The Role of the Tissue Perfusion Index in Predicting Disease Severity and Prognosis in Patients with Severe and Critical COVID-19.

OBJECTIVES: The study investigated whether percutaneous partial pressure of oxygen (PtcO2), percutaneous partial pressure of carbon dioxide (PtcCO2), and the derived tissue perfusion index (TPI) can predict the severity and short-term outcomes of severe and critical COVID-19. DESIGN: Prospective observational study conducted from January 1, 2023 to February 10, 2023. SETTING: A teaching hospital specializing in tertiary care in Nanjing City, Jiangsu Province, China. PARTICIPANTS: Adults (≥18 years) with severe and critical COVID-19. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The general information and vital signs of the patients were collected. The PtcO2 and PtcCO2 were monitored in the left dorsal volar. The ratio of TPI was defined as the ratio of PtcO2/fraction of inspired oxygen (FiO2) to PtcCO2. Mortality at 28 was recorded. The ability of the TPI to assess disease severity and predict prognosis was determined. ENDPOINT: Severity of the disease on the enrollment and mortality at 28. RESULTS: A total of 71 patients with severe and critical COVID-19, including 40 severe and 31 critical cases, according to the COVID-19 treatment guidelines published by WHO, were recruited. Their median age was 70 years, with 56 (79%) males. The median SpO2/FiO2, PtcO2, PtcCO2, PtcO2/ FiO2, and TPI values were 237, 61, 42, 143, and 3.6 mm Hg, respectively. Compared with those for severe COVID-19, the TPI, PtcO2/ FiO2, SpO2/FiO2, and PtcO2 were significantly lower in critical COVID-19, while the PtcCO2 was significantly higher. After 28 days, 26 (37%) patients had died. TPI values < 3.5 were correlated with more severe disease status (AUC 0.914; 95% CI: 0.847-0.981, P < 0.001), and TPI < 3.3 was associated with poor outcomes (AUC 0.937; 95% CI 0.880-0.994, P < 0.001). CONCLUSIONS: The tissue perfusion index (TPI), PtcCO2, and PtcO2/ FiO2 can predict the severity and outcome of severe and critical COVID-19.

Supergravity-Steered Generic Manufacturing of Nanosheets-Embedded Nanocomposite Hydrogel with Highly Oriented, Heterogeneous Architecture.

Designing nanocomposite hydrogels with oriented nanosheets has emerged as a promising toolkit to achieve preferential performances that go beyond their disordered counterparts. Although current fabrication strategies via electric/magnetic force fields have made remarkable achievements, they necessitate special properties of nanosheets and suffer from an inferior orientation degree of nanosheets. Herein, a facile and universal approach is discovered to elaborate MXene-based nanocomposite hydrogels with highly oriented, heterogeneous architecture by virtue of supergravity to replace conventional force fields. The key to such architecture is to leverage bidirectional, force-tunable attributes of supergravity containing coupled orthogonal shear and centrifugal force field for steering high-efficient movement, pre-orientation, and stacking of MXene nanosheets in the bottom. Such a synergetic effect allows for yielding heterogeneous nanocomposite hydrogels with a high-orientation MXene-rich layer (orientation degree, f = 0.83) and a polymer-rich layer. The authors demonstrate that MXene-based nanocomposite hydrogels leverage their high-orientation, heterogeneous architecture to deliver an extraordinary electromagnetic interference shielding effectiveness of 55.2 dB at 12.4 GHz yet using a super-low MXene of 0.3 wt%, surpassing most hydrogels-based electromagnetic shielding materials. This versatile supergravity-steered strategy can be further extended to arbitrary nanosheets including MoS2, GO, and C3N4, offering a paradigm in the development of oriented nanocomposites.

Mass Spectrometry-Imaging Analysis of Active Ingredients in the Leaves of Taxus cuspidata.

