Ultra-high performance liquid chromatography coupled to tandem mass spectrometry-based metabolomics study of diabetic distal symmetric polyneuropathy.

AIMS/INTRODUCTION: Distal symmetric polyneuropathy (DSPN) is a common complication of type 2 diabetes mellitus, but the underlining mechanisms have not yet been elucidated. The current study was designed to screen the feature metabolites classified as potential biomarkers, and to provide deeper insights into the underlying distinctive metabolic changes during disease progression. MATERIALS AND METHODS: Plasma metabolite profiles were obtained by the ultra-high liquid chromatography coupled to tandem mass spectrometry method from healthy control participants, patients with type 2 diabetes mellitus and patients with DSPN. Potential biomarkers were selected through comprehensive analysis of statistically significant differences between groups. RESULTS: Overall, 938 metabolites were identified. Among them, 12 metabolites (dimethylarginine, N6-acetyllysine, N-acetylhistidine, N,N,N-trimethyl-alanylproline betaine, cysteine, 7-methylguanine, N6-carbamoylthreonyladenosine, pseudouridine, 5-methylthioadenosine, N2,N2-dimethylguanosine, aconitate and C-glycosyl tryptophan) were identified as the specific biomarkers. The content of 12 metabolites were significantly higher in the DSPN group compared with the other two groups. Additionally, they showed good performance to discriminate the DSPN state. Correlation analyses showed that the levels of 12 metabolites might be more closely related to the glucose metabolic changes, followed by the levels of lipid metabolism. CONCLUSIONS: The finding of the 12 signature metabolites might provide a novel perspective for the pathogenesis of DSPN. Future studies are required to test this observation further.

Decitabine in combination with fludarabine and cyclophosphamide as a lymphodepletion regimen followed by CD19/CD22 bispecific targeted CAR T-cell therapy significantly improves survival in relapsed/refractory B-ALL patients.

Relapse is a major limitation of chimeric antigen receptor (CAR) T-cell therapy. Here, we speculated that decitabine (DAC) in combination with fludarabine and cyclophosphamide (FC) as a lymphodepletion regimen may improve the efficacy of CD19/CD22 CAR T-cell therapy. Fourteen of 26 patients with relapsed/refractory B cell acute lymphoblastic leukemia (r/r B-ALL) without remission before lymphodepletion treatment were treated with DAC (total dose 100 mg/m2 in 3 days) followed by the FC regimen (DAC group), while twelve patients received the FC regimen (CON group). On Day 28 after CAR T-cells infusion, no significant differences in complete remission (CR) and minimal residual disease negative CR rates were found between both groups. However, there were significant differences in overall survival (OS) and leukemia-free survival (LFS) between two groups: 3-year OS, 92.3% (DAC) versus 41.7% (CON), P = 0.005 and 3-year LFS, 92.9% (DAC) versus 27.3% (CON), P < 0.001. There was no significant difference in the incidence of cytokine release syndrome between both groups. Median time to platelet and neutrophil counts recovery was similar in both groups. All adverse events were reversible and manageable. In conclusion, DAC in combination with the FC lymphodepletion regimen may be a new treatment option that can improve the efficacy of CAR T-cell therapy in r/r B-ALL.

JianPi-QingHua formula attenuates nonalcoholic fatty liver disease by regulating the AMPK/SIRT1/NF-κB pathway in high-fat-diet-fed C57BL/6 mice.

CONTEXT: Non-alcoholic fatty liver disease (NAFLD) is a common liver disease, accompanied by liver lipid accumulation and inflammation. JianPi-QingHua formula (JPQH), a Chinese herbal formula, exhibits effects on obesity and T2DM. However, the hepatoprotective effect of JPQH has not been elucidated. OBJECTIVE: To investigate the hepatoprotective effect of JPQH in NAFLD induced by a high-fat diet (HFD) in mice. MATERIALS AND METHODS: C57BL/6J mice were divided into four groups and fed a normal-fat diet (ND), high-fat diet (HFD), HFD + JPQH (2.5 g/kg), or HFD + metformin (300 mg/kg) for 6 weeks, respectively. Furthermore, the body weight, epididymal fat mass, blood glucose, and liver weight were measured. Serum total cholesterol (TC), triglycerides (TG), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were performed. Hematoxylin and eosin staining and Oil Red O staining were observed in hepatic histopathological changes. Western blotting and quantitative real-time polymerase chain reaction were utilized to assess the key protein expression of hepatic lipid metabolism and inflammation. RESULTS: Compared with the HFD group, JPQH could reduce body weight, epididymal fat mass, blood glucose and liver weight (p < 0.05), and markedly decreased the levels of serum TC, TG, ALT, AST (p < 0.05). Additionally, JPQH improved liver pathological changes. Consistent with the hepatic histological analysis, JPQH intervention suppressed lipid accumulation and inflammatory responses. Mechanistically, JPQH boosted SIRT1/AMPK signalling, and attenuated NF-κB pathway, which suppressed inflammatory responses. DISCUSSION AND CONCLUSIONS: These findings indicate that JPQH supplementation protected against HFD-induced NAFLD by regulating SIRT1/AMPK/NF-κB pathway, which provides a theoretical basis for the clinical treatment of patients with NAFLD.

