Intravenous fluid therapy has long been the mainstay of treatment of kidney disease, including acute kidney injury and uremic crisis associated with chronic kidney disease. Careful management of fluid dose is critical, as animals with kidney disease may have marked derangements in their ability to regulate fluid homeostasis and acid-base status. Understanding of the physiology of renal fluid handling is necessary, along with repeated attention to parameters of fluid status, electrolytes, and acid-base balance, to achieve optimal hydration status and avoid further damage or decrease in function from dehydration or overhydration. Fluid therapy is the most commonly administered intravenous treatment for hospitalized veterinary patients. Adequate fluid resuscitation is essential for the restoration of cardiac output, systemic blood pressure, and renal perfusion. Achieving an appropriate level of volume management requires knowledge of underlying pathophysiology, evaluation of volume status, selection of appropriate solution for volume repletion and maintenance, and modulation of the tissue perfusion .resuscitation phase anticipates an escalation of fluid therapy in patients with life-threatening shock  and is characterized by the use of fluid bolus therapy . When transitioning to the optimization phase, the patient should no longer be in immediate life-threatening danger, but in a stage of compensatory shock and high risk for decompensation. At this point, additional fluid therapy is given more cautiously with the intent of optimizing cardiac function and improving tissue perfusion. The goal is to administer the volume necessary to alleviate organ dysfunction. Fluid challenges, defined as a small volume over short period of time (~5 ml/kg over 20 min), are typically given in this phase to test the effects of delivering more volume (resuscitation phase (with no evidence of hypotension) and present to the hospital in a compensated state. In these first two phases, compensatory neuroendocrine reflexes and possible renal dysfunction result in sodium and water retention, contributing to a positive fluid balance. Progression to the stabilization phase encompasses a point at which the patient is at steady state without signs of shock. Fluid therapy in this phase is used for ongoing maintenance losses ; as well as rehydration if the patient is experiencing ongoing losses due to unresolved pathology. Patients may experience temporary deterioration and revert back to the optimization phase if faced with a newly developed infection or organ dysfunction. Lastly, the evacuation phase is characterized by the removal of fluids and promotes a negative fluid balance  is determined by the difference in hydrostatic and oncotic pressure gradients between the glomerular plasma and the filtrate in Bowman space. Each nephron has its own single-nephron glomerular filtration rate (SNGFR), and the sum of the SNGFRs of the functioning nephrons make up the total glomerular filtration rate (GFR). Maintaining a normal GFR is dependent on adequate renal perfusion.The primary function of the kidney is to maintain a stable extracellular compartment by selective retention/elimination of water, electrolytes, and other solutes. This is achieved via filtration of the circulating blood into ultrafiltrate from the plasma, selective reabsorption from tubular fluid into peritubular capillary blood, and selective secretion from peritubular capillary blood into the tubular fluid. Glomerular filtration (Acute kidney injury (AKI) is defined as a rapid decline in GFR through the measurement of serum creatinine and urine output. There are inherent challenges with this definition as creatinine is poorly correlated with GFR at low levels of renal dysfunction . ClinicaIntrinsic renal etiologies can be challenging to evaluate due to a wide variety of injuries that can occur to the kidney. In general, renal damage can be divided into four major structural groupings: the tubules, glomeruli, interstitium, and intra-renal blood vessels. Tubular damage can arise from either ischemic injury  or nephrotoxic compounds (exogenous and endogenous). Severe acute glomerulonephritis secondary to immune-complex disease causes glomerular damage. Interstitial damage can result from acute interstitial nephritis secondary to medications or infectious etiologies . Lastly, vascular damage can occur secondary to injury to intra-renal vessels , subsequently decreasing renal perfusion and diminishing GFR . Ischemiinitiation phase occurs when renal blood flow decreases, resulting in cellular ATP depletion and subsequent tubular epithelial cell injury. These changes alter the ability of tubular epithelial cells and vascular endothelial cells to maintain normal renal function (reabsorption and secretion), as well as up-regulate a variety of chemokines and cytokines to initiate an inflammatory cascade , or later, during the proposed period of acute kidney disease (AKD), which is defined as AKI persisting for 7–90 days . Lack ofDisruption of normal renal function impairs maintenance of homeostasis. A normochloremic high anion gap metabolic acidosis is common, due to inadequate excretion of organic and inorganic acids such as phosphate and sulfate. Hyperkalemia is also common when urine production is low and distal tubular secretion of potassium is impaired. Conversely, hypokalemia may develop with polyuria, as the high urine flow through the distal tubule enhances potassium secretion by maintaining a concentration gradient between the tubular cells and the ultrafiltrate in the tubule lumen. Disorders of sodium are variable and depend on the degree of impairment of sodium reabsorption relative to water excretion. Because of impaired filtration and thus excretion of phosphate, leading to hyperphosphatemia, an ionized hypocalemia may develop acutely.The physiological rationale for fluid administration in AKI and CKD is to optimize intravascular circulating volume, increase cardiac output and perfusion pressure, with the aim of improving renal blood flow, renal oxygen supply, and GFR . HypotenFluids are differentiated into crystalloids and colloids. Disregarding the impact of fluid overload, there is growing evidence that renal function is affected by the type of fluid and certain fluids are associated with an increased risk of AKI , 26, 27.Isotonic crystalloids are the accepted first-line IV fluid in most ICU patients. There is ongoing research as to which isotonic crystalloid, 0.9% NaCl vs. a buffered crystalloid , is appropriate in people at risk for AKI. The impact of chloride concentration on renal function has been researched in a Greyhound model, showing that increasing plasma chloride levels produce progressive renal vasoconstriction and decreased GFR. These effects appeared to be related to tubular chloride reabsorption . Both anClinical trials comparing various crystalloid fluids in critically ill people at risk of AKI have produced conflicting results , 10, 30.stabilization phase. At this stage, the authors preferentially use hypotonic solutions to reduce sodium load in animals with renal dysfunction. Monitoring the animal's electrolytes and acid-base status frequently is essential for prescribing the appropriate fluid during the resuscitation and early stabilization phase.Maintenance solutions  are administered to meet the patient's basal requirements of water and electrolytes. Specific maintenance solutions are commercially available but are far from ideal. Studies in people have shown over the course of an ICU admission, a substantial amount of daily fluid volume is delivered with maintenance/replacement fluids, medications, and nutrition compared to resuscitation fluids . GeneralIn human medicine, the administration of synthetic colloids has been linked with the development of acute kidney injury (AKI) and the need for renal replacement therapy (RRT) in ICU patients, especially those with sepsis , 36. FinAlbumin is a natural colloid, specifically studied in resuscitation, that has not been shown to have consistent survival benefit. Although, albumin is considered safe in people at risk or with established AKI, studies are needed to assess potential benefits , 26, 42.There are few evidence-based studies evaluating the dose response of intravenous fluids in animals with kidney dysfunction. Standard formulas for what is commonly called a maintenance intravenous fluid rate make two presumptions, namely that animals have similar evaporative losses and that urine output is “average” (1–2 mL/kg/h). In patients with renal dysfunction, standard maintenance formulas do not apply and fluid requirements must be assessed on an individual basis. Evaporative losses in dogs and cats are predominantly through the respiratory tract, as perspiration is generally negligible, and salivary and fecal losses are generally not accounted for when determining fluid balance. Respiratory losses can be quite dissimilar and are impacted by environmental temperature and humidity, and by patient activity level. In one study of healthy dogs, evaporative losses varied from 8.1 to 75.7 ml/kg/day, with a mean of 27 mL/kg/day –46. BarkWestgren et al. evaluated 11 dogs with suspected kidney disease using scintigraphy to measure GFR before and after a 15 ml/kg intravenous bolus of crystalloid fluid . The GFRIn one study of systemically healthy dogs undergoing an orthopedic surgery and receiving standard intraoperative fluid rates (10 ml/kg/h of lactated Ringers solution), the median urine output was 0.46 mL/kg/h . GFR wasBrandstrup et al. compared goal directed therapy to a zero-balance approach in humans undergoing colorectal surgery . In the Fluid overload is a commonly mentioned negative side effect of intravenous fluid therapy, especially in patients with initial renal dysfunction. It is well-documented in humans, and sparse evidence in veterinary medicine indicates that fluid overload contributes to progression of kidney dysfunction and increase in mortality –58. In aThe use of diuretics to increase urine output does not improve renal function. If renal replacement therapy is not available, diuretics may help control hyperkalemia by increasing distal tubular flow and allow more liberal administration of nutrition and medications with less risk of volume overload. Despite the widespread use of diuretics in human medicine, there are few guidelines pertaining to the dose and interval of administering furosemide. A recent meta-analysis in humans showed continuous furosemide was associated with greater diuretic effect in total urine output as compared to bolus dosing, although neither had any difference in mortality . The autManagement of dogs and cats with AKI involves treating the underlying cause and providing time for the kidneys to repair themselves. Appropriate fluid therapy is paramount in the medical management of AKI, aiming to restore hydration and euvolemia. The preconceived notion to increase the fluid rate and force diuresis in animals with AKI must be absolutely avoided. This is especially true in animals with established oliguria or a relative oliguria, in which they are unable to appropriately respond by increasing urine production, thus developing generalized edema that directly exacerbates further organ dysfunction. If the animal is not able to remove the excess fluid due to lack of kidney function, renal replacement therapy is indicated to help facilitate fluid removal and achieve appropriate fluid balance. It is only once the animal has established a consistent urine output and advanced to the polyuric phase, that it becomes reasonable to increase the fluid rate to match urine output. Emphasis is placed on the importance of frequent patient assessments  to determine the fluid needs of these patients.Fluids should be gradually tapered when hydration and urine production are restored, fluid “in” and urine “out” are matched, and the serum creatinine has plateaued . The authors recommend decreasing the fluid rate by 15–20% every 8 h, with the goal of discontinuing intravenous fluids in a 48 h period. It is not uncommon for animals with AKI to require a feeding tube (esophagostomy or gastrostomy) to not only administer proper nutrition and meet the demands of the hypercatabolic state, but also supplement enteral fluids in a markedly polyuric animal. The feeding tube allows the owner to play an integral role in the recovery phase of AKI as well as reduce the time and cost associated with hospitalization. A less physiologic option for maintaining hydration in an animal with AKI is the use of subcutaneous fluids. Subcutaneous fluids involve administration of large quantities of “salt water” , making this option less than ideal for animals with intrinsic renal dysfunction.Consideration for fluid type  along with reduction in cumulative sodium load is more physiologic for dysfunctional kidneys. Additional studies are needed to characterize the urine chemistry of dogs and cats that present with AKI . We haveUnfortunately, accurate assessment of animal weight, which is used as a surrogate for fluid status, is challenging, as the body converts to a hypercatabolic state in established AKI and loss of muscle mass. Luckily, providing nutrition and water through an established feeding tube  is an ideal way to help manage the catabolism of muscle and daily fluid requirement. Ultimately, the best fluid therapy is one that maintains euvolemia, with the goal of delivering fluid in the most physiologic manner (via the GI tract).CL and DG contributed to write the manuscript. All authors contributed to the article and approved the submitted version.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. The reviewer DC declared a shared affiliation with the authors to the handling editor at time of review.


