Undifferentiated embryonal sarcoma of liver (UESL) and hepatic mesenchymal hamartoma (HMH) are two rare entities which mainly affect the pediatric population. The aim of this investigation was to provide a comprehensive overview of the clinicopathologic characteristics of the patients diagnosed with these two conditions in a tertiary referral center in Iran.In this retrospective study patients diagnosed with UESL or HMH between 2012 and 2020 were studied. A comprehensive histopathologic evaluation of the cases along with immunohistochemistry evaluation using a panel of antibodies was conducted. Furthermore, clinical, paraclinical, and treatment data and follow up information was collected.p = 0.002) higher age at diagnosis compared with those with HMH. Histologically, UESL cases were characterized by anaplastic cells with eosinophilic cytoplasm and bizarre nuclei and frequent atypical mitosis and spindling in a myxoid stroma while disordered arrangement of hepatic parenchyma, bile ducts, and primitive mesenchyme was seen in HMH. Furthermore, small round cells and extramedullary hematopoiesis were seen in 2 UESL and 3 HMH cases, respectively. Concurrent HMH was also seen in two UESL cases. Immunohistochemistry panel showed positive staining for Vimentin, Glypican-3, Desmin, CD56, CD10, and BCL2 in UESL cases and immunoreactivity for Vimentin, HepPar 1, Glypican-3, SMA, CD56, BCL2, and CD34 in various components of HMH.A total of 16 patients  were studied in this investigation. Patients with UESL had a significantly (In this study, the clinicopathologic features of UESL and HMH cases are presented. We also evaluated the utility of an immunohistochemistry panel in the diagnosis of these two rare entities and suggested novel markers. Our study corroborated the findings of previous investigations and expanded the clinicopathologic features of these two rare entities with diagnostic and potential therapeutic implications. Undifferentiated embryonal sarcoma of the liver (UESL) and hepatic mesenchymal hamartoma (HMH) are two rare pathologic entities that are primarily seen in the pediatric population . UESL isThe underlying pathologic mechanisms playing a role in the development of UESL and HMH are unclear. However, different studies have proposed a number of potential mechanisms. Comparative genome hybridization (CGH) studies of UESL have shown different patterns of chromosomal changes including losses of chromosome 9p, 11p, and 14 and gains of chromosome 1q, 5p, 6q, 8p, and 12q pointing to the potential role of chromosomal instability . Genetic1 anti trypsin, CD10, and CD68 [UESL is usually diagnosed based on the patient’s age, tumor location, and an immunohistochemistry panel of undifferentiated markers including vimentin, desmin, αand CD68 , 16. HowIn this investigation, a retrospective evaluation of patients diagnosed with UESL and HMH at Shiraz University of Medical Sciences between 2012 and 2020 was conducted. The diagnosis was based on histopathological evaluation of tumor samples according to WHO classification of tumors of the digestive system. The specimens were obtained by surgical resection and were subsequently fixed in formalin and then embedded in paraffin. They were then stained using hematoxylin and eosin staining, periodic acid–Schiff (PAS) staining for UESL cases, and immunohistochemistical staining for all cases using the following antibodies: Vimentin , HepPar 1 , Glypican 3 , Arginase-1 , Ki67 , Desmin , SMA , CD56 , CD10 , CD68 , BCL2 , PD-L1 , C-Kit , CD34 . Appropriate positive and negative controls were used throughout the experiments. The immunohistochemistry slides were subsequently evaluated by a pathologist. In the event that less than 1% of the cells in a slide showed immunoreactivity, the case was considered negative. The positive cases were subsequently graded based on staining intensity as weak, intermediate, and strong. If more than half of the cells of interest were stained, the staining was considered diffuse. Otherwise, in cases with a staining percentage between 1 and 50%, the staining was considered focal.The following information was collected for both groups of the patients: patient age, sex, presenting symptoms, tumor location, significant laboratory findings. Furthermore, for patients diagnosed with UESL extrahepatic metastasis, recurrence, disease stage, and radiologic findings were collected. The treatments received by the patients with UESL and the disease outcome were also collected by contacting the family members. In addition, the gross and microscopic pathologic findings were documented for all the cases.R ver 4.0.2 (2020-06-22) was used for statistical analysis. Considering the small sample size of the study, continuous variables were reported as the median and interquartile range (IQR). Mann-Whitney U test was used to compare the distribution of variables between two groups. The correlation between tumor size and age was assessed with Spearman’s ρ. Kaplan-Meier survival analysis for the patients with UESL. A p value < 0.05 was considered statistically significant.The clinicopathologic characteristics and demographic data of the patients with UESL and HMH are presented in Tables p = 0.002) higher than those with HMH. Abdominal pain was the most common (8/8) presenting symptom in patients with UESL, followed by nausea/vomiting (3/8) and fever (2/8). Abdominal distention (4/8) and accidental identification of an abdominal mass by the patient’s caregiver (3/8) were the most common complaints on initial presentation in patients with HMH. All the UESL and HMH patients identified had right liver lobe masses. Except for one patient with UESL, all of the UESL and HMH masses identified were unifocal. Initial laboratory abnormalities were more commonly observed in patients with UESL compared with those with MH. Anemia (4/8) and elevated hepatic transaminases levels (3/8) were seen in patients with UESL. Notably, elevated CA-125 levels were seen in one of the patients with UESL. Furthermore, one patient with HMH had elevated alpha-fetoprotein (AFP) levels. All patients diagnosed with HMH had undergone surgical resection of the liver mass and were alive after a median follow-up of 5.5 years without any complications. Most of the patients with UESL underwent gross tumor resection followed by adjuvant chemotherapy (7/8). Furthermore, 2/8 patients underwent radiation therapy as well. In patients with UESL, after a median follow-up time of 3 years, one patient had passed away and one of the patients was still under treatment due to recurrence. Overall, tumor recurrence was observed in two of the patients. No evidence of the disease after the treatment was detected among the other six patients with UESL. Patients with UESL had a mean survival time of 7.2 (95% CI 5.7 to 8.7) years estimated by Kaplan-Meier survival analysis.Overall, there were 8 patients  with UESL with a median age at diagnosis of 12.0 (IQR 4.6 to 13.3) years. In addition, 8 patients  with HMH with a median age at diagnosis of 2.3 (IQR 1.4 to 2.5) years were identified. The age at diagnosis for those with UESL was significantly  Table .Table 3ρ = 0.584, p = 0.128). Histological findings in UESL included anaplastic stellate to spindle-shaped or epithelioid tumor cells with poorly defined, light eosinophilic cytoplasm . HMH was histologically characterized by the disordered arrangement of hepatic parenchyma, bile ducts, and mesenchyme consisting of spindled cells and myxoid stroma . No correlation between the tumor size and age at diagnosis was noticed  and therefore did not include them in the IHC studies. HMH associated with UESL in case 5 was included as a separate HMH case in the final analysis Tables  and 5.TUESL and HMH are rare hepatic lesions primarily seen in the pediatric and early adult populations. In this investigation, we, for the first time, provide a comprehensive clinicopathologic overview of these two entities in a case series from Iran. Overall, our findings show that patients with HMH are younger at presentation compared with those with UESL. Furthermore, both conditions had nonspecific initial clinical presentations with abdominal pain being present in all patients with UESL. These findings are in line with the previous investigations , 17. AneAll of the patients with UESL had undergone gross surgical resection of the tumor followed by chemotherapy except for one of the patients who had not received chemotherapy. In addition, two of the patients with UESL also received radiotherapy. In the past, the prognosis of liver sarcomas was poor overall. In the original report of 31 patients with UESL by Stocker and Ishak, only six patients were alive without any evidence of the disease . Over thOn gross evaluation, all of the masses were located in the right hepatic lobe with variable sizes of up to 28 cm. UESL masses usually showed hemorrhage and cystic changes with variable degrees of necrosis while HMH cases presented with unifocal solid or cystic structures. Small round cells were seen on histologic evaluation of two UESL cases which could be an important finding if present in liver biopsies from these patients and can mimic other pathologies. In addition, severe hepatic steatosis seen in one of HMH cases points to potential molecular defects leading to deregulation of cellular energetics as seen in other liver disorders . FurtherThe immunohistochemical phenotypes of UESL and HMH have only been investigated in a few studies so far. Overall, in three case series, positive immunostaining for vimentin and Bcl-2 has been reported in most of the cases while positive staining for desmin, SMA, p53, pancytokeratin, Glypican-3, and calponin has been observed in some of the cases. Immunostaining for HepPar1, CD34, CD117 (C-kit), S100, HMB45, myogenin, ALK-1, and α-fetoprotein were found to be negative in the primary tumor cells –24. In aAbsence of PD-L1 expression in all of the UESL cases investigated in this study points to the potential lack of efficacy of immune checkpoint inhibitors targeting this pathway as a therapeutic target in these patients . HoweverThe main differential diagnoses of UESL in the pediatric and adolescent population include hepatoblastoma, HMH, embryonal rhabdomyosarcoma, hepatic angiosarcoma, and hepatocellular carcinoma , 33. IHCIn summary, this investigation reports the first case series of patients with UESL and HMH from Iran. Herein, we reported the clinicopathologic findings of sixteen patients from a single referral pediatric center. Although due to the rarity of these two pathologic entities we were not able to recruit a large number of patients in order to investigate the prognostic significance of different pathologic findings, we were able to identify significant histopathologic findings and novel IHC markers with diagnostic and therapeutic implications. Further investigations have to be conducted to shed light on the clinicopathologic and pathophysiologic basis of these two rare entities.


