Implementation science, defined by NIH as “the scientific study of the use of strategies to adopt and integrate evidence-based health interventions,” continues to grow within research, education, and practice-based settings. Building on principles from organizational psychology, intervention science, health economics, and health services research, implementation science aims to explore how, and under what conditions, evidence-based interventions are successfully implemented and sustained in real-world settings. Applying implementation science to aging programs and settings may help to accelerate the translation of effective programs and policies into practice. This interdisciplinary symposium will provide an introduction to key principles and applications of implementation science. The first three presentations will focus on largescale spread of interventions while the last two presentations will focus on broader applications of implementation science. The first two presentations will focus on adapting interventions from delivery in one setting or population to another. The third presentation will discuss the role of implementation strategies in scaling an intervention from a controlled research setting into a large integrated healthcare system. The third presentation will focus on the intersection of implementation science and policy. The final presentation will discuss the role of implementation science in alleviating health disparities and advancing health equity. Each presentation will utilize examples from ongoing research studies to demonstrate principles. The session will close with an interactive discussion on the role of implementation science within aging, including challenges and considerations for aging programs, policies, and populations as well as opportunities for further training and education.


The Spanish Civil War (1936–1939) is an example of a historic event involving nurses, with the participation of professional and volunteer nurses from Spain and other countries. In this context, nurses were trained over short periods of time and recruited to work at hospitals serving the two warring camps.To identify the characteristics of the training received by volunteer nurses on both sides in the Spanish Civil War and compare it with previous experiences in the history.Historical research.ABC and La Vanguardia. The following variables were analysed: duration, entry requirements, and theoretical content of the training courses. Consolidated Criteria for Reporting Qualitative Research (COREQ) has been used.Heuristic and hermeneutical analysis of nurse training manuals and news articles from 1936 to 1939. Spanish primary sources were consulted at the Red Cross Documentation Centre Archive in Madrid, the General Military Archive in Ávila, the Municipal Newspaper Archive in Madrid, and the archives of Spanish daily newspapers Both sides in the conflict offered a varied training programme, which was supported by official institutions and private initiatives. The courses lasted between one week and two months. Entry requirements were influenced by education level, age, moral conduct, health status, and social and political background. Training content focused on the techniques needed in conflict settings and covered specific moral values.Despite the different social and political characteristics of the two warring factions, the variety of training programmes on offer, the entry requirements, and the theoretical content of volunteer nurse training were similar on both sides. At the end of the Spanish Civil War, volunteer nurses on the Republican side suffered reprisals or had to go into exile. We now know that some countries involved in World War II provided training courses for volunteer nurses. It would therefore be interesting to ascertain whether Spanish volunteer nurses contributed their experience to these courses. Like any other social or health emergency, armed conflict has shaped the role played by nurses in healthcare delivery , forgingThroughout the 20th century, nurses participated in a number of armed conflicts around the world, tackling physical, psychological, and clinical problems. Training for civilian nurses differs in a number of ways from specific training allowing nurses to work in military hospitals, where specific preparation for ethical and care dilemmas is vital . ResearcNurse training is crucial in preparing nurses for the challenges of working in a conflict setting, where their theoretical knowledge, ethical commitment, and social responsibility are put to the test as they provide care in hostile, unpredictable, and challenging environments . Public Public health emergencies have shaped the development of the nursing profession, imbuing it with the social, political, and economic values of each historical context and influencing and modifying its image over time. It is important to study these emergencies and their incorporation into training programmes in order to understand nurses’ influence and contribution to society .practicante (practitioner). The nurse was a professional related to the woman-caregiver-salaried duality and the practitioner with the male-healer-autonomous duality  and translated from the French by María de Corral, a nurse with the Spanish Red Cross, was available  despite the fact that the rules state that the minimum age is 20 years old and she is 16. It’s nonsense that these girls hang around in hospitals instead of school, so they can’t be given the [training] card! Not being mobilised or on night shift, we cannot be indulgent until 18, but not less in any way. I don’t know what these parents are thinking about!” .Continuing with the Nationalist zone, applicants were asked to submit a certificate of good conduct, their birth certificate, and their academic qualifications with their application . In otheThe conflict situation led to a change in training content see , which fAs well as new training manuals focusing on knowledge relating to the conflict situation, some existing manuals also added sections for this purpose, including nursing, chemical warfare, and military administration .Theory lessons covered the spirit of sacrifice, sense of duty, caution, patience, and charity . VolunteTraining manuals also addressed matters relating to public perceptions of nurses, encouraging specific moral qualities. Their humanitarian work was expected to be characterised by kindness, gentleness, and altruism, as well as warmth, which nurses were required to display to all patients while remaining discreet and respecting patient confidentiality .In the training provided for nurses on the Nationalist side of the conflict, a sense of vocation and Christian charity  were presented as the model of perfection that nurses should strive to attain, with no expectation of professional recognition beyond that of God. Religious indoctrination became more entrenched as the war went on and nurses were asked to profess their love of God “by practising a Christian life of meditation and piety” that would allow them to care for the sick .The contribution of volunteer nurses during World War I is widely recognised , raisingAlthough dependence on the medical profession waned during World War I , doctorsIn World War II, the countries involved were already equipped with professional nurses, albeit in insufficient numbers. Nurses had to be mobilised from different countries , 69, stuDuring the Spanish Civil War, training courses lasted for a short period of time as their purpose was to provide intensive training for volunteers, including World War II volunteer nurses from Brazil  and FinlWe have identified that although the courses provided by both sides in the Spanish Civil War varied in terms of the training provided, their duration, and their entry requirements, the theoretical content was similar in all of them. The aim was to prepare volunteer nurses to provide healthcare in conflict settings. In such settings, knowledge and professional skills are extremely important. Studies such as Firouzkouhi et al. provide evidence of this, focusing on the need to include specific training in triage to ensure adequate healthcare .As we have seen, comprehensive, targeted training was needed during the Spanish Civil War to meet healthcare needs. The volunteers’ lack of experience and training were compensated by their eagerness to help and their good intentions, but these were not always sufficient to enable them to cope with the emotional distress caused by working in a war zone. None of the lessons in the manuals referred to the pain and suffering that the nurses would witness. They were asked to be kind, pious, and caring, but they were not prepared for the mental fatigue that they would face when providing compassionate care . These pThe training provided by the Spanish Civil War courses contributed to the public image of what a nurse should be, emphasising the moral qualities that nurses were expected to possess in particular. As well shaping their image, training courses also helped to foment a sense of belonging to a group and served as a way of homogenising attitudes and practices, as well as highlighting gender issues in this context . In thisWe have not found any cases of training courses for male nurses (practitioners) during the Spanish Civil War. This is related to the sexualisation of care that was present in the early 20th century . It woulAs well as theory lessons on providing healthcare and assistance to the wounded, the training manuals also contained recommendations on rest, diet, and exercise for nurses to ensure that they remained healthy and able to carry out their work to the best of their abilities. Recent studies have demonstrated the importance of self-care among nurses. Clinical training, rest, recuperation, exercise, and diet are all important factors in reducing psychological stress in war zones .During the Spanish Civil War, volunteers nurses were trained in the ethics of care, twinned with vocation and humanitarianism, which are essential in any conflict setting . Both siThe outcome of the Spanish Civil War and the first few decades of the Franco dictatorship (1939–1975) shaped the development of the nursing profession in Spain. The dictatorship revoked nursing diplomas issued by the Republican side , retaliaLey de Sanidad), nursing, midwifery, and nursing assistant studies were unified in Spain in 1953 under a new qualification named ayudante técnico sanitario  [Under the 1944 Spanish Health Law (sistant) . For decsistant)  and focusistant) .The health emergency caused by the Spanish Civil War gave rise to a need for greater numbers of nurses, leading to the emergence of courses aiming to train volunteers on both sides in a pattern that would be repeated in World War II years later. The variety of training programmes, entry requirements, and theoretical content were similar in both factions, although they were shaped by different sociopolitical contexts. The outcome of the war was pivotal in the lives of the volunteers. Volunteer nurses on the Republican side went into exile, so it is difficult to know how their experiences in the Spanish Civil War may have influenced volunteer nurse training systems in World War II or their integration into the workforce in their destination countries. The volunteer nurses on the winning Nationalist side helped to consolidate the nursing profession and nurses’ professional identity, which were shaped by the values of the Franco dictatorship.


