Patients with chronic liver disease (CLD) have extrahepatic manifestations and impaired health-related quality of life (HRQOL), and hepatitis C virus (HCV) infection is a leading cause of CLD, cirrhosis, and hepatocellular carcinoma (HCC). This study is aimed at assessing HRQOL in patients with HCV infection in the rural areas and identifying factors associated with impairment of HRQOL.  A cross-sectional study was conducted in a county of Liaoning Province in northeast China. HRQOL of patients with HCV infection was assessed using the chronic liver disease questionnaire (CLDQ) and EuroQol-5 dimensions (EQ-5D). Data were transformed to score comparisons of six major CLDQ domains, EQ index, and visual analog scale (VAS).  A total of 397 (93.4%) subjects, including 67 healthy subjects (HSs), 314 patients with chronic hepatitis C (CHC), and 16 patients with liver cirrhosis (LC) completed the study. The overall quartile CLDQ scores for HSs, patients with CHC, and patients with LC were 6.4 , 5.8 , and 4.1 , respectively. The quartile scores of EQ index for the three groups were 1.0 , 1.0 , and 0.9 , respectively. The median scores of EQ VAS for the three groups were 85.0, 60.0, and 60.0, respectively. Female sex, patients with family history of hepatitis, other comorbid chronic diseases, drinking, and disease duration ≥ 10 years were associated with significant improvement in overall CLDQ scores, and family history of hepatitis and other comorbid chronic diseases were considered predictive factors for EQ index and VAS, respectively.  Compared with HSs, HCV infection had a greater negative impact on HRQOL in patients with CHC and LC. The significant factors associated with HRQOL include female sex, patients with a family history of hepatitis, other comorbid chronic diseases, drinking, and disease duration ≥ 10 years. Patients with HCV infection in the rural areas should be paid careful attention regarding their HRQOL with proper health education and disease management. Viral hepatitis ranks first among infectious diseases, and the chronic hepatitis C (CHC) has currently been considered the “invisible killer” of chronic hepatitis in China . AccordiHealth-related quality of life (HRQOL), as an objective instrument for evaluating patients' physical, psychological, and social adaptation and other indicators, has become significantly favorable to clinical doctors and health managers . Most stPrevious international studies have reported a consistent and marked reduction in HRQOL in patients with chronic hepatitis . AlthougThus, this study is aimed at evaluating HRQOL outcomes of patients with HCV infection in rural areas and identifying factors associated with impairment of HRQOL.Since August 2014, to analyze the comprehensive prevention and treatment of CLD in Liaoning Province, the National Ministry of Science and Technology of China commissioned the Center for Disease Control and Prevention of Liaoning Province to complete the research. This study conducted an epidemiological screening in CLD research from August 2014 to June 2015. As a cross-sectional study, the convenient sampling method was used, subjects volunteered to participate in the survey, and the information was consecutively collected from patients with CHC, patients with LC, and the HSs. The diagnostic criteria of the disease were established following the standards in the guideline of prevention and therapy of hepatitis C, which was issued by the Hepatology Branch, Infectious Disease & Parasitologic Diseases Branch, Chinese Medical Association . All patFace-to-face interviews were conducted by well-trained interviewers and noninductive language was used for investigation. In order to protect the information of subjects, researchers cannot identify the information of each individual. Subjects' sociodemographic characteristics, including age, gender, marital status (married or not married), education level , comorbidity chronic illness, family history of hepatitis, and disease duration, were collected. Meanwhile, subjects' HRQOL was measured using the CLDQ and EQ-5D. The questionnaire will be excluded if the missing data exceeds 20% and above.The CLDQ is a standardized disease-specific HRQOL measurement for liver disease that is developed by Younossi et al. . The queEQ-5D is one of the most widely used generic scales that was presented by the EuroQol Group . It consU test was performed to compare the HRQOL score of each domain of CLDQ and EQ-5D among the three groups. Associations between variables were measured using Spearman's correlation coefficient to examine the association between each domain of CLDQ and EQ-5D. Additionally, multivariate linear regression was performed to estimate independent association of each variable with the score of overall, EQ index, and VAS. All tests were two-sided with a significance level < 0.05. All data were double-typed with Epidata3.2 by two different persons to avoid data errors, and SPSS, version 16.0  was used to conduct all the analysis.Descriptive analysis for continuous variables was performed with mean ± standard deviation for normally distributed data and interquartile range and median for nonnormally distributed data. Categorical variables were described by counts and related percentages. Pearson's chi-square test and Fisher's exact test were used to compare the distribution of sociodemographic variables between all patients and the healthy subjects. Mann-Whitney All subjects were from rural areas in Jianping County, and a total of 425 subjects participated in the study, of which 28 were excluded because they did not complete the questionnaire. A total of 397 (93.4%) subjects, which included 67 HSs, 314 patients with CHC, and 16 patients with LC, completed the study, and the mean ages were 51.5 ± 9.5, 55.2 ± 8.2, and 60.4 ± 7.4 years, respectively. Greater than two-fifths (42.3%) were aged from 50 to 59 years old. A total of 67.5% of the subjects were female. Regarding marital status, most of the subjects (96.0%) were married and lived with their families; subsequently, the remaining subjects had no spouse . As regards disease duration, 58.8% of the patients (CHC and LC) had disease duration greater than 5 years. Information about subject's sociodemographic characteristics is summarized in U test, all the domain CLDQ and EQ-5D scores were significantly lower in patients with CHC than that in HSs, and similar results were observed in patients with LC and HSs. The median scores of the patients with CHC were significantly higher for FA, SS, AC, EF, WO, and overall CLDQ, except for AS, WO, and EQ-5D, compared to that of patients with LC.We calculated the CLDQ and EQ-5D scores for every domain according to the subject's specific response using the computational formula that is commonly used in r > 0.408, P < 0.001); the associations between the overall score and each domain score using the EQ index and EQ VAS ranged from weak to moderate in All CLDQ domains were significantly associated with all the scores of EQ-5D subscales , patients with family history of hepatitis , other comorbid chronic diseases , drinking , and disease duration ≥10 years  were predictive factors of overall CLDQ scores.Multivariate linear regression analysis predicted the overall CLDQ scores, EQ index, and VAS. β = −0.056; 95% CI, -0.104 to -0.008) were a predictive factor for EQ index, and other comorbid chronic diseases  were predictive factor for EQ VAS.Notably, independent factors for EQ index and VAS were not similar to that of overall CLDQ scores. As shown in Using the EQ-5D and CLDQ simultaneously is the most promising approach to evaluate the HRQOL of patients with HCV infection in the present study. Compared to the generic scale, the disease specificity scale can more accurately express the specific clinical symptoms of patients . We founA recent study, which was conducted using the Japanese version of the CLDQ among Japanese patients with chronic viral hepatitis, in Japan has reported that the CLDQ scores of these patients were lower compared to that of the present study except for the AC domain . The medSome studies reported that psychiatric disorders, FA, and depression are common symptoms of HCV patients, which may constitute a major influencing factor for patients with low QOL , 21. In To the best of our knowledge, patients generally show significant WO about the harm caused by diseases, which can seriously affect their QOL , 23. IntThe results from generic questionnaire EQ-5D and disease-specific questionnaire CLDQ were in agreement with the fact that a marked decrease of QOL was observed in patients with HCV in this study. All EQ-5D domain scores were significantly lower in patients with HCV than that in HSs. The median EQ indices of patients with CHC and LC were 1.0 and 0.9, which were higher than that in Spain. EQ VAS of patients in the two groups was 60.0, which was lower than that in Spain .Significant association between scores on EQ-5D subscales and CLDQ domains was observed. Overall CLDQ scores were highly associated with the six domains, and the associations between WO and other domains were the lowest. Compared to the EQ index, EQ VAS had a lower association with each domain of the CLDQ, and the results were consistent with the previous report . The higMultivariate linear regression was performed to confirm the effect of variables on CLDQ and EQ-5D scores while controlling the influence of other variables. Regression analysis showed that female sex, patients with family history of hepatitis, other comorbid chronic diseases, drinking, and disease duration ≥ 10 years were the predictive factors of overall CLDQ scores. We found out that female sex had negative influence on HRQOL. Similarly, findings from a study in Thailand revealed that females have more health concerns and are more treatment-seekers than males . TakahasCompared with HSs, HCV infection had a greater negative impact on HRQOL in patients with CHC and LC. The significant factors associated with HRQOL include female sex, patients with a family history of hepatitis, other comorbid chronic diseases, drinking, and disease duration ≥ 10 years. Patients with HCV infection in the rural areas should be paid careful attention regarding their HRQOL with proper health education and disease management.


