Immune checkpoint inhibitors (ICIs) targeting programmed cell death protein 1 (PD-1) have been widely used in treating different malignancies. Several studies have reported that the gut microbiota modulates the response and adverse events (AEs) to ICIs in melanoma, non–small cell lung cancer (NSCLC), renal cell cancer and hepatocellular carcinoma, but data on other cancer types and ICI combination therapy are limited.Stool samples were collected from patients with cancer who received anti–PD-1 and chemotherapy combination treatment and were analyzed by fecal metagenomic sequencing. The microbiota diversity and composition were compared between the responder (R) and non-responder (NR) groups and the AE vs. the non-AE (NAE) groups. In addition, associated functional genes and metabolic pathways were identified.Parabacteroides, Clostridia bacterium UC5.1_2F7, and Bifidobacterium dentium were enriched in the R group, whereas Bacteroides dorei and 11 species of Nocardia were enriched in the NR group. At 6 weeks, the beta diversity was significantly different between the R and NR groups. Further analysis found that 35 genera, such as Alipes, Parabacteroides, Phascolarctobacterium, Collinsella, Ruminiclostridium, Porphyromonas, and Butyricimonas and several genera of the Fibrobacteraceae family, were frequently distributed in the R group, whereas 17 genera, including Enterococcus, Lachnoclostridium, Hungatella, and Bilophila and several genera of the Pseudonocardiaceae and Beijerinckiaceae families, were more abundant in the NR group. A total of 66 and 52 Kyoto Encyclopedia of Genes and Genomes (KEGG) orthologs (KOs) were significantly enriched in the R and NR groups, respectively. In addition, pathway analysis revealed functional differences in the gut microbacteria in the R group, including the enrichment of anabolic pathways and DNA damage repair (DDR) pathways. Dynamic comparisons of the bacterial composition at baseline, 6 weeks, and 12 weeks showed that the abundance of Weissella significantly increased in the R group at 6 weeks and the abundance of Fusobacterium and Anaerotruncus significantly increased in the NR group at 12 weeks. Linear discriminant analysis effect size analysis indicated that bacteria of Bacteroidetes, especially Bacteroides, were enriched in the NAE group, whereas flora of Firmcutes, such as Faecalibacterium prausnitzii, Bacteroides fragilis, and Ruminococcus lactaris, were enriched in the AE group.At baseline, the microbiota diversity of the groups was similar, but the genera Beta diversity and differences in the gut microbiota modulated AEs and the response to anti–PD-1 blockade combined with chemotherapy, by regulating related anabolic and DDR pathways. Dynamic changes in the intestinal microbiome may predict the efficacy of PD-1 inhibitor–based therapy. In recent years, immune checkpoint inhibitors (ICIs), which target the cytotoxic T lymphocyte antigen-4 (CTLA-4) or programmed cell death protein 1 (PD-1)/PD-1 ligand (PD-L1) pathway, have been shown to be effective in the treatment of different malignancies –7, were B. thetaiotaomicron and B. fragilis were associated with the response to CTLA-4 blockade –dependent manner , 6 weeks, and 12 weeks were collected and immediately stored at −80°C until DNA extraction was performed, whereas the stool samples from three patients with AEs were collected only at baseline. The gut microbiota was analyzed by metagenomic sequencing. Clinicopathological data and treatment information were independently collected and recorded by two physicians, and all patients were classified as responders  and non-responders  based on radiological evaluation by two radiologists according to the Response Evaluation Criteria in Solid Tumors, version 1.1 (RECIST 1.1). Patients were classified as the AE group and the non-AE (NAE) group according to the National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0 (CTCAE 4.0). This study was approved by the Institutional Ethics Committee of Chinese PLA General Hospital, Beijing, China .The gut bacterial composition was evaluated by fecal metagenomic sequencing. Briefly, bacterial genomic DNA was extracted using the QIAamp DNA Stool Mini Kit . After the integrity and concentration of DNA was determined, individual libraries were constructed with the NEBNext Ultra DNA Library Prep Kit for Illumina , loaded onto the BGISEQ-500 RS platform , and then were sequenced according to a 2 × 100-bp paired-end read protocol. Quality filtering, trimming, and demultiplexing were performed as described previously . A totalhttps://anaconda.org/bioconda/soapaligner) with default parameters to remove human reads. The retained clean reads were aligned to ~1 M clade-specific marker genes from approximately 17,000 reference genomes to estimate relative phylotype abundance using MetaPhlAn (version 2.5.0). For gene annotation, the clean reads were aligned to the integrated gene catalog (IGC) by using SOAPalign 2.21 with the default parameters; only the reads with both ends mapped to the same gene were used in the subsequent analysis. An average IGC mapping rate of 53% was achieved. Functional annotations were carried out via BLASTP searches against the Kyoto Encyclopedia of Genes and Genomes (KEGG) database . The KEGG ortholog (KO) abundance was estimated by accumulating the relative abundance of all genes belonging to this feature. All of the above procedures were carried out as previously described  genome assembly hg38 using SOAPalign 2.21 . Two-sided P-values were evaluated, and P < 0.05 was considered statistically significant. The Shannon and Simpson indices were used to calculate alpha diversity, and principal coordinates analysis (PCoA) and the analysis of similarities (ANOSIM) test with the Bray–Curtis distance were used to evaluate beta diversity. A non-parametric Wilcoxon rank sum test was applied to analyze the statistical significance of diversity indices, taxa, and KOs between the R and NR groups. The linear discriminant analysis (LDA) effect size (LEfSe) algorithm was further used to identify the phylotypes that had a significantly different abundance in different groups; phylotypes with an LDA score cutoff of 2.0 and P < 0.05 in built-in rank sum test were regarded as statistically significant. A ternary plot in the R language (ggtern package) was used to compare differences among three groups. Spearman sequential correlation analysis was used to estimate the correlation between two variables , and only significant correlations with P < 0.01 and rho > 0.5 are shown. The network was visualized with Cytoscape 3.0.2.Clinical characteristics and demographic data were summarized In total, 27 patients with cancer  were enrolled in our study, including 12 patients with non–small cell lung cancer (NSCLC), nine patients with digestive system cancers, and one patient each with ovarian, bladder, and prostate cancer, separately. We collected patients’ demographics and clinicopathological data, including baseline antibiotic use (within 1 month), metastasis, number of treatment regimens received, PD-L1 expression, tumor mutation burden, lymphocyte number, and Lactate dehydrogenase (LDH). We placed these patients in the R or NR group, and the clinical characteristics were balanced between these groups Table 1.Firmicutes and Gram-negative Bacteroidetes dominated the fecal microbiota of both the R and NR groups at the phylum level, which was in accordance with the previous findings in healthy human –producing species were included in the R group, and Hungatella hathewayi, several species of the genus Enterococcus genus, Erysipelotrichaceae bacterium I46, Bilophila wadsworthia, and Lactobacillus phage A2 were included in the NR group , Weissella cibaria (W6), and Enterobacteria phage SfV(W12) . Coabundance genes (CAG) analysis found 65 differential genes at different taxonomic levels . A total of 66 and 52 KOs with significant differences were more enriched in the R and NR groups, respectively  were ≥ grade 2, including five cases of pneumonitis and two patients of immunotherapy-induced colitis. With the exception of one patient with grade 2 pneumonitis, who restarted immunotherapy after pneumonitis was well-controlled, patients with irAEs discontinued immunotherapy.P > 0.05; P = 0.036; Firmicutes and Proteobacteria were more abundant in the AE group, and Bacteroidetes was more abundant in the NAE group (Bacteroides (Firmicutes) were correlated with non-AEs, whereas 13 species of Firmcutes, such as Faecalibacterium prausnitzii, and Bacteroides sp. 2_1_56FAA (Bacteroides fragilis) were enriched in the AE group  showed no significant difference between the AE group and NAE group  in our study, especially Bacteroides at the genus level and Faecalibacterium prausnitzii at the species level. This might be explained by the fact that Bacteroidetes promoted the biosynthesis and metabolism of anti-inflammatory components, including streptomycin metabolism, penicillin and cephalosporin biosynthesis, glycan biosynthesis and metabolism, sphingolipid metabolism, and steroid hormone biosynthesis  can be found below: The studies involving human participants were reviewed and approved by Institutional ethics committee of Chinese PLA General Hospital. The patients/participants provided their written informed consent to participate in this study.ZW and YH conceived and designed the study. ZW and LL collected samples and completed the laboratory experiments. ZW and DH collected the data. ZW, SZ, and ZH analyzed the data. ZW, SZ, and LL drafted the manuscript. The other authors revised the manuscript. All authors have reviewed and approved the manuscript.This study was supported by the Major Research plan of the National Health Commission (No.GWJJ2021100304) and by the Military Health Special Research Project (No.20BJZ37).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.The reviewer GS declared a shared parent affiliation with the author(s) to the handling editor at the time of review.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.


