Mandibular distraction osteogenesis, a recommended therapy for hemifacial microsomia, has brought much agony because of its traumatic procedures and peri-osteotomy complications. Our study aims to retrospectively compare piezoelectric osteotome with conventional reciprocal bone saw for hemifacial microsomia patients and validate its meliority in operability, surgical risks and patient outcomes.All patients included underwent osteotomies conducted by either piezosurgery or bone saw. Information of intraoperative blood loss, operation duration, postoperative pain and complications was collected from patient files, ward round inspections and follow-ups.p < 0.001) and operation duration (p = 0.030). No significant difference was found in hospitalization duration, total expenses or complication rates between two groups. There were positive relations between operation duration and intraoperative blood loss (p = 0.042), and between hospitalization duration and total expenses (p = 0.0096). Postoperative pain scores of both groups declined over time while the piezosurgery group had a statistically significant tendency (p = 0.006) to suffer less than the conventional group.Among all 40 patients, 13 underwent piezo-osteotomy. Piezosurgery performed better than conventional reciprocal bone saw in decreasing intraoperative blood loss (Piezosurgery diminishes intraoperative blood loss, operative duration, and postoperative pain, making an alternative to conventional osteotomes to mitigate patients' and families' peri-osteotomy sufferings, and a more humane solution to HFM. Piezosurgery debuted on an operating table in 1975 , 9. The Whereas the implementation of piezosurgery is rarely reported in hemifacial microsomia, neither has it been compared with reciprocal bone saws . Our stu2.2.1.A total of 38 patients aged from 2 to 14 years with clear diagnosis of HFM OMENS-Plus  classification type M2A, M2B, and M3  who have2.2.This study has been approved by the ethics committee of Shanghai Ninth People's Hospital (2016-156-T105) and carried out in accordance with the World Medical Association Declaration of Helsinki (2013 amended version). Parents have been informed of the surgical risks before they chose either way of osteotomy and then given their written consent to patient inclusion.2.3.Before the surgery, archives, preoperative full cephalometric three-dimensional CT scan , and virtual surgical planning were arranged for every patient. Under general anesthesia, surgeries were performed by the same adept team consisting of craniomaxillofacial surgeons, registered nurses, and anesthesiologists.An intrabuccal incision was performed after injection of 1% lidocaine and 1:100,000 epinephrine, along the occlusal line from the first molars to in between the upper and lower teeth. The medial and lateral outer periostea of the mandible were released and carefully managed with a bipolar coagulator to minimize hemorrhage. The surgical guide was fixed onto the ramus under endoscope, between plates of which the osteotomy line was indicated, and then cleaved by either the reciprocal bone saw  or piezosurgery  from the interior side as shown in A distractor was installed intraorally and fixed by three screws, respectively, at the proximal end and distal end with protection of the inferior alveolar nerve .After insertion of a drainage, the oral mucosa was sutured with absorbable Vicryl 5-0 .Following a 7-day postoperative latency phase, the distraction was initiated and kept at a pace of 1 mm elongation per day. This process was terminated at cephalogram and panoramic radiograph confirmation of overcorrected mandibular midline and followed by the distractor removal surgery.2.4.Intraoperative blood loss and operation duration were accessed from the anesthesia chart of every surgery, while postoperative pain and complications were revealed by subsequent inspections during hospitalization. Patients were asked to point out their pain level on a visual analog scale (VAS) on ward rounds from day 2 to day 5 after surgery. For non-verbal young patients , childret-test, chi-square test, correlation analysis, and general linear model. All statistical analyses in this study was given α = 0.05 and statistical significance level at p < 0.05.All data were assessed by IBM SPSS Statistics Software Package, version 20.0 . Statistical methods include independent sample 3.t-test, while comparison between complication cases of conventional osteotomies and piezosurgery was made by the chi-square test. Relevance between intraoperative blood loss and operation duration or hospitalization duration and total expenses was achieved through the correlation analysis. Postoperative pain scores on different days and their tendency were analyzed by the general linear model.Data of the 38 patients aged 2–14 years with diagnosis of HFM OMENS-Plus type M2A, M2B, and M3 were collected. Eleven of them (28.9%) underwent osteotomy conducted by piezosurgical instruments. These patients were defined as the piezosurgery group. The other 27 patients who underwent reciprocal bone saw osteotomy were defined as the conventional group. Other epidemiological data were listed in p < 0.001) between the two groups.The mean amount of intraoperative blood loss was 95.56 ml (SD: 60.98 ml) in the conventional group, 38.18 ml (SD: 17.22 ml) in the piezosurgery group, and 78.95 ml (SD: 58.21 ml) in all patients. There was a distinct difference (p = 0.030) in the piezosurgery group compared with a mean of 165.19 min (SD: 43.445 min) in the conventional group. The mean operation duration in all patients was 154.87 min (SD: 45.522 min).The operation duration with a mean of 129.55 min (SD: 42.039 min) was also significantly lower . These patients were found to have stayed shorter in hospital and reported their infections after discharge. The correlation analysis between hospitalization duration and postoperative complications reported an r = −0.248 and a unilateral p = 0.108.Five patients in the conventional group (18.52%) were reported to have postoperative infection, while none in the piezosurgery group was found with complications . Yet thir = 0.331, p = 0.042) and between hospitalization duration and total expenses .The correlation analysis showed positive relations with medium strength between operation duration and intraoperative blood loss (p = 0.032) and day 3 (p = 0.001) between the two groups. The mean scores were, respectively, 5.89 out of 10 (SD: 1.74) in the conventional group and 4.63 (SD: 1.03) in the piezosurgery group on day 2 and 5.67 (SD: 1.44) in the conventional group compared with 4.00 (SD: 1.00) in the piezosurgery group on day 3. Although postoperative pain scores of both groups were declining over time (p = 0.006) to suffer less than those in the conventional group  are vulnerable to great social pressure owing to their appearance. Yet MDO, the most widely endorsed therapy for these patients, despite its esthetic and auxetic improvements, burdens patients with pain and their family with high medical expenses and large efforts on aftercare attributed to its technical difficulty, complexity, and risks.In this rapidly developing era, empathetic doctors like us strive to improve MDO from various aspects to lighten patients’ burdens, namely, cephalometric technique of better precision—3D CT, more elaborated preoperative design—virtual modeling, more flexible intraoperative guidance-augmented reality, advanced anesthesiology and nursing science, or even some subtle details such as bipolar coagulation. The newly emerged surgical instrument piezosurgery has been seen as a boon by the orthopedists and therefore gains our preference as an alternative to conventional osteotomy devices.Piezosurgical device transduces electricity toward mechanical energy and makes the titanium tool bit vibrate at a high-frequency resonance, strong acceleration generated by which allows efficient pulverization, and cutting on target bones, thus distinctly shortening the operation duration. Upon the first contact with bone tissues, the piezoelectric tool bit acts immediately yet purely on the bone in a restricted scale of a few hundred micrometers with density selectivity that switches its work mode to low-frequency vibration on low-density objects, expelling the possibility of wringing, grinding forces, and damages to adjacent tissues. This may explain a smaller dissection field on the interior side of the mandible caused by piezoelectric osteotome when entering through an intrabuccal incision. Conversely, bone saws with a larger range of motion tend to impact soft tissues and, in most cases, penetrate the mandible, causing neurovascular injuries on the lateral side.A build-in cooling system on the piezoelectric device reduces the heat load, prevents marginal osteonecrosis which could impact the ability of bone regeneration and ultimately the effect of distraction osteogenesis, and at the same time washes away bone debris during the osteotomy to tidy the fracture end and give a clear vision. Piezoelectric scalpels with micro-vibrations are of less tendency to bounce and at greater ease to handle, so when surgeons find out an exposed nerve or vessel, or an excessive entrance of tip close to tooth buds and intend to detour, there would be few interference from scalpels’ own jounce with their delicate grasp of movement directions. In other words, piezosurgery has less dependence on surgeons’ feeling or pre-judgment; instead, it endows with enough time to respond and redress. This precaution against inexperience results in easy manipulation and long-term pedagogical benefit for beginner surgeons. Thermal effect arisen from vast cavitation bubble rupture during piezosurgery working coagulates bleeding vessels with denaturized protein clots in adjacent tissues and decreases intraoperative blood loss to facilitate better convalescence.Both osteotomy instruments achieve anticipated surgery effects with few noticed differences albeit an extra cost of a few tenths of a millimeter's length on the mandibular ramus on account that the thickness of piezoelectric scalpel is twice that of a bone saw. Though this discrepancy is too subtle to be visualized on CT imaging or with the naked eye, it makes a foremost limitation of this study. The lack of measurements on sectioned bone volume  or ultim5.Piezosurgery serves as a next-generation way of osteotomy with unique property that offers definite convenience and support to surgeons. It preserves the outcomes of MDO and simultaneously diminishes intraoperative blood loss, operative duration, postoperative pain, and complications of osteotomy, including soft tissue, neurovascular, and tooth bud injuries. In our outlook, the safer, more efficient, and more approachable alternative to conventional osteotomes, piezosurgery, is able to mitigate patients’ agony and families’ financial and energy drain and open the vista of a more humane solution to HFM.


