Background: Fibrinogen albumin ratio (FAR) is significantly correlated with the severity and prognosis of cardiovascular disease (CVD). Arterial stiffness is an early lesion of CVD, but no studies have examined the correlation between arterial stiffness and FAR. This study aimed to examine the relationship between FAR and arterial stiffness in patients with type 2 diabetes (T2D), as measured by brachial-ankle pulse wave velocity (baPWV).Methods: In this cross-sectional investigation, patients with T2D were enrolled between January 2021 and April 2022. In each patient, the levels of fibrinogen and albumin in the serum, and baPWV in the serum were measured. A baPWV greater than 1800 cm/s was utilized to diagnose arterial stiffness.Results: The study included 413 T2D patients. The mean age of these participants was 52.56 ± 11.53 years, 60.8% of them were male, and 18.6% of them had arterial stiffness. There were significant differences in baPWV level and proportion of arterial stiffness (p < .001) between the four subgroups categorized by the FAR quartile. The relationships between the FAR and baPWV and arterial stiffness were significantly favorable in the overall population and subgroups of elderly men and non-elderly men (p < .01), while they were insignificant in subgroups of elderly and non-elderly women (p > .05). To investigate the correlation between the FAR and baPWV, the arterial stiffness and the FAR in male T2D patients, respectively, multivariable logistic regression analysis and multiple linear regression analysis were developed. The lnFAR and lnbaPWV had a significant relationship in the multiple linear regression analysis fully adjusted model. After adjusting for potential covariables, multivariable logistic regression analysis revealed that the FAR was independently associated with arterial stiffness . In addition, receiver operating characteristic analysis indicated that the best FAR cutoff value for detecting arterial stiffness in male T2D patients was 76.67 mg/g.Conclusion: The level of FAR had an independent and positive correlation with baPWV and arterial stiffness in male patients with T2D, but not in female patients. The rate of type 2 diabetes (T2D) is rising each year, posing a significant threat to public health, as a result of China’s rapid economic development, lifestyle changes, and ageing population . In 2015Both fibrinogen and albumin are produced in the liver; fibrinogen is implicated in inflammation and clotting cascades , whereasTherefore, this observational study was carried out to investigate the relationship between FAR and baPWV in T2D patients.The current study included T2D patients who were hospitalized in the endocrinology department of the second affiliated hospital of Nantong University from January 2021 to April 2022. T2D was diagnosed using the American Diabetes Association criteria . ExclusiChecking medical records allowed for the collection of information on demographics, drinking and smoking habits, past medication usage, and disease diagnoses. The medication history was particularly focused on the use of drugs for T2D, hypertension, and dyslipidemia.2). The average of the two blood pressure readings was recorded for further analysis after being measured twice with a standard mercury sphygmomanometer.Each subject was measured for anthropometric characteristics, including weight, height, and blood pressure. Body mass index (BMI) was determined by the following formula: weight (kg)/height  was computed utilizing the CKD-EPI creatinine-cystatin C equation (2012) .As previously described, each subject’s baPWV was measured by a trained technician utilizing an automated system  . Each sup value < .05 was considered as statistical significance. Continuous variables with skewed and normal distributions and categorical variables were presented as the mean ± standard deviation (SD), frequencies with percentages, and medians with interquartile range, respectively. For analysis, the data on fibrinogen and albumin levels were ln-transformed due to their skewed distributions. Comparisons of continuous variables with skewed and normal distributions and categorical variables were conducted between groups using the Kruskal–Wallis test and the one-way analysis of variance, and the chi-square test, respectively. Spearman’s analyses of bivariate correlation were applied to measure the strength of associations between FAR level and other clinical variables. In addition, spearman’s bivariate correlation analyses were employed to investigate the associations between the FAR and baPWV and arterial stiffness in the overall population and subgroups of elderly men, non-elderly men, elderly women, and non-elderly women, respectively. To investigate the independent relationships between the FAR level and the baPWV level and the independent relationships between the FAR level and arterial stiffness, multiple linear regression analyses and multivariable logistic regression analyses were constructed. Receiver operating characteristic (ROC) analysis was also carried out to examine the FAR levels’ capacity to detect arterial stiffness.SPSS statistical software version 18.0  was utilized for the analysis of the data. A p < .001) along with the gradual rise in the FAR quartiles. Age, the duration of diabetes, the utilization of acarbose, triglyceride (TG) level, albumin level, fibrinogen level, hemoglobin level, neutrophil percentage, platelet count, and neutrophil/lymphocyte ratio (NLR) level were all significantly different between the four subgroups (p < .05). While there were no significant differences in the proportion of males, smoking and drinking status, systolic and diastolic blood pressure, use of additional antihypertensive and antidiabetic treatments, HbA1c level, eGFR level, urinary albumin-to-creatinine ratio (UACR) level, total cholesterol (TC) level, low-density lipoprotein cholesterol (LDL-C) level high-density lipoprotein cholesterol (HDL-C) level, and white blood cells (WBC) count (p > .05).In total, 413 T2D patients were enrolled in the study. The mean age was 52.56 ± 11.53 years, 60.8% of the participants were male, and 18.6% of the participants had arterial stiffness. The clinical characteristics of the four subgroups are presented in p < .001), as well as significant negative associations with eGFR, TG, and hemoglobin level .As shown in p < .01), but were not significantly associated in subgroups of elderly and non-elderly women (p > .05). The independent association between the FAR and baPWV in male patients with T2D was further investigated using multiple linear regression models, as shown in p < 0.001, R2 = 0.609).The multivariable logistic regression analysis of the correlation between FAR and arterial stiffness in male T2D patients is presented in In addition, a ROC analysis was conducted to determine the FAR cutoff value that would indicate the presence of arterial stiffness instances in male T2D patients. As depicted in In the present investigation, the association between FAR and arterial stiffness as determined by baPWV in T2D patients was investigated. In comparison to female T2D patients, male T2D patients had a positive association between the FAR and baPWV and the prevalence of arterial stiffness.Arterial stiffness can increase cardiac afterload, causing cardiac hypertrophy and left ventricular dysfunction , as wellArterial stiffness is caused by a combination of variables such as an imbalance in elastin collagen ratio, oxidative stress, chronic inflammation, and so on, and diabetes can accelerate this process . NumerouIn a cross-sectional examination of risk factors for diabetic kidney disease (DKD) in T2D patients, FAR was significantly found to be positively associated with neutrophil count and NLR, leading researchers to hypothesize that FAR may be substantially associated with inflammation and consequently DKD . SimilarThe relationship between FAR and platelet count, a critical component of the coagulation system, was found to be statistically significant and positive in this study. Platelet, the primary cause of coronary thrombosis and atherosclerosis, is an essential target for the management of coronary heart disease . AlbuminThe relationships between arterial stiffness and the FAR in T2D patients were shown to differ by gender in this study. Numerous investigations have conclusively shown that the clinical features and sex-specific processes underlying arterial stiffness in males and females were different . In a crThe following are the study’s limitations, which cannot be avoided. First, the limitation of cross-sectional studies prevents the demonstration of a coincidental relationship between FAR and arterial stiffness. Second, due to a lack of data, it was impossible to account for confounding variables, including detailed alcohol and tobacco consumption and daily activity levels. Finally, all of the participants in this study were Chinese, which may restrict the generalizability of the findings.In conclusion, the FAR level was positively and independently associated with baPWV and arterial stiffness in male T2D patients. When considered in combination with other investigations, FAR has the potential to assist in the better management of cardiovascular problems in patients with T2D, particularly male patients.


