Analysis of microscopy techniques to measure segregation in continuous-cast steel slabs

The accurate characterisation of centreline segregation requires precise measurements of composition variations over large length scales (10- 1 $^{-1}$ m ${\rm {m}}$ ) across the centreline of the cast product, while having high resolution, sufficient to quantify the significant composition variations between dendrites due to microsegregation at very small length scales (10- 5 m $^{-5}{\rm {m}}$ ). This study investigates the potential of a novel microscopy technique, named Synchrotron Micro X-ray Flurorescence (SMXRF), to generate large-scale high-resolution segregation maps from a steel sample taken from a thin slab caster. Two methods, Point Analysis and Regression Analysis, are proposed for SMXRF data calibration. By comparing with the traditional Laser-Induced Breakdown Spectroscopy (LIBS), and Electron Probe Micro Analyser (EPMA) techniques, we show that SMXRF is successful in quantitative characterisation of centreline segregation. Over large areas (e.g. 12 × $\times$ 16mm 2 ${\rm {mm}}^2$ ) and at high resolution (10-50μ m $\mu\text{m}$ pixel size) various techniques yield comparable outcomes in terms of composition maps and solute profiles. The findings also highlight the importance of both high spatial resolution and large field of view to have a quantitative, accurate, and efficient measurement tool to investigate segregation phenomena.

Mo3S13 Chalcogel: A High-Capacity Electrode for Conversion-Based Li-Ion Batteries

Despite large theoretical energy densities, metal-sulfide electrodes for energy storage systems face several limitations that impact the practical realization. Here, we present the solution-processable, room temperature (RT) synthesis, local structures, and application of a sulfur-rich Mo3S13 chalcogel as a conversion-based electrode for lithium-sulfide batteries (LiSBs). The structure of the amorphous Mo3S13 chalcogel is derived through operando Raman spectroscopy, synchrotron X-ray pair distribution function (PDF), X-ray absorption near edge structure (XANES), and extended X-ray absorption fine structure (EXAFS) analysis, along with ab initio molecular dynamics (AIMD) simulations. A key feature of the three-dimensional (3D) network is the connection of Mo3S13 units through S-S bonds. Li/Mo3S13 half-cells deliver initial capacity of 1013 mAh g-1 during the first discharge. After the activation cycles, the capacity stabilizes and maintains 312 mAh g-1 at a C/3 rate after 140 cycles, demonstrating sustained performance over subsequent cycling. Such high-capacity and stability are attributed to the high density of (poly)sulfide bonds and the stable Mo-S coordination in Mo3S13 chalcogel. These findings showcase the potential of Mo3S13 chalcogels as metal-sulfide electrode materials for LiSBs.

A new assessment method for water environment safety and its application

The Three Gorges Reservoir area is recognized by its vast size, dense population, bustling economic and social activities along its banks, and by the significant volume of waterway traffic. These factors make it with a high risk of water pollution accidents, posing a serious threat to water environmental safety. Therefore, it is imperative to conduct a water environmental safety assessment in this region to ensure the safety of the water environment. In the present work, the Driving-Pressure-State-Impact-Response-Risk Water Environmental Safety model was proposed, and a comprehensive water environmental safety assessment system was established. The Water Environment Safety Index was introduced to measure the degree of water environment safety. This model synthesized multiple factors and their interrelationships, enabling a more accurate assessment of water environment safety. By adopting scientifically rigorous evaluation criteria, this assessment method enhanced the reliability and credibility of the results obtained. The water environment safety in the 22 counties and districts of the Three Gorges Reservoir area of Chongqing region from 2017 to 2021 was assessed in terms of temporal changes and spatial differentiation. In general, the overall water environment safety situation in the Three Gorges Reservoir area of Chongqing region is relatively safe, but a few counties/districts (such as Wanzhou District, Jiangjin District, etc.) are still in Warning. Spatially, the water environmental safety condition was relatively better in the northeast compared to the southwest. The main factors threatening water environment safety include: 1) the consequence of the Three Gorges Project, 2) severe soil erosion, 3) industrial, agricultural, and domestic pollution, and 4) frequent water pollution accidents. The present work provided a new method for conducting water environment safety assessments, which is expected to positively contribute to further research in this field.

Selective and Scalable CO2 Electrolysis Enabled by Conductive Zinc Ion-Implanted Zeolite-Supported Cadmium Oxide Nanoclusters

Catalyst supports play an essential role in catalytic reactions, hinting at pronounced metal-support effects. Zeolites are a propitious support in heterogeneous catalysts, while their use in the electrocatalytic CO2 reduction reaction has been limited as yet because of their electrically insulating nature and serious competing hydrogen evolution reaction (HER). Enlightened by theoretical prediction, herein, we implant zinc ions into the structural skeleton of a zeolite Y to strategically tailor a favorable electrocatalytic platform with remarkably enhanced electronic conduction and strong HER inhibition capability, which incorporates ultrafine cadmium oxide nanoclusters as guest species into the supercages of the tailored 12-ring window framework. The metal d-bandwidth tuning of cadmium by skeletal zinc steers the extent of substrate-molecule orbital mixing, enhancing the stabilization of the key intermediate *COOH while weakening the CO poisoning effect. Furthermore, the strong cadmium-zinc interplay causes a considerable thermodynamic barrier for water dissociation in the conversion of H+ to *H, potently suppressing the competing HER. Therefore, we achieve an industrial-level partial current density of 335 mA cm-2 and remarkable Faradaic efficiency of 97.1% for CO production and stably maintain Faradaic efficiency above 90% at the industrially relevant current density for over 120 h. This work provides a proof of concept of tailored conductive zeolite as a favorable electrocatalytic support for industrial-level CO2 electrolysis and will significantly enhance the adaptability of conductive zeolite-based electrocatalysts in a variety of electrocatalysis and energy conversion applications.

Prediction and countermeasures of heavy metal copper pollution accident in the Three Gorges Reservoir Area

In order to mitigate the hazards of water pollution in drinking water source areas (DWSAs), developing applicable models and proposing effective solutions is of paramount significance. The study developed the Heshangshan Drinking Water Source Area (HDWSA) Hydrodynamic Model, integrating Geographic Information System (GIS) into a two-dimensional hydrodynamic water quality model using FORTRAN. TECPLOT360 software (Software Tools for Numerical Simulation with Visualization) visualized contamination transportation and diffusion. The model's relative error is less than 6%, indicating its strong stability and high reliability. The HDWSA in the Three Gorges Reservoir Area (TGRA) was used as a case study, focusing on copper (Cu) as a pollutant. By regulating the flow downstream from the Xiangjiaba Reservoir, Scheduling Group 1 and Scheduling Group 2 respectively increased the flow by 4000 m3/s and 8000 m3/s. The study analyzed the spatio-temporal variations of Cu concentration following pollution accident and flow scheduling. Under accident conditions, it took 71, 61, 49, and 56 min for the Cu concentration in the study area to decrease to below the standard value (1 mg/L) during dry, falling, flood, and storage periods. Scheduling Groups 1 and 2 reduced the pollutant exceedance duration by 19-26 min and 12-18 min across the four water periods.

Competitive Coordination Structure Regulation in Deep Eutectic Electrolyte for Stable Zinc Batteries

Rechargeable zinc-based batteries are finding their niche in energy storage applications where cost, safety, scalability matter, yet they are plagued by rapid performance degradation due to the lack of suitable electrolytes to stabilize Zn anode. Herein, we report a competitive coordination structure to form unique quaternary hydrated eutectic electrolyte with ligand-cation-anion cluster. Unraveled by experiment and calculation results, the competing component can enter initial primary coordination shell of Zn2+ ion, partially substituting Lewis basic eutectic ligands and reinforcing cation-anion interaction. The hydration-deficient complexes induced between competing eutectic as hydrogen bond donor-accepter and water also broaden the electrochemical window and confine free water activity. The altered coordination further leads to robust hybrid organic-inorganic enriched solid electrolyte interphase, enabling passivated surface and suppressed dendrite growth. Noticeably, stable Zn plating/stripping for 8000 cycles with high Coulombic efficiencies of 99.6 % and long cycling life of 10000 cycles for Zn-organic batteries are obtained. Even under harsh conditions (small N/P ratio, low temperature), the profits brought by the competitive eutectic electrolyte are still very prominent. This design principle leveraged by eutectic electrolytes with competitive coordination offers a new approach to improve battery performance.

