Objective: The COVID-19 global pandemic has created severe, long-lasting challenges to college students in the United States (US). In the present study, we assessed mental health symptomatology , academic challenges, and economic stress during the first wave of the Coronavirus pandemic. Method: A total sample of 361 college students  was gathered from a community college (N = 134) and mid-size public university (N = 227) in Southwest US, both designated as Hispanic Serving Institutions. Results: Pearson and point biserial correlations indicated associations between mental health symptomatology, academic challenges, and economic stress, including expected delays in graduation. Multivariate analysis revealed that community college students had statistically significantly higher scores on anxiety F = 5.27, p = .02, 2  = 28.56, p = .00) than other ethnic/racial groups. Conclusions/Contributions: Findings revealed that community college students faced disparately negative mental health symptomatology, academic challenges, and economic stress during the first wave of the Coronavirus pandemic. Further, Latinx students’ families experienced significant economic hardship that may have impacted students’ academic progress and future planning. The COVID-19 global pandemic upended higher education institutions, forcing many campuses to temporarily close and placing many undergraduate students in the precarious position of not knowing what the future holds. A key response to COVID-19 was the implementation of widespread shelter-in-place orders to slow the spread of the virus, inadvertently increasing social isolation for many students for whom social and academic networks on campus are integral to their mental and academic health. In the general US population, COVID-19 demonstrated unprecedented detrimental effects on stress, anxiety, and loneliness . Among cThe disparate effect of COVID-19 among ethno-racial minority and community college students is an important area of research that only just begun to emerge. Across the US, Latinxs, and African Americans have been disparately negatively affected by COVID-19 contraction, hospitalization, and death  in additAs the pandemic continues to unfold, infection, hospitalization, and mortality rates continue to climb as new variants spread across the US. It remains unclear how COVID-19 will continue to impact US higher education systems in the years to come. It is therefore critical to understand how pandemic conditions, including at the onset of city and statewide mandates, influence college students’ mental health as well as their academic and economic demands.COVID-19 has been shown to have significant mental health effects on college students. The COVID-19 global pandemic brought extreme changes to everyday functioning and socialization. Reports indicated that 52% of young adults moved in with family members for cohabitation during the extended lockdowns , with thGiven the limited known effects of COVID-19 among college students at the time of this study, the present study’s hypotheses were exploratory in nature. Consistent with California and national trends, our first hypothesis was that Latinx students would report higher rates of negative economic and mental health symptomatology than their ethno-racial peers during the first wave of the pandemic, which was defined as the beginning of the first pandemic lock-down in March of 2020 . While tThe goal of the present study was to assess mental health symptomatology, academic challenges, and economic stressors among college students during the first wave of the Coronavirus pandemic. Participants were sampled from a community college (36.8%) and mid-size public university (63.2%) in Southern California. Data were collected between May 20 and May 30, 2020. The survey was closed on May 30, 2020 at the start of protests in Southern California in response to the death of George Floyd. It is important to note that shelter-in-place began on March 19, 2020 in California . Thus, tUpon securing IRB approval, participants were recruited from a community college and a mid-size public university in Southern California, both designated as Hispanic Serving Institutions. Recruitment advertisements were sent out by the research team to department listservs, student groups, and an online network of community college counselors in Southern California. The recruitment flyer detailed the participation criteria as anyone who was a college student and 18 years of age or older in Southern California. Participants were given the opportunity to join a lottery to win a $20 Amazon gift card for participation in the study.The aim of the present study was to recruit a diverse sample of college students in Southern California. Recruitment solely occurred in Southern California given the unique socio-economic and racial-ethnic composition of the region. In 2019, prior to the start of Coronavirus, the median household income in Los Angeles was $68,044 and Latinxs comprised 48.6% of the population.M = 22.26, SD = 5.56) with 36.8% enrolled in a community college and 63.2% enrolled in a 4-year public university. Community college students were an average of 23 years old, while four-year university students were 21 years old. The majority of the sample identified as cisgender women (67.3%). In terms of race and ethnicity, 36.3% of the sample identified as Latinx, 28% as White, 18% as Asian American, 8.3% as Multiracial, 6.1% as Other unspecified, and 3.3% as African American.On average, participants were 22 years old  were collapsed into a single “Other Underrepresented Minority (URM)” as a means to retain them in the study since respective number of participants per group was too small to permit individual analyses. Together, Other URM students comprised 17.7% of the sample.Related to sexual orientation, 79.5% of participants identified as heterosexual, 8% as queer, pansexual or other, 7.8% as bisexual, and 4.7% as gay/lesbian. With respect to economic standing, 77% of participants reported a family income that fell under the California poverty line . We also developed measures specific to academic and technology challenges and economic stressors that were linked to COVID-19 and consequent shelter-in-place mandates. Participants were administered a single instrument containing these measures.The demographic section of the questionnaire included items about age, race and ethnicity, gender identity, sexual orientation, school of attendance, education level, health insurance status, economic stressors, and healthcare access. Participants were also asked whether their employment and that of their family members was impacted by COVID-19.Depressive symptomatology was measured using the Center for Epidemiologic Studies Depression Scale Revised-10  scale . The GADLife stress was measured using the Stress in Context (SIC) scale . The SICAcademic challenges were assessed by asking participants whether online classes impacted their ability to succeed, if they anticipated graduation delays, and their access to technology and internet as a result of COVID-19. Specifically, we asked, “How has the switch to online classes affected your ability to succeed in school?” Participants responded to one of two options that included, 1 = “It’s difficult for me to complete assignments” and 2 = “I haven’t had any difficulties.” We also asked, “Has COVID-19 impacted your graduation plans?” with two response options being 1 = “No,” and 2 = “Yes.” With respect to technology issues, we asked participants: “Have you faced any challenges with technology or the internet?” Participants responded to one of three options: 1 = “No, I have not faced any challenges, 2 = “Yes, I sometimes don’t have access to a computer,” and 3 = “Yes, I sometimes don’t have reliable internet.”Economic stress was measured through a series of questions regarding how COVID-19 affected participants’ own employment and their family’s employment status. The following questions were posed to participants. “Are you currently employed?,” to which participants could respond either 1 = “No” or 2 = “Yes.” Two additional questions specifically focused on the effects of COVID-19 on employment; “Have you lost your job, or had hours reduced due to COVID-19?” and “Has someone in your family lost their job or had hours reduced due to COVID-19?.” Participants were able to choose one of three responses: 1 = “No,” 2 = “Yes, I have lost my job ,” and (3) “Yes, my hours were reduced .”Qualtrics.com. Each participant created an original username. Following completion of the survey, participants had the option of emailing their username to the study team’s email address provided at the end of the survey to be entered into a drawing to win a $20 Amazon gift card. A total of 533 responses were initially collected and a final sample of 361 was retained. Participant data were not retained if there was more than 20% missing data , anxiety , and life stress  demonstrated that normalcy assumptions were met. Scores between −2.0 and 2.0 were considered to be within acceptable bounds for skewness while scores of −7.0 and 7.0 were within acceptable bounds for kurtosis . Next, wM = 14.37, SD = 6.31), on average scoring higher than the suggested cut off of 10 points for symptomatic depression  met the criteria for mild to moderate symptomatic anxiety , White (N = 101), Asian American (N = 65), and Other URM (N = 64). Box’s Test of Equality of Covariance Matrices indicated that groups were not significantly different from each other (p = .59), meeting normality assumptions. Multivariate tests showed non-significant effects by race/ethnicity  = 1.62, p = .078, A one-way MANOVA was conducted to examine differences in reported symptomatology in the areas of depression, anxiety, and life stress between ethno-racial groups. Categories were: Latinx  = 4.84, p = .001, F = 5.27, p = .022, A one-way MANOVA was conducted to examine differences across depression, anxiety, and life stress by college type see . Multiva2 = 6.34, p = .10). Across the board, the switch to online learning appeared to negatively affect all students. In fact, a large majority of Asian American (83.1%) and Hispanic/Latinx (80.2%) respondents reported inability to succeed in school, followed by 75% of Other URM students and 68.3% of White students. A Chi-Square test of independence was also conducted to test the relationship between race/ethnicity and expected delay in graduation. The relationship was not significant  = 6.84, p = .08). Results showed that Latinx students reported the highest rate of expected delay in graduation (35.9%) followed by students in the Other URM category (34.4%), White students (28.7%), and Asian American students (18.5%).A Chi-Square test of independence was conducted to test the relationship between race/ethnicity and whether the switch to online learning impacted students’ ability to succeed in school. The relationship was not significant  =6.32, p = .10). Most respondents indicated having access to a computer with highest access among White students (97%) followed by Asian