We compared the characteristics of the most cited, most downloaded, and most mentioned (the highest Altmetric Attention Score) articles published in general medical journals. We identified the 640 most frequently cited, 662 most frequently downloaded, and 652 most mentioned articles from 48 general medical journals. A comparison was made of the following characteristics of articles in the most cited, most downloaded, and most mentioned articles: medical specialty, publication type, country of origin, year of publication, and accessibility. There was only a 2.5% overlap in these three groups. Original articles were the more frequent among the most mentioned articles, whereas reviews, case reports, and guidelines/consensus statements were more frequent among the most downloaded articles. The most cited articles were more frequently published in 2010 and before, whereas the most downloaded articles were published in 2017−2018. The most mentioned articles were more frequently open-access articles, compared to the most downloaded articles. The most cited were more frequently older, the most downloaded were more frequently recent and educational, and the most mentioned were more frequently original and open-access articles. The results of our study may provide insights into various measures of article impact. Accurate measurement of the impact of a scientific publication is important for evaluating an individual’s academic performance and for guiding decisions for promotions, tenure, and grant funding .Traditionally, the number of citations an article receives is the most commonly used measure of the impact of an article and may reflect the impact among researchers rather than the interest of a broad audience . A citatAlthough there have been many studies to identify the most influential articles in a specific biomedical field, to the best of our knowledge, no study has compared the most cited, most downloaded, and most mentioned articles ,16,17,18The present study did not involve human subjects and, thus, did not require institutional review board approval.n = 8), most cited articles (n = 12), or both (n = 87) on their websites. Consequently, 48 general medical journals that provided information on both the most cited and most downloaded articles were included in the study. An author (J.H.H.) confirmed that each journal covers a broad spectrum of topics throughout the medical field, based on PubMed’s “Abridged Index Medicus  Journal Titles” and on “Instructions for Authors” in the journal’s website. Authors visited websites of 48 general medical journals, which displayed the list of the most cited and downloaded articles. The total sum of the most cited and downloaded articles from 48 general medical journals were 640 and 662, respectively.A search of the Web of Science , Science Edition 2016 was conducted which identified 155 journals listed under the subject category “Medicine, General and Internal”. Of these, 107 journals were excluded from the analysis because they did not display the lists of most downloaded articles  medical specialty, (2) publication type , (3) country of origin, (4) year of publication, and (5) accessibility (open-access or pay-for-access). Original articles were considered reports that investigated clearly stated objectives or hypotheses and contained original data, precisely articulated methods, and results sections. When an article had multiple authors from different countries, the country of the first author was considered the country of origin. If the first author had affiliations that were in more than one country, the corresponding author’s country of origin was used.Two reviewers (J.H.H. and K.J.L.) independently reviewed the titles and abstracts and extracted data from the articles. When relevant information was not available in the abstract, the full text of the article was obtained. In cases of disagreement, a third reviewer (D.Y.Y.) was included in the discussion until consensus was achieved.p-value of <0.05 was considered statistically significant.The characteristics between the most cited, most downloaded, and most mentioned articles were compared using the Chi-Square test. Statistical analyses were performed using IBM SPSS Statistics for Windows , and a Among the 640 most cited, the 662 most downloaded, and the 652 most mentioned articles published in the general medical journals, only 16 (2.5%) articles were included in all three lists. Thirty-seven (5.7%) articles were featured in the lists for both the most cited and most downloaded articles, 61 (9.3%) for the most downloaded and most mentioned articles, and 21 (3.3%) for the most mentioned and most cited articles.p < 0.0001), and gastroenterology/hepatology was more frequent among the most downloaded articles (p < 0.05) (p < 0.0001), whereas reviews, case reports, and guidelines/consensus statements were more frequent among the most downloaded articles  (p = 0.7). In almost all countries, there were no significant differences between the three groups  . Originafor all) . The coue groups .p < 0.0001), the most downloaded articles were published in 2017−2018 (p < 0.0001), and the most mentioned articles were published in 2013−2014 and 2015−2016 (p < 0.005 for both) (p < 0.05) (The most cited articles were published significantly more frequently in 2010 and before (or both) . Regardi < 0.05) .This study has several potential limitations. First, the survey was limited to lists of the most cited and most downloaded articles on the journals’ website; in most journals, however, no data are available on the period for citation and download of articles. All metrics for individual articles may fluctuate over time. Second, it was not possible to analyze the correlation between the number of citations, download count, and AAS of articles. Most general medical journals included in this study did not provide the number of times each article was cited and downloaded by readers. Third, only data supplied by Altmetric.com was used for assessing alternative metrics given its wide availability and coverage of the most comprehensive social media data. Other tools that provide article-level alternative metrics, such as Plum Analytics, ImpactStory, and ALM-PLoS, were not evaluated. These altmetric tools use different online sources and algorithms, which may lead to different results . In addiThe number of citations has been widely used as an accurate measure of the impact of an individual article. However, citation rate has been criticized because older articles have a greater citation potential simply because of the length of time they have been in the public domain. Scientific articles usually are not cited until one or two years after publication, and citations reach a maximum after 3–10 years . TherefoScientific publications are the primary channel for the widespread dissemination of research findings. Therefore, it is likely that the number of downloads of articles provides a good indicator of the papers that are most popular with readers . SeveralAltmetrics provides a real-time measure of the impact of articles on both researchers and the public through social media. Altmetrics, therefore, indicate a wider range of research-related activities than citations and downloads provide . HoweverSeveral previous studies have examined the relationship between citation counts and various altmetric measures for scientific papers ,26,27,28Before the appearance of the altmetrics concept, several studies have investigated the relationship between citations and downloads of publications and found varying results. Early studies have shown that the rank correlation between downloads and citations was high at the journal level but only medium-sized at the article level ,30. HoweIn this study, the characteristics of the most cited, most downloaded, and most mentioned articles published in general medical journals were compared, and substantial differences were found between these three groups.In terms of the medical specialty, “health care” specialty was significantly more frequent for the most cited articles, whereas “miscellaneous” was significantly more frequent for the most mentioned articles. Although the comparison of medical specialty should be interpreted with caution because of the numerous kinds of specialties which can lead to a small number of articles in each specialty, these findings suggest that citations are more related in general medical topics compared to other groups. In contrast, it is possible that a wide spread public audience is likely to share medical knowledge across diverse specialties rather than major medical specialties.The distribution of publication type of articles shows that reviews, case reports, and guidelines/consensus statements were more frequent among the most downloaded articles than other groups. This result suggests that readers of medical journals  are more interested in articles with an educational purpose. This is consistent with our previous research, which showed that the most downloaded articles published in radiology journals were more frequently reviews, case reports, guidelines/consensus statements, editorials/commentaries, and pictorial essays, compared with the most cited articles . On the Regarding the year of publication, 51.9% (332/640) of the most cited articles were published in 2010 and before, whereas 33.8% 224/662) of the most downloaded articles and 27.3% (178/652) of the most mentioned articles were published in 2017–2018. It takes a long time for citations to accumulate because to receive a citation, the citing articles must be written, edited, peer-reviewed, and finally published. In contrast, media has a function to announce new knowledge, so recent articles tend to be frequently mentioned on social media and, consequently, altmetrics accrue at a much faster rate than for citations [/662 of tSeveral previous studies have reported the advantage of open access in terms of article citations and downloads . Our stuOn the whole, our results indicate that there are important disparities between the most cited, most downloaded, and most mentioned articles. In addition, only 16 (2.5%) articles overlapped across the three groups. Therefore, the number of citations, download rate, and AAS should be considered as tools with different meanings in assessing the impact of scientific publications. Given faster availability and reflection of a broader audience, download rate and altmetric scores represent interesting and relevant indices of article impact, complementary to citation indicators. By combining these metrics, a more holistic assessment of the scientific and social impact of research can be substantiated.The most cited were more frequently older, the most downloaded were more frequently recent and educational, and the most mentioned were more frequently original and open-access articles. The results of our study may provide insights into various measures of article impact.


