Cholangiographic features of biliary strictures after liver transplantation for primary sclerosing cholangitis: evidence of recurrent disease

OBJECTIVE

Biliary strictures occur more frequently after liver transplantation for primary sclerosing cholangitis (PSC) than for other diseases. A hypothesized cause is recurrence of PSC in the liver graft. In our study, we compared cholangiographic features of biliary strictures after transplantation for PSC to those after transplantation for other diseases.

MATERIALS AND METHODS

A study group of 32 PSC grafts in adults with biliary strictures was compared with a control group of 32 non-PSC grafts with strictures. Both groups were matched for the type of biliary anastomosis (choledochojejunostomy) and for the time interval between transplantation and stricture diagnosis. We then performed a blind retrospective review of cholangiograms in these 64 cases to evaluate for features of PSC.

RESULTS

Location, number, and length of strictures and ductal dilatation were similar in the PSC and non-PSC groups. Mural irregularities of bile ducts were present in 15 of 32 (47%) PSC grafts compared with four of 32 (13%) in the control group (p=.005). Diverticulum-like outpouchings occurred in six of 32 (19%) PSC graft compared with one of 32 (3%) in the control group. An overall resemblance to PSC was observed in eight of 32 (25%) grafts in the PSC group compared with two of 32 (6%) in the control group.

CONCLUSION

Mural irregularity and diverticulum-like outpouchings--findings suggestive of PSC--and an overall appearance resembling PSC occur more frequently in PSC transplants than in transplants for other diseases. These findings are consistent with the hypothesis that PSC may recur in liver transplants.

Hepatic artery stenosis in liver transplant recipients: prevalence and cholangiographic appearance of associated biliary complications

OBJECTIVE

The occurrence of biliary strictures or bile duct necrosis in liver transplant recipients with hepatic artery stenosis has been well documented. This study was done to determine the prevalence and cholangiographic appearance of biliary complications in liver transplant recipients with hepatic artery stenosis and to determine if such complications occur with increased frequency compared with transplant recipients with patent hepatic arteries.

MATERIALS AND METHODS

The study population consisted of 33 patients (17 male, 16 female; 1-65 years old) with angiographically proven significant hepatic artery stenosis after liver transplantation. All patients had T-tube or percutaneous transhepatic cholangiography performed within 4 months of hepatic arteriography. A retrospective review of radiographs was done to determine the prevalence and appearance of biliary complications in the study group compared with a control group of 58 patients with angiographically patent hepatic arteries who had liver transplants during the same period.

RESULTS

Biliary complications were significantly more prevalent in patients with hepatic artery stenosis, with 22 (67%) showing cholangiographic abnormal findings compared with 16 (28%) in the control group (p = .001). The most significant abnormalities in patients with arterial stenosis were nonanastomotic biliary strictures seen in 16 (49%), compared with 13 (22%) in the control group (p = .04). Other findings (intraductal filling defects, anastomotic biliary stricture, and anastomotic bile leak) showed no statistically significant difference between the study and control groups.

CONCLUSION

Biliary complications are significantly more prevalent in liver transplant recipients with hepatic artery stenosis. The most common complication seen on cholangiography was nonanastomotic biliary stricture.

Hypervascular liver metastases: do unenhanced and hepatic arterial phase CT images affect tumor detection?

PURPOSE

To evaluate the relative roles of unenhanced and hepatic arterial phase (HAP) computed tomographic (CT) imaging in the detection of hypervascular liver metastases.

MATERIALS AND METHODS

Eighty-four patients with biopsy-proved liver metastases from hypervascular primary tumors other than hepatocellular carcinoma underwent unenhanced and HAP and portal venous phase (PVP) helical CT studies. Three blinded radiologists evaluated each series of images separately for the number, size, and enhancement characteristics of lesions. Sixty-nine patients had follow-up imaging proof of tumor burden.

RESULTS

The three readers detected 381-402 lesions on the PVP images and 397-416 lesions on the unenhanced images. Unenhanced images allowed detection of 72%-80% of the lesions seen on PVP images. They detected 94-137 additional lesions on unenhanced but not PVP images. On the HAP images, 375-395 lesions were identified. HAP images allowed detection of 81%-90% of the lesions seen on PVP images. Forty-five to 78 additional lesions were detected on HAP but not on PVP images. In the 69-patient subset, maximal detection of tumor foci occurred in 94% of patients with unenhanced plus PVP images and in 78% with HAP plus PVP images. Unenhanced plus PVP images allowed detection of 96% of the 322 tumors in the subset population.