A new human coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged at the end of 2019 in Wuhan, China that caused a range of disease severities; including fever, shortness of breath, and coughing. This disease, now known as coronavirus disease 2019 (COVID-19), quickly spread throughout the world, and was declared a pandemic by the World Health Organization in March of 2020. As the disease continues to spread, providing rapid characterization has proven crucial to better inform the design and execution of control measures, such as decontamination methods, diagnostic tests, antiviral drugs, and prophylactic vaccines for long-term control. Our work at the United States Army’s Combat Capabilities Development Command Chemical Biological Center (DEVCOM CBC) is focused on engineering workflows to efficiently identify, characterize, and evaluate the threat level of any potential biological threat in the field and more remote, lower resource settings, such as forward operating bases. While we have successfully established untargeted sequencing approaches for detection of pathogens for rapid identification, our current work entails a more in-depth sequencing analysis for use in evolutionary monitoring. We are developing and validating a SARS-CoV-2 nanopore sequencing assay, based on the ARTIC protocol. The standard ARTIC, Illumina, and nanopore sequencing protocols for SARS-CoV-2 are elaborate and time consuming. The new protocol integrates Oxford Nanopore Technology’s Rapid Sequencing Kit following targeted RT-PCR of RNA extracted from human clinical specimens. This approach decreases sample manipulations and preparation times. Our current bioinformatics pipeline utilizes Centrifuge as the classifier for quick identification of SARS-CoV-2 and RAMPART software for verification and mapping of reads to the full SARS-CoV-2 genome. ARTIC rapid sequencing results, of previous RT-PCR confirmed patient samples, showed that the modified protocol produces high quality data, with up to 98.9% genome coverage at >1,000x depth for samples with presumably higher viral loads. Furthermore, whole genome assembly and subsequent mutational analysis of six of these sequences identified existing and unique mutations to this cluster, including three in the Spike protein: V308L, P521R, and D614G. This work suggests that an accessible, portable, and relatively fast sample-to-sequence process to characterize viral outbreaks is feasible and effective. A new coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China in 2019. It was quickly sequenced and identified as being related to severe acute respiratory syndrome (SARS) virus, with some homology to bat coronaviruses . The disSARS-CoV-2 has a single-stranded, positive sense RNA genome with a 5′ cap and poly A tail . Its RNA1. Furthermore, GISAID has introduced a nomenclature system for major clades .Twenty positive samples and twenty negative samples were received from Justin T. Bacca’s group at the University of New Mexico. The samples were tested by their reference lab The total RNA was extracted from the TRIzol-inactivated clinical samples by using the Direct-zol RNA MicroPrep Kit  from Zymo Research. The manufacturer’s instructions were followed with the exception of the elution volume being doubled from a volume of 15 to 30 μL. After the RNA was extracted, the concentration and quality of the RNA was determined by Nanodrop analysis.The RNA was converted to cDNA and amplified using a targeted approach developed by the ARTIC Network. The ARTIC “nCoV-2019 sequencing protocol”  was follAll sequencing runs were performed using either a MinION connected to a MinIT (or the Mk1C with MinKNOW 19.12 software). Each run was performed using a MinION flow cell . For experiments using barcoded samples, four samples were run per flow cell. Samples that were not barcoded were run individually; one per flow cell. Prior to every run, the flow cells were assessed for the amount of total active nanopores available for sequencing, as per manufacturer’s protocol. Live basecalling with high accuracy (ONT Guppy 3.2.10) was selected for the run if the final concentration of the library was less than 10 ng/μL. If the final library concentration was too large, the basecalling would lag behind and significantly extend the time of the run. For these samples, high-accuracy basecalling was performed after the run was complete (ONT Guppy 3.2.10). For each run, the sequencing time was set to end at 20 h.2. A report containing the top ten organisms sorted by number of reads aligned, and excluding human hits, was generated as shown in After basecalling, passed fastq files were processed by an in-house metagenomic pipeline  and provided read mapping statistics and visual representations of coverage across the genome.The ARTIC Network’s RAMPART  software was downloaded with instructions from: 3 version artic 1.1.3 were downloaded and installed inside an anaconda ver 4.8.34 environment to facilitate reference based genome assembly. Assemblies with at least 89% coverage of the genome with sequencing depth of 10X were selected for whole genome assembly. Assembly was performed using a medaka5 based workflow for our analysis  was used to assign genome sequences to global CoV-2 lineages  located on the GISAID site. The GISAID reference strain, hCOV-10/Wuhan/WIV04/2019, was used as the reference strain for comparison. The app computes and provides a list of variations and mutations in the genome. It also provides clade classification as per the GISAID classification scheme. CoV-GLUE , as enablineages . After Pvia EUA-cleared RT-PCR assays, were tested in this pilot study. CoV-2 RNA that was obtained from BEI Resources  was used as? A positive control for the assay and using the standard ARTIC protocol, 95 and 97% of 170K reads mapped to the CoV-2 genome as analyzed by Centrifuge and RAMPART, respectively  for P02-P04. The depth of coverage at over 10X for these ARTIC with Rapid sequencing positive samples were 99, 48, and 65% for P02, P03, and P04. Finally, N01 as prepared by the ARTIC with Rapid sequencing approach yielded a high number of reads  with a 62% depth of coverage at over 10X. Negative control water samples were also amplified via PCR and prepared using the Rapid Kit to generate background/baseline levels to expect from this assay. Two samples returned 0 and 7,487 reads by Centrifuge analysis and 0 and 8,336 by RAMPART of analysis with a depth of coverage of 1.5% at 10X depth of coverage for the negative sample that returned reads. Since the pilot study revealed that the ARTIC with Rapid sequencing approach was promising due to reduction in steps, time, and increase in CoV-2 specific reads and coverage, additional positive and negative samples were prepared and sequenced using the ARTIC with Rapid sequencing approach.The goal of the study was to test the ARTIC CoV-2 protocol and make modifications to simplify and streamline the approach to make it faster and more accessible in its employment. We first performed a pilot, proof of concept study using a small set of previously diagnosed clinical samples. Three positive samples  and one negative (N01), as previously diagnosed ectively . Of noteIn total, 20 positive samples (P01-P20) and 12 negative samples (N01-N12) were sequenced using the ARTIC with Rapid sequencing approach . The numSome unexpected results were encountered upon analysis of negative samples N01-N12. Besides the N01 sample in the pilot study, six other negative samples had reads that mapped to CoV-2 ranging from 1,273–446,225 as per analysis with Centrifuge . Upon moMN908947.3) as the reference sequence. Once the sequences were successfully assembled, we used CoVsurver for clade classification and mutational analyses . Coppée et al. reported this mutation as the fourth frequent mutation observed in European populations after D164G, P323L, and L84S as accessed in sequences collected through April 17, 2020. The Q57H mutation was frequent in samples from France and Belgium, but not Italy and Spain . By NoveOther unique mutations to our assemblies included those in the multidomain, multifunctional Nsp3 protein  in samplA subset of negative samples, as determined by PCR analyses returned hits that mapped to SARS-CoV-2 as analyzed by Centrifuge and RAMPART. A caveat of this study is that we did not have detailed PCR assay information with the samples, including which PCR test was used or Ct values. However, the PCR tests with EUA at the time from April to May 2020 consisted of single to three target site assays . Since tEscheria coli, Shigella boydii, Shigella flexneri, Shigella phage, and Escheria phage Mu as examples. These reads may be related to contaminating bacterial DNA derived from the extraction kit or library preparation kits. These hits were associated with a low percentage of unique reads . There were also reads that failed to map using Centrifuge, and these could have been reads associated with the host (human). However, human/host reads can now be filtered out during sequencing using “adaptive sequencing” from MinKNOW and selecting for depletion of human sequences. This is an approach that may be used in future studies.Non-specific or contaminating reads that we observed in the samples as reported by Centrifuge mapped to In short, the work presented shows that it is possible to streamline the Artic v3 protocol for nanopore sequencing, saving an hour and 10 min in sample and library preparation time ,and stilhttps://www.ncbi.nlm.nih.gov/nuccore/), with accession numbers provided in The data presented in the study are deposited in the NCBI GenBank repository (MA and RB conceived the study, design, and experiments. MA, MK, SK, and JVH performed experiments. JMH, SD, PR, and AL performed bioinformatic analysis and assembly of the sequences. MA performed classification and mutational analyses. MA prepared the manuscript with input, review, and contributions provided by MK, SK, JVH, JMH, SD, PR, AL, and RB. All authors contributed to the article and approved the submitted version.JMH, PR, and AL were employed by DCS Corporation. The remaining 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.


Costovertebral hydatidosis is a rarely reported clinical and radiological entity, estimated at less than 1% of thoracic hydatid locations. Its management is still not codified.The aim of our study was to specify the management peculiarities of costovertebral hydatidosis.Between January 2000 and December 2018, 14 patients were managed for costovertebral hydatidosis in a thoracic surgery department.The mean age of our patients was 48 years. The history of a prior hydatid disease was found in 7 patients. Imaging features were suggestive in 13 cases. They showed: involvement of the spinal canal (6 cases), of the soft tissues (5 cases) and spinal cord compression (3 cases). Costovertebral resection of the hydatid lesions was complete in 12 cases. Four patients presented postoperative complications.Costovertebral hydatid involvement, may threaten the functional and vital prognosis. Therefore, early diagnosis and management are mandatory, before the occurrence of irreversible neurological impairment. Surgical resection remains the treatment of choice and must be complete whenever possible. Relapse is frequent, hence the importance of a regular follow-up. Hydatid disease is a cosmopolitan zoonosis caused by the development in humans of a taenia: Echinococcusgranulosus, in its larval form.Between January 2000 and December 2018, 14 patients were managed for a CVH in our thoracic and cardiovascular surgery department. The study was approved by the local hospital ethics committee. Data were retrospectively gathered from the patient's medical records and analyzed in terms of symptoms, radiological findings and surgical techniques and outcomes. All of our patients had complete physical examination and chest radiography. Chest and abdominal computed tomography (CT) scans were performed in all cases. They allowed assessment of bone involvement and extent of hydatic disease to the neighbouring soft tissues, lung parenchyma, pleura and spinal canal .T1 and T2-weighted magnetic resonance imaging (MRI) were performed, to further study bone, soft tissue, spinal canal and spinal cord involvement, in 10 cases .Other tests were carried out inconstantly: thoracic ultrasound and hydatid serology.Patients were managed by a multi-disciplinary surgical team of thoracic surgeons and orthopedists. Surgical approach was selected according to the cyst's location, size and number, the extent of the lesions to the spinal canal, vertebrae and neighboring structures. Posterolateral thoracotomy directly above the affected rib was performed in all cases, associated with a posterior vertebral approach in 2 cases.Protection of the operative field with hypertonic saline soaked gauzes was systematic. Abundant washing of the operative field with hydrogen peroxide or povidone iodine were systematic, in order to avoid the spread of the parasite and secondary hydatic lesions.Associated neighbouring locations, were treated at the same time. Pulmonary or pleural cysts were treated at first, then the CVH. Treatment of the HC included two steps. The first one consisted in treatment of the parasite. After sterilization with hypertonic saline solution and suction of the cyst's content, the