It is increasingly agreed upon that cognitive and audiological factors are associated with self-perceived hearing handicap in old adults. This study aimed to compare self-perceived hearing handicap among mild cognitive impairment (MCI) subgroups and a cognitively normal elderly (CNE) group and determine which factors  are correlated with self-perceived hearing handicap in each group. A total of 46 MCI patients and 39 hearing threshold-matched CNE subjects participated in this study, and their age ranged from 55 to 80 years. The MCI patients were reclassified into two groups: 16 with frontal-executive dysfunction (FED) and 30 without FED. All subjects underwent audiometric, neuropsychological, and self-perceived hearing handicap assessments. The Korean version of the Hearing Handicap Inventory for the Elderly (K-HHIE) was administered to obtain the hearing handicap scores for each subject. After controlling for age, years of education, and depression levels, we found no significant differences in the K-HHIE scores between the MCI and the CNE groups. However, after we classified the MCI patients into the MCI with FED and MCI without FED groups, the MCI with FED group scored significantly higher than did both the MCI without FED and the CNE groups. In addition, after controlling for depression levels, significant partial correlations of hearing handicap scores with frontal-executive function scores and speech-in-noise perception performance were found in the MCI groups. In the CNE group, the hearing handicap scores were related to peripheral hearing sensitivity and years of education. In summary, MCI patients with FED are more likely to experience everyday hearing handicap than those without FED and cognitively normal old adults. Although educational level and peripheral hearing function are related to self-perceived hearing handicap in cognitively normal old adults, speech-in-noise perception and frontal-executive function are mainly associated with hearing handicap in patients with MCI. Hearing impairment does not necessarily parallel self-perception of hearing handicap in everyday life . AccordiBoth audiological and non-audiological variables are associated with self-perceived hearing handicap. Several studies indicate an association between self-perceived hearing handicap and patient outcomes on speech-in-noise measures –8. A recThe aforementioned studies suggest that non-audiometric factors may play an important role in self-perceived hearing handicap in old adults. Thus, factors other than the degree of hearing impairment may contribute to self-perceived hearing handicap in old adults. One recent study on the impact of cognitive function on self-perceived hearing handicap indicates that old adults with high working memory capacity have more hearing difficulties in their daily lives, and the results contradict the authors’ initial hypothesis . AccordiTo overcome such limitations, this study was carefully designed in order to account for the effect of cognitive function on hearing-related difficulties. We hypothesized that old patients with mild cognitive impairment (MCI) would have more hearing-related difficulties than their hearing threshold-matched peers with normal cognitive function would. Specifically, we hypothesized that MCI patients with frontal-executive dysfunction (FED) would report greater hearing handicap than those without FED. Because previous studies have demonstrated that frontal-executive function strongly impacts speech-in-noise perception in patients with MCI ,14 and sth edition; and 4) normal activities of daily living. Exclusion criteria included a history of major medical, neurological, or psychiatric illness. The MCI patients were further classified into patients with FED  and patients without FED . The FED patients had to meet the following criteria: 1) age- and education-adjusted scores below -1.0 SD on the animal naming or phonemic-letter naming tests in the Controlled Oral Word Association Test (COWAT) [We recruited 46 MCI patients, aged 55 to 80 years, at the Memory and Dementia Clinic at the Dong-A University Medical Center. MCI was diagnosed according to the Petersen’s criteria : 1) subj (COWAT) . If patiWe recruited 39 cognitively normal old adults (14 men and 25 women) as a control group. The cognitively normal old adults had to meet the following criteria: 1) no significant underlying medical, neurological, or psychiatric illness; 2) normal performance as defined by age- and education-adjusted scores above -1.0 SD on the Korean version of the Mini-Mental State Examination (K-MMSE) , digit sFor hearing acuity, all subjects had to meet the following inclusion criteria: 1) no conductive components on tympanometry and pure tone audiometry; 2) hearing threshold levels at 0.5, 1, and 2 kHz ≤ 25 dB HL; 4 kHz ≤ 40 dB HL; and 8 kHz ≤ 70 dB HL for each ear; 3) no greater than 10 dB HL of inter-aural asymmetry on pure-tone averages (PTAs) ; 4) a speech discrimination score ≥ 80% for each ear; and 5) no previous use of hearing aids. The elderly subjects were recruited at a relatively early stage of age-related hearing impairment, which is characterized by threshold elevation beginning at high frequencies. This study was approved by the Institutional Review Board of the Dong-A University Medical Center, Busan, Korea (IRB#: 16–048). Written informed consent was obtained from every participant before the experimental procedures. The capacity of participants to give informed consent was assessed using the Clinical Dementia Rating (CDR) scale . It has All participants underwent pure-tone audiometry, speech audiometry, tympanometry, and speech-in-noise perception tests. Air and bone conduction thresholds were measured with a clinical pure-tone audiometer . We calculated the PTAs at 0.5, 1, 2, and 4 kHz for each ear. We measured the speech reception threshold, speech discrimination score, and most comfortable loudness level for each ear. Speech-in-noise perception was measured via sentence recognition tests with speech-spectrum and multi-talker babble background noise at a signal-to-noise ratio of -5 dB. The means or medians of the binaural average of the pure-tone audiometric thresholds at each frequency are shown in pure-tone audiograms for each group .All participants underwent a standardized neuropsychological test, the Seoul Neuropsychological Screening Battery (SNSB) . The SNSAll participants completed the Korean version of the Hearing Handicap Inventory for the Elderly (K-HHIE) ,26. SelfP = 0.05, and statistical analyses were carried out using SPSS 23.0 software.All continuous variables were first tested for normality using the Shapiro-Wilk test. Continuous variables not normally distributed, presented as medians and interquartile ranges, were analyzed using the Kruskal-Wallis test. However, the continuous variables normally distributed, presented as mean and SD, were analyzed using the one-way analysis of variance. Second, because normality was rejected for the hearing handicap scores, nonparametric analysis of covariance based on Quade’s test in SPSS was used to compare the hearing handicap scores among groups after adjusting for age, years of education, and depression levels. Post-hoc analyses were conducted using pairwise comparisons with Bonferroni corrections to examine the differences among groups. Additionally, multiple regression analysis using the backward elimination approach was performed in order to determine which independent variables, including cognitive impairment, age, years of education, and depression levels, were predictors of the K-HHIE total scores for the entire sample. Third, for nonparametric partial correlation, Spearman rank correlation coefficients (rho) were computed by controlling for depression levels in each group to examine the correlations of self-perceived hearing handicap with demographic, audiometric, and neuropsychological variables. Alpha levels were set at F1,83 = 2.590, P = 0.111), emotional , and total scores  on the K-HHIE. In addition, multiple regression analysis was performed using the backward elimination approach in order to determine which independent variables, including cognitive impairment , age, years of education, and depression levels, were predictors of the K-HHIE total scores for the entire sample. In the final model , depression levels  and years of education  remained significant while age (P = 0.917) and cognitive impairment (P = 0.273) were eliminated from the analysis. Simple linear regression analysis confirmed that the years of education and depression levels were significantly correlated with the K-HHIE total scores, respectively .After controlling for age, years of education, and depression levels, we found no significant main effects of group on social/situational , emotional , and total scores  on the K-HHIE. Post hoc analysis revealed that the MCI with FED group scored significantly higher than did both the MCI without FED (P < 0.001) and the CNE (P < 0.001) groups on the social/situational section. In addition, the MCI with FED group scored significantly higher than did the MCI without FED (P < 0.001) and the CNE (P < 0.001) groups on the emotional section. Moreover, the MCI with FED group scored significantly higher in total scores than did the MCI without FED (P < 0.001) and the CNE (P < 0.001) groups. No significant differences were found between the MCI without FED and the CNE groups on the social/situational, emotional, and total scores on the K-HHIE , CNE (dummy variable) , MCI without FED (dummy variable) , and depression levels  remained significant while age (P = 0.537) and years of education (P = 0.143) were eliminated from the analysis.In addition, we also performed multiple regression analysis using the backward elimination approach in order to determine which independent variables, including cognitive impairment , age, years of education, and depression levels, were predictors of the K-HHIE total scores for the entire sample. Dummy coding was conducted for cognitive impairment with the MCI with FED group as the reference group. In the final model (P = 0.041), color reading time per item , or interference scores  in the K-CWST. In the MCI without FED group, we found a significant correlation between the K-HHIE total score and the sentence recognition score in the multi-talker babble noise condition . In the total MCI group, we found significant correlations between the K-HHIE total score and the sentence recognition score in the multi-talker babble noise condition , word reading time per item , or color reading scores  in the K-CWST. In the CNE group, we found significant correlations of the K-HHIE total score with the PTA  or years of education   . ScatterIt is increasingly agreed that cognitive factors and audiological factors are associated with self-perceived hearing handicap, especially in old adults, suggesting that old adults with cognitive impairments may have more hearing-related difficulties than their hearing threshold-matched peers with normal cognitive function. As old adults with hearing handicap experience emotional distress and restrictions on social engagement in everyday life, which ultimately reduce their quality of life ,27, it iFirst, MCI patients with FED are more likely to experience hearing difficulties in their daily lives compared with those without FED or cognitively normal old adults. Considering the relationship between working memory capacity and executive functioning , the finIn the present study, among measures on frontal-executive function, variables related to the K-CWST were specifically correlated with hearing handicap scores in the MCI groups. In the MCI with FED group, hearing handicap scores were positively correlated with the color reading time per item and interference score, which is calculated by subtracting the time per item of the word reading from the time per item of the color reading. Moreover, in the total MCI group, hearing handicap scores were positively correlated with the word reading time per item and were negatively correlated with the color reading scores. The Stroop test mainly assesses the ability to inhibit cognitive interference and the processing speed by measuring the accuracy and speed of performance . BecauseSecond, speech perception performance is significantly correlated with self-perceived hearing handicap in patients with MCI. Specifically, hearing handicap scores were negatively correlated with the sentence recognition scores in the multi-talker babble noise condition in the MCI without FED and total MCI groups and in the speech-spectrum noise condition in the MCI with FED group. However, it should be noted that only the correlation between the K-HHIE total score and the sentence recognition score in the multi-talker babble noise condition in the total MCI group remained significant after applying a Bonferroni correction for multiple comparisons. Several previous studies indicate an association between self-perceived hearing handicap and outcomes on speech-in-noise measures –8. The fThird, peripheral hearing sensitivity explains little of the variance in MCI patients’ self-reported hearing handicap. The degree of peripheral hearing loss was not one of the factors correlated with subjective hearing difficulties in the MCI patients. In the CNE group, we found a relatively low correlation between hearing sensitivity and self-perceived hearing handicap. In addition, although numerous studies have shown that peripheral hearing sensitivity is correlated with self-perceived hearing handicap in old listeners, the correlations are only weak to moderate ,10. MoreThe fourth discussion point is that we found a significant positive correlation between hearing handicap scores and years of education in the CNE group. Although no such correlations were found in the MCI groups, old adults with higher education reported greater hearing handicap than those with lower education in the CNE group. The results are somewhat consistent with those