The program lasted 6 weeks, and data were collected at baseline, immediately after the intervention, and 4 months post-intervention. There was a significant interaction between group and time for salivary flow rate, fluid control, IDWG, and DQOL . Compared with the control group, the experimental group had a significantly improved salivary flow rate, fluid control, IDWG, and DQOL at weeks 6 and 22, whereas the comparison group had improved fluid control and DQOL at week 6. The combination of AA and a fluid-restriction adherence program could be provided to hemodialysis patients as cost-effective, safe, and complementary interventions to promote sustainable patient adherence to fluid-restriction.Adherence to fluid-restriction is a clinical priority in nephrology care. This study examines the effects of a combination of auricular acupressure (AA) and a fluid-restriction adherence program on the salivary flow rate, xerostomia, fluid control, interdialytic weight gain (IDWG), and diet-related quality of life (DQOL) among hemodialysis patients in South Korea. Using a quasi-experimental design, 84 hemodialysis patients were assigned to the experimental group (AA + fluid-restriction adherence program;  The adherence to fluid-restriction is a clinical priority in nephrology care . Among tLimiting fluid consumption is a complex part of treating end-stage renal disease (ESRD) as there are various factors that influence patients’ acceptance of this requirement . FactorsEmpowerment models identifying factors related to decision-making for behavior change and have been used to facilitate self-management . The comXerostomia caused by reduced salivary production is a major obstacle to the adherence to fluid-restriction of HD patients ,11. WhilHowever, most of the existing studies for fluid management programs in HD patients have not reflected the complex nature of fluid-restriction, as they provided only educational or cognitive interventions, fluid intake monitoring, skill training, and diet counseling ,17,18,19The intervention program was developed based on the empowerment model . EmpowerA quasi-experimental pretest–posttest design was used. Measurements were taken at baseline, immediately after the 6-week intervention, and 4 months post-intervention.Participants of the study were hemodialysis patients, recruited from three HD centers  of three university hospitals based in Seoul, South Korea. We used a convenience sampling method for the HD centers and participants. The centers were similar in size, operation status, staff composition, and number of patients. To prevent between-participant interaction, the patients in center A were allocated to the experimental group (combined AA and fluid-restriction adherence program), those in center B to the control group , and those in center C to the comparison group (fluid-restriction adherence program). Inclusion criteria were as follows: patients aged ≥20 years, requiring HD three times a week for ≥6 months, and available for saliva measurement. Exclusion criteria were as follows: having a history of acute cardiovascular disease, Sjögren’s syndrome, ear infection, allergy to seeds of semen vaccaria or use of drugs that may induce xerostomia . The sample size was determined using G*Power program Ver.3.1.The calculation was set for repeated measures analysis of variance with an effect size of 0.16, a significance level of 0.05, a power of 0.80, three groups, and three repetitions. We set the effect size with reference to a previous study that examined the effectiveness of acupressure on saliva flow rate and xerostomia in HD patients [This study was approved by the institutional review board at K University Hospital (KHNMC-07-025-001). All participants joined the study after providing written consent and were given the freedom to withdraw from the study at any time.This 6-week intervention program included a fluid-restriction adherence program and AA. The experimental and comparison groups attended the 60-min fluid-adherence program once a week for 6 weeks. The experimental group received additional AA at three auricular acupoints for 6 weeks. This was developed with reference to the recommendations of the National Kidney Foundation for HD patients to improve fluid-restriction adherence . The flu(1)Individual counseling: Each participant underwent face-to-face counseling with the RN for about 10 min before each group session. In an attempt to facilitate fluid-tracking and provide personalized fluid goals, participants submitted their diet and fluid intake logs and reviewed the records with the RN. They were encouraged to set their fluid intake goals for the following week. Participants were provided with a printout of the contracts and were encouraged to post the printout on an easily noticeable spot at home.(2)Group education: A 20-min group lesson regarding the dietary sources of fluid, salt restriction strategies, ways to alleviate dry mouth without increasing fluid intake, self-monitoring of the amount of urine output and fluid intake, and problem-solving skills for situations leading to non-adherence was provided by the RN. Participants received fluid-restriction adherence booklets and a one-page summary of the information learned every week; they were encouraged to post these summaries next to their fluid intake contracts to remind themselves of ways to limit their fluid intake.(3)Group discussion: Participants were divided into small groups of 5–8 people. The RNs served as facilitators to encourage patients to actively participate in the group discussion for 30 min. By discussing difficulties associated with fluid-restriction and experiences of successful adherence with their peers, the participants could improve their confidence and social support to continue their fluid-restriction.The protocol for AA was based on previous literature ,20. The The control group received the usual renal care. They were also provided a fluid-restriction adherence booklet and a diary to record their fluid intake at home.The unstimulated whole saliva flow rate was measured. Saliva was collected using a cotton roll kept in the mouth for 5 min. Saliva samples were collected during HD at least 1 h after eating, smoking, or drinking. An electronic scale  with 0.0001 g precision was used. The cotton weight was subtracted from the measurement, and the saliva weight was converted to the amount of secretion per minute (mL/min).A visual analog scale from 0 (none) to 10 (severe) was used to measure xerostomia.IDWG refers to the difference (kg) between the pre- and post-dialysis body weight. The pre-dialysis body weight was measured within 30 min of beginning dialysis, using an electronic scale , and the post-dialysis body weight was measured within 30 min of the completion of dialysis, using the same scale. The weekly average IDWG value was considered.The 24-item Fluid Control in Hemodialysis Patient Scale by Cosar and Pakyuz  was usedThe 25-item Korean version of the Quality of Life Related to Dietary Change Questionnaire, an adapted version of the original tool developed by Delahanty, Hayden, Ammerman, and Nathan , was useData were analyzed using IBM SPSS Statistics for Windows . Homogeneity among the three groups was analyzed using chi-square tests, Fisher’s exact tests, and one-way analyses of variance. Considering the correlated structure of data from repeated measures at baseline and at 6- and 22-weeks, a generalized estimating equation (GEE) was used for analysis. Changes across time points for each group were analyzed using the Friedman test.Of the 84 participants, one participant in the comparison group died during the study period and did not complete the post-program survey. Participants’ mean age was 64.2 ± 13.5 years, and 54.8% were men. The rest of demographic and baseline data are shown in p = 0.009), the comparison and control groups did not show significant changes in the salivary flow rate across the study period ; however, there were no significant differences in the comparison group at any of the follow-up assessments ; however, there were no significant changes in the fluid control score in the control group across the study period . However, the comparison group had a significantly higher fluid control than the control group at week 6 . However, the control group showed a significant increase in IDWG . No significant differences in IDWG between the comparison and control group were found at any of the follow-up assessments . However, the control group showed a significant decline in the DQOL over time ; however, the comparison group only had a higher DQOL score than the control group at week 6 (p = 0.028; The experimental group showed a significant increase in DQOL across the three time points (This study demonstrated that a combined use of AA and a fluid-restriction adherence program significantly improved salivary flow rate, fluid control, IDWG, and DQOL of HD patients. Given that a leading cause of mortality and morbidity among this population is related to fluid overload, the improvement and maintenance of fluid management is clinically meaningful.The average baseline salivary flow rate of our participants was 0.08 mL/min, which indicated hyposalivation. This result suggests that our participants may have experienced xerostomia and had difficulty chewing dry food, which led to drinking fluids to help them swallow. To avoid xerostomia symptoms, saliva needs to be secreted at a minimum rate of 0.1 mL/min . While cWe found that xerostomia was not affected by the intervention program and revealed no significant changes between the groups. This is similar to a finding that thirst and xerostomia did not change significantly after a 5-week psychological intervention , and to Compared to the comparison and control groups, the experimental group yielded benefits in the level of fluid control and IDWG. Our results align with the previous findings indicating that the combination of 6 weeks of muscle relaxation exercises and an empowerment program resulted in significant improvements in decision-making, stress reduction, positive attitudes, and IDWG in HD patients . HoweverDiet-related quality of life refers to a state of well-being influenced by diet that is assessed from social and psychological aspects , and it There were some limitations to our study. First, our conclusion is not definitive because of the small sample size. Further studies with larger samples are recommended. Second, the individuals administering the intervention were not blinded to the treatment conditions; thus, the potential for bias exists. Third, we enrolled only Koreans who had been admitted to three HD centers in one of the largest cities in Korea. Thus, the results may not be generalized to different populations.A combined use of AA and a fluid-restriction adherence program had beneficial effects on improving salivary flow rate, fluid control, IDWG, and DQOL. The significant improvements were retained at the 22-week follow-up, suggesting that adding AA to a fluid-adherence program has a stronger and longer impact on improving fluid control and quality of life compared to only providing a fluid-restriction intervention to HD patients. Therefore, health-care professionals working in HD units may adopt this program as a cost-effective, safe, and complementary tool to promote sustainable patient adherence to fluid-restriction.


