The attainment of health system goals is largely hinged on the health workforce availability and performance; hence, health workforce planning is central to the health policy agenda. This study sought to estimate health service activity standards and standard workloads at the primary health care level in Ghana and explore any differences across health facility types. A nationally representative cross-sectional survey was conducted among 503 health professionals across eight health professions who provided estimates of health service activity standards in Ghana’s Primary Health Care (PHC) settings. Outpatient consultation time was 16 min, translating into an annual standard workload of 6030 consultations per year for General Practitioners. Routine nursing care activities take an average of 40 min (95% CI: 38–42 min) for low acuity patients; and 135 min (95% CI: 127–144 min) for high dependency patients per inpatient day. Availability of tools/equipment correlated with reduced time on clinical procedure. Physician Assistants in health centres spend more time with patients than in district hospitals. Midwives spend 78 min more during vaginal delivery in health centres/polyclinics than in district/primary hospital settings. We identified 18.9% (12 out of 67) of health service activities performed across eight health professional groups to differ between health centres/polyclinics and district/primary hospitals settings. The workload in the health facilities was rated 78.2%, but as the workload increased, and without a commensurate increase in staffing, health professionals reduced the time spent on individual patient care, which could have consequences for the quality of care and patient safety. Availability of tools and equipment at PHC was rated 56.6%, which suggests the need to retool these health facilities. The estimated standard workloads lay a foundation for evidence-based planning for the optimal number of health professionals needed in Ghana’s PHC system and the consequent adjustments necessary in both health professions education and the budgetary allocation for their employment. Finally, given similarity in results with Workload Indicators of Staffing Need (WISN) methodology used in Ghana, this study demonstrates that cross-sectional surveys can estimate health service activity standards that is suitable for health workforce planning just as the consensus-based estimates advocated in WISN. The extent of health service coverage and its quality anywhere is primarily hinged on the health workforce’s availability and quality ,2. ThereProponents of the needs-based approach have not had consensus on the best proxy measure of health worker productivity; hence different measures have been used in previous estimates, mostly with validity concerns ,13,14. AAlthough all WISN studies have inherently elicited service (activity) standards and determined the standard workloads, most papers have focused on reporting the staffing estimates and gaps, which tend to be the WISN study outcome of policy interest. Thus, it has become necessary to systematically elicit and document the service standards and standard workloads of various health workers, which becomes an important reference standard for health workforce planning and management.Ghana operates a multi-tier gatekeeper health system where community-based health planning and service (CHPS) compounds/zones serve as the first contact of the health system. CHPS are mainly manned by nurses who live within the communities to serve a population of 5000 or 750 households in sparsely populated areas . At thisOver the years, Ghana’s health workforce situation dramatically improved from 1.07 doctors, nurses, and midwives per 1000 population in 2005 to 2.56 per 1000 population in 2018 ,20. DeteGhana completed a WISN study in 2018 in which the activity standards were elicited using an open-ended questionnaire in which conveniently selected health professionals across health facilities provided information on their main activities and the corresponding time for accomplishing each of them . Aimed tA cross-sectional survey design was adopted for this study to obtain information on the prevailing practice of health professionals under the given circumstances of their health facilities. The target population in this study included health professionals  working in Primary Health Care (PHC) settings  in Ghana. The inclusion criteria were full-time health professionals of the GHS with the requisite practising license from the relevant professional regulatory council who were working in either a primary/district hospital, or a health centre/polyclinic or a CHPS zone/compound and with a minimum of one-year post-qualification working experience in their duty post at the time of the study. Professionals with less than one year post-qualification working experience were assumed to be less proficient in the performance of key tasks  and coulAvailable data from the GHS  showed tBox 1n = required sample sizeN = Accessible populatione = alpha level or significance levelThus,where: Adjusted sample size = 612A multistage stratified sampling approach was used to recruit a nationally representative sample . First, ® Excel random numbers. In each health facility, the proportionally allocated sample size was further divided proportionally for the various health professional categories of interest in that health facility. For the health professionals, a simple random sampling using Microsoft® Excel was used to select those to contact from the facility’s staff list . Whenever a health professional who has been randomly selected was contacted and he/she declined to participate in the study, others of similar health professional category in the facility (if available) were randomly sampled as a replacement until the required sample from that facility was exhausted. Each geographical stratum (represented by the regions) was allocated a sample proportional to its share of the national stock of the respective occupational groups of health professionals of interest see . SimilarFollowing ethical approval from the ethics review committees, permission was sought from the Director-General of GHS, which was granted, and an introductory letter was written from the office of the Director-General to the respective Regional Directors of Health Services (RDHS) to allow the study to proceed and serve as regional gatekeepers. The RDHS, in turn, informed the selected health facilities of the study to grant access to the participants. In each hospital, the facility quality assurance or research coordinator served as mediators to facilitate the identification and access to potential participants. A research information sheet was handed out to prospective participants individually at their various units or wards by the research coordinator or the facility’s quality assurance coordinator. However, in health centres and CHPS compounds, the staff are usually very few and with no quality assurance or research coordinators. In these settings, the researchers approached the team leader in the facility to identify one of the staff who was not within the study’s inclusion criteria and had no power relationship with the other staff to serve as a mediator. The mediator supported the researchers to contact the rest of the staff to hand out the information sheet. Health professionals who met the inclusion criteria and voluntarily agreed to participate in the study were given a voluntary consent form to carefully study, ask the necessary questions and sign if they willing to take part in the study. ®, an online data collection platform with end-to-end encryption widely used for survey data collection. The geographical coordinates of the location where the participant completed the data collection tool were automatically recorded and linked to the data to enable audit. The data collection was conducted from 21 September 2020 to 21 December 2020.Upon signing informed consent, willing participants were given the questionnaire and guided as needed to complete it via Data AnalyticsThe data collection tool was adapted from the job components tool used for data collection in the Workload Indicators of Staffing Needs (WISN) study in Ghana ,32. The The study was reviewed and approved by the North-West University’s Health Research Ethics Committee (NWU-00416-20-A1) and the GHS Ethics Review Committee (GHS-ER17/07/20) before the commencement of the study. Following ethical approval from both institutions, permission and introductory letters were obtained from the Director-General of GHS to the Regional Directors of Health Services (RDHS) and heads of health facilities to access participants. Participation was entirely voluntary, and the informed consent was obtained by an independent person who had no power relation with the participants. No individual information of health professionals or the facility they work in have been reported; instead, aggregate data is analysed and reported.® Software to Microsoft Excel® for cleaning, after which it was imported into SPSS® version 26 for analysis. Descriptive analysis with estimates of uncertainty was undertaken mainly to estimate the average time taken by various health professionals to perform their service delivery activities and the 95% confidence interval around the point estimates. Inferential analysis in the form of an independent t-test [The raw data was downloaded from the online Survey Analyticst t-test ,33 was ct t-test ,33 was aAWT)—the time a health worker has available in one year to do his/her work, taking into account all absences (Equation (2)).AWT is the total available working timeA is the number of days in a year = 365B is the number of days off for public holidays in a yearC is the number of days off for annual leave in a yearD is the number of days off due to sick leave in a yearE is the number of days off due to other leave, such as training, etc., in a year.F is the number of weekend days or off-duty daysn,ySW is the standard workload for health professional category n when performing health service activity y.nAWT is the available working time of the health professional category n.y,nSS is the Service Standard or the time it takes a well-trained health professional of type n to deliver the service activity, y.As defined in the WISN manual , the stan = 267, 53%) were between the ages of 30–39 years, followed by those in the 20–29 years age group . About 86% of the health professionals were below 40 years which signifies the youthful nature of the health professionals. Only 4.2% (n = 21) were 50 years or older . The majority of the health professionals  followed by Community Health Nurses  and Laboratory Scientist/Technicians  while Nutritionist/Dietician were the least . Almost one (1) in three (3) of the health professionals  had post-secondary school certificate qualification in their respective professions, a similar proportion  had either a university degree or post-graduate qualification. About 26% (n = 133) had diploma qualifications and nearly 5% (n = 24) indicated having other qualifications which included fellowship with medical colleges, higher national diplomas, and doctorate degrees. Most participants were clinical nurses—Registered General Nurses and Enrolled Nurses  to forty-four (44) years, with the average being about 7 years . Additionally, at the time of the study, the health professionals, on average, had been working in their health facilities for nearly 4 years , followed by the Upper East region  and the rest from Bono East region . Additionally, more than half were based in primary/district hospitals , whereas the health centres/polyclinics and CHPS had 37% (n = 186) and 10.1% (n = 51), respectively. The vast majority  considered the location of their health facilities to be urban areas, while 38.7% thought they were either working in a rural (12.3%) or semi-urban (26.4%) area.Consistent with the distribution of the health workers in the country, most of the participants were from the Greater Accra region  around the mean. The activity standards are presented in more detail in Across the primary health care (PHC) settings, General Practitioners spent an