Generalization of a Deep Learning Model for Continuous Glucose Monitoring-Based Hypoglycemia Prediction: Algorithm Development and Validation Study.

Background: Predicting hypoglycemia while maintaining a low false alarm rate is a challenge for the wide adoption of continuous glucose monitoring (CGM) devices in diabetes management. One small study suggested that a deep learning model based on the long short-term memory (LSTM) network had better performance in hypoglycemia prediction than traditional machine learning algorithms in European patients with type 1 diabetes. However, given that many well-recognized deep learning models perform poorly outside the training setting, it remains unclear whether the LSTM model could be generalized to different populations or patients with other diabetes subtypes. Objective: The aim of this study was to validate LSTM hypoglycemia prediction models in more diverse populations and across a wide spectrum of patients with different subtypes of diabetes. Methods: We assembled two large data sets of patients with type 1 and type 2 diabetes. The primary data set including CGM data from 192 Chinese patients with diabetes was used to develop the LSTM, support vector machine (SVM), and random forest (RF) models for hypoglycemia prediction with a prediction horizon of 30 minutes. Hypoglycemia was categorized into mild (glucose=54-70 mg/dL) and severe (glucose<54 mg/dL) levels. The validation data set of 427 patients of European-American ancestry in the United States was used to validate the models and examine their generalizations. The predictive performance of the models was evaluated according to the sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). Results: For the difficult-to-predict mild hypoglycemia events, the LSTM model consistently achieved AUC values greater than 97% in the primary data set, with a less than 3% AUC reduction in the validation data set, indicating that the model was robust and generalizable across populations. AUC values above 93% were also achieved when the LSTM model was applied to both type 1 and type 2 diabetes in the validation data set, further strengthening the generalizability of the model. Under different satisfactory levels of sensitivity for mild and severe hypoglycemia prediction, the LSTM model achieved higher specificity than the SVM and RF models, thereby reducing false alarms. Conclusions: Our results demonstrate that the LSTM model is robust for hypoglycemia prediction and is generalizable across populations or diabetes subtypes. Given its additional advantage of false-alarm reduction, the LSTM model is a strong candidate to be widely implemented in future CGM devices for hypoglycemia prediction.

Lens Autofluorescence Based Advanced Glycation End Products (AGEs) Measurement to Assess Risk of Osteopenia Among Individuals Under the Age of 50.

Introduction: Simple non-invasive biomarker is urgently needed to detect the largely silent osteopenia in order to prevent osteoporosis-related fracture later in life. The accumulation of advanced glycation end products (AGEs) has been related to reduced bone density and osteoporotic fractures. Whether lens autofluorescence (LAF) based AGEs (LAF-AGEs) measurement could be used to assess the risk of osteopenia is aimed to investigate in this paper. Methods: Through routine health examination, 368 individuals under the age of 50 were enrolled. A dual-energy X-ray absorptiometry (DXA) device was used to measure bone mineral density (BMD) of the forearm and determine osteopenia. AGE levels were derived with LAF along with the other demographic and laboratory parameters. After deriving the age-adjusted AGE levels (AALs), a linear regression analysis and an ordered logistic regression analysis were applied to examine the associations between osteopenia and LAF-AGEs as well as AALs. Results: Negative correlations (Pearson r = -0.16, p < 0.001) were found between LAF-AGEs and T-scores. Higher AALs were significantly associated (p = 0.004) with escalated level of osteopenia in the ordered logistic analysis. Discussion: After reviewing the relevant studies, it is concluded that LAF-AGE is a more stable measure of long-term metabolic dysfunction than circulating AGE. LAF-AGEs are a valid, practical and non-invasive parameter for osteopenia risk evaluation. Further studies with longer follow-up will be helpful to clarify its effectiveness for osteoporosis risk assessment.

Aging weakens Th17 cell pathogenicity and ameliorates experimental autoimmune uveitis in mice.

Aging-induced changes in the immune system are associated with a higher incidence of infection and vaccination failure. Lymph nodes, which filter the lymph to identify and fight infections, play a central role in this process. However, careful characterization of the impact of aging on lymph nodes and associated autoimmune diseases is lacking. We combined single-cell RNA sequencing (scRNA-seq) with flow cytometry to delineate the immune cell atlas of cervical draining lymph nodes (CDLNs) of both young and old mice with or without experimental autoimmune uveitis (EAU). We found extensive and complicated changes in the cellular constituents of CDLNs during aging. When confronted with autoimmune challenges, old mice developed milder EAU compared to young mice. Within this EAU process, we highlighted that the pathogenicity of T helper 17 cells (Th17) was dampened, as shown by reduced GM-CSF secretion in old mice. The mitigated secretion of GM-CSF contributed to alleviation of IL-23 secretion by antigen-presenting cells (APCs) and may, in turn, weaken APCs' effects on facilitating the pathogenicity of Th17 cells. Meanwhile, our study further unveiled that aging downregulated GM-CSF secretion through reducing both the transcript and protein levels of IL-23R in Th17 cells from CDLNs. Overall, aging altered immune cell responses, especially through toning down Th17 cells, counteracting EAU challenge in old mice.

