixing machine and form a paste, afterwards, suspended in distilled water. The garlic homogenate was provided freshly each day.12Garlic  and were subjected free access to the wheel 24 hours per day for 6 weeks. The wheels were attached to a permanent sensor for counting of revolutions. Running distance was monitored daily. If the running distance was less than 2000 m/d, that animal was excluded from the study. Control rats were kept in standard holding cages without running wheels during 6 weeks.14At the end of experiment, the animals were deeply anesthetized with pentobarbital sodium  . Then the thoracic cavity was disclosed and blood samples were obtained by syringes from the heart of anesthetized rats. Some blood centrifuged at 4000 ×g for 20 minutes immediately. The serum obtained and stored in tubes at −80°C for determination of cholesterol, TAC and MDA levels. Some blood as whole blood used for measuring HbA1c (glycosylated haemoglobin) level. Hearts were isolated, frozen in liquid nitrogen and stored at deep freeze (-70°C). For MDA estimation heart samples were homogenized in 1.15% KCl solution . The homogenates were centrifuged at 1000 rpm for 1 minute at 4°C, and then stored at −80°C for later measurements.14MDA as the end-product of lipid peroxidation was evaluated in the blood and tissue samples as described by the Esterbauer and Cheeseman method. Accordingly, MDA reacts with thiobarbituric acid , and the pink pigment was produced, that has a maximum absorption at 532 nm.+ production. Finally, at 600 nm a stable blue-green color was observed.13TAC was assessed by a Randox  total antioxidant kit. Accordingly, 2,2’-azino-bis(3-ethylbenzothiazoline-6-sulfanate) (ABTS) is incubated with peroxidase and H2O2 resulting in the radical cation ABTS Blood samples were obtained from the tip of tail and glucose levels were assesed by a digital glucometer .HbA1c was also evaluated in whole blood by immunoturbidimetry kit  according to manufacturer´s structure. Serum samples were evaluated for total cholesterol levels using an auto blood analyzer (Bayer Corp. USA). The related kit was purchased from Pars Azmoon CO, Iran.15To perform histopathological staining, heart tissues were immediately excised and fixed in 10% buffered-formalin solution. After dehydration in ascending grades of alcohol, tissues were embedded in paraffin. To evaluate interstitial edema, congestion, leukocytosis infiltration, and myonecrosis, H&E staining was applied. Sections of 5 μm were obtained, stained and evaluated under a light microscope  by a blinded pathologist. Histological changes were scored as follows: (-) none, (+) mild, (++) moderate, and (+++) severe damage.P < 0.05. Data are expressed as means ± SEM.Evaluating of Normality was checked by Kolmogorov-Smirnov test. Data were statistically evaluated by one-way analysis of variance (ANOVA) followed by Tukey’s test. The significant level was considered at P < 0.001) in the heart and serum of the diabetic group compared with the control group. However, 6 weeks treatment of the diabetic animals with garlic or exercise alone (P < 0.01) and in combination (P < 0.001) significantly decreased serum MDA level in comparison to the group with diabetes. Also garlic (P < 0.01) and exercise (P < 0.001) treatment and their combination (P < 0.001) in the diabetic heart reversed MDA level. Furthermore, in the diabetic animals, combination therapy with garlic and exercise had a signiﬁcant reduction in heart MDA compared to groups treated with garlic (P < 0.01) or exercise (P < 0.05) alone. In addition, we found that in the groups with garlic administration or exercise performance alone (P < 0.01) or together (P < 0.001) serum TAC level appeared to be signiﬁcantly higher than that in the diabetic group. Also, combination therapy of rats with garlic and exercise had a higher TAC level (P < 0.05) in the serum of diabetic rats compared with Diabetes+Exercise group.P < 0.001), Diabetes+Exercise (P < 0.01), and Diabetes+Garlic+Exercise (P < 0.001) groups than the diabetic group. Furthermore, simultaneous treatment of the diabetic group with garlic and exercise significantly decreased blood glucose level (P < 0.001) compared to the Diabetes+Garlic (P < 0.05) and Diabetes+Exercise (P < 0.01) groups. HbA1c level was also evaluated in all groups; it was significantly (P < 0.001) higher in diabetic rats compared to the control rats (P < 0.01) or in combination (P < 0.001) also significantly decreased HbA1C level in diabetic rats compared to the diabetes group. Total cholesterol level in the serum of diabetic group was significantly (P < 0.01) higher than in the control rats. Garlic (P < 0.05) and exercise training (P < 0.01) alone and together (P < 0.001) significantly reversed the increase in total cholesterol level in the serum of diabetic rats. Furthermore, simultaneous treatment with garlic and exercise in diabetic group significantly (P < 0.05) decreased cholesterol level compared to Diabetes+Exercise group  and result in scavenge the superoxide ions leading to cellular redox status balance.38 In addition, it was indicated that oxidative stress caused by the production of free radicals exacerbated by hypercholesterolemia may lead to endothelial dysfunction.39 Therefore we also measured cholesterol level in the serum of diabetic animals following garlic consumption and voluntary exercise performance. In general, blood lipid levels have an important role in preventing long-term complications of DM including atherosclerosis.40 The mechanism of lipid-lowering effect of garlic in part is inhibition of lipogenesis and stimulation of lipolysis in mature 3T3-L1 adipocytes.41 However, molecular mechanisms for the protective effect of combined garlic and voluntary exercise during diabetes is unclear and requires further investigation.The pathogenesis of diabetic cardiomyopathy which is a multifactorial process, includes metabolic disturbances including increased oxidative stress and modulated non-oxidative glucose pathways and lipid metabolism.In conclusion, this study demonstrated that garlic and voluntary exercise alone or together reduced blood glucose, HbA1c, cholesterol, lipid peroxidation marker and improved antioxidant defense system in rats with type 1 diabetes. In addition, combined treatment of garlic and voluntary exercise is more effective in controlling above mentioned parameters in diabetic animals. These findings briefly reported the benefits of combination effect of garlic and voluntary exercise on cholesterol, redox state, and glycemic parameters. Therefore, we confirmed the potential value of combination therapy in diabetic individuals.This study was agreed by the Ethics Committee on Animal Experiments of the Tabriz University of Medical Sciences under the protocol number 91.4-2.4.All authors declare no competing financial interests exist.This study was supported by a grant from the Drug Applied Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.


