Here, we report multiple phosphorite deposits in strata that immediately precede the ETE at Williston Lake, Canada, which allow the paleoenvironmental conditions leading up to the mass extinction to be investigated. The predominance of phosphatic coated grains within phoshorites indicates reworking in shallow water environments. Raman spectroscopy reveals that the phosphorites contain organic carbon, and petrographic and scanning electron microscopic analyses reveal that the phosphorites contain putative microfossils, potentially suggesting microbial involvement in a direct or indirect way. Thus, we favor a mechanism of phosphogenesis that involves microbial polyphosphate metabolism in which phosphatic deposits typically form at the interface of euxinic/anoxic and oxic conditions. When combined with data from deeper water deposits (Kennecott Point) far to the southwest, it would appear a very broad area of northeastern Panthalassa experienced anoxic to euxinic bottom water conditions in the direct lead up to the end-Triassic mass extinction. Such a scenario implies expansion and shallowing of the oxygen minimum zone across a very broad area of northeastern Panthalassa, which potentially created a stressful environment for benthic metazoan communities. Studies of the pre-extinction interval from different sites across the globe are required to resolve the chronology and spatial distribution of processes that governed before the major environmental collapse that caused the ETE. Results from this study demonstrate that fluctuating anoxic and euxinic conditions could have been potentially responsible for reduced ecosystem stability before the onset of CAMP volcanism, at least at the regional scale.The end-Triassic mass extinction (ETE) is associated with a rise in CO Approximately 80% of all marine and terrestrial species became extinct during the ETE making it the second biggest biodiversity7 and the third biggest ecological crisis8 during the Phanerozoic. Proposed causes of the mass extinction include CAMP-related global warming10, global cooling11, ocean acidification15, sea-level changes16, and ocean anoxia18. The knowledge base of the conditions leading up to the ETE is poorly resolved, as the main focus has remained on the timing associated with an initial emplacement of CAMP. Yet, recent studies of the pre-extinction interval reveal biotic, climatic and geochemical changes before the onset of known CAMP volcanism22. Here, we present the first detailed study investigating the genesis of Upper Triassic phosphorite deposits from Williston Lake, British Columbia, which intriguingly occur directly before the ETE interval  appears nearly coincident with the emplacement of the Central Atlantic Magmatic Province (CAMP) ~201.51 million years ago25. It is widely accepted that direct precipitation of phosphates occurs near the sediment-water interface and requires distinct environmental conditions29. Formation of authigenic phosphorites (phosphogenesis) is generally associated with microbial polyphosphate metabolism and biogeochemical processes where steep, or temporally dynamic, redox gradient conditions occur28. Pufahl and Grimm29 suggested that phosphatic coated grains are proxies for fluctuations in organic carbon flux and primary productivity. Our study suggests that the formation of these phosphatic coated grain deposits was microbially mediated based on textural features and Raman spectroscopy. While phosphorites are an indicator of steep or dynamically-variable redox gradient conditions, the occurrence of benthic macrofauna within phosphatic beds implies that transient oxygenation events occurred during phosphogenesis24. Our results demonstrate a development of oxygen restricted conditions, which would be stressful to most benthic metazoans established in shelf waters off northeastern Panthalassa prior to the ETE and preceding the earliest known CAMP volcanism.Phosphorite beds at Williston Lake are predominantly composed of phosphatic coated grains. Deposits containing phosphatic coated grains are rare throughout the Phanerozoic and their origin remains incompletely understood24  that contain phosphorite deposits in the interval immediately preceding the ETE. The sea-level fall during the Rhaetian generated a major hiatus in the more proximal Black Bear Ridge section such that nearly the entire Rhaetian sequence is missing at this locality; nevertheless, a veneer of phosphatic coated grains is preserved at the sequence boundary. Strata recording a more complete Rhaetian Stage are at the distal sites of Ne Parle Pas Point and Pardonet Creek where both sites record lowstand strata missing at the Black Bear Ridge locality Fig. . The uppet al.24, the phosphatic units contain some of the more biotically diverse assemblages versus surrounding units, and include infaunal and epifaunal bivalves, nautiloids, ammonoids, and echinoderms. In all localities, phosphatic coated grains vary in shape from spheroids to ellipsoids and are predominantly fragmented due to reworking and winnowing  and 1600 cm−1 (G band) within phosphatic cortices which are diagnostic of organic matter (kerogen)34 .Raman spectroscopy is widely used as an analytical tool for differentiation between carbonaceous material of biogenic versus abiogenic origin in the rock record. At all Williston Lake localities, micro Raman spectroscopy documents intense and broad bands occurring at around 1350 cm)34 Fig. . Further)34 Fig. . The sec)34 Fig. . Both di35. Cosmidis et al.36 documented coccus-like and rod-like biomorphs in a Miocene/Pliocene Peruvian phosphatic crust that are identical in shape, size and distribution to our microscopic spherical objects. Salama et al.37 showed that microspheres (0.5 to 2.5 μm in diameter) embedded in carbonaceous matrix from Upper Cretaceous phosphatic peloids are fossilized remains of coccoidal bacteria. Both studies concluded that the observed microspheres were once a part of microbial colonies that formed near the oxic-anoxic boundary in zones of sulfate reduction37. Thin section observations revealed the presence of curved filamentous structures, ~1 μm in width and varying in length from 5 to 27 μm  within phosphatic coated grains cortices Fig. . Photomi μm Fig. , which w36. We would like to emphasize that the presence of microbes within the cortices of phosphatic coated grains do not necessarily imply their direct role in the apatite accretion within phosphatic coated grains, although such a scenario is plausible, but rather that they may have played a fundamental role in the delivery of P via polyphosphate metabolism. Documented pyrite framboids within phosphoclasts imply the presence of sulfide likely provided by sulfate reducing bacteria in reducing conditions38  overlying organic-rich sediments e.g.39, or from dissolving Fe-oxide-bearing mineral phases, again under stratified redox conditions40. While these P sources are plausible drivers of Williston Lake phosphogenesis, we do not favor them as explanations. In the former case, fish bones are not abundant in the Williston Lake deposits and they do not serve as nuclei for the phosphatic coated grains. Similarly, with respect to P being concentrated through adsorption and subsequent dissolution of iron hydroxides, we would expect this mechanism to operate in a system dominated by iron-rich siliciclastic deposition, as opposed to the organic-rich system here that contains pyrite  in organic-rich sediment under suboxic to anoxic conditions where repeated reworking of phosphatic grains and fluctuation of redox conditions play a crucial role. Although phosphatic coated grains are sometimes referred to as phospho-ooids, the process responsible for phospho-ooid formation is different from carbonate ooids, which precipitate by wave agitation in supersaturated waters with calcium carbonate37, while the apatite in phosphatic coated grains precipitates authigenically below the sediment-water interface29. We suggest that these phosphatic coated grains formed between storm and fair weather wave-base, but specifically in proximity to the wave-agitation zone where they were more prone to episodic reworking and mixing by storms and where the upwelling front would be best developed and intensified32. High-energy storm events reworked phosphate clasts further transporting them to the current place of deposition (phosphatic grainstone beds). The infilling of microbial borings in carbonate clasts by phosphate indicates relatively rapid phosphatization, before the borings were infilled by cements, or the microbial borers could fully micritize the carbonate grains  from northeastern Panthalassa, spanning the Triassic-Jurassic boundary several hundred km to the west of Williston Lake, at Kennecott Point, British Columbia  and Williston Lake  sites are likely contemporaneous, it would appear that a broad area of northeastern Panthalassa experienced fluctuating euxinic-anoxic conditions in the lead up to the ETE, beginning ~500 kyr before the extinction. Fluctuating, oxygen-restricted conditions likely created a hostile environment for benthic fauna at least in shallow water settings where most benthos are less adapted to low oxygen conditions. For example, off the coast of Oregon, recent intensified upwelling brought oxygen-poor waters to shallow shelf depths (<50 m) where emergent anoxia nearly eradicated the macroscopic benthic invertebrate community and initiated the development of sulfide-oxidizing bacterial mats43. At Williston Lake sites, Wignall et al.24 documented the demise of shallow-water infaunal bivalves right before the initial negative carbon isotope excursion marking the major environmental collapse of the ETE. This stressed environment potentially made marine biota more susceptible to subsequent cascading effects from CAMP emplacement, at least in northeastern Panthalassa.Schoepfer 18. It is worth noting that the first appearance of euxinia on the shelves, as suggested by the presence of upper Rhaetian phosphorites, could indeed precede the onset of CAMP volcanism, adding to the growing dataset that environmental conditions began to deteriorate before the beginning of CAMP volcanism in different parts of the globe22. Dike and sill intrusions in organic rich sediments in Brazil were proposed as a potential mechanism that drove the climate change preceding the onset of CAMP volcanism44. Study44 using pedogenic carbonate isotopes as a proxy for temperature variations has documented two periods of extreme temperature increase by 6 °C in congruence with atmospheric CO2 rise preceding the ETE. Thus, it is worth considering that intensified oceanic upwelling and OMZ expansion in northeastern Panthalassa was possibly related to climate warming as a result of higher pCO2. Additional studies are required to reveal conditions leading up the ETE which governed on the regional versus global scale.Photic zone euxinia combined with anoxic conditions is considered to be a potent mechanism for the ETE since these conditions are widely documented in Panthalassic and Tethys basins during the ETE29. Our study provides direct biosedimentary evidence that fluctuating euxinic-anoxic conditions existed in relatively shallow marine settings (above storm-wave base) preceding the ETE in northeastern Panthalassa. These results are compatible with previous studies of Schoepfter et al.20 and Kasprak et al.,18 from the deep-water Kennecott Point section, suggesting that environmental disturbances, likely episodic euxinia, preceded the ETE for approximately 500 kyr. For the first time, our study shows that euxinic-anoxic conditions existed not just in the deeper part of the northeastern Panthalassic basin prior to the ETE, but also in shallow water settings of the foreland basin covering a very broad area of northeastern Panthalassa. Intervals of phosphogenesis are linked to periods of an intensified oceanic upwelling and OMZ expansion where possibly sulfide-oxidizing microbial communities were thriving inducing apatite precipitation, while the benthic biota flourished in between euxinic/anoxic intervals, at least at the Williston Lake region. Such conditions were likely stressful for shallow water benthic metazoans making them more susceptible to cascading effects from CAMP volcanism. Additional studies from Panthalassic and Tethys basins are required to further elucidate conditions leading up to the ETE at the regional and global scale and their effects on ecosystems.Spectroscopic, petrographic and SEM investigations on the genesis of uppermost Triassic phosphorites from Williston Lake, British Columbia, provide evidence supporting microbially-induced mineralization, likely by polyphosphate-accumulating bacteria. The genesis of phosphatic coated grains requires deposition near the sediment-water interface under suboxic to anoxic conditions where repeated reworking of phosphatic grains and fluctuation of redox conditions play an essential roleSpecimens from different phosphatic horizons covering all three studied sections were examined. Standard petrographic microscopy was performed on thin sections using a Zeiss Axio Imager.M2m equipped with a Zeiss HRc camera. Internal grain structure and elemental composition were investigated on a FEI Nova NanoSEM 450 in back-scattered electron mode with the help of an Energy-dispersive X-ray spectroscopy microprobe. To determine mineral content and the presence of kerogen, we used a Horiba XploRa PLUS Raman Microscope and Horiba XGT-7200 X-ray fluorescence microscope. Samples were dissolved in 10% acetic solution for 72 hours in order to observe the morphology of phosphatic clasts.


