However, serum levels of ketone bodies and HCG did not correlate with neonatal body shape. When weight loss during pregnancy was used as an index of morning sickness, a higher pre-pregnancy body mass index was associated with greater weight loss. This study is the first to show that serum ketone body levels are maximal in the third trimester of pregnancy. As the elevation of serum ketone bodies in the third trimester is a physiological change, high serum levels of ketone bodies may be beneficial for mothers and children. One of the possible biological benefits of morning sickness is the prevention of diseases that have an increased incidence due to weight gain during pregnancy.Among the physiological changes occurring during pregnancy, the benefits of morning sickness, which is likely mediated by human chorionic gonadotropin (HCG) and induces serum ketone production, are unclear. We investigated the relationship between serum levels of ketone bodies and HCG in the first, second, and third trimesters and neonatal body shape  in 245 pregnant women. Serum levels of 3-hydroxybutyric acid peaked in late-stage compared with early stage pregnancy (27.8 [5.0–821] vs. 42.2 [5.0–1420] μmol/L, median [range],  Approximately 80% of pregnant women develop morning sickness, with 0.5–0.8% becoming severe enough to necessitate hospitalization ,2,3. TheIn patients with severe morning sickness, ketone bodies are detected on urinalysis. Ketone bodies can pass through the placenta and become a source of nutrition for the fetus . In adulThe HCG level increases in early stage pregnancy, and this increase is considered one of the causes of morning sickness —a theoryWe hypothesized that an increase in the levels of maternal serum ketone bodies and HCG in early pregnancy is possibly beneficial for the fetus. Therefore, this study was conducted to investigate the biological benefits of morning sickness by comparing the levels of serum ketone bodies and HCG during early pregnancy with factors related to neonatal growth.This study was approved by the Institutional Review Board of the Hokkaido University Hospital (019-0390). All participants provided written informed consent prior to their participation in the study. The study enrolled 379 pregnant women who were scheduled to give birth in Obihiro-Kosei General Hospital, Hakodate Central General Hospital, or the Japan Community Health Care Organization Hokkaido Hospital between October 2018 and April 2019. Physicians at the study sites selected participants based on the following inclusion criteria: (1) those aged 18 years or above, (2) those scheduled to give birth at participating institutions, and (3) those who agreed to participate in the study. The exclusion criteria were as follows: (1) those with complications from earlier pregnancy and (2) those with a gestational age of 14 weeks or above.Blood samples were collected at the time of regular blood tests in the first , second , and third trimesters , and the serum levels of ketone bodies  and HCG were quantified. In addition, the participant’s age, height, pre-pregnancy weight, pre-pregnancy body mass index (BMI), weight at blood sampling, weight at delivery, BMI at delivery, pregnancy and delivery history, weeks of delivery, delivery pattern, placental weight, and neonatal findings  were recorded from the medical records. The relationship of morning sickness with serum levels of ketone bodies and HCG was retrospectively examined.In the analysis phase, pregnant women who delivered after 36 weeks of gestation were included, whereas patients with twin pregnancies, thyroid disease, preeclampsia, kidney disease, and defect data were excluded.Serum was stored at −80 °C until assays were conducted for the following four blood variables: total ketone bodies, acetoacetic acid, 3-hydroxybutyric acid, and HCG levels were measured using enzyme linked immune sorbent assay kits TKB-L , 3HB-L , and II HCG , respectively.t-test and the Tukey–Kramer method. Single regression analysis was used to investigate the relationship between ketone bodies and perinatal prognosis. In all analyses, statistical significance was set at p < 0.05. Statistical analyses were performed using the JMP Pro14© statistical software package . Changes in variables within a group were compared using the Among the 379 pregnant women who participated in the study, 197, 94, and 88 were screened from Obihiro-Kosei General Hospital, Hakodate Central General Hospital, and the Japan Community Health Care Organization Hokkaido Hospital, respectively. However, after screening, 105 eligible women who missed blood sampling during the first, second, or third trimester (including preterm birth at <36 weeks of gestation), 6 women with twin pregnancies, 15 with thyroid disease, 4 with preeclampsia, 2 with kidneys disease, and 2 with missing data in the medical records were excluded; thus, a total of 245 women, including 11 with gestational diabetes, were included in the final analysis dataset .Among the 245 participants, 85 were primiparas. The mean (standard deviation) age and gestational period at delivery were 31.9 ± 5.0 years and 39.1 ± 1.2 gestational weeks, respectively. The timing of blood sampling was 10.2 ± 1.5, 25.8 ± 1.3, and 36.2 ± 0.9 gestational weeks for the first, second, and third trimesters, respectively. There were 13 deliveries at 36 gestational weeks, 191 transvaginal deliveries, and 54 cesarean deliveries .The median 3-hydroxybutyric acid levels were 27.8, 21.2, and 42.2 μmol /L in the first, second, and third trimesters, respectively. The median concentrations of acetoacetic acid, which reflects the ketone body index for a longer period than the 3-hydroxybutyric acid, were 18.6, 19.9, and 24.1 μmol/L in the first, second, and third trimesters, respectively. The median HCG levels were 132,000, 16,400, and 22,300 IU/L for the first, second, and third trimesters, respectively. The 3-hydroxybutyric acid concentration decreased in the second trimester, but the acetoacetic acid levels showed a tendency to gradually increase from the first to the third trimester. As a 50 g glucose challenge test (GCT) is conducted at the time of regular blood sampling in the second trimester, it was considered that the blood sampling at 60 min after consuming 50 g glucose affected the levels of total ketone bodies and decreased the 3-hydroxybutyric acid level. However, as acetoacetic acid has a long half-life, it is considered to have been less affected by the glucose challenge test .p < 0.001)  and the other participants (with GCT). The median 3-hydroxybutyric acid level was significantly higher among the participants in the without GCT group than among those in the with GCT group  . Therefo< 0.001) . The 3-hydroxybutyric acid level during pregnancy in the without glucose challenge test group gradually increased in the order of the first, second, and third trimester.The serum HCG level was high in the first trimester, peaked at 8 weeks of gestation, and decreased gradually, but did not change considerably from the second to the third trimester .The serum HCG level was high in the first trimester, peaked at 8 weeks of gestation, and decreased graduallyWe examined the correlations between the neonatal body shape and the serum levels of 3-hydroxybutyric acid, acetoacetic acid, and HCG in the first trimester, but found no significant correlation with the birth weight, birth length, birth head circumference, or birth chest circumference .There were no correlations between the neonatal body shape and the serum levels of 3-hydroxybutyric acid, acetoacetic acid, and HCG in the first trimester.No correlation was found between placental weight and the serum levels of 3-hydroxybutyric acid or HCG. There was a positive correlation between the placental weight and birth weight .For an evaluation of the severity of morning sickness, we compared whether there was any weight loss during pregnancy: 88 women lost weight, whereas 157 did not. In the weight-loss group, the levels of total ketone bodies, 3-hydroxybutyric acid, and acetoacetic acid in the first trimester were significantly higher than the levels in the non-weight-loss group; however, there was no significant intergroup difference in the perinatal prognosis. Although the weight loss group had a significantly high pre-pregnancy BMI, there was no significant intergroup difference in the BMI at delivery .This study showed that: (1) serum levels of ketone bodies gradually increased during pregnancy; (2) the serum levels of ketone bodies and HCG in the first trimester did not affect the neonatal body shape; and (3) women who lose weight in early pregnancy have a higher pre-pregnancy BMI, which may lead to physiological benefits from morning sickness that could prevent complications.To our knowledge, this is the first report to show that the serum levels of ketone bodies gradually increased during pregnancy. The abovementioned trend was particularly evident in institutions that did not perform the GCT during the second trimester. There was a significant difference in the serum levels of ketone bodies between institutions that performed the GCT in the second trimester and those that did not, suggesting that sugar intake affected the results of the blood tests . Ketone In this study, we examined the hypothesis that ketone bodies, which are by-products of morning sickness, and, HCG, which is a possible cause of morning sickness, may confer benefits on fetal development. However, there was no correlation between the serum levels of ketone bodies or HCG in the first trimester of pregnancy, when morning sickness is most severe, and the body shape, as ascertained by the birth weight, length, head circumference, and chest circumference of the newborn . We infeWe focused on weight loss during pregnancy as a method for evaluating the severity of morning sickness. On comparing the group that had weight loss and the group that did not, we found that the group with weight loss had significantly higher serum 3-hydroxybutyric acid concentrations in the first trimester. The pre-pregnancy BMI was slightly higher in the group with weight loss during pregnancy than in the non-weight-loss group . This reThere are several limitations of this study. First, weight loss during pregnancy was used as an evaluation method for morning sickness. However, weight loss information is not an adequate indicator of morning sickness. Second, we also excluded cases of preterm delivery, preeclampsia, and several diseases; therefore, the relationship between initial ketone body levels and these diseases remains unclear. Third, a research design to explore the function aspect would be desirable, but it would require monitoring of the growth of newborns and changes in neurological development, which was difficult considering the short study period. Since formation of the neural tube requires cell movement in the surrounding tissues that do not form the neural tube , we thouDuring pregnancy, serum levels of ketone bodies increased from early to late pregnancy and peaked in late pregnancy. As the elevation of serum levels of ketone bodies in the third trimester is a physiological change, high serum levels of ketone bodies may be beneficial for both the mother and the child. However, serum levels of ketone bodies and HCG in early pregnancy had no effect on the neonatal body shape. One of the biological benefits of morning sickness in early pregnancy was the prevention of diseases that possibly increase in frequency due to excessive weight gain during pregnancy. This study did not examine the effects of maternal ketone bodies on fetal neurodevelopment, and further studies are warranted.