In the context of tremendous progress in congenital cardiology, more attention has been given to patient-related outcomes, especially in assessing health-related quality of life (HRQoL) of patients with congenital heart diseases (CHD). However, most studies have mainly focused on teenagers or adults and currently, few HRQoL controlled data is available in young children. This study aimed to evaluate HRQoL of children with CHD aged 5 to 7 y.o., in comparison with contemporary peers recruited in school, as well as the factors associated with HRQoL in this population.This multicentre controlled prospective cross-sectional study included 124 children with a CHD  during their outpatient visit and 125 controls  recruited at school. A generic paediatric HRQoL instrument was used (PedsQL 4.0).Self-reported HRQoL in children with CHD was similar to controls, overall , and for each dimension. Parents-reported HRQoL was significantly lower in the CHD group than in controls. HRQoL was predicted by the disease severity and by repeated invasive cardiac procedures (surgery or catheterization).HRQoL in young children with CHD aged 5 to 7 years old was good and similar to controls. This study contributed to the growing body of knowledge on HRQoL in congenital cardiology and emphasized the need for child and family support in the most complex CHD.Trial registration This study was approved by the institutional review board of Montpellier University Hospital (2019_IRB-MTP_02-19) on 22 February 2019 and was registered on ClinicalTrials.gov (NCT03931096) on 30 April 2019, https://clinicaltrials.gov/ct2/show/NCT03931096. In the past two decades, great advances in medical and surgical treatments for patients with congenital heart diseases (CHD) have significantly increased their life expectancy, and currently most children with CHD are expected to reach adulthood without any severe physical impairment , 2. Consmax)  . Neverthmax) –10.In the literature, the existing correlation between HRQoL and the severity of the CHD has mostly been found when considering the physical dimension of HRQoL , 11, 12.Nevertheless, most HRQoL studies with a consistent level of evidence have mainly included teenagers or adults with CHD, and, currently, few HRQoL controlled data is available in young children with CHD, especially in those under the age of 8 years , 19. YetIn this multicentre prospective controlled study, we aimed to evaluate HRQoL of children with CHD aged 5 to 7, in comparison with contemporary peers recruited in schools. We also intended to evaluate the factors associated with HRQoL in this population.This multicentre controlled prospective cross-sectional study was carried out in two paediatric cardiology tertiary care centres , and in 6 school classes in the Occitanie region, France, randomly selected from the Department of Education’s database.Children with a CHD, as defined by the ACC-CHD classification , and ageIn the 6 selected school classes, parents or legal guardians of all children aged 5 to 7 years were offered to participate in the study, with a common recruitment procedure for each class and similar to the one at the hospital. Children completed the HRQoL self-questionnaire under clinical research assistant supervising, at school. Parents filled in separately the HRQoL proxy-questionnaire at home.www.mapi-trust.org), following the international guidelines , number of cardiac surgeries, number of interventional cardiac catheterization procedures, drug medication, and electrocardiographic status (presence of pacemaker or implantable defibrillator), and echocardiography data .In the control group, only gender and age were collected.The characteristics of the population were presented using mean and standard deviation for continuous variables, and frequencies and proportions for qualitative variables.Age- and gender-adjusted means  of HRQoL scores were measured . To compare HRQoL scores between CHD and controls with adjustment on age and gender, a covariance analysis (ANCOVA) was performed. The same method was used to study the effect of Ross classification  and Bethesda classification  on HRQoL scores. For pairwise comparisons, the Holm’s correction was taken into account.To identify the clinical factors associated with HRQoL summary scores  in the CHD group, a multiple linear regression was used. Except for age and gender, which were forced in the models, the other clinically relevant variables with a P value ≤ 0.20 in the univariate analysis were included in the model. The final model was obtained using a backward selection with a removal level of 0.10. Colinearity between factors was tested with variance inflation factors. To test the validity of the model, the normality of residues was tested with the Shapiro–Wilk test. The statistical significance was set at 0.05 and analyses were performed with SAS V.9 software.A total of 249 children aged 5 to 7 years were recruited , including 124 subjects in the CHD group , and 125 subjects in the control group . Both groups were similar in terms of age and gender.In the CHD group, the anomalies of the ventricular outflow tracts represented the most frequent sub-group . In greater detail, the most frequent types of CHD were in the following order: ventricular septal defects , anomalies of the atria and interatrial communications n = 16, 13%), aortic valve stenosis , and tetralogy of Fallot . The smallest samples were complex anomalies of the atrioventricular connections (n = 2) and heterotaxy (n = 2). Most children in the CHD group had no congestive heart failure , nearly half of them had a low severity status , and nearly half of them had a good prognosis . CHD diagnosis was performed prenatally in nearly one out of three cases. A total of 58 subjects (47%) underwent at least one cardiac surgical procedure and 29 subjects (24%) underwent at least one interventional cardiac catheterization procedure. Most patients had no cardiac medication and a normal left ventricular systolic function. Clinical characteristics of the CHD group were detailed in Table 6, 13%, aNo significant differences were founded between CHD and control groups in self-reported HRQoL total score  as in all dimensions , as no patient included in the study presented with Ross class III or IV status. Self-reported HRQoL was statistically different between those three severity groups, overall , in emotional functioning P = 0.05), and in psychosocial summary functioning (P = 0.03)  in social functioning (P = 0.03) and psychosocial functioning (P = 0.05). However, no differences were found in the total scale score . Mother-reported HRQoL was different between the four severity groups, overall , as well as in physical functioning (P = 0.02), school functioning (P = 0.01), and psychosocial functioning (P = 0.02). Father-reported HRQoL scores comparisons were different between the four classes, overall , and in physical functioning (P = 0.05). Among CHD patients, Bethesda classification univariate and multivariate analyses found no association with self and proxy-HRQoL scores , self-reported HRQoL was affected by the number of cardiac surgical procedures in the total scale score and in the psychosocial functioning Table . Mother-Father-reported HRQoL was affected by the presence and the number of cardiac surgical procedures in psychosocial functioning, and in the total scale score, in the univariate analysis , or the presence of a pulmonary arterial hypertension, or an impaired left ventricular function , and therefore similar to that of their contemporary peers recruited in schools (e.g. 72.8 ± 1.2). Such HRQoL levels probably reflect all tremendous medical advances in the screening and care of CHD in the last decades, in terms of prenatal diagnosis, non-invasive real-time imaging, neonatal cardiac surgery, paediatric intensive care, and cardiac catheterization. Indeed, in the current era, over 90% of children with a CHD are expected to survive more than 30 years after first cardiac surgery , 33. YetWhen focusing on proxy reports, our study found that parents-reported HRQoL was significantly lower in the CHD group than in controls, with an approximate mean difference of 5 points (out of 100) in both mother and father reports. Our results are consistent with previous similar studies, but few HRQoL data involving both mothers and fathers of the same child have been reported in paediatric cardiology , 28, 41.Our results also suggested that young children with the more severe CHD had significantly poorer HRQoL, as reported by themselves and their parents. In previous studies, disease severity has been found to impact the HRQoL of children with CHD . Indeed,In our study, HRQoL was predicted by the disease severity based on the infant heart failure classification from Ross et al. . The RosHRQoL in this cohort of children with CHD was good and similar to controls but patients were recruited from outpatient visits in expert centres. Therefore, severe conditions have been underestimated , as well non-severe conditions (no follow-up in a tertiary care centre). However, we previously reported HRQoL data on young children with severe conditions  and mostMany patients with a CHD may also be concerned with a genetic syndrome or a neurological deficit, with a potential impact on their HRQoL. They have purposely not been included in this study for methodological issues (inability to understand and/or fill-in the questionnaires). However, investigating HRQoL in this specific population using appropriate measurement tools remains necessary.Currently, nearly half CHD are diagnosed prenatally, most future children are expected to benefit from an efficient treatment with a low morbidity and mortality. As a result, many parents ask the following question during prenatal diagnosis: “what will be the quality of life of my future child?”. Therefore, future research, using large international registries, should investigate the reliability of prenatal prognosis assessment, such as the scale from Davey et al., in terms of HRQoL prediction.HRQoL in young children with CHD aged 5 to 7 years old was good and similar to controls. HRQoL in this population correlated with CHD severity, especially when assessed by the infant heart failure Ross classification. This study contributed to the growing body of knowledge on HRQoL in congenital cardiology and emphasized the need for child and family support in the most complex CHD. In the current era, prognosis in CHD is excellent, therefore the beneficial role of HRQoL assessment in routine clinical practice for screening and decision-making is of great importance. However, other domains remain under-investigated in the CHD population, such as the impact of psychomotor and cognitive developmental disorders on HRQoL.Additional file 1:Supplementary Table 1. Health-related quality of life in children with CHD compared to control children. Supplementary Table 2. Mother-report QoL explanatory variables in the CHD group. Supplementary Table 3. Father-report QoL explanatory variables in the CHD group.


