In this cross-sectional and longitudinal analysis of mapping the T-cell repertoire in kidney transplant recipients, we have investigated and validated T-cell clonality, immune repertoire chronology at rejection, and contemporaneous allograft biopsy quantitative tissue injury, to better understand the pathobiology of acute T-cell fraction, T-cell repertoire and antibody-mediated kidney transplant rejection. To follow the dynamic evolution of T-cell repertoire changes before and after engraftment and during biopsy-confirmed acute rejection, we sequenced 323 peripheral blood samples from 200 unique kidney transplant recipients, with (n=100) and without (n=100) biopsy-confirmed acute rejection. We report that patients who develop acute allograft rejection, have lower (p=0.01) T-cell fraction even before transplantation, followed by its rise after transplantation and at the time of acute rejection accompanied by high TCR repertoire turnover (p=0.004). Acute rejection episodes occurring after the first 6 months post-transplantation, and those with a component of antibody-mediated rejection, had the highest turnover; p=0.0016) of their T-cell repertoire. In conclusion, we validated that detecting repertoire changes in kidney transplantation correlates with post-transplant rejection episodes suggesting that T-cell receptor sequencing may provide recipient pre-transplant and post-transplant predictors of rejection risk. Recest kidney transplantation. All blood samples were submitted for sequencing using the ImmunoSEQ Assay . For STA patients, 50 subjects had a 6-month post-transplant sample at the time of management (protocol) biopsy and none of them went on to develop AR over the next year of follow-up. For AR patients, 50 subjects had a blood sample at the time of AR, and 39 of those patients had an additional 6-month management biopsy blood draw. All subjects were enrolled following IRB approval and had informed consent. Study subjects’ baseline characteristics are summarized in The objective was to assess the evolution of the T-cell immune repertoire in peripheral blood samples and their patterns in the context of allograft phenotypes. For this, the study included biobanked biopsy-matched total blood samples (n=323) collected by an IRB approved research protocol at the University of California San Francisco (Study ID- #14-13573) and selected from a biobank of over 3000 blood samples collected from kidney transplant recipients. The blood samples selected for this study included pre-transplant baseline samples from 100 renal allograft recipients who had biopsy-confirmed AR, inclusive of both T cell-mediated rejection (TCMR) and antibody-mediated rejection (ABMR); 100 renal allograft recipients had STA biopsies and graft function. Study subjects were chosen who had their 1The matching allograft biopsy at the time of blood sampling was read by a single pathologist using semi-quantitative histological scores. Clinical AR was defined as an AR episode, associated with graft dysfunction, based on a greater than 20% rise in serum creatinine from baseline values, and confirmed through central pathological reading of the biopsies according to the updated Banff classification with semi-quantitative scoring for tubulitis , inflammation  and interstitial fibrosis and tubular atrophy  . All sam® tubes, gently inverted, and incubated at room temperature for 30 min until the clot was formed. The sample was then centrifuged at 2000 × g for 5 min, the upper layer of serum was then transferred to a cryotube, and the remaining clot was stored in the original tube at −80 °C until use. Genomic DNA from whole-blood clot was extracted using the QIAsymphony DSP DNA Midi Kit . The DNA was quantified with NanoDrop and the extracted DNA was stored in -80°C until use for sequencing of the CDR3 regions of human TCRβ locus using the immunoSEQ assay. Extracted genomic DNA was amplified in a bias-controlled multiplex PCR with a pool of primer pairs targeting the V and J genes, as well as primers targeting reference genes to quantitate the total nucleated cells in each sample. PCR products were sequenced on an Illumina NextSeq System. Sequences were collapsed and filtered in order to identify and quantitate the absolute abundance of each unique TCRβ CDR3 region for further analysis as previously described (Blood samples (4.5 mL) were collected into a 5 mL plain glass Vacutainerescribed –18. Twelescribed Table 2.https://clients.adaptivebiotech.com/pub/ DETERMINED ON ACCEPTANCE.TCRβ sequencing data that support the findings of this study have been deposited at the publicly available immuneACCESS platform at: We compared TCRβ sequencing data from demographically matched renal transplant recipients who had either protocol or clinically indicated biopsies and paired blood samples for immune repertoire analysis; group comparisons were conducted between patients with histologically clean protocol biopsies (designated as the stable group (STA)) and histologically confirmed acute rejection as graded by the Banff classification on either protocol or indicated biopsies (designated as the acute rejection group (AR)).ip is the proportional abundance of rearrangement i and N is the total number of rearrangements  to 0 (completely disparate repertoires)  .Post-Hoc Dunn Test. Associations between two continuous variables were tested using Spearman’s Rank-Order Correlation. Associations between pairs of categorical groups were tested with a Fisher Exact Test.All statistical analysis was performed using standard packages in R version 3.6. Associations between groups were tested with either a Wilcoxon Rank Sum Test  or a Kruskal-Wallis Test . Pairwise comparisons after Kruskal-Wallis Tests were conducted with a The study cohort included a carefully selected set of peripheral blood samples obtained from demographically matched renal allograft patient groups with and without biopsy-confirmed acute renal allograft rejection , and witAt pre-transplant phase, a greater diversity of the T-cell repertoire was observed in peripheral blood samples collected from subjects who developed acute rejection after transplant , we infe). We observed increased use of TCRBV01 and TCRBJ01-02 in subjects with AR . Overall, the magnitude of the difference may not be sufficient alone to be predictive of outcomes, as it may also reflect variations in HLA types among individuals in this data set enriched on patients who reside on the US pacific west coast, this observation requires further validation.We further assessed the patterns of V and J TCR gene usage within the baseline samples to identify differential gene usage, which may be associated with increased risk of AR (post-hoc Dunn test p=3.35e-6 (T-cell fraction (TCFr), the proportion of nucleated cells that are T cells, was determined as the number of T cells out of the total number of nucleated cells in the sample (similar in concept to an estimation of CD3+ T cells by flow sorting) ; this de2-fold change median STA: - 0.34, median<6 months AR: 0.59, median >6 months AR: 3.52; post-hoc Dunn test, adjusted P=0.0037 vs. AR<6mo, P=7.4e-5 vs STA) , suggesting that the expansion in TCFr is likely due to an overall increase in the T-cell pool rather than just an expansion of the highest-frequency clones.To compare for possible confounders, we compared whether baseline T-cell fraction varied by sex, age or race. We did not observe significant differences between sex (M vs. F) or age (<=37 vs. 38+), p>0.05 wilcox rank sum test. We observed a sharp rise in TCFr in the AR cohort, specifically for patients who had late acute rejections, after the first 6 months post-transplantation (logpost-hoc Dunn test) . Together these findings suggest that measuring the TCR immune repertoire changes in an isolated post-transplant sample will likely be insufficient to predict rejection and integrating changes between the pre-transplant or baseline blood sample and a post-transplant blood sample will be more valuable to to evaluate the clinical impact of the repertoire dynamics.Comparing V and J gene usage post-transplant we observed a slightly greater usage of TCRBV18 in STA patients; however, this was not significant when correcting for multiple testing. No other TCRβ V gene showed differential enrichment (Microcirculation Inflammation (MI), which is a cumulative score that includes glomerulitis (gs) and peritubular capillaritis (ptc), has been associated with worse outcomes in kidney transplantation . A signiThis study provides data on TCR immune repertoire sequencing on the largest cohort of kidney transplant recipients to date, to evaluate the changes in TCR before and after transplantation, by analysis of peripheral blood samples paired with transplant biopsies, and paired peripheral blood samples from the same transplant patients, before and after engraftment, using highly validated and demographically matched STA and AR cohorts. Using sequencing of the third complementarity-determining region (CDR3) of the TCRβ chain of the T-cell receptor from 323 blood samples collected from 200 kidney transplant recipients, we report multiple significant observations including associations between AR and Morisita Index and TCFr. Patients with acute rejection had lower (TCFr) before transplantation, followed by greater repertoire turnover and increased TCFr at the time of acute rejection after transplantation. Repertoire clonality is largely driven by the highest frequency clones, thus while there is significant repertoire turnover in patients with rejection, the observed lack of change in clonality indicates the acute rejection is driven by global changes in the TCR repertoire and not specifically by an increase in the highest frequency clones, which are most likely donor reactive. We observe that same repertoire of immunoreactive clones appear to continue to be immunodominant during the post-transplant rejection, even though there is repertoire turnover with regards to clone frequency. Given this observation, one of the reasons for the lower TCFr association with higher risk of post-transplant rejection can be hypothesized to be due to heterologous immunity where cross reactivity with pre-transplant auto-antigens results in increased reactivity to donor allo-specific antigens after transplant, and the evolution of rejection.Our cohort had a an almost two-fold higher proportion of CMV-ve recipients pre-transplant in the rejection group (51% vs.26%), as predicted by TCRSeq. We recognize that CMV-ve recipients overall have a higher risk of CMV infection after transplant, and that there is an increase in the CMV positivity rate in the AR group. As there are known associations between clinical  and sub-+ T cells, otherwise observed in ABMR  can be found in the article/The studies involving human participants were reviewed and approved by University of California San Francisco (Study ID- #14-13573). The patients/participants provided their written informed consent to participate in this study.CMV Systems Immunobiology Group: Richard Ahn, Janice Arakawa-Hoyt, Patrick Boada, Jenny Brook, Suphamai Bunnapradist, Izabella Damm, Nakul Datta, Mario Deng, Don J. Diamond, Janette Gadzhyan, David Elashoff, David Gjertson, Alexander Hoffmann, Kenichi Ishiyama, Maggie Kerwin, Lewis L. Lanier, Megan Llmas, Erik Lum, Tariq Mukatash, Harry Pickering, Zach Qian, Michelle Ramirez, Rodney Rodgers, Elaine F. Reed, Minnie M. Sarwal, Maura Rossetti, Dmitri Rychov, Marina Sirota, Joanna Schaenman, Swastika Sur, Subha Sen, Tara Sigdel, Danielle Sim, Praveena Velperusiva, Otto O. Yang.TS, JH, HR, and MS designed the study, PF, JL, ID, MK, and TS generated the data, TS, PF, MS and MS analyzed the data. All authors participated in manuscript writing. All authors contributed to the article and approved the submitted version.This study was supported by a National Institutes of Health grant U19 AI128913 and 3U19AI128913-03S3 to MS.We acknowledge help from Stephanie Bien in manuscript revision. We acknowledge the kidney transplant recipients who consented to participate in this study. We acknowledge Dr. Zoltan Laszik (UCSF) for pathology scores and Dr. Priyanka Rashmi for critically reading the manuscript.Authors PF, JH, and HR were employed by Adaptive Biotechnologies.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


