Gestational weight gain (GWG) criteria recommended by the Institute of Medicine may not be appropriate for Asians. Our aims are to investigate the association between GWG and adverse pregnancy outcomes, and to propose optimal total GWG and rates of GWG for Chinese women.Prospective data of 51,125 mother-child pairs from 27 hospitals and community health care centers from Guizhou, Yunnan and Sichuan provinces in China between 2014 and 2018 were analyzed. Generalized Additive Models were performed to determine the associations of GWG with the risk of aggregated adverse outcomes . The range that did not exceed a 2.5% increase from the lowest risk of aggregated adverse outcomes was defined as the optimal GWG range.Among all participants, U-shaped prospective association was found between GWG and the risk of aggregated adverse pregnancy outcomes. The optimal GWG range of 8.2–13.0 kg was proposed for underweight, 7.3–12.5 kg for normal weight, and 2.0–9.4 kg for overweight/obese women. Meanwhile, a higher GWG rate in the first two trimesters than that in the last trimester was suggested, except for overweight/obese women. After stratified by maternal age, mothers ≥35 years were suggested to gain less weight compared to younger mothers.To keep a balance between maternal health and neonatal growth, optimal GWG ranges based on Asia-specific BMI categories was suggested for Chinese women with different pre-gravid BMIs and maternal ages.The online version contains supplementary material available at 10.1186/s12884-023-05398-8. Excessive or inadequate gestational weight gain (GWG) has been associated with various adverse pregnancy outcomes, including gestational diabetes mellitus (GDM) , preeclaSeveral analyses have tried to explore the optimal GWG in Chinese population, yet the limited sample size –14 or reMoreover, increasing rates of multi-parity and advanced maternal age (AMA) have been detected  after thUsing prospective data from a large cohort, we thus aimed 1) to investigate the association of GWG on multiple maternal and neonatal outcomes including GDM, preeclampsia, cesarean delivery, stillbirth, preterm birth, macrosomia, LGA, and SGA using the GAMs, and 2) to create an optimal total GWG range and trimester-specific GWG range based on Asian-specific body mass index (BMI) categories for Chinese women.To investigate the impacts of maternal status on the health of mothers and their children, this prospective cohort study was conducted in China between 2014 and 2018. Details on the cohort design are described elsewhere . In brieOverall, 52,221 pregnant women were recruited from 27 study sites. After exclusion of 1096 participants with missing values of GDM, preeclampsia, stillbirth, and pre-gestational BMI, 51,125 women and their children were included for the final analysis.2). Specific pre-gravid-BMIs were categorized according to the World Health Organization (WHO) BMI categorization criteria recommended for Asian population [2), normal weight (18.5–22.9 kg/m2), overweight (23–24.9 kg/m2), and obese (≥25 kg/m2). Overweight and obese categories were combined into one category in this analysis, as limited number of obese participants (2.3%) were recruited [Detailed maternal information on maternal age, residence , occupation, school education, and personal income at enrollment  were collected by trained investigators. Information on marital (unmarried/married) and fertile (counts of conception and childbirth) histories were also collected. Detailed instruction on collecting height and bodyweight with 3 months before pregnancy were carefully given to participants. Pre-gravid BMI was calculated as weight divided by height squared . Maternal pre-gravid self-reported height was rechecked by medical professionals with electronic stadiometer to the nearest 0.1 cm at the first anthropometric measurement. All anthropometric measurements were performed twice for each participant, which dressed lightly and barefoot during measurements. The overall GWG was calculated by the difference between the bodyweight of a woman at childbirth (the latest measurement of bodyweight) and that within 3 months before the pregnancy. To explore the relevance of GWG on various outcomes in a more precise way, GWG was calculated for each trimester. The first two trimesters were combined as women usually gain a small amount of body weight in the first trimester . TherefoMeasurements and diagnoses of adverse pregnancy outcomes were performed by professionals in each study center by standard procedure and acknowledged criteria.Through a two-hour 75 g oral-glucose-tolerance test at gestational week 24–28, patients with GDM were identified if any of the following plasma glucose levels was met: 0 hour (fasting), ≥ 5.1 mmol/L; 1 hour, ≥ 10.0 mmol/L; and 2 hour, ≥ 8.5 mmol/L . Blood pNeonates who were delivered earlier than 37 weeks of gestation were defined as preterm delivery . StillbiMean and standard deviation were expressed for normally distributed continuous variables. Categorical variables were expressed as frequency and proportion. These summary statistics were calculated for all data and each subgroup . Statistical models were constructed to estimate the lowest risk at which weight gain causing one of the following adverse events: GDM, preeclampsia, cesarean delivery, stillbirth, preterm delivery, SGA, LGA, and/or macrosomia. GAMs  with logither 1%  or 5% [8The questionnaire used in this study was reviewed by experts and was then pretested for comprehensibility, acceptability, and logic and flow. The questionnaire was revised on the basis of the results of the pretests. The investigators in each study sites were strictly trained before the formal investigations, including understanding the principles and methods of the investigation and standardizing the interview skills. Physical measurements and clinical examinations were performed by medical professionals using standard methods. All the data were entered by two persons and checked one by one to ensure the accuracy of the entered data.The characteristics of the participants are shown in Table : Table S1 and Table S2). For neonatal outcomes, the predicted probabilities of macrosomia and LGA increased whereas the predicted probability of SGA decreased as weight gain increased at each BMI. Compared to pregnant women who gained 20.0 kg, those gained 5.0 kg or 13.0 kg weight had lower predicted probabilities of GDM, preeclampsia and cesarean delivery for all BMI categories.The association between GWG and the combination of eight aggregated adverse pregnancy outcomes at each BMI category is displayed in Table 2The predicted probability of each adverse pregnancy outcome and of the aggregated adverse pregnancy outcome according to GWG by pre-gravid BMI, maternal age and trimester is displayed in Additional file The optimal GWG, which was proposed by the least risky range for Chinese women developing adverse pregnancy outcomes categorized by pre-gravid BMI, is presented in Fig. Table Additional file In this cohort, we figured out a U-shaped prospective association between GWG and the risk of aggregated adverse pregnancy outcomes among 51,125 participants. Based on these associations, an optimal GWG range was suggested as 8.2–13.0 kg, 7.3–12.5 kg, and 2.0–9.4 kg respectively for underweight, normal weight and overweight/obese Chinese women, and a higher rate of GWG in the first two trimesters than the last trimester was suggested.During gestation, pregnant women and their children are, to varying degree, simultaneously at risk of multiple adverse health outcomes. Our finding of the U-shaped association between GWG and total risk of combined adverse maternal and neonatal outcomes was in line with previous analyses –9, 11, wBased on prospective data from 51,125 mother-child pairs, we suggested the optimal GWG ranges for Chinese pregnant women, which were generally lower than that recommended by the IOM, for all pre-gravid BMIs. Different from the WHO BMI categories applied in the IOM, the GWG range established in our analysis was based on the Asia-specific BMI categories, which are more proper recommendations for Chinese women. From the aspect of racial or ethnic differences, Asian populations have lower BMI levels but higher body fat levels than Caucasians  leading The 2009 IOM guideline  has recoThere is an increasing trend of delayed childbearing in China, given the fertility rate of women aged 30–34 years increased from 5.7‰ in 1995 to 18.6‰ in 2015, whereas the rate declined for younger women , 39. FurOur study has several strengths. Our participants and their children were representative of the general population in age, distribution of pre-gravid BMI and birth weight according to National Statistical Yearbooks , 39 and In conclusion, optimal GWG ranges of 8.2–13.0 kg, 7.3–12.5 kg and 2.0–9.4 kg were indicated respectively for underweight, normal weight and overweight/obese Chinese women by Asian-specific BMI categories, which was proposed to keep a balance between maternal health and neonatal growth.Additional file 1: Figure S1. The age category specified maternal pre-gravid BMI distributionaccording to WHO classifications for Asian population Figure S2. The growth curve for gestational weight gain. The brown area represents GWG growth curves for normal-weight mothers reported in the prospective multi-country study by Ismail et al. (PMID: 26926301). The green area represents the IOM recommendation.Additional file 2: Table S1. Separated predicted probability of whole pregnant GWG on neonatal outcomes in 51,125 offspring. Table S2 Separated predicted probability of whole pregnant GWG on maternal outcomes in 51,125 mothers. Table S3 Optimal gestational weight gain for Chinese pregnant women at different maternal ages.Additional file 3. Predicted probability of each adverse pregnancy outcome and of aggregated adverse pregnancy outcome with increasing GWG by pre-gravid BMIs, maternal ages and trimesters.


