The International Cardio-Metabolic Forum held a plenary session to establish a multinational consensus on the challenges faced in diabetes management within lower-middle-income countries (LMICs) and their potential solutions. Stakeholders, including patients, family/caretakers, healthcare professionals, and healthcare policymakers & organizations, participated in discussions. The audience of 280 doctors from 15 different countries  was divided into 4 groups led by Group Leaders to represent each stakeholder group. Questionnaires addressing key challenges and solutions specific to each group were used to facilitate consensus development. Participants voted on relevant options based on their clinical experience. SLIDO software was used for polling, generating separate results for each group. The insights shared by healthcare professionals highlighted the importance of improving medication accessibility and cost-effectiveness for patients, emphasizing the need for adherence to treatment plans and lifestyle modifications. The significance of balanced nutrition with low glycemic index food for enhancing quality of life was recognized. Caregivers of diabetic patients with comorbidities face increasing demands for care, particularly in relation to age-related milestones. Healthcare professionals emphasized the challenges posed by cultural beliefs and health awareness, underscoring the importance of teamwork and early referral for managing comorbidities. Healthcare policymakers need to focus on disease education, awareness programs, screening guidelines, and advocacy for community and clinical screening. By addressing these challenges, a more comprehensive and effective approach to diabetes management can be achieved in LMICs, ultimately improving outcomes for individuals with diabetes. Non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, cancer, and chronic respiratory illness are recognized worldwide as the leading causes of death and disabilityAccording to the World Health Organization, diabetes prevalence has been more pronounced in low- and middle-income countries (LMICs) compared to high-income countriesPatients with diabetes in low- and middle-income countries (LMICs) experience a number of obstacles that make it difficult for them to receive the best care possible, which leads to inadequate diabetes control and the emergence of disease-related comorbidities.6Effective strategies exist for preventing or delaying the onset of Type-2 diabetes, focusing on lifestyle modifications such as adopting a healthy diet, engaging in regular physical activity, maintaining normal body weight, and avoiding tobacco use. Implementing these measures is crucial, as they have been proven to be effective in preventing or delaying the onset of T2D The Global Action Plan for the Prevention and Management of NCDs for the period 2013 to 2020 emphasizes the importance of prioritizing NCD prevention and addressing the social determinants underlying these diseases In LMICs, strategies involving community engagement play a significant role in health promotion and disease prevention, including the management of NCDs. Community-clinical linkage models, such as the utilization of community health workers, have demonstrated effectiveness in delivering healthcare services to individuals with chronic diseases or those at risk, particularly in resource-limited settingsTherefore, the objective of the proposed study was to gather insights from healthcare providers regarding challenges faced by each stakeholder involved in diabetes care in LMICs and establish a multinational consensus. The study aimed to identify the specific challenges experienced by patients, their families/caretakers, healthcare professionals, and healthcare policymakers/organizations. Through the utilization of questionnaires and a consensus-building process, the study seeks to develop a structured approach towards diabetes management that effectively addresses the key concerns raised by each stakeholder group.A survey was carried out at the International Cardio-Metabolic Forum 2023 in Antalya, Turkey, to learn more about the difficulties faced by patients, their families and caregivers, medical professionals, and healthcare policymakers and organizations.The audience consisted of about 280 doctors from 15 different nations including Pakistan, Qatar, Sri Lanka, Kenya, Myanmar, Georgia, Nigeria, Philippines, Uzbekistan, Iraq, Tanzania, Cambodia, Kazakhstan, South Sudan and Libya. The participants were then randomly divided into four groups to guarantee that each stakeholder group was represented. A Group Leader oversaw each group. By sending questionnaires created especially for each stakeholder group, consensus development was enhanced. These surveys had at least four questions, each of which addressed a known problem with illness management and potential remedies that would interest the designated stakeholder group.Polling on the choices they felt were the most pertinent based on their clinical expertise was requested of all participants, including the group leaders. SLIDO software was used to carry out the polling procedure more efficiently. At the conclusion of the plenary session, this program allowed for the generation of distinct poll results, giving a thorough picture of the responses from each stakeholder group.Each poll’s findings were combined, and the group leaders and other participants came to an agreement. This agreement served as the basis for creating a better-organized approach to diabetes care that addressed the major difficulties each stakeholder group experienced. This strategy aimed to improve diabetic patient outcomes and disease management tactics. In order to evaluate the survey data, SPSS Version 22.0 was used. The quantitative results were presented as frequencies and percentages, which made it easy to grasp the preferences and viewpoints of the participants.According to enrolled healthcare professionals (HCPs), one of the most prevalent factors hindering the effective management and motivation of individuals with diabetes, or those at risk, is poor adherence to the treatment plan and recommended lifestyle modifications (57%).In terms of patient demands, the primary measure requested for managing diabetes is the availability of cost-effective, convenient, and easily accessible medications (71%).One essential aspect of lifestyle modification that diabetic patients tend to neglect, despite acknowledging its significance in enhancing their quality of life, is balanced nutrition. Patients recognize the importance of making choices that involve consuming foods with a low glycemic index to avoid hypo- or hyperglycemia (66%).Caregivers and families of diabetic patients, particularly those with multiple comorbidities, commonly face the challenge of an increasing demand for care as the disease progresses (59%).For vulnerable populations such as geriatric and pediatric patients, caregivers experience increasing stress due to concerns about developmental milestones in children and the worsening health conditions in the elderly (64%).The most appropriate role identified for family members and caregivers of diabetic patients is to provide appropriate diet and support in monitoring and managing weight, thereby reducing the occurrence of hypo- and hyperglycemia events (67%).Physicians should ensure they convey important instructions and information to caregivers of dependent high-risk diabetic patients in an appropriate manner. This includes educating them about the potential consequences of common side effects such as hypoglycemia, dehydration, and hypotension, as well as providing information about newer and safer treatment options available (79%).Healthcare professionals (HCPs) face several challenges in the management of diabetes, particularly in developing countries. One of the primary challenges identified is the low adherence of patients to HCP advice and therapy, resulting in poor compliance (83%).In terms of service delivery at diabetes management clinics, a significant challenge reported by HCPs is the absence of integrated medical records systems that would allow for a more holistic approach to treatment (74%).HCPs also encounter challenges related to cultural beliefs, traditions, and health awareness, particularly in relation to denial of diabetes and low compliance with medication and a healthy lifestyle (83%).To enhance care and promote health among the diabetic population, it is emphasized that healthcare professionals should work in teams and prioritize early referrals for the identification or treatment of comorbidities, including cardiovascular and kidney diseases (77%).Preventive measures in low- and middle-income countries (LMICs) should prioritize increased efforts by healthcare policymakers towards disease education and awareness programs, involving multiple stakeholders (55%).According to healthcare providers’ perceptions, professional and governmental organizations play a crucial role in ensuring the development and application of screening guidelines, as well as advocating for screening in both community and clinical settings (50%).To effectively address the burden of diabetes, healthcare policymakers and organizations should adopt a strategic approach that includes the development of communication, education, and engagement tools for coaches. These tools can be utilized to deliver the Diabetes Prevention Program, focusing on lifestyle and behavioral changes (58%).Among the strategies employed by healthcare organizations to manage diabetes and reduce complications, healthcare providers prioritize early detection and treatment with a strong emphasis on achieving target HbA1C levels (67%).The present study aimed to gather insights from healthcare providers regarding the challenges faced by different stakeholders involved in diabetes care in low- and middle-income countries (LMICs) and establish a multinational consensus. The findings shed light on the perceptions of patients, caregivers, healthcare professionals, and healthcare policymakers, providing valuable information for developing a structured approach towards diabetes management in LMICs.Our findings revealed several key challenges faced by diabetes patients in LMICs as per the perception of HCPs. Poor adherence to the treatment plan and recommended lifestyle modifications emerged as a prevalent barrier to controlling diabetes. This finding underscores the importance of addressing patient education and motivation to enhance compliance with therapy. Patients also expressed a strong demand for cost-effective, convenient, and easily accessible medications, which highlights the need for affordable and accessible healthcare services in LMICs. Additionally, the significance of balanced nutrition, including choices of low glycemic index food, was emphasized by patients to improve their quality of life and prevent hypo/hyperglycemia. Numerous studies have identified several variables leading to inadequate diabetic self-management. One key barrier, for instance, has been noted as the challenge of implementing and maintaining lifestyle modificationsAdditionally, it has been discovered that ineffective communication interfaces within the healthcare system hinder successful self-managementDiabetic patients’ caregivers in