At harvest, Zn biofortification reached a 4.3- and 2.3-fold increase with ZnO 1350 g ha−1 in Castelão and Syrah, respectively . On a physiological basis, lower values of NDVI were found in the biofortified grapes, although not reflected in photosynthetic parameters with cv. Syrah shows even a potential benefit with the use of Zn fertilizers. Regarding physical and chemical parameters , relative to the control no significant changes in both varieties were observed, being suitable for winemaking. It was concluded that ZnSO4 and ZnO foliar fertilization efficiently increased Zn concentration on both varieties without a negative impact on quality, but cv. Castelão showed a better index of Zn biofortification and pointed to a potentially higher quality for winemaking.One-third of the world’s population is suffering from “hidden hunger” due to micronutrient deficiency. Zinc is acquired through diet, leading its deficiency to the development of disorders such as retarded growth, anorexia, infections, and hypogeusia. Accordingly, this study aimed to develop an agronomic workflow for Zn biofortification on two red winegrapes varieties (cv. Castelão and Syrah) and determine the physicochemical implications for winemaking. Both varieties produced in Setúbal  were submitted to four foliar applications of ZnSO Micronutrient deficiency also known as “hidden hunger” is considered a public health problem, affecting about two billion people  worldwide ,2. Globa2+ or bounded to organic acids) is dependent on the remobilization through xylem or phloem  to the growing tissues [As a strategy to mitigate Zn deficiency, agronomic biofortification has been applied to several crops. This approach leads to an increase in nutrient concentration in edible parts of plants, through agronomic practices ,12,13,14 tissues ,23,24. T tissues ,26.−1dw [2/HCO3 in the leaf, necessary for the photosynthetic fixation of CO2 [−1dw) [Zinc occurs in the six enzyme classes , with numerous binding sites in proteins, lipids, and nucleic acid molecules ,27,28,29−1dw . Insuffi−1dw ,42. Moren of CO2 . These bn of CO2 ,45,46,472 [−1dw) . Zinc to2 [−1dw) ,49.4 and ZnO, considering the potential modulation of physiological parameters mediated by these fertilizers during the production cycle of the vines. Additionally, the index of Zn accumulation and the physicochemical characteristics were assessed. This study will provide us with Zn agronomic biofortification data of fruit in natural climatic conditions, associated with the global wine market by developing a potential new product with more health benefits.The aim of this study was the development of an itinerary for Zn biofortification of two red grape varieties (Castelão and Syrah) through foliar application of ZnSO4-Cl type (sodium–sulfate–chloride type), belonging to class C1S1 and with a sodium adsorption index (SAR) 1.4  1.4 .4 and ZnO foliar applications, a better NDVI response was found with 900 g ha−1 of ZnSO4 in both varieties   of both Castelão and Syrah vineyards revealed a higher vigor in the vines without foliar spraying with Zn chemical forms  ; Table 1ctively) . Additio−1), whereas relative to the control, only E showed the highest concentration with ZnSO4 (1350 g ha−1) (−1 of ZnO and ZnSO4) maintained the performance of the photosynthetic machinery, even showing potential positive effects reflected in the Pn of Syrah  [Net photosynthesis (Pn), stomatal conductance to water vapor (gs), transpiration (E), and leaf instantaneous water use efficiency (iWUE) of both vineyards Castelão and Syrah were monitored during the production cycle, to determine the potential physiological effects of Zn leaf spraying. After the fourth foliar spraying (21 August), significant differences could not be found for cv. Castelão and Syrah  . Regardi g ha−1) . Moreovedioxide) .4, Zn content in the leaves was similar among all treatments for Castelão , but some fluctuations were found in Syrah  (−1 leading to the highest Zn concentration) (Before foliar spraying with ZnO or ZnSO g ha−1) . After ttration) . Betweentration) .4 sprayed grapes presented a higher Zn concentration compared to the control in both varieties   . In Zn-tso found . Compariof ZnSO4 .−1 of ZnO in Syrah and 900 g ha−1 of ZnSO4 in Castelão for total soluble solids)  of Castelão were significantly higher than Syrah   . In Cast solids) . As for antified . A compaan Syrah .−1 of both ZnO and ZnSO4) (−1).Concerning the colorimetric analysis, the absence of significant variations was observed in L, a*, and b* parameters for both varieties . Betweend ZnSO4) . In addiVitis vinifera, in different vineyards of Setubal/Portugal, were used as experimental field trials for Zn biofortification. As water management through irrigation affects grape composition and wine quality [−1) and SAR value   were calculated, are usually used to monitor the amount of photosynthetically active biomass, and also changes in crop states  [2 diffusion in the chloroplast [As the vines’ growth and quality depend on edaphoclimatic conditions, namely variety and viticultural management ,53, two  quality , the pro quality . Regardi quality , as obsee., 1.4) . Conside others) ,58,59. A others) ,61,62. I others) . Moreove others) . Additiooroplast . In factoroplast .4 and ZnO, the leaves with a higher Zn content led to their higher accumulation in the fruit (4 [−1 (4 which is rapidly acquired and can more easily lead to signs of toxicity) [Zinc has a high phloem mobility in the vine, being prone to the concentrations increase in plant organs ,68. Indehe fruit ; Table 3fruit  . The difoxicity) .3 could have nutraceutical and sensory advantages [At harvest, after Zn biofortification with both fertilizers, the absence of negative impacts on the quality parameters such as dry weight, density, °Brix, and color was found . Data fovantages , being tvantages  where L*vantages ,85. In tvantages , a patteVitis vinifera L. , were used as a case study for Zn agronomic biofortification with ZnSO4 (AGROZAP) or ZnO (VITTIA) at concentrations of 0, 900 and 1350 g ha−1 . Vineyard fields were located in Setúbal, Portugal with GPS coordinates 38°36′00.01376123″ N; 8°48′18.66998178″ W and 38°35′20.84975562″ N; 8°51′43.39046267″ W . Harvest was performed on 14 and 25 September of 2019 for Castelão and Syrah, respectively. Between 29 June (1st foliar application) and 25 September (latest harvest), maximum and minimum mean temperatures ranged between 22.7 and 17.9 °C, respectively. The air humidity revealed its maximum and minimum with values of 99% and 17%, and the total precipitation accumulated was 18.28 mm (with a daily maximum of 12.95 mm) which according to [Two red grape varieties of rding to  this yea3−), sulfate (SO42−), chloride (Cl−), sodium (Na+), calcium (Ca2+), magnesium (Mg2+), potassium (K+) and phosphate (PO43−)) parameters. Electrical conductivity (EC) and pH were acquired using a Consort multiparameter analyzer (C 6030) and SP21 (pH) and SK20 T (CE) electrodes. Calcium, Na, K, and Mg ions were quantified using a chromatograph , equipped with column and pre-column , using an eluent mixture (4 mM tartaric acid/1 mM dipicolinic acid) at a flow rate of 1 mL/minute and a sample injection of 10 μL. Alkalinity/bicarbonate was determined with titration, in 100 mL of water samples, using 0.1 N hydrochloric acid as titrant, in the presence of 0.1% methyl orange [Water quality of the vineyards was determined considering physical  and chemical (bicarbonate (HCOl orange . Chloridl orange . Sodium l orange . Data ac4 or ZnO). To monitor the physiological response to Zn biofortification the orthophoto maps and NDVI index  were obtained, according to [Using a UAV  with altimetric measurement sensors and synchronized by GPS, images of both fields were acquired and processed in ArcGIS Pro  and photosynthetic photon flux density (PPFD) ranging between 1200–1400 µmol m−2 s−1. Leaf instantaneous water use efficiency (iWUE) was calculated as the Pn-to-E ratio, indicating the units of assimilated CO2 per unit of water lost through transpiration.Leaf gas exchange parameters were determined using 4–6 leaves from different plants and only considering second youngest leaves (fully expanded) per treatment on 21 August, according to . Net phoZinc concentration was determined on 10 selected leaves from different plants and considering only the second youngest leaves (fully expanded) per treatment  on two evaluation dates (samples harvest on 20 May and 24 July of 2019): without Zn foliar application and after the 4th Zn foliar application. Measurements were performed in triplicate, using an XRF analyzer  under helium atmosphere and with emission of radiation for 180 s. For data analysis, NITON Data Transfer software (XL 3t-36653) was used .3−:HClO4 (4:1) [At harvest, Zn concentration of randomized grapes was determined . Then, an acid digestion procedure was performed with a mixture of HNOO4 (4:1) , followeAt harvest, density, dry weight, and total soluble solids were measured considering three grapes randomly selected per treatment. Total soluble solids were measured in grape juice using a digital refractometer from Atago , and the values obtained were expressed as °Brix.Colorimetric parameters were accessed at harvest, considering triplicates of three independent randomized grapes. The methodology followed , where bp ≤ 0.05) to determine differences between treatments and between both Vitis vinifera L. cv. Castelão and Syrah in the same treatment. After, a Tukey’s test for mean comparison was performed .Data were statistically analyzed using a one-way or two-way ANOVA (4 and ZnO at concentrations of 900 and 1350 g ha−1 on Castelão and Syrah winegrapes. Indeed, both sources of Zn led to a higher accumulation of this nutrient, although the ZnO at the higher concentration was more efficient revealing a 4.3- and 2.3-fold increase in Castelão and Moscatel, respectively. Biofortification seems to be a strategy that allows a higher accumulation of Zn in grapes without a negative impact from a physiological perspective. Although, for a better understanding and process optimization, it is necessary more studies with other varieties and under different conditions and other Zn sources.This study showed the efficiency of Zn biofortification with ZnSO


MJD has two major ancestral backgrounds: the Machado lineage, found mainly in Portuguese families; and the Joseph lineage, present in all five continents, probably originating in Asia. MJD has been described in a few African and African-American families, but here we report the first diagnosed in Sudan to our knowledge. The proband presented with gait ataxia at age 24; followed by muscle cramps and spasticity, and dysarthria, by age 26; he was wheel-chair bound at 29 years of age. His brother had gait problems from age 20 years and, by age 21, lost the ability to run, showed dysarthria and muscle cramps. To assess the mutational origin of this family, we genotyped 30 SNPs and 7 STRs flanking the ATXN3_CAG repeat in three siblings and the non-transmitting father. We compared the MJD haplotype segregating in the family with our cohort of MJD families from diverse populations. Unlike all other known families of African origin, the Machado lineage was observed in Sudan, being shared with 86 Portuguese, 2 Spanish and 2 North-American families. The STR-based haplotype of Sudanese patients, however, was distinct, being four steps (2 STR mutations and 2 recombinations) away from the founder haplotype shared by 47 families, all of Portuguese extraction. Based on the phylogenetic network constructed with all MJD families of the Machado lineage, we estimated a common ancestry at 3211 ± 693 years ago.Machado-Joseph disease (MJD/SCA3) is the most frequent dominant ataxia worldwide. It is caused by a (CAG) Machado-Joseph disease (MJD) is a late-onset neurological disease, characterized mainly by gait ataxia, usually followed by loss of coordination in lower limbs, dysarthria, dystonia, pseudobulbar or bulbar dysphonia, and progressive external ophthalmoplegia (Coutinho and Andrade ATXN3 (14q32.12), contains a highly polymorphic CAG repeat tract, expanded above 61 units in patients , and is known also as SCA3. The causative gene, In Africa, MJD has been reported from Morocco, Algeria, Mali, Ivory Coast, Ghana, Nigeria and Somalia, as well as in several African-American patients  The Joseph lineage, predominant in the Portuguese-Azorean island of Flores (birthplace of the Joseph family), including a few phylogenetically close “Joseph-like” sublineages, seem to share a common mutational event, which probably occurred in Asia, 6,000 to 16,000 years ago n. Informed written consents were obtained from analysed individuals. We genotyped 3 siblings (F49-396–398) and their non-affected father (F49-395) , for the identification of MJD lineages (Table Two siblings from a Sudanese family (F49-396 and F49-398) were examined neurologically