[Clinical and electrophysiological characteristics and treatment outcomes of anti-neutrophil cytoplasmic antibody ANCA-associated vasculitic neuropathy]

Objective: To investigate the clinical and electrophysiological characteristics of ANCA-associated vasculitic neuropathy (VN) and analyze the predictors of treatment outcomes. Methods: Retrospective case series. In all, 652 consecutive patients with ANCA-associated vasculitis were admitted to the First Medical Center of the Chinese PLA General Hospital between January 2006 and December 2022. Peripheral neuropathy occurred in 91 patients. Patients were excluded if other known causes of neuropathy were present. Sixty-one patients were eventually enrolled, including 17 with eosinophilic granulomatosis with polyangiitis (EGPA), 11 with granulomatosis polyangiitis (GPA), and 33 with microscopic polyangiitis (MPA). Their clinical data were collected and clinical characteristics, VN manifestations, electrophysiological findings (including interside amplitude ratio [IAR]), and treatment outcomes were compared among the three subsets of AAV. Then, factors influencing the treatment outcomes were analyzed using multivariable logistic regression analysis. Results: Peripheral neuropathy occurred in 62.1%(18/29) of EGPA, 8.3%(15/180) of GPA, and 13.1%(58/443) of MPA patients. The age at onset and examination was higher in patients with MPA than those with EGPA or GPA (P<0.01). The occurrence of VN was later in patients with GPA than those with EGPA (P<0.01), and the GPA group had fewer affected nerves than the other two groups (P<0.016). The abnormal IARs of motor nerves in lower limbs were more detected in the EGPA than the MPA group (P<0.01). Logistic regression analysis suggested that higher Birmingham vasculitis activity score-version 3 (BVAS-V3) (OR=6.85, 95%CI 1.33-35.30) was associated with better treatment outcomes of VN. However, central nervous system involvement was a risk factor for poor treatment outcomes (OR=0.13, 95%CI 0.02-0.89). Conclusions: The clinical and electrophysiological characteristics of VN were slightly different among subsets of AAV. Patients with GPA often presented with polyneuropathy and had fewer nerves affected; mononeuritis multiplex was more common in EGPA than GPA and MPA. Higher BVAS-V3 and central nervous system involvement might predict the treatment outcome of VN.

Targeted long-read sequencing for comprehensive detection of CYP21A2 mutations in patients with 21-hydroxylase deficiency

BACKGROUND

21-Hydroxylase deficiency (21-OHD) is caused by pathogenic CYP21A2 variations. CYP21A2 is arranged in tandem with its highly homologous pseudogene CYP21A1P; therefore, it is prone to mismatch and rearrangement, producing different types of complex variations. There were few reports on using only one method to detect different CYP21A2 variants simultaneously.

AIMS

Targeted long-read sequencing method was used to detect all types of CYP21A2 variants in a series of patients with 21-OHD.

METHODS

A total of 59 patients with 21-OHD were enrolled from Peking Union Medical College Hospital. Long-range locus-specific PCR and long-read sequencing (LRS) were performed to detect the pathogenic variants in CYP21A2.

RESULTS

Copy-number variants of CYP21A2 were found in 25.4% of patients, including 5.1% with 3 copies of CYP21A2, 16.9% with 1 copy of CYP21A2, and 3.4% with 0 copy of CYP21A2. The remaining 74.6% of patients had 2 copies of CYP21A2. Pathogenic variants were identified in all 121 alleles of 59 patients. Specifically, single-nucleotide variants and small insertions/deletions (< 50 bp) were detected in 79 alleles, of which conversed from CYP21A1P were detected in 63 alleles, and rare variants were found in the other 16 alleles. Large gene conversions (> 50 bp) from pseudogene were detected in 10 alleles, and different chimeric genes (CYP21A1P/CYP21A2 or TNXA/TNXB) formed by large deletions were detected in 32 alleles. Of all variants, p.I173N was the most common variant (19.0%).

CONCLUSIONS

Our study demonstrated that targeted long-read sequencing is a comprehensive method for detecting CYP21A2 variations, which is helpful for genetic diagnosis in 21-OHD patients.

Energy harvesting from water impact using piezoelectric energy harvester

Energy, as an indispensable part of human life, has been a hot topic of research among scholars. The water kinetic energy generated by ocean currents, as a kind of clean energy, has high utilization rate, high power generation potential, and a broad prospect of powering microelectronic devices. As a result, the water kinetic piezoelectric energy harvester (WKPEH) has made significant progress in powering ocean sensors by harvesting ocean currents. This paper provides a comprehensive review of technologies that have been used in recent years to harvest energy from marine fluids using WKPEH. Detailed study of the energy harvesting mechanism of WKPEH. WKPEH can use the flutter-induced vibrations, vortex-induced vibrations, and wake oscillation principles to harvest water kinetic energy. The structural characteristics and output performance of each mechanism are also discussed and compared, and finally, a prospect on WKPEH is given.

Anomalous thermal activation of green upconversion luminescence in Yb/Er/ZnGdO self-assembled microflowers for high-sensitivity temperature detection

Non-contact optical temperature detection has shown a great promise in biological systems and microfluidics because of its outstanding spatial resolution, superior accuracy, and non-invasive nature. However, the thermal quenching of photoluminescence significantly hinders the practical applications of optical temperature probes. Herein, we report thermally enhanced green upconversion luminescence in Yb/Er/ZnGdO microflowers by a defect-assisted thermal distribution mechanism. A 1.6-fold enhancement in green emission was demonstrated as the temperature increased from 298 K to 558 K. Experimental results and dynamic analysis demonstrated that this behavior of thermally activating green upconversion luminescence originates from the emission loss compensation, which is attributed to thermally-induced energy transfer from defect levels to the green emitting level. In addition, the Yb/Er/ZnGdO microflowers can act as self-referenced radiometric optical thermometers. The ultrahigh absolute sensitivity of 1.61% K-1 and an excellent relative sensitivity of 15.5% K-1 based on the 4F9/2/2H11/2(2) level pair were synchronously achieved at room temperature. These findings provide a novel strategy for surmounting the thermal quenching luminescence, thereby greatly promoting the application of non-contact sensitive radiometric thermometers.

