Hepatocellular carcinoma (HCC) displays dismal prognosis even after surgical resection. Metabolic reprogramming is a hallmark of cancers, but the existence of tumor heterogeneity makes it difficult to comprehensively reflect the overall characteristics of HCC prognosis with only a single or a few biomarkers. The aim of our study was to elucidate HCC metabolic reprogramming based on metabolomics and enable HCC prognostic risk evaluation using metabolic characteristics. We identified three distinct metabolic clusters and a metabolite classifier composed of six fatty acids for HCC prognosis risk stratification, which was externally validated in another independent dataset. Metabolic classification may provide a new insight into the molecular pathological characteristics of HCC for clinical prognosis evaluation and personalized treatment.Hepatocellular carcinoma (HCC) displays a high degree of metabolic and phenotypic heterogeneity and has dismal prognosis in most patients. Here, a gas chromatography–mass spectrometry (GC-MS)-based nontargeted metabolomics method was applied to analyze the metabolic profiling of 130 pairs of hepatocellular tumor tissues and matched adjacent noncancerous tissues from HCC patients. A total of 81 differential metabolites were identified by paired nonparametric test with false discovery rate correction to compare tumor tissues with adjacent noncancerous tissues. Results demonstrated that the metabolic reprogramming of HCC was mainly characterized by highly active glycolysis, enhanced fatty acid metabolism and inhibited tricarboxylic acid cycle, which satisfied the energy and biomass demands for tumor initiation and progression, meanwhile reducing apoptosis by counteracting oxidative stress. Risk stratification was performed based on the differential metabolites between tumor and adjacent noncancerous tissues by using nonnegative matrix factorization clustering. Three metabolic clusters displaying different characteristics were identified, and the cluster with higher levels of free fatty acids (FFAs) in tumors showed a worse prognosis. Finally, a metabolite classifier composed of six FFAs was further verified in a dependent sample set to have potential to define the patients with poor prognosis. Together, our results offered insights into the molecular pathological characteristics of HCC. Liver cancer, one of the most common malignances, accounts for about 8.4 million new cases and 7.8 million deaths annually worldwide , and hepMetabolic reprogramming is a hallmark of cancers and participates directly in the tumorigenesis ,11. MetaDifferent genotypes or phenotypes existing in the same tumor due to their heterogeneity result in difference in cell growth, drug sensitivity and prognosis. Although a variety of prognostic biomarkers of HCC have been reported by previous studies ,16,17, iIn this study, a metabolic profiling method based on gas chromatography–mass spectrometry (GC-MS) was applied to explore the metabolic reprogramming of 130 pairs of matched tumor tissues (hepatocellular carcinoma tissue (HCT) and adjacent noncancerous tissue (ANT). Nonnegative matrix factorization (NMF) clustering ,20 was cMethanol (high-performance liquid chromatography grade) was purchased from Merck . Ultrapure water was filtered through a Milli-Q water system . Derivatization reagents including methoxyamine hydrochloride, pyridine and N-methyl-N-(trimethylsilyl)-trifluoroacetamide (MSTFA) were supplied by Sigma-Aldrich . Valine-d8, succinic acid-d4, phenylalanine-d5, tridecanoic acid, citric acid-d4 and myristic acid-d27 were used as internal standards and obtained from Sigma-Aldrich. Metabolite standards for structure identification were acquired from Sigma-Aldrich, Alfa Aesar , Fluka  and J&K Scientific .Matched pairs of HCT and ANT samples were obtained from 130 patients undergoing curative resection of HCC at the Eastern Hepatobiliary Surgery Institute of the Second Military Medical University from July 2013 to June 2014. The ANTs were collected from the adjacent edge, less than 2 cm away from the solid tumor border. Another batch of 65 matched pairs of HCT and ANT samples collected from The First Affiliated Hospital of Dalian Medical University were used as an external validation cohort. All samples were freshly frozen and stored at −80 °C prior to metabolomics analysis.Patients were followed up after surgical resection, and overall survival was defined as the time from the date of surgery to the time of death. For the subjects who still survived at the end of the follow-up period, the latest follow-up time was counted as the endpoint of overall survival. During the follow up, 42 of the patients from the Eastern Hepatobiliary Surgery Hospital of the Second Military Medical University survived, and 38 of them died (the other patients were lost to follow up). Among the patients from The First Affiliated Hospital of Dalian Medical University, 51 of the patients survived, and 14 of them passed away. The detailed clinical characteristics of all patients are listed in g) for 10 min to remove the protein fraction. Finally, 480 μL of the supernatant was lyophilized in Labconco vacuum concentrators and then subjected to an oximation reaction with 50 μL methoxyamine–pyridine solution (20 mg/mL) at 37 °C for 1.5 h, and a silylation reaction with 40 μL of MSTFA at 37 °C for 1 h for subsequent metabolic profiling analysis. Quality control (QC) samples, which were technical replicates by pooling an equal aliquot of extracts from all experimental samples, were processed with the same method as the experimental samples and inserted every 10 samples during the analytical batch to monitor the data quality.A piece of tissue (~10 mg) was mixed with 600 μL of cold 80% methanol solution containing 5 μg/mL internal standards  and then homogenized using a high-speed blender after vortexing for 30 s. The mixture was centrifuged at 4 °C , and a DB-5MS fused-silica capillary column  was used. The column temperature was maintained at 80 °C for the first 1 min, increased to 210 °C at 30 °C/min, and then ramped to 320 °C at a rate of 20 °C/min, and ultimately kept for 4 min. The injection volume was 1 μL with a 40:1 split ratio  and the detector voltage was set at 1.11 kV . Other detailed system parameters of the metabolomics method were published in our previous studies [The peaks in a QC sample were deconvoluted by importing the NetCDF file into ChromTOF 4.43 software  and then identified by comparing the derivatized mass fragments and retention index based on commercial standard libraries  and a house-made metabolite library.p value using the Benjamini–Hochberg method through the MATLAB program . Hierarchical cluster analysis (HCA) was performed using the MultiExperiment Viewer software package  (http://mev.tm4.org (accessed on 31 December 2021)), and the relative responses of differential metabolites were plotted in histograms using the GraphPad software . Metabolic clustering was run by a flexible R package named NMF [Before statistical analysis, all metabolic features were calibrated to internal standards with the RSD-minimum principle and tissue weight . QCs andamed NMF  based onamed NMF . VolcanoTo enable comprehensive metabolic disturbance in HCC, a nontargeted GC-MS-based metabolomics strategy was applied to obtain metabolic profiling in 130 pairs of matched fresh HCT and ANT samples, encompassing tumors of different clinical TNM and BCLC staging systems . A totalp value < 0.05)  b. Among To visualize the variation trends of differential metabolites, the logarithms of the fold changes (HCT/ANT) to the base 10 were plotted in a heatmap c, and thTo investigate the metabolic reprogramming, a metabolic pathway map to depict changes between the two groups was constructed based on the differential metabolites . Elevatep value < 0.05). For each cluster, the log10- of significantly changed metabolites was plotted as the X-axis, and the log2-(fold change ratio) of these metabolites was plotted as the Y-axis. Interestingly, Cluster 3 was characterized by the highest fold change of six FFAs  in the HCT to the ANT, while Cluster 1 had the most significant low fold change of four FFAs , and Cluster 2 mainly displayed a higher fold change of nucleotides  showed the most striking differences in tumor tissues. Notably, Cluster 3 still had significantly higher levels of six FFAs than Clusters 1 and 2, but different from the ratio analysis of HCT to ANT, Cluster 2 exhibited higher levels of eight other metabolites   a.p = 0.016) (p = 0.004)  level was also distinct among the three clusters. The proportion of patients with higher AFP level (>400 μg/L) in Cluster 3 accounted for 80%, which was significantly higher than that in the other clusters, and this was consistent with the poor prognosis of Cluster 3 . The ove= 0.016) . Three c= 0.004) b. Univar= 0.004) . In addi= 0.004) .p < 0.05), and there was also an upward trend in three other FFAs (p = 0.039) (Unsupervised metabolic clustering identified one cluster of high-risk patients whose tumors were characterized by high levels of FFAs (Cluster 3) . To valiher FFAs . Then, t= 0.039) . The aboA difference enrichment score (DES) was defined to quantify and evaluate the differences in six FFAs  between HCT and ANT samples in each patient.p < 0.001; p < 0.001; A significant difference was observed in DES between low-risk and high-risk groups, with higher DES of Cluster 3 than those of Clusters 1 and 2  ,28,29. FAmino acids play an important role in cell metabolism. As a nonessential amino acid, serine is an intermediate connecting saccharide, lipid and nucleotide metabolism, and it produces a marked effect in maintaining tumor proliferation and homeostasis . Serine The activity of DNA and RNA polymerases in tumor tissues was higher than that in adjacent noncancerous tissues. Correspondingly, the process of nucleotide catabolism was significantly reduced. XOR, a key enzyme catalyzing the decomposition of hypoxanthine, had a significantly lower expression level in HCC tissues. The activity and expression of XOR were confirmed to be abnormal in various tumors and related to the prognosis ,44, suggThe metabolic abnormalities and phenotypes of HCC are highly heterogeneous, which suggests that the influence of heterogeneity should not be ignored in the study . With thNotably, three metabolic clusters were identified by unsupervised clustering analysis, and high levels of FFAs in tumor tissues were the key characteristics of the cluster with poor prognosis, accompanied by a high level of AFP. The positive correlation between abundance of the FFAs and prognosis was further validated by another metabolomics dataset. The FFAs that composed the metabolite classifier were either saturated or monounsaturated and have been reported to get involved in the formation and prognosis of HCC. Upregulated oxidation of fatty acids, as a driving force for tumor proliferation, may also be closely related to the HCC prognosis. As confirmed, MUFAs produced by stearoyl-CoA desaturase provided a Wnt-positive signaling loop via stabilization of low-density lipoprotein-receptor-related proteins 5 and 6, which contributed to liver fibrosis and tumor growth . PalmitiNMF can effectively reduce the dimension of a large-scale matrix, extract and classify features, indicating the correlation between information, which has great potential in academic research. The risk stratification defined by NMF unsupervised clustering was an independent prognostic factor for HCC, revealing an association between metabolic characteristics and prognosis. ROC analysis results showed that the classifier constructed by the pivotal metabolic characteristics of the high-risk group could well distinguish the patients with different levels of HCC prognostic risk. Hence, metabolic classification based on the metabolic characteristics of HCC tissues in this study offered a new insight for the heterogeneity of HCC and could be used as a new method to explore the molecular features of tumors and prognosis.Clinically, surgical resection is one of the optimal options for patients in early stage, but for patients who have not received surgical resection or are on drug therapy, the prognosis cannot be evaluated based on tissue samples. Therefore, it is still necessary to integrate widely accepted clinical parameters and biomarkers for a comprehensive prognostic risk assessment.Overall, our study demonstrated that nontargeted metabolomics strategy was a reliable tool to explore the metabolic characteristics of HCC. HCC was characterized by distinct metabolic reprogramming to satisfy energy and substance demand for tumor cell survival and proliferation. Briefly, the Warburg effect that cancer cells were more inclined to rely on active aerobic glycolysis was verified in our study, and the TCA cycle showed an obvious downregulation. Moreover, β-oxidation of FFAs was upregulated to obtain energy and reductants, while all detected saccharides and most of the polyols had a low abundance in tumor tissues due to the abnormal activation of carbohydrate metabolism. Three metabolic clusters with different characteristics were classified by applying NMF consensus clustering based on the ratio analysis of HCT to ANT. The cluster characterized by the highest fold change of FFAs exhibited a worst prognosis, which was further validated in another dataset of tissue metabolomics. Risk-stratification based on a classifier composed of six FFAs may provide new insights into the clinical prognosis evaluation and personalized treatment of HCC.