BACKGROUND: Taxus cuspidata is an endangered evergreen conifer mainly found in Northeast Asia. In addition to the well-known taxanes, several active ingredients were detected in the leaves of T. cuspidata. However, the precise spatial distribution of active ingredients in the leaves of T. cuspidata is largely unknown. RESULTS: in the present study, timsTOF flex MALDI-2 analysis was used to uncover the accumulation pattern of active ingredients in T. cuspidata leaves. In total, 3084 ion features were obtained, of which 944 were annotated according to the mass spectrometry database. The principal component analysis separated all of the detected metabolites into four typical leaf tissues: mesophyll cells, upper epidermis, lower epidermis, and vascular bundle cells. Imaging analysis identified several leaf tissues that specifically accumulated active ingredients, providing theoretical support for studying the regulation mechanism of compound biosynthesis. Furthermore, the relative accumulation levels of each identified compound were analyzed. Two flavonoid compounds, ligustroflavone and Morin, were identified with high content through quantitative analysis of the ion intensity. CONCLUSIONS: our data provides fundamental information for the protective utilization of T. cuspidata.

Foxp2 Is Required for Nucleus Accumbens-mediated Multifaceted Limbic Function.

The forkhead box protein P2 (Foxp2), initially identified for its role in speech and language development, plays an important role in neural development. Previous studies investigated the function of the Foxp2 gene by deleting or mutating Foxp2 from developmental stages. Little is known about its physiological function in adult brains. Although Foxp2 has been well studied in the dorsal striatum, its function in the nucleus accumbens (NAc) of the ventral striatum remains elusive. Here, we examine the physiological function of Foxp2 in NAc of mouse brains. We conditionally knocked out Foxp2 by microinjections of AAV-EGFP-Cre viruses into the medial shell of NAc of Foxp2 floxed (cKO) mice. Immunostaining showed increased c-Fos positive cells in cKO NAc at basal levels, suggesting an abnormality in Foxp2-deficient NAc cells. Unbiased behavioral profiling of Foxp2 cKO mice showed abnormalities in limbic-associated function. Foxp2 cKO mice exhibited abnormal social novelty without preference for interaction with strangers and familiar mice. In appetitive reward learning, Foxp2 cKO mice failed to learn the time expectancy of food delivery. In fear learning, Foxp2 cKO mice exhibited abnormal increases in freezing levels in response to tone paired with foot shock during fear conditioning. The extinction of the fear response was also altered in Foxp2 cKO mice. In contrast, conditional knockout of Foxp2 in NAc did not affect locomotion, motor coordination, thermal pain sensation, anxiety- and depression-like behaviors. Collectively, our study suggests that Foxp2 has a multifaceted physiological role in NAc in the regulation of limbic function in the adult brain.

Disturbed nutrient accumulation and cell wall metabolism in panicles are responsible for rice straighthead disease.

Rice straighthead disease substantially reduces crop yield, posing a significant threat to global food security. Dimethylarsinic acid (DMA) is the causal agent of straighthead disease and is highly toxic to the reproductive tissue of rice. However, the precise physiological mechanism underlying DMA toxicity remains unknown. In this study, six rice varieties with varying susceptibility to straighthead were utilized to investigate the growth performance and element distribution in rice panicles under DMA stress through pot experiments, as well as to explore the physiological response to DMA using transcriptomic methods. The findings demonstrate significant variations in both DMA accumulation and straighthead sensitivity among cultivars. The susceptible varieties exhibited higher DMA accumulation indices and displayed typical symptoms of straighthead disease, including erect panicles, deformed rachides and husks, and reduced seed setting rate and grain yield when compared to the resistant varieties. Moreover, DMA addition promoted mineral nutrients to accumulate in rachides and husks but less in grains. DMA showed preferential accumulation in rice grains with a distribution pattern similar to that of Copper (Cu) and zinc (Zn) within the panicle. Transcriptome analyses underscored the substantial impact of DMA on gene expression related to mineral metabolism. Notably, DMA addition significantly up-regulated the expression of pectin methylesterase, pectin lyase, polygalacturonase, and exogalacturonase genes in Nanjingxiangzhan, while these genes were down-regulated or weakly expressed in Ruanhuayou 1179. The alteration of pectin metabolic pathways induced by DMA may lead to abnormality of cell wall assembly and modification, thereby resulting in deformed rice panicles.

