This study aimed to establish a low-risk zone to avoid neurovascular injury during a temporary extra-articular calcaneo-tibial pin fixation in an unstable ankle or subtalar joint. A line from the calcaneal tuberosity center to the lateral end of the posterior malleolus at the ankle joint level defines the lateral border of this zone. Another line from the calcaneal tuberosity center to the midpoint of the anterior distal tibial articular surface at the joint level defines its medial border. This region was assumed to have a low neurovascular injury risk upon pin insertion. Fifty ankles from 50 patients who had undergone magnetic resonance imaging (MRI) for ankle disorders were assessed. T1-weighted oblique axial MRI slices were oriented to the pin trajectory. The mean distances between the sural nerve and the lateral border of the low-risk zone and between the posterior tibial neurovascular structures and the medial border of the low-risk zone were 15.0 ± 2.5 (range 9.1 to 21.1) and 12.8 ± 2.6 (6.3 to 20.8) mm, respectively. No neurovascular structures were identified within the low-risk zone. These findings demonstrated that an unstable ankle or subtalar joint can be temporarily fixated with an extra-articular calcaneo-tibial pin at a defined zone with a low neurovascular injury risk. It can maintain alignment after fracture reduction, reduce the movement of the fractured area, and reduce the pain and the following inflammatory reactions of neighboring tissues, helping the swollen soft tissue to subside4. The benefit of staged operation with the use of the temporary external fixation includes decreased wound complications and infections6. An external fixator can also be quickly applied to fix an unstable ankle in critical polytrauma patients when time is an essential component of damage control10. Various types of external fixators have been developed, including multiple pins and bars constructs (delta frame) or a circular ring fixator10. However, to form a stable construct, multiple pins, bars, and wires are required, which may theoretically increase the risk of pin-tract infections. There are neurovascular injury risks during percutaneous insertion of the pins4. In a study of 52 distal tibial fractures which were temporarily fixated with bridging external fixators, medial calcaneal nerve was injured in 2 cases (4%)4. When these pins and wires are closely located to the wounds, it may be difficult to dress and seal up the wound for a negative pressure therapy when indicated  and lateral to the midpoint of the anterior distal tibial articular surface  at the joint level on the C-arm fluoroscopic ankle mortise radiograph  with a mean age of 45.6 years (range 16 to 79 years) who had undergone magnetic resonance imaging (MRI) for ankle disorders between November 2020 and June 2021 were assessed. The institutional review board approval was obtained [IRB of Hallym University Kangnam Sacred Heart Hospital (IRB-2017–12-004)]. All methods were performed in accordance with the relevant guidelines and regulations. The study focused on MRIs taken in the normal clinical practice for ankle disorders, and the informed consent from the patients was waived by the IRB of Hallym University Kangnam Sacred Heart Hospital. The MRIs were taken to evaluate for chronic ankle problems, including chronic ankle instability, osteochondral lesion of the talus, chronic ankle pain, etc. We excluded the patients aged less than 16 years because extra-articular calcaneo-tibial pin stabilization is not indicated for distal tibia and calcaneus with open growth plates. Patients with ankle joint deformity, such as varus ankle arthritis, or with conditions that can distort normal anatomy were excluded from the measurement. Patients with previous ankle surgeries or with metal hardware were also excluded.The temporary extra-articular calcaneo-tibial pin stabilization can be performed in a supine, lateral, or prone position depending on the requirements of concomitant procedures. In the supine position, the hip is externally rotated, and the knee is flexed to make a Fig. A Siemens 3.0-T MR scanner  was used for the study, and all measurements were made from the Pictured Archives and Communication System (PACS) Fig. . To meas24. Statistical analysis was performed using the SPSS version 21.0 .T1 oblique axial slices were measured with a thickness of 2 mm. The center of the calcaneal tuberosity was marked where it was most prominent to the posterior side. This mark could be highlighted in every oblique axial slice using the PACS program. The lateral end of the posterior malleolus at the joint level and the anteromedial end of the anterior distal tibial articular surface were marked, and a line was then drawn to connect the two ends. Then, a line corresponding to the medial border of the low-risk zone was drawn from the center of the calcaneal tuberosity bisecting the line connecting the two ends. For the lateral border, a line was drawn from the center of the calcaneal tuberosity to the lateral end of the posterior malleolus at the joint level. Also, a line was drawn from the center of the calcaneal tuberosity to the anteromedial end of the anterior distal tibial articular surface. This line indicated the most medial border, allowing us to check if it is safe to aim the pin toward the medial end of the anterior distal tibial articular surface during fixation. The three borders of the low-risk zone could be shown in every oblique slice using the PACS program. The distance between the sural nerve and the lateral border of the low-risk zone was measured. Similarly, the distance between the posterior tibial neurovascular structures and the medial border of the low-risk zone and between the posterior tibial neurovascular structures and the most medial border were also measured. The sural nerve and the posterior tibial neurovascular structures could be best identified on the T1 axial image at the joint level and could be traced on the T1 oblique axial slices using the PACS program. Additionally, five consecutive oblique axial slices within 1 cm proximal from the distal tip of the posterior malleolus were conducted to determine the safety of inserting the pin into the posterior malleolus 1 cm proximal from the distal tip. The T1 oblique axial slice from the center of the calcaneal tuberosity to the distal tip of the posterior malleolus was the primary slice for the analysis and five more slices were added for the analysis for each of the 50 ankles. One musculoskeletal radiologist and one orthopedic surgeon, both with more than 10 years of experience, measured the distances twice with an interval of one week. The mean values with standard deviation, range and 95% confidence intervals were presented. The inter- and the intra-observer reliabilities of the measurement were assessed using the intraclass correlation coefficient (ICC) with a 95% confidence interval, calculated by a 2-way mixed model. The absolute agreement was measured. The ICC was interpreted as poor agreement (< 0.50), moderate agreement (0.50–0.75), good agreement (0.75–0.90), or excellent agreement (> 0.90)This study was approved by IRB of Hallym University Kangnam Sacred Heart Hospital (IRB-2017–12-004).The results are summarized in Table The distance between the neurovascular structures and the borders of the low-risk zone decreased on the proximal slices. The shortest mean distance from the sural nerve to the lateral border  and from the posterior neurovascular structures to the medial border  was on the most proximal slice (slice 6). There were no neurovascular structures located inside the low-risk zone within 1 cm proximal of the distal tip in all the cases. The mean distance between the posterior tibial neurovascular structures and the most medial border of the low-risk zone was 5.3 ± 2.2  mm on the slice 1. However, in the proximal slices (from slice 2 to 6), there were cases wherein the posterior tibial neurovascular structures were located lateral to the most medial border , placing them at risk of being damaged when the pin is inserted along the most medial border toward the medial end of the anterior distal tibial articular surface. On the most proximal slice (slice 6), the mean distance between the posterior tibial neurovascular structures and the most medial border of the low-risk zone was − 2.0 ± 3.3 (range − 8.4 to 