This study aimed to optimize computed tomography (CT) parameters for detecting ground glass opacity nodules (GGNs) using a computer-assisted detection (CAD) system and a lung cancer screening phantom.A lung cancer screening phantom containing 15 artificial GGNs  in the left lung was examined with a CT scanner. Three tube voltages of 80, 100, and 120 kVp were used in combination with five tube currents of 25, 50, 100, 200, and 400 mA; additionally, three slice thicknesses of 0.625, 1.25, and 2.5 mm and four reconstruction algorithms of adaptive statistical iterative reconstruction (ASIR-V) of 30, 60, and 90% were used. For each protocol, accuracy of the CAD system was evaluated for nine target GGNs of 6, 8, or 10 mm in size. The cut-off size was set to 5 mm to minimize false positives.Among the 180 combinations of tube voltage, tube current, slice thickness, and reconstruction algorithms, combination of 80 kVp, 200 mA, and 1.25-mm slice thickness with an ASIR-V of 90% had the best performance in the detection of GGNs with six true positives and no false positives. Other combinations had fewer than five true positives. In particular, any combinations with a 0.625-mm slice thickness had 0 true positive and at least one false positive result.Low-voltage chest CT with a thin slice thickness and a high iterative reconstruction algorithm improve the detection rate of GGNs with a CAD system in a phantom model, and may have potential in lung cancer screening. The term ‘subsolid nodules (SSNs)’ include both pure ground-glass nodules (GGNs) and part-solid nodules . A GGN iA computer-assisted detection (CAD) system detects a specific lesion in an image using a computer algorithm . On chesTherefore, optimizing the CT parameters is an important factor in increasing the accuracy of the CAD system for identifying SSNs, particularly GGNs. However, limited studies have been conducted on this topic. Therefore, in this study, we conducted a preliminary study to optimize the CT parameters to detect GGNs using a CAD system and a lung cancer screening phantom.A lung screening CT (LSCT) phantom  was used for optimization of the CT protocol to identify GGNs. Several previous phantom studies used this phantom for the detection of GGNs –19. The All CT scans were performed with a 256-row multi-detector CT scanner . Chest CT was performed using a helical technique and a mediastinal window setting with the following exposure parameters: Three tube voltages of 80, 100, and 120 kVp in combination with five tube currents of 25, 50, 100, 200, and 400 mA. The data were reconstructed with three slice thicknesses of 0.625, 1.25, and 2.5 mm; four different reconstruction algorithms of adaptive statistical iterative reconstruction (ASIR-V) of 30, 60, and 90% on the scanner workstation. Each of the variables was determined by dividing the parameters in the clinically available range into 3~5 sections. All CT images were transferred to the picture archiving and communication system  and CAD system for analysis.Two radiologists  analysed the CT scans. The CAD system used in this study was Lung VCAR from GE healthcare. For each protocol, the accuracy of the CAD system was evaluated for the nine target GGNs that were 6, 8, or 10 mm in size and present in the left lung Figs . The cutThree factors were used to evaluate the detection accuracy for each parameter. First, the true-positive rate (TPR) was defined as the percentage of the total number of nodules identified using each parameter divided by the total number of nodules in each parameter. Second, the number of FP per examination result was defined as the sum of identified false positive nodules per examination of each parameter. Lastly, we determined the optimal combination of parameters for the detection of nodules. For statistical analysis, logistic regression using the generalized estimating equation method, including the main effects for each CT parameter, was used . All analyses were performed by SAS  software.There were 60 combinations in each tube voltage, and the number of true positive nodules and FP nodules found at each tube voltage were obtained . At tubeThere were 36 combinations for each tube current, and the number of true positive nodules and FP nodules found at each tube current were obtained . When thThere were 60 combinations for each slice thickness. The TPR and number of FP were obtained by counting the number of true positive and FP nodules in each slice thickness . When thThere were 45 combinations for each reconstruction method . When thAmong the 180 combinations of tube voltage, tube current, slice thickness, and reconstruction algorithms, 80 kVp, 200 mA, and 1.25 mm slice thickness with an ASIR-V of 90% had the best performance in the detection of GGNs with six true positives and no FPs. For 80 kVp, 400 mA, and 1.25-mm slice thickness with an ASIR-V of 90%, there were five true positives and one FP; for 100 kVp, 100 mA, and 1.25-mm slice thickness with an ASIR-V of 90%, there were four true positives and one FP; 100 kVp, 50 mA, and 1.25-mm slice thickness with an ASIR-V of 90% resulted in four true positives and one FP; and for 120 kVp, 25 mA, and 1.25-mm slice thickness with an ASIR-V of 90%, there were four true positives and three FPs . Other cIn the present study, chest CT at a low voltage with a thin slice thickness and a high iterative reconstruction algorithm improved the detection rate of a CAD system for small GGNs in a phantom model. However, overly thin slices hampered the CAD system.3 (atomic number), contrast increases with the atomic number of the nodule [In our study, as the tube voltage increased, the TPR decreased and the number of FPs increased significantly. Therefore, according to our results, the detection rate of GGNs using the CAD algorithm decreases as the tube voltage increases. Considering the photoelectric effect, the contrast between nodules and the lung parenchyma increases as the tube voltage decreases. Because the probability of the photoelectric effect is proportional to Ze nodule . Howevere nodule ,22.According to our result, as the tube current increased, the TPR tended to increase significantly but the number of FPs did not significantly differ. The image noise decreases as the tube current increases, and when the tube voltage, slice thickness, and reconstruction method are fixed, the contrast-to-noise ratio (CNR) tends to increase and the noise tends to decrease significantly with increasing tube current .As the slice thickness increased, both the TPR and number of FPs increased, indicating that the detection rate increased with increasing slice thickness . The difAs the ASIR-V value increased, the TPR was significantly increased and there was no significant difference in the number of FPs. In the study by Yanagawa et al. , the senResearch on early lung cancer screening by detecting SSNs using the CAD algorithm has been limited. GGNs, in particular, are more difficult to detect using the CAD algorithm because of the small difference in attenuation with regard to the lung parenchyma. Benzakoun et al. evaluateThere are some limitations to our study. First, our study aimed to detect artificial GGNs in a phantom. Therefore, it is uncertain whether these results could be applied to the detection of GGNs in actual patients or in solid nodules. In daily practice, there are both solid and subsolid nodules, which might have different optimal CT parameters. Some parameters, such as slice thickness and iterative reconstruction, could be changed after image acquisition. However, some parameters, such as tube voltage or tube current, should be selected prior to CT scanning. However, we focused on optimizing the CT parameters for GGNs because there have been several studies that have shown that the CAD detection rate is adequate for detecting solid nodules. Further studies are required that evaluate the optimized CT parameters for solid and subsolid nodules simultaneously. Second, in our study, GGNs <5 mm were not detected because of the characteristics of the lung VCAR CAD program, which can only detect nodules having a size of more than twice the slice thickness. However, in real practice, both solitary GGNs and part-solid nodules <6 mm in size are not clinically significant ; therefoLow-voltage chest CT with a thin slice thickness and a high iterative reconstruction algorithm might improve the detection rate of a CAD system for small GGNs in a phantom model, and may have potential in lung cancer screening.S1 File(XLSX)Click here for additional data file.


