In low- and middle-income countries, the prevalence of antimicrobial resistance (AMR) is increasing. To control AMR, WHO recommends monitoring antibiotic use, in particular Watch antibiotics. These are critically important antibiotics, with restricted use because at risk of becoming ineffective due to increasing AMR. We investigated pre-hospital antibiotic use in rural Burkina Faso.During 2016–2017, we collected data from patients aged > 3 months presenting with severe acute fever to the rural hospital of Nanoro Health District, Burkina Faso, including antibiotic use in the two weeks prior to consultation or hospitalization. We analysed reported antibiotic use by applying the WHO Access, Watch, Reserve classification.p < 0.001) and among referrals from the primary health care centers (42.2%) compared to self-referred patients . Most frequently reported Watch antibiotics were ceftriaxone  and ciprofloxacin .Of 920 febrile participants (63.0% ≤ 14 years), pre-hospital antibiotic use was reported by 363 (39.5%). Among these 363, microbiological diagnoses were available for 275 (75.8%) patients, of whom 162 (58.9%) were non-bacterial infections. Use of more than one antibiotic was reported by 58/363 (16.0%) participants. Of 491 self-referred patients who did not previously visit a primary health care center, 131 (26.7%) reported antibiotic use. Of 424 antibiotics reported, 265 (62.5%) were Access and 159 (37.5%) Watch antibiotics. Watch antibiotic use was more frequent among patients > 14 year olds (51.1%) compared to those 0–14 year old (30.7%, The reported frequent use of Watch group antibiotics among febrile patients prior to presentation to the hospital in rural Burkina Faso highlights the need to develop targeted interventions to improve antibiotic use in community settings as part of strengthening antibiotic stewardship in low- and middle-income countries. This should include facilitating referral, access to qualified prescribers and diagnostic tools in rural primary health care centers.Trial registration ClinicalTrials.gov identifier: NCT02669823. Registration date was February 1, 2016. The emergence of antimicrobial resistance (AMR) is driven by appropriate and inappropriate use of antimicrobials. Increasing microorganisms’ exposure to antibiotics results in selection pressure, while suboptimal regimen allows selective survival of resistant microorganisms , 2. GlobIn sub-Saharan Africa, self-medication with over-the-counter antibiotics from private pharmacies or informal drug stores, without prior prescription by a qualified health worker, is frequent and facilitates uncontrolled antibiotic use –11. To oFrom March 23, 2016 to June 30, 2017, the PaluBac study recruited patients aged > 3 months presenting to the Nanoro district hospital with acute fever (tympanic temperature ≥ 38.0 °C) or history of fever in the last 48 h and ≥ 1 symptom(s) of respiratory distress, generalized weakness (prostration), impaired consciousness, seizures (one or more episodes), clinical jaundice, signs of shock, or with suspected severe malaria, invasive bacterial infection, or severe viral infection. A total of 920 patients of whom 344 (37.4%) inpatients and 576 (62.6%) outpatients were included. From March 23 to November 8, 2016, only inpatients were recruited; from November 9, 2016 to June 30, 2017 also outpatients were included. PaluBac evaluated the performance of an automated cell counter to quantify malaria parasitaemia [high malaria transmission season from July to November. This period overlaps with the rainy season, which extends from June to October. The low malaria transmission season is from December to June.The study was conducted in the Nanoro Health District in the West-Central region of Burkina Faso, about 90 km from Ouagadougou, the capital city of Burkina Faso. The district has 24 primary health care centers and one district hospital, “Centre Médical avec Antenne Chirurgicale” (CMA). Primary health care centers are meant to be the patients’ first point of contact with the healthcare system, during outpatient consultations. There are no medical doctors attached. More complicated cases are referred from the primary health care centers to the district hospital . The disIn Burkina Faso health districts, antibiotics can be obtained from formal public or private drug stores after prescription by a Medical Doctor or a nurse. Importation and quality of antibiotics  is under the control of the national pharmaceutical regulatory agency . Howeverpre-hospital antibiotic use, the date of symptom onset, and whether the patient was referred or not from a primary health care center. Referral patients first attended a primary health care center where a nurse decided about the need for higher-level care and referral to the district hospital, based on clinical symptoms. Proper inpatient care is not possible at a primary health care center, the patient can only be observed for a maximum of 48 h. Self-referred patients were those presenting directly at the district hospital without first attending a primary health care center.At inclusion, study clinicians completed case report forms with medical history, including the use of antibiotics and antimalarials in the two weeks prior to consultation, which we refer to as Pre-hospital antibiotics were classified (1) according to WHO's Access, Watch, Reserve (AWaRe) classification and (2) according to products name as stated in the WHO essential medicines list . For theOf 1212 screened febrile patients, 920 (75.9%) patients were included in the study and had complete data available about pre-hospital antibiotic use. Of these 920, 344 (37.4%)were hospitalized upon arrival at the hospital and 576 (62.6%) were treated as outpatients. Children aged 0–14 years represented 580 (63.0%) of patients and 533 (57.9%) patients were male. A total of 428 (46.5%) patients were referrals from primary health care centers, the remaining were self-referred (Table p = 0.12). Referral patients significantly more frequently reported pre-hospital antibiotic use  than self-referred patients . Fewer patients  reported antibiotic use during the high malaria transmission season than outside .Pre-hospital antibiotic use was reported by 363/920 (39.5%) patients, of whom 58 (16.0%) used more than one antibiotic. Proportion of use tended to be more prevalent among 0–14 year olds  compared to those > 14   were available for 275/363 (75.8%) patients who reported pre-hospital antibiotic use. Of these, 113 (41.1%) were bacterial infections; the other diagnoses were malaria , viral infections excluding HIV , and HIV  HIV.p < 0.001) and by referrals  compared to self-referred patients . There was no difference in the proportion of Watch antibiotics used between the high and low malaria-transmission season  antibiotics belonged to the Access group, 159 (37.5%) to the Watch group and none to the Reserve group. Watch antibiotics were more frequently reported by > 14 year olds  than by 0–14 year olds  was the most reported antibiotic, accounting for 137/424 (32.3%) of all antibiotics reported. The most frequently reported Watch antibiotics were ceftriaxone  and ciprofloxacin . Among antibiotics reported by referral patients (n = 277 antibiotics), ceftriaxone was recorded 100 times (36.1%) and ciprofloxacin 12 times (4.3%). Among antibiotics reported by self-referred patients (n = 146), ciprofloxacin was recorded 20 times (13.7%)  antibiotics were most frequently used, Watch antibiotics were used by 42% of patients referred from a primary health care center. The high use of Watch antibiotics in referred patients is worrisome particular since ceftriaxone (Watch) is not on the Burkina Faso medicine list for use in primary health care centers and is recommended at this level only in case of a meningitis outbreak (which did not occur during our study period) . MoreoveHigh and increasing use of Watch antibiotics has been observed in other low- and middle-income settings , 25, 26.Enterobacterales. Indeed, most (90.5%) of non-Typhi Salmonella and 87.5% of Escherichia coli were resistant to ampicillin in Nanoro during 2012–2013 [Despite ampicillin being the treatment of choice for patients with severe infectious diseases at primary health care center level pending referral, it is increasingly ineffective against 012–2013 . This co012–2013  is then 012–2013 . Integra012–2013 .Some caution interpreting these findings is needed. First, the inclusion of outpatients during the second half of the study period might have resulted in some changes in the study population and pre-hospital antibiotic use. However, we observed no difference in the prevalence of antibiotic use, when comparing the two populations from both recruitment periods. Further, data about pre-hospital antibiotic use were missing for a quarter of screened patients. Also, antibiotic use was collected via a survey capturing use during the two weeks before consultation at the hospital, potentially underestimating actual use. Whenever possible, reported antibiotic use was verified from referral forms, patient medical files , and antibiotic packaging or blisters. Dosage and duration of antibiotic used were not available and the final diagnoses at the district hospital may not correspond to those that had triggered prescription or self-medication within the two preceding weeks.The frequent use of Watch antibiotics in primary health care centers and at community-level in rural Burkina Faso is concerning in a context of increasingly ineffective first-line antibiotics. It points to the need to set up antibiotic use monitoring and antibiotic stewardship in rural communities in low- and middle-income countries (LMIC. As no alternatives for the currently available Watch antibiotics are available nor affordable in many LMIC settings, it is imperative to act to avoid even more alarming levels of resistance in years to come.


