Potential low toxic alternative for Na-Cl cotransporter inhibition: A diuretic effect and mechanism study of Pyrrosia petiolosa

BACKGROUND

Hydrochlorothiazide, a diuretic commonly used for the treatment of hypertension, is often associated with serious metabolic side effects. Pyrrosia petiolosa (Christ) Ching is a traditional Chinese medicine that possesses diuretic properties, without any obvious side effects.

AIM

To evaluate the diuretic effect of P. petiolosa (Christ) Ching and to elucidate its underlying mechanism of action.

METHODS

Extracts obtained from different polar components of P. petiolosa (Christ) Ching were analyzed for toxicity in a Kunming mouse model. The diuretic effects of the extracts were compared to that of hydrochlorothiazide in rats. In addition, compound isolation procedures, cell assays of Na-Cl cotransporter inhibition and rat diuretic test of monomeric compounds were conducted to identify the active ingredients in the extract. Subsequently, homology modeling and molecular docking were performed to explain the reason behind the diuretic activity observed. Finally, LC-MS analysis was used to elucidate the underlying mechanism of action of P. petiolosa (Christ) Ching.

RESULTS

No toxicity was observed in mice administered P. petiolosa (Christ) Ching extracts. The ethyl acetate fraction showed the most significant diuretic effect. Similar results were obtained during the analysis for Na+ content in rat urine. Further separation of P. petiolosa (Christ) Ching components led to the isolation of methyl chlorogenate, 2',3'-dihydroxy propyl pentadecanoate, and β-carotene. Results from cell assays showed that the Na-Cl cotransporter inhibitory activity of methyl chlorogenate was greater than that of hydrochlorothiazide. This result was again confirmed by the diuresis tests of monomeric compounds in rats. The molecular simulations explain the stronger interactions between the methyl chlorogenate and Na-Cl cotransporter. Of the compounds determined using LC-MS analysis, 185 were identified to be mostly organic acids.

CONCLUSIONS

P. petiolosa possesses significant diuretic activities without any obvious toxicity, with least two possible mechanisms of action. Further study on this herb is warranted.

N6-methyladenosine modification of PLOD2 causes spermatocyte damage in rats with varicocele

BACKGROUND

In recent years, N6-methyladenosine (m6A) methylation modification of mRNA has been studied extensively. It has been reported that m6A determines mRNA fate and participates in many cellular functions and reactions, including oxidative stress. The PLOD2 gene encodes a protein that plays a key role in tissue remodeling and fibrotic processes.

METHODS

The m6A methylation and expression levels of PLOD2 were determined by m6A methylated RNA immunoprecipitation sequencing (MeRIP-seq) and MeRIP-quantitative polymerase chain reaction (qPCR) in the testes of varicocele rats compared with control. To determine whether IGF2BP2 had a targeted effect on the PLOD2 mRNA, RNA immunoprecipitation-qPCR (RIP-qPCR) and luciferase assays were performed. CRISPR/dCas13b-ALKBH5 could downregulate m6A methylation level of PLOD2, which plays an important role in PLOD2-mediated cell proliferation and apoptosis in GC-2 cells.

RESULTS

PLOD2 was frequently exhibited with high m6A methylation and expression level in the testes of varicocele rats compared with control. In addition, we found that IGF2BP2 binds to the m6A-modified 3' untranslated region (3'-UTR) of PLOD2 mRNA, thereby positively regulating its mRNA stability. Targeted specific demethylation of PLOD2 m6A by CRISPR/dCas13b-ALKBH5 system can significantly decrease the m6A and expression level of PLOD2. Furthermore, demethylation of PLOD2 mRNA dramatically promote GC-2 cell proliferation and inhibit cell apoptosis under oxidative stress.

CONCLUSION

As a result, we found that varicocele-induced oxidative stress promoted PLOD2 expression level via m6A methylation modification. In addition, targeting m6A demethylation of PLOD2 by CRISPR/dCas13b-ALKBH5 system can regulate GC-2 cell proliferation and apoptosis under oxidative stress. Taken together, our study has acquired a better understanding of the mechanisms underlying male infertility associated with oxidative stress, as well as a novel therapeutic target for male infertility.

[Therapeutic mechanism of Shenbing Decoction Ⅲ for renal fibrosis in chronic kidney disease: a study with network pharmacology, molecular docking and validation in rats]

OBJECTIVE

To observe the effect of Shenbing Decoction Ⅲ for improving renal function and pathology in rats with 5/6 nephrectomy and analyze its therapeutic mechanism for renal fibrosis in chronic kidney disease using network pharmacology combined with molecular docking.

METHODS

Forty male SD rats were randomized into two groups to receive two-staged 5/6 nephrectomy (n=30) or sham operation (n=10), and 2 weeks after the final operation, serum creatinine level of the rats was measured. The rats with nephrectomy were further randomized into Shenbing Decoction Ⅲ group, losartan group and model group for daily treatment with the corresponding drugs via gavage starting at 1 week after 5/6 nephrectomy. After 16 weeks of treatment, serum creatinine and urea nitrogen levels of the rats were measured, and HE staining and Western blotting were used to examine the changes in renal pathology and fibrosis-related factors. Network pharmacology combined with molecular docking study was performed to explore the therapeutic mechanism Shenbing Decoction Ⅲ against renal fibrosis in chronic kidney disease, and Western blotting was used to verify the expressions of the core targets.

RESULTS

Compared with those in the model group, the rats receiving 5/6 nephrectomy and Shenbing Decoction Ⅲ treatment showed significantly reduced serum creatinine and urea nitrogen levels, lessened renal pathologies, and improvement of the changes in epithelial mesenchymal transition-related proteins. Network pharmacological analysis showed that the main active ingredients of Shenbing Decoction Ⅲ were acacetin, apigenin, eupatilin, quercetin, kaempferol and luteolin, and the key targets included STAT3, SRC, CTNNB1, PIK3R1 and AKT1. Molecular docking study revealed that the active ingredients of Shenbing Decoction Ⅲ had good binding activity to the key targets. Western blotting showed that in rats with 5/6 nephrectomy, treatment with Shenbing Decoction Ⅲ obviously restored the protein expression of STAT3, PI3K, and AKT in renal tissue.

CONCLUSION

Shenbing Decoction Ⅲ can reduce renal injury induced by 5/6 nephrectomy in rats, and its therapeutic effects are mediated possibly by its main pharmacologically active ingredients that alleviate renal fibrosis via modulating multiple targets including STAT3, PIK3R1, and AKT1.

