The outcomes of deep-seated abscesses attributed to chronic disseminated candidiasis (CDC) in patients with hematological malignancies have rarely been reported in recent years.We retrospectively reviewed and analyzed the data of patients with hematological malignancies who received a diagnosis of CDC at a medical center in Taiwan between 2008 and 2013.Candida species: C. tropicalis (8), C. albicans (2), C. glabrata (2), and C. famata (1).Sixty-one patients (32 men and 29 women) were diagnosed with CDC. The median age was 51 years (range: 18–83). The overall incidence of CDC was 1.53 per 100 patient-years in patients with hematological malignancies between 2008 and 2013. The highest incidence of CDC was 4.3 per 100 patient-years for acute lymphoblastic leukemia, followed by 3.6 for acute myeloid leukemia. We detected 3 (4.9%) proven, 13 (21.3%) probable, and 45 (73.8%) possible cases of CDC. A total of 13 patients had positive blood cultures for The median duration of antifungal treatment was 96 days (range: 7–796 days). Serial imaging studies revealed that the resolution rate of CDC was 30.0% at 3 months and 54.3% at 6 months. Five patients (8.2%) had residual lesions that persisted beyond one year. A multivariate analysis of the 90-day outcome revealed that shock was the only independent prognostic factor of 90-day survival in patients with CDC.The incidence of CDC did not decrease between 2008 and 2013. Patients with acute leukemia had a higher risk of CDC than those with other hematological malignancies. Imaging studies conducted at 6 months after diagnosis revealed that only half of the patients showed complete resolution. CDC requires prolonged treatment, and serial imaging at 6 months interval is suggested. Shock is the only independent prognostic factor of 90-day survival in patients with CDC. Candida is a common pathogen worldwide and in patients with cancer, high morbidity and mortality are attributed to invasive candidiasis [Candida species colonizing the bowel, invade and seed to hepatosplenic sinusoids from the portal splenic bloodstream following chemotherapy-induced mucosal damage [didiasis , 2. Chrodidiasis –6. The el damage , 8. CDC l damage , 10.The reported incidence of CDC has ranged from 2.0 to 7.4% in patients with acute leukemia , 11–15. The treatment duration of CDC depends on clinical symptoms and signs, and the resolution of abscesses from imaging studies. The Infectious Diseases Society of America (IDSA) recommends that therapy should be continued until lesions have resolved on repeat imaging, which is usually after several months . The preThe National Taiwan University Hospital (NTUH) is a 2800-bed teaching hospital in the metropolitan area of Taipei that provides both primary and tertiary care. The medical records of patients admitted to the hematological wards of the NTUH from January 1, 2008, to December 31, 2013, were retrospectively reviewed. The inclusion criteria were patients with acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), lymphoma, multiple myeloma (MM), chronic myeloid leukemia (CML), myeloproliferative neoplasm (MPN), chronic lymphocytic leukemia (CLL), myelodysplastic syndrome (MDS), or severe aplastic anemia (SAA). Patients with other hematological diseases such as hemolytic anemia, idiopathic thrombocytopenia, hemophilia, or coagulation disorders were excluded. The methods have already been described in our previous studies .Imaging studies using CT and ultrasonography and other examinations were performed if clinically indicated. This retrospective study was approved by the Research Ethics Committee of NTUH , and informed consent was waived for this analysis based on approval by the Research Ethic Committee, as the data was analyzed anonymously.CDC was diagnosed according to the EORTC and the Mycosis Study Group consensus criteria to define invasive fungal infection in this study, and CDC cases were categorized as proven, probable, or possible , 10.At NTUH, no antifungal prophylaxis agent was administered to patients with hematological malignancies, except for a nystatin oral suspension, between 2008 and 2013. Patients awaiting allogeneic stem cell transplantation received micafungin for prophylaxis before neutrophil recovery on the transplantation ward. Antifungal treatments were provided according to the local guidelines of the Infectious Diseases Society of Taiwan , 19.P values < 0.2 in the univariate analysis were selected for the Cox proportional hazard regression analysis. A survival analysis was performed using the Kaplan–Meier estimator and a log-rank test. A P value of < 0.05 indicated statistical significance. All statistical analyses were performed using SPSS for Windows .We used the Chi-square test for categorical comparisons of the data. Significant predictors in the univariate analysis were included in a forward, stepwise multiple logistic-regression model to identify the most crucial risk factors for 90-day mortality. A Cox proportional hazard analysis was used to determine the relative contribution of various factors to the risk of 90-day mortality. In the multivariate analysis, factors with n = 607) were aged 65 years-old or more. These elderly patients (≥65 years) had a lower risk of CDC than younger patients . In this cohort, 397 patients underwent allogeneic stem cell transplantation, among whom 26 patients developed CDC (4 before transplantation and 22 after transplantation). Overall, patients who underwent stem cell transplantation had a higher risk of CDC than those who did not undergo transplantation . The other clinical characteristics of the patients are listed in Table A total of 2083 patients with hematological malignancies between 2008 and 2013 were included in this study, and 61 of these patients were diagnosed with CDC based on clinical and imaging criteria. In total, 968 patients were women, and the median age was 56 years (range: 15–97). A significant proportion of patients , ALL (n = 13), lymphoma (n = 7), CML/MPN (n = 1), MDS/SAA (n = 1), and myeloma (n = 1). Four patients underwent allogeneic stem cell transplantation before the diagnosis of CDC, and 22 patients underwent allogeneic stem cell transplantation after the diagnosis of the CDC. CDC was detected in all 61 patients either by computed tomography or by abdominal ultrasonography. By imaging studies, CDC was detected in 56 (94.9%) of 59 patients through computed tomography and in 44 (75.9%) of 58 patients through abdominal ultrasonography. Thirty-nine patients had positive findings on both CT and abdominal ultrasound imaging. The most common organs involved were the liver , spleen , and incidentally, the kidney . Twenty-seven patients underwent liver biopsy, and only 3 patients yielded a confirmatory result (11.1%); candidal hyphae were detected in the pathological specimens of 2 patients and C. albicans was recovered by tissue culture in 1 patient. A total of 13 patients had concomitant positive blood cultures yielding C. tropicalis (8 patients), C. albicans (2 patients), C. glabrata (2 patients), and C. famata (1 patient), respectively. In this study, we detected 3 (4.9%) proven, 13 (21.3%) probable, and 45 (73.8%) possible cases of CDC.In total, 61 patients (32 men and 29 women) were diagnosed with CDC. The median age was 51 years (range: 18–83). The underlying hematological malignancies were AML (P = 0.005) was associated with a more rapid resolution of CDC in imaging studies. Sixteen (84.2%) of 19 patients recovered from neutropenia, but 3 (15.8%) patients died within 90 days.A variety of antifungal agents were administered to patients with CDC Table . Thirty-P < 0.001) and initial antifungal agents (P < 0.001), and timing of allogeneic transplantation (P < 0.001) influenced 90-day survival. Age, gender, underlying diabetes, hepatitis B, neutropenia, and thrombocytopenia were not associated with 90-day survival. A multivariate analysis with a Cox hazard regression revealed that shock was the only independent prognostic factor of 90-day survival in patients with CDC .We analyzed the 90-day mortality of 61 patients with CDC Table . A totalIn this study, 51 6.3%) of 808 patients with acute leukemia were diagnosed with CDC. This finding is consistent with that of our previous study, which revealed that 37 of 500 (7.4%) patients with acute leukemia developed CDC. Despite recent advances in the use of pre-emptive or prophylactic antifungals, the incidence of CDC has not decreased compared with earlier studies (incidence: 2.0–7.4%) .3% of 80–15. The The resolution of abscesses in imaging studies is crucial for optimizing patient care. IDSA guidelines state that therapy should continue until the lesions are resolved on repeat imaging, which is usually after several months. The premature discontinuation of antifungal therapy can lead to relapses . Howeverp < 0.001). This result implicates recovery of neutropenia is associated with rapid resolution of the microabscesses. By contrast, the hepatosplenic or renal abscesses of patients without neutropenia at the time of CDC diagnosis recovered less rapidly since the underlying immune defects predisposing to invasive fungal infections may be less easily reversed than by recovery of absolute neutrophil counts. Shoham et al. proposed that the propensity for the persistence of the fungus in infected tissues may be a consequence of cell-mediated immune dysregulation with the suppression of Th1 and the overexpression of Th2 responses [No consensus has been reached on the required duration of antifungal treatment. Parenteral antifungal agents are usually necessary at the time of diagnosis and are substituted with oral agents thereafter . In this study, the median duration of antifungal treatment was 96 days (range: 7–796 days). As the antifungal agent administered was heterogeneous and the study retrospective in nature, the comparative therapeutic effect was difficult to determine. However, half of the abscesses on imaging studies resolved at 6 months. A treatment course of 3–6 months is warranted if lesions persist in serial imaging studies. When the factors associated with the resolution of CDC were analyzed, only recovery of neutropenia was correlated with the rapid resolution of CDC in imaging studies. Nineteen patients had neutropenia at the time of CDC diagnosis; patients whose neutropenia subsequently recovered had significantly faster imaging documented resolution than patients whose neutrophil counts did not recover , followed by amphotericin B (14.8%). The multivariate analysis revealed no significant outcome differences between the first-line antifungal agents. In this study, antifungal treatment was administered according to local guidelines in Taiwan , 19. SevThe univariate analysis revealed that hematological subtypes, preceding allogeneic transplantation, and administration of initial antifungal agents were poor prognostic factors of CDC. The multivariate analysis indicated that shock was an independent prognostic factor of CDC. In total, 22 patients underwent allogeneic transplantation after the infection was controlled. CDC was not an absolute contraindication to stem cell transplantation , 30 sincThe incidence of chronic disseminated  candidiasis did not decrease between 2008 and 2013. Patients with acute leukemia have a higher but not exclusive risk of CDC than those with other hematological malignancies. Repeated imaging studies at six months revealed that the hepatosplenic microabscesses had resolved in only half of the patients and it was necessary to continue therapy beyond six months for the remaining half. According to our findings, CDC requires prolonged treatment and follow-up. Among all criteria, shock is the only independent prognostic factor of 90-day survival in patients with CDC.


