Atom-Modified gDNA Enhances Cleavage Activity of TtAgo Enabling Ultra-Sensitive Nucleic Acid Testing.

The DNA-guided (gDNA) Argonaute from Thermus thermophilus (TtAgo) has little potential for nucleic acid detection and gene editing due to its poor dsDNA cleavage activity at relatively low temperature. Herein, the dsDNA cleavage activity of TtAgo is enhanced by using 2'-fluorine (2'F)-modified gDNA and developes a novel nucleic acid testing strategy. This study finds that the gDNA with 2'F-nucleotides at the 3'-end (2'F-gDNA) can promote the assembly of the TtAgo-guide-target ternary complex significantly by increasing its intermolecular force to target DNA and TtAgo, thereby providing ≈40-fold activity enhancement and decreasing minimum reaction temperature from 65 to 60°C. Based on this outstanding advance, a novel nucleic acid testing strategy is proposed, termed FAST, which is performed by using the 2'F-gDNA/TtAgo for target recognition and combining it with Bst DNA polymerase for nucleic acid amplification. By integrating G-quadruplex and Thioflavin T, the FAST assay achieves one-pot real-time fluorescence analysis with ultra-sensitivity, providing a limit of detection up to 5 copies (20 µL reaction mixture) for miR-21 detection. In summary, an atom-modification-based strategy has been developed for enhancing the cleavage activity of TtAgo efficiently, thereby improving its practicability and establishing a TtAgo-based nucleic acid testing technology with ultra-sensitivity and high-specificity.

Physiochemical characterization and ameliorative effect of rice resistant starch modified by heat-stable α-amylase and glucoamylase on the gut microbial community in T2DM mice.

In the presented study, natural rice containing high resistant starch content was used as a raw material to produce rice resistant starch (RRS) through enzymatic hydrolysis with heat-stable α-amylase and glucoamylase. The chemical composition, structural characteristics and in vitro glycemic index (GI) of RRS were evaluated. The effects of RRS at different doses on the body weight, serum biochemical levels, pathological indexes, production of short-chain fatty acids (SCFAs) in the gut and the intestinal microbial composition in T2DM mice were investigated. The results of physiochemical characterization indicated that, relative to rice flour, RRS mainly comprising resistant starch had higher crystallinity (25.85%) and a more stable structure, which contributed to its lower digestibility and decreased GI in vitro. Compared with the model control group, 1 g per kg BW and 2 g per kg BW oral gavage dosages of RRS effectively enhanced the SCFA productivity in the T2DM mouse gut, as well as alleviating T2DM symptoms, involving an increase in body weight, reduction in fasting blood glucose, total cholesterol, triglyceride, low-density lipoprotein cholesterol, alanine transaminase and aspartate aminotransferase, and an increase in serum insulin and high-density lipoprotein cholesterol. Besides, 1 g per kg BW and 2 g per kg BW dosages of RRS mitigated T2DM-induced pancreas damage. Furthermore, up-regulation in the abundance of probiotics (Lactobacillus, Ruminococcus, etc.) and down-regulation in the number of harmful bacteria (Desulfovibrio, Prevotella, etc.) were observed in all RRS-treated groups. In summary, this work suggested that RRS prepared using heat-stable α-amylase and glucoamylase could be a potential functional component for amelioration of T2DM applied in the fields of food and pharmaceutics.

Hypoglycemic Activity of Rice Resistant-Starch Metabolites: A Mechanistic Network Pharmacology and In Vitro Approach.

