Colorectal gastrointestinal stromal tumors (GISTs), mesenchymal malignancy, only accounts for about 6% of GISTs, but prognosis is generally poor. Given the rarity of colorectal GISTs, the prognostic values of clinicopathological features in the patients remain unclear. Nomograms can provide a visual interface to help calculate the predicted probability of a patient meeting a specific clinical endpoint and communicate it to the patient.We included a total of 448 patients with colorectal GISTs diagnosed between 2000 and 2019 from the Surveillance, Epidemiology, and End Results (SEER) database. For nomogram construction and validation, patients in the SEER database were divided randomly into the training cohort and internal validation cohort at a ratio of 7:3, while 44 patients with colorectal GISTs from our hospital patient data set between 2010 to 2016 served as the external validation cohort. The OS curves were drawn using the Kaplan–Meier method and assessed using the log-rank test. And, Fine and Gray’s competing-risks regression models were conducted to assess CSS. We performed univariate and multivariate analyses to select prognostic factors for survival time and constructed a predictive nomogram based on the results of the multivariate analysis.Through univariate and multivariate analyses, it is found that age, primary site, SEER stage, surgery, and tumor size constitute significant risk factors for OS, and age, primary site, histological grade, SEER stage, American Joint Committee for Cancer (AJCC) stage, surgery, and tumor size constitute risk factors for CSS. We found that the nomogram provided a good assessment of OS and CSS at 1-, 3- and 5- year in patients with colorectal GISTs. The calibration plots for the training, internal validation and external validation cohorts at 1-, 3- and 5- year OS and CSS indicated that the predicted survival rates closely correspond to the actual survival rates.We constructed and validated an unprecedented nomogram to predict OS and CSS in patients with colorectal GISTs. The nomogram had the potential as a clinically predictive tool for colorectal GISTs prognosis, and can be used as a potential, objective and additional tool for clinicians in predicting the prognosis of colorectal GISTs patients worldwide. Clinicians could wield the nomogram to accurately evaluate patients’ OS and CSS, identify high-risk patients, and provide a baseline to optimize treatment plans. Although gastrointestinal stromal tumors (GISTs) are rare, they are among the most common mesenchymal malignancy in the whole digestive tract, with an annual worldwide incidence of 11 to 19.6 per million , originaGiven the scarcity of colorectal GISTs, the meager amount of research, and the inadequacy of studies, the prognostic values of clinicopathological features and treatments in patients remain uncertain. Therefore, recurrent or metastatic risk stratification of GISTs has been attempted worldwide, which is mainly based on tumor size, mitotic activity and location , 10. In In this study, we aim to analyze and compare the prognostic features of colorectal GISTs using a relatively prodigious amount of cases obtained from the Surveillance, Epidemiology, and End Results (SEER) database and to develop a delicate nomogram based on significant prognostic factors to predict 1-, 3-, and 5-year overall survival (OS) and cancer specific survival (CSS). Further, we verified the prognostic value of the prediction model using an external validation set from our hospital database.https://seer.cancer.gov/datasoftware/). The screening of patients with colorectal GISTs was as follows: 1) patients came from the database of “SEER Research Plus Data, 17 Registries, Nov 2021 Sub (2000-2019)”; 2) the International Classification of Diseases for Oncology (ICD-O) site codes caecum (C18.0), ascending colon (C18.2), hepatic flexure of the colon (C18.3), transverse colon (C18.4), splenic flexure of colon (C18.5), descending colon (C18.6), sigmoid colon (C18.7), rectosigmoid junction (C19.9) and rectum (C20.9) were used to identify patients; and 3) according to “Histologic Type ICDO-3,” the following pathological types were included in this study: GISTs (8936). We only included patients positively diagnosed with histology tests and excluded the patients with incomplete survival information. Since the SEER database contains no identifiers and were publicly available, the approval of the institutional review board was not required. The second source comprised of colorectal GISTs patients who were diagnosed and received treatment at Xijing Hospital from 2010 to 2016. The included patients from our center were approved by the Ethical Committee of Xijing Hospital, with orally informed consents. The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.This study used data from two sources - the SEER database and the Xijing Hospital database. The first source was from the SEER database provided by the National Cancer Institute’s SEER*Stat software version 8.4.0.1 , clinicopathological characteristics , tumor size, SEER stage, American Joint Committee for Cancer (AJCC) stage, AJCC T stage, AJCC N stage, AJCC M stage), primary treatment modality , survival time, vital status, and cause-specific death classification at the last follow-up from the chosen cases. The study used OS and CSS as the primary end point, and results are presented as hazard ratios (HRs) with 95% confidence intervals (CIs). OS is defined as time to death from any cause, and CSS was defined as the time to death from colorectal GISTs. X-tile software version 3.6.1  was used to analyze the optimal cutoff point of age and tumor size . The X-tMissing values for candidate predictors were handled with multiple imputation (R package MICE). The imputation model included all candidate predictors and outcomes (time to event). The resulting 10 complete datasets were separately analyzed and the results combined with Rubin’s rules to produce overall estimates and confidence intervals.n) and percentages (%). To estimate cancer survival probabilities, we considered death due to the diagnosed cancer as the event of interest and death due to other causes as the censoring event. We used Fine and Gray’s competing risk analysis  and R software (version 4.1.2). Descriptive statistics are presented as frequencies  of the receiver operating characteristic (ROC) was used to evaluate the discrimination performance of the nomogram, TNM staging system, and histological grade, which ranges from 0.5 (no discrimination) to 1.0 . AUC measures the discrimination ability of the different staging systems to stratify patients with different outcomes: higher the AUC, better the model is about a patient’ prognosis. Second, the calibration plot was performed using a bootstrap method with 1,000 resamples to compare the agreement between actual observed and predicted survival rates. Intuitively, the closer the simple regression line between the actual and predicted survival rates is to the diagonal, the closer the predicted survival rates are to the actual survival rates. All statistical tests used a significance level of 5% in a two-tailed test.n = 69), left-sided colonic GISTs (n = 60), rectum GISTs (n = 184), were included in the study for comparisons. The above data suggest that patients with rectum GISTs had much more cases than patients with right-sided colonic GISTs and left-sided colonic GISTs. In addition, we found that the proportion of male patients was higher than that of female patients with colorectal GISTs. Roughly three-quarters of the patients (n = 336 [75.00%]) underwent surgery. Less than half of patients (n = 193 [43.08%]) received definitive chemotherapy, whereas only 5.58% patients received radiation. Tumor size was less than 65 mm in 51.79% of patients, and greater than or equal to 65 mm in 48.21% of patients. In addition, we found that patients with rectum GISTs were younger and received less surgical resection than those with colonic GISTs. Patients with colonic GISTs had a higher proportion of distant disease, and had significantly more proportion of tumors with size >65 mm, especially left-sided colonic GISTs. These results are summarized in n = 9), left-sided colonic GISTs (n = 8), rectum GISTs (n = 27), were included in the study for comparisons. Concerning the treatment strategy, 68.18% patients with colorectal GISTs underwent surgery, while the remain 31.82% of patients with colorectal GISTs did not. Tumor size was less than 65 mm in 52.27% of patients, and greater than or equal to 65 mm in 47.73% of patients. These results were consistent with results from the SEER database.After excluding patients with missing follow-up data, a total of 448 patients with colorectal GISTs diagnosed between 2000 and 2019 were selected from the SEER database and assigned to the training cohort (n = 313) and the internal validation cohort (n = 135). For the whole cohort, the median follow-up time was 80.50 months . Number of deaths from any cause was 246 and number of deaths from colorectal GISTs was 146. Based on the same inclusion and exclusion criteria as the SEER cohort, 44 patients with colorectal GISTs were included in the external validation cohort from the Xijing Hospital. Of the total SEER group, the demographic and clinical characteristics did not differ between the training and internal validation cohorts. Colorectal GISTs, mesenchymal malignancy, only accounts for about 6% of GISTs , but proIn this study, epidemiological and clinicopathologic characteristics were analyzed for patients with colorectal GISTs, and the related risk factors for patients’ prognosis were determined. Our present study identified AJCC stage, the most basic and widely used cancer staging system, as an independent prognostic predictor of CSS but not OS in patients with colorectal GISTs. This finding is in agreement with previous investigations showing that the higher AJCC stage represents a worse prognosis in the patients with small intestinal, duodenal, stomach GISTs , 39, 40,Although multifactorial analyses confirmed risk factors associated with patient prognosis, these variables did not allow for accurate and differentiated prediction of colorectal GISTs, especially for estimating survival rates for each individual. Therefore, specifically designed prognostic prediction models is of considerable importance in answering this question. The nomogram generates accurate predictions based on an assessment of important factors and provides pinpoint and personalized risk predictions for each individual to estimate the conditional risk of disease outcomes. And, we found no other literature had reported nomograms to accurately estimate the prognosis of patients with colorectal GISTs. Thus, studies with larger sample size involving multiple centers should be conducted to construct a nomogram to predict the prognosis of patients with colorectal GISTs. Our study at least partially fills this gap by creating a nomogram model to establish the OS and CSS of colorectal GISTs on the basis of a large