by Drs. Ashraf Yahia, Hassab Elrasoul Siddig and Mahmoud Koko. This family was part of a cohort of Sudanese families with hereditary spinocerebellar degenerations  Fig.  to asseses Table . The PHAes Table  was used–3, taking into account that we analysed 4 di, 2 tri and 1 tetranucleotide STRs—the mutation rate for trinucleotides (6.13 × 10−4) was estimated as the median value between that for di (7.8 × 10−4) and tetranucleotide repeats (1.5–2.0 times lower than for dinucleotides)  is given by ε = 1 − [(1 − θ)(1 − μ)], and the average of mutation and recombination events (λ) equals εt, where t is the number of generations  and recombination (θ) rates included as generating variation, as detailed before  and F49-398 were sibs born to non-consanguineous parents Fig. , who preIn his sib, F49-398, onset was at age 20, with gait ataxia. One year later, he still walked independently, but had lost the ability to run, developed dysarthria and started having muscle cramps. Examined at age 24 years, this patient had hyperreflexia without spasticity in upper limbs, and severe spasticity and hyperreflexia in lower limbs and bilateral Babinski sign. His lower-limbs’ muscles were mildly wasted, but had a grade five power in upper and lower limbs. He showed moderate upper-limbs and mild lower-limbs ataxia. He had slow saccades, but apparently no limitation of eye movements. The time from the first symptoms to death was 7 years. Neither of the patients had bulging eyes, nor sensory or extrapyramidal involvement, including dystonic posturing.ATXN3_(CAG)n allele was observed in each patient: F49-396 (29/74) and F49-398 (29/75)  Fig. . By segr75) Fig. , Fig. 1.Previously, we studied SNP-based MJD haplotypes in more than 20 populations , as well as in 79 other families of the Machado lineage ge Table , shared exp-18-7-19-24) was shared by 47 families, all of Portuguese origin. The two Spanish families showed a haplotype phylogenetically close to H1, probably resulted from a recombination in the founder haplotype. A recombination event (instead of stepwise mutations in STRs) is also the most parsimonious option to explain the origin of H4 and H5 from H1, since their downstream haplotype (4 STRs) is shared by all of them, with phylogenetically distant haplotypes observed only upstream.We observed a low gene diversity  in the Machado lineage, with only 12 STR-haplotypes being found among 82 families , 3% in Asia (n = 122), and 0% in Africa (n = 96)) and allele 18_AC21 (0.7% in Europe (n = 420); 3% in Asia (n = 119), and 0% in Africa (n = 97)).We have currently analysed a total of 393 MJD families , and could draw a broad picture of MJD lineages (and sublineages) worldwide. This Sudanese family with MJD shares the ancestral (“pure”) Machado lineage, present in 24% of all families studied. Thus, we estimated the time ensued from their likely common ancestor. As the most ancient STR haplotypic background, we assumed H1 to be the founder core haplotype of the network  physical distance between the two farthest STRs typed (θ = 0.0058 cM); and (2) meiotic events . Thus, assuming a generation time of 25 years, and based on the most accurate recombination estimates (from family data), we estimated the Machado lineage to be 3,211 ± 693 years.MJD has been reported from Africa and in a few families of African descent in the USA. To the best of our knowledge, these are the first MJD patients described in Sudan. Previous studies, including only three core intragenic SNPs, showed patients with African descent to have ACA, AGA or GCC (rs1048755–rs12895357–rs7158733) haplotypes, but not the GGC core haplotype that defines the Machado lineage   was at a relatively early age (24 and 20 years old), and time of disease evolution was short . In the Portuguese-Azorean islands of São Miguel and Flores (homelands of the Machado and Joseph families), as well as in Portuguese migrants in the USA and Canada, there is a well-established difference in AO and disease duration: onset occurs later and disease course is more protracted in the Machado family and others from São Miguel and in the east coast of the USA; mean AO ± SD was 43.2 ± 13.5 in patients from São Miguel  and H5 (found in Portuguese patients) implies one recombination plus 2 STR mutation steps , even if only three or six SNPs were typed in those studies (Gaspar et al. The fact that most Portuguese families with this lineage share the ancestral haplotype H1, strongly suggests that a major founder effect contributed to the high frequency of MJD in Portugal, as previously suggested (Martins et al. In spite of our extensive search in many other populations, the full picture of the Machado mutational origin may yet be incomplete, as MJD could still being underdiagnosed in some populations from Africa and elsewhere. If that were the case, the age of 3211 ± 693 years, as now anticipated for the ancestral origin of this lineage, would be an underestimate. In any case, as previously postulated (Martins et al.


While emergency medicine (ER)-based emergency care is prevalent in many countries, in Japan, the “department-specific emergency care model” and the “emergency center model” are mainstream. We hypothesized that many secondary emergency medical institutions in Japan have inadequate systems. Using a questionnaire, we investigated the status of and problems in the emergency medical services system in secondary emergency medical institutions in Japan. Until date, there has not been an exhaustive survey of emergency facilities on a countrywide scale. The main objective of this study was to investigate problems in the Japanese emergency medical services system and thereby improve optimal care for emergency patients.P < .001).A nationwide questionnaire survey involving 4063 facilities  in Japan was conducted. Of the facilities that responded, all secondary emergency facilities were included in the analysis. Responses from 1289 facilities without a tertiary emergency medical care center were analyzed. Among them, 61% (792/1289) had ≤ 199 beds, and 8% were emergency department specialty training program core facilities. Moreover, 42% had an annual patient acceptance number of ≤ 500, 19% did not calculate the number of acceptances, 29% had an acceptance rate of ≥ 81%, and 25% had an acceptance rate of 61–80%. Pregnant women (63%) and children (56%) were the major types of patients that affected the acceptance rate. Factors affecting facilities with a response rate of 81% or higher were “hospitals designated for residency training” and “facilities making some efforts to improve the quality of emergency care and the emergency medical system” . This study may lead to further improvement in the optimal care of emergency patients through the nationwide establishment of the proposed measures as well as through grouping and integrating the structures and systems in emergency and other medical facilities. There are several issues around the emergency systems in Japan, such as multi-specialty staffing, insufficient numbers of emergency physicians, and transfer of older patients in nursing homes during emergencies . The incEmergency hospitals in Japan are classified in three levels according to the severity of patients. Primary emergency medical institutions treat outpatients who do not require hospitalization, secondary emergency medical institutions treat patients who require hospitalization, and tertiary emergency medical institutions treat patients who are so serious that they need to be managed in an intensive care unit . The mosIn Japan, the “emergency center-type emergency medical care model”  and the “department-specific emergency medical care model,” unique to the country, have been the main models in operation for a long time . The “ERNo detailed survey has been conducted regarding the status of secondary emergency medical institutions in Japan. Thus, there is a lack of visibility of issues that need to be resolved by the academic community, government , and local hospitals certified emergency hospital in the region. We hypothesized that secondary emergency medical institutions, which are responsible for most emergency transportation in Japan, accept many ambulances despite their systems being inadequate. Therefore, we surveyed secondary emergency medical institutions and clarified the status and problems of the emergency care system.A total of 1476 facilities responded (response rate: 36.3%), and 1289 facilities were included in the analysis after excluding facilities with tertiary emergency centers , making up the largest group  responded to patients 24 h a day, 365 days a year; 17% (222/1289 facilities) responded on a rotating basis, and 3.6% (46/1289 facilities) responded only during weekdays. The annual number of emergency casualties was 0–500 in 42% (539/1289 facilities) and 501–1000 in 14%  included non-physicians who accepted a request for transportation from the fire department; 69% (885/1289 facilities) recorded the reason for not accepting the request, 24% (304/1289 facilities) did not, 4.1% (53/1289 facilities) recorded the reason as “other,” and 3.7% (48/1289 facilities) recorded “no answer.” Among hospitals with clinical training, the number of institutions that recorded the reason was significantly higher (data not shown).The presence or absence of rules in selecting a hospital in the area was “Yes” for 24% (304/1289 facilities), “No” for 45% (580/1289 facilities), “Don’t know” for 28% (366/1289 facilities), and 3.0% (39/1289 facilities) did not respond. The factors that influenced (or made facilities hesitate to accept) were as follows: pregnant women , children , drug addicts , patients with a history of mental disorder , alcoholics , trauma patients , patients with fever , others , patients living alone , and patients dependent on welfare payments ; 3.1% did not respond.Except during weekdays, the number of physicians in charge of treating patients transported by ambulance ranged from 0 to 1 in more than half of the facilities Fig. . The numP < 0.001). The number of dedicated physicians  at the 381 facilities that reported having a dedicated physician was 1–5, 72% (266/367); 2–3, 15% (54/367); 4–5, 4.4% (16/367); 6–10, 3.5% (13/367); and 11–20, 4.9% (18/367). The number of emergency department specialists among the dedicated physicians was 0, 27% (99/361); 1, 33% (119/361); 2–3, 25% (89/361); 4–5, 8.3% (30/361); 6–10, 5.5% (20/361); and 11–20, 1.1% (4/361). Among the facilities with dedicated physicians, 62% (224/360) had 0 female physicians, 23% (83/360) had 1, 10% (36/360) had 2–3, 2.2% (8/360) had 4–5, 1.9% (7/360) had 6–10, and 0.6% (2/360) had 11–20. The number of dedicated physicians and emergency medicine physician specialists was significantly higher in the clinical training hospitals , while there was no significant difference in the number of female physicians .Facilities that “always had a dedicated emergency physician available” were significantly more likely to be “clinical training hospitals” than non-clinical training hospitals .In the system for receiving ambulances, 41% (527/1274) of clinical technologists were always involved, 44% (558/1274) were conditionally involved, and 15% (189/1274) were not involved. Among pharmacists, 25% (314/1274) were always involved, 45% (574/1274) were conditionally involved , and 30% (386/1274) were not involved. Among radiologists, 56% (710/1278) were always involved, 37% (475/1278) were conditionally involved (depending on the time of day), and 7.2% (93/1278) were not involved. Involvement was significantly higher in training hospitals for all occupations . Of the facilities with initiatives, 64% (529/830) were involved in internal validation , 55% (453/830) participated in medical control councils, and 20% (169/830) held case-review meetings among local hospitals. The number of facilities not involved in any initiative was 35% (449/1279 facilities). Of the facilities that were not involved in such efforts, 37% (164/446) cited “no time,” 34% (15/446) “don’t know what to do,” 15% (68/446) “don’t need to,” and 21% (92/446) “other” as reasons.Of all facilities, 65% (830/1279 facilities) were taking initiatives to improve the quality of emergency care and the local emergency medical system, 35% (453/1279) were not, and 1% (10/1289) did not respond to this parameter. Facilities with initiatives were more likely to be clinical training hospitals (78% (558/715) vs. 46% (238/523); Fisher’s exact test, P < 0.01).Regarding whether physicians (excluding residents) who respond to emergency patients take measures based on standardized initial care tools , and so on), 43% (558/1289) answered “yes,” 17% (220/1289) answered “no,” 17% (214/1289) answered “neither,” 22% (281/1289) answered “don’t know,” and 1.2% (16/1289) did not respond. More facilities acted based on the initial care standardization tool in clinical training hospitals (83% (398/478) vs. 50% (135/269), Fisher’s