American students (93.8%), Other URM students (87.5%) and Latinx students (88.5%). A Chi-Square test of independence also revealed no significant relation between race/ethnicity and lacking consistent access to the internet  = 7.35, p = .06). The highest rate of lacking access was experienced by Other URM students (57.8%) followed by Latinx students (53.4%), White students (43.6%), and Asian American students (40%).A Chi-Square test of independence revealed no significant relation between race/ethnicity and access to a computer  = 28.56, p = .00). Findings demonstrated that Latinx students’ families experienced the highest employment impacts with 84.4% reporting job loss and/or reduced hours. Next, 75% of Other URM students reported job loss and/or reduced hours followed by 57.4% of White and 55.4% of Asian American respondents. A Chi-Square test of independence was also conducted to test the relationship between race/ethnicity and personal job loss and/or reduction in work hours. The relationship was not significant  = 7.48, p = .06). The highest rates of personal job loss and/or reduction in work hours was experienced by Other URM students (48.4%) followed by Latinx students (44.3%), White students (36.6%), and Asian American students (27.7%).A Chi-Square test of independence was conducted to test the relationship between race/ethnicity and family job loss and/or reduction in work hours see . The rel2 = 6.34, p = .10). A high proportion of both groups reported negative impacts; 78.9% of community college students and 76.8% of 4-year university students. A Chi-Square test of independence was also conducted to test the relationship between college type and expected delay in graduation. The relationship was significant  = 6.88, p = .01). Results showed that 39.7% of community college students reported a delay in graduation plans compared to 25.9% of 4-year university students. Thus, community college students were 1.9 times more likely to report a delay in graduation plans.A Chi-Square test of independence was conducted to test the relationship between college type and whether the switch to online learning impacted students’ ability to succeed in school. The relationship was not significant  = 3.34, p = .07). However, findings revealed that 11.2% of community college students had no access to a computer, contrasted to 5.7% of 4-year university students. A Chi-Square test of independence also revealed no significant relation between college type and lacking consistent access to the internet  = 2.33, p = .13). That said, a greater proportion of community college students reported trouble accessing the internet (54.3%) compared to 4-year university students (45.6%).A Chi-Square test of independence revealed no significant relation between college type and access to a computer  = 28.11, p = .00). Findings showed that 87.9% of community college students reported that a family member had lost their job or had their hours reduced compared to 60.1% of 4-year university students. A Chi-Square test of independence was also conducted to test the relationship between college type and personal job loss and/or reduction in work hours. The relationship was significant  = 8.41, p = .00). Findings showed that 50.9% of community college students reported that they themselves had lost their job or had their hours reduced compared to 34.6% of 4-year university students.A Chi-Square test of independence was conducted to test the relationship between college type and family job loss and/or reduction in work hours. The relationship was significant . While recent pre-Coronavirus national data suggested an increase of mental health challenges, with 14% to 23% of students reporting symptoms of depression Active Minds, 2020), 73% of participants in the present study reported depressive symptomatology and 46.3% reported anxiety symptomatology in response to COVID-19. The higher rates of depressive and anxious symptomatology revealed within the presented study confirm other college student COVID-19 mental health research findings , 73% of .A key goal of the present study was to examine group differences in the presentation of mental health symptomatology, academic challenges, and economic stressors by race/ethnicity and college type (4-year university vs. community college). Our findings demonstrated no statistically significant differences in mental health symptomatology by race/ethnicity. Rather, students across the board reported high levels of depression and anxiety symptomatology. With respect to other group differences, data revealed that a higher proportion of Latinx and Other URM students reported having family members lose their jobs and/or face a reduction in work hours than Asian American and White students. These data confirm national trends of economic stress among Latinx workers .At the time of our study few extant studies of COVID-19 among college students had sampled community college students. In the current study, community college students reported statistically significantly higher scores on measures of anxiety than 4-year university students. Community college students already contend with a shortage in mental health resources with many campuses facing stark cuts to their mental health services prior to COVID-19 . It is tA key finding in our study was that a greater proportion of community college students anticipated a delay in their graduation plans. In October 2020, US Census data  showed tThe current study demonstrated several noteworthy methodological strengths and contributions. This study is novel in that it contributes to a limited body of work focused on the experiences of community college students during the COVID-19 shelter-in-place order. While this demographic was not the sole focus of the study, the representation of community college students in the sample allowed for a closer examination into the needs of these students and how they might differ from those at 4-year institutions. The use of Hispanic Serving Institutions in participant recruitment afforded greater inclusion and diversity compared to other convenience sampling methods. This study’s sample closely reflects the racial-ethnic student composition of the community colleges and 4-year institutions where recruitment occurred.Another strength of our study was that the background demographic survey questions were intentionally developed to allow for a diverse representation of our participants’ experiences related to COVID-19. Specifically, we developed items related to academic challenges and economic stress specific to COVID-19, capturing the immediate impact of shelter-in-place on students and their families.This study also included several limitations important to consider. A cross-sectional design was used which means that causal claims were unable to be made. A longitudinal study would provide additional information about the long-term effects of COVID-19 and the associated stay-at-home orders. Additionally, our sample was comprised of a low number of Multiracial and African American respondents, and zero respondents that self-identified as Native American. Preliminary analysis was run on the key mental health scores to ensure no statistically significant differences existed between these groups, thus allowing their resulting placement into an “Other URM” category. However, collapsing ethnic/racial groups into an “Other URM” category likely obfuscated important group differences. Finally, the George Floyd protests across the United States that began May 26, 2020 may have posed a potential confounding factor to measures of anxiety, depression, and life stress. While recruitment closed prior to protests reaching Southern California, we would be remiss if we did not acknowledge that national media attention, including social media, may have impacted students’ mental health symptomatology.Several recommendations for academia and clinical practice follow from the present study findings. First, higher education institutions should consider that particular student groups may experience disparate challenges navigating the effects of the ongoing pandemic see . In the The California Work Opportunities and Responsibility to Kids , which provide financial support via books, tuition and in some cases, housing assistance and health insurance for student parents.As demonstrated by our findings, it is possible that while certain academic institutions have attempted to accommodate the technological needs of their students during the COVID-19 pandemic see , informaThe study findings on mental health symptomology amidst COVID-19 suggest implications for university and community college counselors and clinicians. University and community college counselors and clinicians should be increasingly conscious of co-occurring symptoms of comorbidities  among students as this may impact potential treatment(s). Students reported heightened symptomatology in the areas of depression, anxiety, and life stress with some of these symptoms more pronounced among Latinx and Other URM students. As such, university counselors and clinicians should consider the role of each student’s unique cultural background given ongoing disparities in California and nationally. In regard to additional support resources for community college students, counselors, and clinicians can help students connect with outside providers and organizations that provide services at no or reduced cost. This includes non-profits, community clinics, and online supports like CalHOPE, which provides crisis counseling during national emergencies AACC, .Results from the present study demonstrate that more research is needed to examine the unique effect of the COVID-19 pandemic on the mental health of students, with clear disparities affecting community college students. To explore key within-group differences of the impact of COVID-19, researchers should collect qualitative data via individual interviews and/or focus groups. These data would be key to developing tailored interventions that account for the long-term and differential impact of COVID-19 across unique student populations.