In ICU patients, digestive tract colonization by multidrug-resistant (MDR) Gram-negative (G−) bacteria is a significant risk factor for the development of infections. In patients undergoing extracorporeal membrane oxygenation (ECMO), colonization by MDR bacteria and risk of subsequent nosocomial infections (NIs) have not been studied yet. The aim of this study is to evaluate the incidence, etiology, risk factors, impact on outcome of gastrointestinal colonization by MDR G− bacteria, and risk of subsequent infections in patients undergoing ECMO.This is a retrospective analysis of prospectively collected data: 105 consecutive patients, treated with ECMO, were admitted to the ICU of an Italian tertiary referral center  from January 2010 to November 2015. Rectal swabs for MDR G− bacteria were cultured at admission and twice a week. Only colonization and NIs by MDR G− bacteria were analyzed.p = 0.029) and duration of mechanical ventilation (MV) before ECMO > 3 days  were associated with increased risk of colonization. Colonized patients had increased odds of infections by the colonizing germs , longer ICU length of stay (LOS) , MV  and ECMO , but did not have higher risk of death . Infected patients had almost halved ICU survival .Ninety-one included patients  underwent peripheral ECMO (87% veno-venous) for medical indications (79% ARDS). Nineteen (21%) patients were colonized by MDR G− bacteria. Male gender (OR 4.03, In patients undergoing ECMO for respiratory and/or circulatory failure, colonization by MDR G− bacteria is frequent and associated with more the tenfold odds for subsequent infection. Those infections are associated with an increased risk of death. Extracorporeal membrane oxygenation (ECMO) is a life-support technique used in patients with potentially reversible refractory respiratory or circulatory failure . HealthcICU patients have higher rates of digestive tract colonization by MDR G− bacteria  and carbapenem-resistant bacteria) compared to patients admitted to general wards , 6. SuchThe aim of the present study is to evaluate the incidence, risk factors, and impact on subsequent HAIs as well as clinical outcomes of digestive tract colonization by MDR G− bacteria in a large cohort of non-surgical patients undergoing ECMO for respiratory or circulatory failure.E. coli, Enterobacter spp.) and carbapenem-resistant  G− bacteria at ICU admission and twice a week. We will refer to ESBL+ and carbapenem-resistant G− bacteria as “MDR G− bacteria”.We present a retrospective analysis of prospectively collected data of all consecutive ECMO patients admitted to the General Intensive Care Unit (ICU) of San Gerardo Hospital  from January 2010 to November 2015. For further details on ECMO setting and patient care see Setting and Standard of Care, Additional file 2/FiO2 at ECMO connection; ECMO configuration ; transfer from peripheral hospital; length of invasive mechanical ventilation (IMV) before ECMO connection; antimicrobial therapy .The Institutional Ethical Committee, and written informed consent was waived due to the retrospective observational design of the study. All patients receiving ECMO support were considered for inclusion. Exclusion criteria were: (1) ICU length of stay (LOS) < 24 h; (2) ECMO use < 24 h; (3) occurrence of a NI prior to ECMO connection; (4) missing medical records. At baseline, the following patients data and ECMO parameters were collected: demographics ; comorbidities ; immunocThe following outcomes were recorded: survival at ICU discharge, ICU LOS, duration of IMV, and duration of ECMO.All the positive microbial cultures obtained from ICU admission until ICU dismissal have been independently evaluated in light of the available clinical, laboratory, and radiographic data by two specialized intensivists (VS and GG) and two infectious diseases specialists (AB and LA) following international guidelines –13. The Due to the retrospective nature of the study, no statistical power calculation was performed a priori, and the sample size was equal to the number of patients treated during the recruitment period. Data are presented as median and interquartile range (IQR) for continuous variables. Categorical variables are expressed as number of patients (percentage of the subgroups). For binary outcome measures, odds ratios (OR) and associated 95% likelihood ratio-based confidence intervals were calculated, and the comparison between patients’ populations  were performed with Chi-square test or Fisher’s test, as appropriate. The Kruskal–Wallis test was utilized to compare non-parametric continuous variables between patients’ populations. Kaplan–Meier survival curve analysis was used with log-rank test for comparison of colonization-free and infection-free rates. Observations were right-censored.p < 0.05. Analyses were performed using JMP 12.1 Pro  statistical program.Univariate regression models were applied to identify risk factors associated with colonization and infection. All subjects were included in the models, and follow-up began at the time of ECMO initiation. All statistical tests were 2-tailed, and statistical significance was accepted at From January 2010 to November 2015, 105 patients were treated with ECMO at the General Intensive Care Unit (ICU) of San Gerardo Hospital . Ninety-one subjects  were included in the analysis. Reasons for exclusion of the remaining patients were: diagnosis of HAI prior to ECMO connection (10 patients), age < 18 years (2 subjects), ICU LOS and ECMO shorter than 24 h (2 patients)  by K. pneumoniae, 2 (11%) by P. aeruginosa, and 2 (10%) by other Enterobacteriaceae. The clinical characteristics of colonized and non-colonized patients are depicted in Table p = 0.029] and duration of IMV before ECMO connection > 3 days . Among the other variables, ARDS and use of RRT prior to ECMO connection were associated with high, but not significant, OR estimates . Multivariable logistic regression was not deemed appropriate due to the small number of events .We analyzed a total of 1213 positive cultures. Nineteen (21%) patients were colonized by MDR G− bacteria. Of them, 11 (58%) were colonized by Colonization was diagnosed after a median interval of 13 (1–22), 16 (8–32) and 17 (10–34) days from ECMO connection, institution of IMV, and hospital admission, respectively. Of note, 5 (26%) of the colonization were diagnosed in the first three days after ICU admission. The time course of colonization is depicted in Fig. p = 0.002], longer IMV  and longer ECMO support . Colonization also increased the risk of need for tracheostomy . In our cohort colonized patients did not have a higher risk of death than not colonized patients , but they had more than tenfold odds of developing an infection caused by the colonizing germs  with high sensitivity [0.432 (95% CI 0.287–0.591)] and specificity [0.944 (95% CI 0.849–0.981)] of prior colonization to predict subsequent MDR G− bacterial infection.Colonized patients had significantly longer ICU LOS , use of RRT prior to ECMO connection , diagnosis of ARDS , infection at admission  and colonization  and longer ICU LOS . Moreover, infected patients had increased needs for RRT  and tracheostomy . Finally, infected patients had almost halved ICU survival .Infected patients had longer ECMO support [i.e., 27 (14–61) vs. 10 (5–16), The time course of antibiotic use is shown in Additional file A. baumannii) were associated with an increased risk of death [In the present study, we analyzed the epidemiology of digestive tract colonization by MDR G− bacteria in a large cohort of non-surgical patients undergoing ECMO for respiratory or circulatory failure. MDR G− bacteria colonization was highly frequent (21% of the patients), and risk factors associated with colonization were male sex and the need for prolonged  IMV prior to ECMO connection. Colonized patients had more than tenfold odds for subsequent infection by MDR G− bacteria, and those infections  were not associated with an increased risk of colonization by G− MDR bacteria. Finally, both invasiveness of care [Recent studies performed in European ICUs , 16, des of care  and crit of care  alter th of care .As previously documented , 9, 27, In our patient cohort, colonization by MDR G− bacteria occurred in patients with longer ICU stay, longer IMV and higher invasiveness of care, but was not associated with an increased risk of death. As such, colonization may be considered as a proxy for a more complicated clinical course, rather than a causative determinant of the unfavorable clinical course.Staphylococcus aureus) was not evaluated since routine surveillance for MRSA colonization is not performed at San Gerardo Hospital General ICU due to the limited incidence of such infection. Finally, since around 25% of the colonizations occurred in the first 3 days from ICU admission, in this specific subgroup, we cannot clearly distinguish between community-acquired and hospital-acquired colonization, as most of our patients were admitted from peripheral hospitals, where surveillance was rarely performed.The main limitation of our study is its retrospective and single-center nature, which precludes the generalization of the results to the overall population of medical ECMO patients. Moreover, colonization due to MDR G+ bacteria  of IMV prior to ECMO connection. Colonized patients had more than tenfold odds for subsequent infection by MDR G− bacteria, and those infections were associated with an increased risk of death.Additional file 1: Methods S1. Setting and standard of care. Table S1. Diagnostic criteria for infections. Results—Figure S1. Patients population flowchart. Table S2. Infections at admission. Table S3. Cox regression of the independent risk factors associated to the first NI. Table S4. Infection onset times.


