The levels of thiamine intake were 1⋅126 mg (2016), 1⋅115 mg (2017) and 1⋅087 mg (2018) for women, which were equal to or only slightly above the recommended intake of 1⋅10 mg/d for women. The levels of thiamine intake from 2014–15 and 2016–18 significantly decreased. The estimated percentage of insufficient thiamine intake was 37⋅8 % . Multivariable regression analysis adjusted for potential confounders showed that thiamine intake was critically associated with lower risks of hypertension, MI or angina, type 2 diabetes, depression and dyslipidemia. The daily thiamine intake from food can reversal the risks of hypertension , MI or angina , type 2 diabetes , depression  and dyslipidemia , respectively. Further works are needed to identify the effects of thiamine and non-communicable diseases (NCDs) and mental health. A preventive thiamine supplementation strategy should be adopted to target NCDs and mental health and risk factors associated with thiamine deficiency. The optimisation of NCD control and mental health protection is also a vital integral part of Korea's public health system.The present study aimed to determine thiamine intake levels and the association between thiamine intake, diabetes, cardiovascular diseases and mental health. Participants were interviewed to obtain data on socio-demographic characteristics, lifestyle, current medications, medical and family history. The daily intake of thiamine was assessed by a 24-h recall. The mean age of the 34 700 study subjects was 42⋅9 years ( However, inappropriate dietary patterns, reduced physical activities, increased tobacco use and the resulting increase of diet-related chronic diseases have increased in concert with living standards and food availability. Furthermore, non-communicable diseases (NCDs) such as obesity, hypertension, diabetes mellitus, cardiovascular diseases (CVDs), stroke and cancers are increasingly becoming causes of disability and premature death, which has placed extra pressure on the national health budget. Of note, in developing and developed countries, CVDs are the main cause of morbidity and mortality and are directly associated with an imbalanced diet.Over the last decade, rapid changes in diets and lifestyles that have taken place due to urbanisation, industrialisation, economic development and globalisation, and these have changed dietary patterns towards high-fat, high-saturated and low-energy-dense diet. Thiamine, also referred to as vitamin B1, is a water-soluble vitamin and a coenzyme in the metabolism of carbohydrates and branched-chain amino acids. Thiamine is a crucial micronutrient and can be obtained from different food sources, but its serum levels can be affected by many factors, such as high temperatures and pH, diuretics, high-calorie diet containing simple carbohydrates, chronic alcoholism, fever, excessive exercise, pregnancy and lactation, stress and trauma–9. Furthermore, the half-life of thiamine in the body ranges only 1–3 weeks. These factors do much to explain why thiamine inadequate diet commonly results in thiamine deficiency in developed countries. Increasing evidence shows that thiamine deficiency is directly or indirectly associated with many CVDs and diabetes, obesity, dyslipidemia, angina, myocardial infarction (MI) and mental health (e.g. depression). However, the relationships between thiamine intake and CVDs, diabetes, dyslipidemia and mental health are still unclear. In the present study, we used data collected during national population-based surveys to determine thiamine intake levels and to examine the associations of thiamine levels and cardiovascular disease, diabetes, dyslipidemia and mental health.Recent studies have expanded to understanding of the effects of diet on morbidity and premature deaths due to NCDs. Each survey includes a new sample of about 8000 individuals from non-institutionalised Korean citizens who are representative of the population. The individuals surveyed were randomly selected from 7550 households (2014), 7380 (2015), 8150 (2016), 8127 (2017) and 7992 (2018). In the present study, participants who (1) have fully take part in three parts including a health interview survey, a health examination survey and a nutrition survey, (2) provided information on nutrients that contribute to thiamine intake. Of the 39 199 participants who participated in KNHANES surveys from 2014 to 2018, we excluded 4499 records missing thiamine intakes. Thus, the data of 34 700 participants were subjected to analysis. Written informed consent was required for both patients and family members; parental informed consent was obtained on behalf of all minors before examinations, which were performed by the Health and Nutrition Examination Department of the Korea Centers for Disease Control and Prevention. The present study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects/patients were approved by the KNHANES inquiry commission and the Institutional Review Board of Sunchon National University. All methods were performed following a standardised protocol. Detailed information on the plan, standardised protocol and licence of these surveys was available on the KNHANES Web site (http://knhanes.cdc.go.kr/).We used a multi-stage, stratified, cluster-sampling procedure that regarded the geographic area, the level of urbanisation, economic growth status, and gender and age distribution, derived from the Korean National Health and Nutrition Examination Survey (KNHANES) conducted by the Korean Ministry of Health and Welfare, specifically the KNHANES VI (2014–15) and the KNHANES VII (2016–18)Blood samples were collected after ≥8-h fasting and were analysed at Neodin Medical Institute in Korea. The levels of total cholesterol, high-density lipoprotein cholesterol (HDL-C), triacylglycerols, low-density lipoprotein cholesterol (LDL-C) and fasting glucose were then measured by an enzymatic assay using a Hitachi automatic analyzer 7600 . Serum low-density lipoprotein cholesterol (LDL-C) is calculated using the Friedewald equation: serum LDL-C ¼ serum total cholesterol − serum HDL-C − serum triacylglycerol/5.2) is calculated using the formula: BMI = weight (kg)/height2 (m2). Waist circumstance (cm) was measured at the midpoint between the bottom of the rib cage and the iliac crest of the mid-axillary line when exhaling. Blood pressure was measured three times with intervals of 5 min using a mercury sphygmomanometer with a subject seated after a 5-min stabilisation period. Final blood pressure was the average of the second and third measurements. Education level was classified as below middle school, high school and college or higher. Residence areas were classified into urban and rural. Occupations were classified as follows: (1) managers and professional, (2) office and clerical workers, (3) service and sales workers, (4) agriculture, forestry and fishing workers, (5) craft, plant and machine operators and assemblers, (6) elementary occupations and (7) unemployed. Monthly house incomes were classified as <2000, 2000–4000, 4000–6000 and ≥6000 thousand won. Alcohol intakes were classified as low and high (high-risk drinking was defined as >5 drinks per day and ≥1 month). Subjects with a lifetime history of smoking of >100 cigarettes in their lifetime and still smoked daily or occasionally were classified as current smokers; others were classified as ex/non-smokers. Physical activity was dichotomised as regular or irregular. Regular physical activity was defined as follows: (1) vigorous physical activity , ≥20 min per session ≥3 d/week; (2) moderate physical activity ; ≥30 min per session ≥5 d/week and (3) walking; ≥30 min per session ≥5 d/week. A family history of cardiovascular disease was defined as having at least one parent or sibling with a diagnosis of hypertension, ischemic heart disease or stroke. A family history of type 2 diabetes and hyperlipidemia was defined as having at least one parent or sibling with a diagnosis of type 2 diabetes and hyperlipidemia.We used the database of the KNHANES health interview survey to classify the demographic status and healthy lifestyles. During medical checkups, the height, weight, waist circumstance and blood pressure were measured using the standard procedure. Body mass index (BMI)  ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg or on anti-hypertensive medication. Type 2 diabetes mellitus was defined as having a fasting plasma glucose ≥126 mg/dl or on anti-diabetic medication, or HbA1c ≥ 6⋅5 %. Stroke, angina, MI, MI or angina were defined as physician diagnosis, the current presence or treatment for stroke, angina, MI, MI or angina. Variables that were taken into account were the self-perception of stress and depression. Participants were asked how much stress they encountered in their everyday routine for self-perception of stress. They were asked to identify stress levels, including very often, sometimes, rarely and a few times or never. Stress was defined if participants answer very often or sometimes. Depression was defined as physician diagnosis, the current presence or treatment for depression.. Nutrient intake was calculated using the Can-Pro Ver 3.0 nutrient intake assessment software developed by the Korean Nutrition Society. In the present study, sufficient daily thiamine intakes were defined as ≥1⋅22 mg/d for men and ≥1⋅03 mg/d for women. Furthermore, we weighted calorie-adjusted thiamine with a minimum of 0⋅33 mg of thiamine for every 1000 kilocalories .Daily food intake was determined using the 24-h recall method. Before assessing the food intake, all participants were told to report their normal dietary habits. A semi-quantitative questionnaire on food frequency, which addressed the intakes of sixty-three food products, was completed for each participant. The frequency of food intake was measured using nine classifications: ‘never or rarely’, ‘once a month’, ‘two to three times a month’, ‘one to two times a week’, ‘three to four times a week’, ‘five to six times a week’, ‘once a day’, ‘twice a day’ and ‘three or more times every day’. The daily total energy intakes were measured using Estimated Energy Requirement (EER) in Koreat test for continuous variables and χ² test for categorical variables.All statistical analyses were undertaken using STATA software . The baseline characteristics of participants were summarised using frequency and proportion for categorical variables; mean and standard deviation or median and interquartile range for continuous variables. Therefore, Student's P-values of ≤0⋅25 in univariate analysis and were entered in the full model including thiamine (mg), energy , calorie-adjusted thiamine (mg), age group , sex, residential area , marital status , the education level , monthly household income , smoking status , high-risk drinking , physical activity , BMI groups , and the presence of hypertension, hyperlipidemia and type 2 diabetes. In multivariable