in a previous study, which demonstrates that less than 12 years of education is an associated factor for less self-perceived hearing handicap . The assInterestingly, multiple regression analysis for the entire sample revealed that years of education and depression levels were possible predictors of the hearing handicap scores, but the correlation between hearing handicap and years of education was negative. This negative correlation for the entire sample was in the opposite direction from that for the CNE group. This result could suggest that educational level may affect hearing handicap differently in cognitively normal old adults and in cognitively impaired old patients. As shown in Finally, multiple regression analysis for the entire sample confirmed that depression level was also a significant positive predictor of hearing handicap scores. That is, the more that older listeners showed symptoms of depression, the more they had hearing difficulties. It is well known that depression symptoms adversely impact cognitive function in elderly people . SymptomNotably, this study suggests that MCI patients with FED experience more hearing difficulties than do their peers with normal cognitive function or MCI patients without FED in daily life. Cognitive function, especially frontal-executive function and speech-in-noise perception performance, is correlated with self-perceived hearing handicap in elderly patients with MCI. This study indicates that, in clinical practice, the self-assessment of hearing handicap, in addition to audiometric assessments, needs to be conducted in order to evaluate each individual’s hearing difficulties in daily life. If old adults report more hearing problems than do their hearing threshold-matched peers, they may have cognitive impairments, especially in frontal-executive function. Therefore, those old adults should be considered for assessment and intervention on neuropsychological function. In audiological settings, clinicians can provide proper intervention services to these patients by early referral to neuropsychology and/or aural rehabilitation specialists.Despite the strengths of our study, it also has some limitations. First, in the present study, we controlled for hearing thresholds, age, years of education, and depression levels to investigate the effect of cognitive function on self-perceived hearing handicap. Although participants’ depressive symptoms were evaluated and adjusted in this study and the relations between depression and self-perceived hearing handicap were indicated in the literature –38, otheS1 Table(DOCX)Click here for additional data file.


LncRNA rankIng by NetwOrk DiffusioN (LION) approach to identify lncRNA-disease associations. The multi-level complex network consisted of lncRNA-protein, protein–protein interactions, and protein-disease associations. We applied the network diffusion algorithm of LION to predict the lncRNA-disease associations within the multi-level network. LION achieved an AUC value of 96.8% for cardiovascular diseases, 91.9% for cancer, and 90.2% for neurological diseases by using experimentally verified lncRNAs associated with diseases. Furthermore, compared to a similar approach (TPGLDA), LION performed better for cardiovascular diseases and cancer. Given the versatile role played by lncRNAs in different biological mechanisms that are perturbed in diseases, LION’s accurate prediction of lncRNA-disease associations helps in ranking lncRNAs that could function as potential biomarkers and potential drug targets.Recently, long-non-coding RNAs (lncRNAs) have attracted attention because of their emerging role in many important biological mechanisms. The accumulating evidence indicates that the dysregulation of lncRNAs is associated with complex diseases. However, only a few lncRNA-disease associations have been experimentally validated and therefore, predicting potential lncRNAs that are associated with diseases become an important task. Current computational approaches often use known lncRNA-disease associations to predict potential lncRNA-disease links. In this work, we exploited the topology of multi-level networks to propose the  Non-coding RNAs can be classified broadly in two types: small non-coding RNAs and long non-coding (lnc) RNAs that are more than 200 nucleotides . LncRNAsTo assist in understanding the pathogenesis of complex diseases, there have been efforts to infer potential associations between lncRNAs and diseases using lncRNA-protein interaction data . ComputaAn emergent concept postulates that a disease reflects the interplay of multiple biomolecules, and is rarely a straightforward consequence of an abnormality in a single gene encoding protein . Given tLncRNA rankIng by NetwOrk DiffusioN (LION). LION is a network-diffusion method that integrates lncRNA-protein, protein–protein, and disease-protein networks to prioritize important lncRNAs for diseases. First, we construct a multi-level complex network (tripartite network) consisting of lncRNA-protein, protein–protein, and protein-disease associations. Next, we apply a random walk network diffusion algorithm. The random walk method exploits the local network neighborhood of diseases to measure the proximity of lncRNAs to the disease genes based on the probabilities of the connecting edges. It is possible to identify which lncRNA is connected to a given disease on the basis of the probability of reachability in the heterogeneous network. To evaluate LION, we utilize the available experimentally verified lncRNA disease associations  curve to evaluate the predictive performance of our method. For the receiver operating characteristic curve, we plotted sensitivity and specificity at different thresholds, using the predicted lncRNA-disease edge weights as the thresholds. A predictor making random guesses would have an AUC of 0.5 and a predictor with perfect performance would have an AUC of 1. Typically, an AUC above 0.85 is considered good performance and an AUC above 0.95 is considered excellent performance.We assessed the relative performance of LION by computing and analyzing three ROC curves: (1) LION method, (2) a current state-of-the-art method called TPGLDA, (3) a randomized network model as a negative control. TPGLDA uses known lncRNA-disease associations and known gene-disease associations, and makes predictions using a resource allocation algorithm that creates interaction profiles at each lncRNA. We generated the random network by starting with the lncRNA-disease network predicted with LION, and randomly shuffling node labels to create a random graph null model with the same connectivity structure, enabling comparison with LION’s predictions as a control.To assess the overall performance of LION in predicting lncRNA-disease associations, we first applied LION to predict lncRNA-disease associations for three broad categories of diseases: cardiovascular diseases, cancers, and neurological diseases . LION yiHaving demonstrated high performance for three broad disease groups, we next evaluated LION on four individual cancers . The comp < 0.01), and between LION and TGPLDA (p < 0.01). The results of the Wilcox test confirm that LION’s better performance, seen in We tested the statistical significance of differences in predictions made by LION, the randomized network, and TPGLDA methods using the Wilcox rank sum test. For each of the 7 diseases in in vivo and in vitro experimental studies, reported in the LncRNADisease database. For example, MALAT1 is a regulator of alternative splicing in breast cancer  and chronic obstructive pulmonary disease (COPD).Lower RTIs are the most common infection and one of the leading causes of death in the United States by infection . COPD isMotivated by the success of network based methods in extrapolating information from the interactome , we devea priori information does not impact the performance of LION. When compared against experimental lncRNA-disease associations, LION accurately predicted lncRNAs for both broad disease categories  and individual cancers , with AUCs all over 0.85. In contrast, the negative control, a lncRNA-disease network randomized with node label shuffling, had AUCs of only 0.5. In comparison to the current state-of-the-art method for lncRNA-disease prediction, TPGLDA, LION had improved or equal performance. LION had improved performance for cardiovascular diseases, cancers, ovarian cancer, and bladder cancer. LION performed equally well as TPGLDA on neurological/psychiatric diseases, breast cancer, and blood cancers. LION has potential value for predicting novel lncRNAs, demonstrated through analysis of case studies in COPD and respiratory tract infections. LION has potential applications in biomedical research to shed light on molecular underpinnings of disease, prioritize putative therapeutic targets and biomarkers, and elucidate disease-disease relationships.Making lncRNA-disease predictions without Despite its promise, the limitations that influence the prediction of LION include the literature biases in the protein-disease, lncRNA-proteins, and protein–protein interactions datasets. In particular, as lncRNA-protein associations are likely quite incomplete owing to the recent discovery of lncRNAs, the lncRNA-protein dataset may be skewed toward a few well studied lncRNAs. Furthermore, the missing links could bias the predictions toward the well-studied lncRNAs, such as HOTAIR, which we found in the top five predictions for myocardial infarction, COPD, and respiratory tract infections. A second limitation is the unweighted and incomplete GWAS and OMIM gene-disease datasets used to build the tripartite network; LION would be improved by weights that enable distinguishing crucial disease genes, such as through using differential gene expression data. We plan to include more complete interaction datasets to improve the accuracy of prediction in the future.To obtain genome-wide lncRNA and protein-coding gene associations, we combine three sources:We downloaded known lncRNA-protein interaction datasets from the following databases. (i) lncRInter, a reliable and high quality lncRNA interaction database containing experimentally validated data whose lncRNA interaction datasets are extracted from peer-reviewed publications . (ii) NPBy analyzing millions of RBP binding sites from 117 CLIP-Seq datasets generated by 50 independent studies, starBase V2.0 has identified 22,735 RBP–lncRNA regulatory relationships .We combine several sources of protein interactions: (i) regulatory interactions derived from transcription factors binding to regulatory elements; (ii) binary interactions from several yeast two-hybrid high-throughput and literature-curated datasets; (iii) literature-curated interactions derived mostly from low-throughput experiments; (iv) metabolic enzyme-coupled interactions; (v) protein complexes; (vi) kinase-substrate pairs; and (vii) signaling interactions. The union of all interactions from (i) to (vii) yields a network of 15,949 proteins that are interconnected by 217,140 interactions .A total of 28,488 associations between protein-coding genes and diseases in the OMIM and GWAS were downloaded from DisGeNET .To predict and rank disease associated lncRNAs, we first constructed a tripartite lncRNA-protein-disease network from the datasets described in section “Data Sources and Construction of Multi-Level Complex Network” .Next, we utilized a random walk with restart to rank lncRNAs for each disease using network based proximity between a lncRNA and a disease’s known proteins . For thiFor example, with myocardial infarction (MI), we created a subnetwork with (1) 1228 protein–protein interactions between the 27 known MI genes and their nearest neighbors, and (2) 2,175 lncRNA-protein interactions involving 1235 lncRNAs. The MI seed genes are included in r = 0.5 to be relocated on the starting genes. The probability distribution at step k + 1 is described by the iterative form:We then executed a random walk process to predict the lncRNA associated to the 27 known MI genes. The basic idea of LION is a walker starting from a single or group of disease genes and visiting other genes and lncRNAs (nodes) in the multi-level network by taking a series of random walking steps. On every moving step, the walker moves from its current node to the neighboring nodes and therefore a distribution value is calculated for every node in the network, which denotes the probability that a walker is at a given node at the current step. At each step, the walker has a probability kp is a vector where the i-th element is the probability of being at node i at step k. p0 is the uniform distribution over all starting disease genes. W is the column normalized graph adjacency matrix. By iterating the process until convergence (|| pk+1 − pk || L1 < 10-6) we obtained the steady state probability p∞, and 1235 lncRNAs were ranked according to their values in p∞. Pseudocode for the network diffusion algorithm is included in the where, This process was repeated for all of the 747 diseases for which a non-bipartite and connected subnetwork could be constructed. These conditions are required for the random walk probabilities to converge to a unique limiting probability distribution.The final predicted lncRNA-disease network contains 304,868 weighted lncRNA-disease associations between 747 diseases and 1,346 lncRNAs. Each association represents a predicted link between a disease and a lncRNA proximal to the disease’s genes. The number of lncRNAs ranked for each disease has a median of 156 and the number of diseases targeted by each lncRNA has a median of 195. To validate the lncRNA-disease predictions by LION, we use the LncRNADisease dataset , a manuaAS and MS conceived the idea of the study. SW co-supervised the analyses. MS and EM performed the computational and statistical analyses. All authors contributed to the interpretation of the results and in writing the manuscript, 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.