This study aimed to investigate family functioning among spouses of gynecologic cancer patients in Korea. McCubbin and McCubbin’s Family Resilience Model (1993) guided the study focus on burden of care, family resilience, coping, and family functioning.An online survey collected data from 123 spouses of gynecologic cancer patients through convenience sampling from online communities for gynecologic cancer patients in Korea. Burden of care, family resilience , coping, and family functioning were measured by self-report.p<.001), family hardiness , problem-solving communication , and coping . Multiple regression identified significant factors for family functioning , with an overall explanatory power of 61.7%. Problem-solving communication  had the greatest influence on family function of gynecologic cancer families, followed by coping  and total treatment period of the wife .The patients (44.7%) and their spouses (47.2%) were mostly in the 41 to 50-year age group. Stage 1 cancer was 44.7%, and cervical cancer was the most common (37.4%) followed by ovarian cancer (30.9%) and uterine cancer (27.6%) regarding the cancer characteristics of the wife. Family function, burden of care, family resilience, and coping were all at greater than midpoint levels. Family functioning was positively related with social support (r=.44, Nurses need to assess levels of family communication and spousal coping to help improve gynecologic cancer patients’ family function, especially for patients in longer treatment. Among gynecologic cancers in Korea, cervical cancer ranked first with 52.9% per 100,000 people, uterine cancer ranked second with 26.2%, and ovarian cancer ranked third with 20.9% [Women with gynecologic cancer experience symptoms related to reproductive function, such as abdominal discomfort, urination and bowel dysfunction, vaginal dryness, and decreased sexual function . In addiIn gynecologic cancer patients, the family is not only a primary source of physical, mental, and social support but can also be an active participant in their treatment and recovery. In addition, considering the situation in Korea, where families often shoulder a large part of caring for patients, the family of gynecologic cancer patients can face various difficulties: such as imbalance of the family system due to the disease, role changes due to the patient’s condition, and lack of knowledge in patient care . In addiFamily caregivers of cancer patients generally had to shoulder the responsibility to take care of their family despite their physical, mental, social, and spiritual suffering and economic difficulty . Family McCubbin and McCubbin  defined Families of gynecologic cancer patients use coping methods to maintain equilibrium against physical and mental difficulties while caring for the patient, and such coping methods differ from family member to family member . While tOf the studies conducted on gynecologic cancer patients in Korea, many focused on the patients’ health problems and quality of life -22. WhilThe purpose of this study was to understand the impact of burden of care, family resilience, and coping on family function in spouses of women with gynecologic cancer. Specific objectives were as follows:1) To identify family function, spouse burden of care, family resilience, and coping2) To identify family function according to spouses’ characteristics and patients’ disease-related characteristics3) To determine the relationships among family function, burden of care, family resilience, and coping4) To identify the factors that affect family function of spouses of gynecologic cancer patientsEthics statement: This study was approved by the Institutional Review Board of Chungnam National University (202107-SB-174-01). Informed consent was obtained from the participants.https://www.strobe-statement.org/).This study employed a correlational design using a cross-sectional survey, to identify the effects of burden of care, family resilience, and coping on family function in spouses of gynecologic cancer patients. This study adhered to the STROBE  reporting guidelines , at least 118 participants were required. Considering a potential loss of 10% due to incomplete responses, 130 spouses were recruited via convenience sampling and 123 people (94.6%) who submitted complete data to the online survey were analyzed for the study.As a preceding study  reportedAll study instruments were used after contacting the developer of the original tool for their consent.Burden of care was measured by the Caregiver Reaction Assessment Scale developed by Given et al. , using tSocial support, family hardiness, and problem-solving communication were selected as constituting family resilience based on McCubbin and McCubbin’s  resilien• Social support: The Korean version  of the 1• Family hardiness: The Family Hardness Index (FHI) was developed by McCubbin et al. , and its• Problem-solving communication: The Korean version  of the FThe 69-item Ways of Copying (WOC) developed by Lazarus and Folkman  was tranThe Korean Family Functioning Scale , which mBased on the literature, the following were assessed: spouse’s age, education level, occupational status change, monthly income, and number of children. For disease-related characteristics of the gynecologic cancer patient, spouse was asked about wife’s age, cancer type, cancer stage, recurrence, total treatment period, and treatment type were investigated. Also, the following care characteristics were assessed: existence of alternative help, alternative help providers, period and time of caring for the wife, changes in spouse’s life after diagnosis of the cancer, presence of spouse’s health problems, person covering medical costs, and monthly medical expenses.Data collection for this study was conducted from October 20, 2021 to January 30, 2022 from three online communities for gynecologic cancer patients in Korea. After obtaining permission from the administrator of the online community, a recruitment flyer was posted and interested participants could voluntarily contact the research team. After screening for eligibility, potential participants were sent a link to the online questionnaire. The survey took 15 to 20 minutes and to those who chose to share personal contact information, a mobile gift card (worth approximately 4 US dollars) was provided after completing the questionnaire.p<.05, descriptive statistics were done for the spouse’s general characteristics, the patient’s disease-related characteristics, care characteristics, burden of care, family resilience, coping, and level of family function. Differences in family function according to the characteristics of spouse and patient were analyzed by independent t-test and one-way analysis of variance, and the Scheffé test was used for post-analysis. Pearson correlation coefficient was calculated for the relationships among care burden, family resilience, coping, and family function. Finally, hierarchical multiple regression analysis was performed to identify the factors influencing family function.Using IBM SPSS Statistics for Windows, ver. 26.0  with the significance level set at Most patients were in the 41 to 50 years of age category . Cervical cancer was the most common , followed by ovarian cancer  and uterine cancer . Stage I gynecologic cancer was close to half  and 90.2% (n=111) were not recurred cancer. Treatment duration was mainly 6-12 months  or 3-6 months , followed by >13 months . For treatment, most had experienced surgery , as well as chemotherapy  and radiation ; some had received target therapy , and antihormonal therapy  .Similar to the patient, most spouses were in the 41 to 50-year age range . Most were college graduates  and 1/4 had experienced work changes since their wife’s diagnosis of cancer , e.g., being absent from work, leaving early, or resigning. Monthly household income was in the 3 million to 5 million Korean Won (KRW) category  for roughly half , which is comparable to the national household average for 2021 (4.73 million KRW)  and one Roughly 2/3  were able to seek alternative help when caregiving support was needed, of which 57.3% (n=47) were their parents. The number of months of caring for the wife was 1 to 6 months , and 1 to 5 hours was most common . Among the changes in spouse’s life after the diagnosis of gynecologic cancer, lack of leisurely time was most common , followed by having new appreciation for wife and family . Physical/mental burdens and housework/childcare burdens , as well as economic burdens  were also noted. Seventeen spouses (13.8%) had health problems and medical costs were mostly covered by the spouse  although parents or siblings also participated . About half  responded their monthly medical expenses were in the 1 million to 3 million KRW range , and 17 people (13.8%) in the 3 million won to 5 million KRW  range .Family function was 75.83±9.34 points out of 104 points, which was higher than midpoint. The burden of care perceived by the spouse was 74.00±7.72 points out of 120 points, which was higher than midpoint. For family resilience, (1) social support was 57.85±6.89 points out of 85 points, suggesting moderate or higher level; (2) family hardiness was 58.45±6.75 points out of 80, suggesting moderate or higher level; and (3) problem-solving communication was 26.05±2.07 points out of 40, suggesting moderate or higher level. Coping was 64.54±9.37 points out of 96 points suggesting moderate or higher level .p=.047) and coping  differed according to the spouse’s age. Spouses who had experienced work changes had significantly higher care burden , used more coping , and had higher family function scores  compared to spouses with no changes.The burden of care . Also by post-hoc analysis, families with two children showed higher family hardiness than those with one child .For the subcomponents of family resilience, there was a significant difference in social support by monthly income, and in family strength by number of children. Spouses with monthly income of 3 million to 5 million KRW  had better social support than those in the <3 million KRW  range by post-hoc test . Family resilience in social support, family hardiness, and family function also differed by duration of the total treatment period. Post-hoc test of the total treatment period found that the degree of social support was higher in cases of >1 year than those of 3- to 6 months ; the degree of family hardiness was higher in cases of ≥13 months compared to those of 7- to 12 months ; and family function was higher in cases of ≥13 months compared to 7 to -12 months . Also, burden of care, problem-solving communication, and coping were significantly different by monthly medical expenses . Post-hoc test of monthly medical expenses show that burden of care was higher in cases of 1 million to 3 million KRW  ; and women in 1 million to 3 million KRW used more problem-solving communication than those in the < 1 million KRW (<800 US dollars) group .Among the wife’’s disease characteristics, the burden of care differed by gynecologic cancer stage , greater family hardiness , problem-solving communication , and family function  compared to their counterparts. The number of months of caring for wife was also significantly related to burden of care, social support, family strength, and coping. Spouses who cared for their wife for 7- to 12 months had a greater burden of care than those with 1~ to months of caring . Spouses with ≥13 months of caring had more social support than those with 1- to 6 months , higher family hardiness than those with 7- to 12 months , and a higher degree of family coping than those with 1- to 6 months of caring   .p<.001), family hardiness , problem-solving communication , and coping . However, burden of care was not significantly related to family resilience, coping, or family function. Family coping had a positive weak correlation with social support , family hardiness , and problem-solving communication . Among the subcomponents of family resilience, social support had a positive moderate correlation with family strength , problem-solving communication , and family hardiness   .Before multiple regression analysis, suitability of the data was confirmed through the assumption of the regression equation  and residual diagnosis . The Durbin-Watson value was 1.85, which was close to reference 2, securing the independence of the error. The tolerance limit (0.42–0.97) and the variance inflation factor (VIF), which was in the range of 1.02 to 2.37, indicated no problem in multicollinearity of the independent variables.p<.001), with an explanatory power of 13.1%. Of the variables, spouse’s work change  and total duration of treatment  affected family function. Adding burden of care in Model 2, the total treatment period of the wife  and alternative help when needed  predicted family function with an explanatory power of 14.1% . Further adding social support, family hardiness, and problem-solving communication, as subcomponents of