Nyssomyia whitmani as the main vector in this region. Regarding VL, urban reports started in 2010 with Lutzomyia longipalpis as the main vector. The aim of this study was to evaluate environmental determinants related to the main vectors of leishmaniasis, to contribute to the prevention and control response to the emergence of VL and CL in the Argentina-Brazil-Paraguay border region.In South America, cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) are emerging diseases, expanding in the border area of Argentina, Brazil and Paraguay. Outbreaks of CL were reported since the 1990s, with Leishmania DNA.The cross-sectional survey includes two cities and two close rural areas in the Argentinean Northeast Region, between November 2014 and January 2015, with a total of 95 sampling sites. REDILA-BL traps were set for three consecutive nights, and a total of 68 meso- and microscale environmental and landscape characteristics were surveyed. The association between vector abundance with different variables was evaluated using a generalized linear model with zero-inflated negative binomial distribution. We analyzed females for detection of Lu. longipalpis indicates an excess of absences when the mean NDWI around the sites were higher. The abundance of Lu. longipalpis at mesoscale level was higher when more urban services were present, and when blood sources such as chickens or dogs at the microscale level were present. For Ny. whitmani, no variable was found to be associated with the absences, while its abundance increased in association with the following variables: percentage of tree cover, presence of garbage collection service, hosted people and, at microscale, the presence of poultry. Leshmania infantum DNA was detected in 2/49 (4%) Lu. longipalpis.The analysis for Lu. longipalpis and the peri-urban and rural segregation of N. whitmani increase the risk of VL and CL. The selection of the better variables for each scale will allow the design of appropriate control strategies depending on species.The abundance of both species is influenced by variables at different scales, their influence probably has a hierarchy and they are acting on different aspects of the biology of these vectors. The urban spatial segregation of  In the last few decades in the New World leishmaniasis are re-emerging in some countries and emerging in others. Visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL) are neglected vector-borne diseases associated with environmental factors and their anthropogenic modifications . Innovatc.200 cases reported per year) are recorded from nine provinces, with scattered outbreaks, and the transmission currently occurs in rural domestic environments. Leishmania braziliensis is the main parasite species isolated from cases related to outbreaks, domestic mammals and vectors [In Argentina, CL is mainly rural and endemic at least since the beginning of the 20th century, while VL is urban with recent epidemic events reported since 2006 . Reporti vectors . The abu vectors –7.Lu. longipalpis was found in Argentina at Clorinda (Formosa Province) in 2004 [Migonemyia migonei as a vector [Phlebotomine surveillance was intensified in border areas since 2000 (due to southern reports of VL in Brazil and Paraguay) and  in 2004 . The fir in 2004 , 9. Sinca vector . There avia the border effect [Lutzomyia longipalpis was not found in the city of Puerto Iguazú before 2010 when was first found together with VL canine cases [The Iguazú waterfall area, located in Iguazú Department where the city of Puerto Iguazú is the most important urban area, reported CL outbreaks in 1998 (Puerto Esperanza), 2004 (Urugua-í), and 2005 (Puerto Iguazú) , 13 and r effect , 14, 15.ne cases , 16. Thene cases . The aimhttps://www.smn.gob.ar/estadisticas).The study area belongs to the department of Iguazú  in the province of Misiones, northeast Argentina, on the three-country border with Brazil and Paraguay, with an altitude between 140–240 m above sea level   with 13 sites  set for three consecutive nights without rain or wind , with a Evandromyia cortelezzii and E. sallesi females cannot be discriminated at the species level by morphology, individuals are reported as Cortelezzii complex [All specimens were kept in a freezer, then separated into fed females, unfed females and males, and counted under a microscope 40× . The identification was performed according to Galati ; abbrevi complex .Le. infantum was conducted following the RV1-RV2 PCR protocol as described by Lachaud et al. [Le. infantum was employed as a positive control; negative controls consisted of water; the reference strain used was WHO Le. braziliensis HOM/BR75M2903. All PCR products were separated by electrophoresis on a 2% agarose gel and visualized with SyberGreen® . For sequencing purposes, PCR products were purified by a commercial kit  from the agarose gel. Sequence qualities were evaluated with Codon Code Aligner™ software (V 2.0.6-LaBiMAp-FCEQyN-UNaM license), and Le. infantum identity was confirmed by BLASTn (blast.ncbi.nlm.nih.gov/Blast).Up to 30 females of each trap/night were separated for molecular analyses, identified by abdominal segment dissection and observation of the spermathecae, while keeping the remnant parts of each specimen individually in 1.5 ml microtubes and kept it at − 20 °C until DNA extraction followed by polymerase chain reaction (PCR). Total DNA was extracted using a commercial kit  according to the manufacturer’s instruction. DNA quality was evaluated by a PCR assay targeting the constitutive gen IVS6 (cacophony) of Phlebotominae, giving an expected 220-bp product with the primers 5Llcac (5′-GGC CCA CTA TTA CAC CAA CCC C-3′) and 3Llcac (5′-GGG GTA GGG GCG TTC TGC GAA-3′) . Detectid et al. , which tAt each site, we performed an epidemiological-environmental characterization. Characteristics surveyed followed a hierarchical ecological scale previously defined for the local phlebotomine species by a workshop in the frame of the IDRC Project# 107577 and already applied by Santini et al.  and Tomhc.25, 50, 100 and 250 m. At the spatial mesoscale (buffer at a radius of > 25 m from the trap location site), environmental characteristics were evaluated using the percentages of different land cover classes and vegetation indices. Land cover classes were defined ad-hoc based on previous phlebotomine studies [Different surface buffer areas were considered at a radius of  studies , 29 and  studies , 31.We used a Spot5-HRG2 multispectral image of the study area on 20 December 2014 (grids) and 24 December 2014 (transects) with a spatial resolution of 2.5 m. Vector Support Machine (SVM) classifier was used to generate coverage maps. The configuration used for the SVM classifier was: (i) Kernel function = RBF; (ii) Constant C = 1000; (iii) Gamma parameter = 1; and (iv) Probability threshold = 0. To increase the precision of the classification of the maps, the homogeneity variable was used . Accurachttps://envi.software.informer.com/4.8/) and Quantum Gis 2.14.15-Essen [Satellites and spatial data were analyzed using ENVI+IDL v.4.8 , we recorded 21 environmental characteristics  . Rare spere used . These aed [egan  and basesoftware .Ny. whitmani and Lu. longipalpis, and the environmental variables.As our samples contained large numbers of zeros Table , we usedZI models are mixture models with two independent components: the ‘zero-inflated’ component, which represents the excess of absences ; and the component that represents the counts, including the absences expected in the count process . For thiTwo sets of explanatory variables were evaluated, according to the spatial scales previously defined: mesoscale (buffer > 25 m) and microscale (buffer < 25 m). The number of hosted people was log(x+1)-transformed when used as a predictor to decrease the leverage of extreme values.P < 0.1 were retained. Based on the results of the univariate analysis, and those that were found significant, our strategy was to formulate multiple models containing explanatory variables from each of the two sets. To avoid overfitting and multicollinearity issues, the explanatory variables with strong correlation were evaluated in separate models. We examined several possible additive combinations of variables to determine the final model. The most parsimonious model was chosen based on Akaikeʼs information criterion (AIC). The analyses were conducted using pscl and lmtest packages in R version 3.4.3 [We fitted univariate regression models for each explanatory variable, and those significant at on 3.4.3 .After the model selection procedure, spatial predictions of the abundance of both species in the city of Puerto Iguazú with a resolution of 30 × 30 m were built using maps of the predictive variables when they were available or assuming constant values for the whole area for different levels of those variables (see Results).Lu. longipalpis (47%) and Ny. whitmani (45%), while the remaining 8 species of the Phlebotominae represented each one less than 2.5% of the overall capture. Rarefaction curves suggest that rural phlebotomine assemblages were adequately sampled with the effort used, while in urban and periurban areas some species could be still missed, and in the forest, more sites are required to be sampled . The exploratory analysis indicated that most of the variance of Lu. longipalpis, and variables at the 50-m radius area for Ny. whitmani.For both species, the characteristics recorded at a 100-m radius area explained the second highest amount of variance. Therefore, we decided to conduct assemblage analysis using variables at the 250-m radius area for P < 0.05) representing 32.6% of the total variability in the phlebotomine abundance in the sites . The first axis discriminated urban sites with Lu. longipalpis and Pintomyia monticola grouped in the most urbanized environments of the city of Puerto Iguazú, while Ny. whitmani, Mg. migonei, Cortelezzii complex and Micropigomyia quinquefer were comparatively more abundant in sites with a mixed landscape. These differences were explained by the differences in the percentage of tree or shrub vegetation cover, mean NDWI values and the number of land cover classes which was comparatively higher in periurban sites , and when blood sources such as chickens or dogs were present at the microscale level  in the whole area was predicted. While if urban services and animals would be present in the household, the higher abundances are predicted in the central area of the city where NDWI showed lower values, reflecting the lower vegetation cover conditions  positive by PCR. This was confirmed by sequence analysis showing 99% identity with reference sequences deposited on GenBank. Considering the total abundance of Lu. longipalpis analyzed, the infection rate was 4% (2/49), from both sites of Puerto Iguazú.One hundred and seventy females  were screened for Lu. longipalpis and periurban-rural Ny. whitmani in the area of the Argentina-Brazil-Paraguay border has already been described [The spatially segregated prevalence of urban escribed , 42. TheBrumptomyia in these sites is an indicator of closeness to undisturbed environments [The rarefaction curve for urban-periurban captures indicates that the captures conducted may have missed some species. But unlike the rural area, at least in the southern latitude localities of South America, the urban-periurban peridomestic environments have a micro-heterogeneous landscape with green patches intermingled with houses of different quality and paved streets, that could change with sudden trends of unplanned urbanization or land occupation. Furthermore, these green patches are contiguous with riparian forests or city belt secondary woods. In this sense, the presence of species of the genus ronments , 44. Theronments , 45. To ronments , 17, 46.Lu. longipalpis-Pi. monticola from periurban environments that are less adapted or species that