Hypertension is one of the major factors for high mortality of adults in Africa. However, complications occur at lower values than those previously classified as hypertension. Thus, prehypertension is considered as a new category of hypertension and a major risk factor for developing clinical hypertension relative to those with normotension, it has been linked with increased future risk of hypertension as well as cardiovascular diseases.The objective of this review was to determine prevalence of prehypertension and describe the associated factors of prehypertension in Africa during the past 10 years.We did a systematic review using the databases PubMed/Medline, and search engine google scholar. We selected sources of publications and conducted an analysis of articles. Keywords in English were: prehypertension, high normal blood pressure, high blood pressure, elevated blood pressure, Africa. Keywords in french were: préhypertension artérielle, préhypertension, pression artérielle normale haute, pression artérielle normale, Afrique.Prehypertension, Africa.Twenty-seven articles were selected. Prevalence of prehypertension ranged from 2.5% to 34% in children and adolescents. In adults, prevalence varied from 32.9% to 56.8%. Several factors were associated with prehypertension in Africa. These factors included: age; sex; lifestyle such as smoking, alcohol consumption, low physical activity, overweight and obesity. There were also cardiometabolic factors and few others factors which were associated with prehypertension.This review allowed us to observe that the prevalence of prehypertension was variable according to age of the population and prehypertension is associated with several factors. It is estimated that more than 1.5 billion people suffer from hypertension 1. The glo3Prehypertension has been defined as a systolic blood pressure between 120 mmHg and 139 mmHg and/or a diastolic blood pressure between 80 and 89 mmHg . In chilPrehypertension is considered as a new category of hypertension and a major risk factor for developing clinical hypertension relative to those with normotension, it has been linked with increased future risk of hypertension as well as cardiovascular diseases . A systeThis systematic review was conducted following PRISMA  guidelines . PrehypeSystolic BP 120–139 mmHg and diastolic BP 80–89 mmHg according to the JNC VII report  in adultIn children “prehypertension” was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥ 90th percentile and < 95th percentile . For adolescents, “prehypertension” was defined as blood pressure (BP) ≥ 120/80 mm Hg and < 95th percentile, or BP ≥ 90th and < 95th percentile  AND [High blood pressure AND Africa]) AND (elevated blood pressure AND Africa) »The selection of articles was done in two steps. The first step consisted in the analysis by reading the titles and abstracts of the articles; then, the second step allowed us to read the body of the articles and select those corresponding to the inclusion criteria. Two investigators (MKS and KJ) independently extracted relevant data from individual studies using a preconceived data extraction form.Information extracted included first author’s name, year of publication, population age, prevalence of prehypertension, sample size, risks factors and study country. Disagreements between authors were reconciled with another author (CM) through discussion and consensus.A total of 3920 articles were identified by combining keywords when searching the Medline/PubMed database and the google scholar search engine. We selected 572 with the PubMed database and 3348 with the google scholar search engine. After reading the titles and abstracts, 76 articles were selected. Finally, 27 articles were selected for this review.Several aspects have been addressed in the selected articles such as prevalence and factors associated with prehypertension.The prevalence of prehypertension varied from 2.5% to 58.7%. This variation depended on the age of the population. In children and adolescents the prevalence of prehypertension ranged from 2.5% to 34% according to studies [131517202425313335361416182123272829303234371922Some factors have been associated with prehypertension or with prehypertension prediction. These factors were: socio demographic caracteristics , lifestyle , alimentation , overweight, obesity, abdominal obesity, cardiometabolic and electrocardiographic characteristics.Several risk factors for prehypertension have been identified. These risk factors were dominated by overweight and obesity 131524253336.242533151515- Socio demographic characteristics Some studies showed an association between prehypertension and age 1623273739.2327371419222730161816- Lifestyle and alimentationA number of research have noted a link between prehypertension, people’s lifestyles and alimentation 141619263739.192637141826371416- Overweight and obesityMany surveys have shown that BMI was correlated with prehypertension 141626273739.262737Oveweight and obesity 1422262737;22262723- Cardiometabolic factorsSome studies have looked for a link between cardiometabolic factors with prehypertension 34.Nwatu et al.  have sho- Other factorsFew other factors have been associated with prehypertension Muchanga et al.  found thIn Africa, some authors have worked on prehypertension, however, to our knowledge, there is not yet a systematic review on this subject. Prevalences have been estimated on the basis of surveys carried out in some localities of the countries concerned. Thus, global or sufficiently representative figures for the prevalence of prehypertension in African countries must be evaluated.This review allowed us to observe that the prevalence of prehypertension was relatively higher than that of hypertension in the different samples analyzed. This observation suggests that cardiovascular disease prevention policies must take into account prehypertensive populations in particular.According to the association between socio-demographic characteristics and prehypertension, there was a trend towards a positive link with age and gender. This association was also noticed in other parts of the world 4142. The41The association with prehypertension and lifestyle and obesity was well documented in over part of the world 4344. Reg43We included only PubMed and google scholar in our search and our review was limited to articles published in English and french, which raises the possibility of omissions.