Campylobacter species are widely distributed pathogens; however, data on its epidemiology in puppies remain scanty, especially in Kenya. A cross-sectional study was conducted in the Nairobi Metropolitan Region to determine molecular prevalence and associated risk factors of Campylobacter species infection in puppies. A total of 260 rectal swabs were collected from puppies from breeding kennels, shelters, and the University of Nairobi Veterinary Teaching and Referral Hospital. The samples were subjected to polymerase chain reaction (PCR) assays for identification of Campylobacter species. Data on potential risk factors associated with puppy exposure were collected using a semistructured questionnaire. Multivariable mixed effects logistic regression analyses were performed with kennels as random effects. Campylobacter species were detected in 64 of the 260 sampled puppies yielding an overall prevalence of 24.6%. Multivariable results showed that puppies from shelters, puppies from kennels that are washed daily, puppies with a recent history of vomiting, and those treated with antibiotics in the past month were significantly associated with the presence of Campylobacter species. Being a kenneled puppy and having had concurrent bacterial infections were identified as protective factors. This study provides molecular evidence of puppy exposure to Campylobacter species which could have impact on puppy health and highlights the need to develop awareness and management strategies to potentially reduce the risk of transmitting this pathogen among puppies, to humans, and other animals. Campylobacter, is a significant zoonotic gastrointestinal disease affecting humans and animals, including dogs, globally [Campylobacter infections in humans are attributable to the consumption of contaminated or undercooked poultry [Campylobacter species infections [Campylobacter infection for their owners, with infants and young children having a higher risk of infection [Campylobacteriosis, caused by thermophilic bacteria of the genus globally –4. The v poultry , 5, 6, c poultry , or raw  poultry . Close cfections , 9 with nfection .Campylobacter species prevalence in dogs varies widely [Campylobacter colonization in dogs [Campylobacter species [s widely –15, depes widely , 16, 17. in dogs –20. The  in dogs , 22. Fur species .Campylobacter species is generally performed using the conventional culture method, it is time-consuming and labor-intensive, due to the fastidious nature of the species [Though the detection of  species . Hence,  species , 24, 25.Campylobacter pathogens, current data on Campylobacter species epidemiology in Kenyan puppies are limited. Therefore, this study aimed at determining the molecular prevalence and associated risk factors of Campylobacter species in puppies in the Nairobi Metropolitan Region, Kenya.Despite reports of puppies serving as essential reservoirs for This study was approved by the Biosecurity, Animal Use, and Ethics Committee (BAUEC) of the Faculty of Veterinary Medicine, University of Nairobi, Kenya (FVM BAUEC/2019/237). Verbal consent was sought from breeders, kennel managers, and puppy owners prior to sampling.Study areas and design have been previously described  Figure . In brieCampylobacter species infection, a detailed questionnaire was administered to collect puppy-level factors  and management factors . Prior to sampling, each puppy was assigned a body condition score (BCS) in accordance with the Waltham Size, Health, and Physical Examination (SHAPE) Score™ which contains seven scores from A (underweight) to G (obese) based on the presence and amount of subcutaneous and abdominal fat [https://www.slideshare.net/WalthamCPN/waltham-pocket-book-of-healthy-weight-maintenance-for-cats-and-dogs-71137293). The Canine Inflammatory Bowel Disease Activity Index (CIBDAI) clinical scoring system by Jergens et al. [n = 210), shelters (n = 6), and veterinary hospital (n = 44).The sampling methods have been previously described  Figure . In brieinal fat   and identified by biochemical tests . Genomic DNA was obtained from these presumptive Campylobacter species isolates using the boiling method as described by Wang et al. [Campylobacter, primers (C412GF 5′-GGATGACACTTTTCGGAGC-3′ and C1228R 5′- CATTGTAGCACGTGTGTC-3′) [16S rRNA gene were used. The polymerase chain reaction was performed in a total volume of 12.5 μl containing mastermix of 6.25 μl and 0.25 μl each of forward and reverse primers, 5 μl of DNA template, and 0.75 μl of sterile distilled water.The isolates utilized in this study were obtained from a previous study on culture prevalence in puppies in Kenya  Figure . Campylog et al. . PolymerTGTC-3′)  targetinThe thermocycling conditions used were initial denaturation at 95°C for 15 minutes, followed by 25 cycles each of denaturation of 95°C for 30 seconds, annealing at 58°C for 1.5 minutes, extension at 72°C for 1 minute, and final heating at 72°C for 7 minutes. Samples were held at 4°C prior to analysis.μl of amplified products was identified by electrophoresis in a 1.5% (weight/volume) agarose gel in 1X Tris-Borate-EDTA (TBE) buffer, subsequently stained with ethidium bromide and ran for 30–45 minutes at 200 V, and visualized by UV-illuminator . The sizes of the amplicons were determined using 100 bp molecular ladder. Specific amplified fragments expected were of size 816 bp which corresponded to the Campylobacter genus.Controls were used for all PCR assays, and 10 Campylobacter was detected by PCR in a sample, the puppy was considered infected.The unit of observation corresponded to an individual sample, and each sample represented an individual puppy. If Campylobacter species prevalence and other demographic parameters were computed using descriptive statistics. The chi-square test was used to compare Campylobacter species carriage ratios between different categorical groups. Potential factors associated with Campylobacter species carriage in puppies were investigated using univariable logistic regression analysis. Covariates were retained in the model if statistically significant at  p ≤ 0.2 using a backward stepwise elimination procedure. All variables that showed an association with the outcome variable in the univariable logistic regression analysis (p < 0.05) were considered in the final mixed effects logistic regression analysis. Potential clustering of puppies within kennels was controlled by including kennels as a random effect in the modeling. Model fit was assessed by checking for multicollinearity, overall goodness of fit of the model, influential data points, and outliers.Questionnaire data and PCR results were entered into Microsoft Excel version 2016  before being exported to STATA 17.0  for analysis. Campylobacter species isolates obtained from a previous study [16S rRNA gene specific to Campylobacter species which produced a specific band corresponding to the expected size of 816 bp (Polymerase chain reaction was used to identify us study . This waf 816 bp . The resCampylobacter species infections based on PCR is described in Campylobacter species was observed in puppies from shelters (50% (3/6)) and those kept as pets (29.7% (11/37)). Similar observations were noted in puppies sharing a kennel (25.1% 55/219)), whose kennels were washed on a daily basis (27.1% (62/229)), from kennels with wooden floors (27.8% (49/176)), and puppies fed homemade diets (30.7% (27/88)).The distribution of various puppy-level and management factors associated with p ≤ 0.2) with positive Campylobacter species PCR status , kennels that are washed daily , puppies with a history of recent vomiting , and puppies treated with antibiotics in the past month . Seven factors were associated with lower Campylobacter species carriage: puppies from breeding kennels , puppies from shelters , puppies kept for security , kenneled puppies , puppies more than 5 months of age , puppies with an ideal body condition or are moderately obese , and puppies with concurrent bacterial infections .Univariable logistic regression identified 11 factors to be associated , kennels that are washed on a daily basis , puppies with a recent history of vomiting , and puppies treated with antibiotics in the past month . Protective factors identified were puppies from breeding kennels  and puppies with concurrent bacterial infections .Multivariable logistic regression analysis revealed that the factors significantly associated with higher Campylobacter species in 36.4% and 13.7% of the puppies whose infection status was classified as severe and clinically insignificant, respectively  by targeting the 16S rRNA gene specific for these microorganisms. This proportion was within the range of 8.58% to 75.7% reported in studies done in the past five years [Campylobacter species observed in this study among puppies is a cause for concern, as their feces contaminate the environment and may serve as a source of infection for humans, particularly children.Polymerase chain reaction (PCR) detected 64 ve years , 31–33. Campylobacter-positive status, a finding that is in agreement with previous research [Campylobacter species. This finding contradicts those of Verma et al. [Campylobacter species infection and the incidence of vomiting in dogs. Findings of this study, however, concur with those of Guest et al. [Campylobacter species infection in puppies.Though clinical manifestations of gastroenteritis include diarrhea and vomiting , this stresearch , 36. Howa et al. , who fout et al. , who fouCampylobacter species carriage. These findings are in agreement with those of previous studies [Campylobacter species carriage is more prevalent among puppies who share a habitat with other puppies such as in shelters [Shelter-housed puppies were at a higher risk for  studies , 38. Camshelters , 39, 40.shelters . The pupshelters  and furtCampylobacter species carriage in dogs [Campylobacter species carriage in the studied puppies. Despite the fact that daily washing of kennels improves hygiene, Campylobacter species are sensitive to desiccation and do not survive in dry environments [It is recognized that kennel hygiene is a potential risk factor for  in dogs . In thisronments , and thuronments , allowinronments . PuppiesCampylobacter species carriage which was in agreement with a study by Leonard et al. [Campylobacter species.Treatment with antibiotics in the past month was greatly significant with the risk of d et al. . This coCampylobacter species which can be transmitted to humans and other animals through contaminated environmental sources. Polymerase chain reaction (PCR) should be regarded as indispensable in clinical and epidemiological research. It is important to develop awareness and management strategies to potentially reduce the risk of transmitting this pathogen from puppies to humans and other animals.This study has shown that puppies in Kenya carry