P < 0.05), whereas superficial lipid level was not improved significantly until week 6 (P < 0.05), and roughness of the skin surface was not improved significantly during the whole treatment. The stratum corneum hydration of lesional skin was significantly increased after three times of treatment (P < 0.05). No observable adverse effect, such as marked erythema, blistering, or atrophy, was observed. Sequential transdermal delivery of small molecular weight drugs  using NTJI is a safe, low-toxicity, and take-home drug-free therapy for the treatment of FSD.Facial seborrheic dermatitis (FSD) is a common facial inflammatory dermatitis. Needle-free transdermal jet injection (NTJI) is a non-invasive injection of drug solution by using a high-pressure liquid injection instrument. To explore a safer, more tolerable, and convenient medical way using NTJI in the treatment of FSD, the patients were treated with vitamin B6, glycyrrhizin compound, metronidazole, and hyaluronic acid sequentially using NTJI every 2 weeks, and only those treated for more than three times were included. A VISIA facial imaging system for the evaluation of erythema, superficial lipid level, and roughness of skin surface and a CK analyzer for biophysical parameters, including the stratum corneum hydration, facial surface lipid, and trans-epidermal water loss, were applied. Erythema was significantly reduced after every treatment (weeks 2, 4, and 6;  Malassezia furfur), and lifestyle factors may be associated with the development of FSD. Topical corticosteroids or other anti-inflammatory ointments have been the mainstay of treatment, but their use has been limited by potential adverse effects such as irritation, telangiectasia, skin atrophy, and rebound after discontinuation , characterized by variable erythematous plaques with oily-yellow desquamation, is a common chronic inflammatory skin condition of the face with a high incidence and prevalence   may further disrupt the epidermal barrier function. Therefore, a comprehensive approach for FSD should include not only cause-relative but also epidermal barrier repairing. Thus, a typical formulary in the treatment of FSD should include antipruritics, anti-inflammatories, and skin barrier repairing. A combination of different therapies to treat FSD may be more effective and could be related to fewer adverse reactions as compared with monotherapy .Vitamin B6 has a role in assuring normal structure and function of the skin and has been used clinically in the treatment of SD for several decades , 4. GlycTransdermal delivery of drugs has many advantages over other routes of administration, including the accessibility of the skin and the large surface area available for delivery. Hypodermic needles are the most commonly used instruments for the delivery because of the skin barrier by the stratum corneum. Issues such as pain, needle-stick injuries, patient compliance, needle phobia, and contamination associated with the reuse of needles have spurred the development of new drug delivery systems. Needle-free transdermal jet injection (NTJI) is a novel liquid drug delivery technology, which uses an inert gas, such as carbon dioxide, nitrogen, or helium, as a power source for drug delivery . The ineIn this study, we retrospectively analyzed patients in whom FSD had been diagnosed and treated with NTJI by sequential delivery of a formula including vitamin B6, compound glycyrrhizin, metronidazole, and hyaluronic acid.This study has obtained clearance from the ethics committee of Shenzhen Hospital, Southern Medical University. We retrospectively analyzed 374 patients in whom “FSD” had been diagnosed and treated with NTJI from May 2017 to December 2019. All patients had continuous symptoms of FSD, which had persisted for more than 1 month. Subjects included in the analysis were those who had undergone at least three NTJI treatments. Neither systematic medication nor other facial topical intervention during the course of the study was concurrently applied. The exclusion criteria were as follows: (1) medication of oral or topical corticosteroids, retinoids, calcineurin inhibitors, or antifungals within 2 weeks before enrollment; (2) the interval between treatments was not 2 weeks; (3) allergic to components of any drugs in this study; (4) complicated with other dermatoses in the facial area; (5) did not continue the same drug formulas; (6) with systemic disease such as diabetes, hypertension, HIV infection, and malignant tumor; (7) failure to continue follow-up; (8) having a neurological disorder or mental disorder; (9) pregnant or lactating women. The study flow is shown in For patients with FSD, we sequentially delivered the therapeutic solutions, as 4 ml of vitamin B6, 20 ml of compound glycyrrhizin, 8 ml of metronidazole, and 6 ml of hyaluronic acid equally to the forehead, chin, and cheeks. After the whole procedure of NTJI (about 50 min), the face gets more hydration than before, making them feel more smooth and soft of their skin surface. The treatment was conducted once every 2 weeks for a total of three times. Patients were advised to avoid sun exposure during the treatment and follow-up. Compound glycyrrhizin injection  consists of 40-mg glycyrrhizin, 400-mg aminoacetic acid, and 20-mg cysteine hydrochloride. Vitamin B6 injection  contained 50 mg/ml. Metronidazole injection  contained 500 mg per 100 ml. Hyaluronic acid  was at a concentration of 0.05% w/w. A needle-free transdermal jet injector was obtained from QIZHI Inc. . The handheld drug delivery device is powered by pressurized carbon dioxide gas. Both VISIA skin analysis imaging system  and CK analyzer with three detection probes  were applied to evaluate the efficacy.Clinical photographs were taken on pretreatment and 2 weeks after each treatment. The effectiveness evaluation was performed by using the VISIA skin analysis imaging system. All measurements were done in the same area and location by the same physician assistant. The mean values were then calculated from these readings. The absolute scores, red area present for the extent of the erythema, porphyrins for superficial lipid level, and pores for the roughness of skin surface, which were generated by the analyzer system automatically, were used as the objective quantitative standard. The absolute score is proportional to the skin characteristics, that is, the higher the absolute score is, the more serious the symptom is. The biophysical parameters were obtained by using the CK analyzer, including facial surface lipid, trans-epidermal water loss (TEWL), and stratum corneum hydration.Investigator Global Assessment (IGA) score  and the Patients' satisfaction with the results was collected at the last follow-up. Improvement of erythematous plaques and seborrhea was scored as follows: 0, worsen; 1, no change; 2, mild (lesion clearance < 25%); 3, moderate improvement (lesion clearance 25–50%); 4, good (lesion clearance 50–75%); and 5, significant (lesion clearance > 75%) .Either worsening of the erythema, scale/flaking, or enlargement of the lesion was considered a recurrence. The total recurrence rate was determined as the percentage of recurrence patients with any symptoms mentioned earlier. Adverse effects such as hypopigmentation, desquamation, edema, and erythema were recorded throughout the entire study.t-test was used to compare the results before and after treatments . Chi-square was performed to evaluate patients' subjective satisfaction, and a non-parametric Wilcoxon test was used to analyze the IGA score. All P-values were bilateral, and a P < 0.05 or < 0.001 was defined as statistical significance.The results were denoted by mean ± SD. SPSS 23.0  and GraphPad 7.0 were used for the statistical and graphing analysis. A coupled After layers of screening per the inclusion and exclusion criteria, 72 subjects  of age 26.84 ± 8.27 years with disease duration of 7.12 ± 2.55 months were included in the study after three times treatment of NTJI. The youngest patient in the study was 16 years of age, and the oldest was 48.P < 0.001), whereas the superficial lipid level was improved significantly in week 6 (P < 0.05) (In comparison with baseline data obtained before the first treatment (week 0), erythema was decreased significantly after every treatment  , 3, reveP < 0.05). The facial surface lipid and TEWL scores were also comparable after three treatments, and they were improved gradually from baseline to week 6. However, the difference was not statistically significant.The mean change values of the biophysical parameter from week 0 to weeks 2, 4, and 6 are shown in P < 0.05). In patients' self-evaluations, 22 (31%) patients assessed the result as remarkable, 31 (43%) rated their improvement as good, 12 (17%) rated their improvement as moderate, and 7 (9%) reported poor improvement  via passive transport caused by diffusion alone. In contrast, NTJI is an active transdermaldelivery that can improve the delivery of drugs of differing lipophilicity and molecular weight, including proteins, peptides, and oligonucleotides . NTJI isIt was reported that seborrheic dermatitis is often caused by mental stress. Stress often indicates a poor prognosis, and depression is more common in patients with facial involvement. Anxiety is an aggravating factor, too . NTJI haThis was a retrospective study where all subjects were placed in a single cohort following the same fixed treatment strategy. The result of this study showed that delivering the comprehensive treatment package using NTJI once every 2 weeks at a total of three times could help improve the erythema and surface lipid of FSD. The one index that showed continued improvement was erythema, which is the worst facial lesion on the face impacting the patient's cosmetic appearance and confidence. The IGA and patient's satisfaction were remarkable, too.Nevertheless, this was a retrospective study; the selection of individuals is not random, which may cause selection bias. Also, constrained by the scope of application of intervention measures, the research objects selected in this paper may not be representative of the experimental results. However, both subjective and objective assessments were used to evaluate the therapeutic effect to reduce bias. A randomized, double-blind clinical trial is needed to warrant the result of this study.Overall, sequential transdermal delivery of vitamin B6, compound glycyrrhizin, metronidazole, and hyaluronic acid by NTJI is a rapid, effective, convenient, and safe option for the treatment of FSD. Its compliance and tolerance were excellent.This was a retrospective study. A prospective study with control groups is needed to warrant the result of this study.All datasets generated for this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by the ethics committee of Shenzhen Hospital, Southern Medical University. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin. Written informed consent was obtained from the individual(s), and minor(s)' legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.XZ was responsible for part of data analysis and article writing. BL was responsible for data collection. HM and LL were responsible for literature search. JD, SW, and QL were responsible for data acquisition and statistical analysis. YL was responsible for design and review of the study. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Background and purpose — In Denmark, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011. We characterized the patients and identified risk factors associated with 30-day, 90-day, and 1-year postoperative mortality in Denmark from 2000 to 2014.Patients and methods — The study builds upon data from the Danish National Patients Register and the National Causes of Death Register including all acute hospitalized HF patients aged 18 years and above. Outcomes were 30-day, 90-day, and 1-year postoperative mortality. Mortality risk was analyzed with a univariable and multivariable Cox regression including predefined variables.Results — 113,721 acute hospitalized HF patients were admitted to Danish hospitals between 2000 and 2014. The 30-day mortality risk was 9.6%, 16% at 90 days, and 27% at 1 year after HF surgery. Mortality risk was similar from 2000 to 2014 while the median lengths of stay declined from 14 (IQR 8–25) to 8 (IQR 5–11) days. Male sex, increasing age, higher Charlson Comorbidity Index, per- and subtrochanteric fracture, and operation type other than total hip arthroplasty were independently associated with postoperative mortality.Interpretation — Short- and long-term mortality was high after hip fracture surgery and did not decline in Denmark from 2000 to 2014. In the Danish population, 44 per 10,000 persons over the age of 50 years suffered a hip fracture (HF) in 2011  and the National Causes of Death Register (NCDR). In Denmark, all contacts between a citizen and the healthcare system are recorded by a unique civil registration number and stored in the national registers. In the DNPR all hospital data are registered: admission, discharge, treatment, and operation date and time, as well as diagnoses and types of examination, treatment, and operation. Since 1994, all contacts have been registered and coded using International Classification of Diseases and Related Health Problems (ICD-10) from the World Health Organization; before that ICD-8 was used , S72.1 (pertrochanteric femur fracture), S72.1A (intertrochanteric femur fracture), S72.1B (trochanteric femur fracture), S72.2 (subtrochanteric femur fracture), and S72.8A . Patients were only included in the study if they had undergone a surgical procedure for their HF with a NOMESCO operation code: KNFB (primary inserting of hip joint prosthesis), KNFC (secondary inserting of hip joint prosthesis), KNFE (operation on hip joint capsula and ligaments), KNFF (operation on hip joint synovia and joint surface), KNFG , KNFJ , KNFK , KNFT , and KNFQ (amputation of hip and thighbone). Only patients undergoing HF surgery for the first time were included in the study.Diagnoses registered within 5 years of admission were used to create an individual comorbidity score using the Charlson Comorbidity Index (CCI). The ICD-10 codes in DNPR used to construct CCI in this study have previously been found to have a high positive predictive value  or median (interquartile range [IQR]), while categorical data were expressed as numbers and percentages. Univariable and multivariable Cox regressions were performed. We adjusted for the predefined variables: sex, age, fracture type, operation type, CCI score, and comorbidities . The proportional hazards assumption was checked graphically with the empirical score process  (95% CI). Trends over time in mortality were analyzed with logistic regression and number of HF and length of hospital stay were analyzed with ANOVA models. The assumptions of Gaussian distributed residuals were evaluated graphically; length of stay had to be log-transformed to fulfil assumptions.Statistical analyses were performed with SAS version 9.4 . A 2-sided p-value < 0.05 was considered statistically significant.The study was approved by the Danish Data Protection Agency . In Denmark—by law—register studies without the use of biological material do not require ethics committee approval. The study has not received any funding. None of the authors has any conflicts of interest to declare. After excluding non-acute admissions, non-hip fracture diagnosis and operation codes, we ended up with 113,957 unique HF patients in the period 2000–2014 . BaselinSupplementary data).The postoperative mortality risk was 9.6% for 30-day, 16% for 90-day, and 27% for 1-year. From 2000 to 2013, the postoperative 30-day, 90-day, and 1-year mortality risks showed no clear trend towards an increase or decrease . CardiovSupplementary data). In both the uni- and multivariable Cox regression male sex, increasing age, and CCI were statistically significantly associated with mortality. We found a statistically significant interaction between sex and age in all analyses. Moreover, the majority of the individual organ-specific comorbidities were statistically significantly associated with an increased risk of postoperative mortality (Table 4). Both existing cerebrovascular and rheumatic disease were associated with a reduced risk of postoperative mortality. Subtrochanteric and pertrochanteric fractures were associated with an increased risk of mortality, and patients undergoing a total hip arthroplasty seemed to have a reduced risk of mortality in the uni- and multivariable Cox regression analysis , the mortality risk varied but with no overall increase or decrease over time. Male sex, increasing age, higher CCI score, type of fracture, and operation were independently associated with postoperative mortality. Comorbidities such as kidney and liver disease, COPD, heart failure, dementia, and cancer with metastases had a strong association with short- and long-term postoperative mortality while the presence of a cerebrovascular or rheumatic disease decreased the mortality risk. Length of stay decreased from 2000 to 2014, from a median of 14 to 8 days. The number of surgical interventions for first-time HF was also found to have decreased in the period 2000 to 2014.Surprisingly, we found that patients with a known cerebrovascular disease had a decreased risk of postoperative mortality. These patients are treated with preventive anticoagulant drugs, thus the finding might reflect the preventive effect of anticoagulant medication on postoperative cardiovascular events and mortality. Regarding the decreased risk of postoperative mortality in patients with known rheumatoid arthritis, the improvements in the treatment of rheumatoid arthritis in the past decades could potentially explain the study result. No conclusion can be drawn on these matters, which should be further investigated.In the uni- and multivariate Cox regression, we found an association between type of fracture, type of operation, and the risk of postoperative mortality. There exists no international consensus on whether the type of fracture influences postoperative mortality following HF surgery. One study with 41,000 patients found that patients with a collum femoris fracture had a longer mean survival time compared with patients with a trochanteric fracture (Kannegaard et al. In recent years, there has been a high awareness of fast-track surgery. The goal is to operate on the patient within 24 hours of admission, achieve fast postoperative mobilization, adequate nutrition, and minimize the use of analgesic drugs (Kehlet and Dahl This study has limitations as it is an observational study and unmeasured confounding is present. The patients were selected by diagnosis and operation codes in the DNPR. Therefore, patients with incorrect coding may not be included; however, the DNPR is validated (Lynge et al. In summary, in this national Danish cohort study, patients undergoing surgery for a hip fracture had postoperative mortality of 9.6% at 30 days, 16% at 90 days and 27% at 1 year. The postoperative mortality varied between years but did not decline from 2000 to 2013. But the length of stay declined from a median of 14 days in 2000 to 8 days in 2014. Further interventional studies must be undertaken in order to improve survival after HF surgery, and potentially study whether a national fast-track program could improve postoperative survival, as seen in regional studies.  supplementary data in the online version of this article, http://dx.doi.org/10.1080/17453674.2019.1680485Tables 2–4 are available as


The important variables in this model included workload metrics and hospital type. State-level spatial lag models using first-order Queen criteria were best at estimating heart failure admission rates (R2 = 0.816). At the county level, OLS was preferred over any GIS model based on Moran’s I and resultant R2; however, none of the traditional models performed well (R2 = 0.169 for the OLS). Gradient-boosted tree models predicted 36% of the total sum of squares; the most important factors were facility workload, mean cash on hand of the hospitals in the county, and mean equity of those hospitals. Online interactive maps at the state and county levels are provided. Conclusions. Heart failure and associated expenditures are increasing. Costs of DRGs in the study increased $61 billion from 2016 through 2018. The increase in the more expensive DRG 291 outpaced others with an associated increase of $92 billion. With the increase in demand and steady-state supply of cardiologists, the costs are likely to balloon over the next decade. Models such as the ones presented here are needed to inform healthcare leaders.Background: Approximately 6.5 to 6.9 million individuals in the United States have heart failure, and the disease costs approximately $43.6 billion in 2020. This research provides geographical incidence and cost models of this disease in the U.S. and explanatory models to account for hospitals’ number of heart failure DRGs using technical, workload, financial, geographical, and time-related variables. Methods: The number of diagnoses is forecast using regression (constrained and unconstrained) and ensemble  techniques at the hospital unit of analysis. Descriptive maps of heart failure diagnostic-related groups (DRGs) depict areas of high incidence. State- and county-level spatial and non-spatial regression models of heart failure admission rates are performed. Expenditure forecasts are estimated. Results: The incidence of heart failure has increased over time with the highest intensities in the East and center of the country; however, several Northern states have seen large increases since 2016. The best predictive model for the number of diagnoses  was an extremely randomized tree ensemble (predictive R Heart failure (HF) is increasing in prevalence and affects at least 26 million adults globally  and 6.5 Age and male gender are known risk factors for HF ,7 along Chronic HF consumed an estimated 1–2% of total healthcare resources in industrialized nations in 2004 , yet HF Despite the national average of 383 people per physician in the United States, the number of people per cardiologist is 14,572 . There iWhile the general trend is up for cardiovascular disease (CVD), the growth of those entering cardiology is relatively flat. It is estimated that 40.5% of the U.S. population will have some form of CVD by 2030. This equates to a 3.1% incidence rate and $818 