A 37-year-old woman presented to the Rheumatology Department with a 3-year history of arthralgia, night sweats and bilateral swollen buttocks. She described unusual levels of fatigue, memory disturbance and low-grade fevers without lymphadenopathy. She had silicone buttock augmentation 10 years earlier. Inflammatory markers, ANA, ENA, ANCA, ACE, immunoglobulins and IgG subclasses were normal; urinalysis was negative. Pelvic MRI demonstrated extensive abnormal signal change, in keeping with silicone deposition within the buttocks, and an inflammatory response extending into the gluteus maximus muscles and surrounding subcutaneous fat. Areas of reduced T2 signal suggested a secondary granulomatous reaction.There are emerging reports of autoimmune-like phenomena in patients with silicone exposure, coined ASIA syndrome (autoimmune/inflammatory syndrome induced by adjuvants) . ClinicaSilicone may cause an amplified immune response by promoting cytokine release and T-cell proliferation, reacting with mucopolysaccharides in connective tissue and causing granulomatous reactions . TherapeFunding: No funding was received from any bodies in the public, commercial or not-for-profit sectors to carry out this.Disclosure statement: The authors have declared no conflicts of interest.Data are available upon reasonable request by any qualified researchers who engage in rigorous, independent scientific research, and will be provided following review and approval of a research proposal and Statistical Analysis Plan (SAP) and execution of a Data Sharing Agreement (DSA). All data relevant to the study are included in the article.


With great interest we read the recent article by Hébert et al. on practice variations in the management of pulmonary hypertension associated with bronchopulmonary dysplasia (BPD-PH) . DespiteHébert et al. show that management of BPD-PH differs between N. American physicians of different subspecialties in several important aspects, such as timing of echocardiography and echocardiographic variables used to screen for BPD-PH . While rBesides the diagnostic approach to BPD-PH, its optimal pharmacotherapy remains challenging. Currently, as shown by Hébert et al., the most commonly used first line medication is oral sildenafil , althougThe profound practice variations among N. American physicians  illustraTo overcome some of these obstacles, we propose the establishment of multidisciplinary teams of neonatologists, cardiologists, pulmonologists, respiratory therapists, and allied health professionals that are involved early in the care of preterm infants at-risk for BPD-PH. These teams may facilitate adequate screening, treatment, and follow-up of PH in BPD infants in the first 2 years of life and beyond. A dedicated team approach has recently been shown to improve outcomes in severe BPD  and will


To evaluate a multidisciplinary inpatient treatment programme for Functional Neurological Disorder (FND) and Non-Epileptic Attack Disorder (NEAD), focussing on clinical effectiveness and patient experience. To produce recommendations for service development and future evaluation.We conducted a service evaluation of the multidisciplinary inpatient programme for FND and NEAD at the Rosa Burden Centre. We contacted all inpatients discharged between December 2019 and March 2020 via telephone in August/September 2020. Quantitative outcomes were gathered on quality of life and psychological distress using the EQ-5D-5L and Core10 tools. Scores were compared to those gathered routinely at admission and discharge, using Wilcoxon's test for differences. Qualitative feedback on patient experience was gathered using open-ended prompts, and thematic analysis of this data was conducted independently by two researchers. Approval was gained from Southmead Clinical Audit Department (CE10237).19 of 22 patients successfully completed the service evaluation. Quantitative results tended toward improvement on all measures between admission and discharge. Following discharge, there was a mixed pattern - sustained improvement in overall quality of life, but regression in other scores. Improvement in overall quality of life between admission and follow-up was statistically significant . Changes in psychological distress (Core10) were also statistically significant, reducing between admission and discharge  and increasing between discharge and follow-up . Changes in other scores were not statistically significant at the p < 0.05 level. Qualitative results highlighted the value of the individual therapies offered, the multidisciplinary approach, and the supportive environment. Participants reported improved understanding of their diagnosis, and of self-management strategies. There was demand for greater access to psychological therapies, and increased provision of follow-up post-discharge. Some expressed dissatisfaction with the ward round format and excess “down-time”. The programme was described as a “turning point” for 9 participants.Quantitative results suggest the programme is associated with global improvement in quality of life, and post-discharge, some benefits are sustained while others are transient. However, interpretation is limited by sample size. We recommend further evaluation with a larger sample to replicate findings, assess effect sizes, and assess which patients or symptoms benefit most. To support this, we recommend improved collection of outcome measures, including routine collection of follow-up data. Positive qualitative findings highlight the strengths of the service and its value to patients. Recommendations for service development include recruiting a psychologist to provide further psychological therapy sessions; expanding the nurse-led follow-up service; and adjustments to the ward round format and activity programme.


We examined the associations of individual and regional-level perceived stress and depression with health-related quality of life (HRQOL) in Korean adults.We used data from the 2017 Korea Community Health Survey, which included 216,713 adults living within 254 municipal districts. As individual-level independent variables, perceived stress (higher vs. lower) and depression  were defined. Regional-level age-adjusted rates of perceived stress (%) and depression (%) were created for 254 municipal districts and categorized into quartiles to generate regional levels of stress and depression. HRQOL was defined as the individual-level EuroQol 5-dimensional index×100. A multilevel analysis was performed to identify the relationship between individual or regional-level independent variables and individual HRQOL.In the null model, the proportions of individual variation in the HRQOL explained by region were 1.7% and 2.7% for men and women, respectively. When adjusted with all individual-level variables, regional stress and depression, as well as individual-level perceived stress and depression, were significantly related to HRQOL for both genders. In the full model including all variables, the decrease in HRQOL from the first to the fourth quartile group of regional stress was greater in women  than in men .Our results suggest that regional-level perceived stress and depression, as well as individual-level perceived stress and depression, are inversely associated with individual HRQOL. Health status can be described in terms of self-rated health (SRH) or health-related quality of life (HRQOL), which are assessed using survey questionnaires -3. HRQOLWithin regional populations, health can be influenced by both individual-level and area-level factors -9. IndivWhile health outcomes occur at the individual-level, a large proportion of their determinants is usually present at upstream levels that are contextual . When pePsychological factors such as perceived stress and depression are also important health determinants at both population and individual levels -16. The Cohen et al.  proposedA negative correlation between perceived stress -24 or deWe attempted to examine the associations of individual and regional-level perceived stress and depression with individual HRQOL using a multilevel model. To this end, we used data from the Korea Community Health Survey (KCHS) , becausehttp://chs.cdc.go.kr/).We used data collected in the 2017 KCHS from 228,381 individuals  living within 254 municipal districts. We excluded 11,668 individuals due to missing data on psychological variables (perceived stress and depression) (n= 852), HRQOL (n= 30), and covariates . Thus, the final study sample included 216,713 subjects . Individual-level raw data without personally identifiable information were obtained from the KCHS website .PHQ-9 is a self-reporting test designed as a simple screening tool for depression and its severity . The tes2) and converted into 4 categories according to World Health Organization (WHO) Asian classifications [2), normal (18.5-22.9 kg/m2), overweight (23.0-24.9 kg/m2), or obese (≥ 25.0 kg/m2). The normal-weight group was used as a reference group.Individual-level KCHS covariates included age (years), body mass index (BMI), marital status , education , monthly household income , residential area , current smoking, high-risk drinking, physical activity  , and diaications  as underWe compared general characteristics between genders in terms of frequency (%) or mean± standard deviation (SD) using the chi-square test or Student t-test. A multilevel analysis was performed to identify the relationship between individual-level or regionallevel psychological factors and individual HRQOL. Since the KCHS contains complex sample survey data, the multilevel analysis was performed by applying the sample weights. This analysis was conducted after subjects were stratified into men and women due to differences in test results according to gender. The intraclass correlation (ICC) was measured as follows: ICC= /. All statistical analyses were performed using Stata version 14.0 , and statistical significance was evaluated at a level of p-value < 0.05.The Institutional Review Board (IRB) of Chungnam National University exempted this study from ethical review (IRB No. 201910-SB-176-01).Men and women showed significantly different distributions of covariates such as BMI, marital status, education, household income, residential area, current smoking, high-risk drinking, physical activity, and diagnosed hypertension, diabetes, or arthritis. Women were more likely to be divorced or widowed, less educated (a higher percentage of those with less than a middle-school education), and to have lower household incomes (a higher percentage of those with an income less than 1.00 million KRW) than men. There were substantial differences in current smoking and high-risk drinking rates between men and women. Men were more likely to be current smokers and high-risk drinkers than women. Men had a higher rate of physical activity than women, while their prevalence of overweight or obesity was higher than that of women. Men had a higher prevalence of diabetes and a lower prevalence of arthritis than women. The gender differences in the urban