Arabidopsis halleri with Turnip mosaic virus for 3 years without severe damage. Virus dynamics and virus–host interactions within hosts were highly season dependent. Virus accumulation in the newly formed leaves was temperature dependent and was suppressed during winter. Transcriptome analyses suggested that distinct defence mechanisms, i.e. salicylic acid (SA)-dependent resistance and RNA silencing, were predominant during spring and autumn, respectively. Transcriptomic difference between infected and uninfected plants other than defence genes appeared transiently only during autumn in upper leaves. However, the virus preserved in the lower leaves is transferred to the clonal offspring of the host plants during spring. In the linage-to-linage infection of the A. halleri–TuMV system, both host clonal reproduction and virus transmission into new clonal rosettes are secured during the winter–spring transition. How virus and host overwinter turned out to be critical for understanding a long-term virus–host interaction within hosts under temperate climates, and more generally, understanding seasonality provides new insight into ecology of plant viruses.Persistent infection, wherein a pathogen is continually present in a host individual, is widespread in virus–host systems. However, little is known regarding how seasonal environments alter virus–host interaction during such metastability. We observed a lineage-to-lineage infection of the host plant  Plant viruses have been studied primarily as important pathogens of crops. They cause various diseases characterised by a combination of severe symptoms and high transmission rates –3. HowevIn natural systems, within-host virus accumulation may largely change with seasons depending on virus replication and host growth. Regarding host populations, seasonality of infection rate and its determinant factors, such as vector activities and host susceptibility, have been studied –14. PrevThe degree of virus accumulation in its host is likely to show seasonality because both viral replication and plant growth are highly temperature dependent. The optimal temperature for the replication of plant viruses varies ranging between 15 °C and 30 °C –20. SimiArabidopsis halleri subsp. gemmifera , and Turnip mosaic virus (TuMV), a virus infecting it in natural environments. In a natural population of A. halleri in central Japan  is a perennial herb. The species flowers from April to May, and then, reproduce sexually by producing seeds and clonally by forming vegetative rosettes. Rosettes grow continually during summer and autumn, and then, overwinter. All field studies and material samplings were conducted at the Omoide gawa study site, Taka-cho  [A. halleri plants grow in open places along small streams running through secondary forests and plantations of Cryptomeria and Chamaecyparis. The TuMV-infected plants were 57% of examined A. halleri plants as sown by a previous plot census [ltitude) . The Mont census . Daily mA. halleri (designated as plant patches 1 and 2). As plant patch 2 was heavily damaged by deer herbivory in January 2014, we further identified another infected patch (plant patch 3). Samples from plant patch 1 were obtained for the whole observation period (157 weeks from September 2012 to September 2015); however, samples from plant patches 2 and 3 were obtained for shorter periods . On each sampling day, we collected one fully expanded young leaf (ca. 1 cm in length of leaf blade) from a randomly chosen rosette within the plant patches. Each leaf was sampled by a tweezer (sterilised with 70% ethanol prior to each sampling) and was immediately placed in a 1.5 mL microtube with 1.0 mL RNAlater  to protect RNA degradation. The samples were kept on ice and were brought back to the laboratory. The samples were immersed in RNAlater at 4 °C for 1 day, and then stored at –20 °C until further analysis.The sampling of 3-year time-series observations on TuMV dynamics was performed using leaves obtained from clonal patches in which genetically identical rosettes were aggregated. In September 2012, we identified two TuMV-infected plant patches in the natural habitat of To estimate TuMV level, we conducted RT-qPCR for the samples from three infected patches every 2 weeks during their observation periods  [H, θ, and π were calculated using DnaSP [To evaluate the temporal constancy of TuMV genome sequences within single plant patches during the 3-year observation period, consensus TuMV sequences were determined by RNA-Seq for selected samples (Supplementary Table Srugosum) , 36 was ng DnaSP .The TuMV distribution in leaves at different positions within plants was examined in the natural population to determine whether winter decrease in virus occurs in the whole plant or only in newly expanded leaves. The TuMV amount was quantified by RT-qPCR. The four sampling times were set at 2-month intervals on 22 December 2015 and 23 February, 19 April, and 21 June 2016. Sampled plants were at the rosette phase in December and February, in the flowering phase in April, and with newly formed rosettes in June. At each sampling time, we sampled four infected plants (Supplementary Table St-tests (two-sided), to evaluate in which positions the level of virus accumulation differed. All statistical analyses, including those described later, were conducted using R 3.4.1 software [For all sampled plants, we harvested eight leaves at different positions/plants and preserved them separately in 1.5 mL microtubes with 0.8 mL RNAlater within 48 h after sampling. We numbered positions of leaves acropetally from basal leaves along the main stem as follows: positions 1 and 8 represent the lowest and uppermost leaves (>2.5 mm in length), respectively. The number of leaves per plant ranged from 6 to 17. When the leaf number was 9‒17, every other leaf was sampled at lower positions to make the total number of sampled leaves eight. When the leaf number was less than eight (one plant), lower positions were treated as missing. Leaves in RNAlater were kept at 4 °C for 1 day, and then stored at –20 °C until analysis. The TuMV quantifications were conducted by RT-qPCR. We applied generalised linear model (GLM) with an underlying Gaussian distribution and log link function to evaluate difference in TuMV accumulation across leaf positions. The full model included effects of position, sampling month, and interaction between position and month. The model were compared those with position and month effects and with position effect only. The best model was selected using Akaike’s information criteria. For the month for which the interaction term was significant in the GLM analyses, we further conducted multiple comparisons to TuMV accumulation at different leaf positions for each month using Bonferroni corrected paired software .N, P, K = 320, 210, and 300 mg/L, Takii, Japan). We obtained eight, four, and four clonal rosettes from the original three infected plants, respectively. These infected plants were incubated for ca. two months in a growth chamber  until they were used for the experiment. The plants were divided into two groups, with eight plants  per group, to apply following two temperature treatments.We conducted a 12-week temperature-switch experiment to examine the temperature dependency of TuMV spread into newly formed leaves of infected plants. We collected three infected plants at the Omoide gawa site and used them to multiply infect clonal rosettes. The plants were incubated in a warm growth chamber to enhance bolting  for 35 days. Then, a 16 h day-length was employed to promote flowering and clonal rosette formation. After the clonal rosettes produced roots, rosettes were transplanted into new pots with soils, a 1:1 mixture of pumice  and culture soil  and 84 (end of the treatments), we recorded total number of leaves (withered leaves were excluded) once a week for all plants to calculate relative increase rates of leaves. Relative increase rates of leaves were estimated as slopes of regressions of natural logarithm of leaf number on experimental days. These values were obtained for each high- and low-temperature condition for the first 42 days and the following 42 days separately. On day 0 and 84, leaf samples were obtained from all plants. At other sampling times, leaves were sampled from half of the investigated plants . During each sampling time, we sampled the first and second newer leaves to quantify TuMV level. The leaves were preserved in RNAlater and kept at 4 °C for 1 day. The samples were stored at –20°C until they were analysed. The TuMV quantifications were conducted by RT-qPCR. For each of measurement dates, the difference in TuMV accumulation in the leaves between the treatments was examined by the Mann–Whitney U test. The effects of temperature on relative increase rate of leaf were also examined by the Mann–Whitney U test.We set two temperature treatments in which plants were subjected to either high (25 °C/15 °C) or low (15 °C/5 °C) temperatures for the first 42 days, and then, alternate temperatures for the following 42 days using two growth chambers . We named the two treatments as H-L and L-H conditions. Day-length was 12 h for both conditions. Light was supplied by fluorescent lights for plant growth . In addition, PAR and R:FR at the pot-surface level for the H-L and L-H growth chambers were averaged to 115.0 ± 9.9 μM/s/m5 total reads. We mapped the RNA-seq reads on TuMV and distinguished infected and uninfected plants. The number of infected/uninfected plants were 12/36, 13/33, 13/31, and 13/35, for SE, SS, AE, and WS, respectively. There was no apparent bias in the sampling time between the infected and uninfected plants. Chloroplast-coded genes, genes with averaged mapped reads < 10, and genes with unmapped samples > 10 were excluded from the analysis of each season. Our previous study reported occurrence of other viruses, i.e., Cucumber mosaic virus (CMV), Brassica yellow virus (BrYV), and Arabidopsis halleri partitivirus 1 (AhPV1), in the study area [A. halleri transcriptome by applying GO terms for A. thaliana  to sequence homologues in A. halleri.We compared transcriptomes of TuMV-infected and -uninfected plants using data obtained during four different seasons at the Monzen site in our previous study  . Althougudy area  for SE, udy area . Gene on4‒105 fold  relative to those among different plant patches  in the region. Among the 142 SNP sites, 116 differed between patches but were fixed within patches. Virus sequences obtained from each of the three plant patches formed a cluster for each host genotype Fig. . We obseThe TuMV distribution was examined four times in two month intervals between WS and SS with different temperature regimes Fig. . Plants P < 0.05) on days 14 and 84 and were marginally significant (P < 0.07) on days 28 and 56. The production rate of leaves was low, and newly formed leaves showed less accumulation of TuMV under low-temperature conditions, which corresponded with winter decrease of virus accumulation in the natural population.In the temperature-switch experiment using infected plants Fig. , new leaAGO2, PHLOEM PROTEIN 2-B1 (PP2-B1), and IST1-LIKE 6 (ISTL6), were common between SE and AE , WRKY 70 (WRKY70), and PATHOGENE-RELATED PROTEIN 2 , AGO1, and AGO2, were upregulated (Fig. AhgRDR6, Supplementary Fig. SNIMIN1, WRKY70, PR2, RDR6, AGO1, and AGO2 in Supplementary Fig. SWe compared gene expression between infected and uninfected plants, and identified DEGs in each season (referred to as SE DEGs, SS DEGs, AE DEGs, and WS DEGs; Supplementary Table S AE Fig. . In A. tnfection , and PP2nfection  that planfection , 45. Mornfection , 47 (Fignfection –50, wereted Fig. . Some ofA. halleri allows both successful clonal propagation of the host and stable