Hemiarthroplasty and total hip arthroplasty are routinely performed procedures. A comparison of these procedures in tumor patients can be performed based on complications and functional outcomes. To weigh the advantages and disadvantages of both procedures, a comparative study is indeed required to decide which procedure is more beneficial for primary bone tumor patients. The outcomes of proximal femur tumor-resected patients were collected from research reports from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 30 December 2022. Differences between these two operative procedures in primary bone tumors patients were analyzed based on dislocation, infection, local recurrence, MSTS, and HHS. Six articles were included according to the selection criteria with a total of 360 patients. Our results showed that there was a significant difference in our primary outcome as hemiarthroplasty participants encountered less dislocation than those with total hip arthroplasty. Moreover, the secondary outcomes of our study were similar. Proximal femur bone tumors, when resected, tend to produce more complications and decrease functional ability due to extensive tumor extension and soft tissue involvement. The lower dislocation rate in hemiarthroplasty participants emphasizes the importance of preserving the acetabular head in hemiarthroplasty as a key to preventing dislocation. Surgical intervention of tumor lesions of the hip is complex and requires major operative management. The proximal femur has been associated with primary bone tumors and metastatic tumors . Before Total hip replacement (THA) requires replacement of the femoral head and acetabulum. Compared with THA, HA only replaces the femoral head, which requires less technical skill from the surgeon . The benComparison of these procedures in tumor patients can be measured on the basis of complications and functional outcomes. Dislocation of the hip is a challenging complication following endoprosthesis replacement due to concomitant soft tissue involvement, especially after tumor resection. Endoprosthesis treatment of proximal femur tumor patients in several studies showed conflicting results on the basis of complications and functional outcomes ,15,16. IBy searching an abundance of literature on HA and THA treatment in patients with proximal femur tumor lesions, we conducted this meta-analysis to reach a comprehensive conclusion on the post-operative outcomes of these two procedures. These results will help us to guide the optimal management of proximal primary bone tumors located in the proximal hip region. In our study, the HA group was set as the experimental group and the THA group as the control group.This study was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines . The PRIThe MEDLINE, Cochrane, EMBASE, PUBMED, and Google Scholar databases were searched for relevant data until 30 December 2022. The reference lists of relevant studies were also hand-searched by two different authors. Keywords used for searching included primary bone tumors, metastatic tumor, proximal femur tumors, complications, dislocations, local recurrence, infection, functional outcome, HHS (Harris Hip Score), and MSTS . Then, manual searches of the reference lists of the studies found in the databases were conducted.English language studies including patients diagnosed with primary bone tumors located in the proximal femur;Studies comparing patients who had undergone THA and HA;Studies that presented comparative data in the respective outcomes of our study.4.Non-English and unpublished studies;5.Non-comparative studies in patients undergoing THA and HA with primary bone tumor;6.Case reports, reviews, and letters to editors;7.Studies that lacked adequate clinical data;Studies that met the criteria for inclusion in the review were not limited to a specific date of publication. Disputes and uncertainties regarding eligibility and viability were resolved through discussions among the reviewers, when necessary.Two authors scanned all the abstracts and titles to evaluate whether the studies addressed the questions raised by our study. Outcomes were collected from the articles by two authors of our study. The authors made a structured table, and then, collected all the data, as well as the related information, in a database. The following data were extracted from articles according to the inclusion criteria: the name of the first author, year of publication, study design and protocol, number of patients in each group, patients’ age and gender, dislocation, infection, local recurrence, MSTS, and HHS.Pieces of literature focusing on similar research issues were included, and all studies were retrospective. All studies had low bias as the studies were similar with similar inclusion criteria, surgical procedures, and study periods. Quality assessment was performed using the Newcastle Ottawa Scale (NOS) . In our 2 tests [2 value >0.5 [2 value . I2 illustrates the percentage of the total variability in effect estimates among trials that is due to heterogeneity rather than chance [The outcomes of the measurement used in our study were dislocation, infection, and local recurrence, which were dichotomous data, and MSTS and HHS, which were continuous data. We used the software of the Cochrane Collaboration (Review Manager 5.2) to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for the dichotomous data and standard mean difference (SMD) and 95% confidence intervals (CIs) for the continuous data. Statistical heterogeneity among the included studies was evaluated using I2 tests . Statistlue >0.5 . Heterogn chance . A randon = 14) and duplication in the study population with other articles (n = 8). Finally, a total of six articles were included in the meta-analysis. The study selection chart is presented in In the primary literature search, 120 relevant articles were retrieved and 62 were excluded based on the exclusion criteria. The abstracts of the remaining 58 were screened, and 30 were excluded based on the exclusion criteria. After conducting all the reviews of the remaining 28 studies, 14 were excluded due to lack of outcome of (p = 0.06), as shown in Only four of the six studies reported dislocation. Dislocation occurred in four of the six studies either in the HA group or the THA group. For this outcome, a fixed-effects model of analysis was used. There was a significant difference in the reported dislocation rate between HA and THA surgery participants undergoing surgery for primary bone tumors, and fewer dislocations were seen in the experimental HA group , as shown in Only two of the six studies reported infection. Infection occurred in two of the six studies either in the HA group or the THA group. For this outcome, a fixed-effects model of analysis was used. There was a significant difference in the reported infection rates between HA and THA surgery participants undergoing surgery for primary bone tumors, and fewer infections were seen in the experimental HA group , as shown in Only two of the six studies reported local recurrence. Local recurrence occurred in two of the six studies either in the HA group or the THA group. For this outcome, a fixed-effects model of analysis was used. There was a significant difference in the reported local recurrence between HA and THA surgery participants undergoing surgery for primary bone tumors, and fewer local recurrences were seen in the experimental HA group , as shown in Two studies reported MSTS in our study. For this outcome, a fixed-effects model of analysis was used. There was only a minimal difference in the SMD of MSTS in the operated limbs of HA participants when compared with THA participants undergoing resection for primary bone tumors , as shown in Two studies reported HHS in our study. A random-effects model of analysis was used. There was only a minimal difference in the SMD of HHS in the operated limbs of HA participants when compared with THA participants undergoing resection for primary bone tumors ; when only the second study was excluded were OR = 0.26, 95% CI 0.09–0.75, and p = 0.01; when only the third study was excluded were OR = 0.53, 95% CI 0.16–1.77, and p = 0.30; and when the fourth study was excluded were OR = 0.51, 95% CI 0.19–1.37, and p = 0.18. All the sensitivity analysis figures are shown in the Sensitivity analyses indicated that the included studies were performed to determine the reliability of the results, with each study removed in turn. The direction and magnitude of the combined estimates did not change markedly with the exclusion of individual studies, indicating that the findings of the meta-analysis are reliable and suggesting that the results of this meta-analysis are significant and non-fluctuating. Sensitivity analysis was performed for the primary outcome dislocation. The statistical value when the first study was excluded were OR = 0.44, 95% CI 0.17–1.14, and The funnel plot of the dislocation, infection, local recurrence, MSTS, and swing phase are shown in the figure added in the 2 of 89%, in which a random-effects model was selected.Overall, in our findings, there was not much heterogeneity in our outcomes; only one outcome, HHS, reported an IPatients who are candidates for wide and extensive femoral resection because of malignant tumors have long been considered a severe risk group for limb-sparing procedures because of the extent of soft tissue resection and the use of radiation therapy and adjuvant chemotherapy . The decp = 0.06). Dislocation was the primary outcome in a retrospective study conducted by Stevenson et al., and this study was conducted for participants undergoing acetabular replacement for proximal femur tumor resection [Dislocation is the most common complication encountered after proximal femur resection; rates range from 11% to 15% ,28. In oesection . The outesection . The stuesection . The stuesection . A few sesection ; both stesection . The higesection . Singh aesection , so newep = 0.30), similar to the study conducted by Zucchini et al. [All our included studies had a longer follow-up evaluation to justify the reliability of the reported local recurrence rate in our respective studies. Hip arthroplasty prosthetic infection rates of between 1% and 6% have been broadly reported ,33. Joini et al. . Functioi et al. , as was i et al. ; in bothi et al. . HHS wasi et al. . The MSTi et al. . The sixi et al. . A compai et al. . The MSTA few limitations of this meta-analysis should be illustrated. Firstly, the lack of detailed and verified data from original studies made it hard to adjust estimates by age, menopausal status, lifestyle, smoking, race, etc.; more accurate analysis requires complete data and a large sample size. Secondly, we could not study other important parameters such as aseptic loosening, revision surgery, and functional parameters (TESS). Thirdly, we could not add other studies than retrospective studies such as RCT and prospective ones, as RCT and prospective studies are high-quality and could shed more light on this rare topic; moreover, there is a lower chance of creating bias for the readers. Fourthly, since there were only a few studies published, it was difficult to obtain statistically significant results.The novelty of this study is in the rarity of this topic as limited research has been conducted in this field on these two routinely performed procedures, for which the advantages and disadvantages against primary bone tumors are studied in this meta-analysis. Other advantages of this meta-analysis are mentioned below. Firstly, a systematic review of the association between two surgical procedures (HA and THA) in primary bone tumor patients is statistically more powerful than any single study. All the studies provided significant comparative data which signified the advantages of prosthesis insertion in proximal femur resection for decreasing complications and improving functions. Secondly, all of the retrospective studies were of high quality and conformed to our inclusion criteria. Thirdly, even though the included studies were few, they still produced statistically significant results, and our study highlights the importance of arthroplasty surgery used in primary bone tumor patients on the basis of complications and limb functions. Therefore, a conclusion has been established that highlights the need for further studies elaborating on its impact on rehabilitation.