Risk factors for portal vein system thrombosis after partial splenic embolisation in cirrhotic patients with hypersplenism

AIM

To determine risk factors for portal venous system thrombosis (PVST) after partial splenic artery embolisation (PSAE) in cirrhotic patients with hypersplenism.

MATERIALS AND METHODS

Between March 2014 and February 2022, 428 cirrhotic patients with hypersplenism underwent partial splenic artery embolisation and from these patients 208 were enrolled and 220 were excluded. Medical records of enrolled patients were collected. Computed tomography (CT) images were reviewed by two blinded, independent radiologists. Statistical analyses were performed by using SPSS.

RESULTS

Progressive PVST was observed in 18.75% (39/208) of cirrhotic patients after PSAE. No significant differences in peripheral blood counts, liver function biomarkers, and renal function were observed between the patients with progressive PVST and the patients without progressive PVST. The imaging data showed significant differences in PVST, the diameters of the portal, splenic, and superior mesenteric veins between the progressive PVST group and non-progressive PVST group. Univariate and multivariate analysis demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for progressive PVST. Seventeen of 173 (9.83%) patients showed new PVST; the growth of PVST was observed in 62.86% (22/35) of the patients with pre-existing PVST. Spleen infarction percentage and the diameter of the splenic vein were independent risk factors for new PVST after PSAE.

CONCLUSION

The present study demonstrated portal vein thrombosis, spleen infarction percentage, and the diameter of the splenic vein were independent risk factors for PVST after PSAE in cirrhotic patients with hypersplenism.

Bridging the Gap of Radiotherapy Treatment Planning Quality between High-Income, and Low- and Middle-Income Countries Using Knowledge-Based Planning

PURPOSE/OBJECTIVE(S)

Radiotherapy departments in low- and middle-income countries (LMICs) like Guatemala have recently introduced intensity-modulated radiotherapy (IMRT). IMRT has become the standard of care in high-income countries (HIC) due to reduced toxicity and improved outcomes in some cancers. The purpose of this work is to show the feasibility of adapting knowledge-based (KB) models established in a HIC to a LMIC lacking experience in IMRT to improve plan quality and planning efficiency.

MATERIALS/METHODS

A Halcyon Linac was installed at our clinic in Guatemala in 2019 and has been used to treat approximately 90 patients daily with IMRT. A model developed on a cohort of head and neck cancer patients at a US academic radiotherapy center were applied at our center to create 20head and neck VMAT plans with different prescriptions, including simultaneous-integrated and sequential boosts.

RESULTS

The plans created using the KB models achieved similar coverage of the planning target volume for each plan KB plans showed better 1) Parotid sparing with a mean dose reduction between 5%-25% and spinal cord maximum dose reduction between 3%-15%. The time efficiency to create VMAT plans using KB model versus manual planning improved four-fold, on average one hour versus more than 4 hours, respectively.

CONCLUSION

Despite different prescriptions, guidelines and demographics of cancer patients between two institutions in a HIC and LMIC, this work demonstrates that KB planning can be used to generate better and more consistent VMAT plans versus manually created plans. In addition, KB planning has the potential to greatly increase planning efficiency higher efficiency and help address the shortage of medical physicists and dosimetrists in LMICs.

Dissecting Systemic T Cell Responses after Stereotactic Ablative Radiotherapy in NSCLC by Single-Cell RNA and T Cell Receptor Sequencing

PURPOSE/OBJECTIVE(S)

There is accumulating evidence that stereotactic ablative radiotherapy (SABR) modulates immune responses to cancer; combining SABR and immunotherapy could promote the abscopal effect, but the precise effects of SABR on patients' systemic T cells is unclear. Here, we investigated SABR-induced systemic T cell response in early-stage non-small cell lung cancer (NSCLC) by single-cell RNA and T cell receptor sequencing.

MATERIALS/METHODS

We performed single-cell RNA and T cell receptor sequencing on 29,439 T cells from four pairs of peripheral blood before and after SABR in early-stage NSCLC patients. Cell clustering and dimensionality reduction, SingleR, feature genes score, and TCR profiling analyses were used to investigate the heterogeneity of T cells and their changes following SABR.

RESULTS

We identified fourteen T cell subtypes using unsupervised graph-based clustering of uniform manifold approximation and projection. By comparing the gene set scores of CD8_TE and CD8_EM pre- and post-SABR, we found both cytotoxic and inhibitory scores were significantly elevated in CD8_TE (both P < 0.001), while cytotoxic score was significantly increased in CD8_EM (P < 0.001) after SABR. We also found that CD4_TE showed increased cytotoxic scores and decreased Treg scores (P < 0.001 and < 0.05, respectively), while Treg cells showed decreased inhibitory and Treg scores (P < 0.001 and <0.01, respectively) after SABR. The proportion of large TCR clones was higher after SABR, which was accompanied by a decrease in proportion of single clones. When we compared the transcriptomes of CD8_TE cells between the single, small and large clones post-SABR, we found high expression of GZMB and KLRC3 in cells with large clones, and GZMK, IL7R, and SELL in small and single clones. This suggested that T cells after SABR with large clones may have higher cytotoxicity than those with small and single clones.