Idarucizumab is a humanized Fab fragment that specifically reverses dabigatran anticoagulation. In trauma, volume expanders are used for resuscitation to compensate for blood loss and hemorrhagic shock, but it is unknown whether volume expanders influence the binding of dabigatran to its antidote. Using a porcine dilutional coagulopathy model, this study investigated whether volume replacement strategies affect binding of dabigatran to idarucizumab.Twenty-five male pigs were treated orally with dabigatran etexilate (30 mg/kg bid) for 3 days. The following day, animals were anesthetized, infused with dabigatran  to achieve supratherapeutic concentrations, and randomized 1:1:1:1:1 (n = 5 per group) to control (no hemodilution) or hemodilution where ~50% of blood volume was substituted with Ringer’s solution, 6% hydroxyethyl starch 130/0.4, 6% hydroxyethyl starch 200/0.5 or 4% gelatin. Idarucizumab was then administered intravenously (30 mg/kg) and serial blood samples were taken for up to 24 hours to measure diluted thrombin time (corresponding with dabigatran activity), total dabigatran (bound to antidote and free drug) and a panel of coagulation parameters.Mean plasma dabigatran levels were 617 ± 16 ng/mL after infusion and 600 ± 114 ng/mL after ~50% hemodilution with no significant differences between groups. Following treatment with idarucizumab, plasma concentrations of unbound dabigatran decreased markedly, with similar reductions in all groups. Dabigatran-induced prolongation of coagulation parameters was rapidly reversed in all groups.This study indicates that several volume expanders used for resuscitation in trauma do not interfere with the binding of idarucizumab to dabigatran. Post-traumatic bleeding is a leading cause of mortality following trauma . CoagulaIdarucizumab, a humanized monoclonal antibody fragment specific to dabigatran, is approved for reversing the anticoagulant activity of dabigatran in patients with uncontrolled bleeding or requiring emergency procedures . By bindIn patients experiencing trauma or severe hemorrhage, volume expanders may be used to maintain circulation, oxygen delivery and avoid severe shock. Initial fluid resuscitation generally involves the use of crystalloids, while colloid volume expanders such as hydroxyethlystarch (HES) and 4% gelatin are recommended for persistent hemorrhagic shock . ResusciDabigatran-treated patients requiring emergency procedures and receiving idarucizumab may also require concurrent volume replacement. It is unknown whether volume expanders might influence the binding of idarucizumab to dabigatran, potentially reducing its ability to reverse the anticoagulant effect of dabigatran. The present study was performed to investigate the effects of frequently used volume expanders on the binding of idarucizumab to dabigatran over 24 hours in a porcine model of dilutional coagulopathy with 50% blood loss.± 5 kg (mean ± standard deviation) were housed in ventilated rooms and acclimatized for a minimum of 7 days before oral dosing with dabigatran etexilate twice-daily for three consecutive days . The final dose was administered 12 hours before hemodilution. Animals were fasted after the final dose and water was provided ad libitum. On day 4, anesthesia was induced as described previously [All experimental procedures were approved by the local animal care committee  and conducted in accordance with the German Animal Protection Act. Twenty-five male German Landrace pigs weighing 50 eviously ,12,13.2 at 36–42 mmHg. Anesthesia was maintained with isoflurane  at an end-tidal concentration of 1%, and continuous infusion of fentanyl  at 3–4 μg/kg/h.For surgical preparation, animals received an intramuscular injection of 4 mg/kg azaperone  and 0.1 mg/kg atropine . Catheters for blood sampling and infusions were placed in the right carotid artery and left jugular vein and a 90-minute infusion of dabigatran (10 mg/mL solution: 0.77 mg/kg/h for 30 minutes and 0.26 mg/kg/h for 60 minutes) was given to achieve consistent plasma concentrations. Anesthesia was induced by intravenous injection of 3 mg/kg propofol , and this was followed by orotracheal intubation. The animals were ventilated with a tidal volume of 8 mL/kg and 16–22 breaths/minute  to maintain end-tidal COAnimals were randomly allocated (n = 5 per group) to control (no hemodilution) or hemodilution with one of four volume expanders: balanced Ringer’s solution , 6% HES 130/0.4 , 6% HES 200/0.5 , or 4% gelatin . In the hemodilution groups, ~50% of the animal’s estimated blood volume (65 mL/kg body weight) was withdrawn at a rate of 100 mL/min following the dabigatran infusion. The appropriate volume expander was then administered over 30 minutes. The total infusion volume of Ringer’s solution was the same as the volume of blood withdrawn, while the dose for all three colloids was 25 mL/kg.Idarucizumab  was administered as an intravenous bolus to all groups immediately following hemodilution. Four hours after treatment with idarucizumab, animals were extubated and allowed to recover. Carprofen  was given i.m. for postoperative pain relief. At the end of a 24-hour observation period, animals were euthanized with an overdose of pentobarbital.Blood samples were taken prior to any treatment (baseline), after i.v. dabigatran, after hemodilution and at 5 minutes, 15 minutes and 3, 12 and 24 hours after idarucizumab dosing. Blood gases were assessed in heparinized blood samples using an ABL700 blood gas analyzer . A standard hematology analyzer  was used for measurement of hemoglobin, erythrocytes, white cell count and platelet count in samples that had been transferred to potassium-EDTA-anticoagulant tubes. Sodium citrate  and EDTA-anticoagulant (Sarstedt) were added to blood samples for coagulation assays and measurements of drug concentrations, respectively, before centrifugation to obtain cell free plasma; the plasma samples were stored at -80°C prior to assessment. Standard laboratory methods were used to measure aPTT , dTT , fibrinogen concentration  and D-dimer levels . Non-anticoagulated whole blood was used for measurement of activated clotting time (ACT), using celite cartridges and an i-STAT point-of-care device . Thromboelastometry was performed with commercially available reagents (ex-tem and in-tem) in citrated whole blood on a ROTEM device .Levels of active, unbound dabigatran in plasma were measured using the dTT assay in citrated plasma . Total dIdarucizumab concentrations in plasma were assessed at Boehringer Ingelheim  using an enzyme-linked immunosorbent assay (ELISA) for porcine plasma. Antihuman IgG antibody (2 μg/mL) was applied overnight to microtitre plates; this was subsequently incubated with calibration standards, anchor points, blank plasma, quality controls, and samples. Horseradish peroxidase (HRP)-conjugated sheep antihuman IgG antibody (0.5 μg/mL) was added, and tetramethylbenzidine was used to detect bound HRP-conjugate (a plate reader was used to take readings). The lower limit of quantification for idarucizumab was 150 ng/mL (3.14 nM).0-24), peak plasma concentration (Cmax), clearance (CL), and terminal elimination half-life (t½). Plasma concentrations immediately before idarucizumab dosing were considered as the time zero values.Non-compartmental analysis of plasma idarucizumab, total dabigatran, and active unbound dabigatran concentration–time data was performed using Kinetica Version 4.4.1 software . Standard methods were used to calculate the area under the plasma concentration–time curve (AUC) over 24 h , data were treated as non-normally distributed and results were presented as median ± interquartile range (IQR), unless indicated otherwise. Differences between the control group and each volume replacement group were assessed by pairwise between-group comparisons with Wilcoxon-Mann-Whitney tests followed by Bonferroni adjustment. SPSS 23  was used to carry out statistical tests with two-tailed methodology; the level of significance was p<0.05. All graphs were created using GraphPad Prism .Prior to oral dabigatran treatment, all assessments including coagulation parameters and blood cell counts, were similar across the five study groups . HemodilDabigatran etexilate dosed orally (30 mg/kg twice-daily) for 3 days resulted in a median trough plasma dabigatran concentration of 352  ng/mL across the treatment groups (data not shown). After the infusion of dabigatran and before hemodilution, the plasma concentration of dabigatran had increased to a median of 611 (596–636) ng/mL, with no significant differences between the groups .In the control group, the plasma dabigatran concentration was initially 663 (395–729) ng/mL post-infusion, decreasing to 474 (253–555) ng/mL after 1 hour, representing normal clearance of the drug . FollowiPlasma concentrations of unbound dabigatran decreased in all groups within 5 minutes of idarucizumab administration, to 0 (0–292) ng/mL . There wHemodilution with any of the four volume expanders did not change the total dabigatran concentrations in pigs . Immedia0-24) was similar in all of the volume expander groups with no significant differences versus control  nM in the control group and 5630 (5360–5940) nM in the 6% HES 130/0.4 group . IdaruciDabigatran treatment prolonged the aPTT  from 15 (15–17) to 39 (39–41) seconds and the ACT from 101 (72–118) to 329 (183–433) seconds, representing increases of 2.7- to 3.3-fold from baseline . HemodilTreatment with idarucizumab promptly decreased aPTT and ACT, with values 5 minutes post-treatment that were close to baseline . Only miClotting time (CT) and clot formation time (CFT) in thromboelastometry (EXTEM) were initially prolonged by dabigatran, with median values of 572 (494–691) and 623 (450–749) seconds, compared to baseline values of 37 (34–41) and 34 (33–37) seconds, respectively . SimilarThis study showed that hemodilution and volume resuscitation had no impact on the concentration–time profiles or pharmacokinetic parameters of idarucizumab, total dabigatran or unbound active dabigatran. Furthermore, none of the four volume expanders investigated in the study had a significant impact on the reversal of dabigatran’s anticoagulant activity by idarucizumab, as shown by the lack of significant differences in unbound dabigatran between the resuscitation groups and the control group without hemodilution. Minor differences observed between the volume expanders are attributable to their direct effects rather than effects on the ability of idarucizumab to bind and inactivate dabigatran.The idarucizumab dose used in this study was not intended to completely reverse the anticoagulant activity of dabigatran. Instead, the study was designed to determine whether the different volume expanders had any impact on dabigatran-idarucizumab binding. This single dose of idarucizumab was able to inhibit ~25% of the total dabigatran on a molar basis. Since dabigatran-idarucizumab binding in the presence of hemodilution was not affected at this dose level, and it has been demonstrated in studies that idarucizumab has no effect on any other proteins or small molecules, other than dabigatran [A return of dabigatran anticoagulant activity within ~15 min following administration of idarucizumab was observed. This is explained by redistribution of dabigatran from extracellular space in tissues into the blood compartment as idarucizumab binds dabigatran in blood in a 1:1 stoichiometric manner, thereby reducing the plasma concentration of the active dabigatran. Preclinical studies have shown that idarucizumab binds dabigatran with a high binding affinity of 2.1 pM, a very fast on-rate and a slow off-rate resulting in immediate, almost irreversible binding. The effectiveness of idarucizumab in reversing dabigatran-induced coagulopathy depends on whether the dose of idarucizumab is sufficient (i.e. equimolar) to inhibit dabigatran , with thThere were some differences in coagulation assay results according to the type of volume expander used. This could be related to direct effects on coagulation–it is known that coagulation assays are affected to differing degrees by different volume expanders ,19. For We recognize that our study has some limitations. It was not feasible to include a group with hemodilution and a ‘placebo’ volume expander, meaning that it is difficult to study the effects of a volume expander only. Although some differences between groups reached statistical significance, the groups were small and this may have resulted in a lack of statistical power. In this and other investigations using similar porcine models, dilutional coagulopathy was induced through blood withdrawal and resuscitation fluid infusion. Such models may not include the complexities of real-world trauma patients, but one advantage is that the extent of hemodilution can be standardized . The seqIn summary, this study demonstrates that volume expanders used in clinical practice for resuscitation do not interfere with the binding of dabigatran to its specific antidote, idarucizumab. The reversal of dabigatran anticoagulation can be assessed qualitatively with a range of surrogate markers including standard plasma-based coagulation assays, thromboelastometry or ACT, even in the presence of dilutional coagulopathy.S1 TableResults are presented as mean (± SD), n = 5/group, unless stated otherwise.(DOCX)Click here for additional data file.S2 TableResults are presented as mean (± SD), n = 5/group.(DOCX)Click here for additional data file.S3 TableResults are presented as mean (± SD), n = 5/group, unless stated otherwise.(DOCX)Click here for additional data file.S1 File(XLSX)Click here for additional data file.


