Intelligently Quantifying the Entire Irregular Dental Structure

Quantitative analysis of irregular anatomical structures is crucial in oral medicine, but clinicians often typically measure only several representative indicators within the structure as references. Deep learning semantic segmentation offers the potential for entire quantitative analysis. However, challenges persist, including segmentation difficulties due to unclear boundaries and acquiring measurement landmarks for clinical needs in entire quantitative analysis. Taking the palatal alveolar bone as an example, we proposed an artificial intelligence measurement tool for the entire quantitative analysis of irregular dental structures. To expand the applicability, we have included lightweight networks with fewer parameters and lower computational demands. Our approach finally used the lightweight model LU-Net, addressing segmentation challenges caused by unclear boundaries through a compensation module. Additional enamel segmentation was conducted to establish a measurement coordinate system. Ultimately, we presented the entire quantitative information within the structure in a manner that meets clinical needs. The tool achieved excellent segmentation results, manifested by high Dice coefficients (0.934 and 0.949), intersection over union (0.888 and 0.907), and area under the curve (0.943 and 0.949) for palatal alveolar bone and enamel in the test set. In subsequent measurements, the tool visualizes the quantitative information within the target structure by scatter plots. When comparing the measurements against representative indicators, the tool's measurement results show no statistically significant difference from the ground truth, with small mean absolute error, root mean squared error, and errors interval. Bland-Altman plots and intraclass correlation coefficients indicate the satisfactory agreement compared with manual measurements. We proposed a novel intelligent approach to address the entire quantitative analysis of irregular image structures in the clinical setting. This contributes to enabling clinicians to swiftly and comprehensively grasp structural features, facilitating the design of more personalized treatment plans for different patients, enhancing clinical efficiency and treatment success rates in turn.

Molecular characteristics and multivariate survival analysis of 43 patients with locally advanced or metastatic esophageal squamous cell carcinoma

Background

Esophageal cancer (EC) is an aggressive malignant tumor with poor prognosis and high incidence. It is the sixth leading cause of cancer-related death in the world, and the 5-year overall survival (OS) rate is only 12-20%. The rapid development of next-generation sequencing (NGS) has provided powerful help for the treatment and management of EC patients.

Methods

Tumor tissue and blood samples of 43 Chinese patients with nonsurgical esophageal squamous cell carcinoma (ESCC) were sequenced using a 425 gene-panel. Genomic profiling was explored and and the Cox proportional hazards model was used to analyze the correlations between gene or signaling pathway alterations and prognosis.

Results

In this study, the most common mutated genes were TP53 (90.5%), CCND1 (45.2%), FGF19 (38.1%), NOTCH1 (26.2%), PI3KCA (21.4%) and CDKN2A (19%). Among these mutations, PI3KCA and NOTCH1 showed mutual exclusion to some extent. In the univariate model, mutations in NOTCH1, CBLB and TSC2 genes and tumor mutation burden (TMB) ≥7 were independent biomarkers of OS. NOTCH1 (P=0.007, HR =2.87), CBLB (P=0.011, HR =4.68) and TSC2 (P=0.024, HR =3.7) were significantly associated with poorer OS, and patients with TMB ≥7 had longer OS (P=0.151, HR =0.31). In addition, patients who carried alteration in NOTCH signaling pathway had reduced OS (P=0.014, HR =2.54).

Conclusions

NOTCH1, CBLB and TSC2 alterations were found to be potential indicators of poor prognosis in patients with ESCC. TMB was also positively correlated with the OS of ESCC patients, providing valuable insights for their treatment strategies.

Novel Ag-modified vanadate nanosheets for determination of small organic molecules with laser desorption ionization mass spectrometry

Laser desorption ionization mass spectrometry (LDI-MS) aroused intensive concerns for the merits of label-free and high-throughput analysis. Here, we designed a silver nanoparticles (AgNP)-modified indium vanadate nanosheets with doping samarium (AgNP@InVO4:Sm) nanosheets. The developed AgNP@InVO4:Sm nanosheets (AIVON) were synthesized based on the microemulsion-mediated solvothermal method and ultraviolet-assisted in situ formation of AgNP, then for the first time applied as a matrix in LDI-MS analysis. With the advantages including enhanced MS signal, little matrix-related background, high reproducibility, and good salt tolerance, AIVON exhibited much better prospect than non-modified indium vanadate nanosheets with doping samarium (IVON) and traditional organic matrix, thus allowing sensitive MS detection for a wide range of low-molecular-weight (LMW) molecules. Moreover, by coupling with headspace sampling thin-film microextraction (TFME), a kind of representative pollutant chlorophenols were identified and quantified via AIVON-assisted LDI-MS in environmental and biological samples. Volatile LMW pollutants could be preconcentrated after TFME, hence a sensitive and rapid assay with negligible sample matrix effect was realized by using AIVON-assisted LDI-MS. It is anticipated that this novel nano-matrix AIVON and the proposed TFME coupling detection strategy were of competitive merits for LDI-MS analysis in the fields of environment, biomedicine, and agriculture.

Therapeutic targets for endometriosis: Genome-wide Mendelian randomization and colocalization analyses

BACKGROUND

Endometriosis (EM) greatly affects women's reproductive health, identifying new drug targets for EM is urgently needed. This study utilizes comprehensive genome-wide Mendelian randomization (MR) and colocalization analyses, using genomic data, to identify potential therapeutic approaches for EM.

METHODS

Genome-wide cis-expression quantitative trait loci (cis-eQTL) data were obtained from GTEx V8, which included 838 participants across 49 tissues or cells, and the eQTLGen consortium, which included 31,684 participants. Genome-wide association analysis (GWAS) data for EM were sourced from the FinnGen study, which consisted of 8,288 cases and 68,969 controls, as well as the UK Biobank study, which included 1,496 cases and 359,698 controls. This study utilized MR analysis to assess the correlation between genes and the risk of EM. Subsequently, colocalization analysis was conducted to investigate potential shared causal variants between the identified genes and EM.