Poly(N,N-diethylacrylamide)-endowed spontaneous emulsification during the breath figure process and the formation of membranes with hierarchical pores.

The spontaneous emulsification for the formation of water-in-oil (W/O) or oil-in-water (O/W) emulsions needs the help of at least one kind of the third component (surfactant or cosolvent) to stabilize the oil-water interface. Herein, with the water/CS2-soluble polymer poly(N,N-diethylacrylamide) (PDEAM) as a surfactant, the spontaneous formation of water-in-PDEAM/CS2 emulsions is reported for the first time. The strong affinity between PDEAM and water or the increase of PDEAM concentration will accelerate the emulsification process with high dispersed phase content. It is demonstrated that the spontaneous emulsification of condensed water droplets into the PDEAM/CS2 solution occurs during the breath figure process, resulting in porous films with two levels of pore sizes (i.e., micron and submicron). The emulsification degree and the amounts of submicron-sized pores increase with PDEAM concentration and solidifying time of the solution. This work brings about incremental interest in spontaneous emulsification that may happen during the breath figure process. The combination of these two simultaneous processes provides us with an option to build hierarchically porous structures with condensed and emulsified water droplets as templates. Such porous membranes may have great potential in fields such as separation, cell culture, and biosensing.

Laser-light cueing shoes with integrated foot pressure and inertial sensing for investigating the impact of visual cueing on gait characteristics in Parkinson's disease individuals.

Gait disorders are a fundamental challenge in Parkinson's disease (PD). The use of laser-light visual cues emitted from shoes has demonstrated effective in improving freezing of gait within less restrictive environments. However, the effectiveness of shoes-based laser-light cueing may vary among individuals with PD who have different types of impairments. We introduced an innovative laser-light visual shoes system capable of producing alternating visual cues for the left and right feet through one-side cueing at a time, while simultaneously recording foot inertial data and foot pressures. The effects of this visual cueing system on gait patterns were assessed in individuals with PD, both those with well-gait and those with worse-gait. Our device successfully quantified gait characteristics, including the asymmetry in the center of pressure trajectory, in individuals with PD. Furthermore, visual cueing prolonged stride times and increased the percentage of stance phase, while concurrently reducing stride length in PD individuals with well-gait. Conversely, in PD individuals with worse-gait, visual cueing resulted in a decreased freeze index and a reduction in the proportion of intervals prone to freezing episodes. The effects of visual cueing varied between PD individuals with well-gait and those with worse-gait. Visual cueing slowed down gait in the well-gait group while it appeared to mitigate freezing episodes in worse-gait group. Future researches, including enhancements to extend the projection distance of visual cues and clinical assessments conducted in real-world settings, will help establish the clinical utility of our proposed visual cueing system.

Laser-light Visual Cueing Shoes with Foot Pressures and Inertial Sensing for Individuals with Parkinson's Disease.

Gait disorder is a core problem in individuals with Parkinson's disease (PD), including bradykinesia, shuffling steps, festinating gait, and freeze of gait (FOG). Laser-light visual cueing has been demonstrated to be efficient in the mediation of gaits and the reduction in number of FOG episodes. However, previous approaches commonly adopted independent controls of visual cueing on left and right sides which was prone to produce two cues while individual was not in normal walking. In this study, we developed laser-light visual shoes which produced interlaced visual cues for left and right feet in a manner of one-side cueing at a time, solving the aforementioned problem. With parallel measurement of foot inertial data and foot pressures in each shoe, our results showed that the proposed visual cueing made PD individuals in the on-medication condition walk with a longer stance and swing times, that is, they walked more carefully and stable. The proposed approach can also be used to study kinematic and kinetic characteristics of gaits in the off-medication condition to clarify the mediation of visual cueing on motor control of PD individuals.Clinical Relevance- This demonstrates the effect of laser-light visual cueing on gaits in individuals with Parkinson's disease.

