Far-advanced otosclerosis (FAO) refers to severe otosclerosis with scarce auditory functions. The identification of the best method to correctly listen to sound and speech has a large impact on patients’ quality of life. We retrospectively analyzed the auditory function of 15 patients affected by FAO who were treated with stapedectomy plus hearing aids independent of the severity of their auditory deficit before surgery. The combination of surgery and hearing aids allowed excellent recovery of the perception of pure tone sounds and speech. Four patients, because of poor auditory thresholds, needed a cochlear implant after stapedectomy. Despite being based on a small sample of patients, our results suggest that stapedotomy plus hearing aids could improve the auditory capacities of patients with FAO independent of their auditory thresholds at T0. The careful selection of patients is fundamental to obtain the best outcomes. Otosclerosis defines the excessive bone resorption that affects the labyrinth capsule followed by the re-deposition of new sclerotic bone . CommonlSevere–profound sensorineural hearing loss (SNHL) caused by otosclerosis is named far-advanced otosclerosis (FAO).In 1961, House and Sheeny  were theFAO can be treated using (i) conventional hearing aids, which due to the poor results that could be obtained, are only indicated in patients with contraindications to surgery ; (ii) stAny treatment has strengths, weaknesses, advantages, and disadvantages. Currently, despite the interesting proposal of Merkus et al. , the guiIn 2011, Merkus et al. proposed a classification based on the score of the speech perception test (SPT) to address patients to the different methods of hearing rehabilitation ; he suggOur study aims to evaluate the improvement in hearing capacities in a series of patients who underwent stapedectomy plus hearing aids independent of the scores obtained in the SPT; this aim could validate  Merkus’s suggestions.This retrospective clinical study was conducted in the Otolaryngology Department of Santa Maria della Misericordia University Hospital, a tertiary referral center. All procedures were approved by the internal revision board (IRB) of the hospital and conducted in accordance with the ethical principles of the Declaration of Helsinki; no approval number was released, given of the retrospective design of the study, following national laws.We revised our clinical records to identify patients who were affected by FAO by screening the department data set from January 2014 to December 2020. In this period, 472 patients underwent stapedotomy surgery; 55 cases were bilaterally treated, for a total of 523 operations. In total, 15 interventions were performed on patients affected by FAO.The following data were extracted from the clinical records: otoscopy findings, pure tone auditory test (PTA) and speech perception test (pre- and post-surgery) results, impedance, vestibular examinations, and the type of surgery performed. The surgical procedure performed on all 15 patients consisted of a primary stapedotomy on the worse-hearing ear.All PTA tests were performed at our institution in the audiology unit before surgery (T0) and after 6 months (T1). From patients’ medical records, we collected data about the preoperative air conduction (AC) threshold (t0)  , the speThe preoperative and postoperative speech perception tests were administered in an open field with bilateral hearing aids to obtain the open-set WRS at 60 dB HL. A list of simple bisyllabic words see  was usedThe SPT was measured by the average percentage, with values from 0%  to >95% .Speech perception was considered satisfactory when the word recognition score recovery (T1 vs. T0) was more than 40%, good when it was between 39 and 21%, and poor when it was ≤20%. This sub-division was created considering the ability to understand speech in an open field in a normal speech interaction.The selection of the ear that needed surgery was made based on the results of the audiological investigation. The ear with the worse auditory results underwent surgery.t tests (τ) were used to compare the PTAv pre- and post-treatment as well as the WRS at T0 and T1. A p value < 0.05 was considered statistically significant.Using one-way ANOVA and Bonferroni–Holmes (BH) ad hoc tests, we compared the single auditory frequency before and after stapedectomy. Two-tailed We identified 15 patients (3.1% of patients undergoing stapedoplasty surgery), including 8 women and 7 men. The average age was 60 years (CI95%: 42–72). The diagnosis of FAO was confirmed during surgery. All these patients had postoperative audiological tests at 6 months; this observation time was considered a short follow-up.All 15 patients had normal tympanic membranes before the operation, negative vestibular tests (no vertigo), and underwent the same surgical procedure (the insertion of a fluoroplastic piston prosthesis with a diameter of 0.4 mm and a variable length of 4–5 mm) performed by the same operator (GR).All patients were prothesized with retroauricular high-power (BTE) hearing aids 21 days after stapedectomy; these prostheses used semi-linear power amplification technology .p < 0.0001). The improvement was statistically significant for 500 Hz (BH: p < 0.01), 1000 Hz (BH: p < 0.01), 2000 Hz (BH: p < 0.01), and 3000 Hz (BH: p < 0.01)  and after treatment (T1) (ANOVA:  < 0.01) .p < 0.0001). As shown in The PTAv improved, with statistically significant values comparing T0 and T1 (τ: p < 0.0001). The average at T0 was 25% ± 13.5 (CI95%: 5–45%), while at T1 the mean was 62% ± 19.3 (CI95%: 25–80%)  .The average WRS recovery was 37 + 12.1 (CI95%: 15–55%); nine patients presented satisfactory results (recovery > 40%), four presented good results, and two presented poor results .Four cases presented postoperative problems: two had postoperative vertigo, which resolved within 48 h, and two cases suffered from dysgeusia, which resolved in a few weeks. Four patients (26.7%) were not satisfied with their hearing performance, despite a recovery over 30, because they had difficulties understanding people in normal, everyday conditions (noise and multi-voice) and had a WRS < 30%; for this reason, they underwent cochlear implant surgery 8–18 months after stapedectomy  who had a score under 30% (candidates for cochlear implants following Merkus) needed a cochlear implant to recover good/satisfactory auditory functions.Currently, several options are available for the treatment of FAO-related HL; thanks to the improvement of technology and surgical techniques, it is possible to perform cochlear implant surgery when necessary ,16.Stapedotomy presents some advantages compared to a cochlear implant. First, it is minimally invasive and can be performed under local anesthesia, a strength for treating elderly patients with comorbidities . The proIn our case series, 11/15 patients (73.3%) achieved satisfactory results in verbal communication, and in four cases the outcome was poor. In these unsuccessful cases, we used a cochlear implant, which allowed the patients to reach a good auditory ability. The literature shows that the success rate of stapedotomy in FAO ranges from 36 to 100% on tonal audiometry tests, with verbal recognition rates ranging from 38 to 75% [The presence of a very high or unvaluable bone conduction threshold does not always represent a negative prognostic factor, even if the success rate does not exceed 30% in those cases . In patiCommon complications of stapedotomy are the further loss of residual hearing, tinnitus, dizziness, and dysgeusia (due to lesions of the chorda tympany). These adverse events were recently reported by Teaima et al. (2022)  in 18.6%The use of a cochlear implant in the treatment of FAO allows patients to obtain better results compared to the conventional stapedotomy plus hearing aid with regards to the improvement in the hearing threshold. While some authors  found a Compared to stapedotomy, cochlear implants present some disadvantages, such as the higher cost of the device, greater surgical difficulties, higher incidence of complications , and greater post-implantation rehabilitation difficulties.A cochlear implant surgical procedure could be challenging in FAO due to cochlea bone alterations caused by the otosclerotic processes. The degree of ossification ranges from 5 to 51%, depending on the study . Bone osOne of the major complications of cochlear implant surgery in FAO is the stimulation of the facial nerve, which was reported by Rotteveel et al. to occur in 38% of cases . StructuIt must be considered that, even after the success of a cochlear implant surgery, the rehabilitation of an otosclerotic patient can be challenging. In fact the evolution of the osteo-thickening processes can affect the performance of the implant, requesting frequent reprogramming with higher stimuli . For thiTeaima (2022)  showed tHeining showed that stapes surgery can be efficient for restoring the auditory function in patients with FAO .Today, there is a lack of guidelines to support hearing specialists in the choice between stapedotomy and cochlear implants for the treatment of patients with FAO. Many authors recommend starting with stapedotomy, followed by a cochlear implant in the case of failure; a stapedectomy is relatively simple to place and has a low cost .In 2011, Merkus  proposedBy analyzing our case series following the Merkus algorithm, the 4 patients who subsequently received cochlear implants had percentages of verbal discrimination lower than 30%, but out of the 11 successfully operated cases, 3 had verbal recognition lower than 30% with a prosthesis.In our study, we obtained stable and short-lasting results in 11 out of 15 patients. Four of them subsequently underwent a cochlear implant. The short follow-up is a significant weakness of our study as well as other previously conducted studies ; in factLong follow-ups at 12 and 24 months after the treatments could better underline the benefit of one technique or the other.Lachance et al. (2012)  showed tLimitations of the study: The main limitation of this study is the retrospective design; prospective studies comparing the auditory results of patients with FAO treated with stapedectomy plus hearing aids versus cochlear implants should be performed to clarify the benefit of one technique or the other. Secondly, these patients had a very short follow-up, so the results could change after 12/24 months, and for this reason our findings should be considered preliminary results. Thirdly, we had a very small group of patients. Additionally, because surgery is routinely performed on the ear with worse auditory thresholds, the difference in the “good ear” among patients could have affected our results. Finally, the diagnosis of FAO was made during the operation, while, as shown by Messineo et al. [o et al. , using ro et al. .Our case series showed that patients with FAO might benefit from stapedectomy plus hearing aids; this could allow them to recover good auditory functions in terms of both the PTA test and the SPT. A quarter of the patients needed additional surgery because the auditory results were unsatisfactory; due to the large impact of auditory abilities on cognition ,40, the


