To investigate the impact of adenotonsillectomy (ADT) and adenoidectomy (AD) on child health and evaluated their post‐operative complications.We included all children aged <16 years undergoing ADT (tonsillectomy ± adenoidectomy) or AD in New South Wales, Australia, 2008–2017. Health information was obtained from administrative hospitalisation data. Rates of post‐operative complications and reoperation were evaluated using generalised estimating equations and Kaplan–Meier methods, respectively.Out of 156 500 included children, 112 361 had ADT and 44 139 had AD. Population rates increased during 2008–2017 , and children were increasingly operated on at a younger age. Overall, 7262 (6.5%) and 1276 (2.9%) children had post‐operative complications (mostly haemorrhage), and 4320 (3.8%) and 5394 (12.2%) required reoperation, following ADT and AD, respectively. Complication rates were highest among children aged 0–1 years, lowest for those 2–5 years and increased with age thereafter. Three‐year reoperation rates for children aged 0–1 years were 9.0% and 25.9% following ADT and AD, respectively, decreasing thereafter to 0.5% and 2.1% in children aged 12–13 years.ADT and AD in Australian children have both increased in frequency and are being done at a younger age. Post‐operative complications and reoperation rates highlight surgery is not without risk, especially for children under 2 years old. These findings support a more conservative approach to management of upper respiratory symptoms, with surgery reserved for cases where potential benefits are most likely to outweigh harms. Adenotonsillectomy (ADT) and adenoidectomy (AD) are one of the most common operations performed in children.ADT and AD are recommended for recurrent tonsillitis, sleep‐disordered breathing and otitis media, and are not exempt of complications and the need for reoperation.Population rates of adenotonsillectomy (ADT) and adenoidectomy (AD) in children are rising with children operated increasingly at a younger age.Post‐operative complications were proportionally low but increased with age.One in five children having AD under 5 years required reoperation.Findings highlight that ADT and AD are not without risk, especially for children under 2 years and support a more conservative management approach.Surgical removal of tonsils (tonsillectomy), adenoids (adenoidectomy (AD)) or both (adenotonsillectomy (ADT)) are the most common operations performed in children, representing a major impact on child health, families and paediatric health care.Clinical guidelines recommend that tonsillectomy and/or ADT be considered for children presenting with obstructive sleep‐disordered breathing affecting growth, school performance or behaviour, or recurrent throat infections. Obstructive sleep‐disordered breathing is a spectrum of breathing disorders from snoring to the most severe obstructive sleep apnoea (OSA). OSA is characterised by disruption of normal ventilation and sleeping patterns detected with overnight polysomnography.However, results regarding the effectiveness of ADT or AD in improving short‐ and long‐term outcomes are mixed. A review of clinical trials suggests that the reduction in throat infections after ADT in the first post‐operative year is moderate, and the benefits do not appear to persist over time.Potential benefits of removing tonsils and/or adenoids have to be balanced against the risk of post‐operative complications, reoperation, potential long‐term adverse effects,We included all children aged younger than 16 years admitted to hospital to undergo ADT or AD in New South Wales (NSW), Australia between January 2008 and December 2017, and followed them up until June 2018. Health information was ascertained via record linkage of the NSW Admitted Patient Data Collection (APDC). The APDC is a statutory collection of all admissions to public and private hospitals comprising patient demographic information and related diagnoses and procedures coded according to the 10th revision of the International Classification of Diseases, Australian Modification (ICD‐10‐AM) and the Australian Classification of Health Interventions (ACHI), respectively.ACHI codes for ADT  and AD (41801‐00) were used to identify the study cohorts. We identified the indication for surgery using the diagnosis fields and categorised them into: (i) chronic diseases of tonsils and adenoids (ICD‐10‐AM: J03 and J35); (ii) sleep‐disordered breathing ; (iii) ear conditions (H61‐H68) other respiratory conditions ; (iv) peritonsillar abscess (J36); and v) other conditions. Study outcomes included post‐operative complications recorded during the initial admission or during readmission within 30 days following discharge from the index surgery and reoperation in any diagnosis field. Post‐operative complications were defined as haemorrhage, respiratory diseases (e.g. pneumonia and bronchitis), infections or related symptoms  and adverse effect of anaesthesia or therapeutic drugs. Post‐operative haemorrhage requiring operative procedure was also differentiated. Reoperations were also defined as a subsequent admission for ADT or AD.Explanatory variables included the calendar year, age, sex, socioeconomic disadvantage, area of residence, hospital type, adjuvant operations and diagnoses of chronic conditions. Socioeconomic disadvantage was determined by recorded postcode of residence using the Socioeconomic Indexes for Areas developed by the Australian Bureau of Statistics (ABS) and classified into quintiles. Adjuvant operations included those involving the nose or sinus (e.g. turbinectomy or septoplasty) and ear operations (e.g. myringotomy). Chronic conditions potentially influencing outcomes were based on diagnoses of neurologic, cardiovascular, respiratory, renal, gastrointestinal, hematologic, metabolic conditions, congenital anomalies and malignancy recorded during the index operation admission or in previous hospital admissions.Ethics approval was obtained from the NSW Population and Health Services Research Ethics Committee (2019/ETH11532).We evaluated the population rates of ADT and AD by year and demographic characteristics using population data reported by the ABS. Health characteristics of children were evaluated using contingency tables. We calculated the crude rates of post‐operative haemorrhage and any complications by the type of operation, age group and whether children had adjuvant operations. Generalised estimating equations with a logit link and exchangeable correlation were used to standardised rates with 95% confidence intervals (CIs) of post‐operative haemorrhage and any post‐operative complications following ADT and AD, while taking into account explanatory variables and clustering of individuals within hospitals. We determined 1‐, 2‐ and 3‐year reoperation rates with 95% CIs using Kaplan–Meier methods and used multivariable Cox regression to calculate standardised reoperation rates. All analyses were conducted using SAS 9.4 .A total of 156 500 children had surgery including 112 361 undergoing ADT and 44 139 AD. Population prevalence of ADT increased from 69 per 10 000 children aged 0–15 years in 2008–2009 to 79 per 10 000 in 2016–2017 and AD increased from 25 to 34 per 10 000 children. There was an overall shift in the age‐specific rates of ADT and AD over time, with children increasingly operated at younger ages in more recent years  included diseases of tonsils and adenoids (68%), followed by sleep‐disordered breathing (22%) and ear conditions (5%). For AD, ear conditions were predominant (44%), followed by diseases of tonsils and adenoids (29%) and other respiratory conditions  of children who had an ADT and 2.9% (n = 1276) having an AD had a post‐operative complication. Haemorrhage was the most common post‐operative complication during the initial admission for ADT and AD, and the most common in 30‐day readmissions following ADT, with respiratory complications the most common in readmissions following AD  children had reoperation following ADT, two‐thirds involving a repeat ADT. Of children having an AD, 12.2% (n = 5394) had a reoperation with half a repeat AD. Overall, 3‐year standardised reoperation rate was 1.9% (95% CI: 1.8%–2.0%) and 10.3% (95% CI: 10.0%–10.7%) following ADT and AD, respectively, and the rate of reoperation was highest among those operated at younger ages. Three‐year reoperation rate was the highest for children aged 0–1 years with 9.0% (95% CI: 7.6%–10.3%) following ADT and 25.9% (95% CI: 24.3%–27.4%) following AD, decreasing thereafter to 0.5% (95% CI: 0.3%–0.7%) and 2.1% (95% CI: 1.4%–2.9%) in children aged 12–13 years  criteria.The strengths of this study include the use of administrative population‐based linked data, ensuring complete ascertainment and follow‐up of children, and the generalizability of findings. Limitations of the study include the lack of information on primary care presentations which also allows the identification of post‐operative complications not involving hospital care. Therefore, our results most likely underestimate the total rates of post‐operative complications. There may have been some misclassification in the indications for surgery recorded in the hospital admissions data. For some children, some indications may have been incomplete, missing or may not fully represent the underlying diagnosis for surgery. These inconsistencies may be partially due to a lack of corresponding codes in the ICD‐10‐AM for indications of sleep‐disordered breathing or snoring. We were also unable to assess the appropriateness of recorded primary indications and we did not have information on the surgical technique used or the surgeons' experience to assess their impact on outcomes.Population rates of tonsil and adenoid removal have increased in the last decade, highest in children aged 3–4 years. Rates of ADT were also higher among children from least disadvantaged areas, residing in metropolitan areas and undergoing operations in private hospitals. Post‐operative complications and reoperation were highest in children younger than 2 years. These findings highlight that ADT and AD are not without risk especially for children at young ages. Measures to prevent unnecessary surgery are needed, including improvements in identifying children who are most likely to benefit from surgery, and prioritising non‐operative approaches and alternatives as the first line of management to ensure informed decision‐making for surgery and optimal health outcomes for children.Figure S1 Post‐operative complications by presence of adjuvant procedures in children undergoing adenoid and tonsil removal in NSW, 2008–2017Click here for additional data file.Figure S2 Trend in rates of post‐operative complications in children undergoing adenoid and tonsil removal in NSW, 2008–2017Click here for additional data file.Table S1 Indications for surgery in children undergoing tonsil and adenoid removal in NSW, 2008–2017Click here for additional data file.