Polysulfide regulation by defect-modulated Ta3N5-x electrocatalyst toward superior room-temperature sodium-sulfur batteries

Resolving low sulfur reaction activity and severe polysulfide dissolution remains challenging in metal-sulfur batteries. Motivated by a theoretical prediction, herein, we strategically propose nitrogen-vacancy tantalum nitride (Ta3N5-x) impregnated inside the interconnected nanopores of nitrogen-decorated carbon matrix as a new electrocatalyst for regulating sulfur redox reactions in room-temperature sodium-sulfur batteries. Through a pore-constriction mechanism, the nitrogen vacancies are controllably constructed during the nucleation of Ta3N5-x. The defect manipulation on the local environment enables well-regulated Ta 5d-orbital energy level, not only modulating band structure toward enhanced intrinsic conductivity of Ta-based materials, but also promoting polysulfide stabilization and achieving bifunctional catalytic capability toward completely reversible polysulfide conversion. Moreover, the interconnected continuous Ta3N5-x-in-pore structure facilitates electron and sodium-ion transport and accommodates volume expansion of sulfur species while suppressing their shuttle behavior. Due to these attributes, the as-developed Ta3N5-x-based electrode achieves superior rate capability of 730 mAh g-1 at 3.35 A g-1, long-term cycling stability over 2000 cycles, and high areal capacity over 6 mAh cm-2 under high sulfur loading of 6.2 mg cm-2. This work not only presents a new sulfur electrocatalyst candidate for metal-sulfur batteries, but also sheds light on the controllable material design of defect structure in hopes of inspiring new ideas and directions for future research.

Interfacial Electronic Modulation of Dual-Monodispersed Pt-Ni3S2 as Efficacious Bi-Functional Electrocatalysts for Concurrent H2 Evolution and Methanol Selective Oxidation

Constructing the efficacious and applicable bi-functional electrocatalysts and establishing out the mechanisms of organic electro-oxidation by replacing anodic oxygen evolution reaction (OER) are critical to the development of electrochemically-driven technologies for efficient hydrogen production and avoid CO2 emission. Herein, the hetero-nanocrystals between monodispersed Pt (~ 2 nm) and Ni3S2 (~ 9.6 nm) are constructed as active electrocatalysts through interfacial electronic modulation, which exhibit superior bi-functional activities for methanol selective oxidation and H2 generation. The experimental and theoretical studies reveal that the asymmetrical charge distribution at Pt-Ni3S2 could be modulated by the electronic interaction at the interface of dual-monodispersed heterojunctions, which thus promote the adsorption/desorption of the chemical intermediates at the interface. As a result, the selective conversion from CH3OH to formate is accomplished at very low potentials (1.45 V) to attain 100 mA cm-2 with high electronic utilization rate (~ 98%) and without CO2 emission. Meanwhile, the Pt-Ni3S2 can simultaneously exhibit a broad potential window with outstanding stability and large current densities for hydrogen evolution reaction (HER) at the cathode. Further, the excellent bi-functional performance is also indicated in the coupled methanol oxidation reaction (MOR)//HER reactor by only requiring a cell voltage of 1.60 V to achieve a current density of 50 mA cm-2 with good reusability.

Longevous Cycling of Rechargeable Zn-Air Battery Enabled by "Raisin-Bread" Cobalt Oxynitride/Porous Carbon Hybrid Electrocatalysts

Developing commercially viable electrocatalyst lies at the research hotspot of rechargeable Zn-air batteries, but it is still challenging to meet the requirements of energy efficiency and durability in realistic applications. Strategic material design is critical to addressing its drawbacks in terms of sluggish kinetics of oxygen reactions and limited battery lifespan. Herein, a "raisin-bread" architecture is designed for a hybrid catalyst constituting cobalt nitride as the core nanoparticle with thin oxidized coverings, which is further deposited within porous carbon aerogel. Based on synchrotron-based characterizations, this hybrid provides oxygen vacancies and Co-Nx -C sites as the active sites, resulting from a strong coupling between CoOx Ny nanoparticles and 3D conductive carbon scaffolds. Compared to the oxide reference, it performs enhanced stability in harsh electrocatalytic environments, highlighting the benefits of the oxynitride. Furthermore, the 3D conductive scaffolds improve charge/mass transportation and boost durability of these active sites. Density functional theory calculations reveal that the introduced N species into hybrid can synergistically tune the d-band center of cobalt and improve its bifunctional activity. As a result, the obtained air cathode exhibits bifunctional overpotential of 0.65 V and a battery lifetime exceeding 1350 h, which sets a new record for rechargeable Zn-air battery reported so far.

Cu-In Dual Sites with Sulfur Defects Toward Superior Ethanol Electrosynthesis from CO2 Electrolysis

The electrosynthesis of multi-carbon chemicals from excess CO2 is an area of great interest for research and commercial applications. However, improving both the yield of CO2 -to-ethanol conversion and the stability of the catalyst at the same time is proving to be a challenging issue. Here we propose to stabilize active Cu(I) and In dual sites with sulfur defects through an electro-driven intercalation strategy, which leads to the delocalization of electron density that enhances orbital hybridizations between the Cu-C and In-H bonds. Hence, the energy barrier for the rate-limiting *CHO formation step is reduced toward the key *OCHCHO* formation during ethanol production, which is also facilitated by the combined Cu site enabling C-C coupling and In site with a higher oxygen affinity based on both thermodynamic and kinetic calculations. Accordingly, such dual-site catalyst achieves a high partial current density toward ethanol of 409 ± 15 mA/cm2 for over 120 hours. Furthermore, a scaled-up flow cell is assembled with an industrial-relevant current of 5.7 A for over 36 hours, in which the carbon loss is less than 2.5% and single-pass carbon efficiency is around 19%. This article is protected by copyright. All rights reserved.

Precise Tailoring of Lithium-Ion Transport for Ultralong-Cycling Dendrite-Free All-Solid-State Lithium Metal Batteries

All-solid-state lithium metal batteries can address crucial challenges regarding insufficient battery cycling life and energy density. The demonstration of long-cycling dendrite-free all-solid-state lithium metal batteries requires precise tailoring of lithium-ion transport of solid-state electrolytes (SSEs). In this work, a proof of concept is reported for precise tailoring of lithium-ion transport of a halide SSE, Li3 InCl6 , including intragranular (within grains) but also intergranular (between grains) lithium-ion transport. Lithium-ion migration tailoring mechanism in crystals is developed by unexpected enhanced Li, In, and Cl vacancy populations and lower energy barrier for hopping. The lithium-ion transport tailoring mechanism between the grains is determined by the elimination of voids between grains and the formation of unexpected supersonic conducting grain boundaries, boosting the lithium dendrite suppression ability of SSE. Due to boosted lithium-ion conduction and dendrite-suppression ability, the all-solid-state lithium metal batteries coupled with Ni-rich LiNi0.83 Co0.12 Mn0.05 O2 cathodes and lithium metal anodes demonstrate breakthroughs in electrochemical performance by achieving extremely long cycling life at a high current density of 0.5 C (2000 cycles, 93.7% capacity retention). This concept of precise tailoring of lithium-ion transport provides a cost, time, and energy efficient solution to conquer the remaining challenges in all-solid-state lithium-metal batteries for fast developing electric vehicle markets.

Lithium-compatible and air-stable vacancy-rich Li9N2Cl3 for high-areal capacity, long-cycling all-solid-state lithium metal batteries

Attaining substantial areal capacity (>3 mAh/cm2) and extended cycle longevity in all-solid-state lithium metal batteries necessitates the implementation of solid-state electrolytes (SSEs) capable of withstanding elevated critical current densities and capacities. In this study, we report a high-performing vacancy-rich Li9N2Cl3 SSE demonstrating excellent lithium compatibility and atmospheric stability and enabling high-areal capacity, long-lasting all-solid-state lithium metal batteries. The Li9N2Cl3 facilitates efficient lithium-ion transport due to its disordered lattice structure and presence of vacancies. Notably, it resists dendrite formation at 10 mA/cm2 and 10 mAh/cm2 due to its intrinsic lithium metal stability. Furthermore, it exhibits robust dry-air stability. Incorporating this SSE in Ni-rich LiNi0.83Co0.11Mn0.06O2 cathode-based all-solid-state batteries, we achieve substantial cycling stability (90.35% capacity retention over 1500 cycles at 0.5 C) and high areal capacity (4.8 mAh/cm2 in pouch cells). These findings pave the way for lithium metal batteries to meet electric vehicle performance demands.

Camrelizumab with Chemoradiotherapy for Locally Advanced Biliary Tract Cancer: Preliminary Results from A Phase II Study

PURPOSE/OBJECTIVE(S)

For locally advanced biliary tract cancer (BTC), capecitabine-based chemoradiotherapy (CRT) is commonly used but has limited benefits. Immunotherapy is potentially effective for BTC and may be synergized with CRT. Followed by gemcitabine and cisplatin (GP) consolidation chemotherapy (CT), we evaluated the safety and efficacy of combined camrelizumab and capecitabine-based CRT for locally advanced BTC.

