Different contents of KIO4 and KClO4 were added to nano Al/CuO and the composites were assembled by sonication. When the peak pressure of nano Al/CuO was increased ~5–13 times, the pressurization rate was improved by ~1–3 orders of magnitude, the ignition delay time was shortened by ~0.08 ms–0.52 ms and the reaction completeness was adjustable when 30–70% KIO4 and KClO4 were added into the composites. The reaction of Al/KIO4 and Al/KClO4 at a lower temperature was helpful to ignite the ternary composite. Meanwhile, CuO significantly reduced the peak temperature of oxygen released from the decomposition of KIO4 and KClO4. The synergetic effect of binary oxidizers made the combustion performance of the ternary composites better than that of the binary composites. The present work indicates that KIO4 and KClO4 are promising additives for nano Al/CuO to tune and promote the combustion performance. The ternary composites have potential application in energy devices and combustion apparatus.In this study, we studied the synergetic effect of potassium oxysalts on combustion and ignition of nano aluminum (Al) and nano copper oxide (CuO) composites. Potassium periodate (KIO With the development and application of nanotechnology, MIC have recently received more and more attention in the field of energetic materials. The ultra-refinement or nanocrystallization of the energetic materials can significantly improve the energy release and increase the reaction rate ,2,3,4. Nd abroad ,15,16,174ClO4, AP), potassium perchlorate (KClO4), potassium periodate (KIO4), potassium permanganate (KMnO4), etc., with high oxygen content and strong oxidizability, are also used to replace traditional metallic oxidizers, both of which can increase the reaction rate of MIC. Huang found that the binary mixture of Bi2O3 and CuO was more effective than any single oxide in improving the combustion performance of B [2O3/WO3 ternary MIC system prepared by Zachariah was dramatically higher than that of any single system [4 was much higher than that of Al/Fe2O3 due to the high concentration of the free oxygen [4 and Al/sodium periodate (NaIO4) binary system prepared by Jian was lower than that of Al/CuO, and its peak pressure and pressurization rate were much higher than that of Al/CuO [4 and found that its activation energy was lower than that of Al/MnO2 and its combustion rate increased [However, due to the low oxygen content in common metallic oxides, MIC with these metallic oxidizers as the single oxidizer possess less gas production and slower reaction rate. In order to solve this problem, suitable double oxidizers are introduced to replace the single oxidizers in the MIC system to form a ternary system, or ammonium perchlorate  was used to characterize the prepared energetic composite particles. The theoretical adiabatic flame temperature (AFT) of the energetic composite material was calculated by REAL software. The thermal decomposition reaction behavior of CuO/xKIO4 and CuO/xKIO4 was studied by differential scanning calorimetry (DSC) and thermogravimetric analysis (TG). The peak pressure and pressurization rate of the MIC were characterized by the combustion test. A carbon dioxide (CO2) laser igniter and a high-speed camera were used to test and record the ignition delay time of the composite material. The calorimeter was used to measure the heat release of Al/CuO/xKIO4 and Al/CuO/xKClO4 composites. The results show that KIO4 and KClO4 play important roles in enhancing the combustion performance of nano Al-based MIC composites.Herein, the effects of KIO4 and KClO4 were purchased from Sinopharm Chemical Reagent Corporation , they were ground in the agate mortar before being used in the experiment. The formulations of composites are shown in 4 means that the molar percentage of KClO4 and CuO in the oxidizers are 30% and 70%, respectively. The content of Al was stoichiometric assuming the fuel reacted with the oxidizer completely. The samples were prepared via sonication method. The weighted Al and oxidizers were put into a vial with ~10 mL hexane, followed by sonication of ~30 min, and dried in a hood for 24 h. Finally, the dried powders could be obtained for further measurements.Aluminum nanoparticles (~30–50 nm) and copper oxide nanoparticles (<50 nm) were purchased from Aladdin Industrial Corporation , and KIO4 and CuO/xKClO4 binary systems and potassium oxysalts. The sample was heated from room temperature to 700 °C in an argon atmosphere (50 mL min−1) at a heating rate of 10 °C min−1.Scanning electron microscope  was used to analyze the morphologies of the raw materials and composites. Thermogravimetric analysis and differential scanning calorimetry  were used to characterize the thermodynamic behavior of CuO/xKIO3. The samples were ignited via joule heating through a nichrome wire above the samples, which was connected to a voltage supply. When ignited, the changes of pressure in time were recorded electrically. The pressurization rate was obtained by calculating the initial slope of the pressure rise, which has been used to present the reactivity of energetic materials. A detailed description about pressure cell could be found in the reference [The peak pressure was evaluated by combustion cell. Around 25 mg-samples were weighted and loaded into a combustion cell with a constant volume of ~20 cm2 laser of 60 W in air. Ignition delay was defined as the time length from the start of the laser to the initial visible spark spot captured by a high-speed camera  at 50,000 fps.Typically, ~15 mg samples were weighted and placed in the center of the specimen stage and the ignition performance of the samples was evaluated by a COThe released heat by energetic materials has been evaluated via a calorimeter .The diagrammatic sketch of the calorimeter is shown in 4 and KClO4 on the adiabatic flame temperature (AFT) of the Al/CuO system. As demonstrated in 4 and KClO4 can enhance the AFT of Al/CuO significantly. The calculated AFT increase monotonously with the increasing molar percentages of potassium oxysalts. 4 and 50% KClO4 can raise the AFT by ~900 °C and ~1100 °C, respectively. Consequently, the addition of potassium oxysalts could improve the AFT of Al/CuO theoretically. In the reaction process, the addition of potassium salts can significantly increase the adiabatic flame temperature of the system, thus promoting the decomposition of the oxidizers, and enabling the Al and oxidizers to react more completely [Based on the formulations of composites, assuming the reaction between the fuel and oxidizers occurs in a constant volume, the REAL code was used based on the principle of minimum free energy to calculate the influence of the addition of KIOmpletely .4 and Al/CuO/xKClO4 composites were characterized via SEM. As shown in 4 and KClO4 evenly, indicating that the fuels and oxidizers could be mixed up well via sonication.The morphologies of the raw materials, Al/CuO/xKIO4 and KClO4, the combustion performance of Al/CuO was improved significantly. Among the Al/CuO/potassium oxysalts ternary systems, the highest combustion performance, including the highest peak pressure and pressurization rate, was achieved by Al/CuO/30% potassium oxysalts.As shown in 4 is 10 times and 4 times higher than that of Al/CuO and Al/KClO4, respectively. With the increase of the content of KClO4, the peak pressure reduced slightly compared with Al/CuO/30% KClO4. The peak pressures of Al/CuO/50% KClO4 and Al/CuO/70% KClO4 are still higher than that of Al/CuO and Al/KClO4, which are 8 times and 5 times higher than that of Al/CuO, respectively. Similarly, the peak pressure of Al/CuO/30% KIO4 is 13 times and 8 times higher than Al/CuO and Al/KIO4, respectively. Therefore, the peak pressure of Al/CuO/30% KIO4 (49600 KPa/g) is the highest among all the ternary systems.As shown in 4 and Al/CuO/xKClO4 is higher than that of conventional Al/KIO4, Al/KClO4, and Al/CuO binary composites. In the meanwhile, the reactivity of Al/CuO/30% potassium oxysalts is the highest. With the addition of 30% KIO4, the pressurization rate is tremendously raised, which is three orders of magnitude higher than Al/CuO and Al/KIO4, which is the highest pressurization rate in this study. With the increasing content of KIO4, the pressurization rate reduced slightly. The pressurization rates of Al/CuO/50% KIO4 and Al/CuO/70% KIO4 are 107 times and 152 times higher than that of Al/CuO, respectively. Similarly, the pressurization rate of Al/CuO/30% KClO4 is three and two orders of magnitude higher than that of Al/CuO and Al/KClO4. Thus, the reactivity of Al/CuO can be significantly improved and tailored by the addition of different contents of potassium oxysalts.For the pressurization rate, which refers to the reactivity of energetic materials , the tre4 and KClO4 can be speculated that the reaction between Al/KIO4 and Al/KClO4 starting at a low temperature is helpful to ignite the ternary composite materials. Meanwhile, it is speculated that CuO can accelerate the decomposition of KIO4 and KClO4 to release O2, leading to the reaction of Al with a large amount of gas. The higher flame temperature of Al/KIO4 or Al/KClO4 improves the pressure of the combustion cell and promotes the decomposition of the oxidizers further, thus more oxygen is produced, the oxidation of Al is further accelerated and the reaction rate is accelerated [4 and KClO4, the TG analysis and DSC analysis of CuO/xKIO4 and CuO/xKClO4 were carried out in the later section.The reason why the combustion performance of Al/CuO is significantly enhanced by the addition of KIOelerated ,27,28. A4 and CuO/xKClO4 at a low heating rate. 4 decomposes and releases O2 in two stages, which is consistent with the reported studies [4 decomposes exothermically into KIO3 and O2 with a peak temperature of the O2 release at ~343 °C. In the second stage, KIO3 starts the decomposition at ~535 °C with an endothermic peak at ~552 °C. 4 during the first stage with exothermic peak temperatures ranging from ~336 °C to ~339 °C. However, with the addition of CuO, the initiation and the endothermic peak of the second-stage decomposition of KIO4 advance by ~100 °C and ~90 °C compared with pure KIO4, respectively.TGA/DSC were used to study the thermal decomposition reaction process of CuO/xKIO studies . In the 4 is shown in 4 decomposes exothermically into KCl and O2 at ~595 °C with an exothermic peak at ~631 °C [4, and the endothermic peak at ~609 °C is caused by the melting of KClO4. The addition of CuO has basically no influence on the crystal transformation of KClO4, which is ~300 °C. However, the addition of CuO advanced the melting and thermal decomposition of KClO4 significantly, resulting in the disappearance of endothermic peak of the melting and thermal decomposition at a lower temperature. The peak temperature of the thermal decomposition reaction of CuO/xKClO4 is ~500 °C, which is ~130 °C lower than that of pure KClO4. Moreover, the initial decomposition temperatures of KClO4 with different contents of CuO are between ~340 °C to ~390 °C, which are ~200 °C to ~250 °C lower than that of pure KClO4. This can be attributed to the fact that CuO, as a p-type transition metal oxide, promotes the electron transfer process during the decomposition of the oxidant [The thermal decomposition of KClO ~631 °C . The end oxidant .4 and KClO4, which makes the thermal decomposition reaction process earlier significantly. Meanwhile, the initial temperature and peak temperature of the oxygen releasing are greatly reduced, leading to the rapid reaction of Al with a large amount of gas through the pathways of the oxide shell, which may cause the internal molten Al to continuously absorb heat and expand, accelerating the rupture of the oxide layer, and further promoting the diffusion of Al core and oxidation of Al, thus enhancing the combustion performance of the composites [Therefore, the addition of CuO has a significant effect on the thermal decomposition reaction process of KIOmposites ,28,33,344 and Al/CuO/xKClO4 composites has been recorded via high-speed camera. As shown in 4 and KClO4 in the ternary systems, the initiation time of the reaction is earlier than that of Al/CuO.The combustion process of Al/CuO/xKIO4 ternary composites is shorter than that of the binary composites. Compared with Al/CuO (~1.28 ms), the ignition delay time of the composite with 50% KIO4 is shortened by ~0.38 ms. The ignition delay time of Al/CuO/70% KIO4 (~0.88 ms) is shorter than that of Al/KIO4 by ~0.32 ms. Among the Al/CuO/KIO4 composites, the ignition delay time of Al/CuO/30% KIO4 is the shortest, ~0.76 ms, which is ~0.52 ms and ~0.44 ms shorter than Al/CuO and Al/KIO4, respectively. As for the Al/CuO/xKClO4 systems, it is shown in 4 and 50% KClO4 occurs ~0.08 ms and ~0.14 ms earlier compared to Al/CuO. The ignition delay time of Al/CuO/70% KClO4 is the shortest, ~1.08 ms, which is ~0.20 ms and ~0.16 ms earlier than that of Al/CuO and Al/KClO4, respectively.4 and Al/CuO/xKClO4 