Rice lacks sufficient amounts of zinc despite its vitality for human health. Leaf senescence enables redistribution of nutrients to other organs, yet Zn retransfer during deficiency is often overlooked. In this hydroponic experiment, we studied the effect of Zn deficiency on rice seedlings, focusing on the fourth leaf under control and deficient conditions. Growth phenotype analysis showed that the growth of rice nodal roots was inhibited in Zn deficiency, and the fourth leaf exhibited accelerated senescence and increased Zn ion transfer. Analyzing differentially expressed genes showed that Zn deficiency regulates more ZIP family genes involved in Zn ion retransfer. OsZIP3 upregulation under Zn-deficient conditions may not be induced by Zn deficiency, whereas OsZIP4 is only induced during Zn deficiency. Gene ontology enrichment analysis showed that Zn-deficient leaves mobilized more biological pathways (BPs) during aging, and the enrichment function differed from that of normal aging leaves. The most apparent “zinc ion transport” BP was stronger than that of normal senescence, possibly due to Zn-deficient leaves mobilizing large amounts of BP related to lipid metabolism during senescence. These results provide a basis for further functional analyses of genes and the study of trace element transfer during rice leaf senescence. Zinc (Zn) is an essential trace element for plant growth and development. However, Zn deficiency is widespread in crops globally, rendering it the most common micronutrient deficiency ,2. In ad2+ and soluble organic fractions; (ii) adsorbed and exchangeable Zn in the colloidal fraction ; and (iii) insoluble Zn complexes and minerals); and (3) transporter uptake. Root absorption can also be divided into three steps  > 1). Among the samples at the four time points in the two treatments, those at three time points were selected for comparison. The three comparisons included comparing the second point of the control group (C2) with the fourth point of the control group (C4), as well as both of these groups with the fourth point during Zn deficiency (D4) . A total of 7622 unique DEGs were identified in the three comparison sets. In total, 828 genes were common among the three comparisons  enrichment analyses. Some biological processes were overexpressed in all three sets of comparisons . In the Among the 7622 DEGs , 10 wereThe negative inhibitory effect caused by Zn deficiency gradually strengthened in the shoot, and shoot biomass accumulation in Zn-deficient rice slowed. In addition, Zn deficiency reduced the fresh and dry weights of the fourth leaf, accelerated senescence, and shortened the growth cycle of the fourth leaf. It is worth noting that on day 0 and day 7, although the shoot fresh weight of the control treatment was higher than that of the zinc deficiency treatment, there was no significant difference. In addition, the difference in shoot fresh weight between the two treatments on day 0 was similar to the difference in shoot fresh weight between the two treatments on day 7. However, the fresh and dry weights of the fourth leaf in the Zn deficiency treatment were considerably lower than those of the control treatment. Normally, with the extension of treatment time, the difference between the two treatments should gradually increase, but this phenomenon did not appear from day 0 to day 7, and in this experiment, it was also found that the fresh weight and dry weight of the fourth leaf of zinc deficiency treatment on day 7 were significantly lower than that of the control. Therefore, there must be some factors that lead to the reduction of differences. Many studies have confirmed that nutritional deficiency can accelerate flowering ; ArabidoThe rice root system is a whisker root system. After rice seeds germinate, the radicle extends down to form seminal roots with only one radicle . In thisZn deficiency considerably reduced the concentration and content of zinc ions in the leaves. From day 7 to 21, the fourth leaf was in senescence, and biomass decreased. Under normal aging conditions, the transfer rate of Zn ions in the fourth leaf slowed. However, when affected by Zn deficiency, the aging and Zn ion transfer rates accelerated. However, the accelerated Zn ion transfer cannot simply be regarded as a result of Zn deficiency, as leaf senescence is not a simple, continuous, and unregulated death process; moreover, leaves undergo stringent and orderly changes during aging ,42,43. TUnder Zn deficiency treatment, compared with the fourth leaf at the first time point, the biomass at the second time point increased considerably; however, the concentration of zinc ions decreased, likely because the roots could not obtain Zn ions from the nutrient solution. In addition, Zn deficiency reduces the total biomass and dry weight of leaves and accelerates leaf senescence and nutrient transfer rates . HoweverWe observed that Zn deficiency accelerates leaf aging. Leaf senescence is a necessary process that affects crop yield and quality . When nuSixteen ZIP transporters have been identified in rice , and sevOsZIP7 is indispensable in transporting Zn and Cd from woody parts to developmental tissues and grains of rice . FurtherOsZIP3 was upregulated in normally aged leaves in this study, indicating that it can transfer Zn ions during leaf aging. In addition, OsZIP3 was upregulated during leaf aging with Zn deficiency. This result was consistent with the expression level of RT-PCR . HoweverOsZIP4 is only related to Zn transport and redistribution in rice and is primarily expressed in the vascular bundle and mesophyll cells of leaves, phloem of stems and roots, and meristem and roots . In thisThe rice variety Zhonghua 11  was used in this experiment. The seeds were disinfected with 50% sodium hypochlorite solution for 45 min. After five washings with deionized water, the seeds were immersed in deionized water in the dark for 2 days at 38 °C. Subsequently, the seeds germinated in the dark at 25 °C on wet filter paper (wet with deionized water) for two days. After germination, the seedlings were transplanted into a hydroponic box containing deionized water for two weeks. Then, deionized water was replaced with the International Rice Research Institute (IRRI) formula nutrient solution, and the culture was continued under control or treatment conditions. Two static conditions were used: control (0.75 μM Zn) and Zn deficiency (0 μM Zn). After 12 days of treatment, the first sample was taken (at which time the fourth leaf was fully unfolded) and recorded as 0 days, followed by sampling every 7 days for a total of 4 times. The fourth leaf and the root systems were sampled. The samples were collected for (i) root and leaf phenotypic analyses, (ii) ion analysis, and (iii) RNA sequencing. The nutrient solution was replaced every 3 days, and the pH was adjusted to approximately 5.4. Harvesting took place 2 h after the beginning of the afternoon. The growth conditions were 14 h of light at 28 °C followed by 10 h of darkness at 20 °C. During all experiments and conditions, the hydroponic boxes and solution containers were washed prior to use with 6N hydrochloric acid to remove Zn traces.Using inductively coupled plasma mass spectrometry (ICP-MS), the concentration and content of zinc ions in the fourth leaves of rice were determined. The fourth leave of rice under control and zinc-deficient treatments was sampled at four time points, with three replicates each. The samples were dried at 65 °C for 4 days. After drying, the samples were ground, and 10 mg was weighed into an EP tube that had been cleaned and dried. The EP tube was washed twice with ultrapure water, using 2 mL each time, and then transferred to a digestion vessel. In the digestion vessel, 5 mL of concentrated nitric acid and 2 mL of hydrogen peroxide were added. The mixture was digested until clear and then heated on an electric heating plate to drive off the acid. The solution was then transferred to a 10 mL volumetric flask, filtered, and analyzed for zinc element .−ΔΔCt method using EP (LOC_Os05g08980) reference genes. Primer pairs are shown in Upon harvest, the fourth leaves were snap-frozen in liquid nitrogen and stored at −80 °C. Total RNAs were extracted from the fourth leaves samples, and cDNA preparation and quantitative RT-PCR were according to the description. Relative transcript level normalization was performed with the 2After sampling, the tissues were frozen in liquid nitrogen and stored at −80 °C. Nine samples were used . Total RNA was extracted, and the RNA quality was tested. Only RNA of good quality was constructed for subsequent libraries. The detection of RNA samples primarily included the following methods: (1) agarose gel electrophoresis to analyze RNA degradation and whether there was contamination, and (2) RNA purity was measured using a Nanodrop (OD260/280 ratio). After the samples were qualified, oligo (dT) beads separated the mRNA, which were then divided into short fragments by adding an interrupting reagent. The resulting fragments were used as a template to synthesize the first cDNA strand, and the Second Strand Synthesis Mix was added to synthesize the second strand. The RNA-Seq adapter was connected, and the connected products were purified for PCR amplification. The 300–600 bp target products were purified using magnetic beads for sequencing. After library construction was completed, a Qubit was used for preliminary quantification. The library was then diluted to 1 ng/uL, and a Qseq100 DNA Analyzer was used to detect the insert size of the library. Quantitative PCR was used to accurately quantify the effective concentration of the library (effective concentration > 2 nM) to ensure its quality. After library inspection, different libraries were pooled according to the requirements of effective concentration and the target amount of data, and the libraries were sequenced on the Illumina NovaSeq 6000 platform using the PE150 sequencing strategy. Raw data were filtered using fastp software v.0.23.4, which includes the following steps: (1) primers and adaptor sequences were removed; (2) removal of sequences with fragment lengths <50 bp; (3) removal of the N base that reached a certain proportion of reads (default: 5 bp); (4) low-quality bases with mass values <20 were removed; and (5) four bases were used as windows to calculate the average base mass. The base was removed if the average base mass was <20 (Q20). Hisat software v.20.6 was used to map the similarity between clean data and reference genomes. The overall mapping rate of the nine groups was >96%.p value, and both p value ≤ 0.05 and Q (FDR) value ≤ 0.05 were satisfied. Genes above the criteria were considered differentially expressed and used for principal component analysis (PCA). The clusterProfiler in R v.4.8.3 was used for GO enrichment analysis of differential genes with an adjusted p value of ≤0.05. Other statistical tests were conducted using analysis of variance or Student’s t-test.edgeR v3.42.4 was used for differential expression gene (DEG) analysis. The DEGs in the standard were as follows: Calculated expression ratio change (fold change) met |log2(fold change)| > 1; 2. The Q value was obtained by FDR correction of the In summary, zinc deficiency inhibited the growth and development of rice shoots and roots to varying degrees. In the zinc deficiency treatment group, the senescence and zinc ion transport rates of leaves were found to be greatly accelerated. In addition, through RNA sequencing analysis, zinc deficiency regulated more BPs, and zinc ion transport BP was particularly evident. In zinc-deficient treatment, more ZIP family members regulated the function of transporting zinc ions during leaf aging, and OsZIP4 and OsZIP10 were only upregulated in the Zn-deficient treatment group. Future studies are needed to validate and explore the potential information of zinc ion transport genes in leaves.