Simple obesity is a worldwide epidemic associated with rapidly growing morbidity and mortality which imposes an enormous burden on individual and public health. As a part of Traditional Chinese Medicine (TCM), acupuncture has shown the positive efficacy in the management of simple obesity. In this article, we comprehensively review the clinical and animal studies that demonstrated the potential mechanisms of acupuncture treatment for simple obesity. Clinical studies suggested that acupuncture regulates endocrine system, promotes digestion, attenuates oxidative stress, and modulates relevant molecules of metabolism in patients of simple obesity. Evidence from laboratory indicated that acupuncture regulates lipid metabolism, modulates inflammatory responses, and promotes white adipose tissue browning. Acupuncture also suppresses appetite through regulating appetite regulatory hormones and the downstream signaling pathway. The evidence from clinical and animal studies indicates that acupuncture induces multifaceted regulation through complex mechanisms and moreover a single factor may not be enough to explain the beneficial effects against simple obesity. Simple obesity is a worldwide epidemic associated with rapidly growing morbidity and mortality which imposes an enormous burden on individual and public health. The expansion of fat mass, adipocyte size increase, and to a lesser extent cell proliferation (hyperplasia) are important features of simple obesity. It is generally believed that simple obesity is the second leading form of metabolic disorders after cardiovascular disease, with the latest projections estimating that there will be 2.16 billion overweight and 1.12 billion obese individuals globally by 2030 . In simpAs an important technique of complementary and alternative medicine in the field of TCM, acupuncture has been utilized for both disease prevention and therapy for several thousands of years in China. The therapeutic effects of acupuncture are achieved via multiple pathways, including anti-inflammation effects, antiapoptotic effects, and neurotrophic effects –15. AccoFurthermore, numberous previous clinical and animal studies have been conducted to investigate the potential mechanisms of acupuncture on simple obesity. A deep insight into the endogenous mechanisms could provide opportunities to develop accurate strategies in the treatment of simple obesity. Crucially, the underlying molecular mechanisms have not yet been comprehensively reviewed. In this article, we review the possible mechanisms of acupuncture on simple obesity in clinical- and animal-based studies to provide guiding references for future research directions.Over the recent years, endocrine disorders have been widely recognized as an important pathogenic factor of simple obesity. Related clinical studies indicated that obese patients without any treatments showed higher apparent endocrine disorder and complex endocrine metabolic mechanism . A study2(PGE2) increased on the effected side [Restoration of gastrointestinal function to the damaged digestive system has a vital impact on better weight management against simple obesity. Obese subjects treated with acupuncture showed decreased salivary amylase (S-Am), serum pepsinogen (SPG), and serum amylase (B-Am) after being performed for 20-30 min, and all the subjects received acupuncture treatment once every other day for 1 month, which indicated thay acupuncture therapy may be a useful method for inhibiting the function of hyperactive gastrointestinal digestion and absorption . After ated side . The locted side . Body acted side . Moreoveted side .Oxidative stress, which is triggered by the imbalance between the clearance and generation of oxygen species (ROS), is a significant mechanism underlying obesity . The ove Hz, dense-disperse wave. Each acupuncture treatment lasted for 20 min. All subjects were asked to receive two treatment sessions per week for a total of 6 weeks. In previous studies, PAB values have been demonstrated to be elevated in patients with established coronary artery disease (CAD) and acute coronary syndrome (ACS)[In obese subjects, acupuncture treatment significantly decreased serum pro-oxidant antioxidant balance (PAB) values, which has been shown to be positively correlated to body weight and also increased in obese patients . Eight aome (ACS). Furtherome (ACS). There wome (ACS).Under oxidative stress circumstances, the overgeneration of ROS breaks the balance of thiol-redox environment and ultimately results in the disorder of biological activities in proteins. The thioredoxin system, which is comprised of thioredoxin reductase (TrxR), thioredoxin (Trx), and NADPH, is a major cellular antioxidant and thiol-reducing system . AcupuncIn obese patients, serum substances such as sugar, lipid, and obesity-related proteins are significantly higher, implying that the serum substances could be the representative biomarkers for the diagnosis of obesity or serve as surrogate markers. A recent analysis showed that acupuncture modulated the secretion of multiple serum lipids in obese patients. Acupuncture downregulated the level of serum triglyceride (TG), total cholesterol l(TC), and low-density lipoprotein cholesterol(LDL-C) and upregulated the level of serum high-density lipoprotein cholesterol(HDL-C), which could contribute to the removal of excess blood lipid. All theCirculating Serum C-reactive protein (CRP) is involved in the genesis and development of obesity as well. As a typical feature of systemic chronic inflammation, CRP is positively associated with parameters of adiposity such as WC and BMI as demonstrated by two large controlled clinical trials , 43. IntCurrent studies show that although acupoints selection varies significantly, certain acupoints are used more frequently than others . To be s in vivo can be metabolized or transported to other places outside the cell membrane. Similarly, lipid efflux also involves a mass of proteins, including ApoE, ABCA1, ABCA1, Apolipoprotein (Apo) A-1, peroxisome proliferators-activated receptors (PPARs), and scavenger receptor class B type 1(SR-B1) [It is well known that lipid metabolism is a complicated physiological process, which involves lipid synthesis, intake, transportation, etc. Lipids are mainly derived from the internal synthesis of acetyl coenzyme A and food intake. The disorder of lipid metabolism is characterized by abnormal lipid secretion and the metabolites of lipid, which is caused by congenital or acquired factors, distributed predominantly in plasma and other tissues as well . Dyslipi1(SR-B1) .α activity and the phosphorylation of ACC [In physiological conditions, adiponectin is exclusively secreted by adipocytes and activates adenosine monophosphate-activated protein kinase (AMPK). In turn, activation of AMPK inactivates acetyl-CoA carboxylase (ACC) by phosphorylation and blocking the transformation of acetyl-CoA into malonyl-CoA . Howevern of ACC , inducinn of ACC . Acupuncn of ACC .The beneficial therapeutic effects of acupuncture treatment could attribute to the regulation on lipid metabolism. A study using Obese Zucker Diabetic Fatty Rats reported that repeated acupuncture at Zhongwan (CV12) and Guanyuan (CV4) acupoints caused an increase in adiponectin and a decrease in leptin . RecentlInflammatory responses, aimed at defending the body from various insults including tissue damage and infection and ultimately leading to the restoration of morphological and functional integrity of affected tissues, play a key role in the pathophysiological process of simple obesity, 56. Typα (TNF-α) [α, which are pro-inflammatory cytokines, have been confirmed to be elevated in obese subjects [α are involved in obesity-related diseases like atherosclerosis and insulin resistance [α, and IL-1β in obese rats. EA treatment decreased the serum concentrations of IL-6, TNF-α, and IL-1β [κB involves various inflammatory responses and undergoes phosphorylation and then an ubiquitination-dependent degradation in response to the stimulation by factors such as IκB and TNF-α [κB signaling pathway could be an appropriate therapeutic target to defend chronic inflammation [α level in blood serum, and the decrease of serum TNF-α level by acupuncture treatment is consistent with previous reported studies [α indicated that acupuncture was effective in reducing insulin resistance and in reducing the overall inflammatory state of the obese rats, which were characterized by adipocyte hypertrophy and hyperplasia [Acupuncture reduced mRNA levels of several cytokines in adipose tissue, including interleukin-6(IL-6), monocyte chemotactic protein-1(MCP-1) and tumor necrosis factor- (TNF-α) . IL-6 ansubjects . Many prsistance . Moreovend IL-1β . As a cend TNF-α , 64. Theammation . By inacammation . Acupuncammation , and repammation . In summ studies , 68. Theerplasia , decreaserplasia , and incerplasia .Acupuncture also regulates other obesity-associated inflammatory cytokines. Interleukin-10 (IL-10) was originally synthesized within multiple organs which included spleen and is responsible for the inhibition of the synthesis of pro-inflammatory cytokines , 72. A lAppetite is known to be primarily dominated by a complex circuit of hypothalamic nuclei which is involved in series of satiety/appetite signals, action areas about messengers regulatory, and act sites. The hypothalamic arcuate nucleus (ARC), which is the major appetite regulatory site, receives