Consensus clustering revealed four immune subgroups with distinct responses to ICI therapy and survival patterns. The cluster with high proportions of infiltrated CD8+ T cells, activated memory CD4+ T cells, and Tfh cells and low levels of resting memory CD4+ T cells exhibited a higher tumor mutation burden and neoantigen load in melanoma and conferred a higher probability of response and improved survival. Local systemic immune cellular differences were associated with outcomes after ICI therapy. Further investigations of the tumor-infiltrating cellular immune response will lay the foundation for achieving durable efficacy.The tumor immune microenvironment (TIME) is likely an important determinant of sensitivity to immune checkpoint inhibitor (ICI) treatment. However, a comprehensive analysis covering the complexity and diversity of the TIME and its influence on ICI therapeutic efficacy is still lacking. Data from 782 samples from 10 ICI clinical trials were collected. To infer the infiltration of 22 subsets of immune cells, CIBERSORTx was applied to the bulk tumor transcriptomes. The associations between each cell fraction and the response to ICI treatment, progression-free survival (PFS) and overall survival (OS) were evaluated, modeling cellular proportions as quartiles. Activity of the interferon-γ pathway, the cytolytic activity score and the MHC score were associated with good prognosis in melanoma. Of the immune cells investigated, M1 macrophages, activated memory CD4 Immune checkpoint inhibitors (ICIs), which modulate immune responses against tumors, have revolutionized the field of tumor therapy. ICIs work not only by blocking the receptor and/or ligand connections of molecules that participate in the inhibitory brakes of T cell activation or function but also by activating other cells to enhance the immune response against tumors. ICIs targeting cytotoxic T lymphocyte-associated protein 4  and programmed cell death 1  and its ligand  have been approved by the US Food and Drug Administration (FDA). In clinical practice, these antibodies are utilized as first-line medicines for a variety of solid and liquid tumors, such as melanoma , and hemAlthough several patients have experienced dramatic tumor regression following ICI therapy across a variety of cancer indications, resistance to ICIs restricts the proportion of patients that can obtain a durable response. For example, for melanoma, one of the cancer types with the highest probability of sensitivity to ICIs, 60–70% of patients cannot achieve a clinical benefit from anti-PD-1 treatment; among those that do, 20–30% ultimately experience tumor progression . General+ T cells located in different positions and with different functional statuses have an effect on the response to ICIs. Intratumoral memory-like CD8+ T cells were positively correlated with the response to ICI treatment  on November 23, 2020. As described in the study by Fu et al., for each RNA-seq dataset, the transcriptomic profiles were log2 (1+ transcripts per kilobase million [TPM]) transformed, the log scale transcriptome data across patients were standardized by quantile normalization, and then the expression values of each gene were further normalized by subtracting the average among all samples. Only samples from ICI pretreatment tumors were included. For the Braun 2020 (http://research-pub.gene.com/IMvigor210CoreBiologies). To be consistent with the above datasets, we transformed the count values into log2(TPM+1), standardized the log-transformed values across patients by quantile normalization, and further normalized the expression values of each gene by subtracting the mean value among all samples. The processed expression matrix was utilized for downstream analyses. The supplementary files of the original publication were searched to collect clinical information. This computational retrospective study takes advantage of ICI trials with publicly available omics data. The clinical and matched mRNA expression data of tumors from 10 published ICI clinical studies  was utilized . The MHChttps://cibersortx.stanford.edu/) deconvolution algorithm was used (Submitted job type: ‘Impute cell fractions’). The LM22 signature was set as a reference, and the relative immune cell proportions from each processed dataset were estimated in 1000 permutations with B mode batch correction, with quantile normalization disabled for RNA-seq data. The B mode batch correction mode was utilized to correct for batch effects between the LM22 signature generated from the microarray-based dataset and the dataset utilized here, which consisted of RNA-seq data. A p value that measures the reliability of the deconvolution results was computed, and samples with a p value >0.05 were discarded from downstream association analyses. For the Uppaluri 2020 dataset  as described in the original publications. We categorized patients with complete response (CR) and partial response (PR) as responders and compared them with non-responders who displayed stable disease (SD) or progressive disease (PD). Samples with CR, PR, and SD > 6 months were considered to show clinical benefit, while patients with SD <= 6 months and PD were classified as nonclinical benefit. The clinical endpoints were response, clinical benefit, PFS and OS. The clinical outcomes provided in each dataset are listed in To test the association between the inferred fractions of immune cell types and response or clinical benefit, logistic regression analysis was performed. Patients with a CIBERSORTx p-value of ≥0.05 were filtered. To derive more easily interpretable ORs, in the logistic regression models, quartiles  of the proportions of each immune cell type were modeled as continuous variables. To evaluate the associations between the immune cell types in the tumor microenvironment and progression-free survival (PFS) and overall survival (OS), survival analysis was conducted. Patients with a follow-up time or OS time of less than 1 month who were likely to have postoperative complications were excluded. Cox regression analyses were stratified by study, with quartiles of each of the 22 immune cell subsets modeled as a continuous variable. The Kaplan-Meier method was used to draw survival curves for the subgroups. The log rank test was used to evaluate the difference in the survival rates. We also tested the associations between clinical outcomes and age and grade. Covariates and immune cell subtypes significantly associated with outcomes in univariate analyses were included in the multivariable models.via the penalized maximum likelihood using the “glmnet” package  were collected , whereas activated NK cells and resting NK cells showed the strongest negative correlation (R=-0.42).The fractions of the 22 immune cell subsets were weakly to moderately correlated with cancers overall (-3) MHC scores  and IFN-γ scores  were associated with an increased probability of response to immunotherapy and significantly improved PFS (p<0.05). The associations between immune content, IFN-γ and OS were not significant for melanoma (-3) and MHC  scores tended to have a higher probability of response to ICIs. However, for ccRCC, patients with higher IFN-γ signature associated with unfavorable OS after ICI therapy .Gene signatures have been shown to affect the immune response of patients. The associations between clinical outcomes after ICI therapy and the following four distinct immune gene expression signatures were evaluated: (1) immune score, which is a measure of the total immune infiltration in the tumor; (2) IFN-γ pathway activity, which is a critical cytokine for activating and sustaining an effective antitumor effect ; (3) cyt-11 for PFS, -9 for OS, -16 for PFS, -16 for OS, -12 for OS, + T cells  cells were associated with an increased probability of response, while resting CD4+ T cells, naïve CD4+ T cells, naïve B cells and activated mast cells were correlated with a decreased probability of response . Univariate and multivariate analyses were conducted for melanoma  contributed to the adjusted model. In multivariable logistic regression models with penalized maximum likelihood estimation, activated memory CD4+ T cells (OR=1.54) and Tfh cells (OR=1.36) demonstrated high OR point estimates  and Tfh cells  contributed to the adjusted model for urothelial cancer.The relationship between immune cell subsets and response to ICIs was evaluated Figure 4) are illustrated with forest plots. Association analyses to evaluate the prognostic effect of immune cells by cancer type (n>10) were performed. There were variations in terms of the prognostic effect of immune cells by cancer type. In ccRCC, M0 macrophages were significantly associated with poor PFS  and OS  , M1 macrophages , and activated memory CD4+ T cells . These findings might somewhat account for the association between these immune cell subsets and a favorable response to ICI therapy. Moreover, naïve CD4+ T cells were associated with poor PFS . Neither age nor sex was associated with PFS (-3) contributed to the multivariate model . A total of 586 patients remained after removing those with OS ≤ 1 month, with a median OS time of 1.17 years (379 events). The HRs and 95% CIs of immune cell subtypes for PFS Figure 5To explore whether different patterns of the TIME could be distinguished based on the 22 immune cell subsets, consensus clustering  of all s-6, -6, -3, + T cells, activated memory CD4+ T cells, and Tfh cells and low levels of resting memory CD4+ T cells, conferred a higher probability of response (47% vs 26% on average) and improved RFS and OS after ICI therapy.We assessed the cumulative distribution function, the proportion of ambiguous cluster values, and the consensus matrix and consensus cluster index, which indicated four clusters in the data  might determine patients’ response to ICI therapy. A higher TMB level was positively correlated with the probability of response to PD-1 inhibitors and favorable PFS in the KEYNOTE 012 clinical trial , 36. In The relationship between tumor-infiltrating immune cells and the antitumor effects of ICIs is complicated. By using CIBERSORTx, a computational technique that can accurately estimate leukocyte constituents in bulk tumors, the distinct patterns of immune cell infiltration across tumors and the complicated relationships with response, RFS and OS of 22 immune cell fractions based on different cancer types, targets and drugs were revealed. Our findings are in line with those of the limited literature, which suggests the reliability of our findings.+ T cell activity, contributing to a Th1 response, exerting antiproliferative effects and so on  were found to be correlated with favorable clinical outcomes, but resting memory CD4+ T cells and resting mast cells showed negative associations with prognosis across cancers and in melanoma and urothelial cancer. Traditionally, CD8+ T cells have been implicated as important effector cells responsible for the induction of antitumor immunity. Studies have demonstrated that the increased amount of memory-like CD8+ T cells either in peripheral tissues or infiltrating tumor tissues before or after the initiation of treatment is predictive of a favorable response to ICIs , a higher number of infiltrated CD8+ T cells in ccRCC was associated with poor prognosis, which is in line with the findings of previous studies . In a recent study, Kagamu et al. , which targets B cells and Tfh cells themselves through CXC-chemokine receptor 5. Both a high abundance of Tfh cells and a high expression level of CXCL13 correlated with increased survival in breast cancer  and colo+ T cells, Tfh cells, M1 macrophages, and activated CD4+ T cells and low levels of resting CD4+ T cells, had high TMB and TNB levels. TMB is a well-recognized biomarker, and higher tumor mutational loads are closely correlated with the response to ICIs across multiple cancers, such as melanoma and NSCLC , National Natural Science Foundation of Hunan (No. 2020JJ5879), Scientific Research Project of Hunan Provincial Health Commission (B2013-097) and Science and Technology Innovation Program of Hunan Province (2018SK50907).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