CONCLUSION

Our study identified systemic T cell activation after SABR at single-cell resolution, providing unprecedented insight into the immune-modulatory role of SABR in early-stage NSCLC.

Standardizing LT Chest Wall Radiotherapy Treatment Planning in a Low- or Middle- Income Country Radiotherapy Clinic Using Knowledge Based Planning

PURPOSE/OBJECTIVE(S)

Radiotherapy departments in low- or middle-income countries (LMICs) tend to lag behind introducing emerging technologies like intensity-modulated radiotherapy (IMRT). IMRT has become the standard of care in high-income countries (HIC) due to reduced toxicity and improved outcomes in a wide variety of cancers. The purpose of this work is showing the results of left Chest-Wall knowledge-based planning (KBP) standardization and implementation in a LMIC setting.

MATERIALS/METHODS

A Halcyon Linac was installed at our clinic in Guatemala in 2019 and currently used to treat ∼90 IMRT patients daily. The standardization of IMRT procedures has been difficult for complex sites like chest-wall. The steps for standardization included: AAPM TG-263 nomenclature implementation, and planning workflows within the TPS, creation of optimization structures, and plan quality evaluation following RTOG1005 protocol hypofractionation arm. 25 plans were created manually achieving all RTOG1005 protocol constraints. The statistics were analyzed trough the model analytics tool provided by KPB manufacturer.

RESULTS

The results show that more plans are needed to improve the KBP model. This initial model was used to create a standardized clinical protocol in the TPS in order to continue adding plans to the KBP model database. This approach ensures that we obtain consistent plan quality and standardize our planning. The manual planning objectives achieved: CONCLUSION: The experience using the TPS to standardize our treatment planning process achieved good consistency in our planning objectives. This approach will help create KBP models according to our own clinic-specific requirements. Future work will be made to compare our LMIC KBP models with those made at a HIC academic radiotherapy center.

Impact of AI-Based Auto-Segmentation on Radiotherapy Processes in Low and Middle-Income Countries

PURPOSE/OBJECTIVE(S)

Radiotherapy processes require significant human resources and expertise, creating a barrier for rapid deployment in low and middle-income countries (LMICs). Optimal radiotherapy (RT) relies on accurate segmentation of tumor targets and organs-at-risk (OARs) during the RT planning process. This study reports the impact of AI-based auto-segmentation on RT processes in an LMIC.

MATERIALS/METHODS

Ten patients including five head and neck (HN), and five prostate cancer patients were randomly selected. Their planning CT images were subjected to auto- segmentation using an FDA-approved AI software tool, and manual segmentation by an experienced radiation oncologist from a Sub-Saharan African RT clinic. The control data consisted of contours from an experienced radiation oncologist and dosimetrists at a large academic institution in the US. For prostate cases, the contours included the prostate, seminal vesicles, bladder, rectum, penile bulb, and both femoral heads. For HN cases, the contours included the brain, brainstem, bilateral eyes, lens, optic nerves, cochlea, parotids, optic chiasm, spinal cord, oral cavity, and mandible. The time to complete the segmentation was recorded for both auto-segmentation and manual contours from the LMIC. The DICE similarity coefficients were used for comparative evaluation.

RESULTS

The average time for contouring per patient was 2 minutes for AI compared to 57 minutes for manual contouring in the LMIC. When comparing the control data, AI pelvic contours provide a slightly better agreement than LMIC manual contours for all the OARs, with the following mean DICE coefficients for AI vs LMIC manual contours: bladder (0.971 vs 0.958), left femoral head (0.960 vs 0.949), right femoral head (0.959 vs 0.941), rectum (0.880 vs 0.867), prostate (0.836 vs 0.824), seminal vesicles (0.696 vs 0.580), and penile bulb (0.536 vs 0.528). For HN contours, AI provide a better agreement for 7 of 11 OARs than the LMIC manual contours, with the following mean DICE coefficients: brain (0.972 vs 0.982), mandible (0.877 vs 0.925), right parotid (0.847 vs 0.800), left parotid (0.798 vs 0.792), spinal cord (0.837 vs 0.821), left eye (0.875 vs 0.832), right eye (0.867 vs 0.836), brainstem (0.866 vs 852), oral cavity (0.796 vs 0.787), left lens (0.650 vs 0.729) and right lens (0.671 vs 0.682). Neither AI contours nor LMIC manual contours had good agreement with the control data (<0.600) for optic nerves, chiasm, and cochlea due to their small volumes.

CONCLUSION

AI-based auto-segmentation tools are capable of producing contours of comparable quality to those generated by manual segmentation for both pelvic and HN cancer patients in LMICs, while also resulting in substantial time savings. AI-based auto-segmentation holds tremendous potential for improving radiotherapy care in LMICs with limited sources.