To investigate the efficacy of dapagliflozin for diabetes mellitus complicated by coronary artery diseases and its impact on vascular endothelial function.  Between August 2020 and August 2021, 80 patients with coronary heart disease complicated by type 2 diabetes mellitus were recruited and randomly assigned to receive either dapagliflozin (5 mg daily) plus original oral hypoglycemic agents (dapagliflozin group) or original oral hypoglycemic agents alone (control group). Outcome measures included blood pressure, blood glucose, cholesterol levels, vascular endothelial function, cardiovascular events, and drug-related adverse events. P > 0.05). After 20 weeks of medication, the two groups of patients showed similar blood pressure, hemoglobin A1c (HbA1c), and low-density lipoprotein (LDL-C) levels versus those before treatment (P > 0.05), and no significant differences were found in intergroup comparison neither (P > 0.05). Dapagliflozin plus conventional hypoglycemic agents resulted in a significantly higher reactive hyperemia index (RHI) value, fewer cases with abnormal vascular endothelial function, and fewer major cardiovascular events during treatment versus the sole use of conventional hypoglycemic agents (P < 0.05). There was no significant difference in drug-related adverse events between the two groups (P > 0.05).  The two groups had similar outcome indices upon admission ( Dapagliflozin improves the vascular endothelial functions of patients with diabetes mellitus complicated by coronary artery disease with a high safety profile and favorable efficacy. Type 2 diabetes mellitus is a major risk factor for cardiovascular disease. Several new antidiabetic drugs have been developed clinically, which have also shown good cardiovascular protection. The DAPA-HF study showed that dapagliflozin reduced cardiovascular and all-cause mortality in patients with heart failure with reduced ejection fraction, regardless of the comorbidity of type 2 diabetes mellitus. Concurrently, the hypertensive disease is a common comorbidity of type 2 diabetes mellitus. Numerous studies have shown that diabetic patients with comorbid hypertension are at higher cardiovascular risk compared to diabetic patients without comorbid hypertension. Coronary heart disease is a common complication in diabetic patients, and disease progression may result in more clinical adverse events. And glycemic management is crucial for the prevention and treatment of vascular disease progression in these patients , 2.Recent studies have revealed a significant role of abnormal endothelial function in the development of vascular diseases such as coronary artery disease. Recent studies suggest that abnormal endothelial function may be one of the nontraditional risk factors for coronary heart disease and independent of traditional risk factors such as age, blood pressure, and lipids and may predict adverse cardiovascular events and myocardial infarction size. Type 2 diabetes is characterized by inadequate or resistant insulin production, whereas coronary heart disease is caused by coronary artery sclerosis, with symptoms such as angina pectoris. The increased incidence of type 2 diabetes mellitus caused by coronary artery disease severely compromises the quality of life of patients.Dapagliflozin is a class of hypoglycemic agents that has received considerable attention in recent years , 4. It lP > 0.05)  plus original oral hypoglycemic agents (dapagliflozin group) or original oral hypoglycemic agents alone (control group). The diagnosis criteria followed the Chinese Medical Association's norms. The baseline statistics for the two groups were comparable ( > 0.05) .http://www.randomizer.org/). For concealment of allocation, the randomization procedure and assignment were managed by an independent research assistant who was not involved in the screening or evaluation of the participants.The randomization was carried out using an online web-based randomization tool  aged ≥60 years; (2) with the current use of dapagliflozin tablets (concomitant use of insulin is available), with a treatment duration of ≥5 months; (3) with current oral administration of non-SGLT2 inhibitor hypoglycemic drugs (can use insulin at the same time); (4) age ≥ 18 years; and (5) with fasting blood glucose (FBG) ≤ 10 mmol/L and glycosylated hemoglobin (HbAlc) ≤ 8.5%.Exclusion criteria are as follows: (1) patients with severe heart failure (cardiac insufficiency grades III-IV); (2) with acute myocardial infarction; (3) with liver and kidney insufficiency; (4) with acute and chronic infections, hematological diseases, malignant tumors, rheumatic connective tissue, and other immune system diseases; (5) with recent surgery or trauma; and (6) with a bodyweight of <50 kg.Oral dapagliflozin (5 mg daily) was added on top of the original oral hypoglycemic drugs, and the original oral hypoglycemic drugs could be reduced or discontinued depending on the blood glucose level of the patients.The initial oral hypoglycemic medicines were continued, and the dose could be modified based on the patients' blood glucose levels. Except for extreme adverse responses, all patients were treated for 20 weeks until the completion of the study. In both groups, the secondary preventive medicine for coronary heart disease remained unchanged.Blood pressure, glycosylated hemoglobin (HbA1c), and low-density lipoprotein (LDL-C) levels were compared between the two groups upon admission and after 20 weeks of treatment.The blood pressure was measured, and morning fasting venous blood was obtained from the patient at 7 : 00 on the day before and the day after the treatment in both groups: (1) HbAlc: high-performance liquid chromatography (HPLC) was performed using an HA-8180 HbAlc analyzer and original reagents. (2) LDL-C: the Japanese Sekisui Surfactant Removal (SUR) method was used to determine the LDL-C using the SP-4430 biochemistry analyzer and original reagents.The values of the vascular endothelial function at admission and after 20 weeks of treatment and the cases of abnormalities in vascular endothelial function were compared between the two groups. Reactive hyperemia index (RHI), which reflects nitric oxide-dependent changes in endothelial function, was obtained using the EndoPAT-2000 Itamar assay, and abnormal vascular endothelial function was determined by an RHI < 1.67. The patient fasted for 4 hours prior to the test, which was conducted in a calm, temperature-controlled environment with consistent illumination. The EndoPAT-2000 finger cuffs were put on the subject's two middle fingers, and pressure changes in the cuffs caused by pulsatile volume changes in the distal fingers were detected by a pressure sensor and communicated to the Endo-PAT device for recording. RHI testing: The baseline measurement was performed for 5 min, after which the blood pressure cuff on the test arm was inflated to 60 mmHg above the baseline systolic pressure, and blood flow was blocked for 5 min, followed by deflation of the cuff and recording for another 6 min after deflation.The incidence of major cardiovascular events  within 20 weeks was recorded and compared between the two groups.The incidence of drug-related adverse events such as hypoglycemia, severe hypoglycemia, hypotension (blood pressure < 90/60 mmHg), and wasting (weight loss with a weight of less than 10% of standard body weight) were recorded and compared between the two groups within 20 weeks.t-test for normally distributed variables and the Mann-Whitney U test for nonnormal variables. SPSS 18.0 was used for data analyses. The measurement data were expressed as x̅±s and processed using the t-test. The count data were expressed as the number of cases (rate) and analyzed using the chi-square test. Differences were considered statistically significant at P < 0.05.The mean difference between the two groups was tested using the Student P > 0.05). After 20 weeks of medication, the two groups of patients showed similar blood pressure, HbA1c, and LDL-C levels versus those before treatment (P > 0.05) (The two groups had similar outcome indices upon admission ( > 0.05) .P > 0.05). Dapagliflozin plus standard hypoglycemic medications resulted in considerably higher RHI values and fewer instances with impaired vascular endothelial function (RHI < 1.67) (P < 0.05)  .χ2 = 4.39; P < 0.05)  .P > 0.05).Each group experienced two hypoglycemic responses, but no severe hypoglycemia, hypotension, or wasting episodes occurred. Three instances in the dapagliflozin group had lower blood pressure than before the treatment, and dapagliflozin was maintained after antihypertensive medicines were reduced appropriately. There was no significant difference between the two groups in terms of drug-related adverse events  Diabetes Map shows that 415 million adults worldwide had diabetes in 2015, and by 2040, more than 640 million adults are diagnosed with diabetes. Data show that 75% of type 2 diabetic patients die from cardiovascular disease. Coronary artery lesions in type 2 diabetic patients are prevalent as subtle, diffuse, calcified, and multivessel lesions, and there is a high incidence of stent restenosis and hemodynamic reconstitution in type 2 diabetic patients after PCI. Glycemic management is a therapeutic priority for patients with coronary artery disease with underlying diabetes mellitus .The results of the present study showed that the combined use with dapagliflozin resulted in a lower incidence of angina and heart failure events versus conventional hypoglycemic agents after 20 weeks of treatment, suggesting the priority of dapagliflozin for glucose-lowering therapy in patients with diabetes mellitus combined with coronary artery disease. Abnormalities in vascular endothelial function appear early in the course of the vascular-related disease and persist throughout. SGLT2i increases urinary glucose excretion, and the osmotic diuretic and natriuretic effects due to increased urinary glucose contribute to a reduction in blood volume, with patients experiencing a reduction in systolic and diastolic blood pressure of 4-6 mmHg and 1-2 mmHg, respectively, which underlies potential cardiovascular benefits.Recent studies have demonstrated that abnormal vascular endothelial function may be