Quercus shumardii Buckley) is a traditional foliage plant, but little is known about its regulatory mechanism of yellow leaf coloration. Here, the yellow leaf variety of Q. shumardii named ‘Zhongshan Hongjincai’ (identified as ‘ZH’ throughout this work) and a green leaf variety named ‘Shumard oak No. 23’ (identified as ‘SO’ throughout this work) were compared. ‘ZH’ had lower chlorophyll content and higher carotenoid content; photosynthetic characteristics and chlorophyll fluorescence parameters were also lower. Moreover, the mesophyll cells of ‘ZH’ showed reduced number of chloroplasts and some structural damage. In addition, transcriptomic analysis identified 39,962 differentially expressed genes, and their expression levels were randomly verified. Expressions of chlorophyll biosynthesis-related glumly-tRNA reductase gene and Mg-chelatase gene were decreased, while pheophorbide a oxygenase gene associated with chlorophyll degradation was up-regulated in ‘ZH’. Simultaneously, carotenoid isomerase gene, z-carotene desaturase gene, violaxanthin de-epoxidase gene and zeaxanthin epoxidase gene involved in carotenoid biosynthesis were up-regulated in ‘ZH’. These gene expression changes were accompanied by decreased chlorophyll content and enhanced carotenoid accumulation in ‘ZH’. Consequently, changes in the ratio of carotenoids to chlorophyll could be driving the yellow leaf coloration in Q. shumardii.Shumard oak ( Acer rubrum L.) of red leaves [Ginkgo biloba L.) of yellow leaves [Prunus cerasifera increased under light induction, and the leaves gradually turned purple. In contrast, although leaf yellowing is a common phenomenon, related research is still rare [yl1) of tree peony.Leaf color, the same as flower color, is very important for ornamental plants. Especially in autumn, when the leaf color of the autumn leaf tree changes, which attracts people’s attention. In order to increase the ornamental effect of a garden, colorful leaf tree species are widely used in gardens, such as red maple  yellow leaf mutant did not develop well [Cymbidium sinense) was much larger than that of yellow leaf [HEMA), Mg-chelatase gene (CHLD/CHLH), chlorophyllide an oxygenase gene (CAO), etc., all decreased in expression during the leaf color transformation [NOL/NYC) play a key role in chlorophyll degradation. For example, NYC1 and NOL in rice form a complex that functions as a chlorophyll b reductase to regulate chlorophyll degradation [PSY) [ZDS) [LCYB) [LCYE) [Pn) and chlorophyll fluorescence parameters of the yellow leaf areas of Aucuba japonica variegata were significantly lower than those in the green areas. Aluru et al. [Pn in the green leaf portion of the Arabidopsis thaliana variegation mutant.In addition to the fact that the pigment content in the leaves directly affects leaf color, the anatomical structure of the leaves and related genes also play important roles in leaf coloration. For example, the chloroplast of the crape myrtle . The imon [PSY) , z-carotY) [ZDS) , β-cycla) [LCYB) , ε-cycla) [LCYE) ,19 and s) [LCYE)  found th) [LCYE)  found thu et al.  also detQuercus shumardii Buckley) is a common garden landscaping tree, esteemed for its leaves turning red in autumn, which has a good ornamental value. Under optimum growth conditions, leaves of Q. shumardii are generally green. We obtained a yellow leaf variety of Q. shumardii named ‘Zhongshan Hongjincai’ (identified as ‘ZH’ throughout this work), and a green leaf variety named ‘Shumard oak No. 23’ (identified as ‘SO’ throughout this work). The mechanism of yellow leaf coloration of ‘ZH’ is still unknown. In this study, their color indices were firstly measured, and then, the related pigment content, photosynthetic characteristics and chlorophyll fluorescence parameters were measured; subsequently, the anatomical structures of leaf mesophyll cells were observed; finally, comparative transcriptomic analysis was performed, and their related metabolic pathways and the expression patterns of key genes were investigated.Shumard oak  and a green leaf variety (‘SO’) were used as the materials  value and pigment content were measured . SPAD vaPn, intercellular CO2 concentration (Ci), stomatal conductance (Gs) and transpiration rate (Tr)  . The Pn The chlorophyll fluorescence parameters of ‘SO’ and ‘ZH’ were showed in The anatomical structures of leaf mesophyll cells were observed by transmission electron microscopy. As shown in Q. shumardii, six libraries from the leaves of ‘SO’ and ‘ZH’ with three biological replicates were constructed and sequenced by the high-throughput Illumina sequencing technology. An average of 51.05 M total reads with total clean bases of 7.29 Gb, Q30 percentage of 94.18% and GC percentage of 40.45% were generated from each library , NT (non-redundant nucleotide sequences), Swissprot , KEGG (Kyoto Encyclopedia of Genes and Genomes), KOG (Clusters of Orthologous Groups of proteins), Pfam (Protein family) and GO (Gene Ontology) databases to understand their functional information. As shown in Among them, the number of unigenes annotated simultaneously by all databases was 26,907 (17.37%). In the GO functional classification, 50,289 unigenes were separately annotated into three aspects of GO: biological process, cellular component and molecular function . When cl2 = 0.896) between their results and RNA-seq data  analysis was conducted between ‘SO’ and ‘ZH’. A total of 39,962 DEGs were expressed, with 20,182 up-regulated DEGs and 19,780 down-regulated DEGs A. Moreovseq data B, which seq data A. Meanwhseq data B.In addition, KEGG annotation was performed on all DEGs between ‘SO’ and ‘ZH’, 13,843 DEGs were obtained, corresponding to 135 pathways, and only 15 pathways met Q-value ≤ 0.05 . Among tCHLD and CHLH, which were magnesium chelatase subunits, had significantly decreased expression levels in ‘ZH’, indicating that Mg-protoporphyrin had a lower biosynthesis rate in ‘ZH’. In addition, the expression levels of DEGs involved in the transformation of Chl a and Chl b in ‘ZH’ were mostly higher than those in ‘SO’, indicating a higher rate of conversion between Chl a and Chl b in ‘ZH’. Moreover, Chl b could only enter the degradation pathway by conversion to Chl a, and pheophorbide a oxygenase gene (PAO) closely related to chlorophyll degradation was significantly up-regulated in ‘ZH’. These results indicated that the rate of chlorophyll degradation in ‘ZH’ was faster than that of ‘SO’.The biosynthesis and degradation of chlorophyll play a crucial role in leaf coloration. Based on the KEGG pathway assignment, 30 DEGs associated with chlorophyll metabolism were identified, including five DEGs associated with chlorophyll degradation, and their expression levels were showed by hierarchical cluster analysis . Among tPDS, ζ-carotene isomerase gene (I-ZOS), ZDS, zeaxanthin epoxidase gene (ZEP) and violaxanthin de-epoxidase gene (VDE), and the down-regulated DEGs were mainly LCYE and carotenoid isomerase gene (CRTISO). These results indicated that the expression levels of most of carotenoid biosynthetic genes in ‘ZH’ were significantly higher than those of ‘SO’.Meanwhile, 16 DEGs associated with carotenoid biosynthesis were annotated in this database . Among tQ. shumardii, in which ‘SO’ was green and ‘ZH’ leaves was yellow. The color difference between ‘SO’ and ‘ZH’ was determined by an instrument in which the negative value of ‘SO’ *a was lower than that of ‘ZH’, and its positive value of *b was also lower. These color indices were consistent with the observed leaf color of plants [*L value of ‘ZH’ was higher than that of ‘SO’, indicating that the yellow color of ‘ZH’ was brighter and its ornamental value was better.Leaf color is an important ornamental and commercial trait. In this study, we clearly observed the leaf color difference between ‘SO’ and ‘ZH’ of f plants ,28. In aArabidopsis thaliana [pylm of Pak-choi (Brassica rapa), resulting in a significant increase in Chl a/b. In this study, there was no significant difference in Chl a/b between ‘SO’ and ‘ZH’, indicating that the transformation between Chl a and Chl b in ‘SO’ and ‘ZH’ was not significantly impeded and the optical system was not severely damaged.Leaf coloration is the result of the combined action of different pigments. The change of pigment type and its content determines the expression of leaf color . There athaliana , and thethaliana  found thIn general, thylakoid membranes in the chloroplasts of higher plants are regularly arranged and stacked into grana, and many leaf color mutants usually exhibit abnormal thylakoid structures ,32. In tChlorophyll is mainly distributed in the thylakoid membrane, and the thylakoid membrane is regularly deposited into grana, which is very effective in the absorption and conversion of light energy . AbnormaComparative transcriptomic analysis could reveal gene expression changes . In thisQ. shumardii. In Arabidopsis thaliana, a total of 15 enzymes were involved in chlorophyll biosynthesis, and these 15 enzymes were encoded by 27 genes [CHLD and CHLH that regulated the transformation of protoporphyrin IX to Mg-protoporphyrin IX were significantly down-regulated, suggesting that the chlorophyll biosynthesis resistance of Mutant might be located in this step. Among them, the expression of CHLH was mainly regulated by illumination affecting the expression of photoreceptor early light inducible protein (ELIP), resulting in changes in chlorophyll biosynthesis ability. For example, the inhibition of CHLH expression in Nicotiana tabacum lead to a decrease in chlorophyll biosynthesis rate [CHLH, HEMA and HEMD decreased as the chlorophyll content decreased [HEMA encoded glutamyl-tRNA reductase, which was the initial enzymatic step in the biosynthesis of chlorophyll [HEMA in ‘ZH’ was decreased, which was consistent with previous studies [HEMA, CHLD and CHLH might be the key to the decrease in the efficiency of ‘ZH’ chlorophyll biosynthesis. Moreover, carotenoids are a family of pigments, ranging in color to yellow to red, which are involved in light harvesting and are indispensable for photoprotection under conditions of excess light [Z-ISO, ZDS, VDE and ZEP expression were significantly up-regulated in ‘ZH’. This enhanced carotenoid biosynthesis gene expression and increased carotenoid content in ‘ZH’ indicated that carotenoids contributed to yellow leaf coloration in ‘ZH’. These results could provide valuable information for understanding the mechanism of yellow leaf coloration in Q. shumardii.Based on the transcriptome data, a total of 39,962 DEGs were identified between ‘SO’ and ‘ZH’. In addition, it was worth noting that our data analysis focused on some of the DEGs associated with chlorophyll biosynthesis and degradation and carotenoid biosynthesis might be involved in leaf coloration of 27 genes . In this27 genes  found insis rate . Moreoveecreased ,12. In aorophyll . In this studies . Therefoss light . Therefoss light . In thisQ. shumardii named ‘Zhongshan Hongjincai’, and a green leaf variety named ‘Shumard oak No. 23’ were used as the materials in this study. They were obtained by sowing the seeds of Q. shumardii introduced from the United States. These plants were asexually propagated by grafting and preserved in Jiangsu Academy of Forestry, Jiangsu Province, China . These potted plants were collected in June, 2019. First, the measurements of leaf color indices, photosynthetic characteristics and chlorophyll fluorescence parameters were performed, and then the samples were stored at −80 °C.A yellow leaf variety of *L, *a, *b values. The hue angle (H° = arctangent (*b/*a)) and chroma (*C= (a*2 + b*2)1/2) were calculated according to the methods reported previously [*L represents the lightness, *a represents the ratio of red/magenta to green and *b represents the ratio of yellow to blue [Color indices of leaf were measured with a hand-held RM200QC spectrocolourimeter  using six color parameters including eviously . In the  to blue .SPAD value was determined using a SPAD-502 chlorophyll meter . Chl a, Chl b, Chl a + b, Chl a/b and carotenoid contents were assayed according to Zou . MoreovePn, Ci, Gs and Tr were recorded. Moreover, a chlorophyll fluorescence spectrometer  was used to measure the chlorophyll fluorescence parameters. Furthermore, this system recorded Fo, Fm, NPQ and qN, and Y(II) together with Fv/Fm were calculated [Photosynthetic characteristics were measured using a LI-6400 portable photosynthesis system  from 7:00 to 9:00 am on a cloudless day. The standard leaf chamber was 2 cm × 3 cm in size. Additionally, in this system, lculated ,48.3 phosphate buffer for 15 min, and post-fixed with 1% osmium tetroxide for 4 h at room temperature (25 °C). After washing 3 times with 0.1 mol/dm3 phosphate buffer for 15 min each, the leaves were dehydrated using 50%, 70%, 85%, 95% and 100% gradient ethanol for 15 min each. Moreover, they were treated with 100% acetone solution (15 min) and acetone solution containing anhydrous sodium sulfate (15 min), infiltrated in spurr resin and then hardened at 70 °C for 24 h. Sections (70 nm thickness) were cut with a diamond knife using a Leica EM UC6 ultramicrotome  and stained with 1% uranyl acetate in 70% methanol, and 1% lead citrate before examination. Finally, the samples were observed on metal plates, the accelerating voltage was 50–100kV, the magnification of the whole cells was 2850 times, and that of chloroplasts was 13,500 times.A Tecnai 12 transmission electron microscope  was used to observe the anatomical details of leaves. The fixed leaves were washed three times with 0.1 mol/dmTotal RNAs extracted from the leaves of ‘SO’ and ‘ZH’ using a MiniBEST Plant RNA Extraction Kit  was used for transcriptome sequencing. After the determination of total RNA concentration and purity, six libraries  were prepared and sequenced by Beijing Genomic Institute  using an Illumina HiSeq™ 4000 platform . After raw reads filtering, transcriptome de novo assembly was performed using short reads assembling program Trinity . In addip-value ≤ 0.05.The unigene expression was calculated and normalized to Reads Per kilo bases per Million reads (RPKM) . GO funcTM Optics Module , and their values were calculated referring to the 2−△△Ct comparative threshold cycle (Ct) method [® RT reagent Kit With gDNA Eraser . qRT-PCR was performed using the SYBR® Premix Ex TaqTM   and contained 12.5 mm3 2 × SYBR Premix Ex TaqTM, 2 mm3 cDNA solution, 2 mm3 mix solution of target gene primers and 8.5 mm3 ddH2O in a final volume of 25 mm3. The amplification was carried out under the following conditions: 95 °C for 30 s, 40 cycles at 95 °C for 5 s, 52 °C for 30 s and 72 °C for 30 s. All used primers were listed in qRT-PCR was used to detect gene expression levels with a BIO-RAD CFX Connect) method . The cDNAll experiments described here were repeated three times arranged in a completely randomized design. Primers were designed using a Primer 5.0 program . All data were means of three replicates with standard deviations. The results were analyzed for variance using the SAS/STAT statistical analysis package .


African American (AA) men experience more than twice the prostate cancer mortality as White men yet are under-represented in academic research involving prostate-specific antigen (PSA), a biomarker of prostate cancer aggressiveness. We examined the impact of self-reported tobacco (cigarette pack-years and current tobacco use including e-cigarettes) and current regular marijuana use on serum PSA level based on clinical laboratory testing among 928 AA men interviewed 2013–2018 in Chicago. We defined outcome of elevated PSA ≥ 4.0 ng/mL for logistic regression models and continuous PSA increases for general linear models. All models were adjusted for age, sociodemographic characteristics, healthcare utilization, body mass index, and self-reported health. Among 431 AA men age ≥ 55 years, we observed ∼ 5 times the odds of elevated PSA among those with > 1 pack-years of cigarette smoking vs. never-smokers  and a quarter the odds of elevated PSA among current marijuana users vs. non-users . PSA increased on average 1.20 ng/mL among other current tobacco users vs. non-users. Among older AA men, cigarette smoking history and current tobacco use were positively associated with an increase in PSA levels and current marijuana use were inversely associated with PSA levels. Future work with studies of diverse patient populations with cancer outcomes are needed to assess whether these behavioral characteristics contribute to racial/ ethnic disparities in prostate cancer outcomes. Our study provides novel evidence regarding potential differences in PSA levels among older AA men according to behavioral characteristics. SociodeRelative to White men, AA men with prostate cancer present with higher PSA at presentation, greater overall tumor volumes per ng/ mL of serum PSA, and more aggressive disease and experChicago Multiethnic Prevention And Surveillance Study (COMPASS).One behavioral risk factor for which there is some evidence of an association with prostate cancer risk is smoking, including tobacco and marijuana use . These b2COMPASS is a population-based longitudinal cohort study with ongoing recruitment. Methods of COMPASS have been described elsewhere . Briefly3We ascertained cigarette smoking history by self-report to 13 items, including 2 on smoking history  and 11 items on pack-years for ever-smokers that included average per day cigarette consumption currently and in the past. We ascertained current marijuana use by self-report to a single question (‘do you currently smoke marijuana?’). We ascertained other current tobacco use by self-report to a single question ’, separately including ‘Cigar’, ‘E Cigarette’, ‘Pipe’, ‘Snuff’, ‘Chewing Tobacco’, and ‘Hookah’). Cigarillos and blunts were not directly queried but were considered by interviewers to be captured in the cigar category.We ascertained information by self-report on age, gender, race, ethnicity, marital status, SES, healthcare utilization , self-rated health, and hypertension medication use. We ascertained visits to a doctor in the last 12 months based on responses to three items: ‘during the past 12 months, how many times have you seen a doctor or other health care professional about your health at a… doctor’s office or clinic’, ‘…hospital emergency room’, ‘…home or some other place’. These were combined and categorized into quintiles. These healthcare utilization factors were also considered separately. Participants were asked to show the interviewer all the medications and supplements they currently use, and these were recorded. This information, together with medication questions in the interview, were used to ascertain hypertension medication use. Hypertension medication was defined as either blood pressure medication described in general terms or specific hypertension medications mentioned or presented . We ascertained health insurance type based on response to a single item measure. Individual SES was defined using a composite of education, employment status, and income developed by the US Department of Justice . Specifically, participants were trichotimized according to the equation  . BMI wasNeighborhood SES was defined by participant address. We used a publicly available measure of census tract level SES based on the 1990 and 2000 U.S. Censuses and the 2008–2012 American Community Survey, which ranges from 0 to 100 with 50 being the national average. The authors, Miles et. al., used an unconstrained single factor model according to the equation (1[ln{median household income}])++(-1.104[ln{%workers ≥ 16 years who are unemployed}])+(-1.974[ln{% of households in poverty}]) + 0.451([% high school grads but not bachelors holders] + 2[% bachelors holders]) . This co4We conducted analyses for two outcomes: 1) binary PSA as < 4 ng/ mL or ≥ 4 ng/ mL and 2) continuous PSA. Descriptive analyses were conducted to assess the relationship between each exposure variable, covariate, and PSA level, using chi-squared p-values for binary PSA and one-way analysis of variance (ANOVA) for continuous PSA. We examined the associations between self-reported cigarette smoking history, current use of other tobacco products, and current use of marijuana on PSA, controlling for potential confounders in multivariable logistic regression models with the outcome of binary PSA and general linear models (GLMs) with the outcome of PSA. Models were adjusted for age, marital status, individual and neighborhood SES, self-reported health, hypertension medication, BMI, health insurance type, previous cancer diagnosis, timing of last PSA test, timing of last DRE, and visits to a doctor in the last 12 months. We stratified our models by age (40–54 years and ≥ 55 years). Age 55 years was selected for stratification as some guidelines, like the American Urological Association guidelines, recommend starting PSA screening in average-risk individuals at that age . We furt5The study sample was comprised of AA men who were 77.6% low SES, 87.2% insured by Medicaid, other government supported insurance or uninsured, and 90.1% residing in the lowest three quintiles of neighborhood SES. Mean PSA for the study sample was 1.51 ng/ mL (standard deviation [SD] = 2.28). Elevated PSA ≥ 4 ng/ mL was measured for 68 AA men (7.3%). Statistically significant differences in elevated PSA ≥ 4 ng/ mL were observed across categories of age (p < 0.001) and cigarette smoking history (p = 0.008). Statistically significant differences in mean PSA were observed across categories of age (p < 0.001) and other current tobacco use (p = 0.038). ParticiFully adjusted logistic regression and linear regression models with all co-variates are presented in Results from the sensitivity analysis of logistic regression models with separate cutoffs for PSA of 2.5, 4.0 and 10.0 ng/ mL are presented in 6Little is known about factors that are associated with PSA levels, a marker of prostate cancer aggressiveness, among AA men who experience the greatest risk of prostate cancer mortality . We examCigarette smoking increases the risk of aggressive prostate cancer and may iin vitro , yet increases risk of aggressive prostate cancer . This suWe are unaware of previous studies that have examined the association between visits to doctor’s offices or clinics and PSA levels among men at high risk of advanced prostate cancer. In our study, we observed that AA men who reported having had more doctor’s office or clinic visits had a relatively small (<-0.14 ng/ mL) but statistically significant lower PSA levels in our multivariable models, including adjustment for BMI, health insurance type, and hypertension medication. Upon further investigation, we found that this finding persisted independent of usual healthcare setting, health insurance provider type, timing of last PSA test, and timing of last DRE.It is unclear whether the findings presented in our study have clinical relevance for risk of prostate cancer, since PSA ≥ 4.0 ng/ mL has a relatively low sensitivity but remains the most common threshold for recommending further imaging or a biopsy. Findings from a trial of 18,882 healthy men 55 years of age or older reported that only 20% of