family resilience, in Model 3, the total duration of treatment for the wife  and problem-solving communication  had an explanatory power of 57.7% for family function . In Model 4, coping was added and the final regression model found that problem-solving communication  had the greatest influence on family function of gynecologic cancer families, followed by coping  and total treatment period of the wife . In other words, the higher the problem-solving communication, the higher coping, and total treatment period of ≥1 year, the higher family function of the gynecologic cancer patient’s family could be expected. Model 4 was significant  with an explanatory power of 61.7% (In Model 1, characteristics that were significant for family function were entered, i.e., spouse’s work change, total treatment period of wife, and alternative help when needed. This model was significant (F=7.14, of 61.7% .The main factors affecting family function of gynecologic cancer patients identified through hierarchical multiple regression analysis were problem-solving communication, coping, and total treatment period of ≥1 ≥1 year. Social support, family hardiness, and problem-solving communication, which were subareas of family resilience, were related to family function; and problem-solving communication was found to be the most important influencing factor on family function. These findings are in line with a previous study on families of cancer patients, that found level of social support of care providers had a significant positive correlation with their resilience , and anoThe level of coping of spouses was the second most significant influential factor on family function in gynecologic cancer. In the correlation analysis, coping had a positive relationship with social support, family hardiness, and problem-solving communication, which are subfactors of family resilience. These findings further support prior literature that family hardiness supported caregiver’s positive coping in families of breast cancer patients  and thatThis study is also consistent with reports that the longer the treatment period of gynecologic cancer, the more positive effect on family function improvement , and thaOn the other hand, there was no independent effect of the burden of care on gynecologic cancer family’s function, nor were there significant correlations with other independent variables. This finding differs from a previous study that reported a significant negative correlation of moderate strength between family function and family burden . Our resThe burden of care in our sample was an average of 74.00±7.72 points out of 120 points, showing a higher level of burden compared to the ‘normal’ level of care burden of 72 points . ConsideThe levels of family resilience in our samples were all at moderate or higher scores for social support, family hardiness, and problem-solving communication. This is similar to another study that reported greater than midpoint scores of social supports of families of cancer patients that included breast cancer, uterine cancer, and ovarian cancer . It alsoFor gynecologic cancer families, coping level was also greater than midpoint, similar to the level of coping reported for families of patients with various cancers, such as digestive, respiratory and genitourinary cancers . Family In this study, spouses noted significant differences in work status changes in caring burden, coping, and family function. Being absent from work or leaving work early to care for family may result in economic loss and possible medical cost burden ,40. AccoAmong the characteristics related to care, there were significant differences in social support, family hardiness, problem-solving communication, and family function according to availability of alternative help when needed. This is similar to the result that family hardiness and communication improved when there were three caregivers as opposed to one . Given tThus, assessing whether supportive help is available may be needed to understand and promote family function, in addition to the possibility of change in spouse’s work patterns, and disease and treatment characteristics of gynecologic cancer patients.This study focused specifically on spouses of gynecologic cancer patients rather than vaguely observing ‘family’ and was thus able to suggest directions for a spouse-focused family function study. However, as this study was conducted through convenience sampling through internet communities related to cancer, representation of the target sample may be insufficient. Also burden of care was measured as limited to the spouse’s experience, this may have affected why burden of care was not an influential factor for family function of gynecologic cancer patients. As such, future research that includes other family members’ role and caregiving burden is needed. Since the degree of care burden may vary depending on the cancer stage and treatment mode, future studies may also benefit from recruiting participants according to treatment completed and/or ongoing treatment status to better understand the burden of care and family function.In conclusion, in order to help family function of gynecologic cancer patients, it is necessary to first assess the spouse’s care burden, and in particular, to check level of family resilience, coping, and family function; as an integrative way to see whether the couple with gynecologic cancer and family members function as a single system. In addition, strengthening the family’s individual support system by checking the degree of mobilizing support from relatives, neighbors, friends, colleagues, and public social services can reduce the burden on cancer families. This study confirmed that spouses of gynecologic cancer patients can have a positive effect on family function through positive communication and coping focused on problem-solving. Therefore, nurses can use findings to develop appropriate programs aimed at improving problem-solving communication and coping skills between the gynecologic cancer patient and spouse during the long-term treatment process.


Early diagnosis and application of non-invasive positive pressure ventilation during sleep can improve the quality of life and outcomes of patients with ROHHAD, and polysomnography and TcPCO2 should be repeated every 3–6 months to follow the progress and regulate ventilator support. Multidisciplinary care is crucial for the successful management of these patients.Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare life-threatening disorder that can occur during childhood. All children with ROHHAD develop alveolar hypoventilation during wakefulness and sleep. The key treatment for these patients is the optimization of oxygenation and ventilation. Here, we report the case of a 5-year-old girl with suspected ROHHAD, with rapid weight gain, breathing cessation, decreased height, hypoventilation, central hypothyroidism, hyperprolactinemia, and absolute deficiency of growth hormone, and negative PHOX2B sequencing results. The presentation met the diagnostic criteria for ROHHAD syndrome. During the 5-year follow-up, she presented with progressive deterioration of the function of the hypothalamus and respiratory center, hypoxemia (PO Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) syndrome is a rare disorder commonly diagnosed in childhood that features disrupted respiratory control, autonomic nervous system regulation, and hypothalamic function . Young pIn this case report, we describe a 5-year-old Chinese girl with ROHHAD syndrome who underwent treatment over time to emphasize the importance of early diagnosis and nocturnal ventilatory support in such patients.via cesarean section, with a 3.55 kg birth weight and 51 cm length, which are normal parameters according to Chinese neonatal birth conditions. The neonatal and infancy periods were unremarkable. Since 2.5 years of age, she has demonstrated rapid weight gain due to overeating, and at age 5, she underwent a sleep study showing gasping, snoring, breathing cessation during sleep, and nocturnal enuresis. At that time, the patient was diagnosed with hypothyroidism and treated with levothyroxine sodium (12.5 mg). She developed behavioral changes, including aggressive behavior, episodes of anxiety, and nervousness. She showed no improvement with thyroid hormone replacement therapy.The girl was admitted at the age of 5 years and 6 months with progressive abnormal weight gain for 3 years along with snoring, sleep apnea, and cyanosis for 6 months. The patient was born at full-term 2 91%, oxygen 4 L/min) and hypercapnia (PCO2 50 mmHg) when awake. During sleep, the hypoxia became even more pronounced  without arousal reactions. 2) was performed. No obstructive or central apnea-hypopnea events were found, and the apnea-hypopnea index was 0 events/h. Due to severe hypoxemia (SpO2 60%) and hypercapnia (PCO2 75 mm Hg), the PSG had to be interrupted and restarted with bi-level positive airway pressure (BPAP) titration via a nasal mask  of 5 cmH2O, and a frequency of 18 times per minute.On physical examination, she was obese with a weight of 30 kg and height of 122.5 cm; the results of other physical examinations were unremarkable. Laboratory tests showed severe hypoxia  titration was performed at night with simultaneous PSG and TcPCO2, with IPAP/EPAP set to 19/6 cmH2O and frequency set to 20 times/min. PSG studies found that the patient could not trigger an IPAP/EPAP cycle during slow-wave sleep; therefore, the backup rate was adjusted to be relatively high (20 times per minute). We set the backup rate to 20 to ensure reliable trigger ventilation and adjusted the IPAP/EPAP to increase tidal volume. Airflow, tidal volume and leaks were monitored. No significant leakages were observed. The pressure support gradually increased with the tidal volume, SpO2, and TcPCO2 improved. The final titration pressure setting was IPAP/EPAP 21/8, supplemental oxygen (2 L/min), the SpO2 reached 95%, and TcPCO2 55–65 mmHg (similar to when she was awake). The patient tolerated the procedure well and did not experience nocturia. However, hypoxemia (SpO2 < 90%) and hypercapnia (TcPCO2 > 70 mmHg) still appeared during stage N3 of the first two sleep cycles  even when she was awake. Cyanosis and urinary incontinence were also observed. A timeline of the symptom and progress was shown in p cycles  without In this case, we report the management of a 5-year-old girl with rapid and early onset obesity, alveolar hypoventilation, hypothalamic dysfunction , and behavioral disorders (irritability and aggression) in her first visit, presenting with convincing evidence of a ROHHAD diagnosis. This is the first reported case of ROHHAD in the Chinese population. ROHHAD syndrome is a life-threatening disease in children, with death occurring at an average age of approximately 10 years . CentralRapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation syndrome may be clinically heterogeneous. Most commonly, the patient initially presents with dramatic and rapid weight gain associated with hyperphagia and varying degrees of hypoventilation and autonomic nervous system dysregulation. Hypothalamic dysfunction is manifested by high prolactin levels, low thyroid hormone levels, GH deficiency, and early or late puberty among other abnormalities. Dhondt et al. also reported a case of ROHHAD with a hypocretin-1 deficiency that displayed the classic features of narcolepsy with cataplexy, which broadened hypothalamus dysfunction and expands the phenotype of ROHHAD . A subseBreathing abnormalities are present in almost all patients . Childre2 retention. This phenomenon is in contrast to other sleep-related breathing disorders, such as obstructive sleep apnea, and other sleep-related hypoventilations, which are often related to REM  in patients with ROHHAD report a transient or partial improvement, but the target and long-term efficacy are unclear –23. ThesIn conclusion, we described the presentation and chronic management of a patient with ROHHAD with non-invasive mechanical ventilation at the time of diagnosis. We believe that early recognition and application of NPPV during sleep is vital to slow the deterioration of respiratory function and improve the quality of life. Multidisciplinary care is crucial for the successful diagnosis and management of these patients.The original contributions presented in this study are included in the article/The studies involving human participants were reviewed and approved by the Ethics Review Committee of Peking University. Written informed consent to participate in this case study was provided by the participants’ legal guardian.XD, ZG, and FH contributed to the study concept and design and reviewed the manuscript. RZ collected the medical information of the participant and completed draft manuscript. XD was the guarantor of the manuscript and took responsibility for the integrity of the data. All authors contributed to the article and approved the submitted version.