6.7) mm.4. Iatrogenic damage from external fixator pins has been reported to result in pseudoaneurysms and other clinical complications, such as partial or complete occlusion of arteries or persistent neurologic symptoms25. As such, it is essential to understand the anatomy of the neurovascular structures around the sites for pin fixation. The posterior tibial artery and tibial nerve pass posteromedially behind the medial malleolus in the distal quarter of the leg. Meanwhile, the sural nerve travels subcutaneously at the distal third of the leg proceeding along the lateral margin of the peroneal tendon and then posterior to the lateral malleolus29. Given their locations, these structures are at risk during the placement of wires for circular external fixation30. Several studies have found safe corridors for the insertion of wires around the ankle joint for circular external fixation32. However, we are not aware of any study in which the investigators attempted to delineate the safe corridor for the extra-articular calcaneo-tibial pin fixation to avoid neurovascular injury.The percutaneous placement of wires, pins, or screws can sometimes cause iatrogenic neurovascular injury, especially when it is performed through the thick layers of soft tissues17. Another study established an optimal trajectory for calcaneo-tibial K-wire fixation, but it only utilized simple radiographs and focused on the entry angle of the wire to avoid penetrating the ankle, subtalar, or distal tibiofibular joints. The mean entry angle to the plantar plane was 59.4° in the lateral radiograph, while it was 18.4° to the distal tibial articular surface in the mortise radiograph. However, the study did not consider the possibility of neurovascular injury. To ensure a stable fixation, the medial boundary was set at the medial end of the anterior distal tibial articular surface, which had the potential risk of neurovascular injury in our study. In our current study, the distance between the posterior tibial neurovascular structures and the trajectory of the pin from the center of the calcaneal tuberosity to the medial end of the anterior distal tibial articular surface was 5.3 ± 2.2 (range 0.5 to 12.4) mm. The distance became shorter at the proximal area, indicating that it may be risky to aim the pin at the medial end of the anterior distal tibial articular surface on the C-arm fluoroscopic mortise ankle radiograph and proximally to the distal tip of the posterior malleolus on the lateral radiograph. However, aiming the pin lateral to the midpoint of the anterior distal tibial articular surface seemed like a safer option. The mean distance between the posterior tibial neurovascular structures and the trajectory of the pin from the center of the calcaneus to the midpoint of the anterior distal tibial articular surface was 12.8 ± 2.6 (range 6.3 to 20.8) mm. There were no cases wherein neurovascular structures were identified lateral to this trajectory. The mean distance between the sural nerve and the lateral border of the low-risk zone, located from the center of the calcaneal tuberosity to the lateral end of the posterior malleolus at the joint level, was 15.0 ± 2.5 (range 9.1 to 21.1) mm. Similarly, no neurovascular structures were identified medial to this border, indicating that it might be a safe route of insertion. In the lateral radiograph, inserting the pin within 1 cm proximal of the distal tip of the posterior malleolus may be a safe option.A cadaveric study reported on the retrograde calcaneo-tibial fixation of unstable ankle fractures. However, it focused on the efficiency and accuracy of a targeting device developed for the fixation and not on its safety and prevention of neurovascular injury21. The said study included 40 ankle MRIs and measured the distance between the instruments and the posterior neurovascular structures, which is similar to our present study. However, our MRI study included more ankles than this study. Furthermore, to the best of our knowledge, our study included the largest number of ankles to measure the safe distance between the neurovascular structures of the posterior ankle and the instrument. However, there is no clear cut-off distance between the neurovascular structures and the instrument that may be considered safe. In an MRI study, the mean distance between the instrument for posterior arthroscopy and the tibial neurovascular structures and sural nerve was 3.5 and 2.8 mm, respectively. The authors concluded that arthroscopic instruments can be safely used without causing injury to the neurovascular structures33. In our study, the distance between the tibial neurovascular structures and the medial border of the low-risk zone was 12.8 mm, while the distance between the sural nerve and the lateral border of the low-risk zone was 15.0 mm. These were farther than the distance presented in the previous MRI study33. Moreover, when a pin is inserted within the low-risk zone, the distance between the neurovascular structures and the pin will be even farther compared to the distance between the neurovascular structures and the borders of the low-risk zone. This technique has been clinically applied in nine patients with acute ankle fractures19, and none sustained iatrogenic neurovascular injury. In the study, the pin was retained for an average duration of 5.3 weeks (range 2 to 8 weeks), and none of the cases developed a pin-tract infection or pin breakage19. However, one patient lost reduction due to noncompliance with weightbearing restrictions. Another limitation is that the current study focused on the safety of the procedure to avoid neurovascular injury but not on mechanical stability. It is evident that a single pin will be less stable compared to a traditional external fixator with a delta frame construct or circular rings. Therefore, this technique is recommended for an unstable ankle or subtalar joint in critical polytrauma patients when time is an essential component of damage control or when the ankle joint is too unstable for a splint or cast immobilization alone and traditional external fixation techniques may not be required or are not cost-effective19. We believe that it may be optimal to aim the pin from the center of the calcaneal tuberosity to the center of the distal tibia to ensure stability.There were several limitations to this study. The distance of the neurovascular structures to the pin was not measured when it had been inserted but was measured on the MRI with an imaginary trajectory and the low-risk zone of the pin on the premise that the ankle is anatomically reduced. The result may be different in the real situation, where the soft tissues are swollen and injured and the ankle is subluxated. However, taking an MRI of the ankle with a metal pin inserted can produce significant artifacts and distorted images. Additionally, the distance was measured on the 2-dimensional image slices but not on the 3-dimensional reconstructed images. A future study with fresh cadavers may confirm the present findings. Another limitation is that the 50 ankles measured in this study may not be enough to confirm the procedure’s safety. Sample size calculation and power analysis may not be appropriate for a non-comparative study without any group allocation. The sample size of 50 ankles was selected based on a previous MRI study that assessed the safe direction of instruments during posterior ankle arthroscopyA MRI analysis demonstrated that an unstable ankle or subtalar joint can be temporarily fixated with an extra-articular calcaneo-tibial pin at a defined zone with a low neurovascular injury risk.To lower neurovascular injury risk during an extra-articular calcaneo-tibial pin fixation, the pin should be inserted from the calcaneal tuberosity center to the distal tip of the posterior malleolus within the low-risk zone.A line from the calcaneal tuberosity center to the lateral end of the posterior malleolus at the ankle joint level defines the lateral border of the low-risk zone, medial to which the pin should stay in order to not injure the sural nerve.A line from the calcaneal tuberosity center to the midpoint of the anterior distal tibial articular surface at the joint level defines the medial border of the low-risk zone, lateral to which the pin should stay in order to not injure the tibial neurovascular structures.Take home messages.


