Trump says will ‘take a look’ at deporting Musk – Daily Times
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Here are the key events on day 1,227 of Russia’s war on Ukraine.
Here is how things stand on Saturday, July 5 :
Fighting
Russian air defences have downed dozens of Ukrainian drones in widely dispersed parts of the country, including two near the country’s second-largest city, Saint Petersburg, according to officials.
All external power lines supplying electricity to the Russian-occupied Zaporizhzhia nuclear plant in Ukraine were down for several hours before being restored, the UN nuclear watchdog said.
Ukrainian authorities blamed Russian shelling for the power cut, adding that technicians had to take action to restore it.
Dutch and German intelligence agencies say that Russia is increasing its use of prohibited chemical weapons in Ukraine, including the World War I-era poison gas chloropicrin. Moscow denies this.
Weapons
United States President Donald Trump said he discussed sending Patriot interceptor missiles to Ukraine in calls with German Chancellor Friedrich Merz and Ukrainian President Volodymyr Zelenskyy.
A German government spokesman said the country was exploring the possibility of purchasing more Patriot air defence systems from the US for Ukraine.
Politics and diplomacy
Trump said that he discussed sanctions with Russian President Vladimir Putin in a Thursday call, who is worried about them and understands they might be forthcoming.
The US president repeated that he was “very unhappy” with his Russian counterpart, adding: “He wants to go all the way, just keep killing people – it is no good.”
Zelenskyy says he agreed with Trump, to work to strengthen Ukraine’s air defences, as concerns mounted in Kyiv over US military aid deliveries. The two leaders had a “very important and fruitful conversation” by phone on Friday, Zelenskyy said.
German Defence Minister Boris Pistorius will travel to Washington later this month for talks with his US counterpart about air defence systems, as well as production capacities, the ministry said.
LAHORE – The buying rate of Canadian dollar moved up slightly as it stood at Rs208.6 in open market of Pakistan on Saturday, according to an online currency exchange portal.
The private exchange companies are selling the Canadian Dollar for Rs213.6, reflecting its dominance over the local currency.
The local currency rates reflect ongoing trend in the forex market influenced by regional demand, remittance inflows, and overall economic sentiments.
How much is $1000 CAD in PKR?
As of July 5, they buying rate of the Canadian dollar stands at Rs208.6. It means an individual can convert $1000 CAD for Rs208,600 in open market.
Remittances play a crucial role in supporting the economies of developing countries. They provide a stable source of income for millions of families, helping them meet basic needs such as food, healthcare, and education.
These funds also boost national foreign exchange reserves and contribute to poverty reduction. Unlike loans or aid, remittances flow directly to households, encouraging local spending and investment.
In May 2025, overseas Pakistanis living in Canada sent $69.55 million in wake of the remittances.
According to the SBP, the workers’ remittances from overseas to Pakistan, recording a significant growth of 28.8 percent during eleven months of fiscal year 2024-25, reached nearly US$ 35 billion in the period from July to May while monthly inflows in May increased to $ 3.69 billion.
During May 2025, the workers’ remittances recorded an inflow of US$ 3.686 billion, depicting 16 percent growth over April 25 and 13.7 percent yearly increase against May 2024, the statistics showed.
Currency exchange is a key component of the global economy and holds special importance for countries such as Pakistan.
It refers to the process of converting one nation’s currency into another, which supports international trade, tourism, and investment.
In Pakistan, exchange rates influence the value of the rupee compared to major currencies like the US dollar and UAE dirham. A stronger exchange rate makes imports cheaper and helps control inflation, while a weaker rate can boost exports.
Regular exercise has numerous benefits, including reducing the risk of chronic diseases like diabetes and heart disease. A recent study published in the New England Journal of Medicine found that cancer patients who participated in a structured exercise program had better outcomes, living longer without cancer recurrence and having a lower risk of death. The study’s findings suggest that exercise should be a key component of cancer treatment, helping patients live longer and healthier lives. By incorporating exercise into their care plan, cancer patients can potentially improve their survival rates and reduce the risk of recurrence of cancer.
The study tells how regular exercise lowers the risk of cancer recurrence
The clinical trial, conducted across multiple countries, followed nearly 900 patients diagnosed with stage II and stage III colon cancer. Participants had completed surgery and chemotherapy and were split into two groups: one group received structured exercise coaching twice monthly for the first six months, then monthly for three years, and the other group received usual care without specific exercise guidance.
The results of the study were striking
Those in the exercise group had a 28% lower risk of cancer recurrence or developing a new cancer. More significantly, they had a 37% lower risk of death from any cause during an eight-year follow-up period. Cardiovascular fitness and endurance also improved in the exercise group, as shown by a better six-minute walk test and VO₂ max results.