Pregnancy-related healthcare utilization is inadequate in Bangladesh, where more than half of pregnant women do not receive optimum number of antenatal care (ANC) visits or do not deliver child in hospitals. Mobile phone use could improve such healthcare utilization; however, limited evidence exists in Bangladesh. We investigated the pattern, trends, and factors associated with mobile phone use for pregnancy-related healthcare and how this can impact at least 4 ANC visits and hospital delivery in the country. We analyzed cross-sectional data from Bangladesh Demographic and Health Survey (BDHS) 2014  and 2017–18 . Only 28.5% and 26.6% women reported using mobile phones for pregnancy-related causes in 2014 and 2017–18, respectively. Majority of the time, women used mobile phones to seek information or to contact service providers. In both survey periods, women with a higher education level, more educated husbands, a higher household wealth index, and residence in certain administrative divisions had greater likelihoods of using mobile phones for pregnancy-related causes. In BDHS 2014, proportions of at least 4 ANC and hospital delivery were, respectively, 43.3% and 57.0% among users, and 26.4% and 31.2% among non-users. In adjusted analysis, the odds of utilizing at least 4 ANC were 1.6 : 1.4–1.9) in BDHS 2014 and 1.4 (95% CI: 1.3–1.7) in BDHS 2017–18 among users. Similarly, in BDHS 2017–18, proportions of at least 4 ANC and hospital delivery were, respectively, 59.1% and 63.8% among users, and 42.8% and 45.1% among non-users. The adjusted odds of hospital delivery were also high, 2.0 (95% CI: 1.7–2.4) in BDHS 2014 and 1.5 (95% CI: 1.3–1.8) in BDHS 2017–18. Women with history of using mobile phones for pregnancy-related causes were more likely to utilize at least 4 ANC visits and deliver in health facilities, however, most women were not using mobile phones for that. Globally, maternal and neonatal deaths declined substantially during the past couple of decades, however, the maternal mortality ratio (MMR) and neonatal mortality rate (NMR) remain high in many low- and middle-income countries (LMICs) , 2. MostGlobally, the ubiquitous presence of mobile phones, has been a phenomenal tool providing healthcare services delivery and information in low-resource settings , 9. SeveThis study has three primary objectives: (1) to describe the mobile phone usage prevalence for pregnancy-related causes; (2) to identify the sociodemographic factors associated with this use; and (3) to investigate the association of mobile phone for pregnancy-related causes with at least 4 ANC visits and hospital delivery. Findings of the present study will be useful for researchers and policymakers to expand the mobile phone use for maternal health care utilization in Bangladesh.BDHS 2014 and 2017–18 received ethical approval from the International Institute for Population Science and ICF International Institutional Review Boards. All adult respondents  provided informed consent to participate. For participants with 15–17 years of age, consent was obtained from a legal guardian; the respondents provided assent as well. In December 2020, electronic approval was obtained to use data from ICF International, Rockville, Maryland, USA.We analyzed BDHS 2014 and BDHS 2017–18 data. These cross-sectional surveys primarily aim to collect data on major demographic and health indicators in Bangladesh, including indicators of maternal and child health. BDHS covers rural and urban regions in all divisions . Both surveys were conducted by Mitra and Associates, a private research organization in Bangladesh. About two hundred data collectors were trained and recruited. BDHS 2014 data were collected from June to November 2014 while data collection for BDHS 2017–18 took place from October 2017 to March 2018. Ever-married women of reproductive-age  were interviewed with the women’s questionnaire , 13.First, a sampling frame was preapred with a list of enumeration regions (EAs). This list was prepared based on housing and population census 2011 in the country. Women were interviewed in households and this list of households were selected in two stages. During BDHS 2014, 393 EAs were selected from rural regions and 207 EAs were selected from urban regions. For BDHS 2017–18, a total of 425 and 250 EAs were selected from rural and urban regions, respectively. Next, a sample of 30 houesholds were selected from each EA. In this way, a naionally representative sample were otained to reflect statistically reliable estimates of the surveyed indicators. The survey results, methodology, questionnaire, and sample size estimates are reported elsewhere , 13. BDHWomen were asked if they or any of their family members used mobile phones to obtain health services or advice during pregnancy or delivery. Then, they were asked the reason for using: “ask what to do”; “contact service provider”; “arrange transport”; “arrange money”; “arrange the place of delivery”; and “others” , 13. ThrWomen were questioned about whether they received any ANC during their pregnancy . They were also asked the number of times they received ANC visits. We dichotomized this based on receiving at least 4 ANC visits . The location of delivery  was determined by asking respondents about their most recent delivery . Hospital deliveries were defined as those that occurred in a hospital. Home deliveries were defined as those made to a woman’s residence, a friend’s residence, or a relative’s residence , 13.Following potential associated factors and confounders were selected based on literature review, scientific plausibility, and data structure: women’s age, parity, women’s education, husband’s education, current work status, religion, household wealth status, and rural-urban place and division of residence. First, we described sociodemographic characteristics of the study sample using weighted percentages (%) and unweighted numbers (n) for categorical variables and mean with standard errors for continuous variables. After describing the purpose of using mobile phones for pregnancy-related causes during the last pregnancy, the prevalence ) of this usage was reported according to background characteristics. To investigate the associated factors of mobile phone usage, we conducted multi-level logistic regression. Similarly, to investigate the association of using mobile phone with at least 4 ANC visits and hospital delivery, we used multilevel logistic regression. Variables that had significance level up to 0.2 during their unadjusted logistic regression analysis with mobile phone use, at least 4 ANC visits, and hospital delivery were adjusted into multivariable analysis . Both unThe analysis included a total of 9368 participants, 4465 in the BDHS 2014 and 4903 in the BDHS 2017–18 . The aveIn both surveys, a higher proportion of respondents called “to ask what to do” than all other reasons, 18.3% in BDHS 2014 and 15.8% in BDHS 2017–18, followed by the reason “to contact service provider”, 10.3% in BDHS 2014 and 12.8% in BDHS 2017–18 . A smallThe proportions and trends of ever using mobile phone for pregnancy-related causes according to background characteristics of the respondents are shown in st pregnancy) than 2nd or more pregnancy history in BDHS 2014  and BDHS 2017–18 . Women with higher education levels, higher educated husbands, or higher wealth status had higher odds of using mobile phones than those with lower education or wealth. Although respondents residing in the Chittagong division had higher odds in BDHS 2014  than Dhaka, the odds were lower in BDHS 2017–18 . Barisal had greater odds both in BDHS 2014  and BDHS 2017–18  than Dhaka. Only in BDHS 2014, the odds were lower among residents in Rajshahi  and Sylhet  divisions while these were higher among respondents from Rangpur  division.In BDHS 2014, 43.3% (95% CI: 38.8–47.8) of women received at least 4 ANC visits among user group while this proportion was 26.4% (95% CI: 23.8–29.1) among non-user group . In 2017This study investigated the patterns and factors associated with using mobile phones for pregnancy-related causes and how this use is associated with at least 4 ANC visits and hospital delivery after analyzing two nationally representative survey datasets from Bangladesh, BDHS 2014 and 2017–18. We found that women with primi gravida, higher socioeconomic status , and residence in some administrative divisions had higher odds of using mobile phones for pregnancy-related causes. Using mobile phones was also associated with higher likelihoods of at least 4 ANC visits and hospital delivery. Our study provided a potential opportunity to generate evidence for incorporating the dynamic tool of mobile phone technology to improve the access, health care seeking approach, and maternal health care utilization practices in Bangladesh.Overall, only a little higher than one-fourth of the total respondents used mobile phones for pregnancy-related causes in both survey years. With increasing ownership and subscription, we expected a simultaneous increase in that, however, the change was in opposite direction. Higher maternal health services  utilization among women with the history of mobile phone use for pregnancy-related causes have important implications for the country. Studies from other LMICs had similar findings, therefore, access to and use of mobile phone for pregnancy-related causes may increase maternal health care utilization in other countries as well , 19–21. The socioeconomic differences in mobile phone using are also observed in utilization of maternal health care utilization , 24. HisWe also observed differences in using mobile phone according to administrative divisions similar to prior studies , 29, 30.The ‘three delays’ model is commonly mentioned to describe delays in accessing maternal health care. These delays are: (1) “delay in decision to seek care”; (2) “delay in reaching care”; and (3) “delay in receiving adequate health care” . ExpandiThis study has several notable strengths. We analyzed two nationally representative datasets with large sample sizes and high response rates to investigate the trends and associations. To minimize recall bias, we only included the history of last pregnancy. The survey used standardized and validated questionnaires that increased authenticity of our findings , 13. HowThis study demonstrated that using mobile phones for pregnancy-related causes can improve maternal health services utilization in Bangladesh. Considering the high MMR and NMR along with a low maternal health service utilization, effective programs, policies, and interventions should be implemented to increase use of mobile phones for maternal health care utilization, particularly among women belonging to lower socioeconomic groups.S1 Fig(TIFF)Click here for additional data file.S2 Fig(TIFF)Click here for additional data file.