The aim of this study was to investigate the potentially modifiable factors affecting age at natural menopause (ANM) in Chinese women.We used cross-sectional data from the China Kadoorie Biobank study which that recruited 0.5 million (0.3 million women) Chinese adults aged 30 to 79 from 2004 to 2008. Multinomial logistic regression models were used to examine the relationships between ANM and various factors recorded at baseline.Among 87,349 postmenopausal women, the mean ANM (SD) was 48.7 (4.3) years. Older age, being a housewife, earlier menarche, and passive smoking were associated with both premature menopause  and early menopause . A higher odds for EM was observed in women who were widowed , had spontaneous abortions (1.33 [1.05-1.69]), current regular smoking (1.19 [1.07-1.37]), and frequent spicy food intake (1.11 [1.05-1.08]). Higher socioeconomic status; later first birth; more live births and induced abortions; longer breastfeeding; tea drinking, as well as intakes of meat, fruits, dairy, and soybean products; and increased body mass index gain were inversely associated with PM and/or EM. In contrast, women who had more pregnancies, occasional alcohol drinking, higher levels of physical activity or body mass index, vitamin intake, and hypertension were more likely to have a later age at menopause .This large epidemiological study found a wide range of sociodemographic, lifestyle, dietary, and reproductive factors related to PM, EM, and LM in Chinese women. Several studies found that premature/early menopause (EM) is associated with higher risk of type 2 diabetes,9 Previous research has shown that menopause is triggered by a low threshold number of predetermined follicles in the ovary10; however, factors that can modify the rate of follicle decline and thus affect the onset of menopause are not fully understood. Except for the genetic contributions to the variation in ANM,12 there are potential effects of other reproductive and lifestyle factors, such as parity and smoking.13Menopausal age varies greatly between and within populations.However, most existing evidence came from Western studies, and little is known in China, where women's lifestyle and reproductive characteristics are significantly different from those in Western women. Based on the nationwide China Kadoorie Biobank (CKB) study, we aimed to examine the relationships between ANM and a wide range of sociodemographic, lifestyle, dietary, and reproductive factors in Chinese women.14 Briefly, the baseline survey was conducted from 2004 to 2008 and recruited 512,715 Chinese adults  aged 30 to 79 from 10 diverse regions in China. Data on participants’ sociodemographic characteristics, dietary and lifestyle behaviors, medical history, and for women only, the history of reproductive characteristics, relevant surgery treatment, and oral contraceptive (OC) use were collected using an interviewer-administered laptop-based questionnaire. Physical measurements including various anthropometry measurements  were undertaken by trained health workers.Details regarding the CKB study design and population have been published elsewhere.15Self-reported ANM was the outcome of interest. On the baseline questionnaire, women were asked whether they had their menopause with the following response options: (1) no; (2) yes, currently; (3) yes, had menopause. Women who had menopause were then asked the age of completion of menopause (open response). In this study, women without menstruation for 12 months or longer were defined as postmenopausal. In categorical analysis, ANM was grouped as age less than 40 , 40 to 44 (EM), 45 to 47, 48 to 50 (reference category), 51 to 52, and 53 years or older .Exposure factors considered in the cross-sectional study included: (i) sociodemographic characteristics included age, area, marriage status, education, occupation, and household income; (ii) lifestyle behavior factors included tea and alcohol drinking, active and passive smoking, physical activity, and the duration of pesticide storage at home; (iii) dietary intake variables included frequency of consuming coarse cereals, meat, poultry, seafood, fresh eggs, soybean and dairy products, preserved vegetables, fresh fruits and vegetables, spicy food, vitamins and minerals, and experienced severe food shortage over 1 year preceding the survey; (iv) physical measurements included body mass index (BMI), BMI change per year from age 25 years, waist circumference, and blood pressure; and (v) reproductive characteristics included age at menarche and first birth, parous status, OC use, number of pregnancies, live births, spontaneous and induced abortions, and breastfeeding duration for each live birth. The details of these exposure factors could be found in the supplementary baseline questionnaire .n = 128,721) or perimenopausal , had missing data on menopause (n = 47), or had a history of surgical menopause  or cancer  at baseline. To avoid any potential distortion of the distribution of ANM among the younger age group which included pre-, peri-, and postmenopausal women, the main analysis was confined to women aged 57 years or older of whom 99% reported being postmenopausal . The extreme top and bottom 0.5% of menopausal age values were also excluded . After these exclusions, 87,349 postmenopausal women remained in the main analysis.Among 302,522 women recruited in the CKB study, 146,160 women were excluded because they were premenopausal  and number of live births . Tests for linear trend were conducted by modeling each exposure as a continuous variable. The Bonferroni correction was used to adjust for multiple comparisons. Finally, to evaluate the robustness of our estimates, we conducted the sensitivity analysis with different categories of ANM: <40 (PM), 40-44 (EM), 45-52 (reference category), and ≥53 years (LM). All analyses were performed using SAS version 9.4  and R version 4.0.2 . All statistical tests were based on the two-sided 5% level of significance.The age-adjusted mean ANM for each category of each exposure variable was calculated. Multivariable linear regression models were used to estimate the adjusted mean differences and their 95% confidence intervals (CIs) for ANM between different categories of each exposure variable. To further estimate adjusted odds ratios (ORs) and 95% CIs for PM, EM, and LM according to each category of exposure variables, we used the multinomial (polytomous) logistic regression models. Based on prior knowledge, the statistical models were adjusted for age , area , education , household income , smoking , BMI ,Among 87,349 postmenopausal women, the mean (SD) age at baseline was 64.5 (5.2) years. The range of reported ANM was 32.0 to 58.0 years, with a mean of 48.7 (4.3) years, and a median of 49.0 years. Approximately 3.2% of women had PM, 10.9% EM, and 16.7% LM. 49.8% of the postmenopausal women were from urban areas and 40.9% had no formal education. Few women were current regular smokers (4.7%) or alcohol drinkers (3.4%) and 8.5% women had ever used OC. Very few women were nulliparous (1.2%) or, among parous women, never breastfed their children (1.7%) during their reproductive period. Compared with women with a later ANM, women with earlier menopause were, on average, slightly older and leaner at baseline, more likely to be less educated, smoked more, and had a higher proportion of nulliparity, less use of OC, younger age at first birth, and lack of breastfeeding (Table Ptrend < 0.001) and EM ; with earlier menarche (≤12 and 13-14 vs 15-16 years): 1.18-2.18 for PM and 1.42-2.00 for EM; experienced passive smoking : 1.16-1.20 (Ptrend = 0.006) for PM and 1.13-1.16 (Ptrend < 0.001) for EM, respectively. A higher odds for EM was also observed in women who were widowed , had three or more spontaneous abortions , current regular smoking , and frequent spicy food intake  , higher odds were present in women who were housewives (vs unemployed/retired/other), with OR of 1.18 (95% CI: 1.04-1.34) for PM and 1.23 (1.14-1.34) for EM; in older age groups (vs 57-60 years) for both PM ; or experienced more induced abortions (vs none): 0.77-0.86 (Ptrend < 0.001) and 0.88-0.94 (Ptrend < 0.001). Low odds for only PM were observed in women with higher education levels , more live births , and later ages at first birth . Other factors such as urban residence, OC ever use, breastfeeding duration, tea drinking, intakes of meat, poultry, seafood, fresh eggs, soybean products, fresh fruits, and dairy products and higher BMI gain per year from age 25 years were also inversely, to some extent, associated with PM and/or EM , who were parous, had more pregnancies, occasionally drank alcohol (vs never), more active, intake of vitamin supplement, or had hypertension Tables , Fig. 1DThe sensitivity analyses showed that the ORs for PM, EM, and LM were largely unchanged when the ANM of 48 to 52 years was taken as the reference group.To our knowledge, this is the first large epidemiological study to comprehensively and simultaneously identify factors related to ANM in China. Based on nearly 90,000 postmenopausal women from ten diverse regions in China, we found various sociodemographic, lifestyle, dietary, and reproductive factors were associated with women's ANM.18 Similarly, the present study showed that older women were at higher odds of both PM and EM than their younger counterparts. The mechanism underlying the generation effect on ANM remains unclear, but may be largely due to the economic growth and health status improvement.18 Menopausal age has been