ternary composites is shorter than that of that of both Al/CuO and Al/potassium oxysalts binary systems. It is reported that in the ternary thermites systems [4 and Al/KClO4 reaction is lower than that of Al/CuO [4 and KClO4, the reaction between Al and potassium oxysalts in ternary systems can initiate earlier than Al/KIO4 and Al/KClO4. Therefore, the application of CuO/potassium oxysalts binary oxidizer system results in a synergetic effect including a lower ignition temperature and earlier oxygen release of oxidizers, thus significantly shortening the ignition delay of ternary thermites.Herein, the ignition delay time of Al/CuO/xKIO systems , the inif Al/CuO ,28, the 4 and Al/KClO4 as shown in Equations (1)–(3), and their molar percentage in the ternary composites according to Hess’s law [4 and KClO4, the heat release of the composites increases monotonously, which can be attributed to the reason that the theoretical enthalpy of Al/KIO4 and Al/KClO4 is higher than that of Al/CuO according to the Equations (1)–(3). The heat release of Al/CuO/30% KIO4 is 4958 ± 111 J g−1 (−1 higher than that of Al/CuO. 4 (6926 ± 150 J g−1) is ~3200 J g−1 higher than that of Al/CuO, which has been increased significantly. In addition, the experimental heat release of the composites is less than the theoretical heat release because the composites cannot react completely during the experiment, which can be confirmed by the XRD characterization of the combustion products (Assuming that the oxidant reacts completely with the fuel, the theoretical heat release of the composites is calculated based on the theoretical enthalpy of Al/CuO, Al/KIOss’s law . Figure 11 J g−1 a, which products . A more 4, the reaction completeness of the ternary composite is higher than that of the binary systems. The highest reaction completeness of 96.1% for Al/CuO/xKIO4 ternary systems is achieved by Al/CuO/50% KIO4, which is 4.8% higher than that of Al/CuO. The reaction completeness of Al/CuO/xKClO4 is higher than that of Al/KClO4, and the reaction completeness of Al/CuO/30% KClO4 is 82.1%, which is 6.8% higher than that of Al/KClO4. It is presumed that as a transition metal oxidizer, CuO can promote the combustion of Al/KIO4 and Al/KClO4 as a catalyst. The relatively lower reaction completeness of Al/CuO/70% KClO4 might be caused by the lower ratio of CuO and the weakening catalysis of CuO.The reaction completeness of composite system is obtained by calculating the ratio of the experimental calorific values to the theoretical ones. For the systems of Al/CuO/xKIO4 and Al/CuO/KClO4 composites (It is reported that when there is more released gas during the combustion process of MIC, higher combustion efficiency could be achieved due to less aggregation of nAl . Consistmposites a means t4 and Al/CuO/xKClO4 ternary composites are significantly higher than that of Al/CuO, Al/KIO4 and Al/KClO4 binary composites. It is speculated that the synergistic effect of CuO/KIO4 and CuO/KClO4 binary oxidizers make the combustion performance of the ternary composites better than that of the binary composites. In other words, the reaction of Al/KIO4 and Al/KClO4 at a lower temperature is helpful to ignite the ternary composite. Meanwhile, CuO promotes the decomposition of KIO4 and KClO4 to release oxygen, which makes Al react quickly with a large amount of gas, accelerates the rupture of the oxide layer, and further promotes the diffusion of Al core and oxidation of Al, thus enhancing the combustion performance of the composites. The results of TG-DSC show that CuO significantly advances the initial temperature and peak temperature of KIO4 oxygen release in the second-step decomposition by ~100 °C and ~90 °C, respectively, and decreases the initial temperature and peak temperature of KClO4 oxygen release by ~200 °C and ~130 °C, respectively. Moreover, the results of ignition tests and heat release measurement show that the ignition delay time of the ternary composites is shorter than that of Al/CuO. The addition of KIO4 and KClO4 can tailor the reaction completeness and heat release of the composites due to more released gas by the reaction between Al and potassium oxysalts. Therefore, KIO4 and KClO4 are promising additives for Al/CuO to tune and promote the combustion performance.In this study, the binary oxidizers composed of potassium oxysalts and CuO were applied in nano Al-based MIC, and their energetic performance has been tested. The pressure cell tests show that the pressure peak and pressurization rate of Al/CuO/xKIO


Hyaluronic acid (HA), a glycosaminoglycan ubiquitous in the skin, has come into the limelight in recent years for its role in facilitating dermal wound healing. Specifically, HA’s length of linearly repeating disaccharides—in other words, its molecular weight (MW)—determines its effects. High molecular weight (HMW)-HA serves an immunosuppressive and anti-inflammatory role, whereas low molecular weight (LMW)-HA contributes to immunostimulation and thus inflammation. During the inflammatory stage of tissue repair, direct and indirect interactions between HA and the innate and adaptive immune systems are of particular interest for their long-lasting impact on wound repair. This review seeks to synthesize the literature on wound healing with a focus on HA’s involvement in the immune subsystems. Skin injury leads to the cascade of highly interrelated processes known as wound healing, which, beginning with hemostasis, can take months to years to finish remodeling. Each year, more than 100 million people in developed countries are expected to develop scars from irregular wound healing outcomes, adding physical, financial, and psychosocial burdens to the problem ,3,4. HowThis review aims to explicate the combined role of HA and various immune cell populations in dermal wound repair using relevant literature from the past decade when possible.HA is a unique glycosaminoglycan in that it is non-sulfated and lacks a core protein, with the bulk of its structure comprising continuous residues of  . Upon tiThe influence of HA on immune responses also goes beyond interactions with specific HA receptors; chemokines interacting with glycosaminoglycans in the ECM modulate the immune response at areas of tissue inflammation. For example, IL-8 binds to matrix bound heparin sulfate to generate a chemoattractive gradient for neutrophils ,18. IL-8Among the roles of hyaluronan, perhaps the most compelling reason to examine the interactions of HA in wound healing is its role in regenerative healing. Mid-gestational fetal wounds are known to heal without a scar ,23. The The mammalian immune system is supported by two subsystems known as the innate immune system and adaptive immune system, which work in concert to defend the body against various pathogens. While activating a response to destroy foreign invaders, a key challenge of this system is to avoid damaging the body’s own tissues and cells in the process. In regard to hyaluronan’s role in immunity, HA can promote or inhibit TLR signaling pathways, which facilitate downstream activation of the innate immune system. In terms of the adaptive immune system, antigen activation of naïve T lymphocytes increases their CD44 expression and thus their ability to bind HA and trigger the adaptive immune system ,27,28. FThe innate immune system provides the body with a first line of defense to a pathogenic invasion by mounting a rapid and robust, though nonspecific, response. Pattern recognition receptors (PRRs) enable a nonspecific reaction by recognition of damage-associated molecular patterns (DAMPs), such as DNA or heat shock proteins, or pathogen-associated molecular patterns (PAMPs), such as lipopolysaccharides, double-stranded RNA, or bacterial DNA . Of the As primary receptors of LMW-HA, TLR activation has been speculated to produce a dose-dependent effect on wound healing, with lower concentrations noted to stimulate regeneration . FurtherThe following sections will delve deeper into specific cell populations of the innate immune system. Refer to HA is found in great abundance in mast cell granules , and masMacrophages, by way of phagocytosis, promote transition of the dermal wound from a pro-inflammatory milieu to an anti-inflammatory environment . AccordiIn the skin, specialized dendritic cells are known as Langerhans cells. As these CD44-rich cells migrate through the dermis, they leverage the HA of nearby keratinocytes as an adhesion substrate . HA promLiterature on the role of other immune cell types, including neutrophils and NKT cells, specifically interacting with HA in the context of wound healing is sparse. In dermal wound repair, neutrophil involvement is generally controversial as neutrophils can release enzymes such as elastase, which can be detrimental to surrounding tissue and increase the likelihood of scarring . In contThe functional cells of the adaptive immune response are lymphocytes, which can be further subdivided into T and B lymphocytes. T cells direct and regulate immune responses via secretion of characteristic profiles of cytokines and chemokines, while B cells are responsible, upon activation, for the production of antigen-specific antibodies. As we will demonstrate below, more studies have been done on HA interactions with T cells in the wound environment rather than on B cell interactions.+ or CD8+, the former involved in production of cytokines directed towards a particular immune response, and the latter responsible for destruction of virally infected host cells. Another subset of T lymphocytes is known as gamma-delta (γδ) T cells, which are able to bridge the innate and adaptive immune systems.Naïve T lymphocytes initially have low expression of CD44 and thus relatively little binding with HA; however, once they are activated by antigen-presenting cells and begin proliferating, their expression of CD44 expands, increasing their capacity to bind HA. ,27. This+ T lymphocytes, their effector or regulatory function in the wound environment is determined by the specific subtype to which they are polarized. The polarization of CD4+ cells is largely governed by the local inflammatory cytokine and growth factor milieu produced by innate lymphoid and tissue resident cells’ response to tissue injury or pathogen invasion [Upon the arrival of activated CD4invasion ,68,69,70Regulatory T lymphocytes (Treg) express the Foxp3 transcription factor and function to curtail both innate and adaptive immune responses . TreatmeLess is known of the interaction between type 1 or 2 helper T cells (Th1/Th2) and hyaluronan in the wound environment. In vitro differentiated Th1 and Th2 demonstrate a somewhat higher binding capacity to HA when compared to naïve T lymphocytes . Despiteγδ T cells are a group of T lymphocytes that demonstrate behavior that blurs the line between being the first line of defense in innate immunity and coordinating a targeted response along with B cells and more conventional T cells as part of adaptive immunity. Regarding innate immunity, studies have shown phagocytic capabilities of human Vγ9/Vδ2 T cells, a feature previously thought to be solely the domain of innate myeloid lineage cells . In the The role of B lymphocytes in wound healing is not well studied, and thus the literature regarding HA–B cell interactions in wound healing is lacking. In a mouse model of B cell deficient mice, wound healing was delayed with a decreased inflammatory cell infiltration . SimilarThe human body’s defense system against outside intruders is a marvel of well-orchestrated mechanisms. In dermal wound healing, the interactions of HA with the innate and adaptive immune systems help regulate the skin’s response to injury, fine-tuned by the high and low molecular weight variants of HA. In the innate immune system, the interaction of LMW-HA with decreased levels of TLRs 2/4 were associated with healing wounds, although a lack of TLR 4 altogether resulted in delayed epithelialization. Moreover, innate immune cells such as macrophages, mast cells, and dendritic/Langerhans cells further regulate wound repair by leveraging HA-dependent mechanisms. In the adaptive immune system, B cells generate antigen-specific antibodies upon activation, and T cells mediate immune responses by their secretion of cytokines and chemokines. For example, augmentation of Foxp3 expression of Tregs by HMW-HA leads to the production of anti-inflammatory cytokines such as IL-2, IL-10, and growth factors such as TGF-β. T cell subsets, such as γδ T cells, toe the line of conventional immune cells and exhibit properties of both subsystems depending on their mechanism of action. Similarly, the mammalian complement system works alongside dynamic cell types such as γδ T cells and NKT cells to enhance the immune response. In sum, this review serves as a reference and tool for researchers to understand the current literature on the role of the immune system and extracellular matrix biology in the context of wound healing in the skin.