Impaired cochlear perfusion is a major etiological factor in idiopathic sudden sensorineural hearing loss. Oxidative stress has been shown to be a risk factor for oxidative damage.We investigated the role of oxidative stress in idiopathic sudden sensorineural hearing loss by comparing serum levels of oxidant and antioxidant molecules including thiol/disulfide homeostasis paraoxonase, stimulated thiol/disulfide homeostasis paraoxonase, arylesterase, ceruloplasmin and myeloperoxidase in patients who did and did not recover after treatment.The amount of dynamic disulfide was calculated by determining half of the difference between the total thiols and native thiols. After the determination of native, total thiol, and disulfide amounts, the disulfide/total thiol percent ratio, native thiol/total thiol ratio and disulfide/native thiol percent ratio were calculated and then compared between the two groups. Additionally, clinical relationship between audiological recovery and native thiol, disulfide, disulfide/native thiol percent ratio, and disulfide/total thiol percent ratio levels was investigated. Blood samples were also analyzed for the assessment of thiol/disulfide homeostasis paraoxonase, stimulated thiol/disulfide homeostasis paraoxonase, arylesterase, ceruloplasmin, and myeloperoxidase levels.p =  0.001, p =  0.001, p =  0.001, p =  0.003, p =  0.001, p =  0.002, respectively). However, no significant difference was found between the two groups with regard to thiol/disulfide homeostasis paraoxonase, stimulated thiol/disulfide homeostasis paraoxonase, ceruloplasmin, and myeloperoxidase levels .A significant difference was found between the two groups with regard to total oxidant status disulfide, disulfide/native thiol percent ratio, disulfide/total thiol percent ratio, and native thiol/total thiol ratio levels (The results supported the common hypothesis that vascular pathologies are the primary cause of idiopathic sudden sensorineural hearing loss and that other etiological factors ultimately result in vascular pathologies. The oxidant-antioxidant and thiol-disulfide balances were impaired in the idiopathic sudden sensorineural hearing loss group. Idiopathic sudden sensorineural hearing loss (ISSNHL) is a syndrome characterized by rapid progression of a sensorineural hearing loss of 30 dB or more across at least three contiguous frequencies, occurring within a period of 72 h or less.5Oxidative stress is defined as an imbalance between pro-oxidant and antioxidant molecules in the body, ultimately leading to the production of reactive oxygen species (ROS). It has also been shown that impaired microvascular perfusion during an ischemic event is associated with oxidative stress that leads to endothelial damage and affects terminal microvascular systems.In this study, we investigated the role of oxidative stress in ISSNHL by comparing serum levels of oxidant and antioxidant molecules including thiol/disulfide homeostasis (TDH), paraoxonase (PON), stimulated PON (SPON), arylesterase (ARES), and myeloperoxidase (MPO) in patients that did and did not recover after treatment.The study included ISSNHL patients who were diagnosed and followed in our clinic between 2017 and 2020. An age-matched control group of healthy volunteers was included in the study and was compared with the patient group. Patients detected with the established causes of ISSNHL  were excluded from the study. Additionally, patients with acute or chronic ear infections, chronic systemic diseases , autoimmune diseases, and acute or chronic infectious diseases, patients receiving antioxidant drug therapies , and patients with a history of smoking within the last four weeks were also excluded from the study. An informed consent was obtained from each participant and the study was approved by Van Training and Research Ethics Committee .Following an 8 h fasting period, blood samples were taken from each participant to assess their serum oxidative stress levels. Samples were placed in biochemical tubes and centrifuged at 2300 rpm for 10 min and then stored at −80 °C until analysis. Reducible disulfide bonds were reduced to form free functional thiol groups. Formaldehyde was used to remove residual sodium monohydrate and DTNB  products. Subsequently, both reduced and native natural thiol groups were formed.The amount of dynamic disulfide was calculated by determining half of the difference between the total thiols and native thiols. After the determination of native, total thiol, and disulfide amounts, the disulfide/total thiol percent ratio (D/TT), native thiol/total thiol ratio (NT/TT), and disulfide/native thiol percent ratio (D/NT) were calculated and then compared between the two groups.11A routine audiometric test was administered for each participant by an audiologist blinded to the study. Hearing thresholds were determined by pure tone audiometry (PTA) in a soundproof booth using an Interacoustics® audiometer . Audiometry was performed at frequencies from 250 Hz to 8000 Hz. Hearing thresholds were measured in dB HL units. Average hearing threshold at each frequency was determined for each ear of all participants and then these levels were compared between the two groups. The category of hearing loss was defined based on the PTA that was taken as the average threshold across 500, 1000, 2000, and 4000 Hz: mild hearing (26–40 dB), moderate hearing loss (41–55), moderate-severe hearing loss (56–70 dB), severe hearing loss (71–90), and very severe hearing loss (91 dB or higher). The response of the patients to the treatment was classified as follows: 1) Completely recovered: the posttreatment hearing loss value less than 10 dB compared to the initial hearing loss value or the intact ear PTA; 2) Partially recovered: posttreatment recovery of more than 50% when compared to the intact ear PTA; and 3) Unrecovered: a recovery of less than 50% compared to the intact ear PTA.t-test. Correlations were determined using Pearson’s Correlation Coefficient. A p-value of < 0.05 was considered significant.Data were analyzed using SPSS for Windows version 24.0 . Normal distribution of continuous variables was determined using Shapiro-Wilk and Skewness-Kurtosis tests and parametric tests were used for the analyses since the variables were found to have a normal distribution. Continuous variables were expressed as mean, Standard Deviation (SD), minimum, and maximum. Categorical variables were expressed as frequencies (n) and percentages (%). Continuous variables were compared using Independent p = 0.54).A total of 43 ISSNHL patients and 43 control subjects that were otherwise healthy were included in the study. The patient group was comprised of 36 (83.7%) women and 7 (16.3%) men with a mean age of 39.5 ± 10.3 years and the control group comprised 30 (69.8%) women and 13 (30.2%) men with a mean age of 38.7 ± 9.5 years. No significant difference was found between the two groups with regard to age and gender distribution , 51–70 dB in 14 (32.6%), and 71–90 dB in 23 (53.5%) patients. In the same group, median symptom duration was 7  days. High-frequency ISSNHL (descending type) was present in 28 (65.1%), low-frequency ISSNHL (ascending type) was present in 11 (25.6%), and an ISSNHL affecting all frequencies (flat type) was present in 4 (9.3%) ears. In terms of treatment response, remission was detected in 23 (53.5%), partial recovery was detected in 15 (34.9%), and no recovery was detected in 5 (11.6%) patients.p =  0.001, p =  0.001, p =  0.001, p =  0.003, p =  0.001, p =  0.002, respectively). However, no significant difference was found between the two groups with regard to PON, SPON, CLP, and MPO levels  , disulfide, D/NT, D/TT, and NT/TT levels  .Table 1Cp =  0.038)  .Table 2CThe etiology and ideal treatment approach of ISSNHL remains contradictory. Although most of the patients have an idiopathic form of ISSNHL, vascular disorders have been reported as the most common cause of the disease.Some of the antioxidants that try to prevent the damage caused by free radicals are enzymes and some of them are non-enzymes molecules. Although the antioxidant/oxidant status of the body and the concentration of antioxidant/oxidant molecules can be assessed separately, the overall antioxidant/oxidant status can be assessed more easily by the measurement of total antioxidant status (TAS) and TOS. In our study, the TOS levels were higher in the patient group compared to the control group, which indicates that a cellular defense is formed against oxidative stress. PON and ARES are enzymes in the esterase group that are encoded by the same gene and have similar active centers. In our study, no significant difference was found with regard to serum levels of PON and SPON, both of which are lipid metabolism products. Serum PON is an enzyme associated high-density lipoprotein (HDL) and exhibits anti-atherosclerotic activity by inhibiting low-density lipoprotein (LDL) oxidation. Significantly elevated PON levels are mostly seen in the presence of atherosclerotic lesions.Ceruloplasmin is a key protein that is responsible for 90% of copper transport in plasma and is synthesized predominantly in the liver. This protein protects tissues against the adverse effects of iron-containing ROS and also exhibits antioxidant and cell protective activity. MPO is a lysosomal enzyme secreted by leukocytes in response to oxidative stress. Increased MPO activity, which leads to nitric oxide inactivation and thereby reduces the vasodilatory and anti-inflammatory effects of nitric oxide, has been blamed in numerous pathological mechanisms, predominantly including vascular pathologies. In our study, the significantly reduced serum ARES level in the patient group and the absence of a significant difference between the two groups with regard to serum levels of other antioxidants  suggest that different enzymes may play a role in the antioxidant system.Thiols are composed of hydrogen and sulfur molecules bound to a single carbon atom and play a major role in the neutralization of body oxidants. Disulfide bonds are attached to thiol groups to reduce the thiol-disulfide balance. Plasma proteins, particularly albumin, are highly susceptible to oxidation since the thiol group in their structure contains free sulfhydryl. In the presence of oxidative stress, free sulfhydryl groups between two proteins form disulfide bonds through their antioxidant properties. The thiol-disulfide balance, on the other hand, is a marker indicating the oxidation process of proteins.Previous studies indicated that noise-induced hearing loss can be controlled by exogenous antioxidants. To date, various antioxidants have been tried in the treatment of ISSNHL and there have been several studies reporting on beneficial effects of antioxidants on inner ear damage and ISSNHL. However, although antioxidants such as N-acetylcysteine, vitamin C and E, selenium, ginkgo biloba extracts, and fish oil have been tried for such treatments, their effects have not yet been elucidated.26Combined use of antioxidants and steroids in ISSNHL treatment may have a synergistic effect and thus may be complementary in improving hearing. Further large-scale randomized blinded studies are needed to explore whether early addition of antioxidants to standard steroid therapy would improve recovery of ISSNHL, particularly in high-frequency hearing losses that are less responsive to treatment.The present study obtained similar findings to those of other studies that confirmed the role of oxidative stress in the etiopathogenesis of ISSNHL. Of note, the total thiol, D/NT, and D/TT values were significantly higher in the ISSNHL group compared to the control group. However, the oxidant-antioxidant and thiol-disulfide balances were impaired in the ISSNHL group and no significant correlation was found between this imbalance and the severity of hearing loss or treatment response. The assessment of serum levels of oxidative parameters in ISSNHL patients can be helpful in organizing the treatment protocol. However, to make definitive assumptions on this subject, further large-scale studies performing correlation analyses are needed.All procedures performed in this study were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.The authors declare no conflicts of interest.