Existing evidence on the relationship between mode of delivery and offspring emotional and behavioural problems, especially in older age groups, is limited and inconsistent. This study aimed to examine the association between obstetric mode of delivery and emotional and behavioural problems in offspring aged 3–16 years.The sample for this study comprised participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) in the United Kingdom. The study cohort ranged from 7074 (at 3 years of age) to 4071 (at 16 years of age) mother–offspring pairs. Data on obstetric mode of delivery were abstracted from obstetric records by trained research midwives and classified as spontaneous vaginal delivery, assisted vaginal delivery and caesarean delivery (elective and emergency). Offspring emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ) when the child was 3, 7, 9, 11, and 16 years. Logistic regression analyses were used to examine associations.Assisted vaginal delivery was associated with an increased risk of emotional problems at age 11 years . No significant associations were observed at ages 3, 7, 9 and 16. We found no evidence of associations between caesarean delivery (elective or emergency) and emotional and behavioural measures in offspring across all age groups.Mode of delivery does not appear to be associated with emotional and behavioural problems in children and adolescents. Further research is needed to understand the potential longer-term effects of assisted vaginal deliveries on offspring emotional development.The online version contains supplementary material available at 10.1007/s00127-022-02374-z. The rates of caesarean section (CS) have been seen increasing worldwide, though to varying extents in different regions and countries . CurrentAlthough CS is a life-saving intervention when medically indicated, there is no evidence showing the benefits of caesarean delivery for women or infants who do not require the procedure and may affect the health of the mother, her child, and future pregnancies , 4. In lCS may affect behavioural development in children through altered gut microbiota, premature birth, and/or changes in maternal-child attachment –15. MostAssisted vaginal delivery might also be associated with offspring emotional and behavioural development. One recognised complication of assisted vaginal delivery is the development of a subdural haematoma when a blood vessel in the space between the skull and the brain  is damaged . ImagingExisting evidence on the relationship between mode of delivery and offspring emotional and behavioural problems is limited and inconsistent. While some studies reported an increased risk of behavioural difficulties in offspring of mothers who gave birth via CS or assisted vaginal delivery –30, othehttp://www.bristol.ac.uk/alspac/researchers/our-data).Our study sample comprised participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort, an ongoing population-based longitudinal birth cohort in Bristol, Avon, United Kingdom (UK). The core enrolled sample consisted of 14,541 pregnancies in women residents in the former county of Avon, the United Kingdom, who had an expected delivery date between 1st April 1991 and 31st December 1992 –37. Of tEthical approval for the ALSPAC study was obtained from the ALSPAC Ethics and Law Committee as well as the Local Research Ethics Committees. Informed consent for the use of data collected via questionnaires and clinics was obtained from participants following the ALSPAC Ethics and Law Committee’s recommendations at the time. The details on the ethical approval, including the dates of approval and associated reference numbers, can be found in the ALSPAC Website .Childhood emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ), completed by parents, usually mothers, when the child was  3, 7, 9, 11, and 16 years . The SDQData on obstetric mode of delivery were abstracted from obstetric records by trained research midwives. The mode of delivery was classified as spontaneous vaginal delivery, assisted vaginal delivery, and caesarean delivery (elective and emergency). Assisted vaginal delivery comprised assisted breech delivery, forceps delivery and vacuum extraction. Elective caesarean deliveries were those with prior planning, and emergency caesarean deliveries were those without prior planning or that took place after labour started.Potential confounders were selected on the basis of previous reports of their association with obstetric mode of delivery and offspring emotional and behavioural problems –32, 41. 2), normal weight (18.5–24.9 kg/m2) and overweight/obese (≥ 25 kg/m2). Prenatal depression was measured at 32 weeks of gestation using Edinburgh Postnatal Depression Scale (EPDS), and scale scores were dichotomized using the recommended cut-off score for depression (12 out of 30).Table We also compared the characteristics of mothers who gave birth by elective CS to those with emergency CS. Compared with mothers who gave birth by elective CS, those who had emergency CS were younger at childbirth, never married, nulliparous, had hypertensive disorders during pregnancy, smoked tobacco, and were less likely to be overweight/obese (Table S1).P ≥ 0.08 for interaction).Table Table S2 shows the mean scores for each SDQ sub-scale and total difficulties. The mean (standard deviation) score of total difficulties was 12.5 (5.7) at age 3 years and 6.2 (4.8) at age 16 years. While the mean SDQ scores for total difficulties and externalising behaviours (hyperactivity/inattention problems and conduct problems) were decreased as the child's age increased, internalising problems  remained the same.Univariable and multivariable associations between mode of delivery and offspring emotional and behavioural problems at five developmental time points  are shown in Tables P = 0.07). Results were broadly consistent when we repeated the analyses using the imputed datasets (Table S4).Most associations between assisted vaginal delivery and emotional problems were no longer seen after adjustment except with emotional problems at the age of 11 years, where we found that children of mothers who gave birth by assisted vaginal delivery were 42% more likely to have emotional problems . Limiting our analysis to term babies did not alter our results (Table S3). Further stratified analyses by types of assisted delivery showed that vacuum delivery  and assisted breech delivery  were found to be associated with emotional problems. The association between forceps delivery and emotional problems was approach statistically significant . After accounting for a range of potential confounders, we found no evidence of an association between CS delivery modes (elective or emergency) and emotional and behavioural measures in offspring  across all developmental time periods. Our findings provide reassurance to those mothers concerned about the potential risks of birth by CS on the mental health of their children at later age. We also found no evidence of associations between assisted vaginal delivery and emotional and behavioural problems at all ages except at age 11, where assisted vaginal delivery was associated with a 42% increased risk of emotional problems.Our findings are broadly consistent with few existing studies that have reported no significant association between mode of delivery and child behavioural problems –34. In tn = 80), and both studies [n = 4071 +) and were able to comprehensively assess confounders in our analysis. Finally, while previous studies used Child Behaviour Checklist (CBCL) to assess children’s emotional and behavioural problems [Our findings are in contrast with studies that reported associations , 29. A r studies , 29 did problems , 29, we problems , 45, theproblems .We found a small increased risk of emotional problems at age 11 in children born via assisted vaginal delivery. The observed association between assisted vaginal delivery and emotional problems is possibly related to cortisol response. Existing evidence suggested that children born by assisted vaginal delivery experienced the highest levels of stress during birth compared to those born by spontaneous vaginal delivery –49, and This study has considerable strengths. The prospective design, large sample size, long-term follow-up period and the availability of data on a wide range of known confounders are some of the strengths of this study. The population-based samples limit the possibility of selection bias. We were able to classify CS into planned or emergency and vaginal delivery into assisted and spontaneous vaginal delivery, which was a limitation of most existing studies , 30, 33.The following limitations should also be considered. Children’s emotional and behavioural problems were reported by parents. Reliance on self-reports may lead to misclassification bias. As parents may underestimate behavioural problems, and any such misclassification would tend to weaken the association. We also relied on symptoms rather than diagnostic instruments. This may lead to random measurement errors. However, SDQ is a valid and reliable tool for assessing emotional and behavioural problems in offspring and has been widely used in research and clinical practice , 40. WhiWe found no evidence of associations between elective or emergency CS and behavioural outcomes in children and adolescents. That said, CS is a surgical procedure with potential short- and long-term health risks. As such, it should ideally only be undertaken when medically necessary. With the exception of emotional problems at age 11, all the observed associations between obstetric mode of delivery and emotional and peer relationship problems in children did not remain after adjustment and/or stratified analysis, suggesting associations were likely due to confounding.We found small evidence of associations between assisted vaginal deliveries and increased risk of emotional problems at age 11. No evidence of associations between CS delivery and emotional and behavioural problems was observed in offspring at all ages. Further research is needed to confirm our findings.Supplementary file1 (DOCX 24 KB)Supplementary file2 (DOCX 20 KB)Supplementary file3 (DOCX 25 KB)Supplementary file4 (DOCX 22 KB)Below is the link to the electronic supplementary material.