database. We constructed and validated a nomogram predicting 1-year, 3- and 5-year OS and CSS in patients with colorectal GISTs. For nomogram construction and validation, patients in the SEER database were randomly grouped into a training cohort and internal validation cohort according to a ratio of 7:3, and utilized our hospital patient data set as the external validation cohort. Through univariate and multivariate analyses, we considered that age, primary site, SEER stage, surgery, and tumor size constitute significant risk factors for OS, and age, primary site, histological grade, SEER stage, AJCC stage, surgery, and tumor size constitute risk factors for CSS. We found that the nomogram provides a exceptional assessment of OS and CSS in patients with colorectal GISTs and AUCs for the model were high in all time points. In addition, the calibration plots stated clearly that the predicted survival of 1, 3, and 5 years had an important bearing on the actual survival, suggesting that the predictive performance of the nomogram was superb. With simple training, healthcare professionals, patients, and the public can quickly grasp the nomogram to assess the individualized risk predictions for each individual. Using the nomogram, it can be seen that an individual aged 70 , left-sided colon GISTs , grade III (34 points for CSS), regional SEER stage , and AJCC I stage (0 points for CSS), who has been treated with surgery  and, tumor size = 70mm  has a total point score of 105 for OS and 169 for CSS. This equates to 1-, 3-, and 5-year OS of 0.78, 0.56, and 0.43, and 1-, 3-, and 5year CSS of 0.85, 0.69, and 0.58, respectively.Our study has several limitations that should be considered while interpreting our results. First, it is a retrospective analysis using a public database and, in this case, the avoidance of selection bias is difficult. Second, our nomogram provided individual predictions of OS for patients with five clinicopathological factors and CSS for patients with seven clinicopathological factors, lacking other additional variables which was reported to be significantly prognostic factor for the prognosis of patients with GISTs, such as mitotic rate, tumor rupture, Ki67 index –54. HoweIn conclusion, age, primary site, SEER stage, surgery, and tumor size constitute significant risk factors for OS of patients with colorectal GISTs, and age, primary site, histological grade, SEER stage, AJCC stage, surgery, and tumor size constitute risk factors for CSS. We constructed and validated a nomogram to predict OS and CSS in patients with colorectal GISTs. The nomogram had the latent capacity as a clinically predictive tool for colorectal GISTs prognosis, and can be used as a potential, objective and additional tool for clinicians in predicting the prognosis of colorectal GISTs patients worldwide. Clinicians can employ the nomogram to accurately evaluate patients’ OS and CSS, identify high-risk patients, and provide a baseline to optimize treatment plans.The original contributions presented in the study are included in the article/YL and YZ participated in the design of this study and wrote the manuscript. LH and DF conceived the original idea, supervised the overall direction and planning of the project. YF, WY, XW, LD, LN, JC, WZ, JL and JW contributed to the acquisition of the data, analysis, and interpretation of the data. All authors contributed to the article and approved the submitted version.This project was supported by Project supported by the National Natural Science Foundation of China (No. 82073210), The grant of Shaanxi Province (No. 2019ZDLSF01-02-01) and Xjijng Zhutui Project. The funding bodies played no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Normal and abnormal respiratory spirometry patterns showed significant differences with the physical role and physical function of quality-of-life scales . The spirometry test was carried out in 87 male miners, with 25% of these miners reporting abnormalities. Out of these, 73% presented a restrictive spirometry pattern, and 27%, an obstructive spirometry pattern. The ASGM population had higher Hg concentrations and worse neurotoxic symptomatology than non-miners of the same community. The aim of this study was, first of all, to associate the mercury (Hg) concentrations and respiratory functions of the gold miners in the artisanal small-scale gold mining (ASGM) environment in San Martín de Loba, Colombia. We carried out a cross-sectional study using a survey whereby we collected basic demographic information, occupational medical history, and applied two validated questionnaires (Q16 and SF36). We measured Hg levels in all volunteers using direct thermal decomposition-atomic absorption spectrometry. Univariate and bivariate statistical analyses were carried out for all variables, performing logistic regression to assess the effect of ASGM on health outcomes. Volunteers enrolled (n = 124) were between the ages of 20 and 84 years . No changes were found in the systolic blood pressure, diastolic blood pressure, and heart rate from the ASGM miners, in crude and adjusted statistical analyses. ASGM miners increased 8.91  times the risk of having these than of having neurotoxic effects. Concentrations of total whole blood mercury (T-Hg) in all participants ranged from 0.6 to 82.5 with a median of 6.0 μg/L. Miners had higher T-Hg concentrations than non-miners ( The MeHg can be bioaccumulated and biomagnified in fish via the food web, and then eaten by the human population [Artisanal and small-scale gold mining (ASGM) directly and indirectly employs more than 100 million people in over 70 countries around the world . An estipulation ,5,6.ASGM is characterized as an informal job that requires limited technical skills and few resources, but requires the use of hazardous substances, such as elemental Hg for gold amalgamation. Mercury contamination has frequently been associated to a set of adverse health effects and environment impacts with social consequences ,8. TheseRecent studies have show that mercury is a powerful neurotoxic and induces serious health effects, such as irreversible neurological disorders, damage to the bone system, teratogenicity, oxidative stress, hormonal alterations, kidney injury, hearing loss, endocrine effects, infertility, menstrual alterations, spontaneous abortions, and other adverse health conditions ,15,16,17In some countries, the precious metal in ASGM is extracted from ores containing gold, in which rocks are finely pulverized  by hand with hammers and later using ball mills. The material reduced to powder is mixed with elemental Hg forming an amalgam  . During Colombia reported between 268 and 418 thousand people working as ASGM miners, who lost a combined total of 23–52 thousand years of life . In San Miners working in ASGM in San Martin de Loba  are exposed to mercury through the extraction of gold from excavations of sinkhole mines which are linked to health hazards related to lung function impairment, chronic lung disease, and cognitive dysfunction, in terms of neurological effects. Therefore, the aim of this study was to determine lung function, total Hg levels in whole blood, neurotoxicity (Q16) and quality of life (SF-36) in ASGM miners and non-miners from this municipality ,31.2  at an altitude of 30 m above sea level with an average temperature of 27 °C and an extension of 414 km2 . The selParticipants completed a brief written survey so we could collect basic demographic information. Occupational medical history and two validated questionnaires (Q16 and SF36) were applied to evaluate the quality of life and the possible neurological impacts on the participants. Health-related quality of life (SF-36) is a standardized questionnaire of 36 items grouped into 8 measurable scales: physical functioning (PF), physical role (PR), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), emotional role (RE) and mental health (MH) . Each diThe spirometry test was applied to the miners involved in this study. Miners working in sinkholes are exposed to PM and may display respiratory conditions. Volunteers who completed the medical history and health surveys underwent a spirometry test using the SpiroBank II  . Spirome® tubes with EDTA as an anticoagulant , which were labeled with the information of the subjects. Tubes with whole blood samples were transported to the laboratory in a refrigerated container at 4 °C and stored at −20 °C until analysis. We organized the blood samples with a consecutive code for each volunteer, avoiding the possibility that any researcher could identify the results of any person in the population. Only medical personnel interviewing patients knew the identity of each subject.A blood sample of 4 mL was extracted by venipuncture and collected in vacutainerThe determination of T-Hg concentrations in blood samples was tested in whole blood samples using a thermal decomposition atomic absorption spectrometer (TD-AAS) with Zeeman-effect background correction technique, RA-915M equipped with pyrolysis accessory, PYRO 915+ for solid sample analysis . T-Hg concentrations were measured directly in the whole blood samples without any digestion or sample preparation before analysis. Blood samples (~100 mg) were weighed into a quartz boat and heated at 800 °C to complete combustion in order to release the Hg gas to be measured based on the absorbance at a wavelength of 253.7 nm in the enclosed system. After thermal release, the quantitative signal for Hg is shown as the total area under the peak. Before every measurement, the quartz boat was cleaned and heated once again to obtain the instrument baseline.A series of analytical quality assurance and quality control procedures were carried out in order to maintain the traceability of the results of mercury concentrations. Each sample was analyzed in duplicate; if the coefficient of variation (CV) was above 20%, a confirmation reading was carried out. The limit of detection (LOD) and limit of quantification (LOQ) were 1.4 and 4.36 µg/L, respectively. calibration curves were created directly using whole blood Standard Reference Materials (SRM) with known mercury concentrations provided by the Wadsworth Center, New York State Department of Health . For thiUnivariate and bivariate statistical analyses were carried out for all variables. The normal distribution of data was assessed using the Kolmogorov–Smirnov one sample test. Due to the lack of normality of some continuous variables as T-Hg concentrations, the Wilcoxon-Mann-Whitney test (WMW) was used to compare only two groups, whereas the Kruskal–Wallis test was used to find the difference between three or more independent groups. Possible associations between T-Hg concentrations and the independent variables were separately explored using the Spearman correlation analysis. Due to the uncertainties in exposure measures and the response to individual variability, the precise minimum concentration of mercury in the blood that may cause toxic effects in humans could not be determined. However, it