MATERIALS/METHODS

Patients had stage II-III (T4N0M0, T1-4N+M0) BTC (per the 7th [2010] edition of the American Joint Committee on Cancer staging system) were eligible for CRT (capecitabine plus [50-60 Gy] radiotherapy), to be followed by GP CT. Camrelizumab was given concurrently with CRT. Safety was defined as the incidence and severity of adverse events (AEs), while efficacy was defined as overall survival (OS), progression-free survival (PFS), objective response rate (ORR) and disease control rate (DCR).

RESULTS

Ten patients completed the planned treatment. None experienced grade ≥3 treatment-related AEs during CRT. Grade ≥3 immune-related AEs occurred in 2 of 10 patients (20%) only during GP CT. The mean OS time was 18.2 months (95% confidence interval [CI] 12.9m-23.5m) while the median OS time was 14.1 months (95% CI 10.1m-18.1m). OS rates were 100%, 59%, 44% at 6 months, 1 year and 2 years, respectively. The ORR was 30% while the DCR was 90%. Two patients (20%) obtained OS over 2 years with partial response (25.9m, 29.1m). Median PFS time was 14.1 months (95% CI 9.3m-18.9m).

CONCLUSION

Camrelizumab in combination with concurrent CRT was well tolerated and did not impair delivery of CRT in patients with locally advanced BTC.

Crystallization Engineering of CuNi2 S4 Ultra-Fine Nanocrystals with Optimized Band Structures for Efficient Photocatalytic Pollutant Degradation and Hydrogen Production

The mono-dispersed cubic siegenite CuNi2 S4 ultra-fine (≈5 nm) nanocrystals are fabricated through crystallization engineering under hot injection. The strong hydroxylation on mostly exposed CuNi2 S4 (220) surface leads to the formation of multi-valence (Cu+ , Cu2+ , Ni2+ , Ni3+ ) species with unsaturated hybridization and coordination micro-environments, which can induce rich redox reactions to optimize interfacial kinetics for the adsorbed reaction intermediates. The as-synthesized CuNi2 S4 nanocrystals with ultra-small particle size and the characteristics of being highly dispersed can increase specific surface area and hydroxylated active sites, which considerably contribute to the improvement of photocatalytic activities. Experimental and theoretical studies indicate that the CuNi2 S4 with unique surface condition can properly modulate the charge density distribution and the electronic band structure, thus achieving an optimal band gap for enhancing visible light absorption. Additionally, the strong hydroxylation on CuNi2 S4 (220) surface can not only make the photocatalytic process stable in alkaline environment but also bring about an impurity level between conduction and valence band, which facilitates the separation of photo-induced charge carriers by suppressing the rapid re-combination of exited electrons and holes. The optimization of band structure should be the intrinsic reason for the efficient photocatalytic pollutant degradation and hydrogen production under visible light illumination.

[A close contact of coronavirus disease 2019 with severe imported malaria: a case report]

This article presents a severe cerebral malaria patient in shock with a close contact of COVID-19 that was successfully cured in a negative pressure ward during the global pandemic of COVID-19. The patient experienced a sudden onset of high fever and coma in a designated isolation hotel after returning from Africa, and was transferred to a designated hospital. Following antimalarial therapy, blood pressure elevation, increase of blood volume, bedside hemodialysis, mechanical ventilation, plasma and platelet transfusions, the case gradual recovered.

Prevalence, drivers and surveillance of antibiotic resistance and antibiotic use in rural China: Interdisciplinary study

This study aimed to characterise antibiotic prescribing and dispensing patterns in rural health facilities in China and determine the community prevalence of antibiotic resistance. We investigated patterns and drivers of antibiotic use for common respiratory and urinary tract infections (RTI/UTI) in community settings, examined relationships between presenting symptoms, clinical diagnosis and microbiological results in rural outpatient clinics, and assessed potential for using patient records to monitor antibiotic use. This interdisciplinary mixed methods study included: (i) Observations and exit interviews in eight village clinics and township health centres and 15 retail pharmacies; (ii) Urine, throat swab and sputum samples from patients to identify potential pathogens and test susceptibility; (iii) 103 semi-structured interviews with doctors, patients, pharmacy workers and antibiotic-purchasing customers; (iv) Assessment of completeness and accuracy of electronic patient records through comparison with observational data. 87.9% of 1123 recruited clinic patients were prescribed antibiotics (of which 35.5% contained antibiotic combinations and >40% were for intravenous administration), most of whom had RTIs. Antibiotic prescribing for RTIs was not associated with presence of bacterial pathogens but was correlated with longer duration of infection (OR = 3.33) and presence of sore throat (OR = 1.64). Fever strongly predicted prescription of intravenous antibiotics (OR = 2.87). Resistance rates in bacterial pathogens isolated were low compared with national data. 25.8% of patients reported antibiotics use prior to their clinic visit, but only 56.2% of clinic patients and 53% of pharmacy customers could confirm their prescription or purchase included antibiotics. Diagnostic uncertainty, financial incentives, understanding of antibiotics as anti-inflammatory and limited doctor-patient communication were identified as key drivers of antibiotic use. Completion and accuracy of electronic patient records were highly variable. Prevalence of antibiotic resistance in this rural population is relatively low despite high levels of antibiotic prescribing and self-medication. More systematic use of e-records and in-service training could improve antibiotic surveillance and stewardship in rural facilities. Combining qualitative and observational anthropological methods and concepts with microbiological and epidemiological investigation of antibiotic resistance at both research design and analytic synthesis stages substantially increases the validity of research findings and their utility in informing future intervention development.

A family of oxychloride amorphous solid electrolytes for long-cycling all-solid-state lithium batteries

Solid electrolyte is vital to ensure all-solid-state batteries with improved safety, long cyclability, and feasibility at different temperatures. Herein, we report a new family of amorphous solid electrolytes, xLi₂O-MCl_y (M = Ta or Hf, 0.8 ≤ x ≤ 2, y = 5 or 4). xLi₂O-MCl_y amorphous solid electrolytes can achieve desirable ionic conductivities up to 6.6 × 10^-3S cm^-1 at 25 °C, which is one of the highest values among all the reported amorphous solid electrolytes and comparable to those of the popular crystalline ones. The mixed-anion structural models of xLi₂O-MCl_y amorphous SEs are well established and correlated to the ionic conductivities. It is found that the oxygen-jointed anion networks with abundant terminal chlorines in xLi₂O-MCl_y amorphous solid electrolytes play an important role for the fast Li-ion conduction. More importantly, all-solid-state batteries using the amorphous solid electrolytes show excellent electrochemical performance at both 25 °C and -10 °C. Long cycle life (more than 2400 times of charging and discharging) can be achieved for all-solid-state batteries using the xLi₂O-TaCl₅ amorphous solid electrolyte at 400 mA g^-1, demonstrating vast application prospects of the oxychloride amorphous solid electrolytes.

[A single-center study on the distribution and antibiotic resistance of pathogens causing bloodstream infection in patients with hematological malignancies]

Objective: To study the incidence of bloodstream infections, pathogen distribution, and antibiotic resistance profile in patients with hematological malignancies. Methods: From January 2018 to December 2021, we retrospectively analyzed the clinical characteristics, pathogen distribution, and antibiotic resistance profiles of patients with malignant hematological diseases and bloodstream infections in the Department of Hematology, Nanfang Hospital, Southern Medical University. Results: A total of 582 incidences of bloodstream infections occurred in 22,717 inpatients. From 2018 to 2021, the incidence rates of bloodstream infections were 2.79%, 2.99%, 2.79%, and 2.02%, respectively. Five hundred ninety-nine types of bacteria were recovered from blood cultures, with 487 (81.3%) gram-negative bacteria, such as Klebsiella pneumonia, Escherichia coli, and Pseudomonas aeruginosa. Eighty-one (13.5%) were gram-positive bacteria, primarily Staphylococcus aureus, Staphylococcus epidermidis, and Enterococcus faecium, whereas the remaining 31 (5.2%) were fungi. Enterobacteriaceae resistance to carbapenems, piperacillin/tazobactam, cefoperazone sodium/sulbactam, and tigecycline were 11.0%, 15.3%, 15.4%, and 3.3%, with a descending trend year on year. Non-fermenters tolerated piperacillin/tazobactam, cefoperazone sodium/sulbactam, and quinolones at 29.6%, 13.3%, and 21.7%, respectively. However, only two gram-positive bacteria isolates were shown to be resistant to glycopeptide antibiotics. Conclusions: Bloodstream pathogens in hematological malignancies were broadly dispersed, most of which were gram-negative bacteria. Antibiotic resistance rates vary greatly between species. Our research serves as a valuable resource for the selection of empirical antibiotics.