Staphylococcus aureus (MRSA) with high integration in the current workflow is critical in clinical practices. We proposed a matrix-assisted laser desorption/ionization-time-of-flight mass spectrometry (MALDI–TOF MS)-based machine learning model for rapid MRSA prediction. The model was evaluated on a prospective test and four external clinical sites. For the data set comprising 20,359 clinical isolates, the area under the receiver operating curve of the classification model was 0.78 to 0.88. These results were further interpreted using shapely additive explanations and presented using the pseudogel method. The important MRSA feature, m/z 6,590 to 6,599, was identified as a UPF0337 protein SACOL1680 with a lower binding affinity or no docking results compared with UPF0337 protein SA1452, which is mainly detected in methicillin-susceptible S. aureus. Our MALDI–TOF MS-based machine learning model for rapid MRSA identification can be easily integrated into the current clinical workflows and can further support physicians in prescribing proper antibiotic treatments.Rapidly identifying methicillin-resistant IMPORTANCE Over 20,000 clinical MSSA and MRSA isolates were collected to build a machine learning (ML) model to identify MSSA/MRSA and their markers. This model was tested across four external clinical sites to ensure the model’s usability. We report the first discovery and validation of MRSA markers on the largest scale of clinical MSSA and MRSA isolates collected to date, covering five different clinical sites. Our developed approach for the rapid identification of MSSA and MRSA can be highly integrated into the current workflows. Staphylococcus aureus (MRSA) has become a major health care concern worldwide because it resists most antibiotic treatments for ordinary staph infections. Rapid identification of MRSA can enable proper antimicrobial therapy and infection-control intervention by clinicians. Conventional methods usually require 12 h to 24 h of sample culture and an additional 24 h to 48 h for identifying the bacterial species and conducting antibiotic susceptibility testing (AST). Phenotypes are typically identified by disk diffusion, Epsilometer testing (E test) gradient disk diffusion, broth macro, and microdilution in the clinical microbiology laboratory  technique has produced peptide/protein mass spectrometry (MS) fingerprints for searching mass-spectra libraries of bacterial species . CombineKlebsiella pneumoniae (Bacteroides fragilis (Mycobacterium chimaera and Mycobacterium intracellulare (MALDI-TOF have been applied to detect phenol-soluble modulin (PSM) in MRSA , KPC-proeumoniae , cfiA pofragilis , and to ellulare . HoweverS. aureus (MSSA) without using AST methods, MALDI–TOF has recently been combined with machine learning (ML) methods for antibiotic-resistance prediction. Tang et al. discovered nine characteristic peaks of MRSA among 214 S. aureus isolates  values . The mosIn this study, we used a large MALDI-TOF data set to develop a reliable ML model for rapid MRSA identification. For routine clinical practice, after MALDI-TOF analysis of cultured clinical strains, the MALDI-TOF spectra can be rapidly identified (within ∼10 s) as MRSA or MSSA using our ML model  instead S. aureus isolates obtained from China Medical University Hospital (CMUH) were used for model training and internal validation. The MRSA and MSSA species were discriminated using LightGBM. Due to the bacterial diversity, we collected real-world clinical data from four external hospitals, representatives of North Taiwan (SSH), Middle Taiwan (FYH), South Taiwan (NTUH-YL), and East Taiwan (HTCH).The MALDI–TOF 5802 spectra of the The model performances and data sizes at each clinical site are listed in y axis  SHAP value indicates a higher impact of the molecular feature in classifying MRSA (MSSA). The top variables make higher contributions to the model prediction  than the bottom ones. Some of these top molecular features, such as m/z 6,590 to 6,599; m/z 5,520 to 5,529; m/z 3,030 to 3,039; m/z 3,760 to 3,769; and m/z 6,550 to 6,559 were observed as potential markers in previous studies, and were related to different clonal lineages  or UPF0337 protein SAUSA300_1582 (UniProt accession no. Q2FGA1) , because this protein was only identified in the seventh fraction from the MRSA isolate but not from the MSSA isolate. The fifth fraction separately collected from the MSSA and the MRSA isolate was also digested and subjected to nanoLC-MS/MS analysis and mascot search. The peak of m/z 6,550.0 was identified as UPF0337 protein SA1452 (UniProt accession no. Q7A593), because this protein was only identified in fifth fraction from the MSSA isolate but not from the MRSA isolate.To identify the protein sequence of  isolate . To havem/z 6,590 to 6,599 was identified as a digital biomarker that discriminated MRSA from MSSA. The protein-sequence results of nanoLC–MS/MS experiments showed that the UPF0337 protein SACOL1680  of MRSA is a mutated form of the UPF0337 protein SA1452  of MSSA. UPF0337 protein SA1452 and UPF0337 protein SACOL1680 belong to the CsbD family of proteins, considered as general stress-response proteins in bacteria  of MSSA and UPF0337 protein SACOL1680  of MRSA.However, there is no direct link between CsbD family protein and methicillin resistance. To pinpoint the possible underlying biological mechanism of drug resistance and CsbD family proteins, we performed protein–ligand docking simulations on methicillin between UPF0337 protein SA1452  and 36VI37-methicilin (MRSA) were −5.4 and −4.9 kcal/mol, respectively. However, if the binding area was limited within the cavity, the binding affinity of 36AT37-methicillin (MSSA) was −5.3 kcal/mol and no docking result was observed for 36VI37-methicillin (MRSA). The above result may indicate that methicillin does not bind with UPF0337 protein SACOL1680 , inducing a possible MRSA drug resistance.Phyre2 was adapted for protein-structure homology modeling . After gThe machine learning approach is superior at finding mapping relationship, and maps peak features in a large data set of MALDI-TOF spectra with their corresponding antibiotics resistance in this study. To retain the completed peak information for machine learning training, we developed MALDI-TOF MS data process pipelines to extract completed peak information from the original raw data but not from the converted/exported peak file, which usually produces oversimplified and low-reproducible peak information. Furthermore, because different clinical sites come with different clinical data format of identification and antimicrobial susceptibility testing results in this study, we also build tools and pipelines for the automation of data processing, including regular expressions and text mining, to pair the clinical information of the I.D. numbers/AST results and their corresponding MALDI-TOF MS data. The data preparation and data cleaning ensured the MS data quality across five different clinical sites for further model training.The performance of our ML model was somewhat less in NTUH-YL, SHH, and HTCH compared with CMUH. However, FYH has a significantly lower AUC value compared with four other clinical sites. The lower AUC in FYH is due to a lower specificity of 0.65, which means some strains were predicted as MRSA in our trained ML predicts but they were identified as MSSA in FYH AST reports. FYH used Vitek 2 instead of Phoenix for AST; however, Gargis et al. have reported that MRSA could be miscategorized into MSSA in Vitek 2 system , which cm/z 6,590 to 6,599 has been observed in other studies  (a loss of 131 Da), the protein average neutral mass is m/z 6,591.31, equaling the observed mass of 6,593.2 ± 3 Da in the MRSA isolate  was identified as UPF0337 protein SA1452 (UniProt accession no. Q7A593). The average neutral mass of UPF0337 protein SA1452 is m/z 6,682.41, but after degrading the first amino acid methionine (Met) (a loss of 131 Da), the protein average neutral mass is m/z 6,551.41, equaling the observed mass of 6,550.0 ± 3 Da in the MSSA isolate  of MSSA but cannot bind with UPF0337 protein SACOL1680  of MRSA.Although the top-ranking protein marker of  studies , 13, its isolate . The pea isolate . CompariIn conclusion, we collected over 20,000 clinical MSSA and MRSA isolates to build a ML model to identify MSSA/MRSA and discovered reliable markers with a possible drug-resistant property. We built data pipelines to collect completed peak information for machine learning, and data visualization tools were also built for better model interpretability. The model was retrospectively and prospectively tested across four external clinical sites to ensure the model’s usability. To the best of our knowledge, we report the first discovery and validation of MRSA markers on the largest scale of clinical MSSA and MRSA isolates collected to date, covering five different clinical sites. Our developed MALDI–TOF MS-based ML model for the rapid identification of MSSA and MRSA can be highly integrated into the current workflows of clinical services and can save valuable time for physicians seeking proper antibiotic treatment; however, this rapid screening assay cannot replace more sensitive and specific methods of MRSA detection.The analytical flowchart is depicted in Clinical samples were collected from blood, cerebrospinal fluid, ascites, pleural fluid, body fluid, sputum, tissue, bile, stool, urine, and other clinical specimens. The study included 8,258 cases  at the China Medical University Hospital (CMUH) clinical microbiology laboratory from January 2018 to June 2021. The mass spectral data for the predictive model development were obtained retrospectively (IRB number: CMUH109-REC3-098). An additional 12,101 mass spectra collected during the 2018–2020 period was provided by other hospitals: Feng Yuan Hospital , National Taiwan University Hospital Yunlin Branch , Shuang Ho Hospital , and Hualien Tzu Chi Hospital . These data were reserved for external validation of the predictive model’s performance. All MSSA and MRSA strains were confirmed by a Phoenix AST system  and a VITEK2 AST system (FYH).S. aureus on tryptone soya broth (TSB) agar plates was picked and smeared onto a spot on a MALDI target plate. The sample spot was overlaid with 1 μL of 70% formic acid (FA) and dried at room temperature. Another 1 μL of α-cyano-4-hydroxycinnamic acid (CHCA) matrix solution  was added to the sample spot. Once the sample spot had dried, the MALDI plate was inserted in a MALDI–TOF mass spectrometer  with FlexControl software (version 3.4) and MALDI Biotyper (MBT) Compass version 4.1 for analysis. Spectra were collected at m/z 2,000 to 20,000. The identification results were produced in MALDI Biotyper Realtime Classification. The sample preparation protocol, MALDI–TOF MS instrument and instrumental control software were all the same to generate the spectra in the five hospitals.A single colony of m/z ratios and the mass spectra within the range of 2,000 to 20,000 Da were extracted, and the following min-max scaling equation was performed to ensure signal intensity is in the range of 0 and 1.The pipelines were built using Python version 3.7 for the data processing, including MALDI-TOF MS raw data extraction, signal processing, model training and data visualization. As the original sampling frequencies differed in some cases, the resolutions of all cases were resampled to a fixed sampling rate (1 Da in this study). TopHat, a square root transformation and Savitzky–Golay-filter were used for baseline correction, normalization and smoothing, respectively. After baseline correction and intensity normalization, the data in the temporal domain were converted to S. aureus cases as described above, the labels (MRSA or MSSA) and the preprocessed MALDI–TOF data were fed into multiple ML algorithms for training and validation.To reduce peak shifting, the extracted spectra were grouped into bins. Peaks located within the same bin were considered as the same attribute. The peak intensities within each bin were averaged to obtain the mean intensity in that bin. After preprocessing all MALDI–TOF data of the 1 score equation:Furthermore, we fed five different bin sizes  into 10 ML algorithms  with 5-fold cross-validation, and the combination of bin size and ML algorithms was presented in Table S1. The best combination was selected according to the following FS. aureus cases at CMUH from 2018 to 2019 as the training data set. The developed model was evaluated prospectively on the 2020 to 2021 CMUH data set and the four external