germinative membrane was removed. Treatment of the residual cavity was performed second. For the associated locations, it was conservative and consisted in pericystectomy. For the bone lesions, it was radical. One to 3 ribs were removed on average. Depending on the extent of vertebral involvement, corporectomy, either total or partial, was performed in 7 cases. Between 2 and 4 vertebrae were resected and spinal osteosynthesis was performed in 5 patients with bone grafts .Medical treatment with Albendazole (10 mg/kg/day) was systematically prescribed preoperatively, at the time of imaging diagnosis. According to the completeness of surgery and CT features of cyst's viability at follow-up, courses of Albendazole were maintained postoperatively, from 6 to 18 months, with a daily intake for 21 days and an interval of 7 days between courses.Fourteen patients were included in the study, with a sex ratio of 1.8 (9 men and 5 women). The mean age was 48±15.4 years [27–76 years]. History of a previously operated HC was found in 7 patients and 4 among them were in the costovertebral setting .Clinical symptoms were dominated by back pain (7 patients) and neurological signs (4 patients), such as: paraparesis (2 patients), paraplegia with sphincter disorders (1 patient) and paresthesia of the two lower limbs with a decreased functional walking distance (1 patient). Frank hemoptysis was reported in 2 cases. Four patients reported the history of a several-year-evolving paravertbral swelling, which became recently painful. Discovery was fortuitous in one case, at a thoracic CT, performed during follow-up for a previously operated soft-tissue HC. Imaging investigations, were suggestive of CVH in 13 cases and the diagnosis of a chondro-sarcoma was evoked in one case. Hydatic lesions were right sided in 11 cases .Assessment of hydatic lesion extent showed that, the 8th rib was the most frequently involved (9 cases). Multi-level involvement was seen in 9 patients. Involvement of the spinal canal was shown in 6 patients and spinal cord compression in 3 cases.Surgical resection was performed in all cases. Decompression laminectomy was necessary and performed at first in 2 cases, in the neurosurgery department. Complete resection of all the hydatid lesions was achieved in 12 cases .Medical treatment with antibiotics was necessary in 1 case pre-operatively, due to drainage of an infected HC to the skin. The mean hospital stay was 9.4±8 days [4–33 days]. The postoperative course was complicated in 4 cases: pulmonary embolism associated with flaccid paraplegia related to spinal cord ischemia in 1 case, spastic paraplegia due to a non-compressive spinal hematoma, which regressed spontaneously in 1 case and post-operative fever in 1 case. One patient presented a postoperative pneumonia and died 12 days after the operation, secondary to acute respiratory distress syndrome. Recovery from neurological impairment was complete in 3 patients. During follow-up, only one patient previously operated for pleural and costovertebral hydatidosis, presented a relapse after 8 years, with progressive onset paraplegia and anal incontinence secondary to hydatid spinal cord compression, requiring emergent surgery for decompression and reoperation. There were no side effects reported secondary to Albendazole treatment.We reported our experience about 14 patients, managed for a hydatid disease in a rather rare setting. Costovertebral location is rare, estimated at less than 1% of thoracic hydatid locations.18A previous study, had shown that Albendazole should be given, for at least 6 months, so that the levels of circulating antigen, indicating the viability and biological activity of the parasite, become negative.19In our series, medical treatment with Albendazole (10 mg/kg/day) was systematically prescribed preoperatively. According to the completeness of surgery and CT features of cyst's viability at follow-up, courses of Albendazole were maintained postoperatively, from 6 to 18 months, with a daily intake for 21 days and an interval of 7 days between courses.In the same study,Risk of recurrence and death was high in the past, due to delayed diagnosis, incomplete resection and different surgical techniques, including an exclusive posterior approach. CVH is difficult to diagnose, assess and manage. Spinal cord involvement is the main prognostic factor. Therefore, MRI should be systematically performed, in order to diagnose and assess spinal canal involvement as early as possible. Surgical resection remains the treatment of choice and must be complete whenever possible. Relapses are frequent and anti-helminthic treatment is paramount postoperatively. Prolonged and regular follow-up and preventive measures are necessary to avoid parasitic reinfection.Presented as: a poster at The 23rd French-language pulmonology congress in Marseille, France in January 2019, with a published abstract in French in Revue des Maladies Respiratoires, Volume 36, Supplement, January 2019, Page a221.


Local and regional anesthetic procedures are valuable tools in veterinary practice. Caudal epidural administration of local anesthetic agents is widely reported for surgical interventions of the tail, anus, rectum, vulva, vagina, urethra, and bladder in the standing horse. Epidural analgesia is also obtained using various drugs such as alpha-2 adrenoceptor agonists, dissociative anesthetics, and opioids. The present study evaluates the anti-nociceptive and sedative effects of epidural administration of romifidine, a romifidine–lidocaine combination, and lidocaine alone in donkeys.n = 6) received either 50 μg/kg of romifidine, 0.30 mg/kg of lidocaine, combined romifidine (50 μg/kg) and lidocaine (0.30 mg/kg) diluted in 0.9% sterile normal saline solution to a total injection volume of 12 ml, or an equivalent volume of sterile saline epidurally. After epidural injection of each treatment, the onset, degree, and duration of sedation and anatomical extension of anti-nociception were documented. Observations began immediately (time 0) pre-administration and at 5, 15, 30, 45, 60, and 30-min intervals subsequently until 210 min after drug injection. Time to onset of perineal analgesia was documented every minute after the epidural injection by evaluating the animal's response to pinpricks.In a randomized prospective study, twenty-four healthy adult donkeys were assigned to four groups  with romifidine (160 ± 15.4 min) than with romifidine-lidocaine (141.6 ± 13.2 min). Longer-lasting analgesia (p < 0.05) was obtained with romifidine (158.3 ± 9.8 min) and romifidine-lidocaine (165 ± 9.4 min) than with lidocaine (75.8 ± 8 min).Only romifidine and romifidine-lidocaine induced mild to moderate sedation. Romifidine, romifidine-lidocaine, and lidocaine induced complete bilateral caudal epidural analgesia with loss of sensation in the perineum, tail, inguinal region, caudal aspect of the upper hind limb, chest areas, and extended distally to the dorsal metatarsal area. Sedation lasted longer (Epidural administration of a single dose of romifidine or a combination of romifidine-lidocaine produced mild to moderate sedation and complete anti-nociception in the perineal and inguinal regions of donkeys. The clinical usefulness of epidural romifidine or romifidine-lidocaine combinations to perform obstetric procedures in donkeys needs to be assessed. Local and regional anesthetic procedures are valuable tools in veterinary practice. The epidural injection of local anesthetic agents in equine clinical practice was first attempted in Germany more than a century ago to avoid the costs and risks associated with general anesthesia and recumbency . CurrentEpidural analgesia is also obtained using various drugs such as alpha-2 adrenoceptor agonists , dissociRomifidine is the alpha-2 adrenoceptor agonist most routinely used in equine practice in certain European and Middle East countries and is used widely as a sedative and analgesic for standing surgeries, as a pre-anesthetic medication in various anesthetic protocols, as a neuraxial  for conduction analgesia, and as a continuous rate infusion , 18.In the veterinary literature, assessment of the anti-nociceptive and sedative effects of epidural romifidine alone or in combination with other drugs has been reported in horses and food animals , 19–22. via a hypodermic syringe. All donkeys were housed in straw-bedded horse boxes  and received the same nutrition and other management practices. They had unlimited access to food and water until the start of each treatment.Twenty-four healthy adult donkeys were selected . Their age was ~3 to 7 years, and their body weights were 180 to 220 kg. All donkeys were concluded to be healthy based on physical examination and the analysis of biochemical and hematological parameters. Based on historical data, the inclusion criteria were donkeys that had not received previous extradural administrations, regional blocks, or local analgesia in the perineal region. The exclusion criteria were donkeys with unhealthy condition, unpalpable intercococcygeal space and those previously received epidural injections or local blocks in the perineal region. Each animal was identified by a microchip inserted subcutaneously into the donkey's neck The Animal Care Committee of King Faisal University  reviewed and approved this protocol in correspondence with Saudi Arabian ethical codes for studies on experimental animals. In the present study a randomized prospective study design was used. Donkeys were assigned randomly to four treatment groups, with six donkeys in each group. Randomization was carried out using the Simple randomization technique, which involved selecting random numbers. Donkeys were assigned randomly to four treatment groups, with six donkeys in each group . All investigations were conducted in a quiet room indoors (≈25°C) with natural sunlight. Two donkeys were brought and constrained in small stocks (2 m from one another) with their heads allowed free movement. Donkeys were acclimated to their surroundings in the room for 15 mins before evaluation.The hair over the second intercoccygeal intervertebral space was clipped and shaved, and the area was cleaned with povidone–iodine. At the beginning of each experiment, the donkeys were weighed and rectal temperature (RT), heart rate (HR), and respiratory rate (RR) for each donkey were measured.Each group received one of four treatments . Treatments were either 50 μg/kg of romifidine , 0.30 mg/kg of lidocaine , combined romifidine-lidocaine (50 μg and 0.30 mg/kg) diluted in 0.9% sterile normal saline solution  to a total injection volume of 12 ml, or an equivalent volume of sterile saline.All treatments directly administered into the extradural space between the second and third coccygeal vertebrae  over approximately 20 s, using an 18-gauge, 5-cm hypodermic needle. The specific space was identified by moving the tail up and down while palpating the depression between the second and third coccygeal vertebrae. The needle was inserted into the skin surface at a 30° angle with the median plane. The detection of negative pressure with the hanging drop technique and the lack of resistance to injection were used to confirm the correct needle placement. All treatments were prepared by one person (MK) and administered by the same investigators (MM and AA), who were blinded to the drug used.The onset time, duration, anatomical extension of anti-nociception, and sedation were documented after the epidural injection of each drug. Clinical observations included HR, RR, RT, and scores for sedation, anti-nociception, and ataxia, tail tone (flaccidity), anal and rectal relaxation, inspiratory sounds, penile prolapse in males, and frequency of micturition. Observations began immediately (time 0) pre-administration and at 5, 15, 30, 45, 60, and 30-min intervals subsequently until 210 min after drug injection. Tail tone (flaccidity) was detected by manual palpation of the tail, and visual assessment was used to evaluate rectal relaxation. The time interval between extradural administration and the beginning of loss of the tail tone and penile prolapse was used to determine the time of onset of tail and penile relaxation. HR was assessed by auscultation as beats per minute, RR was evaluated as the number of rising and falling movements of the ribs or flank area per minute, and RT was measured with a lubricated rectal veterinary digital thermometer.via pinprick test . This test entailed the introduction of the needle “pinpricking” into the underlying tissues (subcutaneous tissues or deep muscles) at the above-mentioned points. The needle was introduced bilaterally at a slightly different location for each time point. The skin prick wounds were swabbed and sprayed with povidone–iodine solution.Anti-nociception was tested at different points, including the tail root, anus, vulva, perineum, the skin of the posterior aspect of the upper hind limb region, flank, lateral abdominal wall, chest areas, shoulder, neck, and the dorsal metatarsal area The intensity of anti-nociception was judged using a whole-number scoring system from 0 to 3 as described in donkeys in a previous study : 0 = no via an electric impulse-based stimulus delivered by a remotely activated neuromuscular electrical stimulator  .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.


