Plasma and Urinary Platelet Factor 4 as Biomarkers for Cardiovascular Risk in Children with Chronic Kidney Disease.

Children suffering from chronic kidney disease (CKD) have a high risk of cardiovascular disease (CVD). The early detection and diagnosis of subclinical CVD in pediatric CKD can reduce mortality later in life. Plasma factor 4 (PF4) is a chemokine released by activated platelets. We examined whether or not PF4 in the plasma and urine, its kidney function normalized ratio, and fractional excretion have differential associations with CVD risk markers in 139 youths aged 3 to 18 years old with CKD stages G1-G4. Significant negative correlations were observed between plasma PF4 and cardiovascular surrogate markers, such as the left ventricular mass index (LVMI), carotid intima-media thickness (cIMT), and pulse wave velocity (PWV). The plasma PF4/creatinine (Cr) ratio was lower in CKD children with a high daytime BP and 24 h BP, high BP load, and nocturnal non-dipping status. After adjusting for confounders, the plasma PF4 and plasma PF4/Cr ratio still independently predicted an abnormal ABPM profile. In addition, both the plasma PF4 and plasma PF4/Cr ratio presented a negative correlation with the L-arginine and asymmetric dimethylarginine ratio. These findings provide convincing evidence supporting the link between PF4 and CVD markers in pediatric CKD. Our study highlights the importance of further research to assess the performance of PF4-related biomarkers in predicting CVD events and CKD progression in children with CKD.

Pregnancy Zone Protein as an Emerging Biomarker for Cardiovascular Risk in Pediatric Chronic Kidney Disease.

Cardiovascular disease (CVD) is a significant cause of mortality and morbidity among children with chronic kidney disease (CKD). The causes of pediatric CKD differ from those in adults, as congenital anomalies in the kidney and urinary tract (CAKUT) are the leading causes in childhood. Identifying ideal markers of CVD risk early is crucial for CKD children to improve their care. Previously, we screened differentially expressed proteins in CKD children with or without blood pressure (BP) abnormalities and identified pregnancy zone protein (PZP). In 106 children and adolescents with CKD stages G1-G4, we analyzed plasma PZP concentration. The associations between PZP and ambulatory BP monitoring (ABPM) profile, parameters of cardiac and carotid ultrasounds, indices of arterial stiffness, and nitric oxide (NO) parameters were determined. We observed that PZP positively correlated with arterial stiffness indices, beta index, and pulse wave velocity in CAKUT. CKD children with abnormalities in ABPM and night dipping displayed a higher PZP concentration than those without. Additionally, the PZP level was positively correlated with NO bioavailability. In conclusion, our results suggest PZP has differential influences on cardiovascular risk in CAKUT and non-CAKUT children. Identification of this relationship is novel in the pediatric CKD literature.

Dopamine-dependent functions of hyaluronic acid/dopamine/silk fibroin hydrogels that highly enhance N-acetyl-L-cysteine (NAC) delivered from nasal cavity to brain tissue through a near-infrared photothermal effect on the NAC-loaded hydrogels.

Hyaluronic acid/silk fibroin (HA/SF or HS) hydrogels with remarkable mechanical characteristics have been reported as tissue engineering biomaterials. Herein, the addition of dopamine/polydopamine (DA/PDA) to HS hydrogels to develop multifunctional HA/PDA/SF (or HDS) hydrogels for the delivery of drugs such as N-acetyl-L-cysteine (NAC) from nasal to brain tissue is examined. Herein, DA-dependent functions of HDS hydrogels with highly adhesive forces, photothermal response (PTR) effects generated by near infrared (NIR) irradiation, and anti-oxidative effects were demonstrated. An in-vitro study shows that the HDS/NAC hydrogels could open tight junctions in the RPMI 2650 cell line, a model cell of the nasal mucosa, as demonstrated by the decreased values of transepithelial electrical resistance (TEER) and more discrete ZO-1 staining than those for the control group. This effect was markedly enhanced by NIR irradiation of the HDS/NAC-NIR hydrogels. Compared to the results obtained using NAC solution, an in-vivo imaging study (IVIS) in rats showed an approximately nine-fold increase in the quantity of NAC delivered from the nasal cavity to the brain tissue in the span of 2 h through the PTR effect generated by the NIR irradiation of the nasal tissue and administration of the HDS/NAC hydrogels. Herein, dopamine-dependent multifunctional HDS hydrogels were studied, and the nasal administration of HDS/NAC-NIR hydrogels with PTR effects generated by NIR irradiation was found to have significantly enhanced NAC delivery to brain tissues.