Rice (Oryza sativa L.) is one of the primary sources of energy and nutrients needed by the body, and rice resistant starch (RRS) has been found to have hypoglycemic effects. However, its biological activity and specific mechanisms still need to be further elucidated. In the present study, 52 RRS differential metabolites were obtained from mouse liver, rat serum, canine feces, and human urine, and 246 potential targets were identified through a literature review and database analysis. A total of 151 common targets were identified by intersecting them with the targets of type 2 diabetes mellitus (T2DM). After network pharmacology analysis, 11 core metabolites were identified, including linolenic acid, chenodeoxycholic acid, ursodeoxycholic acid, deoxycholic acid, lithocholic acid, lithocholylglycine, glycoursodeoxycholic acid, phenylalanine, norepinephrine, cholic acid, and L-glutamic acid, and 16 core targets were identified, including MAPK3, MAPK1, EGFR, ESR1, PRKCA, FYN, LCK, DLG4, ITGB1, IL6, PTPN11, RARA, NR3C1, PTPN6, PPARA, and ITGAV. The core pathways included the neuroactive ligand-receptor interaction, cancer, and arachidonic acid metabolism pathways. The molecular docking results showed that bile acids such as glycoursodeoxycholic acid, chenodeoxycholic acid, ursodeoxycholic acid, lithocholic acid, deoxycholic acid, and cholic acid exhibited strong docking effects with EGFR, ITGAV, ITGB1, MAPK3, NR3C1, α-glucosidase, and α-amylase. In vitro hypoglycemic experiments further suggested that bile acids showed significant inhibitory effects on α-glucosidase and α-amylase, with CDCA and UDCA having the most prominent inhibitory effect. In summary, this study reveals a possible hypoglycemic pathway of RRS metabolites and provides new research perspectives to further explore the therapeutic mechanism of bile acids in T2DM.

Exosome-based engineering strategies for the diagnosis and treatment of oral and maxillofacial diseases.

Oral and maxillofacial diseases are one of the most prevalent diseases in the world, which not only seriously affect the health of patients' oral and maxillofacial tissues, but also bring serious economic and psychological burdens to patients. Therefore, oral and maxillofacial diseases require effective treatment. Traditional treatments have limited effects. In recent years, nature exosomes have attracted increasing attention due to their ability to diagnose and treat diseases. However, the application of nature exosomes is limited due to low yield, high impurities, lack of targeting, and high cost. Engineered exosomes can be endowed with better comprehensive therapeutic properties by modifying exosomes of parent cells or directly modifying exosomes, and biomaterial loading exosomes. Compared with natural exosomes, these engineered exosomes can achieve more effective diagnosis and treatment of oral and maxillary system diseases, and provide reference and guidance for clinical application. This paper reviews the engineering modification methods of exosomes and the application of engineered exosomes in oral and maxillofacial diseases and looks forward to future research directions.

The impact of DRG on resource consumption of inpatient with ischemic stroke.

Background: Diagnosis-related group (DRG) payments were gradually introduced and used in 12 public hospitals in L city. Given the high incidence and burden of ischemic stroke, the study aimed to assess the impact of DRG payment reform on inpatient medical resource utilization. Methods: Data were obtained from the DRG local database of the new Chinese cooperative medical program in L city. The study used interrupted time series analysis to examine changes in length of stay and medical costs before and after the reform, and also assessed changes in different subgroups. Results: There were 763 and 4,731 ischemic stroke patients in tertiary hospitals and 1953 and 10,439 patients in secondary hospitals before and after the DRG payment reform, respectively. After the reform, LOS was reduced 0.047 and 0.47 days in tertiary and secondary hospitals, respectively. Medical expenses decreased by 30.189 yuan in tertiary hospitals, but those increased by 44.918 yuan in secondary hospitals monthly. For gender, the average LOS reduced by 0.462 and 0.471 days for male and female in secondary hospitals. The change in medical expenses for male patients in tertiary hospitals and female in secondary hospitals were more significant, with a decrease of 65.396 yuan and increase of 56.257 yuan. The most pronounced change in resource consumption was seen for patients aged 85 years and older, with an increase in average LOS and medical expenses by 0.394 days and 382.422 yuan in tertiary hospitals. They showed a reduction in the average LOS by 1.480 days, and increase in the average medical expenses by 133.485 yuan in secondary hospitals monthly. Regarding disease severity, the most significant changes were seen in MCC patients. The average LOS decreased by 0.197 and 0.928 days and the average medical expenses decreased by 131.526 and 21.631 yuan in tertiary and secondary hospitals, respectively. Conclusion: The implementation of DRG payment system has led to a reduction in the LOS in various levels of hospitals, which would save in bed resources. However, DRG payment reform can help to control medical expenses for ultra-high cases, but it may not be useful to control the overall increase in medical expenses.

Synthesis of multicolor luminescent carbon dots based on carboxymethyl chitosan for cell imaging and wound healing application: In vitro and in vivo studies.