billion in cost of care . A 2018 Explanatory models for healthcare costs have included linear and penalized linear models such as a lasso regression  with reaGeospatial analyses are becoming increasingly important and relevant in the area of public health . With viSpecific research in public health has leveraged geospatial analysis to look at several aspects of heart disease such as emergency transport and interhospital transfer of myocardial infarction  as well This research seeks to understand the geospatial incidence of CHD by state and county and to build predictive models that forecast hospitals’ number of HF DRGs using technical, workload, financial, and geospatial variables. Analysis and forecasting of the raw numbers of HF DRGs provides for financial and demand estimation based on empirical inflationary pressures and existing/forecast disease rate increases. Understanding patterns is important to both policy makers, epidemiologists, and health administrators alike for cost control and planning efforts. Finally, the demand and supply analysis highlight potential shortfalls that may require redress. Data from this study come from the Definitive Healthcare dataset . DiagnosThe primary variable of interest is admissions for “heart failure” diagnoses as defined by diagnostic-related groups 291, 292, and 293 . DiagnosVariable groups evaluated in the explanatory models included four categories: financial variables, workload variables, technical variables, and geospatial temporal variables. All variables are measured at the hospital level by year. 2, the proportion of the sum of squares accounted for by variables in the model. For the non-spatial model exploration, data were divided randomly using a pseudo-random seed for replication and consistency in model comparison into 80% training and 20% test set of sizes 32,206 and 8051, respectively. Models were built on the training set and evaluated on the test set. The splitting of the data occurred prior to any imputation or transformations, so that no information would be leaked from one set to the other. The primary model selection metric for non-spatial models was RLittle data were missing (2%). Observations with 33% or more missing data were deleted. Imputation was conducted separately for the total data, the training data, and the test data. Six workload-related variables  were highly collinear and replaced with a single principal component that accounted for 84.8% and 84.9% of the variability in the total and training datasets, respectively. The workload variable for the test set was built using the linear combination estimated on the training set to avoid information leakage between the two data sets. Data were then scaled between zero and unity, as some models are not scale invariant. Linear regression, lasso regression, robust regression, elastic net regression, random forests, extra trees random forests, extreme gradient-boosted random forests, and bagging regressors estimate the DRG HF admissions. To investigate the bias–variance trade-off , we builLasso regression is a constrained regression that penalizes overfitting using an L1-norm penalty function , while ridge regression is similar to lasso regression but penalizes using the L2-norm (squared) . ElasticRandom forests are an ensemble of de-correlated tree models. Extremely randomized regression trees (extra trees) add randomness by generating random split locations for features and using the best threshold as the splitting rule . These mThe Elements of Statistical Learning tmap [sf  [sf [sp , and spagression . Online [leaflet . https://rpubs.com/R-Minator/heart [Descriptive statistics for all data are freely available online at or/heart . A roll Year over year, both DRGs and rates of DRGs per 1000 population increased as illustrated in California, Texas, and Florida had the largest number of diagnoses for all years and year over year, largely due to population size, with averages of 1.7 million, 1.6 million, and 1.5 million, respectively. When adjusted per 1000 population, the District of Columbia, West Virginia, and Delaware dominated the with total rates per 1000 population of 109, 103, and 94, respectively. Utah, Hawaii, and Colorado had the smallest average rates, 26, 29, and 35, respectively. Most hospitals were in urban settings (58%). Fifty-two percent were voluntary non-profits with 29% proprietary and 18.7% governmental. The vast majority (75%) had no affiliation with a medical school and were short-term care facilities (60%). Nearly no hospitals were classified as Department of Defense (DoD) or children’s hospitals. In Fiscal Year (FY) 2008, the Centers for Medicare and Medicaid (CMS) estimated that HF DRGs 291, 292, and 293 national average total costs per case were $10.235, $6.882, and $5.038 thousand, respectively. By FY 2012, CMS increased those estimates to $11.437, $7.841, $5.400 thousand, respectively. In four years, the accumulation rates (1 plus the inflation rate) were 1.139, 1.117, and 1.072 for the DRGs in descending order. Using these accumulation rates, estimates for 2016, 2017, and 2018 were generated. Another method for estimating these costs involved the use of the Federal Reserve Bank of Saint Louis (FRED) producer price index for general medical and surgical hospitals . The annBoth estimates are reasonably close. To estimate costs, we used both of these tables separately as upper and lower bounds. Since these total costs represent only CMS costs, the actual financial burden across all payers is likely underestimated as commercial third-party insurers can reimburse up to 90% more than Medicare for the same diagnosis . Figure In Hierarchical clustered correlation analysis of quantitative variables  illustraAnalysis of the relationship between some categorical variables and the number of diagnoses also proved interesting. Notched boxplots by year and medical school affiliation reveal that hospitals with major medical school affiliations experience a larger median number of diagnoses at the 0.05 level, a result that is to be expected. See . Further2 values of 0.501, 0.328, and 0.417 (training) and 0.454, 0.323, 0.348 (test) for the OLS, lasso, and elastic net models, respectively. The OLS model predicted better than the constrained regression models and did not overfit. Linear, lasso, and elastic net regression evaluated the number of diagnoses as a function of all other variables. Models built on the training set and applied to the training and test sets resulted in predicted R2), DRGs , and hospital type . Very few coefficients are recommended by the lasso and elastic net models. The lasso model suggests that the workload principal component and DRG 293 are important predictors, both of which are associated with reduced diagnoses ceterus parabus. Elastic net was similar in recommending inclusion of workload as well as DRG 292 and DRG 293, all associated with reduced diagnoses. The OLS model had a larger array of variables that were statistically significant, and the coefficients of the largest magnitude for the min-max scaled variables were associated with workload (−0.439), Short-Term Acute Care hospitals , cash on hand (0.082), and Critical Access Hospitals . When evaluated by categorical groups, the most significant variables were workload . The number of trees used for each estimator was tuned along with the maximum depth of the trees (number of branches). A pseudo-random number ensured that any model improvements were not due to the random number stream. All models accounted for more variance than any regression model. Random forests, extra trees regression, gradient boosting, and bagging regressors after some hyperparameter tuning on the training set predicted HF diagnoses on the test set with reasonable accuracy . A descriptive analysis of HF from 2016 through 2018 using geographical information systems was conducted to evaluate regional differences. Primarily, we were interested in rates per standardized unit in the population of the geographical area. Populations were based on Census Bureau estimates for each geographic region ,45. The https://rpubs.com/R-Minator/HeartState [Results of the state analysis are available here: artState ). There artState . 22=70.941, p < 0.001). From 2016 through 2018, the average rate of diagnoses per 1000 population increased for nearly all states. A Friedman rank sum test  of rates by state by year revealed significantly different rates by year by state  shows significant correlation between obesity and DRGs per 1000 . A Spearhttps://rpubs.com/R-Minator/heart [p < 0.001 and I = 0.306, p < 0.001, respectively) [Ordinary least square regression was performed on the state admission rate as a function of the quantitative, aggregated variables. While the model was statistically significant and accounted for reasonable variability esiduals  as well or/heart . The spactively) . Lagrangctively) ).2 for OLS, Queen, and Rook models were 0.529, 0.816, and 0.809, respectively. Queen and Rook models performed better on the state-aggregated data. The coefficient results of the spatial models were nearly identical to each other, while the OLS was obviously needed geospatial data to improve its performance ; Norton, Virginia (3.21 per 1000), Montour, Pennsylvania (3.01 per 1000); Fredericksburg, Virginia (2.13 per 1000); DeKalb, Illinois (1.95 per 1000); Harrisonburg, Virginia (1.58 per 1000); Petersburg, Virginia (1.57 per 1000); Boyd, Kentucky (1.45 per 1000); St. Francois, Missouri (1.34 per 1000); and Adams, North Dakota (1.21 per 1000). Of interest is that half of these counties are in the state of Virginia, perhaps due to the large military and veteran medical centers located in the area. Many of these counties  are small but have large healthcare facilities. p = 0.100); however, we explored further with Lagrangian multiplier diagnostics. The robust from of these statistics slightly favored a lag model. Results of the regression are in 2R = 0.169, 2R = 0.132, 2R = 0.132, respectively). Similar to what was done at the state level, an exploratory spatial regression model using first-order Queen and Rook contiguity criteria to evaluate the importance of geography was performed using rolled, Z-scaled, county-level independent variables on the county-level admission rate variable (admissions per population in each county). Moran’s I global test suggested that the OLS model was probably sufficient  was quite similar. Profit margin, and cash on hand were negatively associated with admission rates in the OLS model, ceterus parabus. All other variables had positive coefficients in the OLS model. Interpretation of directionality must be done cautiously, as the variables act together in prediction. Interactive maps of the admission rate, model residuals , as well as residuals for individual variables are provided online . The res2 for random forests, extra trees, extreme gradient boosting, and bagging regressors was 0.242, 0.292, 0.264, and 0.130, respectively. The first three models performed much better on the 20% withhold set than regression models. The variable importance analysis suggested that workload, cash on hand, and mean equity were the most important variables with importance scores of 0.35, 0.13, and 0.13, respectively.Given