Straw incorporation induces rice straighthead disease in As-contaminated paddy soil.

Rice straw incorporation is globally recognized as a viable alternative to incineration. However, it might lead to arsenic (As) methylation in soils, resulting in increased accumulation of methylated As in rice plants, potentially contributing to the emergence of rice straighthead disease. To evaluate the effect of straw incorporation on the As transformation in the paddy field system, we conducted a pot experiment for rice cultivation in two paddy soils with different As background levels and also characterized the response of the soil microbial community to straw incorporation. The results showed that straw incorporation elevated the total and methylated As concentration within the soil solution and rice plants, which in turn reduced rice seed setting rate and yield, and caused straighthead disorder in rice cultivated in soils with high As levels. 16S rRNA-based sequencing demonstrated reduced abundance and diversity of microorganisms upon adding straw. Notably, the dominant phylum, Bacteroidetes, exhibited a significant increase in abundance due to straw integration, while the abundance of Proteobacteria and Acidobacteria decreased. At the family level, the prevalence of Rikenellaceae increased only in soils contaminated with As following straw incorporation. Redundancy analysis showed positive associations between Rikenellaceae and levels of methylated As present in both soil porewater and rice husks, suggesting a potentially pivotal role of Rikenellaceae in the As methylation process after straw integration. These findings collectively emphasize that including straw can reshape the soil's microbial community and amplify As methylation in the soil, thereby promoting the uptake and accumulation of methylated As in rice and inducing straighthead disease in As-contaminated soil.

Differential Development of Dendritic Spines in Striatal Projection Neurons of Direct and Indirect Pathways in the Caudoputamen and Nucleus Accumbens.

Synaptic modification in postnatal development is essential for the maturation of neural networks. Developmental maturation of excitatory synapses occurs at the loci of dendritic spines that are dynamically regulated by growth and pruning. Striatal spiny projection neurons (SPNs) receive excitatory input from the cerebral cortex and thalamus. SPNs of the striatonigral direct pathway (dSPNs) and SPNs of the striatopallidal indirect pathway (iSPNs) have different developmental roots and functions. The spatial and temporal dynamics of dendritic spine maturation of these two types of SPNs remain elusive. Here, we delineate the developmental trajectories of dendritic spines of dSPNs and iSPNs in the caudoputamen and nucleus accumbens (NAc). We labeled dendritic spines of SPNs by microinjecting Cre-dependent AAV-eYFP viruses into newborn Drd1-Cre or Adora2a-Cre mice, and analyzed spinogenesis at three levels, including different SPN cell types, subregions and postnatal times. In the dorsolateral striatum, spine pruning of dSPNs and iSPNs occurred at postnatal day (P)30-P50. In the dorsomedial striatum, the spine density of both dSPNs and iSPNs reached its peak between P30 and P50, and spine pruning occurred after P30 and P50, respectively, for dSPNs and iSPNs. In the NAc shell, spines of dSPNs and iSPNs were pruned after P21-P30, but no significant pruning was observed in iSPNs of lateral NAc shell. In the NAc core, the spine density of dSPNs and iSPNs reached its peak at P21 and P30, respectively, and subsequently declined. Collectively, the developmental maturation of dendritic spines in dSPNs and iSPNs follows distinct spatiotemporal trajectories in the dorsal and ventral striatum.

Mitigating the allergenicity of peanut allergen Ara h 1 by cold atmospheric pressure argon plasma jet.