average of 16 min (95% CI: 13–19 min) on the assessment, diagnosis and treatment of new patients in the outpatient clinic but 9 min (95% CI: 8–11 min) for outpatients on follow-up visits. Reviewing patients who are on admission  took an average of 15 min (95% CI: 12–18 min), while minor surgeries, including repair of lacerations, incisions and drainage, etc., took 19 min (95% CI: 16–23 min). Major surgeries within the PHC context, including caesarean section, laparotomy, herniorrhaphy, etc., took an average of 64 min. However, given wide variations in these procedures’ complexity, there was also considerable uncertainty in the estimated time spent. Therefore, when the 95% confidence interval is considered, major surgeries at the PHC level could be done within 44 min or take as long as 84 min. The direct patient care activities performed by Physician Assistants (PAs) at the PHC settings closely mirrored those of the General Practitioners, except major surgeries, which they are, by law and job description, not mandated to undertake. PAs spent an average of 16 min (95% CI: 13–18 min) on the consultation of new outpatient but an average of 10 min (95% CI: 8–11 min) for follow-up/review of old outpatient cases. However, unlike the General Practitioners who spend about 19 min on minor surgical procedures, the PAs spent about 25 min (95% CI: 22–28 min). When the 95% confidence intervals are taken into consideration, there is no significant difference between them .For midwives, antenatal care consultation took an average of 22 min (95% CI: 18–26 min). For postnatal consultations, an average time of 19 min was spent on each patient by midwives (95% CI: 17–27 min); 16 min (95% CI: 12–21 min) for non-invasive family planning services; and 39 min (95% CI: 33–45 min) for invasive family planning procedures. Additionally, for each supervised vaginal delivery, midwives spend an average of 131 min which could be as short as 101 min or as long as 160 min, when the uncertainty in the estimate  is taken into account. For each day that a patient stays on admission after delivery, midwives spend about 30 min on each of the mother and the newborn for routine care but as much as 45 min if there is a pregnancy complication. Besides, patients received roughly 23 min (95% CI: 21–25 min) of patient education and counselling from midwives. In addition to the direct patient care activities, midwives spent about 31 min (95% CI: 25–36 min) per day on handing over (and taking over) from one shift to another—this represents 6.5% of the daily working time of midwives.The survey revealed that clinical nurses spend up to 10 min on history taking and checking vital signs in out-patient clinics, but where they were conducting a full out-patient consultation, an average of 13 min (95% CI: 12–14 min) is spent on each outpatient. Patients requiring admission into inpatient wards consumed about 19 min (95% CI: 18–20 min) of nurses’ time for the admission process while the process of discharging them also took about 16 min (95% CI: 14–17 min), in addition to an average of 18 min nurses spend on patient education and counselling. Preparing a patient for surgical procedures (which is considered not part of routine inpatient care) took an average of 26 min (95% CI: 23–28 min) of nurses’ time, whereas the post-operative management of surgical patients (excluding routine nursing care) was estimated to be an average of 42 min (95% CI: 38–46 min) per patient per inpatient day.Depending on the patient’s acuity level, there is a substantial variation in the time nurses spend in routine nursing care activities, including monitoring vital signs, administering prescribed medications, and supporting patients in their daily living activities. Low dependent patients received an average of 40 min per inpatient day (95% CI: 38–42 min), while patients with moderate dependency required some 43 min (95% CI: 40–46 min) per inpatient day. Expectedly, high dependency patients required an average of 135 min per inpatient day at the primary care level, but the true estimate could be between 127 min and 144 min when the 95% confidence interval is taken into consideration. In addition to the various direct patient care activities, clinical nurses, on average, spend some 25 min each day on handing/taking over and another 32 min on writing daily reports. Thus, nearly 12% of nurses’ daily working time could be spent on handing/taking over and report writing (not including the recording of nursing actions that are part of each nursing procedure).The average time to provide family planning services by Community Health Nurses (CHNs) at the PHC level was about 14 min (95% CI: 12–17 min). In line with national policy, CHNs at the CHPS compounds undertakes consultation and treatment of minor ailments, which takes about 12 min (95% CI: 10–14 min) per patient. A similar amount of time  is spent per each school child anytime school health activities are conducted. Both immunisation and growth monitoring each took an average of 6 min, whilst home visits took about 23 min (95% CI: 20–26 min) per household visited (excluding travel time for the home visiting). Additionally, CHNs spend 17 min per day to check and report on the maintenance of the cold chain for their vaccines.With a limited sample, it is estimated that Nutritionists and Dieticians spend about 13 min per patient on nutritional status assessment, and patients requiring nutritional interventions receive about 27 min (95% CI: 12–42 min) per visit or inpatient day while an additional 22 min is spent on each patient for education and counselling. It is worth emphasising that due to the limited sub-sample of only 6 nutritionist/dieticians in the study, these estimates must be interpreted with caution.On average, obtaining and processing specimens (samples) for laboratory examination took 9 min (95% CI: 8–11 min) per patient. On actual tests, undertaking a full blood count using an automated analyser machine took about 6 min (95% CI: 5–7 min). Performing a rapid diagnostic test for malaria, HIV, and similar ones took an average of 17 min (95% CI: 16–18 min), the same for performing a batch of blood chemistry test using automated machines. Culture and sensitivity analysis, a procedure seldomly performed at the PHC level, was estimated to take about 74 min but spread over a period of 2–4 days. When the uncertainty in the estimate is taken into account, culture and sensitivity analysis could take only 67 min or as much as 81 min. Besides the direct patient care activities performed on patients/sample, laboratory scientist/technicians spend roughly 10–13 min per day writing some summary reports and up to 8 h per month (upper confidence limit) on blood donation campaigns.The time spent by Pharmacists/Pharmacy Technicians in auditing and dispensing prescribed medicines for outpatients  and inpatients  were similar; same for the refilling of medications for patients with chronic illnesses. However, patient education and medication adherence counselling took 13 min (95% CI: 11–15 min). In addition to the direct individual patient care activities, Pharmacist/Pharmacy Technicians spend roughly 14 h per week or 35% of their working time reconstituting powdered preparations (3 h per week), managing pharmaceutical stock (7 h per week), and attending clinical meetings (4 h per week).Using Equation (2), we computed the available working time (AWT) for each health professional , which sAs shown in t-test ; review of follow-up patients , minor surgical procedures  as well as interventions for moderate-to-severe medical emergencies . For General Practitioners, there was no statistically significant difference between the time spent on the various health service activities in health centres/polyclinic compared to the district/primary hospitals. Similarly, no statistically significant difference was seen for activities performed by midwives except for time spent on supervised vaginal delivery. In health centres/polyclinics, midwives spend an average of 147 min on women during vaginal delivery as compared to an average of 70 min spent in the district/primary hospital settings. The mean difference of 78 min between health centres/polyclinics and district hospitals/primary hospitals is statistically significant . With regard to clinical nurses, the time spent on consultation (where they were permitted to do) varied between district hospitals and health centres/polyclinics . For CHNs, only the time spent on growth monitoring significantly varied between district hospitals and health centres . In the case of Laboratory Scientist/Technicians, the t-test shows a significant difference between the time taken to conduct blood sugar test in the district/primary hospitals versus those of the health centres/polyclinics  as well as culture and sensitivity . Whereas no t-test was conducted in respect of activities performed by Nutritionist/Dietician due to sample size limitation, those of the Pharmacist/Pharmacy Technician was not statistically significant. The services rendered at CHPS compounds are usually basic and performed by CHNs and some clinical nurses. However, all the cadres included in the study were available in the health centres/polyclinics and primary hospital/district hospitals. Hence, it was deemed appropriate to compare the activity standards between health centres/polyclinics and primary hospitals/district hospital using an independent t-test . The anaUsing a five-point Likert’s scale, health professionals were asked to self-rate the degree of workload in their health facility, workload level in their unit, and the availability of tools/equipment for work. The results show health facilities’ workload was 3.91 out of 5, which represents 78.2% (95% CI: 76.8–79.6%); and 4.01 out of 5 at the unit level . Also, the availability of equipment was self-rated as 2.83 out of 5, which represents only 56.6% (95% CI: 54.8–58.4%) availability of the requisite tools and equipment. r = −0.314, p < 0.05). Similar moderate but statistically significant negative association are observed between workload at the unit level and PAs consultations for new outpatients ; consultation for old outpatient cases  and review of inpatients . Additionally, PAs time spent on minor surgical procedures significantly reduced with increasing workload level at the unit . Similarly, increasing availability of tools/equipment significantly reduced the time spent on minor surgical procedures  and referrals . On the other hand, the time PAs spent on interventions for critically ill medical emergencies rather increased with increasing levels of overall workload in the health facility .Using Pearson’s correlation, we explored the relationship between the main health service activity standards on the one hand and self-rated health facility workload level, unit workload level and availability of tools/equipment on the other hand . The anar = 0.313, p < 0.05), family planning ; inpatient care for the newborn ; patient education/counselling  and management of complication of pregnancy . Availability of tools/equipment also had a moderate but statistically significant negative association with the time Clinical Nurses spend on the routine care of inpatients with moderate dependency . Noteworthy is also the Laboratory Scientists/Technicians spending more time on routine stool examination if there are tools/equipment and vice versa  but the time spent on full blood count being positively correlated with higher workload in the unit ; same for blood sugar test  and blood chemistry analysis . Surprisingly, none of the health service activities performed by Pharmacists/Pharmacy Technicians had a statistically significant correlation with either self-rated workload levels or availability of the tools and equipment.For midwives, workload at the health facility moderately and positively correlated with the time spent on postnatal care consultations  for patients on follow-up visits. The WISN study conducted in Ghana in 2015  set a stp < 0.05) and clinical nurses time spent on moderate dependency patients by 33.3% (p < 0.05). This finding points to the potential benefit of improving the availability of