RESULTS

After conducting MR and colocalization analyses, we identified a total of 13 genes that showed significant evidence of colocalization. These genes are considered promising therapeutic candidates for treating EM. Among them, inner membrane mitochondrial protein (IMMT), src kinase associated phosphoprotein 1 (SKAP1), lysine methyltransferase 5A (KMT5A), KLF transcription factor 12 (KLF12), GRB10 interacting GYF protein 1 (GIGYF1), Wnt family member 7A (WNT7A), Sad1 and UNC84 domain containing 1 (SUN1), and poly (ADP-ribose) polymerase family member 3 (PARP3) were found to have positive associations with the risk of EM. On the other hand, progestin and adipoQ receptor family member 8 (PAQR8), adaptor related protein complex 3 subunit mu 1 (AP3M1), surfeit 6 (SURF6), TUB bipartite transcription factor (TUB), and DNA polymerase delta interacting protein 2 (POLDIP2) were found to have inverse relationships with the risk of EM.

CONCLUSIONS

Through genome-wide MR studies, a comprehensive set of genes associated with EM has been identified. Among them, IMMT, PAQR8, SKAP1, KMT5A, AP3M1, SURF6, KLF12, GIGYF1, TUB, WNT7A, SUN1, POLDIP2, and PARP3 show potential as therapeutic targets for EM treatment. Nonetheless, it is crucial to conduct further rigorous investigations to validate these prospects.

The causal relationship of female infertility and psychiatric disorders in the European population: a bidirectional two-sample Mendelian randomization study

BACKGROUND

Infertility affects many couples globally, causing physical, emotional, and financial burdens. While observational studies suggest a link between psychiatric disorders and female infertility, causal relationships remain uncertain. Mendelian randomization analysis, using genome-wide association studies data, minimizes confounding factors and reverse causation, providing valuable insights into causal associations.

METHODS

We conducted Mendelian randomization analysis to explore the potential causal relationship between female infertility and psychiatric disorders. Genome-wide association studies summary data for female infertility (112,105 individuals of European ancestry, comprising 11,442 cases and 100,663 controls), depression (807,553 individuals of European ancestry, comprising 246,363 cases and 561,190 controls), anxiety (21,763 individuals of European ancestry, comprising 7,016 cases and 14,745 controls), bipolar disorder (51,710 individuals of European ancestry, comprising 20,352 cases and 31,358 controls), and eating disorders (72,517 individuals of European ancestry, comprising 16,992 cases and 55,525 controls) were utilized. Instrumental variables were selected based on significant single nucleotide polymorphisms associated with each phenotype. We assessed instrumental variable strength, examined confounding factors, and employed inverse variance weighting, weighted median, and MR-Egger approaches for analysis.

RESULTS

Our analysis included 85 single nucleotide polymorphisms for female infertility and 62 single nucleotide polymorphisms for psychiatric disorders. Results suggest a potential causal relationship between depression and female infertility, with both inverse variance weighting and weighted median methods showing increased infertility risk in depressed patients. Evidence is weak regarding bipolar disorder not increasing female infertility risk. We found no evidence supporting causal links between anxiety, eating disorders, and female infertility. Similarly, no causal relationship was found between female infertility and psychiatric disorders in the opposite direction. Sensitivity analyses and tests for heterogeneity and polymorphism supported result robustness.

CONCLUSIONS

This analysis provides evidence for a potential causal relationship between depression and female infertility. Addressing depression in infertile women may improve fertility outcomes. Further research is needed to explore underlying mechanisms and potential interventions for improving fertility outcomes in women with psychiatric disorders.

Temporally and spatially resolved molecular profiling in fingerprint analysis using indium vanadate nanosheets-assisted laser desorption ionization mass spectrometry

This study presents the first-ever synthesis of samarium-doped indium vanadate nanosheets (IVONSs:Sm) via microemulsion-mediated solvothermal method. The nanosheets were subsequently utilized as a nano-matrix in laser desorption/ionization mass spectrometry (LDI-MS). It was discovered that the as-synthesized IVONSs:Sm possessed the following advantages: improved mass spectrometry signal, minimal matrix-related background, and exceptional stability in negative-ion mode. These qualities overcame the limitations of conventional matrices and enabled the sensitive detection of small biomolecules such as fatty acids. The negative-ion LDI mechanism of IVONSs:Sm was examined through the implementation of density functional theory simulation. Using IVONSs:Sm-assisted LDI-MS, fingerprint recognitions based on morphology and chemical profiles of endogenous/exogenous compounds were also achieved. Notably, crucial characteristics such as the age of an individual's fingerprints and their physical state could be assessed through the longitudinal monitoring of particular biomolecules (e.g., ascorbic acid, fatty acid) or the specific biomarker bilirubin glucuronide. Critical information pertinent to the identification of an individual would thus be facilitated by the analysis of the compounds underlying the fingerprint patterns.

[Clinical research of multisystem inflammatory syndrome in children]

Objective: To analyze the clinical characteristics of children with multisystem inflammatory syndrome (MIS-C) associated with SARS-CoV-2 in China, and to improve the understanding of MIS-C among pediatricians. Methods: Case series study.Collect the clinical characteristics, auxiliary examinations, treatment decisions, and prognosis of 64 patients with MIS-C from 9 hospitals in China from December 2022 to June 2023. Results: Among the 64 MIS-C patients, 36 were boys and 28 were girls, with an onset age being 2.8 (0.3, 14.0) years. All patients suffered from fever, elevated inflammatory indicators, and multiple system involvement. Forty-three patients (67%) were involved in more than 3 systems simultaneously, including skin mucosa 60 cases (94%), blood system 52 cases (89%), circulatory system 54 cases (84%), digestive system 48 cases (75%), and nervous system 24 cases (37%). Common mucocutaneous lesions included rash 54 cases (84%) and conjunctival congestion and (or) lip flushing 45 cases (70%). Hematological abnormalities consisted of coagulation dysfunction 48 cases (75%), thrombocytopenia 9 cases (14%), and lymphopenia 8 cases (13%). Cardiovascular lesions mainly affected cardiac function, of which 11 patients (17%) were accompanied by hypotension or shock, and 7 patients (12%) had coronary artery dilatation.Thirty-six patients (56%) had gastrointestinal symptoms, 23 patients (36%) had neurological symptoms. Forty-five patients (70%) received the initial treatment of intravenous immunoglobulin in combination with glucocorticoids, 5 patients (8%) received the methylprednisolone pulse therapy and 2 patients (3%) treated with biological agents, 7 patients with coronary artery dilation all returned to normal within 6 months. Conclusions: MIS-C patients are mainly characterized by fever, high inflammatory response, and multiple organ damage. The preferred initial treatment is intravenous immunoglobulin combined with glucocorticoids. All patients have a good prognosis.