one of the nontraditional risk factors for coronary heart disease and independent of traditional risk factors, such as age, blood pressure, and blood lipids, and may predict adverse cardiovascular events and myocardial infarction size –13. The The present study also revealed an overall increase in RHI values in the dapagliflozin group and fewer cardiovascular events versus the patients in the control group, indicating that dapagliflozin is effective in improving vascular endothelial function, and the improvement of vascular endothelial function is speculated to be a contributor to the reduction of cardiovascular events. The absence of significant differences in the adverse events between the two groups indicates a high safety profile of dapagliflozin. Nevertheless, the occurrence of occasional hypoglycemic reactions requires close monitoring of blood glucose for drug changes. It is hypothesized that SGLT2 may inhibit oxidative stress and inflammatory responses in the vascular endothelium, optimize cardiomyocyte energy metabolism, and improve hemodynamics through inhibitors, but the specific mechanisms by which it improves vascular endothelial function remain to be explored .As an SGLT-2 inhibitor, dapagliflozin improves clinical outcomes in coronary artery disease through multiple mechanisms. First, dapagliflozin has good glycemic control. The results of several large multicenter clinical studies showed that dapagliflozin significantly reduced glycated hemoglobin, fasting glucose, and postprandial glucose . Second,The present experiment has many shortcomings. First, the study sample size was small, the follow-up period was short, and the length of observation was insufficient for such a complex mechanism of change as ventricular remodeling. Ultrasonographic observables were unavailable to observe functional improvement, and therefore, no more structural corroboration was available. In the process of reconstructing the control variables by observation, insufficient monitoring led to certain fluctuations in blood glucose and blood pressure of individual patients during the treatment process, which had an impact on the final results as an influencing factor. Subsequent studies will refine and improve the experimental shortcomings, expand the sample size, extend the observation time, increase the observation index, control the influencing factors, and eliminate the drawbacks, so as to produce more accurate research results. In some current basic and clinical studies, a growing number of possible pathways and biomarkers affecting ventricular remodeling are being confirmed, providing more potential targets for drug research and indicating the direction of exploration to improve the prognosis of patients with cardiovascular disease. In the future, more novel drugs against inhibition of ventricular remodeling and improvement of patient's quality of life can be developed based on such studies, providing more possibilities for clinical treatment.To sum up, dapagliflozin reduces the incidence of all-cause mortality and cardiovascular death in coronary artery disease combined with type 2 diabetes but fails to lower the incidence of nonfatal myocardial infarction, stroke, revascularization, and readmission. Despite its safety in improving vascular endothelial function in patients, the exact mechanism of dapagliflozin remains unclear.


Sympathetic overactivation is one of the main contributors to development and progress of hypertension. Renal denervation (RDN) has been evidenced by series of clinical trials for its efficacy and safety to treat overactivated sympathetic nervous system induced diseases. However, the results were inconsistent and not all patients benefited from RDN. Appropriate patient selection and intraoperative factors to improve the efficacy of RDN need to be solved urgently. Over the decade, research studies on the correlations between indicators and the antihypertensive effects have been conducted and made a fairly well progress. Herein, we comprehensively reviewed the research studies on how to make RDN more predictable or improve the efficacy of RDN and summarized these potential indicators or devices which might be applied in clinical settings. Sympathetic overactivity is a major drive of initiation and development of many cardiovascular diseases . HoweverAs reported in the previous clinical trials above, although the responders received a significant reduction of blood pressure after RDN and the efficacy exists persistently , 19  in African-Americans versus −6.63 mmHg  in non-African-Americans  , 89 3, 8The ConfidenHT system , using RNS for mapping renal nerves, contains a console and a dedicated catheter which consists of a flexible multielectrode in a basket shape. Notably, the preprogrammed stimulation is performed at 2 mA, followed by 4 mA for 2 min without causing discomfort to the patients under conscious condition. However, only a few participants were enrolled for assessment of feasibility without ablation . On the Renal denervation has been validated in a number of clinical trials for its safety and efficacy and not only confined to treatment of resistant hypertension. However, such benefits are not shared by all subjects, some of which even manifest more severe hypertension after RDN. Though many indicators have been listed, the leading clinical need to be met is the patient selection, which is critical for clinicians to bring benefit for ideal candidates, especially in younger and early staged primary hypertensive patients with better vascular function, especially those with obesity, higher baseline blood pressure and/or heart rate, and avoid to burden nonresponders. Moreover, patient preference seems to be an instant and readily information for patient selection and even may influence the outcomes of the efficacy of renal denervation. From the survey of the patient preference for renal denervation conducted in Europe and Asia –93, the Correlations between baseline blood pressure and efficacy after RDN are complicated and various, while blood pressure responses to renal nerve stimulation and radiofrequency energy seem promising, and another shot of RNS after renal denervation at the same site could confirm a successful ablation if the blood pressure remains relatively stable. Last but not the least, improvement of devices and strategies is expected to be more direct and sufficient to overcome such limitations.Patients would benefit more from RDN when complicated with chronic obstructive pulmonary disease , chronicBesides the predictors mentioned above, other studies have also proposed some fragmented markers for responders: patients with lower absolute values of activated double negative T cells and lower but more stable values of total CD8+, CD4+, and naïve T CD8+ cells , increasMany as the indicators are, there is lack of an actual gold standard or prediction model for inclusion of responders, the threshold of which remains to be addressed by a larger sample size and racial difference. Renal nerve stimulation seems much promising, while RNS needs to be further verified by large randomized controlled clinical trials. Also, a dedicated algorithm could be built in the ablation system to help interventionalists for decisions on ablation or avoidance. Nevertheless, above predictors should be further evidenced, and new indicators or treatment devices might be necessary.


The aim of this study was to examine the association between remote diffusion-weighted imaging lesions (R-DWILs) and blood pressure variability (BPV) in patients with primary intracerebral hemorrhage (ICH).We conducted a retrospective review of a consecutive cohort of 375 patients with primary ICH within 24 h onset. R-DWILs were defined as hyperintensity lesions in DWI remote from the hematoma. Blood pressure recordings were extracted up to 24 h post-admission. BPV was measured using SD, coefficient of variation (CV), and successive variation (SV).Remote DWI lesions were detected in 65 (17.3%) primary ICH patients. In multivariable logistic regression analysis, parameters of BPV were independently associated with R-DWILs, and the results remained consistent after being adjusted with mean SBP. SD, CV, and SV values in the highest quintile, showed 3- to 8-fold increased risk of R-DWILs, compared with the lowest quintile. ΔSBP demonstrated a significant difference in 2 different predictive models. Max SBP only dictated a significant difference in model 1. Mean SBP, admission SBP, and min SBP, failed to present an association with R-DWILs in model 1 or model 2.Our results provided additional evidence that BPV is associated with the development of R-DWILs in primary ICH. Remote lesions identified using diffusion-weighted imaging (DWI) in primary intracerebral hemorrhage patients have been reported with an incidence of 11–41% . HoweverIt has been argued that aggressive blood pressure (BP) lowering in acute ICH may increase the possibility of cerebral hypoperfusion, and thus induce cerebral ischemia –5. NeverThere is increasing evidence supporting that not only the absolute value of BP values but also their variations over time contributing to cerebrovascular events, as well as the outcome , 12. TheWe reviewed our prospectively collected data from a consecutive enrolled patient cohort with acute primary ICH who were admitted to the department of neurology at the Second Affiliated Hospital of Zhejiang University between November 2016 and October 2019. Patients were included in this study if they had acute primary ICH within 24 h of symptom onset, and magnetic resonance imaging (MRI), including DWI, apparent diffusion coefficient (ADC), and fluid-attenuated inversion recovery (FLAIR) sequences. Patients with ICH due to aneurysms, vascular malformations, moyamoya disease, cavernous hemangioma, head trauma, cerebral venous thrombosis, hemorrhagic transformation after ischemic infarction, or neoplasm were excluded. Patients were also excluded if they had inadequate BP data. The study protocol was approved by the institutional Human Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University.Demographic data , medical history , laboratory results , as well as clinical assessments [National Institutes of Health Stroke Scale (NIHSS) scores on admission] were collected in all patients. Hematoma volume was calculated using the ABC/2 method based on initial computed tomography (CT) scan , and hemAll patients underwent on admission a non-invasive BP monitoring  over the first 24 h after symptoms onset. Standard arm cuffs suitable for arm circumferences ranging from 25 to 35 cm were supplied. The supine BP was measured in the non-paretic arm using an oscillometric method, which is clinically proven to produce fast and reliable results. Systolic BP (SBP) and diastolic BP (DBP) readings were obtained every 2 h in the first 24 h. The parameters of BP variability were derived manually, including SD, coefficient of variation , and successive variation (SV). SV is the square root of the average difference in BP between successive measurements. We also measured admission, average (mean), maximum (max), minimum (min), and difference between max and min (Δ) of BP. Treatment of BP was performed according to guideline recommendations and the physician' discretion. We