exact test, Basic life support (BLS) was recommended to physicians and nurses involved in emergency care by 58% (751/1289) of the facilities, ICLS by 40% (513/1289), JATEC by 16% (202/1289), and Japan Prehospital Trauma Evaluation and Care by 15% (193/1289), and “Not recommended” 33% (427/1289), respectively. The number of annual training sessions  related to first aid and resuscitation (in 2019) conducted were 10 or more times in 8.2% (106/1289) of the facilities, 5–10 times in 9.4% (122/1289), 1–5 times in 60% (779/1289), and none in 21% (270/1289).Multivariate logistic regression analysis was conducted using the following explanatory variables: whether the facility has an annual demand rate of 81–100% as the objective variable, and factors that could affect demand, such as “core emergency department training program,” “facilities with 200 or more beds,” “clinical training hospitals,” “facilities making efforts to improve the quality of emergency care at the facility and the emergency medical system in the community,” and “facilities that always have a dedicated physician available.” A multivariate logistic regression analysis was conducted using “facilities that always have a dedicated physician available” as an explanatory variable. “Clinical training hospitals” and “facilities that are making efforts to improve them” were identified as factors that significantly influenced the objective variable (Table P < 0.001), “core facility of the emergency training program” (P = 0.016), “rotation participating hospitals” (P = 0.017), facilities with “more than 200 beds” (P < 0.001), “annual demand rate of 81% or more” (P = 0.004), and “making some efforts to improve the quality” (P < 0.001). A total of 198 opinions from 179 facilities were categorized  provided responses, and 120 facilities responded with “none in particular.” The remaining 179 facilities that responded with specific descriptions were characterized as “clinical training hospitals”  were “clinical training hospitals,” 38% (11/29) had “more than 200 beds,” and 59% (17/29) were “making some efforts to improve the quality.” Such a response was more common in facilities with higher annual response rates.Subsequently, the most common requests included an increase in the number of emergency physicians, training of specialists, and filling and eliminating the maldistribution of emergency physicians at core hospitals. All the facilities that submitted this request were also not “core facilities of the emergency department specialty training program,” with 77% (20/26) of them being “clinical training hospitals,” 73% (19/26) having “more than 200 beds,” and 96% (25/26) “making some efforts to improve the quality of emergency care and the local emergency medical system.” Such a response was more common in facilities with higher annual response rates.P < 0.05). Each statement was categorized by item  provided responses, and 105 cited “none.” The remaining 315 facilities that responded with specific descriptions were characterized as “clinical training hospitals,” “core facilities of emergency training programs,” “rotation participating hospitals,” facilities with “more than 200 beds,” “an annual demand rate of 81% or more,” and “making some efforts to improve the quality”  were “clinical training hospitals,” 7% (10/147) “core facilities of emergency department specialty training programs,” 56% (82/147) “hospitals with 200 or more beds,” and 75% (110/147) “making some efforts to improve the quality.” The higher the annual demand rate, the more often this request was made.Subsequently, the most common request was “sharing roles, enhancing cooperation among hospitals and medical regions, and building a cooperative system through information sharing.” All but one of the facilities that submitted this request were not “core facilities of the emergency department training program; 74% (79/107) were “clinical training hospitals,” 53% (57/107) were “more than 200 beds,” and 80% (86/107) were “making some efforts to improve the quality,” with higher annual response rate indicating more responses in this category.P < 0.001). There was no significant difference between the “core facilities of emergency training programs” and “rotating participating hospitals.” Each statement was categorized by item  113 cited “none.” The remaining 295 facilities that responded with specific descriptions were characterized as “clinical training hospitals,” facilities with “more than 200 beds,” “annual response rate of 81% or more,” and “making some efforts to improve the quality”  were “clinical training hospitals,” 2.9% (41/141) were “core facilities of emergency specialty training programs,” 46% (65/141) mentioned having “more than 200 beds,” and 80% (113/141) were “facilities that are making some efforts to improve the quality.” Facilities with higher annual demand rates indicated more responses in this category.Regarding the annual number of emergency medical transports, “secondary emergency medical institutions are responsible for most emergency medical services” . HoweverThe results support our hypothesis that secondary emergency medical institutions accept many ambulances despite their systems being inadequate, in terms of a lack of full-time emergency physicians. Thus, they could be making requests to academic societies and others.The survey revealed the current human and qualitative plight in secondary emergency medical institutions. Regarding human resources, while the number of emergency physicians is insufficient even at facilities that provide ER-type emergency care , the surThe current results revealed the human resource and quality limitations of many notified emergency medical institutions, as they do not have dedicated emergency physicians. The limitations of the “individual department type emergency medicine model.” In studies in other countries, a lack of emergency medical residencies was also noted for bedside teaching . It coulRegarding the issues surrounding emergency medical care, support measures are required to raise the level of response capability of secondary emergency medical institutions and enable them to accurately fulfill their roles , 3. In aFurther, emergency medicine residents must rotate not only between tertiary facilities but also between primary and secondary facilities to gain comprehensive experience. Some have noted the necessity of “a system that puts to practice a multi-specialty staffing model in designated tertiary emergency care centers, or the development of a single-specialty staffing model in the designated primary and secondary emergency care centers or possibly even in tertiary emergency care centers. This systemic change will subsequently reflect the needs of Japan’s super-aging society” .The human plight and the shortcomings of many emergency medical institutions without dedicated emergency department physicians or emergency physicians in the survey results suggest the limitations of the “individual department type emergency medical care model.” In addition, many respondents expressed their expectations for “ER-based emergency medicine” in their free responses to the survey. Therefore, it is desirable to further increase the number of the number of emergency physicians, facilities that provide “ER-type emergency medicine.” Moreover, further research is needed on the effects of improving the emergency medical care system by organically integrating “ER-type emergency medicine” with the “emergency medical center-emergency medical care model” and “department-specific emergency medical care model,” which are complementary to each other. Consequently, a new and better emergency medical care system can be created for regions and countries where ER-emergency medicine is not widespread.A histogram of the distribution by beds of the facilities that distributed the survey and those that actually responded shows a trend toward more responses from facilities with more beds than the actual distribution (not shown). Of the responding facilities, Hospitals with 199 beds or less accounted for 62%, making up the largest group . Selection bias based on the responding facilities  could be involved. Contrarily, it was possible to include responses from emergency medical institutions with several beds. Nevertheless, the results must be interpreted with caution because of the many limitations of the survey method employed.This is the first large-scale survey on the status and issues of emergency medical care systems at secondary emergency medical institutions in Japan. The results of this survey are expected to be considered during the formulation of policies of the Japanese Society of Emergency Medicine and other related academic societies, governments, local medical planning, and medical control. Based on the results of this survey, the JAAM and core regional facilities, national and local governments should consider and implement specific measures for regions and hospitals with few emergency medicine specialists and physicians . This will lead to the improvement of the emergency medical care system that supports the region and the establishment of a new emergency medical care system that society demands.This observational study utilized questionnaires.All 4063 emergency medical facilities in Japan  were included in the survey . This study was also approved by the Board of Directors of the JAAM and was conducted mainly by the Study Committee of the Emergency Department of the JAAM. Participants’ responses constituted their consent for participation.A survey form Table  was distFor “81% or more annual response rate,” cross-tabulation was conducted based on whether the institution was “designated as a clinical training hospital;” “has full-time physicians;” “has pharmacists, clinical technologists, and radiologists available at all times;” “is making efforts to improve the quality of emergency care and the local emergency medical system;” “has 200 or more beds;” and “is a core facility of an emergency department training program.” Cross-tabulation was conducted on whether the facility was a “core facility of the emergency medicine specialty training program.”U test). Logistic regression analysis was also performed, with the objective variable being whether the facility had an “annual response rate of 81% or more.”The following items were also cross-tabulated according to whether the hospital was designated as a clinical training hospital: “keeps records of reasons for failure to respond to requests for admission;” “always has a full-time physician available;” “pharmacists, clinical laboratory technicians, and radiology technicians are always available;” “is working to improve the quality of emergency care and the local emergency medical system;” and “is taking steps to standardize initial treatment by doctors treating emergency patients.” The results were cross-tabulated according to whether the hospital was designated a clinical training hospital. The “number of full-time physicians” and “number of female physicians among full-time physicians” were compared based on whether the hospital was designated as a clinical training hospital or not , and “making some efforts to improve quality of emergency care and local emergency medical system.” All statistical analyses were performed using SPSS 28.0 . Significance was set at