men with PSA ≥ 4.0 ng/mL actually had the disease, and 6% of men who do not have prostate cancer falsely tested positive at this threshold . There aOur study was strengthened by the relatively large sample of AA men–a group traditionally under-represented in research involving PSA measurements and more likely than other populations to experience disparities in prostate cancer aggressiveness and mortality. Additionally, we tailored recruitment strategies to AA participants, including concordance of interviewer race/ ethnicity and provision of bio-specimen education to community members.Our study was limited by our inability to screen for prostate cancer. Furthermore, our study was comprised of relatively few participants with elevated PSA, which limited statistical power. An additional limitation of our study was that our results were based on a single PSA measure at one point in time. PSA Measures can fluctuate and the PSA on a given day may not be representative of a participant’s average PSA. Additionally, a single PSA test lacks potentially important information such as PSA kinetics (PSA velocity and doubling time) and free-to-total PSA ratio, which are potentially important predictors of prostate cancer aggressiveness . Our stuWe were further unable to account for unobserved characteristics such as plasma volume, sexual behavior and ejaculation patterns, sleep patterns, and genetic variants that may be associated with both PSA levels and the factors examined in our study . Additio7Generating knowledge about vulnerable populations is an important priority for reducing social inequities in cancer . We founThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Diabetes mellitus is one of the most important threats to human health in the twenty-first century.The use of complementary and alternative medicine to prevent, control, and reduce the complications of diabetes mellitus is increasing at present. Glutamine amino acid is known as a functional food.The purpose of this systematic review is to determine the potential role of glutamine supplementation on metabolic variables in diabetes mellitus. For this review, PubMed, SCOPUS, Embase, ProQuest, and Google Scholar databases were searched from inception through April 2020. All clinical trial and animal studies assessing the effects of glutamine on diabetes mellitus were eligible for inclusion. 19 studies of 1482 articles met the inclusion criteria. Of the 19 studies, nine studies reported a significant increase in serum GLP-1 levels. Also, eight studies showed reducing in serum levels of fasting blood sugar, four studies reducing in postprandial blood sugar, and triglyceride after glutamine supplementation. Although glutamine resulted in a significant increase in insulin production in seven studies, the findings on Hb-A1c levels were inconclusive. In addition to, despite of the results was promising for the effects of glutamine on weight changes, oxidative stress, and inflammation, more precise clinical trials are needed to obtain more accurate results. In conclusion, glutamine supplementation could improve glycemic control and levels of incretins (such as GLP-1 and GIP) in diabetes mellitus. However, more studies are needed for future studies. Diabetes mellitus is one of the major threats to human health in the twenty-first century . The preDiabetes mellitus refers to metabolic diseases which are characterized by hyperglycemia that develops as a result of impairment in insulin secretion, insulin action, or both , 6. ChroRecently, the use of complementary therapy to improve and reduce the symptoms of diabetes mellitus, along with drug therapy and reduced drug dosage, have increased in use . GlutamiGlutamine is the physiological precursor of arginine for the production of nitric oxide (NO), whose creation in β-cells potentiates insulin secretion . FurtherAlthough several studies have shown positive effects of glutamine supplementation on metabolic variables in diabetes mellitus, there is no systematic review that summarizes the results of these studies. This study aims to evaluate the effects of glutamine on metabolic variables in diabetes Mellitus and to determine possible directions for future studies.To find relevant publications earlier than April 2020, two independent investigators performed a literature search in PubMed, SCOPUS, Embase, ProQuest, and Google Scholar electronic databases using following keywords: ““glutamine” OR “L–glutamine OR “glutamine supplementation OR “glutamine dipeptides” AND “diabetes mellitus” or “Type 2 diabetes” or “type II diabetes” or “Type 1 diabetes” or “type I diabetes” or “diabetic” or “T2DM” or “T1DM” or “noninsulin-dependent diabetes mellitus” or “insulin-dependent diabetes mellitus” or “NIDDM” or “IDDM” or “hyperglycemia” or “diabetic” or “FBS” or “fasting blood sugar” or “glycemic outcomes” or”fasting blood glucose” or “HOMA-IR” or “B-cell function” or “insulin” or “glucose” or “glycemic” or “hyperglycemic”. Reference lists and related records were manually reviewed. The search was limited to English language articles up through April 2020. This study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol for reporting systematic reviews and meta-analyses. The protocol for this review was registered in the PROSPERO database under registration number CRD42018090829.All clinical trial and animal studies assessing the effects of glutamine on metabolic variables  in diabetes mellitus were eligible for inclusion; exclusion criteria were (1) in vitro models, and (2) studies published in non-English language journals.Data extraction was conducted independently by two investigators using a standardized data collection form. The following information was also obtained from each study: first author, year of publication, country of origin, age range, sample size, daily dose, duration of intervention, and principal outcome. The quality of the included studies was assessed by a third reviewer using primary data extraction. Finally, the reviewers discussed articles to reach an agreement.Two independent researchers analyzed the quality of eligible studies. Randomized control trials were evaluated using Physiotherapy Evidence Database  (PEDro) A flow diagram of the study selection is summarized in Fig. .In total, 20 studies were selected after meeting the inclusion criteria, including ten animal studies and nine human studies. All of the animal studies were conducted on diabetic rats, including three studies on type 1 diabetic rats and six studies on type 2 –25. Besi3Three studies investigated the effect of glutamine on weight change in animals. Weight in rats decreased after induction of diabetes by STZ. Although high dose supplementation of glutamine at 500 or 1000 mg/kg caused prevention of weight loss, no significant weight loss or gain was reported in these studies.Obesity, especially central adiposity, is involved in diabetes pathogenesis via insulin resistance , 36. SevAll included studies assessed the possible effect of glutamine on glycemic status in diabetic animals. However, due to the different duration of supplementation and the wide range of glutamine dosage, contradiction was observed in the results. Glutamine supplementation with three different dosages (250–500–1000 mg/kg) resulted in a significant reduction in plasma glucose level, with an increase in plasma and pancreatic levels of insulin . In the The effects of glutamine on hormone secretion and pyloric motility seem to conform in a dose-dependent manner . MansourIn another study by Samocha-Bonet et al., T2DM patients consumed 15 g glutamine with 100 mg/d sitagliptin or 15 g glutamine with a placebo . After 4Incretin hormones trigger physiological pathways to release insulin following a meal . Some evGlutamine significantly increased GLP-1 compared to water alone. Elevation of circulating GLP-1 levels following the ingestion of glutamine was detectable as early as 15 min post-ingestion. Glutamine also caused a significant increase in plasma insulin levels, particularly in obese subjects; however, glucagon levels also increased. GIP levels increased following glutamine consumption; however, the effectiveness was less than that of glucose .The mechanism by which glutamine influences glycemic status may be explained by GLP-1–induced slowing of gastric emptying . Chang eThe changes of active GLP-1 and insulin-to-glucose AUC were also incremental with a significant time-treatment effect; however, fasting total GLP-1, fasting active GLP-1, and postprandial total GLP-1 increased without a significant time-treatment interaction . In a stAmong the included studies, six examined the possible effect of glutamine on lipid parameters. Eight weeks of administering 1gr/kg glutamine resulted in a significant reduction in LDL, TC, and TG levels, and a significant improvement in HDL levels . Three oOnly two human studies evaluated the effect of glutamine on the lipid profile, and neither resulted in a significant change. 30 g/day for 6 weeks showed no significant changes in LDL, HDL, TG, or TC levels .Seven studies evaluated the effects of glutamine on oxidative stress and inflammatory biomarkers. Glutamine dosage was between 250 to 1000 mg/kg among the studies, and supplementation duration was from 15 days to 4 months. Three studies conducted by Badole et al. showed a significant reduction in oxidative stress, which resulted from an improvement in SOD, MDA, GSH, TAC, and CAT after supplementation with three different dosages (250–500–1000 mg/kg) of glutamine for over two months , 18. In In the only human study that evaluated the effect of glutamine of inflammatory markers, Mansour et al. found no significant change in CRP after supplementing 30 g/day glutamine for 6 weeks .The results of this systematic review showed that glutamine supplementation has a potential effect on improving fasting plasma glucose , 31, 32,Generally, incretin hormones such as GLP-1 and GIP are released from intestinal L-cells and play an essential role in physiologically mediating insulin secretion after a meal . Since GDifferent mechanisms for glutamine signaling pathways should be taken into account. First, glutamine uptake with GLUTage cells is sodium-dependent, which could itself initiate GLP-1 secretion . Indeed,Dyslipidemia is one of the major complications of diabetes mellitus; thus, reducing lipid profile parameters may play a protective role in cardiovascular disease. Results demonstrated significant reductions in TG levels after glutamine administration , 21, 24.Anthropometric data derived from the studies is inadequate, although glutamine prevented weight loss after diabetes induction in animals , 21. AltChanges in body composition are a common feature in diabetic patients with abnormal decreases in lean body mass, particularly in elderly individuals . ConcernResults suggest a potential effect of glutamine on oxidative stress and inflammatory markers. Glutamine supplementation showed a significant increase in SOD, GSH, GPx, and catalase in animal studies –20, 22 aThis systematic review found that glutamine supplementation can lead to a decrease in fasting blood glucose, post-meal glucose, and triglyceride levels and an increase in insulin production. However, the results on the effect of glutamine on Hb-A1c and TC, LDL, and HDL levels were inconclusive. Glutamine supplementation also resulted in increased levels of GLP-1.Although the outcomes seem promising for the effects of glutamine on weight changes, oxidative stress, and inflammation, more precise clinical trials are needed to obtain more accurate results.