BACKGROUND: Peanut allergy is recognized as a major food allergy that triggers severe and even fatal symptoms. Avoidance of peanuts in the diet is the main option for current safety management. Processing techniques reducing peanut allergenicity are required to develop other options. Cold plasma is currently considered as a novel non-thermal approach to alter protein structure and has the potential to alleviate immunoreactivity of protein allergen. RESULTS: The application of a cold argon plasma jet to peanut protein extract could reduce the amount of a 64 kDa protein band corresponding to a major peanut allergen Ara h 1 using sodium dodecyl sulfate-polyacrylamide gel electrophoresis, but the overall protein size distribution did not change significantly. A decrease in peanut protein solubility was a possible cause that led to the loss of protein content in the soluble fraction. Immunoblotting and enzyme-linked immunosorbent assay elucidated that the immunoreactivity of Ara h 1 was significantly decreased with the time treated with plasma. Ara h 1 antigenicity reduced by 38% after five scans (approximately 3 min) of cold argon plasma jet treatment, and the reduction was up to 66% after approximately 15 min of treatment. CONCLUSION: The results indicate that cold argon plasma jet treatment could be a suitable platform for alleviating the immunoreactivity of peanut protein. This work demonstrates an efficient, compact, and rapid platform for mitigating the allergenicity of peanuts, and shows great potential for the plasma platform as a non-thermal technique in the food industry. © 2023 Society of Chemical Industry.

Cross-Project Defect Prediction Based on Two-Phase Feature Importance Amplification.

As the typical application of computational intelligence in software engineering, cross-project defect prediction (CPDP) uses labeled data from other projects (source projects) for building models to predict the defects in the current projects (target projects), helping testers quickly locate the defective modules. But class imbalance and different data distribution among projects make CPDP a challenging topic. To address the above two problems, we propose a two-phase feature importance amplification (TFIA) CPDP model in this paper which can solve these two problems from domain adaptation phase and classification phase. In the domain adaptation phase, the differences in data distribution among projects are reduced by filtering both source and target projects, and the correlation-based feature selection with greedy best-first search amplifies the importance of features with strong feature-class correlation. In the classification phase, Random Forest works as the classifier to further amplify the importance of highly correlated features and establish a model which is sensitive to highly correlated features. We conducted both ablation experiments and comparison experiments on the widely used AEEEM database. Experimental results show that TFIA can yield significant improvement on CPDP. And the performance of TFIA CPDP model in all experiments is stable and efficient, which lays a solid foundation for its further application in practical engineering.

Discovery of a novel and potent inhibitor with differential species-specific effects against NLRP3 and AIM2 inflammasome-dependent pyroptosis.

The NLRP3 inflammasome, which regulated a proinflammatory programmed cell death form termed pyroptosis, is involved in the pathological process of various human diseases, such as multiple sclerosis, type 2 diabetes, and gout. Thus, compounds inhibiting activation of the NLRP3 inflammasome can be promising treatments for these diseases. In this study, we conducted a phenotypic screening against NLRP3-dependent pyroptosis and discovered the hit compound 1, which showed moderate antipyroptotic activity. Chemistry efforts to improve potency of 1 resulted in a novel compound 59 (J114), which exhibited a half-maximal inhibitory concentration (IC50) of 0.077 ± 0.008 µM against cell pyroptosis. Interestingly, unlike all pyroptosis inhibitors currently reported, the activity of J114 showed significant differences in human- and mouse-derived cells. The IC50 of J114-mediated inhibition of IL-1ß secretion by human THP-1 macrophages was 0.098 µM, which was nearly 150-fold and 500-fold more potent than that of J774A.1 (14.62 µM) and bone marrow-derived macrophages (BMDMs) (48.98 µM), respectively. Further studies showed that J114 displayed remarkable inhibitory activity against NLRP3- and AIM2-but not NLRC4-dependent activation of caspase-1 and the release of IL-1ß in human THP-1 macrophages. Mechanistically, J114 disturbed the interaction of NLRP3 or AIM2 with the adaptor protein ASC and inhibited ASC oligomerization. Overall, our study identified a unique molecule that inhibits NLRP3 and AIM2 inflammasome activation and has species differences, which is worthy of further research to understand the differential regulation of the NLRP3 and AIM2 inflammasomes in humans and mice.

Developmental Characterization of Schizophrenia-Associated Gene Zswim6 in Mouse Forebrain.