residence rate and the prevalence of hypertension were only about 1% each .Factors related to EQ-5D for men and women according to the weighted multilevel model results are shown in In the full model, all covariates except residential area  were significantly associated with HRQOL in both men and women. Aging, underweight or obesity, and divorced or never married states were associated with lower HRQOL; higher education and household income levels were associated with higher HRQOL; high-risk drinking and physical activity were associated with higher HRQOL; smoking was associated with higher HRQOL in men, but lower HRQOL in women; and chronic diseases including hypertension, diabetes, and arthritis were associated with lower HRQOL.In models I, II, and III, as well as in the full model, individual-level perceived stress and depression were significantly related to HRQOL in both men and women. Higher perceived stress and depression were associated with lower HRQOL. Regional stress in model II and regional depression in model III were also significant factors in both men and women. In the full model, regional stress was also a significant factor, whereas regional depression was not. Higher regional stress levels were associated with lower HRQOL in both men and women. The decrease in HRQOL from the first to the fourth quartiles of regional stress was greater in women  than in men . When compared to model II, the absolute value of regression coefficient of regional stress (first to fourth quartiles) on HRQOL attenuated by 14.0% and 5.4% in men and women, respectively, in the full model .This study examined the associations of individual and regional-level perceived stress and depression with individual HRQOL measured in terms of the EQ-5D using a multilevel model. The ICCs calculated by the null model indicated regional variation in HRQOL among municipal districts, with greater variation among women than among men. Regional variation in HRQOL was mainly explained by individual-level variables according to the results of model I. Individual-level perceived stress and depression were significantly related to individual HRQOL. Regional stress and depression were also significant factors and both had greater negative impacts on HRQOL among women than among men.The ICC of the null model (0.017 in men and 0.027 in women) in this study implies that the contribution of regional-level factors to HRQOL is relatively small. However, the small ICC does not mean that it is not worthwhile to investigate the effects of regional factors on individual-level HRQOL . AlthougCompared to those with lower perceived stress and depression states at the individual-level, those with higher states had decreased HRQOL in this study, consistent with previous studies -27 that In this study, the decrease in HRQOL from the first to the fourth quartiles of regional stress was greater in women than in men, perhaps due to gender differences in vulnerability, coping strategies, and social support -43. WomeThe application of a multilevel analysis model in this study allowed us to simultaneously examine the effects of individual-level and regional-level indicators of psychological factors. Previous studies have often evaluated health levels using a single self-rated question ,24,26,45This study had some limitations. First, since this was a cross-sectional study, the relationship between psychological factors and HRQOL cannot be confirmed as causal; a further longitudinal study is required.Second, because the perceived stress variable of the KCHS was evaluated using only 1 question, we have no direct information on its reliability. However, perceived stress has been found to have stable relationships with socio-demographic characteristics, health behaviors, and chronic disease in several studies that have used KCHS data ,47, so iFinally, without using directly measured environmental demands, we used only regional-level percentages derived from individual perceived stress or depression levels. To understand the role of regional psychological factors on individual HRQOL more fully, contextual variables that reflect environmental demands should be added to future analytical models.In conclusion, our results indicate that regional stress and depression, as well as individual stress and depression, are inversely associated with individual HRQOL in both genders. Future research should consider the territorial characteristics of municipalities to identify the specific environmental demands that account for regional stress levels.


Transcranial direct current stimulation (tDCS) can improve cognitive function. However, it is not clear how high-definition tDCS (HD-tDCS) regulates the cognitive function and its neural mechanism, especially in individuals with mild cognitive impairment (MCI). This study aimed to examine whether HD-tDCS can modulate cognitive function in individuals with MCI and to determine whether the potential variety is related to spontaneous brain activity changes recorded by resting-state functional magnetic resonance imaging (rs-fMRI). Forty-three individuals with MCI were randomly assigned to receive either 10 HD-tDCS sessions or 10 sham sessions to the left dorsolateral prefrontal cortex (L-DLPFC). The fractional amplitude of low-frequency fluctuation (fALFF) and the regional homogeneity (ReHo) was computed using rs-fMRI data from all participants. The results showed that the fALFF and ReHo values changed in multiple areas following HD-tDCS. Brain regions with significant decreases in fALFF values include the Insula R, Precuneus R, Thalamus L, and Parietal Sup R, while the Temporal Inf R, Fusiform L, Occipital Sup L, Calcarine R, and Angular R showed significantly increased in their fALFF values. The brain regions with significant increases in ReHo values include the Temporal Inf R, Putamen L, Frontal Mid L, Precentral R, Frontal Sup Medial L, Frontal Sup R, and Precentral L. We found that HD-tDCS can alter the intensity and synchrony of brain activity, and our results indicate that fALFF and ReHo analysis are sensitive indicators for the detection of HD-tDCS during spontaneous brain activity. Interestingly, HD-tDCS increases the ReHo values of multiple brain regions, which may be related to the underlying mechanism of its clinical effects, these may also be related to a potential compensation mechanism involving the mobilization of more regions to complete a function following a functional decline. Mild cognitive impairment (MCI) refers to the clinical state of a person who suffers from a deficit but otherwise functions normally and does not meet the diagnostic criteria for dementia . MCI is Non-invasive stimulation techniques include transcranial magnetic stimulation, tDCS, transcranial alternating current stimulation, transcranial pulse stimulation, and transcranial ultrasound stimulation. These techniques have been used by researchers as interventions to ameliorate memory deficits . CompareA previous study has shown that anodal-tDCS improved age-related cognitive deficits . Thus, tNeuroimaging technology can identify abnormalities in brain structure and function earlier than functional deficits can be detected , 31. ThefALFF is used to measure the spontaneous fluctuation amplitude of bold-fMRI signal intensity in a given area of the brain, reflecting the level of spontaneous activity of each voxel in the resting state , 38. ReHThe current study aimed to explore the effect of repeated anodal HD-tDCS on cognitive function by analyzing the data collected from neuropsychological tests and rs-fMRI data in individuals with MCI. We hypothesized that 1) repeated anodal HD-tDCS causes changes in the resting state of the brain. 2) alterations in spontaneous brain activity are associated with cognitive performance.This study was approved by the Medical Ethics Committee of Xijing Hospital Affiliated with the Air Force Military Medical University. All procedures were performed in accordance with the Declaration of Helsinki and registered at ClinicalTrials.gov (ChiCTR2000036603). Participants were included only after informed consent was obtained after explaining the study procedures in detail.We recruited the participants through two channels: outpatients of the Xijing Hospital and other participants through an advertised recruitment program from January 2016 to December 2018, the age of participants ranged from 55 to 85 years. Individuals with MCI were diagnosed based on criteria by Petersen et al.  who defiWe initially recruited forty-eight individuals with MCI, the patients were randomly assigned to an anodal HD-tDCS group and a sham group according to a computer-generated randomization list. Three participants were excluded due to not completing the entire trial, and two participants were excluded due to excessive head movements during the scan (head movements > 3 mm or > 3°), the other individuals with MCI were included in the final analysis. None of the participants received any medications that could affect their cognition functions.All participants underwent a series of neuropsychological tests at baseline and after the stimulation. The series of standardized neuropsychological tests included the MMSE, Montreal Cognitive Assessment (MoCA). All clinical evaluations were double-blinded.A battery-powered constant-current direct current stimulator  was used to deliver 1mA HD-tDCS in each intervention. Participants in the HD-tDCS group received HD-tDCS in the L-DLPFC. To stimulate the L-DLPFC, the anode electrode was placed over F3 according to the 10–20 international system for EEG electrode placement, surrounded by four cathodes at a radius of 3 cm, with high-definition mini electrodes , 19, witAll participants were imaged with a 3-Tesla MRI system  at the Department of Radiology of Xijing Hospital, Air Force Medical University, Xi’an, China. Before imaging, participants were asked to keep their eyes closed and relaxed, stay awake and move as little as possible during the imaging. A standard birdcage head coil was used, and restraint foam pads were used to minimize head movement and reduce scanner noise. The resting-state functional images were obtained using a gradient-echo planar imaging sequence with the following parameters: repetition time (TR) = 2000ms, echo time (TE) = 30ms, image matrix = 64×64, slice thickness = 3.5mm, flip angle (FA) = 90°, field of view (FOV) = 240mm×240mm, layers = 45. Three-dimensional (3D) anatomical data were acquired using a 3D Bravo T1-weighted sequence equipped with an eight-channel receiver head coil, with the following parameters: repetition time = 8.2 ms, echo time = 3.2 ms, field of view (FOV) = 240 mm×240 mm, slice thickness = 1 mm, resolution = 256×256×256.Data preprocessing was conducted using the Data Processing Assistant for Resting-State fMRI (DPARSF) toolbox , which bThe fALFF provides information on the magnitude of brain activity of each brain region within a network of interest. It represents the ratio of the fluctuation of the BOLD signal in the low-frequency range to the entire frequency