Psychological problems are prevalent in the general population, and their impacts on sleep health deserve more attention. This study was to examine the associations of OSA risk with depression, anxiety, and life events in a Chinese population.A total of 10,287 subjects were selected from the Guangzhou Heart Study. Berlin Questionnaire (BQ) was used to ascertain the OSA. The Center for Epidemiologic Studies Depression Scale (CES-D) and Zung's self-rating anxiety scale (SAS) were used to define depression and anxiety. A self-designed questionnaire was used to assess life events. Odds ratio (OR) with 95% confidence interval (95% CI) was calculated by using the logistic regression model.There were 1,366 subjects (13.28%) classified into the OSA group. After adjusting for potential confounders, subjects with anxiety  and depression  were more likely to have OSA. Subjects suffering from both anxiety and depression were associated with a 3.52-fold (95% CI: 1.88–6.31) risk of OSA. Every 1-unit increment of CES-D score and SAS index score was associated with 13% (95% CI: 1.11–1.15) and 4% (95% CI: 1.03–1.06) increased risk of OSA. Neither positive life events nor adverse life events were associated with OSA.The results indicate that depression and anxiety, especially co-occurrence of both greatly, were associated with an increased risk of OSA. Neither adverse life events nor positive life events were associated with any risk of OSA. Screening for interventions to prevent and manage OSA should pay more attention to depression and anxiety. Obstructive sleep apnea (OSA), a relatively common sleep disorder in both general and specific disease-related populations , is charMany factors including aging, male, obesity, snoring, and craniofacial and upper airway abnormalities were found to be associated with OSA occurrence , 11. IncAdverse life events, one of the major sources of social stress, were found to be related to the onset of a wide range of psychiatric disorders, such as depression, anxiety, and substance use . Some coTherefore, this study aimed to investigate the associations of depression, anxiety, and life events with OSA occurrence.Subjects in this cross-sectional study were selected from the baseline survey of an ongoing prospective longitudinal study-the Guangzhou Heart Study. A detailed description of the cohort has been presented in our previous reports , 25. In 2. If two or more categories were positive, the participant was considered at high risk of OSA and classified into the OSA group, otherwise at low risk of OSA and classified into the non-OSA group (The risk of OSA was assessed with Berlin Questionnaire (BQ) . The 10-SA group .Depression and anxiety were measured using the Center for Epidemiologic Studies Depression Scale (CES-D)  and ZungThe SAS is a 20-item scale, adopting a 4-point scale ranging from 1  to 4 . Fifteen items presented adverse experiences, and 5 items presented positive experiences with reverse scoring. Each participant was asked to select the frequency of each item and the total score was calculated by adding the score of each item. The raw total score ranged from 20 to 80, and then the raw total score was converted to an index score by dividing the sum of the raw score by 80 and multiplying by 100 . TherefoConsidering that depression and anxiety often coexist  and the Life event was defined as a social experience or change with a specific onset and course that has a psychological impact on a person . A self-2). The waist-hip ratio was calculated by dividing waist circumference (cm) by hip circumference (cm).A self-administered questionnaire was used to collect demographic and lifestyle information, including age (years), sex , education , and marital status (married and others), smoking , alcohol drinking , fruit intake , vegetable intake  and leisure-time physical activity (LTPA). The total volume of leisure-time physical activity was the sum of the volume of each type of leisure-time physical activity, which was obtained by multiplying the intensity of the physical activity by its duration and by its frequency. The physician-diagnosed disease of hypertension , dyslipidemia , cardiovascular disease  was required to report. Cardiovascular disease included any myocardial infarction, stroke, valvular heart disease, heart failure, and atrial fibrillation. Physical measurements, including height, weight, waist circumference, hip circumference, and blood pressure, were performed in line with standard instruments and protocols. Body mass index was calculated as weight divided by height squared  model of OSA and the minimal sufficient adjustment sets for estimating the direct effect of anxiety, depression, life events on OSA were adopted (2), and hypertension (category 3)] as the outcomes to eliminate the potential bias. Statistical analysis was conducted by using R (version 3.6.3). All tests were two-tailed and a P-value of <0.05 was considered statistically significant.Shapiro-Wilk test was used to examine the normality; then the chi-squared test,  adopted . UnadjusP <0.05). There was no significant difference in the occurrence of depression and adverse life events between the non-OSA group and the OSA group (P > 0.05).A total of 10,287 participants were included in this study, of which 8,921 (86.72%) were classified into the non-OSA group and 1,366 (13.28%) into the OSA group . There wP < 0.05), whereas, the mean of the volume of leisure-time physical activity was higher in the non-OSA group (P < 0.05). Besides, more participants in the non-OSA group than in the OSA group were non-smoker, non-drinker, ate fruits at least once per day, ate vegetables at least once per day, and did not have hypertension, dyslipidemia, or cardiovascular disease .The means of age, BMI and waist-hip ratio were all larger in the OSA group than those in the non-OSA group . Neither adverse life events nor positive life events were associated with any risk of OSA. The life event score was not associated with the risk of OSA, even every 1-unit increment of life event score did not reach a significant result.Participants suffering from anxiety  and depression  were associated with an increased risk of OSA after considering potential confounders . In compP−trend <0.001) and 40%  increased risk of OSA after considering potential confounders.The risk of OSA increased with the increment of the CES-D score and SAS index score . Every 1In sensitivity analysis, repeated analyses were conducted after excluding the subjects aged 60 years or above and similar consistent results were obtained , 2. We aThe results from this study manifest that the presence of anxiety and depression was associated with an increased risk of OSA and the coexistence of depression and anxiety had a more significant adverse effect on OSA risk. Neither adverse life event nor positive life event was associated with OSA risk.In this study, participants with anxiety were 2.60 times more likely to suffer from OSA than those without anxiety after adjustment for all potential confounders. This was consistent with the results from a lifestyle intervention that the persistence of anxiety was independently associated with elevated levels of sleep-disordered breathing . MoreoveDepression was observed to improve the risk of OSA in this study, which was consistent with results from a population-based longitudinal study among Taiwanese . SubjectWe found that the impact of both depression and anxiety exposure on OSA risk was much more significant than that of the single exposure. Although depression and anxiety have essentially been seen as distinct conditions, the two disorders were not mutually exclusive and often coexist to varying degrees in the same patient possibly due to the overlapped risk factors . In thisPositive life event exposure was not observed to be related to the OSA risk, which was inconsistent with reports by Tripathi et al. . StudiesGiven the significant discrepancy in life experience and physical functioning between middle-aged and elderly adults , 54, we This study has several strengths. First, we used international standardized questionnaires to ascertain OSA, depression, and anxiety, which help to minimize information bias and benefit the comparisons with counterpart studies. Second, selection bias was minimized by using the multi-stage sampling method, which could to some degree make sure that participants in this study had good representativeness. Third, we adjusted as many as covariates to control the confounders using the multivariate model. Fourth, we performed several sensitivity analyses to examine the stability of our results, and the consistent results indicate the robustness of our results.The limitations of this study are as follows. First, the prevalence of depression (1.49%) and anxiety (1.39%) in this study was lower than those in other studies which used the same instruments to assess depression and anxiety . BecauseThe results indicate that depression and anxiety, especially co-occurrence of both greatly, were associated with an increased risk of OSA. Neither adverse life events nor positive life events were associated with any risk of OSA. Screening for interventions to prevent and manage OSA should pay more attention to depression and anxiety.The raw data supporting the conclusions of this article will be available from the corresponding author upon request. A proposal with description of study objectives and statistical analysis plan will be needed for evaluation of the reasonability of requests if someone requests data sharing.The studies involving human participants were reviewed and approved by the Ethical Committee of Guangdong Provincial People's Hospital and the Ethical Review Committee for Biomedical Research, School of Public Health, Sun Yat-sen University. The patients/participants provided their written informed consent to participate in this study.XL and HD conceived and designed the study. XD, MZ, JH, LL, and HL collected the data. XD analyzed the data. XD, MZ, and JH drafted the manuscript. LL, HL, WZ, JL, WC, HD, and XL reviewed and edited the manuscript. All authors read and approved the final manuscript.This work was supported by the National Key R&D Program of China (Nos. 2018YFC1312502 and 2018YFE0208000), the Guangdong Provincial Key R&D Program (No. 2019B020230004), the Guangdong Basic and Applied Basic Research Foundation (No. 2019A1515011599), and the Science and Technology Program of Guangzhou City (No. 202102080404). The founder had no role in the design, analysis, or writing of this manuscript.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.