input from central and peripheral  sources . The ARCα-MSH) expression could contribute to the anorexigenic effect of acupuncture. The ARC, which is a core hypothalamic nucleus in the regulation of appetite, is well established to integrate a mass of peripheral signals associated with food intake, such as insulin and leptinand ghrelin [A previous study indicated that acupuncture up-regulated CART peptide expression in the ARC. As a hypothalamic satiety factor, CART neurons in the ARC contain a number of pro-opiomelanocortin (POMC) mRNA which plays a key role in the regulation of inhibiting appetite , 83. It  ghrelin , 85. Fur ghrelin . By regu ghrelin . Acupunc ghrelin .The transient receptor potential vanilloid type-1(TRPV1), which is primarily expressed at the afferent neurons, also plays a key role in thermal, mechanical, chemical, and many other sensory transmission systems , 90. Acuβ-oxidation, lipolysis, mitochondria production, and increased UCP-1 expression. Importantly, the browning process and therefore thermogenesis are reported to be stimulated by a number of external factors like physical exercise, cold exposure, and medication [The adipose tissue is mainly composed of two types: white adipose tissue (WAT) and brown adipose tissue (BAT). The two tissues have different morphological distributions, gene expressions, and functions in the body. WAT stores energy and releases cytokines and hormones that regulate insulin resistance and metabolism, while BAT consumes energy mainly through mitochondrial uncoupling in nonshivering thermogenesis mediated by Uncoupling protein-1 (UCP-1), as an adaption process to cold exposure . Recent dication . Therefoγ are involved. Acupuncture increased the expression of Pparγ gene in WAT significantly. Specifically, SirT1-dependent deacetylation of Lys293 and Lys268 is required to recruit the BAT program co-activator Prdm16 to Pparγ, resulting in the repression of visceral WAT genes and a selective induction of BAT genes associated with obesity-related diseases [γ was obviously decreased after the acupuncture treatment, which indicated acupuncture might promote Pparγ deacetylation so as to up-regulate the expression of UCP1 gene and then inducing the browning process. Moreover, other BAT markers such as Cox4il and Nrbf1 are also significantly elevated by acupuncture. Although, animal studies have found that acupuncture could promote weight loss and WAT browning, the detailed mechanisms at the cellular level by which the effectiveness exerted still stay unclear. Further studies in the clinical patients and animal models are of interest to make sure the significance of acupuncture on simple obesity in models.Recent studies indicated that acupuncture is notably effective in targeting WAT browning in obesity . Acupuncdiseases . FurtherIt is demonstrated that acupuncture applied at specific acupoints can contribute to the restoration of endocrine and metabolic disorders in subjects with simple obesity. The mechanisms behind the beneficial effects of acupuncture can be explained by molecular biology. In obese patients, acupuncture modulated cerebral nervous system and activated specific brain regions and relevant molecules. On the other hand, evidence from clinical and animal studies show that the therapeutic mechanisms of acupuncture nearly cover all the cellular and molecular events during the pathophysiological process of simple obesity . It seemFrom the perspective of research, acupuncture may be regarded as a complementary and alternative therapy for simple obesity in which potential therapeutic targets can be explored and investigated. It requires more rigorous studies on how acupuncture exerts therapeutic effects by influencing relevant signaling pathways, specific brain regions, or molecules. However, it should be noticed that several issues with methodological weaknesses and small sample size are still needed to be discussed. Firstly, lots of literatures included in the current clinical study lack clear randomization methods and long-term follow-up. Secondly, the quality of some literatures chosen is not high and the number of literatures related to obesity is limited as well, so inadequate conclusions may potentially exist. In general, more and larger definite clinical and animal studies are necessary to advance our understanding of the basic mechanism and provide high quality evidence for future clinical application.Based on findings to date, clinical studies about the mechanisms of acupuncture on simple obesity mainly focused on regulating endocrine system, promoting digestion and modulating relevant molecules of metabolism, while evidence from laboratory indicated that acupuncture regulates lipid metabolism, attenuates oxidative stress, modulates inflammatory responses and promotes white adipose tissue browning. Acupuncture also suppresses appetite through regulating appetite regulatory hormones and the downstream signaling pathway. These effects of acupuncture on simple obesity have been generally acknowledged. As early initiation of therapeutic forms is not always available in clinical practice owing to the limitations of therapeutic treatment window, acupuncture therapy may be a potential TCM method against damages induced by obesity.To our knowledge, this study is the most comprehensive overview that systematically reviewed clinical and animal trials on acupuncture for patients with simple obesity. Despite the fact that acupuncture therapy demonstrated significant effects on obesity in the laboratory, several obstacles are included hampering the transition between animal and clinical research. Based on the accuracy and specificity of acupoint localization in acupuncture treatment and acupoint selection among over 300 acupoints of human body, the areas covered by the acupoints in animals are much less than that in human as animals involved were smaller. In the experimental acupuncture research, simulation of traditional acupoints on animals is the crucial step. The location of acupoints in experimental animals should be based on the simulation study of human body acupoints and combined with the animal experiments map. At the same time, the differences between animals and humans should be realized, and the simulation of human acupoints should not be simply projected to animals according to a certain proportion. So far, how many meridians located on rats specifically remains to be further discussion; this in itself is open to challenge and any results in relation to acupoints in rats are certainly open to criticism, which make it tenuous to be readily generalized to humans. What's more, acupoint prescriptions in clinical studies often contain ten or more acupoints with other medical interventions, while animal studies use only single or no more than five acupoints. From the research standpoint, clinical studies emphasize on the effectiveness of acupuncture which highlights standardization of acupuncture manipulation, while animal studies aim to explore potential molecular mechanisms underlying acupuncture manipulation. All of these differences make it difficult for animal studies to serve the clinical studies.Appropriate acupuncture manipulation is an important factor that determines the results of acupuncture studies. The parameters including acupuncture models (MA or EA), acupoints, duration, and frequency in acupuncture manipulation may influence the efficacy of acupuncture. The mechanism underlying the therapeutic effects of acupuncture has been shown to be similar to therapies associated with activities, including dietary restriction, exercise, and enriched environment, many of which have been widely applied to simple obesity –108. HowAlthough great advances have been made in the researches of acupuncture parameters, how these kinds of clinical and animal studies would be applied into clinical practices still remains a huge challenge. To overcome this flaw, we believe that the following problems should be paid attention to in future researches. Firstly, we should testify the changes of signaling pathways or relevant molecules in animal studies to comprehensively understand the mechanism behind acupuncture when using specific acupuncture parameter. Secondly, evaluate the optimal acupuncture regimen by making comparison of the therapeutic effects when we use different acupuncture parameters. Thirdly, we should justify whether the best acupuncture option acquired in animal studies could be applied to clinical studies. That is, the outcomes of animal studies should provide strong molecular biological evidence for acupuncture therapy and assist in screening out the optimal acupuncture therapeutic option for clinical.In summary, acupuncture exerts beneficial effects via modulating a series of biological events in simple obesity. As an economical medical technology without adverse effects, acupuncture could be used in obese patients who cannot tolerate exercise or drug therapy and could also be used for lots of metabolic disorders along with other therapies. Further studies are still needed to explore the deeper mechanisms and their biological significance. In particular, future studies should focus on the potential mechanism of acupuncture on obesity-related complications such as hyperlipemia and polycystic ovarian syndrome, which is associated with metabolism dysfunction. Besides, more animal studies of acupuncture should be encouraged to be translated into clinical studies.