PMS2 mutation. To our knowledge, this has only been reported in a few cases in the literature. While the family history is less typical of LS, previous studies have indicated the absence of a significant family history in patient cohorts with PMS2 mutations due to its low penetrance. Notably, only a handful of studies have worked on characterizing PMS2 mutations in LS, and even fewer have looked at these mutations in the context of brain tumor development. This report aims to add to the limited literature on germline PMS2 mutations and oligodendrogliomas. It highlights the importance of genetic testing in neuro-oncology.Most tumors, including brain tumors, are sporadic. However, a small subset of CNS tumors are associated with hereditary cancer conditions like Lynch Syndrome (LS). Here, we present a case of an oligodendroglioma, IDH-mutant and 1p/19q-codeleted, and LS with a germline pathogenic  In a any more –9. PMS2 MR genes . There iciations .The patient is a 65-year-old gentleman diagnosed with a recurrent oligodendroglioma, IDH-mutant and 1p/19q-codeleted, CNS WHO grade 3. He was initially found to have a non-enhancing lesion in the left posterior temporal lobe at the age of 30. As illustrated in PMS2 (c.251-2A>T splice variant)  revealed that he carries a pathogenic germline mutation in PMS2 germline mutation, and he was advised to undergo a colonoscopy as surveillance in accordance with the new germline finding. Although he does not have children, the patient believed that it was important for him to share the information with his brother who had a diagnosis of colon cancer. He also planned to share his genetic testing results with his primary care physician so that his medical care can be customized to this condition.The patient was counseled on the implications of the -mutant and 1p/19q co-deleted, CNS WHO grade 3. The tumor also harbored a pathogenic mutation in PMS2, a DNA MMR gene, which was determined to be a germline mutation. PMS2 is associated with LS and in turn, with a predisposition to several types of cancers, including brain tumors.In this case report, we describe the case of a 65-year-old man diagnosed with a recurrent oligodendroglioma, IDHMSH2, 15% had mutations in MLH1, 15% in MSH6, and 2% in PMS2  syndrome (PMS2 mutations and brain tumors (PMS2 (PMS2 mutations (Due to the reduced penetrance and genetic testing complications of monoallelic syndrome –16. Seven tumors . One sucrs (PMS2 . Anotherutations .PMS2 mutations are at an increased risk for cancer, however, less is known about monoallelic PMS2 mutations and their association with brain tumors (PMS2 mutations found that only 6.2% of the class 4/5 variant carriers had a family history that fulfilled the Amsterdam diagnosis criteria (PMS2 mutations uncovered that if clinicians relied solely on Amsterdam criteria to identify potential PMS2 mutation carriers, 90.9% of the mutation carriers in their study would not have been identified, or if clinicians relied on revised Bethesda guidelines alone, 25% of the mutation carriers in their study would have been missed (PMS2 germline mutation, there was still positive protein expression in the proband, potentially describing why the patient did not have a strong LS phenotype. Moreover, retained protein expression of PMS2 also makes it hard to exclude the possibility of a coincidence in the occurrence of two moderately rare but unrelated diseases. Senter et al. further demonstrated that PMS2-associated LS presents highly variable clinical characteristics. For example, the age of the first LS-associated tumor in monoallelic PMS2 carriers varies from 23-77 years (PMS2 mutation.Carriers of monoallelic n tumors . A reporcriteria . Anothern missed . Our pat77 years . Since hPMS2 mutation in the patient reported here has a gnomAD allele frequency of 0.0004%, underscoring its rarity. To date, it has only been previously reported in few other cases – in an individual with suspected LS (PMS2 mutations with brain tumors, and the extremely low gnomAD allele frequency of the c.251-2A>T mutation in PMS2.The specific ected LS , in a paected LS , and in ected LS . There aThese findings emphasize that despite the uncommon nature of hereditary cancer syndromes in neuro-oncology, genetic testing and counseling can help identify genetic conditions that may require specific surveillance regimens, in turn improving patient care. Since early detection could lead to early intervention and routine surveillance, brain imaging may be indicated in some patients with LS.jing.wu3@nih.gov.The data analyzed in this study is subject to the following licenses/restrictions: a. The reported PMS2 mutation in this manuscript is from the germline whole exome sequencing. Other than this alteration, the rest of the dataset cannot be shared with the public, even by request. b. Requests to access these datasets should be directed to Jing Wu, The studies involving human participants were reviewed and approved by the Institutional Review Board of the National Institutes of Health. The participant provided the written informed consent to participate in this study.MM, MRay, YP, OK, ZS, and JW drafted the manuscript. MQ, MRaf, LX, JK, MT, ZA, and KA performed pathologic and molecular diagnostic testing. TP, BO, KZ, JH, TA, MG, and JW were involved in patient care. All authors contributed to the article and approved the submitted version.This research was supported by the NIH Intramural Research Program and Lasker Clinical Research Scholar Program. Clinical genetics and genetic counseling were supported by the NCI-CONNECT program.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 specific impulses of blendfuels were calculated by a thermodynamic method and compared to ILs.When the droplet was ethylene glycol/[EMIm]DCA with a 2.1 mm diameterand a 1.69 m/s colliding velocity, the ID time was the shortest. Kerosenewas not an applicable additive for [EMIm]DCA owing to its lower intermiscibilitywith ILs and HNO3 than alcohol fuels; alcohol fuels, however,were appropriate. The concentration of ethylene glycol in the oxidizerpool increased faster than the concentration of propylene glycol,triggering more rapid hypergolic ignition in the first 50 ms. Theprotocols regarding the hypergolic ignition conditions were verified,i.e., the size of the droplet had to be minute when the collidingvelocity was as fast as possible; this was carefully calculated usingethylene glycol. According to thermodynamic calculations, the additionof alcohol fuels can improve the specific impulse of fuels, with ethyleneglycol performing the best. The feasibility of adding alcohol fuelsto ILs was confirmed via experiments and thermodynamic computations,with the simulation results providing some guidance on selecting theexperimental or engineering conditions or both.To make ionic liquids (ILs) accessible and economical,ethyleneglycol was mixed in 1-ethyl-3-methylimidazolium-dicyanamide ([EMIm]DCA)to obtain droplets that could experimentally collide white fumingnitric acid. To investigate the ignition delay (ID) time theoreticallyin terms of hydrodynamics, alcohol fuels and kerosene were used ascombustibles, while the intermiscibility between them and nitric acid(HNO Moreover, the wide range of thrust and higher specificimpulses than solid propellant rockets render it important in rocketengines.Bipropellants are widelyapplied in various areas, including liquidrocket engines, space engines, and guided missiles.2 In 2008, the first protocolinvolving the use of dicyanamide (DCA)-based ionic liquids (ILs) asa propellant (rather than hydrazine) was proposed.3 However, given the growing concerns about ILs, considerableefforts have been made to establish more environmentally friendlyand nontoxic hypergolic ILs.The use of hydrazine and hydrazine derivatives as traditionalpropellantshas long been criticized for their toxicity, high volatility, andsensitivity to diabatic compression, which can result in operationaldifficulties.4 Specifically, Li et al. conducted drop tests in which two ILs, i.e.,[EMIm]DCA and 1-butyl-3-methylimidazolium ([BMIm]DCA), were mixedwith three oxidizers .5 Elsewhere, as a mature IL, [EMIm]DCA was investigated interms of vapor pressure, thermal stability, specific heat, and ionfragmentation.8 Contrarily, WFNA, DCA-based ILs, do not react witheither NTO or RFNA, which is essentially nitric acid (HNO3) with added NTO.Ignition occurs when DCA-basedILs react vigorously with fumingnitric acid (FNA). The resultant reaction products have been identifiedusing Fourier transform infrared spectroscopy.9 whereas in macroscopic terms, the viscosity ofILs and the experimental method  are also influencing factors.12 In addition, specific impulse is also an important performance parameterfor rockets. Except for the structural design of rockets, the choiceof propellant is also a factor in determining the specific impulse.13 Specific impulse can be increased by decreasingwater content in an oxidizer, or increasing heat of formation andenergy-density of fuel.15 [EMIm]DCA is a less-than-spectacularfuel5 with respect to specific impulsecompared with RP-1 and hydrazine derivatives.The ignition delay (ID) time is one of themost important criteriaof IL performance, provided that hypergolic ignition occurs; the componentsand structure of ILs impact both the ID time and the ignition process,In this study,[EMIm]DCA was selected as the IL and WFNA as anoxidizer, and the IL viscosity and the experimental methods were variedaccordingly. Alcohol fuels were used as the combustible liquid andwere mixed in the [EMIm]DCA to improve fuel economy. In addition toobserving any emerging phenomena, a computational fluid dynamics (CFD)model was created to calculate the rate at which one liquid phasedissolved into another. The results of the simulation experimentsprovide a reference for subsequent experimental design and predictions.At last, the specific impulse calculation of the blended fuels canevaluate whether the alcohol fuel is a favorable additive.22.1A drop testinvolving a single droplet collision was conducted, and to identifyan optimized solution, a variable-control approach was adopted. Theexperimental setup is shown in 2.1.1As noted, [EMIm]DCA wasselected as the IL and three variables were selected for the experiment,i.e., collision velocity, droplet size, and fuel content, with thecollision