data sets obtained from other hospitals. The MRSA/MSSA classification performance was evaluated using the AUC, sensitivity (true positive rate), and specificity (true negative rate) measures. Furthermore, we also developed a pseudo-gel plot module by using Python for data visualization of a large data set.In the study, we applied 10–Da bin size for binning and LightGBM  as the cm/z 6,593.2 and 6,550 Da, the proteins were extracted from a MRSA isolate and a MSSA isolate obtained from blood, respectively, as previously described  buffer (pH 8.5), followed by reduction using 10 mM dithiothreitol  and alkylation in the dark using 55 mM iodoacetamide . The alkylation reaction was quenched using 40 mM DTT for 1 h. The samples were separately digested overnight in sequencing-grade endoprotease Glu-C  and trypsin  at 37°C and evaporated via vacuum centrifugation. The digested samples were resuspended in 10 μL of 0.1% FA before nanoLC–MS/MS.The MRSA fractions containing the peak of m/z 400 to 2,000) were dynamically selected for MS/MS scanning . The MS/MS data were processed using DataAnalysis software version 4.4 . The S. aureus proteome  was downloaded from UniProt for reference. The MASCOT search parameters were as follows: fixed modification of carbamidomethylation (C), variable modification of oxidation (M), and deamidation (NQ), trypsin or Glu-C enzyme cleavage specificity, and mass-error tolerances of 50 ppm and 0.05 Da for the precursor and fragment ions, respectively. The false discovery rate (FDR) was set to 1%. Peptides were identified if their MASCOT individual ion scores were higher than 25.NanoLC–MS/MS was performed using a nanoflow UPLC system  coupled with a hybrid quadrupole TOF mass spectrometer  by employing a CaptiveSpray ion source. Digested peptide samples were injected into a trap column  at a flow rate of 10 μL/min for 4 min. The trapped peptides were then eluted and separated in an analytical column  at a flow rate of 300 nL/min. Peptides were separated along an ACN/water gradient (1% to 40%) within 60 min. For data-dependent acquisition, the five most intense precursors with charges +2, +3, and +4 from each TOF MS scan (https://zenodo.org/record/5502292#.YUXjRWaA6dY.The de-identified materials supporting the findings of this study are available from the corresponding author upon request. The MALDI–TOF MS data generated in this study have been deposited in the Zenodo database available at


The relevance of elevated serum triglyceride (TG) levels in the early stages of acute pancreatitis (AP) not induced by hypertriglyceridemia (HTG) remains unclear. Our study aims to determine the role of elevated serum TG levels at admission in developing pancreatic necrosis.We analyzed the clinical data collected prospectively from patients with AP. According to TG levels measured in the first 24 h after admission, we stratified patients into four groups: Normal TG (< 150 mg/dL), Borderline-high TG (150–199 mg/dL), High TG (200–499 mg/dL) and Very high TG (≥ 500 mg/dL). We analyzed the association of TG levels and other risk factors with the development of pancreatic necrosis.p = 0.001). A multivariable analysis using logistic regression showed that elevated TG levels ≥ 200 mg/dL (High TG and Very high TG groups) were independently associated with pancreatic necrosis .A total of 211 patients were included. In the Normal TG group: 122, in Borderline-high TG group: 38, in High TG group: 44, and in Very high TG group: 7. Pancreatic necrosis developed in 29.5% of the patients in the Normal TG group, 26.3% in the Borderline-high TG group, 52.3% in the High TG group, and 85.7% in the Very high TG group. The trend analysis observed a significant association between higher TG levels and pancreatic necrosis (An elevated TG level at admission ≥ 200 mg/dl is independently associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG.The online version contains supplementary material available at 10.1186/s12876-023-02684-9. Acute pancreatitis (AP) is a highly prevalent disease associated with local  and systemic complications such as persistent single or multisystemic organ failure –3. It isHypertriglyceridemia (HTG) is a known etiology of acute pancreatitis. However, the exact mechanism of pathophysiology is not clearly defined. The most accepted theory is that the excess triglycerides are hydrolyzed by pancreatic lipase, forming high concentrations of free fatty acids . Free faThe HTG is commonly present in the early stage of non-HTG-induced AP, and its clinical significance remains unclear. Some studies have found that triglyceride (TG) elevation upon admission of patients with AP predicts poor prognosis and local and systemic complications –22.However, no studies specifically analyze the association between HTG and the occurrence of pancreatic necrosis in patients with non-HTG-induced AP. Considering that pancreatic necrosis does not necessarily imply organ failure and that non-necrotic pancreatitis can be accompanied by organ failure , a speciThe HTG in the early phases of acute pancreatitis has been explained due to systemic lipolysis secondary to acute inflammation and the release of pancreatic lipases . The mecOur study aimed to ascertain the role of high stratified serum TG levels at admission in developing pancreatic necrosis and its related complications.A prospective single-cohort observational study of adult patients diagnosed with acute pancreatitis in a third-level referral center was designed to evaluate the role of high stratified serum TG in developing pancreatic necrosis.(1) Patients aged over 18 years with the diagnosis of AP, (2) determination of TG levels at admission (first 24 h), and (3) performing contrast computed tomography (CT) during hospitalization.AP was defined according to the revised Atlanta Classification 2012 . The dia(1) Patients with AP of HTG etiology: AP of HTG etiology was defined as when serum TG levels on admission were ≥ 1000 mg/dL or 500–1000 mg/dL accompanied by lactescent serum in the absence of another etiology of pancreatitis –29, (2) Management of AP patients was done according to international guidelines: initial fluid therapy was installed according to patient characteristics  for a urinary output of ≥ 0.5 ml/kg/hr. No empirical use of ATB. The patient was referred to an intensive care unit for management when severe AP was suspected .We measured the serum TG levels in the first 24 h of admission to avoid alterations in TG values that can occur due to factors such as prolonged fasting or administration of parenteral nutrition. TG levels were measured by enzymatic techniques based on spectrophotometric methods (Beckman Coulter Method). In our laboratory, the normal reference intervals are 43–200 mg/dL, regardless of the sex and age of the patient.We classified patients according to the triglyceridemia stratification proposed by the National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III)  and wereThe clinical-demographic data collected included age, sex, and body mass index (BMI). We recorded previous diabetes mellitus, arterial hypertension, cardiovascular disease, chronic lung disease, pre-existing chronic kidney disease, and dyslipidemia. The etiology of AP was classified as biliary, alcoholic, idiopathic, post-ERCP, and others .The evaluation of AP with computed tomography was performed. All procedures have a portal venous phase 35 s after administering intravenous contrast. CT was performed at least 24 h after the onset of abdominal pain and preferably between 72 and 96 h. The indications for performing CT in our hospital were: suspicion of moderate/severe or severe AP, presence of persistent SIRS, differential diagnosis with other causes of acute abdomen, and etiological study of non-biliary AP.Pancreatic necrosis was defined as the absence of enhancement in pancreatic tissue after contrast-enhanced CT. Infected pancreatic necrosis (IPN) was defined as a positive culture for microorganisms after necrosectomy or interventional drainage  [oscopic) .The local complications evaluated were fluid collections, pancreatic necrosis, pancreatic necrosis infection, and the need for invasive procedures against necrosis .We also evaluated the radiological severity of AP using the classical CT severity index classification  and the We assessed the severity of AP based on the 2012 revision of the Atlanta Classification . Mild APMortality was defined as a death that occurred during admission or up to 90 days after discharge.Laboratory markers analyzed were creatinine, hematocrit, blood urea nitrogen (BUN), and C-reactive protein. Based on thresholds established in previous studies, the following values were considered elevated: creatinine ≥ 1.8 mg/dL , hematocp < 0.05 was considered statistically significant. We performed the statistical analyzes using IBM SPSS software, version 20.0  and Stata version 16 .Chi-square test or Fisher's exact test were used to analyze qualitative variables. Quantitative variables were analyzed using the Kruskal–Wallis test, and the qualitative variables using linear-by-linear association. For normal distributions, the quantitative variables were compared by Student's t-test for two groups, and the nonparametric test used was the Mann–Whitney U test. The Cochran-Armitage trend test was used to evaluate the presence of a statistically significant trend association between TG levels and pancreatic necrosis categories. Multivariable logistic regression analysis was performed to analyze risk factors associated with pancreatic necrosis. Receiver-operating characteristic (ROC) curves for pancreatic necrosis and the area under the curve (AUC) were calculated using TG levels, biochemical markers, and scoring systems. A value of This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of Hospital Universitari Vall d'Hebron (PR-AG 328/2017). All participants signed informed consent to participate in our prospective register.p = 0.137).Between January 2016 and August 2021, after inclusion and exclusion criteria, 211 patients were included. , 38 in the Borderline-high TG group (150–199 mg/dL), 44 in the High TG group (200–499 mg/dL) and 7 in the Very high TG group (≥ 500 mg/dL). No differences were found among groups except in age and pancreatitis etiology (Table p = 0.001) (Table p = 0.001). , severe pancreatitis  and mortality .When we analyze the incidence of systemic complications according to the extent of pancreatic necrosis , we observe that a greater extent of necrosis presented a higher incidence of organ failure . Hematocrit at admission was also associated with the development of pancreatic necrosis in the multivariable analysis . The ROC curves of the biochemical markers were plotted in the Additional file Area under the curve (AUC) analysis of TG and biochemical markers predicting pancreatic necrosis were as follows: TG levels: AUC: 0.601 (CI 95% 0.519–0.684), creatinine: AUC: 0.611 (CI 95% 0.53–0.692), and hematocrit at admission AUC ROC: 0.644 . We did not find significant statistical differences when comparing the ROC curves using the Delong test , but not for mortality (p = 0.062).Incidence of organ failure, multi-organ failure, and persistent organ failure increased significantly and accordingly to the increase in TG levels groups (Our study found that TG levels ≥ 200 mg/dL (High TG and Very high TG) were a risk factor for developing pancreatic necrosis. Elevated TG levels were associated with a higher incidence of pancreatic necrosis, and this association was more significant at higher TG levels. p = 0.001).This study is one of the few studies published in the literature that demonstrated the relation between elevated TG levels and pancreatic necrosis development. In this line, Tariq et al.  found thWe also found that higher levels of TG are associated with the extent of parenchymal necrosis. Those findings support our hypothesis that TG has a role in necrosis development and are similar to those reported by Cheng et al. . AnotherWhen exploring the role of other potential factors related to necrosis, such as age, sex, and previous comorbidities were not associated with the development of pancreatic necrosis. These results agree with previous studies , 38, 47.One of the hypotheses explaining the increase of TG in AP is the lipolysis of the visceral fat occurring in the early phases of the disease, considering TGs compose 80% to 90% of the volume of adipocytes , 51. TheOur study included a period in which the COVID-19 pandemic occurred. Patients included after inclusion/exclusion criteria did not present