Health Care Costs Following Anterior Cervical Discectomy and Fusion or Cervical Disc Arthroplasty

STUDY DESIGN

Observational cohort study.

OBJECTIVE

To describe the postoperative costs associated with both anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) in the two-year period following surgery.

SUMMARY OF BACKGROUND DATA

CDA has become an increasingly common alternative to ACDF for the treatment of cervical disc disorders. Although a number of studies have compared clinical outcomes between both procedures, much less is known about the postoperative economic burden of each procedure.

MATERIALS AND METHODS

By analyzing a commercial insurance claims database (Marketscan, Merative), patients who underwent one-level or two-level ACDF and CDA procedures between January 1, 2017 and December 31, 2017 were identified and included in the study. The primary outcome was the cost of payments for postoperative management in the two-year period following ACDF or CDA. Identified postoperative interventions included in the study were: (i) physical therapy, (ii) pain medication, (iii) injections, (iv) psychological treatment, and (iv) subsequent spine surgeries.

RESULTS

Totally, 2304 patients (age: 49.0±9.4 yr; male, 50.1%) were included in the study. In all, 1723 (74.8%) patients underwent ACDF, while 581 (25.2%) underwent CDA. The cost of surgery was similar between both groups (ACDF: $26,819±23,449; CDA: $25,954±20,620; P =0.429). Thirty-day, 90-day, and two-year global costs were all lower for patients who underwent CDA compared with ACDF ($31,024 vs. $34,411, $33,064 vs. $37,517, and $55,723 vs. $68,113, respectively).

CONCLUSION

Lower two-year health care costs were found for patients undergoing CDA compared with ACDF. Further work is necessary to determine the drivers of these findings and the associated longer-term outcomes.

Parasympathetic neurons derived from human pluripotent stem cells model human diseases and development

Autonomic parasympathetic neurons (parasymNs) control unconscious body responses, including "rest-and-digest." ParasymN innervation is important for organ development, and parasymN dysfunction is a hallmark of autonomic neuropathy. However, parasymN function and dysfunction in humans are vastly understudied due to the lack of a model system. Human pluripotent stem cell (hPSC)-derived neurons can fill this void as a versatile platform. Here, we developed a differentiation paradigm detailing the derivation of functional human parasymNs from Schwann cell progenitors. We employ these neurons (1) to assess human autonomic nervous system (ANS) development, (2) to model neuropathy in the genetic disorder familial dysautonomia (FD), (3) to show parasymN dysfunction during SARS-CoV-2 infection, (4) to model the autoimmune disease Sjögren's syndrome (SS), and (5) to show that parasymNs innervate white adipocytes (WATs) during development and promote WAT maturation. Our model system could become instrumental for future disease modeling and drug discovery studies, as well as for human developmental studies.

Radioactive iodine therapy improves overall survival outcome in oncocytic carcinoma of the thyroid by reducing death risks from noncancer causes: A competing risk analysis of 4641 patients

BACKGROUND

Oncocytic carcinoma of the thyroid (OCA) is an independent type of thyroid cancer. Radioactive iodine (RAI) therapy was frequently administered to OCA patients, but its contribution to improving survival is indefinite.

METHODS

4641 OCA patients from 2000 to 2018 were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Cox proportional hazard regression and competing risk analysis were applied.

RESULTS

Tumor size, SEER stage, primary surgery, and neck dissection were prognostic factors for cancer-specific survival. The results of competing risk analysis demonstrated that age over 55 years dramatically increased non-OCA death risks. Treatments that improve non-OCA survival (including total thyroidectomy, RAI therapy, and systemic therapy) should be recommended in OCA patients older than 55 years of age. Neck lymphadenectomy should not be recommended for OCA, since the metastatic lymph node ratio was low (about 3%).

CONCLUSIONS

RAI therapy can improve survival in OCA by reducing noncancer death risks.

Suppression of presynaptic corticostriatal glutamate activity attenuates L-dopa-induced dyskinesia in 6-OHDA-lesioned Parkinson's disease mice

A common adverse effect of Parkinson's disease (PD) treatment is L-dopa-induced dyskinesia (LID). This condition results from both dopamine (DA)-dependent and DA-independent mechanisms, as glutamate inputs from corticostriatal projection neurons impact DA-responsive medium spiny neurons in the striatum to cause the dyskinetic behaviors. In this study, we explored whether suppression of presynaptic corticostriatal glutamate inputs might affect the behavioral and biochemical outcomes associated with LID. We first established an animal model in which 6-hydroxydopamine (6-OHDA)-lesioned mice were treated daily with L-dopa (10 mg/kg, i.p.) for 2 weeks; these mice developed stereotypical abnormal involuntary movements (AIMs). When the mice were pretreated with the NMDA antagonist, amantadine, we observed suppression of AIMs and reductions of phosphorylated ERK1/2 and NR2B in the striatum. We then took an optogenetic approach to manipulate glutamatergic activity. Slc17a6 (vGluT2)-Cre mice were injected with pAAV5-Ef1a-DIO-eNpHR3.0-mCherry and received optic fiber implants in either the M1 motor cortex or dorsolateral striatum. Optogenetic inactivation at either optic fiber implant location could successfully reduce the intensity of AIMs after 6-OHDA lesioning and L-dopa treatment. Both optical manipulation strategies also suppressed phospho-ERK1/2 and phospho-NR2B signals in the striatum. Finally, we performed intrastriatal injections of LDN 212320 in the dyskenesic mice to enhance expression of glutamate uptake transporter GLT-1. Sixteen hours after the LDN 212320 treatment, L-dopa-induced AIMs were reduced along with the levels of striatal phospho-ERK1/2 and phospho-NR2B. Together, our results affirm a critical role of corticostriatal glutamate neurons in LID and strongly suggest that diminishing synaptic glutamate, either by suppression of neuronal activity or by upregulation of GLT-1, could be an effective approach for managing LID.

Minority-Serving Hospitals Are Associated With Low Within-Hospital Disparity

BACKGROUND

Disparities in obstetric care have been well documented, but disparities in the within-hospital population have not been as extensively explored. The objective is to assess cesarean delivery rate disparities at the hospital level in a nationally recognized low risk of cesarean delivery group.

METHODS

An observational study using a national population-based database, Nationwide Inpatient Sample, from 2008 to 2011 was conducted. All patients with nulliparous, term, singleton, vertex pregnancies from Black and White patients were included. The primary outcome was delivery mode (cesarean vs vaginal). The primary independent variable was race (Black vs White).

RESULTS

A total of 1,064,351 patients were included and the overall nulliparous, term, singleton, and vertex pregnancies cesarean delivery rate was 14.1%. The within-hospital disparities of cesarean delivery rates were lower in minority-serving hospitals (OR: 1.20 95% CI: 1.12-1.28), rural hospitals (OR 1.11 95% CI: 1.02-1.20), and the South (OR 1.24 95% CI 1.19-1.30) compared to their respective counterparts. Non-minority serving hospitals (OR: 1.20 95% CI 0.12-1.25), and urban hospitals (OR1.32 95% CI 1.28-1.37), the Northeast (OR 1.41 95% CI 1.30-1.53) or West (OR 1.52 95% CI 1.38-1.67), had higher within-hospital racial disparities of cesarean delivery rates. The odds ratios reported are comparing within-hospital cesarean delivery rates in Black and White patients.

DISCUSSION

Significant within-hospital disparities of cesarean delivery rates across hospitals highlight the importance of facility-level factors. Policies aimed at advancing health equity must address hospital-level drivers of disparities in addition to structural racism.

[Application and research advances of delayed sural neurotrophic vascular flap for diabetic foot ulcers]

Diabetic foot ulcer is one of the serious complications of diabetes. Diabetic wounds are of great difficulty to repair, causing a high amputation rate and a great burden to patients and their family members and society. Researches showed that the delayed sural neurotrophic vascular flap has a great effect in repairing diabetic foot ulcers. This article mainly reviewed the clinical status and research advances of the delayed sural neurotrophic vascular flap in repairing diabetic foot ulcers, intending to provide a reference for its application and research.