Pan-carpal dissociation is very rare injury and there is little information as to diagnosis, treatment, and prognosis of this injury.A 35-year-man presented to our hospital with severe pain and swelling of the left wrist and forearm after slipping and falling while riding a motorcycle.The wrist simple radiographs demonstrated unrecognizable severe fracture-dislocation of the carpal bones concomitant with fractures of the radioulnar shaft. Three-dimensional computed tomography revealed a capitate fracture-dislocation, as well as hamate dislocation, lunotriquetral (LT), and scapholunate (SL) dissociation. These findings suggested pan-carpal dissociation.To prevent compartment syndrome, fasciotomy, carpal tunnel release, and open reduction and plate fixation for both bone fracture were performed first. Then, for pan-carpal dissociation, the capitate, carpometacarpal joint (CMCJ), and hamate were reduced and fixed first. Then, the SL, LT, and other intercarpal ligaments were repaired. Finally, additional trans-carpal pins to reinforce the ligament repair and 2.0 mm plate to buttress the third CMCJ were fixed. The patient was instructed to begin gentle range of motion exercises of the wrist with pins from four weeks after surgery and all pins were removed at six weeks postoperatively.12 months after the operation, the patient exhibited almost full range of motion with mild pain with VAS  1–2 at rest and VAS 3–4 with effort. Quick DASH  score was 25 and modified Mayo score was 70. The radiographs demonstrated union of the radioulnar shaft, and the carpal bone alignment was successfully maintainedPan-carpal dissociation can be diagnosed in patients with capitate fracture-dislocation, hamate dislocation, LT, and SL dissociation. This pattern of injury is very rare and the authors recommend reduction and fixation of the distal carpal row, followed by the proximal row to facilitate an easy approach to the distal carpal row. Although it is very severe injury, rigid anatomical fixation and an early rehabilitation can lead to favorable functional outcomes. Only one case report has been published, but this case was more consistent with capitate fracture-dislocation than pancarpal dissociation.Carpal dislocation and fracture-dislocation are usually caused by high-energy trauma.Diagnosis of this type of injury may be difficult and treatment can be challenging. Pancarpal dissocation may be regarded as most severe form of perilunate injury, however, it is different because it involves more complex injuries to the distal carpal row. To the authors’ knowledge, there has been no report of a case with pancarpal dissociation. The authors experienced a patient with “pancarpal dissociation” and would like to share this injury with a review of the relevant literature.2A 35-year-man presented to our hospital with severe pain and swelling of the left wrist and forearm after slipping and falling while riding a motorcycle. The wrist posteroanterior and lateral view demonstrated unrecognizable severe fracture-dislocation of the carpal bones, and fractures of the radioulnar shaft. Three-dimensional computed tomography (3DCT) revealed a capitate fracture-dislocation, as well as hamate dislocation, lunotriquetral (LT), and scapholunate (SL) dissociation Fig. . These fSurgery was performed on the day of the injury to prevent compartment syndrome. Fasciotomy, open reduction, and internal fixation using 3.5 mm LCP plates  were performed on his forearm fractures. Since the forearm swelling was severe, wiring sutures were applied to the volar-side of the forearm for gradual closure. To address the pancarpal dissociation, a longitudinal incision was made at the dorsum of the wrist. First, the capitate was reduced and fixed with a 1.1 mm Kirschner wire (K-wire). Second, the third to fifth carpometacarpal joint (CMCJ) and hamate were reduced and fixed with the K-wires. Then, a 3.0 Headless Compression Screw (Synthes Inc.) was inserted to rigidly fixate the capitate. Third, the SL and LT ligaments were repaired using two mini Mitek devices, and the other intercarpal ligaments were repaired with 2-0 Ethibond sutures. Finally, additional transcarpal pins were inserted to reinforce the ligament repair, and the 2.0 mm LCP (Synthes Inc.) was fixed to buttress the third CMCJ (Fig. Postoperatively, an above-elbow splint was applied with the forearm in neutral position. Two weeks postoperatively, the splint was changed to a short-arm splint. The patient was instructed to begin gentle range of motion exercises of the wrist with pins from four weeks after surgery and all pins were removed at six weeks postoperatively.Twelve months after the operation, the radiographs demonstrated union of the radioulnar shaft, and the carpal bone alignment was successfully maintained Fig. . There w3Acute carpal instability has numerous variations and pancarpal dissociation may be the most severe form of injury. Because of the rarity of this injury, however, pancarpal dissociation has not been clearly defined so far and there is no standard treatment. The patient presented here showed combination of perilunate dislocation, capitate fracture-dislocation, and hamate dislocation and the authors believe that this pattern can be regarded as pancarpal dissociation. A significant amount of force is required to create additional fractures and dislocation of the capitate that accompany perilunate injury or other complex carpal abnormalities. A typical perilunate injury associated with capitate injury is scaphocapitate syndrome. This injury is defined as combination of a scaphoid fracture and a capiate fracture which was reported as a unique form of carpal bone injury. Our case is similar to scaphocapitate syndrome, but it also had hamate dislocation, which were different from scaphocapitate syndrome.Among the carpal bones, the capitate has inherent stability because of its cuboid shape, central location, and the surrounding ligaments.,9 Axial disruptions are mostly reported to be caused by industrial crushing injuries such as punch or rolling presses machines. Our case had hamate dislocation but axial injury pattern was not observed. To the authors’ knowledge, this is the first case of hamate dislocation associated with perilunate injury and capitate fracture-dislocation. Although the mechanism of injury is unclear, it is believed that a significant amount of force after a fall while riding a high-speed motorcycle caused hyperextension and crushing of the palm and wrist, causing pancarpal dissociation.Hamate dislocation is also very rare injury and has been classified under axial carpal instability. discussed wrist fusion as a treatment for pancarpal dissociation, but in this case, anatomical reduction was performed. One year after surgery, the patient had near-full range of motion, and radiographs showed adequate carpal bone alignment.Although surgical treatment is usually indicated, the treatment strategy for pancarpal dissociation has not been standardized, and it is challenging. The authors recommend performing the surgery in the following order. First, the displaced capitate is reduced and fixed to prevent avascular necrosis. Next, the CMCJ, hamate are reduced and fixed. Then, proximal row is treated sequentially. Ting et al.In this brief communication, the authors shared a rare case of pancarpal dissociation demonstrated surgical methods. Pancarpal dissociation can be defined as combination of perilunate dislocation, capitate fracture-dislocation, and hamate dislocation. The authors recommend reduction and fixation of the distal carpal row, followed by the proximal row. This sequence facilitates an easy approach to the distal carpal row. Although it is very severe injury, an early rehabilitation can lead to favorable functional outcomes.Conceptualization: Ho Youn Park, Il-Jung Park.Data curation: Ho Youn Park.Supervision: Dohyung Lim.Validation: Yoo Joon Sur.Visualization: Ho Youn Park.Writing – original draft: Kwanwoo Lee.Writing – review & editing: Il-Jung Park, Ho Youn Park.


