Currently, adrenalectomies are trending toward minimally invasive approach including robotic and laparoscopic surgery. We aimed to describe the clinical presentation and outcomes associated with the 3 different surgical approaches in patients who underwent adrenalectomy for adrenal mass at a single tertiary center.A retrospective descriptive observational study was conducted to include all patients who underwent surgical interventions for adrenal gland mass between 2004 and 2019. Patients were categorized into three groups according to the interventional approach  and data were analyzed and compared.p = 0.001), had more nonfunctional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), and were frequently operated on the right side (p = 0.03). There was no post-operative mortality; however, during follow-up, 8 patients died . The median follow-up was 746 days .A total of 124 patients underwent adrenalectomies . Incidentally discovered adrenal mass was reported in 67% of patients, and hypertension was the most prevalent comorbidity (53%). The tendency for malignancy increased with increasing tumor size while the functioning tumors were more in the smaller tumor size. Larger tumors were more common in younger patients. The robotic approach showed shorter surgical intensive care and hospital length of stay. Patients in the open adrenalectomy group frequently presented with abdominal pain (The study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach for patients with benign functioning adrenal tumors of a diameter <6 cm. However, the choice of a surgical approach varies according to the adrenal mass presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of the robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, cost, and quality of life. The prevalence of adrenal masses has significantly increased over the past few decades along with the advanced diagnostic tools . Most ofData on adrenal incidentalomas are often derived from autopsy studies which reported a prevalence rate of 1–8.7% depending on the age, tumor size, as well as the imaging tool (0.8–5%) , 3, 9. NOver the past few decades, the management of adrenal tumors has shifted from open radical adrenalectomy to advanced minimally invasive robotic and laparoscopic surgery . NotablyA retrospective comparative observational study was conducted to include patients who had adrenal mass and presented to the general surgery department at Hamad General Hospital (HGH) between January 2004 and December 2019. All adult patients of any gender who underwent surgical interventions for adrenal mass were included in the study. Indication for surgical intervention based on the clinical presentation, functionality of the adrenal lesion (whether adenoma or hyperplasia), patient fitness, and the finding on CT imaging. Regarding the clinical presentation, all functional adrenal lesions referred from the endocrine clinics were offered a minimally invasive surgical approach in the form of laparoscopic or robotic-assisted surgery as the first option unless there is a contraindication. The robotic-assisted surgery  was installed at the HGH in 2009 and becomes the approach of choice. Laparoscopic surgery was introduced in 2005 in our hospital. Patients who presented with hypotension secondary to ruptured adrenal mass with hemorrhage underwent open transperitoneal adrenalectomy. The option of angioembolization for active bleeding was done on a selective basis depending on patients' general condition, availability of surgeon, and interventional radiologist. A benign lesion on a CT scan, especially the cystic one was mostly treated with minimum invasive surgery regardless of the tumor size. Any large lesions on the CT scan (>6 cm) or suspicious of malignancy were offered open surgery.Retrieved data from the surgical database and electronic medical records included patients' demographics, clinical presentation, comorbidities, radiological findings, size and laterality of the adrenal pathology, functional status of the tumor, surgical approaches , operation time, blood loss and transfusion requirement (intra- and post-operative), complications, surgical intensive care unit (SICU) length of stay and total hospital stay, in-hospital mortality, follow-up outcome, and cause of death.The American Society of Anesthesiologists (ASA) physical status classification system was used for assessing the fitness of patients before surgery.The study was conducted in full conformance with principles of the “Declaration of Helsinki,” Good Clinical Practice (GCP), and within the laws and regulations of MoPH in Qatar. The Medical Research Center (MRC-01-20-254) at Hamad Medical Corporation has approved the study with a waiver of consent as de-identified data with no direct contact with the patients were collected retrospectively. This study follows the STROBE checklist of items that should be included in reports of observational studies .2 test and Yates' corrected Chi-square if the expected cell frequencies were below 5. The continuous variables between different groups were compared using Student's t-test or one-way analysis of variance (ANOVA) test for more than 2 groups. Receiver Operating Characteristic (ROC) curve analysis was performed for the optimum tumor size cutoff, plotted against the open surgical intervention. Patient groups were also compared based on the different tumor size. The area under the curve (AUC) and the C-statistic were calculated to evaluate the performance and discriminatory power of the tumor size. Two-tailed p values < 0.05 were considered as significantly different. Data analysis was carried out using the Statistical Package for Social Sciences version 26 .Data were presented as frequency, mean ± standard deviation, and median and range, whenever appropriate. Patients were categorized into three groups according to the interventional approach, that is, open, robotic, or laparoscopic adrenalectomy. Differences in categorical variables were analyzed using χDuring the study period, a total of 124 patients with adrenal mass underwent adrenalectomy. Robotic adrenalectomy (61.3%) was the most frequent surgical approach followed by open (22.6%) and laparoscopic adrenalectomy (16%). Eight (6.5%) patients had additional procedures along with adrenalectomy and two (1.6%) had a conversion. About 61% of patients had left-sided, 38% had right-sided operation, and one patient was operated for bilateral tumor. Adrenal carcinoma was discovered in 5 patients and metastasis from extra-adrenal cancer was found in another 5 patients. There were 2 cases that required conversion to open surgery due to bleeding from the adrenal vein during the early phase of the adoption of robotic surgery, but it did not impact the patients' s outcome.p = 0.04), had a higher frequency of ASA classification III (p = 0.001), and frequently underwent left-sided operations (p = 0.03) as compared to the other groups. The significantly higher proportion of patients with hypertension (p = 0.01) and ASA classification II (p = 0.001) had robotic adrenalectomy and this group had a smaller mean tumor size (4.9 ± 2.7 cm) than the other groups. Patients in the open adrenalectomy group were frequently presented with abdominal pain (p = 0.001), had more non-functional adrenal mass (p = 0.04), larger mean tumor size (p = 0.001), frequently were operated on the right side (p = 0.03), and had prolonged SICU stay (p = 0.001).p = 0.001) and transfusion as compared to the other groups.The ROC curve to define the optimum tumor size for open surgery showed that tumor size greater than 4 cm had an AUC of 0.94 (95% CI 0.902–0.986) with sensitivity and specificity of 100 and 47%, respectively .p = 0.001) than the other groups. Eight patients died during the follow-up period . No mortality was directly related to the operation as all the deaths occurred after 465 days . The cause of death was cardiac arrest (n = 2), advance adrenal carcinoma metastasis (n = 3), hemorrhagic shock (n = 1), advanced breast (n = 1), and colon (n = 1) cancer.The length of stay in the SICU was significantly lower in patients with robotic surgery in comparison to other procedures. The median follow-up period was significantly higher for the laparoscopic group  should be tailored based on criteria that vary according to the adrenal pathology presentation, patient fitness, surgeon skills, and hospital resources. The present study presents our local experience in the surgical management of the adrenal pathology and the changes that had happened during the past few years. The HGH is the largest teaching hospital in Qatar, with Accreditation Council for Graduate Medical Education–International (ACGME-I) accredited surgical programs. All the operations are used as an opportunity to teach the residents and fellows the operative techniques which may impact the overall operative time. During the study period, there was a restructure of the surgical department resulting in subspecialty development. This had resulted in streamlining the adrenalectomy to two surgeons . All the open adrenalectomy was done by the general surgeon, whereas the robotic approach was done by both the general and urology surgeons. This led to the wide adoption of the robotic adrenalectomy approach at the HGH. The present study is unique from an Arab Middle Eastern country to analyze the clinical characteristics and outcomes of patients with adrenal tumors treated with different surgical approaches. In addition to the long follow-up, the present study has several key findings. Incidental detection of adrenal mass was frequent, but its proportion was comparable among the different study groups. The study showed that robotic surgery is feasible in most of the adrenalectomies of variable sizes. Large tumor size (>6 cm) were removed by open (47%), robotic (44%), or laparoscopic (9%) approach. Small tumor size (<4 cm) were removed by robotic (78%) or laparoscopic (22%) approach. However, 73% of the intermediate-sized tumors (4–6 cm) were removed by robotic approach as it has better handling and manipulation of the tumor than the laparoscopic approach. Although ROC and AUC showed that tumor size greater than 4 cm is an indicator for open surgery, other factors should be considered such as tumor functionality, malignancy, surgeon experience, and physical fitness of the patient. A higher proportion of patients with severe systemic disease and not expected to survive without the operation, as per the ASA classification, underwent laparoscopic adrenalectomy. Patients who had open surgery were more likely to be admitted to the SICU with a longer length of stay. The longer intensive care length of stay and increased rate of bleeding in the open surgery group could be related to the presence of larger and right-sided tumors.However, prolonged hospital stay was observed in patients treated with laparoscopic approach as well. This may reflect the tendency to adopt more robotic surgery in fitter patients as a consequence of the restructuring of our surgical department. Although there was no post-operative mortality in the 3 groups, patients in the laparoscopic group were more likely to die during the follow-up. However, all deaths that occurred during the follow-up were not related to any of the surgical approaches.Notably, adrenal incidentalomas are common especially with the advanced age . A pool Evidence suggests that larger tumor size (>4 cm) is a predictor of malignancy, and it is recommended to resect such tumors irrespective of the functional status , 23. In A comparative study between robotic and laparoscopic resection of large adrenal tumors concluded that robotic surgery had shorter operative time and less conversion than laparoscopic resection . Notably2.In our study, one patient had bilateral open adrenalectomy and two patients from the robotic surgery group converted to open surgery secondary to bleeding from the adrenal vein. This lower rate of conversion is in line with the previous reports. Agcaoglue et al.  reportedColvin et al.  prospectIn our series, open surgery resulted in more blood loss followed by laparoscopic and robotic surgery, and the need for intraoperative and post-operative blood transfusion was also higher in the open surgery group. Brandao et al.  reportedThe retrospective design is one of the limitations of the present study. Being single center, the frequency of patients who underwent adrenalectomy in different groups in our study are higher as compared to other published studies. Internal and external validation of the study findings would be of value in prospective and multicenter studies in the region. Our hospital is the only tertiary government not-for-profit facility in the country. In addition, most of the earlier studies mainly focused on two surgical approaches while we compared the three surgical intervention groups. The follow-up period was long and was justified to come up with conclusions about the immediate and long-term complications of the 3 approaches. Also, the present study did not address information regarding the hospital and surgeon volume, experience, and skill of surgeons as it could relate to the patient's outcomes. However prior data showed that surgical sub-specialty did not significantly influence the perioperative results, but the learning curve and volume workload play an important role in the outcomes . SelectiThe study explored the three surgical adrenalectomy approaches in a dedicated center for patients with adrenal pathology. It showed that robotic adrenalectomy could be safe and effective surgical approach in patients with benign functioning adrenal tumors of a diameter less than <6 cm. However, the choice of surgical intervention depends on the case presentation, patient fitness for surgery, type and sizes of the tumor, surgeon's experience, and hospital resources. Open surgery is considered the first choice for larger, ruptured adrenal tumor, or malignancy. However, the recent restructuring of the surgical department resulted in selection bias in favor of robotic surgery. Further studies are required to address the risk factors, selection criteria for appropriate management, and impact on cost and quality of life.mrchelpdesk@hamad.qa).All data had been shown in the results section, tables, and figures. Access to raw data will need agreement from the medical research center at HMC, Doha , and within the laws and regulations of MoPH in Qatar. The Medical Research Center (MRC-01-20-254) at Hamad Medical Corporation has approved the study with a waiver of consent as de-identified data with no direct contact with the patients were collected retrospectively.HA-T and NA-T: conceptualization, study design, and manuscript writing and review. MA-S and AT: manuscript review. MA and AE-M: data analysis, manuscript draft, and review. HA-T, NA-T, MA-S, and AT: data collection. MA-S, MA, AE-M, and AT: interpretation. All authors have a substantial contribution in the study and approved the manuscript submission.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.