Rapid detection of intrinsic vancomycin resistance and acquired resistance genes  (n=101) received standard of care (SOC) culture and antimicrobial susceptibility testing (AST). Additionally, samples were evaluated with the BCID-GP panel but only SOC results were reported in the EMR and available to inform clinical decisions. Patients were excluded if the sample was a subsequent culture in a persistent episode of bacteremia (n=17) or if the assay failed (n=4). Chart review was performed to evaluate the expected impact of the BCID-GP panel on the time to organism identification, AST results, and optimization of antimicrobial therapy. S. epidermidis was the most common bacteria identified, followed by S. aureus, and other coagulase-negative staphylococci. Thirty-nine patients with staphylococci (48.8%) had the mecA gene detected and 2 patients with E. faecium had the vanA gene detected. The BCID-GP panel saved a mean of 24.4 hours (h) to identification and 48.3h to susceptibility testing compared to standard methods across all patients. In 38 patients (47.5%), the BCID-GP panel result could have enabled an earlier change in antibiotic therapy. Table 2 highlights opportunities to optimize antimicrobial therapy 53.4h earlier for 16 (20%) patients with organisms expressing AMR genes, 29.2h earlier for 8 (10%) patients infected with organisms, such as streptococci, with very low resistance rates, and to stop antimicrobial therapy 42.9h earlier for 14 (17.5%) patients with contaminated blood cultures.A total of 80 patients were included in the final analysis (Table 1). The BCID-GP panel could have enabled earlier optimization or stopping of antibiotics in many patients with significant time savings compared to standard laboratory methods. Todd P. McCarty, MD, Cidara (Grant/Research Support)GenMark T2 Biosystems (Consultant) Sixto M. Leal, Jr., MD, PhD, Abnova (Grant/Research Support)AltImmune (Grant/Research Support)Amplyx Pharmaceuticals (Grant/Research Support)Astellas Pharmaceuticals (Grant/Research Support)CNINE Dx (Grant/Research Support)GenMark Diagnostics IHMA (Grant/Research Support)IMMY Dx (Grant/Research Support)JMI/Sentry (Grant/Research Support)mFluiDx Dx (Grant/Research Support)SpeeDx Dx (Grant/Research Support)Tetraphase Pharmaceuticals (Grant/Research Support)


Tumour associated macrophages (TAMs) and tumour infiltrating lymphocytes (TILs) are considered dominant cells in glioblastoma microenvironment.+ M2-polarized TAMs in glioblastomas and their relationship with CD4+TILs, Iba+microglia, and IDH1 mutation. We also exploreed the prognostic value of these markers on the recurrence-free interval (RFI).The purpose of this study was to assess the expression of CD204+TAMs, CD4+TILs, and Iba1+microglia were quantitively assessed in 45 glioblastomas using immunohistochemistry. Kaplan–Meier analysis and Cox hazards were used to examine the relationship between these factors.The expressions of CD204+TAMs were highly expressed in 32 tumours (71%) and the remaining 13 tumours (29%) had reduced expression. CD4+TILs were highly expressed in 10 cases (22%) and 35 cases (77.8%) had low expression. There was an inverse correlation between CD204+TAMs and CD4+TILs, in which 85% of tumours had a high expression of CD204+TAMs and a low expression of CD4+TILs. Nevertheless, there was no significant difference in IDH1 mutation status between the two groups (p = 0.779). There was a significant difference in Iba1+microglial activation between IDH1mutant and IDH1wildtype groups (p = 0.031). For cases with a high expression of CD204+TAMs and a low expression of CD4+TILs, there was a significant difference in RFI after treatment with chemoradiotherapy or radiotherapy (p = 0.030).CD204+TAMs and few CD4+TILs is associated with IDH1wildtype. These findings suggest that TAMs masks tumour cell and suppress T-cell tumoricidal functions via immunomodulatory mechanisms. Blockade of the CD204-TAM receptor may prevent this mechanism and allow the evolution of TILs.Glioblastoma with a dense CD204 Glioblastoma is the most common primary malignant tumour of the central nervous system (CNS), accounting for ~ 50% of all primary brain tumours . DespiteThe glioblastoma microenvironment exhibits a high level of intratumoural heterogeneity, which contains different types of non-neoplastic cells, including immune cells and stromal cells . Tumour M1-polarized TAMs are induced by interferon gamma to produce proinflammatory molecules including tumour necrosis factor-alpha and are associated with acute inflammatory insults; and (b) M2-polarized TAMs are induced by interleukin-4 stimulation to produce pro-angiogenic growth factors involved in chronic inflammation, tumour growth, and immunosuppression [M2-polarized TAMs expressing CD163, CD204, and CD206, correlated with a poor prognosis of multiple cancers including melanoma and cancers of the breast, bladder, ovaries, and lungs [+ or CD8+ represent 0.25% of all cells in the glioblastoma microenvironment [+T-cells showed an essential role in initiating anti-cancer immune responses, which significantly affects the function of CD8+T-cells [+T-cells are essential for killing tumour cells, their low numbers in the tumour microenvironment are insufficient to have a targeted effect on tumour proliferation and prognosis [TAMs are proangiogenic immune cells that interact with glial cells to promote tumour growth and progression . They arpression , 8, 22 lpression . Clinicand lungs . In thesnd lungs , 27, theironment . However+T-cells , 15. AltM2-polarized TAM receptor, is also known as macrophage scavenger receptor 1 (MSR1) [+ TAMs as immune checkpoint regulators to inhibit T-cells [+ TILs and PD-L1 were reported to be significantly expressed in mouse glioblastomas [CD204, the 1 (MSR1) , prefere1 (MSR1) , 23 Howe1 (MSR1) . Recentl1 (MSR1) . Althoug T-cells . When tu T-cells  and promlastomas . Howeverlastomas .M2-polarized TAMs (CD204) in the glioblastoma microenvironment and their relationship with circulating TILs, mainly CD4+TILs, as well as resident microglia. We also investigate the relationship between TAMs and TILs with isocitrate dehydrogenase-1 (IDH1) mutation. The prognostic value of these markers with previous treatment modalities was also explored and correlated with RFI.In this study, we assess the expression of 2 for 6–12 cycles, was given to all patients at the time of management. Other adjuvant therapies were added to TMZ in some cases, which included . All patients enrolled in this study have passed away.This study included 45 patients, aged between 30 and 70 years, and histologically diagnosed as classical glioblastoma -grade IV Glioma) in the period 2014–2019. This study was approved by the National Biomedical Ethics Committee at King Abdulaziz University (HA-02-J-008) under a general ethical report. All patients underwent complete surgical resection of the tumour followed by postoperative chemoradiation according to the Stupp protocol . PatientIDH1R132H immunostaining.Archival routine formalin-fixed and paraffin-embedded (FFPE) tumour tissues were collected from 45 patients diagnosed histologically with classical glioblastoma. Haematoxylin and Eosin (H&E)-stained sections were re-examined by a certified neuropathologist (MK) to confirm that the histopathological diagnosis was based on the 2016 WHO classification. Four unstained positive-charged slides from each of 45 FFPE tissue blocks were prepared for CD204, CD4, Iba1, and First, 4-μm FFPE tissue sections were used for immunohistochemistry (IHC). The IHC assay was performed for different clonal types, directed against human antibodies. The procedure was performed with the ultraView DAB detection Kit from Ventana on a BenchMark XT automated stainer . A protocol was established so that the entire assay procedure consisted of deparaffinization with EZ Prep at 75 °C, heat pre-treatment in Cell Conditioning medium (Ag unmasking) CC1; Ventana) for 60 min and then primary incubation for 16 min at 37 °C. The antibodies were optimized using different dilutions, ranging between 1:100 and 1:300 except for Iba1 was (1:2000). The slides were counterstained with haematoxylin II for 16 min and blueing reagent was used for another 16 min. Then, the slides were removed from the slide stainer and immersed into successive alcohol buffers at different concentrations for 3 min. The antibodies used in this protocol are listed in Table ; Ventana+TAMs and the total cells (stained TAMs and unstained TAMs) were counted manually, and the labelling index was assessed using the following equation:TAMs, TILs, and resident microglia were stained for anti-CD204, anti-CD4, and anti-Iba1 expressions, respectively. Each group of cells was evaluated separately. A single focal area per patient sample, rich in tumour cells and containing sufficient aggregate TAMs, TILs, or resident microglia, was quantitively analysed under light microscopy using high-power (40 ×) magnification  diffusely expressed, (ii) partially expressed, (iii) focally expressed, and (iv) not expressed. Diffuse and partial expressions were considered to indicate “high or increased expression” whereas focal expression and not expressed were considered to indicate “low or reduced expression” Fig. a, b. TheIDH1R132H glial tumour cells that only harboured a point mutation. Sections with > 10% of tumour cells positively stained were defined as IDH1mutant.We assessed +TAMs, CD4+TILs, Iba1-associated macrophages, and IDH1R132H mutation. Hazard regression plot (univariable and multivariable) was used to assess the relationship between CD204 and CD4 expression and treatment modalities on RFI. Kaplan–Meier curves and log-rank test were used to compare the distribution of RFI among glioblastoma cases with different quantities of CD204+TAMs and CD4+TILs. The RFI was defined as the period from the beginning of adjuvant therapy after surgical resection to the possible first date of recurrence. All statistical analyses in this study were performed using IBM SPSS1 ver. 24  and “R” statistical software programs.Data were described as frequencies and percentages. Pearson’s Chi-Square test was used to explore the relationship between CD204This study included 45 patients diagnosed with classical glioblastoma (mean age: 51 years ± 21 years); 28 males (62.2%) and 17 females 37.8%)). Approximately 40% (n = 18) of the tumours were in the frontal lobe followed by