Effect of Exercise Interventions on Health-Related Quality of Life in Patients with Fibromyalgia Syndrome: A Systematic Review and Network Meta-Analysis

OBJECTIVE

Several guidelines highlight the beneficial impact of exercise on the management of symptoms and health-related quality of life (HRQOL) in patients with fibromyalgia syndrome (FMS). However, few analyses have compared different types of exercise. We, therefore, intent to compare the effects of different exercise types on improving the overall HRQOL and typical symptoms in patients with FMS.

METHODS

Medline, Embase, the Cochrane Register of Clinical Trials, and NIH ClinicalTrials.gov were searched from inception to April 21, 2022. Randomized clinical trials (RCTs) were included to assess the impact of exercise intervention on health parameters in adult FMS patients. Data were extracted independently and a frequentist network meta-analyses (NMA) was performed to rank the effects of interventions according to P-scores. The NMA evidence certainty was assessed using the method recommended by Grading of Recommendations Assessment, Development, and Evaluation Working Group.

RESULTS

A total of 57 RCTs were identified, including 3319 participants, involving 9 interventions (7 types of exercise, 2 controls). Of all treatments compared with usual care in efficacy outcomes, Mind-body exercise was associated with the best HRQOL (SMD, -12.12; 95% CI, -15.79 to -8.45). On the other characteristic symptom dimensions, based on moderate quality evidence, sensorimotor training was associated with minimal pain scores compared with usual care (SMD, -1.81; 95% CI, -2.81 to -0.82), whole body vibration therapy was most promising for improving sleep quality (SMD, -6.95; 95% CI, -10.03 to -3.87), pool-based aerobic exercise was most likely to ease anxiety (SMD, -4.83; 95% CI, -7.47 to -2.19), and whole body vibration was most likely to improve depression (SMD, -10.44; 95% CI, -22.00 to 1.12).

CONCLUSION

Mind-body exercise seems to be the most effective exercise to improve the overall HRQOL of patients with FMS. But at the same time, clinicians still need to develop individualized exercise plans for patients according to their symptoms and accessibility.

[A case report of congenital osteogenesis imperfacta with corneal ectasia]

An 8-year-old male patient was admitted to ophthalmology for bilateral progressive blurred vision for 5 years. He had a history of multiple spontaneous fractures. Ocular examination revealed best-corrected visual acuity (BCVA) of 0.5 in the right eye and 0.6 in the left eye. Slitlamp examination showed bilateral blue sclerae, thining of the entire cornea and corneal ectasia. General physical examination demonstrated multi-site ligamentous laxity. The diagnosis of osteogenesis imperfacta was made. The patient was advised to wear rigid gas permeable contact lens with large diameter and stabilized peripheral curve, and the BCVA achieved 0.8 for both eyes.

Evaluation of the reliability of the upper lip bite test and the modified mallampati test in predicting difficult intubation under direct laryngoscopy in apparently normal patients: a prospective observational clinical study

Background and aims

Difficult endotracheal intubation is one of the most challenging operations in anesthesia. How to better predict difficult airway and make corresponding preparations to reduce the occurrence of accidents is a difficult task faced by anesthesiologists every day. This study decide to evaluate the value of the Upper Lip Bite Test (ULBT) and the Modified Mallampati Test (MMT) in predicting difficult intubation under direct laryngoscopy and find out the most intuitive and simple method to predict difficult intubation under direct laryngoscopy in apparently normal patients.

Patients and methods

This descriptive-analytical study was performed on 450 patients for elective surgery under general anesthesia requiring endotracheal intubation. The ULBT and MMT grading were evaluated preoperatively and Cormack and Lehane’s (CL) classification was recorded on the day of surgery during intubation under direct laryngoscopy. The accuracy, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR), Youden index and area under ROC curve of ULBT and MMT respectively and in combination were calculated and compared. And the consistency between the total scores of ULBT and MMT combined in different ways and CL grading was counted.

Results

Of the 450 patients, 69 (15.3%) were classified as difficult cases of direct laryngoscopy. The accuracy, sensitivity, specificity, PPV and NPV of ULBT were 81.33, 11.59, 93.96, 25.81, 85.44%; and those the corresponding values for MMT were 66.22, 62.32, 69.29, 26.88 and 91.03%. A combination of ULBT and MMT did not improve the sensitivity in the sample tested. The combined total scores of ULBT and MMT in both ways were less consistent with CL grading in predicting difficult intubation under direct laryngoscopy.

Conclusion

Based on findings of current study, we conclude that ULBT and MMT for difficult intubation have only poor to moderate discriminative power when used alone.

The combination of the two tests in fractional form is also not a good predictor of difficult intubation under direct laryngoscopy.