[Current status of diagnosis and treatment of chronic lymphocytic leukemia in China: A national multicenter survey research]

Objective: To understand the current status of diagnosis and treatment of chronic lymphocytic leukemia (CLL) /small lymphocytic lymphoma (SLL) among hematologists, oncologists, and lymphoma physicians from hospitals of different levels in China. Methods: This multicenter questionnaire survey was conducted from March 2021 to July 2021 and included 1,000 eligible physicians. A combination of face-to-face interviews and online questionnaire surveys was used. A standardized questionnaire regarding the composition of patients treated for CLL/SLL, disease diagnosis and prognosis evaluation, concomitant diseases, organ function evaluation, treatment selection, and Bruton tyrosine kinase (BTK) inhibitor was used. Results: ①The interviewed physicians stated that the proportion of male patients treated for CLL/SLL is higher than that of females, and the age is mainly concentrated in 61-70 years old. ②Most of the interviewed physicians conducted tests, such as bone marrow biopsies and immunohistochemistry, for patient diagnosis, in addition to the blood test. ③Only 13.7% of the interviewed physicians fully grasped the initial treatment indications recommended by the existing guidelines. ④In terms of cognition of high-risk prognostic factors, physicians' knowledge of unmutated immunoglobulin heavy-chain variable and 11q- is far inferior to that of TP53 mutation and complex karyotype, which are two high-risk prognostic factors, and only 17.1% of the interviewed physicians fully mastered CLL International Prognostic Index scoring system. ⑤Among the first-line treatment strategy, BTK inhibitors are used for different types of patients, and physicians have formed a certain understanding that BTK inhibitors should be preferentially used in patients with high-risk factors and elderly patients, but the actual use of BTK inhibitors in different types of patients is not high (31.6%-46.0%). ⑥BTK inhibitors at a reduced dose in actual clinical treatment were used by 69.0% of the physicians, and 66.8% of the physicians had interrupted the BTK inhibitor for >12 days in actual clinical treatment. The use of BTK inhibitors is reduced or interrupted mainly because of adverse reactions, such as atrial fibrillation, severe bone marrow suppression, hemorrhage, and pulmonary infection, as well as patients' payment capacity and effective disease progression control. ⑦Some differences were found in the perceptions and behaviors of hematologists and oncologists regarding the prognostic assessment of CLL/SLL, the choice of treatment options, the clinical use of BTK inhibitors, etc. Conclusion: At present, a gap remains between the diagnosis and treatment of CLL/SLL among Chinese physicians compared with the recommendations in the guidelines regarding the diagnostic criteria, treatment indications, prognosis assessment, accompanying disease assessment, treatment strategy selection, and rational BTK inhibitor use, especially the proportion of dose reduction or BTK inhibitor discontinuation due to high adverse events.

Nanosecond Laser Confined Bismuth Moiety with Tunable Structures on Graphene for Carbon Dioxide Reduction

Substrate-supported catalysts with atomically dispersed metal centers are promising for driving the carbon dioxide reduction reaction (CO₂RR) to produce value-added chemicals; however, regulating the size of exposed catalysts and optimizing their coordination chemistry remain challenging. In this study, we have devised a simple and versatile high-energy pulsed laser method for the enrichment of a Bi "single atom" (SA) with a controlled first coordination sphere on a time scale of nanoseconds. We identify the mechanistic bifurcation routes over a Bi SA that selectively produce either formate or syngas when bound to C or N atoms, respectively. In particular, C-stabilized Bi (Bi-C) exhibits a maximum formate partial current density of -29.3 mA cm^-2 alongside a TOF value of 2.64 s^-1 at -1.05 V vs RHE, representing one of the best SA-based candidates for CO₂-to-formate conversion. Our results demonstrate that the switchable selectivity arises from the different coupling states and metal-support interactions between the central Bi atom and adjacent atoms, which modify the hybridizations between the Bi center and *OCHO/*COOH intermediates, alter the energy barriers of the rate-determining steps, and ultimately trigger the branched reaction pathways after CO₂ adsorption. This work demonstrates a practical and universal ultrafast laser approach to a wide range of metal-substrate materials for tailoring the fine structures and catalytic properties of the supported catalysts and provides atomic-level insights into the mechanisms of the CO₂RR on ligand-modified Bi SAs, with potential applications in various fields.

[Analysis of the causes of long-standing pelvic anterior sacral space infection and discussion of management techniques]

Objective: To investigate the causes and management of long-term persistent pelvic presacral space infection. Methods: Clinical data of 10 patients with persistent presacral infection admitted to the Cancer Hospital of Zhengzhou University from October 2015 to October 2020 were collected. Different surgical approaches were used to treat the presacral infection according to the patients' initial surgical procedures. Results: Among the 10 patients, there were 2 cases of presacral recurrent infection due to rectal leak after radiotherapy for cervical cancer, 3 cases of presacral recurrent infection due to rectal leak after radiotherapy for rectal cancer Dixons, and 5 cases of presacral recurrent infection of sinus tract after adjuvant radiotherapy for rectal cancer Miles. Of the 5 patients with leaky bowel, 4 had complete resection of the ruptured nonfunctional bowel and complete debridement of the presacral infection using an anterior transverse sacral incision with a large tipped omentum filling the presacral space; 1 had continuous drainage of the anal canal and complete debridement of the presacral infection using an anterior transverse sacral incision. 5 post-Miles patients all had debridement of the presacral infection using an anterior transverse sacral incision combined with an abdominal incision. The nine patients with healed presacral infection recovered from surgery in 26 to 210 days, with a median time of 55 days. Conclusions: Anterior sacral infections in patients with leaky gut are caused by residual bowel secretion of intestinal fluid into the anterior sacral space, and in post-Miles patients by residual anterior sacral foreign bodies. An anterior sacral caudal transverse arc incision combined with an abdominal incision is an effective surgical approach for complete debridement of anterior sacral recalcitrant infections.

Exome-wide screening identifies novel rare risk variants for bone mineral density

Bone mineral density (BMD) is an independent risk factor of osteoporosis-related fractures. We performed gene-based burden tests to assess the association between rare variants and BMD, and identified several BMD candidate genes.

PURPOSE

BMD is highly heritable and a major predictor of osteoporotic fractures, but its genetic basis remains unclear. We aimed to identify rare risk variants contributing to BMD.

METHODS

Utilizing the newly released UK Biobank 200,643 exome dataset, we conducted a gene-based exome-wide association study in males and females, respectively. First, 100,639 males and 117,338 females with BMD values were included in the polygenic risk scores (PRS) analysis. Among individuals with lower 30% PRS, cases were individuals with top 10% BMD, and individuals with bottom 10% BMD were the controls. Considering the effects of vitamin D (VD), individuals with the highest 30% VD concentration were selected for VD-BMD analysis. After quality control, 741 males and 697 females were included in the BMD analysis, and 717 males and 708 females were included in the VD-BMD analysis. The variants were annotated by ANNOVAR software, then BMD and VD-BMD qualified variants were imported into the SKAT R-package to perform gene-based burden tests, respectively.

RESULTS

The gene-based burden test of the exonic variants identified genome-wide candidate associations in ANKRD18A (P = 1.60 × 10^-5, P_{Bonferroni adjust} = 2.11 × 10^-3), C22orf31 (P = 3.49 × 10^-4, P_{Bonferroni adjust} = 3.17 × 10^-2), and SPATC1L (P = 1.09 × 10^-5, P_{Bonferroni adjust} = 8.80 × 10^-3). For VD-BMD analysis, three genes were associated with BMD, such as NIPAL1 (P = 1.06 × 10^-3, P_{Bonferroni adjust} = 3.91 × 10^-2).

CONCLUSIONS

Our study suggested that rare variants contribute to BMD, providing new sights for broadening the genetic structure of BMD.

Regulation of Outer Solvation Shell Toward Superior Low-Temperature Aqueous Zinc-Ion Batteries

Aqueous Zn-ion batteries are well regarded among a next-generation energy-storage technology due to their low cost and high safety. However, the unstable stripping/plating process leading to severe dendrite growth under high current density and low temperature impede their practical application. Herein, it is demonstrated that the addition of 2-propanol can regulate the outer solvation shell structure of Zn²⁺ by replacing water molecules to establish a "eutectic solvation shell", which provides strong affinity with the Zn (101) crystalline plane and fast desolvation kinetics during the plating process, rendering homogeneous Zn deposition without dendrite formation. As a result, the Zn anode exhibits promising cycle stability over 500 h under an elevated current density of 15 mA cm^-2 and high depth of discharge of 51.2%. Furthermore, remarkable electrochemical performance is achieved in a 150 mAh Zn|V₂ O₅ pouch cell over 1000 cycles at low temperature of -20 °C. This work not only offers a new strategy to achieve excellent performance of aqueous Zn-ion batteries under harsh conditions, but also reveals electrolyte structure designs that can be applied in related energy storage and conversion fields.