analysis, backward elimination was used. Any variable which had a P-value > 0⋅05 was removed from the model. A log-likelihood ratio test was carried out to compare the ‘bigger’ and ‘reduced’ models. If the log-likelihood ratio test provided a P-value of ≤0⋅05, the corresponding variable was retained in the model. The process was repeated till no other variables in the model yielded P-values of >0⋅05 . To visualise the moderating effect of thiamine, marginal effect analysis was carried out using the results of Poisson regression analysis. Statistical tests were two-sided, P-value < 0⋅05 was considered statistically significant.The association between thiamine levels and cardiovascular disease, diabetes, dyslipidemia and mental health was examined by logistic regression in adults ≥18 years. Potential covariates were first recognised in the existing literature, or subjective prior knowledge plus those variables with sd 22⋅8, min–max: 1–80), 19 342 (55⋅7 %) were women. The insufficient and sufficient thiamine intake groups were significantly different in terms of sex, age, married status, occupation, education level, monthly household income, BMI level, waist circumference, elevated cholesterol, reduced HDL-C, elevated HbA1c, elevated glucose, energy intake, haemoglobin, smoking status, drinking status, physical activity, SBP and diastolic blood pressure. Total cholesterol level, HbA1c and fasting glucose were lower in the sufficient thiamine intake group than in the insufficient thiamine intake group. However, dietary energy intake was higher in the sufficient intake group (1369⋅4 (567⋅3) v. 2253⋅6 (904⋅6) kcal, P < 0⋅001; In total, 34 700 individuals who participated in the KNHANES 2014–18 survey were included in the present study. The mean age of participants was 42⋅9 years (P < 0⋅001). The estimated percentage of participants with insufficient thiamine intake from 2014 to 2018 was 37⋅8 % . The average daily intake of thiamine from food was 0⋅82 mg  for those aged <3 years, 1⋅24 mg  for those aged 3–10 years, 1⋅70 mg  for those aged 11–18 years and 1⋅57 mg  for those aged ≥18.v. 18⋅8 %), stroke (2⋅5 v. 1⋅7 %), MI or angina (2⋅8 v. 2⋅1 %), MI (1⋅03 v. 0⋅8 %), angina (2⋅0 v. 1⋅5 %), dyslipidemia (18⋅9 v. 15⋅2 %), type 2 diabetes (8⋅8 v. 6⋅9 %), depression (4⋅4 v. 3⋅5 %) and stress (27⋅3 v. 25⋅3 %) was lower in the sufficient than in the insufficient intake group.Univariable regression analysis showed that the risks of hypertension, type 2 diabetes, dyslipidemia, angina, myocardial infarction, MI or angina, depression and stress were lower in the sufficient group than in the insufficient group (Table S1). Furthermore, thiamine intake is inversely associated with hypertension, MI or angina, type 2 diabetes, depression and dyslipidemia. Multivariable regression analysis adjusted for potential confounders showed that thiamine intake was critically associated with lower risks of hypertension, MI or angina, type 2 diabetes, depression and dyslipidemia. The daily thiamine intake can reversal the risks of hypertension , MI or angina , type 2 diabetes , depression  and dyslipidemia , respectively .Table 2This large-scale study is the first to report the association between dietary thiamine intake and the prevalence of CVDs, diabetes and mental health issues at the national level in Korea. The study also provides thiamine dietary consumption trends over recent years and contributes to understanding of the effect that thiamine consumption has on the Korean population.. Although the relationship between type 2 diabetes and thiamine deficiency has not been fully elucidated, reduced thiamine supply in diabetic vascular cells has been reported to exacerbate metabolic dysfunction under hyperglycemic conditions, and thiamine deficiency was found to contribute to severe insulin synthesis and secretion dysfunction in human cell lines. Distal nephrons excrete excess thiamine that is not bound to protein, and thiamine loss is closely related to renal clearance, thus, increased renal clearance due to type 2 diabetes may be linked to thiamine deficiency. In addition, intestinal motility affected by autonomic neuropathy in type 2 diabetes causes overgrowth of bacteria in the small intestine and inhibits thiamine absorption.The present study shows that thiamine intake is significantly and negatively associated with the risk of type 2 diabetes. In addition, HbA1c and fasting glucose levels were lower in the sufficient thiamine intake group than in the insufficient intake group. Our findings support those of a previous study, in which a substantial decrease in plasma fasting glucose concentration was observed in drug-naïve patients with type 2 diabetes administered 150 mg of thiamine daily for 1 month. Furthermore, we found that thiamine intake had a significant impact on the development of CVDs such as hypertension, MI or angina, which supports the notion that thiamine ameliorates the detrimental effect of elevated endothelial glucose by reducing the glycation of intracellular proteins. Thiamine also plays a fundamental role in the prevention of atherosclerotic plaque because it has a defensive effect on the impact of glucose- and insulin-mediated proliferation on human infragenicular arterial smooth muscle cells. Our data support reports that regular thiamine administration boosts endothelial functions and retards atherosclerosis progression, which is in-line with a report that short-term thiamine therapy regenerated endothelial function in healthy smokers with endothelial dysfunction triggered by smoking.Our results also show a significant decrease in total serum cholesterol among individuals with sufficient thiamine intake. The percentages of participants with elevated total cholesterol and LDL-C levels were lower in the sufficient thiamine intake group and the percentage with a low HDL-C level was lower in this group, which is consistent with previous findings,27. Another study also showed that the short-term daily thiamine administration prompted a feeling of well-being in the elderly and enhanced the energetic statuses and ‘clear-headedness’ of young women,29, which may be because oxidative stress caused by thiamine deficiency reduces hippocampal volume and causes neural damage in depressed patients,31. Besides, thiamine is an important coenzyme during the syntheses of many neurotransmitters, such as acetylcholine, aspartate, serotonin and glutamate, and deficiencies in the functions of these neurotransmitters, and thus, thiamine deficiency would be expected to result in symptoms like depression or stress.Notably, we found that thiamine intakes can reversal the risks of depression. This concurs with the findings of cross-sectional studies performed in China and the United Kingdom, which showed low thiamine serum concentrations were associated with high prevalence of depression symptoms,2. Furthermore, rapid industrialisation has led to an increase in the number of nuclear families and single households. Of note, eating alone is related to an unhealthy dietary intake, including more fried foods or carbonated beverages, and less fruits and vegetables. On the other hand, the majority of participants in the present study located in urban areas ; therefore, they were more likely to be used fat foods and consumed less fruits and vegetables. Our findings were consistent with the previous studies–36.Importantly, the present study raises a public health concern for people in Korea. The average thiamine intakes reported in Korea decreased from 2014 to 2018. It could be explained that rapid changes in diets and lifestyles that have taken place because of urbanisation, industrialisation, economic development and globalisation, and these have changed dietary patterns towards high-saturated, high-fat and low-energy-dense dietv. 1⋅95 mg , 1⋅39 (women)). Furthermore, the present study also shows the average whole population thiamine intake was lower than that in Spain . Of note, thiamine intakes in Korean women in 2016–18 were 1⋅126, 1⋅115 and 1⋅087 mg, which were equal to or only slightly above the recommended intake of 1⋅10 mg/d for women. On the other hand, the average daily intake of thiamine among children aged 1 to <3 years old (0⋅58–0⋅98 mg/d), aged 3 to <10 years old (0⋅68–1⋅29 mg/d), aged 10 to <18 years old (0⋅93–1⋅92 mg/d) and among aged ≥18 years old (0⋅88–1⋅99 mg/d) in nine countries of the European Union was higher than the present study. The average daily intake of thiamine in the United States followed a similar pattern. The average daily intake of thiamine is 1⋅51 mg for 2–5 years, 1⋅76 mg for 6–11 years, 1⋅95 mg in 12–19 years of age and adults aged 20 and older is 4⋅89 mg in men and 4⋅90 mg in women. In the present study, the average daily intake of thiamine among adults aged ≥65 living in the rural and urban areas was 1⋅53 mg, 1⋅58 mg in men and 1⋅17 mg, 1⋅19 mg in women, which was higher than a study in fifteen provinces  in China (0.80 mg in men and 0.70 mg in women). Given the steady decrease in thiamine intake observed in the present study and the observed beneficial effects of thiamine in the elderly on the risks of stroke, diabetes, depression and stress, we suggest health policymakers and public health practitioners invest in prevention and control plans.Thirteen dietary surveys in nine countries of the European Union reported average thiamine intakes between 0⋅31 and 0⋅65 mg/d, and the present study shows that thiamine intake in Korea was lower than that in the United States in adult aged ≥20 years (1⋅76 (1⋅07) mg , 1⋅34 (0⋅79) mg The present study has some limitations that deserve consideration. First, the cross-sectional design of the study prevented evaluations of causality between NCDs and mental health and thiamine intakes. Second, since no physiological markers of antioxidant status were measured in KNHANES, oxidation status and thiamine levels in plasma and tissues were not evaluated. Third, thiamine intake was calculated based on 24-h recall data and intake amounts may have differed on weekdays and weekends, and thus, intakes may have been under- or overestimated. However, 24-h recall offers a cost-effective means of assessing food intakes, and our findings show a significant decreasing trend in thiamine use over recent years.Our findings showed that the trend in the levels of thiamine intake tends to be decreasing in recent years. It is crucial to develop a prevention strategy targeting the population to slow down this progression to postpone risk factors related to insufficient thiamine intake and reduce prevalence. The present study confirmed the role of thiamine in the reversal of NCDs and mental health and risk factors associated with its deficiency. These findings highlight the value of urgent efforts to establish targeted thiamine supplementation in Korea. We believe that these strategies would effectively reduce the prevalence of NCDs and mental health.