To compare the accuracy of photogrammetry, intraoral scanning and conventional impression techniques for complete-arch implant rehabilitation.A master cast containing 6 implant abutment replicas was fabricated. Group PG: digital impressions were taken 10 times using a photogrammetry system; Group IOS: intraoral scanning was performed to fabricate 10 digital impressions; Group CNV: splinted open-tray impression technique was used to fabricate 10 definitive casts. The master cast and conventional definitive casts were digitized with a laboratory reference scanner. For all STL files obtained, scan bodies were converted to implant abutment replicas using a digital library. The accuracy of a digitizer was defined by 2 main parameters, trueness and precision. "Trueness" was used to describe the deviation between test files and reference file, and "precision" was used to describe the closeness between test files. Then, the trueness and precision of three impression techniques were evaluated and statistically compared (α = 0.05).P < 0.001) and group CNV (P = 0.033), group CNV showed more accurate trueness than group IOS (P = 0.033). The median precision was 2.00, 36.00 and 29.40 μm for group PG, IOS and CNV; Group PG gave more accurate precision than group IOS (P < 0.001) and group CNV (P < 0.001), group CNV showed more accurate precision than IOS (P = 0.002).The median trueness was 24.45, 43.45 and 28.70 μm for group PG, IOS and CNV; Group PG gave more accurate trueness than group IOS (For complete-arch implant rehabilitation, the photogrammetry system showed the best accuracy of all the impression techniques evaluated, followed by the conventional impression technique, and the intraoral scanner provided the least accuracy. It is generally believed that the passive fit of a prosthesis is a key factor affecting the long-term success of implant-fixed complete dental prostheses , and a cIn the workflow of conventional procedures, the splinted open-tray impression technique is mostly used to transfer the implant positions from the patient’s mouth through the impression material. The splined open-tray impression technique provides acceptable clinical results, but it requires complicated procedures that are time consuming and discomfortable for the patient. Moreover, the accuracy of definitive casts is influenced by multiple factors, for instance, impression materials , matchinWith the development of CAD/CAM, digital impression methods have gained popularity in implant dentistry. Intraoral scanning is a widely used digital impression technique in clinical practice. The accuracy of intraoral scanners used with implant-supported single crown and short-span restorations has been recognized –8. HowevPhotogrammetry technology is a method of making precise measurements by using reference points in photographs –30. As eThe purpose of this study was to compare the accuracy of three impression techniques for complete arch implant rehabilitation: photogrammetry, intraoral scanning, and conventional impression techniques. Accuracy consists of trueness and precision  . TruenesA maxillary polymer resin model containing 6 implant abutment replicas  was prepared by using a polymer 3D printer  and polymer resin . Then, a stone master cast was fabricated from the polymer resin model by taking a splinted open-tray impression. The impression was poured with type IV dental stone . This stone cast served as the master cast Fig. . The depFor group PG, scan bodies  were positioned and hand tightened on each implant abutment replication on the master cast Fig. A, and a For group IOS, an intraoral scanner  and scan bodies  were used to fabricate 10 digital impressions under the same room lightening conditions. All the scan bodies were brand new, and the intraoral scanner was calibrated prior to every scan. After scan bodies were screwed onto the implant abutment replicas on the master cast by hand tightening  were connected to the implant abutment replicas on the master cast by hand tightening, and the impression copings were splinted using autopolymerized acrylic resin . To reduce the polymerization shrinkage of the resin splint, the resin splint was sectioned and reconnected , and scan bodies were converted to implant abutment replicas using a digital library Fig. A. 15] T T15] TheStatistical evaluation was performed using an analysis software program . The Shapiro–Wilk test revealed that the data were not normally distributed. Differences between groups in trueness and precision were evaluated using the Kruskal–Wallis test, and the Dunn–Bonferroni test was performed for post hoc analysis. The level of significance was set at α = 0.05.P < 0.001) and precision (P < 0.001). Table The trueness and precision are shown by the median and interquartile range (IQR) of the RMS values Tables , 3. The P < 0.001) and group CNV (P = 0.033), group CNV showed more accurate trueness than group IOS (P = 0.033). A boxplot of the trueness of the three impression techniques is shown in Fig. The median of trueness was 24.45 (IQR 0.73), 43.45 IQR 6.17), 28.70 (IQR 7.90) μm for group PG, IOS and CNV, respectively; Group PG gave more accurate trueness than group IOS  and group CNV (P < 0.001), group CNV showed more accurate precision than group IOS (P = 0.002). A boxplot of the precision of the three impression techniques is shown in Fig. The median of precision was 2.00 (IQR 1.65), 36.00 (IQR 9.95), 29.40 (IQR 4.80) μm for group PG, IOS and CNV, respectively; group PG gave more accurate precision than group IOS (This study compared the accuracy of photogrammetry, intraoral scanning, and conventional impression techniques in an edentulous maxilla stone cast with 6 implant abutment replicas. The null hypothesis was rejected, as significant differences were found among the three test groups. For both trueness and precision, the photogrammetry system tested showed the best outcomes, the second place was the conventional impression technique, and the last was the intraoral scanner evaluated.At present, research on the accuracy of photogrammetry systems is still very scarce, and the results are inconsistent. Tohme et al.  reportedDifferent studies have investigated the accuracy of intraoral scanners in complete arch implant rehabilitation, but there is no consensus. Some reports have shown that the accuracy of intraoral scanners can be comparable to that of conventional impression techniques –14, 17, The photogrammetry system overcomes the limitations of intraoral scanners in obtaining the location of implant abutments in complete-arch implant rehabilitation. Intraoral scanners generate 3D images by a series of image stitches, and a longer scanning path may lead to the expansion of error , 38, 42.This study compared the three-dimensional position of implant abutment replicas, which was under the assumption that the accuracy of the implant abutment replica positions was more important than that of the peri-implant mucosa in complete-arch implant rehabilitation cases; therefore, the location of the scan bodies was converted to implant abutment replicas in the digital library. However, there is an inherent connection error between different components , and theThere are still a few limitations to the present study. This in vitro study could not completely simulate a patient's oral situation. This in vitro study avoids the influence of oral saliva, gingival crevicular fluid, humid environment, mucosal mobility, and patient mouth opening. These advantages may also make the accuracy higher than the accuracy achieved with intraoral scanner or photogrammetry system in clinical applications. Further studies are needed to explore the accuracy of different photogrammetry systems, as well as the impact of the number of implants, interimplant distance, angle and depth on it. The present study provides a certain degree of support for the clinical application of photogrammetry system, but more in vivo and in vitro studies are needed to verify its effectiveness.The photogrammetry system obtained the lowest 3D discrepancy in terms of trueness and precision for the implant abutment positions.The intraoral scanner tested resulted in the highest 3D discrepancy for both trueness and precision, representing the least accuracy among the three impression techniques tested.The trueness and precision of conventional impression technique were both less accurate than photogrammetry system, but both more accurate than intraoral scanner.Within the limitations of this in vitro study, the following conclusions were drawn:


Targeted obesity prevention policies would benefit from the identification of population groups with the highest risk of weight gain. The relative importance of adult age, sex, ethnicity, geographical region, and degree of social deprivation on weight gain is not known. We aimed to identify high-risk groups for changes in weight and BMI using electronic health records (EHR).In this longitudinal, population-based cohort study we used linked EHR data from 400 primary care practices  in England, accessed via the CALIBER programme. Eligible participants were aged 18–74 years, were registered at a general practice clinic, and had BMI and weight measurements recorded between Jan 1, 1998, and June 30, 2016, during the period when they had eligible linked data with at least 1 year of follow-up time. We calculated longitudinal changes in BMI over 1, 5, and 10 years, and investigated the absolute risk and odds ratios (ORs) of transitioning between BMI categories , as defined by WHO. The associations of demographic factors with BMI transitions were estimated by use of logistic regression analysis, adjusting for baseline BMI, family history of cardiovascular disease, use of diuretics, and prevalent chronic conditions.vs 24%) of transitioning from normal weight to overweight or obesity at 10 years. Likewise, adults in the youngest age group with overweight or obesity at baseline were also at highest risk to transition to a higher BMI category; OR 4·60 (4·06–5·22) and absolute risk (42% vs 18%) of transitioning from overweight to class 1 and 2 obesity, and OR 5·87 (5·23–6·59) and absolute risk (22% vs 5%) of transitioning from class 1 and 2 obesity to class 3 obesity. Other demographic factors were consistently less strongly associated with these transitions; for example, the OR of transitioning from normal weight to overweight or obesity in people living in the most socially deprived versus least deprived areas was 1·23 (1·18–1·27), for men versus women was 1·12 (1·08–1·16), and for Black individuals versus White individuals was 1·13 (1·04–1·24). We provide an open access online risk calculator, and present high-resolution obesity risk charts over a 1-year, 5-year, and 10-year follow-up period.We included 2 092 260 eligible individuals with more than 9 million BMI measurements in our study. Young adult age was the strongest risk factor for weight gain at 1, 5, and 10 years of follow-up. Compared with the oldest age group (65–74 years), adults in the youngest age group (18–24 years) had the highest OR (4·22 [95% CI 3·86–4·62]) and greatest absolute risk  for individual-level and population-level prevention of obesity and its long-term consequences for health and health care.The British Hearth Foundation, Health Data Research UK, the UK Medical Research Council, and the National Institute for Health Research. Adult obesity prevention policies, which are largely untargeted, have had limited success globally,Evidence before this study2), overweight , and obesity . We searched PubMed on Dec 20, 2020, using the search string “(weight[Title])” OR “(body mass index[Title])” AND “(change)”. We searched for longitudinal population-based studies of intra-individual weight and BMI changes according to age and other demographic factors published between Jan 1, 2000, and Dec 20, 2020. We found 18 studies involving population-based cohorts of intra-individual BMI changes in adults in studies with sufficiently large sample size  had a markedly greater risk for transitioning to higher BMI categories than did older age groups . Compared with age, we found smaller additional contributions to the risk of BMI change, including being male, living in socially deprived neighbourhoods, and being from a Black ethnic background. Second, in by far the largest study done to date , we provide high-resolution estimates of BMI change across 900 strata defined by age (six groups), sex (two groups), degree of social deprivation (five groups), and initial BMI (15 categories). We provide the first estimates of the risks of transitioning between underweight, normal weight, overweight, and obesity BMI categories at 1, 5, and 10 years (risk charts and an online tool). Finally, we show the value of