LMICs encounter a unique set of challenges. The study noted the rise in care needs as the illness worsens, especially in patients with several coexisting conditions. This research emphasizes the need to provide caregivers with proper support systems and resources because they are crucial in managing and assisting patients with complicated healthcare requirements. Concerns about children’s age-related developmental milestones and deteriorating health conditions in the elderly were also found, underscoring the significance of specialized care strategies for vulnerable populations. In a study, Zyberg and colleagues examined the challenges experienced by caregivers when caring for children with diabetes in various contexts. These difficulties span a range of areas, including regular blood glucose testing, developing and adhering to a nutrition plan, and monitoring the child’s physical activity When it comes to managing diabetes, healthcare practitioners in LMICs have specific challenges. Significant barriers to efficient diabetes management have been identified as cultural attitudes, traditions, and low health knowledge. These elements play a part in the denial of diabetes, poor adherence to treatment and a healthy lifestyle, and false information spread on social media. In order to connect and educate patients in a meaningful way, the study emphasizes the significance of cultural sensitivity and knowledge among healthcare personnel. Additionally, in order to provide complete care and enhance patient outcomes, the importance of healthcare professionals working cooperatively in teams and using early referral for comorbidities, such as cardiovascular and kidney disorders, was underlined.The difficulties faced by patients and healthcare professionals in managing diabetes mellitus (DM) in a low- and middle-income country (LMIC) were examined in a study by Nang et al. The findings brought to light a number of worries mentioned by medical staff regarding their lack of expertise and lack of confidence in managing diabetes. It was discovered that there were few diabetic care facilities available, and poor laboratory services presented additional difficultiesDiabetes management presents difficulties for healthcare policymakers in LMICs. The report highlights the necessity for policymakers to put up more effort into illness education and awareness programs that involve a variety of stakeholders. Priority topics for healthcare policymakers include prevention measures, such as the implementation of screening recommendations and the promotion of screening in community and clinical settings. These results highlight the significance of a thorough and coordinated strategy involving decision-makers, healthcare providers, and community stakeholders to effectively address the burden of diabetes.The development of scalable and sustainable methods for measuring diabetes risk, identifying those at high risk, and providing evidence-based interventions to this high-risk population are necessary for effective diabetes prevention at the population level The multinational consensus achieved through this study provides valuable insights for enhancing diabetes care in LMICs. The results underline how crucial it is for LMICs to have individualized interventions, complete healthcare systems, and greater illness education and awareness. The study also underlines the value of international cooperation and knowledge exchange in order to develop global standards for diabetes care.Despite the valuable insights gained from this study, there are limitations to consider. The study focused on the perspectives of healthcare providers and did not directly involve patients and caregivers. Including the voices of patients and caregivers could provide a more comprehensive understanding of their experiences and needs. Furthermore, the study was carried out in the confines of a particular international forum, which can restrict the applicability of the findings in other contexts.The current study adds to the body of literature by shedding light on the challenges faced by various stakeholders involved in the management of diabetes in LMICs. The multinational consensus highlights the need for patient-centered approaches, integrated healthcare systems, and increased disease education and awareness. The findings provide a foundation for developing tailored strategies to address the specific challenges identified by patients, caregivers, healthcare professionals, and healthcare policymakers. By working collaboratively and implementing evidence-based interventions, it is possible to envisage a better future for diabetes care in LMICs and improve the overall health outcomes of individuals affected by the disease.


Droplet microfluidics has gained widespread attention in recent years due to its advantages of high throughput, high integration, high sensitivity and low power consumption in droplet-based micro-reaction. Meanwhile, with the rapid development of computer technology over the past decade, deep learning architectures have been able to process vast amounts of data from various research fields. Nowadays, interdisciplinarity plays an increasingly important role in modern research, and deep learning has contributed greatly to the advancement of many professions. Consequently, intelligent microfluidics has emerged as the times require, and possesses broad prospects in the development of automated and intelligent devices for integrating the merits of microfluidic technology and artificial intelligence. In this article, we provide a general review of the evolution of intelligent microfluidics and some applications related to deep learning, mainly in droplet generation, control, and analysis. We also present the challenges and emerging opportunities in this field. It was first proposed as a research area at the Dartmouth Conference in 1956 . HoweverDeep learning is a subset of machine learning proposed in the 2010s . It was The high throughput of microfluidics enables the generation of massive and detailed data. Compared to traditional methods of data analysis that rely more on human intervention, deep learning utilizes large amounts of data for feature extraction, requiring less manual intervention to improve the performance of computer-aided tasks such as classification and prediction of data from microfluidic systems . MicroflThe advent of droplet-based microfluidic devices has paved the way for the application of lab-on-a-chip (LoC) concept. As an essential part of LoC experiments, the generation of microdroplets forms the basis for the extensive use of droplet microfluidic technology . HoweverTo predict the dimensionless length of water-infused droplets in microfluidic systems, Furthermore, targeting at achieving design automation of fiow-focusing droplet generators, The “flow sculpting” technique involves using the pillar structure to shape the fluid into various geometric forms . DiffereIn deep learning-aided droplet generation, fluid parameters , channel geometry parameters , and driving parameters  collectively affect the predictions of droplet size . TraininDifferent applications of microfluidics require unique processes, and microfluidic devices require design and optimization based on each study, which involves a variety of droplet manipulation and post-processing functions, thus advanced droplet control technology is needed for the conduct of correlational research.To detect and track droplets in dense microfluidic emulsions, Achieving laminar flow control and droplet size control are essential tasks in microfluidics, involving the precise positioning of the interface between miscible flows and the dynamic management of oil-infused droplet sizes in the segmented stream, respectively . CorrespSimulating blood cells as elastic objects in the flow of blood plasma is a valuable approach for optimizing microfluidic devices for blood sample analysis. In droplet control tasks involving flow regulation, fluid parameters, channel geometry parameters, and driving parameters remain crucial . When asIn some studies, it is necessary to analyze the reactions within the droplets, as well as the concentration of the droplet contents and the droplet status for more abundant information. The employment of deep learning makes the effective prediction of these features possible, which is conducive to improving the efficiency and performance of droplet based microfluidic experiments.In order to monitor the mixing within droplets, To distinguish individual droplets in a microfluidic system, The combination of droplet analysis and deep learning is also extensively utilized in research pertaining to cells. In order to improve the accuracy and efficiency of single cell sequencing, In addition to image processing and model parameters, various droplet characteristics, such as size, shape, concentration, and data acquisition parameters, including droplet collection frequency and time intervals, are essential for effectively monitoring mixing and reactions inside droplets . DiffereMicrofluidics has the ability to intersect with different research fields, offering the opportunity to generate a wide variety of datasets for deep learning models. Conversely, deep learning can process the generated data to yield innovative and optimized solutions for microfluidics. Despite a wide range of promising applications of intelligent microfluidics, several under-developed and unsolved issues remain to be explored. Firstly, components in microfluidics can vary significantly from lab to lab, creating inconsistencies across the field that limit generalization. Deep learning model performance is only as good as the data the models are trained on, thus large batch variability limits the building of high-quality cross-institutional datasets. By training on a single lab’s data, the models are at a high risk of overfitting: building a dataset across a narrow distribution, models may perform well within the developer’s fabrication and operational workflow but poorly in others . SecondlThe proportion of scientists adopting machine intelligence into their laboratories will increase with the emergence of highly generalizable artificial neural networks that can be implemented without extensive retraining. Progress in cloud computing and the growth of computational power will also be significant contributors . MicroflThe application of deep learning in microfluidic systems has shown a strong trend of development, presenting significant advantages and practical effects in target detection, correlation prediction and result classification. With the rapid progress of big data, Internet of Things (IoT), blockchain, cloud computing and edge computing, artificial intelligence technology will gradually cover the microfluidic systems in data processing, status assessment, intelligent decision-making and automatic optimization. Despite the presence of some unexplored obstacles that require attention for continued advancement, the improvement of intelligent level in microfluidic systems is unstoppable. And intelligent microfluidics will find more extensive and significant applications in fields such as chemistry, biology, medicine, material science, and particularly provide assistance for the smart and high-precision analysis of biological samples.