Following publication of the original article , the aut21Founded in 1921, the Austria-based Bund was a split-off from the Christian-German Student Union (CDSB) but stressed its affinities with the German Youth Movement as represented by the “Meißner formula,” which Asperger cited in 1974 as a guiding principle in his life [3].30Asperger’s political socialization in Neuland likely blinded him to National Socialism’s destructive character due to an affinity with core ideological elements (see [36]: 848–9).This passage has been quoted as evidence that Asperger tried to publicly protect his patients from forced sterilizations .This includes Asperger’s mentor Franz Hamburger and also applies to Erwin Jekelius, a youth psychiatrist trained at Hamburger’s clinic, who in 1940 became the main organizer of the “T4” killing operation in Vienna.Jekelius had received part of his training at the Therapeutic Pedagogy Ward under Asperger’s direction, where he was employed from August 1933 to February 1936 .From Herta’s religious denomination gottgläubig (theistic), it can be inferred that the family had left the Catholic Church under the influence of the Nazis’ opposition to organized religion, a practice that was usually followed only by a radical minority of Nazi sympathizers ([82]: 281–3).Anny Wödl, a Viennese nurse, had no doubt that the transfer of her son Alfred to Spiegelgrund, enforced in early 1941 despite her resolute resistance, would mean his death ([87]: 298).106In November 1941, the authorities in Niederdonau (the province surrounding Vienna) noticed that patients in the children’s ward at the Gugging psychiatric hospital were not attending school, despite not having been excused.In this context, a critical assessment of Asperger’s brand of Heilpädagogik with its “pronounced dominance of restrictive pedagogical concepts” ([74]: 613) is overdue.1A copy of the postdoctoral thesis as submitted in 1942 is at the Vienna University Library. It is practically identical to the 1944 paper.12DÖW 6217, Liste von Gelehrten österreichischen Ursprungs in den Vereinigten Staaten, 1958; ([21]: 87).29WStLA, 1.3.2.202, Personalakt Hans Asperger, Fragebogen, 7 Oct. 1940. Another document refers to Asperger’s membership in the Vaterländische Front , the single party of the Austrofascist regime that governed Austria from 1933/34 to 1938.48WStLA, 1.3.2.202, Personalakt Hans Asperger, Schreiben des Führers des SD-Leitabschnittes Wien to Personalamt der Stadt Wien, 14 November 1940.138The choice of the expression niederschießen (to gun down) in what sounds like a carefully scripted monologue hints at the particular character of the warfare he experienced, since it suggests the killing of unarmed individuals rather than military battle. A remark in his textbook, first published in 1952, points in a similar direction: “Also during the war, one had to experience time and again how strong the pressure of the “collective” could be, what terrible deeds a group of people as a whole were capable of, deeds that none of them would have committed on their own in their civil lives” ([76]: 81).Abbreviation should be: CDSB: Christian-German Student Union.Reference 13: Czech H. Der Spiegelgrund-Komplex. Kinderheilkunde, Heilpädagogik, Psychiatrie und Jugendfürsorge im Nationalsozialismus. Österreichische Zeitschrift für Geschichtswissenschaft. 2014;25:194–219.Reference 40: Korger F. Zur heutigen Behandlung der Judenfrage. Neuland. Blätter jungkatholischer Erneuerungsbewegung. 1933;10:171–4.


Coronavirus Disease 2019 (COVID-19) has become a worldwide pandemic and is a threat to global health. Patients who experienced cytokine storms tend to have a high mortality rate. However, to date, no study has investigated the impact of cytokine storms.This retrospective cohort study included only COVID-19 positive patients hospitalized in a Private Hospital in West Jakarta between March and September 2020. All patients were not vaccinated during this period and treatment was based on the guidelines by the Ministry of Health Indonesia. A convenience sampling method was used and all patients who met the inclusion criteria were enrolled.The clinical outcome of COVID-19 patients following medical therapy was either cured (85.7%) or died (14.3%), with 14.3% patients reported to have cytokine storm, from which 23.1% led to fatalities. A plasma immunoglobulin (Gammaraas®) and/or tocilizumab  injection was utilised to treat the cytokine storm while remdesivir and oseltamivir were administered to ameliorate COVID-19. Most (61.5%) patients who experienced the cytokine storm were male; mean age 60 years. Interestingly, all patients who experienced the cytokine storm had hypertension or/ and diabetes complication (100%). Fever, cough and shortness of breath were also the common symptoms (100.0%). Almost all (92.3%) patients with cytokine storm had to be treated in the intensive care unit (ICU). Most (76.9%) patients who had cytokine storm received hydroxychloroquine and all had antibiotics [1) azithromycin + levofloxacin or 2) meropenam for critically ill patients] and vitamins such as vitamins C and B-complex as well as mineral. Unfortunately, from this group, 23.1% patients died while the remaining 70% of patients recovered. A significant (p<0.05) correlation was established between cytokine storms and age, the presence of comorbidity, diabetes, hypertension, fever, shortness of breath, having oxygen saturation (SPO2) less than 93%, cold, fatigue, ward of admission, the severity of COVID-19 disease, duration of treatment as well as the use of remdesivir, Actemra® and Gammaraas®. Most patients recovered after receiving a combination treatment  for approximately 11 days with a 90% survival rate. On the contrary, patients who received oseltamivir + hydroxychloroquine + Gammaraas® + antibiotics +Vitamin/Mineral, had a 83% survival rate after being admitted to the hospital for about ten days.Factors influencing the development of a cytokine storm include age, duration of treatment, comorbidity, symptoms, type of admission ward and severity of infection. Most patients (76.92%) with cytokine storm who received Gammaraas®/Actemra®, survived although they were in the severe and critical levels (87.17%). Overall, based on the treatment duration and survival rate, the most effective therapy was a combination of oseltamivir + favipiravir + hydroxychloroquine + antibiotics + vitamins/minerals. Cytokine storm, also known as hypercytokinemia or “cytokines release syndrome,” is implicated in the worsening of several conditions, including pulmonary inflammation leading to acute respiratory distress syndrome (ARDS) and in severe COVID-19 cases. Nevertheless, there is lack of information on the latter to provide a better understanding of its role clinically. Information on the impact of cytokine storm in elucidating inflammation, especially involving treatments and vaccines given to the patients is also lacking. The mortality rate from COVID-19 acute respiratory distress is reported to be almost 40–50% .younger people are less affected where it produces lower levels of inflammation due to less involvement of the immune system Reviewers' comments:Reviewer's Responses to Questions  Comments to the Author1. Is the manuscript technically sound, and do the data support the conclusions?  The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********   2. Has the statistical analysis been performed appropriately and rigorously?   Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********   3. Have the authors made all data underlying the findings in their manuscript fully available?PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.  The Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********   4. Is the manuscript presented in an intelligible fashion and written in standard English?  PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.Reviewer #1: YesReviewer #2: YesReviewer #3: Yes**********   5. Review Comments to the Author  Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. Reviewer #1: The research article entitled, "Impact of Cytokine Storm on severity of COVID-19 infection in a private Hospital in West Jakarta Prior to Vaccination" by Ramatillah et al., assessed the role of cytokine storms in patients’ high mortality rate during COVID-19 pandemic using retrospective cohort study included only COVID-19 positive patients hospitalized in a Private Hospital in West Jakarta between March and September 2020. Authors found the clinical outcome of COVID-19 patients following medical therapy was either cured (85.7%) or died (14.3%), with 14.3% patients reported to have cytokine storm, from which 23.1% led to fatalities. Finally, authors have concluded that based on the treatment duration and survival rate, the most effective therapy was a combination of oseltamivir+favipiravir+hydroxychloroquine+antibiotics+vitamins/mineral. Altogether this is an important and timely research article, this reviewer has certain suggestions that would help produce a more comprehensive overview of the topic:Comments:1. Did authors find any global data on female COVID-19 patients with cytokine storms? This will be noteworthy to know and authors can include this data to their study.2. Did authors/or any other find cytokine storms in relatively younger COVID-19 patients and how was the response to the cytokine storms?3. At least one supplementary Figure as illustration may be afforded as to highlight the summary or prospect of this study.4. Author may explain how to adjust the limitation in their study?5. The abbreviations should be cross validated in the manuscript (First define them fully followed by abbreviation) and one paragraph can be added for abbreviations.Reviewer #2: This retrospective study investigated the impact of cytokine storm on severity of COVID-19 disease in a private Hospital in West Jakarta Prior to Vaccination. The authors should distinguish infection from disease, because in COVID-19 disease, SARS-CoV-2 infection severity  is not corelated to COVID-19 disease severity [1]In Title, “COVID-19 infection” should be “COVID-19 disease”Page 5, line 5, “severity of COVID-19 infection” should be “severity of COVID-19 disease”Page 6, line 12 from bottom, “more severe infection” should be “more severe disease”Page 9, line 6, “the severity of COVID-19 infection” should be “the severity of COVID-19 disease”Page 9, Table 1, row 24, “Severity of COVID-19 infection” should be “Severity of COVID-19 disease”Page 11, line 3 from bottom, “COVID-19 infection” should be “COVID-19 disease”Page 12, line 6, “following COVID-19 infection” should be “following SARA-CoV-2 viral infection”Page 14, last line, “patients with COVID-19 infection” should be “patients with COVID-19 disease”Page 15, line 9, “COVID-19 infection” should be “COVID-19 disease”Page 16, Conclusion, line 2, “severity of infection” should be “severity of disease”Reference1. Shah S, Singhal T, Davar N, Thakkar P. No correlation between Ct values and severity of disease or mortality in patients with COVID 19 disease. Indian J Med Microbiol. 2021; 39(1): 116- 117.DOI: 10.1016/j.ijmmb.2020.10.021Reviewer #3: In this paper entitled "Impact of cytokine storm on the severity of COVID-19 infection in a private hospital in West Jakarta prior vaccination", the authors used the convenience sampling method and included subjects who are not vaccinated. The clinal outcomes of the study are fascinating. The manuscript showed that cytokine storm was more in males (mean age 60) than women and interestingly, all hypertension/diabetes subjects experienced cytokine storm. It has many exciting findings which make this manuscript engaging and lucid. However, It has minor concerns.Minor comments:1) Please add limitations of the study.2) The cytokine storm is a fatal reaction of human immune system. Cytokine storm is present in influenza, SARS, and MERS. In few lines, please compare it. (doi:10.1016/j.clim.2020.108652).********** https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.