Background and Objectives: Aquaporins are a family of water channel proteins. In this study, the renal and intrapulmonary expression of aquaporin-5 (AQP5) was examined in forensic autopsy cases to evaluate it as a drowning marker and to differentiate between freshwater drowning and saltwater drowning. Materials and Methods: Cases were classified into three groups: freshwater drowning (FWD), saltwater drowning (SWD), and controls (CTR). Samples were obtained from forensic autopsies at less than 72 h postmortem  and were subjected to histological and immunohistochemical investigations. Results: In FWD group, intrapulmonary AQP5 expression was significantly suppressed compared with SWD and CTR; there was no significant difference in AQP5 expression among the other two groups. The same differences in expression were also observed in the kidney. Conclusions: These observations suggest that AQP5 expression in alveolar cells was suppressed by hypotonic water to prevent hemodilution. Moreover, it is possible to hypothesize that in the kidney, with the appearance of hypo-osmotic plasma, AQP5 is hypo-expressed, as a vital reaction, to regulate the renal reabsorption of water. In conclusion, the analysis of renal and intrapulmonary AQP5 expression would be forensically useful for differentiation between FWD and SWD, or between FWD and death due to other causes. Drowning represents the second leading cause of death from unintentional injury, after road traffic injuries . AccordiOver the years, further different tests have been proposed as potential tools in determining drowning; in particular, the detection of diatoms in internal organs ,6,7,8 haThis is a very subtle diagnosis since these two processes, despite having different pathophysiology, share a common pathway in brain and organ hypoxia . The difIn recent years new markers have been explored from the forensic perspective of both assessing drowning as cause of death and differentiating FWD and SWD, among which the typing of myelomonocytes , the evaMoving from studies showing the presence of AQP5 in the apical membrane of type-B intercalated cells (ICs) in the connecting tubule and cortical collecting duct of human kidneys , in thisCase selection. Cases were selected from the case series of the Section of Legal Medicine, University of Ferrara, Italy, and the Section of Legal Medicine, University of Foggia, Italy.The study was conducted on tissues previously included in paraffin, and therefore should be considered retrospective. Samples were anonymized following the selection of cases based on cause and mode of death.n = 6), polytrauma (n = 4), overdose (n = 1), gunshot head injuries (n = 6).A total of 30 corpses diagnosed with drowning death, with 15 cases of freshwater drowning (FWD) and 15 cases of saltwater drowning (SWD) included. All cases were subjected to complete autopsy, standard histological examinations (hematoxylin–eosin) and diatom test. As controls (CTR), we selected a total of 17 subjects, who died from sudden cardiac death  until autopsy. Standard sample blocks were taken from lungs and kidneys. In each case, the tissue samples were fixed in 10% formalin and then processed and embedded in paraffin.Histological and immunohistochemical study. For each case, lung and kidney sections of about 4 μm thickness were cut. The sections were immersed in a succession in trays containing xylene, two baths lasting 20 min each, then two 100% alcohol baths of 5 min each, then in 90% alcohol for 5 min, followed by a 20-min bath in 90% alcohol and hydrogen peroxide, then they were immersed in 70% alcohol for another 5 min and finally passed briefly in distilled water. Heat induced antigen retrieval (90 °C for 8 min) was performed using a 0.01 M pH 6 citric acid buffer. After cooling, the slides were washed with PBS. Aquaporin-5 Antibody NBP2-39043—Novus Biologicals was used as a primary antibody, diluted in PBS at 1:100 and incubated for two hours. The samples were subsequently developed with the CTS005 HRP-DAB system R&D kit, exploiting the avidin-biotin system, according to the manufacturer’s indications.We evaluated the presence of non-specific markings due to the avidin-biotin system. Hence, we carried out tests using a polymer system (BioCare Goat-on-rodent HRP-Polymer), obtaining the markings of the same areas.imagej.nih.gov/ij/, accessed on 11 July 2022) and expressed as an extension of the positive stained area.Sections were counterstained with hematoxylin, dehydrated, cover-slipped and observed in a Nikon Eclipse E600 microscope . Quantification of AQP5 positive areas was performed using the ImageJ software . Data were checked for normality and analyzed by Kruskal–Wallis test, followed by Dunn’s multiple comparisons test. For all tests, a p value < 0.05 was considered statistically significant.First, we examined the distribution of AQP5 in the control lungs. As expected, AQP5 was expressed in pneumocytes and bronchial epithelial cells; AQP5-labeling positivity of intra-alveolar macrophages was observed too.p < 0.0001). There was no statistically significant difference in expression between SWD and controls . There was no statistically significant difference in expression between SWD and controls . There is no direct contact of the renal collecting duct cells with the drowning medium, explaining how these cells modify their expression of AQP5 in the very fast time of FWD.Renal expression of AQP5 in FWD cases was significantly lower than in SWD and controls (The authors who identified AQP5 in the human kidney  hypothesIt is possible to hypothesize that in the kidney, with the appearance of hypo-osmotic plasma, AQP5 is hypo-expressed, as a vital reaction, to regulate the renal reabsorption of water.In case of SWD drowning, a very small overexpression of renal AQP5 was observed, although not statistically significant. A possible hypothesis is that the SWD-induced hyperosmolarity is similar to the hyperosmolar state of patients with diabetic nephropathy, a condition that leads to an overexpression of AQP5.The significant immunohistochemical hypo-expression of AQP5 in the samples of lungs and kidneys from FWD compared to those from SWD induces us to consider AQP5 as a reliable marker to which the pathologist may resort whenever dealing with the differential diagnosis between FWD and SWD ,35. The


This study is the first observation of Alcon's PanOptix trifocal intraocular lens (IOL) implanted in 55 cataract patients with femtosecond laser-assisted cataract surgery.  Fifty-five patients (63 eyes) with cataract were treated with femtosecond laser-assisted cataract surgery combined with trifocal IOL implantation. Visual acuity, defocus curve, higher order aberration (HOA), refractive stability, eyeglass removal rate, and satisfaction were evaluated and analyzed.  We found that the visual acuity of patients with near, intermediate, and distance vision was better than 0.1 LogMAR at 1, 3, and 6 months after the completion of surgery. The uncorrected near visual acuity (UCNVA), uncorrected intermediate visual acuity (UCIVA), and uncorrected distance visual acuity (UCDVA) of patients at 1, 3, and 6 months after surgery were compared with those before operation, showing statistical significance. Six months after the operation, all patients' surgical eyes had a smooth transition in the defocus range from +0D to -2.5D, and the visual acuity of the surgical eyes reached a level better than 0.1 LogMAR. The statistical results of 6-month follow-up showed that the eyeglass removal rate at near, intermediate, and far distances was 100%. At 6 months postoperatively, only 1 case had nocturnal glare, which affected life; 3 cases developed glare and halo but did not affect life. The patient satisfaction rate was 98.18%.  Femtosecond laser-assisted cataract surgery with trifocal IOL implantation can remove the lens from the patient with satisfactory visual quality and significantly improve the postoperative satisfaction of the patient. Cataract, one of the most important blinding diseases in the world , is causAt present, phacoemulsification (PHACO) is the mainstay of treatment for cataract among various surgical treatments . PHACO wThe procedure involves removing the damaged lens, which is often replaced with a new artificial lens to restore vision . An IOL The study has been approved by the Ethics Committee of our hospital. Fifty-five patients (63 eyes) with cataract admitted to our hospital from November 2018 to November 2019 and met the surgical requirements were included. Inclusion criteria are as follows: (1) lens opacity; (2) patients with visual acuity <0.3; (3) regular corneal astigmatism ≤0.75D; and (4) Alpha angle <0.5 mm and Kappa angle <0.3 mm. Exclusion criteria are as follows: (1) severe corneal opacity, obstructing the passage of laser; (2) unable to cooperate with this study; (3) severe systemic diseases (such as diabetes); and (4) other eye diseases, such as macular degeneration. All patients in this study signed an informed consent form and agreed to a 6-month follow-up visit. General information of subjects is shown in Patients all underwent routine eye examinations before treatment, including eye B-ultrasound, slit lamp microscope, corneal endothelium, optical coherence tomography, best-corrected visual acuity (BCVA), and uncorrected visual acuity (UCVA). IOL was measured by an IOLMaster optical biometer. The power of IOL was calculated by SRK/T formula, and the target diopter was set close to 0°.All operations were performed by the same experienced doctor. The pupils were fully dilated before the operation, and the surgical eye of the patient placed in the supine position was subjected to topical anesthesia. LenSx , uncorrected intermediate visual acuity (UCIVA), and uncorrected distance visual acuity (UCDVA) were measured before and 1, 3, and 6 months after operation. UCNVA was detected with standard near vision chart, and the detection distance was 40 cm. UCIVA was tested using the standard near vision chart, and the detection distance was 80 cm. And UCDVA was evaluated using the standard logarithmic visual acuity chart, with the detection distance of 40 m.Y-axis and spherical degree as X-axis.Six months postoperatively, the comprehensive refractometer was used to reduce the spherical degree from +2D to -4D with 0.5d as the first gear, and the corresponding spherical degree vision of the patient was detected. The