Older adults are particularly at risk from infectious diseases, including serve complications, hospitalization, and death.This study aimed to explore the drivers of vaccine hesitancy among older adults based on the “3Cs”  framework, where socioeconomic status and vaccination history played the role of moderators.A cross-sectional questionnaire survey was conducted in Jiangsu Province, China, between June 1 and July 20, 2021. Older adults (aged ≥60 years) were recruited using a stratified sampling method. Vaccine hesitancy was influenced by the 3Cs in the model. Socioeconomic status and vaccination history processed through the item parceling method were used to moderate associations between the 3Cs and hesitancy. Hierarchical regression analyses and structural equation modeling were used to test the validity of the new framework. We performed 5000 trials of bootstrapping to calculate the 95% CI of the pathway’s coefficients.P=.002), convenience , and less complacency  were positively associated with less vaccine hesitancy. Socioeconomic status weakened the positive effect of low complacency  on low vaccine hesitancy. COVID-19 vaccination history negatively moderated the positive association between confidence  and lower vaccine hesitancy.A total of 1341 older adults participated. The mean age was 71.3 (SD 5.4) years, and 44.7% (599/1341) of participants were men. Confidence (b=0.967; 95% CI 0.759-1.201; Our study identified that confidence was the more influential dimension in reducing vaccine hesitancy among older adults. COVID-19 vaccination history, as well as confidence, had a positive association with less vaccine hesitancy and could weaken the role of confidence in vaccine hesitancy. Socioeconomic status had a substitution relationship with less complacency, which suggested a competitive positive association between them on less vaccine hesitancy. Older adults are at risk of illness, serious complications, hospitalization, and death from vaccine-preventable diseases owing to declining immunity associated with aging ,2. Vacci“Vaccine hesitancy,” proposed by the Strategic Advisory Group of Immunologists working group, could considerably hinder vaccinations. This term was defined as “delayed acceptance or refusal of vaccines despite their availability” . SeveralThe causes of vaccine hesitancy among older adults were summarized by the following factors, including misinformation, perception of good health, perception of vaccine ineffectiveness, side effects, and distrust of the health care system . Many stAs China is the most populous country in the world, the number of adults aged ≥60 years (267 million in 2022) is larger than in any other country . This stA cross-sectional questionnaire survey was conducted between June 1 and July 20, 2021, using a stratified sampling method. We assessed vaccine hesitancy among adults aged ≥60 years. After stratifying by economic level, the cities of Changzhou and Yancheng were selected as the survey areas for this study, among 13 cities in Jiangsu province, China, using the random number method. The gross domestic product per capita in Jiangsu province in 2019  was used as the cutoff between high  and low  economic levels . Then, wOlder adults who visited designated medical checkup clinics for annual physical examinations, which were government-organized checkups for all eligible residents within that residence, were recruited as participants. Participation was voluntary. All adults aged older than 60 years were encouraged to participate. The one-on-one interview survey method was adopted, and all investigators were trained uniformly. Those with cognitive impairment were excluded, as were those who had a relative complete the survey for them. The calculation of the sample size required for this study was shown in Material S1 in The questionnaire consisted of 3 sections. The first section was demographic , SES, and health information. Individual SES was evaluated by survey area (low or high economic level), education (primary or lower or secondary school or higher), medical career background (yes or no), occupation , and monthly revenue  “The poor quality of service at the vaccine clinic would make me not want to go for vaccination”; (2) “It was easy and took me a short time to get the vaccination”; (3) “I can get the vaccine that I want”; and (4) “I can afford the vaccine.” Complacency was measured using four items: (1) “If I do not get vaccinated, I will not get the disease”; (2) “Natural immunity is better than that produced by vaccination”; (3) “The probability of getting a disease is low, so I do not need to get vaccinated”; and (4) “Even if I get infected with a disease I can resist it, so I do not need to be vaccinated.” For structural consistency, we shifted all items in the complacency dimension.In addition, a vaccine hesitancy scale was included in the third section, which included three items: (1) “How likely would you go for a COVID-19 vaccine?” (2) “Would you get an inﬂuenza shot this year?” and (3) “If you could now get an influenza vaccine at your own expense, what is your choice?” Each item in the second and third sections was assessed using a 5-point Likert scale. A higher score chosen for each item in the second section means higher confidence, a greater level of complacency, and a higher level of convenience in the vaccine. A higher score chosen for the third section (vaccine hesitancy) means less vaccine hesitancy. The detailed information and the original questionnaire are presented in Material S2 in We proposed 5 hypotheses according to our purpose:Hypothesis 1: More confidence is positively associated with less vaccine hesitancy.Hypothesis 2: More convenience is positively associated with less vaccine hesitancy.Hypothesis 3: Less complacency is positively associated with less vaccine hesitancy. .Hypothesis 4: Vaccination history moderates the strength of the association between confidence (Hypothesis 4a), convenience (Hypothesis 4b), and complacency (Hypothesis 4c) with less vaccine hesitancy.Hypothesis 5: SES moderates the strength of the association between confidence (Hypothesis 5a), convenience (Hypothesis 5b), and complacency (Hypothesis 5c) with less vaccine hesitancy.t values, as well as factor loadings and average variance extracted (AVE) [A confirmatory factor analysis was conducted to assess the reliability and validity of each scale. Reliability was evaluated by calculating squared multiple correlations and composite reliability ,34. Thised (AVE) . ValiditAccording to Gerbing et al , the gooMICE package in R software  was used to complete this imputation. Sensitivity analyses were also conducted for the original data and where the missing data were deleted. Participants’ characteristics were described with mean  and frequencies . The variables of SES and vaccination history were processed using the item parceling method [P<.05.To minimize bias from the exclusion of any missing data for the older adults, we used multivariate multiple imputations to fill in missing values. The g method . All iteg method . Hierarcg method . Controlg method . HierarcBefore completing the questionnaire, it was mandatory for all participants to provide verbal informed consent. They were informed that this was an anonymous survey and that all data would remain confidential. Participants would receive US $2 worth of gifts in return for completing the survey. The Ethics Committee of the Wuxi Center for Disease Control approved this study (2020No10).Initially, 1384 participants  took part in this survey. Based on the inclusion and exclusion criteria, a total of 1341 participants were included finally . Of thesOf the specific vaccines, the percentages of older adults who self-reported having received herpes zoster vaccine, influenza vaccine (last year), and pneumonia vaccine were 0.8% (n=11), 1.5% (n=20), and 0.1% (n=2), respectively. A total of 30.9% (n=415) of the participants had received at least one dose of the COVID-19 vaccine. Additionally, 21.4% (n=287), 3.7% (n=50), and 29.9% (n=401) of the participants self-reported choosing uncertainty, postponing, and refusing vaccination, respectively. Further, 45% (n=603) of the participants were willing to receive vaccines.The items of each scale were censored based on the factor loadings, followed by the modification indices. Items with factor loadings below 0.5 were not retained, principally. The modified questionnaire is presented in Table S1 in P=.003), whereas single participants  were more hesitant. Age, sex, chronic diseases, self-assessment of health status, and self-assessment of the financial situation were not associated with vaccine hesitancy .Married participants were more willing to be vaccinated than their counterparts . Of these, confidence , convenience , SES , and vaccination history  were all significantly and positively associated with less vaccine hesitancy. Complacency was not