are in the state of an ongoing adaptation to the more heterogenous anthropized environments such as Ny. whitmani-Mg. migonei, and species from the rural-forest environments such as Ny. neivai-Brumptomyia sp.Thus, phlebotomine diversity both in rural and urban environments is related to the heterogeneity of the landscape. In urban environments, the presence of vegetation offers multiple microhabitats as resting-breeding sites. The CCA analysis showed that the species assemblage structure is associated with the amount of land cover classes, the percentage of woody plants and NDWI. It is important to note that greater diversity was expected in forest and periurban environments as presented in a previous study in the Argentinean area , which wBrumptomyia as an indicator of environmental health. The sites or season with higher abundance in urban settings are usually not coincidental with Lu. longipalpis [This result reasserts the spatial segregation of the species, and the role of the genus gipalpis –50.Ny. neivai is the main vector of Le. braziliensis and also of peridomestic CL, but in the province of Misiones it is related to outbreaks of CL associated with deforestation fronts, while Ny. whitmani is the incriminated vector in the studied area [Pi. monticola with the urban gradient together with Lu. longipalpis, in three different trappings sites separated from each other by up to 1000 m, requires further sampling.In other ecoregions of Argentina, ied area , 9. The Lu. longipalpis, we found a lower probability of finding this vector where higher values of NDWI are present in a 250-m radius area, conditions presented mainly in forest and rural landscapes. We assumed that the absence of Lu. longipalpis in these areas with high values of NDWI are true absences rather than sampling bias, as could respond to environmental suitability requirements of this species. Abundance of Lu. longipalpis is greatest when more public services are present in the dwelling, associated also with the presence of a food source at the microscale level, reflecting an urban environment but with food availability. An interesting result of the present models is that each species is associated to different variables at different scales; for example Lu. longipalpis at the mesoscale level does not need trees but at the microscale level is associated with trees if a source of food is within reach. Models combining variables at different scales represent different risk scenarios, which allow the identification of the type of environment at the time of implementing effective control and/or surveillance strategies.Consistently with the urban distribution and microhabitat suitability for Lu. longipalpis through Puerto Iguazu was predicted in 250 m mesoscale windows , with actual NDWI values, most of the urbanized area was suitable for Lu. longipalpis. The forecasted distribution of this species is concentrated along the main avenue on the vertical axis, more than in the peripheral more homogeneous and forested areas. This broad distribution was associated also with dogs as a source of blood and urban services as a proxy of landscape microheterogeneity. However, when chickens were included in the predictive maps with or without dogs, a few “hot spots” of vectors were spatially segregated.When the spatial distribution of Lu. longipalpis “hot spots” and chickens, blood-meal availability, and tree coverage-landscape heterogeneity in urban settings were already described in the same ecoregion [Lu. longipalpis of low levels of humidity could help to the urbanization and adaptation of this species to anthropized environments [Lu. longipalpis suggest a broad plasticity that facilitates a step by step spread within the city [The association between coregion , 45, 46 coregion . Breedinronments , while athe city , 21.Lu. longipalpis at two spatial scales rise the possibility to design two different sets of interventions of integrated vector management at the urban operational level, but always acting on both scales simultaneously with proper indicators of impact. In Santo Tomé, a city in the same ecoregion of this study, the microscale variables were found to be associated with the abundance of Lu. longipalpis, while the mesoscale the variables were associated both with the presence/absence and abundance of this species [Discrimination of variables associated with the distribution of  species . Of cour species , 53–56.Lu. longipalpis is persistent in time with most “hot spots” of steady abundance, while other sites with occurrence of Lu. longiplapis could appear-disappear due to microenvironment changes [Lu. longipalpis as the species abundance could increase up to 60 times from the first reports to an established population [Another issue to support the idea of focused control on the “hot spots” is the possibility that these sites act as source populations for the remaining low-abundance sites. The longitudinal studies suggest that the clustering of urban  changes , 57–60.  changes , 61–63 ipulation , 63.Ny. whitmani related to the periurban, more relatively homogeneous landscape, by ZINB modeling only show association in the count component at the mesoscale with vegetation coverage and garbage collection and at the microscale with two sources of blood, poultry and humans. Therefore, in the forecasting map with 50-m microscale windows, the spatial buffer that best explains the variance of this species, shows the continuous peripheral distribution of Ny. whitmani in riparian forest, and the city green belt continuous with the secondary and preserved forest around the city. Nyssomyia whitmani also seems ornithophilic and anthropophilic but less cynophilic, as suggested by the positive effect of poultry or clustered humans on the distribution of the abundance of this species at the microscale. Regarding the association with rural and forest landscapes, Ny. whitmani in some regions of Brazil are still not urbanized or are in process of urbanization as in the present study [The distribution of nt study –67, whilnt study , 69. TheLeishmania infantum DNA detection confirms the central role of Lu. longipalpis in the VI cycle by parasite transmission in urban landscapes, mostly when it is found in specimens with empty guts, i.e. with at least a previous digested infected blood meal. Other species reported in this study were also found with DNA of Le. infantum in Puerto Iguazu area  but only Mg. migonei was suggested a role as permissive vector of Le. infantum in Argentina and Brazil [Le. infantum DNA was detected in three phlebotomine  without a visible blood meal inside, captured in the same site as the previously infected ones suggesting the presence of a “hot spot” of parasites [d Brazil , 70–72 od Brazil , 45, 73.arasites .Lu. longipalpis and periurban-rural Ny. whitmani, and therefore the VL and CL risk, but with a potential trend of Lu. longipalpis to spread to the rural areas and of Ny. whitmani to the urban areas [Lu. longipalpis, Ny. whitmani and Mg. migonei, the ruralized periurban ecotone could act as a bridge between the domestic and forest cycles of transmission by permissive vectors [Lu. longipalpis causing human VL clustered there in “hot spots” [Lu. longipalpis abundance will allow to design and evaluate the impact of focused cost-effective surveillance only in the few sites with optimal suitability for the vector, and to perform preventive interventions just in the few persistent “hot spots” as they are eventual source populations. This approach is also supported by the low genetic diversity of Lu. longipalpis in the area [We reinforce the results about the spatial segregation of urban an areas , 74–77.  vectors , 78, and vectors . The modt spots” , 46, 80.the area , and thethe area . The latAdditional file 1: Figure S1. Spatial predictions of the abundance  of Lu. longipalpis (a-b) and Ny. whitmani (c). a Without services, dogs or poultry. b Without services and with poultry. c Without garbage collection service, one hosted people and without poultry.


Teledermatology is a health care tool that has been increasingly used around the world, mostly because dermatology has an emphasis on visual diagnosis. Many studies have shown that access to specialized care improves using teledermatology, which provides accurate diagnosis and reduces the time taken for treatment, with high patient satisfaction. As the population around the world grows old, there will be even more demand for dermatologists in years to come. It is essential to know which are the most prevalent skin conditions in the primary care population and if they can be addressed through teledermatology.Our main goal was to evaluate the proportion of lesions in individuals aged 60 years and older that could be managed using teledermatology in conjunction with primary care physicians. Second, we aimed to assess the most frequent skin lesions, the most common treatments provided to patients, and the distribution and causes of referrals made by the teledermatologists.This was a retrospective cohort study from July 2017 to July 2018 in São Paulo, Brazil. We included 6633 individuals aged 60 years and older who presented with 12,770 skin lesions. Teledermatologists had three options to refer patients: (1) to undergo biopsy directly, (2) to an in-person dermatologist visit, and (3) back to the primary care physician with the most probable diagnosis and treatment.Teledermatology managed 66.66% (8408/12614) of dermatoses with the primary care physician without the need for an in-presence visit; 27.10% (3419/12614) were referred to dermatologists, and 6.24% (787/12614) directly to biopsy. The most frequent diseases were seborrheic keratosis, solar lentigo, onychomycosis, melanocytic nevus, benign neoplasms, actinic keratosis, epidermoid cyst, xerosis, leucoderma, and wart, with significant differences between sexes. Malignant tumors increased with age and were the leading cause for biopsies, while infectious skin conditions and pigmentary disorders decreased. Emollient was the most frequent treatment prescribed, in 31.88% (909/2856) of the cases.Teledermatology helped to treat 67% of the dermatoses of older individuals, addressing cases of minor complexity quickly and conveniently together with the primary care physician, thus optimizing dermatological appointments for the most severe, surgical, or complex diseases. Teledermatology does not aim to replace a face-to-face visit with the dermatologist; however, it might help to democratize dermatological treatment access for patients and decrease health care expenses. Teledermatology is a health care tool that has been increasingly used around the world, mostly because dermatology has an emphasis on visual diagnosis. Studies from all over the world have been performed on this subspecialty . Real-tiTypical skin conditions such as mild atopic dermatitis, acne, fungal infections, xerosis, and others are common diseases that may be manageable within the primary care attention service. However, this is not often observed because health professionals are not well trained in diagnosing or triaging skin diseases. The lack of well-trained primary care physicians can lead to unnecessary referral of patients to dermatologists. When there are not enough dermatologists to meet demand, appointments can be filled by patients who do not need specialist care limiting availability of visits for those who do need them.The city of São Paulo has nearly 12 million inhabitants , and 58%Due to this high unmet demand, the municipal health department established a teledermatology project in partnership with Hospital Israelita Albert Einstein, a large private hospital in the city. The aim was to assist patients in primary care, avoiding unnecessary consultations with dermatologists and accelerating in-presence visits and biopsies for those who have more complex, surgical, or even lethal conditions.The primary goal