defocus curve was drawn with visual acuity as The higher order aberration (HOA) was measured with an I-Trace visual function analyzer  with a pupil diameter of 3 mm. The total HOA, Trefoil, Coma, and Spherical aberration were recorded before operation and 1, 3, and 6 months after operation. All tests were completed by a doctor who is skilled in operating the system, instructing the patient to open both eyes and open the fixation target. The average was taken after three measurements.Six months after the operation, the diopters (D) of the patients were observed and recorded, and the spherical equivalent (SE) of D was calculated. The histogram was drawn according to the interval distribution of ±1.0d, ±0.75D, ±0.50D, and ±0.25D.Six months after surgery, the subjective visual quality of patients was investigated with the self-made questionnaire, including the rate of eyeglass removal and visual satisfaction. The postoperative eyeglass removal rate was assessed from UCNVA (watching mobile phone), UCIVA (reading), and UCDVA (watching TV). Visual satisfaction, evaluated according to halo, glare, and other visual interference phenomena, was divided into 4 grades ranging from dissatisfied to very satisfied.n (%), and quantitative data were expressed as (−x ± s). Qualitative data, quantitative data, and repeated measurement data were analyzed by χ2, t-test, and analysis of variance (ANOVA), respectively. P < 0.05 means the difference is statistically significant.SPSS 23.0 statistical software  was used to statistically analyze the data. Qualitative data were expressed as P < 0.05), while the comparison of UCNVA, UCIVA, and UCDVA at 1, 3, and 6 months after surgery revealed no statistical significance among different postoperative periods , while the HOA, trefoil aberration, coma aberration, and spherical aberration showed no statistical significance among different postoperative periods   apoptosis . The lenataracts . The proataracts .LenSx is mainly based on the principle of photolysis and dielectric breakdown. It uses high irradiance, high-precision focusing, and short pulse laser spot to be highly localized in transparent tissues (such as cornea), so that the beam can be absorbed in a very short time. At 100°C to 300°C, the energy generates plasma, whose expansion and contraction generates shock waves. While the expansion and contraction of tissues leads to cavitation and formation of bubbles that fuse and burst to allow accurate cutting of adjacent tissues . When thIn the development of IOL, monofocal IOL solves the problem of blindness that may occur after lens removal. However, because its lens can only be used as a lens to replace its refractive function, it is still necessary to wear glasses to adjust the vision after monofocal IOL implantation, so as to basically restore normal vision. The lens adjusts its thickness through the human body to adjust the focus, but the IOL can only obviously fix its size, and the implantation of it cannot use the principle of natural lens to adjust the focus. Therefore, bifocal IOLs were invented based on the principle of refraction and diffractive optics to adjust the focus. According to different principles, bifocal IOLs are divided into refractive, diffractive, and hybrid IOLs. The refractive IOL is a refracted light with aspherical concentric rings on its front surface to produce near and distance vision. The diffractive bifocal IOL uses the principle of light wave dynamics to construct diffraction steps and diffraction zones of the micro slope ring on the back surface to produce near and distance vision. The hybrid IOL is designed to achieve diffraction in the middle and refraction in the periphery. The width and height of the annulus are gradually changed from the center to the periphery to smooth out the light and thus achieve clear vision in the near and far. However, the disadvantage of these designs is that nonfocal imaging on the focal plane can also appear blurred, which will interfere with focus imaging, presenting as glare and halos, decreased contrast sensitivity, and loss of fine vision . To solvAt present, trifocal IOLs include Fine Vision trifocal IOLs, Zeiss trifocal (AT LISA tri839MP) IOLs, and PanOptix trifocal IOLs. Fine Vision trifocal IOLs are developed based on the principle of diffraction, with the diffraction ring highly focused on myopia and intermediate vision, allowing for near vision increase by +3.5D and intermediate vision increase by +1.75D. The pupil size adjusts the light to enter to adjust distance vision, with 43% of the light used for distance vision, 28% for near vision, and 15% for intermediate vision . AT LISAPanOptix trifocal IOLs, which are the latest AcrySof series developed by Alcon Corporation of the United States in 2015, were used in this study. The optical diameter of such IOLs is 6.0 mm, and the total diameter is 13.00 mm, with 15 diffraction zones in the optical zone, which can distribute the light energy to 3 focal points. Among them, the energy of the first diffracted class is redistributed to the zero, second, and third classes. The zero class is used for distance vision to retain the original single focus lens vision, the second class is used for vision, increasing +2.17D, and the third class is used for near vision, increasing the near vision by +3.25D . The resThe defocus curve is an important indicator evaluating the performance of multifocal IOLs, which mainly reflects the continuous visual range of patients . The chaStudies have pointed out that nonfocal imaging on the focal plane can also be blurred and interfere with focal imaging due to HOA. The glare and halo, decreased contrast sensitivity, and loss of fine vision after the above-mentioned bifocal IOL are due to HOA . MeasuriRefractive stability reflects the performance of cataract surgery . If the Patient satisfaction and eyeglass removal rate reflect the patient's overall surgery and postoperative recovery. In this study, the eyeglass removal rate of near, middle, and far distances was 100%. Six months after the operation, only 1 patient was reported with night glare, which affected life, and 3 cases experienced glare and halo that did not affect life. The patient's satisfaction rate reached 98.18%, which is relatively high. The results of the above complications and satisfaction rate were similar to those of Brozkova et al. . Kretz eThe novelty of this study lies in the analysis of femtosecond laser-assisted cataract surgery combined with trifocal IOL implantation from the perspectives of visual acuity, defocus curve, HOA, refractive stability, eyeglass removal rate, and patient satisfaction. It is confirmed that femtosecond laser-assisted cataract surgery combined with trifocal IOL implantation has a positive effect on the visual quality of cataract patients and can provide comfortable visual perceptions for patients. However, this study still has several limitations. First, it is a small single-center study, which may have information collection bias. Second, the subjects included in this study were mainly middle-aged and elderly patients. If the study on young patients can be increased, it will be beneficial to further verify the effectiveness of femtosecond laser-assisted cataract surgery combined with trifocal IOL implantation in young patients. Third, the effect of this therapy on patients' contrast sensitivity and defocus curve has not been analyzed. In the future, the research project will be gradually improved around the above points.This study, as far as we know, presents the first observation of Alcon's PanOptix trifocal IOL implanted in 55 cataract patients with femtosecond laser-assisted cataract surgery and studied and analyzed its clinical effects, providing valuable references for the wide development of trifocal IOLs. Femtosecond laser-assisted PHACO combined with trifocal IOL implantation has achieved good application effects in the treatment of cataract patients. It can provide natural full-course vision and quick recovery for patients, with small trauma, few side effects, high postoperative stability, and high patient satisfaction after surgery.


The cleaning of some wooden artefacts can be challenging due to peculiar surface roughness and/or particular finishing treatments that favour the deposition of dirt and contaminants. The most common cleaning system used by conservators is agar gel, characterized by its rigidity and brittleness, which challenges the cleaning of rough and irregular surfaces typical of most wooden artefacts. In this work, alginate crosslinked with calcium (CA) and konjac glucomannan crosslinked with borax (KGB) gels were proposed to solve this issue. They were prepared and applied to smooth- and rough-surfaced mock-ups replicating wooden musical instruments’ surfaces that had been subsequently covered by artificial soiling and sweat contaminants. The mechanical properties of CA and KGB gels, including their stability over a 60-day storage time, were evaluated by a texture analyzer, while cleaning efficacy was analytically evaluated by non-invasive X-ray fluorescence mapping and profilometric investigation. CA gel appeared to have a higher tensile strength and elongation at break. KGB gel was shown to be soft and resilient, indicating its suitability for cleaning rough surfaces. After repeating the cleaning application three times on the rough-surfaced mock-ups, both the CA and KGB gels were shown to have cleaning efficacy. The results obtained with CA and KGB were compared with those from the Agar application. Cultural artworks are a valuable heritage that conservators, restorers, researchers, and other stakeholders strive to preserve. Nevertheless, long-term storage in an indoor environment and improper care frequently lead to an accumulation of diverse foreign matters, such as dust and contaminants that could interact with and alter artefact surfaces . TherefoNatural polysaccharide-based gels are widely used for cleaning heritage materials due to their tunable rheological properties and mechanical behaviours ,22, theiIn the previous study , alginatHence, this research is aimed at (i) understanding the mechanical properties  of CA and KGB gels, as well as their stability over a 60-day storage time, and (ii) providing a detailed analytical evaluation at the microscale level of the cleaning efficacy on both flat and smooth Western varnished surfaces and rough and irregular