Congenital heart disease (CHD), birth defect with the highest incidence rates worldwide, and is mainly characterized by the abnormal internal structure of the heart or/and the anatomical structure of great vessels. In the past few decades, CHD repair surgery through standard median sternotomy incision combined with cardiopulmonary bypass (CPB) technology has been considered the gold standard for surgical correction of heart and great vessels. With the promotion and clinical application of interventional catheterization technology, transcatheter closure of CHD under radioactive radiation has gradually been recognized and applied. However, its radiation exposure and potential complications related to arteriovenous vessels still face challenges. In recent years, an increasing number of surgeons have explored new surgical procedures, for the safe and effective treatment of CHD, as far as possible to reduce surgical trauma, avoid radiation exposure, and improve the cosmetic effect. Therefore, on the premise of satisfactory exposure or guidance, how to integrate ultrasound and percutaneous interventional technology remained the focus of the exploration. This mini-review highlights and summarizes the signs of progress of ultrasound intervention in the last decade that have proven the effectiveness and operability of a well-established procedure for percutaneous closure of congenital heart diseases under echocardiographic guidance only. We discuss potential diseases that will benefit from this emerging procedure based on this progress. Owing to the crucial advantages played by this strategy in the treatment of CHD, better understanding and promotion of this less exploited field may contribute to the development of therapeutics targeting CHD, improve medical utilization rate, promote the optimization of medical resources, and ultimately achieve precise and efficient medical treatment. Congenital heart disease (CHD), birth defect with the highest incidence rates worldwide, and is mainly characterized by the abnormal internal structure of the heart or/and anatomical structure of Great vessels , 2. BaseIn the past few decades, CHD repair surgery through standard median sternotomy incision combined with cardiopulmonary bypass (CPB) technology has been considered the gold standard for surgical correction of heart and great vessels. However, this early golden standard surgical approach faces challenges such as postoperative discomfort and residual long scar incisions in the median incision , 4.With the promotion and clinical application of interventional catheter technology, the transcatheter intervention program assisted by radiation is gradually applied to treat some simple CHDs and is gradually recognized by the Food and Drug Administration (FDA) under the long-term monitoring of effectiveness and safety. Meanwhile, this simple transcatheter CHD strategy is still a valuable alternative and is currently widely used in many developing countries (such as China and other countries) and developed countries, even becoming a mature standard treatment for simple CHD –9, but tWith the popularization of echocardiography-guided technology, cardiac surgery combined with an interventional catheterization department has explored a new surgical method for the treatment of simple CHD, for the safe and effective treatment of CHD, as far as possible to reduce surgical trauma, avoid radiation exposure, and improve the cosmetic effect –20. The The development of cardiac intervention strategies is closely related to the advancement of computer imaging technology and clinical applications. Based on ultrasound technology, transcatheter intervention in simple CHD not only has less trauma, but also enables rapid recovery, saves medical costs, and shortens hospital stays. Many international ultrasound and heart disease guidelines , 25 poinPFO is a common and persistent intracardiac anatomic abnormality, which has certain relevance to the occurrence of nervous system disease  , 28. EpiBased on our heart center's mature and simple CHD occlusion technology and experience , we exclASD can be divided into four types: ostium primum, ostium secundum, sinus venosus, and unroofed coronary sinus and is the third common anatomical abnormality in CHD. Approximately 65% to 70% of patients with a secundum defect and about 50% of patients with primary ASD . The revVentricular septal defect (VSD) refers to the direct abnormal defect of left and right ventricles, which accounts for the highest proportion of CHDs, of which 80% is classified as perimembranous VSD . In the As a traditional gold standard treatment method, midline sternotomy and open heart surgery with cardiopulmonary bypass (CPB) have always been the only options for VSD repair; however, it is undeniable that there are multiple postoperative complications and residual long scar incisions during open chest surgery . Under tResidual shunting after VSD repair or occlusion is a common phenomenon and has been reported to account for 5–36% of all VSDs undergoing surgical repair . PartialAs an isolated lesion, PDA refers to a disease in which the blood vessels between the pulmonary artery and the descending aorta are not yet closed within a certain period after birth, resulting in left to right shunting and accounting for 8% to 10% of all CHDs . In 1939PVS refers to the narrowing of pulmonary artery valves caused by congenital developmental abnormalities, accounting for 8–10% of CHD. Its treatment methods mainly include thoracotomy under direct vision and balloon angioplasty. There is a risk of extracorporeal circulation and sternal sawing during pulmonary valvotomy, which can cause significant trauma to patients . In 1982The clear visualization of intervention operations is of great significance for ensuring the safety and operability of simple CHD treatment. Although the traditional method can provide some visual images and tracking guidance under the guidance of fluorescent radiation and the use of contrast agents, there is no doubt about the risks of this treatment strategy, especially for cardiac surgeons who often carry out surgical intervention, kidney dysfunction and children in the growth and development stage . ResearcBased on the existence of these potential risks, cardiac surgeons are encouraged to seek alternative imaging tools for guidance or develop a new intervention method to complete the shaping process. In recent years, with the continuous improvement and promotion of echocardiography, it has been widely used as an imaging guide for percutaneous occlusion of simple CHD in various heart centers around the world, with real-time dynamics, and non-invasive and inexpensive advantages. Echocardiography plays an important role in the intervention and treatment of simple CHD, especially inpatient diagnosis, preoperative clarification of cardiac anatomy, surgical approach, selection of occluder model and delivery system, real-time intraoperative monitoring and guidance, and postoperative effectiveness evaluation , 87.When guiding intervention with echocardiography, some materials will be routinely used to complete the surgery. Femoral vein access was achieved using a matched Fr sheath. A 0.038-inch bent stiff guidewire was advanced from the inferior vena cava via the right atrium into the superior vena cava. A 5Fr JR 4 diagnostic catheter was subsequently advanced into the right atrium over the guidewire which was then entered into the right ventricle via the catheter. Under the guidance of TEE, the operation can be completed by inserting the matching conveying system, occluder device, and balloon dilation system through the established trajectory.Compared with traditional transthoracic echocardiography, TEE is located in the patient's esophagus, eliminating the influence of chest wall and lung tissue, enabling clearer images and clearer and more detailed cardiac anatomy. Real-time monitoring can achieve clarity and non-interference. In addition, TEE can display the entire pathway, including all blood vessels and tissue structures involved, to the operator without radiation throughout the entire process, and can provide three-dimensional images when appropriate, which can more vividly help the operator complete the occlusion operation smoothly. Echocardiogram guidance stenting ductus venous also plays an important role in intracardial anomalous pulmonary venous connection . For carHowever, there are certain shortcomings in the intervention of simple CHD guided by echocardiography. There are certain challenges for the surgeon, who not only have a thorough understanding of the anatomical structure of the heart and blood vessels, but also need to be very familiar with ultrasound guidance, ultrasound sections, and related parameters. Secondly, ultrasound-guided surgery is easily influenced by subjective factors, which further strengthens the test for surgical operators. The success of surgery is closely related to the experience of surgeons and ultrasound doctors. For TEE-guided intervention in simple CHDs surgery, echocardiogram doctors should have rich experience to prevent surgeons from having a blank in ultrasound professional knowledge, thus avoiding the inability to execute the program. In addition, ultrasound is prone to interference from tissues such as intrathoracic gas during guided intervention, which poses certain difficulties for surgery and may increase surgical time and anesthesia risks.This mini-review highlights and summarizes the signs of progress of ultrasound intervention in the last decade that have proven the effectiveness and operability of a well-established procedure for percutaneous closure of congenital heart diseases under echocardiographic guidance only. We discuss potential diseases that will benefit from this emerging procedure based on these progresses. Owing to the crucial advantages played by this strategy in the treatment of CHD, better understanding and promotion of this less exploited field may contribute to the development of therapeutics targeting CHD, improve medical utilization rate, promote the optimization of medical resources, and ultimately achieve precise and efficient medical treatment. The TEE-guided percutaneous simple CHD treatment intervention method combines the advantages of Cardiac surgery, interventional radiology, and auxiliary medical departments, which has good safety and feasibility, and avoids the problems of low-dose radiation exposure, CPB, intraoperative and postoperative adverse events, and incision scars. One challenge faced by this new technology is how to apply it in low-weight or vascular dysplasia infants and young children. Notedly, Mini et al. , 83 repoDespite minor shortcomings, this well-established procedure has emerged as a powerful method for treating simple CHDs during the last decade. Its application is not limited to the establishment of known simple CHDs for therapeutic development, but should be extended to discovering new therapies and diseases. In the upcoming decade, this novel procedure promises to make a big splash in CHDs.Based on this brief review, we discussed the potential for simple CHDs to benefit from an emerging procedure. Owing to the crucial advantages played by this strategy in treating CHD, better understanding and promoting this less exploited field may contribute to the development of therapeutics targeting CHD. Furthermore, because this technology only depends on TEE and operator experience technology, it does not need to purchase expensive equipment, which is conducive to the promotion and application in grass-roots hospitals and Community hospitals, especially in remote and poor areas in China, ultimately improving medical utilization, promoting the optimization of medical resources, and ultimately achieving accurate and efficient medical services for patients.