To identify adherence to follow-up recommendations in long-term breast cancer survivors (LTBCS) of the SURBCAN cohort and to identify its determinants, using real-world data.We conducted a retrospective study using electronic health records from 2012 to 2016 of women diagnosed with incident breast cancer in Spain between 2000 and 2006 and surviving at least 5 years. Adherence to basic follow-up recommendations, adherence according to risk of recurrence, and overall adherence were calculated based on attendance at medical appointments and imaging surveillance, by year of survivorship. Logistic regression models were fitted to depict the association between adherence and its determinants.A total of 2079 LTBCS were followed up for a median of 4.97 years. Of them, 23.6% had survived ≥ 10 years at baseline. We estimated that 79.5% of LTBCS were overall adherent to at least one visit and one imaging test. Adherence to recommendations decreased over time and no differences were found according to recurrence risk. Determinants of better overall adherence were diagnosis in middle age (50–69 years old), living in a more-deprived area, having fewer years of survival, receiving primary treatment, and being alive at the end of follow-up.We identified women apparently not complying with surveillance visits and tests. Special attention should be paid to the youngest and eldest women at diagnosis and to those with longer survival. Breast cancer is the most frequent cancer in women worldwide. Improvements in diagnosis, treatment, access to health care systems, and screening programs have greatly enhanced the likelihood of surviving the disease . CurrentThe guidelines of the American Society of Clinical Oncology, the European Society of Medical Oncology, and the Spanish Society of Medical Oncology (SEOM) recommend that follow-up include active surveillance of recurrence and new primary tumors, treatment of complications and late adverse effects, management of comorbidities, general preventive care for other conditions as in the rest of the population, and health promotion. All guidelines recommend an annual consultation and mammography for active surveillance –11. SincThere is no established threshold to define adequate adherence and it is usually defined following investigators’ criteria. Adherence to surveillance imaging tests and visits has been assessed separately. Evidence so far indicates that LTBCS visit a physician at least once a year, although not necessarily in primary care; furthermore, they are not screened as recommended, whether because they underuse or overuse recommended tests . DescribIn this study, we aimed to (1) estimate adherence to follow-up recommendations in LTBCS in the Spanish SURBCAN cohort, in general and according to recurrence risk and (2) to identify the factors associated with adherence using real-world data.The Spanish National Health System (NHS) provides universal coverage and is mainly financed by tax revenue. The system is decentralized and consists of three organizational levels: (1) Central, The Ministry of Health; (2) autonomous communities (AC); and (3) administrative health areas, smallest territorial areas within each AC responsible for the management of the health services offered. Residents are insured under two categories according to their affiliation to the Social Security System: active, for workers contributing to Social Security, and pensioners, for those receiving benefits due to retirement, permanent disability, widow/orphan-hood, or old age. Also, around 16% of the population buys voluntary private health insurance and becomes double covered . PrivateThis observational retrospective study was conducted among the Breast Cancer Survival (SURBCAN) Cohort . Briefly, this cohort includes information on 19,416 women. Of these, 6512 are LTBCS diagnosed with incident cancer between January 1, 2000 and December 31, 2006 in the NHS from five Spanish regions , aged 18 or older at diagnosis, and who were alive at the beginning of the follow-up period . The remaining 12,904 are women without breast cancer matched two-to-one by age and administrative health area to LTBCS. To be included, women in each group were required to have at least one contact with primary care during follow-up. Information was retrieved during 2018. More information on the SURBCAN cohort is detailed elsewhere , tumor behavior at diagnosis (in situ or invasive), treatment received , and Charlson Comorbidity Index at baseline . Charlson Comorbidity Index was calculated using the original diagnoses captured by International Classification of Diseases (ICD 9th and 10th edition) or the International Classification of Primary Care (CIAP2), although, excluding breast cancer diagnosis from the algorithm. Risk of recurrence is established by the SEOM according to tumor behavior, tumor receptors, size, invasion, and response to treatment, as well as the genetic platform profile. In the absence of this information for most participants, risk of recurrence was established according to the treatment received: (a) women at low risk, defined as those treated with surgery and radiotherapy only and (b) women at high risk, defined as those treated with chemotherapy either alone or in combination with surgery and/or radiotherapy.Health services use variables included annual contact rate per women, during the follow-up period. Rates were calculated for primary care , specialized care , cancer-related visits , complementary exams , imaging tests , and mammograms. Type of imaging test was not available for Andalusia; therefore, annual mammogram rate was not calculated for women from the region.n = 2079) and (2) considering mammograms only, when information on type of imaging test was available (n = 1758).The main study variable was adherence to follow-up recommendations. Three types of variables for adherence were created: annual adherence to basic recommendations, annual adherence by risk of recurrence, and overall adherence. Each type was defined twice according to the available information: (1) considering any imaging test  with its 95% confidence intervals (CI). Statistical tests were two-sided and the significance level was set at p < 0.05. All analyses were performed using the statistical software IBM SPSS Statistics 25.We performed a descriptive univariate analysis of the cohort using frequencies and percentages for categorical variables, mean, and standard deviation for continuous normally distributed variables and median and inter-quartile range for continuous not normally distributed variables. Health services use is described as annual contact rates per woman. The total number of contacts to each service was used as the numerator and the total number of women-year throughout the study period as the denominator. Percentage of women adherent to basic recommendations and adherent to recommendations according to risk of recurrence is described by survival year (6th through 17th) and trend in adherence was assessed using the Study participants are described in Table n = 1032) of LTBCS were adherent and 3.32% (n = 69) consistently received less than recommended care each year of follow-up. The remaining 64.4% switched between adherence and non-adherence during the study period (Table n = 315) of women were adherent to basic recommendations each year. When we included women with more than one mammogram in some years of their follow-up, the percentage of adherent women increased to 26.6% (n = 468). A total of 19.2% (n = 337) received less than recommended care in each year of follow-up and the rest showed irregular adherence over the study period. Assessed annually, the percentage of women adherent to basic recommendations decreased over time. When we analyzed all imaging tests, adherence ranged from 82.8% in the 8th year to 68.1% in the 17th year ; when considering mammography, adherence ranged from 61.9% in the 7th year to 27.5% in the 17th year . The percentage of women with more than one mammogram per year never exceeded 10%.When we included all imaging studies, 49.6% n = 103 of LTBCSχ2 test for trend, p < 0.001). No differences were found in the percentage of adherent women on comparison of groups at low and high recurrence risk in any year .Figure We estimated that 79.5% of LTBCS were adherent for more than half of the follow-up period to at least one visit and one imaging test. This percentage decreased to 63.3% if only mammograms were included as imaging tests , while if mammograms only were analyzed, adherence was highest among women aged 50–59 years (71.3%). Analysis by treatment showed that women receiving surgery, radiotherapy and chemotherapy were more adherent than those who did not received these treatments. However, women receiving hormone therapy were less adherent than those not receiving it, when we considered all imaging tests and were more adherent when we considered mammograms alone. Regarding the Medea index, women living in less-deprived areas showed the lowest adherence .The results of the multivariate logistic regression models are shown in Table When mammograms were considered, women aged 50 to 69 at diagnosis and those living in deprived areas were more adherent . In contrast, those who died during follow-up had the lowest odds of being adherent . Women who had survived 10 or more years from diagnosis at the beginning of follow-up showed 27% lower odds of being adherent than those surviving 5–9 years . Women receiving any kind of treatment had higher odds of being adherent than those who did not.Only a few studies have focused on adherence among LTBCSs, including ≥ 10 years survivors –23 or inThis study is the first to analyze adherence with real-world data among Spanish LTBCS, and the results are in line with those of studies performed in other contexts , 26–31.Irrespective of imaging type and recurrence risk, adherence decreased over time. This pattern has been reported by other studies , 32, 33.Age at diagnosis seems to play an important role in adherence. Compared with women under 40 years, those aged ≥ 70 years at diagnosis were less likely to be adherent when we analyzed all imaging tests, whereas women aged between 40 and 69 years were more likely to be adherent when we analyzed mammograms only. This result aligns with previous studies –23, 27. Prior studies have reported that women with a high comorbidity burden were less likely to receive surveillance mammograms , 23, 28,Similar to our findings, other studies have reported that treatment with radiation and chemotherapy was associated with higher rates of adherence , 32–34. Unlike other authors , we founIn our study, we had access to complete longitudinal data on health services use for up to 5 years, for a large population of insured LTBCS in Spain. Other strengths include a mixed age population and a novel focus on long-term survival using real-world data. Although we consider regional diversity a strength of this study and all three AC work within the framework of the Spanish National Health Service, each region has a different health service organization and management model. Therefore, the availability of data differs in each sub-cohort. Electronic health records from primary care and hospital databases provide detailed information on demographics, breast cancer characteristics, treatment, consultations, and comorbidities, reducing memory bias and allowing chronic processes to be analyzed from a multi-causal approach. This study provides valuable information to improve current practices and survivors’ adherence to follow-up recommendations.This study also has some limitations. Adherence could be overestimated. Because we could not ascertain the reasons for consultations and test prescriptions or symptoms at the time of the test, we could have included visits unrelated to breast cancer follow-up and diagnostic exams. While relevant, no data were available on the type and site of surgery, recurrence, metastasis, or menopausal status. In addition, it is difficult to ascertain time intervals, because some women may receive two mammograms in a year (at the beginning and at the end) and therefore none the following year. We intended to minimize misclassification with overall adherence analysis. Most of our population was Spanish (94.4%) with no other comorbidities (69.7%) at baseline. Estimates may be lower in populations with less access to medical services and those with more comorbid conditions , 37. DatOther aspects that might influence adherence and were not considered in this study include participants’ educational level, preferences, fear and health literacy, and provider recommendations. These may act as unobserved confounders.A considerable percentage of women in contact with health services are not been properly followed up. These findings reinforce the need for active engagement of all breast cancer survivors in long-term aftercare, especially the youngest and eldest at diagnosis and those with the longest survival. Further research is needed to better understand patient and provider attitudes to survivorship care as well as guideline adequacy.