The wide use of ruxolitinib, approved for treating primary and secondary myelofibrosis (MF), has revolutionized the landscape of these diseases. This molecule can reduce spleen volume and constitutional symptoms, guaranteeing patients a better quality of life and survival or even a valid bridge to bone marrow transplantation. Despite a rapid response within the first 3 to 6 months of treatment, some patients fail to achieve a significant benefit or lose early response. After ruxolitinib failure, new drugs are available to provide an additional therapeutic option for these patients. However, the correct timing point for deciding on a therapy shift is still an open challenge. Recently, a clinical prognostic score named RR6 (Response to Ruxolitinib after 6 months) was proposed to determine survival after 6 months of treatment with ruxolitinib in patients affected by MF. We applied this model to a cohort of consecutive patients treated at our center to validate the results obtained in terms of median overall survival (mOS): for the low-risk class, mOS was not reached (as in the training cohort); for the intermediate-risk, mOS was 52 months (95% CI 39–106); for the high-risk, it was 33 (95% 8.5–59). Moreover, in addition to the other studies present in the literature, we evaluated how the new RR6 score could better identify primary MF patients at high risk, with a slight or no agreement compared to DIPSS, contrary to what occurs in secondary MF. Thus, we were able to confirm the predictive power of the RR6 model in our series, which might be of help in guiding future therapeutic choices. Myeloproliferative neoplasms (MPNs) are a group of hematological pathologies characterized by various degrees of overall survival (OS). Among them, myelofibrosis (MF) is undoubtedly the condition with the worst life expectancy, influenced by multiple factors. In fact, one of MF’s classic hallmarks is the extraordinary heterogeneity in presentation and the variable course of the disease. This condition can be primary (PMF) or occurs secondarily (SMF) either to polycythemia vera (PPV-MF) or to essential thrombocythemia (PET-MF). The OS may range from <2 to 20 years , dependiMoreover, subjects who are, or become in the course of the disease, refractory or intolerant to ruxolitinib treatment pose a challenge. Several trials are still ongoing to find different therapies for this category of patients ,15. In tTherefore, a tool enabling the attending physician to refine an individual patient’s potential response to ruxolitinib treatment  could be helpful for early identification of patients in which therapy is not giving the hoped and expected benefits and choosing the appropriate time target to shift therapy.Maffioli et al.  recentlyAfter this analysis, through the prognostic model named Response to Ruxolitinib after six months (RR6), they divided the patients into three risks categories, assigning 1 point to the presence of a single of the described variables: low , intermediate , and high . Their results confirmed that the RR6 prognostic model allows for the early identification of MF patients treated with ruxolitinib and patients with defined features who might benefit from an earlier treatment shift.n = 209), it includes patients from several centers. Moreover, they based the validation of their results on a cohort of 40 patients. Recently, this model has been externally validated by Breccia et al. .The remaining baseline features of the enrolled patients are shown in Out of 103 patients analyzed, two (1.9%) were lost to follow-up . At the end of the observation period, 50 patients (48.5%) died. Forty-two patients (40.8%) continued ruxolitinib therapy at the end of the observation period. In contrast, the remaining 59 (57.3%) discontinued treatment for underlying disease and treatment-related reasons  or different unrelated reasons . One patient who discontinued ruxolitinib therapy was treated with navitoclax in a clinical study, while the others switched to the best supportive treatment.Survival analysis with the Kaplan-Meier curve was performed by dividing the patients by the risk class calculated according to the RR6 prognostic model .2 = 20.1, p = 0.00004).The median survival (mOS) was not reached for the low-risk class. For the intermediate and high-risk classes, the mOS was respectively 52 (95% CI 39–106) and 33 months (95% CI 8.5–59), with differences in OS statistically significant between the three groups  in the sixth month after the start of ruxolitinib therapy. In primary MF , patientFurthermore, we assessed whether the RR6 score could adequately identify and divide patients into risk classes in a similar way to the standard prognostic scores used (DIPSS and MYSEC-PM). We compared RR6 and DIPSS groups in PMF to investigate this issue, clustering them according to the reported median OS. In particular, the comparison was made between DIPSS low versus RR6 low, Int-1 versus intermediate, and Int-2 and high versus high, respectively. Based on these data, the validity indexes were 80.7% for low-risk , 49.3% for intermediate-risk , and 45.6% for high-risk .Similarly, in patients with SMF, we compared MYSEC-PM low and Int-1 classes versus RR6 low, Int-2 versus intermediate, and high versus high, respectively. The validity indexes were 73.3% for low-risk , 62.2% for intermediate , and 84.4% for high .In the last ten years, significant improvements have been made in diagnosing, treating, and managing chronic myeloproliferative syndromes. The therapeutic progress was mainly due to JAKi drugs, which have revolutionized the approach to these pathologies and brought focus to myelofibrosis. While these innovations have been a turning point in managing these diseases, on the other side, early identification of patients with a non-optimal response to ruxolitinib remains an unmet need ,15. ThisThe RUXOREL-MF study enrolled 209 MF patients affected by primary and secondary myelofibrosis from several Italian centers and treated them with ruxolitinib as the first or subsequent line of therapy. Based on these data, four risk factors were identified: (a) dose of ruxolitinib <20 mg twice daily at baseline and months three and six, (b) palpable spleen length reduction from baseline ≤30% at months three and six, (c) red blood cell transfusion needs at month three and/or six, and (d) RBC transfusion need at all time points of observations until the sixth month. Between these, a higher ruxolitinib dose intensity (≥10 mg twice daily) is associated with better spleen response rates, especially at early time points.We validated the RR6 model in our series of patients with MF treated with ruxolitinib in a single center, with a maximum follow-up of ten years. Our results confirmed the ability of RR6 to identify candidates for subsequent lines of treatment. Comparing our validation cohort with patients from the original study on RR6, the median of OS was not reached for patients in the low-risk class in both series. For patients with intermediate and high risk, the median OS was respectively 61 (95% CI 43–80) and 33 months (95% CI 21–50), comparable to those initially identified in the original study .Concerning the assignment in the prognostic score groups , a better correlation (fair and straight) is evident in SMF patients, confirming the ability to stratify these patients through MYSEC-PM at this time point, similar to that obtained with RR6.On the other hand, in PMF patients, there is no good correlation between intermediate- and high-risk cases, suggesting the potential usefulness of the RR6 score in these patients. A more advanced dynamic score was developed, namely DIPSS Plus , that evFurthermore, in primary MF, the RR6 score is characterized by an upgraded prognostic classification in 16 out of 57 patients and downgraded in 20. Instead, in the secondary myelofibrosis setting, 6 out of 46 patients were downgraded, and 13 were upgraded.p = 0.2). In contrast, patients in the intermediate-risk groups have a superimposable mOS with the standard score and the recently proposed one (p = 0.7). Data for low-risk patients are too small to draw adequate statistical conclusions . A study with a larger number of young high-risk patients who can undergo allogeneic HSCT is needed to confirm the latter issue. To reach this target, multicenter series are required, as the median age at MF diagnosis is around 68 years, and transplants are indicated for patients aged at or under 70. To summarize, this model seems to be of greater usefulness for PMF and with a better prediction power than DIPSS.