using longitudinal population-based EHRs to identify and monitor specific population groups at risk of weight gain. Health records offer advantages of being large scale, low cost, and updatable, and of providing policy-relevant insights.Implications of all the available evidenceA radical shift in policy is required to focus on individuals at highest risk of weight gain  for individual and population-level prevention of obesity and its long-term consequences for health and health care. Particular opportunities for intervention might arise as young adults transition away from living at home, or into education, relationships, and work.An emerging data science opportunity to identify population groups at high risk for weight gain comes from longitudinal population-based electronic health records (EHRs). Understanding how adult age, sex, ethnicity, geographical region, and degree of social deprivation might together influence the risk of weight changes to identify groups at highest risk of weight gain is essential if targeted policies are to be considered. We found no previous studies providing such evidence. Population-based EHRs offer valid measurements of weight and BMI changes,We used population-based EHRs to address longstanding calls for monitoring basic population weight dataCALIBER research platform). CALIBER, led by the UCL Institute of Health Informatics , is an open resource for researchers providing validated EHR phenotyping algorithms and tools for the use of national structured health record data sources. Through the CALIBER platform,In this longitudinal, population-based cohort study, we used clinically recorded measures of height, weight, and BMI from primary care practices in England, accessed through the Clinical Practice Research Datalink. This study was done as part of the The study was approved by the UK Medicines and Healthcare products Regulatory Agency Independent Scientific Advisory Committee (18_010R), under Section 251 of the National Health Service (NHS) Social Care Act 2006, for the use of anonymised records in research without individual participant written consent.2) measurements, as recorded during usual care by physicians, nurses, and health-care assistants using a range of devices. We included individuals with BMI and weight measurements recorded during the period in which they had eligible linked data, with at least 1 year of follow-up. We excluded individuals with BMI recorded during pregnancy; who had BMI measurements taken on the same day that differed by more than 0·5 kg/m2; whose highest recorded BMI was more than double their lowest recorded BMI; and in whom the absolute difference between recorded and calculated BMI on the same day was more than 1 kg/m2  as a BMI of 30·0–39·9 kg/m2; and severe obesity (class 3) as a BMI of 40 kg/m2 or higher.NHS policy is for a patient's weight and height to be recorded at registration with a general practice clinic, with these measurements repeated at health checks (currently offered to patients aged 40–74 years and done once every 5 years) and at clinical discretion. 1 kg/m2 . FollowiWe grouped individuals by age ; sex ; ethnicity ; degree of social deprivation, measured by use of the region-based Index of Multiple Deprivation ; and geographical region . Data on chronic disease, smoking status, and physical activity were also extracted from EHRs.To compare trends in mean BMI changes over time, we randomly selected one BMI measurement from all eligible individuals included in CALIBER, and compared mean BMI between 1998 and 2016 in England with standardised survey measures of BMI from an annual cross-sectional survey , according to age and sex.To estimate 1-year, 5-year, and 10-year changes in BMI, we randomly selected one pair of BMI measurements from individuals who had measurements taken during time windows of 6 months to 2 years, 4 years to 6 years, and 8 years to 12 years, respectively. We assumed that any change in BMI for each patient was linear during each time window .The problem of missing values arises because not all individuals had two BMI measurements within the specific time windows of interest . We assuFor sociodemographic factors, we estimated the odds ratios (ORs) for transitioning between BMI categories over 1-year, 5-year, and 10-year periods using of logistic regression models. For example, to estimate the ORs for transitioning from overweight to obesity BMI categories, logistic regression was used whereby the dependent variable was “0” for individuals who did not transition and “1” for those who did transition . In all online risk calculator  and BMI information from the HSE . We prodlculator .The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.We identified 2 396 540 individuals with linked EHR data and at least one BMI measurement recorded between 1998 and 2016 in England, of whom 2 092 260 individuals aged 18–74 years with at least one valid BMI measurement were included in the analysis . The bas2 higher in each biannual period and age group compared with England  data compared with HSE data. Minor differences between mean BMI estimates obtained from EHR and HSE were observed, particularly in individuals aged younger than 65 years . Mean BM England .Using EHR data, we estimated the initial and estimated average weight at 10 years according to age and sex . We founAdults in the youngest age group (18–24 years) had the highest increase in weight at 10 years, and the widest distribution in each BMI category . Each ofWe estimated that, in the normal weight BMI category, 13% transitioned to the overweight category at 1 year, 22% at 5 years, and 29% at 10 years . In the vs 24%) of transitioning from the normal weight BMI category to overweight or obesity categories at 10 years (vs least deprived OR 1·23 [1·18–1·27]), sex (men vs women OR 1·12 [1·08–1·16]) and ethnicity , were less associated with this transition. Compared with the 65–74 years age group, individuals in the 18–24 years age group had the highest relative risk (OR 4·60 [4·06–5·22]) and absolute risk (42% vs 18%) of transitioning from the overweight to the obesity BMI category, and the highest relative risk (OR 5·87 [5·23–6·59]) and absolute risk (22% vs 5%) of transitioning from class 1 and 2 obesity to class 3 obesity. We found that the association between IMD and transition to a higher BMI category was even more pronounced among individuals in the 18–24 years age group compared with older age groups (Compared with adults in the oldest age group (65–74 years), adults in the youngest age group (18–24 years) had the highest relative risk (OR 4·22 [95% CI 3·86–4·62]) and absolute risk  of remaining in the obesity BMI category at 10 years. We observed similar results for the youngest age group for the transitions at higher BMI categories at 1 and 5 years  without controlling for the prevalent chronic conditions ; (2) excYoung adults (aged 18–24 years) have the highest absolute and relative risk for transitioning to a higher BMI category than older age groups; smaller additional contributions to the risk of BMI changes from living in socially deprived regions and ethnicity were also observed. In the largest study done to date, we provide the first high-resolution obesity risk calculator based on age, sex, degree of social deprivation, ethnicity, and current BMI to identify the risk of intra-individual changes in BMI and transitioning across BMI categories. Our findings show that it is possible to identify individuals at the highest risk of weight gain using EHRs and information readily available to public health agencies, and that young adults should be a major focus of strategies to prevent the onset of overweight and obesity.We did this large-scale study  to provide high-resolution estimates of BMI change across 900 strata, defined by age (six groups), sex, social deprivation (five groups), and initial BMI (15 categories). Most of the individual strata contained more than 1000 individuals. Approximately 77% of adults have at least one BMI measurement recorded in their primary health-care record; a percentage that is higher compared with the response rates in consented cross-sectional surveys such as HSE20Adults in the youngest age group (18–24 years) had the highest absolute and relative risk of transitioning from the normal weight to overweight or obesity BMI categories, from the overweight to obesity BMI categories, and from class 1 and 2 obesity to class 3 obesity BMI categories at 1, 5, and 10 years. Individuals aged 35–54 years had the highest risk for remaining in the obesity BMI category, further emphasising the importance of early intervention.Our findings have policy implications in three inter-related areas: (1) obesity prevention; (2) the health priorities of young adults; and (3) addressing lockdown-associated weight gain. First, obesity prevention policies should identify groups at a high risk of weight gain for targeted interventions. There could be key opportunities for intervention in young adults because certain factors, such as changes in dietary and exercise behavioursPopulation-based EHRs are the only high-resolution source of information on changes in BMI with a sufficient sample size to estimate risk across combinations of age, sex, ethnicity, degree of social deprivation, and BMI category. Our study was the first large-scale study to focus on modern BMI change patterns at 1, 5, and 10 years at a high resolution, taking socioeconomic and demographic factors into consideration.Our study has important limitations. We focused on BMI changes at 1, 5, and 10 years; however, individuals had their bodyweight measurements taken at their general practice clinic infrequently, and younger  individuals had their bodyweight measurements taken less frequently than older indviduals.Our findings suggest the importance of appropriate interventions for obesity prevention at both population and individual levels. At the population level, structural mechanisms  might influence the risk of transitioning to the obesity BMI category in young adults. There is a need to develop interventions targeted at groups of individuals who have the highest risk of weight gain, with the aim of achieving weight maintenance in the normal weight BMI category. Given the projected weight gain in children and adolescents, complementary approaches before and after the age of 18 years should be followed.In summary, we found that young adults aged 18–24 years had the highest risk of transitioning to a higher BMI category compared with older age groups. Compared with age, other sociodemographic factors had weaker absolute and relative associations with weight gain and transitioning to higher BMI categories. Young adulthood offers an important, and currently neglected, opportunity for both population-level prevention of the onset of obesity and the identification of individuals at high risk of weight gain for targeted interventions.https://www.caliberresearch.org/portal/codelists. Estimates for weight change can be found via our online tool at bmi.caliberresearch.org.Individual participant data are available from the CPRD. A data dictionary with details of the definitions of the variables used in the study is available at RLB reports consulting fees from Novo Nordisk, ViiV Healthcare, Pfizer, and Gila Therapeutics; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Novo Nordisk, ViiV Healthcare, International Medical Press, and Medscape; participation on a data safety monitoring board or advisory board for Novo Nordisk, Pfizer, and ViiV Healthcare; being a committee member of the British Obesity and Metabolic Surgery Society, a trustee for the Association for the Study of Obesity, a scientific chair of the International Federation for the Surgery for Obesity (IFSO) and metabolic disorders European Chapter, a chair of the Royal College of Physicians advisory Committee on Nutrition, Weight and Health, an European Society of Endocrinology clinical committee member, and a trustee of Obesity Empowerment Network UK; being a member of the IFSO scientific committee; being a member of the NICE Weight Management Guideline Development Group; and being a principal investigator on two obesity clinical trials of cagrilintide versus placebo and semaglutide versus placebo (sponsored by Novo Nordisk), and one clinical trial of liraglutide versus placebo (both drugs were provided by Novo Nordisk). AB reports grants from Astra Zeneca. All other authors declare no competing interests.