Injury to the lateral femoral cutaneous nerve (LFCN) from compression or entrapment may result in meralgia paresthetica, a painful mononeuropathy of the anterolateral thigh. Surgical decompression of the LFCN may provide relief when conservative management fails. However, the considerable anatomic variability of this nerve may complicate surgical localization and thus prolong operative time. Herein, we report the use of preoperative high-resolution ultrasonography to map the LFCN in a patient with bilateral meralgia paresthetica. This simple, noninvasive imaging technique was seen to be effective at providing precise localization of the entrapped and, in this case, bilateral anatomically variant nerves. Preoperative high-resolution ultrasound mapping of the LCFN can be used to facilitate precise operative localization in the treatment of bilateral meralgia paresthetica. This is especially useful in the setting of suspected unusual nerve anatomy. The lateral femoral cutaneous nerve (LFCN) arises from the lumbosacral plexus, travels through the pelvis, and may pass above, through, or under the inguinal ligament on its course into the superficial thigh. In most cases, the LCFN crosses medial to the anterior superior iliac spine (ASIS) and then divides into the anterior and posterior branches that innervate the anterolateral aspect of the respective thigh .Injury to the LFCN causes meralgia paresthetica (MP), a painful mononeuropathy of the anterolateral thigh with an incidence of 4.3 per 100,000 person-years . CompresHerein, we present a case of bilateral MP for which preoperative ultrasound guidance provided an extremely accurate anatomic localization, thus significantly reducing the intraoperative exploration. To our knowledge, this is the first report demonstrating the utility of a preoperative high-resolution ultrasound to guide definitive operative localization of both LFCNs. We propose a treatment paradigm to include precise ultrasound mapping before the LFCN decompression to maximize surgical efficacy and treatment outcome.A 63-year old male presented with a history of lumbar laminectomy and fusion seven months prior to his initial presentation. He recalls that two days following his prone lumbar operation he began experiencing severe bilateral pain along the respective anterolateral thigh. Lumbar magnetic resonance imaging (MRI) ruled out spinal nerve root-related pathology as causative and a definitive diagnosis of bilateral MP, secondary to LFCN compression during the prone spinal surgery, was rendered. Conservative measures with oral analgesics were initially recommended given the typically self-limited course of this pathology. Despite an increasing regimen, including NSAIDs, narcotics, and anti-neuropathic pain medications, the pain persisted over the course of several months. Additionally, traditional anatomically-guided local anesthetic injections were attempted without improvement in his symptoms. Thus, the patient elected to proceed with operative decompression after eight months of failed conservative therapy and worsening quality of life.The history of failed local anesthesia to even temporarily alleviate symptoms suggested a possible non-classic nerve location and prompted preoperative ultrasound to outline the superficial course of the LFCN. The ultrasound technique utilized has been previously described in the setting of percutaneous injection guidance Figure  5]..5].Skin markings in the inguinal region and upper thigh indicating the course of the LFCNs were made by the ultrasound technician prior to operative site preparation for surgery. Indeed, anatomically variant LFCNs were identified bilaterally on the preoperative ultrasound with neither nerve passing in a classic location medial to the anterior superior iliac spine (ASIS) Figure . On the Ultrasonography has increasingly been used for peripheral nerve localization . UltrasoThe LFCN demonstrates considerable anatomic variability, making ultrasound localization useful for cases such as ours. A cadaveric study of 200 patients revealed that 25.5% of patients have “abnormal” anatomy, and anatomic variants may be at higher risk for surgical injury , 13. MosAlthough MP is typically diagnosed clinically and remits spontaneously in the vast majority of cases , this etPreoperative high-resolution ultrasound can be a useful guide to the location of the lateral femoral cutaneous nerve when surgical intervention is being considered to treat meralgia paresthetica. Ultrasound may be even more useful in cases, such as ours, where a non-classic LFCN anatomic location is suspected based on a poor response to anatomically-guided local anesthetic delivery.


Vascular smooth muscle cells undergo differenthyperpolarization and relaxation when exposed to nitric oxide (NO), prostacyclin andendothelium-derived hyperpolarizing factors (EDHF), among others, as a result of thefactors described above.2Human microcirculation has some aspects that make it unique in its capacity to adjust thesupply of oxygen and nutrients to the metabolic demands of all cells throughout the bodyby adjusting vascular tone and releasing different vasoactive substances.3 In thiscontext, cutaneous microcirculation has been considered an accessible and representativevascular bed for assessing microvascular reactivity.4 Indeed, there is evidence of an association between cutaneousmicrovascular reactivity and the microcirculatory function in different vascular beds,concerning both the underlying mechanisms and the intensity of the endothelium-dependentvasodilation response.4 Therefore,assessing cutaneous microvascular reactivity has been proposed as a prognosis markerboth for chronic disease and for the action of drugs related to the microvascularendothelial function.5In the last decade, the importance of assessing microvascular function has become evidentin research on the pathophysiology of cardiovascular disease and cardiovascular riskstratification.6Microcirculation assessment in humans was initially performed using invasive techniquessuch as coronary angiography; however, the evolution of imaging techniques has made itpossible to diagnose microcirculatory abnormalities in cardiovascular disease usingnon-invasive methods that range from ultrasound techniques such as stress echocardiogramand myocardial perfusion scintigraphy  to more expensivetechniques such as positron emission tomography (PET). The prognostic importance ofmyocardial microvascular dysfunction has been acknowledged, which has boosted studies onthe subject, though it is not possible so far to directly visualize its structuralabnormalities, which can only be assessed through myocardial flow or coronary flowreserve (CFR).7evaluates the whole hemodynamics of coronary circulation, from epicardial arteries tomicrocirculation, including endothelial and vascular smooth muscle function.7 Reduced CFR has been shown to be anindependent predictor of mortality, also in patients with normal epicardial coronaryarteries.8 CFR can be examinedby PET,9 but because that method is notlargely available, CFR exams have recently become possible by means of myocardialscintigraphy (SPECT) using solid-state gamma cameras such as the telluride-cadmium-zinc(CZT) type, which provide higher sensitivity and better temporal and spatialresolutions.10CFR, or the ratio of hyperemic myocardial blood flow – i.e., at peak stress – tomyocardial blood flow at rest,11 These techniques are usuallyassociated with physiological or pharmacological stimuli that allow assessingendothelium-dependent (or independent) microvascular reactivity.12 The physiological stimulus is usuallyforearm post-occlusive reactive hyperemia, which induces an endothelium-dependentvasodilation response. The most commonly used pharmacological stimulus is the cutaneousinfusion of acetylcholine (endothelium-dependent vasodilation) or sodium nitroprusside(endothelium-independent vasodilatation), both through micro-iontophoresis.12As mentioned earlier, the systemic microcirculatory function can be examined usingtechniques for measuring the microvascular flow in the skin in a non-invasive way. Inthe clinical context, the methods most commonly used are based on laser light, includinglaser Doppler imaging and laser speckle contrast imaging (LSCI).12. Inaddition, the microvascular response related to vascular smooth muscle dilatation wasalso reduced in those patients, in parallel with significant increases of carotidintima-media thickness.12 In anotherstudy, we demonstrated that the systemic microvascular endothelial function is similarlycompromised in patients with ischemic heart disease or chronic Chagas heartdisease.13In this context, we have recently conducted a study using the LSCI technique where wedemonstrated that the endothelium-dependent vasodilation response of cutaneousmicrocirculation is reduced in patients with early-onset coronary artery diseasecompared to healthy individuals14 In thatstudy, we demonstrated that LSCI can be used to assess the effects of type 5phosphodiesterase inhibitors on penile microcirculation in patients with hypertensionand erectile dysfunction.14Recently, we adapted the LSCI technique for noninvasive assessment of penilemicrovascular reactivity.15Microcirculation rarefaction has been associated with cardiovascular and metabolicdiseases, including hypertension, diabetes, obesity and metabolic syndrome.16 In addition, the rarefaction of microcirculation in capillary bedsis related to target organ damage, which was suggested by the existence of anassociation between myocardial disease and the reduction of capillary density, as wellas another association between left ventricular hypertrophy and cutaneous microvasculardysfunction, regardless of the level of systemic arterial pressure.17,18 In a recent study, we demonstrated that cutaneouscapillary density, as well as endothelium-dependent capillary recruitment, are reducedin patients with early-onset coronary artery disease.19Change in the microvascular function in the skin has also been shown to correlate with anincreased risk of coronary artery disease.20 Moreover,microcirculation assessment could be useful to evaluate the chronic effects ofcardiovascular drugs, making it attractive not only in research contexts but also inclinical practice.Therefore, the early detection of subclinical cardiovascular disease through theassessment of microcirculatory density and reactivity non-invasive techniques couldrepresent an opportunity for early intervention, and consequently, prevention ofcardiovascular events.Thus, we believe that microcirculation assessment will be increasingly employed incardiovascular practice, both for diagnostic and prognostic purposes and for testingnovel therapeutic interventions.