viral transmission to host clonal offspring. In the TuMV–A. halleri system, transcriptomic difference other than defence-related genes appeared only in autumn, being represented by the largest number of DEGs across seasons. Autumn symptoms are expected to be transient until temperature decreases. Low temperature suppressed the speed of virus spread/replication, and consequently, kept virus accumulation low in newly formed leaves during winter. It is likely that transient symptoms and reduced within-host virus accumulation provided by winter temperatures allowed the persistent host growth. The temperature dependence of TuMV spread within plants observed here was consistent with that in previous experimental studies [A. thaliana populations in central Spain [The seasonal schedule of TuMV replication and seasonal growth cycle of  studies . On the  studies . Our stu studies , 57, it  studies , 13, 57.al Spain .A. halleri and whether the activation of SA dependent defence in spring consequently enhance horizontal transmission via aphids through the JA suppression. Increased vector attraction by virus infection through the SA-JA antagonistic relationship has been reported for Tospovirus-infected A. thaliana [. In autumn, when within-host virus accumulation was high, we detected an upregulation of homologous genes involved in RNA silencing, which is a defence mechanism against viruses [A. thaliana by the experimental infection of Cucumber mosaic virus with satellite RNA [AhgFLS in TuMV-infected plants in our observation in autumn. The downregulation of these genes in AE coincided with the observation that TuMV-infected plants lacked the accumulation of anthocyanin on leaves which were commonly observed in uninfected plants in autumn (Fig. Interestingly, distinct defence mechanisms have been suggested to function in spring and autumn. In March, we observed upregulation of homologous genes related to the SA dependent defence in TuMV-infected plants, and SA has been considered to play a critical role in plant innate immunity . In sprithaliana . In autu viruses , 28 and  viruses . This fi viruses –68. The lite RNA , and thiumn Fig. . BecauseA. halleri system, the effective transmission of virus through clonal propagation [A. halleri. In one case, we confirmed that a single lineage of TuMV remained within a clonal plant patch for 3 years and probably longer. Low sequence variation of TuMV genome within clonal patches of A. halleri relative to that between patches suggested that the horizontal transmission rate was extremely low making subsequent infection of TuMV rare. Otherwise, the mechanism for cross protection, the ability of an established virus to interfere with second infection by other strains of the same virus [It has been speculated that long-term pathogen–host interactions via vertical transmission favours low viral virulence and high host resistance –73. Howepagation  is likelme virus , 78, migme virus ; howeverAs our results suggested, the processes that keep viral load low were highly season dependent in a natural environment. We predicted that changes in the temperature regime might lead to imbalances in the virus–host interactions identified here. Further long-term field and experimental studies are required to evaluate how the seasonal processes are important in maintaining persistent relationships between virus and host individuals. Our study demonstrated that the combined approach to evaluate field situations and to reproduce the expected effects in the laboratory provides a robust strategy to study host–virus interactions as a part of ecosystem. Remaining questions to be challenged in future studies include effects of endogenous environments, such as crosstalk with clock genes  and inteSupplementary Materials and MethodsSupplementary FiguresSupplementary Tables


Background: Nusinersen is an antisense-oligonucleotide (ASO) approved for treatment of 5q-spinal muscular atrophy (SMA). Since the drug cannot cross the blood-brain barrier (BBB), it must be administered into the cerebrospinal fluid (CSF) space repeatedly by lumbar puncture. However, little is known whether ASOs have an impact on CSF routine parameters that may yield information on CSF flow and/or intrathecal inflammation. The objective of this study was to examine CSF routine parameters in SMA patients treated with nusinersen.Methods: Routine CSF parameters  of 60 SMA patients  were retrospectively analyzed.Results: White cells ranged from 0 to 4/μL in CSF; a singular case of pleocytosis (8/μL) was observed in a patient in parallel with a systemic infection. Total protein and Qalb showed a mild increase from baseline to the following lumbar punctures . Lactate levels revealed a stable course. In one patient, positive OCB in CSF were transiently observed. The slight change in total CSF protein and Qalb may be caused by repeated lumbar puncture and/or intrathecal administration of the drug.Conclusion: Our data suggest that a regular examination of routine CSF parameters in patients in which intrathecal ASOs are administered is important to obtain information on possible side effects and to gain further insights into intrathecal processes. SMN) 1 gene on chromosome 5 leading to muscle weakness and muscle atrophy  is a rare neuromuscular disease caused by homozygous deletion or point mutation in the survival of motoneuron  and all patients or their relatives  gave informed written consent to participate in the study.Patient samples were collected from June 2017 to April 2019 at the following centers of the MND-NET (German Network for Motoneuron Diseases): Department of Neurology, Ulm University Hospital (Germany), Department of Neurology, Technische Universität Dresden (Germany), Department of Neurology, University Medical Center Göttingen (Germany) and Department of Neurology, Klinikum rechts der Isar der Technischen Universität München .SMN1 gene). Patients history and clinical data were gathered before therapy started. Motor scores .Although there was a statistical difference between the white cell count of T1 and T2 . In the remaining 48 patients, total protein levels were detected below the reverence boarder of 450 mg/L in baseline CSF.p = 0.0004), T1–T3 (p < 0.0001), T1–T4 (p = 0.0012), T1–T5 (p < 0.0001), T1–T6 (p = 0.0001), T1–T7 (p = 0.0010), and T1–T8 (p = 0.0195)]. While a mild increase in total protein could be observed from baseline (T1) to treatment days T2, T3, T5, T6, T7, and T8, median total protein levels were slightly lower at T4 compared to baseline protein levels.CSF total protein differed significantly from baseline (T1) to all following lumbar punctures ; white cell count in this patient was within the normal range, lactate levels minimal elevated at T4 (2.2 mmol/L) and OCB were not determined. Apart from a pronounced scoliosis, there were no further anamnestic or clinical abnormalities in this patient, neither before nor during therapy. The highest total protein (715 mg/L) along with the highest (age-related) Qalb level (11.4 × 103) in baseline CSF (T1) was detected in a 15-year-old SMA type 3 patient, in whom positive OCB in CSF (type 2) in baseline and follow-up samples were observed. In this patient, total protein slightly increased to 913 mg/L in the second lumbar puncture (T2), but showed a stable course in the following lumbar punctures . A medical history for inflammatory CNS diseases was not reported by the patient and no clinical features beyond the flaccid amyotrophic proximal tetraparesis were noticed. Because white cell counts and lactate levels were normal, we classify the findings in this patient as immunological scar due to a former infection.The highest total protein levels of all CSF samples  were detected in a 46-year-old SMA type 3 patient with baseline total protein of 710 mg/L (T1), who showed the highest (age-related) Qalb levels of all samples in accordance . At T8 median Qalb levels were lower compared to baseline (T1) (p = 0.0469), however, only 8 patient samples could be evaluated at T8.Qalb was elevated in 14 SMA patients at baseline (T1). Qalb increased from baseline (T1) to the following six lumbar punctures .Qalb did not differ significantly from baseline (T1) to the following lumbar punctures in this subgroup . Our data suggest that a systematic examination of routine CSF parameters in patients in which intrathecal ASOs are administered is important to obtain information on possible side effects and to gain further insights into intrathecal processes.In summary, the examination of CSF routine parameters in 60 SMA patients  treated with nusinersen revealed that repeated intrathecal administration of the drug seems to be in general safe and well-tolerated. This is in line with previous but limited results from clinical phase 1 studies on intrathecal delivery of ASOs in human –42. NeveThe datasets generated for this study will not be made publicly available as it concerns patient data.The studies involving human participants were reviewed and approved by University of Ulm approval number 19/12; 2012. Written informed consent to participate in this study was provided by the patients and/or patients' legal guardian/next of kin.CW and RG designed the study. CW and JD performed statistical analysis. CW wrote the manuscript. All authors, were involved in the data collection process analyzed global study data and revised and approved the final version of the manuscript.The authors declare the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: CW has received honoraria from Biogen as advisory board member and for lectures and as consultant from Hoffmann-La Roche. She also received travel expenses from Biogen. JK has received financial research support from TEVA Pharmaceuticals and honoraria as speaker/consultant for AbbVie, Allergan, Biogen, Ipsen, and AveXis/Novartis. MO received honoraria as consultant for Biogen, Axon, and Fujirebio. ZU has received honoraria from Biogen as consultant. BW has received honoraria from Biogen for a lecture. PW has received honoraria from Biogen and Desitin for lectures and as a consultant from Hoffmann-La Roche and Abbvie. AL received financial research support from AB Science, Biogen Idec, Cytokinetics, GSK, Orion Pharma, Novartis, TauRx Therapeutics Ltd. and TEVA Pharmaceuticals. He also has received honoraria as consultant from Mitsubishi, Orion Pharma, Novartis, Teva and as advisory board member of Biogen, Treeway, and Hoffmann-La Roche. MD received a travel grant from Biogen and speaker honoraria from Desitin and Genzyme. PL has received financial research support from TEVA Pharmaceuticals and honoraria as speaker/consultant for AbbVie, BIAL, Desitin,Licher MT, Medtronic, Novartis. HT has received research support and/or honoraria as speaker/consultant/advisory board member from Bayer, Biogen, Celgene, Fresenius, Genzyme Sanofi, Merck, Mylan, Novartis, Roche Diagnostics, Teva. AH has received honoraria from Biogen and Desitin as advisory board member. RG has received honoraria from Biogen as advisory board member. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to investigate the prognostic significance of the serum γ-glutamyltransferase (γ-GT)-to-prealbumin ratio (GPR) and whether combining this ratio with other parameters can lead to an improved prognostic value for patients with hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolization (TACE) combined with local ablation therapy.A total of 235 HCC patients who were treated with combined therapies were retrospectively analyzed. The demographic data and clinicopathological data were collected. A fibrinogen (Fib)-GPR score of 2 was assigned to patients with elevated Fib and GPR values, and a score of 1 or 0 was assigned to patients with one or neither of these two markers, respectively. In addition, an N-score of 2 was assigned to patients with low neutrophil and high GPR values, and a score of 1 or 0 was assigned to patients with one or neither of these two markers, respectively. The optimal cutoff values and prognostic roles of GPR and other markers were identified according to the time-dependent receiver operating characteristic (ROC) curves and Youden’s index.Multiple tumors, high levels of α-fetoprotein (AFP) and Fib, as well as a high GPR, were found to be independent risk factors in recurrent patients, while multiple tumors, a low neutrophil count, and a high GPR were associated with reduced overall survival (OS) in patients with HCC who received combined therapies. Patients with a Fib-GPR score of 2 and N-GPR score of 2 had poor recurrence-free survival (RFS) and OS, respectively.Fib-GPR and N-GPR scores may be helpful in predicting both recurrence and the prognosis of HCC patients, thereby assisting in the process to make a true clinical decision and optimize therapeutic options. The proposed Fib-GPR and N-GPR scores for HCC patients might effectively predict recurrence and mortality.2. Our scores, which were based on γ-GT, may possess some advantages for making a true clinical decision for patients with HCC undergoing TACE plus local ablation therapy.3. This is a retrospective single-center study and thus is affected by confounding factors; therefore, our results need to be validated by further multicenter studies.Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths and the sixth most common cancer worldwide, with approximately 841,000 new cases and 782,000 deaths annually . In receAs an almost ubiquitous enzyme, γ-glutamyltransferase (γ-GT) initiates the degradation of extracellular glutathione and is also conjugates and correlates with biotransformation, nucleic acid metabolism, and oncogenesis . PreviouA limited number of studies have investigated whether γ-GT combined with PA could predict the prognosis of HCC patients treated with TACE plus locoregional ablation. Therefore, the present research aimed to study the data of HCC patients who received combined therapies as the primary treatment and validate the predictive value of combining GPR with other parameters for HCC patients.A retrospective analysis of 235 patients with HCC who received combined therapies as initial treatment was conducted in Beijing You’an Hospital  between January 1, 2016 and December 31, 2017. HCC was diagnosed according to the radiological/histological criteria recommended by the guidelines published by the American Association for the Study of Liver Diseases (AASLD) . All subStandard demographic and clinicopathological data were collected and summarized as follows: 1) demographic data, such as age, sex, history of hypertension, and diabetes mellitus; 2) etiologies of HCC, including hepatitis B virus (HBV), hepatitis C virus (HCV), and alcoholic liver disease (ALD); 3) tumor-related indices, such as the number of tumors, size of tumors, and alpha-fetoprotein (AFP) level; 4) liver function indices, including cirrhosis, Child-Pugh class, and alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, serum albumin, globulin, and γ-GT levels; 5) routine blood examinations, such as neutrophil count, lymphocyte count, platelet count, and Fib and GPR level; and 6) ablation modalities, including radiofrequency ablation (RFA), microwave ablation (MWA), and argon-helium cryoablation (AHC). This study was conducted in accordance with the 1964 Declaration of Helsinki, and the study protocol was approved by the Ethics Committee of Beijing You’an Hospital; the patient data were kept confidential. As a study with minimum risk, the requirement for informed consent was waived because it was arduous to contact the patients again.The procedure was performed by two qualified hepatologists. With the selective/superselective technique, the tumor-feeding arteries were catheterized using a highly flexible coaxial microcatheter passed through a 5-Fr Yashiro catheter , which was previously placed approximately in the hepatic artery. After placing the microcatheter, a mixture of doxorubicin  and lipiodol  was injected; then, embolization was performed with embolic materials, such as gelfoam or polyvinyl alcohol particles, until full stasis was achieved in the segmental or subsegmental arterial branches in the tumor-feeding vessels. The dose of the drugs depended on the patient’s white blood cell count, platelet count, and liver function. Angiography showed occlusions in the tumor vasculature, filling of the embolic agent, and disappearance of the tumor stain, which was regarded as the endpoint of embolization.Thermal ablation was carried out within 2 weeks after TACE. The procedure was percutaneously conducted under local anesthesia by qualified hepatologists with the guidance of triple-phase computed tomography (CT) or magnetic resonance imaging (MRI). The procedure was as follows: 1) the ablation procedure was determined according to the CT or MRI scans with the patient in the proper position; 2) the area was disinfected, towels were laid down, anesthesia was administered at the puncture site, and the ablation needle was inserted into the skin; 3) to perform the ablation, multiple sites and overlapping ablation were considered according to the number of tumors and size of the tumors, and CT scans were acquired in a timely manner to follow the ablation process; and 4) after the ablation was completed, the ablation needle was pulled out, and the needle tract was ablated to prevent needle transplantation and bleeding. Regardless of how many ablation sessions were performed, the range of ablation extended 0.5–1.0 cm into the surrounding noncancerous tissue to ensure full coverage; otherwise, the procedure was defined as an incomplete ablation.All patients were followed-up in the outpatient clinic. Abdominal CT or MRI was carried out 4–6 weeks after treatment. The follow-up involved a physical examination and blood tests, including assessments of liver function and AFP levels, as well as medical imaging examinations that included an abdominal ultrasound every 3–6 months and triple-phase CT/MRI every 6 months. Recurrence included local recurrence, distant intrahepatic recurrence, and extrahepatic metastasis . RecurreAnonymized patient data were used in the present study. Patients and the public were not involved in the study process.P-value < 0.05 was considered statistically significant.All data were analyzed with SPSS 25.0 software . Continuous variables were expressed as the mean ± standard deviation (SD), and categorical data were presented as the frequency. The baseline GPR data were compared with the Mann-Whitney U test. Univariate and multivariate Cox regression analyses were performed to assess the independent risk factors of prognosis in HCC patients undergoing combined therapies. The RFS and OS rates were calculated with the Kaplan-Meier method, and the differences between groups were compared by using the log-rank test. The optimal cutoff values were identified according to the receiver operating characteristic (ROC) curves and Youden’s index. All statistical tests were two-sided, and a This cohort consisted of 183 males (77.9%) and 52 females (22.1%) with a mean age of 58 ± 8 years . Additionally, 64 patients (27.2%) had high blood pressure, and 50 (21.3%) patients had type 2 diabetes mellitus. In addition, 124 patients (52.8%) were treated with antiviral therapy before they underwent combined therapies. There were 98 patients (41.7%) who had a history of smoking and 76 patients (32.3%) with a history of drinking. In terms of etiologies, 177 (75.3%) patients had HBV-related HCC, 43 (18.3%) patients had HCV-related HCC, and 15 (6.4%) patients had ALD-related HCC. The median follow-up duration was 38.2 months . The 1-, 2-, and 3-year cumulative recurrence rates were 24.3% (57/235), 48.1% (113/235), and 59.1% (139/235), respectively. Moreover, the 1-, 2-, and 3-year cumulative OS rates were 98.3% (231/235), 94.0% (221/235), and 88.5% (208/235), respectively  , score 1 (Fib level < 3.105 g/L or GPR < 0.344), and score 2 (Fib level ≥ 3.105 g/L and GPR ≥ 0.344) , neutrophil count , and GPR  were independent predictors of HCC recurrence  , score 1 (neutrophil count≥4.145 × 10^9/L or GPR < 0.602), and score 2 (neutrophil count< 4.145 × 10^9/L and GPR ≥ 0.602) Table . The Kaply) Fig. . The timP = 0.001 and 0.002, respectively). Furthermore, among the group with large tumors, the GPR was higher in patients with multiple tumors than in patients with a single tumor (P = 0.017), but this finding was not observed in the group with small tumors (P = 0.087). Additionally, among group with multiple tumors, the GPR was higher in patients with large tumors than in patients with small tumors (P = 0.030), but this finding was not observed in the group with single tumors (P = 0.063)  and multiple tumors than in patients with small (≤30 mm) and single tumors (63) Fig. .Fig. 5TIn China, the incidence and mortality of HCC globally accounts for approximately half of all patients with liver cancer. Hence, HCC has aggravated the medical burden in China and is a serious health problem . TACE coThe results of the present study showed that high Fib and AFP levels were independent risk factors for RFS in patients with HCC who underwent combined treatments. Elevated plasma Fib levels have been associated with tumor progression in several malignancies, including esophageal carcinoma, small cell lung carcinoma, and non-small cell lung carcinoma –17. The The present study confirmed that low neutrophil levels are an independent risk factor for only OS in patients who received combined therapies, which is controversial with several results. For my part, liver disease may inhibit the hematopoietic function of marrow, another aspect is that hypersplenism may lead to neutropenia. However, bias resulting from fewer death cases cannot be ignored .The multivariate regression analysis revealed that the number of tumors and GPR were independent predictors for both RFS and OS of HCC patients. Multiple tumors are typically characterized by the multicentric development of neoplasms. In addition, there may be microscopic lesions around the tumors that cannot be clearly detected by imaging examinations and are more likely to relapse and metastasize. A previous study reported that the expression of γ-GT provides tumor cells with an additional source of cysteine and cystine from the cleavage of extracellular glutathione and oxidized glutathione . In addiA number of studies have indicated the predictive values of the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), NLR-PLR, albumin-bilirubin index (ALBI), and improved platelet-albumin-bilirubin index (PALBI). I think it may be explained as follows. First, neutrophilia inhibits the cytolytic activity of immune cells . And theMedical imaging examinations, such as CT and MRI, are not appropriate routine methods for monitoring prognosis because of the unclear visualization of microscopic metastases, high cost of inspection, and radiation hazards. Consequently, valid serum markers from routine blood and liver function examinations are of great significance for determining the optimal therapeutic modalities. However, this is a retrospective single-center study that was affected by confounding factors; thus, our results need to be validated by further multicenter studies.In summary, the proposed Fib-GPR and N-GPR scores based on independent risk factors might effectively predict the risk of early recurrence and mortality for HCC patients who received combined therapies and may possess a number of advantages for making a true clinical decision for patients with HCC who underwent TACE plus locoregional ablative therapy.