Reduction of artifacts and noise in small electrogram datasets without manual annotation using transfer machine learning

Background/Introduction

Mapping AF is challenging. Monophasic action potentials (MAPs) show that most of the recorded signals are not representing the atrial activity, and arise from far-field or other artifacts. Thus, reducing noise in electrophysiological signals is essential, yet it can be difficult for cross-talk from other chambers and pacing. Strategies to reduce noise include template matching, averaging, and smoothing, but all of them have major limitations. Furthermore, expert interpretation requires knowledge to discriminate signals from noise, but is subjective.

Purpose

We hypothesised a) that atrial and ventricular electrograms with varying artifact and noise can be denoised using autoencoder neural networks (NNs) without requiring manual annotation and in a reproducible manner, and b) we could train these NNs on a large available dataset ventricular signals, then apply transfer learning to the original smaller atrial dataset. We applied this approach to MAPs, which have interpretable shapes and would help identifying local from far-field signals helping in diagnosis, mapping and ablation.

Methods

We first trained with 5706 left and right ventricular MAPs from 42 patients with ischemic cardiomyopathy (age 65±13y; Fig. 1A), with 60% for training, 20% (validation) and 20% (testing). Transfer learning and parameter-tuning were then used to apply this NN to a smaller sample of atrial MAPs (N=641 from 21 patients, 67±5y, 13 women; Fig. 2B, D, F). The autoencoder was used to eliminate pacing artifacts in ventricular MAPs (Fig. 1B, C) and denoise atrial MAPs (Fig. 2C, E, G) by reconstructing key learned features. The accuracy of the reconstruction was evaluated using Pearson Correlation Coefficient (PCC) and a novel similarity coefficient (SC). No manual annotation was required to identify noisy signals.

Results

The trained NN encoder learned key features of ventricular MAPs and reconstructed these clean signals with a SC=0.91±0.16 and PCC=0.99±0.01 (Fig. 1A). With this training, the NN was able to denoise ventricular MAPs with pacing artifact (Fig. 1B, C). After fine-tuning, the NN learned key signal features (upstroke, triangular descent, terminus) and thus reduced diverse noise without specific training or manual annotation. Namely, it was able to reconstruct atrial MAPs eliminating ventricular noise, high frequency noise and truncated signals (Fig. 2).

Conclusions

Machine learned encoder-decoders are powerful tools that can learn essential features of atrial and ventricular signals and hence isolate noise. Transfer learning is effective when large datasets are unavailable for training. This approach can separate atrial beats from far-field ventricular beats and other sources of noise. The ability to eliminate a diverse range of noise improves this approach over existing techniques and may have far-reaching applications in electrophysiology, such as mapping and ablation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH

Novel electrogram featurization reveals a spectrum of response to ablation from atrial tachycardia to types of atrial fibrillation

Background

Although atrial tachycardia (AT) may interconvert with fibrillation (AF) in many patients, it is undefined if this represents a pathophysiological spectrum of organization, or whether it indicates that AF will respond better to ablation.

Objective

To test the hypothesis that the spatial area within which electrograms (EGMs) repeat in synchronized fashion over time indicates a spectrum from AT, in which areas span the entire atria, to AF, in which areas are limited. We further hypothesized that repetitive areas would be larger in AF patients with acute termination than in those with poor response to ablation.

Methods

We studied N=234 patients (47% women, 64±10Y), of whom (i) N=10 had AT, (ii) N=120 had AF that terminated with ablation (“Term”), (ii) N=104 had AF that did not terminate (“Non-term”). All patients had global left atrial mapping by 64 pole baskets (Abbott, IL). Spatial areas of repetitive activity (REACT) were calculated by correlating unipolar EGMs in 2x2 grids for 4 sec, repeated for the entire atria (Figure 1A, B). We quantified global organization by averaging the REACT map for each patient.

Results

Figure 1C shows progressively decreasing areas of repetitive EGM from AT to AF Term to AF Non-term (p<0.001, ANOVA). Figure 1D shows a case of AT in a 71 YO male and global REACT >0.90, a case of AF REACT 0.45 in a 65 YO male with termination by ablation, and a case of AF with REACT 0.19 in an 85 YO male that did not terminate. Further, ROC analysis of REACT analysis in AF cases predicted termination with an AUC of 0.71.

Conclusion

Spatial areas of repeating electrogram shapes indicates a spectrum from AT to AF with good and AF with poor acute response to ablation. Future studies should investigate whether REACT areas can be identified non-invasively, such as by body surface ECG, to guide ablation or prognosis.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

Spatiotemporal signatures of response to atrial fibrillation ablation

Background

Atrial fibrillation (AF) can have organized regions, in the form of consistent dominant frequency sites, focal or reentrant sites, but it is unclear how these overlap with or differ from focal atrial tachycardias (AT) or potential drivers. We set out to develop an intuitive method based on fundamental electrogram shape and timing to separate types of AF.

Objective

To test the hypothesis that spatial regions of electrogram (EGM) in AF that show similar shapes over time based on cross-correlation analysis may separate patients with differing response to ablation.

Methods

We recruited N=133 patients (63.8±12.1 Y, 32% women), (i) N=10 had AT, (ii) N=122 AF that was or was not terminated by ablation, and (iii) N=1 pacing. All patients had left atrial mapping by 64 pole baskets. We applied repetitive activity (REACT) mapping that correlates EGMs in contiguous 2x2 regions (Fig. 1A) over 4sec. To calibrate REACT, we introduced simulated variations in shape (gaussian noise) and timing (gaussian delay) to pacing EGMs and computed nomograph over 100 random trials (Fig. 1C).

Results

Fig. 1B shows that REACT in a 71-year-old man with AT is more organized than in a 65 YO man with AF (100% vs 40% mapped field). Overall, REACT was higher in AT than AF (0.63±0.15 vs 0.36±0.22, p<0.001). There were 24 cases in which global REACT between AF and AT groups had the overlapping range of values, indicating organized “islands” in AF analogous to AT. From nomograph in Fig. 1C we identified that this overlap reflects 15 ms variation in cycle length and 20% variation in EGM shape (labelled “x” in Fig. 1C).

Conclusion

Basic electrogram properties in AF of similar shapes in spatial areas over time can separate response to ablation and may represent “islands” of AT. Future studies should investigate the mechanisms for such islands and whether they may be targeted for therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

Automatic left atrial segmentation from cardiac CT using computer graphics imaging and deep learning

Introduction

Segmenting left atrial (LA) substructures, including the LA body, appendage (LAA), and pulmonary veins (PVs), from computed tomography (CT) is central to electroanatomic mapping for ablation and functional studies in patients with atrial fibrillation (AF). However, this process requires manual outlining which needs special training, is subjective, and is difficult to scale. Computer graphics imaging (CGI) has been applied in media, film, and computer-aided design to reliably segment complex structures using their basic geometric representations.

Purpose

We hypothesized that LA substructures can be “virtually” dissected using CGI to separate geometric contours of the “convex ellipsoid” LA, “tubular” PVs, and “conical” LAA. We further hypothesized that the results of virtual dissection can be used to train a deep learning (DL) model to segment raw CT scans.

Methods

First, a mathematical method based on CGI techniques – erosion and dilation – was developed to “virtually dissect” the convex LA body from the original concave shell in publicly available digital atria with diverse simulated morphologies (Fig. 1A). The PVs and LAA were then automatically revealed and labeled by a 3D subtraction approach. Second, we refined precise LA/PV/LAA boundaries by tuning hyper-parameters from N=5 patient shells (Fig. 1B). Third, we used virtual dissection to train a DL model to segment CTs in N=20 patient atria (Fig. 1C). Finally, we applied this pipeline to segment raw CTs in a validation cohort of N=105 patients (23.8% women, 63.8±10.3Y; Fig. 1D).

Results

Virtual dissection accurately identified LA/PV/LAA boundaries in the training set (Dice coefficients 89–98%). In the independent test cohort (N=105), this automated pipeline accurately segmented raw CTs with Dice 81–95% (Fig. 1D) compared to a panel of experts (p<0.001).