[Analysis of the efficacy and safety of CT-guided radiofrequency ablation of posterior root of the spinal nerve in the treatment of postherpetic neuralgia]

Objective: To investigate the efficacy and safety of CT-guided radiofrequency ablation of posterior root of spinal nerve in the treatment of postherpetic neuralgia (PHN). Methods: A total of 102 PHN patients (42 males and 60 females) aged (69.7±9.4) years who underwent CT-guided radiofrequency ablation of posterior root of spinal nerve in the Department of Pain Medicine of the Affiliated Hospital of Jiaxing University from January 2017 to April 2020 were retrospectively included. Patients were followed up, and numerical rating scale (NRS) score, Pittsburgh sleep quality index (PSQI), satisfaction score and complications before surgery (T₀) and at 1 d (T₁), 3 months (T₂), 6 months (T₃), 9 months (T₄) and 12 months (T₅) after surgery were recorded. Results: The NRS score of PHN patients at T₀, T₁, T₂, T₃, T₄, and T₅ [M(Q₁, Q₃)] was 6(6, 7), 2(2, 3), 3(2, 4), 3(2, 4), 2(1, 4), 2(1, 4), respectively. Likewise, the PSQI score [M(Q₁, Q₃)] at aforementioned time points was 14(13, 16), 4(3, 6), 6(4, 8), 5(4, 6), 4(2, 8), 4(2, 9), respectively. Compared with T₀, the NRS and PSQI scores at all time points from T₁ to T₅ were lower, with statistically significant differences (all P<0.001). The overall effective rate of surgery at 1 year postoperatively was 71.6% (73/102) with a satisfaction score of 8(5, 9), and the recurrence rate was 14.7% (15/102) with a recurrence time of (7.5±0.8) months. The main postoperative complication was numbness, with an incidence of 86.0% (88/102), and the degree of numbness gradually decreased with time. Conclusion: CT-guided radiofrequency ablation of posterior root of spinal nerve for PHN has a high effective rate and a low recurrence rate, with high safety profile, and may be a feasible surgical option for the treatment of PHN.

[Efficacy of transcatheter pulmonary valve perforation in neonates with pulmonary atresia with intact ventricular septum]

Objective: To explore the efficacy and safety of transcatheter pulmonary valve perforation in the treatment of neonatal pulmonary atresia with intact ventricular septum (PA-IVS). Methods: The clinical data on surgical treatment and follow-up in 16 patients with PA-IVS who underwent transcatheter pulmonary valve perforation in Women and Children's Hospital, Qingdao University from October 2018 to October 2021 were analyzed retrospectively. The right ventricular systolic pressure and percutaneous oxygen saturation (SpO₂) were compared before and after operation. In addition, the SpO₂ and echocardiographic data at preoperative and the last follow-up were compared. Comparisons between groups were performed using paired-samples t test. Results: Among the 16 patients (10 males and 6 females) with the age at operation of 19 (14, 26) days, 12 cases underwent transcatheter pulmonary valve perforation successfully, 2 cases were transferred to surgery department for open-heart pulmonary valvulotomy, and the remaining 2 cases were transmitted to surgery department for transthoracic pulmonary valve perforation. The age at operation of the 12 patients who underwent transcatheter pulmonary valve perforation was 18 (14, 27) days, and the weight was (3.6±0.4) kg. The immediate postoperative right ventricular systolic pressure decreased significantly ((57±16) vs. (95±19) mmHg (1 mmHg=0.133 kPa), t=7.49, P<0.001), and the postoperative SpO₂ was improved effectively (0.90±0.48 vs.0.75±0.09, t=-5.61, P<0.001). The follow-up time was 22 (7, 33) months for 12 patients who underwent transcatheter pulmonary valve perforation successfully. At the last follow-up, the ratio of right to left ventricular transverse diameter was significantly higher than that before operative (0.55±0.05 vs. 0.45±0.05, t=-3.27,P=0.007). Furthermore, the Z-scores of pulmonary valvular diameter (-0.78±0.23 vs. -1.73±0.56, t=-8.52, P<0.001) and the tricuspid valvular diameter (-0.52±0.12 vs. -1.46±0.38, t=-10.40, P<0.001) were all significantly higher than preoperative data. At last, all the patients achieved biventricular circulation without death or major complications. Conclusion: Transcatheter pulmonary valve perforation is a safe and effective therapy for neonatal PA-IVS, and its curative effect has been confirmed by the medium follow-up data.

[Interim follow-up of fetal cardiac intervention in five fetuses with pulmonary atresia with intact ventricular septum]

Objective: To summarize the interim outcome and right heart development of pulmonary atresia with intact ventricular septum (PA-IVS) in children after fetal cardiac intervention (FCI). Methods: The clinical data of 5 live births underwent FCI from October 2018 to April 2019 in Women and Children's Hospital, Qingdao University were analyzed retrospectively. The development of right ventricle (RV) and tricuspid valve (TV) in uterus after FCI, at birth, the age of 6 months, 1 year and 2 years, and the final outcome were assessed. Results: Five PA-IVS fetuses were included in this study. The first evaluation was performed at 24-26 weeks of gestational age, and the FCI was performed at 26-28 weeks of gestational age. During the follow-up of 6 weeks after FCI, the minimum diameter of tricuspid annulus increased from 0.85 cm to 0.92 cm, and the minimum Z-score of tricuspid annulus decreased from -0.03 to -1.62. The minimum values of TV/mitral valve annular diameter and RV/left ventricular length ratios of all fetuses increased from 0.57, 0.52 to 0.88, 0.82, respectively. The maximum tricuspid regurgitation velocity decreased from 4.60 m/s to 3.64 m/s. No severe hemodynamic change was found in any of the fetuses. All 5 fetuses were born alive. Three cases underwent percutaneous balloon pulmonary valvuloplasty (PBPV) and stent implantation for ductus arteriosus. Two cases received PBPV alone. At follow-up (26 to 32 months), obvious development of TV was observed 6 months to 1 year after birth in 5 cases with the growth rate ranging from 19.64% to 40.00%. Meanwhile, the RV development was relatively slow at 6 months with the growth rate ranging from 9.41% to 21.42%. There were individual differences in RV development at 2 years. The growth and development of all children were equal to healthy children of the same age with the body mass index less than 18.4 kg/m². At the last follow-up, all children had a transcutaneous oxygen saturation of greater than 0.95, three became biventricular circulation and two had circulation approximation to biventricular circulation with almost closed stent. Conclusions: The findings support the potential of development of right ventricular and tricuspid valve for fetuses with PA-IVS underwent FCI. All fetuses underwent FCI received intervention after birth, and biventricular circulation can be realized finally. The development of right ventricular and tricuspid valve is not proportional. In utero, the right ventricle develops rapidly, and the development of tricuspid valve is more advantageous after birth.