significantly associated with vaccine hesitancy (P=.82). In block 3, the added moderators, SES and vaccination history, also had significant changes, compared with block 2 . SES moderated the impact between confidence  and complacency  with vaccine hesitancy. Convenience  was not statistically significant. Therefore, SES can positively moderate the positive effects of confidence on reducing vaccine hesitancy. In other words, the higher SES in people with higher confidence scores was associated with less vaccine hesitancy. SES negatively moderated the positive effect of less complacency on less vaccine hesitancy, which meant that lower SES weakened this positive effect between complacency and vaccine hesitancy. In addition, SES had a substitution effect with complacency. The positive effect of less complacency on vaccine acceptance was more pronounced when the degree of SES was low; however, as the degree of SES increased, the positive effect of less complacency decreased.Compared with the model in block 1, where control variables were presented, significant changes were made in block 2 (∆P=.06), less complacency (P=.14), and convenience (P=.16) with lower vaccine hesitancy. Hence, hypotheses 4a, 4b, 4c, and 5b were rejected, and hypotheses 5a and 5c were accepted. All detailed information about hierarchical moderator regression analysis is presented in Vaccination history had no moderating effect on the association between confidence (P=.02). COVID-19 vaccination history had a substitution effect with confidence. The positive effect of COVID-19 vaccination history on less vaccine hesitancy was more pronounced when the degree of confidence was low. Complacency and convenience were not moderated by COVID-19 vaccination history. In the herpes zoster, influenza, and pneumonia vaccination history subgroup  and convenience  exhibited a significant positive association with less vaccine hesitancy, thus confirming hypotheses 1 and 2. Unlike the hierarchical regression analysis, in the structural equation model, less complacency had a statistically significant effect on less vaccine hesitancy . Since the structural equation model considered the potential of multicollinearity, whereas the regression analysis did not, the result in the complacency dimension is the more reliable one. Detailed information is shown in To avoid the effects of multicollinearity, we calculated the effects of each of the 3 dimensions of confidence, convenience, and complacency on older adults’ vaccine hesitancy separately. Then, a full model was constructed, where the effects were split equally to solve multicollinearity ,42. As wThe confidence dimension was assigned 2 components: participants’ confidence in the vaccines, and participants’ confidence in the manufacturer who provided the vaccine and in the health care workers who administered it to them. The results for the second-order constructs showed that the direct effects (unstandardized estimate) between confidence in the vaccine confidence and confidence in health care workers and vaccine manufacturers confidence were 1.000 and 0.810, respectively.In this study, a 3Cs model moderated by SES and vaccination history was developed in the group of older adults. The explanation power of the new framework was examined, and the findings supported that confidence, complacency, and convenience all played an important role in older adults’ vaccine hesitancy. Additionally, SES was a significant moderator of confidence and complacency that scales with vaccine hesitancy. COVID-19 vaccination history moderated the association between confidence and vaccine hesitancy. The dual testing of the hierarchical moderator regression and structural equation modeling analyses made the results more reliable and robust.Analysis of the 3Cs model revealed several factors that influenced older adults' vaccination perceptions. Our findings in the confidence dimension among Chinese older adults were consistent with studies conducted in other countries, such as Peru ,44, EuroThe positive moderating effect between SES and the confidence dimension suggested that older adults with high SES had less vaccine hesitancy owing to better educational attainment and higher income than their counterparts. The positive effect of lower complacency on reducing vaccine hesitancy was more pronounced at lower SES. In other words, as SES increased, the positive effect of low complacency gradually decreased. This suggested a substitution effect between low complacency and SES on vaccine hesitancy among older adults. For disadvantaged older adults, complacency was exacerbated by low SES because of low knowledge level and social media occlusion . In the The difference in the moderating effect of COVID-19 vaccination history and the other vaccines indicated that the promotion of getting COVID-19 vaccination was a success among the older adults in China. The findings presented the substitution relationship between COVID-19 vaccination history and confidence, which was not presented in the other vaccines history group. Although vaccination history (either COVID-19 or other) did not reduce older adults’ complacency, their hesitancy would be decreased after COVID-19 vaccination by influencing confidence, which was a more powerful indicator of vaccine hesitancy in this study.Marital status was the significant demographic factor that could influence vaccine hesitancy among older adults. As summarized in a large review, positive perceptions and encouragement of vaccination by older adults’ family members and social communities were important for increasing vaccination rates . TherefoThis study provided evidence for practical applications in reducing vaccine hesitancy among older adults. Our findings suggested that increasing the vaccination willingness of older adults was strongly dependent on increasing confidence, both in the vaccine and in health care workers. Future interventions should focus on increasing vaccine recommendations by health care workers, especially those in primary care, on which older adults rely heavily . MoreoveFurther, since some older adults do not use social media and are distrustful of pharmaceutical interventions, future interventions among older adults should focus on instilling information about the safety, importance, and necessity of vaccines. The convenience dimension was a variable that required special attention in the older adult population compared with other groups. Increasing the convenience of vaccination, such as opening convenient vaccination sites, increasing reimbursement rate by health insurance, and increasing transportation convenience measures, can also reduce vaccine hesitancy among older adults .Finally, awareness of the severity of vaccine-preventable diseases and infection risk should be increased, especially among older adults with low SES. Complacency was a substitute factor for SES, and our findings provided evidence that reducing complacency could eliminate the large impact of SES—a variable that was essentially immutable in older populations—on vaccination intentions.Selection bias is one possible limitation. Although all older adults were required to participate in this free annual physical examination where we recruited participants, it was not mandatory. Therefore, the individuals who participated in this survey might have been more concerned about health care than their counterparts. However, we controlled for demographic factors in our analysis. In addition, the AVE of convenience for the questionnaire was slightly lower than the related correlation with complacency; however, the overall model fit was ideal. This questionnaire should be improved in future studies. All the data were self-reported, and realistic data such as vaccine efficacy and safety were not included in this study. This study was conducted in Jiangsu Province, an economically developed province in China; hence, extrapolation need to be considered with great caution, especially in less economically developed areas. In these areas, for example, the association between convenience and older adults’ vaccine hesitancy may increase positively.This study developed a model based on the 3C theory including SES and vaccination history as moderating variables to explore the drivers of vaccine hesitancy among older adults. Confidence was the more influential factor in reducing vaccine hesitancy among older adults. Our findings also highlighted that COVID-19 vaccination history, which had a positive influence on less vaccine hesitancy, weakened the role of confidence in vaccine hesitancy. The substitution relationship between SES and complacency suggested a competitive positive effect of SES and less complacency on less vaccine hesitancy. These associations could provide potential strategies that can be used to mitigate vaccine hesitancy for older adults with different reasons for SES, confidence, and complacency.