Bushen Huoxue formula for the treatment of diminished ovarian reserve: A combined metabolomics and integrated network pharmacology analysis

Objective

This study aimed to explore the mechanism of the Bushen Huoxue Formula (BHF) in treating diminished ovarian reserve (DOR) through the use of metabolomics and integrated network pharmacology.

Methods

The study involved 24 non-pregnant female Sprague-Dawley rats, divided into four groups of six rats each: control, model, BHF, and DHEA (n = 6 per group). The model group was induced with DOR by administering Tripterygium glycosides orally [50 mg (kg·d)-1] for 14 days. Subsequently, BHF and Dehydroepiandrosterone (DHEA) treatments were given to the respective groups. Ovarian reserve function was assessed by measuring anti-Müllerian hormone (AMH), estradiol (E2), and follicle-stimulating hormone (FSH) levels and conducting hematoxylin-eosin staining. In addition, UHPLC-QTOF-MS analysis was performed to identify differential metabolites and pathways in DOR rats treated with BHF. In this study, LC-MS was utilized to identify the active ingredients of BHF, while network pharmacology was employed to investigate the correlations between BHF-related genes and DOR-related genes. An integrated analysis of metabonomics and network pharmacology was conducted to elucidate the mechanisms underlying the efficacy of BHF in treating DOR.

Results

The model group exhibited a poor general condition and a significant decrease in the number of primordial, primary, and secondary follicles (P < 0.05) when compared to the control group. However, BHF intervention resulted in an increase in the number of primordial, primary, and secondary follicles (P < 0.05), along with elevated levels of AMH and E2 (P < 0.05), and a decrease in FSH levels (P < 0.05) in DOR rats. The modeling process identified eleven classes of metabolites, including cholesterol esters (CE), diacylglycerols (DAG), hexosylceramides (HCER), lysophosphatidylcholines (LPC), phosphatidylcholines (PC), phosphatidylethanolamines (PE), sphingomyelins (SM), ceramides (CER), free fatty acids (FFA), triacylglycerols (TAG), and lysophosphatidylethanolamines (LPE). The study found that PC, CE, DAG, and TAG are important metabolites in the treatment of DOR with BHF. LC-MS analysis showed that there were 183 active ingredients in ESI(+) mode and 51 in ESI(-) mode. Network pharmacology analysis identified 285 potential genes associated with BHF treatment for DOR in ESI(+) mode and 177 in ESI(-) mode. The combined analysis indicated that linoleic acid metabolism is the primary pathway in treating DOR with BHF.

Conclusion

BHF was found to improve ovarian function in rats with DOR induced by Tripterygium glycosides. The study identified key metabolites such as phosphatidylcholine (PC), cholesteryl ester (CE), diacylglycerol (DAG), triacylglycerol (TAG), and the linoleic acid metabolism pathway, which were crucial in improving ovarian function in DOR rats treated with BHF.

Recent advances in nanostructured substrates for surface-enhanced infrared absorption spectroscopy

Surface-enhanced infrared absorption (SEIRA) spectroscopy is an emerging research field that has received more attention from the research community. Unlike conventional infrared absorption spectroscopy, SEIRA spectroscopy is a surface sensitive technique which exploits the electromagnetic properties of nanostructured substrates to amplify the vibrational signals of adsorbed molecule. Unique advantages like high sensitivity, wide adaptability, and convenient operation, endow SEIRA spectroscopy to be applied in the qualitative and quantitative analysis for trace of gases, biomolecules and polymers, and so on. In this review, we summarize recent advances in the nanostructured substrates for SEIRA spectroscopy, including the developing history and widely accepted SEIRA mechanisms of SEIRA spectroscopy. Most importantly, characteristics and preparation methods of representative SEIRA-active substrates are introduced. In addition, current deficiencies and prospects in the field of SEIRA spectroscopy are discussed.&#xD.

[Bronchoscopic manifestations and interventional treatment of pulmonary mucormycosis]

Objective: To analyze the bronchoscopic manifestations and interventional treatment of pulmonary mucormycosis. Methods: Clinical data of patients with pulmonary mucormycosis undergoing bronchoscopy and interventional therapy in 4 tertiary general hospitals in China from May 2006 to May 2022 were retrospectively analyzed and the literature on the subject were reviewed. Results: The data of 10 patients with pathologically diagnosed pulmonary mucormycosis undergoing bronchoscopy and interventional therapy were collected, including 8 males and 2 females. The patients' age ranged from 21 to 72 (44±15) years. The underlying diseases included 6 cases of diabetes ketoacidosis, 3 cases of leukemia, 1 case after operation of lung cancer. Bronchoscopy showed that white viscous necrotic matters grew along the airway and blocked the airway in 9 cases, accompanied by airway bleeding in 3 cases, bloody secretion blocked the airway in 1 case, and bronchopulmonary cavity fistula in 2 cases. The biopsy histopathology of white necrotic matters showed that many mucor filaments were tangled together which were named mucormycelium. Among the 10 patients, 9 were treated with systemic drugs, including intravenous application of amphotericin B deoxycholate in 5 cases, intravenous application of amphotericin B liposome in 4 cases, oral posaconazole in 6 cases and intravenous injection in 1 case. Local drug therapy included aerosol inhalation of amphotericin B deoxycholate in 8 cases and local perfusion under bronchoscope in 5 cases. Bronchoscopic interventional therapy was used to remove mucormycelium in the bronchus, including cryotherapy in 8 cases, biopsy forceps in 7 cases, snare treatment in 2 cases and foreign body forceps in 2 cases. All 10 patients were clinical cured and with no death. Conclusions: Pulmonary mucormycosis is more common in immunocompromised hosts. Bronchoscopy often showed mucormycelium blocking the airway. Systemic and local drug therapy combined with bronchoscopic interventional therapy can achieve good clinical efficacy.