Conclusion: This meta-analysis provides reliable evidence that GPR may be an effective method for treating LBP by decreasing pain and improving function, with strong evidence.Background: The aim of this systematic review and meta-analysis was to evaluate the global postural re-education (GPR) program’s effectiveness compared to other exercise programs in subjects with persistent chronic low back pain. Methods: A systematic review and meta-analysis were carried out using PRISMA2020. An electronic search of scientific databases was performed from their inception to January 2021. Randomized controlled trials that analyzed pain and patient-reported outcomes were included in this review. Four meta-analyses were performed. The outcomes analyzed were disability due to back pain and pain. The risk of bias and quality of evidence were evaluated. The final search was conducted in March. Results: Seven trials were included, totaling 334 patients. The results showed improvement in pain measured by Visual Analogue Scale (VAS) (Standardised Mean Difference (SMD) = −0.69; 95% Confidence Interval (CI), −1.01 to −0.37;  Global postural re-education (GPR) is a physical therapy method, developed by Phillipe Souchard in the 1950s. This therapeutic approach is based on an integrated idea of the muscular system as formed by muscle chains, which can be shortened resulting from constitutional, behavioral and psychological factors . This phThis study focused on the analysis of GPR efficacy for chronic low back pain (LBP) patients, since we found several authors who have studied this topic ,8,9. TheThe most common chronic LBP treatments are pharmacological, minimally invasive interventional therapy and rehabilitation, within which exercise is recommended . PreviouBecause of this, the objective of this study was to carry out a systematic review and meta-analyses of the effectiveness of global postural re-education in chronic non-specific low back pain.Following the criteria of the PRISMA statement , a systeThe search strategy was:  AND “Global Postural Reeducation”;  AND “Global Postural Reeducation);  AND ;  AND ; Global Postural Reeducation.Filters were used to include studies conducted in humans; age of participants: over 18 years; type of study: clinical trials and reviews. We excluded those published in Korean, clinical trials without control groups, duplicates and those in which the main pathology is not chronic LBP. The flowchart describes the process of obtaining the results, selection and eligibility.The eligibility criteria were clinical trials and studies conducted in people over 18 years old with chronic non-specific low back pain ,19, stanThe outcome measures considered were level disability perception due to back pain using the Roland–Morris Disability Questionnaire (RMDQ) and Oswestry Disability Questionnaire (ODI). For pain measure, the Visual Analogue Scale (VAS) and the Numeric Rating Scale (NSR) were used. In addition, other outcome measures were the fingertip-to-floor test (FFT), the Short-Form Health Survey (SF-36), the Borg Scale, the Beck Inventory and Range of Articular Motion (ROM).The grey literature was reviewed. The studies considered important for this research were requested from the main authors. The studies were selected by two blinded and independent researchers. For the final selection, a discussion was held to determine the outcome. In cases of disagreement, the help of a third investigator was sought who determined, through a vote, whether or not to include the study. The Mendeley platform was used to register the studies included.Data extracted from clinical trials were: bibliography ); study characteristics ; participant characteristics ; description of the intervention ; results assessed; study results and DOI. The information was obtained with an in-depth, unbiased reading by one of the researchers and verified by another. Only publicly available data were taken into account. Stratified data were managed with the Excel 2016 program . The variables for which the data were sought were perceived level of disability and pain.The Review Manager (RevMan 5.3) software version (Cochrane IMS)  was usedSubgroup calculation was used for the meta-analysis. The generic inverse of variance with standardized mean difference was applied. Scales measuring the same variable were associated in these subgroups. In all cases, the confidence interval (CI) was 95%.2 coefficient was used to determine the degree of heterogeneity. More specifically, the following values were taken: I2 > 50% and/or Chi2 test (p < 0.05), indicating substantial heterogeneity where random effect models were applied and I2 < 50% and/or Chi2 test (p > 0.05), indicating substantial homogeneity where the fixed effect model was applied. For the calculation of the risk of publication bias, the Begg and Egger tests were applied where possible.The IThe Physiotheray Evidence Database (PEDro) scale  was applThe classification of the evidence was carried out with the Grading of Recommendations Assessment, Development and Evaluation (GRADEPro) . It consThe number of studies screened, assessed for eligibility and included in the review with reasons for exclusions is shown in the flow chart .The selected studies were published between 2010 and 2016, with 2015 being the year with the most studies published on this subject. The main objective of the studies included was to test the effectiveness of RPG in the chronic LBP. For this purpose, RCTs were developed. The sample size for all studies was 357 participants. Three studies reported the loss of patients ,9,20. A Regarding the gender of the subjects, in all the studies, the number of females was greater than that of males. However, the proportion varies according to the study. In some, the number of female participants was four times that of male participants ,23. In oThe main intervention in all studies was GPR. The comparisons were isostretching ,19, stanAfter the study selection process, two articles were selected for the qualitative study and five for the quantitative study. A total of three meta-analyses were performed. Disability due to back pain using the Roland–Morris Disability Questionnaire (RMDQ) and Oswestry Disability Questionnaire (ODI), pain by the Visual Analogue Scale (VAS) and the Numeric Rating Scale (NSR) and quality of life by the SF36 questionnaire.In addition, other outcomes measured have been found such as the fingertip-to-floor test (FFT), Borg Scale, Beck Inventory and Range of Articular Motion (ROM). In these cases, they were only used once, so a meta-analysis could not be performed.p < 0.0001, I2 = 0%). A small effect  was found in the intervention groups using GPR compared to other treatments/control.p = 0.03, I2 = 55%). A small effect  was found in the intervention groups using GPR compared to other treatments/control.A meta-analysis by subgroups was performed for the pain variable, since different outcome measures were included: VAS, NSR and SF36 pain . Regardip = 0.90), with no heterogeneity but close to it (I2 = 49%)  .p > 0.05) (The results of the Begg and Egger tests ( > 0.05)  indicate > 0.05) . On the  > 0.05) . The senThe results for the quality of the studies, measured with the PEDro scale, are shown in The quality of studies, in general, is average. The quality of the studies included in the meta-analysis is medium-high, with the exception of the study of Guimarães, M.L. et al. , which iThe items that were least met in the methodology of these studies were: item 3 ; item 5  and item 6 , those who did not complete any of the studies; and item 9 (intention to treat).The quality of the evidence, as measured by GRADEPro, is shown in The objective of this study was to determine the efficacy of global postural re-education in chronic low back pain. Taking into account our results, this meta-analysis suggests that global postural re-education is effective as a treatment in adults diagnosed with chronic LBP in terms of perceived level of disability and pain reduction. These results agree with previous studies, which have shown the effectiveness of GPR treatment . In otheThere are many measurement tools to assess low back pain/disorders and their ability has been demonstrated ,35,36,37p = 0.003, I2 = 0%) than that found in the present study with the RMDQ.A meta-analysis by subgroups was carried out for the disability variable, since different outcome measures were included: RMDQ and ODI. The meta-analysis showed significant results with a small effect in favor of the GPR intervention for the perceived level of disability measured with RMDQ and ODI and pain reduction. These results are important, since all the objectives proposed for the clinical significance of these variables are met ,37,41. Ip = 0.03, I2 = 55%). A small effect  was found in the intervention groups using GPR compared to other treatments/control. These results coincide with Lomas et al.’s study [The meta-analysis by subgroups was performed for the pain variable, since different outcome measures were included: VAS, NSR and SF36 pain. Regarding the effect of the RPG on pain, it was observed to significantly improve with heterogeneity (’s study , in whic’s study . HoweverNevertheless, the effect of GPR on quality of life became non-significant. The characteristics of the sample studied differ from other studies that analyzed chronic LBP. In this review, the number of women was greater than that of men. This fact is in line with previous studies that indicate that women are more affected with chronic LBP ,47. In rThe RPG interventions used in the studies included in this review were very similar. Two to three postures were used, mainly focused on the treatment of the posterior chain ,21,22,23It should be noted that in the qualitative analysis of the studies, we observed that there were no significant differences between the groups when stretching exercises were applied in the comparison ,19,20. SThe isostretching exercise has principles in common with the GPR. In both cases, the same process, that is, viscoelastic stress relaxation, takes place and muscles are maintained in a static elongated position, regardless of the type of stretching . This faThe overall quality of the studies was medium to high. Bonetti et al.  and MoreThe important points of this review and meta-analysis are that the grey literature has been explored and a specific and in-depth study of the RPG in the LBP has been carried out based on the literature review and its statistical study. However, there are limitations such as the number of studies found, the heterogeneity in the use of measurement tools and the low quality of some of these. Therefore, we suggest that these points should be considered in further studies.GPR is beneficial for chronic LBP in improving functional limitation and reducing pain perception. We suggest more future studies of good methodological quality to clarify the usefulness of RPG in other parameters such as the measurement of disability.