Musculoskeletal disorder (MSD) is currently recognized as one of the most common occupational injuries for which nursing personnel in the medical service industry have been identified as a high-risk group. In this study, we explore the prevalence of MSD in various body parts as well as their risk factors among hospital nurses.A cross-sectional descriptive design with stratified cluster sampling was used to collect data from 1,803 nurses. The survey included a demographic questionnaire, and Nordic Musculoskeletal Questionnaire.p < .05). Risk factors for neck discomfort includes seniority in the current unit, “job title, and “history of MDS (p < .05). Risk factors for upper back discomfort includes age and seniority in the current unit (p < .05). Risk factors for lower back discomfort including seniority in the current unit, department type, and number of days worked per week (p < .05).The results showed that the greatest prevalence of MSD symptoms by body regions were in the right shoulder (85.8%), the left shoulder (80.9%), the neck (62.4%), the right wrist (62.2%) and the lower back (60.4%). Risk factors for shoulder discomfort includes department type, exercise habits, and age (The results of this study can serve as a reference for nursing administration managers and decision-makers for reducing musculoskeletal discomfort among nurses and thereby achieving superior quality in clinical care. Musculoskeletal disorder (MSD) is defined as connective tissue or musculoskeletal disease that causes muscle pain or injury due to sudden or continuous contact, repeated exercise, force, vibration, or incorrect posture movements ,2. MSD hThe prevalence of work-related MSD among nurses varies between studies. Salama and Eleshenamie  studied Numerous studies have shown that nurses have one of the highest prevalence rates for MSD, which is a factor that contributes to reductions in the nursing workforce and negatively affects the quality of care . The higThe Bureau of Labor Insurance  indicateSeveral studies have indicated that basic attributes of an individual are factors that affect the risk of developing MSD. The origin of MSDs is complex and multi-factorial. Body Mass Index (BMI) is associated with MSDs in various regions of the body . A high A cross-sectional design which used a self-administered questionnaire survey was employed. All participants were recruited from a single northern Taiwan medical center. It has a total of 2,089 beds and for the purpose of this study were divided into internal medicine, surgical department, obstetrics & gynecology, intensive care unit, pediatric department, and others . A total of 2,161 registered nurses in that institution covered internal medicine, surgery department, obstetrics & genecology, intensive care unit, and pediatric department. They worked 40 hours a week and sometimes worked overtime. Taiwan’s clinical nursing staff is divided into N1, N2, N3 and N4 clinic al ladder levels : N1 is rThe study period was from November 2011 to January 2012.All participants were asked to fill out the questionnaire in their own time and then to place it into a box that was located outside their worksite within 7 days. Participants were reassured that their participation was entirely voluntary. The demographic characteristics questionnaire and the Nordic Musculoskeletal Questionnaire lasted for 10 to 20 minutes.Gender, job title , department type , work mode , other), daily work rest time, history of MSD (yes or no), age, exercise habits, body weight, work seniority, number of hours worked per day, number of days worked per week, and BMI. Each group’s descriptive statistics are expressed in terms of number of people and only reflect current symptoms.This study used the Nordic Musculoskeletal Questionnaire  to invesThis study was approved by the Ethical Review Committee of the Mackay Memorial Hospital Institutional Review Board . The objectives of the study and the questionnaire were explained to all of the participants and they were assured of their anonymity as well as confidentiality of their responses. All the participants provided a signed informed consent to participate.p value of less than .05 was considered statistically significant. Each group’s statistics are expressed in terms of number of people those who had musculoskeletal discomfort.Data was analyzed using the IBM SPSS software statistical version 23.0 for Windows . Prevalence of musculoskeletal discomfort was analyzed using descriptive statistics. Chi-square tests were used to examine variations in musculoskeletal discomfort prevalence between difference participants’ demographics. Logistic regression was performed to determine risk factors related to musculoskeletal discomfort. Odds ratios (OR) were calculated to determine the contribution of each risk factor for shoulder and neck/back, and a 2 = 18.41, 21,92, 32.93, 23.01, 32.48, p < .001, χ2 = 12.34, p = .015, χ2 = 17.02, p < .01, χ2 = 7.68, p = .006); (2) age, work seniority, job title, department type, number of hours worked per day, and exercise habits were significantly associated with those who experienced left shoulder discomfort ; (3) age and number of hours worked per day were significantly associated with those who right shoulder discomfort ; (4) age, work seniority, seniority in the current unit, department type, and work mode were significantly associated with those who upper back discomfort ; (5) age, work seniority, seniority in the current unit, department type, number of hours worked per day, number of days worked per week, BMI, and BW were significantly associated with those who lower back discomfort   age, work seniority, seniority in the current unit, job title, number of hours worked per day, hours standing per day, number of days worked per week, and history of MDS were significantly associated with those who experienced neck discomfort (χ = .016) .2 = 9.47, p = .024, χ2 = 14.26, p = .003, χ2 = 11.19, p = .024); (2) age, work seniority, seniority in the current unit, exercise habits, and BMI were significantly associated with those who experienced right elbow joint discomfort ; (3) age, hours standing per day, BMI, and BW were significantly associated with those who experienced left wrist discomfort; (4) age, work seniority, seniority in the current unit, department type, work mode, BMI, and BW were significantly associated with those who experienced right wrist discomfort ; (5) age, work seniority, seniority in the current unit, number of hours worked per day, number of days worked per week, history of MSD, and BW were significantly associated with those who experienced multiple sites discomfort .  number of hours worked per day, exercise habits, and BMI were significantly associated with those who experienced left elbow joint discomfort (χ= .022). .2 = 13.62, p = .003, χ2 = 12.46, p = .006, χ2 = 9.12, p = .028, χ2 = 26.43, p < .001, χ2 = 36.21, p < .001, χ2 = 25.37, p < .001); (2) age, work seniority, seniority in the current unit, department type, BMI and BW were significantly associated with those who experienced right knee joint discomfort ; (3) job title, department type, BMI and BW were significantly associated with those who experienced left ankle joint discomfort ; (4) work mode, hours standing per day, BMI and BW were significantly associated with those who experienced right ankle joint discomfort ; (5) age and number of hours worked per day were significantly associated with those who experienced left hip joint discomfort ; (6) department type was significantly associated with those who experienced right hip joint discomfort ; (7) age, work seniority, seniority in the current unit, job title, department type, work mode, number of hours worked per day, number of days worked per week, exercise habits, history of MSD, BW and BMI were significantly associated with those who multiple sites discomfort .Lower limb muscle discomfort referred to discomfort of the left knee joint, right knee joint, left ankle joint, right ankle joint, left hip joint, or right hip joint. A chi-square test was performed to determine the association between participants’ demographics, and lower limb muscle discomfort. The results presented in In this study, we used a logistic regression to identify the potential risk factors of discomfort in the shoulder and neck/back, which was more common than discomfort in other locations among the research participants.p = .023) had a higher risk than those in the “internal medicine” department and that those in the “intensive care unit” department  had a lower risk than those in the “internal medicine” department. Regarding “exercise habits“, participants who “exercised twice a week”  had a lower risk of experiencing shoulder discomfort than those who “rarely” exercised habits. Risk factors for right shoulder discomfort included “age“. Further comparison indicated that participants who were ages “30 to < 40 years” , “40 to <50 years” , or “≧50 years”  had a higher risk of experiencing right shoulder discomfort than those less than 30 years old.In this study, shoulder discomfort referred to discomfort of the left or right shoulder. The results presented in p = .025) or “≧10 years”  had a higher risk of experiencing neck discomfort than those with experience of “<1 year” in their current unit. Regarding “job title,” “full-time nurses” , “part-time nurses” , and “other”  had a lower risk of experiencing neck discomfort than “nursing supervisors.” Regarding “history of MDS” participants with a history of injury  had a higher risk of experiencing neck discomfort than those who had no history of MDS.The logistic regression results presented in p = .033) had a higher risk of upper back discomfort than those who were “< 30 years”. Regarding “seniority in the current unit,” participants with “≧10”  of work experience had a higher risk than those with “< 1 year” of experience  of work experience had a higher risk of lower back discomfort than those with “< 1 year” of work experience in their current unit. Regarding “department type,” participants working in the “intensive care unit” department  or “pediatric department”  had a lower risk of lower back discomfort than participants in the “internal medicine” department. Regarding “number of days worked per week,” participants who worked “4 days”  or “5 days”  had a lower risk of lower back discomfort than those who worked “1–3 days.”Logistic regression results revealed that risk factors for lower back discomfort included “seniority in the current unit,” “department type,” and “number of days worked per week”. Further comparison indicated that regarding “seniority in the current unit,” participants with “1 to 3 years” Click here for additional data file.S2 File(SAV)Click here for additional data file.S3 File(DOC)Click here for additional data file.