Trial registration

Chinese Clinical Trial Registry, ChiCTR2100052987, Registered 07 November 2021, http://www.chictr.org.cn

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01855-7.

Glabridin from Glycyrrhiza glabra Possesses a Therapeutic Role against Keloid via Attenuating PI3K/Akt and Transforming Growth Factor-β1/SMAD Signaling Pathways

Glabridin (Gla) is a typical flavonoid isolated from the Glycyrrhiza glabra with various bioactivities and is a common additive in many cosmetics. In our study, we evaluated the antiscarring effect of Gla from G. glabra in a rabbit ear hyperplastic scar model. Hematoxylin and eosin staining and Masson staining were applied to determine the pathological changes and collagen fibers of scar tissue in rabbits. The results suggested that Gla could reduce rabbit ear scar hyperplasia, inhibit inflammation, and decrease collagen production. Furthermore, the in vitro cell experiments were applied to determine the effects of Gla on human keloid fibroblasts (HKFs), and we observed that Gla suppressed the HKF cells' proliferation via inducing apoptosis. Subsequently, we found that Gla reduced collagen production in HKF cells. The further molecular mechanisms investigations suggested that Gla played a therapeutic role against keloid by attenuating PI3K/Akt and TGFβ1/SMAD pathways. Our study would be beneficial for extending the applications of the known sweet plant of G. glabra.

[Gene expression signature analysis of peripheral blood mononuclear cells from patients with for high altitude pulmonary hypertension and value for potential drug selection]

Objective: To investigate the gene expression characteristics of peripheral blood mononuclear cells from patients with high altitude pulmonary hypertension (HAPH) in Naxi residents living in Lijiang, Yunnan, and to explore the underlying pathogenesis and value for potential drug selection. Methods: This is a case-control study. Six patients with HPAH (HPAH group) and 4 normal subjects (control group) were selected from the Naxi residents who originally lived in Lijiang, Yunnan Province. The general clinical data of the two groups were collected, and the related indexes of pulmonary artery pressure were collected. Peripheral blood mononuclear cells of the subjects were collected for RNA sequencing. The differences on gene expression, regulatory network of transcription factors and drug similarity between the two groups were compared. The results were compared with the public data of idiopathic pulmonary arterial hypertension (IPAH). Biological processes and signal pathways were analyzed and compared between HPAH and IPAH patients. Results: The age of 6 patients with HAPH was (68.1±8.3) years old, and there were 2 males (2/6). The age of 4 subjects in the control group was (62.3±10.9) years old, and there were 2 males (2/4). Tricuspid regurgitation velocity, tricuspid pressure gradient and pulmonary systolic pressure in HAPH group were significantly higher than those in control group (all P<0.05). The results of RNA sequencing showed that compared with the control group, 174 genes were significantly upregulated and 169 genes were downregulated in peripheral blood mononuclear cells of HAPH group. These differentially expressed genes were associated with 220 biological processes, 52 molecular functions and 23 cell components. A total of 21 biological processes and 2 signal pathways differed between HPAH and IPAH groups, most of which were related to inflammation and immune response. ZNF384, SP1 and STAT3 were selected as highly correlated transcription factors by transcription factor prediction analysis. Trichostatin A and vorinostat were screened out as potential drugs for the treatment of HAPH by drug similarity analysis. Conclusions: There are significant differences in gene expression in peripheral blood monocytes between HAPH patients and normal population, and inflammation and immune dysfunction are the main pathogenic factors. Trichostatin A and Vorinostat are potential drugs for the treatment of HAPH.

Comparison of the Effectiveness of Various Drug Interventions to Prevent Etomidate-Induced Myoclonus: A Bayesian Network Meta-Analysis

Background

Myoclonic movement is a very common but undesirable phenomenon during the induction of general anesthesia using etomidate. Such movement may cause unnecessary problems. Currently, there is an increasing number of drugs for preventing etomidate-induced myoclonus (EM). However, direct comparisons of various drugs are lacking, and this interferes with clinical decision-making. Our network meta-analysis (NMA) aimed to compare the efficacy of different drugs for the prevention of moderate-to-severe general myoclonus.

Methods

Using several biomedical databases, randomized controlled trials (RCTs) published in English from inception to August 22, 2021 were searched. Among the various interventions, we selected nine types of intervention drugs (dexmedetomidine, etomidate, lidocaine, NMDA receptor antagonist, κ opioid receptor agonist, μ opioid receptor agonist, muscle relaxant, gabapentin, and midazolam) for comparison, according to the number of studies. Bayesian NMA was performed using STATA16 and R softwares. The relative risk of EM was assessed using risk ratios (RRs) and the corresponding 95% confidence intervals (CI).