Given the increasing prevalence of autism spectrum disorder (ASD) and the public health problems it creates; early identification and interventions are needed to improve the prognosis of ASD. Hence, this study surveyed different groups of people who are likely to have early contact with autistic children to provide an informed basis for early detection and effective diagnosis and interventions.Three groups of people were recruited for the study from Changshou District and Wushan County of Chongqing, in Western China: 269 medical workers, 181 educators, and 188 community residents. Their understanding and knowledge of autism was measured using a self-made questionnaire.The positive finding was that the three groups had a certain level of understanding of autism, but they had some misunderstandings of the core problems, and there were significant differences in the understanding of autism among the three groups. Younger medical workers knew more about autism than older ones did. The ability of educators and community residents to identify autistic symptoms was positively related to their level of education and their experience with autistic children. Television and the internet were the main sources of information about autism for participants.The medical workers, educators, and community residents in the investigated areas in western China may be able to identify early signs of autism but have an inadequate understanding of autism. In areas far from cities, it is necessary to strengthen the training of medical workers in primary health care to promote autism screening and referral in educational institutions and communities. Using internet technology to provide public education and professional training about autism in remote areas could be a very promising method in Western China. Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by impairments in social communication and restricted and repetitive patterns of behavior, interests, or activities . Early iN = 471) reported that 83% of preschool teachers inaccurately answered more than half of the questions that assessed knowledge about ASD , and early screening for ASD has been established in communities in some areas that rely on China's three-level child health care system . ChongqiN = 1,254) have adequate knowledge of ASD, including its diagnosis, symptoms, etiology, and treatment . The Changshou District, which is located around the central urban area, is a county with a net population in-flow, and its economic level is at the upper-middle level of Chongqing. Wushan County, which is located at the city boundary in Chongqing, is a county with net population out-flow, and its economic level is at the lower-middle level of Chongqing. The study was designed as a cross-sectional survey that distributed questionnaires to different groups to determine differences in their attitudes toward and knowledge of autism. We used cluster sampling method to conduct a sampling survey on hospitals, educational institutions, and communities under the jurisdiction of local maternal and child health centers. The study was approved by the Ethics Committee of the Children's Hospital of Chongqing Medical University, Chongqing, China. All questionnaires were voluntarily completed after informed consent was provided. The respondents were divided into a medical worker group, an educator group, and a community resident group. The sample size of this study was based on the calculation formula of the cross-sectional study. Relevant research has shown that 57% to 65% of surveyed Chinese citizens , for an effective questionnaire rate of 99.2%; invalid data were not included in the statistical analysis. A total of 269 medical workers, 181 educators, and 188 community residents participated in the survey.The researcher prepared the first draft of the questionnaire, with some questions based on previous studies . Then thhttps://weixin.qq.com) was created by Tencent Technology Company and it is free to download and use. The web-based survey tool Sojump  was used to create electronic questionnaires, form the QR code of the questionnaire, and collect data. Sojump (http://www.sojump.com) is a free professional evaluation and polling platform that provides personalized services, including questionnaire design, data collection, and customized reports.The local medical and education departments and relevant community departments at the survey sites uniformly distributed the electronic questionnaire. There was no time limit for completing the questionnaire, which usually took 10–15 min to complete. If participants had any questions, the trained investigators answered them during the survey. Participants did not need to register, and they completed the questionnaire anonymously. There was an informed consent form at the beginning of the questionnaire, and participants could answer questions after they agreed. Investigators scanned the questionnaire's Quick Response (QR) code using mobile WeChat. The WeChat  for categorical data. Chi-square tests were used to analyze differences in categorical variables across the three groups. Multiple regression was performed to explore variables that might predict recognition of autism symptoms. The multiple regression analysis was performed using the stepwise method to screen variables. The inclusion criterion of variables was SLE = 0.15, and the exclusion criterion of variables was SLS = 0.10. The recognition of autism was a dependent variable. The control variables included in the multiple regression model were gender, age, occupation of medical workers, educational level, and experience with autistic children. These variables were assigned the following codes: gender ; age ; occupation of medical workers ; educational level (1 = High school or less and 2 = Higher education); and experience with autistic children . Tests of significance were two-tailed, and p < 0.001). Just over a quarter (26.4%) of medical workers and 28.7% of educators had experience with autistic children, compared to 8% of community residents. A total of 220 medical workers were engaged in clinical work, including 90 doctors and 130 nurses, and 49 were engaged in technical work. Approximately 30% (n = 82) of medical workers worked in the Department of Pediatrics, 23% (n = 63) worked in the Department of Child Health Care, 7% (n = 19) worked in the Department of Rehabilitation, 5% (n = 15) worked in the Department of Neurology, 1% (n = 3) in the Department of Psychology, and 1 worked in the Department of Psychiatry.The demographic characteristics of the 638 study participants are presented in n = 86) of the community residents thought that autism is a rare disorder, whereas 40.33% (n = 73) of educators and 34.20% (n = 92) of medical workers thought it is rare. The three groups varied widely in their opinions about the intellectual level of autistic children, and most failed to know that autism is a developmental disorder. Only 24.91% (n = 67) of medical workers, 24.86% (n = 45) of educators, and 14.89% (n = 28) of community residents thought autism is a developmental disorder; there was statistically significant difference across groups (p = 0.001). Most participants thought autism is a psychological problem. There was a statistically significant difference across groups in their recognition of the main symptoms of autism (p < 0.001). The recognition rate was highest in the group of medical workers.There were significant differences in knowledge about autism among the three groups . Most pan = 140) of medical workers, 36.65% (n = 103) of community residents, and 26.56% (n = 81) of educators. The second most frequently selected cause in each group (22% to 25%) was “abnormal brain development.”More than a quarter of participants in each group thought autism was caused by “improper family education” : this inIn response to the question, “What do you think if a child can't communicate until the age of 2, or has little eye contact with others?” most of the people in each group (91.71% to 98.51%) thought that they should go to the hospital for professional help see . When asn = 131) of medical workers said the most effective intervention is special education training, whereas 46.41% (n = 84) of educators and 55.85% (n = 105) of community residents said psychological counseling is best; there was a statistically significant difference across the groups' choices of treatment methods (p < 0.001). More than 9 out of 10  medical workers thought that autism requires long-term interventions, whereas 77.90% (n = 141) of educators and 77.60% (n = 146) of community residents thought long-term treatments are needed for autistic children. When asked, “Where can autistic children get interventions?,” the most common responses were hospitals, rehabilitation institutions, and psychological clinics. More than 9 in 10  educators and 89.59% (n = 241) of medical workers said autistic children should receive special education services in school, whereas only 79.26% (n = 149) of community residents thought they should; the difference across groups was statistically significant (p < 0.001).The vast majority of participants in each group agreed that autism requires treatment . Nearly n = 142) of medical workers and 47.87% (n = 90) of community residents thought autism can be completely improved by early intervention, compared to 36.46% (n = 66) of educators (p < 0.001) ~ 25–30% of participants in each group said early detection and treatment can improve the prognosis of autism.More than half .Television and the internet were the main sources of information about autism for participants, with hospitals being a far less common third source . Medicalp < 0.05). The results showed that young female medical workers, especially doctors, had relatively better ability to identify autism, compared to other medical workers. The educational level of the teacher group was positively related to their ability to recognize autism (p < 0.05), wherein teachers with higher education levels had a greater ability to identify autism. Educational level was also positively related to the ability to identify autism in the community residents group (p < 0.001); that is, community residents with higher educational levels had a greater ability to identify autism. No significant correlation was found between