 While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool,  20 Dec 2021Reviewer 11. Did authors find any global data on female COVID-19 patients with cytokine storms? This will be noteworthy to know and authors can include this data to their study.Answer : Unfortunately, to date, there is no reported global data on female COVID-19 patients with cytokine storm, to date, since our data is the first reported one on male.2. Did authors/or any other find cytokine storms in relatively younger COVID-19 patients and how was the response to the cytokine storms?Answer : Similar to point 1 above, since our sample population was mostly among the older age group (mean age of 60 years), we could not report on the incidence of cytokine storms in relatively younger COVID-19 patients as well as their responses. It would be interesting to see the differences in a future study, using our data as a basis for the comparison.3. At least one supplementary Figure as illustration may be afforded as to highlight the summary or prospect of this study.Answer : We have included a supplementary Figure accordingly. Refer to Figure 2.4. Author may explain how to adjust the limitation in their study?Answer : This is something that is challenging since they are indeed the limitations of the study. Nevertheless, we have attempted to explain it more clearly in the text now and have added another statement: “Additionally, since our data reported mainly on males and also the elderly, it would be interesting to see the incidence in females as well as in the younger age group and their responses against cytokine storms”. Thank you for the suggestion. 5. The abbreviations should be cross validated in the manuscript (First define them fully followed by abbreviation) and one paragraph can be added for abbreviations.Answer: We have added it in the newly-revised manuscript. Thank you for the suggestion.Reviewer 2Reviewer #2: This retrospective study investigated the impact of cytokine storm on severity of COVID-19 disease in a private Hospital in West Jakarta Prior to Vaccination. The authors should distinguish infection from disease, because in COVID-19 disease, SARS-CoV-2 infection severity  is not correlated to COVID-19 disease severity [1]In Title, “COVID-19 infection” should be “COVID-19 disease”: This has been changed accordingly, thank you.Page 5, line 5, “severity of COVID-19 infection” should be “severity of COVID-19 disease”. This has been changed accordingly, thank you.Page 6, line 12 from bottom, “more severe infection” should be “more severe disease”. This has been changed accordingly, thank you.Page 9, line 6, “the severity of COVID-19 infection” should be “the severity of COVID-19 disease”. This has been changed accordingly, thank you.Page 9, Table 1, row 24, “Severity of COVID-19 infection” should be “Severity of COVID-19 . This has been changed accordingly, thank you.disease”Page 11, line 3 from bottom, “COVID-19 infection” should be “COVID-19 disease”. This has been changed accordingly, thank you.Page 12, line 6, “following COVID-19 infection” should be “following SARA-CoV-2 viral infection”. This has been changed accordingly, thank you.Page 14, last line, “patients with COVID-19 infection” should be “patients with COVID-19 disease”. This has been changed accordingly, thank you.Page 15, line 9, “COVID-19 infection” should be “COVID-19 disease”. This has been changed accordingly, thank you.Page 16, Conclusion, line 2, “severity of infection” should be “severity of disease”. This has been changed accordingly, thank you.Answer: We have added all in the newly-revised manuscript. Thank you for the suggestion.Reviewer 3Reviewer #3: In this paper entitled "Impact of cytokine storm on the severity of COVID-19 infection in a private hospital in West Jakarta prior vaccination", the authors used the convenience sampling method and included subjects who are not vaccinated. The clinal outcomes of the study are fascinating. The manuscript showed that cytokine storm was more in males (mean age 60) than women and interestingly, all hypertension/diabetes subjects experienced cytokine storm. It has many exciting findings which make this manuscript engaging and lucid. However, It has minor concerns.Thank you for the overall positive comments on our paper. We highly appreciate it.Minor comments:1) Please add limitations of the study.Answer : We have added the limitation of the study in the manuscript accordinglyThe study has some limitations since the duration is rather short and the fact that the published care data to date came from a small observational data (no more than 250 patients). Additionally, the types of treatment administered are not based on the WHO guideline but rather, on the local context, besides being conducted during the time when vaccines have not been introduced in the country. We have elaborated further to include the fact that future study should focus on females and the younger age group since our sample includes mostly males and the elderly.2) The cytokine storm is a fatal reaction of human immune system. Cytokine storm is present in influenza, SARS, and MERS. In few lines, please compare it. (doi:10.1016/j.clim.2020.108652).Thank you very much for the excellent suggestion. We have added a paragraph “Besides COVID-19, cytokine storms are also present in influenza, SARS, and MERS. Based on the immunopathology in COVID-19, SARS, and influenza infections, all the diseases show some hyperinflammation, hypercytokinemia, increased CRP levels, hyperferritinemia associated with poor prognosis, immunosuppression, lymphopenia associated with the severe disease, reduction of NK cell counts in the blood and/or NK cell dysfunction and reduction in both CD4 and CD8 T-cell counts in the blood associated with more severe disease. However, MERS tends to reveal hyperinflammation and hypercytokinemia associated with a poorer prognosis [56].” and have also quoted the said paper accordingly. Thank you.AttachmentResponse to reviewers comments PLOS ONE.docxSubmitted filename: Click here for additional data file. 24 Dec 2021Impact of Cytokine Storm on severity of COVID-19 disease in a private Hospital in West Jakarta Prior to VaccinationPONE-D-21-31980R1Dear Dr. Ramatillah,We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at onepress@plos.org.If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact Kind regards,Sanjay Kumar Singh Patel, Ph.D.Academic EditorPLOS ONE 31 Dec 2021PONE-D-21-31980R1 Impact of Cytokine Storm on severity of COVID-19 disease in a private Hospital in West Jakarta Prior to Vaccination Dear Dr. Ramatillah:I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. onepress@plos.org.If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact plosone@plos.org. If we can help with anything else, please email us at Thank you for submitting your work to PLOS ONE and supporting open access. 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Prunus L. collection  comprising more than 3000 accessions. NBG is also a breeding center for stone fruits, including peach (Prunus persica (L.) Batsch). In the present study a set of 85 peach cultivars bred in NBG, Europe, and North America was analyzed using 12 SSR markers to assess their genetic diversity and relatedness. The detected polymorphism level was comparable to the previous estimates of genetic variability in peach cultivars. The average number of alleles per locus was 5.67, PIC value averaged 0.49, expected, and observed heterozygosity averaged 0.52 and 0.31, respectively. Among the detected alleles, 19 (27.94%) were rare and 12 (17.65%) were unique. All studied accessions except two could be identified with the used marker set. Cluster analysis revealed some groups according to the cultivars’ pedigrees. No clear differentiation of the studied sample according to geographic origin or fruit characteristics of peach cultivars was revealed. The results provide valuable information for identification and rational management of the material preserved in the NBG peach collection.The Nikita Botanical Garden (NBG) has a unique  The Nikita Botanical Garden (NBG) located on the southern coast of Crimea has a large gene pool collection of wild growing and cultivated plants, collected over 200 years. The favorable climate and geographical position provided the creation and successful development of a unique nurseries and acclimatization point for fruit crops in NBG on the border between Asia and Europe.Prunus L. collections , presented by more than 3000 species, hybrids, landraces, cultivars, and breeding forms of local and foreign breeding. The collection comprises 624 accessions of Prunus persica (L.) Batsch including cultivars and breeding forms of local breeding and cultivars from North America, Southern Europe, Central Asia, and the Caucasus. Additionally, more than 150 accessions of nectarine and ornamental peach are presented in the NBG collection.The NBG has unique The Nikita Botanical Garden is also a breeding center for stone fruits, including peach. Although in temperate climate peach growing is limited, breeding efforts are taken to improve peach cultivars for growing in unfavorable climatic conditions. There are 58 peach cultivars in the State Register for Selection Achievements Admitted for Usage in Russian Federation, of which 43 cultivars were bred by the researchers of the Nikita Botanical Garden. In this respect, conservation, maintenance, and study of the plant material, preserved in the collection