The construction of biomaterials that can facilitate wound healing is significantly challenging in the medical field, and bacterial infections increase this complexity. In this study, we selected the biomacromolecule carboxymethyl chitosan as a carbon source and citric acid as an auxiliary carbon source. We prepared carbon quantum dots with multicolor luminescence properties and higher quantum yields (QYs) using a facile one-pot hydrothermal method. We characterized them to select carbon dots (CDs) suitable for cell growth. Subsequently, their biocompatibility with L929 cells, antibacterial properties against Staphylococcus aureus, and efficiency in promoting wound healing in vivo were investigated. Our experimental results showed that CDs at an appropriate concentration had excellent bioimaging ability, were suitable for cell growth, and accelerated the healing of infected wounds. We believe these bioactive CDs have great potential in promoting wound healing.

Biosafety evaluation of BaSi2O2N2:Eu2+/PDMS composite elastomers.

In recent years, mechanoluminescent (ML) materials have shown great potential in stress sensing, mechanical energy collection and conversion, so they have attracted wide attention in the field of stomatology. In the early stage of this study, BaSi2O2N2:Eu2+ ML phosphors were synthesized by two-step high temperature solid state method, and then mixed with Polydimethylsiloxane (PDMS) in different proportions to obtain BaSi2O2N2:Eu2+/PDMS ML composites with different mass fractions (10%,20%,30%,40%,50%). Then its biosafety was evaluated by Cell Counting Kit-8 (CCK-8), Calcein-AM/PI fluorescence staining, hemolysis, oral mucosal irritation, acute and subacute systemic toxicity tests. The experimental results show that the biosafety of BaSi2O2N2:Eu2+/PDMS ML composite elastomers with different mass fraction is in line with the existing standards, and other related properties can be further studied.

Two-step widefield fundus fluorescein angiography-assisted laser photocoagulation in pediatric retinal vasculopathy: A pilot study.

Purpose: To introduce the procedures of two-step fundus fluorescein angiography (FFA) and evaluate its utility in the management of pediatric retinal vasculopathy. Materials and methods: In this retrospective study, medical records of 12 patients who received two-step FFA were studied. The two-step FFA consisted of step 1 [low-dose (LD)] FFA at an intravenous dose of 1.5 mg/kg fluorescein, followed by step 2 [reduced dose (RD)] FFA at a dose of 6.2 mg/kg fluorescein. Demographic data, including age, gender, diagnosis, weight, gestational age, birth weight, and weight on the examination day were taken, were collected. The results of two-step FFA and treatment were recorded. Results: A total of 20 eyes were studied. The top 5 common FFA changes in RD-FFA included peripheral avascular zone (15 eyes), fluorescein leakage (10 eyes), supernumerous vascular branching (10 eyes), neovascularization (NV) (8 eyes), and absence of the foveal avascular zone (6 eyes). LD-FFA was efficient to show all the NV without severe vitreous dye in 8/8 (100.0%) eyes with NV, partial peripheral avascular zone in 11/15 (73.3%) eyes, while RD-FFA always offered more information in all the eyes. Thirteen eyes had laser photocoagulation under the guidance of LD-FFA. In 4 (30.8%) eyes, RD-FFA revealed more lesions and an immediate relaser was performed. Laser photocoagulation was successfully performed in all the 13 eyes in one session without being rearranged. After a median follow-up of 28.1 months, all the eyes were in a stable status. Conclusion: Step-one LD-FFA acted as a pre-FFA to show the NV, and step-two RD-FFA acted as a double-check. The modified strategy may be a helpful clinical adjuvant in the laser photocoagulation of pediatric retinal disorders, especially for young ophthalmologists.

Prophylactic juxtapapillary laser photocoagulation in pediatric morning glory syndrome.