Results

A total of 31 RCTs (3209 patients) were included. NMA results showed that, compared with a placebo, etomidate (RR 4.0, 95%CI 2.1–7.8), κ opioid receptor agonist (RR 2.9, 95%CI 1.9–4.6), μ opioid receptor agonist (RR 3.1, 95%CI 2.3–4.3), NMDA receptor antagonist (RR 1.7, 95%CI 1.0–2.8), dexmedetomidine (RR 2.4, 95%CI 1.5–3.9), lidocaine (RR 2.1, 95%CI 1.2–3.9), and midazolam (RR 2.2, 95%CI 1.5–3.2) can significantly reduce the risk of EM. In contrast, the effects of muscle relaxants (RR 2.1, 95%CI 0.81–5.3) and gabapentin (RR 2.8, 95%CI 0.92–9.3) were inconclusive. Further subgroup analyses showed that preoperative low-dose etomidate, μ-opioid receptor agonist, and κ-opioid receptor agonist were significantly better than other interventions in the prevention of moderate to severe EM.

Conclusion

Preoperative use of small doses of etomidate or opioids may be the most effective way to avoid EM, especially moderate and severe EM, which makes anesthesia induction safer, more stable, and aligns better with the requirements of comfortable medicine.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero/], [CRD4202127706].

[Detection of the spontaneous blinking pattern of dry eye patients using the machine learning method]

Objective: To establish a method to record the spontaneous blink pattern with a machine learning model, and to clarify the spontaneous blink pattern in patients with dry eye. Methods: It was a cross-setional study.We selected 357 dry eye patients (102 males and 255 females), aged (46.2±13.3) years, who visited corneal specialist clinics of Beijing Tongren Eye Center in 2019, as the dry eye group. The control group enrolled 152 normal controls, including 32 males and 120 females, aged (48.1±13.9) years. All participants completed the Ocular Surface Disease Index questionnaire, blink video capture, lipid layer thickness measurement, tear break-up time measurement, corneal fluorescein staining, and Schirmer Ⅱ test. Based on the assembled model built using UNet image segmentation algorithm and ResNet image classification algorithm, single frames of the blink video were analyzed, and then the palpebral opening height of each frame was obtained in order to establish a spontaneous blink wave. Finally, the characteristics of spontaneous blinks in dry eye patients were analyzed based on different types of complete blinks (types A, B and C) and partial blinks (types Ⅰ, Ⅱ and Ⅲ). Independent sample t test and Wilcoxon rank-sum test were used to judge if there was significant difference between the dry eye group and the normal group. Results: The accuracy of the segmentation model and the classification model was 96.3% and 96.0%, respectively, and the consistency with the manual analysis was 97.9%. In dry eye patients, the number of blinks was 30 (18, 42)/min, which was higher than that in normal controls [20 (9, 46)/min] (U=18 132.50, P=0.002). The number of complete blinks in dry eye cases was significantly lower than that in normal controls [6 (3, 24)/min vs. 12 (3,33)/min; U=12 361.00, P=0.016], and the number of partial blinks was significantly higher than that in normal controls [15 (6, 27)/min vs. 3 (0, 10)/min; U=22 839.00, P<0.001]. In complete blinks, the proportion of type A blinks in dry eye patients was significantly higher than that in normal controls [53.7% (2 796/5 177) vs. 39.3% (633/1 698); χ²=101.83, P<0.001]; in partial blinks, the proportion of type Ⅱ blinks in dry eye patients was significantly higher than that in normal controls [36.0%(2 334/6 477) vs. 29.6%(126/426); χ²=6.99, P=0.007]. The average interblink interval of dry eye patients was 1.2 s, which was not significantly different from that of normal controls (1.1 s; U=15 230.00, P=0.093). The eyelid closed phase of dry eye patients was 0.8 s, which was significantly shorter than that of normal controls (1.3 s; U=16 291.50, P=0.006). There were no significant differences in eyelid closing phase, early opening phase and late opening phase between the two groups (all P>0.05). Conclusions: In dry eye patients, the number of partial blinks increased, the number of complete blinks decreased, and the duration of eyelid closed phase shortened significantly. The main blink patterns of dry eye patients included type Ⅱ partial blinks with a reduced closure amplitude and type A complete blinks with a shortened closure time.

