Serotype distribution, antimicrobial resistance, and molecular characterization of group B Streptococcus isolates from Chinese pregnant woman

OBJECTIVE

This study was aimed to investigate the serotypes, antibiotic susceptibilities, and multi-locus sequence type (MLST) profiles of group B Streptococcus (GBS) in the Beijing area.

METHODS

Lower vaginal and rectal swabs were obtained from pregnant women of 35-37 gestational weeks (GWs) who attended the Beijing Obstetrics and Gynecology Hospital. All GBS isolates were identified with Gram staining, catalase reaction assays, and CAMP tests, followed by antibiotic susceptibility testing, serotype identification, multilocus sequence typing and erythromycin resistance gene analysis (ermB and mefE).

RESULTS

From July 2020 to June 2022, 311 (5.17%) of 6012 pregnant women that were screened for GBS colonization were detected positive. Of the eight serotypes identified (III, Ia, Ib, IV, II, VIII, V, and NT), serotypes III (43.09%), Ia (34.08%) and Ib (17.04%) were the predominant species. In the antimicrobial susceptibility experiments, the resistant rates measured for erythromycin, clindamycin, levofloxacin, and tetracycline were 76.21%, 63.99%, 50.80%, and 81.03%, respectively, and 7.6% of GBS isolates showed inducible clindamycin in resistance (D-test phenotype). Meanwhile, the multilocus sequence typing analysis showed that sequence type 19 (ST19) (30.34%) and ST10 (18.62%) were the dominant sequence types. Among the 237 erythromycin-resistant isolates, 176 harbored ermB (128, 54.00%) or mefE (48, 20.30%) gene alone.

CONCLUSION

The infection rates, serotypes or MSLT distribution, and antimicrobial resistance of GBS in Beijing area were investigated, which may be applied in analyses of the epidemiological characteristics of GBS. This contributes to the basic knowledge required for successful GBS vaccine development suited for disease prevention and treatment in China, as well as the implementation of effective clinical antimicrobials.

Decadal shifts in Qingzang Plateau lake carbon dynamics (1970-2020): From predominant carbon sources to emerging sinks

The evasion of carbon dioxide (CO2) from lakes significantly influences the global carbon equilibrium. Amidst global climatic transformations, the role of Qingzang Plateau (QZP) lakes as carbon (C) sources or sinks remains a subject of debate. Furthermore, accurately quantifying their contribution to the global carbon budget presents a formidable challenge. Here, spanning half a century (1970-2020), we utilize a synthesis of literature and empirical field data to assess the CO2 exchange flux of QZP lakes. We find markedly higher CO2 exchange flux in the southeast lakes than that in the northern and western regions from 1970 to 2000. During this time, both freshwater and saltwater lakes served primarily as carbon sources. The annual CO2 exchange flux was estimated at 2.04 ± 0.37 Tg (Tg) C yr-1, mainly influenced by temperature fluctuations. The CO2 exchange flux patterns underwent a geographical inversion between 2000 and 2020, with increased levels in the west and decreased levels in the east. Notably, CO2 emissions from freshwater lakes diminished, and certain saltwater lakes in the QTP transitioned from carbon sources to sinks. From 2000 to 2020, the annual CO2 exchange flux from QZP lakes is estimated at 1.34 ± 0.50 Tg C yr-1, with solar radiation playing a more pronounced role in carbon emissions. Cumulatively, over the past five decades, QZP lakes have generally functioned as carbon sources. Nevertheless, the total annual CO2 emissions have declined since the year 2000, indicating a potential shift trend from being a carbon source to a sink, mirroring broader patterns of global climate change. These findings not only augment our understanding of the carbon cycle in plateau aquatic systems but also provide crucial data for refining China's carbon budget.

Attention-based investigation and solution to the trade-off issue of adversarial training

Adversarial training has become the mainstream method to boost adversarial robustness of deep models. However, it often suffers from the trade-off dilemma, where the use of adversarial examples hurts the standard generalization of models on natural data. To study this phenomenon, we investigate it from the perspective of spatial attention. In brief, standard training typically encourages a model to conduct a comprehensive check to input space. But adversarial training often causes a model to overly concentrate on sparse spatial regions. This reduced tendency is beneficial to avoid adversarial accumulation but easily makes the model ignore abundant discriminative information, thereby resulting in weak generalization. To address this issue, this paper introduces an Attention-Enhanced Learning Framework (AELF) for robustness training. The main idea is to enable the model to inherit the attention pattern of standard pre-trained model through an embedding-level regularization. To be specific, given a teacher model built on natural examples, the embedding distribution of teacher model is used as a static constraint to regulate the embedding outputs of the objective model. This design is mainly supported with that the embedding feature of standard model is usually recognized as a rich semantic integration of input. For implementation, we present a simplified AELFs that can achieve the regularization with single cross entropy loss via the parameter initialization and parameter update strategy. This avoids the extra consistency comparison operation between embedding vectors. Experimental observations verify the rationality of our argument, and experimental results demonstrate that it can achieve remarkable improvements in generalization under the high-level robustness.

Double layered asymmetrical hydrogels enhanced by thermosensitive microgels for high-performance mechanosensors and actuators

Thermosensitive hydrogels have found extensive applications in soft devices, but they often suffer from limited functionalities, low response rate and small response amplitude. In this work, double layered asymmetrical hydrogels composed of a thermosensitive layer and a non-thermosensitive layer are developed to simultaneously achieve high-performance mechanosensing and actuating properties in a single hydrogel. In thermosensitive layer, thermosensitive microgels are introduced to construct hierarchical structure, which accounts for the enhanced thermosensitive behaviors by cooperative responsiveness. In non-thermosensitive layer, poly(acrylamide-co-acrylic acid) (P(AM-co-AA)) hydrogel is constructed. KCl is introduced as conductive component. Mechanosensors for monitoring various mechanical stimuli in daily life have been fabricated utilizing such hydrogels and high gauge factors (GF) have been achieved, 0.38 for resistive strain sensors, 9.40 kPa-1 for piezoresistive pressure sensors and 3.92 kPa-1 for capacitive pressure sensors. Because of the asymmetrical structure, such hydrogels also exhibit outstanding actuating properties with a fast response rate of 863°/min and a bending amplitude about 360°. Interestingly, grasping-releasing of target objects utilizing an octopus-shaped hydrogel actuator and temperature alerting based on hydrogel actuator are also demonstrated. Overall, the double layered asymmetrical ionic hydrogels have provided a new clue to construct hydrogel devices with multiple functionalities and enhanced response properties.

UPLC-QTOF-MS based metabolomics unravels the modulatory effect of ginseng water extracts on rats with Qi-deficiency

Ginseng is commonly used as a nutritional supplement and daily wellness product due to its ability to invigorate qi. As a result, individuals with Qi-deficiency often use ginseng as a health supplement. Ginsenosides and polysaccharides are the primary components of ginseng. However, the therapeutic effects and mechanisms of action of these components in Qi-deficiency remain unclear. This study aimed to determine the modulatory effects and mechanisms of ginseng water extract, ginsenosides, and ginseng polysaccharides in a rat model of Qi-deficiency using metabolomics and network analysis. The rat model of Qi-deficiency was established via swimming fatigue and a restricted diet. Oral administration of different ginseng water extracts for 30 days primarily alleviated oxidative stress and disrupted energy metabolism and immune response dysfunction caused by Qi-deficiency in rats. Ultra-high-performance liquid chromatography combined with quadrupole time-of-flight mass spectrometry (UPLC-QTOF-MS) was used for untargeted serum metabolomic analysis. Based on the analysis results, the active constituents of ginseng significantly reversed the changes in serum biomarkers related to Qi-deficiency in rats, particularly energy, amino acid, and unsaturated fatty acid metabolism. Furthermore, analysis of the metabolite-gene network suggested that the anti-Qi-deficiency effects of the ginseng components were mainly associated with toll-like receptor (TLR) signaling and inflammatory response. Additional verification revealed that treatment with the ginseng components effectively reduced the inflammatory response and activation of the myocardial TLR4/NF-κB pathway induced by Qi-deficiency, especially the ginseng water extracts. Therefore, ginseng could be an effective preventive measure against the progression of Qi-deficiency by regulating metabolic and inflammatory responses.

High performance self-assembled sulfidized nanoscale zero-valent iron for the immobilization of cadmium in contaminated sediments: Optimization, microbial response, and mechanisms

Sulfidized nanoscale zero-valent iron (S-nZVI) showed excellent removal capacity for cadmium (Cd) in aqueous phase. However, the remediation effects of S-nZVI on Cd-contaminated sediment and its interactions with microorganisms in relation to Cd fate remain unclear. The complexity of the external environment posed a challenge for Cd remediation. This study synthesized S-nZVI with different S and Fe precursors to investigate the effect of precursors and applied the optimal material to immobilize Cd in sediments. Characterization analysis revealed that the precursor affected the morphology, Fe0 crystallinity, and the degree of oxidation of the material. Incubation experiments demonstrated that the immobilization efficiency of Cd using S-nZVIFe3++S2- (S/Fe = 0.14) reached the peak value of 99.54%. 1% and 5% dosages of S-nZVI significantly reduced Cd concentration in the overlying water, DTPA-extractable Cd content, and exchangeable (EX) Cd speciation (P < 0.05). Cd leaching in sediment and total iron in the overlying water remained at low levels during 90 d of incubation. Notably, each treatment maintained a high Cd immobilization efficiency under different pH, water/sediment ratio, organic acid, and coexisting ion conditions. Sediment physicochemical properties, functional bacteria, and a range of adsorption, complexation and precipitation of CdS effects dominated Cd immobilization.