velocity set to 1.34, 1.69, and 1.9 m/s, based on the heightof the syringe from the pool; the droplet size was set to 2.1, 2.5,and 2.9 mm in diameter. These two sets of data were obtained via thecalibration calculation process shown in 2.1.2w isthe mass fraction and η is the dynamic viscosity. The calculatedresults for the mixture viscosity are shown in The preparation cost of ILsis higher compared with traditional fuels; this is one reason thatprohibits the widespread adoption of ILs in engineering contexts.In this study, alcohol fuels were used as combustibles and mixed intothe [EMIm]DCA to improve fuel economy. Ethylene glycol and propyleneglycol are widely used as combustible chemicals in many fields andare immiscible with [EMIm]DCA in any given proportion. The ethyleneglycol and [EMIm]DCA mixture was labeled “EE,” whereasthe propylene glycol and [EMIm]DCA mixture was labeled “PE,”as shown in 2.22.2.116 To describethe hydrodynamics of the mixture, the Cahn–Hilliard and theNavier–Stokes equations for incompressible flows were combined.In the phase-field interface, the two-phase flow dynamics were governedby the Cahn–Hilliard equation, which is often used to describethe evolution of phase boundaries in phase-field models for multiphasefluids,17 with the equation tracking adiffuse interface separating the immiscible phases. After generalizingthe diphasic Cahn–Hilliard model noted above for the simulationof three immiscible component flows without phase changes, the finalCahn–Hilliard equations were obtained as follows:i is the phase-field help variable, and M0 is a diffusion coefficient, which may depend on a smoothfunction known as the “mobility”.18The field ofCFDs presents an emerging cross-discipline that integrates fluid mechanicsand computer science. It uses a calculation method and rapid calculationcapacity of a computer to obtain the approximate solution for a fluidcontrol equation. In this paper, the ternary phase-field (TPF) methodwas adopted to simulate the immiscibility of the two liquids usedin this study in the air.21 and can be described as follows:u isthe velocity, p is the pressure, T is the temperature, g is the acceleration of gravity,and F is the bulk free energy. The mass transferin the reactor domain is given by the transient convection and diffusionequation as follows:iD (m2/s) denotes the diffusion coefficient, iR (mol/[m3·s]) denotes the reactionterm, and c refers to the concentration of one liquidphase (droplet of fuel) in another liquid phase (HNO3).The Navier–Stokes equations describe the transportof mass and the momentum of fluids with a constant densitystF is the surface tension force.The multiphysics coupling feature determines the density and viscosityof the mixture to enable varying it smoothly over the interface byallowing the following:2.2.2The differencebetween specific mixture fuels can influence the numerical results.A practical protocol for clearly investigating the fluid dynamicsinvolved magnifying this difference by only selecting alcohol fuelsand kerosene as the liquid droplets in the simulation. The consideredphysical properties (at 16 °C) are shown in Working under the premise of two-dimensional axisymmetry,the airfield was a 50 × 10 mm rectangle, the liquid field (liquid pool)was a 50 × 15 mm rectangle, and the other liquid field (fueldroplet) was a semicircle with varying diameters  under various simulation conditions. In accordance with the actualconditions, the initial collision velocities were set to 1.34, 1.69,and 1.9 m/s in the numerical model. Additionally, to perform the finiteelement grid division method, quadrilateral and triangular partitionswere developed in the model 2.2.35 In this model, the initial temperature (T0) and pressure (P0) were 298.15 K and 20 bar, respectively. The nozzle area expansionratios were set as 30, 50, 70, and 90. According to the definitionof blend fuels above, amounts of substance are shown in Inthe condition of uncertain type of rocket engine, equilibrium flowand frozen flow can be calculated by the infinite-area chamber modelusing Chemical Equilibrium Applications (CEA) code developed at NASA.33.122 The quiddity of hypergolicignition is that the heat generation rate of the chemical reactionexceeds the heat dissipation rate of the system, i.e., the chemicalreaction accelerates exponentially through the gas mixture heatedby an excessive temperature. This process occurs repeatedly untilfuels burn.23 In this study, the entireprocess was recorded using a camera, and the resting images are shownin A strong hypergolicitygenerally signals an ability to react faster and to release more heatto rapidly increase a system temperature, which ultimately leads toa shorter ID time.In the experiments, the large size of the dropletoften resultedin two scenarios, i.e., the failure of hypergolic ignition or an excessiveID time, which caused a violent explosion. 3.23 in 1.69 m/s.Following the collision, a mass of ethylene floated on the HNO3, whereas the remaining portion rushed to the bottom of thepool.3 process during thefirst second and the first 50 ms of the simulation, in which the collisionvelocity was 1.69 m/s. The performance in the first 50 ms was considerablebecause the ID time was expected to be less than 50 ms. The concentrationof kerosene consistently underwent a sharp and rapid drop followingsubstantial growth, which indicated a disappointing intermiscibilitybetween kerosene and HNO3. Additionally, the alcohol fuels,particularly the ethylene glycol, exhibited a relatively stable concentrationfollowing an initial increase, with the ethylene glycol reflectinga higher concentration during a 1 s period and a higher speed fromthe start (50 ms) compared with the propylene glycol.3 indicated that the collision velocity could be expectedto be slow when the droplet size was large and more rapid when thedroplet was small.Given the stability and velocity of intermiscibility,ethyleneglycol was determined as an applicable fuel, and further calculationsusing this fuel were performed 8. Here, 3.3I) calculation withevery fuel. Specific impulse, on the whole, is increased in logarithmicgrowth with the nozzle area expansion ratio (Ae/At). The nozzle area expansionratio depends on the structure of rocket engine, which is barely changedonce decided. It makes more sense to compare in the same ratio. Asfor the specific impulse in vacuum (Ivac), it is higher than in nonvacuum (Isp), and the results in equilibrium is higher than those in frozen,which are common sense. The specific impulse is increased with relativecontent of WFNA (oxidizer), in which the fuel that only contains [EMIM]DCA(ILs) is more sensitive to the change of content. In the same condition,EE (ILs mixed with ethylene glycol) gets the highest Isp and Ivac compared to PE((ILs mixed with ethylene glycol) and ILs. It is observed that mixinga small amount of alcohol fuels can increase the specific impulse.2, which were regarded as the products of incompletecombustion; Prod.2 group includes N2, O2, CO2, and H2O, which were regarded as the productsof complete combustion. The sum of the proportions of these two groupsis close to 100% (97–99.5%), and the rest are other particles.Prod.1 and Prod.2 are changing in a linear fashion if the variableis F/O. When the fuel is an IL, the products get more Prod.1 thanPE and EE, which makes a lower specific impulse because of more incompletecombustion. The change of ILs’ Prod.1 or Prod.2 is much moresensitive to the relative content of WFNA (oxidizer), which is consistentwith the calculation results of specific impulse above. EE and PEcan cause more complete combustion, and EE causes the most completeone.As for the products for the reaction of fuels (PE/EE/ILs)and oxidizer, 43 as the liquid pool. At last, differentfuels’ specific impulses were calculated by the CEA code.In this work, the hypergolicignition ID time and the behaviorof EE mixed with WFNA were reported using high-speed photographictechniques. Furthermore, the mixing was calculated using the TPF methodwhen ethylene glycol, propylene glycol, and kerosene were used asdroplets and HNOThe results demonstrated the feasibility of hypergolic ignitionwhen mixing common fuels  with [EMIm]DCA.The selection of alcohol fuels should follow the following principles:(i) the alcohol fuel and the ILs must be immiscible at any given proportion;(ii) the viscosity of the alcohol fuel should be as low as possible;(iii) the alcohol fuel must be both combustible and economical.The results of the simulation experiment, which was used as a predictivemethod, were not entirely consistent with the experiment results,likely because the ignition entailed a chemical–hydrodynamiccoupling model, but the simulation only considered the aspect of hydrodynamics.Despite this limitation, the simulation results could provide a referencefor the selection of the parameters that are used in various engineeringapplications, with the results indicating that the collision velocityshould be as high as possible and the droplet as small as possible.If the droplet is large, the collision velocity will be low, resultingin the failure of hypergolic ignition, which occurred during thisstudy’s experiments.Based on the analysis, WFNA canbe expected to collide with atomizingEE at high speeds. However, additional phase-solubility analysis relatedto atomizing EE and WFNA can be conducted using the finite elementmethod alongside supplementary parameters, including the angle andthe velocity of the squirt, the atomizing level, and the content ofthe alcohol fuel, all of which can be calculated to provide furtherguidance for engineering applications.2OH)2, C3H8O2), the energies of the C–C bond and C–H bond are high,the standard enthalpies of formation are low, but the combustion maybe more complete because of atom of oxygen in it. That is the reasonwhy specific impulse of EE is higher than PE: C3H8O2 has more C–C bonds and C–H bonds, whichleads to the lower standard enthalpies of formation.Meanwhile, the thermodynamiccomputing backed up the feasibilityof using blend fuels as a propellant by a theoretical method: thespecific impulse of blend fuels is higher than ILs. For alcohol fuels((CHFrom apractical application point of view, the choice of propellantshould take into all these factors: the performance of hydrodynamicsand thermodynamics, toxicity, and economy.