Sophora tonkinensis Gagnep., a traditional Chinese medicine, is known as Shan Dou Gen in the Miao ethnopharmacy. A large number of previous studies have suggested the usage of S. tonkinensis in the folk treatment of lung, stomach, and throat diseases, and the roots of S. tonkinensis have been produced as Chinese patent medicines to treat related diseases. Existing phytochemical works reported more than 300 compounds from different parts and the endophytic fungi of S. tonkinensis. Some of the isolated extracts and monomer compounds from S. tonkinensis have been proved to exhibit diverse biological activities, including anti-tumor, anti-inflammatory, antibacterial, antiviral, and so on. The research progress on the phytochemistry and pharmacological activities of S. tonkinensis have been systematically summarized, which may be useful for its further research.The roots of  Sophora tonkinensis Gagnep. belongs to the Sophora genus of the Leguminosae family, which is widely distributed in the southwest provinces of China .rophages . Moreove,75.ropha on IL-6 . Sophotoal cells . MoreoveL fluids . Anotherrageenan .S.tonkinensis  for leukemia U937 cells were investigated [The anti-tumor effect was one of the most reported activities of kinensis . The chlt manner . Meanwhima cells . The antma cells . The natstigated .S. tonkinensis were reported significant protective effects against immune induced liver injury , aspartate aminotransferase (AST) serum, malondialdehyde (MDA), and nitric oxide (NO), as well as increased the superoxide dismutase (SOD) and glutathione (GSH) in mice with immune-induced liver injury [S. tonkinensis alleviated hepatic inflammation, liver fibrosis, and hepatic lipids accumulation [1) and oxymatrine (4) may be the main components contributing to the lipid-lowering activity of the water extract of S. tonkinensis [S. tonkinensis have been reported to attenuate hepatic oxidative damage in vivo [34) from S. tonkinensis have been reported to significantly improve liver injury in mice [The components of r injury . Previour injury . The watmulation . Compounkinensis . Meanwhi in vivo . In addi in mice . S. tonkinensis (75), cermizine C (70), jussiaeiine A (68), jussiaeiine B (67), (+)-5α-hydroxyoxysophocarpine (17), (−)-12β- hydroxyoxysophocarpine (18), and (−)-clathrotropine (64), have reported the anti-coxsackie virus B3 (CVB3) activities with IC50 values rang of 0.12~6.40 µmol/L [188) and (−)-trifolirhizin (190) from S. tonkinensis exhibited anti-tobacco mosaic virus (TMV) activities with the inhibition rates of 69.62% and 68.72%, respectively, at a concentration of 100 µg/mL [23), sophtonseedline F (8), and (−)-N-formylcytisine (52), have been reported to have anti-TMV activities as well [20), (−)-sophocarpine (34), and (−)-13,14-Dehydrosophoridine (16) have showed anti-HBV activities [The compounds isolated from kinensis , such as0 µmol/L . The com00 µg/mL . The othlirhizin 0 from S.N-butanol, and ethanol extracts of S. tonkinensis have been tested (S. tonkinensis exhibited antioxidant activities. It is noteworthy that shandougenine A (263), shandougenine C (127), shandougenine D (128), and 7,4’-Dihydroxyisoflavone (103) showed stronger superoxide anion radical scavenging capacity than the known flavanone luteolin. Shandougenines B (264) showed DPPH free radical and ABTS cation radical scavenging capacity. Shandougenine A (263), shandougenine C (127), shandougenine D (128), bolusanthin IV (261), 2--5,6-methylenedioxybenzofuran (260), and demethylmedicarpin (179) were reported parallel ABTS cation radical scavenging capacity to the positive control [The antioxidant activities of chloroform, ethyl acetate, n tested . The res control .S. tonkinensis were the famous toxic Miao drug  to zebrafish was mainly characterized as hepatotoxicity, neurotoxicity, cardiovascular toxicity, and nephrotoxicity in the acute toxicity model [1), oxymatrine (4), cytisine (50), and sophocarpine (34) of S. tonkinensis showed significant cardiotoxicity [The roots of iao drug  and wereatocytes ,112. Meae stress . The obvty model . Besidestoxicity .S. tonkinensis have the ability to reduce blood glucose and resist microbial activities (310) and H (306) inhibit a variety of plant pathogens [S. tonkinensis administrated orally to mice significantly increased sensibility to insulin, as well as reduced fasting blood-glucose levels [1) from S. tonkinensis could improve glucose metabolism and increased insulin secretion in diabetic mice, which may be used as a potential drug for diabetes treatment [S. tonkinensis exhibited antidiarrheal activities [S. tonkinensis and its endophytic fungi have been reported [The extracts of tivities . Cytochaathogens . The flae levels . Moreovereatment . Methanotivities . Moreovereported ,67.S. tonkinensis. Structurally, more than 300 compounds have been isolated from S. tonkinensis and its endophytic fungi, including alkaloids, triterpenes and triterpenoid saponins, flavonoids, and so on. Some of the star molecules, including matrine (1) and oxymatrine (4), were documented to exhibit well biological activities [S. tonkinensis in the folk treatment of upper respiratory tract infection diseases. It is generally believed that the alkaloid components of S. tonkinensis were the main active substances in the roots of S. tonkinensis [S. tonkinensis have been reported for hepatotoxicity, while the other related studies showed the opposite hepatoprotective effects. The in-depth toxicological or structure-activity relationship study may be worth for further research. Moreover, the roots of S. tonkinensis combined with other medicines form dozens of marketing Chinese patent medicine for the treatments of pharyngitis, tonsillitis, and aphthous ulcers [In this review, we provide a detailed summary of the medicinal chemistry, pharmacological activities, and related toxicity research of tivities . For itskinensis . Interess ulcers ,10,11. H


A highly efficient technology for generating new monoclonal single-domainrecombinant antibodies (nanobodies) was used to obtain a panel of nanobodiesrecognizing human apo- and/or holo-transferrin. This article is devoted to theprimary analysis of the properties of two different variants of the newnanobodies obtained by us, as well as to the demonstration of the uniquepotential of their application for diagnostic studies. The simultaneous use ofimmunosorbents based on these nanobodies apparently makes it possible to detectchanges in the relative abundance of apo- and holo-transferrin in humanbiological fluids. Such changes could potentially be indicative of an increasedrisk or degree of development of pathological processes, such as malignantneoplasms in humans. The iron-saturated form of Tf is referred to as holo-Tf. An iron-free formof Tf is known as apo-Tf. The apo-Tf binds Fe3+ in blood with highefficiency and transports it to the cell surface for internalization throughinteraction with TfR [Kd1 < 0.1nM, Kd2 = 3.8 nM, pH 7.4), while the affinity in case ofapo-Tf is ~ 100 times lower  [3+) is converted toferrous iron (Fe2+); the receptor/apo-Tf complex then returns to thecell surface, where apo- Tf is released from its bonding with the receptor atneutral pH [Iron is a vital element for a number of key biological processes. Transferrin(Tf) and its receptors TfR1 and TfR2) are the key proteins regulating ironmetabolism in the human body [ and TfR2utral pH .The transferrin iron saturation ratio is a widely used clinical parameter,which is calculated as the ratio between the iron content in thepatient’s blood and the indicator of the total iron-binding capacity ofserum . It is aThe peripheral blood plasma of three patients diagnosed with FIGO stage IVovarian cancer and a urine sample of one patient with invasive bladder cancerwere kindly provided by the National Medical Research Center for Radiology ofthe Ministry of Health of the Russian Federation. Blood plasma from healthydonors was obtained from blood samples taken from employees at a medicallaboratory, with their consent, according to the standard protocol. Thepreviously obtained libraries of sequences encoding nanobodies  were useThe binding constants of nanobodies to each form of transferrin (holo-Tf andapo-Tf) in standard phosphate- buffered saline  were determined ona MicroCal PEAQ-ITC microcalorimeter  using the MicroCalPEAQ-ITC Analysis Software at the Shared Use Center of the Institute of GeneBiology. The fitting model  was unambiguous fromthe data.To perform an electrophoretic analysis of the proteins, aliquots of the eluateswere collected and analyzed in a 5–19% gradient SDS polyacrylamide gelaccording to Laemmli. We used the MiniProtean 3 device ; thepower source was Elf-4 . Spectra Multicolor Broad RangeProtein Ladder  was used as a protein marker.“Native” polyacrylamide gel electrophoresis developed by Novakovskyet al.  was adapTable).Using commercially available transferrin preparations, we selected two markedlydifferent major variants of high-affinity nanobodies which had relativelydifferent affinities for holo-Tf and apo-Tf and, apparently, recognizeddifferent transferrin epitopes,these nanobodies worked unexpectedly selectively in the solution(Table)and as a part of an immunosorbent.The aTf1 nanobody in solution (PBS) at pH 7.4 binds holo-Tf witha very high affinity, while binding apo-Tf is 100 times weaker. Interestingly,the TfR1 receptor interacts with transferrin in a similar manner[Whereas the difference in binding of different forms of transferrin by theresulting nanobodies was only slightly noticeable in ELISA.In the case of aTf2, CDR3 is significantly increased and thereappears to be an additional Cys–Cys bond between CDR1 and CDR3. Bothvariants of nanobodies were adapted, produced in bacterial periplasm, andpurified as described previously [Fig. 2A).To our surprise, in the column format,the aTf2 nanobody barely binds holo-Tf while binding apo-Tf very efficiently.In contrast, the aTf1 nanobody binds holo-Tf very well and binds the purifiedapo-Tf much weaker than aTf2. Next, immunosorbents in a column format were usedin parallel to test potential differences in the relative abundances of thebound forms of transferrin in normal and pathological conditions. The firstresults of such testing are presentedin Fig. 2. One can seethat while for blood plasma samples from healthy donors the eluates from both columns contain approximately the same amount oftransferrin, for the samples obtained from cancer patients , one can clearly see that more protein isbound and then eluted in the case of aTf2 nanobodies. A very similar situationis observed when analyzing transferrin in the urine of a patient with aninvasive form of bladder cancer (sample 7). In healthy donors, the urinarylevel of transferrin is ten times lower, and, according to our preliminaryobservations, we do not see noticeable differences in the amounts oftransferrin bound by these two immunosorbents. Hence, this test makes itpossible to detect changes in the relative amounts – and availability forbinding – of certain epitopes of different transferrin forms usingnanobodies. This could probably have a diagnostic potential, including forcancer monitoring; however, the reliability and reproducibility of the proposedtest needs to be evaluated on a larger number of samples.The sequences of these two nanobodies are very different of apo-Tf (this may be Tfwith one bound iron ion). As a result, both immunosorbents bind approximately2/3 of the total plasma transferrin (differing in composition). Cancer cellsare known to consume iron particularly efficiently, which can lead to irondeficiency in the biological fluids surrounding the tumor and a relativeincrease in the proportion of apo-Tf. On the other hand, holo- Tf, unlikeapo-Tf, binds very efficiently to the TfR1 receptor on the cell surface.However, TfR1 is also detected in free, extracellular form (as soluble sTfR1). It canIn conclusion, we note that in this study we have obtained new single-domainantibodies and immunosorbents based on them which differently bind forms oftransferrin differing in iron saturation. This ability of differential bindingof the resulting immunosorbents makes it possible to observe relative changesin the representation of different transferrin forms that are either directlyor indirectly associated with cancer.