shown to vary by socioeconomic status (SES) across studies. A recent meta-analysis of 46 studies from 24 countries found that higher education and occupation levels were associated with later ANM.19 Similarly, in a national, cross-sectional study of 31,508 Korean women, the authors reported that rural residence, as well as lower household income and education levels were associated with increased risk of PM and/or EM.20 The direction of our results supported these studies with findings that women characterized by urban residence, higher education, and household income levels were less likely to experience PM and/or EM. A study of 4,056 women aged 60 to 79 years selected from Latin America and Caribbean showed that manual occupation/being a housewife were associated with earlier menopause.21 In our study, housewives consistently showed higher odds of both PM and EM. The relationship of unmarried status with earlier ANM is a relatively consistent observation in the literature. In line with a previous report from Lay et al,22 this study also observed that widowed women had a higher odds of EM than those currently married.Recent evidence has indicated that there is an upward secular trend of ANM in the past decades, with the older generation more likely to experience earlier menopause.24 In line with findings from several large population studies,26 the present study observed that women with earlier menarche were more likely to have earlier menopause, which may be explained by the fixed follicle pool and therefore possibly fixed number of ovulatory cycles. This mechanism may also explain the relationship between LM and OC use, being parous, increased number of pregnancies and live births, and longer breastfeeding duration, which all disrupt the ovulation cycle to some extent.28 It was suggested that later age at first birth may be associated with earlier ANM, due to a decline in follicle count and/or sex hormone levels.29 In contrast, the present study found that later age at first birth was positively associated with LM, which was also reported from a study in India,30 and the possible reasons are unknown. The influence of abortion on menopausal age has been rarely studied with conflicting findings presented. Although no relationship was reported in an Iranian study,31 the positive associations of spontaneous and induced abortion with EM and PM odds were reported in a Korean study (137 PM and 281 EM women).28 The present study also found that women who reported having three or more spontaneous abortions were at higher odds of EM. Potential explanation was that more spontaneous abortions may accelerate the rate of follicle loss in the decade preceding menopause.32 Interestingly, we found that the ANM tended to be later with increasing number of induced abortions, which may be due to the birth cohort effect .To date, the relationship between age at menarche and ANM remains unclear.33 consistent with observations in our study. Few studies have explored the potential effect of passive smoking on ANM and the results are inconsistent.35 The present study found that passive smoking exposure, similarly to active smoking, was also related to earlier menopause. The most important explanation for the accelerating effect of smoking on menopause was that the yielded polycyclic aromatic hydrocarbons would increase the rate of oocyte apoptosis.36 Only the Shanghai Women's Health Study of 33,054 Chinese postmenopausal women has investigated the link between tea consumption and menopausal age,29 and unlike the null relation reported in their study, our study showed that tea drinking was inversely associated with PM, which was supported by the previously published biological evidence on the antioxidant effects of tea and nonsteroidal estrogenic effects of tea flavonoids.38 The slightly higher odds of LM in occasional alcohol drinkers that we found is also reported by studies in other countries,39 which may be partly due to the increased estrogen levels from alcohol consumption noted in premenopausal women.40 Prior evidence for the relationship of physical activity with ANM has been generally mixed. Some studies reported increased physical activity was associated with older age at menopause,29 whereas others showed null or inverse associations.41 In this study, we consistently found that higher physical activity was positively associated with LM. Increased physical activity may delay menopause by causing irregular menstrual cycles, a potential factor associated with later ANM.42Prospective evidence has confirmed the role of current regular smoking in accelerating menopause,29 Specifically, the consistently observed positive association between meat and ANM in our cohort and previous studies supported the hypothesis that meat protein may increase episodic releases of luteinizing hormone, follicle stimulating hormone and the length of the menstrual cycle.43 In addition, concurring with prior evidence,44 the relationship of higher dairy product intake with later ANM observed here may also support the association of dairy product intake with reduction of decline of anti-Mullerian hormone (AMH) level,45 a direct marker of ovarian reserve and menopausal age. A similar mechanism may also play a role in our finding that women with higher intake of fresh fruits were less likely to have PM and EM.45 In addition, fruits are rich in antioxidants and thought to ameliorate oxidative stress on ovarian follicles and thus affect menopausal age.46 The lower odds of EM associated with soybean product intake found in the present study differed from previous studies. An association of soy product intake with earlier menopause was found in a cross-sectional Japanese study47 but not in the subsequent follow-up study.48 In the Nurses’ Health Study II cohort study of 85,682 premenopausal US women, neither soy nor tofu intake was related to EM over twenty years of follow-up.49 The present study also indicated a positive relationship of vitamin intake with LM and women with daily spicy food intake were more likely to have EM. Further studies on observational associations and potential mechanisms are warranted.The present study found that women with higher consumption of meat, poultry, seafood, eggs, dairy and soybean products had lower odds of having PM and/or EM, which to some extent, confirms the possible delaying effect of protein intake on ANM.50 the present study showed that compared to women with normal weight, overweight and obese women tended to have LM. A possible explanation for these findings is that women with higher BMI are expected to have more estrogen supplied by adipose tissue in the later reproductive years.51 Many studies have also investigated the associations between dynamic changes of weight or BMI over time and menopausal age, however findings were inconsistent.53 In this study, we found that BMI gain since young adulthood was inversely associated with EM. In contrast to previous studies showing that premenopausal hypertension was associated with earlier ANM,54 interestingly, we found that women with clinically identified and screen-detected hypertension were more likely to have LM, which did not materially changed when further confined to premenopausal clinically identified hypertension in women.In line with prior evidence,55 considering an average of 15 years have passed since menopause, the recall bias of ANM is inevitable. Furthermore, generally high or moderate agreements on the self-reported exposure factors between the baseline survey and resurvey suggested recall bias may be relatively small in CKB. Taking age at menarche that was recalled decades later as an example, the intraclass correlation coefficient was 0.84 between the baseline survey and the resurvey.56The present study has several strengths. This is the first study to comprehensively examine the related factors of ANM in China with the largest sample of postmenopausal women from ten diverse geographic regions in China. In addition, the high quality and completeness of data collection, and the wide adjustment for co-variables simultaneously limit the possible confounding bias in the analyses. However, some limitations exist. The greatest weakness of the study is that the mean age at baseline and menopause among women was 64.5 and 48.7 years, respectively, which means that some baseline exposure factors used for analysis were collected on average 15 years after menopause. Under this circumstance, some of the identified associations may be the result of EM or PM, rather than the cause. For example, a woman who started smoking at age 60 would be considered a smoker for this analysis and contribute to findings that smoking is associated with an earlier ANM, even if she started smoking many years after menopause. Thus, these factors we examined and their associations with ANM need to be interpreted with great caution and identified in longitudinal studies. In addition, the data of menopause and most exposure variables collected relied on subjective self-reports thus recall bias may exist. Although evidence has shown that recalled and actual menopausal age is reasonably well correlated,In summary, this study indicates that a wide range of sociodemographic, lifestyle, dietary, and reproductive factors are found to be related to PM, EM, and LM in Chinese women. As the ANM has implications for several health outcomes, the findings in this study also provide support for early monitoring of women who are at high risk for chronic diseases occurring in later life.