AIM: To determine the anatomic and visual outcomes of prophylactic juxtapapillary laser photocoagulation treatment alone in the prevention of retinal detachment (RD) in a cohort of pediatric patients diagnosed with morning glory syndrome (MGS). METHODS: A total of 24 eyes of 22 consecutive patients aged 0-15y diagnosed with MGS treated with prophylactic juxtapapillary laser photocoagulation alone were reviewed. Data including demographics, ocular examination, anatomic and visual outcomes, following treatment and complications were collected. RESULTS: Two patients had bilateral laser treatment and 20 had monocular laser treatment. The age at treatment of 13 (59.1%) patients was less than 12mo. The presenting symptoms included strabismus (6/22, 27.3%), decreased vision (2/22, 9.1%), and routine fundus screening (14/22, 63.6%). Fifteen (68.2%) patients underwent cranial magnetic resonance imaging (MRI) examinations, and 3 of those 15 (20.0%) had abnormal findings in the nervous system. Based on preoperative wide-field fundus photography and B-scan echography, all (100.0%) eyes had no obvious RD. On postoperative 1mo and 6mo and the following follow-ups, the anatomic outcomes of all eyes remained stable. The mean follow-up duration was 27.7±17.5mo. No severe complications were found. Preoperative visual acuity acquired from 2 (9.1%) patients ranged from light perception to 20/200. Postoperative acuity acquired from 11 (50.0%) patients ranged from light perception to 20/125. CONCLUSION: The preliminary anatomic and visual outcomes of prophylactic juxtapapillary laser treatment alone in pediatric MGS patients are relatively stable in a short-term follow-up. Further long-term clinical observation will be needed to confirm its efficacy and safety.

Secondary glaucoma caused by a special type of persistent fetal vasculature.

PURPOSE: To investigate the clinical features and surgical outcomes in infants with glaucoma secondary to a special anterior-anterior type of persistent fetal vasculature (AAPFV). METHODS: This study retrospectively reviewed the medical records of infants who underwent of the synechialysis, pupilloplasty, with or without lensectomy and limbal vitrectomy due to AAPFV and with at least 6 months of postoperative follow-up. RESULTS: Eleven patients were included. The median age at surgery was 4.0 months (interquartile range: 7 months). The mean follow-up was 21.0 ± 11.3 months. All patients achieved a normal anterior chamber, improved pupillary configuration, and normal intraocular pressure (IOP), except one that developed phthisis bulbi at the last visit. A total of 81.8% (9/11) eyes exhibited improved corneal transparency. Histopathologic findings of four pupillary membranous specimens under light microscopy showed similar components compared with PFV. Two eyes developed postoperative complications, including retinal detachment and hyphema, requiring additional surgeries. Postoperative visual acuity changed from no light perception to light perception in 6/9 patients. CONCLUSIONS: AAPFV is a special type of PFV with a potential for secondary glaucoma. Surgery treatment may offer better vision with improved cosmetic outcomes and a better controlled IOP. TRIAL REGISTRATION: The study was approved by the local institutional review board (IRB) (Approval No. XHEC-D-2021-043, Ethical Committee of Xin Hua Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China).

Early Sexual Initiation Is Associated with Suicide Attempts among Chinese Young People.

This study aimed to investigate the association between early sexual initiation and suicide attempts (SAs) among Chinese young people. Our analysis included 9131 college students who had sexual experience from a national sample of 31 provincial administrative regions. Self-reported age at first intercourse was categorized as ≤15, 15-18, and ≥18 years, and the experience of SAs was recorded and analyzed. Compared with females whose sexual debut age was ≥18 years, those ≤15 years (defined as early sexual initiation) had higher odds of SAs in both the forced debut group (odds ratio (OR) 17.04, 95% confidence interval (CI) 4.87-59.66) and the voluntary debut group (OR 37.63, 95% CI 14.96-94.66). Early sexual initiators who lived in rural areas were more inclined to have SAs (female: OR 65.76, 95% CI 19.80-218.42; male: OR 15.39, 95% CI 1.64-144.19). Early sexual initiators who never had parent-child communication about sex were more likely to report having SAs (female: OR 37.81, 95% CI 12.28-116.46). Sexual debut during adolescence, particularly early sexual initiation, was a crucial risk factor for SAs among both sexes. Comprehensive sexuality education and smooth parental communication about sex will provide a supportive environment for young people and hence reduce the potential risks of SAs.

Bromine Radical (Br• and Br2•-) Reactivity with Dissolved Organic Matter and Brominated Organic Byproduct Formation.