Ankle foot orthoses are mainly applied to provide stability in the stance phase and adequate foot clearance in the swing phase; however, they do not sufficiently assist during the entire gait cycle. On the other hand, robotic-controlled orthoses can provide mechanical assistance throughout the phases of the gait cycle. This study investigated the effect of ankle control throughout the gait cycle using an ankle joint walking assistive device under five different robotic assistance conditions: uncontrolled, dorsiflexion, and plantar flexion controlled at high and low speeds in the initial loading phase. Compared with the no-control condition, the plantar flexion condition enhanced knee extension and delayed the timing of ankle dorsiflexion in the stance phase; however, the opposite effect occurred under the dorsiflexion condition. Significant differences in the trailing limb angle and minimum toe clearance were also observed, although the same assistance was applied from the mid-stance phase to the initial swing phase. Ankle assistance in the initial loading phase affected the knee extension and ankle dorsiflexion angle during the stance phase. The smooth weight shift obtained might have a positive effect on lifting the limb during the swing phase. Robotic ankle control may provide appropriate assistance throughout the gait cycle according to individual gait ability. Smooth walking requires proper movement of the ankle joint. The rocker function plays an important role as a rotation axis for shock absorption in the early stance and in generating an anterior propulsive force in the late stance and pre-swing phases  tuned for individual walking disabilities compensates for gait disturbance by adequately controlling the motion of the tibia during the stance phase  provides ankle plantar flexion and dorsiflexion in the stance and swing phases at the preferred timing, which is based on angular velocity. In previous studies, we focused on the device's assistance in forefoot rocker function and revealed its positive effects on gait function and spinal cord excitability  without lower limb orthopedic disease participated in this study. This study was approved in advance by the Ethics Committee of Hiroshima University in accordance with the Declaration of Helsinki, and written consent was obtained from all participants.RE-Gait is a close-fitting assistive walking device that consists of a controller  and an ankle foot orthotic equipped with a motor and two sensors on the toe and heel (weight 1 kg) . Only thParticipants were asked to walk on a treadmill  at a comfortable speed (2.0–2.8 km/h) under five conditions, wearing RE-Gait on their right leg. The comfortable speed for each participant was determined by measurements before the experiment.Walking was performed for 2 min, with the first 1 min serving as a warm-up period, and the last 1 min as the assessed period. Furthermore, the participants walked for another 30 s with the device attached but not controlled by the motor to avoid the aftereffects of each walking condition .Five conditions were set depending on the initial control method from the heel contact to toe contact period . The setSubsequently, the control between the mid-stance and swing phase was set to be constant except for the OFF condition as follows: plantar flexion assistance (55°/s) for 10% of the gait cycle period after the heel off, and dorsiflexion assistance (55°/s) for 10% of the gait cycle period were applied immediately after the plantar flexion assistance, based on previous studies  and assessed the joint angles of the knee and ankle, trailing limb angle (TLA), and minimum toe clearance (MTC) using markers attached to body feature points at the greater trochanter, lateral epicondyle of the knee, lateral malleolus, fifth metatarsal head of the right leg, and heel on the right leg. The marker of the lateral malleolus was placed perpendicular to the lateral malleolus on the device.The joint angle was calculated by capturing the video and tracking the coordinates of the markers of each landmark using MATLAB R2020a Image Processing Toolbox and Computer Vision System Toolbox . If the marker was not detected, linear interpolation was applied.The knee joint angle was calculated as the angle between the thigh vector joining the greater trochanter with the lateral epicondyle and the lower leg vector joining the lateral epicondyle with the lateral malleolus. The ankle joint angle was calculated as the angle between the lower leg vector and the foot vector with the fifth metatarsal head and the heel. Changes in each gait cycle were analyzed by identifying two consecutive heel contacts. To analyze the angular changes, five periods were identified based on the toe and heel foot pressures: heel-contact, toe-contact, middle-stance, heel-off and toe-off. The middle-stance was defined as the intermediate period between toe-contact and heel-off. The gait cycle was divided into five phases according to the following five periods: loading response, mid-stance, terminal stance, pre-swing, and swing phases. Angular changes were calculated from peak-to-peak values in each phase.The TLA was defined as the peak angle between the vertical axis and the vector joining the greater trochanter with the fifth metatarsal head , and the electrodes were placed on the tibialis anterior (TA), soleus (SOL), medial head of the gastrocnemius (MG), rectus femoris (RF), vastus medialis (VM), and biceps femoris (BF) of the right leg. After proper cleaning of the skin, EMG electrodes were placed over the belly of each muscle. The EMG signals were amplified ( × 100) using an EMG amplifier system  and digitized at 1000 Hz using Power Lab system .The EMG data were band-pass filtered at 10–200 Hz and rectified for offline analysis using LabChart v.8.1.12 (AD Instruments). They were then time-normalized and rectified into 100 data points for each gait cycle. The EMG amplitudes were normalized by the average amplitude of each muscle over the gait cycle for comparison of each condition .The angular changes and, TLA, MTC, and EMG amplitudes in each phase were compared under the five different conditions  using a one-way repeated measures analysis of variance. Before the analysis, we confirmed that the data were normality distributed using the Mauchly's sphericity test. If the significant differences were appeared, paired  = 12.19, P < 0.01). Moreover, the post-hoc test revealed that it was significantly increased under the PFh condition compared with that under the OFF condition.The average changes in the knee and ankle joint angles throughout the gait cycle are shown in  = 18.44, P < 0.01), terminal stance phase  = 7.69, P < 0.01), and swing phase  = 7.64, P < 0.01). Post-hoc tests showed that the dorsiflexion angle in the mid-stance phase was significantly lower under the PFs (7.79 ± 3.54°) and PFh (6.19 ± 3.90°) conditions than under the OFF (10.36 ± 2.31°) condition, and that in the terminal stance phase was significantly smaller under the DFs (7.12 ± 2.21°), DFh (7.70 ± 2.79°), and PFs (8.32 ± 2.31°) conditions than under the OFF condition. During the swing phase, the dorsiflexion angle in the DFh (14.15 ± 6.41°) condition was significantly higher than the OFF (7.21 ± 3.42°) condition.The ankle dorsiflexion angle also differed among the conditions; the timing of dorsiflexion was earlier under the DF conditions, and later under the PF conditions. Statistical analysis revealed significant differences in the dorsiflexion angle in the mid-stance phase  = 3.64, P < 0.05, MTC: F = 6.06, P < 0.01). Post-hoc tests revealed that the TLA was significantly lower under the OFF condition than under the DFs, DFh, and PFh conditions. The MTC under the DFh condition was significantly higher than that under the OFF condition.The averaged results of the TLA and MTC under each condition are also shown in  = 3.21, P < 0.05, SOL: F = 5.41, P < 0.01). The VM activation under the PFh condition was significantly higher in the loading response phase  = 3.52, P < 0.05) and significantly lower in the pre-swing phase  = 3.38, P < 0.05).In this study, the effects of ankle control using an ankle joint walking assistive device were assessed. The advantages of robotic ankle control are as follows: (1) ankle dorsiflexion and plantar flexion assistance in the initial loading phase control knee extension and ankle dorsiflexion in the stance phase, (2) assistance for the forefoot rocker function enhances TLA, and (3) obtaining smooth heel rocker function may have a positive effect on the lifting of the limb in the swing phase.To improve the weight shift, appropriate rocker functions are needed , and funded by Space Bio Laboratories Co., Ltd. Part of this work was supported by the Center for Integrated Medical Research, at Hiroshima University Hospital.The authors declare that this study received funding from Space Bio-Laboratories Co., Ltd. The funder had the following involvement in the study: Provision of equipment. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication. Author LY is employed by Space Bio-Laboratories Co., Ltd. The remaining 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.