gender and the ability to identify autism. The ability to identify autism was better (p < 0.05) for the educator and community residents groups, and people who had experience with autistic children.The results of the multiple regression on variables predicting the ability to correctly identifying symptoms of autism are shown in Early detection and diagnosis are important prerequisites for obtaining a good therapeutic effect for ASD . The pubIn our research, the two study areas differed in their geographical locations, economic development, and population flow. Some studies have shown that economies and cultures may affect the public's knowledge, stigmatization, and identification of autism –22. The This paper further analyzes and discusses differences in understanding autism among three different populations. It also provides a basis for relevant government departments to conduct community health professional training and health education, and to conduct targeted publicity and education, or professional knowledge training, to promote the early detection and diagnosis of autistic children as soon as possible.Overall, most people in the three groups knew of autism and had some simple knowledge about autism, which is the “good news” of our study. Medical workers had a better understanding of autism-related information and recognition of autistic symptoms. However, some misunderstandings about ASD were found by this survey. Most people in all three groups thought autism was uncommon. This was especially true in the educator and community resident groups. Many studies have also reported that variations in ASD incidence rates are related to the ability to identify and diagnose autism in different populations , 24. A JEarly identification is key to diagnosing ASD. At present, the doctors who can screen and diagnose autism in China are mainly developmental-behavioral pediatricians, child health doctors, psychologists, and psychiatrists . HoweverMore than 90% of the participants in each group recognized that autism requires an intervention, and medical workers and educators agreed that autism requires long-term training and recognized the importance of special education in schools, which is positive awareness. Effective treatment for children with ASD involves an interdisciplinary approach. It includes a combination of educational interventions, behavioral therapies, speech-language therapy, occupational/physical therapy, and medical treatment . Evidence-based research shows that effective intervention methods include Application Behavior Analysis (ABA), Naturalistic Teaching Strategies, and Pivotal Response Treatment . In ChinMedical workers in our survey were more likely to identify the core symptoms of autism than educators and community residents were, which may be because medical workers can obtain more relevant knowledge. Television and the internet were the main ways of obtaining knowledge of autism in our study, but medical workers can acquire more information from hospitals, communities, newspapers, and books than the other two groups can. In China, the maternal and child health service network includes maternal and child health institutions and primary medical and health institutions, which provide health services for women and children. Primary health care workers receive relevant medical training on a regular basis. Many regions have conducted community autism screening and referral . Our survia multipoint video conferencing. The results showed that this model builds knowledge and fosters expertise among PCPs, enabling them to provide family-centered, best-practice care, while reducing health care inequities. In many remote areas of China, autism-related services are lacking or insufficient. However, there are maternal and child health care systems. Therefore, based on China's three-level maternal and child health care system, we plan to conduct further public education and professional development/training on autism in the two surveyed areas of Chongqing in the future. We will explore the mode of combining remote training with on-site guidance in the hope of improving autism services in Western China further.For underserved areas, public education about autism is needed and/or the professional development/training for medical workers, educators, and communities needs to be improved. Given the differences in people's understanding of autism, targeted training for different groups should be conducted, which should be presented through a variety of methods. Remote technology based on in the internet has the potential to provide timely and low-cost alternatives to expand access to specialist services to people in remote locations, especially considering the global Corona Virus Disease 2019 (COVID-19) situation , 39. SohOur survey on awareness of information about autism included a wide range of content in Western China. Overall, most people knew of autism and had basic knowledge about autism, but some misunderstandings existed. It is necessary to strengthen the training of medical workers in primary health care to promote autism screening and referrals in educational institutions and communities. Using information technology to provide training on autism related knowledge for people in remote areas is also a very promising method.This study has some limitations. First, the study was based on a self-report questionnaire, which may be subject to reporting bias. Second, in our questionnaire, there was no section about the stigma of autism, which limits our further discussion on the impact of knowledge level and culture on public awareness of ASD. In addition, this was not a wider range of population-based study, the result only represented the situation of the selected region in western China. Further multicenter, large-scale studies are needed to investigate awareness of and knowledge about ASD in China better.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The study was approved by the Ethics Committee of the Children's Hospital of Chongqing Medical University (Ref No. 201932), Chongqing, China. All questionnaires were voluntarily completed after informed consent was provided.HW designed the study and wrote the initial draft of the manuscript. YLi, YZ, JL, SW, QD, and YT trained investigators. LG, YF, MS, ZC, LC, XL, YD, LQ, and ZS contributed to data collection. YLiu was responsible of statistical studies. QC, JC, and TL supervised the study process, reviewed, and revised the manuscript. All authors approved the final manuscript as submitted and are responsible for all aspects of the work.This work was supported by the Chongqing Science and Technology Bureau Research Project  (cstc2019jscx-msxmX0217), the Chongqing Medical Scientific Research Project  (2019MSXM037), the National Nature Science Foundation of China (82002399), and the Key Scientific and Technological Projects of Guangdong Province (Grant Number 2018B030335001) and Guangzhou City (Grant Number 202007030002).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The role of methylene blue (MB) in patients with vasodilatory shock is unclear. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of MB in patients with vasodilatory shock.We searched MEDLINE at PubMed, Embase, Web of Science, Cochrane, CNKI, CBM and Wanfang Medical databases for all observational and intervention studies comparing the effect of MB vs. control in vasodilatory shock patients. This study was performed in accordance with the PRISMA statement. There were no language restrictions for inclusion.P = 0.008; I2 = 7%]. This benefit in mortality rate was also seen in a subgroup analysis including randomized controlled trials and quasi-randomized controlled trials. In addition, the vasopressor requirement was reduced in the MB group . Regarding hemodynamics, MB increased the mean arterial pressure, heart rate and peripheral vascular resistance. In respect to organ function, MB was associated with a lower incidence of renal failure, while in regards to oxygen metabolism, it was linked to reduced lactate levels. MB had no effect on the other outcomes and no serious side effects.A total of 15 studies with 832 patients were included. Pooled data demonstrated that administration of MB along with vasopressors significantly reduced mortality [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.34 to 0.85, Concomitant administration of MB and vasopressors improved hemodynamics, decreased vasopressor requirements, reduced lactate levels, and improved survival in patients with vasodilatory shock. However, further studies are required to confirm these findings.Identifier: CRD42021281847. Vasodilatory shock is defined as life-threatening acute circulatory failure characterized by low arterial pressure, normal or elevated cardiac output, and reduced systemic vascular resistance, resulting in inadequate oxygen utilization , 2. It cMethylene blue (MB), a water-soluble dye and an inhibitor of nitric oxide (NO), is an alternative method to restore vascular tone and improve perfusion . In vasoAlthough MB may improve vasodilation, a corresponding mortality benefit was not seen overall. A recent retrospective study found that MB responders had a lower mortality compared to MB non-responders . Li et aTherefore, we performed a meta-analysis to evaluate the efficacy and safety of MB in vasodilatory shock patients. Subgroup analyses were performed to explore the benefits of MB for different populations, modes, and administration doses.This systematic review was registered at PROSPERO with the registration number CRD42021281847. It was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  AND (“Shock” or “Septic” or “Vasoplegia” or “Hypotension”). There were no language restrictions. The search strategy in provided in more detail in the 2I), oxygen consumption (VO2I)]; organ function; intensive care unit (ICU) and hospital length of stay (LOS); mechanical ventilation duration; as well as adverse effects.The initial and full-text reviews were performed independently by two authors (CCZ and YJZ). The inclusion criteria were as follows: 1) type of study: observational study or interventional study (either randomized or non-randomized); 2) population: adult patients (≥18 years) suffering from vasodilatory shock treated with routine fluid and catecholamine