A single-cell transcriptomic landscape of the lungs of patients with COVID-19.

The lung is the primary organ targeted by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), making respiratory failure a leading coronavirus disease 2019 (COVID-19)-related mortality. However, our cellular and molecular understanding of how SARS-CoV-2 infection drives lung pathology is limited. Here we constructed multi-omics and single-nucleus transcriptomic atlases of the lungs of patients with COVID-19, which integrate histological, transcriptomic and proteomic analyses. Our work reveals the molecular basis of pathological hallmarks associated with SARS-CoV-2 infection in different lung and infiltrating immune cell populations. We report molecular fingerprints of hyperinflammation, alveolar epithelial cell exhaustion, vascular changes and fibrosis, and identify parenchymal lung senescence as a molecular state of COVID-19 pathology. Moreover, our data suggest that FOXO3A suppression is a potential mechanism underlying the fibroblast-to-myofibroblast transition associated with COVID-19 pulmonary fibrosis. Our work depicts a comprehensive cellular and molecular atlas of the lungs of patients with COVID-19 and provides insights into SARS-CoV-2-related pulmonary injury, facilitating the identification of biomarkers and development of symptomatic treatments.

Prognostic Significance of the Lymph Node Ratio in Surgical Patients With Distal Cholangiocarcinoma.

BACKGROUND: The aim of this study was to compare the prognostic impact of the lymph node ratio (LNR) versus positive lymph node count (PLNC) in patients who had undergone resection for distal cholangiocarcinoma. METHODS: We identified 448 patients with resected distal cholangiocarcinoma from the Surveillance, Epidemiology, and End Results database. The X-Tile program was used to calculate the cutoff values for the LNR and PLNC that discriminate survival. The overall survival and cancer-specific survival rates were calculated. Relationships between clinicopathological factors and patient survival were assessed using univariate and multivariate analyses. RESULTS: The optimal cutoff values for the LNR and PLNC were 0.45 and 3, respectively. Univariate analysis revealed that tumor size, the American Joint Committee on Cancer stage, T stage, the LNR and PLNC were significantly associated with prognosis (P < 0.05). Multivariate analysis demonstrated that the LNR, T stage, and tumor size were independent prognostic factors for cancer-specific and overall survival, whereas PLNC was not. In the subgroup of patients with positive lymph nodes, patients with an LNR of greater than 0.45 had significantly worse cancer-specific survival (hazard ratio, 2.418; 95% confidence interval, 1.588 to 3.682; P < 0.001) and overall survival (hazard ratio, 2.149; 95% CI, 1.421 to 3.249; P < 0.001) than those with an LNR of 0.45 or less. CONCLUSIONS: The LNR was a better predictor of long-term prognosis than PLNC in patients with distal cholangiocarcinoma.

The Combined Antitumor Effects of 125I Radioactive Particle Implantation and Cytokine-Induced Killer Cell Therapy on Xenograft Hepatocellular Carcinoma in a Mouse Model.

The combination of radiotherapy and immunotherapy has shown great promise in eradicating tumors. For example, 125I radioactive particle implantation and cytokine-induced killer cell therapies have demonstrated efficacy in treating hepatocellular carcinoma. However, the mechanism of this combination therapy remains unknown. In this study, we utilized cytokine-induced killer cells obtained from human peripheral blood mononuclear cells along with 125I radioactive particle implantation to treat subcutaneous hepatocellular carcinoma xenograft tumors in BALB/c nude mice. The effects of combination therapy on tumor growth, tumor cell apoptosis and proliferation, animal survival, and immune indexes were then assessed. The results indicated that 125I radioactive particle implantation combined with cytokine-induced killer cells shows a much greater antitumor therapeutic effect than either of the therapies alone when compared to control treatments. Mice treated with a combination of radiotherapy and immunotherapy displayed significantly reduced tumor growth. 125I radioactive particle implantation upregulated the expression of major histocompatibility complex (MHC) class I chain-related gene A in hepatocellular carcinoma cells and enhanced cytokine-induced killer cell-mediated apoptosis through activation of caspase-3. Furthermore, cytokine-induced killer cells supplied immune substrates to induce a strong immune response after 125I radioactive particle implantation therapy. In conclusion, 125I radioactive particle implantation combined with cytokine-induced killer cell therapy significantly inhibits the growth of human hepatocellular carcinoma cells in vivo and improves animal survival times through mutual promotion of antitumor immunity, presenting a promising therapy for hepatocellular carcinoma.