This study aimed to investigate the prevalence of developmental regression in children with Autism Spectrum Disorder (ASD) and to explore its relationship with disease severity.We finally included 1,027 ASD children aged 2–5 years from 13 cities in China: 138 with regressive ASD and 889 with non-regressive ASD. The Social Responsiveness Scale (SRS), Autism Behavior Checklist (ABC), Child Autism Rating Scale (CARS), and Children Neuropsychological and Behavioral Scale-Revision 2016 (CNBS-R2016) were used to evaluate the core symptoms and developmental status of children in the two groups.P < 0.05; β = 1.104, 95% CI: 0.120, 2.089, P < 0.05; β = 1.388, 95% CI: 0.038, 2.737, P < 0.05), the SRS total scores and the sub-score of autistic mannerisms  of children in the regressive group were all higher than the non-regressive group. The total developmental quotient (DQ) of CNBS-R2016 and the DQ of gross motor, fine motor, adaptive behavior, language  and personal society in the regressive group were lower than the non-regressive group and the proportion of children with intelligent developmental impairment was higher the non-regressive group.Among the 1,027 ASD children eventually included, 138 (13.44%) cases showed regressive behavior and the average regression occurring age was 24.00 (18.00–27.00) months. Among the regressive children, 105 cases (76.09%) had language regression, 79 cases (57.25%) had social regression, and 4 cases (2.90%) had motor regression. The total scores of ABC and the sub-score of sensory and stereotypic behavior (β = 5.122, 95% CI: 0.818, 9.426, Regressive autism is mainly manifested as language and social regression. Children with regressive ASD have more severe core symptoms, lower neurodevelopmental level DQ, and more serious disease degree than children with non-regressive ASD, which requires further etiological examinations and more clinical attention. Autism Spectrum Disorder (ASD) is a complex neurodevelopmental disorder characterized by persistent impairments in social interaction and communication, and the presence of restrictive and repetitive patterns of behavior, interests and activities, and sensory anomalies . The latAll research participants aged 2–5 were recruited from the China Multi-center Preschool Autism Project (CMPAP). From May 2018 to December 2019, the project recruited ASD children from 13 cities where the project sub-centers are located-northern, eastern, western, southern, and central China. According to the completion of the questionnaire, it was confirmed that the effective sample size of 1,027 cases was included. The area where the sub-centers are located is defined as: the north ; the east (Shanghai and Nanjing); the west ; the south ; the middle (Wuhan and Zhengzhou).Autism Spectrum Disorder children were recruited from outpatient clinics and special education institutions. The diagnosis of ASD was performed by psychiatrist, psychologists, or developmental behavioral pediatrician with extensive experience and using the Diagnosis and Statistical Manual of Mental Disorders-fifth edition (DSM-5) . ASD chiAutism Spectrum Disorder Child Health Questionnaire includes detailed content such as basic child information, family environment information, health status after birth, and description of developmental regression. Among them, the developmental regression includes: whether there is regression, the regression occurring age, and the detailed description of the regression behavior.Autism Behavior Checklist (ABC) consists of 57 items in five dimensions, including sensory, relating, stereotypic behavior, language, and social self-help. Which is completed by parents to describe the behavioral characteristics of children with ASD. A score of 53 was used as thresh-old value for the diagnosis of autism, while scores for children with autism should be ≥67 .A scale filled out by parents to assess the social ability of autism. A total of 65 items consists of 5 subscales including social awareness, social cognition, social communication, social motivation and autistic mannerisms. Normal children’s assessment score should be <65. The higher the total score, the more severe the social disorder .This scale is used by professionals to assess the symptoms and severity of autism, and is suitable for children over 2 years old. A total of 15 items are scored using four levels of 1, 2, 3, and 4. The total score is 30–36 points, and the items below three points are less than five items indicates mild-moderate autism; the total score is ≥36 points and at least 5 items with a score higher than three points indicates severe autism .It is assessed by professionals and used to assess the neurodevelopmental level of children aged 0–6 in the six domains of gross motor, fine motor, adaptive behavior, language, personal society, and autism warning behavior. DQ < 70 in each domain indicates developmental disorders. The warning behavior score <7 indicates normal, and >30 indicates highly suspected ASD, which can be used for risk identification and prediction of ASD .n (%). Differences in demographic data betweeen groups were assessed by using the Chi-Square test or Mann–Whitney test. Multivariate (adjusted for age and gender) linear regression models were used to compare the scores of the Autism symptom scale and developmental level scale between the regressive and non-regressive groups. A P < 0.05 was considered statistically significant.SPSS statistical software 26.0 was used for statistical analysis. The Kolmogorov–Smirnov goodness-of-fit test was used to test the distribution of each dataset for normality before analysis. Continuous variables were described as mean ± standard deviation (M ± SD) and medians (inter-quartile ranges) [M (IQR)]. Categorical variables were described as z = −0.329, P = 0.742) .According to the inclusion and exclusion criteria, a total of 1,027 ASD children aged 2–5years were enrolled in this study , with an= 0.742) . There wx2 = 0.010, P = 0.922). Among the regressive children, 105 cases (76.09%) had language regression, 79 cases (57.25%) had social regression, and 4 cases (2.90%) had motor regression (The average age of the onset of regression was 24.00(18.00–27.00) months. Among them, the regression rate of male children was 13.40% (113/843), and that of female children was 13.66% (25/183). The difference was not statistically significant (gression .P < 0.05), stereotypic behavior  and ABC total score  were statistically significant.The results of multivariate (adjusting for age and gender) linear regression models are shown in P < 0.05) and SRS total score  between the two groups.The regressive ASD children also had higher scores in the Social Responsiveness Scale (SRS) total score and the scores of sub-items compared with the non-regressive ASD children, while there were only two statistically significant differences in autistic mannerisms score .The Child Autism Rating Scale (CARS) total score in the regression group was slightly lower than that in the non-regression group, however, the difference is not statistically significant. The regressive ASD children also had a higher score in the communication warning behavior totle score .It can be seen from Although previous studies have gradually paid attention to the regressive ASD, there is still a lack of large sample investigations on its rates and onset of regression, regression subtypes, and disease severity in China. Therefore, this study conducted the first nationwide multi-center study to further describe the onset pattern of regressive ASD and its relationship with the severity of the disease. Our research results showed that although the prevalence rates for regressive ASD was not very high, it was more serious than non-regressive ASD.Findings from the meta-analysis indicated that regression prevalence varies with different regression classification methods and sampling methods . Recent Our research results suggested that the incidence of regression was 13.44%, which was lower than the domestic retrospective research result (32.97%) of Wu et al. . The reaRegarding the age of onset of regression, Tan et al. reviewed other studies and concluded that the average occurring age was 1.65 years or 19.80 months  Because this research is a retrospective study, there is a certain recall bias, and there may be some deviations in the occur age of regression and whether the regression behavior occurred. (2) This study adopted the form of questionnaire survey, which has certain requirements for the comprehension and cognition level of the person who completes the questionnaire, so there may be a certain amount of information bias.This multi-center study found that the prevalence of regressive ASD was low, and regressive skills were mainly manifested in language and social. However, due to its more severe clinical symptoms and worse prognosis, both medical staff and parents should actively monitor the development levels of children, so as to identify regression in time, and conduct early intervention training. Next, we will carry out a large-sample prospective cohort study to further explore the more subtle development trajectory of children with ASD, and provide data support for in-depth understanding of the disease pattern of ASD.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of the Children’s Hospital of Chongqing Medical University. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.CH and FY completed the statistical analyses, drafted the initial manuscript, and reviewed and revised the manuscript. TY, JieC, YD, FJ, LW, YH, LL, JZ, XK, MY, QH, JinC, SF, YW, QW, and CJ contributed to the conceptualization and design of the study and supervised the data collection. TL and LC conceptualized and designed the study and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.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.