can be used as a cut-off concentration in the whole blood of 5 μg/L based on the US-EPA reference dose (RfD) . The popp ≤ 0.05. All statistical analyses were calculated with R, version 4.2.1 .A logistic regression analysis was used to assess the effect of mining exposure on the items of the Q16 questions. In the multivariable model the confounder variables included were age, sex, systolic blood pressure, diastolic blood pressure, heart rate, and body-mass index. Non-significant variables in crude analyses were deemed non-confounders and were not included in the final model. The body-mass index entered the model as a second-degree polynomial to account for non-linearity. We report adjusted odds ratios (OR) with 95% confidence intervals (CI). All comparisons among groups or correlations were presented a level of significance of t-test, p = 0.26). A total of 46% of the participants had attended elementary school; and 38%, middle/high school; and 5% had obtained an undergraduate degree. On average, participants had a body-mass index (BMI) of 24.3 ± 3.9 and ranged from 16.9 to 32.3 kg/m2. Ten percent of participants surveyed were overweight (BMI ≥ 30). No ASGM miners were found to have changes in systolic blood pressure, diastolic blood pressure, and heart rate with crude and adjusted analyses  . A total of 58.9% of all the participants had higher concentrations of T-Hg than the environmental exposure (>5 μg/L) and 10.4% for higher occupational exposure (≥15 μg/L).Concentrations of T-Hg in all participants presented a median of 6.0 μg/L and ranged from 0.6 to 82.5 μg/L. Miners had higher T-Hg concentrations than non-miners, with a statistical difference between the two groups in which the median of T-Hg concentrations for the miners was twice as high as those for the non-miners  . ConcentNeurotoxicity factors obtained from the miners were associated to Hg exposure (low and high) . ASGM acp < 0.05). The physical function, pain, general health, vitality, social function, emotional role and mental health were different between Low and High mercury concentrations in the male and female populations (p < 0.05)  and general health (57%), although the highest quality of life was social function (87.5%) and emotional role (86%). Both mining and non-mining women had a lower quality of life than men . The phy < 0.05) . The results of the spirometry test were classified in different patterns according to lung function such as normal, abnormal, obstructive, and restrictive spirometry. The patterns of the spirometric test were associated with the results of quality of life (SF-36) for a better intepretation . The 87 Neurotoxic symptoms were measured in 124 participants, out of which 58.2% reported at least 6 negative responses. Recent studies in Latin America on ASGM workplaces have shown high mercury concentrations in biological samples  taken from miners, due to the use of mercury ,40,41,42Our results concurred with the findings of previous studies. Mean concentrations of T-Hg in blood samples of the miners from San Martin de Loba were similar or greater to values from miners or communities near ASGM in other studies in Colombia ,44,45,46The largest concentration of Hg in whole blood was found in ASGM in departments such as Choco , a poor The ASGMs have been considered hazardous working places for miners because they involve rudimentary and semi-automatic tools, and miners are usually associated with poor health without following the safety standards such as wearing personal protection elements (PPE) that could include gloves, safety glasses, shoes, earplugs, hats, respirators, or body suits, etc. Miners from ASGMs in San Martin de Loba do not wear PPE or they have poor PPE compliance, greatly increasing the risk of mercury exposure. Therefore, these miners had high mercury concentrations in blood samples because they have been directly exposed to mercury vapor produced during the amalgamation and the burning processes, as well as eating fish that has been contaminated with methylmercury. Previous studies report that the exposure of miners to mercury in order to extract gold can cause immune, sensory, neurological, motor, and behavioral dysfunctions similar to neuronal diseases ,33. In aThe results of this study showed that the male miners with a normal spirometry had a better quality of life than miners with an abnormal spirometry, specifically in physical function and physical role . These rIn this study, 60% of the miners from San Martin de Loba had neurotoxic abnormalities (≥6) according to the Q16 neurological toxicity test. In addition, miners had 8.9 times more neurotoxic abnormalities (≥6) than non-miners. Therefore, miners with neurotoxic abnormalities (≥6) should be referred to higher levels of health care. These results were significant and were also found in adjusted analyses, including our small sample size. The present analysis also shows significant increases of some neurological parameters in miners, such as loss of understanding of TV/radio, problems with usual activities, fatigue, oppression in chest, painful tingling, loss of strength in arms, legs, loss of sensitivity in arms, legs and having more than 6 abnormalities, which guides us to advance with more specific neurological studies.In Latin America, ASGM activities play an important role in affecting the quality of life of many communities. Dysfunctional households end up being a burden for women in these settings . In San ASGM is the primary source of employment or income for mining communities in Colombia and other countries, although it has raised concerns due to the effect of mercury pollution impacting the environment, and the health of miners and their families, including children and pregnant women. The exposure of miners to vapor and dust in ASGM activities has impacts on public health and on the environment. This study showed evidence of the association between mercury concentrations in blood samples from miners and neurotoxicity outcomes. In addition, it was observed that a significant association between spirometry results and quality of life in miners could be caused by the exposure to dust produced by limestone mining. This is the first report in Latin America that related the pulmonary function of miners working in ASGM sites. Spirometry patters as a pulmonary function test may be used as a bioindicator of the health status in an ASGM workplace and can be an important tool for health surveillance programs. Government, via the environmental and health agencies, must pay close attention to the mining population, because ASGM is characterized as a health risk and it lacks safety equipment and training for miners.


The application of medical image three-dimensional (3D) reconstruction technology can provide intuitive 3D image data support for accurate preoperative evaluation, surgical planning, and operation safety. However, there is still a lack of high-quality evidence to support whether 3D reconstruction technology is more advantageous in liver resection. Therefore, this study systematically evaluated the clinical effects of 3D reconstruction and two-dimensional (2D) image-assisted hepatectomy.  Databases were searched to collect published clinical studies on 3D reconstruction technology and 2D image-assisted liver resection. Data were extracted from the database construction to March 2022 and the risk of bias in the included studies was evaluated. Meta-analysis was performed using RevMan5.3 software. P=0.001) and also reduced operation time , decreased intraoperative blood loss , decreased incidence of postoperative liver failure , decreased postoperative recurrence rate , and increased postoperative survival rate .  A total of 13 clinical studies were included, including 1616 patients, 795 in the 2D group and 819 in the 3D group. The meta-analysis showed that the incidence of postoperative complications was lower in the 3D group than in the 2D group (OR = 0.64, 95% CI = 0.49–0.83,  Current data suggest that 3D reconstruction-assisted hepatectomy can reduce intraoperative blood loss, postoperative complications, and recurrence, and improve postoperative survival. Therefore, the 3D reconstruction technique is worthy of application and promotion in assisted liver resection. The liver is the largest organ in the human viscera and the largest digestive gland in the human digestive system –3. At thHowever, there is still a lack of high-quality evidence to support whether the 3D reconstruction technique is more advantageous in liver resection. Therefore, this study systematically evaluated the clinical effect of using 3D reconstruction technology and 2D imaging to compare the clinical effect of assisted hepatectomy and provided a reference for the selection of a clinical treatment plan.Study type: clinical study on the application of the 3D reconstruction technique in hepatectomy. Randomized controlled trials (RCTS) were the first choice. If RCTS were not available, other types of clinical controlled trials were included. Participants: patients who have been clinically diagnosed with primary benign or malignant liver tumors, hepatolithiasis, metastatic liver tumors, or other diseases requiring surgical treatment. Intervention and control: the liver of the experimental group was evaluated by the 3D reconstruction technique before surgery, and the liver of the control group was evaluated by conventional 2D imaging before surgery. Outcomes: (1) postoperative complications; (2) operating time; (3) intraoperative blood loss; (4) the incidence of liver failure; (5) the postoperative 1-year recurrence rates; and (6) the postoperative 1-year survival rates.The exclusion criteria were as follows: (1) repeated literature; (2) non-English literature; (3) the original research data cannot be extracted; (4) inconsistent intervention measures; and (5) the control group (2D group) was not set in the experimental design.Embase, PubMed, and the Cochrane Library databases were searched for published clinical trials on 3D reconstruction compared with 2D image-assisted liver resection from database establishment to March 2022. Search terms: 3D; 3D visualization reconstruction; hepatectomy; and hepatectomies.First, the repeatedly published literature was screened out, and then, the literature was screened by reading the title. After excluding clearly irrelevant literature, the abstract and the full text of the literature were further read, and finally, the inclusion criterion was determined. The main contents of data extraction include the following: (1) basic data, such as first author, year of publication, study time, type of study design, sample size, and type of disease studied. (2) Basic characteristics of participants, such as age, sex, and disease status. (3) Intervention, such as preoperative evaluation methods and postoperative actual measurement indicators. (4) Bias risk assessment. (5) Outcomes, including postoperative complication rate, intraoperative blood loss, postoperative liver failure rate, postoperative recurrence