Children with Sickle Cell Disease (SCD) show endocrine complications and metabolic alterations. The physiopathology of these conditions is not completely understood: iron overload due to chronic transfusions, ischemic damage, and inflammatory state related to vaso-occlusive crises may be involved. Aims of this study were to evaluate the growth pattern, endocrine complications, and metabolic alterations and to detect the relationship between these conditions and the SCD severity in affected children and adolescents.Fifty-two children and adolescents with SCD  were recruited. Anthropometric  and laboratory  data were evaluated. The SCD severity was defined according to hematological and clinical parameters.Height-SDS adjusted for TH and BMI-SDS were significantly higher in HbSC children than in HbSS ones. Forty-eight out of 52 patients (92%) had at least one metabolic and/or endocrine alteration: insufficiency/deficiency of vitamin D (84.7%), insulin resistance (11.5%), growth hormone deficiency (3.8%), subclinical hypothyroidism (3.8%), and hypogonadism (1.9%). Levels of vitamin D were significantly and negatively correlated with clinical indicators of the SCD severity. Subjects with HbSS genotype show significant lower levels of both insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein 3 than children with HbSC. In the study population IGF-1 values were significantly and positively correlated with Hb and negatively with lactate dehydrogenase.Metabolic alterations and endocrine complications are very common in children and adolescents with SCD. A regular follow-up is necessary to identify subjects at risk for complications to precociously start an appropriate treatment and to improve the quality of life of SCD patients.The online version of this article (10.1186/s12887-019-1423-9) contains supplementary material, which is available to authorized users. Sickle cell disease (SCD) is an inherited disease due to a single-point mutation on the β-globin subunit of hemoglobin (Hb) determining polymerization of the mutant HbS and resulting in sickling of erythrocytes. It is characterized by a high clinical variability because of inflammation, hemolysis, and micro-vascular obstruction leading to unpredictable acute complications and chronic organ damage , 2. The In high-income countries the great and continuous rise of the SCD survival rate demonstrated in the last decades was mainly due to newborn screening programs –6, advan+ or healthy controls  were evaluated in all recruited subjects. Height and sitting height were measured to the nearest 0.1-cm with a wall-mounted stadiometer and stadiometer for sitting height , respectively. Body weight was measured to the nearest 0.1-kg. Arm span was represented by the distance, measured in cm, between the end of the third finger of the two hands and it was measured to the nearest 0.1-cm with a no extensible meter. We calculated: sitting height/height ratio, arm span/height ratio, and BMI (weight in kg/height in meters squared).Height-SDS and BMI-SDS were reported according to age- and sex- specific World Health Organization (WHO) growth chart 2007 . ParentaBlood and plasma samples were collected in all SCD children to measure: blood cell counts , lactate dehydrogenase (LDH) as hemolysis index, iron levels, metabolic and nutritional status indices , thyroid hormones [thyroid-stimulating hormone (TSH) and free thyroxine 4 (fT4) (fluorometric assay AutoDELFIA automatic immune assay system)], vitamin D , reproductive and growth function .Vitamin D insufficiency and deficiency were defined by 25-hydroxy-vitamin D levels between 10 and 30 ng/ml and < 10 ng/ml, respectively.Insulin resistance was estimated using the homeostasis model assessment (HOMA) model as fasting insulin (microU/L) x fasting glucose (mmol/L)/22.5. Insulin resistance was defined by HOMA-IR values of ≥3.16 in pubertal subjects and HOMA-IR of ≥2.67 in prepubertal ones , 18.Subclinical hypothyroidism was defined by normal FT4 values associated to TSH > 5 μIU/ml .Growth hormone (GH) deficiency (GHD) was diagnosed according to both specific anthropometric (height < − 3 SDS or height < − 2 SDS associated with height growth velocity < -1SDS) and biochemical parameters  .Hypergonadotropinic hypogonadism was defined by high serum gonadotropin concentrations in the absence of pubertal signs at the appropriate age for puberty .Ovarian insufficiency was defined in post pubertal female with secondary amenorrhea, high concentration of FSH and low anti-mullerian hormone (AMH) levels .The severity of SCD was evaluated according to the following indices: the average of total Hb and LDH (year 2016), the average number of hospitalizations and days of hospitalization (year 2016), the average number of hospitalizations of the last five years, and the total number of lifetime Acute Chest Syndrome (ACS) episodes.Descriptive data are reported as mean ± standard deviation (SD), number of observations, and percentages. Data were checked for normal distribution using the Kolmogorov-Smirnov test, so non-parametric statistical analysis  was performed.Subjects’ data were analyzed according to gender , SCD genotype (HbSC vs. HbSS), HDL-C levels (cut-off 40 mg/dl), and HU treatment (HU > 1 year vs. HU < 1 year).U-test. Spearman correlation was used to evaluate correlations between clinical, anthropometric, and biochemical parameters.Between-group comparisons were performed using the Mann-Whitney p < 0.05.For each test, statistical significance was considered for This study reports data from 52 children and adolescents  with SCD having mean age of 11.1 ± 4.6 years. Thirty-eight subjects (73%) presented HbSS genotype while others were HbSC. Among our population, 50% of patients was pubertal; 9 out of 23 female had menarche (average age of menarche 12.8 years). Analyzing patients according to the genotype (HbSS and HbSC), 42% of subjects with HbSS and 70% of subjects with HbSC were pubertal.HbSS showed lower level of Hb and higher level of HbS %, WBC, PTL, LDH, and bilirubin than HbSC ones Table .Table 1Lp = 0.027) and BMI-SDS  despite chronological age was not different , average number of days of hospital admissions/2016 , and average number of ACS .Height-SDS adjusted for TH was significantly and negatively correlated with clinical severity parameters such as number of hospital admissions/2016 (Spearman R = − 0.31 p = 0.008) and sitting height/height ratio   showed height-SDS < − 2 SDS and 9.6% (5/52) showed BMI-SDS < − 2 SDS. Patients on treatment with HU for more than one year  respect to those on HU for less time had lower values of BMI-SDS  , 6 (11.5%), and 1 (1.9%) presented respectively one, two, and three alterations at the same time. The most detected conditions were the vitamin D insufficiency/deficiency (84.7%), the insulin resistance (11.5%), and to a lesser extent the GHD 3.8%), the subclinical hypothyroidism (3.8%), and the hypergonadotropic hypogonadism (1.9%) , average number of days of hospital admissions/2016  and average number of hospital admissions in the last 5 years .In particular, in 63.5% of patients vitamin D levels were between 10 and 30 ng/ml while in 21.2% were < 10 ng/ml. We found a significant negative relationship between plasmatic levels of vitamin D and clinical severity of the disease, represented by number of hospital admissions/2016 (Spearman R = − 0.29 p = 0.044). The mean values of HDL-C were correlated with neutrophils , LDH , and serum ferritin   with HbSS genotype, who have been started human recombinant GH replacement therapy.p < 0.001) and IGFBP-3   and LDH levels  .p = 0.029). No correlation between IGF-1, IGFBP-3, TSH, fT4, testosterone, estradiol, LH, FSH levels and ferritin values [both as a relative value at the time of enrollment and as the average value of the last two years (2015–2017)] were identified in our population both in prepubertal and in pubertal patients.The mean values of testosterone in our males were also positively correlated with the mean values of Hb  of endocrine complications and metabolic alterations in the pediatric SCD population, mainly represented by vitamin D insufficiency or deficiency, insulin resistance, and to a lesser extent GHD, subclinical hypothyroidism, and hypogonadism. In literature, it is really difficult to understand the cumulative incidence of these disorders in subjects with SCD because of published studies evaluated mainly one single endocrine alteration. Specifically, growth impairment and delayed puberty are the most frequent disorders observed among SCD pediatric patients , 11.Özen et al. reported that 50% of the examined population show endocrine disorders mainly represented, as in our study, by insufficiency/deficiency of vitamin D and to a lesser degree of osteopenia, hypoplasia/testicular atrophy, hypogonadism, hypothyroidism, and insulin resistance [sistance .