Exploring Lorentz Invariance Violation from Ultrahigh-Energy γ Rays Observed by LHAASO

Recently, the LHAASO Collaboration published the detection of 12 ultrahigh-energy γ-ray sources above 100 TeV, with the highest energy photon reaching 1.4 PeV. The first detection of PeV γ rays from astrophysical sources may provide a very sensitive probe of the effect of the Lorentz invariance violation (LIV), which results in decay of high-energy γ rays in the superluminal scenario and hence a sharp cutoff of the energy spectrum. Two highest energy sources are studied in this work. No signature of the existence of the LIV is found in their energy spectra, and the lower limits on the LIV energy scale are derived. Our results show that the first-order LIV energy scale should be higher than about 10^{5} times the Planck scale M_{Pl} and that the second-order LIV scale is >10^{-3}M_{Pl}. Both limits improve by at least one order of magnitude the previous results.

[Cognition and related factors on the use of HIV non-occupational post-exposure prevention among men who have sex with men]

Objective: To understand the cognition and related factors on the use of HIV non-occupational post-exposure prophylaxis (nPEP) among men who have sex with men (MSM). Methods: The snowballing method was applied to recruit research subjects who were ≥18 years old, had sex with men in the past three months, and were aware of nPEP in MSM groups in Beijing, Shenzhen, and Kunming from March 15 to April 14, 2019. Data on social demographics, behavioral characteristics, basic knowledge of nPEP, consultation, and using nPEP were collected through "i guardian Platform". The logistic regression model was used to analyze the related factors affecting the use of nPEP. Results: Among 1 809 investigated, 39.8% (720 persons) were aware of the basic knowledge of nPEP, 33.4% (605 persons) had consulted nPEP, and 15.0% (271 persons) had used nPEP. In addition, multivariate logistic regression analysis showed that factors as whether to have sex with men infected with HIV in the last three months (OR=2.58, 95%CI: 1.64-4.07), the frequency of HIV testing in the past year (OR=2.47, 95%CI: 1.28-5.11), nPEP knowledge awareness (OR=0.70, 95%CI: 0.49-0.99), whether to consult nPEP (OR=70.98, 95%CI: 40.51-136.83) were related to the use of nPEP. Conclusions: MSM still have poor cognition of nPEP. It is necessary to strengthen the publicity and education of nPEP in MSM and promote the use of nPEP after HIV exposure as soon as possible.

[Correlation of inflammatory cells and corneal nerve damage in fungal keratitis on in vivo confocal microscopy]

Objective: To investigate the relationship between inflammatory cell infiltration and nerve damage in patients with fungal keratitis at different degrees of severity. Methods: Retrospective study. A total of 44 consecutive patients (44 eyes) with fungal keratitis in Beijing Tongren Hospital Affiliated to Capital Medical University from January 2017 to December 2019 were selected as the patient group, including 30 males and 14 females, with an age of (58.3±11.5) years old. Twenty healthy people (20 eyes) were included as control group. Slit-lamp microscopy was performed to observe the corneal ulcer. According to the diameter of corneal ulcer, patients were divided into mild, moderate and severe groups. With in vivo confocal microscopic ,the images were obtained from the epithelial layer to the endothelial layer in the central cornea and superior, inferior, nasal and temporal peripheral cornea. Parameters of the maximum density of fungal hyphae, the maximum depth of hyphal infiltration, the density, area and length of dendritic cells (DCs), the nerve density, and the number and curvature of nerve trunks were collected. The Kruskal-Wallis test, Wilcoxon test, and Spearman correlation analysis were used for analyses. Results: On confocal microscopy, many uniform, highly reflective, segment-like structures in parallel or staggered rows were detected in the cornea, with a certain degree of physiological curvature and branching. Quantitative analysis of hyphal density found that the median rating of hyphal density was 2.6 (2.0, 3.0), mainly with medium to large amounts of hyphae. Most hyphae were 100-150 μm in depth (18 cases, 40.9%), and the maximum depth of hyphae in 95.5% (42 cases) of patients was within 300 μm. The hyphal invasion depth in the mild group was 89.4 (50.5, 106.8) μm, in the moderate group was 133 (122, 203) μm, and in the severe group was 135 (74, 151) μm. As the severity of the disease increased, the depth of hyphal invasion increased (F=4.248, P=0.001). Compared with the control group, the DC density [166 (81.3, 212.5) vs. 24.0 (20.8, 32.3) cells/μm²], area [441.3 (291.9, 529.5) vs. 63.7 (47.7, 70.3) μm²] and length [68.3 (39.4, 91.0) vs. 9.2 (7.0, 11.3) μm] increased in patients (W=493.5, 500.0, 500.0; P<0.01). The nerve density [5 398.3 (3 202.7, 6 828.3) vs. 19 171.8 (17 558.8, 21 550.4) μm/mm²; t=-14.448, P<0.01] and the length [692.7 (402.0, 925.1) vs.2 138.4 (1 940.4, 2 597.2) μm; t=-11.930, P<0.01] and number [2.9 (2.0,3.0) vs. 6.0 (5.5,7.0); t=-8.282, P<0.01] of nerve trunks in patients decreased. There were strong negative correlations between the nerve density, the number of nerve trunks, and the DC density (r=-0.555, -0.466; P<0.01). Conclusions: The depth of fungal hypha invasion in patients with fungal keratitis is mainly concentrated in the epithelial layer and superficial stroma layer. The density of mature dendritic cells in the lesion area was negatively correlated with the density and number of subbasal nerves. The density of subbasal nerves decreased as the increase of the severity of the lesion. (Chin J Ophthalmol, 2021, 57: 580-588).