Experts suggest structured exercise should be a part of a cancer recovery plan
As CNN spoke with Dr. Leana Wen, the potential for exercise to revolutionize cancer treatment became clear. The study’s findings are significant, showing that exercise can substantially reduce the risk of recurrent or new cancers and death. According to Dr. Wen, these results could change cancer treatment protocols. Currently, patients often receive general advice to exercise after treatment, but many don’t receive structured support. She suggests that patients should have “exercise prescriptions” and healthcare providers should track their progress. Insurance companies might also consider covering health coaching for cancer patients, potentially reducing the need for costly treatments.
Why exercise helps fight cancer
According to Dr. Leana Wen, exercise doesn’t just make you feel good, it alters your body at a cellular and hormonal level, helping to:
Regulate hormones like insulin and estrogen that are linked to cancer growth.
Reduce chronic inflammation, which contributes to cancer progression.
Enhance immune function, supporting your body’s ability to detect and destroy abnormal cells.
Support a healthy body weight, which is a major factor in cancer recurrence.
This multi-layered impact makes exercise a powerful, non-pharmacological tool for improving cancer outcomes.
The stars are aligning for four-time Olympic gold medallist Sydney McLaughlin-Levrone ahead of her 2025 Prefontaine Classic (Eugene Diamond League) debut at Hayward Field in Oregon on Saturday, 5 July. Although, she won’t be competing in her signature 400m hurdles, where she holds the world record, but rather, flexing her sprint speed in the 400m flat.
Though a non-Diamond League event, the 400m race is shaping up to be a marquee showdown as McLaughlin-Levrone looks to better her 48.74 second mark, which she set at Hayward Field during the 2023 U.S. Championships. A time that sits just 0.04 seconds off the American record of 48.70seconds, set by Sanya Richards-Ross in 2006.
At a pre-event press conference on 4 July, McLaughlin-Levrone was hesitant to talk about chasing records, instead offering praise for Richards-Ross: “It’s a great record. Sanya is an amazing athlete.” McLaughlin-Levrone added, “I’m grateful for the opportunity to run it free. It’s my first time, and I’m really hoping to go out there and execute it—I’ve got to focus on myself and see what happens.”
In a lighthearted moment, the lane draw results were revealed during the press conference, and McLaughlin-Levrone lit up. “I hope it’s five,” she said. “I’ve had some great races in five.” She got her wish—lane five, the same lane at Hayward where she set her personal best in 2023.
Her presence alone raises the stakes, but McLaughlin-Levrone will face heavy competition, including from her compatriots, NCAA outdoor champion Aaliyah Butler (49.26 SB) and Alexis Holmes, who raced on the gold medal-winning 4x400m relay team at Paris 2024 alongside hurdles legend. World Indoor Champion Amber Anning (49.96 SB), isn’t to be discounted either ahead of the hotly anticipated race.
Jurassic World Rebirth Out now Forget Chris Pratt and the friendly velociraptors: this reboot of the dinofranchise returns to the premise that the beasties with the big sharp teeth are not to be trusted – and this time around we’ve got some mutant dinosaurs in the mix. Human stars include Scarlett Johansson, Mahershala Ali and Jonathan Bailey.
The Shrouds Out now The master of body horror is back – and a new David Cronenberg film is always cause for celebration. Now in his 80s, the Canadian auteur can always be relied upon to probe the deeper and darker parts of the human psyche, and his latest exploration of grief and dystopian technology, starring Vincent Cassel, is no exception.
Jane Austen 250 The Ultimate Picture Palace, Oxford; 6 July to 20 August It is 250 years since the birth of one of the greatest comic novelists of all time. This season celebrates Austen’s big-screen outings and includes Love & Friendship, Pride & Prejudice (2005), Sense & Sensibility (1995) and – yes! – the spectacular Emma riff Clueless (1995).