Özen et al. [In our study the prevalence of endocrine complications was even higher that those reported by n et al. , but it It has been demonstrated that children with SCD had a poorer growth compared to matched healthy subjects . Near twThe underline mechanism on growth delay in SCD is very complex and probably influenced by many variables, such as hematologic and cardiovascular status, socio-economic factors, endocrine function, metabolic function and nutritional status .It has been shown that the mean height SDS of children with SCD is comparable to those of children with constitutional growth delay but it is higher than those of children with GHD , 27. In According to the therapeutic regimen, significant differences were found with respect to BMI-SDS and sitting height/height ratio. Although not expected, patients treated with HU for more than one year had lower BMI-SDS and sitting height/height ratio. The reason of these findings is likely related to the more severe phenotype of patients treated with HU for more than a year. In fact, in our opinion, the disease severity could influence these anthropometric parameters. However, it would be important to continue these evaluations in order to assess whether treated patients may have an improvement in growth parameters over time by a reduction in clinical severity. In fact, the prospective use of HU can both improve clinical outcome of the disease and also positively influence growth and development, reducing the risk of iron overload due to the chronic transfusion regimen.Our data showed significant correlations between clinical parameters of disease severity and anthropometric parameters: children with better control of the disease  had higher values of height-SDS adjusted for TH. Subjects with HbSS genotype showed a negative correlation between the number of ACS and the values of height-SDS adjusted for TH. A good clinical control of the disease seems not only to affect the survival but also to reduce the long-term comorbidity.Buison et al., 65% of children with SCD had levels of vitamin D lower than those of healthy children [Jackson et al [Garrido et al. [In our SCD population, vitamin D insufficiency was demonstrated in 63.5% while 21.2% had a deficient level. In a study conducted by children . Jacksonon et al  reportedo et al.  report tThe vitamin D metabolism is complex because of the involvement of different organ including skin, intestines, liver, kidney, and parathyroid . PatientThe different prevalence of vitamin D deficiency/insufficiency demonstrated between African Americans and Caucasians populations can be explained by the decreased synthesis of vitamin D in the skin  and diffIn our population, vitamin D levels showed an inverse and statistically significant correlation with the number of admissions and hospitalizations in 2016 and the average number of admissions in the last 5 years, suggesting that this deficit could adversely affects the clinical severity of the disease.p < 0.05) to neutrophils percentage, LDH and ferritin values, particularly in subjects with HbSS genotype. Seixas et al. [It was hypothesized that inadequate levels of vitamin D could be linked to a condition of chronic inflammation, as well as low levels of HDL-C . This fis et al.  found a The 3.8% of our population showed GHD. An impairment of the GH-IGF1-IGFBP3 axis was demonstrated in SCD subjects , 39. ChiFung et al. [In our population 11.5% of patients had pathological HOMA index. In literature there is evidence of insulin resistance among patients with SCD . A multig et al.  revealedg et al. . HoweverWe found a case of hypergonadotropic hypogonadism and one case of ovarian failure in HbSS genotype group. The etiology of hypogonadism in SCD is not fully understood yet: in some cases, primitive gonadal failure is related to structural anomalies, resulting from chronic tissue damage associated with chronic anemia condition and local vaso-occlusive crises . AccordiThis study has some important limitations. This is a single center study with a small sample size. Secondly there are some confounders factors . The main outcome of this study was to report clinical features of our patients, in a cross sectional way, to better understand the actual prevalence of both metabolic alterations and endocrine complications. Surely, a longitudinal study design of these parameters will provide us more information on the natural history of these complications in SCD. However, it must be considered that in our country SCD is a rare disease and, at the best of our knowledge, this is the first Italian study on these topics. In literature there are very little data available on these condition in pediatric patients with SCD mainly in European Countries. We think that it is important to evaluate these conditions in different environmental setting.Subjects with SCD show a high prevalence of metabolic alterations and endocrine complications. However, our results suggest that through the achievement of a good clinical control the SCD patients can obtain a positive impact on growth, metabolic and endocrine function.Consequently, it is crucial to perform periodic anthropometric and endocrine evaluations, especially during puberty, and to have a comprehensive approach to this disease in order to reduce its long-term complications.Additional file 1:Table S1. Anthropometric parameters in males and females. (DOCX 30 kb)


Allergic rhinitis (AR) is characterized by tissue and blood eosinophilia. Previous studies showed enhanced eosinophilia in allergic rhinitis patients with obesity, suggesting an association between obesity and eosinophilia. However, the interaction and mechanism between obesity and eosinophilia is still unclear.  We recruited thirty AR children and 30 controls in this study. Expression of leptin and osteopontin (OPN) proteins in serum was detected, and correlation analysis with eosinophilia was performed. The effect of leptin or OPN on eosinophil apoptosis, adhesion, migration, and activation of eosinophil was examined. Ovalbumin-sensitized mice were established to prove the role of obesity on eosinophil regulation by leptin and OPN. P < 0.05). Leptin and OPN promote expression of cluster of differentiation 18 (CD-18) and intercellular adhesion molecule 1 (ICAM-1) and inhibit expression of ICAM-1 and L-selectin by eosinophils, which contribute to the adhesion of eosinophils. Leptin and OPN mediated migration and activation of eosinophil through phosphatidylinositol-3-OH kinase (PI3K) pathway. Obese AR mice presented with more severe eosinophilia and symptoms compared with nonobese AR mice or control mice. Immunochemistry staining of leptin and OPN of nasal turbinate in obese AR mice was also stronger than those in nonobese AR mice or control mice. Anti-OPN, anti-leptin, and anti-α4 treatments reduce nasal eosinophilia inflammation and clinical symptoms in model mice.  We found that upregulated serum and nasal leptin and OPN expression in AR were positively correlated with eosinophilia and eosinophil cationic protein levels. Leptin or OPN inhibited eosinophil apoptosis, demonstrated as inhibited DNA fragmentation and phosphatidylserine (PS) redistribution (α4 pathways. Our results suggested that in an obese state, upregulation of leptin and OPN regulates apoptosis, adhesion, migration, and activation of eosinophils, and this process may be mediated by the PI3K and anti- Tissue and blood eosinophilia is a common feature in allergic airway diseases such as allergic rhinitis (AR), nasal polyposis, and bronchial asthma . DelayedLeptin, an adipokine of the obesity (ob) gene, has been shown to regulate food intake and energy expenditure via a hypothalamic-mediated effect , 8. Leptα4β1 integrin binding [Osteopontin (OPN) is an extracellular matrix protein with a wide range of functions. It contains arginine-glycine-aspartate (RGD) and SVVYGLR domains that bind various integrins and promote adhesion and migration of inflammatory cells , 15. Ost binding .In view of the similar roles of OPN and leptin in the regulation of eosinophil, we postulated that there may be an interplay between OPN and leptin in AR. In this study, we aimed to explore the correlation between leptin and OPN in eosinophilia of AR children with obesity.We recruited thirty AR children (5–10 years old) from the Department of Otolaryngology, Guangzhou Women and Children's Medical Center, from January 2016 to October 2016. Local ethics committee boards approved the study and informed consent was signed by the parents. Perennial AR was diagnosed according to disease history, nasal examination, and specific IgE values according to the Allergic Rhinitis and its Impact on Asthma (ARIA) guideline (2010) . The comChildren with other allergic diseases , purulent nasal infection, any infection within the past 2 weeks, and recent use of drugs  were excluded from this study.Body weight and height were measured using an electronic weighing scale, and body mass index (BMI) was calculated. BMIs greater than the 95th percentile were considered as obesity according to a local population survey .Nasal symptoms including sneezing, rhinorrhea, itchy nose, and nasal congestion were recorded and assessed as follows: 0, none; 1 point, mild; 2 points, moderate; and 3 points, severe. The total nasal symptom score (TNSS) was calculated accordingly. The nasal symptoms were averaged in an 8-week observation period.Fasting venous blood samples were collected between 6 am and 8 am. The samples were centrifuged at 1000g for 15 minutes at 4°C and stored at −80°C for further measurement.The serum levels of leptin and OPN were measured in duplicate and averaged using ELISA kits  according to the manufacturer's instructions. Total serum IgE level was tested by an ELX-800 system. ECP level was detected using Unicap system . The detection limits of the assays were as follows: leptin (22 pg/mL), OPN (312.5 pg/mL), and ECP (2.0 ng/mL). Results were from three independent experiments.Human eosinophils were purified from the venous blood of children by MACS-negative immunomagnetic isolation kit  according to the instructions provided by the manufacturer. The purity of eosinophils was 98–100% (Giemsa staining) and the viability was larger than 98% (Trypan blue staining). The isolated eosinophils were cultured in RPMI 1640 medium supplemented with 10% FBS and 20 mM HEPES .