range . CalculaReHo analysis was performed using the DPARSF toolbox . Accordihttp://www.fil.ion.ucl.ac.uk/spm).Statistical analysis was performed using SPSS software version 16.0  for demographic and clinical data, and fMRI data’s statistical analysis was performed using SPM12  toolbox [t-test to explore the differences in each group before and after the sessions. These voxels were regarded as regions of interest, showing significant differences between the two groups. The intervention effect of HD-tDCS was calculated by conducting a repeated-measures analysis of variance (ANOVA) on the neuropsychological test scores. Condition (HD-tDCS vs. sham stimulation) was taken up as a between-subject factor and time (before vs. after sessions) as a within-subject factor. After statistical results were obtained, a multiple comparison correction was performed with Gaussian random field correction (GRF) . The specific anatomical positions of the brain regions with statistical significance on the corresponding MNI coordinates were determined using the viewer tool within the REST software. The voxels of different brain regions were obtained, and the results were presented using REST software.For fMRI data, a two-sample  toolbox . . ReHo and fALFF values were subsequently extracted from these seed regions within each participant, and Pearson correlations were calculated to measure the association between the group mean ReHo and fALFF values within ROIs and MoCA, as well as MMSE scores at P< 0.05, Bonferroni corrected.The groups did not differ in gender, age, years of education, MMSE, and MoCA scores. Forty-three participants were included in the final analysis, including twenty-four in the HD-tDCS group and nineteen in the sham group. The demographic characteristics of the participants are presented in There is no significant difference before and after HD-tDCS stimulation in the MMSE scores and the MoCA scores. Similarly, there is no significant difference before and after sham stimulation in the MMSE scores and the MoCA scores. The results are shown in The significant differences in fALFF between the post-HD-tDCS group and post-sham stimulation group, pre-HD-tDCS group and post-HD-tDCS group, pre-sham group, and post-sham group are summarized in Using mixed effect analysis, it was found that the HD-tDCS group and sham groups had opposite directions for fALFF value regulation in the Middle Temporal Gyrus, Cerebellum, and Supp Motor Area positions, as shown in Significant differences in ReHo between the post-HD-tDCS group and post-sham group, pre-HD-tDCS group and post-HD-tDCS group, pre-sham group, and post-sham group are summarized in In putamen and supramarginal, the HD-tDCS group and sham groups had opposite directions for ReHo value regulation, as shown in In summary, in the present study, we found a unique pattern of brain activity alterations in individuals with MCI. The fALFF values of HD-tDCS participants showed decreased in the Insula R, Precuneus R, Parietal sup R, and Thalamus L areas, whereas these values increased in the Fusiform L, Occipital Sup L, Calcarine R, and Angular R regions. Interestingly, after repeated HD-tDCS, the ReHo values increased in multiple areas, such as the Putamen L, Frontal Mid L, Precentral R, Frontal Sup Medial L, Frontal Sup R, and Precentral regions.No significant correlations were found between fALFF or ReHo values and MMSE or MoCA scores between the two groups.In this study, we examined the changes of fALFF and ReHo in individuals with MCI after HD-tDCS or sham stimulation. We found that several brain regions showed significant differences in terms of their fALFF and ReHo values. We focused on the effect of HD-tDCS, so we paid special attention to the changes before and after HD-tDCS. Compared with the pre-HD-tDCS group, the post-HD-tDCS group had increased fALFF and ReHo values in the Temporal Inf region. Decreased fALFF values in the Insula R, Precuneus R, Parietal Sup R, and Thalamus L region, as well as increased fALFF in the Fusiform L, Occipital Sup L, Calcarine R, and Angular R regions were observed. Interestingly, after repeated HD-tDCS, the ReHo values increased in multiple areas such as the Putamen L, Frontal Mid L, Precentral R, Frontal Sup Medial L, Frontal Sup R, and Precentral.Using fALFF and ReHo measures, this study explored the effect of repeated HD-tDCS on individuals with MCI. These two methods are based on different neurophysiological mechanisms, with ALFF demonstrating neural intensity and ReHo demonstrating the coherence of neural activity regardless of intensity. fALFF has been used as an alternative indicator of the intensity of spontaneous nerve activity and as a biomarker for neurological disorders. The ReHo analysis showed the consistency of the time series of activities in different regions, fALFF and ReHo are complementary to each other in depicting regional spontaneous neural activity and provide different perspectives in understanding the impact of HD-tDCS on individuals with MCI.The area where both fALFF and ReHo values increased after HD-tDCS were located in the Temporal Inf R. The coexisting change in functional intensity and activity coherence in the region might represent more obvious functional changes in brain areas than those reflected by only one of these two methods . The incDecreased fALFF values were observed in Parietal Sup R, Precuneus R, Insula R, and Thalamus L after HD-tDCS. The Parietal Sup R and Precuneus R make up a component of the default mode network (DMN). Decreased fALFF values in these regions indicated that HD-tDCS allow brain activity that is resting to transition into the task state more easily . One stuThe Insula R is a very important node of the salience network (SAN), the increases in fALFF seen in this region will result in negative interpretations of external events. HD-tDCS causes the fALFF value of the Insula R to decrease, which may reduce the negative interpretations of events. This, in turn, helps improve the symptoms of depression in individuals with MCI . The InsIncreased fALFF values were observed in Occipital Sup L, Fusiform L, Temporal Inf R, Calcarine R, and Angular R regions following HD-tDCS. Increased fALFF of Occipital Sup L and Fusiform L regions is more conducive to recognize external visual information, especially facial recognition abilities, considering that the fusiform gyrus is related to facial recognition abilities. Studies have shown that the activation of the fusiform gyrus is higher when attractive faces were seen , 61. It The influence of HD-tDCS on brain areas is particularly prominent in the three parts of the Middle Temporal Gyrus, Cerebellum, and Supp Motor Area. In the Middle Temporal Gyrus, HD-tDCS activated the spontaneous activity of the local brain. We speculate that HD-tDCS can help patients transition from the default mode network in the resting state to the task-executing network. In the Cerebellum, HD-tDCS activates the spontaneous activity of the brain, and activation of the cerebellum is related to the cognitive circuit, which can help participants to complete tasks well , 65. TheSurprisingly, in this study, ReHo values significantly increased after HD-tDCS in multiple regions. We found increased ReHo values in the Temporal Inf R, Precentral R, Frontal Sup R, Precentral L, Putamen L, Frontal Mid L, and Frontal Sup Medial L regions.The ReHo value reflects the level of functional consistency between a given voxel and its nearest neighbors. It can be used to assess brain activity in a static state and to reveal the complexity of human brain functions. Both the reductions and increases in ReHo values represent abnormal changes in brain activity and indicate different phenomena. Decreased ReHo values indicate that the cerebral blood flow in some areas is reduced, and the change in regional metabolic rate is reduced, as shown in previous studies in individuals with MCI –70. IncrKang et al. found that individuals with MCI had higher ReHo values in the Bilateral Putamen Region, Posterior Central Gyrus, and left Middle Cingulate Gyrus compared to healthy controls . IncreasHD-tDCS has the potential to modulate the neurophysiological components of impulsivity . A studyOur findings indicate that HD-tDCS alters brain activity and affects the resting brain network. Studies have investigated the effects of repeated tDCS combined with cognitive training, suggesting that tDCS effects may not always be additive in memory rehabilitation programs . In summNo significant correlations were found between ReHo or fALFF values and MMSE or MoCA scores among the two groups. The reason for this could be as follows: First, the duration of HD-tDCS is not sufficient. A recent study suggested that repeated anodal-tDCS (10 sessions) induces cumulative effects on the cognitive performance of patients with brain injury, and significant superiority in the anodal-tDCS group appeared after two weeks or one month after the end of the stimulation, which may reflect the difference seen in this study . Second,Our study has several limitations. First, the sample size was small, and a small sample size can lead to statistical errors. More studies with a larger sample size should be undertaken in the future. Second, our functional MRI data were not evaluated with biochemical indicators. If combined with biochemical indicators, the impact of HD-tDCS on brain activity may be more clearly revealed. Third, during HD-tDCS, the task-state fMRI data could not be collected and analyzed. We only analyzed the resting-state functional MRI data. If this data were combined with the fMRI changes in the task state, we could better understand how HD-tDCS affects the internal activities of the brain. Fourth, the cognitive assessment scale was relatively simple. It would be easier for us to observe the effects of HD-tDCS on cognitive behavior if we used a more accurate scale for assessing cognitive function.In summary, the present study demonstrated that repeated HD-tDCS modulates functional brain activity not only in the area close to the stimulation site but also in more remote areas. In this study, we used fALFF and ReHo to measure the brain’s functional activity and found alterations in related brain regions. More specifically, the altered fALFF and ReHo indices were located in the key nodes of the default mode network and the right frontal-parietal network. This finding may indicate that HD-tDCS lowers the default mode network and activates the right frontal-parietal network. These regions help participants selectively respond to external stimulation and perform tasks they are interested in. These findings add to our understanding of the mechanism of action of HD-tDCS, specifically in terms of HD-tDCS affecting resting brain network indicators. Interestingly, HD-tDCS increased the ReHo values of multiple brain regions, which may be related to the underlying mechanism of its clinical effects, and may be related to a potential compensation mechanism involving mobilizing more regions to complete a function after the function declines.