the small contribution of the OLS, Queen and Rook models to estimating county-level admission rates, ensemble models were investigated at the county level. With 2431 valid observations, sufficient power existed to split the data into training and test sets (80%/20%). Results of hyperparameter tuned models suggested that extreme gradient boosting was the best model as the predictive RFrom The heterogeneity found in this study and others inside the United States  is preseOur results indicate there has been a significant shift in cardiology diagnoses since 2016. As we note, it is clear that DRG 291, Heart Failure and Shock with Major Complication of Comorbidity (MCC), counts and costs have increased non-linearly. DRG 292, Heart Failure and Shock with Complication or Comorbidity (CC), has seen a small drop and DRG 293, Heart Failure and Shock without Complication or Comorbidity (CC)/Major Complication or Comorbidity, is flat. A DRG is determined by the principal diagnosis, the principal procedure, if any, and certain secondary diagnoses identified by CMS as comorbidities and complications (CCs) and major comorbidities and complications (MCCs) . A comorTree models at the hospital unit of analysis were capable of capturing close to 90% of the variability on a 20% withhold test set. The variables of most importance to this prediction were consistent with the variables found through regression modeling. Specifically, hospital type and workload variables captured by a single principal component re important in predicting the number of diagnoses by facility. This finding is particularly useful in that localities and states may forecast expected costs associated with the ever-increasing number of HF admissions with hospital-level granularity.2 = 0.816). No sophisticated predictive models were available due to the small samples size (50 states plus the District of Columbia). For the state-level GIS analysis, OLS as well as first-order Queen and Rook models were estimated, and the coefficients were both stable and congruent across models. Facility ownership and hospital type were important predictors, and the first-order Queen model provided the best variance capture  are highly costly yet coded across multiple DRGs.While it is likely that many individuals receiving care in a geographic area are from outside that county or state, the majority are likely to receive care near the vicinity of the admission, particularly since HF may result in a medical emergency. Further, the intent of the study is to explain admissions and their associated treatment locations. For public health professionals interested in where HF events (rather than admissions) occur, the state-level geospatial analysis would be more reflective as it reduces bias associated with facility locations.Although our research has demonstrated substantial reliability in the explanatory factors associated with the longitudinal growth trajectory, it does not explain the reasons why we see such substantial growth in DRG 291 versus DRGs 292 and 293. Given our study results, there are several potential drivers that could meaningfully contribute to the growth in DRG 291 from 2016 through 2018. First, there may have been a significant increase in patients with cardiac conditions and additional major comorbidities. This cannot be simply dismissed given the rapid increase in Medicare eligible beneficiaries—by some estimates as many as ten thousand per day—and the prevalence of obesity, chronic obstructive pulmonary disease, and other age and lifestyle-related conditions ,77,78. HSecond, up until October 2018, all extracorporeal membrane oxygenation (ECMO) cases were assigned to DRG 003, which typically reimburses at a rate of approximately $100,000 per case . In fiscThird, since 2010 and the passage of the Affordable Care Act, many cardiologists have sought hospital employment versus private practice. The uncertainty of continued healthcare reform efforts, burdensome electronic health record costs, declining CMS reimbursement rates in physician professional fees for non-invasive testing procedures , and younger clinicians’ different expectations related to work and personal life balance have all combined to prompt cardiology groups to seek ways to stay financially viable. Today more than 70 percent of cardiologists are employed by hospitals or health systems ,85. HospFourth, we suspect the recent transition from ICD-9 to ICD-10 that occurred in October 2015 is a contributing factor. Starting on 1 October 2015, there were 68,069 valid ICD-10-CM diagnosis codes, representing a nearly 5-fold increase from the 14,025 valid ICD-9-CM diagnosis codes. ICD-10-CM diagnosis codes are structured differently from ICD-9-CM codes and provide more detail . This coAs we look at the number of times many of the codes are being assigned to any particular patient, we see a notable change in how physicians are diagnosing. Previously, we had an ICD-9 diagnosis code with some generic areas that covered many patients. A very general and generic set of HF codes existed under 428.x in ICD-9. There was little specificity as to sidedness of the issue or specifics of the disease. ICD-10 codes allow a specific diagnosis per code, and these codes will continue to change over time due to physicians’ adaptation of coding in this manner. For example, the I50.8xx codes did not exist in 2016, but they have been used since 2017, with another change adding more sub-codes in 2018.Today, we have specific codes for specific diseases and processes which go on within the heart, to include acute on chronic concerns as well. The adjustment to ICD-10 codes has undoubtedly created a learning phase for practitioners on determining the appropriate codes as well as when and how to use them. We would expect to see some elevation from year to year with the growth of the Baby Boomer population coming into healthcare, without an age adjustment to the population. This is shown in the numbers from 2016 through 2018 with total admissions diagnoses increasing from 5.39 M to 5.61 M to 5.69 M. However, how the diagnosis codes are being applied shows variation from year to year, to include some years of negative numbers in several codes. Many of the negative values for codes are for “unspecified” types of heart disease. This shows that we are moving away from generic diagnoses and towards diagnoses based in specificity instead, which is one of the purposes of moving to ICD-10.One could draw a conclusion of upcoding: a monetary free for all, assigning diagnoses based on what pays the most. However, in many cases the physician is not billing based on a diagnosis code, but on the level of the visit and the type. This is obviously dependent upon insurance types, contracts, and other inputs outside the discussion level of this paper.The policy implications of this analysis are several. First, clearly there is a need to continue to focus on a population health approach to reduce obesity rates across the country, specifically focusing on the geographic states identified with the highest incidence and prevalence across the study timeline. The substantial increase in DRGs 291–293 show that shifting funding to prevention from chronic disease management certainly has the financial evidence to support this approach. The argument is certainly made that education is not sufficient to change lifestyle and behaviors contributing to the rise of heart disease shown here, so it is time to begin exploring a punitive annual health assessment requirement for high-risk individuals who fail to make significant risk factor changes. While a punitive health assessment might incentivize behavioral modifications and might result in lower costs, there is also the possibility that these modifications will possibly require medication and surgical interventions. Using such a strategy alone is not likely to produce the results required. The health administrator will certainly need to analyze both the volume and scope of services within these analyzed DRGs to ensure the evident increase in demand indicated will be available, specifically in the identified high incidence geographic areas. In Certificate of Need (CON) states, this analysis will be beneficial in getting the CON approved based on the increased demand. Evidence shows that CON states for cardiac services, of which most of the high incidence and prevalence states in the study are, have higher mortality rates for cardiac services . Another


ST standards, at preschool age with World Health Organization (WHO) child growth standards. The employment of INTERGROWTH-21ST Preterm Postnatal longitudinal standards during the in-hospital follow-up significantly reduced the diagnosis of short term extrauterine growth restriction when compared to commonly used cross sectional neonatal charts, with significant lower loss of percentiles between birth and term corrected age (p < 0.0001). The implementation of a package of standards at birth, preterm postnatal growth standards and WHO child growth standards proved to be consistent, with correlation between centile at birth and at follow-up, and therefore effective in monitoring growth in a moderate and late preterm infant cohort without chronic or major morbidities. Infants identified as small for gestational age at birth showed significantly more frequently a need for auxological referral.Preterm infant growth is a major health indicator and needs to be monitored with an appropriate growth curve to achieve the best developmental and growth potential while avoiding excessive caloric intake that is linked to metabolic syndrome and hypertension later in life. New international standards for size at birth and postnatal growth for preterm infants are available and need implementation in clinical practice. A prospective, single center observational study was conducted to evaluate the in-hospital and long-term growth of 80 preterm infants with a mean gestational age of 33.3 ± 2.2 weeks, 57% males. Size at birth and at discharge were assessed using the INTERGROWTH-21 Monitoring preterm infant growth is a key point in the assessment of these children during hospitalization and after discharge from neonatal intensive care unit. ,2Weight gain evaluation is used in clinical practice as a guidance to individualize nutritional intakes: as a consequence, the choice of an appropriate reference growth curve is key to achieve the best developmental and growth potential while avoiding excessive caloric intake, that is linked to metabolic syndrome and hypertension later in life. ,4In the past, fetal growth was considered the standard of growth also for the preterm neonate;  nowadaysST Project [International standards for size at birth and postnatal growth standards for preterm infants have been developed within the INTERGROWTH-21 Project , using t Project ,8 TestinFinally, since we are dealing with relatively new size at birth standards ,10, therST centiles at birth [To summarize, the present observational study was conducted in order to (1) evaluate the in-hospital growth of a population of preterm infants and the prevalence of growth failure at discharge using preterm standards compared to widely used size-at-birth charts ,12; (2) at birth ,10 of that