Conclusion

CGI of basic cardiac geometry combined with deep learning in small datasets can accurately segment raw CT scans in large populations. This computational pipeline may automate and simplify cardiac image processing and ablation procedures, and could be applied to the ventricle or other organ systems for diverse therapeutic strategies or to train machine learning.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health

Artificial intelligence to reduce artifact in cardiac electrophysiological signals

Background/Introduction

Signals in Electrophysiology cases are often noisy despite laboratory shielding and filtering, and current noise-reduction methods are suboptimal. Template matching can identify a “nearest type” of electrogram, but libraries of signal shapes may be unavailable. Beat averaging can reduce noise but obscures beat-to-beat variations and is not optimal to analyze dynamically changing signals, such as when moving a catheter in the heart. Smoothing reduces noise yet blurs high frequency components.

Purpose

We set out to test if machine learned autoencoders could reduce noise in single beats without requiring massive training data or beat libraries. Specifically, we hypothesised that noisy electrograms in small datasets of atrial signals could be de-noised using an encoder-decoder neural network (NN) using transfer learning of machines trained to recognize key features in larger datasets of related signals.

Methods

We applied NN to monophasic action potentials (MAPs), because they have visually verifiable shapes. The NN was first trained to reconstruct 5706 left and right ventricular MAPs in 42 patients (67±13y; Fig. 1A). Transfer learning was then used to apply the NN to a much smaller dataset of 641 atrial MAPs in 21 patients (67±5y, 13 women; Fig. 1B, D, F).

Results

NN reconstructed atrial MAPs with a Pearson correlation of 0.87±0.11. After fine-tuning, NN reconstruction accuracy improved dramatically (Pearson 0.99±0.01; p<0.001). In Fig. 1B–G the NN learned key MAP features (upstroke, triangular descent, terminus) and thus could eliminate ventricular artifact and electrical circuit noise without specific training or manual annotation.

Conclusion

Machine learned autoencoders are a novel and powerful approach to de-noise electrophysiological signals in a dynamic, beat-to-beat fashion. The ability to learn fundamental signal features from models trained in large datasets, and apply them via transfer learning to small datasets in different heart chambers may have wide ranging applications for automated signal annotation, mapping and ablation.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH

Self-repairing interphase reconstructed in each cycle for highly reversible aqueous zinc batteries

Aqueous zinc (Zn) chemistry features intrinsic safety, but suffers from severe irreversibility, as exemplified by low Coulombic efficiency, sustained water consumption and dendrite growth, which hampers practical applications of rechargeable Zn batteries. Herein, we report a highly reversible aqueous Zn battery in which the graphitic carbon nitride quantum dots additive serves as fast colloid ion carriers and assists the construction of a dynamic & self-repairing protective interphase. This real-time assembled interphase enables an ion-sieving effect and is found actively regenerate in each battery cycle, in effect endowing the system with single Zn²⁺ conduction and constant conformal integrality, executing timely adaption of Zn deposition, thus retaining sustainable long-term protective effect. In consequence, dendrite-free Zn plating/stripping at ~99.6% Coulombic efficiency for 200 cycles, steady charge-discharge for 1200 h, and impressive cyclability (61.2% retention for 500 cycles in a Zn | |MnO₂ full battery, 73.2% retention for 500 cycles in a Zn | |V₂O₅ full battery and 93.5% retention for 3000 cycles in a Zn | |VOPO₄ full battery) are achieved, which defines a general pathway to challenge Lithium in all low-cost, large-scale applications.

Metallic zinc is an ideal anode material for aqueous rechargeable batteries but reversibility is a challenge. Here, the authors realise a dynamic real-time reconstructed interphase on zinc anode formed by graphitic carbon nitride quantum dot as an electrolyte additive to improve the performance of Zn metal anodes.

Photocatalytic disinfection for point-of-use water treatment using Ti3+ self-doping TiO2 nanoparticle decorated ceramic disk filter

The challenge from pathogenic infections still threatens the health and life of people in developing areas. An efficient, low-cost, and abundant-resource disinfection method is desired for supplying safe drinking water. This study aims to develop a novel Ti³⁺ doping TiO₂ nanoparticle decorated ceramic disk filter (Ti³⁺/TiO₂@CDF) for point-of-use (POU) disinfection of drinking water. The production of Ti³⁺/TiO₂@CDF was optimized to maximize disinfection efficiency and flow rate. Under optimal conditions, the log reduction value (LRV) could reach up to 7.18 and the flaw rate was 108 mL/h. The influences of environmental factors were also investigated. Natural or slightly alkaline conditions, low turbidity, and low concentration of humic acid were favorable for the disinfection of Ti³⁺/TiO₂@CDF, while co-existing HCO₃^- ions and diatomic cations (Ca²⁺ and Mg²⁺) exhibited the opposite effect. Furthermore, the practicability and stability of Ti³⁺/TiO₂@CDF was demonstrated. Ti³⁺/TiO₂@CDF showed high disinfection efficiency for E. coli and S. aureus under a range of concentrations. Long-term experiment indicated that Ti³⁺/TiO₂@CDF was stable. The underlying disinfection mechanisms were investigated and concluded as the combination of retention, adsorption, and photocatalytic disinfection. The developed Ti³⁺/TiO₂@CDF can provide an effective and reliable disinfection tool for POU water treatment in remote area.

AB1485 PATIENT-REPORTED OUTCOMES AND BIOMARKERS ASSOCIATED WITH THE CUTANEOUS DERMATOMYOSITIS AREA AND SEVERITY ACTIVITY (CDASI-A) SCORE IN A PHASE 2 CLINICAL TRIAL IN DERMATOMYOSITIS

Background

Retrospective reviews of clinical databases from two sites have identified strong relationships between patient-reported outcomes and skin activity in dermatomyositis (DM), as measured by CDASI-A.1,2 No studies validate these associations in a controlled setting. Additionally, the relationship between the PROMIS-29 Short Form and skin activity in DM has not been assessed. Previous investigations have demonstrated a correlation between IL-31 and itch in DM.3 IFN-β and IFN-γ are known type I and II interferons, which are critical drivers of DM pathogenesis.4

Objectives

To assess correlations between CDASI-A, quality of life (QoL), and biomarkers of disease activity in a double-blind, randomized, placebo-controlled clinical trial.

Methods

Data were retrospectively collected from five visits of a Phase 2 trial evaluating Lenabasum, a cannabinoid receptor type 2 agonist. Quality of life assessments extracted from the trial included Patient Global Assessment (PtGA) scores, PROMIS domains, and Skindex domains. Skindex question 10, regarding itch, was included in the analysis as a separate domain. Physician Global Assessment scores were also evaluated. Additionally, biomarkers derived from skin samples via IHC/PCR collected at visits 1 and 6 were assessed for predictors of CDASI-A response and association with disease activity. Analysis used linear mixed effect models to account for within subject-variability and repeated measures, where applicable. Analysis was performed without regard to treatment arm, as our goal was to correlate CDASI, QoL, and biomarkers among all subjects.

Results

Data from 22 subjects with DM and a combined total of 110 visits were included. Biopsies were collected from 12 subjects. Improvement in CDASI-A significantly correlated with Skindex-S, Skindex-E, Skindex-F, Skindex-Itch, PtGA global skin, PtGA global skin, PtGA global skin, and PtGA global skin, with p < 0.001. Improvement in PROMIS social role (p = 0.046) correlated with improvement in CDASI-A. Worsening of PROMIS fatigue (p = 0.019) and pain (p < 0.001) correlated with improvement in CDASI-A. Decreases in PGA overall disease, PGA skin activity, and PGA global skin all correlated with improvement of CDASI-A (p < 0.001). Change in IL-31 protein area positively correlated with change in disease activity (p = 0.047). A positive relationship between changes in IFN-β and IFN-γ protein area and disease activity trended towards significance.

Conclusion

In accordance with previous investigations from our group, well-established measures of QoL correlated significantly with CDASI-A. These findings support that CDASI-A reflects both clinical and patient-reported aspects of skin disease and is an appropriate outcome in DM clinical trials. Additionally, Skindex and PtGA scores may better relate to skin activity as measured by the CDASI compared to PROMIS domains. IL-31, a cytokine previously associated with itch in DM,3 correlated significantly with CDASI-A in our study. Trends for IFN-β and IFN-γ reduction with disease improvement support their role in the pathogenesis of DM. This study helps define patient-reported outcomes and biomarkers that may be informative in DM trials.

References

[1]Goreshi R, et al. J Am Acad Dermatol. 2011;65(6):1107-1116

[2]Robinson ES, et al. Br J Dermatol. 2015;172(1):169-174.