Determinants of CPET parameters were investigated with multivariable linear regression analysis.A cohort of adolescents  underwent Cardiopulmonary Exercise Test (CPET) and administration of the International Physical Activity Questionnaire – Short Form (IPAQ-SF) with estimation of weekly PA , and VO2/HR max . Importantly, physical activity level was a predictor of VO2 max  whereas O2 pulse was independent from PA level .As expected, when compared to HC, PE had lower VO2 max (cardiopulmonary performance), whereas it appears not to affect O2 pulse (a measure of stroke volume at peak exercise) related to constrained diastolic filling in PE.Physical activity is a determinant of VO Pectus excavatum (PE) is the most common congenital chest wall deformity of childhood. It occurs with an incidence of approximately 1 every 300–400 children  and it oAlthough initially considered only an esthetic problem, it gradually emerged that this deformity can also cause functional disorders . Dependi2 max, predominately because of impaired cardiovascular performance, rather than ventilatory limitation  and cardiac output (O2 pulse) was highlighted in patients with PE (2 max) but would probably have limited effects on cardiac output.Anatomical severity of PE is commonly measured by Haller Index, the ratio of the transverse diameter of the rib cage to the minimum distance of the lower sternum from the vertebra . However with PE . HoweverAim of this pilot study is to explore the possible differential influence of physical activity on cardiopulmonary performance and stroke volume parameters obtained at Cardiopulmonary Exercise Test (CPET) in PE.In total, 15 consecutive patients  with PE, referred to our Unit for functional evaluation between March 2020 and August 2021 were investigated. The diagnoses were established by a thoracic surgeon (AMe) with 30 years’ experience. All the patients were in good health and had no evidence of cardiac or respiratory disease; none were taking medication that would affect cardiorespiratory fitness. Criteria for exclusion were severe lung disease, pre-existing heart disease, or an underlying causative syndrome such as Marfan’s disease, previous repair of pectus excavatum by any technique; previous thoracic surgery; congenital heart disease or pregnancy. The healthy control (HC) group consisted of 15 age- and sex-matched adolescents who responded to a local advertisement. The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Tuscany Region clinical research ethics board . All participants provided written informed consent. All participants went through the same examinations and tests throughout the study.–1⋅week–1. The mean intensity of light PA, moderate PA, and vigorous PA was assigned as 3, 4, and 8 METs, respectively  . The queectively .r = 0.67) and reliable tool (rho = 0.77–1.00)  , that isActivity ].–2) was calculated as the body mass divided by body height squared. Forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and Tiffeneau index (FEV1/FVC) were also measured before the exercise test and expressed in percentage of the predicted value.Each participant was asked to refrain from strenuous exertion the day before the test day and to refrain from eating solid foods or carbohydrate-rich drinks in the 3 h prior to the test. The test was performed in the morning in controlled environmental conditions . Prior to exercise testing, body mass and body height were measured using an electronic scale. Body Mass Index . Briefly, participants were equipped with an oronasal face mask connected to a metabolic cart (COSMED Quark CPET). COrotocols .–1) in VO2 over the last 30 s of the test. Tests were interrupted if signs of cardiovascular distress were present . A twelve-lead ECG, and oxygen saturation were continuously monitored.Selection of the workload ramp was based on predicted values for height . Minimum2), Carbon dioxide Production (VCO2), Tidal Volume (VT), Breathing Frequency (BF), Ventilation (VE), Heart Rate (HR) and Work Rate (WR) were measured throughout the test. The ventilatory Anaerobic Threshold (AT) was determined using the V-slope and the ventilatory equivalent approaches. Other variables were the ratio of VO2 and heart rate , oxygen-uptake to work-rate relationship , the product of VO2 max (in milliliters per kilogram per minute) by systolic blood pressure .Oxygen Consumption (VO2 max) with three independent variables, height, body mass, and age/sex.Z score values were calculated by adopting the prediction model developed by 2). With an estimated standard deviation of 20%, a difference between the 2 groups of 20%, an alpha of 0.05 and a power of 0.80, the number necessary for investigation was 15 subjects for each group.Statistical analyses were performed using SPSS 27 software . Sample size determination and power calculations were made for the volume of oxygen uptake/kg .All continuous variables are expressed as mean ± SD, unless specified. A paired, two-tailed Student’s p < 0.05 was considered statistically significant.A difference of –1⋅week–1 were not significantly different from those in the HC group  and FEVo groups .Maximal heart rate was 184 ± 13 bpm in patients with pectus excavatum and 186 ± 7 bpm in controls (ns), indicating an equivalent maximal exercise effort in the 2 groups. Conversely, SBP at peak exercise showed lower values in the PE than in the HC group.2 max was lower in the PE group than in HC both in absolute  and in percentage of the predicted value  (2 max was -1.3 ± 1.0 (95% CI −1.97 to −0.58) and 0.2 ± 0.6 (95% CI −0.20 to 0.93) respectively. Similarly, O2 pulse at exercise peak (VO2/HR max) was lower in the PE group than in HC both in absolute  and in percentage of the predicted value   . Average < 0.05) . LikewisHC group .2 max), stroke volume at peak exercise , and work efficiency (VO2/W slope)  with average PA per week measured with IPAQ (independent variable) were then investigated at multivariable linear regression analysis adjusted for sex, BMI, FEV1%, and presence of pectus excavatum , whereas no association was observed with O2 pulse (VO2/HR max), a measure of stroke volume.According to the present data, the average physical activity per week measured with the IPAQ questionnaire  was asso2 pulse, a measure of this mechanical parameter, was found to characterize the difference between PE and controls, independently of the estimation of PA or ventilatory function.The relative role of psychological, anatomical and physiological alterations in determining functional impairment in PE is not easily discernible in the individual patient, although this point is crucial for the choice of the treatment strategy. A conservative strategy based on the promotion of PA may be useful to improve functional capacity, while the presence of an anatomical defect, with compression of the sternum resulting in a diastolic filling defect, could indicate a surgical choice. The results of this preliminary study seem to indicate that a cardiopulmonary test can help to assess the potential effectiveness of these two instruments. In patients with PE a reduced retrosternal space, leading to a diastolic dysfunction mainly in the right ventricle, could lead to a stroke volume reduction with a final impairment of cardiorespiratory fitness. In this study, O2 max, also lower in PE compared to controls, instead also recognized among its determinants the average PA per week measured with the IPAQ. The promotion of PA in pectus excavatum, an important element in the treatment strategy of these patients, may improve cardiopulmonary performance, whereas stroke volume (O2 pulse) impairment that might be present in this condition seems to be independent from PA. A reduced O2 pulse at the peak of exercise could thus better address toward surgery.Cardiopulmonary performance expressed by VO2 max in PE patients compared to controls  might instead suggest the surgical option.Minimally invasive Nuss procedure for PE was consistently reported to improve stroke volume independently from the distance between surgery and functional evaluation due to the acute relief of constrained diastolic filling . The inc surgery . The pre2 max the limit of normality was usually set at 80% of the predicted value  a measured value deviates from the population mean, expressed in units of the population SD. The limit of the ± 2 Z score directly identifies the 95% limit of a normal distribution and has often been chosen as the cut point to distinguish healthy from unhealthy. As a standardized measure, the Z-Score allows comparisons across different ages, genders and measurements. Most importantly, differently from adults, the use of the Z-Score allows more accurate assessments in children and adolescents, where small changes in age or pubertal stage produce big differences in sub-populations.For VOed value . This loed value , but its2 pulse. The study must be considered a proof of principle study that may offer a perspective, although requiring confirmation. Second, there is a lack of accurate investigation of the diastolic function and of the morphological parameters used to characterize these patients, such as the echocardiographic indexes and the Haller index. Third, PA was measured with a questionnaire (IPAQ) and not an objective tool as accelerometer. Fourth, in the current study, differences in perceptions of body image and social appearance were not assessed. It may be important to assess the psychological impact by comparing the patient group with controls.This is a pilot study with several limitations. First of all, an important limitation of the study is the limited number of participants studied. This limited number could be responsible for a type II error (beta) with the lack of correlation between PA and O2 max, whereas no relationship was observed with stroke volume at peak exercise, expressed by O2 pulse.In conclusion, average PA per week measured with the IPAQ was found to be associated with cardiopulmonary performance expressed as VOThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comitato Etico Regionale per la Sperimentazione Clinica della Regione Toscana. Written informed consent to participate in this study was provided by the participants’ legal guardian/next of kin.PAM: conceptualization and writing—original draft preparation. LC and AP: methodology. AMo: formal analysis. LC, AP, AMe, MG, and FF: investigation. All authors have read and agreed to the published version of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Vitamin D deficiency is a global public health issue in women and children and is associated with adverse impacts on child growth, such as rickets. However, prior studies have mainly focused on measuring vitamin D levels in singleton pregnant women and their offspring, and very limited studies have revealed the prevalence of vitamin D deficiency in twin pregnant women and their offspring. The aim of this study was to investigate vitamin D levels in twin-pregnant women and their neonates. We also explored the correlation of maternal vitamin D levels with neonatal outcomes and infant growth.A prospective subcohort investigation was carried out among 