as a source of genetic diversity for breeding is of special importance.Prunus species [Microsatellites or SSR markers (Simple Sequence Repeats) based on variability of tandemly repeated DNA sequences have proved to be highly efficient for genetic diversity studies and cultivar identification in different fruit trees such as apricot , apple , almond  species ,7,8,9,10 species . The res species . Another species . Differe species ,14,15 an species , to eval species ,18,19,20 species . The molIn this study, 12 SSR markers were used to genotype 85 peach accessions from the NBG collection to assess their genetic diversity and population structure. The results will allow conserving and managing the collection more efficiently, because currently, the peach collection is being re-laid, so its genotyping is especially important.UDP97-402 and UDP98-405) to 9 (CPPCT-022) and averaged 5.67  was identified using UDP96-005, BPPCT025, and CPPCT-022 markers. Polymorphism information content (PIC) varied from 0.04 (UDP98-405) to 0.68  and averaged 0.49. The observed heterozygosity (Ho) values were not higher than 0.53 and averaged 0.31. Average value of expected heterozygosity (He) was 0.52 and varied from 0.05 (UDP98-405) to 0.73 (UDP98-022) (The number of genotypes per markers averaged 10.08. Only two genotypes were identified for P98-022) .The 12 selected SSR markers allowed the identification of 84 different genotypes among the 85 studied accessions. All the studied accessions had a unique SSR profile, except ‘Clyde Wilson’ and ‘Topaz’ which had identical fingerprints.Dice genetic similarity coefficient was calculated for each pair of studied accessions. The maximum similarity (1) was revealed for the pair of accessions which had the same set of alleles (‘Clyde Wilson’–‘Topaz’). For three pairs of accessions, Dice genetic similarity coefficient was also high (‘Gagarinskij’–‘Kosmonavt 2′ (0.97); ‘Bokser’–‘German Titov’ and ‘Krymskij Shedevr’–‘Redcap’ (0.96)). The lowest level of similarity (0.13) was found for two pairs of accessions (‘Sovetski’j–‘Zerdabi’ and ‘Bokser’–‘Zerdabi’).To elucidate genetic relationships among the studied peach cultivars the PCoA and cluster analyses were performed using the Dice similarity coefficient matrix. The result of the principal coordinate analysis is presented on The UPGMA cluster analysis grouped samples in several clusters . The firdeltaK method demonstrated that the studied accessions most likely can be divided into four groups  North American cultivars and (2) NBG cultivars. The AMOVA results showed that only 4% of the total variation occurred between these groups . DiffereST value between group of North American cultivars and group of NBG cultivars was 0.025. Pairwise FST values for groups with different fruit characteristics varied from 0.025 (between clingstone–non-melting and clingstone–melting groups) to 0.05 (between clingstone–non-melting and freestone–melting groups).Fo = 0.31.The studied sample of 85 peach accessions represented mainly by the cultivars from the Nikita Botanical Garden (32) and North America (31) was rather diverse: 68 alleles were detected with 5.67 alleles per locus and Ho (0.35 vs. 0.34) [o = 0.41 [These results are also consistent with previous studies of European and American peach germplasm, taking into account that nectarines and flat peaches were not included into our study. Microsatellites used for fingerprinting of 50 peach and nectarine cultivars detected 4.5 alleles per locus with the average heterozygosity value of 0.47 . The lats. 0.34) ,23. The s. 0.34) . Four als. 0.34) . While fo = 0.41 .Being the center of origin and domestication of peach, China has more genetically diverse peach germplasm. The study of 104 peach landraces from six Chinese geographical regions using 53 SSR markers revealed 6.4 alleles per locus, with an average PIC value 0.533 and the average genetic diversity 0.567 . In the The set of 12 SSR markers used in this study allowed detecting 84 unique genotypes among 85 accessions. Cultivars ‘Topaz’ and ‘Clyde Wilson’ derived from cultivar ‘Loring’ had identical alleles in all studied SSR loci, that may be due to the insufficient resolving power of the chosen markers, or misidentification of closely related cultivars in the collection. Still, 97.6% of the studied sample can be successfully identified using a set of 12 markers, even cultivars with common pedigree. For example, cultivars ‘Barhatistyj’ and ‘German Titov’ (‘Rochester’ × ‘Gum Kling’) had differences in two SSR loci and cultivars ‘Demerdzhinskij’, ‘Granatovyj’, and ‘Mechta’  differed in four SSR loci.CPPCT-022 was the most polymorphic and allowed to detect nine alleles. This marker has also shown a high level of polymorphism in previous studies [UDP97-402 and UDP98-405 that detected only two alleles made it possible to differentiate some accessions. Marker UDP97-402 differentiated cultivar ‘Persej’ and marker UDP98-405 differentiated cultivars ‘Kievskij Samyj Rannij’ and ‘Zheltoplodnyj Rannij’.Marker  studies ,23,24. NOn the whole, the informativeness of the selected marker set  was comparable to other studies that used larger marker sets. In the study of 195 peach genotypes from the breeding pools of the University of Florida using a set of 36 SSR markers, PIC value was practically the same as in our study and averaged 0.48 . In anotThe analysis of the obtained results with different statistical approaches revealed the genetic differentiation of cultivars ‘Gagarinskij’, ‘Kosmonavt 2’, ‘Merkurij’, ‘Rekordist’, ‘Sovetskij’, ‘Steven Christian’ (NBG), and ‘Lyubimec Krasnodara’ (NCFSCHVW). This group of cultivars was separated from other studied accessions on the PCoA plot, formed separate clusters on the dendrogram and on the Structure graph b. These Another group, that formed separate clusters on the dendrogram and on the Structure graph, included Caucasian landraces ‘Asmik’, ‘Zerdabi’ and ‘Gavazuri’, hybrid form (‘Druzhba Narodov’ × ‘Babygold-5 γ 40’) 97–120, and cultivars ‘Jerseyglo’, ‘Kievskij Samyj Rannij’, and ‘Zheltoplodnyj Rannij’ b. Most oStill, most of the detected groups were formed based on the cultivars’ pedigrees. The NBG cultivars ‘Gagarinskij’, ‘Rekordist’, ‘Steven Christian’, and ‘Sovetskij’, from a separate group mentioned above have cultivar ‘Golden Jubilee’ in their pedigree. Cultivar ‘Merkurij’, obtained by mutagenesis from ‘Sovetskij’, belongs to the same group. All cultivars derived from ‘Valiant’ × ‘Favorita Morettini’  clustered together. As well as three out of five cultivars obtained from crossing ‘Veteran × Cardinal’: ‘Yuzhnaya Garmoniya’, ‘Ulyublennyj’, and ‘Nikitskij Podarok’.p < 0.001)) of North American and European peach cultivars was demonstrated between groups of peach cultivars from different provinces of Spain and cultivars from the USA [Thus, no clear differentiation of cultivars according to their geographical origin was revealed . This is the USA . The gen the USA .ST = 0.05) were clingstone-non-melting peaches, and freestone-melting peaches. In previous studies of large collections, a differentiation between melting peaches, nectarines, and non-melting peaches was reported, with the higher polymorphism level and lower heterozygosity detected in non-melting peaches [Additionally, no significant differentiation of the studied sample by fruit characteristics including flesh type was revealed. This may be due to the high proportion of melting cultivars analyzed in our study (76 melting and 9 non-melting) and a small set of SSR markers used. Still, the number of alleles per locus for non-melting peaches was 4.08, and for melting 5.42. Comparing four groups, the most differentiated  [2, Reaction Buffer 2SO4; 67 mM Tris-HCL (pH 8.8 at 25 °C); 0.01% Tween20), 0.3 µM forward and reverse primers, and 0.5 U of BioTaq DNA polymerase . Forward primers were labeled with four different fluorescent dyes . The PCR conditions were initial denaturation for 4 min at 94 °C, followed by 34 cycles of 94 °C for 30 s, 57 °C for 40 s (except for CPPCT-022—50 °C) and 72 °C for 40 s, and a final extension of 5 min at 72 °C. All microsatellites were amplified separately and combined in multiplexes after PCR products were checked on 1.5% agarose gels in 1X TBE buffer and visualized by staining with ethidium bromide to test for the presence of PCR products.PCR reactions were performed in T100 Thermal Cycler  in a final volume of 15 µL containing 20 ng of genomic DNA, 0.2 mM each dNTP, 1.6 mM MgClFluorescently labeled PCR products were separated by capillary electrophoresis on ABI Prism 3130xl . Fragment sizes were determined using GeneMapper v4.0 software .iP and jP are the population frequency of the ith and jth allele [e) and observed (Ho) heterozygosity values of each microsatellite and frequency of rare (less than 5% of the accessions) and unique (less than 1%) alleles were calculated using the GENALEX 6.41 software [The frequencies of observed microsatellite alleles were measured using the GENALEX 6.41 software . The polh allele  in MS Exsoftware .Dice coefficient measured in PAST 3.16 software  was usedGenetic structure analysis of the collection was performed using Structure v.2.3.4 software . From 1 ST estimates for groups of accessions were calculated using GENALEX 6.41 software [Differentiation of accessions depending on geographic origin ) and fruit traits , was investigated with Analysis of Molecular Variance (AMOVA) in the GENALEX 6.41 software . The thrsoftware .