rate, and survival rate.Risk assessment of bias in the included studies.Since RCTS were not retrieved, the Newcastle–Ottawa Scale (NOS)  was usedP < 0.05 was considered statistically significant.The standard mean difference (SMD) was used to measure continuous variables, the rate ratio (RR), and 95% confidence interval (CI) were used to measure categorical variables, and the funnel plot was used to evaluate publication bias. The Egger analysis was carried out with Stata 15.0. A total of 632 relevant literatures were obtained in the initial search and 13 clinical studies were finally included after screening. The literature screening process and results are shown in 11 studies –28 reporP=0.001), and the difference between the two groups was statistically significant , and the difference between the two groups was statistically significant , and the difference between the two groups was statistically significant , and there was no statistical significance between the two groups , and the difference between the two groups was statistically significant , and the difference between the two groups was statistically significant (Five studies reported 1-year survival rates of the software , 24, 27.nificant .RevMan 5.3 software was used to conduct a sensitivity analysis of outcome indicators by removing single included studies one by one, and the combined results did not change significantly, indicating that the meta-analysis results of this study were relatively stable.Based on the incidence index of postoperative complications, RevMan 5.3 software was used to draw a funnel plot for publication bias analysis, and the results showed that the distribution of each study on both sides of the funnel was not completely symmetrical, suggesting the possibility of publication bias .Since the 1970s, medical imaging equipment has been continuously improved, and there are more and more medical imaging methods. New imaging techniques provide a very effective means to observe the function of tissues and organs, thus becoming an important medical diagnostic tool. However, the 2D imaging is difficult to meet the requirements of accurate preoperative evaluation and preoperative planning, so it can only make a qualitative analysis of the disease, and the diagnosis result depends on the experience of reading film and subjective understanding of medical imaging. When different doctors diagnose the same disease, they sometimes come up with different results. After the 1990s, computer image processing technology developed rapidly and gradually penetrated the medical field. We use computers to analyze and process 2D images, segmentation, extraction, 3D reconstruction, and so on. With the gradual popularization and application of the 3D reconstruction technology in clinical practice, the technology has gradually transferred from orthopedic-assisted nail placement , craniocOn the 3D liver models, the virtual liver excision technique can accurately provide safe surgical removal and judge the distribution range of the blood vessels in advance. Then, we calculate the blood vessels and their branches' area and avoid the risk of liver parenchyma perfusion inadequacy or obstruction; the maximum limit retains the functional liver tissue. By observing virtual liver resection, doctors can evaluate and design the best surgical resection plan, so as to improve the success rate of complex liver resection, reduce postoperative complications, and accelerate the recovery of patients.The results of this study show that, compared with traditional 2D imaging, 3D reconstruction can reduce postoperative complications and intraoperative blood loss, and the volume of liver resection predicted by precise planning is consistent with the actual volume of liver resection. It avoids the problems of liver insufficiency or even failure caused by the insufficient residual volume of the liver after the operation.In this study, 12 studies were included and no RCTs were included, so study type-based subgroup analysis was not conducted. Differences in basic diseases, surgical methods, technical level, and study design of included patients will affect the reliability of the results.In conclusion, the 3D liver reconstruction is helpful for safety assessment before anatomic hepatectomy and is beneficial for fine operation during surgery, reducing intraoperative blood loss, shortening treatment time, and reducing complications. However, due to the limitation of the quantity and quality of the included literature, more reliable conclusions from high-quality RCT studies are needed to better determine the practical application value of 3D reconstruction of medical images. However, current evidence shows that the application of the 3D reconstruction-assisted liver resection can improve the resection rate of the liver tumors, shorten the operation time, reduce intraoperative blood loss, and reduce the occurrence of postoperative complications. It has strong advantages in accurate preoperative evaluation and surgical planning and excellent postoperative management. –43.


Within each group, no differences in sleep latency were detected between genders. Furthermore, no difference in EEG abnormality detection was observed between the two groups. Our study confirmed the efficacy and safety of melatonin administration in sleep induction. Nonetheless, liposomal melatonin presents a greater bioavailability, ensuring a faster effect and allowing lower dosages. Such results, never before reported in the literature, suggest that the routine employment of melatonin might improve clinical practice in neurophysiology, reducing unsuccessful recordings.Electroencephalography (EEG) is pivotal in the clinical assessment of epilepsy, and sleep is known to improve the diagnostic yield of its recording. Sleep-EEG recording is generally reached by either partial deprivation or by administration of sleep-inducing agents, although it is still not achieved in a considerable percentage of patients. We conducted a double-blind placebo-controlled study, involving a hundred patients between 1 and 6 years old, randomized into two groups: Group 1 received liposomal melatonin (melatosome) whereas Group 2 received a placebo. Sleep latency (SL), defined as the time span between the onset of a well-established posterior dominant rhythm, considered as a frequency of 3 to 4 Hz, increasing to 4–5 Hz by the age of 6 months, to 5–7 Hz by 12 months, and finally to 8 Hz by 3 years, and the first EEG sleep figures detected, were measured for each patient. A significant difference in SL was observed (10.8 ± 5 vs. 18.1 ± 13.4 min,  Electroencephalography (EEG) is a pivotal diagnostic tool in the clinical assessment of a first seizure episode in children for a differential diagnosis between seizure and seizure-like attacks, and as a necessary diagnostic instrument in monitoring epilepsy evolution ,2.However, only 50% of epileptiform abnormalities are detected during a standard, awake recording . Sleep iSleep deprivation before EEG recording seems to increase both the chance of sleep recording during the procedure and the detection of interictal epileptiform discharges : epileptSleep in children is generally reached by either partial deprivation or by the administration of sleep-inducing drugs ,9. InterPharmacological agents, including barbiturates, chlorpromazine, triclofos and chloral hydrate, have all been employed to induce sleep, although most of them can impact the sleep macrostructure and/or affect the analysis of the recorded EEG data . FurtherMoreover, delayed awakening or persistent sleepiness after the exam could lead to prolonged observation or even hospitalization for safety reasons .Melatonin, an indoleamine which is mostly produced in the pineal gland, has been reported as a promising alternative to achieve sedation in children ,19. It hExogenous melatonin is also an advantageous oral natural-sleep inducer, currently employed in the treatment of sleep disorders and jet lag ,22. Its In most studies, melatonin is administered at dosages ranging between 5 and 20 mg/day , in the absence of significant adverse effects, confirming its excellent pharmacological profile.We conducted a double-blind placebo-controlled study, in order to evaluate the efficacy of liposomal melatonin as a sleep inducer in pediatric patients performing a polygraphic electroencephalograph (pEEG) during sleep. The aim of the present study was to assess the efficacy in sleep induction of liposomal melatonin against a placebo; the future application is the introduction of liposomal melatonin in clinical practice in pediatric EEG. We also evaluated the safety of liposomal melatonin, closely monitoring the occurrence of eventual adverse events.Participants were randomized into a two-group, parallel, placebo-controlled double blind trial. Neither the experimenter nor the patients’ caregivers knew to which group they were randomized.Group 1 (G1) received liposomal melatonin (melatosome), which was administered in two different doses: 3 mg (0.75 mL) for children aged 1 to 3 years old, and 5 mg (1.25 mL) for children between 4 and 6 years old. Group 2 (G2), on the other hand, received placebo in vials of 0.75 mL and 1.25 mL, administered, respectively, to the same age groups as G1. The two product were visually identical.All our patients were sleep deprived, according to the current guidelines for performing EEG in sleep. Namely, all children were awakened at 6.00 am; in addition, patients from two to four years old were kept up for additional hours past their bedtime, whereas older children kept up until midnight. Electrodes were arranged through an EEG cap according to Jasper 10–20 system.We included patients between 1 and 6 years old assessed at the Pediatric Neurologic Clinic of Pisa and equipped with a referral for an EEG in wakefulness and sleep. Exclusion criteria included the denial of informed consent, a previously diagnosed sleep disorder, inability to follow the instructions given by the operator due to communication problems , or being unable to take the product.During the analysis, we discarded patients whose EEG could not be performed, whose parents withdrew informed consent, or who were not compliant enough to consume the product.After the signature for informed consent was obtained from the caregivers of all eligible children, a randomly assigned vial was administered to the patient, and the EEG was recorded at the sleep lab of our Department.Subsequently, two independent pediatric neurologist experts in epilepsy and EEG evaluated the EEG tracking and determined the sleep latency (SL) for each patient. SL was defined as the time span between the onset of a well-established posterior dominant rhythm and the first EEG sleep figures detected .The primary outcome of the study was to evaluate the efficacy of melatonin administration as a sleep-inducer in children who undergo a sleep-EEG examination.t-tests and ANCOVA analysis was performed in order to remove the effect of age. To study the relationship between