vasopressor therapy; 3) intervention: intravenous MB treatment vs. placebo or blank; 4) outcomes: the primary outcome was mortality without time limits, and secondary outcomes were vasopressor requirement; hemodynamic changes ; oxygen metabolism [including lactate, oxygen delivery (DOin vitro studies.The exclusion criteria were as follows: 1) oral administration of MB or MB as a prophylactic treatment; 2) lack of a baseline condition or control group; 3) lack of data on any outcome; and 4) review articles, cohort studies, case reports and studies without full text, animal and Two authors (CCZ and YJZ) independently extracted data from the included studies. The kappa coefficient was calculated as a measure of agreement about study selection and quality appraisal. Any discrepancies were resolved by the third author (ZQL), and a decision was reached by consensus.For each study, the following information was extracted: publication , participant characteristics , details of the intervention , follow-up duration, and outcome data.Two authors independently assessed the risk of bias to evaluate the quality of the included studies. The Cochrane Collaboration tool  was usedI2-test. A P value > 0.1 or I2 statistic below 50% indicated low levels of heterogeneity. In these cases, a fixed-effect model was used. Otherwise, a random-effects model (Mantel–Haenszel method) was selected. P < 0.05 indicated statistical significance. Several subgroup analyses were performed for mortality according to population (septic shock and non-septic shock), mode (intravenous injection and continuous infusion) and the design of the trial (RCTs and non-RCTs).SPSS 25.0  was used to calculate the kappa coefficient. Data analysis was conducted by RevMan 5.4 . The results are presented with forest plots using odds ratio (OR) for dichotomous data and the mean differences (MD) for continuous data. If continuous data with different units, the standardized mean differences (SMD) was used. All estimates were provided with 95% confidence interval (CI). Heterogeneity was assessed by Cochran's Q statistic and the The search strategy identified 3,937 unique publications. After excluding 1,439 duplicates and screening 2,381 titles and abstracts, 117 studies were assessed in full text for eligibility. The full-text screening excluded 102 studies for the reasons shown in The characteristics of all the included studies are summarized in n = 526, 257 in the MB group and 269 in the control group) of the 15 included studies reported mortality ranging from 0–70% with different follow-up times, including 28 days, 30 days, 90 days and hospitalization. The pooled data showed that compared with the control group, MB significantly reduced mortality in patients with vasodilatory shock . No sign of significant publication bias was observed  of the 15 included studies reported MAP, which was significantly increased by MB  revealed that MB significantly increased HR  was also higher in the MB group than in the control group  revealed no significant difference in cardiac index between the two groups  of the 15 included studies reported lactate values. The results showed that MB could significantly reduce the level of lactate  reported the incidence of renal failure, and three studies (n = 163) reported the effect of MB on creatinine. The pooled data showed that MB was associated with a lower incidence of renal failure  reported the data of alanine aminotransferase. The pooled data showed that MB could significantly reduce the level of alanine aminotransferase  and hospital LOS  were −0.41 days  reported the mechanical ventilation duration. Compared with the control group, MB had no effect on the duration of mechanical ventilation (SMD −0.47, 95% CI −1.06 to 0.13, P = 0.13; I2 = 78%; The effects of MB treatment on ICU LOS (6 studies, No serious side effects were found in this study. The adverse effects of MB reported in the included studies were blue discoloration of the skin and urine and a temporary decrease in mixed venous oxygen saturation.This systematic review and meta-analysis examined the effect of MB in 15 studies including more than 800 vasodilatory shock patients with various causes, including septic shock, vasoplegic syndrome, and ischemia reperfusion injury. The main finding is that MB as a catecholamine-sparing agent may improve the survival of patients with vasodilatory shock. For secondary outcomes, MB significantly decreased the requirement for vasopressors. MB also had the beneficial effect on hemodynamic changes, organ function, and lactate level. However, MB had no effect on mechanical ventilation duration, ICU LOS or hospital LOS.In vasodilatory shock, elevated levels of NO and activation of sGC are the main reasons for vasodilation. As an NO inhibitor, MB has the ability to restore vascular tone and increase blood pressure . AlthougOur review found that compared with placebo, MB treatment significantly reduced the mortality of patients with vasodilatory shock. Consistently, Levin et al. reported that MB was associated with a lower mortality and potentially faster reversal of vasoplegia compared to placebo in vasoplegic patients . A recenIn contrast to our study, Furnish et al.  showed tOur study further analyzed the possible mechanisms by which MB improved mortality. First, it is worth noting that almost all of the included studies used MB as an adjunct intervention to catecholamine vasopressor, which is the first choice for the treatment of vasodilatory shock . AlthougIn addition, our study found that MB had a beneficial effect on oxygen metabolism, manifested as a decrease in lactate. Consistently, a recent meta-analysis  reportedNo serious side effects were found in the included studies in this meta-analysis. The main adverse effect of MB was blue discoloration of the skin and urine. It should be noted that MB has been found to lead to local skin necrosis, increased pulmonary vascular resistance, arrhythmias, and decreased oxygen saturation . MoreoveTo our knowledge, the present study is the most extensive systematic review and meta-analysis on the role of MB in patients with vasodilatory shock, with a broad search strategy, inclusion of extensive studies and the latest research with high methodological quality. Moreover, we performed various subgroup analyses for mortality, the main outcome of this study, and generated new hypotheses for practical applications. In addition, this study was the first to analyze the effect of MB on oxygen metabolism.Several limitations should be considered when interpreting the findings of this study. First, many included studies were observational studies. The evidence level was not high enough. However, a subgroup analysis for RCTs was also performed in this meta-analysis. Second, the etiology of shock, severity of illness and MB intervention were diverse in the included studies. These can be a risk of bias and weaken the strength of the evidence. Third, although the number of included studies was large, all of them were restricted to small sample sizes. Therefore, large-scale clinical trials are needed to clarify the findings of this study.In conclusion, this meta-analysis suggests that the adjunction of continuous administration of MB to vasopressors may be associated with lower mortality in patients with vasodilatory shock with no severe side effects. Further large-scale RCTs are required to ascertain MB efficacy and safety.The original contributions presented in the study are included in the article/The study was designed by G-JZ. C-CZ and Y-JZ acquired the data, performed the analysis, and wrote the manuscript. Z-QL helped with the search criteria. Z-JH corrected and contributed to the manuscript. Tables were produced by YH. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The department of PS was ranked first in the face and external categories after analyzing the relevance of the 17 trauma-related departments in six categories of AIS, through the random forest algorithm. Of the 1108 patients in the face category of AIS, the PS group was not correlated with all outcomes, except for the rate of discharge to home (P < .0001). Upon re-verifying the results using random forest, we found that PS did not affect the outcomes. In the external category in AIS, there were 30 patients in the PS group and 56 patients in the non-PS group, and there was no statistically significant difference between the two groups when comparing the outcomes. PS has contributed considerably to the face and external regions among the six AIS categories; however, there was no correlation between plastic surgical treatment and the outcome of trauma patients. We investigated the plastic surgeons’ role based on anatomical injury, using machine learning for the first time in the field of trauma care.While plastic surgeons have been historically indispensable in the reconstruction of posttraumatic defects, their role in trauma centers worldwide has not been clearly defined. Therefore, we aimed to investigate the contribution of plastic surgeons in trauma care using machine learning from an anatomic injury viewpoint. We conducted a retrospective study reviewing the data for all trauma patients of our hospital from March 2019 to February 2021. In total, 4809 patients were classified in duplicate according to the 17 trauma-related departments while conducting the initial treatment. We evaluated several covariates, including age, sex, cause of trauma, treatment outcomes, surgical data, and severity indices, such as the Injury Severity Score and Abbreviated Injury Scale (AIS). A random forest algorithm was used to rank the relevance of 17 trauma-related departments in each category for the AIS and outcomes. Additionally,  This underscores the need for organized efforts to address the burden of traumatic events. In South Korea, amendments of laws regarding the “emergency medical service act” in 2012 resulted in the selection of regional trauma centers by the government, with the aim of reducing the preventable trauma death rate (PTDR). These regional trauma centers are modeled upon the trauma centers of nations with advanced healthcare systems, such as the United States or the United Kingdom, and they have now been established in almost every province and with high accessibility.Trauma is the leading cause of death worldwide, particularly in individuals of reproductive age. These deaths impose a significant economic burden on society, as prime working years are lost in addition to other costs.