Schizophrenia is a devastating neuropsychiatric disease with a globally 1% life-long prevalence. Clinical studies have linked Zswim6 mutations to developmental and neurological diseases, including schizophrenia. Zswim6's function remains largely unknown. Given the involvement of Zswim6 in schizophrenia and schizophrenia as a neurodevelopmental disease, it is important to understand the spatiotemporal expression pattern of Zswim6 in the developing brain. Here, we performed a comprehensive analysis of the spatiotemporal expression pattern of Zswim6 in the mouse forebrain by in situ hybridization with radioactive and non-radioactive-labeled riboprobes. Zswim6 mRNA was detected as early as E11.5 in the ventral forebrain. At E11.5-E13.5, Zswim6 was highly expressed in the lateral ganglionic eminence (LGE). The LGE consisted of two progenitor populations. Dlx+;Er81+ cells in dorsal LGE comprised progenitors of olfactory bulb interneurons, whereas Dlx+;Isl1+ progenitors in ventral LGE gave rise to striatal projection neurons. Zswim6 was not colocalized with Er81 in the dorsal LGE. In the ventral LGE, Zswim6 was colocalized with striatal progenitor marker Nolz-1. Zswim6 was highly expressed in the subventricular zone (SVZ) of LGE in which progenitors undergo the transition from proliferation to differentiation. Double labeling showed that Zswim6 was not colocalized with proliferation marker Ki67 but was colocalized with differentiation marker Tuj1 in the SVZ, suggesting Zswim6 expression in early differentiating neurons. Zswim6 was also expressed in the adjacent structures of medial and caudal ganglionic eminences (MGE, CGE) that contained progenitors of cortical interneurons. At E15.5 and E17.5, Zswim6 was expressed in several key brain regions that were involved in the pathogenesis of schizophrenia, including the striatum, cerebral cortex, hippocampus, and medial habenular nucleus. Zswim6 was persistently expressed in the postnatal brain. Cell type analysis indicated that Zswim6 mRNA was colocalized with D1R-expressing striatonigral and D2R-expressing striatopallidal neurons of the adult striatum with a higher colocalization in striatopallidal neurons. These findings are of particular interest as striatal dopamine D2 receptors are known to be involved in the pathophysiology of schizophrenia. In summary, the comprehensive analysis provides an anatomical framework for the study of Zswim6 function and Zswim6-associated neurological disorders.

Synergistic effects of combined treatment with ultrasound-mediated cisplatin-loaded microbubbles and atorvastatin on head and neck cancer.

BACKGROUND: Previously, we used ultrasound (US)-mediated cisplatin (CDDP)-loaded microbubbles (CDDP-MBs) to increase intratumoral CDDP level while decreasing systemic cytotoxicity. Statins have shown antitumorigenic properties. Our study investigated the effects of atorvastatin with CDDP-MBs and US on head neck cancer. METHODS: Cell viability analysis with CDDP-MBs and atorvastatin combined with US in FaDu cell line were tested. Cell proliferation and glutathione level were also evaluated. RESULTS: Both CDDP and atorvastatin reduced cell's viability. Coadministration of CDDP and atorvastatin resulted in synergistic inhibitory effect. After US sonication, cell viability with atorvastatin and CDDP was significantly reduced for CDDP combined with MBs (65.98% to 49.13%) and for CDDP-MBs (86.17% to 50.15%). CDDP-MBs combined with atorvastatin and US inhibited the proliferation of cells: 19.61% for CDDP-MBs + atorvastatin + US, 36.28% for CDDP + atorvastatin, and 71.73% for atorvastatin alone. Also, CDDP-MBs + atorvastatin + US induced apoptosis by decreasing cellular level of glutathione. CONCLUSIONS: Atorvastatin combined with MB-conjugated CDDP exerts synergistic inhibitory effect on head neck cancer.

State laws matter when it comes to school provisions for structured PE and daily PE participation.