Hot Milk Out now The Booker-shortlisted novel is adapted for the big screen by Rebecca Lenkiewicz, with Fiona Shaw and Emma Mackey playing a mother and daughter who travel to a Spanish clinic hoping for a cure for the mother’s paralysis. Vicky Krieps also stars. Catherine Bray
Going out: Gigs
Hats entertainment … Confidence Man. Photograph: Julian Buchan
TRNSMT Glasgow Green, 11 to 13 July It makes sense that this Glasgow three-day party is sponsored by an energy drink; you’ll need something to see you through the whiplash of its lineup. Rapper 50 Cent headlines on Friday, not long after Confidence Man, then Biffy Clyro helm the following day and Jade features on Sunday. Michael Cragg
Sounds of the City Castleford Bowl, Manchester, 9 July to 12 July This annual city festival continues with grizzled US rock duo the Black Keys (9 Julynesday), followed by enduring British indie party-starters Bloc Party (10 Julysday) and returning hip-hop pair Rizzle Kicks on 11 July. Bingo Bango hitmakers Basement Jaxx close the party on 12 July. MC
Berlioz: Te Deum Gloucester Cathedral, today The first major event of the Cheltenham music festival, 80 years old this year, takes place not in the spa town, but nine miles away. Gloucester Cathedral will be a suitably majestic venue for Berlioz’s great setting of the Latin hymn of praise, in which Adrian Partington will be conducting the British Sinfonietta. Andrew Clements
Love Supreme festival Glynde Place, East Sussex, today4 & 5 July Now in its 12th year, the outdoor jazz festival continues to span many variations on contemporary jazz, funk, soul and electronica. Highlights include Jacob Collier’s only UK performance this year, and jazz stars Branford Marsalis, Lakecia Benjamin, Chucho Valdés, Avishai Cohen and many more. John Fordham
Going out: Art
Emily Kam Kngwarray’s Ntang Dreaming. Photograph: Emily Kam Kngwarray/Copyright Agency/DACS 2025
Emily Kam Kngwarray Tate Modern, 10 July to 11 January This bold painter brought ancient traditions and memories to the forefront of modern art. Look at Kngwarray’s paintings – their fierce colours, pulsing with dots and trackways – through a lens of modernism and they resemble abstract art, especially Jackson Pollock. But each mark relates to the ancestral history of the Dreamtime.
Lindsey Mendick Kenilworth Castle, Warwickshire, 9 July to 31 October Queen Elizabeth I visited Kenilworth Castle 450 years ago for a lavish series of entertainments. Mendick recreates these in its great hall with her mischievous mixture of ceramics and installation art, featuring women from classical mythology alongside Anne Boleyn, mother of Elizabeth I. They warn the great Tudor queen of coming dangers.
Watteau British Museum, to 14 September The sensual yet ethereal art of Antoine Watteau creates a unique, imaginative world where sad clowns gaze at you wistfully and lovers picnic in softly depicted woodlands. It is a poetic fiction based on observation of reality. This exhibition of Watteau’s drawings takes you to the heart of his genius.
Resistance National Galleries of Scotland: Modern Two, Edinburgh, to 4 January Steve McQueen’s intense and sharp eye shapes this survey of a century of protest. Photographs of rallies, marches and other collective acts from the era of the suffragettes to the Iraq war reveal nuance and pathos, with many powerful photographers including John Deakin, Fay Godwin and Humphrey Spender bearing witness. Jonathan Jones
Bebe Cave Soho theatre, London, 10sday to 12 July The out-of-work actor to character comedian pipeline can be a busy one, but Cave turns Plan B into brilliance with her pastiches of onscreen heroines: her exceptional Instagram satire of period drama protagonists, and her latest full-length show, The Screen Test, in which she plays Betsy Bitterly, an aspiring starlet in Hollywood’s golden age. Rachel Aroesti
Hope Hunt and the Ascension into Lazarus The Mount Without, Bristol, 9 & 10 July A brilliant solo by Belfast choreographer Oona Doherty. She used to perform it herself; now she trains up other dancers in the work’s particular, transformational physicality, embodying the oft-maligned character of the working-class male, veering between overconfident swagger and tightly wound tension. A truly original piece of dance. Lyndsey Winship
Till the Stars Come Down Theatre Royal Haymarket, London, to 27 September Beth Steel’s meticulously observed and brilliantly funny new play is set in the East Midlands on the eve of a family wedding. What does the future hold for three sisters – and one exceptionally funny aunt – still so tightly bound to their home town’s history? Miriam Gillinson
Big Big Sky New Vic, Newcastle-under-Lyme, to 24 July Tom Wells’s plays are always ones to savour; full of heart and sumptuous characters. His latest is set on the North Sea coastline, where the locals are shutting up shop for the winter – before one final visitor changes everything. MG
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Staying in: Streaming
All killer, no filler … Dexter: Resurrection. Photograph: Zach Dilgard/Paramount+/Showtime
Dexter: Resurrection Paramount+, 11 July Last time we saw Michael C Hall’s vigilante murderer, he seemed like a goner – but this sequel reveals he actually survived the gunshot delivered by his son. Now recovered, Dexter’s hunt for his child is interrupted when he is recruited by a strange billionaire (Peter Dinklage) who is attempting to arrange a serial killer symposium.
Too Much Netflix, 10 July Once upon a time, Lena Dunham met a musician in London – now the Girls creator has refashioned her real-life love story into a very promising romcom. The wildly funny Megan Stalter (Hacks) plays Jessica, a New Yorker who falls for singer-songwriter Felix (The White Lotus’s Will Sharpe). Richard E Grant and Emily Ratajkowski co-star.
Poisoned Channel 4, 9 July, 9pm In 2021, 22-year-old Tom Parfett died after consuming poison he’d bought online. Tipped off by Tom’s bereaved father, Times journalist James Beal traced the substance to a Canadian chef – and discovered many more victims around the globe. This documentary recounts his investigation while grappling with the disturbing online suicide industry.