ObjectivesOsteoradionecrosis is one of the most severe complications in patients with head and neck cancer, which is characterized by persistent exposed and devitalized bone without proper healing after radiation. The extent to which mandibulotomy and marginal mandibulectomy influence the occurrence of osteoradionecrosis remains unclear. This study evaluated the incidence and risk factors for developing osteoradionecrosis of the mandible after oral cancer treatments.MethodsA retrospective study was performed to analyze medical records of patients who underwent surgery and postoperative radiotherapy for oral cancers from 2009 to 2019 at a tertiary care hospital. Patient characteristics, incidence, and risk factors for developing osteoradionecrosis were reviewed. Comparisons between continuous and categorical data were performed using t-test and Chi-squared test. Cox regression analysis was used to assess the association between factors and the development of osteoradionecrosis.ResultsAmong the 61 patients included in the study, osteoradionecrosis of the mandible occurred in 9 of 32 (28.1%) patients who underwent mandibular surgery during oral cancer resection  and 2 of 29 (6.9%) patients without mandibular surgery.The development of osteoradionecrosis was significantly associated with performing mandibular surgery  and HIV infection . In the subgroup analysis of mandibular surgery, the development of osteoradionecrosis significantly increased in patients undergoing mandibulotomy  but not in patients undergoing marginal mandibulectomy .The analysis also showed that concurrent chemoradiation, radiation doses ≥ 60 Gy, and smoking were potential risk factors for the development of osteoradionecrosis, but none of these factors were statistically significant.ConclusionOur findings suggest that mandibular surgery is a significant risk factor for the development of osteoradionecrosis in patients with oral cancer. Further studies including larger population sizes are required to verify these findings. Oral cancer is a common type of head and neck cancer, which is reported to be the fifth most common cancer among countries in Southeast Asia and ranks among the top ten dominant cancers in Thailand .While surgical treatment and postoperative radiotherapy are the mainstay treatments for oral cancer, surgical management of these cancers is often more challenging because of the small area of the mouth and adjacent bony structures, which limit surgical exposure. Adequate surgical exposure and en-bloc resection are crucial to ensure oncological safety .Mandibulotomy is an approach that divides the mandible to gain surgical access to the oral cavity and oropharynx. Although this technique requires repair of the mandible afterwards, it provides excellent exposure to the submental area and posterior part of the mouth . ComplicMandibulectomy is a procedure used to eradicate a disease that involves the mandible. Marginal mandibulectomy involves resecting a portion of the lingual cortex or the alveolar ridge of the mandible as part of the surgical margin. This technique is indicated for oral cancers that abut or minimally erode the mandible without gross invasion. A decrease in mandibular bone thickness after resection may increase the risk of developing fracture and osteoradionecrosis .Several risk factors, such as poor dental health, post-radiation dental extractions, and radiation doses, have been reported to be associated with the development of osteoradionecrosis . HoweverThe aim of this retrospective study was to provide objective data on the role of mandibular surgery as a risk factor for the development of osteoradionecrosis in patients with oral cancer. The characteristics, incidence, and risk factors for developing osteoradionecrosis after oral cancer treatments were analyzed.This retrospective study reviewed surgical cases performed in the Department of Otolaryngology at the Chonburi Cancer Hospital, Thailand. Data regarding surgical techniques, clinical course, and complications were obtained from patients’ medical records.The inclusion criteria were: new diagnosis of oral cancers with at least three-year survival and receiving postoperative radiotherapy. The exclusion criteria were: receiving radiotherapy prior to surgery; premature discontinuation of treatment; performing segmental mandibulectomy with or without free flap reconstruction; or requiring revision surgery due to major surgical complications. Patients with a daily frequency of smoking were classified as smokers, regardless of duration.Surgical techniquePatients were divided into two groups based on mandibular involvement. The first group was composed of patients who underwent oral cancer surgery without mandibular surgery, while the second group was composed of patients who underwent mandibular surgery . All patients in the mandibulotomy group underwent straight midline mandibulotomy and repair with double mini-plates Figure .Marginal mandibulectomies were either performed vertically or horizontally depending on the location of the tumor. Figure Statistical analysisComparisons between continuous and categorical data were performed using t-test and Chi-squared test. Cox proportional hazard model was used to assess the association between these factors and the occurrence of osteoradionecrosis. Statistical significance was set at p ≤ 0.05.Ethical approvalThe Chonburi Cancer Hospital ethics committee approved this study and permitted a waiver of informed consent .Between 2009 and 2019, from a total of 421 patients with operable oral cancer, 61 patients were included in this study. The reasons for exclusion were surviving less than three years in 154 patients, receiving surgery alone in 112 patients, and loss to follow-up in 39 patients.The follow-up period was 3-10 years. Since osteoradionecrosis usually occurs late after radiation, only patients who survived for at least three years were included in the analysis. All patients had started dental treatment during surgery and dental problems, such as retained root, extensive periapical lesion, and periodontitis, were completely corrected prior to postoperative radiotherapy.Postoperative radiotherapy was administered to patients with stage III-IV disease or inadequate margins. Chemotherapy was also used to treat patients with positive margins or adverse features, such as lymphovascular invasion. Concurrent chemotherapy was cisplatin-based and was administered every week at a dose of 40 mg/m2. Chemotherapy was administered for four to six cycles depending on the patient tolerance. The characteristics of the patients included in this study are shown in Table In our institute, the transoral approach is used for small oral lesions (T1), whereas resection of T4 tumors is usually performed using the mandibulotomy approach. For intermediate oral lesions (T2-3), selection of the approach technique depends on the location of the tumor and the surgeon’s preference and experience. The mandibulotomy approach is usually performed for larger tumors that are difficult to access. This may have led to higher stages of disease in patients who underwent mandibular surgery in this study.In patients without mandibular surgery, the proportion of patients with lip and buccal cancer was higher. Most patients in this group were elderly women with a history of betel quid chewing. These factors explained the difference in sex and smoking between the groups in Table Of the 32 patients who underwent mandibular surgery, 11, 15, and six underwent marginal mandibulectomy, mandibulotomy, as well as combined mandibulotomy and marginal mandibulectomy, respectively. Among the 17 patients who underwent marginal mandibulectomy, none experienced postoperative fracture or osteomyelitis.Among the 21 patients who underwent mandibulotomy, three had mandibulotomy-related complications, one of which had an immediate postoperative wound fistula. The fistula resolved with conservative treatment within three weeks after surgery. The other two patients had plate exposure. These complications were corrected prior to administering radiotherapy. Malunion, non-union, malocclusion, and dental complications were not observed.The radiotherapy protocol for each patient was conventional two-dimensional radiation with cobalt or a linear accelerator. Among these patients, eleven developed osteoradionecrosis of the mandible. Table Table In subgroup analysis, marginal mandibulectomy was nonsignificantly associated with the development of osteoradionecrosis. Moreover, other factors, such as tumor concurrent chemoradiation, radiation dose ≥ 60Gy, and smoking, showed hazard ratios of two or more but none of these factors were statistically significant.Table Osteoradionecrosis is one of the most serious oral complications following head and neck cancer treatment. It is characterized by bone tissue necrosis and failure to heal for at least three months . AlthougSeveral factors, such as poor dental health, post-radiation dental extractions, radiation doses, smoking and alcohol use, tumor locations , proximity of the tumor to the bone, and nutritional status, have been implicated as risk factors for the development of osteoradionecrosis ,10-12.While previous studies suggested that mandibular surgery during oral cancer operation might increase the risk of osteoradionecrosis, to date, few studies have demonstrated a statistically significant association between mandibular surgery and osteoradionecrosis occurrence ,12,13. TThe mandibulotomy approach is associated with increased complications, such as wound infection, plate exposure, and osteoradionecrosis . PreviouThe overall incidence rate of osteoradionecrosis in this study was 18.0%. This was similar to the rates from other studies using the same two-dimensional radiotherapy technique, which ranged from 5% to 20% . Recent The extent to which mandibular surgery influences the occurrence of osteoradionecrosis remains unclear. The analysis of risk factors for osteoradionecrosis may have various results, depending on population selection, types and stages of tumors, radiotherapy protocol, and duration of study. The existence of confounding variables in previous studies makes it difficult to establish a clear causal link between mandibular surgery and osteoradionecrosis occurrence ,7-12.In this study, confounding factors from the site of tumor, oral hygiene, and nutrition were minimized because only patients with oral cancer were included. In addition, the hospital treatment protocol required all patients to correct their oral hygiene and nutrition prior to surgery and radiotherapy. Unlike previous studies that might include various protocols of radiotherapy and conditions of patients, the treatment in this study was surgery and postoperative radiotherapy with curative intent for every patient ,12,18.The univariate and multivariate analyses revealed that mandibular surgery and mandibulotomy were significantly related to the occurrence of osteoradionecrosis. However, the study is underpowered to clarify the role of marginal mandibulectomy as an independent risk factor for developing osteoradionecrosis.Our study also found that patients with HIV infection showed a significant increase in the occurrence of osteoradionecrosis. HIV-infected patients are at a higher risk of developing osteonecrosis disease due to vascular compromise. This may be related to the HIV disease itself or its therapy . To our The primary limitation of this study is the inherent selection bias and confounders associated with the retrospective nature of this study. Analysis of risk factors for osteoradionecrosis may have limited the validity. Osteoradionecrosis is a late complication and many patients died or were lost to follow-up prior to the occurrence of osteoradionecrosis. The incidence rate of osteoradionecrosis varies depending on population selection. Although patient factors were minimized, as only patients with oral cancer were included, the relatively small number of cases included in this study limited the statistical significance of several parameters.The findings of this study suggest that mandibular surgery, especially in patients undergoing mandibulotomy, was significantly associated with the occurrence of osteoradionecrosis. Preventive therapies, such as the maintenance of meticulous oral hygiene and frequent visits to the dentist, should be the key focus for these patients. However, further studies including larger population sizes are required to verify these findings.