active SARS-CoV-2 infection and were not vaccinated in the days before admission for acute pancreatitis. Some authors have reported acute pancreatitis and HTG after COVID-19 vaccination , 59.A recent meta-analysis found that pancreatic necrosis occurs more frequently in alcoholic pancreatitis than in biliary pancreatitis. However, differences in the proportion of pancreatic necrosis by etiology were analyzed in few studies, which does not allow comparison with other etiologies . Our stuOur study had limitations, such as not knowing the serum TG levels before the pancreatitis episode. Therefore, it is unclear whether elevated TG levels preceded the development of acute pancreatitis or whether acute pancreatitis caused elevated TG levels. Because CT scans were performed at the discretion of treating physicians, not all patients from the initial cohort underwent CT scan. Our analysis only included patients with CT to avoid this bias. We analyzed the entire initial cohort and the patients who underwent CT scan and found no differences in baseline characteristics.However, our study has strengths, such as the prospective data collection, the exclusion of HTG-induced AP, and the exclusion of patients with more than 72 h from the onset of symptoms and admission to reduce the bias of including patients with prolonged disease.We propose considering hypertriglyceridemia as a potential risk factor for pancreatic necrosis development. In that line, it is necessary identified the pathological mechanisms of TG increasing in AP, and the pathways by which TGs and FFA are involved in pancreatic tissue damage and systemic complications, to develop new treatment strategies for diminishing the impact of pancreatic necrosis. Studies in HTG-induced AP suggest that enzyme blockers, early removal of TG, and toxic free fatty acids by plasmapheresis may be advantageous –63; howeElevated TG levels in the early stages of AP were a risk factor associated with the development of pancreatic necrosis. The incidence of pancreatic necrosis increases proportionally with the severity of HTG. More research is necessary to know the pathophysiological mechanism that explains this relationship and design novel interventions for pancreatic necrosis.Additional file 1: Table S1. Performance of biochemical markers at admission in predicting pancreatic necrosis: Triglyceride ≥ 200 mg/dL, Creatinine ≥ 1.8 mg/dL, Hematocrit ≥ 44%, BUN ≥ 20 mg/dL, C-reactive protein ≥15 mg/dL. Fig. S1. Receiver operating characteristic (ROC) curve for pancreatic necrosis of triglycerides and biochemical markers at admission.


When treating patients with head-and-neck cancer (HNC), in addition to the primary tumour, commonly involved lymph node (LN) levels are often electively irradiated. This requires the definition of the elective LN target volume. Because the LN levels that will be included in the target depend on the clinical situation, and because manual contouring is a laborious task that can also introduce inter- and intra-observer variation, being able to automate the segmentation of individual LN levels would reduce the clinical burden and would allow use of contours regardless of the primary tumor location. We trained and evaluated three patch- and/or voxel-based deep learning frameworks to segment elective LN levels. Our results suggest that accurate segmentations can be obtained using an ensemble of patch-based UNets and that this result can be further refined by sequentially applying a 2.5D, multi-view voxel classification network.p < 0.0001) outperformed other arrangements and yielded DSC = 0.87, 0.85, 0.86, 0.82, 0.77, 0.77 for the combined and individual level I–V structures, respectively. Both PTVs were also significantly (p < 0.0001) more accurate with UNet+MV, with DSC = 0.91 and 0.90, respectively. The accurate segmentation of individual LN levels I–V can be achieved using an ensemble of UNets. UNet+MV can further refine this result.Depending on the clinical situation, different combinations of lymph node (LN) levels define the elective LN target volume in head-and-neck cancer (HNC) radiotherapy. The accurate auto-contouring of individual LN levels could reduce the burden and variability of manual segmentation and be used regardless of the primary tumor location. We evaluated three deep learning approaches for the segmenting individual LN levels I–V, which were manually contoured on CT scans from 70 HNC patients. The networks were trained and evaluated using five-fold cross-validation and ensemble learning for 60 patients with (1) 3D patch-based UNets, (2) multi-view (MV) voxel classification networks and (3) sequential UNet+MV. The performances were evaluated using Dice similarity coefficients (DSC) for automated and manual segmentations for individual levels, and the planning target volumes were extrapolated from the combined levels I–V and II–IV, both for the cross-validation and for an independent test set of 10 patients. The median DSC were 0.80, 0.66 and 0.82 for UNet, MV and UNet+MV, respectively. Overall, UNet+MV significantly ( Head-and-neck cancer (HNC) radiotherapy (RT) planning frequently includes the contouring of neck lymph nodes (LN) as a part of the elective RT target volume. However, the manual delineation of the elective target volume is a labour-intensive task that is prone to inter-observer variation , despiteOver the last few years, developments in deep learning approaches have shown impressive results for automated segmentation of organs at risk (OAR) by using convolutional neural networks (CNN) ,4,5,6 anThe automated segmentation of the LN levels is a challenging task because of anatomical limitations in the manual reference. The guidelines prescribe delineation based on anatomical markers in axial slices and assume that no voxels of levels II, III and IV can exist in the same axial plane, irrespective of the curvature and pitch of the neck. In addition, the LN target volumes do not encompass anatomical structures, but rather the expansions of groups of LNs.In this work, three combinations of deep learning networks were investigated to segment individual LN levels I–V as separate structures. To do this, we evaluated the performance of two CNNs, alone and in combination. First, since UNet is a widely established CNN that is used for a variety of imaging-related problems  and sincThis work expands the existing literature by demonstrating the feasibility of deep learning for auto-segmentation for the target definition of individual LN levels I–V towards a flexible RT planning for locally advanced HNC. Based on earlier work, we estimate that accurate performance levels are attained for the segmentation of individual LN levels I–V with Dice similarity coefficient (DSC) of at least 0.8 ,13,14 anThis retrospective study was exempted from requiring participants’ informed consent by the medical ethics committee and was performed using the three-dimensional (3D) planning computed tomography (CT) scans  of 70 patients treated between 2019 and 2022 with (chemo-)radiotherapy for locally advanced HNC, of which 60 were used for training and testing, and 10 were retained for an independent test set. We used isotropic, in-plane acquisition resolutions of [0.92–1.56] mm and a 2.5 mm slice thickness, except for two cases in which the slice thickness was 1.25 mm. The CT acquisition dimensions were 512 × 512 × (147 − 361) voxels. Patient-specific radiotherapy head-and-neck moulds and immobilisation masks were used to position the patients in a neutral position. Ground truth contours were created for the specific purpose of this study by manual contouring of individual LN levels I–V according to contouring guidelines  was 0 [700], as was previously used for lymph structure segmentation . Rotated images were acquired by 3rd order spline interpolation for the CT image and by nearest-neighbour interpolation for the corresponding segmentation maps. The default window level center , the resulting segmentations of combined structures of LN levels I–V and II-IV were expanded by a margin of 4 mm and were denoted as PI–PV and PII–PIV. These two PTVs were chosen because they were used for planning the majority of HNC sub-types.The evaluation of a full 3D image by UNet was achieved by sliding the 64 × 64 × 64 UNet field of view over the image with stride 32 and subsequently only evaluating the central 32 × 32 × 32 voxels. By doing this, we ensured that the network had sufficient context for reliable inferences, while also making sure that each voxel was classified exactly once. The spatial performance of all models was measured by using DSC, Hausdorff distance (HD) and mean surface distance (MSD) between predictions and manual contours and between the PTVs that resulted from the predictions and manual contours. Because the measures were not normally distributed upon histogram inspection and omnibus test of normality , the difTo assess the model generalizability, the two best performing models (UNet and UNet+MV) were tested on the independent test set of 10 patients. These were unique samples that were not seen or used during the model development. For this independent testing, the UNet and UNet+MV models were re-trained using the complete cross-validation dataset (60 patients) as the training data. All training and evaluation settings were identical to the cross-validation setting.N = 49) and 58.5 ± 4.9 (N = 11) for males and females, respectively. UNet and UNet+MV showed better agreement with the manual reference than MV for the complete LN structure, all individual LN levels and both PTVs (p < 0.0001) outperformed the other models, with the DSCs (median [interquartile range (Q1–Q3)]) of all individual LN structures present in the dataset being 0.804 [0.763–0.814], 0.658 [0.616–0.678] and 0.821 [0.769–0.831] for the models UNet, MV and UNet+MV, respectively. Even with some deformation, e.g., patient not aligned straight in the mask, median-level DSC results were attained . However, UNet showed higher spatial agreement with the manual reference for LN level I. The transitions of LN levels II–III by UNet+MV typically agreed most strongly with the manual reference. All models commonly disagreed with the manual reference on the caudal and cranial ends of LN level V. In addition, there existed a substantial disagreement on the lateral and dorsal ends of this structure in the model predictions. The models benefitted marginally from ensembling all model configurations for all classes, as the results from the model ensembles were more consistent , several trends were observed. First, the manual reference was judged to be suboptimal  and 64.3 ± 13.6 (N = 3) years for males and females, respectively. The median [interquartile range (Q1–Q3)] DSCs of all individual LN level structures were 0.769 [0.703–0.834] and 0.809 [0.729–0.852] by the UNet and UNet+MV configurations, respectively, and differed significantly (p < 0.0001). UNet+MV showed significantly higher DSCs for the complete I–V structure, LN levels II and III, as well as both extrapolated PTVs , and that these results can be further refined by using a UNet+MV sequential model . Despite a limited gain compared to UNet, UNet+MV exhibited a significantly better spatial performance for the complete I–V structure, individual levels II–IV and both PTV structures, and better volumetric performance for all structures. Comparable results were achieved using an independent test set for the model configurations UNet and UNet+MV, suggesting that the models have the ability to generalize beyond the data used for model training and development.N = 15) highlighted cases where the automated methods were factually closer to the truth than the manual reference, due to inconsistencies in the manual reference that arose from patient angulation and anatomical limitations in contouring guidelines  segment individual LN levels I–V for the majority of patients and that this result can be further refined by using a UNet for the segmentation of foreground structures, followed by a sequential voxel classification network. With this generalized approach, any set of lymph levels can be combined to define patient-specific LN level target structures. When dealing with angulated patients, one should be aware that the current contouring guidelines can lead to situations where the LN level contours may become inconsistent, which may be prevented by using more standardized, automated deep learning methods. Future work should investigate whether clinically acceptable RT plans can be obtained using predicted contours.