Minimal residual disease (MRD) by multiparametric flow cytometry (MFC) has been recently shown as a strong and independent prognostic marker of relapse in pediatric AML (pedAML) when measured at specific time points during Induction and/or Consolidation therapy. Hence, MFC-MRD has the potential to refine the current strategies of pedAML risk stratification, traditionally based on the cytogenetic and molecular genetic aberrations at diagnosis. Consequently, it may guide the modulation of therapy intensity and clinical decision making. However, the use of non-standardized protocols, including different staining panels, analysis, and gating strategies, may hamper a broad implementation of MFC-MRD monitoring in clinical routine. Besides, the thresholds of MRD positivity still need to be validated in large, prospective and multi-center clinical studies, as well as optimal time points of MRD assessment during therapy, to better discriminate patients with different prognosis. In the present review, we summarize the most relevant findings on MFC-MRD testing in pedAML. We examine the clinical significance of MFC-MRD and the recent advances in its standardization, including innovative approaches with an automated analysis of MFC-MRD data. We also touch upon other technologies for MRD assessment in AML, such as quantitative genomic breakpoint PCR, current challenges and future strategies to enable full incorporation of MFC-MRD into clinical practice. Pediatric acute myeloid leukemia (pedAML) is a heterogeneous group of hematological malignancies classified according to morphology, immunophenotyping, and genomics . In the Minimal or, more appropriately, measurable residual disease (MRD) detection allows the identification of 0.1–0.001% leukemic cells according to the adopted technique. MRD assessment in AML may establish a more in-depth remission status compared with the morphology-based evaluation, refining outcome prediction. A proper MRD approach should be sensitive and highly specific, reproducible and standardized with ideally an extended inter-institutional validation. Different techniques are currently available for MRD detection in pedAML, each one showing advantages and limitations: quantitative RNA-based polymerase chain reaction (RT-PCR) analysis of specific gene fusions, next-generation sequencing (NGS), gene expression profiling (GEP) and multiparametric flow cytometry detection (MFC) of aberrant immunophenotypes . NowadayRT-PCR of fusion transcripts allows MRD detection with a sensitivity level of up to 0.001%. Regardless, it is applicable only in about 50–60% of pedAML with a detectable fusion gene or mutations. Moreover, a precise quantification of MRD may be difficult due to the unpredictable number of transcripts per leukemic cell . Among ANGS allows the identification of molecular anomalies, particularly relevant in AML with normal cytogenetics . In prinMFC-MRD has a lower sensitivity than RT-PCR (up to 0.01%), but it is applicable in more than 90% of patients. Therefore, MFC-MRD is generally the method of choice for MRD detection in clinical AML studies. MFC-MRD may be assessed through two different techniques: (i) Leukemia-Associated Immunophenotype (LAIP) approach allows to identify leukemic blasts immunophenotype at diagnosis and track it at re-evaluation points; (ii) Different-from-Normal approach relies on the discrimination of aberrant immunophenotypes from normal cells during follow-up , 33.This review focuses on the most relevant findings on MFC-MRD in pedAML and examines recent advances and new approaches for its standardization, including novel concepts for automated analysis of MFC-MRD data.Even if MRD monitoring has become the standard of care in ALL, only recently it has been acquiring an even more important role in AML management .In the last three decades, different retrospective studies on MFC-MRD monitoring have been performed in adult and pedAML. They suggested its strategic role in AML risk stratification. Regardless, to date, no guidelines or recommendations are available on methods, time points, and clinical application of MFC-MRD in AML. That depends on the heterogeneity of MRD assessment in AML, due to different available techniques, difficulties in comparing MRD data among laboratories and clinical trials, and the impact of sample quality on MRD level –38.de novo pediatric AMLs. MFC-MRD emerged as the most influential independent prognostic factor associated with poor outcome  cells (≥0.1%). MRD positivity after Induction I was associated with an unfavorable outcome in high-risk AML (P = 0.01). Moreover, any MRD positivity after Induction II was predictive of an adverse outcome. The authors were able to monitor MRD in more than 90% of patients after each therapeutic course. The combined approach showed an improvement in patients' outcome .In support to the St. Jude study, MFC-MRD was an independent prognostic variable in the Dutch Childhood Oncology Group ANLL 97/Medical Research Council of the UK AML12 experience, as well as in the COG AAML03P1 AML study , 18.Regardless, the AML-BFM study published in 2006 did not find any significant role of MFC-MRD based on a standardized panel for four-color immunophenotyping in outcome prediction when compared to other known risk factors. A significant difference in 3-years EFS was demonstrated in the presence of positive MFC-MRD before the second Induction, and third therapy course but those data were not confirmed by a multivariable analysis including FAB subtype, cytogenetics, and morphologically determined blasts on day 15 .To ensure comparability of results among different laboratories, and facilitate the clinical use of MFC-MRD as a surrogate for OS and EFS, a standardized and reproducible assay is required , 47. CurSeveral national and international networks have been established to optimize and standardize MFC-MRD detection and quantification –51. In tConventional approaches for analysis and interpretation of MFC-MRD data, lag behind standardization of the wet-lab issues because of the many limitations of manual gating and data analysis strategies, especially when dealing with higher-dimensional complex datasets. Hence, data analysis and interpretation currently is kind of a bottleneck for safely applying MFC-MRD methodology in AML since it strongly relies on the operator's skills and is highly subjective and time-consuming . This isDiagnostic laboratories have shifted from 4 to 6 colors upto 12 colors MFC, with a substantial improvement of LAIP detection and discrimination between aberrant and normal cells , 66. IntAberrant LAIPs can be identified at diagnosis in the vast majority of childhood AML cases . Neverth+ progenitors in BM (Current marker panel recommendations, including those published by the ELN  contain rs in BM , 77. Bozrs in BM  reportedrs in BM . Advancers in BM  or mass rs in BM  are incrrs in BM  used genrs in BM . In an ars in BM  generateIn the majority of late-phase clinical trials, the primary endpoints are OS and EFS . Hence, With continuous efforts in standardization, MFC-MRD response may guide treatment intensity, and become a useful surrogate endpoint for clinical drug development in pedAML. Hence it is time to perform prospective, multicenter randomized trials to evaluate the impact of therapeutic interventions driven by MFC-MRD, together with its role as an early marker of response-to-therapy and a potential surrogate survival endpoint.BB and MD designed the study. BB, MM-G, EV, and MD wrote the 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.