Climate warming negatively affects plant water-use efficiency in a seasonal hydroperiod wetland

Climate warming has substantial influences on plant water-use efficiency (PWUE), which is defined as the ratio of plant CO2 uptake to water loss and is central to the cycles of carbon and water in ecosystems. However, it remains uncertain how does climate warming affect PWUE in wetland ecosystems, especially those with seasonally alternating water availability during the growing season. In this study, we used a continuous 10-year (2011-2020) eddy covariance (EC) dataset from a seasonal hydroperiod wetland coupled with a 15-year (2003-2017) satellite-based dataset (called PML-V2) and an in situ warming experiment to examine the climate warming impacts on wetland PWUE. The 10-year EC observational results revealed that rising temperatures had significant negative impacts on the interannual variations in wetland PWUE, and increased transpiration (Et) rather than changes in gross primary productivity (GPP) dominated these negative impacts. Furthermore, the 15-year satellite-based evidence confirmed that, in the study region, climate warming had significant negative consequences for the interannual variations in wetland PWUE by enhancing wetland Et. Lastly, at the leaf-scale, the light response curves of leaf photosynthesis, leaf Et, and leaf-scale PWUE indicated that wetland plants need to consume more water during the photosynthesis process under warmer conditions. These findings provide a fresh perspective on how climate warming influences carbon and water cycles in wetland ecosystems.

[Evolution and progress of surgical intervention strategies for acute pancreatitis]

Acute pancreatitis is one of the common surgical acute abdominal diseases. Since people first recognized acute pancreatitis in the middle of the nineteenth century, a diversified minimally invasive treatment model with standardization has been formed today. According to the main line of surgical intervention of acute pancreatitis treatment,this period can be roughly divided into five stages:exploration stage, conservative treatment stage, pancreatectomy stage, debridement and drainage of the pancreatic necrotic tissue stage, and minimally invasive treatment as the first choice led by the multidisciplinary team mode stage. Throughout history, the evolution and progress of surgical intervention strategies for acute pancreatitis cannot be separated from the progress of science and technology, the update of treatment concepts and the further understanding of the pathogenesis. This article will summarize the surgical characteristics of acute pancreatitis treatment at each stage to explain the development of surgical treatment of acute pancreatitis,to help investigate the development of surgical treatment of acute pancreatitis in the future.

Design and Manufacturing of a Novel Trabecular Tibial Implant

The elastic modulus of traditional solid titanium alloy tibial implants is much higher than that of human bones, which can cause stress shielding. Designing them as a porous structure to form a bone-like trabecular structure effectively reduces stress shielding. However, the actual loading conditions of bones in different parts of the human body have not been considered for some trabecular structures, and their mechanical properties have not been considered concerning the personalized differences of other patients. Therefore, based on the elastic modulus of the tibial stem obtained from Quantitative Computed Tomography (QCT) imaging between 3.031 and10.528 GPa, and the load-bearing state of the tibia at the knee joint, a porous structure was designed under compressive and shear loading modes using topology optimization. Through comprehensive analysis of the mechanical and permeability properties of the porous structure, the results show that the Topology Optimization-Shear-2 (TO-S2) structure has the best compressive, shear mechanical properties and permeability and is suitable as a trabecular structure for tibial implants. The Gibson-Ashby model was established to control the mechanical properties of porous titanium alloy. A gradient filling of porous titanium alloy with a strut diameter of 0.106-0.202 mm was performed on the tibial stem based on the elastic modulus range, achieving precise matching of the mechanical properties of tibial implants and closer to the natural structure than uniformly distributed porous structures in human bones. Finally, the new tibial implant was printed by selective laser melting (SLM), and the molding effect was excellent.

[Application of veno-arterio-venous extracorporeal membrane oxygenation in patients with critical respiratory failure combined with refractory shock]

Objective: To preliminarily analyze the application experience of veno-arterio-venous extracorporeal membrane oxygenation (VAV-ECMO).The VAV-ECMO is a rescue strategy for patients with extremely critical respiratory failure combined with refractory shock. Methods: From February 2016 to February 2022, the characteristics and outcomes of patients who were started on either veno-venous or veno-arterial ECMO due to respiratory or hemodynamic failure, and then converted to VAV-ECMO in respiratory intensive care unit (ICU) of Beijing Chaoyang Hospital were analyzed. Results: A total of 15 patients underwent VAV-ECMO, aged 53 (40, 65) years, and 11 of whom were male. Within the group, VV-ECMO was initially used in 12 patients due to respiratory failure, but then VAV-ECMO was used due to cardiogenic shock (7/12) and septic shock (4/12), while VAV-ECMO was established in two patients due to lung transplantation. One patient was diagnosed with pneumonia complicated by septic shock, which was initially determined to be VA-ECMO, but then switched to VAV-ECMO because it was difficult to maintain oxygenation. The time from the establishment of VV or VA-ECMO to the switch to VAV-ECMO was 3 (1, 5) days and the VAV-ECMO support time was 5 (2, 8) days. ECMO-related complications were bleeding, mostly in the digestive tract (n=4) and airway hemorrhage (n=4), without intracranial hemorrhage, and poor arterial perfusion of the lower limbs (n=2). Among these 15 patients, the overall ICU mortality was 53.3%. The mortality of patients who received VAV-ECMO due to septic shock and cardiogenic shock was 100% (4/4) and 42.8% (3/7), respectively. Two patients who received VAV-ECMO due to lung transplantation all survived. Conclusion: VAV-ECMO may be a safe and effective treatment for carefully selected patients with critical respiratory failure associated with cardiogenic shock or end-stage lung disease lung transplantation transition, however, patients with septic shock may benefit the least.

Tailoring the p-Band Center of NS Pair for Accelerating High-Performance Lithium-Oxygen Battery

The local coordination environment of catalytical moieties directly determines the performance of electrochemical energy storage and conversion devices, such as Li-O₂ batteries (LOBs) cathode. However, understanding how the coordinative structure affects the performance, especially for non-metal system, is still insufficient. Herein, a strategy that introduces S-anion to tailor the electronic structure of nitrogen-carbon catalyst (SNC) is proposed to improve the LOBs performance. This study unveils that the introduced S-anion effectively manipulates the p-band center of pyridinic-N moiety, substantially reducing the battery overpotential by accelerating the generation and decomposition of intermediate products Li_1-3 O₄ . The lower adsorption energy of discharging product Li₂ O₂ on NS pair accounts for the long-term cyclic stability by exposing the high active area under operation condition. This work demonstrates an encouraging strategy to enhance LOBs performance by modulating the p-band center on non-metal active sites.

