As of 18 March 2020, a total number of 194909 cases of COVID-19 have been reported, including 7876 deaths, the majority of which have been reported in China (3242) and Italy (2505)3.COVID-19 is a coronavirus outbreak that initially appeared in Wuhan, Hubei Province, China, in December 2019, but it has already evolved into a pandemic spreading rapidly worldwide4. Smoking, to date, has been assumed to be possibly associated with adverse disease prognosis, as extensive evidence has highlighted the negative impact of tobacco use on lung health and its causal association with a plethora of respiratory diseases5. Smoking is also detrimental to the immune system and its responsiveness to infections, making smokers more vulnerable to infectious diseases6. Previous studies have shown that smokers are twice more likely than non-smokers to contract influenza and have more severe symptoms, while smokers were also noted to have higher mortality in the previous MERS-CoV outbreak8.However, as the pandemic is still unfortunately under progression, there are limited data with regard to the clinical characteristics of the patients as well as to their prognostic factorsGiven the gap in the evidence, we conducted a systematic review of studies on COVID-19 that included information on patients’ smoking status to evaluate the association between smoking and COVID-19 outcomes including the severity of the disease, the need for mechanical ventilation, the need for intensive care unit (ICU) hospitalization and death.The literature search was conducted on 17 March 2020, using two databases , with the search terms: [‘smoking’ OR ‘tobacco’ OR ‘risk factors’ OR ‘smoker*’] AND [‘COVID-19’ OR ‘COVID 19’ OR ‘novel coronavirus’ OR ‘sars cov-2’ OR ‘sars cov 2’] and included studies published in 2019 and 2020. Further inclusion criteria were that the studies were in English and referred to humans. We also searched the reference lists of the studies included. A total of 71 studies were retrieved through the search, of which 66 were excluded after full-text screening, leaving five studies that were included. All of the studies were conducted in China, four in Wuhan and one across provinces in mainland China. The populations in all studies were patients with COVID-19, and the sample size ranged from 41 to 1099 patients. With regard to the study design, retrospective and prospective methods were used, and the timeframe of all five studies covered the first two months of the COVID-19 pandemic .9 studied the epidemiological characteristics of 191 individuals infected with COVID-19, without, however, reporting in more detail the mortality risk factors and the clinical outcomes of the disease. Among the 191 patients, there were 54 deaths, while 137 survived. Among those that died, 9% were current smokers compared to 4% among those that survived, with no statistically significant difference between the smoking rates of survivors and non-survivors (p=0.21) with regard to mortality from COVID-19.Specifically, Zhou et al.10 presented clinical characteristics of 140 patients with COVID-19. The results showed that among severe patients (n=58), 3.4% were current smokers and 6.9% were former smokers, in contrast to non-severe patients (n=82) among which 0% were current smokers and 3.7% were former smokers , leading to an OR of 2.23; .Similarly, Zhang et al.11 studied the epidemiological characteristics of COVID-19 among 41 patients. In this study, none of those who needed to be admitted to an ICU (n=13) was a current smoker. In contrast, three patients from the non-ICU group were current smokers, with no statistically significant difference between the two groups of patients (p=0.31), albeit the small sample size of the study.Huang et al.12 from multiple regions of mainland China. Descriptive results on the smoking status of patients were provided for the 1099 patients, of which 173 had severe symptoms, and 926 had non-severe symptoms. Among the patients with severe symptoms, 16.9% were current smokers and 5.2% were former smokers, in contrast to patients with non-severe symptoms where 11.8% were current smokers and 1.3% were former smokers. Additionally, in the group of patients that either needed mechanical ventilation, admission to an ICU or died, 25.5% were current smokers and 7.6% were former smokers. In contrast, in the group of patients that did not have these adverse outcomes, only 11.8% were current smokers and 1.6% were former smokers. No statistical analysis for evaluating the association between the severity of the disease outcome and smoking status was conducted in that study.The largest study population of 1099 patients with COVID-19 was provided by Guan et al.13 found among their population of 78 patients with COVID-19 that the adverse outcome group had a significantly higher proportion of patients with a history of smoking (27.3%) than the group that showed improvement or stabilization (3.0%), with this difference statistically significant at the p=0.018 level. In their multivariate logistic regression analysis, the history of smoking was a risk factor of disease progression .Finally, Liu et al.12. However, from their published data we can calculate that the smokers were 1.4 times more likely  to have severe symptoms of COVID-19 and approximately 2.4 times more likely to be admitted to an ICU, need mechanical ventilation or die compared to non-smokers .We identified five studies that reported data on the smoking status of patients infected with COVID-19. Notably, in the largest study that assessed severity, there were higher percentages of current and former smokers among patients that needed ICU support, mechanical ventilation or who had died, and a higher percentage of smokers among the severe casesIn conclusion, although further research is warranted as the weight of the evidence increases, with the limited available data, and although the above results are unadjusted for other factors that may impact disease progression, smoking is most likely associated with the negative progression and adverse outcomes of COVID-19.


Neonatal lupus erythematosus (NLE) is an autoimmune syndrome caused by transplacental transmission of maternal autoantibodies, often with devastating consequences. The objective of this systematic literature review was to analyze the demographic data, geoepidemiology, clinical, and serological characteristics associated with NLE. We performed a systematic literature search of the Pubmed database covering the period from 1976 to August 2015, using the MeSH terms “neonatal lupus” or “congenital heart block”. To be included in the study, articles of any type  had to report on infants with NLE on an individualized (i.e. patient-by-patient) basis. A total of 198 studies were included in the review, reporting on a total of 755 NLE patients. The most frequently reported clinical manifestations of NLE were congenital heart block , cutaneous lupus (33.1%), and cytopenias (15.5%). We found differences in NLE characteristics based on study geographical origin, with CHB being much more frequent in patients of European or American descent , while reports originating from Asia reported a higher prevalence of skin involvement (45.2%). Most CHB cases (72.9%) were diagnosed between the 18th and 26th week of gestation. Phenotypic differences of NLE depending on race and country may reflect true pathophysiologic differences or methodologic discrepancies. While maternal autoimmune disease is not a prerequisite for the development of NLE, the existence of a truly “immunonegative” CHB is questionable.  Neonatal lupus erythematosus (NLE) is an autoimmune syndrome caused by transplacental transmission of maternal antibodies, mainly anti SS-A/Ro and anti SS-B/La antibodies, and binding of these antibodies to foetal tissues . Anti SS-A/Ro  and anti SS-B/La are responsible for direct toxic effects on the myocardium and other organs, when transferred from mother to fetus . The risk for congenital heart block (CHB) is ~ 1%–2%, in cases of maternal positivity for anti SS-A/Ro and/or anti SS-B/La antibody, but rises to almost 18% in cases with a history of CHB in a prior pregnancy  [5]. The presence of anti SS-A/Ro and anti SS-B/La antibodies is necessary but not sufficient to cause CHB and the complete NLE syndrome, as environmental and foetal factors seem to play an additional role [6–8]. Interestingly, at the time of NLE diagnosis, the majority of mothers do not have a prespecified rheumatic condition [9]. In the remaining patients, systemic lupus erythematosus (SLE), Sjögren’s syndrome, rheumatoid arthritis, and undifferentiated connective tissue diseases are most often seen . Most data regarding NLE to date originate from observational studies and case reports/case series. Detailed data about the differences in geoepidemiology, frequency of organ manifestations other than CHB, situations that may be associated with recurrent NLE, and whether various therapeutic modalities affect the clinical outcomes, are scarce.The objective of this systematic literature review was to analyse, on a patient-by-patient basis, the demographic data and geoepidemiology, maternal history traits, clinical and serological characteristics associated with NLE.(i.e. patient-by-patient) basis, for example giving information about the presence or absence of each component of NLE, were selected. Articles that did not include individual patient information (i.e. reported on frequency/percentage of characteristics in groups of patients) were excluded because this kind of information could not be subject to further comparative analyses. Review articles, editorials, randomized clinical trials, systematic reviews, and letters were also excluded. We performed a systematic literature review of the Pubmed/MEDLINE database covering papers from studies published during the time period from 1976 to August 2015. Relevant publications were sought using the MeSH terms neonatal lupus or congenital heart block. Included publications were restricted to studies in humans and articles in English language. To be included in the review, articles of any type  which reported on infants with NLE on an individualized The initial selection process was based on titles and abstracts of retrieved articles, followed by full-text review of articles that were considered relevant. We documented the following variables: maternal age at NLE occurrence, connective tissue disease of the mother (if any) and disease duration, treatments received before and during pregnancy, gestational age at NLE diagnosis, organ manifestations of NLE, type and timing of CHB occurrence, treatments administered for CHB, type of delivery, and mortality. The literature search was performed by AE, article selection and data extraction were conducted by all authors collaboratively.Because not every study reported all characteristics and outcomes of interest for this study, for each characteristic, a number in brackets is given (n=...), referring to the total number of patients for whom these data were available in the original studies.The study protocol was approved by the local research ethics committee.All statistical analyses were performed using SPSS software, version 21 . Continuous variables were tested for normality of data distribution, using the Kolmogorov–Smirnov test, and were expressed as mean  and median  values, in case of normally and nonnormally distributed or ordinal data, respectively. Categorical variables were reported as frequencies (percentages) and were compared with the chi-square test. A P-value of <0.05 was considered significant for all comparisons.A total of 1125 abstracts of articles were evaluated. After excluding articles other than case reports/series and original articles and overlapping patients in case reports or original articles, the full text for 267 original articles/case reports were evaluated. Following full text evaluation, a total of 69 papers were excluded: 7 case reports and 15 original articles because of