The Trouble With Mr Doodle Channel 4, 9 July, 10pm Co-directed by Jaimie D’Cruz (Exit Through the Gift Shop), this film traces Sam Cox’s staggering rise from childhood drawing obsessive to one of Britain’s most lucrative artists – including the delusions and psychotic break he experienced while trying to doodle over the entirety of his Kent mansion. RA
Staying in: Games
Board silly … Tony Hawk’s Pro Skater 3 + 4. Photograph: Iron Galaxy
Tony Hawk’s Pro Skater 3 + 4 Out 11 July; PC, PS4/5, Xbox; Switch 1/2 Head back to the skatepark (above) with Activision’s second collection of classic Tony Hawk titles from the early 2000s. All the gnarly tricks and thrash metal music you remember, plus a smattering of new skaters and arenas to make it extra radical.
Missile Command Delta Out July 8; PC, PS5, Switch, Xbox Atari’s revered airspace defence game returns, but this time as an intriguing turn-based strategy title, where you have to carefully manage your anti-missile arsenal while exploring the bunker you’re mysteriously trapped in. An unexpectedly timely cold war thriller. Keith Stuart
Staying in: Albums
Let’s dance … Nilufer Yanya. Photograph: Molly Daniel
Nilüfer Yanya – Dancing Shoes EP Out now Less than a year after her third album, the excellent My Method Actor, Nilüfer Yanya teases her next chapter via this four-track EP. Over a lo-fi drum machine and eerie guitar figures Cold Heart floats about like In Rainbows-era Radiohead, while Where to Look’s atmospherics are eventually punctured by sonic implosion.
Kesha – Period Out now After a protracted departure from her former label, Kesha unleashes her first album as an independent artist. Ricocheting between jacked-up pop, country EDM and, on the bonkers lead single Joyride, a hyperpop version of polka, Period feels like both a return to early Kesha and a brand new start.
Double Virgo – Shakedown Out now Jezmi Tarik Fehmi and Sam Fenton, AKA two-thirds of London art-pop curios Bar Italia, return to their side-project for Shakedown, the duo’s third album. While not a million miles away from the mothership in terms of sound (both share a beguiling brittleness), songs such as Bemused have a stranger melodic sensibility.
Kae Tempest – Self Titled Out now South London’s literary polymath – recording artist slots alongside spoken-word performer, poet, novelist and playwright – returns with the Fraser T Smith-produced Self Titled, which also features Neil Tennant, Young Fathers and Tawiah. Featuring Tempest’s poetic flow, the powerful Know Yourself is a dialogue with the past. MC
Staying in:Brain food
The Killing Call Podcast In 2022, promising Punjabi rapper Sidhu Moose Wala was murdered. Gangster Goldy Brar claimed responsibility but three years on, no one has been convicted and Brar is still on the run. This incisive five-part series (above) investigates.
Baldwin Library of Historical Children’s Literature Online The University of Florida’s Baldwin Library holds an extensive archive of charming children’s books from the 18th century onwards. Browse scans of everything from a collection of mysterious “Elfin Rhymes” to an illustrated 1871 Bible.
Jaws @ 50 Disney+, 11 July Celebrating a remarkable half-century since the release of the blockbuster that has led to shark phobias around the world, this film charts the chaos of its production, as well as a surprising legacy of shark conservation. Ammar Kalia
Alex Horne said he knew he had to be involved after a few minutes into his first visit
Comedian and author Alex Horne has become a patron of a much-loved adventure playground used by people with special needs and their families.
The Thames Valley Adventure Playground (TVAP), near Maidenhead, Berkshire, opened in 1982 and high profile supporters have included Sir Terry Wogan, who was also a patron, and Tim Brooke Taylor, a former president.
Horne was approached by Lola, the daughter of the charity’s community outreach coordinator, Lucie Grange, who sent a letter that she had written on a typewriter.
He said he knew within a few minutes into his first visit to the playground that he wanted to get involved.
“It’s not often I receive a letter direct from an actual typewriter so that was a good start,” Horne said.
“Then when I was shown around the playground by Lucie, I knew within a few minutes that I would have to get involved in some way.”
TVAP/Google
TVAP was first set up in 1982 and has gradually expanded
“The commitment the whole team so clearly has to provide adventure and play for people who need those things the most was both powerful and persuasive.
“So I’m as excited as anyone to have now joined that team and will hopefully be able to join in and make more fun happen before too long. Thanks again to Lola for the letter.”
TVAP’s chairman Jim Wilks added: “Alex’s ethos aligns with our vision, and we look forward to working with him to raise both our profile and our funds, ensuring that we continue to provide an inspiring, inclusive environment for all our visitors and their families.”
In January, TVAP said its visitors come from as far as Swindon and west London to use its specialist facilities.