[The mechanism, inducement and long-term effects of acquired weakness in intensive care units]

With the development of critical care medicine, the case fatality rate in intensive care units (ICU) patients has decreased significantly, but most patients still suffer from the long-term problems of related complications after discharge, which seriously affects the quality of life and social integration after discharge. Complications such as ICU acquired weakness (ICU-AW) and Post-ICU Syndrome (PICS) are not uncommon throughout the treatment of severe patients. The treatment of critically ill patients should not only focus on the treatment of the disease, but also gradually extend to the whole-process physiological-psychological-social medical intervention mode in the ICU, during the stay in the general ward and after discharge. On the basis of ensuring patient safety, patients' physical and psychological status assessment in the early stage of ICU admission, and disease prevention as soon as possible, which can reduce the long-term impact on the quality of life and social work after discharge.

Semiparametric Efficient G-estimation with Invalid Instrumental Variables

The instrumental variable method is widely used in the health and social sciences for identification and estimation of causal effects in the presence of potential unmeasured confounding. In order to improve efficiency, multiple instruments are routinely used, leading to concerns about bias due to possible violation of the instrumental variable assumptions. To address this concern, we introduce a new class of G-estimators that are guaranteed to remain consistent and asymptotically normal for the causal effect of interest provided that a set of at least γ out of K candidate instruments are valid, for γ≤K set by the analyst ex ante, without necessarily knowing the identity of the valid and invalid instruments. We provide formal semiparametric efficiency theory supporting our results. Both simulation studies and applications to the UK Biobank data demonstrate the superior empirical performance of our estimators compared to competing methods.

[Clinical characteristics and outcomes of acute respiratory distress syndrome caused by severe Chlamydia psittaci pneumonia]

Objective: To investigate the clinical characteristics and outcomes of acute respiratory distress syndrome (ARDS) caused by Chlamydia psittaci pneumonia. Methods: From June 2016 to January 2021, 10 cases were diagnosed as severe Chlamydia psittaci pneumonia induced ARDS in Intensive Care Unit of Respiratory and Critical Care Medicine Department (RICU) of Beijing Chao-Yang Hospital Affiliated to Capital Medical University. We collected the clinical data including clinical features, laboratory tests, imaging and outcomes of the patients. Results: The pathogenic diagnosis was confirmed by metagenomic Next-generation Sequencing (mNGS) in these 10 patients, with a median age of 59 (46, 67) years. In addition to high fever, cough and dyspnea, the patients also had multiple organ involvement. Six patients had elevated peripheral leukocyte count, 10 cases had increased type B natriuretic peptide, 7 cases had increased aspartate aminotransferase/alanine aminotransferase, 9 cases had hyponatremia and 3 cases had elevated creatinine. The imaging findings were bilateral consolidation with air bronchogram and infiltrates, and pleural effusion were found in 5 cases. All cases were combined with respiratory failure. Six patients received invasive mechanical ventilation. Nine patients received moxifloxacin and one patient was administrated with Azithromycin. All the patients were improved and discharged after the treatment, and the mean duration of RICU stay was 13.5 (11, 16.7) days. One month follow-up of nine patients showed significant improvement in lung lesions. Conclusions: Severe Chlamydia psittiaci pneumonia may be complicated with respiratory failure and/or multiple organ involvement. For severe pneumonia with an exposure history of sick birds, the possibility of Chlamydia psittaci infection should be considered. mNGS may help etiological diagnosis. All patients in this study had a good prognosis after targeted treatment.

Design of a Novel Trabecular Acetabular Cup and Selective Laser Melting Fabrication

The acetabular cups used in total hip arthroplasty are mostly made of dense metal materials with an elastic moduli much higher than that of human bone. This leads to stress shielding after implantation, which may cause aseptic loosening of the implant. Selective laser melting (SLM) technology allows us to produce tiny and complex porous structures and to reduce the elastic moduli of dense metals, thereby avoiding stress shielding. In the present study, rhombic dodecahedron porous structures with cell sizes of 1 mm, 1.5 mm, and 2 mm were designed. The strut diameter was changed to ensure that the porosity and pore size would meet the bone ingrowth requirements. Then, porous Ti6Al4V alloy specimens were printed using SLM, and compressive tests were carried out. The results showed that the compressive strength and elastic modulus values of the specimens with a cell size of 1.5 mm were in the range of 78.16-242.94 MPa and 1.74-4.17 GPa, respectively, which are in line with the mechanical properties of human cortical bone. Finite element analysis of a total hip joint model was carried out to simulate gait, and the surface of the trabecular acetabular cup was divided into 10 regions according to the stress distribution, with the stress interval in the range of 37.44-219.24 MPa. According to the compression test results, the gradient structure of Ti6Al4V alloy with different porosity was designed for trabecular coating. The gradient porous structure meets the mechanical requirements and is closer to the natural structure of human bone than the uniformly distributed porous structure.