The physical and mental benefits children receive from physical activity have been well documented, and physical education is a key way to ensure that physical activity opportunities are available during the school day. This study evaluates whether state PE laws are associated with school-level practices of requiring structured PE classes and whether students take PE classes daily. State laws were obtained as part of the National Cancer Institute's Classification of Laws Associated with School Students (CLASS) and were compiled for all 50 states and District of Columbia using Boolean keyword searches in LexisAdvance and WestlawNext. PE time requirements and state daily PE requirements in the laws were subsequently linked to school-required structured PE classes and daily PE in the School Nutrition and Meal Cost Study (SNMCS) Principal Survey. Logistic regression analyses were conducted while controlling for grade level, district child poverty rate, district race/ethnicity, school urbanicity, and school size. The state daily PE analysis also controlled for region. Schools located in a state that required at least 90 min of PE per week at the elementary level or 150 min of PE per week at the middle or high school levels had almost seven times higher odds of requiring structured PE. Schools located in a state that required daily participation of PE had almost five times higher odds of at least some students taking PE daily. State policymakers can utilize these findings to promote laws that require time for PE every week, daily if possible.

Usefulness of multi-labelling artificial intelligence in detecting rhythm disorders and acute ST-elevation myocardial infarction on 12-lead electrocardiogram.

Aims: To develop an artificial intelligence-based approach with multi-labelling capability to identify both ST-elevation myocardial infarction (STEMI) and 12 heart rhythms based on 12-lead electrocardiograms (ECGs). Methods and results: We trained, validated, and tested a long short-term memory (LSTM) model for the multi-label diagnosis of 13 ECG patterns (STEMI + 12 rhythm classes) using 60 537 clinical ECGs from 35 981 patients recorded between 15 January 2009 and 31 December 2018. In addition to the internal test above, we conducted a real-world external test, comparing the LSTM model with board-certified physicians of different specialties using a separate dataset of 308 ECGs covering all 13 ECG diagnoses. In the internal test, the area under the curves (AUCs) of the LSTM model in classifying the 13 ECG patterns ranged between 0.939 and 0.999. For the external test, the LSTM model for multi-labelling of the 13 ECG patterns evaluated by AUC was 0.987 ± 0.021, which was superior to those of cardiologists (0.898 ± 0.113, P < 0.001), emergency physicians (0.820 ± 0.134, P < 0.001), internists (0.765 ± 0.155, P < 0.001), and a commercial algorithm (0.845 ± 0.121, P < 0.001). Of note, the LSTM model achieved an accuracy of 0.987, AUC of 0.997, and precision, recall, and F 1 score of 0.952, 0.870, and 0.909, respectively, in detecting STEMI. Conclusions: We demonstrated the usefulness of an LSTM model in the multi-labelling detection of both rhythm classes and STEMI in competitive testing against board-certified physicians. This AI tool exceeding the cardiologist-level performance in detecting STEMI and rhythm classes on 12-lead ECG may be useful in prioritizing chest pain triage and expediting clinical decision-making in healthcare.

"Waiving" Goodbye to PE: State Law and School Exemption and Substitution Practices in the United States.

Purpose: The importance of schools providing physical education (PE) and promoting physical activity (PA) and the benefits of PA for children are well documented. However, a majority of students do not get the nationally recommended 60 min of daily PA. Many states grant waivers, substitutions, or exemptions from PE despite national recommendations. This study examined the association between state laws allowing for the use of PE substitutions and exemptions and school-level substitution and exemption practices. Methods: School-level PE exemption and substitution data from the 2014 School Health Policies and Practices Study were linked to state law data from the National Wellness Policy Study and the National Cancer Institute's 2013 Classification of Laws Associated with School Students. The analytic sample included 320 schools located in 42 states. Separate multivariable logistic regression models linked five types of school PE exemptions/substitutions to corresponding state laws, controlling for school characteristics. Results: Overall, 24 of the 42 states had laws addressing PE waivers, exemptions, or substitutions. Schools had higher odds of allowing PE substitutions for school sports (adjusted odds ratio (AOR), 3.59; 95% confidence interval (CI), 1.33-9.68), other school activities (AOR, 8.52; 95% CI, 2.90-25.03), and community sports (AOR, 4.30; 95% CI, 1.43-12.96) and allowing exemptions for fitness test scores (AOR, 4.67; 95% CI, 1.49-14.62) or vocational training (AOR, 5.92; 95% CI, 1.04-33.68) if state law allowed it, compared with schools in states that did not allow such practices. Conclusions: Given the connection between PA and beneficial outcomes for children, decision makers, school administrators, practitioners, advocates, and researchers should consider and further examine how PE waiver, exemption, and substitution policies and practices may affect students' PA and related outcomes.