This prospective, randomized, double-blinded, noninferiority study aimed to compare the effects of analgesia and recovery between transmuscular quadratus lumborum block (TMQLB) and paravertebral block (PVB).  Sixty-eight, American Society of Anesthesiologists level I–III patients, who underwent laparoscopic partial nephrectomy in Peking Union Medical College Hospital were randomly allocated to either TMQLB or PVB group (independent variable) in a 1 : 1 ratio. The TMQLB and PVB groups received corresponding regional anesthesia preoperatively with 0.4 ml/kg of 0.5% ropivacaine and follow-up at postoperative 4, 12, 24, and 48 hours. The participants and outcome assessors were blinded to group allocation. We hypothesized that the primary outcome, postoperative 48-hour cumulative morphine consumption, in the TMQLB group was not more than 50% of that in the PVB group. Secondary outcomes including pain numerical rating scales (NRS) and postoperative recovery data were dependent variables. P=0.004). The intraoperative analgesic dose was higher in the TMQLB group than in the PVB group . The postoperative pain NRS at rest and on movement, incidences of side effects, anesthesia-related satisfaction, and quality of recovery scores were similar between the two groups .  Thirty patients in each group completed the study. The postoperative 48-hour cumulative morphine consumption was 10.60 ± 5.28 mg in the TMQLB group and 6.40 ± 3.40 mg in the PVB group. The ratio (TMQLB versus PVB) of postoperative 48-hour morphine consumption was 1.29 (95% CI: 1.13–1.48), indicating a noninferior analgesic effect of TMQLB to PVB. The sensory block range was wider in the TMQLB group than in the PVB group (difference 2 dermatomes, 95% CI 1 to 4 dermatomes, NCT03975296. The postoperative 48-hour analgesic effect of TMQLB was noninferior to that of PVB in laparoscopic partial nephrectomy. This trial is registered with  Ultrasound-guided transmuscular quadratus lumborum block (TMQLB), first proposed by Børglum et al. in 2013 [It has been speculated that TMQLB might produce an analgesic effect similar to that of the thoracic paravertebral block (TPVB), because a previous study on cadavers showed that the injectate injected with the TMQLB approach could spread via a pathway posterior to the arcuate ligaments and into the thoracic paravertebral space, thus infiltrating the thoracic somatic nerves and sympathetic trunk to provide both somatic and visceral analgesia . A retroTo the best of our knowledge, no prospective clinical trials have compared the analgesic effects of single-shot TMQLB and TPVB. Both TMQLB and TPVB have been reported to be effective analgesic modalities for laparoscopic urological surgeries –12. Comphttps://clinicaltrials.govNCT03975296) on June 3, 2019. Patient enrollment was started on June 10, 2019. Written informed consent was obtained from all participants before participating. This manuscript adheres to the applicable Consolidated Standards of Reporting Trials guidelines, and the study was conducted in accordance with the Declaration of Helsinki.This is a prospective, randomized, double-blind, noninferiority study. The study design was approved by the Institutional Review Board of Peking Union Medical College Hospital in Beijing, China (ZS-1559), and was registered at ClinicalTrials.gov (The inclusion criteria were as follows: (1) 18–70 years old; (2) American Society of Anesthesiologists level I–III; and (3) scheduled for laparoscopic partial nephrectomy. The exclusion criteria were as follows: (1) allergy to medications used; (2) coagulopathy or use of anticoagulants; (3) history of substance abuse; (4) inability to describe the pain ; and (5) participation in other clinical trials.All blocks were performed in a dedicated procedure room before surgery. After applying standard monitors, supplemental oxygen, and intravenous access, patients were placed in the lateral decubitus position with the operation side upwards.In the TMQLB group, TMQLB was performed using the approach described by Børglum et al. . A curveIn the TPVB group, TPVB was performed using the approach described by Renes et al. . A curveSensory block dermatomes were tested 30 minutes after the nerve block. A cold stimulus was applied along the midclavicular line to compare bilateral sensory changes. A cold sensation regression compared to the contralateral side of the same dermatome was considered an effective block. The total numbers and levels of sensory block dermatomes were recorded and compared between the two groups. Heart rate and blood pressure were also recorded as preoperative vital signs. Block-related complications, including hemorrhage, organ injury, pneumothorax (related to TPVB), LA toxicity, and injection site infection, were also recorded.µg/kg fentanyl, and 0.8 mg/kg rocuronium and maintained with sevoflurane in an air-oxygen mixture and a BIS value of 40 to 60. The baseline heart rate and blood pressure were defined as the mean value of the heart rate and blood pressure measured on the three consecutive days before surgery. The intraoperative heart rate was maintained within ±10 bpm of the baseline and recorded every ten minutes. The intraoperative blood pressure was maintained within ±20% of the baseline and recorded every ten minutes. Fentanyl was administered as needed with 1 µg/kg per bolus. Intraoperative medications and fluids were recorded by the anaesthesiologists during the surgery. Sevoflurane was stopped, and neostigmine was given after the innermost layer of the wound was closed.All patients underwent standardized general anesthesia with tracheal intubation. Anesthesia was induced with 2 mg/kg propofol, 1 After surgery, both groups received electronic patient-controlled intravenous analgesia (PCIA) pumps . Morphine was given by pressing the self-dosing button when the patients needed it, with the parameters set at 1.5–2 mg per bolus at a 5-minute lockout interval and an upper limit of 6–8 mg per hour, without continuous background infusion. Parecoxib, as a rescue for insufficient analgesia, was administered if the patient still complained of pain NRS ≥4 after using PCIA. Postoperative follow-up and outcome assessment was performed by an experienced anesthesiologist who was blinded to the group allocation.The primary outcome was postoperative 48-hour cumulative morphine consumption recorded by the electronic PCIA pump. The secondary outcomes included: (1) sensory block dermatomes 30 min after blockade; (2) intraoperative hemodynamic changes and medications used; (3) NRS pain scores at rest and during movement at postoperative 0, 4, 12, 24 and 48 hours; (4) cumulative morphine consumption at postoperative 4, 12 and 24 hours; (5) postoperative recovery data, including gas passing, urination and off-bed times, and incidences of postoperative nausea and vomiting (PONV), pruritus and dyspnea; (6) anesthesia-related satisfaction scores evaluated by a 1- to 5-point Likert scale, with 1 point defined as very unsatisfied, 2 points defined as unsatisfied, 3 points defined as acceptable, 4 points defined as satisfied, and 5 points defined as very satisfied , 15; (7)δ) was set to a 50% increase over 48 hours of cumulative morphine consumption [The sample size was calculated using the noninferiority module of PASS 11 based on the primary endpoint according to the noninferiority hypothesis. According to a previous study, the predetermined noninferiority limit , together with a single assistant nurse who was otherwise not involved in the study. All other research personnel and outcome assessors were blinded to group allocations. Patient blinding was maintained as much as possible by standardizing some of the perceptible block elements, such as positioning and LA injection volumes. However, differences in ultrasound probe placement and needle insertion site still existed.Y), was tested with a YTMQLB/YTPVB ratio of less than 1.5 as null. Linear regression was performed on Ln(Y)∼group  to obtain a coefficient B. Based on the formula Ln (YTMQLB) − Ln (YTPVB) = Ln (YTMQLB/YTPVB) = (B∗ 1 + constant) − (B∗0 + constant) = B, YTMQLB/YTPVB was obtained as eB. Noninferiority was established if the upper limit of the 95% CI of eB < 1.5. Postoperative intravenous morphine consumption and pain NRS scores were also compared between the TMQLB and TPVB groups using two-wayrepeated-measures ANOVA. No post hoc tests were performed because there were only two treatment groups. Other outcomes were compared between the TMQLB and TPVB groups using the independent t-test or the Mann–Whitney test for continuous variables and the chi-square test or Fisher's exact test for categorical variables. The group allocation was an independent variable and all outcomes were dependent variables. Data analysis was performed using SPSS software . For all analyses, P <  0.05 was considered to indicate significance.After testing the normality of the data distribution using the Q-Q plot, continuous variables with normal distribution, including postoperative cumulative intravenous morphine consumption, pain NRS score, heart rate, blood pressure, sevoflurane and fentanyl doses, urine output and crystalloid infusion volumes, recovery time, quality of life, and anesthesia-related satisfaction scores, were presented as the means ± SDs. Continuous variables with non-normal distribution, including intraoperative vasoactive agent doses, colloid, and blood product infusion volumes, were presented as medians and interquartile ranges. Categorical variables, including incidences of postoperative nausea, vomiting, pruritus, and dyspnea, were presented as numbers and percentages. The primary outcome, postoperative 48-hour cumulative morphine consumption  were randomly assigned to one of the two treatment groups (n = 34 each). Eight patients were excluded due to changes in surgical modality (n = 4) and missing data (n = 4). Thirty patients in each group were included in the final analysis . The sensory block dermatomes are shown in P=0.004).The baseline data are listed in P value of 0.001. The ratio (TMQLB versus TPVB) of morphine consumption at 48 hours postoperatively was 1.29 (95% CI 1.13–1.48). Because the upper limit of the 95% CI was lower than the prespecified noninferiority margin, noninferiority was established. The analgesic effect of TMQLB was noninferior to that of TPVB 48 hours after laparoscopic partial nephrectomy. The mean differences in postoperative 12-hour and 24-hour cumulative morphine consumption between the TMQLB and TPVB groups were 2.09 mg  and 3.61 mg , respectively. Pain NRS both at rest and during movement at postoperative 0, 4, 12, 24, and 48 hours were similar between the two groups . The rescue analgesic rate was similar between the two groups (P  >  0.05).The postoperative analgesia data are listed in P  >  0.05). After nerve block but before general anesthesia, the preoperative diastolic blood pressure  was lower in the TPVB group than in the TMQLB group. The intraoperative heart rate and blood pressure were similar between the two groups . The TMQLB group used more sevoflurane  and fentanyl  but less ephedrine  than the TPVB group. The fluid input and output volumes were similar between the two groups .The intraoperative hemodynamic changes and medications used are listed in P  >  0.05). The incidences of PONV, pruritus, and dyspnoea were similar between the two groups . The anesthesia-related satisfaction scores evaluated 48 hours postoperatively and 15-item quality of recovery scores evaluated 3 and 5 days postoperatively were similar between the two groups .The postoperative recovery data are listed in No regional block-related adverse events were reported.To the best of our knowledge, this study was the first prospective, randomized, controlled study comparing perioperative analgesia and recovery between TMQLB and TPVB in patients undergoing laparoscopic partial nephrectomy. The results demonstrated that the analgesic effect of TMQLB was noninferior to that of TPVB in terms of postoperative 48-hour cumulative morphine consumption. Both groups achieved good postoperative analgesia with similar pain NRS scores at rest and during movement. No significant differences in postoperative recovery data between the two groups were noted.The perioperative pain due to laparoscopic nephrectomy consists of both somatic and visceral elements. The somatic pain caused by gas distention of the abdominal wall, abdominal port placement, and dissection of the abdominal cavity arises from the spinal nerves of T6 to T12. The visceral pain in the renal pelvis is innervated by the sympathetic trunk from T12 to L2 . In thisWhen injected with the same dosages of ropivacaine, TMQLB produced a wider sensory block range than TPVB. This phenomenon might be explained by the different LA spreading patterns of these two techniques. TMQLB injects LA within a latent fascial space between the PM and QLM. The fascial planes follow the PM and QLM cranially through the medial and lateral arcuate ligaments and the aortic hiatus of the diaphragm, forming the endothoracic fascia and inferior diaphragmatic fascia , 4. HencH1/H0 < 1.5 hypothesis in our study, we did note significant statistical differences in intraoperative and postoperative 24-hour and 48-hour analgesic doses between the TMQLB and TPVB groups based on an H1 = 0 hypothesis. This outcome can be explained statistically and might also imply a potential inferior analgesic effect, especially the visceral analgesic effect of TMQLB compared to TPVB due to differences in the sympathetic block effect. The lower postblock diastolic blood pressure of TPVB compared to TMQLB also supports this inference. The sympathetic block effect of TPVB can be explained mainly by the following three mechanisms: (1) injection of LA directly anterior to the endothoracic fascia and into the extrapleural compartment [Despite a noninferior postoperative 48-hour analgesic effect of TMQLB compared to TPVB based on an partment , 25; (2)partment . A healtpartment . Hence, For postoperative recovery, the incidences of adverse events, patients' satisfaction with anesthesia scores, and 15-item quality of recovery scores were all similar between the two groups, indicating a comparable safety and recovery profile of both blocks.There are several noteworthy limitations of the current study. First, the ultrasound transducer placement and needle injection sites were different between the TMQLB and TPVB groups; thus, patients might not be fully blinded to the injection methods. However, the chances of identifying different block techniques were low in patients without medical backgrounds. Second, this study did not provide information about differences in pharmacodynamics and risks of systemic toxicity between the two blocks since we did not measure serum LA concentrations. To minimize the risk of toxicity, further studies are needed to determine the minimum dosage of LA that produces the maximum beneficial clinical effects. Third, this study was a single-center study in a specific surgical setting and suffered from all of the shortcomings of this type of study. Since laparoscopic nephrectomy is a moderately invasive surgery with a less invasive wound than open surgery –30 the pThe present study demonstrated a noninferior postoperative analgesic effect of TMQLB compared to T10 level TPVB in terms of postoperative 48 hours cumulative morphine consumption in laparoscopic partial nephrectomy. TMQLB could be considered a substitution for TPVB in specific surgical settings and patient populations, and it is worthy of further investigation.