Vented Individual Patient (VIP) Hoods for the Control of Infectious Airborne Diseases in Healthcare Facilities

By providing a means of separating the airborne emissions of patients from the air breathed by healthcare workers (HCWs), vented individual patient (VIP) hoods, a form of local exhaust ventilation (LEV), offer a new approach to reduce hospital-acquired infection (HAI). Results from recent studies have demonstrated that, for typical patient-emitted aerosols, VIP hoods provide protection at least equivalent to that of an N95 mask. Unlike a mask, hood performance can be easily monitored and HCWs can be alerted to failure by alarms. The appropriate use of these relatively simple devices could both reduce the reliance on personal protective equipment (PPE) for infection control and provide a low-cost and energy-efficient form of protection for hospitals and clinics. Although the development and deployment of VIP hoods has been accelerated by the coronavirus disease 2019 (COVID-19) pandemic, these devices are currently an immature technology. In this review, we describe the state of the art of VIP hoods and identify aspects in need of further development, both in terms of device design and the protocols associated with their use. The broader concept of individual patient hoods has the potential to be expanded beyond ventilation to the provision of clean conditions for individual patients and personalized control over other environmental factors such as temperature and humidity.

[Novel MFN2, BSCL2 and LRSAM1 variants in a cohort of Chinese patients with Charcot-Marie-Tooth disease]

Objective: Charcot-Marie-Tooth disease (CMT) comprises a group of clinically and genetically heterogeneous inherited neuropathies with an estimated prevalence of 1 in 2500. This study aimed to analyze the clinical and mutational characteristics of Chinese CMT patients with MFN2, BSCL2 and LRSAM1 variants. Methods: In this study, genetic analysis was performed in 206 Chinese patients at Chinese PLA General Hospital from December 2012 to March 2020 with clinical diagnosis of CMT, and reported variants of MFN2, BSCL2 and LRSAM1 related to CMT2. Results: We reported ten MFN2 mutations in ten unrelated patients (7 male, 3 female), two of whom had positive family history. Three novel mutations were detected including c.475-2A>G (splicing); c.687dupA (p.E230Rfs*16) and c.558dupT (p.S186fs). We reported three BSCL2 mutations of four unrelated patients, including c.461C>G (p.S154W), c.461C>T(p.S154L), and novel variants of c.1309G>C (p.A437P) and c.845C>T (p.A282V). Furthermore, two novel variants of LRSAM1, including c.1930G>T (p.G644C) and c.1178T>A (p.L393Q) were detected in two unrelated patients. Conclusion: Mutational spectrum of MFN2-, BSCL2-and LRSAM1-related CMT disease is expanded with the identification of novel variants in Chinese patients.

[Analysis of China's influenza vaccine application policy based on the macro model of the health system]

This article uses the analysis framework of the macro model of the health system to analyze the influenza vaccine policy documents issued by the state and governments at all levels from three perspectives: structure, process and results, and provides a scientific basis for improving the application strategy of influenza vaccine. It is suggested that on the basis of continuing to strengthen publicity, mobilization and organizational guarantee, measures to promote the application of influenza vaccine in China by exploring multi-channel financing mechanisms, combining the experience of new crown vaccination to improve the convenience of influenza vaccination, and scientifically setting vaccination rate targets, improve preparedness for an influenza pandemic.

[Weaning of veno-venous extracorporeal membrane oxygenation: when to use the "resting lung"]

Differences in weaning strategies for veno-venous extracorporeal membrane oxygenation (VV-ECMO) are based on expert opinions rather than clinical evidence. Therefore, each center has its own "unique skills". The timing of VV-ECMO weaning has not received due attention. It is difficult to find research on the choice of VV-ECMO weaning timing in the database. There are few studies involving VV-ECMO that describe the weaning process in detail. At present, the weaning process of VV-ECMO is mainly based on expert opinions. This article classified the current VV-ECMO weaning strategies, appealed to a unified VV-ECMO weaning protocol in China as soon as possible, and further improved the prognosis of patients with extracorporeal life support.

[Treatment choices for infected pancreatic necrosis:surgery debridement or endoscopy drainage?]

Infected pancreatic necrosis (IPN) is a crucial reason for the poor prognosis of patients with acute pancreatitis,which is complicated and difficult to predict the outcomes. Surgery is an important way to cure IPN,and "step-up approach" is the mainstream mode of IPN treatment. In the era of minimally invasive surgery,the full course endoscopic treatment of IPN has been gradually hot and achieved good outcomes as endoscopic technology' improvement. However,it is controversial that whether technique is better for IPN by surgery debridement or endoscopy drainage,and there is no consensus on the scope of applicability and the timing of intervention. The paper aims to explore the intervention methods,indications and timing of endoscopic and surgical treatment of IPN and elaborate the selection strategies of them in clinical practice,so as to develop individualized treatment options,accurately implement minimally invasive intervention and improve the prognosis.

[SWOT analysis of influenza vaccination promotion of primary care staff based on the perspective of the supplier, customer, and management]