Mr Wilks said running it had been “tough” because of rising costs and that it had been forced to increase its prices for the first time since the Covid pandemic.
Former Spandau Ballet frontman Tony Hadley and folk group The Unthanks are among headline acts at this year’s Lichfield Festival, organisers have announced.
The festival, which runs from 8 to 20 July, takes place across venues such as Lichfield Cathedral, St Michael’s Church, the Guildhall and Beacon Park.
Organisers said the event, which it dubbed one of the country’s “most eclectic multi-arts festivals” would feature world-class artists and local voices from music, theatre, dance and comedy.
The festival also included a world premiere of Gingerland, a new dance show created by Strictly Come Dancing dancer Neil Jones, a spokesperson added.
On for two nights, the family-friendly comedy features a “dazzling cast of top professional dancers, with glamorous costumes and original music,” organisers added.
Other artists headlining this year’s event include brass ensemble Black Dyke Band, Sam Every (Little) Big Band, choir Tenebrae and jazz artist Jacqui Dankworth.
The 11-day festival will close with a candlelit concert by Jeneba Kanneh-Mason in Lichfield Cathedral.
A new discounted ticket initiative was also launched this year, offering discounted prices for under 30s, carers, children and eligible community groups,
Tickets and the full event programme have been listed on the festival’s website.
As an ancient disease, tuberculosis (TB) has existed for thousands of years since the origin and evolution of mankind.1 Pulmonary tuberculosis (PTB) is caused by the infection with Mycobacterium tuberculosis (Mtb), which primarily spreads among people through the air and affects the lung.2 PTB was classified as a Global Health Emergency by the World Health Organization (WHO) in 1993, and it was the world’s second leading cause of death from a single infectious agent, after Coronavirus disease 2019 (COVID-19) in 2022. According to the statistics of the WHO, the number of people who developed TB was approximately 10.6 million and the number of people newly diagnosed with TB was 7.5 million in 2022, of which TB patients newly diagnosed in China were approximately 748,000 (accounted for 7.1%),3 ranking third among the 30 countries with a high TB burden.4 Although the global incidence of TB has been well controlled, it still poses a severe challenge to global public health because of the poor prognosis caused by such as rising resistance rates and the severe complications. Currently, the epidemic situation of TB epidemics in China remains very serious. The risk factors for tuberculosis include overcrowding, poverty, malnutrition, and immunosuppression including human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS).5 Diabetes mellitus (DM) is increasingly being recognized as an independent risk factor for tuberculosis.6,7 DM is a chronic metabolic disease resulting from a combination of genetic and environmental factors.8,9 The main pathogenesis of DM is an absolute or relative reduction in insulin secretion, which affects the metabolism of carbohydrates, proteins, fats, electrolytes, and water, resulting in chronic organ injury and dysfunction.10,11 DM epidemic has grown worldwide and is associated with high morbidity and mortality.12 During recent decades, the prevalence of DM has been sharply increased owing to an aging population, urbanization, physical inactivity and obesity caused by lifestyle changes.13 According to International Diabetes Federation (IDF) reports in 2019, the number of patients with DM worldwide was as high as 463 million, with the most rapid increase occurring in low- and middle-income countries (LMICs).14 Simultaneously, these countries face serious TB situations. The rising prevalence of diabetes may be contributed to the persistently high incidence of TB in countries with a high TB burden.
The bidirectional association between PTB and DM is well established, and the relationship between them is bidirectional. Studies have shown that the overall risk of PTB in patients with DM is three times higher than in the general population,15,16 and the prevalence of DM among PTB patients ranges from 1.9% to as high as 35%.17 Nearly 80% of adult DM cases are expected to occur in developing countries, and the convergence of these two epidemics may lead to an increased incidence of PTB.18 The patients with PTB and DM lead to treatment failure, longer sputum conversion time to normal, relapse, increased risk of developing multidrug-resistant tuberculosis (MDR-TB), and high mortality.19 According to the WHO PTB screening guidelines, uncontrolled diabetes doubles the risk of TB treatment failure, relapse, and death.20 There are significant challenges in the treatment and care of patients with DM and TB. Systematic evaluation of Asian countries showed that the prevalence of diabetes among PTB patients is between 5% and 50%, while the prevalence among DM patients in developing Asian countries is 1.8–9.5 times the general population.21 China has experienced the largest dual DM and TB epidemic globally, and DM combined with PTB poses a major public health problem. The incidence rates of DM and PTB comorbidity (PTB-DM) among Chinese individuals increased from 19.3% to 24.1%.22 Therefore, clarifying the diagnostic value of clinical laboratory indices for PTB-DM is of great clinical significance.