Ultraviolet radiation (UVR) exposure is commonly reported as a risk factor for Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). However, minimal evaluation of photo-induced SJS/TEN has been conducted. Thus, this review identifies all cases of SJS/TEN that are linked to an acute exposure of UVR and outlines the unifying characteristics of these cases. Furthermore, the theoretical pathogenesis, differential diagnoses, and proposed diagnostic criteria are defined.PubMed, Google Scholar, and other databases and websites were searched from inception to September 2021 to identify studies that met inclusion criteria. The following keywords were utilized: “Stevens-Johnson syndrome” and “toxic epidermal necrolysis” with “ultraviolet,” “photodistributed,” “photo-induced,” “photosensitivity,” and “photo.” One reviewer assessed study characteristics, with confirmation by a second. The risk of bias was assessed independently by another.Thirteen patient cases were identified, all reporting ultraviolet radiation prior to rash onset and an underlying causal drug. Case classifications included 7/13 SJS and 6/13 TEN. All cases described the rash as photodistributed with UVR exposure prior to rash onset (delay of 1–3 days) and a causal drug. 10 cases provided evidence that the photodistributed rash lacked linear demarcation (as in a sunburn) with satellite target-like lesions. No cases described a flu-like prodrome.Mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish from photosensitive reactions, while a negative direct immunofluorescence test is important to distinguish from other photo-induced disorders.Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. After a 24-h delay from UVR exposure, a non-distinct, photodistributed rash appears with no flu-like prodrome and progresses for at least 48 h to include vesiculobullous eruptions and mucous membrane involvement. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.The online version contains supplementary material available at 10.1186/s40001-023-01142-2. Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare cutaneous reactions with epidermal necrosis, vesiculobullous formation, epidermal detachment, and mucous membrane involvement. The classification is determined by the percentage of body surface area (BSA) with epidermal detachment: SJS  < 10%, SJS/TEN overlap 10–30%, and TEN  > 30 .Adverse drug reactions are the most common causes of SJS/TEN with over 100 drugs recognized as causative agents . UltraviThe purpose of this review is to identify all cases of SJS/TEN that are linked to UVR and outline the unifying characteristics of these cases while comparing and contrasting the findings with traditional SJS/TEN cases –3. This It is important for physicians to recognize the distinguishing factors of photodistributed SJS/TEN as many conditions present similarly, such as photosensitivity reactions, that generally do not require intensive treatment. Recognizing a presentation of photodistributed SJS/TEN can help the patient promptly obtain the critical care they need.https://scholar.google.com/ searched 09/10/2021), Grey Matters: a practical search tool for health-related grey literature , Bielefeld Academic Search Engine (BASE) (https://www.base-search.net/ searched 09/15/2021), USA.gov (https://www.usa.gov/ searched 09/15/2021), Medicine Case Reports and Protocols , Medscape (https://www.medscape.com/ searched 09/16/2021), UpToDate (https://www.uptodate.com/ searched 9/16/2021). The first 150 results of each search were screened for inclusion in Google Scholar, USA.org, and Qinsight if individual searches produced more than 150 results. Studies were searched in English; however, studies that were published in languages other than English were translated and evaluated in the same manner as English-language studies. For each search, the following keywords were used: “Stevens–Johnson syndrome” and “toxic epidermal necrolysis” with “ultraviolet,” “photodistributed,” “photo-induced,” “photosensitivity,” and “photo.” UpToDate was searched using the following keywords: “Stevens–Johnson syndrome” and “toxic epidermal necrolysis.” The full strategies are shown in Additional File Databases, registers/repositories, and websites/web search engines were searched for relevant studies from inception to the reported search dates. The following databases were searched: PubMed (searched 09/09/2021), TRIP medical database (searched 09/10/2021), OECD (searched 09/13/2021), OAIster: Find the Pearls (searched 09/13/2021), New York Academy of Medicine Grey Literature Report (searched 09/13/2021), Cochrane Library (searched 09/14/2021), Qinsight (searched 09/15/2021). The following registers/repositories were searched: ClinicalTrials.gov (searched 09/13/2021), Sigma Repository (searched 09/13/2021), Social Science Research Network (SSRN) (searched 09/13/2021), National Technical Information Service (NTIS) (searched 09/13/2021). The following websites/web search engines were searched: Google Scholar . An identified cause, most commonly in SJS/TEN being a drug, was necessary to support a SJS/TEN diagnosis. The cause of the SJS/TEN disorder also needed to be active prior to UVR exposure, but UVR exposure needed to occur prior to SJS/TEN onset. For example, a patient who is exposed to UVR between the ingesting of a causal drug and the onset of SJS/TEN would qualify for the study. This timeline is important to support that the acute exposure of UVR contributed to the patient’s SJS/TEN. Furthermore, an active potential cause of SJS/TEN was necessary prior to rash onset as UVR exposure itself has not been reported to cause SJS/TEN. We excluded any case that merely mentioned the possibility of SJS or TEN as a diagnosis. Cases that included a diagnosis of erythema multiforme were also excluded.Many studies of patients with underlying lupus erythematosus (LE) reported SJS/TEN-like reactions linked to drug use and rashes presenting after UVR; however, most of these cases recognize lupus erythematosus as the causative factor for the rash presentation rather than clearly diagnosing SJS/TEN –27. FurtThis was a pre-planned search with the objective to locate all available studies that align with the inclusion criteria, including abstracts. No studies were discarded based on publication date. One reviewer determined if the studies met inclusion criteria by reading titles and abstracts and performing a full-text evaluation before including a study in the review Fig. . Anotherprior to rash onset. Rash extension to clothing covered skin was evaluated by reviewing the images that were provided in each case report. Images were evaluated for the lack of linear demarcation between UVR exposed skin and clothing covered skin (not a sharp line as is observed in a common sunburn) and satellite lesions (target-like lesions that are isolated from the rest of the rash on clothing covered skin). Findings consistent with either of these criteria were considered positive. Once data were extracted, it was confirmed by another. The risk of bias was assessed independently by a third investigator.Case-specific details were identified for each case report. The case details included the associated patient demographics of age and sex (race was not reported as only two cases provided this information); type of case: SJS, SJS/TEN, or TEN; causal drug for SJS/TEN cases with the corresponding diagnosis for which it was prescribed; UVR exposure amount and location; time from UVR exposure to rash onset; reported timeline of progression/worsening of rash; whether the rash was described as photodistributed; whether the rash extended to clothing covered skin; whether a flu-like prodrome was reported; initial signs/symptoms; SJS/TEN diagnostic specific details such as mucus membrane involvement, biopsy results, palmar and plantar rash, Nikolsky sign results; and treatment Table . One revThe approach for data synthesis and analysis was qualitative. The combined data extracted from the studies comprised the results. These results were then compared to traditional SJS/TEN cases to assess for congruent or conflicting findings. Drug causality assessment was determined for each drug-induced case using the algorithm of drug causality for epidermal necrolysis (ALDEN) . No softAfter a thorough review, 13 total cases were identified, dating from the year 1989 to 2021. The studies consisted of 12 case reports , 38, 39 The source of the UVR was specified in 10/13 (76.9%) cases: eight reported direct sunlight exposure and two reported artificial UVR exposure from tanning beds. Cases that reported the source of direct sunlight varied in their descriptions: sunburned on cruise, sun-bathed for hours over three consecutive days, rolled around and laid in the grass for 19 consecutive days while hospitalized in the psychiatric ward, exposed to 45 min of intense sunlight, and four spent a day at the beach/lake/seashore. The UVR obtained from a tanning bed was explained as a single eight-minute session in one case, while the other reported daily sessions for 10 days.Drug regimens that were responsible for the individual SJS cases: three weeks on carbamazepine, two months on sulfasalazine, ten days on ciprofloxacin with one-day on fluconazole, three weeks on chloroquine and sulfadoxine–pyrimethamine, three days on itraconazole, unspecified duration on lamotrigine, and a single dose of tramadol. Drug regimens that were responsible for the individual TEN cases: 19 days on lamotrigine and an increased dose of chlorpromazine after ten years of use, ten days on lamotrigine, 14 days on clobazam, three years on hydroxychloroquine, a single dose of naproxen sodium, and a single dose of ibuprofen. The only repeat causal drug was lamotrigine with three cases: one of SJS and two of TEN. These drugs fall into classes that are known to cause SJS/TEN, including antibiotics, antiepileptics, antimalarials, sulfonamides, and nonsteroidal anti-inflammatory drugs. The ALDEN algorithm revealed 8/13 (61.5%) case specific drugs as very probable for causing SJS/TEN (highest category), 1/13 (7.7%) as probable, 3/13 (23.1%) as possible, and 1/13 (7%) as undetermined due to lack of information  cases described the rash presentation to be in a photodistributed pattern, largely affecting the cutaneous areas exposed to direct sun with minimal rash involvement of the regions covered by a swimsuit or clothing. Ten cases provided images to evaluate if the rash extended to clothing covered skin, all positive. In six cases, the time to rash onset after UVR exposure was specified, ranging from 1 to 3 days after sun exposure. A rash was described as either the initial sign ± concomitant signs/symptoms in 10/13 cases, while 2/13 cases described experiencing itchiness that was followed quickly by rash onset and one case did not provide a description of initial signs/symptoms. Thus, no cases described a flu-like prodrome prior to rash onset. Timeline of the progression/worsening of rash was reported as continuing for at least 48 h and reported evidence suggested that it lasted for 12–14 days in multiple cases. Mucous membrane involvement was mentioned in twelve cases: 12/12 (100%) with oral mucosa ± lip involvement, 9/12 (75%) with conjunctival involvement, and 8/12 (66.7%) with genital involvement. Nikolsky’s sign was positive in the 5/6 (83.3%) cases in which it was mentioned. Six cases described findings of palmar and plantar surfaces: 5/6 (83.3%) rashes were present. Skin biopsy was included in 10/13 (76.9%) case reports, all consistent with SJS/TEN. Findings of direct immunofluorescence (DIF) were reported in 4/10 (44.4%) biopsies; all four cases were negative. Treatment was specified in 10/13 (76.9) cases. Of those, 5/10 (50%) involved systemic steroids, 6/10 (60%) involved antibiotics, 2/10 (20%) involved cyclosporine, and 1/10 (10%) involved intravenous immunoglobulin G. As a part of treatment, all offending drugs were discontinued and there were no indications that any were restarted, including drugs used to treat chronic