The advantages of peritoneal dialysis (PD) over hemodialysis (HD) are well-documented. Notwithstanding, only a small proportion of patients with end-stage renal disease (ESRD) are managed with PD. This may be related to the high glucose load that PD solutions in current use have on the patient. The effects of such excess glucose include the relatively early limitation of the ultrafiltration capacity of the peritoneal membrane, and the metabolic effects associated with hyperglycemia, e.g., decreased insulin sensitivity. This article describes the advantages that may be realized by the glucose-sparing effects of substituting part of the glucose load with other osmotically active metabolites, particularly L-carnitine. The latter is anticipated to have metabolic advantages of its own, especially as in PD patients, high plasma concentrations can be achieved in the absence of renal clearance. Besides its better biocompatibility, L-carnitine demonstrates anti-anemia action due to its effects on erythropoiesis, and positive effects on the longevity and deformability of erythrocytes. Observations from our trials on the use of carnitine-enriched PD solutions have demonstrated the effectiveness of L-carnitine as an efficient osmolyte in PD, and its favorable effect on the insulin sensitivity of the patients. The significance of these findings for future developments in the use of PD in the management of patients with ESRD is discussed. Peritoneal dialysis (PD) represents an established home-care, cost-effective modality of renal replacement therapy (RRT) for patients suffering from end-stage renal disease (ESRD). Though prescribed to only a minority of patients requiring dialysis, PD offers several advantages as compared to hemodialysis, including a more gradual and continuous removal of solutes and fluid, minimal cardiac stress, a better preservation of residual renal function, and similar survival . When coPD uses the semipermeable peritoneum as a biological dialysis membrane . RemovalPD solution  is composed of physiological concentrations of electrolytes , a buffer (lactate and/or bicarbonate), and an osmotic agent needed to remove excess water from the patient . Fluid can be drawn from the peritoneal capillary blood through both the water-exclusive aquaporins and the small-pore, solute-coupled fluid pathways . FailureGlucose is the standard osmotic agent used in PD solution. It has a molecular weight of 180 Da, a high osmotic capacity, low cost, an acceptable safety profile, and represents an energy source for patients who are often not well nourished. However, prolonged exposure to the high glucose content in PD solution is thought to be associated with acceleration of the progressive changes in peritoneal membrane function, causing ultrafiltration failure . FurtherL-carnitine has become of interest in ESRD because decreased renal synthesis and dialysis losses have been suggested as causes of L-carnitine deficiency in patients on hemodialysis . In turnThere have been relatively few reports on carnitine in ESRD patients receiving PD therapy. In this article, we have reviewed the available evidence for the status of L-carnitine and its potential therapeutic use in PD.L-carnitine is a highly water soluble compound (>2500 g/L at 20 °C) which, owing to the presence of both a positively charged quaternary ammonium group and a carboxylate group, exists as zwitterion at pKa of 3.8 when dissolved in water at 20 °C.Carnitine metabolism may be significantly altered in ESRD patients on PD as compared to healthy controls. Abnormal plasma levels for free and acetyl-carnitine have been reported in several studies in both adult ,16,17 anCarnitine metabolism disorders in ESRD patients on PD may be attributed to several mechanisms, including inadequate dietary intake, reduced renal synthesis, accumulation of metabolism intermediates, intestinal malabsorption, and dialytic age ,17,25,26Taking into account the vital role of L-carnitine in fatty acid metabolism, and given the derangement of the carnitine system in ESRD patients on PD, several studies have tested the effects of oral carnitine supplementation .Some observational studies have suggested a possible association in PD patients between abnormalities of the carnitine system and of lipid metabolism ,23,27. IOther studies have assessed the effects of carnitine supplementation on hematological parameters relative to anemia and on the requirement of human recombinant erythropoietin (rHuEPO). Normochromic normocytic anemia is a frequent and serious complication in uremic patients, which reduces the quality of life and is associated with many adverse clinical consequences, and is primarily treated with erythropoiesis-stimulating agents such as rHuEPO and adjuvant iron therapy . The antp < 0.03) and hemoglobin levels  was found, paralleled by a significant reduction in rHuEPO dose necessity/patient/week . Interestingly, the rigidity index of erythrocytes proved to be significantly decreased, suggesting an improvement of their deformability [Sotirakopoulos et al. examined the effect of L-carnitine (2 g daily per os) on hematocrit and hemoglobin levels in 12 adult patients on CAPD . A signimability , is fundmability , can impmability . Positivmability .It is difficult to combine the results so far obtained  in orderAnother limitation of the studies done to date on oral L-carnitine supplementation in PD patients has been the short follow-up period, hampering the assessment of hard outcomes including mortality and cardiovascular disease. At the present time, the available data do not allow high expectations from oral L-carnitine supplementation in patients treated with PD.Oral L-carnitine administration to PD patients is able to increase and normalize free carnitine levels ,20, in sThe poor local (peritoneum cavity) and systemic biocompatibility of the currently available glucose-based solutions for PD is increasingly being recognized . Since gL-carnitine has a molecular weight of 161.2 Da and is highly water soluble and chemically stable in aqueous solutions , which rWhen developing a new PD solution for clinical use, one should first examine its impact on the peritoneal membrane, which consists of three layers: the mesothelium, the interstitium, and the capillary endothelium . SeveralClinical studies examining the effects of L-carnitine added to PD fluid are reported in Bazzato et al. examined the effects of 2 g L-carnitine added to the PD fluid for the nocturnal exchange in seven CAPD patients . Plasma Since L-carnitine has been shown to possess osmotic properties in different biological systems ,59, we eOur results indicate that L-carnitine has potential use as a new osmotic agent in PD solution . The capSeveral studies have shown the beneficial effects of L-carnitine administration in mitigating insulin resistance or even improving glycaemic control in diabetic animal models or in humans . It has n = 15), and was associated with a significant improvement in insulin sensitivity, as compared to both baseline and results in the control group (n = 12). Interestingly, while in the control group daily urine output was significantly decreased, diuresis did not change in the intervention group, a finding which may be explained by L-carnitine-increased urinary excretion , and may be of clinical relevance, since urine output is quite important in maintaining fluid balance in PD patients [Recently, we evaluated in a multicenter, randomized controlled trial the effects of an L-carnitine-containing PD solution on insulin sensitivity (as determined by performing a euglycemic hyperinsulinemic clamp) in CAPD patients . Insulinpatients . Plasma patients .As APD has become increasingly popular as a PD modality, we next explored the feasibility of adding L-carnitine to the PD solution in APD-treated ESRD patients . The perActually, there are no data on hard outcomes for L-carnitine-containing PD solutions. These solutions are, however, still under investigation.In all studies performed so far , L-carniL-carnitine in PD fluid may be envisaged as a prototypical osmo-metabolic agent. Osmo-metabolites can be defined as those substances exhibiting both osmotic and metabolic favorable properties ,72. The Osmo-metabolic agents may also be used in combination, in order to maximize their therapeutic effects. We have recently developed a new PD solution containing L-carnitine (1.24 mmol/L), xylitol (46 or 98.6 mmol/L), and a low amount of glucose (27.7 mmol/L) . XylitolIn human endothelial cell models, such an experimental PD solution  did not ESRD patients on PD treatment frequently suffer from abnormalities of the carnitine system, which might contribute to the complex pathophysiology of uremic syndrome. Oral supplementation of L-carnitine does not appear to be able to ensure the plasma carnitine exposure needed to trigger a beneficial effect in target organs. However, this may be achieved through the safe use of L-carnitine added to the PD fluid. Patients suffering from ESRD on PD therapy may benefit from a glucose-sparing approach, in terms of solution prescription . The useThe clinical practice will ultimately clarify and define the appropriate use of osmo-metabolic enriched PD solutions for PD therapy.


Syncope could be related to high risk of falls and injury in adults, but documentation is sparse. We examined the association between syncope and subsequent fall-related injuries in a nationwide cohort.By cross-linkage of nationwide registers, all residents ≥18 years with a first-time diagnosis of syncope were identified between 1997–2012. Syncope patients were matched 1:1 with individuals from the general population. The absolute one-year risk of fall-related injuries, defined as fractures and traumatic head injuries requiring hospitalization, was calculated using Aalen-Johansen estimator. Ratios of the absolute one-year risk of fall-related injuries (ARR) were assessed by absolute risk regression analysis.We identified 125,763 patients with syncope: median age 65 years (interquartile range 46–78). At one year, follow-up was complete for 99.8% where a total of 8394 (6.7%) patients sustained a fall-related injury requiring hospitalization, of which 1606 (19.1%) suffered hip fracture. In the reference group, 4049 (3.2%) persons had a fall-related injury. The one-year ARR of a fall-related injury was 1.79  in patients with syncope compared with the reference group; however, increased ARR was not exclusively in older patients. Factors independently associated with increased ARR of fall-related injuries in the syncope population were: injury in past 12 months, 2.39 , injury in relation to the syncope episode, 1.62 , and depression, 1.37 Patients with syncope were at 80% increased risk of severe fall-related injuries within the year following discharge. Notably, increased risk was not exclusively in older patients. Syncope episodes are frequent in both young and older adults, –3 and chOver the last decade, the overlap in symptoms of syncope and falls, particularly in older persons, has received growing attention. –13 A numWe conducted a nationwide study of adult patients with a first-time diagnosis of syncope, to provide longitudinal population-based data on the association between syncope and subsequent fall-related injuries. Our objectives were to assess the risk of fall-related injuries following syncope and evaluate if physical injury in this population occurs predominantly in older adults, and to compare the risk of fall-related injuries following syncope with that of the general population.The study is a nationwide register-based cohort study from January 1, 1997 to December 31, 2013. The study was conducted in Denmark where health services are predominantly tax-funded, which ensures free access to healthcare for the entire population. Individual-level linkage of information between population-based registers is possible due to a unique and personal identification number, which is assigned to each resident at birth or upon immigration. The Civil Registration System holds information on the date of birth, death, sex, and migration for all residents.  