Ovarian sertoli-leydig cell tumor (OSLCT) is extremely rare. We reported a OSLCT case in whom postmenopausal vaginal bleeding was the first symptom.The patient came to our hospital due to postmenopausal vaginal bleeding.Serum tumor markers and color Doppler ultrasound for her pelvic cavity were negative. The patient was finally diagnosed with left OSLCT by pathology. It was difficult to make a definite diagnosis before operation, the diagnosis of OSLCT required postoperative pathology in the patients.the patient underwent laparoscopic hysterectomy+bilateral adnexectomy+lysis of pelvic adhesions.Postoperative laboratory examinations were normal. The patient was discharged from our hospital on the seventh day after operation and came to our hospital for follow-up check in April 2020. Physical and laboratory examinations were normal.OSLCT can show different endocrine abnormalities, which are related to the various types of tumor tissues. Missed diagnosis and misdiagnosis are likely to occur in the patients who only have elevated serum testosterone. For the menopausal women with elevated serum testosterone, ovarian tumor shoule be highly suspected after excluding adrenal gland-related diseases. It is a functional ovarian tumor, with androgen secretion, leading to virilization and de-feminization. OSLCT is mainly diagnosed by postoperative biopsy because preoperative clinical features are not marked in most OSLCT patients. According to different tissue morphologies, OSLCT is divided into high, middle, and low differentiation. At present, high-differentiated OSLCT is regarded as benign, while middle or low-differentiated OSLCT containing reticular growth pattern or heterogenic component is thought to have malignant biological behaviors.,5 There are a few reports on OSLCT due to its low incidence. In order to provide a reference for diagnosis and treatment of OSLCT, we reported a patient in whom OSLCT was incidentally found during laparoscopic hysterectomy plus bilateral adnexectomy performed for postmenopausal irregular vaginal bleeding.Ovarian sertoli-leydig cell tumor (OSLCT), a subtype of ovarian sex cord stromal cell tumor, is extremely rare and accounts for less than 0.5% of ovarian tumors.2All study methods were approved by Institutional Review Board and Ethics Committee of Hubei Maternal and Child Health Hospital. The patient reported in this study gave written inform consent to publish the case details and images.2.A 61-year-old woman, who attained menopause when she was 50 years old, was referred to our hospital on July 8th, 2019 due to 2-year intermittent vaginal bleeding. She complained of intermittent vaginal bleeding since 2017. A diagnostic curettage was performed in a local hospital. The patient said that she did not receive any further treatment in the local hospital because the diagnostic curettage displayed benign lesions. In February and October 2018, as well as June 2019, new episodes of vaginal bleeding occurred and then, the patient was referred to our service. The patient had a history of 3-year hypertension , but she had no history of diabetes. Her body mass index (BMI) was 27.6 kg/mPhysical examination showed the following: vulva inspection was unremarkable. A small amount of blood was collected in the vagina. A tumor of 3 mm × 3 mm was observed in the uterine cervix. The uterus was slightly enlarged with mobility and adnexa were not palpable.Gynecological color Doppler transvaginal ultrasound showed enlarged uterus (6.7 cm × 5.8 cm × 5.0 cm), endometrial thickness of 1.6 cm, nabothian cysts and normal bilateral appendages (the left ovary of 2.4 cm × 2.0 cm × 1.5 cm and the right ovary of 2.1 cm × 1.5 cm × 0.6 cm).Laboratory examination was as follows: results of thyroid function tests and the level of human chorionic gonadotrophin (β-HCG) were normal. Tumor markers were negative. The preoperative abnormal results of laboratory examinations and their reference values for menopause are shown in Table A hysteroscopy followed by uterine curettage was performed on July 10th, 2019. The cervical lesion and an endometrial polyp were excised. The histopathological results were as follows: endometrial polyp with endometrial typical hyperplasia, and cervical polyp. In the days following the procedure, several new episodes of vaginal bleeding occurred. A laparoscopic hysterectomy with bilateral adnexectomy and lysis of pelvic adhesions was performed on July 17th, 2019.Intraoperative findings were as follows: uterine size of 7.0 cm × 7.0 cm × 6.0 cm with smooth surface, left ovary 3.0 cm × 2.0 cm × 1.0 cm with upper part showing dark red granular aspect. Adhesion of small intestine with the proper ligament, left fallopian tube without macroscopic peculiarities was observed. Right ovary of size 3.0 cm × 2.0 cm × 1.0 cm and right fallopian tube without macroscopic peculiarities was observed. The intraoperative frozen pathology suggested possibility of left ovarian sex cord stromal tumor.Gross appearance was as follows: the left ovary of size 2.5 cm × 2 cm × 1.5 cm with gray yellow and gray white sections, and the right ovary of size 2 cm × 1.5 cm × 0.5 cm with gray white sections.Pathological diagnosis: under microscope for the left ovary, nodular structures were divided into lobes by fibrous bands, and consisted of hollow tubules and solid tubules. In tubular lining, there were sertoli cells which were columnar, round, or oval without obvious nuclear atypia and karyokinesis. In interstitium, there were clusters of highly differentiated leydig's cells containing lipids and less Reinke crystallization. Based on above findings, it was consistent with middle-differentiated OSLCT. Reticular growth pattern and heterogenic component were not found in the left ovarian lesion, and tumor embolus was also not seen in vessels Fig. . ImmunohPostoperative laboratory examinations indicated progesterone <0.050 ng/mL , testosterone <0.030 ng/mL , lactotropin of 18.17 ng/mL , estradiol of 6.64 pg/mL , luteinizing hormone of 13.60 mIU/mL , and follicle stimulating hormone (FSH) of 28.80 mIU/mL  on the fifth day after operation . Due to the favorable histopathological characteristics, no adjuvant therapy was performed. The patient was discharged from our hospital on the seventh day after operation  and came to our hospital for follow-up check in April 2020 (the time period of follow-up in 9 months). Her blood pressure was controlled within normal range  and other physical examinations were normal. Her fasting blood glucose was controlled between 5.1 and 6.7 mmol/L, and her highest postprandial blood glucose was less than 14 mmol/L under oral metformin twice a day.3 In the patient of this study, gene analysis was not performed, so it was not known whether there was abnormal gene expression.OSLCT is very rare and its pathogenesis is still unclear. It has been reported that some genes such as DICER1, STK11, and FOXL2, or somatic mutations are associated with ovarian sex cord stromal tumor.3.1 OSLCT consisted of sertoli cells, stromal cells, and fibroblasts in different proportions and different differentiating degree. Sertoli cells mainly produce estrogen and a little of progestogen and androgen, while leydig's cells mainly produce androgen and a little of progestogen and estrogen. Therefore, the clinical manifestations of OSLCT vary according to different compositions of OSLCT. A typical clinical feature is de-feminization and masculinization, suggesting that early action of androgen is mainly characterized by de-feminization such as infrequent menstruation or amenorrhea, infertility, and breast atrophy followed by masculinization such as hirsutism, clitorimegaly, and occurrence of Adam's apple. The action of estrogen is mainly characterized by female pseudoprecocious puberty, menorrhagia, menstrual disorder, or postmenopausal vaginal bleeding. Some OSLCT patients also present with abdominal pain, abdominal distension, or abdominal mass, but have no endocrine disorder-related symptoms. In this study, the patient was a 61-year-old woman with postmenopausal vaginal bleeding as the first symptom, and she also had adenomyosis, uterine adenomyoma, endometrial irregular hyperplasia, and endometrial polyps, which suggested that estrogen played a leading role in her body. However, in the patient, estrogen level was near to its normal upper limit; while testosterone level was over normal upper limit. This patient did not develop androgen-related clinical manifestations, probably because of an overexpression of aromatase P450 (CYP19A1) that converted androgen into estrogen. After operation, the estrogen level dropped sharply from 48.27 pg/mL to 6.64 pg/mL, and testosterone level from 0.720 ng/mL to 0.030 ng/mL in the patient.OSLCT is a rare female reproductive tumor and accounts for less than 0.5% of ovarian tumors. OSLCT may occur at any age from 6 months to 75 years old, but most occur at 25 years of age and less than 10% of OSLCT occur before menarche or after menopause. so it was difficult to diagnose ovarian tumor before operation.Functional ovarian tumors are commonly ovarian sex cord stromal tumors including steroid cell tumor, leydig cell tumor, granulosa cell tumor, sertoli-cell tumor, sertoli-leydig cell tumor, gonadoblastoma, and other rare metastatic ovarian tumors from endocrine tumors. In this patient, only testosterone level was over normal upper limit, but it did not reach its warning level of 6 nmol/L, Metabolic diseases such as hypertension and diabetes are common in the elderly, so it is not often considered that they are caused by ovarian tumor. Whether metabolic diseases are related to OSLCT remains to be further confirmed. It has been reported that in postmenopausal women, the elevated androgen level increases the risks for cardiovascular disease and insulin resistance, and plays a key role in metabolic syndrome. In this patient, her hormone level returned to normal after operation. It is difficult to confirm that whether her hypertension and diabetes were associated with OSLCT.Some patients with OSLCT may have metabolic diseases such as