Drugs constitute one of the leading causes of acute kidney injuries (AKIs) and can appear in community (CA‐AKI) or hospital (HA‐AKI) population. The objectives of the present study of a cohort of hospitalized patients with AKI were to describe the characteristics of drug‐induced AKIs and the patients' short‐term outcomes and assess risk factors for drug‐induced AKIs overall, CA‐AKIs, and HA‐AKIs. Based on a cohort of 1557 hospitalized patients suffering from AKIs based on PMSI extraction and chart review (IRA‐PMSI), drug‐induced AKIs were identified by applying the Naranjo adverse drug reaction (ADR) probability scale. Multivariate logistic regression was used to identify factors associated with CA‐AKIs and/or HA‐AKIs. When considering the 1557 patients who experienced an AKI, 445 (28.6%) of the injuries were drug‐induced (180 CA‐AKIs (40.4%) and 265 HA‐AKIs (59.6%)). Antibiotics, diuretics, and contrast agents were significantly more likely to be involved in HA‐AKIs, whereas antineoplastic, lipid‐lowering drugs, antidiabetics, and immunosuppressive were significantly more likely to be involved in CA‐AKIs. Female sex (odds ratio [OR] [95%CI] = 1.3 [1.04–1.67]), chronic kidney disease (CKD) (OR = 1.8 [1.40–2.67]), and a history of ADRs of any type (OR = 1.3 [1.05–1.73]) were significant risk factors for drug‐induced AKIs. CKD was a risk factor for both CA‐AKI and HA‐AKI. In view of the long‐term impact of AKI on the kidneys and the differences between our CA‐AKI and HA‐AKI subgroups, our present results are interesting for optimizing treatments, limiting the occurrence of CA‐ and HA‐AKIs and (ultimately) reducing healthcare costs. ADRadverse drug reactionAKIacute kidney injuryATCanatomical therapeutic chemicalBMIbody mass index a history of hypertensionCAcommunity‐acquiredCIconfidence intervalCKDchronic kidney diseaseCVDcardiovascular diseaseeGFRestimated glomerular filtration rateEMRselectronic medical recordsESRDend‐stage renal diseaseHAhospital‐acquiredICUsintensive care unitsKDIGOKidney Disease: Improving Global OutcomesNSAIDsnon‐steroidal anti‐inflammatory drugsORodds ratioPMSIProgramme de médicalisation des systèmes d'information SDstandard deviation1Acute kidney injury (AKI) is a common, treatable, reversible syndrome that can be immediately life‐threatening and can have serious long‐term consequences . The maiMedications constitute one of the leading causes of AKI  and the Drug‐induced HA‐AKI is a common problem; in a cross‐sectional survey conducted in mainland China, it accounted for 37.5% of all hospital‐acquired AKIs . Robert The objectives of the present study of a cohort of hospitalized patients with AKI were to describe the characteristics of drug‐induced AKIs and the patients' short‐term outcomes and assess risk factors for drug‐induced AKIs overall, CA‐AKIs, and HA‐AKIs.2This study was conducted in a university hospital . In 2019, this hospital had 1664 beds and places, including 1238 in medicine, surgery, and obstetrics wards. A total of 60 134 patients were admitted during this year, including 289 to the transplantation unit (82 for kidney transplantation), 2566 to the cardiothoracic surgery unit, 787 to the ICUs, and 1285 to the nephrology department.2.1ClinicalTrials.gov (NCT04923750). The primary objective of the IRA‐PMSI study was to assess the ability of several ICD‐10 codes to identify AKIs. Results have already been published, such as description of the patient's selection which we described in the A single‐center retrospective study (“IRA‐PMSI”) from January 1, 2019, to June 30, 2019, was performed to build a cohort of hospitalized patients suffering from AKIs based on PMSI extraction and chart review. The IRA‐PMSI study's objectives and procedures were approved by an independent ethics committee , and the study was registered at  NCT0492350. The p2.2In order to determine whether a given AKI identified with our algorithm Figure  was drug2.32], 3B [eGFR between 30 and 44 mL/min/1.73 m2], 4 [eGFR between 15 and 29 mL/min/1.73 m2], or 5 and not on dialysis [eGFR <15 mL/min/1.73 m2]), nephrectomy, kidney transplant, previous AKI, and a history of ADRs. Lastly, clinical data related to the episode of AKI were gathered: the medical unit, KDIGO grade, length of hospital stay, use of dialysis or not, and outcome.For each identified AKI, we collected several clinical and demographic information from the patients' EMRs. The demographic variables included age, sex, and BMI. The comorbidities considered as risk factors for AKI were hypertension, diabetes, dyslipidaemia, heart disease, cancer, gout, CKD  ≥ 45 mL/min/1.73 m2.4Descriptive statistics were used to characterize the study population. Patients were divided according to whether the AKI was drug‐induced or not and then whether the injury was acquired in the community or in hospital. Groups were compared using a chi‐squared test or Fisher's test, depending on the data distribution.The prescription drugs administered to patients with CA‐AKI versus HA‐AKI were assessed using a chi‐squared test or Fisher's test.P value. Next, we used multivariate logistic regression to model the relationship between risk factors and drug‐induced AKI, by taking the non‐drug‐induced AKI group as a reference. The potential adjustment variables were age, sex, obesity (defined as a BMI ≥ 30 kg/m2), and risk factors for AKI . To optimize the model's fit, we used a parsimonious model that included all variables with P < 0.2 in a univariate analysis or contextual interest.To compare drug‐induced AKIs with non‐drug‐induced AKIs, we calculated the crude odds ratio (OR) [95% confidence interval (CI)] and the P < 0.2 in a univariate analysis or contextual interest.In a secondary analysis, the above‐mentioned values were calculated for the CA‐AKI and HA‐AKI subgroups (relative to the non‐drug‐induced AKI group). Likewise, same variables were used to determine the crude OR [95%CI] . Lastly, the multivariate logistic regression model included all the variables with P < 0.05. All analyses were performed using R software   = 1.3 1.04–1.67]), CKD (1.8 [1.40–2.67]), and a previous ADR (1.3 [1.05–1.73]) (Table –1.67), C3.3Of the 445 drug‐induced AKIs, 180 (40.4%) were classified as CA‐AKIs, and 265 (59.6%) were classified as HA‐AKIs Table . In bothAntibiotic, diuretics, and contrast agents were significantly more likely to be involved in HA‐AKI, whereas antineoplastic, lipid‐lowering drugs, antidiabetics, and immunosuppressive agents were significantly more likely to be involved in CA‐AKI Table .CKD was a significant risk factor in both subgroups (OR 95% CI] = 1.9 [1.22–2.82]) for CA‐AKI and 1.8 [1.29–2.58] for HA‐AKI). Female sex was a risk factor for CA‐AKI only  of patients with drug‐induced AKI. Our comprehensive analysis of determinants of drug‐induced AKI enabled us to identify female sex, CKD, and a history of ADRs as risk factors in this population. The comparison between CA‐AKI and HA‐AKI drug‐induced highlights that patient characteristics, drugs, and the issues are not the same and that the key messages are different. Indeed, general practitioners and clinicians should be more cautious when prescribing these drugs—especially in at‐risk patients such as those with CKD.The proportion of drug‐induced AKIs in our cohort 28.6%) was slightly higher than in the epidemiological literature .6% was sThe main drugs involved in AKIs in our study were similar to those mentioned in the literature. It is well known that diuretics and angiotensin‐converting enzyme inhibitors are frequently involved in AKI . By decrUsing the Naranjo scale for ADRs, we found that CA‐AKIs and HA‐AKIs involved different ATC classes. Antibiotic, diuretics, and contrast agents were significantly more likely to be involved in HA‐AKI, which is in line with the literature data . This miContrast agents have a direct nephrotoxic effect on tubular epithelial cells, with the release of vasoactive molecules, an increase in oxidative stress, and subsequent ischaemic renal cell injury .Antineoplastic, antidiabetic, and immunosuppressive agents were significantly more frequently involved in CA‐AKI. This might have been due to the characteristics of the affected population, such as a greater comorbidity burden and more frequent polypharmacy for chronic health conditions. Antineoplastic agents can produce chronic interstitial injury by inducing oxidative stress, apoptosis, necrosis, local and systemic inflammation, the release of inflammatory mediators, and autophagy . ImmunosDrug‐induced AKIs are often avoidable , 35. GivIn the community, optimal hydration should be constantly encouraged and monitored in patients at risk of drug‐induced AKI. This approach encompasses patient education and prescription policies. Combinations of nephrotoxic drugs should be avoided whenever possible and especially in patients with polypharmacy . The useOur multivariate analysis identified several significant risk factors for drug‐induced AKI: female sex, CKD, and previous ADR. These findings were consistent with the literature data . A sex dSeveral studies have found that a history of ADRs is a risk factor for further ADRs , 43. ThiA history of CKD was a consistent risk factor for drug‐induced AKI overall and for the CA‐AKI and HA‐AKI subgroups. The relationship between CKD and AKI has already been highlighted by several studies , 3. FirsIn the literature, drug‐induced AKIs are often compared with non‐drug‐induced AKIs. Few studies have described the influence of drugs on AKI outcomes. Alkhunaizi et al. showed that patients with drug‐induced AKI were younger, more likely to be female and more likely to have CKD than those with non‐drug‐induced AKI but did not report on the outcomes . Here, wThe length of stay was shorter for drug‐induced AKIs than for non‐drug‐induced AKIs. A deeper understanding of these data might help to improve the management of drug‐induced AKI and to preserve kidney function.Our study had a number of strengths. Firstly, the AKI cases were selected rigorously by applying the KDIGO guidelines  and by screening the EMRs. Secondly, all ADRs were fully reviewed by a pharmacovigilance specialist. Thirdly, the consecutive patient recruitment and the large numbers of included AKIs enabled us to describe drug‐induced events and evaluate them according to where they occurred . To the best of our knowledge, the present study is the first to have determined the proportions of HA‐AKI and CA‐AKIs in a cohort of patients with drug‐induced AKIs and to have determined the affected patients' characteristics and outcomes.Our study had some limitations. Firstly, our single‐center study was conducted in a university hospital in northern France, and so our findings might reflect the prescribing habits of our local general practitioners and the hospital's clinicians. However, as shown by the literature data, we expect the clinical characteristics of patients with drug‐induced AKI to be much the same in France as in other countries. Secondly, we focused on a specific cause of AKI, even though the latter it is often multifactorial. Hence, it would be useful to determine whether certain causes are more likely than others to be associated with poorer outcomes. Thirdly, we did not collect information on the use of over‐the‐counter drugs or self‐medication; this might have led us to underestimate exposure to certain drugs such as NSAIDs. Indeed, analgesics like NSAIDs are frequently used for self‐medication, and the continuous use of NSAID  for pain relief over long periods of time is associated with the development of progressive kidney disease or AKI . Informa5Drug‐induced AKIs account for a large (and possible underestimated) proportion of community‐ and hospital‐acquired AKIs. The serious consequences of AKI on kidney and the potential for further ADRs mean that efforts should be made to optimize treatment and understanding all the risk factors in specific populations . Indeed, we found some differences between the CA‐AKI and HA‐AKI subgroups with regard to patient characteristics and outcomes. Since a large proportion of drug‐induced AKIs are avoidable, the close monitoring of female patients with multiple comorbidities (particularly CKD and a history of ADRs) might limit the risk of drug‐induced AKI and thus have a positive impact on healthcare costs and patient care. To study AKI in more depth and improve the quality of the data, future research might usefully include a longer follow‐up period, a larger, multicentre cohort, the use of natural language processing (to avoid time‐consuming reviews), and a pharmacovigilance database.The authors declare that they have no competing interests.CPP Nord Ouest II, Amiens, France; reference: RCB 2020‐A00556‐33).The IRA‐PMSI study's objectives and procedures were approved by an independent ethics committee .The study was registered at AR was a major contributor to the acquisition, analysis, and interpretation of data; drafted the article; and revised it critically for important intellectual content. GC and KM were the major contributors to analysis and interpretation of the data and revised the article critically for important intellectual content. VG and SL were the major contributors to the study conception and design and acquisition, analysis, and interpretation of the data; drafted the article, and revised it critically for important intellectual content. All authors read and approved the final manuscript.Data S1. Supplementary.T1: Distribution of the cohort sourcesSupplementary.T2: Imputed antibacterial classes for drug‐induced AKIsSupplementary.T3: Main imputed drugs for drug‐induced AKIs in the overall study populationClick here for additional data file.