the temporal lobe  (Table 7.8%). Ap1 years; +TAMs were highly expressed in 32 glioblastomas (71%) and the remaining 13 tumours (29%) showed reduced expression. CD4+TILs were highly expressed in 10 cases (22%) of glioblastomas, and 35 cases (77.8%) showed low expression. There was an inverse correlation between CD204+TAMs and CD4+TILs. Approximately 85% of the tumours had a high expression of CD204+TAMs with a low expression of CD4+TILs. Of 13 cases with a low expression of CD204+TAMs, only five cases (38.5%) were associated with a high expression of CD4+TILs. Although this finding was scientifically consistent, it was statistically insignificant (p = 0.095)  when compared with IDH1mutant glioblastomas (n = 7), there was no significant difference between the two groups (p = 0.930) (Table +TILs was associated more with IDH1wildtype glioblastomas (n = 26) compared with IDH1mutant glioblastomas (n = 9). However, there was no significant difference between the two groups (p = 0.292)  (Table Despite the high expression of CD2049) Table .Table 6Twildtype glioblastomas compared with IDH1mutant glioblastomas (p = 0.031) .Iba1-associated microglial activation was high in the glioblastoma microenvironment . Regarding Iba1-microglial activation, Iba1 expression was significantly increased in IDH11) Table . Regardi+TAMs was 0.75 (1/0.75 = 1.33), indicating a 1.33 times significantly lower chance of tumour recurrence compared with patients with a high expression of CD204+TAMs (p = 0.039). The multivariate HR for a low expression of CD204+TAMs was 0.44 (1/0.44 = 2.27) indicating a 2.27 times significantly lower chance of tumour recurrence compared with patients with a high expression of CD204+TAMs, when controlled for CD204 and subtype of treatment modality (p = 0.038) (Table The univariate hazard ratio (HR) for a low expression of CD204Univariate or multivariate HR for use of radiation therapy alone for the treatment of glioblastoma was 1.94 and 1.85, respectively. This indicates a 0.5 times lower chance of tumour recurrence if radiotherapy is used individually compared with combination therapy. However, the HR for univariate and multivariate regressions were statistically insignificant  Table .+TAMs and a low expression of CD4+TILs  in glioblastoma cases with a high expression of CD204ILs Fig. a.Fig. 6T+TAMs was 0.56 (1/0.56 = 1.78) indicating a 1.78 times lower chance of tumour recurrence compared with patients with a high expression of CD204 + TAMs. However, this was not statistically significant (p = 0.226). The multivariate HR for a low expression of CD204+TAMs was 0.43 (1/0.43 = 2.32) indicating a 2.32 times lower chance of tumour recurrence compared with patients with a high expression of CD204+TAMs when controlled for CD4 and chemotherapies; however, this difference did not reach statistical significance (p = 0.091)  indicating a 2.00 times lower chance of tumour recurrence compared with TMZ only therapy. The multivariate HR for the use of TMZ with additional adjuvants was 0.55 (1/0.55 = 1.81) indicating a 1.81 times lower chance of tumour recurrence compared with TMZ only therapy. The HR for univariate and multivariate regressions did not reach statistical significance  Fig. .+TAMs and a low expression of CD4+TILs  in glioblastoma cases with a high expression of CD204ILs Fig. b.The glioblastoma microenvironment consists of different cellular heterogeneities including neoplastic cells and non-neoplastic cells that are segmented as tumour niches where treatment-resistant glioma stem cells are localized . TAMs arM1-polarized “anti-tumoural” TAMs and M2-polarized “anti-inflammatory” TAMs M2-polarint Table . This im+TAMs and CD4+TILs with IDH1 mutation. Cases with a high expression of CD204+TAMs and a low expression of CD4+TILs had late tumour recurrence   making it difficult to determine whether each identified target was a pan-TAM target or was specific for a specific model. Because IDH1 mutation is considered a major prognosticator in glioblastoma, we report a correlation between CD2047%) Fig. . Furthercts Fig. .+TILs had an essential role in initiating anti-cancer immune responses that significantly affected the function of CD8+TILs against tumour cells [+TILs are essential for killing tumour cells, their low numbers in the tumour microenvironment are insufficient to affect tumour growth. The low numbers of CD8+TILs might be related to their inability to cross the blood–brain barrier efficiently. Han et al. found that the number of CD8+TILs was inversely correlated with tumour grade whereas the number of CD4+TILs was positively correlated with tumour grade [+TILs (77.8%) because there were high numbers of TAMs that inhibit T-cell recruitment. The presence of low numbers of CD8+TILs in the glioblastoma microenvironment is associated with a poor outcome because cytotoxic lymphocytes are unable to kill tumour cells while CD4+TILs are completely suppressed. This only occurs when CD204+TAMs are infiltrated the tissue, which allows tumour cells to evade the immune system. Therefore, the prognostic value of T-cells in glioblastoma is still unclear; however, their roles may be strongly linked with TAMs.As mentioned earlier, there was a synergetic relationship between TAMs and TILs, which affected tumour cell proliferation. CD4ur cells . Althougur grade . This th+TAM receptors are blocked, which in turn, allows CD4+TIL evolution and enhanced CD8+TIL toxicity. As a result, CD204+TAM receptors may be a suitable target for TAMs blockade. In recent clinical trials, some immune checkpoint inhibitors were used as TAMs receptor blockers, which stimulated CD4+TILs activity and limited the threshold of the immune response. Cytotoxic T-lymphocyte- associated antigen-4 (CTLA-4), programmed cell death-1 receptor (PD-1), and T-cell inhibitory receptor (TIM-3) are expressed on T-cells and mediate inhibitory effects by interacting with their ligands on tumour cells or TAMs [+TILs as well as PD-L1 expression were significantly increased in glioblastoma, suggesting the use of immune checkpoint blockade to interrupt the PD-1/PD-L1 pathway [+TAMs and immune checkpoint regulators to limit T-cell functions [Based on these findings, we concluded that malignant glial cell proliferation can be prevented if CD204 or TAMs  Fig. 8)+TAM rece pathway . Althoug pathway . However pathway , 25. T c pathway . Currentunctions .+TAM expressions, using univariate and multivariate HR regression plots   with tumour recurrence has not been investigated. Here, we explored the impact of chemoradiotherapy on tumour recurrence in glioblastoma with different CD204ts Table ; Fig. 7.on) Fig. a. This son) Fig. a. HoweveILs Fig. b. This s+TAMs and CD4+TILs in glioblastoma microenvironment and to determine how these immune cells affect tumour recurrence. To date, immune checkpoint inhibitor biomarkers are used as surrogates for antitumor T-cell responses, which include T-cell counts in the tumour microenvironment. M2-TAMs (CD204) modulate tumour cell proliferation and inhibit T-cell evolution. All these factors affect the tumour recurrence status. Understanding the mechanism of TAMs in glioma progression might help develop therapies that suppress the tumour-progressing effects of TAMs.The aim of our study was to investigate the synergetic mechanisms of CD204


Medical journals use Twitter to engage and disseminate their research articles and implement a range of strategies to maximize reach and impact.This study aims to systematically review the literature to synthesize and describe the different Twitter strategies used by medical journals and their effectiveness on journal impact and readership metrics.A systematic search of the literature before February 2020 in four electronic databases  was conducted. Articles were reviewed using the PRISMA  guidelines.The search identified 44 original research studies that evaluated Twitter strategies implemented by medical journals and analyzed the relationship between Twitter metrics and alternative and citation-based metrics. The key findings suggest that promoting publications on Twitter improves citation-based and alternative metrics for academic medical journals. Moreover, implementing different Twitter strategies maximizes the amount of attention that publications and journals receive. The four key Twitter strategies implemented by many medical journals are tweeting the title and link of the article, infographics, podcasts, and hosting monthly internet-based journal clubs. Each strategy was successful in promoting the publications. However, different metrics were used to measure success.Four key Twitter strategies are implemented by medical journals: tweeting the title and link of the article, infographics, podcasts, and hosting monthly internet-based journal clubs. In this review, each strategy was successful in promoting publications but used different metrics to measure success. Thus, it is difficult to conclude which strategy is most effective. In addition, the four strategies have different costs and effects on dissemination and readership. We recommend that journals and researchers incorporate a combination of Twitter strategies to maximize research impact and capture audiences with a variety of learning methods. This approach requires awareness of and access to the journal, which is not always the case for health researchers and practitioners [The main goals of health science research are to improve health, services, and practice, as well as develop health care technologies . Researcse goals . This prse goals . Althougse goals , it typise goals . One prise goals . Medicalse goals . Traditise goals  and reliitioners .Twitter is a microblogging service that allows the sharing of short messages (tweets) within a 280-character limit and can include images, videos, and hyperlinks to other sites. Users can share the tweet (retweet) with their web-based network or community (followers) .pushes content to its audience [Twitter’s global popularity and ubiquitous nature offers a rapid, accessible, and cost-effective medium for communication and sharing of information . Among haudience .Altmetrics) and includes Altmetric attention scores, pageviews, article downloads, and Twitter metrics. Altmetrics measure how often an article has been shared, viewed, or referenced on the web by both professional and lay audiences [Increased dissemination of research on Twitter can