Pediatric human immunodeficiency virus (HIV) care in resource-limited settings remains a major challenge to achieving global HIV treatment and virologic suppression targets, in part because the administration of combination antiretroviral therapies (cART) is inherently complex in this population and because viral load and drug resistance genotyping are not routinely available in these settings. Children may also be at elevated risk of transmission of drug-resistant HIV as a result of suboptimal antiretroviral administration for prevention of mother-to-child transmission. We investigated the prevalence and the correlates of pretreatment HIV drug resistance (PDR) among HIV-infected, cART-naive children in Ethiopia. We observed an overall PDR rate of 14%, where all cases featured resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs): ~9% of participants harbored resistance solely to NNRTIs while ~5% harbored resistance to both NNRTIs and nucleoside reverse transcriptase inhibitors (NRTIs). No resistance to protease inhibitors was observed. No sociodemographic or clinical parameters were significantly associated with PDR, though limited statistical power is noted. The relatively high (14%) rate of NNRTI resistance in cART-naive children supports the use of non-NNRTI-based regimens in first-line pediatric treatment in Ethiopia and underscores the urgent need for access to additional antiretroviral classes in resource-limited settings.  Morbidity and mortality associated with human immunodeficiency virus (HIV) infection have substantially decreased with the introduction of effective combination antiretroviral therapy (cART) ,2,3. TowPediatric HIV treatment, especially in resource-limited settings, remains a major challenge to achieving and sustaining global treatment and virologic suppression targets . This isIn Ethiopia, prevalence of HIV infection in the adult population is 1.4%, though there is substantial urban–rural variation . The proIn Ethiopia, neither routine plasma viral load monitoring nor HIV drug resistance testing are readily available to guide individualized patient care. Empiric choice of cART is therefore the routine practice, and for this reason, understanding the overall burden and the pattern of PDR among HIV-infected children could help inform empiric treatment guidelines and practices. Towards this goal, the current study assessed the prevalence and the correlates of PDR among HIV-infected cART-naive children from a resource-limited setting in Ethiopia using dried plasma and blood samples . The present study comprised children who were originally screened for eligibility for inclusion in the Efavirenz Pediatric Dose Optimization Study (EPDOS) cohort. EPDOS enrolled cART naïve HIV-infected children at seven HIV/AIDS treatment centers across two of the largest administrative regions in Ethiopia: Oromia and Southern Nations Nationalities and Peoples Region (SNNPR), whose combined populations exceed 55 million . The cen3 were initiated on cART. At this time, women who did not meet the CD4-based eligibility criteria were provided antepartum zidovudine (AZT) and intrapartum single dose nevirapine. In 2013, the guidelines were amended to recommend Option B+, and uptake has scaled up since then. By 2014, around 2500 health facilities had started providing PMTCT services. Currently, PMTCT coverage estimates in Ethiopia vary between 50–70% depending on region . Moreover, genotyping success rate was not significantly associated with any of the participant characteristics listed in p = 0.03), though we acknowledge that this may be a chance finding. Despite using dried blood or plasma as starting material, some sequences nevertheless bore evidence of amplification of within-host sequence diversity. The number of nucleotide mixtures detected in successful genotypes ranged from 0 to 40 . One of the isolated sequences (EPDOS_9) was defective with an internal stop codon near the end of the sequence.Dried blood spots .Overall, 8/57 successfully genotyped participants harbored HIV drug resistance mutations, yielding a total PDR prevalence of 14% (95% CI: 4.8–24.0%) in our study . All eigThe mutation profiles observed in the eight PDR cases are listed in p = 0.06]. Moreover, children with PDR had modestly lower albumin levels at HIV diagnosis as compared to their counterparts . Even though a low albumin might suggest undernutrition in HIV-infected children who harbor HIV drug resistance mutations, anthropometric indicators did not show statistically significant differences between children with pretreatment HIV drug resistance mutations and those without. No significant associations were observed between other laboratory and clinical parameters and the presence of HIV drug resistance mutations. There were insufficient cases of NRTI resistance  to robustly evaluate this category separately; however, we observed that children with dual-class NNRTI/NRTI PDR tended to be younger than those who harbored single or no PDR 0.2 [(0.1–0.3) years for dual-class versus 8 (5–12) for single or none] (p = 0.02).Even though the number of children with observed PDR was small, thereby potentially limiting the power to detect associations, we nevertheless wished to identify correlates of pretreatment HIV drug resistance mutations . For thiOur study represents the first characterization of pretreatment HIV drug resistance (PDR) among children newly diagnosed with HIV in Ethiopia in 2017–2019. We found that 14% of participants for whom HIV PR-RT sequences could be obtained harbored PDR; of these, approximately two-thirds solely harbored (NNRTI) resistance mutations, and the remainder harbored dual-class (NRTI and NNRTI) resistance mutations. Importantly, all participants with NNRTI resistance had intermediate- to high-level resistance to efavirenz (EFV) and nevirapine (NVP), the NNRTI components of first line cART in Ethiopia. Resistance to PIs was not observed. One important limitation of this study is that we had no information on the PMTCT exposure of the participants. Noting that limitation, the level of HIV drug resistance observed in the present study is comparable to PMTCT-unexposed HIV infected children  and is tOur findings also indicate that, in Ethiopia, the burden of PDR among children newly diagnosed with HIV is substantially higher than that in adults newly diagnosed with HIV, in which PDR prevalence has been estimated at 3.9% . DespiteOver the past two decades, rates of HIV PDR in many sub Saharan African regions have been increasing, in some cases to alarming levels ,45. Our Our findings may also have implications for future treatment practices. Currently, the WHO guidelines recommend against the use of an NNRTI-based regimen as a first line treatment if the prevalence of NNRTI PDR in the region exceeds 10% . In EthiSome limitations of our study merit mention. The lack of PMTCT information in the EPDOS cohort precludes us from interpreting results in the context of prior antiretroviral exposure and complicates comparisons with other studies from the region. However, as the majority of the children studied were diagnosed at a relatively late age (median nine years), it is possible that these children were only tested subsequent to one or both parents’ recent HIV diagnosis—a common clinical occurrence in Ethiopia. Moreover, most of these children were born before the 2013 scale up of PMTCT Option B+. Taken together, it is likely that most children were not exposed to PMTCT. However, it is important to note that, for those children with prior PMTCT exposure, later diagnosis and enrollment into EPDOS may have allowed resistance mutations associated with NVP exposure to revert to wild-type, leading to an underestimation of the burden of PDR in this cohort. Moreover, our use of Sanger sequencing could have limited our ability to detect low frequency mutations.In conclusion, the overall prevalence of PDR reported in the current study (14%) is comparable to the prevalence of PDR among PMTCT-unexposed HIV infected children in sub Saharan Africa . As the


With essentially no drug available to control the infection caused by the extensively drug-resistant Acinetobacterbaumannii (XDR-Ab) in infants and young children, this study explored the clinical outcomes of pediatric patients withdrug-resistant XDR-Ab who were treated with rifampicin in combination with sulbactam sodium.The data for clinical outcomes, microbiological responses, and side effects were collected and evaluated for 12critically ill infants and young children diagnosed with ventilator-associated pneumonia caused by XDR-Ab following surgicaltreatment for congenital heart disease in a pediatric cardiac intensive care unit. This study was approved by localinstitutional review board (IRB).Two patients died from the complex underlining diseases. The other 10 patients were weaned off the mechanicalventilation successfully within 4–15 days after the start of treatment with rifampicin combined with sulbactam sodiumand discharged home. Three cases experienced adverse side effects, including severe rash and elevated aminotransferaselevel.The combination of rifampicin and sulbactam sodium appeared to be an effective and safe therapy for severeventilator-associated pneumonia caused by XDR-Ab in infants and young children. Side effects such as skin rashes and elevatedaminotransferase levels can be reversed once rifampicin is discontinued in time.  Acinetobacter baumannii (Ab) is one of the most common gram-negative bacteria in nosocomial infection. Extensively drug-resistantAb (XDR-Ab) has become a global challenge because of its resistance to treatment and high mortality. Therefore, efforts have been made tofind the cure for the infection of this XDR-Ab in the past decade –4. The cMedical records of more than 2, 500 patients who were hospitalized in the pediatric cardiac intensive care unit (PCICU)following surgical treatment for CHD from June 2014 to June 2016 were retrospectively analyzed. Of these, 108 patients were diagnosedwith infections, of which 41 patients were colonized/infected with Ab. The patients with mixed infections, infections in othertissues, or infections sensitive to antibiotics were excluded. The final study population included 12 critically ill pediatricpatients with VAP caused by multi-drug resistant(MDR)/ XDR / pan-drug resistant (PDR) Acinetobacter baumannii (MDR/XDR/PDR-Ab)infection (3 pediatric patients simultaneously had bloodstream infection) . The diaIn the patient whose ventilator could not be withdrawn within a short-term after CHD surgery, the secretion in the airway wassucked or the alveolar lavage fluid was collected using a bronchofiberscope for culture every day for 3 consecutive days frompost-operation day 2. Peripheral blood culture was carried out three times for patients with high white blood cell counts  and high fever (> 38.5oC). If there was redness or purulent exudate at the puncture site of the deepvein catheter, the deep vein catheter was removed and the front end was sent for culture along with simultaneous peripheral bloodculture. All specimens were sent to the hospital laboratory where they were tested with reference to NCCLS antimicrobialsusceptibility testing standards. A WalkAway 96 automatic bacterial identification and antimicrobial susceptibility testing system was employed. Quality-control strains were supplied by the National Center for Clinical Laboratories. Theantimicrobial