hypertension and diabetes. It was reported that a 56-year-old patient who had postmenopausal vaginal bleeding and was diagnosed with OSLCT, had a history of hypertension and type 2 diabetes.3.2 Most OSLCTs are classified as stage I and its diagnosis is mainly based on histopathology. OSLCTs are generally cystic solid mass with gray red or grayish brown sections, bleeding, and necrosis. Under microscope, OSLCT consists of sertoli cells and leydig's cells in different proportions. The sertoli cells are arranged into tubular structures, and the leydig's cells are distributed around them. According to the different tissue morphologies, OSLCT is divided into high, middle, and low differentiation, as well as reticular growth pattern and heterogenic component. It was reported that a middle-differentiated OSLCT was cystic and solid mass with smooth surface, and there was transparent yellow liquid in the cyst and papilla on the cystic wall. It is generally believed that the smaller tumor has better differentiation. For the OSLCT with atypical clinical and pathological features, immunohistochemistry is necessary. In OSLCT, sertoli cells usually express calretinin, inhibin-α, keratin, vimentin, and CD99, while leydig's cells express vimentin, inhibin-α, calretinin, and Mela-A. In this study, inhibin-α, CD99, calretinin, and Mela-A were positive. The specificity of inhibin-α is strong, and the sensitivity of calretinin is high, so inhibin-α and calretinin are usually applied together in diagnosis of OSLCT. However, OSLCT has no absolutely specific immunohistochemical markers, so immunohistochemical results only are used as a reference in diagnosis of OSLCT.OSLCTs are usually confined to unilateral ovary, and only less than 3% of the OSLCTs spread throughout the whole ovary.3.3 However, Gui et al believed that pelvic plus aortocaval lymphadenectomy was not necessary due to rare lymphatic metastasis in OSLCT. According to the clinical stages and pathological results made by Federation International of Gynecology and Obstetrics (FIGO), the patient in this study was diagnosed with stage 1A OSLCT (middle-differentiation). In the patient reported here, she was 61-year-old and menopausal and she did not have OSLCT-related high risk factors; so only hysterectomy plus bilateral adnexectomy were performed in this patient.At present, there is no standard treatment for OSLCT, surgery is still the first treatment option. The choice of operation method is based on age, fertility requirement, clinical stage, tumor size, and differentiation degree. High risk factors for SLCTs include advanced clinical stage, low differentiation, large tumor, and presence of reticular growth pattern or/and heterogenic component. For the patients who have high-differentiated OSLCT but do not require to preserve fertility, the affected ovary combined with affected-sided appendage or double-sided appendages are usually removed, or hysterectomy combined with bilateral adnexectomy is performed. The OSLCT patients with high risk factors often receive comprehensive staging operation, namely that hysterectomy + bilateral adnexectomy + appendectomy + pelvic lymphadenectomy. It is reported that clinical staging is an important indicator for OSLCT postoperative chemotherapy. The 5-year survival rate is about 95% for stage I patients and zero for stage III or IV patients. The patient in this study did not receive chemotherapy and no recurrence was found until the last follow-up .Chemotherapy is usually used in the OSLCT that has advanced clinical stage, middle or low-differentiation, active karyokinesis or/and heterogenic component; and the chemotherapy protocol  is often applied in OSLCT.4Ovarian tumors combined with endocrine changes often suggest the possibility of ovarian tumors. However, the preoperative diagnosis of OSLCT is difficult when OSLCT clinical manifestations are not obvious and the ovarian tumor is too small to be detected by imaging examinations. This study suggests that for the menopausal women with irregular vaginal bleeding, abnormal endocrine test, history of hypertension or/and diabetes, ovarian endocrine-related tumors should be highly suspected for OSCLT after excluding endometrial lesions and related endocrine diseases.Conceptualization: Jie Duan.Data curation: Li-juan Huang, Liang-yan Shi.Writing – original draft: Li-juan Huang.Writing – review & editing: Jie Duan.


People who engaged in physical activity less than twice a month learned to cycle later (M = 7.5 ± 5.3 years) than people who engaged in physical activity on a daily basis (M = 5.7 ± 2.2 years) (p < 0.001). There were also significant differences in learning age according to birth order  = 7.31, p = 0.00, ηp2 = 0.005). Only children had the highest learning age (M = 5.5 ± 2.4 years), whereas those who were born last had the lowest, (M = 5.1 ± 1.9 years) (p = 0.013). Creating opportunities for children to be engaged in play and physical activity and social modulation through their older siblings seem to be key conditions to encourage children to learn how to ride a bicycle from a young age and to foster their motor development.The present article aimed to verify whether the age at which children learn to ride a bicycle is related to their physical activity or birth order. Data were collected from an online structured survey between November 2019 and June 2020. A total of 8614 responses were obtained from 22 countries. The results reveal significant differences in learning age depending on the frequency of physical activity  = 35.12,  The concept of physical activity (PA) refers to any bodily movement produced by a muscle’s contraction that substantial increases the energy expenditure above baseline , includiAccording to Stodden’s model , good leThis new model  providesThe idea that cycle could be a factor that triggers and further promotes physical activity engagement throughout life , is corrHaving siblings is another factor that can influence children’s participation in PA and their motor development. However, there is no consensus regarding the effect of having an older sibling in the literature. Some authors claim that older brothers or sisters negatively influence younger siblings’ development, arguing that having siblings implies dividing parental attention, affecting communication opportunities and contributing to a delay in language development . On the Considering that riding a bicycle is a foundational skill and an important motor milestone for children, and taking also into account that motor development is influenced by several individual  and enviThe present study is part of the international project L2Cycle (Learning to Cycle), which aims to assess different aspects related to the process of learning how to cycle in different countries . For this purpose, a survey was created on LimeSurvey, hosted by the Faculty of Human Kinetics , and approved by its ethics committee.An initial version of the survey was developed by four motor development experts and was tested online on 485 participants, with a sub-sample of 30 participants additionally asked about their comprehension of the survey. Some adjustments were made . At a second stage, the survey was examined and discussed with five other international experts who provided further suggestions . Finally, the survey was translated into different languages, now available in 10 languages .The survey has 3 sections: (1) “About you”, questions about the participant’s (adult) personal experience of learning to cycle and demographic data; (2) “About your oldest child” (only if the participant is a mother or father), the same questions as in the previous section, but regarding the participant’s oldest child; (3) “About your youngest child” (only if participant has more than one son/daughter), the same questions as in the previous section, but regarding the participant’s youngest child.The questions of the survey regarding physical activity were as follows: “When you (your child) learned to ride a bicycle, how often did you (he/she) practice sports, outdoor play, or physical activity?” For this study, six frequencies of PA practice were considered: (1) less than twice a month, (2) twice a month, (3) once a week, (4) two or three times a week, (5) four to six times a week, (6) daily.The variable birth order had three categories: older, younger or only child. The birth order of the adults was not questioned, and for this reason it was not considered for this study.The survey was publicized through the social media , and by email. In addition, partnerships with cycling federations, kids and parent’s magazines and non-profit cycling organizations were established in different countries for dissemination on their websites and paper magazines. Data for this study were collected between 22 November 2019 and 8 June 2020. p = 0.05.Descriptive data analysis was performed to characterize the sample. One-way ANOVAs were used to determine the effects of the frequency of physical activity and birth order on learning age for cycling. Post hoc Scheffé tests were conducted when needed. The level of significance was set at There were 8614 responses to this survey. Those responses referred to 4637 adults (self-response) and 3977 children . Participants’ mean age was 29.11 years (SD = 17.7), 4975 were male, 3595 were female and 44 preferred not to disclose the sex. Data came from 22 countries: Portugal (2386), Brazil (1556), Italy (1484), Finland (991), United Kingdom (769), Mexico (463), Belgium (438), Croatia (364), Germany (63), Spain (39), USA (21), France (11), Canada (9), Norway (5), Austria (4), Japan (3), United Arab Emirates (2), Bosnia (2), New Zealand (1), Cape Verde (1), Cayman Islands (1), and Taiwan (1).p < 0.001, ηp2 = 0.24) (p < 0.001). Those who practiced 2×/month also learn later than those who practiced 4–6×/wk (p = 0.009), and daily (p = 0.001). Children who practiced once a week learn later than those who practiced 2–3×/wk (p = 0.003), 4–6×/wk (p < 0.001) and daily (p < 0.001). There was no difference in learning age between children who practiced 4–6×/wk