irrelevance, 10 case reports and 37 original articles because of providing insufficient data. A total of 198 studies were finally included in the analysis, reporting on a total of 755 NLE patients. A flow chart illustrating the systematic literature search for the identification of relevant studies is shown in Figure [details of the study designs for the studies included the review are provided in Table 1].We identified a total of 755 cases of NLE from all of the included studies. At the time of NLE diagnosis, the mean (SD) age of mothers was 29.7 (4.8) years, and a little over one third (36%) were nulligravidae (Table 2). The most frequently reported clinical manifestations of NLE were CHB , cutaneous lupus , and cytopenias 117 (15.5%). Hepatic, pulmonary, and neurologic complications were less frequently reported (≤ 10% each) (Table 3). The majority of cases with NLE (any manifestation) were diagnosed postnatal . However, in cases of cardiac involvement/CHB, the diagnosis was made during pregnancy in 72.1% (n = 256). Maternal age was not different between NLE cases with and without CHB ) (Table 5).In only 36% of cases (n = 272), the autoantibody status of infants was assessed by investigators (Table 3). Presence of anti-SSA, anti-SSB, and anti-RNP, either alone or in some combination thereof, were detected in 82.7%, 46.3%, and 9.1%, respectively; of note, in 20 cases (7.3%), no serum autoantibody could be detected. These seronegative infants did not differ significantly in terms of organ manifestations, week of diagnosis, survival rate or implantation of pacemaker from infants with autoantibodies.The status of maternal autoantibodies with CHB was reported in 376 mothers (76.4%) (Table 6). Anti SS-A/Ro, the most frequently detected autoantibody, was positive in 295 (78.4%) mothers; anti SS-B/La was positive in 181 (48.1%) mothers. Interestingly, 40 mothers (10.6% [40/376]) did not have any circulating autoantibodies. Accordingly, in 344 cases wherein information about maternal disease was available, the most frequent maternal diagnoses were SLE [101 (29.3%)] and Sjögren’s syndrome [75 (21.8%)], although other diseases were occasionally reported. No autoimmune rheumatic disease was evident in 110 cases (31.9%).Mean (SD) gestational age at the time of detection in cases with CHB  was 23.8 (4.5) weeks. Almost ¾ of cases (72.9%) with CHB were diagnosed between the 18th and 26th week of gestation. However, we found 4 cases (2.2%) diagnosed at weeks 16–17 and an additional 11.8% (n = 22), in which CHB was detected after 30th week of gestation (Table 7). Of note, less than half of pregnancies  resulted in a term pregnancy, while 20% resulted in at least moderate prematurity (≤34 weeks) (Table 8). The majority of cases had type III (i.e. complete) atrioventricular block .For 250 mothers, information on previous gestational history and birth outcome were provided by authors. Among them, 41 (16.4%) had given birth to a baby with NLE in a prior gestation. Recurrence rate of CHB was 31/250 (12.4%). All mothers with recurrent NLE were autoantibody positive. Interestingly, however, while the majority was positive for anti-Ro and/or anti-La , 3 women with recurrent NLE were negative for anti-Ro and anti-La and showed positivity only for ANA. Prevalence of rash was slightly higher in girls (55.8%) and those born at term (69.0%) (Table 9). We have performed a systematic literature review to characterize the clinical spectrum of the NLE syndrome. Of note, our work focused on studies that provided detailed individual case presentations to understand better maternal and foetal characteristics (issues regarding therapy of NLE are the topic of a separate systematic review). CHB was the most prominent clinical manifestation (65.2% of cases), followed by cutaneous rash and cytopenias . Presence of a maternal autoimmune disease was not a prerequisite for NLE, as in almost 1 in 3 pregnancies (31.9%) resulting in NLE, no disease was evident in the mother, Also, while anti-SSA/Ro was expectedly the most frequent autoantibody found in maternal serum, it is noteworthy that, in 10% of mothers , no circulating autoantibody could be detected in the serum; this observation clearly poses questions regarding the underlying pathophysiology of CHB in these cases. We separated all NLE cases depending on the country of origin of the study, and respective ethnic and racial distribution of cases, to identify potential differences in disease phenotype. Strikingly, we found that studies originating from Europe or America (mainly the the United States of America) reported significantly higher rates of CHB, the most serious complication of NLE , while studies in Asian patients revealed cardiac abnormalities in little over 30% of patients. On the contrary, cutaneous involvement was twice as frequent in studies from Asian countries versus other populations; as an illustrative example, in 2 studies from Japan and China, more than 80% of the combined 316 patients had cutaneous NLE, while the rate of CHB was 8.9%–23% . While it is tempting to speculate about the involvement of genetic or environmental factors underlying this disparity, one must also be aware of the possibility of under-reporting, as well as the absence of a common definition, especially for CHB.The notion that NLE is a syndrome mediated by the passive transfer of autoantibodies from mother to fetus is widely accepted. Clinical and experimental data support the pivotal role of the anti-SSA/Ro antibodies (directed against the 52 kDa or the 60kDa protein) in the development of autoimmune CHB. Indeed, in our systematic literature review, anti-SSA was by far the most frequently detected autoantibody in maternal sera (78.4% [295/376] of mothers). The pathogenetic roles of other autoantibodies, mainly anti-SSB/La and anti-U1RNP, are less clear and further obscured by the fact that, in most circumstances, these autoantibodies coexist with anti-SSA/Ro . In mothers with SLE, ANA trans passes from placenta and works with anti SS-A/Ro to make harm in fetal thyroid tissue and myocardium[1]. Clinicians should consider testing for maternal anti-U1RNP and only ANA positivity in congenital heart block cases in which anti-SSA/Ro and/or anti-SSB/La are negative and there is no structural etiology [14].. A maternal autoimmune disease is not a prerequisite for the development of NLE. On the contrary, our analysis shows that almost 32% of patients did not suffer from any disease at the time of birth of a child with NLE. Clearly, absence of maternal disease makes the diagnosis of NLE even more challenging because asymptomatic women will usually not be tested for autoantibodies. This highlights the need to test for the latter in all women of reproductive age who present to rheumatology care even for mild, nonspecific symptoms.More intriguing is the fact that 10.6% (40/376) of mothers tested were negative for any circulating autoantibody. The possibility of inter-laboratory differences in sensitivity must naturally be taken into account. Moreover, in a recent review, Brito-Zeron et al questioned the existence of “immunonegative” CHB, owing to the fact that most of such cases were diagnosed in children in adolescence or mothers who had not been tested for the full panel of potentially cardio toxic autoantibodies [15]Our review attempted to capture all data regarding CHB subtypes and detection time in neonates born with NLE. Transplacental transfer of IgG antibodies from mother to fetus starts at 12th gestational week . The period traditionally considered to confer the highest risk is during the middle to late parts of the second trimester, especially between the 16th and 26th weeks . Indeed, we found that almost ¾ of cases (72.9%) were diagnosed between the 18th and 26th week of gestation, with a mean gestational age of ~ 24 weeks. However, we also found 4 cases (2.2%) diagnosed at weeks 16-17 and an additional 11.8% (n = 22), in which CHB was detected after 30th week of gestation, spanning a total period of more than 15 gestational weeks. Withstanding the fact that the majority of infants (78.0%) develop type III (i.e. complete) atrioventricular block, the rarity and of its occurrence as well as inability to predict, and the questionable efficacy -at best- of any therapeutic modality, we believe it may not be feasible to recommend strict weekly scheduling of foetal echocardiography throughout this whole period. Rather, we tend to favour a more practical approach regarding frequency of foetal echocardiography in pregnant women with circulating anti-SSA and/or anti-SSB antibodies, which consists of biweekly examinations for the period of 16–28 th gestational weeks [2]. This recommendation should by no means serve as a universal guide, but may provide a framework to reduce unnecessary stress on future mothers.In our study we found that anti SSA/Ro antibody positivity was 84.6% and anti-SSB/La antibody positivity was 58.9% in cutaneous manifestations. On the other hand, anti U1-RNP antibody is responsible from skin involvement [14]. In our study, anti U1-RNP positivity was 11.5%.Apart from cardiac involvement, involvement of other organs in the NLE has been much less characterized to date. Outside the skin, we found that hematologic involvement, hepatic dysfunction, pulmonary and neurologic complications, all appear in decreasing order of frequency in neonates with the NLE syndrome . Interestingly, pulmonary manifestations showed a predilection for male gender , in contrast to the other system manifestations. Skin lesions, hematologic involvement, hepatobiliary involvement spontaneously disappear by cleaning of antibodies from the circulation of the baby at 6th to 12th months . We were not able to characterize further the type of manifestations in each of these organ systems, as most of this information was not provided by original studies.In 2 studies, recurrence of CHB was seen in 17% of pregnancies after the birth of a child with CHB . Recurrence after first pregnancy was found as 12.1% in another study and all these recurrences were seen in patients with autoantibody  positivity, none of them were autoantibody negative [19]. In our study, none of the mothers with recurrent CHB baby were autoantibody negative. Additionally, percentage of recurrent pregnancy with NLE was 16.4%, CHB was 12.4%, and rash was 4%.Certain limitations of our study deserve acknowledgment. First, due to strict methodologic limitations, we included only published studies which reported data on an individual patient basis. Inevitably, this has led to noninclusion of studies reporting on groups of patients, as these data could not be similarly analysed. Moreover, studies included in our systematic review had their own limitations, mainly in terms of missing data. Nevertheless, by including more than 750 patients with available detailed data, our literature review captured most clinical aspects of NLE, as well as intriguing phenotypic differences by race and ethnicity.In conclusion, we performed a systematic literature review to portray the full clinical spectrum of NLE, beyond its most devastating consequence, autoimmune CHB. The latter is rather rare, and the possibility of its occurrence spans a substantial period within gestation. This, together with the paucity of therapeutic options (which we attempt to summarize in a separate systematic review), warrants a rational screening approach for its detection.All authors disclose no conflict of interest that may have influenced either the conduct or the presentation of the research. This work was supported by the Research Fund of the Hacettepe University, project number: TBB-2016-12742.Abdulsamet Erden, Antonis Fanouriakis, Levent Kılıç, Alper Sarı, Berkan Armağan, Emre Bilgin, Yusuf Ziya Şener, Benazir Hymabaccus, Fatih Gürler, Serdar Ceylan participated in data collection, analyses, and writing of the manuscript; Sedat Kiraz, Ömer Karadağ, Dimitrios Boumpas participated in data analyses and writing of manuscript.