medical conditions such as carbamazepine, sulfasalazine, hydroxychloroquine, and lamotrigine. All patients recovered  and satellite lesions on UVR protected (clothing covered) skin . Thus, it is important to validate that the reported drugs were responsible for their cases of photodistributed SJS/TEN. Drug causality assessment tools (CAT) are limited in their ability to determine culprit drugs in SJS/TEN cases. Their findings have been shown to vary between investigators . ConsequDue to technological advancement and continued research, our understanding of the pathogenesis of SJS-TEN continues to be better understood. Drugs are implicated as the causative agent in as many as 80% of cases with anticonvulsants, antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs) being the most common drug classes , 46. TheUVR plays a key role in the pathogenesis of photodistributed SJS/TEN. There are several classifications of UVR based off wavelength: ultraviolet A (UVA) = 320–400 nm, ultraviolet B (UVB) = 290–320 nm, and ultraviolet C (UVC) = 200–290 nm , 51. It Neither type of photosensitivity reaction  alone can account for the patient cases in this review. However, all of the causal drugs in this review have been implicated in causing photosensitive reactions , 56–80  . This thThe next theory is the alterations in intercellular adhesion molecule 1 (ICAM-1) expression. UVR has been shown to induce tumor necrosis factor-alpha  secretion by keratinocyte, resulting in increased ICAM-1 expression , 89. TheThe last theoretical mechanism is an increase in Fas/FasL expression. Fas ligand (FasL or CD95L) belongs to the TNF family and is responsible for inducing apoptosis in Fas  + cells . KeratinPhotosensitivity reactions consist of phototoxic and photoallergic reactions. These reactions are considered the most common type of drug-induced rashes that present in a photodistributed pattern. As the cases in this study appear to present at least partially like drug-induced photosensitive reactions, it is important to distinguish characteristics of phototoxic and photoallergic reactions from photodistributed SJS/TEN.Phototoxicity is dose dependent and can happen in anyone who ingests  or applies  enough offending agent with concomitant UVR exposure. These responses are unpredictable between people and even repeat exposures . ClinicaPhotoallergy requires an immunological response that only occurs in sensitized patients. This requires re-exposure of a drug or the continued use of a drug for sufficient time to allow sensitization to occur, reported as three days to years . Most coPhotodistributed SJS/TEN share more commonalities with photoallergic reactions than phototoxic reactions. Photoallergic reactions require sensitization of the immune system, the onset of the rash is generally > 24 h from UVA exposure –36, 39, Findings not observed in a photoallergic or a phototoxic reaction, but that are commonly found in photodistributed SJS/TEN include mucous membrane involvement , 38, 39,Photodistributed erythema multiforme (PEM) is rarely reported, but an important differential diagnosis. In one review in 2012, 18 cases of PEM were identified: 10 were drug-induced, four were due to herpes simplex virus, one polymorphous light eruption, and three idiopathic . ErythemUVR is known to induce or aggravate autoimmune bullous diseases, including pemphigus foliaceus, pemphigus vulgaris, bullous pemphigoid, and less commonly, linear IgA dermatosis . BullousThe following diagnostic criteria was proposed by the authors to help guide physicians when distinguishing photodistributed SJS/TEN from an alternative diagnosis Table :Table 7DThe criteria should continue to be reviewed, and updated when appropriate, with future investigation of photodistributed SJS/TEN. Further elucidation for each criterion is outlined here:A photo-distributed rash as a result of UVR exposure after drug initiation (or other known SJS/TEN cause). The timeline of UVR is important as a recall-phenomenon has been reported which likely represents unique pathophysiology , 126.Rash progression/worsening that continues for a minimum of 48 h with rash evolution to include vesicles/bullae and/or sloughing of the epidermis. This is a systemic immune disorder that progresses over days to weeks.Negative DIF. If positive, LE, bullous diseases, and porphyria disorders should be further investigated.More likely SJS/TEN than EM. It is important to make this distinction due to mortality risk in SJS/TEN patients. If the disorder is EM, it is self-limited, does not require specialized treatment in a burn center, and the patient is able to perform additional photobiological testing to aid in culprit drug identification: phototesting followed by photopatch testing . PhotobiMust identify = need all 4:A causal drug. All cases in this review include a casual drug, while cases without drug involvement have been reported in SJS/TEN-like LE, PEM, bullous diseases, and porphyria disorders.Mucous membrane involvement. Oral, ocular, and/or genital mucositis is reported in 92–100% of SJS patients and nearly all TEN patients, with oral involvement being the most common . It is s4.7 case inclusion consideration for more on Nikolsky sign).Positive Nikolsky sign. Nearly all should have, but not a “must identify” criteria due to limitations of the test.  = need 3/4:Palmar and plantar rash. No formal report of the incidence could be identified in the literature, although it is commonly reported in SJS/TEN  and in tDelayed rash onset that presents no earlier than the day after UVR exposure. This was observed in this report and consistent with a delayed hypersensitivity reaction commonly reported in SJS/TEN .Satellite lesions/non-discrete borders on UVR protected (clothing covered) skin. These findings were consistent in all cases in this review (those that provided images) to varying degrees.No flu-like prodrome. This finding was consistent with all cases in this review.Minor criteria (common findings) = need 2/4:Minor criteria 2–4 were important findings in this review that need additional evaluation from further accumulation and investigation of cases to assess their prevalence before they can be considered a “must identify” or “major criteria”. These three findings, in addition to an overall photodistributed rash (number 1 in the “must identify” section), are the findings that are unique from traditional SJS/TEN, summarized as a photodistributed rash with non-discrete borders, occurring at least a day after UVR exposure, and without a flu-like prodrome. The remaining criteria are consistent with traditional SJS/TEN and are important to help distinguish from other photodistributed disorders.Total % of BSA involvement can help further distinguish between photodistributed SJS, SJS/TEN overlap, and TEN . AlthougThe authors recommend following up to date treatment guidelines for SJS/TEN, emphasizing the importance of a quick diagnosis and transfer to an appropriate care facility, like a burn center . All patTwo cases were less clear about meeting the criteria of disease onset of SJS/TEN after UVR exposure. First, a female with a history of abnormal reactions to ibuprofen chose to take ibuprofen for menstrual cramps which resulted in lip swelling and a minimally reactive rash of small red macules and papules . The rasAdditionally, cases that reported Nikolsky’s sign findings are worth discussing. A positive Nikolsky’s sign is observed when light pressure is applied to the skin, usually from a clinician’s finger, resulting in the disassociation of the epidermis from the dermis . Five ofSeveral studies fell short of meeting inclusion criteria but are worth discussing. A case of a 67-year-old female with SJS/TEN overlap and a positive Nikolsky’s sign reported that sun exposure was a potentiating factor, providing images of the patient’s rash with photo-demarcated borders . This caThere are also reports of UVR exposure preceding introduction of the causal drug that resulted in SJS/TEN presentations. A patient who experienced a bullous sunburn on his back and thighs presented seven months later with a case of TEN after taking trimethoprim-sulfamethoxazole; his rash replicated the distribution of the previous sunburn . AnotherRadiotherapy has also been reported to cause drug-induced SJS/TEN presentations after the initiation of a new drug regimen, similar to the UVR cases described in this review. One such case of SJS was reported after a patient received concomitant phenobarbital and radiation therapy, which resulted in rash distribution limited to the radiation exposure areas . The samThere were many studies that met inclusion criteria. However, one limitation to this review is the level of detail provided by the individual studies, thus limiting the analyses and comparisons that could be performed. Furthermore, it is difficult to ascertain the prevalence of photodistributed SJS/TEN. In the literature, UVR’s role in SJS/TEN cases is not widely documented. Due to the minimal coverage, it is plausible that many UVR-linked cases have gone unrecognized or unreported.Future directions should focus on further investigation of the pathophysiology that is responsible for photodistributed SJS/TEN, as the current understanding is theoretical.Physicians should be aware that UVR may precipitate SJS/TEN in patients taking susceptible drugs. Rash onset occurs after UVR exposure in a photodistributed pattern, with a delay of at least 24 h. As the rash progresses for at least 48 h, vesiculobullous lesions with skin sloughing form. The photodistributed pattern remains with non-discrete borders and satellite lesions on UVR protected (clothing covered) skin. A lack of a flu-like prodrome is also unique from traditional cases of SJS/TEN. Additionally, findings of mucositis, palmar and plantar rash, a positive Nikolsky sign, and a prolonged disease course can help distinguish photodistributed SJS/TEN from photosensitive reactions. Similarly, a negative DIF can help rule out other photo-induced autoimmune bullous diseases, porphyria disorders, and SJS/TEN-like LE. Photodistributed SJS/TEN appears to be photo-drug-induced with a unique onset and rash presentation that should be recognized as a distinct diagnosis.Additional file1: A log of individual searches with their corresponding results to identify photodistributed cases of SJS/TEN.