Plywood has poor sound insulation due to its insufficient areal density, which cannot satisfy the demands of an indoor acoustic environment. This report proposed to use furfuryl alcohol to impregnate poplar veneer as a raw material for plywood and explored the sound insulation potential of furfuryl alcohol-modified poplar veneer. The effect of different formulations on the sound insulation performance of modified veneers was discussed, such as furfuryl alcohol concentrations, catalyst categories, and solvent categories. The weight percent gain (WPG) and areal density (AD) were used to evaluate the impregnation effectiveness of furfuryl alcohol modification. The sound insulation was measured by the impedance tube method. The results showed that the WPG of the furfuryl alcohol-modified veneers was evident, and the AD was effectively improved. Furthermore, the average sound insulation of furfuryl alcohol-modified poplar veneer was 25.68~40.10 dB, which increased by 10.8~19.1% compared with that of unmodified veneer. The modified veneer with 50% furfuryl alcohol concentration, taking isopropanol as a solvent, and maleic anhydride as a catalyst, had the optimal sound insulation performance. At the same time, the cell microstructure and chemical components were characterized by scanning electron microscope (SEM), Fourier-transform infrared spectroscopy (FTIR), and Brunauer–Emmett–Teller (BET) theory to explain the sound insulation mechanism further. The results showed that the distortion of cell walls was improved, suggesting a change in the mechanical properties of the cell wall. At the same time, more micropores formed since the filling of furfuryl alcohol resin, yielding a tortuous propagation pathway, so the sound insulation performance improved. Finally, it demonstrated the potential of furfuryl alcohol-modified poplar veneer as raw material to prepare plywood with excellent sound insulation. With the development of modern industry and traffic, noise has become one of the most dangerous environmental pollution problems, which could cause hearing difficulties, hypertension, and sleeping disorders. There are two main ways to reduce the damage caused by noise. The first is to take action against the noise sources, making facilities produce less noise. Although this method is effective, it is hard for the construction industry to control all noise sources. The second way is to set up barriers with sound insulation materials in the building envelope system to diminish or eliminate sound waves during propagation . However−3 but had a stable sound insulation performance in the high-frequency band. Ghofrani et al. (2016) used beech and alder with a thickness of 1.8 mm to prepare plywood and used methylene diphenyl diisocyanate (MDI) to compound the rubber layer. The results showed that increasing the beech wood layers and rubber content can improve the acoustic properties of plywood [Light-weight wood materials, which are beneficial in reducing energy consumption, have been an exciting and innovative alternative in construction systems. Among them, plywood is a long-standing wood product with various applications in furniture ,3 and in plywood . Some ag plywood ,13,14. F plywood ,16.Impregnation modification can improve basic wood properties, such as mechanical properties , thermalFurfuryl alcohol (FA) is prepared by catalytic hydrogenation of furfural gas or liquid phase, and furfural can be obtained from renewable resources such as corn cobs, cottonseed husks, and bagasse. Therefore, wood modified by FA is environment-friendly and has recently received extensive attention . PreviouIn our investigation, taking poplar veneer commonly used in plywood as an object, WPG and AD were discussed to evaluate FA modification’s effectiveness. Then, the effects of FA contents, catalyst categories, and solvent categories on the sound insulation performance were emphatically studied. Apart from those, characterization analysis techniques were used to discuss the sound insulation mechanism of the FA-modified veneer.Populus spp.) was harvested in Heze, Shandong Province, China. The log was rotary-cut into veneers that were 1.8 mm by 140 mm in cross-section and 140 mm in the longitudinal direction, with the initial moisture content of 13.8%. All the veneers were flat without knots or visible cracks. After being absolutely dried, the veneers were weighed and underwent complete cell impregnation with the furfuryl alcohol (FA) solution. The veneers were presoaked for 30 min to ensure all the veneers were submerged in the impregnation solution, then the vacuum impregnation began. All the veneers were placed in a vacuum drier  at 14 psi for 30 min, then released the vacuum so that the wood absorbed the FA solution. Finally, it was immersed under normal pressure for 3 h [Poplar  were also included as the control, and 10 samples were prepared for each treatment combination. The specimens for the sound insulation test, whose diameters were 100 mm and 30 mm, respectively, were processed by a CNC engraving machine .m0 is the absolute dry weight of unmodified veneer, g; m1 is the absolute dry weight of the veneer impregnated with FA, g.As a simple and intuitive method, weight percent gain (WPG) was used to reflect the degree of impregnation. It was calculated using Equation (1) by a weighting method.−2; m is the absolute dry weight of the specimens, kg; S is the area of the incident surface of the sound, m2.The sound insulation performance was mainly affected by the mass per unit area and frequency, so areal density (AD) was also used as a parameter for evaluation. It was calculated using Equation (2).The sound insulation performance of the specimens was carried out by four-microphone impedance tube method according to international standard ISO 12999-2:2020 . The expPa and Pb, respectively. Similarly, the forward and reflected waves in the receiving tube were Pc and Pd, respectively. The distances between the four microphones and the specimen’s surface were x1, x2, x3, and x4, respectively. The sound pressures of the four measuring points were P1, P2, P3, and P4, respectively [k is wave number, f—frequency, Hz; c is the sound speed in the cube, m·s−1; T is the air temperature, K.As shown in ectively . AccordiThe transmittance coefficient of the specimen could be obtained by Equation (7).Finally, the transmission loss of the specimen was found by Equation (8).The sound transmission loss ranging from 63 Hz to 1600 Hz was measured with the SW422 impedance tube. Specifically, the measurable frequency range was from 63 Hz to 500 Hz when connecting 0, 2, 3, and 9 microphones. If accessing 1, 2, 3, and 4 microphones, the sound transmission loss in 400~1600 Hz could be measured. Furthermore, the sound transmission loss ranging from 800 Hz to 6300 Hz was measured with the SW477 impedance tube by accessing 5, 6, 7, and 8 microphones. The experiment tested the transmission loss from 100 Hz to 6000 Hz, and the arithmetic average of the transmission loss ranging from 125 Hz to 4000 Hz was used as the average sound insulation .To observe the distribution of FA in cell walls and lumen, a scanning electron microscope (SEM) was applied using FEI equipment . Fourier transform infrared (FTIR) Spectrometer  was carried out to find functional molecule changes to explore whether the chemical reaction between FA and wood would affect sound insulation performance. The pore distribution and surface area of the control group (UPV) and the optimal group (OPV) were analyzed by the nitrogen adsorption-desorption method. The samples were both degassed at 80 °C for 10 h in the fully automatic surface and porosity analyzer , with the isotherm data analyzed by the BET method and t-plot method.G1, G2, G3, and G4 were veneers impregnated with different FA concentrations. WPG and the growth rate of WPG were increased with FA concentrations. At the same condition of acid catalyst and solvent, FA concentration no longer had a noticeable effect on the pH of the impregnation solution when reaching 30 wt.%.G3, G5, and G6 were modified veneers using different acid catalysts. G5 treated with oxalic acid (OA) had the highest WPG, followed by maleic anhydride (MA) and citric acid (CA). Different catalysts directly affected the pH of the impregnation solutions, resulting in various degrees of polycondensation of FA. The result revealed that the more acidic environment created by OA in this experiment was more conducive to the polycondensation of FA, thereby increasing the WPG.G3, G7, and G8 were modified veneers using distilled water (DI), isopropyl alcohol (IPA), and ethanol (EA), respectively. The WPG of FA-modified veneer using IPA as solvent was the best. In previous research, Thygesen et al. (2020)  confirmeThe average sound insulation improved with the increase of FA concentration until the concentration reached 50% b, consisFA-modified veneers with MA as catalyst had higher average sound insulation b, confirCombined with the results in The morphology change of modified veneers after furfurylation was observed by SEM, as presented in Compared with the control group, the FA-modified veneer with CA as the catalyst improved the distortion of the cell wall, but the effect was not ideal f. AlthouAs shown in −1).The infrared spectra of modified poplar veneers with different FA solutions and the control group were shown in −1 [−1, 2915 cm−1, 1740 cm−1, and 1050 cm−1 decreased significantly, and the absorption peak near 615 cm−1 almost disappeared, indicating that wood components were degraded during the FA modification process. This phenomenon may be caused by the cross-linking reaction between FA and wood cell wall components or the thermal and acid conditions during the modification process.The modified veneers showed absorption peaks of C-C bonds attributable to a furan ring and branched chain around 786 cm−1 ,48, illuGiven in Besides, we also believed that the distribution of FA was also a critical factor affecting sound insulation performance. According to the SEM results, there were three principal distributions of FA resin