Escherichia coli (ExPEC) can cause systemic infections in both humans and animals. As an essential nutrient, iron is strictly sequestered by the host. Circumventing iron sequestration is a determinant factor for ExPEC infection. However, the ExPEC iron acquisition mechanism, particularly the mechanism of transferrin (TF) acquisition, remains unclear. This study reports that iron-saturated holo-TF can be utilized by ExPEC to promote its growth in culture medium and survival in macrophages. ExPEC specifically bound to holo-TF instead of iron-free apo-TF via the surface located elongation factor G (EFG) in both culture medium and macrophages. As a moonlighting protein, EFG specifically bound holo-TF and also released iron in TF. These two functions were performed by different domains of EFG, in which the N-terminal domains were responsible for holo-TF binding and the C-terminal domains were responsible for iron release. The functions of EFG and its domains have also been further confirmed by surface-display vectors. The surface overexpression of EFG bound significantly more holo-TF in macrophages and significantly improved bacterial intracellular survival ability. Our findings reveal a novel iron acquisition mechanism involving EFG, which suggests novel research avenues into the molecular mechanism of ExPEC resistance to nutritional immunity.Extraintestinal pathogenic IMPORTANCE Extraintestinal pathogenic Escherichia coli (ExPEC) is an important pathogen causing systemic infections in humans and animals. The competition for iron between ExPEC and the host is a determinant for ExPEC to establish a successful infection. Here, we sought to elucidate the role of transferrin (TF) in the interaction between ExPEC and the host. Our results revealed that holo-TF could be utilized by ExPEC to enhance its growth in culture medium and survival in macrophages. Furthermore, the role of elongation factor G (EFG), a novel holo-TF-binding and TF-iron release protein, was confirmed in this study. Our work provides insights into the iron acquisition mechanism of ExPEC, deepens understanding of the interaction between holo-TF and pathogens, and broadens further researches into the molecular mechanism of ExPEC pathogenicity. Escherichia coli (ExPEC) is responsible for infections in both humans and farm animals , which impose a substantial burden on both public health and economics  critical for iron acquisition from TF, whereas TbpB is a surface-exposed lipoprotein that enhances the efficiency of iron uptake  and OmpC are considered to be TF-binding proteins; however, it is unknown whether E. coli can utilize the iron in TF . Dose-dependent effects were observed among different holo-TF concentrations at 6 to 8 h . In macrophages, significantly greater numbers of bacteria per cell were isolated in holo-TF-supplemented THP-1 cells (P < 0.05) (P < 0.05) . These results indicated that holo-TF promoted ExPEC RS218 growth in culture medium and survival in macrophages.ExPEC strain RS218 is a clinical neonatal meningitis isolate that can cause bacteremia and meningitis . To dete < 0.05) . Dose-deP < 0.05) (P > 0.05). The binding of fluor-TF to the RS218 surface was also detected by fluorescence microscopy  , which icroscopy . In addi3+) but not by Ca2+ or Mg2+. As shown in P < 0.05), which indicated that iron had been acquired. With increasing holo-TF concentrations, the iron acquisition of bacteria significantly increased (P < 0.01).Bacteria have been reported to take up the iron in holo-TF . To deteM. tuberculosis has been reported to recruit holo-TF to the cytoplasm to acquire iron . However, there was no significant difference when bacteria were incubated at 4°C, indicating that ExPEC RS218 cannot convert holo-TF at 4°C (P < 0.05) (P > 0.05), whereas the total TF signals significantly decreased following incubation at 4°C (P < 0.05). This finding indicated that the conversion of holo-TF to apo-TF by RS218 should be performed at 37°C instead of 4°C. Bacterial binding to holo-TF occurred at 4°C. Moreover, when RS218 was incubated with bio-TF at 37°C, the total TF signal levels were similar to that in the reference (P > 0.05), whereas iron-carrying TF signals levels were significantly lower than the reference signals (P < 0.05), indicating that converted apo-TF detached from the bacteria and was released into the supernatant  instead of apo-TF was detected by enzyme-linked immunosorbent assay (ELISA) using anti-TF antibodies . Therefore, the iron uptake event could be characterized through comparison of the difference of relative desthiobiotin signals  and relative iron-carrying TF signals after RS218 was incubated with bio-TF. As shown in  < 0.05) . Furtherernatant .The above results indicated that ExPEC RS218 bound to holo-TF and acquired the TF-associated iron. This process did not involve the transport of holo-TF to the cytoplasm. After the iron of holo-TF was plundered by RS218, apo-TF detached from the surfaces of bacteria.The desthiobiotin pulldown assay from ExPEC RS218 total membrane fractions to determine the identity of holo-TF-binding protein(s) indicated the presence of proteins . The subsequent mass spectrometry analysis indicated that EFG is one of the proteins with the largest number of matched peptides (Table S1), so it was selected for further research.E. coli BL21 carrying the pET-32a plasmid) bands interacting with holo-TF or rEFG were detected, indicating that the interaction between EFG and holo-TF was specific. The results of the ELISA plate binding assays indicated that rEFG bound to bio-TF in a concentration-dependent manner (P < 0.05)  was expressed  and the interaction between rEFG and holo-TF was detected by far-Western blotting, ELISA plate binding assays, desthiobiotin pulldown assays, and recombinant protein inhibition assays. The results of far-Western blotting detected that the holo-TF signal was associated with the rEFG on the polyvinylidene difluoride (PVDF) membrane and the rEFG signal was associated with the holo-TF on the PVDF membrane  and B. Nt manner . In addit manner  and G. T < 0.05) .http://pfam.xfam.org/), and the results indicated that EFG contains five domains: the GTP_EFTU (amino acids 8 to 288), GTP_EFTU_D2 , EFG_III , EFG_IV , and EFG_C (amino acids 611 to 689). In this study, amino acids 1 to 288 were regarded as Dm1 and amino acids 611 to 704 were regarded as Dm5. The schematic diagram of domains is showed in Fig. S5. To identify TF-binding domains in EFG, recombinant proteins with domain deletions  were constructed . The results of ELISA binding assays in P < 0.01), which indicated that Dm1 and Dm2 of EFG were key regions of EFG binding to holo-TF.The domains of EFG were predicted by Pfam , and recombinant proteins deficient in each region were constructed . The results in The above results indicated that the EFG interacted with holo-TF via its N-terminal domains .450; iron-carrying TF/total TF) were significantly lower in the 0.5 μM rEFG and 1 μM rEFG groups than in the reference group (P < 0.05). When incubated at 37°C, the relative values of OD450 were significantly lower in the 0.2, 0.5, and 1 μM rEFG groups than in the reference group (P < 0.05)  , indicat450  of rEFG, ΔDm1, and ΔDm2 were significantly lower (P < 0.01), which indicated the production of apo-TF. The relative values of OD450 of ΔDm3, ΔDm4, and ΔDm5 were not significantly different from those of the reference group (P > 0.05), indicating that the deletion of Dm3, Dm4, and Dm5 of EFG resulted in the failure of apo-TF generation. These results suggested that the C-terminal domains of EFG, including Dm3, Dm4, and Dm5, were involved in the process of iron release after binding with holo-TF.The key domains of EFG associated with iron release were also explored. As shown in The reported bacterial TF-binding proteins  are surface proteins. To investigate whether EFG might be located on the surface of RS218, Western blotting, colony blotting, and immunofluorescence assays were performed. The positive signals of EFG and OmpA on RS218 outer membrane fractions  and the efg are presented in PBP57058) was used as the anchoring motif to enable display of heterologous proteins on the surfaces of E. coli. The mCherry protein (GenBank: MK753226.1) was used as an indicator of protein expression on the surfaces. The fusion expression of EFG or its variants with InaZN and mCherry enabled heterologous expression of EFG or its variants on the surfaces of bacteria.The pEImC plasmid for heterologous protein surface-display was constructed according to previous studies with modifications –29. Gene–efg, pEImC::ΔDm1, pEImC::ΔDm2, pEImC::ΔDm3, pEImC::ΔDm4, and pEImC::ΔDm5, were transformed into E. coli BL21(DE3). The obtained strains were named BL21-pEImC, BL21-pEImC-EFG, BL21-pEImC-ΔDm1, BL21-pEImC-ΔDm2, BL21-pEImC-ΔDm3, BL21-pEImC-ΔDm4, and BL21-pEImC-ΔDm5, respectively -induced bacterial pellet turned bright fuchsia (P < 0.05) (P < 0.01) (P > 0.05)  . Whole b < 0.01) . Outer m < 0.01) . Gray in > 0.05) . These rP < 0.001) (P < 0.05) (P < 0.01). However, the fluorescence intensity of fluor-TF bound to BL21-pEImC-ΔDm1 and BL21-pEImC-ΔDm2 was significantly lower than that of BL21-pEImC-EFG (P < 0.01), which indicated that Dm1 and Dm2, not the Dm3 to Dm5 of EFG, were involved in holo-TF binding.Our study revealed that the binding of rEFG and holo-TF facilitated iron release in phosphate-buffered saline (PBS). To detect the interaction between EFG and holo-TF at bacterial level, the binding of fluor-TF to BL21 strains containing a series of pEImC plasmids was detected. As shown in < 0.001) . An exce < 0.05) , thus exP < 0.05). BL21-pEImC-EFG acquired TF-related iron in a concentration-dependent manner (P < 0.01) (P < 0.001) (P < 0.001), indicating that overexpressed EFG significantly promoted the conversion of holo-TF to apo-TF. The BL21-pEImC-EFG converted holo-TF to apo-TF in a bio-TF concentration-dependent manner (P < 0.01) (P < 0.001)  . The flu< 0.001) . In addi < 0.01) . For BL2< 0.001) .E. coli to holo-TF. The deletion of iron-releasing domains and the holo-TF-binding domains in EFG suppressed the iron uptake capacity on the whole bacterium level.These results indicated that the overexpression of EFG on the bacterial surfaces was positively correlated with holo-TF-binding and iron absorption ability. The N-terminal domain of EFG played an important role in the binding of P < 0.05). However, the deletion of Dm1 and Dm2 impaired the holo-TF-binding ability of BL21-pEImC-EFG (P < 0.05).To determine the effects of the interaction between EFG and holo-TF on bacterial viability in macrophages, the ability of BL21 strains containing a series of pEImC plasmids strains to bind holo-TF and their ability to survive in THP-1 cells were determined. As shown in P < 0.005), which suggested that holo-TF promoted the tolerance of bacteria to macrophages. Furthermore, the survival ability of BL21-pEImC-EFG was significantly stronger than that of the BL21-pEImC strain in holo-TF-supplemented THP-1 cells (P < 0.001) (P > 0.05) (P < 0.05)  . No sign > 0.05) , which e < 0.05) . These rMetal ions  are the components of metalloproteins, including metalloenzymes, transcription factors, and storage proteins . These iEnterobacteriaceae enterobactin has been shown to chelate and subsequently import iron through FepA receptors in the FepBCDG system  to acquire ferric iron or secrete hemolysin to release hemoglobin-bound heme from erythrocytes  holo-TF had a stronger effect on bacterial growth than the high-dosage holo-TF (50 μg/mL). This is because excessive iron is harmful to bacteria. Moreover, iron is a mediator of oxidative stress. Excess iron can produce hydroxyl free radicals that damage DNA and proteins, which affects bacterial growth , 43.E. coli, obtain iron from the labile iron pool in host cell, although some of the iron in the unstable iron pool comes from holo-TF  of the E. coli genome did not identify TbpA-like or TbpB-like proteins. To identify the holo-TF-binding proteins associated with ExPEC RS218, desthiobiotin pulldown assays were used to capture the bound membrane proteins with bio-TF. Surprisingly, EFG was screened as a holo-TF-binding protein.To study the mechanism by which ExPEC RS218 uses holo-TF, the combination