Most participants rated MCP concepts as extremely important, ranging from 73.75% to 95.5%. Additionally, 86.8% favored finding meaning in their life after a cancer diagnosis. Participants (80.7%) also selected the concept of finding and maintaining hope to cope with their cancer diagnosis. Finally, participants found CST concepts and skills acceptable, ranging from 81.6% to 91.2%. Results indicate the acceptability of Meaning-Centered Therapy and Communication Skills Training among Latino advanced cancer patients and caregivers coping with advanced cancer. These results will inform the topics to be discussed in a culturally adapted psychosocial intervention for advanced cancer patients and their informal caregivers.Latinos are more likely to be diagnosed with advanced cancer and have specific existential and communication needs. Concepts within Meaning-Centered Psychotherapy (MCP) interventions and Communications Skills Training (CST) assist patients in attending to these needs. However, Latino-tailored MCP interventions have yet to be adapted for advanced cancer patients and caregivers. A cross-sectional survey was administered to Latino advanced cancer patients and caregivers where participants rated the importance of the goals and concepts of MCP and CST. Fifty-seven ( Foreign-born Latinos, from countries such as Cuba, Puerto Rico, Mexico, and Central and South America, are more likely to be diagnosed with cancer at an advanced stage when compared to non-Latino whites ,2,3. In William Breitbart developed Meaning-Centered Psychotherapy (MCP) as an intervention to address the existential distress often experienced by patients with advanced cancer . What diCommunication between patients and their caregivers is crucial after a diagnosis of advanced cancer, as themes regarding the patient’s values and end-of-life care may surface , leadingA meta-analytic review has shown that culturally adapted treatments tailored for a specific cultural group are four times more effective than interventions provided to participants from a variety of cultural backgrounds, and those conducted in Latino participants’ native language are twice as effective as interventions conducted in English . Though Literature underscores the importance and impact of MCP and communication for advanced cancer patients and their caregivers. Moreover, it highlights the need for culturally adapted interventions. The team used a quantitative approach with patients and caregivers coping with advanced cancer to identify the accepted concepts of Meaning-Centered Psychotherapy and Communications Skills Training. This paper aims to evaluate the importance of MCP concepts and communication concepts among Latino patients and caregivers coping with cancer. The results of this study will be used to inform the topics to be discussed in the psychosocial intervention for advanced cancer patients and their informal caregivers.Meaning-Centered Psychotherapy is grounded in the work of Dr. Breitbart and aims to target the specific psycho-spiritual needs of patients with advanced cancer . Its priUsing the Communication Skills Training approach , the teaParticipants for this study comprised patients and caregivers who were recruited as dyads from an oncology clinic in the southern area of Puerto Rico between October 2020 and September 2021. The Ponce Research Institute Institutional Review Board (IRB) and Ethical Committee approved all the study procedures. An IRB-approved introductory letter to familiarize potential participants with the study. Patients’ inclusion criteria included: (1) patients with solid stage III or IV tumors, (2) age 21 or older, and (3) self-reported Latino. Eligible family caregivers included those who were: (1) a caregiver with a family member diagnosed with solid stage III or IV tumors referred by the advanced cancer patient, (2) age 21 or older, and (3) self-reported Latino. Patients’ exclusion criteria included: (1) diagnosed with a major disabling medical or psychiatric condition, (2) unable to understand the consent procedure, or (3) too ill to participate, reported by the patient and determined by the PI’s judgment. After completing the screening process, those eligible and interested were consented and scheduled to complete the questionnaire. Following informed consent, patients, and family caregivers (FCs) were assigned a subject number and administered the survey and self-report assessment to evaluate the patients’ and FCs’ perspectives and psychosocial needs.The cross-sectional survey in Spanish included rating the importance of the goals and concepts of MCP and CST. In addition, the survey included general demographic questions  and a series of standardized scales described in the protocol paper . Particip < 0.05) to detect a medium-sized effect (Cohen’s d = 0.50) [All analyses were conducted using IBM SPSS Statistics 21. The database was checked for coding errors and missing data using descriptive statistics. The analyses included descriptive statistics and frequency analysis for the survey to rate the importance of the goals and concepts of MCP and CST. The study was properly powered to use the findings in this formative work. The G Power statistical program  was used = 0.50) . Based on = 57) Latino cancer patients with stages III (38.5%) and IV (61.4%) cancer participated. Most patients (57.9%) and caregivers (71.9%) were married. On average, patients were 63 and caregivers were 56 years old. Most patients were male (57.9%), and most caregivers were female (67.9%). The predominant cancer diagnoses were cervical (17.5%), breast (14.0%), and prostate (14.0%). The sociodemographic and diagnostic characteristics are included in Fifty-seven  ranked the concept of their “love for loved ones” as extremely important when coping with a cancer diagnosis. Participants (91.2%) valued the concept of “maintaining hope” as extremely important. Many participants (89.5%) ranked the concept of “being responsible for themselves after cancer diagnosis” as extremely important. Most participants (89.5%) rated the concept of their “love for life” extremely important when coping with a cancer diagnosis. Participants (87.6%) ranked the concept of “finding beauty in music, nature, and other life experience” as extremely important. Regarding the concept of the “care of others after a cancer diagnosis”, 86% of participants rated it as extremely important. Most participants (81.6%) ranked the concept of “understanding their life’s purpose after a cancer diagnosis” as extremely important. Additional concepts were ranked as extremely important: ”reflecting or thinking about their changes after a cancer diagnosis” (79.8%), “changing or adjusting their attitude when circumstances are out of their control” (77.25), “creating meaning in life or thinking about their purpose” (78.1%), “reflecting on heritage and thinking about their life’s contributions” (75.4%), and “making sense of the cancer experience” (73.7%) see .When asked about MCP concepts, most patients rated the concepts as extremely important, ranging from 75.4% to 94.7%. Patients (94.7%) ranked the concept of their “love for loved ones” as extremely important when coping with a cancer diagnosis. Patients (93%) assessed the concept of “maintaining hope” as extremely important. Many patients (91.2%) ranked the concept of “persevering a sense of humor has helped them cope with their cancer diagnosis” as extremely important. Most patients (89.5%) rated the concepts of their “love for life”, “being responsible for themselves after cancer diagnosis”, and “finding beauty in music, nature, and other life experience” as extremely important when coping with a cancer diagnosis Regarding the concept of the “care of others after a cancer diagnosis”, 82.4%% of patients rated it as extremely important. Additional concepts were ranked as extremely important:” create meaning in life or think about their purpose in life” (78.9%), “changing or adjusting their attitude when circumstances are out of their control” (78.9%), “understand their life’s purpose after being diagnosed with cancer” (77.2%), “making sense of the cancer experience” (77.2%), “reflect or think about how they have changed after a cancer diagnosis” (75.4%), and “reflect on their heritage or thinking about what they have contributed with their life” (75.4%) see .When asked about MCP concepts, the majority of caregivers ranked the concepts as extremely important, ranging from 70.2 to 96.4%. Caregivers (96.4%) rated the concept of their “love for loved ones” as extremely important when coping with a cancer diagnosis. Caregivers (89.5%) also rated the concepts of “maintaining hope”, “being responsible for themselves after a cancer diagnosis”, “love for life has helped them cope after a cancer diagnosis”, and “taking care of others after a cancer diagnosis” as extremely important. Most caregivers (86%) ranked the concept of “understanding their life’s purpose after a cancer diagnosis” as extremely important. Caregivers (84.2%) ranked “finding beauty in music, nature, and other life experience” as extremely important. Regarding the concept of “reflect or think about how they have changed after a cancer diagnosis”, 84.2% of caregivers rated it as extremely important. Many caregivers (83.9%) rated “preserving a good sense of humor” as extremely important when coping with a cancer diagnosis. Additional concepts were ranked as extremely important: “creating meaning in life or thinking about their purpose” (77.2%), “changing or adjusting their attitude when circumstances are out of their control” (75.4%), “reflecting on heritage and thinking about their life’s contributions” (75.4%), and “making sense of the cancer experience” (70.2%) see .When asked about communication skills training concepts and skills, most participants wanted to learn more, ranging from 81.6% to 91.2%. Most participants (91.2%) chose that they would like to acquire problem-solving skills, and 90.4% favored the concept of “wanting to learn that they worry about each other”. A large portion (89.5%) favored the concept of “learning ways to show they are accompanying each other in the process”. Participants (86.6%) also favored the concept of “learning to talk about their thoughts regarding cancer”. Eighty-six percent (86%) of participants favored the concept of “acquiring communication strategies to accept and validate others”. Furthermore, 85.8% of participants chose the concept of “wanting to express their feelings about cancer” and 85.1% selected the concept of “acquiring communication skills to accept other people’s feelings”. Many participants (82.5%) favored the concept of “learning communication strategies to accept other people’s perspectives”. Finally, 81.6% of participants selected the concept of “reviewing their life and considering their heritage”  selected that they would like to acquire problem-solving skills. A large portion (89.5%) favored the concepts of “wanting to learn that they worry about each other”, “learning ways to show they are accompanying each other in the process”, “learning to talk about their thoughts regarding cancer”, and “wanting to express their feelings about cancer”. Patients (87.7%) also favored the concepts of “acquiring communication strategies to accept and validate others” and “acquiring communication skills to accept other people’s feelings”. Furthermore, 84.2% of patients chose the concept of “learning communication strategies to accept other people’s perspectives” Finally, 80.7% of patients selected the concept of “reviewing life and considering their heritage”  chose that they would like to acquire problem-solving skills and favored the concept of “wanting to learn that they worry about each other”. A large portion (89.5%) favored the concept of “learning ways to show they are accompanying each other in the process”. Caregivers (87.7%) also favored “learning to talk about their thoughts regarding cancer”. Additionally, caregivers (84.2%) selected “acquiring communication strategies to accept and validate others”. Moreover, 82.5% of caregivers chose the concepts of “acquiring communication skills to accept other people’s feelings” and “reviewing their life and considering their heritage”. Many (82.1%) favored the strategy of “wanting to express their feelings about cancer”. Finally, 80.7% of caregivers selected the concept of “learning communication strategies to accept other people’s perspective” (see When patient and caregiver dyads were asked about the concepts of MCP and CST, the majority of participants favorably rated all of the concepts. The acceptance of MCP concepts ranged from 73.75% to 95.5%, while CST ranged from 81.6% to 91.2%. Comparable results were seen in the adaptation of MCP for a Latino population, where patients expressed a need to integrate communication skills as well as accepted MCP concepts in the process of adapting to their cancer diagnosis ,39. SomeResults indicate that participants favored love for their loved ones to cope with their diagnosis, which is consistent with studies that underscore how many patients lean on family for support as a coping mechanism during a cancer diagnosis . AdditioMany of the participants indicated that reflecting on the changes in one’s life after receiving a cancer diagnosis was important. Even though the MCP concept of change after a diagnosis focuses on general life, hope, and experiences, Latino participants might also reflect on changes attributed to physical changes ,46, sexuSome Latinos would rather not discuss the end-of-life stage  or deathResults within this study show how advanced cancer patients and caregivers favor Meaning-Centered Psychotherapy and Communication Skill training concepts. Existing literature also aids in showing how patients favor these concepts independently and when integrated into an MCP intervention or a communication-based intervention. These results highlight the importance of integrating both patient and caregiver perspectives into the development and application of a culturally adapted psychosocial intervention.The instrument used in the study, which contained Meaning-Centered Concepts and Communication Skills Training, was developed in a questionnaire manner; therefore, analyses were limited to a descriptive approach. As a result, inferential analyses cannot be measured. If a scale were to be devised, the analysis could explore statistical differences between patients and caregivers, as well as sex, income, and clinical variables.