Individualized Supplement of Folic Acid Based on the Gene Polymorphisms of MTHER/MTRR Reduced the Incidence of Adverse Pregnancy Outcomes and Newborn Defects

Background

The association between conventional folic acid supplement (FAS) in pregnancy and the occurrence of adverse pregnancy outcomes, newborn defects has been proven. However, recent researches have reported a weakened association. Based on the different maternal metabolism capability of folic acid, it's beneficial for clinicians to provide pregnant women with different doses of FAS, that's individualized FAS.

Subjects and Methods

A total of 2,677 pregnant women in Dazu, Chongqing, China were recruited in this cohort study. 1,539 women volunteered to receive individualized FAS, in which FAS dose increased with the risk level of maternal genotype? specify MTHFR and MTRR (write in full then abbreviate bracket open and close) while 1,138 women received conventional FAS with unified FAS dose. Additionally, 1,964 pregnant women without FAS were retrospectively analyzed as the control. Finally, the incidence of adverse pregnancy outcomes and newborn defects were recorded.

Results

Based on the genotype of MTHFR and MTRR, women were identified as five risk levels of folic acid metabolism. The distributions of genotype and risk levels were not significantly different between FAS-individualized supplement group and FAS-unified supplement group. However, compared with control or FAS-unified supplement group, the incidence of spontaneous abortion, prolonged pregnancy, premature labor, fetal macrosomia and congenital heart disease were significantly decreased in FAS-individualized supplement group. In subgroup analysis, individualized FAS significantly improved pregnancy outcomes for women between 20-40 years old and inhibited the occurrence of newborn defects in both women of the first gestation and women of ≥2 gestations.

Conclusions

The application of individualized FAS based on gene polymorphisms was more effective in preventing adverse outcomes in the mother and child.

Notoginsenoside R1 protects hypoxia-reoxygenation deprivation-induced injury by upregulation of miR-132 in H9c2 cells

BACKGROUND

Myocardial ischemia/reperfusion injury (IRI) is a common perioperative complication of heart and great vessels surgery, aggravating the original myocardial damage and seriously affecting the postoperative recovery of cardiac function. The aim of this study was to reveal the functional effects and potential mechanisms of notoginsenoside R1 (NG-R1) in myocardial cells injured by hypoxia-reoxygenation (H/R).

METHODS

The rat cardiomyocyte line H9c2 was subjected to H/R with or without NG-R1 treatment. The levels of miR-132 and HBEGF in the cell were altered by microRNA or short-hairpin RNA transfection. Cell viability, apoptosis, lactate dehydrogenase (LDH) and malondialdehyde (MDA) were monitored. Dual luciferin was used to detect the relationship between miR-132 and HBEGF.

RESULTS

NG-R1 (20 μM) had no impact on H9c2 cells, but cell viability was significantly reduced at 80 μM. NG-R1 (20 μM) protected H9c2 cells against H/R-induced cell damage, accompanied by increased cell viability, reduced cell apoptosis, and downregulation of LDH and MDA. Furthermore, the level of miR-132 was decreased in response to H/R exposure but then increased after NG-R1 treatment. When miR-132 was overexpressed, H/R-induced cell damage could be recovered. Downregulation of miR-132 limited the protective effect of NG-R1 on H/R damage. We also found that HBEGF was a direct target of miR-132. The expression of HBEGF was increased upon H/R damage, and this increase was reversed after NG-R1 treatment.

CONCLUSIONS

This study demonstrated that NG-R1 markedly protected H9c2 cells against H/R-induced damage via upregulation of miR-132 and downregulation of its target protein HBEGF.

Reactive-oxygen-species-scavenging nanomaterials for resolving inflammation

Reactive oxygen species (ROS) mediate multiple physiological functions; however, the over-accumulation of ROS causes premature aging and/or death and is associated with various inflammatory conditions. Nevertheless, there are limited clinical treatment options that are currently available. The good news is that owing to the considerable advances in nanoscience, multiple types of nanomaterials with unique ROS-scavenging abilities that influence the temporospatial dynamic behaviors of ROS in biological systems have been developed. This has led to the emergence of next-generation nanomaterial-controlled strategies aimed at ameliorating ROS-related inflammatory conditions. Accordingly, herein we reviewed recent progress in research on nanotherapy based on ROS scavenging. The underlying mechanisms of the employed nanomaterials are emphasized. Furthermore, important issues in developing cross-disciplinary nanomedicine-based strategies for ROS-based inflammatory conditions are discussed. Our review of this increasing interdisciplinary field will benefit ongoing studies and clinical applications of nanomedicine based on ROS scavenging.

ECT2 promotes proliferation and metastasis of esophageal squamous cell carcinoma via the RhoA-ERK signaling pathway

OBJECTIVE

In this study, the effect of epithelial cell transformation sequence 2 (ECT2) on the proliferation, invasion and migration of esophageal squamous cell carcinoma (ESCC) was investigated by interfering the expression of ECT2.

PATIENTS AND METHODS

Interfering with the expression level of ECT2 in human squamous cell carcinomas KYSE140 and EC9706 cell lines, the changes of KYSE140 and EC9706 cell proliferation, invasion, and migration were measured using the CCK-8 method, transwell test, and scratch test, respectively. The effects of ECT2 on the Ras homolog gene family, member A-extracellular regulated protein kinases (RhoA-ERK) signaling pathway were also observed.

RESULTS

Compared with the control group, the proliferation, migration, and invasion ability of EC9706 and KYSE140 cells after ECT2 knockout were significantly reduced (p <0.05). The knockdown of ECT2 expression in ESCC cell lines suppressed the activation of RhoA-ERK signaling pathway and protein expression of VEGF and MMP9.

CONCLUSIONS

ECT2 could regulated the expression of VEGF and MMP9 to inhibit cells proliferation, invasion, migration and tumor development through RhoA-ERK signaling pathway. Therefore, ECT2 could be an available marker, and provide a new theoretical basis for the treatment of ESCC.