To explore the effect of applying continuous nursing care based on hierarchical diagnosis and treatment in Stage II cardiac rehabilitation of patients after percutaneous coronary intervention (PCI) and provide a theoretical basis for clinical nursing intervention.Patients in PCI postoperative II cardiac rehabilitation were selected and randomly divided into the experimental group (community group), the experimental group (rehabilitation group), and the control group. Patients in the control group received the routine cardiac rehabilitation management scheme, while those in the experimental groups received continuous nursing protocol based on the hierarchical diagnosis and treatment mode. All patients were compared for the cardiac rehabilitation evaluation indexes at discharge and 6 months after discharge.P < 0.05). The improvement in the rehabilitation group was more significant than in the community group. There were more patients with high cardiac rehabilitation compliance in the rehabilitation group than in the community group, with the difference being statistically significant (P < 0.05).Compared with the control group, the left ventricular ejection fraction, 6-minute walking distance test, medication compliance, and quality of life were all improved in the two experimental groups, and the differences were statistically significant (Continuous nursing care rehabilitation based on the hierarchical diagnosis and treatment mode can improve the cardiac function of patients after PCI, enhance their quality of life, and improve their rehabilitation and medication compliance, facilitating their cardiac rehabilitation. Report on Cardiovascular Health and Diseases in China 2019 (Guidelines for Cardiac Rehabilitation and Secondary Prevention in China (GCRSPC) (According to the (GCRSPC) . This stA total of 100 patients discharged from Shanghai Songjiang District Central Hospital after initial PCI from July 2021 to December 2021 were randomly selected as the study subjects.The inclusion criteria were as follows: (1) patients who were definitively diagnosed as coronary heart disease according to the World Health Organization diagnostic criteria; (2) patients who were permanent residents of the Songjiang District of Shanghai who underwent PCI during hospitalization; (3) patients whose risk stratification complied with low–medium risk of coronary heart disease (CHD) in accordance with the GCRSPC; (4) patients with <30% residual stenosis after PCI as shown by coronary angiography; (5) patients who voluntarily participated in the study and signed the informed consent; and (6) patients aged 18–75 years.Risk Stratification of Patients with Coronary Heart Disease; (5) patients who did not live in the region in the recent period ; and (6) patients with loss of consciousness, mental illness, physical dysfunction, disability, or who were unable to cooperate with rehabilitation.The exclusion criteria were as follows: (1) patients complicated with aortic stenosis, valvular disease, or hypertrophic obstructive cardiomyopathy; (2) patients complicated with tumors, thrombosis, severe hepatic and renal insufficiency, or other diseases that may aggravate the condition; (3) patients with postoperative complications, such as bleeding, embolism, restenosis, or occlusion; (4) patients classified as high risk according to the The elimination criteria were as follows: (1) patients with coronary heart disease risk stratification from low–medium risk to high risk; and (2) patients who died or dropped out of the study. Two patients who failed to meet the criteria and seven patients who were absent from data collection or withdrew from the study were excluded.P > 0.05, There were no statistically significant differences in age, gender ratio, left ventricular ejection fraction (LVEF) (%), the 6-minute walking distance (6MWD) test (m) and BMI of patients among the three groups , which includes eight dimensions: physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning, role emotional (RE), and mental health (MH), with 100 points for each dimension, where a higher score indicates a better quality of life.The calculation method for cardiac rehabilitation compliance referred to the percentage of patients' actual/expected participation in Stage II cardiac rehabilitation, where a participation rate >50% was defined as high compliance.The Morisky medication compliance scale was used to determine the medication compliance. The scale consists of four questions, which are mainly aimed at the conditions of medication and unauthorized drug withdrawal, and the answers to each question included “often,” “occasionally,” and “never,” corresponding to 1, 2, and 3 points, for a maximum of 12 points .® SPSS™ Statistics v21.0 software was used for statistical analysis. Measurement data were expressed as mean ± standard deviation , LVEF in the community group and the rehabilitation group was significantly improved after rehabilitation, which were 56.63 ± 8.03 and 63.61 ± 7.77, respectively, and the improvement in the rehabilitation group was more obvious. The differences were statistically significant (P > 0.05). However, the 6MWD of community group and rehabilitation group reached 373.47 ± 68.81 and 431.97 ± 73.39 respectively after rehabilitation, which was significantly higher than that of control group (310.14 ± 68.32), and was also significantly improved compared with the two groups before rehabilitation, with statistical significance , and the difference was statistically significant . The improvement in the rehabilitation group was more significant than that of the community group, with the differences being statistically significant (P < 0.05). The compliance with cardiac rehabilitation in the rehabilitation group was higher than that in the community group, with the difference being statistically significant (P < 0.05).Two continuous nursing care modes based on the hierarchical diagnosis and treatment mode have been proposed: tertiary hospital to community hospital, and tertiary hospital to professional rehabilitation hospital to community hospital. Compared with traditional cardiac rehabilitation, the two modes could significantly improve the patients' quality of life, LVEF, 6MWD, and medication compliance, with the differences observed in the present study being statistically significant , while the LVEF and 6MWD were significantly improved in the community group and the rehabilitation group (P < 0.05), and the improvement in the rehabilitation group was more significant than in the community group. Therefore, the continuous nursing cardiac rehabilitation mode based on hierarchical diagnosis and treatment was beneficial to the improvement of patients' cardiac functioning.The most widely accepted cardiac function rehabilitation index in clinical practice is LVEF , while 6It has been proven that cardiac rehabilitation is beneficial to cardiac function recovery of patients after PCI. In the continuous nursing care mode based on hierarchical diagnosis and treatment, Stage II cardiac rehabilitation patients can be transferred to rehabilitation hospitals after PCI for professional rehabilitation exercise before being transferred to community hospitals. Continuous nursing care can be implemented during the entire time, which not only avoids the unbalanced development of cardiac rehabilitation in the community but also improves the quality of patients' cardiac rehabilitation by helping them to form beneficial habits in specialist hospitals.P < 0.05).The SF36 has been widely used to evaluate the health status of patients with cardiovascular disease and can fully reflect their quality of life. In the present study, the SF36 was used to evaluate the patients' quality of life at discharge and 6 months after discharge, and showed that the scores for the seven factors PF, RP, BP, GH, VT, RE, and MH were improved after recovery, with the differences statistically significant . Sun et al. (P > 0.05), in which the score of the Chinese norm was 83 ± 17.8, and the score of the patients was 78.1 ± 29.4. In the present study, the score of patients before and after rehabilitation ranged from 50 to 70, which was lower than that in the study conducted by Sun et al. This might be related to the fact that patients in the rehabilitation group and the community group received rehabilitation more often, spent most of their time in hospitals, had a smaller social scope, and focused their time and energy on cardiac rehabilitation, or there might be some differences between local and domestic norms.Social functioning was improved in the observation group, but the level in the rehabilitation group and the community group was the same before and after rehabilitation, with no improvement found . Rehabilitation compliance ≤ 50% is considered as low compliance by foreign scholars  in the rehabilitation group showed a high rehabilitation compliance, and 9 patients (27.3%) followed the original rehabilitation plan exactly; 2 patients (6.7%) in the community group showed a high rehabilitation compliance, and 0 patients followed the original rehabilitation plan exactly. The comparison between the two groups showed that the rehabilitation group had a higher rehabilitation compliance than the community group  . The patients/participants provided their written informed consent to participate in this study.Conception and design of the research: Z-JD and J-YZ. Acquisition of data: P-HG and S-TX. Analysis and interpretation of the data: J-FZ. Statistical analysis: S-TX and C-FZ. Obtaining financing: Z-JD. Writing of the manuscript: Z-JD and S-TX. Critical revision of the manuscript for intellectual content: J-YZ. All authors read and approved the final draft.This work was supported by Scientific Research Project of Shanghai Nursing Society (No. 2020MS-B09).