Brain tumor analysis is essential to the timely diagnosis and effective treatment of patients. Tumor analysis is challenging because of tumor morphology factors like size, location, texture, and heteromorphic appearance in medical images. In this regard, a novel two-phase deep learning-based framework is proposed to detect and categorize brain tumors in magnetic resonance images (MRIs). In the first phase, a novel deep-boosted features space and ensemble classifiers (DBFS-EC) scheme is proposed to effectively detect tumor MRI images from healthy individuals. The deep-boosted feature space is achieved through customized and well-performing deep convolutional neural networks (CNNs), and consequently, fed into the ensemble of machine learning (ML) classifiers. While in the second phase, a new hybrid features fusion-based brain-tumor classification approach is proposed, comprised of both static and dynamic features with an ML classifier to categorize different tumor types. The dynamic features are extracted from the proposed brain region-edge net (BRAIN-RENet) CNN, which is able to learn the heteromorphic and inconsistent behavior of various tumors. In contrast, the static features are extracted by using a histogram of gradients (HOG) feature descriptor. The effectiveness of the proposed two-phase brain tumor analysis framework is validated on two standard benchmark datasets, which were collected from Kaggle and Figshare and contain different types of tumors, including glioma, meningioma, pituitary, and normal images. Experimental results suggest that the proposed DBFS-EC detection scheme outperforms the standard and achieved accuracy (99.56%), precision (0.9991), recall (0.9899), F1-Score (0.9945), MCC (0.9892), and AUC-PR (0.9990). The classification scheme, based on the fusion of feature spaces of proposed BRAIN-RENet and HOG, outperform state-of-the-art methods significantly in terms of recall (0.9913), precision (0.9906), accuracy (99.20%), and F1-Score (0.9909) in the CE-MRI dataset. The brain is a complex and vital organ of the human body, controlling the nervous system. Irregular and uncontrolled growth of cells in the brain can cause a brain tumor. Brain tumors are usually categorized into primary and secondary tumors. The creation of brain tumors is not identifiable along with the growth rate, and brain tumors have the world’s highest mortality ratio of cancers. Primary brain tumors are devised in the brain tissues, whereas secondary tumors are produced in some other part of the body and shift to the brain through blood flow. Among the primary brain tumors, meningioma, glioma, and pituitary are harmful types of brain tumors and are most challenging for their early detection and effective treatment. Furthermore, these may lead to critical conditions if not addressed in a timely manner .Early detection and classification of brain tumors with high prognosis accuracy is the most critical step for diagnosis and treatment to save a patient’s life. However, the manual analysis of brain MR images is laborious for radiologists and doctors to detect as is localizing the tumor and normal tissues and categorizing the tumors from medical images . A compuConventional machine learning (ML)-based approaches have been employed for brain tumor analysis. However, ML-based techniques entail manual feature extraction and classification and also are used on limited data. Deep learning (DL) has combined feature extraction and classification into a self-learning manner on a significant amount of labeled data, which considerably improved the performance. Moreover, CNN is a branch of DL, specially designed for image or two-dimensional (2D) data. It only takes datasets with minimal preprocessing and captures various features from MR images without human intervention . Deep CNIn this regard, we develop a deep-boosted hybrid learning-based approach to overcome these limitations by customizing the CNN models to exploit brain tumor-specific patterns from the brain MRI dataset. CNNs have shown admirable performance for identifying tumors from normal individuals and segregation of tumor types by using medical images. Moreover, deep feature boosting, ensemble learning, and ML classifiers help to improve performance considerably. Experimental results suggest that the proposed deep learning-based approaches would assist radiologists in diagnosing tumors and other irregularities from medical imaginings. The key contributions of the work are listed as follows.An automated two-phase deep hybrid learning-based detection and classification (DHL-DC) framework is proposed for brain tumor analysis by using MRI images.A novel deep-boosted features space, and ensemble classifiers (DBFS-EC)-based scheme is proposed to detect brain tumors. In this scheme, deep-boosted feature space is accomplished by using outperforming customized CNNs and provided to a majority voting-based ensemble of ML classifiers.For the classification of brain tumor types, a new deep hybrid features space-based brain tumor classification approach is proposed. In the proposed technique, the dynamic features are obtained from the proposed novel brain region-edge net (BRAIN-RENet) and concatenated with a histogram of gradients (HOG) features to increase the feature space diversity and to improve the learning capacity of ML classifiers. Moreover, the proposed BRAIN-RENet carefully learns various tumors’ heteromorphic and inconsistent behavior.The paper is arranged as follows. In In medical image analysis, many research horizons are explored. These include various areas of medical imaging, such as detection, classification, and segmentation ,6,7,8,9.DL-based approaches performed better than conventional ML methods like Abdolmaleki et al. , who conKhan, M.A. et al.  proposedMost of the previously done works have been evaluated using accuracy on the validation dataset. However, precision, recall, and MCC are assessed for better performance evaluation on unbalanced datasets. Evaluation of such performance metrics is essential to measure the model’s generalization on the test dataset.Previous work is largely restricted to either detection or classification of brain tumors. However, only the detection of tumors puts radiologists in an ambiguous situation due to insufficient details of the tumor type.Largely normal individuals and tumors are classified in a single phase; this increased the overall complexity of models. Hence, isolating normal instances from tumor images for the classification phase may decrease the model’s complexity.Many researchers used the challenging benchmark dataset  consistiIn this manner, the proposed two-phase brain tumor identification and classification framework can improve the diagnostics model’s performance by using standard performance assessment metrics like Accuracy, Precision, Recall, F-score, MCC, and AUC-PR.The detailed architecture of the proposed DHL-DC framework is explained in this part. The proposed framework includes two phases. A deep-boosted features space and ensemble classifiers (DBFS-EC) method for brain tumor detection is proposed in the phase 01. In the phase 02, a hybrid features fusion-based brain tumor classification (HFF-BTC) model is proposed to classify brain tumor MR images detected from the first phase into three different classes: meningioma, glioma, and pituitary. MR images are categorized into different types by employing the proposed novel BRAIN-RENet based model. Feature space diversity is attained by composing a fusion feature space comprised of dynamic and static features. The proposed multi-stage brain tumor detection and classification framework is shown in In DL-based models, a deficient amount of data tends to model overt fit. Image augmentation is employed for efficient training and the improved generalization ability of models. Data augmentation techniques help to improve the performance of DL models ,25. ThisWe perform three distinct experimental approaches for brain tumor detection in the proposed scheme. It includes; (1) Softmax-based implementation of existing customized transfer learning-based (TL-B) and training from scratch (TR-SC) deep CNN models in an end-to-end mode to differentiate tumor and normal brain MRI images (2). Secondly, a deep feature space-based hybrid learning (DFS-HL) technique is designed. In DFS-HL, feature spaces of the four best TL-B fine-tuned models are fed into three ML classifiers to enhance the discrimination ability and generalization of the proposed scheme (3). In the third approach, we propose the DBFS-EC based framework to exploit the benefits of ensemble deep feature spaces and ensemble of ML classifiers. The block diagram of the DBFS-EC approach is shown in In our proposed two-phase framework, both detection and classification models are trained independently. Initially, we employ two different methods in our proposed DL-BTD approach for Softmax-based classification by using TR-SC and TL-B fine-tuned deep CNN models. For TL-B and TR-SC, we employed ten well-known customized CNN models and trained them on the MRI image dataset. Employed CNN models include: i—VGG-16 , ii—VGG-Our suggested DFS-HL scheme selects four well-performing TL-B CNN models as feature extractors and fed feature vectors individually into three competitive ML classifiers. The MRI dataset used in this study is not enough for the training of the deep CNN model, and there are chances of overfitting. So we have incorporated TL by using the pre-trained weight of the CNN models on the ImageNet dataset. TL-B deep CNN models learn the most discriminative features efficiently. We employ three different ML classifiers for classification: SVM , MLP 3535, and AEnsemble learning aspires to performance improvement and encourages combining multiple feature vectors of various models into one rich information feature vector, and avoids the risk of using a feature vector extracted from a single model with unsatisfactory performance . It can In Equation (1), In the phase 02, a hybrid features fusion-based brain tumor classification (HFF-BTC) methodology for brain tumor categorization is proposed. Dynamic and static features are concatenated to enhance the feature space diversity, and an ML classifier is employed to improve the distinction power of the proposed approach. Deep features are extorted from the one layer before the last fully connected (FC) layer of the proposed novel BRAIN-RENet. Static features are extracted by using the HOG features descriptor. The proposed brain tumors classification framework is illustrated in A novel brain tumor classification model using BRAIN-RENet is proposed in the phase 02 of the current study. A deep feature space that contains 1024 features is obtained from the one layer before the last fully connected layer of BRAIN-RENet, as shown