To investigate the persistent remission rate (PRR) and its predictors within the first year of antipsychotic treatment in first-episode schizophrenia (FES) patients.In a sample of 301 FES patients who remained in antipsychotic treatment for 1 year, we assessed symptoms with the Positive and Negative Syndrome Scale (PANSS), cognition in six domains and functioning with the Personal and Social Performance Scale (PSP).In total, 75.4% (227/301) of FES patients remaining in antipsychotic treatment reached persistent remission (PR) in one year. The PSP score was higher in remitters than non-remitters at the endpoint of the 1-year follow-up (P <0.0001). The PANSS negative score—but not the PANSS total score, positive score or general psychopathological score; PSP score; or cognitive performance at baseline—was negatively associated with PR. Lower scores for “abstract thinking” and “stereotyped thinking” were independent predictors of PR.In FES, nearly 3/4 patients could achieve PR with 1 year of antipsychotic treatment, and having fewer negative symptoms, especially thinking and volition symptoms, can predict PR.www.ClinicalTrials.gov, identifier NCT01057849. The prognosis of schizophrenia is considered much worse than that of other psychoses . PatientIt has been reported that the remission rate in FES patients is between 17.0 and 78.0% , and thiMost studies reporting the persistent remission rate (PRR) of FES patients throughout 1 year of antipsychotic treatment were randomized controlled trials (RCTs) , 9. HoweMost non-RCT longitudinal studies reported remission rates with criteria other than the criteria by the RSWG –15. LallThus, the PRR of FES during 1 year of antipsychotic treatment remains unclear. We aimed to examine the PRR and its predictors during 1 year of antipsychotic treatment for FES. We hypothesized that 1) more than half of the FES patients could remit during the 1-year antipsychotic treatment and 2) baseline sociodemographic, clinical and cognitive characteristics would predict PR.The data came from a 1-year randomized, open-label clinical trial conducted in 6 major psychiatric hospitals in China from 2008 to 2010 . The triFES patients with the following characteristics were recruited: illness duration of fewer than 3 years (the onset was determined in the SCID-I/P according to when the first symptom appeared), continuous antipsychotic treatment for fewer than 4 weeks and a cumulative period of intermittent antipsychotic treatment of fewer than 12 weeks. A 3-phase design was employed to mimic the reality of clinical practice . Phase IBasic demographic data were collected with a standard data collection form designed especially for this study. Clinical characteristics, including illness duration, acute onset (less than 3 months from symptom onset to full disease manifestation), and early onset (onset before 18 years) was drawn from the SCID-I/P. Psychopathology was measured with the PANSS . FunctioThere were two to three psychiatrists responsible for the clinical assessments at each site. All interviewers attended a 1-week training workshop on the use of the rating instruments  prior to the study and reached a high level of consistency .The primary outcome was PRR within 52 weeks, which was calculated as the number of patients who achieved PR within 52 weeks divided by the number of patients who completed the 52-week follow-up. PR was defined with the PANSS as a score on items P1, P2, P3, N1, N4, N6, G5, and G9 ≤3 for at least 6 consecutive months .A final multivariate logistic analysis was conducted on the variables that were confirmed to be significant in the multivariate logistic analysis mentioned above to explore potential interactions.At the endpoint of the 1-year follow-up, 75.4% (227/301) of patients had achieved PR. In total, with the early discontinuers included in denominator, 39.9% (227/569) of patients achieved PR. At the endpoint, the PSP score was higher in remitters than non-remitters (P < 0.0001) , early onset (onset before 18 years) and concomitant antidepressants or mood stabilizers. Totally, 27 subjects accepted antidepressants, with fluoxetine equivalent dose 25.7 ± 8.9)mg .7 ± 8.9m. Non-remAt baseline, the PANSS negative score was lower in remitters than in non-remitters; however, there were no differences in the PANSS total, positive and general psychopathological scores; PSP score; and cognitive performance  , N2 “emotional withdrawal” , N4 , N5 , and N7 “stereotyped thinking”  scores, respectively with the 6 cognitive scores, their significance persisted.In logistic regression analysis including N2 “emotional withdrawal”, N4 “passive/apathetic”, N5 “abstract thinking” and N7 “stereotyped thinking” as independent variables, N5 “abstract thinking” and N7 “stereotyped thinking” remained significant but N2”emotional withdrawal” and N4 “passive/apathetic” did not. Considering the potential overlap of N2 “emotional withdrawal” and N4 “passive/apathetic”, we conducted two additional logistic regression analyses including N2 “emotional withdrawal”, N5 “abstract thinking” and N7 “stereotyped thinking” and N4 “passive/apathetic”, N5 “abstract thinking” and N7 “stereotyped thinking” respectively, and the significance of N5 “abstract thinking” and N7 “stereotyped thinking” persisted.Nearly 3/4 FES patients, who completed the 1-year routine antipsychotic treatment, achieved relatively stable clinical recovery and functional recovery. Patients with fewer negative symptoms had a better chance of PR. One higher score on item N2 “emotional withdrawal”, N4 “passive/apathetic”, N5 “abstract thinking” or N7 “stereotyped thinking” could reduce the possibility of PR by nearly 1/5 to 1/4.Gabeal et al. obtained an average PRR of 42.3% (2–3 years after the acute phase) based on the results from more than 10 FES studies conducted from 2006 to 2011 . A recenWhen only patients who completed the 1-year follow-up were included in the denominators in RCTs, Boter et al. reported a PRR of 68.7% in the EUFEST study, and Crespo-Facorro et al. reported a PRR of 35.2% . AnotherOne naturalistic follow-up study of 104 FEP patients in Hong Kong showed that the PRR was 59.6% , but thiThis study indicates that PR in FES patients who completed the 1-year antipsychotic treatment was not associated with gender, age, onset age , 8, 16, Cognitive impairment is considered a diathesis factor in schizophrenia. However, Boter et al. failed to demonstrate that cognitive impairment predicted PR in the EUFEST study . VenturaNotably, negative symptoms were the only independent predictor of PR within the first year of antipsychotic treatment, consistent with several previous studies . BaselinWe found that negative symptoms rather than overall symptoms might predict PR and further revealed that “emotional withdrawal”, “passive/apathetic”, “abstractive thinking” and “stereotyped thinking” but not “blunted affect”, “poor rapport” and “lack of spontaneity and flow of conversation” predicted PR. This result suggested that only some negative symptoms are associated with PR.“Emotional withdrawal” and “passive/apathetic” both refer to others’ observations and are used to assess volition impairment in patients with schizophrenia. There is abundant evidence demonstrating daily activity reduction in schizophrenia; however, the potential predictive power of these symptoms had not been explored previously.post hoc analysis. Thus, impairment in the ability to comprehend and abstract and in thinking flexibility rather than other thinking impairments  might predict a lower likelihood of PR. Abstract thinking impairment is an established deficit in schizophrenia  describing thinking impairment and not the items describing volition impairment were shown to independently predict PR. In other words, volition symptoms were mediated by thinking symptoms in their prediction of PR. P5 “abstractive thinking” refers to the ability to comprehend and abstract. N7 “stereotyped thinking” refers to the flexibility of thinking, that is, the ability to shift between two perspectives (or two beliefs about the world) according to the demands of the social situation. The Word Fluency Test in the cognitive assessment battery was used to assess the richness of thinking; however, performance on this test did not differ between remitters and non-remitters in a ophrenia , and impophrenia . This suophrenia . It has ophrenia . Compareophrenia . Howeverophrenia , 36. OurClinically, our findings suggested that FES patients with even mild difficulty in understanding others’ words or shifting their perspectives according to the social situation or who exhibit a mild reduction in daily activities might be less likely to remit during the first year of antipsychotic treatment, despite the severity of their other symptoms, including positive symptoms and negative affective symptoms.via studies with special designs and large samples. Third, patients who did not continue the follow-up may have received treatment from other psychiatric hospitals, the remission rate and its predictors in this group of patients were beyond the study. Fourth, we did not employ the MATRICS Consensus Cognitive Battery (MCCB) in cognitive assessment which is the most widely used and standardized neuropsychological test battery for assessing cognition in schizophrenia worldwide and was in the process of development when this trial was conducted. Social cognition included in the MCCB was not assessed in this study. Fifth, this study included FES patients with an illness duration not exceeding three years; thus, whether patients with an illness duration longer than 3 years are less likely to remit could not be determined by this study.The study had several limitations. First, the follow-up period was 1 year, so the results cannot be generalized to a longer period. However, Ceskova et al. found that in male patients with FES, the remission rates after 1, 4 and 7 years of treatment were comparable, and patients who did not remit within the first year of treatment did not remit after 4 or 7 years of treatment either . It is pThe present study showed that over 3/4 FES patients achieved PR within 1 year of antipsychotic treatment. Patients with no impairment in their comprehension ability, thinking flexibility and daily activities were more likely to achieve PR, indicating that thinking and volition negative symptoms define the subset of FES patients who are less likely to achieve ideal symptom outcomes in 1 year of antipsychotic treatment. Thus, assessing these symptoms in detail is necessary in clinical practice. Optimization of the current pharmacological and non-pharmacological strategies for treating this group of patients is warranted.The datasets generated for this study are available on request to the corresponding author.The studies involving human participants were reviewed and approved by Peking University Sixth Hospital Ethics Committee. The patients/participants provided their written informed consent to participate in this study.XY, YY, FY, ZL, CW, HD, and JZ designed the study. XY obtained funding and supervised the study. XZ and ZC analyzed the data. XY, ZC, and XZ interpreted the data and drafted the report. ZC, XH, LY, FY, ZL, CW, HD, JZ, and YY participated in the collection of data. All authors contributed to the article and approved the submitted version.This study was supported by National Key Project of Scientific and Technical Supporting Programs funded by Ministry of Science & Technology of China (No. 2007BAI17B04) and the Key Program of Beijing Science and Technology Commission (D171100007017002). CNFEST received study drugs from Eli Lily, Janssen & Janssen and Kanghong Pharmaceutical Co. Ltd. The funding agency of the study as well as the pharmaceutical companies providing the study medications in kind had no role in study design, data collection, data analysis, data interpretation, writing of the report, or decision where to publish the results.XY has been an advisor or in speaker’s bureau to or has received honoraria from: Eli Lilly China, Xian Janssen, Lundbeck, Pfizer China, Eisai China, Novartis China and Sanofi China.