This paper explores the effect of particle breakage on the mechanical behavior of coarse sand through 3D Discrete Element Method (DEM) simulations of direct shear tests (DST). The objective is to gain insights into the macro- and micro-mechanical behaviors of crushable coarse sand, with a particular focus on the stress–strain relationship, volumetric deformation, and evolution of grain crushing. The simulations involve a comparison between non-crushable and crushable particle models, where the crushable particles are implemented in the shear zone of the DST subjected to different high normal stresses. The findings indicate that the crushable particles experience partial crushing at peak shear stress, with further particle crushing leading to the production of finer particles at the shearing plane during shearing at the critical state. The migration of these finer particles under pressure and gravity generates their accumulation predominantly in the lower section of the simulation box. Importantly, the presence of crushing in the DST induces a decrease in the shear stress and an increase in the volumetric strain leading to contractive behavior instead of dilation, which gradually stabilizes the volumetric deformation at higher normal stresses. From field practice and laboratory tests, it is widely observed that stress levels sufficient for particle breakage are encountered in deep penetration and compaction, and examples of such situations include displacement pile driving, cone penetration testing in coarse-grained soils and high earth or rockfill dams. Particle breakage is a phenomenon that is commonly observed in offshore engineering practices, occurring in various types of soil particles, including both strong particles like quartz sand, as well as weaker ones such as carbonate or calcareous sands ,25,26,27Almeida et al.  noticed Therefore, the issue of particle breakage has garnered significant attention from researchers within the field of geotechnical engineering, primarily due to the frequent occurrence of crushable materials. Several researchers have conducted calibration chamber and centrifuge tests on carbonate sands to better understand what happens when a pile is driven into weak sands ,6,7,8. TConducting calibration chamber tests, White and Bolton  observedUnder high stresses, it is observed that crushing at sliding contacts affects stress–strain behavior and decreases the rate of dilation for both triaxial tests ,13,14 anCoop et al.  utilizedHowever, the micromechanics and evolution of particle breakage in granular soils are difficult to observe at the particle level during shearing through laboratory testing. Therefore, X-ray microtomography has been applied to the crushing process at the particle scale to understand the grain-scale characteristics of calcareous sands ,27,28. THall et al.  employedFrom the above, it is clear that obtaining information about shear band evolution and micro-mechanics of particle crushing in conventional laboratory experiments is very difficult.Recently, studies of direct shear tests at the microscopic level have become more popular using the Discrete Element Method among others by ,47,48,49Jeong et al.  investigNitka et al.  conducteLi et al.  conducteThese earlier studies have shown the feasibility of the DEM in evaluating the breakage effect. However, there are still some aspects that need improvement to reproduce the effect of breakage on the micro- and macroscopic behavior of crushable granular materials.Understanding the micro-mechanics of particle breakage evolution in shearing granular soils is very useful to control the effect of breakage on shear stress and material dilatancy in both laboratory tests and engineering practices.In this paper, a novel 3D DEM model of the direct shear test on crushable coarse sand was developed using sphere particles and crushable bonded agglomerates to demonstrate that it is possible to simulate the evolution of particle breakage in direct shear tests on crushable coarse sands with large amounts of particles, using particle flow code (PFC3D) . The maiThe numerical simulations in this study were performed using the commercial DEM software PFC version 7.0 . This soIn DEM simulations of granular materials, the inter-particle contact law plays a crucial role in determining the macro- and micro-behavior of the entire assembly. Simulating granular materials with different contact types can be more complex than using a single contact type. In this research, three contact models were utilized for different contact types.Considering the shape effect of sand, the rolling resistance linear contact model was adopted between sand particles, which were modeled as spheres, to reduce the computational cost and have acceptable performance. The linear parallel-bond model was applied to contacts between micro-particles within the crushable agglomerate (breakable particle). The use of crushable agglomerates can reasonably capture all crushing mechanisms that can occur. To describe the interaction between particles and walls, the linear contact model was employed. This model is a built-in constitutive model commonly used in the discrete element software PFC, which ensures compatibility with standard practices in the field.The linear model represents an interface with infinitesimal behavior that does not resist relative rotation resulting in a contact moment The linear force can be updated using the following equation:In addition, a friction coefficient The calculation of the normal and shear contact forces between particles involves the evaluation of the dashpot model, which can be expressed as follows:In the equations, In the DST model, a rolling resistance contact model was utilized to account for the behavior of sand particles. This model introduced rolling friction at the contacts between the simulated sand particles, as illustrated in The rolling resistance contact model implemented in PFC3D extends the functionality of the linear model by incorporating a rolling resistance mechanism. This model introduces modifications to the force-displacement relationship to update the contact force and moment as follows:In the given equations, the linear force is denoted by Here, Here, The limiting torque is defined as follows:Here, the coefficient of rolling resistance is The linear parallel bond operates alongside the linear contact model, except when the maximum stresses exceed the bond strength. In such cases, the bonding is canceled, and only the linear contact model remains between the contact particles. A visual illustration of this behavior is presented in The contact force is divided into three components: the linear force The following sections outline the processes involved in determining particle motion, contact and tensile forces, and rotational moments.The normal force is updated: Here, Here, Here, Here, In this study, the developed Discrete Element Method (DEM) model for the direct shear test (DST) was used to investigate the effect of particle breakage on the shear strength and dilatation of the granular material under different normal high stresses of 160, 200, 300, 400, 600, 800, 1200 and 1600In order to establish a numerical model and determine the micro-parameters of the material, 3D DEM simulations were conducted using the Particle Flow Code (PFC3D) software by Itasca  to simulThe DEM model setup of a The mechanical behavior of granular materials is significantly influenced by the shape of their particles. However, using non-spherical particles in simulations can be computationally intensive and require significant storage capacity ,37. NeveIn this study, the grain size of particles is often up-scaled due to computational costs and previous research suggesting that up-scaling to a reasonable factor has a minimal impact on experimental results ,40,41,42The numerical simulation of the direct shear test involved three main steps: specimen preparation, consolidation, and shearing. In the specimen preparation phase, the dimensions of the box were defined, and spheres were randomly distributed inside the box using the PFC porosity command to achieve the target porosity regardless of overlap. Subsequently, the overlap between particles was gradually reduced as particles were allowed to move and rearrange, ensuring an optimal fit within the boundaries of the simulation box. Furthermore, in order to minimize the inter-particle strength during the particle generation process, the friction between particles was set to The consolidation process was performed under a predefined normal stress applied using a servo-controlling loading mechanism. This mechanism adjusts the speed of the top wall to achieve the desired reaction force in the vertical direction corresponding to the targeted normal stress levels (160, 200, 300, 400, 600, 800, 1200, and 1600 The normal stress Here, In PFC3D, the behavior of the granular material at the macroscopic level is derived from the interactions of its microscopic properties. To obtain accurate results, it is important to calibrate the micro-scale parameters used in the contact particle model of the PFC3D simulation. In previous work of Benmebarek and Movahedi , the coaIn the current study, the calibration process was conducted to facilitate the implementation of crushable particles, aiming to streamline its usage. For the sake of simplicity, the model focused on five specific diameters, ranging from 2 to 4 Obtaining information about the micro-mechanics of particle breakage through laboratory experiments is a challenging task that requires a significant amount of effort. However, the DEM provides an alternative solution for simulating particle crushing. The location of the horizontal shear band during DST is still a topic of research, and it is suggested that it is aligned along the vorticity axis.Based on previous research ,44,45,46In this study, direct shear test simulations were conducted on crushable coarse sand under different normal stresses from medium to high (The simulation involved individual particles and plates for focusing on highly stressed particles . For modThe shear stress versus lateral displacement curves displayed in Interestingly, at normal stresses of From p et al. , Tarantip et al. , and Qinp et al. . For tesp et al.  and Wei p et al. ,20 that The reduction of dilative behavior is related to particle breakage occurrence. Increasing the vertical load leads to an increase in particle breakage, and the creation of smaller particles due to breakage resulted in the reduced volume and porosity of the assembly as the gaps between primary particles were filled rather than from the occurrence of expansion behavior due to interlocking. These observations align with