CONCLUSION

Unenhanced plus PVP CT images allow detection of statistically significantly more hypervascular liver metastases than do HAP plus PVP images or imaging only in the PVP.

Percutaneous transluminal angioplasty of venous anastomotic stenoses complicating liver transplantation: intermediate-term results

PURPOSE

The authors evaluated the safety and efficacy of percutaneous transluminal angioplasty (PTA) for the treatment of venous stenoses in liver transplant recipients.

PATIENTS AND METHODS

Over a 5-year period, 15 venous stenoses were treated with PTA in 12 patients with liver transplants (seven children and five adults). PTA was performed for portal vein stenoses in five patients, inferior vena cava (IVC) stenoses (n = 6) in five patients, combined superior mesenteric vein-portal vein graft anastomosis and hepatic vein-IVC anastomosis in one patient, and combined IVC and hepatic vein-IVC anastomosis in one patient. PTA was repeated in three patients (five procedures) for recurrent IVC stenoses.

RESULTS

Initial technical and clinical success of PTA was achieved in 11 patients (92%); failure occurred in one patient (8%) with a portal vein anastomotic stenosis. No complications occurred in the immediate post-procedure period (up to 7 days). Nine patients (75%) are clinically well, with follow-up ranging from 7 to 33 months (mean, 18 months). Two of them required one or more repeated PTA procedures to maintain vessel patency. One patient required retransplantation for chronic rejection at 3 months, and another died of gastrointestinal tract bleeding from a gastric ulcer at 2 months after initially successful IVC PTA.

CONCLUSIONS

PTA is a safe procedure for the treatment of venous anastomotic stenoses in liver transplant recipients. PTA of portal vein anastomotic stenosis has favorable intermediate-term results. Repeat PTA may be necessary in some cases of IVC anastomotic stenoses to maintain vessel patency and avoid surgical revision or retransplantation.

Transhepatic balloon dilation of biliary strictures in liver transplant patients: a 10-year experience

PURPOSE

The authors report their initial and long-term results using transhepatic balloon dilation to treat biliary strictures in liver transplant patients.

PATIENTS AND METHODS

Over a 10-year period, 72 liver transplant patients with biliary strictures underwent 81 balloon dilation treatments. Anastomotic strictures were present in 56 patients; nonanastomotic strictures were present in 16.

RESULTS

Initial technical success was achieved in 64 of 72 patients (89%). Balloon dilation failed in eight patients (11%), and they were treated surgically. Complications occurred in nine (12%) patients, and all were successfully treated. Within the first 6 months, five patients (6.9%) required surgical revision. Three patients (4.2%) underwent repeated liver transplantation; and five patients (6.9%) died. Fifty-one patients in whom balloon dilation was initially successful were available for at least a 6-month follow-up. Life-table analysis showed an overall 81% +/- 4.8 success rate at 6 months; it dropped to 70% +/- 6.2 at 6 years. For anastomotic strictures, it was 77% +/- 5.8 at 6 months and 66% +/- 7.3 at 6 years. For nonanastomotic strictures, it was 94% +/- 6.2 at 6 months, which dropped to 84% +/- 10 at 5 years.

CONCLUSION

Transhepatic balloon dilation represents an effective and relatively safe treatment for biliary stricture in liver transplant recipients.

Biliary stones and sludge in liver transplant patients: a 13-year experience

PURPOSE

To determine the prevalence, radiologic features, and clinical significance of bile duct filling defects (BDFDs) in liver transplant recipients studied with cholangiography.

MATERIALS AND METHODS

During 13 years, 4,100 cholangiograms were obtained in 1,650 patients. All studies showing BDFD suggestive of stones, sludge, cast, or necrotic debris were retrospectively evaluated.