Biomarkers of muscle damage  and inflammation  were not significantly changed in all courses, but CRP  showed a tendency to decrease after the expedition course 1 . Lastly, the Cortisol level significantly increased in all courses (per p < 0.05), but the Cortisol level after expedition course 3  was lower than that of after the expedition course 1 . In summary, it seems that repetitive and continuous 50–90 km/day of cycling can increase joint cartilage damage risk and stress hormone temporarily. However, this result suggests that the appropriate intensity of cycling for thirteen weeks does not increase physical damage, and rather enhances the human body to adapt to exercise training.This study was to investigate the effects of 13 weeks of long-distance cycling on biomarkers of joint cartilage, muscle damage and inflammation. All subjects in this study were seven participants of the “One Korea New-Eurasia Peace Cycle Expedition”, in which they rode cycles from Berlin, Germany to Seoul, Korea for thirteen weeks. The total course of the expedition was divided into three sub-courses: course 1 (from Berlin to Moscow), course 2 (from Moscow to Ulaanbaatar) and course 3 (from Ulaanbaatar to Seoul). All the selected participants rode 87.4 km/day (course 1), 70.4 km/day (course 2) and 57.6 km/day (course 3) on average, respectively. We collected their blood samples before the expedition in Seoul (S1), after course 1 in Moscow (M), after course 2 in Ulaanbaatar (U) and after the expedition in Seoul (S2), to analyze biomarkers of joint cartilage damage , muscle damage , inflammation  and stress hormone (Cortisol). According to this result, COMP  showed a significant increase after the expedition course 1 (M; 246.69 ± 51.69 ng/mL,  Endurance training improves cardiopulmonary endurance and immune function, and is also effective in preventing various metabolic diseases, such as obesity, diabetes and cardiovascular disease. Given these benefits, more people are participating in endurance exercise ,2, but lCartilage oligomeric matrix protein (COMP) is a non-collagenous extracellular matrix protein that maintains collagen structure in joint cartilage. It is secreted into the blood when joint cartilage is damaged, and is thus used as an index of joint cartilage damage ,6. In otIn summary, with increases in the participation of non-professional athletes in endurance exercise, as well as increases in competitions and sports events, it is important to elucidate the influence of long-distance endurance exercise on markers of tissue damage in the body, in order to set safe exercise plans. Nevertheless, the influence of long-distance endurance exercise on joint cartilage damage, muscle damage and level of inflammation according to exercise type, distance and duration remains unclear, with a lack of relevant research. Therefore, this study aimed to investigate the influence of 13 weeks of long-distance cycling on inflammatory markers associated with muscle and joint cartilage damage.The participants of this study were adults aged from in their 20s to their 50s who did not have any musculoskeletal disorder, but had more than 7 years of experience with cycling. Furthermore, they were healthy individuals who had not participated in an exercise program or diet for the 3 months, and no specific disease was found in the medical examination. The participants were screened for their cycling abilities to complete the ultra-long-distance cycling event across Europe and Asia ; course 2 (from Moscow to Ulaanbaatar); and course 3 (from Ulaanbaatar to Seoul). Although the original plan was to cycle for 5 days and have 1 day of rest, some changes were made depending on environmental conditions . Blood samples were collected in the morning of the day after cycling after fasting at the following time points: before the expedition (in Seoul); during the expedition in Moscow (day 29) and Ulaanbaatar (day 63); and on the last day of expedition in Seoul (day 93). The collected samples were immediately placed into serum tubes and EDTA tubes and centrifuged . The supernatant serum and plasma were separated and carried on dry ice (−78.5 °C), and stored at −80 °C in a freezer until analysis.In order to assess the level of joint cartilage and muscle damage from long-distance cycling, the concentration of COMP, an index of joint cartilage damage, was measured using Human COMP Quantikine ELISA kits  through an enzyme-linked immunosorbent assay (ELISA). The levels of CPK, LDH and myoglobin, which are markers of muscle damage, were analyzed using Modular Analytics  through UV assay. Inflammatory markers  were analyzed using Human High Sensitivity Cytokine kits  through Luminex assay, and CRP was analyzed using Modular Analytics  through immunoturbidimetric assay. The concentration of cortisol, a stress hormone, was analyzed using a fully automated chemistry analyzer . This study was conducted as a joint study. The results pertaining to serum cortisol have already been published through Gil’s study . Howeverp < 0.05.Mean and standard deviation were calculated for the collected data using SPSS/PC+Version 20.0. One-way repeated measures ANOVA was used to assess the differences in serum markers according to cycling distance. When differences were present, they were analyzed through Duncan multiple test analysis, and the level of statistical significance was set as p = 0.012) and course 2 (p = 0.047). Compared to course 1, the concentration decreased after course 3 (p = 0.036).When serum COMP concentration, which is an indicator of joint cartilage damage, was analyzed , the conp > 0.05).When serum CPK concentration, a marker of muscle damage, was analyzed , the conp > 0.05).When serum concentration of myoglobin, an indicator of muscle damage, was analyzed , the conp > 0.05).When serum concentration of LDH, an index of muscle damage, was analyzed , the conp > 0.05).When serum concentration of IL-6, an inflammatory marker, was analyzed , the conp > 0.05).When serum concentration of IL-1β, an inflammatory marker, was analyzed , the conp > 0.05).When serum concentration of TNF-α, an inflammatory marker, was analyzed , the conp = 0.044).When serum concentration of CRP, an inflammatory marker, was analyzed , the conp < 0.05), and the concentration decreased significantly after course 3 compared to that after course 1 (p = 0.028).When serum concentration of cortisol, a stress hormone, was analyzed , the conThe present study was conducted to assess the influence of 13 weeks of long-distance cycling on serum markers of joint cartilage damage, muscle damage and inflammatory response after each of 3 sub-courses . According to the results, joint cartilage damage and stress hormone increased in proportion to daily cycling distance in each course during the 13 weeks of long-distance cycling, and the values decreased with increases in cycling duration. Inflammatory response was found to decrease with long-distance cycling. In summary, although markers of damage had a positive correlation with daily cycling distance, with long-distance cycling, the participants adapted to the given exercise intensity, and had overall positive training effects in terms of muscle damage, joint cartilage damage and inflammatory response.During the 13 weeks of long-distance cycling expedition, serum COMP concentration increased after course 1 and course 2. After course 3, the concentration returned to the normal range from the increased values measured after courses 1 and 2. The COMP concentration that increased after course 1 would have stayed elevated until after course 2, as the cycling distance was longer for courses 1 and 2 than course 3. Moreover, joint cartilage would have adapted to long-distance repeated exercise over the three courses. In this study, the participants cycled 87 km per day on average in course 1 for a total distance of 2097 km, 70 km per day on average in course 2 for a total of 1678 km and 57 km per day on average in course 3 for a total of 1094 km. Therefore, the daily cycling distance would have influenced the serum COMP concentration. Qi & Changlin (2006) measured COMP every 2 weeks after 10 weeks of exercise training in lab animals; the serum concentration was highest at weeks 4 and 6, and started to decrease from week 10 . CorsettHigh-intensity exercise is known to increase the serum concentration of muscle damage markers, and such changes are influenced by exercise intensity, duration, type and temperature during exercise ,22,23,24IL-6, IL-1β, TNF-α and CRP are well-known markers of inflammation. They increase in specific conditions, and indicate the level of inflammation in the muscles and body ,13,14. ACortisol is a stress hormone secreted by the adrenal cortex in response to various stimuli, which is known to suppress adrenocorticotropic hormone, promote gluconeogenesis and mediate inflammatory responses . When sen = 7), and the direct and indirect influence of changing geographic characteristics and climatic changes during the expedition on the participants could not be excluded or quantified objectively.Regarding the limitations of the present study, for the results of this study to show a moderate difference, 80* power and 5% significance level, 24 subjects are needed . HoweverAfter 13 weeks of long-distance cycling, joint cartilage damage markers and stress hormone increased in proportion to daily cycling distance during each sub-course, and decreased with increases in exercise duration. Inflammatory response decreased with long-distance cycling. The results suggest that continued cycling for 50–90 km per day temporarily increases joint cartilage damage and stress hormone in the initial phases of adaptation. However, continued (13 weeks) long-distance cycling of appropriate intensity decreases the damage response through adaptation of tissues to exercise training, rather than increasing body damage.