High-Resolution Profiling of Human Vocal Fold Cellular Landscapes With Single-Nuclei RNA Sequencing

INTRODUCTION

The function of the vocal folds (VFs) is determined by the phenotype, abundance, and distribution of differentiated cells within specific microenvironments. Identifying this histologic framework is crucial in understanding laryngeal disease. A paucity of studies investigating VF cellular heterogeneity has been undertaken. Here, we examined the cellular landscape of human VFs by utilizing single-nuclei RNA-sequencing.

METHODS

Normal true VF tissue was excised from five patients undergoing pitch elevation surgery. Tissue was snap frozen in liquid nitrogen and subjected to cellular digestion and nuclear extraction. Nuclei were processed for single-nucleus sequencing using the 10X Genomics Chromium platform. Sequencing reads were assembled using cellranger and analyzed with the scanpy package in python.

RESULTS

RNA sequencing revealed 18 global cell clusters. While many were of epithelial origin, expected cell types, such as fibroblasts, immune cells, muscle cells, and endothelial cells were present. Subcluster analysis defined unique epithelial, immune, and fibroblast subpopulations.

CONCLUSION

This study evaluated the cellular heterogeneity of normal human VFs by utilizing single-nuclei RNA-sequencing. With further confirmation through additional spatial sequencing and microscopic imaging, a novel cellular map of the VFs may provide insight into new cellular targets for VF disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 2024.

Roles of oxidative stress/JNK/ERK signals in paraquat-triggered hepatic apoptosis

Paraquat (PQ), a toxic and nonselective bipyridyl herbicide, is one of the most extensively used pesticides in agricultural countries. In addition to pneumotoxicity, the liver is an important target organ for PQ poisoning in humans. However, the mechanism of PQ in hepatotoxicity remains unclear. In this study, we found that exposure of rat hepatic H4IIE cells to PQ (0.1-2 mM) induced significant cytotoxicity and apoptosis, which was accompanied by mitochondria-dependent apoptotic signals, including loss of mitochondrial membrane potential (MMP), cytosolic cytochrome c release, and changes in the Bcl-2/Bax mRNA ratio. Moreover, PQ (0.5 mM) exposure markedly induced JNK and ERK1/2 activation, but not p38-MAPK. Blockade of JNK and ERK1/2 signaling by pretreatment with the specific pharmacological inhibitors SP600125 and PD98059, respectively, effectively prevented PQ-induced cytotoxicity, mitochondrial dysfunction, and apoptotic events. Additionally, PQ exposure stimulated significant oxidative stress-related signals, including reactive oxygen species (ROS) generation and intracellular glutathione (GSH) depletion, which could be reversed by the antioxidant N-Acetylcysteine (NAC). Buffering the oxidative stress response with NAC also effectively abrogated PQ-induced hepatotoxicity, MMP loss, apoptosis, and phosphorylation of JNK and ERK1/2 protein, however, the JNK or ERK inhibitors did not suppress ROS generation in PQ-treated cells. Collectively, these results demonstrate that PQ exposure induces hepatic cell toxicity and death via an oxidative stress-dependent JNK/ERK activation-mediated downstream mitochondria-regulated apoptotic pathway.

Deciphering Endothelial and Mesenchymal Organ Specification in Vascularized Lung and Intestinal Organoids

To investigate the co-development of vasculature, mesenchyme, and epithelium crucial for organogenesis and the acquisition of organ-specific characteristics, we constructed a human pluripotent stem cell-derived organoid system comprising lung or intestinal epithelium surrounded by organotypic mesenchyme and vasculature. We demonstrated the pivotal role of co-differentiating mesoderm and endoderm via precise BMP regulation in generating multilineage organoids and gut tube patterning. Single-cell RNA-seq analysis revealed organ specificity in endothelium and mesenchyme, and uncovered key ligands driving endothelial specification in the lung (e.g., WNT2B and Semaphorins) or intestine (e.g., GDF15). Upon transplantation under the kidney capsule in mice, these organoids further matured and developed perfusable human-specific sub-epithelial capillaries. Additionally, our model recapitulated the abnormal endothelial-epithelial crosstalk in patients with FOXF1 deletion or mutations. Multilineage organoids provide a unique platform to study developmental cues guiding endothelial and mesenchymal cell fate determination, and investigate intricate cell-cell communications in human organogenesis and disease.

Highlights

BMP signaling fine-tunes the co-differentiation of mesoderm and endoderm.The cellular composition in multilineage organoids resembles that of human fetal organs.Mesenchyme and endothelium co-developed within the organoids adopt organ-specific characteristics.Multilineage organoids recapitulate abnormal endothelial-epithelial crosstalk in FOXF1-associated disorders.

[Clinical repair strategy for ischial tuberosity pressure ulcers based on the sinus tract condition and range of skin and soft tissue defects]

Objective: To investigate the clinical repair strategy for ischial tuberosity pressure ulcers based on the sinus tract condition and range of skin and soft tissue defects. Methods: The study was a retrospective observational study. From July 2017 to March 2023, 21 patients with stage Ⅲ or Ⅳ ischial tuberosity pressure ulcers who met the inclusion criteria were admitted to the First Affiliated Hospital of Nanchang University, including 13 males and 8 females, aged 14-84 years. There were 31 ischial tuberosity pressure ulcers, with an area of 1.5 cm×1.0 cm-8.0 cm×6.0 cm. After en bloc resection and debridement, the range of skin and soft tissue defect was 6.0 cm×3.0 cm-15.0 cm×8.0 cm. According to the depth and size of sinus tract and range of skin and soft tissue defects on the wound after debridement, the wounds were repaired according to the following three conditions. (1) When there was no sinus tract or the sinus tract was superficial, with a skin and soft tissue defect range of 6.0 cm×3.0 cm-8.5 cm×6.5 cm, the wound was repaired by direct suture, Z-plasty, transfer of buttock local flap, or V-Y advancement of the posterior femoral cutaneous nerve nutrient vessel flap. (2) When the sinus tract was deep and small, with a skin and soft tissue defect range of 8.5 cm×4.5 cm-11.0 cm×6.5 cm, the wound was repaired by the transfer and filling of gracilis muscle flap followed by direct suture, or Z-plasty, or combined with transfer of inferior gluteal artery perforator flap. (3) When the sinus tract was deep and large, with a skin and soft tissue defect range of 7.5 cm×5.5 cm-15.0 cm×8.0 cm, the wound was repaired by the transfer and filling of gracilis muscle flap and gluteus maximus muscle flap transfer, followed by direct suture, Z-plasty, or combined with transfer of buttock local flap; and transfer and filling of biceps femoris long head muscle flap combined with rotary transfer of the posterior femoral cutaneous nerve nutrient vessel flap; and filling of the inferior gluteal artery perforator adipofascial flap transfer combined with V-Y advancement of the posterior femoral cutaneous nerve nutrient vessel flap. A total of 7 buttock local flaps with incision area of 8.0 cm×6.0 cm-19.0 cm×16.0 cm, 21 gracilis muscle flaps with incision area of 18.0 cm×3.0 cm-24.0 cm×5.0 cm, 9 inferior gluteal artery perforator flaps or inferior gluteal artery perforator adipofascial flaps with incision area of 8.5 cm×6.0 cm-13.0 cm×7.5 cm, 10 gluteal maximus muscle flaps with incision area of 8.0 cm×5.0 cm-13.0 cm×7.0 cm, 2 biceps femoris long head muscle flaps with incision area of 17.0 cm×3.0 cm and 20.0 cm×5.0 cm, and 5 posterior femoral cutaneous nerve nutrient vessel flaps with incision area of 12.0 cm×6.5 cm-21.0 cm×10.0 cm were used. The donor area wounds were directly sutured. The survival of muscle flap, adipofascial flap, and flap, and wound healing in the donor area were observed after operation. The recovery of pressure ulcer and recurrence of patients were followed up. Results: After surgery, all the buttock local flaps, gracilis muscle flaps, gluteus maximus muscle flaps, inferior gluteal artery perforator adipofascial flaps, and biceps femoris long head muscle flaps survived well. In one case, the distal part of one posterior femoral cutaneous nerve nutrient vessel flap was partially necrotic, and the wound was healed after dressing changes. In another patient, bruises developed in the distal end of inferior gluteal artery perforator flap. It was somewhat relieved after removal of some sutures, but a small part of the necrosis was still present, and the wound was healed after bedside debridement and suture. The other posterior femoral cutaneous nerve nutrient vessel flaps and inferior gluteal artery perforator flaps survived well. In one patient, the wound at the donor site caused incision dehiscence due to postoperative bleeding in the donor area. The wound was healed after debridement+Z-plasty+dressing change. The wounds in the rest donor areas of patients were healed well. After 3 to 15 months of follow-up, all the pressure ulcers of patients were repaired well without recurrence. Conclusions: After debridement of ischial tuberosity pressure ulcer, if there is no sinus tract formation or sinus surface is superficial, direct suture, Z-plasty, buttock local flap, or V-Y advancement repair of posterior femoral cutaneous nerve nutrient vessel flap can be selected according to the range of skin and soft tissue defects. If the sinus tract of the wound is deep, the proper tissue flap can be selected to fill the sinus tract according to the size of sinus tract and range of the skin and soft tissue defects, and then the wound can be closed with individualized flap to obtain good repair effect.