Dissolved organic matter (DOM) is a major scavenger of bromine radicals (e.g., Br• and Br2•-) in sunlit surface waters and during oxidative processes used in water treatment. However, the literature lacks quantitative measurements of reaction rate constants between bromine radicals and DOM and lacks information on the extent to which these reactions form brominated organic byproducts. Based on transient kinetic analysis with different fractions and sources of DOM, we determined reaction rate constants for DOM with Br• ranging from <5.0 × 107 to (4.2 ± 1.3) × 108 MC-1 s-1, which are comparable with those of HO• but higher than those with Br2•- (k = (9.0 ± 2.0) × 104 to (12.4 ± 2.1) × 105 MC-1 s-1). Br• and Br2•- attack the aromatic and antioxidant moieties of DOM via the electron transfer mechanism, resulting in Br- release with minimal substitution of bromine into DOM. For example, the total organic bromine was less than 0.25 µM (as Br) at environmentally relevant bromine radicals' exposures of ∼10-9 M·s. The results give robust evidence that the scavenging of bromine radicals by DOM is a crucial step to prevent inorganic bromine radical chemistry from producing free bromine (HOBr/OBr-) and subsequent brominated byproducts.

LENS CAPSULAR FLAP TRANSPLANTATION AS PRIMARY TREATMENT FOR CLOSURE OF LARGE MACULAR HOLES.

PURPOSE: To report the long-term outcomes of lens capsular flap transplantation (LCFT) as initial treatment for large macular holes (MHs). METHODS: Thirteen consecutive eyes with large MHs who received LCFT as primary treatment were reviewed retrospectively. All enrolled eyes underwent standard 23-gauge vitrectomy, internal limiting membrane peeling, LCFT, and 15% perfluoropropane tamponade. Autologous whole blood was applied in selected eyes to make the LCT intact. A face-down position maintained for 2 weeks postoperatively. Data including demographic information, medical history, anatomical and functional outcomes, and complications were recorded. RESULTS: The mean preoperative MHs diameter was 979.42 ± 388.28 µm. Eight eyes received autologous LCFT, and the other five eyes received allogenic LCFT. Whole blood was applied in seven eyes. The mean follow-up duration was 19.57 ± 6.24 months (range: 12.0-32.2 months). The macular hole was successfully closed in all cases (13/13). The median best-corrected visual acuity improved from 1.76 (interquartile range, 1.23-1.91) logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,150) preoperatively to 1.16 ± 0.47 logarithm of the minimum angle of resolution (mean Snellen acuity: 20/290) (P < 0.01) at the last visit. No severe complications were noted. CONCLUSION: Lens capsular flap transplantation may help to improve the closure rate and visual outcomes in large MHs, which could be an alternative method as primary treatment for large MHs.

N,N-Dimethylformamide as Carbon Synthons for the Synthesis of N-Heterocycles: Pyrrolo/Indolo[1,2-a]quinoxalines and Quinazolin-4-ones.

N,N-dimethylformamide (DMF) as synthetic precursors contributing especially the methyl, acyl, and amino groups has played a significant role in heterocycle syntheses and functionalization. In this protocol, a wide range of pyrrolo/indolo[1,2-a]quinoxalines and quinazolin-4-ones were obtained in moderate to good yields by using elemental iodine without any metal or peroxides. We considered that N-methyl and N-acyl of DMF participate and complete the reaction separately through different mechanisms, which displayed potential still to be explored of DMF.

Early detection of ocular abnormalities in a Chinese multicentre neonatal eye screening programme-1-year result.

PURPOSE: Early detection of ocular abnormalities in newborns is essential for timely diagnosis and treatment. This study aimed to assess the 1-year result of a multicentre prospective neonatal eye examination programme with wide-field digital imaging system in China. METHODS: A multicentre collaborative prospective study group for neonatal eye screening was established in nine hospitals, including eight Maternal and Children's Hospitals, and one general hospital across China from July 2016 to June 2017. Ocular examinations were performed on newborns within 28 days after birth using a wide-field digital imaging system. Data were reviewed and analysed. The primary outcome was the prevalence of ocular abnormalities in neonates. RESULTS: We detected 13 514 (20.91%) abnormal cases in 64 632 newborns. The most frequent abnormality was retinal haemorrhage (RH; 11.83%). Most of mild RH resolved spontaneously. Among those who were beyond retinopathy of prematurity (ROP) screening criteria of China (gestational age ≥32 w and birthweight ≥2000 g), the total number of neonates with ocular abnormality was 12 218/62 799(19.45%). 59.44% of neonatal ocular abnormalities detected (accounting for 11.56% of all the screened population) needed further interference or observation. Among them, 258 patients (0.41% of all the screened population) needed immediate or timely intervention, including congenital cataract, retinal detachment, retinoblastoma and other ocular abnormalities. One thousand and ninety-eight patients (1.75% of all the screened neonates) should be followed up closely and needed further diagnosis or intervention if necessary, such as ROP or ROP-like retinopathy, familial exudative vitreoretinopathy and persistent hyperplasia of primary vitreous. Five thousand nine hundred and six patients (9.4%) with minor clinical significance needed short-term follow-up. CONCLUSIONS: This prospective multicentre study of newborn ocular examination showed a relatively high prevalence of ocular abnormalities. There are a relatively high percentage of congenital eye pathology that required further referral and treatment in those neonates who were not screened routinely. According to the benefits and risks associated with neonatal eye examinations, neonatal ocular screening programme can detect ocular abnormalities at the very early stage and may play a positive role in promoting paediatric eye health.