The primary objective of this study was to investigate the potential correlation between gut microbes and postoperative pulmonary infection in gastric cancer patients. Additionally, we aimed to deduce the mechanism of differential functional genes in disease progression to gain a better understanding of the underlying pathophysiology.A nested case–control study design was utilized to enroll patients with gastric cancer scheduled for surgery at West China Hospital of Sichuan University. Patients were categorized into two groups, namely, the pulmonary infection group and the control group, based on the development of postoperative pulmonary infection. Both groups were subjected to identical perioperative management protocols. Fecal samples were collected 24 h postoperatively and upon pulmonary infection diagnosis, along with matched controls. The collected samples were subjected to 16S rDNA and metagenomic analyses, and clinical data and blood samples were obtained for further analysis.A total of 180 fecal specimens were collected from 30 patients in both the pulmonary infection and control groups for 16S rDNA analysis, and 3 fecal samples from each group were selected for metagenomic analysis. The study revealed significant alterations in the functional genes of the intestinal microbiome in patients with postoperative pulmonary infection in gastric cancer, primarily involving Klebsiella, Enterobacter, Ruminococcus, and Collinsella. During postoperative pulmonary infection, gut flora and inflammatory factors were found to be associated with the lipopolysaccharide synthesis pathway and short-chain fatty acid (SCFA) synthesis pathway.The study identified enriched populations of Klebsiella, Escherella, and intestinal bacteria during pulmonary infection following gastric cancer surgery. These bacteria were found to regulate the lipopolysaccharide synthesis pathway, contributing to the initiation and progression of pulmonary infections. Inflammation modulation in patients with postoperative pulmonary infection may be mediated by short-chain fatty acids. The study also revealed that SCFA synthesis pathways were disrupted, affecting inflammation-related immunosuppression pathways. By controlling and maintaining intestinal barrier function, SCFAs may potentially reduce the occurrence of pulmonary infections after gastric cancer surgery. These findings suggest that targeting the gut microbiome and SCFA synthesis pathways may be a promising approach for preventing postoperative pulmonary infections in gastric cancer patients. AccordiStreptococcus pneumoniae infection in experimental mice  to identify alterations in the intestinal microbiome and pulmonary infection following gastric cancer surgery and (2) to identify key factors associated with pulmonary infection using 16S rDNA sequencing technology and metagenomic sequencing. The research findings may facilitate accurate monitoring and nursing of pulmonary infection after gastric cancer surgery.2.2.1.This study was approved by the Biomedical Ethics Committee of West China Hospital of Sichuan University [Trial No. 223 in 2021]. All study patients signed written informed consent. Use of convenience sampling method, patients diagnosed with gastric cancer who underwent surgical treatment at West China Hospital of Sichuan University from January 2021 to December 2021 were selected as study subjects. Patients without other metabolic or infectious diseases or distant metastasis of cancer cells were included, and all patients participated voluntarily. Exclusion criteria: ①Previous history of gastrointestinal surgery. ②Probiotics, microbial preparation, antibiotics, metformin, proton pump inhibitors, berberine and purgative agents were used in the last 3 months. ③ Intestinal inflammation, perforation, obstruction and severe systemic diseases were observed before the operation.This nested case–control study enrolled all gastric cancer patients meeting the criteria in the study cohort. Patients with pulmonary infection were matched as the case group, and patients without pulmonary infection were selected from the same cohort as the control group. Relevant information such as age, gender, and disease of cases were matched. Pulmonary infection can be diagnosed according to the “Diagnostic Standards for Hospital Infection” of the People’s Republic of China, and if one of the following two conditions is met: (1) The patient has coughing, sticky phlegm, and moist rales in the lungs, with one of the following conditions: ① fever; ②X-ray (or CT) shows inflammatory infiltrating lesions in the lungs; ③An increase in white blood cell count and/or neutrophil ratio. (2) Acute infection secondary to stabilization of chronic airway disease with pathogenetic changes or X-ray chest radiograph (or CT) showing significant changes from the time of admission.2.2.The perioperative management for both groups of patients was the same, as follows. Preoperative preparation stage: (1) Patients without gastrointestinal dyskinesia fasted for 6 h and abstained from drinking for 2 h preoperatively. (2) nondiabetic patients were allowed to take carbohydrate drinks ≤400 mL for 2–3 h preoperatively. (3) No gastric tube was placed before surgery. (4) No intervention measures were given to patients before surgery, such as probiotics, antibiotics, proton pump inhibitors, berberine, or laxatives, which may affect the intestinal microbiota. Intraoperative treatment: (1) All surgeries are completed by the same medical team. (2) General anesthesia. (3) Patients undergone proximal subtotal gastrectomy, distal subtotal gastrectomy, or total gastrectomy. (4) The reconstruction method of the digestive tract was gastroesophagostomy, Billroth I, Billroth II, or Roux-en-Y. (5) Intraoperative prophylactic use of cefoxitin/cefmetazole 1 g, intravenous drip. Postoperative treatment: (1) No nasogastric tube was left in the patients after surgery. (2) On the first day after surgery, the patient began to consume clear fluid, attempted to consume semi liquid food on the second day. (3) Give daily intravenous drip of cefoxitin/cefmetazole, once every 8 h, 1 g each time. (4) No probiotics or other live bacterial preparations were used after surgery until discharge.2.3.Fecal samples (3–5 g) were collected 24 h after surgery and pulmonary infection, and concurrent control samples were collected from the control group at the same time point. The specimens in the pulmonary infection group at 24 h postoperatively and at the time of occurrence of pulmonary infection were named pi-two, pi-three, respectively. The specimens in the control group at 24 h postoperatively and during the same period when pulmonary infection occurred in the case group were named con-two, con-three, respectively. Fecal samples were collected using the anal swab method, with the following steps: ①Clean the area around the anus with 70% alcohol. ②After moistening the sterile swab with physiological saline, insert it into the anus for 4–5 cm and gently rotate it. Take a sample from the anal recess, and obvious fecal marks can be seen on the swab. ③Insert the sampled swab into a sterile cryopreservation tube and store it in a − 80°C refrigerator. In the event of pulmonary infection, peripheral blood samples were collected from patients in the pulmonary infection group and the control group and submitted for testing white blood cell count and neutrophil ratioin a timely manner.2.4.Fecal specimen DNA extraction, PCR amplification, and library building were performed to construct species abundance profiles at the corresponding taxonomic level using 16S rDNA sequencing technology. Raw sequence processing, OTU classification, and species annotation were then performed. The samples used for metagenomic sequencing analysis were selected using MicroPITA analysis . Metagen2.5.p value in Adonis analysis . The structure of the intestinal flora at different taxonomic levels was expressed by a boxplot diagram. Postpoly NMDS mapping was performed using the partitioning around medoids method according to the Jensen–Shannon divergence distance. Differences in KO between the two groups were compared using the Wilcoxon rank-sum test. Differential pathways and differential modules were calculated using the Z score. The correlation of Map/Module to patient general and clinical data and inflammatory indicators was calculated using Spearman correlation analysis.The study was conducted using the R software package. General and clinical data were analyzed using two independent sample t tests, chi-square tests, or Fisher’s exact probability tests. Species richness and distribution evenness were evaluated by calculating the Chao1 index, Shannon index, and Simpson index for α diversity analysis. The community similarity and difference of different groups were evaluated by β diversity analysis. The significance of the sample community distribution between groups was evaluated by NMDS analysis based on the Bray–Curtis distance matrix algorithm and the difference significance 3.A total of 120 stool samples were collected, with 30 patients each from the pulmonary infection group and the control group. No participants were lost during the experimental period of the study. There were no significant differences identified between the groups in terms of age, sex, preoperative comorbidities, preoperative neoadjuvant chemotherapy, surgical procedures, and intraoperative blood loss, et al .3.1.3.1.1.p > 0.05).The Chao1 index, Shannon index, and Simpson index were used to reflect the α diversity. The Wilcoxon rank sum test results showed no significant difference in the Chao1 index, Shannon index, and Simpson index between the pulmonary infection group and the control group at 24 h post postoperatively . Therefore, further comparison of gut microbiota structure at different taxonomic levels will not be conducted.The β diversity of the intestinal microbiota between the pulmonary infection group and the control group at 24 h post postoperatively was analyzed using the NMDS algorithm of weighted UniFrac, as shown in 3.1.2.p > 0.05).The Chao1 index, Shannon index, and Simpson index were used to reflect the α diversity of patients in the pulmonary infection group and the contemporary control group. The Wilcoxon rank sum test results showed no significant difference in the Chao1 index, Shannon index, and Simpson index between the two groups . The Adonis statistics showed that the R2 value of the grouping factors was 0.042.The β diversity of the intestinal microbiota in the pulmonary infection group and the contemporary control group was analyzed using the NMDS algorithm of weighted UniFrac, as shown in p < 0.05), as shown in p < 0.05).The top 15 relative abundances of patients at the phylum level in the pulmonary infection group and the contemporary control group are shown in p < 0.05). The top 10 differentially abundant species at the genus level of pulmonary infection in the pulmonary infection group and the contemporary control group are shown in The top 15 relative abundances of patients at the genus level of the pulmonary infection group and the contemporary control group are shown in 3.1.3.p > 0.05).The Chao1 index, Shannon index, and Simpson index were used to reflect the α diversity of the intestinal flora. The Wilcoxon rank sum test showed no significant difference between the Chao1 index, Shannon index, and Simpson index at 24 h postoperatively and at the time of pulmonary infection in the pulmonary infection group (p = 0.001), and the R2 value of the grouped factors was 0.108. The top 15 relative abundances of species at the phylum level at 24 h postoperatively and at the time of the occurrence of the pulmonary infection in the pulmonary infection group is shown in p > 0.05).The β diversity of the pulmonary infection group at 24 h postoperatively and at the time of the occurrence of the pulmonary infection was analyzed using the NMDS algorithm of weighted UniFrac, as shown in p < 0.05). Specifically, the top 10 differentially abundant flora are shown in p < 0.05), while Streptococcus, Ruminococcus, Clostridioides, Erysipelatoclostridium, Eggerthella, Solobacterium, Howardella, and Eubacterium were significantly increased (p < 0.05).The top 15 relative abundances of species at the genus level at 24 h postoperatively and at the time of the occurrence of the pulmonary infection in the pulmonary infection group is shown in 3.2.3.2.1.Bacteroides fragilis (19). Among the genes enriched in the contemporary control patients, 23 genes were annotated at the species level, of which 57.34% were distributed in Phocaeicola plebeius , Prevotella (79), Escherichia (121), and Ruminococcus (52). Among the genes enriched at 24 h after surgery in the pulmonary infection group, 56 were annotated to the species level, of which 53.25% belonged to Phocaeicola (27) and plebeius .p < 0.05), as shown in p < 0.05; NMDS analysis was applied to represent the species information. Each dot in the figure represents a sample, and the same color represents the same grouping. The distance between points reflects the degree of difference between different samples, with the closer the sample of the same group and the more obvious the distance from other groups. The results showed a significant difference in the species abundance of the intestinal microecology between the pulmonary infection group and the contemporary control group (p < 0.05).The top 30 species in total abundance at the genus level were selected, and a heatmap map of related differential species was drawn. The horizontal and vertical coordinates represent the corresponding species, with a negative correlation in blue and a positive correlation in red. As shown in 3.2.2.p < 0.05), as shown in The comparison of nonredundant genes with the egg NOG database showed that orthologous groups (OGs) added 774, 1,298, and 513 OGs in the pulmonary infection group 24 h after surgery, at the time of infection, and in the contemporary control group, respectively. Compared with 24 h after surgery, the functional gene clusters that increased when pulmonary infection occurred were mainly distributed in [G] (Carbohydrate transport and metabolism), [E] (Amino acid transport and metabolism) (3.2.3.K00540), signal transduction system (K02020), heterogeneous biomass degradation (K01220). However, the KEGG module abundance of cell motility chemotaxis (K02030), flagellar assembly (K02040) was significantly reduced , as shown in The intestinal microbial function genes were involved in many biological metabolic pathways. In particular, the functional genes with the largest number of intestinal microbes were carbohydrate metabolism, accounting for 18.76%, and amino acid metabolism, accounting for 13.27%. Compared with 24 h after surgery of the pulmonary infection group, the relative abundance of gut microbial genome annotation to the KEGG module in the event of pulmonary infection was significantly increased in lipopolysaccharide biosynthesis (K01220) and ornithine (K00616). Significant reduction in KEGG module abundance of isoleucine organisms synthesis (K00290) was observed , as shown in The gut microbial genome was annotated to KEGG when pulmonary infection occurred compared with the contemporary control group. The significant increase in module relative abundance was involved in xenobiotic degradation (3.2.4.M00250) and RNA polymerases that are closely related to the alanine and glutamate metabolic pathways (M03420) and the abundance of metabolic pathways associated with the biosynthesis of peptidoglycan (M00510) were also significantly reduced .As shown in M00540) and purine nucleotide synthesis (M00230) involved in pulmonary infection compared with concurrent control patients . In contrast, the metabolic pathways associated with short-chain fatty acid (SCFA) formation (M02020), isoleucine biosynthesis (M00460), and fatty acid biosynthesis and oxidation (M00061) were significantly reduced in the above two groups .As shown in 3.2.5.p < 0.05). However, the metabolic pathways associated with carbohydrate biosynthesis, isoleucine biosynthesis, and short-chain fatty acid biosynthesis were inversely related to leukocyte count and neutrophil ratio .The intestinal flora, clinical data, inflammatory indicators, funtional and metabolic pathways of the pulmonary infection group were compared with those of the contemporary control group, including age, sex, complications, BMI, remodeling pattern of the digestive tract, and inflammatory index. There was a positive correlation between Klebsiella, lipopolysaccharide biosynthesis and the inflammation index, including white blood cell count and neutrophil ratio . Streptococcus produce virulence factors by secretion of podocarboxylic polysaccharides, and enhance their invasiveness and virulence by promoting the body’s production of neuraminidase hemolysin, phospholipid wall acid, etc.  will inhibit the maturation of dendritic cells, thus reducing the production of cytokines, such as IL-12 and TNF-α, which play an important role in the regulation of inflammatory responses in the body . Wang foK00540), signal transduction system (K02020), and foreign biomass degradation (K01220). Available studies reported that LPS biosynthesis (K00540) is widely distributed in the Gram-negative bacteria, such as Fusobacteria and Proteobacteria. Lipopolysaccharide is a component of the outer wall of the cell wall of these Gram-negative bacteria. In this study, Enterobacter and Clostridioides, which were enriched in pulmonary infection group occurring after gastric cancer surgery, belonged to the phylum Proteobacteria and Fusobacteria, respectively. The enrichment of these Gram-negative bacteria in pulmonary infection occurring after gastric cancer surgery caused an increase in functional genes related to LPS synthesis, which resulted in an upregulation of lipopolysaccharide synthesis in patients with pulmonary infection occurring after gastric cancer surgery. The NF-kB pathway is activated by LPS-binding proteins, which play a key role in inflammation and immunity processes. In a study by Russa, LPS was found to be associated with T-cell activation and elevated pro-inflammatory responses, leading to a “cytokine storm” (K02020) and foreign biomass degradation (K01220) increased in pulmonary infection  production, isoleucine synthesis, and acetyl coenzyme synthesis were significantly reduced in abundance, suggesting that the synthesis of short chain fatty acids and isoleucine may be reduced in the intestines of patients with pulmonary infection occurring after gastric cancer surgery. SCFA are produced by bacteria in the gut when fermenting dietary fiber and are beneficial metabolites. SCFA are mainly derived from the metabolism of oduction . Moreoveoduction . Therefooduction . We therp < 0.05). However, the metabolic pathways associated with carbohydrate biosynthesis, isoleucine biosynthesis, and short-chain fatty acid biosynthesis were inversely related to leukocyte count and neutrophil ratio . These results once again validate the promotional role of LPS in the development of postoperative pulmonary infection after gastric cancer surgery and suggest that downregulation of metabolic pathways associated with SCFA synthesis attenuates the ability of gut microbes to resist inflammatory responses.The results of the correlation analysis showed that there was a positive correlation between Klebsiella, lipopolysaccharide biosynthesis and the inflammation index, including white blood cell count and neutrophil ratio  oral cleansing is necessary to prevent pulmonary infection due to colonization of the upper respiratory tract with pathogenic bacteria. (2) Considering that there may be a bidirectional pathway between the lungs and the intestines, the monitoring of the intestinal flora of postoperative patients should be strengthened to recognize flora changes. In addition, intestinal homeostasis can be promoted by supplementing beneficial bacteria and their metabolites to indirectly promote lung health. (3) Give postoperative gastric cancer patients reasonable dietary instructions, such as appropriate dietary fiber supplementation preparations, thereby increasing SCFA, which will facilitate inflammation suppression.This study also has certain shortcomings. First, although this study confirmed that the down-regulation of metabolic pathways related to SCFA synthesis may attenuate the ability of intestinal microorganisms to resist inflammatory responses, it is insufficient to indicate exactly what metabolites are playing a key role because metabolites were not detected and analyzed in this study. Furthermore, the results of the study were not verified in animal experiments, so it is necessary to further validate the role of differential flora in the regulation of pulmonary infection by constructing an animal model of postoperative pulmonary infection after gastric cancer in the future.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving humans were approved by Biomedical Ethics Committee of West China Hospital of Sichuan University. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.JY: Funding acquisition, Project administration, Writing – review & editing. YH: Data curation, Writing – original draft. XL: Writing – review & editing. JH: Methodology, Writing – review & editing. KL: Supervision, Writing – review & editing.