screened for patients who were prescribed antihypertensive medication in the first 24 h, that was classified as a continuous infusion, intermittent infusion, and oral medication.b = 0/1000s/ mm2, 6-mm slice thickness, 0.5-mm gap, FOV 230 mm, base resolution 176, phase resolution 100%, voxel size, 1.3 ×1.3 ×6 mm.MRI was performed on 1.5-Telsa  with a standardized protocol consisting of axial T1-weighted, T2-weighted, T2 FLAIR, DWI, and apparent diffusion coefficient (ADC) sequences. Axial DWI sequences were acquired based on following parameters: repetition time [TR] 3,100 ms, echo time [TE] 84 ms, Remote DWI lesions were defined as hyperintensity lesions in DWI and <20 mm in diameter, with a corresponding hypo-intensity in the ADC map . Those DWhite matter hyperintensity (WMH) was identified as hyperintensity on FLAIR sequences . PerivenWe collected standardized functional outcomes [modified Rankin Scale (mRS)] at 3 months by telephone or in-person interviews. An unfavorable outcome was defined as mRS of 4–6 at 3 months. All outcome data were obtained by examiners certified in the mRS. The examiners were blinded to each patient's clinical course and radiographic imaging.2 test and Fisher's exact test for categorical variables, and the independent-sample t test or the Mann–Whitney U test for continuous variables, as appropriate. The proportion of patients with R-DWILs was then compared according to quintiles of each of the BPV parameters (Q1 means lowest quintile group and Q5 means highest quintile group). Finally, binary logistic regression analysis was performed to assess the independent association of each BP parameter, as quintiles, with the presence of R-DWILs. Model 1 involved variables with p < 0.10 in the univariate analysis as well as those which are known to have a definite association with the R-DWILs in clinical practice. Because BPV increases proportionally to the increased BP level, model 2 was adjusted using mean BP besides model 1 variables. All covariates were proved to be independent using the likelihood ratio test. To avoid the risk of multicollinearity caused by including highly correlated variables in the same model, we replaced each variability parameter one by one instead of including all the BP variability parameters in one model. Regarding that binary regression might create artificially significant values, Spearman's correlation analysis was performed to explore associations between BPV parameters, as continuous variables, and R-DWILs numbers. Then, multiple linear regression analysis was used with the covariates mentioned above. All the assumptions for linear regressions were met. We also undertook an exploratory analysis to compare BP variability in patients with mRS scores of 0–3 vs. 4–6. A p-value <0.05 was considered to be statistically significant. All statistical analyses were carried out using SPSS Version 24.0 .In our study, categorical variables were presented as percentages, and continuous variables were presented as mean standard deviation if normally distributed or median (interquartile range) if not normally distributed, which were checked by the Shapiro–Wilk test. We compared the demographic, clinical characteristics, and BPV parameters of patients with and without R-DWILs using the χOf the 976 cases enrolled within the timeframe of analysis, a total of 515 were included in the final analysis . The timp-values ranging from <0.01 to <0.001), as well as max (p = 0.007) andΔSBP (p = 0.011), while mean, minimal SBP or SBP on admission were not associated , and marginally significant difference in model 2 (p = 0.050). Max SBP achieved significant difference in model 1 (p = 0.024), while failed to reveal significance in model 2 (p = 0.122). In contrast, mean SBP, admission SBP, min SBP, was not consistently associated with R-DWILs. Besides, we also applied a sensitivity analysis exploring the associations between SBP variability and R-DWILs number, and similar results were found , and unfavorable outcomes (mRS 4–6) occurred in 84 patients (25.1%). In univariate analysis, BPV parameters were not associated with unfavorable outcomes at 3 months, although there was a tendency for increased SV SBP in the worse functional outcome group  cohort, in which greater changes in mean arterial pressure (MAP) prior to the MRI were significantly associated with the presence of DWI lesions . AnotherWe also found that max SBP achieved a significant difference in model 1, but did not remain significant after adjusting for mean SBP in model 2. Besides, we failed to find an association between admission SBP and R-DWILs. In prior studies, several studies have reported an association with admission SBP , 8, wherIt is noteworthy in the present study that the variability parameters for SBP were more closely related to R-DWILs than those for DBP. Previous studies about BP variability and ICH outcome have also reported that SBP variability might be more closely correlated with ICH outcome than either mean DBP or DBP variability , 22, altThis study has several limitations. First, our cohort may have a selection bias toward patients with milder hemorrhages due to MRI image requirements. Second, we did not differentiate varieties of BP-lowering medications, resulting in the inability to assess the effects of specific antihypertensive agents. Third, we did not assess the impact of BPV in the hyperacute period of ICH due to the limitation of patients, during which hemodynamic changes are most prominent. Furthermore, given the small size of R-DWILs, 6 mm slice thickness with 0.5 mm gap to acquire DWI sequences could cause a large measuring error, as well as T2 shine-through calculated based on b0.In conclusion, the results of our study revealed that SBP variability during the first 24 h after ICH ictus was independently associated with remote DWI lesions. This finding implies an effort to maintain BP stably instead of rigorously during the acute stage of ICH. Further studies with longer and more comprehensive BP surveillance are required to confirm the influence of blood pressure on not only R-DWILs but also hematoma growth and neurological outcome after ICH.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by the Institutional Human Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.XX and SP interpreted the data and drafted the manuscript. YZ performed the statistical analyses. JL collected the data. LT and FG read the images, revised the manuscript, and supervised the whole framework. All authors contributed to the article and approved the submitted version.This work was supported by the National Natural Science Foundation of China (NSFC) (81471168), the National Natural Science Foundation of China (NSFC) (81971155), Science and Technology Action Plan for Major Diseases Prevention and Control in China (2017ZX-01S-006S3), the Science and Technology Department of Zhejiang Province (2022KY174), and the Basic research Fund of Zhejiang University (226-2022-00027).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Bilevel positive airway pressure in spontaneous/time and average volume-assured pressure support (BiPAP·S/T–AVAPS) could maintain an adequate tidal volume by reducing the patient's inspiratory effort; however, this ventilatory strategy has not been compared with other ventilatory modes, especially the conventional BiPAP S/T mode, when noninvasive mechanical ventilation (NIMV) is used. The primary objective of this study was to determine the rate of success and failure of the use of BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with mild-to-moderate “de novo” hypoxemic respiratory failure.  This was a matched-cohort study. Subjects with mild-to-moderate de novo hypoxemic respiratory failure were divided into two groups according to the ventilatory strategy used. The subjects in the BiPAP·S/T group were paired with those in the BiPAP·S/T-AVAPS group. P=0.44) and mortality (P=0.1).  A total of 58 subjects were studied. Twenty-nine subjects in the BiPAP·S/T group were paired with 29 subjects in the BiPAP·S/T-AVAPS group. Twenty patients (34.5%) presented with “failure of NIMV,” while 38 (65.5%) patients did not. In addition, 13 (22.4%) patients died, while 45 (77.6%) recovered. No differences were found in the percentage of intubation (https://doi.org/10.1186/ISRCTN17904857. The BiPAP S/T-AVAPS ventilator mode was not superior to the BiPAP·S/T mode. A high mortality rate was observed in patients with NIMV failure in both modes. This trial is registered with  Noninvasive mechanical ventilation (NIMV) is an effective treatment for pulmonary insufficiency with acute respiratory failure of various etiologies , 2. RegaThe ventilatory strategy, bilevel positive airway pressure in spontaneous/time and average volume-assured pressure support (BiPAP·S/T-AVAPS), allows the use of a fixed preprogrammed tidal volume (TV), which is kept constant by virtue of inspiratory pressure variations . This veWe evaluated the BiPAP·S/T–AVAPS mode in patients with de novo hypoxemic respiratory failure and observed that it provides a better approach to protective ventilation in a selected group of subjects with mild-to-moderate hypoxemic respiratory insufficiency and spontaneous breathing to control the exhaled TV and inspired pressures .It is now known that high exhaled TV and inspired airway pressure during NIMV use cause alterations in the bioelasticity of the respiratory system with lung damage. Therefore, to avoid acute lung injury, an optimal ventilatory option is used to limit both the exhaled TV and inspired pressure. At present, this strategy, although described in patients with hypoxemic respiratory failure, has not been compared with other ventilatory modes, especially the conventional mode of BiPAP·S/T when using NIMV.There is a lack of information and research studies that compare the efficacy of the new ventilatory modes used in NIMV, specifically the ventilatory strategy with BiPAP·S/T-AVAPS, in the management of patients with ARF, making this topic attractive and novel.This study was designed to compare the results of the use of guaranteed volume support pressure BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with mild-to-moderate de novo hypoxemic respiratory failure. The primary objective was to compare the rate of rescue intubation between the two different modes. Secondary outcomes were days of NIMV, ICU stay, hospital stay, and mortality.A matched-cohort study was conducted between January 2010 and December 2013 in which all participants were admitted at the Santa Maria Hospital and Military Hospital. The study was approved by the ethics committee of Santa Maria Hospital and Military Hospital ). Informed consent was signed by a surrogate if the subject lacked the autonomy necessary for consent.https://doi.org/10.1186/ISRCTN17904857).A total of 58 patients were recruited in this study, and patients were divided into two groups according to the ventilatory strategy used: 29 in the BiPAP·S/T-AVAPS group and 29 in the control group . The person responsible for the decision to participate in the study was the patient or surrogate if he/she was not capable of making the decision. The study was conducted based on CONSORT regulations (2/FiO2) within 10 points of the value of the treated group, and