tools/equipment, which was rated to be only 57% by the health professionals. Although PAs spent about 6 min more on minor surgical procedures than General Practitioners, the difference between them is not statistically significant. When interpreted alongside the similarity in outpatient service time between these categories of health professionals, it appears that there may not be substantial variations in the quality of their services. Although previous studies ,40 demonp = 0.013). In the context of Ghana, there are very few women who deliver in health centres where they usually record one or two per day. As a result, midwives at health centres who usually reside within walking distance of the health centre seem to pay greater attention to the monitoring and psychosocial support to the pregnant in labour. The present study found that midwives’ antenatal care consultation took an average of 22 min (95% CI: 18–26 min) is not significantly different from 25 min estimated from the previous WISN study in Ghana and 20–30 min estimated in a Namibian WISN study . AdditioWe found that routine nursing care activities  was an average of 40 min per inpatient day (95% CI: 38–42 min) for low acuity patients; 43 min (95% CI: 40–46 min) per inpatient day for moderate acuity patients and 135 min (95% CI: 127–144 min) per inpatient day for high dependency patients. These were, however, negatively correlated with the availability of tools/equipment, which suggests that clinical nurses would spend more time on direct routine care to inpatients if they had sufficient tools and equipment. Indeed, the resource constraints in the PHC setting, especially in health facilities and their effects on inpatient care, is well documented . WISN stPerforming a full blood count analysis using an automated analyser machine is estimated to take 6 min (95% CI: 5–7 min), while it takes an average of 17 min (95% CI: 16–18 min) to conduct a rapid diagnostic test for malaria, HIV and similar ones routinely carried out in PHC settings. These estimates are not only consistent with the results of the Ghana WISN study but also similar to estimates from a Kenyan study [The correlation analysis revealed that a unit increase in perceived or actual workload was associated with a 31–44% reduction in the time PAs spend on the various health service activities; a similar finding was found for some activities undertaken by clinical nurses. These suggest that when workload increases, health professionals with the moral duty not to turn patients away rather reduces the time spent on patients to be able to attend to all the patients. This, however, have huge implications for quality of care and patient safety. The analysis shows that General Practitioners  spend at least 3 hours per week or 7.5% of their working time on clinical meetings, while nurses and midwives spend up to 14% on both clinical meetings and handing over (or taking over) from one shift to another. When blood donation campaigns are taken into account, laboratory scientist spends up to 22.5% of their time on catalytic or support activities while Pharmacist spends at least 35% of their time on activities that are essential but not measurable per patient. These underscore the need to factor support activities into all health workforce planning models, especially needs-based planning tools that are regarded as the most conceptually appropriate and intuitively consistent planning framework for the tenets of UHC ,42,43. Although the study used a cross-sectional study design with a carefully selected nationally representative sample, only six nutritionists/dieticians  responded to the survey, which requires the exercise of caution when interpreting or using the results of that category of health professionals. Linked to the sampling, the study was based on public health facilities and hence, excluded the private sector, some of which is known for low standards of care in Ghana ,43. BesiThe study systematically estimated the service standards , identifying statistically significant differences between health centres/polyclinics and district/primary hospitals in 18.9% (12 out of 67) of health service activities performed across eight health professional groups. For example, the standard workload for General Practitioners in PHC settings is 6030 new patients per year ; 6108 new outpatients per year for Physician Assistants, while midwives can conduct 735 spontaneous vaginal deliveries per year. In patients with low-to-moderate dependency, Clinical Nurses’ standard workload is between 2078 and 2549 per year, or a nurse-patient ratio of one is to 5–7 inpatients; and a CHN could give roughly 16,000 immunisations per year. p < 0.05) and clinical nurses time spent on moderate dependency patients by 33.3% (p < 0.05). The intensity of workload in health facilities was rated to be 3.91 out of 5 (78.2%) but as workload increases, and without a commensurate increase in staffing, health professionals reduced the time spent on individual patient care so as to be able to attend to all patients—a practice that could have adverse implications for quality of care and patient safety. Availability of tools and equipment at PHC was rated 2.83 out of 5 (56.6%) which a unit improvement is associated with a significant reduction in the time PAs spend on minor surgical procedures by 35.5%  across the public and private sectors. Finally, a form of observation (preferably time-motion in nature) can be included as part of future data gathering process should the COVID-19 situation allow for direct observation, which was not feasible in this study due to COVID-19 restrictions and logistical challenges.


Childcare workers are reported to have poor cardiorespiratory fitness and health. The Goldilocks Work Principle argues that productive work should be designed with the right composition, intensity and alternations of physical behaviors so that workers get fit and healthy. The purpose of this study was to investigate: (1) composition, (2) intensity and (3) alternations of physical behaviors during work and leisure among childcare workers. Data were collected using accelerometers and heart rate monitors over five workdays among 51 childcare workers at five Danish childcare institutions. Workers mainly spent their work time sedentary (43.0%), spent little time (0.7%) at sufficiently high cardiometabolic intensity to increase cardiorespiratory fitness and often alternated between physical behaviors (67.0% occurred in bouts of <5 min). These findings indicate that the workers have a composition of behaviors at work dominated by sedentary time, little time with high cardiometabolic intensity, and frequent alternations between behaviors. During leisure, workers spent more time sedentary (59.4%), more time at high cardiometabolic intensity (3.4%) and less time occurred in bouts <5 min (38.7%). We see a potential for promoting cardiorespiratory fitness and health of childcare workers by redesigning the way they play with the children, so that work time with high cardiometabolic intensity is increased. Childcare workers perform an important societal task by providing a safe, healthy and developmentally enhancing environment for children. However, childcare workers are reported to have poor cardiorespiratory fitness and health ,2,3. ForWorkplace interventions have tried to address these health issues by implementing health-promoting workplace interventions in childcare organizations, but with modest or no effect ,9. One rThe Goldilocks Work Principle has been proposed as a new idea of how to design productive work so it becomes ‘just right’ with respect to the composition, intensity and alternations of physical behaviors  to improve cardiorespiratory fitness and health of workers ,12. MoreThus, to develop workplace interventions in line with the Goldilocks Work Principle, it is necessary to know to what extent the current productive work fulfils these three characteristics . MoreoveResearch on the health of childcare workers is limited . Most ocTherefore, the purpose of this study was to investigate, using wearable sensors , the (1) composition, (2) intensity and (3) alternations of physical behaviors during work and leisure among childcare workers.This paper reports baseline data forming part of the ‘Goldilocks childcare project’, a randomized controlled intervention trial aiming to evaluate the effectiveness of implementing the Goldilocks Work Principle in childcare work .The National Research Center for the Working Environment has an institutional agreement with the Danish Data Protection Agency about procedures to treat confidential data , e.g., by securing data at a protected drive with limited access, and by anonymizing all individual data. The Danish National Committee on Biomedical Research Ethics  has evaluated a description of this study and concluded that, according to Danish law as defined in Committee Act § 2 and § 1, the intervention described should not be further reported to the local ethics committee (Ref number: H-18041423). The study is registered in the International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry (ISRCTN15644757).Childcare institutions were recruited from the greater Copenhagen municipality in collaboration with the employer organizations, unions and local government municipalities. The study was announced through e-mails distributed to the childcare institution managers. In order to be eligible for participation, the institution had to supervise children aged 3–6 years, which is the age at which Danish children attend kindergarten and can actively participate in Goldilocks games . To secuInstitutions decided whether to participate, but participation in data collection  was still voluntary for the individual workers. All workers at the participating institutions were informed about the general aims of the study and those participating gave their written consent. Exclusion criteria were adhesive allergy, fever on the first test day, and pregnancy, since the latter has been shown to influence both heart rate and physical behaviors .Data were collected in 2020 from late January to late February. Prior to the on-site data collection week, the childcare workers completed an online questionnaire sent in a text message to their mobile phone, using a unique link to the online survey tool SurveyXact . The questionnaire contained questions regarding (1) sociodemographic factors, i.e., age, gender; ethnicity; length of service as a childcare worker and length in current job; job title, (2) health behaviors, i.e., alcohol intake; smoking and (3) self-reported time in moderate to vigorous physical activity (h/week) . Since t2)), fat percentage  and resting blood pressure . Cardiorespiratory fitness level was assessed using the Ekblom-Bak submaximal cycle ergometer test  [® OH1 heart rate monitor .Anthropometric measurements included height, weight (kg), body mass index (weight (kg)/(height squared (m Sweden) , in whic Sweden) . During Physical behavior composition, intensity and alternations were measured using wearable sensors worn continuously over five working days in week 2 . The chiAn AX3 accelerometer  was mounted using adhesive tape  on the childcare worker’s right thigh at the most prominent part of the quadriceps femoris, midway on the line between the anterior inferior iliac spine and the upper edge of the patella. Additionally, a FirstBeat Bodyguard 2 heart rate monitor  was mounted with Ag/AgCl pre-gelled electrodes  below the right clavicle and at the left ribcage.The diaries were digitized and used to identify working hours, leisure time and sleep periods for accelerometer and heart rate data.A custom-made MatLab-based program  was used to identify physical behaviors from the accelerometer recordings, i.e., sitting/lying, standing, moving, walking, running, stair climbing, cycling and rowing. The last five behaviors were collapsed into the category ‘active’. The program has a documented high sensitivity and specificity . SleepinThe heart rate data were downloaded using the FirstBeat Uploader software  and further processed for evaluation of beat errors using an established software ,25. RelaAll