Klebsiella pneumoniae (CRKP), especially in elderly patients, results in higher morbidity and mortality. The purpose of this study was to assess risk factors associated with CRKP BSI and short-term mortality among elderly patients in China.Bloodstream infection (BSI) caused by carbapenem resistant In this retrospective cohort study, we enrolled 252 inpatients aged ≥ 65 years with BSI caused by KP from January 2011 to December 2020 in China. Data regarding demographic, microbiological characteristics, and clinical outcome were collected.P < 0.001). Hypertension , exposure to carbapenems , and ICU stay  were found to be associated with the development of CRKP BSI in elderly patients. A multivariate analysis showed that isolation of CRKP  and KP isolated in ICU  were independent risk factors for 28-day mortality of KP BSI.Among the 252 BSI patients, there were 29 patients (11.5%) caused by CRKP and 223 patients (88.5%) by carbapenem-susceptible KP (CSKP). The overall 28-day mortality rate of elderly patients with a KP BSI episode was 10.7% (27/252), of which CRKP BSI patients  were significantly higher than CSKP patients  (In elderly patients, hypertension, exposure to carbapenems and ICU stay were associated with the development of CRKP BSI. Active screening of CRKP for the high-risk populations, especially elderly patients, is significant for early detection and successful management of CRKP infection. Klebsiella pneumoniae (CRKP) is a major public health problem worldwide, which causes the multiple nosocomial outbreaks, high morbidity and high mortality [Bloodstream infection (BSI) caused by carbapenem-resistant ortality , 2. Worlortality .K.pneumoniae (CSKP) (30–50% versus 2.4–12.5%) [K. pneumoniae(KP) [The mortality rates of patients with BSI caused by CRKP is reported to be significantly higher than that caused carbapenem-susceptible niae(KP) , 7. The .Population-based studies demonstrate that BSIs are more common in older people, due to a variety of factors such as comorbidity, immunocompromised, malnutrition, and environmental factors. More than 50% of the cases occurred in patients aged 65 and over , 5. In aThe aim of this study was to assess risk factors associated with CRKP BSI and mortality among elderly patients in China, improving the awareness of medical institutions on the prevention and control of CRKP infections in the elderly.K. pneumoniae BSI were included. According to established criteria, K. pneumoniae BSI is defined as the presence of at least one positive blood culture with infectious symptoms and signs [K. pneumoniae BSI cases were identified from the microbiology laboratory database. Only the first episode of K. pneumoniae BSI was included. Patients with multibacterial BSI or patients with incomplete medical records were excluded. A total of 252 episodes were enrolled in this study.This study was conducted in the 2850 beds of First Affiliated Hospital of Sun Yat-sen University from January 2011 to December 2020. Patients aged ≥ 65 years with confirmed nd signs . K. pneuPatients included were followed for 28 days from the day of the first positive blood culture. The CRKP was defined as an isolate with a minimum inhibitory concentration (MIC) of ≥ 2 μg/mL for ertapenem or ≥ 4 μg/mL for imipenem/meropenem, according to the CLSI criteria . The outcome measured was death within 28 days of the first positive blood culture, respectively.The data collected included information regarding demographics, underlying diseases, length of hospitalization, intensive care unit (ICU) admission, exposure to invasive procedure, antibiotic treatment, significant history of infection, immunosuppressive therapy in the 90 days prior to the date of BSI onset, microbiological data and patient outcomes.E. coli ATCC 25,922 and K. pneumoniae ATCC 700,603 were used as the the quality control strains for susceptibility testing.The strains were identified by the Vitek 2 system . The antibiotics susceptibility tests for the strains were examined by Gram-negative susceptibility (GNS) cards on the Vitek system . Susceptibility testing results were interpreted according to the criteria recommended by the Clinical and Laboratory Standards Institute . P value of < 0.05 were then selected into binary logistic regression model for multivariate analysis to evaluate risk factors of CRKP BSIs. Risk factors for 28-day KP-BSI mortality were analyzed by cox logistic regression. Multivariable analysis including binary logistic regression and cox logistic regression using Forward LR method. Survival analysis was examined by Kaplan–Meier survival analysis.Categorical variables are expressed in numbers and percentages. Continuous variables are showed as mean and standard deviation (SD)  or median and interquartile range (IQR) . Chi square test or Fisher’s exact test were used for comparing categorical variables. According to their distribution, Student’s test or Mann–Whitney U-test was analyzed for continuous variables. The results of univariate analysis were as follows: Odds ratio (or), 95% confidence interval (CI), and P value. Significant variables with P-value < 0.05 were considered statistically significant. All statistical analyses were performed using IBM SPSS 24.0 software.During all the statistical analysis, variables with P < 0.001).Among these 252 KP BSI inpatients, 29 (11.5%) KP isolates were carbapenem-resistant. The overall 28-day mortality rate of elderly patients with a KP BSI episode was 10.7% (27/252). It was significantly higher for patients with CRKP BSI  than patients with CSKP BSI   had at least one underlying disease, including hypertension (40.5%), previous bacterial infections (40.5%), solid organ tumors (37.3%), diabetes mellitus (27.0%), organ dysfunction (24.6%), septic shock 14.7%), hematologic malignancies (5.2%), and immunodeficiency (2.8%). Besides, 23.4% of these patients had been admitted to ICU department before BSI onset. The median duration of hospital stay before the onset of BSI was 6 days . The clinical and demographic characteristics of cohort patients with KP BSI isolates were shown in Table 4.7%, hemThe clinical characteristics of patients with CRKP BSIs and CSKP BSIs were compared in Table P < 0.001), exposure to carbapenems , and ICU stay .Further, our multivariate analysis summarizes independent risk factors for developing CRKP BSI versus CSKP BSI: hypertension , combination with other site infection , P < 0.001), sepsis shock , hospital stay , ICU stay before onset , infection with other pathogen, BSI onset in ICU , catheter , mechanical ventilation .The univariate analysis to identify potential risk factors for 28-day mortality of KP BSI include isolation of CRKP  and KP isolated in ICU   P < 0.001) . It was significantly higher for patients with CRKP BSI  than patients with CSKP BSI  . This mortality was lower compared with another study with 46.2% (48/104) .The mortThere were some limitations in this study. First of all, it was a retrospective study conducted in a single center, including 252 elderly patients. This may affect the ability to generalize the study results. Further large-scale prospective multicenter investigations are needed. Moreover, molecular characterization on the clinical isolates to examine the carbapenem resistance mechanisms was not performed in this study. To our knowledge, this is the first study in China to demonstrate the epidemiological characteristics of the risk factors and mortality of BSI caused by CRKP in the elderly for the last decade, which provides a useful basis for the diagnosis and treatment of KP BSI in the elderly.K. pneumoniae BSI in elderly patients in ICUs. Active screening of CRE for high-risk groups, especially for elderly patients, is conducive to the early identification, treatment and control of CRE infections, so as to achieve the successful management.In summary, hypertension, exposure to carbapenems and ICU stay were associated with the development of CRKP BSI in elderly patients. We also found a high mortality caused by


The connection between obesity, lipid accumulation, and lymph node metastasis (LNM) in gastric cancer (GC) is unclear.The association of body mass index (BMI) and serum lipid levels with LNM was measured by calculating the odds ratio (OR) and 95% confidence interval (CI) in 1,058 eligible GC patients with a mean age of 61.4 years. Meanwhile, differentially expressed genes (DEGs) were identified between lymph node metastasis-positive (N +) and -negative (N0) groups using public RNA-seq data. Neutral lipids in human GC samples were detected by Oil red O staining. The expression of cluster of differentiation 36 (CD36), fatty acid synthase (FASN), and lipoprotein lipase (LPL) was detected by immunohistochemistry (IHC) and quantitative real-time PCR.P > 0.05). Subgroup analysis suggested that increased low-density lipoprotein cholesterol was a risk factor in females . Functional enrichment analysis of DEGs revealed a connection between lipid metabolism and LNM. Meanwhile, lipid staining showed a mass of lipids in obese N + tumor samples, and IHC analysis indicated an increase in LPL and CD36 expression in N + cases, implying a crucial role for exogenous lipid supply in LNM.Compared with normal-weight patients, overweight  and obese  patients showed increased ORs for LNM. However, no significant results were obtained for serum lipids in the multivariable-adjusted model (High BMI significantly increases the risk of LNM in GC and promotes lipid accumulation in GC cells in LNM.The online version contains supplementary material available at 10.1186/s12944-022-01734-7. Gastric cancer (GC) is one of the deadliest malignancies, with an estimated 769,000 deaths worldwide in 2020 . In receObesity, as a state of nutrient excess, shows enhanced storage of lipids in adipose tissue and accumulation of serum lipids. Cancer cells experience lipid metabolic changes to fulfill the growing demand for lipids during metastasis . These lFatty acids (FAs) are the main component of lipids, and their acquisition in tumor cells is also achieved in two ways: de novo FA synthesis or exogenous supply . FASN, tIn this study, we investigated the associations of preoperative BMI and serum lipids with LNM in 1,058 GC patients. In addition, the existence of lipid accumulation and lipid metabolism abnormalities in LNM was identified.From December 2016 to June 2021, 1,422 primary GC patients were first enrolled in our study. All patients were treated with total, proximal, or distal D2 gastrectomy. The Ethics Committee of the First Affiliated Hospital of Nanjing Medical University approved this study.Patients were included if they had a histological diagnosis of gastric adenocarcinoma and complete information about BMI, serum lipid levels, and lymph node status. However, cases with the following conditions were