Association of Family History With Incidence and Outcomes of Aortic Dissection.

BACKGROUND: Aortic dissection (AD) is a life-threatening emergency. However, the heritability and association of family history with late outcomes are unclear. OBJECTIVES: The purpose of this study was to evaluate the effect of family history of AD on the incidence and prognosis of AD and estimate the heritability and environmental contribution in AD in Taiwan. METHODS: Both cross-sectional and cohort studies were conducted using Taiwan National Health Insurance database. A registry parent-offspring relationship algorithm was used to reconstruct the genealogy of this population for heritability estimation. The cross-sectional study included 23,868 patients with a diagnosis of AD in 2015. The prevalence and adjusted relative risks (RRs) were evaluated, and the liability threshold model was used to examine the effects of heritability and environmental factors. Furthermore, a 1:10 propensity score-matched cohort comprising AD patients with or without a family history of AD was included to compare late outcomes in the cohort study. RESULTS: A family history of AD in first-degree relatives was associated with an RR of 6.82 (95% confidence interval [CI]: 5.12 to 9.07). The heritability of AD was estimated to be 57.0% for genetic factors, and 3.1% and 40.0% for shared and nonshared environmental factors, respectively. After excluding individuals with Marfan syndrome or bicuspid aortic valve, a family history of AD was associated with an RR of 6.56 (95% CI: 4.92 to 8.77) for AD. Furthermore, patients with AD and a family history of AD had a higher risk of later aortic surgery than those with AD without a family history (subdistribution hazard ratio: 1.40; 95% CI: 1.12 to 1.76). CONCLUSIONS: A family history of AD was a strong risk factor for AD. Furthermore, patients with AD with a family history of AD had a higher risk of later aortic surgery than those with no family history of AD.

Association of pregnancy outcomes in women with type 2 diabetes treated with metformin versus insulin when becoming pregnant.

BACKGROUND: Metformin use in pregnancy is controversial because metformin crosses the placenta and the safety on the fetus has not been well-established. This retrospective study aimed to compare pregnancy outcomes in women with preexisting type 2 diabetes receiving metformin or standard insulin treatment. METHODS: The cohort of this population-based study includes women of age 20-44 years with preexisting type 2 diabetes and singleton pregnancies in Taiwan between 2003 and 2014. Subjects were classified into three mutually exclusive groups according to glucose-lowering treatments received before and after becoming pregnant: insulin group, switching group (metformin to insulin), and metformin group. A generalized estimating equation model adjusted for patient age, duration of type 2 diabetes, hypertension, hyperlipidemia, retinopathy, and aspirin use was used to estimate the adjusted odds ratio (aOR) and 95% confidence interval (CI) of adverse pregnancy outcomes. RESULTS: A total of 1166 pregnancies were identified in the insulin group (n = 222), the switching group (n = 318) and the metformin group (n = 626). The insulin group and the switching group had similar pregnancy outcomes for both the mother and fetus, including risk of primary cesarean section, pregnancy-related hypertension, preeclampsia, preterm birth (< 37 weeks), very preterm birth (< 32 weeks), low birth weight (< 2500 g), high birth weight (> 4000 g), large for gestational age, and congenital malformations. The metformin group had a lower risk of primary cesarean section (aOR = 0.57; 95% CI, 0.40-0.82) and congenital malformations (aOR, 0.51; 95% CI; 0.27-0.94) and similar risk for the other outcomes as compared with the insulin group. CONCLUSIONS: Metformin therapy was not associated with increased adverse pregnancy outcomes in women with type 2 diabetes as compared with standard insulin therapy.