The Interaction Between Age and Risk Factors for Diabetes and Prediabetes: A Community-Based Cross-Sectional Study.

Objective: This study aimed to investigate the interaction between age groups and risk factors for diabetes and prediabetes in Shanghai communities and to identify the effect of age on other risk factors for diabetes and prediabetes. Methods: This study recruited 3540 participants with undiagnosed diabetes or prediabetes in 14 communities in Shanghai from February to August 2019. All participants underwent a comprehensive examination, including filling out a detailed questionnaire, physical examination, 75 g oral glucose tolerance test, and blood sample collection. In addition, logistic regression was used to analyze the interaction between age and risk factors for prediabetes and diabetes. Results: The statistical analysis included 2776 people. In this study, the prevalence of diabetes and prediabetes were 15.1% and 52.3%, respectively. The prevalence of diabetes and prediabetes is higher in the elderly than in the middle-aged group. Among the risk factors for diabetes, overweight was associated with higher age (P-interaction 0.028). In addition, among the risk factors for prediabetes, a high level of education was associated with higher age (P-interaction 0.039) and elevated serum cholesterol level was associated with lower age (P-interaction 0.019). Conclusion: This study confirmed an interaction between age and other influencing factors, which may be important in explaining differences in risk factors for diabetes and prediabetes in the middle-aged and elderly populations. Community health facilities can provide health guidance to people of different age groups to prevent and control prediabetes and diabetes.

Transcriptomic landscape of staminate catkins development during overwintering process in Betula platyphylla.

Betula platyphylla, belonging to the cold-specialized lineage Betulaceae, exhibits a unique reproductive strategy where staminate catkins emerge in the first summer and undergo an overwintering process, culminating in flowering in the following year. However, the underlying regulatory mechanism remains unclear. In this study, we investigated the male germline development of B. platyphylla in four distinct stages: microsporocytes in Oct. (S1), uninuclear microspores from Dec. (S2) to Mar. of the following year (S3), and bicellular microspores in Apr. (S4). We performed RNA sequencing on mature pollen and the four stages of staminate catkins. Using weighted gene co-expression network analysis (WGCNA), we identified five highly correlated gene modules with distinct expression profiles. These modules exhibited strong correlations with sugar metabolism, cell cycle, flowering, and cell wall dynamics, highlighting their dynamic roles during male germline developmental stages. During the overwintering process, we observed that the expression of transcription factors such as BpDUO1 and BpAMS at the appropriate developmental stages, suggests their significant roles in male germline development. The expression patterns of BpFLC and BpFT suggest their potential involvement in temperature perception during male reproductive development. These findings offer valuable insights into the reproductive success of plants adapting to cold environments.

Case report: CD38-directed CAR-T cell therapy: A novel immunotherapy targeting CD38- positive blasts overcomes TKI and chemotherapy resistance of myeloid chronic myeloid leukemia in blastic phase.