To compare the therapeutic efficacy and safety of microwave ablation (MWA) and lauromacrogol injection for ablation (LIA) for benign predominantly cystic thyroid nodules.In this retrospective study, 85 patients with predominantly cystic thyroid nodules (PCTNs) who underwent microwave ablation (MWA) or lauromacrogol injection for ablation (LIA) between June 2019 and August 2022 at three hospitals were included in our research. Forty-six patients were treated with microwave ablation, and thirty-nine patients were treated with lauromacrogol injection for ablation. The baseline characteristics, nodal volume, volume reduction rate (VRR), and incidence of postoperative complications were compared between these two groups.After treatment, there were significant differences in the thyroid nodule volume and the volume reduction rate (VRR) at different follow-up times between the groups (p < 0.001). There were no significant differences in the nodal volume or the volume reduction rate (VRR) between the MWA group and the LIA group at 1, 3, 6, and 12 months (p > 0.05). Of note, no serious intraoperative or postoperative complications occurred in the corresponding group.MWA and LIA are very effective and safe strategies for the treatment of predominantly cystic thyroid nodules. However, LIA is more advantageous in that it is less expensive and has a shorter length of hospital stay than MWA. In recent decades, the advancement of imaging technology, particularly the use of high-resolution ultrasound (US), has improved the diagnosis of thyroid nodules (TNs) –3. AccorTraditionally, surgery is the main treatment for predominantly cystic thyroid nodules (PCTNs) despite its disadvantages such as scarring, nerve damage, and the risk of hypothyroidism –14. In rHowever, there are few studies comparing the efficacy of microwave ablation and lauromacrogol injection for ablation in the treatment of predominantly cystic thyroid nodules. This study aims to compare the efficacy of MWA and LIA in the treatment of predominantly cystic thyroid nodules, and it is hoped that the study will provide more effective information for clinical decision-making and the selection of patients with predominantly cystic thyroid nodules.This study was a retrospective study that was approved by the Ethics Committee of the Affiliated Hospital of Jiangsu University (SWYXLL20190225–2). Informed consent was not required for the review of ultrasound images and medical records. To ensure uniformity among the three study centres, the data were analysed and processed by personnel who strictly followed the inclusion and exclusion criteria of the study. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for observational studies .Before each procedure, all the patients who were scheduled for ultrasound-guided fine-needle aspiration (FNA), MWA or LIA provided written informed consent.Inclusion criteria: patients who were older than 18 years of age; patients with preoperative ultrasound images showing predominantly cystic thyroid nodules ; patients with thyroid nodules without signs of malignancy (each nodule underwent at least two fine-needle aspiration cytology (FNAC) examinations to rule out the possibility of malignancy and ultrasound suggests no suspicious ultrasound features such as calcification, poorly defined borders, aspect ratios > 1 and so on); patients with relevant laboratory test results  within the normal range; and patients with thyroid gland disease who had not undergone any previous surgical treatment .The exclusion criteria were as follows: patients with a malignant tumour confirmed by fine needle aspiration cytology; patients with malignant ultrasound features of thyroid nodules ; patients with an abnormal coagulation function; and patients with serious primary illnesses such as comorbidities or other serious infectious diseases.According to the need of the study, whether it was the MWA group or the LIA group, we divided the patients into two groups based on the size of the thyroid initial volume. Patients with smaller thyroid volume were group A (volume < 10 ml) and patients with larger thyroid volume were group B (volume ≥ 10 ml).Before the operation, the patients underwent relevant tests. (1) Laboratory tests included routine blood tests, blood coagulation tests, and thyroid function tests. (2) The pathological results of ultrasound-guided fine needle aspiration cytology were benign. (3) The thyroid nodules were examined via ultrasound, and the location and volume of the nodules, the proportion of cystic components, and the blood flow in and around the nodules were evaluated in detail.All ablation procedures were performed by sonographers with more than 10 years of experience in performing ultrasound intervention.The microwave ablation (MWA) procedure: The patient was placed in the supine position with the neck fully exposed. The patient was then routinely disinfected and covered with towels. According to the location of the lesion, 2% lidocaine was used for local infiltration anaesthesia. An 18G puncture needle was placed into the cystic part of the nodule, and as much cystic fluid as possible was extracted. Under the guidance of ultrasound, a 2% lidocaine injection and a 0.9% sodium chloride injection were mixed 1:1, and local infiltration anaesthesia was administered in the space between the anterior thyroid capsule and the anterior cervical muscle group. To prevent causing a thermal burn injury to the normal tissues during the operation, 0.9% sodium chloride was injected in the local gap to form a liquid isolation zone. Then, the microwave ablation needle was inserted into the thyroid nodules according to the predesigned puncture path, and ablation was performed by a continuous moving method, with a power of 30–40 W, from deep to shallow, from the lower pole to the upper pole, layer by layer, until the whole nodule was ablated. If necessary, contrast-enhanced ultrasound should be used to determine the extent of ablation for lesions to prevent residual lesions and additional organ damage.The Lauromacrogol injection for ablation (LIA) procedure: The patient was positioned supine so that the neck was slightly extended. Routine disinfection and draping were performed before local anaesthesia was administered. Under ultrasound guidance, an 18G puncture needle was inserted into the centre of the cystic dark area, and all the cystic fluid was extracted. A 0.9% sodium chloride injection or a small amount of alcohol or lauromacrogol was used for multiple flushing , and then, lauromacrogol was injected.Postoperative complications such as intraoperative bleeding and organ damage and postoperative complications such as infection and abnormal voice were recorded in a timely manner. Thyroid ultrasound was performed at 1, 3, 6, and 12 months after thyroid treatment and every 6 months thereafter, and contrast-enhanced ultrasound was performed if necessary. The size of the nodules was observed, and the volume of the nodules was measured  .The voluStatistical analysis of the data was performed using SPSS (IBM SPSS 26.0). The continuous data were expressed as the means ± standard deviations (Χ ± SD). Independent samples t-tests were used to compare the changes in nodule volume and rate of volume reduction before and after treatment, provided that normality of the data was ensured. The intergroup comparison of counting data was conducted by χ2 test. All P values were two-sided, and P < 0.05 indicated that the difference was statistically significant.A total of 85 patients participated in our retrospective research, including 46 patients in the MWA group and 39 in the LIA group. After following the strict inclusion criteria, 85 patients with 85 nodules were included in the research Fig. .There were 4 males and 42 females in the MWA group. The youngest patient was 24 years old, the oldest was 79. The mean age was 50.30 ± 14.07 years. In another group, there were 8 males and 31 females. The youngest patient was 24 years old, and the oldest patient was 72 years old. The mean age was 49.79 ± 13.14 years. In the MWA group, the volume of the nodules was 2.67–33.40 ml before treatment, with an average of 11.03 ± 7.16 ml. The volume of nodules in the LIA group before treatment was 2.53–28.33 ml, with an average of 11.41 ± 6.53 ml. Before treatment, there were no significant differences in sex, age, long diameter of nodules, initial volume, or location between the two groups . . Whereas in LIA group, there was no significant difference in VRR between group A and group B at 1 month, 3 months, 6 months and 12 months after ablation   This study was a retrospective study with potential selective bias. When selecting subjects for the study, they may have been included or excluded due to human factors, which may have affected the results of the study. Future studies need to collect more patient information and develop more stringent inclusion and exclusion criteria. (2) The relatively small sample size of this study may lead to biased results and requires further validation in a randomized clinical trial with a large sample size. (3) Non-comparative and non-homogeneous statistical analyses are also a limitation, and the findings were confirmed by rigorous experimental grouping in future prospective multicentre studies.In our research, both MWA and LIA were therapeutically effective and safe in treating predominantly cystic thyroid nodules. MWA or LIA can effectively reduce the thyroid nodule volume and improve the patients’ clinical symptoms. LIA can shorten the length of hospital stay and reduce the overall cost. Hence, based on the patient’s general condition, we must perform a thorough assessment and select the best course of action.