partial pressure of carbon dioxide (pCO2) within 5 points.This was a prospective study; for each patient treated with BiPAP·S/T-AVAPS, one matched control was selected, according to the following matching criteria: cause of ARF, severity of illness on admission within assessment score of acute physiology and chronic health evaluation (APACHE II) 5 points, age difference ≤5 years, ratio of partial arterial oxygen pressure and inspired fraction of oxygen (PaOThe matched group was selected from a consecutive database of patients previously treated with BiPAP S/T in our intensive care units (ICUs).2 of 0.5 to 0.6, for the shortest possible time. NIMV was restored as soon as patients' pulse oximetry SO2 reached 90% or less.NIMV was administered on the first day for 24 h according to patients' tolerability. When NIMV was suspended, patients received oxygen through a mask connected to an oxygen reservoir having an FIO2/FiO2, 200–300 mmHg) to moderate  de novo hypoxemic respiratory failure with PaO2/FIO2 ≤ 300 mmHg were enrolled in this study.Patients presented with mild (PaO2 < 60 mmHg), breathing ambient air (SaO2 < 92%), PaO2/FiO2 < 300 mmHg, and severe dyspnea (RR > 25 breaths/minute), with use of accessory muscles, according to the noninvasive ventilation care standards committee of the British Thoracic Society (British Thoracic Society Standards of Care Committee) [The patients enrolled in this study met the following criteria: (1) ≥ 18 years of age; (2) admitted to an intensive care unit (ICU); and (3) diagnosed with ARF: inadequate oxygenation (PaOmmittee) , 14.Participants were excluded based on the following criteria: (1) patients with facial deformity; (2) obstruction of the upper airway by surgery or trauma; (3) alterations in the central nervous system not related to hypercapnic encephalopathy; (4) cardiogenic pulmonary edema, pulmonary embolism, pneumothorax, hemoptysis, or septic shock; (5) urgent intubation due to cardiorespiratory arrest and hemodynamic instability with systolic pressure (SBP) < 80 mmHg; (6) if they demonstrated hemodynamic instability or excess respiratory secretions; (7) if they did not cooperate or were agitated or could not use the device interface; (8) if the patient had recently undergone upper airway surgery; and (9) if the patient had received NIMV with “Do Not Resuscitate” order.Patients assigned to the intervention group received NIMV with guaranteed volume support pressure (BiPAP·S/T-AVAPS) for 12 h a day for at least 24 h.2O; minimum IPAP, 8 cmH2O; expiratory positive airway pressure (EPAP), 6–8 cmH2O.Ventilation parameters initially programmed in the BiPAP·S/T-AVAPS mode were as follows: maximum inspiratory positive airway pressure (IPAP), 14–26 cmH2 was programmed to maintain SaO2 above 90%. The maximum IPAP, exhaled TV (ETV), volume per minute (Vmin), and leaks were controlled using a ventilator software. The synchronization of BiPAP with AVAPS was carried out using Auto-Trak , along with a series of Mirage IV (Resmed) facial masks.The programmed tidal volume (TV) was 6–8 mL/kg of ideal body weight calculated using the following formula: 55.5 ± 2.3 × (height in inches−60) kg for men and 45.5 ± 2.3 × (height in inches−60) kg for women. The respiratory rate (RR) was 14–20 breaths/min, rise time was 300–400 ms, and inspiratory time was 0.8–1.2 s. FiO2O, according to the physician's assessment; EPAP, 6 cmH2O; rRR, 15 breaths/min; rise time, 300–400 ms; and inspiratory time, 0.6–1.2 s. The IPAP was progressively augmented with 2 cmH2O, according to the prescription of the attending physician. Oxygen supplements were added through an O2 adapter close to the mask to maintain the SaO2 above 90%. The exhaled current volume (EVT), Vmin, and leakage were controlled using a ventilator software. The synchronization of BiPAP with AVAPS was carried out using Auto-Trak (Respironics Inc. Murrysville. Pennsylvania. USA), a series of Mirage IV (Resmed) masks, and a Confourt Series II mask (Respironics).Ventilatory parameters initially programmed in the S/T mode were as follows: IPAP, 12–20 cmHArterial blood gases (ABG) were measured at baseline and 1, 12, and 24 h after the use of NIMV. Patients were evaluated by a respiratory therapist under strict supervision of the physician trained in NIMV. Complications of mask use were reported, if any. The severity of the disease was assessed by the APACHE II score. Maximum programmed VT, maximum patient IPAP, exhaled tidal volume, Vmin, leakage, RR of the patient, and IPAP were reported at baseline and during the first 48 h of NIMV obtained in the early morning hours. The mask use and tolerability were also evaluated. The tolerance capacity of the mask (comfort score) was evaluated as follows: 1 = low, 2 = average, and 3 = good . Complic2/FiO2 ratio was above 400 mmHg, and the decision of the medical staff considered a partial or total resolution of the cause that led to receiving NIMV. The weaning process was initiated when clinical stability was achieved, which was defined as an RR less than 25 resp/min, a heart rate (HR) of 100 beats/minute, improvement in the level of consciousness, compensation of the pH, ambient air with SaO2 > 90%, or a low rate of FiO2 (3 L/min). NIMV was discontinued when the patient remained stable for >24 hours.NIMV was initially used continuously in accordance with the patients' tolerance until the PaOComparisons were made between the two groups (BiPAP·S/T-AVAPS and BiPAP·S/T). Patients were classified according to “de novo” hypoxemic respiratory failure, from mild to moderate.2/FiO2 ratio, ABGs including pH carbon dioxide concentration (pCO2) (mmHg), partial pressure of arterial oxygen (PO2) (mmHg), blood bicarbonate (HCO3) (mmol/L), excess base (EB), FIO2 (%), ventilation mode (spontaneous/time), IPAP (cmH2O), EPAP (cmH2O), inspiratory time (IT) (mseg), ramp, ETV (mL), Vmin (L/min), leakage (cmH2O), radiological involvement , days of NIMV, days of hospital stay, intubation, and mortality.The following variables were evaluated between groups: age, sex, weight in kg (PBW), APACHE II, risk factors for acute respiratory distress syndrome (ARDS), community pneumonia, postoperative acute abdomen, acute pancreatitis, involvement of radiographic quadrants, SBP (mmHg), diastolic blood pressure (DBP) (mmHg), HR (beat/min), RR (breaths/min), PaOThe primary outcome was success or failure of NIMV . The secondary outcomes were ICU duration of hospitalization and mortality.In this study, to detect a 20% difference between success and failure of NIMV between the two groups with a Type I error of 0.05 (Alpha significant) and a Type II error of 0.20 , sixty patients (30 in each group) were required.https://www.medcalc.org, 2016).Statistical analyses were performed using MedCalc Statistical Software, version 16.4.3  for continuous variables and percentages for categorical variables. Normally distributed continuous variables were determined using the Kolmogorov-Smirnov test and were compared using Student's A total of 58 subjects were studied (29 subjects in the BiPAP S/T group were paired with 29 subjects in the BiPAP·S/T-AVAPS group) . The ave2, 32.5 ± 5.8 mmHg; PO2, 74.9 ± 9.6 mmHg; HCO3, 22.6 ± 4.1 mmol/L; SaO2, 94% ± 4% during the first 10 min of the initial ventilatory support.The ABG levels were as follows: pH, 7.43 ± 0.1; pCOThe vital signs of the patients were as follows: SBP, 123.3 ± 19.4 mmHg; DBP, 74.3 ± 8.7 mmHg; HR, 97.6 ± 13.7 beats/min; RR, 29.3 ± 4.7 breaths/min.2O; patient IPAP levels, 15 ± 3.2 cmH2O; leaks, 17.1 ± 9 cmH2O, ETV, 473.3 ± 196.1 mL, Vmin, 10.8 ± 4.15 L/min. The baseline characteristics are presented in The ventilatory parameters included the following: VT-AVAPS levels, 489.7 ± 74.5 ml; maximum IPAP levels, 17 ± 4.04 cmHNo differences were found between the BiPAP·S/T and BiPAP·S/T–AVAPS groups .P=0.44) and mortality (P=0.1)  presented with “failure of NIMV,” while 38 (65.5%) patients did not. In addition, 13 (22.4%) patients died, while 45 (77.6%) recovered. No differences were found in the percentage of intubation ( (P=0.1) .The physiological and ventilator parameters in hypoxemic ARF from baseline to 1, 6, and 12 h on BIPAP-ST-AVAPS are presented in In this study, we found no differences in the outcomes of BiPAP·S/T-AVAPS versus BiPAP·S/T alone in patients with “de novo” hypoxemic respiratory failure. There were no differences in the percentage of intubation or mortality in either group, or in the duration of IMV, hospital stay, or ICU stay. To our knowledge, this study is the first to compare the two ventilatory strategies in this subgroup of patients with de novo hypoxemic respiratory failure.BiPAP·S/T-AVAPS has been shown to be useful in patients with hypercapnic ARF, especially in obstructive pulmonary disease and alveolar hypoventilation . Other sCurrent therapeutic options for hypoxemic ARF are limited and mainly focus on minimizing ventilator-induced lung injury (VILI) . It is nHigh inspired pressures with high ETVs were observed in most patients in whom the AVAPS ventilatory strategy failed. In addition, the use of low TVs with limited airway pressure is essential for lung protection. In some cases, especially in patients with hypoxemic respiratory failure, an excessive increase in inspired pressure could increase intrathoracic pressure and reduce venous return. Moreover, the cardiac index decreases at high inspired pressures .AVAPS attempts to maintain an adequate TV by decreasing the inspiratory effort of the patient and increasing the programmed pressure automatically without exceeding the programmed maximum IPAP when the preset TV is not reached . We founOur study had the following limitations: (1) it is a “single-center” study and not a randomized controlled trial; (2) other types of interfaces used in de novo respiratory failure NIMV, such as helmet systems that tolerate high levels of positive end-expiratory pressure, have not been evaluated; (3) the majority of these patients were diagnosed with community-acquired pneumonia; therefore, the results could not be extrapolated to hypoxemic respiratory failure of another etiology; (4) the effect of the learning curve could influence the results because our results were obtained in two ICUs with staff having extensive NIMV experience and familiarity with the use of the AVAPS ventilatory strategy, which should be considered when generalizing the results to other centers with less experience.Nevertheless, we believe that this study provides important data, as this is the first study to evaluate these two ventilatory modes of BiPAP·S/T-AVAPS vs. BiPAP·S/T alone in patients with “de novo” hypoxemic respiratory failure. However, a large-scale randomized controlled study is necessary to assess and compare this approach with other strategies such as continuous high-flow nasal oxygen therapy .The results of this study suggest that BiPAP·S/T-AVAPS can be used in patients with ARF. Patients with hypercapnic ARF had a greater positive response to a ventilation strategy with BiPAP·S/T-AVAPS than those with de novo hypoxemic ARF. BiPAP·S/T-AVAPS mode ventilators were not superior to the conventional NIMV mode BiPAP·S/T. A high percentage of mortality was observed in patients with failure of NIMV in both modes, especially “de novo” respiratory hypoxemic failure.