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Public health programs are tasked with educating the community on health topics, but it is unclear whether these programs are acceptable to learners. Currently, these programs are delivered via a variety of platforms including in-person, virtually, and over the telephone. Sickle cell trait (SCT) education for parents of children with this trait is one of many education programs provided by the Ohio Department of Health. The novel SCTaware videoconference education program was developed by a research team after central Ohio’s standard program transitioned from in-person to telephone-only education during the COVID-19 pandemic.Our objectives were to investigate the acceptability of the format and engagement with the SCTaware education and assess parental worry about having a child with SCT before and after receiving SCTaware.previously received SCT education by telephone, were able to be contacted, and had access to an electronic device capable of videoconferencing were eligible to complete surveys after receiving the virtual SCTaware education program. The SCTaware educator also completed a survey to assess participant engagement. Data were summarized descriptively and a McNemar test was used to compare parental worry before and after receiving SCTaware.This was a single-center, prospective study of English-speaking parents of children <3 years of age identified to have hemoglobin S trait by newborn screening. Parents who P<.001).In total, 55 participants completed follow-up surveys after receiving standard SCT telephone education and then completing SCTaware. Most (n=51) participants reported that the SCTaware content and visuals were very easy to understand (n=47) and facilitated conversation with the educator (n=42). All of them said the visuals were respectful and trustworthy, helped them understand content better, and that their questions were addressed. Nearly two-thirds  reported that the pictures appeared very personal and applied to them. The educator noted most participants (n=45) were engaged and asked questions despite having to manage distractions during their education sessions. Many participants (n=33) reported some level of worry following telephone-only education; this was significantly reduced after receiving SCTaware (Our results suggest that SCTaware is acceptable and engaging to parents. While telephone education may make SCT education more accessible, these findings suggest that many parents experience significant worry about their child with SCT after these sessions. A study to evaluate SCTaware’s effectiveness at closing parents’ SCT knowledge gaps is ongoing. Public health programs are tasked with educating communities on health topics such as diabetes, asthma, and heart disease. The Ohio Department of Health (ODH) oversees many such education programs, the format of which can vary from in-person to telephone to virtual. One example is the sickle cell trait (SCT) education program for parents of newborns identified as having hemoglobin S trait through newborn screening (NBS) .Nearly 3 million people in the United States have SCT, and approximately 2000 infants are born annually with sickle cell disease (SCD) ,5. This The ODH supported one-on-one in-person SCT education of parents of children with SCT by a trained educator prior to 2020, which increased many parents’ knowledge and was well received, but approximately one-third of parents who were eligible to receive this education in central Ohio did not attend these sessions, likely due to difficulties in transportation and access. With the COVID-19 pandemic, ODH shifted to a telephone-only program. While changing to this format has potential benefits of reducing transportation barriers and increasing parental access to SCT education, it also adds challenges, including difficulty building rapport between the educator and parent and the inability to use supporting visual materials to explain SCT. Its effectiveness, acceptability, and impact on parents’ level of worry about having a child with SCT and/or SCD have not been studied. Given work that suggests parents with a trait for a genetic disease report that effective education about their trait decreases their anxiety, increases their preparedness, and increases their sense of control about the potential of having a child with a genetic disease , studiesAccording to Centers for Disease Control and Prevention guidance on providing health education curricula, effective education not only presents clear and understandable information but is also engaging and acceptable to learners in that it addresses their values, attitudes, and beliefs . To overSCTaware was developed by a multidisciplinary research team after evaluation of the existing in-person SCT program in central Ohio . SCTawarThis was a single-center, institutional review board–approved, prospective study of parents of children identified to have hemoglobin S trait by NBS. English-speaking adult biological parents of children <3 years of age with hemoglobin S trait who received telephone education were identified from the telephone educator’s schedule within the electronic mearents who were able to be contacted via telephone by the virtual educator and member of the study team were eligible to participate if they did not have SCD or a child with SCD, had not received SCT education in central Ohio for another child, were not (or partner was not) currently pregnant, and had access to an electronic device capable of videoconferencingParents who consented to participate were asked to complete surveys after receiving the SCTaware content. In addition to completing a demographics survey and reporting the type of device they used to receive SCTaware, acceptability and level of worry were assessed using the Education Effectiveness Survey (EES). This survey includes an 18-item Likert scale of multiple-choice items and one open-ended item. The EES was developed using a modified version of the education satisfaction survey that was used in a prior SCT study . It was After each session, the virtual educator also completed a survey to assess parent engagement and distractions, to quantify the number of questions parents asked, to assess parents’ ability to teach-back key content, and to record the time it took to complete the session. The 5-item survey included 4 multiple-choice responses and 1 open-ended question. This survey was pilot-tested with the SCTaware development team. To assess reliability over time, 6 education sessions were also randomly observed by an additional SCTaware development team member who also completed the survey.P value <.05 was considered statistically significant. Analyses were completed using the base R statistical package .Data were summarized descriptively. Frequency and percentage for qualitative variables and mean or median and IQR were calculated for quantitative variables. A McNemar test was used to compare parental worry before and after receiving SCTaware. A Documentation of verbal informed consent was required prior to study participation . This study was approved by the Nationwide Children’s Hospital Institutional Review Board (STUDY00000122).Of the 391 parents of children with SCT who received