μg/mL propidium iodide, 0.1% sodium citrate, 0.1% Triton X-100) for 10 hours in the dark at 4°C. Then, the relative amounts of apoptotic eosinophils were determined by discrimination of hypodiploid and diploid cells through flow cytometry. PS appears on the external leaflet in apoptotic cells, and Annexin V is a PS-binding protein used for detecting apoptotic cells. Therefore, a commercial apoptosis detection kit  was used for evaluating the appearance of PS assessed by flow cytometry. All results were from three independent experiments.Eosinophil death was assessed based on uptake of 1 mM ethidium bromide and flow cytometric analysis  described as previously . DNA fraμL of fibronectin overnight at 4°C. The eosinophil suspension was then incubated for 30 minutes at 37°C (5% CO2) with different concentration of leptin or OPN. After incubation of treated cells, the nonadhered cells were removed, and the remaining cells were washed twice with PBS. The eosinophil adhesion was calculated by measuring the residual eosinophil peroxidase (EPO) activity of adherent cells as described previously [2SO4, the absorbance was determined at 490 nm in a microplate reader . The adherence was calculated by comparing the absorbance of the samples to standard curve. Expression of surface adhesion molecule was analyzed using flow cytometry as median fluorescence intensity (MFI). Results were from three independent experiments.In the adhesion assay, 96-well plates  were prepared by coating individual wells with 60 eviously . In brieμg/mL), leptin , or inhibitors were incubated with eosinophil (105/mL) treated with or without anti-OPN antibody  in 24-well transwell system. Recombinant eotaxin (R&D systems) was used as positive control of chemotaxis analysis. After incubation, the number of migrated cells was determined by Giemsa staining. Migrated cells were counted in 10 fields using light microscopy at a magnification of 400x. ECP level in the supernatant was measured using the Unicap system. Results were from three independent experiments.Different concentrations of recombinant OPN  or a high-fat diet (HFD)  for ten weeks. The mice were randomly grouped as control (10 mice), OVA (10 mice), OVA + obese (10 mice), and intervention groups (20 mice).3 in 0.9% NaCl subcutaneously. On day 7, a second subcutaneous injection of 100 mg OVA was given. The control mice received only a subcutaneous injection of Al(OH)3. From day 14 to day 18, the mice were challenged nasally by the administration of 10 mg of OVA in 40 mL of PBS (20 mL per nostril) or saline for controls. The mice were anaesthetized and exsanguinated one day after the final challenge, and the peripheral blood was obtained from the abdominal vena cava. Serum total cholesterol (TC), high-density lipoprotein (HDL), and triglycerides (TGs) were tested using commercially available kits. Epididymal fat mass was weighed and nasal turbinate were sampled for morphological study. Nasal symptoms were evaluated by counting the frequency of nasal rubbing and sneezing during a 15-minute observation period.On day 0, all the mice were injected with 100 mg (0.4 mL) of ovalbumin (OVA)  mixed with 1.6 mg Al(OH)μg of recombinant mouse anti-leptin, anti-OPN protein, or anti-α4 integrin  in 40 mL of PBS was given intranasally 2 hours before each OVA challenge in different subgroups, respectively.The 100 μm) were prepared through deparaffinization xylene and rehydration alcohol. After incubation with 0.3% H2O2 and pretreated by autoclave heating in citrate buffer (pH 6.0) for 20 minutes, the haematoxylin–eosin (HE) staining was performed. For immunohistochemistry (IHC), the section was treated with rabbit polyclonal antibody against OPN  (1 : 200) or rabbit polyclonal antibody against leptin  overnight at 4°C. Twenty-four hours later, the sections were incubated with secondary biotinylated goat anti-mouse/rabbit IgG antibody and then with avidin-peroxidase complex. Isotype-matched IgG was selected as negative control.Nasal turbinate sections . The AR children with obesity had higher TNSS score compared with AR children without obesity. Our data indicated that serum leptin and OPN levels were significantly higher in AR children compared with controls, especially in obese children (P < 0.05)  and ECP concentration  in AR children, suggesting that leptin and OPN levels may be involved in eosinophil infiltration and activation  . The uprtivation .Leptin and OPN delayed spontaneous eosinophil death in a dose-dependent manner  similar Leptin and OPN also promote eosinophil adhesion to human fibronectin , and thein vitro. We found that leptin and OPN significantly enhanced eosinophil chemotaxis, as well as activated eosinophils as indicated by increased ECP level, especially when the two were given together .HE staining indicated that the number of eosinophils in the nasal mucosa of OVA-challenged obese mice was significantly higher than that of OVA-challenged nonobese and control mice  in obese AR mice was significantly higher than that of nonobese AR mice and normal controls  of eosinophil inflammation compared with nonobese children with AR or controls, suggesting that obesity may be involved in the regulation of eosinophil through leptin and OPN. Leptin is one of the energy-regulating hormones, and serum leptin is positively correlated with body fat mass. Our and previous studies had proved that both leptin and OPN are upregulated during AR and involved in Th2 response. Moreover, it has been reported that serum OPN levels are correlated with obese state and may be reduced by loss of fat mass. Therefore, the elevated level of leptin and OPN in our study was consistent with previous reports –23.in vitro experiments using purified eosinophils. Our data showed that leptin and OPN delayed spontaneous eosinophil death in a dose-dependent manner, which is consistent with Conus et al.'s study [Next, we performed 's study . We alsoAs for adhesion to fibronectin, our results showed that leptin and OPN promoted adhesion synergistically and either anti-leptin or anti-OPN can block the adhesion. The interaction of ICAM-1 and integrins has been shown to be essential for the recruitment and trans-endothelial migration of eosinophils . The uprα4 integrin expressed on the surface of eosinophils [In eosinophil migration assay, we found that both leptin and OPN may promote migration of eosinophils, which was similar to that of eotaxin. Our results suggested that eosinophils preincubated with leptin and/or OPN showed significantly enhanced eosinophil chemotaxis and activation through PI3K pathway, manifested as eosinophil migration and upregulation of ECP. Consistently, Wong et al.  also fouinophils , 29. Theα4 integrin has been demonstrated to be highly expressed on eosinophils and primarily responsible for eosinophil trafficking in the airways, reduced nasal inflammation by blockade of α4 integrin suggested that leptin and OPN may mediate eosinophil inflammation through α4 integrin receptor on OPN [α4 integrin antibody on the development of allergic airway inflammation have been reported in an animal model [In the mice model, we found that enhanced eosinophil inflammation and disease severity in obese-OVA mice compared with OVA and control mice. The local expression of leptin/OPN by nasal tissues in obese-OVA mice was also significantly higher compared with that in OVA and control mice. Since the r on OPN . Similaral model , 32, andα4 pathways. Future studies were needed to prove the detailed interaction between leptin and OPN under obese and allergic state.In summary, our results confirmed that upregulation of leptin and OPN in AR regulates apoptosis, adhesion, migration, and activation of eosinophils, which is mediated by the PI3K and anti-


Multivariate forward linear regression analysis showed that EMAT/LVST before HD was negatively associated with albumin  and ABI  and positively associated with bPEP/bET . Screening HD patients with acoustic cardiography may help to identify patients at a high risk of malnutrition, peripheral artery disease, and left ventricular systolic dysfunction.Patients with end-stage renal disease are at an increased risk of cardiovascular diseases and associated mortality. Acoustic cardiography is a technique in which cardiac acoustic data is synchronized with electric information to detect and characterize heart sounds and detect heart failure early. The aim of this study was to investigate acoustic cardiographic parameters before and after hemodialysis (HD) and their correlations with ankle-brachial index (ABI), brachial-ankle pulse wave velocity (baPWV), and ratio of brachial preejection period to ejection time (bPEP/bET) obtained from an ABI-form device in HD patients. This study enrolled 162 HD patients between October 2016 and April 2018. Demographic, medical, and laboratory data were collected. Acoustic cardiography was performed before and after HD to assess parameters including third heart sound (S3), fourth heart sound (S4), systolic dysfunction index (SDI), electromechanical activation time (EMAT), and left ventricular systolic time (LVST). The mean age of the enrolled patients was 60.4 ± 10.9 years, and 86 (53.1%) patients were male. S4 ( End-stage renal disease (ESRD) is a serious health care issue, and patients with ESRD are at an increased risk of cardiovascular disease and mortality , 2. In aLeft ventricular (LV) dysfunction is highly prevalent in ESRD patients, and LV dysfunction is an important factor predisposing ESRD patients to sudden death –7. LV ejThe third heart sound (S3) is caused by an abrupt limitation of LV inflow during early diastole that causes vibration of the cardiohemic system . The abnArterial stiffness, peripheral artery disease (PAD), and LV systolic dysfunction are known to contribute to LV hypertrophy and cardiovascular risks –30. The The timely identification and treatment of hemodialysis (HD) patients with LV dysfunction may improve the prognosis of ESRD. To the best of our knowledge, acoustic cardiography has not been previously investigated in HD patients. Moreover, no previous study has investigated changes in acoustic