excluded: 1) history of neoadjuvant or conversion therapy for GC before surgery; 2) gastric stump carcinoma; 3) history of other primary tumors; 4) usage of lipid-lowering agents; and 5) history of liver disease. Ultimately, 1,215 eligible GC patients were included. Given the impact of age and sex on obesity, we carried out 1:1 propensity score matching based on age and sex. Finally, this study included 1,058 patients.Pathologic data were collected, including depth of tumor invasion , tumor size (the longest diameter), lymph node status (positive or negative), tumor location , tumor grade , perineural invasion status, lymphovascular invasion status, number of examined lymph node status (ELN), and Lauren classification type . In addition, demographic data were also collected, such as age and sex.n = 40, < 18.5 kg/m2), normal weight , overweight , and obese  [In this study, preoperative BMI was calculated by dividing weight in kilograms by the square of height in meters. According to the WHO classification in Asia, BMI was grouped as follows: underweight (5 kg/m2) . Of noteAfter overnight fasting, preoperative venous blood samples were collected in the early morning. The profiles of serum lipids, including total cholesterol , triglycerides , high-density lipoprotein cholesterol , low-density lipoprotein cholesterol , and lipoprotein (a) (LP (a), mg/L), were measured by an automated analyzer using standard methods. Moreover, the TG/HDL-C ratio (THR) was also calculated . Lipids TCGAbiolinks, and relative clinicopathological features were retrieved from the cBioPortal program (n = 372) [n = 0); 2) missing information on nodal status (n = 17); and 3) had distant metastasis or unknown metastatic status (n = 38). We then identified DEGs between N0 (n = 103) and N + (n = 214) samples using the package DEseq2 in R software, with a cutoff value of |log2 fold change|> 1 and false discovery rate < 0.05. LNM-related DEGs were also detected in the GSE15459  and GSE84437  datasets using the R package limma. Volcano plot representation of DEGs was achieved by performing the R package ggplot2. Gene Ontology (GO) enrichment analyses were conducted using the R package clusterProfiler.RNA expression data of 375 GC patients from the TCGA database were downloaded using the R package n = 372) . HoweverWe collected tumor tissue and adjacent normal tissue from twenty-five GC patients who received radical gastrectomy at the First Affiliated Hospital of Nanjing Medical University. None of the patients received any treatment before surgery. Frozen sections of tissues were immediately subjected to lipid staining.Oil red O staining was performed according to the manufacturer’s protocol . In brief, tissue sections were incubated with staining wash solution for 20 s and then incubated with working solution at room temperature for 30 min. Then, nuclei were stained with hematoxylin for 3 min. The lipid droplets were visualized using a bright-field microscope .Then, quantitative RT‒PCR assays were performed according to previous procedures . The resImmunohistochemistry was conducted according to a previous protocol . AntibodP for interaction in subgroup analysis was obtained after the incorporation of two-factor interaction terms. SPSS version 22.0 and R version 4.1.3 were used to conduct all statistical analyses.Comparisons of baseline characteristics were conducted using the Pearson chi-squared test or unpaired Student’s t test. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using the logistic regression model. Before variables entered the model, we detected linear relationships between the continuous independent variables and the logit transformation value of the dependent variable using the Box-Tidwell method. Restricted cubic spline (RCS) analysis was applied to explore the nonlinear association between continuous BMI and lymph node status, with knots at equally spaced percentiles. P > 0.05). However, the N + group presented with higher BMI (P < 0.001) and lower levels of TC and HDL-C (P < 0.001) than the N0 group. Consistent with other literature [P < 0.001). In addition, the N + group showed a lower percentage of intestinal-type and more harvested lymph nodes .The case‒control study included 1,058 GC patients, with 529 cases with LNM and 529 controls without LNM. As summarized in Table terature , 33, the2, OR = 1.49, P = 0.008; obese vs. < 23 kg/m2, OR = 1.77, P < 0.001). Meanwhile, the OR for LNM in the comparison between the highest and lowest quartiles of TC was also significant . Compared with the first quartile, the fourth LP (a)  and THR  quartiles showed an increased risk of LNM. In contrast, the third and fourth quartiles of HDL-C showed a protective effect on LNM . However, in the multivariate-adjusted model, only BMI groups showed significant results: patients in the overweight  and obesity  groups were associated with a higher risk of LNM (P for trend = 0.006). Hence, these results indicated that BMI was an independent risk factor for LNM in GC.Table 2 increase = 1.43, 95% CI = 1.16–1.75) (Table P > 0.05). However, a marginal effect of BMI on LNM could be detected   and HDL-C  still showed a negative correlation with LNM while a high BMI indicated an increased risk of LNM  and in lower stomach tumors , while the association between LDL-C and LNM was only evident in females . Meanwhile, BMI was an independent risk factor in males , lower stomach tumors , and tumors with moderately to poorly differentiated grade .As continuous variables, LP (a), LDL-C, and BMI were associated with LNM in certain groups Table . Higher P < 0.05). Furthermore, the overweight group showed a higher risk of LNM in patients older than 65 years  or tumors located in the upper stomach . Meanwhile, we detected positive correlations between the obesity group and LNM risk in tumors with T1 or T2 stage  and tumors in the lower stomach . None of the P values for the interaction were statistically significant.The association between BMI groups and LNM risk also differed by age, sex, tumor location, grade, and T stage , and GO analysis of these DEGs showed the same CC enrichments as the TCGA cohort  . TherefoIn our case‒control study, BMI stratified by the WHO classification was an independent risk factor for LNM of GC. However, serum lipids did not show significant results in any of the cases during the multivariate analyses. GO analyses of three public sequencing databases showed concordant enrichment of DEGs in lipid metabolism-related modules. In addition, lipid accumulation and significant upregulation of LPL and CD36 expression were discerned in N + tumor tissue samples and obesity cases, further strengthening the association of lipid metabolism with LNM. Therefore, we believe that obesity, at least from BMI, is a risk factor for LNM and provides a lipogenic environment in GC.. showed that BMI was a protective factor against LNM [. found that decreased LNM was associated with high visceral obesity but not BMI [. did not show information about the underweight group and prediagnostic weight loss [. reported a mean harvested number of 38.4, and Zou et al. did not provide this value [n = 495 for the Park study, n = 323 for the Zou study), resulting in limited statistical power. Finally, various studies have proposed a link in tumor biology between obesity and cancer metastasis [. found that obese omental adipocytes increase DGAT2 expression and thus promote lipid droplet accumulation and redox balance in the peritoneal metastasis of GC [A positive association between high BMI and LNM risk has been detected in several cancer sites, such as the thyroid, breast, bladder, and prostate –38. Howeinst LNM . Park et not BMI . The abo not BMI . Regrettght loss . Anotherght loss . Park etis value , 40. In tastasis . The postastasis . Moreovetastasis , 46. In is of GC . OverallIn clinical practice, BMI is frequently employed to evaluate the degree of obesity . Intrigu. found that hypertriglyceridemia was an independent risk factor for nodal metastasis in men with early-stage gastric cancer, and Shen et al. demonstrated that a low level of HDL-C indicates a high risk of LNM in GC [Enhanced lipid synthesis, storage, and catabolism are features of tumorigenesis and disease progression . ObesityNM in GC , 53. In The greatest strength of our study was the comprehensive analysis of the relationship between obesity, lipid accumulation, and LNM in terms of epidemiology, histology, and molecular expression. Our study, based on the largest enrolled population as we know, first unraveled an accelerative role of high BMI on nodal metastasis of GC. On the other hand, our study explored a positive association between lipid accumulation and nodal metastasis, which histologically confirmed the role of high BMI in the lipid accumulation of nodal metastasis. In a way, we could think this study found a new characteristic of GC patients with LNM, lipid accumulation in primary cancer tissues. In addition, the high expression level of CD36 and LPL in N + samples further verified the importance of an exogenous supply of lipids in LNM, reflecting the impact of obesity on nodal metastasis in another way. However, several limitations in this study should not be neglected. First, this study was conducted based on retrospective information from one medical center, which might introduce selection biases and influence the results. Second, other obesity-related factors, such as body composition metrics, dietary habits, and prediagnostic weight loss, were not included in this study. Third, the sample size of the underweight group was relatively small, limiting our further analysis of the relationship between obesity and LNM . Fourth,This study revealed a positive correlation between preoperative BMI and LNM in GC. This conclusion emphasizes the value of BMI in predicting nodal metastasis and suggests that normal weight might be of benefit in preventing metastasis in certain cancers. In addition, the bioinformatic analysis and lipid staining in tissue samples further strengthened the involvement of lipid metabolism in the biology of LNM.Additional file 1: Figure S1. Detection of nonlinear relationships between BMI and lymph node metastasis. a Using the restricted cubic spine (RCS) function in the logistic regression model did not observe a nonlinear association between the BMI and lymph node metastasis risk. b RCS analysis with adjustment of sex, age, tumor location, grade, T stage, PNI, LVI, ELN, tumor size, and Lauren type. FigureS2. Bioinformatic analysis of the GSE84437 cohort. a Identification of DEGs between N0 and N+ patients in the GSE84437 cohort. b GO enrichment analysis of DEGs that were derived from the GSE84437 cohort.Additional file 2: Supplementary Table 1. Subgroup analysis for the association between categorized BMI and lymph node metastasis.