Inflammation has long been identified as an essential component of both DM and TB.23,24 DM increases the risk of TB infection by inducing chronic inflammation and immune deficiency. TB infection aggravates abnormal blood glucose through inflammatory responses, forming a bidirectional worsening cycle of “DM-tuberculosis”. Inflammation is the core mechanism connecting diabetes and tuberculosis, running through the entire process of disease occurrence and development. The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR) have been found to be useful markers for the diagnosis and differential diagnosis of TB,25,26 and DM related disease and prognosis.27–29 In addition, system immune inflammation index (SII) and system inflammation response index (SIRI) are two markers of system immune inflammation, and their links to DM are being revealed.30,31 However, the association between immunoinflammatory markers and PTB-DM remains unclear. In the present study, we aimed to investigate whether these immunoinflammatory markers and clinical features are associated with the risk of DM in patients with PTB. It would provide a scientific basis for the prevention and control of PTB in patients with DM.
Materials and Methods
Study Population
A total of 1106 patients with PTB were selected as the case group at Meizhou People’s Hospital between April 2016 and December 2020 were retrospectively. During the study period, 326 cases with PTB (observation group) of DM patients with PTB were randomly selected, and compared with 780 PTB patients without DM during the same period (control group). PTB patients were diagnosed according to the criteria of “WS 288–2017 Pulmonary Tuberculosis Diagnosis”32 by microbiological diagnosis. The diagnostic criteria for T2DM were as follows: (1) There were typical clinical symptoms of DM (polydipsia, polydipsia, polyuria, polydipsia, and unexplained weight loss), and random intravenous plasma glucose ≥11.1mmol/L; or fasting blood glucose (FBG) ≥7mmol/L; or blood glucose level at the 2-hour oral glucose tolerance test ≥11.1mmol/L.33 Patients with leukemia, HIV infection, septic shock, organ failure, malignancy, or mental disorders; those with diseases that can affect immune function, such as AIDS, malignant tumor, chronic hepatitis, cirrhosis, primary kidney disease, renal failure, blood disease, renal transplantation, gastrectomy, or use of hormones and immunosuppressants within four months were also excluded. Clinical data, including age, sex, cough, fever, respiratory symptoms, expectoration, and extrapulmonary tuberculosis, were collected from all study subjects. This study was approved by the Human Ethics Committee of Meizhou People’s Hospital.
Data Collection
Data on clinical characteristics, laboratory outcomes, and inflammation indices were systematically collected from the medical record system of Meizhou People’s Hospital. Clinical symptoms recorded included fever (defined as a body temperature ≥38°C, measured using a standard clinical thermometer), sputum production (assessed based on the presence and quantity of sputum, categorized as mild, moderate, or severe), shortness of breath/difficulty breathing (evaluated using clinical assessment tools such as the Respiratory Distress Observation Scale or the Modified Borg Dyspnea Scale), and extrapulmonary tuberculosis (diagnosed based on clinical presentation, imaging studies, and laboratory confirmation). Laboratory outcomes included erythrocyte sedimentation rate (ESR), measured using the Westergren method and reported in millimeters per hour (mm/hr); C-reactive protein (CRP), quantified using high-sensitivity CRP assays and reported in milligrams per liter (mg/L); and complete blood count (CBC), analyzed using automated hematology analyzers to record absolute neutrophil count (ANC), absolute lymphocyte count (ALC), absolute monocyte count (AMC), and platelet count (reported as cells per microliter). Inflammation indices were calculated as follows: neutrophil-to-lymphocyte ratio (NLR=ANC/ALC), platelet-to-lymphocyte ratio (PLR=Platelet count/ALC), monocyte-to-lymphocyte ratio (MLR=AMC/ALC), systemic immune-inflammation index (SII=Platelet count × ANC/ALC), and systemic inflammation response index (SIRI = AMC × ANC/ALC). These indices were used to assess systemic inflammation and immune response.
Data Processing and Statistical Analysis
SPSS 26.0 and GraphPad Prism software were used for the statistical analysis of the experimental data. Data with non-normal distributions were described as median and interquartile range (IQR) values, and evaluated using the Mann–Whitney U-test. Categorical variables were represented numerically and as percentages, and were compared using the chi-squared test. Univariate regression analysis (Pearson) and Spearman correlation analysis were used to analyze the relationship between the correlation test indicators. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cutoff values of ESR, NLR, MLR, PLR, SII, and SIRI for differentiating whether pulmonary tuberculosis patients developed DM or not, and the area under the ROC curve (AUC) was calculated. In addition to the logistic regression model, a 95% confidence interval (95% CI) was used to determine the diagnostic probability of PTB combined with DM. The significance level was set at P < 0.05.