Prevention of common bile duct injury during laparoscopic cholecystectomy.

BACKGROUND: Since the widespread adoption of laparoscopic cholecystectomy (LC) in the late 1980s, a rise in common bile duct (CBD) injury has been reported. We analyzed the factors contributing to a record of zero CBD injuries in 10 000 consecutive LCs. METHODS: The retrospective investigation included 10 000 patients who underwent LC from July 1992 to June 2007. LC was performed by 4 teams of surgeons. The chief main surgeon of each team has had over 10 years of experience in hepatobiliary surgery. Calot's triangle was carefully dissected, and the relationship of the cystic duct to the CBD and common hepatic duct was clearly identified. A clip was applied to the cystic duct at the neck of the gallbladder and the duct was incised with scissors proximal to the clip. The cystic artery was dissected by the same method. Then, the gallbladder was dissected from its liver bed. A drain was routinely left at the gallbladder bed for 1-2 days postoperatively. RESULTS: No CBD injuries occurred in 10 000 consecutive LCs, and there were 16 duct leaks (0.16%). Among these, there were 10 Luschka duct leaks (0.1%) and 6 cystic duct leaks (0.06%). Four hundred thirty cases were converted to open cholecystectomy (OC), giving a conversion rate of 4.3%. After a mean follow-up of 17.5 months (range 6-24 months), no postoperative death due to LC occurred, and good results were observed in 95% of the patients. CONCLUSIONS: In our 10 000 LCs with zero CBD injuries, the techniques used and practices at our department have been successful. Surgeon's expertise in biliary surgery, preoperative imaging, precise operative procedures, and conversion from LC to OC when needed are important measures to prevent CBD injuries.

[Study on inhibiting the intimal hyperplasia after rabbit artery injury by local transfection of tissue-type plasminogen activator gene].

AIM: To observe the effects of local transfection of tissue-type plasminogen activator(tPA) gene on intimal hyperplasia of right external iliac artery in rabbits after operation injury, and its possible mechanism. METHODS: Microsurgery injury was used to establish the intimal injury model of right external iliac artery in rabbits. 105 male New zealand rabbits were randomly divided into 3 groups (35 rabbits each group). Group A was normal saline control group, group B was pBudCE4.1-transfected group, and group C was pBudCE4.1/tPA-tansfected group. The normal saline, pBudCE4.1 and pBudCE4.1/tPA transfection solutions were injected into injured vessel walls. Each group was again divided into five subgroups (7 rabbits each subgroup) which were sacrificed at different time (2 d, 3 d, 7 d, 14 d and 28 d after operation). The injured vascular specimens were then harvested for pathologic examination, electron microscope observation, RT-PCR and immunohistochemical staining detection. RESULTS: The intimal thickness and area of vessel walls in group C at every time points after operation were significantly less than those in group A and group B (P<0.01). The stenosis rate of vessels in group C at 28 days after operation decreased by 51.5% and 54.2%, respectively, as compared with groups A and B. The expression of tPA mRNA in group C was significantly higher than that in groups A and B at every time points after operation (P<0.01), reaching the peak at 7 days. The scanning electron microscope examination showed that there were a few thrombocytes adhering to vessel walls in group C but no thrombus, whereas a lot of thrombocytes and thrombi on vessel walls in groups A and B. Immunohistochemical staining exhibited that platelet-derived growth factor (PDGF)-positive cells in the vessels of group C were significantly more than those in group A and B (P<0.01). CONCLUSION: Local transfection of tPA gene can inhibit hyperplasia of neo-intima and prevent restenosis, which is proof of concept for gene therapy of intimal hyperplasia.

Role of NF-kB in multiple organ dysfunction during acute obstructive cholangitis.