Peta-electron volt gamma-ray emission from the Crab Nebula

The Crab Nebula is a bright source of gamma rays powered by the Crab Pulsar's rotational energy through the formation and termination of a relativistic electron-positron wind. We report the detection of gamma rays from this source with energies from 5 × 10^-4 to 1.1 peta-electron volts with a spectrum showing gradual steepening over three energy decades. The ultrahigh-energy photons imply the presence of a peta-electron volt electron accelerator (a pevatron) in the nebula, with an acceleration rate exceeding 15% of the theoretical limit. We constrain the pevatron's size between 0.025 and 0.1 parsecs and the magnetic field to ≈110 microgauss. The production rate of peta-electron volt electrons, 2.5 × 10³⁶ ergs per second, constitutes 0.5% of the pulsar spin-down luminosity, although we cannot exclude a contribution of peta-electron volt protons to the production of the highest-energy gamma rays.

Extended Very-High-Energy Gamma-Ray Emission Surrounding PSR J0622+3749 Observed by LHAASO-KM2A

We report the discovery of an extended very-high-energy (VHE) gamma-ray source around the location of the middle-aged (207.8 kyr) pulsar PSR J0622+3749 with the Large High-Altitude Air Shower Observatory (LHAASO). The source is detected with a significance of 8.2σ for E>25  TeV assuming a Gaussian template. The best-fit location is (right ascension, declination) =(95.47°±0.11°,37.92°±0.09°), and the extension is 0.40°±0.07°. The energy spectrum can be described by a power-law spectrum with an index of -2.92±0.17_{stat}±0.02_{sys}. No clear extended multiwavelength counterpart of the LHAASO source has been found from the radio to sub-TeV bands. The LHAASO observations are consistent with the scenario that VHE electrons escaped from the pulsar, diffused in the interstellar medium, and scattered the interstellar radiation field. If interpreted as the pulsar halo scenario, the diffusion coefficient, inferred for electrons with median energies of ∼160  TeV, is consistent with those obtained from the extended halos around Geminga and Monogem and much smaller than that derived from cosmic ray secondaries. The LHAASO discovery of this source thus likely enriches the class of so-called pulsar halos and confirms that high-energy particles generally diffuse very slowly in the disturbed medium around pulsars.

Atypical Sensory Processing and Its Correlation with Behavioral Problems in Late Preterm Children at Age Two

This study aimed to compare the prevalence rate of atypical sensory processing in late preterm (LP) and term children at two years of age and to further investigate the co-occurrence of atypical sensory processing and behavioral problems (internalizing/externalizing) in both groups of children. A total of 104 children (52 LP and 52 sex- and birth order-matched term children) were included. The primary caregivers were asked to complete the Infant/Toddler Sensory Profile-Chinese version and the Child Behavior Checklist 1.5-5Y-Chinese version (CBCL-C/1.5-5). We found that the LP group had a similar prevalence rate of atypical sensory processing to the term group. However, neonatal intensive care unit experience (r = -0.356, p = 0.013, with visual processing) and days of ventilation and supplementary oxygen (r = -0.392, p = 0.004, with low registration) after birth were significantly correlated with the atypical sensory processing of LP children. Both LP and term children with behavioral problems seemed to have a higher prevalence rate of atypical sensory processing than their peers without behavioral problems. However, when Bonferroni correction was used to control for the statistical errors of multiple comparisons, only in the LP group did the co-occurrence of atypical sensory processing (auditory and oral sensory processing and sensation avoiding) and behavioral problems reach significance. In conclusion, the influence of late preterm birth on sensory processing may become subtle at age two, with the exception of those LP children experiencing complicated medical management after birth. A high level of co-occurrence of atypical sensory processing and behavioral problems suggests that the administration of a sensory processing assessment may be helpful to clarify the cause of problematic behavior and to recommend an appropriate intervention for LP children with behavioral problems.