There was a broad range of biological pathways involved in AR and longevity genes shared with AD genes. AR genes identified 261 pathways within the threshold of p < 1.00 × 10−5, of which 26 pathways (10% of AR gene pathways) were further identified by overlapping genes among AD and AR genes. The overlapped pathways included gene expression (p = 4.05 × 10−11) including ApoE, SOD2, TP53, and TGFB1 (p = 2.84 × 10−10); protein metabolism and SUMOylation, including E3 ligases and target proteins (p = 1.08 × 10−7); ERBB4 signal transduction (p = 2.69 × 10−6); the immune system, including IL-3 and IL-13 (p = 3.83 × 10−6); programmed cell death (p = 4.36 × 10−6); and platelet degranulation (p = 8.16 × 10−6), among others. Longevity genes identified 49 pathways within the threshold, of which 12 pathways (24% of longevity gene pathways) were further identified by overlapping genes among AD and longevity genes. They include the immune system, including IL-3 and IL-13 (p = 7.64 × 10−8), plasma lipoprotein assembly, remodeling and clearance (p < 4.02 × 10−6), and the metabolism of fat-soluble vitamins (p = 1.96 × 10−5). Thus, this study provides shared genetic hallmarks of aging, longevity, and AD backed up by statistical significance. We discuss the significant genes involved in these pathways, including TP53, FOXO, SUMOylation, IL4, IL6, APOE, and CEPT, and suggest that mapping the gene network pathways provide a useful basis for further medical research on AD and healthy aging.Human genomic analysis and genome-wide association studies (GWAS) have identified genes that are risk factors for early and late-onset Alzheimer’s disease (AD genes). Although the genetics of aging and longevity have been extensively studied, previous studies have focused on a specific set of genes that have been shown to contribute to or are a risk factor for AD. Thus, the connections among the genes involved in AD, aging, and longevity are not well understood. Here, we identified the genetic interaction networks (referred to as pathways) of aging and longevity within the context of AD by using a gene set enrichment analysis by Reactome that cross-references more than 100 bioinformatic databases to allow interpretation of the biological functions of gene sets through a wide variety of gene networks. We validated the pathways with a threshold of  Aging and genetic variations are well-known risks for AD. The genetic basis of AD has been characterized in the early onset of AD (EOAD), including amyloid precursor protein (APP) [Alzheimer’s disease is the most frequent cause of dementia, in which about 5 million people were living with AD in 2014, and the number is estimated to nearly triple by 2060 [in (APP) , and prein (APP) ,8. A comin (APP) , as wellin (APP) . Howeverin (APP) ,8,11. WeReactome is an open-source bioinformatic database with two functions. Firstly, it is a knowledge database of biological pathways manually curated and peer-reviewed, including twenty-seven biological pathway groups: they are autophagy, cell cycle, cell–cell communication, cellular responses to external stimuli, chromatin organization, circadian clock, developmental biology, digestion and absorption, and disease, among others . The patUsing the Reactome analysis, we investigated three types of human genes: AD genes, aging-related (AR) genes, and Longevity genes. AD genes have been reported previously, which are validated based on meta-analyses of human GWAS (genome-wide association) studies ,8,16. Agp < 10 × 10−5; in other words, we excluded the pathways with a false discovery rate of more than 10 × 10−3. In each table, we included the top ten results from each Reactome analysis to be included in our results. We further identified specific Reactome groups from within the generalized groups.p < 1.0 × 10−5, which is roughly equivalent to the false discovery rate < 1.0 × 10−3. The top ten results are shown in The Reactome analysis of the AD genes identified 161 pathways . Of them−13; p = 1.11 × 10−16), which was a sub-pathway topic under “tRNA processing” , which was a sub-pathway topic under “metabolism of RNA” in the hierarchy panel. “tRNA processing in the mitochondrion” involves 42 proteins, and 19 of those proteins were found to be shared in our positively tested AD genes . The second top hit was “plasma lipoprotein assembly, remodeling, and clearance”  from the “transport of small molecules” general pathway. The third-quarters top hit, “Interleukin-4 and Interleukin-13 signaling”  is a part of the “immune system” general pathway.The top hit for the enriched pathway analysis (of AD-positive genes) was “tRNA processing in the mitochondrion” , DNA double-stranded break repair (DNA repair), PIP3 activates AKT signaling , FOXO-mediated transcription (gene expression), cellular responses to stress , SUMO E3 ligases SUMOylate target proteins (metabolism of proteins), cellular senescence , transcriptional regulation by TP53 (gene expression), and SUMOylation (protein metabolism). All results had an FDR = 8.66 × 10 stress” .p < 1.0 × 10−5. The top ten results are shown in −14; p = 1.11 × 10−16) is a sub-pathway topic under “intracellular signaling by second messengers” . The “MTOR signaling pathway” involves 41 proteins, and 19 of those proteins were found to be shared in our longevity genes. “PIP3 activates AKT signaling”  is also a sub-pathway topic under the same pathway. In the “gene expression” general pathway, the significant pathways were “RNA polymerase II transcription”  and two sub-pathways—“TP53 regulates metabolic genes”  and “FOXO-mediated transcription” . Longevity genes identified SIRT1 and its homologs in three of the pathways, including “generic transcription pathway”, “RNA polymerase II transcription”, and “FOXO-mediated transcription”  overlapped with AD genes (AD–AR overlap genes) . The Rea−8; p = 4.05 × 10−11), which was a sub-pathway topic under “RNA polymerase II transcription” , which was a sub-pathway topic under the “Gene Expression” general pathway. Within “Generic Transcription Pathway”, the analysis highlighted “nuclear receptor transcription pathway”  and “TP53 regulates transcription of cell death genes” . “Generic transcription pathway” involves 1234 proteins and 22 of those proteins were found to be shared in AD–AR overlap genes .The top result for the enriched pathway analysis was “Generic Transcription Pathway” (FDR = 1.85 × 10Pathways within the AD–AR overlap genes  for the p < 1.0 × 10−5. The top ten results are shown in 43 genes of longevity genes (12% of the genes) overlapped with AD genes . The Rea−5; p = 7.64 × 10−8), which is a sub-pathway of “signaling by Interleukins”  and part of the “Immune System” general pathway. Out of the 112 proteins found to be involved in the “Interleukin-4 and Interleukin-13 signaling” pathways, 7 were shared by AD–longevity overlap genes. Key hit genes involved with these pathways include TNF, IL10, IL18, and IL6. These genes are also shown to be involved in Interleukin 10 signaling. Interleukin pathways are shown in The top result from the enriched pathway analysis is “Interleukin-4 and Interleukin-13 signaling” . Genes in this pathway , which is a sub-pathway of “plasma lipoprotein remodeling“, “chylomicron remodeling”, “chylomicron assembly”, and “HDL remodeling”. The hit genes CEPT and APOE are present in all of these subcategories, highlighting their importance in this AD and longevity overlap dataset. Other top results included “Retinoid metabolism and transport”, which is a subset of “Metabolism of fat-soluble vitamins” and “NR1H2 and NR1H3-mediated signaling”, a subset of the “signal transduction” pathway. APOE is also a hit gene in these pathways.The second major Reactome group is “Plasma lipoprotein assembly, remodeling, and clearance”  gene sets. The AD genes are associated with the health risk of AD, which were identified previously ,8. The tMitochondrial RNA metabolism aligns with the mitochondrial cascade that controls mitochondrial function and change rates influence AD chronology. Reactome analysis has made mitochondrial genes the top hit when associated with AD genes alone, signaling its importance and the need for more data on possible interventions. Mitochondrial RNA metabolism falls into diverse functions of mitochondrial complexes, tRNA, and rRNA. Although the roles of mitochondrial RNA in AD remain unclear, mitochondrial dysfunctions and cascades have been involved in AD pathogenesis, thus providing potential markers for neurodegeneration ,22,23,24The AR genes are associated with aging. The top pathways  can be gCellular senescence, or cellular aging, is a cellular response characterized by stable growth arrest, altered proinflammatory secretome, and other phenotypic alterations. The alterations are known to play a role in normal development, tissue homeostasis, and preventing tumor progression . It has The longevity genes are associated with increased lifespan, which is an indicator of delayed aging. The top pathways  can be gThe IIS pathway is also involved in cellular processes such as cell growth and survival, including FOXO3 and FOXO1 genes . The mecBased on our Reactome analysis, there are shared biological pathways among AR and longevity genes, including the immune system and cytokine signaling, signal transduction, and gene expression, involved in the balance between aging and longevity. Aging also has components of impaired DNA repair and metabolism of proteins, as well as cellular senescence. We have compared the pathways involved in AR and longevity genes, which represent the balance of shared pathways .Although the gene ontology for the AD–AR overlap genes demonstrated involvement in a broad range of biological pathways, concurrent with previous studies, some of our most significant associations involve TP53, FOXO, and SUMOylation . The AD The TP53 gene, or the gene product p53, is well known for its guardian function as a prominent tumor suppressor protein that protects genome integrity through cell cycle control and the DNA damage response, among others. In neurons, p53 has pleiotropic functions. AD brain pathology shows abnormal cell cycle and apoptosis and increased DNA damage, all of which are dependent on p53 . In addiCaenorhabditis elegans and dFOXO in Drosophila melanogaster, as well as mammalian FoxO1, FoxO3, FoxO4, and FoxO4. FOXO has diverse functions, including Lipid metabolism, DNA damage repair, stress resistance, autophagy, and glucose metabolism, among others [FOXO proteins are a subgroup of the Forkhead family of transcription factors involved in the regulation of aging and stress resistance, metabolism, regulation of reactive species, and regulation of cell cycle arrest and apoptosis. The FOXO family includes DAF-16 in g others ,47,61,62g others . Importag others .Significant pathways generated from the AD–longevity overlap set include three pathways, cytokine signaling in the immune system, lipoprotein metabolism, and the metabolism of fat-soluble vitamins and NR1H2- and NR1H3-mediated signaling . The latIn the first category immune system, cytokines play an integral role in regulating inflammatory pathways, including neuroinflammation in Alzheimer’s disease. Aß plaques have been shown to increase levels of proinflammatory cytokines IL6 and TNF alpha, among others, leading to a vicious cycle of cytokine-derived inflammation and plaque accumulation . ProinflThe lipoprotein metabolism was the second category in the AD–longevity overlap genes. A lipoprotein metabolism associated with AD has been discussed previously ,8. BriefInterestingly, stress damage and response interlock the immune system and lipoprotein metabolism in multiple ways. Some examples are (1) oxidative damage to low-density lipoproteins (LDL) is a well-known initial step of atherosclerosis, inducing inflammatory responses