OBJECTIVES/GOALS: Studying IPF associated health care utilization (HRU) in real world settings, provides the opportunity to produce generalizable results that can directly inform models of care delivery. The objective of this study was to examine real-world differences in the natural history of annual HRU and treatment trends associated with IPF in a large, community-based population of patients with IPF, compared to matched non-IPF controls. METHODS/STUDY POPULATION: Cases of IPF were identified using case validated algorithms in the Kaiser Permanente Northern California adult population from 2000 to 2014. Each case was matched to at least one and no more than five non-IPF controls by age, sex, race/ethnicity and length of enrollment. The date of the first occurrence of the IPF-specific diagnostic code was considered the index date for cases and matched controls. Comorbidity burden and HRU was assessed in the five years pre- and post-index date, including hospitalizations, outpatient visits, use of diagnostic and monitoring studies and medications. Poisson generalized estimating equations models with robust standard errors were used to estimate adjusted case-control differences in HRU, accounting for clustering within matched sets. RESULTS/ANTICIPATED RESULTS: 691 patients were identified with incident IPF during the study period and matched to 3,452 control subjects. Demographics were well balanced between cases and controls due to matching. Patients with IPF had a higher burden of all selected co-morbidities and higher HRU compared to controls. In the pre-index period, IPF members had significantly higher rates of all diagnostic procedures (p < 0.001) and health care visits, with the exception of skilled nursing facility care (p < 0.001). The greatest relative difference was observed with use of Chest CT . In the post-index period compared to controls, patients with IPF had higher rates of serial testing (p < 0.001) and inpatient and outpatient care including, all-cause hospitalization (1.55), emergency room visits (1.19), outpatient visits (1.18), and skilled nursing facility stay (1.35). DISCUSSION/SIGNIFICANCE OF IMPACT: Patients with idiopathic pulmonary fibrosis experience increased co-morbidity and healthcare resource utilization compared to controls. This increased burden extends beyond the index-period as previously documented and is true for a large real-world cohort. CONFLICT OF INTEREST DESCRIPTION: NA


The interaction between plants and pathogenic microorganisms is a multifaceted process mediated by both plant- and pathogen-derived molecules, including proteins, metabolites, and lipids. Large-scale proteome analysis can quantify the dynamics of proteins, biological pathways, and posttranslational modifications (PTMs) involved in the plant–pathogen interaction. Mass spectrometry (MS)-based proteomics has become the preferred method for characterizing proteins at the proteome and sub-proteome  levels. MS-based proteomics can reveal changes in the quantitative state of a proteome and provide a foundation for understanding the mechanisms involved in plant–pathogen interactions. This review is intended as a primer for biologists that may be unfamiliar with the diverse range of methodology for MS-based shotgun proteomics, with a focus on techniques that have been used to investigate plant–pathogen interactions. We provide a summary of the essential steps required for shotgun proteomic studies of plants, pathogens and plant–pathogen interactions, including methods for protein digestion, identification, separation, and quantification. Finally, we discuss how protein PTMs may directly participate in the interaction between a pathogen and its host plant. As a multifaceted process, plant–pathogen interactions have been extensively researched from both the pathogen and plant viewpoints. Plants are surrounded by many microorganisms, some of which can cause diseases and lead to negative impacts on yield, quality, and value . PathogeProteomics is defined as the large-scale study of different proteins expressed by an organism  and has An efficient sample preparation method for obtaining high-quality peptides for proteomic analysis of pathogens and plants represents a greater challenge than most other cell/tissue types . Plant t2+ and 10 mM of phytate was used to precipitate Rubisco from soybean leaf protein extract [Protein extraction is one of the most critical steps in proteome analysis studies . The ide extract . This tePlant and pathogen proteomics has currently moved from gel-based methods to gel-free shotgun (bottom-up) approaches ,42,43. SSpongospora subterranea, the S-Trap method delivered a higher number of protein identifications with an improved reproducibility compared to the SP3 method [The selection of sample preparation method is highly dependent on tissue type, and no sample preparation method has been found to be applicable for all sample types. For example, Mikulášek et al.  showed t3 method ,62. There are many options for MS-based proteomics, and decisions on what approaches to use are influenced by the equipment and expertise available as well as the specific research questions . An untaFusarium crown rot resistance in wheat. A total of 9234 proteins were identified, including proteins associated with defense, photosynthesis, and cell wall formation. Mass spectrometry using data-dependent acquisition (DDA) and, increasingly, data-independent acquisition (DIA) approaches have dominated the methodology for untargeted proteomics . In DDA 15N. Zhang et al. [Proteomic approaches can also be classified as label-based or label-free, which both have their own sets of strengths and limitations . For intg et al.  later usg et al. , pathogeg et al. , and plag et al. . One of g et al. . In labeg et al. ,93. Sampg et al.  and can g et al. . In contS. subterranea in resistant and susceptible potato cultivars [Spongospora–potato interaction. The interaction between barley and Pyrenophora teres was also studied using DIA-MS [Pseudomonas syringae were identified using DIA-MS [Phytophthora infestans. Among the changed proteins, several were involved in plant defense responses, metabolic pathways, and signaling. The effect of Funneliformis mosseae in soybean roots was investigated using a transcriptomic and proteomic (DDA-MS) analysis. A total of 9488 proteins were identified, and the key pathways and differentially abundance proteins were involved in plant–pathogen interaction, phenylalanine metabolism, hormone signal transduction, and metabolic pathways [Peyronellaea pinodes, causing Ascochyta blight, were identified. This study revealed the importance of plant cell walls to hinder the growth of the pathogen within cells and redox response for the detoxification of fungal toxins [Several recent studies have employed DIA approaches for the analysis of the interaction between pathogens and their host plants. A DIA-MS workflow was used to profile the proteome of ultivars . The fing DIA-MS . Over 10g DIA-MS . More thg DIA-MS . The sigg DIA-MS  employedpathways . Using al toxins . Kerr etl toxins  used DIAAll living organisms need to respond to environmental changes quickly and efficiently using a strict regulatory system through molecular interactions of hundreds to thousands of biomolecules . Due to 2) phosphopeptide enrichment, electrostatic repulsion hydrophilic interaction chromatography (ERLIC), and phosphopeptide precipitation [Verticillium dahliae infection identified 92 and 38 specific phosphoproteins in the resistant and susceptible lines, respectively [Similar to proteomics, a phosphopeptide analysis workflow starts with protein extraction and digestion . Phosphopitation ,118,119.pitation ,120. Quapitation . Phosphoectively . Cochliobolus carbonum infection confirmed the hyperacetylation of several proteins, including chromatin remodeling enzymes and transcription factors [In addition to phosphorylation, large-scale profiling of other PTMs such as acetylation and ubiquitination during plant–pathogen interactions is becoming more common. In rice ,124 and  factors . Althoug factors ,131,132.p-value histograms. In addition to the technical advance in proteomics data analysis software, specific bioinformatics tools have been developed to study the relationships between plants and pathogens. For example, PhytoPath, which is a database on plant–pathogen interactions, provides genome-scale data from pathogens with information about plant infection phenotypes. To date, this database includes the genome information of 99 plants, 107 pathogens, and 350 interactions. The access to the complete assembly of genome and gene models of phytopathogens in PhytoPath gained using the Ensembl Genomes browser [Molecular research routinely involves the application of computational methods to convert raw experimental data into condensed results for biological interpretation. In recent years, several software packages and online platforms have been developed to facilitate the analysis, interpretation, and visualization of proteomics data. The MaxQuant/Perseus platform is a user-friendly, interactive workflow environment and can provide complete documentation of computational methods, and has become one of the most popular software suites for biological interpretation of protein quantification, interaction, and PTM data . Relativ browser . NIASGBd browser .Data sharing in MS-based proteomics is becoming a standard for proteomics researchers. However, any proteomics data set is only partially understood according to the availability of the currently available analytical tools . Therefore, there is an excellent opportunity for re-analyzing and reusing public data, particularly for benchmarking studies and evaluation of new bioinformatics software. While the majority of publicly available data sets correspond to human and other main model organisms, there has been a rapid expansion in proteomic datasets for non-model organisms in recent years . The firIn summary, recent advances in MS-based proteomics and bioinformatics tools now enable the robust profiling of plant and pathogenic microbe samples to an unprecedented depth. Global proteome profiling using shotgun approaches during infection can identify specific proteins, molecular functions, and PTMs involved in plant disease resistance and susceptibility and pathogenicity processes. Therefore, proteomics will remain one of the fastest-growing areas in plant and pathogen research. Increasingly, studies that use “omics” technologies in combination (multi-omics approaches) enable cross-validation of data sets and the ability to filter out the most significant biological changes. Integration of shotgun proteomics with other omics approaches will further expand our understanding of biological mechanisms involved in host–pathogen interactions. Proteomics analysis of mixtures containing different cell populations only provides a quantitative analysis of proteins that reflect the average variation in the whole cell population. Thus, the molecular changes in distinct subpopulations of rare cells will be missed in bulk sampling methods . TechniqIn addition, cross-linking mass spectrometry (XL-MS) has recently emerged to study protein interactomics on the system-wide level . XL-MS i