Plug-and-Play latent feature editing for orientation-adaptive quantitative susceptibility mapping neural networks

Quantitative susceptibility mapping (QSM) is a post-processing technique for deriving tissue magnetic susceptibility distribution from MRI phase measurements. Deep learning (DL) algorithms hold great potential for solving the ill-posed QSM reconstruction problem. However, a significant challenge facing current DL-QSM approaches is their limited adaptability to magnetic dipole field orientation variations during training and testing. In this work, we propose a novel Orientation-Adaptive Latent Feature Editing (OA-LFE) module to learn the encoding of acquisition orientation vectors and seamlessly integrate them into the latent features of deep networks. Importantly, it can be directly Plug-and-Play (PnP) into various existing DL-QSM architectures, enabling reconstructions of QSM from arbitrary magnetic dipole orientations. Its effectiveness is demonstrated by combining the OA-LFE module into our previously proposed phase-to-susceptibility single-step instant QSM (iQSM) network, which was initially tailored for pure-axial acquisitions. The proposed OA-LFE-empowered iQSM, which we refer to as iQSM+, is trained in a simulated-supervised manner on a specially-designed simulation brain dataset. Comprehensive experiments are conducted on simulated and in vivo human brain datasets, encompassing subjects ranging from healthy individuals to those with pathological conditions. These experiments involve various MRI platforms (3T and 7T) and aim to compare our proposed iQSM+ against several established QSM reconstruction frameworks, including the original iQSM. The iQSM+ yields QSM images with significantly improved accuracies and mitigates artifacts, surpassing other state-of-the-art DL-QSM algorithms. The PnP OA-LFE module's versatility was further demonstrated by its successful application to xQSM, a distinct DL-QSM network for dipole inversion. In conclusion, this work introduces a new DL paradigm, allowing researchers to develop innovative QSM methods without requiring a complete overhaul of their existing architectures.

Novel alternative tools for metastatic pheochromocytomas/paragangliomas prediction

OBJECTIVE

The existing prediction models for metastasis in pheochromocytomas/paragangliomas (PPGLs) showed high heterogeneity in different centers. Therefore, this study aimed to establish new prediction models integrating multiple variables based on different algorithms.

DESIGN AND METHODS

Data of patients with PPGLs undergoing surgical resection at the Peking Union Medical College Hospital from 2007 to 2022 were collected retrospectively. Patients were randomly divided into the training and testing sets in a ratio of 7:3. Subsequently, decision trees, random forest, and logistic models were constructed for metastasis prediction with the training set and Cox models for metastasis-free survival (MFS) prediction with the total population. Additionally, Ki-67 index and tumor size were transformed into categorical variables for adjusting models. The testing set was used to assess the discrimination and calibration of models and the optimal models were visualized as nomograms. Clinical characteristics and MFS were compared between patients with and without risk factors.

RESULTS

A total of 198 patients with 59 cases of metastasis were included and classified into the training set (n = 138) and testing set (n = 60). Among all models, the logistic regression model showed the best discrimination for metastasis prediction with an AUC of 0.891 (95% CI, 0.793-0.990), integrating SDHB germline mutations [OR: 96.72 (95% CI, 16.61-940.79)], S-100 (-) [OR: 11.22 (95% CI, 3.04-58.51)], ATRX (-) [OR: 8.42 (95% CI, 2.73-29.24)] and Ki-67 ≥ 3% [OR: 7.98 (95% CI, 2.27-32.24)] evaluated through immunohistochemistry (IHC), and tumor size ≥ 5 cm [OR: 4.59 (95% CI, 1.34-19.13)]. The multivariate Cox model including the above risk factors also showed a high C-index of 0.860 (95% CI, 0.810-0.911) in predicting MFS after surgery. Furthermore, patients with the above risk factors showed a significantly poorer MFS (P ≤ 0.001).

CONCLUSIONS

Models established in this study provided alternative and reliable tools for clinicians to predict PPGLs patients' metastasis and MFS. More importantly, this study revealed for the first time that IHC of ATRX could act as an independent predictor of metastasis in PPGLs.

Tumor markers for lipid metabolism-related genes: Based on small cell lung cancer and bronchial asthma dual analysis

Numerous studies have elucidated the intricate relationship between bronchial asthma and small cell lung cancer (SCLC), as well as the role lipid metabolism genes play in transitioning from bronchial asthma to SCLC. Despite this, the predictive power of single gene biomarkers remains insufficient and necessitates the development of more accurate prognostic models. In our study, we downloaded and preprocessed scRNA-seq of SCLC from the GEO database GSE164404 and severe asthma scRNA-seq from GSE145013 using the Seurat package. Using the MSigDB database and geneCard database, we selected lipid metabolism-related genes and performed scRNA-seq data analysis from the gene expression GEO database, aiming to uncover potential links between immune signaling pathways in bronchial asthma and SCLC. Our investigations yielded differentially expressed genes based on the scRNA-seq dataset related to lipid metabolism. We executed differential gene analysis, gene ontology, and Kyoto Encyclopedia of Genes and Genomes analyses. In-depth GSEA pathway activation analysis, crucial target gene predictions via protein-protein interactions, and key cluster gene evaluations for differential and diagnostic ROC values correlation analysis confirmed that key cluster genes are significant predictors for the progression of bronchial asthma to SCLC. To validate our findings, we performed wet laboratory experiments using real-time quantitative PCR to assess the expression of these relevant genes in SCLC cell lines. In conclusion, this research proposes a novel lipid metabolism-related gene marker that can offer comprehensive insights into the pathogenesis of bronchial asthma leading to SCLC. Although this study does not directly focus on senescence-associated molecular alterations, our findings in the lipid metabolism genes associated with inflammation and cancer progression offer valuable insights for further research targeting senescence-related changes in treating inflammatory diseases.

Multimodal Physiological Analysis of Impact of Emotion on Cognitive Control in VR

Cognitive control is often perplexing to elucidate and can be easily influenced by emotions. Understanding the individual cognitive control level is crucial for enhancing VR interaction and designing adaptive and self-correcting VR/AR applications. Emotions can reallocate processing resources and influence cognitive control performance. However, current research has primarily emphasized the impact of emotional valence on cognitive control tasks, neglecting emotional arousal. In this study, we comprehensively investigate the influence of emotions on cognitive control based on the arousal-valence model. A total of 26 participants are recruited, inducing emotions through VR videos with high ecological validity and then performing related cognitive control tasks. Leveraging physiological data including EEG, HRV, and EDA, we employ classification techniques such as SVM, KNN, and deep learning to categorize cognitive control levels. The experiment results demonstrate that high-arousal emotions significantly enhance users' cognitive control abilities. Utilizing complementary information among multi-modal physiological signal features, we achieve an accuracy of 84.52% in distinguishing between high and low cognitive control. Additionally, time-frequency analysis results confirm the existence of neural patterns related to cognitive control, contributing to a better understanding of the neural mechanisms underlying cognitive control in VR. Our research indicates that physiological signals measured from both the central and autonomic nervous systems can be employed for cognitive control classification, paving the way for novel approaches to improve VR/AR interactions.

Modeling Rationality: Toward Better Performance Against Unknown Agents in Sequential Games

Opponent modeling is necessary for autonomous agents to capture the intents of others during strategic interactions. Most previous works assume that they can access enough interaction history to build the model. However, it may not be realistic. To solve this problem, we present a novel rationality-consistent opponent modeling (ROM) method for games with imperfect information. In our approach, a game-theoretical concept of consistence about rationality is proposed to take advantage of the characteristic of imperfect information sequential games that rational behavior at disjoint information sets is correlated through anticipated opponent's behavior. With the correlation between different information sets, agents could infer the opponents' strategies at information sets correlated to observed behavior. To exploit the correlation, ROM attempts to conduct reasoning from the opponent's perspective and rationalize its past behavior. In this way, ROM acquires the ability to better adapt to different opponents and achieves a more accurate opponent model with insufficient observation history, which is verified by experiments in different settings. A heuristic adaptation approach is also applied in ROM, which updates the opponent model in an online manner and significantly reduces the computation cost. We evaluate ROM in both a grid world game and a poker game. Compared with other opponent modeling methods, ROM shows better performance and has more accurate predictions in both games against different types of opponents with limited action interactions. Experimental results also show that ROM's time cost is significantly reduced through heuristic adaptation.

Clustering of gout-related comorbidities and their relationship with gout flares: a data-driven cluster analysis of eight comorbidities

OBJECTIVES

To study the aggregation of multiple comorbidities in people with gout and explore differences in prognosis of gout flares among different subgroups.

METHODS

Hierarchical clustering was performed to identify homogeneous subgroups among 2639 people with gout using eight comorbidities. A one-year follow-up of acute gout flares in 463 of these people was conducted; the incidence and the timing of gout flares in each cluster were assessed to explore prognosis of gout flares. Binary logistic regression was applied to assess factors associated with gout flares.

RESULTS

In baseline study, we identified five subgroups (C1-C5). C1 (n = 671, 25%) was characterized by isolated gout with few comorbidities. C2 (n = 258, 10%) were all obese. Almost all people in C3 (n = 335, 13%) had diabetes (99.7%). All people in C4 (n = 938, 36%) had dyslipidemia. C5 (n = 437, 17%) had the highest proportion of cardiovascular disease (CVD, 53%), chronic kidney disease (CKD, 56%), and cancer (7%). In follow-up study, C5 had the highest incidence (71.9%) and earliest onset (median 3 months) of gout flares. C2 had the lowest incidence (52.1%) and the latest onset (median 10 months) of gout flares. The highest relative risk for gout recurrent was seen for C5 (OR = 2.09). Other factors associated with the risk of gout flares were age at diagnosis of gout, duration of gout, presence of tophi, and smoking ≥ 20 cigarettes/day.