Results
General Characteristics in PTB Patients with or without DM
A total of 1106 patients diagnosed with PTB were enrolled, including 326 (29.5%) PTB patients with DM and 780 (70.5%) without DM. The clinical characteristics of the two patient groups of patients are shown in Table 1. The majority of PTB patients were male (84.6%), and most had no fever (83.7%) or shortness of breath/difficulty breathing (76.9%). There were 39 (3.5%) had concurrent extrapulmonary tuberculosis. The differences in gender distribution, age distribution, and clinical manifestations including fever, shortness of breath/difficulty breathing, and expectoration, and extrapulmonary tuberculosis between the two groups were not statistically significant. The level of ESR (44.00 (22.00, 80.00) vs 30.00 (12.00, 54.00), p<0.001) was higher while the levels of NLR (4.61 (2.90, 7.64) vs 6.43 (3.62, 11.20), p<0.001), MLR (0.50 (0.31, 0.75) vs 0.64 (0.38, 1.00), p<0.001), PLR (197.38 (135.53, 299.16) vs 248.44 (149.74, 396.43), p<0.001), SII (1333.06 (712.37, 2289.35) vs 1603.72 (844.73, 3224.20), p<0.001), and SIRI (3.13 (1.73, 6.42) vs 3.93 (2.00, 8.79), p<0.001) were lower in PTB-DM patients than those in non-DM PTB patients.
Table 1 Comparison of Clinical Features and Peripheral Blood Inflammatory Markers Between Non-DM PTB Group and PTB-DM Group
Logistic Regression Analysis of Related Factors for DM in Patients with PTB
Logistic regression analyses of the association between PTB-DM and related factors were performed (Table 2). Univariate logistic regression analysis showed that PTB patients with DM were more likely to have a higher ESR (odds ratio (OR): 1.024, 95% CI: 1.018–1.30, p<0.001), lower levels of NLR (OR: 0.964, 95% CI 0.945–0.983, p<0.001), MLR (OR: 0.440, 95% CI 0.319–0.607, p<0.001), PLR (OR: 0.998, 95% CI: 0.998–0.999, p<0.001), and SIRI (OR: 0.965, 95% CI: 0.944–0.987, p=0.002). Clinical features such as gender, age, fever, expectoration, shortness of breath/difficulty breathing, extrapulmonary tuberculosis, and other blood indicators were not associated with DM in PTB patients. Multivariable logistic regression analyses indicated that a high ESR (OR: 1.024, 95% CI: 1.018–1.030, p<0.001), low levels of MLR (OR: 0.352, 95% CI 0.145–0.856, p=0.021), and PLR (OR: 0.997, 95% CI: 0.995–0.999, p=0.003) were independent risk factors for DM in patients with PTB.
Table 2 Logistic Regression Analysis of Related Factors for DM in Patients with PTB
The Value of Different Indexes and Their Combined Detection in the Differential Diagnosis of PTB-DM
To analyze the discriminating ability of these inflammatory parameters in the PTB-DM versus PTB groups, ROC curves for the related parameters were plotted (Figure 1). Results revealed the AUC value of ESR was 0.619 (95% CI: 0.590–0.648, cut-off value: 45.5), MLR was 0.600 (95% CI 0.570–0.629, cut-off value: 0.765), PLR was 0.584 (95% CI: 0.554–0.613, cut-off value: 239.615), ESR+MLR was 0.689 (95% CI: 0.661–0.716), ESR+PLR was 0.694 (95% CI: 0.666–0.721), MLR+PLR was 0.610 (95% CI: 0.574–0.645), and ESR+MLR+PLR was 0.712 (95% CI 0.685–0.739), respectively. The PTB-DM and PTB groups could be well discriminated by the combination of indicators ESR, MLR and PLR, with sensitivity and specificity of 63.8% and 70.6%, respectively. Table 3 presents the comprehensive features of ESR, MLR, and PLR for the diagnosis.
Table 3 The Diagnostic Efficacy of ESR, MLR, PLR, and Their Combination on PTB-DM
Figure 1 The ROC curve of ESR, MLR, PLR, and their combination on PTB-DM.
Discussion
This study compared the characteristics of the PTB patients with and without DM. Among the patients diagnosed with PTB, 29.5% had DM. The results showed that there were no significant differences in clinical manifestations including gender distribution, age distribution, fever, shortness of breath/difficulty breathing, expectoration, and extrapulmonary tuberculosis. ESR was higher, while NLR, MLR, PLR, SII, and SIRI were lower in PTB-DM patients than in non-DM PTB patients. In addition, high ESR and low MLR and PLR were independent risk factors for PTB-DM.
The high prevalence of DM creates more pressure on the PTB burden. DM increases the risk of PTB, posing a significant threat to the public health, particularly, in countries with a high burden of both diseases.34 Thus, experts have raised concerns regarding the co-prevalence of PTB and DM. PTB patients with DM often have nutritional deficiency, leading to body injury and disease recurrence, which ultimately affects prognosis and increases the risk of mortality.22,35 In many studies on the Chinese population, male sex and advanced age were identified as factors associated with PTB with DM;36–38 however, in this study, age and gender were not statistically different. In addition, the presence of symptoms such as fever, cough, sputum, shortness of breath, difficulty breathing, or extrapulmonary tuberculosis was similar between patients with and without DM. Therefore, we cannot estimate whether TB patients are at risk for diabetes based on simple clinical manifestations.