In summary, our data revealed that the mechanism of dFdC resistance may be that c-Myc overexpression contributed to increased PD-L1 expression, and ARTS could overcome dFdC-resistant pancreatic cancer by inhibiting c-Myc and PD-L1. Our findings not only suggest c-Myc and PD-L1 as novel prognostic biomarkers in dFdC-resistant pancreatic cancer, but also provide ARTS as a promising candidate for overcoming dFdC resistance.Pancreatic cancer ranks fourth among cancer-related deaths, with a 5-years overall survival rate being below 10%. Gemcitabine (dFdC) has been considered the first-line drug for patients with pancreatic cancer. However, the clinical effectiveness is less than 20% due to drug resistance. Most importantly, overwhelming evidence suggested c-Myc and PD-L1 were generally highly expressed in pancreatic cancer patients. However, whether dFdC-resistant pancreatic cancer is associated with c-Myc and PD-L1 has not been elucidated. In our present study, we found that the expression of c-Myc and PD-L1 was markedly increased in pancreatic tumor tissues compared with adjacent tissues. Similarly, c-Myc and PD-L1 expression were also remarkably elevated in dFdC-resistant Panc-1 cells compared with parental cells. In addition, dFdC sensitivity was enhanced by the combination of dFdC and c-Myc inhibitors in Panc-1 cells. Interestingly, its sensitivity was reduced when c-Myc was overexpressed. Moreover, PD-L1 protein expression was dramatically down-regulated when treated with c-Myc inhibitors. Furthermore, artesunate (ARTS) screened from 18 compounds could reverse dFdC resistance in combination with dFdC in dFdC-resistant Panc-1 cells  Howevers. 4.8%) . Thus, tvia NT to be active. Studies have shown that the exact dFdC resistance mechanism is a decrease of human equilibrative nucleoside transporter 1 (hENT1) expression, which results in restricted intracellular uptake  Nucleoside transporters (NT): dFdC must cross the plasma membrane r uptake ; 2) Nuclr uptake ; 3) Tumor uptake ; 4) Epitr uptake . In addir uptake . HoweverRecent studies demonstrate that programmed death ligand 1 (PD-L1) and receptor molecule PD-1 are important targets in immune checkpoint blocking therapy. PD-L1 molecules highly expressed on the tumor cells surface specifically bind to PD-1 on the T cell membrane surface to inhibit the activity and function of T cells, thereby promoting tumor immune escape and drug resistance . PD-L1 eHerein, our findings revealed the effect of c-Myc and PD-L1 on dFdC resistant pancreatic cancer: 1) c-Myc and PD-L1 expression markedly raised in clinical cases of pancreatic cancer, and c-Myc expression correlated with PD-L1 expression in pancreatic cancer and may serve as prognostic predictors clinically. By constructing dFdC-resistant pancreatic cancer Panc-1 cells, our data found that the expression of c-Myc and PD-L1 was significantly elevated, suggesting c-Myc and PD-L1 may be novel prognostic biomarkers in pancreatic cancer, and inhibiting c-Myc and PD-L1 may be a potential strategy to rescue dFdC resistance in pancreatic cancer therapy. 2) By assessing the effect of natural compounds alone or in combination with dFdC in dFdC-resistant Panc-1 cells, our study revealed that ARTS in combination with dFdC could overcome dFdC resistance and inhibit DMBA-induced pancreatic cancer, implying that ARTS wound be a promising candidate to overcome dFdC resistance.Homo c-Myc plasmid was obtained from Gene Pharma . Primary antibodies against c-Myc and PD-L1 were purchased from Cell Signaling Technology ; β-actin was purchased from Santa Cruz Biotechnology . All secondary antibodies were purchased from Cell Signaling Technology .c-Myc inhibitors  were obtained from Selleckchem . Artemisinin (ARTS), Dihydroartemisinin (DHA), Shikonin, Oridonin, Andrographolide, Baicalein, Sulforaphane and Luteolin (purity ≥98%) were purchased from Shanghai Yuanye Bio-Technology Co., Ltd. . RPMI-1640, Dulbecco’s Modified Eagle’s medium (DMEM), Opti-MEM and fetal bovine serum (FBS) were purchased from Gibco/BRL . Sulforhodamine B (SRB) and DMSO were purchased from Sigma-Aldrich . 2 cell incubator preserved by international institute for translational Chinese medicine, Guangzhou University of Chinese Medicine .Panc-1 and Mia-paca cells were obtained from Guangzhou Cellcook Biotech Co., Ltd. . All cells were culture in a 37°C, 5% COPanc-1 and Mia-paca cells were grown to 60–80% confluence in 6-well plates. Plasmids and Lipofectamine™ 2000 (Invitrogen) were transfected with c-Myc overexpression in Opti-MEM medium, respectively, and incubated for 20 min at room temperature. Their mixture was then added to the cells.3 cells were seeded in 96-well plates (100 μL per well), and treated with different compounds for 72 h. After that, cells were fixed with 10% trichloroacetic acid and then stained with 0.057% SRB, and crystals were solubilized with 10 mM Tris-HCl. Measure the absorbance of each well at 540 nm in a microplate reader (Bio-Rad Laboratories).Cell viability was assessed by SRB assays. 3 × 10Whether dFdC with 10,058-F4 and 10,074-G5 had synergistic, additive or antagonistic effect was analyzed by combination index (CI) method . CI = CAPanc-1 cells were treated with 15 nM dFdC and passaged after reaching 80% confluence. One-third of the cells continued to be maintained in culture with 15 nM dFdC and counted as R-P (passage number); one-third of the cells were tested for dFdC sensitivity; one-third were analyzed and cryopreserved.−ΔΔct method. The sequences of PCR primers MYC is: 5′-GCCACGTCTCCACACATCAG-3′ 5′-TCTTGGCAGCAGGATAGTCCTT-3’; sequences of PCR primers CD274 is: 5′-AAATGGAACCTGGCGAAAGC-3′ 5′-GATGAGCCCCTCAGGCATTT-3’.Total mRNA was extracted using Trizol reagent  and cDNA was synthesized by the PrimeScriptTM RT reagent Kit . PCR was performed with SYBR Green real-time PCR using an ABI 7500 system . Relative gene expression was normalized to GAPDH. All the primers were designed and obtained from Beijing Genomics Institute . The data were analyzed by 2The pancreatic cancer cells were collected and lysed on ice for 30 min, centrifuged, and quantified by the BCA protein quantification kit . Then protein samples were subjected to gel electrophoresis and transferred to PVDF membranes. The proteins were incubated overnight at 4°C with primary antibodies against c-Myc, PD-L1 and β-actin diluted in 2.5% BSA, and were detected with ECL luminescent solution (Thermo Fisher Scientific).Male C57BL/6J mice were purchased from Guangdong Medical Laboratory Animal Center , and maintained in the animal facility in the SPF animal laboratory (License number: SYXK (GZ) 2019–0,144) with 12 h light/dark cycle, 21 ± 2°C, humidity 50 ± 10% at International Institute for Translational Chinese Medicine, Guangzhou University of Chinese Medicine . All the animal experiments were approved by the Animal Experiment Committee of Guangzhou University of Chinese medicine .n = 10) and then administered intragastrically with 0.9% saline, dFdC (100 mg/kg), ARTS (100 mg/kg) or dFdC combined with ARTS for 5 weeks. Ultrasound and MRI were performed to visualize pancreatic cancer development. After the end of experiment, the mice were sacrificed and the pancreatic tissues and tumors of each mouse were dissected.After anesthesia by pentobarbital injection into the abdominal cavity, the pancreas was exposed by laparotomy in mice, and 10 mg 7,12-dimethyl-1,2-benzanthracene (DMBA) dissolved in 0.1% trioctane triglyceride was once injected into the pancreas . In addiMouse pancreatic tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and sectioned (5 µm). Sections were deparaffinized with xylene and rehydrated with graded ethanol. The slices were stained with hematoxylin for 5 min, then eosin for 10 s, and covered with neutral gum. The images were taken with a microscope.Pancreatic cancer