To determine the risk prediction of various degrees of impaired renal function on all‐cause mortality in patients following percutaneous coronary intervention (PCI).Patients with chronic kidney disease (CKD) are at high risk of all‐cause mortality after PCI. However, there are less data of various degrees of impaired renal function to predict those risks.2): I (≥90), II (60−89), III (30−59), IV (15−29), or V (<15) without or with dialysis. Baseline clinical and angiographic characteristics were compared among patients in each stage. One‐year all‐cause mortality was reported with risk prediction based on CKD stages and other risk factors.This was a subgroup analysis of nationwide PCI registry of 22 045 patients. Patients were classified into six CKD stages according to preprocedure estimated glomerular filtration rate (eGFR) (ml/min/1.73 mp < .001 by log‐rank test). After adjusting covariables, the hazard ratios of all‐cause mortality for CKD stages II−V as compared to stage I by multivariate Cox regression analysis were 1.5, 2.6, 5.3, 5.9, and 7.0, respectively, (p < .001).Patients with CKD stage I−V without and with on dialysis were found in 26.9%, 40.8%, 23.2%, 3.9%, 1.5%, and 3.7%, respectively. PCI procedural success and complication rates ranged from 94.0% to 96.2% and 2.8% to 6.1%, respectively. One‐year overall survival among CKD stages I−V was 96.3%, 93.1%, 84.4%, 65.2%, 68.0%, and 69.4%, respectively (Among patients undergoing PCI, lower preprocedure eGFR is associated in a dose‐dependent effect with decreased 1‐year survival. This finding may be useful for risk classification and to guide decision‐making. It is well known that CAD and its severity increase as renal function deteriorates.In the Asian population, limited published data are existing on quantifying risk and assessment of long‐term outcomes after PCI's treatment in impaired renal function patients, especially with ESRD patients on dialysis. Identifying the poor prognostic factors might help reduce morbidity and mortality, especially in the first year of patients undergoing PCI. Furthermore, if the procedural risk associated with each stage of CKD can be predicted, an operator would be able to weigh the risks and benefits properly, as well as informing PCI decision‐making. Therefore, the objective of this study was to distinguish the risk prediction of various degrees of impaired renal function on all‐cause mortality in patients after undergoing PCI.2This study utilized a nationwide prospective multicenter Thai PCI registry, initiated by the Cardiac Intervention Association of Thailand. The registry protocol was published previouslyCreatinine levels determined before the procedure, along with clinical characteristics and angiographic along with procedural data, were retrieved from the main electronic registry databases. Subject data included the history of cardiovascular risk factors , history of underlying diseases , or prior treatment (PCI and CABG), as well as left ventricular ejection fraction (LVEF).Angiographic and procedural data included clinical presentation , number of diseased vessels, PCI status , presence of cardiogenic shock, type of contrast and volume, access site, lesion characteristics , adjunctive devices , stent length, and diameter, lesion severity assessment intravascular ultrasound study (IVUS), optical coherence tomography (OCT), or fractional flow reserve wire (FFR)], and intraaortic balloon pump (IABP). Perioperative medications were also recorded along with unfractionated heparin, low‐molecular weight‐heparin (LMWH), glycoprotein IIb/IIIa inhibitor, and P2Y12 inhibitors.The definition of “angiographic success” was residual stenosis <20% with stent treatment, or <50% with balloon angioplasty alone. Procedural complications were also recorded, including death, MI, stroke, cardiogenic shock, heart failure, a new requirement of dialysis, bleeding required blood transfusion, bleeding within 72 h, endotracheal intubation, cardioversion/defibrillation, and in‐hospital CABG.2.12) without dialysis, and stage V with dialysis. The estimated GFR (ml/min/1.73 m2) was calculated based on the CKD epidemiology collaboration (CKD‐EPI) equations.Impaired renal function was the study factor of interest and was classified into six CKD groups: stage I (GFR ≥ 90), stage II (GFR 60−89), stage III (GFR 30−59), stage IV,2.2The primary clinical outcome was 1‐year all‐causes of death. The secondary clinical outcomes were 1‐year fatal and nonfatal MI, fatal and nonfatal stroke, and unplanned revascularization. Death was substantiated by the death certificate, the National Statistics Office, Ministry of Interior. MI was defined as an increase in cardiac troponin (cTn) plus either: (1) evidence of prolonged ischemia as demonstrated by prolonged chest pain (>20 min); or (2) ischemic ST‐segment changes or new pathological Q waves; or (3) angiographic evidence of coronary occlusion or no‐reflow/slow flow; or (4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. Stroke was defined as a new neurological deficit during the first 24 h following PCI secondary to cerebral ischemia or cerebral hemorrhage detected by computed tomography or magnetic resonance imaging. Unplanned revascularization was defined as unplanned repeated PCI or CABG. MI during the first 48 h following revascularization was defined as an increase in cTn to >5 × 99th percentile of the upper reference limit  or an increase of 20% (in patients with elevated cTn before PCI or CABG). All of those adverse outcomes were adjudicated for accuracy by the study committee.2.3Data were initially collected and recorded in the case record forms. Then, it was computerized by well‐trained research assistants. All electronic databases were stored at the Central Data Management Unit, Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, and Ramathibodi Hospital. Data cleaning and checking were regularly performed after retrieving each survey. In addition, cross‐linked conditions were also developed to ensure the accuracy and consistency of the data.2.4χ2 or Fisher's exact test. All tests of significance were two tailed. Hence, Kaplan–Meier overall survival curves were applied to describe survival probabilities by CKD stages I–V with and without dialysis and compared by log‐rank test. Each of the above variables was examined for its association with mortality using a univariate Cox regression analysis. Associated variables with mortality (p ≤ .1) in the univariate analysis were also included in the multivariate Cox regression model. The proportionality‐of‐hazards assumption was assessed using the Schoenfeld test, and the assumption was met for all variables included. Adjusted hazard ratios (HR) along with 95% confidence interval (CI) were then estimated.Baseline characteristics were described among CKD groups using means ± SD for continuous variables or as percentages for categorical variables. Continuous data were analyzed using analysis of variance or the Kruskal−Wallis test as appropriate and presented as mean values ± SD. Categorical data were analyzed using the p Value of less than .05 was considered as statistical significance.All analyses were performed using STATA 17.0. . 33.1n = 22 045) had a baseline eGFR and were included in the analysis. Two‐thirds of patients were in CKD stages I (26.9%) or II (40.8%), while one‐third were in stages III (23.2%), IV (3.9%), or V . Baseline patient characteristics by CKD stages are described in Table Out of 22 741 patients, 96.9%  followed by stage III, II, and I  . After adjusting for covariables, CKD stages were still a strong predictor of 1‐year all‐cause mortality. The HR of all‐cause mortality for CKD stages II–V compared to stage 1 by multivariate Cox regression analysis were as follows: 1.5, 2.6, 5.3, 5.9, and 7.0, respectively (p < .001). Kaplan−Meier curves were used to describe survival probabilities by CKD groups  were well‐known risk predictors and independently associated with all‐cause mortality. Only dyslipidemia was a risk reduction and probably caused by the statin treatment effect.Based on our contemporary PCI experience, the consecutively registered patients with a variety of clinical presentations from stable CAD to MI were stratified by baseline eGFR into six groups. There was a high prevalence of patients with mildly impaired (eGFR 60−90) or overtly impaired (eGFR < 60) renal function; only one‐quarter of patients had normal renal function (eGFR > 90). Subjects with CKD stage II–V without dialysis were found to be at strong risk for in‐hospital and 1‐year mortality after successful PCI. This dose‐dependent lower GFR associated with decreased long‐term survival is similar to the previous study by Patel et. al.As known, patients with CKD stage V with regular dialysis are at high risk for CV mortality and morbidity.2 is a strong predictor of 5‐year MACEs  and suggested that PCI is more suitable and safer in patients with eGFRs > 30 ml/min/1.73 m2. However, there is also evidence that even mild renal impairment (eGFR 60−90) is associated with an increase in the incidence of in‐hospital MACEs after PCI.Antecedently, there was no single eGFR cutoff value that was a strong predictor of in‐hospital and long‐term mortality after PCI. Recently, Nozari, et al.2) with stable CAD, PCI did not reduce the risk of death or MI when added to optimal medical treatment.2) with stable CAD and moderate to severe ischemia on noninvasive stress testing, initial invasive strategy with PCI, as compared with an initial conservative strategy, failed to reduce the risk of death or nonfatal MI.In general, the decision of whether a patient should be treated with medical treatment or undergo revascularization (either PCI or CABG) depended on the patient's condition and the operator's judgment. In CKD patients (eGFR < 60 ml/min/1.73 mA majority of the study patients with advanced CKD presented with NSTEMI/UA or STEMI, and required that PCI be done on an urgent or emergency basis. These patients usually present with more comorbidities, more complex lesions, and hemodynamic instability when compared with the normal or mild impaired renal function population. As noted, CKD patients with STEMI receive significantly less PCI compared with patients without CKD. A previous study has shown that CKD was associated with adverse outcomes in patients presenting with STEMI and reduced the likelihood of successful fibrinolysis and increased the risk of short‐term MACEs.Unlike STEMI, the role of PCI compared with medical treatment in patients with NSTEMI and advanced CKD is still uncertain, given the increased risk of procedural complications. Recently, using the largest, in‐hospital database in the United States, Bhatia, et al.2 would be a suitable cutoff for using to consider early invasive management. Importantly, only culprit‐PCI may be a better reperfusion option for CKD patients with STEMI or NSTEMI with the multivessel disease rather than multivessel‐PCI, concerning the procedure time and the risk of contrast‐induced nephropathy. To answer these uncertainties, further well‐designed, large‐scale prospective studies, and randomized controlled trials are warranted to substantiate these findings and to assess the best revascularization strategies in each sub‐group of this high‐risk population.In summary, the severity of renal function impairment, comorbid diseases, clinical presentation, and coronary complexity and severity are the major component for making a decision making. From the results of previous studies, it seems that CKD patients should not be deprived of standard treatment but how invasive management ought to be titrated to avoid adverse outcomes is a major issue to consider. Using this study's findings, patients with eGFR >30 ml/min/1.73 m4.1Though this was a well‐designed, and prospective cohort study, some limitations need to be mentioned. First, this was only one eGFR result from before the procedure to use for stratification of patients. The subsequent effect on renal function, whether it deteriorated or improved, was not known. Second, we assessed direct effect of CKD on mortality but CKD might be a surrogate marker for other comorbidities that are also causes of mortality. To prove this, a mediation analysis should be further applied. Third, some data were incomplete and not included for analysis such as a syntax score, bleeding risk, which can be important for decision making. Forth, the efficacy of the treatment in each group could not be evaluated because of the lack of randomization and compliance of treatment. Fifth, the different treatment effect and prognoses of patients in each CKD group were not compared because these were out of scopes of this study and they depended on various uncontrolled factors, including clinical profile and anatomical differences. A randomized controlled trial or a real‐world data with propensity score analysis comparing long‐term survival after different treatment modalities in these CKD stages should be further conducted.5CKD is a common comorbid disease in CAD patients who undergo elective or urgent/emergency PCI. Various stages of CKD are independently associated with 1‐year mortality even after adjustment for other risk factors. Deterioration of renal function, even to a mild degree, was a strong independent risk predictor of in‐hospital MACEs and 1‐year all‐cause mortality in a dose‐dependent effect after successful PCI. Currently, the choice of coronary revascularization in these high‐risk patients is individualized. This finding may be advantageous for risk classification and to guide decision‐making. Whether this risk prediction of the CKD stage can help to reduce the long‐term all‐cause mortality is a question requiring further study.The authors declare no conflict of interest.