surfaces replicating Asian musical instruments.Two different sets of wooden mock-ups inspired by the surfaces of historical musical instruments of the Western area  and East Asian traditional music (primarily the zither instrument) were prepared. For the Western mock-up (WM), a smooth surface finished with an oil-based varnish was prepared ,32,33. Fw/w in water), with the ground layer being applied using a brush to create a regular surface before applying varnish. After that, two applications of an oil-based varnish composed of linseed oil and colophony (1:1 ratio) were applied by brush and dried under UV light for 30 h, as explained in the literature [For Western mock-ups (WM), in order to reproduce the coating system generally identified on the Cremonese bowed string instruments ,37, spruterature .For the East Asian mock-ups (EAM), paulownia wood of 10 cm × 10 cm × 1 cm  was treated with the Nakdong technique. Inside the hot kiln stove, a traditional iron tool specifically used for this treatment, customized by a blacksmith, was heated until red-hot. Afterward, the red-hot iron tool was pressed onto the wood in one stroke for 1–3 s .w/w: burnt sienna pigment 0.5%, gelatine 10.4%, soluble starch 10.4%, Portland type I cement 20.5%, silica 1.9%, lime 16.7%, kaolin 18.6%, and peat moss 20.8%; and wet portion v/v: mineral oil in chloroform 4.5%) and standardized synthetic sweat in accordance with DIN ISO 9022-12 were dispersed, as reported in Lee 2022 [On the prepared WM and EAM mock-ups, a synthetic soiling mixture , and Mw ~ 80,000 to 120,000 g/mol, was purchased from Sigma Aldrich . Konjac glucomannan, purity ≥ 95%, and Mw ~ 960,000 g/mol was provided by Hubei Yizhi Konjac Co., Ltd. . Calcium chloride and borax were also purchased from Sigma Aldrich. For CA gel, sodium alginate 2% han 2 mm . For KGBv/v) surfactant water solution. The soaking time was decided according to the fully swollen states of the two gels reported in Lee 2022 [The prepared CA and KGB cleaning gels were loaded with the non-ionic and biodegradable surfactant Ecosurf TM EH-9  by soaking the gels for 24 h and 5 h, respectively, in a 2%  or by compression (compressive test) ,40,41,42Since CA and KGB gels were in film and soft forms, respectively, both mechanical tests were used. CA gel mechanical properties were assessed through a tensile test by means of a TA.XT plus Texture Analyzer , equipped with a 5 kg load cell. Each sample of gel, respectively, with a 2 mm thickness in the film form (1 cm × 3 cm), was clamped on an A/TG tensile grips probe, and an initial distance of 1 cm between the grips was set. The upper grip was raised at a constant speed of 2 mm/min for a distance of 50 mm. Before testing, the film thickness was measured using a Sicutool 3955G-50  apparatus. Tensile strength and elongation at break were calculated; at least three measurements were performed for each film.KGB gel was prepared in cylindrical moulds of 30 mm × 30 mm (diameter × height) and stored at 4 °C before acquiring the compression measurement. The test was accessed by a TA.XT plus Texture Analyzer, equipped with a 5 kg load cell and a P/10 measuring system consisting of a cylindrical probe with a diameter of 10 mm. The probe was lowered with a test speed equal to 1.00 mm/s to determine a 70% sample deformation. Two measurements were carried out for each gel. Compressive stress-strain curves were produced, and the following parameters were considered: (i) hardness as the maximum compressive force (Fmax) per unit area required for sample destructuring; (ii) Young’s modulus (YM) calculated as the slope of the tangent at the first part of the compressive stress–strain curve (<5% of strain) to investigate the ability of each gel to withstand changes in length when subjected to compression.Experimental data were subjected to statistical analysis, carried out through the statistical package Statgraphics 5.0 . In particular, a one-way ANOVA was carried out, followed by a Multiple Range Test.X-ray fluorescence (XRF) represents one of the most used elemental analysis in the field of archaeometry and diagnostics of cultural heritage ,46,47, tXRF measurements were carried out using the energy-dispersive portable XG Lab—Bruker  ELIO spectrometer with a Rh anode and a 1.2 mm collimator. XRF maps were carried out at a tube voltage of 40 kV and a tube current of 40 µA, with a measurement time of 3 s and a step size of 1 mm. Data were collected and elaborated with Elio 1.6.0.29 software. Based on the previous XRF investigation on cleaned and uncleaned areas , calciumTo visually overview the cleaning actions on the contaminated mock-ups, an Olympus stereomicroscope  was used with an Olympus HD DP73 camera. Images were acquired using Stream Essentials 2.1 software.To investigate the complex surface of the mock-ups, 3D profilometric maps and roughness data were acquired by means of a non-contact 3D Taylor Hobson profilometer .Optical profiling is a non-contact, interferometric-based method used for the characterization of surface topography and is commonly applied in several fields, from cultural heritage to engineering and medical applications ,51,52. IThe amplitude parameters were selected in this study to describe the surface of the mock-ups before and after cleaning: arithmetic mean height (Sa), skewness (Ssk), and a maximum depth of valleys (Sv) ,54. ThisDifferent mechanical tests were performed on alginate gel crosslinked with calcium cations (CA) and konjac gel linked with borax (KGB), which were prepared in the film and soft forms, respectively. Measurements of Agar gels in thin and thick forms were added to this study for comparison purposes. Comparing fresh-CA and -Agar gels, CA was characterized by statistically significant higher tensile strength and elongation at break values . Agar geAfter 7 days of storage at 4 °C, microorganisms were already observed on the thin-form Agar gel, and after 60 days, it appeared dry. As a result, no measurements were performed on the aged-Agar gel as it could affect the accuracy of this assay. By comparing fresh- and aged-CA gels, a significant decrease in elongation at break appeared after 60 days . AlthougComparing fresh-KGB gel with fresh-Agar when subjected to a uniaxial compressive force, the latter showed a hardness of 47 kPa and a Young’s modulus of 556 kPa, which are significantly higher than KGB values . These rIn KGB gel, the hydroxyl groups of the konjac chains crosslink with the borax ions, creating physical connections that confer a gel-like behaviour, as the rheological tests demonstrated on a comparable formulation of konjac–borax gel . In FiguThe cleaning efficacy of CA, KGB, and Agar gels applied one time  up to three times  was calculated using XRF mapping data, as explained in On both soiled-WM and soiled-EAM, KGB_1 to KGB_3 demonstrated a higher percentage of cleaning efficacy than CA_1 to CA_3 a. By repThe removal of sweat was better completed on the smooth surface of sweat-WM than sweat-EAM, as it appeared to have over 90% cleaning efficacy by both CA and KGB gel b. AdditiIn order to deepen this study of the surface features in relation to the XRF results described in Regarding soiled-WM, it is clear that the high roughness of the surface is strictly related to the presence of deposits a. After Different from WM, the surface of the EAM is visibly rough and inhomogeneous . The 3D It is worth noting that the Sv value for EAM is higher with increasing cleaning applications, while for WM the value decreases c. This cThe complex surface morphology of EAM was also found in the sample contaminated with sweat , where aIn this paper, we introduce two biopolymer gels for cleaning, calcium alginate (CA) and konjac glucomannan borax (KGB) gels, loaded with an ecological surfactant for the removal of soiling and sweat deposits from smooth or rough wooden surfaces. These biocompatible products have shown successful performance for artefact conservation, with favourable mechanical properties compared to the traditional Agar rigid-gel.Compressive and tensile tests were performed on both CA and KGB fresh and aged gels to measure the stability of the mechanical properties over time. CA showed sufficient elasticity and mechanical resistance to be applied to and removed easily from the mock-up surface without breaking. Despite the decrease in this property after ageing, CA proved to be still less brittle than Agar, reducing the risk of leaving residues on the surface after cleaning. KGB gel showed the highest softness and elasticity even after 60 days of storage, which is an advantageous aspect for conservation interventions. The texture of this gel is its most distinctive feature, also compared with Agar, which is instead classified as a rigid gel.These desirable mechanical characteristics led CA and KGB gel to be effective in the cleaning of different surfaces, including a smooth varnished surface inspired by classical Western bowed string instruments (WM) and a rough and irregular surface treated with the traditional East Asian Nakdong technique (EAM). The monitoring of the soil deposit removal by XRF, in accordance with the morphological profilometric analysis of the cleaned surfaces, demonstrated that KGB was better at cleaning soil from both smooth and rough surfaces. In the WM, efficiency significantly increased after the second application of the gel, while in the EAM, effectiveness reaches good levels of cleaning after just one application. CA showed slightly lower efficiency than KGB on soiled-WM, but comparable on EAM. As for the soiled-WM and -EAM, the control tests performed with Agar revealed results similar to those obtained with CA and KGB, in particular after three cleaning repetitions. Conversely, the cleaning of sweat from both kinds of mock-ups was comparable for all three gels, already after one application.This research proved evident progress in the cleaning of artefacts by applying CA and KGB on smooth and rough wooden surfaces, implying that the proposed biopolymer gels are able to achieve cleaning performance comparable to the diffuse Agar gel, with fewer application times, and with improved mechanical properties. However, further investigation and application on different materials and surface treatments, as well as on significant real case studies, will be pursued to extend the potential of the application of these gels in the field of cultural heritage cleaning.