similar experimental findings reported by Qin et al. . In contThe findings highlight the significant influence of particle crushing on the macroscopic behavior of soil, particularly in terms of strength and strain. This impact is particularly prominent in direct shear tests, where particle breakage reduces the rate of dilation.After conducting the DST simulations, the deformed specimens were visualized from the virtual DST box. Simulation results were obtained from both the lateral and inner views of the shear zone band in the middle of the specimen, where the crushable particles were located. Visualizing the micro particles provides a more comprehensive understanding of the macroscopic behavior of material crushing.Based on latation b.For normal stresses of d 600kPa c–e, a cor higher f–h, mostAdditionally, the figure shows that large crushed particles are concentrated in the center of the shear box, while small particles migrate up and down through the empty spaces and accumulate mostly at the lower part of the box due to the gravity effect during shearing. These numerical observations confirm the results of experimental shear tests ,50,51.The observations made in Particle crushing is essential to replicate the realistic behavior of sand, especially volumetric contraction, in high normal stress shear tests;With an increasing normal stress, the difference in the shear strength and volumetric strain of the crushable model and the non-crushable model increases;Crushable sand behaves similarly to non-crushable sand at low normal stresses, as long as the stress is not sufficient to cause particle crushing;Increasing the normal stress in DST causes a transition in the soil’s volumetric strain during shearing from dilative to contractive behavior for crushable sands;Particle breakage inside DST reduces shear strength and dilatancy, resulting in a less stiff shear stress–strain response;Shear stress increases with an increase in normal stress, regardless of whether crushable or non-crushable models are used;Particles on the shear band are partially crushed at peak shear stress, and further shearing produces finer particles along the shearing plane;3D DEM simulations visually demonstrate the generation of smaller particles due to grain crushing, which fill pore spaces, thus reducing assembly dilatancy, and the effect of particle interlocking. At higher normal stress levels, the volumetric strain converges to a stable value;DEM simulations of DST which include crushable particles align well with laboratory experiments and provide physically realistic macro-scale results.In this study, a 3D DEM of DST on breakage granular material was performed using the PFC3D code to explore the effect of particle breakage evolution under different normal stresses on the shear strain and volume change during shearing. The implementation of crushable particles represented by agglomerates in the horizontal shear band of the DST was found to be crucial in accurately capturing the material’s response under high normal stresses. Based on the 3D DEM computation results, the following main conclusions may be drawn:


Lichen sclerosus (LS) is a chronic inflammatory dermatosis mostly localized in the genital area, characterized by vulvar alterations that can severely impact a patient’s quality of life. Current treatment modalities often provide incomplete relief, and there is a need for innovative approaches to manage this condition effectively. Platelet-rich plasma (PRP) and adipose-derived stem cells (ADSCs) have emerged as potential regenerative therapies for LS, offering promising results in clinical practice. This comprehensive review explores the utilization of PRP and ADSC therapy in the treatment of genital LS, highlighting their mechanisms of action, safety profiles, and clinical outcomes. PRP is a blood product enriched in growth factors and cytokines, which promotes tissue regeneration, angiogenesis, and immune modulation. ADSC regenerative potential relies not only in their plasticity but also in the secretion of trophic factors, and modulation of the local immune response. Numerous studies have reported the safety of PRP and ADSC therapy for genital LS. Adverse events are minimal and typically involve mild, self-limiting symptoms, such as transient pain and swelling at the injection site. Long-term safety data are encouraging, with no significant concerns identified in the literature. PRP and ADSC therapy have demonstrated significant improvements in LS-related symptoms, including itching, burning, dyspareunia, and sexual function. Additionally, these therapies enable many patients to discontinue the routine use of topical corticosteroids. Several studies have explored the efficacy of combining PRP and ADSC therapy for LS. In combination, PRP and ADSCs seem to offer a synergistic approach to address the complex pathophysiology of LS, particularly in the early stages. The use of PRP and ADSC therapy for genital lichen sclerosus represents a promising and safe treatment modality. These regenerative approaches have shown significant improvements in LS-related symptoms, tissue trophism, and histological features. Combination therapy, which harnesses the synergistic effects of PRP and ADSCs, is emerging as a preferred option, especially in early-stage LS cases. Further research, including randomized controlled trials and long-term follow-up, is warranted to elucidate the full potential and mechanisms of PRP and ADSC therapy in the management of genital LS. These regenerative approaches hold great promise in enhancing the quality of life of individuals suffering from this challenging condition. Lichen sclerosus (LS) is a relatively rare and often misdiagnosed dermatological condition, that primarily affects the skin in the genital and perianal region . While iWhile the exact cause of lichen sclerosus remains unclear, several factors seem to contribute to its development. There is evidence to suggest that autoimmune factors may play a role, as the condition is associated with other autoimmune diseases such as thyroid disorders and vitiligo ,11. HormTopical corticosteroid creams or ointments are commonly prescribed to reduce inflammation and alleviate itching . In someThe aim of the present review is to provide an overview of current knowledge in the setting of LS specifically focusing on PRP and ADSCs, as these represent promising therapeutic tools in this setting. PRP is a hemoderivative rich in growth factors and cytokines, and is hypothesized to stimulate tissue regeneration and repair, making it a potential candidate for mitigating the symptoms and structural changes associated with LS ,17.Autologous and homologous PRP are two distinct approaches to harnessing the therapeutic potential of platelets in regenerative medicine. These techniques differ primarily in the source of the PRP and their applications. A notable advantage of autologous PRP therapy is its safety profile, as it utilizes the patient’s own blood components, minimizing the risk of adverse reactions or immune responses . This tyAs previously mentioned, the therapeutic potential of PRP (either autologous or homologous) is closely related to their content rich in platelets ,22. PlatWith regards to LS, early investigations have reported encouraging results, particularly in terms of symptom relief. PRP therapy has shown the potential to reduce itching, pain, and discomfort, which are hallmark symptoms of lichen sclerosus . FurtherSeveral authors also focused on histological changes induced by PRP. Goldstein and collaborators, in fact, performed a randomized double-blind placebo-controlled trial to evaluate the safety and the efficacy of PRP in vulvar LS and chose the grade of inflammation in post-treatment biopsy as a primary endpoint ,29. DespHowever, it is important to note that the available data on PRP’s effectiveness for genital lichen sclerosus are limited, and larger, well-designed clinical trials are needed to establish its long-term benefits and safety. Moreover, the degree of improvement can vary among individuals, and not all patients may experience the same level of relief. While much of the research on PRP therapy for lichen sclerosus has focused on female patients, there is a growing interest in its applicability for males. Preliminary studies and clinical observations in male patients have suggested that PRP therapy may offer some degree of relief from the symptoms associated with lichen sclerosus. A recent study by Casabona et al. aimed to assess the effectiveness of PRP injections in treating penile LS . Forty-fMesenchymal stem cells, nowadays more precisely defined as mesenchymal stromal cells (MSCs), represent a fascinating tool in regenerative medicine for their regenerative and immunomodulatory properties . MSCs arMSCs include many different cell types, with probably the most widely studied being the bone-marrow stromal stem cells (BMSCs) . HoweverADSC therapy has garnered attention for its potential in the treatment of lichen sclerosus. Preliminary studies have explored the use of adipose-derived stem cells (ADSCs) as a therapeutic approach to address the complex pathophysiology of the condition . The regIn addition to this, ADSCs do not exploit their regenerative and immunomodulatory function only when isolated and subsequently injected but also when transplanted together with other components of the fat tissue. This happens in the setting of lipofilling, nano- or micro-fat grafting and SVF  transplantation . These pADSC-based therapies have already been proven to be effective in the setting of chronic vulvar trophism alterations associated with physiological and pathological conditions and the available literature suggests that ADSCs hold promise for treating vulvar dystrophies, primarily due to ADSCs’ angiogenic and trophic properties . A prospBoero and collaborators published a prospective study on 36 patients with LS who were offered fat grafting . All of p < 0.05) [Retrospective evaluation of 39 patients affected by vulvar LS treated with autologous fat grafting enriched with adipose-derived stromal vascular fraction (SVF) indicated that 94.87% of patients experienced a significant decrease in their global scores at both six and 24 months after treatment ( < 0.05) . A modifWhile the preliminary findings regarding ADSC therapy for lichen sclerosus are promising, it is essential to acknowledge that the research is still in its early stages. The existing studies are relatively small in scale and often lack long-term follow-up data. Therefore, although ADSC therapy holds potential as a treatment option, further investigation through well-designed clinical trials is necessary to establish its efficacy, safety, and optimal