in The proposed BRAIN-RENet contains six convolutional blocks. Every block is comprised of one convolutional layer, ReLU, and batch-normalization. The convolution layer extracts the tumor-specific features while ReLU act as an activation function. At the end of each block, average- and max-pooling operation is applied to learn region uniformity and boundary features of brain tumors as illustrated in Equations (4) and (5). Region and boundary-based operators are implemented systematically to capture patterns of different types of brain tumors. The detailed architecture of the proposed BRAIN-RENet is illustrated in avg and Wmax processes, denoted by WAvg and WMax, respectively. In Equations (4) and (5), t denotes the average- and max-window sizes. In Equation (6), the output of the dense layer is defined by Q, which employ global operation on The convolutional operation is used in Equation (3). The input feature-map has size The proposed BRAIN-RENet improves imitating the image’s sharpness and smoothing dynamically, and can also fine tune the magnitude of smoothing and sharpening according to the spatial content of the image without human intervention.Systematic employment of edge- and region-based operations after each convolutional block enhances the region homogeneity of different image segments.The region operator smooths variations by applying average-pooling and suppresses the noise added during the MRI acquisition process. In contrast, the edge operator inspires CNNs for learning highly discriminative features by using a max-pooling operation.In the proposed BRAIN-RENet, the systematic employment of edge- and region-based operations Equations (4) and (5), with a combination of convolutional operation Equation (3), facilitates the model for enhancing pattern-specific properties for brain tumor classification . The advIn our proposed hybrid features fusion-based brain tumor classification (HFF-BTC) model, we compose a hybrid feature space comprising static and dynamic features. Static features are extracted by using the HOG feature descriptor. Dynamic features are extracted by using the proposed BRAIN-RENet from the second last layer. Features fusion with hybrid learning exploited the advantages of empirical and structural risk minimization to enhance the performance of the brain tumor classification stage . Deep CNWe collect a brain tumor data set of normal and tumor images; normal images are collected from the open-source Kaggle website  and name® GTX₋1060 Tesla. Our proposed model took almost 5–7 h, ~20–30 min/epoch for training. The experimental setup in both detection and classification approaches training was fixed for all networks in TL-B, TR-S, and proposed methods.In the proposed work, we divide data into training and testing in the detection phase with a percentage of 60:40% for training and testing, correspondingly, and a percentage of 80:20% in the classification phase. Furthermore, the training data is again subdivided into train and validation sets for parameter optimization. Optimization of the model is attained by employing holdout cross-validation. We used stochastic gradient descent (SGD)  as an opThe categorization capability of the proposed approaches is empirically assessed by using classification accuracy  (Acc.), A two-phase DL-based framework is designed for brain tumor analysis in this proposed work. In the phase 01, the detection of brain tumor individuals from normal instances is performed. In the phase 02, the classification of tumor images into further family classes is accomplished. Tumor detection alone is not completely beneficial for the successful curing process, hence, it is essential to classify tumors further into relevant classes for effective and efficient treatment. The empirical effectiveness of the proposed framework is evaluated by performing two experiments. In the first experiment, the brain tumor detection task is performed by assessing the performance of DL and DFS-HL-based models. In the phase 02, we evaluated the advantages of feature spaces fusion by combining dynamic-static feature spaces to discriminate patterns of different brain tumors. The suggested brain tumor analysis framework is validated on unseen data by using accuracy, sensitivity, precision, AUC-ROC, MCC, and F1-Score. The experimental results of dual stages are deliberated below.In the proposed framework, initially, to categorize all samples into the tumor or healthy brain image, a DL-based DBFS-EC approach is proposed. Optimization of this stage results in minimum numbers of false positives for identifying tumors. The detection rate is enhanced by using three improvements in the detection phase. In the first step, we evaluate customized TR-SC and TL-B -based CNN models and determined that TL-B models perform better than TR-SC models ((0.75–8.4%) improvement in accuracy ). The peExperimentation results for the proposed brain tumor detection scheme are obtained by using a combined dataset (DS-3). In the first experiment, we compare several customized TL-B and TR-SC deep CNN models by using an end-to-end way to obtain the tumor-related features. Performance assessment advocates that TL-B fine-tuned models learn the tumor-related feature better than the deep CNN models, trained from scratch on brain MR images. This is because of pre-trained weights that were learned from an extensive dataset named ImageNet . As for the second experiment, we employ a hybrid learning-based approach by extracting the dominant features and exploiting the learning capability of deep CNNs with the strong discrimination power of ML classifiers. For this, we extract deep features spaces from the end layers of four best-performing TL-B deep CNNs , and fed them into competitive ML classifiers  The performance assessment based on accuracy, sensitivity, precision, and AUC-ROC, MCC, F1-Score, which are shown in The deep features of DenseNet201 with all three ML classifiers perform better than extracted deep features of other pre-trained CNNs. However, the performance of the deep features extracted by using inceptionV3 fell shorter than features extracted from other pre-trained CNN networks on DS-3. The performance assessment is based on accuracy, recall, precision, F-score, and MCC .In the last experiment for the proposed DBFS-EC approach, the effectiveness of the deep-boosted ensemble learning is evaluated. A hybrid feature space is formed by concatenating all four selected feature spaces and ensemble classifier by using all three classifiers employed in experiment 2. Utilizing ensemble deep feature spaces from more than one TL-B deep CNNs is effective for ML classifiers. An ensemble of classifiers enhanced the overall performance of the proposed DBFS-EC approach for brain tumor detection.Analyzing the ROC curve is crucial for achieving the optimum analytic threshold for a classifier. It pictorially shows the differentiation capacity of the classifier at possible threshold values. As shown in Tumor classification is essential for designing effective treatment and diagnosis processes. Thus, brain MR images recognized as the tumor in the detection stage by using the proposed DBFS-EC are allocated to the brain tumor classification model for tumor categorization. In the classification phase, we have proposed a hybrid features fusion-based approach for tumor MR images categorization into particular classes, namely, meningioma, glioma, and pituitary. Dynamic and static features are concatenated to enhance the feature space diversity, and classification ability enhancement of the model is achieved by employing an ML classifier (SVM). Deep features are extracted by using the proposed novel BRAIN-RENet, and static features are extracted by using the HOG descriptor.The proposed model’s performance is assessed with the proposed BRAIN-RENet and several ML-based models. In the brain tumor classification stage, we initially analyze the performance of our proposed HFF-BTC model with other existing hybrid learning-based models by using different ML classifiers, namely Naïve Bayes, Decision Tree, Ensemble (Adaboost-M2), and SVM with the linear, RBF, poly order-2 kernel. Confusion matrix-based performance comparison of proposed HFF-BTC with other existing ML methods is illustrated in Performance of the proposed HFF-BTC model using deep and static features individually and existing DL models are evaluated and demonstrated in Features space diversity attained by the proposed DBFS-EC and DFS-HL is assessed to elucidate the tumor detection and classification process. In general, the discrimination ability of the model is dependent on the associated properties of the features set. Distinguishing the class features strengthens the learning ability of the model and improves robustness on a wide-ranging set of instances. The proposed DBFS-EC framework boosted the feature space diversity and improved brain tumor recognition and categorization. The 2-D scatter plot of principal components (PC) and their divergence attained by proposed DBFS-EC with the comparison of best-performing TR-SC and TL-B deep CNNs on test data are shown in An efficient brain tumor diagnosis system is necessary for the early treatment of the patient. In this regard, a new two-phase brain tumor detection and classification framework is proposed to improve brain tumor diagnosis and reduce computational complexity. In the detection phase, we proposed a novel DBFS-EC approach for differentiating brain tumor instances from normal individuals with fewer false negatives, and performance is compared with the existing DL techniques. Experimental results demonstrate that the proposed DBFS-EC outperformed other models by achieving better accuracy (99.56%), recall (0.9899), precision (0.9991), F1-Score (0.9945), and MCC (0.9892). In the tumor classification phase, an FSF-HL technique is proposed, which is based on novel brain-RENet model and benefits from feature space fusion and ML. The feature space fusion exploits region uniformity, edge-related, and static features and then provides to ML to improve the model generalization by reducing structure risk minimization. The proposed technique achieved recall (0.9906), precision (0.9913), accuracy (99.20%), and F1-score (0.9909) for brain tumor classification on a benchmark dataset. The two-phase framework is expected to assist clinicians in decision-making in clinical practice and will be helpful for radiologists in brain tumor diagnosis. In the future, we will appraise our proposed framework’s performance and a more optimized one on other large medical image datasets to improve efficacy and reliability for real-time detection and classification. In this regard, we will focus on augmenting the training sets by generating synthetic examples using the generative adversarial network.