The acquisition of invasive tumor cell behavior is considered to be the cornerstone of the metastasis cascade. Thus, genetic markers associated with invasiveness can be stratified according to patient prognosis. In this study, we aimed to identify an invasive genetic trait and study its biological relevance in lung adenocarcinoma.  250 TCGA patients with lung adenocarcinoma were used as the training set, and the remaining 250 TCGA patients, 500 ALL TCGA patients, 226 patients with GSE31210, 83 patients with GSE30219, and 127 patients with GSE50081 were used as the verification data sets. Subtype classification of all TCGA lung adenocarcinoma samples was based on invasion-associated genes using the R package ConsensusClusterPlus. Kaplan-Meier curves, LASSO (least absolute contraction and selection operator) method, and univariate and multivariate Cox analysis were used to develop a molecular model for predicting survival.  As a consequence, two molecular subtypes for LUAD were first identified from all TCGA all data sets which were significant on survival time. C1 subtype with poor prognosis has higher clinical characteristics of malignancy, higher mutation frequency of KRAS and TP53, and a lower expression of immune regulatory molecules. 2463 differentially expressed invasion genes between C1 and C2 subtypes were obtained, including 580 upregulation genes and 1883 downregulation genes. Functional enrichment analysis found that upregulated genes were associated with the development of tumor pathways, while downregulated genes were more associated with immunity. Furthermore, 5-invasion gene signature was constructed based on 2463 genes, which was validated in four data sets. This signature divided patients into high-risk and low-risk groups, and the LUDA survival rate of the high-risk group is significantly lower than that of the low-risk group. Multivariate Cox analysis revealed that this gene signature was an independent prognostic factor for LUDA. Compared with other existing models, our model has a higher AUC.  In this study, two subtypes were identified. In addition, we developed a 5-gene signature prognostic risk model, which has a good AUC in the training set and independent validation set and is a model with independent clinical characteristics. Therefore, we recommend using this classifier as a molecular diagnostic test to assess the prognostic risk of patients with LUDA. Lung cancer is the leading cause of cancer-related deaths, both in China and globally. , with noHolistic gene expression profiling using microarray technology has proven to be an important tool to help reveal the molecular basis of cancer. The molecular classification of different cancers  consistently stratifies tumors into different subtypes, with prognostic outcomes independent of traditional clinical staging , 10. GenThe aim of this study was to identify biomarkers of cancer cell invasion through a collection of invasive-specific gene signatures obtained from genome-wide gene expression profiles. Therefore, we recommend using this classifier as a molecular diagnostic test to assess the prognostic risk of patients with LUDA.https://portal.gdc.cancer.gov/). The raw data of the three data sets GSE31210  Affymetrix Human Genome U133 Plus 2.0 Array). RMA (Robust Multiarray Average expression measure) in the R package affy (V1.66.0) [https://www.gsea-msigdb.org/gsea/index.jsp), and finally, a total of 1202 genes were obtained. All the enrolled samples have not undergone any treatment including chemotherapy and radiotherapy. The sample clinical information of the database is shown in Table RNA-Seq data (FPKM) and clinical follow-up information data of lung adenocarcinoma (LUAD) were acquired from TCGA database   was usedV1.66.0)  website p < 0.001 was selected as the threshold for filtering. Next, LASSO (least absolute shrinkage and selection operator) regression, multivariate Cox survival analysis, and stepAIC were conducted to further compress the filtered genes to reduce the number of genes in the risk model. The final selected genes were those of the prognostic model. The calculation formula of the prognostic risk model is as follows:First, the 500 samples in TCGA data set are divided into a training set and a validation set. In order to avoid random allocation deviations from affecting the stability of subsequent modeling, all samples are randomly grouped 100 times in advance with replacement according to the ratio of training set : validation set = 1 : 1. The training set and test set samples were tested using chi-squared test, and the results showed that our grouping had no preference. In the training data set, univariate cox survival analysis was performed for differentially expressed genes using the coxph function of the R package survival (V3.1-12), and i) refers to the coefficient of the ith gene, and gene(i) refers to the expression level of the ith gene. Each sample is calculated to obtain a RiskScore value. The cutoff of the RiskScore is the middle value, those greater than the middle value are high-risk samples, and those less than or equal to the middle value are low-risk samples.Among them, coef were obtained. Next, the R package ConsensusClusterPlus  was used to uniformly cluster TCGA samples . The chi-squared test was used to identify the distribution of clinical features on molecular subtypes. The R software package MCPcounter (V1.2.0) was used to calculate the immune cell score of each sample. The R software package limma (V3.44.3) was used to perform differential expression gene between molecular subtypes, and FDR < 0.001 and ∣FC | >1.5 acted as thresholds. R package clusterProfiler (V3.16.0) was used to perform GO function annotation and KEGG pathway enrichment analysis on differentially expressed genes, and FDR < 0.05 as the threshold. Univariate and multivariate Cox survival analyses of clinical characteristics and RiskScore were used to demonstrate the independence of the RiskScore model. Based on the results of univariate and multivariate Cox survival analyses, the nomogram and the correction chart of the nomogram were constructed to provide the basis for clinical diagnosis and prognosis. And at the same time, we drew a DCA diagram to prove the reliability of the model.Univariate cox analysis was used to analyzed 1202 metastasis-related genes using the coxph function of the R package survival (V3.1-12), and the genes related to the prognosis of lung adenocarcinoma (p < 0.05). The R package ConsensusClusterPlus was used to cluster TCGA samples uniformly and divide them into two categories  using 322 genes (p = 0.00038). We compared the distribution of survival status, gender, age, T stage, N stage, M stage, stage, and smoking status among the two subtypes. The results showed that the number of dead, male, smoking sample was higher, while the T1 samples, N0 samples, and stage I samples are lower in the C1 subtype, compared with the C2 subtype  of each sample. The results showed that except for fibroblasts, the scores of other immune cells are higher in the C2 subtype than that in the C1 subtype, which includes T cells and CD8 T cells . It may γ) genes in molecular subtypes and found that the expression of these three genes in the C2 subtype was significantly higher than that in the C1 subtype  research has made breakthroughs in the clinical response of a variety of human cancers. However, most cancer patients do not benefit from ICI. We compared the expression of PDCD1 (PD-L1), CTLA4, and IFNG  were obtained. Then, the R software package glmnet was used to perform LASSO cox regression analysis. First, the change trajectory of each independent variable is analyzed (p < 0.0001). The ROC curve analysis showed that the 1, 3, and 5-year AUC of RiskScore were 0.64, 0.73, and 0.81, respectively   . In our Furthermore, we compared the differences of our models in the chemotherapy and radiotherapy samples, and the results are shown in p value in the clinical information of the entire TCGA data using univariate and multivariate survival analysis. We systematically analyzed the clinical information of TCGA patient records, including age, gender, T stage, N stage, M stage, smoking, stage, and our RiskType grouping information  , 5-gene et al. and Wilkerson et al. used ConsensusClusterPlus to determine the subtype of LUAD using gene expression data [et al. combined multiplatform genomics data sets, including DNA methylation, DNA copy changes, mRNA expression, miRNA expression, and protein expression and proposed a “cluster-cluster” lung cancer classification analysis method [et al. used genome-wide mRNA expression profile to establish the robust molecular subtypes of LUAD by using a combination method [With the development of microarray technology and RNA sequencing technology, many studies have used gene expression profiles to classify tumors , 26. Genion data , 30. Ches method . Hu et an method . Many stn method , 34. MorAdditionally, a metastasis-specific 5-mRNA signature was derived based on differentially expressed genes between C1 and C2, containing KRT8, MAFK, PTTG1, ENPP5, and INPP5J, which identified groups with low and high risk in terms of TCGA training data set. KRT8 is a type II basic intermediate filament (IF) protein, associated with EMT, which is essential for the occurrence and metastasis of various cancers. KRT8 mRNA expression was significantly upregulated in LUAD tissues, indicating unfavorable prognosis for poor OS and RFS in LUAD patients , 36. OveHowever, some limitations of the current study should be considered. First, the population ethnicity in TCGA database is primarily limited to whites and blacks, and extrapolation of the findings to other ethnicities is needed. Second, the prognostic model needs to be further validated in multicenter clinical trials and prospective studies. In the future, we will also explore the possibility of including additional prognostic variables to further improve performance. Other regression modeling approaches will be applied to determine if predictive accuracy can be further improved. Basic experimental studies are also a limitation of our study.We first identified a new 5-gene marker metastasis risk model that performed well in predicting the prognosis of LUAD. These 5 genes have complex molecular functions, among which ENPP5 and INPP5J have not been reported to be related to LUAD. Our study emphasized the relationship between metastasis-related genes and the prognosis of LUAD. Our results may provide precision and personalized treatment for clinical lung adenocarcinoma patients.