72 dichorionic, diamniotic twin-pregnant mothers and their twin offspring from the Longitudinal Twin Study. Peripheral blood was collected from the mothers in the third trimester, and cord blood was collected from neonates at birth to identify 25[OH]D levels. Data on the characteristics of the mothers and neonates were collected. Infant growth data and food sensitivities were also collected.The average maternal 25[OH]D level was 31.78 ng/mL, with 19.4% being deficient and 20.8% insufficient, while the average neonatal 25[OH]D level was 15.37 ng/mL, with 99.3% being deficiency or insufficient. A positive correlation was found between maternal and neonatal 25[OH]D levels . Interestingly, the higher the maternal 25[OH]D level was, the smaller the cotwin birthweight discordance . In addition, the infants of mothers with vitamin D deficiency were more likely to be allergic to foods at 6 months than those of mothers with vitamin D sufficiency.Twin neonates were at high risk of vitamin D deficiency, although their mothers’ vitamin D deficiency partially improved. Higher maternal vitamin D levels were associated with smaller discordance of cotwin birthweight.ChiCTR-OOC-16008203, 1st April 2016.Chinese Clinical Trial Registry The online version contains supplementary material available at 10.1186/s12884-021-03707-7. Vitamin D is a potent steroid hormone that is not only essential for building and maintaining bones but also plays an important role in the immune, endocrine and cardiovascular systems –4. AlthoVitamin D deficiency is a global public health problem, especially among pregnant women and newborns , 13. A dIn recent decades, the prevalence of twin pregnancies has increased 1.8-fold according to the National Vital Statistics Report of the US due to the development of assisted reproductive technology and advanced maternal age –26. In cTherefore, in the present study, we aimed to investigate the status of 25[OH]D in mothers and their newborns in a twin pregnancy and birth cohort from Southwest China. Given the previous findings reported for singleton pregnancy, we also aimed to determine the impact of maternal 25[OH]D deficiency on maternal and neonatal outcomes as well as child growth.The present study was embedded in the Longitudinal Twin Study (LoTiS), an ongoing twin pregnancy and birth cohort study conducted in Chongqing, which aims to determine the relative contributions of genes and the environment to early-onset intermediate phenotypes related to later adult onset disease. Chongqing is situated in southwestern China at a latitude of 29.35° N and characterized by a subtropical monsoon humid climate. This city has insufficient sunshine (1000–1400 h/year), especially in winter and spring. The LoTiS twin cohort study was established in January 2016 and aims to unravel the complex interplay between genes and the environment in specifying early life determinants of illness in infancy  and was approved by the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University No. 201530). Written informed consent was obtained from all participants. This subgroup study included dichorionic twin pregnant women confirmed prenatally by ultrasound with a prepregnancy BMI in the normal range (18.5 ~ 23.9) as well as daily multivitamin (vitamin D: 500 IU) supplementation from the first trimester to delivery. Due to the high incidence of adverse outcomes in monochorionic twin pregnancies, they were excluded from this study. Therefore, this study investigated vitamin D status in dichorionic diamniotic twin pregnancies. In addition, previous studies have shown that obese pregnant women may have abnormal vitamin D intake D2 were measured separately, and the total level of 25[OH]D was the sum of 25[OH]D3 and 25[OH]D2.Peripheral blood samples were collected from the mothers in the third trimester, and cord blood samples were immediately collected from newborns after placental delivery by using a coagulation-promoting blood collection tube. The specimen was transported to the Maternal and Fetal Medical Laboratory under refrigeration, where they were centrifuged to obtain serum. The serum 25[OH]D level was measured by high-performance liquid chromatography-electrospray tandem mass spectrometry , which is the gold standard method . The conSerum 25[OH]D is the best estimator to assess body vitamin D levels in the body . For anahttps://www.who.int/childgrowth/software/en/).Infant growth was monitored for weight and length at the corrected age of 6 months. The corrected age was defined as the infant’s chronological age minus the difference between term birth (40 weeks) and chronological gestational weeks of delivery. Weight and length were simultaneously measured unclothed by a digital measuring bed  operated by trained nurses at the Department of Child Health Care of Chongqing Health Center for Women and Children. The indexes of weight, height and BMI were converted to Z-scores for sex and age according to WHO Child Growth Standards software  was performed to preliminarily diagnose food allergies. The SPT was performed on the volar surface of the forearm with a lancet through the use of a drop of an allergen extract, and test results were produced in 15 to 20 min. The routine test screened for food types including milk, egg white, egg yolk, peanut, fish, wheat, soybean, citrus, and apple.2 and 4–200 ng/mL for 25[OH]D3, with <±15% RSD and RE. The intra-assay and inter-assay coefficients of variation were < 15% in all assays, indicating good repeatability.The mass spectrometry conditions were an electrospray ionization source with multiple reaction ion scanning modes. Voltages: capillary (3 kV), cone (20 V), source offset (50 V), temperature (400 °C). GAS Flow: Desolvation (800 L/Hr), Cone (150 L/Hr), Nebulizer . Categorical variables are presented as the count and percentage and were analyzed by the chi-squared or Fisher’s exact test. Continuous variables are presented as the means and standard deviation and were analyzed by Student’s t-test, LSD Student’s t test, one-way analysis of variance or the nonparametric test. Linear correlation analysis was used to explore the correlation between 25[OH]D levels in mothers and newborns and the correlation of 25[OH]D levels between cotwins. Multivariable linear regression analysis was used to detect the associations between neonatal 25[OH]D levels and related clinical characteristics. All tests were two-tailed, and The selection process for this study population is presented in Fig. In the maternal vitamin D deficiency group, over half of the mothers conceived with ART and were complicated with gestational diabetes, and 78.6% delivered in the winter or spring; this group had the highest incidence of SGA, with the lowest birthweight as well as the highest birthweight discordance Table .Table 2r = 0.90, p < 0.001)   and birth season  and were not found to have a correlation with maternal age, BMI, gestational weight gain, gestational age, GDM, GHP, ICP or neonatal birthweight   daily during pregnancy.Several studies conducted on singleton pregnancy among the Chinese population have investigated maternal 25[OH]D levels. Maternal vitamin D deficiency was reported in 79.2% of a multiethnic population without an investigation of prenatal vitamin D supplementation . ApproxiPrevious studies have revealed that the rates of maternal and neonatal vitamin D deficiency are comparable in singleton pregnancy , 38. A sThe clinical practice guidelines of the Endocrinology Society recommend that pregnant women take vitamin D supplements of at least 600 IU daily. However, twin neonates were at a very high risk of vitamin D deficiency when twin pregnant women took vitamin D supplements of 500 IU daily. Therefore, further investigations are needed to establish an appropriate dose that is effective for improving neonatal vitamin D deficiency and safe for maternal metabolism.Consistent with previous studies , 41, we There are conflicting reports about the association between maternal vitamin D levels and neonatal birthweight in singleton pregnancy. Hajianfar et al found a significant inverse association between maternal vitamin D level and the rate of low birthweight neonates ; others Vitamin D deficiency in neonates has been shown to lead to a higher risk of food sensitivities later in life. In our study, because 99.3% of neonates were vitamin D deficient or insufficient, we compared the status of infants allergic to foods by maternal vitamin D levels. Although no significant difference was found among the maternal vitamin D deficiency, insufficiency and sufficiency groups in terms of allergies to foods, the allergy rate was highest in the maternal vitamin D deficiency group. It is worth exploring whether maternal vitamin D deficiency or neonatal vitamin D deficiency predominantly influences infant allergies to foods.The strength of our study is the specialized study population. We used strict inclusion and exclusion criteria to screen the participants. Monochorionic twin pregnant women were not selected due to the higher risks of maternal and fetal complications, higher rate of preterm birth and lower neonatal birthweight. Prepregnancy BMI also has an obvious impact on perinatal outcomes, so we only recruited women with prepregnancy BMIs in the normal range. Additionally, the food sensitivities of infants at 6 months were followed, representing a relatively complete study design. Due to the low natural incidence of twin pregnancy , it is tThis preliminary study contributes new knowledge about the status of maternal and neonatal vitamin D levels in twin pregnancies, but several limitations of this study should be taken into consideration. First, compared with that of similar studies in singleton pregnancy, the sample size in this study was relatively small. Second, pregnant women in our hospital were routinely advised to take multivitamin supplements daily based on the clinical guidelines, particularly twin pregnant women; thus, there were no women who did not take multivitamin supplements as controls. Third, it is more appropriate to measure vitamin D levels in women pregnant with twins in the first trimester, prescribe adequate dose supplements and monitor vitamin D levels during pregnancy. Then, the related variables of vitamin D metabolism were limited, such as dietary vitamin D intake and daily solarization not involved. Finally, singleton pregnant women taking the same multivitamin supplements and their neonates should be included as a control group. A large-scale study including singleton pregnancy and twin pregnancies conducted in multiple centers is essential to better understand the prevalence of maternal and neonatal vitamin D deficiency in China among twin pregnancy populations.In summary, this study suggested that despite twin-pregnant women taking prenatal vitamin D supplements and the mothers’ vitamin D deficiency partially improving, their twin neonates were at high risk of vitamin D deficiency. These findings indicated that obstetricians should pay special attention to the dose of vitamin supplements provided to the twin pregnancy population.Additional file 1.Additional file 2.