Resistance to tyrosine kinase inhibitor (TKI) is a tough problem in the treatment of chronic myeloid leukemia in blastic phase (CML-BP), which was often associated with acquired mutations in the kinase domain and not eliminating the leukemic stem cells. The efficacy of TKI or combination with chemotherapy in CML-BP remains unsatisfactory. Chimeric antigen receptor T (CAR-T) cell immunotherapy may overcome TKI and chemotherapy resistance. However, lack of ideal targetable antigens is a major obstacle for treating patients with myeloid malignancies. CD38 is known to be expressed on most (acute myeloid leukemia) AML cells, and its lack of expression on hematopoietic stem cells renders it as a potential therapeutic target for myeloid CML-BP. We develop a CD38-directed CAR-T cell therapy for AML, and two patients with myeloid CML-BP were enrolled (NCT04351022). Two patients, harboring E255K and T315I mutation in the ABL kinase domain, respectively, were resistant to multiple TKIs (imatinib, dasatinib, nilotinib, and ponatinib) and intensive chemotherapy. The blasts in the bone marrow of two patients exhibited high expression of CD38. After tumor reduction chemotherapy and lymphodepletion chemotherapy, 1 × 107 CAR-T-38 cells per kilogram of body weight were administered. They achieved minimal residual disease-negative and BCR::ABL1-negative complete remission and experienced grade II cytokine release syndrome manifesting as fever. Our data highlighted that CAR-T-38 cell therapy may overcome TKI and chemotherapy resistance in patients with myeloid CML-BP.

Nomogram based on multimodal echocardiography for assessing the evolution of diabetic cardiomyopathy in diabetic patients with normal cardiac function.

Background: Diabetic cardiomyopathy (DCM) remains asymptomatic for many years until progression to asymptomatic left ventricular diastolic dysfunction (ALVDD), a subclinical cardiac abnormality present in early-stage DCM. Because LV function in patients with type 2 diabetes mellitus (T2DM) may be subtly altered long before the onset of ALVDD, quantitative assessment of the risk of progression to early-stage DCM in T2DM patients with normal hearts is critical for delaying or even reversing DCM. Objective: This study aimed to establish a nomogram with the aid of DCM characteristics revealed by multimodal echocardiography to assess the likelihood of the progression to early-stage DCM in T2DM patients with normal cardiac function. Methods: Of the 423 T2DM patients enrolled, 302 were included in the training cohort and 121 in the validation cohort. The clinical characteristics, biochemical data, and multimodal echocardiographic parameters were collected. In the training cohort, the screened correlates of ALVDD were utilized to develop a nomogram for estimating the risk coefficient for early-stage DCM. This model was validated both in the training and validation cohorts. Results: ALVDD was independently correlated with the number of comorbidities [with one comorbidity: odds ratio (OR) = 3.009; with two comorbidities: OR = 4.026], HbA1c (OR = 1.773), myocardial blood flow (OR = 0.841), and global longitudinal strain (OR = 0.856) (all P < 0.05). They constituted a nomogram to visualize the likelihood of DCM development in T2DM patients with normal cardiac function. The model was validated to present strong discrimination and calibration, and obtained clinical net benefits both in the training and validation cohorts. Conclusion: We constructed and validated a nomogram to estimate the likelihood of developing early-stage DCM in T2DM patients with normal cardiac function. The alteration of the nomogram-predicted risk coefficient is expected to be proposed as a therapeutic target to slow or stop DCM progression.

Identifying Distinct Risk Thresholds of Glycated Hemoglobin and Systolic Blood Pressure for Rapid Albuminuria Progression in Type 2 Diabetes From NHANES (1999-2018).

Background: It is widely recognized that glycated hemoglobin (HbA1c) and systolic blood pressure (SBP) are two key risk factors for albuminuria and renal function impairment in patients with type 2 diabetes mellitus (T2DM). Our study aimed to identify the specific numerical relationship of albumin/creatinine ratio (ACR) with HbA1c and SBP among a large population of adults with T2DM. Method: A total of 8,626 patients with T2DM were included in the data analysis from the National Health and Nutrition Examination Surveys (NHANES) (1999-2018). The multiple linear regressions were used to examine the associations of ACR with HbA1c and SBP. Generalized additive models with smooth functions were performed to identify the non-linear relations between variables and interactions were also tested. Results: Significantly threshold effects were observed between ACR and HbA1c or SBP after multivariable adjustment, with the risk threshold values HbA1c = 6.4% and SBP = 127 mmHg, respectively. Once above thresholds were exceeded, the lnACR increased dramatically with higher levels of HbA1c (ß = 0.23, 95 CI%:0.14, 0.32, P < 0.001) and SBP (ß = 0.03, 95 CI%:0.03, 0.04, P < 0.001). Subgroup analysis showed high protein diet was related to higher ACR. In addition, a higher risk of ACR progression was observed in central obesity participants with HbA1C ≥ 6.4% or hyperuricemia participants with SBP ≥ 127 mmHg among patients withT2DM. Conclusion: We identified thresholds of HbA1c and SBP to stratify patients with T2DM through rapid albuminuria progression. These might provide a clinical reference value for preventing and controlling diabetes kidney disease.