Despite extensive international research, musculoskeletal injuries remain a key problem for the Thoroughbred racing industry, with multiple welfare and ethical consequences. High-speed exercise (HSE) history is an important risk factor for injury. However, studies report conflicting findings concerning the effect of HSE on the risk of injury. Although most injuries and fatalities occur during training rather than racing, many research studies only evaluate injuries reported on race day, which likely underrepresents the injuries acquired by these horses. This study aimed to determine the effect of combined training and racing HSE on injuries in racehorses. We performed a systematic search of the relevant literature and evaluated the effect of seven measures of HSE on injury through meta-analyses. The total career HSE distance significantly affected the odds of musculoskeletal injuries (MSI). With every 5-furlong (1 km) increase in career HSE distance, the odds of MSI increased by 2%. The average HSE distance per day also affected the odds of MSI. With every additional furlong (200 m) of average HSE per day, the odds of MSI increased by 73%. However, the strength of the available evidence is restricted by methodological limitations, which will need to be addressed in the future, to explore the level of risk and mechanisms for injury in more detail.®, Scopus®, Web of Science®, and Embase® online databases and the gray literature using sites containing “.edu” or “.edu.au”. Studies included in the review had explored seven different measures of HSE, including total career HSE distance, cumulative HSE distance in the 30 and 60 days before MSI, average HSE distance per day, per event and per 30 days, and the total number of HSE events. The total cumulative career HSE distance significantly affected the odds of MSI, with every 5-furlong increase, the odds of MSI increased by 2% . The average HSE distance per day also affected the odds of MSI, with every additional furlong increasing the odds of MSI by 73% . Other measures of HSE were not found to be consistently associated with risk of MSI, but these results should be interpreted with caution. Significant methodological limitations were identified and influence the comparability of studies. Standardizing the measures of HSE in studies of MSI, and describing training conditions in more detail, would support a more thorough investigation of the relationship between HSE and MSI. An improved understanding of this relationship is critical to mitigating the impact of MSI in the Thoroughbred racehorse.Despite over three decades of active research, musculoskeletal injuries (MSI) remain a global problem for the Thoroughbred (TB) racing industry. High-speed exercise history (HSEH) has been identified as an important risk factor for MSI. However, the nature of this relationship remains unclear, with an apparent protective effect of HSE against injury, before it becomes potentially harmful. Many MSI cases and fatalities occur during training rather than during racing, resulting in an underestimation of injury from studies focused on race day. The objective of this study was to examine the current evidence of the effect of combined training and racing HSEH on MSI in TB flat racehorses, through a systematic review and meta-analysis. A systematic search of the relevant literature was performed using PubMed Despite over three decades of active research, musculoskeletal injuries (MSI) remain a global problem for the Thoroughbred (TB) racing industry ,2,3. TheThere has been and continues to be a strong interest in developing training and management strategies to reduce the impact of MSI. High-speed exercise history (HSEH) has been identified as an important risk factor for MSI due to the high loads and strains generated ,18,19. HMany MSI cases and fatalities occur during training rather than during racing ,42,43,44A recent meta-analysis of risk factors for catastrophic MSI in flat racing reported that a greater number of race starts increased the risk of catastrophic MSI, but the effect of cumulative distances HSEH were inconsistent . There iWe examined the research question “What is the effect of the combined training and racing HSEH on MSI in flat TB racehorses?” The protocol for this systematic review and meta-analysis was developed according to the guidelines from the Cochrane Handbook , the PreStudies were eligible to be included if they were cohort, case-control, or cross-sectional studies of HSEH and MSI in TB flat racehorses. HSEH was defined as exercise at speeds greater than or equal to 15 s/furlong  which incorporates “three-quarter pace”, “evens”, “working gallop”, “gallop off the bit”, and “racing speed” ,29,50. S®, Scopus®, Web of Science®, and Embase® online databases using the following search terms: Horse*, Equine, Thoroughbred, Racing, Racehorse*, Training, Epidemiolog*, Musculoskeletal injury, Wastage, Fracture*, and Fatal*. The following Medical subject heading (MeSH) terms were also incorporated into the search strategy: Horses, Equidae, Epidemiology, and Cumulative Trauma Disorders. The search strategy is further detailed in Articles were identified through searching PubMedp-values. Where sufficient data could not be extracted from the manuscript, for example, where an effect size was reported but not the total numbers of events, authors were contacted for clarification. When more than one outcome category was available, the category which provided the largest number of individuals with the outcome was extracted for analysis. When race, timed workout, and combined race and workout data were provided, the combined data were extracted for analysis. When active career and total career data were provided the active career data were extracted for analysis. Data were extracted by KC and BA, including authors, title, year of publication, country, study type, population source, outcome definition, selection of individuals without the outcome, number of individuals with the outcome, number of individuals without the outcome, the HR/RR/OR from univariable regression analysis, 95% confidence intervals, and the The incidence rate ratio (relative risk) (IRR/RR) and odds ratios (OR) were considered equivalent effect sizes (ES) for this analysis by virtue of the rare outcome assumption. The OR approximates the RR when the probability of the event is less than 0.10, which holds true for horses in all included studies and for all exposures to HSE . When thRisk of bias assessment was performed by two investigators (KC and BA), using relevant items from the Cochrane tool for assessing risk of bias  and the ® (Statacorp). Separate analyses were performed for each measure of HSEH exposure, using a random effects model described by DerSimonian and Laird [p < 0.10 was used to ameliorate the possibility of a type 1 error due to low numbers of studies [2 was used to evaluate the proportion of between study variation in ES that was due to true heterogeneity rather than sampling variability. Confidence intervals for I2 were calculated when there were greater than 2 degrees of freedom for Cochrane’s Q test statistic. We interpreted the I2 values of 0% to 30% to be not clinically important, 31–60% to represent moderate heterogeneity, 60–75% to represent substantial heterogeneity, and >75% to represent high heterogeneity [Meta-analyses were performed by KC using Stata 15.1nd Laird . The rannd Laird . A cut-o studies . Higginsogeneity . The articles identified, screened, and assessed as relevant and eligible for inclusion in the review are summarized in a PRISMA flow diagram 49 . The chaA graphical summary of the articles excluded at full text level and the reasons for exclusion are presented in Review articles/editorials, case series/case reports, clinical trials, descriptive not analytical studies, or abstracts only (n = 86);Reported only race day rather than training data (n = 17);The outcome (MSI) was reported as morphological changes to bone/soft tissue, rather than as a clinical MSI (n = 49);The exposure, high-speed exercise (HSE) was not reported as total career cumulative HSE distance, cumulative HSE distance 30 days before MSI, cumulative HSE distance 60 days before MSI, average HSE distance per day, average HSE distance per event, average HSE distance per 30 days, or total number of HSE events;The effect size was not reported as either an odds ratio, relative risk, or hazard ratio (n = 143).Exclusion Criteria: Thirteen studies examined the effect of HSEH on MSI, including one cross-sectional, seven case-control (including two nested case-control), and five prospective cohort studies. Study characteristics for all eligible studies are detailed in The risk of bias (RoB) assessment indicated that overall, the 13 studies meta-analyses had low risk of bias, with nine criteria assessed as a low risk in all studies, four criteria with at least half the studies assessed as low risk, and only three criteria where a significant number, or all studies, were assessed as having unclear or high risk of bias, including demonstrating MSI was not present at start of study, outcome assessor being aware of the level of exposure, and exercise data completeness. Results from the RoB assessment are presented in (1)Total cumulative HSE distance;HSE distance accumulated 30 days before injury;HSE distance accumulated 60 days before injury.Cumulative HSE distance:(2)Average