Development of a Rare Earth Nanoprobe Enables In Vivo Real-Time Detection of Sentinel Lymph Node Metastasis of Breast Cancer Using NIR-IIb Imaging.

Sentinel lymph node (SLN) biopsy plays a critical role in axillary staging of breast cancer. However, traditional SLN mapping does not accurately discern the presence or absence of metastatic disease. Detection of SLN metastasis largely hinges on examination of frozen sections or paraffin-embedded tissues post-SLN biopsy. To improve detection of SLN metastasis, we developed a second near-infrared (NIR-II) in vivo fluorescence imaging system, pairing erbium-based rare-earth nanoparticles (ErNP) with bright down-conversion fluorescence at 1,556 nm. To visualize SLNs bearing breast cancer, ErNPs were modified by balixafortide (ErNPs@POL6326), a peptide antagonist of the chemokine receptor CXCR4. The ErNPs@POL6326 probes readily drained into SLNs when delivered subcutaneously, entering metastatic breast tumor cells specifically via CXCR4-mediated endocytosis. NIR fluorescence signals increased significantly in tumor-positive versus tumor-negative SLNs, enabling accurate determination of SLN breast cancer metastasis. In a syngeneic mouse mammary tumor model and a human breast cancer xenograft model, sensitivity for SLN metastasis detection was 92.86% and 93.33%, respectively, and specificity was 96.15% and 96.08%, respectively. Of note, the probes accurately detected both macrometastases and micrometastases in SLNs. These results overall underscore the potential of ErNPs@POL6326 for real-time visualization of SLNs and in vivo screening for SLN metastasis. SIGNIFICANCE: NIR-IIb imaging of a rare-earth nanoprobe that is specifically taken up by breast cancer cells can accurately detect breast cancer macrometastases and micrometastases in sentinel lymph nodes.

Exploratory study of ultraviolet B (UVB) radiation and age of onset of bipolar disorder.

BACKGROUND: Sunlight contains ultraviolet B (UVB) radiation that triggers the production of vitamin D by skin. Vitamin D has widespread effects on brain function in both developing and adult brains. However, many people live at latitudes (about > 40 N or S) that do not receive enough UVB in winter to produce vitamin D. This exploratory study investigated the association between the age of onset of bipolar I disorder and the threshold for UVB sufficient for vitamin D production in a large global sample. METHODS: Data for 6972 patients with bipolar I disorder were obtained at 75 collection sites in 41 countries in both hemispheres. The best model to assess the relation between the threshold for UVB sufficient for vitamin D production and age of onset included 1 or more months below the threshold, family history of mood disorders, and birth cohort. All coefficients estimated at P ≤ 0.001. RESULTS: The 6972 patients had an onset in 582 locations in 70 countries, with a mean age of onset of 25.6 years. Of the onset locations, 34.0% had at least 1 month below the threshold for UVB sufficient for vitamin D production. The age of onset at locations with 1 or more months of less than or equal to the threshold for UVB was 1.66 years younger. CONCLUSION: UVB and vitamin D may have an important influence on the development of bipolar disorder. Study limitations included a lack of data on patient vitamin D levels, lifestyles, or supplement use. More study of the impacts of UVB and vitamin D in bipolar disorder is needed to evaluate this supposition.