GNAS gene in the proband as well as in her mother. A Single Nucleotide Polymorphism (SNP) array analysis failed to demonstrate pathogenic copy number variants (CNVs) but showed several regions with loss of heterozygosity (LOHs) for a final percentage of 1.75%, compatible with a fifth degree of relationship. Clinical exome sequencing (CES) ruled out any damaging variants in all the teeth agenesis-related genes. In conclusion, although we performed an extensive genetic analysis in search of possible additional gene alterations that could explain the presence of the peculiar phenotypic characteristics observed in our patient, we could not find any additional genetic defects. Our results suggest that the association of genetically confirmed PHPT-1a and complete pseudo-anodontia associated with persistent patchy alopecia areata is a new additional nonclassical feature related to the GNAS pathogenic variant.Pseudo-anodontia consists in the clinical, not radiographic, absence of teeth, due to failure in their eruption. It has been reported as part of an extremely rare syndrome, named GAPO syndrome. Pseudo-hypoparathyroidism type 1a (PHPT-1a) is a rare condition, characterized by resistance to the parathyroid hormone (PTH), as well as to many other hormones, and resulting in hypocalcemia, hyperphosphatemia, and elevated PTH. We report here the case of a 32-year-old woman with a long-standing history of non-treated hypocalcemia, in the context of an undiagnosed PHPT-1a. She had an intellectual disability, showed clinical features of the Albright hereditary osteodystrophy (AHO) and presented signs of multiple hormone resistances. She received treatment for seizures since the age of six. Examination of her mouth revealed a complete absence of teeth. Treatment of hypocalcemia and hormone deficiencies were started only at 29 years of age. Genetic testing demonstrated the presence of a frameshift variant in the  GNAS, due to heterozygous-inactivating mutations in the maternally inherited allele (locus 20q13), can be detected [GNAS gene [Anodontia OMIM 206780) is a rare disorder characterized by the failure to develop all primary teeth by the age of 12 to 13 months or permanent teeth by the age of 10 years. Pseudo-anodontia is defined as the clinical, but not radiographic, absence of teeth due to a failure in their eruption. In these cases, radiographic examination allows the disclosure of the retained teeth in the jaws. The exact incidence of this condition is not known and it can be due to many different possible causes 06780 is . The comdetected ,6. Such A 32-year-old woman, whose diagnosis of iPPSD was made at 29 years of age, came to our attention, accompanied by her mother. The hypocalcemia was not recognized nor treated until that age; therefore, she suffered from many complications related to both hypocalcemia and resistance to various hormones. The patient was born at 41 weeks of gestation by cesarean section. She had a normal weight at birth but quickly began to gain weight excessively, with a consequent early onset of obesity. In addition to obesity, the mother referred a history of motor and mental retardation and epilepsy in infancy, treated with carbamazepine and phenobarbital. Both parents (Dominicans in origin) were healthy. The patient was not treated with calcium until the age of 29 when hypocalcemia was detected and oral calcium supplementation was started. The patient experienced menarche at 11 years of age, but gonadotropin resistance resulted in the incomplete development of secondary sexual characteristics. At 15 years of age, she developed bilateral cataracts, and underwent cataract surgery. At 30 years of age, she underwent surgery for the removal of an ovarian serous cystadenoma, measuring 15 cm in diameter. At 29 years of age, the lab tests were remarkable for calcium of 6.7 mg/dL (8.4–10.2), phosphorus of 4.2 mg/dL (2.5–4.5) and magnesium of 1.5 mg/dL (1.5–2.6). The PTH was markedly elevated at 453 pg/mL (15–68), while the 25-hydroxy vitamin D was insufficient at 28 ng/mL (30–100), and the diagnosis of pseudohypoparathyroidism (PHP) was made. Three years later, she came to our attention and she was receiving supplementation with calcium 1 gr QD and with calcifediol 50 µg/dose at 1-week interval, and with levothyroxine at the dose of 50 µg QD, because of hypothyroidism due to TSH resistance. Treatment normalized the calcium level at 8.4 mg/dL (8.4–10.2), and the PTH was still high but reduced to 329 pg/mL (15–68), while the 25-hydroxy vitamin D was sufficient at 43 ng/mL (30–100). At the physical examination, the patient was conscious, cooperative and alert. The blood pressure was 103/71 mmHg and the pulse rate 81/min. Even if the serum calcium level was normal, the muscle showed generalized hypertonicity and stiffness, and the arms were hard to maneuver. She had a singular phenotype, showing the typical features of the AHO .2), with a round face, a short neck, a broad chest and obese abdomen (She was short-statured (height 143 cm) and overweight . Dental anomalies consisted in 16 abnormal un-erupted teeth in the maxilla and 12 in the mandible. It was not possible to define if they are deciduous or permanent. Many of these teeth had very short roots and many had no roots at all. Many of them were mal-positioned, with various degrees of inclination. No teeth were visible in the incisive area of the mandible. Almost all teeth appeared small and morphologically not-well-defined. Only a few of them showed a different degree of radiopacity between the superficial crown layer and the remaining part of the tooth. This was possibly due to no difference in the degree of mineralization between dentine/cement and enamel, or due to a lack of enamel .The patient is now receiving supplementation with calcium 1 gr BID and with calcifediol 50 µg/dose at 1-week interval. She is also receiving levothyroxine supplementation at the dosage of 50 µg QD. Treatment of epilepsy consists in administration of carbamazepine and phenobarbital. After one year of observation, before she returned to her country of origin, there was no change in the clinical condition of the patient.Since the typical clinical presentation of PHPT-1a does not include complete pseudo-anodontia and alopecia, we decided to perform an extensive molecular genetic analysis in search of the molecular bases of such novel presentation. To this purpose, we first identified the specific mutation responsible for the occurrence of PHPT-1a. Then, we searched for possible pathogenic copy number variants (CNVs) or loss of heterozygosity (LOH) that could suggest the presence of homozygous damaging variants due to consanguinity/uniparental disomy. Finally, we performed a genetic analysis by clinical exome sequencing (CES) in search of alterations in genes known to be related to the pathogenesis of tooth agenesis.After obtaining written informed consent, genomic DNA samples of the proband and her mother were extracted from peripheral blood lymphocytes, using the DNeasy Blood & TissueKit and QIAamp DNA Blood Mini Kit according to the manufacturers’ instructions. The coding regions and boundaries of flanking introns (±25 nucleotides) of the GNAS gene (Refseq: NM_000516.4) have been analyzed through Sanger sequencing , using owner-designed primers .The identified variants have been evaluated, based on evidence from the scientific literature, and classified according to the criteria of the American College of Medical Genetics and Genomics (ACMG). Only those predicted to alter the protein and with a minor allele frequency, (MAF) < 0.01, were considered.https://www.omim.org/ accessed on 4 November 2022) were considered.We also performed Affymetrix Single Nucleotide Polymorphism (SNP) array in our patient, to detect possible pathogenic copy number variants (CNVs) or loss of heterozygosity (LOH) that could suggest the presence of homozygous damaging variants due to consanguinity/uniparental disomy . GenomicRuns of Homozygosity (ROH) analysis of autosome chromosomes was performed using the SNPs and filtered considering 3 Mb of length as a minimum size . CES wasAXIN2, EDA, LRP6, MSX1, PAX9, WNT10A, WNT10B, BMP4, DKK1, EDAR, EDARADD, GREM2, KREMEN1, LTBP3 and SMOC2 [GNAS gene, which was prioritized with a significant p-value (p > 0.001) by the Exomiser tool when clinical phenotypes of PHPT-1a were set up in bioinformatic analysis tool.The main genes investigated were nd SMOC2 ,13. PhenGNAS gene, leading to premature termination codon and truncated protein , in the exon 8 of the  protein .Segregation analysis confirmed the maternal origin of the identified variant. The SNP array did not identify any clinically significant deletions or duplications. However, it revealed ~1.75% autosomal homozygosity across multiple chromosomes, affecting a total of ~664 Mb (blocks ≥3 Mb), higher than the general population .AXIN2, EDA, LRP6, MSX1, PAX9, WNT10A, WNT10B, BMP4, DKK1, EDAR, EDARADD, GREM2, KREMEN1, LTBP3 and SMOC2 genes, or in recessive genes located in the LOH regions and related to the proband’s phenotype, a CES was performed in the patient. No damaging mutations emerged in all those genes analyzed by CES, with the exception of the already-known c.624dup pathogenic variant in GNAS.This level of homozygosity is consistent with a close parental relationship or more distant relatedness in an isolated population. In order to investigate the presence of possible damaging variants in tooth agenesis genes, including GNAS gene. Although this variant has never been described to date, neither in patients with GNAS-related diseases nor in the general population, null variants in GNAS are predicted to be pathogenic, as loss of function of this gene is a known mechanism of disease. The same variant was also detected in the asymptomatic mother. The absence of clinical manifestations in the older woman may be explained by the complex imprinted expression pattern of GNAS. Indeed, this gene produces paternally (XLAS), maternally (NESP55) and biallelically (Gsα) expressed transcripts from alternative promoters in the 5′-UTR. However, in the proximal renal tubule, adenohypophysis and thyroid, the expression of Gsα is exclusively maternal. Thus, damaging variants in GNAS on the maternal allele cause multihormonal resistance syndrome with AHO, while damaging variants in the GNAS paternal allele are associated only with isolated AHO . Realistically, the mother, not affected by PHPT-1a, has the pathogenic variant on the paternal allele, while, in the proband, the same variant, inherited from the mother, is the cause of her complex phenotype. The oral manifestations found in patients with parathyroid deficiency had been initially recognized by Gottlieb in 1920 [BMP2 gene expression in the dental follicle is considered essential for tooth eruption [GNAS null mutation identified in our patient could play a pivotal role in determining her peculiar phenotype. We believe that this mutation, associated with the delay in the treatment of hypocalcemia, could be responsible for the occurrence of complete pseudo-anodontia, in addition to the other manifestations of the disease.We describe here, for the first time, a new clinical feature of PHPT-1a in a patient carrying the damaging variant c.624dup in the  in 1920 . In 1956 in 1920 . Pseudoh in 1920 ,17. Howe in 1920 ,22. Rece in 1920 . All pat in 1920 . The rel in 1920 . In part in 1920 ,28,29,30 in 1920 . In this in 1920 . The mec in 1920  and, in eruption ,35. The 1.Dental manifestations of AHO are seldom sought after and they have only occasionally been described in a few case reports.2.Complete pseudo-anodontia, defined as the clinical, but not radiographic, absence of all teeth, due to a failure in their eruption, has, so far, never been reported in patients with PHPT-1a.3.In our patient, complete pseudo-anodontia may be the result of long-standing, untreated hypocalcemia.4.Early diagnosis and treatment of hypocalcemia in patients affected by PHPT-1a is of paramount importance in order to avoid severe hypocalcemic symptoms, such as seizures, paresthesia, and tetany, and to allow physiological tooth formation and eruption.