Jianpi Qinghua Fomula alleviates insulin resistance via restraining of MAPK pathway to suppress inflammation of the small intestine in DIO mice.

BACKGROUND: Jianpi Qinghua Fomula (JPQHF), a clinically proven prescription,has been applied to cure insulin resistance(IR) and type 2 diabetes (T2DM) for more than 20 years. Here, we will unravel the underlying molecular mechanisms relevant to the therapeutic actions of JPQHF. METHODS: High-fat(HF)diet-induced obesity(DIO)mouse were established in our research, along with insulin resistance. After the administration of JPQHF 5 or 6 weeks, the parameters of the glucose and lipid metabolism were measured. Flow cytometry and Luminex were utilized to assess the inflammation in small intestine,whilst Western blot was used to determine the relative expression levels of the MAPK pathway-related proteins. The glucose and lipid transporter of small intestine was assessed by immunofluorescence and ELISA, and the expression of insulin signaling pathway was detected by Western blot. RESULTS: The metabolic phenotypes of DIO mouse were ameliorated after 6-week oral administration of JPQHF; Meanwhile,JPQHF downregulated levels of IL-1ß,IL-6, TNF-α and IFN-γ but upregulated the ratio of M2/M1 macrophages in the small intestine. The elevated expressions of p-P38 MAPK/P38 MAPK、p-JNK/JNK and p-ERK1/2/ERK1/2 were reversed by JPQHF. Moreover, JPQHF enhanced expression of PI3K,p-AKT/AKT, p-IRS1/ IRS1, p-IRS2/ IRS2 and apoB48 in small intestine, and facilitated the translocation of GLUT2 to the basal side of small intestine epithelial cells. CONCLUSION: JPQHF alleviates insulin resistance in DIO mice, and this effect may be associated with its restraining of inflammation of small intestine via attenuating MAPK pathway, and then diminishes small intestinal glucose and lipid absorption.

Comparison of the Finnish Diabetes Risk Score Model With the Metabolic Syndrome in a Shanghai Population.

Aims: This study aimed to compare the diagnostic accuracy of the metabolic syndrome with the Finnish Diabetes Risk Score (FINDRISC) to screen for type 2 diabetes mellitus (T2DM) in a Shanghai population. Methods: Participants aged 25-64 years were recruited from a Shanghai population from July 2019 to March 2020. Each participant underwent a standard metabolic work-up, including clinical examination with anthropometry. Glucose status was tested using hemoglobin A1c (HbAlc), 2h-post-load glucose (2hPG), and fasting blood glucose (FBG). The FINDRISC questionnaire and the metabolic syndrome were examined. The performance of the FINDRISC was assessed using the area under the receiver operating characteristic curve (AUC-ROC). Results: Of the 713 subjects, 9.1% were diagnosed with prediabetes, whereas 5.2% were diagnosed with T2DM. A total of 172 subjects had the metabolic syndrome. A higher FINDRISC score was positively associated with the prevalence of T2DM and the metabolic syndrome. Multivariable linear regression analysis demonstrated that the FINDRISC had a linear regression relationship with 2hPG levels (b'= 036, p < 0.0001). The AUC-ROC of the FINDRISC to identify subjects with T2DM among the total population was 0.708 (95% CI 0.639-0.776), the sensitivity was 44.6%, and the specificity was 90.1%, with 11 as the cut-off point. After adding FBG or 2hPG to the FINDRISC, the AUC-ROC among the total population significantly increased to 0.785 (95% CI 0.671-0.899) and 0.731 (95% CI 0.619-0.843), respectively, while the AUC-ROC among the female group increased to 0.858 (95% CI 0.753-0.964) and 0.823 (95% CI 0.730-0.916), respectively (p < 0.001). The AUC-ROC of the metabolic syndrome to identify subjects with T2DM among the total and female population was 0.805 (95% CI 0.767-0.844) and 0.830 (95% CI 0.788-0.872), respectively, with seven as the cut-off point. Conclusions: The metabolic syndrome performed better than the FINDRISC model. The metabolic syndrome and the FINDRISC with FBG or 2hPG in a two-step screening model are both efficacious clinical practices for predicting T2DM in a Shanghai population.