Polypyrrole-induced active-edge-S and high-valence-Mo reinforced composites with boosted electrochemical performance for the determination of 2,4,6-trichlorophenol in the aquatic environment.

With the extensive application of halogenated aromatic compounds, including 2,4,6-Trichlorophenol (2,4,6-TCP), improper treatment or discharge contribute to persistently harmful effects on humans and the ecosystem, rendering the identification and monitoring of 2,4,6-TCP in the aquatic environment urgently required. In this study, a highly sensitive electrochemical platform was developed using active-edge-S and high-valence-Mo rich MoS2/polypyrrole composites. MoS2/PPy illustrates superior electrochemical performance and catalytic activity and has not been explored for detecting chlorinated phenols previously. The local environment of polypyrrole induces the richness of active edge S and a high oxidation state of Mo species in the composites, both of which endorse a sensitive anodic current response due to the favored oxidation of 2,4,6-TCP through nucleophilic substitution. Also, the higher complementarity between pyrrole and 2,4,6-TCP with respective electron-rich and electron-poor features through π-π stacking interactions enhances the specific detection capability of 2,4,6-TCP by the MoS2/polypyrrole-modified electrode. The MoS2/polypyrrole-modified electrode achieved a linear range of 0.1-260 µM with an ultralow limit of detection of 0.009 µM. Additionally, the structural stability boosted by the linkage of polypyrrole and MoS2 results in good resistance and satisfactory recovery in real water samples. The compiled results demonstrate that the proposed MoS2/polypyrrole composite opens up a new potential to advance a sensitive, selective, facile fabrication, and low-cost platform for the on-site determination of 2,4,6-TCP in aquatic systems. The sensing of 2,4,6-TCP is important to monitor its occurrence and transport, and can also serve to track the effectiveness and adjust subsequent remediation treatments applied to contaminated sites.

[Research Progress of Next Generation Sequencing in Acute Leukemia --Review].

With the advent of precision medicine, next-generation sequencing (NGS) is playing an increasingly important role in clinical oncology diagnosis and treatment with its advantages of high sensitivity, high accuracy, high efficiency and operability. NGS reveals the genetic characteristics of acute leukemia(AL) patients by screening for specific disease-causing genes to identify occult as well as complex genetic mutations in patients with AL, leading to early diagnosis and targeted drug therapy for AL patients, as well as to predict disease recurrence by detecting mnimal residual disease (MRD) and analyzing mutated genes to determine patient prognosis. NGS plays an increasingly important role in the diagnosis, treatment and prognosis assessment in AL, providing a direction for the pursuit of precision medicine. This paper reviews the research progress of NGS in AL.

Custom-designed sensors embedded 3D-printed wearable device for improving the hemodialysis-related vascular dysfunction detection.

BACKGROUND: The increasing prevalence of end-stage renal disease (ESRD) imposes a substantial economic burden on public health-care systems. Hemodialysis (HD) is a pivotal treatment modality for patients with ESRD. However, prolonged use of HD vessels may result in stenosis, thrombosis, and occlusion due to repeated daily punctures. Thus, early detection and prevention of the dysfunction of dialysis routes are crucial. OBJECTIVE: In this study, we designed a wearable device for the early and accurate detection of arteriovenous access (AVA) stenosis in HD patients. METHODS: A personalized three-dimensional (3D) printed wearable device was designed by combining the phonoangiography (PAG) and photoplethysmography (PPG) techniques. The capability of this device to monitor AVA dysfunction before and after percutaneous transluminal angioplasty (PTA) was evaluated. RESULTS: After PTA, the amplitudes of both PAG and PPG signals increased in patients with arteriovenous fistulas and those with arteriovenous grafts; this might be due to increased blood flow. CONCLUSION: Our designed multi-sensor wearable medical device using PAG, PPG, and 3D printing appears suitable for early and accurate detection of AVA stenosis in HD patients.

Correction: The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients.