Anterior Cervical Discectomy and Fusion With Structural Allograft is Associated With Lower Postoperative Health Care Utilization and Reoperations Compared With Cage Implants

BACKGROUND AND OBJECTIVES

Implants represent a large component of surgical cost, with several available options for anterior cervical discectomy and fusion (ACDF). Rising ACDF volume highlights the need for accurate cost characterization among implant configurations to inform efficient utilization.

METHODS

A cohort study of patients who underwent 1-level or 2-level ACDF in 2017 was conducted using the MarketScan national insurance databases, which contain deidentified clinical and financial data. Implant configurations included plate with cage, standalone cage, and plate with structural allograft. Patients who switched insurance providers within 2 years after surgery or underwent concurrent posterior cervical surgery, cervical disk arthroplasty, or cervical corpectomy were excluded. A combined plate/cage and standalone cage group was compared with the allograft group followed by the comparison of the plate/cage and standalone cage groups. In total, 30-day, 90-day, and 2-year aggregate costs; component costs of physical therapy, injections, medications, psychological treatment, and subsequent spine surgery; and reoperation rates were evaluated.

RESULTS

Of 1723 patients identified, 360 (20.9%) underwent surgery with plate/cage, 184 (10.7%) with standalone cage, and 1179 (68.4%) with allograft. Aggregate costs were lower in the allograft group compared with the combined cage group at 90 days ($36 428 vs $39 875, P = .04) and 2 years ($64 951 vs $74 965, P = .005) postoperatively. There were no significant differences in aggregate costs between the plate/cage and standalone cage groups. The 2-year reoperation rate was higher in the combined cage compared with the allograft group (23.9% vs 10.9%, P < .001) and was also higher in the standalone cage compared with the plate/cage group (32.0% vs 19.7%, P = .002).

CONCLUSION

Compared with alternative ACDF constructs, allograft is associated with lower postoperative costs and reoperation rates. Although costs are similar, reoperation rates are lower with plate/cage constructs compared with those of standalone cages. Surgeons should consider these financial and clinical differences when selecting implant configurations.

Arthroscopic Procedures Are Performed in 5% of Patients With Knee Osteoarthritis 1 Year Preceding Total Knee Arthroplasty and Are Associated With Increased Stiffness and Increased Costs

Purpose

To describe the different types of arthroscopic procedures that patients undergo in the year prior to total knee arthroplasty (TKA), reveal the cost associated with these procedures, and understand the relationship between preoperative arthroscopy and clinical outcomes after TKA.

Methods

An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with knee osteoarthritis who underwent unilateral isolated primary TKA between January 1, 2018, and September 30, 2019, were included. Knee arthroscopic procedures performed in the 1-year period before a primary TKA was identified. The primary outcomes of interest were cost of these procedures and the risk of 90-day postoperative complications.

Results

In total, 2,904 patients, representing 5.2% of the analyzed cohort, underwent arthroscopic procedures in the year prior to TKA. The most common procedure and diagnosis were meniscectomy and meniscal tear, respectively, with procedures performed an average of 7.2 ± 3.0 months before TKA. Average per patient costs were $9,716 ± $5,500 in the highest payment quartile vs $1,789 ± 636 in the lowest payment quartile. Patients with a history of arthroscopy were more likely to develop postoperative stiffness (P = .001), while no difference was found in the risk of 90-day periprosthetic joint infection (PJI).

Conclusions

Of the patients, 5.2% underwent knee arthroscopy in the year prior to TKA. While no association was seen with PJI risk, the costs associated with these procedures are high and may increase the overall cost of management of knee osteoarthritis.

Level of Evidence

Level III, retrospective comparative study.

Time to surgery: A health equity metric in breast cancer patients

BACKGROUND

We evaluated whether time to surgery by race can be a health equity metric of surgical access.

METHODS

An observational analysis was performed using the National Cancer Database from 2010 to 2019. Inclusion criteria were women with stage I-III breast cancer. We excluded women with multiple cancers and whose diagnosis was made at a different hospital. The primary outcome variable was surgery within 90 days of diagnosis.

RESULTS

A total of 886,840 patients were analyzed, with 76.8% White and 11.7% Black patients. 11.9% of patients experienced delayed surgery, which was significantly more common in Black patients than White patients. On adjusted analysis, Black patients were still significantly less likely to receive surgery within 90 days when compared to White patients (OR 0.61, 95% CI 0.58-0.63).

CONCLUSION

The delay in surgery experienced by Black patients highlights the contribution of system factors in cancer inequity and should be a focus for targeted interventions.

[One case of acute poisoning with stramonium]

This paper reported 1 case of poisoning caused by stramonium. Cases of Datura poisoning have been reported nationwide, Its effect on the central nervous system of patients is characterized by first excitation and then inhibition, clinical manifestations include decreased gland secretion, dilated pupils, and tachycardia, etc. Its poisoning mechanism is anticholinergic effect, the effect on Peripheral nervous system is to inhibit Parasympathetic nervous system. Hemoperfusion combined with neostigmine anticholinergic therapy at the early stage of poisoning can effectively improve the clinical symptoms of patients in a short time.

Early vs Delayed Transurethral Surgery in Acute Urinary Retention: Does Timing Make a Difference?

PURPOSE

Our goal was to compare outcomes of early vs delayed transurethral surgery for benign prostatic hyperplasia after an episode of acute urinary retention compared to men without preoperative acute retention.

MATERIALS AND METHODS

We conducted a retrospective cohort analysis using data from the New York Statewide Planning and Research Cooperative System from 2002-2016. We identified men ≥40 years old who underwent primary ambulatory transurethral resection or photoselective vaporization of the prostate, assessing surgical failure as time to reoperation or recatheterization. We categorized presurgical acute urinary retention by number of episodes: none (reference), 1, or ≥2 precatheterizations, and time from first retention episode to surgery: none (reference), 0-6 months, and >6 months. We used Fine-Gray competing-risk models to predict surgical failure at 10 years, with presurgical acute retention as the primary predictor, adjusted for age, race, insurance, Charlson Comorbidity Index score, preoperative urinary infection, and procedure type, with death as the competing risk.

RESULTS

Among 17,474 patients undergoing transurethral surgery, 10% had preoperative acute retention with a median time to surgery of 2.4 months (IQR: 1-18). Among men with preoperative retention, 37% had ≥6 months of delay to surgery. The 10-year cumulative treatment failure rate was 17.2% among catheter naïve men vs 34.0% with ≥2 precatheterizations and 32.9% with ≥6 months delay to surgery. Delays from catheterization to surgery were associated with higher rates of treatment failure (<6 months SHR 1.49, P < .001; ≥6 months SHR 2.11, P < .001) vs catheter naïve men.

CONCLUSIONS

Preoperative acute urinary retention and delay to surgery once catheterized are associated with poorer long-term postoperative outcomes after surgery for benign prostatic hyperplasia.