CONCLUSIONS

We clustered people with gout into five groups with varying comorbidities. People with CVD, CKD, and cancer had the highest risk of gout flares and should receive comprehensive care.

Quantitative susceptibility mapping through model-based deep image prior (MoDIP)

The data-driven approach of supervised learning methods has limited applicability in solving dipole inversion in Quantitative Susceptibility Mapping (QSM) with varying scan parameters across different objects. To address this generalization issue in supervised QSM methods, we propose a novel training-free model-based unsupervised method called MoDIP (Model-based Deep Image Prior). MoDIP comprises a small, untrained network and a Data Fidelity Optimization (DFO) module. The network converges to an interim state, acting as an implicit prior for image regularization, while the optimization process enforces the physical model of QSM dipole inversion. Experimental results demonstrate MoDIP's excellent generalizability in solving QSM dipole inversion across different scan parameters. It exhibits robustness against pathological brain QSM, achieving over 32 % accuracy improvement than supervised deep learning methods. It is also 33 % more computationally efficient and runs 4 times faster than conventional DIP-based approaches, enabling 3D high-resolution image reconstruction in under 4.5 min.

Targeting PARP14 with lomitapide suppresses drug resistance through the activation of DRP1-induced mitophagy in multiple myeloma

Multiple myeloma (MM) is a hematological malignancy that remains incurable, primarily due to the high likelihood of relapse or development of resistance to current treatments. To explore and discover new medications capable of overcoming drug resistance in MM, we conducted cell viability inhibition screens of 1504 FDA-approved drugs. Lomitapide, a cholesterol-lowering agent, was found to exhibit effective inhibition on bortezomib-resistant MM cells in vitro and in vivo. Our data also indicated that lomitapide decreases the permeability of the mitochondrial outer membrane and induces mitochondrial dysfunction in MM cells. Next, lomitapide treatment upregulated DRP1 and PINK1 expression levels, coupled with the mitochondrial translocation of Parkin, leading to MM cell mitophagy. Excessive mitophagy caused mitochondrial damage and dysfunction induced by lomitapide. Meanwhile, PARP14 was identified as a direct target of lomitapide by SPR-HPLC-MS, and we showed that DRP1-induced mitophagy was crucial in the anti-MM activity mediated by PARP14. Furthermore, PARP14 is overexpressed in MM patients, implying that it is a novel therapeutic target in MM. Collectively, our results demonstrate that DRP1-mediated mitophagy induced by PARP14 may be the cause for mitochondrial dysfunction and damage in response to lomitapide treatment.

Multifaceted roles of lymphatic and blood endothelial cells in the tumor microenvironment of hepatocellular carcinoma: A comprehensive review

The tumor microenvironment is a complex network of cells, extracellular matrix, and signaling molecules that plays a critical role in tumor progression and metastasis. Lymphatic and blood vessels are major routes for solid tumor metastasis and essential parts of tumor drainage conduits. However, recent studies have shown that lymphatic endothelial cells (LECs) and blood endothelial cells (BECs) also play multifaceted roles in the tumor microenvironment beyond their structural functions, particularly in hepatocellular carcinoma (HCC). This comprehensive review summarizes the diverse roles played by LECs and BECs in HCC, including their involvement in angiogenesis, immune modulation, lymphangiogenesis, and metastasis. By providing a detailed account of the complex interplay between LECs, BECs, and tumor cells, this review aims to shed light on future research directions regarding the immune regulatory function of LECs and potential therapeutic targets for HCC.

Prognostic and clinical significance of tumor-associated macrophages in esophageal squamous cell carcinoma after surgery: do biomarkers and distributions matter?

BACKGROUND

The role of tumor-associated macrophages (TAMs) in patients with esophageal squamous cell carcinoma (ESCC) following surgery remains controversial. Hence, we performed the present study to systematically analyze the prognostic and clinical significance of distinct TAMs biomarkers and distributions in ESCC patients underwent surgery.

METHODS

PubMed, Web of Science, and EMBASE databases were searched up to March 31, 2023. The pooled analysis was conducted to evaluate the effects of TAMs on overall survival (OS), disease-free survival (DFS), and clinicopathological characteristics using fixed-effects or random-effect model.

RESULTS

Involving a total of 2,502 ESCC patients underwent surgery from 15 studies, the results suggested that the total count of CD68+ TAMs was inversely associated with OS and DFS in ESCC patients, which was also noticed in the relationship of CD68+ TAMs in tumor islet (TI) with OS (all P<0.05), although no association between CD68+ TAMs in tumor stroma (TS) and OS (P>0.05). Moreover, either islet or stromal CD163+ TAMs density was a prognostic factor ESCC (all P<0.05). Similarly, an elevated CD204+ TAMs density in TI predicted a poor DFS (P<0.05), although CD204+ TAMs in TI had no relationship with OS (P>0.05). Besides, a high CD68+ TAMs density was significantly associated with lymphatic vessel invasion, vascular invasion, and lymph node metastasis (all P<0.05).

CONCLUSION

Our results demonstrated the prognostic and clinical significance of TAMs in ESCC patients underwent surgery. TAMs should be considered a target that could improve prognostic stratification and clinical outcomes in ESCC after surgery.

Jiao-tai-wan and its effective component-berberine improve diabetes and depressive disorder through the cAMP/PKA/CREB signaling pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Jiao-tai-wan (JTW), a classic herbal formula of traditional Chinese medicine recorded in Han Shi Yi Tong, has been used to alleviate sleep disorders since ancient times. In modern pharmacological research, JTW has been adopted for treating diabetes mellitus and even exerts antidepressant effects. However, the potential mechanisms deserve further elucidation.

AIM OF THE STUDY

The prevalence of diabetes mellitus combined with depressive disorder (DD) is continuing to increase, yet it is currently under-recognized and its treatment remains inadequate. The present study aims to explore the underlying therapeutics and mechanisms of JTW on DD.

MATERIALS AND METHODS

Chronic restraint stress was used on db/db mice to construct a mouse model of DD. The therapeutic effects of JTW were assessed by glucolipid metabolic indexes, behavioral tests, and depression-related neurotransmitter levels. The inflammatory status and cell apoptosis of different mice were investigated and the changes in the cAMP/PKA/CREB pathway were detected. Combining the results of fingerprinting with molecular docking, the active components of JTW were screened. A cellular model was constructed by intervention of glucose combined with corticosterone (CORT). The levels of apoptosis and depression-related neurotransmitters in HT-22 cells were examined, and the changes in the cAMP/PKA/CREB pathway were tested. Finally, the activator and inhibitor of the PKA protein were used for reverse validation experiments.

RESULTS

JTW could improve the impaired glucose tolerance, lipid metabolism disorders, and depression-like symptoms in DD mice. Meanwhile, JTW could alleviate the inflammatory status, suppress the microglia activation, and improve hippocampal neuron apoptosis in DD mice. The dual effects of JTW might be associated with the activation of the cAMP/PKA/CREB pathway. Berberine (Ber) was identified for the in vitro experiment, it could reverse the apoptosis of HT-22 cells and up-regulate the depression-related neurotransmitter levels, and the effects of Ber were related to the activation of the cAMP/PKA/CREB pathway as well.

CONCLUSION

JTW could exert both hypoglycemic and antidepressant effects through activating the cAMP/PKA/CREB signaling pathway, its active component, Ber, could improve the damage to HT-22 cells induced by glucose combined with CORT via the activation of the cAMP/PKA/CREB pathway. Ber may be one of the effective components of the dual effects of JTW.

Directional Polarization of a Ferroelectric Intermediate Layer Inspires a Built-In Field in Si Anodes to Regulate Li+ Transport Behaviors in Particles and Electrolyte

The silicon (Si) anode is prone to forming a high electric field gradient and concentration gradient on the electrode surface under high-rate conditions, which may destroy the surface structure and decrease cycling stability. In this study, a ferroelectric (BaTiO3) interlayer and field polarization treatment are introduced to set up a built-in field, which optimizes the transport mechanisms of Li+ in solid and liquid phases and thus enhances the rate performance and cycling stability of Si anodes. Also, a fast discharging and slow charging phenomenon is observed in a half-cell with a high reversible capacity of 1500.8 mAh g-1 when controlling the polarization direction of the interlayer, which means a fast charging and slow discharging property in a full battery and thus is valuable for potential applications in commercial batteries. Simulation results demonstrated that the built-in field plays a key role in regulating the Li+ concentration distribution in the electrolyte and the Li+ diffusion behavior inside particles, leading to more uniform Li+ diffusion from local high-concentration sites to surrounding regions. The assembled lithium-ion battery with a BaTiO3 interlayer exhibited superior electrochemical performance and long-term cycling life (915.6 mAh g-1 after 300 cycles at a high current density of 4.2 A g-1). The significance of this research lies in exploring a new approach to improve the performance of lithium-ion batteries and providing new ideas and pathways for addressing the challenges faced by Si-based anodes.