RESULTS

The prevalence of BDFD was 5.7% (n = 94). On the basis of cholangiographic appearance, BDFDs were categorized as sludge or cast in 53 grafts (56%), stones in 32 (34%), and necrotic debris in nine (10%). Forty-three patients (46%) underwent surgical biliary reconstruction, while 14 (15%) underwent interventional radiologic treatments. Twenty-four of 32 stones (75%) were treated with surgical reconstruction, compared with 31% (19 of 62 grafts) of other BDFDs (P < .0001). Necrotic debris and sludge were associated with hepatic artery occlusion in seven of nine (78%) and 16 of 53 (30%) grafts, respectively.

CONCLUSION

Stones and sludge are relatively infrequent after liver transplantation but are associated with high morbidity. Surgical or interventional radiologic treatments are usually performed. Bile duct stones are usually treated with surgical biliary reconstruction. While debris and bile duct necrosis are due to ischemia from hepatic artery occlusion, sludge may also have an ischemic pathogenesis in some cases.

Intrahepatic biliary strictures after liver transplantation

PURPOSE

To evaluate the prevalence, cholangiographic features, causes, and management of intrahepatic biliary strictures in hepatic transplants.

MATERIALS AND METHODS

Over a 12-year period, cholangiography was performed in 1,590 liver allografts. Confirmed cases of stricture were evaluated and correlated with clinical variables.

RESULTS

Intrahepatic biliary strictures occurred in 130 of 1,590 grafts (8.2%). Strictures were multiple in 99 grafts (76.2%) and single in 31 (23.8%). Locations were the common hepatic duct bifurcation in 46 grafts (35.4%), the peripheral ducts in 44 (33.8%), and both in 40 (30.8%). Strictures caused mild to moderate bile duct dilatation in 72 grafts (55.4%), marked dilatation in 11 (8.5%), and obstruction in four (3.1%). Hepatic artery occlusion, pretransplantation primary sclerosing cholangitis, choledochojejunostomy, use of Euro-Collins organ preservation solution, cholangitis at liver biopsy, and young age were statistically significantly associated with strictures (P < .001).

CONCLUSION

Strictures have multiple causes and may be an important indicator of underlying abnormalities. They often require interventional radiologic or surgical treatment.

Biliary strictures in hepatic transplants: prevalence and types in patients with primary sclerosing cholangitis vs those with other liver diseases

OBJECTIVE

The purpose of this study was to determine the prevalence and types of biliary strictures seen in liver allografts transplanted for primary sclerosing cholangitis and other end-stage liver diseases and to determine if such strictures occur more often in the allografts transplanted for primary sclerosing cholangitis than in the others.

MATERIALS AND METHODS

During a 10-year period, 643 liver transplantation patients (687 allografts) with choledochojejunostomy biliary anastomoses underwent 1728 cholangiographic studies. Three hundred six cholangiograms were obtained in 100 transplant recipients who had primary sclerosing cholangitis (112 allografts) and 1422 cholangiograms were obtained in 543 recipients who had other liver diseases (575 allografts). We retrospectively reviewed all cholangiograms of transplant recipients who had primary sclerosing cholangitis and 909 cholangiograms of the recipients who had other liver diseases and a diagnosis of biliary strictures, possible biliary strictures, or duct irregularity based on radiologic reports. The presence, number, and locations of strictures were recorded. The remaining 513 cholangiograms of recipients with other liver diseases without strictures were not reviewed. Biliary strictures were classified as intrahepatic (including bifurcation), anastomotic, and nonanastomotic extrahepatic.

RESULTS

Cholangiograms showed intrahepatic biliary strictures in 105 allografts (15%), anastomotic strictures in 105 allografts (15%), and nonanastomotic extrahepatic biliary strictures in 17 allografts (2%). Intrahepatic biliary strictures were diagnosed in 27% (30/112) of the allografts transplanted for primary sclerosing cholangitis and in 13% (75/575) of the allografts transplanted for other end-stage liver diseases (p = .0005). Anastomotic strictures developed in 18% (20/112) of the allografts transplanted for primary sclerosing cholangitis and in 15% (85/575) of the others (p = .381). Nonanastomotic extrahepatic strictures were seen in 6% (7/112) of the allografts transplanted for primary sclerosing cholangitis and in 2% (10/575) of the others (p = .008).

CONCLUSION

Intrahepatic and nonanastomotic extrahepatic biliary strictures are significantly more common in patients who have liver transplantation for primary sclerosing cholangitis than in patients who receive allografts for other end-stage liver diseases. However, strictures at the choledochojejunostomy anastomosis occur with equal frequency in both groups of patients.