Patients with lymphoma are at risk for developing pulmonary opportunistic infections due to immunocompromise. However, clinical reports of concurrent lymphoma and opportunistic infection at presentation are rare and often confined to single cases. A delayed diagnosis of either opportunistic infection or lymphoma usually occurs in this complex situation. Here, we report such a case and analyse 18 similar cases searched in the PubMed database to deepen clinicians’ understanding.Aspergillus fumigatus complex was identified from a bronchoalveolar lavage fluid culture. However, antifungal treatment combined with multiple rounds of antibacterial therapy was unsuccessful, and the patient’s lung lesions continued to deteriorate. Multiple puncture biopsies finally confirmed the coexistence of diffuse large B-cell lymphoma. Despite the initiation of combination chemotherapy, the patient died of progressive respiratory failure.A 48-year-old man presented with a 3-month history of fever, cough and emaciation. High-resolution computed tomography revealed bilateral cavitating lesions of different sizes. Synchronous pulmonary lymphoma and simultaneous opportunistic infection is rare and usually lacks specific clinical and imaging manifestations. Lymphoma should be considered as part of the differential diagnosis of patients with an opportunistic infection when treatment fails or other symptoms are present that could be considered “atypical” for the condition. Tissue biopsy is the gold standard, and multiple biopsies are essential for making the final diagnosis and should be performed upon early suspicion. Aspergillus was the most frequent causative pathogen, and most cases appeared during intensive therapy for tumours using chemotherapy, immunosuppressive agents or haematopoietic stem cell transplantation [Lymphomas are a diverse group of clonal neoplasms arising from B and T lymphocytes and natural killer cells. Manipulation and silencing of the host’s immune system by methods ranging from changes in the cellular microenvironment composition to changes in distinct signalling pathways is an important feature of various lymphomas , 2. Chemantation , 6. HoweA 48-year-old male was referred to the clinic for recurrent fever, cough and 5-kg weight loss during past 3 months. He denied breathing difficulties, chest pain, night sweats, wheezing and other uncomfortable symptoms. He was a smoker of 30 pack-years and had no history of travel or TB. There were no significant findings in his prior medical or family history.At the time of the initial evaluation, the patient showed an auricular temperature of 39.2 °C, a blood pressure of 108/70 mmHg, a pulse of 108, and a respiratory rate of 20. He had diminished breath sounds on both sides, and no enlarged lymph nodes were noted. Examinations of the heart, abdomen, extremities and nervous system were normal.Aspergillus fumigatus complex was identified from the BALF culture on the 10th day. Due to the new microbiological findings, the patient was treated with voriconazole. In addition, the patient was still treated with linezolid, moxifloxacin and imipenem-cilastin sodium combined with metronidazole successively during the third round of antibiotic use. He was persistently febrile and developed breathing difficulties. We recommended the patient undergo positron emission tomography/computed tomography (PET-CT) to assess the possibility of haematological malignancies. It was refused because of the financial burden. We performed bone marrow aspiration on the 20th day. No abnormal cells were observed in the bone marrow examination. A CT scan performed 23rd day revealed further expanding consolidation and bilateral pleural effusion . He was therefore diagnosed with synchronous pulmonary aspergillosis and DLBCL. Despite the combined R-COPE chemotherapy (rituximab 600 mg d 0 + cyclophosphamide 0.4 g d1–2 + vindesine 4 mg d1 + dexamethasone 20 mg d1–4 + VP-16 0.1 g d1–2) starting 38th days after hospitalization, the patient’s situation continued to deteriorate. He developed cervical, axillary and inguinal lymph node enlargement, which were unremarkable on admission. His LDH increased to 1627 U/L. The following CT scan  levels were elevated at 151.00 mg/L  and 395.00 U/L 0~247 U/L). Tumour markers, such as CEA, NSE, SCCA, ProGRP and CYFRA21-1, were all in the normal range. HIV serology was also negative. Computed tomography (CT) of the chest showed bilateral cavitating lesions with mediastinal enlarged lymph nodes  infection  of the patients had an explicit history of diabetes mellitus, and one patient had urothelial cancer , and the other patients had no immunocompromised statuses previously. The three most prevalent clinical presentations among such patients are fever (50.0%), cough 38.9%) and superficial lymph node enlargement (27.8%). Most chest images indicate mediastinal or hilar lymph node enlargement, solitary or multiple pulmonary nodules and cavitating lesions. Other presentations include consolidation and hydrothorax on thorax CT scans  were diagnosed only by postmortem analysis. The time from initial onset to definite diagnosis ranged from 3 days to 14 months , bronchoscopy or BAL (38.9%), bone marrow aspiration (38.9%), transbronchial biopsy (33.3%), needle aspiration biopsy of lung lesions (27.8%), surgical operations (22.2%), mediastinoscopy (11.1%) and thoracoscopy (11.1%) Table   Common symptoms and radiographic findings are shared by both disorders. When lymphoma and opportunistic infection exist simultaneously, it is difficult to judge whether the multifocal lesions and lymphadenopathy are lymphoma infiltrations or associated with infection. It makes the selection of the biopsy site challenging. (2) Tissue biopsy is the gold standard for the diagnosis and typing of lymphoma. While needle biopsy is inclusive, the majority of the tumour is constituted by reactive or inflammatory cells in varying compositions, especially HL. In HL, the neoplastic Hodgkin and Reed-Sternberg cells represent only a minority of the cellular infiltrate, with a frequency ranging from 0.1–10% . TherefoThe dilemma of lymphoma complicated with opportunistic infection is also reflected in treatment. Immediate application of chemotherapy may induce potential infection and aggravate the severity of the primary infection, especially for a particularly weak patient. Thus, it is necessary to identify whether evidence of infection exists in pathological specimens by specimen culture or special stains in addition to immunohistochemical staining. If anti-infectious treatments are given first, clinicians must notice that continuous antibiotic treatment for chronic infection may result in suppression of lymphoma and then create an illusion of clinical remission . TherefoIn conclusion, simultaneous lymphoma and opportunistic infection in a primary presentation is a challenging condition. The diagnostic process should involve maintaining a high index of suspicion based upon an understanding of the clinical and imaging manifestations, of the therapeutic effect, and of the limitations of diagnostic methods. Different and various invasive diagnostic methods, including needle aspiration or excision biopsy of lymph nodes, CT-guided transthoracic needle aspiration, transbronchial biopsy and bone marrow puncture, should be performed to reach an early diagnosis.