To compare the surgical trauma and outcomes between oblique lateral interbody fusion (OLIF) and posterior fixation and posterior lumbar interbody fusion (PLIF) with fixation for adult degenerative scoliosis (ADS).We included ADS patients who underwent OLIF with fixation or PLIF with fixation treatment from June 2020 to December 2022. The preoperative and postoperative spinal pelvic parameters were measured using X-rays. Clinical symptoms were measured using the Oswestry Disability Index and a visual analog scale. We recorded operation time, intraoperative blood loss, blood transfusion, albumin infusion, surgical fixation segment, surgical osteotomy segment, time, and drainage volume.p > 0.05). There were no statistical differences in postoperative spinal parameters or clinical symptoms (p > 0.05). Patients in the OLIF group had less intraoperative blood loss (p < 0.01) and fewer intraoperative blood transfusions (p < 0.001) than the posterior surgery group. The number of fixed segments was fewer (p < 0.01), and there were fewer total osteotomy segments (p < 0.001).Forty patients with ADS were included: 20 with OLIF with posterior fixation and 20 with PLIF matched for age, sex, pelvic incidence, and Cobb angle with the OLIF group. There were no significant differences in age, gender, BMI, preoperative spinal parameters, or preoperative clinical symptoms between the groups (OLIF with posterior fixation surgery can achieve the same corrective effect and efficacy as a posterior internal fusion with fixation surgery for treating ADS. OLIF with posterior fixation surgery causes less trauma and reduces the number of fixation segments. Adult degenerative scoliosis (ADS) is a spinal deformity with a scoliotic angle of over 10 degrees that develops post-adulthood. ADS usually begins around age 50 and progresses with aging . The preThe posterior approach of long fusion with osteotomy correction of the deformity is the conventional technique to treat ADS . HoweverBesides posterior approach, the approaches to the spine forward of the vertebral canal, such as oblique lateral interbody fusion (OLIF), lateral lumbar interbody fusion (LLIF), and extreme lateral interbody fusion (XLIF), are increasingly used in performing fusion . StudiesOblique lateral interbody fusion (OLIF) is gaining popularity because it provides indirect decompression, preserves the posterior column structure, and causes less trauma and blood loss –10. SomeCompared with posterior correction and fixation, the affection of OLIF on the second-stage posterior surgery osteotomy level, the number of fusion segments, and the operation time for treating the patients with ADS are still unknown. Therefore, we performed a cohort study to compare the clinical and radiological outcomes between OLIF and posterior lumbar interbody fusion (PLIF) for treating patients with ADS.In this retrospective study, we obtained ethical approval from the ethics committee at our hospital. A total of 101 patients underwent OLIF with posterior fixation, and 236 patients underwent three (or more)-level PLIF by a single surgeon from June 2020 to December 2022. All patients meet the following surgical indications: (1) recurrent low back and leg pain gradually worsens, seriously affecting normal life and ineffective non-surgical treatment; (2) accompanying lumbar spinal stenosis or stubborn nerve root pain and neurological dysfunction, with intermittent claudication; (3) muscle strain secondary to imbalance of spine or scoliosis; (4) progressive exacerbation of scoliosis, with scoliosis progression > 10°; (5) pulmonary dysfunction secondary to spinal deformities, affecting normal daily life; and (6) there were no obvious surgical contraindications during preoperative evaluation. The goal of surgery is to relieve the nerve root compression and correct deformity [Inclusion criteria are as follows: (1) patients with more than 10 degrees of Cobb angle; (2) aged more than 40 years old; and (3) a completion of more than 3 months follow-up.T-score < − 3.5); (4) spinal deformity caused by spinal tumor or infection; and (5) paraplegia or difficulty standing.Exclusion criteria were as follows: (1) idiopathic or congenital scoliosis; (2) history of previous spine surgery; (3) severe osteoporosis , duration of follow-up time period, and major intraoperative and perioperative complications. Albumin and hemoglobin were recorded before and on the first day after surgery.All patients underwent general anesthesia before surgery. In the OLIF group, the procedure used a lateral approach. The incision was transverse, centered on the anterior margin of the disk space. The natural space between the retroperitoneal abdominal aorta and the front edge of the psoas major muscle was used to remove the intervertebral disk. PEEK intervertebral cages filled with artificial bone were inserted into intervertebral space. Subsequently, or in the second stage, patients were placed in the prone position and underwent posterior fixation. Posterior decompression was performed according to compression segments. Pedicle screw augmentation with cement or proximal segment strengthening was performed according to the bone condition.In the PLIF group, the patients were positioned prone. An incision was made in the middle of the posterior square of the back. Paraspinal muscles were dissected layer by layer to expose the lamina and articular process. Decompression was performed according to compression segments. Fusion was performed with cages filled with autograft from a laminectomy. Fixation was performed with rods and pedicle screws. Pedicle screw augmentation with cement or proximal segment strengthening was performed according to the bone condition.The posterior osteotomies were performed according to the stiff deformity and imbalance to correct the deformity and rebalance the spine. The osteotomies were usually Smith–Petersen osteotomy (grade I), Ponte osteotomy (grade II), and pedicle subtraction osteotomy (grade III). Operation time, fixation segments, osteotomy level, blood loss, blood transfusion , human albumin 20% infusion, time, and drainage volume were recorded.Whole-spine standing radiographs were obtained before surgery and at follow-up in a standardized upright position. Spine alignment measurements in this study were defined with neutral standing X-ray images Fig. .Fig. 1MePelvic tilt (PT) was defined by the angle between the line connecting the midpoint of the S1-endplate to the axis of the femoral heads and the vertical plane. The sacral slope (SS) was defined as the angle between the horizontal and sacral endplates. Pelvic incidence (PI) was defined as the angle perpendicular to the sacral endplate at its midpoint and the line connecting this point to the axes of the femoral heads. Thoracic kyphosis (TK) was measured from the upper endplate of T4 to the lower endplate of T12. Lumbar lordosis (LL) was defined as the angle between S1-endplate and L1 upper endplate. Thoracolumbar kyphosis (TLK) was measured by the CA between the upper endplate of T10 and the lower endplate of L2. The C7 sagittal vertical axis (SVA) was defined by the horizontal distance from the superior posterior end of the upper sacral endplate to the C7 plumbline. The C7 coronal vertical axis (CVA) is the distance from the C7 plumb line to the central sacral vertical line. The scoliosis Cobb angle (CA) was also measured. We defined lordosis as a positive value and kyphosis as a negative value.The lumbar function was evaluated using the Oswestry Disability Index (ODI), and the degree of low back pain and lower limb pain was evaluated using a visual analog scale (VAS).T-test for parametric test or Wilcoxon test for nonparametric test. The results were expressed as the mean value ± standard deviation. A probability (p) value of < 0.05 was considered statistically significant.All collected data were analyzed using IBM SPSS Statistics, version 25.0 . One-to-one propensity score matching was performed. Covariates were age, sex, PI, and CA. OLIF cases were matched in a 1:1 ratio to PLIF patients based on the propensity score with a standard caliper width of 0.2. Statistical analysis was performed using the p > 0.05, Table In the OLIF group, 20 of 101 patients underwent OLIF for ADS. Twenty of 236 patients in the PLIF group were matched with 20 patients in the OLIF group using a match tolerance of 0.2 based on age, sex, PI, and CA. The average age was 70.45 ± 8.94 years old in the OLIF group and 70.55 ± 6.93 years old in the PLIF group. There were no significant differences in age, gender, BMI, or follow-up . Hemoglobin and albumin did not differ between the two groups . The mean ODI score was 32.25 ± 8.06% in the PLIF group and 30.95 ± 10.66% in the OLIF group. The mean lumbar VAS score was 5.80 ± 1.52 in the PLIF group and 5.85 ± 1.42 in the OLIF group. The mean leg VAS score was 3.25 ± 1.65 in the PLIF group and 3.20 ± 1.91 in the OLIF group.The radiological parameters before surgery are displayed in Table P = 0.055). The OLIF group showed less blood loss (P = 0.006), fewer intraoperative blood transfusions (p < 0.001), fewer postoperative blood transfusion (p = 0.020), fewer fixation segments (p = 0.003), and fewer osteotomy levels (p < 0.001). The OLIF group had less drainage time and volume . The groups had similar interbody fusion levels, postoperative albumin infusion, postoperative hemoglobin, and postoperative albumin   . The mean ODI, lumbar VAS, and leg VAS at the final follow-up were significantly lower than the preoperative values in both groups (p < 0.001). No significant differences were found in postoperative ODI, VAS of the back, or VAS of the leg .We compared the radiological parameters and clinical outcomes at follow-up between the groups Table . There wThree case of urinary tract infection, two cases of dural tears, one case of cage subsidence, one case of local hematoma, one case of deep venous thrombosis (DVT), and one case of deep wound infection were confirmed in PLIF group. The most common intraoperative complication was endplate injury (3/20) in the OLIF group. The postoperative complications included transient psoas (6/20), cage subsidence (5/20), delirium (1/20), and DVT (1/20) in OLIF group. No major complication that required prolonged hospitalization or revision was found in both two groups.ADS is associated with sagittal and coronal plane malalignment caused by asymmetric intervertebral disk degeneration and facet joint degeneration . The preThe OLIF technique involves inserting a very large cage with the anterior approach, which can directly increase the height of the interbody, indirectly decompress the spinal canal, and improve coronal and sagittal spinal alignment , 9. StudWe found that both groups' VAS-back, VAS-leg, and ODI scores improved significantly. The groups had no differences in postoperative VAS-back, VAS-leg, or ODI scores. These findings suggest OLIF can achieve clinical outcomes that are not inferior to those of PLIF. Shimizu et al. reported that OLIF had the same short-term efficacy as PLIF in treating lumbar spinal stenosis . Zhao etThere was