[Willingness of post-exposure prophylaxis and possible related factors in men who have sex with men]

Objective: To analyze the willingness of post-exposure prophylaxis (PEP) to prevent HIV transmission and related factors in men who have sex with men (MSM). Methods: Cross sectional survey design was used in this study. After informed consent, MSM aged 18 years or above and having had homosexual anal or oral sex in the past 6 months were recruited through "i WeChat" official account between September and November, 2019. Results: Of 1 517 MSM were surveyed, the proportion of MSM who had ever heard of PEP were 72.5% (1 100/1 517) and 87.9%(1 333/1 517) of the MSM said they would like to use PEP if it is needed.Multivariate logistic regression analysis suggested that aged above 25 year (OR=1.807, 95%CI: 1.090-2.995), HIV test history (OR=1.953, 95%CI: 1.171-3.256) and being aware of PEP (OR=2.163, 95%CI: 1.468-3.186) were the positive factors for PEP use, but an aware of the HIV status of sexual partner was the negative factor for PEP (OR=0.602, 95%CI: 0.407-0.890). Among MSM who had ever heard of PEP, the positive factors for PEP use included living in Zhejiang (OR=1.942, 95%CI: 1.097-3.438), aged above 25 years (OR=2.431, 95%CI: 1.331-4.439), being aware of PEP (OR=3.714, 95%CI: 1.532-9.007) obtaining information about PEP service from MSM organization/volunteer/health organization. Conclusions: MSM's willingness to use PEP services was relatively high. Age, awareness of PEP related knowledge, and awareness of sexual partner's HIV infection status were the related factors. MSM organization/volunteer/health organization were the main forces for PEP promotion in MSM.

Ultrahigh-energy photons up to 1.4 petaelectronvolts from 12 γ-ray Galactic sources

The extension of the cosmic-ray spectrum beyond 1 petaelectronvolt (PeV; 10¹⁵ electronvolts) indicates the existence of the so-called PeVatrons-cosmic-ray factories that accelerate particles to PeV energies. We need to locate and identify such objects to find the origin of Galactic cosmic rays¹. The principal signature of both electron and proton PeVatrons is ultrahigh-energy (exceeding 100 TeV) γ radiation. Evidence of the presence of a proton PeVatron has been found in the Galactic Centre, according to the detection of a hard-spectrum radiation extending to 0.04 PeV (ref. ²). Although γ-rays with energies slightly higher than 0.1 PeV have been reported from a few objects in the Galactic plane^3-6, unbiased identification and in-depth exploration of PeVatrons requires detection of γ-rays with energies well above 0.1 PeV. Here we report the detection of more than 530 photons at energies above 100 teraelectronvolts and up to 1.4 PeV from 12 ultrahigh-energy γ-ray sources with a statistical significance greater than seven standard deviations. Despite having several potential counterparts in their proximity, including pulsar wind nebulae, supernova remnants and star-forming regions, the PeVatrons responsible for the ultrahigh-energy γ-rays have not yet been firmly localized and identified (except for the Crab Nebula), leaving open the origin of these extreme accelerators.

[Long-term outcome of 48 unoperated adult patients with Ebstein's anomaly]

Objective: To analyze the long-term outcome of unoperated Ebstein's anomaly (EA) patients aged over 18 years, and to evaluate the related factor of outcomes. Methods: The data of 48 unoperated EA patients from March 2004 to December 2008 in the First Hospital of Tsinghua University, were analyzed. The clinical data of the patients were collected, and patients received regular echocardiography, ECG and chest X-ray examinations. Septal leaflet attachment ratio (SLAr) was calculated based on transthoracic echocardiography imagines. The patients were divided into 3 groups according to SLAr: SLAr<0.45 (n=18), 0.45≤SLAr≤0.60 (n=21) and SLAr>0.60 (n=9). Chest X-ray was used for measurement of cardiothoracic ratio (CTR). Kaplan Meier survival curve was used to calculate the long-term survival rate. Cox proportional hazards regression model was used to analyze the influencing factors of death. Results: There were 19 males, and the mean age at diagnosis was (21.3±11.1) years. Forty-two patients (87.5%) were complicated with arrhythmia, including W-P-W syndrome (n=4), supraventricular tachycardia (n=16), right bundle branch block (n=37), and atrial fibrillation (n=2). The mean duration of follow-up was (148.8±16.8) months, the follow-up rate was 100% with no loss-to-follow up. Nine cases (18.8%) died during follow-up: 6 cases (12.5%) died of cardiac origin, including 3 cases of heart failure, 1 case of arrhythmia, and 2 cases of sudden death; 1 case died of accident; 2 cases died from unknown causes. During the follow-up period, the survival rates were 17/18, 19/21 (90.5%) and 3/9 in the SLAr<0.45, 0.45≤SLAr≤0.60 and SLAr>0.60 group, respectively. According to Kaplan-Meier survival curve, the 5-year survival rates among the three groups were 100%, 100% and 78%, respectively. The 10-year survival rates among the three groups were 94%, 95% and 44%, respectively. Decreased activity tolerance and heart failure were found in 7 patients (6 patients in SLAr>0.60 group and 1 patient in 0.45≤SLAr≤0.60 group). Two patients had cerebrovascular embolism. There were 3 cases with tachyarrhythmia lasting more than 24 hours. Cox regression analysis showed that the risk of death was higher in patients with SLAr>0.60 than in patients with SLAr<0.45 (HR=12.375, 95%CI 1.692-22.146, P=0.015); the risk of death in patients with CTR≥0.65 was 1.306 times higher than that in patients with CTR<0.65 (HR=1.306, 95%CI 0.417-12.754, P=0.038). Conclusions: EA patients often combines with arrhythmia. For unoperated EA patients, SLAr>0.60 and CTR≥0.65 are risk factors of death. EA patients with arrhythmia should be actively treated with drugs or radiofrequency ablation.