To explore the incidence and risk factors for radiographic knee osteoarthritis (ROA) in a suburban area of China.Shunyi Osteoarthritis Study was a population-based, longitudinal study of knee osteoarthritis in Shunyi, a suburban area of Beijing, China. A total of 1295 residents aged over 50 years were recruited with fully informed by randomized cluster sampling and were followed up 3 years later. At the time of baseline and follow-up visits, participants completed a home interview questionnaire and received a clinical examination including height, weight, range of motion (ROM), chair stand test, 50-foot walk test, and weight-bearing posterior-anterior semi-flexed view of radiographs at tibiofemoral joints. The incident ROA for a knee was defined if its KL grade was no more than grade 1 at baseline visit and no less than grade 2 at the follow-up visit. A patient without ROA in both knees at the baseline visit and with ROA in at least one knee at the follow-up visit was viewed as an incident case of ROA in patient level. Generalized linear model and generalized estimating equation were performed to examine the association between socio-demographic factors, physical function as well as baseline knee joint condition, and incident ROA in patient and knee level.A total of 1295 residents were recruited at baseline in 2014, and 962 (74.3%) residents were followed in 2017. The annual cumulative incidence of ROA was 3.6% at knee level and 5.7% at patient level. Older age  = 1.079; 95% confidence interval (CI), 1.042-1.117), overweight , female , less ROM  and Kellgren and Lawrence (KL) grade 1 at baseline  were risk factors for incident ROA.The incidence of knee ROA in Chinese suburban area was high. Advanced age, female, overweight, less range of motion, and KL grade 1 at baseline were associated with an increased risk of incident ROA. Knee osteoarthritis (OA) is one of the most prevailing forms of osteoarthritis, causing pain, stiffness, deformity, and functional disability, which further leads to cardiovascular events and increases all-cause mortality –3.Obesity and aging have long been shown to be strong risk factors for the incidence and progression of knee osteoarthritis. With the aging population and increase prevalence of obesity, this disorder and total knee replacement have become substantially more common in recent decades . AccordiAlthough a large number of potential risk factors for incident radiographic knee OA have been studied, most of those studies were performed in European population, and were limited by their cross-sectional design, and moreover some results are conflicting –9. ThereThe purpose of this population-based longitudinal study was to explore the incidence and risk factors for radiographic knee OA among the Chinese in suburban community.The Beijing Shunyi osteoarthritis study was a population-based, longitudinal, and prospective study of knee osteoarthritis, which was approved by the Ethics Committee of Peking University People’s Hospital. The study was based on a random cluster sampling method in 2014. Fourteen villages in Shunyi District, Beijing, China, were selected, and every resident who participated in the survey had signed the informed consent document. The inclusion criteria for this study were (1) residence in Shunyi District, Beijing, and (2) age over 50 years. Exclusion criteria: (1) people with rheumatoid arthritis, (2) physically disability, (3) mental retardation, (4) people with advanced malignant tumors or bedridden people, and (5) people recently living or working outside for more than 6 months. And the rejection criteria: (1) people who did not meet the inclusion criteria, (2) people who met the exclusion criteria, (3) people who failed to complete the main records, and (4) people who showed obvious incompatibility in the survey.At the time of each visit, subjects completed a home interview questionnaire and received a clinical examination including height, weight, range of motion, chair stand test, 50-foot walk test, and weight-bearing posterior-anterior semi-flexed view of radiographs at tibiofemoral joints.Radiographic osteoarthritis (ROA) was assessed using the Kellgren and Lawrence (KL) criteria ; 3 = moderate osteophytes and/or definite JSN; and 4 = large osteophytes, severe JSN, and/or bony sclerosis) . Radiogrn = 100), 10 films from the Osteoarthritis Initiatives study were added to test inter-reader reliability. In addition, 10 previously read knee radiographs from the Shunyi OA Study were fed back to the reader to test intra-reader reliability. Weighted kappa statistics for inter-reader and intra-reader reliability were 0.82 and 0.95 respectively.Radiographs were read twice by two readers trained at Boston University, and films from Osteoarthritis Initiatives were used as gold standard as well as training material . For eacDemographic information, such as age, sex, education level, history of knee injury smoking, alcohol consumption, manual occupation, marriage, was collected at baseline using a standard questionnaire. Height was measured twice for each subject, using a wall-mounted stadiometer. Weight was assessed using a balance beam scale with a precision to 0.1 kg. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. A subject with BMI ≤ 25, 25 < BMI ≤ 30, BMI > 30 was defined as normal, overweight and obesity, respectively. History of knee injury was identified by asking subjects “Have you ever suffered an injury in your knees causing a limitation of walking ability for at least one week?” The injured knee side and date of injury were recorded. Range of motion (ROM) and the degree of flexion contracture of the knee joints were assessed by goniometric measurements. A chair stand test was carried out using a 43-cm high, straight back armless chair. A full sit-to-stand and consecutive stand-to-sit cycle was counted as one chair stand, and the total time for 5 cycles was calculated by a well-trained examiner . A 50-foT test and chi-squared test. Generalized linear model (GLM) was performed to examine the association between factors  and incidence ROA in patient level. ROM, flexion contracture, knee pain, and KL grade at baseline were examined by generalized estimating equation (GEE) in knee level. A two-sided P value 0.05 was considered statistically significant.All data was analyzed by IBM® SPSS® Statistics (Version 24.0) software and was presented as means ± standard deviation (SD). Difference between follow-up group and non-follow-up group was assessed by independent samples A total of 1295 residents were recruited at the baseline in 2014, and 967 (74.7%) were followed in 2017. Four hundred ninety-one residents suffered from one or both knee ROA at the baseline visit diagnosed by knee X-ray were excluded from the further incidence analysis. Of the remaining 803 residents, 598 residents received follow-up examination  with poor walk ability tended to lose in the follow-up compared with the subjects who were successfully followed up.Incidence was calculated in both knee level and patient level. Five hundred ninety-eight subjects with 1196 knees without radiographic osteoarthritis at baseline were taken into analysis. After 3 years follow-up, 102 subjects with 128 knees developed radiographic osteoarthritis according to the X-ray result. The incidence of ROA was 10.7%  during 3 years  in knee level and 17.1%  during 3 years  in patient level. According to the statistical year book of Beijing Shunyi 2017, male villagers constituted 61.87% of the population in Zhaoquanying Town, for which the sex-standardized ROA incidence was 10.1%  in knee level and 15.9%  in patient level. The number of the population and incidence of ROA by sex and age are shown in Fig. Table To our knowledge, the current study is one of the first population-based, longitudinal, and prospective cohort studies demonstrating epidemiological characteristics and risk factors for knee OA in an elderly population in China. A total of 1295 residents were recruited at baseline in the year of 2014, and 962 (74.3%) residents were followed in the year of 2017. We found that the incidence of ROA annually was 3.6% in knee level and 5.7% in patient level. Advanced age, overweight, less range of motion at baseline, and KL grade 1 at baseline were relevant risk factors for incident ROA.The incidence reported in previous studies varied across countries and racial groups. It was reported that the incidence of knee OA was higher among Asian residents than among white population , 16, 17.The higher progression rate of radiographic knee OA in our study might be due to the following reasons. First, our study had a higher follow-up rate (74.5%) compared to previous studies  in Korea 63.9%). It is generally believed that lower percentage of defaulters can bring less bias to the estimation of the incidence. Patients with severe osteoarthritis, with less walking ability, were much easier to be absent, which decreased the rate of the incidence. Second, the incidence of knee OA may have regional difference. Marita et al. found that the prevalence of knee OA was highest in the Asia Pacific developed region, followed by Oceania and North Africa/Middle East, and that was lowest in South and Southeast Asia. Most data of knee OA coming from developed countries, it was thought that there may be a high incidence in undeveloped and developing countries . Third, Our study also found that advanced age, female, overweight, less range of motion, and KL grade 1 at baseline were significantly associated with incident ROA.Advanced age, female, and higher BMI have long been viewed as main risk factors of ROA , 21. RecLess ROM is also a significant risk factor for incident knee osteoarthritis. Akinobu Nishimura firstly reported the relationship between ROM and ROA . They foSome investigators claimed that subjects with KL grade 1 at baseline should be treated differently because those doubtful osteophytes highly predict OA in the near future , 24. In Knee joint osteoarthritis is often accompanied by flexion contracture (FC). Our study found that flexion contracture tended to be statistically significant in both univariate and multivariate analysis, which showed that flexion contracture might be a risk factor for knee osteoarthritis incidence. Using the OAI data, Campbell found that knee FC was a risk factor for radiographic OA incidence, joint space narrowing, worse clinical outcomes, radiographic progression, and the need for early TKA . BiomechFrailty and low limb physical function has been proved to be associated with prevalent ROA . Chair sA study conducted in symptomatic population showed that a 3-year-cumulative incidence of ROA with pain was 21.7%, which was pretty higher compared with the study mentioned above conducted in normal population, proving the relationship of pain and ROA . BaselinInjury in young age has been proved to be a risk factor related to osteoarthritis except for non-specific injury , 32. In With regard to low education level, it is widespread accepted to be associated with prevalence and progression of osteoarthritis , 34. AccOur study had strengths and limitations. First, to our knowledge, our study was one of the first prospective study to investigate the incidence of knee ROA in China. We found that the incidence in Beijing suburban area was higher than those in other published regions. Second, we identified risk factors in demographic information, physical examination, physical function test, and imaging, which may offer more evidence-based policy-making for prevention and treatment of ROA. We found that advanced age, overweight, less range of motion, and KL grade 1 at baseline were relevant risk factors for incident ROA. However, despite its prospective design, 3 years is a rather short time to evaluate the progression of OA. Our study contains a relatively small sample size and a high percentage of female samples, which may cause difficulties in risk factors analysis and overestimate the incidence rate of OA. Some subjects with poor walk ability were more likely to be lost in the follow-up, which may bring bias for evaluation for both rate and factors. All the subjects came from Zhaoquanying, a small town in the suburban area around Beijing, may reduce the representativeness of the sample.The incidence of knee ROA in Chinese suburban area was high. Advanced age, female, overweight, less range of motion, and KL grade 1 at baseline were associated with an increased risk of incident ROA.