Objective: To analyze the situation of influenza vaccination among primary healthcare workers, find out the problems, and explore the strategies and measures to promote influenza vaccination among grass-roots medical staff. Methods: From April to May 2021, key insider interviews and literature research were carried out based on the perspectives of influenza vaccine suppliers (influenza vaccine manufacturers), consumers (primary medical institutions and primary healthcare workers), and managers (governments at all levels, health administrative departments and disease prevention and control departments). The SWOT (strengths, weaknesses, opportunities, and threats) analysis technique was used to comprehensively evaluate the current situation of influenza vaccination among grass-roots healthcare workers, and a SWOT analysis matrix was established. Results: Influenza vaccination of grass-roots healthcare workers have advantages and opportunities, including primary medical and health institutions' vital influenza vaccination accessibility, influenza vaccine safety is higher, COVID-19 outbreak improves the public awareness of respiratory infectious diseases and vaccine production enthusiasm, coronavirus vaccination has strengthened the capacity of the vaccine distribution system. There are also disadvantages and threats such as the high price of influenza vaccine, insufficient supply, low awareness of influenza vaccine vaccination among grass-roots healthcare workers, lack of demand assessment mechanism on influenza vaccine, poor vaccine deployment, structural imbalance in vaccine supply in different areas, and severe vaccine waste. SWOT analysis matrix of the influenza vaccination status of grass-roots healthcare workers was established, forming dominant opportunity (SO) strategy, dominant threat (ST) strategy, inferior opportunity (WO) strategy, and inferior threat (WT) strategy. Conclusion: Measures should be taken by the supplier, the demand-side, and the management side to improve the influenza vaccine coverage rate of primary healthcare workers, but the emphasis should be on the coordination and management of the management side.

Single-Atom Tailored Hierarchical Transition Metal Oxide Nanocages for Efficient Lithium Storage

Mitigating the mechanical degradation and enhancing the ionic/electronic conductivity are critical but challengeable issues toward improving electrochemical performance of conversion-type anodes in rechargeable batteries. Herein, these challenges are addressed by constructing interconnected 3D hierarchically porous structure synergistic with Nb single atom modulation within a Co₃ O₄ nanocage (3DH-Co₃ O₄ @Nb). Such a hierarchical-structure nanocage affords several fantastic merits such as rapid ion migration and enough inner space for alleviating volume variation induced by intragrain stress and optimized stability of the solid-electrolyte interface. Particularly, experimental studies in combination with theoretical analysis verify that the introduction of Nb into the Co₃ O₄ lattice not only improves the electron conductivity, but also accelerates the surface/near-surface reactions defined as pesudocapacitance behavior. Dynamic behavior reveals that the ensemble design shows huge potential for fast and large lithium storage. These features endow 3DH-Co₃ O₄ @Nb with remarkable battery performance, delivering ≈740 mA h g^-1 after ultra-long cycling of 1000 times under a high current density of 5 A g^-1 . Importantly, the assembled 3DH-Co₃ O₄ @Nb//LiCoO₂ pouch cell also presents a long-lived cycle performance with only ≈0.059% capacity decay per cycle, inspiring the design of electrode materials from both the nanostructure and atomic level toward practical applications.

MiR-572 promotes the development of non-small cell lung cancer by targeting KLF2

OBJECTIVE

The aim of this study was to uncover the role of miR-572 in regulating proliferative and migratory abilities in non-small cell lung cancer (NSCLC) and the possible mechanism.

PATIENTS AND METHODS

Expression levels of miR-572 in 46 matched NSCLC and paracancerous samples were detected. The relationship between miR-572 level and clinical features of NSCLC was analyzed. Subsequently, the regulatory effects of miR-572 on proliferative and migratory abilities in lung cancer cells were assessed by functional experiments. Finally, the downstream genes of miR-572 were tested by luciferase assay, and their functions in the development of NSCLC were finally explored by rescue experiments.

RESULTS

It was found that miR-572 was upregulated in NSCLC samples. High level of miR-572 predicted high rates of lymphatic and distant metastases, as well as poor prognosis in NSCLC. Besides, the knockdown of miR-572 suppressed proliferative and migratory abilities in A549 and SPC-A1 cells. KLF2 was identified to be the downstream gene of miR-572, which was involved in the regulation of NSCLC phenotypes influenced by miR-572.

CONCLUSIONS

MiR-572 is closely linked to metastasis and prognosis in NSCLC patients, and it promotes the malignant development of NSCLC via targeting KLF2.

Experimental warming reduces ecosystem resistance and resilience to severe flooding in a wetland

Climate warming and extreme hydrological events are threatening the sustainability of wetlands across the globe. However, whether climate warming will amplify or diminish the impact of extreme flooding on wetland ecosystems is unknown. Here, we show that climate warming significantly reduced wetland resistance and resilience to a severe flooding event via a 6-year warming experiment. We first found that warming rapidly altered plant community structure by increasing the dominance of low-canopy species. Then, we showed that warming reduced the resistance and resilience of vegetation productivity to a 72-cm flooding event. Last, we detected slower postflooding carbon processes, such as gross ecosystem productivity, soil respiration, and soil methane emission, under the warming treatment. Our results demonstrate how severe flooding can destabilize wetland vegetation structure and ecosystem function under climate warming. These findings indicate an enhanced footprint of extreme hydrological events in wetland ecosystems in a warmer climate.

[Clinicopathological features of verrucous hemangioma]