agents used to test the sensitivity to Ab were: ampicillin/ sulbactam, ticarcillin / clavulanic acid, amikacin,aztreonam, ceftazidime, cefotaxime, ciprofloxacin, cefepime, cefoperazone/sulbactam, gentamicin, imipenem, levofloxacin, meropenem,minocycline, piperacillin/tazobactam, co-trimoxazole, and tigecycline .Patients without preoperative pulmonary infection were given class I or II cephalosporin antibiotics postoperatively to preventinfection as standard, and close observation of body temperature along with blood examination and chest radiography were carried outroutinely. The patients with symptoms of infection were empirically treated with cefoperazone/sulbactam sodium (100mg/kg/dayintravenously every 8 hours) If the results of secretion or blood culture indicated XDR-Ab infection with resistance to carbapenems,the patients were treated with cefoperazone / sulbactam combined with rifampicin according to the results of drug sensitivity test. Weused sulperazone  with a sufficient dosage; the dosage for pediatric patients infected withdrug-resistant bacteria or bacteria that tended to be drug-resistant was 160 mg/kg/day, which was administered in four fractions every6 hours through intravenous infusion. Meanwhile, rifampicin at a dose of 10 mg/kg/day was administered in two fractions every 12 hoursthrough intravenous infusion. Attention was paid to the skin over the whole body and liver function during the drug application, andrifampicin was immediately stopped in patients with serious adverse drug reactions. Otherwise, rifampicin was used until the infectionindexes were controlled, the white blood cell count normalized, the sputum volume was reduced, the imaging results were improved, andthe patient was successfully weaned off the ventilator or even microbiological clearance was achieved.In addition to antibiotic therapy, the following treatments were applied: positive inotropic drugs were used to supportcardiac function; physical therapy was begun in all children after the hemodynamics were stable and the expectoration drainagewas promoted; immunoglobulin at 300 mg/kg/day was routinely used for 3 days; enteral nutrition was provided while the gastrointestinalcondition and daily calorie amounts were assessed and the nutrition volume was gradually increased; and the liquid intake and outputwere monitored hourly with a negative liquid balance goal in the early stage after surgery and a positive liquid balance allowed tosome extent in the middle and advanced stages after surgery to ensure tissue repair.All 12 critical pediatric patients after surgical treatment for CHD had MDR/XDR/PDR Ab infection due to extended ventilatorsupport time, an extended stay in the ICU, and complicated underlying conditions. The mean age of the 12 patients was 466 days, andthe mean weight was 8.5 kg . In caseThree patients had preoperative heart failure and pneumonia that was difficult to control. The neonate in case 2 underwentemergency surgery due to an obstructed total anomalous pulmonary venous connection (TAPVC). Three patients had severe airway stenosis,and four patients had low cardiac output after surgery. Case3 underwent peritoneal dialysis due to renal failure, and case 9 underwentextracorporeal membrane oxygenation (ECMO) to assist circulation due to severely low cardiac output after tricuspid valve replacement(TVR). Case 5 had severe postoperative laryngeal edema and stayed in the ICU for 2 weeks. Case 12 underwent repeated endotrachealintubation due to recurrent hemoptysis after pulmonary atresia operation.The patient in case 7 who had a bilateral diaphragmatic defect combined with DORV died after abdominal wall defect repair dueto complicated conditions and multi-organ failure. The patient in case 8 died at 120 days after endotracheal intubation due to seriousstenosis at the lower end of the trachea near the carina, which seriously affected the ventilation and secretion discharge and led tothe formation of tracheal granulation and blockage of the airway due to prolonged stimulation on the tracheal wall mucosa by the endof the endotracheal tube.The other 10 patients were treated with cefoperazone / sulbactam combined with rifampicin, and their infections could beeffectively controlled with improvement in clinical symptoms after bundle treatments such as etiological treatment and supportivetreatment were also provided. Microbial clearance was achieved in cases 1,4 and 12. Ventilator support was withdrawn for thesepediatric patients at 4–15 days after combined drug treatment, and they were considered cured and discharged from the hospital.The detailed data of all cases are provided in Adverse side effects included serious rash and mildly elevated aminotransferase levels during combination therapy withrifampicin in three cases. Therefore, close observation and timely withdrawal of the drug should be carried out if such effectsoccur.Acinetobacter baumannii is a non-fermentative, gram-negative bacillus that is widely distributed in nature and hospitals, andit can cause a variety of infections. According to reports in China and abroad, Ab has become the mam pathogenic bacteria for commonsevere infections in the ICU in the past decade . BecauseIn the past 10 years, in vitro experiments and in vivo studies in animal models targeting the refractoriness of MDR-Ab werecarried out worldwide. In many studies, in vitro drug sensitivity or in vivo animal experiments confirmed a very good sensitivity ofXDR or PDR Ab to tigecycline, colistin, and rifampicin –11. HoweIn all pediatric patients in the present study, XDR / PDR Ab was resistant to carbapenems. Two patients had PDR Ab infection, and theμg/ml to 8μg/ml , such as 21-trisomy and Noonan syndromes, the postoperative recovery time was long. Some children withcomplex CHD had low cardiac output syndrome after cardiac surgery, and kidney injury or even multi-organ function failure occurred insevere cases. Common features of these patients included: recovery from CHD surgery, prolonged ventilator support time, long-termretention of a central venous catheter, extended stay in the ICU, application of broad-spectrum antibiotics, malnutrition, and immunedysfunction. These are independent factors for nosocomial infection , 20, 21.On the basis of anti-infection treatment with drug combinations, more comprehensive bundle treatment measures are necessary toobtain good clinical outcomes for this type of critical illness in children: maintaining good heart function, ensuring organperfusion, and creating conditions for ventilator withdrawal as soon as possible; trying to maintaining fluid balance or negativefluid balance as appropriate; adhering to scheduled feeding, maintaining intestinal function, and providing supplementary parenteralnutrition to ensure calorie supply when necessary; requiring pulmonary physical therapy to achieve good respiratory management; andadministering supportive treatments such as gamma globulin to increase immunity, in order to accelerate the rehabilitation of thepediatric patients .The major limitations of this retrospective study were the small number of cases and the absence of controls.This accumulated experience indicates that the nosocomial infection should be prevented to the greatest extent possible.However, once VAP is caused by XDR/PDR Ab, a combined use of cefoperazone/sulbactam and rifampicin for anti-infection treatment is agood choice for infants and young children.1


Participants were grouped into 1 of 3 categories: high risk of OSA ; intermediate risk of OSA ; and low risk of OSA . Candidate risk factors for delirium and pain were also extracted from this record. RESULTS/ANTICIPATED RESULTS: Logistic regression will be used to test whether OSA independently predicts postoperative delirium and linear regression to assess OSAs relationship to acute pain severity. We hypothesize that patients in the HR-OSA category will experience a higher incidence of postoperative delirium and greater postoperative pain severity. We also predict a step-wise increase in risk of these adverse outcomes when analyzing patients stratified by OSA risk (HR-OSA vs. IR-OSA vs. LR-OSA). For our secondary analyses, we anticipate these outcomes are modified by compliance with CPAP treatment. We believe patients with OSA who do not use prescribed CPAP will experience a higher incidence of postoperative delirium as well as increased pain severity. DISCUSSION/SIGNIFICANCE OF IMPACT: OSA is a common and frequently undiagnosed perioperative problem associated with altered pain processing and a high incidence of postoperative delirium. While likely providing stronger evidence of OSA’s reported impact on postoperative delirium and pain, our findings might also help discern points of intervention for treatment and prevention. Since OSA’s presumed impact poses challenges to clinicians and patients, prospective, randomized trials testing preventative or mitigating interventions are necessary. We hope to use these results to design such trials and clinical plans, with the goal of reducing postoperative delirium and acute postsurgical pain severity for the large number of patients at risk due to OSA.OBJECTIVES/SPECIFIC AIMS: To study the role of OSA as an independent predictor of perioperative outcomes. METHODS/STUDY POPULATION: For this single-institution cohort study, we included data from patients who were enrolled into 1 of 3 prospective parent studies. All participants underwent in-patient surgeries, excluding neurosurgeries, which required general anesthesia and a postoperative stay of at least 1 day. Patients included in this study were assessed daily for postoperative delirium and pain severity as part of the parent studies. In the current study, determination of delirium diagnosis was based on the 3-minute Diagnostic Confusion Assessment Method (3D-CAM), and the Visual Analogue Pain Scale (VAS) was used for pain severity. Data on OSA diagnosis (determined by sleep study); OSA risk (determined by the STOP-Bang tool; snoring, tiredness, observed apnea, high blood pressure, body mass index>35 kg/m