Data on The study population comprised all residents ≥18 years with a first-time primary discharge diagnosis of syncope between 1997 and 2012. Both inpatient and emergency department (ED) encounters were included. Subjects with prior syncope outpatient contacts were excluded. The reference group was obtained with risk set matching: Each subject in the syncope population was matched with one subject from the general population without prior syncope hospitalizations by year of birth and sex. The ICD diagnosis of syncope (10th revision code R55.9) refers to the most common etiologies of syncope, Potential confounding factors were pre-specified and identification was based on current knowledge in combination with the construction of a model diagram.  The follThe primary outcome of a fall-related injury was defined as any hospital encounter (ED visit or inpatient admission) from fractures  or traumatic head injuries . The appDifferences in baseline characteristics were compared using chi-squared test for categorical variables. We report loss to follow-up at one year. The level of significance was set at 5%. To assess the time-dependent absolute risk of fall-related injuries following syncope, we used the Aalen-Johansen estimator to account for the competing risk of death.  FurthermIn our main analysis, we performed absolute risk regression analysis,  and repoSensitivity analyses adjusted for osteoporosis and prior fall-related injury respectively, and in another analysis, we excluded all patients with fall-related injury in relation to the syncope episode. We also examined whether the risk was similar for patients with syncope who were admitted to hospital and patients discharged from the ED. All analyses were repeated with hip fracture as the outcome of interest; specifically, because hip fractures are both highly correlated with falls, and require hospitalization. Statistical analyses were performed using SAS version 9.4  and R version 3.4. The study was approved by the Danish Data Protection Agency (ref. number: 2007-58-0015 / GEH-2014-013 I-Suite number: 02731). In Denmark, ethical approval is not required for retrospective register-based studies. All analyses were executed on servers placed at Statistics Denmark.In the period from 1997 through 2012, 125,763 adult patients with a first-time diagnosis for syncope were identified (n = 8288 were excluded due to prior syncope outpatient contacts), of which 68,671 (54.6%) represented inpatient admissions. The median age of patients with syncope was 65 years (interquartile range [IQR] 46–78) and 65,608 (52.2%) were women . The mosAt one year, follow-up was complete for 99.8% of the syncope population . A total of 8394  patients had a fall-related injury requiring re-hospitalization, whereas 4049  persons in the reference group had a fall-related injury . Hip fraThe one-year adjusted ARR of fall-related injuries was 1.79  in patients with syncope compared with the reference group . The three factors most associated with increased ARR of fall-related injuries in the syncope population were: fall-related injury in past 12 months , fall-related injury in relation to the syncope episode , and depression , whereas high socioeconomic status, and use of antihypertensive drugs were associated with decreased one-year risk of fall-related injuries .The syncope-associated one-year risk of fall-related injuries was similar for patients seen in the ED  and patients admitted to hospital . Adjustment for osteoporosis did not challenge the results from the main analysis , neither did adjustment for prior fall-related injury , or exclusion of patients with fall-related injury in relation to their syncope episode . Moreover, the main analysis was repeated with hip fracture as outcome, but yielded similar results among subjects’ ≥65 years , The main finding of the study was that first-time syncope was associated with 80% increased one-year risk of fall-related injuries, in terms of fractures and traumatic head injuries requiring hospitalization, compared with an age- and sex matched reference group. The study is the first to provide comprehensive longitudinal data on injury risk in a real-world clinical setting of adult patients with syncope. Although the absolute risk increased with advancing age, the relative risk of fall-related injuries associated with syncope decreased in the elderly. Plausibly, because multiple factors influence fall-injury risk in older persons the attributable risk associated with syncope decreases with advancing age. Notably, increased risk of injury was not exclusively in older patients, but also substantially increased in young adults with syncope. Depression, prior fall-related injury, and injury in relation to the syncope episode were important risk factors associated with increased risk of sustaining a fall-related injury.Our observation of increasing absolute risk of fall-related injuries with advancing age, particularly in older women is in line with current knowledge. , 35, 36 Although the majority of injuries were observed in the elderly population, younger patients with a history of syncope also had markedly increased risk of injury. However, the injury mechanism is liable to be different in younger and older adults, and while the injuries identified in the current study are strongly related to falls in older adults,  other caOur findings are in keeping with prior research on the association of some individual causes of syncope and unexplained falls and fall injuries in older persons.,19,21,41With advancing age, the attributable risk of cardiac causes of syncope increases. We observed that in patients with a cardiac pacemaker, syncope was not significantly associated with risk of subsequent fall-related injuries. This is in line with a study, which demonstrated a substantial reduction in the number of injurious events amongst individuals with cardio-inhibitory carotid sinus hypersensitivity randomized to pacing. However,Although a single cause is evident in a minority of falls, a multitude of factors, such as environmental factors, acute and chronic medical conditions, and medications are likely to influence the risk of falling. , 49 MediThe main strength of this study was the use of nationwide registers that enabled identification and complete follow-up of a large cohort of patients with syncope irrespective of age, morbidity, socioeconomic status, and health insurance schemes, and with independent data collection of outcomes. However, the study has several potential limitations. First, due to the observational design, direct conclusions on causal relationships of our findings remain unviable. Second, important clinical parameters including blood pressure, electrocardiographic, echocardiographic or carotid sinus massage findings were unavailable in the registries, so despite extensive adjustments for potential confounding factors, we cannot exclude effects of residual confounding. Furthermore, the ICD registration does not specify the etiologies of syncope; consequently, we do not address effect measures attributable to specific causes of syncope. Instead, we have evaluated subgroups, mainly within different cardiovascular conditions. Third, we cannot exclude the possibility that persons who contact the ED or hospital due to syncope may be inherently different from those who do not; however, effect measures of hip fracture, which should always lead to hospitalization, supported the main results. Of note, the reported risk of fall-related injuries only reflects the number of injury events coming to acute medical attention at EDs and hospitals, and may, therefore, represent an underestimate of total fall-related events. Information pertaining to fatal fall incidents resulting in immediate death prior to hospitalization was unavailable.In this nationwide study, adult patients with first-time syncope were at 80% increased risk of severe fall-related injuries within the year following discharge. Notably, increased risk was not exclusively in older patients. These findings underscore the necessity of increased clinical awareness about traumatic injury risk and appropriate management of patients with syncope of all ages in clinical practice, and support increased multidisciplinary assessment in falls-prevention among older adults. Further cohort and intervention studies will be needed to reveal causal effects and efficacy of preventive strategies.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.S1 FigThe age- and sex matched group without prior syncope served as reference in all analyses. Multiple absolute risk regression analyses with adjustment for: age, sex, calendar year, socioeconomic status, comorbidities, and pharmacotherapy. ARR indicates absolute risk ratio.(PDF)Click here for additional data file.S2 FigThe age- and sex matched group ≥65 years served as reference. Multiple absolute risk regression analyses with adjustment for: age, sex, calendar year, socioeconomic status, ischemic heart disease, arrhythmia, atrioventricular block or left bundle branch block, pacemaker, use of antihypertensive, loop diuretic or anxiolytic drugs, depression, diabetes, cancer, Parkinson disease, and dementia. ARR for total fall-related injury is provided for comparative purpose. ARR indicates absolute risk ratio.(PDF)Click here for additional data file.


No statistically significant effect modification by either sodium or potassium intake alone was observed. These findings suggest that relatively high intake of sodium relative to potassium may play an important role in the mobilization of lead from bone into the circulation.Bone is a major storage site as well as an endogenous source of lead in the human body. Dietary sodium and potassium intake may play a role in the mobilization of lead from bone to the circulation. We examined whether association between bone lead and urinary lead, a marker of mobilized lead in plasma, was modified by dietary intake of sodium and potassium among 318 men, aged 48–93 years, in the Veterans Affairs (VA) Normative Aging Study. Dietary sodium and potassium were assessed by flame photometry using 24-h urine samples, and a sodium-to-potassium ratio was calculated from the resulting measures. Patella and tibia bone lead concentrations were measured by K-shell-x-ray fluorescence. Urinary lead was measured by inductively coupled plasma mass spectroscopy in 24-h urine samples. Linear regression models were used to regress creatinine clearance-corrected urinary lead on bone lead, testing multiplicative interactions with tertiles of sodium, potassium, and sodium-to-potassium ratio, separately. After adjustment for age, body mass index, smoking, vitamin C intake, calcium, and total energy intake, participants in the highest tertile of sodium-to-potassium ratio showed 28.1%  greater urinary lead per doubling increase in patella lead, whereas those in the second and lowest tertiles had 13.8%  and 5.5%  greater urinary lead, respectively ( Lead toxicity is a prevalent and persistent public health problem. People have been commonly exposed to lead through various routes including air, dust, paint, water, and food . In receOnce lead has entered the body from external environmental exposure, there are several possible fates and pathways. Initially, the blood serves as the receptacle of absorbed lead and more than 99% of lead is bound to erythrocytes . HoweverThe role of dietary micronutrients in lead metabolism has specifically