HSE distance per day;Average HSE distance per event;Average HSE distance per 30 days.Rate of HSE distance accumulation:(3)The total number of accumulated HSE events.The seven different measures of HSE exposure were grouped into three categories as follows: Within each of these categories, some studies performed time to event analyses and reported effect sizes as hazard ratios, while others reported odds ratios. These were pooled independently, resulting in a total of ten separate meta-analyses to explore all types of HSE exposure. Four meta-analyses were performed to investigate the measures of cumulative HSE distance on MSI .p = 0.004) (p = 0.22); and I2 (the proportion of the variation in effect size attributed to true heterogeneity rather than sampling error) was 30% (95% CI 0% to 73%). This indicated that the heterogeneity was low and not significant.There were five studies examining the effect of the total career cumulative HSE distance on MSI and reporting odds ratios as the effect size ,58,59,60= 0.004) . With evp = 0.08) (p = 0.25); and I2 was 28% . This indicated the heterogeneity was low and not significant. There were three studies examining the effect of the total career cumulative HSE distance on MSI, using time to event analyses and reporting HR as the effect size ,40,61. T = 0.08) . The taup = 0.36) (p < 0.001), and I2 was 96%, (95% CI 93% to 98%) indicating high and significant heterogeneity. Five studies, from the US (n = 4) and NZ (n = 1), examined the effect of the HSE distance accumulated in the 30 days prior to injury on MSI, and reported odds ratios ,33,57,58 = 0.36) . The taup = 0.65). The tau-squared was 0.002, Cochrane’s Q was 45.22 (p < 0.001), and I2 was 93%,  indicating high and significant heterogeneity.The four studies from the USA which examined HSE in the 30 days prior to MSI also explored HSE distance in the 60 days prior to MSI, reporting the effect size as odds ratios ,31,57,58Five meta-analyses were performed to investigate the measures of the rate of HSE distance accumulation on MSI .p < 0.001). With every increase of 1 furlong of HSE per day, the odds of MSI increased by 73%. The tau-squared was 0.0000, Cochrane’s Q was 0.24 (p = 0.62), and I2 was 0%, indicating the heterogeneity was low and not significant.There were two studies exploring the effect of average HSE distance per day on MSI, using odds ratios as the effect size ,57. The p = 0.20). The tau-squared was 0.03, Cochrane’s Q was 7.83 (p = 0.01), and I2 was 87%, indicating the heterogeneity was substantial and significant.A further two studies from the UK also examined the effect of the average HSE distance per day on MSI using hazard ratios as the effect size ,61. Injup = 0.21)). The tau-squared was 0.05, Cochrane’s Q was 91.01 (p < 0.001), and I2 was 96% , indicating high and significant heterogeneity. Five studies examined the effect of the average HSE distance per event on MSI using odds ratios as the effect size ,58,59,62p = 0.60)). The tau-squared was 0.01, Cochrane’s Q was 6.97 (p = 0.01), and I2 was 86%, indicating high and significant heterogeneity. Two of the studies examining HSE distance per event also evaluated the effect of the average HSE distance per 30 days on MSI using odds ratios as the effect size ,58. Thesp = 0.11)). The tau-squared was 0.003, Cochrane’s Q was 6.28 (p = 0.01) and I2 was 84%, indicating high and significant heterogeneity.A further two studies from the UK explored the effect of the average HSE distance per 30 days on MSI using time to event data and reporting hazard ratios as the effect size ,61. The We quantified the effect of HSEH on MSI using seven measures of HSE exposure that were broadly classified into cumulative HSE distance, the rate of HSE distance accumulation, and the number of accumulated HSE events. Of the three measures of cumulative HSE distance, the total career cumulative HSE distance significantly increased the odds of MSI. Of the three measures of the rate of HSE distance accumulation, the average HSE distance accumulated per day significantly increased the odds of MSI. The heterogeneity (variance in effect sizes between studies) observed was low, supporting the reliability of these findings.The remaining measures of cumulative HSE distance, the rate of HSE distance accumulation, and the number of accumulated HSE events were not found to significantly affect the risk of MSI. However, caution should be exercised when interpreting these findings. The significant heterogeneity indicates that we are not comparing equivalent studies, and the variability between studies is too high . This hiPossible explanations for the heterogeneity in this study included differences in study design, populations of horses, geographic location, outcome definitions, and methods to determine the outcomes. Study designs in this meta-analysis were cross-sectional , case-coGeographic location is likely a major source of variability between studies, despite no consistent pattern was observed in these meta-analyses. Differing management practices between racing jurisdictions influence the accessibility and nature of available data. For example, racehorses in Japan and Hong Kong are accommodated, trained, and raced at centers tightly controlled by racing authorities ,65. ConsThe disparity in findings between studies may also be due to a second order effect of HSE on MSI, whereby the risk of MSI could move in any direction depending on the level of HSE. We hypothesize that it initially decreases with increasing HSE, plateaus, and then increases again after a critical level of HSE has been reached. Such a relationship has been reported in studies of racehorses ,31,33,37Our findings are consistent with this second order relationship. The positive linear association between increasing total cumulative HSE distance and MSI in analysis 1 is consistent with excessive HSE in well-adapted bone. This is plausible as most horses in these studies were older horses and were likely to have had sufficient HSE for bone adaptation, and further increases in HSE resulted in increased odds of MSI. Similarly, in analysis 5, the positive association between increasing average HSE per day and increasing odds of MSI could also be consistent with increasing HSE overloading the already adapted tissues. The non-significant association between the other five measures of HSEH and MSI in the current meta-analysis may also reflect a second order relationship and the two above mentioned mechanisms of injury. For example, approximately half the studies reported increasing the cumulative distances of HSE 30 and 60 days before MSI decreased the risk of MSI, and half of the studies reported it increased the risk. This could hold true in both general ends of the second order association between HSE and injury. In early training, with poorly adapted tissues, elevated HSE distance on a given day may overwhelm tissue tolerance and lead to injury. In later training with adapted tissues, excessive average HSE may still exceed tissue tolerance but the threshold for injury may be either higher, or potentially impacted by lifetime cumulative HSE, leading to microdamage and an increased susceptibility to injury. These polarized findings could reflect these two mechanisms of injury. Investigating the length of time before HSE is undertaken when commencing training or resuming from a break in training, reduction in training and racing intensity or a sudden disruption in the full training program could also help define the amount of HSE required for tissue adaptation and the point beyond which it is harmful. The predominant limitation of this study is the heterogeneity observed between studies preventing a meaningful interpretation of the effect of several measures of HSE on MSI. Our stringent exclusion criteria have also excluded studies containing generic data with surrogate measures of HSE exposure such as age or length of time in training. Exploring the effect of HSE in horses of different ages was also not possible as this information was not available.This study highlighted the need for a detailed investigation into the epidemiology of training practices and how they vary between geographic regions. There is a need to capture this information in a standardized manner, analogous to the European consensus on reporting the epidemiology of injuries of jockeys and racing industry participants . This woWe recommend that future studies use a prospective study design to obtain the best possible quality data, although they require more time and resources to conduct ,77,78. RIn conclusion, increasing HSE increases the odds of MSI. The measures of HSE distance that best capture this relationship are the total career cumulative HSE distance and the average HSE distance accumulated per day. The remaining measures of HSE distance, rate of accumulation, and the number of events could not be properly evaluated due to the heterogeneity observed in the meta-analyses. Consequently, we recommend that a detailed investigation into the epidemiology of training practices and how they vary between geographic regions is required. This information must be standardized to facilitate comparability between studies and multi-center collaboration, which would better elucidate the relationship between HSE and MSI. An improved understanding of this relationship is critical to mitigating the impact of MSI in the Thoroughbred racehorse.