Clinical and Echographic Features of Morning Glory Disc Anomaly in Children: A Retrospective Study of 249 Chinese Patients.

PURPOSE: To report the clinical and echographic features, the prevalence of retinal detachment (RD), and associated visual acuity in a cohort of pediatric patients with morning glory disc anomaly (MGDA). METHODS: This was a retrospective review of 249 pediatric patients with MGDA (271 eyes) seen at the Dept. of Ophthalmology, Xinhua Hospital. Their medical records were reviewed for demographic data and ocular and systemic findings. The maximal depth and width of the cavity were measured using standardized echographic images. The ratios of cavitary depth to axial length, cavitary depth to maximal cavitary width, and the product of cavitary depth and width were calculated and used to indicate the relative size of the excavation. The clinical and echographic findings were correlated with visual acuity and the occurrence of RD of the patient. RESULTS: The relative size of the excavation and the presence of RD were positively associated with increased risk of poor vision (p < 0.05). The presence of persistent fetal vasculature was not associated with the risk of RD and poor vision. The ratio of cavitary depth to axial length more than or equal to 0.25 conferred an increased risk of RD (OR, 2.101; 95% CI, 1.469-3.003). CONCLUSIONS: Clinical and echographic features of MGDA may be used in predicting the risk of RD. Measuring the relative size of excavation via echography may guide the follow-ups and assist in the early diagnosis of RD.

LONG-TERM SURGICAL OUTCOMES OF LENS CAPSULAR FLAP TRANSPLANTATION IN THE MANAGEMENT OF REFRACTORY MACULAR HOLE.

PURPOSE: To report long-term surgical outcomes of autologous and allogenic lens capsular flap transplantation (LCFT) in refractory macular hole (MH) treatment. METHODS: Fifty consecutive eyes with refractory MH who received LCFT were reviewed retrospectively. Twelve eyes underwent autologous LCFT (LCF obtained from the same eye in 7 eyes and the fellow eye in 5 eyes) and 38 eyes with allogenic LCFT. All eyes underwent complete vitrectomy, internal limiting membrane peeling if not peeled, LCF transplantation, and 15% perfluoropropane tamponade. Simultaneous autologus whole-blood application was applied in 31 eyes to reduce LCF dislocation. The patients maintained a facedown position for 2 weeks postoperatively. Demographic information, functional results, and structural changes were evaluated. RESULTS: The mean preoperative MH diameter was 1,102.00 µm ± 561.63 µm. The mean follow-up duration was 18.50 months ± 6.05 months (range, 12.0-38.9 months). The MH was completely closed in 48 eyes (96.00%) (18 eyes receiving autologous LCFT and 30 receiving allogenic LCFT). There are no differences of age, previous MH surgery times, MH diameter, preoperative and postoperative best-corrected visual acuity, and closure rate between the subgroups. The median visual acuity improved from 1.78 (interquartile range, 1.28-1.85) logarithm of the minimum angle of resolution (median Snellen acuity: 20/1,200) preoperatively to 1.00 (interquartile range, 0.90-1.70) logarithm of the minimum angle of resolution (median Snellen acuity: 20/200) (P < 0.01) in all patients. CONCLUSION: Both autologous and allogenic LCFT application may provide anatomical and visual improvements in refractory MH cases. Blood application can be applied in selected cases to reduce LCF dislocation. LCFT can be performed as first-line treatment for refractory MHs.