protocols for addressing the multifaceted challenges posed by lichen sclerosus.The rationale for the combined use of PRP and ADSCs for LS resides in previous reports of a possible synergistic action of these regenerative strategies in other settings  ,61. LipoOne of the largest casuistries of patients affected by genital LS treated with combination of PRP and fat grafting has recently been published by Casabona et al. . The preIn a milestone prospective pilot trial by Gutierrez-Ontalvilla, 20 patients diagnosed with moderate to severe vulvar LS were divided into two groups . The treIn a study published in 2020, the authors compared the efficacy of adipose-tissue derived stromal vascular fraction (AD-SVF) and AD-SVF enriched with PRP, in the setting of genital lichen sclerosus (LS) in 40 symptomatic patients who were unresponsive to medical treatment . PatientFat grafting appears to be a valuable supplementary treatment for selected cases of vulvar LS, especially in patients who do not respond to first-line therapies or have severe anatomical impairments affecting sexual function and quality of life. The effectiveness of lipofilling and other fat grafting techniques at least partially resides in the regenerative potential of ADSCs . PRP theThe effectiveness of PRP and ADSC based therapies in the management of genital lichen sclerosus is a topic of growing interest within the field of dermatology and regenerative medicine . CurrentDespite the promising results, the present paper intrinsically brings to our attention some limitations of the ongoing research in the setting of regenerative strategies for LS. The high heterogeneity of the published casuistries, the lack of common endpoints, and shared protocols among the available studies make it difficult to draw consistent conclusions, which gives reason to the present review for being narrative end not enabling further metanalysis. Moreover, most of the available literature on this topic is composed of short reports and research letters which do not contain a detailed description of the methodology used, making it impossible to provide complete and comparable data in terms of outcome and FUP among published casuistries. The available studies are relatively small in scale, and the duration of follow-up is often limited. The duration of the follow-up, for example, available in just over half of cases, ranged from 1 up to 24 months. Therefore, while the initial results are promising, more extensive and well-designed clinical trials are necessary to establish the long-term efficacy and safety of PRP therapy in the management of lichen sclerosus. Study endpoints also bring a significant bias in the interpretation of published results, as only few studies use validated scales to assess clinical efficacy; among these, further analysis is limited by the presence of high variability in chosen parameters. However, CSS, DLQI, and FSFI should be considered currently for wider use in clinical research see Potential limitations of the use of ADSCs and PRP reside in the real-life feasibility of such treatments in a broader clinical setting. Patients considering these therapies should consult with qualified dermatologists or healthcare providers who can provide guidance based on the most current scientific evidence and clinical experience. Additionally, it is essential to consider individual factors, including the severity of the condition and any underlying health issues, when exploring these innovative treatment options.Despite the promising results achieved in the setting of LS, the use of PRP and ADSCs on a large scale remains far from being close to happen in the clinical daily practice. Shared protocols and official guidelines are urgently needed. Future research with multicenter international randomized controlled trials will likely bring new evidence in order to better define which LS cases should be treated with PRP and/or ADSCs, and the protocols for their administration.


The dental operative microscope has been widely employed in the field of dentistry, particularly in endodontics and operative dentistry, resulting in significant advancements in the effectiveness of root canal therapy, endodontic surgery, and dental restoration. However, the improper use of this microscope continues to be common in clinical settings, primarily due to operators’ insufficient understanding and proficiency in both the features and established operating procedures of this equipment. In October 2019, Professor Jingping Liang, Vice Chairman of the Society of Cariology and Endodontology, Chinese Stomatological Association, organized a consensus meeting with Chinese experts in endodontics and operative dentistry. The objective of this meeting was to establish a standard operation procedure for the dental operative microscope. Subsequently, a consensus was reached and officially issued. Over the span of about four years, the content of this consensus has been further developed and improved through practical experience. The human eye possesses a versatile optical mechanism capable of accommodating various visual requirements. By means of contracting or relaxing the ciliary muscles, the convexity of the lens is altered, enabling the formation of clear images of objects situated at different distances on the retina. As objects decrease in size and increase in distance from the eye, the angle at which they are projected onto the retina diminishes. Consequently, finer details can solely be discerned when objects are in closer proximity to the eye, resulting in a larger angle of projection onto the retina. One effective approach involves positioning the visual object in close proximity to the eye, accompanied by the contraction of the ciliary muscles to enhance the convexity of the lens, thereby facilitating the perception of intricate details. Consequently, dentists frequently find themselves bending over the patient’s oral cavity to address the minuscule teeth, as the human eye possesses restricted adaptability and experiences a decline in its capacity to accommodate close-range objects with advancing age. Nonetheless, the utilization of the Dental Operative Microscope (DOM) presents a viable solution for dentists to surmount this constraint. Firstly, the utilization of the DOM enhances the discernment of intricate structures, thereby facilitating improved discrimination. Secondly, the DOM affords the opportunity for ocular relaxation and mitigates the occurrence of ciliary muscle fatigue, necessitating minimal adaptation. Thirdly, the DOM promotes spinal relaxation for dentists, enabling a more ergonomic and comfortable seated posture.2 Over the course of four decades, DOM has gained widespread utilization within the field of dentistry. While endodontics remains the primary discipline employing DOM, other specialties such as periodontics, implantology, and prosthodontics are swiftly incorporating microscopic magnification techniques.8 The American Association of Endodontists (AAE) played an early and influential role in promoting microscopy training for endodontic residents. Their efforts resulted in the successful inclusion of a microscope proficiency standard within the educational requirements for postgraduate endodontic programs by the Commission on Dental Accreditation (CODA) in 1998.9 In 2016, the Society of Cariology and Endodontology, Chinese Stomatological Association established and released guidelines for the utilization of microscopes in endodontics, which have significantly influenced the standardized implementation of DOM in endodontic treatment within China.10 Nonetheless, the absence of comprehensive instructions and application specifications has resulted in frequent misunderstandings and improper utilization of DOM among dental practitioners, thereby diminishing its potential value in clinical practice. In October 2019, an expert seminar was organized by Professor Jingping Liang, Vice Chairman of the Society of Cariology and Endodontology, Chinese Stomatological Association, with the aim of refining and standardizing the application of DOM in the diagnosis and treatment of endodontics and operative dentistry. Subsequently, a set of consensus statements were reached and published.11 Over the course of about four years, through practical experience, the content of the consensus has been enhanced and can now be summarized as follows.The year 1981 marked the introduction of the first commercially available DOM known as “Dentiscope”.16DOMs offer enhanced visualization capabilities, presenting amplified, brightened, and more distinct images that enable a higher level of detail for improved observation. Consequently, this facilitates refined dental procedures, minimizing potential harm to the tooth structure during preparation and treatment. However, the successful execution of precise operations with DOMs relies on the aid and backing of diverse purpose-built instruments, ensuring accurate diagnosis and treatment. It is worth mentioning that the instruments utilized for treatment under a microscope exhibit a progressive enhancement in their design, a heightened specialization in their functions, and a diversification in their types. Certain devices have incorporated a matte or black surface treatment to minimize light reflection, thereby enhancing the safety and comfort of the practitioner during treatment. Furthermore, the utilization of conventional instrumentation is also necessary to support microscopic treatment, with the specific devices required varying depending on the nature of the treatment being performed.Rubber dam isolation system, front-surface dental mirror, endodontic explorer DG-16, micro-opener, nickel-titanium rotary instruments, ultrasonic units and tips , warm gutta-percha vertical condensation system, etc.Examination/inspection instruments , incision and elevation instruments , tissue retraction instruments, osteotomy instruments , curettage instruments , ultrasonic units and tips for root-end preparation, micro irrigator/drier , microplugger and burnisher instruments, micro suturing instruments , etc.Rubber dam isolation system, minimally invasive burs and instruments, instruments dedicated to composite resin placement, condensation, adaptation, and contouring, instruments for finishing and polishing of composite resin restorations, etc.18Endodontics, as well as operative dentistry, are the main disciplines in which DOMs are used in dentistry. The application of DOM in endodontics and operative dentistry mainly focuses on diagnosis and treatment.DOM mainly plays a supporting role in diagnosis, including the auxiliary diagnosis of caries, such as the early diagnosis of superficial caries, the conformation of marginal secondary