a reduced coronal CA postoperatively in both groups, 14.29 ± 9.70° CA reduction in the PLIF group and 17.44 ± 9.70° in the OLIF group. There was no difference in the correction of coronal CA. The wide cages in the OLIF group provided the ability to correct CA. Many studies found that sagittal imbalance is associated with quality of life; thus, restoring sagittal balance can improve outcomes , 18, 19.The present study found that the number of intervertebral fusion levels was similar between the groups; however, the average volume of intraoperative blood loss was less in the OLIF group than in the PLIF group. The postoperative drainage volume was less, and the drainage time was shorter in the OLIF group than in the PLIF group. Unlike PLIF, which relies more on osteotomy correction, OLIF can achieve correction by opening the intervertebral space and lateral osteophytes. Therefore, OLIF uses fewer osteotomy levels and requires a lower grade of osteotomy than PLIF. OLIF achieved similar correction effects to PLIF by using fewer osteotomies. Furthermore, the wide cages in the OLIF group opened the lateral osteophytes, widened the intervertebral space to correct the deformity, supported the lateral rims of the endplate, and prevented subsidence and subsequent loss of deformity correction  Fig. 2)2).Fig. 2The PLIF group had more intraoperative and postoperative blood transfusion volume than the OLIF group. Six patients in the PLIF group received postoperative albumin infusion, while only three patients in the OLIF group received albumin infusion. There was no significant difference in average albumin infusion between the two groups. There was no significant difference in postoperative hemoglobin and albumin between the groups, suggesting that the nutritional statuses of the groups were similar after blood transfusion and albumin infusion. Although OLIF did not extend the surgery time, some patients require extra anesthesia for the second-stage surgery. The damage caused by second anesthesia may require further attention.The recognizable criteria to determine fusion level are fixation, including the apex of the curve, junctional kyphosis, severe lateral subluxation, spondylolisthesis, and retrolisthesis . To shorSurgical complications include perioperative and long-term complications. Due to different surgical approaches, perioperative complications of OLIF include vascular injury, endplate destruction, transient thigh pain or numbness and hip flexor weakness or pain, ileus injury, neurologic injury, and sympathetic chain injury , 25. OLIThis study was retrospective. We summarized patients who had undergone surgery rather than a prospective analysis of patients with scoliosis. Nevertheless, this study matched the age, gender, PI, and CA of the groups to minimize selection bias as much as possible. A large sample with long-term follow-up is more suitable to validate the efficacy of OLIF. Nevertheless, we believe that our results are helpful for surgeons who treat ADS.OLIF with posterior fixation surgery can achieve the same corrective effect and clinical efficacy as a posterior internal fusion with fixation surgery for treating ADS. OLIF with posterior fixation surgery introduces less trauma and reduces the number of fixation segments.


In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model.From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration.SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer–Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification.Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture. In 1911, French radiologist Etienne Destot first described pilon fractures as injuries to the distal tibia's articular weight-bearing surface –4. PilonIn the AO/OTA classification of long bone fractures, pilon fractures are classified as extra-articular (43A), partially articular (43B), and intra-articular (43C), and are further subdivided according to the degree of comminution . For cloPostoperative infection is often catastrophic, and there is even a risk of amputation . VariousIn this study, we try to investigate the risk factors for postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model. To provide a reference for the prevention and treatment of high-risk infection patients in the future.This study was approved by the Ethics Committee of our Institute (NO. 2021-K-241-01) in accordance with the guiding principles of the Declaration of Helsinki. All electronic medical records and image data were anonymised and personal identifiers were completely removed.Patients who underwent surgical treatment for pilon fractures in our hospital from January 2012 to June 2021 were included in this retrospective study. The inclusion criteria were: (1) age ≥ 18 years; (2) the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 43 pilon fracture; (3) closed fracture; (4) underwent open reduction and internal fixation (ORIF); (5) complete clinical data. Exclusion criteria were as follows: (1) open fracture; (2) pathological fracture; (3) tibia shaft fracture; (4) trimalleolar ankle fracture; (5) conservative treatment; (6) kirschner wire or external fixation. Finally, a total of 516 pilon fracture patients were enrolled in our study.Demographic information including, age, gender, hemoglobin, serum albumin, c-reactive protein (CRP), blood platelet, leukocyte, preoperative blood sugar, waiting time for surgery, current smoking status and drinking status were extracted from the medical records. Among the causes of injury were falling from height, traffic accident, hit by heavy object and other. Polytrauma was defined as trauma to more than one of the following systems: musculoskeletal, abdominal, cardiothoracic, urogenital, vascular, and central nervous systems. Fractures were classified as extra-articular (43A), partially articular (43B), and intra-articular (43C) according to the AO/OTA system . The degA staged approach was used for pilon fractures with severe soft tissue damage, first with external fixation of the tibia and/or restoration of fibula length, and then with delayed tibial open reduction and internal fixation after soft tissue improvement. We defined surgical site infection as any infection that occured at the surgical incision site or deep tissue within 30 days of surgery (within one year of implant used) according to the U.S. Centers for Disease Control and Prevention (CDC) . SSI incP < 0.1 was then performed to determine the independent risk factors for SSI [Patients were randomly divided into a training group and a validation group (3:1). The data from the training group were used to search for independent risk factors to establish nomogram model. Data from the validation group were used to evaluate the prediction effectiveness of the nomogram model. Measurement data are expressed as mean ± standard deviation, and count data are expressed as n (%). In the training group, univariate analysis using Mann–Whitney U and Chisquared tests as appropriate was performed to assess the association between different variables and SSI. Multivariate analysis of variables with  for SSI . Based ohttp://www.empowerstats.com, X&Y Solutions, Inc., Boston, MA) and R version 4.0.2 for Windows . Two-tailed analysis with P value less than 0.05 indicated that the difference was statistically significant.Discrimination of dichotomous result was most often evaluated by calculating the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Generally, an AUC between 0.5 and 0.7 indicates low accuracy, 0.70–0.9 is considered acceptable, and AUC > 0.9 means that the model has excellent discriminative power . ROC curP > 0.05).From January 2012 to June 2021, 516 pilon fracture patients who underwent open reduction and internal fixation were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). The baseline data of the training group and the validation group were analyzed, and there was no significant difference between the two groups (P < 0.001). Similar results appeared in the validation group, 23 (17.83%) patients developed SSI with an average age of 54.1 ± 11.0 years, and 106 (82.17%) patients did not develop SSI with an average age of 48.8 ± 11.2 years (P = 0.034). The preoperative blood sugar was significantly high in SSI patients than in non-SSI patients . In the training and validation group, patients with prolonged operative time were more likely to develop SSI . Similarly, patients with multiple incisions were more likely to develop SSI . According to results of fracture and Tscherne classification, patients with comminuted fractures and severe soft tissue injuries were more feasible to occur SSI (P < 0.05). There were no statistically significant differences according to gender, hemoglobin, serum albumin, C-reactive protein, blood platelet, leukocyte, waiting time for surgery, intraoperative blood loss, number of people in the operating room, cause of injury, polytrauma, drainage, bone graft, smoking or drinking.Table P < 0.05). The statistically significant variables selected from the univariate analysis were included in the multivariate logistic regression analysis. Ultimately, age , preoperative blood sugar , operative time , Tscherne classification , and fracture classification  were identified as independent risk factors for SSI in pilon fracture patients  [P = 0.040) was an independent predictor of deep infection [In our research, 71 (18.35%) patients in the training group developed SSI and 23 (17.83%) patients in the validation group developed SSI. Previous studies have shown similar deep infection rates , 16, 26.= 0.019) . Resultsnfection .The relationship between diabetes and SSI in pilon fractures remains unclear. Some articles reported that diabetes was not associated with deep infection in pilon fractures , 31. HowOperating time is a well-established risk factor for SSI and may be a marker of technical difficulties, more extensive soft tissue dissection, and prolonged wound exposure, all of which contribute to an increased incidence of SSI. Our results demonstrated that patients with prolonged operative time were more likely to develop SSI. Ren et al. believed that operative time longer than 150 min was associated with an increased risk of SSI following surgical fixation of pilon fractures . It has Previous studies have shown that open fracture was associated with deep infection after pilon fractures, but there are few reports of closed soft tissue injuries associated with infection , 13, 34.To our knowledge, our article was the first study on risk factors and predictive model for SSI in closed pilon fracture patients. However, our work had some limitations. First, this study was a single-center retrospective study, and the sample size of the selected cases was relatively small. Second, the baseline characteristic data were not truly homogenous and there was bias. Third, for the validation of the predictive model we used internal data, not external data.In this study, we found that age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were the independent risk factors for SSI. Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.