KLF13 promotes VSMCs phenotypic dedifferentiation by directly binding to the SM22α promoter

Krüppel-like factor 13 (KLF13), a zinc finger transcription factor, is considered as a potential regulator of cardiomyocyte differentiation and proliferation during heart morphogenesis. However, its precise role in the dedifferentiation of vascular smooth muscle cells (VSMCs) during atherosclerosis and neointimal formation after injury remains poorly understood. In this study, we investigated the relationship between KLF13 and SM22α expression in normal and atherosclerotic plaques by bioanalysis, and observed a significant increase in KLF13 levels in the atherosclerotic plaques of both human patients and ApoE-/- mice. Knockdown of KLF13 was found to ameliorate intimal hyperplasia following carotid artery injury. Furthermore, we discovered that KLF13 directly binds to the SM22α promoter, leading to the phenotypic dedifferentiation of VSMCs. Remarkably, we observed a significant inhibition of platelet-derived growth factor BB-induced VSMCs dedifferentiation, proliferation, and migration when knocked down KLF13 in VSMCs. This inhibitory effect of KLF13 knockdown on VCMC function was, at least in part, mediated by the inactivation of p-AKT signaling in VSMCs. Overall, our findings shed light on a potential therapeutic target for treating atherosclerotic lesions and restenosis after vascular injury.

Self-Organized Gradually Single-Atom-Layer of Metal Osmium for an Unprecedented Hydrogen Production from Seawater

Atomic thick two-dimensional (2D) materials with exciting physical, chemical, and electronic properties are gaining increasing attention in next-generation science and technology, showing great promise in catalysis and energy science. However, the precise design and synthesis of efficient catalytic systems based on such materials still face many difficulties, especially in how to control the preparation of structurally determined, highly active, atomic-scale distribution of material systems. Here, we report that a highly active zerovalent osmium single-atom-layer with a thickness of single atom size has been successfully and controllably self-organized on the surface of 2D graphdiyne (GDY) material. Detailed characterizations showed that the incomplete charge transfer effect between the Os atoms and GDY not only stabilized the catalytic system but also improved the intrinsic activity, making the Gibbs free energy reach the best and resulting in remarkable performance with a small overpotential of 49 mV at 500 mA cm-2, large specific j0 of 18.6 mA cm-2, and turnover frequency of 3.89 H2 s-1 at 50 mV. In addition, the formation of sp-C-Os bonds guarantees the high long-term stability of 800 h at a large current density of 500 mA cm-2 in alkaline simulated seawater.

[Epidemiological investigation of iron deficiency among preschool children in 10 provinces, autonomous regions, or municipalities in China]

Objective: To understand the current status of anemia, iron deficiency, and iron-deficiency anemia among preschool children in China. Methods: A cross-sectional study was conducted with a multi-stage stratified sampling method to select 150 streets or townships from 10 Chinese provinces, autonomous regions, or municipalities (East: Jiangsu, Zhejiang, Shandong, and Hainan; Central: Henan; West: Chongqing, Shaanxi, Guizhou, and Xinjiang; Northeast: Liaoning). From May 2022 to April 2023, a total of 21 470 children, including community-based children aged 0.5 to<3.0 years receiving child health care and kindergarten-based children aged 3.0 to<7.0 years, were surveyed. They were divided into 3 age groups: infants (0.5 to<1.0 year), toddlers (1.0 to<3.0 years), and preschoolers (3.0 to<7.0 years). Basic information such as sex and date of birth of the children was collected, and peripheral blood samples were obtained for routine blood tests and serum ferritin measurement. The prevalence rates of anemia, iron deficiency, and iron-deficiency anemia were analyzed, and the prevalence rate differences were compared among different ages, sex, urban and rural areas, and regions using the chi-square test. Results: A total of 21 460 valid responses were collected, including 10 780 boys (50.2%). The number of infants, toddlers, and preschoolers were 2 645 (12.3%), 6 244 (29.1%), and 12 571 (58.6%), respectively. The hemoglobin level was (126.7±14.8) g/L, and the serum ferritin level was 32.3 (18.5, 50.1) μg/L. The overall rates of anemia, iron deficiency, and iron-deficiency anemia were 10.4% (2 230/21 460), 28.3% (6 070/21 460), and 3.9% (845/21 460), respectively. The prevalence rate of anemia was higher for boys than for girls (10.9% (1 173/10 780) vs. 9.9% (1 057/10 680), χ2=5.58, P=0.018), with statistically significant differences in the rates for infants, toddlers and preschoolers (18.0% (475/2 645), 10.6% (662/6 244), and 8.7% (1 093/12 571), respectively, χ2=201.81, P<0.01), and the rate was significantly higher for children in rural than that in urban area (11.8% (1 516/12 883) vs. 8.3% (714/8 577), χ2=65.54, P<0.01), with statistically significant differences in the rates by region (χ2=126.60, P<0.01), with the highest rate of 15.8% (343/2 173) for children in Central region, and the lowest rate of 5.3% (108/2 053) in Northeastern region. The prevalence rates of iron deficiency were 33.8% (895/2 645), 32.2% (2 011/6 244), and 25.2% (3 164/12 571) in infants, toddlers, and preschoolers, respectively, and 30.0% (3 229/10 780) in boys vs. 26.6% (2 841/10 680) in girls, 21.7% (1 913/8 821), 40.0% (870/2 173), 27.1% (2 283/8 413), 48.9% (1 004/2 053) in Eastern, Central, Western, and Northeastern regions, respectively, and each between-group showed a significant statistical difference (χ2=147.71, 29.73, 773.02, all P<0.01). The prevalence rate of iron-deficiency anemia showed a significant statistical difference between urban and rural areas, 2.9% (251/8 577) vs. 4.6% (594/12 883) (χ2=38.62, P<0.01), while the difference in iron deficiency prevalence was not significant (χ2=0.51, P=0.476). Conclusions: There has been a notable improvement in iron deficiency and iron-deficiency anemia among preschool children in China, but the situation remains concerning. Particular attention should be paid to the prevention and control of iron deficiency and iron-deficiency anemia, especially among infants and children in the Central, Western, and Northeastern regions of China.

Unraveling the Heterogeneity of CD8+ T-Cell Subsets in Liver Cirrhosis: Implications for Disease Progression

Background/Aims

: Liver cirrhosis involves chronic inflammation and progressive fibrosis. Among various immune cells, CD8+ T cells are considered a major contributor to hepatic inflammation and fibrosis. However, the exact molecular pathways governing CD8+ T-cell-mediated effects in cirrhosis remain unclear.

Methods

: This study analyzed transcriptomic and single-cell sequencing data to elucidate CD8+ T-cell heterogeneity and implications in cirrhosis.

Results

: Weighted gene co-expression analysis of bulk RNA-seq data revealed an association between cirrhosis severity and activated T-cell markers like HLA and chemokine genes. Furthermore, single-cell profiling uncovered eight CD8+ T-cell subtypes, notably, effector memory (Tem) and exhausted (Tex) T cells. Tex cells, defined by PDCD1, LAG3, and CXCL13 expression, were increased in cirrhosis, while Tem cells were decreased. Lineage tracing and differential analysis highlighted CXCL13+ Tex cells as a terminal, exhausted subtype of cells with roles in PD-1 signaling, glycolysis, and T-cell regulation. CXCL13+ Tex cells displayed T-cell exhaustion markers like PDCD1, HAVCR2, TIGIT, and TNFRSF9. Functional analysis implicated potential roles of these cells in immunosuppression. Finally, a CXCL13+ Tex-cell gene signature was found that correlated with cirrhosis severity and poorer prognosis of liver cancer.

Conclusions

: In summary, this comprehensive study defines specialized CD8+ T-cell subpopulations in cirrhosis, with CXCL13+ Tex cells displaying an exhausted phenotype associated with immune dysregulation and advanced disease. Key genes and pathways regulating these cells present potential therapeutic targets.

Angiogenesis-related immune response may be the prelude to the syndesmophyte formation in Ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis (AS) is a chronic autoimmune arthritis that mainly affects spine joints. To date, the pathogenesis of AS remains unclear, although immune cells and innate immune response cytokines have been suggested to be crucial players.

METHODS

By adopting a single-cell RNA sequencing approach in the AS cynomolgus model, we profiled and characterized PBMC proportions along disease progression.

RESULTS

Here, our primary focus was on the activation of an immune cascade-initiating lymphocyte subtype known as CD4+CXCR5+ T follicular helper (Tfh) cells. These Tfhs demonstrated a localized residence in AS bone lesion as an ectopic lymphoid structure. Moreover, Tfhs would serve as an upstream initiator for a pro-angiogenic cascade. Then, an expansion in CD14+ monocytes and DC cells subsets resulted in enhanced expression of angiogenesis genes in these AS cynomolgus monkeys. With a confirmed higher abundance of TNF-α accompanying H-type vascular invasion in the osteophytic region, pronounced expansion of Tfhs at such lesion site signaling for monocytes and DCs intrusion is considered as the prelude to the characteristic angiogenic bony outgrowth in AS known as syndesmophytes.

CONCLUSIONS

We explored the intimate relationship between local inflammation and bone formation in AS from the perspective of nascent vascularisation. Hence, our study lays the foundation for elucidating a unified AS pathogenesis through the immune-angiogenesis-osteogenesis axis.