telephone education between October 2020 and October 2022, 154 (39%) were able to be contacted, and 86 (56%) consented to participate. Of these, 60 (70%) completed the SCTaware education session , and 55 The mean length of the SCTaware education session was 34.4  minutes. A total of 14 parents reported having learning barriers  that make it hard for them to learn new things.Nearly all participants  reported the words used by the educator were somewhat to very easy to understand. All participants agreed that they had a chance to ask questions, that these questions were answered, and that they were given the opportunity to teach-back key concepts to ensure that they understood.All participants agreed or strongly agreed that the SCTaware visuals helped them understand SCT. Most participants  reported that the visuals used were very easy to understand, appeared professional , told helpful information , and facilitated conversation with the educator . Nearly two-thirds  reported that the pictures appeared very personal and applied to them, and 27% (n=15) felt that the visuals were actionable, in that they told the participant what to do .Most participants either preferred the virtual session  or having the combination of the telephone education and then the virtual session . A few  reported they preferred the telephone-only education to the virtual session. Those who preferred the virtual or the combination of virtual and telephone-only education reported that the virtual format “made it like we (Educator and Parent) were face to face,” and that “it allowed me (Parent) to feel present in the conversation and learning.” They also reported that it allowed the educator “to show them things,” and that “I (Parent) was able to learn at my own pace.” Participants reported their preferences about potential methods to receive additional SCT information after the SCTaware session .The educator reported that most (n=45) of the participants who completed SCTaware were highly engaged in the education; however, 10 did not use their camera on their electronic device, making engagement assessment among these participants challenging. The educator noted that most  asked at least one question and 40% (n=24) asked more than three questions. The educator also noted that distractions, frequently a young child crying, were common among parents , but that many distracted participants were still “fairly engaged despite being distracted and made an effort to indicate listening.”The observers’ and educator’s assessments of perceived engagement aligned for all 6 randomly observed sessions. Perceptions of level of distraction were aligned for 3 sessions and were closely aligned for the other 3 sessions.Of the 55 participants who completed the EES, 60% (n=33) reported some level of worry about having a child with SCT after receiving telephone-only education and before receiving SCTaware, 24% (n=13) of those being very worried. After receiving SCTaware, 55% (n=30) of parents had less worry; only 5% (n=3) had increased worry. Only 2% (n=1) remained very worried after receiving SCTaware .A few parents reported that the virtual educator “explained things very well” and “got me to think about getting blood work done to see if I'm a trait carrier,” that the education was “very enlightening,” and that “the educator was clear and explained everything in a systematic way that made it easy to understand.” One participant also reported that the teach-back method was “cool...but at times it made me feel like a kid being told to listen up.” However, this same individual also felt that teach-back “helped things to stick a little better [so] it's a thin line between good and unsure.”With an increase in reliance on digital technology use, especially to provide education , virtualThis study found that 62% (n=34) of participants reported the pictures appeared very personal and applied to them. This was lower than expected when compared to the high rating of understandability of visuals by participants. This may reflect efforts to address cultural sensitivity and diversity such that the figures depicted in the visuals had a generic appearance. Additional research is needed to better identify optimal depiction of human figures in SCTaware and similar materials to promote both individual connection as well as inclusiveness. Nevertheless, participants reported high satisfaction, affirming the visuals were very easy to understand, professional, helpful, and facilitated conversation with the educator.Notably, we observed that participants often faced distractions and interruptions, most of which were out of the parents’ control  during their virtual education session. These interruptions did not necessarily impact parental engagement as assessed through the educator survey. However, divided attention while learning has been shown to impair long-term memory retention and decrease one’s ability to apply learned knowledge to new context . This maWe observed many parents had high levels of worry after receiving telephone-only SCT education, but this level of concern lessened after SCTaware. This is consistent with prior literature that suggests that effective genetic counseling for abnormal hemoglobin traits can lower anxiety among family members . Future In contrast to our prior study of in-person SCT education , where pThis study has a few limitations. First, since only English-speaking parents were recruited via telephone, we were unable to assess SCTaware’s acceptability among those who could not be contacted, were not proficient in English, who did not have the ability to access the virtual education, or who declined participation. It is possible that parents who participated were more motivated, worried, and engaged in learning about SCT and were, therefore, more likely to report high acceptability of SCTaware. While access to the technology required to complete SCTaware could limit the applicability of our program, we suspect this will be less of a limitation with time, since digital technology is becoming more ubiquitous . DevelopSecond, while mothers and fathers were eligible, mothers were primarily recruited. This is likely because mothers were listed as the primary contact for telephone SCT education in the electronic medical record. This finding is consistent with the literature. Studies have found that fewer than a third of fathers attended pretesting cancer genetic counseling appointments, yet findings suggest that attendance of both parents in a genetic counseling session may result in parents feeling more informed . Future Third, SCTaware was provided by a single educator who was aware that some sessions were going to be randomly observed by members of the study team and evaluated by participants. This may have impacted how the educator provided the education, and future studies need to consider if ongoing evaluation is needed to ensure that the SCTaware program is consistently delivered. Additionally, the acceptability of the virtual program may be related to this educator’s ability to connect with parents and may not be generalizable. Careful selection criteria for future educators and standardized training will be needed to effectively disseminate SCTaware to a larger audience.Lastly, survey responses may have been biased. For example, participants reported both their pre- and postlevel of worry about having a child with SCT after receiving SCTaware. Postsession impressions may have affected their rating of presession worry. Additionally, participants had an ongoing relationship with the educator as they completed the study activities, which may have influenced their responses. The eucator and participants were also aware when an additional team member observed the education session, which may have impacted the parent’s engagement. Finally, it is necessary to determine if SCTaware closes knowledge gaps and if the program results in increased parental testing.Virtual HL-informed SCT education was found to be highly acceptable as a method for distributing information about a common and important public health topic. This suggests that virtual education in the public health setting may be a promising intervention to increase accessibility to other public health information, especially among populations who may have challenges attending in-person education sessions. Future research is needed to determine if this format increases accessibility, whether it closes knowledge gaps and leads to actionable behavior, and if it is applicable to other health topics.