been of interest as they pose a logistically simple intervention to prevent lead toxicity due to bone lead resorption. Dietary factors affecting bone turnover such as sodium and potassium may be associated with the mobilization of lead from bone into the circulation. Low potassium and high sodium dietary intake have each been reported to be associated with accelerated bone resorption in both animal and population-based studies ,22,23. ATo address this issue, we examined associations between markers of dietary sodium and potassium intakes, measured from 24-h urine collection, which is considered more accurate measures of dietary intake , and bonAll participants provided written informed consent. This study was reviewed and approved by the Institutional Review Boards of each participating institute: the University of Michigan School of Public Health, Harvard School of Public Health, and the Department of Veterans Affairs Boston Healthcare System. Ethical approval number is HUM00026596. Participants in the current analysis were from the Normative Aging Study, a prospective cohort of community-dwelling middle-aged to elderly men with no known occupational lead exposure over time. Between 1961 and 1962, a total of 2280 men from Boston, Massachusetts participated. They were predominantly non-Hispanic white and ranged in age from 21 to 80 years upon enrollment. All participants were free of past or present chronic medical conditions including heart disease, cancer, diabetes, peptic ulcer, gout, bronchitis, sinusitis, recurrent asthma, or hypertension at the time of enrollment. They returned for an examination every three to five years for a detailed core examination including the collection of medical history, routine physical examination, laboratory tests, dietary intake, and other factors that might influence health.Between August 1991 and August 2002, 871 consecutive NAS participants underwent patella and tibia bone lead measurements using K-shell-x-ray fluorescence (KXRF). Between June 1991 and April 1995, 372 participants had their 24-h urine samples collected for urinary lead, sodium, and potassium concentration determinations. In addition, a blood sample for blood lead analysis was collected at each visit since 1988. For the present study, we identified 361 NAS participants who participated in the KXRF bone lead sub-study and who had 24-h urinary lead, sodium, potassium, and blood lead concentrations measured at the same visit as the bone lead measurements. We excluded nine participants with high bone lead concentration uncertainties, 23 participants with reduced renal function (serum creatinine concentration ≥ 1.5 md/dL), and 11 participants with missing information on key covariates , leaving a final sample of 318 men for the analyses .Whole blood samples were collected in trace metal-free tubes containing ethylenediaminetetraacetic acid and analyzed to obtain blood lead concentration by graphite furnace atomic absorption spectroscopy . Detailed measurement procedures are described elsewhere . The limNAS participants had bone lead concentrations measured for 30 min each at the patella and mid-tibial shaft, using the ABIOMED KXRF instrument, as described in detail previously . AnalysiDetailed measurement procedures for urinary lead, sodium, and potassium were described elsewhere ,29. In b2) obtained during physical examination. To assess the dietary intake, we used a validated, semi-quantitative food frequency questionnaire adapted from the one used in the Nurses’ Health Study that inquired about the average consumption of 135 food items during the past year , which represents the volume of blood plasma that is cleared of creatinine per unit time. Creatinine clearance-corrected urinary lead excretion was calculated using the residual method, where residuals from a linear regression model with log-transformed urinary lead as the dependent variable and CCr as the independent variable were added to a constant, which was equal to the value for predicted urinary lead when CCr was at the mean value of the study population. To examine the influence of dietary sodium and potassium on the mobilization of lead into the circulation, we regressed creatinine clearance-corrected urinary lead on bone/blood lead as well as with interaction terms indicating tertiles of sodium, potassium, and Na/K ratio, separately, in linear regression models. Age, BMI, smoking status, vitamin C intake, calcium intake, and total energy intake were adjusted in all models. Given the highly skewed distributions of urinary, blood, and bone lead concentrations, logarithmic transformations with base 2 were applied to all lead measures; dose-response relationships were closer to linear after log-transformation. We chose base 2 rather than natural log-transformation for easier interpretation of the regression coefficients. Effect estimates and 95% CIs were expressed as percent change in 24-h urinary lead excretion per 2-fold increase in patella, tibia, and blood lead concentrations.In light of previous evidence from the NAS cohort suggesting that bone resorption significantly modifies release of lead from bone , we furtp < 0.0001). Geometric mean concentration of patella lead was lowest in men in the first tertile of the Na/K ratio (p = 0.04). No significant differences in urinary, tibia, or blood lead concentrations across the Na/K tertiles were observed.Characteristics of the study population by tertiles of Na/K ratio are listed in p-for-interaction = 0.10) was observed (observed . After ap-for-interaction = 0.04). Similarly, stronger associations between urinary lead and tibia lead were observed in higher Na/K ratio tertiles. However, the interaction between tibia lead and Na/K ratio was less pronounced and not statistically significant (p-for-interaction = 0.25). Again, we found no statistically significant effect modification by Na/K ratio on the relationship of blood lead to urinary lead.A significant modifying effect of Na/K ratio on the relationship between urinary lead and patella lead was observed . The relp-for-interaction = 0.04).The effect modification by Na/K ratio on the association between urinary lead and bone lead, after further incorporation of blood lead as a covariate in the regression models, is shown in p-for-interaction = 0.08 in p-for-interaction = 0.04 in p-for-interaction = 0.32 in p-for-interaction = 0.25 in In models with further adjustment for NTx and its cross-product term with patella/tibia lead, attenuated modifying effects of Na/K ratio on the relationships of both patella lead  . The souOur findings suggest that a high intake of sodium relative to potassium may increase bone lead resorption among the middle-aged to older men. In this context, the release of bone lead into the circulation may be minimized by dietary recommendations that include both decreased sodium and increased potassium intakes. However, our findings need to be interpreted with a caution given the modest sample size. More epidemiologic studies utilizing longitudinal design with larger sample sizes as well as animal studies directly evaluating the role of sodium, potassium, and other dietary nutrient intake in bone lead resorption are needed to confirm our findings. If confirmed, such information will be crucial to help prevent lead toxicity, especially in populations where mobilization of lead from the bone is the dominant contributor to lead body burden. These findings also provide the impetus to further investigate the relationship between bone lead and health outcomes, with the addition of dietary sodium/potassium intake as a potential modifier in future studies.


Using data from surveys with older Korean Americans  conducted at five sites in the U.S. , the present study explored the status of physical/mental/oral/cognitive health and its determinants. For each health domain, we examined how self-rating (excellent/very good/good/fair/poor) of health was associated with other domain-relevant indicators  and sociocultural factors . Geographic variation was also considered. The correlations between self-ratings and domain-relevant indicators in all health domains were significant but moderate. A series of multivariate regression models of self-ratings of physical/mental/oral/cognitive health not only confirmed the effect of the domain-relevant health indicators but also demonstrated a critical contribution of sociocultural determinants. Implications for older immigrants were discussed in terms of place, culture, and context.


Necrotizing sarcoid granulomatosis (NSG) is a rare granulomatous pneumonitis which is composed of a background of sarcoidosis-like granulomas, granulomatous vasculitis, and variable amount of necrosis. We reported a case of a 38-year-old nonsmoking woman presented with left-sided chest pain and dyspnea for three days. Chest CT scan exhibited collapse consolidation of the left lower lobe with the presence of two separated small-sized cystic lesions within the collapsed segment. Lung lesion resection was performed, and histological examination confirmed the diagnosis by excluding other causes of granulomatous diseases. The prognosis of NSG is favorable, and medical treatment is usually not necessary, as well as in our case. NSG is a rare disease with nonspecific symptoms and good prognosis which is frequently confused with Wegener's granulomatosis, sarcoidosis, and Churg–Strauss syndrome. This entity should also be considered as differential diagnosis of necrotizing granulomatous diseases. Necrotizing sarcoid granulomatosis (NSG) has been distinctly recognized as an infrequent disease. Eloquently, this disease was principally described by Liebow, who defined the pathological features, such as noncaveating epithelial cell granuloma and granulomatous vasculitis with an intermittent degree of necrosis . NSG is A 38-year-old nonsmoking female presented with left-sided chest pain and dyspnea for three consecutive days. The patient was admitted to Masih Daneshvari Hospital on September 19, 2016. She had no history of fever, weight loss, and arthralgia or skin rash. Her blood pressure was 110/70 mmHg, pulse rate was 85, temperature was 37.5°C, and respiratory rate was 28. The breath sound was decreased in the left lower zone of the lung, and other physical examinations were unremarkable.Chest radiograph manifested two pulmonary nodules and basal atelectasis in the left lower lobe with pneumothorax . Chest CThe laboratory tests revealed the increase in WBC count with predominantly neutrophils; the erythrocyte sedimentation rate and C-reactive protein were elevated. The nitroblue tetrazolium (NTB) blood test was at the 99% accuracy level. Anti-nuclear antibodies (ANAs), anti-neutrophil cytoplasmic antibodies (C-ANCA and P-ANCA), and anti-double-stranded DNA (anti-dsDNA) were negative; in addition, the anti-HIV antibody test was negative. Transparently, the pulmonary function tests showed moderately restriction.Lung lesion resection for two intraparenchymal pulmonary nodules and cavitary lung lesion in the left lower lobe was performed; furthermore, the histological examination showed some epithelioid and giant cell granulomas with necrotizing arteritis in conjunction of a large area of necrosis Figures  and 4. ANSG is a rare disease with nonspecific symptoms; however, the prognosis is persuading which affects female more than male with a mean age of approximately 35 years. Morphologically, there are three criteria for NSG composed of sarcoidosis-like granulomas, variable amount of necrosis, and granulomatous vasculitis . NSG etiIn conclusion, it was magnificently attained that NSG is a disease with beneficial prognosis which should be considered as one of the differential diagnosis tools to identify necrotizing granulomatous diseases indeed.