Ex vivo electrophysiological recordings from CeA neurons indicated that oxytocin decreases evoked GABA transmission in nondependent but not in dependent rats, whereas oxytocin decreased the amplitude of spontaneous GABAergic responses in both groups. Oxytocin blocked the facilitatory effects of acute alcohol on GABA release in the CeA of dependent but not nondependent rats. Together, these results provide converging evidence that oxytocin specifically and selectively blocks the enhanced motivation for alcohol drinking that develops in alcohol dependence likely via a central mechanism that may result from altered oxytocin effects on CeA GABA transmission in alcohol dependence. Neuroadaptations in endogenous oxytocin signaling may provide a mechanism to further our understanding of alcohol use disorder.Oxytocin administration has been reported to decrease consumption, withdrawal, and drug-seeking associated with several drugs of abuse and thus represents a promising pharmacological approach to treat drug addiction. We used an established rat model of alcohol dependence to investigate oxytocin’s effects on dependence-induced alcohol drinking, enhanced motivation for alcohol, and altered GABAergic transmission in the central nucleus of the amygdala (CeA). Intraperitoneal oxytocin administration blocked escalated alcohol drinking and the enhanced motivation for alcohol in alcohol-dependent but not nondependent rats. Intranasal oxytocin delivery fully replicated these effects. Intraperitoneal administration had minor but significant effects of reducing locomotion and intake of non-alcoholic palatable solutions, whereas intranasal oxytocin administration did not. In dependent rats, intracerebroventricular administration of oxytocin or the oxytocin receptor agonist PF-06655075, which does not cross the blood-brain barrier , but not systemic administration of PF-06655075 , decreased alcohol drinking. Administration of a peripherally restricted oxytocin receptor antagonist did not reverse the effect of intranasal oxytocin on alcohol drinking.  Ex vivo electrophysiological recordings in the central nucleus of the amygdala  indicated that oxytocin blocked the facilitatory effects of alcohol on inhibitory signaling in dependent but not nondependent rats. These results provide compelling evidence that dysregulation in the endogenous oxytocin system is of functional relevance to a mechanistic understanding of alcohol use disorder.Alcohol use disorder is characterized by a reduction in reward function and gain in stress function. The neuropeptide oxytocin is involved in the regulation of both reward and stress systems. We tested the hypothesis that oxytocin administration could normalize the dysregulations that occur in alcohol dependence and thereby reduce alcohol drinking in dependent rats. We demonstrated that oxytocin administered systemically, intranasally, or into the brain blocked the enhanced drinking exhibited by alcohol-dependent rats. These effects were demonstrated to be centrally rather than peripherally mediated. Oxytocin blocked this enhanced alcohol drinking at doses that did not alter non–alcohol-related behaviors or alcohol drinking in nondependent rats, suggesting the effect was specific to alcohol drinking in alcohol dependence.  Alcohol use disorder is a global public health issue; 6% of the world’s population is subject to morbidity and mortality from alcohol . AlcoholOxytocin has been hypothesized to have an important role in social behavior, fear and anxiety, and learning and memory . Recent Oxytocin has been detected in the brain following both intraperitoneal and intranasal administration in mice and rats –24. OxytA receptor agonist decreased alcohol drinking in alcohol-dependent rats OVT alone did not alter sIPSCs , suggestEx vivo electrophysiology recordings indicated that oxytocin inhibits spontaneous action-potential–dependent GABAergic transmission in CeA slices from both dependent and nondependent rats. However, oxytocin’s ability to dose-dependently reduce evoked network GABAergic activity was absent in slices from dependent rats. Furthermore, oxytocin blunted acute alcohol-induced facilitation of evoked GABAergic responses in both nondependent and dependent rats but blocked alcohol-induced facilitation of spontaneous action-potential–dependent GABA release only in CeA slices from alcohol-dependent rats, suggesting differential GABA network effects in nondependent and dependent rats produced by oxytocin.Oxytocin delivered via intraperitoneal, intranasal, and intracerebroventricular routes blocked the enhanced motivation for alcohol drinking that developed in alcohol-dependent rats. Intraperitoneal and intranasal oxytocin at certain doses blocked the increased alcohol consumption and motivation for alcohol in dependent rats, without impacting these behaviors in nondependent rats. Intranasal oxytocin did not disrupt spontaneous locomotion, grooming behavior, motor coordination, or consumption of sweet or caloric palatable solutions. Central administration of oxytocin produced a dose-dependent reduction in alcohol drinking in dependent rats, and this effect was replicated by central administration of an oxytocin receptor agonist (PF-06655075) that does not cross the blood-brain barrier and therefore was expected to not diffuse to the periphery. However, peripheral administration of PF-06655075 (expected to not reach the brain) had no effect. Additionally, peripheral administration of an oxytocin receptor antagonist that does not cross the blood-brain barrier did not reverse the ability of intranasal oxytocin to reduce alcohol drinking in dependent rats. Together, the data suggest a central mechanism for oxytocin’s actions on alcohol drinking. Systemic oxytocin blocked the enhanced motivation for alcohol observed in dependent rats, indexed by escalated alcohol drinking and increased breakpoint in a PR test, at doses that did not change the behavior of nondependent rats. These findings are consistent with previous reports that oxytocin can decrease alcohol drinking in nondependent mice and rats ,21 and tDespite the precise mechanism remaining unknown, there is accumulating evidence that peripherally applied oxytocin can cross the blood-brain barrier in adult rodents. As suggested by others ,23, therAlthough intraperitoneal oxytocin administration decreased locomotion in the open field and the consumption of a nonalcoholic, noncaloric sweet solution and a nonalcoholic, unsweetened caloric solution, intranasal administration did not. Neither intraperitoneal nor intranasal oxytocin administration altered grooming behavior in the open field or performance in the rotarod task, indicating that the intraperitoneal effect on locomotion is likely not a result of altered motor coordination. A possible explanation for nonspecific effects of intraperitoneal oxytocin administration is that that oxytocin may have “side effects” that result from binding at peripheral sites  that disrupt behavior in general and that were induced following intraperitoneal oxytocin administration in the present study. Congruent with this account is the observation that intraperitoneal oxytocin suppressed water consumption during tests for oxytocin’s effect on alcohol consumption. In contrast, oxytocin treatment did not alter water consumption when administered intranasally, intracerebroventricularly, or intranasally in combination with L-371,257, suggesting that peripheral “side effects” were avoided during these tests . IntrapeTo further test the hypothesis of central oxytocin action, we demonstrated that intracerebroventricular infusion of oxytocin and PF-06655075 (expected to not diffuse to the periphery) reduced alcohol drinking in dependent rats. Systemic administration of PF-06655075 (expected to not to cross the blood-brain barrier) did not affect alcohol intake in dependent rats. Finally, the peripherally restricted oxytocin receptor antagonist L-371,257 did not alter the effects of intranasal oxytocin in reducing alcohol drinking in dependent rats. Together, these data suggest that peripheral receptors make a minimal contribution to intranasal oxytocin’s effects on alcohol drinking.A receptor function in both nondependent and dependent rats. Similar to previous studies in the medial subdivision of CeA OVT; sIPSC, spontaneous inhibitory postsynaptic current.(TIF)Click here for additional data file.S8 FigThe oxytocin receptor antagonist OTA did not affect eIPSP amplitude but blocked oxytocin induced decreases in amplitude and restored ethanol induced increases in amplitude in CeA neurons from nondependent animals. CeA, central nucleus of the amygdala; eIPSP, evoked inhibitory postsynaptic potential; OTA, desGly-NH2-d(CH2)5OVT.(TIF)Click here for additional data file.S1 Text(DOCX)Click here for additional data file.S1 Data(XLSX)Click here for additional data file.


Automatic computer-based seizure detection and warning devices are important for objective seizure documentation, for SUDEP prevention, to avoid seizure related injuries and social embarrassments as a consequence of seizures, and to develop on demand epilepsy therapies. Automatic seizure detection systems can be based on direct analysis of epileptiform discharges on scalp-EEG or intracranial EEG, on the detection of motor manifestations of epileptic seizures using surface electromyography (sEMG), accelerometry (ACM), video detection systems and mattress sensors and finally on the assessment of changes of physiologic parameters accompanying epileptic seizures measured by electrocardiography (ECG), respiratory monitors, pulse oximetry, surface temperature sensors, and electrodermal activity. Here we review automatic seizure detection based on scalp-EEG, ECG, and sEMG. Different seizure types affect preferentially different measurement parameters. While EEG changes accompany all types of seizures, sEMG and ACM are suitable mainly for detection of seizures with major motor manifestations. Therefore, seizure detection can be optimized by multimodal systems combining several measurement parameters. While most systems provide sensitivities over 70%, specificity expressed as false alarm rates still needs to be improved. Patients' acceptance and comfort of a specific device are of critical importance for its long-term application in a meaningful clinical way. In general, automatic seizure detection must be distinguished from automatic seizure prediction. While seizure detection methods aim to detect ongoing seizures as soon as possible after seizure onset, seizure prediction models try to identify upcoming seizures well before seizure onset. In the present review we will focus on automatic seizure detection, while the reader is referred to excellent reviews on the current status of seizure prediction –4.Documentation of seizure frequency, seizure severity and seizure type by patients and their relatives represents the most important outcome parameter for epilepsy treatment both in everyday clinical practice and for the assessment of the efficacy of medical and non-medical treatment interventions in clinical trials. However, seizure documentation by patients and their relatives has been shown to be highly unreliable. In a study using video-EEG monitoring as the gold standard for seizure documentation, 55.5% of all seizures, 73.2% of complex partial seizures, 26.2% of simple partial seizures, 41.7% der secondary generalized tonic-clonic seizures, 85.8% of seizures arising out of sleep and 32.0% of seizures arising out of wakefulness remained unnoticed or were not documented by patients  in the epilepsy monitoring unit (EMU), applications for automatic seizure detection systems include enhancement of patient safety, more efficient data analysis, automatic documentation of seizures, and computer-based neurological and neuropsychological testing during and after seizures.Patient safety in order to avoid seizure related injuries, to recognize seizure induced cardiac arrhythmias and finally to prevent SUDEP has become a central issue during VEM –25. WhilAutomatic seizure detection could optimize data review in the EMU and thus could facilitate a more efficient personnel assignment –30. AlthThe exact analysis of clinical seizure semiology is essential for correct seizure classification as well as for the localization of the seizure onset zone and pathways of seizure spread , 33. ProFinally, automatic seizure detection has become increasingly important for the detection of non-convulsive seizures and non-convulsive status epilepticus in critical care patients .Automatic computer-based seizure detection currently is one of the major research questions in clinical epileptology for the following reasons:Visual annotation of seizures by EEG experts remains the gold standard for performance