An active trend of immunotherapy combination regimen as second-line therapy for advanced biliary tract cancer: A multicenter retrospective study

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Background: FOLFOX as second-line therapy remains the standard of care in patients with biliary tract cancer (BTC), but its efficacy is suboptimal. Currently, cytotoxic chemotherapy, targeted therapy, and immunotherapy alone or in combination are being tested in patients with pretreated advanced BTC for in clinical trials. This study aimed to evaluate and compare the anticancer of distinct treatment regimen in patients with advanced BTCs who progress after first-line chemotherapy. Methods: Patients diagnosed BTC who received second-line therapy were retrospectively identified at 3 sites across the Zhejiang province between January 1, 2018, and June 31, 2022. Clinicopathological information and therapeutic outcome, including subtype of BTC, response per RECIST v1.1, treatment duration, adverse events (AE), progression-free survival (PFS), and overall survival (OS), were recorded and estimated. Results: A total of 98 patients with BTCs were reviewed and recruited eventually: the chemotherapy group (cohort A, n=30), the chemotherapy plus ICIs group (cohort B, n=25), the TKIs group (cohort C, n=17), and the TKIs plus ICIs group (cohort D, n=26). The median PFS and OS were 2.4 months (95%CI: 1.6–3.2) and 7.0 months (95% CI: 6.4–7.5) for cohort A, 3.9 months (95%CI: 2.8–5.0) and 10.7 months (95% CI: 6.9–14.5) for cohort B, 1.6 months (95%CI: 0.8–2.4) and 7.1 months (95% CI: 0.7–13.5) for cohort C, and 4.7 months (95%CI: 3.1–6.2) and 10.1 months (95% CI: 4.1–16.1) for cohort D, respectively. In the cohort A, B, C, and D, confirmed ORRs were 10%, 20%, 11.8% and 19.2%, separately, and DCRs were 46.7%, 68%, 43.8% and 76.9%, respectively. The efficacy of ICIs plus TKIs was optimal in terms of tumor response and associated with prolong PFS. Six patients (20%), nine patients (36%), five patients (29.4%), and elven patients (42.3%) were experienced ≥ grade 3 treatment-related AEs in cohort A, B, C, and D, respectively. Conclusions: Immunotherapy combination strategy beyond first-line systemic chemotherapy plays a positive role in advanced BTCs. Both TKIs plus ICIs and chemotherapy plus ICIs could be considered as candidates to second-line trails and turn into a competitive second-line treatment regimen for advanced BTCs in clinical practice.

Effect of Zhuyun I Recipe Capsule Enema on the Immune Microenvironment of the Endometrium during Implantation Window in Rats

Background

Preterm birth is the leading cause of neonatal death, and there are no effective clinical means for the prevention and treatment of spontaneous preterm birth, mainly because the mechanism for labor initiation has not been fully elucidated.

Objective

The effect of enucleation with Zhuyun I Recipe Capsule enema (ZRC) on the maternal-fetal interface microenvironment in SD rats with kidney deficiency and blood stasis.

Methods

In this study, poor endometrial tolerance was induced by hydroxyurea and epinephrine in SD rats with kidney deficiency and blood stasis type of endometrium, and gavage with norethindrone (estradiol) or Bamboo Rhythm No.1 formula. HOXA10 mRNA levels were measured by qPCR. In addition, the expression of IL-6, VEGF, TGF-β, and IGFBP-1 in the uterus was detected by IHC and ELISA.

Results

Hydroxyurea- and epinephrine-induced PER was associated with low levels of HOXA10 in the endometrium and reduced levels of IL-6, TGF-β, VEGF, and IGFBP-1 in the endometrium. These were abolished by ZRC and Progynova treatment compared to PER rats, resulting in a dramatic increase in the levels of HOXA10 mRNA, IL-6, TGF-β, VEGF, and IGFBP-1 proteins.

Conclusions

ZRC improves metaplasticization of endometrial stromal cells and promotes angiogenesis in rats with kidney deficiency and blood stasis. The moderate dose of kidney tonic to promote blood circulation method is superior in promoting angiogenesis, facilitating the establishment and maintenance of pregnancy, limiting trophoblast invasion of metaplasia, reducing miscarriage, and improving pregnancy rate.

Double Signal Amplification Strategy for Dual-Analyte Fluorescent Aptasensors for Visualizing Cancer Biomarker Proteins

The simultaneous analysis of diversified biomarkers with high sensitivity and in a point-of-care (POC) manner is of great significance for facile and early cancer diagnosis. Herein, we develop a target amplification-assisted ratiometric fluorescence assay (TARFA) platform integrating the dual-amplification strategy and colorimetric readout technology for sensitive and specific detection of two malignancy-associated biomarkers. Meanwhile, the NIR-excited alkaline-earth sulfide nanodots (ASNDs) with an ultrasmall (<10 nm) diameter and tunable emission wavelength are employed to replace commonly UV/visible light-excited fluorescent labels to minimize background interference from the sample matrix. Unique advantages of the ASNDs, together with superiority of consecutive signal amplification of enzymatic target recycling (ETR) and hybridization chain reaction (HCR), realize the pg/mL-range detection limit in specifically recognizing the vascular endothelial growth factor (VEGF) and soluble interleukin-6 receptors (sIL-6R). The combination detection of the dual analyte exhibits an improved sensitivity for cancer diagnosis. The addition of the target biomarkers leads to an increasingly ratiometric RGB signal, and quantification based on the ratio-dependent signal is more reliable rather than measuring the absolute RGB signals. Moreover, perceptible color transformation makes the TARFA platform competent for visual analysis of the target analytes as convenient as reading the pH indicator strip, and hue-based image analysis also improves the method with fine precision by quantitatively identifying the visual color. This work provides a new kind of NIR-excited aptasensing platform with a low detection limit, high throughput, and great portability, which also highlights the potential of the ASNDs in biomolecular fluorescent labeling.

[Identification of potential regulatory genes for embryonic stem cell self-renewal and pluripotency by random forest]

OBJECTIVE

To identify novel genes associated with self-renewal and pluripotency of mouse embryonic stem cells(mESCs)by integrating multiomics data based on machine learning methods.

METHODS

We integrated multiomics information of mESCs involving transcriptome, histone modifications, chromatin accessibility, transcription factor binding and architectural protein binding, and compared the signal differences between known stem cell self-renewal and pluripotency genes and other genes.By integrating these multiomics data, we established prediction models based on several machine learning classifiers including random forests and performed 5-fold cross validations.The model was trained using the training dataset containing two thirds of the input samples, and the remaining one third of the input samples were used as the test dataset to assess the performance of the model in independent tests.Finally, the results predicted by the model were validated through gene function annotation and cell function experiments including cell viability assay, colony formation assay and cell cycle analysis.