data from the questionnaires and the physical assessments were imported into SPSS . Following quality control and visual confirmation of data distributions not deviating from normality, descriptive statistics were calculated for anthropometric variables, cardiorespiratory fitness and physical behavior variables for each period , and summarized in terms of means  and standard deviations between workers.Accelerometer and heart rate data were analyzed to characterize the composition, intensity and alternations of physical behaviors using Rstudio (RStudio Team (2020). RStudio: Integrated Development for R. RStudio, PBC, Boston, MA, USA) and Microsoft Excel (2016). Composition was expressed as time in physical behaviors classified in four categories; (1) sedentary, i.e., sitting and lying; (2) standing, i.e., stationary standing and standing with movement; (3) active, i.e., walking, running, stair climbing, cycling and rowing; (4) sleeping . The proportion of time in the first three physical behaviors during work, leisure and in total time awake was calculated relative to the total duration of the period assessed . Intensity was expressed as the time at low, medium and high cardiometabolic intensities, classified as ≤25% HRR, >25% HRR–<60% HRR and ≥60% HRR, respectively. The proportion of time in each %HRR class during each period  was calculated relative to the total duration of heart rate recordings during that period.To assess alternation between physical behaviors , time spent in bouts of <5 min, 5–30 min, and >30 min was calculated for each of the three behaviors. Results are presented in a modified Exposure Variation Analysis (EVA) . This waFinally, we calculated correlations for accelerometer and heart rate data between work and leisure, in order to examine the extent to which behaviors and intensities in the two periods may be influenced by each other.n = 70; Five Danish childcare institutions agreed to participate and 70 of their workers handling children aged 3–6 years were invited to participate n = 70; . Nine of2 (SD 5.2) and an average blood pressure of 126.5 mmHg (SD 13.0) systolic and 82.6 mmHg (SD 9.5) diastolic , on average 36.2 (SD 10.3) years old, had an average BMI of 25.0 kg/miastolic . On averA total of 1178 working hours (mean 23.1 h per childcare worker), 1300 leisure time hours (mean 27.1 h per childcare worker) and 1118 sleeping hours (mean 21.9 h per childcare worker) of accelerometer measurements were included in the analysis . This coThe childcare workers spent less time sedentary during work (43.0% of the time awake) compared to leisure (59.4%) and a larger part standing (39.6 vs. 27.9%). Thus, they spent 17.4 and 12.7%, respectively, of their wake time being active at work and during leisure.A total of 794 (mean 15.9 per childcare worker) working hours and 1040 (mean 20.8 per childcare worker) leisure time hours (excluding sleep time) of heart rate measurements were included in the analysis . This trThe childcare workers spent less time ≤25% HRR during work (44.1% of the time awake) compared to leisure (55.1%) and a larger part >25–<60% HRR during work (55.2%) compared to leisure (41.5%). Thus, they spent 15.3 min (3.4%) of their leisure time ≥60% HRR and 2.3 min (0.7%) during work.For the childcare workers included in this study, a total of 3678 h of accelerometer measurements and 1834 h of heart rate measurements were analyzed. The findings showed that during working hours, the childcare workers had a composition of physical behaviors dominated by sedentary time (43.0%), and almost no time with high cardiometabolic intensity (0.7%). Most sedentary work time occurred in bouts of 5–30 min (23.1%) and the vast majority of work time spent standing and active was in bouts of <5 min (36.9% and 16.9%). During leisure, workers spent more time sedentary (59.4%), more time at high cardiometabolic intensity (3.4%) and most of their sedentary time occurred in bouts of >30 min (31.0%).Based on the accelerometer measurements, we found that the childcare workers had a composition of physical behaviors during working hours consisting in 43.0% sedentary, 39.6% standing and 17.4% active. Only one previous study examined these physical behaviors among childcare workers with accelerometer measurements during working hours and found almost identical results  . Other sn = 19) finding that childcare workers spent <1% of their work time at a high cardiometabolic intensity [Based on the heart rate measurement, we found that the childcare workers spent hardly any of their working hours at a high cardiometabolic intensity . This result is in agreement with a small proof-of-concept study , mainly occurring in long bouts, i.e., >30 min (31%). Thus, the childcare workers spent considerable time being sedentary, seen over the whole day (43.0% at work and 59.4% at leisure), which might increase their risk of negative effects, including cardiovascular disorders and reduced physical capacity ,38. On tMoreover, we found that the childcare workers spent more time at high cardiometabolic intensity during leisure  than during work . We expected this, since leisure time physical activity often includes dynamic movements at higher intensity levels, such as deliberate training activities . We did Although some greater time at a high cardiometabolic intensity was found during leisure than during work, we see a need for—and a great potential in—redesigning childcare work to include more time with high cardiometabolic intensity; one reason being that high-intensity physical activity has been shown to buffer the harmful effect on health from extensive sedentary time . MoreoveBy providing novel information about the composition, intensity and alternations of physical behaviors during work and leisure time for childcare workers, our study contributes to the understanding of why the work of childcare workers does not seem to benefit their cardiorespiratory fitness and health, and also which interventions might be needed to redesign their work so it can promote health. We have previously shown that redesigning the way childcare workers play with the children can lead to more time at a high cardiometabolic intensity . TherefoA strength of our study was the high worker participation rate (82%). Another strength was the use of validated accelerometer measurements  to captuHowever, a limitation was the exclusion of some heart rate data due to a beat error ≥ 50%. A high beat error could be due to rapid body movements  disturbing the signal, and therefore time spent at ≥60% HRR may have been higher than reported in this study. Another limitation was that we only measured leisure time during working days, and not during non-workdays and weekend days. Thus, the reported physical behaviors during leisure time might not be representative of the total weekly leisure time. However, physical activity levels per day on week days and weekend days has previously been reported for 553 childcare workers , indicatThis study gives a novel contribution to our understanding of the composition, intensity and alternations of physical behaviors among childcare workers during both work and leisure. The results indicate that childcare work is composed of behaviors dominated by sedentary time, very little time with high cardiometabolic intensity and frequent alternations between behaviors. During leisure we found that the workers spent more time sedentary, more time with high cardiometabolic intensity and more time in long sedentary bouts. Overall, the composition and the alternations of physical behaviors during childcare work appear healthy. However, the time spent with high cardiometabolic intensity is not sufficient to increase the cardiorespiratory fitness and health of the workers. Thus, we see a potential in promoting cardiorespiratory fitness and health among childcare workers by increasing their work time at a high cardiometabolic intensity, preferably by redesigning the way they play with the children. Further studies should investigate the effectiveness of implementing such a change in childcare work in improving cardiorespiratory fitness and health among childcare workers.


Ei), radiation use efficiency (RUE), and harvest index (HI). The relative contribution of these three parameters on the final grain yield (GY), their interrelation with other phenological–physiological traits, and their environmental stability have not been well established for soybean. In this study, we determined the additive–genetic relationship among 14 physiological and phenological traits including photosynthesis (A) and intrinsic water use efficiency (iWUE) in a panel of 383 soybean recombinant inbred lines (RILs) through direct  and indirect learning methods [least absolute shrinkage and selection operator (LASSO) algorithm]. We evaluated the stability of Ei, RUE, and HI through the slope from the Finley and Wilkinson joint regression and the genetic correlation between traits evaluated in different environments. Results indicate that both supervised and unsupervised methods effectively establish the main relationships underlying changes in Ei, RUE, HI, and GY. Variations in the average growth rate of canopy coverage for the first 40 days after planting (AGR40) explain most of the changes in Ei. RUE is primarily influenced by phenological traits of reproductive length (RL) and seed-filling (SFL) as well as iWUE, light extinction coefficient (K), and A. HI showed a strong relationship with A, AGR40, SFL, and RL. According to the path analysis, an increase in one standard unit of HI promotes changes in 0.5 standard units of GY, while changes in the same standard unit of RUE and Ei produce increases on GY of 0.20 and 0.19 standard units, respectively. RUE, Ei, and HI exhibited better environmental stability than GY, although changes associated with year and location showed a moderate effect in Ei and RUE, respectively. This study brings insight into a group of traits involving A, iWUE, and RL to be prioritized during the breeding process for high-yielding cultivars.Soybean grain yield has steadily increased during the last century because of enhanced cultivars and better agronomic practices. Increases in the total biomass, shorter cultivars, late maturity, and extended seed-filling period are frequently reported as main contributors for better soybean performance. However, there are still processes associated with crop physiology to be improved. From the theoretical standpoint, yield is the product of efficiency of light interception ( Finally, we evaluated the stability of Ei, RUE, and HI using the genetic correlations between the same trait evaluated in a different environment and the slope from the Finlay and Wilkinson joint regression (FWR). This paper suggests traits to be prioritized during the breeding process as a strategy to improve the grain yield in soybean.In this study, we established the genetic correlations among agronomical, physiological, and phenological variables and the three efficiencies controlling the potential grain yield in soybean: efficiency of light interception, radiation use efficiency, and harvest index , 1977. LR8 (GY (HY), high yielding under drought conditions (HYD), and diverse ancestry (DA). A complete description of families, crosses, and extra information is available in1 and –2. Plots with non-uniform emergence were discarded, reducing the number of RILs to 322 for ACRE_2017 and 381 for RMN_2018. Soil types for ACRE included Chalmers silty clay loam (Typic Endoaquolls) and Raub–Brenton complex (Aquic Argiudolls), while RMN corresponded to Drummer soils (Typic Endoaquolls) (A maturity-controlled panel of 383 recombinant inbred lines (RILs) selected from the Soybean Nested Association Mapping collection SoyNAM was used. A panel was selected constraining maturity and evaluated as days required to get R8 , while rR8  . High naaquolls) , which, aquolls) –6. The mUAV-type eBee equipped with an S.O.D.A red–green–blue (RGB) camera  was flown with a frequency of ∼12 days. Canopy coverage (CC) was obtained from the RGB imagery through the software Progeny®  using a multilayer mosaic approach as described by DAP) were considered for both