Complete cervical spinal cord injury (CSCI) is a devastating injury that usually requires surgical treatment. Tracheostomy is an important supportive therapy for these patients. To evaluate the effectiveness of early one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery, and to identify clinical factors for one-stage tracheostomy during surgery in complete cervical spinal cord injury.Data from 41 patients with complete CSCI treated with surgery were retrospectively analyzed.Ten patients (24.4%) underwent one-stage tracheostomy during surgery, thirteen (31.7%) underwent tracheostomy when necessary after surgery, and eighteen (43.9%) did not have a tracheostomy.p = 0.025), increased the PaO2 (p < 0.05), and decreased the length of mechanical ventilation (p = 0.005), length of stay (LOS) in the intensive care unit (ICU) (p = 0.002), hospital LOS (p = 0.01) and hospitalization expenses compared with necessary tracheostomy after surgery (p = 0.037). A high neurological level of injury (NLI) (NLI C5 and above), a high PaCO2 in the blood gas analysis before tracheostomy, severe breathing difficulty, and excessive pulmonary secretions were the statistically significant factors for one-stage tracheostomy during surgery in the complete CSCI patients, but no independent clinical factor was found.One-stage tracheostomy during surgery significantly reduced the development of pneumonia at 7 days after tracheostomy (In conclusion, one-stage tracheostomy during surgery reduced the number of early pulmonary infections and the length of mechanical ventilation, ICU LOS, hospital LOS and hospitalization expenses, and one-stage tracheostomy should be considered when managing complete CSCI patients by surgical treatment.  Complete cervical spinal cord injury (CSCI) is a devastating injury with a high rate of mortality and morbidity . The leaTracheostomy, as an important supportive therapy, is required in 8.4%–77% of patients with CSCI because it can improve their ventilatory function, decrease the risk of pulmonary complications, and save the patient's life –12. DespThe purpose of this retrospective study was to evaluate the early effectiveness of one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery in complete CSCI patients having surgical treatment and to identify the clinical factors for one-stage tracheostomy during surgery in these patients.We conducted a retrospective single-center study in a university affiliated-tertiary referral hospital in China from January 2012 to June 2019, and this study was approved by the institutional review board. The inclusion criteria were as follows: patients aged 18 years or older; with cervical SCI between the levels of C3 and C7; with an AIS A grade; and who had surgical treatment. The exclusion criteria included tracheostomy before surgery, a significant craniocerebral or head injury, history of cerebral stroke, respiratory disease when the injury occurred, or death during hospitalization.2 less than 70 mmHg and a PaCO2 higher than 45 mmHg), and any factors which were associated with expected prolonged mechanical. Since December 2016, we performed the one-stage tracheostomy during surgery for the complete CSCI patients who had some risk factors before surgery but were not up to the standards of needing a necessary tracheostomy, such as difficulty breathing, excessive respiratory secretions, blood gas disorders, and a high level CSCI (C5 and above). The tracheostomies were performed after the incision for the cervical surgery was closed.A total of 41 patients with complete CSCI treated with surgical treatment were included in the study. There were 18 patients in the no tracheostomy group, 13 patients in the necessary tracheostomy after surgery group, and 10 patients in the one-stage tracheostomy during surgery group. Also, we summarized the baseline characteristics of the patients such as age, gender. After surgery, the decision to perform a necessary tracheostomy was made by the spine surgeons together with intensive care unit (ICU) physicians. These decisions were based on the standards: if the individual patient had severe breathing difficulties, had blood gas disorders  posterior cervical laminectomy reduction and short segmental fixation using lateral mass screws were performed according to the cervical intervertebral disc injury or particular cervical facture and dislocation. Posterior unilateral open-door laminoplasty was performed in the patients who had spinal stenosis without fracture or dislocation.2 according to a blood gas analysis, and PaCO2 according to a blood gas analysis before tracheostomy and at 1, 3, 5 and 7 days after the tracheostomy , it includes temperature, white blood cell count, tracheal secretion, oxygenation index, and chest x-ray, with a total score of 0 to 10. PaOheostomy , 16. We 2, PaCO2 and PaO2/FiO2 according to a blood gas analysis, difficulty breathing, excessive respiratory secretions (requiring hourly suction), history of smoking, and evidence of direct thoracic or abdominal trauma. In total, the clinicians identified nine factors , the overall injury severity expressed by the ISS , 17, the factors . The NLI factors . To eval factors , 19.  followed by Dunnett's test for the data that was in accordance with the normal distribution and homogeneity of variance and by using a nonparametric rank sum test for the data that did not conform to normality. The effectiveness for one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery was analyzed using the independent samples Student's t test for the normally distributed unpaired continuous data, the nonparametric rank sum test for the skewed data, and the chi-square test for the counting data and rates.p value less than 0.05. The statistical package SPSS version 22.0  was used for the analysis.To identify the clinical factors for one-stage tracheostomy during surgery, univariate analyses were first carried out. ANOVA followed by Dunnett's test was used to compare the data that were in accordance with normality and homogeneity of variance, and a nonparametric rank sum test was used to compare the data that did not conform to normality. To further judge whether a factor was an independent influencing factor, a multivariate logistic regression analysis was conducted. The significance level was set at a Forty-one patients with complete CSCI treated by surgical treatment were included in the analysis. The average age was 47.3 ± 13.8 years, and 86% were male. The overall median ISS was 25 , and the median anatomic level of the cervical spinal cord injury was 5 . The overall length of time from injury to cervical spinal surgery was 5.8 ± 3.24 days. The cervical spinal surgery of each patient at admission revealed that 30 of the 41 patients underwent anterior surgery, 6 underwent posterior surgery, and 5 underwent anterior surgery combined with posterior surgery.Ten patients (24.4%) underwent one-stage tracheostomy during surgery, thirteen (31.7%) underwent tracheostomy when necessary after surgery , and eighteen (43.9%) did not have a tracheostomy. The demographic and clinical data for the one-stage tracheostomy during surgery, necessary tracheostomy after surgery, and no tracheostomy subgroups are summarized in p = 0.025). However, the CPISs in the necessary tracheostomy after surgery group at 1, 3, 5 and 7 days after tracheostomy were no different compared with those before tracheostomy (p > 0.05). The CPISs were significantly lower in the one-stage tracheostomy during surgery group than those in the necessary tracheostomy after surgery group at 1, 3, 5 and 7 days after tracheostomy . The PaO2 was higher in the one-stage tracheostomy during surgery group than in the necessary tracheostomy after surgery group at 1, 3, 5 and 7 days after tracheostomy, but the difference was not statistically significant . The PaCO2 in the necessary tracheostomy after surgery group at 1, 5 and 7 days after tracheostomy was significantly decreased compared with that before tracheostomy (p < 0.05), but there was no difference at 3 days after tracheostomy compared with that before tracheostomy (p = 0.156). The PaCO2 was lower in the one-stage tracheostomy during surgery group than in the necessary tracheostomy after surgery group at 1, 3, 5 and 7 days after tracheostomy, but the difference was not statistically significant at 3, 5 and 7 days after tracheostomy  were important categorical discriminators of tracheostomy in CSCI patients. Compared with the patients who did not receive a tracheostomy, the patients who underwent one-stage tracheostomy during surgery had a significantly higher NLI (p = 0.013), a higher PaCO2 (p = 0.039), more severe difficulty breathing (p < 0.001), and more pulmonary secretions (p < 0.001). Moreover, the patients who underwent necessary tracheostomy after surgery had a significantly higher NLI (p = 0.026), a higher PaCO2 (p < 0.001), lower PaO2 (p < 0.001) and PaO2/FiO2 (p < 0.001), more severe difficulty breathing (p < 0.001), and more pulmonary secretions (p < 0.001) than the patients who did not receive a tracheostomy.The univariate analyses of the clinical factors for tracheostomy revealed that high NLI (NLI C5 and above), increased PaCOp = 0.370), PaCO2 (p = 0.313), difficulty breathing (p = 0.846), or pulmonary secretions (p = 0.092). The patients' PaO2 (p = 0.021) and PaO2/FiO2 (p = 0.009) in the necessary tracheostomy after surgery group were significantly lower than those in the one-stage tracheostomy during surgery group.However, between the patients in the one-stage tracheostomy during surgery group and those in the necessary tracheostomy after surgery group, there was no significant difference in the NLI .The aforementioned items with significant differences were further analyzed using multivariate logistic regression. The results revealed that there was no independent clinical factor for one-stage tracheostomy during surgery in the complete CSCI patients treated by surgery who are in the one-stage tracheostomy during surgery, necessary tracheostomy after surgery and no tracheostomy subgroups  score, vertebral fracture and dislocation, hematoma-like changes on MRI, the variables for forced vital capacity, the volume of pulmonary secretions, the gas exchange, respiratory complications, smoking, thoracic and abdominal trauma, sex, and age, as reported in different studies , 23, 24.2 in the blood gas analysis is also a simple and convenient pulmonary ventilation index. Our results indicated that decreased pulmonary ventilation, including a high PaCO2 in the blood gas analysis, severe difficulty breathing, and significant pulmonary secretions, combined with a high NLI (NLI C5 and above), were the factors associated with one-stage tracheostomy during surgery for complete CSCI patients treated surgically.The pulmonary ventilation of complete CSCI patients was also important to predict the need for one-stage tracheostomy during surgery. In spite of some shortcomings, the variable forced vital capacity is able to reflect the pulmonary ventilation and is considered indispensable to predict the need for tracheostomy in patients with CSCI during the acute stage , 19, 20.This study has several limitations. First, it was a retrospective study that reflected the experience at a specialized spinal center in a university affiliated-tertiary referral hospital in China. Second, although complete CSCI is a low-incidence event, the sample size of the study is relatively small. Third, a longer follow-up time is needed to assess the effects of one-stage tracheostomy during surgery in complete CSCI patients with surgical treatment.2 in the blood gas analysis, severe difficulty breathing, and significant pulmonary secretions.In conclusion, one-stage tracheostomy during surgery reduced the number of early pulmonary infections, the length of mechanical ventilation, the ICU LOS, the hospital LOS and hospitalization expenses when compared with necessary tracheostomy after surgery in complete CSCI patients treated surgically. Therefore, one-stage tracheostomy should be considered in complete CSCI patients with a high NLI, a high PaCO