Sulfatide is an abundant glycosphingolipid in the mammalian nervous system, kidney, trachea, gastrointestinal tract, spleen, and pancreas and is found in low levels in other tissues. Sulfatide is characterized by the presence of a sulfate group in the hydrophilic galactose moiety, with isoforms differing in their sphingosine base and the length, unsaturation, and hydroxylation of their acyl chain. Sulfatide has been associated with a variety of cellular processes including immune responses, cell survival, myelin organization, platelet aggregation, and host-pathogen interactions. Structural studies of protein-sulfatide interactions markedly advanced our understanding of their molecular contacts, key-interacting residues, orientation of the sulfatide in its binding site, and in some cases, sulfatide-mediated protein oligomerization. To date, all protein-sulfatide interactions are reported to display dissociation constants in the low micromolar range. At least three distinct modes of protein-sulfatide binding were identified: 1) protein binding to short consensus stretches of amino acids that adopt α-helical-loop-α-helical conformations; 2) sulfatide-bound proteins that present the sulfatide head group to another protein; and 3) proteins that cage sulfatides. The scope of this review is to present an up-to-date overview of these molecular mechanisms of sulfatide recognition to better understand the role of this glycosphingolipid in physiological and pathological states. O-sulfogalactosylceramide or SM4) is a sphingolipid found on the surface of all eukaryotic cells. Through its negatively charged head group, sulfatide interacts with adhesive receptors, coagulation factors, innate immunity receptors, and extracellular proteins  are the major glycosphingolipids in myelin, representing about 4 and 23% of the total lipid content, respectively . Their cSulfatide synthesis begins in the endoplasmic reticulum (ER) where 2-hydroxylated ceramides and non-hydroxylated ceramides are substrates for UDP-galactose in a reaction mediated by the ceramide galactosyltransferase , leading to the formation of GalC . GalC isLysosomal catabolism of sulfatide is mediated by the co-action of ARSA and the sphingolipid activator protein-1 or saposin B, producing GalC . Indeed,Disabled 2 (Dab2) is a modular protein involved in a variety of cellular processes, including endocytosis and modulation of platelet function . In huma2]  of ∼30–50 μM  is localized at the lumen of the ER where it functions as a secretory factor . MANF isIt remains unclear whether sulfatide promotes or blocks inflammation and autoimmunity. Unlike GalCs, sulfatide stimulates monocyte expression and secretion of cytokines . Type II+ T-cells, whereas the group 2, which is represented by CD1d, presents antigens to the invariant natural killer (iNK) T-cells (Initiation of an adaptive immune response in vertebrates depends upon the activation of T-cells through the recognition of foreign antigens by T-cell receptors (TCRs) . Activat T-cells .18 sphingosine backbone of the sphingolipid, whereas the sulfatide acyl chain comes out from the A′ pocket and makes contacts with the F′ pocket , a transmembrane domain, and a cytosolic region. Two α-helices (α1 and α2), on top of a β-sheet, build a lipid-binding groove that is responsible for presenting the antigen to iNK T-cells . The hyd′ pocket   3δ of the TCR δ-chain is responsible for contacting the sulfatide head group by forming electrostatic interactions with R103, likely providing sulfatide specificity . Surpris19–26 μM  , which are α-helical sensors of glycolipid levels that target the plasma membrane and the ER . GLTPs . Indeed,ing mode . Compariing mode , which mThere is strong evidence that the membrane binding region of GLTP overlaps, or it is nearby, the glycolipid-binding site of the protein [reviewed in ]. In addThe Naja atra Taiwanese cobra β-structured cardiotoxin A3 (CTX A3) belongs to a family of positively charged toxins that can induce severe necrosis in tissues and systolic heart arrest in envenomed individuals . CTX A3 Several groundbreaking studies have revealed that membrane sulfatide facilitates a wide range of cellular functions using recognition mechanisms with a remarkable degree of heterogeneity. Given the localization of sulfatide at the outer plasma membrane, one common function is to serve as a receptor for cell-surface proteins. The high-resolution of the protein-sulfatide structures provide some comparative information about how specific a sulfatide head group is or whether the ceramide portion of the sphingolipid drives protein activity. The consensus structural data indicates that it is likely that the side chain of an arginine, and in some cases lysine, makes electrostatic contact with the sulfate moiety . It is pThere are major challenges that hopefully will be resolved through future research efforts such as how sulfatide signals, identification of external cues that direct either sulfatide synthesis or turnover, the contribution of circulating sulfatide in body fluids under different metabolic states and the impact on lipid rafts, high-resolution technology to visualize individual sulfatide molecules, the existence of protein partners that enhance and stabilize protein-sulfatide interactions, and the elucidation of the specificity for the sulfatide head group and/or for the ceramide moiety. Since the affinity for sulfatide-binding proteins is in the micromolar range  and that


Despite the availability of more than 30 antiseizure medications (ASMs), the proportion of patients who remain refractory to ASMs remains static. Refractory seizures are almost universal in patients with epileptic encephalopathies. Since many of these patients are not candidates for curative surgery, there is always a need for newer ASMs with better efficacy and safety profile. Recently, the anti-obesity medication fenfluramine (FFA) has been successfully repurposed, and various regulatory agencies approved it for seizures associated with Dravet and Lennox–Gastaut syndromes. However, there is a limited in-depth critical review of FFA to facilitate its optimal use in a clinical context. This narrative review discusses and summarizes the antiseizure mechanism of action of FFA, clinical pharmacology, and clinical studies related to epilepsy, focusing on efficacy and adverse effects. Epilepsy is one of the most common neurological disorders. Approximately 50 million people globally live with epilepsy. Epilepsy is primarily treated with antiseizure medications (ASMs), and appropriate treatment can make 60–70% of the patients seizure-free . HoweverFenfluramine (FFA), a serotonergic medication, has recently gained popularity as an ASM. It is an amphetamine derivative and racemic mixture of D- and L-enantiomers . It was FFA and D-FFA rapidly declined from huge popularity as reports of serious cardiovascular adverse effects emerged. In 1981, two cases of pulmonary artery hypertension (PAH) associated with FFA use were reported . In 1997Before FFA was withdrawn globally from the market, it was noted to be effective in pediatric epilepsy in the 1980s and 1990s. Belgian researchers were able to continue using FFA for epilepsy with the government’s help. A Belgium Royal Decree was issued in March 2002 to make it available for treating seizures as the drug stopped being commercially available . SubsequThis narrative review discusses and summarizes the antiseizure mechanism of action of FFA, clinical pharmacology, and clinical studies related to epilepsy, focusing on efficacy and adverse effects. MEDLINE using PubMed and OvidSP vendors were searched in March and June 2022 with appropriate keywords (“Fenfluramine” in combination with “seizures” and “epilepsy”). To find other pertinent publications, the author used a “snowball sampling” approach to go through each article’s references. After reviewing the titles and abstracts of all these articles, relevant English language FFA articles  were included in this review. The following standards were used in compiling the final reference list: innovation, importance, quality, and relevance to the review’s objectives.FFA controls the serotonergic system by increasing extracellular serotonin (5-hydroxytryptamine/5-HT), which in turn activates 5-HT receptors. First, FFA interacts with serotonin transporter to inhibit 5-HT uptake . In addiIncreased 5-HT levels in the brain were noted to inhibit seizures in rats since 1957 . In expe1-5-HT7). Except for 5-HT3, other 5-HT receptors are G protein-coupled seven-transmembrane receptors that activate the intracellular second messenger cascade. 5-HT3 is a ligand-gated Na-K channel responsible for an excitotoxic effect causing depolarization. Although additional research is needed on which specific 5-HT receptor subtypes and underlying pathways are engaged, 5-HT1D and 5-HT2c receptors may be primarily responsible for the antiseizure action of FFA [1 receptors decrease adenyl cyclase and cyclic adenosine monophosphate, causing inhibitory effects, whereas 5-HT2 receptors activate phospholipase C and increase inositol phosphate and diacylglycerol, leading to excitation. In general, increased 5-HT enhances GABAergic neurotransmission in inhibitory interneurons by increasing the frequency and amplitude of spontaneous inhibitory postsynaptic currents [2A and 5-HT2c could inhibit rhythmic thalamic burst firing, resulting in possible effectiveness in absence seizures.Aside from the indirect effect of increasing extracellular 5-HT levels, FFA’s metabolites, D- and L-norfenfluramine (norFFA), activate 5-HT receptors directly ,17. 