In conclusion, according to our preliminary study, low-pressure laparoscopy represents a valid alternative to standard laparoscopy and could facilitate the development of outpatient surgery.The aim of our study was to evaluate the benefits of a low-pressure insufflation system  vs. a standard insufflation system in terms of anesthesiologists’ parameters and postoperative pain in patients undergoing laparoscopic surgery for early-stage endometrial cancer. This retrospective study involved five tertiary centers and included 152 patients with apparent early-stage disease who underwent laparoscopic surgical staging with either the low-pressure AirSeal system  or standard laparoscopic insufflation . All the intraoperative anesthesia variables evaluated  were significantly lower in the AirSeal group. We recorded a statistically significant difference between the two groups in the median NRS scores for global pain recorded at 4, 8, and 24 h, and for overall shoulder pain after surgery. Significantly more women in the AirSeal group were also discharged on day one compared to the standard group. All such results were confirmed when analyzing the subgroup of women with a BMI >30 kg/m This system provides a more stable pneumoperitoneum by responding to the slightest changes in IAP and is associated with a reduced rate of CO2 use, absorption, and elimination [Over the last two decades, laparoscopy has become the favorite approach for the surgical treatment of apparent early-stage endometrial cancer worldwide ,2,3,4. Mmination ,11. Furtmination ,13,14. Tmination ,16. HoweThis was a multicenter, two-arm, retrospective pilot study conducted at the Michele e Pietro Ferrero Hospital, Verduno ; San Gerardo Hospital, University of Milano-Bicocca, Monza ; Ospedale Santa Croce e Carle, Cuneo ; Division of Obstetrics and Gynecology, University Hospital of Udine; and at the Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome . The ethics committee of the principal investigator has declared that it was not necessary to obtain informed consent from patients for this retrospective study specifically, since all patients had given informed consent before surgery.One hundred and fifty-two women with apparent early-stage endometrial cancer who had undergone laparoscopic surgical staging with the AirSeal System between January 2019 and December 2021 were retrospectively included in this study and were compared to a subgroup of women operated with the standard insufflation system.The primary objective was to compare and evaluate the impact of the low-insufflation system in terms of anesthesiology parameters and postoperative shoulder pain at 4, 8 and 24 h after surgery. Intra-operatively, the following were evaluated: systolic blood pressure, end-tidal CO2, peak airway pressure, volume of CO2 used, duration of surgery, and blood loss. Pain was evaluated with the Numeric Rating Scale (NRS) with a range between 0 and 10.2. Considering the retrospective nature of the study, which did not involve any direct patient contact or diagnostic or therapeutic intervention, a waiver of informed consent and a waiver of authorization were requested. All patient information was guaranteed to be confidential. The study was conducted according to the guidelines of the Declaration of Helsinki.Secondarily, we investigated the impact of low-pressure insufflation in the subgroup of women with a BMI > 30 mg/mAfter the induction of standard general anesthesia, the induction of pneumoperitoneum was achieved by using either the Veres needle technique or the open technique at the standard flow of 12 mmHg. After primary port placement, the intra-abdominal pressure was decreased to 8–10 mmHg in the AirSeal system group, while it was maintained at 12–14 mmHg in the standard insufflation group.The AirSeal insufflation system, once activated, works with three essential components, the iFS AirSeal control, the Tri-Lumen Filtered Tube Set, and the Access Port, which together allow the creation of a stable pneumoperitoneum and of continuous smoke evacuation. The access port is available in two sizes: 5 or 10 mm. The 5 mm port was usually placed on the right side of the iliac quadrant, whereas the 10 mm port was placed on the camera site, i.e., on the umbilicus scar. In order to prevent smoke evacuation from impairing visualization, the 5 mm trocar was placed away from the camera. Two more accessory 5 mm diameter trocars that do not require fascial closure were placed, as shown in The general anesthesia induction protocol included Propofol as a hypnotic, Fentanyl or Remifentanyl as an analgesic, and Rocuronium as a muscle relaxant, followed by intubation, and maintenance with Desflurane or Sevoflurane and Remifentanil. Nausea and vomiting prevention were obtained with Dexamethasone administered at 4 or 8 milligrams intravenously.In the absence of contraindications, postoperative pain was controlled with the intravenous administration of Paracetamol at 1 g and Ketoprofene at 160 milligrams (Artrosilene) 3 times daily. In the presence of a Numeric Rating Scale of pain (NRS) higher than 4, Ketoprofene 160 mg was given intravenously and, eventually, subcutaneous morphine 10 mg was given if NRS was still higher than 4 after administration of Ketoprofene.p-values with p < 0.05 were considered statistically significant. We performed a multivariate analysis to adjust for potential confounding factors. We used logistic regression to perform the analysis because of the binary endpoint. Stata software 9.0  was used for performing the statistical analysis.Descriptive statistics are presented as frequencies and proportions for categorical variables and mean/median with a standard deviation/interquartile range for continuous variables. These descriptive characteristics are reported in tables so that readers can inspect the distribution of these variables in the two study groups (ultrastaging protocol A vs. B) and for the lymph node status (positive node disease vs. negative node disease). Continuous variables were compared using Wilcoxon rank-sum tests. Proportions were compared using Chi-Square tests or Fisher’s exact tests. All 2-sided One hundred and fifty-two patients were included in this retrospective study. A total of 84 patients (55.3%) underwent laparoscopic surgery with the AirSeal system at 8–10 mmHg, whereas 68 (44.7%) were treated with conventional laparoscopic surgery and the standard insufflation system. The baseline characteristics of the study population are shown in 2 (range 23.7–36.4) and 27.9 kg/m2 (range 22.6–33.2) for the AirSeal and the standard group, respectively. No differences in terms of the presence of previous surgery, smoking habits, pulmonary disease and ASA score were observed between the groups. Surgical outcomes such as duration of surgery, blood loss, and number of lymph nodes removed were similar between the two groups.Surgical procedures, including simple hysterectomy, bilateral salpingo-oophorectomy and sentinel node biopsy, were performed with a traditional laparoscopic tower. The median age of patients was 63 years (IQR 52–73) for the AirSeal group, and 65 years (IQR 54–75) for the standard group. The median BMI was 30.0 kg/mp = 0.224). However, patients in the AirSeal group recovered significantly faster compared to the standard group. In the AirSeal group, 98% (80/81) of women were discharged within 2 days, compared to 75% (51/68) of patients in the standard group (p < 0.0001). The complication rate did not differ between the two groups.Median length of hospital stay was 2 days in both groups (p < 0.0001). In the subgroup of 67 women with a BMI greater than 30 mg/m2, the differences were maintained  were significantly lower in the AirSeal group . Furtherintained .p = 0.023). This difference was maintained at 8 and 24 h after surgery, when the median reported global pain was 0.8 (IQR range 0–1.6) and 0.2 (IQR range 0–0.8), respectively, for the AirSeal arm compared to 1.4 (IQR range 0.7–2.1) and 1.1 (IQR range 0.2–2.0) for the control arm (p < 0.0001). The administration of morphine was statistically different across the two groups, with 4.8% and 27.9% in the AirSeal and the standard group, respectively (p < 0.0001). The analysis of women with a BMI greater than 30 mg/m2 showed that the differences between the Airseal and standard groups were maintained  for endometrial cancer patients have been widely demonstrated in the last decade ,18. Womep = 0.0001).Pneumoperitoneum with CO2 increases the risks of respiratory, cardiovascular and metabolic complications, mainly caused by the increase in the intra-abdominal pressure that triggers the increase in median systolic pressure. In obese women, this phenomenon is accentuated and with the activation of the kidney-angiotensin renin system, a further increase in blood pressure can occur. Furthermore, elevation of the intra-abdominal pressure with pneumoperitoneum causes an upward elevation of the diaphragm, resulting in increased intra-thoracic pressure, thus decreasing pulmonary compliance and augmenting peak airway pressure, which results in an increased risk of barotrauma. In this study, the use of low-pressure insufflation with the AirSeal system allowed for a significant limitation of the increase in et-CO2, peak airway pressure and maximum systolic blood pressure during surgery. The overall consumption of CO2 was also reduced with AirSeal  compared with traditional insufflation . Moreover, as already shown by Sroussi et al., the pain control was lower overall in the AirSeal group compared to the standard insufflation group, in both the general population and the obese subgroup , which dp = 0.0001). Even if outpatient surgery is not widespread in Italy, the development and increased adoption of low-pressure laparoscopy associated with 3 mm trocars [In our opinion, our results should further encourage the adoption of this technology in patients with a higher risk of complications such as obesity and older age with malignancies, as demonstrated by the LAP2 study, where laparoscopy did not increase with age and analysis showed that a higher percentage of patients had undergone the open approach [ trocars , togethe trocars , may furOur results have some drawbacks, including the retrospective design and the relatively small sample size, and should be interpreted with caution. However, the differences highlighted between groups are significant and further multicentric studies should evaluate and further confirm our preliminary results in the oncologic population.In conclusion, the use of low-pressure laparoscopy should be encouraged mainly in the subgroup of obese women with endometrial cancer, as well as to promote the development of outpatient surgery. Low-pressure laparoscopy with the valveless platform in our experience represents a valid and innovative alternative to the standard insufflation system during minimally invasive surgery in gynecologic oncology.