tissue microarray (HPan-Ade120Sur-01) was obtained and analyzed from Shanghai Outdo Biotechnology Co., Ltd. There was a total of 63 cases on the tissue microarray, of which 58 cases detected paired tumor- adjacent tissue.Human pancreatic tissues were fixed in 4% paraformaldehyde, embedded in paraffin, and sectioned (4 µm). Sections were deparaffinized with xylene and rehydrated, followed by antigen retrieval. The samples were incubated with anti-c-Myc and PD-L1 antibodies overnight at 4°C, followed by incubation with secondary antibodies for 1 h. Sections were stained to brownish-yellow with diaminobenzidine (DAB). The images were taken with a microscope.p < 0.05, **p < 0.01 and ***p < 0.001. Survival analysis of the patients was compared by the Kaplan-Meier method.All statistical analyses were conducted using GraphPad Prism 7.0. Significant differences were analyzed by one-way ANOVA between the samples and their respective controls. Differences were considered statistically significant at *p = 0.042; p = 0.022) and PD-L1 (p < 0.001) expression were associated with poor prognosis of patients  and 3-fold (p < 0.01), respectively (p < 0.05) and 4-fold (p < 0.001), respectively . And the CI of dFdC with 10,058-F4 and 10,074-G5 were 0.47 and 0.39, respectively, suggesting that c-Myc inhibitor combined with dFdC improved drug sensitivity. Additionally, similar results were also observed in Mia-Paca cells. When Mia-Paca cells were treated by dFdC, 10,058-F4 and 10,074-G5 alone for 72 h, the IC50 values were 15.59 nM, 63.09 and 60.76 μM, respectively , we initially examined the cell viability in pancreatic cancer Panc-1 and Mia-Paca cells. When Panc-1 cells were treated by dFdC, 10,058-F4 and 10,074-G5 with different concentrations for 72 h, the ICectively . To furtectively . But wheectively . Taken tp < 0.05; Some of evidences demonstrated that PD-L1 binds to PD-1 expressed on immune T cells, thereby promoting tumor immune escape and drug resistance . PD-L1 ep < 0.05; p < 0.001; 50 of dFdC was markedly elevated in Mia-Paca cells with overexpression of c-Myc , the c-Myc protein expression was enhanced by 1.4-fold and 1.5-fold in the c-Myc over-expressed group in Mia-Paca and Panc-1cells, respectively , and dFdC in combination with ARTS markedly decreased tumor weight/volume by 65.5 and 50.3%  and PD-L1 (p < 0.001) in pancreatic tumor tissues predicted a poor prognosis  contains numerous bioactive components, some of which exert anti-pancreatic cancer effects by reversing drug resistance, providing a new drug candidate for the treatment of pancreatic cancer . HoweverMyc axis . Meanwhiignaling . Consistt cancer . Considell death . Howeverll death . Consistll death , implyinIn conclusion, our present data revealed that c-Myc expression correlated with PD-L1 expression in pancreatic cancer and may serve as prognostic predictors clinically, indicating that restrainting c-Myc and PD-L1 overexpression in pancreatic cancer may provide a window to overcome dFdC resistance. Moreover, ARTS in combination with dFdC inhibited DMBA-induced pancreatic cancer, suggesting that ARTS may become an adjuvant dFdC-resistant agent for patients who suffer from pancreatic cancer. In addition, mechanistic studies on natural compounds such as ARTS have contributed to developing safer and more effective chemotherapeutic agents. This research provided a theoretical basis for the mechanism of dFdC resistance in pancreatic cancer, and provided potential targets and ideas for the treatment of pancreatic cancer and the exploitation of natural compounds.


Material and Methods. Model cells for AS were created by inducing oxidized low-density lipoprotein (Ox-LDL) in human umbilical vein endothelial cells (HUVECs). After processing with AF and interleukin-1 receptor-associated kinase 1- (IRAK1-) overexpressed plasmid, cell viability was assessed by CCK-8; cholesterol efflux was tested using liquid scintillation counter; IL-6 and TNF-α levels were determined with ELISA kits; ROS and apoptosis were confirmed using Flow cytometry. Besides, IRAK1-TAK1 pathway and apoptosis- and mitochondrial fusion-related proteins were monitored with western blotting analysis.  Atherosclerosis (AS) is a chronic inflammatory disease characterized by lipid metabolism disorder and vascular endothelial damage. Albiflorin (AF) has been certified to be effective in the therapy of certain inflammatory diseases, while the therapeutic effect and mechanism of AF on AS have not been fully elucidated.  Our results verified that AF could not only dramatically accelerate viability and cholesterol efflux but also attenuate inflammation, ROS production, and apoptosis in Ox-LDL-induced HUVECs. Meanwhile, AF could prominently prevent the activation of IRAK1-TAK1 pathway, downregulate apoptosis-related proteins, and upregulate mitochondrial fusion-related proteins in Ox-LDL-induced HUVECs. Moreover, we testified that IRAK1 overexpression memorably could reverse suppression of AF on inflammation, apoptosis, and IRAK1-TAK1 pathway and enhancement of AF on viability, cholesterol efflux, and mitochondrial fusion in Ox-LDL-induced HUVECs.  By blocking the IRAK1/TAK1 pathway, AF can significantly slow the course of AS, suggesting that it could be a viable therapeutic option for AS. Cardiovascular disease (CVD) is the leading cause of death worldwide, causing about 17.3 million deaths each year . AS is aRadix Paeoniae Rubra (RPR) is a traditional Chinese medicine derived from the dried root of Paeonia lactiflora Pall. or Paeonia veitchii Lynch . RPR hasIn the current study, we used oxidized low-density lipoprotein (Ox-LDL) to stimulate human umbilical vein endothelial cells to create a cellular model of AS (HUVECs). Then, we explored the influences of AF on the related biological functions  of AS model cells. Moreover, we revealed the possible mechanisms of AF in alleviating HUVEC injury induced by Ox-LDL. Thus, AF might provide a new therapeutic opportunity for AS treatment.2.HUVECs were provided by American Type Culture Collection  and maintained in DMEM medium  with 10% fetal bovine serum  at 37°C with 5% COμM AF for 24 h, respectively. Vector (control) and IRAK1-overexpressed plasmids were purchased from Origene . Ox-LDL-induced HUVECs were evenly placed into a 6-well plate and cultured for 12 h at 37°C. Then, the cells were transfected with the vector and IRAK1-overexpressing plasmid with Lipofectamine 3000  on the basis of the instructions.The cultured HUVECs were stimulated using 100 mg/L Ox-LDL  in endothelial basal medium for 24 h, and Ox-LDL-induced HUVECs were treated with 0, 4, 20, 100, 200, and 300 4/well. The HUVECs were treated based on the experimental purpose, respectively, and each group had 6 duplicate holes. After routine culture for 0, 24, 48, and 72 h, HUVECs in each well were added with 10 μL CCK-8 reagent . After 3 h of culture, the OD value at 450 nm was tested with a microplate analyzer.HUVECs were inoculated uniformly into 96-well plates at a rate of 1 × 10As described in previous literature , HUVECs α levels were verified using IL-6 ELISA kit  and TNF-α ELISA kit , respectively [On the basis of the instructions, IL-6 and TNF-ectively .5/well. After processing in line with different groups, HUVECs were washed 3 times with precooled PBS. After centrifugation and resuspended, HUVECs were dyed with propidium iodide (PI) and Annexin V-FITC based on the instructions of Annexin V-FITC/PI Apoptosis Detection Kit . Cell apoptosis was tested and analyzed using flow cytometry (Becton-Dickinson FACScan).The HUVECs were evenly inoculated into 6-well plates at a rate of 5 × 106 cells/well) in each group were inoculated into a 6-well plate and addressed with 2.5 mmol/L DCFH-DA (Cat. No. d6883) at 37°C for 25 min. After washing and staining, the fluorescence intensity values were detected by flow