[This corrects the article DOI: 10.1371/journal.pntd.0010066.].

Novel Self-Assembled Multifunctional Nanoprobes for Second-Near-Infrared-Fluorescence-Image-Guided Breast Cancer Surgery and Enhanced Radiotherapy Efficacy.

Breast-conserving surgery (BCS) is the predominant treatment approach for initial breast cancer. However, due to a lack of effective methods evaluating BCS margins, local recurrence caused by positive margins remains an issue. Accordingly, radiation therapy (RT) is a common modality in patients with advanced breast cancer. However, while RT also protects normal tissue and enhances tumor bed doses to improve therapeutic effects, current radiosensitizers cannot meet these urgent clinical needs. To address this, a novel self-assembled multifunctional nanoprobe (NP) gadolinium (Gd)-diethylenetriaminepentaacetic acid-human serum albumin (HSA)@indocyanine green-Bevacizumab (NPs-Bev) is synthesized to improve the efficacy of fluorescence-image-guided BCS and RT. Fluorescence image guidance of the second near infrared NP improves complete resection in tumor-bearing mice and accurately discriminates between benign and malignant mammary tissue in transgenic mice. Moreover, targeting tumors with NPs induces more reactive oxygen species under X-ray radiation therapy, which not only increases RT sensitivity, but also reduces tumor progression in mice. Interestingly, self-assembled NPs-Bev using HSA, the magnetic resonance contrast agent and Bevacizumab-targeting vascular growth factor A, which are clinically safe reagents, are safe in vitro and in vivo. Therefore, the novel self-assembled NPs provide a solid precision therapy platform to treat breast cancer.

Multifaceted Sulfone-Carbazole-Based D-A-D Materials: A Blue Fluorescent Emitter as a Host for Phosphorescent OLEDs and Triplet-Triplet Annihilation Up-Conversion Electroluminescence.

Electroluminescence (EL) from the singlet-excited (S1) state is the ideal choice for stable, high-performing deep-blue organic light-emitting diodes (OLEDs) owing to the advantages of an adequately short radiative lifetime, improved device durability, and low cost, which are the most important criteria for their commercialization. Herein, we present the design and synthesis of three donor-acceptor-donor (D-A-D)-configured deep-blue fluorescent materials (denoted as TC-1, TC-2, and TC-3) composed of a thioxanthone or diphenyl sulfonyl acceptor and phenyl carbazolyl donor. These systems exhibit strong deep-blue photoluminescence (422-432 nm) in solutions and redshifted emission (472-486 nm) in thin films. The solid-state photoluminescence quantum yield (PLQY) was estimated to be 78 and 94% for TC-2 and TC-3, respectively. TC-2 and TC-3 possess good molecular packing and large molecular cross-sectional areas, which not only improves the PLQY but enhances the triplet-triplet annihilation up-conversion (TTAUC) efficiency of fluorescent emitters. Furthermore, both compounds were applied as an acceptor for confirming their TTAUC property using bis(2-methyldibenzo[f,h]quinoxaline)(acetylacetonate)iridium(III) (Ir(MDQ)2acac) as the sensitizer. Non-doped OLEDs based on TC-2 and TC-3 exhibit blue EL in the 461-476 nm range. In particular, TC-3 exhibits a maximum external quantum efficiency (EQEmax) of 5.1%, and its EL maximum is 476 nm. In addition, the three emitters were employed as hosts in red OLEDs using bis(1-phenylisoquinoline)(acetylacetonate)iridium(III) (Ir(piq)2acac) as the phosphorescent dopant. The red phosphorescent OLEDs based on TC-1, TC-2, and TC-3 achieve excellent EQEmax values of 21.6, 22.9, and 21.9%, respectively, and peak luminance efficiencies of 12.0, 14.0, and 12.3 cd A-1. These results highlight these fluorophores' versatility and promising prospects in practical OLED applications.

Hydrogen Sulfide-to-Thiosulfate Ratio Associated with Blood Pressure Abnormalities in Pediatric CKD.