Pharmacoproteomic associations were explored in 35 CRC cell lines annotated with drug sensitivity data on > 400 approved and investigational drugs. ECAD, ITGB4, and ZO‐1 were positively associated with survival, while cytokeratins were negatively associated with survival. Only ECAD showed independent prognostic value in multivariable Cox models. Clinical and molecular associations for ECAD were technically validated on a different mfIHC platform, and the prognostic value was validated in another Norwegian series (n = 798). In preclinical models, low and high ECAD expression differentially associated with sensitivity to topoisomerase, aurora, and HSP90 inhibitors, and EGFR inhibitors. E‐cadherin protein expression is a robust prognostic biomarker with potential clinical utility in CRC.Cell–cell and cell–matrix adhesion proteins that have been implicated in colorectal epithelial integrity and epithelial‐to‐mesenchymal transition could be robust prognostic and potential predictive biomarkers for standard and novel therapies. We analyzed  BRAF mutations. In addition, pharmacoproteomic analyses of CRC cell lines demonstrated that ECAD levels modulated the sensitivity to EGFR, topoisomerase, aurora, and HSP90 inhibitors.Cell–cell and cell–matrix adhesion proteins have been implicated in colorectal cancer (CRC) progression. Here, we preformed multiplex immunohistochemistry analyses of E‐cadherin (ECAD), zona occludens‐1 (ZO‐1), integrin‐ß4 (ITGB4), and pan‐cytokeratins (PanCK) in two CRC patient series. We identified ECAD as a robust, independent, prognostic biomarker. Low expression of ECAD was associated with low differentiation grade, microsatellite instability, and  DeregulKRAS/NRAS wild‐type (anti‐EGFR therapy), have BRAF V600E mutation (BRAF inhibitor) [Ten percent of all cancer cases and deaths are due to colorectal cancer (CRC)  and abouhibitor) . HoweverDespite large biomarker discovery efforts over the last four decades, very few biomarkers have been integrated in clinical practice  and onlyn = 1720) and to study their associations with drug response (n > 400 drugs) in 35 CRC cell lines  and the Norwegian series 2 (n = 798) underwent major resection surgery at Oslo University Hospital, in the time periods 1993–2003 and 2003 to 2013, respectively. Clinical data were recorded in a local database and quality control was performed. The Cancer Registry of Norway records data on all patients diagnosed with CRC and was used to cross‐check the data used in this study. The series are representative of the Oslo area and considered of sufficient size to perform relevant subgroup analyses. Information on tumor location, histopathological grade, stage, adjuvant chemotherapy, deaths, and locoregional and/or distant recurrence during 5‐year regular follow‐up was registered prospectively.Two independent single‐hospital patient series of primary CRC were analyzed for epithelial marker expression using multiplex fluorescence‐based immunohistochemistry (mfIHC) Fig. . Patientn = 6/140) or with stage II or III rectal cancers (n = 10/260). Five‐year follow‐up for cancer recurrence and survival was complete for all patients except two (one censored at 4.2 years and one with missing information).Adjuvant chemotherapy was administered according to national guidelines at the given time periods. From 1997 adjuvant chemotherapy became standard treatment for all stage III colon cancer patients in Norway up to 75 years of age expected to tolerate such treatment. Adjuvant chemotherapy was given on a case‐by‐case basis according to risk assessments in stage III colon cancer patients above 75 years of age (BRAF in exon 15 (including codon 600) was performed for a subset of the patients on a 3730 DNA Analyzer  as previously described [BRAF mutational status were obtained from IHC staining using the anti‐BRAF V600E (clone VE1) mouse monoclonal antibody from Ventana  according to the manufacturer’s instructions. For the two series combined, BRAF mutational status was available for 1114 patients and 1236 were scored by IHC . In cases of discrepancy, the results from BRAF mutational analyses were used. The two series were merged for the final ECAD analyses to increase the statistical power of the multivariable models and subgroup analyses.For the Norwegian series 1, DNA was extracted, MSI status was determined, and a tissue microarray (TMA) was constructed from matching formalin‐fixed paraffin‐embedded (FFPE) tumor tissue, as described in , 13. Forescribed . AdditioThis project was approved by the Norwegian Data Protection Authority and the Regional Committee for Medical and Health Research Ethics, South‐Eastern Norway (REK number 1.2005.1629), and written informed consent was obtained from all patients prior to enrollment. The research was carried out according to the Declaration of Helsinki, and the research biobanks were constructed according to national legislation.2.22 and WiDr cells which were kept in EMEM) supplemented with fetal bovine serum (FBS), 2 mm glutamine, 100 units·mL−1 penicillin, and 100 μg·mL−1 streptomycin  and kept at 37 °C and 5% CO2 in a humidified incubator. Culture media was enriched with 10% FBS (20% for CaCo2 cells). The MycoAlert Mycoplasma Detection Assay  was used to regularly test for mycoplasma contamination.Cell lines were obtained from various providers as previously described in , and HT52.3Thirty‐five unique CRC cell lines were cultured and detached by trypsinization at exponential growth phase and fixed using Shandon fixative for 20 min (RT). Cell pellets were washed with Tris‐buffered saline (TBS) and processed to paraffin using Cytoblocks . Punches (1 mm core) with two replicates were taken from donor cell line paraffin blocks to generate the cell line paraffin array blocks.2.4Multiplex IHC protocols were conducted using 4–μm‐thick sections. The analyses did not include cases with poor tumor preservation, loss of tissue, low number of epithelial cells , extensive tissue folding, or necrosis.2.4.1−1), mounted with ProLong Gold (Thermo Fisher Scientific) and whole‐slide imaged (see imaging below).For IHC staining of the Norwegian series 1, we used a protocol described in . The pri2.52.5.1Five‐channel fluorescent images were acquired using Metafer 5 scanning and imaging platform  consisting of AxioImager.Z2  microscope equipped with Zeiss Plan‐Apochromat 2× objective (NA 0.8), CoolCube 2m CCD camera (MetaSystems), PhotoFluor LM‐75  metal‐halide light source, and Zeiss EPLAX VP232‐2 power supply. DAPI, FITC, Cy3, Cy5, and Cy7 filters were used with the following exposure times: DAPI = 3.1 ms, FITC (PanCK) = 1.6 ms, Cy3 (ZO‐1) = 2.2 ms, Cy5 (ITGB4) = 50 ms, Cy7 (ECAD) = 400 ms. Nine field of views were acquired per each TMA spot, composed using VSlide (MetaSystems), and the images were exported as one tiled image per spot as Lossless compressed TIFFs (95% resolution) for image analysis.2.62.6.1cellprofiler version 2.2.0) [The image analysis was carried out using a cell image analysis software (n 2.2.0) . Epithel2.6.2For the scoring of cell lines with intensity categories 0–2, we combined digital image analysis and visual scoring. A consensus score was formed between the digital image analysis and visual interpretation of the stains. This is due to the fact that cell paraffin arrays contained technical artifacts of unfocused and folded sample areas.2.72.7.1For technical and clinical validation of the prognostic value of ECAD, we stained the Norwegian series 1 and 2 using mfIHC following the protocol described in . BrieflyOptimal antibody concentrations were determined by evaluating the specificity, intensity, and signal to noise of the individual signals using both chromogenic DAB and fluorescence stains. A dedicated test TMA was used for this purpose, including 42 primary CRC cases and six cases from normal colon mucosa. Recommended signal ranges and balancing of the fluorescence signals were used for all markers. A negative control stain was made by excluding the primary antibody on one slide.2.7.2vectra software version 3, PerkinElmer/Akoya). Multispectral image analysis of multiplex IHC stains was performed using inform Image Analysis Software . For training of the image analysis algorithm, representative images were initially loaded and spectrally unmixed with the spectral libraries made based on the individual fluorophore library stains and the tissue autofluorescence slide. After that, a machine‐learning algorithm was trained by the investigator specifying relevant tissue annotations aided by the signal from the epithelial markers to accurately segment tumor tissue versus stromal tissue and background, as well as individual cells based on the nuclear DAPI signal. Review of all images was performed after batch processing. Protein expression was quantified as the mean signal intensity within the whole epithelial compartment.Standard settings at 20× magnification were used to generate multispectral images using the Vectra 3.0 Automated Quantitative Pathology Imaging System, 200 slides . Efficacy of the individual drugs was estimated as a drug sensitivity score (DSS) according to the model developed by [n = 293).The drug screen was performed as described in . Brieflyloped by . Only dr2.9rstudio version 1.2. 