The diet-center hypothesis has gained much support from the apparent protective effect of the Mediterranean diet on breast cancer. However, the evidence of the association between Mediterranean diet adherence and breast cancer molecular subtypes remains small, especially in non-Mediterranean populations.The subjects from the Chinese Wuxi Exposure and Breast Cancer Study, a population-based case-control study, included 818 patients and 935 healthy controls. A validated food frequency questionnaire used for diet assessment and a modified version of the alternate Mediterranean Diet Score, which is called the alternate Chinese Diet Score, was developed to assess adherence to a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern. Soy foods, rapeseed oil, and coarse cereals replaced legumes, olive oil, and whole grains reflecting the cuisine of the region. We examined the association between the vegetable-fruit-soy diet adherence and breast cancer risk, stratified by menopause status  and receptor status  oncogene expression, followed by five specific combinations .P trend < 0.001] and that the inverse association was somewhat stronger to detect among ER- subtypes  and ER–/PR–subtypes . We did not observe any significant association between the vegetable-fruit-soy diet characteristics and ER+ subtype, as well as between PR+ and ER+/PR+ subtypes.The results suggest that the vegetable-fruit-soy dietary pattern was inversely associated with postmenopausal breast cancer risk [4th vs. 1st quartile, odds ratio (OR) = 0.57, 95%CI = 0.41, 0.80; The favorable influence from the Mediterranean diet may also apply to Chinese women. The vegetable-fruit-soy dietary pattern may reduce the risk of postmenopausal breast cancer, particularly among ER- subtype, and ER–/PR–subtype. Some extensive cohort studies reported the inverse association for the dietary pattern characterized by the traditional diet among populations in Mediterranean countries of breast cancer risk –8, whichOf particular interest were the low breast cancer incidences that have been reported in Asian countries . It has However, it is almost impossible to perform a long-term feeding trial in a large-scale population in achieving high compliance to follow the Mediterranean diet except with intensive intervention . TherefoThis study aims to scrutinize the association between a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern, and breast cancer risk among Chinese women, stratified by the menopausal status and different breast tumor molecular subtypes.The Chinese Wuxi Exposure and Breast Cancer Study (2013–2014) was a case-control study of the role of biology, diet, lifestyle, and environmental factors in the etiology of breast cancer in Asian women. Subjects were all adult women and were restricted to local residents who have lived in Wuxi for at least 5 years. All newly diagnosed (the diagnosis date was within 1 year before enrolment) women with breast cancer (ICD code: C50) among local residents identified by cancer registries were eligible to be included as cases. Secondary and recurrent cancers were excluded. Controls were derived from the local area as cases and were 1:1 individually matched with cases by age (±2 years) and residence. As personal information such as name, address, date of birth, and sex for all residents was available in the local demographic information database; eligible controls were randomly identified from this database. For each control chosen, two additional subjects were selected as a backup at the same time. When the first control could not be interviewed, an alternative was enrolled in the study. The selection procedure repeated until an eligible subject was interviewed. A total of 1,042 eligible breast cancer cases and 1,042 health controls were identified during the study period. Case and controls with major dietary habits changed over the past 10 years, which were excluded from this study. In analysis, 818 cases and 935 controls were included, with a frequency match (cases and controls have the same distributions over age and residence). All subjects gave voluntary written informed consent to participate in this research. The Institutional Review Boards of the Jiangsu Centers for Disease Control approved the study protocol.The usual diet was assessed by a validated, semiquantitative food frequency questionnaire (FFQ), which included 149 items along with the recipes commonly used in China; a detailed description is given in Zhao et al. . NutrienDietary intake assessment included whether the food was consumed, consumption frequency (times of per day/week/month/year), and the average amount of food consumption at each time. The 149 food items in the FFQ were classified into 18 predefined food groups based on similarities in nutrient profile and culinary usage.A modified version on the alternate Mediterranean Diet Score (aMED) which we called the alternate Chinese Diet Score (aCHD) was developed to assess adherence to a migrated Chinese version of the Mediterranean diet, which we called the vegetable-fruit-soy dietary pattern. Soy foods, rapeseed oil, and coarse cereals replaced legumes, olive oil, and whole grains, reflecting the cuisine of the region. The aMED , 19 is aTo test the role of the vegetable-fruit-soy dietary pattern in the etiology of breast cancer, we design an interaction test between the aCHD and the duration of diet habits. The “duration” indicator was based on interviewing subjects about how long they have maintained their current diet habits, and the medians were calculated based on the distribution of the premenopausal controls and postmenopausal controls, respectively.Demographic, lifestyle characteristics, menstrual and reproductive events, dietary intake, medical history, and physical activity-related data were obtained from a structured questionnaire through in-person interviews conducted by trained interviewers. Anthropometric measures were obtained by trained personnel following standardized protocols; the core elements of anthropometry are height, weight, body mass index (BMI), body circumferences , and skinfold thickness. Physical activity was measured by referencing the Global Physical Activity Questionnaire . Women wThe molecular subtypes of breast tumor based on ER status, progesterone-receptor (PR) status, and human epidermal growth factor 2 (HER2) oncogene expression, followed by five specific combinations .t-test or the Wilcoxon rank-sum test and chi-squares tests were performed for continuous and categorical variables, respectively, to compare the differences between cases and controls.The demographic characteristics and anthropometric measures of the subjects were presented as means± SD for normal distribution or median (Q1 and Q3) for non-normal distribution and frequency percentages. A Student’s To estimate the impact of the separate foods component of the vegetable-fruit-soy dietary pattern on breast cancer, we calculated adjusted odds ratios (ORs) for the intake ≥ median of the specific foods component compared to the intake < median (as reference), medians were calculated based on the distribution of the premenopausal controls and postmenopausal controls, respectively.Associations between the aCHD score  and breast cancer were estimated in terms of adjusted ORs and respective 95%CIs by logistic regression models.In the sensitivity analysis, soy foods were often considered to be an independent potential benefit for breast cancer prevention in Asian populations , 24. Thuor≥3), age at first full-term delivery (by years), breastfeeding (no or yes), height (by cm), BMI (in kg/m2), energy intake . In addition, postmenopausal stratification analysis was further adjusted for the menopausal age (by years). All subjects were included in the present analysis, with the missing covariates data imputed by using the fully conditional specification Multivariate Imputation by the Chained Equations method. Interactions were examined by the likelihood ratio tests (LRTs).In analyses, we controlled potential confounders associated with breast cancer risk, included age at diagnosis for cases or enrollment for controls (by years), education , tobacco smoking (no or yes: including smoking and second-hand smoking ≥ 3days/week), moderate physical activity (minutes/day), oral contraceptives use (no or yes: current use or ever use), hormone replacement therapy (no or yes: current use or ever use), family history of breast cancer (no or yes: in a first-degree relative), history of benign breast disease , age at menarche (by years), number of full term births , P-value near 0.05 taken by itself offers only weak evidence against the null hypothesis.All analyses were performed with R version 4.0.2 .The demographic characteristics and anthropometric measures of the subjects stratified by menopausal status are presented in P-value for trend < 0.001) and women with the highest quartile aCHD score had a significantly lower risk compared with women with the lowest quartile aCHD score , while no significant association was found for premenopausal breast cancer (P interaction = 0.013). Long-term (≥median) vegetable-fruit-soy diet adherence (highest quartile of aCHD) significantly reduced postmenopausal breast cancer risk compared with short-term (<median) adherence and showed lowest quartile of aCHD , The association between the vegetable-fruit-soy diet adherence and breast cancer is shown in t cancer . FurtherP-value for trend < 0.001). When all soy foods were excluded from the aCHD score calculation, a high soy-free aCHD score was also found to be inversely associated with postmenopausal breast cancer .Breast cancer risk in association with the quartile of soy foods intake and the modified soy-free aCHD score is also shown in For the impact of the separate food components of the vegetable-fruit-soy dietary pattern on breast cancer, we found alcohol consumption to be a significant risk factor for postmenopausal breast cancer , and a high intake of soy foods was inversely associated with breast cancer . No significant association was observed between separate food components intake and premenopausal breast cancer risk . The aveP trend = 0.003); results were similar for ER-/PR- subtype  (P trend = 0.371). A test for heterogeneity examines the null hypothesis that the beneficial effect of vegetable-fruit-soy diet adherence on the ER- subtype is the same as that of the ER+ subtype. However, the test of heterogeneity yields a P-value of 0.013, conventionally interpreted as being non-significant. Results for ER+/PR+ and ER–/PR– breast cancers were similar to those for ER+ and ER– breast tumors, respectively; results for ER–/PR– /HER2– were not significant.Since the significant inverse association with the vegetable-fruit-soy diet adherence was only found in postmenopausal breast cancer, further analyses for different breast tumor molecular subtypes were restricted only to the postmenopausal participants. We observed the vegetable-fruit-soy diet adherence was significantly inversely associated with of ER- subtype  . We did We found that the vegetable-fruit-soy diet adherence was inversely associated with postmenopausal breast cancer risk, especially with ER- and ER-/PR-subtypes. This favorable influence of the vegetable-fruit-soy diet adherence on postmenopausal breast cancer risk cannot be explained by the single effect of soy foods since only a very slight attenuation in estimates was noted after excluding the effect of soy foods. Our finding supports the hypothesis that food components and their combinations in the vegetable-fruit-soy dietary pattern play an etiologic role in breast cancer.The abundant vegetables and moderate fruits intake are the common features of the Mediterranean and Chinese traditional diets . Both divia estrogen-independent mechanisms, such as inhibiting the nuclear transcription factor jB DNA binding activity and the Akt signaling pathway  , our resThe strengths of our study were the use of a validated food-frequency questionnaire and a modified questionnaire surrounding the Mediterranean dietary pattern and individual dietary factors to examine their association with breast cancer risk in the Chinese female population. Since the diet is a modifiable risk factor, identifying the characterization of the population most susceptible to harmful and beneficial dietary habits is critical for breast cancer prevention policy design. Our findings support vegetable-fruit-soy diet compliance associated with reduced postmenopausal breast cancer risk, especially with ER- or ER-/PR- subtypes.The favorable influence from the Mediterranean diet pattern may also apply to Chinese women, and the vegetable-fruit-soy dietary pattern reduced the risk of postmenopausal breast cancer, particularly among ER- subtype, and ER–/PR–subtype.