improve article readership and the impact of a journal in terms of citation-based and alternative metrics , such asudiences . Compareudiences . Despiteudiences . One of udiences ,15. Thus“a microblogging and social networking service on which users post and interact with messages.” Medical journals were defined as “a peer-reviewed scientific journal that communicates medical information to health practitioners.” Journal impact was measured using citation-based metrics, such as citation count and impact factor. Article readership was measured using pageviews and full-text article downloads. Article dissemination was measured using Altmetric attention scores and Twitter metrics, including impressions, engagements, link clicks, and retweets. The definitions of each dissemination metric are provided in For this review, Twitter was defined as RetweetsThe number of times a user retweeted (reposted) a tweet. This feature allows users to share information from the source with their followers. You can retweet your Tweets or Tweets from someone else .ImpressionsThe number of people who saw your tweet .EngagementsThe total number of times a user interacted with a Tweet. Clicks anywhere on the Tweet, including retweets, replies, follows likes, links, cards, hashtags, embedded media, username, profile photo, or Tweet expansion .Link ClicksThe number of times the article link in the Tweet is clicked .DownloadsThe number of times a research article was download as a pdf from the website of the medical journal .PageviewsThe number of times an article on the website of the medical journal was loaded on a web browser (abstract and full text combined) irrespective of the source .Altmetric ScoreA weighted count of all the web-based attention an individual research output has received from web-based media platforms, including social media networks, news outlets, blogs, and others .A systematic review was conducted to retrieve all relevant research studies. All study designs were included in the review to identify the best evidence available to address the research objectives. The literature search was conducted using the following four electronic databases: PubMed, Web of Science, Scopus, and ScienceDirect. The search was performed using the following search terms: “MEDICAL,” “MEDICINE,” “JOURNALS,” “SOCIAL MEDIA,” and “TWITTER.” For example, we searched PubMed using the following strategy:  AND “journals” AND “social media” AND “Twitter.”Following the collection of studies from different electronic databases, duplicate studies were removed and screened for eligibility using the PRISMA  guidelines. The inclusion criteria were as follows: (1) English language, full-text original research articles; (2) studies of medical journals; (3) evaluations of Twitter strategies implemented for article dissemination  or analysis of the relationship between alternative metrics and citation-based metrics; (4) published any time before February 2020; and (5) all research study designs. The exclusion criteria were (1) studies not in English; (2) literature reviews, dissertation theses, review papers, reports, conference papers or abstracts, letters to the editor, commentaries, and feature articles; and (3) studies involving nonmedical academic journals. Following abstract and title screening, we conducted a full-text review of the selected articles.The following data were extracted from the included studies: first author, year of publication, study aim, study sample, Twitter strategy implemented, study methodology , primary study outcomes, and results. A customized data extraction sheet was developed using Microsoft Excel. The Medical Education Research Study Quality Instrument was used to evaluate the quality of all included studies .The database search identified 4416 titles . After rOf the 43 included studies, 27 (63%) health-related disciplines were reviewed, with urology 6/43, 14%) and radiology  representing the top two disciplines. A total of 74% (32/43) of the published studies were within the last 4 years. A total of 53% (23/43) of the studies analyzed the relationship between alternative and citation-based metrics as their primary objective. The remaining 47% (20/43) studied how specific Twitter strategies used by medical journals impacted these relationships. In all, 74% (32/43) of studies used an observational study design % and rad-43,45-50The studies received an average score of 9.5 out of 13.5, ranging from 8 to 10.5. A total of 70% (30/43) of the studies scored above 9.5. For detailed scores, see Studies that compared journals with and without a Twitter account showed that Twitter has a higher impact factor (n=4) ,29,32,34A total of 6 studies ,28,37,38Twitter strategies implemented by medical journals to promote their research articles ranged from hosting internet-based journal clubs  -44,46-50Journal ClubParticipants discuss a selected research article virtually using Twitter, often meeting at a set date and time.Basic TweetPosting a message on Twitter with the title of an academic article along with a link to the full-text version on the journals’ websites. The article may or may not be accessible.InfographicPosting a message on Twitter with the title of an academic article, a summary of the results in the form of an infographic, and a link to the full-text version on the journals’ websites. The article may or may not be accessible.PodcastPosting a message on Twitter containing the title of an academic article and a link to the full-text version of the article as well as a downloadable podcast based on the article on the journals’ websites. The article may or may not be accessible.ObservationalNo intervention was implemented. The authors analyzed the relationship between Twitter metrics or alternative metrics and citation-based metrics for journals or articles.This is the first review to analyze the use of Twitter in medical journals and its effect on research dissemination, readership, and journal impact metrics. The first key finding of this review is that journals should endeavor to have a dedicated Twitter account to promote their publications. This Twitter promotion will improve article dissemination, article readership, and citation-based metrics, ultimately leading to an increase in the impact factor. Beyond this, implementing different Twitter strategies maximizes the web-based dissemination of and engagement with publications and journals. There were four main Twitter strategies implemented by medical journals: basic tweeting, infographics, podcasts, and internet-based Twitter journal clubs. Each strategy was successful in the dissemination of publications, but different metrics were used to measure success. Thus, it was difficult to conclude which strategy was the most effective. The discussion below details the benefits and challenges of each strategy and how they increase the potential for successful dissemination.Basic tweeting was the simplest Twitter strategy used by medical journals, that is, tweeting the title of the article along with the link to the abstract or full-text version on the journal’s website. Basic tweeting had varying impacts on article readership and dissemination, based on a number of factors. These factors include the source of the tweet, posting frequency, and the number of Twitter followers.The tweet source is as important as the content of the tweet. For example, Hawkins et al  increaseIncreasing the posting frequency may increase the dissemination of articles. Fox et al  found noA large number of Twitter followers are essential for the success of social media promotion. Two studies, both by Fox et al ,53, founBasic article promotion is an easy, cost-effective, and time-effective strategy for journals. From a reader’s perspective, it keeps them up to date with the latest publications, especially if they choose to be notified every time a journal tweets. However, it requires readers to click the link to the journal’s website to read the abstract of the article . In addispillover effect. For example, two studies reported an increase in impressions, pageviews and engagements for basic tweets sent from the same journal account after implementing the visual abstract strategy [Including a visual abstract, that is, a simplified graphical summary of a study’s scientific abstract, within article tweets increases their dissemination on Twitter and, subsequently, readership. In contrast to basic tweets, the visual abstract tweets receive significantly more abstract pageviews, impressions ,51,54, estrategy ,54.Thoma et al  and HuanThe responsibility of designing visual abstracts is usually left to the journal editors, which is costly and time-consuming, even though open-source templates are available to help authors create their own . The posArticles tweeted with linked podcasts receive greater increases in Altmetric attention scores and abstract pageviews than visual abstracts or basic tweets, although they show no increase in full-text readership . A possiHosting monthly 24-hour Twitter discussions of recent publications demonstrate positive growth metrics over the course of the intervention in terms of active participation (number of Twitter profiles involved in the discussion), tweet volume, engagement, and impressions and has the potential to increase traffic to the journal’s website . Unlike tweet in the search terms.The research designs of studies that tested the effectiveness of the same strategy differed. This made it difficult to draw definitive conclusions regarding Twitter strategy effectiveness . InterveTwitter is a valuable science communication and marketing tool for academic journals to increase web-based visibility, promote research, and translate science to lay and scientific audiences. Four key Twitter strategies are implemented by medical journals: tweeting the title and link of the article, infographics, podcasts, and hosting monthly internet-based journal clubs. In this review, each strategy was successful in promoting publications but used different metrics to measure success. Thus, it is difficult to conclude which strategy is most effective. In addition, the four strategies have different costs and effects on dissemination and readership. We recommend that journals and researchers incorporate a combination of Twitter strategies to maximize research impact and capture audiences with a variety of learning methods.