cardiographic markers before and after HD. Therefore, the aim of this study was to investigate acoustic cardiographic parameters in HD patients before and after HD and correlations between ABI, baPWV, and bPEP/bET obtained from an ABI-form device in HD patients.We performed this study at the Dialysis Unit of Kaohsiung Medical University Hospital (KMUH), a regional hospital in the south part of Taiwan, from October 2016 to April 2018, and included patients who received HD treatment three times per week, with each session lasting 3.5 to 4 hours. The blood flow rate of the dialyzer ranged from 250 to 300 mL/min with a dialysate flow rate of 500 mL/min. In total, we enrolled 162 maintenance HD patients into this study. This study was approved by the Institutional Review Board of KMUH, and all of the patients provided informed consent.We obtained data on sex, age, current smoking status, and comorbidities from interviews and medical records. Blood samples were collected following overnight fasting and within 1 month of study enrollment to measure various biomarkers including albumin, fasting glucose, triglycerides, total cholesterol, hemoglobin, creatinine, total calcium, phosphorus, and uric acid. The ultrafiltration rate was defined as the ultrafiltration/body weight, and the efficiency of dialysis was determined by Kt/V according to the Daugirdas method .The detailed methods have been described in previous studies –38. In bElectromechanical activation time (EMAT) and %EMAT—the time from the Q wave onset to the mitral component of the first heart sound (S1): EMAT represented the time required for the left ventricle to generate sufficient force to close the mitral valve. Percent EMAT (%EMAT) was computed as the EMAT divided by the dominant R-R intervalLV systolic time (LVST) and %LVST—the time from S1 to S2: percent LVST (%LVST) was computed as the LVST divided by the dominant R-R intervalThe third heart sound (S3)—the probability that S3 exists: one value between 0 and 10 was reported, and a value ≥ 5 was used to define the presence of S3The fourth heart sound (S4)—similar to S3: one value from 0 to 10 was reported, with a value ≥ 5 defining the presence of S4Systolic dysfunction index (SDI): SDI was derived from the nonlinear transformation of [(S3 score ÷ 10) × QRS duration × QR interval × %EMAT] and mapped onto a scale of 0 to 10Each patient received the acoustic cardiographic examination in the supine position 30 minutes before HD and 30 minutes after HD. Acoustic cardiographic data and ABI were measured in the same month. Acoustic cardiographic sensors were placed two sensors on the V3 and V4 positions of the chest. Two standard electrodes were attached on the limb which leads the position of standard electrocardiography. Acoustic cardiographic data were transferred to an AUDICOR® system , on which heart sounds and related systolic time intervals were analyzed. The following acoustic cardiographic parameters were measured in this study , 40:Elet-test for continuous variables with approximately normal distribution, and the Mann-Whitney U test for continuous variables with skewed distribution. The paired t-test was used to compare acoustic cardiographic parameters before and after HD. Multiple forward linear regression analysis was used to identify the factors associated with EMAT/LVST, EMAT, and LVST before HD. Forward selection involves starting with no variables in the model, testing the addition of each variable using a chosen model fit criterion, adding the variable (if any) whose inclusion gives the most statistically significant improvement of the fit, and repeating this process until none improves the model to a statistically significant extent. A difference was considered significant if the p value was less than 0.05. Statistical analyses were performed using SPSS 18.0 for Windows .Data are expressed as percentages and mean ± standard deviation for acoustic cardiographic parameters and median (25th–75th percentile) for triglyceride level and dialysis duration. All of the patients were classified into two groups by a median EMAT/LVST value. Differences between groups were assessed using the chi-square test for categorical variables, the independent n = 81) or >0.27 . A comparison of the clinical characteristics between the study groups is shown in The mean age of the 162 HD patients included in this study was 60.4 ± 10.9 years, and 86 (53.1%) were male. The median EMAT/LVST value was 0.27, and the patients were stratified into two groups according to whether their EMAT/LVST value was ≤0.27  and LVST (ms and %) (p < 0.001) significantly decreased after HD; however, EMAT (p < 0.001) significantly increased after HD in all patients. In group 2, S4, the prevalence of S4 ≥ 5, and LVST (%) (p < 0.001) significantly decreased after HD; however, there was no difference in SDI after HD. In group 1, S4 and LVST (ms and %) significantly decreased after HD (p < 0.001); however, EMAT (ms and %) significantly increased after HD (p < 0.001). S3 and the proportion of S3 ≥ 5 had the statistical tendency to decrease after HD, but they did not achieve significance.Changes in acoustic cardiographic parameters before and after HD are shown in β) of EMAT/LVST before HD after adjusting for age, sex, smoking habit, a history of diabetes, hypertension, coronary artery disease, cerebrovascular disease, systolic blood pressure, diastolic blood pressure, body mass index, ABI, baPWV, bPEP/bET, duration of HD, albumin, fasting glucose, triglycerides, total cholesterol, hemoglobin, creatinine, calcium-phosphorous product, uric acid, Kt/V, and ultrafiltration percent. In forward multivariate analysis, EMAT/LVST before HD was negatively associated with serum albumin level  and ABI  and positively associated with bPEP/ET . EMAT was negatively associated with serum albumin level  and positively associated with bPEP/bET . LVST was positively associated with ABI  and negatively associated with bPEP/bET . Because the baPWV was frequently underestimated and also deteriorated by PAD in the hemodialysis population [β = ‐0.042, p = 0.095) and creatinine  and positively associated with bPEP/ET  and BMI . EMAT was negatively associated with serum albumin level  and positively associated with bPEP/bET . LVST was negatively associated with bPEP/bET , BMI , and duration of HD .pulation , we analThis is the first study to assess HD patients before and after HD using acoustic cardiography. Our results showed that S4 and LVST decreased after HD and EMAT increased after HD. In addition, high EMAT/LVST was associated with low albumin, low ABI, and high bPEP/bET, which indicated malnutrition, PAD, and LV dysfunction, respectively.The advantages of acoustic cardiography include the relatively low cost, noninvasiveness, and ease of use and the ability to recognize LV dysfunction early in HD patients. Moreover, acoustic cardiography is available at the bedside, and cardiographic data of LV function can be obtained faster than with other traditional examination methods. Previous studies have indicated that S3 score can be used in combination with B-type natriuretic peptide to increase the diagnostic accuracy of heart failure , 43. In p = 0.02), whereas in patients with a baseline dP/dt > 1500 mmHg/sec, EMAT increased from 88 ± 13 ms to 93 ± 16 ms (p = 0.02). These data show an increase in EMAT in the patients whose baseline dP/dt was abnormally low. A directionally opposite change occurred in the patients with a normal baseline dP/dt, probably because of the negative inotropic effect of iopromide, which may also partially explain the opposite finding of EMAT after HD [This study investigated changes in acoustic cardiographic markers before and after HD. Shah et al. suggested an association between the strength of S4 and LV stiffness . We founafter HD . We propLeft ventricular systolic dysfunction leads to heart failure and increased morbidity and mortality in ESRD patients , 50. PreHD patients tend to develop structural and functional heart abnormalities due to complex pathophysiological mechanisms . A long-Another important finding of this study is that a high EMAT/LVST ratio was associated with a high bPEP/bET. Increased PEP and shortened ET have been associated with impaired LV systolic function , 60, andThere are several limitations to this study. First, due to the cross-sectional nature of the study, we could not confirm causal relationships. Further prospective studies are needed to verify our findings. Second, the number of patients in this study was relatively small. Third, the quality of acoustic cardiography data is influenced by exogenous and endogenous noises. Fourth, the patients' acoustic cardiographic parameters were measured only before and after HD, and repeated measurement may be necessary. Fifth, we did not measure ABI after HD, and we will investigate the relationship between the change of ABI and acoustic cardiographic parameters (ACPs) simultaneously before and after the HD in a further study. Finally, the ABI, baPWV, PEP, and ET may not be accurate if the HD patients had upper-limb arterial stenosis. Further prospective studies are warranted to explore the prognostic role of acoustic cardiographic parameters.In conclusion, our results demonstrate the changes in acoustic cardiographic parameters before and after HD and that a high EMAT/LVST was associated with low albumin, low ABI, and high bPEP/bET in our HD patients. Acoustic cardiography is a cost-effective and useful tool which may facilitate the timely recognition and treatment of LV systolic dysfunction in asymptomatic HD patients and thereby halt the progression of cardiovascular disease. Further research is warranted to investigate the use of acoustic cardiography in HD patients to predict cardiac outcomes.