Bile leak after hepatic transplantation: cholangiographic features, prevalence, and clinical outcome

PURPOSE

To evaluate cholangiographic features and prevalence of bile duct leaks in liver transplant recipients and correlate the different types of leaks with clinical outcomes.

MATERIALS AND METHODS

For 6 years, 3,242 cholangiograms were obtained in 1,363 liver allografts in 1,306 patients. All cholangiograms with definite or suspected bile duct leaks, per the radiology reports, were retrospectively reviewed.

RESULTS

Leaks were diagnosed in 59 allografts in 59 patients. The prevalence of leaks after liver transplantation, as depicted on cholangiograms, was 4.3% (59 of 1,363 grafts). Sixteen of 21 patients with anastomotic leaks needed 17 surgical repairs, four leaks were surgically drained without repair, and one was treated with percutaneous biliary catheter drainage. Twelve of 21 patients with T-tube exit-site leaks underwent T-tube drainage. Seven underwent surgical repair or drainage, one died, and one underwent retransplantation. Nine of 13 patients with leaks from bile duct necrosis required retransplantation.

CONCLUSION

Bile duct leaks at biliary anastomoses and those resulting from bile duct necrosis have high morbidity, mortality, and graft loss rates and usually require surgical intervention. Most T-tube exit-site leaks heal with conservative treatment.

LepR-Expressing Stem Cells Are Essential for Alveolar Bone Regeneration

Stem cells play a critical role in bone regeneration. Multiple populations of skeletal stem cells have been identified in long bone, while their identity and functions in alveolar bone remain unclear. Here, we identified a quiescent leptin receptor–expressing (LepR+) cell population that contributed to intramembranous bone formation. Interestingly, these LepR+ cells became activated in response to tooth extraction and generated the majority of the newly formed bone in extraction sockets. In addition, genetic ablation of LepR+ cells attenuated extraction socket healing. The parabiosis experiments revealed that the LepR+ cells in the healing sockets were derived from resident tissue rather than peripheral blood circulation. Further studies on the mechanism suggested that these LepR+ cells were responsive to parathyroid hormone/parathyroid hormone 1 receptor (PTH/PTH1R) signaling. Collectively, we demonstrate that LepR+ cells, a postnatal skeletal stem cell population, are essential for alveolar bone regeneration of extraction sockets.

Dissecting pseudoaneurysm of the hepatic artery: a delayed complication of angioplasty in a liver transplant

We report a 59-year-old female with a dissecting pseudoaneurysm of the allograft hepatic artery, as a delayed complication of percutaneous transluminal angioplasty (PTA). PTA of a severe anastomotic stenosis was successful, but complicated by a dissection involving the allograft hepatic artery. A large dissecting pseudoaneurysm developed and was incidentally detected during routine sonographic evaluation 14 months after PTA. Because of the extent of the pseudoaneurysm, percutaneous repair or surgical reconstruction was considered impossible. The patient underwent successful retransplantation 1 week after diagnosis.

Production of no-carrier-added 186Re via deuteron induced reactions on isotopically enriched 186W

Rhenium-186 was produced from the reaction induced by 16 MeV deuterons on isotopically enriched 186W metal powder target. Following its separation from 187W, 183Ta and the bulk of target materials 186W through an acid alumina column, the 186Re was converted to HNO3 solution through an anion exchange column, or to ammonia solution by extracting with N-235-dimethylbenzene, and finally the no-carrier-added 186Re saline solution was obtained. The radionuclidic purity of 186Re was >99.9% and the isotopic impurities were mainly 183Re (5.0 x 10(-3)%) and 184gRe (4.6 x 10(-2)%). The experimental thick-target yield of 186Re was determined to be approximately 529 microCi/microA h and the overall chemical recovery yield was > 80%.

Risk Factors for the Relapse of Graves' Disease Treated With Antithyroid Drugs: A Systematic Review and Meta-analysis

PURPOSE

Antithyroid drugs (ATDs) are the first-line treatment for Graves' disease (GD). A common problem with ATD treatment is the high relapse rate after drug withdrawal. The goal of this study was to analyze the influencing factors for the relapse of GD patients treated with ATD by using a systematic review and meta-analysis, provide some predictive indexes for the susceptibility of GD recurrence, and then further explore some useful methods to decrease the GD relapse rate after ATD treatment.