5-HTcurrents . In addi1A receptor antagonist or 5-HT reuptake inhibition. In mice, FFA could protect against audiogenic seizures and seizure-induced respiratory arrest [1D and 5-HT2C agonist activity [The anticonvulsant effect of FFA is diverse in experimental models. FFA could block epileptiform activity induced by lowering Mg concentration in rat entorhinal cortical slices . FFA’s ay arrest . In a may arrest . Similary arrest . In a Zeactivity . FFA couactivity . In addiactivity . Limitedactivity .2+ stores and modulate ion channels and neurotransmitters. For example, sigma-1 receptors may bind to N-methyl-D-aspartate (NMDA) and G-protein coupled receptors to control Ca2+ influx. Although initially FFA was suspected to be an antagonist of sigma-1 receptors, later, it was thought to induce positive allosteric modulation, which may have additional benefits on behavior and cognition [Beyond serotonergic activity, FFA reacts with other receptors, most notably a subtype of plasma membrane-localized opioid receptor, namely sigma-1 receptors ,26. Whilognition ,29,30. Aognition . Sigma-1ognition .Following quick absorption from the gastrointestinal tract, FFA reaches peak plasma concentration in 3–5 h . Absolut2B receptors. FFA and its active metabolite norFFA weakly inhibit CYP2D6 and induce CYP2B6 and CYP3A4 [Stiripentol acts on all six of the CYP450 enzymes that affect FFA metabolism . Concomid CYP3A4 ,39. FFA d CYP3A4 ,39. In ad CYP3A4 ,39. In gThere is significant inter-and intra-patient variability in the plasma concentration of FFA and its metabolites. The plasma concentration was evaluated in 321 samples obtained from 61 patients (49 patients with Dravet syndrome and seven with LGS) . Lower cA high FFA level has been associated with fatigue and sedation but not anorexia or seizure control. Patients with good responsiveness to FFA may improve even with a low plasma concentration of FFA. A plasma level greater than 150–200 µg/L may not provide additional benefit in seizure control. Previous studies suggested that an FFA level of 240–850 µg/L is associated with excessive serotonergic adverse effects, including hyperreflexia, tachycardia, hyperthermia, etc. ,42,43. DSince the 1980s, neurologists have reported the use of FFA in treating paroxysmal episodes. In 1984, Gastaut reported FFA’s efficacy (30–60 mg/d) in children with self-induced syncope from the Valsalva maneuver . In 1988In 2012, Ceulemans et al. published a retrospective study of 12 Dravet syndrome patients (five patients were included in Boel and Caesar’s 1996 study) with intractable epilepsy . Two patp < 0.0001) and 32.4%  placebo-adjusted seizure reduction in monthly convulsive seizures. Fifty percent seizure-responder was 68% (p < 0.001) and 38% (p < 0.01) in high-and low dose FFA groups compared to 12% in the placebo. A 75% seizure-responder rate was 50% (p = 0.0005) and 23% (p = 0.0229) in the high and low-dose FFA groups compared to 2% in the placebo. Eight percent of patients were completely seizure-free in both high and low-dose groups compared to none in the placebo group. Additionally, 18% of additional patients in the high dose group had only one seizure over the entire 14 weeks period. Patients exposed to the high dose also required significantly fewer days of rescue medicines.These initial successful studies led to the arrangement of three randomized controlled trials (RCTs) in Dravet syndrome with intractable convulsive seizures (>six seizures in 6 weeks baseline period) . In the p < 0.0001). Compared to patients in the placebo group, a significantly higher proportion of patients given either dose of FFA experienced a ≥50%  or ≥75% seizure- reduction  in monthly convulsive seizures. Patients in both FFA groups had significantly longer seizure-free intervals vs. placebo. In addition, efficacy of 0.7 mg/kg/day exceeded 0.2 mg/kg/day for primary and secondary endpoints, suggesting a dose–response relationship. More investigators and caregivers judged FFA than placebo-treated patients as much improved/very much improved. In a similar international phase 3 trial, 142 patients with Dravet syndrome had a statistically significant reduction of monthly convulsive seizures in both high and low doses of FFA . FFA 0.7p < 0.001). The 50% seizure-responder rate was also higher in the FFA group . A >75% reduction in monthly convulsive seizure frequency was noted in 35% (p = 0.003) of patients. The longest mean seizure-free interval was approximately 30 days, about three times higher than the placebo. Finally, the open-label extension of the two RCTs showed that a median decrease in convulsive seizure frequency was maintained (−66.8%) over a longer follow-up  [In the third Dravet syndrome trial, the FFA dose was 0.4 mg/kg/d (max 17 mg/d) as this trial included patients taking concomitant stiripentol , which inhibits the metabolism of FFA . The pla-period) .In the above mentioned three independent pivotal RCTs, the efficacy of FFA against convulsive seizures approximated the responder rate at the ≥75% level that was previously noted at the ≥50% level by other ASMs . FurtherDravet syndrome patients have a high risk of Sudden Unexpected Death in Epilepsy (SUDEP) and all-cause mortality. These patients have frequent GTCS and intractable epilepsy, and both are independent major risk factors for SUDEP . FFA’s eStatus epilepticus (SE) is common in Dravet syndrome and one of the most common causes of death . AlthougAside from Dravet syndrome, FFA has been investigated in patients with LGS in an open-label study and then in one RCT.Lagae et al. reported FFA’s effectiveness in LGS in an open-label prospective phase 2 study . Among 1p < 0.01) with 0.7-mg/kg/d, 14.2% (p = 0.09) with 0.2-mg/kg/d, and 7.6% in the placebo group during 14 weeks of the treatment period. The 50% seizure-responder rate  was higher in the 0.2 and 0.7-mg/kg/d FFA groups than the placebo. Among all seizure types, generalized tonic-clonic seizures  appeared to be most responsive to FFA. In contrast to an increase of 3.7% in the placebo group, the frequency of GTCS decreased by 45.7% and 58.2% in the 0.7-mg/kg/d and 0.2-mg/kg/d FFA groups, respectively. More patients in the 0.7-mg/kg/d group than in the placebo group had ‘much improved’ or ‘very much improved’ ratings on the Clinical Global Impression of Improvement scale . Following completion of the phase 3 RCT, 247 patients enrolled for the open-label extension study [A multicenter, double-blind, placebo-controlled RCT was conducted in 263 LGS patients (2–35 years old) with ≥2 drop seizures/week  Figure . The medon study . InterimAlthough FFA is only approved so far for seizures associated with Dravet and LGS, small-scale studies evaluated its efficacy and safety in other epilepsy syndromes.p = 0.06) but was not statistically significant. Other cognitive and behavioral scores did not change following treatment. The most common adverse effects were fatigue and loss of appetite, noted in four patients. Aside from Sunflower syndrome, FFA was used in six patients (2–26 years) with CDKL5 deficiency disorder [FFA use has been reported in rare epilepsy called Sunflower syndrome. In this syndrome, patients seek a light source, such as the Sun, and wave hands before them with or without staring and eye fluttering. They also may have GTCS. One of the initial epilepsy studies of FFA included one patient who likely had Sunflower syndrome . Recentldisorder . FFA wasSCN1B missense variant (p.Arg85Cys)-linked to early infantile DEE, who was treated with FFA [The use of FFA for early infantile EE and DEE has been reported infrequently. Aeby et al. reported a case of inherited homozygous with FFA . As thisLimited research has been done to assess non-seizure outcomes of FFA, including cognitive function, health-related quality of life, and behavior. Lagae et al. reported improved executive function with short-term (14 weeks) use of FFA . Bishop Short-term adverse effects of FFA were extensively studied in multiple RCTs  36,55,5,69. CommAppetite suppression and weight loss should be specially mentioned as FFA was previously used as an anti-obesity medication. FFA may primarily impact appetite by its effect on 5-HT2c at the hypothalamus ,76. FFA 2B receptors [2B stimulation, other contributing factors to cardiac toxicity are 5-HT2A receptor activation and cytoskeletal protein serotonylation [Cardiac valvulopathy is a significant concern secondary to FFA exposure . The careceptors ,81,82. Weceptors . 5-HT execeptors . These cThe prevalence and risk factors of valve dysfunction after exposure to high-dose FFA have been studied. The estimated prevalence of valvulopathy depends on the study population and the measurement technique  . A meta-Another adverse cardiovascular effect reported with high-dose FFA was pulmonary arterial hypertension (PAH) . FFA viaDue to these previously reported adverse effects, cardiovascular adverse effects were monitored extensively in RCTs for Dravet and Lennox-Gastaut syndromes, and no cases of pulmonary arterial hypertension (PAH) or clinically significant signs or symptoms of cardiovascular disease were observed ,55,56,69Multiple rigorous RCTs have shown that FFA is highly efficacious against Dravet syndrome-associated convulsive seizures and, to a lesser degree, against LGS-associated drop seizures. An international consensus on the management of Dravet syndrome noted FFA as a possible first-line therapy with moderate to strong consensus among physicians and caregivers . Both phAlthough FFA’s role in managing Dravet syndrome-associated seizures is receiving strong support from physicians and caregivers, its real-world impact in treating LGS-associated seizures is still unknown. Importantly, there is no standard treatment algorithm for LGS, and there are seven FDA-approved ASMs . In addiThe potential efficacy of FFA in epilepsies other than Dravet syndrome and LGS is unknown, although a small case series of other epileptic encephalopathy suggested its potential utility in other epilepsy syndromes ,99. A piThe antiseizure activity of FFA has been established in some rodent and Zebrafish models. However, further research should evaluate FFA’s impact in standard animal models . These animal studies may lead to a better understanding of which epilepsy syndromes FFA would be most effective. Similarly, further studies may focus on FFA and its enantiomers’ effect on specific 5-HT receptors. These studies may be helpful if the enantiomer-specific antiseizure effect of FFA becomes evident. D-enantiomers of either FFA or norFFA are primarily responsible for adverse effects, such as anorexia and cardiac valvulopathy. If l-FFA is found to have a significant independent antiseizure impact, a chiral switch with developing this single enantiomer can be a safer treatment option.