these variables, the Pearson correlation coefficient was calculated. Chi-squared test was employed for the analysis of categorical variables which were expressed as percentages. Sleep latencies were also analyzed with Kaplan–Meier estimator, and compared through Mantel–Cox test. For statistical analysis, we used IBM SPSS, ver. 28.For the statistical analysis of quantitative variables, we evaluated mean, median, and standard deviations, which were compared through p = 0.67). Furthermore, the software generated a randomized univocal code for each patient. All subjects and investigators were blind to treatment conditions until after data analysis.Randomization was performed with software NCSS 2020 . NCSS, LLC. Kaysville Utah, USA, ncss.com/software/ncss). A balanced randomization for G1 and G2 was obtained with Efron’s procedure , whereas fifty received liposomal melatonin .We evaluated 44 boys and 56 girls, the mean age was 3.7 years (±1.74). Forty-two patients underwent EEG to control a previously diagnosed epileptic syndrome (17 in the CG and 25 in the MG), 12 for febrile seizures (7 in the CG and 5 in the MG), 13 for suspected seizures (7 in the CG and 6 in the MG), 5 for sleep disturbances (1 in the CG and 4 in the MG) and 8 for behavioral problems/psychomotor delay (3 in the CG and 5 in the MG). Thirty-seven patients were treated with an ASM (antiseizure medication), 19 in the MG and the 18 in CG .p-value = 0.002) . The amount of variation accounted for by melatonin increased to 994.57 (from 827.85) units and the unexplained variance (SSr) was reduced to 9248.05 (from 9634.25). In addition to such results, the Kaplan–Meier curves underlined a significant difference in SL estimation between the two groups  .The overall average SL was found to be 13.9 ± 10.5 min (range 2–25). A significant difference in SL between the two groups was observed  . Within : 0.002) . No diffFor all 100 patients, no adverse events were observed during the examination, and no patients abandoned the study.Although difficult to perform, an optimal EEG recording plays a crucial role in the diagnosis and clinical management of alleged epileptic patients. However, sleep deprivation, which, to date, appears to be necessary for sleep-EEG recordings, might represent a difficult struggle, becoming a source of stress for caregivers, who often find sleep deprivation impossible or excessively stressful for their children and themselves ,12,13.Melatonin is currently employed in acute and chronic circadian rhythm disorders in children and adolescents, either healthy or with neurologic or neurodevelopmental disorders, such as autism spectrum disorder (ASD) .Although it is reported that sleep duration might be shorter with melatonin, a meta-analysis  of 13 peCompared to other sedatives, melatonin administration has shown a similar sleep latency and length of sleep, with a shorter drowsiness period ,28. In pFurthermore, our study confirms the efficacy of melatonin administration in sleep induction, and in particular, enhancing its role as an efficient tool in sleep-EEG recording. Furthermore, at the dosages used (3 and 5 mg), we did not find any type of interference in the detection of interictal EEG anomalies. In addition, in our study, we used liposomal melatonin as it has been shown to have a greater bioavailability, which allowed us to use a lower dosage with a faster effect. Such results, which have not previously been reported in the literature, suggest that melatonin could be administered at common dosages for EEG purposes in both epileptic and non-epileptic patients; therefore, we believe that the routine administration of melatonin should be systematically adopted for current practice in neurophysiology, although, to date, there are no guidelines on melatonin administration for sleep-EEG purposes either in adults or pediatric patients.Given the consistent results of our work, we believe that a combined method  should be adopted prior to EEG recording, at least in specific groups of children, such as patients with behavioral disorders, with inadequate sleep deprivation, or whose parents have not been able to guarantee efficient sleep deprivation.Of note, our group was able to achieve these results with the administration of the minimum dose of melatonin (3 to 5 mg). We could therefore presume that even better results might be obtained with higher doses. However, safety has yet to be established.A main limitation of the present study could be represented by the low number of patients. However, our results should encourage further research that might lead to a larger employment of melatonin in neurophysiology. Surprisingly, many parents whose children were recruited for our study spontaneously requested the administration of melatonin for subsequent sleep EEGs, claiming that the examination had been more comfortable for their children.In conclusion, ours was the first double-blind, placebo-controlled study that assessed the safety and efficacy of liposomal melatonin as a sleep inducer in pediatric patients undergoing a sleep EEG. We believe that the routine employment of such an indoleamine  might improve clinical practice in neurophysiology by helping to reduce procedural stress in parents and children, enhance the chances of recording sleep during EEG and reduce the number of failed, unsuccessful recordings.


Diuretics have been one of the well-known nephrotoxic drugs which can lead to acute kidney injury (AKI). However, there are few real-world studies on the incidence of AKI in hospitalized patients received diuretics. In the present study, a single-center retrospective study was conducted in our center. The clinical data of hospitalized patients received diuretics from January 2018 to December 2020 was retrospectively analyzed. Among the 18,148 hospitalized patients included in the study, 2,589 patients (14.26%) were judged as incidence with AKI, while only 252 patients were diagnosed with AKI in the medical record. Among diuretics drugs in the study, the incidence rate of AKI with torasemide was the highest with 21.62%, and hydrochlorothiazide had the lowest incidence rate (6.80%). The multiple logistic regression analysis suggested that complicated with hypertension, anemia, pneumonia, shock, sepsis, heart failure, neoplastic diseases, combined use of proton pump inhibitors (PPI) were independent risk factors for AKI related to diuretics. The logic regression models for diuretics related AKI were developed based on the included data. The model for diuretics-AKI achieved the area under the receiver operating characteristic curves (AUC) with 0.79 on 10-fold cross validation. It is urgent to improve the understanding and attention of AKI in patients received diuretics for medical workers, and the assessment of risk factors before the use of diuretics should be contributed to the early prevention, diagnosis and treatment of AKI, and ultimately reducing morbidity and improving prognosis. Acute kidney injury (AKI) is a series of clinical syndromes in which serum creatinine (Scr) concentrations increase over a short period of time, or urine output decreases. It has become an increasing global concern . In the Diuretics are one of the well-known nephrotoxic drugs, since they can directly or indirectly cause a significant decrease in renal blood perfusion and glomerular filtration rate through the mechanism of affecting tubulobulb feedback, which leads to kidney ischemia and hypoxia . HoweverThis study was approved by the Ethics Committee of First Affiliated Hospital of Shandong First Medical University . There is no personally identifiable information in this manuscript.A retrospective cohort study was conducted based on the clinical information from the electronic medical records at the First Affiliated Hospital of Shandong First Medical University. The clinical data for this study was collected from the hospital healthcare big data platform, which integrated multi-source data from hospital information system (HIS), electronic medical records (EMR), laboratory information management system (LIS), picture archiving and communication system (PACS) and nursing information system (NIS). The clinical information included sociodemographic characteristics, comorbidities, inpatient departments, diagnostics, laboratory testing, operation, hospitalization days, hospitalization costs, and concomitant nephrotoxic medication. A multidisciplinary research team, including clinical pharmacist, clinician, epidemiologist, and statistician, was developed to ensure effective implementation of the study.2 within 48 h after admission; 4) AKI was diagnosed on admission; 5) less than two Scr test results during hospitalization; 6) the Scr values were always lower than 40 μmol/L during hospitalization; 7) cases with incomplete medical history information.The patients were included if received treatment with diuretics and discharged from the hospital between 1 January 2018 and 31 December 2020. We excluded the patients who met any of the following criteria: 1) hospital stay < 48 h; 2) Age < 18 years; 3) GFR < 30 ml/min/1.73 mThe diagnosis of AKI was based on Scr changes in accordance with the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for AKI . AKI cant test or analysis of variance. The data disobeying the normal distribution were expressed by the median and interquartile spacing, and comparison between groups adopted Wilcoxon rank sum test. For counting data, the number of cases (n) or constituent ratio (%) were used to express. Chi-square test was employed for comparison between groups. The investigated variables were taken as independent variables and AKI groups as dependent variables, and the chi-square test was used for univariate analysis. Then the variables with p < 0.05 in univariate analysis were included in multivariate logistic regression analysis to identify the significant independent risk factors of acute kidney injury caused by aminoglycosides in hospitalized patients. The analysis results were expressed in odds ratio (OR) and 95% confidence interval (95% CI). All p values are 2-sided, and a p value of <0.05 was deemed significant.R software (version 3.6.3) was used for all data analyses in this study. For continuous variables, the Kolmogorov Smirnov (K-S) test was used to assess whether the data were normally distributed. The data obeying the normal distribution were expressed by mean ± SD, and the difference between groups was tested by The logistic regression has become one of the most widely used analytical tools in the medical information field , due to There were 18,148 patients prescribed with diuretics included in the analysis. Among them, 2,589 patients could be diagnosed with AKI according to KDIGO 2012 guidelines, the incidence of diuretics related AKI was 14.26% .