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 explore the expectations and fears faced by doctors during Covid-19 Pandemic.This is a mixed method exploratory survey. A questionnaire exploring expectations of doctors from administration and seniors as well as their fears while working during pandemic, was developed on Google survey Forms. It included eight closed ended questions and four open ended questions. Data was collected through online Google survey Forms during month of March and April 2020. Doctors were approached through email and WhatsApp group.The mean age of participants was 33.58±4.21 years. Female 150(67.5%) and Male 72(32.4%) participated. 29(13.1%) Associate Professor, 34(15.3%) Assistant Professor, 56(25.2%) Senior Residents and 103(46.3%) residents, medical officers and house officers responded to the survey. 134(60.3%) doctors were working in hospitals which were not dealing with Covid-19. Fear included, infecting family members 177(79.7%), rapid spread of disease 140(63%), complications of disease 134(60.3%), becoming a carrier in 64(28.8%) and 62(27.9%) feared missing the diagnosis. More than 80% expected from seniors and administration, of providing PPE, facilitation, continue chain of supply of essential items, ensuring doctor safety, avoiding exposure of all doctors and keeping reserve workforce, limiting routine checkups, avoid panic and 20% had no expectations.It was concluded that doctors had their fears and perceptions regarding pandemic which need to be addressed while policy making. They fear wellbeing of their families and contacting Covid-19, if not provided proper PPE. Our study provides insight of expectations, fears and perceptions of our frontline which invariably gives insight of the views of healthcare workers. End of 2019 brought the global community to be aware of an emerging health crisis which originated in WUHAN CHINA. Most of the world was not prepared for a situation in which their whole lives will change so in spite of warning messages, the response by global health community and policy makers was slow. In January 2020 the World Health Organization (WHO) declared the outbreak of a new coronavirus disease, COVID-19, to be a Public Health Emergency of International Concern.This outbreak is a unique and unprecedented scenario for most of the health workers and their families too. This is a long-term fight and requires sustained response.The biggest concern is bringing the virus home to their families. There is also a fear that if they fall ill they will be betraying the health system and their patients as they will not be able to contribute.A cross-sectional web-based survey was carried out by using google forms. A new questionnaire was developed, after validation from five experts, who were working as medical educationist as well as senior consultants with experience of more than 15 years. it was pilot tested. The final survey consisted of total 12 questions; 8 of which were close-ended and 4 were open-ended. Participants included the Pakistani as well as few UK 22.2% (n=10), USA 22.2% (n=10) clinicians, who were actively involved in clinical practice and duties during Covid-19 pandemic. Sample size was calculated by using open Epi calculator. These clinicians included anesthetist, surgeons, physicians, radiologists, pathologists, pediatricians, gynecologists, postgraduate trainees, medical officers & house officers working in various healthcare institutes. The diversity of the group allowed for generalization of results to all specialties to assess the clinicians. Opinions from all the angles. After ethical approval ER-A/28, and informed consent, 250 participants, selected through purposive sampling, were contacted through E-mails and WhatsApp group’s anonymity and confidentiality was assured. Later, reminders were also sent via e-mails and WhatsApp. 222 participants filled questionnaire and returned forms. Data was saved in Excel sheets directly from the Google forms. For close-ended questions frequencies and percentages were calculated. For open-ended questions inductive coding was done in excel. After initial coding, line-by-line coding was done for each response by primary researcher (UU) and the similar codes were grouped together to make themes. Frequencies were calculated for each theme. The coding process and themes were cross-checked by four reviewers separately  for validation.The study included 150(67.5%) Female and 72(32.4%) Male participants. The mean age was 33.58±4.21 years. 29(13.1%) Associate Professor, 34(15.3%) Assistant Professor, 56(25.2%) Senior Residents and 103(46.3%) residents, medical officers and house officers responded to the survey.Covid-19 patients were not present in hospitals of 134(60.3%) doctors and 88(39.3%) doctors had Covid-19 patients in their hospitals. Fears of doctors are shown in Covid-19 patients were not present in hospitals of 60.36% (n=134) doctors who responded and 39.3% (n=88) doctors had Covid-19 patients in their hospitals. 83.3% (n=185) doctors were aware of the SOPs and policies related to Covid-19, whereas 15.8% (n=35) were not aware and 0.9% (n=2) responded “may be”. Donning and doffing awareness was there in 76.1% (n=169), no awareness in 5.8% (n=13) and “may be” was answer of 18.1% (n=40). Following themes were generated from the open-ended questions,Fears of doctors included, infecting family members 177(79.7%), rapid spread of disease 140(63%), complications of disease 134(60.3%), becoming a carrier in 64(28.8%) and 62(27.9%) feared missing the diagnosis. Some of the statements of participants were;-“Facing a situation where I am helpless against the state of the patient” (P 2)-“To get infected” (P 13)-“We are working without PPE….may be infected with corona virus” (P 23)-“To have the severe complications of the disease in the patients n in ourselves” (P 30)-“…..Disease can spread rapidly” (P 35)-“Fearful for the family back home” (P 40)-“Treating a patient normally who turns out to be covid19 positive later on” (P 41)no fear…” (P 44)-“I have to perform my duty because I am doctor…Allah” (P 45)-“I have faith in -“Exposing my family to infection as well” (P 49)-“Catching the infection and unknowingly becoming a spreader rather than the care giver.” (P 178)-“Asymptomatic carriers and transmission are worrisome” (P 180)-“Panic among the paramedics and junior staff” (P 185)-“As we work without PPE……fear of getting corona virus” (P=196)Doctors expressed different feelings while working during Covid-19 pandemic. Some of these feelings were; Uncertainty and fear 12.1% (n=27), sense of duty 27.9% (n=62), depressing circumstances 58% (n=129), anxiety 86% (n=191), worried 28.8% (n=64), motivated 33.3% (n=74), hopeful 56.7% (n=126), cautious 31% (n=69), ambitious 15.3% (n=34), apprehensive and confused 4% (n=9). Some of the statements were;-“We feel proud of being the frontline fighters against this illness” (P 136)-“As a doctor, I’m at high risk and I’m feeling proud while performing high risk duties during this pandemic” (P 153)-“Praying to be out of this pandemic as early as possible” (P 169)-“Feel grateful to be given a chance to help the affected” (P 176)-“Fearful but ambitious” (P 181)-“Uncertainty about the entire situation and fears of contacting infection” (P 188)-“Worried because of not having proper PPE”-“Feelings of empathy for people who are quarantined and for patients who have contracted covid-19” (P 193)-“We have to work through thick and thin and protect our families as well” (P 197)-“Working with full energy along with faith in Allah Almighty” (P 201)-“Serving humanity and mankind” (P213)-“I feel obliged that I am fulfilling my duties…” (P 220)-“Situation is same everywhere. Protective kits, PPE is available to only the administration who will never directly see the patient, the real healthcare teams are given scanty sources”Responses of doctors on question regarding their thoughts while they are on way to hospital were mixed. Some of these thoughts are documented in their words as follows;-“May ALLAH protect us all and give speedy recovery to the ill, and will I be getting proper PPE today or not” (P 07)-“To adhere to SOP regarding patient handling” (P 11)-“To be safe, responsible and stick to guidelines but there’s a hidden fear as well” (P 19-“That I will get the disease somehow” (P 16)-“I am a health care professional and it’s my duty to help patients suffering from diseases, and at the same time keep myself protected” (P 27)-“Can this be avoided….is my duty warranted…or is it causing unnecessary exposure” (P 33)-“Considering duties as our main responsibility being a doctor and having trust on Allah that He will protect us …” (P 41)-“Nothing specific. Not always thinking about corona. Thinking about my juniors to keep their moral up” (45)-“This time shall pass” (P 46)-“Thinking of dealing a patient with covid19 positive but not knowing” (P 51)-“That I don’t get to manage a critically ill Covid-19 patient” (P 58)-“Thinking about its spread and protection by social distances” (P 63)-“Here I come again Corona. You can’t stop me at home” (P 70)-“About crisis will have to face” (P 73)-“Another tough day dealing with the fear of covid-19, that I might not get infected and become a source for my family” (P 79)-“My thoughts are towards performing my duties with full concentration and no negligence” (P 84)-“Thinking about my mix feelings of fear and responsibilities” (P 103)-“To work efficiently” (P 289)There were many expectations from administration, seniors and peers. These are shown in To quote few statements in which participants had no expectations from administration 39% (n= 86), such as;-“I don’t have any expectations as this is a brand-new front, unprecedented, no one alive has fronted an issue of this magnitude….so I don’t expect policies to be perfect….and I know everyone has fear in their hearts…. naturally” (P 7)-“No expectations from admin Our seniors and colleagues very cooperative we all will beat this war” (P 17)-“Not a lot” (P 37)More than 80% expected full support, provision of protective equipment, cooperation and organization from administration.It won’t be wrong to say that 99% of doctors had feelings, thoughts and expectations centered towards their families.This survey enrolled 222 participants and gathered the data of doctors working in critical and uncertain conditions of pandemic. In this study significant number of participants expressed feelings of concern, anxiety, uncertainty and stress similar to other studies done which showed same psychological responses while working in high-risk situations.11The fact that COVID-19 is human-to-human transmissible, associated with high morbidity, and potentially fatal may intensify the perception of personal danger.13Health Care Workers working in emergency departments, intensive care units, and isolation wards had a greater risk of developing adverse psychological outcomes than those of other departments, because they were directly exposed to the infected patients in a highly demanding environment.14Expectations of most of the doctors from administration were to provide full support, protective equipment provision, planning and logical distribution of resources in order to Gare up for future uncertainty. First and foremost, organizational leaders should provide clear messages that clinicians are valued and that managing the pandemic together is the goal.15Although global health crises share common characteristics across national contexts, each country has its unique political and social systems that affect information behaviors and environments.7All doctors showed concern for carrying the disease to their families and expected support from seniors and administration, leaders should aim to monitor clinician wellness and proactively address concerns related to the safety of clinicians and their families.This study was conducted during pandemic and lockdown. There is a need to carry out more studies to explore the environment and working conditions of healthcare workers. It will help policy makers and administration to take appropriate decisions and work as team with motivation during this crisis.Covid-19 pandemic has raised numerous challenges all around the world. The health care system is at breaking point in many developed countries. Keeping opinion of doctors in view we need to plan as quickly as possible, to identify how we can reconfigure our services. Our frontline medical staff need to be protected both mentally and physically, which can be achieved by working together as a team.UU: Conceived, designed, data analysis and editing of manuscriptAA: Data analysis and editing of manuscriptAS and SK: Data collection/analysis.HT: Data collection.UU: Takes the responsibility and is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