was to determine the proportion of dermatosis in the older population (aged 60 years and older) that could be managed in primary care through teledermatology, but the project included patients of all ages. Second, we assessed the distribution of referrals and frequency (according to sex and age), treatment, and causes of the most common skin diseases for patients assisted in the project. Both objectives have been achieved in this study.This study was approved by the Hospital Israelita Albert Einstein and Municipal Ethics Committees (CAAE: 97126618.6.3001.0086), and it is in accordance with ethical standards on human experimentation and the Declaration of Helsinki. Data were fully anonymized before being accessed, and the institutional review board waived the requirement for informed consent.As this teledermatology project included a large number of individuals, it was divided into topics of interest to better analyze the subpopulations. The study design and method are similar to ones that have been previously published ,10. In sPatients on the waiting list for dermatological assistance were phoned by the public health care service and scheduled to go to an appointment in one of three public city hospitals participating in the project. From July 2017 to July 2018, 13 teledermatologists worked to triage patients, first deciding whether the photographs of the lesions and essential clinical history were satisfactory for diagnostic purposes. If not, they would mark the “bad photo” box on the platform and refer the patient for a face-to-face appointment with a dermatologist. If the photos and essential clinical information were of good quality, the triage dermatologists would formulate the most probable diagnostic hypothesis and choose among three referral options for each lesion assessed: (1) directly to biopsy (after which the patient would return to an in-presence dermatologist appointment with the result); (2) to a dermatologist consultation; or (3) back to the primary care physician with the most probable diagnosis and recommended treatment or guidance on how to proceed with the investigation or management of the lesion. If the same patient had more than one lesion with different referrals, a biopsy referral would prevail over dermatologist referral, which would prevail over a back to primary care physician referral. All patients who attended the project were included in this study.To better analyze the population of interest, patients aged 60 years and older, we divided them into four categories: 60 to 69 years, 70 to 79 years, 80 to 89 years, and 90 years and older. Only dermatologists certified by the Brazilian Board of Dermatology participated in the project to decrease the chance of diagnostic error by teledermatology. In our municipal basic health unit, a direct exam to search for fungal infection is not done. For this reason, suspicious cases of superficial fungal infections received antifungal treatment as a therapeutic test and were reevaluated afterward. If deep fungal infections were suspected, the teledermatologist would refer the patient to biopsy or a dermatologist and not treat the patient before confirmation of the pathogen.P<.05 was considered significant.Missing data were reported when the patient had the photographs taken. If for any reason, such as problems with the platform, the photographs did not make their way to the teledermatologists or the reports made by the teledermatologists were not uploaded to the platform , those cases were referred to face-to-face dermatologists. All calculations and frequency analyses were done using only the available teledermatologist reports, meaning that missing data and bad photos were not included. For differences between groups (sex), a statistical calculation was done using a 2-tail chi-square with Yates correction test using Prism 6.0 (GraphPad Software). From a population of 10,545 individuals aged 60 years and older waiting for dermatologist consultations, 6633 patients participated in this project (62.90%); 6320 referrals were made, and 313 participants were lost due to technical problems (4.7%). The total number of photographed lesions was 13,432, and 12,614 diagnoses were made. The mean number of photographed lesions per person was 2. Bleeding was present in only 8.09%  of the lesions, but pruritus was reported in 40.62%  of them, being more frequent in lesions on individuals aged 90 years and older. Photographs with poor quality were calculated at 1.22%  of patients were referred back to their primary physicians, 42.10% (2661/6320) to consultation with an in-presence dermatologist, and 8.09% (511/6320) directly to biopsy; 66.66%  of all lesions were referred back to the primary care physician, 27.10%  to the in-presence dermatologist, and 6.24%  directly to biopsy. The mean waiting time for a face-to-face dermatologist was 6.7 months before the project, which dropped to 1.5 months during the project (reduction of 78%).P<.001), wart (P=.04), and actinic keratosis (P=.008) were more frequent in men. Solar lentigo (P<.001), onychomycosis (P=.02), leucoderma (P=.01), and melanocytic nevus (P<.001) were statistically more frequently diagnosed in women. Seborrheic keratosis, xerosis, and benign neoplasms showed no difference in frequency between the sexes.The most common causes of consultation for individuals aged 60 years and older are shown in We assessed the most common diseases according to age and divided them into disease groups . Benign The most frequent lesions referred to biopsy, dermatologists, and back to the primary care physician are shown in Referrals to dermatologists occurred in 27.10%  of the lesions. Actinic keratosis was the lesion which most frequently sent the patient to an in-presence appointment (in 87.93% [532/605] of the times), followed by warts , epidermoid cyst , lipomas , melanocytic nevus , and seborrheic keratosis . Chronic skin diseases that frequently require follow-ups, such as psoriasis, vitiligo, onychomycosis, and androgenic alopecia, were also in the top 10 causes for referrals to dermatologists. Frequency of referral was 60.27% (132/219), 74.17% (89/120), 9.84.% (84/854), and 32.34% (76/235), respectively.Teledermatologists sent the patients back to their primary care physicians in 66.71% (8408/12614) of cases. Seborrheic keratosis could be treated at primary care in 80.25% (1410/1757) of cases, solar lentigo in 94.85% (865/912), benign neoplasms in 87.30% (550/630), leuchoderma in 96.73% (355/367), melanocytic nevus in 62.16% (496/798), and epidermoid cyst in 41.00% (189/461). Onychomycosis was managed by teledermatology in 90.16% (770/854) of cases, xerosis in 98.78% (405/410), seborrheic dermatitis in 90.79% (207/228), and tinea on the feet in 93.92% (170/181) of cases.We also searched for the most frequent treatments prescribed by teledermatologists. Emollients were the most common prescription, in 31.88% (909/2856) of all cases. The other top classes of drugs prescribed were as follows: topical antifungal in 29.52% (843/2856), sunscreen in 27.87% (796/2856), topical corticosteroids (low and high potency) in 24.40% (697/2856), oral antifungals in 7.18% (205/2856), and hydroquinone in 1.33% (38/2856) of cases.The vast majority of the dermatoses assessed did not require an in-presence evaluation by a dermatologist (73%), suggesting that most skin conditions in our primary care setting are of low complexity and, therefore, can be addressed appropriately without referral to more specialized centers. This finding also reinforces the feasibility and importance of teledermatology in this context, helping primary care physicians to manage such conditions and optimizing patient access to care for more severe, surgical or complex illnesses, which do require a dermatologist, especially in the public system. The reduction in the mean waiting time for a face-to-face dermatologist during the project is a great advantage, especially considering that many of these cases could be skin cancers. During the study, the patient was always treated by a physician, which gave us more confidence that potentially severe, life-threatening, or rare diseases were not being overlooked. This work shows that teledermatology is a well-defined, structured, scalable process with standardized collection and fairness of care, which might promote the democratization of access to dermatology for underprivileged patients.Most of the cases referred for biopsy were patients with malignant lesions, especially basal cell and squamous cell carcinomas. Melanoma, although rarer, was the third cause of biopsy referrals, which is of great concern, since it can lead to death if not promptly diagnosed and treated. The fact that biopsy was indicated in 74% and not 100% of the melanoma cases, as expected, could reflect the teledermatologists’ fear about the type of biopsy that would be performed in those cases: incisional versus excisional. They probably sent the melanoma patients to the dermatologist aiming to ensure the indication of excisional biopsy, which is the gold standard treatment for this disease . Only a Referrals to dermatologists were made mostly for treatment of premalignant lesions (actinic keratosis) and warts, lesions that usually require procedures such as cryotherapy with liquid nitrogen, excision, curettage, and electrocoagulation. A small portion of patients with benign tumors, such as melanocytic nevi and seborrheic keratosis, were sent to an in-presence dermatologist consultation. Still, these numbers could be even smaller if access to dermoscopic images were granted . DermoscRegarding the frequency of lesions, seborrheic keratosis was the most common complaint found in the study. It is one of the most common skin tumors, but due to its benign nature, treatment is not mandatory. The second condition in frequency was solar lentigo, a benign lesion associated with aging, constituting a general aesthetic and social concern. It appears mostly on chronically sun-exposed surfaces  and is frequently present among the elderly population. Estimates are that more than 90% of white patients aged older than 50 years are affected . OnychomRegarding treatment, a list of drugs available to the population studied is found in One significant limitation of our work is the chance of error and bias in teledermatology diagnosis. However, many articles have attested to a high agreement rate between teledermatology and in-presence dermatology diagnosis ,18. The Only one study including 500 patients analyzed the proportion of in-person consultations that could be avoided using teledermatology and showed that in 73% of patients, no referral to an in-person dermatologist was needed .The current teledermatology initiative in São Paulo managed most of the patients’ dermatoses without the need for an in-presence appointment with a dermatologist, keeping them within the primary care setting. The mean waiting time reduction for an in-presence visit was a definite benefit for the population who presented with more complex diseases. Although it does not aim to replace a face-to-face visit with a dermatologist, teledermatology proved to be an efficient tool for triage and management of less complicated skin conditions quickly and conveniently, and, in our project, it has promoted the democratization of access to dermatology for underprivileged patients. Future works should focus on the cost effectiveness of the project, on the accuracy of teledermatology in inflammatory and tumoral dermatoses, and on the efficacy of the management proposed by teledermatologists to general physicians.The frequency of skin diseases differed according to age and sex. Recognizing the prevalence and distribution of the most common diseases affecting individuals aged 60 years and older is crucial to address social and health policies that could orient treatment or prevention through popular campaigns and advertisements.