5019 (r version 3.6.2) were used for the statistical analyses. Five‐year relapse‐free (RFS) and 5‐year overall survival (OS) plots were generated by the Kaplan–Meier method. The logrank test was used to compare survival curves, while the Cox proportional hazards model was used to calculate hazard ratios (HR) and confidence intervals (CI) for disease recurrence. RFS was defined as the time from surgery to the first event of either locoregional recurrence or metastasis, or death from any cause. Any second primary cancer or other cancer for the same patient was ignored. The RFS analyses included only patients with complete resection. The patients were censored at loss to follow‐up, defined as the last date for clinical or radiological examination or at five years after surgery.SPSS version 21.0 , STATA version 15.1 , and Z‐scores prior to combined downstream analyses for the two Norwegian series.The functional forms of individual protein expressions were evaluated with the mfp algorithm in Stata, and a log2 transformation was found to be an adequate representation. For ECAD, the raw protein expression was log2‐transformed and normalized as P < 0.05 inclusion and P > 0.1 exclusion). Full multivariable models were chosen as the final models because they are simpler to build and reproduce. The analyses did not include patients with missing data. Formal interaction tests were integrated in the Cox models to assess whether effects were different between subgroups. These interaction tests have low power and must be interpreted carefully. The Schoenfeld test and graphical evaluation of log  versus log (time) plots were used to evaluate the proportional hazards assumptions.Multivariable model‐building was based on the fit of the data, the interpretability of the covariates and their consistency with subject‐matter knowledge, with the aim to facilitate replication by other researchers and transportability to other settings. Clinical relevance determined which parameters to evaluate in multivariable models. Tumor differentiation grade is associated with patient survival Fig.  and was BRAF mutation status, tumor location, and tumor differentiation grade were conducted with the a priori knowledge that these covariates are associated with the protein expression of ECAD, and these analyses were therefore not corrected for multiple testing. The R functions wilcox.test and p.adjust were used to conduct two‐sided Wilcoxon rank‐sum tests with Benjamini–Hochberg false discovery rate (FDR) estimation adjustment [P‐value < 0.05 (two‐tailed) was considered statistically significant.Subgroup analyses for ECAD including tumor stage, MSI status, justment  and with33.1n = 922, 689 evaluable cases, Table The expressions of epithelial cell–cell adhesion and polarity markers were assessed in the Norwegian CRC series 1 , ITGB4 , and ZO‐1  were positively associated with survival, while cytokeratins showed a negative association . These relationships could also be illustrated by Kaplan–Meier analysis of the trichotomized variables  and a separate mfIHC platform, employing different protocols for staining and digital image analysis  Kaplan–Meier models of chemotherapy versus no chemotherapy as a function of ECAD expression divided into three equal groups. The survival differences were similar among the groups and formal interaction tests did not identify any significant differences Fig. . Similar3.5max > 10). The cell lines showed a trimodal distribution of ECAD where six cell lines had a particularly low expression, and these cell lines were compared against the rest in differential sensitivity analyses including all drugs. We found that cell lines with loss of ECAD expression were significantly more sensitive to topoisomerase, aurora, and HSP90 inhibitors , apical tight junctions (ZO‐1), and basolateral hemidesmosomes (ITGB4) are disassembled , 3, 23. In this study, we observed inverse association of ECAD and PanCK expression, and they were also inversely associated with disease progression and patient survival in CRC. The loss or decrease in the expression of epithelial ECAD has been linked with tumor budding and more aggressive disease in CRC , 26, 27.Mechanistically, ECAD association with unfavorable survival in CRC could be linked with the onset of invasion (EMT) and induction of cancer stem cell phenotype (CSCs) at least through Wnt‐beta‐catenin pathway. Deletion of APC or activating mutation of beta‐catenin is an early event in colorectal carcinomas (> 75%), pointing out that these cancers largely depend on Wnt signaling activation . ExperimDespite the high biomarker discovery rate, very few biomarkers are robustly validated and even fewer are implemented in the clinic . We havea priori hypotheses for which patient subgroups the different markers would show particular prognostic effects. Hence, the conducted subgroup analyses were exploratory. However, ECAD showed strongest prognostic effect in stage II  or protein expression, as opposed to mesenchymal or EMT phenotype, is associated with increased sensitivity to EGFR inhibitors [n = 19) to antibody‐based EGFR inhibition therapy (cetuximab) had significantly higher cancer tissue expression of ECAD (IHC scoring) than patients not responding (n = 17) [EGFR‐targeted therapy is commonly used in patients with hibitors , 44, 45.hibitors  and in lhibitors , 48. Fur(n = 17)  to treatThe pharmacoproteomic associations identified warrant further studies to address limitations inherent to our approach. For instance, to what extent does the expression of epithelial markers change under different growth conditions . Relatedly, although colorectal cancer cell lines are representative disease models , 51, theIn the present study, we investigated whether proteins implicated in maintaining epithelial integrity are associated with patient prognosis and cancer cell drug sensitivity in colorectal carcinoma. We used mfIHC to simultaneously detect adherence junction protein ECAD, hemidesmosomal adhesion protein ITGB4, tight junction protein ZO‐1, and intermediate filament proteins, cytokeratins, both in patient samples and in cell lines. We found and validated ECAD as a robust and independent predictor of patient survival, but not as predictor of response to adjuvant chemotherapy in CRC. Our preclinical drug screen results validated the association of ECAD expression and EGFR inhibitor sensitivity. We discovered that low ECAD expression is associated with sensitivity to topoisomerase, aurora, and HSP90 inhibitors in CRC models.5Reproducibility of biomarker results across technical and analytical platforms, and across laboratories shows that fluorescent immunohistochemical analysis of ECAD can be robustly standardized in diagnostic laboratories. ECAD can be a clinically useful biomarker to guide management of patients with CRC.The authors declare no conflict of interest.JB and TP conceived and designed the study. OB, MA, KV, and TP performed the discovery mfIHC experiments on the Norwegian series 1 TMA and the cell line microarrays, and JB and MB performed the technical and clinical validation mfIHC experiments of ECAD on the Norwegian series 1 and 2. JB, PWE, and TP performed and analyzed the pharmacoproteomic experiments. JB, PWE, CHB, OB, AS, MA, KV, MB, MGG, OK, AN, RAL, and TP acquired biological and/or clinical data. JB, PWE, OB, CHB, MG, AN, RAL, and TP analyzed and interpreted the data. JB drafted the manuscript, and all authors were involved in revision of the manuscript and have read and approved the final version. JB, RAL, and TP supervised the study.https://publons.com/publon/10.1002/1878‐0261.13159.The peer review history for this article is available at Fig. S1. Kaplan‐Meier plots illustrating prognostic associations for tumor differentiation grade in Norwegian series 1 and 2 .Fig. S2. Example image of mfIHC staining with a magnification.Fig. S3. Correlation among epithelial integrity markers.Fig. S4. Clinical and molecular associations for epithelial integrity markers.Fig. S5. Prognostic associations for epithelial integrity markers in primary colorectal cancer.Fig. S6. Predictive evaluation of ECAD for association with adjuvant chemotherapy.Table S1. REMARK Checklist.Table S2. Patient characteristics for Norwegian series 1 and 2.Table S3. Multivariable Cox models including the epithelial integrity markers .Table S4. Multivariable Cox model of ECAD in Norwegian series 1 and 2 .Table S5. Top 25 drugs based on differential drug sensitivity analysis between cell lines with loss of ECAD and medium to high expression of ECAD (MSS and MSI cell lines included).Table S6. Top 25 drugs based on differential drug sensitivity analysis between cell lines with loss of ECAD and medium to high expression of ECAD (only MSS cell lines included).Click here for additional data file.