An accurate prediction of the hepatotoxicity associated with low-dose methotrexate can provide evidence for a reasonable treatment choice. This study aimed to develop a machine learning-based prediction model to predict hepatotoxicity associated with low-dose methotrexate and explore the associated risk factors. Eligible patients with immune system disorders, who received low-dose methotrexate at West China Hospital between 1 January 2018, and 31 December 2019, were enrolled. A retrospective review of the included patients was conducted. Risk factors were selected from multiple patient characteristics, including demographics, admissions, and treatments. Eight algorithms, including eXtreme Gradient Boosting (XGBoost), AdaBoost, CatBoost, Gradient Boosting Decision Tree (GBDT), Light Gradient Boosting Machine (LightGBM), Tree-based Pipeline Optimization Tool (TPOT), Random Forest (RF), and Artificial Neural Network (ANN), were used to establish the prediction model. A total of 782 patients were included, and hepatotoxicity was detected in 35.68% (279/782) of the patients. The Random Forest model with the best predictive capacity was chosen to establish the prediction model . Among the 15 risk factors, the highest score was a body mass index of 0.237, followed by age (0.198), the number of drugs (0.151), and the number of comorbidities (0.144). These factors demonstrated their importance in predicting hepatotoxicity associated with low-dose methotrexate. Using machine learning, this novel study established a predictive model for low-dose methotrexate-related hepatotoxicity. The model can improve medication safety in patients taking methotrexate in clinical practice. Methotrexate (MTX), a folic acid antagonist that inhibits dihydrofolate reductase in the S-phase cell cycle, was first developed as an anticancer treatment in the 1940s . Since tDue to lower doses of MTX, life-threatening adverse drug effects (ADE) are rarely observed in MTX treatment for immune system diseases. However, severe ADEs can still occur, especially hepatotoxicity . AbnormaMachine learning is one of the fastest-growing technical fields  and has This retrospective study was conducted at the West China Hospital of Sichuan University, a large tertiary teaching hospital in China. This hospital uses an electronic medical record (EMR) and bar code systems to document medication administrations. The study inclusion criteria were (1) patients with immune system diseases and (2) treated with low-dose MTX (≤30 mg per week)  during hA two-stage review process for medical records was conducted to identify the presence of hepatotoxicity. In the first stage, two trained clinical pharmacists (Hu and Wang) independently reviewed each medical record for the presence of hepatotoxicity. The following sections of the charts were reviewed: basic patient information, diagnostic and progress notes, medication charts, laboratory data, surgical records, nursing flow sheets, and admission and discharge documents. In the second stage, a physician reviewed all medical records identified in the first stage to determine the presence of hepatotoxicity. Disagreements were resolved through a team discussion. Because the clinical interventions usually preceded patients reaching clinical diagnostic criteria of drug-induced liver injury , hepatotBased on data from included patients’ records, risk factors were screened from multiple patient characteristics to establish a prediction model. Specifically, the following variables were documented: age, gender, height, weight, alcohol use, history of liver diseases , admission, discharge, blood lipid level, antibiotics, other immunosuppressive agents, and Chinese patent medicines. The scores of all risk factors were calculated using the machine learning method and represented by a ranking figure. The factor with a higher score had a more significant impact on the occurrence of hepatotoxicity. Factors with a score of zero were removed because they did not affect the prediction. A Shapley Additive Explanations (SHAP) figure demonstrated the positive or negative correlations between risk factors and hepatotoxicity. Risk factors with a large sample size would affect their impact on the SHAP figure. The SHAP figure was developed by using Python software Missing data were imputed using the missForest method, and variables with more than 30% missing data were discarded . Patient2 test for categorical variables. By convention, p values of less than 0.05 were considered statistically significant. These analyses were performed using the SPSS 25.0 software .Categorical variables were summarized using frequency counts and percentages, and continuous variables were presented as means with standard deviations (SD) or medians with ranges. Comparisons between the training set and the testing set were made using the nonparametric Mann–Whitney U test for continuous variables and the χ2 (range from 13.27 to 41.14 kg/m2). A total of 279 (35.68%) patients experienced hepatotoxicity. Among these variables analyzed, BMI had 53 missing data points (6.78%) imputed using the missForest method. There was no significant difference between the processed data and the original data. The enrolled patients were divided into training and testing sets in a ratio of 8:2, with 625 and 157 patients, respectively. There were no significant differences in any variables between the training and testing sets (p > 0.05)  .The visual comparisons of the eight models in the total population are shown in versus 0.97). After general consideration of the prediction performance, Random Forest was selected to predict the hepatotoxicity associated with low-dose MTX.Adaboost and Random Forest had the highest accuracy (64.33%). Adaboost had the highest precision value (51.35%), followed by GBDT (50.94%). GBDT had the highest sensitivity value (41.07%), followed by Adaboost (33.93%) and XGboost (33.93%). GBDT had the highest specificity value (30.69%), followed by XGboost (24.75%). GBDT had the highest recall value (41.07%), followed by Adboost (33.93%) and XGboost (33.93%). GBDT had the highest F1 value (41.82%), followed by Adaboost (40.86%). These results showed that Adaboost had slight advantages in precision and accuracy with good recall, sensitivity, and F1 values. Adaboost had a significantly lower AUC than Random Forest  knowledge about specific risk factors is still lacking in this study. Although factors such as taking MTX for the first time, other immunosuppressive agents, age, and Chinese patent medicines affected the occurrence of hepatotoxicity, the direction of influence of these factors was unclear. These factors could be influenced by other factors, such as drug regimens (the number of drugs and drug interactions), gender, and BMI; (2) the sample size was small. Future studies should include more patient data from different health care centers; (3) long-term studies are required to verify the association of these risk factors with liver fibrosis or cirrhosis.Machine learning can be applied to establish the prediction model for low-dose hepatotoxicity associated with MTX. The model can help to improve medication safety in patients taking methotrexate in clinical practice. However, due to the above limitations, further studies are required to test our findings.