The role of extracellular OPN in ASC differentiation was further demonstrated by supplementation and neutralization of OPN. Additionally, OPN suppresses adipogenic differentiation in ASCs through the C/EBP pathways. Consistent with these in vitro results, by intravenous injection of OPN-expressing adenovirus to the mice, we found OPN can delay the development of obesity and improve insulin sensitivity. Therefore, our study demonstrates an important role of OPN in regulating the development of obesity, indicating OPN might be a novel target to attenuate obesity and its complications.Obesity is a major risk factor for many chronic diseases, including diabetes, fatty livers, and cancer. Expansion of the adipose mass has been shown to be related to adipogenic differentiation of adipose-derived mesenchymal stem cells (ASCs). However, the underlying mechanism of this effect has yet to be elucidated. We found that osteopontin (OPN) is downregulated in ASCs and adipose tissues of obese mice and overweight human beings because of methylation on its promoter, indicating that OPN may affect the development of obesity. Silencing of OPN in wild-type ASCs promotes adipogenic differentiation, while reexpression of OPN reduced adipogenic differentiation in OPN Prevalence of obesity and obesity-associated metabolic problems has become a major economic and medical burden worldwide , 2. Obesin vitro, can differentiate into adipocytes depending on the presence of adipogenic factors  [It has been reported that adipose-derived mesenchymal stem cells (ASCs) play an important role in the development of obesity . ASCs arthasone) , 16. It thasone) , 17.in vitro from different organs and tissues, such as bone marrow, embryos, and adipose tissues. ASCs are the kind of MSCs derived from adipose tissues [Osteopontin (OPN), an arginine-glycine-aspartate-containing glycoprotein, is known as a soluble protein that is present in most body fluids. As an important inflammatory cytokine originally identified in osteoblasts, OPN has multiroles in bone remodeling, cell migration, immune regulation, and tumor metastasis , 19. OPN tissues .However, the mechanisms by which OPN regulates adipogenesis by ASCs during the development of obesity remain poorly understood. Therefore, the aim of this study was to determine the role of OPN in adipogenic differentiation by ASCs during the process of obesity.http://www.slaccas.com). OPN−/− C57BL/6 mice  were obtained from Jackson Laboratory  (http://www.jax.org). In the construction of the obese mice experiment, C57BL/6  mice were randomly assigned to normal chow diet (CD)  groups and high-fat diet (HFD)  groups. Each cage housed 4 mice for 12 weeks. In vivo OPN effect verification experiment, C57BL/6  mice were randomly assigned to two 60% kcal high-fat  groups. Each cage housed 4 mice which received either adenovirus vehicle (pcmv) or 108 PFU once a week of adenovirus OPN for 8 weeks (intravenous injection). Food consumption was determined by measuring the difference between the amount provided and the amount left every three days. Food intake per mouse was calculated based on the amount consumed divided by time and the number of mice per cage. The body weight of each mouse was measured on an electronic balance once per week. All animals were kept and bred in environmentally controlled and specific pathogen-free conditions in the Animal Unit of Shanghai Second Military Medical University of the People's Republic of China. All animal experimental protocols were approved in accordance with the guidelines of the Animal Experiment Committee of Shanghai Second Military Medical University of the People's Republic of China.C57BL/6J mice (wild type (WT)) were purchased from the Shanghai Experimental Animal Center of Chinese Academic of Sciences  . The study protocol was obtained from surgical resections of patients in Changhai Hospital (Shanghai China). Patients' consent and approval were obtained to use these clinical materials for research purposes.A total of 8 men aged 25–45 years were enrolled from individuals who visited Changhai Hospital . In our study, all participants were then stratified according to body mass index (BMI) into the following two groups: overweight people and normal people. Overweight was defined as 25 ≤ BMI< 30 kg/m2 cell culture dish. Next, the cells were filtered through a 70 mm nylon mesh and cultured in low glutamine Dulbecco's modified Eagle's medium (DMEM) supplemented with 10% fetal bovine serum (FBS), 100 U/ml penicillin, and 100 mg/ml streptomycin . The cultures were incubated in an atmosphere of 5% CO2 and 37°C. All nonadherent cells were removed after 24 h. Medium was changed every 3 days.ASCs were obtained from subcutaneous adipose tissue. The inguinal fat pads were harvested and extensively washed with PBS three times. They were then finely minced and followed by digestion with 0.1% collagenase I (Gibco) for 1 h at 37°C in a 25cmhttp://www.sigmaaldrich.com).Differentiation of ASCs was induced according to established protocols  with minThe cell supernatant level of OPN was determined using the ELISA kit (Westang) as described in the manufacturer's instructions. Concentrations were calculated using a standard curve generated by OPN standards included in the kit.http://www.tiangen.com). Quantitative real-time PCR was measured with the FastStart Universal SYBR Green Master  using the StepOnePlus Real-Time PCR System . The total amount of mRNA was normalized to endogenous β-actin mRNA. The primer sequences used for the quantitative PCR are provided in Supporting Information The total RNA was isolated from cell pellets and subjected to reverse transcription using the FastQuant RT Kit . ASCs were grown to 80% confluency and transfected with 5 μl siRNA (40 pM) using the DharmaFECT transfection reagent following the manufacturer's instruction.siRNA specific for mouse OPN, DNMT1, and control siRNA with scrambled sequences were purchased from GenePharma  (Sigma-Aldrich), and then changed medium 24 hours later. OPN expression in target cells was detected by real-time PCR and western blot analysis.We constructed lentiviral vectors encoding scrambled shRNA and short-hairpin RNAs (shRNAs) targeting OPN . We addehttp://www.genomeditech.com). Target cells were infected using 108 PFU adenovirus. OPN expression in target cells was detected by real-time PCR.Overexpressed adenovirus specific for mouse OPN and control adenovirus vector were purchased from Genomeditech  according to the manufacturer's instructions. The same amount of genomic DNA was treated with sodium bisulfite as described (TIANGEN Biotech) and subjected to methylation-specific PCR (MS-PCR) analysis. Primers specific for methylated DNA were TIPMF (5′-TTTTATGGATTTTTGATGTTTTTTC-3′) and TIPMR (5′-CATAAAATTTTTACCACTACCCGAC-3′); primers for unmethylated DNA were TIPUF (5′-TTTATGGATTTTTGATGTTTTTTTG-3′) and TIPUR (5′-ATAAAATTTTTACCACTACCCAAC- 3′). The two regions of primers were designed to amplify the same region in the 5′-untranslated region (UTR) of OPN gene from -229 to -71. The PCR conditions were as follows: 95°C for 2 min, 38 cycles of 94°C for 30 s, 60°C for 30 s, and 72°C for 20 s and a final elongation at 72°C for 5 min. PCR products were electrophoresed by the ethidium bromide gels. DNA from control subjects was used as a negative control. Mouse methylated (P) and unmethylated (N) DNA standards were from A&D Technology. Results from duplicate experiments were used to determine the methylation status.Intraperitoneal glucose tolerance test (IPGTT) was carried out one week prior to the end of the experiments. Mice were injected with glucose at 2 g/kg body weight after an 8 h fast. Blood samples were taken at 0, 30, 60, and 120 min points, and glucose concentrations were determined using glucose meters from Nipro Diagnostics Inc. .μm. We quantified adipocyte size by quantification analysis using an imaging system .Hematoxylin and eosin (H&E) staining was performed using tissue sections at a thickness of 6 t-test associated with Excel software. Statistical significance was set to ∗P < 0.05, ∗∗P < 0.01, and ∗∗∗P < 0.001.The experiments were performed at least three times. Data were expressed as “mean ± SEM.” Differences between groups were analyzed by using Student's To assess the role of OPN in obesity, a mouse model of high-fat diet- (HFD-) induced obesity was established as described in Material and Methods. Control mice with normal chow diet (CD) showed an average rate of body weight gain at 0.7 g/week, while that of mice with high-fat diet was 1.3 g/week. Eventually, the difference in the body weight between the two groups was 7.45 g , and found similar results with that in mice , which defines a CpG island as showing >50% CG content and an observed/expected CpG frequency of >0.6. However, previous studies showed that genes with non-CpG island promoters share many epigenetic features that are associated with CpG island promoter genes, despite their low CpG density [http://www.urogene.org/methprimer/index1.html) (The  density . MS-PCR x1.html) . OPN prox1.html) . Besidesx1.html) . Moreovex1.html) , which i−/− mice. OPN expression was undetectable in OPN−/− ASCs  was examined in vitro after ASC infection with Ad.OPN or Ad.vec (control empty Ad)  . After tmpty Ad) . We obsempty Ad) . Animalsmpty Ad) , which impty Ad)  or apparmpty Ad) . Taken tin vitro experiments showed that OPN inhibits adipogenic differentiation of ASCs by binding to extracellular receptors integrin αν/β1 and CD44. OPN adenovirus intravenous injection in mice to reduce obesity more effectively verified that the OPN might be a novel therapeutic target for attenuating obesity.Obesity is a worldwide health problem, and elucidation of the determinants of adipogenesis during the evolution of obesity is important to design targeted interventional strategies. Our studies observed that OPN expresses lower in ASCs and adipose tissue from overweight human beings and obese mice than in those from normal individuals. We also found that OPN is frequently inactivated due to methylation in ASCs and adipose tissue from obese mice. Furthermore, DNA methylation plays an important role in obesity and related metabolic complications . MethylaOPN gene are protected by obesity and insulin resistance induced by a 24-week HF diet [Controversially, previous studies have shown that mice lacking the  HF diet , which i HF diet . Additio HF diet . What is HF diet , which fAs we know, OPN is an important factor for maintaining the stemness of the blood stem cells. In our previous study, we demonstrated that autocrine OPN is required for hepatic progenitor cells to maintain their stem-like properties. In addition, OPN promotes a cancer stem cell-like phenotype in hepatocellular carcinoma. In quiescent cancer stem cells, the expression of OPN is higher to maintain its self-renewal capacity. As we know, adipose-derived mesenchymal stem cells, with immunomodulatory properties and multilineage differentiation potential, become a great alternative source of acquiring stem cells, due to high abundance and a much safer and less time-consuming liposuction procedure . In thisαν/β1 and CD44 and further attenuate obesity.In summary, our study revealed that OPN expresses lower in adipose tissue and ASCs from obese mice because of methylation, eliciting the role of OPN in obesity. We showed that OPN could inhibit adipogenesis through inhibition of the C/EBP signal via integrin