Chronic infection with Mtb can induce hematopoietic stem cell proliferation and immune changes, which in turn cause changes in the proportion of lymphocyte and other cells.39 There is a correlation between the immune status (including ESR, NLR, MLR, PLR, SII, and SIRI) and clinicopathological features of PTB patients,40 which are some of the more novel inflammatory markers currently available.41 ESR is a sensitive marker of the inflammatory response, and is often used to obtain information regarding disease progression and retrogression.42 The ESR value was significantly higher in tuberculosis patients with tuberculosis, and was even elevated in 98% of the patients.43,44 MLR has been proven to be associated with the diagnosis of PTB and the predictive value of MLR in patients with tuberculosis, and higher MLR levels are associated with more severe disease and poorer prognosis.45,46 The importance of PLR has been emphasized as a marker in some disorders such as non-small-cell lung cancer, acute coronary syndrome, end-stage renal disease, and so on.47,48 PLR could be developed as a valuable maker for identifying tuberculosis infection in chronic obstructive pulmonary disease (COPD) patients,40 indicating that PLR is a convenient, and easily measured prognostic indicator. In this study, the inflammation index of ESR was significantly increased, MLR, PLR, SII, and SIRI were significantly decreased in the PTB patients with DM compared to those in PTB patients alone. Further regression analysis indicated that the ESR, MLR, and PLR were relevant factors for PTB-DM. It indicates that a higher ESR and lower MLR and PLR may indicate PTB-DM.
However, these indicators fluctuate to a certain extent and do not have the significance of an independent diagnosis in patients with PTB-DM. Hence, these factors need to be combined to improve the diagnostic value of PTB complicated by DM. Thus, we analyzed the diagnostic efficacy of ESR, MLR, and PLR in PTB patients with DM, and found that ESR has low sensitivity and MLR has low specificity, while PLR has slightly higher sensitivity and specificity. In addition, we also analyzed the sensitivity and specificity of ESR, MLR, and PLR combined tests, and found that the combined tests of these indicators were superior to the single indicator in both sensitivity and specificity. Therefore, the combined detection of ESR, MLR, and PLR is helpful in the differential diagnosis of PTB with DM and non-DM PTB. The results of this study provide a convenient method for clinicians to assess the risk of developing DM in patients with PTB.
This study offers valuable insights into the relationship between hematological markers and DM in patients with PTB, though there are opportunities for further exploration. Firstly, the relationship between these indicators and the severity of DM has not been studied. Future research could investigate the association between inflammation markers (ESR, MLR, and PLR) and the severity of DM. Secondly, the research subjects included in this study were from a single medical structure. Due to the incomplete representativeness of the research subjects, the application of the results of this study in other populations was limited. So, expanding the study to multiple centers would provide a more diverse sample, enhancing the generalizability of the results. Thirdly, this study only analyzed the differences in ESR, NLR, MLR, PLR, SII, and SIRI levels, and did not investigate the role of other factors in the occurrence of DM in patients with PTB, especially some confounding factors. Lastly, collecting data at multiple time points, rather than a single pre-treatment measure, would allow for a more comprehensive analysis of the dynamic changes in these hematological indicators and their clinical significance throughout the treatment process. Addressing these factors would provide a more complete understanding of the role of these markers in DM and PTB, which depends on more research in the future.
Conclusion
ESR, MLR, and PLR were associated with the risk of DM in patients with PTB. In particular, combined tests of these indicators were superior to the single indicator in both sensitivity and specificity in the diagnosis of DM among patients with PTB. It provides a convenient method for clinicians to assess the risk of developing DM in patients with PTB. Specifically, during the treatment of tuberculosis, it is necessary to closely monitor the changes in the patient’s blood sugar, adjust the diabetes treatment plan in a timely manner, and reduce the fluctuations in blood sugar caused by inflammation. Secondly, for pulmonary tuberculosis patients with abnormal inflammatory indicators, their association with diabetes should be emphasized. Through anti-inflammatory treatment or immunomodulatory measures, insulin resistance can be improved, immune balance can be regulated, and the risk of disease progression can be reduced.
Data Sharing Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
Ethics Approval and Consent to Participate
The study was approved by the Ethics Committee of Medicine, Meizhou People’s Hospital number. All participants signed informed consent in accordance with the Declaration of Helsinki.
Acknowledgments
The author would like to thank other colleagues whom were not listed in the authorship of Meizhou People’s Hospital for their helpful comments on the manuscript.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Funding
This study was supported by the Science and Technology Program of Meizhou (Grant No.: 2019B0202001).
Disclosure
The authors declare that they have no competing interests.
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