Finally, fingerprint-activity relationship modeling, which was capable of discovering the bioactive markers used in the quality evaluation, was investigated by the chemical fingerprints and the hepatoprotective activities utilizing multivariate statistical analysis, gray correlation analysis (GCA) and bivariate correlation analysis (BCA). The results showed that the accumulation of polyphenols, such as flavonoids and phenolic acids, in AVF subjected to low levels of salt stress could result in the effective scavenging of free radicals. Therefore, the present study may provide a powerful strategy to holistically evaluate the quality of salt-treated AVF in combination with chemical fingerprint and bioactivity evaluation.In this study, a fingerprint-activity relationship between chemical fingerprints and hepatoprotective activity was established to evaluate the quality of salt-treated Apocyni Veneti Folium (AVF). Characteristic fingerprints of AVF samples exposed to different concentrations of salt were generated by ultrafast liquid chromatography tandem triple time-of-flight mass/mass spectrometry (UFLC-Triple TOF-MS/MS), and a similarity analysis was performed based on common characteristic peaks by hierarchical clustering analysis (HCA). Then, the hepatoprotective activity of AVF against CCl Apocynum venetum L., as one of the known medicinal halophytes, has attracted much attention in terms of its antioxidant properties associated with human well-being. This plant grows widely in China, especially in a variety of saline habitats, and therefore, it is characterized by a high physiological plasticity for salt tolerance. Salinity has adverse effects on all aspects of plant health by activating salinity-induced molecular networks associated with salt stress perception, ion and osmotic homeostasis, and regulation of stress-related genes, proteins and metabolic pathways2. However, halophytes develop a robust and sophisticated protective system and accumulate secondary metabolites under appropriate levels of salt stress, which may be responsible for maintaining homeostasis and protecting against excessive reactive oxygen species-induced oxidative stress3.4. Modern pharmacological studies have demonstrated that AVF has anti-hypertension, anti-depressant, hepatoprotection, anti-anxiety, antioxidation and diuretic functions6. In the Chinese Pharmacopoeia (2015 edition), hyperoside, a stable active ingredient of AVF occurring at a high concentration, was selected as the marker for the quality control analysis of AVF7. In fact, most published reports quantify one or a limited number of components to achieve quality evaluation9. However, considering the fluctuations in chemical compositions and contents on the basis of many factors, such as abiotic stress, cultivation region and harvest time, it is difficult to achieve consistent quality in medicinal herbs3. Furthermore, it is generally recognized that Chinese medicines exert therapeutic efficacies holistically through a ‘multicomponent, multitargeted, and multipathway’ mode10. In addition, as mentioned above, AVF is composed of many bioactive components, and its therapeutic effects are not confined to the individual or simple effects of a single bioactive component. Therefore, it is necessary to establish a truly meaningful protocol to effectively and systematically achieve quality control of this plant.Apocyni Veneti Folium (AVF) contains abundant bioactive compounds, including the main and prominent antioxidative constituents of phenolic acid and flavonoids11, gas chromatography (GC)12, thin-layer chromatography (TLC)13, and high-performance capillary electrophoresis (HPCE)14, have been used to construct chemical fingerprints of AVF, which has allowed researchers to visualize and identify as many components of the plant as possible. Among these techniques, a high-performance liquid chromatography (HPLC) system is typically employed to establish the chemical fingerprints and quality assessment of AVF because of its ease of operation, high selectivity, and accuracy15. However, limits of this HPLC system include the identification of unknown components. Accurate masses and molecular formulae of untargeted compounds acquired from LC coupled with mass spectrometry/mass spectrometry (LC-MS/MS) have been used to predict and find such components17. In particular, triple time-of-flight mass spectrometry/mass spectrometry (Triple TOF-MS/MS) is considered to be the first accurate, high-throughput and high-resolution system of its kind and operates by means of information-dependent acquisition19. Therefore, the ultrafast liquid chromatography (UFLC)-Triple TOF-MS/MS system could be introduced to obtain AVF chemical fingerprints. Although similarity analysis of chromatographic fingerprints can directly reflect whether an analyzed sample is chemically similar to others, it alone cannot assess quality consistency. Many studies have proven that samples with high similarity values do not always exhibit the expected equivalent efficacies21. Hence, fingerprint-activity relationship modeling correlating major components to bioactivity is meaningful to achieve quality consistency and discover bioactive markers25.The fingerprint test proved to be a useful tool in assessing the chemical consistency of traditional Chinese medicine (TCM) and has been widely accepted by the World Health Organization (WHO), China Food and Drug Administration (CFDA), the United States Food and Drug Administration (FDA), and European Medicines Agency (EMEA). Several chromatographic techniques, including liquid chromatography (LC)4) is one of the most widely used experimental models26. Increased serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and hepatic malondialdehyde (MDA) contents along with decreased superoxide dismutase (SOD), catalase (CAT) and peroxidase (POD) activities demonstrate hepatotoxicity induced by CCl4 in mice27. Many published studies have indicated that natural substances, such as phenolic acids and flavonoids from plants, exhibit strong antioxidative activity that could act against CCl4-induced liver damage29. References have shown that AVF has protective effects against CCl4-induced acute liver injury due to its antioxidative, anti-inflammatory and immunomodulatory constituents6.Liver injury induced by carbon tetrachloride  and bivariate correlation analysis (BCA) to assess the quality of AVF in response to salt,  and screen out the efficacy-associated bioactive markers and the underlying biological pathways.The main objectives of the present study are thus to chemically and biologically characterize the quality of salt-stressed AVF by fingerprint-activity relationship modeling and discover efficacy-associated bioactive markers. First, the chromatogram fingerprints of AVF exposed to salt stress were established by UFLC-Triple TOF-MS/MS. Then, hierarchical clustering analysis (HCA) was used to discriminate fingerprints based on common characteristic peaks to support the chemical consistency of AVF. Second, CCl4 and olive oil were purchased from Aladdin .The diagnostic kits for alanine aminotransferase , aspartate aminotransferase , malondialdehyde , superoxide dismutase , catalase , peroxidase  and protein  were purchased from the Institute of Biological Engineering of Nanjing Jiancheng . References of silymarin (UV ≥80%), hyperoside and quercetin were obtained from Shanghai Yuanye Biotechnology Co., Ltd. ; isoquercitrin and chlorogenic acid were purchased from Baoji Chenguang Biotechnology Co., Ltd. . Cryptochlorogenic acid was acquired from Chengdu Chroma Biotechnology . HPLC-grade acetonitrile was purchased from Merck . CCl3. Briefly, 4 salt treatment concentrations were used: 0 (control), 100 (low stress), 200 (medium stress) and 300 (high stress) mM NaCl treatments were designed with 3 replicates and 3 pots per replicate. After 12 h of the last salt treatment experiment, AVF samples were harvested and dried at room temperature. Naturally dried, salt-treated samples were powdered and passed through a 60 mesh sieve. Four groups of dried samples (20 g) were extracted twice with 200 mL of 70% (v/v) ethanol for 2 h under reflux followed by centrifugation at 3,500 rpm for 10 min, and the supernatant was collected. After rotary evaporation and freeze-drying to a powder, a small portion was redissolved in 70% ethanol to form a 1 mL solution containing 0.05 g of AVF, and the solution was centrifuged at 12,000 rpm for 15 min. Then, the supernatant was stored at 4 °C and filtered through a 0.22 μm membrane before being subjected to UFLC-Triple TOF-MS/MS analysis. The rest of the freeze-dried powder was redissolved with 0.5% sodium carboxymethyl cellulose (CMC-Na) to form a 1 mL solution containing 0.5 g of AVF for the animal experiments. Mixed reference standard solutions were prepared by accurately weighing corresponding amounts of reference compounds dissolved in 70% ethanol to obtain a final concentration of approximately 1 μg/mL.Salt stress experiments have been described in detail in our previous papersTM 5600 System-MS/MS, AB Sciex, Framingham, MA, USA) equipped with an electrospray ionization (ESI) source. Chemical fingerprints were obtained and peak identification was performed via the UFLC-Triple TOF-MS/MS system. An XBridge® C18 column  was used for the analysis. The mobile phase consisted of water containing 0.1% formic acid (A) and acetonitrile containing 0.1% formic acid (B). The samples were eluted using a linear gradient program as follows: 0–3 min, 5% B; 3–8 min, 5–18% B; 8–12 min, 18–20% B; 12–15 min, 20% B; 15–17 min, 20–60% B; 17–18 min, 60–80% B; 18–18.5 min, 80–5% B; and 18.5–22.1 min, 5% B. The flow rate was set at 0.8 mL min−1 with the column maintained at 30 °C, and the injection volume was 5 μL. Runs under the positive and negative ion modes were set separately as follows: nebulizer pressure, 55 psi; drying gas pressure, 55 psi; curtain gas pressure, 40 psi; source temperature, 550 °C; and capillary voltage, 5500 V and −4500 V, respectively, for the runs under positive and negative ion modes. Data were acquired for each sample from 50 to 1,500 Da, and dynamic range enhancement was applied throughout the MS experiment to ensure accurate mass measurement.MS data were recorded by a high-resolution quadrupole time-of-flight mass spectrometer , SciFinder (https://www.cas.org/products/scifinder) and PubChem (https://pubchem.ncbi.nlm.nih.gov/) through comparing MS/MS fragment ions.Based on the established methods, precision and repeatability were assessed independently by successively analyzing 6 injections of sample 1 solution and 5 replicates of 100 mM NaCl-stressed AVF solution, respectively. Stability was assessed by analyzing one sample over a 48 h time period . “Chinese traditional medicine chromatographic fingerprint similarity evaluation system 2004, A Edition” was used to correct the retention time of each peak. The peak area was processed by equalization to obtain quantitative data. The reference atlas was generated with the median method from a general comparison of chromatograms obtained for the 12 samples. Similarity between the reference fingerprints and various chromatograms was determined by the software. Common characteristic peaks were identified by comparison with the reference compounds, while for compounds without a standard reference, the characteristic peaks were inferred using PeakView 1.2 software , references on AVFHCA was introduced to cluster samples based on common characteristic peaks by Cluster 3.0 and Java Treeview 3.0. Clustering was based on the Euclidean distance coefficient and average linkage method. The mean values of all parameters were taken from the measurements of three samples, and every sample had three replicates from which the standard deviations were calculated.SPF-grade ICR male mice (weighing 18–22 g) were obtained from Qinglong Mountain Animal Breeding Farm Limited Company . All animals were maintained under standard laboratory conditions  with dark and light cycles (12/12 h). The mice were acclimatized to laboratory conditions for 3 days before the commencement of the experiment. All animal procedures were approved by the IACUC  of Nanjing University of Traditional Chinese Medicine and carried out in accordance with the Guidelines of Accommodation and Care for Animals formulated by the Chinese Convention for the Protection of Vertebrate Animals used for Experimental and Other Scientific Purposes. All efforts were made to minimize animal suffering as well as to reduce the number of animals required for experimentation.4-intoxicated groups, animals were given a single dose of 0.5% CMC-Na orally using a gavage daily for 14 days. A positive control group was administered silymarin (100 mg/kg body weight (bw)) as a reference drug. The low dose (0.3 g/kg bw) and high-dose (3 g/kg bw) groups were given different treatments of AVF exposed to various levels of salt stress, named L0, L100, L200, L300, H0, H100, H200 and H300 at 0.1 mL/10 g bw and a 0.2 mL volume. After 2 h of the last treatment, the control group was given olive oil (10 mL/kg), while the other groups were simultaneously injected intraperitoneally (i.p.) with 10 mL/kg of 0.3% (v/v) CCl4 in olive oil. Then, all animals were fasted for 16 h and anesthetized using sodium pentobarbital . Blood was collected