A pregnant woman with severe aplastic anemia was managed using biweekly red blood cell transfusion and oral eltrombopag olamine administration during pregnancy. She was diagnosed with preeclampsia at 35 weeks of gestation. The severity of aplastic anemia is very important for predicting the course of pregnancy. The frequency of preeclampsia in pregnant women with aplastic anemia may be higher than that in general pregnancies. Attention is paid to severe anemia in the early trimesters. Eltrombopag can be used in pregnancy. Thrombocytopenia is also associated with preeclampsia. When women with AA develop preeclampsia during pregnancy, their condition may be serious. However, there are limited data on the rare co‐occurrence of AA and preeclampsia, and the exact relationship between AA and preeclampsia remains unclear.In this case report, we describe a pregnant woman with severe AA who developed preeclampsia.2A 35‐year‐old primiparous woman presented to our hospital at 6 weeks of gestation. At 23 years, she had been diagnosed with acquired AA that was refractory to immunosuppressive therapy, including cyclosporine and corticosteroid therapy. Her disease was without a known cause, not secondary as drug‐induced and radiation. Her bone marrow findings 7 years ago were hypoplastic and no dysplastic cells and cellularity was about 20%. She achieved spontaneous pregnancy, and at the initial visit, her blood pressure was normal and her proportion was normal instead of obesity. However, she was stable even without treatment, with pre‐pregnancy hemoglobin (Hb) levels and platelet count of 9–10 g/dl and 20,000–25,000/ml, respectively. At 8 weeks of gestation, her Hb level, white blood cell count, and platelet count had decreased 6.9 g/dl, 2900/ml, and 15,000/ml, respectively. During her next visit at 9 weeks of gestation, her Hb level and platelet count were 6.6 g/dl and 14,000/ml, respectively.Therefore, after 9 weeks of gestation, she underwent red blood cell transfusion every 1–2 weeks to maintain her Hb level >8.0 g/dl and was started on oral eltrombopag olamine (25 mg once daily) for severe thrombocytopenia. Her Hb level and platelet count were maintained at 8–10 g/dl and 14,000–18,000/ml, respectively, up to 32 weeks of gestation. We could not detect any fetal abnormality on ultrasound screening during the second trimester, except that the umbilical cord was inserted in the fetal membranes. Weekly and fortnightly ultrasonography revealed that the estimated fetal weight was within the normal range for gestational age. There were no abnormal changes in the fetal biophysical profile, amniotic fluid volume, or umbilical artery Doppler velocimetry until 30 weeks of gestation. Her blood pressure was slightly elevated at 130–140 /80–90 mmHg above after 30 weeks of gestation. Fetal growth restriction was observed by ultrasound at 32 weeks of gestation, and the growth was arrested during the next 2 weeks. Her Hb increased to 11 g/dl without red blood cell transfusion, while the platelet counts slightly decreased from 11,000 to 12,000/ml. At 34 weeks and 5 days, fetal weight was estimated to be 1448 g, with a high umbilical artery pulsatility index (>95th percentile). Her blood pressure increased to 150/80 mmHg for the first time; the urine protein/creatine ratio was 1.26 g/g Cr, while the platelet count decreased to 9000/μl. Her liver enzymes were within normal range, and serum creatinine was 0.68 mg/dl. She was admitted for close monitoring. After admission, her blood pressure rose to above 160/100. Transient cardiotocography showed severe variable decelerations, occasionally in the absence of uterine contractions. With these major findings  a diagnosis of preeclampsia was made. Transient cardiotocography showed severe variable decelerations, occasionally in the absence of uterine contractions. With these major findings, a diagnosis of severe preeclampsia was made and decided to terminate the pregnancy.After platelet transfusion, she delivered a 1348 g female baby via cesarean section at 35 weeks and 0 day under general anesthesia. Intraoperative hemorrhage was 670 ml; she had no intraoperative or postpartum complications. Her baby did not develop respiratory distress syndrome and had mild transient tachypnea of newborn. The baby needed only mild respiratory support with a nasal cannula in room air. Neonatal laboratory data did not show pancytopenia. The baby was discharged 1 month after birth, and the follow‐up was normal at 18 months. The mother was treated with nicardipine injection from the preoperative period to the first day postpartum, followed by oral nifedipine administration for about 2 weeks to strictly control the blood pressure. Within 1 month postpartum, her blood pressure normalized without medication, and urine protein became undetectable. Her Hb level and platelet count had returned to the pre‐pregnancy level at 2 weeks postpartum.3In this case, a woman with severe AA developed preeclampsia. Her platelet count was <20,000/ml at the onset of pregnancy and significantly decreased to critical level with the onset of preeclampsia at 34 weeks of gestation.In AA, stem cells in the bone marrow are damaged by various causes, and the bone marrow is either empty or contains few blood cells and cannot produce blood cells. Therefore, in pregnant women with AA, physicians must watch for infection due to fewer white blood cells, severe anemia due to fewer red blood cells, and intra‐postpartum bleeding due to fewer platelets in addition to common pregnancy complications. A previous retrospective study in pregnant women with AA2 demonstrated that 16.7% of pregnancies were uneventful, but 83.3% had complications such as premature labor (33.3%), gestational diabetes (18.3%), preeclampsia (16.7%), acute heart failure (5.0%), pPROM (3.3%), pregnancy and postpartum hemorrhage (5.0%), and postpartum infection (1.7%). Chen et al.When pregnant women with AA develop severe preeclampsia, platelet counts decrease to a potentially critical level. Few studies have demonstrated the relationship between acquired bone marrow failure syndromes, such as AA and myelodysplastic syndrome (MDS), and preeclampsia. Bo et al.Chen et al.Eltrombopag, a thrombopoietin‐receptor agonist (TPO‐Ra), has proven to be effective in managing immune thrombocytopenic purpura in clinical studies, but its safety in pregnancy remains uncertain.4Here, we reported the case of a pregnant woman with severe AA who developed preeclampsia. Fewer reports of complications of both aplastic anemia and preeclampsia, but the frequency of preeclampsia in pregnant women with acquired bone marrow failure reported higher than that in general pregnancies. Severe anemia in early first trimester may potentially related to develop preeclampsia. We recommend that anemia occurring in early trimesters be carefully monitored and managed in pregnant women with AA. In our case, eltrombopag did not have harmful effects for pregnant women, but her baby's birth weight was small for gestational age. It is unclear whether eltrombopag had a causing a reduction in birth weight.IK contributed to the clinical management of the patient, and drafted the manuscript and contributed substantially to its revision. RK, SY, JO, MK, TI, and MY contributed to the clinical management of the patients. YK, HY, and SS were involved supervision and critical revision of this manuscript. All authors contributed to the preparation of this case report and have read and approved the final manuscript.No funding from an external source supported the publication of this case report.The authors declare that they have no conflict of interest regarding the publication of this case report.This study has been approved by the ethics committee of Nippon Medical School Hospital (B‐2021‐465).The patient provided written informed consent for this publication.


Using the Emotional Cascade Model as a theoretical framework, this study tested whether the relationship between perfectionism and non‐suicidal self‐injury (NSSI) operates through rumination and negative affect. Additionally, we tested whether the associations between perfectionism and both rumination and negative affect are moderated by attention control.N = 197) and without (N = 271) a history of NSSI completed measures of perfectionism, rumination, negative affect, attention control, and NSSI.Using a correlational cross‐sectional design, adults aged 18–25 with (Perfectionism was directly associated with increased odds of NSSI, and indirectly associated with odds of NSSI through rumination and negative affect. The relationship between perfectionism and rumination was moderated by attention focusing, such that the relationship was stronger for individuals who were higher in attention focusing.Integrating perfectionism and attention with existing models of NSSI may improve understanding of the factors contributing to NSSI and offers insights into future clinical directions. Given the overlap between these concepts of NSSI and perfectionism, two key ideas warrant exploration. First, the relationship between perfectionism and NSSI may be considered in the context of the Emotional Cascade Model such that perfectionism may act as a catalyst for the emotional cascades that lead to NSSI. We, therefore, propose that elevated perfectionism may be associated with greater rumination and negative affect and in turn, increased risk of NSSI. Second, the relationship between perfectionism and emotional cascades may be stronger for individuals with weaker attention control as they are less able to disengage from the emotional cascade than individuals with stronger attention control.In the current study, we test a model that integrates perfectionism, attention control, and NSSI into the framework of the Emotional Cascade Model ; 110 were male (24.7%) and 336 were female (75.3%). All participants were enrolled at Australian universities, with 354 participants (75.6%) born in Australia, 42 (9.0%) born in South and Southeast Asia, and 19 (4.1%) born in Europe.The study was approved by the Curtin University Human Research Ethics Committee. Data were collected as a part of a broader survey on emotion and cognition. The sample comprised 446 undergraduate university students aged between 18 and 23 years old .The Frost Multidimensional Perfectionism Scale—Brief  and has demonstrated construct validity with measures of negative affect and psychological distress  and negative (α = 0.85) subscales . Additional recruitment was conducted via social media advertisements for Australian undergraduate university students interested in participating in research for entry into a prize pool to win an iPad (N = 135). Participants provided informed consent at the beginning of the online survey and completion took approximately 60 min for all questions. After completing the measures, participants were provided with resources about self‐injury and stress.Participants responded to online advertisements for undergraduate psychology students participating in research for course credit  estimation and a logit link function for the binary outcome (NSSI no/yes). A path model was tested with one predictor (perfectionism), two mediators (rumination and negative affect), two moderators (attention control—focusing and shifting) on the paths between the predictor and mediators, and one binary outcome (NSSI). The analyses were conducted with bootstrapping with 10,000 samples, and indirect effects were assessed using bias‐corrected bootstrapped confidence intervals (CIs). ML was chosen as it is a “full‐information” procedure that uses all available observations to inform the estimation, compared to weighted least squares , which uses pairwise deletion to handle missing values . Gender was subsequently controlled for in the path model.Of the 446 participants, 190 (41.9%) indicated a history of NSSI. Of those with a lifetime history of NSSI, 104 (54.7%) indicated they had self‐injured in the past 12 months. The three most commonly reported methods of NSSI were cutting (76.3%), banging or hitting oneself (55.3%), and pinching (55.3%). Further, 87 (45.8%) indicated that their main form of self‐injury was cutting, followed by 22 (11.6%) who reported banging or hitting self, and 21 (11.1%) engaged in severe scratching. The mean age of onset of NSSI was 13.6 years (SD = 3.14). Descriptive statistics and correlations between variables in the model are presented in Table 3.2p = 0.005  or shifting and NSSI . Overall, the model accounted for approximately 29.6% of the variance in NSSI, 26.0% of the variance in rumination, and 26.8% of the variance in negative affect.Perfectionism had a direct relationship with odds of NSSI, odds ratio [OR] = 1.05, 95% CI = 1.02, 1.09], , 1.09, p3.3p < 0.001. Additionally, there were significant direct effects of both focusing  and shifting  on rumination.There was a significant direct relationship between perfectionism and rumination, and a direct relationship between rumination and NSSI. There was also an indirect relationship between perfectionism and odds of NSSI through rumination, OR = 1.03, 95% CI = , 3.4B = 0.51, 95% CI = , p < 0.001, and a direct relationship between negative affect and NSSI, OR = 1.04, 95% CI = , p = 0.004. There was an indirect relationship between perfectionism and odds of NSSI through negative affect, OR = 1.02, 95% CI = , p < 0.001.There was a direct effect of perfectionism on negative affect, B = −0.45 , p < 0.001) and shifting  on negative affect.There were significant direct effects of both focusing , or shifting .The relationship between perfectionism and negative affect was not moderated by focusing  delivered online, face‐to‐face, individually, and in groups is effective for treating perfectionism . Our findings suggest that perfectionism may be one factor that increases vulnerability to emotional cascades and, in turn, NSSI and therefore provides an additional potential avenue for intervention. Future prospective and experimental research is required to replicate and extend our findings with longitudinal designs and through the use of experimental measures of attention control and flexibility. We hope this study prompts further research into critically evaluating the precursors to emotional cascades that may lead to NSSI.This study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Human Research Ethics Committee of Curtin University (HRE2018‐0536).