Measurement of the Positive Muon Anomalous Magnetic Moment to 0.46 ppm

We present the first results of the Fermilab National Accelerator Laboratory (FNAL) Muon g-2 Experiment for the positive muon magnetic anomaly a_{μ}≡(g_{μ}-2)/2. The anomaly is determined from the precision measurements of two angular frequencies. Intensity variation of high-energy positrons from muon decays directly encodes the difference frequency ω_{a} between the spin-precession and cyclotron frequencies for polarized muons in a magnetic storage ring. The storage ring magnetic field is measured using nuclear magnetic resonance probes calibrated in terms of the equivalent proton spin precession frequency ω[over ˜]_{p}^{'} in a spherical water sample at 34.7 °C. The ratio ω_{a}/ω[over ˜]_{p}^{'}, together with known fundamental constants, determines a_{μ}(FNAL)=116 592 040(54)×10^{-11} (0.46 ppm). The result is 3.3 standard deviations greater than the standard model prediction and is in excellent agreement with the previous Brookhaven National Laboratory (BNL) E821 measurement. After combination with previous measurements of both μ^{+} and μ^{-}, the new experimental average of a_{μ}(Exp)=116 592 061(41)×10^{-11} (0.35 ppm) increases the tension between experiment and theory to 4.2 standard deviations.

[Fetal cardiac intervention and perioperative management of fetus with hypoplastic right heart syndrome]

Objective: To summarize the experience of perioperative management strategy of fetal pulmonary valvuloplasty (FPV) for hypoplastic right heart syndrome (HRHS). Methods: In the retrospective study of perioperative data, 13 fetuses of HRHS were treated with FPV in Qingdao Women and Children's Hospital from July 2018 to June 2019. Results: (1) The evaluation indexes of the right ventricle in 13 fetuses before FPV: the mean ratio of tricuspid/mitral annulus, right/left ventricular length, pulmonary/aortic annulus, and tricuspid inflow time/cardiac cycle were 0.81±0.04, 0.56±0.14, 0.69±0.06, and 0.35±0.03, respectively. (2) All pregnant mothers underwent general anesthesia. The basic fetal heart rate was (156±12) beats per minutes before FPV, and 9 fetuses showed bradycardia during the operation, and recovered to normal after drug resuscitation. On the first day after FPV, two cases had bradycardia and pregnancy was terminated. The fluctuation of systolic blood pressure of pregnant mother was less than 20%, and there was no significant difference between preoperative and intraoperative pulse pressure [(36.0±5.6) vs (35.8±6.9) mmHg (1 mmHg=0.133 kPa); t=8.102, P=0.951]. (3) All cases of HRHS fetus successfully underwent FPV. The average gestational age was (27.3±0.8) weeks. The average operation time was (23.2±1.0) minutes. The ratio of tricuspid to mitral annulus (t=-2.513, P=0.022) and the ratio of right to left ventricular length (t=-3.373, P=0.003) were significantly improved at 6 weeks postoperatively. Ten fetuses were delivered, and there was no death after early intervention. (4) Of 13 pregnant women, 3 cases were nausea and vomiting on the day of FPV operation, the treatment of the symptoms was improved by tropisetron; one case had tolerable abdominal pain and improved without special treatment. Pregnant women had no major complications such as cardiac failure, abortion and death. (5) Chromosome karyotype analysis and microarray analysis of amniotic fluid was retained during the operation. No typical chromosome abnormality or other abnormal genetic diagnosis was found. Conclusions: FPV colud be used as an effective intervention measure to promote the development of right ventricle in HRHS fetuses. The scientific management of multidisciplinary professional technical team in perioperative period is particularly important to ensure the success of FPV and the safety of pregnant women and fetuses.

Negative Correlation Between Serum Levels of Homocysteine and Apolipoprotein M

BACKGROUND

Homocysteine (Hcy) has been suggested as an independent risk factor for atherosclerosis. Apolipoprotein M (apoM) is a constituent of the HDL particles. The goal of this study was to examine the serum levels of homocysteine and apoM and to determine whether homocysteine influences apoM synthesis.

METHODS

Serum levels of apoM and Hcy in 17 hyperhomocysteinemia (HHcy) patients and 19 controls were measured and their correlations were analyzed. Different concentrations of homocysteine (Hcy) and LY294002, a specific phosphoinositide 3- kinase (PI3K) inhibitor, were used to treat HepG2 cells. The mRNA levels were determined by RT-PCR and the apoM protein mass was measured by western blot.

RESULTS

We found that decreased serum apoM levels corresponded with serum HDL levels in HHcy patients, while the serum apoM levels showed a statistically significant negative correlation with the serum Hcy levels. Moreover, apoM mRNA and protein levels were significantly decreased after the administration of Hcy in HepG2 cells, and this effect could be abolished by addition of LY294002.

CONCLUSIONS

Present study demonstrates that Hcy downregulates the expression of apoM by mechanisms involving the PI3K signal pathway.

0773 Why Did Pandemrix Trigger Narcolepsy? A Structural Approach

Introduction

The 2009 Pandemrix influenza A pH1N1 vaccine has been linked to an increased number of Narcolepsy type I onsets in children across Europe whereas administration of a very similar adjuvanted vaccine, Arepanrix, had little effects in Canada. One possible explanation for the difference may be vaccine composition differences that could modify peptide binding to narcolepsy associated HLA-DQ0602 allele, as viral extracts for these two vaccines used distinct processes in different factories. Other explanations may involve differences in vaccination timing in relation to the pandemic H1N1 infection wave, or other environmental factors. We have previously compared the amino acid sequence of the Hemagglutinin (HA) component of the Pandemrix and the 2010 Arepanrix vaccine, finding possible contributors, but excluding most of these after DQ0602-tetramer analysis of T cell reactivity in narcolepsy versus controls.

Methods

Mass spectrometric characterization of multiple additional batches of Pandemrix and Arepanrix used during 2009 influenza pandemic vaccination campaign was performed.