of RS218 and holo-TF was tested. Some bacteria, such as uropathogenic  holo-TF . Howeverain iron . The obsE. coli isolates, such as other pathotypes, commensal strains, or even laboratory workhorse strains . It is speculated that EFG might have the potential to bind TF and release iron from TF if EFG is a surface protein in these E. coli strains even in these various pathogens.In general, EFG is a cytoplasmic protein. In this study, the surface location of EFG was confirmed. In various pathogens, EFG, elongation factor Tu, and glycolytic enzymes without signal peptides are detected in membrane components –46. Thes–49–M. tuberculosis has suggested that for bacteria that do not possess professional TF-binding proteins, the moonlighting protein is a key breakthrough in studying the mechanism of iron uptake in holo-TF. Furthermore, we also found that although both EFG and GAPDH were moonlighting proteins with the function of binding holo-TF, their iron uptake mechanisms, especially iron release mechanisms, were quite different.Research into the EFG of ExPEC and GAPDH of https://swissmodel.expasy.org/) was used to predict the EFG structure, the result presented in Fig. S8 indicated that the EFG did not contain a 22-stranded β-barrel or an N-terminal plug domain, which are common structures for most TBDRs. This result further confirms that EFG was not a TBDR. Previous studies have also reported that TbpA and TbpB utilize FbpA rather than TonB to mediate iron transport . Bacteria were cultured at 37°C with shaking at 180 rpm in a Tecan Spark microplate reader. The value of ODTEM assays were performed as previously described with few modifications . Log pha8 CFU) was blocked as described in TEM assays. The bacteria were incubated with 20 μg fluor-TF alone or in the presence of unlabeled holo-TF for 1 h at 4°C. Bacteria were incubated with unlabeled holo-TF functioned as the background control. Bacteria with FITC-apo-TF were also subjected to the same process. The fluor-TF was purchased from Life Technologies (USA). FITC-apo-TF was prepared by labeling apo-TF with FITC  according to manufacturer’s instructions. After washing, the fluorescence intensity of the 107 cells was detected at an excitation of 485 nm and an emission of 535 nm. The fluorescence of the background control group was subtracted from all values. The ExPEC incubated with fluor-TF was observed under a fluorescence microscope.Fresh ExPEC strain RS218 . Anti-OmpA antibodies prepared in our laboratory  was washed with M9 medium. Then, bacteria incubated with 200 μg bio-TF for 4 h at 37°C or 4°C. Bio-TF was prepared by labeling holo-TF with EZ-Link sulfo-NHS-LC-desthiobiotin  according to the manufacturer’s instructions. Bacteria were washed four times with cold PBS. The cytosolic fractions were isolated and then incubated with streptavidin agarose resins . Captured proteins were loaded on a PVDF membrane and detected using horseradish peroxidase (HRP)-streptavidin . The isolated cytosolic fractions were verified by Western blotting using anti-LexA and anti-OmpA antibodies. The outer membrane proteins of ExPEC RS218 were used as a positive control for anti-OmpA antibodies.Log phase ExPEC strain RS218 (5 × 10efg (locus_tag W817_18790) and its domain deletion genes (ΔDm1 to ΔDm5) or regions deletion genes (Δ4.1 to Δ4.4) were recombined into pET-28a using a ClonExpress II one step cloning kit  or ClonExpress MultiS one step cloning kit . Recombinant plasmids were transformed into E. coli BL21(DE3). Expression and purification of recombinant proteins were performed as described previously  and the Bio-Rad ChemiDoc touch imaging system  according to the manufacturer’s instructions.The far-Western blotting was performed as previously described with modifications . The holThe ELISA plate binding assays were performed as previously described with modifications , 58. Rec7 bacterial cells was detected. Data were calculated as the fold change relative to the reference group.Fluor-TF (20 μg) was incubated with rEFG  for 2 h at 4°C. The mixtures were coincubated with ExPEC RS218 as described in the holo-TF-binding assays of ExPEC. Bacteria incubated with fluor-TF were used as the reference control. The fluorescence intensity of 10Desthiobiotin pulldown assays were performed according to the manufacturer’s instructions of an EZ-Link desthiobiotinylation and pulldown kit . Bio-TF (50 μg) and desthiobiotin labeled  were incubated with streptavidin agarose resins according to the manufacturer’s instructions. Bio-CA was prepared as described in the bio-TF preparation section. The interacted proteins were RS218 total membrane proteins (1 mg) or rEFG (100 μg). Captured proteins were detected by Western blotting using anti-EFG antibodies. To detect the total membrane fractions in this assay, Western blotting was performed using anti-OmpA and anti-LexA antibodies, and the whole bacterial proteins were used as a control.450 values of iron-carrying TF and total TF signals in the mixtures were detected using anti-TF antibodies and HRP-streptavidin, respectively. Background readings of the wells coated without proteins were subtracted from the samples. The relative OD450 value was calculated as the ratio of the OD450 value of the iron-carrying TF signal to that of total TF signal.The rEFG  and ΔDm1 to ΔDm5 (1 μM) were incubated with bio-TF (0.1 μM) for 2 h in a total volume of 200 μL PBS at 4°C or 37°C. The same concentration of bio-TF was used as a reference. The protein mixtures were diluted and coated on an ELISA plate. The ODWestern blotting, colony blotting, and suspension immunofluorescence assays were performed as previously described with some modifications , 59. OutmCherry were recombined into the pET-28a vector. All of the above genes were codon optimized and synthesized by GenScript (Nanjing). The new plasmid was termed pEImC. efg and ΔDm1 to ΔDm5 were recombined into the pEImC plasmid, respectively. The recombinant plasmids were termed pEImC::efg, pEImC::ΔDm1, pEImC::ΔDm2, pEImC::ΔDm3, pEImC::ΔDm4, and pEImC::ΔDm5. All seven of these series pEImC plasmids were transformed into E. coli BL21(DE3).The heterologous protein surface-display plasmid was constructed as described in previous studies with some modifications –29. Gene–7 cells of the seven induced BL21 strains containing a series of pEImC plasmids at an excitation of 579 nm and an emission of 624 nm. Background readings of uninduced bacterial controls were subtracted from the samples. The surface expression of EFG in the BL21-pEImC-EFG and BL21-pEImC strains was measured by whole strain ELISAs as described previously  for 150 min at 37°C. After washing, the bacteria were incubated with or without holo-TF for 6 h at 37°C. For the ExPEC, BL21-pEImC-EFG, and BL21-pEImC strains, the concentration of supplementary holo-TF was 0, 5, 10, 20, and 50 μg/mL. For the BL21-pEImC-ΔDm1 to BL21-pEImC-ΔDm5 strains, the holo-TF concentration was 10 μg/mL. After washing, the fluorescence intensity of 107 cells was measured at an excitation of 490 nm and an emission of 538 nm.Calcein-AM fluorescence quenching assays were performed as described previously with modifications , 60. Log8 bacterial cells were incubated with bio-TF  in M9 medium for 6 h at 37°C or 4°C. The bacteria were then placed on ice for 10 min to stop the iron acquisition process. Culture supernatants were diluted and coated on an ELISA plate. The total TF and iron-carrying TF signals in the culture supernatants were detected using HRP-streptavidin and anti-TF antibodies, respectively. The value of the blank control M9 medium was subtracted from all values. The same concentration of bio-TF was used as the reference control. The relative values of total TF signals or iron-carrying TF signals were calculated as the ratio of the OD450 value of the experimental group to the OD450 value of the reference group.Fresh ExPEC strain RS218 was washed twice with M9 medium. Then, 1 × 10450 values of total TF and iron-carrying TF signals in culture supernatants were detected as described above. The relative values were calculated as the ratio of the OD450 value of the iron-carrying TF signal to the OD450 value of the total TF signal.For seven BL21 strains containing a series of pEImC plasmids, bacteria were incubated with 10 μg/mL bio-TF at 37°C. ODIntracellular survival assays were performed according to previous studies with some modifications . ExPEC s2 for 1 h to allow for fluor-TF internalization. After washing, the cells were fixed, permeabilized, and blocked as described previously  as described in the colocalization detection assay. After the extracellular bacteria were cleaned, cells were incubated with 1 mg bio-TF for 1 h at 4°C. Then, cells were incubated at 37°C, 5% CO2 for another 1 h. Cells were washed four times with cold RPMI 1640 medium. The intracellular E. coli cells were isolated from THP-1 cells as described previously . The filter containing the captured E. coli was cut and subjected to Western blotting. Bio-TF, bacteria, and THP-1 cells were used as controls. Anti-LexA antibodies were used to detect bacteria recovered from inside THP-1 cells. Anti-GAPDH antibodies  were used to detect the THP-1 cells, and HRP-streptavidin was used to detect the bio-TF bound with bacteria.Seven BL21 strains containing a series of pEImC plasmids were incubated with THP-1 cells  and unpaired


Eine hohe Versorgungsqualität in der präklinischen Notfallmedizin zeichnet sich durch eine leitliniengerechte Therapie aus. Grundvoraussetzung für diese Therapie ist das Vorhalten der benötigten Medikamente entsprechend den gültigen Leitlinienempfehlungen. Ob dies flächendeckend gewährleistet wird, ist aktuell unklar. Ein einheitlicher Standard zur medikamentösen Ausstattung arztbesetzter Rettungsmittel in Deutschland existiert nicht. Ziel der vorliegenden Arbeit ist die Identifikation von wichtigen Diagnosen und der zu ihrer Therapie benötigten Medikamente. Ein Abgleich dieser Ergebnisse mit der realen Ausstattung arztbesetzter Rettungsmittel ermöglicht die Bewertung hinsichtlich leitliniengerechter Therapieoptionen.Nach einer strukturierten Leitlinienrecherche wurden Tracerdiagnosen definiert und ihnen relevante Medikamente zugeordnet. Hier wurde auch der Evidenz- und Empfehlungsgrad berücksichtigt. In einem zweiten Schritt wurden Ärztliche Leitungen Rettungsdienst zu der Ausstattung der von ihnen verantworteten Rettungsmittel befragt und die Ergebnisse mit den empfohlenen Medikamenten verglichen.Insgesamt wurden 156 verschiedene Medikamente identifiziert. Der Median der vorgehaltenen Medikamente beträgt 58 bei einer minimalen Vorhaltung eines Standorts von 35 Medikamenten und maximaler Vorhaltung mehrerer Standorte von 77 Medikamenten.In der vorliegenden Erhebung wurden die in Leitlinien empfohlenen Medikamente mit der realen Ausstattung von arztbesetzten Rettungsmitteln verglichen. Insgesamt zeigt sich, verglichen mit einer Studie aus dem Jahr 2011, eine verbesserte Strukturqualität. Die empfohlenen Medikamente werden zu einem hohen Maß prähospital vorgehalten. Die Daten dieser Erhebung können von Rettungsdienstbereichen in ganz Deutschland zur Beurteilung ihrer individuellen Strukturqualität genutzt werden.Die Online-Version dieses Beitrags (10.1007/s10049-022-01036-6) enthält ergänzende Übersichtstabellen. Leitlinien wissenschaftlicher Fachgesellschaften sind Grundlage für eine optimale Patientenversorgung im Rahmen der evidenzbasierten Medizin. Leitlinien dienen hierbei dem Transfer von wissenschaftlicher Evidenz und Konsensempfehlungen von Fachexperten in den klinischen Alltag. Die Umsetzung dieser Leitlinien stellt einen wichtigen Qualitätsindikator der klinischen Versorgung dar . Für dieIm Rahmen der prähospitalen Patientenversorgung in Deutschland konnten Rörtgen und Kollegen im Jahr 2011 zeigen, dass eine leitliniengerechte Therapie am Einsatzort nach höchstem Evidenzgrad aufgrund mangelnder medikamentöser Ausstattung häufig nicht erfolgen konnte . Je nachDie vorliegende Arbeit ist eine deskriptive Beobachtungsstudie, die in zwei Schritten erfolgte. Zunächst erfolgte eine Leitlinienrecherche hinsichtlich notfallmedizinisch relevanter Leitlinien und deren Empfehlungen für die medikamentöse Therapie. In einem zweiten Schritt führten wir eine Befragung der ÄLRD bezüglich der medikamentösen Ausstattung der arztbesetzten Rettungsmittel durch. Für die Studie lag ein positives Votum der Ethikkommission der Medizinischen Hochschule Hannover (Nr. 9191_BO_K_2020) vor.Es erfolgte eine Schlagwortsuche innerhalb der Leitliniendatenbank