[3]Patel J, et al. J Invest Dermatol. 2021;141(9):2151-2160.

[4]Wong D, et al. PLoS One. 2012;7(1):e29161

Disclosure of Interests

Joshua Dan: None declared, Jay Patel: None declared, Grant Sprow: None declared, Josef Concha: None declared, Rui Feng: None declared, Nilesh Kodali: None declared, Thomas Vazquez: None declared, DeAnna Diaz: None declared, Barbara White Shareholder of: Corbus Pharmaceuticals, Victoria Werth Speakers bureau: University of Pennsylvania, which owns the copyright for the CDASI, Grant/research support from: Corbus Pharmaceuticals

Sleep apnea is associated with stroke in young patients with or without atrial fibrillation:A population study of &gt;2 million individuals

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH, R01 HL149134, R01HL83359

Background

Both Sleep Apnea (SA) and Atrial Fibrillation/flutter (AF) are known risk factors for stroke, and both are increasing in prevalence. They are both under-diagnosed in young adults &lt;60 Y. There is an urgent need to define stroke risk portended by SA and AF yet there a paucity of data in adults aged 20-60 years.

Purpose

To define the relationship between stroke, SA, and AF in a very large cohort of 2 million young-middle aged adults aged 20-60 Y in Northern California.

Methods

We probed the Stanford Research Repository of electronic health data from 01/01/2008 to 11/30/2021 for the diagnoses of stroke, transient ischemic attacks, AF and SA using relevant codes (stroke: 433.X, 434.X, 436.X, I63.X, I65.X, I66.X, G45.X, G46.X; AF: I48.X; SA: G47.X, 327.27).

Results

We identified 2267485 patients aged 20-60Y (55% F; 32% White, 12% Asian, 3% Black), of whom SA was diagnosed in 52730 (2.3%), AF in 10230 (0.4%) and incident stroke in 10385 (0.4%) (Figure 1A)

In patients with SA, 1.5% developed incident stroke. Stroke was more common in patients with SA than those without, regardless of co-existing diagnosis of AF; OR with AF: 1.5 [1.3-1.7, p&lt;0.001] and OR without AF: 3.0 [2.8-3.3 p&lt;0.0001]. Risk of stroke with SA than without was noted to be higher in the younger age subgroups (Figure 1B) regardless of AF.

Although AF was more common in patients with SA than without (odds ratio, OR: 10.1 [9.6-10.6, p&lt;0.0001]), the majority of SA patients (63% with CHADS2VASC ≥2) with stroke did not have a diagnosis of AF (75%), of whom 96% were not anticoagulated (Fig 1, left panel). Of the remaining patients with SA and incident stroke, who did have AF (25%), only 26% were taking OACs at the time of stroke despite median CHADS2 VASC score=3 (Fig 1A, left panel).

Finally, 7% of AF patients developed incident stroke. Of these, 73% had CHADS2VASC ≥2, yet 44% were not anticoagulated. Patients with SA comprised a third of all AF patients with stroke and, compared to AF patients with stroke and without SA, had higher CHADS2VASC (median 3 vs 2, p&lt;0.001) and a similarly low use of anticoagulation (56% vs 54% on OAC) (Fig 1A, right panel).

Conclusions

In &gt;2 million young individuals, we uncover a novel association between SA and incident stroke, regardless of the diagnosis of AF. Surprisingly, three quarters of patients with SA developed incident stroke in the absence of AF, and were not anticoagulated. These results underscore the need to screen for AF and sleep apnea in young adults.

Noise reduction in electrophysiological signals using transfer machine learning

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH

Background/Introduction

Reducing electrophysiological signal noise is essential for diagnosis, mapping and ablation, yet most approaches are suboptimal. Template matching requires libraries of known signal types, that are difficult to obtain. Beat averaging can reduce noise, yet cannot be applied to single beats and obscures beat-to-beat variations. Beat smoothing can lose critical and subtle signal features. We set out to use neural networks (NN) based on encoder-decoders, which are able to extract key signal features and hence reconstruct them without noise and artifact.

Purpose

We hypothesised that electrograms with varying sources of artifact can be denoised using autoencoder neural networks. We further hypothesised that this could be achieved in a small data set by developing the method in a larger dataset of related signals, then using transfer learning. We tested this approach for atrial monophasic action potentials (MAPs) that have verifiable shapes.

Methods

The NN was first trained with 5706 left and right ventricular MAPs from 42 patients with ischemic cardiomyopathy (age 65±13y; fig 1.A): 60% for training, 20% (validation) and 20% (testing). Transfer learning and parameter-tuning were then used to apply this NN to a smaller sample of atrial MAPs (N=641, 21 patients, 67±5y, 13 women; fig D,F,H).

Results

The autoencoder was able to learn key features of MAPs, and hence reconstruct them without artifacts. NN learned ventricular MAPs with similarity coefficient 0.91±0.16, Pearson correlation 0.99± 0.01 (fig A) and learned key features (upstroke, triangular descent, terminus) to reduce noise (fig B-C). Applying this trained NN to atrial MAPs, the approach automatically eliminated ventricular artifact (fig E), high frequency noise (fig G), truncation (fig I), saturation and other artifacts. After fine-tuning, the NN reconstructed atrial MAPs with Pearson correlation = 0.99±0.01 (p&lt;0.001).

Conclusions

Machine learned encoder-decoders are powerful tools that can automatically eliminate diverse types of noise in single beats by learning essential signal features. Transfer learning makes this possible without large datasets for training, even from signals in a different cardiac chamber. This approach may have far-reaching applications for mapping and ablation.

Defining refractoriness in single atrial beats using autoencoder neural networks

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NIH

Background

Mapping atrial fibrillation (AF) is complicated by signals which may be local or far-field, but which cannot currently be separated. This could be clarified by a knowledge of atrial refractory periods, yet these are difficult to define from monophasic action potentials (MAP) in patients. We hypothesized that transfer learning using an autoencoder neural network (ANN), first trained with less-noisy ventricular signals, can be applied to de-noise and classify atrial MAPs.

Methods

We first developed an ANN to encode MAPs in 5706 ventricular MAPs from N=42 patients (age 65±13y) during pacing (fig1. A-B). This created a latent feature space. We now tuned the ANN to classify atrial MAPs in a different cohort of patients with AF. We used a statistical loss function based on mathematical optimization to evaluate the accuracy of final representations of the MAP and classify the different signals.

Results

The autoencoder ANN reconstructed ventricular MAPs with an average similarity of 0.85 (range 0-1) (an example is shown in fig 1.B). We tested on 3000 atrial MAPs in AF patients (N=21; 67±5y, 13 women). Atrial MAPs were accurately represented (fig 1.E-F) with similarity indices that were higher than those obtained by a panel of 3 experts. Fig. 1 shows the reconstruction of different signals: ventricular MAP (fig 1.A-B), ventricular MAP with pacing artifact (fig. 1.C-D), atrial MAP (transfer learning is assumed in here; fig 1.E-F) and noise or signals with morphologies of no interest (fig 1.G-H). Fig. 2 shows the classification of signals according to the similarity metric that allows distinguishing among the different types of signals without manual annotation (p&lt;0.05 between groups).

Conclusion

Atrial refractory periods can be defined in single beats in AF patients using autoencoder neural networks and transfer learning. This approach can separate atrial beats from far-field ventricular beats and other sources of noise. Future work can study if this approach can be used to improve AF mapping or define novel physiological phenotypes.

Machine-learned physiological signatures from the ECG predict sudden death in ischemic cardiomyopathy

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institute of Health (NIH)

Background

Low left ventricular ejection fraction (LVEF) is an imperfect predictor of sudden cardiac death (SCD) in patients with ischemic cardiomyopathy. Novel features from the ECG might provide a readily available tool to better predict risk.

Purpose

We hypothesized that machine learning (ML) of the ECG can be used to predict SCD, and the ML-learned ECG features could be referenced to interpretable intracardiac signals (monophasic action potentials: MAP) to provide mechanistic insights.

Methods

We studied 5603 ECG Lead V1 beats in 41 patients (64±10 Y) with coronary disease and LVEF≤40% in steady-state pacing. Patients were randomly allocated to independent training and test cohorts in a 70:30 ratio, repeated K=10-fold. Support vector machines were trained to predict mortality at 3Y from the top 20 features derived from these beats. Patient-level predictions were made by computing an ECG score that indicates the proportion of test set beats in that patient computed by the beat-level model to predict death. Explainability analysis was performed using the arithmetic mean of MAP and ECG beats that predicted SCD versus those that predicted survival.