Among the measures of CT and echocardiography, TEV and RV/LV ratio were significantly associated with impending shock. In backward stepwise logistic regression, TEV, age and respiratory rate remained independent associated with impending shock .Total embolic burden assessed by CT-based quantification serves as a useful index for stressed cardiopulmonary circulation condition and can provide insights into RV dysfunction and the prediction of impending shock.Detailed descriptions of acute pulmonary emboli (PE) morphology, total embolic volume (TEV), and their effects upon patients’ clinical presentation and prognosis remain largely unexplored. We studied 201 subjects with acute PE to the emergency department of a single medical center from April 2009 to December 2014. Patient hemodynamics, Troponin I and D-dimer levels, echocardiography, and the 30-day, 90-day and long-term mortality were obtained. Contrast-enhanced computed tomography (CT) of pulmonary structures and 3-dimensional measures of embolic burden were performed. The results showed a linear association between the greater TEV and each of the following 4 variables (increasing incidence of right ventricular (RV) dysfunction, higher systolic pulmonary artery pressure (sPAP), greater RV diameter, and RV/left ventricular (LV) ratio (all  Once a diagnosis of acute PE has been successfully established, patient risk stratification and prognostication are essential for guiding subsequent clinical management. The recent clinical guidelines published by the American Heart Association (AHA) and the European Society of Cardiology (ESC)3 stratify patients based on massive, submassive, and low-risk PE categories or the Pulmonary Embolism Severity Index (PESI)4, respectively. Both incorporate key prognostic indicators such as the level of hemodynamic stability, myocardial injury, and right ventricular dysfunction.Acute pulmonary embolism (PE) is a major public health concern and a potentially fatal disease. In the United States, the average incidence is about 0.1% per year, and more than 100,000 people die from acute PE annually5. This has revolutionized the diagnostic approach and serves as the first-line imaging diagnostic tool for acute PE clinically6.Rapid and accurate diagnosis is critical for managing patients presenting with acute PE, and over the last twenty years, multidetector computed tomography (MDCT) with high spatial resolution (1–2 mm) has become highly capable of detecting emboli within the main branches of the pulmonary arteries7, but studies have not shown any significant correlation between clot burden, as measured using current two-dimensional (2D) methods, and adverse clinical outcomes9. In contrast, some studies have shown a correlation between a patient’s clot location and burden, as measured using either 2D methods or the Mastora or Qanadli scores, and their clinical condition11. Praveen et al. also found that a higher clot burden was associated with right heart strain and adverse clinical events12. Previously, measuring clot burden using three-dimensional (3D) methods was impractical because it requires a large amount of manpower during daily clinical practice. It is also debated that the role of clot burden as an indicator of short-term prognosis13. Recently, however, a 3D-based computed tomography (3D CT) method was developed, and it has been widely applied to oncology patient images for precise tumor measurement15. As a result of the advancement of computer science and software, this 3D CT method has become more accurate and less demanding. Therefore, we aimed to assess the association between clot volume burden estimated using this 3D CT method and the Qanadli score, biomarkers, and clinical outcomes, including impending shock  and short-term mortality.Interestingly, as the most commonly used diagnostic test for acute PE, MDCT can provide detailed information on embolic location and burden, neither of which is considered in the above guidelines to be a prognostic marker. Tuzovic et al. found that central and multilobar clots were correlated with right ventricle (RV) dysfunctionThe mean age of the patient population was 66.8 ± 17 years, and it included 122 females (60.7%) and 79 males (39.3%). Their characteristics are shown in Table 3, and the embolic volume in the right and left pulmonary arterial tree was 5.26 ± 5.96 cm3 and 3.17 ± 4.33 cm3 .We used multivariate logistic regression analysis to evaluate the relationship between RV dysfunction and several clinical and radiologic factors . The TEV was expressed as unit of 10cmit Table . TEV wasp < 0.001; Fig. 3 and weaker when TEV was > 10 cm3  and the RV/LV ratio  were significantly correlated with impending shock (Table p = 0.58). Multivariate logistic regression analysis with backward selection was used to identify the factors related to impending shock. In addition, since the patients with cancer had poorer outcomes in our study , age , and respiratory rate  were significantly related to impending shock , 13.9% (28 cases), 24.4% (49 cases) and 29.9% 60 cases), respectively, and these were not significantly correlated to TEV or the Qanadli score. The leading cause of death was cancer , SpO16. However, it has played a limited role in prognostication. In the current clinical guidelines issued by the AHA and ESC, a high RV/LV ratio is one of the CT factors associated with poor prognosis3. A meta-analysis showed that a RV/LV ratio > 1.0 on CT was associated with a 2.5-fold increased risk for all-cause mortality 17. In our study, we also found that an increased RV/LV ratio was significantly associated with an increased risk for impending shock. Conversely, TEV may be an important predictor for stratifying acute PE patients who are referred to the emergency department. Increases in sPAP were correlated with increasing TEV quartiles , changes in cardiac morphology and function are minor. To our knowledge, no other studies prove the relationship between cardiac function and precise embolic burden, and we offer this perspective to clarify the relationship.For echo-based RV dysfunction Table , Q2 .Compared to the Qanadli score, TEV not only more accurately assesses 3D emboli burden but is also better correlated with RV dilatation and echo-based RV dysfunction. Increasing TEV and Qanadli score can both indicate a larger clot burden in the pulmonary arterial circulation, which can lead to pressure overload and RV dilatation. Recently, a small study with fifty-eight patients with acute pulmonary embolism showed that quantitative volumetric measures of TEV was positive correlation with RV/LV ratio21, whereas several more recent studies with a large number of subjects have failed to show a significant association between the Qanadli score and short-term survival23. This may be due to improvements in the early diagnosis and treatment of patients with shock and cardiac arrest from acute PE, which has increased their overall survival rate. Recently, Stein et al. investigated the mortality of PE patients in the United States and showed that, from 1999 to 2017, the mortality of all high-risk patients decreased from 72.7 to 49.8%24. A decreasing mortality rate for acute PE makes demonstrating a significant correlation between radiologic markers and mortality more difficult. This could explain why, despite 79.3% of our patients having a high-risk sPESI score, TEV was not significantly associated with short-term mortality. In contrast, cancer, which is a major risk factor for PE and is used in calculating the sPESI score, was the leading cause of death in our patients  death, additional factors such as hemodynamic status, clinical condition, RV dysfunction, and troponin I levels are important and need to be explored24.In this study, there was no significant association between TEV and 30- and 90-day mortality rates, but this was not unexpected. There are only two small studies published before 2010 that have shown a significant association between semiquantitative clot burden assessment and short-term survival27 using deep learning with realistic data augmentation showed good results in PA segmentation compared to semi-automatic quantification ground truths. Liu el al demonstrated the good correlation between deep leaning convolutional neural network full quantitative embolic burden and the Quanadli, Mastora scores in acute pulmonary emblism, but no further investigation into laboratory data and echocardiographic findings28. Future large cohort studies compares quantitative embolic burden among different semi-automatic and AI softwares may help to improve clinical efficiency by generating 3D volumetric results before radiologist interpretation and reducing possible manual operator errors.Our study has some limitations. First, it is a retrospective study with an exclusively Asian population from a single medical center, which may represent a selection bias and limit generalizability. Second, our 3D CT volumetric method is semiautomatic, still requires manual adjustments and doesn’t compared to other vendor-independent softwares. Recently, a fewstudies used artificial intelligence (AI) for training the data augmentation and fully automatic quantification of embolic burden. Roman et al.In conclusion, our study demonstrated that a 3D CT method for quantifying acute pulmonary embolism provides results that are significantly linked to clinical condition, laboratory data, RV dysfunction, and impending shock. 