Pancreatic lymphoepithelial cyst (LEC) is a rare, benign collection of keratinizing squamous epithelial cells encapsulated by lymphoid tissue. Because of its limited data and nonspecific features that can mimic malignant lesions, LECs can lead to unnecessary operations. A 62-year-old male with a known pancreatic mass presented with abdominal pain. CT scan showed an increased mass in the pancreatic head, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) revealed “rare fragments of benign-appearing squamous epithelium in a background of keratin debris, cyst contents, and scattered lymphocytes,” consistent with a lymphoepithelial cyst. Pancreatic LEC is an extremely rare lesion that comprises of only 0.5% of all pancreatic cysts. EUS-FNA has become the mainstay for diagnosing pancreatic LECs. Given the slow growing and benign nature, conservative management and observation is adequate for pancreatic LECs with excellent long-term outcome. With increasing number of imaging ordered by clinicians, it is anticipated that there will be a greater number of incidental pancreatic LECs detected. Thus, EUS-FNA should be utilized more frequently to help distinguish benign pancreatic LECs from premalignant or malignant lesions to avoid surgery. Pancreatic lymphoepithelial cyst (LEC) is a rare, benign collection of keratinizing squamous epithelial cells encapsulated by lymphoid tissue , 2. AbouA 62-year-old male with a known pancreatic mass presented with a nonspecific abdominal pain. He had an abdominal ultrasound performed about 7 years before that showed a suspected 4.7 × 3.4 × 5.2 cm mass in the region of the pancreatic head. This was not further addressed, and the patient was not referred. He then presented to the ED 4 years later for chest and back pain for which he received a CTA aorta showing a 4.5 × 2.9 × 3.8 cm hypoenhancing mass by the superior pancreatic neck with no pancreatic ductal dilation or atrophy. This was followed up by an MRI of abdomen that year that showed a 2.6 × 3.8 cm heterogenous nodule in the pancreatic head, high signal on T2, and hypointensity on T1 weighted imaging, without any ductal dilation. Again, he was lost to follow-up but represented with abdominal pain 3 years later, prompting a right upper quadrant ultrasound that showed a suspected lesion near the head of the pancreas, measuring 4.7 × 3.4 × 5.2 cm. Subsequent CT of the abdomen showed a 3.6 × 5.2 cm mass in the pancreatic head with no pancreatic ductal dilation or retroperitoneal lymphadenopathy . Given tPancreatic LEC is an extremely rare lesion that comprises of only 0.5% of all pancreatic cysts . They arPancreatic LEC predominantly occurs in males aged 50 to 60 years , 14, 15,Hence cytopathological evaluation through EUS-FNA has become the mainstay to increase accuracy of diagnosis for pancreatic LECs. LEC tends to have common distinct features comprised of an outer layer of lymphoid tissue and an inner layer of mature, nucleated squamous epithelium without atypia , 24, 25.Given the slow growing and benign nature, conservative management and observation is adequate for pancreatic LECs with excellent long-term outcome , 25, 30.While there is a general consensus of how pancreatic LECs present under various imaging modalities, pancreatic LECs are still a rare entity and can portray different features in EUS depending on the content of mucin, keratin, and lymphoid tissue in the cyst . With in


Scientific Reports 10.1038/s41598-019-53328-6, published online 19 November 2019Correction to: The original version of this Article contained errors in the Reference list. Reference 69 was a repetition of reference 43.In addition, Reference 55 was incorrectly given as:J. Phys. Chem. C111, 13794–13803 (2007).Le, R. E. C., Blackie, E., Myer, M. & Etchegoin, P. G. Surface enhanced Raman scattering enhancement factors: A comprehensive study. The correct reference is given below:J. Phys. Chem. C111, 13794–13803 (2007).Le Ru, E. C., Blackie, E., Myer, M. & Etchegoin, P. G. Surface enhanced Raman scattering enhancement factors: A comprehensive study. Furthermore, this Article contained typographical errors in the reference citations.In the Introduction,55, enables a unique approach for obtaining versatile SERS-active devices at high throughputs.”“This aspect, coupled with ultrafast laser inscription techniques for writing reproducible, sub-wavelength structures directly using femtosecond laser pulses by virtue of strong, highly localized nonlinear optical effectsnow reads:58, enables a unique approach for obtaining versatile SERS-active devices at high throughputs.”“This aspect, coupled with ultrafast laser inscription techniques for writing reproducible, sub-wavelength structures directly using femtosecond laser pulses by virtue of strong, highly localized nonlinear optical effectsIn the Materials and Methods,et al.57 58 can be calculated using the following definition:”“Since we do not know the number of molecules probed and wish to know how much more signal is generated by SERS compared to normal Raman, the analytical enhancement factor (AEF) as described by Le Ru now reads:et al.55 57 can be calculated using the following definition:”“Since we do not know the number of molecules probed and wish to know how much more signal is generated by SERS compared to normal Raman, the analytical enhancement factor (AEF) as described by Le Ru In Table 1 Reference 57 was incorrectly given as Reference 56. Additionally, References 60–67 were incorrectly given as References 61–68 respectively.Also in Table 1,69,69”“Electrochemical etching of a silicon wafer in HF electrolyte, followed by immersion plating in silver nitrate solutionnow reads:“Electrochemical etching of a silicon wafer in HF electrolyte, followed by immersion plating in silver nitrate solution”In the Results and Discussion section, under the subheading ‘Analytical estimate of the SERS enhancement factor for silver clusters’,r1 from one of the particles will experience an enhanced electric field due to coupling of their plasmon resonances. Following the treatment as described by Sun et al.69”“A molecule which is placed at a distance now reads:r1 from one of the particles will experience an enhanced electric field due to coupling of their plasmon resonances. Following the treatment as described by Sun et al.68”“A molecule which is placed at a distance This Article contained a typographical error in the Results and Discussion section, under the subheading ‘SERS-active buried channels’,“Table 1, comparing techniques to generate SERS surfaces within microfluidic channels, is shown above to put the work presented in this manuscript into context.”now reads:“Table 1, comparing techniques to generate SERS surfaces within microfluidic channels, is shown below to put the work presented in this manuscript into context.”These errors have been corrected in the PDF and HTML versions of the Article.


Analysis of tumours and tumour-infiltrating lymphocytes (TILs) may provide insight into the progression of HPV− HNSCC.The prognosis of HPV− tumours were classified into “Infiltrating” and “Pushing” subtypes based on their different tumour nest configuration and prognosis) were retrospectively analysed. HNSCC data from the Cancer Genome Atlas (n = 263) were analysed for CD8α, HPV and overall survival (OS). A murine HNSCC model was used to verify the antitumour role of PD-1+CD8+ TILs.The tumour and TIL phenotypic characteristics of 134 HNSCC specimens  of “Infiltrating” HPV− tumours. PD-1+CD8+ TILs recognised autologous HNSCC cells and showed stronger inhibition of tumour growth in a murine HNSCC model resistant to PD-1 blockade.The “Infiltrating” HPV− HNSCC and TILs is characterised by an “Infiltrating” phenotype and less tumour-specific PD-1+CD8+ TILs, which may provide a framework for further translational studies and patient stratification.Coevolution of HPV All primary or recurrent tumours from the tonsils or lymph nodes were excluded, considering that surrounding lymphocytes in these subsites may interfere with the phenotypic analysis. Ultimately, 101 primary tumour samples, 22 matched local recurrent HPV− samples and 11 primary HPV+ samples from the same centre were obtained. Histologic examination was performed by two pathologists. Tumour grade, stage and basic patient clinical information of HPV− primary tumour samples are summarised in Supplementary Table Tumour samples of patients with HNSCC were obtained between 2007 and 2017. For HPV detection of primary HNSCC, p16 immunohistochemistry  using Fiji software. For immunofluorescence-stained image acquisition, slides were scanned using the Vectra platform (PerkinElmer) or TissueFAXS slide scanning system (TissueGnostics). Analysis was performed using InForm software (PerkinElmer), TissueQuest or StrataQuest software (TissueGnostics). Cells were identified based on segmentation of DAPI-stained nuclei. When StrataQuest software was used, whole-tumour section was scanned, and cells in indicated areas were analysed.For IHC analysis, CD85 cells into the right flanks. α-PD-1 (200 μg) and IgG isotype (200 μg) were administered intraperitoneally twice weekly. In total, 3 × 106 PD-1+CD8+ or PD-1−CD8+ TILs from autologous tumours were administered intravenously on day 4 after the inoculation. Tumour size was calculated as length × width. Nasal anaesthesia (isoflurane) was used before the tumours were collected, and the mice were then killed by cervical dislocation. Mice with length greater than 2 cm were euthanized  for ethical consideration.Female C3H/He mice aged 6–8 weeks were purchased from the Charles River Laboratories. All mice were maintained under specific pathogen-free conditions in the animal facilities of the Ninth People’s Hospital. Prior to treatment, mice were randomised. Nasal anaesthesia (isoflurane) was used before the subcutaneous injection. SCC7 cells were implanted by subcutaneous injection of 2 × 10t test for pairwise comparison or ordinary one-way ANOVA for multiple comparisons); if not, the nonparametric test was used . All multiple comparisons were corrected by Bonferroni test. Overall survival (OS) was defined as the time from initial diagnosis until death or the most recent follow-up. Survival distributions were displayed using the Kaplan–Meier method, and their comparisons were conducted using Log-rank test, unless otherwise indicated. The results are presented