Inhalation of ACE2 as a therapeutic target on sex-bias differences in SARS-CoV-2 infection and variant of concern

Despite similar infection rates, COVID-19 has resulted in more deaths in men than women. To understand the underlying mechanisms behind this sex-biased difference in disease severity, we infected K18-human angiotensin converting enzyme 2 (ACE2) mice of both sexes with SARS-CoV-2. Our study revealed a unique protein expression profile in the lung microenvironment of female mice. As a result, they were less vulnerable to severe infection, with higher ACE2 expression and a higher estrogen receptor α (ERα)/androgen receptor (AR) ratio that led to increased antiviral factor levels. In male mice, inhaling recombinant ACE2 neutralized the virus and maintained the ERα/AR ratio, thereby protecting the lungs. Our findings suggest that inhaling recombinant ACE2 could serve as a decoy receptor against SARS-CoV-2 and protect male mice by offsetting ERα-associated protective mechanisms. Additionally, our study supports the potential effectiveness of recombinant ACE2 therapy in human lung organoids infected with the Delta variant.

[Application and exploration of small dose omalizumab in patients with recurrent eosinophilic sinusitis after extended sinus surgery]

Objective: To explore the short-term efficacy of small dose omalizumab in refractory sinusitis with eosinophilia after extended sinus surgery. Methods: A total of 24 patients who met the diagnostic criteria for eosinophilic chronic rhinosinusitis and remained poorly controlled after multiple surgical treatments were included in this study. These patients were admitted to Hunan People's Hospital between January 2020 and June 2022, and comprised 13 males and 11 females with an average age of (46.43±13.74) years. The patients were randomly divided into experimental group (12 cases) and control group (12 cases), both of which underwent extended sinus opening surgery. The experimental group received a small dose of omalizumab (150 mg/month) for 4 months, while no omalizumab was applied in the control group. All patients were followed up monthly, subjective and objective symptom scores were collected and compared between groups, which included visual analogue scale (VAS) score, sino-nasal outcome test (SNOT)-22 score, Lund-Mackay score, and Lund-Kennedy score. Statistical analysis was performed using SPSS 24.0 software. Results: The baseline was set at 1 month after surgery. There was no significant difference in baseline clinical characteristics between the two groups. After 4 months of treatment with omalizumab, the experimental group showed significant improvements in VAS scores for nasal obstruction, rhinorrhea, hyposmia, SNOT-22 score, and Lund-Kennedy score (3.11±1.05 vs 6.44±1.13, 2.00±0.87 vs 6.55±1.33, 2.22±0.67 vs 7.00±1.22, 4.44±0.88 vs 15.22±1.20, 1.67±1.00 vs 7.44±0.88, respectively, all P<0.001). Compared to the control group at 4 months after baseline, the experimental group had significantly lower scores for nasal obstruction, rhinorrhea, hyposmia, SNOT-22, and Lund-Kennedy (3.11±1.05 vs 7.11±1.17, 2.00±0.87 vs 7.67±1.41, 2.22±0.67 vs 7.56±0.88, 4.44±0.88 vs 15.33±2.34, 1.67±1.00 vs 9.00±1.41, respectively, all P<0.001). During a 2-month follow-up period after drug withdrawal, the VAS, SNOT-22, and Lund-Kennedy scores of the experimental group were slightly higher than those before drug withdrawal but showed no significant difference (3.44±1.33 vs 3.11±1.05, 2.22±1.09 vs 2.00±0.86, 2.55±0.88 vs 2.22±0.66, 4.77±0.97 vs 4.44±0.88, 2.11±1.05 vs 1.67±1.00, respectively, all P>0.05). Conclusion: For patients of refractory sinusitis with eosinophilia, a combination of extended sinus surgery and postoperative small dosage of omalizumab can effectively control mucous inflammation, promote mucosal epithelization, and play an important role in the critical early stage of disease recovery.

Optical spectrum analyzers and typical applications in astronomy and remote sensing

Scientists are increasingly relying on astronomical and remote sensing technologies to gain deeper insights into the Earth and the universe. In these fields, the optical spectrum analyzer (OSA) or spectrometer plays a pivotal role. This Review offers a comprehensive overview of the fundamental principles, key parameters, and applications of various branches of traditional OSAs, including prisms, gratings, interferometers, tunable filters, and reconstructive spectrometers. We specifically focus on their latest major applications in astronomy and remote sensing. Additionally, we present a mathematical model of the generalized reconstructive spectrometer and provide a summary of its principles pertaining to spectral mapping, reconstruction, and imaging. Despite its limited aperture and étendue, the reconstructive spectrometer holds great potential for future use in astronomy and remote sensing due to its compact size and exceptional ultrahigh spectral resolution.

Can Live-Actor Patients in a Mass Casualty Incident Exercise Benefit as Exercise Players?

OBJECTIVES

In a mass casualty incident (MCI) exercise, live-actor patients (LAPs) simulated different scenarios in the exercise. This study compared the benefit to LAPs with that to exercise players (EPs) and nonparticipants (NPs).

METHODS

An MCI exercise was conducted in 2018. Emergency department (ED) nurses were assigned as EPs, LAPs, or NPs and asked to attend a pre-exercise lecture. A pre-exercise survey evaluated all ED nurses' background, confidence level, and knowledge of MCI management. Knowledge assessment included disaster medicine knowledge (DMK) and on emergency operation plan familiarity (EOPF). The same survey was conducted again after the exercise. A paired t-test was used to analyze the difference before and after the exercise in the 3 groups.

RESULTS

Twenty-nine ED nurses completed both surveys. Confidence improved significantly for both the EP and LAP groups. The DMK of the LAP group improved significantly. EOPF also improved significantly for all 3 groups. A comparison of the improvement levels showed no significant difference between the EP and LAP groups for confidence, DMK, and EOPF.

CONCLUSIONS

ED nurses can benefit from participating as LAPs in full-scale MCI exercises. Having ED nurses act as LAPs makes it possible to train more staff in 1 exercise.

Generation of host-directed and virus-specific antivirals using targeted protein degradation promoted by small molecules and viral RNA mimics

Targeted protein degradation (TPD), as exemplified by proteolysis-targeting chimera (PROTAC), is an emerging drug discovery platform. PROTAC molecules, which typically contain a target protein ligand linked to an E3 ligase ligand, recruit a target protein to the E3 ligase to induce its ubiquitination and degradation. Here, we applied PROTAC approaches to develop broad-spectrum antivirals targeting key host factors for many viruses and virus-specific antivirals targeting unique viral proteins. For host-directed antivirals, we identified a small-molecule degrader, FM-74-103, that elicits selective degradation of human GSPT1, a translation termination factor. FM-74-103-mediated GSPT1 degradation inhibits both RNA and DNA viruses. Among virus-specific antivirals, we developed viral RNA oligonucleotide-based bifunctional molecules (Destroyers). As a proof of principle, RNA mimics of viral promoter sequences were used as heterobifunctional molecules to recruit and target influenza viral polymerase for degradation. This work highlights the broad utility of TPD to rationally design and develop next-generation antivirals.

Workforce Attrition Among Male and Female Physicians Working in US Academic Hospitals, 2014-2019

Importance

Retaining female physicians in the academic health care workforce is necessary to serve the needs of sociodemographically diverse patient populations.

Objective

To investigate differences in rates of leaving academia between male and female physicians.

Design, Setting, and Participants

This cohort study used Care Compare data from the Centers for Medicare & Medicaid Services for all physicians who billed Medicare from teaching hospitals from March 2014 to December 2019, excluding physicians who retired during the study period. Data were analyzed from November 11, 2021, to May 24, 2022.

Exposure

Physician gender.

Main Outcome and Measures

The primary outcome was leaving academia, which was defined as not billing Medicare from a teaching hospital for more than 1 year. Multivariable logistic regression was conducted adjusting for physician characteristics and region of the country.

Results

There were 294 963 physicians analyzed (69.5% male). The overall attrition rate from academia was 34.2% after 5 years (38.3% for female physicians and 32.4% for male physicians). Female physicians had higher attrition rates than their male counterparts across every career stage (time since medical school graduation: <15 years, 40.5% vs 34.8%; 15-29 years, 36.4% vs 30.3%; ≥30 years, 38.5% vs 33.3%). On adjusted analysis, female physicians were more likely to leave academia than were their male counterparts (odds ratio, 1.25; 95% CI, 1.23-1.28).

Conclusions and Relevance

In this cohort study, female physicians were more likely to leave academia than were male physicians at all career stages. The findings suggest that diversity, equity, and inclusion efforts should address attrition issues in addition to recruiting more female physicians into academic medicine.