Hippocampus-related cognitive deficits in working and verbal memory are frequent in schizophrenia, and hippocampal volume loss, particularly in the cornu ammonis (CA) subregions, was shown by magnetic resonance imaging studies. However, the underlying cellular alterations remain elusive. By using unbiased design-based stereology, we reported a reduction in oligodendrocyte number in CA4 in schizophrenia and of granular neurons in the dentate gyrus (DG). Here, we aimed to replicate these findings in an independent sample. We used a stereological approach to investigate the numbers and densities of neurons, oligodendrocytes, and astrocytes in CA4 and of granular neurons in the DG of left and right hemispheres in 11 brains from men with schizophrenia and 11 brains from age- and sex-matched healthy controls. In schizophrenia, a decreased number and density of oligodendrocytes was detected in the left and right CA4, whereas mean volumes of CA4 and the DG and the numbers and density of neurons, astrocytes, and granular neurons were not different in patients and controls, even after adjustment of variables because of positive correlations with postmortem interval and age. Our results replicate the previously described decrease in oligodendrocytes bilaterally in CA4 in schizophrenia and point to a deficit in oligodendrocyte maturation or a loss of mature oligodendrocytes. These changes result in impaired myelination and neuronal decoupling, both of which are linked to altered functional connectivity and subsequent cognitive dysfunction in schizophrenia. Abnormalities in the cortical cytoarchitecture in dementia praecox, later termed schizophrenia, were first reported by Alzheimer who described “damage to or destruction of the nervous cortical elements” . HoweverThe hippocampus plays a role in working memory and visual and verbal learning, and deficits in these cognitive domains, along with reduced volumes and altered connectivity, have consistently been described in clinical and MRI studies in patients with first- and multi-episode schizophrenia ,7,8,9. PEarlier studies focusing on the hippocampus in schizophrenia described smaller volumes and fewer pyramidal neurons in the CA but did not find changes in granular neurons in the DG ,11. A reThe present postmortem study used rigorous, design-based stereology to assess neuron, oligodendrocyte, and astrocyte numbers and density in the right and left CA4 and DG of the brains of patients with schizophrenia and matched controls. In addition, it measured the volumes of CA4 and the granular cell layer of the DG in these regions of interest .The investigated brains were the same as those analyzed in previous stereology studies by our group ,18,19,20The brain autopsy tissue evaluated in this study was provided by the Heinsen Collection . The study was approved by the ethics committee of the University of Wuerzburg. Brains from 11 men with schizophrenia  and 11 age-matched male controls  that included the whole hippocampus were available for analysis .Patients fulfilled the diagnostic criteria for schizophrenia in the Diagnostic Statistical Manual, 4th revision (DSM-IV), and International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) and had been treated in German clinical facilities . All of them had been treated with antipsychotics during most of their illness and medical records were available for all cases, but the last medication doses and lifetime medication exposures were not available. Two experienced psychiatrists assessed the reports to ensure the absence of psychiatric diagnoses in the controls and to verify that the diagnoses of schizophrenia complied with DSM-IV and ICD-10 criteria. In addition, they reviewed the autopsy records, including a brief medical history. The ethnic background of patients with schizophrenia and controls was white European, but the groups were not matched with respect to socioeconomic status or education because the patients had lower education status. In both groups, exclusion criteria included neurological diseases requiring treatment or that may have influenced cognitive tests ; history of recurrent seizures lifetime severe craniocerebral trauma with loss of consciousness; history of alcohol or substance abuse disorders; and type 2 diabetes with a free plasma glucose level greater than 200 mg/dL . HoweverAll tissues were fixed and processed in the same way at the Morphological Brain Research Unit ; all brains were embedded in gelation except C7, for which celloidin was used. For detailed information, see Kreczmanski et al. , who invThe whole hippocampus was analyzed, with a focus on the CA4 and the DG . We did Typical findings in neurons were a large cytoplasm, a less distinct nuclear membrane, a pale nucleus in a clearly visible nucleolus, and a more uniform distribution of nuclear chromatin material. Mature oligodendroglia showed no staining in the cytoplasm, no nucleolus, and pronounced nuclear staining with scattered chromatin. We also included immature oligodendrocytes, which are larger and paler than mature ones . Astrocy®, Carl Zeiss Microscopy GmbH, Jena, Germany); Zeiss objectives ; oil; a stage controller; software ; and a 27.2-in monitor. The CA4 and DG hippocampal subregions , with diagnosis as the between-subject factor, hemisphere as the within-subject factor, and age and PMI as covariates.p value of less than 0.005 or less than 0.025 for post hoc analyses  was considered to indicate a statistically significant difference (after Bonferroni correction for 10 variables). SPSS version 28  was used for statistical analyses.Because of differences in the distribution of fixation time and subsequent deviation from the normal distribution, non-parametric Spearman correlations were calculated for the influence variables fixation time, PMI, and age. The fixation time had no significant effect on the investigated variables, so it was not used in the MANCOVA. In case of significant results in the MANCOVA, post hoc tests were performed as univariate analyses of covariance separately for the left and right sides. A p = 0.002; p = 0.40). Because of significant correlations (see below), results were adjusted by the covariates age and PMI. The post hoc univariate analyses of covariance performed for each hemisphere separately confirmed that, compared with controls, schizophrenia patients had significantly fewer oligodendrocytes in CA4 in both the left  = 11.47, p = 0.003) and the right hippocampus  = 11.09, p = 0.004).The mean total number of oligodendrocytes  in CA4 was significantly lower in patients than in controls  = 13.36, p < 0.001; p = 0.35). The post hoc analyses performed for each hemisphere separately confirmed a significantly lower oligodendrocyte density in the left  = 8.69, p = 0.009) and right hemisphere  = 16.24, p = 0.001). We did not find differences in oligodendrocyte number or density between suicide victims and patients with a non-suicidal cause of death. The mean volumes of the subregions . In patients, age had a significant effect on mean astrocyte number in the left CA4 , mean oligodendrocyte number in the right CA4 , and mean oligodendrocyte density in the right CA4 . Therefore, the MANCOVA results were adjusted for age and PMI. No correlations with the duration of fixation were detected. The results from brain C7 (which was embedded in celloidin) did not systematically deviate from those in the other gelatin-embedded brains.In controls, the left DG volume and PMI were significantly correlated  or 2 (Olig2) between patients with schizophrenia and controls in the subregions of the posterior hippocampus . HoweverOligodendrocytes play a role in the myelination of neurons and neuronal network connectivity . In addiOur study did apply morphological criteria, so we were not able to analyze pyramidal neurons and interneurons separately . A sterer = 0.552, p = 0.098; unpublished results).We identified cell types by histology, but we did not confirm results by immunohistochemical staining of oligodendrocytes. The latter is not possible on thick sections of the human brain as used in the present study, as antibodies usually do not penetrate through thick tissue sections . MeasureIt should be noted that the present sample was small because of the limited availability of serially prepared postmortem brain sections from patients with schizophrenia and low autopsy rates. However, the study was independent and replicated previous findings. In addition, all patients were treated with antipsychotics, so the effects of these drugs cannot be ruled out. However, a stereological study that examined the parietal cortex of monkeys after haloperidol or olanzapine treatment showed no significant reduction of oligodendrocytes immunostained with CNPase . In the In summary, we replicated previous findings of lower numbers and density of oligodendrocytes in CA4 in men with schizophrenia. In contrast, we did not find reduced volumes or numbers of neurons in the CA4 and DG subregions. These results may be related to the effects of sex and the small sample size. A decreased oligodendrocyte number indicates a deficit in the differentiation of oligodendrocyte precursor cells, which warrants more detailed evaluation in immunohistochemical postmortem studies of the CA4 with markers of oligodendrocyte precursors at the early myelination stage . Such st


To explore the effect of Yiqi Huayu Pinggan Zishen recipe combined with valsartan in the treatment of hypertension and its effect on MMP-9, Ang II, and MCP-1.  About 100 patients with hypertension treated in our hospital from March 2020 to April 2021 were enrolled. All patients were arbitrarily assigned to the control group and the study group. The former group was cured with valsartan, and the latter group was cured with Yiqi Huayu Pinggan Zishen recipe combined with valsartan. The curative effect, blood pressure level, renal function index, serum matrix metalloproteinase-9 (MMP-9), monocyte chemoattractant protein-1 (MCP-1), angiotensin II (Ang II) level, traditional Chinese medicine (TCM) syndrome score, and the incidence of adverse reactions were compared. P < 0.05). Secondly, we compared the blood pressure level. Before treatment, there was no remarkable difference (P > 0.05). After treatment, the blood pressure of the two groups decreased. The systolic blood pressure and diastolic blood pressure of the study group were lower (P < 0.05). In terms of renal function indexes, the levels of blood urine nitrogen (BUN), Cr, and β 2-MG in the study group were lower, while the level of eGFR in the study group was higher (P < 0.05). The serum levels of MMP-9, MCP-1, and Ang II decreased. Of note, the levels of serum MMP-9, MCP-1, and Ang II in the study group were lower (P < 0.05). After treatment, the TCM syndrome scores decreased, and the study group was lower (P < 0.05). Finally, we compared the incidence of adverse reactions. The incidence of adverse reactions in the study group was lower (P < 0.05).  