3D CT measurements of clot burden may thus become a useful and feasible method for acute PE risk stratification and prognostication.This retrospective study was approved, and all methods were performed in accordance with the relevant guidelines and regulations by the institutional review board of Mackay Memorial Hospital (no. 19MMHIS293e), Taipei, Taiwan. From April 2009 to December 2014, 1134 patients with either a clinical or a radiologic diagnosis of acute PE were evaluated. The medical records and images for all cases were reviewed by two radiologists (W.H. and C.Y.), and all images have been anonymous. A total of 201 patients were included in the final analysis after the following exclusion criteria had been applied: (1) no CT angiography for PE ; (2) no thin-slice (≤ 3 mm) image reconstruction; (3) poor imaging quality; (4) radiologic evidence of chronic PE; (5) no significant emboli detected in the CT images; (6) thromboemboli in non-pulmonary vascular locations ; or (7) no echocardiography results; (8) echocardiography performed more than 7 days after admission  and cardiac biomarkers  were recorded. The simplified Pulmonary Embolism Severity Index (sPESI)29 was calculated. To evaluate the effect of embolic volume on RV function, we collected the following echocardiographic data: estimated systolic pulmonary artery pressure (sPAP); RV and left ventricle (LV) diameter; and presence of RV dysfunction. RV dysfunction was diagnosed if the echocardiogram showed any of the following morphological remodeling features: (1) morphological segmental RV abnormality  with RV diameter ≤ 30 mm; (2) RV/LV diameter ratio > 1; or (3) RV diameter > 30 mm32. To evaluate clinical prognosis, we recorded the presence of shock (defined as requiring vasopressors) at emergency-department presentation or during the course of hospitalization, 30- and 90-day mortality, and the leading cause of mortality.Patient characteristics , their clinical presentation data  or a 64-slice  MDCT scanner. The standard CTPA for PE was performed according to the following scan and reconstruction protocols: scans were acquired within a single breath-hold and obtained with a detector width of 16 × 0.672 mm or 64 × 0.5 mm, a tube voltage of 120 kVp, automatic exposure control (AEC) for the tube current, a 0.5 s gantry rotation time, and a 2 mm reconstructed slice thickness. The injection rate of the contrast medium, which was 80 mL of intravenous iohexol (Omnipaque-300) or iopromide (Ultravist-300), was 2.5–3 mL/s. Scans were performed using a bolus-tracking technique and initiated when the contrast medium was first seen in the pulmonary trunk after injection. The scan covered the region from the lung apex to the lowest hemi-diaphragm.All CTPA images were reviewed by a radiologist (W.H.) with eight years of experience in chest CT. Any indeterminate image interpretation was resolved after discussion and review with a senior radiologist (C.Y.) with 18 years of experience in chest CT. For each case, the PE was identified and defined as an intraluminal central filling defect with partial or complete occlusion of the pulmonary artery. Cases with poor imaging quality  were excluded.10 was used for semiquantitative calculation of clot burden. Using the Qanadli score, the arterial tree of each lung was divided into 10 segmental arteries . The presence of an embolus in a segmental artery was scored 1 point and the proximal arterial level was scored points equal to the sum of the distal segmental arteries. To indicate the severity of the embolus obstruction, the following weighting factor was used: 2 for total occlusion, 1 for partial occlusion, and 0 for no thrombus observed. The maximal Qanadli score for one patient was therefore 40.The Qanadli scoreA 3D-based CT method was used for absolute quantitative evaluation of the total embolic volume (TEV). CTPA images were transferred to a dedicated workstation  and the embolic volume was measured semiautomatically. Filling defects were visually identified within the arterial tree , and the boundaries of the filling defects were defined semi-automatically by the workstation using 3D segmentation method known as Draw smart ROI Figure A and visTo evaluate clinical prognosis, we prespecified and recorded the clinical presentation of shock (defined as requiring vasopressors) at emergency-department presentation as the primary endpoint. We further assessed 30- day and 90-day, 1-year and 2-year all-cause mortality and rehospitalization during subsequent follow-up.http://www.r-project.org/). Quartiles were used to display the pattern of increasing TEV and its effects on cardiac echo, CT, Qanadli score, and lab data findings. A multivariate logistic regression model with backward stepwise selection was used to evaluate the factors affecting RV dysfunction and shock. The correlations between the different image modalities—CT  and cardiac echography —and impending shock were evaluated using odds ratios (OR). Receiver operating curve (ROC) analysis was used to compare the ability of TEV and Qanadli scores to predict RV dysfunction. The threshold for statistical significance was p < 0.05.Statistical analysis was performed using R  blinded to the initial results. The intraclass correlation coefficient was used for analysis.Study approval was obtained from the Mackay Memorial Hospital Institutional Review Board (IRB no. 19MMHIS293e). This 3D CT image was reconstructed from de-identified data and the informed consent was waived during Mackay Memorial Hospital Institutional Review Board review.


Peripheral neuropathy (PN) is present in diabetic gastroparesis but is not described in idiopathic gastroparesis.(1) Determine prevalence of PN in idiopathic gastroparesis; (2) assess if patients with symptoms of gastroparesis and PN differ in gastric emptying and symptoms, both gastrointestinal and psychosocial, from patients without PN (nPN); (3) compare this relationship to that in other etiological groups.250 patients with symptoms of gastroparesis underwent gastric emptying scintigraphy and answered questionnaires including severity of gastroparesis symptoms using the Gastroparesis Cardinal Symptom Index (GCSI) and presence of peripheral neuropathy using the Neuropathy Total Symptom Score-6 (NTSS-6).p < 0.01). Among 148 patients with symptoms of idiopathic gastroparesis, defined as non-diabetic, non-postsurgical, and not caused by a known disorder such as Parkinson’s or connective tissue disease, symptoms of gastroparesis were more severe in PN than nPN: bloating , abdominal distension , and upper abdominal pain . Ninety-nine idiopathic patients underwent gastric emptying scintigraphy: 7/43 (16%) patients with delayed gastric emptying and 9/56 (16%) patients with normal gastric emptying had PN. Among patients with idiopathic gastroparesis, abdominal distension  was more severe in PN than nPN. The association of PN and worse gastrointestinal symptoms was not as apparent in patients with symptoms of diabetic or postsurgical gastroparesis.PN, defined by NTSS-6 > 6, was present in 70/250 (28%) patients: 22/148 (15%) idiopathic, 33/61 (54%) diabetic, and 11/32 (34%) postsurgical (PN was present in 70/250 (28%) of patients with symptoms of gastroparesis and was present to a lesser extent in idiopathic than diabetic gastroparesis. The presence of PN in IG was associated with more severe gastroparetic symptoms than in nPN. Screening for PN may help identify a gastroparesis cohort with peripheral neuropathy who are more symptomatic. Gastroparesis describes a gastric motility disorder characterized by delayed gastric emptying (GE) with symptoms of nausea, vomiting, early satiety, and postprandial fullness . SymptomSymptoms of PN vary based on which sensory, motor, and autonomic fibers are affected. Large-diameter sensory fibers relay vibratory sensation and proprioception while small-diameter fibers transmit pain and temperature sensation. Sensory symptoms, which usually present before autonomic symptoms, can include a loss of sensation of vibration, touch, and/or pain. Sensory and motor neurological tests can be performed to assess the extent of peripheral nerve damage, such as the Romberg test for proprioception and pin prick tests for sensation. Nerve conduction studies and electromyography can help determine if large-fiber PN is present but may be normal in small-fiber PN . AutonomSince autonomic dysfunction is present in IG, and autonomic dysfunction is a subtype of PN, we hypothesized that peripheral neuropathy may also be present in IG. The aims of this study were to: (1) Determine prevalence of PN in IG; (2) assess if patients with symptoms of gastroparesis and PN differ in GE and symptoms, both gastrointestinal and psychosocial, from patients without PN (nPN); (3) compare this relationship to that in other etiological groups.Figure We evaluated patients with symptoms of gastroparesis. Gastroparesis includes the cardinal symptoms of nausea, vomiting, early satiety, and postprandial fullness in addition to delayed GE . In thisPresence of PN was determined by the NTSS-6, a questionnaire developed for diabetic PN but used for all patients in this study, including non-diabetic. Scoring is based on a combined value of frequency and severity for a total subscore: 1.00 corresponds to “mild and occasional (less than 1/3 of the time),” 1.33 corresponds to “mild and often (1/3 to 2/3 of the time),” 1.66 corresponds to “mild and almost continuous (more than 2/3 of the time).” The increment in thirds repeats with “moderate” symptoms at the 2.00, 2.33, 2.66 levels and “severe” symptoms at the 3.00, 3.33, 3.66 levels. The original Bastyr article on NTSS-6 defines “mild” to mean that the symptoms do not interfere with daily living and require no treatment, “moderate” to mean that the symptoms interfere with or restrict at least one aspect of daily living or treatment is required, and “severe” to mean that the symptoms interfere with daily living even with treatment . Scores The severity of gastroparesis symptoms was assessed by the Patient Assessment of Gastrointestinal Disorders-Symptoms Severity Index (PAGI-SYM) which includes the Gastroparesis Cardinal Symptom Index (GCSI) , 12. EacAdditional questionnaires included a history of co-morbidities, history of the patient’s experience with gastroparesis including eating habits, treatments, and medications, and the Hospital Anxiety and Depression Score (HADS). For the HADS, scores are tallied based on anxiety or depression related questions. A score of 0–7 is “normal,” 8–10 is “borderline abnormal,” and 11–21 is “abnormal” .Patients underwent GES if it had not been performed in the recent past (defined as within the past twelve months of filling out the questionnaire). GES was performed over 4 h using the standard low-fat, Eggbeaters® meal to measure solid emptying –17. PatiFor this cross-sectional analysis, data from questionnaires and GES were entered into a Microsoft Excel® spreadsheet. Patients were categorized by etiology:  idiopatht tests and one-way ANOVA or Mann–Whitney and Kruskal–Wallis tests were used to compare groups depending on data normality. Correlation of gastric retention to PN severity was tested using Pearson’s Correlation. Comparison of percentage values, such as sex distribution and neuromodulator use, were analyzed using Chi Square tests. In this exploratory study, no statistical adjustments for multiple comparisons were made. Statistical analysis was performed using Excel and the Real Statistics Resource Pack software (Release 7.6). Copyright (2013–2021) Charles Zaiontz. www.real-statistics.com [Data is either presented as mean ± standard deviation or number (%). Two-tailed tics.com .250 patients with symptoms of gastroparesis were assessed; Fig. p = 0.490). Among patients with symptoms of idiopathic gastroparesis, PN was present in 22/148 (15%), 7/43 (16%) patients with delayed GE, and 9/56 (16%) patients with normal GE (p = 0.962). PN was present in 33/61 (54%) diabetic patients with symptoms of gastroparesis, 14/22 (64%) patients with delayed GE, and 8/20 (40%) patients with normal GE (p = 0.304). Among non-diabetic postsurgical patients with symptoms of gastroparesis, PN was present in 11/32 (34%), 4/16 (25%) patients witih delayed GE, and 2/5 (40%) patients with normal GE (p = 0.741). When comparing the prevalence of PN among