AIM: To elucidate the role of NF-kB activation in the development of multiple organ dysfunction (MOD) during acute obstructive cholangitis (AOC) in rats. METHODS: Forty-two Wistar rats were divided into three groups: the AOC group, the group of bile duct ligation (BDL group), and the sham operation group (SO group). All the animals in the three groups were killed in the 6th and 48th hour after operation. Morphological changes of vital organs were observed under light and electron microscopy. NF-kB activation was determined with Electrophoretic Mobility Shift Assay (EMSA). Arterial blood gas analyses and the serum levels of lactate dehydrogenase (LDH), alanine aminotransferase (ALT), blood urea nitrogen (BUN) and creatinine were performed. The concentrations of TNF-alpha and IL-6 in plasma were also measured. RESULTS: The significant changes of histology and ultrastructure of vital organs were observed in AOC group. By contrast, in BDL group, all the features of organs damage were greatly reduced. Expression of NF-kB activation in various tissues increased in AOC group when compared to other two groups. At 6 h, the arterial pH in three groups was 7.52+/-0.01, 7.46+/-0.02, and 7.45+/-0.02, and the blood pCO(2) was 33.9+/-0.95 mmHg, 38.1+/-0.89 mmHg, 38.9+/-0.94 mmHg, there was difference in three groups (P<0.05). At 48 h, the blood pH values in three groups was 7.33+/-0.07, 7.67+/-0.04, and 7.46+/-0.03, and blood HCO(3)(-) was 20.1+/-1.29 mmol x L(-1), 26.7+/-1.45 mmol x L(-1) and 27.4+/-0.35 mmol x L(-1), there was also difference in three groups (P<0.05). In AOC group, Levels of LDH, ALT, BUN and creatinine were 1,6359.9+/-2,278.8 nkat x L(-1), 5,796.2+/-941.9 nkat.L(-1), 55.7+/-15.3 mg/dl, and 0.72+/-0.06 mg/dl, which were higher than in SO group (3,739.1+/- 570.1 nkat x L(-1), 288.4+/-71.7 nkat x L(-1), 12.5+/-2.14 mg/dl, and 0.47+/-0.03 mg/dl) (P<0.05). Levels of plasma TNF-alpha and IL-6 in AOC at 48 h were 429+/-56.62 ng x L(-1) and 562+/-57 ng x L(-1), which increased greatly when compared to BDL group (139+/-16 ng x L(-1), 227+/-43 ng x L(-1)) and SO group (74+/-10 ng x L(-1), 113+/-19 ng x L(-1)) (P<0.05). CONCLUSION: The pathological damages and the NF-kB activation of many vital organs excised during AOC. These findings have an important implication for the role of NF-kB activation in MOD during AOC.

Mononuclear macrophages in pathogenesis of acute lung injury during acute obstructive cholangitis.

OBJECTIVE: To determine the role of mononuclear macrophages in the pathogenesis of acute lung injury during acute obstructive cholangitis. METHODS: Sixty Wistar rats were used to study the correlation between the behavior of mononuclear macrophages and acute pulmonary injury during acute obstructive cholangitis (AOC). Animal model of AOC was made according to the method that the common bile duct was injected with Escherichia coli and ligated. The rats were killed at 6 h, 12 h, 24 h and 48 h after operation. The phagocytic function of Kupffer cells (KCs), the number of alveolar macrophages (AMs) in bronchoalveolar lavage liquid, and the extravascular water content of lung tissue were measured. The levels of lipid peroxide (LPO) and supperoxide dismutase (SOD) were determined too. Pathological alterations of liver and lung tissue were observed under light and electron microscopes. RESULTS: KCs phagocytic function was significantly elevated at the 6th hour but markedly decreased from the 24th hour to the 48th hour in the AOC group as compared with the control (P<0.05). From the 12th to the 48th hour, the number of AMs, the extravascular water content of lung tissue, and the content of LPO significantly increased, but the SOD level of lung tissue decreased greatly (P<0.05). Morphologically, KCs proliferated diffusely in the early period in livers of the AOC group, but decreased markedly in the late period. Mitochondria of KCs were swollen or even vacuolated; focal cytoplasmic degeneration and many myeli like figures could be seen in the cytoplasm. The changes of injury such as disturbance of pulmonary capillary blood circulation, degeneration and/or necrosis of the lung tissue and endothelium, and inflammatory reactions could be observed. In other two groups, no evident morphological changes were observed. CONCLUSIONS: KCs phagocytic function is decreased, whereas AM is activated by the invading bacteria to release such inflammatory mediators as free radicals, resulting in acute pulmonary injury. It seems that there is a close relationship between the functional status of mononuclear macrophages and the development of acute lung injury. The dysfunction of mononuclear macrophages may play an important role in the pathogenesis of multiple organ damage, especially acute pulmonary injury.