BackgroundAcute care surgery (ACS) models address high volumes of emergency general surgery and emergency room (ER) overcrowding. The impact of ACS service model implementation on the quality and efficiency of care (EOC) outcomes in acute appendicitis (AA) and acute cholecystitis (AC) cohorts was evaluated.MethodsA retrospective chart review  of adult AA and AC patients admitted prior to  and after regionalization .ResultsR-ACS time to ER physician assessment was significantly longer for AA . Surgical response times  and acquisition of imaging  occurred significantly faster with R-ACS. R-ACS resulted in a significant increase in night-time appendectomies , perforated appendices , 30-day readmissions , and lower rate of intraoperative complications for AC patients .ConclusionsDespite the increased volume of patients seen with the implementation of R-ACS, surgical assessments and diagnostic imaging were significantly more prompt. EOC measures were maintained. Worse AA outcomes highlight areas for improvement in delivering R-ACS. General surgeons face the challenge of managing high volumes of emergency general surgery (EGS) patients with advanced age and increasingly complex conditions . Often, An organized ACS team is proposed to facilitate the prompt, comprehensive, evidence-based care of EGS patients, leading to improved efficiency of care (EOC) measures, reduced complications, and decreased length of stay and cost -16. A deThere are 13 ACS services in Canada with significant variation in organization and function . The lacThe lack of agreement and utilization of standard metrics to report EOC and patient outcomes within ACS service delivery, in addition to the high degree of variability in the definitions of each variable, make reporting and comparisons challenging. Standardization and consensus is required among ACS surgeons  to create an organized system of data capture and analysis to establish national standards for ACS service implementation and delivery, including support for evidence-based practice, quality improvement initiatives, as well as research, training/education, and innovation. Metcalfe et al.  reportedThree Winnipeg hospitals’ EGS services were consolidated into a regionalized ACS service (R-ACS) , resultiThe average annual number of cases admitted to the ACS service was 4,024; depending on the hospital, between 32% to 53% are medically managed while 47% to 68% are surgically managed. Per capita, the Winnipeg ACS service receives approximately 566 ACS admissions per 100,000 people. Research evaluating whether R-ACS in Winnipeg leads to improved efficiency and patient outcomes is crucial in facilitating evidence-based care, creating benchmark standards, and highlighting areas for system improvement. The study objective was to determine the impact of implementing a regionalized ACS on EOC and patient outcomes for common general surgical emergencies (acute appendicitis and acute cholecystitis).A retrospective chart review of AA and AC patients was performed to compare EOC and patient outcome measures between the Pre-ACS and R-ACS cohorts . A flow diagram of the patient chart extraction process is provided in Figure Three hospitals in Winnipeg (Canada) contributed to this investigation: St. Boniface General Hospital (tertiary academic), Concordia General Hospital (urban community), and Victoria General Hospital (urban community). The Pre-ACS implementation period from January 1 to December 31, 2007, represented the traditional “on-call” model. This cohort included patients admitted emergently to the general surgery services of each hospital. The ACS service was implemented in 2008 and the regionalized or R-ACS study period was January 1 to December 31, 2011. This year was selected for R-ACS to represent a stable mature system that had been functioning for several years. In the regionalized model, patients from the Concordia and Victoria General Hospitals were routinely transferred to St. Boniface for evaluation. During this period, there was a dedicated weekday operating room time designated for emergency general surgery patients (1000 hrs to 1530 hrs). Each of the three Pre-ACS hospitals had their own ‘on-call’ roster servicing their emergency department that acted independently and was staffed by a single surgeon (urban community sites) or a single surgeon/resident team . The surgeon/resident team took EGS calls, had regular elective duties, and completed their EGS responsibilities on an ad hoc basis.Patient baseline demographics were recorded, including age at admission (years), gender, body mass index (BMI), previous laparotomy, smoking status, medications (anticoagulants and steroids), and the following five comorbidities: (1) Cardiac , 2) Respiratory (chronic obstructive pulmonary disease (COPD), asthma), (3) Bleeding diathesis , (4) Endocrine (diabetes mellitus), (5) Hematology . The existence of these comorbidities was important to document, as they may impact the peri-operative variables under investigation. Data for the Pre-ACS and R-ACS periods were collected for multiple EOC time points along the patient trajectory (admission to discharge), allowing a retrospective temporal trend analysis of the data . Both date and time were recorded for the general surgery/ACS consultation , triage/assessment room, emergency room physician assessment, surgical consultation, surgical assessment, hospital admission, and hospital discharge EOC variables. Date, time, and location were recorded for the radiology  and non-operative intervention (endoscopic retrograde cholangiopancreatography (ERCP), percutaneous drain insertion, gastroscopy, and colonoscopy) EOC variables. Start time , end time (skin closure), time of day (day (07:00-15:59); evening (16:00-23:59), or night (00:00-06:59)), surgical procedure type/classification  were recorded for the operative intervention EOC variable. The EOC time variables are depicted in Figure  RespiratThe patient outcome variables measured included intra-operative, intervention-related, and postoperative complications, time to operating room, total length of stay (LOS), 30-day hospital readmission rate, 30-day emergency room (ER) visits, risk of perforated appendicitis, and pathology for appendectomy and cholecystectomy specimens. Post-operative complications were graded according to the Clavien-Dindo Classification System on a scale of I through V; minor grades I to II, major grades III to V .Study-specific reference documents, specifying the chart location for each outcome variable being extracted, facilitated reproducible and uniform data extraction . If the variable was not found in the pre-specified location, it was recorded as “not specified.” Uniform and consistent data extraction methods were facilitated through joint data extracted by two research team members (HG and JM); 50 charts at both Concordia and Victoria General Hospitals. Where differences in assessment existed, discussion and resolution were attained and, if required, arbitrated by KH. SAS procedures were utilized to handle missing data. For data missing completely at random, listwise deletion was used . Data missing at random were dealt with through imputation.A sample size/power calculation was not performed for this research study, as all of the charts for each cohort (Pre-ACS and R-ACS) for both the acute appendicitis (AA) and acute cholecystitis (AC) groups were retrieved and reviewed.Data were analyzed with SAS® statistical software . The AA and AC groups within the Pre-ACS and R-ACS cohorts were analyzed separately. Continuous data were analyzed with the two-tailed student’s t-test. Chi-square tests were used to test categorical variables; Fisher’s exact test was used if sample numbers were small (<5). A logistic regression analysis was performed for postoperative complications, readmissions, risk of perforated appendicitis, time to OR, and total length of stay (LOS). Logistic regression model covariates were chosen by a clinical decision and the backward selection method. Age and gender were deemed significantly relevant and included in all logistic models. The backward selection method started with all covariates included in the analysis plan. Variables were deleted from the model based on p-value; p-values > 0.02 were deleted. Cook’s D statistics were plotted for each regression model to determine the influence of each observation. Tolerance values to test for multicollinearity among the covariates was performed and absence confirmed among the variables tested; all tolerance values were greater than 0.1 and had Variance Inflation Factor (VIF) less than 10.Data were extracted from a total of 1,229 charts and represents two cohorts: the Pre-ACS (n=507) and R-ACS (n=722) cohorts. The Pre-ACS cohort includes patients from three hospitals . The AA and AC procedures were utilized to compare the Pre-ACS and ACS surgical outcomes. Table EOC and patient outcome measures were compared between the Pre-ACS and R-ACS cohorts for both the AA and AC patient groups Table . For botFor patients with AA, regionalization of the ACS service did not result in significant improvements from the Pre-ACS service for transfer time, time from operating room to discharge, or total length of stay (LOS). Time to emergency room physician (ERP) for AA patients was significantly higher in the R-ACS as compared to the Pre-ACS cohort . However, these same patients experienced a significantly shorter time to surgical assessment/surgical response time  as well as time from ERP or surgical assessment to imaging . In addition, the frequency of pre-operative imaging (ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI)) was significantly higher among R-ACS AA patients as compared to Pre-ACS AA patients . Similarly, the R-ACS service significantly reduced both time to surgical assessment/surgical response time  and time from ERP or surgical assessment to imaging for those patients with AC . All other EOC outcome variables were unaffected under R-ACS services. Data collected from multiple time points pre- and post-ACS implementation were used to retrospectively assess for temporal trends in the data, similar to an interrupted time series analysis. Evaluation of length of stay (LOS) for the AA and AC patient groups confirmed the absence of pre-existing trends towards decreased LOS prior to the implementation of ACS and no additional temporal trends were identified. Table Multivariate logistic regression demonstrated that post-operative complications and/or readmission for AA was associated with age, laparoscopic surgical procedure, transfer from another hospital, and admission to VGH or CGH as compared to SBGH Table . PerforaThis study assessed multiple EOC and patient-related outcomes for acute appendicitis and acute cholecystitis following the implementation of an R-ACS service in Winnipeg .The R-ACS in Winnipeg resulted in not only some improvements in efficiency but also highlighted some areas for improvement. Time to ER physician assessment increased but time to surgical assessment/surgical response time and time to imaging decreased, indicating improved efficiency by a dedicated surgical team. With R-ACS, time to surgery was slightly increased for AA and did not improve for AC, highlighting the challenge of timely access to operating room resources for EGS patients even with the presence of a dedicated team. Time to discharge and LOS trended towards improvement. Postoperative care was already efficient under the traditional model, with the average LOS between 1.4 to 2.8 days (depending on simple versus complex appendectomy) for AA and 2.9 days for AC, and improvements in this area were not demonstrated. Mean LOS for AA and AC from 2011 to 2017 were one and three days, respectively; one day less than the two additional Winnipeg hospitals performing these procedures. Multiple factors have been shown to impact LOS for AA patients, including time of presentation, perforation, and time of surgery -22.Currently, there are no established EOC benchmarks for common EGS diagnoses. The development of wait-time benchmarks for common EOC measures is required to promote patient safety and inform program planning and evaluation.Winnipeg has historically reported some of the longest ER wait times in Canada. The Canadian Institute for Health Information (CIHI) reported that four Winnipeg emergency departments were among the top five, with the longest wait times in Canada . MultiplWe assessed intraoperative and perioperative patient outcomes related to AA and AC using commonly reported measures and classifications. Despite trainee involvement in the R-ACS services model, post-operative complications did not increase and there were significantly fewer intra-operative complications for AC and no change for AA. The same surgeons were involved in the pre-ACS and R-ACS cohorts but the reduction in complications for AC might be explained by increased experience with laparoscopy during the study period or possibly by the conduct of these procedures at a tertiary teaching institution. Variation in study definitions and outcome measures for EGS conditions are common throughout the scientific literature . This maIn this study, R-ACS resulted in a substantial increase in patient transfers, with 67.1% of appendectomies being transferred, as compared to only 14.3% in the Pre-ACS cohort. These patients were at higher risk of pathologically confirmed perforation and post-operative complications (or readmission). At 29%, the R-ACS AA perforation rate is at the high end of published national rates of 20%-30% . Other AThe risk of perforation might be influenced by delays in imaging or consultation requests at the origin hospital, inadequate initial care (antibiotics and fluid resuscitation), or as the result of more serious disease. We did not capture index hospital treatment and efficiencies as part of the current study. This would involve significant resources to review paper-based emergency department data at multiple sites, including transfers from outside of Winnipeg. This has been considered for future research.Short delays in surgical intervention for AA are well-tolerated, with several studies reporting no increase in rupture when surgery is delayed until daytime hours -27. One Our study has a few limitations. Firstly, while transfer time was similar among the Pre-ACS and R-ACS cohorts, we did not capture the time spent at the referring hospital or treatments administered at the initial hospital. Secondly, our pre/post-study design lacked a concurrent control/comparison group, making it difficult to establish a cause and effect relationship between the intervention (ACS service implementation) and the outcomes measured. Thirdly, our results may be confounded by temporal and secular changes independent of the intervention. Surgeons who participated in EGS calls under the traditional (Pre-ACS) service model of care were the same as those involved in the R-ACS model and their laparoscopic experience increased over time.Regression analysis showed that laparoscopic cases were associated with a decreased risk of postoperative complications, decreased readmissions, and shorter LOS. In the last five years, early surgical intervention for AC has been advocated and the hospitals providing the R-ACS service adopted this change. However, our results show no significant differences in time to OR or operative rate for AC between the Pre-ACS and R-ACS cohorts. Other temporal trends in practice patterns have not been captured by this study . Also, competing procedures for the emergency OR were not assessed and could have impacted the R-ACS daytime OR measure.The introduction of formal ACS services, along with changes in surgeon practice patterns across Canada, make the further regionalization of EGS likely, and its impact must be highlighted. As with other conditions with standardized protocols for care  , pre-traEGS patients are a uniquely challenging population, particularly prone to poor outcomes. Improved efficiency and quality of EGS care can significantly impact the emergency department, operating room, and hospital resources. We must continue to define, measure, and monitor specific outcomes in order to identify opportunities for improvement.