[An interpretation of global consensus on the diagnosis and management of limbal stem cell deficiency]

Limbal stem cell deficiency is an ocular surface disease with the imbalance of corneal epithelial homeostasis caused by decrease of number or weakening of function of limbal stem cells. In 2019 and 2020, the international limbal stem cell deficiency working group developed and released the international consensus on the definition, classification, diagnosis, staging and management of limbal stem cell deficiency, which provided a standard protocol for related research and clinical diagnosis and treatment of limbal stem cell deficiency. In order to help Chinese ophthalmologists to properly understand its core components, there is a need to make in-depth interpretation to the key and difficult contents of the international consensus. (Chin J Ophthalmol, 2021, 57: 95-99).

Near-future levels of ocean temperature weaken the byssus production and performance of the mussel Mytilus coruscus

Marine mussels are key ecological engineers that form dense aggregations to maintain the vital habitat in benthic systems. It is essential to understand the consequences of mussel byssus attachment in elevated temperatures associated with ocean warming. We evaluated byssus production and the mechanical performance of threads in the mussel Mytilus coruscus at 21° (control), 27 °C (average temperature in the M. coruscus habitat during the summer season) and 31 °C (4 °C raised) for 72 h. We quantified byssus secretion and shedding number, measured byssal breaking force, byssal polyphenol oxidase (PPO) activity, byssal thread length and diameter. Expression of byssus foot protein genes was analyzed by quantitative real-time PCR in foot tissue. High seawater temperature decreased the number of newly secreted byssus and the diameter of byssal threads, leading to the reduction of byssal breaking force and the alteration of the weakest part of the thread. Increased breakpoints in the upper part of the thread (proximal region) were higher at 27 °C than at 21 °C. High-temperature stress significantly reduced the PPO activity in byssus at 31 °C in comparison to 21 °C. The expression of mussel foot protein genes was affected by elevated temperature. The increased gene expression of byssus collagen-like protein 2 (Mccol2) at 31 °C conflicted with the number of byssuses produced. Suggesting the reduction of mussel foot protein abundance is not the cause of decreased byssus production at 31 °C. These results show that byssus, as an extracellular structure of mussels, may be highly susceptible to the adverse effects of ocean warming.

[The 477th case: muscular spasms, alopecia, diarrhea]

Diarrhea is a common digestive symptom. Here, we reported a case of young patient admitted with diarrhea caused by lead poisoning and cytomegalovirus infection. Through informative medical history and multi-disciplinary team discussion, Satoyoshi syndrome was finally diagnosed.

[Alveolar soft part sarcoma in children: a clinicopathological study of 13 cases]

Objective: To investigate the clinicopathological manifestations, molecular genetic, diagnostic histology and differential diagnosis of alveolar soft part sarcoma (ASPS) in children. Methods: A total of 13 cases of ASPS diagnosed at Beijing Children's Hospital from August 2009 to November 2018 were collected. HE staining, histochemical staining for PAS and D-PAS, immunohistochemical (IHC) staining for TFE3, INI1 and CD68 and florescence in situ hybridization (FISH) for TFE3 gene translocation were performed. Results: There were four males and nine females, age ranged from 1 year and 2 months to 13 years and 8 months (mean 7.8 years); and four patients were under 5 years old. Histologically, the tumors showed a distinctive and characteristic nested or organoid growth pattern (11 cases) or solid, diffuse growth (2 cases). The tumor cells possessed abundant eosinophilic, or glycogen-rich and clear to vacuolated cytoplasm. The chromatin was relatively dispersed, with prominent and pleomorphic nucleoli; mitotic figures were rare. Vascular invasion was frequently seen. IHC staining showed specific nuclear TFE3 staining. The tumor cells were also positive for INI1,CD68 and vimentin; but were negative for MyoD1, Myogenin, CK and S-100 protein. Seven cases showed PAS and D-PAS staining, with fuchsia acicular or rod-shaped crystals in tumor cytoplasm. Nine cases showed TFE3 break-apart signals by FISH. Conclusions: ASPS is a rare soft tissue sarcoma in children. Compared with ASPA in adults, it has both similarities and unique clinicopathologic characteristics. The diagnosis needs to be confirmed by combining clinical, pathologic, IHC and genetic testing.