χ2: 1.03, p = 0.31).In the AKI group, there were 1,643 males (63.46%) and 946 females (36.54%), and there were 9,711 males (62.41%) and 5,851 females (37.59%) in the non-AKI group, as shown in p < 0.001). The incidence rate of young group (18–40 years old), middle age group (41–65 years old) and elderly group (66 years old or above) were 13.40% , 12.97% , 15.47%  respectively, among which the elderly group had the highest incidence of AKI . For smoking history, there was no difference between AKI and non-AKI groups . The nutritional status of the patients was divided into four groups based on Body Mass Index (BMI), including underweight (BMI < 18.5), normal weight (18.5 ≤ BMI < 24), overweight (24 ≤ BMI < 28), and obesity (BMI ≥ 28). The median BMI of AKI group was 23.70 , the median BMI in the non-AKI group was 23.89 , and there was no statistical significance between the two groups (p = 0.42).The median age of AKI group was 67.0  years, which was slightly higher than that of non-AKI group with 65.0  years (p < 0.001).In AKI group, the median length of stay of hospitalized patients was 15.94  days, and the median total cost of hospitalization was 92,593.2  Chinese yuan (CNY). While, the median length of stay of inpatients in non-AKI group was 15.19  days, and the median total cost of hospitalization was 48,543.98  CNY. The length of stay and total cost of patients in AKI group were significantly higher than those in non-AKI group . On the basic condition of hospitalization, the median length of stay and the median cost of hospitalization in AKI group were also higher than those in non-AKI group. As shown in By consulting the in-hospital medical records of adult inpatients included in this study, only 9.73%  were diagnosed as acute kidney injury by doctors during hospitalization. All other patients met the diagnostic criteria for AKI in terms of changes in kidney function and all indicators during their hospital stay. However, the diagnosis was not confirmed, with an underdiagnosis rate of 90.27% . The patients diagnosed as AKI on the first page of inpatient medical records are mainly distributed in departments of ICU, cardiovascular medicine, neurology, Hepatology, neurosurgery, and oncology.χ2: 31.37, p < 0.001), diabetes , cerebral apoplexy , anemia , coronary heart disease , pneumonia , shock , sepsis , heart failure , skin tissue infection , neoplastic diseases , chronic kidney insufficiency , chronic obstructive pulmonary disease , hypokalemia , hyponatremia , liver injury , acidosis .In the study, the hospitalized patients with AKI usually had a variety of diseases at the same time, as shown in χ2: 3.87, p = 0.04), angiotensin IIreceptor inhibitor (ARB) drugs , angiotensin converting enzyme inhibitor (ACEI) drugs , proton pump inhibitor (PPI) , β-Lactam drugs  had significant difference between AKI and non-AKI groups.As shown in In the AKI group, 15.99%  of patients underwent surgery during hospitalization, 5.26%  underwent cardiac surgery and 10.39%  underwent angiographic surgery. In the non-AKI group, 68.87%  underwent surgery, of which 4.52%  and 11.85%  underwent cardiac surgery and angiography, respectively.p < 0.05) between AKI group and non-AKI group were selected for multivariate logistic regression to further analyze the relevant risk factors. The results are shown in The variables with significant difference  in our center. It was reported that the in-hospital AKI detection rate in China was 2.3%  and a stp < 0.001). Besides, the proportion of patients with AKI admitted to ICU was higher, which increased the hospitalization expenses of patients to a certain extent. The huge expenses brought by AKI and its complications to patients should not be underestimated.Moreover, both length of stay in hospital and total cost of hospitalization in the AKI group were higher than those in non-AKI group  cases were clearly diagnosed as AKI in medical records, the missed diagnosis rate was quite high. The high missed diagnosis rate may be due to that kidney injury and kidney function monitoring were generally lacking. Therefore, it is extremely urgent to improve kidney safety. For several departments with high diagnosis rate, the clinical indicators were paid closer attention. The changes of indicators reflecting kidney function, such as creatinine and urine volume, can be found timelier. It can result in early diagnosis of acute kidney injury and the prognosis of patients. The diagnosis of AKI mainly relied on the changes of serum creatinine and urine volume. The lack of continuous monitoring or low attention of dynamic kidney function indicators may lead to more serious missed diagnoses. Besides, the strength of inference on the causality was thus weakened given the nature of retrospective study.The adequate dynamic monitoring of kidney indicators and enough attention of the medical team must be helpful to improve the diagnosis rate of AKI caused by diuretics. In addition, we also recommend that clinical pharmacists be provided to the department needing special attention, since the clinical pharmacists are more aware of drug-induced diseases . The sufThe surgery during hospitalization may contribute to the increased probability of AKI. It is generally believed that the operations can lead to changes in hemodynamics, activation of inflammatory mediators , and theThere were several limitations for our study related to the retrospective design. First, in the present study, AKI was diagnosed based on the dynamic changes in Scr independently of urine output, which would have missed some AKI cases. Second, the determination of AKI was based on reviewing medical records and therefore might result in misdiagnosis in some cases. Third, the diagnosis of AKI emphasizes the change of creatinine in a short time, but the monitoring of creatinine was not adequate in our center. Lastly, the patients with missed clinical test indicators and inaccurate test results were eliminated in the study, this may bring bias on the final statistical results to a certain extent.The investigation indicated the high incidence rate of diuretics associated AKI (14.26%) in our center, while more than 90% cases were not detected and diagnosed in time. It is urgent to improve the understanding and attention of AKI for medical workers. Several risk factors for diuretics associated AKI were screened out, including old age, admission to ICU, suffering underlying diseases , combined use of PPI and β-Lactam drugs. Based on the meaningful variables obtained from single factor analysis, we developed the logistic regression models for AKI risk in hospitalized patients received diuretics. The model for diuretics-AKI performed well and the AUC value was 0.79 on 10-fold cross validation. Before using diuretics, full evaluation of the risk factors and close attention to the indexes of kidney function must be helpful to the decrease of diuretic related AKI. Meanwhile, it is necessary to improve the cognition and incidence rate of AKI among medical staff and patients. We suggested the incidence of AKI in hospitalized patients received diuretics should be taken seriously, and the risk factors for AKI need to be fully assessed before the patients receive diuretics to avoid the incidence of AKI.


Since 2020, longer stay-at-home time in response to the coronavirus disease 2019 (COVID-19) pandemic has changed the weight-related behaviors of Chinese population.To explore the demographic and basic characteristics of body fat scale users and to investigate the changes in obesity-related body composition of overweight and obese users during COVID-19. Further, we analyzed the factors associated with successful weight loss and improved body composition changes in overweight and obese people.2 were screened to investigate the independent factors associated with effective weight loss and improved body composition changes by multivariable logistic regression analyses.The study included 107,419 Chinese adults registered in the smart app connecting to the body fat scale in 2020 to describe the demographic characteristics of body fat scale users by Unpaired Student’s t-test and Chi-Square test. Subsequently, overweight and obese participants with body mass index (BMI) of more than 24 kg/mDuring the pandemic, the number of body fat scale users increased markedly compared with pre-pandemic. Over half of the participants were women and with normal baseline BMI. Based on BMI classification, multivariable logistic regressions showed that age, gender, measurement frequency classification, baseline BMI, visceral adipose index and skeletal muscle rate were associated with weight loss and fat loss in the overweight and obese population, with the high-frequency measurement being the most important factor for effective weight and fat loss. In the population with normal BMI obesity, younger age was the most significant factor for effective fat loss.During the COVID-19 pandemic, participation in self-monitored weight loss increased markedly compared with pre-pandemic, and women accounted for the majority. We found that many overweight and obese participants achieved weight loss goals by smart body fat scales, and the effectiveness of weight and fat loss was greater in obese participants than in overweight participants, both based on BMI and PBF classification. In addition, promoting the usage of smart body fat scales could contribute to more effective weight and fat loss in the overweight and obese population based on BMI classification. However, in the population with normal BMI obesity, young subjects might be easier to successfully lose fat compared with the elder. Digital self-management by smart body fat scales could become a promising approach for the obese population with high BMI to lose weight and keep healthy. Due to the rapid improvement of economic level and the westernization of dietary habits in China, the proportion of overweight and obese patients in the adult population climbed from 18.9% and 2.9% in 2002 to 34.3% and 16.4% in 2020, respectively . Obesityvia Bluetooth compared with the group that entered weight data manually, and the percentage of participants who achieved weight-loss goals was also noticeably higher  and PBF (below 10%) were excluded. Furthermore, participants whose annual measurement frequency was less than 2 times were also excluded. 