P < .001). After operating table rotation from the Trendelenburg to the horizontal position, the lower limb PI did not change significantly after 15 min. However, lower leg pressure showed a significant decrease immediately after returning to the horizontal position. This result provides evidence for operating table rotation as a preventive measure for well leg compartment syndrome.We focused on “returning to the horizontal position,” one of the measures for preventing well leg compartment syndrome implemented at our hospital, and aimed to clarify the effect of intraoperative positional changes by operating table rotation on blood perfusion in the lower extremities during lithotomy in patients under general anesthesia. This prospective observational study examined 64 patients scheduled to undergo general anesthesia in the lithotomy position from March 2021 to May 2022. The primary endpoint was the perfusion index (PI) of the lower limb before and after operating table rotation. The baseline lower limb PI before the operating table rotation was 2.376 (1.591), and the lower limb PI after the change from Trendelenburg to the horizontal position was as follows: immediately after, 2.123 (1.405); 5 minutes, 1.894 (1.138); 10 minutes, 1.915 (1.167); and 15 minutes, 1.993 (1.218). Compared with the baseline, no significant difference was noted in the change in the lower limb PI due to the Trendelenburg to horizontal positional change. The baseline lower leg pressure before the operating table rotation was 51.4 (13.4) mm Hg, and the lower leg pressure after the change from the Trendelenburg to the horizontal position was as follows: immediately after, 36.6 (10.3) mm Hg; 5 minutes, 36.5 (10.2) mm Hg; 10 minutes, 36.4 (10.0) mm Hg; and 15 minutes, 36.5 (10.2) mm Hg. Compared with the baseline, the change in lower leg pressure due to the Trendelenburg to horizontal positional change showed a significant decrease immediately afterward ( The incidence of WLCS has been reported by Halliwill et al over the past 30 years; data for the lithotomy position showed a frequency of 1 in 3500 cases. Simms and Terry reported a WLCS incidence of 1 in 500 cases of total bladder cystectomy, and cases have also been reported in surgery and obstetrics and gynecology.–7 WLCS can cause critical sequelae in patients, including metabolic acidosis, atrophic renal failure, Volkmann contracture, limb loss, and death. Risk factors for WLCS have been identified as an operative time longer than 4 hours, lithotripsy, peripheral vascular disease, obesity, diabetes, use of intermittent pneumatic compression devices, insufficient intravascular volume, traction, and compression of blood vessels by pelvic manipulation, and compression of the lower extremities.Patients undergoing surgery should be optimally fixed in the surgical position based on the surgical site, procedure, and anesthesia method. However, patients are exposed to various postoperative complications related to the surgical position. One important complication related to surgical position is compartment syndrome after lithotomy, wherein the pressure inside the muscle compartment covered by fascia is increased due to conditions such as edema and hemorrhage, resulting in microcirculatory disturbances innervating the muscles and nerves. In 1979, Leff et al Therefore, we consulted operating room nurses, general surgeons, obstetricians, and urologists and developed the following recommendations for procedures that can be modified to the open leg position: a-1) change from the lithotomy position to the open leg position; b-1) base lower limb elevation restriction on the right atrium height; b-2) prevention of compression at the lower leg contact site; and b-3) provision of nursing care. Five interventions completely prevented the incidence of WLCS, including a-2) intraoperative decompression of the lower leg contact site by the surgeon and b-4) returning the patient to the horizontal position every 3 hours by Trendelenburg position. No occurrence of WLCS has been reported at our operation center since these measures were implemented. However, the lack of supporting evidence, such as changes in blood perfusion due to interventions, remains an issue for further investigation. Modifications in blood perfusion of the body can be observed by rotating the operating table and changing the patient’s position.,11 However, most previous studies on this topic have been conducted with unanesthetized healthy adults, and to the best of our knowledge, no studies have reported on blood flow changes caused by operating table rotation in patients under general anesthesia. Among the regional studies, there are only reports on the blood perfusion index (PI) in the lower limbs of neonates.At our surgical center, WLCS has been reported in 0.83% of cases.Therefore, we focused on “returning to the horizontal position,” which is one of the WLCS prevention measures implemented at our hospital, to clarify the effect of intraoperative positional changes due to operating table rotation on blood perfusion in the upper and lower extremities during lithotomy in patients under general anesthesia. We hypothesized that the PI of the lower limb would increase as a result of returning the patient from the Trendelenburg to the horizontal position. The results of this study are expected to provide evidence for WLCS prevention measures.This study was approved by the Ethics Committee of the Nagasaki Medical Center . The researchers provided written and oral explanations to the study participants about the study procedures that were approved by the head of the research institution. The participants were also provided with opportunities to ask questions and sufficient time to decide whether to provide their consent to participate. For participation in the study and publication of the results, all participants provided written informed consent of their free will after confirming that they understood the study.This prospective observational study of patients scheduled to undergo general anesthesia in the lithotomy position at the Nagasaki Medical Center Surgical Center was conducted from March 2021 to May 2022 (patient enrollment period: March–August 2021 and February–April 2022). The exclusion criteria were emergency surgery and pediatric patients.The following clinical information of the study participants was obtained from their medical records: patient information included age, sex, height, weight, body mass index, and medical history . Surgical information included the surgical time and lower leg pressure. The operating table rotation in this study indicates a positional change from the Trendelenburg to the horizontal position. The lower leg pressure measurement site was the lower leg of the lower extremity, which became the upper leg when the head was lowered. Anesthesia information included American Society of Anesthesiologists classification, anesthesia duration, infusion volume, urine output, intraoperative vital signs , and PI. For PI during Trendelenburg to horizontal position change, data from the timing of Trendelenburg to horizontal position return, which was performed 3 h after the start of surgery, were used.,14 Because the PI of the toe as a local PI correlates with blood flow in the triceps and the upper limb PI is used as an index of systemic circulatory dynamics in patients under general anesthesia, we decided to obtain the lower limb PI. A Radical-7® Pulse CO-Oximeter® (Masimo) was used. Intraoperative body pressure: The SR Soft Vision software (Sumitomo Science and Technology) was used. The measurement range was 20–200 mm Hg, and the data were saved as continuous data in a video format. Operating table and lithotripter: The operating table used was Operating Table MOT-5701® (Mizuho), and the lithotripter used was Levitator® (Mizuho).PI is expressed as the ratio of pulsatile to nonpulsatile blood volume in peripheral tissues. PI is a noninvasive measure of peripheral perfusion that can be measured continuously and noninvasively using a pulse oximeter (range: 02–20%). The lower extremity PI measurement site was the second toe of the lower limb that is on the upper side when the head is lowered.The primary endpoint was the PI of the lower limb before and after rotation of the operating table. Baseline data were collected 1 min before rotation and continuously from immediately after to 15 min after rotation. Fifteen minutes after the rotation was set based on the progress of surgery at our institution, and because it is the time when blood flow stabilizes after the positional change.The secondary endpoint was the change in leg pressure before and after operating table rotation from Trendelenburg to the horizontal position.The study was set up with an effect size of.3, a significance level of.05, and a power of.8, calculated with G*Power 3.1.9.4 (Heinrich-Heine Universität), resulting in 64 patients. Simple tabulations were performed for patient, surgical, and anesthesia information, and the means (standard deviations) are shown.PI and leg pressure data were collected continuously from the operating table rotation baseline for 15 min; however, data collected every 5 min were used for statistical analysis. To minimize potential bias and accuracy issues, we used the mean of 10 s of data before and after the rotation . The mean values from immediately after the operating table was rotated 15 min later, and the mean (standard deviation) of the change value and rate of change compared with 1 min before and 15 min after rotation were obtained . If normality was present, the paired t test was used to analyze the data; if there was no normality, the Wilcoxon signed-rank test was used.For the secondary endpoint, that is, leg pressure changes before and after rotation of the operating table, data were collected every 5 min up to 15 min  from immediately after the rotation of the operating table. If normality was found, the paired Differences were considered significant at the 5% significance level. The JMP® 16 software  was used for all statistical analyses.Among the 70 patients who participated during the study period, 6 were excluded due to emergency surgery (n = 4) and consent was not obtained n = 2). Ultimately, 64 patients were included in the analysis. The patient background characteristics and vital signs are shown in Tables . UltimatThe baseline lower limb PI before operating table rotation was 2.376 (1.591), and the lower limb PI after the change from Trendelenburg to the horizontal position was as follows: immediately after, 2.123 (1.405); 5 min, 1.894 (1.138); 10 min, 1.915 (1.167); and 15 min, 1.993 (1.218). Compared with baseline, no significant difference was noted in the change in lower limb PI after Trendelenburg to the horizontal positional change (Table P < .001) (Table The baseline lower leg pressure before operating table rotation was 51.4 (13.4) mm Hg, and the lower leg pressure after the change from the Trendelenburg to the horizontal position was as follows: immediately after, 36.6 (10.3) mm Hg; 5 minutes, 36.5 (10.2) mm Hg; 10 minutes, 36.4 (10.0) mm Hg; and 15 minutes, 36.5 (10.2) mm Hg. Compared with baseline, the change in lower leg pressure after Trendelenburg to horizontal positional change showed a significant decrease immediately afterward  and Editage (https://www.editage.jp/) for English language editing.We gratefully acknowledge the work of past and present members of our medical center. We would like to thank Paperpal Preflight Service (Kentaro Hara and Kodai Ichihara were responsible for the organization and coordination of the study. Kentaro Hara was the chief investigator responsible for the data analysis. Michiko Yamaguchi and Hiroaki Takeshita provided study data. Tamotsu Kuroki made critical revisions to incorporate relevant information. All authors contributed to the writing of the final manuscript and approved it.Conceptualization: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Data curation: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Formal analysis: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Funding acquisition: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Investigation: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Methodology: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Project administration: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Resources: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Software: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Supervision: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Validation: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Visualization: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Writing – original draft: Hiroaki Takeshita, Kentaro Hara, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.Writing – review & editing: Kentaro Hara, Hiroaki Takeshita, Kodai Ichihara, Michiko Yamaguchi, Tamotsu Kuroki.