Hence, we sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy.Increasing the prevalence of optimal breastfeeding practices, including exclusive breastfeeding for 6 months, could prevent an estimated 823,000 child deaths annually. Self-efficacy is an important determinant of breastfeeding behaviors. However, existing measures do not specifically assess n = 239) and 3 (n = 238) months postpartum . We performed inter-item and adjusted item-test correlations, as well as exploratory factor analysis and parallel analysis at 1 month postpartum to remove redundant items and determine their latent factor structure. We further applied confirmatory factor analysis to test dimensionality of the scale at 3 months postpartum. We then assessed the reliability of the scale and conducted tests of predictive and discriminant validity. Known group comparisons were made by primiparous status and correct breastfeeding knowledge.We modified and added items from Dennis’ Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF). It was then implemented in an observational cohort in Gulu, Uganda at 1  contains supplementary material, which is available to authorized users. The BSEThe item generation and adaptation of the BSES-SF produced an initial set of 19 items  and 3 month (n = 238) postpartum visits. Data were analyzed in six phases: descriptive analysis, item reduction and functionality, extraction of factors, test of dimensionality, reliability and validity. Data were analyzed using Mplus v. 8.0  and STATA v.14 .We used data from the 1 month  the number of factors that fit a set of items is determined and, 2) it contributes to construct validity. The emphasis is on the number of factors, the salience of factor loading estimates, and the relative magnitude of residual variances , 42. We The test of dimensionality is a confirmatory test where the hypothesized factors or factor structure extracted from a previous model is tested , 55. OurModel modification is used in confirmatory factor analysis to improve model fitness using modification indices while providing remedies for discrepancies between proposed and estimated models , 56. ModReliability is the degree of consistency when a scale or measure is repeated under identical conditions . We asseThe coefficient of stability is used to assess how consistent a participant’s performance on a scale is when repeated over time. We assessed coefficient of stability through test-retest reliability . This wan = 239).Validity of a scale is how well it measures what it is intending to measure . The fint-test followed by logistic regression [Predictive validity is how well test scores predict outcomes  in the future. We assess predictive validity using a Student’s gression , 60. PreDiscriminant validity is the degree to which a scale is able to capture a distinct construct and not reflective another construct(s) . We asseWe also assessed known group comparisons, i.e. groups we expected to experience higher scores on BSES-EBF Scale. This is an approach that examines the distribution of a newly developed scale score over known binary items , 62. We Convergent validity was not assessed as there was no construct similar to exclusive breastfeeding self-efficacy in our data. Additionally, criterion concurrent validity was not assessed, as no ‘gold standard’ has been developed for measuring exclusive breastfeeding self-efficacy. Nonetheless, the use of these three approaches provide multiple evidence to support the validity of the BSES-EBF Scale .The mean age of participants was 25.2 with a range of 16 to 42 years  and a second item ‘Manage BF’ with a lower (< 0.30) and a non-significant factor loading were dropped from the list of items in the two-factor model , CFI (0.93), SRMR (0.06), AIC (7521.89), and BIC (7671.38) . The functional subscale consisted of 5 items reflecting the competence, and ability of the participants to breastfeed (e.g. Enough Milk). Each factor had a Cronbach’s alpha value greater than 0.70. Results from the analysis indicated satisfactory model fitness: χ2 34) = 99.07,  = 99.07,n = 238). The overall fit of the model for the initial test was poor on an absolute basis: χ2 (26) =90.62, p < 0.001; however, the descriptive model fit statistics indicated satisfactory model fitness: RMSEA (0.10), CFI (0.94), SRMR (0.06), AIC (5837.01), and BIC (5934.11)  in Mplus using an MI of 3.84 to identify items that needed re-specification , 56. A rAfter re-specification of the model, our model fit indices improved greatly, without having a major effect on the estimates of other parameters in the model Table .p < 0.001; RMSEA (0.08), CFI (0.97), TLI (0.95), WRMR (0.95), AIC (5837.01), and BIC (5912.48). Based on the results, a two-dimensional scale was accepted as an appropriate fit for our data giving a finalized scale of 9 questions reflecting exclusive breastfeeding self-efficacy  =58.05, ), AIC 587.01, andIn order to obtain the composite score for each of the two dimensions, we calculated the sum of responses for scale items at one and three months postpartum. At one month, the Cognitive subscale had a mean of 13.5 ± 4.1 and a range of 4–20 and the Functional subscale had a mean of 17.2 ± 4.3 and range of 5–25. The range for each of the sub-scales remained the same at 3 months postpartum; however, there were slight increases in each of the scores  and Functional  subscales. Our logistic regression model showed that the Cognitive sub-scale at 1-month postpartum was predictive of EBF at 1 month and 3 months, but not at 6 months postpartum  and 6 months  postpartum. The Functional subscale at 3 months postpartum was predictive of EBF behavior at 3 months , but not the relationship was not statistically significant at 6 months. BSES-EBF scores predicted exclusive breastfeeding both concurrently and three months later.For predictive validity, we regressed exclusive breastfeeding behavior simultaneously on each of the subscales at 1, 3 and 6 months postpartum  and Emotional EBFSS  showed strong evidence of a weak (linear) relationship between exclusive breastfeeding self-efficacy and EBFSS , Informational EBFSS , Emotional EBFSS , and depression   of the BSES-EBF Scale score and two constructs, Exclusive Breastfeeding Social Support (EBFSS) and maternal depression. The model fit indexes suggested the LVMs were tenable for 6 out of the 8 interrelationships  Fig. 4-. In botht = − 4.19, p = 0.001) and Functional  subscales than participants without correct breastfeeding knowledge.In the final step, known group comparisons, we compared the position of multiparous vs. primiparous participants and participants with correct breastfeeding knowledge vs. incorrect breastfeeding knowledge on the two subscales , compared to the BSES-SF (14 items) or the original BSES scale (33 items) , 63. TheValidity was tested using construct validity with both exploratory and confirmatory factor analysis, predictive validity, discriminant validity , and known group comparisons. Previous scales developed on this subject used at most 3 out of the 4 validation procedures, except Dennis , who use, Table The results of this study have programmatic and policy implication for supporting exclusive breastfeeding in northern Uganda. First, our descriptive results of BSES-EBF items showed high confidence with items depicting behavioral skills and lower confidence in items describing beliefs and attitudes towards EBF Fig. , Table 2where mothers may be succeeding or struggling with exclusive breastfeeding practice, which can help target appropriate support. Finally, this scale may be useful programmatically in that it can be administered to participants during the evaluation of programs and policy initiatives aimed at increasing commitment to exclusive breastfeeding.A second programmatic implication may be that the use of the BSES-EBF scale by health practitioners in clinics and the community may be able to target those with lowest perceived exclusive breastfeeding self-efficacy, i.e. those most in need of support. Interventions aimed at following-up with mothers who score low on the BSES-EBF Scale could significantly improve their breastfeeding behaviors through early intervention. Third, the two domains: functional and cognitive, of the BSES-EBF Scale can differentiate Although there are many strengths, there are several limitations in our study. First, the correlational effect we find between the different sub-scales at month one and three may be due to common method variance. Hence, it will be appropriate to test the hypothetical factor structure on a new sample to ascertain if they have the same meanings, latent factors, and factor loadings , 60. SecIndeed, there is plenty of opportunity for further work on the BSES-EBF Scale. First, estimating the convergent validity of the scale  will add another piece of evidence to the validity of the scale . Second,In summary, this study has demonstrated strong validity and reliability of a modified version of the original BSES-SF scale, the BSES-EBF Scale, which is shorter, more relevant, and valid for use in a setting with low rates of exclusive breastfeeding. Its use will surely enhance our understanding of the correlates of exclusive breastfeeding self-efficacy and exclusive breastfeeding practices globally.Additional file 1:Table S1. Survey module on exclusive breastfeeding self-efficacy as implemented in PostNAPS. Strikethrough indicates items that were ultimately dropped, highlighting refers to items developed. (PDF 60 kb)Additional file 2:Figure S1. Scree plot showing cut-off point for retained scale factors using parallel analysis. (PDF 98 kb)Additional file 3:Table S2. Confirmatory Factor Analysis Modification Indices Output from Mplus showing WITH statements for model re-specification. (PDF 52 kb)Additional file 4:Table S3. Indicators of Validity for Cognitive and Functional sub-scales of the BSES-EBF Scale at 1,3, and 6 months postpartum among Ugandan women (N = 239). (DOCX 14 kb)Additional file 5:Table S4. Measures of Discriminant validity: Population correlation estimates of the Breastfeeding Self-Efficacy Scale to Measure Exclusive Breastfeeding with Exclusive Breastfeeding Social Support and Depression Scores using Latent Variable Modeling with model fit indices at 1 month postpartum (n = 239) (PDF 91 kb)