To determine the diagnostic value of 'soft stops' encountered during lacrimal syringing and probing.Single-center retrospective review. Adult patients with epiphora attending a tertiary lacrimal clinic from May 2010 to April 2021 were reviewed. Cases with evidence of soft stop encountered during lacrimal syringing/probing were included, and patients with possible canaliculitis or a history of lacrimal surgery were excluded. Findings of syringing/probing consistent with pre-sac obstruction were correlated with dacryocystography (DCG) and surgical findings.p = 0.016). Canalicular stenosis on syringing/probing manifested as pre-sac abnormality on DCG in 5/7 (71.4%) compared to 0/6 common canalicular stenosis cases (p = 0.021). Based on the surgical findings, the false-positive rate of a soft stop on syringing/probing was highest for common canalicular ‘stenosis’ (100%) and lowest for canalicular ‘block’ . Findings of pre-sac obstructions on DCG were confirmed in 85.7% of the cases intraoperatively .53 (10.2%) canalicular systems had soft stops on syringing/probing and were included in the analysis. The mean age of the patients was 63.8 ± 15.6 (range 28–87) years, and 27 (65.9%) were females. Intraoperative examination findings were available for 27 of 30 cases that underwent lacrimal surgery and DCG was available for 40 systems. Pre-sac obstruction found on syringing/probing was confirmed in 40% and 37% of cases on DCG and surgery, respectively. The correlation between syringing/probing and DCG was stronger for canalicular than for common canalicular location (Soft stops on probing showed poor correlation with DCG and surgical findings, particularly in common canalicular location.The online version contains supplementary material available at 10.1007/s10792-022-02510-3. Canalicular and common canalicular pathologies (obstruction/stenosis) are found in 4.2–11% of cases of epiphora, depending on the population . AccuratPrevious studies showed that syringing/probing is associated with low sensitivities in detecting pre-sac pathology  , 11–13. Hence, this study aimed to correlate findings of lacrimal syringing/probing consistent with pre-sac pathology to DCG and surgical findings.A retrospective review was conducted of consecutive adult patients attending the Royal Adelaide Hospital lacrimal clinic with a recorded soft stop during syringing/probing between May 2010 and April 2021. Cases identified in the clinic as possible canaliculitis or patients with a history of lacrimal surgery were excluded. The study received Institutional Review Board (IRB) approval and adhered to the tenets of the Declaration of Helsinki.Oculoplastic surgeons performed syringing, all trained under the last author (DS), who supervised and validated the technique. Lateral tension was applied to the eyelid, while a lacrimal cannula on a 2 ml syringe was inserted 1–2 mm vertically through the punctum. The lacrimal cannula was advanced slowly through the canaliculus until it reached a soft or hard stop. A ‘soft stop’ is defined as resistance to progression of the cannula by soft tissue. The cannula was then retracted and held in place, while syringing was performed with minimal pressure. The site of the soft stop from the punctum in mm, location of reflux , and subjective estimation of the degree of reflux (%) were documented.Based on the recorded soft stop distance, ≤ 10 mm from punctum and reflux from the same punctum was designated as canalicular stenosis or block and > 10 mm, and reflux from the opposite punctum was designated as common canalicular stenosis or block.A complete 'block' was defined as 100% reflux on syringing, whereas partial patency to the nose was defined as ‘stenosis. ’DCGs were performed with patients in the supine position. A drop of topical anesthetic (1% tetracaine hydrochloride) was instilled into the inferior conjunctival fornix of both eyes. The punctum was cannulated with a 27-gauge lacrimal cannula. Baseline X-ray images were taken, followed by real-time imaging during injection of contrast  through the cannula. This allowed digital subtraction of the pre-contrast image from post-contrast images.Canalicular ‘stenosis’ was defined as reflux of contrast medium through the intubated canaliculus and drainage to the nasal cavity. Common canalicular ‘stenosis’ was defined as reflux of contrast medium through the non-intubated canaliculus and drainage to the nasal cavity. Furthermore, pre-sac stenosis appeared as a narrowing of the canaliculus or common canaliculus or even as a defect . CompletSurgical findings were obtained from the patients' operative records. All lacrimal procedures were carried out or supervised by experienced oculoplastic surgeons . External or endoscopic dacryocystorhinostomy (DCR) (with or without tubes) or lacrimal (silicone) intubations were performed under general or local anesthesia with sedation. These procedures were occasionally combined with dacryoendoscopy and/or canalicular trephination, as detailed in Supplementary Table 1.Intraoperative canalicular probing was performed in all procedures to confirm (or rule-out) pre-sac pathology. In cases that DCR was performed , direct visualization of the common internal canaliculus was recorded. Dacryoendoscopy was combined in 7/10 of the lacrimal intubations and 1/14 of the endoscopic DCRs (Supplementary Table 1).Data were analyzed by the StatSoft Statistica software, version 10 . Correlations between a soft stop on lacrimal syringing/probing and DCG findings, between a soft stop on lacrimal syringing/probing and surgical findings, and between DCG and surgical findings were calculated and are presented as proportions. Differences in proportions  were compared by the chi-square or Fisher's exact tests, as appropriate. A two-sided p value of less than 0.05 was considered significant.The surgical findings  were considered the gold standard for establishing the false-positive rate and the positive predictive value (PPV) of the diagnostic tests . The false-positive rate denotes the proportion of soft stop cases on syringing/probing or the proportion of cases with a pre-sac abnormality on DCG, which had a normal canalicular system intraoperatively, respectively. The PPV denotes the proportion of soft stop cases on syringing/probing or the proportion of cases with a pre-sac abnormality on DCG, which was confirmed to have a pre-sac etiology intraoperatively, respectively.From May 2010 to April 2021, syringing/probing was available for 519 symptomatic lacrimal systems. Out of these, 62 (11.9%) soft stops in 49 patients  were documented. In nine of these cases, the soft stop was noted to have been overcome on subsequent syringing/probing performed in the clinic, and they were thus excluded from the analysis .The mean age of the patients with a soft stop was 63.8 ± 15.6 (range 28–87) years, and 27 (65.9%) were females. Based on the syringing/probing, the location of obstruction was the canaliculus in 27 (50.9%), common canaliculus in 24 (45.3%), and unavailable for 2  lacrimal systems with a soft stop on probing. The correlation between the syringing/probing and the DCG is shown in Table p = 0.016, Table p = 0.021, Table The correlation between syringing/probing and DCG was stronger for canalicular than for common canalicular location . The intraoperative canalicular examination was available for 27 of the 30 soft stop cases that underwent a lacrimal procedure.p = 0.24). More specifically, 6/11 (54.5%) of canalicular blocks, 1/3 (33%) of canalicular stenoses, 3/8 (37.5%) of common canalicular blocks, and 0/5 of common canalicular stenoses on syringing/probing were confirmed intraoperatively.A pre-sac etiology was confirmed intraoperatively in 10/27 cases, representing a 37% general positive predictive value (PPV) of a soft stop on preoperative syringing/probing. Depending on the soft stop location on preoperative probing, 7/14 (50%) of canalicular and 3/13 (23.8%) of common canalicular soft stops were confirmed intraoperatively as a pre-sac etiology (p = 0.093) due to the low number of cases in the subgroups.Based on the surgical findings, the false-positive rate of a soft stop on syringing and probing was highest for common canalicular stenosis (100%) and lowest for canalicular block (45.5%); however, the difference did not reach statistical significance . Thus, representing an 85.7% general PPV of pre-sac abnormality on DCG . On the imaging, the single false-positive DCG (14.3%) appeared as common canalicular stenosis (combined with a post-sac block) and was noted to have a normal canalicular system intraoperatively. There was a 1/7 (14.3%) false-negative rate for the DCG, namely a post-sac stenosis on DCG that was found intraoperatively to have canalicular stenosis.Preoperative DCG was available for 21 of the 27 soft stop cases with an intraoperative examination. A pre-sac etiology was confirmed intraoperatively in 6/7 of the DCG cases showing a pre-sac abnormality  [0.2% 1–33. HoweveIn our cohort, 45% of cases were diagnosed with common canalicular obstruction during syringing/probing. These cases showed the lowest correlation with both DCG and surgical findings. Furthermore, the agreement between syringing and DCG/surgery was greater for canalicular than common canalicular obstructions. This was most striking for the common canalicular stenosis group .There are plausible explanations for the high false-positive common canalicular soft stops on syringing/probing. Firstly, common canalicular/lacrimal sac mucosal folds (CLS-MFs) have been shown to impact the internal canalicular orifice on endoscopy and falsely suggest an obstruction during probing , 16. ThePrevious studies emphasized the inaccuracy of syringing and probing for diagnosing a pre-sac etiology . In studDCG was previously shown to be sensitive in detecting canalicular pathology , 23–25, Limitations to this study firstly include its retrospective nature. Secondly, some trends did not reach significance due to a small cohort. This was because suspected canalicular and common canalicular pathologies formed a very small proportion in our studied population over ten years. This is in contrast to some other populations where a pre-sac etiology was a more common finding . FurtherIn conclusion, our results demonstrated a low predictive value of a soft stop in diagnosing a pre-sac etiology for epiphora. Clinicians should be aware of this when consenting patients for surgical intervention and be prepared to alter their surgical approach if preoperative findings are not confirmed intraoperatively. Clinicians may also consider performing dacryocystography to improve diagnostic accuracy for common canalicular pathology.Supplementary file1 (DOCX 24 kb)Below is the link to the electronic supplementary material.