birth ,14; (3) All infants admitted after birth to the Special Care Unit for Infants of Regina Margherita Children Hospital, Turin, Italy who have reached an age of 4 to 5 years between 1st December 2018 and 31st December 2019 (3 months deviation from the indicated ages was tolerated) were assessed for inclusion in this prospective, single center observational study.Gestational age at birth ≥ 37+0 weeks;Syndromes, conditions or diseases known to affect growth and/or requiring specific charts, e.g., Down’s syndrome or other genetic syndromes, short bowel syndrome, etc.;Chronic diseases which required prolonged parenteral nutrition.Exclusion criteria were:A total of 237 children were assessed for eligibility. A total of 124 subjects were preterm and met inclusion criteria and parents were called by phone in order to invite them to take part into the study: of those, 33 had invalid phone number, 11 refused to participate. Finally, 80 infants born preterm were included in the study.Obstetric antenatal charts were reviewed in order to record gestation complications and IUGR, defined according to the recommendations of the American College of Obstetricians and Gynecologists Neonatal records were also examined to get exact data about length of hospital stay, feeding practices during hospitalization and early morbidities.Weight, length or height and head circumference were taken at birth as well as at term corrected age and at the follow-up visit by a trained anthropometrist using an electronic scale, Harpenden stadiometer and SECA craniometer (non-extensible tape). Parents’ heights were measured in order to calculate child’s statural target ,14.At the follow-up visit all participants underwent a physical examination. Parents completed a questionnaire enquiring data on the child’s health, feeding practices, acquired vaccinations and reaching the developmental milestones.Anthropometry at birth was plotted on INTERGROWTH-21st size at birth standards ,10, anthChildren with unsatisfactory growth were referred to auxological follow-up with the following criteria: statural height lower than third percentile on WHO standards and/or height-growth-percentile falling outside parent targets and/or reduced growth velocity for sex and age calculated longitudinally with at least two measurements during follow-up. ,14 ParenSmall for gestational age (SGA) was defined as with birth weight below the 10th percentile ,18.Parents or guardians gave informed consent for inclusion of their children before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki and the protocol was approved by the Ethics Committee of Torino, code 219/2010.t-test, chi-squared test or analysis of variance (ANOVA), for example to assess the correlation between measures at birth and at follow-up. Statistical analysis was conducted using IBM® SPSS® Statistics 24.0 software.Depending on the variable and on its distribution, Eighty children  were recruited. Average age at the time of clinical evaluation was 4.21 ± 0.28 years. Additional baseline characteristics are reported in p < 0.0001).In order to assess the so-called extrauterine growth restriction, the variation of weight percentiles between birth and term “corrected” age was calculated, comparing results obtained using INTERGROWTH-21st ,10,11 anp = 0.436 for weight, p = 0.638 for length/height and p = 0.975 for head circumference, using t-test)  were evaluated, resulting normally distributed. Percentiles at birth (according to INTERGROWTH-21st) ,10 and a t-test) a–c.p-value of 0.004 for length/height and of 0.046 for head circumference.Significant individual positive correlations between percentiles of length and head circumference at birth and of height and head circumference at follow-up were detected, respectively with a moderate and a weak correlation An increase of one percentile of length at birth determined an increase of 0.352 percentiles of height at follow-up, while an increase of one percentile of head circumference at birth determined an increase of 0.214 percentiles of head circumference at follow-up.2 = 4.595; p = 0.032), while subjects who were identified as IUGR during intrauterine life (being or not SGA at birth) did not (p = 0.676).Children who were SGA at birth showed a significant increased risk of unsatisfactory growth and need to auxological referral  were hospitalized again during the first year of life. Thirty-three children (41.25%) are in clinical follow-up because of minor problems not affecting feeding nor growth and 6 subjects (7.5%) have food allergies. Vaccination rate was high in the evaluated sample: 78 children (97.5%) were regularly vaccinated, 1 child was exempt due to severe immunodeficiency and only 1 had a delayed vaccination schedule. No socioeconomic problems were present in children’s families.In the first six months of life 53.8% of infants were exclusively or predominantly breastfed, 46.2% were exclusively formula-fed, using standard formulas for preterm and then for term infants in the great majority of cases. Average weaning time was 6.00±1.09 months. No infant followed special diets and 19 children (23.75%) were given food supplements  at the time of follow-up.ST size at birth Standards [p < 0.0001) when compared to routinely used size at birth charts, among whom Fenton charts [ST size at birth standards [The main findings of the present study were first, that the use of INTERGROWTH-21tandards ,10 and otandards  thereaftn charts  were chotandards ,10 harmotandards ,14, at lST size at birth standards [Finally, being born SGA on, INTERGROWTH-21tandards ,10 is prThis study was conducted on a population of preterm infants admitted to a special care neonatal unit, without chronic or major morbidities. Most the infants were moderate and late preterm, who were reported in literature to be a population at risk of growth impairment and adverse outcome later in life, even if not as much as the severely preterm infants ,8. ST Preterm Postnatal Growth Standards [For such a vulnerable group of infants, the growth during hospitalization and the prevalence of growth failure at discharge were evaluated. A longitudinal approach is advisable in order to assess the EUGR, which can be calculated in different ways, with the percentile loss between birth and discharge or 40 weeks postmenstrual age, whichever comes first, being the most credited. In our study, the employment of INTERGROWTH-21tandards  significtandards  widely utandards  Infants ST standards [The small percentile loss experienced at discharge was recuperated over time and the distribution of percentiles at recruitment (on WHO standards) was very close to percentiles at birth in our cohort. For this cohort of moderate and late preterm infants, who did not develop relevant morbidities over the follow-up period, WHO charts ,14 repretandards ,10,11, iFinally, a focus was put on SGA infants, who are known to be at increased risk of growth faltering and developing complications. ,20,21,22Recruited children did not show significant morbidities during follow-up, average weaning age was in line with guidelines and there was high adherence to vaccination schedule.The main strengths of the study were the relatively large sample if considered that reliable and accurate measurements were taken for all subjects at least at three time points, i.e., birth, term corrected age and preschool age; the study has a major novelty that relies in its extension not only up to term corrected age, but to preschool age, and validates the use of INTERGROWTH-21ST and WHO Child growth standards as a consistent tool to monitor growth in the first years of life for preterm infants; finally, the gestational age at birth range between 30 and 36 weeks allows a good focus on moderately and late preterm infants, thus excluding confounding factors such as extremely low gestational age with its known burden of comorbidities and nutritional challenges.Limitations of the study are the retrospective collection of obstetric antenatal data, the use at follow-up visits of questionnaires, which may be affected by recall bias and the fact that approximately one third of the intended preterm infant sample could not be included, for parental refusal or invalid phone numbers.The employment of INTERGROWTH-21st charts  during tThe implementation of a package of standards at birth, preterm postnatal growth standards ,10,11 anSize at birth neonatal standards ,10 identST existent charts, that are more reliable after 32 weeks of gestational age. Those infants are also more complicated to study because of frequent comorbidities and still debated nutritional strategies.The present study was conducted on a moderate and late preterm infants cohort: future studies focused on very preterm neonates may shed light on the growth monitoring of this high risk population, even if those infants are more difficult to be followed-up on INTERGROWTH-21


These isoforms are highly overexpressed in many types of cancer, where they contribute to the acidification of the tumor environment, promoting tumor cell invasion and metastasis. In this work, in order to identify novel dual hCA IX and XII inhibitors, virtual screening techniques and biological assays were combined. A structure-based virtual screening towards hCA IX and XII was performed using a database of approximately 26,000 natural compounds. The best shared hits were submitted to a thermodynamic analysis and three promising best hits were identified and evaluated in terms of their hCA IX and XII inhibitor activity. In vitro biological assays were in line with the theoretical studies and revealed that syringin, lithospermic acid, and (-)-dehydrodiconiferyl alcohol behave as good hCA IX and hCA XII dual inhibitors.The tumor-associated isoenzymes  These enzymes are grouped into eight distinct and not related genetic families  and are a typical example of biological convergent evolution directed toward the catalysis of essential biochemical processes [hCAs) belong to the α-class and exist in 15 different isoforms, which differ for tissue distribution, subcellular localization, and catalytic activity. In particular, hCA I-III, hCA VII, and hCA XIII are cytosolic isozymes; hCA VA and VB are located in the mitochondria; and hCA IV, hCA IX, hCAXII, and hCA XIV are membrane-bound isozymes [The Carbonic Anhydrases CAs, EC 4.2.1.1) are metalloenzymes that reversibly catalyze the hydration of carbon dioxide  [hCAs inhibitors, special attention should be given to their selective profile. In fact, several drug interactions and side effects have been linked to non-selective hCAs inhibition, thus, a selective profile over the appropriate isoforms is mandatory [hCA IX and hCA XII inhibitors could be considered as potential anticancer drugs [Nowadays, cancer is ranked as the second cause of death worldwide, therefore, the development of new anticancer therapies is an urgent need ,23. In prodrugs) ,25,26, prodrugs) ,28. Furtrodrugs) ,30,31,32andatory ,33. Undeer drugs .hit compounds. The in silico studies are able to speed up the identification of bioactive compounds, thus, reducing the cost and time of research-associated activities [hCA IX and hCA XII inhibitors, we performed a SBVS using a database of natural occurring