immediately from the fundus vein and kept at 4 °C. After death, the liver was removed and placed in chilled saline solution, dried with filter paper and excised into two portions. One part was frozen quickly using liquid nitrogen and stored at −80 °C until the preparation of hepatic homogenates for the determination of biochemical parameters, while the other portion was preserved in 10% formalin for histopathological investigations.Mice were randomly divided into five groups of 11 animals each. The experimental process is summarized in Table 30. Liver tissues (0.1 g) were excised and homogenized using a homogenizer. The sample livers were homogenized on ice with a 9× volume of homogenate prepared by precooled saline solution (0.9%) and centrifuged at 3,500 rpm for 15 min. The tissue homogenates were inspected for the determination of total soluble proteins by the Bradford method, and the calibration curve was prepared using solutions of bovine serum albumin (BSA)31. Absorbance was recorded at 562 nm via a UV-visible spectrophotometer . The MDA content was detected by the thiobarbituric acid method32; SOD activity was measured at 550 nm following the nitro-blue tetrazolium method; and the basis for the evaluation CAT activity was decomposition of H2O2 to less reactive molecules, which was recorded at 240 nm and assessed by following the kit instructional protocol34. POD activity was estimated on the basis of guaiacol peroxidation measured at 420 nm36.During the whole experiment, the general conditions and bw of mice were monitored at 0, 7 and 14 days. For biochemical analysis, assays were conducted using kits obtained from the Institute of Biological Engineering of Nanjing Jiancheng  according to the manufacturer’s protocol. Blood was centrifuged at 3,000 rpm for 10 min at 4 °C, and then the serum levels of ALT and AST were determined by colorimetryHistopathological observation was performed as follows: liver tissues preserved in 10% neutral formalin solution for at least 24 h were embedded in paraffin and cut into 5 μm thin sections, deparaffinized, dehydrated, and stained with hematoxylin-eosin for the estimation of hepatocyte necrosis and vacuolization. Histopathological changes and injuries were observed under light microscopy , and photographs were captured at 400× magnification.ξ) derived from the GCA represents the degree to which the correlation factor sequence is close to the behavioral feature. The higher the value of ξ is, the closer the sequence of associated factors to the behavioral characteristics. Detailed steps can be found in the experimental section of the supporting information. The basic idea of BCA is to study the correlation between two sets of variations37, and BCA is widely used in the quality evaluation of TCMs38. Fingerprint-activity relationship analysis was performed by transferring common fingerprint peak area and pharmacological test data into SPSS software, and then BCA was used to assess the spectrum-effect relationships between the areas of common characteristic peaks in the fingerprint and the main hepatoprotective parameters. The statistical analysis was performed by one-way ANOVA followed by Duncan’s multiple-range test to compare the means with the significance level set as 0.05 by SPSS 17.0. Biological pathway analysis was constructed based on the bioactive markers according to KEGG and MetaboAnalyst 4.0. Colors varying from yellow to red indicate that the metabolite data have different levels of significance.GCA and BCA were performed to assess the fingerprint-activity relationship model with Excel 2010 for Windows 10 and SPSS 17.0 statistical software , respectively. The correlation coefficient  of AVF stressed by four concentrations of NaCl for 14 days prior to CCl4-induced hepatotoxicity significantly decreased ALT activity by 29.16%, 25.89%, 20.97% and 24.16%, respectively, and AST activity by 31.14%, 31.47%, 29.84% and 23.72%, respectively, compared to the model group levels. Administration of a high dose (3 g/kg) of AVF prior to CCl4 injury markedly reduced hepatotoxicity, with the aminotransferase activities decreasing by approximately half, indicating promising effects of AVF protection against CCl4-induced damage by the regulation of enzymatic expression to a level similar to that of silymarin. Our results were in accordance with other findings in which treatment with a crude methanol extract of medicinal plants restored the levels of liver biochemical markers after CCl4 treatment35.Metabolic products of CCl4-induced hepatotoxicity and significantly reduced the level of MDA, which was inversely proportional to the salt dose  are shown in Fig. 4-treated mice, extensive liver injuries were observed in hepatocytes, characterized by hepatocellular degeneration and necrosis around the central vein, inflammatory cell infiltration, ballooning degeneration, and the loss of cellular boundaries. However, coadministration with a low dosage of AVF prior to CCl4 treatment reduced the extent of histopathological injury. Furthermore, silymarin and high-dose AVF, especially 100 mM salt-stressed AVF, restored the altered parameters to the control levels. These results were in good agreement with the serum aminotransferase and hepatic antioxidant enzyme activity results, and similar results have been found for Brachychiton populneus extract against CCl4-induced liver injury35. Although the effects of salt-treated AVF manifested differently with respect to liver protection, the liver injury was remarkably ameliorated by pretreatment with H100, resulting in lower hepatocellular degeneration and less hydropic necrosis.The protective effects of AVF against CCl45. Fingerprint-activity relationship modeling of TCM is based on the guidance of TCM theory. The fingerprints and pharmacodynamics of TCMs, which are correlated by chemometric models, establish a comprehensive evaluation system for revealing the material basis of the pharmacodynamics of TCMs46. This has been one of the approaches used for predicting active ingredients and performing quality control in natural products. In this study, multivariate statistical analysis was conducted to associate chemical composition with efficacy to evaluate AVF quality and, furthermore, to discover bioactive markers. GCA is often used to reveal quantitative comparisons of trends in dynamically changing systems and is suitable for solving problems with complicated interrelationships between multiple factors and variables48. GCA also provides a reliable method for the quality evaluation of TCMs. Compared with other analysis methods, such as regression analysis and canonical correlation analysis, GCA has several advantages, such as requiring only a small sample size and a small amount of calculations and providing intuitive results50. GCA can be used to assess the size of the relevance between the efficacy index and the chromatographic peak and offers a possibility for predicting the active components51. BCA is also known as canonical correlation analysis. The basic idea of BCA is to study the correlation between two sets of variations37, revealing much of the information about them and finding their linear combinations that have the highest correlation22. The Pearson correlation coefficient has a clear quantitative meaning and can reflect the magnitude and direction of the linear correlation between variables52. Although the outcomes analyzed by GCA and BCA were not completely consistent, there were either synergetic or antagonistic effects among these components52.The assessment of spectrum-effect relationships represents a powerful tool for the quality control of herbal medicines. However, the key difficulty in the application of spectral relationships to TCMs is how to associate complex chromatographic peaks with pharmacodynamic informationr) being greater than 0.5 -β-D-glucoside, acetylated isoquercitrin, and quercetin 3-O--β-D-galactoside), terpenoids , phenylpropanoids (chlorogenic acid and cryptochlorogenic acid), quinones (hyperforin) and two unknown compounds (P3 and N4). This finding revealed that the defensive properties of AVF might be attributed to the presence of potent antioxidant constituents preventing tissue degeneration by inhibiting lipid peroxidation of the liver.Based on the GCA and BCA results, 19 peaks  were correlated with pharmacodynamic effects. P2/N3, P5/N6, P8/N8 and P11/N11 were identified as the same compound, respectively. Therefore, 15 bioactive markers were obtained, including organic acids (citric acid/ isocitric acid and shikimic acid), flavonoids , and the alteration of these metabolites might disrupt energy metabolism. Citric acid acted as a potential biomarker, showing hepatoprotective effects and contributing directly to the therapeutic effect of 58. Procyanidin B2 was investigated against hepatic oxidation in diabetic rats and exhibited a protective effect against CCl4-induced hepatic injury by elevating the antioxidative defense potential and consequently suppressing the inflammatory response60. The hyperoside and isoquercitrin in AVF could be potential natural hepatoprotective agents protecting the liver from injury though inhibition of oxidative stress as well as regulation of acetaminophen metabolism, and reports revealed that administration of these compounds effectively restored liver functions61. Although it has been speculated that the derivatives of hyperoside and isoquercitrin are biotransformed into corresponding glycosides62 or partly involved in the hepatoprotective function of AVF39, little research has been performed on their biological activities. In addition, as a phloroglucinol derivative, hyperforin, found in Hypericum perforatum L., provided protection against free radical-induced DNA damage based on its scavenging activity63; however, there is currently no related information on the hepatoprotective activity of hyperforin or allamandin.The most abundant bioactive flavonoid constituents correlated with hepatoprotective activity were quercetin, procyanidin B2, hyperoside, isoquercitrin, and derivatives of hyperoside/isoquercitrin. The potential mechanism of quercetin-induced hepatic protection is mainly mediated through its powerful antioxidative capacity, inhibition of hepatocyte apoptosis and suppression of inflammatory cytokines via signaling pathways3. In terms of the heat map, it seemed that a low concentration of salt stress could increase the accumulation of secondary metabolites, and AVF exposed to low levels of salt stress might be considered a source for dietary supplementation of polyphenols.The most significantly impacted biological pathways Fig. , e.g., f4-induced acute liver injury in mice, and the effects of AVF were achieved via a reduction in serum transaminase activities, elevating hepatic antioxidative enzyme activities and ameliorating tissue lesions. Then, fingerprint-activity relationship modeling between the spectrum and the medicinal efficacy was examined by GCA and BCA to perform the quality evaluation and screen out bioactive markers for the AVF response to salt. According to the results, the abundant polyphenols might be responsible for the protective effects against acute liver damage in mice, and AVF with low-salt treatment was better in terms of efficacy than the other three groups. This strategy could serve as a useful reference for the quality evaluation, the discovery of bioactive markers and the future exploitation of salt-tolerant Chinese herbal medicines.In this study, fingerprint-activity relationship modeling was established to perform a quality evaluation of salt-tolerant AVF based on chemical fingerprints and efficacy. First, UFLC-Triple TOF-MS/MS fingerprints were established, and cluster analysis was performed based on the common characteristic peaks to evaluate the similarity between groups. Second, salt-stressed AVF protected against CClSupporting information