Results

In addition to confirming previously published results such as increased deamidation of hemagglutinin (HA) (146N&gt;D) in Pandemrix (p=2.1e-9), we identified novel differences, including a significant 2-fold post-translation deamidation increase in 277N in Arepanrix versus Pandemrix (p=0.032), together with increased 2-fold glycosylation in the 286-323 positions in Arepanrix (p=0.00036). The 277 N to D/isoD substitution is located in pocket 1 of the binding core of a strong binder NAGSGIIIS, (&lt; 10% rank) for HLA-DQ0602 allele and abolishes epitope binding. The increased glycosylation in Arepanrix occurs in the immediate flanking area of the same 277N epitope and could also reduce DQ0602 presentation of the same epitope through differential binding and/or proteolysis of HA in this region of the molecules. As CD4 T cells recognizing this epitope have been reported to be significantly increased in narcolepsy versus DQ0602 controls, with possible mimicry with homologous hypocretin sequence.

Conclusion

These changes could explain why Arepanrix was less narcolepsy inducing. Confirmatory studies, as well as studies of all novel changes observed, are ongoing, but this is a promising result.

Support

Wake Up Narcolepsy

Apolipoproteins, as the carrier proteins for lipids, are involved in the development of breast cancer

Apolipoproteins, the key components of lipoproteins, play vital roles in the combination and transportation of lipids. Numerous research articles have accumulated solid evidence that lipoproteins are closely related to various types of tumorigenesis. In this review, we focused on the associations between several apolipoproteins and breast carcinoma and distinguished the effects and significance of apolipoproteins in different locations to validate their roles in breast carcinoma development. For example, apoD and apoE in serum are viewed as risk factors for breast carcinoma. ApoD, apoE and apoA-I in mammary tissues inhibit tumor growth. Moreover, apoB, apoJ and apoA-I have the potential to function as diagnostic or prognostic markers in the clinic. ApoEdp and apoJ treatment on breast carcinoma could significantly restrict tumor growth. In general, the aim of this review was to further analyze the associations between some members of the apolipoprotein family and breast cancer.

[Application of arterial duct stent in ductus-dependent hypoplastic right heart syndrome]

Objective: To summarize the experience of arterial duct (AD) stenting in children with ductus-dependent hypoplastic right heart syndrome (HRHS). Methods: Seven children including 4 cases of pulmonary atresia with intact ventricular septum (PA-IVS) with HRHS and 3 cases of critical pulmonary stenosis (CPS)-IVS with HRHS underwent AD stenting in Qingdao Women and Children's Hospital between January 2012 and January 2019. During the same period, 9 patients of PA-IVS with HRHS received Blalock Taussig (B-T) shunt. Two groups of children on the operation time, hospital stay time, intensive care time and mortality were compared.T test or Mann-Whitney U test was used for comparison between the two groups. Results: There was no significant difference in the age (18 (7-100) vs. 17 (1-142) d, U=31.000, P>0.05) and weight ((3.8±1.1) vs. (3.7±1.3) kg, t=0.272, P>0.05) between the AD stenting group and the B-T group.The operation time ((108±7) vs. (160±49) min, t=-4.304), intensive care time ((3.4±1.0) vs. (6.3±4.5) d, t=-8.692) and total hospitalization time ((10.3±1.0) vs. (26.3±1.0) d, t=-7.822) in the AD stenting group were differed significantly compared with the B-T group (all P<0.05). The transcutaneous oxygen saturation improved significantly (0.723±0.125 vs. 0.926±0.005, t=-6.044, P<0.05) after AD stenting. The diameter of AD stent ranged from 3.5 to 4.0 mm, and the length of AD stent was 16-21 mm. There were no complications such as vascular injury, acute thrombus, catheter spasm and death in the AD stenting group. The mortality of children in the B-T group was 3 in 9 cases. Three cases in the AD stenting group received pulmonary valvulotomy and bilateral Glenn operation at 6, 9 and 9 months after AD stenting, respectively. Conclusions: AD stenting is a feasible, effective, safe and minimally invasive procedure for children with ductus-dependent HRHS. It can even be used as an alternative to B-T shunt.

Determination of Ephedrine Alkaloids in Botanicals and Dietary Supplements by HPLC-UV: Collaborative Study

An international collaborative study was conducted of a high-performance liquid chromatography (HPLC)-UV method for the determination of the major (ephedrine [EP] and pseudoephedrine [PS]) and minor (norephedrine [NE], norpseudoephedrine [NP], methylephedrine [ME], and methylpseudoephedrine [MP]) alkaloids in selected dietary supplements representative of the commercially available products. Ten collaborating laboratories determined the ephedrine-type alkaloid content in 8 blind replicate samples. Five products contained ephedra ground herb or ephedra extract. These 5 products included ground botanical raw material of Ephedra sinica, a common powdered extract of Ephedra sinica, a finished product containing only Ephedra sinica ground botanical raw material, a complex multicomponent dietary supplement containing Ma Huang, and a high-protein chocolate flavored drink mix containing Ma Huang extract. In addition, collaborating laboratories received a negative control and negative control spiked with ephedrine alkaloids at high and low levels for recovery studies. Test extracts were treated to solid-phase extraction using a strong-cation exchange column to help remove interferences. The HPLC analyses were performed on a polar-embedded phenyl column using UV detection at 210 nm. Repeatability relative standard deviations (RSD r) ranged from 0.64–3.0% for EP and 2.0–6.6% for PS, excluding the high protein drink mix. Reproducibility relative standard deviations (RSD R) ranged from 2.1–6.6% for EP and 9.0–11.4% for PS, excluding the high protein drink mix. Recoveries ranged from 84.7–87.2% for EP and 84.6–98.2% for PS. The data developed for the minor alkaloids are more variable with generally unsatisfactory HORRATS (i.e., &gt;2). However, since these alkaloids generally add little to the total alkaloid content of the products, the method gives satisfactory results in measuring total alkaloid content (RSD r 0.85–3.13%; RSDR 2.03–10.97%, HORRAT 0.69–3.23, exclusive of the results from the high protein drink). On the basis of these results, the method is recommended for Official First Action for determination of EP and PS in dietary supplements exclusive of the high protein drinks.