Single-cell transcriptome landscape elucidates the cellular and developmental responses to tomato chlorosis virus infection in tomato leaf

Plant viral diseases compromise the growth and yield of the crop globally, and they tend to be more serious under extreme temperatures and drought climate changes. Currently, regulatory dynamics during plant development and in response to virus infection at the plant cell level remain largely unknown. In this study, single-cell RNA sequencing on 23 226 individual cells from healthy and tomato chlorosis virus-infected leaves was established. The specific expression and epigenetic landscape of each cell type during the viral infection stage were depicted. Notably, the mesophyll cells showed a rapid function transition in virus-infected leaves, which is consistent with the pathological changes such as thinner leaves and decreased chloroplast lamella in virus-infected samples. Interestingly, the F-box protein SKIP2 was identified to play a pivotal role in chlorophyll maintenance during virus infection in tomato plants. Knockout of the SlSKIP2 showed a greener leaf state before and after virus infection. Moreover, we further demonstrated that SlSKIP2 was located in the cytomembrane and nucleus and directly regulated by ERF4. In conclusion, with detailed insights into the plant responses to viral infections at the cellular level, our study provides a genetic framework and gene reference in plant-virus interaction and breeding in the future research.

Opportunity and challenges in recovering and functionalizing anode graphite from spent lithium-ion batteries: A review

Recent concerns have emerged regarding the improper disposal of spent lithium-ion batteries (LIBs), which has garnered widespread societal attention. Graphite materials accounted for 12-21 wt % of LIBs' mass, typically contain heavy metals, binders, and residual electrolytes. Regenerating spent graphite not only alleviated the shortage of plumbago, but also contributed to the supports environmental protection as well as national carbon peak and neutrality ("dual carbon" goals). Despite significant advancements in recycling spent LIBs had been made, a comprehensive overview of the processes for pretreatment, regeneration, and functionalization of spent graphite from retired LIBs, along with the associated technical standards and industry regulations enabling their smooth implementation still needed to be mentioned. Hence, we conducted the following research work. Firstly, the pre-treatment process of spent graphite, including discharging, crushing, and screening was summed up. Next,. Subsequently, graphite recovery methods, such as acid leaching, pyrometallurgy, and combined methods were summarized. Moreover, the modification and doping approach was used to enhance the electrochemical properties of graphite. Afterwards, we reviewed the functionalization of anode graphite from an economically and environmentally friendly view. Meanwhile, the technical standards and industry regulations of spent LIBs in domestic and oversea industries were described. Finally, we provided an overview of the technical challenges and development bottlenecks in graphite recycling, along with future prospects Overall, this study outlined the opportunities and challenges in recovering and functionalizing of anode materials via a efficient and sustainable processes.

Mechanism of l-cysteine-induced fibrous structural changes of soybean protein at different high-moisture extrusion zones

In this study, the fibrous structure formation mechanism of soybean protein during high moisture extrusion processing was investigated using a dead-stop operation, and based on the interaction between soybean protein concentrate (SPC) and L-cysteine (CYS). The thermal properties, SDS-PAGE and particle size distribution of the samples from different extrusion zones were investigated. It was revealed that the addition of a moderate amount of CYS (0.1 %) promoted the fibrous structure formation in the SPC extrudates and optimised the textural properties of the SPC extrudates. In the extruder barrel, addition of CYS (0.1 %) promoted protein depolymerisation and unfolding in the mixing and cooking zones, and facilitated protein aggregation in the die and cooling zones. Protein solubility and raman spectroscopy revealed that disulfide bonds were principally responsible for fibrous structure formation; favoured when the intermolecular disulfide bonds (t-g-t mode) was increased. Finally, the transformation of protein conformation was revealed by secondary structure and surface hydrophobicity, which confirmed that the effect of CYS on protein conformation mainly occurred in the cooling zone. This study provides a theoretical basis for the application of CYS to regulate the fibrous structure of meat analogues.

Geometry optimization of cantilever-based optical microphones

The introduction of cantilever-based fiber-optic microphones (FOMs) has proven to be effective in acoustic sensing. Further improvements in cantilevers face two key constraints: the challenge of achieving minimal sizes with sufficient reflective area and the trade-off between sensitivity and response bandwidth. Herein, we present a geometry optimization framework for a cantilever-based FOM that addresses this issue. Employing drumstick-shaped cantilevers housed within a Fabry-Perot (F-P) interferometric structure, we showcase a heightened sensitivity of 302.8 mV/Pa at 1 kHz and a minimum detectable acoustic pressure (MDP) of 2.35 µPa/H z. Notably, these metrics outperform those of the original rectangular cantilever with identical dimensions. Furthermore, our proposed cantilever effectively mitigates the reduction in resonance frequencies, thereby improving the response bandwidth. This geometry optimization framework offers considerable design flexibility and scalability, making it especially suitable for high-performance acoustic sensing applications.

Characterisation of the mitochondrial genome and phylogenetic analysis of Toxocara apodemi (Nematoda: Ascarididae)

We first sequenced and characterised the complete mitochondrial genome of Toxocara apodeme, then studied the evolutionary relationship of the species within Toxocaridae. The complete mitochondrial genome was amplified using PCR with 14 specific primers. The mitogenome length was 14303 bp in size, including 12 PCGs (encoding 3,423 amino acids), 22 tRNAs, 2 rRNAs, and 2 NCRs, with 68.38% A+T contents. The mt genomes of T. apodemi had relatively compact structures with 11 intergenic spacers and 5 overlaps. Comparative analyses of the nucleotide sequences of complete mt genomes showed that T. apodemi had higher identities with T. canis than other congeners. A sliding window analysis of 12 PCGs among 5 Toxocara species indicated that nad4 had the highest sequence divergence, and cox1 was the least variable gene. Relative synonymous codon usage showed that UUG, ACU, CCU, CGU, and UCU most frequently occurred in the complete genomes of T. apodemi. The Ka/Ks ratio showed that all Toxocara mt genes were subject to purification selection. The largest genetic distance between T. apodemi and the other 4 congeneric species was found in nad2, and the smallest was found in cox2. Phylogenetic analyses based on the concatenated amino acid sequences of 12 PCGs demonstrated that T. apodemi formed a distinct branch and was always a sister taxon to other congeneric species. The present study determined the complete mt genome sequences of T. apodemi, which provide novel genetic markers for further studies of the taxonomy, population genetics, and systematics of the Toxocaridae nematodes.

The adverse effects of developmental exposure to polystyrene nanoparticles on cognitive function in weaning rats and the protective role of trihydroxy phenolacetone

Polystyrene nanoplastic(PS-NP) can originate from sources such as plastic waste and industrial wastewater and have been shown to have deleterious effects on abnormal neurobehaviors. However, evidence regarding the health impacts, biological mechanisms, and treatment strategies underlying developmental exposure to low dose PS-NP is still lacking. This study aimed to fill this knowledge gap by administering low doses of PS-NP(50 and 100 μg/L) to weaning rats for 4 consecutive weeks. Behavioral and morphological experiments were performed to evaluate hippocampal damage, and transcriptomics and Assay for Transposase Accessible Chromatin with hight-throughput sequencing(ATAC) analyses were conducted to identify potential key targets. Additionally, Connectivity Map(CMap) database, Limited proteolysis-mass spectrometry(LiP-SMap), and molecular-protein docking were used to examine potential phytochemicals with therapeutic effects on key targets. The results indicated that developmental exposure to PS-NP can induce hippocampal impairment and aberrant neurobehaviors in adulthood. Multi-omics analyses consistently showed that apoptosis-related signaling pathways were sensitive to PS-NP exposure, and mitogen-activated protein kinase 3(Mapk3) was identified as the core gene by the gene network, which was further validated in vitro experiments. The CMap database provided a series of phytochemicals that might regulate Mapk3 expression, and trihydroxy-phenolacetone(THP) was found to have directly binding sites with Mapk3 through LiP-SMap and molecular docking analysis. Furthermore, THP administration could significantly alleviate apoptosis induced by PS-NP exposure in primary hippocampal cells through down-regulation of Mapk3. These findings suggested that developmental exposure to PS-NP has adverse effects on cognitive function and that THP can alleviate these effects by directly binding to Mapk3.

Evaluating the developmental potential of 2.1PN-derived embryos and associated chromosomal analysis

PURPOSE

Zygotes with 2.1 pronuclei (2.1PN) present with two normal-sized pronuclei, and an additional smaller pronucleus, that is approximately smaller than two thirds the size of a normal pronucleus. It remains unclear whether the additional pronucleus causes embryonic chromosome abnormalities. In the majority of cases, in vitro fertilization (IVF) clinics discarded 2.1PN zygotes. Thus, the present study aimed to evaluate the developmental potential and value of 2.1PN zygotes.

METHODS

2.1PN-derived embryos from 164 patients who underwent IVF or intracytoplasmic sperm injection (ICSI) treatment between January 2021 and December 2022 were included in the present study. All embryos were monitored using a time-lapse system, and blastocyst formation was used to assess 2.1PN-derived embryo developmental potential. The blastocyst formation was quantified using generalized estimating equations, and chromosome euploidy was analyzed using next-generation sequencing (NGS). In addition, the potential association between age and occurrence of 2.1PN zygotes was determined.

RESULTS

The present study demonstrated that numerous 2.1PN zygotes developed into blastocysts. Early cleavage patterns and embryo quality on Day 3 were the independent predictors for the blastocyst formation of 2.1PN-derived embryos. The 2.1PN zygotes displayed a comparable developmental potential compared to 2PN zygotes in advanced age patients (≥ 38). Moreover, there was a tendency that 2.1PN-derived blastocysts showed a similar euploidy rate compared to 2PN-derived blastocysts.