Objective: Laser acupuncture has become increasingly attractive in clinical practice, especially for patients with needle phobias well as elderly people and children. However, literature concerning the safety of laser acupuncture has been limited. This systematic review synthesizes the current available literature on the safety of laser acupuncture.Methods: Ovid MEDLINE,® Epub Ahead of Print, In-Process & Other Non-Indexed Citations Daily, Ovid Embase, Scopus, and EBM Reviews—Cochrane Central Register of Controlled Trials databases were searched for available randomized controlled trials (RCTs) on laser acupuncture. Safety data were extracted from the included studies. Adverse events (AEs) data were extracted and assessed in terms of severity and causality.Results: Of 737 articles, 21 RCTs were included. The majority of these RCTs reported that laser acupuncture was safe, without AEs; 6 trials reported AEs . All AEs were mild and resolved spontaneously within 24 hours. The causal relationship between AEs and laser acupuncture was felt to be “certain” in 4 studies, “probable” in 1 study, and “possible” in 1 study. AEs were collected and monitored by evaluation methods in 7 trials: 5 with AE questionnaires, 1 with a checklist, and 1 with oral reports.Conclusions: Laser acupuncture appears to be a safe therapy associated with few mild and transient AEs. However, given the heterogeneity of current studies, large, well-designed placebo-controlled RCTs with rigorous evaluation methods are needed to assess the safety of laser acupuncture more completely. Rather than mechanical stimulation produced by traditional needle therapy, acupoints irradiated by the laser acupuncture elicit physiologic effects at the cellular level with sufficient energy.4 Because it is a gentle, less-invasive and simple-to-perform nonpharmacologic technique, laser acupuncture has become increasingly attractive for patients with needle phobias, as well as for elderly people and children.5–7Laser acupuncture is a photonic stimulation of acupoints and areas, initiating therapeutic effects similar to that of needle acupuncture and related therapies together with photobiomodulation.8–11Several systematic reviews have shown that laser acupuncture is efficacious for some conditions, such as lateral-elbow tendinopathy, chronic nonspecific low-back pain, musculoskeletal pain, and obesity. However, 1 study did not find laser acupuncture effective for smoking cessation. As this kind of acupuncture becomes more popular, it becomes more important to understand its safety.12 To the current authors' knowledge, the use of laser acupuncture seems to be safe; however, literature concerning the safety of laser acupuncture has been limited. To date, there is no comprehensive review about laser acupuncture's safety. Given the increasing use of this kind of acupuncture as a clinical treatment option, studies on its safety are needed urgently. Therefore, this review systematically collected and synthesized previous published randomized controlled trials (RCTs) regarding the clinical safety evidence of this medical approach.According to a prospective observational study on the safety of traditional acupuncture in 229,230 patients with chronic osteoarthritis pain, the adverse event (AE) risk of acupuncture was 8.6%. While most of the AEs were only minor events, such as bleeding, pain, vertigo, or nausea, 2 patients experienced serious AEs , with 1 patient requiring hospital treatment and the other patient needing observation only. Thus, overall, acupuncture was regarded as a relatively safe treatment.® Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Scopus, and EBM Reviews–Cochrane Central Register of Controlled Trials. The search strategy was designed and conducted by an experienced librarian with input from the study's principal investigator. Controlled vocabulary supplemented with keywords was used to search for studies describing laser acupuncture. Search terms used were laser therapy or laser acupuncture or electro-acupuncture or acupuncture or acupuncture points. Reference lists of review articles and included relevant studies were hand-searched for additional studies. Commentaries, letters, responses, editorials, and original articles were sought. Randomized controlled trials that mentioned safe or safety or adverse event or adverse reaction or risk were searched. Given that most articles reported AEs and were indexed poorly, search terms were not combined for safety at the cost of sensitivity. Searching was limited to the English language. 13A comprehensive search was conducted of several databases, from inception to October 1, 2018, limited to English language only, and excluding animal studies. The databases included Ovid MEDLINE,(1)Had original patient data(2)Involved laser acupuncture treatment for any disease(3)Reported AEs or had safety reports(4)Randomized controlled trials (RCTs)(5)Involved with keeping records of laser acupuncture safety and risks.Trials that met the following criteria were included:Exclusion criteria were as follows:(1)Reviews(2)Languages other than English(3)Studies related to animal and cellular research.Two authors extracted the data independently regarding article author(s), publication year, country, study design, sample size, trial type, disease, interventions, practitioners' information, and detailed information on AEs. Any dispute was resolved by discussion between the 2 authors, and the original study author was contacted for further information by e-mail if needed.AE data from divergent sources were summarized in a qualitative analysis instead of combining them using meta-analysis. AEs were synthesized from 3 aspects: (1) severity; (2) causality assessment; and (3) evaluation tools.14 The CTCAE Scale grades 1 through 5 refer to the severity of the AEs. The 5-point grading categories were applied as detailed in This was assessed by two reviewers independently on the basis of the Common Terminology Criteria for Adverse Events (CTCAE) scale V.5.0.15This refers to causal relation between AE and LA treatment, which was assessed by 2 reviewers independently based on the World Health Organisation—Uppsala Monitoring Centre (WHO-UMC) system for standardized case-causality assessment.certain, probable/likely, possible, unlikely, conditional/unclassified, and inaccessible/unclassifiable. Any discrepancy in this procedure was resolved by consensus between the 2 reviewers or by consultation with the article's author. Terminology was modified for use in a device rather than for a therapeutic product, and for clinical trial than a laboratory test. The categories for causality assessment were 16–36 The geographic distribution of these RCTs trials included several countries, with 8 trials that originated in Australia,35 2 in in the United States,26 1 in Germany,21 2 in Indonesia,34 1 in Iran,18 1 in Denmark,31 1 in Egypt,25 1 in Scotland,16 1 in Austria,32 1 in China,23 1 in India,36 and 1 in Brazil.33 See For this review, 737 references were identified initially. Of these, 680 irrelevant records were removed based on their titles and abstracts. Of the 57 RCTs, 30 articles were excluded for irrelevance of laser acupuncture safety. After 6 of the 27 non–full-text RCT articles were also excluded, 21 RCTs full-text articles remained for this review.31–36 reported that laser therapy was safe without AEs. AEs varied substantially among 6 studies, mainly including: tingling29; pain flare-up20; fatigue30; insomnia, dry mouth, and headache30; and transient tiredness and dizziness, vagueness, and nausea.29A large proportion of AEs in the literature reports originated from European and North American countries.  The majo35 1 study by an investigator supervised by a certified acupuncturist, 1 by experienced general practitioner therapists,20 1 by a trained physiotherapist,16 and 36 See 32–36 For safety, safeguard measurements were given to medical providers; patients were instructed to wear goggles to shield their eyes35; and the laser probe was fully in contact with each participant's skin surface32 to deliver active laser radiation. Characteristics of included RCTs can be seen in Table 2.The treatment in 13 studies was administered by a licensed acupuncturist,26 but there was tingling reported at the site of laser acupuncture manipulation.Two trials reported tingling with laser acupuncture. As a noninvasive intervention applied to the skin, laser acupuncture produced no sensation and did not burn the skin,n = 47, 0.9 mW continuous wave (HeNe laser) and a control group . The affected thumbs of both groups were “irradiated” with a laser beam for 15 seconds, thrice weekly for 3 weeks. One participant in the treatment group reported transient tingling on the distal superficial branch of the radial nerve; this sensation disappeared spontaneously within 24-hours. The researchers concluded that HeNe laser irradiation at 0.9 mW was safe.17In 1 trial evaluating the efficacy of low-energy helium-neon (HeNe) laser treatment for thumb osteoarthritis (OA), 81 patients were randomized into a treatment group  laser-diode laser on pain and disability was investigated in patients with chronic nonspecific low-back pain, compared with a sham control. Results showed that 59% participants had minor pain flare-ups and 6% had major flare-ups, but there was no statistically significant difference between the 2 groups.20In the other trial, 144 patients were randomized to sham (0 J/point), low-dose (0.2 J/point), or high dose (0.8 J/point) groups for 8 once-weekly treatments. No pain- or disability-relieving difference was found among the groups. About 28% of treatments were recorded as followed by flare-ups of low-back pain within 1 week after treatment and there were no obvious differences in the flare-up frequencies.30 reported transient fatigue after low-level laser acupuncture treatment in patients with mild-to-moderate depression.Two trials reported transient fatigue with laser acupuncture. Quah-Smith and her colleagues30In 1 trial, 30 participants were randomized to either active or inactive laser treatment trial groups. In the active treatment group, 0.5-J laser treatment was delivered to each of 6–8 acupuncture sites per visit, twice weekly for 4 weeks, then once weekly for another 4 weeks. About 29% of the active group reported AEs, and 17% of the inactive group reported AEs. Fatigue was the most-common complaint in the former group (60%).27In the other double-blinded RCT, 47 participants, ages 18–50, were randomized to 2 groups who received laser acupuncture or placebo laser at acupoints CV 14, HT 7, LR 14, LR 8, and KI 3, twice weekly for 4 weeks and once per week for a further 4 weeks—12 sessions in total. After the 12 sessions were completed, minimal transient fatigue was noted in the laser acupuncture group; while transient fatigue, aches, days of fatigue, and vagueness were noted in the placebo group. No significant AE differences between the 2 groups were seen.All of the fatigue in both trials was mild and transient, which disappeared without special treatment within 24 hours after the acupuncture.30 They were mild and transit and resolved spontaneously within 1 day post treatment.Some other adverse events related to laser acupuncture—such as insomnia, dry mouth, and headache, transient tiredness and dizziness, and vagueness and nausea were also reporded.AEs in the 21 RCT reports were examined in 1244 participants regarding causality. Among the trials, only 4 were evaluated as certain causality; the rest included 1 as probable, 1 as possible, and 0 were unlikely, conditional/unclassified, or inaccessible/unclassifiable cases. In addition, all of the AEs were evaluated as mild in severity assessment. Severe AEs or deaths related to AEs were all regarded unlikely to have been caused by laser acupuncture treatment.30; 1 with a checklist20; and 1 with oral reporting.19 In 1987, during a study of a low-energy He laser for thumb OA, each participant was asked if there was a “good” or “bad” effects since the last treatment, at the first, third, sixth, and last treatment.17 Questions were also asked about pain, stiffness, activity, and medication usage, and the responses were quantified with ordinal scales ranging from 0 to 4 or 5. After completion of treatment, questions regarding late-occurring benefits or AEs were asked in telephone follow-ups.17Among the 21 analyzed trials, just 7 (33%) provided explicit information on the methods used to monitor or collect AE data. Accounting for the AE evaluation methods of the 7 trials included: 5 collected with AE questionnaires30 sent an AE questionnaire to participants after they completed their final treatments in 2005 and found that 29% participants of the active laser group and 17% of the placebo group reported AEs.Quah-Smith et al.29 In the trial evaluating the efficacy of laser acupuncture for chronic nonspecific low back pain, AEs post each treatment were documented on a checklist regarding with pain flare-ups occurrence and other symptoms.20 In another trial to observe AEs and pain exacerbations during treatment, the study therapist and assessors were required to not comment during the treatment, and follow-up surveys were assessed orally. Participants were asked how they were over the previous week; no side-effects were documented apart from pain variations.19In two trials in 2013, after 12 sessions of treatment, all of the participants were