Exposure to air pollutants may elevate the injury severity scores (ISSs) for road traffic injuries (RTIs). This multicenter cross-sectional study aimed to investigate the associations between air pollution, weather conditions, and RTI severity. This retrospective study was performed in Taiwan in 2018. The location of each road traffic accident (RTA) was used to determine the nearest air quality monitoring and weather station, and the time of each RTA was matched to the corresponding hourly air pollutant concentration and weather factors. Five multiple logistic regression models were used to compute the risk of sustaining severe injury (ISS ≥ 9). Of the 14,973 patients with RTIs, 2853 sustained severe injury. Moderate or unhealthy air quality index, higher exposure to particulate matter ≤2.5 μm in diameter, bicyclists or pedestrians, greater road width, nighttime, and higher temperature and relative humidity were significant risk factors for severe injury. Exposure to nitrogen oxide and ozone did not increase the risk. Auto occupants and scene-to-hospital time were the protective factors. Sensitivity analyses showed consistent results between air pollutants and the risk of severe injury. Poor air quality and hot and humid weather conditions were associated with severe RTIs. Active commuters were at higher risk of sustaining severe RTI. However, a previous study conducted in Iran found that O3, particulate matter ≤10 μm in diameter (PM10), NO2, and carbon monoxide (CO) concentrations were inversely associated with mortality after adjusting the confounders [2.5 was significantly associated with the number of traffic accidents. However, no significant correlation was observed between NO2 and the number of traffic accidents [Road traffic injuries (RTIs) are the eighth leading cause of death worldwide and the number one cause of death among people aged 5–29 years . Environformance . In thisfounders . Anotherccidents . The ass2.5 and nitrogen oxide (NOx) emissions. The annual average PM10 and PM2.5 concentrations were 35.7 μg/m3 and 17.3 μg/m3, respectively. For O3 and NO2, their annual average concentrations were 31.4 parts per billion (ppb) and 11.5 ppb, respectively [In Taiwan, ambient air pollution primarily originates from three sources: long-range transport of air pollutants from other countries, emissions from local factories and construction, and traffic-related air pollution. According to a study conducted in 2019, on-road vehicles were the primary source of PMectively . As of 2ectively ,25. For ectively ,27. The ectively .Driving performance is a key component of road safety, and a driver’s cognitive and behavioral capacities affect the driving performance. Air pollution negatively affects the cognitive and behavioral capacities, thus causing impulsivity, irritability, and aggression ,30. Air By exploring the association of meteorological factors and air pollution with RTIs, our study provides useful information for the healthcare authorities in planning effective interventions to reduce deaths and injuries caused by RTAs. In addition, this exploration may open a new pathway for trauma research whose results can be applied in a clinical setting in order to mitigate the severity of RTIs. For the transport sector, it is important to maintain a convenient public transport system that can decrease the need for private transport, improve road congestion, alleviate environmental pollution, and decrease the injury severity after RTAs. Combining the transport and environmental sectors’ efforts in urban and environmental planning will lead to the implementation of the concept of green transportation, including electric vehicles, ride-sharing, and green space. Urban greenery is also an effective strategy for mitigating air pollution . These iA multicenter cross-sectional study was performed involving patients from five trauma centers in Taiwan: Shuang Ho Hospital, Wan Fang Hospital, the Taipei and Tamsui branches of Mackay Memorial Hospital, and the National Cheng Kung University Hospital. The locations of these hospitals are shown in Data were retrospectively collected from the electronic medical records of patients with RTIs treated at the aforementioned trauma centers between 1 January 2017 and 31 December 2017. The patients’ national identification numbers were used to connect the collected data to the police traffic accident dataset (PTAD) in order to identify patients whose RTIs were treated in the emergency department (ED) and obtain information regarding the RTAs in which they were involved. The identification numbers were deleted upon connection. To further ensure that RTAs and ED visits were causally related, we only included patients admitted in the ED within 24 h after an RTA. For each patient who visited the ED several times after sustaining an RTI, only the records of the initial visit were included. The patient selection process is illustrated in The PTAD, which included coded information of the crashes and the involved personnel, was compiled from records created by on-scene police officers. The PTAD contained information on the road user types and other conditions, including the time of the RTA, the involved driver, and the involved vehicle, which may have been related to each RTA described therein. The roadway data included information on the location of each RTA, while the accident-related data included information on contributing circumstances, driver/vehicle actions, and collision types.The following demographic and environmental factors were retrieved from the PTAD: sex, age , day of the crash (weekday or weekend), time of the crash (daytime (06:00 to 17:59), evening (18:00 to 23:59), or nighttime (00:00 to 05:59)), rush hour  or non-rush hours, and road user type . Data on the injury severity score (ISS), ED arrival time, and Glasgow Coma Scale (GCS) score (which measures the level of consciousness) were retrieved from the hospital data. The scene-to-hospital arrival time (min) was calculated to determine the delay between the accident time and time of arrival at the hospital.2.5, PM10, O3, NO2, and NOx.The air pollutants examined in this study included hourly concentrations of PM2.5, PM10, O3, SO2, CO, and NO2 [The hourly AQI was also assessed, which was determined based on the maximum subindex value among the concentrations of the following air pollutants: PM and NO2 . The AQI and NO2 .In terms of the location of the crash scene, only the address was included in its corresponding record in PTAD. Geographic information system platforms, including Google Maps application programming interfaces  and TaiwThe data regarding weather conditions at the time of RTA, such as hourly mean temperature (°C), hourly mean relative humidity (%), and 24-h accumulated precipitation (mm), were obtained from the Taiwan Central Weather Bureau . The 24-The hours of each RTA were matched to the corresponding hourly air pollutant concentration, AQI, temperature, and relative humidity. The cumulative precipitation within 24 h preceding each RTA event was recorded.The ISS was used as an outcome measure. Although the patients’ ISSs are not mandatorily recorded in EDs in Taiwan, the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes are universally used to record the diagnoses of patients when they are discharged from the ED. A previously validated package (ICDPIC-R) for R statistical software  was usedp value of <0.2 in the univariate analysis [A univariate analysis was conducted to evaluate the association between each independent variable and the outcome measure. Pearson’s Chi-square test, Cochran–Armitage trend test, and Wilcoxon rank-sum test were used to analyze the categorical, ordered categorical, and continuous variables, respectively. Because the dependent variable was binary (ISS < 9 vs. ≥9 points), a multiple logistic regression analysis was performed using the patient’s sex, age, and the independent variables with a analysis . Howeveranalysis ,48, GCS The binary logistic regression model has been commonly estimated in the trauma or traffic injury literature ,49,50 tojx is the value of the jth independent variable, jβ is the corresponding coefficient for j = 1, 2, 3,…, p, and p is the number of independent variables.In the binary logistic regression model, the equation is formulated as follows:The conditional probability of a positive outcome given the independent variable is as follows:iy denotes the ith observed outcome with a value of either 0 or 1 and i = 1, 2, 3,…, n, where n is the number of observations. The best regression estimate of β was determined by maximizing the log-likelihood expression:The maximum likelihood method was used to estimate the parameters of the logistic regression model by constructing the likelihood function:jβ), odds ratio (OR), is usually interpreted for a logistic regression model to reveal the effect of attributes on the likelihood of severe injuries:jβ − 1.96jsβ), exp(jβ + 1.96jsβ)), where sβ is the standard error of coefficient β. An OR of >1 indicated a positive association between the interest attribute and severe injuries, whereas an OR of <1 indicated a negative association between the interest attribute and severe injuries. An OR of 1 indicated that no association was found between the interest attributes and severe injuries.The exponentiated coefficient exp was defined as follows:2.5, PM10, O3, SO2, CO, and NO2 concentrations, a separate model was required to avoid collinearity problems in the multivariable model. In addition, considering that strong correlations between PM2.5 and PM10  and between NO2 and NOx  were identified in the multiple air pollutant model, these air pollutants were entered separately in five multivariable models . The variance inflation factor (VIF) was used for identifying collinearity; a VIF value of <5 was considered acceptable during variable selection. A sensitivity analysis was further conducted by removing the auto-occupant patients.As the AQI was determined according to the maximum subindex values of the PMp value of <0.05 was considered significant. Statistical analyses were restricted to patients with no missing values for each specific variable and were performed using the SAS software .The ORs and 95% CIs were calculated to estimate the risk of sustaining severe injuries. A two-sided A total of 14,973 patients with RTIs treated at the EDs of the five participating hospitals were identified; of them, 2853 patients (19.1%) sustained severe injury (ISS ≥ 9 points). The patient’s mean age was 37 years, and 54.6% of them were men.2.5, PM10, NO2, and NOx concentrations.The results of univariate analysis are presented in Results of the multiple air pollutant model are listed in In the AQI model, compared with patients aged <24 years, those aged 45–64 years or >64 years were more likely to have an ISS of ≥9 . Involvement in a nighttime crash was a risk factor for obtaining an ISS of ≥9 . The risk of obtaining an ISS of ≥9 was significantly higher among patients involved in RTAs on wider roads . Compared with motorcyclists, bicyclists and pedestrians were more likely to have an ISS of ≥9 , whereas auto occupants were less likely to sustain severe injuries . With regard to weather conditions, the risk of obtaining an ISS of ≥9 increased