Object: The fluid management strategy in ARDS is not very clear. A secondary analysis of RCT data was conducted to identify patients with ARDS benefitting from a conservative strategy of fluid management.Methods: The data of this study were downloaded from the ARDS network series of randomized controlled trials . Based on the clinical feature of patients, within the first 24 h after admission, clustering was performed using the k-means clustering algorithm to identify the phenotypes of ARDS. Survival was analyzed using the Kaplan-Meier survival analysis to assess the effect of the two fluid management strategies on the 90-day cumulative mortality. Categorical/dichotomic variables were analyzed by the chi-square test. Continuous variables were expressed as the mean and standard deviation and evaluated through a one-way ANOVA. A P-value < 0.05 was defined as the statistically significant cut-off value.Results: A total of 1,000 ARDS patients were enrolled in this unsupervised clustering research study, of which 503 patients were treated with a conservative fluid-management strategy, and 497 patients were treated with a liberal fluid-management strategy. The first 7-day cumulative fluid balance in patients with the conservative strategy and liberal strategy were −136 ± 491 ml and 6,992 ± 502 ml, respectively (P < 0.001). Four phenotypes were found, and the conservative fluid-management strategy significantly improved the 90-day cumulative mortality compared with the liberal fluid-management strategy  in patients classified as “hyperinflammatory anasarca” phenotype (phenotype II). The characteristics of this phenotype exhibited a higher WBC count (20487.51 ± 7223.86/mm3) with a higher incidence of anasarca (8.3%) and incidence of shock (26.6%) at baseline. The furthermore analysis found that the conservative fluid management strategy was superior to the liberal fluid management strategy in avoiding superinfection  and returned to assisted breathing  in patients classified as “hyperinflammatory anasarca” phenotype. In addition, patients with other phenotypes given the different fluid management strategies did not show significant differences in clinical outcomes.Conclusion: Patients exhibiting a “hyperinflammatory anasarca” phenotype could benefit from a conservative fluid management strategy. Acute respiratory distress syndrome (ARDS) refers to acute inflammatory injury of the lung, disruption of the alveolar–capillary barrier and the formation of non-cardiogenic, protein-rich pulmonary oedema –4. A conAlthough lung failure alone can be lethal, death in patients with acute lung injury is usually due to the failure of the non-pulmonary organs. Conservative fluid management strategies may lead to lower intravascular volume and perfusion , 8. WiedArtificial intelligence (AI) has found its way into clinical studies in the era of big data. Meanwhile, as increasing number of ARDS clinical trials data is open to public, secondary analysis on these combined datasets provide a powerful way of finding solution to clinical questions with a new perspective , 11. WheBased on this clinical problem, the hypothesis for identification of the specific ARDS patients who could benefit from conservative fluid management would be tested through a secondary analysis on RCT data from Wiedemann et al. using a machine learning algorithm (unsupervised clustering).The data of this study were downloaded from the ARDS network series of randomized controlled trials  . A totalClinical features of ARDS patients were obtained before the start of treatment with a conservative strategy or liberal strategy within the first 24 h after admission. If missing data for a certain feature or sample is more than 5% then we will leave that feature. The other missing data (<5%) were estimated by multiple imputations through the R package, following the process described by Zhang with minor modifications . The micP < 0.05) were utilized as the criterion for the identification of suitable clinical features for the best classification model.To screen suitable clinical features for clustering analysis, we attempted to train several classifiers from scratch. The clear separations and significant statistical results . The best classifications were selected based on clear separations of the consensus heatmaps.Clustering was performed using the Survival was analyzed using the Kaplan-Meier survival analysis to assess the effect of the two fluid management strategies on the 90-day cumulative mortality. Categorical/dichotomic variables were analyzed by the chi-square test. Continuous variables were expressed as the mean and standard deviation and evaluated through a one-way ANOVA.P-value < 0.05 was defined as the statistically significant cut-off value.A All the analyses in this study were conducted using R 4.0.3.P < 0.001).A total of 1,000 ARDS patients were enrolled in this unsupervised clustering research study, of which 503 patients were treated with a conservative fluid-management strategy, and 497 patients were treated with a liberal strategy fluid-management strategy. The first 7-day cumulative fluid balance in patients with the conservative strategy and liberal strategy were −136 ± 491 ml and 6,992 ± 502 ml, respectively  score, PaO2, central venous pressure (CVP), predicted body weight (PBW), white blood cell count (WBC), platelet count, and the presence or absence of shock and anasarca were finally enrolled in further unsupervised clustering analysis.The patients were classified as 2 phenotypes to 7 phenotypes through unsupervised clustering analysis, shown in . As the P = 0.024), as shown in P = 0.030). In addition, the conservative fluid management strategy was superior to the liberal fluid management strategy in avoiding superinfection  and returned to assisted breathing , as shown in Phenotype II was identified as the specific population that benefited from the conservative fluid-management strategy because the conservative fluid-management strategy significantly improved the 90-day cumulative mortality compared with the liberal fluid-management strategy  and had a higher incidence of anasarca (8.3%) and incidence of shock (26.6%) at baseline, as shown in Patients classified as phenotype II exhibited a higher WBC  with a higher incidence of anasarca (8.3%) and incidence of shock (26.6%) at baseline. Distributive shock and oedema due to ARDS-induced systemic inflammatory host responses on cardiovascular systems were marked signs in these patients .The original contributions presented in the study are publicly available. This data can be found here: ARDS network public database  for the publication of any potentially identifiable images or data included in this article.SZ took responsibility for the integrity and the accuracy of the data analysis. All authors contributed to the article and approved the submitted version.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.


The spatial organization of collagen fibers has been used as a biomarker for assessing injury and disease progression. However, quantifying this organization for complex structures is challenging.To quantify and classify complex collagen fiber organizations.Using quantitative second-harmonic generation (SHG) microscopy, we show that collagen-fiber orientation can be viewed as pseudovector fields. Subsequently, we analyze them using fluid mechanic metrics, such as energy We show that metrics used in fluid mechanics for analyzing fluid flow can be adapted to analyze complex collagen fiber organization. As examples, we consider SHG images of collagenous tissue for straight, wavy, and circular fiber structures.The results of this study show the utility of the chosen metrics to distinguish diverse and complex collagen organizations. We find that the distribution of values for  VF analysis has been applied to understand diverse problems such as human mobility, fiber reconstruction, and bacteria collective motion. In one study, recurrent human mobility flow has been captured and simulated through a mesoscopic VF, which could facilitate the understanding of the spread of an epidemic in a region as well as help with urban planning.In this paper, we propose a method to analyze SHG collagen images as pseudo-VFs and apply measures for assessment that are derived from fluid mechanics. In our approach, we first derive a 2D quadrilateral mesh that encapsulates pseudounit vectors in each cell based on preferred local orientations by FT-SHG analysis.This paper is organized as follows. In Sec. 2Bovine tendon was stored in phosphate-buffered saline (PBS) and sectioned with a cryostat  at In characterizing the structure of collagen fibers, we consider the parameters To calibrate our method, we utilize digital phantoms generated in MATLAB. 3FT-SHG images of bovine tendon, rat vaginal tissue, and porcine cortical bone are the subjects of this study. Bovine tendon has a relatively organized collagen fibrillar structure, and thus is a useful case study for understanding our algorithm to relatively straight fibers or in-plane wavy fibers. After applying our analysis on a bovine tendon SHG image , where aound 1.1 . As noteFurthermore, we apply a similar analysis to several porcine cortical bone SHG images, where fibers are uniformly aligned , as wellFinally, representative images of rat vaginal tissue near the cervix  and intrSamples chosen for this study have diverse architectures ranging from straight to vortex-like collagen-fiber organizations. We observe that From the 4While current FT methods capture individual fiber orientation, the complexity of collagen architectures are not easily quantified by FT methods alone. An analytical approach based on fluid mechanics enables assessment of fiber orientation as part of a unified system of vectors akin to fluid flow. Finally, our approach could benefit from exploring multiphase fluid flow analysis to single out fibers for individual study if desired. In addition, we explored SHG imaging of a single plane, but we are currently exploring adapting to three-dimensional image stacks.