asked to complete a scale with a score range from 0 to 6 to assess any AEs .High doses of radiation therapy are more likely to stimulate target tissues and cause AEs.18 According to European Norm (EN 60825-1), low-level lasers were classified in the category of 3R category, which was equivalent to the old classification, 3B: radiation could potentially cause serious damage to the eyes, therefore eye protection is critical and required by law.37 Eye irradiation of laser acupuncture treatment was mentioned as having the potential to cause common and severe AEs, such as possible damage to the conjunctiva and retina etc.,32 while these AEs did not occur in any included trial of our review. This might be attributed to the more-routine use of proper protective measures. All the studies were reviewed and approved by the research ethics committees of the institutions where the trials occurred.In this review, all the identified AEs were mild and transient, suggesting that laser acupuncture appears to be safe. Despite these favorable findings, laser acupuncture might still be associated with some significant risks in certain circumstances. The laser device emits visible and/or invisible laser beams, which can cause irradiation to the eyes. 32 The effectiveness of protections, as required for Class 3B lasers, and application of the low-level laser were tested and approved by the administration departments of the institutions that carried out the studies,32 and the research laser devices were routinely checked to ensure proper functioning.16Participants, parents, or persons having the custody of patients who are considering receiving laser acupuncture must be given accurate and detailed information about the research intervention and possibility of AEs. Safeguard measurements for laser acupuncture in the clinical setting were obviously indicated in this current review, such as before the laser was switched on, the robe of the laser device should have been perpendicularly in contact with the skin and all the people in the room had been instructed to wear protective goggles against radiation that could damage their eyes. Newborns or infants who were receiving laser acupuncture interventions had eye protectors to cover their eyes.These guideline and precautions should be addressed by other practitioners in training; regulating the operations, therapeutic dose, and protections can reduce the high risks of irradiation.The evidence for the safety of laser acupuncture is not conclusive, but this can be improved in future trials by simple measures, such as utilizing uniform definitions of AEs for all studies. Explicitly including assessment of AEs in future studies, objectively recorded and analyzed, is also a critical step in the development of a more-robust and scientifically valid safety assessment of laser acupuncture. The specific AE questionnaires and symptom checklists as used in several of the reviewed studies may be an excellent resource for data monitoring and collecting.To the current authors' knowledge, this is the first systematic review to evaluate the safety of laser acupuncture therapy. Some limitations of this review should be noted. For example, the electronic search was initially conducted with the limitation to publications relevant to safety only. This may have led to the potential exclusion of some important information on the clinical efficacy of laser acupuncture. Furthermore, due to the diversity of laser parameters , it would be premature to try to draw conclusions about minimal effective dosages. Therefore, all the available laser parameters from the reviewed studies were included in this review, with the hope of forming a foundation for future systematic reviews of laser acupuncture efficacy. In addition, most studies did not provide appropriate information regarding AE incidence reporting. In this review, AEs were reported by only 32% of the included studies, and, due to unclear prescriptions in some of the original publications—such as vague AEs, number of sessions occurred, unclear AE case numbers, etc.—it might be difficult to draw any meaningful conclusions about AE occurrence-incidence reports. Future studies, performed rigorously—with specific emphasis on identifying and recording AEs—are needed.Laser acupuncture, performed within standardized guidelines and in compliance with all safety precautions, seems to be a safe and well-tolerated therapy that is associated with few mild and transient AEs. Large, well-designed placebo-controlled RCTs with rigorous evaluation methods are needed in the future.


Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum.Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores  were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores.Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected.Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies. Testicular torsion is an immediate surgical emergency, without prompt intervention it results in an ischemia-reperfusion (IR) injury with subsequent infertility or testicular loss , 2. The In the past diagnosis relied heavily on clinical factors such as short symptom duration, nausea or vomiting, absence or abnormality of ipsilateral cremaster reflex, high testicle position or hard testicle , 10, 11.To improve diagnostic reliability, by combining clinical with imaging factors, several scores have been established. Boettcher et al. defined a prediction score  based on a retrospective and prospective analysis of 242 children in a center in which all children with acute scrotum were surgically explored. They identified four factors that predict testicular torsion: (1) pain duration less than 24 h, (2) nausea or vomiting, (3) high position of testis, (4) abnormal cremasteric reflex. A score of ≥ 2 was considered as high probability of testicular torsion , 8. MoreRetrospective cohort study of all male children (age 1–17) that were admitted for acute scrotum at the Department of Pediatric Surgery at the Altonaer Children's Hospital Hamburg (AKK) and the University Medical Centre Hamburg-Eppendorf (UKE) between January 2013 till March 2019.The patients were selected from the hospital database using the ICD10 codes for acute scrotum including testicular torsion, testicular appendage torsion, epididymitis and idiopathic scrotal edema. Patients suffering a testicular trauma were excluded. Additionally, patients with reduced perception of symptoms of testicular torsion due to chronic illness as well as patients with peripartal testicular torsion were excluded. Medical files, including patient charts, operating theater records and office notes, were reviewed and routinely obtained characteristics were recorded. Following items were assessed: age, duration, nausea or vomiting, position of the testicle, presence of erythema or swelling, testicle side, abdominal pain, fever, dysuria, presence of cremasteric reflex , tenderness of testicle/epididymis and blue dot sign as well as findings of ultrasound, serum infectious parameters, urine analysis using urine dipstick and intraoperative and microbiological findings. Physical examinations were performed by a resident and/or a senior physician of pediatric surgery and ultrasound examinations were performed by a resident of Pediatric Surgery or Pediatric Radiology.Two different testicular torsion scores including the BALS and the TWIST score were assessed in all children , 10, 17.A controlled remote analysis of the nationwide DRG database from 2016 to 2017 was undertaken to evaluate inpatient data provided by the Research Data Centers of the Federal Statistical Office and the Statistical Offices of the Länder. The German adaptation of the International Classification of Diseases (ICD) Tenth Revision and the procedure coding system  were used to identify diagnoses and procedures. Every inpatient case with a procedure code for testicular torsion was included. Used ICD codes were N44.0, and the procedure codes were 5–622 and 5–624.Statistics were performed using SPSS Statistics 26  and R 4.0 . The AI-based approach was calculated using the R package randomForest . Random The level of significance was set to 0.05.In total 460 boys were included in the current study and 161 patients were excluded due to exclusion criteria. Due local policy all patients with elevated probability of testicular torsion underwent surgical exploration, which was nearly half of all patients presented with acute scrotum . In 48/460 (10.4%) patients' testicular torsion was confirmed and no testicular torsion patients was missed. The most common diagnosis was testicular appendix torsion , followed by epididymitis  and idiopathic scrotal edema . In 18 children no defining clinical or surgical feature was found. These cases were considered as intermitted testicular torsion .Mean patient age was 9.38 (4.12) years. As shown in As shown in p <0.001) and hospital stay was significantly shorter (p <0.001). The above-mentioned 3,374 procedures were performed in a total of 447 centers (mean caseload per center: 7.55). Of these, 1,056 procedures were performed in low-volume institutions (1–8 procedures/2 years), and 2,318 in high-volume centers (≥9 procedures/2 years).The nationwide database analysis revealed that in 2 years 3,374 procedures for confirmed testicular torsion were performed in Germany. Of these 443/3,374 consisted or orchiectomy without -pexie of the opposite site, 2,644/3,374 consisted orchidopexy only and finally 287/3,374 surgeries included simultaneous orchiectomy of the affected side and orchidopexy of the opposite site. Thus, in a total of 730 cases orchidectomy was necessary. Mean age was 11.20 (6.11) years and mean hospital stay was 2.19 (1.42) days. In the 2,644 children in which the testicle could be rescued (orchidopexy only) mean age was 13.25 (3.89) years and mean hospital stay was 1.56 (1.00) days. Thus, these boys in which the testis was rescued were significantly older in comparison to the boys who underwent orchidectomy (Complications were rare: T81 (Complications of procedures) arose in 68/3,374 cases and T88  occurred in 6/3,374 cases.As shown by the nationwide database analysis yielding around 1,687 cases annually, testicular torsion is a very common reason for consultation. In order to prevent testicular atrophy and infertility, TT warrants immediate surgical intervention . UnfortuEven though, the BALS and AIS are similarly effective, we recommend using the BAL-Score, in particular due to its enhanced specificity in comparison to the AIS. The BALS is very easy and quick to access. It includes only four features, which are directly to access via medical history and physical examination, so no time delay is expected. Even for inexperienced residents BAL-Score is well applicable. Almost all patients with TT had (1) a duration of pain <24 h (2) a high riding testicle (3) nausea and/or vomiting and (4) absent cremasteric reflex.It is remarkable, that while the AIS and the BALS depend more or less on the same anamnestic features plus the clinical feature “high riding testicle,” the TWIST comprises amongst others the factors “hard testicle” and “testicular swelling,” even weighing them double. In our experience evaluation of both factors can be rather complex, especially for the less experienced residents. Hence, the TWIST underperforms the AIS and BALS both in terms of sensitivity and specificity.The combination of a clinical prediction score, e.g., BAL-Score, with ultrasonography  enabled even safer diagnosis of the different reasons of acute scrotal pain, within an estimated sensitivity for identifying testicular torsion ranging between 85 and 100% , 22, 23.Most limitations of the current study are inherent in a retrospective study. As in most studies that rely on clinical features, another limitation is the inter-observer variability, as experience may significantly affect the examiner's interpretation of the clinical findings . HoweverIn conclusion, different clinical tools are available and helpful to predict testicular torsion. In our population, BAL-Score showed excellent capabilities to predict testicular torsion and reduce negative explorations to 6.1%. Due to its easy and quick application, BAL-Score is convenient for unexperienced residents as well and reduces time to conclusive diagnosis, resulting in less ischemia time.Since, the modifications of the BAL-Score refer to the results in our cohort, prospective validation should be performed in future studies.The original contributions presented in the study are included in the article/supplementary materials, further inquiries can be directed to the corresponding author/s.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.MK conceptualized and designed the study, acquired and analyzed clinical and experimental data, performed statistics, drafted the initial manuscript, and approved the final manuscript as submitted. JE, CS, and JW acquired and analyzed clinical and experimental data, drafted the initial manuscript, and approved the final manuscript as submitted. TG and KR acquired clinical data, drafted the initial manuscript, and approved the final manuscript as submitted. MB conceptualized and designed the study, analyzed clinical and experimental data, drafted the initial manuscript, and approved the final manuscript as submitted. All authors contributed to the article and approved the submitted version.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.