Tnfr1 and TNFα were up-regulated after ONC. At 5 days post-lesion, R7050 intravitreal or systemic treatment neuroprotected RGCs as much as BDNF alone. At 14 days, RGC rescue by systemic or intravitreal administration of R7050 was similar. At this time point, intravitreal treatment with BDNF was significantly better than intravitreal R7050. Combinatory treatment was not better than BDNF alone, although at both time points, the mean number of surviving RGCs was higher. In conclusion, antagonism of the extrinsic pathway of apoptosis rescues axotomized RGCs as it does the activation of survival pathways by BDNF. However, manipulation of both pathways at the same time, does not improve RGC survival.Here, we have blocked the signaling pathway of tumor necrosis factor α (TNFα) in a mouse model of traumatic neuropathy using a small cell permeable molecule (R7050) that inhibits TNFα/TNF receptor 1 (TNFR1) complex internalization. Adult pigmented mice were subjected to intraorbital optic nerve crush (ONC). Animals received daily intraperitoneal injections of R7050, and/or a single intravitreal administration the day of the surgery. Some animals received a combinatorial treatment with R7050  and a single intravitreal injection of brain derived neurotrophic factor (BDNF). As controls, untreated animals were used. Retinas were analyzed for RGC survival 5 and 14 days after the lesion i.e., during the quick and slow phase of axotomy-induced RGC death. qPCR analyses were done to verify that  The link between tumor necrosis factor-α (TNFα) and retinal ganglion cell (RGC) loss in glaucoma and traumatic optic neuropathies has been extensively investigated in humans , a death receptor that triggers the extrinsic pathway of apoptosis  both, the blockade of TNFα using decoy-receptors  in mice  were obtained from the University of Murcia breeding colony. All animals were treated in compliance with the European Union guidelines for Animal Care and Use for Scientific Purpose (Directive 2010/63/EU) and the guidelines from the Association for Research in Vision and Ophthalmology (ARVO) Statement for the Use of Animals in Ophthalmic and Vision Research. All procedures were approved by the Ethical and Animal Studies Committee of the University of Murcia, Spain (number: A1320140704).Animals undergoing surgery were anesthetized by intraperitoneal injection of a mixture of ketamine  and xylazine . Analgesia was provided by subcutaneous administration of buprenorphine . During and after surgery, the eyes were covered with an ointment  to prevent corneal desiccation. Animals were sacrificed with an intraperitoneal injection of an overdose of sodium pentobarbital .Animal groups are detailed in The left optic nerve was crushed at 0.5 mm from the optic disc following previously described methods  was done daily for 7 or 14 days. Some animals received a combinatorial therapy of intravitreal and intraperitoneal treatments. All groups are detailed in Animals were perfused transcardially with 0.9% saline solution followed by 4% paraformaldehyde in 0.1 M phosphate buffer. Retinas were prepared as flat mounts, or eyes were cryo-sectioned. In all experimental groups, RGCs were immunodetected in whole-mounts as reported  and Brn3a  were double immunodetected. Secondary antibodies were donkey α-mouse IgG1-Alexa fluor 488 or α-rabbit-Alexa fluor 594 . Briefly, sections were incubated overnight a 4°C with the primary antibodies diluted in blocking buffer. Secondary detection was carried out as in flat-mounts.Images were acquired using an epifluorescence microscope  equipped with a computer-driven motorized stage  controlled by image analysis software .+RGCs were reconstructed from 154 (11 × 14) individual images . Total RNA was extracted using Trizol reagent (Thermo Fisher Scientific) and the RNA samples were dissolved in 20 μL Milli-Q water. Total RNA concentration was determined using SimpliNanoTM . Complementary DNA amplification was performed according to the instructions provided by the manufacturer SuperScriptTM IV VILOTM Master Mix, Thermo Fisher Scientific) using 1 μg total RNA.Fresh dissected retinas were immediately frozen on dry ice  were purchased from Sigma Aldrich.Mouse pre-designed SYBR green primers (pair 1) for CtΔΔ method  based qPCR was carried out by the Genomic Platform at the IMIB-Arrixaca in a final volume of 5 μl with a primer concentration of 450 nM using the QuantStudio 5 . Technical triplicates were done for each sample. The Ct values were converted to relative quantification using the 2p < 0.05. Tests are detailed in results.Data were analyzed and plotted with GraphPad Prism v.7 . Anatomical data are presented as mean ± standard deviation (SD), and qPCR data as mean ± standard error of the mean (SEM). Differences were considered significant when + cells in the GCL do not express Brn3a, and most possibly are displaced amacrine cells, since they are 50% of the cells in the GCL  and in the ganglion cell layer (GCL) . TNFR1+ Tnfr1 mRNA compared to intact retinas  because this is the first time this route is used for this drug. Since R7050 is dissolved in DMSO, which has been reported toxic for RGCs after intravitreal administration , 26% , 23% , and 30%  higher than after ONC alone. Neuroprotection by R7050 is relatively better at 14 than at 5 days: at 14 days there are 54%  and 42%  more RGCs than in untreated retinas.BDNF is, excluding knocking out pro-apoptotic proteins or transfecting anti-apoptotic ones  than that shown in a previous work where TNFα was intercepted with etanercept, a decoy-receptor  be used in human patients. Given that to date there are no therapies to overcome neuronal death, proof of concept pre-clinical studies are needed to expand the possible therapeutic avenues to treat not only traumatic neuropathies, but also neurodegenerative diseases.All datasets generated for this study are included in the manuscript/supplementary files.The animal study was reviewed and approved by the Ethical and Animal Studies Committee of the University of Murcia, Spain (number: A1320140704).FL-R, CG-R, MS-N, MG-R: methodology, data analysis and representation, and review and editing. MV-S: writing, review and editing, and funding acquisition. MA: conceptualization, supervision, data analysis and representation, writing, review and editing, and funding acquisition.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Prevalence of erectile dysfunction (ED) in diabetic men is considerably high but it is often underdiagnosed and undermanaged. There were no data available about the prevalence and the risk factors of ED in our region. So a cross-sectional study was conducted to identify the prevalence and associated risk factors of ED in a tertiary care diabetic center in Northern Sri Lanka.326 diabetic male patients between ages 18–60 years were interviewed. Majority  of the diabetic patients suffered from ED and 22.4% (95% CI 17.8–26.8%) were found to have severe ED. Most of the patients (98.8%) were not screened or treated for ED. Bivariate analysis showed age above 40, duration of DM (> 5 years), type of diabetes (type 2), having micro-vascular complications, co-existing hypertension, BMI, consuming unsafe level of alcohol and taking beta-blockers were associated with ED at 5% level (P < 0.05). This study failed to show association with dyslipidemia, macro vascular complications such as coronary artery disease , glycemic control (P-0.082) and smoking. Regression analysis revealed age > 40 , duration of diabetes , co-existing hypertension , and unsafe level alcohol intake  were independent risk factors.The online version of this article (10.1186/s13104-019-4244-x) contains supplementary material, which is available to authorized users. Erectile dysfunction is defined as persistent inability to achieve or maintain erection of the penis firm enough to have satisfactory sexual intercourse . PrevaleSexual function is one of the important indices of quality of life. The development of ED is negatively associated with men’s relationship, social interactions, emotional and particularly psychological well-being . ErectilHyperglycemia is the main determinant of vascular diabetic related complications. But it is still not clear the involvement of hyperglycaemia in the pathogenesis of sexual dysfunction . Also EDThis was a cross-sectional study in patients attending to diabetic center Teaching Hospital Jaffna. All the male diabetic patients between ages 18–60 were recruited during the study period. Patients who are mentally incompetent; suffering from end stage organ failure such as chronic kidney disease, chronic liver cell disease and heart failure; history of spinal injury and who had major stroke were excluded from the study.Ethical clearance was obtained from ethical review committee, faculty of Medicine, University of Jaffna. Data collected for a period of 5 months from August 2017. We collected details from all male patients who satisfied the inclusion criteria. Data collection done by investigators via interviewer administered questionnaire.The evaluation of ED was done by International Index of Erectile function (IIEF-5) questionnaire. This widely accepted tool evaluates five aspects of sexual function such as erectile function, orgasm, desire for sex, satisfaction after intercourse and overall satisfaction. Each aspect was evaluated by five points scale and the score more than 21 was considered as normal erectile function. Depending on the score, ED is further classified as mild (17–21), mild to moderate (12–16), moderate (8–11) and severe ED (less than 8) .Measurement of weight and height was done with standard steps to calculate BMI. Diabetic related micro vascular and macro vascular complications, duration of diabetes, history of hypertension, hyperlipidemia and details of hypertensive medications were retrieved from medical records. Latest HbA1C and fasting blood sugar readings were also obtained from records.Smokers were classified according to standard National Health Interview Survey. In their life time, if patient smoked at least 100 cigarettes is considered as smoker. Safe level of alcohol intake was defined according to the American Heart Association as no more than two standard drinks per day.Analysis of the data was done by using SPSS version 25. Prevalence was described using percentage with confidence interval (CI). Results were summarized using tables and graphs. Chi squared test was used to establish association. Establishment of statistical significance was done at P < 0.05. Binary Logistic regression analysis was conducted by using significant variables identified in bivariate analysis. Variable(s) entered on into the model: age, type of DM, duration of DM, presence of micro vascular complications, existing-HT, BMI, taking beta-blockers and consuming unsafe level of Alcohol.The mean age of the 326 male diabetics was 49 ± 7.5 years. Majority (58.6%) belongs to lower socio economic group, 33.1% studied up to primary school and 38% completed secondary school. Among them 33.1% were reported unsafe level of alcohol consumption and 21.8% were smokers.Around 56% of participants have been diagnosed within 5 years and 23.6% have diabetes for more than 10 years. Majority of (62.0%) participants’ diabetic control not up to the mark (HbA1C ≥ 7). Significant percentage (45.7%) of participants were identified to having micro vascular complications such as neuropathy (15.3%), nephropathy (25.5%) and retinopathy (22.5%), but only 9.2% were identified as having macro vascular complications such as cerebrovascular accident (CVA), coronary artery disease (CAD) and peripheral vascular disease (PVD). Further 46.6% of study population had co-existing hypertension and 44.5% had hyperlipidemia. Figure Among participants erectile dysfunction (ED) was identified in 62.9% (CI 57.5–68.0%), while 22% (CI 17.8–26.8%) were found to have severe ED , duration of DM (P < 0.0001); type of diabetes (type 2) , associated micro vascular complications such as diabetic neuropathy  and nephropathy ; co-existing hypertension ; BMI > 25 , consuming unsafe level of alcohol  and taking beta-blockers  , duration of diabetes (more than 5 years) , co-existing hypertension , and unsafe level alcohol intake  were independent risk factors  noted in the research done in Northern Ethiopia recently . The ED Only four patients were getting treatment for ED at the time of interview. Remaining 98.8% were either reluctant to get treatment or unaware of ED treatment modalities. This might be due to the social stigma or not-considering ED as a treatable disease. Therefore, it is obvious that ED is a common worrisome complication of diabetes which is under diagnosed. This could affect the quality of life of the affected men and that might in turn worsen the diabetic control .Increasing age is a common risk factor for ED. In our study even though analysis done in patients between 18 and 60 years prevalence of ED significantly increased with age as in par with some other studies . There aWhen considering complications of diabetes it is reasonable to assume that both micro vascular and macro vascular complications of diabetes are associated with high risk of ED –18. ThisCo-existing hypertension is an important cardiovascular risk factor of diabetes showed significant association (P < 0.001) and has to be optimized in order to prevent ED in diabetics. Having hypertension with the back ground of diabetes significantly increases the risk of arthrosclerosis which might affect the penile arteries , 8. AlonRecent control of diabetes mellitus showed no significant relationship with ED (P-0.08). Similar finding were also noted in some of the recent studies , 11. HowCigarette smoking is a recognized risk for ED in diabetics . HoweverWhen considering the medications, significant association with the beta-blockers (P = 0.02) was noted. Other hypertensive medications failed to show association . Previous studies demonstrated that beta blocker and diuretics are risk factors for ED , 21. OveIn conclusion, the prevalence of erectile dysfunction is high among diabetic patients and most of them (98.8%) were not screened or managed for ED. Majority of men could be considered as silent suffers. The main predictors of ED were age above 40, duration of DM, hypertension and unsafe level of alcohol intake. Therefore, it is vital to have the routine screening for ED in diabetic clinics periodically and manage accordingly. The co-existing hypertension should be treated with appropriate medications which minimally interfere with sexual dysfunction and preventive measures need to be targeted to reduce the alcohol intake.The study population slightly different from the diabetic men who attend other clinics as usually patients with complex medical problems tend to attend tertiary Centre.The evaluation of ED was done by IIEF-5 questionnaire and it is not validated to our population as a result there is a chance misclassification error even though this tool widely accepted worldwide.We have excluded the patients with major psychiatric illness but psychological evaluation should be carried out, in addition to BMI data could be collected as continuous variable and sample size could be calculated to include possible risk factors to get more accurate results.A detailed evaluation of the long term glycemic control, lipid profile and smoking could improve the validity of the study.Additional file 1: Table S1. Multivariate logistic regression results of study variables for ED.