A distal lung organoid model to study interstitial lung disease, viral infection and human lung development

Organoids have been an exciting advancement in stem cell research. Here we describe a strategy for directed differentiation of human pluripotent stem cells into distal lung organoids. This protocol recapitulates lung development by sequentially specifying human pluripotent stem cells to definitive endoderm, anterior foregut endoderm, ventral anterior foregut endoderm, lung bud organoids and finally lung organoids. The organoids take ~40 d to generate and can be maintained more than 180 d, while progressively maturing up to a stage consistent with the second trimester of human gestation. They are unique because of their branching morphology, the near absence of non-lung endodermal lineages, presence of mesenchyme and capacity to recapitulate interstitial lung diseases. This protocol can be performed by anyone familiar with cell culture techniques, is conducted in serum-free conditions and does not require lineage-specific reporters or enrichment steps. We also provide a protocol for the generation of single-cell suspensions for single-cell RNA sequencing.

Breathing-induced forces influence lung cell fate

Respiration exerts a mechanical strain on the lungs, which has an unclear effect on epithelial cell fate. Now in Cell, Shiraishi et al.¹ reveal the crucial role of mechanotransduction in maintaining lung epithelial cell fate, representing a significant milestone in understanding how mechanical factors regulate differentiation.

Lung endothelial cells regulate pulmonary fibrosis through FOXF1/R-Ras signaling

Pulmonary fibrosis results from dysregulated lung repair and involves multiple cell types. The role of endothelial cells (EC) in lung fibrosis is poorly understood. Using single cell RNA-sequencing we identified endothelial transcription factors involved in lung fibrogenesis, including FOXF1, SMAD6, ETV6 and LEF1. Focusing on FOXF1, we found that FOXF1 is decreased in EC within human idiopathic pulmonary fibrosis (IPF) and mouse bleomycin-injured lungs. Endothelial-specific Foxf1 inhibition in mice increased collagen depositions, promoted lung inflammation, and impaired R-Ras signaling. In vitro, FOXF1-deficient EC increased proliferation, invasion and activation of human lung fibroblasts, and stimulated macrophage migration by secreting IL-6, TNFα, CCL2 and CXCL1. FOXF1 inhibited TNFα and CCL2 through direct transcriptional activation of Rras gene promoter. Transgenic overexpression or endothelial-specific nanoparticle delivery of Foxf1 cDNA decreased pulmonary fibrosis in bleomycin-injured mice. Nanoparticle delivery of FOXF1 cDNA can be considered for future therapies in IPF.

The Cost of Stiffness After Total Knee Arthroplasty

BACKGROUND

Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.

METHODS

An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.

RESULTS

The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.

CONCLUSION

Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

Rewired m6A epitranscriptomic networks link mutant p53 to neoplastic transformation

N6-methyladenosine (m6A), one of the most prevalent mRNA modifications in eukaryotes, plays a critical role in modulating both biological and pathological processes. However, it is unknown whether mutant p53 neomorphic oncogenic functions exploit dysregulation of m6A epitranscriptomic networks. Here, we investigate Li-Fraumeni syndrome (LFS)-associated neoplastic transformation driven by mutant p53 in iPSC-derived astrocytes, the cell-of-origin of gliomas. We find that mutant p53 but not wild-type (WT) p53 physically interacts with SVIL to recruit the H3K4me3 methyltransferase MLL1 to activate the expression of m6A reader YTHDF2, culminating in an oncogenic phenotype. Aberrant YTHDF2 upregulation markedly hampers expression of multiple m6A-marked tumor-suppressing transcripts, including CDKN2B and SPOCK2, and induces oncogenic reprogramming. Mutant p53 neoplastic behaviors are significantly impaired by genetic depletion of YTHDF2 or by pharmacological inhibition using MLL1 complex inhibitors. Our study reveals how mutant p53 hijacks epigenetic and epitranscriptomic machinery to initiate gliomagenesis and suggests potential treatment strategies for LFS gliomas.

[Clinical characteristics of anomalous aortic origin of a coronary artery in children]

Objective: To analyze the clinical characteristics, diagnosis and treatment of anomalous aortic origin of a coronary artery (AAOCA) in children. Methods: There were 17 children diagnosed with AAOCA from January 2013 to January 2022 in Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine.Their clinical manifestations, laboratory and imaging data, treatment and prognosis were retrospectively analyzed. Results: These 17 children included 14 males and 3 females, with the age of (8.7±3.5) years. There were 4 anomalous left coronary artery (ALCA) and 13 anomalous right coronary artery (ARCA). Seven children presented with chest pain or chest pain after exercise, three patients presented with cardiac syncope, one complained chest tightness and weakness, and the other six patients had no specific symptoms. Cardiac syncope and chest tightness occurred in patients with ALCA. Fourteen children had the dangerous anatomical basis of myocardial ischemia caused by coronary artery compression or stenosis on imaging. Seven children had coronary artery repair, of whom two were ALCA and five were ARCA. One patient had received heart transplantation because of heart failure. The incidence of adverse cardiovascular events and poor prognosis in ALCA group was higher than that in ARCA group (4/4 vs. 0/13, P<0.05). They were followed up in the outpatient department regularly for 6 (6, 12) months; except for the one who lost visit, the rest of the patients had a good prognosis. Conclusions: Cardiogenic syncope or cardiac insufficiency usually occurs in ALCA, and adverse cardiovascular events and poor prognosis are more common in ALCA than in ARCA. Early surgical treatment should be considered for children with ALCA and ARCA accompanied by myocardial ischemia.

Gender Homophily in Interphysician Referrals to Surgeons

INTRODUCTION

The literature on gender homophily has mostly been focused on patient-physician relationship but not on interprofessional referrals. The goal of this study is to quantify interphysician gender homophily of referring physicians in surgical referrals.

METHODS

An observational study of the referral data at a large academic center was performed. Patients referred through Epic to the department of general surgery from January 2016 to October 2019 were included. The primary end point was gender homophily and the primary independent variable was referring physician gender. Gender homophily was defined as greater than expected rates of gender concordance. Gender concordance was defined when referring physicians have the same gender as receiving surgeons. The expected concordance rate was defined as the availability of gender-concordant surgeons in the population. Absolute homophily is the difference between observed and expected concordance rates, whereas relative homophily is the ratio between observed and expected concordance rates.

RESULTS

A total of 25,271 patient referrals from 2625 referring physicians to 91 surgeons were analyzed. The overall observed concordance rate for the entire study population was 55.3% and was 31.7% among female physicians and 82.4% among male physicians. Compared to the expected concordance rate, the absolute gender homophily among all female physicians was +7.2% or a relative homophily of 1.29%. In contrast, the absolute gender homophily among all male physicians was +6.9% or a relative homophily of 1.09%.

CONCLUSIONS

Gender homophily exists in interprofessional referrals. Although referral decisions are presumably based solely on clinical factors, referrals can be affected by subjective biases.

The trend and future projection of technology-assisted total knee arthroplasty in the United States

BACKGROUND

As technology-assisted surgery has boosted in the last decades, we aimed to investigate the factors affecting adoption and to predict the future utilization of technology among patients who underwent total knee arthroplasty (TKA).

METHODS

Patients underwent TKA in 2017-2019 in the MarketScan Database were included. Percentage of technology-assisted surgery was calculated. Multivariable logistic regression models were performed to analyse the factors and make the prediction.

RESULTS

Of 112,161 TKA procedures, 7.2% were technology-assisted. The proportion of technology-assisted TKA is expected to reach 50% by 2032. The West showed the highest proportion of technology-assisted TKA (12.3%), while the South had the lowest (5.7%). Over time, the Midwest showed the greatest increase in technology adoption (OR = 1.26 compared to the Northeast, 95% CI [1.15, 1.38]).

CONCLUSIONS

Technology adoption rate of TKA will continue to increase for the next 20 years in the United States with a slight geographical variation.