Venom immunotherapy (VIT) is an effective treatment in the patients at high risk of anaphylaxis or life-threatening systemic reactions due to Hymenoptera venom allergy. But, systemic and large local reactions can be observed, especially during the build-up phase of VIT. We evaluated the safety of conventional and ultra-rush build-up protocols.Two protocols in 71 patients  with honeybee and wasp venom allergy were evaluated retrospectively. Patients were diagnosed and selected for VIT according to the criteria established by the European Academy of Allergy and Clinical Immunology. The severity of systemic reactions was evaluated according to the criteria of Mueller.n = 47) without any reaction. Allergic adverse reactions were observed in 33.8% (n = 24): large local reactions 22.5% (n = 16) and systemic reactions 11.3% (n = 8). There was no significant difference in the number of adverse reactions comparing patients receiving conventional and ultra-rush protocol. In addition, no association was found between allergic adverse reactions and the following factors: sex, previous systemic sting reactions, honeybee and wasp venom extract.Build-up phases were tolerated in 66.2% (VIT is the only curative treatment method that reduces the risk of severe reactions after a bee sting and improves the quality of life in patients with Hymenoptera venom allergy.Ultra-rush VIT protocol has advantages such as few injection and time savings.Both ultra-rush and conventional VIT are safe treatments to prevent potentially life-threatening reactions in patients with honeybee and wasp venom allergy.We found that both protocols were tolerated in patients with honeybee and wasp venom allergy. Ultra-rush protocol will be preferred for patients and clinicians because of its advantages in terms of time and costs. Hymenoptera venom allergy (HVA) is an immunoglobulin E (IgE)-mediated disease and may present with clinical manifestations ranging from mild systemic reactions such as generalized cutaneous symptoms to severe systemic reactions such as cardiac or respiratory arrest . In epidVenom immunotherapy (VIT) is the only safe and effective curative treatment approach that reduces the risk of systemic reactions in patients with HVA. It is known that, in the general population, honeybee venom immunotherapy is effective in 77–84% of the patients, and wasp venom immunotherapy is effective in 91–96% . HoweverAlthough VIT is generally well tolerated by patients, adverse reactions such as large local reactions (LLR) and life-threatening systemic reactions (SR) can sometimes occur. These adverse reactions are usually IgE-mediated and are observed especially during the build-up phase , 8, 9. AThis study aims to compare the frequency and severity of adverse reactions during the build-up phases of conventional and ultra-rush VIT protocols.In this retrospective study, treatment cards and visits records of patients aged ≥18 years who received VIT in the Allergy and Clinical Immunology Unit of Gulhane Training and Research Hospital were evaluated through patient files. Patients receiving angiotensin-converting enzyme inhibitors and beta-blockers were switched to an alternative drug in all patients before VIT. This study was accomplished according to the guidelines of the Helsinki Declaration and verified by the Clinical Research Ethics Committee of Gulhane Training and Research Hospital, Ankara, Turkey .The previous systemic sting reaction evaluations of the patients were performed according to H.L. Mueller . In addiConventional and ultra-rush VIT protocols  were performed. Ultra-rush build-up phase of immunotherapy was performed with a venom dose of 0.1, 1, 10, 20, 30, 40 µg . The patient was seen again after 1 week (day 8) and given 50 µg in each of two injections and subsequently returned after 1 week (day 22) for an injection of 100 µg. Conventional protocol consisted of 17 injections (one weekly) with cumulative dose of 332.14 µg . In all VIT protocols, patients' intravenous lines were placed, and vital signs were recorded. Routine antihistamine and/or corticosteroid administration for pre-treatment was not performed. The purified aqueous preparations Alyostal  were administered during the ultra-rush protocol. Conventional protocol was performed with depot extracts Alutard SQ .All injections were administered subcutaneously to the mid-lateral or posterior region of the upper arm. Erythema and swelling ≥10 cm at the injection site were considered as large local reaction. Systemic reactions were evaluated according to H.L. Mueller . After tU test, Chi-square test, and Fisher’s Exact test were used to make univariate comparisons. Data were presented as mean ± standard deviation (SD), min.–max. values, frequencies, and percentages using 95% confidence limits. p-values <.05 were considered as statistically significant.Data were analyzed with the SPSS© v20.0 software . Distribution of the numerical variables were tested by the Kolmogorov–Smirnov test. Mann–Whitney n = 47) had no adverse reactions, while 22.5% (n = 16) had LLR and 11.3% (n = 8) had SR.Data of 71 participants were analyzed. Of the participants, 39 (54.9%) had received conventional VIT, and 32 (45.1%) ultra-rush VIT. Most participants  were observed on the first day. The presence of adverse reactions and adverse reaction subgroups LLR or SR were similarly distributed between the conventional and ultra-rush groups .n = 24) and 36.4 ± 12.3 (n = 47). There were no significant differences in the mean ages of participants with and without adverse reactions . The clinical characteristics of the patients who developed SRs during the build-up phase of VIT are presented in No significant differences were observed between the different groups from the perspective of adverse reactions . Furtherp = .722).In multicenter studies, the frequency of systemic reactions with VIT ranges from 8% to 20% ,8,13,14.p = .151).In our ultra-rush protocol, all adverse reactions (SR and LLR) were observed on the first day we reached a cumulative dose of 101.1 µg. Birnbaum et al. found the SR rate 11.1% during the build-up phase of the ultra-rush protocol, and the mostly of SRs were observed on the first day (cumulative dose of 101.1 µg) . Roll etThe vast majority of systemic reactions due to VIT are mild or moderate ,11–19. Ip = .111). In our study, ultra-rush was performed with a purified aqueous preparation, while conventional was performed with a depot extract. In general, purified aqueous preparations tend to cause more LLR than depot extracts [In our study, LLR occurred in 22.5% of patients. In addition, the rate of LLR was higher during the ultra-rush protocol than the conventional protocol . All LLRs were treated with topical corticosteroids and oral antihistamine.In the study conducted by Roll et al., the LLR rate was 5% during the build-up phase of the ultra-rush protocol . SimilarThe main limitations of our study were that it was retrospective and was conducted with a small group of patients. However, the majority of the studies in the literature investigating the adverse reactions of VIT seem to have similar limitations. Prospective studies with large patient groups are needed to determine possible risk factors for these adverse reactions that develop during VIT. Another limitation of our study was that basal serum tryptase levels were not measured at the time of beginning VIT. Therefore, it was not possible to reveal a possible relationship between adverse reactions and basal serum tryptase level.We found that rates of adverse reactions were similar between ultra-rush and conventional protocol. In addition, there was no difference in frequency and severity of adverse reactions between honeybee and wasp venom. The majority of adverse reactions were mild and responded easily to properly treatment. In the light of these data, ultra-rush immunotherapy protocol, with its many advantages, can serve as first-line treatment for honeybee or wasp immunotherapy.