Determination of Ephedrine Alkaloids in Human Urine and Plasma by Liquid Chromatography/Tandem Mass Spectrometry: Collaborative Study

A collaborative study was conducted to evaluate the accuracy and precision of a method for ephedrine-type alkaloids (i.e., norephedrine, norpseudoephedrine, ephedrine, pseudoephedrine, methylephedrine, and methylpseudoephedrine) in human urine and plasma. The amount of ephedrine-type alkaloids present was determined using liquid chromatography (LC) with tandem mass selective detection. The test samples were diluted to reflect a concentration of 5.00–100 ng/mL for each alkaloid. An internal standard was added and the alkaloids were separated using a 5 μm phenyl LC column with an ammonium acetate, glacial acetic acid, acetonitrile, and water mobile phase. Eight blind duplicates of human urine and eight blind duplicates of human plasma were analyzed by 10 collaborators. In addition to negative controls, test portions of urine and plasma were fortified at 3 different levels with each of the 6 ephedrine-type alkaloids at approximately 1, 2, and 5 μg/mL for urine and 100, 200, and 500 ng/mL for plasma. On the basis of the accuracy and precision results for this collaborative study, it is recommended that this method be adopted Official First Action for the determination of 6 different ephedrine-type alkaloids in human urine and plasma.

Determination of Ephedrine Alkaloids in Dietary Supplements and Botanicals by Liquid Chromatography/Tandem Mass Spectrometry: Collaborative Study

An interlaboratory study was conducted to evaluate the accuracy and precision of a method for ephedrine-type alkaloids [i.e., norephedrine (NE), norpseudoephedrine (NPE), ephedrine (E), pseudoephedrine (PE), methylephedrine (ME), and methylpseudoephedrine (MPE)] in dietary supplements and botanicals. The amount of ephedrine-type alkaloids present was determined using liquid chromatography with tandem mass selective detection. The samples were diluted to reflect a concentration of 0.0200 to 1.00 μg/mL for each alkaloid. An internal standard was added and the alkaloids were separated using a 5 μm phenyl LC column with an ammonium acetate, glacial acetic acid, acetonitrile, and water mobile phase. Eight blind duplicates of dietary supplements or botanicals were analyzed by 10 collaborators. Included was a negative control, ephedra nevadensis, and negative controls fortified at 2 different levels with each of the 6 ephedrine-type alkaloids. The spike levels were approximately 100 and 1000 μg/g for NE, 100 and 600 μg/g for NPE, 6500 and 65 000 μg/g for E, 1000 and 10 000 μg/g for PE, 300 and 3000 μg/g for ME, and 100 and 1000 μg/g for MPE. On the basis of the accuracy and precision results for this interlaboratory study, it is recommended that this method be adopted Official First Action for the determination of 6 different individual ephedrine-type alkaloids in dietary supplements and botanicals.

[Mid-term outcomes of coronary artery bypass surgery with left radial artery bypassed to right main coronary artery of severe stenosis]

Objective: To evaluate the mid-term outcomes of coronary artery bypass grafting (CABG) with left radial artery (RA) graft bypassed to right main coronary artery (RCA) of severe stenosis. Methods: Between September 2014 and April 2019, a total of consecutive 47 patients who had severe stenosis (≥90%) of RCA underwent total arterial revascularization, with left RA bypassed to RCA. There were 31 males and 16 females, with a mean age of (56.5±9.7) years old. The perioperative outcomes were observed and mid-term results were followed up. Results: A total of 46 left internal mammary artery (LIMA) grafts, 47 left radial artery (LRA), and 40 right RA grafts (RRA) were harvested with pedicles. LIMA was bypassed to LAD in 43 patients, RRA was to diagonal branches, ramus or oblique marginal in 37 cases, and LRA was to RCA. All grafts (except 3 composite Y or T grafts) were single. Mean graft number was 2-4 (2.7±0.9). There was one death due to cardiac tamponade. Three patients had postoperative atrial fibrillation, 1 had a forearm hematoma, 1 had acute renal insufficiency, and 2 had acute myocardial infarction. The mean tracheal intubation duration was 3.5-20.3 (8.3±4.7) hours, and the mean hospital stay was 6-13 (7.1±2.9) days. The average follow-up was 3-47 (23.3±7.5) months, with a follow-up rate of 86.96% (40/46). There were no major cardiovascular events during the follow-up. Three month after surgery, the mean left ventricular ejection fraction was significantly improved than that of pre-operation (60.0%±4.0% vs 42.4%±7.5%, P=0.003). Computed tomography angiography (CTA) examination showed that 58.7% (27/46) of patients had patent LRA after a mean follow-up duration of (19.5±7.3) months. Conclusion: CABG with LRA bypassed to RCA of severe stenosis proves to be safe and effective, with good mid-term outcomes.

Melanoma-associated antigen A2 is overexpressed in glioma and associated with poor prognosis in glioma patients

Malignant glioma is the most common and aggressive primary brain tumor and the overall prognosis for glioma patients remains poor. Clarification of the molecular mechanism responsible for glioma progression is critical for the effective treatment of glioma. Melanoma antigen gene (MAGE)-A2 (MAGEA2) is a member of the MAGE-A family proteins widely studied for cancer vaccine development and identification of tumor markers. However, MAGEA2 clinical significance  and biological function in glioma remain unclear, especially for the prognosis of glioma patients. This study investigates MAGEA2 expression in glioma tissue samples and its significance in predicting glioma patient prognosis. MAGEA2 protein expression in tissue samples was measured by immunohistochemistry and western blotting, and MAGEA2 mRNA expression was determined by real-time polymerase chain reaction. Our results confirmed that MAGEA2 mRNA and protein expression levels were upregulated in glioma tissues, compared with normal brain tissue. The high expression of MAGEA2 in glioma tissues significantly correlated with World Health Organization advanced grade. Univariate and multivariate analyses revealed that high MAGEA2 expression is an independent prognostic factor for glioma patient poor overall survival. The P53 mRNA expression levels were downregulated in glioma tissues compared to noncancerous brain tissue and MAGEA2 expression negatively correlated with P53 expression. Taken together, our results suggest that MAGEA2 plays an oncogenic role in glioma progression, and they provide insight into MAGEA2 application as a novel predictor of clinical outcomes and a potential glioma biomarker.