CCAAT box, the specificity of the plant trimers has yet to be determined. Here we report that Arabidopsis thaliana NF-Y trimeric complexes, containing two different NF-YA subunits, bind DNA in vitro with similar affinities. We assayed precisely sequence-specificity by saturation mutagenesis, and analyzed genomic DNA sites bound in vivo by selected HFDs. The plant NF-Y CCAAT matrix is different in nucleotides flanking CCAAT with respect to the mammalian matrix, in vitro and in vivo. Our data point to flexible DNA-binding rules by plant NF-Ys, serving the scope of adapting to a diverse audience of genomic motifs.Nuclear Factor Y (NF-Y) is an evolutionarily conserved trimer formed by a Histone-Fold Domain (HFD) heterodimeric module shared by core histones, and the sequence-specific NF-YA subunit. In plants, the genes encoding each of the three subunits have expanded in number, giving rise to hundreds of potential trimers. While in mammals NF-Y binds a well-characterized motif, with a defined matrix centered on the  Data represent the mean of at least three independent competition experiments, +/− sd.Fluorescence gel images were acquired and analyzed with a ChemidocMP imaging system with the ImageLab Software (Bio-Rad Laboratories). Competitor oligo efficiency was calculated as follows: Percent bound probe was quantified in each data point of the dose curve, and plotted vs the competitor concentration . Competitor efficiency (slope/WT) represents the slope of the regression line obtained through the 0, 1x, 5x competition data points A. thaliana and G. max were retrieved from the Ensemble Plants genome browser [Reference genomes and corresponding annotations for  browser . Promote browser . Motifs  browser .


The explosive growth of microbiome data provides ample opportunities to gain a better understanding of the microbes and their interactions in microbial communities. Given these massive data, optimized data mining methods become important and necessary to perform deep and comprehensive analysis. Among the various priorities for microbiome data mining, the examination of species-species co-occurrence patterns becomes one of the key themes in urgent need.Hence, in this work, we propose the Meta-Network framework to lucubrate the microbial communities. Rooted in loose definitions of network  as well as association rule mining , this framework outperforms other methods in restoring the microbial communities, based on two cohorts of microbial communities: (a) the loose definition strategy is capable to generate more reasonable relationships among species in the species-species co-occurrence network; (b) important species-species co-occurrence patterns could not be identified by other existing approaches, but could successfully generated by association rule mining.Results have shown that the species-species co-occurrence network we generated are much more informative than those based on traditional methods. Meta-Network has consistently constructed more meaningful networks with biologically important clusters, hubs, and provides a general approach towards deciphering the species-species co-occurrence networks.The online version of this article (10.1186/s12864-019-5471-1) contains supplementary material, which is available to authorized users. Network-based approaches are gaining momentum as one of the most helpful tools for the analysis of microbial community structure. They offer new methodological and biological insights to investigate species interactions. Many microorganisms co-exist by interacting with each other and effectively exert various functions . In addiTo address these limitations, we propose Meta-Network to establish the species-species co-occurrence network. The loose definition method is introduced first to recover more correlations before correlation calculation. Then we utilize the FS-Weight and PCA-PMI  methods to explore the indirect and non-linear correlations, respectively. To investigate the optimized species-species co-occurrence network, systematic evaluation is investigated to discover meaningful biological implications in the species-species co-occurrence network.While direct and linear correlations were calculated by Pearson and Spearman , limitatTo measure the number of co-exist samples for pairwise species, we introduce the co-occurrence probability Fig. , a.1. ToWhile direct relationships have been reported in many existing works in the context of intricate bacterial community, it is possible to detect more complex correlations using association rule mining . In bactFor pairwise species, FS-Weight value between them was calculated in two steps. First, the direct correlations were calculated using a user-defined threshold for edge value. In this work, Pearson coefficient correlation was selected and the thresholds was set as 0.5 on genus level and 0.7 on OTU level based on previous research . Second,In microbial communities, nonlinear relationships play important roles . Thus, tWhere the Part independence of species x and y given indirect neighbor z is defined as:In order-one PCA-PMI, only one species was considered as indirect neighbor between two species, and the Path Consistency Algorithm (PCA)  was appl, b) supply an important material to understand the microbial network. First, we perform cluster calculation and hub nodes detection based on density clustering. We apply the MCODE cluster algorithm to detect the potential clusters [Detecting co-occurrence patterns and their biological significance Fig. , b supplclusters . AligninTo identify hub nodes, we calculate the most connected nodes as candidates for hub nodes. These nodes are selected to perform Kruskal-Wallis test (test differences in network distribution before and after deleting hub node) to decide whether they are hub nodes. Finally, we interpret the clusters and hub nodes based on known taxonomical and functional databases and literatures.In order to compare Pearson, loose definition, FS-Weight, PCA-PMI algorithm, the correlation coefficient calculated by loose definition which is implemented by the loose definition plus Pearson method.First, we calculate the global network alignment by MAGNA++  based onhttp://igraph.org/r/), including coreness, degree, eigenvector centrality, eccentricity, betweeness and degree centrality.Secondly, these four algorithms were compared based on their topological structures including network similarity, global properties and local properties by compNet software . FurtherThirdly, we examined the correlation distribution using the same set of species as target. Based on top 100 abundant genera in gut microbiome datasets, four networks are constructed to investigate their edge distributions, which reflect the correlation difference. Then network motif distribution was investigated by mfinder (version 1.2) . The motWe applied the Meta-Network on a dataset of health young Chinese as our representation of human gut (MGP15838 in MG-RAST database) . It consWe compared networks constructed by all four algorithms  on genus level. First, we calculated the global properties and illustrated in Fig. We performed a systematic evaluation to compare the network constructed by Pearson, loose definition, FS-Weight and PCA-PMI algorithms. Global network alignment was carried to compare the network constructed by these four algorithms on OTU level Fig. , a. The Based on the similarity tree based on Jaccard index, network constructed by Pearson method had a low similarity with other three networks Fig. , b. NetwBased on their motif distributions, we compared these four networks to reflect homology relationship Fig. , c. NetwTo investigate the edge distribution, four algorithms were compared based on the top 100 genera Fig. , a. In nLactocuccus and Granulicatella processed low abundance  and existed in 15 and 14 samples, respectively. In addition, a strong and significant positive correlation were detected between them . No convincing literature and reported function  could prove their relationships and both genera [In the network constructed by Pearson and Spearman algorithm Fig. , b, Geneh genera , 20. TheSyntrophomonas is reported as a fatty-acidoxidizing genus which cooperates with methanogens such as genus Methanosphaera and Methanobrevibacter [Syntrophomonas and methanogens could be clearly identified by FS-Weight and PCA-PMI methods . The interaction mechanism was illustrated in Fig. Bacteroides and Ruminococcus degrade the non-digestible carbohydrates into the short-chain fatty acid [Syntrophomonas and methanogens cooperate to transfer the short-chain fatty acid into methane and energy. Combining the network analysis results with literature review, we speculate that Bacteroides and Ruminococcus play the role, as indirect neighbor, between the Syntrophomonas and methanogens.More importantly, FS-Weight and PCA-PMI methods are capable to discover correlations undetected by the Pearson and Spearman algorithms Fig. , d. For vibacter . Howevertty acid . Second,In network constructed by CCLasso, the indirect correlation pattern could also be found, which could again prove the indirect pattern and advantage of FS-Weight and PCA-PMI. The result is provided in Additional file Tara Oceans Project . The processed nucleotide sequences from 245 experimental runs were publicly available, of which the volume exceeded 1.3 TB. Parallel-Meta (version 3.0) [Proteobacteria, which was confirmed as the largest phylum in the ocean bacterial community [We applied the same workflow to ion 3.0)  was adopommunity .Fig. 5ThNitrosopumilus and Candidatus_Scalindua were detected only in network constructed by PCA-PMI method and were identified as common members in the ocean environment [Figure ironment .These results have again, proved that the Meta-Network workflow has the ability to discover more complex formats of correlations. Moreover, Networks constructed by two different methods (FS-Weight and PCA-PMI) shared many identical network members and clusters, indicating that both methods portrayed the complex formats of correlations in microbial communities.Species-species co-occurrence network is becoming one of the emerging fronts for microbiome research, largely due to the important ecological patterns it could reveal. However, previous methods are limited by only detecting the direct correlations among pairwise species. This work presents the Meta-Network method that optimized the construction, analysis and interpretation of the species-species co-occurrence network, focusing on three critical processes for species-species correlation analysis: we first employ loose definition to recover correlations missed by strict co-occurrence probability before calculating correlations. Based on these candidate correlations, we also develop two association rule mining methods for the recurrence of the real bacterial community network: a graph-based method FS-Weight to detect indirect correlations, PCA-PMI method to detect indirect correlations. Therefore, we believe that Meta-Network provides a general approach towards deciphering the species-species co-occurrence networks.This method could be improved in several ways: in line with current gene expression network inferences, we can also improve its high-level associations . A complete species-species network, which provides the full picture of the regulation profile in the community, should also include viruses. All of these will be considered in our future work.Additional file 1:Figure S1. Threshold selection for FS-Weight and PCA-PMI method. (A) Global network properties for networks constructed by FS-Weight method. (DOCX 354 kb)