Enhanced recovery after surgery (ERAS) protocols were rapidly adopted in many surgeries such as fast-track arthroplasty. The study aimed to investigate the impact of ERAS protocols on the clinical effect of total knee arthroplasty (TKA) via the midvastus approach.A total of 69 patients who underwent primary unilateral TKA via the midvastus approach from October 2018 to June 2019 were enrolled and randomly divided into two groups: ERAS group and Control group. The ERAS protocols were adopted for the ERAS group and consisted of pure juice drinking 2 h before the surgery, optimization of the preoperative anesthesia plan, phased use of tourniquets, and the use of tranexamic acid as well as a drug cocktail. The operative time, first postoperative walking time, first straight leg elevation time, postoperative hospitalization time, visual analogue scale score (VAS score), Hospital for Special Surgery score (HSS score), conventional Knee Society score (KSS), and knee range of motion (ROM) were used to assess the clinical effects in the two groups. All the included patients were followed up for 12 months.P > 0.05). The first postoperative walking time (2.11 ± 0.11 h) and first postoperative straight leg elevation time (6.14 ± 1.73 h) in the ERAS group were significantly earlier than those in the Control group (P < 0.001) and the postoperative hospitalization time was significantly shorter (3.11 ± 0.32 days). The postoperative mean VAS scores in both groups were significantly reduced compared with those before surgery (P < 0.001). The VAS scores for the ERAS group were significantly lower than those for the Control group at 1, 2, and 7 days after surgery (P < 0.001). The mean HSS scores, KSS, and knee ROM were significantly increased in both the ERAS and Control groups at 1, 3, 6, and 12 months after surgery (P < 0.001). In addition, the HSS scores, KSS, and knee ROM in the ERAS group were significantly higher than those in the Control group at 1 month after surgery (P < 0.001).There were no significant differences in the basic demographic information and operation time between the ERAS and Control groups (ERAS protocols improved the clinical effects of TKA via the midvastus approach, facilitating early out-of-bed activity and comfortable postoperative rehabilitation exercise, and further increasing patient satisfaction.NCT04873544.ClinicalTrials.gov Identifier:  Total knee arthroplasty (TKA) is an effective treatment for end-stage knee osteoarthritis, as it can significantly alleviate pain symptoms and improve knee function . Knee fuIn 1997, Kehlet et al. , 9. MiniThis study adheres to CONSORT guideline and was registered in the ClinicalTrials.gov (registration number: NCT04873544). The clinical trial was approved by the local ethics board (ethics number: KY20170418–02), and written informed consent was obtained prior to the enrollment. All the methods were conducted according to the CONSORT 2010 statement. The inclusion criteria for this study were as follows: 1) unilateral primary knee osteoarthritis; 2) varus, valgus, and flexion contracture deformity of the knee joint < 10°; 3) the ROM of the knee joint was > 80°; 4) body mass index (BMI) < 30; 5) no previous history of knee surgery on the affected side; 6) agreed to participate in the trial. The exclusion criteria for this research were as follows: 1) rheumatoid arthritis; 2) extra-knee deformity; 3) simultaneous bilateral knee arthroplasty; 4) severe dysfunction of the liver, kidney, and blood system; 5) severe cardiovascular diseases; 6) gastrointestinal ulcer; 7) other medical conditions like nausea, vomiting, snoring, and allergy to related analgesic drugs.A total of 84 patients from the outpatient department were included in this trial. The recruited patients were randomly divided into two groups using sealed envelopes opened before surgery, namely the ERAS group and control group. All TKA surgeries were performed by the same team of surgeons. All patients received an Evolution® medial pivot prosthesis from MicroPort, Inc. . All patients were treated with the midvastus approach. The researchers who performed randomization and outcome measurements were different from the surgeons who conducted the TKA. The primary outcome was the postoperative hospitalization time and the secondary outcomes were the operative time, first postoperative walking time, first straight leg elevation time, VAS score, HSS score, conventional KSS and knee ROM.Preoperative anteroposterior and lateral X-ray films of the targeted knee joints, full-length X-ray films, and 3D computed tomography (CT) of both lower extremities were conducted for both groups. Thus, we could accurately measure the alignment of the lower limbs before TKA, which was beneficial for the selection of the osteotomy angle during the surgery. According to the guidelines from the European Society for Clinical Nutrition and Metabolism in 2017 , patientLeg lifting was used to drive the blood during the operation in both groups. In the ERAS group, a tourniquet was applied periodically . In the Control group, a tourniquet was used during the entire surgical process after 30 s of leg lifting to expel blood. None of the patients received a patellar replacement, and no drainage tube and urethral catheter were placed after the operation. The skin was sutured intradermally without removing the stitches. The patients in both groups received 1 g tranexamic acid by intravenous drip 30 min prior to the operation and 0.5 g tranexamic acid by local irrigation. All TKA surgeries were performed by the same team of surgeons. All patients received an Evolution® medial pivot prosthesis from MicroPort, Inc. .All included patients were treated with the midvastus minimally invasive approach as follows: an anterior median incision  was made in the targeted knee. After exposure, an oblique vastus medialis incision 1–2 cm in length was made 30 degrees along the superior pole and longitudinal axis of the patella. Then, the joint cavity was exposed through the medial parapatellar incision. The quadriceps femoris and patella were pushed to the outside without turning over the patella.During the operation, the “moving window” technique was used to expose the operated area in turn, and the gap balance technique was used to complete the osteotomy and soft tissue balance. After confirming the balance of knee flexion and extension, the knee prosthesis was installed using cement fixation. Then, the patella surface was formed and peripheral denervation was performed. The prepared “cocktail” (0.75% ropivacaine 20 ml 150 mg), dexamethasone 1 ml (5 mg), and normal saline added up to 60 ml) was injected into the joint capsule, extensor device, patellar ligament, muscle, and subcutaneous tissue around the knee joint. The incision was sutured layer by layer without drainage tubes, and the skin was sutured intradermally and bandaged with elastic bandage  . Patients in the ERAS group drank pure fruit juice in the postanesthesia care unit (PACU) and began to walk with a walking aid 2 h after the operation. After returning to the ward, the patients were instructed to perform ankle pumps, lower limb straight leg raising exercises, and knee flexion and extension exercises. The time of the first postoperative straight leg raising exercise was evaluated. Intravenous non-steroidal anti-inflammatory analgesics were routinely used. On the first and second days after the operation, functional exercises were conducted under the guidance of rehabilitation physicians, including quadriceps femoris muscle strength exercises and knee flexion and extension exercises. The patients were discharged about 3 days after the operation. They were prescribed oral non-steroidal anti-inflammatory and analgesic drugs and instructed to continue the rehabilitation exercises at home as required. VAS scores were assessed on days 1 and 2 after the operation, as well as 1 week later in the outpatient department. The VAS scores, HSS scores, KSS, and knee ROM were evaluated in the outpatient department at 1, 3, 6, and 12 months after the operation.The patients in the Control group underwent the same rehabilitation procedures. However, on the first day after the operation, the patients were encouraged to walk with walking aids. On the second day, the patients began functional exercises under the guidance of rehabilitation physicians. The patients were mostly discharged 1 week after the operation and continued oral nonsteroidal anti-inflammatory analgesics and rehabilitation exercises at home under guidance. The VAS scores, HSS scores, KSS, and knee ROM were assessed with the same protocols as in the ERAS group.P < 0.05 was considered statistically significant.SPSS 18.0 software was used for statistical analysis. The chi-square test was used to compare the differences in gender between the ERAS and Control groups. The measurement data were expressed in the form of the mean ± standard deviation. Two independent samples t-tests were used to compare the differences in the age, BMI, operation time, postoperative first walking time, postoperative first straight leg raising time, postoperative hospital stay, VAS scores, HSS scores, KSS, and knee ROM between the ERAS and Control groups. The VAS scores, HSS scores, KSS, and ROM of the knee joint in each group at different times were compared using one-way analysis of variance (ANOVA), and P > 0.05)  (Table There was no significant difference in the operation time between the two groups (P > 0.05). The intraoperative blood loss in the ERAS group was significantly higher than that in the Control group (negligible). The first postoperative walk time, the first postoperative straight leg elevation time, and the length of postoperative hospital stay in the ERAS group were significantly shorter than those in the Control group (1) Table .Table 2CP < 0.001). On the 1st, 2nd, and 7th days after the operation, the VAS scores in the ERAS group were significantly lower than those in the Control group (P < 0.001). Additionally, the VAS scores of the ERAS group did not significantly decrease on days 1–7 after the surgery (P > 0.05), whereas the VAS scores of the Control group on day 2 after the surgery were significantly higher than those on day 7 (P < 0.001). There were no significant differences in the VAS scores between the two groups in the 1-, 3-, 6-, and 12-month follow-up (P > 0.05) . In addition, the HSS scores, KSS, and knee ROM in the ERAS group were significantly higher than those in the Control group in the 1st month (P < 0.001). On the 3th, 6th, and 12th months, no significant differences were observed between the two groups (P > 0.05)  Fig. .Fig. 4ThOur present study demonstrated that patients following the ERAS protocols could walk with a walking aid about 2 h after surgery. Moreover, the ERAS protocols reduced the first postoperative straight leg elevation time and the average postoperative hospital stay, and improved the early postoperative clinical scores and knee functional activities within 1 month following TKA.Conventionally, preoperative fasting and drinking abstinence can effectively prevent the occurrence of regurgitation and aspiration in patients undergoing elective surgery, but can cause discomfort such as thirst, hunger, hypoglycemia, tension, and anxiety before and after surgery . With thThe goals of postoperative analgesia after TKA are to effectively control the anterior and posterior pain in the knee joint and to preserve the muscle strength as much as possible, which can facilitate early functional exercise. General anesthesia alone results in a high incidence of postoperative nausea and vomiting due to the large amount of opioids involved. Although peripheral nerve block anesthesia alone has an obvious analgesic effect, achieving satisfactory intraoperative analgesia is difficult with only the nerve due to the rich peripheral nerve innervation around the knee joint . It has During TKA, a tourniquet is often used in combination with blood repellent in the lower extremity. Through physical squeezing, extrusion can cause ischemia and hypoxia of the targeted limb, and further release inflammatory factors. Moreover, some hidden blood loss can penetrate into the tissue space through extrusion, resulting in postoperative pain and swelling of the targeted limb, thus affecting early postoperative functional exercise. Lower extremity lifting is a safe and effective method to expel blood and can significantly reduce intraoperative muscle injury, postoperative swelling, and pain compared with extrusion to expel blood . The useTranexamic acid, an antifibrinolytic drug, can play a hemostatic role by inhibiting the activation of plasminogens and reducing fibrinolytic activity . Huang ePostoperative urinary retention is one of the most common complications in the perioperative period for TKA, and urinary catheter indwelling may be required if urinary retention occurs. As an invasive operation, an indwelling urethral catheter may damage the urethral mucosa and cause urinary tract infection, increasing the risk of periprosthetic infection after TKA . In addiThe placement of drainage following TKA also affects early walking and functional exercise by patients. Studies found that without indwelling drainage after TKA, the amount of postoperative blood loss, the time the patients got out of bed, and the length of hospital stay were significantly reduced , 35. In However, there were some limitations in this study. First, due to the sample size was small, the ERAS protocols improved the short-term postoperative clinical results within 1 month, so the larger studies with a multi-center design are needed in the future. Secondly, the clinical effects of ERAS in this study were the cumulative results of several optimization schemes, but the specific effects of each scheme were not investigated. Thirdly, the study was not a double-blinded trial, as the surgeons and patients were not blinded to the specific intervention. However, the researchers who assessed the clinical outcomes and analyzed the data were completely independent.ERAS improved the post-surgical outcomes after TKA via the midvastus approach, including early postoperative knee joint function and activity. The patients in the ERAS group could start walking earlier and safely, and performed early functional exercise comfortably after TKA, resulting in enhanced satisfaction.