by releasing cytokines and chemokines ,83,84. , which provides a reasonable level of statistics with a p-value and false discovery rate. Thus, we suggest that the results from this study represent the most current genetic hallmarks involved in AD, aging, and longevity. This study provides a comprehensive update of the genomic map of the AR genes reported nearly two decades ago [Gene set enrichment analysis (GSEA) is a computational method that is useful to interpret the biological functions of a gene set with statistical confidence. Reactome incorporates GSEA embedded with the knowledge database that covers more than 100 bioinformatics resources. The Reactome outputs include statistical confidence levels with ades ago .p < 1.00 × 10−5), which is backed up by the false discovery rate < 1.00 × 10−3. Additionally, knowledge databases, such as Reactome (https://reactome.org/) and KEGG (https://www.genome.jp/kegg/), process the data rigorously with continued updates, which should reduce the incorporating experimental errors. Another limitation is manually curated annotation nomenclatures, some of which may not be easy to understand. For example, stress resistance to a variety of stresses  is a component of longevity [However, the results from GSEA should be viewed as living knowledge, which requires updates until the knowledge is saturated and complete. A potential limitation is that connections among genes and annotations may be influenced by outliers among previous studies, which should be minimized by peer review, systematic review, and meta-analysis. Although poor study design and controls in a GWAS study may influence overall annotations, it is likely that GSEA and the review systems reduce the impact of such a study. We also used a stringent condition . GSGA is a powerful method to identify and overview pathways that come with statistical confidence and minimum bias since a single-gene effect is not necessarily predictable to define phenotypes and trajectories. For example, the TP53 gene also shows both positive and negative trajectories: p53 as guardian of the genome is positive for longevity, while misfolded p53 observed in the background of MCI and AD has negative trajectories against longevity  that identifies gene hits within a group of genes in a particular pathway supported by statistical confidence  to extract a list of 680 identified human AD genes from GWAS and previous linkage studies [p-value from previous studies for each gene. If p < 0.05, we assumed the data was reliable and counted them as a positive result; studies with p > 0.05 were regarded as negative and were not included in our study. Note that we used a more stringent threshold of p < 1.0 × 10−5 to validate the Reactome pathways (see text). Research outcomes listed as trends or inconclusive were also not included in our study. Secondly, we utilized the GenAge database , a benchmark database of 307 genes possibly related to human aging (AR). The genes were extensively reviewed for inclusion based on findings in the model organisms put in the context of human biology, plus genes directly related to aging in humans [www.genomics.senescence.info/longevity/; last accessed 12 December 2021), a database of 751 genes associated with human longevity [We used three sets of genes for our study: human Alzheimer’s disease (AD) genes, aging-related (AR) genes, and longevity genes. With these three gene sets, two additional gene sets were created by: (1) identifying the genes shared both by the AD genes and by the AR genes (AD–AR Overlap) and (2) identifying the genes shared both by AD genes and longevity genes (AD–longevity overlap). Firstly, we utilized the AlzGene database  to analyze the pathways involved in each gene set. The pathways with a threshold of p < 10 × 10−5 were selected and used for this study. Reactome analysis was performed as described previously [We used Reactome , mitochondrial RNA metabolism, cytokine balance, and lipoprotein metabolism, among others. The genetic hallmarks identified in this study provide unexpectedly broad mechanisms, suggesting a wide variety of implications in the field of aging. Importantly, AD genes are associated with a variety of pathways that link to age-related comorbidities, thus providing a view in which AD genes create the ground of age-related comorbidities , particuPreviously, we have proposed to include feedback from patients in research when studying health  and prov


Glucose-dependent insulinotropic polypeptide (GIP) confers a variety of metabolic benefits in type 2 diabetes mellitus (T2DM). This meta-analysis was conducted to investigate the impact of dipeptidyl peptidase 4 (DPP4) inhibitors on GIP levels in T2DM patients.GIP) using a meal or oral glucose tolerance test were included. A random-effects model was used for data pooling after incorporating heterogeneity.Medline (PubMed), CENTER (Cochrane Library), and Embase (Ovid) were searched and randomized controlled trials (RCTs) evaluating the impact of DPP4 inhibitors on fasting and postprandial GIP levels were obtained. For postprandial GIP, only studies with the data of GIP changes reported as the total area under the curve  and postprandial AUCGIP . Influence analysis by excluding one dataset at a time showed consistent results. Sensitivity analyses only including studies with radioimmunoassay showed also consistent results . Further subgroup analyses demonstrated that the influence of DPP4 inhibitors on fasting and postprandial GIP levels in T2DM patients was not significantly changed by study characteristics such as study design, patient mean age, baseline glycated hemoglobin (HbA1c) concentration, body mass index (BMI), background treatment, treatment duration, or method for postprandial GIP measurement .Overall, 14 RCTs with 541 T2DM patients were included. Compared to placebo/no treatment, the use of DPP4 inhibitors significantly increased the fasting GIP level (standard mean difference [SMD]: 0.77, 95% confidence interval [CI]: 0.48–1.05, The use of DPP4 inhibitors effectively increases the fasting and postprandial GIP concentrations in T2DM patients.https://www.crd.york.ac.uk/prospero/, identifier CRD42022356716. Increasing evidence suggests that incretin hormones, such as glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1), are actively involved in glucose regulation , 3. In aDipeptidyl peptidase 4 (DPP4) inhibitors are commonly prescribed antidiabetic drugs (OADs) that may provide additional benefits besides glucose-lowering effects, such as attenuating β-cell loss, inhibiting glucagon secretion, reducing glucose fluctuation, and improving glycemic durability during the progression of T2DM –8. Moreohttps://www.crd.york.ac.uk/prospero/) with the code CRD42022356716.This study is in accordance with the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses , 26 and A combined search strategy was used for study identification in Medline (PubMed), CENTER (Cochrane Library), and Embase (Ovid), which included: (1) “sitagliptin” OR “vildagliptin” OR “linagliptin” OR “trelagliptin” OR “omarigliptin” OR “anagliptin” OR “teneligliptin” OR “saxagliptin” OR “alogliptin” OR “gemigliptin” OR “evogliptin” OR “dutogliptin” OR “aemigliptin” OR “DPP-4” OR “DPP4” OR “dipeptidyl peptidase-4 inhibitors”; (2) “GIP” OR “glucose-dependent insulinotropic polypeptide” OR “gastric inhibitory peptide” OR “incretin” OR “hormone” OR “hormonal” OR “postprandial” OR “oral glucose tolerance test” OR “meal” OR “prandial” OR “OGTT;” and (3) “randomly” OR “placebo” OR “allocated” OR “control” OR “randomized” OR “randomised” OR “random”. We only considered studies including human subjects. We also manually searched the references to related reviews and original articles. The date of the last database search was June 16, 2022.GIP) using the meal tolerance test or the oral glucose tolerance test. Specifically, GIP is secreted as an intact 42-amino acid peptide, which is rapidly degraded by dipeptidyl peptidase 4 into inactive GIP : Adult patients with T2DM; I (intervention): Oral DPP4 inhibitors with approved dosages; C (control): Placebo or no treatment; O (outcomes): Between-group difference of changes of either the fasting intact/active GIP level or postprandial GIP level from baseline as the total area under the curve (AUCtive GIP –42 28)..GIP) usiTwo authors independently searched databases, collected data, and evaluated quality. Whenever disagreements arose, the corresponding author was consulted. The following data were collected: study general information, study design characteristics, patient characteristics , previous antidiabetic treatments, drug name and dose of the DPP4 inhibitor used, regimen of the controls, treatment duration, and method for measuring circulating GIP. Quality of RCTs included in this review was assessed using the Cochrane Risk of Bias Tool  involvinGIP in T2DM patients were calculated as the standard mean difference (SMD) with the 95% confidence interval (CI), because of the inconsistent methods for GIP measuring. Heterogeneity was investigated using Cochrane Q test .The impacts of DPP4 inhibitors on fasting GIP and postprandial AUCe Q test . In addiogeneity . A randoogeneity . Influenogeneity . Additioogeneity  and has ogeneity . Analysiogeneity . In studogeneity . P<0.05 2. Various DPP4 inhibitors were used among these studies, such as sitagliptin, vildagliptin, linagliptin, and evogliptin, while placebo was used as the control in all of the included RCTs except for one study that had one group receiving no treatment  after excluding one dataset at a time. Sensitivity analyses also demonstrated similar results limited to studies using a radioimmunoassay . In addition, DPP-4 inhibitors significantly increased fasting GIP concentrations in all subgroup analyses by study characteristics such as study design, mean age, baseline HbA1c, BMI, background treatment, or treatment duration (P for subgroup effects <0.05). However, DPP-4 inhibitors increased fasting GIP to a greater extent in patients with background OADs as compared to patients who were drug-naive or without background OADs (P for subgroup difference = 0.001)Because one study reported data following three dosage levels of vildagliptin separately, these datasets were included in the meta-analysis independently . AccordiGIP in T2DM patients. The pooled results showed that compared to placebo or no treatment, the use of DPP4 inhibitors significantly increased AUCGIP in these patients . Sensitivity analyses limited to studies using a radioimmunoassay  also showed similar results. Further subgroup analyses revealed that the influence of DPP4 inhibitors on postprandial AUCGIP in T2DM patients was not significantly affected by the study characteristics, including study design, mean age, baseline HbA1c, BMI, background treatment, treatment duration, or method for postprandial AUCGIP measurement .Overall, 15 datasets from 12 RCTs were included for the meta-analysis evaluating the influence of DPP4 inhibitors on postprandial AUCP=0.248 and 0.515, respectively).The funnel plots underlying the meta-analyses were symmetrical, which reflected a low risk of publication bias   . Howevertration) , but itstration) . TherefoAs mentioned previously, subgroup analyses according to the study characteristics all consistently showed that compared to placebo/no treatment, DPP4 inhibitors significantly increased the levels of fasting and postprandial GIP in T2DM patients. Moreover, the increase of fasting GIP following DPP4 inhibitor administration may be apparent in T2DM patients with concurrent OAD use compared to those who were drug-naive or without concurrent OAD use. The studies with concurrent OAD use all included metformin, which has been suggested to synergistically increase the GLP-1 levels with DPP4 inhibitor administration. However, there is limited evidence on whether coadministration of DPP-4i and metformin further increases GIP concentrations compared to either drug alone . In the Our study also has some limitations that must be addressed. First, the number of studies included is limited, and the sample sizes of the included studies are generally small. Large-scale RCTs are preferable to validate the effects of DPP4 inhibitors on GIP in T2DM patients. In addition, moderate heterogeneity exists for the meta-analyses of the fasting and postprandial GIP. Although not supported by the subgroup analyses, the differences in patient and study characteristics may be important sources of heterogeneity, such as study design, age, BMI, and baseline HbA1c of the participants, background antidiabetic treatments, and follow-up duration; moreover, some other uncontrolled factors may affect the GIP level and subsequently lead to heterogeneity, such as dietary factors . AlthougAs a summary, this meta-analysis demonstrated the effectiveness of DPP4 inhibitors for increasing the fasting and postprandial intact/active GIP levels in T2DM patients. These results further validate the hypothesis that augmentation of GIP concentration is among the multiple mechanisms of pharmacological efficacy of DPP4 inhibitors in T2DM.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.SC, RZ and MY conceived, designed, or planned the study. SC, RZ and JC collected or assembled the data. SC and MY performed or supervised analyses. SC, RZ, RC, CD, YZ, SR and MY interpreted the results. SC wrote the initial draft. YZ obtained funding. All authors contributed to the article and approved the submitted version.