Cryptococcus neoformans/C. gattii species complex (CNGSC) are etiological agents of serious and not infrequently fatal infections in both humans and animals. Trees are the main ecological niche and source of potential exposition concerning these pathogens. With regard to epidemiology of cryptococcosis, various surveys were performed worldwide, enabling the establishment of a map of distribution and genetic structure of the arboreal population of the CNGSC. However, there are regions, among them Central and Eastern Europe, in which the data are lacking. The present study shows the results of such an environmental study performed in Wrocław, Poland. The CNGSC strains were detected in 2.2% of the tested trees belonging to four genera. The obtained pathogen population consisted exclusively of C. neoformans, represented by both the major molecular type VNI and VNIV. Within the tested group of isolates, resistance to commonly used antimycotics was not found, except for 5-fluorocytosine, in which about 5% of the strains were classified as a non-wild type.Fungi belonging to the  Cryptococcus. Though several species of the genus were found responsible for the disease occurrence [Cryptococcus neoformans/Cryptococcus gattii species complex (CNGSC) were the etiological agents of the majority of cases. The worldwide impact of cryptococcosis in the human population only is assumed to be more than 220,000 infections and up to 180,000 deaths annually [C. neoformans is usually observed in persons with impaired immune status, while C. gattii is thought to be able to cause infection in immunocompetent individuals; yet, there are reports suggesting genetically mediated differences both in host and pathogen may affect this typical epidemiological pattern [Cryptococcosis is a serious, not infrequently fatal infection of humans and animals caused by fungi belonging to the genus currence , those b pattern . Cryptococcus neoformans var. grubii, serotype A); VNIV ; and VNIII  as well as VGI, VGII, VGIII, VGIV, and VGV . The nomenclature concerning the CNGSC has been changing during the previous and ongoing century. These pathogens can be described by their species, major molecular type, or serotype. With respect to the species, presently, the two-species or seven-species schemes relating to the complex are of use, as the discussion concerning classification of the fungi did not reach a consensus among the scientific community ,4. Accor(MAT) represented by two different mating types (MATa and MATα). Both bisexual and unisexual mating was observed within the CNGSC [The discussed fungi are in possession of a bipolar mating system consisting of a single mating-type locus he CNGSC ,8.C. neoformans seems to be global, while C. gattii was regarded as associated rather with tropical and subtropical zones [With respect to the geographical distribution of pathogens belonging to the described complex, al zones . For aboal zones ,11. Cryptococcus was indicated among the top potential agents causing fungal co-infections in COVID-19 patients. Despite the seriousness of cryptococcosis, the data concerning the occurrence of the agent and its population structure in Poland were not very well documented to date. In our previous study, the population of non-clinical strains of animal origin isolated in Poland was analysed [It is assumed that infection with fungi of the CNGSC is a result of inhalation of spores or dehydrated yeast cells and is acquired from environmental sources, such as plant materials, soil, or bird excreta ,13. Arboanalysed . With thp = 0.227). The fungal strains were also cultivated from one of the tested soil samples, which was collected around one of the positive trees. The detailed information concerning the results of isolation of CNGSC are given in There were 13 (2.16%) positive outcomes for the presence of the CNGSC strains out of 602 tested samples. With reference to arboreal material, the fungi were detected within specimens collected from 12 trees, among them 9 oaks, as well as one specimen each from birch, pine, and Douglas fir. Statistically significant differences considering the isolation frequency were not detected with regard to tree species  represented the MMT VNIV, while the rest  belonged to the MMT VNI. One of the MMT VNIV strains was the bearer of a point mutation giving it an atypical URA5-RFLP banding profile [All the 19 obtained strains were identified as  profile . NeitherURA5-RFLP, sero-, and mating type and MALDI-TOF MS analyses are given in the Applying the MALDI-TOF MS method, all the tested strains achieved scores above 1.7 , which enabled reliable recognition. With respect to the manufacturers’ base alone, scores of eight isolates made it possible to recognise a possible genus, and another 10 strains were recognised on the level of secure genus and probable species. Only one isolate exceeded the score of 2.3 and was identified as a highly probable species. The mean score secured within the tested group was 2.051, with this value slightly higher among strains belonging to the MMT VNI (2.154) when compared to the MMT VNIV (1.976). Using the best-match strains’ MMTs for comparison, all the tested strains were assigned to MMTs that remained in accordance with results of the other used methods. With the supplemented version of the base, the score values obtained for seven strains (36.8%) increased, resulting in a shift of four of them to the groups with the higher threshold, enabling more secure identification. The mean score obtained for the whole tested group of strains using the updated tool was 2.120, whereas the value concerning the MMT VNI remained almost the same (2.157), and for the MMT VNIV (2.093), it increased enough to exceed the threshold value of the more secure recognition group (2.0–2.3). Considering identification of the MMTs, however, two among the tested strains (10.5%) were misrecognised, as their best-match strains’ MMTs were MMT VNIII instead of the MMT VNIV. The details concerning results of The result of drug-susceptibility tests of the investigated environmental CNGSC isolates are presented in All the tested isolates were classified as susceptible to amphotericin B (AMB) with a MIC ≤ 1 mg/L . The medThe MIC values established for triazole derivatives ranged from 0.5 to 32 mg/L for fluconazole (FLU), from 0.03 to 0.25 mg/L for voriconazole (VOR), from 0.015 to 0.25 mg/L for isavuconazole (ISV), from 0.03 to 0.5 mg/L for itraconazole (ITR), and from 0.015 to 0.5 mg/L for posaconazole (POS). The MIC50 for FLU, VOR, ISV, ITR, and POS was 4.0, 0.06, 0.06, 0.125, and 0.125, respectively, whereas MIC90 amounted to 32, 0.25, 0.125, 0.25, and 0.25, respectively. According to adopted ECVs for triazoles, all but one isolate were classified as belonging to the WT population. The only exception was strain FW2 (3168), which showed an ISV MIC of 0.25 mg/L, which is one dilution above the adopted ECV (0.125 mg/L). Regarding statistically significant differences concerning the resistance to specific antimycotics, when compared, the MMT VNI and the MMT VNIV were not detected.Though pathogenesis of the cryptococcal infections has been extensively examined over the last decades, knowledge considering the environmental origin of the agent remains less well established. In the review presented by Cogliati , among aC. neoformans has been detected in 35.3% of the tested sandpits and 19% of soil samples obtained from children’s recreational areas in Łódź, a city located in the central of Poland [Quercus, Betula, Pinus, and Pseudotsuga; yet, none of these were associated with a significantly higher frequency of isolation of the fungi. The prevalence of the CNGSC in the arboreal sources in Europe varied substantially. In the ISHAM’s project [C. neoformans has been isolated from trees belonging to the following genera: Eucaliptus, Olea, Pinus, Creatonia, Pyrus, Prunus, Platanus, Aesculus, Carpinus, Juglans, Juniperus, Gleditsia, and Quercus, representing both Mediterranean and temperate climate regions [C. gattii, the fungus has been obtained from trees of the following genera: Eucaliptus, Olea, Creatonia, Pinus, Pseudotuga [C. gattii prefers trees with waxier cuticles [C. gattii was statistically higher pertaining to the genus Creatonia. C. neoformans var. grubii has been isolated statistically more often from the Creatonia and Olea, while C. neoformans var. neoformans as well as the hybrid of these two have been obtained mainly from the genus Platanus. None of the 36 tested trees of the genus Platanus swabbed in our study were positive with regard to presence of the CNGSC.In Poland, only a handful of examinations with reference to the environmental prevalence of the pathogenic complex were carried out. f Poland ,41. The f Poland ,43. In