Bacteria are the main pathogens that cause sepsis. The pathogenic mechanisms of sepsis caused by gram-negative and gram-positive bacteria are completely different, and their prognostic differences in sepsis remain unclear.The PubMed, Web of Science, Cochrane Library, and Embase databases were searched for Chinese and English studies (January 2003 to September 2023). Observational studies involving gram-negative (G (−))/gram-positive (G (+)) bacterial infection and the prognosis of sepsis were included. The stability of the results was evaluated by sensitivity analysis. Funnel plots and Egger tests were used to check whether there was publication bias. A meta-regression analysis was conducted on the results with high heterogeneity to identify the source of heterogeneity. A total of 6949 articles were retrieved from the database, and 45 studies involving 5586 subjects were included after screening according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Twenty-seven high-quality studies and 18 moderate-quality studies were identified according to the Newcastle‒Ottawa Scale score. There was no significant difference in the survival rate of sepsis caused by G (−) bacteria and G (+) bacteria . Subgroup analysis according to survival follow-up time showed no significant difference. The serum concentrations of C-reactive protein (CRP) , procalcitonin  and tumor necrosis factor-alpha (TNF-α)  in the G (−) bacterial infection group were significantly higher than those in the G (+) bacterial infection group, but there was no significant difference in IL-6  and WBC count . There were no significant differences between G (−) and G (+) bacteria in D dimer level, activated partial thromboplastin time, thrombin time, international normalized ratio, platelet count, length of stay or length of ICU stay. Sensitivity analysis of the above results indicated that the results were stable.The incidence of severe sepsis and the concentrations of inflammatory factors  in sepsis caused by G (−) bacteria were higher than those caused by G (+) bacteria. The two groups had no significant difference in survival rate, coagulation function, or hospital stay. The study was registered with PROSPERO (registration number: CRD42023465051).The online version contains supplementary material available at 10.1186/s13054-023-04750-w. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection . The hosThis review followed the PRISMA Statement .The PubMed, Web of Science, Cochrane Library, and Embase databases were searched for Chinese and English studies in the past 20 years (January 2003 to September 2023). The complete search strategy is detailed in Additional file Two researchers performed the screening independently. The two researchers discussed with each other first if there were differences. A third investigator was consulted if disagreements could not be resolved. Screening was performed according to PRISMA guidelines.The following inclusion criteria were used: (1) human subjects; (2) clinical research; (3) observational studies; (4) patients with sepsis; and (5) studies including prognostic outcomes associated with G (−) and G (+) bacteria.The following exclusion criteria were used: (1) in vitro studies and animal studies; (2) only infants (age < 3 years) included in the study; (3) intervention studies; (4) conference abstracts, comments, letters, case reports, and expert opinions; (5) the language was not Chinese or English; (6) duplicate articles; (7) incomplete data provision; (8) measurement data not provided or unable to be converted to mean and standard deviation; and (9) research data obtained from the database.The risk of bias was assessed using the NOS by two researchers independently. The NOS consists of three parts: study population selection, comparability between groups, and outcome measures. The specific items and their scores are as follows: representativeness of the exposed cohort (1); selection of the nonexposed cohort (1); ascertainment of exposure (1); demonstration that the outcome of interest was not present at the start of the study (1); comparability of cohorts based on the design or analysis (2); assessment of outcome (1); sufficient follow-up length to allow outcomes to occur (1); and adequacy of follow-up of cohorts (1). Points are scored for each “yes” answer. According to the total score, studies were classified as high quality (7–9), moderate quality (4–6), and low quality (0–3).Two researchers extracted information from the included studies, including (1) basic research information: author, year of publication, country, study type, sample size, source of sample, and whether to be included in the meta-analysis, site of infection, underlying host disease, whether patients with immunodeficiency and chemoradiotherapy for malignant tumors were excluded, and treatment measures, whether subjects were enrolled only from the ICU; (2) primary outcome data: survival; and (3) secondary outcome data: inflammatory factor concentrations, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sequential Organ Failure Assessment (SOFA) score, coagulation function, and length of hospital stay. It was preferred to obtain the relevant information directly from the publications. We obtained the data indirectly through the figures and datasets provided by the publication, if necessary.I2 statistics were computed, and a χ2 test was performed. Heterogeneity was considered high when I2 > 50%, and a random-effects model was used. Heterogeneity was considered insignificant when I2 ≤ 50%, and a fixed-effects model was used. Subgroup analysis was performed for some of the results. Meta-regression analysis was used to obtain the source of heterogeneity for results with high heterogeneity and more than 10 included articles. Sensitivity analyses were used to assess the robustness of the results. Funnel plots and Egger’s test were used to detect publication bias. The significance for all two-sided p values was set at less than 0.05.Data synthesis was performed using RevMan software 5.3 and Stata 12. We performed pooled analyses of survival across time points. We chose data for 28-day survival if data for multiple survival times were presented in the same study. For continuous variables, the standardized mean difference (SMD)/mean difference (MD) and 95% confidence interval of the two groups were calculated. The odds ratio (OR) between the two groups and the 95% confidence interval were calculated for binary variables. To test heterogeneity, A total of 6949 articles were initially retrieved from the database. After screening, a total of 45 studies were ultimately included Fig. . All stuI2 = 62%). The results showed that the survival rate of sepsis caused by G (+) bacteria (G (+) group) was not significantly different from that caused by G (−) bacteria (G (−) group) . No sources of heterogeneity were identified after a meta-regression analysis of 8 confounding factors  . Egger’s test (p = 0.821) , suggesting that the definition of sepsis may be one of the sources of heterogeneity in this study . The incidence of septic shock/severe sepsis in the G (−) group was higher than that in the G (+) group . Meta-regression analysis suggested that whether patients were admitted only from the ICU might be the source of heterogeneity (p = 0.033)  . The difference between the two groups was not significant . Meta-regression analysis revealed that the study region (p = 0.013 < 0.1), sample size (p = 0.041 < 0.1) and definition of sepsis (p = 0.093 < 0.1) may be sources of heterogeneity  . After excluding a study [p = 0.0008). Holub [A total of five studies reported SOFA scores. There was no significant difference between the two groups ( a study  publishe). Holub  was consFour studies reported the length of hospital stay, and four studies reported the length of ICU stay. There was no significant difference between the G (−) group and the G (+) group Fig. .Fig. 6FoI2 = 20%). The random-effects model was used for analysis.The year of publication was considered a possible source of heterogeneity. The combined effect sizes of studies published within ten years showed that there was no significant difference between the G (−) and G (+) groups  . Subgroup analyses were performed according to the year of study publication. The combined effect sizes of studies published within ten years showed homogeneity (I2 = 94%), and a random-effects model was used. The serum CRP concentration of the G (−) group was higher than that of the G (+) group . Meta-regression analysis revealed that admission to the ICU (p = 0.055 < 0.1) and study region (p = 0.05 < 0.1) might be the sources of heterogeneity  . The serum PCT concentration of the G (−) group was significantly higher than that of the G (+) group . Meta-regression analysis suggested that the study region (p = 0.061 < 0.1) might be the source of heterogeneity. Egger's test (p = 0.004) . There was no significant difference in serum IL-6 concentration between the two groups  . The serum TNF-α concentration in the G (−) group was significantly higher than that in the G (+) group  counts. After combining effect values, it was found that the G (−) and G (+) groups were not significantly different  bacteria was more severe than that caused by G (+) bacteria. In addition, the concentrations of inflammatory factors in the G (−) group were significantly higher than those in the G (+) group. However, our study found that there was no significant difference in survival rate, coagulation function, length of stay, APACHE II score, or SOFA score between the G (−) and G (+) groups. We identified some sources of heterogeneity by meta-regression analysis, subgroup analysis, funnel plot, and Egger's test. Sensitivity analyses suggested that all results were stable.Bacteria are one of the most common pathogens that cause sepsis, and there are significant differences in pathogenic mechanisms between G (−) bacteria and G (+) bacteria . There aBacterial cell wall components include lipopolysaccharide (LPS), peptidoglycan (PGN), and lipoteichoic acid (LTA). LPS is the main component of the G (−) outer membrane. LPS and other cell wall components are released when bacteria multiply or die in the host. The toxic fraction lipid A causes the body's immune response . The strStaphylococcus aureus and Pseudomonas species were the most common G (−) bacteria and G (+) bacteria. Different microorganisms and sites of infection interact in determining mortality [A total of 5259 patients had at least one positive microbiological culture in a study involving 15,202 subjects. Sixty-seven percent were gram-negative bacteria, 37% were gram-positive bacteria, and 16% were fungi . The maiortality . The incortality . The devortality . In thisPolymicrobial infection is a scenario that should be considered. Studies have shown that polymicrobial infection is a risk factor for severe sepsis . The morOur study has some limitations. 1) Studies in languages other than Chinese or English were excluded, which may have resulted in an incomplete number of included studies. 2) Some results of this meta-analysis showed high heterogeneity. We identified some sources of heterogeneity through a series of methods, but some sources of heterogeneity are still unclear. 3) Because there are significant differences between children and adults in the prognosis and physiology of sepsis, we excluded studies involving only infants. However, we did not perform separate analyses for the other age groups. 4) Polymicrobial infection was not considered as a variable in this study.In conclusion, sepsis caused by G (−) bacteria has higher serum inflammatory factor concentrations and greater disease severity than sepsis caused by G (+) bacteria. However, there was no significant difference in survival rate, length of stay, APACHE II score, SOFA score, or coagulation function between the two groups. This provides suggestions for the treatment of sepsis. The pathophysiological differences between G (−) and G (+) bacteria causing sepsis still need to be further studied.Additional file 1. Search strategy.Additional file 2. Characteristics of included studies.Additional file 3. NOS Score.Additional file 4. Meta-regression.Additional file 5. Egger's test.Additional file 6. Plot of funnel.Additional file 7. Forest plots.