Background and Objectives: An altered sympathetic function is established in primary arterial hypertension (PAH) development. Therefore, PAH could be targeted by applying an electric current to the medulla where reflex centers for blood pressure control reside. This study aims to evaluate the electric caudal ventrolateral medulla (CVLM) stimulation effect on blood pressure and animal survivability in a freely moving rat model. Materials and Methods: A total of 20 Wistar rats aged 12–16 weeks were randomly assigned to either: the experimental group  or the control group . After a period of recovery (4 days), an experimental phase ensued, divided into an “OFF stimulation” period (5–7 days post-surgery) and an “ON stimulation” period (8–14 days post-surgery). Results: Three animals  dropped out due to postoperative complications. Arterial pressure in the experimental group rats during the “OFF stimulation” period decreased by 8.23 mm Hg (p = 0.001) and heart rate by 26.93 beats/min (p = 0.008). Conclusions: From a physiological perspective, CVLM could be an effective deep brain stimulation (DBS) target for drug-resistant hypertension: able to influence the baroreflex arc directly, having no known direct integrative or neuroendocrine function. Targeting the baroreflex regulatory center, but not its sensory or effector parts, could lead to a more predictable effect and stability of the control system. Although targeting neural centers in the medullary region is considered dangerous and prone to complications, it could open a new vista for deep brain stimulation therapy. A possible change in electrode design would be required to apply CVLM DBS in clinical trials in the future. Deep brain stimulation (DBS) is a modern therapy used to treat symptoms of patients suffering from Parkinson’s disease, essential tremor, and dystonia . ApplyinOne disorder that could be treated by applying an electric current to the brain tissue is drug-resistant arterial hypertension . PrimarySeveral DBS targets are used in preclinical research and are considered suitable candidates for hypertension . The besApplying electric current to the caudal ventrolateral medulla (CVLM) in non-survival surgery leads to profound hypotensive effects . CVLM isThis study aims to evaluate the electric CVLM stimulation effect on blood pressure and animal survivability in a freely moving rat model.A backpack-mounted device (combined brain stimulator and pressure sensor) was custom-built from the “off-the-shelf” components allowing wireless data transmission  29]. Wi. Wi29]. n = 10) or control groups (n = 10). The rats were housed individually with 12 h light/dark cycles, in constant temperature conditions, and food and drinks were allowed ad libitum. One week before the planned surgery, animals were equipped with a jacket and a case simulating the device size and weight to seek adaptation.All study protocols and experiments followed current European Union regulations. Lithuanian institutional authorities approved the experiments—State Food and Veterinary Service, No. G2-128. A total of 20 Wistar male rats aged 12–16 weeks weighing 320–421 g were randomly assigned to experimental (2 administered through a nose cone), rats were placed in a supine position and a paramedian cervical incision was made. The left carotid artery was dissected under a light microscope  with 6.4× magnification and the vagal nerve was carefully separated and spared. The artery was cannulated with a polyethylene tube, 0.96 mm external diameter, filled with heparinized (500 UI/mL) 99.5% glycerol solution . The catheter was tunneled under the skin, externalized over the suprascapular region, and connected to a device for blood pressure recording. Afterwards, animals were placed in a stereotactic frame  for electrode implantation. A custom-made stainless steel twisted bipolar electrode  with polyamide insulation was inserted in the right CVLM. The coordinates of CVLM were: −4.40 mm anteroposteriorly, 2.10 mm mediolaterally, and 9.90 mm dorsoventrally from lambda, according to Paxinos and Goodchild [The animal’s body temperature was maintained at 36.6 °C during the surgery with a thermostatically controlled heating pad. Under sevoflurane (Baxter) anesthesia  once per day with the known filling volume of the system. Continuous blood pressure recordings were taken with no additional infusions of heparinized glycerol lock solution. Only rats free of neurological compromise were enrolled in the final calculations of blood pressure data.The experimental period was divided into three parts: the recovery phase (days 1–4), the “OFF stimulation” phase (days 5–7), and the “ON stimulation” phase (days 8–14). The recovery phase, during which no stimulation was attempted, allowed complete healing after surgery and stabilization of the blood pressure curve. The data were continuously collected during the “OFF stimulation” period, but no stimulation was attempted. During the “ON stimulation” phase, continuous stimulation was performed with parameters 50 μA, 50 Hz, and 0.1 ms.Blood pressure data were transmitted to a nearby PC running a Linux-based operating system with a PostgreSQL database. R and MS Excel were used for the analysis of the blood pressure data. The heart rate was extracted by smoothing data using Gaussian kernels with 10 kernel bandwidth.t-test in both groups of rats. An independent Student t-test was used to compare mean blood pressure and average heart rate differences between the groups during the “OFF stimulation” and “ON stimulation” periods. Statistical significance was taken at p < 0.05. Data were expressed as the mean ± standard deviation of the mean.Mean blood pressure and average heart rate differences between the “OFF stimulation” and “ON stimulation” phases were compared by dependent Student p/min. The pressure range could, of course, depend on various factors, such as the dampening effect of the catheter system, the lock solutions used, etc.Animals of our Wistar rats breeding colony typically show mean blood pressure ranging from 85 to 105 mm Hg and average heart rates from 340 to 420 beats Rats in both groups that responded to stimulation by an observable decrease in blood pressure (responder), did not respond to stimulation (non-responder), died during the experiment (death), or had neurological side effects  are presented in Typical changes in mean blood pressure and average heart rate during ten days in a single responder rat of the experimental group are presented in p = 0.08). During the “ON stimulation” period, mean arterial pressure decreased by 8.23 mm Hg (p = 0.001) in the experimental group and increased by 0.75 (p = 0.78) in the control group. The “OFF stimulation” baseline average heart rate was 376.34 ± 15.46 beats/min and 365.94 ± 18.26 beats/min in rats of experimental and control groups, respectively. The difference in average heart rate during the “OFF stimulation” period between groups, as expected, was not significant (p = 0.297). During the “ON stimulation” period average heart rate decreased by 26.93 beats/min (p = 0.008) in the experimental group and by 3.10 (p = 0.503) in the control group. There was no statistically significant difference between the two groups during the “ON stimulation” periods in MAP (p = 0.229) and BP (p = 0.139).The “OFF stimulation” baseline mean arterial pressure was 96.22 ± 5.79 mm Hg and 90.84 ± 5.55 mm Hg in rats of experimental and control groups, respectively. The difference in blood pressure during the “OFF stimulation” period between groups, as expected, was not significant  systems to target this region. In the literature, we found the locus coeruleus region and parabrachial complex, both in the lower pons, being the lowest human brainstem targets where insertion of DBS electrodes was successfully attempted ,44. WhilClinical data evaluating the hypotensive DBS effect in drug-resistant hypertension come from studies targeting PAG ,24,46,47RAD and BS procedures are established methods for treating resistant hypertension ,21. AlthUnlike RAD, the BS procedure is non-destructive, and optimization of the device effect is possible by changing the stimulation parameters . HoweverThe main limitation of this study is the lack of histological validation of the target. Although we used physiological confirmation during the electrode placement, post hoc histological validation would be beneficial to evaluate the histological damage on the CVLM.Future studies should address the comparison of bilateral and unilateral CVLM stimulation: whether bilateral stimulation would lead to an enhanced hypotensive effect or a higher mortality rate. Furthermore, it would be beneficial to substitute the current model of Wistar rats with spontaneously hypertensive rats, as a more pronounced hypotensive effect should be expected.Although targeting neural centers in the medullary region is considered dangerous and prone to complications, it could open a new vista for deep brain stimulation therapy. This study shows that CVLM implantation procedures do not lead to significant mortality in animals, and the rate of neurological complications is acceptable. Furthermore, this study indicates that chronic stimulation of the CVLM region can effectively lower arterial blood pressure in otherwise healthy conscious Wistar rats. As discussed, stimulation of the CVLM region could have some inherent benefits as opposed to PAG stimulation. With its intricate cardiovascular, respiratory, wakefulness, and other regulatory networks, the lower medullary region could be an effective yet challenging site for electrode implantation. However, it could still help treat such complex diseases and conditions as drug-resistant hypertension, vasovagal syncope, or even vegetative state.Considering the high prevalence and frequent drug resistance of PAH and the significance of the sympathetic nervous system in PAH pathogenesis, it would be beneficial to have more treatment options added to already established techniques. DBS could be a minimally invasive, safe, and non-destructive procedure that acts directly on the regulatory centers of blood pressure control.