The incidence of premature myocardial infarction (PMI) has gradually increased in recent years. Genetics plays a central role in the development of PMI. Familial hypercholesterolemia (FH) is one of the most common genetic disorders of cholesterol metabolism leading to PMI.This study investigated the relationship between FH-associated genes and the phenotype of PMI to clarify the genetic spectrum of PMI diseases.n = 225) and detected the mutations in their FH-associated genes  by Sanger sequencing. At the same time, patients free of PMI  were enrolled as control, and a logistic regression analysis was used to identify risk factors associated with PMI. The diagnosis of FH was confirmed using “2018 Chinese expert consensus of FH screening and diagnosis” before the prevalence and clinical features of FH were analyzed.This study enrolled PMI patients , and all mutations were loss of function (LOF) and heterozygous. The genotype-phenotype relationship of patients carrying FH-associated mutations showed high heterogeneity. The logistic regression analysis showed that the smoking history, obesity and the family history of premature CHD were independent risk factors of PMI. In this study, a total of 19 patients (8.4%) were diagnosed as FH, and the proportion of smoking subjects in FH patients was higher than that in non-FH patients.FH-associated gene mutations were present in about 7.6% of Chinese patients with PMI. In addition to genetic factors, smoking history, lifestyle and other environmental factors may play a synergistic role in determining the phenotype of PMI.http://www.chictr.org.cn/showproj.aspx?proj=7201.Essential gene mutation of cholesterol metabolism in patients with premature myocardial infarction. ChiCTR-OCH-12002349.Registered 26 December 2014,  As the most severe type of coronary artery diseases, myocardial infarction (MI) has posed a threat to public health because of its high morbidity and mortality. More than 600,000 people suffer from MI, which leads to 180,000 deaths yearly in China . In receA previous study carried out by the author of this study showed that the prevalence of FH diagnosed by genetic testing was 4.4% . Howeverhttp://www.chictr.org.cn/showproj.aspx?proj=7201). All subjects provided written informed consent at the time of their enrollment. The investigational protocol was designed in accordance with CONSORT2010.All MI patients were enrolled at Peking University People’s Hospital between May 1, 2015 and March 31, 2017. MI, including ST-segment elevation MI and non-ST-segment elevation MI, which was defined according to the Third Universal Definition of Myocardial Infarction . PMI patData of PMI patients were retrieved from previously published studies to assess the clinical characteristics of PMI . The cliFH was diagnosed using “2018 Chinese expert consensus of FH screening and diagnosis” . Adults Peripheral venous blood samples were collected after patients were admitted into the hospital and were processed within 30 min of collection. Blood cells was isolated by centrifugation at 3000 rpm/min for 10 min and then transferred into new tubes, which were stored at − 80 °C until use.Genomic DNA was extracted from blood cell samples using a DNeasy Blood Kit  according to the manufacturer’s protocol.The entire exon region of LDLR, PCSK9, and LDLRAP1 genes, as well as the exon 26 of APOB gene (from 100 bp to 200 bp of p.Arg3500) located at the LDL receptor-binding site, were studied by Sanger sequencing using an ABI 3730-XL Genetic Analyzer .https://databases.lovd.nl/shared/genes/), the NCBI-ClinVar database (https://www.ncbi.nlm.nih.gov/clinvar/), and the NCBI-Pubmed database (https://www.ncbi.nlm.nih.gov/pubmed) were used to determine whether the sequenced mutations were “pathogenic” or “potentially pathogenic” mutations that have been reported. Polyphen-2 software was used to predict whether a newly found mutation was pathogenic.The LOVD database  and examined using XA total of 225 PMI patients meeting the inclusion criteria were collected, including 188 males (83.6%) and 37 females (16.4%). 19 non-synonymous variants were identified in these PMI patients, including 12 pathogenic mutations and 7 benign variants , and all pathogenic mutations were loss of function (LOF) and heterozygous. However, these mutations also included 7 PCSK9 LOF mutations. In contrast to LOF mutations in LDLR, APOB and LDLRAP1, PCSK9 LOF mutations could increase hepatic LDLR expressions and reduce circulating levels of LDL. One patient carried LDLR(c.129G > C), PCSK9(c.277C > T) and LDLRAP1(c.274G > A) mutations, and all other patients carried a single gene mutation. As shown in a previous study [Among the 225 PMI patients, their age at MI onset was (46.64 ± 7.21) years old. In addition, the average age at MI onset in 56 non-PMI patients was (73.73 ± 6.97) years old.P = 0.035), its impact on PMI was relatively weak, because PMI might also be affected by BMI, smoking and other factors.Compared to non-PMI patients, the PMI patients had a higher level of LDL-C or body mass index (BMI), and were more likely to have a smoking history and a family history of premature CAD Table . The logIn this study, PMI patients were divided into 4 groups according to their age  patients met at least two of the Chinese criteria for FH diagnosis. Of these patients, 2/11 (1.8%) patients were also diagnosed by genetic testing. At the end, a total of 19 patients (8.4%) were diagnosed as FH. The proportion of smoking subjects in FH patients was higher than that in non-FH patients Table .Table 6CMI places a heavy psychological and the socioeconomic burden on “young” patients because it greatly affects the patients’ ability to work,. The registration study of acute myocardial infarction in China (CAMI) showed that PMI patients accounted for about 27.7% of all MI patients . BecauseIn this study, it was observed that 7.6% PMI patients carried FH-associated mutations and the value was higher than that reported in the study by Khera et al., who showed that a familial hypercholesterolemia mutation was present in 36 of 2081 (1.7%) patients with early-onset myocardial infarction . The aboPCSK9 LOF mutations  were also found in this study. In particular, as a mutation previously reported only in the Japanese population, the c.277C > T mutation can decrease the level of LDL-C and reduce the risk of ASCVD . HoweverMen dominated PMI patients in most studies on PMI, including this study , 16, whiThe genotype-phenotype relationship of patients with FH-associated mutations showed high heterogeneity. Numerous studies have demonstrated that the carriers of LDLR mutations had the highest levels of LDL-C , 20, whiIn this study, the “2018 Chinese expert consensus of FH screening and diagnosis” was used first to diagnose FH. Only 2/11(1.8%) patients with clinical FH carried FH-associated gene mutations and the percentage was lower than that reported in a previous study, suggesting that different diagnostic criteria of FH may lead to different prevalence values of FH. Most studies have also found that 20–60% of subjects with phenotypic FH did not carry a causative mutation in LDLR, APOB, PCSK9 or LDLRAP1 genes, suggesting that phenotypic FH may also be induced by multiple small-effect common variants, mutations in unknown FH-associated genes, or environmental factors , 22. NonNevertheless, several limitations in this study need to be addressed. Firstly, the sample size in this study is small and may cause a statistical bias. Secondly, the approach used in this study to annotate missense variants by prediction algorithms may lead to misclassification in some cases, and the predicted variants need to be validated through in vitro functional experiments. Thirdly, only 4 FH-associated common genes were detected in this study, while some other rare FH-associated genes, including APOE and STAP1, were not detected.In conclusion, FH-associated gene mutations were present in about 7.6% of Chinese PMI patients. In addition to genetic factors, smoking history, lifestyle and other environmental factors may play a synergistic role in determining the phenotype of PMI.