evaluation of seizure detection and seizure alarm algorithms. In general, agreement on seizure annotation between EEG experts is high. However, discrepancies can occur in case of high seizure rates as well as in case of seizures with short and long durations. These caveats have to be considered during assessment of computer-based seizure detection algorithms . PreferaTrue positives (TP) meaning that the algorithm detected a seizure identified by the human expert;False negatives (FN) meaning that the algorithm missed a seizure identified by the human expert;False positives (FP) meaning the algorithm erroneously detected a seizure which was not confirmed by the human expert;Sensitivity defined as the ratio TP/(TP + FN);Specificity defined as the number of false positive alarms per hour referred to as false positive alarm rate (FAR).Alarm algorithms need to provide both on-line calculation and short detection delays.Detection delay is defined as the time interval between the time of seizure onset identified by the human expert and the time when the computer algorithm sets the alarm. Detection delays in the range of a few seconds are required for alarm devices , 39.Seizure detection and alarm algorithms usually are evaluated and compared concerning the following performance measures , 37:TruIctal EEG changes which can be measured on scalp-EEG and intracranial EEG represent the electrophysiological correlates of epileptic seizures. Therefore, analysis of ictal EEG represents the most direct biomarker for automatic epileptic seizure detection. While specificity of intracranial EEG is considerably higher than that of scalp-EEG, drawbacks of intracranial EEG based seizure detection include the sampling problem due to limited coverage of the cerebral cortex and a less well defined specificity as compared to scalp-EEG. Motor manifestations representing a prominent feature of many seizures can be assessed with surface electromyography (sEMG), accelerometry (ACM), video detection systems, and mattress sensors. Most epileptic seizures are accompanied by changes in physiologic parameters like heart and respiration rate, oxygen saturation, skin temperature, and sweat secretion. These parameters can be measured by electrocardiography (ECG), respiratory monitors, pulse oximetry, surface temperature sensors, and electrodermal activity (EDA) Table .We focused our review on automatic seizure detection based on scalp electroencephalography , electrocardiography (ECG) and surface electromyography (sEMG) because these modalities have been studied most extensively in the literature. For seizure detection based on other modalities the reader is referred to some recent excellent reviews , 16, 40.Ideally scalp-EEG based seizure detection algorithms should detect a broad range of seizures in patients with different epilepsy syndromes and seizure-onset zones with high sensitivity and specificity. Algorithms should facilitate fast and robust analysis of large amounts of EEG data. All EEG data acquired during VEM should be analyzed, including artifacts, all neurophysiological states as well as non-ictal physiological and pathological EEG patterns .While scalp-EEG based seizure detection algorithms can use either single or multiple scalp-EEG channels, most algorithms applied in a clinical setting use multiple EEG channels. In multiple channel systems, the montage can significantly influence for performance of the algorithm . For comIn general non-patient specific and patient specific algorithms can be distinguished. Non-patient specific algorithms can be applied without a priori knowledge about the patient's individual electrographic seizure patterns. Therefore these algorithms are easy to use with identical parameter settings for all patients which is important for the application in a busy clinical environment. Patient specific algorithms, on the other hand, try to improve the performance by parameter adjustments for each individual patient –49. HoweTable Due to the large amount of EEG data, patients and seizures analyzed we summarize here the studies published by the Erlangen group , 41 and Hopfengärtner et al. , 41 analFürbass et al.  performeTable In conclusion, non-patient specific scalp-EEG based seizure detection algorithms provide sensitivities between 73 and 96% . DifficuWhile patient specific algorithms can further enhance sensitivity and selectivity, drawbacks of these approaches include sometimes complex parameter adjustments and the necessity of training for individual patients –49.If a detection algorithm is used as an alarm system, on-line calculation with short detection delays represents a prerequisite. Detection delays reported in the literature vary between 2 and 19 s .Draw-backs of scalp-EEG based seizure detection systems include the complexity of the EEG signal, attenuation of the EEG signal by skull and scalp and the fact that large parts of the cerebral cortex including mesial frontal, basal frontal, and mesial temporal areas are not accessible to the scalp-EEG. The most significant limitation remains the application of scalp-EEG based seizure detection systems in an outpatient setting because it is not acceptable for patients to wear EEG electrode arrays for prolonged time periods in everyday life . RecentlECG represents a simple and easy to record signal for automatic seizure detection. Many seizures are accompanied by a pronounced ictal sinus tachycardia . Ictal sCompared to the EEG, the ECG signal is highly robust and less prone to artifacts. Long-term ECG recordings can be easily obtained in an ambulatory setting using ambulatory ECG, smart watches and minimally invasive implantable loop recorders for prolonged time periods. Contrary to long term scalp EEG recordings these systems impose no burdens or restrictions to the patient and are well tolerated by patients. Compared to long-term intracranial EEG recordings, implantable loop recorders are far less invasive, carry only negligible risks for the patients, are widely available commercially and considerably less costly than implantable EEG recording devices. Finally, the ECG signal is simpler to process and to analyze than the EEG signal.Definition of ictal sinus tachycardia is rather heterogeneous in the literature . The mosIn general, a lower threshold will result in a higher sensitivity, but lower specificity corresponding to a higher FAR, whereas a higher threshold will be associated with a lower sensitivity, but a higher specificity corresponding to a lower FAR.Concerning algorithms for detection of ictal sinus tachycardia, so-called threshold and curve fitting algorithms can be distinguished. Threshold algorithms set an alarm when the average heart frequency in an analyzing time window exceeds the average heart frequency in a baseline time window by a predefined threshold parameter of 2.5–25 bpm. The duration of the analyzing time window can be varied for instance from 5 to 15 s, while the duration of the baseline time window is kept constant at 20 s . The mosAccording to a recent review article incorporating 34 articles ictal sinus tachycardia can be observed in 82% of patients . While sIn a study with intracranial electrodes, the temporal relationship between the onset of ictal tachycardia, seizure onset on intracranial EEG, seizure onset on scalp-EEG and clinical seizure onset was investigated . Ictal tConcerning specificty, heart rate increases during epileptic seizures occur faster and are more pronounced as compared to those associated with physical exercise or nocturnal arousals , 84. In Analysis of heart rate variability represents a very promising approach for ECG based seizure detection. Especially the so-called modified cardiac sympathetic index (CSI100) seems to be suitable to detect the abnormal increase in sympathetic tone during epileptic seizures . Thus, tQuantitative analysis of surface electromyography (sEMG) represents a valuable tool for the detection of seizures with prominent motor manifestations .The deltoid muscle, the anterior tibialis muscle –89 as weFor the detection of generalized tonic-clonic seizures sEMG from the deltoid muscle yielded higher sensitivity, but lower specificity than sEMG from the anterior tibialis muscle [deltoid muscle: sensitivity 100%, false positive alarm rate 1 per 24 h, detection latency 13.7 s ; anterioContinuous sEMG recordings for 1,399 h from the brachial biceps and triceps muscle were performed in 33 patients with 196 epileptic seizures  and 4 nonepileptic spells. The algorithm detected 20 of 21 generalized tonic-clonic seizures corresponding to a sensitivity of 95% with an average detection latency of 20 s. While only one false positive alarm was observed in the postictal phase after a generalized tonic-clonic seizure, no false positive alarms were triggered by other seizure types .In a prospective multicenter phase III trial in 199 patients investigated in 11 epilepsy monitoring units, sEMG from the brachial biceps muscle detected 35 out of 46 of generalized tonic-clonic seizures corresponding to a sensitivity of 76% with a false positive alarm rate of 2.52/24 h. If the device was correctly placed over the midline of the biceps muscle, 29/29 of generalized tonic-clonic seizures could be detected . While mild to moderate adverse events (mostly skin irritation caused by the electrode patch that resolved without treatment) occurred in 28% of participants leading to study withdrawal in 9%, no serious adverse events were reported .In a prospective study in 71 patients from 3 centers sEMG recordings from brachial biceps muscle , a sensitivity of 93.8%  with a median detection latency of 9 s (range: −4 to 48 s) and a false alarm rate was 0.67/24 h could be obtained. No adverse events were observed .Quantitative sEMG analysis provides direct information about the electric activity in the motor cortex and therefore is useful to elucidate the pathomechanisms of convulsive seizures . Thus sEAutomatic computer-based seizure detection and warning devices are important for objective seizure documentation, for SUDEP prevention, to avoid seizure related injuries and social embarrassments as a consequence of seizures, and to develop on demand epilepsy therapies. Automatic seizure detection systems can be based on direct analysis of epileptiform discharges on scalp-EEG or intracranial EEG, on detection of motor manifestations of epileptic seizures using surface electromyography (sEMG), accelerometry (ACM), video detection systems, and mattress sensors and finally on the assessment of changes of physiologic parameters accompanying epileptic seizures measured by electrocardiography (ECG), respiratory monitors, pulse oximetry, surface temperature sensors, and electrodermal activity (EDA). Different seizure types affect preferentially different measurement parameters. While EEG changes accompany all types of seizures, sEMG and ACM are suitable primarily for the detection of seizures with major motor manifestations. Therefore, multimodal systems combining several different measurement parameters certainly represent the future of automatic seizure detection , 58. WhiCB conceived, designed and wrote the manuscript, prepared the tables and reviewed the final version. JK revised the manuscript, prepared the tables and proofread the final version. MR revised the manuscript, prepared the tables and proofread the final version of the paper.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.