Since the start of the COVID-19 pandemic, there have been over 2 million deaths globally. Acute respiratory distress syndrome (ARDS) may be the main cause of death.This study aimed to describe the clinical features, outcomes, and ARDS characteristics of patients with COVID-19 admitted to the intensive care unit (ICU) in Chongqing, China.The epidemiology of COVID-19 from January 21, 2020, to March 15, 2020, in Chongqing, China, was analyzed retrospectively, and 75 ICU patients from two hospitals were included in this study. On day 1, 56 patients with ARDS were selected for subgroup analysis, and a modified Poisson regression was performed to identify predictors for the early improvement of ARDS (eiARDS).Chongqing reported a 5.3% case fatality rate for the 75 ICU patients. The median age of these patients was 57 (IQR 25-75) years, and no bias was present in the sex ratio. A total of 93% (n=70) of patients developed ARDS during ICU stay, and more than half had moderate ARDS. However, most patients  underwent high-flow nasal cannula oxygen therapy, but not mechanical ventilation. Nearly one-third of patients with ARDS improved  in 1 week, which was defined as eiARDS. Patients with eiARDS had a higher survival rate and a shorter length of ICU stay than those without eiARDS. Age (<55 years) was the only variable independently associated with eiARDS, with a risk ratio of 2.67 (95% CI 1.17-6.08).A new subphenotype of ARDS—eiARDS—in patients with COVID-19 was identified. As clinical outcomes differ, the stratified management of patients based on eiARDS or age is highly recommended. In December 2019, Wuhan, Hubei Province, China, reported a cluster of pneumonia cases of unknown cause, later identified as COVID-19 .The leading cause of COVID-19–related death may be severe respiratory failure caused by acute respiratory distress syndrome (ARDS) . AccordiThis study aimed to describe the epidemiology, clinical features, laboratory findings, treatments, and outcomes of intensive care unit (ICU) patients with COVID-19 in Chongqing, China, which neighbors Hubei Province. In addition, a subphenotype of ARDS—early improvement of ARDS (eiARDS)—which occurred in about one-third of patients, was identified. eiARDS predicted a favorable clinical outcome.This retrospective cohort study included two cohorts of ICU patients from the Chongqing Public Health Medical Center and the Chongqing Three Gorges Central Hospital , both of which were designated hospitals for the treatment of patients with COVID-19 in Chongqing. Patients admitted to the ICU between January 21, 2020 (the date the first patient was admitted), and March 15, 2020 (the date the last patient was discharged during the first wave), were enrolled in this study.2)/oxygen concentration (FiO2) ≤300 mm Hg. Patients meeting one of the following criteria were defined as critically ill: (1) mechanical ventilation needed as a result of respiratory failure, (2) shock, and (3) intensive care needed owing to the failure of other organs.Patients with COVID-19 were confirmed by a positive real-time reverse transcription–polymerase chain reaction (RT-PCR) assay using nasal swab specimens per WHO guidance . The sevThe two designated hospitals were Grade A hospitals in China, and all case data were retrieved from their electronic case system. Epidemiological and demographic data, symptoms, underlying diseases, comorbidities, treatments, clinical course, and outcome data of the patients were recorded in a spreadsheet. Vital signs, arterial blood gas analysis, laboratory data, acute physiology and chronic health evaluation II, and the sequential organ failure assessment score were recorded on specified dates  for each patient. If any question emerged regarding the case data, clarification was sought from the treating team physician. As data collection was completed, another doctor was responsible for checking and integrating the data. The proportion of pneumonia volume was calculated by the Pulmonary Infection–Assisted Diagnosis System (V1.7.1) based on computed tomography (CT) imaging.ARDS was diagnosed according to the Berlin definition . Liver it test was used for comparison between two groups. The continuous variables that did not meet the criteria for normal distribution were presented as the median (IQR), and the Mann-Whitney U test was used to compare differences between two groups. Categorical variables were summarized using frequencies and percentages, and the chi-square test or the Fisher exact test was used to compare two or more groups. A modified Poisson regression analysis (sandwich variance estimator) was performed to identify the predictors of eiARDS; variables with P<.05 in the univariate analysis were entered into the multivariate Poisson regression analysis. All tests were two sided, and P<.05 was considered statistically significant.SPSS 26.0 (IBM Corp) was used for statistical analysis. Normally distributed continuous variables were presented as mean (SD), and the independent Student The study was approved by the Research Ethics Committee of the Second Affiliated Hospital of Chongqing Medical University, the Chongqing Public Health Medical Center, and the Chongqing Three Gorges Central Hospital. Written informed consent was waived by the ethics committees of the designated hospitals for emerging infectious diseases.Original data can be requested from the corresponding author.From January 21 to March 15, 2020, Chongqing reported 576 new cases of COVID-19 and 6 deaths. In this study, 75 ICU patients from two hospitals were recruited, including 48 severe patients, 27 critically ill patients, and 4 deceased patients.A comparison of clinical characteristics between the two groups is shown in ARDS developed in most patients , and more than half  had moderate ARDS . HoweverThe clinical course and outcomes of patients with COVID-19 in Chongqing are shown in 2/FiO2 <300 mm Hg) on day 1 (first day of ICU admission) were included for a subgroup analysis. These patients were then divided into two groups based on the severity of illness on day 7: eiARDS patients with PaO2/FiO2 ≥300 mm Hg and non-eiARDS patients with PaO2/FiO2 <300 mm Hg  between the two groups. Predictably and regrettably, all the four deceased patients did not have eiARDS. Moreover, patients with eiARDS spent a shorter duration in the ICU than those without   was the only variable independently associated with eiARDS, with a risk ratio of 2.67 (95% CI 1.17-6.08). This finding indicated that patients younger than 55 years were 2.67 times more likely to have eiARDS than older people.A Poisson regression analysis was performed to determine the factors associated with eiARDS. In this study, the mortality rate associated with COVID-19 in Chongqing was 1.04%, and the 28-day case fatality rate of ICU patients was 5.3%. ARDS developed in 93% of ICU patients, and HFNC was the most commonly used type of oxygen therapy. About one-third of patients with ARDS improved in 1 week, which we defined as eiARDS. Patients younger than 55 years were more likely to exhibit eiARDS.The mortality of COVID-19 varied widely across different periods and areas. In the early stage of the outbreak, Wuhan reported a mortality rate of 4.3% among hospitalized patients  and 61.5ARDS is the primary factor that increases mortality. According to the Berlin definition, stages of mild, moderate, and severe ARDS were associated with increased mortality  . StudiesIn our study, nearly one-third of patients with ARDS recovered in 1 week, which we defined as eiARDS. However, eiARDS was found in only 18% of patients with mild ARDS caused by other factors, with 36% of patients persisting and 46% worsening during the first week after ARDS onset . It is w2/FiO2 value was independently associated with eiARDS. Indeed, multiple studies showed that older age (>65 years) was one of the risk factors for death in patients with COVID-19 [Regardless of the reasons why the proportion of eiARDS was high, paying attention to eiARDS itself is clinically meaningful. Early or rapid improvements in ARDS has always been associated with increased survival or better outcomes ,26. For COVID-19 ,27-29 anCOVID-19 . SimilarThis study had several limitations. First, because of the retrospective study design, laboratory tests  might not be performed for all patients at a specific time; the missing data were replaced by values obtained within the prior 2 days. Second, although the treatment strategies of the two hospitals were in accordance with the guidelines issued by the Chinese National Health Commission, some of the treatments were different, such as the composition of traditional Chinese medicine, leading to different clinical outcomes. Third, the sample size was relatively small, and some of the conclusions need to be verified using multiple care centers and larger sample sizes.A new subphenotype of ARDS—eiARDS—in patients with COVID-19 was identified. As clinical outcomes differ, the stratified management of patients based on eiARDS or age is highly recommended.