Current clinical practice guidelines for idiopathic pulmonary fibrosis (IPF) conditionally recommend use of pirfenidone and nintedanib. However, an optimal treatment sequence has not been established, and the data of treatment sequence from pirfenidone to nintedanib are limited. This study aimed to evaluate safety, tolerability and efficacy of nintedanib switched from pirfenidone in patients with IPF.Thirty consecutive IPF cases, which discontinued pirfenidone because of a decline in forced vital capacity (FVC) or intolerable adverse event (AE), and newly started nintedanib (150 mg twice daily) from September 2015 to August 2017 (switch-group) were retrospectively reviewed. Subsequently, we compared the characteristics, treatment status, and AEs between the switch-group and other 64 IPF patients newly started nintedanib during the same period without any prior anti-fibrotic treatment (pirfenidone-naïve group).2, and 52.9%, respectively. Most common AE of nintedanib was aspartate aminotransferase/alanine aminotransferase elevation (71.9%), followed by anorexia (46.7%) and diarrhea (46.7%); whereas, anorexia (63.3%) and ≥ 5% weight loss from baseline (56.7%) were common during pirfenidone administration. Sixteen patients (53.3%) discontinued nintedanib within 6 months (early termination). Multivariate logistic regression analysis revealed a significant association between low BMI and early nintedanib termination in the switch-group (p = 0.0239). Nintedanib suppressed FVC decline as compared with that during administration period of pirfenidone in 70% of the patients who could undergo lung function before and after switching to nintedanib. The incidence of early termination of nintedanib was higher in the switch-group than in the pirfenidone-naïve group, whereas body-weight, BMI, absolute FVC values, and %FVC were significantly lower in the switch-group (just before nintedanib initiation) than in the pirfenidone-naïve group. Nintedanib-induced anorexia was more frequent and severer in the switch-group than in the pirfenidone-naïve group, but no significant differences were observed in terms of other AEs.In the switch group, median age, body weight, body mass index (BMI), and %FVC were 72 years old, 54.9 kg, 21.0 kg/mA high incidence of early termination of nintedanib was noted when patients were switched from pirfenidone. Anorexia and weight loss during prior pirfenidone administration may increase the rate of the early termination of subsequent nintedanib treatment. N = 7).The development of two anti-fibrotic drugs, pirfenidone and nintedanib, has markedly changed the management of idiopathic pulmonary fibrosis (IPF) over the last decade , 2. ThesThe present study evaluated the safety, tolerability, and efficacy of nintedanib in IPF patients switched from pirfenidone to nintedanib for establishing an optimal treatment strategy for IPF in the future.This retrospective study was performed at Kanagawa Cardiovascular and Respiratory Center in Yokohama, Japan. All consecutively enrolled patients had (1) IPF diagnosed based on the official American Thoracic Society/European Respiratory Society/Japanese Respiratory Society/Latin American Thoracic Association statement of 2011 , (2) disThe datasets generated and/or analyzed during this study are available from the corresponding authors on reasonable request.The clinical and laboratory data were retrieved from patient medical records. Age, gender, height, body weight, laboratory data , pulmonary function tests, and concomitant therapy were evaluated. Serum levels of KL-6 and SP-D were measured using chemiluminescent enzyme immunoassay system .The grading of worst examination values of AEs was based on the Common Terminology Criteria for Adverse Events (CTCAE) ver. 4.0 . When a p value of < 0.05 was considered statistically significant. All statistical analyses were performed using EZR  [Categorical data are presented as numbers (percentages), and compared using Fisher’s exact test. Continuous data are presented as medians (interquartile ranges), and compared using Mann–Whitney U test. A multivariate logistic regression analysis was performed to verify the risk. A , Japan) , which i2, respectively. The median percent predicted FVC (%FVC) and percent predicted diffusing capacity for lung carbon monoxide (%DLco) at baseline were 52.9 and 44.2%, respectively. The physique-related factors, absolute FVC values, and %FVC were considerably lower than those reported in the INPULSIS trials; as for the Japanese patients of nintedanib group in the INPULSIS trials, the mean body weight, BMI, absolute FVC value, and %FVC were 63.8 kg, 24.4, 2.42 L, and 80.9%, respectively. Twenty-seven patients (90%) revealed definite usual interstitial pneumonia pattern on high-resolution computed tomography, and 8 patients (26.7%) have undergone surgical lung biopsy for the diagnosis of IPF.Thirty IPF patients were enrolled in this study and patient characteristics observed just before initiating nintedanib are summarized in Table Twenty-three patients (76.6%) were switched to nintedanib with an interruption period of less than 1 month, and the median duration of prior pirfenidone treatment was 8.3 months. Fifteen patients (50%) were switched to nintedanib because of FVC decline and 15 patients (50%) because of intolerable AEs. The median follow-up duration from the initiation of nintedanib was 10.4 months .The details of AEs during the pirfenidone and nintedanib administration periods are summarized in Table The treatment status during the observation period is summarized in Table Figure p = 0.007 and 0.048, respectively). Logistic regression analysis was performed to verify the risk factors for the early termination of nintedanib (Table p = 0.0239). We selected BMI not only as the most likely candidate risk factor but also as a representative factor related to physique. We also selected weight loss with a CTCAE grade of ≥2 occurring during the pirfenidone administration period and surfactant protein D (SP-D)  as candidate risk factors. Multivariate logistic regression analysis using backward stepwise selection revealed a statistically significant association between BMI and the early termination of nintedanib (p = 0.0111).As stated, 16 patients 53.3%) discontinued nintedanib within 6 months (early termination group), whereas 14 patients (46.7%) received nintedanib for ≥6 months (continuous treatment group). A comparison of the clinical and laboratory data between the two groups (Table 3.3% discN = 30) and other IPF patients who were newly started on nintedanib without any prior anti-fibrotic treatment at our hospital  revealed that body weight, BMI, %FVC, and %DLco were significantly lower in the switch-group than in the pirfenidone-naïve group (Table p = 0.028). Moreover, nintedanib-induced anorexia tended to be more severe in the switch-group than in the pirfenidone-naïve group (Table p = 0.0720). However, just before initiating pirfenidone, patients in the switch-group had approximately the same body weight, BMI, BSA, FVC, and DLco values as the baseline values of the pirfenidone-naïve group.A comparison of the baseline characteristics (observed just before nintedanib initiation) and data related to nintedanib therapy between the aforementioned study participants  have already experienced anorexia during prior pirfenidone treatment. Furthermore, in the switch group of the present study, anorexia along with weight loss was one of the most common immediate causes of nintedanib discontinuation (Table It is also noteworthy that nintedanib suppressed FVC decline compared with pirfenidone in 70% of patients who could undergo lung function tests before and after switching to nintedanib. As indicated both in a previous case series , dose moRecently, several clinical trials of the combined use of pirfenidone and nintedanib, which mainly evaluated the safety and pharmacokinetics, have been reported –24. To pA limitation of the present study was the retrospective single-center study design. Additionally, the number of included patients was small and the distribution of patients may have been skewed. There is a need to accumulate more cases from several hospitals and conduct further investigations for the validation of the present results. The short observation period was also a limitation when assessing long-term safety. Moreover, we didn’t set specific criteria for the FVC decline to consider switching from pirfenidone to nintedanib in our center, thus leaving the attending physicians to determine whether pirfenidone treatment is to be continued or changed.A high incidence of early termination of nintedanib was noted when patients were switched from pirfenidone. Anorexia and weight loss during prior pirfenidone treatment may increase the rate of early termination of subsequent nintedanib treatment. Further investigation is required to establish an optimal treatment strategy.