environments in 2018, while just one sampling when maximum biomass accumulation was achieved at 91 DAP was carried out in 2017. Biomass was adjusted through a linear model involving RIL, environment, and replication as variables and number of plants as a covariate to avoid potential differences in biomass due to the number of plants. Seed weight was directly calculated from a lineal sample size of 0.56 m harvested and threshed at maturity (R8)  available. To determine the daily solar radiation intercepted, a series of 766 logistic models, one per plot, were fitted following equation (1) through the R software (growthrates” (CC as a proxy for light interception considering the direct relationship between these two parameters previously documented by A fixed-wing ity (R8) . Ei was software  package thrates” . We usedy is canopy coverage, yo is the minimum canopy coverage value measured, k corresponds to the maximum canopy value or load capacity, μmax is the maximum relative growth rate, and time indicates days after planting.where PAR intercepted. In 2017, since only one biomass sampling was performed, a simple ratio between the total aboveground dry matter and the cumulative PAR intercepted was used. Apparent HI was calculated as the direct ratio between the seed weight (0% moisture) and the total aboveground dry matter. Grain yield was determined in two perfect competence rows from each plot through a mechanical harvest. The weight registered was adjusted to 13% seed moisture and extrapolated to the hectare. Phenological stages R1, R5, and R8 corresponding to days required to achieve flowering, beginning of seed, and maturity were scored three times per week following the criteria presented by R8 to days to R1, while seed-filling length was calculated as R7 minus R5 in days.Radiation use efficiency in 2018 environments was calculated as the slope of a linear regression between the total dry matter aboveground and the cumulative AGR40 was measured as the mean of the daily growth rate during the first 40 days after planting. Growth rate corresponds to the first derivative from each logistic model adjusted for CC. Photosynthesis and intrinsic water use efficiency were measured through a portable photosynthesis system  set with a PAR value of 1,600 μmol photons m–2 s–1. CO2 concentration, temperature, and relative humidity were controlled to be 400 μmol mol–1, 25°C, and 75 ± 10%, respectively. The gas exchange parameters were measured before the seed filling phenological period, from late R4 and early R5 . A portable canopy analyzer  following the protocol for small plots in row crops suggested by LICOR (K) was calculated through the light attenuation within a canopy theory reported by LAI along with light measurements above and below the canopy was considered following equation (2):Maximum leaf area index was recorded in a single measurement when the full canopy was achieved (60–70 by LICOR  was usedI is the photosynthetic photon flux density (PPFD) measured on a horizontal plane, LAI is the leaf area index cumulated from top of the canopy, and K is the extinction coefficient. I0 is the PPFD above the canopy.where BLUE) per environment was calculated through a mixed model approach through the “lme4” package  controls the spatial heterogeneity within replications, α accounts for the effect of replication, αβ corresponds to the interaction replication × block, δ accounts for the genetic effect, and e controls the error. The covariate f(x) was computed as the average phenotypic value from the four closer surrounding plots , and e ∼ MVN.where ng plots  through  package . In thisBLUEs standardized by environment for all the traits were used to fit a second mixed model in a multivariate approach through the function reml in the “NAM” R package  as the additive–genetic correlation between the same traits measured in the three different environments and (2) through the slope of the FWR  of 0.48, 0.02, and 0.09, respectively , K directly participates in the determination of the amount of solar light remaining after passing through layers of LAI . Thus, greater LAI augments the number of layers that light must pass through, increasing the likelihood of solar radiation trapped by the leaves.Path analysis is a multivariate methodology closely related to multivariate regression where the path coefficients correspond to standardized regression coefficients for the linear model suggested by the path diagram . The effing date  as viablin yield . The posin yield . Light es of LAI . TherefoRUE indicates the capability to transform solar radiation, a free resource, into biomass through the plant metabolism. Our results indicate that this efficiency is mainly associated with phenological traits. Longer reproductive length has been previously associated with higher grain yield in soybean . These changes in ranking, GxE, found for RUE contrast with the low sensitivity to variations in location and year showed by HI and, along with the low dispersion of the FWR slope, suggest high stability and fewer requirements of multi-environment trials during the HI determination. Light interception coefficients, in turn, are strongly influenced by changes in the canopy among years but highly correlated among locations. Differences among years in this study may be explained by particular responses of lines to planting dates since ACRE_2017 was planted late (May 31) compared with ACRE_2018 (May 22) and RMN_2018 (May 17). A negative effect of late planting in LAI is reported for soybean  and north of the United States  is already reported, aligning with our findings (1. We observed less stability for GY denoted through the wide distribution of the slopes around the center with 25% (70) of the RILs showing slopes >1.5, suggesting stability type III, better performance than the average in favorable environments but less than average in unfavorable environments  stability is a desirable performance when new cultivars are released . In soybfindings . Accordifindings . In thisronments . On the ronments . Fifty pEi, RUE, or HI was implemented.Directed and undirected methodologies are able to capture the main relationships underlying light interception efficiency, radiation use efficiency, harvest index, and grain yield, bringing new insights to strategically approach the breeding of complex traits. Advances in soybean productivity must encompass optimization in phenological and physiological processes where improvement on harvest index appears as a suitable strategy to achieve fast and significant advances in final grain yield. Breeding strategies to increase photosynthesis and water use efficiency are a priority because of their positive impact not only in harvest index but also in radiation use efficiency. Although extending the reproductive period length without affecting the total length cycle would require reducing the photoperiod sensitivity and probably increasing the tolerance to cold temperature during the early stages, this phenological improvement has a potential return in the overall soybean perform involving grain yield, harvest index, and radiation use efficiency. Trait stability for individual efficiencies accounting for grain yield, evaluated through the joint regression’s slope, is higher than the stability for grain yield itself, which represent an advantage if selecting for https://www.soybase.org/SoyNAM/index.php.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found at ML and KR conceived and designed the experiments. ML and FF collected the field data. ML conducted the data analysis and interpretation, wrote and edited the manuscript. KR coordinated–supervised the research and ensured the funding. All authors contributed to the article and approved the submitted version.FF was employed by company Bayer, Inc. The remaining 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.


The aim of this systematic review was to compare knee pain and function after tibial nail insertion through an infrapatellar, semi-extended and suprapatellar technique.A search was carried out to identify articles with an exact description of the method used for insertion of the tibial nail and description of the outcome parameters (knee pain or function). Data on study design, population, rate and severity of anterior knee pain and function scores were extracted. Pooled rates and scores were calculated.67 studies with 3,499 patients were included. The pooled rate of patients with anterior knee pain was 38% (95% CI 32–44) after nail insertion through an infrapatellar approach and 10% (95% CI 1–26) after insertion through a suprapatellar approach. Pooled analysis was not possible for the semi-extended technique. Knee pain scores as measured by visual analogue score (0–10) ranged from 0.2 (95% CI − 0.1–0.5) for general knee pain to 3.7 (95% CI 1.3–6.1) for pain during kneeling. Pooled estimates for the Lysholm score were 87 points (range 77–97) for the infrapatellar technique and 85 points (range 82–85) for the suprapatellar technique. Iowa Knee scores were 94 (range 86–96) and Anterior Knee Pain Scale scores were 76 (range 75–80) after infrapatellar nail insertion.Depending on the technique used, the proportion of patients with knee pain after tibial nailing varied between 10 and 38%. The actual measured knee pain scores were, however, surprisingly low. Knee function was good for both the infra- and suprapatellar technique.The online version of this article (10.1007/s00068-020-01458-2) contains supplementary material, which is available to authorized users. Diaphyseal fractures of the tibia are commonly treated with an intramedullary nail. The infrapatellar approach is most commonly used. However, hyperflexion of the knee during this procedure is associated with an increased risk of valgus and procurvatum deformities in proximal third tibial shaft fractures. In an attempt to address this problem, a semi-extended technique has been developed , 2, of wAlthough all techniques for nail insertion have been proven feasible, a comparison of their rates of anterior knee pain and functional outcome is lacking. The aim of this systematic review and pooled analysis was, therefore, to compare these parameters between different techniques for tibial nail insertion. This information gives perspective to the patient’s rehabilitation after tibial nailing and can aid surgeons in their decision to choose between these surgical techniques.The following databases were searched on December 19, 2018: Embase, Medline (OvidSP), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. Searched items consisted of terms related to tibia shaft, intramedullary nailing and terms related to pain and function .i.e., patients with a floating knee), studies that described only pathological fractures or those with a population aged < 18 years, were excluded. Case reports and letters to or from the editor were also excluded. Reference lists of review articles and eligible studies were examined for additional studies that may have been missed.Titles and abstracts were screened independently by three reviewers . Inconsistencies were resolved by consensus. Studies were included if they met the following inclusion criteria: (1) tibial shaft fracture treated with intramedullary nailing, (2) description of the surgical method used for insertion of the tibial nail  semi-extended or suprapatellar; insertion through patellar tendon, medial or lateral to patellar tendon; use of longitudinal or transverse incision) and (3) primary data for at least one of the outcome parameters . No limitations on language were considered and only studies from 1990 onwards were included. Studies were excluded if no full-text version was available after contacting corresponding authors. Studies encompassing patients with intra-articular fractures  or only patients with ipsilateral fractures  and cohort studies were found to be eligible. Patient groups of comparative studies that were treated with the same incision were taken together; the pooled study population was considered one cohort over which knee pain rate, pain and functional scores were calculated.Two reviewers (MSL and EAVB) independently assessed the