–5 Meanwhile, burn injury is also one of the principal causes of death. In the US, such traumatic and burn injuries are the most common cause of death in persons aged 1 to 44 years regardless of socioeconomic background and ethnicity, with hundreds of thousands of cases referred to hospitals annually.,4 Notably, the expansion of industry has resulted in an increase in the rate of traumatic accidents in developing nations, such as traffic accidents and gunshot wounds.Head injuries are a serious health concern that often result in severe disfigurement, disability, or death.,6 In 50 years, advancements in diagnostic and therapeutic technologies, such as imaging, microscopy, dressing materials, and surgical instruments, have also been conducive to the role that plastic surgeons play in treating patients with trauma. However, their role in trauma centers globally remains poorly defined despite providing comprehensive care for patients with critical injuries.Plastic surgeons have the skill sets to treat traumatic injuries, including management of soft tissue injuries, fractures in facial structures, neurovascular injuries, and salvaging extremities. Thus, our study aimed to investigate the contribution of plastic surgeons in trauma care using machine learning from an anatomic injury viewpoint.With the rapid development of machine learning, a more rapid and reliable multi-factor analysis can be performed. A random forest, an ensemble decision method based on random subsets with classification and regression trees, has been verified as a useful model for prediction.This retrospective study adhered to institutional guidelines and was approved by the Institutional Review Board of the Dankook University Hospital (IRB No. 2022-08-016). The study was designed to review data on trauma patients recorded from March 2019 to February 2021 in the Trauma Registry System of our hospital, which has been accredited as a regional trauma center. Of the 5264 patients in the registry, those with missing injury severity score (ISS) values were excluded. Accordingly, 455 patients were excluded. A total of 4809 patients were finally enrolled in the study. The IRB waived all patients’ consent due to the retrospective nature of the study. Participants were classified in duplicate according to the trauma-related departments while conducting the initial treatment. There were seven dedicated departments and ten supportive departments within the trauma-related departments, in accordance with the policies of the trauma care system in South Korea. The detailed information concerning the departments and number of patients in this study are as follows:Dedicated departments (7 departments) included general surgery , cardiothoracic surgery , neurosurgery , orthopedic surgery , emergency medicine , anesthesiology , and radiology .Supportive departments (10 departments) included plastic surgery , ophthalmology , otorhinolaryngology , urology , obstetrics and gynecology , internal medicine , pediatrics , psychiatry , rehabilitation medicine , and dental surgery .The trauma registry system of the institution served as a source for information on all trauma patients. Data extracted and used included age, sex, cause of trauma, progression from the emergency room . The causes of trauma included traffic accidents, falls, slipping, injuries by persons or objects, burns, and unknown causes. In addition, the severity of trauma injury was determined by referring to the Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), which are well-established anatomical measurements. The AIS assesses six predefined body regions , each ranging from 1 (minor) to 6 . The ISS, another anatomical severity index, was calculated based on the AIS. The ISS ranges from 1 to 75 points.The assessments of surgical data included the number of patients, number of operations, surgical regions, type of anesthesia, and surgical procedure. Treatment outcomes were evaluated using the duration of hospitalization , rate of ICU admission, and post-discharge progress .The random forest is composed of many decision trees that were created using a stochastic process. In the classification tree algorithm, a training set of data is divided into nodes to allow a previously unknown record to be appropriately assigned to a class at the end of the procedure. The R program version 4.04  was used to separate the data into two groups: training data (70%) and testing data (30%). We determined that four nodes per tree were needed for optimal correlation of the results. To obtain appropriate stabilization, we used the under-sampling method if one variable contributed to less than 20% of the total sample.Using this method, we were able to comprehend the relationship between the six AIS categories and outcomes among 17 departments, and it was recognized that the ranking classification was meaningful when the area under curve (AUC) was over 0.7. The strength of the correlation was represented in terms of the variable importance (mean decrease accuracy).P < .05. Statistical analyses were performed using IBM SPSS Statistics software version 21 .In each AIS category, patients were divided into two groups based on whether they had received initial treatment in the trauma bay from the plastic surgery department (PS group) or not (non-PS group). Analysis of variances in sex, cause of trauma, progression from the emergency room, the rate of ICU admission, the number of operations and post-discharge progress was assessed using the chi-square test. Analyses of age, severity score, and duration of hospitalization were conducted using t-test. All statistical significance was set at A total of 4809 patients. The number of patients in each of the six AIS categories was as follows: head and neck , face , thorax , abdomen , extremity , and external . A random forest algorithm was used to rank the relevance of 17 trauma-related departments in each category of the AIS, as shown in Figure P = .986) in both groups. The mean age of patients was 51.82 ± 18.96 years  in the PS group and 50.70 ± 20.10 years  in the non-PS group (P = .359). Traffic accidents were the most common cause of trauma in both groups, with the PS group having a significantly greater incidence than the non-PS group . According to the anatomical severity analysis, the mean of both the AIS and ISS showed no significant difference between the two groups .Of the 1108 patients in the face category of AIS, the plastic surgery (PS group) department treated 364 patients (32.9%) at the initial visit; the 744 patients (67.1%) not treated by the PS department were classified as the non-PS group. There was a predominance of male patients , and there were 20 patients that died in the non-PS group. During hospitalization, there was no statistically significantly difference between the two groups in terms of total LOS, ICU LOS, and the rate of ICU admission  . To elaborate, 259 cases in the PS group and 103 cases in the non-PS underwent plastic surgical treatment, with the average surgical procedure per operation being 1.26 ± 0.51 in the PS group and 1.15 ± 0.35 in the non-PS group respectively, with a statistically significant difference between the groups (P = .017). The face was the area most frequently operated on in both groups , and general anesthesia was the preferred anesthetic method in both groups . In both groups, open reduction was the most commonly performed surgical treatment in terms of type of procedure, followed by dressing in the PS group and debridement in the non-PS group, among all procedures   in both groups. The mean age of patients was 46.03 ± 19.37 years  in the PS group and 55.21 ± 19.52 years  in the non-PS group (P = .040). Regarding causes of trauma, traffic accidents were the most common cause in the non-PS group while burns were the most common cause in the PS group (P = .028). According to the anatomical severity analysis, the mean value for both AIS and ISS showed no significant difference between the two groups .Of the 86 patients in the external category of AIS, the plastic surgery (PS group) department treated 30 patients (34.9%) at the initial visit; the 56 patients (65.1%) not treated by the PS were classified as the non-PS group. There was a predominance of male patients , and there were 3 deaths recorded in the non-PS group. During hospitalization, there was no statistically significant difference between the two groups in terms of total LOS, ICU LOS, and the rate of ICU admission  . That is, 55 cases in the PS group and 47 cases in the non-PS underwent plastic surgical procedures, with the average surgical procedure per operation being 1.02 ± 0.14 in the PS group and 1.00 ± 0.00 in the non-PS group (P = .358). The number of cases that underwent procedures in the sum of the upper extremity and body regions was significantly higher in the PS group than in the non-PS group . The most common type of anesthesia was local anesthesia in both groups . In both groups, dressing was the most commonly performed surgical treatment regarding type of procedure, follow by debridement and skin graft, among all procedures  , whereas the non-PS group had a higher proportion of transfer to another hospital . Despite this, there was no significant difference between the two groups  were predominantly associated with the discharge to home. However, the AUC was <0.7; hence, the reliability of the result was low. Meanwhile, these departments also had a strong correlation with death, with an AUC value of 0.81 Fig. . The initial guidance on trauma care proposed by the American College of Surgeons in 1976 served as the foundation for current Level I trauma centers.,4,10 Subsequent years to early 2000s saw the establishment of “trauma systems” in every state in the US.International armed conflicts such as the First and Second World Wars and the Korean and Vietnamese wars have also catalyzed developments in motion trauma systems. Prompt evacuation, early resuscitation, and referral to competent surgical centers constitute critical lessons of these global conflicts. The American College of Surgeons acknowledged the need for an organized