Lymph node metastasis (LNM) has a significant impact on the prognosis of patients with early gastric cancer (EGC). Our aim was to identify the independent risk factors for LNM and construct nomograms for male and female EGC patients, respectively.Clinicopathological data of 1,742 EGC patients who underwent radical gastrectomy and lymphadenectomy in the First Affiliated Hospital, Second Affiliated Hospital, and Fourth Affiliated Hospital of Anhui Medical University between November 2011 and April 2021 were collected and analyzed retrospectively. Male and female patients from the First Affiliated Hospital of Anhui Medical University were assigned to training sets and then from the Second and Fourth Affiliated Hospitals of Anhui Medical University were enrolled in validation sets. Based on independent risk factors for LNM in male and female EGC patients from the training sets, the nomograms were established respectively, which was also verified by internal validation from the training sets and external validation from the validation sets.p = 0.030), depth of invasion , Lauren type , lymphovascular invasion (LVI) , and menopause  were independent risk factors for female EGC patients. For male EGC patients, tumor size , depth of invasion , tumor location , WHO type , Lauren type , and LVI  were independent risk factors. Moreover, nomograms were established to predict the risk of LNM for female and male EGC patients, respectively. The area under the ROC curve of nomograms for female and male training sets were 87.7% : 0.8397–0.914) and 94.8% (95% CI: 0.9273–0.9695), respectively. For the validation set, they were 92.4% (95% CI: 0.7979–1) and 93.4% (95% CI: 0.8928–0.9755), respectively. Additionally, the calibration curves showed good agreements between the bias-corrected prediction and the ideal reference line for both training sets and validation sets in female and male EGC patients.Tumor size (odd ratio (OR): 1.386, Nomograms based on risk factors for LNM in male and female EGC patients may provide new insights into the selection of appropriate treatment methods. Early gastric cancer (EGC) is classified as a gastric tumor confined to the mucosa or submucosa, regardless of lymph node metastasis (LNM). In recent years, endoscopic resection (ER), as an effective and safe minimally invasive approach, has been widely used in patients with EGC without LNM –3. TherePrevious studies have explored the risk factors for LNM of EGC patients and established corresponding prediction models –11. PrevThe clinical and pathological data of 16,281 GC patients who underwent radical gastrectomy and lymphadenectomy in three clinical centers  between November 2011 and April 2021 were retrospectively collected. The exclusion criteria were as follows: (1) patients without complete clinical and pathological data; (2) patients with gastric stump carcinoma; (3) patients who had received neoadjuvant therapy; and (4) multiple primary tumors. Finally, a total of 1,742 patients with EGC were enrolled in the present study. Among them, 494 female and 1,248 male patients with EGC were identified. This study was approved by the Ethics Committee of The First Affiliated Hospital of Anhui Medical University.To determine the independent risk factors for LNM in EGC, the associations between different clinicopathological characteristics and LNM were analyzed. The following factors were examined in this study: age, sex, invasion depth, tumor size, tumor location, histological type, lymphovascular invasion (LVI), perineural invasion, LNM, ulcer, carcinoembryonic antigen (CEA), carbohydrate antigen 199 (CA199), carbohydrate antigen 125 (CA125), menopausal status, smoking, drinking alcohol, and family history of cancer. According to the World Health Organization classification for GC, the WHO types are polypoid, tubular, poorly differentiated, signet-ring cell, and mucinous adenocarcinoma . Besidesχ2 or Fisher’s exact test was performed to analyze categorical variables, and the Students’ t-test or rank-sum test was used to examine continuous variables. Logistic regression was used for multivariate analysis to screen out the independent risk factors for LNM in EGC.Statistical analysis was performed using SPSS software  and R software (Version 4.0.5). Measurement data are presented as the mean ± standard deviation. In univariate analysis, Pearson’s p < 0.05 was considered statistically significant.Furthermore, female and male patients with EGC from the First Affiliated Hospital of Anhui Medical University were assigned to the training sets, respectively. The independent risk factors in the training set were screened out by logistic regression. Based on the above independent risk factors, the nomogram prediction models were constructed to predict the risk of LNM in female and male patients with EGC, respectively. Additionally, the 246 patients from the Second Affiliated Hospital and Fourth Affiliated Hospital of Anhui Medical University were assigned to the test sets for external validation. The reliabilities of the nomogram prediction models were evaluated based on its discrimination and calibration. The concordance index, which is similar to the area under the receiver operating characteristic (ROC) curve, was calculated using the bootstrap resampling method to evaluate the discrimination ability of the model. Calibration curves were used to detect consistency between the actual LNM and the predicted LNM probability from the nomogram. The nomogram model was constructed using the “plotROC” package. The ROC curve was plotted using the “pROC” package, and the calibration curve was prepared using the “RMS” function package. A total of 16,281 patients with GC were collected, among which 1,742 (10.7%) patients with EGC meeting the requirements were screened out. One thousand four hundred ninety-six (85.9%) of these patients enrolled into the training set were from the First Affiliated Hospital of Anhui Medical University and 246 (14.1%) of these patients enrolled into the validation set were from the Second and Fourth Affiliated Hospital of Anhui Medical University Figure 1p = 0.030), depth of invasion , Lauren type , LVI , and menopause  were independent risk factors for female EGC patients  ranged from 0 to 100, providing corresponding points for the variables of the following lines. Patients’ points in each variable were added up to the total points. The scale aligned with the total points on the risk line is the predicted risk of EGC patients occurring LNM. In the nomogram, total points ranged from 0 to 350 for female EGC patients. A female patient with a tumor reaching 2 cm got 17.5 points, and the risk for LNM was about 5%. Among the categorical variables, the effect of Lauren type (mixed and diffuse type) on female patients was the most significant factor Figure 2p = 0.007), depth of invasion , tumor location , WHO type , Lauren type , and LVI  were independent risk factors for male EGC patients  and endoscopic mucosal resection (EMR). According to the Japanese Gastric Cancer Treatment Guidelines 2018 (5th edition) , the absThe incidence of male GC is known to be higher than that of female GC, but the mortality rate of female patients with GC is higher than that of male patients –17. In tIn the male population with EGC, tumor size, depth of invasion, tumor location, WHO type, Lauren type, and LVI were independent risk factors for LNM. Among the WHO type and Lauren type, signet-ring cell carcinoma and diffuse type owned the greatest risk of LNM, respectively Figure 4In the present study, we analyzed the independent risk factors for LNM in female and male EGC patients, respectively. Importantly, menopausal status was firstly identified as an independent risk factor for LNM in female population with EGC. Additionally, based on the above risk factors, the nomograms were established for predicting risk of LNM in female and male EGC patients, which might be beneficial for selecting a more precise treatment.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Ethics Committee of The First Affiliated Hospital of Anhui Medical University. The patients/participants provided their written informed consent to participate in this study.WH and ZC designed this study and revised this manuscript. WS, ZC, and CL collected and analyzed the data and drafted and revised this manuscript. PC, KS, ZW, HL, and JH were engaged in the collection of the clinical data. All authors contributed to the article and approved the submitted version.This work was supported by the Natural Science Project of Anhui Province (No. KJ2017A829).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.