each etiology, inclusive of patients who hadn’t undergone GES, the p value was < 0.005.PN as determined by NTSS-6 > 6 was present in 70/250 (28%) patients; 166 patients underwent GES. PN was present in 27/85 (32%) patients with delayed GE and 19/81 (23%) patients with normal GE (p = 0.048), but both groups reported a similar duration of gastroparesis symptoms . The 7/70 (10%) patients with PN reported slightly more neuromodulator use than 6/180 (3%) nPN (p = 0.033); neuromodulators include gabalin, pregabalin, mirtazapine, and tricyclic antidepressants (nortriptyline and amitriptyline). Otherwise, patients' age, sex, and duration of symptoms were similar between PN and nPN cohorts within each etiological group.Table p = 0.232). There was a similar prevalence of delayed GE for those with PN and nPN among each etiological group except for diabetic patients. There were no significant correlations between the severity of PN and gastric retention at two nor four hours in any of the cohorts.Inclusive of patients with all etiologies, 27/85 (32%) had delayed emptying and PN, 58/85(68%) had delayed emptying but nPN, 19/81 (23%) had normal emptying and PN, and 62/81 (77%) had normal emptying but nPN (p < 0.005) and PAGI-SYM total score  than their counterparts with nPN. Specific symptoms that were significantly worse in PN vs. nPN: vomiting , bloating , abdominal distension , and upper abdominal pain .Table p = 0.057), retching , stomach fullness , bloating , abdominal distension , upper abdominal pain . It follows that GCSI  and PAGI-SYM  scores were also more severe in PN vs. nPN.Among 148 patients with symptoms of IG, the following presented more severely in PN than nPN: nausea , GCSI , and individual symptoms scores were similar between PN and nPN. In patients with symptoms of PSG, PAGI-SYM  and GCSI  scores were similar, as were other GI symptoms.In patients with symptoms of DG, PAGI-SYM . Vomiting was especially more severe in patients with delayed GE and PN (p = 0.006). Nausea, retching, bloating, and abdominal distension tended to be higher among groups with PN than nPN, but stomach fullness and not being able to finish a meal were reported to have similar severity among all groups.Table p = 0.065). Retching and abdominal distension were especially more severe in patients with delayed GE and PN compared to with patients with normal GE and PN or any with nPN . In patients with symptoms of DG or PSG, GCSI and PAGI-SYM scores were more similar to each other among all subsymptoms.In patients with symptoms of IG, the GCSI score tended to follow a similar trend: patients with delayed GE and PN (3.86 ± 0.83) and patients with normal GE and PN (3.40 ± 0.98) reported more severe total scores than patients with delayed GE but nPN (3.12 ± 1.05) and normal GE but nPN . Out of 43 patients with IG (symptoms of IG and delayed GE), seven (16%) patients reported PN and presented with more significant abdominal distension than their 36 (84%) nPN counterparts . PAGI-SYM  and GCSI  scores tended to be more severe in IG-PN than IG-nPN but other symptoms were similar among this smaller sample size. Out of 22 patients with DG, 14 (64%) had PN and most symptoms were similar in severity compared to the eight (36%) with nPN. An exception was loss of appetite, which was more severe among DG-PN than DG-nPN .Table p = 0.045) and PAGI-SYM  scores were more severe in PN than nPN, and again, this pattern was reflected in the patients with symptoms of IG and normal emptying. However, this relationship was not apparent in the patients with symptoms of DG, in which all gastroparetic symptoms were similar in severity.Table p = 0.007) with 39/70 (56%) PN presenting with a borderline or abnormal case of anxiety vs. 66/180 (37%) in nPN (p = 0.006) (Table p = 0.002) with a similar distribution of 38/70 (54%) PN and 66/180 (37%) nPN presenting with borderline or abnormal cases (p = 0.011). Among patients with symptoms of IG, anxiety scores  were more severe among patients with PN, 15/22 (68%) of whom presented with borderline or abnormal levels of anxiety compared to 46/126 (37%) nPN (p = 0.005), but depression scores were similar . Anxiety and depression scores and distribution were similar in severity among diabetic and non-diabetic postsurgical subgroups.All patients with PN reported more severe anxiety (8.28 ± 4.26) vs. nPN . There were no major differences among which specific symptoms of PN presented more often or more severely between groups.Table This study used the NTTS-6 questionnaire to assess for PN in patients with symptoms of gastroparesis. Our results suggest that PN is present not only in DG but is also present in IG, though less prevalent. Additionally, the cohort of patients with symptoms of IG and PN reported more severe manifestations of gastroparesis than patients with symptoms of IG but nPN.In patients with symptoms of idiopathic gastroparesis, PN was present in 15% overall, with similar prevalence in patients with delayed GE (16%) and normal GE (16%). In patients with symptoms of diabetic gastroparesis, PN was present in 54% overall, being more frequent in patients with delayed GE (64%) than normal GE (40%). These numbers are slightly higher than a reported 45% prevalence of PN in a study focused on patients with symptoms of diabetic gastroparesis .p = 0.04) and at 4 h  [Our study found no correlation between peripheral neuropathy scores as assessed by the NTSS-6 and gastric retention in any etiological group. The NIH Gastroparesis Consortium found that in diabetic patients, the presence of peripheral neuropathy was associated with increased gastric retention at 2 h  . This co = 0.07) , 19.Patients with symptoms of IG and PN reported “moderate-severe” gastrointestinal symptoms of Gp, on average, while those with nPN averaged “mild-moderate” symptoms. Especially significantly worse symptoms included retching, bloating, abdominal distension, and upper abdominal pain. In idiopathic patients with delayed GE, mainly abdominal distension was more severe. A study focusing on patients with gastroparesis from the community at large (inclusive of academic centers) found that nausea, abdominal pain, and vomiting were important symptoms for treatment from the patient’s perspective. Along with early satiety, these symptoms were found to significantly impact the quality of life .In addition to more severe gastrointestinal symptoms, patients with PN reported more severe psychosocial symptoms correlating with an increased number of borderline abnormal and abnormal levels of anxiety and depression as compared to patients without PN. Of all patients with PN, 54–56% presented with borderline to abnormal anxiety and depression compared to 37% of patients with nPN. A 2017 systematic review found that as the severity of gastrointestinal symptoms from Gp worsened, so did the severity of symptoms of anxiety and depression, which were associated with a decreased quality of life . This knThe distinction between symptom severity among patients with PN and nPN was most pronounced in patients with symptoms of IG and less pronounced in diabetic or postsurgical patients. Examining GCSI subscores revealed similar severity reported in both PN and nPN among diabetic patients with symptoms of gastroparesis. This data correlates with the NIDDK Gastroparesis Clinical Research Consortium findings that symptom severity as assessed by the GCSI and PAGI-SYM were similar among 153 diabetic patients with gastroparesis with and without peripheral neuropathy, as assessed by the NTSS-6 .The strength of this study was determining if IG patients might have PN, which is known to be present in DG but is not described in IG. Limitations included that this study used the NTSS-6, which was designed as the screening tool for diabetic peripheral neuropathy, although patients with symptoms of IG or DG experienced similar symptoms of peripheral neuropathy that corresponded with the questionnaire. For all peripheral neuropathies, objective autonomic testing may be helpful in distinguishing autonomic neuropathy, however, this testing is not as easily accessible as the NTSS-6 and is not usually available to asymptomatic patients, which is why the NTSS-6 was ultimately preferred as a screening tool for PN . The assWhile a sample size of 250 patients with symptoms of gastroparesis provided ample data for analysis, the final sample size of patients with official idiopathic gastroparesis confirmed by delayed GE on GES was 7, which was significantly smaller. This may have contributed to statistical bias in the analysis. GES studies were reported at the two- and four-hours timestamps but not one-hour, precluding identification of patients with rapid emptying. Additionally, this study was performed at a tertiary academic medical center, where patients tend to have more advanced symptoms and comorbidities than at other medical centers.In this study, idiopathic patients with symptoms of gastroparesis and PN reported significantly more severe bloating, abdominal distension, and upper abdominal pain than idiopathic patients with nPN. This contrast allows for the idea that idiopathic patients with symptoms of gastroparesis can potentially benefit from neuromodulator pharmacotherapy, which are often used to treat painful peripheral neuropathy and are useful as ancillary therapies for symptoms of gastroparesis: nausea, vomiting, and abdominal pain. Pharmacotherapies such as gabapentin, pregabalin are prescribed for symptoms of abdominal pain, while mirtazapine is often used for symptoms of nausea and vomiting. Tricyclic antidepressants may modify nerve functions in the gut that depend on serotonin, which can blunt the effects of perceived pain or distension . While aIn our study, 3–10% of patients in either groups with or without peripheral neuropathy reported neuromodulator use, which were lower values than reported in a 2015 review of symptomatic management of gastroparesis, where 16% of idiopathic patients with gastroparesis and approximately 28% of diabetic patients with gastroparesis were using neuromodulators . This obThis study demonstrates that PN is prevalent in patients with symptoms of gastroparesis, not only in diabetic patients, but also patients with symptoms of idiopathic gastroparesis, a specific group in which those with PN present with more severe gastrointestinal symptoms than those without PN. This relationship is clear although no correlation between the severity of peripheral neuropathy and gastric retention among patients with symptoms of idiopathic gastroparesis was found. Discerning this relationship allows physicians to further understand the range of gastroparetic symptoms that a patient may experience, regardless of the etiology. As current treatment for gastroparesis is focused on the relief of symptoms, screening for PN may help identify a gastroparesis cohort who can benefit from neuromodulator use.