significantly with every interquartile range (IQR) increase in temperature  and relative humidity . Moderate and unhealthy AQIs were risk factors for an ISS ≥9 . The risk of obtaining an ISS of ≥9 was lower among patients with shorter scene-to-hospital arrival times .2.5 concentration was also associated with a significant increase in the risk of sustaining severe injury . NOx and O3 concentrations were negatively associated with an ISS of ≥9. IQR increments in NOx or O3 concentrations were not associated with increases in the risk of obtaining an ISS of ≥9 . The risk of obtaining an ISS of ≥9 was lower among patients with shorter scene-to-hospital arrival times .In the multiple air pollutant model , the risFinally, the sensitivity analysis results, including five models , revealeTo the best of our knowledge, no large epidemiological studies have elucidated the associations between air pollution, other weather and environmental conditions, and RTI severity. A high resolution of the temporal and spatial information collected in this study is crucial for clarifying such associations. The time between environmental exposure and the occurrence of RTA is often short, and the incident time is correlated with different risk factors. The precise location of a crash can be used to investigate the road features, compute the transportation time from the scene to the hospital, and identify the nearest weather or air quality monitoring station. Furthermore, previous studies have mostly focused on investigating RTAs rather than on the RTI severity. Analyzing the injury burdens associated with different ISSs is useful for formulating appropriate public health policies.10 and PM2.5 concentrations are correlated with RTA rates [3 increment in PM2.5 concentration [2.5 concentrations were more likely to sustain severe RTIs. To our knowledge, this study was the first to address the association between air pollutant exposure and RTI severity. For active commuters, a higher inhalation rate and longer commuting time increase the amount of air pollutant exposure. Among all traffic-related air pollutants, exposure to PM2.5, the primary pollutant emitted from vehicles, can lead to acute and chronic cardiovascular injuries [Active commuters (pedestrians and cyclists) inhale higher doses of air pollutants compared with commuters who use motorized transport . A previTA rates . In the ntration . The preinjuries . In addiinjuries . The posx and O3 concentrations and the risk of sustaining severe injury. A possible reason for this association is the lagged effect of NO2 (NOx) and O3, as they are secondary and photochemical oxidants [2.5, PM10, or those with the maximum sub-index values (reflected using the AQI), were clearly associated with RTI severity. The existing strategies to reduce air pollution in urban environments have mainly focused on the reforming sustainable transport systems to reduce the health risks of air pollution (https://www.who.int/publications/i/item/WHO-HEP-ECH-AQH-2021.6 accessed on 3 May 2022). Urban planning of greenspaces might also help reduce the air pollution levels. Green space plays a role in improving air quality through particle deposition, dispersion, and modification [10 concentrations [An inverse association was observed between NOoxidants . In thisfication . Anothertrations . Green sA previous study using the National Health Insurance database and National Traffic Crash Dataset in Taiwan from 2003 to 2012 revealed that bicyclists were at a higher risk of sustaining severe injury than motorcyclists  . The preWeather conditions may be associated with the incidence or severity of RTIs. Under hot and humid conditions, crashes may be attributed to the changes in the behavior of drivers or pedestrians. On hot days, limited skill or power performance may cause tiredness and impaired effectiveness, resulting in a higher risk of accidents . HoweverAt night, poor visibility may result in a higher risk of RTI and RTA mortality. A 5-year epidemiological study in Ghana revealed that the relative risk of mortality in a nighttime traffic crash was 1.3 times higher than that in a daytime traffic crash . The preAge is an important risk factor for RTIs, particularly in older adults. A previous review indicated that 23.6% of RTIs are sustained by older adults . In addiThis multicenter approach strengthened the generalizability of our results. The findings of this study were derived from the data of 14,973 patients with RTIs, making our analysis the first with a sufficient sample size to report an association between air pollution and injury severity in patients with RTIs. To assess for collinearity, five models were established for different air pollutants to more effectively demonstrate the association between air pollution and RTI severity. Finally, the consistency of the sensitivity test results among the five models proved the reliability of the study results. Our study provides useful information for the prevention and control of RTIs.This study has some limitations. First, exposure to air pollution might have triggered the acute exacerbations of underlying diseases and resulted in severe RTIs. However, the underlying diseases of these patients are unknown. Nevertheless, age can be used as a surrogate measure. Second, the lower risk of sustaining severe RTIs among motorcyclists may be attributable to the increased utilization of helmets among the motorcyclists in Taiwan. In this study, information on helmet use among the cyclists was not obtained. Third, this analysis focused on investigating the association between acute pollution exposure and RTI severity. However, if the modes of transport remain similar from day to day, the cumulative effects of air pollution exposure on RTI severity may also be possible. Finally, data on drug use were lacking, and 18% of the data related to alcohol consumption among victims was missing. Therefore, these two factors were not included in our analysis.2.5 concentration, and hot and humid weather conditions are all associated with severe RTIs; therefore, real-time environmental monitoring data should be incorporated into the traffic warning systems. This study highlights the positive associations between RTI, air pollution, and weather factors. Further in-depth evaluation of the aforementioned air pollution factors may yield valuable insights for the prevention of severe RTIs.Male sex, older age, and time of crash being nighttime were associated with a higher risk of sustaining severe RTI. Active commuters, including bicyclists and pedestrians, are at higher risk of sustaining severe RTI. Poor air quality measured based on the AQI or PM


Ischemic stroke (IS) has imposed significant threat to both middle-aged and elderly people worldwide. Acute myocardial infarction (AMI) is a rare but serious complication following IS, which can further increase patient disability and mortality rates. With the development of intravenous thrombolysis and endovascular treatment, the prognosis of IS has been greatly improved. However, the pathogenesis of IS complicated with AMI is still unclear. To fill this gap, this work uses bioinformatic analysis, where IS and AMI datasets were combined for differential gene analysis, and then, a ROC prediction model for target gene analysis was constructed. It is found that OSM gene has the highest prediction accuracy (AUC = 0.793), followed by IL6ST, IL6, JAK1, IL6R, and JAK2 genes. Joint prediction model showed higher accuracy in predicting the outcome of control and case (AUC = 0.918). The etiology of ischemic stroke and acute myocardial infarction is complicated. Their cooccurring pathological mechanisms and the conversion between the two diseases could not be explained by a single gene. Therefore, the joint prediction model in this work can provide a better prediction accuracy for research purpose. Stroke, ischemic heart disease, and malignant tumors are currently the three leading causes of death worldwide, among which, stroke, the second leading cause of death, poses a serious threat to human health. According to statistics, about 5.5 million people die of stroke every year globally. Without timely treatment since the onset of stroke, various degrees of physical and mental disabilities may be caused, which will lead to a great burden on individuals, families, and the society. Based on the findings of a national disease burden study, stroke has become the first cause of death in China . The oveStudies have shown that acute myocardial infarction (AMI) is closely related to the occurrence of stroke. About 80% of AMI patients have IS within a year, of which 80% occur within 2 weeks after AMI . New-onsThe current limited epidemiological data shows that the heart and brain are closely related, since they have a mutual hemodynamic and pathophysiological basis. However, due to their anatomical differences, it is difficult to determine either the heart- or brain-originated factors are the leading causes. This article aims to use bioinformatic analysis to predict the target genes of IS and AMI, which could indicate the possibility of AMI occurrence when IS occurs and vice versa, so one can achieve early prevention of either disease.p < 0.05 were used as the cut-off criterion for differential gene expression analysis. A negative number represent downregulation, and a positive number represent upregulation. By applying the above criteria, DEGs were determined by comparing the normal control group and the stroke group, the normal control group and the myocardial infarction group, the myocardial infarction group and the myocardial infarction with stroke, and the myocardial infarction with AF group, respectively. Probes are then converted into gene names through the GPL570 platform. ComplexHeatmap package was used to generate heat maps [http://bioinformatics.psb.ugent.be)/webtools/Venn/) was used to obtain the intersection genes of IS, CES, AMI, and AF, respectively. The R language ggplot2 package Venn diagram was used to visualize these intersecting genes for subsequent analysis.Target chip was searched and downloaded through GEOquery package from the Gene Expression Omnibus (GEO) chip database . Brieflyeat maps , and R leat maps  package http://biogps.org). Transcripts mapped to a single tissue that meet the following criteria were identified as having high tissue specificity: (1) tissue-specific expression levels were 10 times higher than the median value of other tissue, and (2) the highest expression level for the second-highest expression was no higher than 1/3 of the median expression [Tissue-specific expression of DEGs was analysed by using the online resource BioGPS (pression .http://www.string-db.org/) was used to analyse and predict the DEGs and interactions between proteins encoded by these genes that may play an important role in the pathogenesis of IS. Medium confidence level (comprehensive score of interaction relationship between 0.4 and 0.7) was chosen as the significant standard. STRING analysis results were imported in Cytoscape 3.7.1 software for visualization. Briefly, CytoHubba and MCODE plug-in were used for protein-protein interaction network (PPIN) analysis. The degree at each node was calculated through CytoHubba. The network composed of the top 10 