caries, the detection of approximal caries, and the determination of pulp exposure in deep caries; the auxiliary diagnosis of non-carious diseases, such as the identification of cracked teeth, the exploration and confirmation of root fracture in apical surgery, etc.Root canal treatment: (1) access preparation ; (2) identification of the inner anatomical structure of the pulp chamber; (3) location of sclerosed canals; (4) identification and assessment of variant root canals; (5) observation during root canal irrigation; (6) assurance of optimal obturation; (7) cleaning the residual sealer in the pulp chamber after root canal obturation; (8) the delivery and placement of bioceramic materials in apical barrier technique, etc.Non-surgical endodontic re-treatment: (1) access preparation ; (2) location of missed canals; (3) removal of existing root filling materials; (4) removal of separated instruments; (5) observation during and after root canal re-preparation; (6) assurance of optimal re-obturation, etc.Endodontic microsurgery: (1) management of soft and hard tissues in apical surgery: incision, flap elevation, osteotomy, periapical curettage, root-end resection, root-end preparation, root-end filling, flap reposition, suturing, etc.; (2) evaluation and repair of perforations, etc.Dental restoration: (1) minimally invasive caries removal and cavity preparation; (2) accurate replacement of the existing restorations; (3) restoration with composite resin ; (4) tooth preparation for indirect restorations such as inlays, onlays, full crown restorations, etc.DOM has a broader range of therapeutic application scope in endodontics and operative dentistry, including but not limited to dental restoration and microscopic endodontics such as root canal treatment, non-surgical endodontic re-treatment, and endodontic microsurgery. The recommended use of DOM in treatment mainly includes:24 However, it should be stressed that the role of DOM should not be artificially exaggerated, and its indications should not be expanded indefinitely. It is not always necessary to use DOM for the entire treatment process.DOM can assist in diagnosis and treatment and improve outcomes.Equipped with a digital image, video acquisition system, and wireless transmission system, DOM can photograph and film the treatment process, enabling (1) simultaneous collection and preservation of clinical data; (2) real-time wireless transmission of video and images; (3) on-site or distance education of microscopic operation skills; (4) remote consultation of difficult cases; and (5) convenient communication and exchange between doctors and patients.Basic requirementsIn order to promote the uniform utilization of DOM and fully exploit its benefits, the implementation of four-handed dentistry and rubber dam isolation is recommended.Have an intimate knowledge of the structure and function of DOM.Know the pupil distance of himself and the diopter adjustment well.Be familiar with the correct use of DOM.Master the rubber dam isolation technique.Master four-handed dentistry.Be acquainted with the diagnosis skills and treatment techniques of related diseases.Complete pre-operatively the necessary evaluation of the patient’s whole body, mouth, temporomandibular joint, teeth, etc.Prior to employing DOM, dentists are required to meet certain prerequisites.Sit-in posture conforms to ergonomics.Ensure hand-eye coordination under a microscope.Choose the appropriate magnification.Be acquainted with the use of instruments under DOM.Additionally, while utilizing DOM, dentists are expected to fulfill specific demands.13Furthermore, it is essential for assistants to acquire proficiency in four-handed dentistry within the context of DOM. It is worth noting that precautions must be taken to prevent eye injuries resulting from the excessively bright light emitted by DOM during its use, necessitating the use of goggles by both assistants and patients. Lastly, it is advisable to limit the duration of DOM usage to avoid potential adverse effects.25  that can be tailored to diverse applications and ergonomic demands by selecting appropriate working distances. The utilization of a zoom lens facilitates effortless adjustment of the microscope’s working distance, enabling precise focus attainment through manipulation of the focus adjustment knob rather than physically raising or lowering the microscope. The maintenance of proper posture during DOM employment is intricately linked to the judicious selection of the working distance. In the event that the working distance is insufficient, the practitioner may be compelled to assume an erroneous posture during the utilization of DOM, characterized by an arched back, lowered head, and forward tilting of the upper body. Conversely, if the working distance is excessive, the practitioner may be compelled to assume an erroneous posture, characterized by an elevated head and backward tilting of the upper body. Inadequate working distances have the potential to strain the practitioner’s back and/or neck muscles, resulting in discomfort or even injury following prolonged usage of the microscope.After establishing the fundamental positions of the dentist, patient, and assistant, it becomes imperative to appropriately position the DOM, set the accurate working distance, and perform the initial focusing. The working distance of the DOM denotes the space between the objective lens’s surface and the object within the treatment field, wherein the object is perceived with utmost clarity under the microscope. The working distance is contingent upon the focal length of the objective lens, whereby a longer focal length corresponds to a greater working distance. The fixed-focus objective lens possesses a constant focal length, typically indicated on the lens mount, such as MT = (ft/fo) MeMc, where MT denotes the total magnification of the DOM, ft represents the focal length of the ocular lens, fo represents the focal length of the objective lens, Me represents the magnification of the ocular lens, and Mc represents the magnification factor displayed on the magnification changer. Hence, it is imperative to concurrently measure the focal lengths of both the ocular lens and the objective lens while documenting the magnification in clinical procedures. The calculation formula is solely applicable to DOMs possessing a constant focal length, rendering it unsuitable for DOMs with a variable focal length due to the disparity between the working distance and the focal distance.25The magnification of a DOM is primarily influenced by the magnification of the ocular lens and the objective lens. However, the final magnification is not simply the product of these two lens magnifications. The calculation for determining the overall magnification of the DOM is expressed as 25The magnification of DOM typically ranges from 3 to 30 times, with certain models capable of achieving even higher magnification levels. In general, magnifications ranging from 3 to 8 are classified as low magnification, characterized by high light intensity, enabling a wide field of view and a substantial depth of field. This range is suitable for observing the entire tooth, cavity, and operative area. Magnifications between 9 and 16 fall under the category of medium magnification, offering a moderate visual field range, depth of field, and brightness, making it suitable for most clinical procedures. Magnifications exceeding 16 are considered high magnification, resulting in a narrower field of view and a reduced depth of field. Due to the significantly limited effective aperture of the DOM, there is a substantial reduction in the quantity of incoming light, thereby necessitating high lighting conditions. Consequently, the DOM proves to be well-suited for the observation of intricate structures pertaining to affected teeth, root canals, root surfaces, and apical regions.To accommodate diverse application scenarios and environments, the light source of DOM is furnished with specialized filters, the yellow filter and the green filter. Dentists have the discretion to opt for the use of filters during treatment based on treatment requirements.The yellow filter is primarily employed in the light-curing composite resin restoration process to prevent premature curing of the resin surface due to the intense light emitted by DOM, thereby avoiding any negative impact on the therapeutic outcome during treatment. Differently, the green filter serves the purpose of diminishing the presence of red hues within the entire visual field, thereby alleviating visual fatigue and augmenting the distinction between blood-filled and bloodless tissues. This enhancement, in contrast, facilitates the observation of intricate tissue and organ structures, rendering it particularly suitable for endodontic surgery and other surgical interventions.26 The recommended general steps for using DOM are as follows.Isolate and protect the knobs and handles, as well as any other parts of the DOM that are susceptible to contamination before use.The dentist and assistant assume an adequate seated position.Ensure that the dental chair and patient are positioned correctly.Position DOM properly.Adjust the eyepiece distance according to the dentist’s interpupillary distance.Set the diopter correction according to the dentist’s eye correction value.Fine-adjust the patient’s head position to ensure the operation area is centered in the visual field.Set the appropriate magnification and fine focusing.Adjust the magnification, brightness, and pinhole aperture, and use specific filters during operation for different purposes.The standardized use of DOM should be carried out in accordance with certain operating procedures.It has been more than four decades since the introduction of the DOM, which was initially utilized in endodontics and has since expanded its application to encompass nearly all branches of dentistry. The DOM offers enhanced visualization through magnified images, a brighter field of view, and precise maneuverability. Consequently, it has not only revolutionized the diagnostic and therapeutic approaches employed by dental practitioners but has also transformed patients’ perceptions of dental treatment while simultaneously elevating the standard of clinical diagnosis and treatment. As microscopy and microscope equipment continue to advance, it is imperative for dentists and their assistants who utilize DOM to possess a comprehensive understanding of the microscope’s structure and functionality. Additionally, they should acquire proficiency in operating the microscope and adhere to standardized techniques in order to effectively harness the benefits of DOM and maximize its potential as a formidable clinical tool.