Introduction: Outcomes of laparoscopic procedures for gastroesophageal reflux disease (GERD) are variable depending on surgical expertise and/or patient-related factors. Some procedures may be inadequate in patients with severe disease. Effectiveness of laparoscopic magnetic sphincter augmentation (MSA) has not been extensively tested in patients with severe disease.Methods: A prospectively collected database was analyzed to identify patients who underwent MSA at a single institution. Individuals who had previous esophago-gastric surgery were excluded. Severe GERD was defined as lower esophageal sphincter pressure <5 mmHg, distal esophageal amplitude <30 mmHg, Barrett's metaplasia, stricture or grade C-D esophagitis, and/or DeMeester score >50. Clinical characteristics and outcomes of patients with severe GERD were compared with those of patients with mild to moderate GERD who served as control group.Results: Over the study period, a total of 336 patients met the inclusion criteria, and 102 (30.4%) had severe GERD. The median follow-up was 24 months (IQR = 75) in severe GERD patients and 32 months (IQR = 84) in those with non-severe GERD. Patients with severe GERD had a higher rate of dysphagia and higher GERD-HRQL scores. After the MSA procedure, symptoms, health-related quality of life scores, and proton-pump inhibitors consumption significantly decreased in both groups (p < 0.05). No difference between groups was found in the prevalence of severe post-operative dysphagia, the need for endoscopic dilation or device removal, and the DeMeester score.Conclusion: Laparoscopic MSA is safe and effective in reducing symptoms, PPI use, and esophageal acid exposure also in patients with severe GERD. The pooled prevalence of gastro-esophageal reflux disease (GERD) is 14%, with more than 1 billion of individuals affected and an enormous economic burden on health-care systems around the world –4. MagnePre-operative indicators of GERD severity have previously been defined based on manometric, pH-monitoring, and endoscopic findings that may predict failure of a partial fundoplication. Of note, the pre-operative DeMeester pH score showed 86% sensitivity for predicting surgical failure . Aim of A retrospective analysis was conducted using a prospectively collected database of patients who had undergone MSA implantation. The study protocol was approved by the Institutional Review Board. Inclusion criteria were age between 18 and 65 years and a minimum post-operative follow-up of 6 months. Exclusion criteria were previous esophagogastric surgery and documented allergy to titanium or nickel. Patients were included in the severe GERD group if one or more of the following conditions were present pre-operatively: LES basal pressure <5 mmHg or distal esophageal amplitude <30 mmHg on esophageal manometry, biopsy-proven Barrett's metaplasia, presence of stricture or grade C-D esophagitis on upper gastrointestinal endoscopy, and DeMeester score >50 on ambulatory esophageal pH monitoring . The remAll patients underwent clinical assessment by completing the gastroesophageal reflux disease health-related quality of life (GERD-HRQL) questionnaire on-PPI. The GERD-HRQL score is based on 10 questions and all queries have a score ranging from 0 to 5. A GERD-HRQL score >15 is considered abnormal .All patients also underwent a full diagnostic assessment including barium swallow study, endoscopy, esophageal pH-monitoring or pH-impedance off PPI, and esophageal manometry. Upper gastrointestinal endoscopy was performed to assess the presence of esophagitis according to the Los Angeles classification, biopsy-proven Barrett's esophagus, peptic stricture, or hiatus hernia. An esophageal pH or pH-impedance study was performed using a trans-nasal catheter or a wireless system (BRAVO™), and the DeMeester score and esophageal acid exposure time were collected. Standard or high-resolution esophageal manometry investigated Lower Esophageal Sphincter (LES) resting pressure, LES overall and abdominal length, and distal esophageal amplitude.The laparoscopic MSA implantation was performed under general anesthesia, as previously described . The gasPatients underwent post-operative clinical assessment with GERD-HRQL and functional outcome swallowing scale (FOSS) questionnaire  to analyU, Student's t test and Chi-square test as appropriate. When pre- and post-operative variables were compared, a two-tailed paired Student's t test was used. A p < 0.05 was considered statistically significant. Statistical analysis was performed using SPSS software 23.0 .Continuous variables are reported as mean ± standard deviation (SD) or median with interquartile range (IQR) when appropriate. Variables were compared between patients with mild to moderate GERD disease to patients with severe GERD, as defined before. Statistical analysis was performed through Wilcoxon test, Mann–Whitney A total of 336  patients were included in the study. Among them, 102 patients (30.4%) met the criteria for inclusion in the severe GERD group. The main pre-operative reasons accounting for disease severity were DeMeester score >50 (49% of patients), biopsy-proven Barrett's metaplasia (33.3%), and LES basal pressure <5 mmHg 27.5%; . A totalDemographic characteristics were similar in the two patient groups. However, patients with severe GERD had a higher rate of pre-operative dysphagia, higher scores of GERD-HRQL questionnaire, and higher PPI use .p < 0.05; p = 0.0124), but less individuals required device removal . No significant differences were found between the groups in terms of acid exposure time, DeMeester score, or number of patients with DeMeester score >14.7. However, there was a trend toward higher acid exposure in patients with pre-operative severe GERD (The median follow-up was 24 months (IQR = 75) and 32 months (IQR = 84) in the severe and in the non-severe GERD group, respectively. In both groups, GERD-HRQL scores and use of PPI significantly decreased compared to baseline  and more patients were using PPI (p < 0.041).The goal of antireflux surgery is to restore competence of the esophagogastric junction, but laparoscopic Nissen and Toupet fundoplication carry the burden of post-operative side effects and high variability in outcomes –22. HorvIn the present study, patients with severe GERD undergoing MSA had excellent outcomes at a mean of 50 months of follow-up, with a significant improvement of GERD-HRQL scores and decreased PPI use compared to baseline. These results are similar to what we observed in our cohort of control patients with mild to moderate GERD. Interestingly, occasional dysphagia was more common in the severe GERD group, both in the pre- and in the post-operative period. This higher prevalence of pre-operative dysphagia may be explained by a motility dysfunction induced by long-standing reflux or by an occasional diaphragmatic entrapment of a sliding hiatus hernia , 25. On Furthermore, a significant reduction in the DeMeester score compared to baseline was noted in both patient groups. Although there was a trend toward an abnormally higher post-operative score in the severe GERD group, the majority of these patients reached pH normalization. Despite the fact that even patients with severe GERD may benefit from MSA, we hypothesize that an earlier surgical intervention has the potential to prevent anatomical deterioration of the esophago-gastric barrier and Barrett's mucosal changes . In two The retrospective design of this research, the possible selection bias, and the lack of systematic post-operative ambulatory pH studies represent the main study limitations. Another intrinsic study limitation is the lack of a universally recognized definition of severe GERD.In conclusion, the laparoscopic MSA procedure can safely be offered to patients with GERD regardless of the severity of the disease as assessed by a set of anatomic and physiologic indicators. However, further prospective studies with longer follow-up are needed and special caution is needed in individuals with long-standing Barrett's esophagus because of the risk of progression to dysplasia and cancer in spite of adequate reflux control.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.DF and LB designed the study, analyzed the data, and were major contributors in writing and reviewing the manuscript. SS, CR, AL, and GG searched the literature, made the statistical analysis, and reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by A.I.R.ES. .The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Cystic fibrosis-related diabetes (CFRD) has become more common due to higher life expectancy with cystic fibrosis. Early recognition and prompt treatment of CFRD leads to improved outcomes. Methods: We performed a network meta-analysis (NMA) in order to identify the most valuable diagnostic metrics for diagnosing CFRD out of available screening tools (index test), using the oral glucose tolerance test as a reference standard. Pooled sensitivity (Se), specificity (Sp), and superiority indices were calculated and used to rank the index tests. Results: A total of 31 articles with 25 index tests were eligible for inclusion. Two-day, continuous glucose monitoring (CGM) ranked the highest (Se: 86% Sp: 76%), followed by glucose measurement from blood capillary samples  and three-day CGM . When we compared the CGM of different durations, two-day CGM performed best , followed by three-day  and six-day CGM . Conclusions: Considering its overall performance ranking, as well as the high sensitivity, two-day CGM appears to be a promising screening test for CFRD. Cystic fibrosis (CF) is an autosomal recessive genetic disease caused by mutations of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The pathogenic mutations cause abnormal chloride transport across secretory epithelial cells, leading to thick, sticky mucus production, mainly affecting the lungs and the digestive system . Due to The current gold-standard for CFRD screening is the 2 h oral glucose tolerance test (OGTT) . It is recommended that this is performed annually in all people with CF beginning at 10 years age and with no previous diagnosis of CFRD.  