Puerarin suppresses the hepatic gluconeogenesis via activation of PI3K/Akt signaling pathway in diabetic rats and HepG2 cells.

Pueraria, a Chinese herbal medicine, plays an important role in many classic prescriptions for the treatment of diabetes. Puerarin is the main component of pueraria. The current in vivo and in vitro research mainly focus on exploring the potential mechanism of puerarin in inhibiting hepatic gluconeogenesis. The type 2 diabetic rats were established by a combination of small dosage of streptozotocin (STZ) injection with high-fat diet. After the administration of puerarin 4 weeks, the parameters of the glucose and lipid metabolism were determined. HepG2 cells were treated by palmitic acid (PA) to induce the insulin resistance in vitro model. After the treatment of puerarin, the glucose consumption and cell viability were examined. Then, the protein expression of PI3K, Akt, pAkt, pFOXO1, FOXO1, PEPCK and G6pase in liver tissue and HepG2 cells were evaluated by western blot. RT-PCR was used to measure the content of PEPCK, G6pase mRNA in liver tissue. The results showed that puerarin administration significantly decrease the level of FBG, HbA1C and triglycerides in diabetic rats. Mechanistic research showed that puerarin activating PI3K/Akt is puerarin-mediated beneficial effects and can be reversed by inhibitor of PI3K or Akt. In conclusion, puerarin inhibits hepatic gluconeogenesis by activating PI3K/Akt signaling pathway.

Effects of constant power microwave on the adsorption behaviour of myofibril protein to aldehyde flavour compounds.

This study explored the influence of constant power microwave on the adsorption ability of myofibril protein from beef to typical aldehyde flavour compounds. Results showed that there was a significant increasing trend in surface hydrophobicity and reactive sulfhydryls content of myofibril protein with an increase in microwave power and treatment time. The adsorption ability of myofibril protein to aldehyde flavour compounds increased with increasing microwave power and time. The percentage of free aldehyde flavour compounds was related to the content of surface hydrophobicity, and reactive and total sulfhydryls of myofibril protein under microwave conditions, which could be fitted according to the multilevel relational (MLR) model. Furthermore, the reduced interface energy was probably the driving force for myofibril protein-flavour compounds adsorption behaviour at the gas-liquid interface.

Behaviors of large A-type and small B-type wheat starch granules esterified by conventional and pulsed electric fields assisted methods.

Large and small wheat starch granules were modified by conventional and pulsed electric fields (PEF)-assisted dual esterification methods. Due to the assistance of PEF, the degree of substitution (DS) of AS and BS increased by 0.0159 and 0.0066, respectively, while the crystallinity of them decreased by 1.7% and 1.2%. An increase in diffraction intensity at q = 0.68 nm-1 was observed in dual modified starch compared to conventional method. The DS of A-type starch (AS) were more sensitive than B-type starch (BS) and the thermal stability of AS was decreased obviously than that of BS. It was found that esterified starch exhibited superior freeze-thaw stability than native starch, especially for the PEF-assisted esterification of AS rather than BS. The resistant starch of esterified BS was increased while the slowly digestible starch was decreased, especially for the assistance of PEF.

Transcranial Direct Current Stimulation Improves Cognitive Function in Mild to Moderate Alzheimer Disease: A Meta-Analysis.

OBJECTIVE: The purpose of this meta-analysis was to evaluate the therapeutic effect of transcranial direct current stimulation (tDCS) on mild to moderate Alzheimer disease (AD) patients. MATERIALS AND METHODS: PubMed, Embase, Web of Science, and Cochrane Library were searched until April 2018. The primary cognitive outcomes were extracted from included articles. A crude standardized mean difference with 95% CI was calculated by using fixed or random effect models. RESULTS: Seven studies with 146 patients were included in this meta-analysis. The pooled result showed that tDCS significantly improved cognitive function of AD patients (standardized mean difference=0.37; 95% CI, 0.09-0.65; P=0.01). Subgroup analyses showed that: a single session of tDCS was significantly effective (P<0.05) whereas repeated sessions of tDCS was not lower current density (0.06 mA/cm) (P>0.05) but not higher current density (0.08 mA/cm) significantly improved cognitive performance; stimulating the temporal cortex (P<0.05) but not the left dorsal lateral prefrontal cortex significantly improved cognitive function of AD patients; and improved cognitive function occurred in the group with higher education (P<0.05) but not in the group with lower education. CONCLUSIONS: Current evidence suggests that tDCS has a beneficial effect in mild to moderate AD patients. We must be cautious about the results of subgroup analysis given small sample sizes, and further well-designed studies with larger sample size are required to verify these results.