t project , surveyi project  with reg project  again in project , or the  project . A ratio project . In Port project . However project   to 100% of the populations analysed in various studies [Cryptococcus gattii is the species that has been reported as occurring in different genera of trees of southern Europe [C. gattii was represented by the MMT VGI and the MMT VGIV [In the present study, 57.9% of the isolated fungi represented the MMT VNIV, while the rest (42.1%) belonged to the MMT VNI. Other molecular types, among them those assigned to the species  studies ,36,38,44 studies ,36,38,44 studies ,37. The  studies  among th studies . While a studies , and it  studies ,38, to t studies . Anothern Europe ,17,36. In Europe . With reMMT VGIV ,13,17,36MATα locus is regarded as the most prevalent both among clinical and environmental strains [MATa is rather rare, and it is more commonly observed within the MMT VNIV strains [MATa was detected in one of 40 strains of the serotype A, whereas in the survey presented by ISHAM [MATa was found in aD or aADa isolates [C. gattii isolated in Europe, researchers observed sero- and mating types αB, aB, and αC [With respect to mating type, within the population of the CNGSC, the  strains , whereas strains . All the strains ,37. On t strains , the locby ISHAM , the locisolates . Among t, and αC ,13,17,36Cryptococcus isolates was rather low (1–2.5%) [C. neoformans var. grubii presented significantly reduced susceptibility compared to clinical strains of the same variety. Although the primary resistant strains identified in our studies were rare (5–10%), the phenomenon is of particular concern, as 5-FC is a drug recommended for treatment of cryptococcal meningitis. Due to the severity of this type of infection and the possibility of a fatal outcome, the therapy is usually introduced in an empirical or preemptive manner before obtaining the final results of microbiological examination and susceptibility tests. Therefore, knowledge with regard to the prevalence of resistant strains within the local environment may enhance the selection of the most potent therapy. The population of the yeasts investigated in the present study showed a low rate of resistance to the tested antimycotics. According to the criteria adopted, all the CNGSC isolates were classified as susceptible to AMB or belonging to WT-population in regard to the susceptibility to FLU, ITR, POS, and VOR. Similar results were presented in our previous study  in which(1–2.5%) ,56,57,58(1–2.5%) . Interes(1–2.5%) , while pThe significant impact of factors, which may be present in the natural habitat of the CNGSC, including nutrient limitation (among them nitrogen limitation), temperature, ultraviolet radiation, enzymatic degradation on the susceptibility of the CNGSC to FLU, and AMB, has been described ,61,62,63It is possible that, for the sake of the small isolate number obtained in the present study, it was impossible to detect statistically significant differences in the MIC distributions of any of the tested drugs with regard to MMTs of the tested strains. On the contrary, our previous work results proved that the average observed MIC value of amphotericin B was significantly lower and of fluconazole was significantly higher for the MMT VNIV compared to the MMT VNI among strains isolated from animals in Poland . Similar2. Since the ranges of particular species within the complex differ slightly, the authors suggest that the number of people potentially exposed to infection on this continent may reach about 360, 266 and 137 million with reference to C. neoformans var. grubii, C. neoformans var. neoformans, and C. gattii, respectively. Yet, in order to calculate the risk, environmental surveys must firstly be performed. Unfortunately, the data covering Central, Eastern, and Northern parts of Europe, to the best of our knowledge, remain unavailable. With respect to regions characterised by continental climate, to date, the only available studies were performed in Russia (Saint Petersburg), Germany, and the continental part of Croatia, where analysis of arboreal specimens gave negative isolation results [Due to the effort of several groups of researchers documenting the presence of arboreal CNGSC strains within various European regions, it was possible to predict the niche of the particular species within the complex and assess potential areas of exposure ,46. Acco results . TherefoThere is still need for ongoing surveillance concerning environmental presence of the CNGSC and not only with regard to those regions that were not examined to date . With phThe arboreal specimen as well as the soil samples were collected between June 2014 and April 2019 in parks situated on the territory of Wrocław  as well as in forests located within the radius of 60 km from the city . The territory is classified Dfb , according to Köppen–Geiger classification. The material was obtained by the swabbing of tree hollows or by collecting samples of woody detritus/soil. Usually, one sample was collected from one tree  or from the soil of the tree surroundings. A total of 592 samples of arboreal specimen and 10 soil samples were obtained. With respect to the arboreal sources, most of the tested samples  were collected from oaks, while other genera of the trees were represented by 1 to 66 specimens. The detailed information concerning sources of specimen used in the present study is given in All the samples were vortexed with 20 mL of a sterile saline solution for 5 min and then left in order to let the suspension settle. The obtained supernatants were diluted 1:10. Two sets of plates containing Niger seed agar (NSA) were inoculated with (100 µL) the supernatant or its dilution. Then, the plates were incubated at 30 °C for up to 14 days although positive samples could usually be detected at 48–96 h. All colonies showing the brown colour effect obtained from each sample were sub-cultured as single-colony isolates on NSA in order to purify cultures and then assessed using India Ink staining. Strains positive in morphological evaluation and able to produce melanin on NSA were classified as the CNGSC. A selection of colonies cultured from the same sample for further tests was performed by means of analysis of the colony morphology and melanisation pattern. Statistical analyses of isolation frequency with regard to certain tree species were performed using Fisher’s exact test and PQStat v.1.8.2.208 (PQStat Software 2021) software. In each analysis, a significance level of 5% was adopted.For the DNA isolation, the obtained CNGSC strains were cultured on Sabouraud dextrose agar (SDA) for 48 h at 30 °C. Extraction of the DNA was obtained using a MasterPure Yeast DNA Purification Kit , in accordance with the manufacturer’s instructions. All PCRs presented in this study were carried out in an MJ Mini Personal Thermal Cycler  utilising 25-µL reaction volume , 20 pM of each primer, and 11.1 µL of water). For each reaction, both positive and negative (sterile water) controls were used.C. gattii and C. neoformans var. grubii (MMT VNI) was executed by applying two separate sets of primers presented in the MLST consensus scheme [C. neoformans var. neoformans (MMT VNIV), an alternative reverse primer for the SOD1 gene described by Sanchini et al. [Recognition of species and/or variety was performed by sequencing of the SOD1 gene . Amplifis scheme . For C. i et al.  was emplSTE20 gene) described by Li et al. [Sero- and mating types of the tested strains were established using the PCR-based method  was conducted according to Meyer et al. [Cfr13I (Sau96I) and HhaI enzymes  for 16 h and then separated in 3% agarose gel (100 V for 3 h). RFLP patterns of the tested strains were analysed visually by comparison with banding characteristic for standard strains representing major molecular types . Restriction fragment-length polymorphism analysis of the orotidine monophosphate pyrophosphorylase gene  analysis was performed on ultrafleXtremer spectrometer , as described in our previous study . BiotypeThe susceptibility of CNGSC isolates to amphotericin B (AMB), 5-fluorocytosine (5-FC), fluconazole (FLU), isavuconazole (ISV), itraconazole (ITR), posaconazole (POS), and voriconazole (VOR) was tested using the microdilution method, according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) Definitive Document E.DEF 7.3.1. . All appThe clinical breakpoints as well as epidemiological cut-off values (ECVs) applied in the present study were consistent with our previous work  and amouIn order to compare the distribution of MICs between particular MMTs, the Mann–Whitney U test was applied using PAST for Mac OS X v.4.0 (Øyvind Hammer 1999–2021) software. In each analysis, a significance level of 5% was adopted.