The Effect of Language on Access to Timely COVID-19 Vaccination of Solid Abdominal Organ Transplant Recipients

In dynamic healthcare environments including the COVID-19 pandemic, it is paramount to communicate health recommendations expediently and clearly. Research has shown social determinants of health affect the impact of COVID-19 on abdominal transplant recipients, but there has been less research on the effect of language proficiency. This is a cohort study of time to first COVID-19 vaccination among abdominal organ transplant recipients in an academic medical center in Boston, MA between 18 December 2020, and 15 February 2021. Cox proportional hazards analysis of time to vaccination by preferred language were adjusted for race, age group, insurance, and transplanted organ. Among 3001 patients, 53% were vaccinated during the study period. Language preference other than English was independently associated with delay to vaccination (0.64, p = 0.001), on adjusted analysis. In addition, Black, Hispanic and other race patients were less likely to be vaccinated than white patients (0.58, 0.67, 0.68 vs. reference, all p < 0.03). Language preference other than English is an independent barrier to solid abdominal organ transplant recipients' access to timely COVID-19 vaccination. Equity in care should be improved by providing targeted services to minority language speakers.

A Safe Number of Perioperative Opioids to Reduce the Risk of New Persistent Usage Among Opioid-Naïve Patients Following Total Joint Arthroplasty

BACKGROUND

Higher initial opioid dosing increases the risk of prolonged opioid use following total joint arthroplasty (TJA), and the safe amounts to prescribe are unknown. We examined the relationship between perioperative opioid exposure and new persistent usage among opioid-naïve patients after total knee and hip arthroplasty.

METHODS

In this retrospective cohort study, 22,310 opioid-naïve patients undergoing primary TJA between 2018 and 2019 were identified within a commercial claims database. Perioperative opioid exposure was defined as total dose of opioid prescription in morphine milligram equivalents (MME) between 1 month prior to and 2 weeks after TJA. New persistent usage was defined as at least one opioid prescription between 90 and 180 days postoperatively. Multivariate regression analyses were performed to examine the relationship between the perioperative dosage group and the development of new persistent usage.

RESULTS

For the total patient cohort, 8.1% developed new persistent usage. Compared to patients who received <300 MME, patients who received 600-900 MME perioperatively had a 77% increased risk of developing new persistent usage (odds ratio 1.77, 95% CI, 1.44-2.17), and patients who received ≥1,200 MME perioperatively had a 285% increased risk (odds ratio 3.85, 95% CI, 3.13-4.74).

CONCLUSION

We found a dose-dependent association between perioperative MME and the risk of developing new persistent usage among opioid-naïve patients following TJA. We recommend prescribing <600 MME (equivalent to 80 pills of 5 mg oxycodone) during the perioperative period to reduce the risk of new persistent usage.

LEVEL OF EVIDENCE

Level III.

Pharmacological conversion of gut epithelial cells into insulin-producing cells lowers glycemia in diabetic animals

As a highly regenerative organ, the intestine is a promising source for cellular reprogramming for replacing lost pancreatic β cells in diabetes. Gut enterochromaffin cells can be converted to insulin-producing cells by forkhead box O1 (FoxO1) ablation, but their numbers are limited. In this study, we report that insulin-immunoreactive cells with Paneth/goblet cell features are present in human fetal intestine. Accordingly, lineage-tracing experiments show that, upon genetic or pharmacologic FoxO1 ablation, the Paneth/goblet lineage can also undergo conversion to the insulin lineage. We designed a screening platform in gut organoids to accurately quantitate β-like cell reprogramming and fine-tune a combination treatment to increase the efficiency of the conversion process in mice and human adult intestinal organoids. We identified a triple blockade of FOXO1, Notch, and TGF-β that, when tested in insulin-deficient streptozotocin (STZ) or NOD diabetic animals, resulted in near normalization of glucose levels, associated with the generation of intestinal insulin-producing cells. The findings illustrate a therapeutic approach for replacing insulin treatment in diabetes.

[Potential application of improved hard tissue section technique in the clinical pathological diagnosis of bone and bone marrow]

Objective: To discuss the application value of hard tissue section in the clinicopathology diagnosis. Methods: From March 2021 to December 2021, bone slices of 19 patients (1 patient with osteochondroma, 2 patients with chondrosarcoma, 4 patients with osteosarcoma, 2 patients with fibrous dysplasia, 2 patients with bone metastasis from thyroid papillary carcinoma, 2 patients with osteomyelitis, 4 patients with giant cell tumor of bone, 2 patients with Ewing sarcoma) and 16 hemopathy patients were collected from the Department of Pathology, Shanghai Sixth People's Hospital. Of the osteopathy patients, there were 14 male and 5 female with a median age of 31 (10-66) years. Meanwhile, there were 7 male and 9 female with a median age of 28 (16-65) years among these hemopathy patients. Thirty-five cases were treated with modified hard tissue slicing technique and paraffin embedding technique, respectively. The advantages and disadvantages of the two methods for clinical diagnosis of bone disease were compared by Hematoxylin-Eosin staining (H&E staining), immunohistochemical staining (IHC), fluorescence in situ hybridization (FISH) and Sanger sequencing. Results: The improved resin-embedded method showed better histological morphology and cell structure. Besides, the expression of Ki67, SATB2, CD34, SMA, CD68,MPO,CD4 and CD33 in immunohistochemical staining in bone tissues which were embedded in resin were more clear in the accurate positive localization than those using paraffin-embedded. MDM2 of FISH exhibited a higher fluorescence intensity and more accurate location. Meanwhile, both methods treated with Sanger sequencing met the requirements of DNA purity and mutation detection. Conclusion: The improved hard tissue section method is simple and short time-consuming, which is suitable for optimizing the clinical bone and bone marrow pathological diagnosis process.

Fatigue in Patients with Chronic Hepatitis C

This study aimed to explore the factors associated with fatigue in chronic hepatitis C patients before and at 4, 8, 12, 16, 20, and 24 weeks after antiviral therapy. The study employed a prospective and repeated-measures design. The Chinese version of the brief fatigue inventory (BFI-C) and the Pittsburg sleep quality index (PSQI) were employed to collect data. Pegylated Interferon plus Ribavirin dosages and serum values (hemoglobin, alanine aminotransferase [ALT], and aspartate aminotransferase [AST]) were monitored before and during the antiviral therapy at 4, 8, 12, 16, 20, and 24 weeks. The study enlisted 115 patients as participants. Multivariate analysis indicated that gender, educational level, body mass index (BMI), and hemoglobin level were significant determinants of patients’ fatigue. When hemoglobin levels in the patients decreased in week 4 and continued to fall to the nadir at week 12, it prompted the healthcare providers to assess their fatigue levels and initiate proactive interventions as needed.

Involvement of AMPKα and MAPK-ERK/-JNK Signals in Docetaxel-Induced Human Tongue Squamous Cell Carcinoma Cell Apoptosis

Cancers of the oral cavity can develop in the anatomic area extending from the lip, gum, tongue, mouth, and to the palate. Histologically, about 85-90% of oral cavity cancers are of the type squamous cells carcinomas (SCCs). The incidence of oral tongue SCC is higher in the tongue than any other anatomic area of the oral cavity. Here, we investigated the therapeutic effects and molecular mechanisms of docetaxel, which is a paclitaxel antitumor agent, on the cell growth of a human tongue SCC-derived SAS cell line. The results showed that docetaxel (10-300 nM) induced cytotoxicity and caspase-3 activity in SAS cells. Moreover, docetaxel (100 nM) promoted the expression of apoptosis-related signaling molecules, including the cleavages of caspase-3, caspase-7, and poly (ADP-ribose) polymerase (PARP). In mitochondria, docetaxel (100 nM) decreased the mitochondrial membrane potential (MMP) and Bcl-2 mRNA and protein expression and increased cytosolic cytochrome c protein expression and Bax mRNA and protein expression. In terms of mitogen-activated protein kinase (MAPK) and adenosine monophosphate-activated protein kinase (AMPK) signaling, docetaxel increased the expression of phosphorylated (p)-extracellular signal-regulated kinase (ERK), p-c-Jun N-terminal kinase (JNK), and p-AMPKα protein expression but not p-p38 protein expression. Moreover, the increase in caspase-3/-7 activity and Bax protein expression and decreased Bcl-2 protein expression and MMP depolarization observed in docetaxel-treated SAS cells could be reversed by treatment with either SP600125 (a JNK inhibitor), PD98059 (an MEK1/2 (mitogen-activated protein kinase kinase 1/2) inhibitor), or compound c (an AMPK inhibitor). The docetaxel-induced increases in p-JNK, p-ERK, and p-AMPKα protein expression could also be reversed by treatment with either SP600125, PD98059, or compound c. These results indicate that docetaxel induces human tongue SCC cell apoptosis via interdependent MAPK-JNK, MAPK-ERK1/2, and AMPKα signaling pathways. Our results show that docetaxel could possibly exert a potent pharmacological effect on human oral tongue SCC cell growth.