[Operative treatment of delayed acetabular fractures through combined anterior and Kocher-Langenbeck approaches]

Objective: To discuss the clinical outcomes of treating delayed acetabular fractures by combined anterior and posterior approach. Methods: A retrospective analysis was conducted of 31 delayed acetabular fractures from February 2012 to February 2017 in the First Affiliated Hospital of Chongqing Medical University, including 18 males and 13 females with age of 48.5 years(23 to 67 years) .The injury to the operation time was 35.9 days(22 to 183 days). Of these 31 cases, there were 6 cases of transverse and posterior wall fracture, 8 cases with anterior column+ posterior half transverse fracture, 12 cases with double column fracture and 5 cases of "T" type fracture according to Letournel-Judet classification.All fractures were treated combined anterior and Kocher-Langenbeck approaches, including 13 cases of ilioinguinal approach+ Kocher-Langenbeck(K-L approach), 4 cases of extensile acetabular approach, 7 cases of stoppa approach + K-L approach and 7 cases of side rectus femoris approach.Correlation was analyzed by Pearson correlation regression testing. Results: Follow up to August 2017, all patients were followed up with 36.0 months(from 6 to 55 months). As calculated, the restorational effect was positively with result of the X-ray film and the clinical effect(r=0.823, 0.856; both P<0.05). The evaluation was conducted with Matta's reduction criteria: there were 11 cases classified as anatomic reduction(35.5%), 13 cases as satisfactory reduction(41.9%), and 7 cases as unsatisfactory reduction(22.6%). Excellent and good rate was 77.4%. Functional reductions were categorized by the standard of Matta hip score: 8 excellent cases(25.8%), 11 good cases(35.5%), 8 fail cases(25.8%), and 4 poor cases(12.9%). Conclusion: The treatment of delayed acetabular fracture by combined anterior and posterior approach can fully exposure the anterior and posterior acetabular fcloumns, which is beneficial to the release and fixation of the old acetabular fractures.

LncRNA gadd7, increased in varicocele patients, suppresses cell proliferation and promotes cell apoptosis

Varicocele-related sperm damages are usually caused by oxidative stresses. Growing evidence indicates that lncRNA growth arrested DNA-damage inducible gene 7 (gadd7) is involved in the regulation of the oxidative stress responses. In this study, we measured the expression level of gadd7 in the sperm and found that the expression of gadd7 was significantly up-regulated in patients with varicocele compared with the healthy control. The relative expression level of gadd7 was negatively correlated with the sperm count. Overexpression of gadd7 suppressed cell proliferation and promoted cell apoptosis in mouse spermatocyte-derived cell lines GC-1 and GC-2. Furthermore, the protein level of Bax was raised while Bcl2 expression was reduced after overexpression of gadd7. This work provides a potential novel insight for the varicocele-related sperm impairment and male infertility.

The metastasis status and tumor burden-associated CA125 level combined with the CD4/CD8 ratio predicts the prognosis of patients with advanced pancreatic cancer: A new scoring system

INTRODUCTION

Although CA125 and the tumor immune response have been reported to be associated with pancreatic cancer, their prognostic value for advanced pancreatic cancer patients undergoing chemotherapy remain uncertain. We thus studied the prognostic value of the combination of the CA125 level with the CD4/CD8 ratio.

METHODS

After excluding patients who were lost to follow-up or for whom complete clinical data were missing, 369 participants were ultimately examined. Univariate and multivariate analyses were performed using the Cox hazards model, and Kaplan-Meier methods and log-rank tests were used for the comparison of survival rates.

RESULTS

Univariate and multivariate analyses showed that a high CA125 level and a high CD4/CD8 ratio were independent prognostic factors (CA125 ≥ 35 U/ml, Hazard Ratio (HR) = 1.90, p < 0.001; CD4/CD8 ≥ 1.8, HR = 1.37, p = 0.004). Moreover, after combining the CA125 level and CD4/CD8 ratio to form a new scoring system, the HR was substantially elevated (CA125 ≥ 35 U/ml and CD4/CD8 ≥ 1.8, score 2, HR = 2.76, 95% confidence interval: 2.04 to 3.74, p < 0.001).

CONCLUSIONS

A new scoring system based on the combination of the CA125 level with the CD4/CD8 ratio could further predict the prognosis of patients with advanced pancreatic cancer.

[Expression of Oct4 and Sox2 and their clinical significance in tongue squamous cell carcinoma]

Objective: To investigate Oct4 and Sox2 protein expression in tongue squamous cell carcinoma (TSCC) and the relationships between the expressions of Oct4 and Sox2 and clinical pathological characteristics and survival of patients. Methods: The paraffin imbedded tissue specimens of 51 patients with histologically confirmed TSCC were included. Immunohistochemistry was employed to detect the protein expression of Oct4 and Sox2 in 51 TSCC tissue samples. The protein expression levels of Oct4 and Sox2 and their relationships with both clinicopathological features and survival of patients with TSCC were evaluated. Results: In 51 TSCC cases,positive expressions of Oct4 and Sox2 were mainly located in the nucleus of tumor cells. The expression of Oct4 was strongly positive in 27 cases (53%), weakly positive in 16 (31%) and negative in 8 (16%), whereas that of Sox2 was strongly positive in 25 cases (49%), weakly positive in 22 (43%) and negative in 4 (8%). Oct4 and Sox2 expression levels were significantly correlated with the histological grade of TSCC (P=0.004, P=0.006, respectively), not correlated with age, gender, T stage, tobacco smoking and alcohol consumption status (P>0.05), but Oct4 expression level was significantly associated with lymph node metastasis (P=0.001). Sox2 expression level was not associated with lymph node metastasis (P>0.05). The expression of Sox2 was significantly correlated with Oct4 (P<0.001). Oct4 and Sox2 expression was associated with poor overall survival of patients with TSCC (P=0.001, P=0.002, respectively), cases with higher Oct4 and Sox2 expression had the poorest overall survival (P<0.001). Sox2 expression and lymph node metastasis were independent prognostic factors of overall survival in patients with TSCC (P=0.02, P=0.001, respectively). Conclusions: Sox2 had independent prognostic effects on overall survival, suggesting that Sox2 expression may be an usefull indicator for predicting the prognosis of patients with TSCC.

Tanshinone IIA ameliorates chronic arthritis in mice by modulating neutrophil activities

Rheumatoid arthritis (RA) is a chronic immune inflammatory disease mediated by the influx of immune cells into the synovial joint space. As Tanshinone IIA (TIIA) has potent anti-oxidant and anti-inflammatory activities, we used the adjuvant-induced arthritis (AA) murine model of RA to investigate the impact of TIIA on RA and immune cell activation. The anti-arthritic activity of TIIA was investigated in an adjuvant-induced arthritis model of RA in mice. Myeloperoxidase and neutrophil elastase expression levels were assessed in ankle joints by immunohistochemistry analysis. Immune cell infiltration was evaluated in air pouch experiments. Proinflammatory cytokines expression levels were determined by quantitative real-time polymerase chain reaction (PCR) and enzyme-linked immunosorbent assays. Neutrophil extracellular traps (NETs) were assessed by immunostaining and confocal microscopy. Treatment with TIIA alleviated cartilage erosion and neutrophil infiltration in the ankle joints of AA mice and reduced proinflammatory cytokine expression levels in sera. TIIA suppressed interleukin-6 and tumour necrosis factor-α expression and release in neutrophils and promoted neutrophil apoptosis. TIIA also inhibited the NET formation of neutrophils. Our findings demonstrated that TIIA can ameliorate RA effectively by targeting neutrophils, indicating that TIIA may act as a potential therapeutic for RA.