Hydrogels loaded with antimicrobial agents have been widely used for treating infected wound defects. However, hydrogels derived from a porcine dermal extracellular matrix (PADM), containing silver nanoparticles (AgNPs), have not yet been studied. Therefore, we investigated the therapeutic effect of an AgNP-impregnated PADM (AgNP–PADM) hydrogel on the treatment of infected wounds.An AgNP–PADM hydrogel was synthesized by embedding AgNPs into a PADM hydrogel. We examined the porosity, moisture retention, degradation, antibacterial properties, cytotoxicity, antioxidant properties, and ability of the PADM and AgNP–PADM hydrogels to treat infected wounds in animals.The PADM and AgNP–PADM hydrogels were pH sensitive, which made them flow dynamically and solidify under acidic and neutral conditions, respectively. The hydrogels also exhibited porous network structures, satisfactory moisture retention, and slow degradation. Additionally, the AgNP–PADM hydrogel showed a slow and sustained release of AgNPs for at least 7 days without the particle size changing. Thus, the AgNPs exhibited adequate antibacterial ability, negligible toxicity, and antioxidant properties in vitro. Moreover, the AgNP–PADM hydrogel promoted angiogenesis and healed infected skin defects in vivo.The AgNP–PADM hydrogel is a promising bioderived antibacterial material for clinical application to infected wound dressings. For the treatment of nonhealing infected skin wounds, localizing an effective bactericidal dose of drugs such as antibiotics is difficult through intravenous administration because the skin barrier and blood vessels are often destroyed in the wound . MoreoveSilver nanoparticles (AgNPs) exhibit a broad spectrum of antibacterial effects because they can accumulate in bacterial intima, increase membrane permeability, and interact with sulfur-containing proteins in the bacterial cell wall to rupture the wall . MoreoveHydrogels are water-insoluble, crosslinked, fibrous network-structured biomaterials exhibiting high-water content, high porosity, and good biocompatibility. Because hydrogels have previously been applied to sustained-drug-release carriers, they can carry and slowly release AgNPs. Moreover, because hydrogels can moisturize wound surfaces, AgNP-containing antibacterial hydrogel dressings have been developed based on wet-wound-healing theory. To ensure effective antibacterial properties, hydrogel dressings can also provide a good wet and closed environment for wounds; thus, the drugs will not adhere to the wound or cause a secondary avulsion injury .Traditional synthetic hydrogel materials include chitosan, alginate, hyaluronic acid, polyethylene glycol, and mercaptosuccinic acid –12. All Staphylococcus aureus, Enterococcus, and Enterobacter. Improving on the PADM hydrogel, the AgNP–PADM hydrogel reduced the inflammatory response of infected wounds and promoted regenerative epithelialization, angiogenesis, and collagen deposition in infected wounds, thereby enhancing wound healability. Therefore, the AgNP–PADM composite hydrogel may be a promising choice for treating infected wounds.In this study, a porcine acellular dermal matrix  hydrogel was used as a carrier to encapsulate physically embedded AgNPs to heal infectious skin wounds Scheme . The AgNAgNPs (⌀5 and 50 nm) were purchased from Xi’an Ruixi Biological Technology Co., Ltd. . Triton™ X100, sodium lauryl sulfate and soy peptone were purchased from Sinopharm Chemical Reagent Co., Ltd. (China). Agar, pepsin, and Masson’s trichrome staining reagent were purchased from Solarbio Science and Technology Co., Ltd. . Tryptone was purchased from OXOID , calcein was purchased from Yeasen Biotech Co., Ltd. , and Cell Counting Kit-8 (CCK8) was obtained from APExBIO Technology, LLC (USA). Trypsin was purchased from Sigma–Aldrich (USA). The 2,2-diphenyl-1-picrylhydrazyl (DPPH) reagent was purchased from GlpBio (USA).− 1 of the powder was digested using pepsin in a dilute hydrochloric acid solution (pH 2–3) for 10 min , where 𝛒 is the isopropanol density. In the second method, the sample cross-section was scanned using SEM, and the hydrogel porosity was calculated using ImageJ software .The PADM and AgNP–PADM hydrogel porosities were investigated by immersion in isopropyl alcohol and SEM cross-section observation . In the − 1, and the Peltier probes were preheated to 37 °C. The PADM and AgNP–PADM hydrogel acid flow dynamics were adjusted between pH 7 and 8, and the gel was rapidly drawn and filled between two parallel ⌀20-mm plates exhibiting ~ 1-mm clearance. The storage modulus (G′) and loss modulus (G″) of the PADM and AGNP–PADM hydrogels were recorded over time until the fluid gel dynamically solidified.Rheological measurements were performed using a rotary rheometer (MCR302). The scanning frequency was set at 1 rad sW2/W1 × 100%, where W2 represents the hydrogel weight measured at each time point, and W1 represents the initial hydrogel weight.The same PADM and AgNP–PADM hydrogel masses were incubated at 37 °C, and the sample masses were measured at different time points until the masses stopped changing. The following formula was used to calculate the hydrogel water retention: water retention rate = To measure the hydrogel degradation under different conditions, we placed the PADM and AgNP–PADM hydrogels in a centrifuge tube, incubated them at 25, 37, or 42 °C, and observed the samples regularly to check whether the PADM and AgNP–PADM hydrogels had dissolved. The liquid in the centrifuge tube was promptly aspirated, and the remaining samples were weighed.In addition, we solidified 500 μL of the PADM and AgNP–PADM hydrogels and placed them in a centrifuge tube containing 1 mL of PBS. Then, 7.5 mg of trypsin was added to the experimental (trypsin) group at 37 °C. When the hydrogels had been immersed for 7 days, both solution groups were refreshed once a day. The PBS and trypsin solutions were removed from the centrifuge tubes at the same time every day, and the hydrogels were rinsed using PBS. The water on the hydrogel surface was wiped off, the sample was weighed, and same solution was readded.To determine the AgNP release from the AgNP–PADM hydrogel under different conditions, we initially prepared a series of AgNP solutions, measured their UV absorbances, and generated a standardized UV absorbance curve to calibrate the measurements. The AgNP release from the AgNP–PADM hydrogel was then measured at different temperatures. The PADM hydrogels  were placed in a centrifuge tube and incubated at 25, 37, or 42 °C for certain times. The dissolved hydrogel solutions were removed for a period, and their optical densities (ODs) were measured at ~ 400 nm. This operation was repeated until the solution OD stopped increasing.Trypsin is a commercial food-grade enzyme exhibiting increased proteolytic activity and is used to break down collagen . The AgNg for 3 min, and 200 μL of the supernatant was removed. The OD was measured at ~ 400 nm. The supernatant was added to the sample after the test, and these operations were repeated until the solution OD stopped increasing.Finally, we measured the AgNP release from the PADM and AgNP–PADM hydrogels using an ultrasonic crushing instrument. The solid samples prepared using 500 μL of the PADM and AgNP–PADM hydrogels were cut into small pieces and placed in a centrifuge tube. Deionized (DI) water (400 μL) was added, and an ultrasonic shatterer was used to vibrate the samples at 25 and 30 Hz. The samples were vibrated for 30 s and rested for 20 s per cycle to prevent overheating the solutions. After 24 cycles, the samples were centrifuged at 4000 Escherichia coli) and gram-positive bacteria  were used for the OCM experiments. First, single colonies of Escherichia coli, Enterococcus, and Staphylococcus aureus were added to the medium-containing test tubes, which were shaken at 150 rpm and 37 °C overnight. Logarithmically growing bacteria were selected for the experiment. An appropriate number (0–1.5 × 108 L− 1) of bacteria was selected, and the bacterial solution OD was adjusted to 0.1. Then, the number of bacteria was diluted to 105 L− 1, and 1/10 of the culture-medium volume was added to a noncoagulated-agar-containing culture medium, which was fully mixed and added to a Petri dish and cooled. Then, the PADM and AgNP–PADM hydrogels were added. The Petri dish was incubated at 37 °C for 12 h, and the bacteriostatic zone diameter around the samples was measured using a scale. Each experiment was repeated thrice.The AgNP–PADM hydrogel antibacterial potential was investigated in vitro using the Oxford cup method (OCM) and the colony count method (CCM). Gram-negative bacteria  solution was added to a test tube and shaken at 150 rpm and 37 °C to culture the bacteria. The bacterial suspension (100 μL) and EP tubes were centrifuged at 2, 4, and 12 h, the supernatant was discarded, and the bacteria were resuspended in normal saline. The bacterial suspension (20 μL) was evenly coated on nutrient agar plates, and the bacteria were cultured for 24 h at 37 °C and then counted.Subsequently, we selected − 1 AgNP solution was placed in a centrifuge tube, and was ultrasonically shocked at 25 Hz first for 30 s and then for 20 s. The AgNP release solution (100 μL) obtained at 60, 100, and 140 min was added to an Oxford cup that had been prepared previously as follows. First, an appropriate Escherichia coli solution concentration was used, its OD was adjusted to 0.1, and it was diluted to 106 L− 1. Then, 1/10 of the culture medium volume was mixed into the nonsolidified agar medium. The culture medium was poured into the Petri dish and cooled, the Oxford cup was placed, and an appropriate volume of the nonsolidified agar medium was readded. After the upper medium solidified, the prepared AgNP release solution was added, and the Oxford cup was removed 12 h later to observe the bacterial removal status at the bottom.The hydrogel prepared using the 80 g mLγ radiation. HeLa cervical epithelioid carcinoma cells were seeded at 4 × 104 well− 1 in blank Petri dishes and on PADM and AgNP–PADM hydrogels [− 1), and streptomycin (100 μg mL− 1). The cells were cocultured in a humid 5% carbon dioxide environment at 37 °C for 48 h, stained using a calcium lutein staining kit, and observed using fluorescence microscopy at 515 nm.The hydrogel (100 μL) was added to a 24-well plate and sterilized using 25 kGy of − 1 and were cultured at 37 °C for 24 h. Then, the supernatant medium was removed from each well, and 100 μL of each medium containing different proportions of leaching solution were added to the DMEM medium. The leaching-solution-free DMEM medium was the control. Then, 10 μL of the CCK8 reagent was added to each well on days 1, 3, and 5. Meanwhile, the cells were incubated at 37 °C for 1 h. Absorbance at ~ 450 nm was measured using a spectrophotometer.Cytotoxicity was investigated using CCK8. The PADM and AgNP–PADM hydrogels were immersed in DMEM (hydrogel/medium = 1:5 v/v). The supernatant was collected as a 100% leaching solution and mixed with a particular proportion of DMEM medium to obtain culture solutions containing 0, 20, 50, and 100% leaching solutions. For further experiments, HeLa cells were seeded in 96-well plates at 2000 cells well− 1 AgNP solution were added to a 0.4 mM DPPH anhydrous ethanol solution, and the solution was stored in the dark for 10 min. An appropriate supernatant volume was obtained from each sample, and its absorbance