Identifying children with chronic kidney disease (CKD) at high risk of cardiovascular disease (CVD) and ensuring they receive appropriate treatment can prevent CVD events and mortality later in life. Hydrogen sulfide (H2S) is a gaseous signaling molecule participating in CVD and CKD. Thiosulfate is not only an oxidation product of H2S but is also a H2S donor. We examined whether H2S, thiosulfate, and their combined ratio have differential associations with CVD risk markers in 56 children and adolescents aged 6-18 years with CKD stages G1-G4. Up to two-thirds of CKD children showed higher BP load on 24 h ambulatory blood pressure monitoring (ABPM), even in the early stage. CKD children with ABPM abnormalities had a higher H2S-to-thiosulfate ratio, while H2S-related parameters were not affected by the severity of CKD. The H2S-to-thiosulfate ratio was positively correlated with 24 h systolic BP (SBP), nighttime SBP, and carotid artery intima-media thickness (cIMT). After adjusting for confounders, H2S was negatively associated with LV mass, thiosulfate was positively associated with 24-DBP, and the H2S-to-thiosulfate ratio was positively correlated with nighttime SBP and cIMT. Our data demonstrate differential associations in circulating H2S, thiosulfate, and their combined ratio with CVD risk in childhood CKD. Further studies are required to determine whether targeting the H2S signaling pathway can develop novel therapeutic strategies against CVD in this high-risk population.

Association between polarity of first episode and solar insolation in bipolar I disorder.

OBJECTIVE: Circadian rhythm disruption is commonly observed in bipolar disorder (BD). Daylight is the most powerful signal to entrain the human circadian clock system. This exploratory study investigated if solar insolation at the onset location was associated with the polarity of the first episode of BD I. Solar insolation is the amount of electromagnetic energy from the Sun striking a surface area of the Earth. METHODS: Data from 7488 patients with BD I were collected at 75 sites in 42 countries. The first episode occurred at 591 onset locations in 67 countries at a wide range of latitudes in both hemispheres. Solar insolation values were obtained for every onset location, and the ratio of the minimum mean monthly insolation to the maximum mean monthly insolation was calculated. This ratio is largest near the equator (with little change in solar insolation over the year), and smallest near the poles (where winter insolation is very small compared to summer insolation). This ratio also applies to tropical locations which may have a cloudy wet and clear dry season, rather than winter and summer. RESULTS: The larger the change in solar insolation throughout the year (smaller the ratio between the minimum monthly and maximum monthly values), the greater the likelihood the first episode polarity was depression. Other associated variables were being female and increasing percentage of gross domestic product spent on country health expenditures. (All coefficients: P ≤ 0.001). CONCLUSION: Increased awareness and research into circadian dysfunction throughout the course of BD is warranted.

Haloperidol and Other Antipsychotics Exposure before Endometrial Cancer Diagnosis: A Population-based Case-control Study.

Objective: Endometrial cancer is the most common malignancy of the female genital tract worldwide, and the associated relationship between endometrial cancer formation and various antipsychotics need to be confirmed. Methods: We conducted a case-control study by using data from Taiwan National Health Insurance Research Database to compare individual antipsychotic exposure between females with and without endometrial cancer. Among 14,079,089 females in the 12-year population-based national dataset, 9,502 females with endometrial cancer were identified. Their medical records of exposure to antipsychotics, including quetiapine, haloperidol, risperidone, olanzapine, amisulpride, clozapine, and aripiprazole, for up to 3 years before endometrial cancer diagnosis were reviewed. Daily dosage and cumulative exposure days were analyzed in the risky antipsychotic users. Additionally, the subsequent 5-year mortality rate of endometrial cancer among users of the risky antipsychotic were also analyzed. Results: Among endometrial cancer patients, the proportion of those who have used haloperidol before being diagnosed with endometrial cancer is significantly higher than other antipsychotic users. The significant odds ratio (OR) and a 95% confidence interval of 1.75 (1.31-2.34) were noted. Furthermore, haloperidol users were associated with a significantly higher 5-year mortality rate after getting endometrial cancer than non-users. Conclusion: There is a high correlation between the use of haloperidol and endometrial cancer formation. However, the underlying pathological biomechanisms require additional investigations.