in the internal structure. One was filled in the cell lumens and the intercellular layer, which was mainly influenced by the degree of polymerization of FA. The second was an attachment to the cell wall, and the third entered the cell wall. Both resulted from the combined effects of the FA polymerization and the cross-linking of FA with chemical components of the cell wall. Although law and order of these three distributions cannot be clearly defined in this work, there was no doubt that various sound media interfaces were formed inside the wood. Li et al. (2016)  used nanIt is of great significance to study the sound insulation performance of furfuryl alcohol-modified veneer for enriching the commercial value. It can also provide a theoretical basis for developing sound insulation functional plywood. This work mainly explored the effect of furfuryl alcohol solution formulation on its sound insulation performance and discussed the sound insulation mechanism of furfuryl alcohol-modified poplar veneer. The main conclusions and prospects were as follows:Furfuryl alcohol modification significantly increased WPG, improving the areal density of poplar veneer. The research proved that furfuryl alcohol modification improved the sound insulation performance of poplar veneer, especially in the human-sensitive frequency band, ranging from 1000 Hz to 3000 Hz. Still, the enhancement effect of furfuryl alcohol modification was not ideal at the low-frequency band.The optimal formulation in this experiment was modified with 50% furfuryl alcohol concentration, using isopropanol as a solvent and maleic anhydride as a catalyst. The preferred modified poplar veneer had average sound insulation of 19.05 dB, 1.6 times higher than the unmodified veneer.Except for the law of mass, the distribution of furfuryl alcohol inside the wood and its crosslinking reaction with wood components might be another critical factor for improving sound insulation performance. From the results of SEM and FTIR, it can be found that furfuryl alcohol modification ameliorated the cell wall distortion, indicating that the mechanical properties of the cell wall were enhanced, resulting in more transmission loss of sound waves inside. The effect of furfuryl alcohol concentration and catalyst on wood components was relatively small, while the components of furfuryl alcohol-modified veneer with different solvents were quite different.The furfuryl alcohol modification technology has been industrialized in Europe . We prov


To the best of our knowledge, only a few DEE91 cases have been reported.Developmental and epileptic encephalopathy 91  in PPP3CA.This study reports a boy who experienced recurrent afebrile convulsions and spasms at the age of 2 months. After being given multiple antiepileptic treatments with levetiracetam, adrenocorticotropic hormone (ACTH), prednisone, topiramate, and clonazepam, his seizures were not completely relieved. At the age of 4 months, the patient exhibited delayed neuromotor development and difficulty in feeding; at the age of 6 months, he was diagnosed with developmental regression with recurrent spasms and myoclonic seizures that could respond to vigabatrin. At the age of 1 year and 4 months, the patient showed profound global developmental delay (GDD) with intermittent absence seizures. Whole-exome sequencing (WES) identified a novel loss-of-function variant c.1258_1259insAGTG  of PPP3CA.This finding expands the genetic spectrum of the  PPP3CA-associated monogenic disease. Thus, the clinical diagnosis of DEE91 is dependent on genetic tests.Developmental and epileptic encephalopathy 91  is a severe, early-onset neurodevelopmental disease. Patients with DEE91 tend to be clinically diagnosed with West syndrome (WS) or infantile spasms syndrome, developmental regression, and hypsarrhythmia . DEE91 iPPP3CA, which is also known as calcineurin A, is a catalytic subunit of calcineurin that mediates Ca2+-dependent signal transduction , respectively  showed that the bilateral frontotemporal extracerebral space was broadened, especially on the left side . An elecAfter levetiracetam was administered for ~15 days, the patient developed 10–20 spasms/spasticity in a cluster per day. The features of the spasms included instant onset of involuntary nodding, forward flexion of head and torso, eyes staring upwards, and unresponsiveness. He was then sent for medication for a second time. His physical examination and laboratory tests were normal. An EEG showed modified hypsarrhythmia . The patAt the age of 4 months, the patient was found to have significantly delayed neuromotor development. He was unable to look up or turn over, and he lost the ability to pronounce vowels, accompanied by hypotonia in the limbs. At the age of 6 months, the patient lost a previous developmental milestone, which was manifested as unstable neck erection, and this was accompanied by feeding difficulties, including an unwillingness to eat and refusal to drink milk, as well as recurrent spasms and bilateral tonic-clonic. For the third time, he was treated by adding 45 mg/kg/day vigabatrin divided by q12H instead of levetiracetam, and maintenance doses of topiramate, clonazepam, and prednisone were administered. At the age of 8 months, 60 mg/kg/day vigabatrin, divided by q12H, and 0.1 mg/kg/day clonazepam, divided by q12H, were added to the treatment, and the patient's seizures were significantly relieved but he still experienced hypotension in his limbs.At the last follow-up examination, the patient was 1 year and 4 months old. The patient weighed 9 kg and had no significant deformity. His motor and language developmental milestones equalled those of normal 1- and 3-month-old infants, respectively, indicating that profound global developmental delay (GDD), including an unstable neck erection and inability to raise his head, turn over, and laugh, occurred with limb hypotension. The patient could only pronounce vowels. Under a treatment with 45 mg/kg/day vigabatrin, divided by q12H, 0.1 mg/kg/day clonazepam, divided by q12H, 6 mg/kg/day topiramate, divided by q12H, and 1 mg/kg/day prednisone, involuntary nodding and forward flexion of head and torso in the patient disappeared; however, he still had mild seizures (with staring eyes for approximately 10 s every time). A follow-up EEG showed modified hypsarrhythmia during sleep .The whole-exon capture chip used by Trio-WES is the IDT xGen Exome Research Panel version 1.0, which was sequenced by an Illumina NovaSeq 6000 series sequencer (PE150). The sequencing coverage of the target sequence was not <99%. The raw sequencing data were screened, and low-quality reads were filtered through a quality control (QC). Then, the BWA software was used to perform a sequence alignment with the reference human genome. Repeated read operations were excluded, the remaining read operations were statistically analyzed, and the GATK software was used to identify variables. Detected variants were bioinformatically annotated based on public databases such as ClinVar, HGMD, gnomAD, and the 1,000 Genomes Project and were predicted to have pathogenic or deleterious effects based on database data. Variation classification mainly refers to the 2015 ACMG Genetic Variation Classification Standards and Guidelines gene mutation classification system.*32) of the PPP3CA gene exon 12 in the proband. The variant was de novo. The result was confirmed by Sanger sequencing (*32 was pathogenic (PVS1 + PS2 + PM2) according to the American College of Medical Genetics and Genomics (ACMG) practical guidelines (https://www.omim.org/phenotypicSeries/PS308350) associated with WS or developmental and epileptic encephalopathies were excluded by WES.Trio-whole-exome sequencing (WES) was performed after signed consent was obtained from the parents, according to the medical ethics statement. We identified a heterozygous variant  that caused DEE91, an early-onset WS-like disorder, in a Chinese male pediatric patient. The specific type of seizure, infantile spasms, and developmental regression were significant in our patient, which prompted the initial diagnosis of WS. In detail, infantile spasms, myoclonus, and multifocal hypsarrhythmia were observed in the EEG in the present case, and these observations share the core phenotype of WS  of the PPP3CA gene was detected in the proband, which is located on exon 12  PPP3CA variant by WES in a boy with severe early-onset epileptic encephalopathy. Western blot experiments in patient cells  showed that the protein expression levels of both mutant and wild-type proteins were significantly reduced despite normal mRNA abundances  in relatively more severe DEE91 cases. It concluded that patients with a truncating variant experienced more severe seizures with earlier onsets compared to those of patients with an LOF missense variant, while autism spectrum disorder was relatively common in the latter . Rydzaniundances . Our finPPP3CA frameshift variant through WES, confirming the disease of the proband at the molecular level. The results expand the spectrum of pathogenic variants of DEE91. The clinical features and molecular evidence in the patient support the theory that LOF mutation in PPP3CA causes DEE91 and truncating variants within RD lead to severe phenotype. Based on the above results, WES has become an important method for diagnosing rare genetic diseases.In conclusion, we identified a novel The datasets presented in this article are not readily available because of ethical and privacy restrictions. Requests to access the datasets should be directed to the corresponding author.Written informed consent was obtained from the minor(s)' legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.JL enrolled the patient, collected, and interpreted the clinical information and wrote the manuscript. JC designed the study and corrected the manuscript. Both authors approved the final manuscript.This study was supported by the Department of Medical General Ward, Children's Hospital of Chongqing Medical University, Chongqing, China.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.