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Review Boards of the Jiangsu Centers for Disease Control. The patients/participants provided their written informed consent to participate in this study.MW, SC, and PW designed and conducted the study. QZ, ZZ, and JZ developed diet indices and data collection. SC and LL performed the statistical analyses and drafted the manuscript. PW and MW interpreted the data, critically revised the manuscript, and had full responsibility for the analyses and interpretation of the data. SC has full access to all study data. All authors contributed to the preparation of the manuscript and read and approved the final manuscript.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 and objectives: The aim of this systematic review was to assess the available evidence of using enamel matrix derivate in the treatment of peri-implantitis. Materials and methods: Three electronic databases  were searched until August 2022 to identify relevant articles. The inclusion criteria consisted in human clinical studies that reported the use of enamel matrix derivate (EMD) in surgical and non-surgical treatment of peri-implantitis. The risk of bias was assessed using Cochrane risk of bias tool for randomized clinical trials (RCTs) and for non-RCTs ROBINS-I tool. Results: Clinical studies included were published between 2012 and 2022 and consisted of two randomized clinical trials (RCTs) for non-surgical therapy and two RCTs, three prospective cohort studies, and one retrospective case series in surgical therapy. Due to the heterogeneity of patients’ characteristics and assessment of peri-implant therapy, statistical analysis could not be achieved. Conclusions: The use of EMD indicated a positive effect on both surgical and non-surgical therapy. However, the available literature is scarce, with low evidence in non-surgical approach and modest evidence in surgical approach using EMD. More RCTs with standardize protocols are necessary to evaluate the efficacy of using EMD in both therapies. Peri-implantitis is considered a major and growing problem in dentistry as the number of patients receiving dental implant restorations increases . Using dPeri-implant tissue is the tissue surrounding the osseointegrated dental implants and can be divided into two different entities: soft tissue (peri-implant mucositis) and hard tissue components, including bone ,5,6. PerThe etiology of peri-implantitis is multifactorial. Both peri-implant diseases are infectious in nature and are induced by bacteria from dental biofilms ,2,8. RecThe most challenging task in the management of peri-implantitis is biofilm removal in order to achieve re-osseointegration and promote the reduction of peri-implant pockets . Peri-imOnce peri-implantitis has been diagnosed, treatment should be initiated without delay . In caseThe principles of surgical treatment of peri-implantitis are to improve the cleanliness of the implant surface and to modify the anatomy of the peri-implant soft and hard tissue to achieve re-osseointegration ,2. NumerAn augmentative approach for peri-implantitis aims at regeneration of the bone defect, achieving re-osseointegration, and limiting the recession of peri-implant soft tissue ,2,11. TrIn regards to the last statement, the aim of our systematic review was to assess the available evidence of using enamel matrix derivate in surgical and non-surgical treatment of peri-implantitis.-Participants: patient diagnosed with peri-implantitis or peri-implant mucositis;-Interventions: surgical treatment of peri-implantitis or peri-implant mucositis using enamel matrix derivate;-Comparison: non-surgical treatment of peri-implantitis or peri-implant mucositis using enamel matrix derivate;-Outcome: changes in periodontal parameters recorded: probing depth (PD), clinical attachment loss (CAL), bleeding on probing (BOP), and radiographic bone level (RBL);-Study design: clinical trials; prospective, retrospective studies; cohort studies, case-control studies; and case series.This systematic review was conducted under the recommendations of Cochrane Handbook for Systematic Reviews of Interventions  and the The following exclusion criteria were applied: in vitro animal studies; no clinical trials, cross-sectional, and cohort studies; systematic/narrative reviews, case reports, monographs, and letters to the editor; missing data regarding periodontal parameters or no reports on the use of erythritol; insufficient/missing/unpublished data; and articles published in other languages than English.PubMed, Web of Science, Scopus) search was performed by two reviewers (R.M. and A.M.) until August 2022 to identify relevant articles. The search strategy was applied as follows: (enamel matrix derivate OR enamel matrix protein) AND . In the first literature selection stage, titles and abstracts were screened for eligibility according to the inclusion criteria. In the second stage, full-text potentially eligible articles were examined. In case of any disagreements, a third reviewer (F.O.) intervened with an additional discussion. The three electronic databases , and a PD ≥ 4 mm ,20. If tThese two studies had a follow-up of 3 months. In the control groups, mechanical subgingival debridement was carried out using ultrasonic scaler instruments and glycine-based powder–air-polishing to remove subgingival biofilm ,20. In tThe RCT of Isehed et al.  from 201A total of 170 patients were included in the six studies; 4 patients dropped out, 154 patients received EMD treatment, and the rest were in the control group. Patients with confirmed peri-implantitis (PD ≥ 4 mm and BOP and at least one implant with angular peri-implant bone loss ≥3 mm) were included. Exclusion criteria were uncontrolled diabetes, heavy smoking . In terms of marginal bone loss, an average value of 6.0 mm at the mesial level and 4.9 mm at the distal level was found on the day of surgery. Measurements one year after surgery showed an average of 4.7 mm on the mesial side and 4.0 mm on the distal side of the implant, indicating an improvement in bone level [In Pilenza’s retrospective case series , after dne level .The three cohort studies ,24,25 usAccording to Mercardo and coworkers , 100% ofNone of the included RCTs, in both surgical and non-surgical therapy, achieved a low ROB . In the Non-surgical and surgical treatment consensus have been published over the years in order to offer to clinicians a better perspective over the approach of peri-implantitis. In clinical practice, the definition of peri-implantitis is necessary in order to establish which treatment should be applied. In 2017, at the World Workshop, Berglundh and coworkers published a consensus paper of peri-implant disease and conditions . AuthorsNon-surgical treatment of peri-implantitis consists of mechanical debridement plus injection of EMD into the peri-implant sulcus. As seen in the p = 0.01) and systemic antibiotics  had great BOP reduction; the adjunctive use of local antiseptics  led to greater PD reduction, and changes in BOP were comparable  [p = 0.42, I2 = 0%) in peri-implant mucositis and also did not improve in peri-implantitis . The same authors mentioned that the efficacy of using chlorhexidine in reducing BOP in peri-implantitis is debatable [Besides using EMD in non-surgical approach, the current literature has mentioned other alternative or adjunctive methods. Ramanauskaite and coworkers published a meta-analysis on the efficacy of non-surgical treatment of peri-implant mucositis and peri-implantitis . Non-sur = 0.29) , the autebatable . Regarding the efficacy of using EMD in the surgical treatment of peri-implantitis, Alberti et al. found that EMD might improve bone–implant contact (BIC) although the long-term effects on bone stability and implant survival still need to be confirmed by more studies . BompardIn the RCT of Isehed et al. , 31% of To promote wound healing and tissue regeneration, Froum et al. ,24 combiRamanauskaite and coworkers published a meta-analysis comparing the effects of adjuvant and alternative methods in the surgical treatment of peri-implantitis following a reconstructive versus a non-reconstructive approach . SignifiRegarding the rationale for systemic antibiotic administration after non-reconstructive peri-implantitis treatment, no differences in PD and BOP improvements were found between the test and control groups . The samp = 0.01; WMD −1.47 mm, p = 0.01), low PD , and soft tissue recession , while changes in BOP  were not significant in the study from Ramanauskaite and coworkers [Adjuvant reconstructive methods in conjunction with surgical treatment of peri-implantitis led to significantly higher radiographic bone defect fill/reduction (WMD 56.46%, oworkers . The effoworkers . The resoworkers .Our systematic review has several limitations. The first limitation would be the low number of RCTs and prospective studies included, which also had a low number of patients. Second would be the use of different diagnosis and treatment protocols, which may have represented a bias. Due to heterogeneity of the included data, a statistical analysis for a meta-analysis could not be achieved. Although the electronic literature search was limited to three electronic databases and was assessed until August 2022, several data may have been left out.Our systematic review evaluated the efficiency of using EMD in surgical and non-surgical peri-implantitis. Our results indicated low evidence in non-surgical approaches and modest evidence in surgical approaches using EMD; however, a statistical analysis could not be achieved due to the heterogeneity of data. For these reasons, our results should be interpreted with caution. More RCTs with standardize protocols are necessary to evaluate the efficacy of using EMD in both therapies.