RESULTS

Compared with the random genes, the genes known to be associated with self-renewal and pluripotency of mESCs in the multiomics data showed significantly different features.Random forest outperformed the other machine learning algorithms tested on these multiomics data, with an area under the curve (AUC) of 0.883±0.018 for cross validation and an AUC of 0.880±0.028 for independent test.Based on this model, we identified 893 potential regulatory genes associated wwith self-renewal and pluripotency of mESCs, which were similar to the known genes in functional annotation.Known-down of the predicted novel regulator gene Cct6a resulted in significant decreases in the cell viability of mESCs (P < 0.0001) and the number of cell clones (P < 0.01), significantly increased the number of cells in G1 phase (P < 0.01) and decreasedthe number of S phase cells (P < 0.05).Knockdown of Cct6a also led to failure of positive alkaline phosphatase staining of the mESCs.

CONCLUSION

Machine learning model based on multiomics data can be used to predict potential self-renewal and pluripotency regulators with high performance.By using this model, we predicted potential self-renewal and pluripotency regulatory genes including Cct6a and applied experimental validation.This model provides new insights into the regulatory mechanism of mESCs and contribute to stem cell research.

Efficacy and safety of traditional Chinese herbal medicine in the treatment of threatened abortion: A protocol for systematic review and meta-analysis

BACKGROUND

Threatened abortion (TA) is the commonest complication that occurs in early pregnancy, especially in 8-12 gestational weeks when the secretion of estrogen and progesterone shifts from corpus luteum to placental. Conventional therapies are little evidence of their value. In China, traditional Chinese herbal medicine has been widely used for the treatment of TA for a long time. The lack of strong scientific evidences make this a priority area for research. We aim to evaluate the efficacy and safety of traditional Chinese herbal medicine in the treatment of TA, provide medical staffs with more useful information, and provide patients with better advises.

METHODS

We will search 8 databases and additional sources, including the Web of Science, PubMed, Cochrane Library, Embase, CBM, Wanfang, VIP, CNKI, and WHO ICTRP, ChiCTR, Clinical Trials, Grey Literature Database, for potentially eligible studies. Literature search, screening and retrieval are performed independently by two researchers. In the event of a dispute, a third party will be consulted to support the judgment. We will use RevmanV.5.3 to perform a fixed-effect meta-analysis for clinical homogeneity study data, and the level of evidence will be assessed using the GRADE method.

RESULTS

This systematic review and meta-analysis will put a high-quality synthesis of the efficacy and safety of traditional Chinese herbal medicine in the treatment of TA.

CONCLUSION

The conclusion of this systematic review will provide evidence to assess traditional Chinese herbal medicine therapy whether is an efficacy and safe intervention to treat TA.

ETHICS AND DISSEMINATION

Since this article does not contain patient personal information, ethical approval is not required. The contract is distributed by a peer-reviewed journal or conference report.

REGISTRATION NUMBER

10.17605/OSF.IO/DG3T8.

Efficacy of sonothrombolysis using acoustically activated perflutren nanodroplets versus perflutren microbubbles

Background

The use of intermittent high mechanical index (HMI) ultrasound impulses in combination with intravenously administered microbubbles (MB) has been shown to dissolve arterial and microvascular thrombi. The recent development of liquid droplets with nanoscale diameter from commercially available microbubbles may optimize thrombus permeation and subsequent thrombus dissolution.

Methods

Thrombi were formed from fresh porcine arterial whole blood mixed with thrombin, and placed in a vascular system mimicking branching epicardial coronary circulation (Figure 1A) at 37 Celsius and flow rate. A diagnostic ultrasound system with a tissue mimicking phantom was placed on top of the thrombus to simulate transthoracic echocardiography. Thrombus treatment consisted of a 10-minute infusion of either diluted nanodroplets (ND) or MB (same concentration) with intermittent HMI fundamental multipulse (3 usec pulse duration; FUS) or single pulse harmonic (HUS) impulses. All treatments were randomized and compared with HMI impulses alone. Efficacy was evaluated by percentage thrombus dissolution (%TD). Transmission electron microscopy (TEM) of residual thrombi after treatment was performed to examine for droplet permeation and resultant formed microbubble size.

Results

A relatively monodisperse nanodroplets size distribution was formed from microbubble cooled compression (mean diameter was 147±54 nm). A total of 60 porcine arterial thrombi were tested, 20 in each MB and ND treated group (20 control). Overall, there was a significant difference in %TD between ND treated thrombi (combining HUS and FUS HMI treated groups) versus MB treated thrombi and control (p&lt;0.0001 and p=0.02, respectively; ANOVA, Figure 1B). The highest %TD was seen in the FUS HMI treated ND group (mean 51±17%; Figure 1B). TEM of the DND treated group demonstrated significant expansion (diameters of 6 microns; Figure 1 C) of acoustically activated droplets embedded within the thrombi.

Conclusion

ND in combination with intermittent HMI ultrasound resulted in significantly greater thrombolysis compared to MB. In-vivo studies on nanodroplet mediated sonothrombolysis for vascular and microvascular thrombi should be performed with this modification of a commercially available microbubble.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Theodore F. Hubbard Foundation

Design and Integration of JMF-Based Multimedia-Supported Environment in a Product Data Management System

In order to meet discipline experts' requirements of knowledge exchange, conflict resolution, and design decision in the collaborative product design process, a JMF-based multimedia-supported environment (MSE) is proposed. The requirement to develop the MSE for multi-disciplinary collaborative design process is analyzed. Related key technologies of multimedia applications required to build the integrated MSE are described. Construction of multimedia interaction mode, design of system architecture, and formulation of development plan are implemented. Discipline experts' roles are defined, and safety certification function of application programs is achieved. Based on the development platform of Java 2 enterprise edition (J2EE), the realization of the system is completed, and the system is integrated into a previously developed product data management system. Through system experiment and test, the JMF-based system environment can well meet the needs of multimedia real-time interaction, knowledge sharing, and collaborative decision making in the process of collaborative product design.

MicroRNA-24 attenuates vascular remodeling in diabetic rats through PI3K/Akt signaling pathway

BACKGROUND AND AIMS

The vascular remodeling plays a crucial role in pathogenesis of diabetic cardiovascular complications. In this study, we intended to explore the effects and potential mechanisms of microRNA-24 (miR-24) on vascular remodeling under diabetic conditions.