methodological quality of the studies using the MINORS  scale   using a standardized data sheet. Discrepancies were resolved by consensus. The following data were extracted for each publication: name of first author, publication year, population size and age, percentage of polytrauma patients and patients with ipsilateral fractures, the approach used, the rate of anterior knee pain, the pain scores, functional outcome scores, and the moment at which these measurements were done. When measurements were done at different time points, the scores at 12 months were used for calculation.https://www.medcalc.org; 2017). The rates of anterior knee pain were computed for each study and expressed as percentage. Visual Analog Scales (VAS) with a scale 0–100 were divided by 10 to compare them with 10 cm VAS and 10-point Numeric Rating Scales (NRS). Heterogeneity of the data was assessed using the Cochrane χ2Q-test (significance set at p < 0.10) and I2 statistic. Outcomes for cohorts with the same surgical approach were pooled if data were available for at least two groups. A random effects model was used if the I2 statistic was > 40%; a fixed-effect model was used if it was < 40%. For comparative studies, the relative risk  was determined for binomial variables and a mean difference for continuous variables. Pooled estimates and relative risks are reported with their 95% confidence interval.Analyses were performed using MedCalc Statistical Software  and applying the inclusion and exclusion criteria, 77 studies remained for analysis  after use of the infrapatellar approach and 10% (95% CI 2–22) after the suprapatellar approach  , 80, 83,The aim of this systematic review was to compare knee pain and function after tibial nail insertion through different surgical methods. For the infrapatellar approach, the proportion of patients with anterior knee pain in the current review was 36%. The percentage found for the suprapatellar technique was 10%. The documented general knee pain scores (VAS/NRS 0–10) were, however, surprisingly low for both techniques (2.5 for the infrapatellar technique and 0.4 for the suprapatellar technique). For the infrapatellar technique, pain scores during common daily activities were also low, except for kneeling (range 3.2–4.7). Knee function was good for both the infra- and suprapatellar techniques.The pooled proportion of 36% of patients with knee pain is lower than the much quoted percentage of 47.4% from the systematic review by Katsoulis et al. , but it One limitation of this systematic review is the lack of randomized controlled trials (RCT) comparing different methods in tibial nailing. Only two RCTs compared nail insertion through the patellar tendon with insertion medial to the patellar tendon , 49 and Overall, adequate reporting of outcome measures was poor. Besides, the previously mentioned lack of how and when measurements were taken, the standard deviation for mean pain or functional scores was not always provided. Furthermore, some authors chose to report scores only in terms of excellent, good, fair etc., without mentioning an overall score. The quality of a systematic review, such as the current review, depends on the quality of the underlying studies and although it is the authors’ responsibility to report their data adequate and complete, it would be helpful if journal reviewers and editors would ask for any missing information.The question whether one surgical approach for tibial nailing is superior to another cannot be answered due to limited availability of adequate data. One can conclude though that in terms of anterior knee pain, the suprapatellar technique has the lowest proportion (10.0%) of patients with this complaint. Overall, general knee pain scores are low (range 0.2–2.7). Knee function was good for both the infra- and suprapatellar techniques.Supplementary file (PDF 262 kb)Below is the link to the electronic supplementary material.


Robotic surgery has been taken as a new modality to surpass the technical limitations of conventional surgery. Here we aim to compare the oncologic outcomes of patients with rectal cancer receiving robotic vs. laparoscopic surgery.Data from patients diagnosed with rectal cancer between March 2011 and December 2018 were obtained for outcome assessment at the First Affiliated Hospital of Nanchang University. All patients were separated into two groups: a robot group  and a laparoscopy group . The primary endpoint was survival outcomes. The secondary endpoints were the general conditions of the operation, postoperative complications and pathological characteristics.P > 0.05). In the multivariable-adjusted analysis, robotic surgery was not an independent prognostic factor for OS and DFS . With respect to the general conditions of the operation, patients in the robot group had significantly shorter operation times (163.5 ± 40.9 vs. 190.5 ± 51.9 min), shorter times to 1st gas passing [2(1) vs. 3(1)d] and shorter hospital stay days [7(2) vs. 8(3)d] compared to those in the laparoscopy group . After the operation, the incidence of short- and long-term complications in the robot group was significantly lower than that in the laparoscopy group , especially for urinary retention . With regard to pathological characteristics, TNM stages II and III were more frequently observed in the robot group than in the laparoscopy group . No significant difference were observed in lymph nodes retrieved, lymphovascular invasion and circumferential resection margin involvement between the two groups .The 5-year overall survival (OS) and disease-free survival (DFS) at years 1, 3 and 5 were 96.6%, 88.7%, and 87.7% vs. 96.7%, 88.1%, and 78.4%, and 98.6%, 80.2-, and 73.5% vs. 96.2-, 87.2-, and 81.1% in the robot and laparoscopy groups, respectively (This monocentre retrospective comparative cohort study revealed short-term advantages of robot-assisted rectal cancer resection but similar survival compared to conventional laparoscopy. Colorectal cancer ranks third in terms of cancer incidence but second in terms of mortality worldwide . Thus, tThe current robotic surgical system provides advanced technology and has advantages in rectal cancer resection. Several previous studies documented that robotic surgery is equivalent to laparoscopic surgery with respect to perioperative and oncologic outcomes –13. To d® surgical system  in China. Here, We evaluate the oncologic outcomes of rectal cancer by robotic surgery or conventional laparoscopic surgery including the primary endpoint of survival outcomes and the secondary endpoints of the general conditions of the operation, postoperative complications and pathological characteristics.Our centre is one of the earliest hospitals to introduce the da VinciThe prospectively collected records of all patients at the First Affiliated Hospital of Nanchang University between March 2011 and December 2018 with histologically proven rectal adenocarcinoma were retrospectively reviewed. All patients were separated into two groups: a robot group in which the patients received robotic surgery, and a laparoscopy group in which the patients received laparoscopic surgery. All patients included in this study met the following criteria: (1) the disease was histologically defined rectal adenocarcinoma; (2) all the patients underwent TME; (3) tumour size was measurable, and pathological evaluation records of pelvic lymph nodes were complete; (4) the patient had no history of malignancy in other organs; and (5) the clinicopathological and follow-up data of the patients were complete. The exclusion criteria were as follows: (1) age > 80 and < 18 y; (2) other malignant tumours; (3) TNM stage at 0, IV; (4) multivisceral resection; (5) palliative resection; (6) restaging surgery; (7) abdominal and pelvic exploration only; and (8) incomplete patient information.Before surgery, all patients were informed of the detailed characteristics of both robotic and laparoscopic surgical procedures. After informed consent was obtained, the patients decided their preferred approach. The study protocol followed the Ethical Guidelines of the 1975 Declaration of Helsinki, revised in 2000. All related procedures were performed with the approval of the Internal Review and the Ethics Boards of the First Affiliated Hospital, Nanchang University.The following clinical and demographic information was collected: age, sex, body mass index (BMI), carcinoembryonic antigen (CEA), American Society of Anesthesiologists (ASA) class, tumour location from the anal verge, preoperative chemoradiotherapy (CRT), and clinical T stage. The intraoperative and perioperative conditions , postoperative complications  and survival time were also collected. The baseline characteristics of patients at enrolment were assessed within 24 h before robotic or laparoscopic surgery.The primary endpoint for this study was survival outcomes, including overall survival (OS) and disease-free survival (DFS). The secondary endpoints were the general conditions of operation, postoperative complications and pathologic characteristics. The general conditions of the operation included operation time, bleeding volume, time to 1st gas passing and length of hospital stay. The postoperative complications associated with robotic and laparoscopic surgery included short- and long-term complications, which were defined as complications that occurred less than 30 days or more than 30 days after the operation, respectively . The recPatients were followed up with for 5 years or until Dec 31, 2018. Operative death was defined as death within 30 days of the operation or any time after the operation if the patient did not leave the hospital alive.® surgical system and laparoscopic surgery, were performed or supervised by a single surgeon (T-Y Li). Briefly, the same principle and steps were applied in both the laparoscopic and robotic surgery procedures: ligature of inferior mesenteric blood vessels close to the origin, mobilization of the sigmoid colon and rectum using sharp dissection, complete splenic flexure takedown for mid- and low rectal cancer, clamping below the tumour, and washing of the rectal stump with 10% povidone-iodine before rectal transection. End-to-end anastomosis was then performed by either mechanical circular stapling or manual anastomosis. The anastomosis was tested with air inflation. Abdominoperineal excision was performed when the levator ani muscle had been invaded by the tumour. In some patients, a temporary ileostomy was conducted to protect the anastomosis, with digestive tract reconstruction performed 3 months later.In our retrospective study, patients who underwent elective laparoscopic or robotic surgery for stages I–III rectal cancer between March 2011 and December 2018 were included. Patients who underwent palliative surgery, intersphincteric resection, abdominoperineal resection, or lateral pelvic lymph node dissection or patients who had hereditary colorectal cancer or distant metastasis were excluded. Since the robotic system was introduced in March 2016, selection of the surgical approach was determined after discussion with patients about the differences and higher costs of robotic surgery. Before March 2016, patients were chosen to undergo laparoscopic surgery. All procedures, including robotic surgery using the da Vinci2 test or Fisher’s exact test was used for categorical variables. Student’s t-test and the Mann–Whitney U test were used for continuous variables. The results are presented as the frequency (percentage), mean ± standard deviation (SD) or median (interquartile range). Survival curves were obtained by the Kaplan–Meier method, and the OS and DFS rates were compared by the log-rank test. The Cox proportional hazard regression model was used to identify factors that were independently associated with OS and DFS. The candidate covariates for univariate analysis included age, sex, BMI, CEA, ASA class, tumour location, robotic surgery, preoperative CRT, previous abdominal surgery, lymph nodes retrieved, proximal resection margin (PRM), distal resection margin (DRM), TNM stage, differentiation grade, circumferential resection margin (CRM), and lymphovascular invasion. Only factors with