The CFRDThe current gold standard procedure is inconvenient, due to fasting and being time-consuming, and does not represent an everyday glucose homeostasis ,7. ThereWe undertook a network meta-analysis (NMA) to compare the diagnostic performance of the currently available screening tools for the diagnosis of CFRD, and to identify a potential alternative screening tool to the formal OGTT in CF patients. NMA structure allows to simultaneously compare multiple diagnostic tests at multiple thresholds to the gold standard at the same time.The network meta-analysis of multiple diagnostic tests (NMA-DT) is reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) for Network Meta-Analyses Statement . The proWe conducted a systematic literature search using five medical databases, including MEDLINE (via PubMed), EMBASE, Web of Science Core Collection, Scopus, and CENTRAL in October 2019 (our search strategy is detailed in The inclusion criteria for the study were the following: (1) prospective diagnostic accuracy studies, in which patients were previously diagnosed with CF; (2) studies must use OGTT T120′ value as the reference standard; and (3) studies must evaluate one or more diagnostic methods, comparing to the reference standard, as index tests. Studies were not limited based on the age of enrolled participants—both pediatric and adult studies were considered eligible.Exclusion criteria were the following: (1) records examining only CF patients with previously known impaired glucose tolerance (IGT) or diabetes; (2) studies that assessed FPG (T0′) or 1-h OGTT (T60′) values as the only index test; and (3) fewer than five participants.We included both full-text papers and conference abstracts to reduce publication bias. If useful data were available for an incomplete proportion of the study population, we used only the valid data from the smaller number of participants. In case of conspicuous overlapping populations between studies , we selected the most recent full text article rather than conference abstract and larger over smaller sample size. Although we included studies with potential risk of overlapping study populations , we created two network analyses to avoid any over-representation of data. One network included all studies regardless of potential overlapping populations, and in the second, overlaps were avoided by evaluating the period and place of enrollment, study authors, eligibility criteria, and baseline characteristics of participants. We chose studies with CGM over other index tests, full-text articles over conference abstracts, and greater sample size over small sample size.Two independent review authors  completed all steps of selection and data collection (onto the pre-defined data collection sheet) in duplicate. A third party (Z.S.) resolved any disagreement between the authors. We imported records from each database into EndNote X9 citation manager . First, we removed duplicates using the citation manager, and then manually. Remaining records were assessed for inclusion according to the eligibility criteria, by their titles, abstracts, and then by full texts.All data, according to study type, author, and publication information, demographic data, study period, details of diagnostic methods, number of CFRD participants, number of non-CFRD participants detected by reference standard, and index tests, were collected in the study data table.The quality of all included studies was assessed by two independent researchers , according to the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool . Any disAfter data collection, we created 2 × 2 contingency tables with true positive (TP), true negative (TN), false positive (FP), and false-negative (FN) values for each comparison. If more than one cut-off value was reported for the same index test, we chose the best-performing cut-off. In trials, if the best cut-off was not given, we chose the one corresponding to the value from the currently available CFRD guidelines ,5,6. If We performed a network meta-analysis for diagnostic tests (NMA-DT) to investigate which diagnostic method performs best for CFRD diagnosis. NMA-DT allows us to simultaneously compare multiple diagnostic tests at multiple thresholds to the gold standard at the same time. This approach allowed us to make direct (head-to-head) as well as indirect comparisons, given the common comparator OGTT 120′) in all studies . We cons0′ in allWe illustrated the network graph using STATA (version 15.1). To display the network, we constructed a graph where nodes represent different screening methods, and lines represent head-to-head comparisons. In the network graph, the direct comparisons are presented with edges, the thickness of the edges represents the number of the head-to-head trials, and the size of the nodes correlates with the number of studies . All staWe included 31 studies (26 full-text papers and 5 conference abstracts) in the network meta-analysis . Nineteen studies used a single index test, 10 included two index tests, while 3, 5, and 8 index tests were used in other studies (one study each). n = 24) to the reference standard. The most commonly used (19 articles) comparator was HbA1c. The two-day CGM (2d-CGM) , blood capillary sample (BCS) , and three-day CGM (3d-CGM) (Se: 96% Sp: 56%) ranked in the first three positions, according to their SI .Network graph A A summaritheir SI .The network graph B B represeNetwork graph C C includeNetwork graph D D was conThe patient selection domain carried a low or unclear risk of bias in the majority of the articles, due to limited reporting in the publications. One study was considered to have a high risk of bias, since the selected patients were known to have abnormal glucose tolerance (but not CFRD), previously diagnosed by OGTT . In the The aim of our study was to robustly compare alternative screening tools to OGTT; therefore, we evaluated currently reported screening methods for CFRD diagnosis for their diagnostic performance. In our results, all four network meta-analyses indicate that the two-day CGM performed best compared to the currently used gold standard: OGTT (T120′).Recent guidelines recommend annual routine OGTT screening for people above the age of 10. Even though OGTT serves as a basis for defining CFRD, its thresholds were established in diabetes without CF, and were not designed to detect hyperglycaemia-associated risk of deterioration in lung function or under-nutrition ,45. ConsHbA1c, the only widely available, simple, relatively cheap diagnostic tool for diabetes, is not recommended for CFRD screening according to recent guidelines, although it is used to guide therapeutic decisions to ensure proper glycaemic control. ,5. WhileOther non-traditional glycaemic biomarkers, such as FSF; fructosamine; 1,5-AG; and glycated albumin are gaining more attention for monitoring short-term glycaemic control in type 1 and type 2 DM, as well as in CFRD ,27. The The CGM system uses a subcutaneous sensor to measure interstitial fluid glucose levels and provides an average measurement every 5–15 min (depending upon the device). The machine is calibrated by capillary blood glucose levels . This method has already been used successfully in type 1 and type 2 diabetes patients, as well as in insulin-treated children with CFRD for guiding safe and effective insulin therapy .Due to frequent glucose measurements, early glucose abnormalities (both hyper- and reactive hypoglicameia), often preceding CFRD, could be identified by CGM. However, current guidelines do not recommend its use as a screening tool, in spite of its ability to detect elevated glucose levels in CF patients  ,25,29,48The CGM device is appropriate for both continuous and intermittent measurements. For tracking continuous blood glucose levels, CGM is applied usually for two to seven days. In order to understand the optimal length, we evaluated studies using various lengths of CGM (2–7 days). The diagnostic accuracy seems to be the highest for 2d-CGM. Short measurement length makes the method accessible for a greater proportion with CF, as well as being less inconvenient, facilitating better uptake.To our knowledge, this is the largest meta-analysis of people with CF evaluating the diagnostic accuracy of the available techniques for the detection of CFRD. Strengths include the selection of homogeneous study populations and standardized OGTT methodology, although the effect of the quality of the studies on the results could not be estimated reliably, since the risk of bias in many studies was unclear.Limitations include the divergent use of cut-off values of the index tests. Many studies used several different cut-off values for the same index tests. Also, this variability was seen within articles, but in the diagnostic test accuracy (DTA)-NMAs, only one cut-off can be used to avoid overrepresentation of participants. Current guidelines do not state specific cut-off values for CGM or non-traditional glycemic markers. Furthermore, we observed the use of alternative values even where cut-off values are clearly stated in the guidelines . In order to reduce confounding, we implemented a transparent decision-making algorithm to select the cut-off values used in the analysis.Originally, we planned to use CGM as a reference standard, as indicated in PROSPERO registration. However, we decided to deviate from our protocol, since OGTT seemed to be the better choice based on methodological recommendations of the Cochrane diagnostic test accuracy (DTA) guidelines, and the professional recommendations of the ADA guideline ,49.DTA-NMA allows the use of only one reference standard . This methodology precluded elucidation of whether an index test is better than the reference standard.Our results indicate that CGM performs well in diagnosing CFRD, which raises the idea of using CGM as an alternative reference standard instead of OGTT in further studies. Two-day CGM seems sufficient, since longer follow-up did not improve global diagnostic performance; this has important financial implications.Studies investigating the role of CGM as the gold standard are awaited. In addition, prospective cohort studies should evaluate if abnormalities detected by CGM and missed by OGTT have prognostic value for clinical outcomes, and if patients benefit from treatment initiated based on CGM results. Furthermore, these abnormalities also should be investigated in special risk groups .