Complement Factor H and Related Proteins as Markers of Cardiovascular Risk in Pediatric Chronic Kidney Disease.

Cardiovascular disease (CVD) is the main cause of mortality among chronic kidney disease (CKD) patients, both in adults and in children. Hypertension is one of the risk factors of CVD. For early detection of subclinical CVD in pediatric CKD, 24 h ambulatory blood pressure monitoring (ABPM), cardiosonography, and arterial stiffness assessment were evaluated. CAKUT (congenital anomalies of the kidney and urinary tract) are the main etiologies of pediatric CKD. Previously, by a proteomic approach, we identified complement factor H (CFH) and related proteins differentially expressed between children with CAKUT and non-CAKUT CKD. In this study, we aimed to evaluate whether CFH, CFH-related protein-2 (CFHR2), and CFH-related protein-3 (CFHR3) were related to CVD risk in children with CKD. This study included 102 subjects aged 6 to 18 years old. The non-CAKUT group had higher plasma CFHR3 levels than the CAKUT group (p = 0.046). CFHR3 was negatively correlated with LV mass (p = 0.009). CFHR2 was higher in children with CKD with 24 h hypertension in the ABPM profile (p < 0.05). In addition, children with non-CAKUT CKD with day-time hypertension (p = 0.036) and increased BP load (p = 0.018) displayed a lower plasma CFHR3 level. Our results highlight that CFH and related proteins play a role for CVD in children with CKD. Early assessment of CFH, CFHR2, and CFHR3 may have clinical utility in discriminating CV risk in children with CKD with different etiologies.

Application of molecular imaging in immune checkpoints therapy: From response assessment to prognosis prediction.

Recently, immune checkpoint therapy (ICT) represented by programmed cell death1 (PD-1) and its major ligands, programmed death ligand 1 (PD-L1), has achieved significant success. Detection of PD-L1 by immunohistochemistry (IHC) is a classic method to guide the treatment of ICT patients. However, PD-L1 expression in the tumor microenvironment is highly complex. Thus, PD-L1 IHC is inadequate to fully understand the relevance of PD-L1 levels in the whole body and their dynamics to improve therapeutic outcomes. Intriguingly, numerous studies have revealed that molecular imaging technologies could potentially meet this need. Therefore, the purpose of this narrative review is to summarize the preclinical and clinical application of ICT guided by molecular imaging technology, and to explore the future opportunities and practical difficulties of these innovations.

Integrative Analysis of the Expression Levels and Prognostic Values for NEK Family Members in Breast Cancer.

Background: In the latest rankings, breast cancer ranks first in incidence and fifth in mortality among female malignancies worldwide. Early diagnosis and treatment can improve the prognosis and prolong the survival of breast cancer (BC) patients. The NIMA-related kinase (NEK), a group of serine/threonine kinase, is a large and conserved gene family that includes NEK1-NEK11. The NEK plays a pivotal role in the cell cycle and microtubule formation. However, an integrative analysis of the effect and prognosis value of NEK family members on BC patients is still lacking. Methods: In this study, the expression profiles of NEK family members in BC and its subgroups were analyzed using UALCAN, GEPIA2, and Human Protein Atlas datasets. The prognostic values of NEK family members in BC were evaluated using the Kaplan-Meier plotter. Co-expression profiles and genetic alterations of NEK family members were analyzed using the cBioPortal database. The function and pathway enrichment analysis of the NEK family were performed using the WebGestalt database. The correlation analysis of the NEK family and immune cell infiltration in BC was conducted using the TIMER 2.0 database. Results: In this study, we compared and analyzed the prognosis values of the NEKs. We found that NEK9 was highly expressed in normal breast tissues than BC, and NEK2, NEK6, and NEK11 were significantly highly expressed in BC than adjacent normal tissues. Interestingly, the expression levels of NEK2, NEK6, and NEK10 were not only remarkably correlated with the tumor stage but also with the molecular subtype. Through multilevel research, we found that high expression levels of NEK1, NEK3, NEK8, NEK9, NEK10, and NEK11 suggested a better prognosis value in BC, while high expression levels of NEK2 and NEK6 suggested a poor prognosis value in BC. Conclusion: Our studies show the prognosis values of the NEKs in BC. Thus, we suggest that NEKs may be regarded as novel biomarkers for predicting potential prognosis values and potential therapeutic targets of BC patients.