Artificial intelligence (AI) is about to transform medical imaging. The Research Consortium for Medical Image Analysis (RECOMIA), a not-for-profit organisation, has developed an online platform to facilitate collaboration between medical researchers and AI researchers. The aim is to minimise the time and effort researchers need to spend on technical aspects, such as transfer, display, and annotation of images, as well as legal aspects, such as de-identification. The purpose of this article is to present the RECOMIA platform and its AI-based tools for organ segmentation in computed tomography (CT), which can be used for extraction of standardised uptake values from the corresponding positron emission tomography (PET) image.The RECOMIA platform includes modules for (1) local de-identification of medical images, (2) secure transfer of images to the cloud-based platform, (3) display functions available using a standard web browser, (4) tools for manual annotation of organs or pathology in the images, (5) deep learning-based tools for organ segmentation or other customised analyses, (6) tools for quantification of segmented volumes, and (7) an export function for the quantitative results. The AI-based tool for organ segmentation in CT currently handles 100 organs (77 bones and 23 soft tissue organs). The segmentation is based on two convolutional neural networks (CNNs): one network to handle organs with multiple similar instances, such as vertebrae and ribs, and one network for all other organs. The CNNs have been trained using CT studies from 339 patients. Experienced radiologists annotated organs in the CT studies. The performance of the segmentation tool, measured as mean Dice index on a manually annotated test set, with 10 representative organs, was 0.93 for all foreground voxels, and the mean Dice index over the organs were 0.86 (0.82 for the soft tissue organs and 0.90 for the bones).www.recomia.org for research purposes.The paper presents a platform that provides deep learning-based tools that can perform basic organ segmentations in CT, which can then be used to automatically obtain the different measurement in the corresponding PET image. The RECOMIA platform is available on request at  Artificial intelligence (AI) is about to transform the field of medical imaging. Deep learning, a subfield of AI, has become the method of choice for image analysis applications. This technique provides new opportunities in developing tools for automated analysis of 3-dimensional computed tomography (CT), positron emission tomography (PET)/CT, and magnetic resonance imaging. These tools have the potential to improve or substitute current methods of assessing CT, PET/CT, and magnetic resonance imaging in patients with cancer, for example, the Response Evaluation Criteria in Solid Tumors and PET Response Evaluation Criteria in Solid Tumors –3. The dThe Research Consortium for Medical Image Analysis (RECOMIA) is a not-for-profit organisation that aims to promote research in the fields of AI and medical imaging. RECOMIA has developed a cloud-based platform to facilitate collaboration between medical researchers focusing on patient images and the related information, and mathematical researchers developing deep learning-based tools. The aim is to minimise the time and effort researchers need to spend on technical aspects, such as transfer and display of digital imaging and communications in medicine (DICOM) images and image annotations, as well as legal aspects, such as de-identification, and compliance with the General Data Protection Regulation and the Health Insurance Portability and Accountability Act.www.recomia.org. At present, more than 100 different organs and lesions can be segmented/detected based on training databases consisting of CT and PET/CT studies. This article aims to present the RECOMIA platform and the status of the current deep learning-based CT tools.Deep learning-based tools can be trained to analyse medical images using images with manual annotations of organs or pathology, such as tumours. The RECOMIA platform provides deep learning-based tools that can perform organ segmentations in CT, detection of lesions in PET/CT, and automated quantitative analysis of the segmented/detected volumes. These tools are freely available for researchers on reasonable request at The RECOMIA platform is a cloud-based platform running on two separate servers Fig. . One is New medical images in DICOM format can be uploaded to the platform using drag and drop. Before leaving your device, the image files are automatically de-identified in accordance with the DICOM standard Fig. . TransfeThe platform also allows viewing and annotating images in the browser. Standard features, such as windowing, zoom, and colour scales for PET studies are available, in similar ways as in conventional workstations. For performing detailed manual segmentations of, for example, organs or lesions, several tools are available. These include basic tools, such as a brush, polygon, and bucket fill tools, but also more advanced tools specialised for medical images Fig. . All tooThe resulting annotations can be saved in separate DICOM files with label information stored in the DICOM file following the DICOM standard.Several deep learning-based tools are already available upon request in the RECOMIA platform, among which the most important is the organ segmentation, described in the next section Fig. . It is aGiven a segmentation, whether performed manually or by AI, several statistics are available for each label. This includes the label volume, mean and max pixel values, and the number of connected components. For example, for PET images, this allows the computation of standardised uptake values and total lesion uptakes. The results can be exported as a CSV file.The RECOMIA platform has allowed the collection of a large dataset of annotated CT and PET/CT images. This data has been used to develop several useful AI tools. Here, we will focus on a tool for organ segmentation. Convolutional neural network (CNN)-based organ segmentation in CT images is already becoming standard, but it is normally limited to segmenting a smaller number of organs , 5. ThisThe organ segmentation tool is based on two CNNs. One CNN handles vertebrae and ribs labels, where there are multiple instances with similar appearances. The other CNN handles all other labels. Both networks are fully convolutional segmentation networks, with structure loosely inspired by the popular U-Net , see FigThe instance CNN has three SoftMax output channels coding for background, vertebra, and rib. The receptive field size of the networks is 136 × 136 × 72, approximately corresponding to a cube in millimeters (185 × 185 × 216 mm). This is too small for the instance CNN to predict the correct index of a vertebra. Instead, it has three extra output channels with linear activations. For each foreground pixel, these channels predict the centre of the corresponding vertebra. As a postprocessing step, these coordinates are clustered to identify the individual vertebrae. The final postprocessing step for all labels consists of extracting the largest connected component and filling holes in that component.Both networks use the same pre-processing; the Hounsfield values are clamped to  and divided by 800, resulting in an input with values in the range .The CNN-based organ segmentation in CT studies in RECOMIA has been used in multiple studies –12. ThesA group of experienced radiologists and nuclear medicine physicians manually segmented different organs using the RECOMIA platform. The organs included 77 bones and 23 soft tissue organs Table . Not allA separate test set of 10 patients  was used to test the method and obtain data on inter-observer variability. Each test case was segmented independently by two different readers. Ten organs  were segmented in each CT study.All images used for training, validation, and test had a pixel spacing of 1.36 mm in slices and a distance between slices of 3 mm. Images with different pixel spacing can still be segmented by resampling the images using trilinear interpolation before running the networks. The resulting segmentation is then resampled to the image resolution using the nearest neighbour interpolation.The annotated data was divided with 80% in a training set and 20% in a validation set used to control hyperparameters. In theory, training a CNN is a simple question of feeding examples to the backpropagation algorithm. In this case, this means feeding randomly selected patches from images in the training group. These patches were augmented using moderate rotations (− 0.15 to 0.15 radians), scaling (− 10 to + 10%), and intensity shifts (− 100 to +100 HU) to enrich the training data. The model was trained using patches of size 136 × 136 × 72 and a batch size of 50. Categorical cross-entropy was used as the loss function, and the optimisation was performed using the Adam method [The CNN-based segmentation was compared to the manual segmentations. The Sørensen-Dice (Dice) index was used to evaluate the agreement between automated and manual segmentations by analysis of the number of overlapping voxels.The model was compared to the manual segmentations . To the best of our knowledge, RECOMIA is the only platform that is freely available for research and can be used to automatically segment a wide selection of organs in CT images and provide PET measurements for the same organs. We continue to train new CNNs to continuously improve performance.Studying the results in Tables Considering the statistical dispersion of Dice indices, it is typically low for organs with high Dice scores. This means standard deviations between 0.01 and 0.05, excluding one outlier case where considerable image noise around the first thoracic vertebra led to an off-by-one error in the numbering of all the subsequent vertebrae and ribs . For the organs with lower average Dice index listed above, the dispersion was also higher with standard deviations between 0.08 and 0.26. Finally, due to large natural variability, the gallbladder, urinary bladder, and ventricle had high standard deviations (0.08 to 0.17) although the average Dice indices were good.The RECOMIA platform and the deep learning-based tools for organ segmentations have already been used in several studies. Lindgren Belal et al. , 8 used Mortensen et al.  and PolySadik et al.  developeThe platform is currently used by research groups from 20 hospitals/universities in 10 countries and includes both CT, PET/CT, and magnetic resonance imaging applications.The organ segmentations are based on low dose CT without contrast on adult patients. The scope will be expanded to include also CT of diagnostic quality and with contrast. Future work will also include organ segmentation of CT studies from children.www.recomia.org for research purposes.The paper presents a platform that provides deep learning-based tools that can perform basic organ segmentations in CT, which can then be used to automatically obtain the different measurements in the corresponding PET image. The tools developed in this project are available on request at