METHODS

Articles published in PubMed, EMBASE, The Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases before January 2019 were collected. Patients newly diagnosed with GD, who were aged >16 years, were treated with ATD. Follow-up was then conducted for at least 12 months after ATD withdrawal. Only prospective or retrospective studies were eligible. The primary end point was the recurrence of GD during follow-up. All the data from the trials were analyzed via meta-analysis and meta-regression. p values < 0.05 were considered statistically significant, and statistical heterogeneity was assessed by using I² statistics.

FINDINGS

A total of 20 studies and 3242 patients were involved in this meta-analysis, with 1681 patients relapsed (incidence rate, 51.9%) during the follow-up time. Analysis of risk factors suggested that younger age (weighted raw mean difference [RMD], -3.51; 95% CI, -5.74 to -1.29), larger thyroid volume (RMD, 4.38; 95% CI, 1.68 to 7.08), bigger goiter size (1.94% risk; 95% CI, 0.43 to 3.46), higher free triiodothyronine level (RMD, 5.09; 95% CI, 4.42 to 5.77), and higher free thyroxine level (RMD, 4.21; 95% CI, 0.54 to 7.89) were associated with the higher relapse rate of GD. The block-replace ATD regimen (a fixed high dose of an ATD with levothyroxine supplementation to maintain euthyroidism) (risk ratio, 0.64; 95% CI, 0.52 to 0.78) exhibits a lower relapse rate than the titration regimen (an ATD used alone and dose adjusted according to thyroid function tests).

IMPLICATIONS

This analysis revealed that certain risk factors were associated with GD relapses such as younger age, larger goiter size or thyroid volume, and the higher free triiodothyronine or free thyroxine level in the diagnosing phase of GD. For patients with these clinical characteristics, early definitive treatment with radioactive iodine or surgery should be offered to those who are unlikely to achieve remission with ATDs only. In addition, more prospective cohort studies with different ATD regimens would help to determine the optimum ATD treatment for patients with GD. PROSPERO identifier: CRD 42019146825.

Photoluminescence characterisations of a dynamic aging process of organic-inorganic CH3NH3PbBr3 perovskite

After unprecedented development of organic-inorganic lead halide perovskite solar cells over the past few years, one of the biggest barriers towards their commercialization is the stability of the perovskite material. It is thus important to understand the interaction between the perovskite material and oxygen and/or humidity and the associated degradation process in order to improve device and encapsulation design for better durability. Here we characterize the dynamic aging process in vapour-assisted deposited (VASP) CH3NH3PbBr3 perovskite thin films using advanced optical techniques, such as time-resolved photoluminescence and fluorescence lifetime imaging microscopy (FLIM). Our investigation reveals that the perovskite grains grow spontaneously and the larger grains are formed at room temperature in the presence of moisture and oxygen. This crystallization process leads to a higher density of defects and a shorter carrier lifetime, specifically in the larger grains. Excitation-intensity-dependent steady-state photoluminescence shows both N2 stored and aged perovskite exhibit a super-linear increase of photoluminescence intensity with increasing excitation intensity; and the larger slope in aged sample suggests a larger density of defects is generated, consistent with time-resolved PL measurements.

Assessment of clinical and communication skills: operationalizing Benner's model

The introduction of ward-based clinical assessment of nursing skills in the 1970s meant a more realistic method of assessment, but still essentially a 'snapshot' of the student's practical abilities. This now being replaced by continuous clinical assessment which requires that student nurses meet the expected level of competence in a range of nursing skills in each clinical placement. Benner's (1984) model of skill acquisition is currently receiving considerable attention by nurse educationalists and is providing the framework for many curricula (English 1993). The model identifies five stages of development in nursing: novice; advanced beginner; competent; proficient; and expert. What is needed, however, is a more detailed description of what those stages mean in terms of the component parts of nursing, especially the clinical and communication skills. This paper describes a framework for the assessment of clinical and communication skills, a framework which seeks to operationalize Benner's model by defining the level of performance expected in clinical and communication skills at each stage.