Single-point incremental forming (SPIF) has emerged as a cost-effective and rapid manufacturing method, especially suitable for small-batch production due to its minimal reliance on molds, swift production, and affordability. Nonetheless, SPIF’s effectiveness is closely tied to the specific characteristics of the employed sheet materials and the intricacies of the desired shapes. Immediate experimentation with SPIF often leads to numerous product defects. Therefore, the pre-emptive use of numerical simulations to predict these defects is of paramount importance. In this study, we focus on the critical role of the forming limit curve (FLC) in SPIF simulations, specifically in anticipating product fractures. To facilitate this, we first construct the forming limit curve for Al1050 sheet material, leveraging the modified maximum force criterion (MMFC). This criterion, well-established in the field, derives FLCs based on the theory of hardening laws in sheet metal yield curves. In conjunction with the MMFC, we introduce a graphical approach that simplifies the prediction of forming limit curves at fracture (FLCF). Within the context of the SPIF method, FLCF is established through both uniaxial tensile deformation (U.T) and simultaneous uniform tensile deformation in bi-axial tensile (B.T). Subsequently, the FLCF predictions are applied in simulations and experiments focused on forming truncated cone parts. Notably, a substantial deviation in fracture height, amounting to 15.97%, is observed between simulated and experimental samples. To enhance FLCF prediction accuracy in SPIF, we propose a novel method based on simulations of truncated cone parts with variable tool radii. A FLCF is then constructed by determining major/minor strains in simulated samples. To ascertain the validity of this enhanced FLCF model, our study includes simulations and tests of truncated cone samples with varying wall angles, revealing a substantial alignment in fracture height between corresponding samples. This research contributes to the advancement of SPIF by enhancing our ability to predict and mitigate product defects, ultimately expanding the applicability of SPIF in diverse industrial contexts. Single-point incremental forming (SPIF) has gained prominence as a cost-effective and rapid method for manufacturing sheet metal parts, complementing traditional machining techniques, and seamlessly integrating with computer numerical control (CNC) machines. Its versatility has led to its adoption across a multitude of industries, including aerospace ,2, automBouhamed et al.  have conShang et al.  exploredSaidi et al.  focused In this study, the modified maximum force criterion (MMFC) was harnessed to predict the forming limit curve of Al1050 sheet material. A graphical method was devised to simplify FLC forecasting, constructed through uniaxial tensile deformation (U.T) and simultaneous biaxial tensile deformation (B.T). The deviation in fracture height between the simulated and experimental samples was notably large, reaching 15.97%. To enhance FLCF in SPIF, this study proposes a method based on simulations of truncated cone parts with varying tool radii and the determination of major and minor strains in simulated samples. The verification of the improved FLCF model involved simulating and testing truncated cone samples with different wall angles, demonstrating a significant agreement in fracture height between corresponding samples. This research endeavors to contribute to the further development and applicability of SPIF across a wide array of industrial domains.This section delves into an extensive examination of the material properties that are integral to this study’s focus on Al1050 aluminum alloy sheets with a thickness of 0.5 mm. This material was chosen as a fundamental element in the investigation, and understanding its chemical composition and mechanical characteristics is pivotal in comprehending its performance in the context of SPIF of truncated cone parts. The chemical composition of the Al1050 aluminum alloy, as referenced in , assumesMaterial anisotropy, an aspect profoundly impacting the quality of the fabricated product, was a significant focus of this research. Tensile test samples were prepared via waterjet cutting in three specific directions: the rolling direction (RD), the horizontal direction perpendicular to the rolling direction (TD), and a direction 45 degrees from the rolling direction. As demonstrated in Subsequent tensile tests were conducted at room temperature on a YS-L45-J11 machine , as depicted in Yσ stands for the yield strength (81.6 MPa). K, t, and h are model coefficients, with values of K = 34.26 MPa, t = 471.62, and h = 0.225. These coefficients were meticulously determined through Formulas (2a)–(2c), with a deviation threshold of 0.2%.The investigation aimed to determine an appropriate plasticity model for the material. The stress–strain curve of Al1050 in the rolling direction (RD), as presented in Formulas for coefficients (2a)–(2c):In this research, the Hill’48R stress function, detailed in Equation (3), is employed to deduce the anisotropy parameters governing the material’s behavior.G, F, H, N, L, M: material constants requiring determination based on experimental data.General equation for equivalent stress (Equation (3)):In the case of plane stress conditions, Equation (3) can be simplified as Equation (4).r0, r90, r45) were derived from three uniaxial tensile tests . Additionally, the uniaxial yield stress (σ₀) was obtained, maintaining a consistent relationship (G + H = 1). Recognizing the difficulty of evaluating anisotropy in the direction of material thickness, the properties were assumed to be isotropic (L = M = 1.5).For this study, anisotropy values .The Hill’48R stress criterion, under plane stress conditions (θ) was determined utilizing the stress criterion in Equation (6).Subsequently, uniaxial anisotropy in the same rolling direction  from these coefficients :A comprehensive investigation was conducted to examine the anisotropy coefficient’s alignment with the Hill’48R stress criteria against experimental data. This comparative analysis, as demonstrated in σ11 and σ22, as showcased in The predicted stress surfaces were plotted using varying yield criteria for This comprehensive exploration of material properties paves the way for a deep understanding of Al1050 aluminum alloys and their mechanical characteristics, enabling informed and rigorous numerical simulations and experiments. This research builds on these foundations to draw insightful conclusions and offer innovative contributions to the field.S denotes the cross-sectional area of the test specimen and F represents the measured tensile force. The condition is further expressed asIn the context of uniaxial tensile testing, the determination of the maximum tensile force can be formulated through Equation (9):Upon careful observation, Swift  introducH’ represents the slope of the hardening curve. According to the principles of continuum mechanics, we can establish the following:In Equations (12) and (13), Consequently, Substituting Equations (12)–(15) into Equation (11) yields an explicit formulation of the modified maximum force criterion (MMFC) asβ = 0), uniaxial tensile strain (U.T) (β = −1/2), and uniform tensile strain in bi-axial tensile (B.T) (β = 1), which are commonly applied in traditional forming methods. For the single-point incremental forming (SPIF) method, the FLC is determined as discussed by various authors [β values of −1/2 and 1. This method is explicitly defined in accordance with Equation (16) and can be subsequently transformed into Equation (17a).In this study, a graphical method was utilized to construct the forming limit curve (FLC) for an Al1050 aluminum alloy sheet. This approach encompasses specific deformation modes, including the plane strain (P.S)  and B(α) can be determined from the coefficients of the Hill’48R stress function, calculated as per Equations (18a)–(19b). Specific deformation modes such as the uniaxial tensile strain (U.T)  can be graphically represented as illustrated in Subsequently,The graphical method, as demonstrated in For the finite element simulations, the Al1050 aluminum material was employed. The material took the form of a square with a side length (L) of 320 mm and a thickness (t) of 0.5 mm. The forming tool used in these simulations had a spherical radius of 7.5 mm. The desired forming profile was that of a truncated cone, with a base radius (R) of 100 mm. The forming height was denoted as “h” (in millimeters), and the forming angle as “α” (in degrees). These parameters are modeled in The finite element model was established to replicate the single-point incremental forming (SPIF) process, using the ABAQUS 6.13 software . As illuThe SPIF experiments for the truncated cone samples were carried out on a Taiwanese MC500 high-speed CNC machine . The machine’s table offered movement along the X × Y × Z axes of 500 mm × 400 mm × 300 mm, with a spindle rotation speed ranging from 100 to 30,000 rpm, table movement speeds during machining from 1 to 30,000 m/min, and a spindle power rated at 15 kW. The numerical control (NC) toolpath was generated using the PowerMill 2021 software, based on the computer-aided design (CAD) geometry of the machined sample, with the offset code corresponding to The experimental setup for the SPIF process is shown in In the simulations, the damage evolution criterion is a crucial component used to model material failure and fracture. It is defined as the point at which the forming limit curve ductile fracture (FLDCRT) value reaches 1.0, which indicates a fracture condition. When this criterion is met, certain mesh elements within the simulation are deleted, and the maximum fracture height is recorded for the corresponding wall corners. The comparison between the detailed fracture height in the SPIF simulation and the experimental results is presented in The finite element simulation, employing the Kim–Tuan hardening law in the RD, along with the anisotropic Hill’48R model and the FLC constructed through graphical methods, aimed to predict the increase in fracture height during forming processes. As shown in C and In SPIF, forming limit curves (FLCs) serve as useful tools for simulating forming and bending processes, especially when material formability is limited under increased forming conditions. Previous studies have demonstrated that when bending and forming loads are applied simultaneously, the formability of materials can exceed the strain values expected from typical FLC predictions. Notably, the FLCs in progressive sheet forming (FLCN for necking and FLCF for fracture) exhibit a near convergence at isotropic strain. Consequently, this research leveraged Clift’s criterion  to propoβ) was set at 1.0. Additionally, the principal fracture strain for a tool radius (R) of 7.5 mm was found to be 0.452, yielding a constant value  and minor (ε2) strains. These columns were subsequently integrated into the FLC damage table within the material properties module of ABAQUS/Explicit to simulate the fracture occurrence in incremental sheet metal forming processes. The finite element (FE) simulation results of the SPIF process with the proposed FLCF are visualized in Data from the MATLAB calculations  were expThe reliability of the proposed FLCF was verified by the predicting failure occurrences and fracture heights for samples with varying forming angles. The finite element (FE) simulation results for these experimental samples are displayed in The value of the forming limit curve for ductile fracture (FLDCRT) approaches 1.0 (indicating a damage condition), after which the mesh elements are removed. The corresponding maximum deformation height for each forming angle is provided in This demonstrates the effectiveness of the proposed forming limit curve model, showing similarity in the forming height of the truncated cone samples during both simulation and experimentation. The results validate the reliability of the new FLCF model when predicting incremental sheet metal forming processes under different shaping angles.Graphical method for FLC construction: a FLC is methodically constructed using the graphical approach and employed in numerical simulations to predict the variation in fracture height during SPIF. The results show a notable deviation between the simulated and experimental outcomes, particularly when forming the truncated cone with a 62° wall angle. The deviation, amounting to 15.97%, underscores the challenge in accurately modeling the SPIF process.Proposed forming limit curve at fracture in SPIF (FLCF): To enhance accuracy, a new FLCF is introduced based on the relationship between major and minor strains, drawing on the simulation results for truncated cone shaping with varying tool radii. The FLCF aligns remarkably well with experimental observations, especially for a 62° forming tilt angle, where the deviation is significantly reduced to 3.13%. This highlights the potential of the proposed FLCF in improving SPIF simulations.Validation across varied forming wall angles: To assess the reliability of the newly proposed FLCF, this study explores its effectiveness in predicting failure and forming fracture heights across a range of forming wall angles, spanning from 60° to 90°. The results are promising: for a 60° wall angle, the samples reach their maximum height without encountering fractures, with an FLDCRT value of 0.6292. With increasing forming wall angles , the forming fracture height of the truncated cone tends to decrease, aligning closely with FLDCRT values approaching 1.0. The deviation in the forming fracture height between the simulations and experiments remains within acceptable limits, with the largest discrepancy observed at 4.6% in most cases.This study delves into the critical role of the forming limit curve (FLC) in the numerical simulation of the single-point incremental forming (SPIF) process for Al1050 sheet material, followed by experimental validation. The investigation yields the following significant findings:In conclusion, this study not only highlights the necessity of an accurate FLC in SPIF simulations, but also introduces a novel FLCF model, which displays promising alignment with experimental results across various forming wall angles. This research contributes to the ongoing efforts to enhance the precision and reliability of the SPIF process, with potential applications in diverse industries requiring intricate sheet metal forming.