This Quality Improvement Project aimed to improve physical activity amongst patients in a 16-bedded, low secure unit in the Downshire Hospital, Northern Ireland. We introduced an exercise programme with the aim of increasing minutes of physical activity per week. Secondary outcome measures were weight, mood and energy levels.This project took place in the context of COVID-19 restrictions having reduced opportunities for off-ward activity and staff noting subsequent deconditioning and weight gain amongst the patient cohort. Cohort consisted largely of patients with a severe mental illness, many of whom had physical health co-mobridities.This project included all patients in the 16-bedded unit.Baseline data were collected prior to programme introduction, including weekly activity levels and weights. A questionnaire explored patient confidence and attitude towards physical activity.Focus groups were held with patients and staff in order to identify how best to introduce the programme, discuss content, and identify potential barriers.We introduced an eight-week programme of weekly, thirty-minute, mixed ability exercise sessions. These were led collectively by the multi-disciplinary team. Patients actively participated in programme design; choosing session soundtracks and contributing to content planning.Likert scales were used to measure self-report mood and energy levels pre- and post-session. Staff engaged in a weekly post session de-brief, where challenges were identified and solutions suggested. Weekly qualitative feedback was sought from participants. The sessions were thus developed and adapted according to patient and staff feedback over the programme's course.Following the 8-week programme, activity levels and weight were re-measured and compared to baseline. Pre-programme questionnaires were also repeated.Patients reported increased enjoyment and confidence engaging in physical activity, as well as improved overall self- confidence and a sense of pride and ownership of the sessions.Staff reported a more cohesive team environment, greater sense of work-place fulfilment and improved therapeutic relationships.Comparing pre and post session ten-point-Likert scales showed a 153% mean increase in self-rated energy levels and a 98% mean increase in self-rated mood. This reflected a mean score increase of 3.8 in both.Minutes of physical activity per week increased for all session participants, although remained below national guidance.Weight reduction did not occur.Exercise benefits not only physical health, but also emotional and psychological well-being. This project demonstrates how introduction of a weekly ward-based exercise class can offer this as well as improving working environment, team cohesion and therapeutic relationships. Weight reduction may be observed in the longer term.


Luciferase activity was examined as iBNP and the iBNP-to-BNP ratio was evaluated. Patient characteristics and clinical parameters were compared, and multivariate regression analysis was performed to determine independent predictors of the iBNP-to-BNP ratio. Female sex and frequencies of atrial fibrillation, hypertension and the use of a calcium channel blocker (CCB) were higher in HFpEF. The iBNP-to-BNP ratio was significantly higher in HFpEF (26.9) than in HFrEF . Multivariate regression analysis identified the existence of HFpEF as an independent predictor of the iBNP-to-BNP ratio after adjusting for all other measurements . Age, hemoglobin, CCB usage and deceleration time were also independent predictors . These results indicate that the elevated BNP in patients with HFpEF is partly due to iBNP from the heart.Brain natriuretic peptide (BNP) levels are increased in both patients with heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF), but the reasons for this remain unclear. Our purpose was to examine whether serum-induced BNP (iBNP) expression partly contributes to increased BNP in patients with HFpEF. BNP reporter cardiomyocytes from pBNP-luc-KI mice were stimulated with serum from patients with HFpEF or HFrEF ( The number of patients with heart failure with preserved ejection fraction (HFpEF) is increasing, representing a growing burden as a health problem around the world ,2. PrognBrain natriuretic peptide (BNP) belongs to a family of vasoactive peptide hormones with favorable physiological properties . BNP is In this study, 196 patients with HF were recruited . Table 1BNP gene, NPPB (To generate the BNP reporter mice (pBNP-luc-KI mice), the luciferase cDNA was inserted into the initiation site of the ne, NPPB . In vivone, NPPB . Next, wne, NPPB A. Interene, NPPB B.Although BNP levels are well-known to be lower in HFpEF than in HFrEF , we examMany investigators have tried to clarify differences between HFpEF and HFrEF, including predictors of onset , comorbiWe identified the existence of HFpEF as an independent predictor of the iBNP-to-BNP ratio, in addition to age, hemoglobin, use of CCBs, and deceleration time. The finding that age is an independent predictor of the iBNP-to-BNP ratio is interesting. Indeed, elderly individuals are well-known to show higher BNP concentrations even in the absence of cardiac disease . HemogloRecently, ARNI have been used as a first-line therapy for patients with HF. ARNI play an important role in the treatment of HF by raising endogenous natriuretic peptides including BNP . It mighObesity and diabetes mellitus have also been reported to contribute to systemic inflammation, leading to cardiac remodeling and the development of HFpEF ,38. AlthIn summary, we have developed a system to measure iBNP using KI technology. This system showed that the iBNP-to-BNP ratio was significantly higher in HFpEF than in HFrEF, suggesting that iBNP may play an important role in the development of HFpEF and may help clarify the pathophysiological differences between HFpEF and HFrEF.All protocols were approved by the Institutional Animal Care and Use Committee of Mie University (protocol no. 24–25) and RIKEN Kobe Branch .http://www.clst.riken.jp/arg/mutant%20mice%20list.html, accessed on 7 December 2021), the luciferase cDNA was inserted into the initiation site of the mouse BNP gene  A targeting vector was constructed to replace the coding region of exon 1 of NPPB with a DNA fragment containing a luciferase cDNA and loxP-flanked neomycin resistance gene driven by PGK promoter (ryuji@clin.medic.mie-u.ac.jp).To generate the BNP in reporter mice (Accession. No. CDB1373K: promoter . A dipht2/steradian) within a region of interest (ROI). Serial images were collected from the heart in the ventral view for 40 min after luciferin injection in 5-min intervals.Mice received 125 mg/kg of luciferin substrate by intraperitoneal injection. Image acquisition was performed on anesthetized mice receiving isoflurane (2%). Bioluminescence signals were collected using an in vivo imaging system . Light intensity of bioluminescence was recorded as maximum photon counts  by ligation of the left anterior descending coronary artery was studied in 10 to 12-week-old male C57BL/6J mice (SLC), as described previously . AnestheMouse neonatal cardiomyocytes were isolated from the ventricles of 2-day-old pBNP-luc-KI mice and luciferase (luc) knock-in (KI) mice with site-specific integration of the luciferase gene, which is regulated by, and acts as an endogenous promotor of, BNP (pBNP), as described previously . Cells wThe study protocol was approved by the Ethics Committee at Mie University Hospital (reference number: 2893). This study was performed using an opt-out methodology. The opt-out option was presented on the hospital’s website and as a notice in a prominent place at Mie University Hospital.HF was defined using a combination of signs and symptoms, as previously reported . We divi–Whitney test was used to compare baseline characteristics. Multivariate regression analyses were performed to identify factors from among risk factors and laboratory data that were associated with the ratio of iBNP to BNP (iBNP-to-BNP ratio). Values of p < 0.05 were considered significant. Data were processed using SPSS version 25 software .Data are reported as mean ± standard deviation. The chi-squared test or MannThese results indicate that the elevated BNP in patients with HFpEF is partly due to iBNP from the heart.Our recruited patients did not receive angiotensin receptor neprilysin inhibitor (ARNI) or sodium/glucose cotransporter 2 inhibitor (SGLT2i), which are important drugs in the latest guideline , because