Single-Cell Transcriptomic Atlas of Gingival Mucosa in Type 2 Diabetes

The oral gingival barrier is a constantly stimulated and dynamic environment where homeostasis is often disrupted, resulting in inflammatory periodontal diseases. Type 2 diabetes (T2D) has been reported to be associated with gingival barrier dysfunction, but the effect and underlying mechanism are inconclusive. Herein, we performed single-cell RNA sequencing (scRNA-seq) of gingiva from leptin receptor-deficient mice (db/db) to examine the gingival heterogeneity in the context of T2D. Periodontal health of control mice is characterized by populations of Krt14⁺-expressing epithelial cells and Col1a1⁺-fibroblasts mediating immune homeostasis primarily through the enrichment of innate lymphoid cells. The db/db gingiva exhibited decreased epithelial/stromal ratio and dysfunctional barrier. We further observed stromal, particularly fibroblast immune hyperresponsiveness, linked to the recruitment of myeloid-derived cells at the db/db gingiva. Both scRNA-seq and histological analysis suggested the inflammatory signaling between fibroblasts and neutrophils as a potential driver of diabetes-induced periodontal damage. Notably, the "immune-like" stromal cells were wired toward the induction of gingival γδ T hyperresponsiveness in db/db mice. Our work reveals that the "immune-like" fibroblasts with transcriptional diversity are involved in the innate immune homeostasis at the diabetic gingiva. It highlights a potentially significant role of these cell types in its pathogenesis.

Estimation of work-related injury and economic burden attributable to heat stress in Guangzhou, China

BACKGROUND

Climate change has exacerbated the health effects of high ambient temperatures on occupational health and safety; however, to what extent heat stress can induce workplace injuries and economic costs is poorly studied. This study aimed to quantify the attributable fractions of injury claims and subsequent insurance payouts using data from work-related injury insurance system in Guangzhou, China.

METHODS

Individual workers' injury claims data were collected for the period of 2011-2012, including demographic characteristics and work-related information. Daily maximum wet bulb globe temperature (WBGT, °C) was calculated from meteorological data. To examine the association between WBGT index and work-related injury, we fit a quasi-Poisson regression with distributed lag non-linear model. Then we calculated the numbers of injury claims and costs of insurance compensations attributable to days with WBGT above the heat stress limit according to the national occupational health standards.

RESULTS

There were 9550 work-related injury claims, resulting in an insurance payout of 282.3 million Chinese Yuan. The risks of injury claims increased with rising WBGT. 4.8% (95% eCI: 2.9%-6.9%) of work-related injuries and 4.1% (95% eCI: 0.2%-7.7%) of work-related injury insurance payouts were attributed to heat exposure for WBGT threshold above the heat stress limit. Male workers, those in small enterprises and with low educational attainment were especially sensitive to the effects of heat exposure.

CONCLUSIONS

Heat stress can contribute to higher risk of work-related injury and substantial economic costs. Quantified the impacts of injuries and related economic costs should be considered to develop targeted preventive measures in the context of climate change.

The analysis of differential diagnosis of benign and malignant thyroid nodules based on ultrasound reports

BACKGROUND

Thyroid cancer is a common endocrine tumor, the incidence of which is increasing each year. Early diagnosis and treatment can effectively prevent thyroid cancer. This article uses Chinese's ultrasound reports to determine the value of early diagnosis.

METHODS

The clinical data center of the First Affiliated Hospital of Nanjing Medical University was screened for patients diagnosed with a thyroid nodule, who had undergone a thyroid function test, ultrasound records and pathological assessment. A total of 811 patients with a total of 1,290 pathologically confirmed nodules (506 benign and 784 malignant) were enrolled. Logistic regression was used to analyze the variables that significantly affected malignant nodules. The sensitivity and specificity of ultrasound thyroid imaging-reporting and data system (TI-RADS) classification results for benign and malignant tumors were calculated.

RESULTS

The age of the patients had a very significant difference in the classification of benign and malignant nodules (P<0.001), and the marital status was significantly different (P<0.05). Gender and medical insurance had no significant effect (P>0.05). Thyroglobulin (TG), free thyroxine (FT4), and free triiodothyronine (FT3) had significant effects (P=0.003) on the incidence of malignant nodules in patients, while thyroid-stimulating hormone (TSH) had no significant effect (P>0.05). Ultrasound analysis showed a Youden's index of 78.97%, a positive predictive value of 93.20%, and a negative predicted value of 84.10% at the most excellent classification effect. The sensitivity was 89.0%, the specificity was 89.9%; much greater than the classification model based on the thyroid function test (sensitivity =80.6%, specificity =55.8%).