The SARS-CoV-2 (COVID-19) pandemic continues to substantially alter previously established clinical practice patterns and has transformed patient care in American healthcare. However, studies to evaluate the impact of COVID-19 on neuroemergent patient care and associated clinical outcomes are limited. Herein, we describe the impact of COVID-19 on the Neuroemergency Transfer Program (NTP) - a novel, urban, high volume interhospital patient transfer program.To evaluate and describe the clinical impact of the COVID-19 pandemic on the NTP.A single-center retrospective study of prospectively collected consecutive neuroemergent patient transfer data between 2018–2021 was analyzed. Adult patients were divided based upon transfer date into a Pre-COVID (PCOV) or COVID cohort. Patient demographics, transfer characteristics and clinical data and outcomes were analyzed.p < 0.01). Total transfer time in the PCOV cohort was 155.1 ± 3.4 min which increased to 169.3 ± 12.8 min in the COVID cohort (p = 0.13). Overall mean transfer distance was significantly longer in the PCOV cohort at 22.0 ± 0.4 miles vs. 20.3 ± 0.67 miles in the COV cohort (p = 0.03). The relative frequency of transfer diagnoses was unchanged between cohorts. A significant increase in mean inpatient length of stay was noted, 7.9 ± 0.15 days to 9.6 ± 0.33 days in the PCOV vs. COVID cohorts (p < 0.01). Ultimately, no difference in the frequency of good vs. poor clinical outcome were noted between the PCOV (79.8% and 19.4%) vs. COV (78.8% and 20.4%) cohorts.3,096 patients were included for analysis. Mean age at transfer in the PCOV and COVID cohorts were 62.4 ± 0.36 and 61.1 ± 0.6 years. A significant decrease in mean transfers per month was observed between cohorts (PCOV = 97.8 vs. COV = 68.2 transfers/month, The impact of COVID-19 on current healthcare dynamics are far reaching. Here, we show a significant decrease in interhospital patient transfers and increased length of stay between a Pre-COVID and COVID cohort. Further work to better elucidate the specific interplay of clinical contributors to account for these changes is indicated. The SARS-CoV-2 (COVID-19) pandemic has substantially altered the traditional means of healthcare delivery in the United States. The direct and indirect effects and implications of the COVID-19 pandemic and related public health crisis brought to the forefront novel challenges in recent healthcare. The impact of COVID-19 on the acute care of patients with time-sensitive neurologic pathologies were likely far reaching. However, to date, a paucity of data to quantify changes in patients, pathologies and clinical outcome for those with neuroemergent diagnoses during the pandemic persists.Globally, as the number of patients hospitalized with COVID-19 increased, individual and collective healthcare systems were overwhelmed and established a clear need to prioritize and reorganize medical resources and healthcare personal. By April 2020, neurologists around the world were reallocated to care for patients with COVID-19, and neurology beds were reduced to better accommodate escalating volumes of COVID-19 patients .A similar response in the reorganization and reallocation of healthcare resources to escalating volumes of patients with COVID-19 was observed across the United States –6. One iIn response to the growing geographic discrepancy between neuroemergent patients and subspecialized providers, the Neuroemergent Transfer Program (NTP) was developed at Rush University Medical Center in Chicago, IL to streamline critical time-sensitive neurologic care. The initial overarching aim of the NTP was the development of a rapid urban interhospital transfer program for patients with acute neurologic emergencies. The NTP continues to achieve a high degree of success and since its inception in 2008 has increased annual transfer volume from 610 to 1,221 patients in 2018 . We are This is an IRB approved (IRB # 17112802), single academic center, retrospective study of prospectively collected data between January 2018 and February 2021. All consecutive interhospital patient transfers of adults ≥18 years of age and transferred via the NTP were accepted without prior screening of healthcare insurance coverage. For comparative analysis, patients were divided based on the date of transfer into two cohorts - a Pre-COVID (PCOV) and COVID. The PCOV and COVID groups were composed of patient transfers from 1/1/2018 to 12/31/2019 and 4/1/2020 to 2/28/2021, respectively.April 1, 2020 was selected as the initiation date for enrollment in the COVID cohort as this represented the month when elective surgery at our institution was discontinued and diagnostic laboratory methods for COVID-19 were widely available and used in Chicago, IL. Data from the period between 1/1/2020 to 3/30/2020 was excluded from the study.A multitude of patient demographics and clinical metrics were captured and include: age, gender, transfer volume, transfer time, transfer distance, transfer diagnosis, length of stay (LOS), and clinical outcome. Categorical determination of transfer diagnosis was based on the primary discharge diagnosis, as this reflected the most informed and accurate diagnosis. Total interhospital transfer time was defined as the interval between initial patient acceptance via phone and arrival at our institution. Total transfer distance was calculated as the shortest ground route to our institution from each individual referral center. Binary stratification of clinical outcome was performed based upon the discharge disposition. A “good” clinical outcome represented patient discharge to a skilled nursing facility, acute rehabilitation or home. Conversely, a “poor” clinical outcome represented patient discharge to a long-term acute care facility, hospice or death from any cause during the index admission.IBM, Version 22) using either a two-tailed T-test or chi-squared test with p < 0.05 establishing significance. Raw data is presented using descriptive statistics, continuous variables as means with ranges and categorical data as frequencies with percentages.Statistical analysis of continuous or categorical data was performed with SPSS  were included in the present study. The PCOV and COVID cohorts were composed of 2,347  and 749 , respectively. No significant differences in patient demographics were detected between cohorts .In the PCOV cohort, the most common transfer diagnoses included: 1. intracranial hemorrhage , 2. subdural hematoma , 3. ischemic stroke , 4. traumatic subarachnoid hemorrhage , 5. brain tumor (9.6%). In the COVID cohort, the most common transfer diagnoses included: 1. ICH (20.0%), 2. IS (14.0%), 3. tSAH (11.6%), 4. SDH (11.2%), 5. brain tumor (9.7%) . A totalp < 0.01). Transfer volume by month was compared between cohorts . In the p = 0.21), while mean transfer distance significantly decreased from 22.0 ± 0.4 miles in the PCOV cohort to 20.3 ± 0.67 miles in the COVID cohort (p = 0.03). Mean inpatient length of stay during the index admission was significantly increased from 7.9 ± 0.15 days in the PCOV cohort to 9.6 ± 0.33 days in the COVID cohort (p < 0.01). In total, 1,873 (79.8%) patients achieved a good outcome in the PCOV cohort as compared to 590 (78.8%) patients in the COVID cohort. Conversely, 455 (19.4%) vs. 153 (20.4%) poor outcomes were observed between the PCOV and COVID cohorts, respectively (p = 0.53). When comparing relative outcomes by month among the COVID cohort, the months of April and March 2020, as well as January 2021, contained the highest percentage of poor outcomes, (ranging from 27.1–31.7%), while August, November and December 2020 contained the lowest percentage of poor outcomes (ranging from 11.3–16.0%)  .The scope and impact of the COVID-19 pandemic on the presentation of patients and pathology, as well as the division and delivery of healthcare resources for patients with acute neurologic emergencies remains poorly characterized. Here, we evaluate and compare two temporal cohorts, a Pre-COVID and COVID group to better understand the implications and impact of the COVID-19 pandemic on the epidemiology of acute neurologic pathology in an urban setting.No definitive epidemiological census to delineate the beginning of the COVID-19 pandemic in the United States exists. However, the growing incidence of COVID-19 infections coupled with enhanced and widespread public health measures in Illinois prompted an unprecedented cessation of elective surgery at our institution on 4/1/2020. As such, this date was selected as the start of the COVID cohort. Moreover, to provide a washout period to represent a transitional period, data from 1/1/2020 to 3/30/2020 was excluded.In the present study, no significant difference in baseline patient demographics or characteristics were detected between the PCOV and COVID cohorts. The relative frequency of transfer diagnoses between cohorts were unchanged over the period studied. ICH and spine pathology represented the most and least frequent transfer diagnoses in both cohorts and is consistent with previously reported data  16). Th. Th16). This data demonstrates a significant decrease in the relative number of neuroemergent patient transfers between cohorts and, when stratified by transfer diagnoses, a similar trend in reduced transfer rate. The decreased volume of neurological emergencies is consistent with reports from health systems around the world - both in rural, low-impact and urban, high-impact regions –12, 21. The geographic distribution and number of referral institutions were evaluated to better understand alterations in patient referral patterns. The mean total distance traveled was significantly greater in the PCOV cohort. Additionally, during the first quarter of 2020 studied, a notable decrease in referral centers was observed . Taken tDespite the requirement of a rapid COVID-19 test for determination of infection prior to initiation of transfer, no significant increase in total patient transfer time was observed between cohorts. The relatively retained mean total transfer time may, in part, be explained by shorter mean total transfer distance. Furthermore, the time spent obtaining a COVID-19 test may have been balanced by the observed reduction of ground traffic in our urban environment . UltimatThe increase in mean length of stay may result, in part, from patients arriving “sicker” upon presentation. Patients that were hesitant to seek treatment early in the disease course may have waited until their condition got worse before ultimately reaching out to providers. Furthermore, facilities, such as nursing homes and rehabilitation centers, were heavily impacted during the height of the COVID-19 pandemic. Severe staff shortages, growing numbers of infected workers and patients, decreased funding, as well as system-level barriers to receive patients with confirmed COVID-19 infection or symptoms, all contributed to increased stress on post-acute care facilities –33. BecaImportantly, based on our binary system of good vs. poor outcomes, no statistically significant difference between our cohorts was noted. In terms of relative outcomes, the worst three months of the pandemic in terms of relative outcomes included April and March 2020 , as well as January 2021. Herein, the relatively high percentage of poor outcomes early in the pandemic correlates with the lowest transfer rates. A similar trend was noted in cases of ischemic stroke in Germany, where hospital admissions were lowest and patient outcomes poorest early in the pandemic before normalizing later as vaccination rate rose and health systems became more experienced with COVID-19 . This maOur data is limited in that it does not currently reflect long-term follow-up after discharge. Our binary system of good vs. poor outcomes does not elucidate true outcomes beyond their discharge disposition. Furthermore, our data only reflects patients that managed to enter the health care system. With decreased visits to emergency rooms reported worldwide, little is known about the potential patients who may have suffered from neurologic emergencies and chose not to seek care. In addition, our study only included an analysis of month-wise data during the pandemic, and there is no comparison of such data between cohorts. This serves as a limitation, as both interhospital transfer rates and patient outcomes tend to fluctuate throughout the year independent of the pandemic.Ultimately, these results demonstrate that even during a pandemic, in one of the most effected geographic regions of the United States, the patients studied did not suffer significant delays in interhospital transfer or worse outcomes. In this, the NTP has been proven efficient and effective in providing outstanding patient care, even during the most turbulent of times in healthcare.With the emergence of novel COVID-19 variants threatening to lead to surges in cases and prolong the pandemic , it woulThe impact of the COVID-19 pandemic on the current landscape and dynamics of healthcare are ongoing and far reaching. In this time of unprecedented alteration of healthcare delivery – both with respect to pathology and patients, we show a decreased volume of patients transferred to our hospital, increased length of stay, increased transfer distance and relatively unchanged transfer time and clinical outcomes. However, the specific relationship and/or interplay of contributing clinical factors between the severity of overall illness and constitutional health of patients, increased index hospitalization and clinical outcome remains to be fully characterized. Despite this, the impact of COVID-19 on neuroemergent patients and their clinical care remains unclear. Future work both to reduce the prevalence of COVID-19 and better understand the pathological mechanism and underpinnings of the diverse effects of COVID-19 on the neurological system are warranted.