response to trauma and established the Committee on Treatment on Fractures in 1922, subsequently named the Committee on Trauma. Several papers discussing preventable deaths with more timely and adequate care promoted the establishment of a more structured and methodical system to manage severe trauma.,12 Level I facilities are equipped to treat patients with the most challenging traumatic injuries and are, therefore, resourced with a full range of specialist surgeons, including orthopedic, neurovascular, microvascular, cardiac, thoracic, plastic, hand, obstetric and gynecologic surgeons, as well as ophthalmologists, otolaryngologists, and urologists. Complex craniofacial injuries require multidisciplinary treatment, whereas maxillofacial trauma cases are treated by otorhinolaryngologists, oral maxillofacial surgeons, plastic surgeons, and ophthalmologists according to the Advanced Trauma Life Support (ATLS) protocol.,4,12Multiple definitive care facilities in the trauma care system form a network that covers the full range of care for all injuries, ordered into four levels of trauma centers in the US. Level I trauma facilities provide tertiary care and are central to the trauma care system. All patients who require resources either have direct access or are efficiently transported via a streamlined transfer process to reach Level I care. The facilities offer end-to-end total care, from prevention to rehabilitation, and must have sufficient material and human resources to fulfill their central roles. Organizing trauma teams that include “activation teams” is essential to ensure efficient and effective operations in regional trauma centers. The activation team, which includes at least two trauma surgeons, should be in the trauma bay within 10 minutes after the arrival of a patient with severe trauma. “Activation” of the trauma team is determined by the physiological and anatomical criteria and mechanisms of trauma as presented in Table In South Korea, a 35% PTDR was reported in 2010, which is more than twice the rate of PTDR in other advanced economies at that time. Thus, the amendments of laws regarding the “emergency medical service act” in 2012 resulted in the selection of regional trauma centers by the government, with the aim of reducing PTDR. Since 2014, between one and five regional trauma centers have been established annually, and as a result, a total of 15 facilities were operative in 2020 (17 centers have been selected until 2020). All centers are supervised by the Department of Trauma Management at the National Emergency Medical Center.,13 Simultaneously, the regional trauma center maintains a roster of on-call specialists from EY, ENT, URO, OG, IM, PD, PY, RM, MS, and PS. These specialists act as supporting specialists whose employment in the trauma center is not financed by the government. Meanwhile, the current disparity in government financing for multidisciplinary approaches continues to be criticized. Indeed, the influential contribution of plastic surgeons in trauma care is underappreciated as a result of regulations prohibiting them from serving as dedicated specialists, depriving them of adequate compensation.The government funds the nation’s trauma center, which includes funding for full-time dedicated specialists and on-call compensation. At present, only seven departments are eligible for the position of dedicated specialists: GS, CS, NS, OS, EM, DR, and AN. Facial injuries range in severity from minor chin lacerations and chipped teeth to life-threatening injuries involving the entire panfacial area that require complex airway management and extended intensive care, including surgery.,15,16 In children, facial fractures may cause permanent damage. Indeed, many pediatric maxillofacial patients suffer from malformations and functional disabilities. In the US, facial injuries cost $1.2 billion in healthcare expenses annually.,17 The complexity of craniofacial injuries necessitates specialist care by plastic surgeons, as evidenced by the fact that roughly 40% of such injuries are treated by plastic surgeons, compared to 5% by general surgeons.Patients with maxillofacial injuries are frequently treated at trauma centers worldwide. According to a 1995 analysis by the Major Trauma Outcome Study, 34% of trauma patients suffered mid-face injuries, while 25% sustained facial bone fractures.–20 A report on Level I trauma centers in India indicated that plastic surgeons treated various anatomical areas, including the upper limb (49%), lower limb (35%), head and neck (8%), and trunk (8%). Further, another study demonstrated a wide range of reconstructions in plastic surgery, including significant injuries in the extremities (40%), general wound care (36.4%), and craniofacial surgery (16.4%). According to Fox et al, procedures performed by plastic surgeons include delayed primary suturing, tangential excision of necrotic tissue, skin graft or flap coverage, and release of secondary scar contractures to manage soft tissue injuries. In our study, we found a strong relationship between the face and external injuries and plastic surgery, with the open reduction in the face area and the dressing in the external area being the most frequently performed procedures.In addition to the expertise provided by plastic surgeons for patients with complex facial injuries, plastic surgeons play a pivotal role in soft tissue reconstruction. All of the data can be used for training and validation while avoiding decision-tree overfitting, and when data are absent, the random-forest approach is relatively powerful when multicollinearity occurs. A tree that has no correlation with another has three types of nodes: the root, the internal, and the leaf. Each tree is built from all data creating the root node, and subsequent splits determined the order of importance of the predictor variables. Data are randomly separated into two groups, namely training dataset and test dataset. The training dataset is utilized to construct the random forest model using three parameters, including the number of trees created, the number of predictor variables used in each tree, and the size of each node. Then the data dataset is applied in order for this model to be validated. The test dataset can be used to make predictions, with the final prediction result being the average of all predicted values from multiple classification trees. As a result, mean decrease accuracy is calculated to estimate the relevant importance of variables within the random forest model.,24 Simultaneously, the reliability of the prediction correlation is evaluated to the area under curve (AUC), and in general, if it is 0.7 or more, it is regarded as a reliable result.However, defining a certain department’s role in the assessment of trauma patients affected by many factors is challenging. In this study, we applied machine learning to overcome the limitations of conventional statistical methods of analysis. Today, with the rapid development of the data processing, various machine learning techniques were introduced, allowing a more accurate and reliable multi-factor analysis. Among them, a random forest, an ensemble decision method based on random subsets with classification and regression trees has been verified as useful model for prediction.,26 Among them, we analyzed the trauma severity in patients using anatomical indicators such as AIS and ISS. Third, we excluded other variables that could have influenced patients’ outcomes, such as past medical history and family history, because obtaining such personal information from trauma patients at the initial evaluation was difficult. Lastly, depending on the hospital, the triage of clinical tasks may vary. At our hospital, for example, hand trauma is triaged by the PS and OS, while mandibular fractures are triaged by the PS and MS.To our knowledge, this study was the first application of the random forest algorithm to investigate the role of trauma patients. We not only found that plastic surgery was highly related to the facial and external areas, but also deduced that there was no correlation between the plastic surgical procedure and the rate of discharge to home in facial trauma patients. The latter result, in particular, was achieved by a combined evaluation of conventional statistical analysis and machine learning. Nevertheless, this study has several limitations. First, due to the retrospective nature of this study, it is not representative of South Korean regional trauma centers in general. Second, the severity of trauma patients could be evaluated in various viewpoints, but this study focused on anatomical criteria only. In general, the severity of trauma injuries is assessed according to anatomical, physiological, and comorbidity systems. The ISS and AIS are used as indicators of anatomical severity, while the Glasgow Coma Scale (GCS) and Revised Trauma Score (RTS) are physiological indices. The trauma and injury severity score (TRISS) and severity characterization of trauma (ASCOT) reflect both anatomical and physiological properties.We investigated the plastic surgeons’ role according to anatomical injury using machine learning. Plastic surgery had contributed considerably to the face and external regions among the six AIS categories; however, there was no correlation between plastic surgical treatment and outcome of trauma patients. Nevertheless, we found that the random forest algorithm is a useful method for multivariate analysis and that when it is used in combination with conventional statistical analysis methods, it supports the interpretation of the results. To our knowledge, this study was the first application of random forest algorithm in investigating the role of plastic surgeons in the field of trauma care.I would like to express my appreciation to Professor Jae Woo Chung  for contributing to the in-depth discussion about machine learning.Conceptualization: Nam Kyu Lim.Data curation: Nam Kyu Lim, Jong Hyun Park.Formal analysis: Nam Kyu Lim.Funding acquisition: Nam Kyu Lim.Investigation: Nam Kyu Lim.Methodology: Nam Kyu Lim.Project administration: Nam Kyu Lim.Resources: Nam Kyu Lim.Software: Nam Kyu Lim.Supervision: Nam Kyu Lim.Validation: Nam Kyu Lim.Visualization: Nam Kyu Lim.Writing – original draft: Nam Kyu Lim.Writing – review & editing: Nam Kyu Lim.