Cunninghamia lanceolata (Lamb.) Hook.] forests over one rotation. We used the g(r) function and spatial parameters to analyze the spatial structure of deadwood, and used logistic regression and Hegyi’s competition index (HCI) to explore competition and mortality. Our results indicate that: (1) Chinese fir dominated in all groups of deadwood , and the abundance, volume, and mortality rates of deadwood were much lower in the thinning forest compared to the MF. (2) Later coming populations (LCPs) comprised the majority of the small diameter classes in the thinning forest, but only accounted for a small proportion of the MF. (3) Broken wood in the thinning forest was randomly distributed, while the other types of deadwood were clustered at most spatial scales. In contrast, the spatial patterns in the MF were random at most spatial scales. (4) Total deadwood in both stands was in a status of intermediate and was randomly surrounded by its four nearest neighbors. All types of deadwood were highly mixed in the thinning forest and moderately mixed in the MF. Our case study suggests that thinning and mixing result in different stand development processes and thus influence the type, amount, and structure of deadwood. Thinning significantly reduces competition, which is the main driver of tree mortality. Converting pure Chinese fir plantations into mixed stands by thinning should be taken in future. Understanding tree mortality after conversion is essential to select appropriate silvicultural treatments and achieve ultimately sustainable forest management.The sustainability of coniferous monoculture plantations is facing challenges with respect to yields, ecology, and biodiversity. Conversion of monocultural coniferous plantations into mixed stands using thinning or direct mixed planting is widely considered to be a key strategy for overcoming these challenges and transforming the characteristics of plantations on a regional scale. Substantial amounts of deadwood may be produced in mixed forests (MFs); this material is important for evaluating and modifying forest management methods, understanding the dynamics of forest stands, and achieving biodiversity conservation. We assessed the quantitative characters and diameter distributions of deadwood in mixed and thinned Chinese fir [ Conversendence) . At the Pinus, Taxodiaceae, and Eucalyptus, which are widely planted in forested regions of southern China, and Larix and Populus, which are abundant in the northeast), has had numerous ecological impacts  and Michelia macclurei Dandy was planted in 1991 in the third compartment  at a ratio of 6:1 C. lanceolata: M. macclurei. Following random mixing, trees were uniformly planted at an initial density of 2,000 plants/ha. The survival rate was 87% after 2 years of management. A pure Chinese fir forest was also established in a neighboring compartment , and during the same period, with similar density and spatial patterns and a survival rate of approximately 87%. Thinning was conducted in this stand (hereafter referred to as TF) in 2008, where 26% of individuals were removed. Trees with a diameter at breast height  ≥ 9 cm were harvested at random by experienced forestry engineers, and logs were removed from the forest for commercial sale  to locate the boundaries of each plot and recorded the three-dimensional coordinates of all individuals with a DBH > 1 cm, as well as stumps in the TF , height (h) and length (l), and crown width of all live trees, and graded the decay  and recorded the central diameter (d½) of fallen wood. In addition, we tagged live trees and identified each individual to species. We collected data on a total of 1,909 live trees  and 558 pieces of deadwood in the MF. In the TF, we surveyed 3,084 live trees , 639 stumps, and 218 pieces of deadwood. Additional details about species composition and characteristics are available in A standard permanent plot was established in each of the study stands. The MF plot was 120 m × 60 m and the TF plot was 100 m × 80 m  of all individuals of Chinese fir based on the two-way volume table for local tree species (l (m) and h (m) represent the length and height of trees, 3 is a constant, and f∂ is a reduction factor; f∂ = 0.4 for conifers and f∂ = 0.2 for broadleaved trees  g(r) to analyze point patterns. PCF is one of the most and powerful and widely used methods for analyzing tree point patterns; in addition to effectively resolving the issue of scale dependence in distribution patterns and eliminating cumulative errors resulting from semicircles in the statistical process (r) of the circle to half the distance of the short side of the plot (r = 60/2 m). We used complete spatial randomness (CSR) as a null model, the “best” option for edge correction, and 999 Monte Carlo simulations (MCS) at each scale. We then tested the goodness of fit relative to an envelope bounded by the 2.5% and 97.5% values from the MCS. Analysis was conducted using the spatstat R package . We used the  process . Accordi package .i  , mingling (M), and dominance (U), based on the spatial relationships among the four nearest neighbors and a reference tree e unit”) . The date unit”) .roc and AUC functions in the pROC R package, to calculate the area under the receiver operating characteristic curve (AUC) . Tree mortality rates can be derived using a logistic regression function, ts e.g., . It is ats e.g., , 2020. Wve (AUC) . AUC valpetitors . Using tobject i . Competin = 2,467). Dead Chinese fir and M. macclurei were generally large, although the sizes of individuals varied substantially, whereas individuals of other species were relatively small and less variable in size  dominated the DBH classes of deadwood in the MF, including snags and fallen wood . Other sr = 1–3 m) but randomly distributed at other scales (r = 30 m)  . In cont = 30 m) . In the r scales . The obsr scales . Broken M value, representing species mixing, was higher in live LCPs (M = 0.855) than in live planted trees (0.590), snags (0.477), and fallen wood (0.473). The U value of live LCPs in the MF (0.752) was also higher than that of fallen wood (0.486), snags (0.421), and live planted trees (0.212)  . All gro (0.212) . All gro (0.212) , and wer (0.212) .Aside from fallen wood in the MF and broken wood in the TF, the mortality rate of trees in both stands increased with increasing DBH. The AUC values were 0.60–0.68 and goodness of fit was thus rated as good in both cases . In contM. macclurei was selected from among many cultivation practices, and was considered an efficient cultivation method in terms of growth and ecological benefits , a fast-growing, shade-intolerant species, and concluded that canopy trees had a higher survival rate than those in the understory. These results suggest that competition results in substantial amounts of deadwood in plantations, although this has scarcely been addressed in the literature. It may also contribute to the promotion and conservation of biodiversity  B.S.P.] stands where natural disasters were dominated by windthrow, the formation of broken wood was related to small-diameter trunk, rather than silvicultural treatments (Wendlandia uvariifolia Hance) was detected in the TF, and may have been caused by accident   . Howeverwth (8a)  suggest wth (8a) .Distribution patterns of deadwood differed among our study plots. The random distribution of broken wood in the TF is mainly attributable to random harvesting patterns , and theSpatial relationships among nearest neighbors in plantations are relatively simple but are often overlooked in management. However, the structure and composition of Chinese fir plantations become rather complex following conversion . ContrarThe conversion of natural forests to plantations has been widely studied, but the findings of these studies cannot be applied to the conversion of plantations to uneven-aged MFs, resulting in an absence of suitable guidelines. For sustainable forest management, the issue of timber supply must be resolved; forest biodiversity, ecological functions and benefits, and social services must also be attended to, which requires a change in the silvicultural methods used in plantations. The challenge is to transform low-yield and low-quality artificial forests into uneven-aged MFs, or to cultivate MFs from scratch. The amount, structure and type of deadwood in Chinese fir plantations implies that thinning and mixing result in different stand development processes. In this study, compared to the mixed stand, thinning reduced the density and mortality rates of planted trees, as well as the number and volume of dead trees. Although some underlying mechanisms of plantations and natural forests  maybe beneficial to tree growth , a smallThe large amount of deadwood in the MF may provide sufficient habitat resources and favors non-woody organisms. Planting, and subsequently thinning, mixed Chinese fir forests may thus be an ecologically appropriate silvicultural method in future. The reasons for tree mortality in Chinese fir plantations are clear on the whole, except for some uncounted tree-level factors, such as dead time, plant diseases, insect pests and senescence. More studies should be conducted to assess the relationship between deadwood and biodiversity, wildlife and to support conversion planning at regional and global scales.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.YuL collected the data and drafted the manuscript. SY revised the manuscript and participated in analyzing the experiment data. MuL, XL, ZL, AM, and HL participated in collecting the experimental data. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The aim of this study was to evaluate whether sufentanil can reduce emergence delirium in children undergoing transthoracic device closure of ventricular septal defect (VSD) after sevoflurane-based cardiac anesthesia.From February 2019 to May 2019, 68 children who underwent transthoracic device closure of VSD at our center were retrospectively analyzed. All patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia. The following clinical data were recorded: age, sex, body weight, operation time, and bispectral index (BIS). After the children were sent to the intensive care unit (ICU), pediatric anesthesia emergence delirium (PAED) and face, legs, activity, cry, consolability (FLACC) scale scores were also assessed. The incidence of adverse reactions, such as nausea, vomiting, drowsiness and dizziness, was recorded.P<0.05). No serious anesthesia or drug-related side effects occurred.There was no significant difference in age, sex, body weight, operation time or BIS value between the two groups. Extubation time (min), PEAD score and FLACC scale score in group S were significantly better than those in group F (Sufentanil can be safely used in sevoflurane-based fast-track cardiac anesthesia for transthoracic device closure of VSD in children. Compared to fentanyl, sufentanil is more effective in reducing postoperative emergence delirium, with lower analgesia scores and greater comfort. The technique has the advantages of a small incision, without the need for cardiopulmonary bypass, a simple operation process and quick recovery. Sevoflurane is often used for cardiac anesthesia in pediatric surgery. It has the advantages of rapid analepsia, little airway stimulation, and stable hemodynamics. However, the incidence of emergence delirium is as high as 40%, which affects the postoperative recovery of children, increases the difficulty of postoperative nursing and aggravates the psychological burden on children and their families,4. Sufentanil has a strong analgesic capacity and sedative effect and lasts longer. It has a mild effect on the cardiovascular system and no effect on histamine release, so it can effectively reduce postoperative pain in children. Therefore, it is widely used in the induction and maintenance of anesthesia in pediatric cardiac surgery. The purpose of this study was to observe the effect of sufentanil on postoperative emergence delirium in children undergoing transthoracic device closure of VSD after sevoflurane-based fast-track cardiac anesthesia.Transthoracic device closure of ventricular septal defect (VSD) in children, which combines the advantages of surgical repair and transcatheter device closure of VSD, has been widely used in the clinic in recent years, especially in ChinaThe ethics committee of our university approved the present study. All treatment measures followed the Declaration of Helsinki. In addition, all