Human Umbilical Cord MSC-Derived Exosomes Suppress the Development of CCl4-Induced Liver Injury through Antioxidant Effect.

Mesenchymal stem cells (MSCs) have been increasingly applied into clinical therapy. Exosomes are small (30-100 nm in diameter) membrane vesicles released by different cell types and possess the similar functions with their derived cells. Human umbilical cord MSC-derived exosomes (hucMSC-Ex) play important roles in liver repair. However, the effects and mechanisms of hucMSC-Ex on liver injury development remain elusive. Mouse models of acute and chronic liver injury and liver tumor were induced by carbon tetrachloride (CCl4) injection, followed by administration of hucMSC-Ex via the tail vein. Alleviation of liver injury by hucMSC-Ex was determined. We further explored the production of oxidative stress and apoptosis in the development of liver injury and compared the antioxidant effects of hucMSC-Ex with frequently used hepatic protectant, bifendate (DDB) in liver injury. hucMSC-Ex alleviated CCl4-induced acute liver injury and liver fibrosis and restrained the growth of liver tumors. Decreased oxidative stress and apoptosis were found in hucMSC-Ex-treated mouse models and liver cells. Compared to bifendate (DDB) treatment, hucMSC-Ex presented more distinct antioxidant and hepatoprotective effects. hucMSC-Ex may suppress CCl4-induced liver injury development via antioxidant potentials and could be a more effective antioxidant than DDB in CCl4-induced liver tumor development.

Antidepressant Effects of Repetitive Transcranial Magnetic Stimulation Over Prefrontal Cortex of Parkinson's Disease Patients With Depression: A Meta-Analysis.

Objective: The purpose of this meta-analysis was to investigate the antidepressant effects of repetitive transcranial magnetic stimulation (rTMS) over the prefrontal cortex (PFC) of patients with Parkinson's disease (PD) and to determine the optimal rTMS parameters, such as the intensity, frequency and the delivered pattern of rTMS stimulation. Methods: EMBASE, PubMed, Web of Science, MEDLINE, and Cochrane data bases were researched for papers published before March 12, 2018. Studies investigating the anti-depression effects of rTMS over PFC in patients with PD were considered. The main outcomes of pre- and post-rTMS treatment as well as score changes were all extracted. The mean effect size was estimated by calculating the standardized mean difference (SMD) with 95% confidence interval (CI) by using fixed or random effect models as appropriate. Results: Nine studies containing 137 PD patients with depression were included. The pooled results showed significant pre-post anti-depressive effects of rTMS over PFC in PD patients with depression (SMD = -0.80, P < 0.00001). The subgroup analyses of stimulation intensity, frequencies, and models also revealed significant effects (Intensities: 90% RMT: SMD = -1.16, P = 0.0006; >100% RMT: SMD = -0.82, P < 0.0001. Frequencies: < 1.0 Hz: SMD = -0.83, P = 0.03; 5.0 Hz: SMD = -1.10, P < 0.0001; ≥10.0 Hz: SMD = -0.55, P = 0.02. Models: Continuous: SMD = -0.79, P < 0.0001; Discontinuous: SMD = -0.84, P = 0.02). But the results of the studies with place-controlled designs were not significant (Overall: SMD = -0.27, P = 0.54. Intensities: 90% RMT: SMD = 0.27, P = 0.68; 100% RMT: SMD = -0.32, P = 0.33. Frequencies: 5.0 Hz: SMD = -0.87, P = 0.10; ≥10.0 Hz: SMD = 0.27, P = 0.66. Models: Continuous: SMD = -0.28, P = 0.68; Discontinuous: SMD = -0.32, P = 0.33). The greater effect sizes of rTMS with 90% RMT, 5.0 Hz in discontinuous days can be observed rather than the other parameters in both kinds of analyses across study design. Conclusions: rTMS may have a significant positive pre-post anti-depressive effect over PFC on patients with depression, especially by using 5.0 Hz frequency with 90% RMT intensity in discontinuous days, which may produce better effects than other parameters. The real effect, though, was not different from that of the placebo. Future studies with larger sample sizes and high-quality studies are needed to further corroborate our results and to identify the optimal rTMS protocols.