107,419 subjects were included to describe the basic and demographic characteristics of body fat scale users registered in 2020. Then, 31,227 overweight participants with BMI of 24-27.9 kg/m2 and 15,509 obese participants with BMI ≥28 kg/m2 were followed up to investigate the improvement of obesity-related body composition indices for at least one year, which meant the time span from the first measurement to the last measurement was more than 1 year. Moreover, 13,724 participants with normal BMI but excessive PBF were also followed up , BMI , skeletal muscle rate (SMR) and fat-to-muscle ratio (FMR) by using the same brand, the same type of body fat scales . The measurement principle of the body fat scales is the multi-frequency bioelectrical impedance analysis (BIA), as same as the previous study . The par2, 18.5 - 23.9 kg/m2, 24 - 27.9 kg/m2, and ≥28 kg/m2 were considered as underweight, normal, overweight and obesity respectively. Male with PBF ≥25.0% and female with PBF ≥30.0% were regarded as obese , measurement frequency was described as median and interquartile range (IQR), and categorical variables were described as count and percentage. Unpaired Student’s t-test or one-way ANOVA was used to analyze differences among groups, and differences in constituent ratios were analyzed by Chi-Square test. Univariable and multivariable logistic regression analyses were used to assess the independent influencing factors of the annual change rates of body weight, PBF, and SMR, respectively. Statistical analyses were performed using the Statistical Package for the Social Sciences . Statistically significance was set at p value <0.05.2, P <0.0001), the proportion of overweight and obese users was also higher in men than in women . Interestingly, the largest proportion of female users was in the normal BMI group (56.4%), and the average annual measurement frequency of female users was much higher than that of male users .The annual number of users registered in 2020 during the pandemic  was significantly higher than that in 2019 before the pandemic . During the pandemic, over half of the participants were women (84.7%) and with normal BMI. On average, participants were 32.87 ± 8.51 years and consisted of underweight (4.1%), normal (52.4%), overweight (29.1%), and obesity (14.4%) Table 1.2. In obese women, the annual weight loss was 4.74 ± 8.78 kg, and the BMI decreased by 1.80 ± 3.36 kg/m2. Grouped by PBF, obese participants showed greater changes in all indices than normal individuals as well (P <0.0001). Among different measurement frequency groups, the changes of all obesity-related indices in the high-frequency group were significantly greater than those of the low and middle-frequency groups (P <0.0001)  at baseline who had healthy needs of weight loss were followed up for longer than one year. There was no statistical difference in the annual weight loss of participants among different age groups. Nevertheless, the group aged 18-40 years experienced a greater decrease in PBF and a greater increase in SMR compared with the group aged 40-60 years. According to BMI classification, obese participants showed greater changes in all indices, including weight, BMI and PBF compared with overweight participants (P <0.0001). In obese men, on average, the annual body weight decreased by 3.90 ± 7.77 kg (<0.0001) Table 2.2 - df). High measurement frequency was the largest predictor for effective weight loss  when other associated factors were corrected, including age, gender, baseline BMI, PBF, VAI and SMR .Multivariable logistic regression analysis showed that lower age, male sex, lower baseline VAI, SMR, higher baseline BMI and measurement frequency were independent factors for effective fat loss Table 3.2 - df = 384.43, P <0.0001) when other factors were corrected. Other than lower age, significant factors associated with successful muscle gain were male sex, higher measurement frequency, higher baseline BMI, lower baseline VAI and SMR , which indicated that participants were not only concerned about changes in weight and BMI, but PBF management was also an important part of health monitoring Table S2Obesity, closely related to chronic metabolic diseases such as hypertension and diabetes, endangers the health of Chinese , 26. RecThe COVID-19 pandemic has resulted in overall changes to weight-related behaviors, including dietary intake and physical activity . Based oSelf-monitoring was the core of behavioral intervention for weight loss, including weight monitoring. Several studies found that self-monitoring was positively correlated with weight loss –33. Howe2 weighed using a commercial online smart scale and received active weight loss therapy simultaneously. This study showed that higher weight monitoring frequency was associated with better weight loss, which was consistent with numerous studies (A clinical study published by Carter et al. found that the participant’s compliance with weight monitoring by smartphone was significantly improved compared with paper diary and website monitoring . In Thom studies , 33. Ben studies . The sus studies , which w studies . This inOur study revealed the beneficial role of self-monitoring of weight and body composition by a smart body fat scale in self-managed weight loss and amelioration of body composition in Chinese overweight and obese people during the COVID-19 pandemic. Moreover, we indicated promoting the usage of smart body fat scales could contribute to weight and fat loss in the overweight and obese population with high BMI, thus promoting remote weight self-monitoring by smart body fat scales in clinical practice might help the progression of weight loss in obese patients. However, there were also some limitations in our study, one of which was that participants’ conditions were not taken into account, such as diabetes and thyroid-related disease, which might affect body composition. Moreover, other contributing factors of weight loss, such as dietary intake or physical activity were not included during the follow-up periods, and some accidental conditions might affect the accuracy of body fat measurements by BIA in our real-world study, such as the hydration status. A large randomized intervention trial could be performed to reinforce the results of this study. Nevertheless, this study analyzed a sizable population from the majority of Chinese urban cities, which implied the potential advantages of health economics through self-monitored weight loss by smart body fat scales.In conclusion, during the COVID-19 pandemic, participation in self-monitored weight loss increased markedly compared with pre-pandemic, and women accounted for the majority. We found that many overweight and obese participants achieved weight loss goals by smart body fat scales, and the effectiveness of weight and fat loss was greater in obese participants than in overweight participants, both based on BMI and PBF classification. In addition, promoting the usage of smart body fat scales could contribute to more effective weight and fat loss in the overweight and obese population by BMI classification. However, in the population with normal BMI obesity, young subjects might be easier to successfully lose fat compared with the elder. Digital self-management by smart body fat scales could become a promising approach for the obese population with high BMI to lose weight and keep healthy.The datasets presented in this article are not readily available because restrictions apply to the availability of these data. Data were obtained from the Qingniu Health app and are available from the authors with the permission of the Qingniu Health app. Requests to access the datasets should be directed to Weixia Jian, jianweixia@xinhuamed.com.cn.The studies involving human participants were reviewed and approved by Xinhua Hospitals’ Ethics Committee. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.XH, ML, YS, HY, ZL, WK, BL, JS, WZ and WJ implemented the study. XH, ML, and WJ wrote the manuscript. YS, HY and ZL analyzed the data. All authors participated in the design of the studies, analysis of the data and review of the manuscript. All authors contributed to the article and approved the submitted version.This research was funded by the Natural Science Foundation of Shanghai, grant number 20ZR1435300.We would like to thank all participants in this study and the Qingniu Health app.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The intra- and post-operative acute (within 72 h) hemorrhagic complications of endovascular treatment (EVT) for a brain arteriovenous malformation (BAVM) are disastrous. Thus, further experiential summaries are required to fully understand them.via EVT with Onyx embolization and suffered intra- and post-operative acute hemorrhage. The clinical and imaging data of the patients were recorded, analyzed, and discussed.This was a retrospective study of 25 patients with consecutive BAVM who were treated Twenty-five patients were aged 11–70 years , of whom 12 were female . Of the 25 hemorrhagic complications, 17  were intraoperative, and 8  were post-operative and occurred between 1 and 12 h after EVT. Of 17 intraoperative hemorrhages, 13  were due to high-pressure Onyx casting. Of eight post-operative hemorrhages, six  were attributed to normal perfusion pressure breakthrough. The degree of nidus Onyx embolization was more than 2/3 or complete in seven  BAVMs. Draining vein occlusion was observed in eight  of 25 BAVMs. After hemorrhage, conservative treatment was administered in 12  cases, and surgical management was performed in other cases. There were eight cases of mortality; the remaining 17 patients had follow-up data. Among them, 15 patients had good outcomes, with Glasgow Outcome Scale scores of 5 and 4, accounting for 60% (15/25).In EVT for BAVMs, intra- and post-operative acute hemorrhagic complications are disastrous; only 60% of patients have a good outcome. Therefore, high-pressure Onyx casting or casting too much Onyx at one time to pursue a high degree of nidus embolization should be performed cautiously, and primary draining vein occlusion should be avoided. In short, EVT needs to be performed carefully. Brain arteriovenous malformations (BAVMs) consist of a tangle of arterialized venular vessels without interposing capillaries, presenting with spirally coiled shapes, which form numerous fenestrated channels; they intercommunicate and empty into thin-walled draining veins . EndovasCurrently, the use of the Onyx liquid embolic system  is popular in EVT for BAVMs . HoweverThe inclusion criteria were as follows: EVT of BAVM with Onyx embolization; and hemorrhagic complication during or in the acute phase after EVT, defined as within 72 h after EVT , 9. The The data included age, sex, clinical presentation, and intracerebral hemorrhage (ICH) score .The location and the Spetzler–Martin (SM) grade of each BAVM were recorded . The strThe origin and remodeling status of the primary and secondary feeding arteries were recorded. The primary feeding artery was the main and largest feeding artery, and the secondary feeding arteries were accessory and thin. Under hemodynamic stress, feeding arteries gradually transition from normal to increasingly abnormal, resulting in remodeling, defined by a diameter two times as large as normal .A BAVM nidus is a venous component that has a diameter many times larger than the diameter of capillaries, and the size of the nidus was recorded . A BAVM via superficial and deep draining veins or via primary and secondary draining veins. The primary vein is the largest and collects most of the outflow from the BAVM. The type of draining vein was recorded. Remodeling of the draining vein was also recorded, including the presence of dilation and stenosis  was used to access the nidus to achieve the wedge position via the feeding artery. Then, the Onyx was cast. If further EVT was needed, another feeding artery could be chosen to repeat the Onyx casting. In