Hemoglobin concentration is associated with the hippocampal volume in community-dwelling adults.

BACKGROUND: This study examined whether the hemoglobin concentration is correlated with the hippocampal volume using voxel-based morphometry (VBM). METHODS: This cross-sectional study included 1923 community dwellers, aged 40‒89 years, from the sixth wave of the National Institute for Longevity Sciences, Longitudinal Study of Aging. The hemoglobin levels were determined through blood examination. The regional cortical volumes were evaluated using three-dimensional T1-weighted magnetic resonance images. Following preprocessing with a statistical parametric mapping software, a VBM analysis of covariance design was implemented to identify the regional gray matter volumes related to hemoglobin concentration, while adjusting for age, sex, education, body mass index, depressive symptoms, alcohol consumption status, smoking status, medical history, and the estimated glomerular filtration rate. RESULTS: VBM analysis revealed a significantly positive correlation between the hemoglobin concentration and gray matter volume in the bilateral anterior hippocampus and the amygdala clusters as well as in the cingulate and middle temporal gyri, cerebellum, and superior sagittal and transverse sinuses. CONCLUSIONS: The hemoglobin concentration could be positively associated with the hippocampal volume among community-dwelling middle-aged and older adults, which highlights the importance of monitoring the hemoglobin concentration in older adults to decrease the possibility of neurodegeneration.

The development of surgical risk score and evaluation of necrotizing soft tissue infection in 161 Naja atra envenomed patients.

BACKGROUND: Naja atra bites cause wound necrosis, secondary infection, and necrotizing soft tissue infection (NSTI) requiring repetitive surgeries. Little information is known about the predictors for surgery after these bites. MATERIALS AND METHODS: We retrospectively evaluated 161 patients envenomed by N. atra, 80 of whom underwent surgery because of wound necrosis and infection. We compared the patients' variables between surgical and non-surgical groups. To construct a surgical risk score, we converted the regression coefficients of the significant factors in the multivariate logistic regression into integers. We also examined the deep tissue cultures and pathological findings of the debrided tissue. RESULTS: A lower limb as the bite site, a ≥3 swelling grade, bullae or blister formation, gastrointestinal (GI) effects, and fever were significantly associated with surgery in the multivariate logistic regression analysis. The surgical risk scores for these variables were 1, 1, 2, 1, and 2, respectively. At a ≥3-point cutoff value, the model has 71.8% sensitivity and 88.5% specificity for predicting surgery, with an area under the receiver operating characteristic curve of 0.88. The histopathological examinations of the debrided tissues supported the diagnosis of snakebite-induced NSTI. Twelve bacterial species were isolated during the initial surgery and eleven during subsequent surgeries. DISCUSSION AND CONCLUSIONS: From the clinical perspective, swelling, bullae or blister formation, GI effects, and fever appeared quickly after the bite and before surgery. The predictive value of these factors for surgery was acceptable, with a ≥3-point risk score. The common laboratory parameters did not always predict the outcomes of N. atra bites without proper wound examination. Our study supported the diagnosis of NSTI and demonstrated the changes in bacteriology during the surgeries, which can have therapeutic implications for N. atra bites.