[The adhesion separation operation with CO₂ laser combined withtriamcinolone acetonide vocal cord submucosal injection for the treatment to vocal cord adhesion]

Objective:To investigate the effect of adhesion separation operation with CO₂ laser via prop-up laryngoscope combine with triamcinolone acetonide submucosal injection via electrolaryngoscope to vocal cords adhesion.Method:Sixteen cases of vocal cord adhesion patients(2 cases of children,14 cases of adult) were enrolled in the study. Fourteen patients had the history of surgery(Reinke edema,vocal polyp,pediatric laryngeal papilloma,laryngeal cancer),2 cases were diagnosed as laryngeal tuberculosis. Adhesion separation operation and triamcinolone acetonide submucosal injection(once a week,three weeks) were conducted. All patients were examined with electronic laryngoscope every month for six monthes.Result:Fourteen patients had good triangle shape of glottis vocalis and good sound voice. One cases of laryngeal cancer and 1 cases of laryngeal tuberculosis patients still had adhesion in the anterior commissure of the vocal cords,but with the improvement in breathing and pronunciation.Conclusion:Adhesion separation operation with CO₂ laser via prop-up laryngoscope combine with triamcinolone acetonide submucosal injection via electrolaryngoscope were effective for treatment to vocal cord adhesion,whichimprove the patient's breathing and voice with little trauma and few complications.

Uncovering the spatial heterogeneity of Ediacaran carbon cycling

Records of the Ediacaran carbon cycle (635-541 million years ago) include the Shuram excursion (SE), the largest negative carbonate carbon isotope excursion in Earth history (down to -12‰). The nature of this excursion remains enigmatic given the difficulties of interpreting a perceived extreme global decrease in the δ¹³ C of seawater dissolved inorganic carbon. Here, we present carbonate and organic carbon isotope (δ¹³ C_carb and δ¹³ C_org ) records from the Ediacaran Doushantuo Formation along a proximal-to-distal transect across the Yangtze Platform of South China as a test of the spatial variation of the SE. Contrary to expectations, our results show that the magnitude and morphology of this excursion and its relationship with coexisting δ¹³ C_org are highly heterogeneous across the platform. Integrated geochemical, mineralogical, petrographic, and stratigraphic evidence indicates that the SE is a primary marine signature. Data compilations demonstrate that the SE was also accompanied globally by parallel negative shifts of δ³⁴ S of carbonate-associated sulfate (CAS) and increased ⁸⁷ Sr/⁸⁶ Sr ratio and coastal CAS concentration, suggesting elevated continental weathering and coastal marine sulfate concentration during the SE. In light of these observations, we propose a heterogeneous oxidation model to explain the high spatial heterogeneity of the SE and coexisting δ¹³ C_org records of the Doushantuo, with likely relevance to the SE in other regions. In this model, we infer continued marine redox stratification through the SE but with increased availability of oxidants (e.g., O₂ and sulfate) limited to marginal near-surface marine environments. Oxidation of limited spatiotemporal extent provides a mechanism to drive heterogeneous oxidation of subsurface reduced carbon mostly in shelf areas. Regardless of the mechanism driving the SE, future models must consider the evidence for spatial heterogeneity in δ¹³ C presented in this study.

[The specificity and limitations of sacroiliac joint magnetic resonance imaging in the diagnosis of axial spondyloarthritis in patients with chronic low back pain]

Objective: To evaluate the specificity and limitations of sacroiliac joint magnetic resonance imaging (MRI) in the diagnosis of axial spondyloarthritis (SpA)in patients with chronic low back pain. Methods: We retrospectively analyzed clinical data of 390 patients with chronic low back pain in Department of Rheumatology, the PLA General Hospital from January 2013 to December 2015, including clinical manifestations, laboratory examinations and MRI data of sacroiliac joints. Results: There were 238 men and 152 women recruited. A total of 326 cases were diagnosed as axial SpA, including 216 men and 110 women with mean age (27.10±8.64) years and mean duration (7.64±3.50) months. Among these 326 patients, 243 (74.5%) were HLA-B₂₇ positive. The other 64 patients were considered as diagnoses rather than SpA (non-SpA), consisting of 22 men and 42 women with mean age (31.29±7.76) years and mean duration (5.75±2.90)months. Non-SpA group had 10 (15.6%) patients with HLA-B₂₇ positive. There were 68.1% and 65.0% SpA patients showing bone marrow edema and bone erosion of sacroiliac joint in MRI imaging respectively. Although there were 25.0% non-SpA patients with bone marrow edema and 7.8% with bone erosion in MRI of sacroiliac joint, the scores of bone marrow edema 0.00(0.00, 0.75) and bone erosion [0.00(0.00, 0.00)] were significantly lower compared with those in axial SpA group [bone marrow edema scores 2.00(0.00, 4.00), bone erosion scores 1.00(0.00, 3.00); P<0.05]. The scores of fat infiltration [1.00(0.00, 4.25), 1.00(0.00, 4.00)] and bone sclerosis [0.00(0.00, 1.00), 0.00(0.00, 1.75)] were not statistically different between two groups. Diagnostic sensitivity of bone marrow edema and bone erosion for axial SpA were 56.4% and 64.1% respectively, specificity were 93.8% and 92.2% respectively. The positive predictive value of bone marrow edema and bone erosion for axial SpA were 9.09 and 8.21, negative predictive value were 0.46 and 0.38.Diagnositic sensitivity of fatty infiltration and bone sclerosis for axial SpA group were 29.1% and 57.7%, specificity were 64.1% and 46.9%.The positive predictive value of fatty infiltration and bone sclerosis for axial SpA were 0.81 and 1.08, negative predictive value were 1.10 and 0.90. Conclusion: Sacroiliac joint MRI is a valuable method to diagnose axial SpA in patients with chronic low back pain. Yet it still has some limitations. Clinical presentations and spinal MRI would be helpful in some patients.