a P < 0.05 in the univariate analysis could be included in the multivariate analysis using a stepwise method, and variables with a P < 0.05 and hazard ratio (HR) > 20% were kept in the final model. A two-tailed P < 0.05 was considered significant. All statistical analyses were performed using the SPSS 22 software package .In the univariate statistical analyses, the χP < 0.001).A total of 629 patients were initially screened, and 534 patients with rectal adenocarcinoma were finally enrolled in this study; 314 patients were in the robot group, and 220 patients were in the laparoscopy group . The time to 1st gas passing [2 (1) vs. 3 (1) d] and length of hospital stay [7 (2) vs. 8 (3) d] were significantly shorter in patients with robotic surgery than in those receiving laparoscopy surgery . No significant differences were observed with regard to intraoperative bleeding volume or time to 1st soft diet or bowel movement.The general conditions of the operation are listed in Table P < 0.001). No significant differences were observed between the two groups with respect to the occurrence of short- and long-term complications, including anastomotic leakage, anastomotic bleeding, wound problems, ileus, intra-abdominal abscesses, anaemia, ascites, adhesions, incisional hernias, anastomotic strictures and rectovaginal/rectovesical fistulas . However, the occurrence of short- and long-term urinary retention in the robot group was significantly lower than that in the laparoscopy group . The above findings indicated that robotic surgery was associated with a decreased prevalence of postoperative complications.The type and proportion of postoperative complications associated with surgical treatment are described in Table P < 0.001). There was no significant difference with respect to lymph nodes retrieved between the two groups . The prevalence of lymphovascular invasion and CRM involvement also showed no significant difference between the two groups .The postoperative pathological characteristics and outcomes of patients in the robotic group were significantly different from those in the laparoscopy group Table . TNM staIn this retrospective comparative cohort study, we found no beneficial survival effect of robotic surgery on patients with rectal cancer compared to those receiving laparoscopic surgery. However, a decreased postoperative complications, operating time, hospital stay and time to 1st gas passing were observed, which revealed a short-term advantages of robotic surgery.In addition, we found that patients who underwent robotic surgery had a lower tumour location and advanced clinical stage than those who underwent laparoscopic surgery. Operation on these patients especially those with a lower tumour location usually means a more challenging procedure and requires higher skills with surgical techniques than for those without; thus, indicating robotic surgery may have advantages in rectal surgery on more sophisticated cases because of its better visualization and the ability to perform a finer and more dexterous pelvic dissection within a narrow pelvic cavity . ImportaThe postoperative pathological parameters that can measure the quality of rectal surgery are CRM positivity and the number of harvested lymph nodes of the resected specimen; both of which were not significantly different between the robotic and laparoscopic surgical approaches. The CRM involvement rate in this study was 1.3% vs. 0% between the robot and laparoscopy groups, which was comparable with previous studies 0–16%) , 12, 16.% , 12, 1Cumulative OS and DFS, the gold-standard prognosticators, indicate long-term oncologic outcomes and reflect the superiority of surgical techniques in cancer resection. Few previous studies have shown the cumulative OS and DFS between the robot and laparoscopy groups. Baek et al.  reported® robotic system , which has been proven to be feasible and safe in general surgery, gynaecology, and urology [Robotic surgery requires that a surgeon take a long time to learn to adapt to new surgical techniques, such as controlling consoles, manipulating new instruments, and cooperation with the surgical team –22. Our  urology . We suppRobotic surgery was not associated with improved survival compared to laparoscopic surgery for rectal cancer, however, robotic surgery is a safe and feasible surgical procedure, especially for some sophisticated cases with lower tumour locations. Further prospective randomized trials are needed to clarify these findings.


IntroductionExtracapsular extension (ECE) in the lymph nodes for patients with head and neck cancer has been found to be a poor prognostic factor in multiple studies. The purpose of the study is to evaluate the predictive factors for ECE on computer tomography (CT) imaging for patients undergoing surgery and to analyze outcomes.MethodsWe conducted an Institutional Review Board-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant retrospective review of 82 patients with biopsy-proven squamous cell carcinomas of the head and neck who underwent definitive surgery without neoadjuvant chemotherapy or radiation therapy. CT scans were evaluated for the level of involvement, size, and presence or absence of central necrosis. Extracapsular extension in lymph nodes on the postoperative pathology was correlated with the central necrosis in the lymph nodes appreciated on the CT neck with contrast. Survival estimates were evaluated using the Kaplan-Meier test.ResultsECE on postoperative pathology was seen in 74.07% of patients who had evidence of central necrosis in lymph nodes on preoperative CT neck compared to 46.43% without CT necrosis (p=0.013). The incidence of ECE is higher in poorly differentiated tumors and also nodal stages >N2c at presentation. Patents with ECE had inferior disease-free and overall survival (OS).ConclusionsOur results reveal that patients with necrosis on CT and with moderately to poorly differentiated tumors have a high incidence of extracapsular extension. There was no difference in local control (LC) between the groups of patients, but the OS was inferior in patients with ECE. Predicting extracapsular extension upfront helps to formulate the appropriate treatment. We propose to study additional chemotherapy to improve outcomes in patients with positive extracapsular extension. Peters et al. studied the criteria predicting the risk of local recurrence in the neck after surgery in patients with squamous cell carcinoma of the head and neck . In theiBoth the European organization for Research and Treatment of Cancer (EORTC) and the Radiation Therapy Oncology Group (RTOG) conducted randomized trials in which patients with high-risk features were randomized to either radiation therapy alone versus concurrent chemo-radiation therapy (CRT) , 3. BothAs previously reported, ECE is highly correlated with the size of the lymph nodes, but nodes less than 1 cm may also harbor ECE at a rate as high as 25% . SeveralAt the University of Mississippi Medical Center, we retrospectively evaluated 82 patients diagnosed with squamous cell carcinomas of the head and neck, treated between 2008 and 2014. Institutional review board approval was obtained for a retrospective review of these patients. Initial staging at diagnosis was performed utilizing CT neck with contrast. CT scans were also evaluated for the level of involvement, size, and presence or absence of central necrosis Figure  was corrRadiotherapy was delivered utilizing Intensity Modulated Radiation Therapy/Volumetric Modulated Arc Therapy (IMRT/VMAT) techniques. After completing the adjuvant treatment, the patients were followed up per National Comprehensive Cancer Network (NCCN) guidelines.SPSS Statistics version 23  was used for statistical analysis. The cross-associations between variables were tested using the cross tabs function. A Chi-Square test was used between categorical variables to justify and estimate the significance of the association. The survival estimates for overall survival, disease-free survival, and distant metastasis-free survival were evaluated using the Kaplan-Meier test. Logrank test was used to estimate the level of significance in these tests. Cox regression using backward elimination was used to determine the significant covariates in the calculation of survival.Of the 82 patients, 33 patients had an oral cavity primary, six with oropharynx, 30 with larynx, six with hypopharynx, six with skin, and one with an unknown primary. Based on the American Joint Committee on Cancer (AJCC) nodal staging 7th edition, 13 patients were grouped into N1, four patients into N2a, 25 patients into N2b, 35 patients into N2c, and five patients had N3 disease. The percentage of nodes with ECE based on the nodal stage was evaluated by substages . As can be seen in Table Among 82 patients, 54 were found to have central necrosis in lymph nodes on CT imaging performed for staging. We correlated the extracapsular extension in the histopathology reports to the necrosis on the CT scans. ECE was positive in 46.4% of patients without necrosis on CT, whereas ECE was positive in 74.07% of patients with necrotic lymph nodes and was statistically significant (p=0.013). We found a similar correlation between necrosis and ECE, even in lymph nodes size <3 cm (n=57), as shown in Table Among the 82 patients under evaluation, only three patients had well-differentiated tumors, while 59 were moderately differentiated, and 20 were poorly differentiated, as seen in Table Besides, we evaluated endpoints, including loco-regional failure (LRF), distant metastases (DM), and overall survival (OS) in patients who completed all the prescribed adjuvant treatment. We excluded 13 patients that were non-compliant with the adjuvant treatment and follow-up visits. Thus, a total of 69 patients were available in the final analysis. The median follow-up was five years. The loco-regional failures were similar in both groups . However, the distant failures Figure  were mucNecrosis can be defined as cell death caused by loss of membrane integrity, intracellular organelle swelling, and adenosine triphosphate (ATP) depletion leading to an influx of calcium. Necrosis involves rapid and passive cell death. Necrosis is associated with the loss of plasma membrane integrity, swelling, and bursting of groups of cells rather than single cells at the cellular level. Necrosis is typically attributed to tumors with aggressive biology, as they have been found to outgrow their blood supply quickly . GeneralIn our study, we found a statistically significant correlation between necrosis in lymph nodes on CT and the presence of extracapsular extension on postoperative pathology . This finding was true even in smaller lymph nodes, size <3 cm. This retrospective review confirms the results from earlier studies that necrosis correlates with ECE in a larger patient population , 19.When the data is further analyzed based on differentiation, a significant correlation was observed in patients with moderate differentiation , but not in poorly differentiated histology patients. However, ECE incidence was high in poorly differentiated (82.6%) compared to moderately differentiated histology (53.4%). This finding proves that poorly differentiated histology itself denotes aggressive tumor biology, thus increasing the risk of ECE with or without central necrosis on the preoperative imaging. More than 80% of patients with neck nodal stage >N2c, poorly differentiated histology, and nodal size >3 cm had ECE. Predicting extracapsular extension becomes valuable information for clinicians planning treatment -23. TherOur results reveal that patients with necrosis on CT and with moderately to poorly differentiated tumors have a high incidence of extracapsular extension. There was no difference in local control (LC) between the groups of patients, but the OS was inferior in patients with ECE, which can be explained by the higher incidence of distant metastases in this group. As the development of distant metastases was higher in patients with ECE, we propose to study administering additional chemotherapy in this group of patients to prevent distant metastases and improve overall survival.