To determine the difference in CT values and image quality of abdominal CT images reconstructed by filtered back-projection (FBP), hybrid iterative reconstruction (IR), and deep learning reconstruction (DLR).PubMed and Embase were systematically searched for articles regarding CT densitometry in the abdomen and the image reconstruction techniques FBP, hybrid IR, and DLR. Mean differences in CT values between reconstruction techniques were analyzed. A comparison between signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) of FBP, hybrid IR, and DLR was made. A comparison of diagnostic confidence between hybrid IR and DLR was made.p = 0.483, SD ± 0.902 HU). In the spleen, the mean difference between hybrid IR and DLR was − 0.099 HU . In the pancreas, the mean difference between hybrid IR and DLR was − 1.372 HU . In 14 articles, CNR was described. In all cases, DLR showed a significantly higher CNR. In 9 articles, SNR was described. In all cases but one, DLR showed a significantly higher SNR. In all cases, DLR showed a significantly higher diagnostic confidence.Sixteen articles were included, six being suitable for meta-analysis. In the liver, the mean difference between hybrid IR and DLR was − 0.633 HU , filtered back-projection (FBP), and hybrid iterative reconstruction (IR).DLR results in improved image quality in terms of SNR and CNR compared to FBP and hybrid IR images.DLR can thus be safely implemented in the clinical setting resulting in improved image quality without affecting CT values.The online version contains supplementary material available at 10.1007/s00330-021-08438-z. Computed tomography (CT) acquires images of tissues inside the human body. Photons, emitted by an X-ray tube, interact with human tissue and either get absorbed due to the photoelectric effect or get scattered due to Compton scattering. A fraction of the initial photon beam leaves the patient’s body and is detected on the opposite side of the CT X-ray tube. The ratio between the incident intensity and the emerging intensity is related to the attenuation coefficient, which forms a material-specific property. Hence, by reconstructing the attenuation coefficient for each voxel , imaging and identification of tissues can be carried out in a non-invasive way. However, since attenuation coefficients of various soft tissues have values close to each other, especially in the abdomen, the Hounsfield unit (HU) was introduced, which is a measure relative to the density of water. These CT values, expressed in HU, are calculated by the following formula:To reconstruct attenuation measurements by the CT scanner into HUs and display these in a comprehensible image suitable for clinical diagnosis, a method for iterative data reconstruction was proposed. This technique simulated the CT system, and based upon this model, it iteratively adjusted measured data for various factors influencing the attenuation measurements as e.g., estimated dose or noise effects. However, due to large amounts of data and the absence of sufficient computational power, iterative reconstruction (IR) was not competent for clinical practice .Instead, the less computational demanding, and hence much faster, reconstruction technique filtered back-projection (FBP) was introduced. This reconstruction technique has been the most used technique for decades, until the awareness of radiation-induced health effects, such as the formation of neoplasms, grew among society. Hence, a new reconstruction technique got introduced that allowed for low-dose CT measurements while maintaining image quality in terms of signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) . This reDeep learning reconstruction (DLR) uses this base of MBIR to further improve image quality. Deep learning is a subset of artificial intelligence and uses convolutional neural networks (CNNs) to learn from the input data itself. These CNNs are trained on high-quality labelled CT images and learn from unlabelled data in clinical settings just like radiologists are trained on the job. The CNNs can differentiate even better between noise and signal in comparison to FBP or hybrid IR, and therefore, even more dose reduction is possible while maintaining image quality and detail preservation . DLR tecThis systematic review and meta-analysis were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .PubMed and Embase databases were searched to find studies that describe the performance of one or more CT image reconstruction techniques. The following search terms were used: ) AND “Hounsfield Units” AND (“Filtered Back Projection” OR “Iterative Reconstruction”) AND  AND “Abdomen”. The complete search string is described in The titles and abstracts of all studies were independently and blindly screened by two researchers. If the two researchers did not agree about inclusion or exclusion, a final decision was made by a third researcher. Papers were excluded if the title clearly indicated that CT densitometry was not described.The exclusion criteria for abstract screening were as follows: (1) FBP, hybrid IR, or DLR were not described; (2) articles about segmentation; (3) not specified to the abdomen; (4) no densitometry described; and (5) full text not available in English or Dutch. The exclusion criteria for full-text eligibility were as follows: (1) no CT values, SNR, or CNR described and (2) no DLR on abdominal organs described.All included studies were assessed with a custom-made quality assessment (QA). The aspects of the QA scale were valuable for assessing quality to all authors. A score with a range of 0–18 was assigned to each study. Points were scored for the following aspects: (1) study design; (2) data collection; (3) samples; (4) statistical analysis; (5) funding; (6) material description; (7) DLR vs FBP/IR comparison; and (8) region of interest (ROI) description. This list also contains aspects of other QA scales for quantitative studies . A pointDescriptive data were extracted independently by two authors. An overview of differences in CT values, SNR, and CNR between reconstruction techniques was given. Study-specific variations were reported. Data on subjective image quality in the liver was extracted by one author. The average diagnostic confidence of hybrid IR and DLR of one vendor was assessed by two radiologists on a scale from 1 to 5, where 1 = unacceptable, 2 = suboptimal, 3 = acceptable, 4 = good, and 5 = excellent.Data of CT values were only extracted for the meta-analysis if the vendor was used in more than one included study. To rule out variations between vendor’s reconstruction algorithms, one meta-analysis per vendor was made. The mean and standard deviation of the CT values were extracted for all organs that were examined in multiple included articles. When images were reviewed by more than one radiologist, the data of the most experienced one were extracted. The mean difference was calculated by extracting the CT values reconstructed by DLR from the values reconstructed by hybrid IR.I2 statistics. Low heterogeneity was defined as I2 < 50%. The statistical significance was defined as p < 0.05. The results were summarized in forest plots.The data were analyzed using random effects (DerSimonian-Laird method) in OpenMeta[Analyst]  softwareThe search in PubMed and Embase resulted in 178 and 148 studies, respectively. After excluding duplicated articles, a total of 217 studies were obtained. Subsequently, all titles were screened, and 155 articles were excluded. After that, abstracts were screened, and 33 studies were excluded based on the pre-determined exclusion criteria. There were several studies excluded based on more than one criterium. As a result, a total of 28 studies were full text reviewed. Among them, 9 studies were excluded due to the lack of HU, SNR, or CNR as an outcome measure, and 3 studies excluded because no DLR on abdominal organs was described. Finally, 16 articles were included in the systematic review. Of these 16 –26, 6 arAll 16 articles were either retrospective or prospective studies. All included studies compared DLR to another reconstruction technique, either a hybrid IR technique, FBP, or both. In all studies, images were reconstructed with different techniques, while using the same raw image data. Table Per study the formula of CNR is shown in Table In all 6 studies, image quality was assessed independently by two radiologists blinded for image reconstruction. Slice thickness varied between 1.25 and 5.0 mm. ROI placement was linked for different reconstruction techniques in three of six articles.The results of the quality assessment are summarized in Table Kaga et al. and Park et al. showed a statistically significantly higher mean CT value in liver tissue in DLR than in hybrid IR , 22. HowAkagi et al.(2019), Li et al., Steuwe et al., and Wang et al.compared FBP to DLR , 24, 25.p = 0.007) in spleen tissue; other abdominal tissues were not significantly different between these reconstruction techniques. The average CT values for liver, spleen, and fat tissue obtained by the three reconstruction techniques  were within ± 0.3 HU (absolute difference) and ± 1.3% (relative difference) [p = 0.837) and 1.8 HU (p = 0.118), respectively) [Steuwe et al.described that DLR was significantly different in the comparison between DLR and IR (ference) . Zeng etctively) .The 14 articles that compared CNRs of DLR with CNRs of FBP or hybrid IR all showed a significantly higher CNR for DLR. While Wang et al.showed no significant difference in SNR between 50% DLR and hybrid IR in obese patients , all othSix articles showed CT values of GE Healthcare’s ASiR-V 30–50% (hybrid IR) and TrueFidelity (DLR) reconstruction techniques, so these papers were included in the meta-analysis –18, 21. p = 0.483, SD ± 0.902 HU)   .In the liver, the mean difference between hybrid IR and DLR was − 0.633 HU (p < 0.05) Cao et al. [p < 0.05) Jensen et al.[p < 0.0001) Kaga et al.[p < 0.002) Li et al.[p < 0.001) Noda et al.[Five of five studies that described diagnostic confidence in the liver showed significantly higher confidence of GE Healthcare’s DLR than hybrid IR, rated by experienced radiologists. Results on the five-point scale of the comparison of hybrid IR vs DLR were as follows:  [n = 2) [An important aspect of DLR is that its performance highly depends on the dataset used for training the algorithm. A heterogeneous dataset representative for all patients is required to prove accuracy for all patient groups. One study was found which was conducted in Europe . Other sn = 13) , 25, 26  [n = 2) , 23. In Hybrid IR data were used for our meta-analysis if the hybrid level was between 30 and 50%. This range represents the hybrid IR technique best. A higher level will result in a higher percentage model-based IR technique which was not the intended reconstruction technique.Differences between the studies included in the meta-analysis existed in methodology of image assessment. Slice thickness could affect SNR, CNR, and diagnostic confidence as increasing slice thickness results in lower noise levels. ROI shape and size were not similar and could also affect SNR, CNR, and diagnostic confidence.In all included studies –23, 26 ,PixelShine described by Steuwe et al.  is not dNo phantom studies were included in this systematic review because the phantoms lacked abdominal characteristics. Phantom studies can, however, be useful in determining the uniformity and validity of CT values of a single reconstruction technique. CT uniformity dictates that for scanning a uniform material, the mean CT value does not depend on the position within the image. This is important when evaluating the accuracy of a reconstruction technique. More research on uniformity and validity is needed for an even better comparison between reconstruction techniques. Phantom studies can also be used to determine whether variable tube currents or tube voltages affect CT values.In conclusion, this systematic review and meta-analysis identified no significant difference in CT values reconstructed by FBP, hybrid IR, and DLR in abdominal organs. This shows that these reconstruction techniques are consistent in reconstructing CT values and can thus be applied safely in the clinical setting. Also, DLR images showed a significantly higher CNR and SNR than FBP and hybrid IR images. However, there was a limited number of studies that described FBP, and the meta-analysis was only done with studies that described GE’s hybrid IR and DLR. Therefore, more research is needed to determine whether the same conclusion is true for the comparison between FBP and DLR and other CT vendors.Supplementary file1 (DOCX 26 KB)Below is the link to the electronic supplementary material.