Results

Fig 1A. shows ECG lead V1 and MAP in a 79 Y man with LVEF 29%. Fig 1B shows the dataflow in the study. Predictive accuracies of ML models were 78 and 70% and optimal with 20 features for both ECG and MAP models respectively (Fig. 1C). Beat-level predictions in the validation (n=1678 Lead I beats) cohorts yielded c-statistics of 0.78 with the ECG (95% CI, 0.62–0.91) and 0.75 with MAPs (95% CI, 0.75-0.76) (data not shown). In multivariable patient-level models, c-statistic was 0.87 with ECGs (95% CI, 0.76-0.98) (Fig 1D) and 0.82 with MAPs. On explainability analysis, ECG beats that predicted SCD (Fig 2; red) had lower amplitude and more notched T-waves in lead V1 than beats that predicted no SCD (Fig 2; blue). MAP that predicted SCD had higher repolarization current at the same time points. Both QT duration (ECG) and action potential duration (MAP) did not differ (Fig 2).

Conclusions

Machine learning of the ECG reveals novel predictors of SCD risk in patients with ischemic cardiomyopathy analogous to those identified in intracardiac signals. This approach can be used as a point-of-care ECG risk tool to improve risk stratification and allocation for ICD therapy beyond LVEF alone and may shed insights into the pathophysiology of ventricular arrhythmias.

Less-Energy Consumed Hydrogen Evolution Coupled with Electrocatalytic Removal of Ethanolamine Pollutant in Saline Water over Ni@Ni3 S2 /CNT Nano-Heterostructured Electrocatalysts

Energy crises, environmental pollution, and freshwater deficiency are critical issues on the planet. Electrolytic hydrogen generation from saline water, particularly from salt-contained hazardous wastewater, is significant to both environment and energy concerns but still challenging due to the high energy cost, severe corrosion, and the absence of competent electrocatalysts. Herein, a novel strategy is proposed for energy-efficient hydrogen production coupled with electro-oxidation removal of ethanolamine pollutant in saline water. To achieve this, an active and durable heterostructured electrocatalyst is developed by in situ growing Ni@Ni₃ S₂ core@shell nanoparticles in cross-linked 3D carbon nanotubes' (CNTs) network, achieving high dispersibility and metallic property, low packing density, and enriched exposed active sites to facilitate fast electron/mass diffusion. The unique Ni@Ni₃ S₂ /CNTs nano-heterostructures are competent for long-term stably electro-oxidizing environmental-unfriendly ethanolamine at a high current density of 100 mA cm^-2 in saline water, which not only suppresses oxygen and chloride evolution reactions but also decreases the energy consumption to boost hydrogen production. Associated with experimental results, density functional theory studies indicate that the collaborative adsorption of electrolyte ions and ethanolamine molecules can synergistically modulate the adsorption/desorption properties of catalytic active centers on Ni@Ni₃ S₂ /CNTs surface, leading to long-term stabilized electrocatalysis for efficient ethanolamine oxidation removal and less-energy hydrogen simultaneous production in saline water.

Regulating the Electron Localization of Metallic Bismuth for Boosting CO2 Electroreduction

Electrochemical reduction of CO₂ to formate is economically attractive but improving the reaction selectivity and activity remains challenging. Herein, we introduce boron (B) atoms to modify the local electronic structure of bismuth with positive valence sites for boosting conversion of CO₂ into formate with high activity and selectivity in a wide potential window. By combining experimental and computational investigations, our study indicates that B dopant differentiates the proton participations of rate-determining steps in CO₂ reduction and in the competing hydrogen evolution. By comparing the experimental observations with the density functional theory, the dominant mechanistic pathway of B promoted formate generation and the B concentration modulated effects on the catalytic property of Bi are unravelled. This comprehensive study offers deep mechanistic insights into the reaction pathway at an atomic and molecular level and provides an effective strategy for the rational design of highly active and selective electrocatalysts for efficient CO₂ conversion.

[The prognostic effects of two comprehensive geriatric assessment methods in elderly patients with acute myeloid leukemia]

Objective: To evaluate the prognostic effects of two comprehensive geriatric assessment (CGA) methods in elderly patients with acute myeloid leukemia (AML). Methods: Ninety-seven patients with newly diagnosed AML at Beijing Hospital from August 2008 to December 2019 were included (≥60 years old). All patients were evaluated by two methods of CGA. One was IACA index proposed by Beijing Hospital, including instrumental activities of daily living (IADL), age, Charlson comorbidity index (CCI), albumin; the other was proposed by Italian FIL study group (FIL-CGA), including activities of daily living (ADL), IADL, age, and modified cumulative illness rating score for geriatrics (MCIRS-G). Results: Among 97 patients, 54 patients received standard chemotherapy, 16 with decitabine, 2 with targeted therapy and 25 with the best supportive therapy. The overall response rate (ORR) in 72 treated patients were 67.7%, 33.3% and 0 respectively in fit, unfit and frail groups according to IACA index (P=0.001). Based on FIL-CGA, the ORRs of fit, unfit and frail groups were 52.5%, 41.7% and 35.0% respectively (P=0.418). The 1-year OS rates of fit, unfit and frail groups regarding IACA method were 78.7%, 27.7% and 0 respectively (P<0.01). The 1-year OS rates of fit, unfit and frail groups regarding FIL-CGA method were 67.8%, 28.2% and 13.9% respectively (P<0.01), while no significant difference was seen between unfit group and frail group (P=0.111). The early death rates of fit, unfit and frail groups by IACA were 0, 6.0% and 28.6% respectively (P=0.006), while those by FIL-CGA were 2.3%, 5.9%, 13.9% respectively (P=0.123). Conclusion: Compared with FIL-CGA method, IACA predicts more effectively the treatment response, survival and early mortality in elderly patients with AML.

[Reoperation and perioperative management of residual cyst wall with perineal intractable sinus after resection of presacral cyst tumors]

Objective: To investigate the reoperation and perioperative management of residual cyst wall with perineal intractable sinus after resection of presacral cyst tumors. Methods: The clinical data of 29 patients with residual cyst wall and perineal intractable sinus after resection of presacral cyst tumors in Affiliated Cancer Hospital of Zhengzhou University from January 2014 to August 2019 were reviewed, including the characteristics of the residual cyst wall with perineal intractable sinus after resection of presacral cyst tumors, surgical method, and perioperative management. Results: Twenty-nine patients with residual cyst wall and perineal intractable sinus after resection of presacral cyst tumors, including 9 cases of epidermoid cysts, 7 cases of dermoid cysts, 10 cases of mature teratomas and 3 cases of malignant cysts (including malignant transformation of caudate cyst and teratoma); The 29 patients underwent posterior approaches for cyst resection in other hospital before, of whom 1 patient underwent posterior combined with transabdominal approach. All of thes patients underwent resection of residual presacral cyst wall and perineal intractable sinus in our hospital, of whom 25 patients underwent a transperineal approach through an arc-shaped incision anterior to the apex of the coccyx, and the other 4 patients underwent transperineal arc-shaped incision combined with transabdominal approach. All of the patients were cured without serious complications occurring, postoperative pathological and the magnetic resonance imaging diagnosis showed that the residual cyst wall and perineal intractable sinus were all completely removed. Conclusion: Appropriate surgical approache and perioperative treatment for the patients with residual cyst wall and perineal intractable sinus are very important to promote the resection of residual cyst wall and the healing of perineal intractable sinus.

New Insights into the High-Performance Black Phosphorus Anode for Lithium-Ion Batteries

Black phosphorus (BP) is a promising anode material in lithium-ion batteries (LIBs) owing to its high electrical conductivity and capacity. However, the huge volume change of BP during cycling induces rapid capacity fading. In addition, the unclear electrochemical mechanism of BP hinders the development of rational designs and preparation of high-performance BP-based anodes. Here, a high-performance nanostructured BP-graphite-carbon nanotubes composite (BP/G/CNTs) synthesized using ball-milling method is reported. The BP/G/CNTs anode delivers a high initial capacity of 1375 mA h g^-1 at 0.15 A g^-1 and maintains 1031.7 mA h g^-1 after 450 cycles. Excellent high-rate performance is demonstrated with a capacity of 508.1 mA h g^-1 after 3000 cycles at 2 A g^-1 . Moreover, for the first time, direct evidence is provided experimentally to present the electrochemical mechanism of BP anodes with three-step lithiation and delithiation using ex situ X-ray diffraction (XRD), ex situ X-ray absorption spectroscopy (XAS), ex situ X-ray emission spectroscopy, operando XRD, and operando XAS, which reveal the formation of Li₃ P₇ , LiP, and Li₃ P. Furthermore, the study indicates an open-circuit relaxation effect of the electrode with ex situ and operando XAS analyses.