METHODS AND RESULTS

MiR-24 recombinant adenovirus (Ad-miR-24-GFP) was used to induce miR-24 overexpression either in carotid arteries or high glucose (HG)-induced vascular smooth muscle cells (VSMCs). Cell proliferation was analyzed using CCK-8 method. Cell migration was examined using wound-healing and transwell assay. mRNA and protein expressions of critical factors were, respectively, measured by real-time PCR and western blot as follows: qRT-PCR for the levels of miR-24, PIK3R1; western blot for the protein levels of PI3K (p85α), Akt, p-Akt, mTOR, p-mTOR, 4E-BP1, p-4E-BP1, p70s6k, p-p70s6k, MMP 2, MMP 9, collagen Ⅰ, as well as collagen Ⅲ. Carotid arteries in diabetic rats suffered balloon injury were harvested and examined by HE, immunohistochemical and Masson trichrome staining. The expression of miR-24 was decreased in HG-stimulated VSMCs and balloon-injured carotid arteries of diabetic rats, accompanied by increased mRNA expression of PIK3R1. The up-regulation of miR-24 suppressed VSMCs proliferation, migration, collagen deposition not only induced by HG in vitro, but also in balloon-injured diabetic rats, which were related to inactivation of PI3K/Akt signaling pathway.

CONCLUSION

The up-regulation of miR-24 significantly attenuated vascular remodeling both in balloon-injured diabetic rats and HG-stimulated VSMCs via suppression of proliferation, migration and collagen deposition by acting on PIK3R1 gene that modulated the PI3K/Akt/mTOR axes.

Causes of ozone pollution in summer in Wuhan, Central China

In August 2016, continuous measurements of volatile organic compounds (VOCs) and trace gases were conducted at an urban site in Wuhan. Four high-ozone (O₃) days and twenty-seven non-high-O₃ days were identified according to the China's National Standard Level II (∼100 ppbv). The occurrence of high-O₃ days was accompanied by tropical cyclones. Much higher concentrations of VOCs and carbon monoxide (CO) were observed on the high-O₃ days (p < 0.01). Model simulations revealed that vehicle exhausts were the dominant sources of VOCs, contributing 45.4 ± 5.2% and 37.3 ± 2.9% during high-O₃ and non-high-O₃ days, respectively. Both vehicle exhausts and stationary combustion made significantly larger contributions to O₃ production on high-O₃ days (p < 0.01). Analysis using a chemical transport model found that local photochemical formation accounted for 74.7 ± 5.8% of the daytime O₃, around twice the regional transport (32.2 ± 5.4%), while the nighttime O₃ was mainly attributable to regional transport (59.1 ± 9.9%). The local O₃ formation was generally limited by VOCs in urban Wuhan. To effectively control O₃ pollution, the reduction ratio of VOCs to NO_x concentrations should not be lower than 0.73, and the most efficient O₃ abatement could be achieved by reducing VOCs from vehicle exhausts. This study contributes to the worldwide database of O₃-VOC-NO_x sensitivity research. Its findings will be helpful in formulating and implementing emission control strategies for dealing with O₃ pollution in Wuhan.

Peripheral kynurenine/tryptophan ratio is not a reliable marker of systemic indoleamine 2,3-dioxygenase: A lesson drawn from patients on hemodialysis

Indoleamine 2,3-dioxygenase (IDO) has emerged as a pivotal enzyme for mediating immune tolerance. Because IDO metabolizes tryptophan into kynurenine, the plasma kynurenine/tryptophan (Kyn/Trp) ratio has been widely used as a marker of systemic IDO. Here, we evaluated the clinical value of using the plasma Kyn/Trp ratio to estimate cell-mediated immune responses to tuberculin skin testing and risk of new bacterial infection. We also compared the Kyn/Trp ratio to a novel IDO marker, the IDO median fluorescence index (MFI) of peripheral blood mononuclear cells, which was determined by flow cytometry. In 228 patients from two hemodialysis centers, the two IDO markers were higher in patients than in healthy controls but were not correlated with each other. In vitro experiments demonstrated that peripheral blood mononuclear cells could not metabolize tryptophan into kynurenine, indicating that the increased Kyn/Trp ratio was IDO-independent. Skin induration diameters of tuberculin skin testing were correlated with the IDO MFI (negatively), but not the Kyn/Trp ratio. Further, in a 24-month prospective cohort, the Kyn/Trp ratio was not correlated with clinical infection. Alternatively, patients with a higher IDO MFI had a lower accumulative infection-free survival rate. Using a Cox proportional hazard model, it was also revealed that a higher IDO MFI was significantly associated with new bacterial infection. Taken together, these results indicate that the Kyn/Trp ratio is not a reliable circulating IDO marker in hemodialysis patients. However, the IDO MFI reflects an immunocompromised state and thus might be a potential clinical marker of bacterial infection.

Efficacy of minimally invasive tonsil surgery for treatment of obstructive sleep apnea-hypopnea syndrome in children

This study aimed to investigate the efficacy of minimally invasive tonsil surgery for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS) in children. Tonsil ablation or turbinate reduction was performed on 49 pediatric patients with OSAHS by minimally invasive tonsil surgery. In order to evaluate the efficacy of surgery, a comparison was conducted between pre-operation and post-operation data in terms of the symptoms, signs and polysomnography test. Total effectiveness rate of the surgery was 83.7%. Subgroup analysis was also performed based on the severity of their conditions: mild, moderate, and severe groups had an effectiveness rate of 90.0, 88.9, and 66.7%, respectively (Hc=6.665, P<0.05). Postoperatively, the apnea-hypopnea index, the minimum oxygen saturation (SaO2), and corresponding symptoms improved compared to pre-operation conditions (P<0.05). Minimally invasive tonsil surgery was a safe and effective method for treating OSAHS in children.

Identification of genes involved in rice seed priming in the early imbibition stage

Phase II of seed imbibition is a critical process during seed priming. To identify genes involved in rice seed priming, the altered proteins between the dry and imbibed (24 h) seeds were compared using a two-dimensional gel electrophoresis system in this study. Ten significantly changed proteins (fold change ≥ twofold; P < 0.01) were successfully identified, which could be categorised as carbohydrate and protein biosynthesis and metabolism-related, signalling-related, storage and stress-related proteins. A meta-analysis indicated that the highest expression of the identified genes was at the milk and dough stages and in the endosperm tissue. Quantitative real-time PCR analysis showed that there was significant variation in gene expression (except FAD-dependent oxidoreductase) in embryos during seed priming (0-48 h). The expression of genes associated with stress appeared at the early imbibition stage, while those associated with carbohydrate metabolism, protein synthesis and signalling increased at the late imbibition stage. Three identified proteins (glucose-1-phosphate adenylyltransferase large subunit, aminotransferase and prolamin precursor) had similar transcript and protein expression patterns in embryos. Based on phenotype and gene expression, the optimal stop time for seed priming is 24 h, when these three genes have relatively low expression, followed by significant induction during imbibition in embryos. These three genes are ideal candidate biomarkers for rice seed priming.