Premature rupture of membranes (PROM), now also referred to as "pre-labour rupture of membranes," is the rupture of gestational membranes after 37 weeks but before the process of labour begins. When membrane rupture occurs before 37 weeks of gestation, it is referred to as preterm PROM (PPROM). Prematurity is held accountable for the majority of newborn morbidity and mortality. PROM causes around one-third of all preterm deliveries and complicates 3% of pregnancies. Significant morbidity and mortality rates have been associated with PROM. Preterm (PROM) pregnancies are more difficult to manage. Pre-labour rupture of membranes is characterised by its short latency, higher intrauterine infection risk, and greater umbilical cord compression probability. Women with preterm PROM are more likely to develop chorioamnionitis and placental abruption. Various diagnostic modalities include sterile speculum examination, the nitrazine test, the ferning test, and the latest advances, which are the Amnisure test and the Actim test. Despite all these tests, there is still a need for newer, non-invasive, rapid, and accurate tests. Admission to a hospital, amniocentesis to rule out infection, and, if necessary, prenatal corticosteroids and broad-spectrum antibiotics are all alternatives for treatment. As a result, the clinician managing a pregnant woman whose pregnancy has been affected by PROM plays a crucial role in the management and must be well aware of probable complications and control measures to reduce risks and increase the likelihood of the required outcome. PROM's proclivity for recurrence in later pregnancies provides a chance for prevention. Furthermore, prenatal and neonatal care developments will continue to enhance the outcomes of women and their children. The purpose of this article is to summarise the concepts related to the evaluation and management of PROM. The inner aspect of the gravid intrauterine cavity is lined by the membranes of the foetus, which are referred to as the placental membranes or the amniochorionic membranes. These foetal tissues separate two compartments, namely the maternal and fetoplacental compartments. Foetal membranes consist of the amnion, the deepest layer of the intraamniotic cavity, and the chorion, which connects to the maternal decidua to form the placental tissue. A collagen-rich extracellular matrix connects the amnion and chorion . TypicalMethodologyWe used PubMed to search Medline and the Cochrane Central Register of Controlled Trials (CENTRAL) databases through the Cochrane Library. The search strategy for PubMed was tailored to individual databases. It was as follows: "premature rupture of membrane" (Title/Abstract) AND "chorioamnionitis" (Title/Abstract) OR "nitrazine test" (Title/Abstract) OR "amnisure test" (Title/Abstract) OR "preterm PROM" (Title/Abstract). Additionally, we looked for other studies by screening the references list for potentially pertinent articles. Studies that were found through these electronic searches, as well as relevant sources included in their bibliographies, were examined. Original studies in English that assessed the risk factors, diagnosis, and management were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) research approach is displayed in Figure Risk factorsAssessment of risk factors remains the mainstay in the evaluation of pre-labour rupture of membranes. The best way to avoid PROM problems is to predict and eliminate the risk factors that cause them. The risk factors for PROM include preterm birth in a previous pregnancy, addiction such as cigarette smoking, polyhydramnios, urinary and sexually transmitted infections, chronic steroid use, twin pregnancy, last PROM, antepartum vaginal bleeding, direct abdominal trauma, collagen vascular disorders like Ehler Danlos and systemic lupus erythematosus (SLE), low basal metabolic rate (BMI), anaemia, and low socioeconomic status . SpecifiEvaluationThe first step in patient evaluation is confirmation of the diagnosis. History taking and physical examination form the mainstay of diagnosis. A pregnant woman presenting with a history of sudden gush of fluid from the vagina leading to soaking of her clothes must warrant suspicion of PROM or PPROM. The fluid is described as either clear or pale yellow by the patient. The first step in the examination is sterile per speculum examination. The diagnosis is usually confirmed on a sterile speculum examination in a patient complaining of "watery vaginal discharge". It depends on the obstetrician's skills to identify the three clinical signs. These are 1) the pooling of fluid in the vaginal vault or fluid leaking from the cervical os; 2) the nitrazine paper test: if it turns blue, it is suggestive of alkaline fluid (amniotic fluid); 3) the fern test: a sample of amniotic fluid is fixed on the slide and observed under the microscope. Amniotic fluid appears as a fern-like pattern.Considering diagnostic validity, cost, and technical simplicity, all of these clinical indicators have certain limitations . On a daSome nonspecific marker tests that are used less commonly for diagnosing membrane rupture are fetal fibronectin, β-human chorionic gonadotropin (β-hcg) -11, alphManagementExpectant ManagementAccording to recent guidelines, expectant management is done in cases of preterm <34 weeks) and late preterm (34-36 weeks + six days) PROM if no contraindications exist. It consists of admitting the patient, administering a course of corticosteroids, short-term tocolysis, rectovaginal swabs for group-B streptococci screening, and starting the group-B streptococci prophylaxis. Antibiotics are stopped if the screening is negative. Magnesium sulphate is administered for neuroprotection if the gestational age is less than 32 weeks. Management of PPROM between 34-37 weeks + six days is the same as that of <34 weeks, except that tocolytics are not administered, and induction of labour is performed if there are indications for the same . Monitor weeks anAntibiotic Regime in the Case of PROMAntibiotics have become the mainstay of therapy for patients with pre-labour membrane rupture. However, little is known about the natural course of intrauterine infection during antibiotic therapy . StudiesImportance of Corticosteroids in the Management of PROMCorticosteroids decrease the occurrence of respiratory distress syndrome, intraventricular haemorrhage, and necrotizing enterocolitis if given to a woman with intact membranes in the case of preterm labour . A similInduction of LabourEarly induction of labour is suggested in term PROM cases to prevent the risks of mortality and morbidity. For this purpose, the most commonly used intravenous agent is oxytocin. Another substitute for oxytocin is misoprostol, which is easier to use and can be administered by various routes rather than IV . If ruptTocolyticsThere is no evidence that giving tocolysis is beneficial to a newborn . ProphylPrediction and preventionPreterm labour and rupture of the membranes continue to be major contributors to preterm birth. In order to have the best newborn outcomes, the time between the rupture of the membranes and delivery is crucial. Predicting the latency period is still a challenge in obstetric practise. Certain studies have established that women with cervical lengths less than/equal to 2.5 cm have a decreased latency period in comparison to females with cervical lengths more than 2.5cm . Hence, Pre-labour rupture of membranes is one of the major contributors to perinatal mortality and morbidity in pregnant women. Out of all the preterm births, almost 40-50% are linked to PROM, in which the prognosis depends upon gestational age and mode of delivery. A timely and precise diagnosis of PROM is essential for a successful pregnancy. The traditional and old clinical tests, such as nitrazine paper tests, pooling, ferning, and amnio dye tests, are eventually being replaced by the comparatively newer and more reliable AmniSure and Actim tests. Admission to the hospital, amniotic fluid sampling to rule out the presence of infection, expectant management, antenatal corticosteroids along with broad-spectrum antibiotic therapy only if indicated, and delivery once a desirable age of gestation is reached are all options once the diagnosis is confirmed. The primary motive is to ameliorate the perinatal outcome and decrease newborn morbidity and mortality. This can only be achieved if clinicians develop a clear understanding of the evaluation and management of PROM.