To examine the feasibility of performing ASL-MRI in paediatric patients with solid abdominal tumours.n = 4) or nephroblastoma (n = 6) during a diagnostic MRI examination at a single visit . Visual evaluation and region-of-interest (ROI) analyses were performed on the processed perfusion-weighted images to assess ASL perfusion signal dynamics in the whole tumour, contralateral kidney, and tumour sub-regions with/without contrast enhancement.Multi-delay ASL data sets were acquired in ten paediatric patients diagnosed with either a neuroblastoma , especially compared with the highly perfused kidneys. Within the tumours, regions with high PWS were observed which, at short PLD, are possibly related to labelled blood inside vessels and at long PLD, reflect labelled blood accumulating inside tumour tissue over time. Conversely, comparison of ASL perfusion-weighted image findings with TThis pilot study demonstrates the feasibility of utilizing ASL-MRI in paediatric patients with solid abdominal tumours and provides a basis for further research on non-invasive perfusion measurements in this study population. In paediatric oncology, imaging plays a defining role in the initial diagnosis, staging, early post-treatment response assessment and surveillance. Magnetic resonance imaging (MRI) is currently the preferred modality for clinical assessment of tumours located in the abdomen . CliniciThe characterisation of tumour hemodynamics in children is still limited. One explanation is that childhood cancers are very heterogeneous with often relatively small patient numbers, limiting standardisation for imaging modality choice and subsequent technical optimisation .Arterial spin-labelling (ASL) MRI may be a valuable method in a paediatric population for non-invasive measurement of tissue perfusion without the need for contrast administration. This method utilises magnetically labelled water-protons in blood as an endogenous tracer. This allows for repeated measurements within the same scan session or frequent follow-up MRI examinations. Thus far, in paediatric patients ASL-MRI has been performed in a few studies for perfusion imaging of brain tumours –14. ThesTherefore, the purpose of this study was to examine the feasibility of performing ASL-MRI in paediatric patients with tumours located outside the brain by evaluating the presentation of ASL perfusion signal dynamics of common abdominal tumours.This is a report on retrospective, cross-sectional data obtained in patients who received diagnostic MR imaging of the abdomen related to an abdominal solid tumour. An ASL scan had been added to the clinical scan protocol in consultation with the pediatric radiologist for the assessment of tumour perfusion. Subjects did not have to follow specific actions or rules for conducting this study, since the patients were scheduled for the MRI examination as part of the clinical diagnostic procedures. A letter waiving ethical approval was obtained from the IRB of our institution. The image data were fully anonymised before processing and analysis.All patients were scanned on a 1.5 T MR system  equipped with a body coil for transmission and a 28-element phased array coil for reception.0). Each PLD was obtained in a separate acquisition that consisted of 10 label-control pairs. The M0 scan, essentially the pCASL scan without labelling, was acquired four times and averaged after motion correction. All scans were performed with the same 2D multi-slice image readout using single-shot gradient-echo EPI. The labelling slab and image readout were planned exactly the same for each ASL acquisition. The applied scan parameters are provided in Table 0 scans was 4min54s.The ASL scan was acquired using pseudo-continuous ASL (pCASL) labelling , as impl0 scans were performed at the end of the MRI examination, before the injection of contrast agent. The localiser scan and subsequently acquired clinical scans were used to enable correct planning of the ASL and M0 scans. Slices were planned in coronal orientation to minimise through-plane motion due to breathing, including as much tumour tissue as possible and (part of) the contralateral kidney within the stack thickness (62 mm). The contralateral kidney was used as a reference organ for comparison with the ASL perfusion signal measured in the tumour. Normally, the kidneys are well perfused, and therefore, measured ASL perfusion signal in this organ could be used as an indication of successful labelling within a subject. The labelling slab of the ASL scan was placed perpendicular to the descending aorta and above the tumour (and kidneys) to prevent these tissues from sliding into the labelling slab during breathing. Care was taken that the labelling slab was as close as possible to the tumour and remained below the diaphragm (if possible) to minimise susceptibility artifacts near the lungs. B0 shimming was applied to the imaging stack and the labelling slab independently. Most patients were under anaesthesia during the entire MRI examination. Acquisitions were performed under non-invasive ventilation or free-breathing conditions in supine position.The ASL and M2-weighted (T2w) and T1-weighted (T1w) scans. A 3D T2w TSE scan was acquired with TE 90 ms and isotropic spatial resolution 1.2 × 1.2 × 1.2 mm3. T1w gradient-echo imaging before and after contrast agent administration (CE-T1w) was performed either using the 3D THRIVE technique with fat suppression, TE 2.7 ms and acquired spatial resolution 1.07 × 1.07 × 3 mm3, or the 3D Vane XD technique with TE1/TE2 1.9/4.0 ms (with Dixon-based water-fat separation) and acquired spatial resolution 1.5 × 1.5 × 3 mm3.A standard clinical scan protocol was obtained in each subject, which included (among others) T0 images were registered slicewise . The groupwise registration method is robust against intensity changes between the images and does not require the choice of a reference image avoiding registration bias [To compensate for misalignments caused by (respiratory) motion during image acquisition, image registration was performed using Elastix . Since tion bias .After image registration, label-control raw ASL images were pairwise subtracted. Next, outlier rejection was performed for each PLD by excluding subtraction images containing > 20% voxels with a value of more than ± 1.5 SD from the voxel wise mean value over all repetitions within the tumour or kidney region. The subtraction images remaining after outlier rejection were averaged per PLD to obtain averaged perfusion-weighted images (1w subtraction images (T1w-subtracted) were used. To this end, first the CE-T1w scan was coregistered to the T1w scan using 3D rigid image registration in Elastix [For assessment of contrast enhancement of the tumour, T Elastix , and nex0 images (after image registration). The ROI of the contralateral kidney included the renal parenchyma. In addition, ROIs were drawn in enhancing and non-enhancing tumour subregions that were identified on T1w subtraction images. ROIs were drawn conservatively in the enhancing and non-enhancing tumour regions, i.e., well within the visible boundary of a non-enhancing or enhancing region, to take into account minor registration errors between the ASL perfusion and the CE-T1w data sets. The 3D anatomical T2w and T1w images were reformatted to the geometry of the M0 images to cross-check the tumour contours. When necessary, ROIs were manually adjusted with in-plane translations between anatomical and ASL scans. In case multiple tumours were present, the largest tumour was used for the ROI analysis. For each tissue type  the same ROI was used within an individual patient. ROIs were drawn by a single observer (A.H) and were verified and corrected by a radiologist (A.L with > 10 years of experience with assessing paediatric oncology MR images).Regions-of-interest (ROI) analyses were performed to quantitatively evaluate the measured ASL perfusion signal in different regions for each subject. ROIs were drawn manually around the tumour and contralateral kidney contours on the averaged MASL perfusion signal dynamics within the tumour and contralateral kidney were assessed by calculating the relative perfusion-weighted signal (PWS) for each delay time as Image processing and analysis were performed using custom scripts in MeVisLab .n = 4) or nephroblastoma (n = 6). In each patient, ASL imaging was performed at a single visit; n = 4 patients  at initial staging MRI examination pre-treatment, and n = 6 patients  at follow-up MRI-examination during treatment. Patient characteristics and primary tumour classification are presented in Table ASL scans were obtained in 10 paediatric patients  diagnosed with either a neuroblastoma  that decreased over time indicated that these regions often coincided with local hypo-intense areas in the TPWS values obtained from pCASL images as a function of PLD within the whole-tumour and kidney regions are shown in Fig. Mean PWS values obtained from pCASL images as a function of PLD within non-enhancing and enhancing subregions of the tumour after contrast administration are shown in Fig. 1w enhancement after contrast administration showed that regions lacking contrast enhancement also showed PWS around zero.We conducted a study to establish the feasibility of ASL-MRI in paediatric neuroblastoma and nephroblastoma. The study showed that this was feasible within 5 min of extra scan time. After realignment, the acquired ASL images were usable for analysis in a paediatric population under non-invasive ventilation and free-breathing conditions. The perfusion signal in the kidney indicates that labelling was successfully performed in all subjects, yet, the majority of the included abdominal tumours presented with relatively low PWS. Within the tumours, regions with higher PWS were observed, either related to labelled blood inside vessels (at short PLD) or to labelled blood accumulating inside tumour tissue over time (increasing with PLD). Conversely, comparison of ASL perfusion-weighted image findings with T1 decay. Since no previous ASL studies on abdominal tumours in children have been reported yet, and hemodynamics and tumour characteristics can be very different from those in adults [1 values that are known to be present between children, and an age-dependency of the arterial transit time of blood flowing from the labelling plane to tissue of interest also have an influence on the measured PWS [The ASL scan was obtained in a clinical setting. This defined our choice for the pCASL labelling approach, since this method was clinically available on our MR system. The pCASL labelling approach is currently recommended for brain and kidney perfusion imaging in adults , 19. pCAn adults , ASL datn adults , underliured PWS –26.2w images  should, therefore, correspond with PWS around zero (no blood flow), which was the case for all non-enhancing tumour regions in this study. Enhancing tumour regions, on the other hand, were more difficult to compare directly with ASL findings in the same tumour regions. Most tumours showed very low PWS inside enhancing regions (as shown in Fig. The comparison of tumour contrast enhancement on TThus far, ASL MRI in the body/abdomen has mainly been applied for renal perfusion imaging in adults. Recently, a consensus-based paper describing technical recommendations for clinical translation of renal ASL MRI has been published , that waThis study has limitations. A first limitation of this study is that the number of patients included was relatively small with heterogeneous characteristics, which are, however, usual limitations inherent to the nature of an explorative study on retrospective data. In general, paediatric abdominal tumours are very heterogeneous with diverse pathological features, and the number of patients for each tumour type are often relatively small. This poses challenges for conducting research with this population. So far, feasibility of ASL has been primarily studied in the brain reflecting the difficulty in evaluating new techniques in paediatric patients with rare diseases. Second, the retrospective nature of this study in a clinical setting limited the amount of time allowed for additional scans that could be performed. This meant that more extensive evaluation that would require additional scans, such as B0 and B1 maps or labelling efficiency measurements, to evaluate the technical validity of the ASL measurements or a repeatability analysis could not be performed. A future study with a prospective setup would, therefore, be a logical next step. Default implemented pCASL labelling settings were used, which have been optimised for brain application in adults. Optimisation of pCASL labelling parameters for blood flow characteristics of the descending aorta in a paediatric population may improve labelling efficiency and reduce labelling variation between patients, as has been shown for renal application in adults . In ASL,In conclusion, this study demonstrated the feasibility of ASL-MRI with a pCASL labelling approach in paediatric patients with solid abdominal tumours. In this population considerable differences in PWS were observed both within the individual tumour and between subjects, with on average sixfold lower PWS in the whole-tumour region compared with the contralateral kidney. Within the tumour, non-enhancing tumour regions consistently corresponded with PWS around zero, whereas some enhancing tumour regions clearly showed higher mean PWS values. The preliminary data presented here provides a basis for further research on non-invasive perfusion measurements of solid abdominal tumours using ASL-MRI, specifically in paediatric patients. Further research should be directed towards improving the labelling approach, for instance by optimizing pCASL labelling settings or by exploring other labelling approaches, such as flow-based ASL techniques.