The study was aimed at exploring the potential predictive factors associated with the recurrence of macular edema (ME) secondary to vein occlusion (RVO) after intravitreal antivascular endothelial growth factor (VEGF) loading treatment in the FALCON study.  This is a post hoc analysis of 30 patients with central RVO and 30 patients with branch RVO. All patients received a monthly administration of intravitreal conbercept during the 3-month loading phase and pro re nata (PRN) treatment during the 6-month follow-up period. Based on the recurrence of ME at the first follow-up visit, patients were classified into the recurrence group or nonrecurrence group. The primary endpoint was to explore the risk factors for recurrence among baseline characteristics, fluorescein angiography (FA) patterns, and optical coherence tomography (OCT). p = 0.32). Significant improvements in VA were noted in both the nonrecurrence and recurrence groups (p < 0.001), however, without significant between-group differences (p = 0.1). A significant reduction in CRT in both groups (p < 0.001) was identified, and patients without recurrence showed a greater reduction in CRT compared with those with recurrence (p < 0.001). In addition, logistic regression analyses indicated the corrections of ME recurrence with baseline macular volume and the disruption of the outer limiting membrane at the fovea.  In general, 38 patients (64.4%) experienced ME recurrence at the first follow-up visit (3 months), regardless of disease type ( This study suggested that OCT parameters, including baseline macular volume and outer limiting membrane disruption, and reduction in CRT after loading therapy were more predictive of ME recurrence than FA patterns or visual changes following conbercept loading therapy. Retinal vein occlusion (RVO) obstructs the retinal veins  and is tME is visible on the fundus as increased macular thickness, fluid, or exudates. Fluorescein angiography (FA) can reveal vascular leakage and filling of cystic spaces , 10. HowConbercept  is a recombinant fusion protein composed of the extracellular domain 2 of VEGF receptor 1 (VEGFR1) and extracellular domains 3 and 4 of VEGFR2 to the constant region (Fc) of human immunoglobulin G1. This drug binds specifically to various isoforms of VEGF-A, VEGF-B, and placental growth factors . PreviouAlthough the efficacy and safety of conbercept were identified previously, there is a lack of investigations on the prognostic factors of ME recurrence after administration of intravitreal anti-VEGF. Thus, we conducted this study to evaluate the association between baseline characteristics, FA patterns, and OCT parameters on ME recurrence after treatment with three consecutive loading doses of conbercept.NCT01809236) [The data used in this post hoc analysis were obtained during the FALCON study (1809236) . It was μm as measured by spectral-domain OCT . We defined CRVO as an RVO involving four retinal quadrants and BRVO by retinal hemorrhages or other biomicroscopic evidence of RVO and a dilated venous system in two or fewer quadrants of the retina drained by the affected vein. One eye per individual was included in this study.The inclusion criteria were as follows: (1) patients were aged 18 years or older; (2) patients had central ME secondary to BRVO or CRVO that had occurred within the past six months; and (3) those had a best-corrected visual acuity (BCVA) of ≤73 Early Treatment Diabetic Retinopathy Study (ETDRS) letters  and a CRT of ≥320 The exclusion criteria included a relative afferent pupillary defect, prior vitreoretinal surgery, intravitreal anti-VEGF (including but not limited to ranibizumab or bevacizumab) in the study eye within the past six months or in the fellow eye within the past three months, systemic treatment of any anti-VEGF within six months, intraocular or periocular steroid treatment in the study eye within the past three months or systemic steroids within the past one month, reductions in visual acuity from any causes other than RVO, ocular inflammation in either eye, uncontrolled glaucoma (intraocular pressure > 25 mmHg or history of filtration surgery), or treatments using scatter or pan-retinal laser, macular grid laser, or sector laser in the study eye.μm as compared with the lowest measured value; a loss of ≥5 ETDRS letters compared with the most recent measurement; the presence of new or persistent cystic retinal changes, subretinal fluid (SRF), or neuroepithelial detachment; or the presence of new macular hemorrhage, retinal neovascularization, or any new BRVO received subsequent injections as needed .A total of 60 patients from the FALCON study in the current research, including 30 ones with BRVO and 30 ones with CRVO. All patients received an administration of intravitreal conbercept (0.5 mg) every month during the loading phase of 3 months. After the loading phase, all patients were followed up monthly for six months. Patients with an increase in CRT by ≥50 The total follow-up time was up to 9 months. Based on the recurrence of ME at the first follow-up visit, all patients were classified into the recurrence group or nonrecurrence group. The primary outcomes were differences between the two groups and risk factors for recurrence among baseline characteristics, FA patterns, and OCT parameters.μm compared with baseline at 3 and 9 months after treatment, and changes in macular edema volume compared with baseline at all visits (months 1-9). (6) Findings of fluorescence angiography  include foveal avascular zone contours, nonperfusion area (NPA), and macular hemorrhage. We assessed BCVA following the ETDRS protocol [We recorded the following data at baseline: (1) demographics; (2) BCVA; (3) intraocular pressure; (4) findings of fundus photography including bleeding and hard exudation in the macular area ; and (5) OCT  including CRT, macular volume (MV), ellipsoid zone (EZ), outer limiting membrane (OLM), disorganization of inner retinal layers (DRIL), SRF, and intraretinal fluid; OCT was measured by mean changes in foveal retinal thickness at all visits (1-9 months) compared with baseline, percentage of subjects with foveal retinal thickness ≤ 250 protocol . Data wep value less than 0.3 were included in a binary backward stepwise logistic regression model. We excluded insignificant predictor variables if the Akaike information criterion of the model including this variable was higher when the predictor was not included.All data were analyzed using R software (version 3.20). Continuous variables are presented as medians with interquartile range (IQR). Person count and percentages describe categorical variables. We compared the baseline ocular characteristics between the two groups, and those characteristics with a p value of <0.05 was considered statistically significant.To compare visual acuity and CRT changes between the two groups, we used repeated-measurement analysis of variance and calculated the odds ratio (OR) and its 95% confidence interval (CI). All statistical tests were two-sided. A Among the study subjects, the mean age was 56.7 years, and 33 (55.0%) were male while 30 were diagnosed with CRVO and 30 with BRVO. The median time to onset of disease was 3 months . Over the 9 months, the total mean number of injections was 7.59 ± 1.39 for CRVO and 7.14 ± 1.90 for BRVO.p = 0.02), a higher CRT , a larger MV , a smaller area of macular NPA (p = 0.0007), a lowerr proportion of macular hemorrhage , and a higher proportion of cystoid macular edema . The vision changes between male and female were without statistical difference . Neither was found in CRT changes .One patient with CRVO was lost to follow-up one month after the loading phase and was, therefore, not included in the subsequent analysis. When we compared the baseline BCVA to that at the first follow-up visit, we considered a gain of ≥15 ETDRS letters from baseline as an improvement, <15 letters as vision maintenance, and a loss of ≥15 ETDRS letters as a worsening disease. Among the patients with CRVO, 12 eyes (41.38%) showed improvement, 16 (55.17%) eyes showed no change, and 1 (3.35%) eye worsened. Among those with BRVO, 17 (56.67%) eyes improved, 13 (43.33%) eyes showed no change, and no eyes worsened. No statistically significant differences were found between the two groups in vision changes. After the loading phase, changes in CRT from baseline were greater for patients with CRVO than for those with BRVO (−339.0 p = 0.32). Among the patients who received redosing, the BCVA at baseline, last examination during the loading phase, and first follow-up visit were 57 letters , 72 letters , and 74 letters , respectively. For those who had not yet needed additional injections, the BCVA at baseline, last examination during the loading phase, and first follow-up visit were 59 letters , 69 letters , and 71.5 letters , respectively. However, there were significant improvements in vision in both groups (p < 0.001) and no significant differences among groups , 329 μm , and 288.5 μm , respectively. For those who did not yet require additional injections, the CRT at baseline, last examination during the loading phase, and first follow-up visit were 573.0 μm , 245 μm , and 244 μm , respectively.After the loading phase, 38 patients (63.3%) experienced ME recurrence and required redosing at the first visit after the loading phase. Among these, 17 patients (56.7%) had BRVO and 21 (70%) had CRVO, and the recurrence was independent of disease type . We detected no significant association between ME recurrence and FA patterns, including irregular FAZ contours, NPA, or macular hemorrhage , we used the baseline MV instead of the CRT as the independent variable in the multinomial regression analyses to determine the correlations with ME recurrence. These factors were subjected to logistic regression analysis. In this model, the Akaike information criterion was 68.5, and the area under the curve was 0.789  and−453 μm (0.5 mg) in CRVO patients and −339 μm (0.3 mg) and −345 μm (0.5 mg) in BRVO patients, respectively [μm at 3 months. Our study found a significant reduction in CRT and an improvement in VA in both groups after the loading phase. At the first follow-up visit, changes in CRT from baseline were −339.0 μm in CRVO patients and −274.5 μm in BRVO patients. Concomitantly, a VA gain of ≥15 ETDRS letters was achieved in 41.38% of patients with CRVO and in 56.67% of patients with BRVO.OCT is one of the most common imaging modalities for assessing the efficacy of therapeutics in ME secondary to RVO . The CRUectively , 24. In ectively . In partp = 0.07) in our study, patients without recurrence had a greater reduction in CRT than those with recurrence after loading therapy (p < 0.001). Moreover, logistic regression analysis showed that the baseline MV significantly correlated with ME recurrence at the first visit after the loading phase. Because MV is a more comprehensive ME indicator than CRT especially for the perifoveal regions, MV can be adopted as a prognostic factor for ME secondary to RVO. In addition, because we established a linear correlation between CRT and MV in this study, CRT could be a confounding variable to MV in ME prognosis. Notably, for subanalysis, no significant differences were identified between genders.Several studies have investigated the OCT parameters related to ME recurrence. For example, in eyes with BRVO, cystic macular changes and DRIL with ME recurrence were identified –28. AlthIn addition to measuring the central foveal thickening of the macula edema, the OCT system allows the microretinal structures to be visualized, including the OLM and EZ. In particular, previous studies identified the correction of disruption in the OLM with poor visual prognosis after RVO treatment –32. HoweClinically, FA remains an essential tool for detecting morphologic changes in the retinal vasculature and provides a functional evaluation of the extent of macular ischemia, vascular leakage, and neovascularization . As repoThe WAVE study revealed a relationship between retinal ischemia and ME severity, as reflected by central macular thickness . In addiHowever, this study has several inherent limitations, such as a small cohort size, a lack of long-term data to rule out the possibility of MV remission after four injections, and a lack of systemic collection of baseline characteristics. All of these factors may result in biases and affect the power and significance of the findings. In the future, long-term prospective cohort studies should be conducted to validate the findings and may obtain more study insights.This study suggests that OCT parameters are more predictive of ME recurrence than FA patterns or visual changes after conbercept loading therapy. Significantly, baseline MV, OLM disruption, and reduction in CRT after anti-VEGF loading therapy could be valuable tools in clinical practice for predicting future recurrence in patients with RVO-related ME.