C-reactive protein to albumin ratio (CAR) has recently been recognized as an independent prognostic marker for vasculitides. This study aims to investigate CAR and its relationship with disease activity and damage in prevalent ANCA associated vasculitis (AAV) patients.Fifty-one patients with AAV and 42 age-sex-matched healthy controls were enrolled in this cross-sectional study. Birmingham vasculitis score (BVAS) was used to assess vasculitis activity and vasculitis damage index (VDI) to provide information on disease damage.th–75th) age of the patients were 55 (48–61) years. CAR was significantly higher in AAV patients than controls . The 75th percentile of BVAS was defined as high BVAS (BVAS≥5) and ROC curve analysis showed that CAR≥0.98 predicted BVAS≥5 with 70.0% sensitivity and 68.0% specificity . When patients with CAR≥0.98 were compared to those without, BVAS , BVAS≥5 , VDI , and CAR  were higher whereas albumin  and haemoglobin  were lower. Multivariate analysis revealed that BVAS  was an independent factor associated with CAR≥0.98 in patients with AAV. Furthermore, correlation analysis showed that CAR significantly correlated with BVAS .The median (25In this study, we observed that CAR was significantly associated with disease activity in AAV patients and can be used to monitor disease activity. C-reactive protein to albumin ratio (CAR), a composite indicator of inflammation and nutritional status, has recently been recognized as an independent prognostic marker in malignancy, Crohn’s disease, critically ill patients and vasculitides. In this study, we aimed to investigate CAR and its relationship with disease activity and damage in prevalent ANCA vasculitis patients.Inflammation markers are essential for predicting disease related morbidity and mortality in AAV patients. In the present study, we showed that CAR is associated with high disease activity in AAV patients.Currently the cut-off serum CAR level to predict disease activity in AAV patients is unknown. In our study, patients with CAR ≥0.98 had higher BVAS.The VDI was developed as a tool to distinguish chronic damage from active inflammation or persistent disease. In our study median VDI was 4 and was significantly higher in patients with CAR ≥0.98.Close monitoring, early recognition and timely treatment of disease activity may limit patient morbidity and mortality.Anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) is characterized by inflammation and necrosis of small/medium sized blood vessels and the presence of circulating anti-neutrophil cytoplasmic antibody (ANCA). They can present with a wide variety of signs and symptoms and include granulomatous polyangiitis (GPA), microscopic polyangiitis (MPA) and eosinophilic granulomatous polyangiitis.1 Albumin is a negative acute-phase protein produced in the liver. A low level of serum albumin is a poor prognostic factor in AAV and correlates with inflammation and severe kidney injury. It has been shown that AAV patients with nephrotic hypoalbuminemia have a higher incidence of infection, end stage renal disease and all-cause mortality than patients with mild hypoalbuminemia or normal serum albumin levels.2 Ahn et al. also reported that Birmingham vasculitis activity index (BVAS) positively correlated with CRP and negatively with albumin.3High plasma C-reactive protein (CRP) levels are frequently observed in AAV patients as well as other chronic systemic inflammatory diseases and are associated with inflammation, oxidative stress and endothelial dysfunction.7 However, data regarding CAR and its relationship with disease activity in AAV patients are scarce. Moon et al. has recently demonstrated that baseline CAR was significantly associated with BVAS and CAR was an independent predictor of all-cause of mortality in patients with newly diagnosed AAV (7). In this study, we aimed to investigate CAR and its relationship with disease activity and damage in prevalent ANCA vasculitis patients.C-reactive protein to albumin ratio (CAR), a composite indicator of inflammation and nutritional status, has recently been recognized as an independent prognostic marker in malignancy, Crohn’s disease, critically ill patients and vasculitides.8 Vasculitis damage index was used to provide information on disease damage.9 We calculated the CRP to albumin ratio (CAR) (mg/g) by dividing CRP level to albumin level. After data collection ROC curve analysis was performed for the study population and showed that CAR ≥0.98 predicted high BVAS with 70.0% sensitivity and 68.0% specificity . AAV patients were further categorized into the two groups according to CAR. Clinical, demographic and laboratory data of the groups were analyzed and compared. The study conforms with the principles outlined in the Declaration of Helsinki. Local ethics committee approved the study and all participants gave written informed consent.This was a cross-sectional study conducted in 3 centres including 51 prevalent ANCA patients and 42 age- and sex-matched healthy controls, conducted between October 2020 and February 2021. Patients with active infection, malignancy or secondary vasculitis were excluded. Medical history and demographic data were recorded. Blood samples were obtained under fasting conditions. Fasting plasma glucose, kidney function tests, liver function tests, erythrocyte sedimentation rate (ESR) and complete blood counts were measured. C-reactive protein levels were measured using the nephelometric method  and expressed as milligrams per litre. Creatinine clearance was estimated according to modification of diet in renal disease (MDRD) formula. Birmingham vasculitis activity index (BVAS) version 3 was used to assess disease activity.th–75th percentile). Continuous variables with parametric distribution were compared with independent samples t-test, and those without normal distribution were compared with Mann-Whitney U-test. Kolmogorov-Smirnov analysis was performed to determine whether continuous variables were normally distributed. Receiver operating characteristic (ROC) curve analysis was performed to determine the cut off CAR that predicted BVAS ≥5 in AAV patients. Logistic regression analyses were performed to determine independent factors associated with CAR ≥0.98 in patients with vasculitis. Pearson correlation test was used for statistical correlation between CAR, BVAS, VDI, albumin, CRP and ESR. For all statistical analyses, a p-value <0.05 was considered significant.SPSS  statistics package was used for statistical analysis. Categorical variables were presented as numbers and percentages and compared with the Chi-square test. Continuous variables were presented as mean ± standard deviation or median (25Table 1. The median (25th–75th) age of the patients was 55 (48–61) years and 25 (49.0%) patients were male. Thirty-two (62.7%) and 19 (37.3%) patients had a diagnosis of GPA and MPA, respectively. Twenty-one patients (41.2%) were positive for p-ANCA and 25 (49.0%) were positive for c-ANCA at diagnosis. The median (25th–75th) duration of disease was 34 (11–72) months. At the time of the study, current immunosuppressive drug use of the patients were as follows: 32 (62.7%) patients were on oral steroids, 6 (11.8%) patients were on cyclophosphamide, 16 (31.4%) patients were on azathioprine, 2 (3.9%) patients were on mycophenolate mophetil and 15 (29.4%) patients were using rituximab. Cumulative steroid dosage of AAV patients was 6.1 (2.0–11.2) grams The median (25th–75th) BVAS was 3 (2–5) and VDI was 2 (1–4). Disease activity scores were categorized based on the 75th percentile of BVAS as high (BVAS ≥5) and low (BVAS <5) BVAS. ROC curve analysis showed that CAR ≥0.98 predicted high BVAS with 70.0% sensitivity and 68.0% specificity . When patients with CAR ≥0.98 were compared to those without, BVAS , BVAS ≥5 , VDI , leukocyte , and CRP  were significantly higher, whereas albumin  and haemoglobin  were significantly lower. The clinical, demographic and laboratory data of both groups are shown in Table 2 and Table 3.CAR was significantly higher in AAV patients than healthy controls . Baseline clinical and laboratory data of AAV patients and controls are shown in On correlation analysis, CAR was significantly correlated with BVAS . BVAS was also positively correlated with ESR  and negatively correlated with albumin . However, there was no correlation between BVAS and CRP . On the other hand, cumulative steroid dosage was negatively correlated with BVAS , there was no correlation with VDI  and CAR .Table 4).Multivariate analysis revealed that haemoglobin  and BVAS  were independent factors associated with CAR ≥0.98 in patients with AAV , respectively.21 In another study, the cut-off value of CAR in predicting the 90-day mortality for patients with acute ischemic stroke was 0.50.22 Furthermore, different cut-off levels have been reported to predict disease activity in patients with inflammatory bowel disease, ranging from 0.18 to 0.60.24 Data regarding CAR in AAV patients is scarce and cut-off levels are currently unknown, as mentioned above.Currently the cut-off serum CAR level to predict disease activity in AAV patients is unknown. In the study by Moon et al., patients with CAR ≥10.35 and diabetes exhibited a higher frequency of all-cause mortality than those without.25 In the present study, we used CAR in addition to BVAS to assess disease activity in AAV patients. We categorized disease activity scores based on the 75th percentile of BVAS as high (BVAS ≥5) and low (BVAS<5) disease activity. CAR was correlated with high disease activity on multivariate analysis. Since CAR is easily calculated from the routine clinical laboratory tests, we propose that it can be used as a simple, feasible and inexpensive method to monitor disease activity and possibly predict prognosis. Larger studies with longer follow-up time are needed to determine whether CAR predicts patient associated outcomes.Ongoing disease activity and persistent chronic inflammation are associated with poor patient outcomes. Thus, early recognition and timely treatment may limit disease specific morbidity and mortality. In AAV patients, BVAS is one of the main tools to assess disease activity. Flossmann et al. showed that BVAS ≥2 was associated with all-cause mortality in 535 AAV patients over a follow-up time of 5.2 years.26 Another study showed that a baseline VDI score >1 was strongly predictive of mortality in patients with GPA.27 In our study median VDI was 4 and was significantly higher in patients with CAR ≥0.98.Over time, patients with AAV may develop chronic organ damage due to vasculitis itself or the treatments used. The VDI was developed as a tool to distinguish chronic damage from active inflammation or persistent disease. A VDI score >4 was associated with mortality in vasculitis patients.The present study has several limitations. The relatively small sample size of the study and cross-sectional nature are the main limitations. However, we don’t have any data of patients’ baseline CAR and BVAS status. It would be interesting to follow-up patients to determine whether CAR predicts patient related morbidity and mortality. We also did not evaluate the nutritional status of our patients. Inflammation markers are essential for predicting disease related morbidity and mortality in AAV patients. In the present study, we found that CAR, a novel inflammation marker, was an independent predictor of disease activity in AAV patients. Close monitoring, early recognition and timely treatment of disease activity may limit patient morbidity and mortality. Studies with a large sample size and long-term follow up are needed to determine whether CAR predicts patient outcomes.