CONCLUSION

Clinicians should consider using 2.1PN-derived euploid embryos for transfer after preimplantation genetic testing in the absence of available 2PN embryo cycles. 2.1PN-derived embryos could be a candidate, particularly beneficial for patients at advanced age.

C-Phycocyanin improves the quality of goat oocytes after in vitro maturation and vitrification

In vitro maturation (IVM) and cryopreservation of goat oocytes are important for establishing a valuable genetic bank for domesticated female animals and improving livestock reproductive efficiency. C-Phycocyanin (PC) is a Spirulina extract with antioxidant, antiinflammatory, and radical scavenging properties. However, whether PC has positive effect on goat oocytes IVM or developmental competence after vitrification is still unknown. In this study, we found that first polar body extrusion (n = 293), cumulus expansion index (n = 269), and parthenogenetic blastocyst formation (n = 281) were facilitated by adding 30 μg/mL PC to the oocyte maturation medium when compared with the control groups and that supplemented with 3, 10, 100 or 300 μg/mL PC (P < 0.05). Although PC supplementation did not affect spindle formation or chromosome alignment (n = 115), it facilitated or improved cortical granules migration (n = 46, P < 0.05), mitochondria distribution (n = 39, P < 0.05), and mitochondrial membrane potential (n = 46, P < 10-4). Meanwhile, supplementation with 30 μg/mL PC in the maturation medium could significantly inhibit the reactive oxygen species accumulation (n = 65, P < 10-4), and cell apoptosis (n = 42, P < 0.05). In addition, PC increased the oocyte mRNA levels of GPX4 (P < 0.01), and decreased the mRNA and protein levels of BAX (P < 0.01). Next, we investigated the effect of PC supplementation in the vitrification solution on oocyte cryopreservation. When compared with the those equilibrate in the vitrification solution without PC, recovered oocytes in the 30 μg/mL PC group showed higher ratios of normal morphology (n = 85, P < 0.05), survival (n = 85, P < 0.05), first polar body extrusion (n = 62, P < 0.05), and parthenogenetic blastocyst formation (n = 107, P < 0.05). Meanwhile, PC supplementation of the vitrification solution increased oocyte mitochondrial membrane potential (n = 53, P < 0.05), decreased the reactive oxygen species accumulation (n = 73, P < 0.05), promoted mitochondria distribution (n = 58, P < 0.05), and inhibited apoptosis (n = 46, P < 10-3). Collectively, our findings suggest that PC improves goat oocyte IVM and vitrification by reducing oxidative stress and early apoptosis, which providing a novel strategy for livestock gamete preservation and utilization.

Preoperative Exercise Training Decreases Complications of Minimally Invasive Lung Cancer Surgery- A Randomized Controlled Trial

OBJECTIVE

Limited evidence exists regarding the efficacy of preoperative exercise (PE) in reducing short-term complications after minimally invasive surgery in patients with non-small cell lung cancer (NSCLC). This study aims to investigate the impact of PE on short-term complications following minimally invasive lung resection.

METHODS

In this prospective, open-label, randomized (1:1) controlled trial at Xiangya Hospital, China (Sep 2020-Feb 2022), patients were randomly assigned to a PE group with 16-day alternate supervised exercise or a control. The primary outcome assessed was short-term postoperative complications, with a follow-up period of 30 days post-surgery.

RESULTS

A total of 124 patients were recruited (PE group n=62; control n=62). Finally, 101 patients (PE group; n=51 and control; n=50) with a median age of 56 years (interquartile range, 50-62 years) completed the study. Compared with the control, the PE group showed fewer postoperative complications (PE:3/51 vs. Control 10/50; OR [95% CI], 0.17 [0.04 to 0.86], P=0.03) and shorter hospital stays (mean difference [95% CI], -2 [-3 to -1], P=0.01). PE significantly improved depression, stress, functional capacity, and quality of life (all P<0.05) before surgery. Furthermore, PE demonstrated a significantly lower minimum blood pressure during surgery, lower increases body temperature on day 2 after surgery, neutrophil-to-lymphocyte ratio, and neutrophil count after surgery (all P<0.05). Exploratory research on lung tissue RNA sequencing (5 in each group) showed downregulation of the tumor necrosis factor signaling pathway in the PE group compared with control.

CONCLUSIONS

Preoperative exercise training decreased short-term postoperative complications in patients with NSCLC.

Room-temperature quantum emission from interface excitons in mixed-dimensional heterostructures

The development of van der Waals heterostructures has introduced unconventional phenomena that emerge at atomically precise interfaces. For example, interlayer excitons in two-dimensional transition metal dichalcogenides show intriguing optical properties at low temperatures. Here we report on room-temperature observation of interface excitons in mixed-dimensional heterostructures consisting of two-dimensional tungsten diselenide and one-dimensional carbon nanotubes. Bright emission peaks originating from the interface are identified, spanning a broad energy range within the telecommunication wavelengths. The effect of band alignment is investigated by systematically varying the nanotube bandgap, and we assign the new peaks to interface excitons as they only appear in type-II heterostructures. Room-temperature localization of low-energy interface excitons is indicated by extended lifetimes as well as small excitation saturation powers, and photon correlation measurements confirm antibunching. With mixed-dimensional van der Waals heterostructures where band alignment can be engineered, new opportunities for quantum photonics are envisioned.

Carfilzomib activates ER stress and JNK/p38 MAPK signaling to promote apoptosis in hepatocellular carcinoma cells

Hepatocellular carcinoma (HCC) is one of the most prevalent and deadly cancers in the world, which is frequently diagnosed at a late stage. HCC patients have a poor prognosis due to the lack of an efficacious therapeutic strategy. Approved drug repurposing is a way for accelerating drug discovery and can significantly reduce the cost of drug development. Carfilzomib (CFZ) is a second-generation proteasome inhibitor, which is highly efficacious against multiple myeloma and has been reported to possess potential antitumor activities against multiple cancers. However, the underlying mechanism of CFZ on HCC is still unclear. Here, we show that CFZ inhibits the proliferation of HCC cells through cell cycle arrest at the G2/M phase and suppresses the migration and invasion of HCC cells by inhibiting epithelial-mesenchymal transition. We also find that CFZ promotes reactive oxygen species production to induce endoplasmic reticulum (ER) stress and activate JNK/p38 MAPK signaling in HCC cells, thus inducing cell death in HCC cells. Moreover, CFZ significantly inhibits HCC cell growth in a xenograft mouse model. Collectively, our study elucidates that CFZ impairs mitochondrial function and activates ER stress and JNK/p38 MAPK signaling, thus inhibiting HCC cell and tumor growth. This indicates that CFZ has the potential as a therapeutic drug for HCC.

Flipped online teaching of histology and embryology with design thinking: design, practice and reflection

BACKGROUND

Flexible hybrid teaching has become the new normal of basic medical education in the postepidemic era. Identifying ways to improve the quality of curriculum teaching and achieve high-level talent training is a complex problem that urgently needs to be solved. Over the course of the past several semesters, the research team has integrated design thinking (DT) into undergraduate teaching to identify, redesign and solve complex problems in achieving curriculum teaching and professional talent training objectives.

METHODS

This study is an observational research. A total of 156 undergraduate stomatology students from Jining Medical University in 2021 were selected to participate in two rounds of online flipped teaching using the design thinking EDIPT (empathy, definition, idea, prototype, and test) method. This approach was applied specifically to the chapters on the respiratory system and female reproductive system. Data collection included student questionnaires, teacher-student interviews, and exam scores. GraphPad Prism software was used for data analysis, and the statistical method was conducted by multiple or unpaired t test.

RESULTS

According to the questionnaire results, the flipped classroom teaching design developed using design thinking methods received strong support from the majority of students, with nearly 80% of students providing feedback that they developed multiple abilities during the study process. The interview results indicated that teachers generally believed that using design thinking methods to understand students' real needs, define teaching problems, and devise instructional design solutions, along with testing and promptly adjusting the effectiveness through teaching practices, played a highly positive role in improving teaching and student learning outcomes. A comparison of exam scores showed a significant improvement in the exam scores of the class of 2021 stomatology students in the flipped teaching chapters compared to the class of 2020 stomatology students, and this difference was statistically significant. However, due to the limitation of the experimental chapter scope, there was no significant difference in the overall course grades.

CONCLUSION

The study explores the application of design thinking in histology and embryology teaching, revealing its positive impact on innovative teaching strategies and students' learning experience in medical education. Online flipped teaching, developed through design thinking, proves to be an effective and flexible method that enhances student engagement and fosters autonomous learning abilities.

Research on steel surface defect classification method based on deep learning

Surface defects on steel, arising from factors like steel composition and manufacturing techniques, pose significant challenges to industrial production. Efficient and precise detection of these defects is crucial for enhancing production efficiency and product quality. In accordance with these requisites, this paper elects to undertake the detection task predicated on the you only look once (YOLO) algorithm. In this study, we propose a novel approach for surface flaw identification based on the YOLOv5 algorithm, called YOLOv5-KBS. This method integrates attention mechanism and weighted Bidirectional Feature Pyramid Network (BiFPN) into YOLOv5 architecture. Our method addresses issues of background interference and defect size variability in images. Experimental results show that the YOLOv5-KBS model achieves a notable 4.2% increase in mean Average Precision (mAP) and reaches a detection speed of 70 Frames Per Second (FPS), outperforming the baseline model. These findings underscore the effectiveness and potential applications of our proposed method in industrial settings.