Findings are consistent with integrative approaches that highlight the value of including both mother- and father-child attachment relationships, as well as their combined effect, when studying emotion regulation.Children acquire and develop emotional regulatory skills in the context of parent-child attachment relationships, nonetheless empirical studies have focused mainly on mother and less information is available regarding the role of both parent-child attachment relationships. Furthermore, despite its importance, there is no information regarding preschool years. This study aims to fill this gap by exploring the potential influences of both mother-child and father-child attachments on preschooler's later emotion regulation observed in the peer group. Fifty-three Portuguese nuclear families  participated in the study; 47% of the children were boys and 53% were girls. Attachment Security was assessed at home using the Attachment Behavior Q-set when children were 3 years of age, and emotion regulation was observed in the preschool classrooms attended by the children at age 5, using the California child Q-sort to derive an Emotion Regulation Q-Scale. Results showed that the combined influence of both parent-child attachment security predicted better emotion regulation results, than did the specific contributions of each parent  Developmental scientists have long recognized that emotion regulation (ER) is a critical influence on development and competent functioning in childhood  focused on later ages (9–18 years), with fewer studies (n = 2) in early ages (12–13 months). At this level, early childhood has been understudied, lacking information, for example, regarding preschool years.Nonetheless when looking at the studies relating attachment and ER, the majority have focused primarily on mother–child attachment relationships and less information is available regarding father's role  joint effects on children's ER. Such data will contribute to the current state of knowledge, adding to the literature that has started to focus on multiple attachment figures  on later children's ER (assessed two years later). We used behavior-relevant observations to assess both security of attachment and ER in ecological valid contexts of children's lives .M = 36.87 months; SD = 6.91), and Emotion Regulation was assessed when children were 5 years , 47% of the children were boys and 53% were girls. Children's age of first school entry was in average 11.35 months (SD = 10.59). Fifty-five percent of the mothers and 59% of fathers reported having a university degree with the remaining having high-school education, 96% of mothers and 98% of fathers worked full-time. Families were middle class by the standards of the local community.Fifty-three Portuguese nuclear families , with both parents living in the household, participated in the study. Mother–child and father–child attachment relationships were observed when children were 3 years of age  was between 0.72 and 0.92. Rater agreements during actual data collection averaged 0.77 for the mothers and 0.79 for the fathers. The final Q-sort for the child was a composite (average) of the two Q-descriptions provided by each observer and criterion scores for security were calculated using this composite. After the visit, observers independently complete the AQS by allocating the 90 items into nine categories, according to a fixed distribution. For scoring, the Q-description of the observed child was compared to the “security criterion sort” described by Waters .Emotion Regulation (ER) data was collected in preschool classrooms when children were 5 years. Distinct teams of two independent observers, spent 20 h in each classroom, observing the group in different moments and activities. Each observer described each child independently, using the California child Q-sort  and father–child (FS) attachment security were also tested, using Pearson's correlation coefficient and paired t-test, respectively. Associations between attachment security and emotion regulation (ER) were explored using Pearson's correlation coefficient. Next, we tested for the predictive value MS and FS on children's ER using regression analyses. How MS and FS interact in their influence on children's ER was also explored. Significance of the interaction term was analyzed using PROCESS macro v3.5 for SPSS  and the mean difference between them was not significant .Attachment security scores were within the range of typical values for a non-clinical sample as ours  but not for MS .Regression analysis tested for the main effects of MS and FS on ER. A significant effect was found for FS  and increased the explained variance by 12% . First, we used father as moderator and when we analyzed regions of significance using Johnson–Neyman technique (see p < 0.05). Meaning that for those children with lower father–child attachment security the model estimates higher ER as the mother–child attachment security gets higher. We performed the same analysis using the mother's score as the moderator and identified that for MS the estimated point below which the conditional effect was significant was 0.33, p < 0.05  was a significant predictor of ER  observed in peer groups, at the end of preschool. Counter to our expectation, we did not find a significant association between mother-child attachment security and ER. We did find, however, that father–child attachment security significantly predicted child ER. This may have to do with the way emotional regulation was conceptualized and measured in the present study. The Shields and Cicchetti  definitiPerhaps more importantly, our results suggest that the combined influences of attachments to each parent provide a stronger prediction to children's ER in the preschool , which is consistent with an integrative approach  .We also recognize limitations that constrain the generalization of these results. For instance, we do not have ER data at 3 years of age  for this sample, however, it would have been important to control this covariate when testing the predictive role of attachment. Given the small size and lack of heterogeneity of the present sample, it would be important to replicate these findings in larger non-convenience samples. For instance, using Also, in order to enhance the predictive power of infant attachment relationships on ER outcomes, it would be useful to replicate this study in clinical and risk samples, where the probability of less secure attachment is higher. In this sense, findings of the present study are preliminary and, although caution is needed regarding interpretations, could represent hypotheses for future research. Overall, findings of this study shed light to the importance of including both mother– and father–child attachment relationships and considering their combined influences when studying emotion regulation, to enhance research on this topic.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by ISPA Ethics Committee. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.MV, AS, and CF: conception of the work. CF, MF, MA, and LM: data collection. CF, MF, MV, and AS: data analysis and drafting the manuscript. CF, MF, MV, AS, LM, and BV: data interpretation and edit the manuscript. All authors read and commented on the 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.


Finally, correlation analysis in the group of stroke survivors with pain showed that higher levels of disability were significantly related to higher psychological distress. This study confirms the negative influence of chronic pain on disability and HrQoL in post-stroke patients and presents preliminary insights on the association between chronic pain, disability, HrQoL, psychosocial distress, and the patient’s approach in dealing with personal difficulties and emotions. These findings carry further implications for multidisciplinary management of post-stroke patients with chronic pain.This study aims at exploring disability, health-related quality of life (HrQoL), psychological distress, and psychological features in post-stroke patients with chronic pain. An observational cross-sectional study involving 50 post-stroke patients (25 with chronic pain and 25 without pain) was conducted. The primary outcome was the self-reported level of disability and HrQoL which were both assessed through the Stroke Impact Scale 3.0. Both psychological distress and specific psychological features  were examined. Post-stroke patients with chronic pain reported statistically significant higher levels of disability and worse HrQoL, higher psychological distress and inflexibility, as well as a lower level of self-efficacy and problem-oriented coping strategies than patients without pain ( Pain is a common and highly disabling complaint in stroke survivors , more frAccording to the International Association for the Study of Pain (IASP), pain has been defined as “[a]n unpleasant sensory and emotional experience associated with or resembling that associated with, actual or potential tissue damage” . In linePatients who experience pain after stroke seem to be more inclined to lower levels of health-related quality of life (HrQoL) , worse cPost-stroke HrQoL depends on a comprehensive view of subjective health, including measures of the perceived physical, mental, and social well-being and functioning. Demographic factors, comorbidities, stroke severity, disability, and psychosocial factors  are significant predictors of HRQoL in stroke survivors . The psyIn line with the statements above, this study aims (I) at determining the difference in self-reported disability and HrQoL scores, psychological distress, and psychological features between a cohort of post-stroke patients with chronic pain and a cohort of post-stroke patients without pain, and (II) at determining the association between disability and HrQoL, pain  and psychological distress and features in the two cohorts of post-stroke patients: with and without pain. Hence, this study will provide preliminary insights on a poorly understood field such as chronic pain experience in post-stroke patients to support the need for a multidisciplinary assessment and management of these patients in the neurorehabilitation setting.This cross-sectional study is part of the “EXPLORE”  project, which arose from the collaboration between the Neurorehabilitation Unit and the Clinical Psychology Unit of the Verona University Hospital . The EXPLORE project aims at investigating the psychological distress, the psychological features, and HrQoL of patients presenting different chronic pain conditions ,28.This study was performed according to the latest version of the Declaration of Helsinki and approved by the Ethics Committee of the Verona University Hospital, Verona . The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations for reporting observational studies were followed .This study included patients with chronic pain compared with a group of post-stroke patients without pain. Post-stroke outpatients were recruited according to the following selection criteria.Inclusion criteria were age ≥18 and ≤85 years; diagnosis of stroke confirmed by a specialist in neurology and by radiologic findings (TC or RM); time from stroke ≥ three months; signature of the informed consent. Exclusion criteria were the presence of severe cognitive or communication deficits interfering with patients’ capacity to provide the informed consent or proper answers to the questionnaires. Patients with language difficulties were known to the Neurorehabilitation Unit, since they had already undergone previous speech and language rehabilitation in which their language abilities were acknowledged. After discussion with the speech and language therapists, the patients’ eligibility was further verified. In case of any unexpected communication difficulties occurring during the face-to-face assessment, the patient was excluded from the study. Patients with other neurological, orthopaedics, or medical comorbidities that could cause pain  and substance abusers were excluded. The patients were considered in the sub-group of stroke survivors with chronic pain if they (a) presented pain for at least three months, (b) rated their pain intensity as at least four on a 11-point Numeric Rating Scale (NRS) . A score of 4 on the intensity scale identifies moderate pain, which is considered to interfere with daily living activities significantly . PatientMedical charts of patient attending the Neurorehabilitation Unit between December 2018 and August 2019 were retrospectively reviewed. A physician performed an initial telephone screening interview lasting approximately 10 min that consisted of ad hoc questions to assess the presence of inclusion and exclusion criteria. During the telephone interview, patients were informed about the EXPLORE project. Moreover, the presence of pain and duration of pain in the previous three months were ascertained. Patients who fulfilled selection criteria and accepted to participate in the study were referred to a face-to-face visit at the Neurorehabilitation Unit. During this visit, they filled out a battery of paper–pencil questionnaires that investigated their sociodemographic and clinical characteristics, level