We compared outcomes of TAVI patients with low stroke volume index (SVI) ≤35 ml/m2 served as controls. The prevalence of cardiovascular disease and symptoms increased stepwise from controls (n = 968) to patients with HFpEF (n = 591), HFmrEF (n = 97), and HFrEF (n = 166). Mortality tended to be highest in HFrEF patients 30 days post-procedure, and it became significant after one year: 10.2% (controls), 13.5% (HFpEF), 13.4% (HFmrEF), and 23.5% (HFrEF). However, symptomatic improvement in survivors of all groups was achieved in the majority of patients without differences among groups.Patients treated by transfemoral TAVI at our center (n = 1822) were classified as 1) ‘HF with preserved ejection fraction (EF)’ , 2) ‘HF with mid-range EF’ , or 3) ‘HF with reduced EF’ . Patients with SVI >35 ml/mPatients with AS and HF benefit from TAVI with respect to symptom alleviation. TAVI in patients with HFpEF and HFmrEF led to an identical, favorable post-procedural prognosis that was significantly better than that of patients with HFrEF, which remains a high-risk population. In specific high-risk patient populations with aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) has only a minor impact on mortality and has even been considered to be a futile treatment with respect to symptom alleviation –3. EfforOur aims in undertaking this study were to compare outcomes of patients in different HF classes after correction of increased afterload by TAVI.In this retrospective, observational study, we analyzed the outcome of patients with symptomatic AS and concomitant HF after TAVI. All data derived from a TAVI registry at a single center. Since 2011, patients who underwent TAVI for symptomatic AS were consecutively included as a result of the local heart team decision at our center. Follow-up visits were scheduled at 30 days and one year post-TAVI. The data were collected in a standardized and anonymized format. The approval for this study was obtained from the ethics committee of the Justus-Liebig University Giessen. Due to the retrospective nature of this study a waiver of written informed consent was issued by the ethics committee.2). Those patients with HF were further categorized based on the EF as ‘HF with preserved ejection fraction (EF)’ , 2) ‘HF with mid-range EF’ , or 3) ‘HF with reduced EF’ . Patients with symptomatic AS and SVI >35 ml/m2 were classified as controls.The flowchart for the creation of study groups and sizes is given in The primary endpoint was death from any cause. Death of unknown origin was classified as cardiovascular. Patients with follow-up time longer than one year were censored as alive after 365 days.2 were examined by transesophageal echocardiography to confirm AVAi <0.6 cm2/m2 by planimetry. EF was estimated visually. LV mass was calculated by the linear method [2 in women and >115 g/m2 in men [Echocardiographic exams were scheduled before TAVI, before discharge from hospital, and at 30 day follow-up. SV was determined at the LV outflow tract by multiplying area by the systolic velocity integral. Aortic valve area (AVA) was calculated according to the continuity equation . Patientr method . LVH was2 in men .2 in women and ≥500 AU/cm2 in men [Noncontrast multidetector computed tomography was used for measurement of aortic valve calcification (AVC). AVC density (AVCd) was calculated as AVC indexed to the cross-sectional area of the aortic annulus, which was calculated from the diameter of the left ventricular outflow tract measured by echocardiography according to Clavel et al. . Anatomi2 in men .2 test. Survival curves were constructed using Kaplan-Meier estimates and were compared by the log-rank test. Multivariate Cox regression analyses were performed with mortality as the outcome variable considering the following baseline parameters: sex, BMI, GFR, NYHA class III or IV, prior cardiac decompensation, DM, COPD, STS score, prior myocardial infarction, atrial fibrillation, prior ICD implantation, EF, LV myocardial infarction, SVI, MPG, mitral regurgitation ≥II°, tricuspid regurgitation ≥II°, SPAP, severe AVCd and the use of a balloon-expandable valve. Univariate predictors with P≤0.1 were entered into multivariate Cox regression analysis. The HF classification was not entered into the analysis because of high co-linearity. All statistical analyses were performed using the SPSS statistical package version 24 .Data are median and interquartile range (IQR). Categorical variables are presented as numbers (percentages). Continuous values were compared by the Mann-Whitney or Kruskal-Wallis test and categorical variables by the χA total of 591 patients with HFpEF, 97 patients with HFmrEF, 166 patients with HFrEF, and 968 patients in the control group were identified . There w2), to HFmrEF (27[2) to HFrEF (24[2), in parallel with the transvalvular MPG ml/m22), HFrEF 24–29ml/m2)ml/m22), Hg vs. 24–29mmHg; More balloon-expandable valves were used in patients in the HFrEF (44.6%) and HFmrEF (45.8%) groups than in the control (33.6%) and HFpEF (38.1%) groups (p = 0.006) . ProceduThirty-day overall mortality varied between 3.2% in controls and up to 6.6% in patients with HFrEF (p = 0.201) . The relThe median follow-up time was 350 (95–365), 335 (77–365), 297 (73–365), and 365 (96–365) days for patients in the control, HFpEF, HFmrEF, and HFrEF groups, respectively. Kaplan-Meier survival curves  showed tIn multivariate analysis , a low bWe determined that 1) patients with HFmrEF revealed a number of similarities with HFpEF patients but were characterized overall by a distinct, intermediate state; 2) TAVI caused a relief of symptoms in the majority of all HF patients; 3) periprocedural safety and early adverse events were not different in HF patients compared with controls; 4) the prognosis of patients with HFmrEF or HFpEF was almost as favorable as that of controls; and 5) one-year mortality in patients with HFrEF after TAVI was still considerably higher than in other HF patients.The observation that correction of increased afterload is still associated with high mortality in certain patients post-TAVI has shifted the focus from the aortic valve alone to inclusion of the left ventricular myocardium as therapeutic target. Indeed, the concept of ventricular hemodynamic unloading by TAVI to improve LV function and HF symptoms in addition to optimal HF therapy will be tested in patients with moderate AS and HFrEF in another study . Our patThe key characteristic that differentiates patients with HFmrEF from other HF patients is an EF range of absolute 10 percentage points. This rather narrow range makes the diagnose of HFmrEF prone to errors, given that EF in our study was estimated visually. However, patients with HFmrEF in our study presented with distinct intermediate characteristics but showed similarities to patients with HFrEF with respect to the ischemic etiology of HF and the prevalence of concomitant coronary artery bypass surgery. The same observations were made for the Swedish Heart Failure Registry . Here, pPatients with HFrEF revealed the highest mortality compared with other HF patients. Mortality during 30-day follow-up was already markedly higher than in both other groups and these differences were highly significant after a one-year follow-up. On one hand, these differences in mortality could be explained by the higher overall cardiovascular risk of HFrEF patients, mirrored by a higher STS score. On the other hand, one could speculate that medical HF treatment, which has been demonstrated to have tremendous prognostic impact in these patients, was lacking. Indeed, one-year mortality in those of our HFrEF patients who had NYHA status II/III at 30 days after TAVI was still 16.7%, and the same mortality rate (15%) was described in NYHA classes II/III in a study dating from 1987 when patients with HFrEF were not yet prescribed ACE inhibitors . FurtherIn prior analyses , a higheEchocardiographic measurements were made by different operators without a centralized core lab. SVI was determined by Doppler echocardiography, which implies angle-dependent errors. EF was estimated visually, which mirrors the everyday reality of this all-comers registry. We had no information on LV diastolic function in our patients. A complete dataset of natriuretic peptide levels and information on HF medication would have added great value to our results.TAVI can be performed safely in patients with AS and low SVI who meet the criteria for concomitant HF and is associated with substantial clinical benefits. Although 30-day mortality and adverse events were not different among controls and patients of different HF classes, and one-year survival in HFmrEF and HFpEF patients was as favorable as that of controls, HFrEF patients still had a high one-year mortality. Ventricular unloading by TAVI appears to benefit prognosis in HFmrEF and HFpEF patients, whereas its effects are less impressive once systolic LV function has significantly failed in HFrEF patients.S1 Text(PDF)Click here for additional data file.