The complexity and application range of interventional and diagnostic procedures using contrast media (CM) have recently increased. This allows more patients to undergo procedures that involve CM administration. However, the intrinsic CM toxicity leads to the risk of contrast-induced acute kidney injury (CI-AKI). At present, effective therapy of CI-AKI is rather limited. Effective prevention of CI-AKI therefore becomes crucially important. This review presents an in-depth discussion of CI-AKI incidence, pathogenesis, risk prediction, current preventive strategies, and novel treatment possibilities. The review also discusses the difference between CI-AKI incidence following intraarterial and intravenous CM administration. Factors contributing to the development of CI-AKI are considered in conjunction with the mechanism of acute kidney damage. The need for ultimate risk estimation and the prediction of CI-AKI is stressed. Possibilities of CI-AKI prevention is evaluated within the spectrum of existing preventive measures aimed at reducing kidney injury. In particular, the review discusses intravenous hydration regimes and pre-treatment with statins and N-acetylcysteine. The review further focuses on emerging alternative imaging technologies, alternative intravascular diagnostic and interventional procedures, and new methods for intravenous hydration guidance; it discusses the applicability of those techniques in complex procedures and their feasibility in current practise. We put emphasis on contemporary interventional cardiology imaging methods, with a brief discussion of CI-AKI in non-vascular and non-cardiologic imaging and interventional studies. CI-AKI is also a leading cause of acute renal failure in hospitalized patients, ranking third after ischemic and drug-induced injury (The first report of contrast-induced acute kidney injury (CI-AKI) appeared in 1962 , althougd injury . The incd injury . For allTo summarize the present understanding of CI-AKI, this review discusses the contemporary methods for CI-AKI prevention and for its risk estimation. The incidence of CI-AKI and the discrepancies in the relevant reports are described together with their implications for prevention strategies. The review concentrates primarily on imaging techniques of interventional cardiology and discusses CI-AKI mitigating methods including device-guided hydration, novel contrast-free imaging, and the emerging pharmacologic pre-treatment possibilities. The review also presents suggestions for further research needed to obtain an evidence-based assessment of the effectiveness and feasibility of novel approaches to CI-AKI.PubMed, Cochrane Library database, and Embase have been searched for publications of Clinical Trials, Meta-analyses, Randomized Controlled Trials, Reviews, and Systematic Reviews with the following keywords: ACUTE AND (“KIDNEY INJURY” OR NEPHROPATHY OR “KIDNEY DISEASE” OR “RENAL FAILURE”) AND “CONTRAST MEDIA”. Publications in English were considered if referring to an adult population (>18 years of age). These searches found 360 articles up to the publication year of 2021. Subsequently, the publications were screened to exclude duplicates and editorial comments.The definition of acute kidney injury (AKI) and of CI-AKI varies in different publications –9. IndeeThe true CI-AKI incidence has recently been discussed –15. PrevInterestingly, some studies found no increase in CI-AKI incidence after CM administration in comparison to a clinically matched control population who received no CM , 22. MetThe role of CM in nephropathy is possibly occasionally overestimated. Nevertheless, the risk of CI-AKI is not negligible. Recent propensity score-matching meta-analysis by Gorelik et al. showed significantly increased likelihood of CI-AKI patients with advanced renal insufficiency who underwent radiocontrast-enhanced computed tomography . SimilarHence there are number of studies that dispute the absence of CI-AKI risk, especially if considering elderly patients or those with advanced chronic kidney disease. Adequately powered and well controlled clinical registry is required to determine the actual risk of CI AKI under different conditions.The pathogenesis of CI-AKI is still not fully understood. Nevertheless, a consensus exists that it is caused by a combination of direct renal toxicity by CM and of the hemodynamic perturbations due to CM administration that led to indirect renal toxicity.in vitro using isolated or cultured human tubular cells, and in vivo using animal models. While all CM types are cytotoxic in vitro, the detailed cytotoxicity mechanisms can only be approximated. Cellular disarray is observed but the details of physiologic pathways that lead to cellular necrosis remain unknown. Translation to clinical practice and clinical studies is rather problematic. This may be, in part, due to the concentrations of CM used in animal studies . As proposed by Ward et al.  revealed that mitochondrial viability decreased considerably faster than cell viability. As a result, it is hypothesized that mitochondrial cells, as one of the first structures in cells, are damaged. In clinically relevant CM exposure, the previously suggested mechanism of misfolded or unfolded protein accumulation with subsequent endoplasmic reticulum stress does not play a critical role in decreasing cell viability . This eventually overwhelms cells innate antioxidant systems and damages cells via interaction with intracellular organelles and proteins . ExposurPresently, the treatment of CI-AKI may still be rather limited. Only supportive measures, such as hemodynamic parameters adjustment or avoidance of nephrotoxic medication, might be considered . A certaAltogether, at least 22 stratification models predicting the risk of CI-AKI in patients undergoing percutaneous coronary intervention (PCI) have been developed. As depicted in 2 (more points for more severe reduction of kidney function). This risk score is presently used in many catheterization laboratories and has been repeatedly externally validated , insulin-like growth factor-binding protein-7 (IGFBP-7), tissue inhibitor of metalloproteinase-2 (TIMP-2), Interleukin 18 (IL-18), liver fatty acid-binding protein (L-FABP), and Kidney injury molecule (KIM-1) have been investigated. Among those, the combination of TIMP-2 and IGFBP 7 proved to be superior to others , 57. Bote of 97% . Cell cye of 97%  or in see of 97% .®  and was one of the first commercially available tests of cell cycle arrest biomarkers in urine. The benefits of such a system are apparent in the quick turnaround time of 20 min, availability as a point-of-care test and requirement of small amounts of urine for diagnostic purposes. In current clinical practice, values of 0.3 (ng/ml)2/1,000 require a nephrology consult due to the high risk of CI-AKI  and BioPorto® NGAL test (BioPorto Diagnostics). Inconveniently cut-off value indicating the presence of the renal disorder is not known for ARCHITECT® and ALINITY®, however higher values are predictive of renal injury and subsequent AKI development. The meta-analysis by Yi He  was published. Following renal injury or stress, KIM-1 gets upregulated and facilitates recognition and clean-up of dead renal cells in the injured kidney. Therefore urinary KIM-1 values has high predictive value for the diagnosis of CI-AKI in patients undergoing administration of iodinated CM .Concerning those discoveries, ongoing trials focused on thorough examination of those novel biomarkers may result in the subsequent implementation of the routine level assessment of these into clinical practice.Serum creatinine and Serum Cystatin C, the most known markers for CI-AKI are elevated only at the later stage of CI-AKI. The search for biomarkers with earlier peak values is therefore of high importance. Current evidence suggests the applicability of MicroRNA (miR) measurement in predicting CI-AKI development. MiR work as regulatory agents that binds to mRNAs and degrade them. It was demonstrated that changes in levels of miRNA correlate to acute and chronic kidney injuries . The mosWe advocate adopting models presented by Chen et al. or Gurm et al. due to the external evaluation and exclusively incorporated pre-procedural risk factors. However, considering currently published breakthroughs, we propose that a new model should be developed. Hematologic and biochemical factors such as neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, red blood cell distribution width, and hsCRP could also be included in this model. These values are normally known ahead of time or are simply calculated, and they do not incur any additional expenses.A more prudent method would be to test novel biomarkers such NGAL, IGFBP-7, and TIMP-2 to predict and detect CI-AKI earlier .In conclusion, a new risk prediction model for practical CI-AKI risk stratification is needed. External validation of models, as well as generalizability to all diagnostic procedures with CM administration, is an important next step in the development of stratification models. However, the true applicability of current models is questionable in emergencies such as STEMI or Cardiogenic shock, where laboratory results or prior medical history is usually not known. Therefore, it is needed to have an easily applicable risk model for those situations as well. We would also recommend an internet-based, app-based, or hospital software-implemented calculator because more sophisticated models are frequently more sensitive while being more difficult to calculate on the spot.According to the published data on CI-AKI prevention, minimizing the use of iodinated contrast agents and using low or iso-osmolar CM agents appears to be of greatest importance , 72. TheIn modern interventional and diagnostic procedures, the most used CM is low-osmolar non-ionic CM or iso-osmolar CM . Low osmolar CM was found to be non-inferior to the iso-osmolar CM . Since tCM administration leads to an increase in urine viscosity proportional to CM volume. Animal and human studies showed that sufficient hydration reduces urine viscosity after CM administration , 76. TheUncertainty remains in respect of the appropriate volume of fluids to be administered. This question was partially answered by the randomized POSEIDON trial . CI-AKI These findings led to the development of devices specifically designed to force diuresis. The principles of such tools also correspond to the older findings of the PRINCE study which showed that maintaining steady high urine flow effectively eliminates CM . The firThe comparison of meta-analyses of iv. hydration regimes have been visualized in n = 61), the BIVA-guided hydration group had a decreased incidence of CI-AKI (3.3% vs 6.5%). It did not, however, achieve statistical significance (p = 0.015)  is an accurate tool for determining the patient’s current extracellular water volume which closely correspond to intravascular volume. Maioli et al. reported a study that used BIVA analysis on patients undergoing PCI for stable coronary artery disease. Lower BIVA fluid status was an independent and significant predictor of CI-AKI. . This inificance . Maioli = 0.015) . TherefoAcetylcysteine (NAC) intravenous or oral administration was among the first methods proposed for the CI-AKI prevention . One of Studies that compared NAC as addon therapy with concomitant Iv., preferably saline, hydration are listed in The NAC doses ranged from 2.500 to 15.000 mg over 2–4 days. Adverse effects of NAC are well known from paracetamol detoxification  and commStudies and trials of CI-AKI prevention by NAC resulted in discordant and uncertain results. The diversity of these results might be explained by different patient populations, variable dosing regimens, and/or concomitant infusions of balanced solutions. Follow-up periods were also not consistent. Despite the absence of a clear benefit of periprocedural NAC administration, the practice appears continued across medical centers. This might be contributed by NAC safety, low cost, and application ease. Nevertheless, considering the discordant observations, NAC administration is not recommended as the sole intervention for CI-AKI prevention .Nevertheless, this recommendation is not entirely consistent with the recent meta-analyses . LargestGiven the overall positive findings in the meta-analyses see , NAC neeRetrospective and prospective studies