To investigate characteristic clinical and imaging features and establish a scoring system for preoperative prediction of malignancy in the bulging duodenal papilla.A total of 147 patients with bulging duodenal papilla  from our hospital between 2010 and 2020 were retrospectively analyzed. We investigated meaningful clinical and CT imaging features and established the score model through logistic regression and weighted. The calibration test, the ROC, AUC, and cut-off points were performed in score model. The model was also divided into three score ranges for convenient clinical evaluation.Three clinical and CT imaging features were finally included in the score model including direct bilirubin (DBil) increase >7 umol/L (3 points), pancreatic duct (PD) dilation >5 mm (2 points), and irregular shape (2 points). The AUCs of the primary predictive model and score model were 0.896  and 0.896 , respectively. This scoring system presented with a sensitivity of 78.8% and a specificity of 88.1% when using 2.5 points as cutoff value. Three score ranges were also proposed for convenient clinical use as follows: 0–2 points; 3–4 points; 5–7 points. The number of patients with malignant duodenal papillary enlargement increased with the increasing scores.We proposed a convenient scoring system to preoperative predict malignancy in the bulging duodenal papilla. The major duodenal papilla is a functional region where the pancreatic duct (PD) and the bile duct enter the duodenum, and the maximal diameter of the size of normal duodenal papilla were 5–10 mm as reported by previous study . VariousEndoscopic retrograde cholangiopancreatography (ERCP) is now used as golden standard to identify the pathologic conditions of the bulging papilla , 7. But CT as one of the most widely used and non-invasive abdominal imaging methods has presented the latent energy to differentiate between benign and malignant bulging papilla as demonstrated by previous imaging study. Lobular masses, dilatation of the common bile duct, PD, intra- and extrahepatic bile duct, and so on were reported as meaningful indication , 10. HowTherefore, this study aims to investigate independent clinical and CT imaging risk characteristics, and then establish a convenient scoring system for preoperative prediction of malignancy in bulging duodenal papilla.Our institutional review board approved this retrospective study and waived consent requirement from patients. A total of 147 patients were finally included in this study population through searching the medical records from 2010 to 2020 in the Second Affiliated Hospital of Zhejiang University School of Medicine according to the following inclusion criteria: (1) patients were pathologically confirmed with benign or malignant bulging duodenal papillary; (2) patients had clinical and CT imaging data; (3) Patients didn’t receive chemotherapy or radiotherapy before these data were collected; (4) conditions originated from the duodenal papilla. Eight patients were excluded because of the following reasons: (1) Data limited (n = 4); (2) The quality of imaging was poor (n = 4). The final study cohort was consisted of 67 patients with benign duodenal papillary enlargement  and 80 with malignant duodenal papillary enlargement Figure 1Abdominal contrast-enhanced CT examinations of patients were performed in one multidetector-row CT . The scanning parameters were same as follows: detector configuration 128 × 0.6 mm, tube voltage 120 kVp, tube current 200 mAs, slice thickness 5 mm, slice interval 5 mm, pitch of 0.6 mm. A total of 120 ml of contrast agent was administered with a pump injector at 3–4 ml/s into an antecubital vein. The arterial and portal venous phases were obtained at 40–50 s and 80–90 s after the injection of the contrast medium, respectively. The clinical data were collected by screening the institutional medical reports.All patients were performed with required examination. The clinical data included age, gender, clinical symptoms , total bilirubin (TBil) increase (>17.1 umol/L), direct bilirubin (DBil) increase (>7 umol/L), indirect bilirubin (IBil) increase (>13.7 umol/L), and Carbohydrate antigen199 (CA199) increase (>37 Ku/L).All the images were evaluated by two experienced abdominal radiologists independently who were unknown of the pathology result. The variables of CT imaging were as follows: The shape of duodenal papilla (regular or irregular), extrahepatic bile duct dilation (EHD) , intrahepatic bile duct dilation (IHD) (>5 mm), PD dilation , asymmetric thicken of the distal of the common bile duct, thicken of the adjacent duodenal wall, target sign, cut off suddenly of the common bile dilation, the CT attenuation of the lesions in three phases, and correlated two ratios. Target sign indicated that dilated common bile duct extended the baseline of the inner wall of the duodenum. Ratio 1 was defined as CT attenuation of arterial phase minus that of plain scanning, ratio 2 was defined as CT attenuation of portal phase minus that of plain scanning.Continuous variables are presented as median with standard deviation (M-S), and categorical variables as number with percentage. The same variables between two groups were compared using the Student t test for continuous variables and chi-square or Fisher’s exact test for categorical variables. Variables that presented statistically significant in univariate analysis (P < 0.05) were obtained into ridge regression analysis to minimize multicollinearity  and thenAll the data were analyzed by SPSS version 25.0 software , except ROCs comparison was performed by MedCalc statistical software, version 19.0 . A two-sided p value <0.05 considered statistically significant.The comparison of clinical characteristics was summarized in The comparison of CT imaging characteristics was summarized in In the univariate analysis, totally 13 clinical and CT features showed statistical difference as demonstrated in Multivariate logistic regression was performed to get further verification, and three variables showed independent correlation with the diagnosis of malignant duodenal papillary lesions in this primary preoperative predictive model including DBil increase (>7 umol/L) , PD dilation (>5 mm) , and irregular shape , as demonstrated in To provide a quantitative method to predict malignant duodenal papillary lesions, a scoring system was proposed based on multivariate analysis. Weighted scores were assigned to three independent variables as follows: DBil increase (>7 umol/L), 3 points; PD dilation (>5 mm), 2 points; irregular shape, 2 points Table 3.To apply this scoring system conveniently in practice, we further divided it into three score ranges as follows: 0–2 points; 3–4 points; 5–7 points. The predictive positive rates of the three ranges increased as demonstrated in The scoring system established in this study could successfully detect malignant bulging duodenal papilla through observing three clinical and CT imaging features, including DBil increase (>7 umol/L), PD dilation (>5 mm), and irregular shape of the papilla Table 5.With the widespread use of various imaging modalities, the enlargement of the major duodenal papilla is increasingly being detected at CT. There are many reasons that could cause the enlargement of the papilla, such as papillitis, periampullary and ampullary cancer, pancreatitis, and choledochocele . And It To focus on pathological abnormalities originated from the duodenal papilla, we excluded some conditions, such as stones in bile duct identified at CT or magnetic resonance imaging (MRI) and some lesions originated from pancreatic and common bile duct involving the major duodenal papilla.We used lager than 5 mm at CT as the standard of the enlargement papilla. The sizes of the normal major duodenal papilla are various , 3. It dIn our scoring system, DBil increase (>7 umol/L) is the only one clinical variable absorbed and the OR is 36.968 (95% CI 12.74–107.277) that weighted the highest score. For obstructive jaundice which can be frequently observed in patients with bulging duodenal papilla, some clinical characteristics has presented potential in the differential diagnosis of the benign and malignant cause like CA199 and total bilirubin –18. In tMalignant lesions of the major duodenal papilla typically present as a hypoattenuating mass with enhancement on arterial and portal phase at CT  and its In previous studies, some other imaging features also had been reported. The enlargement of the major duodenal papillary caused by benign edematous thickening at the ampulla of Vater could present wall thickening and more intense enhancement than normal papillary , 23. We There are some limitations in our study. Firstly, there may be inherent selection bias due to retrospective study design. Secondly, we wanted to further study the meaningful difference between patients with inflammation or diverticulum and with duodenal papillary adenoma, but there were no variables presented statistical significance in univariate analysis in this cohort, which indicating more patients and more variables may need to be brought in.In conclusion, we established a scoring system for preoperative prediction of malignancy in the bulging duodenal papilla, which incorporating three critical variables, including DBil increase (>7 umol/L), PD dilation (>5 mm), and irregular shape of the bulging papilla. This scoring system has good discriminative ability for malignant enlargement of the papilla, and we believe that such prediction could have significant assistance in the clinical practice.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by the Second Affiliated Hospital of Zhejiang University School of Medicine. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.The work reported in the above for publications has been done by all authors. X-JW contributed to data analysis and manuscript editing. J-LK collected the data of patients and J-XX supported. J-PZ, Y-FL, and DS helped in images analysis. Q-MZ helped in manuscript preparation. And R-SY contributed to the supervision of the whole process. All authors contributed to the article and approved the submitted version.This study was supported by funding from the Medical Science and Technology Project of the Health Department of Zhejiang Province of China (no. 2019334245).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.