of HrQoL, level of disability, pain, and psychological features.All patients gave their written informed consent to participate in the study.For each patient, sex, age, educational level, civil status, and work condition were collected to describe the sample’s sociodemographic characteristics. An ad hoc clinical record was created aimed at acquiring diagnosis information, stroke onset, interest in starting a psychological intervention, as well as the duration of the multidisciplinary rehabilitative care. Moreover, a multimodal assessment was conducted aimed at analysing their HrQoL, pain perception, psychological distress, and psychological features. The assessments lasted approximately one hour. The patients were helped in the event of difficulties by the researcher. The time since stroke (in months) was collected for all patients, whereas the duration of pain (in months) was collected only in the group with pain.The self-reported level of disability and HrQoL were evaluated through the Stroke Impact Scale (SIS) 3.0 ,32. The The multidimensional level of pain was evaluated through the Brief Pain Inventory (BPI) scale . BPI proThe psychological assessment was performed in line with the EXPLORE protocol ,28. PsycThe level of self-efficacy was evaluated through the General Self-Efficacy (GSE) scale, which is a 10-item scale rating “people’s optimistic self-beliefs to cope with a variety of difficult demands in life” on a four-point Likert-type scale (higher scores = higher levels of perceived self-efficacy) . Coping Potential sources of bias were addressed. Firstly, during the medical chart revision, the presence of post-stroke pain was not always reported. Hence, patients attending the Neurorehabilitation Unit in the reference period were contacted by phone for further investigations. Secondly, to avoid any specific influences in reporting data of the patients who decided to participate in the study, the telephone interviews were performed by two physicians who had never been in contact with them before. Moreover, an ad hoc telephone questionnaire was set up to be consistent among patients on the information collection. We cannot exclude a selection and questionnaire administration bias. The patients who were recruited and accepted to participate in the study should be not representative of all stroke survivors’ patients since, for example, they reported a level of cognitive functioning adequate to fill out questionnaires. Moreover, we cannot exclude that they were already more willing toward a possible psychological intervention and to undertake the psychological assessment. The fixed order of providing the questionnaire might be acknowledged as a possible administration bias. All the questionnaires used were validated instruments for the Italian context and already used in the context of neurological diseases ,28,42,43t-test for independent samples (or the Mann–Whitney test) was used to test statistical differences in demographic and clinical outcomes between the two groups. The Fisher test was used to check differences in sex between the two groups. A Pearson’s correlation (or Spearman’s correlation) was run to determine the relationship between the severity of disability and HRQoL assessed by the SIS, the BPI, and psychological features. The correlation strength was defined as very high (ρ > 0.9), high (ρ = 0.7–0.89), moderate (ρ = 0.5–0.69), low (ρ = 0.3–0.49), or very low (ρ < 0.29) [p-value for significance was set at 0.05. Bonferroni correction was applied for multiple correlation analyses on the same dependent variable. When exploring the association between the SIS  and pain, the alpha level for significance was set at 0.00625. When exploring the association between the SIS  and psychological outcomes, the alpha level was set at 0.004545. Statistics analyses were carried out through SPSS 26.0 .Descriptive statistics included frequency tables, means, and standard deviation (SD). Parametric or non-parametric tests were used for inferential statistics according to the data distribution (Shapiro–Wilk test). Outliers, defined as values laying two standard deviations above the mean values of the group, were excluded. The  < 0.29) . The p-vA total of 247 in-hospital clinical records were reviewed. Fifty-four patients were excluded because they did not meet the inclusion criteria. In the remaining 193 medical charts, 77 patients reported the presence of pain, of which 36 reported a pain intensity ≥4 (NRS) for at least three months. Among this group, 11 patients refused to participate in the study, so 25 patients with chronic post-stroke pain were included. In line with that, patients without chronic post-stroke pain were randomly contacted until reaching a sample of 25 patients per group. The randomisation process was done by assigning to the 116 medical charts of patients without pain a serial number from 1 to 116, from which 25 patients were extracted randomly through the ‘Random’ Excel function.The final sample was composed by 50 post-stroke outpatients , of those 25 with chronic pain  and 25 without pain . Demographic and clinical characteristics are reported in All patients were assisted by family members and were living in their home. No patients were institutionalised or living in a nursing home. In this cohort, 32% were female, and 20% were employees. Most patients were married (76%) with high-school qualification (34%). As far as the site of lesion was concerned, 48% were left lesion, 48% were right lesion, and 2% were bilateral. Most patients suffered from Partial Anterior Circulation Syndrome (61%) due to ischemic lesion (75%). Aphasia and neglect were present in 24% and 14% of patients, respectively. Patients had been on a rehabilitation program for neurorehabilitation on average for 26.43 months. More than half of the sample (66%) was interested in receiving psychological support.p = 0.002) as well as a higher percentage of ischemic stroke (p = 0.023) and aphasia (p = 0.04) than patients without pain. No significant between-group differences were found regarding the employment condition, civil status, brain lesion side and site, duration of the rehabilitation program, and interest in receiving psychological support.Patients with chronic pain did not differ for age and sex from patients without pain. Despite this, they had a significantly lower education level  and a mean duration of 21.48 (SD: 29.71) months. The most frequent type of pain was musculoskeletal pain, affecting six patients (24%), followed by shoulder pain, central post-stroke pain, and headache syndromes in five patients (20%), spasticity-related pain in three patients (12%), and complex regional pain syndrome in one (4%) patient. The mean time with pain was 21.48 (SD: 29.7) months. Pain occurred on average 15.04 (SD: 23.89) months after stroke onset. The results of BPI are reported in The SIS scores gathered from the overall sample as well as in the two cohorts of analysed patients are reported in p < 0.001), memory and thinking (p < 0.001), emotion (p = 0.024), communication (p < 0.01), ADL/IADL (p = 0.008), hand function (p = 0.016), and participation/role function (p < 0.001) compared to patient without pain (Patients with chronic pain reported significantly lower score (higher disability) in the SIS total score (out pain .p = 0.001) compared to patients without pain, indicating a higher level of psychological distress. In particular, 10 (40%) stroke survivors with chronic pain and three (12%) without pain obtained a GSI score > 0.57, which is considered a cut-off for the presence of psychological distress [p = 0.015), lower COPE-Problem Oriented (p < 0.001), and higher AAQ-II (p = 0.005) scores than the patient without pain.Psychological distress and psychological features scores are reported in distress ,45,46. Tp < 0.001; r = 0.46, p = 0.019). Moreover, a low negative correlation between length of care and the strength domain  was reported. Correlations between SIS and BPI are reported in p = 0.001) and the single domain scores concerning participation/role function  and memory and thinking . Negative correlation was found between the SIS total score and the BPI for interference with mood .In patients with chronic pain, the pain intensity assessed by the BPI and pain duration were moderate and strongly correlated with the length of care respectively . Specifically, the SIS sub-scores referring to emotions  and participation  showed a negative correlation with the GSI. Regarding coping strategies, the SIS sub-scores referring to memory and thinking were significantly correlated with the COPE-PO . In the framework of psychological inflexibility, in the group with pain, there was a significant negative correlation between the SIS sub-scores in the emotion domains , and participation  and the AAQ-II.In this explorative study, we found evidence to support the negative influence of chronic pain on the self-reported levels of disability and HrQoL in post-stroke patients with and without pain. Our findings provide preliminary evidence to support an association between psychosocial features, the level of disability, the level of HrQoL, and chronic pain in post-stroke patients.By analysing the differences between the cohort with pain and the cohort without pain, the former reported higher levels of disability in the SIS total score and in the different domains. The differences in ADL/IADL, mobility, and hand function reached the MCID , indicating that disability severity in patients with chronic pain was significantly higher, also from a clinical point of view . A higheThe fact that patients with chronic pain did not differ from patients without pain in muscle strength and mobility performance suggests that the self-reported perception of general motor aspects were apparently not affected by chronic pain. In contrast, a self-reported higher disability was reported on hand function in chronic pain patients, confirming that upper limb pain syndromes mostly affect post-stroke patients with a negative impact on disability . HoweverAs regards psychological distress, a previous study by Zhang et al. showed that the mean level obtained at the SCL-90 was higher in post-stroke patients compared to the control group . In our Considering the other psychological features, chronic pain in post-stroke patients was associated with lower levels of self-efficacy, psychological flexibility, and problem-oriented coping strategies, therefore suggesting a more dysfunctional approach in dealing with personal difficulties, stress, and emotions. Self-efficacy beliefs for people experiencing chronic pain can negatively modify their expectation about their ability to perform a particular activity and their confidence to accomplish that task despite the pain. According to literature, lower self-efficacy levels are consistently related to greater clinical pain ratings in various chronic pain conditions . HoweverDue to the small sample of patients, we cannot identify demographic or clinical factors associated with the presence of post-stroke pain. However, in our small sample, patients with chronic pain presented lower levels of education, a higher percentage of ischemic stroke, and a higher percentage of aphasia. A low formal education level is commonly associated with a higher prevalence of several chronic pain conditions  and low The higher level of post-stroke pain in patients suffering from aphasia is in line with the one reported in the literature . People Patients with chronic pain had a longer duration of multidisciplinary rehabilitation care (in our sample twice as long as patients without pain) and therefore, more significant care effort also from an economic perspective . Longer The implication of these findings is relevant for a multidisciplinary assessment and management of chronic post-stroke patients. The fact that with the same perceived motor disability (mobility and strength), patients with chronic pain reported a greater disability in the domains related to emotional aspects emphasises the need for psychological interventions to promote a better emotional adjustment to the stroke experience and its consequences. This suggestion is confirmed also by the positive attitude of patients regarding psychological help, with the majority of the sample reporting interest for psychological interventions. Considering the psychological characteristics investigated in the current study, the psychological intervention might be targeted to promote problem-oriented coping strategies, psychological flexibility, and self-efficacy. However, further studies with a larger sample are needed to confirm our results.One of the strengths of this study is that it explored disability, HrQoL, and psychological distress and features in a cohort of patients generally overlooked in the literature and often under-recognised in clinical practice. Another strength of the study is the comprehensive protocol to explore diverse psychological aspects that can be impaired in patients with chronic pain and then addressed by multidisciplinary management. Moreover, the use of patient-reported outcome measures to evaluate the self-reported level of disability and HRQoL (SIS) should also be considered as a strength of the study. This instrument reports high validity, since an excellent correlation has been reported in post-stroke patients between the SIS cognitive factors and the MMSE, between the SIS physical factors and the Barthel Index and instrumental ADL, and between SIS emotional factor and anxiety and depression .The limitations of this study are the small sample of patients, the lack of pre-registration of the study, the cross-sectional nature of the study, which did not allow for an evaluation of the causative relationship between pain, HrQoL, and psychological distress, and the lack of information about the pharmacological treatment of the patients. Moreover, the patients who were recruited and accepted to participate in the study are not representative of all stroke survivors’ patients, since, for example, they reported a level of cognitive functioning adequate to fill out questionnaires. Moreover, we cannot exclude that they were already more willing to take part in a possible psychological intervention and to undergo psychological assessment. Finally, we cannot exclude a selection and questionnaire administration bias.Chronic pain is a common symptom in post-stroke patients increasing patients’ disability and affecting rehabilitation outcomes. To date, the management of these patients is a challenge in the neurorehabilitation setting . As a ma