Microvascular invasion (MVI) is an independent risk factor for postoperative recurrence of hepatocellular carcinoma (HCC). To perform a meta-analysis to investigate the diagnostic performance of radiomics for the preoperative evaluation of MVI in HCC and the effect of potential factors.A systematic literature search was performed in PubMed, Embase, and the Cochrane Library for studies focusing on the preoperative evaluation of MVI in HCC with radiomics methods. Data extraction and quality assessment of the retrieved studies were performed. Statistical analysis included data pooling, heterogeneity testing and forest plot construction. Meta-regression and subgroup analyses were performed to reveal the effect of potential explanatory factors  on the diagnostic performance.I²=94%, 95% CI: 88, 99). Meta-regression showed that all investigative covariates contributed to the heterogeneity in the sensitivity analysis (P < 0.05). Combined clinical factors, MRI, CT and number of participants contributed to the heterogeneity in the specificity analysis (P < 0.05). Subgroup analysis showed that the pooled sensitivity, specificity and AUC estimates were similar among studies with CT or MRI.Twenty-two studies with 4,129 patients focusing on radiomics for the preoperative prediction of MVI in HCC were included. The pooled sensitivity, specificity and area under the receiver operating characteristic curve (AUC) were 84% , 83%  and 0.90 . Substantial heterogeneity was observed among the studies (Radiomics is a promising noninvasive method that has high preoperative diagnostic performance for MVI status. Radiomics based on CT and MRI had a comparable predictive performance for MVI in HCC. Prospective, large-scale and multicenter studies with radiomics methods will improve the diagnostic power for MVI in the future.https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=259363, identifier CRD42021259363. Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related deaths and the second most lethal tumor , with 90Biopsy is the preoperative reference standard for the diagnosis of MVI. Nevertheless, it is an invasive operation that may cause correlative complications and tumor seeding . In addiIn 2012, Dutch scholar Lambin  proposedThe present study followed the Preferred Reporting Items for Systematic reviews and Meta-Analysis of Diagnostic Test Accuracy (PRISMA-DTA) , and it We selected published relevant studies by systematically searching the PubMed, Embase and Cochrane Library databases without language, nation, or time restrictions. The deadline for searching the databases was June 06, 2021. We used subject words and free words such as “hepatocellular carcinoma”, “microvascular invasion”, and “radiomics” and their variations. A detailed search strategy is described in the The inclusion criteria were as follows: diagnosis of HCC by pathology after hepatectomy or liver transplantation; presence or absence of MVI by pathologic diagnosis; US, CT, MRI or PET-CT performed one month before surgery; and imaging analysis based on a radiomics algorithm. The exclusion criteria were as follows: antitumor therapy was performed preoperatively; the studies did not have enough information to construct a two-by-two contingency table; the type of study included animal experiments, nondiagnostic tests, case reports, reviews, expert opinions and conference abstracts.Data extraction and quality assessment of the retrieved studies were completed by two authors independently . Any discrepancies were resolved by consensus with a senior author . We extracted data on patient characteristics, imaging modalities, and study characteristics from each selected study. Patient characteristics included the total number of participants, the number of participants with MVI present and MVI absent, sensitivity and specificity. We tabulated the number of true positives (TPs), false positives (FPs), false negatives (FNs) and true negatives (TNs) by the number of MVI-present and MVI-absent cases, sensitivity and specificity reported in each included study. If there were two or more predictive models based on the same cohort of patients in one study, the best model reported in the study was included in our meta-analysis.We evaluated the methodological quality of the included studies by using the standard Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool  . We follWe used the MIDAS module for STATA version 16  to analyze the raw data. We calculated the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR) and their corresponding 95% confidence intervals (CI) using a bivariate regression model. Moreover, we plotted the results on a summary receiver operating characteristic (SROC) curve, and the area under the receiver operating characteristic curve (AUC) exhibited the diagnostic power of the included studies . AUCs of2I, and the difference was considered significant when P < 0.05, with 2I ≥ 50% regarded as being indicative of moderate-to-high heterogeneity among studies  are presented in The relevant characteristics and details of the 22 included studies are shown in The forest plots and comprehensive results of all studies included in this diagnostic meta-analysis are shown in I² 94%; 95% CI: 88, 99; P < 0.001). Similarly, the forest plots indicated high heterogeneity with 2I values > 50% for sensitivity  and specificity . The proportion of heterogeneity likely due to the threshold effect was small (8%). Therefore, we recorded no evidence of a threshold effect. To identify the source of heterogeneity, we performed univariable meta-regression analysis. P < 0.05). In addition, combined clinical factors, MRI, CT and number of participants contributed to the heterogeneity in the specificity analysis (P < 0.05).Considerable heterogeneity existed among the studies  had higher sensitivity  and specificity  than retrospective studies . Regardless of whether radiomics was combined with clinical risk factors to construct a predictive diagnostic model, the sensitivity  was basically equivalent for both. However, radiomics alone had a slightly higher specificity  than radiomics combined with clinical risk factors .In terms of different imaging modalities, US (n=3) had a higher sensitivity  and specificity  than CT  and MRI . On the other hand, the pooled sensitivity, specificity and AUC  estimates were similar among studies with CT or MRI.In addition, the pooled sensitivity estimates were higher in studies with 100 participants or more  than in studies with fewer than 100 participants , but the pooled specificity  showed the opposite trend. Similarly, studies without high risk according to QUADAS (n=17) had a higher pooled sensitivity  but a lower specificity  than studies with high risk according to QUADAS .Our meta-analysis showed high pooled sensitivity , specificity , and AUC  values. which demonstrated that radiomics has the potential ability to preoperatively differentiate MVI status in HCC. The confirmation of this evidence will be beneficial to the formulation of optimal preoperative therapeutic strategies for patients with MVI of HCC. For example, if the presence of MVI is confirmed preoperatively, the extent of resection or ablation will be expanded. So it has great clinical value in reducing recurrence and improving the survival rate of HCC patients.Likelihood ratios and posttest probabilities can also provide important information about the likelihood that a patient with a positive or negative test actually has MVI or not. Through our meta-analysis, a PLR of 5 indicates that the test is five times more likely to correctly judge a positive result than incorrectly judge a positive result, and the posttest probability for a positive test result is 77%. Similarly, an NLR of 0.19 indicates that the test is 0.19 times more likely to incorrectly judge a negative result than correctly judge a negative result, and the posttest probability for a negative test result is 11%. These results further indicate that radiomics has important clinical value in preoperatively evaluating the MVI status in HCC.A previous meta-analysis reported that the sensitivity, specificity, and AUC of MVI prediction in HCC were 78% , 78%  and 0.855 for radiomics and 73% , 82%  and 0.860 for non-radiomics, respectively . The resSubstantial heterogeneity among the studies was observed, so we performed meta-regression and subgroup analyses to detect the sources of heterogeneity. Due to the limitation of the number of included studies, we only performed univariable meta-regression analysis instead of multivariable meta-regression analysis. The results showed that all the observed indicators contributed to the source of heterogeneity. In addition, each included study used a different methodological design, which was only a part of the heterogeneity, and it was not possible to find all sources of heterogeneity.We used five key factors for subgroup analysis. In the study design subgroup analysis, prospective studies were better than retrospective studies. This result is reasonable given that prospective studies have a clear purpose, a thorough design, proper observational indicators and so on, suggesting that more prospective studies in the future will improve the predictive performance for MVI. However, only 2 prospective studies addressed the use of radiomics for the evaluation of MVI status in HCC, and more high-quality evidence is needed to reach more definitive conclusions. Some previous studies have shown that an MVI predictive model with combined clinical risk factors had higher diagnostic performance , 27, 42.We performed subgroup analysis to compare the diagnostic performance of radiomics based on different imaging modalities. The results showed that CT and MRI were essentially equivalent, consistent with previous studies , 43. HowWe recognize that our meta-analysis has several limitations. First, mostly retrospective studies were included in our analysis, and patient selection could introduce some bias. Second, all included studies were from China. Studies from other countries were excluded for various reasons; for example, 2 studies from the United States were excluded because we could not reconstruct the 2×2 contingency table , 46. ThuIn summary, our meta-analysis demonstrated that radiomics is a promising noninvasive method, and it has high preoperative identification performance for MVI status, which has crucial guiding significance for surgical planning of HCC patients in clinical practice. CT and MRI had a comparable predictive performance for MVI, but US and PET-CT still need to be conducted in more studies for further analysis based on radiomics methods. Moreover, it is necessary to carry out additional prospective, large-scale and multicenter studies with radiomics methods to improve the preoperative diagnostic performance of MVI in the future.The original contributions presented in the study are included in the article/Study design: LL, CW, YH, JC, DY, and ZS. Literature search and study selection: LL, CW and YH. Data extraction and quality assessment: LL, CW, JC and ZS. Statistical analysis: LL, DY and YH. Study supervision: ZS and YH. ZS obtained the research fund. Editing and review of the manuscript: all authors. All authors contributed to the article and approved the submitted version.This study was supported by the National Natural Science Foundation of China (Grant No. 82072038) and the Natural Science Foundation of Guangdong Province, China (Grant No. 2018A0303130070).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.