EVT for BAVMs, weak structures, such as associated aneurysms and fistulous components, should be given priority for treatment. If no weak structure is identified, the main purpose of EVT is to reduce the blood flow of BAVMs to help reduce nidus/perinidal angiogenesis , or subarachnoid hemorrhage (SAH), among other types, which were recorded. When hemorrhagic complications occurred, the degree of BAVM nidus embolization was recorded as < 1/3, 1/3–2/3, > 2/3, or complete embolization. Whether the draining vein was occluded was also recorded.When intraoperative hemorrhage occurred, continuous EVT was performed promptly to stop the bleeding. EVT cannot be performed for post-operative hemorrhage. In this case, first, the patients were treated with sedation and controlled hypotension, reducing the systolic pressure to 80–90 mmHg or the average arterial pressure to ~50–65 mmHg . For hemBleeding can originate from any part of a BAVM . During Postoperative hemorrhage can originate from an intranidal aneurysm , the nidThe Glasgow Outcome Scale (GOS) score was used to evaluate the outcome at discharge and during the follow-up. The GOS score, ranging from grade 1 to 5, was recorded for all of the patients .During the period from January 2010 to December 2021, 673 patients diagnosed with a BAVM accepted EVT with 856 Onyx embolization procedures. Of them, 25 experienced intra- or post-operative acute hemorrhage, for a rate of 3.7% (25/673) per patient and 2.9% (25/856) per procedure.The patients were aged from 11 to 70 years , of whom 12 were female . Four  patients had an unruptured BAVM; among them, one complained of headache, and three were admitted for epilepsy. Twenty-one  patients were admitted for intracranial hemorrhage, including eight patients with ICH, six patients with IVH, five patients with SAH, and two patients with both ICH and IVH. Among the 21 patients with intracranial hemorrhage onset, the ICH score was 1.4 ± 0.7 .The primary feeding arteries of the 25 BAVMs were as follows: middle cerebral artery, 6 ; posterior cerebral artery, 6 ; superior cerebellar artery, 4 ; posterior choroidal artery, 3 ; anterior inferior cerebellar artery, 2 ; anterior cerebral artery, 2 ; anterior choroidal artery, 1 ; and middle meningeal artery, 1 . Regarding the feeding arteries, remodeling of the primary artery was observed in nine  BAVMs . Of the All 25 BAVM niduses were compact, with a diameter of 2.8 ± 1.1 cm (0.75–5 cm). The locations were as follows: posterior temporal lobe, 5 ; temporal horn of the lateral ventricle, 4 ; trigone of the lateral ventricle, 3 ; cerebellar hemisphere, 3 ; cerebellar vermis, 2 ; frontal lobe, 2 ; body of the lateral ventricle, 1 ; brainstem, 1 ; occipital lobe, 1 ; parietal lobe, 1 ; basilar ganglia, 1 ; and posterior thalamus, 1 . Perinidal angiogenesis was observed in 11  BAVMs. The SM grades were as follows: grade 1, 2 ; grade 2, 12 ; grade 3, 8 ; and grade 4, 3 .The deep vein was used as the primary vein draining model in 12  BAVMs, and the superficial vein was used in 13 . Remodeling of the primary draining vein was observed in 14  BAVMs, of which 12 draining veins showed dilatation and two draining veins showed both dilatation and stenosis. Of the 25 BAVMs, 10  fit the secondary draining vein model, while a hidden draining vein was observed in one patient, appearing after EVT .Of the 25 BAVMs, 13  were associated with aneurysms; three had aneurysms on the feeding artery, six had intranidal aneurysms, and four had aneurysms on the draining vein. No fistulas associated with BAVMs were found.Of the 25 patients, two patients accepted EVT with Onyx embolization before admission. Of the 21 patients with ruptured BAVMs, the period between onset and EVT was < 1 day in five patients, 2 days in six patients, 3 days in seven patients, 4 days in one patient, and 5 days in two patients. Of the 25 BAVMs, 17  required a single EVT procedure, and eight  required two EVT procedures; overall, 33 procedures were performed. Of them, the Marathon was used in 28 procedures, an Apollo detachable microcatheter was used in four procedures, and the Echelon-10 was used in one procedure. The pressure cooker technique was applied in four  procedures.Seventeen  of the hemorrhagic complications were intraoperative, and eight  were post-operative, occurring between 1 and 12 h  after EVT. The hemorrhagic complications included ICH in seven  patients, IVH in six , both ICH and IVH in five , SAH in two , both SAH and ICH in four , and SAH, ICH, and IVH in one .The hemorrhagic origin in the 17 intraoperative cases included four  perforating complications  and 13  ruptures of the BAVM structure from high-pressure Onyx casting . The hemorrhagic origin in the eight post-operative cases included three  nidus ruptures, two  intranidal aneurysm ruptures, one  perinidal angiogenesis rupture, and two  draining vein system ruptures.When a BAVM ruptured, of the 17 intraoperative hemorrhages, the degree of nidus embolization with Onyx was < 1/3 of the nidus in four  BAVMs, 1/3–2/3 of the nidus in four , more than 2/3 of the nidus or the complete nidus in five , and no embolization of the nidus in four  due to perforating complications. Of the eight post-operative hemorrhages, the degree of the nidus embolization with Onyx was < 1/3 of the nidus in one  BAVM and more than 2/3 of the nidus or the complete nidus in seven .Among the 13 associated aneurysms, Onyx embolization was performed for three feeding artery aneurysms and four intranidal aneurysms, Onyx embolization failed in two intranidal aneurysms, and Onyx casting was performed to reduce the blood flow to four venous aneurysms on draining veins.Of the 25 BAVMs, eight  showed varying degrees of primary draining vein occlusion, including complete occlusion of the primary vein in one BAVM, complete occlusion of both the primary and secondary veins in two BAVMs, incomplete occlusion of the primary vein in four BAVMs, and incomplete occlusion of the primary vein and complete occlusion of the secondary veins in one BAVM. Of the eight occluded primary draining veins, four were associated with intraoperative hemorrhage, and four were associated with post-operative hemorrhage.Of 17 BAVMs associated with intraoperative hemorrhage, continuous Onyx casting to stop the bleeding was applied in 16 BAVMs, and no management was given in one BAVM . After hAt discharge, seven 28%, 7/25) patients had a GOS score of 5, five  patients had a score of 4, four  patients had a score of 3, one  patient had a score of 2, and eight  patients were deceased, with a score of 1. Among the 17 surviving patients, the follow-up period ranged from 1 to 132 months . Eleven of these patients had a GOS score of 5, four patients had a score of 4, one patient had a score of 3, and one patient had a score of 2, with a good outcome (GOS score of 5 or 4) in only 60% (15/25). The detailed clinical and imaging data are shown in 8%, 7/25 Except for SM grade IV or V BAVMs, which are generally monitored by observation unless ruptured, EVT plays an important role in securing high-risk bleeding points  or reducing the flow to help shrink the nidus or area of perinidal angiogenesis , 26. ForHowever, EVT for BAVMs is a challenge, especially considering hemorrhagic complications, which are the most frequent complication of EVT, reported in 2–12.5% of procedures , 36. In In our study, the rate was 3.4% per patient and 2.9% per procedure, which is lower than that in the above reports. The main reason for this difference is that our study excluded hemorrhagic complications occurring more than 72 h post-operatively, which resulted in the inclusion of fewer cases. At our center, microwire navigation and microcatheter catheterization are performed very cautiously. Therefore, the rate of arterial rupture due to technical complications is not as high as that reported by Baharvahdat et al. in their report, 48% of hemorrhagic complications were related to arterial rupture ; in our High-pressure Onyx casting plays an important role in the intraoperative rupture of BAVMs, and this type of complication should also be considered a technical complication . During via dual catheters because injection from two different feeders can result in the gradual, centripetal exclusion of the nidus  hemorrhages attributed to draining vein system rupture, six 75%, 6/8) post-operative hemorrhages were attributed to normal perfusion pressure breakthrough. The casting of an excessive amount of Onyx at one time can increase the occurrence of post-operative normal perfusion pressure breakthrough –47. In a5%, 6/8 pIn our study, of the eight BAVMs with post-operative complications, primary draining vein occlusion occurred in four, accounting for 50%, which increased the risk of post-operative hemorrhagic complications. When the draining function of the primary draining vein is impaired due to unexpected Onyx occlusion or curative embolization, venous congestion in the adjacent brain region might progress through delayed thrombosis in the draining vein, and the scant venous flow may result in delayed occlusion of the remaining drainers, resulting in post-operative venous hemorrhage , 49. OurIntra- and post-operative acute hemorrhagic complications may be disastrous; in our study, 40% of patients died. For intraoperative hemorrhage, the only treatment available is continuous embolization until the bleeding stops. If the rupture point is small, there is less bleeding, and a good prognosis can be achieved; otherwise, the bleeding can be disastrous or fatal. EVT cannot be performed for post-operative hemorrhage, and the prognosis is determined by the severity and location of the hemorrhage.For intraoperative hemorrhagic complications, in addition to vessel rupture-related complications, high-pressure Onyx casting is an important risk factor. For post-operative acute hemorrhagic complications, casting an excessive amount of Onyx at one time to increase the degree of nidus embolization may result in post-operative hemorrhage due to normal perfusion pressure breakthrough. Primary draining vein occlusion can also increase the risk of intra- and post-operative acute hemorrhage. Hemorrhagic complications can be disastrous; in our study, only 60% of patients had a good outcome.This was a retrospective study without a control group. The conclusion should be interpreted with caution. In addition, the results cannot indicate whether the rupture status of BAVMs prior to EVT is related to the occurrence of post-operative hemorrhagic complications, whether hemorrhage complications tend to occur in infratentorial BAVMs or high SM grade BAVMs, or whether the pressure cooker technique increases hemorrhage complications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.JY and XC contributed to the conception, design of the manuscript, and critically revised the manuscript. XC and YW wrote the manuscript and collected the medical records of the patients. All authors approved the final version of this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.