The number of patients with heart failure (HF) is increasing with aging in our society worldwide. Patients with HF who are resistant to medication and device therapy are candidates for heart transplantation (HT). However, the shortage of donor hearts is a serious issue. As an alternative to HT, cardiac regenerative therapy using human pluripotent stem cells (hPSCs), such as human embryonic stem cells and induced pluripotent stem cells, is expected to be realized. Differentiation of hPSCs into cardiomyocytes (CMs) is facilitated by mimicking normal heart development. To prevent tumorigenesis after transplantation, it is important to eliminate non-CMs, including residual hPSCs, and select only CMs. Among many CM selection systems, metabolic selection based on the differences in metabolism between CMs and non-CMs is favorable in terms of cost and efficacy. Large-scale culture systems have been developed because a large number of hPSC-derived CMs (hPSC-CMs) are required for transplantation in clinical settings. In large animal models, hPSC-CMs transplanted into the myocardium improved cardiac function in a myocardial infarction model. Although post-transplantation arrhythmia and immune rejection remain problems, their mechanisms and solutions are under investigation. In this manner, the problems of cardiac regenerative therapy are being solved individually. Thus, cardiac regenerative therapy with hPSC-CMs is expected to become a safe and effective treatment for HF in the near future. In this review, we describe previous studies related to hPSC-CMs and discuss the future perspectives of cardiac regenerative therapy using hPSC-CMs. The incidence of heart failure (HF) is high in the aged population, which is growing at a rapid pace worldwide. HF patients with who are resistant to optimal medication and device therapy are candidates for heart transplantation (HT). However, the number of HTs is <100 per year in Japan, and the mean waiting period is ~4 years –4.A large number of hPSC-derived cardiomyocytes (hPSC-CMs) are required for cardiac regenerative therapy . Many stWhen hPSC-CMs are transplanted into the host myocardium, residual non-CMs, including undifferentiated hPSCs, are a problem because these cells can induce tumors such as teratomas. Even if the contamination of undifferentiated hPSCs spiked into non-tumorigenic cells is ~0.025%, teratomas may be generated if these cells are injected into the legs of immunodeficient mice . To solvTable 1(A) elimination of undifferentiated hPSCs or selection of hPSC-CMs and (B) large-scale culture of hPSCs and hPSC-CMs.Overview of the main studies investigating The methods using fluorescence-activated cell sorting (FACS) or magnetic cell sorting (MACS) are reasonable. Antibodies against pluripotent markers such as TRA-1-60, SSEA-4, and SSEA-5 on hPSCs enable their removal , 14. In Chemical treatment is a fast and inexpensive method for eliminating undifferentiated hPSCs. For example, the addition of a recombinant lectin-toxin fusion protein that combines with hPSCs eliminates them selectively . AdditioMetabolic regulation affects cell fate and is a cost-effective method for eliminating undifferentiated hPSCs or selecting hPSC-CMs. Methionine and its metabolite, S-adenosylmethionine (SAM), are key regulators of hPSC maintenance and differentiation. Short-term methionine deprivation results in a rapid decrease in intracellular SAM levels, triggering the activation of p53-p38 signaling, reducing NANOG expression, and poising hPSCs for differentiation. Moreover, prolonged methionine deprivation induces hPSC apoptosis and elimination .Elimination of residual proliferating cells, including undifferentiated hPSCs, is effective in preventing tumorigenesis. We focused on the differences in metabolism between CMs and non-CMs. Glycolysis is enhanced in proliferating cells, including undifferentiated hPSCs, even under sufficient oxygen conditions. They produce energy by glycolysis, and they also produce nucleic acids, amino acids, and lipids, which are required for cell proliferation. In contrast, hPSC-CMs produce energy effectively using the tricarboxylic acid (TCA) cycle and fatty acid oxidation. In addition, unlike hPSCs, hPSC-CMs can use lactate as an energy source. Therefore, we selected only hPSC-CMs by culturing them in glucose-free medium supplemented with lactate .Next, we focused on amino acid metabolism. We discovered that hPSCs use glutamine in addition to glucose in the TCA cycle. Using this characteristic of hPSCs, we selected hPSC-CMs more effectively in glucose- and glutamine-free media supplemented with lactate . In addiLipid metabolism is also important for hPSCs. An inhibitor of stearoyl-CoA desaturase, the key enzyme in oleic acid biosynthesis, induces endoplasmic reticulum (ER) stress and apoptosis in hPSCs . MoreoveThe human left ventricle contains approximately four billion cardiomyocytes , 40. It 9 CMs/L using 1 L spinner flasks after 25 days of differentiation. They achieved this by modulating the Wnt pathway and optimizing cell aggregate size, small molecule concentrations, induction timing, and agitation rate  suspension culture using a large bioreactor or spinner flask is suitable for the large-scale hPSCs culture. The advantage of 3D culture is that it does not require expensive cell-adhesive coating proteins, such as vitronectin and laminin. Moreover, 3D cultures can be easily harvested from medium. In some studies, microcarriers were used in combination with 3D suspension culture, and were used as a matrix for floating cells , 34. Thiion rate . Halloinntiation .2 concentration increased and the O2 concentration decreased in the medium. Using an active gas ventilation system with 5% CO2, we could produce ~1.2 × 109 CMs at ~80% purity per culture and increase the purity to >97% using metabolic selection  plays a key role in the proliferation and maintenance of pluripotency. We produced a large number of hPSCs in TRP-supplemented medium in combination with a large-scale 2D culture system .In conclusion, both 3D and 2D cultures could yield a large number of hPSC-CMs required for clinical application, although each method has its advantages and disadvantages.There are two main methods for the transplantation of hPSC-CMs into the host myocardium. One method is to transplant hPSC-CMs as a patch on the surface of the host heart. The other method involves injecting hPSC-CMs into the host myocardium using a needle.The advantage of transplanting hPSC-CMs as a patch or sheet is that operators can visually confirm attachment to the host heart. Also, the damage to the host myocardium by patch attachment is less than that by the direct injection method. In contrast, hPSC-CM patches transplanted onto the epicardium tended to drop out in a relatively short time. For example, Kawamura et al. reported that transplantation of hPSC-CM sheets to infarcted porcine hearts improved cardiac performance; however, but after 8 weeks after transplantation, very few hPSC-CMs survived . Therefo8 hPSC-CMs. They transplanted the patches into pig hearts and confirmed their technical feasibility, although they were followed up for only 2 weeks (Engineered heart tissue (EHT) made from hPSC-CMs is commonly used in drug screening and disease modeling. In addition, studies using EHT for transplantation have also been reported –54. In g 2 weeks .in vivo  , 62, 73.Another problem with hPSC-CM transplantation is immune rejection. In the present state, allotransplantation is considered favorable because it is necessary to use hPSCs with proven quality and safety. Immunosuppressants should be used to reduce immune rejection. The optimal regimen of immunosuppressants after transplantation of hPSC-CMs is not yet known, although the regimen for patients who undergo HT is helpful. In addition, we should match the hPSC-major histocompatibility complex (MHC) and recipient-MHC in order to reduce the severity of rejection. This is a concern for patients who do not have MHC-compatible hPSCs. Hypoimmunogenic hPSCs are being developed using genetic modification to enable allotransplantation in patients with multiple types of MHCs. For example, hPSCs that are deficient in HLA-I via disruption of beta 2-microglobulin can evade recognition of recipient T cells, but they can be attacked by NK cells . TherefoMany problems are gradually being solved to achieve cardiac regenerative therapy. Menasché et al. reported that they transplanted ~8.2 million hESC-derived cardiovascular progenitors embedded in a fibrin patch onto the epicardium of HF patients and supported their safety . Our groYS and ST wrote the original manuscript. YM, YK, HK, KF, and ST reviewed and edited the manuscript. YS, KF, and ST acquired funding. All authors contributed to the article and approved the submitted version.This work was supported by Projects for Technological Development, Research Center Network for Realization of Regenerative Medicine by Japan, the Japan Agency for Medical Research and Development (AMED) grant 20bm0404023h0003 to ST, the Japan Society for the Promotion of Science (JSPS) KAKENHI 20H03768 to ST, and Grant-in-Aid for JSPS Fellows 21J10680 to YS.KF is a co-founder and CEO of Heartseed, Inc. ST was an advisor of Heartseed, Inc. ST, HK, and KF owned equity in Heartseed, Inc. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.