Several studies suggest race-based health disparities in men with low-risk prostate cancer (PCa), with African American males having poorer oncological outcomes. We sought to determine the prevalence and predictors of pathological upgrading and upstaging in Jamaican men with low-risk PCa treated with radical prostatectomy (RP). Data on 141 men who met the National Comprehensive Cancer Network criteria for low-risk PCa and underwent RP at a single institution were reviewed. All men had a transrectal ultrasound-guided biopsy. Pre-operative clinical and final pathological data were obtained. Data were summarised as means and standard deviations or percentages as appropriate. Bivariate analyses such as independent samples t-tests and chi-square tables were conducted and logistic regression models were estimated to predict upgrading (>Gleason 6) and upstaging (p ≥ T3).The mean age was 59.5 ± 7.8 years with mean prostate specific antigen (PSA) of 6.6 ± 2 ng/mL. A total of 48.3% of men were upgraded and 11.4% were upstaged. Bivariate analyses indicated that PSA (p = 0.008) and percentage positive cores (p = 0.002) were associated with upgrading. PSA (p = 0.042) and percentage positive cores (p = 0.003) were significantly associated with upstaging. The odds of upgrading increased with increased PSA levels  or increased percentage positive cores . The odds of upstaging increased with increased PSA levels  and with increased percentages positive cores . Jamaican men with low-risk PCa are at high risk of pathological upgrading and upstaging at RP. These findings should be taken into consideration when discussing treatment options with these patients. Jamaican men, like most black males, are at high risk of developing prostate cancer (PCa) . At leasThere is great incongruity between prostate biopsy grade and clinical stage and RP grade and pathological stage. Estimates suggest that over 50% of patients classified with low-risk PCa are either upgraded or upstaged at RP , 10. TheWe therefore sought to determine the prevalence of pathological upgrading and upstaging in Jamaican men with low-risk PCa treated with RP between 2000 and 2015. Additionally, we sought to determine the clinicopathological variables which increased the risk of upgrading or upstaging.A retrospective analysis of the Pathology database at the University Hospital of the West Indies, Kingston, Jamaica was conducted. The University Hospital of the West Indies is a large tertiary facility in Kingston Jamaica and is one of the three public facilities providing full-time urological care for patients in Jamaica. All men diagnosed with histologically confirmed low-risk PCa, who underwent radical retropubic prostatectomies at the institution between 1 January 2000 and 31 December 2015 were identified. All men treated between 2004 and 2015 had systematic transrectal ultrasound-guided biopsies with a minimum of 12 cores taken (Sextant biopsies were performed prior to 2004). Biopsy and RP specimens were reviewed by pathologists at the University Hospital of the West Indies. RPs were performed in an open retropubic fashion by several urologists at the University Hospital of the West Indies, Kingston, Jamaica. Patients who received neoadjuvant therapy were excluded.Low-risk PCa was defined using the National Comprehensive Cancer Network (NCCN) (2010) criteria as persons with a life expectancy of at least 10 years, PSA < 10 ng/mL at diagnosis, clinical T stage of PCa of T1c or T2a and Gleason score of ≤ 6 .Pre-operative clinical and pathological variables included patient age, clinical stage, PSA, Gleason score and percentage positive cores on biopsy  and number of positive cores. Surgical pathology of the RP specimen included pathological stage, Gleason score and presence of adverse pathological features . Upgrading was defined as an increase in Gleason score between the biopsy and the RP sample. Upstaging was defined as pathological stage T3 and greater.t-tests, chi-squared tests or Fisher’s exact tests were conducted to determine which characteristics were associated with upgrading and upstaging. After this, two separate logistic regression models were estimated predicting upgrading and upstaging, respectively. These models were estimated in order to quantify the bivariate associations that were found.Data were summarised as means and standard deviations or percentages as appropriate. Bivariate analyses including independent samples The cohort consisted of 141 men. The mean patient age was 59.5 ± 7.8 years (range: 37–75). The median PSA was 6.7 ng/mL (range: 0.2–9.9 ng/mL). Most patients (82.3%) had clinical stage T1c disease while 17.7% had clinical stage T2a disease. The median number of positive cores on prostate biopsies was two (range: 1–6). Of the patients in the cohort, 60.7% had less than 10% positive cores while 21.4% had greater than 20% involvement .Of the patients in the cohort, 48.3% (57 of 118) were upgraded (There were missing data on grade in the remaining 23 patients) . Gleasonp = 0.014) (p = 0.002) (p = 0.021). The odds of upgrading were eight times higher among patients with greater than 20% positive cores when compared to patients with less than 20% positive cores .Tests of association indicated that median PSA levels were higher among men who experienced upgrading compared to those who did not  . Chi-squ= 0.002) . There w= 0.002) . A logisp = 0.042) (p = 0.003). There was no association between upstaging and age, number of positive cores or clinical stage (p = 0.046) for each unit increase in PSA level. Another crude logistic regression model predicting pathological upstaging indicated that patients with greater than 20% positive cores had more than 10 times the odds of experiencing upstaging compared to those with less than 10% . In a model including both PSA levels and percentage cancer cells, only greater than 20% positive cores continued to predict upstage status .Tests of association indicated that median PSA levels were higher among men who experienced upstaging compared to those who did not  . Chi-squal stage . A crudeIn a cohort of Jamaican men with low-risk PCa  treated with radical retropubic prostatectomy, it was found that approximately 60% of these men had either pathological upgrading or upstaging. Of these men, 48.3% were upgraded to Gleason 7 and 8 and 11.4% were upstaged to T3/N0-1 disease. Predictors of upgrading and upstaging were higher PSA and higher percentage positive cores.Previously published prevalence rates of pathological upgrading and upstaging in low-risk PCa are similarly high as in our study. In a cohort of over 10,000 men in the Surveillance Epidemiology and End Results Program (SEER) database, 44% of cases were upgraded to Gleason 7–10 and 9.7% were upstaged .et al [p < 0.01). Dinh et al [p < 0.001). Unlike other studies, we did not find an association between patient age and pathological upgrading and upstaging. Age greater than 60 years has been found in previous studies to be associated with pathological upgrading and upstaging [Our results are similar to other studies that have shown associations between PSA levels as well as percentage positive cores and upgrading and upstaging , 16, 17.et al  reportednh et al  reportedpstaging . Other upstaging .et al [p < 0.01) and adverse pathological features  after surgery compared to CA men. A major limitation of the study was the small number of AA men included in the cohort. In addition, this study included only men with very low-risk PCa. Maurice et al [p < 0.01). Despite these findings, other studies have not found a significant association between black race and pathological upgrading or upstaging [Several studies have reported that the black race is a significant predictor of pathological upgrading and upstaging in men with low-risk PCa , 11, 12.ce et al  have reppstaging , 19–21. et al [et al [p = 0.003) and in those patients who were upgraded, AA men were more likely to have an anterior nodule . Tiguert et al [et al [Upgrading and upstaging may be due to a number of factors. These include under-sampling at the time of biopsy, atypical location of cancers or variability in pathologist’s expertise. Transition from sextant biopsies to increasing the minimum number of cores to 12 on systematic prostate biopsies has reduced rates of under-sampling . Howeveret al  reportedl [et al  found thrt et al  also repl [et al  reportedl [et al .Our rate of positive surgical margins was 23.5%. This rate of positive surgical margins could be due to the biology of PCa in our patients or surgical technical challenges , 28. Prep = 0.032) [et al [p = 0.18). Despite these differing results, there are no data documenting reduced overall or disease-specific survival of AA men compared to CA men enrolled in active surveillance cohorts. Iremashvili et al [et al [p = 0.01). AA men in the active surveillance cohort from Johns Hopkins were more likely to have reclassification to Gleason 7 or greater, compared to CA men, leading to discontinuation of surveillance  [The American Urological Association (AUA) guideline on management of clinically localised PCa suggests that men with low-risk PCa may be offered active surveillance as a management option, regardless of race . Since t) [et al  using dali et al  reportedl [et al  reported< 0.001) . All thr< 0.001) . At a meWe acknowledge limitations to our study. This was a retrospective, single-centre series from a tertiary academic institution where RPs were performed by several urologists. Pathological reporting was not done by a central uro-pathologist, possibly introducing detection bias. Patients included in the analysis between 2000 and 2003 (30 patients) had sextant biopsies done, also introducing detection bias. We were not able to provide specific details on biopsy characteristics such as single core tumour volume, prostate volume, PSA density or tumour location. Our study only included patients with low-risk PCa who had surgery and did not report on outcomes in all low-risk PCa patients. No assessment of the long-term oncologic outcome was done in our patients.We consider our study meaningful as it adds to the body of knowledge on PCa in Afro-Caribbean men. Prostate cancer is not only very common in many Caribbean nations but it is also the leading cause of male cancer deaths . The CarJamaican men with low-risk PCa are at high risk of pathological upgrading and upstaging at RP. PSA and percentage positive cores are associated with upgrading and upstaging. These findings should be taken into consideration when discussing treatment options with these patients.The authors declare that they have no conflicts of interest.There was no funding for this study.Ethical approval was obtained from the Institutional Review Board, University of the West Indies, Faculty of Medical Sciences, Mona, Jamaica.


Gestational diabetes mellitus (GDM) is a big health problem that adversely affects both the maternal and perinatal outcomes. We aimed to predict the development of GDM in the first trimester using high sensitivity C-reactive protein (hs-CRP) and serum magnesium.The study conducted in the antenatal care clinic of Saad Abualila Hospital . Pregnant women were enrolled in this longitudinal cohort study during first trimester ≤14 weeks of gestation. Serum hs-CRP and magnesium concentrations were measured between weeks 11 and 14 of gestation. Glucose tolerance test and fasting plasma insulin (FPI) measurement were performed between 24 and 28 weeks gestational age. To assess insulin sensitivity and β-cell function, Homeostatic Model Assessment Insulin Resistance (HOMA-IR), HOMA-β indices and Quantitative Insulin Sensitivity Check Index (QUICKI) were calculated and used.P = < 0.001] compared to women without GDM. There was no significant difference in hs-CRP, serum magnesium, HOMA-IR, QUICKI and HOMA- β between women with GDM and women without GDM. No correlation was observed between body mass index (BMI), serum magnesium, hs-CRP, FBG and insulin levels.Out of the 126 who completed the study 19 (15%) were diagnosed as GDM. The median (interquartile) of FBG was significantly higher in women with GDM [81 (70–95) vs. 67(60–75) mg/dl; First trimester hs-CRP and serum magnesium levels were not correlated with the later development of gestational diabetes in this setting. Gestational diabetes mellitus (GDM), according to American Diabetes Association (ADA) it is defined as a true diabetes that firstly recognized at first or second trimester and not proceeded by either type 1 or type 2 diabetes , 4. Liketh gestational week where there is a possible delay in implementing the desired/ planned interventions e.g. pharmacological therapy, diet, and exercise [Screening to identify women at risk for GDM among pregnancies may allow more time for interventions and can yield a reduction in both GDM and its related adverse effects. Unfortunately, screening for GDM is commonly practiced after the 24exercise . Therefoexercise . Low serexercise . It is kexercise . Moreoveexercise . On the exercise . Recent exercise , 12–19. 2). Pregnancy and its duration was confirmed by ultrasound operated in the clinic by a senior obstetrician. Then 5 ml of blood were withdrawn in EDTA tube, 2 mLs of it was used for hemogram and the rest were centrifuged and stored at − 20 °C until the assay of hs-CRP level, which was performed by EUROIMMUN analyser I-2P . The same procedure was used to measure insulin level lately in the third trimester. Atomic absorption spectrophotometry  was used to determine levels of serum magnesium.A longitudinal cohort study was conducted at the antenatal care clinic of Saad Abualila Hospital  during the period of January–November 2015. All women with singleton pregnancy, started antenatal care follow-up in the first trimester (≤14 weeks of gestation) were approached to participate in the study. Women with chronic disease e.g. thyroid disease, hypertension, renal disease, diabetes, liver disease and on medication were excluded from the study. After signing an informed consent, socio-demographic and obstetric characteristics were gathered by questionnaire . The weight and height were measured and body mass index (BMI) was computed  and ADA were used to detect GDM among cases in this study. Which is described very briefly as one or more of the following blood glucose values met or exceeded; fasting blood glucose (FBG) ≥92 mg/dl, 1-h blood glucose was ≥180 mg/dl, and 2-h blood glucose ≥153 mg/dl, after 75-g oral glucose load . The stuGlucose oxidase test was used to assess the level of blood glucose . Insulin resistance was measured using the homeostasis model assessment (HOMA) of insulin resistance index (HOMA-IR) = fasting glucose level (mg/dl) × fasting insulin level (μU/ml) / 405  and the Sample size calculated based on previous data , it was t-test and Mann-Whitney U test _ if the data were not normally distributed_ were used to evaluate the mean differences between the studied groups. P <  0.05 was considered statistically significant.Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) for Windows, version 20.0 . Proportions of the studied variables were expressed in numbers (%). Continuous data were checked for normality using Shapiro-Wilk test. The means (standard deviations) or median (interquartile) were used to describe the studied variables if normally and abnormally distributed, respectively. Spearman correlation was conducted between BMI, magnesium, hs-CRP, FBG and insulin sensitivity indices. Student’s One hundred and sixty women were initially enrolled, 126 (78.7%) women completed the follow-up, have complete data and analysed here. The main reason for the loss of follow-up was change of the address. The mean (SD) of gestational age in early pregnancy 10.2(2.4) and it was 26.5 (1.2) weeks at the time of the glucose tolerance testing.General characteristics of the 126 enrolled women are shown in Table n = 126), Table There was no correlation between, BMI, serum magnesium, hs-CRP, FBG and insulin level in the enrolled pregnant women n = 16, Table n = 19) and women who had no GDM (n = 107), Table While FBG was significantly higher in women with GDM, BMI, serum magnesium, insulin, HOMA-IR, QUICKI and HOMA-β were not different in women with GDM (The current study shows no significant difference between serum magnesium, FBG and insulin resistance indices among women with GDM and women without GDM. Similarly, Nabouli et al. reported no significant difference in the serum magnesium level between women with GDM and women without GDM . HoweverThe hs-CRP level in the current study was not statistically different between women with GDM and women without GDM. This goes with Syngelaki et al. findings . In contIn summary, we fail to show any prediction of first trimester hs-CRP and serum magnesium with the development of GDM in this setting. Also, no correlation has been observed between insulin hormone level and insulin resistance indices, magnesium levels and hs-CRP.This study has many limitations, firstly; the current study recruited small sample size and under power. The number of women with GDM is very low and comparison of them with women without GDM might not be reasonable. Secondly; other inflammatory markers e.g. cytokines were not measured and infections that might have effects on hs-CRP were not ruled out. Therefore, larger sample size with longitudinal study design is needed.