der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF). Hierfür wurden die Schlagwörter „Notarzt“, „Notfallmedizin“, „prähospital“, „Präklinik“ sowie „Rettungsdienst“ verwendet. Die ermittelten Leitlinien wurden zunächst durch zwei Untersucher gesichtet und anhand des Titels wurde eine mögliche Relevanz für die Fragestellung erfasst. In einer zweiten Sichtung erfolgte durch fünf Untersucher mit mindestens 5‑jähriger Erfahrung in der Notfallmedizin die Identifizierung von präklinisch relevanten Empfehlungen. Für die oben genannten Tracerdiagnosen wurde ergänzend eine MEDLINE-Recherche durchgeführt und die nationalen Empfehlungen um die der europäischen Leitlinien ergänzt. Die Leitlinienempfehlungen werden, wenn möglich, für eine bessere Vergleichbarkeit hinsichtlich Empfehlungs- und Evidenzgrad nach dem Vorbild der European Society of Cardiology  dargestwww.bv-aelrd.de) erfolgte eine Kontaktdatenakquise auch auf Bundeslandebene. Die ÄLRD wurden per E‑Mail kontaktiert und um Übersendung der Medikamentenausstattungslisten der arztbesetzten Rettungsmittel in ihrem Zuständigkeitsbereich gebeten. Alle ÄLRD, die nach drei Wochen keine Antwort übermittelt hatten, wurden maximal zweimal erneut angeschrieben.Es erfolgte die Kontaktaufnahme über im Internet frei zugängliche Kontaktdaten von ÄLRD. Neben der Homepage des Bundesverbands der Ärztlichen Leiter Rettungsdienst e. V.  deskriptiv erfasst. Kategoriale Variablen wurden als numerische Werte und prozentuale Anteile angezeigt.Am Erhebungstag konnten 127 Leitlinien identifiziert werden, die mindestens für eines der verwendeten Schlagwörter einen Treffer ergaben. Abb. Nach der Stufenklassifikation des AWMF-Regelwerks  zur PlanDie Sichtung der 127 Leitlinien durch zwei Untersucher hinsichtlich einer möglichen Relevanz bezüglich der medikamentösen Ausstattung ergab für 27 Leitlinien die Nennung durch beide Untersucher. Hiervon waren 10 Leitlinien in ihrer Gültigkeit abgelaufen, wurden jedoch aufgrund ihrer vermuteten Relevanz im folgenden Schritt der Auswertung berücksichtigt. Darüber hinaus gab es weitere 16 Leitlinien (3 abgelaufene), die von jeweils einem Untersucher genannt wurden. Somit ergaben sich 43 Leitlinien, die durch die 5 erfahrenen Notfallmediziner begutachtet wurden. Die Sichtung der Leitlinien ergab, dass in 22 Leitlinien Empfehlungen unterschiedlicher Graduierung für eine medikamentöse Therapie in der Initialphase der Versorgung formuliert sind. Die MEDLINE-Recherche zeigte für 5 der 8 Tracerdiagnosen relevante Leitlinien von europäischen Fachgesellschaften.Für insgesamt 216 Rettungsdienstbereiche konnte ein ÄLRD identifiziert werden. Tab. Insgesamt wurden 156 verschiedene Medikamente benannt. Der Median der vorgehaltenen Medikamente beträgt 58 bei einer minimalen Vorhaltung eines Standorts von 35 Medikamenten und maximaler Vorhaltung mehrerer Standorte von 77 Medikamenten. Alle genannten Wirkstoffe mit der zugehörigen Vorhaltung in Prozent sind bei absteigender Sortierung in den ergänzenden Übersichtstabellen im Online-Material dargestellt. In Tab. In der vorliegenden Studie wurde die medikamentöse Ausstattung arztbesetzter Rettungsmittel untersucht und mit den Empfehlungen von nationalen und europäischen Leitlinien verglichen.Nach Empfehlung der Bundesärztekammer  unterlie2-Sympathikomimetika werden bei führender bronchialer Obstruktion zusätzlich zum Epinephrin empfohlen. Mindestens ein Vertreter dieser Substanzgruppe ist auf allen Medikamentenlisten der Befragten zu finden. Insgesamt zeigt sich somit eine hohe Implementierung der Empfehlungen.In der zum Erhebungszeitpunkt aktuellen, jedoch bereits 2018 abgelaufenen Leitlinie zur Therapie der anaphylaktischen Reaktion von 2014  wird Epi2-Sympathomimetika (SABA), deutlich zugenommen [Die in den Leitlinien , 14 zum Die zum Befragungszeitpunkt gültige Leitlinie des European Resuscitation Council  empfiehIn dem Kapitel zu Peri-Arrest-Arrhythmien werden unverändert seit 2010 weitere Medikamente empfohlen. Für Bradykardien wird Atropin als Mittel der ersten Wahl empfohlen und flächendeckend vorgehalten. Bei einer ursächlichen Bradykardie durch Intoxikation mit Beta- oder Kalziumkanalblockern ist die Wirkung von Atropin häufig nicht ausreichend. Hier empfiehlt die Leitlinie den Einsatz von Glukagon. Die Vorhaltung dieser Substanz ist mit 4 % sehr selten und sollte verbessert werden. Bei Breitkomplextachykardien wird neben Amiodaron der Einsatz von Magnesium bei der Sonderform der Torsade-de-pointes-Tachykardie empfohlen. Hier zeigt sich eine verbesserte Implementierung der Empfehlung mit 94 % gegenüber 2011 mit 45,3 % [Die ESC veröffentlichte 2019 eine europäische Leitlinie zur Therapie von supraventrikulären Tachykardien . BemerkeDer ST-Hebungs-Infarkt stellt eine der häufigsten Notarztindikationen dar . Die EmpDie Empfehlung zum Einsatz von Morphin zur notwendigen Analgesie ist aufgrund einer möglichen Interaktion mit ADP-Rezeptor-Antagonisten im Vergleich zu früheren Versionen herabgestuft worden. Eine 2019 veröffentlichte Metaanalyse [Guidelines for the management of arterial hypertension“ der ESC und der European Society of Hypertension (ESH) aus dem Jahre 2018 ist hier richtungsweisend [Abweichungen des Blutdrucks von den Normwerten sind ein häufiges, oft auch akut behandlungsbedürftiges Symptom im Rettungsdienst. Für die Senkung hypertensiver Werte stehen verschiedene Substanzen zur Verfügung. Die gemeinsame europäische Leitlinie „sweisend  und Kommsweisend  wird in Der aufgrund seiner kurzen Halbwertszeit und daraus resultierenden guten Steuerbarkeit besonders empfohlene Betarezeptorblocker Esmolol wurde bei keiner der Antworten genannt. Das alternativ vorgeschlagene Metoprolol hingegen wird auf jeder Liste geführt. Weder in der englischsprachigen Originalpublikation noch in der deutschen Übersetzung wird für die Substanzgruppe der Betarezeptorblocker eine Differenzierung nach Empfehlungsgrad vorgenommen. Insgesamt kann für die präklinische Therapie bei zu hohen Blutdruckwerten ein sehr hoher Implementierungsgrad der Leitlinienempfehlungen der 1. und 2. Wahl festgestellt werden. Lediglich für das bei bestehender Agitiertheit, Unruhe oder Alkoholentzugssyndrom empfohlene zentrale Sympatholytikum Clonidin trifft dies mit 30 % nicht zu. Aufgrund der deutlichen Verzichtsempfehlung für den Einsatz von sublingual verabreichten, unretardierten Kalziumkanalblockern wie Nitrendipin (44 %) und Nifedipin (2 %) ist hier eine Anpassung der Medikamentenbestückung sinnvoll.Die medikamentöse Therapie einer kritischen Hypotension ist zum einen bei der Versorgung von Patienten mit schwerem isoliertem Schädel-Hirn-Trauma  indizierAuf Grundlage einer 2012 veröffentlichten Leitlinie  der DeutIm Wesentlichen befassen sich zwei S1-Leitlinien der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin e. V. (DGAI) und die S3-Leitlinie Polytrauma/Schwerverletzten-Behandlung unter Federführung der Deutschen Gesellschaft für Unfallchirurgie e. V. mit der prähospitalen Notfallnarkose , 30 und Die Befragung der ÄLRD erfolgt zu einem ungünstigen Zeitraum im Rahmen der SARS-CoV-2-Pandemie (August bis November 2020). Pandemiebedingt ist von einer hohen Arbeitsbelastung der ÄLRD auszugehen. Dies könnte ein Grund für die mit Rörtgen  verglichInsgesamt zeigt sich verglichen mit den Daten von Rörtgen et al. eine verbesserte Implementierung der Leitlinienempfehlungen. Rörtgen und Kollegen mussten 2011 noch feststellen, dass für bestimmte Tracerdiagnosen eine medikamentöse Therapie nach höchstem Evidenzgrad mit einer Häufigkeit von bis zu 80 % nicht möglich war . Im VergUm tatsächlich eine einheitliche Ausstattung aller arztbesetzten Rettungsmittel nach höchstem Evidenzniveau sicherzustellen, wäre der bereits vor 20 Jahren formulierte Vorschlag zur Konsensfindung durch die Deutsche Interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin e. V. (DIVI) und der Bundesvereinigung der Arbeitsgemeinschaften der Notärzte Deutschlands e. V. (BAND) sowie des Bundesverbands der Ärztlichen Leiter Rettungsdienst Deutschland e. V. sinnvoll.


GLUL (GS) and GLUD1 (GDH) may be the cause of glutamate alterations in astrocytes in AD. These results provide a basis for understanding the characteristic changes in astrocytes in AD and provide ideas for the study of AD pathogenesis.Astrocytes play an important role in the pathogenesis of Alzheimer’s disease (AD). It is widely involved in energy metabolism in the brain by providing nutritional and metabolic support to neurons; however, the alteration in the metabolism of astrocytes in AD remains unknown. Through integrative analysis of single-nucleus sequencing datasets, we revealed metabolic changes in various cell types in the prefrontal cortex of patients with AD. We found the depletion of some important metabolites , as well as the inhibition of some metabolic fluxes  in astrocytes of AD. The abnormality of glutamate metabolism in astrocytes is unique and important. Downregulation of  Alzheimer’s disease (AD) is the most common neurodegenerative disease in the world. The clinical features include memory loss, and the pathological features include amyloid-β (Aβ) accumulation, neurofibrillary tangle formation (accumulation of p-tau), extensive neuroinflammation, and synaptic toxicity. Unfortunately, there is currently no cure for AD, and the development of drugs, such as those targeting Aβ has not been successful, possibly because the focus of the field is narrow. Therefore, new concepts of AD are needed.APOE, APOJ, and SORL  of patients with AD by integrating a single-nucleus sequencing (snRNA-seq) database. Our analysis results illustrated the unique metabolic state of astrocytes in AD brains. Some of important metabolites, such as 2-oxoglutarate (2OG), acetyl-coenzyme A (CoA), aspartate, pyruvate, and glucose-6-phosphate (G6P), are consumed or accumulated. Glutamate metabolism is an important and unique metabolic process in astrocytes. In the astrocytes in AD brains, glutamate accumulates, while levels of the glutamine and 2OG are downregulated. This reprogrammed metabolism in astrocytes may result from the downregulation of The snRNA-seq datasets (raw or gene expression matrices) of the human PFC used in this study were downloaded from the NCBI Gene Expression Omnibus database (GEO)Single-cell flux estimation analysis scFEA;  was usedWGCNA) and module preservations. The 5,000 most highly variable genes and the differentially expressed enzymes were used. A softPower of 6 was selected as the soft-threshold parameters to ensure a signed co-expression gene network. After filtering, there left a total of 5,007 genes. The correlation coefficient calculation process uses the Spearman correlation coefficient method of the Cor function. To identify the genes in the yellow module that were regulated in AD, gene set enrichment analysis (GSEA) and hypergeometric tests with the clusterProfiler R package were used for functional enrichment analysis.The WGCNA R package  was usedWe used the pyscenic  based onAQP4+, SLCA2+), endothelial cells , excitatory neurons , inhibitory neurons , microglia , oligodendrocytes , and oligodendrocyte precursors  flux, the metabolites (aspartate), and flux-related transporter (SLC1A3) were also significantly downregulated  were included in the astrocytes by performing SCENIC. We performed a hierarchical clustering analysis of the transcriptional regulators and obtained five modules . Using ttrocytes . Interese SLC1A2 , which we SLC1A2 . The intnd GLUD1 .Recent proteomics studies on human AD brain samples have found a strong correlation between the severity of AD pathology and the proteins associated with astrocytes metabolism . By inteGLUL), which is specifically expressed in astrocytes  can be found in the article/L-YF and G-YG collected and analyzed the data. L-YF wrote the manuscript. JY, M-LL, R-YL, YK, and S-YD conceptualized and oversaw the study and data analysis. J-HY and Y-MX provided funding supports. All authors have read and approved the final manuscript.This work was supported by the National Natural Science Foundation of China (Grant U1904207); National Key R&D Program of China (Grant 2017YFA0105003); Non-profit Central Research Institute Fund of Chinese Academy of Medical Sciences (Grant 2020-PT310-01); Innovative and Scientific and Technological Talents Training Project of Henan Province (Grant YXKC2021062).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.https://www.frontiersin.org/articles/10.3389/fnmol.2023.1136398/full#supplementary-materialThe Supplementary material for this article can be found online at: Click here for additional data file.