Large language model enhanced corpus of CO2 reduction electrocatalysts and synthesis procedures

CO2 electroreduction has garnered significant attention from both the academic and industrial communities. Extracting crucial information related to catalysts from domain literature can help scientists find new and effective electrocatalysts. Herein, we used various advanced machine learning, natural language processing techniques and large language models (LLMs) approaches to extract relevant information about the CO2 electrocatalytic reduction process from scientific literature. By applying the extraction pipeline, we present an open-source corpus for electrocatalytic CO2 reduction. The database contains two types of corpus: (1) the benchmark corpus, which is a collection of 6,985 records extracted from 1,081 publications by catalysis postgraduates; and (2) the extended corpus, which consists of content extracted from 5,941 documents using traditional NLP techniques and LLMs techniques. The Extended Corpus I and II contain 77,016 and 30,283 records, respectively. Furthermore, several domain literature fine-tuned LLMs were developed. Overall, this work will contribute to the exploration of new and effective electrocatalysts by leveraging information from domain literature using cutting-edge computer techniques.

Study of the f_{0}(980) and f_{0}(500) Scalar Mesons through the Decay D_{s}^{+}→π^{+}π^{-}e^{+}ν_{e}

Using e^{+}e^{-} collision data corresponding to an integrated luminosity of 7.33  fb^{-1} recorded by the BESIII detector at center-of-mass energies between 4.128 and 4.226 GeV, we present an analysis of the decay D_{s}^{+}→π^{+}π^{-}e^{+}ν_{e}, where the D_{s}^{+} is produced via the process e^{+}e^{-}→D_{s}^{*±}D_{s}^{∓}. We observe the f_{0}(980) in the π^{+}π^{-} system and the branching fraction of the decay D_{s}^{+}→f_{0}(980)e^{+}ν_{e} with f_{0}(980)→π^{+}π^{-} measured to be (1.72±0.13_{stat}±0.10_{syst})×10^{-3}, where the uncertainties are statistical and systematic, respectively. The dynamics of the D_{s}^{+}→f_{0}(980)e^{+}ν_{e} decay are studied with the simple pole parametrization of the hadronic form factor and the Flatté formula describing the f_{0}(980) in the differential decay rate, and the product of the form factor f_{+}^{f_{0}}(0) and the c→s Cabibbo-Kobayashi-Maskawa matrix element |V_{cs}| is determined for the first time to be f_{+}^{f_{0}}(0)|V_{cs}|=0.504±0.017_{stat}±0.035_{syst}. Furthermore, the decay D_{s}^{+}→f_{0}(500)e^{+}ν_{e} is searched for the first time but no signal is found. The upper limit on the branching fraction of D_{s}^{+}→f_{0}(500)e^{+}ν_{e}, f_{0}(500)→π^{+}π^{-} decay is set to be 3.3×10^{-4} at 90% confidence level.

Quinoline-based compounds can inhibit diverse enzymes that act on DNA

DNA methylation, as exemplified by cytosine-C5 methylation in mammals and adenine-N6 methylation in bacteria, is a crucial epigenetic mechanism driving numerous vital biological processes. Developing non-nucleoside inhibitors to cause DNA hypomethylation is a high priority, in order to treat a variety of significant medical conditions without the toxicities associated with existing cytidine-based hypomethylating agents. In this study, we have characterized fifteen quinoline-based analogs. Notably, compounds with additions like a methylamine ( 9 ) or methylpiperazine ( 11 ) demonstrate similar low micromolar inhibitory potency against both human DNMT1 (which generates C5-methylcytosine) and Clostridioides difficile CamA (which generates N6-methyladenine). Structurally, compounds 9 and 11 specifically intercalate into CamA-bound DNA via the minor groove, adjacent to the target adenine, leading to a substantial conformational shift that moves the catalytic domain away from the DNA. This study adds to the limited examples of DNA methyltransferases being inhibited by non-nucleotide compounds through DNA intercalation, following the discovery of dicyanopyridine-based inhibitors for DNMT1. Furthermore, our study shows that some of these quinoline-based analogs inhibit other enzymes that act on DNA, such as polymerases and base excision repair glycosylases. Finally, in cancer cells compound 11 elicits DNA damage response via p53 activation.

Abstract Figure

Highlights

Six of fifteen quinoline-based derivatives demonstrated comparable low micromolar inhibitory effects on human cytosine methyltransferase DNMT1, and the bacterial adenine methyltransferases Clostridioides difficile CamA and Caulobacter crescentus CcrM. Compounds 9 and 11 were found to intercalate into a DNA substrate bound by CamA. These quinoline-based derivatives also showed inhibitory activity against various base excision repair DNA glycosylases, and DNA and RNA polymerases. Compound 11 provokes DNA damage response via p53 activation in cancer cells.

Tunable Structured 2D Nanobiocatalysts: Synthesis, Catalytic Properties and New Horizons in Biomedical Applications

2D materials have offered essential contributions to boosting biocatalytic efficiency in diverse biomedical applications due to the intrinsic enzyme-mimetic activity and massive specific surface area for loading metal catalytic centers. Since the difficulty of high-quality synthesis, the varied structure, and the tough choice of efficient surface loading sites with catalytic properties, the artificial building of 2D nanobiocatalysts still faces great challenges. Here, in this review, a timely and comprehensive summarization of the latest progress and future trends in the design and biotherapeutic applications of 2D nanobiocatalysts is provided, which is essential for their development. First, an overview of the synthesis-structure-fundamentals and structure-property relationships of 2D nanobiocatalysts, both metal-free and metal-based is provided. After that, the effective design of the active sites of nanobiocatalysts is discussed. Then, the progress of their applied research in recent years, including biomedical analysis, biomedical therapeutics, pharmacokinetics, and toxicology is systematically highlighted. Finally, future research directions of 2D nanobiocatalysts are prospected. Overall, this review to provide cutting-edge and multidisciplinary guidance for accelerating future developments and biomedical applications of 2D nanobiocatalysts is expected.

Dynamic changes in lysosome-related pathways in APP/PS1 mice with aging

Senile plaque, composed of amyloid β protein (Aβ) aggregates, is a critical pathological feature in Alzheimer's disease (AD), leading to cognitive dysfunction. However, how Aβ aggregates exert age-dependent toxicity and temporal cognitive dysfunction in APP/PS1 mice remains incompletely understood. In this study, we investigated AD pathogenesis and dynamic alterations in lysosomal pathways within the hippocampus of age-gradient male mice using transcriptome sequencing, molecular biology assays, and histopathological analyses. We observed high levels of β-amyloid precursor protein (APP) protein expression in the hippocampus at an early stage and age-dependent Aβ deposition. Transcriptome sequencing revealed the enrichment of differential genes related to the lysosome pathway. Furthermore, the protein expression of ATP6V0d2 and CTSD associated with lysosomal functions exhibited dynamic changes with age, increasing in the early stage and decreasing later. Similar age-dependent patterns were observed for the endosome function, autophagy pathway, and SGK1/FOXO3a pathway. Nissl and Golgi staining in the hippocampal region showed age-dependent neuronal loss and synaptic damage, respectively. These findings clearly define the age-gradient changes in the autophagy-lysosome system, the endosome/lysosome system, and the SGK1/FOXO3a pathway in the hippocampus of APP/PS1 mice, providing new perspectives and clues for understanding the possible mechanisms of AD, especially the transition from compensatory to decompensated state.

A high resolution reaction microscope with universal two-region time-focusing method

This paper presents a novel reaction microscope designed for ion-atom collision investigations, established at the Institute of Modern Physics, Chinese Academy of Sciences, Lanzhou, China. Its time-of-flight (TOF) spectrometer employs an innovative flight-time focusing method consisting of two acceleration regions, providing optimal time focusing conditions for charged fragments with diverse initial velocities. The TOF spectrometer's axis intentionally tilts by 12° relative to the ion beam direction, preventing potential obstructions from the TOF grid electrodes. The introduced focusing method allows for a flexible time-focusing TOF spectrometer design without restricting the length ratio of the two regions. In addition, this configuration in our case significantly suppresses noise on the recoil ion detector produced by residual gas in the ion beam trajectory, which is a considerable challenge in longitudinal spectrometers. In a test experiment on the single electron capture reaction involving 62.5 keV/u He2+ ions and a helium atomic beam, the recoil longitudinal momentum resolution achieved 0.068 atomic units. This novel configuration and successful test run show excellent precision for ion-atom collision studies.

Reinforcement hybridization in staggered composites enhances wave attenuation performance

Advanced composites with superior wave attenuation or vibration isolation capacity are in high demand in engineering practice. In this study, we develop the hybrid dynamic shear-lag model with Bloch's theorem to investigate the hybrid effect of reinforcement on wave attenuation in bioinspired staggered composites. We present for the first time the relationship between macroscopic wave filtering and hybridization of building blocks in staggered composites. Viscoelasticity was taken into account for both reinforcement and matrix to reflect the damping effect on wave transmission. Our findings indicate that reinforcement hybridization significantly enhances wave attenuation performance through two critical parameters: the linear stiffness and linear density of reinforcements. For purely elastic constituents, reinforcement hybridization consistently improves wave attenuation by reducing the initial frequency of the first bandgap and broadening it. For viscoelastic constituents, increasing the heterogeneity of reinforcements can benefit wave attenuation, particularly in ultralow frequency regimes, due to the strengthening of the damping effect. Our case study demonstrates that controlling the difference in linear density can result in up to a 59 % reduction in energy transmission. Our analysis suggests that hybridizing reinforcements could provide a new approach to designing and synthesizing advanced composites with exceptional wave attenuation performance.