Acute kidney injury (AKI) in COVID-19 patients is associated with poor prognosis. Characterization of AKI by timing and trajectory and early prediction of AKI progression is required for better preventive management and the prediction of patient outcomes.A total of 858 patients who were hospitalized due to coronavirus disease 2019 (COVID-19) were retrospectively enrolled from December 2020 to August 2021. The occurrence of AKI was evaluated throughout hospitalization. The hazard ratios (HRs) of mortality outcomes according to the trajectory of AKI were measured using Cox regression models after adjustment for multiple variables.Among 858 patients, 226 (26.3%) presented AKI at admission, and 44 (5.1%) developed AKI during hospitalization. Patients with AKI at admission or hospital-acquired AKI had a higher risk of mortality than those without AKI, with HRs of 9.87 (2.81–34.67) and 13.74 (3.57–52.84), respectively. Of 226 patients with AKI at admission, 104 (46.0%) recovered within 48 hr, 83 (36.7%) had AKI beyond 48 hr and recovered in 7 days, and 39 (17.3%) showed no recovery from AKI on Day 7. Delayed recovery and persistent AKI were significantly associated with an increased risk of mortality, with HRs of 4.39 (1.06–18.24) and 24.33 (7.10–83.36), respectively.The onset and progression of AKI was significantly associated with in-hospital mortality in patients with COVID-19. A thorough observation of the recovery trajectory of early AKI after infection is necessary. Coronavirus disease 2019 (COVID-19) is primarily known to affect respiratory systems, however, the kidney has also been recognized as a vulnerable target organ for infection. The reported prevalence of acute kidney injury (AKI) has been shown to be elevated among individuals diagnosed with COVID-19 in comparison to those without the disease .The pathogenesis behind the impact of COVID-19 on kidney injury is understood to be multifaceted. One possible mechanism of kidney involvement could be similar to that observed during severe acute respiratory syndrome coronavirus (SARS-CoV) infection in the past, including cytokine release syndrome, inter-organ communication, and systemic effects . The devMost previous studies of the trajectory after AKI in the pre-COVID era show favorable outcomes after renal recovery compared to nonrecovery, including a lower risk of progression to CKD or mortality . Howevern = 100) and those who had been on dialysis because of end-stage kidney disease (n = 82) were excluded. Baseline information at the time of admission was not available for 362 patients; thus, a total of 858 patients were ultimately analyzed. The study design was approved by the institutional review board of the Seoul National University Boramae Medical Center (no. 20-2021-88) and complied with the Declaration of Helsinki. The requirement for informed consent was waived by the review board.The study was retrospective in nature and included a cohort of 1402 patients who were hospitalized with COVID-19 at a single secondary hospital from December 2020 to August 2021. Among them, patients who were under 18 years old  values of real-time reverse transcription-polymerase chain reaction (RT–PCR) assays, which are a confirmatory test for COVID-19. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation. Underlying chronic kidney disease (CKD) was identified using previous medical records, laboratory data, and patient reports. The study outcome was in-hospital mortality until discharge.n = 27), and if not available, the minimum serum creatinine value during hospitalization (n = 831). According to the timing of AKI, patients were divided into two groups: those with AKI at admission and those with hospital-acquired AKI that developed after hospitalization.The baseline serum creatinine level was defined as a preadmission outpatient creatinine measurement within the 6 months before admission  criteria as: Stage 1, an increase in serum creatinine level by 0.3 mg/dL within 48 h or a 1.5–1.9-fold increase from baseline within 7 days; Stage 2, a 2.9-fold increase in serum creatinine level within 7 days; and Stage 3, a 3-fold or greater increase in serum creatinine level within 7 days or initiation of renal replacement therapy.AKI at admission was defined using the retrospective diagnostic criteria proposed in the previous literature as follows: Stage 1, 0.66–0.49 times the reference value; Stage 2, 0.5–0.32 times the reference value; and Stage 3, ≤0.33 times the reference value . The reft test or Mann–Whitney U test was applied depending on the normality.The expressions of categorical and continuous variables were reported as proportions and means with standard deviations, respectively, if they were found to have a normal distribution based on the results of the Kolmogorov–Smirnov test. For non-normally distributed variables, medians with interquartile ranges were used instead. The chi-square test or Fisher’s exact test was applied to compare categorical variables. In the case of continuous variables, the Student’s Kaplan–Meier survival curves were drawn and compared between groups using the log-rank test. The hazard ratios (HRs) and confidence intervals for hospital mortality were calculated using a Cox proportional hazards regression model in which multiple variables were adjusted. The odds ratios (ORs) and confidence intervals for delayed recovery or persistent AKI in the AKI at admission group were calculated using logistic regression analysis. All statistical analyses were performed using SPSS software  and R software .The mean age of the patients was 56 ± 20 years, and 37.1% of the patients were male. Patients who developed AKI were more likely to be older and have comorbid diseases such as hypertension, diabetes, and CKD. The difference was more pronounced in the hospital-acquired AKI group. Laboratory findings such as hemoglobin, platelet count, serum albumin, C-reactive protein (CRP) and brain natriuretic peptide (BNP) also showed significant differences between groups. Other baseline characteristics are presented in p < 0.001, Among a total of 858 patients, 50 patients (5.8%) died. The mortality incidence was 3.8 deaths per 1,000 person-days. In the Kaplan–Meier survival curves, the survival rates differed according to the timing of AKI  recovered within 48 h, 83 (36.7%) had AKI beyond 48 h and recovered in 7 days, and 39 (17.3%) showed no recovery from AKI on Day 7. No recurrence of AKI was observed within the first 7 days. Patients in the delayed recovery or persistent AKI group were more likely to be older and male and have underlying CKD than those in the early recovery group. Laboratory findings such as hemoglobin, platelet count, serum albumin, CRP and BNP also showed significant differences between groups. Other baseline characteristics are presented in p = 0.852). However, the delayed recovery group and the persistent AKI group had significantly higher mortality than the non-AKI group (p = 0.005). In the Cox proportional hazards regression model, delayed recovery or persistent AKI significantly increased the risk of hospital mortality  and complied with the Declaration of Helsinki. The requirement for informed consent was waived by the review board.


This study aimed to determine the predictive factors for post-conization of residual disease in subsequent hysterectomy for cervical intraepithelial neoplasia grade 2 or 3.This retrospective study included 267 patients with histologically confirmed cervical intraepithelial neoplasia grade 2 or 3 who underwent hysterectomy within 7 months after conization. Clinical data  as well as pathological data pertaining to conization and hysterectomy were collected from medical records. A logistic regression model was used to analyze the relationship between the variables and risk of residual lesions in hysterectomy samples.p=0.019), endocervical gland involvement(p=0.013), positive margin(p < 0.001), and involvement of 3–4 quadrants(p < 0.001) were risk factors for residual lesions. Conversely, postmenopausal status, gravidity ≥ 3, parity ≥ 2, loop electrosurgical excision procedure, and type III transformation zone were not risk factors for residual lesions. A positive margin(p < 0.001) and multiple-quadrant involvement(p < 0.001) were identified as independent risk factors for residual lesions on multivariate analysis.Overall, 70 (26.2%) patients had residual lesions in their hysterectomy specimens. Univariate analyses revealed that age ≥ 50 years (Multiple-quadrant involvement and a positive cone margin were reliable predictive factors for residual disease. Total hysterectomy or repeated cervical conization should be considered for patients with these two risk factors. The identification of high-risk patients with extensive lesions by colposcopic examination before conization is indispensable, as it will enable surgeons to perform conization with consideration of risk factors and possibly improve the approach used for the excisional procedure. For high-risk patients, colposcope-guided cold-knife conization is preferred when resources permit.The online version contains supplementary material available at 10.1186/s12905-023-02568-w. Therapeutic cervical conization is an effective method for treating women with cervical intraepithelial neoplasia grade 2 or 3 (CIN 2/3) , 2. NoneThe retrospective study protocol was approved by the Institutional Review Board of the Second Hospital of Hebei Medical University. The requirement for patient consent was waived by the Board because of the retrospective nature of the study. This study conforms to the provisions of the Declaration of Helsinki . This stp-values were two-tailed, with statistical significance set at p < 0.05.Discrete and categorical variables are expressed as median (range) and numerical (percentage) values, respectively. A univariate logistic regression analysis was conducted to assess predictive factors for residual lesions in patients with CIN 2/3 after hysterectomy following conization. For comparison, we used cutoff values of ≥ 50 years for age, 3 for gravidity, and 2 for parity. Additionally, we semi-quantitatively described the lesion size as quadrant(s) of the cervix involving CIN lesion. Patents were divided into groups according to the number of quadrants showing disease involvement: patients with one or two and these with three of four quadrants. All risk factors associated with residual lesions in the univariate logistic regression analysis were analyzed using multivariate logistic regression. Considering that we included women with no follow-up losses, sample size calculation was performed using the estimation of a confidence interval (CI) with a required width for a single proportion based on the primary outcome: odds ratio (OR) of residual CIN 2/3 or worse in patients with positive and negative margins. The literatures report a range of OR between 2.43 and 4.8 , 14, andA total of 267 patients (median age: 48.0 years [range: 29–77 years]) were included in the analysis of residual lesions. The median interval from conization to hysterectomy was 5 days range: 1–192 days). Within the time interval between these two operations, six patients underwent a high-risk human papillomavirus test and pap smear. Two patients underwent colposcopic examination and cervical biopsy. Among the patients, 134(50.2%) were postmenopausal. The median gravidity and parity were 3.0 (range: 0–10) and 2.0 (range: 0–5), respectively. Type I or II TZ was observed in 210 patients (78.7%). LEEP and CKC were performed for therapeutic conization in 8.6% and 91.4% of the patients, respectively. Clinical characteristics of the patients are summarized in Table –192 daysn = 40), both CIN 3 and EGI (n = 15), and CIN 2 (n = 12), were detected in hysterectomy specimens of 67 (25.1%) patients. Additional details are provided in Table The pathological results of conization indicated that EGI was present in 175 65.2%) patients, and 83 (30.7%) of them had a positive resection margin. Of the 83 cases, 30 had positive endocervical margin, 44 had positive ectocervical margin, and 9 had both positive endocervical and ectocervical margins. Following hysterectomy, 197 (73.8%) patients exhibited no evidence of CIN 2/3, whereas 3 (1.1%) patients had previously undiagnosed cervical cancer (2 patients with adenocarcinoma in situ [AIS] and 1 with microinvasive carcinoma). The two patients with AIS were postmenopausal women. Their pre-cone human papillomavirus (HPV) testing results suggested high-risk HPV positivity, and the pre-cone cytology results of one woman suggested atypical squamous and atypical glandular cells. Pathological examination of the uterine specimens of both patients showed HPV-related adenocarcinoma. Residual lesions, including CIN 3  was associated with residual lesions in subsequent hysterectomy specimens, which is consistent with previous results . A previIn addition to positive margins and