have shown that statins have a protective effect in preventing contrast-associated nephropathy . These fSecond or third-generation statins have been used in most randomized clinical trials investigating their effect in CI-AKI prevention. Specifically, rosuvastatin, atorvastatin, or simvastatin were used at doses corresponding to high-dose intensity. This corresponds to 20–40 mg for rosuvastatin and 40–80 mg for atorvastatin or simvastatin. The duration of treatment ranged from hours to days after the intervention or inclusion of patient into the trial.One of the first clinical trials investigating statin therapy for CI-AKI prevention was the PROMISS study . HoweverSome systematic meta-analyses have recently reviewed the use of statins as a CI-AKI prevention method see . Their rA multicenter randomized clinical trial is therefore needed to address the protective CI-AKI effect of high-intensity statins in patients undergoing interventional cardiology and other imaging procedures. Notwithstanding this need, the recent clinical practice guidelines uniformly indicate high-intensity statins for atherosclerotic disease. Therefore, almost all cardiac patients undergoing imaging procedures will be on HMG-CoA reductase inhibiting drugs.Many other agents that have been evaluated to prevent CI-AKI. Anti-ischemic agent trimetazidine  has beenp = 0.05)   118). I. Ip = 0. = 0.05) .2)  , 73. Int2) , 120. GiHeme-oxygenase is an inducible enzyme with anti-apoptotic and antioxidant properties. Its antioxidant properties are explained by the overexpression of bile pigments, which scavenge free radicals, and by trapping hydrogen peroxide in the biliverdin-to-bilirubin conversion reaction. Carbon monoxide is another by-product with anti-inflammatory properties . Animal Remote ischemic precondition (RIPC) is a phenomenon in which episodes of transient ischemia on distal organs provide the resistance to the subsequent episode of ischemia on central organ. It was demonstrated that the brief periods of ischemia to muscular muscle protect kidney and cardiac tissue . InteresNumber of studies examined whether RIPC may be able to protect the kidney. Wever et al. investigated whether cycles of brief limb occlusion by manual sphygmomanometer can protect against renal ischemia-reperfusion injury. Bilateral RIPC was more effective than unilateral RIPC, but both improved renal function by 30–60% . Effect Although many new studies have further advanced our knowledge in this area, the appropriate intensity of RIPC and its mechanisms of action are still unknown. RIPC is a safe procedure, as no relevant adverse events related to RIPC application were reported in the clinical trials performed to date. This approach may offer a novel, non-invasive and inexpensive treatment strategy for decreasing AKI incidence in high-risk patients.Hemodialysis can remove CM from the circulation and its role in the treatment of kidney failure is well established. However, this does not apply to CI-AKI prevention . DespiteInnovative and/or alternative imaging techniques might assist in CI-AKI avoidance attempts. Specific techniques have been proposed to reduce the CM volume. These include including CM dilution, contrast modulation systems, intravascular ultrasound (IVUS), and non-contrast optical coherent tomography (OCT) based-guided PCI.The most basic method for contrast volume reduction is CM saline dilution. It has been proposed that dilution of up to 50% could be used without compromising imaging quality . In few The volume of CM can be minimized, provided an ideal coronary artery visualization. This can be achieved by limiting coronary reflux through optimized delivery profile of CM and minimized excess aortic reflux. The emerging methods for CM volume reduction are lately being investigated.Most notably, FDA-cleared a dedicated contrast-reducing DyeVert™ system . It’s a device intended to reduce CM volume while maintaining image quality. It available in options compatible with manual as well as automated contrast injections.p = 0.03). As a result, the number needed to treat for CI-AKI prevention is 20, preserving adequate image quality in 98% patients , no significant differences in CI-AKI incidence were observed compared to periprocedural hydration alone . On the patients . Furtherpatients . The ongAnother alternative is to remove the CM directly from the coronary sinus. Because CM is removed from the myocardium via the coronary sinus, direct engagement, and the aspiration of blood from the coronary sinus may reduce peri-procedural CI-AKI. One of the initial studies used CINCOR™, an 11-French modified catheter. Although this system can reduce administered CM volume by 27% without affecting hemoglobin levels, it requires a femoral approach (a proven risk factor for CI-AKI) . Similarad hoc nature of the procedure. Therefore CI-AKI incidence reduction by IVUS-guided PCI compared to conventional angiography-guided PCI still needs to be proved in properly designed randomized trials, e.g., in the ongoing MOZART II trial  , nor hep2 delivery systems. No documented adverse renal effects make it the perfect substitute in patients with CKD undergoing interventional diagnostic procedures. The fundamental restriction in current practice is that CO2 should not be utilized in arteries above the diaphragm  due to the potential risk of cerebral air embolism. Although this complication is uncommon , it can theoretically lead to stroke and death   . Anothern of CO2 . CO2 couining CM . Recentlining CM .A novel technology for real-time live navigational guidance in coronary tree was recently patented by Philips. It is called Dynamic coronary roadmap™ (DCR) and was designed for procedure efficiency in complex PCI. This is achieved due to the overlaying automatically generated map of coronary tree vessels which are superimposed on live fluoroscopic images. First clinical use was reported in 2015 . HereaftFindings from coronary artery procedures translate to structural interventional cardiology with few changes. TAVI has a lower risk of CI-AKI. Despite the higher rate of anemia and the higher degree of CI-AKI in a study comparing TAVI vs. PCI, the occurrence of CI-AKI was significantly lower in the TAVI cohort. (6.7% vs. 14.5%) . A recenSince the discovery of CA-AKI, prevention recommendations have centerd on the optimizing of hemodynamics and fluid status, avoiding nephrotoxic treatments, and identifying and treating the underlying cause as soon as possible. As a result, the authors of this manuscript suggest the following approach . We recoAccording to the ESC guidelines, every patient with CKD should receive periprocedural hydration with intravenous saline . For at least 24 h, all patients should abstain from taking nephrotoxic drugs if feasible ; preoperative ACEI/ARB discontinuation may be considered if tolerated. Given the low costs and the low risk of side effects, statin therapy should be initiated or titrated to a high-dose statin if already being administered. If the patient has modifiable patient-related risk factors see  and coroIf a patient is classified as high to intermediate risk of CI-AKI, it should be proceeded with all contrast-reducing and non-contrast procedures accessible. If available, the use of Renal Guard or a comparable approach for tailored aggressive intravenous fluid therapy  should be considered. Based on the findings of meta-analyses and trials with the DyeVertTM system, the use of such a device may be useful in any CKD patient undergoing an interventional or diagnostic procedure with CM. If available, techniques for dynamic coronary vessel imaging, biplane imaging and stent visualization (such as ClearStent™ by Siemens etc.) should be used. If technically feasible, new biomarkers for early diagnosis and prediction of CI-AKI could be used . This method could aid in an earlier CI-AKI diagnosis and eventual intervention.We propose developing a new risk prediction model based on standard risk factors of CI-AKI yet including novel diagnostic possibilities such as inflammatory hematological and biochemical parameters. The inflammatory process in the kidney is complex, but in the early stages of CI-AKI, neutrophils are recruited first, followed by lymphocytes. As a result, we could include in risk prediction models the neutrophil-to-lymphocyte ratio (NLR), segmented-neutrophil-to-monocyte ratio (SMR), neutrophil-lymphocyte-platelet ratio (NLPR), red blood cell distribution width, and hsCRP. These values are usually known ahead of time or can be easily calculated with no added costs. Because of ongoing research with novel CI-AKI biomarkers such as NGAL, TIMP, IGLF 17, and microRNAs, future early prediction models may rely on them.The treatment optimization aimed at recognizing and correcting identified risk factors may reduce the likelihood of CA-AKI. Thus, the treatment customization based on biochemical and hematological values measured should be critical for the future management of CI-AKI. Recent CI-AKI research focuses on developing a potent antioxidant or vasoactive agent capable of reducing vasospasm or the intrinsically cytotoxic properties of CM. Recent studies with nicorandil, trimetazidine, inorganic nitrate, or pentoxifylline have produced promising results, but these should be confirmed by a robust multicenter study yet. Recent trials with antioxidant inducers such as Heme-oxygenase may be a future prevention method, but definitive evidence of its benefit is still required. Remote ischemic preconditioning and protein isolation responsible for its beneficial effect could have a significant impact not only on CI-AKI prevention but also on AKI prevention in general.The most significant technological advances in the prevention of CI-AKI occurred in alternative imaging technologies, contrast modulation systems and interventional procedures. Assuming the future decrease of the costs and better availability of these methods, their general applicability in most situations could significantly reduce the CI-AKI prevalence. As a result, completely zero contrast, non-iodinated CM, or ultra-low contrast techniques may be routinely used in high risk patients in the future.Contrast-induced acute kidney injury represents a clinically significant complication. Its importance has increased because of the increasing number different iodinate CM investigations. The multitude of variable confounding factors and frequent exclusions of patients with a substantial CI-AKI risk have not allowed the creation of universal rules for patients undergoing imaging procedures with CM administration. In addition to the recommended standard fluid hydration protocol and to the CM reduction and modulation, some novel approaches have been studied involving individualized hydration and sophisticated tools minimizing the CM administration. Specifically, we discuss novel approaches advocating for zero contrast, ultra-low or alternative media administration. The general applicability of these approaches proved to be safe and feasible yet limited by the top-tier availability. Another promising method such as carbon dioxide angiography are discussed: based on current animal studies, this method could be extended to be used above diaphragm angiographies without any safety concerns, if future clinical trials prove this. We also discuss advanced dynamic coronary mapping technology, which aids in orientation during low to zero contrast interventional cardiology procedures. Understanding of pathogenesis and advances in proteomics allowed us to locate the specific molecule responsible for cell death and the initiation of pro-apoptic pathways in injured renal cells. As a result, the new age of targeted therapy and novel biomarkers appears to be on the horizon. Finally, we discussed the implications of the RIPC findings, which, despite being a simple preventive method, has no adverse effects and could be offered to the patients with a higher risk of CI-AKI. There is, however, an unmet need for additional multicenter randomized trials with large cohorts to clarify effect of discussed prevention methods on CI-AKI incidence reduction. Such trials should ideally include longer follow-up periods and should also study non-cardiovascular procedures. Patients with severe chronic renal insufficiency and those on hemodialysis also need to be investigated.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.