Advanced age is a major determinant of mortality and poor outcome at any level. In hospitalized patients, advanced age is a major issue in terms of prognosis, resource use, and therapeutic choices.We aimed at assessing the 1 year outcome of elderly patients admitted to a neurology unit for various acute conditions.Consecutive patients admitted to a neurology unit were enrolled and followed-up at 3, 6, and 12 months with structured phone interviews gathering information about mortality, disability, hospital readmissions, and place of residency. Inclusion criteria were age ≥ 85 years, availability of written consent and phone contact; no exclusion criteria were applied.Over a period of 16 months, 131 patients  were admitted. The pre-hospitalization modified Rankin Scale (mRS) median (IQR) score, obtainable in 125 patients, was 2  and > 3 in 28/125 (22.4%) patients. Fifty-eight (46.8%) patients had pre-existing dementia (this information was missing for one patient). Eleven patients died during hospitalization. Of the 120 discharged patients, 60 (50%) were alive at 12 months, 41 died during follow-up (34.2%), and 19 (15.8%) were lost. At 12 months, out of the 60 alive patients, 29 (48.3%) had a mRS > 3. We did not detect predictors of 12-month survival. Predictors of 12-month worsening of functional status were pre-hospitalization mRS, pre-existing cognitive impairment, and male sex.One-year mortality of elderly patients admitted to a neurology unit is extremely high. After one year, less than one fourth of elderly patients hospitalised for an acute neurological disease are left with only no-to-moderate disability.The online version contains supplementary material available at 10.1007/s40520-023-02468-x. Aging of the population is a major issue. The World Health Organization estimates that in the next 30 years, the world's population over 60 years will pass from 12 to 22%, with consequences for all countries that will have to face major health and social challenges [Many neurological diseases, such as cerebrovascular and neurodegenerative ones, are age-related and many of them may lead to hospitalization with increasing direct costs. Neurological diseases are also associated with high rates of disability and mortality. It is therefore relevant to understand the outcome of the oldest-old patients hospitalized for neurological diseases and to outline possible predictors of outcome in this very frail population to better assess and plan the health investments and the interventions during hospitalization and thereafter.Considering the paucity of data about this particular group of patients, we aimed to assess: (1) the prognosis of hospitalized oldest-old neurological patients in terms of mortality and functional outcome; and (2) the factors associated with their functional autonomy and survival.This was a prospective study on ≥ 85-year-old, consecutive patients admitted to the neurological ward of the “Luigi Sacco” hospital in Milan from January 1, 2019 to May 31, 2020. The COVID-19 pandemic outbreak led to a marked reduction in admissions to our ward, and thus to the decision to stop the study on May 31, 2020.The study was performed in accordance with the 1964 Declaration of Helsinki and its later amendments. Informed consent was obtained by patients or caregivers.Inclusion criteria were: (1) age ≥ 85 years; (2) neurology unit admission from emergency room; (3) written consent given by the patient or caregiver; (4) availability of a phone contact. No exclusion criterion was applied.Within 48 h of admission, we collected information about: (1) age; (2) sex; (3) place of provenance ; (4) social and family environment ; 5) cause of hospitalization; (6) associated diseases; (7) dementia, defined as Clinical Dementia Rating (CDR) ≥ 1 [ cause ofAt discharge, we gathered data about: (1) length of hospitalization in days; (2) discharge diagnosis; (3) discharge destination.Phone interviews were made at 3 months (± 5 days), 6 months (± 10 days), and 12 months (± 20 days) after discharge, inquiring the caregiver about: (1) current living place; (2) new hospitalization; (3) functional status (assessed with mRS); (4) possible COVID-19 related events (this question was added after January 2020).Patients for whom no phone answer was obtained on five phone calls in 3 or more different days were considered as lost at follow-up.The functional study outcome, as measured by means of the modified Rankin Scale (mRS), was dichotomized as none-to-moderate degree of disability (mRS ≤ 3) vs. severe disability (3 < mRS < 6) at the follow-up visits. Furthermore, a comorbidity sum score was computed taking into account the presence of each of the following conditions: cognitive impairment, previous stroke, hypertension, diabetes, cancer, heart failure, ischemic heart disease, previous surgery , other neurological, cardiologic, orthopedic, oculistic, pulmonary, gastroenterological, hematologic, endocrine, otorhinolaryngologic, psychiatric, nephrological, rheumatologic, vascular, and dermatologic diseases. The comorbidity sum score ranged from 0 (no condition present) to 23  [Descriptive statistics  were used to illustrate the total sample characteristics.U test, Pearson’s chi-squared test) were used to compare alive and dead patients in terms of demographics, presence of cognitive impairment, pre-hospitalization functional status, comorbidities, length of hospitalization, discharge diagnosis and destination, and emergency room access or hospitalization at each time point . The same models of analyses were used to compare patients presenting a none-to-moderate degree of disability and those with a severe disability at the follow-up visits.Univariate statistical analyses  with 95% confidence intervals (95% CI) were reported.To explore the influence of the heterogeneity of discharge diagnoses and of the pre-morbid functional status, the univariate and multivariate models of analyses were repeated in two subgroups analyses: (1) limited to patients with a discharge diagnosis of cerebrovascular event, and (2) limited to patients with a pre-hospitalization mRS ≤ 3.All analyses were done using the SPSS software version 27, and a 0.05 significance threshold was applied.Over the study period, 131 patients  were admitted to the neurology ward  the cause of hospitalization was an acute cerebrovascular event. Less frequent causes of hospitalization were gait disturbance or falls (n = 13), seizure (n = 8), acute confusional state or vigilance disturbance (n = 5), headache (n = 2), visual impairment (n = 2). Other causes accounted for 6.9% (n = 9).Data on living condition and referral were available in 130 patients. Out of 130 patients, 125 (96%) were by living home, and five were transferred from other hospital wards. Among the 125 patients that lived at home, 50 (40%) were living alone, 27 (22%) lived with a partner, 21 (17%) with other relatives, and 27 (22%) were assisted by a full-time caregiver before hospitalization.The pre-hospitalization mRS score was obtainable in 125 patients and the median (IQR) value was 2 . mRS was > 3 in 28/125 (22.4%) patients. Fifty-eight (46.8%) patients had pre-existing dementia (defined as CDR > 1) (information about antecedent cognitive status was not obtainable in one patient). Comorbidities are reported in Table Eleven patients (8.4%) died during hospitalization Fig. . DischarAt the 3-month phone follow-up, we obtained information on 107/120 patients (89.1%) of whom 28% were males  were still alive at 12 months, 41 died during follow-up (34.2%), and 19 (15.8%) were lost. At 12 months from the discharge, out of the 60 alive patients, 43 (72%) had a mRS ≤ 3.Pre-hospitalization mRS was associated with both outcomes at 3 months .At 3 months, pre-hospitalization mRS , and living condition  were confirmed as significantly associated with the functional outcome  and 12 months  , while pre-existing cognitive impairment  and comorbidity sum score  were both confirmed as independent predictors at 6 months  collected by the Italian National Institute of Statistics (ISTAT). In 2020, ISTAT data reported the following mortality rates per 1000 individuals per year: 258 in the age group 85–89, 447 in the group 90–94, and 672 > 95 years. Stratifying our data according to the same age ranges, our patients presented higher mortality rates both in the 85–89 group  and > 95 , with an increased probability of death of approximately 30%.Looking at hospitalized elderly patients, our results on survival outcome are in line with data from two previous studies including very elderly patients admitted to general hospital for acute illness or exacerbation of a chronic disease , 8. In aOur study has several limitations. The first one is that the sample size is limited, partly because of the occurrence of the COVID-19 pandemics during its progression that prevented additional enrolment in our unit that was shut down during that period. However, we believe that the results we reported are of interest as they shoot the picture of a neurology general ward for acute patients. Also, the follow up was exclusively done by phone interviews although we focused on strong outcomes such as mortality and basic functional outcome that can be reliably assessed in this way. Other outcomes, for example cognitive measures, might be of interest in defining the outcome of this very old population. It should be noted however that a great amount of our patients had already pre-existing cognitive impairment, which of course is a strong predictor of poor outcome. The high incidence of pre-existing cognitive decline is consistent with previous data from the same area . At presIn conclusion, hospitalization of patients older than 85 years for acute neurological conditions is associated with high mortality and great disability burden. These results have to be confirmed in larger studies. Our study was not set, nor has the power, to explore and deliver information about the use of medical resources in this elderly population. However, it might be a first step on the way to produce such type of data.Supplementary file1 (DOCX 49 KB)Below is the link to the electronic supplementary material.