Objective: To investigate the clinicopathological features, and differential diagnosis of verrucous hemangioma (VH). Methods: Twenty-eight VH cases diagnosed from 2005 to 2020 in Henan Provincial People's Hospital, Zhengzhou, China were analyzed retrospectively. Immunohistochemical studies were used to detect diagnostic markers. The mutation status of PIK3CA (exons 9 and 20) was detected using fluorescence PCR. Results: There were 13 males and 15 females in 28 cases, with the male to female ratio of 1.0∶1.2. There were 25 patients under the age of 18 years. The age range was from 10 months to 56 years (mean, 9.7 years; median, 4.5 years). There were 17 cases occurred in the lower extremities, 7 in the upper extremities and 4 in the trunk. All 28 cases were irregular red patches on the skin, which grew slowly. Some of them were thickened with uneven surface, which was light pink or red-white. Skin lesions of the 7 cases ranged from dark red and reddish brown, with a rough and hard surface. Satellite foci were present. Microscopically, 28 cases had a wide range of pathological features. Dilated, malformed vessels were observed from dermal papilla to deep soft tissue. Among them, the dermal papillary layer was mainly composed of many proliferating and expanding thin-walled capillaries and cavernous blood vessels. Thin-walled small vessels were found in the dermal reticular layer and subcutaneous fascia layer, with no obvious endothelial cell proliferation, occasional papillary hyperplasia, and lobular distribution of the malformed vessels in the fascia layer mixed with the fibroadipose tissue. There was epidermal papillary hyperplasia with hyperkeratosis and parakeratosis, lengthening and mutual fusion of epithelial horns. Immunohistochemistry showed that CD31, CD34, ERG and WT-1 were diffusely and strongly positive. The expression of GLUT-1 was present in superficial dermal vascular endothelial cells, but undetectable in the deep layer. The PIK3CA tests of 13 cases showed that no somatic mutations were found in exons 9 and 20. Twenty-five patients were followed up for 5 months to 10 years. Seven patients underwent multiple surgical resections and plastic surgeries due to the large size, and 8 patients had recurrence. Conclusions: VH is a rare congenital vascular malformation and more commonly occurs in infants and children. It tends to appear in limbs, especially lower limbs and distal limbs. Its morphology and immunophenotype are characteristic and should be distinguished from other vascular malformations and the resolution phase of infant hemangiomas. In about one third of the cases, postoperative recurrence may occur and long-term follow-up is often required.

Warming reshaped the microbial hierarchical interactions

Global warming may alter microbially mediated ecosystem functions through reshaping of microbial diversity and modified microbial interactions. Here, we examined the effects of 5-year experimental warming on different microbial hierarchical groups in a coastal nontidal soil ecosystem, including prokaryotes (i.e., bacteria and archaea), fungi, and Cercozoa, which is a widespread phylum of protists. Warming significantly altered the diversity and structure of prokaryotic and fungal communities in soil and additionally decreased the complexity of the prokaryotic network and fragmented the cercozoan network. By using the Inter-Domain Ecological Network approach, the cross-trophic interactions among prokaryotes, fungi, and Cercozoa were further investigated. Under warming, cercozoan-prokaryotic and fungal-prokaryotic bipartite networks were simplified, whereas the cercozoan-fungal network became slightly more complex. Despite simplification of the fungal-prokaryotic network, the strengthened synergistic interactions between saprotrophic fungi and certain prokaryotic groups, such as the Bacteroidetes, retained these phyla within the network under warming. In addition, the interactions within the fungal community were quite stable under warming conditions, which stabilized the interactions between fungi and prokaryotes or protists. Additionally, we found the microbial hierarchical interactions were affected by environmental stress (i.e., salinity and pH) and soil nutrients. Interestingly, the relevant microbial groups could respond to different soil properties under ambient conditions, whereas under warming these two groups tended to respond to similar soil properties, suggesting network hub species responded to certain environmental changes related to warming, and then transferred this response to their partners through trophic interactions. Finally, warming strengthened the network modules' negative association with soil organic matters through some fungal hub species, which might trigger soil carbon loss in this ecosystem. Our study provides new insights into the response and feedback of microbial hierarchical interactions under warming scenario.

Modified anterior midline approach to treat hyperextension bicondylar tibial plateau fractures: Surgical technique and clinical experience with 18 cases

BACKGROUND

We evaluated the modified anterior midline approach and its efficacy for hyperextension bicondylar tibial plateau (HEBTP) fractures.

METHODS

From 2015 to 2019, 18 patients with HEBTP fractures with just little posterior cortical displacement were treated using the modified anterior midline approach. The operative protocols are fully described in this article, and the following parameters: articular step-off height (ASH), posterior tibial slope angle (pTSA), and medial tibial plateau angle (mTPA) were measured perioperatively and at the final follow-up. We also recorded the Rasmussen score and range of motion (ROM) to assess knee joint function at the final follow-up.

RESULTS

No complications, such as percutaneous nerve damage, infection, skin necrosis, and internal fixation breakage or loosening occurred perioperatively. The mean time for bony union was 13.7 weeks, and the mean preoperative ASH of the anterior cortex was 4.49 mm; this was restored to its normal height after surgery. The mean preoperative pTSA and mTPA were - 5.89° and 81.69°, respectively, compared with 3.89° and 87.91°, respectively, postoperatively. Comparing the postoperative and final follow-up radiographs, there were no significant differences in ASH, pTSA, and mTPA (P < 0.05). The average Rasmussen score was 27.2 (range, 23-29) at the final follow-up. Excellent results were achieved in 14 (77.8%) patients and good in 4 (22.2%) patients. The mean ROM in flexion was 123.2° and 2.9° in extension at the final follow-up.

CONCLUSIONS

This study suggested that the modified anterior midline approach is a reasonable alternative for HEBTP fracture repair.

[Rethinking on the classification of infected pancreatic necrosis and its surgical intervention strategy]

Infected pancreatic necrosis is a complex disease which is difficult to deal with.Timely and effective removal of the infection is the core of surgical treatment.Accurate determination and location of the infected area as well as targeted drainage and debridement are the key to further enhance the overall cure rate of necrotizing pancreatitis.Combining the clinical practice and relevant literatures,the classification of infected pancreatic necrosis is tentatively proposed based on the site of infection and necrosis or treatment in this paper.Meanwhile, the diversified intervention methods in the new era and the issues that need attention in the concept of step-up approach are rediscussed, aiming at scientific planning of treatment strategies and targeted intervention methods to reduce patients' mortality and improve prognosis.