genes that ranked by the degree score can be regarded as the core module.The online STRING database  were also regarded as core subnetworks. Hub genes were identified by selecting the intersection of modules with the highest score and the top 10 genes of the highest degree scores and top 20 DEGs that met the above mentioned |Log2FC| criteria.http://david.nciferf.gov). Kyoto Encyclopedia of Genes  was used for signal pathway analysis, which included cellular component (CC), molecular function (MF), biological process (BP), and KEGG pathways. Pathways are considered to be statistically enriched when p < 0.05.Biological functions  of specific genes were analysed by using DAVID website  curves on selected DEGs, where the area under the curve (AUC) of the hub genes were compared to identify the genes of significant prediction value. Finally, the ggplot2 package was used for ROC curve visualization.Stroke-related datasets  were merged, which included 43 normal control groups and 97 stroke groups. Cardiogenic-related stroke datasets (GSE58294 and GSE66724) were also merged, which include 23 normal control groups and 77 CES groups. Sample normalization was performed for each merged dataset, respectively. The normalization results showed that the median of each sample was basically on a horizontal line, which indicated a high level of normalization between samples .p.adj < 0.05 criteria. For stroke-related datasets , there were 2 upregulation (positive log2FC) and 2 downregulation (negative log2FC) DEGs. For cardiogenic-related datasets (GSE58294 and GSE66724), there were 145 upregulation (positive log2FC) and 91 downregulation (negative log2FC) DEGs. For AMI dataset (GSE66360), there were 336 upregulation (positive log2FC) and 124 downregulation (negative log2FC) DEGs.Heat maps and volcano maps of stroke-related, cardiogenic-related, and AMI gene expressions are shown in Figures Based on the results of online Wayne analysis , there whttp://biogps.org) to study the tissue-specific expressions. Gene expressions with the highest tissue specificity was CD33+ myeloid  and smooth muscle . Besides, similar expression in cardiac myocytes and in whole blood    was founκB signalling pathway).The GO and KEGG pathway analysis of the common genes between AMI and IS  showed tGO and KEGG pathway analysis of the common genes between AMI and CES  showed tCytoscape software was used to construct the PPI network to identify hub genes from common DEGs . The comThe hub genes of CES and AMI  were detγ signalling pathway and is the kinase chaperone of interleukin IL-2R receptor. IL6 (Interleukin-6) has various biological functions as a cytokine, and it is effective regulator for acute phase response. It plays an important role in the final differentiation of B cells into immunoglobulin secreting cells involved in the differentiation of lymphocytes and monocytes. It can act on B cells, T cells, hepatocytes, hematopoietic progenitor cells, and cells of the central nervous system and is essential for the production of TH17 cell. JAK2 (Tyrosine-protein kinase JAK2) nonreceptor tyrosine kinase is involved in various processes, such as cell growth, development, differentiation, or histone modification, which mediates the basic signal events in innate immunity and adaptive immunity. OSM (Oncostatin-M) is a growth regulator, which inhibits the proliferation of some tumor cell lines and regulates the cytokine production of endothelial cells.The hub genes screened for interaction between AMI and CES and IS diseases  were IL6In order to verify the diagnostic values of the first 6 hub genes obtained from the above analysis, the ROC curves constructed and the corresponding area under the curve (AUC) for the gene expression levels in the IS, CES, and AMI datasets were calculated. The first six central genes were diagnosed on ROC curves for AMI, IS, and CES diseases . In predp = 0.015); CLEC4D was superior to FOLR3 (p = 0.016). The subsequent joint RCO model showed a certain level of accuracy .For AMI-CES datasets , ARG1 shFor AMI-IS-CES datasets , OSM shoStroke is a cerebrovascular disease characterized by the sudden onset of symptoms. It is a common disease but involves high risks in the field of neurology. It has the characteristics of high morbidity, mortality, disability, and recurrence, which has serious negative impact on the patient's health and causes heavy burden to the stroke patients' family and society . CardiacIn this study, by searching IS, CES, AMI, and AF datasets from GEO, different datasets were combined, and common DEGs were screened out in IS, CES, AMI, and AF. GO enrichment and KEGG pathway enrichment analyses were performed, and PPI networks were established to identify the top hub genes from these common DEGs.Human interleukin-6 (IL-6) gene is located at 7P21 , which iInflammation is an important pathological mechanism of AIS. When AIS occurs, the level of IL-6 in the patient's body increases rapidly in a short period of time, and the prognosis of AIS after 3 months is poor due to elevated level of inflammation, mainly in terms of the modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS), and increased mortality. The higher the expression level of IL-6, the greater the risk of stroke recurrence . In addiThe mechanism of cardiac function damage after the occurrence of AIS may be as follows: (1) IL-6 is an important inflammatory factor in the in vivo inflammatory response of atherosclerosis-related diseases. The larger the atherosclerotic plaque, the higher serum IL-6 level is found . AccordiIn this article, we merged the three datasets of AIS, CES, and AMI and found that IL-6 was one of the hub genes obtained by constructing PPI networks. It is proposed that IL-6 plays an important role in the three diseases. Therefore, after the occurrence of AIS, it is necessary to closely monitor the changes of IL-6 expression. If timely intervention and effective regulation of IL-6 expression in the body can be achieved, it can not only reduce the adverse prognosis of stroke but could also reduce the damage of heart function.IL1B (Interleukin-1 beta) is located on chromosome 2 and is thought as a potent proinflammatory cytokine. It can exert biological effects through MAPK signalling, EGF-EGFR-RAS-JNK signalling pathway, IL1-IL1R-JNK signalling pathway, IL1-IL1R-p38 signalling pathway, and RAC/CDC42-PAK-ERK signalling pathway. It is produced extracellularly by the activation of Ras-MEKK1-JNK and MYD88-TRAF6-TAK1-p38-MAHKHK under the stimulation of cytotoxic drugs, pyrogens, reactive oxygen species, etc., which can induce the synthesis of prostaglandins, the influx and activation of neutrophils, T cell activation and cytokine production, B cell activation and antibody production, and fibroblast proliferation and collagen production and promote the differentiation of Th17T cells , 37. It α and IL1B to promote neuronal cell death [Chemokines are small chemotactic cytokines that play an important role in regulating cell migration and can recruit white blood cells to the site of inflammation. CXCL2 is the ligand of CCR2, which is produced by activated monocytes and neutrophils, and is expressed in inflammation sites to induce macrophage infiltration. Activated macrophages can produce TNF-ll death , and CXCll death . Followill death –46. Chemll death  conductell death  conductell death ; hUC-ovell death .JUN (AP-1 transcription factor subunit) gene is involved in cell growth, development, and differentiation under normal conditions, but with very low expression level. Via the intracellular CRHR-PKA-ACTH signalling pathway, it can overactivate hippocampal neurons and cause cell death. Studies have suggested that JUN can be used as a marker for the progression of cell damage . After IARG1 is a cellular enzyme mainly expressed in liver cells and a component of the urea cycle. It is also expressed in peripheral blood immune cells and participates in the immune response after the body is injured , 55. It β [OSM (Oncostatin-M) belongs to the IL-6 family of cytokines. It is produced by activated macrophages and T cells. It can inhibit the growth of tumor cells, can induce the differentiation of certain tumor cells, and can also play a role in a variety of central nervous system diseases. It has the functions of inhibiting inflammation and exciting nerve damage, protecting neurons, and promoting the elongation of axons . As a cyβ  while inβ  and humaβ . IL-6 inβ –71. The β , and incβ, thereby triggering the innate adaptive immunity of pathogens. The innate immunity of CLEC4D is manifested in the expression on circulating neutrophils [CLEC4D (C-type lectin domain family 4 member D) is a C-type lectin receptor “Dectin-2 cluster,” which is mainly expressed by peripheral blood neutrophils, monocytes, and macrophages, and can transduce signal via SYk kinase of myeloid cells. After ligand binding, CLR stimulates the intracellular signal cascade to induce the production of inflammatory cytokines IL-6, IL-23, IL-12, and IL-1trophils , 73. CLEFor the three hub genes selected from AMI and IS, the diagnostic value of IS combined with AMI was further investigated. The prediction AUC of JUN, CXCL2, and IL1B for IS and AMI were 0.575, 0.605, and 0.652, respectively. The prediction AUC of the joint model was 0.656. For the diagnosis of CSE and AMI, 4 hub genes were selected for disease diagnosis value prediction. The prediction AUC of ARG1, CLEC4D, and FCAR were 0.803, 0.798, and 0.761, respectively. The predictive power AUC of FOLR3 was 0.665. The prediction of the joint model has relatively high accuracy (AUC = 0.842). Further, DeLong's test for the above indicators showed that the diagnostic efficiency of ARG1 is better than that of FOLR3 and the diagnostic efficiency of CLEC4D is better than that of FOLR3. Validation of common genes for the three diseases shows that OSM has the highest prediction value, followed by IL6ST and IL6, JAK1, and JAK2. The joint model has high prediction accuracy  in predicting the outcome of controls and cases. The above results show that a single gene has a low predictive ability for diseases, and when the hub genes are jointly used, its predictive ability is greatly improved. It also shows that when a disease occurs, it is not due to a single gene, but a network system built by multiple genes. The onset regulation function affects the occurrence, development, and outcome of the disease.This work focuses on the datasets of IS, CES, and CES combined with AF and AMI. Since the dataset of CES combined with AF has less data, following differential expression analysis, no intersection with the other three datasets was found. Therefore, datasets that have intersections were further investigated, and it was concluded that the prediction accuracy of OSM gene is high, while OSM, IL6ST, and IL6 genes have better joint predictions in the above three diseases. Joint diagnosis using these 3 genes can further improve the prediction performance. However, this study still has certain limitations. This article uses bioinformatic methods to mine the GEO database that can predict the risk of IS, CSE, and AMI. The conclusions drawn are only based on bioinformatic mining, and further experiments or clinical studies are needed to confirm the prediction value.