Fluid resuscitation is a cornerstone of modern burn care. Despite the use of well-established formulae to determine the appropriate amount of fluid resuscitation for the first 24 hours of care, there is increasing recognition that patients receive fluids in excess of predicted volumes, a phenomenon termed fluid creep. Underscoring the significance of this phenomenon is the association between large volumes of fluid resuscitation and adverse outcomes. Although research in non-burn ICU patients reveals a clear association between overall fluid intake and increased morbidity, minimal burn-related literature exists regarding fluid patterns after the initial 24-hour period and their impact on outcomes. We hypothesized that increased fluid administration after the standard initial resuscitation period is associated with increased morbidity and mortality.A retrospective chart review was performed for 113 patients with ≥20% TBSA burns admitted to an American Burn Association-verified burn center between 2010 and 2020. Patients admitted with Stevens-Johnson Syndrome and/or Toxic Epidermal Necrolysis, with length of stay ≤ 72 hours, who required renal replacement therapy (RRT) within 72 hours of admission, and those with withdrawal of care ≤ 7 days of admission were excluded. Univariate and multivariate logistic regression was used to determine the association between the primary outcome of in-hospital mortality and secondary outcomes of increased ventilator days, acute kidney injury, need for RRT, and hospital length of stay, with increasing total and net fluid volumes from days 2 through 7 of treatment. Additionally, the association between first OR day and total fluid volumes in the first week were assessed.p = 0.013). Increasing total fluid volumes were significantly associated with increased ventilator days  and acute kidney injury . Early first OR day was associated with decreased net fluid balance between hospital days 2-7 .Median age was 41 years (IQR 23-55) and TBSA was 31% (IQR 24-43). 21 patients (18.6%) died during hospitalization. Increase in net fluid balance from days 2-7 were associated with increased mortality (OR 1.016, 95% CI 1.00 – 1.03, Similar to studies on other ICU populations, increasing total fluid volumes and net fluid balance is associated with adverse outcomes in critically ill burn patients. Additionally, earlier initial OR is associated with less total fluid volumes and lower net fluid balance in the first week of hospitalization. Further investigation is needed to elucidate optimal markers of resuscitation in burn patients in an effort to decrease adverse fluid administration.


In this work, we have identified Pinkment-OH as a unique “plug-and-play” synthetic platform that can be used to develop a range of ONOO− responsive fluorescent probes for a variety of applications. These include theranostic-based applications and potential material-based/bioconjugation applications. The as prepared probes displayed an excellent sensitivity and selectivity for ONOO− over other ROS. In vitro studies using HeLa cells and RAW 264.7 macrophages demonstrated their ability to detect exogenously and endogenously produced ONOO−. Evaluation in an LPS-induced inflammation mouse model illustrated the ability to monitor ONOO− production in acute inflammation. Lastly, theranostic-based probes enabled the simultaneous evaluation of indomethacin-based therapeutic effects combined with the visualisation of an inflammation biomarker in RAW 264.7 cells.Reaction-based fluorescent-probes have proven successful for the visualisation of biological species in various cellular processes. Unfortunately, in order to tailor the design of a fluorescent probe to a specific application ( Pinkment, a resorufin based ONOO− selective and sensitive ‘plug and play’ fluorescence-based platform for in vitro and in vivo use, enables facile functionalisation for various imaging and theranostic applications. The inflammatory response often results in the generation of reactive oxygen species/reactive nitrogen species (ROS/RNS), which are involved in the functional regulation of M1 and M2 macrophages.7,8 The M1 pro-inflammatory phenotype is induced by lipopolysaccharide (LPS), which triggers the generation of ROS from NADPH using NADPH oxidase (NOX).9 This production of ROS regulates an array of cellular events including the activation of the nuclear factor kappa-B (NF-κB), the production of cytokines and cell survival whereas, high levels of ROS are associated with programmed cell death, i.e. apoptosis.7,10–14 The high sensitivity and high spatial and temporal resolution of fluorescent probes allow us to visualise these key cellular events. Our group and others have focused on the fluorescence-based detection of ROS/RNS such as ONOO−, H2O2 and HOCl.1,15–21 To achieve the selective detection of a particular ROS requires the careful consideration of both fluorophore and reactive motif. In this regard, resorufin is a particularly attractive fluorophore due to its red shifted fluorescence and easy to functionalise scaffold. Pioneering work led by Chang et al. developed peroxyresorufin-1 (PR1) for H2O2 detection whereby resorufin is masked with boronic esters.22,23 Boronic esters have been identified as a relevant sensing group for both H2O2 and ONOO− detection. However, in an environment with both species present, boronic esters preferentially react with ONOO− due to the inherent faster reactivity of ONOO− in comparison to H2O2.24 Previously, we have demonstrated PR1's ability to preferentially detect ONOO− over H2O2in vitro.25 Consequently, we decided to investigate functionalized synthetic derivatives of PR1.26 This led to the development of Pinkment-OH for the design of dual analyte AND-logic probes, Pinkment-OTBS (ONOO− “AND” fluoride) and Pinkment-OAc (H2O2 “AND” esterase) using Pinkment-OH  in RAW 264.7 macrophages  to the abdominal region of mice followed by the injection of 6 (200 μM) led to its fluorescence activation. The quantified fluorescence intensity in the probe(+)/LPS(+) group was significantly larger than that in the probe(+)/LPS(−) group  group , demonst32 we then turned our attention towards the potential of Pinkment-OH for the design of fluorescence-based drug releasing probes. Therefore, we used the drugs chlorambucil and indomethacin to afford two distinct theranostic probes 7 and 8, respectively .34,35 Both 7 and 8 were easily accessible from Pinkment-OH  was investigated using qRT-PCR in the presence or absence of 8 (37 The mRNA level of COX-2 decreased in the presence of 8 (50 μM) in comparison to the LPS-induced group. A similar effect to the LPS-induced group was observed with indomethacin alone. This suggests that 8 can monitor ONOO− production in acute inflammation, and in addition, reduce the inflammatory response by releasing indomethacin.Fluorescence studies were carried out including ROS selectivity, H Fig. S22. The prerophages . Indometnce of 8 .37 The mPinkment scaffold to be functionalised with any unit of choice without compromising the overall ROS selectivity, opens up new possibilities for the design of highly specific ONOO− probes that can be used in a variety of applications. In this work, we have successfully illustrated the applicability of Pinkment-based probes for diagnostic and theranostics applications. Our probes displayed good selectivity and sensitivity towards ONOO− over a range of other ROS. Cellular studies with the Pinkment probes led to the identification of alkyne-functionalised Pinkment probe 6 as a suitable candidate for in vivo studies using an inflammatory mouse model. These promising results led us to design potential theranostic probes 7 and 8 with candidate 8 displaying promising properties in vitro. We believe this work demonstrates Pinkment-OH as a useful synthetic platform to enable the rapid development of a ONOO− fluorescent probe that can be tailored to the needs of the chemical biologist. In particular, the alkyne Pinkment probes offer the possibility of attaching any desired unit via click chemistry. Therefore, we anticipate that the Pinkment scaffold can be further elaborated for the development of dual analyte, organelle targeting and theranostic probes for a range of diagnostic and theranostic applications.The ability of the There are no conflicts to declare.SC-011-D0SC02438D-s001