This study aims to develop and validate, a clinically useful modified index of fragility (mIFG) to identify patients at risk of fragility and to predict postoperative adverse events.An observational study was performed using the American College of Surgeons National Surgical Quality Improvement Program database, from 2006 to 2018. All patients undergoing nonemergency head and neck cancer surgery were included. A seven-item index (mIFG) was developed using variables associated with frailty, cachexia, and sarcopenia, drawn from the literature . Multivariable logistic regression was used to model the association between mIFG, postoperative adverse events and death. A validation cohort was then used to ascertain the diagnostic accuracy of the mIFG.A total of 23,438 cases were included . There was a total of 4273 postoperative major adverse events (AE) and deaths, 1023 postoperative pulmonary complications and 1721 wound complications. Using the derivation cohort, the 7-item mIFG was independently associated with death, major AEs, pulmonary and wound complications, when controlling for significant covariates. The mIFG predicted death and major adverse events using the validation cohort with an accuracy of 0.70 (95% CI: 0.63–0.76) and 0.64 (95% CI: 0.63–0.66), respectively. The mIFG outperformed the modified Frailty index.The modified index of fragility is a reliable and easily accessible tool to predict risk of postoperative adverse events and death in patients undergoing head and neck cancer surgery.The online version contains supplementary material available at 10.1186/s40463-022-00607-4. Around 40% of head and-neck cancer (HNC) surgeries are associated with postoperative morbidity, which often occurs in the first 30 days after the surgery . While pFrailty is generally defined as a multisystem dysregulation associated with fatigue, weakness and fat-free weight loss . SarcopeDespite differences in their definition, these three overlapping syndromes all lead to body tissue loss and interplay to create a state of fragility in cancer patients. Therefore, the objective of this study is to develop and internally validate an easily accessible pragmatic modified index of fragility (mIFG) to identify patients most at risk of postoperative AEs, including wound complications and pulmonary complications, and death using a large international cohort study.A retrospective chart review was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. The ACS NSQIP is an internationally validated, risk-adjusted, outcomes-based program to measure and improve the quality of surgical care. It provides multi-institutional data on postoperative outcomes (up to 30 days) of patients undergoing surgery. In the case of postoperative AEs, the exact time of occurrence is available in the database. Between 2006 and 2018, all patients who underwent nonemergency, inpatient HNC surgery were included in the study using Current Procedural Terminology (CPT) codes. Ethical approval was granted by the McGill University Health Centre research board (MP-37-2018-3568).Baseline sociodemographic information was noted, including age, gender, ethnicity, alcohol consumption and tobacco usage. Alcohol consumption was quantified as > 2 drinks per day, 2 weeks before the surgical procedure. Active smoking was defined as daily tobacco use within 1 year of the surgery. Comorbidities such as cardiovascular diseases , metabolic risk factors (long term steroid usage and diabetes mellitus) and other comorbidities  were also noted. We included other information such as preoperative laboratory results , nutritional factors (body mass index (BMI), mean weight and recent loss of body weight in 6 months prior to surgery) and additional operative information  in the data analysis.Postoperative AEs, PPCs, wound complications and death were the outcomes of interest in this study. Pneumonia, unplanned intubation, pulmonary embolism and usage of ventilator for > 48 h were grouped as PPCs. Major postoperative AEs were selected based on the most recent literature and included PPCs, acute kidney injury, cerebrovascular accident, coma, myocardial infarction, cardiac arrest, sepsis, septic shock, more than four blood transfusions, and return to the operating room –17. WounA series of seven preoperative biomarkers and risk factors related to frailty, sarcopenia and cachexia were identified in order to formulate the modified index of fragility (mIFG). The selection of these variables was based on data from the European Working Group on Sarcopenia in Older People (EWGSOP) , the intIn addition of being an integral part of the definition of cancer cachexia by Fearon et al. and the frailty classification by Fried et al., an unintentional weight loss of > 5% of total body mass, is also associated with sarcopenia and with increased morbidity and mortality rates , 21, 22.Both low hematocrit and low albuminemia –26 were As for respiratory effects, sarcopenia has been shown to be associated with shallow breathing and diverse sensory and affective components of exertional dyspnea in patients with chronic respiratory diseases , 33. TheThe presence of each of the seven aforementioned risk factors was accounted as a score of one, for a minimal mIFG score of zero and a maximal score seven.A total of 43 968 cases were found using the ACS NSQIP database. 23 438 cases met the inclusion criteria of this study using CPT codes for HNC surgery. 70% 16,407) of the cases were randomly assigned in the derivation group and 30% (7031) were randomly assigned in the validation group. Logistic regression was used to identify statistically significant covariates. A multivariate logistic analysis was subsequently performed to study the association between mIFG and major AEs, death, PPC and wound complications. We adjusted for clinically and statistically significant covariates . The validation group was used for interval validity testing. The fit and accuracy of the final model was performed using Hosmer–Lemeshow test. Lastly, the mIFG was compared to existing models such as modified frailty index-5 (mFI-5) , America7 of the During the 30 days following their surgery, among the 23 438 patients within the derivation cohort, 4273 18.2%) had a major AEs or death, 1023 (4.4%) had a recorded PPC and 1721 (7.3%) had wound complications. For both the derivation and validation sets, clinicopathological and baseline information, including demographics, social factors, comorbidities, physical measurements and surgical information were collected . A score of 1 was given to 3872 (23.6%) patients, a score of 2–1365 (8.3%) patients, a score of 3–475 (2.9%) patients, a score of 4–131 (0.8%) patients, a score of 5–27 (0.2%) patients and a score of 6–2 (0.01%) patients. As such, patients with a score of 4 or greater were combined to facilitate statistical analysis. Table 4, 64.2%.The AUCs showed that the mIFG had a better ability to predict death among all other outcomes, with an AUC of 0.73 (95% CI: 0.69–0.77) for death, 0.65 (95% CI: 0.63–0.67) for PPCs, 0.64 (95% CI 0.63–0.65) for major AEs including death and 0.60 (95% CI: 0.58–0.61) for wound complications  were shown to be associated with increased risk of PPCs, wound complications, major AEs and death following HNC surgery. The mIFG showed a satisfactory diagnostic accuracy when compared to other risk-stratification tools, such as the mFI-5, ACS risk calculator and the ASA score.Risk stratification tools have a major role in today’s surgical practice. A very commonly used example is the ASA scale. The ASA scale is used to subjectively estimate preoperative health status, predict perioperative risk and some postoperative AEs including mortality and cardiac complications . It is fFrailty, sarcopenia and cachexia remain as well-established negative predictors of surgical and oncologic outcomes. Numerous studies in different surgical fields have reported the association of these syndromes with both long- and short-term postoperative mortality, thus reinforcing, the importance of early diagnosis and management of sarcopenia in surgical candidates –50. UnfoDespite the burden of frailty, cachexia and sarcopenia, and clinical barriers to accurately identify patients at risk, evidence indicates that proper intervention, may have a positive impact on prognoses and outcomes of patients undergoing head and neck surgery . MultiplSeveral limitations of this study could prevent, to a certain extent, the generalization of its results. The variable used to predict risk of fragility are mostly theoretical and drawn from the literature, based on expert consensus. Given that the ACS NSQIP database is limited to postoperative day 30, this study was only able to assess short-term outcomes. This could limit our interpretations of the true extent of impact of these syndromes on postoperative outcomes, especially mortality. Furthermore, the ACS NSQIP database do not address postoperative complications that are specific to HNC surgeries. Specific oncological characteristics, such as staging and type of malignancy, were also not included in the database and we were therefore not able to control for them in our analysis. Some other limitations are inherent to the use of the NSQIP database. Although this database provides a very large sample size and precise data collected rigorously, it does not represent the entire breadth of US hospitals. Previous studies have shown that hospitals participating in NSQIP have differences in patient volume, practice style, and case mix compared with hospitals not in NSQIP . Lastly,In this study, factors related to frailty, sarcopenia and cancer cachexia were associated with postoperative death, major AEs, wound complications and PPCs in patients undergoing HNC surgery. We also developed and internally validated an easily accessible and simple modified index of fragility that was shown to be a satisfactory predictor of the aforementioned outcomes, when compared to other pre-existing preoperative risk stratification tools. This tool could be a useful complement to pre-operative evaluation and other pre-existing tools. Although there are elements of the mIFG that may possibly be modified pre-operatively  further investigation is required to clarify how effective this may be in practice. Nonetheless, implementation of preventive interventions to reduce preoperative sarcopenia in at-risk surgical candidates should have a more significant role in preoperative management of cancer patients. This is particularly important in the HNC population given the high incidence of feeding difficulties before, during and after treatment.Additional file 1. contains further data on comparing mIFG for wound complications and postoperative pulmonary complications in the derivation and validation group in addition to the distribution of PPCs, major AEs, death and wound complication among the cohort.