was measured at 517 nm. The test sample content in the DPPH-containing anhydrous ethanol solution was adjusted until the DPPH anhydrous ethanol solution absorbance corresponding to the AgNP–PADM hydrogel sample stopped changing. The sample free-radical scavengability at a particular concentration was calculated using the formula Scavengability (%) = C2/C1*100%, where C1 represents the difference between the maximum and minimum absorbances of the ascorbic-acid-containing DPPH solution, and C2 represents the difference between the absorbances of the DPPH solution at this sample concentration and of the pure DPPH solution. The 50% inhibiting concentration (IC50) was used to record the median sample concentration required when the oxygen radical clearance rate was 100%.The PADM and AgNP–PADM hydrogel free-radical scavengabilities were measured using the DPPH free-radical scavenging assay , in whic− 1), their dorsal hair was removed, and their skin was rinsed using 70% ethanol. A scalpel and tweezers were used to create three 1-cm2 skin wounds on the midline side, 30 μL of a Staphylococcus aureus (1 × 108 CFU L− 1) solution was dropped into each wound, and the bacteria were given 2 h to fully infiltrate the wounds, which were divided into three groups as follows. Group I was the control group and did not receive any treatment ; group II was treated with the PADM hydrogel; group III was treated with the AgNP–PADM hydrogel and covered with gauze, and the PADM and AgNP–PADM hydrogels were refreshed on days 3, 5, 7, 9, and 11.Six-month-old rats weighing 200–300 g were purchased from the Zhejiang Academy of Medical Sciences. The rats were reared in separate cages, fed standard feed and tap water, and the cages were maintained at 25 °C and 55% humidity. Day and night were alternated for 12 h. According to the National Institute of Health publication No. 18–23, 1985, which is typically referenced for the care and use of laboratory animals, great care should be taken with rats. The rats were anesthetized using ketamine (30.0 mg kgC1 − C2)/C1 × 100%, where C1 represents the initial wound area, and C2 represents the wound area at each measurement time.The wound area reduction  was used to indicate the therapeutic outcome. The wound contractions were recorded on days 0, 7, and 14. The wound healing area was expressed as a percentage. The wound-shrinkage percentage was estimated using the formula wound-healing ratio (%) =  for 2–3 days before tissue processing and paraffin embedding. Tissue sections (5 μm thick) were prepared using a sectioning mechanism and stained with hematoxylin and eosin (H&E). The neovascularization, epidermis, scarring, and granulation tissue were observed and photographed.Masson’s trichrome staining can be used to dye early and mature collagens in light and dark blues, respectively to assess wound healing. On days 7 and 14, the wound paraffin sections were stained using Masson’s trichrome reagent, and the tissue section collagen content was analyzed under a microscope. Masson’s trichrome stain was designed to distinguish smooth muscle cells from collagen. Additionally, paraffin sections were immunohistochemically stained to measure the CD68 and CD34 expressions in the samples to evaluate the changes in the macrophage and tissue microvessel contents, respectively, during wound healing.P < 0.05 was considered statistically significant.Statistical analysis was performed using GraphPad Prism 8 . The results were expressed as mean ± standard deviation. One- and two-way analysis of variance (ANOVA) were used to determine whether the results were significantly different, and When the AgNPs were added to the acidic PADM hydrogel solution, the hydrogel color changed from white to pale yellow. After proper agitation and pH adjustment, a hydrogel was formed, and the AgNPs were uniformly distributed Figs. A and B. − 1 AgNP solutions. Compared with the PADM hydrogel, all the AgNP–PADM hydrogels formed a mesh fiber structure, which is consistent with the results of the extracellular matrix and tendon hydrogels [− 1 AgNP solutions exhibited porosities of 61.67 ± 3.535, 63.57 ± 3.106, 61.30 ± 2.975, and 56.73 ± 3.316%, respectively, P > 0.05, indicating that the AgNP concentration negligibly affected the hydrogel porosity  , indicating that the PADM and AgNP–PADM hydrogels were still viscous fluids. With prolonged storage, G′ increased significantly faster than G″, indicating that the gel had gradually transformed into an elastic solid. The AgNP–PADM hydrogel gelatinized slightly slower than the PADM hydrogel, which had completely transformed into an elastic solid within 15–20 minutes. After 20 minutes, the PADM and AgNP–PADM gel G′ and G″ were . The porosities of the PADM and AgNP–PADM hydrogels containing different AgNP concentrations were measured using the immersion method. The pristine PADM hydrogel and the hydrogels prepared using the 20, 50, and 80 μg mL− 1 AgNP solutions exhibited similar porosities of 52.74 ± 3.406, 49.59 ± 2.559, 54.03 ± 4.069, and 53.84 ± 4.928%, respectively , which is consistent with the results shown in Figs. The rheological properties of both hydrogels are shown in Fig. The PADM and AgNP–PADM hydrogel water retentions are shown in Fig. The PADM and AgNP–PADM hydrogel degradations were carefully measured at different temperatures. As shown in Fig. P < 0.05; AgNP–PADM groups: 39.55 ± 1.269 vs. 20.67 ± 2.510%, P < 0.05). On day 8, the PADM and AgNP–PADM hydrogel group degradation rates in PBS and pure trypsin were negligibly different . The degradation behaviors are similar, which may be because the AgNPs and the PADM hydrogel interact primarily for adsorption, and the AgNPs negligibly affected the enzyme degradation [Trypsin was used to evaluate the PADM and AgNP–PADM hydrogel degradations. The degradation rates at various times are shown in Fig. radation . These rWe measured the AgNP–PADM hydrogel AgNP release rates at 25, 37, and 42 °C. As shown in Fig. The AgNP–PADM hydrogel AgNP release behavior was investigated using PBS and trypsin solutions. As shown in Fig. We also measured the AgNP concentration released from the AgNP–PADM hydrogel by ultrasonic oscillation. As shown in Fig. − 1 AgNP solutions were negligibly different from those of the PADM hydrogel. Because the AgNP–PADM hydrogel prepared using the 80 μg mL− 1 AgNP solution exhibited a marked antibacterial effect, we used it for the subsequent experiments . The diameters of the areas in which the AgNP–PADM hydrogel inhibited the growth of Staphylococcus aureus, Enterococcus faecalis, and Escherichia coli were 49.26 ± 6.852, 50.62 ± 10.65, and 152.8 ± 6.183 mm, respectively, indicating that the AgNP–PADM hydrogels exhibited stronger antibacterial effects than the PADM hydrogels . On day 3, the number of cells in the PADM hydrogel groups increased significantly, and the number of cells in the 100% AgNP–PADM hydrogel soaking-solution groups decreased compared to the number of cells in the 100% PADM group. On day 5, although the number of cells exhibiting metabolic activities in the PADM and the 25, 50, and 100% AgNP–PADM hydrogel soaking-solution groups increased (P > 0.05), the cell survival rate did not decrease. Thus, the PADM and AgNP–PADM hydrogels did not clearly exhibit HeLa cell cytotoxicity, indicating that the AgNP-embedded PADM hydrogel can reduce the AgNP cytotoxicity and that bioderived hydrogels are appropriate biomaterials for growing recipient cells and healing wounds.We evaluated the PADM and AgNP–PADM hydrogel cytotoxicities using calcein staining. After the hydrogels were cocultured with HeLa cells for 48 h, the calcein staining results indicated that the number and density of viable cells on the PADM and AgNP–PADM hydrogel surfaces increased significantly compared with those of the viable cells on the blank group surface. Additionally, the cells exhibited good morphology. Thus, although the PADM and AgNP–PADM hydrogels did not produce any detectable HeLa cell cytotoxicity, they did promote cell growth Fig. A and B. − 1, the ascorbic acid exhibited the highest DPPH free-radical scavengability and the lowest IC50 (50 μg mL− 1), followed by the AgNP–PADM hydrogel with an IC50 of 125 μg mL− 1. Furthermore, the PADM hydrogel exhibited partial free-radical scavengability . However, on day 14 after the injury, the CD68 expression level decreased significantly, indicating that the inflammatory response had been alleviated. On days 7 and 14 after the injury, the CD68 expression in the AgNP–PADM hydrogel groups was significantly lower than those in the blank and PADM hydrogel groups. This may be because the hydrogels contained AgNPs, which exhibit specific antiinflammatory effects, reduce the infected wound inflammatory response, and significantly accelerate wound healing. In summary, the AgNP–PADM hydrogel accelerated wound healing by reducing the local inflammatory response, promoting microvascular formation, and accelerating collagen deposition.We also examined the inflammatory response  and angiWe synthesized 5 and 50 nm AgNP-containing PADM hydrogels to determine whether the PADM hydrogels influenced the size and stability of different-diameter AgNPs. Because the AgNP sterilizability negatively correlates with the AgNP size, maintaining the AgNP size and stability is conducive to maintaining effective sterilizability. For example, Rao et al. encapsulated 50 nm AgNPs inside surface-layer proteins through electrostatic interactions and hydrogen bonding to maintain the stability and stagger the release of the AgNPs . Using UAdditionally, the acidic AgNP–PADM hydrogel was stored for a week in a refrigerator at 4 °C and still maintained its fluidity, which is consistent with the results of Farnebo et al., who found that the tendon extracellular matrix hydrogel could be preserved under acidic conditions without altering its properties . In addiBecause the AgNP-embedded hydrogels were synthesized in situ by chemical reduction on the hydrogel surface , 40, theAdditionally, the neutralized AgNP–PADM hydrogel could be plasticized to form different shapes and solidified within 15–20 min, which is beneficial for healing irregularly shaped infected wounds. As the main PADM hydrogel component was biologically derived collagen, the hydrogel was dissolved by pepsin. When the PADM hydrogel was neutralized to the isoelectric points using alkalis, the hydrogel was also reconstituted into collagen fiber networks. For the PADM and AgNP–PADM hydrogels, G′ increased significantly in 20 min. Both hydrogels exhibited increased G′ and G″, indicating that the fluid hydrogels had solidified . The hydECM hydrogels can maximize the retention of the low-molecular-weight peptides and growth factors in natural ECM . The ECMThe AgNP antibacterial effect, which reduces human keratinocyte viability , is usuaTo treat infected skin defects, AgNP–PADM hydrogels were prepared by embedding AgNPs into a PADM hydrogel, and the hydrogel performance was tested in vivo and in vitro. The AgNPs were uniformly distributed in the PADM hydrogel and slowly released at the body temperature, while maintaining the particle size. The AgNP–PADM hydrogel exhibited significant antibacterial and antioxidant properties, increased nontoxicity, and the ability to promote angiogenesis in vivo. Therefore, the AgNP–PADM hydrogel successfully treated infected skin defects in rats, thereby demonstrating its potential for clinical applications.