Costs of Nonoperative Procedures for Knee Osteoarthritis in the Year Prior to Primary Total Knee Arthroplasty

BACKGROUND

The convergence of national priorities to reduce health-care costs and deliver high-value care warrants the need to examine health-care utilization. The objective of this study was to describe the costs associated with nonoperative procedures in the 1-year period leading up to primary total knee arthroplasty (TKA).

METHODS

An observational cohort study was conducted using the IBM Watson Health MarketScan databases. Patients with late-stage knee osteoarthritis (OA) who underwent unilateral, isolated primary TKA from January 1, 2018, to December 31, 2019, were included. The main outcome was the cost of knee OA-related payments for identified nonoperative procedures in the 1-year period before surgery. Nonoperative procedures examined were (1) physical therapy (PT); (2) bracing; (3) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS); (4) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen; and (5) knee-specific imaging.

RESULTS

The study population included 24,492 TKA patients with a mean age of 60.4 ± 8.0 years. The average total cost of nonoperative procedures per patient was $1,355 ± $2,087. The most common nonoperative treatment prescribed was IA-CS (54.3%). The nonoperative procedure with the highest cost per patient was IA-HA ($1,019 ± $913 per patient). The total cost of nonoperative procedures was higher among female compared with male patients ($1,440 ± $2,159 versus $1,254 ± $1,992 per patient; p < 0.01). The highest costs were found for patients in the Northeast ($1,740 ± $2,437 per patient). A total of 14,346 (58.6%) and 7,831 (32.0%) of the patients had >1 and ≥3 nonoperative treatments, respectively.

CONCLUSIONS

There is substantial variation in the type and the cost of nonoperative treatment for patients with late-stage OA. Future studies should investigate the effectiveness of nonoperative treatments at different stages of the disease.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Drivers of Unequal Healthcare Costs in the Nonoperative Treatment of Late-Stage Knee Osteoarthritis Prior to Primary Total Knee Arthroplasty

BACKGROUND

In the United States, patients with late-stage knee osteoarthritis (OA) often undergo several nonoperative treatments and related procedures prior to total knee arthroplasty. The costs of these treatments and procedures are substantial, and the variation in healthcare costs among different groups of patients may exist. The purpose of this study is to examine these costs and determine the drivers of costs in patients with the highest healthcare expenditure.

METHODS

An observational cohort study was conducted using the IBM Watson Health MarketScan databases from January 1, 2017 to December 31, 2019. The primary outcome was the cost of payments for nonoperative procedures which included (i) physical therapy (PT), (ii) bracing, (iii) intra-articular injections: professional fee, hyaluronic acid (IA-HA), and corticosteroids (IA-CS), (iv) medication: nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and acetaminophen, and (v) knee-specific imaging.

RESULTS

Among the 24,492 patients included in the study, the total payments per patient for nonoperative care were $3,735 ± 3,049 in the highest payment quartile (Q4) and $137 ± 70 in the lowest payment quartile (Q1). Per-patient-per-month costs generally increased across quartiles for procedures. Comparing Q4 to Q1, the largest changes in prevalence were found in IA-HA (348×), bracing (10×), and PT (7×). Patients who were prescribed IA-HA and PT had a 28.3-times and 4.8-times greater likelihood, respectively, to be a higher-paying patient.

CONCLUSION

Unequal healthcare costs in the nonoperative treatment of late-stage knee OA are driven by differences in prevalent management strategies. Overall healthcare expenditure may be reduced if only guideline-concordant treatments are used.

[Investigation of newly diagnosed pneumoconiosis from artificial quartz stone manufacturers]

Artificial quartz dust exposure may cause associated pneumoconiosis. From November 2019 to July 2020, a total of 27 cases of silicosis associated with artificial quartz stone manufacturers were diagnosed and treated in the Occupational disease Department of Suzhou Fifth People's Hospital. The average age of onset was (46.8±6.6) years, and the average working age of dust exposure was (5.7±1.7) years.The main feature of high KV chest radiography is P/S shadow with strip shadow. CT imaging findings showed diffuse small nodules and ground glass shadows with band shadows. The lesions were mainly distributed in the upper lung, accompanied by pleural thickening, lymphadenopathy and calcification. The pulmonary function impairment was mainly mild restrictive ventilation disorder, and the bronchial mucosa longitudinal plica was the main manifestation under tracheoscopy. The age of silicosis of workers in artificial quartz stone production enterprises is younger, the working age of dust exposure is short, the lung function and bronchial mucosa have a certain degree of damage, and effective preventive measures should be taken in time.

[Application of three-dimensional visualized model of impacted tooth for surgical extraction in undergraduate oral experimental teaching]

Objective: To evaluate the effect of the application of a self-developed three-dimensional visualized model of impacted tooth for surgical extraction in undergraduate oral experimental teaching. Methods: Forty-one undergraduates majoring stomatology of Tongji University from 2018 [19 males and 22 females, aged (22.4±0.8) years] were enrolled and randomly divided into the conventional group and the experimental group. Students of the conventional group (21 students including 8 males and 13 females) received a teaching protocol for the surgical extraction of impacted tooth including theoretical lectures, watching operation videos, and operating on head-simulator teaching systems. Students of the experimental group (20 students including 11 males and 9 females) received an additional training of resistance assessment and surgical extraction using the three-dimensional visualized model of impacted tooth before operating on the head simulators. After class, a questionnaire survey was carried out among students, and the operation results on the head simulators were evaluated by the teacher. Results: The results of the questionnaire showed that the students in the experimental group were rated higher than those in the traditional group in terms of being able to imagine the relationship between impacted teeth and adjacent structures (U=114.00, P=0.006), avoiding damage to adjacent teeth (U=87.00, P<0.001) and inferior alveolar nerve during tooth extraction (U=111.50, P=0.006), and being more confident in clinical operations in the future (U=120.00, P=0.013). According to the evaluation results of tooth extraction on the head simulators, there was no significant difference in the operation time between the two groups (U=138.50, P=0.056). In the experimental group, 5% (1/20) caused adjacent tooth loosening and 15% (3/20) caused the excessive bone defect, which was less than those in the traditional group [38% (8/21) and 48% (10/21), respectively] (P=0.021; P=0.043). There was no significant difference in the incidence of grinding out the deep bone of impacted teeth between the two groups (P=0.232). Conclusions: The application of three-dimensional visualized model of impacted tooth for surgical extraction in undergraduate oral experimental teaching had achieved good results and was worth popularizing.

Differential effects of macrophage subtypes on SARS-CoV-2 infection in a human pluripotent stem cell-derived model

Dysfunctional immune responses contribute critically to the progression of Coronavirus Disease-2019 (COVID-19), with macrophages as one of the main cell types involved. It is urgent to understand the interactions among permissive cells, macrophages, and the SARS-CoV-2 virus, thereby offering important insights into effective therapeutic strategies. Here, we establish a lung and macrophage co-culture system derived from human pluripotent stem cells (hPSCs), modeling the host-pathogen interaction in SARS-CoV-2 infection. We find that both classically polarized macrophages (M1) and alternatively polarized macrophages (M2) have inhibitory effects on SARS-CoV-2 infection. However, M1 and non-activated (M0) macrophages, but not M2 macrophages, significantly up-regulate inflammatory factors upon viral infection. Moreover, M1 macrophages suppress the growth and enhance apoptosis of lung cells. Inhibition of viral entry using an ACE2 blocking antibody substantially enhances the activity of M2 macrophages. Our studies indicate differential immune response patterns in distinct macrophage phenotypes, which could lead to a range of COVID-19 disease severity.