The present work reports the synthesis and characterization of polycaprolactone fibers loaded with particulate calcium magnesium silicates, to form composite materials with bioresorbable and bioactive properties. The inorganic powders were achieved through a sol–gel method, starting from the compositions of diopside, akermanite, and merwinite, three mineral phases with suitable features for the field of hard tissue engineering. The fibrous composites were fabricated by electrospinning polymeric solutions with a content of 16% polycaprolactone and 5 or 10% inorganic powder. The physico-chemical evaluation from compositional and morphological points of view was followed by the biological assessment of powder bioactivity and scaffold biocompatibility. SEM investigation highlighted a significant reduction in fiber diameter, from around 3 μm to less than 100 nm after the loading stage, while EDX and FTIR spectra confirmed the existence of embedded mineral entities. The silicate phases were found be highly bioactive after 4 weeks of immersion in SBF, enriching the potential of the polymeric host that provides only biocompatibility and bioresorbability. Moreover, the cellular tests indicated a slight decrease in cell viability over the short-term, a compromise that can be accepted if the overall benefits of such multifunctional composites are considered. Tissue engineering (TE) means the development of biological substitutes to “restore, maintain, or improve tissue function” . One of Polymer–bioceramic composites, which result from combining two or more distinct phases, can be successfully used as heterogenous functional matrices with the ability to mimic the natural extracellular matrix (ECM), and are currently intensively researched . Dependi2+, as the main element of bone tissue, is vital for osteogenesis, supporting cell growth and adapting cellular responses to bioceramics; Si2+ inhibits osteoporosis and stimulates the metabolic pathways of bone calcification; and Mg2+ modulates the degradation rate and mechanical strength of calcium silicates [2+ and Mg2+ are more important than Ca2+ in the process of cell differentiation [Among bioceramics, calcium magnesium silicates-based systems play an important role in TE due to their proven biocompatibility, excellent mechanical properties, and high versatility, as their chemical composition and structure can be easily redesigned to respond to different clinical conditions . During ilicates ,13,14,15ntiation . So, in ntiation ,14.2-based bioceramics can be fabricated by wet or dry techniques: coprecipitation, sol–gel, combustion, spray pyrolysis, fusion process, solid-state sintering, etc. [Considering all the above, it is easy to acknowledge ternary silicate bioceramics, such as diopside (D), akermanite (A), or merwinite (M), as frequently used materials in bone regeneration applications. Numerous studies previously investigated their properties, including the capacity to inhibit microbial growth, which is particularly critical for bone matrix ,16,17, ang, etc. ,25,26,27ng, etc. ,25.With respect to the main classes of polymers used in TE, natural and synthetic, the latter category offers the advantage of controlled composition and structure, tunable biodegradability, and possibility of functionalization. Polycaprolactone (PCL), as a synthetic material that enables good processability, precise control over degradation, molecular weight, or hydrophobicity , is ofteThus, in this work, three types of mineral powders, differing in terms of calcium content, were loaded on polycaprolactone fibers by introducing them in the precursor electrospinning solutions. The novelty of this work resides in the achievement of new composites based on calcium magnesium silicates and polycaprolactone, namely the combination of the bioactive properties of the first with the bioresorbability of the second. Since few studies are available on this topic, their morphological and biological characteristics were investigated, and correlations were established with the compositional and processing parameters.2O6, D), akermanite , and merwinite ; these were thermally treated at 1000 or 1300 °C. The pulverulent samples employed as mineral loading consist of consolidated blocks with a high percentage of open porosity; the first composition (D) contains diopside as leading crystalline compound, the second (A) is a balanced mixture of diopside, akermanite, and merwinite, and the third (M) has a majority of dicalcium silicate [The inorganic powders were synthesized by a sol–gel method and characterized from compositional, structural, and morphological points of view . The solsilicate .3, ≥99%, Sigma-Aldich, St. Louis, MO, USA) and N,N-dimethylformamide  as solvents, polycaprolactone n, Mw = 80,000 g/mol, Sigma-Aldich) as the polymeric phase, and the previously described powders as the inorganic component . The CF:DMF solvent ratio was set at 4:1. Electrospinning uses electrical forces to shape a jet of polymeric solution with adequate rheological properties that is pushed through a nozzle and afterwards subjected to processes of drying and stretching, until collected on a grounded support [The composite fibers were fabricated through an electrospinning technique using chloroform  with a FEI Quanta Inspect F electron microscope , 20 or 30 kV accelerating voltage, 10 mm working distance, and gold coating by DC magnetron sputtering for 40 s. The vibrational characteristics were investigated by attenuated total reflection Fourier-transform infrared spectroscopy (ATR-FTIR) with a Thermo Scientific Nicolet iS50 spectrophotometer , 400–4000 cmpH = 7.3, at 37 °C, for 4 weeks. It is widely accepted that such in vitro studies represent a standard approach to evaluate the apatite-forming capability of implantable materials, as a first step towards hard tissue bonding through a chemically stable and mechanically appropriate interface; by immersion in SBF solutions that mimic the composition of human plasma and selecting suitable testing parameters, reliable data on specimen bioactivity can be achieved [The powder bioactivity was assessed by immersion in simulated body fluid (SBF) prepared according to Kokubo et al. , pH = 7.achieved . In our 2. All cell cultivation media and reagents were purchased from Biochrom AG .Mouse fibroblasts (L929 cells) were grown in MEM supplemented with 2 mM L-glutamine, 10% fetal calf serum (FCS), 100 units/mL of penicillin, and 100 µg/mL of streptomycin, at 37 °C, in a humidified incubator, under an atmosphere containing 5% CO2 squares were placed in 24-well plates and seeded with 20.000 cell/well for 24 and 48 h. After the desired time passed, the medium was exchanged with medium containing 1 mg/mL MTT and further incubated for 4 h in the incubator. Finally, the solution was extracted and the formed formazan crystals were dissolved in dimethyl sulfoxide (DMSO). Negative control was represented by cells cultivated on aluminum foil. The percentage of viable cells was obtained using Equation (1).Cell viability was evaluated using 3--2,5-diphenyltetrazolium bromide (MTT) assay at 24 and 48 h after the cells were seeded onto the investigated fibrous composites. Briefly, the surfaces were sterilized in flow with UV light, 15 min on each side. Following the sterilization, 1 cmMorphological investigation was performed using fluorescence microscopy for cells grown for 24 h on the developed scaffolds. The cells were grown in the same way presented above; after 24 h, they were washed with PBS, fixed in 4% paraformaldehyde dissolved in PBS for 15 min, followed by a washing step. Sequentially, the cells were stained for 15 min with 20 μg/mL Acridine Orange solution and washed again with PBS. Finally, the fluorescence images were taken using a confocal microscope  mounted on an Olympus BX51 epifluorescence microscope, employing a 40× objective. The images were recorded using a suitable filter cube .The addition of mineral powders  at a proportion of 5 or 10% triggers significant modifications in the general appearance, reducing the fiber diameter to a large extent, below 100 nm, most of them being around 30 nm . This be2, and HAp [Bafandeha et al.  fabricat and HAp .Otherwise, the inorganic aggregates are caught as if in a spider web, either covered with a small layer of PCL or just attached to the fiber surface , making −1, respectively [−1, some additional bands emerge; in the range 800–1100 cm−1, the signals of Si–O bonds and Si–O–Si groups are visible, whereas below 550 cm−1, bands specific to the Ca–O and Mg–O oxide bonds overlap [The loading procedure was also validated from the FTIR spectra  recordedectively ,49. For  overlap ,52.In the SEM images taken of the thermally treated powders immersed in SBF for 4 weeks , the behWhen combined with chitosan for the production of scaffolds by 3D-bioprinting, akermanite conferred bioactivity, the surface becoming almost wholly coated with a thick layer of bone-like apatite after 10 days of immersion in SBF; the newly formed precipitate had a sponge-like morphology [Merwinite has been studied to a lesser extent, but the available data suggest that the rate of apatite growth is extremely high for merwinite compared to akermanite and diopside, following the same trend as CaO content; as observed, the freshly emerged layer displayed a cauliflower-like morphology and completely covered the scaffold surface, the density was extremely favored in the case of calcium resources provided by merwinite .After testing the biocompatibility of the developed composite materials, it was found out that they were not cytotoxic and ensure a favorable platform for fibroblast proliferation. Thus, Indeed, PCL stands out as the sample with the highest cell viability; this result can be explained based on its different morphology compared to all other specimens. In other words, if PCL fibers have a diameter around 3 μm, the size of the powder-containing fibers drops below 100 nm . Due to The morphological evaluation of L929 cells grown on the investigated materials was performed using fluorescence microscopy; the corresponding images are reported in The in vitro assays performed in this paper are in concordance with previous studies, which have confirmed that polycaprolactone-based scaffolds, membranes, or gels have good biocompatibility with osteoblasts, bone marrow mesenchymal stem cells, dental pulp cells, or fibroblast-like cells ,58,59,60Calcium has a key role in bone remodeling by modulating the cellular responses to bioceramics, as well as promoting cell growth and osteogenic differentiation. Therefore, three calcium magnesium silicate compositions, corresponding to diopside, akermanite, and merwinite, were processed as thermally treated sol–gel-derived powders and subsequently integrated in polycaprolactone fibers. The fibrous composites were fabricated by electrospinning and evaluated in terms of powder loading degree and particle distribution in the fibers, as well as response to immersion in simulated biological fluid and influence on fibroblast cells. If the inorganic component proved to be bioactive, gradually increasing from diopside to akermanite and then to merwinite (the bioactivity increased with the increase in Ca amount), the loaded fibers represent cell-friendly supports, achieving better cell proliferation when combined with a higher powder concentration.