Expression of long non-coding RNA (lncRNA) H19 in immunodeficient mice induced with human colon cancer cells

OBJECTIVE

To study the expression of long non-coding RNA (lncRNA) H19 in immunodeficient mice induced with human colon cancer cells. Long non-coding RNAs (lncRNA) have a vital and regulatory role, in almost all cancers including colon cancer. In the present study, the prominent regulatory role of IncH19 RNA in immunodeficient mice induced with human colon cancer cells was identified. Interestingly, the lncH19 RNA was up-regulated in human colon cancer cells induced immunodeficient mice colon cancer samples.

PATIENTS AND METHODS

The expression profile of the lnc H19 RNA in the colon cancer tissues were identified by RT-PCR and the further the data was confirmed and validated by Northern blot analysis.

RESULTS

Based on the data, it was identified that lnc H19 RNA was increased significantly in immunodeficient mice induced with human colon cancer cells, when compared with controls. The data was further confirmed and validated by Northern blot analysis.

CONCLUSIONS

The obtained data future potential application in colon cancer diagnosis. At the same time, lncH19 RNA may serve as a new target for anti-tumor therapy in colon cancer. Also, the obtained data is the important clue to find out the key roles of lncH19 RNA-miRNA functional network in colon cancer.

Diagnostic performance of anti-citrullinated protein/peptide antibodies in juvenile idiopathic arthritis

The prevalence rates of anti-citrullinated protein/peptide antibodies (ACPAs) were investigated in a cohort of juvenile idiopathic arthritis (JIA) patients, and their diagnostic performances were compared. ACPAs, including anti-cyclic citrullinated peptide IgG (anti-CCP), anti-CCP IgG/IgA (anti-CCP3.1), citrullinated recombinant rat filaggrin antibodies (CPA), anti-mutated citrullinated vimentin (anti-MCV), and antibodies to citrullinated human IgG-derived peptides (RA/CP), were measured in the sera from 81 JIA patients. Serum samples from 55 children with other joint diseases or viral infections and 49 healthy donors were tested as controls. Of the 81 JIA patients, 7 (8.6%), 8 (9.9%), 17 (21.0%), 23 (28.4%), and 18 (22.2%) were found to be positive for anti-CCP, anti-CCP3.1, CPA, anti-MCV, and RA/CP, respectively, with specificities of 98.1, 95.1, 93.3, 84.6, and 86.5%. Analysis by subtype revealed that 7/7 (100%) of RF-positive polyarticular JIA patients tested positive at high serum levels for anti-MCV or RA/CP, and 5/7 (71.4%) were positive for anti-CCP, anti- CCP3.1, or CPA (P < 0.001, compared with controls). Eighteen of 81 JIA patients demonstrated joint erosions on radiographs and erosive arthritis occurred more often in ACPAs positive patients (P < 0.01). Our findings indicate that although ACPAs are not satisfactory screening biomarkers for JIA due to low sensitivity, ACPA measurement can aid in diagnosing RF-positive polyarticular JIA and identifying JIA patients with severe bone involvement. The diagnostic performance of each ACPA in JIA is different, and the careful selection of assays is necessary.

Polarization modulation of two-photon excited fluorescence in a V-shaped dipicolinate-triphenylamine compound

Polarization modulation of two-photon excited fluorescence in a V-shaped dipicolinate-triphenylamine compound was investigated with 100 fs 800 nm laser pulses. The peak fluorescence intensity versus the input irradiance was measured to meet a square dependence, which offered evidence for two-photon excited fluorescence. The variations of the two-photon excited fluorescence intensity showed strong response to the different polarized incident lights and were tightly dependent on the linearly polarized component of the incident light. Furthermore, the polarization modulation efficiency of the two-photon excited fluorescence had an obvious concentration dependence when the concentration of solution was under 2.5×10(-4)  mol/L. The enhancement of modulation efficiency was attributed to the concentration dependence of the two-photon absorption cross section.

Effects of MK-801 concentration on cell proliferation in rats with focal cerebral ischemia-reperfusion

We explored the relationship between MK-801 concentration and neural stem cell proliferation in rats with focal cerebral ischemia-reperfusion (FCIR). A total of 60 male Sprague Dawley rats were randomized into control (six rats), sham-operation (six rats), operation (12 rats), and MK-801 groups. The MK-801 group comprised 36 rats that were subjected to different doses of MK-801 (0.2, 0.4, 0.6, 0.8, 1.0, and 1.2 mg/kg). Suture occlusion was used to establish an ischemia reperfusion model of middle cerebral artery occlusion (MCAO); 30 min before establishing the FCIR model, the MK-801 group rats were intraperitoneally injected with different doses of MK-801, while the sham-operation and control groups were injected with normal saline. Seven days after model establishment, bromodeoxyuridine-positive cerebral cortex cells adjacent to the focus of infarction were labeled for immunohistochemistry. MK-801 at a concentration of 0.4 mg/kg prevented endogenous neural stem cell proliferation, and this inhibitory effect was strengthened with increasing MK-801 concentration, especially at concentrations greater than 0.8 mg/kg. MK-801 inhibits endogenous neural stem cell proliferation in rats with FCIR, and the inhibitory effect is strengthened with increasing MK-801 concentration.

Parallel enzyme-linked immunosorbent assay screening for human immunodeficiency virus among blood donors in five Chinese blood centres: a retrospective analysis

AIMS

To evaluate the strategy of parallel screening with different enzyme-linked immunosorbent assays (ELISA) among Chinese blood donors.

BACKGROUND

Parallel screening with ELISA has been the main strategy to detect human immunodeficiency virus (HIV) in blood donations in China for more than a decade. The performance of the strategy should be analysed.

METHODS

A total of 821,927 donations collected from five Chinese blood centres in 2008-2010 were tested using two third-generation ELISAs by different manufacturers licenced and confirmed by the Western blot (WB) in this study. The confirmatory positive predictive values (PPV), false positive rates (FPR), false negative rates (FNR) and potential risks for transfusion resulting from single or sequential ELISA screening were evaluated.