We read with great interest the review by Riedel et al. highlighting the role of the intestinal system in the development of metabolic diseases . For a lThe intestinal barrier is a complex structure, while intestinal microbiota shape the biological barrier of the intestine. IBD causes increased intestinal permeability and allows undesirable luminal immunogens into the lymphatic and blood systems, finally contributing to systemic inflammation . In addiBesides T2D, hyperglycemia and IBD are also frequently observed in critical illnesses. Since the intestine is the motor of multiple organ dysfunction, the compromised intestinal barrier is involved in the development and deterioration of a critical illness . In addiAt first glance, it is not easy to accept the causal relationship between SIH and T2D. As is well known, there is a prediabetes stage between patients with and without T2D, which strongly indicates that hyperglycemia is a gradual process. Given the crosstalk of the intestinal system and metabolic diseases , SIH andKnowing that hyperglycemia is not unique to T2D, it is time to reconsider the role of hyperglycemia in T2D. When we talk about the management of a certain disease, both prevention and treatment should be included. Unlike the diverse recommendations on the prevention of T2D, the treatment of T2D is paradoxically limited to controlling hyperglycemia. In addition, only those agents with the capability of lowering blood glucose are qualified to be called antidiabetic drugs. With the crosstalk of the intestinal system and metabolic diseases mentioned in Riedel’s review , temporaToo much attention has been paid to the management of hyperglycemia during T2D treatment, although hyperglycemia is only one part of the complex reciprocal causation of the intestinal system, metabolic diseases, and associated pathophysiological changes . A new pAfter all, this review inspires us to update our understanding of T2D. It is time to shift our focus from hyperglycemia alone to include the accompanying pathophysiological changes summarized in the crosstalk . By chalYW and SW performed the review of literature, YW wrote the article, HX and LL conceived the commentary structure and revised the commentary, All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


P-value < 0.05 or 95% confidence interval fence. It was found that CPO FFA increases with an increase in moisture content, temperature, and time in their linear term and in respect to decreases in their quadratic term, and interaction between moisture content and temperature. The CPO MC was also found to decrease with an increase in temperature and time and increases in the quadratic term of temperature. Although while the model for CPO FFA, based on Fisher's F-test: 2 {0.9933–0.8614} and RMSE {0.0020–3.6716}); that of CPO MC was a poorly fitted first-order kinetic model (R2 {0.9885–0.3935} and RMSE {0.0605–17.8501}).Consequent to the importance of crude palm oil (CPO) to global food processing industries, and the need for quality assurance of CPO. A kinetic model that describes changes of free fatty acid (FFA) in industrially stored CPO has been developed. CPO FFA is a well-known indicator of the deterioration of CPO. The effect of initial moisture content, storage temperature, and time on CPO FFA have been investigated in this work. Specifically, statistical multi-regression models for changes in FFA and moisture content (MC) were developed at  It contributes significantly to the gross domestic product (GDP) of Indonesia, Malaysia, Guatemala, Nigeria, and Brazil2. Commercially, crude palm oil (CPO) is normally produced in large quantities by wet (i.e. water enhanced) extraction from its fruits, stripped from fresh fruit bunches (FFB)3. As an illustration, the Okomu oil palm company processes 60 tonnes of FFB/hr  >> 3%8) and storage temperature facilitate an increase in the CPO free fatty acid (FFA), due to hydrolysis of various triglyceride, diglyceride, and monoglyceride molecules. These molecules are built with glycerols attached to about 50% saturated fatty acid , 40% monounsaturated fatty acids (mostly oleic acid), and 10% polyunsaturated fatty acids (linoleic acids)9. The hydrolysis of these triglyceride molecules contributes in different portions to the increase of FFA10. However, low FFA value (2–5%), among other standards (such as moisture and impurity content (0.15–0.30%), bleachability index (2.1–2.8), colour (Orange–red), etc.14) is an important quality assurance standard for global sales of CPO. Usually FFA, moisture, and impurity content are an indicator of the other standards15. Therefore, to prevent the deterioration of CPO beyond the standard FFA value, stored CPO is continuously dried with the mist extractor and sold quickly.Palm oil, the world's most-produced vegetable oil16. Zhang et al.10 reported that as temperature increases, the percentage degradation of CPO triglyceride constituents to FFA is such that triglyceride with, linoleic > stearic > oleic > palmitic acid. Although it should be noted that there are more triglycerides with palmitic chains than other triglyceride constituents, and as such palmitic acid significantly influences CPO FFA. Almeida et al.17, and Taluri et al.18 also reported that storage temperature influenced the FFA of CPO and olive oil respectively. Furthermore, Lin et al.19 reported a kinetic model for FFA formation in lipid extracted from stored almonds, with consideration of the influence of relative humidity, and temperature. Although having highlighted from literature that the MC and temperature of stored vegetable oil increase FFA value, there are however no reports on a kinetic model to predict CPO FFA changes based on these two highlighted storage factors. This model when developed would facilitate the simulation, monitoring, and control of FFA in industrially stored CPO. The dynamics of FFA in vegetable oil can be investigated through the reactants (i.e. reaction of glyceride and water molecules), Eq.  of the minimum and maximum limit of factors , temperature and time) and with final FFA and MC as responses; Storage of the CPO samples at the designed BBD condition, and subsequent evaluation of the specified responses; Deduce statistical multi-regression model for the designed BBD, and evaluation of the factors and equations at 95% confidence level using the Fisher's F-test; Evaluation of FFA and MC kinetics and deduction of an n14. Three sample sets of 0.20 ± 0.02%, 0.25 ± 0.02%, and 0.30 ± 0.02% MC were identified, and their FFA were also determined . Thereafter adequate quantity (1000 ml) of these samples were collected, sealed, and stored as a source sample in an enclosure with an Ultraviolet-C radiation lamp to limit FFA increase as reported by Said et al.28. Table CPO samples were selected from the regular sampling routine of a CPO processing company based on the acceptable maximum limit (0.20%) and range 0.015–0.30%) of MC in edible vegetable oil5–0.30% o30, 2 g of CPO sample, 31. The hydrolysis of palm oil, based on glyceryl palmitate,Based on Eq. 29,30, 2 After the initial measurement of FFA for the source sample, ple, Eq. .5\docume32 based on Eq. (Following the American Oil Chemists’ Society (AOCS) air oven (Ca 2c-25) methodd on Eq. , 10 g ofNote that the initial or total ple, Eq. .7\documeDesign of experiment via BBD was implemented to determine whether MC, temperature, and storage time indeed influence the CPO FFA as reported in literature. This was achieved by the deduction of multi-variable regression model using Python Jupyter Notebook, and was also deduced for CPO MC.A “three-variable-three-level” BBD of three (3) centre points was adopted resulting in fifteen (15) experimental runs, del, Eq.  and Tablentclass1pt{minimaIn a similar manner for which the three sample sets for CPO have been chosen . The upper and lower limit of temperature has also been chosen based on the suggested range at which CPO is processed and stored by commercial CPO processing companies. by Eqs.  and 7)  9\documeThe reaction kinetics for the CPO FFA and MC was deduced using Eq. , by curvIn modelling FFA kinetics,  by Eqs.  and 12)\document−1·K−1, −1) is the activation energy, −1) is activation energy due to Equation  is deducfrom Eq. . While \mentclasspt{minima0 in Eq.  with resk as Eq. . Where RIn modelling MC kinetic, MC, Eqs.  and 11)\document2), Eq. , Eq.  and Root2), Eq. . The useThe curve fitting of kinetic models was implemented using Lsqcurvefit curve-fitting tools in MATLAB.P-value ** < 0.05 or 95% confidence interval fence. The resulting multi-regression models for the statistical analysis are given by Eqs. \documententclass1pt{minimaFurthermore, CPO MC in reference to Eq.  decreaseAlthough these equations showed the significant variables and their relationship to FFA and MC. While mentclass2pt{minimThe resulting response surface plot for entclass1pt{minimas of Eq.  and Fig.entclass1pt{minima and Eq.  and Fig.entclass1pt{minimaBased on the discussion thus far, it can be inferred that in developing the CPO FFA kinetics, the effect of moisture content, and temperature should be incorporated into the model. And as would be expected temperature would be used for CPO MC kinetics.The result of curve-fitting experimental data to the kinetic model, Eq.  via triaIn general, from the tread in the values of Figure Furthermore, to account for the effect of moisture content, the deduced Arrhenius constants, mentclasspt{minimaThe final curve-fitted model for CPO FFA kinetics is given by Eq.  as deduc19 for FFA kinetics of extracted oil from stored almonds. However, in Lin et al.19 report, first-order reaction kinetics were proposed with consideration of the influence of relative humidity (RH), and temperature. The reported data indicated that FFA formation was more temperature-dependent and the reaction rate increased faster at higher RH than at lower RH. The RH in Lin et al.19 report can be assumed to have the same effect as the initial moisture content, 19 report can be observed from the increasing rate constant, 19 estimated both variables as a function of RH.The modelling approach and results for CPO FFA kinetics, Eq.  describedel, Eq. . Lin et Similar to the CPO FFA kinetics, CPO MC kinetics were also investigated. The resulting curve-fit of experimental data to the proposed kinetic model, Eq. , showed Furthermore, the rate constants, The curve-fitted CPO MC kinetics from the combination of Eqs.  and 11)11) is gi36. Having earlier highlighted the inadequacy of CPO MC kinetics, there is a need to deduce an elaborate model to predict the changes of CPO MC with temperature, following comprehensive approaches described in literature39.By comparison of the CPO MC kinetics with the Thin-layer drying curve equations, Eq. , when alIn conclusion, the result of this work showed mathematically how moisture content, Supplementary Information.