Oral squamous cell carcinoma (OSCC) is an invasive cancer with a high recurrence rate. Most clinical studies have focused on the prognosis of patients with OSCC, few have investigated the causes and interventions that affect the recurrence. Our study is to explore the temporal and spatial patterns of recurrence in OSCC.234 OSCC patients with recurrence in our hospital and 64 OSCC patients with recurrence in TCGA database were included in the study. Log-rank test and Multivariate Cox Regression Analysis were used to determine whether there was a significant difference between each selected demographic or clinical factors and recurrence. The Kaplan–Meier method was used to plot survival curves for each recurrence interval.The proportion of OSCC patients in clinical and TCGA with early recurrence was 93.6% and 84.4%, respectively. Age, chewing betel nut, previous radiotherapy, histopathological grading of the primary tumor (poorly differentiated), lymph node metastasis and postoperative infection were found to be associated with the timing of recurrence. It was found that tongue cancer has more regional recurrences, while buccal cancer is mostly local and loco-regional recurrences. The earlier the recurrence, the greater the possibility of local-regional recurrence and the worse the prognosis.Most of recurrent OSCC patients present early recurrence (< 18 months) with poor prognosis, and early recurrence is more prone to local recurrence. Moreover, recurrence site is related with primary site of OSCC. Oral cancer is one of the most common malignancies, ranking the top 10 of all malignant tumors, with more than 450,000 new cases worldwide each year, accounting for 2.4% of all cancer deaths. More than 90% of oral cancers are oral squamous cell carcinoma (OSCC), the surMany literatures stated that the recurrence rate of OSCC varies from 7–47.4%–18. DespThe patients’ data was collected and sorted from our hospital’s electronic database, which contains prior medical records and postoperative follow-up information.The study was approved by the Ethics Committee of Second Xiangya Hospital of Central South University. A total of 1560 consecutive OSCC patients underwent major surgery with primary reconstruction at our Department of Oral and Maxillofacial Surgery from January 2010 to December 2016. All patients underwent complete surgical resection with curative intent. For OSCC recurrence, 5 years is a cut-off point. If OSCC does not relapse in 5 years, the chance of recurrence will be greatly reduced. Therefore, the 5-year survival rate is always used to indicate the effect of OSCC treatment. Inclusion criteria were defined: (1) the patients were histologically confirmed with primary OSCC, (2) more than 5 years follow-up after surgical treatment without a loss or until death, (3) primary tumor without distant metastasis. Patients who had (1) a history of radiation or chemotherapy for oncological diseases of other origins and (2) inadequate clinical follow-up information were excluded.Recurrence interval was defined as the duration from the end of initial treatment to the confirmation of recurrence by pathological examination after incisional biopsy. For patients with multiple tumor recurrences, only the time interval from the completion of the first treatment to the first recurrence was calculated. The recurrence interval is significantly associated with the survival rate of OSCC patients, with an interval < 18 months appearing to be a more dismal cut-off point for survival according to some literature reports , 9. In tTo distinguish between recurrent tumors and new primary tumors, only patients with OSCC with the same or higher histologic grade as the primary tumor were included . In thishttps://tcga-data.nci.nih.gov/tcga/) is a publicly available dataset. We screened 347 OSCC patients from the head and neck squamous cell carcinoma (HNSCC) dataset in TCGA and downloaded the clinical data for this study. Among them, 64 cases had recurrence.TCGA  (n = 219) group and late recurrence (LR) (n = 15) group.Statistical analysis was performed using SPSS 25.0 software , and R, version 3.6.1 . The clinical prognostic risk factors associated with early recurrence were screened out by Log-rank test, and then these screened variables were further incorporated into the Multivariate Cox Regressive Analysis model for further analysis. The Kaplan–Meier method was used to plot survival curves for each recurrence interval. P value < 0.05 was considered statistically significant.From January 2010 to December 2016, a total of 1560 OSCC patients  with an average age of 49.62 ± 4.34 years who had undergone surgery were admitted to our hospital , 55.1% (129/234), 85.9% (201/234), and 93.6% (219/234), respectively. Only 6.4% (15/234) of patients had recurrence within 18 to 60 months after surgery  , we screened out 234 occurrence patients with complete data from 1560 patients. A significant correlation was found between the timing of recurrence and the age (P = 0.045), chewing betel nut (P = 0.048), previous radiotherapy (P = 0.038), histopathological grade of the primary tumor (poorly differentiated) (P = 0.048), lymph node metastasis (P = 0.032) and postoperative infection (P = 0.043) by Log-rank test  in clinical, which was similar to the ratio of 1.04:1(25:24) in TCGA database. The ratio of local recurrence to loco-regional recurrence was about 3.89:1 (105:27) clinically and 1.67:1(25:15) in TCGA database.P = 0.035), but the results from TCGA database showed there was no statistical difference in the probability of loco-regional recurrence between them (P > 0.05)  of cases within 1 ~ 3, 4 ~ 6, 7 ~ 9, 10 ~ 12, 13 ~ 15, 16 ~ 18 months from clinical was 12(25.5%), 7(8.5%), 4(8.3%), 2(8.3%), 1(8.3%), 1(8.3%), respectively , signs and imaging examinations , 39. ThrFurther, we analyzed the clinicopathological factors related to early and late recurrence. Abundant evidence exists for association between the occurrence interval and grade of primary tumor , 25, 37,In addition to the recurrence interval, some other clinical factors are found to be associated with the recurrence site. As described in previously studies, OSCC patients with primary lymph node metastases to the neck have an increased recurrence rate , 53–55. Although there have been numerous studies on the incidence of local, regional, and local-regional recurrence in patients with OSCC, fewer have been reported on the proportion of these three in the same group of relapsed patients or in different OSCC subtypes. Studies by Yasmine Ghantous  and ThomMore and more studies have shown that the recurrence interval and recurrence location were related to the prognosis of OSCC patients , 20, 37.In the study, we found that not only recurrence interval, but also recurrence site was associated with the OS of OSCC.Considering that most patients relapse within 18 months(nearly 90%), it is recommended to pay regular examination every month for 1year after the operation. Follow-up examinations will be performed every 3 months in the second year, and then every 6 months in the third to fifth years. For the surveillance of patients with OSCC after primary surgery, we believe that MRI/CT/PET-CT examination, especially for patients with deep neck pain, MRI/CT examination or even PET-CT should be performed immediately to confirm the diagnosis. At 1 year after surgery, it is also desirable to perform PET-CT to rule out early microscopic lesions. In addition, considering the poor prognosis of patients with earlier recurrence, re-operation should be cautious.