Early-axial PD patients had short-term recall impairment, not seen in non-axial PD . These variables were similar between late-axial PD (n = 18) and non-axial PD, but late-axial PD showed worse frontal dysfunction. Conclusions: PD patients with early axial symptoms after DBS may have a significantly worse presurgical motor phenotype, poorer dopaminergic response and memory impairment. This may correspond to a more severe form of PD.Background: The relationship between axial symptoms in Parkinson’s disease (PD) and subthalamic deep brain stimulation (STN-DBS) is still unclear. Purpose: We searched for particular clinical characteristics before STN-DBS linked to on-state axial problems after surgery. Methods: We retrospectively analyzed baseline motor, emotional and cognitive features from PD patients with early axial symptoms (within 4 years after STN-DBS) and late axial symptoms (after 4 years). We also considered a group of PD patients without axial symptoms for at least 4 years after surgery. Results: At baseline, early-axial PD patients ( Parkinson’s disease (PD) is the second neurodegenerative disease in frequency after Alzheimer’s disease. On-axial symptoms in Parkinson’s disease (PD) include gait, posture and balance problems, dysarthria and dysphagia. They are frequent in the advanced stage of the disease . Given iFreezing of gait has been correlated to the dysfunction of the supraspinal locomotor network . This nePD shows remarkable clinical heterogeneity. Combining motor and non-motor symptoms, different PD phenotypes have been established . Mainly These PD clinical subtypes, already identifiable in early phases of the disease, are to true subgroups within PD rather than to different phases of the same entity. Recently, it has been suggested that different PD clinical subtypes may have different speeds in the pathological process until they reach a common endpoint . PreviouGait is not affected at initial stages of PD. Later, its deterioration implicates a degeneration of non-dopaminergic pathways, maybe cholinergic . Cognitioff meds before STN-DBS with on stim. This only shows the STN-DBS beneficial effect on the off-state axial symptoms. Off-state axial symptoms are mainly due to bradykinesia and rigidity and respond to dopaminergic treatments. Nevertheless, these studies curiously compare axial symptoms in pars reticulata and high-frequency stimulation of subthalamic nuclei (STN) [On the other hand, some groups have described improvement in axial symptoms by switching to low-frequency stimulation ,19. Thisei (STN) ,23.On-state axial symptoms are currently poorly understood and many times, they have been approached in somewhat controversial manners. This study aims to search for a possible presurgical parkinsonian profile associated with the development of on-state axial symptoms after surgery.This retrospective and observational study conducted on a registry of PD patients with STN-DBS included consecutively to our maintained databank from the Movement Disorder Unit of the Hospital Clínico Universitario de Santiago de Compostela, Spain. For determining the criteria for STN-DBS, we have based on the Core Assessment Program for Surgical Interventional Therapies in Parkinson’s Disease (CAPSIT-PD)  with somon-state, as well as UPDRS part II items for falls, freezing and walking. We calculated UPDRS improvement (i) as follows: UPDRS III (i) = UPDRS III off-UPDRS III on/UPDRS III off.We recorded demographical  and clinical data. We assessed daily patient activities and motor state with the UPDRS part II and part III, resulting from a preoperative evaluation around six months before the surgery. After the overnight withdrawal of dopaminergic medications and after a levodopa challenge with 1.5 times the morning dose, we evaluated the patients. Apart from the total motor score of UPDRS part III, we individually analyzed an axial score  and a tremor score  in p” and category “animal” fluency were measured. The Yesavage Depression Scale (YDS) was performed to quantify depression (>14) or subdepressive mood (>11).When performing an STN-DBS surgery, all patients had a neuropsychological evaluation. We evaluated the global cognitive status with the Mattis Dementia Rating Scale (MDRS). Memory was assessed using the Rey Auditory-Verbal Learning Test (RAVLT). Executive functions were evaluated by 3-piece Tower of Hanoi. Working memory was measured the Wechsler Adult Intelligence Scale (WAIS-digits) digits test digits). Visual memory and visuospatial skills were evaluated using the Benton Visual Retention Test (BVRT) and the Benton Judgement of Line Orientation (BJLO). Verbal phonetic “t-tests with Bonferroni correction. The Cochran test was chosen to compare more than two groups for categorical variables.Data are expressed as percentages for qualitative variables and mean and standard deviation for quantitative variables (we have included UPDRS and items or derived scores in this group). Data normality and equality of variances were assessed using the Shapiro–Wilk and Levene tests. ANOVA for repeated measures was completed for the quantitative variables to determine statistical differences across three situations  if the normal distribution assumptions were met. If not, the Friedmann test was used. Post hoc analyses were completed using on meds evaluation, and one had an acute complication with permanent neurological sequelae . We did not consider either two patients who developed unmistakable symptoms of atypical parkinsonism and one patient who suffered from cervical myelopathy, resulting in a permanent tetraparesis. Between January 2010 and December 2020, a total number of 170 PD patients underwent STN-DBS surgery. For the follow-up analysis, sixteen patients were excluded due to the following reasons: nine had their follow-up elsewhere, four had intolerability to levodopa, so we lacked an n = 153), we selected those who experienced a significant gait, balance and speech impairment, defined by 8 or more points in the axial score [axial-PD had a negative levodopa challenge with stimulation off .For the remaining patients  and 18 in late-axial PD (75.3 ± 19.2 months). Fifty-one patients were included in non-axial PD .p = 0.010), but not older than late-axial PD. All three groups did not differ in years with PD before surgery or in LEDD. Early-axial PD had significantly higher scores for on-state UPDRS II , including gait , in comparison to non-axial PD. Early-axial PD also had significantly higher scores in on-state for UPDRS III , axial score  and lower UPDRS improvement  in comparison to non-axial PD. Concerning late-axial PD, early-axial PD only reached statistical differences for freezing and falls. Late-axial PD had motor scores similar to non-axial PD, except for a lower tremor score . Clinical characteristics before STN-DBS of each group are detailed in At baseline presurgical evaluation, early-axial PD was significantly older than non-axial PD  concerning non-axial PD. Besides, early-axial PD had the lowest scores of all three groups in RAVLT long-term recall and BJLO, although there were no statistical differences between them. Late-axial PD had significantly lower scores at baseline for MDRS , BVRT  and 3-piece Tower of Hanoi  in comparison to non-axial PD. Early-axial and non-axial PD had similar scores for global cognition (MDRS) and frontal tasks , and late-axial PD non-axial PD did not differ so much in memory. Early-axial PD had higher scores for YDS obtaining results for established depression. Neuropsychological evaluation before DBS of each group is shown in At baseline, early-axial PD had significantly lower scores for RAVLT short-term recall  and subcortical (automatic and fast) networks. PD patients are compelled to rely on cortical control due to basal ganglia dysfunction . A decliWe may not exclude that non-axial and late-axial PD probably represent a continuum in the disease. Some non-axial PD patients will eventually become late-axial. Nevertheless, our data suggest that late-axial PD represents the classic rigid-akinetic phenotype of the disease. This does not mean a limitation for the analysis of patients who develop early prominent axial symptoms since we have not considered non-axial PD patients under four years after surgery.On-axial symptoms involve a more severe stage of PD, as they do not respond to dopaminergic medication. A meta-analysis [off meds/on stim situation significantly improves axial symptoms compared to the baseline off meds. Therefore, the effect of STN-DBS lies in a better stimulus for previously dopaminergic, responsive axial symptoms. Therefore, what happens when the axial symptoms do not respond to the medication remains to be evaluated. Actually, “on-freezing” patients are not candidates for STN-DBS.analysis  and two analysis ,13 show off (worst) or in an on (best) situation. A levodopa challenge with DBS switched off is required [When the axial symptoms happen in operated patients, especially if they do it early, we should assess whether they occur in an required . An improff meds/on stim situation does not substantially improve the off meds/off stim, in contrast to the on meds/on stim [Therefore, we find the results of the publications that support the effectiveness of lowering the frequency of stimulation (between 60 and 100 Hz) in axial symptoms controversial. About half of the subjects in two of these studies have questionable effectiveness of the STN-DBS as the /on stim ,36. It i/on stim . ChangesMany factors may be influencing the DBS adjustments. First, to assess the early response to the stimulation, we should be guided by fast responding signs, such as rigidity, the most reliable sign, or tremor. On the contrary, bradykinesia has a latency of hours to days, so it is less useful . Second,Our clinical experience after over 300 patients operated on in 20 years is in line with observations by Ricchi et al.  and SidiThis study suggests that different PD phenotypes may have different responses to STN-DBS. To identify these particular phenotypes may be important for predicting the result after surgery. It is remarkable that poor response to stimulation probably has more to do with non-dopaminergic pathways. Current tests for presurgical examination lack sensibility to identify this phenotype with worse result. Finally, PD patients who develop earlier prominent axial symptoms show particular motor and cognitive characteristics. On the one hand, they seem to have a previous worse motor phenotype and a poorer response to dopaminergic medication. On the other hand, their cognitive profile is not typical, with selective memory impairment, probably due to a cholinergic dysfunction. There is a proven relationship between cholinergic dysfunction and axial symptoms. PD patients who develop later axial symptoms have similar features to non-axial patients, except for a more pronounced frontal dysfunction. This suggests that longer evolution for PD is critical for developing axial symptoms in late axial PD. We believe that these factors are the main determinants for developing axial symptoms, not the STN-DBS itself, but many aspects of the functionally of cerebral oscillatory networks remain to be elucidated.Our study has some limitations, first of all, being retrospective. It was chosen to view the mean axial score obtained in the studies cited, in which axial symptoms after STN-DBS were evaluated. To consider the axial symptoms only as a cut-off value of the UPDRS scale may be too simple. In the same way, we selected 4 years as a reasonable lapse of time in the advanced PD. An ongoing study with survival analysis using the time to axial features may provide better data. A similar study in a different site or a single study with data from two sites would be more explanatory. It would be interesting to include the electrodes locations and stimulation parameters employed or medication adjustments. We have always checked the levodopa response when axial symptoms occur in an operated patient. This has ensured its non-dopaminergic nature or makes us suspect of inefficient stimulation.It is likely that a particular clinical PD phenotype and, therefore, an underlying pathology, are more prone to develop axial symptoms after STN-DBS. However, there may be other factors such as age, vascular comorbidity or changes in medication. There remain many questions to be solved regarding high-frequency stimulation and axial motor symptoms. Two meta-analysis concluded that the benefits of STN-DBS for axial symptoms showed a decline in the long term ,44. This