[A clinicopathological classification analysis of ocular mass lesions in 7 910 cases]

Objective: To investigate the anatomical region, histopathological classification and histogensis distribution of ocular mass lesions in South China. Methods: Retrospective cases study. The clinical and pathological data of 7 910 samples with ocular (adnexal) tumors or proliferative lesions which were examined from January 2000 to May 2018 were retrospectively retrieved. The constituent ratios of ocular mass lesions in different anatomical regions and histogenesis have been analyzed. Results: There were 3 445 males and 4 465 females aged from 3 months to 106 years. Classification by anatomical region. Eyelid 4 976 cases (62.9%): benign-pigmented nevus (31.7%, 1 342/4 235), squamous cell papilloma (12.3%, 519/4 235), seborrheic keratosis (9.4%, 396/4 235); malignant-basal cell carcinoma (48.5%, 359/741), sebaceous gland carcinoma (34.4%, 255/741), squamous cell carcinoma (12.3%, 91/741). Ocular surface 1 449 cases (18.3%): benign-pigmented nevus (26.6%, 359/1 348), squamous cell papilloma (12.8%, 173/1 348); malignant-lymphoma (34.7%, 35/101), squamous cell carcinoma (30.7%, 31/101).Orbit 1 485 cases (18.8%): benign-hemangioma (28.5%, 332/1 167), lacrimal gland (duct) cyst(13.2%, 154/1 167); malignant-lymphoma (44.7%, 142/318), adenoid cystic carcinoma (10.1%, 32/318). Classification by histogenesis: epithelial 2 145 cases (27.1%), cutaneous appendages 378 cases (4.8%), cystoid 1 068 cases (13.5%), mesenchymal 748 cases (9.5%), lymph-hematopoietic 225 cases (2.8%), neurogenic 31 cases (0.4%), melanocytic 1 765 cases (22.3%), others 1 550 cases (19.6%). Conclusions: Over the past 18 years, the ocular tumors identified at the Second Affiliated Hospital, Zhejiang University School of Medicine most frequently occur in eyelid and originate from epithelium. The most common types are as followings. Benign lesions: pigmented nevus, squamous cell papilloma are the most common types for eyelid and ocular surface, whereas hemangioma, lacrimal gland (duct) cyst and epidermoid cyst are the most common types for orbit. Malignant cancers: basal cell carcinoma is the most prevalent disease in eyelid, whereas lymphoma occurs more frequently in ocular surface and orbit. (Chin J Ophthalmol, 2019, 55: 847-853).

[Value of magnetic resonance imaging in assessment of iron deposition among patients with hepatic alveolar echinococcosis: a preliminary evaluation]

OBJECTIVE

To assess the value of MRI combined with serum ferritin analysis in measurement of hepatic iron deposition among patients with hepatic alveolar echinococcosis.

METHODS

A total of 96 patients with definitive diagnosis of hepatic alveolar echinococcosis and 30 healthy volunteers were enrolled and underwent routine 1.5T MR scanning, and all laboratory examination data were captured. The liver-to-muscle signal intensity ratio, serum ferritin level and liver functions were analyzed.

RESULTS

The liver-to-muscle signal intensity ratio was (1.95 ± 0.57) in patients with hepatic alveolar echinococcosis and (2.22 ± 0.28) in healthy volunteers (t = 2.022, P < 0.05), and the liver-to-muscle signal intensity ratio was negatively associated the serum ferritin level in patients with hepatic alveolar echinococcosis (r_s = -0.446, P < 0.01).

CONCLUSIONS

Abnormal iron deposition is detected in the liver of patients with hepatic alveolar echinococcosis, and serum ferritin level may be helpful for the identification of abnormal iron deposition in the liver of patients with hepatic alveolar echinococcosis. The liver-to-muscle signal intensity ratio measured by MRI may be a non-invasive approached used to assess the hepatic iron deposition in patients with hepatic alveolar echinococcosis.