extensive cervical cone margin involvement, we suspected some variables to be associated with residual lesions; however, this suspicions were not proven. In particular, we found no significant differences in menopausal status, type of TZ, gravidity, parity, and conization method. Interestingly, age ≥ 50 years and EGI were associated with residual lesions on the univariate analysis, whereas a significant correlation for both was not observed on the multivariate analysis. The relatively small sample size and the heterogeneity of the patient population might have influenced our results. Age and menopausal status have been shown to be significant predictors of residual disease in several studies. This finding is anatomically plausible; atrophy of the genital tract and deep inversion of the TZ make the complete resection of the abnormal cervical epithelium challenging after menopause. However, neither of these factors was a risk factor for residual lesions in present study. This finding may be attributed to the patient heterogeneity. The majority of our patients were reproductive premenopausal women, among whom CIN was the most prevalent. In our study, 78.7% of patients had type I or II TZ, and the majority of patients had a positive ectocervical margin, which is anatomically plausible. Therefore, these factors should be evaluated further in future studies, and more accurate prediction of residual disease after conization is indispensable, especially in women of child-bearing age.The strength of this present study was that the majority of our patients were in the reproductive and premenopausal periods, which are the main periods for the onset of CIN 2/3. Additionally, most patients underwent reoperation within a short period of time; hence, residual lesions were more accurately defined, and there was little likelihood of a new disease or regression. Moreover, we simultaneously included age, menopausal status, gravidity, parity, type of TZ, conization method, pathology of conization specimens (including the quadrants of lesions), and glandular involvement in a single study. Nonetheless, this study had some limitations, particularly its retrospective design, relatively small sample size, and heterogeneous patient population.In this study, we identified positive margins and extensive cone margin involvement as strong predictors of residual disease. Repeated cervical conization or total hysterectomy should be considered for patients with these two factors. In addition, extensive lesions increase the risk of a positive margin on cone specimens. The identification of high-risk patients with lesions involving 3–4 cervical quadrants before conization with consideration of risk factors and improve the approach used for the excisional procedure. For patients with extensive lesions, colposcope-guided CKC is preferred where resources permit.Below is the link to the electronic supplementary material.Additional File 1: Table 1 and Table 2


Vertebroplasty is the main minimally invasive operation for osteoporotic vertebral compression fracture (OVCF), which has the advantages of rapid pain relief and shorter recovery time. However, new adjacent vertebral compression fracture (AVCF) occurs frequently after vertebroplasty. The purpose of this study was to investigate the risk factors of AVCF and establish a clinical prediction model.We retrospectively collected the clinical data of patients who underwent vertebroplasty in our hospital from June 2018 to December 2019. The patients were divided into a non-refracture group (289 cases) and a refracture group (43 cases) according to the occurrence of AVCF. The independent predictive factors for postoperative new AVCF were determined by univariate analysis, least absolute shrinkage and selection operator (LASSO) logistic regression, and multivariable logistic regression analysis. A nomogram clinical prediction model was established based on relevant risk factors, and the receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA) were used to evaluate the prediction effect and clinical value of the model. After internal validation, patients who underwent vertebroplasty in our hospital from January 2020 to December 2020, including a non-refracture group (156 cases) and a refracture group (21 cases), were included as the validation cohort to evaluate the prediction model again.Three independent risk factors of low bone mass density (BMD), leakage of bone cement and “O” shaped distribution of bone cement were screened out by LASSO regression and logistic regression analysis. The area under the curve (AUC) of the model in the training cohort and the validation cohort was 0.848 (95%CI: 0.786–0.909) and 0.867 (95%CI: 0.796–0.939), respectively, showing good predictive ability. The calibration curves showed the correlation between prediction and actual status. The DCA showed that the prediction model was clinically useful within the whole threshold range.Low BMD, leakage of bone cement and “O” shaped distribution of bone cement are independent risk factors for AVCF after vertebroplasty. The nomogram prediction model has good predictive ability and clinical benefit. In China, the prevalence of osteoporosis among people aged 40 years and older is 5.0% among men and 20.6% among women . By 2050Although vertebroplasty provides rapid pain relief and functional recovery, some patients will present with complications including refracture, spinal cord compression, infection, nerve root injury, and embolism. The most widely investigated complication is adjacent vertebral compression fracture (AVCF) with an incidence of 6.8–37.5% , 9–11. HWe retrospectively collected and analyzed clinical data from patients undergoing vertebroplasty in our hospital between June 2018 and December 2020. The inclusion criteria included the following: (1) patients with low back pain and radiographic diagnosis of fresh vertebral fracture ;(2) patients who met the diagnostic criteria for osteoporosis (A or B): (A) Dual energy X-ray absorptiometry (DXA) showing T ≤-2.5 at spine/hip. (B) Sagittal L1-Hounsfield unit value ≤ 110 on computed tomography scan;(3) patients with OVCF caused by low energy injury; and (4) patients who underwent vertebroplasty. The exclusion criteria were as follows: (1) patients with OVCF caused by tumor, infection, or tuberculosis; (2) patients with OVCF caused by severe violence; (3) patients who had spinal cord compression and obvious neurological symptoms, such as numbness or muscle weakness; (4) patients who cannot tolerate surgery due to coagulation dysfunction or systemic diseases; and (5) incomplete clinical data.This retrospective study initially included 386 patients who had undergone vertebroplasty in our hospital from June 2018 to December 2019. We excluded 47 patients who lacked complete clinical information and 7 patients who died during the follow-up. Finally, 332 patients were included as the training cohort. These patients were divided into a non-refracture group (289 cases) and a refracture group (43 cases) according to the occurrence of AVCF during the follow-up.The median follow-up time of training cohort was 33.39(28.88 ~ 38.09)months and the median timing of AVCF was 6.03~3.00 ~ 12.20~months. Another sample of 177 patients who undergone vertebroplasty in our hospital from January 2020 to December 2020 was included as a validation cohort to evaluate the prediction model again, comprising a non-refracture group (156 cases) and a refracture group (21 cases) after excluding 34 patients with similar criteria . The median follow-up time of validation cohort was 17.77~15.04 ~ 20.50~months and the median timing of AVCF was 2.07~0.87 ~ 8.89~months, BMD, fracture segment, number of fractured vertebrae, history of diabetes, and history of hypertension.Surgical related factors: surgical method , dosage of bone cement, shape of bone cement (“H” or “O” shape) , dispersTo record the imaging measurements, all images were independently reviewed by two spine surgeons . In case of disagreement, consensus was achieved by group discussion with another surgeon . Definition and measurement of related factors: (1) shape of bone cement: group A (“H” shape), the filling pattern in the vertebral body involved two briquettes connected with / without a cement bridge and group B (“O” shape), the filling pattern in the vertebral body was a complete crumb and without any separation Fig. .P < 0.05 was considered statistically significant. R version 4.0.0 was used for nomogram model establishment and verification. Least absolute shrinkage and selection operator (LASSO regression) and logistic regression was used to screen the independent risk factors, and R was used to establish the risk prediction model of adjacent vertebral refracture after vertebroplasty. The area under the receiver operating characteristic (ROC) curve, calibration curve, and DCA were used to evaluate the prediction ability of the model.SPSS 22.0 version was used for statistical analysis of related risk factors. Measurement data are represented as median (interquartile range), namely M (P25 to P75), and categorical data are presented as percentages. Variables were tested for normality using the Shapiro–Wilk test. For data with normal distribution, differences between groups were analyzed using a t-test. The Mann–Whitney U test was used to compare data that were not normally distributed. A Chi-square test or Fisher exact test was used for enumeration data. Wilcoxon rank sum test was used for ranked data. P > 0.05). The BMD of patients with refracture was significantly lower than that of patients without refracture (P < 0.001). There was no significant difference in age, BMI, history of hypertension and diabetes, fracture segment, or the number of fractured vertebrae between the two groups (P > 0.05), as shown in Table A total of 332 patients who underwent vertebroplasty in our hospital were included in the training cohort. After at least 2 years of follow-up, 43 patients had AVCF and the incidence of refracture was 13.0%. There were 289 non-refracture patients, including 227 females (78.5%) and 62 males (21.5%), and 43 refracture patients, including 36 females (83.7%) and seven males (16.3%). More women had primary and secondary vertebral fractures, but there was no significant difference in the ratio of male to female between the two groups (P > 0.05). The proportion of leakage of bone cement in the refracture group (62.8%) was higher than that in the non-refracture group (17.6%) and the difference was statistically significant (P < 0.001). In terms of the distribution of bone cement in the vertebral body, the bone cement in the refracture group was more likely to show the “O” shape . However, there was no significant difference in dosage of bone cement, dispersion distribution grade of bone cement, AVH restoration, kyphotic angle restoration, or Cobb angle restoration (P > 0.05), as shown in Table In the non-refracture group, 200 patients (69.2%) underwent PKP and 89 patients (30.8%) underwent PVP. In the refracture group, 29 patients (67.4%) underwent PKP, and 14 patients (32.6%) underwent PVP. There was no significant difference in surgical method between the two groups (LASSO regression analysis was performed using R 4.0.0 to screen relevant risk factors. Five factors related to age, BMD, bone cement dosage, bone cement leakage, and shape of bone cement were selected as risk factors for AVCF after vertebroplasty Fig. . MultivaAccording to the three independent risk factors of BMD, leakage of bone cement, and shape of bone cement, a nomogram clinical prediction model was established in the training cohort Fig. . The areVertebroplasty, as a minimally invasive treatment technique, is considered to be the first choice for the treatment of patients with OVCF, as it has the advantages of rapid pain relief and short recovery time –15. HoweDifferent distributions of bone cement during surgery have different effects on the stress on the vertebral body and adjacent vertebrae. Compared with the vertebral body with uniform distribution of bone cement, the vertebral body with inadequate distribution of bone cement showed significantly increased Von mises stress in vertical, flexion, extension, and lateral bending . The excBMD, as measured by DXA, has been used for definition of osteoporosis since the mid-1990s . Bone loLeakage of bone cement is one of the major complications of vertebroplasty , 29. A lIn view of the high incidence of refracture in patients with clinical OVCF, it is particularly important to predict AVCF so as to carry out targeted prevention. In a previous study, Zhong et al.  establisWe found that low BMD, leakage of bone cement, and an “O” shaped distribution of bone cement were independent risk factors for AVCF after vertebroplasty. The nomogram clinical prediction model established in this study has good prediction accuracy and clinical benefit.