A bimodal nomogram as an adjunct tool to reduce unnecessary breast biopsy following discordant ultrasonic and mammographic BI-RADS assessment

OBJECTIVE

To develop a bimodal nomogram to reduce unnecessary biopsies in breast lesions with discordant ultrasound (US) and mammography (MG) Breast Imaging Reporting and Data System (BI-RADS) assessments.

METHODS

This retrospective study enrolled 706 women following opportunistic screening or diagnosis with discordant US and MG BI-RADS assessments (where one assessed a lesion as BI-RADS 4 or 5, while the other assessed the same lesion as BI-RADS 0, 2, or 3) from two medical centres between June 2019 and June 2021. Univariable and multivariable logistic regression analyses were used to develop the nomogram. DeLong's and McNemar's tests were used to assess the model's performance.

RESULTS

Age, MG features (margin, shape, and density in masses, suspicious calcifications, and architectural distortion), and US features (margin and shape in masses as well as calcifications) were independent risk factors for breast cancer. The nomogram obtained an area under the curve of 0.87 (95% confidence interval (CI), 0.83-0.91), 0.91 (95% CI, 0.87 - 0.96), and 0.92 (95% CI, 0.86-0.98) in the training, internal validation, and external testing samples, respectively, and demonstrated consistency in calibration curves. Coupling the nomogram with US reduced unnecessary biopsies from 74 to 44% and the missed malignancies rate from 13 to 2%. Similarly, coupling with MG reduced missed malignancies from 20 to 6%, and 63% of patients avoided unnecessary biopsies. Interobserver agreement between US and MG increased from - 0.708 (poor agreement) to 0.700 (substantial agreement) with the nomogram.

CONCLUSION

When US and MG BI-RADS assessments are discordant, incorporating the nomogram may improve the diagnostic accuracy, avoid unnecessary breast biopsies, and minimise missed diagnoses.

CLINICAL RELEVANCE STATEMENT

The nomogram developed in this study could be used as a computer program to assist radiologists with detecting breast cancer and ensuring more precise management and improved treatment decisions for breast lesions with discordant assessments in clinical practice.

KEY POINTS

• Coupling the nomogram with US and mammography improves the detection of breast cancers without the risk of unnecessary biopsy or missed malignancies. • The nomogram increases mammography and US interobserver agreement and enhances the consistency of decision-making. • The nomogram has the potential to be a computer program to assist radiologists in identifying breast cancer and making optimal decisions.

A Multivariate analysis on evoked components of Chinese semantic congruity: an OP-MEG study with EEG

The application of wearable magnetoencephalography using optically-pumped magnetometers has drawn extensive attention in the field of neuroscience. Electroencephalogram system can cover the whole head and reflect the overall activity of a large number of neurons. The efficacy of optically-pumped magnetometer in detecting event-related components can be validated through electroencephalogram results. Multivariate pattern analysis is capable of tracking the evolution of neurocognitive processes over time. In this paper, we adopted a classical Chinese semantic congruity paradigm and separately collected electroencephalogram and optically-pumped magnetometer signals. Then, we verified the consistency of optically-pumped magnetometer and electroencephalogram in detecting N400 using mutual information index. Multivariate pattern analysis revealed the difference in decoding performance of these two modalities, which can be further validated by dynamic/stable coding analysis on the temporal generalization matrix. The results from searchlight analysis provided a neural basis for this dissimilarity at the magnetoencephalography source level and the electroencephalogram sensor level. This study opens a new avenue for investigating the brain's coding patterns using wearable magnetoencephalography and reveals the differences in sensitivity between the two modalities in reflecting neuron representation patterns.

A NRF2 Regulated and the Immunosuppressive Microenvironment Reversed Nanoplatform for Cholangiocarcinoma Photodynamic-Gas Therapy

Photodynamic therapy (PDT) is a minimally invasive and controllable local cancer treatment for cholangiocarcinoma (CCA). However, the efficacy of PDT is hindered by intratumoral hypoxia and the presence of an antioxidant microenvironment. To address these limitations, combining PDT with gas therapy may be a promising strategy to enhance tumor oxygenation. Moreover, the augmentation of oxidative damage induced by PDT and gas therapy can be achieved by inhibiting NRF2, a core regulatory molecule involved in the antioxidant response. In this study, an integrated nanotherapeutic platform called CMArg@Lip, incorporating PDT and gas therapies using ROS-responsive liposomes encapsulating the photosensitizer Ce6, the NO gas-generating agent L-arginine, and the NRF2 inhibitor ML385, is successfully developed. The utilization of CMArg@Lip effectively deals with challenges posed by tumor hypoxia and antioxidant microenvironment, resulting in elevated levels of oxidative damage and subsequent induction of ferroptosis in CCA. Additionally, these findings suggest that CMArg@Lip exhibits notable immunomodulatory effects, including the promotion of immunogenic cell death and facilitation of dendritic cell maturation. Furthermore, it contributes to the anti-tumor function of cytotoxic T lymphocytes through the downregulation of PD-L1 expression in tumor cells and the activation of the STING signaling pathway in myeloid-derived suppressor cells, thereby reprogramming the immunosuppressive microenvironment via various mechanisms.

A Unified Particle-Based Solver for Non-Newtonian Behaviors Simulation

In this article, we present a unified framework to simulate non-Newtonian behaviors. We combine viscous and elasto-plastic stress into a unified particle solver to achieve various non-Newtonian behaviors ranging from fluid-like to solid-like. Our constitutive model is based on a Generalized Maxwell model, which incorporates viscosity, elasticity and plasticity in one non-linear framework by a unified way. On the one hand, taking advantage of the viscous term, we construct a series of strain-rate dependent models for classical non-Newtonian behaviors such as shear-thickening, shear-thinning, Bingham plastic, etc. On the other hand, benefiting from the elasto-plastic model, we empower our framework with the ability to simulate solid-like non-Newtonian behaviors, i.e., visco-elasticity/plasticity. In addition, we enrich our method with a heat diffusion model to make our method flexible in simulating phase change. Through sufficient experiments, we demonstrate a wide range of non-Newtonian behaviors ranging from viscous fluid to deformable objects. We believe this non-Newtonian model will enhance the realism of physically-based animation, which has great potential for computer graphics.

OPM-MEG Measuring Phase Synchronization on Source Time Series: Application in Rhythmic Median Nerve Stimulation

The magnetoencephalogram (MEG) based on array optically pumped magnetometers (OPMs) has the potential of replacing conventional cryogenic superconducting quantum interference device. Phase synchronization is a common method for measuring brain oscillations and functional connectivity. Verifying the feasibility and fidelity of OPM-MEG in measuring phase synchronization will help its widespread application in the study of aforementioned neural mechanisms. The analysis method on source-level time series can weaken the influence of instantaneous field spread effect. In this paper, the OPM-MEG was used for measuring the evoked responses of 20Hz rhythmic and arrhythmic median nerve stimulation, and the inter-trial phase synchronization (ITPS) and inter-reginal phase synchronization (IRPS) of primary somatosensory cortex (SI) and secondary somatosensory cortex (SII) were analysed. The results find that under rhythmic condition, the evoked responses of SI and SII show continuous oscillations and the effect of resetting phase. The values of ITPS and IRPS significantly increase at the stimulation frequency of 20Hz and its harmonic of 40Hz, whereas the arrhythmic stimulation does not exhibit this phenomenon. Moreover, in the initial stage of stimulation, the ITPS and IRPS values are significantly higher at Mu rhythm in the rhythmic condition compared to arrhythmic. In conclusion, the results demonstrate the ability of OPM-MEG in measuring phase pattern and functional connectivity on source-level, and may also prove beneficial for the study on the mechanism of rhythmic stimulation therapy for rehabilitation.

Targeted long-read sequencing for comprehensive detection of CYP21A2 mutations in patients with 21-hydroxylase deficiency

BACKGROUND

21-Hydroxylase deficiency (21-OHD) is caused by pathogenic CYP21A2 variations. CYP21A2 is arranged in tandem with its highly homologous pseudogene CYP21A1P; therefore, it is prone to mismatch and rearrangement, producing different types of complex variations. There were few reports on using only one method to detect different CYP21A2 variants simultaneously.

AIMS

Targeted long-read sequencing method was used to detect all types of CYP21A2 variants in a series of patients with 21-OHD.

METHODS

A total of 59 patients with 21-OHD were enrolled from Peking Union Medical College Hospital. Long-range locus-specific PCR and long-read sequencing (LRS) were performed to detect the pathogenic variants in CYP21A2.

RESULTS

Copy-number variants of CYP21A2 were found in 25.4% of patients, including 5.1% with 3 copies of CYP21A2, 16.9% with 1 copy of CYP21A2, and 3.4% with 0 copy of CYP21A2. The remaining 74.6% of patients had 2 copies of CYP21A2. Pathogenic variants were identified in all 121 alleles of 59 patients. Specifically, single-nucleotide variants and small insertions/deletions (< 50 bp) were detected in 79 alleles, of which conversed from CYP21A1P were detected in 63 alleles, and rare variants were found in the other 16 alleles. Large gene conversions (> 50 bp) from pseudogene were detected in 10 alleles, and different chimeric genes (CYP21A1P/CYP21A2 or TNXA/TNXB) formed by large deletions were detected in 32 alleles. Of all variants, p.I173N was the most common variant (19.0%).

CONCLUSIONS

Our study demonstrated that targeted long-read sequencing is a comprehensive method for detecting CYP21A2 variations, which is helpful for genetic diagnosis in 21-OHD patients.