and daily.There was a significant difference in the learning age for cycling depending on children’s frequency of physical activity practice  = 35.12,  = 0.24) . Childrep = 0.001, ηp2 = 0.005), (p = 0.004) and only children (p = 0.013). No significant differences were found between the learning age of older children and only children (p = 0.821).A significant difference in learning age was found according to birth order  = 7.31;  0.005), . Youngerp < 0.001). It seems that the relationship between learning to cycle and PA could be bidirectional. In this way, learning to cycle would promote future PA [Hulteen’s model  highlighuture PA ,19, and uture PA . When leuture PA ,28. MostPracticing PA also improves the child’s cardiorespiratory condition and muscular fitness . Some prp = 0.030, ηp2 = 0.004), whereas, in Northern Europe  = 4.40, p = 0.013, ηp2 = 0.13), younger children learned significantly earlier than only children. There were no significant differences in Latin America  = 2.67, p = 0.71, ηp2 = 0.012). Perhaps younger siblings benefit from watching the older ones and even from their help in some cases [The influence of the family, especially of the parents, in the process of learning to cycle has already been approached. Studies indicated that having parents who value cycling and promote its practice leads children to learn how to cycle earlier ,19. Howeme cases ,26. Otheme cases . Riding me cases , which ume cases , while ame cases . Finallyme cases ,35. Cleame cases , in a soThe third hypothesis, predicting that older siblings would learn to cycle earlier than only children, was not confirmed. Some studies indicate that there are reciprocal effects of sibling relationships on motor development . The ideThe present research findings reinforce the sociocultural nature of motor development, more specifically of the age from which a child learns how to cycle independently. Such a process is affected by factors, resources, properties, dispositions and constraints made available by the socioecological niche of children’s and families’ lives. Future studies should therefore consider the theoretical perspectives of motor development and task performance as a biosocial process as suggested by authors such as Bronfenbrenner and Morris  and NeweIn conclusion, the amount of physical activity that children do is related with their learning age for cycling. Children whose parents report partaking in daily physical activity learn, on average, 1.8 years earlier than those whose parents report exercising less than twice a month. It is possible that physical activity affords better balance, coordination, muscular fitness, and perceived competence, accelerating the learning age for independent cycling. Younger siblings learn earlier than older siblings and only children. The younger siblings might benefit from having an available bicycle earlier, and probably also learn by imitation and interaction with their older siblings.The fact that the amount of physical activity and birth order are related to the learning age for cycling emphasizes the importance of context constraints in motor development during early childhood.


This meta-analysis was implemented to evaluate the association between hypoxia-inducible factor-1α (HIF-1α) C1772T/G1790A polymorphisms and susceptibility to head and neck cancer (HNC).CRD42021257309). The PubMed, Embase and Web of Science databases were searched to retrieve eligible published papers. STATA software was used to calculate the pooled odds ratios (ORs) and corresponding 95% confidence intervals (CIs) to assess the correlation strength.This meta-analysis has been registered on PROSPERO platform , especially in Caucasians . Similarly, a remarkable correlation was discovered between the G1790A polymorphism and HNC risk . Moreover, in the subgroup analysis by source of controls, a statistically significant correlation was discovered in the population-based (PB) subgroup  but not in the hospital-based (HB) subgroup.Our study found that both HIF-1α C1772T and G1790A polymorphisms might be a higher risk of HNC, especially in the Caucasian group with the C1772T polymorphism.The online version contains supplementary material available at 10.1186/s12957-021-02324-0. Head and neck cancer (HNC), which includes oropharyngeal cancer, nasopharyngeal cancer, laryngeal cancer and tongue cancer, is the eighth most common cancer according to the latest data reported in the Global Cancer Statistics 2018 . AlthougHypoxia initiates a series of cellular responses, such as angiogenesis, proliferation and glucose and energy metabolism, which might result in the occurrence and development of tumours . HypoxiaHIF-1 gene polymorphisms mediate genetic predisposition to cancer, of which C1772T and G1790A are two common single nucleotide polymorphisms (SNPs) of the HIF-1 gene . Both poIn recent years, several researchers have reported the potential relationship between HIF-1α polymorphisms and susceptibility to HNC, but the results have been conflicting , 36–40. https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021257309) with the registration number CRD42021257309. We used the "PICOs" strategy to guide the development of the research question  and A(G1790A); C: C(C1772T) and G(G1790A); O: the risk of HNC; S: case–control study). The computerized literature retrieval was conducted using the PubMed, Embase and Web of Science databases to identify qualified studies with the following terms: ‘hif-1α’, or ‘hypoxia-inducible factor-1α’, or ‘hif-1’, or ‘hypoxia-inducible factor-1’, or ‘rs11549465’, or ‘C1772T’, or ‘P582S’, or ‘rs11549467’, or ‘G1790A’, or ‘A588T’ And ‘mutation’, or ‘mutations’, or ‘variants’, or ‘variant’, or ‘polymorphism’, or ‘polymorphisms’ And ‘carcinoma’, or ‘neoplasm’, or ‘tumour’, or ‘cancer’, or ‘carcinogenesis’ And ‘head and neck’, or ‘HNC’, or ‘oral’, or ‘oral cavity’, or ‘pharyngeal’, or ‘laryngeal’, or ‘laryngopharyngeal’, or ‘hypopharyngeal’, or ‘nasopharyngeal’, or ‘oropharyngeal’. The retrieval time was from database establishment to 5 November, 2020. Finally, all the included studies were carefully reviewed by the researchers (WT and BBT) to determine eligible studies, and another researcher (LL) discussed any differences.The meta-analysis was guided in strict accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement  Additio. The metLiterature that satisfied the following criteria was included: (1) case-controlled, (2) described the correlation between the polymorphisms of HIF-1α C1772T and G1790A and HNC risk, and (3) data provided by the study were available. Literature that conformed to the following criteria were not enrolled: (1) nonhuman studies, reviews, editorials, commentaries and case reports; (2) full text could not be found; and (3) no sufficient information was provided.P value of Hardy-Weinberg equilibrium (HWE) in controls. The Newcastle-Ottawa Scale (NOS) was selected for literature quality assessment, including population selection, comparability between groups, and exposure factors [The following data were retrieved: first author, publication year, country, ethnicity, genotyping methods, sources of controls, counts of case group and control group, genotype and allele frequencies for cases and controls, cancer site and  factors . The Off factors –45. DataQ test and I2 test were used for heterogeneity analysis. When P < 0.10 or I2 > 50%, we believed that there was heterogeneity among the studies, and the DerSimonian and Laird random effects model was used for analysis; otherwise, the Mantel-Haenszel fixed effect model was used for analysis. Publication bias was evaluated by Begg's test and Egger's test, and the stability of the results was evaluated by sensitivity analysis. A Z test was conducted to analyse the statistically significant results, and a P value less than 0.05 was regarded as statistically significant.STATA 11.0  was used for our meta-analysis. The strength of the correlation between HNC risk and HIF-1α C1772T/G1790A polymorphisms was assessed by ORs along with the corresponding 95% CIs. In our meta-analysis, we examined the relationship using allelic, homozygous, heterozygous, dominant and recessive genetic models. The genotyping method, ethnicity, source of control group and tumour site were used to perform subgroup analysis to determine whether certain factors were correlated with the overall ORs. Cochran's After excluding animal studies, reviews, repeated studies, conference studies and reading the full text, 7 original studies , 36–40 wAmong the 7 enrolled studies, 7 studies were ultimately correlated with the C1772T polymorphism , 36–40, The results of the meta-analysis, namely, the relationship between HIF-1α C1772T and G1790A polymorphisms and HNC, are shown in Table P > 0.05). In the subgroup analyses, we found that the C1772T polymorphism could significantly increase HNC risk in the polymerase chain reaction–restriction fragment length polymorphism (PCR-RFLP) genotyping method subgroup . Moreover, a significant relationship was discovered between the C1772T polymorphism and an increased HNC risk for Caucasians .For the HIF-1α C1772T polymorphism, a random-effects model was adopted due to the obvious heterogeneity among the studies. We evaluated the association of the C1772T polymorphism with HNC risk in all genetic models except allelic and recessive models. The overall results demonstrated that the C1772T polymorphism was significantly related to a higher HNC risk under the homozygous and recessive genetic models .For the HIF-1α G1790A polymorphism, we still applied a random effects model to count all the genetic models. We noticed a substantial relationship between the G1790A polymorphism and the increased risk of HNC for the homozygous and recessive genetic models . In the stratified analyses, a substantial relationship was observed for the PCR-RFLP genotyping method subgroup , population-based study subgroup . In addition, the shape of Begg’s funnel plot appeared to be symmetric . Table Supplementary 2. The risk of bias of included studies on the basis of the OHAT.