Generally, the results of the study showed that new poly urea-formaldehyde adsorbent can be efficiently used to remove highly concentrated cadmium ions from aqueous solutions.Cadmium is a heavy metal toxic that enters water resources through industrial, household, agricultural waste and non-sanitary landfill of urban and industrial wastes. Pollution of water resources by cadmium increases incidence of diseases including Itai-Itai, kidney disorders, cancer, chromosome effects and kidney tubular damages in low exposures. The aim of this study is to study the efficiency of a new poly urea-formaldehyde adsorbent in the removal cadmium ions from aqueous solutions. The effect of different variables such as initial pH, contact time, initial concentration of cadmium and test of real wastewater samples were evaluated. In addition, laboratory data of cadmium adsorption by urea-formaldehyde adsorbent were matched to Langmuir, Freundlich and Temkin isotherm models. The results of the study showed that maximum adsorption capacity obtained by Langmuir model was 76.3 mg/g at pH = 5.5. Laboratory adsorption data matched mostly by Freundlich isotherm model (R Specifications Table•Preparation a new highly efficient polymer urea-formaldehyde for the removal of cadmium ions from aqueous solutions.•Maximum adsorption capacity of cadmium was 76.3 mg/g.•Suitable application of urea-formaldehyde adsorbent in removing cadmium ions from wastewater is shown.3COOH) (purity degree of 100%), nitric acid (purity degree of 65%), acetate sodium (C2H3NaO2), sodium dihydrogen phosphate (NaH2PO4), di-sodium hydrogen phosphate (Na2HPO4) and sodium hydroxide (NaOH) were provided from Merck company, Germany. A stock solution of 500 mg/L of cadmium was prepared by dissolving a certain amount of cadmium nitrate salt in de-ionized water. Different concentrations of cadmium solution were prepared by diluting the stock solution.All chemical materials used in the present research were in analytical grade. Chemicals including cadmium nitrate, urea, formaldehyde, acetic acid  0.01 M and acetic acid 0.01 M (CH3COOH) were used and to prepare buffers with a pH ranging from 6.5 to 8.5, sodium dihydrogen phosphate (NaH2PO4) 0.01 M was used. pH of the solutions was measured by a pH-meter (model Basic 20 Crison). After adsorption tests, adsorbents were removed from solution by membrane filter and the concentration of filtered cadmium solution was measured by an Atomic Absorption Spectrophotometer (Shimadzu AA-670 model) equipped with GFA-4B graphite furnace atomizer and D2 lamp for background correction. Cadmium hollow cathode lamp was applied as radiation source at 4 mA. An atomic absorption signal at 228.8 nm line was recorded on a graphic printed PR-4 with peak height and gas stop mode for quantification.All cadmium adsorption tests on urea formaldehyde polymeric adsorbent were performed using 50 mL of cadmium solution in 100 mL Erlenmeyer at a temperature range 22–24 °C on a 300 rpm shaker. In this study, the effects of initial pH , contact time  and initial cadmium concentrations  parameters were studied. Before adsorption process, in order to prepare buffers with pH ranging from 3.5 to 6.5, acetate sodium  was also studied. The sample was collected from effluent of a wastewater treatment plant located in south of Tehran in Ray. First, concentration of cadmium ion was measured in real sample which was 0.078 mg/L. Then, 2 mg/L cadmium was added to the real sample and they were put next to 1 gr adsorbent for 15 min under optimum pH conditions at 22–24 °C and the amount of cadmium adsorption was determined by atomic adsorption spectroscopy method. To improve accuracy and validity, all adsorption tests were repeated in triple.In surveying efficiency of synthesized polymer on real samples equations (1) and (2) were used to calculate percentage of standard deviation and relative standard deviation, respectively:SD: Standard deviationRSD (%): Relative standard deviationN: Number of times that test performedIn order to calculate the efficiency of cadmium removal by urea-formaldehyde equation i is initial concentration of pollutant in the solution (mg/L) and Ct is final concentration of pollutant in the solution (mg/L).Where, RE is removal efficiency (%), C+ ions and cadmium ions, but in pHs higher than 5.5 the rate of cadmium adsorption by studied adsorbent increases and this may be due to the formation of solution complexes [Solution pH is one of the most important parameters in adsorption process, because the binding of cations to active surface groups is strongly dependent on the surface charge of particles . The effomplexes .Fig. 3ThContact time between adsorbate and adsorbent is an important parameter in adsorption process . As showIn order to design an adsorption process for application in field, the isotherms for an adsorbate-adsorbent system should be determined experimentally . The isoLangmuir isotherm is valid for single layer surface adsorption and was first performed with the aim of describing gas surface adsorption on activated carbon .Assumptions of Langmuir model: 1-adsorption energy is the same and does not depend on the amount of absorbed material on the adsorbent, in other words, the adsorption capability of each site is the same as the other and the presence of absorbed material in each site has no other effect, 2-adsorption bonds are reversible and 3-absorbed material is a layer with thickness of a molecule ,16.The linear form of Langmuir isotherm is represented by the expression:The most important multisite adsorption isotherm for heterogeneous surfaces is the Freundlich adsorption isotherm . FreundlLnK is y-intercept. Slope of this line is The Temkin isotherm is usually applied for heterogeneous surface energy systems (non-uniform distribution of sorption heat) . AssumptIn the above equation, B = RT/b is a constant showing heat of sorption (J/mol) obtained from the Temkin plot (qe against lnCe), A (slope) is Temkin isotherm equilibrium binding constant (L/g), b (intercept) is Temkin isotherm constant, R is universal gas constant (8.314 J/mol.k) and T is absolute temperature (Kelvin).2 correlation coefficient, the results showed that cadmium adsorption on urea formaldehyde adsorbent best matches Freundlich isotherm model. Since Freundlich isotherm indicates multi-layer adsorption on heterogeneous surfaces, it can be concluded that cadmium adsorption by urea formaldehyde occurred in multi layers (In this study, three isotherm models such as Langmuir, Freundlich, and Temkin adsorption isotherms were used. Maximum adsorption capacity was 76.3 mg/g. Freundlich, Langmuir and Temkin adsorption isotherms parameters are presented in i layers , Fig. 7.Results of tests performed on real sample are presented in


Aconitum carmichaelii Debx.; AL), which is an herb used to treat extremely cold symptoms in traditional Korean medicine, on BPH using a testosterone propionate- (TP-) induced BPH rat model. Eight-week inguinal injection of TP induced BPH in rats, the prostate of which was displaying an abnormal proliferation. The pathological proliferation of the prostate was ameliorated by AL treatment of 4 weeks. Pathohistological changes in the prostate including epithelial thickness and lumen area were restored in AL-treated rats. Furthermore, 5α-reductase (5AR) and androgen receptor (AR), the two main factors in the pathogenesis of BPH, were decreased. In addition, the ratio of BAX and Bcl-2, an indicator of apoptosis, was increased by AL as well. Similar results were observed in AL-treated LNCaP prostate cancer cells. AL treatment suppressed the expression of the 5AR-AR axis and increased the ratio of BAX and Bcl-2. Apoptosis in the testis is considered a crucial side effect of finasteride, a 5AR inhibitor used to treat BPH. Our results showed that AL treatment did not display such effects, while finasteride treatment resulted in loss of spermatogenic cells within the prostate. Overall, these results suggest AL as a potentially safe nature-derived therapeutic agent for BPH treatment.Benign prostatic hyperplasia (BPH) is a common disease in elderly men which can be characterized by an abnormal enlargement of the prostate associated with lower urinary symptoms. Current medications available for BPH treatment display several adverse effects; thus, the search for effective treatments with less side effects is still ongoing. In this study, we investigated the effect of Aconiti Lateralis Radix Preparata (dried root of  Benign prostatic hyperplasia (BPH) is a chronic disease commonly found especially in aging men . It is rα-reductase (5AR). DHT is considered a main factor of BPH pathogenesis, as it is expressed five times more than testosterone in BPH patients [The detailed mechanism of BPH pathogenesis is not fully revealed, but testosterone and dihydrotestosterone (DHT) are well known as inducers of BPH . After tpatients . DHT haseductase AR. DHT ipatients .α1-adrenergic receptors, relax the smooth muscle tone in the prostate and improve the urinal flow [α-blockers is limited because of side effects such as headaches, hypotension, or ejaculation changes . Furthermore, the α-blocker itself cannot regulate the size of the prostate [There are two mainly considered medical treatments for BPH. Alpha-blockers, which are inhibitors of nal flow , 8. Howeprostate , 10. Anoprostate  and evenprostate . Becauseprostate .Aconitum carmichaelii Debx., of family Ranunculaceae, has been traditionally used as an essential herbal drug for cold sensation by stimulating heat generation in East Asia [Aconiti Lateralis Radix Preparata (AL), the processed daughter root of ast Asia . Studiesast Asia –18, and ast Asia . Nowadayast Asia .Aconitum heterophyllum suppressed prostate enlargement in testosterone-treated rats. However, this study only reports the antiproliferative effect lacking the related action mechanism. Therefore, we conducted a study to evaluate the effect of AL on BPH using testosterone propionate- (TP-) induced BPH rats and LNCaP prostate cancer cells.The antiproliferative effect of AL on the prostate has been first reported by Dumbre et al. . Dumbre'Aconitum carmichaelii Debx. in 1 L of distilled water at 100°C for 150 min based on the traditional extraction method of herbal prescriptions used in Korean medicine [μm syringe filter, evaporated, and then stored at −20°C until usage.The water extract of AL was obtained by boiling 100 g of dried roots of medicine . The solTP was purchased from Wako Pure Chemical Industries , and Fi (≥97% pure) was purchased from Sigma-Aldrich Inc. . Antibody for AR was from Pierce Biotechnology , and antibody for 5AR was from Abcam Inc. . Antibody for glyceraldehyde 3-phosphate dehydrogenase (GAPDH) was from Santa Cruz Biotechnology , and antibodies for BAX and Bcl-2 were purchased from Cell Signaling Technology .μL of this injection formula in the inguinal area. Normal control rats were injected with the same solvent without TP included. Then, the rats were divided into the following four groups (n = 5 per group) and were treated for 4 additional weeks: (a) a normal control (NC) group that received ethanol with corn oil, (b) a BPH group that received TP with corn oil, (c) a positive control group that received finasteride (Fi) (1 mg/kg/day) with TP (5 mg/kg/day), and (d) a group that received AL (20 mg/kg/day) with TP (5 mg/kg/day). AL and Fi were administrated via oral gavage. After the final treatment, animals were fasted overnight and euthanized using CO2, and the ventral region of prostate tissues was obtained as described previously [Twelve-week-old male Sprague Dawley (SD) rats (body weight 200–220 g) were purchased from the Dae-Han Experimental Animal Center . The animals were all maintained in conditions in accordance with the regulation issued by the Institutional Review Board of Kyung Hee University (confirmation number KHUASP(SE)-P-034). The rats were housed in a pathogen-free room maintained at 23 ± 2°C under a 12 h light/dark cycle. Water and standard laboratory diet  were provided ad libitum. BPH was induced as previously described [eviously . The relThe prostate tissue section preparation and H&E staining were performed as described previously . The sliProtein expression analysis was performed as previously reported . In brieThe human prostatic cancer cell line LNCaP was obtained from the Korean Cell Line Bank . LNCaP cells were cultured in the Roswell Park Memorial Institute (RPMI) medium  supplemented with 100 mg/mL penicillin/streptomycin  and 10% FBS (Sigma-Aldrich Inc.).4 cells/well) and incubated in the RPMI medium plus 10% FBS for 24 h. Then, the cells were incubated in fresh media containing various concentrations of BBR for an additional 24 h. Cell viability was monitored using the cell proliferation MTS kit by the Promega Corporation as recommended by the manufacturer as previously described [LNCaP cells were seeded  with an Agilent 6550 iFunnel Q-TOF LC/MS system was used to perform high-resolution liquid chromatography-mass spectrometry (LC-MS) of AL according to the manufacturer's instructions by the Western Seoul Center of Korea Basic Science Institute. Data acquisition was performed using 6200 series TOF/6500 series Q-TOF B.06.01 (B6172 SP1) software . Specific conditions for LC-MS analysis are described in P < 0.05) was analyzed by the Kruskal–Wallis H test followed by Bonferroni's method as a post hoc test using GraphPad Prism 5 for Windows .The data were presented as mean ± standard deviation (SD). Statistical significance , component 2 (molecular weight: 634.2889) could be hypaconitine  or mesaconitine , and component 3 (molecular weight: 648.305) could be aconitine . However, to clarify, further studies should be carried out with different fractions and/or identified constituents to confirm which is the active compound responsible for the effects of AL.Hit identification is the basic level of small molecule discovery, and therefore, it is necessary to identify effective compounds to value the effects of natural products. Our LC-MS analysis identified three constituents which may possibly be responsible for the beneficial effect of AL on BPH. Although the molecular weight of identified compounds did not match exactly with that of previously known constituents of AL, based on previous reports , 49, theIn conclusion, we confirmed increased levels of 5AR and AR and a decreased ratio of BAX and Bcl-2 as well as the changes of the histological structure in BPH rats. These changes were reversed by AL treatment, and in addition, AL-treated LNCaP cells also showed similar results. Furthermore, AL treatment did not induce any abnormal changes in the histology of the testis as Fi treatment did. These results suggest AL as a potentially safe nature-derived therapeutic agent for BPH treatment.