Wnt5a Promotes AT1 and Represses AT2 Lineage-Specific Gene Expression in a Cell-Context-Dependent Manner

Lung maturation is not limited to proper structural development but also includes differentiation and functionality of various highly specialized alveolar cell types. Alveolar type 1 (AT1s) cells occupy nearly 95% of the alveolar surface and are critical for establishing efficient gas exchange in the mature lung. AT1 cells arise from progenitors specified during the embryonic stage as well as alveolar epithelial progenitors expressing surfactant protein C (Sftpcpos cells) during postnatal and adult stages. Previously, we found that Wnt5a, a non-canonical Wnt ligand, is required for differentiation of AT1 cells during the saccular phase of lung development. To further investigate the role of Wnt5a in AT1 cell differentiation, we generated and characterized a conditional Wnt5a gain-of-function mouse model. Neonatal Wnt5a gain-of-function disrupted alveologenesis through inhibition of cell proliferation. In this setting Wnt5a downregulated β-catenin-dependent canonical Wnt signaling, repressed AT2 (anti-AT2) and promoted AT1 (pro-AT1) lineage-specific gene expression. In addition, we identified 2 subpopulations of Sftpchigh and Sftpclow alveolar epithelial cells. In Sftpclow cells, Wnt5a exhibits pro-AT1 and anti-AT2 effects, concurrent with inhibition of canonical Wnt signaling. Interestingly, in the Sftpchigh subpopulation, although increasing AT1 lineage-specific gene expression, Wnt5a gain-of-function did not change AT2 gene expression, nor inhibit canonical Wnt signaling. Using primary epithelial cells isolated from human fetal lungs, we demonstrate that this property of Wnt5a is evolutionarily conserved. Wnt5a therefore serves as a selective regulator that ensures proper AT1/AT2 balance in the developing lung.

Methylmercury Induces Mitochondria- and Endoplasmic Reticulum Stress-Dependent Pancreatic β-Cell Apoptosis via an Oxidative Stress-Mediated JNK Signaling Pathway

Methylmercury (MeHg), a long-lasting organic pollutant, is known to induce cytotoxic effects in mammalian cells. Epidemiological studies have suggested that environmental exposure to MeHg is linked to the development of diabetes mellitus (DM). The exact molecular mechanism of MeHg-induced pancreatic β-cell cytotoxicity is still unclear. Here, we found that MeHg (1-4 μM) significantly decreased insulin secretion and cell viability in pancreatic β-cell-derived RIN-m5F cells. A concomitant elevation of mitochondrial-dependent apoptotic events was observed, including decreased mitochondrial membrane potential and increased proapoptotic (Bax, Bak, p53)/antiapoptotic (Bcl-2) mRNA ratio, cytochrome c release, annexin V-Cy3 binding, caspase-3 activity, and caspase-3/-7/-9 activation. Exposure of RIN-m5F cells to MeHg (2 μM) also induced protein expression of endoplasmic reticulum (ER) stress-related signaling molecules, including C/EBP homologous protein (CHOP), X-box binding protein (XBP-1), and caspase-12. Pretreatment with 4-phenylbutyric acid (4-PBA; an ER stress inhibitor) and specific siRNAs for CHOP and XBP-1 significantly inhibited their expression and caspase-3/-12 activation in MeHg-exposed RIN-mF cells. MeHg could also evoke c-Jun N-terminal kinase (JNK) activation and reactive oxygen species (ROS) generation. Antioxidant N-acetylcysteine (NAC; 1mM) or 6-hydroxy-2,5,7,8-tetramethylchroman-2-carboxylic acid (trolox; 100 μM) markedly prevented MeH-induced ROS generation and decreased cell viability in RIN-m5F cells. Furthermore, pretreatment of cells with SP600125 (JNK inhibitor; 10 μM) or NAC (1 mM) or transfection with JNK-specific siRNA obviously attenuated the MeHg-induced JNK phosphorylation, CHOP and XBP-1 protein expression, apoptotic events, and insulin secretion dysfunction. NAC significantly inhibited MeHg-activated JNK signaling, but SP600125 could not effectively reduce MeHg-induced ROS generation. Collectively, these findings demonstrate that the induction of ROS-activated JNK signaling is a crucial mechanism underlying MeHg-induced mitochondria- and ER stress-dependent apoptosis, ultimately leading to β-cell death.

A Portable Controllable Compressive Stress Device to Monitor Human Breast Cancer Cell Protrusions at Single-Cell Resolution

In vitro devices offer more numerous methods than in vivo models to investigate how cells respond to pressure stress and quantify those responses. Several in vitro devices have been developed to study the cell response to compression force. However, they are unable to observe morphological changes of cells in real-time. There is also a concern about cell damage during the process of harvesting cells from 3D gels. Here we report a device employing transparent, thin gel layers to clamp cells between the interfaces and applied a controllable compression force by stacking multiple layers on the top. In this approach, cells can be monitored for alteration of cellular protrusions, whose diversity has been proven to promote cancer cell dissemination, with single-cell resolution under compression force. Furthermore, p-Rac-1 and rhodamine staining on the device directly to confirm the actin filaments of lamellipodia. The method was able to fulfill real-time live-cell observation at single-cell resolution and can be readily used for versatile cell analysis. MDA-MB-231 and MCF7 breast cancer cells were utilized to demonstrate the utility of the device, and the results showed that the stimuli of compression force induce MDA-MB-231 and MCF7 to form lamellipodia and bleb protrusions, respectively. We envision the device may be used as a tool to explore mechanisms of membrane protrusion transitions and to screen drug candidates for inhibiting cancer cell protrusion plasticity for cancer therapy.

Alteration of imprinted genes and offspring organ development caused by environmental factors

Imprinted genes are a special subset of about 100 genes, which are mainly expressed in the form of parental monoallelic genes, and play important roles in the growth and development of embryos. In recent years, it has been found that epigenetic modification of imprinted genes induced by environmental factors can cause fetal multi-organ dysplasia and even susceptibility to multiple diseases in adulthood, which also exhibit multi-generational inheritance. In this review, we summarize the effects of expression changes of imprinted genes on ontogenetic development and organ functions in late stage of life, and propose that abnormal epigenetic modification and expression of imprinted genes caused by environmental deleterious factors are important mechanisms for explaining the multi-organ dysplasia in offspring. Such mechanisms are greatly significant for understanding the phenotypic changes caused by alteration of imprinted gene expression during ontogeny and exploring early prevention and treatment strategies of diseases.

The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States

OBJECTIVE

To assess the association between the timing of surgery relative to the development of Covid-19 and the risks of postoperative complications.

SUMMARY BACKGROUND DATA

It is unknown whether patients who recovered from Covid-19 and then underwent a major elective operation have an increased risk of developing postoperative complications.

METHODS

The risk of postoperative complications for patients with Covid-19 undergoing 18 major types of elective operations in the Covid-19 Research Database was evaluated using multivariable logistic regression. Patients were grouped by time of surgery relative to SARS-CoV-2 infection; that is, surgery performed: (1) before January 1, 2020 ("pre-Covid-19"), (2) 0 to 4 weeks after SARS-CoV-2 infection ("peri-Covid-19"), (3) 4 to 8 weeks after infection ("early post-Covid-19"), and (4) ≥8 weeks after infection ("late post-Covid-19").

RESULTS

Of the 5479 patients who met study criteria, patients with peri-Covid-19 had an elevated risk of developing postoperative pneumonia [adjusted odds ratio (aOR), 6.46; 95% confidence interval (CI): 4.06-10.27], respiratory failure (aOR, 3.36; 95% CI: 2.22-5.10), pulmonary embolism (aOR, 2.73; 95% CI: 1.35-5.53), and sepsis (aOR, 3.67; 95% CI: 2.18-6.16) when compared to pre-Covid-19 patients. Early post-Covid-19 patients had an increased risk of developing postoperative pneumonia when compared to pre-Covid-19 patients (aOR, 2.44; 95% CI: 1.20-4.96). Late post-Covid-19 patients did not have an increased risk of postoperative complications when compared to pre-Covid-19 patients.

CONCLUSIONS

Major, elective surgery 0 to 4 weeks after SARS-CoV-2 infection is associated with an increased risk of postoperative complications. Surgery performed 4 to 8 weeks after SARS-CoV-2 infection is still associated with an increased risk of postoperative pneumonia, whereas surgery 8 weeks after Covid-19 diagnosis is not associated with increased complications.