Forty-three countries have now implemented best-practice policies for tackling trans fat in food, with 2.8 billion people protected globally.Despite substantial progress, however, this still leaves 5 billion worldwide at risk from trans fat’s devastating health impacts with the global goal for its total elimination in 2023 remaining unattainable at this time.Industrially produced trans fat  is commonly found in packaged foods, baked goods, cooking oils and spreads. Trans fat intake is responsible for up to 500 000 premature deaths from coronary heart disease each year around the world.“Trans fat has no known benefit, and huge health risks that incur huge costs for health systems,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “By contrast, eliminating trans fat is cost effective and has enormous benefits for health. Put simply, trans fat is a toxic chemical that kills, and should have no place in food. It’s time to get rid of it once and for all.”Currently, 9 of the 16 countries with the highest estimated proportion of coronary heart disease deaths caused by trans fat intake do not have a best-practice policy. They are Australia, Azerbaijan, Bhutan, Ecuador, Egypt, Iran (Islamic Republic of), Nepal, Pakistan and Republic of Korea.Best-practices in trans fat elimination policies follow specific criteria established by WHO and limit industrially produced trans fat in all settings. There are two best-practice policy alternatives: 1) mandatory national limit of 2 grams of industrially produced trans fat per 100 grams of total fat in all foods; and 2) mandatory national ban on the production or use of partially hydrogenated oils (a major source of trans fat) as an ingredient in all foods.“Progress in eliminating trans fat is at risk of stalling, and trans fat continues to kill people,” said Dr Tom Frieden, President and CEO of Resolve to Save Lives. “Every government can stop these preventable deaths by passing a best-practice policy now. The days of trans fat killing people are numbered – but governments must act to end this preventable tragedy.”While most trans fat elimination policies to date have been implemented in higher-income countries (largely in the Americas and in Europe), an increasing number of middle-income countries are implementing or adopting these policies, including Argentina, Bangladesh, India, Paraguay, Philippines and Ukraine. Best-practice policies are also being considered in Mexico, Nigeria and Sri Lanka in 2023. If passed, Nigeria would be the second and most populous country in Africa to put a best-practice trans fat elimination policy in place. No low-income countries have yet adopted a best-practice policy to eliminate trans fat.In 2023, WHO recommends that countries focus on these four areas: adopting best-practice policy, monitoring and surveillance, healthy oil replacements and advocacy. WHO guidance has been developed to help countries make rapid advances in these areas.WHO also encourages food manufacturers to eliminate industrially produced trans fat from their products, aligning to the commitment made by the International Food and Beverage Alliance (IFBA). Major suppliers of oils and fats are asked to remove industrially produced trans fat from the products sold to food manufacturers globally.The report, called Countdown to 2023 WHO Report on global trans fat elimination 2022, is an annual status report published by WHO in collaboration with Resolve to Save Lives, to track progress towards the goal of trans fat elimination in 2023.https://www.who.int/news/item/23-01-2023-five-billion-people-unprotected-from-trans-fat-leading-to-heart-diseaseAvailable from:


Here, we demonstrate the role of miR-184, a microRNA regulated by nutritional status, also helps in the survival of the larvae to adulthood in low food conditions.Nutrition is one of the critical factors known to regulate the development and growth of organisms. Lack of nutrients affects the proper functioning and survival of organisms. However, fluctuation of the levels of nutrients is quite common in a natural environment, and organisms have evolved various molecular and physiological means by which they can survive such conditions. microRNAs are short non-coding RNAs that play significant biological functions, primarily by acting as post-transcriptional buffers of noisy gene expression. Recent studies show that miR-184, a conserved microRNA, is expressed at higher levels in low nutrition conditions. Our experiments show that Many different environmental and genetic factors regulate the growth and development of an organism. Nutrition, one of the key factors known to regulate development, does so by inducing epigenetic changes and modulating various molecular mechanisms, for instance, by regulating DNA methylation status  and modulating the activity of both Insulin and TOR signalling pathways .Drosophilalarvae . Recently, the role of short noncoding RNAs called microRNAs in regulating growth and metabolism inDrosophilahas been reported. With miR-277 observed to control branched-chain catabolism and regulate lifespan . miR-33 was demonstrated to regulate TAG metabolism in mammals andDrosophila.miR-278mutants have excess circulating sugar levels and have low lipid stores, and they were also found to be insulin resistant . miR-14 regulates insulin signalling in flies and thereby fat metabolism . miR-8 inDrosophilaacts in the fatbody to promote insulin signaling and body growth . A recent study by Gendron et al. identified let-7, miR-184, miR-34, and miR-8 as differentially expressed in varying dietary conditions in adult flies . This work demonstrated the possible role these microRNAs could play in regulating the internal energy status following the external nutritional cues. Further, overexpression of miR-184 was found to decrease lifespan regardless of the food condition without any effects on triglyceride levels . However, the possible roles of miR-184 during a low nutrient environment have not been tested yet.Appropriate levels of nutrients are essential for the normal metabolism, growth, and development ofDrosophilainsulin-producing cells . miR-184 is a maternally deposited microRNA , expressed in a highly dynamic pattern throughout fly development with peak expression at stages 12–13 of embryogenesis and L3 larvae . It is known to play a role in various developmental processes and regulate many genes involved in the formation of septate junctions.miR-184 was also recently identified to increase in response to fasting in pancreatic islet cells . miR-184 was shown to be negatively regulated in a sucrose-rich diet, and the levels of this microRNA increased in response to starvation in the adult fly head . miR-184 was recently identified as an inhibitor of insulin secretion in pancreatic β-cell lines . However, no effects on growth were observed when miR-184 was over-expressed in themiR-184homozygous mutant larvae compared to the heterozygous control larvae when reared on DR food . There was an increase in lethality whenmiR-184mutant homozygous larvae were compared tow[1118]larvae also, which was used as an additional control, when reared on DR food . No lethality was observed during the pupal stages, as all the pupae emerged as adult flies.To check if miR-184 levels are affected in larvae raised on a low nutrient diet, we raised the larvae in food containing 50% diluted fly media (will be denoted as dietary restricted/DR food) in comparison to the standard food conditions in the lab . The level of the microRNA was measured and compared between early L3 larvae raised on standard food and larvae raised on DR food. The level of miR-184 was higher in larvae raised on DR food than those fed on standard food . Thus, upregulation of miR-184 in response to a low nutrient diet is observed even during larval growth stages. Homozygous deletion mutants of miR-184 are viable, with 79% of the larvae pupating and surviving till adulthood in normal food conditions . We found a significant increase in lethality in theDrosophilalarvae during low food conditions. Although the molecular mechanism via which miR-184 fine-tunes development in accordance with the nutritional cues remains to be elucidated.While lack of miR-184 during larval stages affected the survival of normally fed larvae, during low food conditions, the lack of miR-184 causes a further reduction of larval survival. In this context, an increase in miR-184 levels observed in response to diet restriction suggests an active role for miR-184 in circumventing the deleterious effects of nutritional stress. Thus, from our data, we conclude that miR-184 is important in the survival and development ofFood Composition:The food preparation was according to Rehman and Varghese. 2021.microRNA qRT-PCR:Total RNA was extracted from early L3 larvae using Trizol extraction method. miR-184 and 2SrRNA were reverse transcribed using a gene-specific stem-loop primer and the Takara MMLV reverse transcriptase. Followed by qRT-PCR with the use of TbGreen with the use of a Universal reverse primer and a miR-184 specific forward primer. The microRNA level was normalised to the levels of 2S rRNA.Survival to pupae: Embryo collection cages were set up using apple juice agar plates and the flies were provided with yeast to stimulate egg laying.miR-184Δ/CyO-GFPflies were crossed with each other to obtainmiR-184Δhomozygotes, non-GFP 1st instar larvae were collected, using a Leica fluorescence Stereoscope.miR-184Δ/CyO-GFPwas crossed tow[1118]to obtainmiR-184Δ/+heterozygotes, non-GFP 1st instar larvae were collected.w[1118]was used as an additional control. 50 L1 larvae were collected per vial and transferred to either of the food conditions . Multiple independent collections were performed. The number of larvae pupating was noted in all the genotypes in different food conditions.Fly stocks:w[1118]was a gift from Dr. Stephen Cohen’s lab.miR-184deletion mutant was purchased from the Kyoto stock center.