Our study aimed to investigate whether serum total IgE and blood eosinophils were associated with radiological features of bronchiectasis in a Chinese cohort.st, 2012 to Oct 7th, 2021. The clinical, laboratory and chest CT characteristics were analyzed in association with serum total IgE level and blood eosinophil count.We retrospectively enrolled bronchiectasis patients who visited Peking University Third Hospital from Jan 1A total of 125 bronchiectasis patients were enrolled, with 50.4% (63/125) female, and a mean age of 62.4 ± 14.1 years. The median serum total IgE level and blood eosinophil count were 47.7  KU/L and 140  cells/µl, respectively. In patients with a higher than normal  total IgE , more lobes were involved , and mucus plugs were more common  on HRCT, as compared to those with a normal level of total IgE. The higher IgE group was more likely to have bilateral involvement (p = 0.059), and had numerically higher Smith and Bhalla scores, but the differences were not statistically significant. In patients with an eosinophil count ≥ 150 cells/µl , the number of lobes involved was greater , and the Smith and Bhalla scores were higher . The Smith score was correlated positively with the eosinophil count . Fractional exhaled nitric oxide (FeNO) was correlated with total IgE  and eosinophil count .Our study demonstrated that serum total IgE and the blood eosinophil count were associated with the radiological extent and severity of bronchiectasis, necessitating further investigation on the role of T2 inflammation in structural abnormalities of this heterogeneous disease.The online version contains supplementary material available at 10.1186/s12890-023-02607-0. Bronchiectasis is defined as abnormal dilation of the bronchi, which typically presents with chronic respiratory symptoms including cough, sputum production, and hemoptysis, resulting in impaired quality of life and lung function decline . The incAlthough bronchiectasis is characterized by neutrophil-predominant airway inflammation, emerging evidence suggests that inflammation in bronchiectasis is heterogeneous, with a subpopulation of patients showing features of type 2 inflammatory response, as demonstrated by higher eosinophil counts and percentages in blood –7, sputuBlood immunoglobulin E (IgE) was also found to be higher in some bronchiectasis patients without allergic bronchopulmonary aspergillosis (ABPA) . One stuOur previous study  found thAspergillus fumigatus were available; and (4) lung function tests were performed within 6 months before or after the visit. The exclusion criteria were as follows: (1) patients who had a diagnosis of asthma based on the referred history of the patients or fullfilled the criteria of ABPA , and the percentage of patients with lobes involved ≥ 3 was higher . Bilateral involvement tended to be more common  in the higher IgE group, which also showed numerically higher Smith and Bhalla scores, but the differences were not statistically significant. There was no difference in the types  of bronchiectasis between the two groups, but mucus plugs were more common in the higher IgE group , shown in Table , 4, p = The patients were then divided into two groups based on the blood eosinophil count: those ≥ 150 cells/µl and < 150 cells/µl, which resulted in an approximately equal number of patients in each group (49.6% vs. 50.4%). In the higher eosinophil group, the number of lobes involved was greater , and both the Smith score  and the Bhalla score , were higher, as shown in Table , 5 vs. 3, 4, p = In 63 bronchiectasis patients who received FeNO measurement, the median level of FeNO was 20  ppb, and 39.7% (25/63) were above 25 ppb. The level of FeNO was well correlated with blood total IgE  and eosinophil count , as shown in Fig. In this cohort of 125 patients with bronchiectasis not concurrent with clinical asthma or ABPA, 56.8% had higher than normal levels of serum total IgE, and 49.6% had blood eosinophil counts ≥ 150 cells /ul. Both higher IgE levels and higher eosinophil counts were associated with more extensive or more severe bronchiectasis on HRCT, suggesting that T2 inflammation may play an active part in airway damage and remodeling characteristic of this heterogeneous disease. Consistent with previous studies [Airway inflammation in bronchiectasis has been historically recognized as neutrophilic in nature, however, recent studies also revealed a T2 endotype of the disease, as manifested by higher blood and/or sputum eosinophil counts, increased serum total IgE, higher FeNO, and allergy to various antigens , 11, 12.Aspergillus fumigatus lung infection [Mycobacterium avium-intracellular complex, was associated with T2 immune responses [Staphylococcus aureus (S. aureus) in the lower airway may indicate an allergic predisposition with staphylococcal enterotoxin sensitization and blood eosinophilia in bronchiectasis [S. aureus in patients with bronchiectasis [Pseudomonas aeruginosa and T2 inflammation is ambiguous. For example, there was no differences in Pseudomonas aeruginosa infection or colonization between the T2 and non-T2 groups in a cohort study from the Spanish Online Bronchiectasis Registry [Pseudomonas aeruginosa and blood eosinophilia was inconsistent in a European multicohort study [As early as 2008, King et al. reported 4 cases of idiopathic bronchiectasis with elevated serum IgE, all having multi-lobar disease  , indicatnfection . It is infection . Anothernfection . It was esponses .A recentiectasis , and anoiectasis . The relRegistry . And theIt is well known that the basic granules of eosinophils contain major basic protein (MBP), while the matrix contains eosinophil cationic protein (ECP), eosinophil derived neurotoxin (EDN), and eosinophil peroxidase (EPO). ECP and MBP are mediators of potent antibacterial and antiparasitic activities . We specWe found no significant differences in FEV1% and FEV1/FVC between the two groups of higher and lower eosinophils in our study, which was consistent with some previous reports. The recent study of 5 European cohorts showed no difference in FEV1% between groups according to blood eosinophil counts . HoweverThere is not enough evidence to clarify T2 inflammation and the disease severity of bronchiectasis. A multi-center cohort study showed that bronchiectasis patients with sensitization to three or more allergens had the highest BSI score ; In contHowever, there were several studies which demonstrated the response to biological treatments in bronchiectasis patients with the T2 endotype. Two real-world studies indicated that IL-5 antagonists were effective in reducing oral corticosteroids and improving respiratory function in patients with coexistent bronchiectasis and severe eosinophilic asthma , 39. In 1 in an obstructive disease like bronchiectasis is a marker of asthma (or asthmatic trait) or not.One of the strengths of this study was that our work revealed, for the first time to our knowledge, the distribution of blood eosinophil counts and serum total IgE levels in a well-characterized cohort of patients with bronchiectasis excluding clinical asthma and ABPA. But our study also had several limitations. Considering that IgE was not a routine test for bronchiectasis in clinical practice, patients receiving IgE measurement might have clinical indications, such as history of allergy or frequent exacerbations, which might lead to selection bias, although clinical asthma was carefully excluded from our analysis. We did not evaluate the number of airway eosinophils, although a relationship between blood and sputum eosinophil counts in bronchiectasis had been demonstrated in 2 European cohorts , and bloIn conclusion, our study revealed an association of blood eosinophil counts and total IgE levels with the radiological severity of bronchiectasis, suggesting that T2 inflammation may participate in airway structural destruction in bronchiectasis, which warrants further clinical and experimental investigation.Below is the link to the electronic supplementary material.Additional Files 1. Flowchart of the enrollment of patients.Additional Files 2. Relationship between FEV1%pred and radiological feature of bronchiectasis .Additional Files 3. Demographic, clinical, laboratory and radiological features according to blood eosinophil counts (300 cell/ul).