Integrating multigenomic data to recognize cancer subtype is an important task in bioinformatics. In recent years, some multiview clustering algorithms have been proposed and applied to identify cancer subtype. However, these clustering algorithms ignore that each data contributes differently to the clustering results during the fusion process, and they require additional clustering steps to generate the final labels. In this paper, a new one-step method for cancer subtype recognition based on graph learning framework is designed, called Laplacian Rank Constrained Multiview Clustering (LRCMC). LRCMC first forms a graph for a single biological data to reveal the relationship between data points and uses affinity matrix to encode the graph structure. Then, it adds weights to measure the contribution of each graph and finally merges these individual graphs into a consensus graph. In addition, LRCMC constructs the adaptive neighbors to adjust the similarity of sample points, and it uses the rank constraint on the Laplacian matrix to ensure that each graph structure has the same connected components. Experiments on several benchmark datasets and The Cancer Genome Atlas (TCGA) datasets have demonstrated the effectiveness of the proposed algorithm comparing to the state-of-the-art methods. Tumor is a malignant heterogeneous disease caused by changes in cellular components at the levels of expression, epigenetics, transcription and proteomics. The heterogeneity will be reflected in that the same cancer will produce the subtypes with different phenotypes, which will affect the clinical treatment and prognosis ,2. With In order to implement the task of clustering, scholars initially focus on dimensionality reduction, matrix decomposition and linear regression technologies. They all use different strategies to project high-dimensional data into low-dimensional feature space, and then achieve clustering by k-means ,7,8,9,10However, most existing graph-based multiview clustering methods separate the data clustering process from graph learning process ,19. In sp value obtained from survival analysis on the TCGA dataset can all show that the proposed LRCMC approach achieves considerable improvement over the state-of-the-art baseline methods. In the analysis of the Glioblastoma Multiforme (GBM) subtypes, we found these clusters have biological significance, e.g., the Proneural subtype granted by G-CIMP phenotype has a better survival advantage. The source code and datasets can be found in the To sum up, we designed a graph-based multiview clustering algorithm, called Laplacian Rank Constrained Multiview Clustering (LRCMC). Firstly, the Laplacian Rank Constraint (LRC) algorithm  is used m views Z. Simultaneously, each view is automatically assigned a different weight Z during the fusion process. Finally, the learned consistent graph matrix Z is used to optimize the affinity graph matrix for each view. The LRC method is also imposed to constrain that the number of connected components in the Z is equal to the required number of clusters c by constructing the fusion embedded matrix U. Our LRCMC improves the affinity matrix of each view, builds a fused consistent graph matrix and obtains clustering results simultaneously.The overall flow of LRCMC is shown in v-th view data with vd features, where n is the number of data points. c categories, the obtained c connected components. Based on the following Theorem 1, Given a single biological data entation , Gaussiaentation , etc. FoTheorem 1.Multiplicity c of zero eigenvalues of Laplacian matrixis equal to the number of connected components of its similarity matrixWhen all the elements in property ,31.i-th smallest eigenvalue of c categories [c eigenvectors of c smallest eigenvalues. Theorem 1 means if tegories , Laplaci theorem , we can jth column of However, the solution to mn of Sv . FinallyA set of the affinity graph matrices Z with noise representation and outlier interference. (2) Z should be given greater weight to reduce the perturbation of the low-quality graphs on the fusion graph. In this way, Z can accurately capture the true similarity hidden in the multiview data. Therefore, we employed the proposed method of Nie et al. [Z as follows:Z and setting the derivative to zero, we can obtain:Integrating these basic graphs to form the fused affinity graph e et al.  to optimZ are obtained from Equation (3). In order to make the learned Z also have c connected components for clustering, the LRC term is added to Equation (3) according to Theorem 1 and Ky Fan’s Theorem. The objective function is as follows:c eigenvectors of c smallest eigenvalues, i.e., the embedded matrix corresponding to Z. Here, a set of weights Z. Therefore, we can combine Equations (2) and (7) into a final objective function, i.e., the proposed Laplacian Rank Constrained Multiview Clustering (LRCMC). It is represented as:As described in Z can help each other embedded in a joint coupling problem. The objective function Equation (8) enjoys the following properties:c connected components, instead of most multiview clustering methods requiring predefined graphs;Our method can effectively learn a set of affinity graph matrices with Z, rather than simply superimposing then together;In the graph fusion process, we assign the weight to each view to represent their contribution to the consistent graph Z, and at the same time complete the task of clustering.We use LRC to constantly adjust the structures of Here, we complete the tasks of graph construction, graph fusion and clustering in one step through the integrated model. In this way, the learning of Z, U. The specific solution process is as follows:1.Z and U, solve Fix Obviously, since the variables in Equation (8) are coupled to each other, we use alternating iterative method and Augmented Lagrange Multiplier (ALM) scheme to solve The Equation (8) becomes:i-th and j-th column of i, j)th element of Due to Denote Then, the Equation (11) can be written as:Therefore, the Lagrangian function of Equation (12) combined with its constraints can be defined as:ondition , the optk nonzero adaptive neighbors for The study in  found thMoreover, according to Equation (15) and the constraint condition Therefore, according to Equations (15) and (16), the range of Then, the parameter 2.Z and U, solve Fix Finally, according to Equations (15), (16) and (18), the optimal solution of Updating 3.Z and U, solve Fix Updating 4.U, solve Z.;Fix U, i, j)th element of Z, Equation (7) yields:Updating Z in Equation (8) is converted to Equation (7). Due to Denote Based on the Karush–Kuhn–Tucker (KKT) condition , the cloEquation (22) can be solved by an efficient optimization method proposed in .5.Z, solve U.Fix U is obtained as follows:According to the method of finding U is the c eigenvectors of c smallest eigenvalues.The final solution of In order to verify effectiveness of LRCMC in cancer subtype recognition, LRCMC was compared with four state-of-the-art clustering algorithms, i.e., ANF , SNF 1111, PFA  and MVCM3-source : It contCalt-7 : The objMSRC : The sceWebKB : It collThe benchmark datasets are described as follows:n, m, and c describe the number of samples, views, and classes for each dataset, respectively, vd denotes the i-th feature of these datasets.k required by ANF, SNF, MVCMO and LRCMC was set within the range of Z is greater than c, we will shrink c, we will increase Z. Algorithm 1. LRCMC algorithmInput: Original data m views, the number of clusters c, the number of neighbors k, the regularization parameter Output: The learned consensus matrix Z.Initialize the affinity matrices Initialize the embedded matrices Initialize the weights Initialize Z by connecting Initialize the fused embedded matrix U by using Equation (23);RepeatFix Z and U, update Fix Z and U, update Fix Z and U, update Fix U, update Z by using Equation (22);Fix Z. update U by using Equation (23);Until Satisfy Theorem 1 or the maximum iteration reached.The learned consensus matrix Z with exact c connected components, which are the final clusters.Three commonly used evaluation metrics, i.e., Accuracy (ACC), Normalized Mutual Information (NMI) and Purity, are used to quantitatively measure the clustering performance of the algorithms. The metrics compare the resulting labels with the real labels provided by the dataset. The larger the value obtained, the better the clustering results. To ensure the fairness of the comparison experiments, each algorithm was run 10 times to reduce the impact of randomness. The mean and standard deviation of the obtained metrics were calculated. In addition, the neighbor e et al. . β is serange of . If the To demonstrate the effectiveness of LRCMC in identifying cancer subtype, the designed LRCMC was applied to four cancer omics datasets, i.e., GBM, BIC, LSCC, and COAD. Each cancer subtype contains three types of expression data from different platforms, i.e., mRNA expression data, DNA methylation data and miRNA expression data. p values based on Cox log-rank model were used to evaluate the clustering results of these algorithms in survival analysis [p value is smaller, the survival rate between different groups is more significant and the difference is greater, which means the cluster is considered to have different characteristics of the underlying cancer subtypes. Cancer survival curves can also represent heterogeneity between different subtypes. As shown in p value in BIC, GBM, KRCCC and COAD. Other algorithms also had good results in specific datasets, but they were all lower than our algorithm. Therefore, we believe that LRCMC is significantly advantageous in the topic of cancer subtype recognition. To ensure that the identified cancer labels conform to the true clinical diagnosis, we specified that the number of samples in each cluster should be at least 3. We used the number of subtypes of GBM, BIC, LSCC, and COAD specified by Wang et al., which were 3, 5, 4 and 3, respectively. Then, the analysis . If the GBM is the most malignant glioma among astrocytomas. It has been studied and analyzed at the genetic level by many scholars, and specific subtypes and treatment protocols have been proposed. For example, according to the mRNA expression data, Verhaak et al.  reportedhttp://www.cbioportal.org/ accessed on 15 December 2020). The age profiles of the three clusters (IDH1) and CNVs  are significantly different in the three identified clusters. In particular, IDH1 mutation only occurs in cluster 2, while EGFR amplification is 0. Then, we divided the patients within the three clusters into two groups: patients treated with TMZ and those not treated with TMZ, then we compared the drug response. TMZ is a drug that is commonly used to treat GBM, but only responds well to a subset of patients. The p values of survival analysis in Cox log-rank model of the three cluster comparison experiments are 2.0 × 10−6, 0.76 and 0.01, respectively, which indicates that TMZ treatment has no effect on the patients in cluster 2. Therefore, in summary, we can infer that the subtype belonging to G-CLMP subtype and Proneural subtype might be a potentially new subtype. This also verified by the fact that that the Proneural subtype granted by the G-CIMP phenotype proposed by Canmenron et al. has unique properties [To further analyze the identified clusters, we downloaded clinical data, somatic mutation data and CNV data for all patients from the cBio Cancer Genomis Portal database . The gene differences in miRNA expression data were not significant enough  and were omitted from consideration. PRKAA1 overexpressed in Cluster 3, also known as AMPK, induces antitumor activity in GBM cells and has become a possible tumor control target [MUC1 overexpressed in cluster 1 is a pathogenic gene that induces GBM and can be used as a target for cellular immunotherapy [In addition, mRNA expression data and DNA methylation data were used to compare the differentially expressed genes in cluster 1 and 3 to look for the heterogeneity between them. We compared the genes in the two clusters using ANOVA (the lower the l target . MUC1 ovotherapy .https://toppgene.cchmc.org/enrichment.jsp accessed on 20 December 2020). From Finally, we compared the three clusters with normal samples and screened for differentially expressed genes using ANOVA. We did Gene Ontology (GO: BP), KEGG pathway and Disease Ontology (DO) enrichment analysis using the top 100 differential genes in ToppGene Suite database  instead of simply treating each view equally, a wealth of heterogeneous information is taken into account to provide appropriate weight for each view; (2) the tasks of constructing the affinity matrix of each view, learning the fused matrix and clustering are completed simultaneously in a system. Furthermore, LRCMC has the following two advantages in algorithm running: (1) there is no need to spend a lot of time choosing the appropriate parameters; (2) the final consensus graph has been assigned to the given categories without adding additional base clustering algorithms. We demonstrated the power of LRCMC using four benchmark datasets and four cancer datasets. The experiments show that LRCMC has a good clustering evaluation. The cancer subtype recognition results on GBM data show that LRCMC can effectively capture cancer subtypes with specific biological characteristics based on omics data.In addition, we must admit that LRCMC also has shortcomings and limitations. It is not suitable for binary data (somatic mutation) or categorical data , and has only limited application to continuous data (mRNA expression) to identify cancer subtype. It also does not have the ability to find the gene modules that affect differences in each subtype. Therefore, we will continue our efforts to improve and extend the LRCMC algorithm to explore cancer heterogeneity.