The primary outcome variable was pain severity, measured by a standardized visual analog scale (VAS). VAS values were collected at 1, 3, 7, and 14 days and 1 and 3 months after patients were treated with NB or PRF. Results: Compared with patients treated with NB (n = 40) and those treated with PRF (n = 48), no significant difference in pain reduction was observed in the short term ; however, in the medium and long term (1 to 3 months), there were statistically significant improvements in the PRF group over the NB group (p < 0.001). Moreover, it was noted that the average pain severity of primary PN and PN due to sacral perineurial cyst was significantly reduced with PRF therapy in the medium and long term when compared to other secondary PNs, including surgery, trauma, and diabetes. Discussion: The ultrasound-guided, improved, and innovative PRF/NB puncture path technique allows for gentler stimulation and faster identification of the pudendal nerve. The PRF technique may provide better treatments for primary PN and sacral perineurial cyst causing secondary PN in the medium and long term.Objectives: To investigate the efficacy and safety of an improved ultrasound-guided pulsed radiofrequency (PRF) and nerve block (NB) for patients with pudendal neuralgia (PN). Methods: This retrospective analysis included 88 adults with PN treated in the Pain Department of Southwest Hospital from November 2011 to June 2021, with treatment including NB ( Pudendal neuralgia (PN) is a well-known medical challenge involving the motor 20%), sensory 50%), and autonomic 30%) functions of the pudendal nerve, with a prevalence of approximately 6.6% in the population in general ,2. The e0%, senso0% functi0%, and aAccurate pulsed radiofrequency (PRF) therapy combined with nerve block is a novel method to improve the function of pudendal nerve and to relieve the pain of PN patients ,9. In reAt present, only a few cases and clinical trials involving nerve block or PRF techniques for refractory PN have been conducted due to insufficient study populations and follow-ups. The objectives of this retrospective study are as follows: (1) to find a novel, simpler, and faster puncture path for ultrasound-guided stimulation and confirmation of the pudendal nerve; (2) to compare the therapeutic efficacy and safety between PRF and NB therapies in the medium to long term; and (3) to further discuss and analyze the efficacy of ultrasound-guided PRF for the therapy of secondary and primary PN.This retrospective study was approved by the ethics committee of the First Affiliated Hospital of the Army Medical University, PLA . Hospitalized patients who visited the pain department at Southwest Hospital from November 2011 to June 2021  were eliWe included age, gender, VAS, and short-term  and med-/long-term (1 to 3 months post-treatment) results as variables for the patients treated with NB and/or PRF. Pain severity and pain reduction were reassessed and standardized from the patient’s initial VAS score level to the latest recent VAS score level to increase the objectivity of the data. Lower VAS scores indicated less severe pain, and higher VAS scores referred to more severe pain. Data on pain severity were collected by telephone or Wechat video call follow-up.For patients with PN in the lithotomy position, a previous study described the conventional pudendal NB approach taken . In brieAfter positioning the PN patient in a prone position , a low-fThe day before a patient with PN receives PRF treatment, physicians must determine the effectiveness of pudendal NB therapy under ultrasound guidance. We administer PRF therapy only when the pain severity in pudendal NB is reduced by more than 50% within 2 continuous hours by pudendal NB therapy. An RF needle  with a 5 mm active tip is placed laterally to the internal pudendal artery and is observed to generate a sensory abnormality by stimulation testing  at a frequency of 50 Hz and a voltage of 0.1–0.5 V. The parameters of PRF ablation are then delivered at a frequency of 2 Hz, a pulse width of 20 msec, and a voltage of 45 V and 42 °C for 240 s, with the procedure conducted in two cycles. A total of 5 mL of the compound liquid with 2% lidocaine 1.5 mL, 1% ropivacaine 2.5 mL, and triamcinolone 5 mg is administered after the PRF application. The same PRF procedure is repeated after 5–7 days, with 2 PRF treatments during hospitalization.In this study, the primary outcome was VAS, a standard measure of pain severity. The pain severity ratio was used as a VAS relative ratio, which measured the VAS score at a given time point (post treatment score) over the baseline (pretreatment score) for each patient. A chi-square test was used to demonstrate whether a significant relationship existed between treatment groups and the characteristic variables, including sex, side, and etiology. Thus, a significant result meant that there was a significant difference in pain severity in the characteristic variables. A t-test was applied to test for equality of the variables of age and pain severity within the NB/PRF group. Post treatment VAS values and pain severity at different post treatment time points  were compared with baseline (pretreatment), respectively, with paired t-tests to analyze whether there were significant changes in pain severity pre/post treatment. One-way ANOVA tests were conducted for 4 types of secondary PN comparison. Statistical software SPSS 19.0  was used to analyze the VAS values, and pain severity of the independent variable groups was defined as significantly different at the 0.05 level.p > 0.05, NB vs. PRF, Phone follow-up of the 88 subjects was conducted at 1, 3, 7, and 14 days, and 1 and 3 months after they completed NB or PRF treatment. The follow-up was terminated if there was no treatment effect. No significant side effects were observed in any treated patients. The clinical characteristics of the PN patients are listed in p > 0.05, conventional vs. improved, p < 0.001, BS vs. 1 and 3 days, p > 0.05, BS vs. 7, 14 days, 1 and 3 months, The NB group consisted of 40 patients, including 22 with conventional pudendal NB and 18 with ultrasound-guided improved pudendal NB puncture. There was no significant difference in pain severity from D1 to M3 after NB treatment  and primary (n = 20) PN, had an impact on the outcome of PRF treatment. As shown in p > 0.05, secondary vs. primary, p < 0.05, secondary PN vs. primary PN, p < 0.001, We further analyzed whether the etiology of PN, including secondary (n = 6), trauma , sacral perineurial cyst (n = 6), and diabetes (n = 4). As shown in n = 6) slowly and gradually increased from 21.7% to 43.3% compared to 22 other secondary PN cases in the medium and long term , p < 0.05). All of these results suggested that although some secondary PN is not significantly relieved in the medium and long term after PRF treatment, it could be possible that PRF treatment of secondary PN patents with sacral perineurial cyst results in improvements in the medium and long term.The etiology of secondary PN patients who had received PRF treatment in our Pain Medicine department included surgery  to post treatment , we set relief values > 50% as treated effectively ,17 Tabl. A standn = 40) or PRF (n = 48). Moreover, the new and improved puncture path under ultrasound guidance was evaluated for the first time. The therapeutic efficacy of PRF for the treatment of patients with secondary and primary PN was then further analyzed.In the present study, we explored a novel and improved puncture path technique to alleviate refractory pain in the medium and long term by observing the therapeutic outcomes of patients with PN who were treated with NB (The standardized pain severity measured by the VAS was significantly decreased by 70% or more in both the NB and PRF groups within 3 days (short term) after treatment. In patients with PN who were considered to be refractory to oral systemic lamotrigine and opioids, PRF treatment significantly relieved pain, especially in the medium and long term (1 month and 3 months). Furthermore, we observed that the pain reduction in the medium and long term (1 month and 3 months) was higher in patients with primary PN treated with PRF than in patients with secondary neuralgia. Another important finding was that PRF treatment of secondary PN with a sacral perineurial cyst could reduce the severity of pain compared to the other three etiologies of secondary PN in the medium and long term.The observation data are from 2011 to 2021, which is a long time span. However, we did follow up the treatment effect by telephone or Wechat video call, and from 2011 to 2015, our treatment for pudendal neuralgia was nonvisualized pudendal nerve block, and only five patients were lost to follow-up. We started using ultrasound-guided pudendal nerve block and pulsed radiofrequency therapy in 2016. Therefore, the long time span has little effect on our ultrasound-guided nerve block and pulsed radiofrequency results.At the ischial spine level, the average diameter of the pudendal nerve is only approximately 5 mm . DespiteIn the current study, under ultrasound guidance, the improved puncture approach is from the lateral side of the transducer. In a previous study, the puncture needle was considered an in-plane approach to the conventional pathway from the medial transducer ,20. HoweAll of the patients with PN in this analysis received a 5 mL liquid mixture of lidocaine, ropivacaine, and triamcinolone. In this retrospective study, patients in both the conventional and improved NB treatment had an onset of pain relief approximately 3 days after treatment. It was assumed that the effectiveness of local anesthesia is predominant in the short term, although the half-life of triamcinolone is close to 30 days, which is consistent with other studies ,26. DuriThe most common sequence is to perform PRF with the parameters of 2 Hz pulse frequency, 45 V, 20 msec pulse width, and 42 °C ,27. HoweFrom a long-term perspective, patients with primary PN receiving PRF treatment had better outcomes than those with secondary PN, from which it is speculated that secondary factors of surgery and trauma may lead to adhesions between the local muscle fascia and the pudendal nerve or branches. In PRF treatment, moreover, secondary PN with diabetes also had poor therapeutic results compared to primary PN in the medium and long term, so patients may need further strict control of their blood glucose fluctuations in the future. Another key finding is that PRF treatment had better efficacy for treating PN caused by sacral perineurial cysts than PN caused by the other three secondary factors, especially during the medium and long term. Sacral perineural cyst, also known as Tarlov cyst, is a cystic nerve root lesion that is common in the sacrum ,29. ElsaFinally, we used the VAS to measure pain intensity; a higher VAS score indicates greater pain intensity. Nevertheless, pain reporting may vary according to subjective factors; the same intensity of pain may be reported differently by different individuals. Thus, the pain severity ratio was used as a VAS relative ratio, which measured the VAS score at a given time point (post treatment score) over the baseline (pretreatment score) for each patient. Furthermore, the results indicated a high standard deviation in pain severity after PRF treatment in patients with PN, especially in those with secondary PN. These patients with secondary neuralgia, including surgery, trauma, sacral perineurial cyst, and diabetes, were administered PRF treatment, and only patients with a sacral perineurial cyst had a significant average reduction in pain severity during the medium and long term, which may be the reason for the large standard deviation.The study’s limitations included a single-center design and a small number of patients. Auxiliary technologies, such as virtual reality (VR) and 3D simulation would be required in the future to improve research precision and practicality.In this study, ultrasound-guided, improved, and innovative pudendal NB and PRF puncture path techniques were proven to be safe and effective for PN patients and were more easily implemented once we understood the pudendal nerve and its adjacent anatomical structure. In addition, the PRF technique showed significant improvement in the treatment of primary PN and PN caused by sacral perineurial cyst in the medium and long term. The results of the current study, as well as the ultrasound-guided improved path technique, are particularly important and meaningful for the treatment of PN and should be widely applied.