compounds. The FooDB database was used to build up a chemical library of natural occurring compounds virtually screened towards several hCAs. The most promising compounds, based on their theoretical binding energy, were further submitted to in vitro assays to point out new promising hCA IX and hCA XII inhibitors. The experimental results confirmed the computational predictions, providing the rationale behind the ligands biological activity and selectivity.In the drug discovery process, the application of computational methods has demonstrated to be important for the identification of new tivities . In parttivities ,39,40,41tivities ,43. FooDtivities  is the mStarting from the three dimensional structure of the human Carbonic Anhydrase IX in complex with 5-thiophene-2-sulfonamide and the crystal structure of the human Carbonic Anhydrase isozyme XII with 2,3,5,6-tetrafluoro-4-(propylthio)benzenesulfonamide, deposited in the Protein Data Bank (PDB) with the PDB codes 5FL4  and 5MSAhCA IX and XII catalytic binding site, equal to 0.545 and 1.059 Å for hCA IX and hCA XII, respectively.With the aim to evaluate the reliability of our molecular recognition approach, we performed redocking calculations by using the Glide Standard Protocol (SP) algorithm, which was able to reproduce the experimentally determined binding modes, obtaining Root Mean Square Deviation (RMSD) values, calculated between the best docking pose and the ligand co-crystallized into the The receptor structures were energy optimized by means of the Protein Preparation Wizard tool implemented in Maestro, using OLPS_2005 as the force field. Residual crystallographic buffer components and water molecules were removed, hydrogen atoms were added, missing side chains were built using the Prime module, and side chains protonation states at pH 7.4 were assigned ,48.For the Virtual Screening (VS) studies, the FooDB database, containing 26,680 compounds, was used . The libhCA isoforms IX (2–5) and XII (1–5) inhibitors  [hCA isoforms IX and XII inhibitors, respectively, were used to further filter the obtained hits.With the purpose to select the scored compounds according to their Glide score (G-score) value, we performed molecular docking studies of already approved and investigational hibitors , such ashibitors . Startinl v10.8) ,52 and thCA isoforms IX and hCA XII were investigated by visual inspection. Then, considering their commercial availability, we purchased the 3 best hits, which were subjected to in vitro assays.Finally, the shared compounds between both 2 hydration activity of the compounds reported was assayed by means of the Applied Photophysics stopped-flow instrument [2SO4 was added for keeping constant the ionic strength, to follow the initial rates of the enzyme-catalyzed CO2 hydration reaction for a period of 10–100 s. The CO2 concentrations for the determination of the kinetic parameters and inhibition constants ranged from 1.7 to 17 mM. For each potential inhibitor, at least six traces of the initial 5–10% of the reaction have been used for determining the initial rate.The CA-catalyzed COstrument . Phenol IS) were obtained by the nonlinear least squares methods using PRISM 3 and the Cheng−Prusoff equation, as reported earlier [in-house [The uncatalyzed rates were determined in the same experimental manner and subtracted from the total observed values. Stock solutions of the potential inhibitor (0.1 mM) were prepared by using distilled deionized water, and the dilutions with the assay buffer were prepared up to 0.01 nM. The solutions containing the inhibitor and the enzyme were preincubated for 30 min at r.t. prior to performing the assay, in order to form the E−I adduct. The inhibition constants  at 10 µM concentration. After 24, 48, and 72 h, 20 µL of 3--2,5 diphenyl tetrazolium  was added on the plate at the final concentration of 5mg/mL, and incubated for two more hours [The human colorectal cancer cells Caco-2 were maintained in Dulbecco’s Modified Eagle Medium  integrated with 10% of FBS  and 1% P/S . Cells’ culture conditions were 5% COre hours . CulturehCA IX and XII isoforms. Starting from the active set   . Therefohits (6–14) were selected  could be purchased and submitted for biological assays. Among them, compound 12 was found to have a good inhibitory activity on hCA XII [hCAs involved in tumors pathogenesis.Finally, after a careful visual inspection analysis of the best poses, nine selected . Structuisoforms . Unfortu hCA XII , thus, wAll the VS steps are summarized in 6, 12, and 14 were evaluated in vitro for their inhibition potencyagainst the most relevant hCAs such as the cytosolic and widely expressed hCAs, I and II, and the tumor-associated hCAs, IX and XII. The obtained data reported below in hCA inhibitor acetazolamide (AAZ).The selected compounds hCAs I and II with KIs >100 µM. Interesting results were obtained for the remaining isoforms:(i)14, the data reported in hCA XII isoform was 3.5-fold more potently inhibited when compared to the hCA IX  with a selectivity index  of 3.5.As for compound (ii)6, although enhanced enzymatic SIs were observed. The tumor-associated hCA XII resulted inhibited 27.0-fold more potently when compared to the IX .The same kinetic profile was also recovered for (iii)12 was already investigated as a potential inhibitor hCA on the widely expressed hCAs, I and II, and on the tumor-associated IX and XII from some authors of this manuscript and the data reported in hCA XII selective inhibition was obtained from such a substance, thus being the most potent and selective against such a tumor-associated isoform .Compound Overall, the compounds resulted ineffective inhibitors against the widely expressed 6, 12, and 14 being effective inhibitors of the tumor-associated hCA IX and XII and in particular, the latter was preferentially inhibited with KI values in the low micromolar range. Among the substances tested, compound 12 was a particularly potent inhibitor of the hCA XII, having a KI value close to the reference drug of the sulfonamide type AAZ .The kinetic data reported here clearly showed compounds hits were well recognized in the catalytic binding site of both hCA IX and XII, as shown in hCAs by means of hydrogen bond (H-bond), salt bridges, electrostatic, and cation interactions. Moreover, the better affinity of all three hits towards hCA XII could be rationalized by the higher number of good contacts and H-bonds with respect to the hCA IX isoform .6) to approximatively 50% of cell viability (12 and 14)  .Considering the aforementioned results, those compounds can have a potential anticancer activity, thus, encouraging their further development.hits. Such a scaffold is known to be incorporated in several antioxidant compounds and, more recently, was found to have a key role in inhibiting hCA I and II [The molecular modeling studies presented evidence of the presence of the phenolic moiety in all best I and II .6, 12, and 14 are food constituents, thus, confirming the strong importance of natural components as a source of lead and bioactive compounds, able to affect several biological processes in our organism. In fact, many studies in the literature have demonstrated that natural products with anti-inflammatory, antimicrobial, and antioxidant activity could be useful for multifactorial diseases [Compounds diseases ,43.hits, compound 6 is known as (-)-dehydrodiconiferyl alcohol, and belongs to the class of organic compounds known as 2-arylbenzofuran flavonoids. It has been detected, but not quantified, in coffee and coffee products and green vegetables. In the literature, it was found to exert anti-Helicobacter pylori [Among the three r pylori , antiadir pylori , and antr pylori . Recentlr pylori . Moreover pylori .6, the lithospermic acid 12 is a member of the class of 2-arylbenzofuran flavonoids and it is also known as lithospermate. Our approach highlighted it as the most interesting dual inhibitor of both hCAs, in line with a previous work related to its hCA XII [As with compound  hCA XII  proven a hCA XII ,65.14 is syringin, also known as eleutheroside b or β-terpineol. It belongs to phenolic glycosides, which are organic compounds containing a phenolic structure attached to a glycosyl moiety. Syringin was first isolated from the bark of lilac (Syringa vulgaris) by Meillet in 1841. Moreover, it can be found in caraway, fennel, and lemon, which makes syringin a potential biomarker for the consumption of these food products. Several pharmacological actions of syringin include plasma glucose reduction, antioxidation, anticancer activity, antidepressant effect, and immunomodulation [Finally, compound dulation ,67.In vitro results demonstrated that all the three hits are able to inhibit both hCA IX and XII isoforms in the micromolar range, although with a preference towards the XII target, thus, confirming their potential anticancer activity.hCA IX and XII isoforms. In particular, we proposed (-)-dehydrodiconiferyl alcohol, lithospermic acid, and syringin as good hCA IX and hCA XII dual inhibitors with a potential anticancer activity, thus, encouraging their further development. Specifically, lithospermic acid and syringin, with KI values in the low micromolar range, showed a better cytotoxic effect seventy-two hours after treatment than (-)-dehydrodiconiferyl alcohol. Interestingly, all the best hits are characterized by a phenol moiety, which has recently aroused considerable interest due to its potential antioxidant effects on human health.In this work, in silico and experimental techniques were combined to identify natural bioactive compounds present in food, such as coffee, green vegetables, common thyme, peppermint, caraway, fennel, and lemon, and are endowed with inhibition properties against both


During the bronchoscopy the patient exhibited hypotension, despite intravascular fluid resuscitation; the patient entered cardiac arrest with no response to cardiopulmonary resuscitation.A 26-year-old male with a medical history of risk sexual behavior, is brought to the Emergency Room (ER) with complaints of dyspnea associated with an oral cavity mass. At the interrogation, he referred that the symptomatology started 2 months ago with a lesion of approximately 1cm, originated from the upper gum. Patient also reported dysphonia, and dysphagia due to the expansion of the mass, and a weight loss of 10 kilograms. At physical examination a purple-black colored mass was identified coming from the oral cavity (A), including the upper gums with extension into the palate, reaching the uvula (B), the mass had exophytic margins, no tenderness at palpation with a fetid smell, multiple maculopapular violaceous lesions of approximated 1cm located in the neck, thorax and upper extremities. At palpation, bilateral cervical and inguinal adenopathies were detected, blood pressure within range, tachycardic, tachypneic but with oxygen saturation of 94% at room-air and a body temperature of 36.8°C. The laboratory tests reported anemia and thrombocytopenia, hyponatremia and an antigen-antibody test positive to HIV. A skin biopsy from skin violaceous lesions in forehead reported a positive result for Human Herpes Virus 8, within the next 48 hours the patient started with fever and hypoxemia (So