The purpose of this study was to assess the effect of somatic and socio-cultural factors on children’s motor competence (MC). MC was assessed through the standing long jump (SLJ), distance throw of a tennis ball (TTB), and 20 m dash (20 m) in 181 children (84 girls) with a mean age of 6.10(0.47) years. The effect of socio-economic status, house/living space, educational practices, the child’s interaction with peers and siblings, and the sum of five skinfolds (SS) were analysed via structural equation modelling (SEM) in each motor skill. The SEM models displayed a good fit to the data. In addition, standardized direct effects are significant on different outcome variables, except for brotherhood relationship (BR) and peer relationship in TTB, and 20 m dash and BR in standing long jump (SLJ). SS are negatively related to all motor skills. Motor competence (MC), defined as a person’s proficiency to execute motor skills as well as the underlying mechanisms including motor coordination and control ,2,3, is Despite the health benefits associated with MC, the prevalence of children classified as having poor MC has increased in recent decades . It was The identification of correlates and potential mechanisms of change of MC could be crucial to develop interventions targeted to improve children’s MC. Despite the fact that interventions can improve MC ,14, it rBronfenbrenner  proposedParents from different socio-economic statuses (SES) tend to have different attitudes towards their children about education, and the process of socialization  is related to SES . While iTherefore, the purpose of this study was to assess the effect of somatic (body mass index and skinfolds) and selected socio-cultural factors on MC of five to six year old children. Specifically, we hypothesize that excess body fat is negatively associated with MC; and that socio-economic factors, educational practice within the family, interactions with peers, variables related with house/living space, and sibling characteristics/brotherhood relationship, are all determinants factors of MC.n = 181 children of both sexes  with mean age of 6.10(0.47) years in an age range between 5 and 6 years (the age year was considered between 0 and 11 months of the respective year), corresponding respectively to 40.3 and 59.7% of the total sample. About half of the children were in kindergarten, while the other half were first graders. Children were recruited as a convenience sample in four urban schools in the inland of the north of Portugal. Not having physical or mental disabilities were the inclusion criteria. Permission was obtained from the respective school director, parents or guardians gave informed consent, and children assented. The ethics committee of the institution of the first author approved this study .Participants were The tests were administered during two days in each of the children’s schools. Anthropometric measurements and MC assessment were performed on the first day; on the second day, MC tests were performed, in the following sequence: standing long jump, tennis ball throw for distance, and speed run. Between tests, there was at least 5 min of rest. The subsequent test was only performed after the participant indicated that he/she was not tired. All the test and measurements were done by one of the authors.To estimate the reliability, MC tests were performed a second time, a week later, in 40 participants (20 boys and 20 girls).Tennis ball throw for distance. The test measured how far  the child could throw a tennis ball within a large, prescribed area using any one-handed throwing pattern. The child could take one step forward during the throw, but was not permitted to step over the restraining line. The child was required to perform seven trials. The final score was the average of five trials, after removing the best and worst throws.Speed run. The child ran as fast as possible for 15 m, after a 2.5 m running start. The score was the average of the best two out of three trials.Standing long jump. The child jumped horizontally as far as possible, using a two-foot take-off and landing. The score was the average of the best four out of five trials.Motor competence was assessed as the performance (product-oriented assessment) on tennis ball throw for distance, speed run, and standing long jump:Test–retest reliability estimated with intra-class correlation coefficient for this study was 0.60 for speed run, 0.95 for standing long jump, and 0.89 for tennis ball throw for distance.Socio-economic status (SES) ;Variables related to house/living space (HS) ;Variables that characterize educational practices within the family (EP) ;Variables that characterize the child’s interaction with peers (PR) , sex of preferred playmates i.e., same sex, opposite sex, age of preferred playmates i.e., same age, younger or older);Variables related to sibling characteristics or brotherhood relationship (BR) i.e., number of siblings, birth order, having an older brother(s) and/or older sister(s) (over four years).Socio-demographic and environment variables were grouped in five main areas:Five skinfolds  were measured to the nearest 0.1 mm using a Holtain skinfold caliper . The five skinfolds were summed (SKF) to provide an indicator of subcutaneous adiposity.All skinfolds were measured twice; the average was used for analysis. All measures were done by the same trained technician following a standardized protocol . TechnicDescriptive statistics, including mean and standard deviations were calculated for all studied variables. A structural equation modelling (SEM) via maximum likelihood estimator method was employed in Amos 23.0 to test the model fit, which was performed for each motor skill (the outcome variable). Nominal variables were previously criterion scaled. In addition, standardized direct effects on the outcome’s variables were analysed. Therefore, Bootstrap resampling (1000 samples), via bias corrected 95% confidence intervals (CI) was used to assess the significance of the direct effects. The magnitude of effects was evaluated through Cohen  suggestiA preliminary analysis revealed no outliers and missing values detected. However, skewness and kurtosis values are comprised within cut-off values  revealing no violation from univariate data. Nevertheless, Mardia’s coefficient for multivariate kurtosis exceeds the recommended value  for model 1, 2, and 3 respectively. Therefore, a Bollen–Stine bootstrapp (2000) was performed for further analysis. Finally, the collinearity diagnosis was checked via variance inflation factor (VIF), and assuming values less than 10 for VIF and greater than 0.01 for tolerance tests. Therefore, the results showed that both in VIF and tolerance tests scores were below 10 and above 0.1 respectively, ensuring the appropriate conditions to test the regression model.Since the nominal variables were criterion scaled before entering in the SEM models, it is necessary to know the mean of the criterion (dependent variable) of the participants in each category of the nominal observed variables to interpret structural coefficients. These means are presented in 2 (115) = 144.53; SRMR = 0.080; B-Sp = 0.033; RMSEA = 0.038 ; TLI = 0.919; CFI = 0.931]; Model 2 (standing long jump): ; Model 3 (speed run): . In addition, standardized direct effects are significant on different outcome variables, except brotherhood relationship (BR) in all outcome variables and peer relationship (PR) in tennis ball throw for distance and speed run. The observed effects varied from small to medium.Adiposity levels (sum of skinfolds) are negatively related to all motor skills performance.In the SES case, the highest motor performance in the three motor skills was attained by children with parents in the lowest and intermediate levels of education and professional occupation. In the case of house/living space, (HS) the best performance was achieved by children that live in a villa or single storey house and by children that live in a house with a courtyard, terrace, garden, or yard. In terms of peer relationship (PR), the highest performance was obtained by children that interact with others out of the school, when the playmates are older, and of the opposite sex. In the case of educational practices within the family (EP), children that can play in the neighbourhood, whose mother spent more time with them and those that prefer to play with active toys, achieved the best performance.The aim of the present study was to assess the relationships of socio-cultural  and of body fat with MC in Portuguese children five to six years old in both sexes.Overall, the formulated hypotheses were confirmed. In fact, socio-economic status , house living space , the child’s interaction with peers , and the educational practices within the family , are significantly associated with children’s MC. In terms of socio-cultural variables, only sibling characteristics/brotherhood relationship (having an older brother(s), having an older sister(s), birth order) were not significantly associated with MC.The results of the present study are in line with the results of previous studies. For instance, Zeng, et al.  found thIn addition, body fat (sum of skinfolds) was, as expected, negatively associated with MC. Excessive body fat is a negative factor in the development of MC during childhood. This outcome is well established in the literature, both in cross-sectional ,26,30 anSocio-economic factors, such as parent’s occupation and education levels, are factors that are systematically found in the literature to be associated with motor development and MC levels ,31,34,35In the context of sibling characteristics, we found that it was not associated with MC, which is a divergent result from the literature. Siblings are seen as an essential component of family systems and as a significant context for development and learning ,40. SiblThe peer group plays an important role in child socialization, which becomes more important with age. Peers can provide reinforcements and important models for the practice of physical activity, including games and play, and the development of MC . We founSocio-spatial factors are, according to Klein and Liesenhoff , of greaThe present study is distinctive in the way that it simultaneously examined the extent to which somatic factors and socio-cultural factors may contribute to children’s MC. The use of SEM, instead of using univariate analysis such as ANVOVA, or even multiple regression, was a major strength since this statistical approach allows for analysis of the effect of sets of variables on MC rather than each variable by itself. However, there are some limitations: the cross-sectional design only permits association inference and not causal inference, as well as the limited sample size and the lack of representability of the convenience sample being possible. Nevertheless, results appeared generally consistent with other studies ,31,34,35In conclusion, body fat with a negative effect, socio-economic variables, sibling characteristics/brotherhood relationship, type of housing/living space, child’s interaction with peers, and educational practices within the family, adequately explain the variance in MC in children aged five to six years.