as the mean ± standard deviation (SD). P < 0.05 was considered statistically significant.For statistical analysis, first, the normal distribution of the data was analysed using Kolmogorov–Smirnov test. If normal distribution was assumed, the parametric test was used  primary HNSCC samples were selected by the following criteria: (1) surgical resection was the primary treatment, and no preoperative chemoradiotherapy was performed, (2) HPV status was known and (3) adequate IM and tumour centre (TC) areas were available for analysis. The density of CD8+ TILs at IM and TC was quantified  , suggesting a more intense immune response in this region  with CD8α expression and HPV status were analysed.25 Three groups were divided: HPV−CD8low (n = 113), HPV−CD8high (n = 112) and HPV+ (n = 38)  samples .Considering that tumour cells in IM are frequently different from those in other parts, and according to reports on the classification of tumour shape in IM,ng” Fig. . In “Pus+ TILs in different HNSCC subtypes. Based on the differences of CD8+ TIL patterns, “Infiltrating” and “Pushing” HNSCC were further divided into four subtypes: inflamed, sloped, excluded and deserted  were similar. In addition, the ratios of IM_epithelia PD-1+CD8+ TILs to IM_stroma PD-1+CD8+ TILs were higher than those of PD-1+CD8− TILs  PD-1+CD8+ TILs were higher than those of PD-1+CD8− TILs , Tregs (FOXP3+), NK cells (CD56+) and macrophages (CD68+) were analysed. There were little NK cells  and HPV+ HNSCC (n = 11) were analysed  of this subset may enhance antitumour immunity  and “Infiltrating” tumours (n = 16) that had plenty PD-1+CD8+ TILs in IM were analysed for CD8, PD-1, TIM3, Granzyme-B (GZMB) and Ki67. The results showed that the percentage of exhausted CD8+ TILs (PD-1+TIM3+) in IM was similar in “Pushing” and “Infiltrating” subsets . There are several possible explanations for this contradiction: (1) small sample size, (2) HPV− HNSCC represents a group of tumours that require further classification and (3) compared with the total CD8+ TILs, the PD-1+CD8+ TILs may more accurately represent the tumour-specific subset and be of greater value to prognosis and immunotherapy.32Even though the detailed mechanisms remain unclear, it is widely accepted that tumour evolution is shaped by two major forces: genetic/epigenetic changes of tumour cells and selective pressure from the tumour microenvironment. Immune predation is a major form of selective pressure.+ T-cell infiltrates.35 However, there is still an urgent need for better biomarkers or combinations that improve the response rate of immune-checkpoint therapy in different cancers, including HPV− HNSCC. In this study, we performed additional analyses in the context of HPV− HNSCC to understand the importance of considering tumoral and immune factors as a whole, to gain insights into their primary resistance to immunotherapy as well as to help clinicians optimise personal therapy for cancer patients.Clinical trials targeting ICR have shown promising results for multiple cancers, and many biomarkers predict the response to PD-1-based immunotherapy, such as PD-L1 expression, tumour mutational burden  and CD813 and we proposed “Pushing” and “Infiltrating” only for the convenience of classification and understanding. Our data showed that “Infiltrating” subtype was associated with worse prognosis. From primary to local recurrent tumours, the coevolutionary trend supports the notion that adaptive immune selection is a main selective pressure for HNSCC cells. The phenotypic coevolution of HPV− HNSCC and CD8+ TILs may serve as a primary blueprint for patient stratification.In this study, we performed a proof-of-concept study in the context of HNSCC to understand the importance of considering tumoral and immune factors as a whole. Pathological features of tumour are important for two reasons: firstly, different genotypes may produce the same phenotype; secondly, phenotypic analysis of whole-tumour section, combined with multipoint sequencing, will lead to more accurate tumour typing. The terms “Pushing” and “Infiltrating” used in this study are similar to “Type A” and “Type B” proposed by Nakanishi et al.,36 From the perspective of tumour, the HNSCCs may have adopted different types of immune-escape strategies. From the perspective of TILs, CD8+ TILs functionally can be further divided into tumour-specific and non-specific groups of cells. This study suggests that the combined analysis of tumours and TILs may help to further increase the response rate of ICI therapy by providing the basis for patient stratification.Despite the presence of programmed death-ligand 1 (PD-L1) in >50% HNSCC patients, only a minority of patients with HNSCC (< 20%) respond to ICI immunotherapy.39 A potential drawback of this study is that the number of tumours is limited, except for HNSCC in the oral or oropharynx, although oral and oropharyngeal squamous cell carcinoma is the most common type of head and neck carcinomas. This is partly because all primary or recurrent tumours from the tonsils or lymph nodes were excluded, given that lymphocytes around these subsites may interfere with phenotypic analysis. The HPV− HNSCCs were divided into “Pushing” and “Infiltrating” subtypes in this study, but their clinical relevance and definite marker (based on blood or biopsy) need further study. However, the relatively low levels of B cells and PD-1+CD8+ cells in high-risk “Infiltrating” HPV− HNSCC suggest that ICI therapy may show a higher response if combined with treatments that reverse the lack of PD-1+CD8+ TILs in these patients. Such treatments are included but not limited to TGF-β blockade, immune modulation, macrophage inhibition or cancer vaccines.40HNSCC covers a lot of different subsites, and the risk factors for HNSCC at different subsites are similar: about 80% of HNSCC attributed to tobacco exposures, other risk factors include alcohol, betel nuts, foods high in nitroso compounds and HPV exposure.+CD8+ TILs in most HNSCC patients, 84.1% of the HPV− HNSCC microenvironments were rich in CD8+ TILs in this study, provides the basis for immunotherapy. First, PD-1+CD8+ TIL ACT is a new option with clinical potential for patients with α-PD-1 resistance. Second, since PD-1+CD8+ TILs are rich in tumour-specific cells, their TCRs can be obtained by single-cell sequencing and bioinformatics analysis, and new personalised TCR weapons may thus be obtained. Moreover, the results suggest that, by combined analysis of HNSCC and PD-1+CD8+ TILs, we may more accurately understand the immunotyping and escape strategy of the tumour. In summary, through the combined analysis of tumour and tumour-specific CD8+ TILs, we could understand the evolutionary status of a tumour more accurately and provide the basis for clinicians to develop personalised treatment plans.The abundance of PD-1Supplementary Materials


Although muscular strength is an important component of explosive movements and sport-specific skills, few studies have quantified indices of muscular strength following NO3− supplementation, particularly isokinetic assessments at different angular velocities. We performed a systematic review and meta-analysis to determine whether dietary NO3− supplementation improves peak torque, as assessed by the gold standard method of isokinetic dynamometry, and if this effect was linked to the angular velocity imposed during the assessment. Dialnet, Directory of Open Access Journals, MEDLINE, PubMed, SciELO, Scopus, and SPORTDiscus were searched for articles using the following search strategy: (nitrate OR beet*) AND (supplement* OR nutr* OR diet*) AND (isokinetic OR strength OR “resistance exercise” OR “resistance training” OR “muscular power”). The meta-analysis of data from 5 studies with 60 participants revealed an overall effect size of −0.01 for the effect of nitrate supplementation on isokinetic peak torque, whereas trivial effect sizes ranging from −0.11 to 0.16 were observed for independent velocity-specific  isokinetic peak torque. Four of the five studies indicated that dietary NO3− supplementation is not likely to influence voluntary knee extensor isokinetic torque across a variety of angular velocities. These results suggest that NO3− supplementation does not influence isokinetic peak torque, but further work is required to elucidate the potential of NO3− supplementation to influence other indices of muscular strength, given the dearth of experimental evidence on this topic. Dietary nitrate (NO Performance outcome in a variety of sports is determined by the ability to perform a range of rapid, dynamic, and explosive movements such as sprinting, changing direction, jumping, and exhibiting sport-specific skills . Indeed, the ability to produce force and power is considered among the most important factors for optimizing overall athletic performance ,2. It is3−), which is typically administered as NO3−-rich beetroot juice (BR)    after NO3− supplementation in females [3− supplementation appears to be linked to NO synthesis, and since various subject population characteristics including health, age, and sex can modulate NO bioavailability, further research is required to aid understanding of the different settings in which NO3− supplementation might influence muscular strength.It is becoming increasingly appreciated that the efficacy of NOlability ,55. For lability  and lowelability ,58. Theriomarker ) after N = 0.60) . Peak to = 0.60)  compared = 0.60) ,32,40,48 females . Since t3− supplementation on the muscle contractile function. It should also be acknowledged that although NO3− supplementation does not appear to influence isokinetic peak torque during independent angular velocity assessments, subsequent calculations of maximal power and velocity of contraction from peak torque values obtained across a series of independent angular velocity assessments were improved by NO3− supplementation [3− supplementation on different aspects of skeletal muscle contractile function is equivocal. Indeed, NO3− supplementation has been reported to increase force production at low stimulation frequencies in some (≤20 Hz) [3− supplementation [3− supplementation. There is also evidence of an increased peak power output during a 30 s Wingate test after dietary NO3− supplementation [3− supplementation improving skeletal muscle strength, power, and velocity cannot be excluded on the basis of the present meta-analysis, and further studies are warranted to provide greater clarity on the effects of NO3− supplementation on skeletal muscle contractile function.It should be noted that there are a variety of methods to assess muscle contractile function; these methods range from isometric to the commonly implemented isotonic methods. In addition, there are methods that employ single-joint (isokinetic dynamometry) or multi-joint movements (1RM testing), which may have better reliability, sensitivity, and validity, while other methods may better translate to sport-specific performance . Given tentation ,31,32,48(≤20 Hz) ,23,24 bu(≤20 Hz) ,26. Althentation ,26,28,29entation  and concentation  have beeentation ,36,37. T3− ingestion is not likely to induce positive benefits to muscle peak torque production at a variety of angular velocities in the lower limbs, at least when assessed using isokinetic dynamometry. The lack of an effect of NO3− supplementation might be linked to NO bioavailability, which is modulated by factors such as dosing strategy, and participant health and training status, and sex. Given the paucity of literature, further research is required for a more complete understanding of the influence of NO3− supplementation on different aspects of muscle strength.In conclusion, the current systematic review and meta-analysis indicates that acute dietary NO