First of all, we compared the curative effects; the study group exhibited remarkably effective in 44 cases and effective in 6 cases, and the effective rate was 100.00%, while in the control group, 24 cases were markedly effective, 16 cases were effective, and 5 cases were ineffective; the effective rate was 90.00%. The curative effect in the study group was higher ( Yiqi Huayu Pinggan Zishen recipe combined with valsartan in the treatment of hypertension can remarkably reduce the clinical symptoms, enhance the renal function, strengthen the therapeutic effect, promote the ability of independent movement, and reduce the levels of serum MMP-9, MCP-1, and Ang II with high safety, which has the value of clinical application. In recent years, with the development of China's social economy, the change in people's lifestyle and diet structure, the rapid acceleration of the pace of life, the increasing social pressure, and the incidence of hypertension are also increasing . NowadayLong-term maintenance of blood pressure above the normal level will cause many serious adverse effects on the human body, affecting its normal physiological function and leading to life-threatening cardio-cerebrovascular accidents . RelatedA total of 100 patients with hypertension treated from March 2020 to April 2021 were enrolled in our hospital. All patients were arbitrarily assigned into the control group and the study group. The former group was cured with valsartan, and the latter group was cured with Yiqi Huayu Pinggan Zishen recipe combined with valsartan. In the control group, the age was 35-83 years, with an average of 60.43 ± 3.65 years, containing 27 males and 23 females, while in the study group, the age was 34-85 years, with an average of 60.44 ± 3.45 years, containing 25 males and 25 females. There exhibited no statistical significance in the general data. This research was permitted by the Medical Ethics Association of our hospital, and patients noticed informed consent.Diagnostic criteria: according to the 2018 revision of Chinese guidelines for the prevention and treatment of hypertension, hypertension was diagnosed after the clinic blood pressure, systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg, was analyzed three times in different days without antihypertensive drugs. With reference to the reference standard of TCM deficiency syndrome differentiation in 1986 and the guiding principles for Clinical Research of New Drugs of TCM, the TCM diagnosis and treatment program for hypertension designated by the State Administration of TCM was adopted as the basis and standard for syndrome differentiation.Selection criteria: (1) patients who meet the clinical diagnostic criteria of hypertension, (2) clear consciousness and good compliance, and (3) family members know this study and sign informed consent.Exclusion criteria: (1) malignant, secondary, or rapidly progressive hypertension; (2) severe dysfunction of organs such as the liver, heart, and kidney; (3) heart valvular disease, cardiomyopathy, coronary heart disease (CHD), diabetes, chronic obstructive pulmonary disease, and severe cerebrovascular disease; (4) immune system diseases, blood system diseases, and blood coagulation disorders; and (5) allergic to research and application of drugs.The exclusion criteria with any of the following four items shall be excluded: (1) after the case is included, it is found that it does not meet the inclusion criteria (such as misdiagnosis and misacceptance); (2) poor compliance ; (3) if there are serious side effects or intolerance to the tested drugs and serious complications and the continuation of the trial may cause harm and danger to the subjects, it is not suitable to continue to complete the trial; and (4) those affected by the evaluation of the efficacy and safety of drugs caused by various reasons, such as participating in other drug trials during this study.The following are the three shedding criteria; that is, it is shedding: (1) those who have not completed the test, (2) those who automatically quit because they think they cannot tolerate the adverse reactions or are not satisfied with the treatment effect, and (3) those who withdraw automatically due to other reasons. For the shedding cases, the causes of shedding and the treatment evaluation at the time of shedding should be truthfully recorded.The control group was treated with valsartan and took oral valsartan 80~160 mg/time in the morning on the basis of taking amlodipine besylate, 1 time/day.The study group received Yiqi Huayu Pinggan Zishen recipe combined with valsartan, and on the basis of the control group, they took the self-made TCM prescription-Yiqi Huayu recipe, Pinggan Zishen recipe; the specific composition is as follows: Radix Astragali 45 g, Codonopsis pilosula 18 g, Salvia miltiorrhiza 30 g, Angelica 30 g, Radix Paeoniae Rubra 20 g, Cortex moutan 10 g, Ligusticum chuanxiong 10 g, Leonurus 10 g, Bupleurum 20 g, papaya 10 g, Gastrodia elata 10 g, Uncaria 10 g, Chrysanthemum 10 g, Prunus vulgaris 10 g, Stone Cassia 10 g, mother of pearl 10 g, Herba Epimedii 15 g, Cornus officinalis 15 g, Fructus psoraleae 15 g, and Achyranthes bidentata 15 g. The TCM was decocted in warm water, and the decoction 100 mL was taken twice a day. The course of treatment in both groups was one month.With reference to the guiding principles for Clinical Research of New Drugs of TCM , the details of the standards are as follows: (1) one of the following conditions shall be satisfied and judged to be effective: (a) diastolic blood pressure decreased above 10 mmHg to normal range and (b) diastolic blood pressure did not fall to normal, but the decrease was more than 20 mmHg; (2) it is determined to be valid if one of the following conditions is satisfied: (a) the decrease of diastolic blood pressure is less than 10 mmHg, but it has dropped to the normal range; (b) 10 ≤ diastolic blood pressure drop < 19 mmHg, but not to normal range; and (c) systolic blood pressure drops to 20 mmHg; and (3) those who do not meet the criteria (1) and (2) are determined to be invalid. Effective rate = markedly effective rate + effective rate.Before the measurement, the subjects had a quiet rest for at least 5 minutes, took the sitting position, and measured the blood pressure of the right brachial artery, which should be analyzed 3 times at intervals of 1-2 minutes, and the average value was recorded. For specific measurement standards and details, refer to the 2018 revised Chinese guidelines for the prevention and treatment of hypertension. Results before and after treatment and each follow-up and before and after treatment and between groups were compared. For the blood pressure level, 24-hour ambulatory blood pressure monitoring was performed in both groups before and after treatment, and the average systolic blood pressure (SBP) and diastolic blood pressure (DBP) during daytime and nighttime were measured, respectively.β 2-MG, eGFR, serum MMP-9, Ang II, and MCP-1 were examined by the hydrolytic enzyme method, and BUN and eGFR were measured by the urease-Boolean colorimetric method.Fasting venous blood specimens were harvested from all patients within 24 hours after admission and before and after treatment to detect the indexes of renal function and serum MMP-9, Ang II, and MCP-1 before and after treatment. For the renal function index, serum BUN, Cr, urine According to the guiding principles of Clinical Research of New Drugs of TCM, the symptom quantitative grading and scoring standard was drawn up, the TCM syndrome score table was established, and the TCM syndrome scores before and after treatment were recorded.The incidence of adverse reactions was calculated.χ2 test. The T-test is employed for measurement data in accordance with normal distribution; otherwise, the rank sum test is employed. When P < 0.05, the difference exhibited statistically remarkable. P less than 0.01 is viewed as highly statistically significant.The software SPSS21.0 is employed to analyze the research data. The rank sum test is employed for rank data. The counting data were tested by the P < 0.05). All the data results are indicated in First of all, we compared the curative effects: the study group was remarkably effective in 44 cases and effective in 6 cases, and the effective rate was 100.00%; in the control group, 24 cases were markedly effective, 16 cases were effective, and 5 cases were ineffective, and the effective rate was 90.00%. The curative effect of the study group was higher (P > 0.05). After treatment, the blood pressure decreased; the systolic blood pressure and diastolic blood pressure of the study group were lower (P < 0.01). All the data results are indicated in Secondly, we compared the blood pressure level. Before treatment, there exhibited no remarkable difference . All the data results are indicated in Tables Thirdly, we compared the renal function indexes. The levels of BUN, Cr, and P > 0.05). After that, the serum levels of MMP-9, MCP-1, and Ang II decreased, and the levels of serum MMP-9, MCP-1, and Ang II in the study group were lower (P < 0.01). All the data results are indicated in Then, we compared the levels of serum MMP-9, MCP-1, and Ang II; before treatment, there exhibited no remarkable difference (P > 0.05). After treatment, the TCM syndrome scores decreased, and the data indicated that the score of the study group was lower (P < 0.05). All the data results are indicated in Next, we compared the TCM syndrome scores before and after treatment, and there exhibited no remarkable difference before treatment (P < 0.05). All the data results are indicated in Finally, we compared the incidence of adverse reactions. There were 1 case of headache and 1 case of stomach discomfort in the study group, with a total incidence of 4.00%, while in the control group, there were 2 cases of headache, 3 cases of stomach discomfort, and 1 case of skin reaction, with a total incidence of 12.00%. The incidence of adverse reactions in the study group was lower , nonselective (β 1 and β 2), and α-receptor blockers, commonly used are metoprolol, atenolol, bisoprolol, carvilol, labetalol, etc.; (4) calcium channel blockers, also known as calcium antagonists, which can be assigned into dihydropyridine and nondihydropyridine; the former includes nifedipine and amlodipine; the latter includes verapamil and diltiazem; (5) there are three kinds of diuretics: thiazide, loop diuretic, and potassium-preserving diuretic. However, in salt-sensitive patients, nocturnal hypertension decreased after salt restriction, but the nondipper pattern increased, and the nocturnal blood pressure of nondipper patients decreased remarkably. ACEI, ARB, and other drugs are stable in reducing nocturnal blood pressure and restoring the dipper blood pressure curve [From the epidemiological study, it is found that there are different factors that promote the increase of blood pressure in patients with hypertension at night, which means most of the patients with hypertension have inducements, and when they are treated, they should generally determine the secondary factors, find out the cause of the augment in blood pressure, and then carry on the corresponding treatment according to this factor, so as to have a clear target and find the root cause of the increase in blood pressure for treatment . In our re curve . Traditire curve .2+ participation, and enzyme cleavage N-2 terminal activation [Ang II is an important component of the RAS system . Ang II tivation . The maitivation . Under ptivation . MCP-1 ctivation .In recent years, treating integrated traditional Chinese and western medicine has gradually become a trend in the treatment of hypertension . In accoConclusively, Yiqi Huayu Pinggan Zishen recipe combined with valsartan in the treatment of hypertension can remarkably relieve the clinical symptoms, strengthen renal function, enhance the therapeutic effect, facilitate the ability of independent movement, and reduce the levels of serum MMP-9, MCP-1, and Ang II and has high safety, so it has the value of clinical application.