Objective: Hypertension is a major cause of cardiovascular disease. Nevertheless, blood pressure (BP) is often inadequately treated. We studied visit patterns at primary health care centres (PHCCs) and their relation to individual BP control.Design and setting: Cross-sectional register-based study on all patients with hypertension who visited 188 PHCCs in a Swedish region.Patients: A total of 88,945 patients with uncomplicated hypertension age 40–79.Main outcome measures: Odds ratio (OR) for the individual patient to achieve the BP target of ≤140/90 mmHg.Results: Overall, 63% of patients had BP ≤ 140/90 mmHg (48% BP < 140/90). The PHCC that the patient was enrolled at and, as part of that, more nurse visits at PHCC level was associated with BP control, adjusted OR 1,10 (95% CI 1.01 to 1.21). Patients visiting PHCCs with the highest proportion of visits with nurses had an even higher chance of achieving the BP target, OR 1.19 (95% CI 1.07 to 1.32).Conclusions: In a Swedish population of patients with hypertension, about half do not achieve recommended treatment goals. Organisation of PHCC and team care are known as factors influencing BP control. Our results suggests that a larger focus on PHCC organisation including nurse based care could improve hypertension care. Hypertension is a major cause of cardiovascular disease and death. The prevalence of hypertension is high and BP control is unsatisfactory . Less thAn ageing population and lower BP criteria have resulted in more patients being diagnosed with hypertension. The challenge for the health care system is immense, and effective ways of handling this large patient population are needed.Besides individual pharmacological treatment, the effects of organisational measures on hypertension care have been studied. Team changes have proven efficient . AssigniThus, previous studies suggest that structure of care is important in achieving BP control and that one component may be assigning part of the responsibility to someone other than the physician.The aim of this study was to describe visit patterns as a measure of how care is structured at the PHCC level based on real-life data, as well as examine whether nurse-based care was associated with better BP control in patients with hypertension without complications.We conducted a cross-sectional regional register study of patients with hypertension without major comorbidities in primary care.Västra Götaland in south-west Sweden is a mixed urban and rural region with 1.6 million inhabitants .The region has about 200 PHCCs after a national health care reform in October 2009. All 200 PHCCs, whether publicly or privately operated, are funded by tax revenue. All patients in the region are enrolled at a specific PHCC. Diabetes and asthma/COPD nurses are mandatory, but PHCCs are free to structure their hypertension care [PHCCs report individual data for patients with hypertension to a regional primary care quality register.National guidelines recommend a BP target of <140/90 mmHg, which complies with European guidelines .n = 237,379).Patients with hypertension in the regional primary care quality register on 31 December 2015 for whom systolic BP data were available were eligible for inclusion in the study , a regional administrative health care database (VEGA), the National Patient Register (NPR), the Prescribed Drug Register, and the Longitudinal Integration Database for Health Insurance and Labour Market Studies (LISA).The index date for each individual refers to the last BP entry before 31 December 2015. The variables used from QregPV are the last entries up to 900 days before the index date.We collected information from the Prescribed Drug Register about antihypertensive and cardiovascular prescriptions picked up within 120 days before the index date: diuretics C03A-C03E, C09BA, C09DA, calcium channel blockers C07FB02, C08, C09BB, C09DB, beta adrenergic receptor blockers C07, renin-angiotensin system inhibitors C09, other antihypertensives C02, statins C10AA and acetylic salicylic acid B01AC06.The variables from LISA were chosen in order of priority as of the index year, one year after, one year before, otherwise missing.Excluded concomitant diseases with ICD-10 codes: Diabetes E10-14, Stroke I61, I63-64, Coronary heart disease I20-25, Heart failure I50, COPD J44, End stage renal disease Z94.0-Z49.2 and Z99.2, Amputation NFQ19, NFQ99, NGQ09, NGQ19, NGQ99, NHQ09, NHQ11-14, NHQ16-17 and NHQ99, Dementia G30.0-1, G30.8-9, F00-03, Cancer C0-9.The regional recommendation is the mean value of two or three BP measurements after 5–10 minutes rest in the sitting or supine position with the arm at heart level. We used systolic BP ≥ 150 as a measure of poorly controlled hypertension.PHCC mean number of visits to nurse: PHCC mean number of visits to physician: Ratio of PHCC mean number of visits to nurse and physician: The PHCC explanatory variables used were as follows:n = 31) or physician (n = 8) were excluded when calculating PHCC explanatory variables.These variables are based on visits within 450 days before the index date with a hypertension diagnosis. To reduce the influence of other causes, patients with more than 12 visits to a nurse   with PHCInferential statistics are based on ten files, in which missing observations were imputed using multiple chained equations.The statistical analyses used R 3.4.0 and SAS version 9.4 .Descriptive data for included patients are shown in If visiting a nurse-based PHCC, the chance of having picked up an antihypertensive prescription was higher (1.21 (1.16–1.27)), as well as being treated with diuretics (1.05 (1.01–1.08)) or renin-angiotensin system inhibitors (1.06 (1.03–1.09)), adjusted for age and sex.Only 52 of 188 PHCCs (30% of patients) were nurse-based. At 118 PHCCs, the mean number of visits with a nurse was less than 1; see the PHCC distribution of visits in Patients at PHCCs with nurse-based care had a 10% higher chance of achieving the BP target (OR 1.10 (1.01–1.21)), The median increased odds of reaching BP target if a patient moved from a low- to a high-performing PHCC was 1.45 whereof, according to results above, approximately 22% (10/45) could be associated with nurse-based care.p = 0.003)Nurse-based care was associated with higher BP target achievement and the OR increased accordingly. Patients enrolled at PHCCs with the highest proportion of nurse visits had a 19% higher OR of achieving the BP target, PHCC enrolment and, as part of that, nurse based care was associated with better BP control. We found a large variation in visit patterns for patients with uncomplicated hypertension among PHCCs in terms of both frequency and the ratio between nurses and physicians. PHCC enrolment was associated with BP target achievement and it is plausible that part of this association was explained by examined visit patterns. The higher the percentage of nurse visits at the PHCC, the greater the likelihood that a patient would achieve the BP target.One strength of our study is that all patients with hypertension in primary care are included in a Swedish region. Another strength is extensive data about visits, comorbidity and picked up medications.One limitation of the study is that we had no information regarding the structure of hypertension care from each PHCC but used visit patterns instead. Another limitation involved the way that BP was measured, but information was included about the professional who presumably measured BP on the index date. BP may also have been measured not as part of hypertension control but to assess other complaints, etc. To minimise this bias, we used BP entries only when the visit had a diagnosis of hypertension. The last BP measurement has been shown to correlate well with the mean of three entries over the period of a year .We chose to focus on patients without cardiovascular disease, diabetes or other serious conditions. One reason is that this large and growing patient population is easily overlooked. Another reason is that patients with chronic conditions may have more physician visits, which would compromise the interpretation of the nurse/physician ratio.Barriers to hypertension control can be related to both the patient and the health care professional . ExampleVarious quality improvement strategies for hypertension care have been identified that target the patient, professional (team change) or healthcare system . A systeWe cannot fully explain better BP target achievement with nurse-based care. Patients at nurse-based PHCCs had slightly more visits altogether and the same mean number of medications but picked up more renin-angiotensin system inhibitors and diuretics. The chance of having picked up antihypertensive prescriptions was higher at nurse-based PHCCs. There may also be differences in dosage and differences related to more intensive lifestyle interventions, etc., as shown previously . AnotherIn conclusion, fewer than 50% of patients with hypertension had BP below 140/90 mmHg. In our study, PHCC enrolment and as part of that nurse-based care was associated with better BP control. Although previous studies have shown that team-based care is effective, and it is recommended in European guidelines, we found that more than 2/3 of PHCCs based their hypertension care mainly on physician visits. Thus, it is important to consider structural factors when planning hypertension care.