RESULTS

A total of 5318 (0·647%) of donations screened HIV reactive and were discarded. WB confirmatory results on 1668 available samples suggested that PPVs for dual ELISA, one round ELISA reactive and grey zone samples were 75·1, 0·7 and 0·5%, respectively. Eight out of 1124 one round ELISA reactive and 1 out of 195 grey zone samples were WB confirmed positive. All but one ELISA assay displayed comparable PPVs but variable FPRs and FNRs that differed by blood centre.

CONCLUSIONS

In the absence of nucleic acid testing (NAT), parallel ELISA screening prevented a substantial number of HIV infected donations from entering the Chinese blood supply. However, the loss of false positive donors should be re-evaluated especially given the frequently reported blood supply shortage in China.

New Oxidovanadium Complexes Incorporating Thiosemicarbazones and 1, 10-Phenanthroline Derivatives as DNA Cleavage, Potential Anticancer Agents, and Hydroxyl Radical Scavenger

Four novel oxidovanadium(IV) complexes, [VO(hntdtsc)(PHIP)] (1) (hntdtsc = 2-hydroxy-1-naphthaldehyde thiosemicarbazone, PHIP= 2-phenyl-imidazo[4,5-f]1,10-phenanthroline), [VO(hntdtsc)(DPPZ)](2)(DPPZ= dipyrido[3,2-a:2',3'-c]phenazine), [VO(satsc)(PHIP)](3) (satsc=salicylaldehyde thiosemicarbazone), and [VO(satsc)(DPPZ)](4), have been prepared and characterized. The chemical nuclease activities and photocleavage reactions of the complexes were tested. All four complexes can efficiently cleave pBR322 DNA, and complex 1 has the best cleaving ability. The antitumor properties of these complexes were examined with three different tumor cell lines using MTT assay. Their antitumor mechanism has been analyzed using cell cycle analysis, fluorescence microscopy of apoptosis, and Annexin V-FITC/PI assay. The results showed that the growth of human neuroblastoma (SH-SY5Y, SK-N-SH) and human breast adenocarcinoma (MCF-7) cells were inhibited significantly with very low IC50 values. Complex 1 was found to be the most potent antitumor agent among the four complexes. It can cause G0/G1 phase arrest of the cell cycle and exhibited significant induced apoptosis in SK-N-SH cells and displayed typical morphological apoptotic characteristics. In addition, they all displayed reasonable abilities to scavenge hydroxyl radical, and complex 1 was the best inhibitor.

Polarization-controlled images based on double-exposure polarization holography in an azobenzene liquid-crystalline polymer

Polarization-controlled optical image operations were demonstrated based on the double-exposure polarization holographic method. Two images were stored in the same volume of an azobenzene liquid-crystalline polymer by recording superimposed holograms, a pair of polarization gratings with one spatial frequency, using two orthogonal circularly polarized 532 nm beams and were reconstructed with a 650 nm laser. The recorded polarization holographic gratings were investigated to show distinctive polarization selectivity, high diffraction efficiency, and good stability. The brightness and the polarization of the diffracted images were found to be dependent on the polarization of the readout beam, and two images could be reconstructed individually or simultaneously.

Occult macrophage activation syndrome in systemic-onset juvenile idiopathic arthritic syndrome--a case report

Macrophage activation syndrome (MAS) is a severe and life-threatening complication of rheumatic disorders in children. We described a 9-year-old girl in whom MAS developed as a complication of systemic juvenile idiopathic arthritis (S-JIA) at onset with obvious hemophagocytosis presented in the marrow. She suffered from high fever and generalized rash subsequently joints swelling for two weeks before admission. Physical examination revealed mild cervical lymphadenopathy and hepatosplenomegaly. Laboratory findings were: abnormal liver enzymes, increased triglyceride and ferritin levels, anemia .Hyperplasia of hemophagocytic macrophages was remarkable in her bone marrow. Methylprednisolone and cyclosporin therapy resulted in clinical and laboratory improvement. It is unusual that hemophagocytosis presented in the marrow at onset of So-JIA without obvious abnormal coagulation profile, thrombocytopenia and leucopenia. It seemed that MAS may be occult at onset of SJIA. It may be integral to the pathogenesis of SJIA. The proper cyclosporine serum lever at the onset of MAS is as high as 200-300 ng/ml.

Primary immunodeficiency in south China: clinical features and a genetic subanalysis of 138 children

OBJECTIVES

We analyzed the clinical features of 138 patients with primary immunodeficiency (PID) and performed genetic testing on a subset of patients in order to complete gaps in research on PID in South China and thus improve pediatricians' ability to recognize and diagnose PID.

METHODS

We performed a retrospective analysis based on the medical records of PID patients hospitalized in our institution between May 1999 and June 2012. Gene sequencing was performed in 59 cases.

RESULTS

Children with PID usually present with fever and repeated infections that generally affect the respiratory and digestive tracts. Growth retardation is observed in some cases. Of the 138 patients, 113 were boys, median age at onset was 5 months (range, 0-119 months), and age at diagnosis was 10 months (2-159 months). A family history of repeated infection or death of family members in infancy because of recurrent infections was recorded in 20 cases (14.49%). Antibody defects were detected in 48 cases (34.78%), combined immunodeficiency disease in 45 cases (32.61%), and other well-defined immunodeficiency syndromes in 45 cases (32.61%). Of the 59 patients from the genetic subanalysis, 24 (15.94%) had a genetic mutation (x-linked agammaglobulinemia, 8 cases; severe combined immunodeficiency, 8 cases; hyperimmunoglobulin M syndrome, 3 cases; hyperimmunoglobulin E syndrome, 3 cases; chronic granulomatous disease, 2 cases). We detected 4 novel mutations. No relevant mutations were found in the remaining 35 cases.After treatment with intravenous immunoglobulin and anti-infectious agents, 16 patients died in hospital, and 5 cases died after discontinuing treatment (mortality, 15.22%).

CONCLUSIONS

In recent years, the number of patients with PID has risen gradually in South China. Genetic testing can confirm diagnosis. Since PID seriously affects children's quality of life, it is important to diagnose, treat, and intervene early.We hope our clinical and genetic analyses of children with PID can provide diagnostic guidance for clinicians.