Kinase-anchored protein 6 (AKAP6) gene polymorphisms and glioma susceptibility and prognosis in Chinese Han population.Glioma is the most common primary malignant brain tumor with high mortality and poor prognosis. Our aim was to clarify the correlation between AKAP6 were genotyped by Agena MassARRAY in 575 glioma patients and 500 healthy controls. Logistic regression model was utilized to calculate odds ratios (OR) and 95% confidence intervals (CI). The associations between polymorphisms and survival were assessed using the log-rank test, Kaplan-Meier analysis and Cox regression model.Five single-nucleotide polymorphisms (SNPs) of p = 0.007) and a worse prognosis for glioma, especially in high-grade glioma . Stratified analysis showed that rs2239647 increased the risk of glioma in female . Whereas, rs4261436  and rs17522122  were associated with better prognosis of astrocytoma. In addition, we also found that surgical methods and chemotherapy are critical factors for the prognosis of glioma patients.We found that rs2239647 polymorphism was strongly associated with an increased risk of glioma (OR = 1.90, AKAP6 polymorphisms on susceptibility and prognosis of glioma, suggesting AKAP6 variants might have potential roles in the etiology of glioma.This study firstly provided evidence for the impact of  Interleukin 4 Receptor (IL-4R), EGF containing fibulin extracellular matrix protein 1 (EFEMP1), Regulator of telomere elongation helicase 1 (RTEL1), Cocaine and amphetamine regulated transcript (CART) and Isocitrate dehydrogenase 1 (IDH1)  –9.AKAP6 gene, is a protein with diverse structures and is highly expressed in various brain regions and cardiac and skeletal muscle. AKAP6 is a member of the AKAP family proteins and performs important functions by binding to the regulatory subunit of protein kinase a (PKA) , encoded by the  a (PKA) . PKA has a (PKA) . Genome- disease , anorexi disease , and poo disease .AKAP6 gene polymorphisms may be related to the pathogenesis of glioma. However, no literature supports the effect of AKAP6 polymorphisms on glioma. In this case-control study, we investigated the correlation between AKAP6 single nucleotide polymorphisms and glioma susceptibility and prognosis in the Han Chinese population.Based on previous results, we hypothesized that In this study, 575 glioma patients (including 448 patients with astroglioma) and 500 healthy subjects were randomly recruited from Second Affiliated Hospital of Xi’an Jiaotong University. All patients were diagnosed with gliomas by imaging and histopathological, and all patients were unrelated. Demographic and clinical data were collected through standardized questionnaires and follow-up surveys, including age, sex, date of the first diagnosis, method of surgery, radiotherapy and/or chemotherapy program, date of last follow-up, and the condition of the patient  at the time of the last follow-up. Healthy subjects in the control group ruled out people with a history of cancer and people with a history of diseases associated with the brain and central nervous system. This study was approved by the ethics committee of Second Affiliated Hospital of Xi’an Jiaotong University and followed the Helsinki declaration. Each subject was informed of the purpose of our study and signed a written informed consent.Genomic DNA was extracted from glioma patients’ peripheral blood samples (5 mL) using Gold Mag-Mini DNA purification kit . DNA concentrations were determined by the NanoDrop 2000 . Multiplexed SNP Mass EXTENDED assay was designed by Agena MassARRAY Assay Design Software version 4.0 . SNP genotyping with a standard protocol was performed using Agena MassARRAY RS1000 . Agena Typer Software version 4.0  was used to management the data.Online software for HaploReg v4.1  and SNPinfo Web Server (https://snpinfo. niehs.nih.gov/snpinfo/index.html) were used to predict the possible functional effects on these SNPs.AKAP6 genotypes on overall survival and progression-free survival  was assessed using the Chi-square test. Odds ratio (OR) and 95% confidence interval (CI) were calculated to estimate the relationships between SNPs and glioma risk using logistic regression analysis. Multiple inheritance models  were assessed by PLINK software. Patient survival curves were plotted using the Kaplan-Meier method, and the log-rank test. Hazard ratio (HR) and 95% confidence interval (CI) were calculated through univariate and multivariable Cox proportional hazard regression analysis to evaluate the effect of the survival –17. Statp = 0.942) and gender-matched (p = 1.000) healthy controls, and the average ages were 40.53 ± 13.90 years and 40.45 ± 18.08 years respectively. The participants’ demographic and clinical information was listed in Table This study included 575 glioma patients and 500 age-matched  were genotyped. The basic information of selected SNPs and potential function predicted by HaploReg database about these variants were summarized in Additional file p values were more than 0.05). The predicted results from the database showed that these SNPs might function as enhancer histone markers or by changing motifs.Five SNPs in AKAP6 rs2239647 and risk of glioma are showed in Table p = 0.010) and recessive model .Multiple inheritance models analysis  for the association between p = 0.012; recessive model: OR = 2.83, p = 0.006) and in the male population . And, people with the rs2239647-AA genotype had a higher risk of astroglioma than healthy controls . Moreover, rs2145587 was associated with an increased risk of glioma in female .In addition, we conducted a stratified analysis to explore the effects of these SNPs on glioma susceptibility in a specific population. The significant results of stratified analysis are showed in Table p > 0.05), while surgical methods and chemotherapy were significantly related to the prognosis of patients (p < 0.05) . The prognosis of patients receiving chemotherapy was better than that of patients not receiving chemotherapy .The log-rank test was applied to analyze the associations between overall survival (OS) or progression free survival (PFS) and clinical factors, and the results indicated that gender, age, WHO grading, and radiotherapy factors were not related to the prognosis of patients p > 0.0, while sAKAP6 polymorphisms on the patient survival. Log-rank test and Kaplan-Meier analysis revealed the relationship between rs2239647 and OS and PFS in glioma patients (Table AKAP6-rs2239647 significantly affected the PFS of patients with high-level glioma (WHO grade III–IV), and patients with CA genotype had a better prognosis .We evaluated the effect of ts Table . We founAKAP6 polymorphisms on the prognosis of patients with astroglioma . AKAP6- rs17522122 also had a significant effect on the OS of patients, and patients with TC genotype had a poor prognosis .Subsequently, we analyzed the effect of ma Table . The resAKAP6 gene variation and glioma risk or prognosis in Han Chinese population. We found that AKAP6 single nucleotide polymorphisms rs2239647 and rs2145587 were associated with glioma susceptibility. More importantly, rs2239647, rs4261436 and rs17522122 were significantly correlated with the prognosis of patients. In addition, we also found that the extent of the surgical resection and chemotherapy are also key factors for the prognosis of glioma patients.This study confirmed the relationship between http://gepia.pku.cn/) to predict the expression of AKAP6 mRNA, the result showed that the mRNA level of AKAP6 gene was significantly up-regulated in glioma . The Y-axis represents the relative level of AKAP6 gene expression. GBM: glioblastoma multiforme. * indicates statistical significance (p < 0.01).Additional file 3: Figure S3. Kaplan–Meier survival curves for overall survival based on AKAP6 gene in low-grade glioma. Data was extracted from the GEPIA database (http://gepia.cancer-pku.cn/).Additional file 4: Table S1. The information and HWE about the candidate SNPs in AKAP6.Additional file 5: Table S2. The impact of clinical factors on glioma patient OS and PFS.