CONCLUSIONS

The present study verifies the effectiveness of using TI-RADS classification for diagnosis of benign and malignant thyroid nodules, and explores the use of new analysis methods for clinical data. To reduce dependence on the doctors, ultrasound image data and clinical phenotypic data can be further used to assist clinical decision making.

Assessment of the Public Health Risks and Impact of a Tornado in Funing, China, 23 June 2016: A Retrospective Analysis

(1) Background: Tornadoes are one of the deadliest disasters but their health impacts in China are poorly investigated. This study aimed to assess the public health risks and impact of an EF-4 tornado outbreak in Funing, China; (2) Methods: A retrospective analysis on the characteristics of tornado-related deaths and injuries was conducted based on the database from the Funing's Center for Disease Control and Prevention (CDC) and Funing People's Hospital. A change-point time-series analysis of weekly incidence for the period January 2010 to September 2016 was used to identify sensitive infectious diseases to the tornado; (3) Results: The 75 to 84 years old group was at the highest risk of both death (RR = 82.16; 95% CIs = 19.66, 343.33) and injury (RR = 31.80; 95% CI = 17.26, 58.61), and females were at 53% higher risk of death than males (RR = 1.53; 95% CIs = 1.02, 2.29). Of the 337 injuries, 274 injuries (81%) were minor. Most deaths occurred indoors (87%) and the head (74%) was the most frequent site of trauma during the tornado. Five diseases showed downward change-points; (4) Conclusions: The experience of the Funing tornado underscores the relative danger of being indoors during a tornado and is successful in avoiding epidemics post-tornado. Current international safety guidelines need modification when generalized to China.

Longitudinal changes in mental health among medical students in China during the COVID-19 epidemic: depression, anxiety and stress at 1-year follow -up

This study aimed to evaluate the influence of COVID-19 on the mental health of Chinese medical students at 1-year of follow-up. From 2 February 2020 to 23 February 2021, we conducted three waves of research online (T1 = during outbreak, T2 = controlling period, T3 = 1 year after outbreak). The survey collected demographic data and several self reporting questionnaires to measure the depressive, anxiety and stress symptoms. A total of 4002 participants complete the whole research phases. The study major, grade level and gender were the main factors related to psychological distress caused by the COVID-19 crisis. Importantly, medical knowledge has a protective effect on medical students' psychological distress during the COVID-19 period.

METTL3 Modulates Ctsk+ Lineage Supporting Cranial Osteogenesis via Hedgehog

N6-methyladenosine (m6A) modification, a eukaryotic messenger RNA modification catalyzed by methyltransferase-like 3 (METTL3), plays a pivotal role in stem cell fate determination. Calvarial bone development and maintenance are orchestrated by the cranial sutures. Cathepsin K (CTSK)-positive calvarial stem cells (CSCs) contribute to mice calvarial ossification. However, the role of m6A modification in regulating Ctsk+ lineage cells during calvarial development remains elusive. Here, we showed that METTL3 was colocalized with cranial nonosteoclastic Ctsk+ lineage cells, which were also associated with GLI1 expression. During neonatal development, depletion of Mettl3 in the Ctsk+ lineage cells delayed suture formation and decreased mineralization. During adulthood maintenance, loss of Mettl3 in the Ctsk+ lineage cells impaired calvarial bone formation, which was featured by the increased bone porosity, enhanced bone marrow cavity, and decreased number of osteocytes with the less-developed cellular outline. The analysis of methylated RNA immunoprecipitation sequencing and RNA sequencing data indicated that loss of METTL3 reduced Hedgehog (Hh) signaling pathway. Restoration of Hh signaling pathway by crossing Sufufl/+ alleles or by local administration of SAG21 partially rescued the abnormity. Our data indicate that METTL3 modulates Ctsk+ lineage cells supporting calvarial bone formation by regulating the Hh signaling pathway, providing new insights for clinical treatment of skull vault osseous diseases.