The novel MTL method not only diagnosed four types of kidney diseases through blurred IF images but also showed good performance in two auxiliary tasks: image quality assessment and de-blurring.Chronic kidney disease is one of the most important causes of mortality worldwide, but a shortage of nephrology pathologists has led to delays or errors in its diagnosis and treatment. Immunofluorescence (IF) images of patients with IgA nephropathy (IgAN), membranous nephropathy (MN), diabetic nephropathy (DN), and lupus nephritis (LN) were obtained from the General Hospital of Chinese PLA. The data were divided into training and test data. To simulate the inaccurate focus of the fluorescence microscope, the Gaussian method was employed to blur the IF images. We proposed a novel multi-task learning (MTL) method for image quality assessment, de-blurring, and disease classification tasks. A total of 1608 patients’ IF images were included—1289 in the training set and 319 in the test set. For non-blurred IF images, the classification accuracy of the test set was 0.97, with an AUC of 1.000. For blurred IF images, the proposed MTL method had a higher accuracy (0.94 vs. 0.93,  Chronic kidney disease (CKD) is a non-communicable disease that contributes to high morbidity and mortality worldwide, including in China ,2. RecenDigital pathology refers to the assemblage of digital workflow and imaging solutions that are geared towards creating a digital image-based practice environment . Deep leIn the image acquisition stage, the acquired images may be blurry due to human or instrumental factors, which makes image recognition and analysis difficult in most cases . Most exThe main contributions of this study are as follows. (1) Novel image quality assessment and de-blurring methods are proposed to enhance the IF image quality, improve the accuracy, and improve the reproducibility of the classification model. (2) The proposed method has superior performance, as evidenced by its total accuracy of 0.94 and area under the receiver operating characteristic curve (AUC) score of 0.993 for blurred IF image classification.Kidney specimens were obtained from patients undergoing renal biopsy treatment in the People’s Liberation Army General Hospital, Beijing, China. Tissue samples were quickly placed in liquid nitrogen, and the frozen tissue was cut into 3–4 μm thick sections in a cryostat. The corresponding mouse anti-human IgG, IgA, IgM, C3, C4, C1q, and Fibrinogen (Fib) fluorescein isothiocyanate antibody was used for labeling and staining. A fluorescence microscope  was used to obtain IF images (200×). All images were taken following a standardized protocol and a 200 ms fixed exposure time.We retrospectively collected IF images of patients with IgAN, MN, DN, and LN in our hospital from June 2003 to November 2013. Seven types of IF images—IgG, IgA, IgM, C3, C4, C1q, and Fib—were collected for each patient. The IF images of each patient were analyzed by two professional renal pathologists with over five years of work experience. When there were discrepancies in diagnosis, a third senior pathologist with over ten years of work experience intervened to make the correct diagnosis. The final diagnosis of kidney disease was made by nephrologists based on the patient’s medical history, examination results, and pathology including IF images, light microscopy images, and electron microscopy images. The inclusion criteria were: (1) primary IgAN, (2) primary MN, and (3) all DN and LN. The exclusion criteria were: (1) patients under 18 years old and (2) patients with two or more kidney diseases. We divided the data into training and test data in a ratio of 8:2. Meantime, in order to build a blurred IF image database to simulate the defocusing scene of microscope, all the IF images were blurred via the Gaussian method .The image quality assessment (IQA) tasks take images as input and aims to regress the exacted feature into quality score. Specifically, our IQA subnet was composed of several convolutional layers for extracting features and linear layers for generating image quality scores. We set quality scores of 0 and 1 to represent blurred and non-blurred, respectively, a binary which is commonly adopted in the IQA tasks. Since the image quality assessment task was aimed to serve the de-blurring task, it did not need to assess the exact quality score of image; instead, it sonly roughly graded the IF image quality as blurred or non-blurred. Then, IF images needed to be de-blurred if the quality was judged as blurred. Otherwise, an image could be directly used for classification without de-blurring. The performance of image quality assessment was measured by the Pearson product-moment correlation coefficient (PLCC). The PLCC measures the correlation between predicted quality scores and ground truth scores, and it is commonly used in IQA tasks. Note that larger values indicate higher prediction correlations between IQA results and corresponding ground-truth. Specially, the PLCC metric can be formulated as follows: In the above equation, To de-blur blurred IF images judged by the image quality assessment subnet, we used a de-blurring subnet inspired by Zhao H et al. . The maiMSE) was used as the loss function, and Adam was used as the optimizer.First, two convolutional layers are used to extract the shallow features, and then the extracted shallow features go through four RDB blocks. Each RDB block includes dense connection, local feature fusion, and local and residual connection. Dense connection refers to a direct connection of each convolutional layer to subsequent layers, which enhances local transmission and optimally uses features from all preceding layers. All local features are concatenated together and pass through a 1 × 1 convolutional layer to achieve local feature fusion. Global residual learning combines shallow features and global fusion features. Finally, the image is restored through up-scaling. The minimum mean square error mean square error  curve was drawn, and the AUC was calculated. The chi-square test was used to compare the accuracy of different models. A Accuracy = (True Positives + True Negatives)/.Accuracy is the ratio between the correct predictions and the total predictions.Recall = (True Positives)/.Recall has the same statistical meaning as sensitivity.Precision = (True Positives)/.Precision has the same statistical meaning as the positive predictive value.F1 score = 2 /.The F1 score is an indicator used in statistics to measure the accuracy of a classification model. The F1 score can be regarded as a weighted average of precision and recall. Its maximum value is 1, and its minimum value is 0.We included 1608 patients’ IF images as the classifier dataset. Our IF diagnosis was jointly determined by three experienced doctors. If the IF images had no noticeable characteristics, our doctors combined light microscopy, electron microscopy, medical history, and our results to diagnose the diseases. There were 655, 348, 201, and 404 cases of IgAN, MN, DN, and LN, respectively. We divided the training and the test data into a ratio of 8:2. The training set had 1289 cases, with 523 cases of IgAN, 281 cases of MN, 162 cases of DN, and 323 cases of LN.The performance of the MTL-IF method was compared to that of the common method in two auxiliary tasks: image quality assessment and de-blurring. For the de-blurring task, the MSE metric was used to evaluate the performance. A lower MSE value indicated better de-blurring performance. The MSE of the proposed MTL method was decreased to 0.00115, whereas that of the common MTL method was decreased to 0.00147. The classification subnet was trained to identify IgAN, MN, DN, LN, and other kidney diseases. p < 0.01), and the AUC was 0.993. The ROC curve is shown in The common MTL method improved the classification accuracy when applied to blurred IF images, with an overall accuracy rate of 0.93 and an AUC of 0.986 shown in . The ROCAI has been widely used in the recognition of renal pathology , such asThe non-standardization of image quality is major problem of AI classification and recognition, and it has led to the poor reproducibility of model. Any medical imaging technology involving human reports is subject to important explanatory subjectivity constraints. Poor reproducibility has been confirmed numerous times in previous renal histopathology studies , and theThe common MTL method, which simply cascades tasks by order, has been used to solve the problem of de-blurring and classification . HoweverThis study shows that the MTL model can evaluate the quality of IF images of kidney disease and enhance the quality of low-quality images. It can also accurately classify and diagnose four types of kidney disease based on IF images. In the future, we hope to apply this model to identify other types of IF images of kidney diseases.