guardians of the patients were informed of the content of the study and signed the written consent form.We retrospectively analyzed the clinical data of 68 children who underwent transthoracic device closure of VSD in our heart center between February 2019 and May 2019. According to the classification of the American Society of Anesthesiologists (ASA), all patients belonged to ASA class I-II. All children were diagnosed with simple perimembranous VSD by transthoracic echocardiography (TTE) before the operation, without any other congenital cardiac malformation, without a history of cardiovascular surgery and without other systemic diseases. The indications for transthoracic device closure were suitable for all patients in this study. According to the anesthetic method, the patients were divided into two groups: 36 patients in group S, who were given sufentanil and sevoflurane-based fast-track cardiac anesthesia, and 32 patients in group F, who were given fentanyl and sevoflurane-based cardiac anesthesia.,8. The electrocardiogram and blood oxygen saturation were also monitored at the same time. Inhalational anesthesia induction was performed with 2-4% sevoflurane and 4 L/min oxygen. An intravenous cannula was inserted on the dorsum of the hand, and physiological saline was infused. Then 0.15 mg/kg intravenous cisatracurium besylate and 1 µg/kg sufentanil were given. After reaching an adequate depth of anesthesia, endotracheal intubation and mechanical ventilation were performed. The pressure-controlled ventilation was used, and the end-tidal carbon dioxide partial pressure was monitored. Invasive blood pressure was monitored through the radial artery, and central venous pressure was monitored in the subclavian vein. Body temperature was monitored as the nasopharyngeal temperature and was kept at approximately 36.5ºC. Anesthesia was maintained with 2% sevoflurane (1-1.5 MAC) inhalation and a continuous sufentanil infusion at a rate of 1 µg/kg/h. During the procedure, the sevoflurane dose was adjusted depending on the depth of anesthesia to maintain the BIS value. In group F, the preoperative preparation process was the same as in group S. Anesthetic induction consisted of inhalational 2-4% sevoflurane, intravenous 0.15 mg/kg cisatracurium besylate and 10 µg/kg fentanyl, while maintenance anesthesia consisted of fentanyl boluses at approximately 5 µg/kg/h and 2% sevoflurane (1-1.5 MAC) inhalation.In group S, all patients routinely fasted before anesthesia. After the patients entered the operating room, we cleaned one side of the forehead and temporal skin, fixed the sensor patches and connected the patches to the BIS-VISTA monitor. After the lead test was passed, the BIS value target range was set at 40-60, while the monitor automatically generated and recorded the BIS value, electromyography and signal quality index (SQI) each secondThe procedure was completed and guided by transesophageal echocardiography (TEE). After successful general anesthesia, we performed a small incision of approximately 2-3 cm in the lower end of the sternum to access the pericardial cavity. After surgical exposure of the right ventricular free wall, heparinization (1 mg/kg) was administered intravenously. Next, the optimal puncture site was selected under TEE guidance. Then, the right ventricular puncture was performed using a needle at this site. A guidewire was inserted, and the right ventricle-VSD-left ventricle transport track was established by TEE guidance. Next, the occluder was sent and released to close the VSD. After the operation, all patients were sent to the intensive care unit (ICU) for further monitoring and treatment.Clinical data included age, sex, body weight, operation time, extubation time, postoperative ICU stay, hospitalization days, complications, pediatric anesthesia emergence delirium (PAED) scale score and face, legs, activity, cry, consolability (FLACC) scale score. BIS values were recorded at 5 time points: before anesthesia induction (T1); the moment of endotracheal intubation (T2); the beginning of skin incision (T3); 30 minutes after operation (T4); and the end of operation (T5). After patients came back to consciousness, nurses scored the postoperative agitation and analgesia condition of the patients every 5 minutes and regarded the highest score as the final score.,10. Each item was scored from 1 to 4 (with reverse scoring when applicable), and the scores were added to obtain a total scale score. The degree of emergence delirium varied directly with the total score. A PAED score ≥5 meant the presence of emergence delirium.The PAED scale score was used to measure emergence delirium in children in the following five psychometric items: 1) the child made eye contact with the caregiver; 2) the child’s actions were purposeful; 3) the child was aware of his/her surroundings; 4) the child was restless; and 5) the child was inconsolable,12. The FLACC scale consists of five domains  with scores of 0, 1 and 2 for each domain and a total score ranging from 0 to 10. A FLACC score ≥3 was considered unsatisfactory analgesia.The FLACC scale was used to assess pediatric postoperative painP<0.05 was defined as statistical significance.The data of this study were analyzed using SPSS 22.0. Continuous data are expressed as mean ± standard deviation, and counting data are represented by usage rate (%). The rates of the two groups were compared by the chi-square test, and the continuous data between groups were compared by the independent samples t-test. P>0.05) (P>0.05) (P<0.05)  . BIS val(P>0.05) . There w(P<0.05) .. Both transcatheter device closure and traditional surgical repair under cardiopulmonary bypass have had definite success and have been widely applied. In recent years, transthoracic device closure of VSD has gradually become an alternative treatment for children with VSD. The advantages of this method are that it is easy to establish the delivery set, it is easy to operate and learn, the incision is small and cosmetic, and the recovery is quick after operation,14,15. Our cardiac center reported a larger series of cases from our experience with this technique. Fast-track cardiac anesthesia for children undergoing transthoracic device closure of VSD has been carried out in our center in an attempt to help patients recover faster by shortening the anesthesia time, hastening the removal of the endotracheal tube and reducing the ICU stay,17. Emergence delirium on awakening from general anesthesia would definitely affect postoperative recovery.VSD is one of the most common congenital cardiac malformations. However, in recent years, it has been shown that one of the main complications after sevoflurane anesthesia in children is emergence delirium upon awakening from general anesthesia, with a reported incidence ranging from 10% to 80%, especially in preschoolers,19. This agitation has a variety of manifestations, including crying, excitement and delirium after awakening. Although emergence delirium is self-limited, it generally does not lead to permanent sequelae. Patients with persistent severe postoperative delirium have negative implications and experience less satisfaction, as do their families, due to the potential for self-injury and other injurious behaviors, being a burden on nursing staff. It has been shown that low-dose fentanyl (an induced dose of less than 1 µg/kg) used in children after sevoflurane-based anesthesia can reduce the incidence of emergence delirium without prolonged hospital stay,21. Sufentanil, as a derivative of fentanyl, is a lipophilic opioid agonist that can easily pass through the blood-brain barrier and bind to plasma proteins at a higher rate than fentanyl. It has high selectivity for opioid receptors, leading to analgesia and sedation. Clinical studies have shown that sufentanil has the highest therapeutic index of all opioids. As a result, sufentanil can provide stronger analgesic effects over a longer period than the same dose of fentanyl or morphine and can reduce respiratory depression and the incidence of adverse reactions,23. Li and his team reported that administration of sufentanil could reduce emergence agitation in children receiving sevoflurane anesthesia for adenotonsillectomy compared to fentanyl, without delaying the recovery time or causing significant hypotension. Luo et al. found that dexmedetomidine combined with sufentanil was able to effectively decrease the incidence of emergence agitation in children receiving sevoflurane anesthesia for cleft palate repair surgery. Liang et al. concluded that sufentanil is better than fentanyl in reducing emergence agitation in children anesthesized with sevoflurane in their study.Sevoflurane is generally the preferred anesthetic agent to induce and maintain cardiac general anesthesia in children due to its rapid induction and recovery characteristics, easily controlled anesthetic depth, stable hemodynamics and minor effect on cardiac functionIn this study, there were no statistically significant differences in age, sex, weight, operation time or sevoflurane inhalation time between the two groups. The mean arterial pressure, heart rate and blood oxygen saturation of the two groups were good throughout the monitoring process. There was no significant difference in BIS between groups at each time point. The safety of the clinical application was the same. Since the operation time of transthoracic device closure of VSD in children is short, there is no need for long-term sedation, analgesia or anesthesia. In the premise of obtaining the same anesthetic effect, compared to group F, patients in group S who received sufentanil during anesthesia maintenance had a lower incidence of emergence delirium and a lower FLACC score. The results showed that the effect of sevoflurane combined with intravenous sufentanil pumping was better than the effect of sevoflurane inhalation combined with fentanyl, which was beneficial for postoperative recovery and perioperative management of patients. This was due to the powerful analgesic effect of sufentanil, which enhances the sedative effect of sevoflurane and reduces the side effects of delirium.. When combined with central nervous system inhibitors, sufentanil may have additional pharmacological effects that increase the likelihood of adverse reactions, such as respiratory depression. If it is inevitable to use them at the same time, the dose and duration of sufentanil treatment should be reduced (to the minimum requirement), and the hemodynamics and respiratory status of patients should be closely monitored. Sufentanil use should be carefully monitored in patients at risk of intestinal obstruction or in patients with existing intestinal obstruction or biliary tract disease. In this study, there were no significant adverse reactions in the sufentanil group, which confirmed the safety of the regimen.Because sufentanil has dose-dependent respiratory inhibition, it is necessary to pay attention to its dosage during useThere were also some shortcomings to this study. It was a retrospective analysis, not a prospective, randomized, controlled, double-blind study, and there was a deviation in the selection of cases, but the results supported the conclusion to some extent. We look forward to future prospective, double-blind, controlled trials, as well as multicenter studies to determine whether our conclusions are correct and feasible.Continuous intravenous infusion of sufentanil can be safely used in children undergoing transthoracic device closure of VSD under fast-track cardiac anesthesia with sevoflurane. Compared to fentanyl, sufentanil is more effective in reducing the incidence of emergence delirium, obtaining a lower postoperative analgesic score and higher comfort. It is beneficial to the recovery of patients after operation and it is worth popularizing.