cytometry.The harvested HUVECs (1 × 10μg) were separated by 10% SDS-PAGE and transferred to PVDF membranes (Roche). PVDF membranes were blocked with 5% skimmed milk powder at room temperature for 2 h and incubated with primary antibody (dilution ratio: 1∶1000) overnight at 4°C and secondary antibody (dilution ratio: 1∶2000) at 37°C for 2 h. The membranes were addressed with ECL solution (Thermo Fisher Scientific), and the results were acquired with a gel imaging system. p-IRAK1 is referenced by IRAK1, p-TAK1 is referenced by TAK1, and GAPDH was applied as the reference for the other proteins. Anti-interleukin-1 receptor-associated kinase 1 (IRAK1), anti-p-IRAK1, anti-TGF-beta-activated kinase 1 (TAK1), anti-p-TAK1, anti-Bax, anti-caspase 3, anti-mitofusion1 (MFN1), anti-mitofusion2 (MFN2) and anti-opticatrophy1 (OPA1) were all purchased from Abcam (USA) [Total proteins were extracted with RIPA lysate from the collected HUVECs in each group, and protein concentration was tested by BCA method . Protein samples (40 am (USA) .5 cells/well) in each group were inoculated into sterile cover glasses in a 6-well plate, respectively. After incubation overnight, HUVECs were fixed by 4% paraformaldehyde  and permeated by 0.5%Triton X-100. After sealing with normal goat serum, the HUVECs were exposed with anti-p-TAK1  overnight at 4°C and fluorescent secondary antibody  at 37°C for 1 h. After DAPI  nucleation, the fluorescence intensity was observed using a fluorescence microscope  [The collected HUVECs  .P < 0.05 was for statistically significant.Statistical analysis was conducted using SPSS 21.0 ; statistical graphs was made using GraphPad Prism 8 software. The experimental data was represented as mean ± SD. One-way analysis of variance (ANOVA) was adopted for data comparison among multiple groups, and μM) to stimulate HUVECs. As displayed in μM AF group. Then, cellular model of AS was established with HUVECs through stimulation of 100 mg/L Ox-LDL, and model cells were processed with 4 μM and 100 μM AF, which were selected based on the CCK-8 results above. Subsequently, the CCK-8 data signified that cell viability was observably attenuated in Ox-LDL group relative to that in control group, while cell viability was signally enhanced in Ox-LDL+100 μM AF group versus that in Ox-LDL group  on cell viability in Ox-LDL-induced HUVECs , and a range of inflammatory cytokines [IRAK family is a family of protein kinases involved in TLR signal transduction . IRAK1, ytokines , 47. Andytokines . Therefoytokines –51. TAK1ytokines . And IRAytokines , 54. In Finally, our findings show that AF can halt the course of AS by inhibiting apoptosis and inducing mitochondrial fusion via IRAK1. As a result, we hypothesized that AF could be a molecular medication for the treatment of AS.


Parental support plays an important role in children's schoolwork motivation and may have been even more important during the first UK COVID‐19 pandemic lockdown because all schoolwork was completed at home. When examining the effect of parental support on children's schoolwork motivation, research has typically focused on comparing families with each other . In reality, however, the effect unfolds as a transactional, bidirectional process between parents and children over time . This research trend can result in imprecise conclusions about the association between parental support and schoolwork motivation.We examined bidirectional effects of parental schoolwork support and children's schoolwork motivation at both the between‐family and within‐family level.N = 98) in Years 7–9.This study reports findings from a weekly‐diary study conducted during the first UK COVID‐19 school lockdown. Cross‐lagged within and between multilevel modelling was used to analyse data from UK secondary school students  predicted more support from parents. However, in contrast with predictions, weekly levels of parental support did not predict children's weekly fluctuations in motivation.Within‐family results were not consistent with between‐family results. This study is novel in showing that child‐driven effects appear to be important in eliciting parental support within families over time. Schoolwork motivation is an important predictor of academic achievement  and within‐person (state) processes, thereby shedding light on the complex interplay of schoolwork motivation and parental support. We proposed the following hypotheses:Based on research focused at the between‐person level such as Heatly and Votruba‐Drzal , SilinskAt the within‐person level, we hypothesized that when children received higher parental support in one week, they would report higher schoolwork motivation in the subsequent week in comparison to a week where they received lower parental support. We also expected that individuals with higher schoolwork motivation in one week would receive more parental support in the subsequent week.Mage = 12.70 years, SD = 1.04 years). Among the students, 47% were in Year 7 (first year of secondary school), 22% were in Year 8, 29% were in Year 9. Most children in the sample were of white ethnicity  and one of their parents. All participants were recruited using email through schools or online advertisements. For the children's questionnaire, responses were obtained from 48 children at week 1 (51% missing), 72 children at week 2 (24% missing), 78 children at week 3 (20% missing), 76 children at week 4 (22% missing), and 65 children at week 5 (34% missing). Most parental responses were from mothers (90.59%). There were 28 participants who had five data points, 33 participants who had four data points, nine participants who had three data points, 11 participants who had two data points, five participants who had one data point, and 12 who did not answer the schoolwork motivation questions. Students' ages ranged from 11–15 years  set up during the pandemic to recruit participants for studies. We included the researcher's email address and sign‐up link in our information. The sign‐up form asked the parent to provide email addresses so we could send a link to the weekly questionnaires. Data were collected through online questionnaires via Qualtrics. Data collection started on 19th June 2020 (week 13 of the UK lockdown) and was completed on 20th July 2020 . During five consecutive weeks, students and parents received an invitation email including the questionnaire link at 10 am every Friday. The weekly questionnaires covered the children's weekly schoolwork experience during the COVID‐19 pandemic, etc. In addition, demographic questions were included at the start of the study (the first questionnaire that participants completed). Therefore, the total duration for the children's weekly questionnaire was around 20 min for the first time and 15 min for all subsequent weeks. For the parents' weekly questionnaire, the total duration was about 15 min for the first questionnaire and 10 min for all subsequent weeks. To increase the responses to the questionnaires, families who completed half the weekly questionnaires received £10 in vouchers, and families who completed all weekly questionnaires received £20 in vouchers. In the current study, we only include demographic information from parents.We used two methods of recruitment. First, we emailed schools asking them to send out an advertisement about our study to parents in their newsletters. Six schools agreed to include our information in school newsletters. The six schools were in southeast England and are broadly representative of English secondary schools. Second, we placed advertisements about the study on social media (Twitter) and a website .Students' schoolwork motivation was measured by self‐report every week and was formed of two subscales assessing expectancy and value beliefs. Expectancy and value beliefs were assessed for two core school subjects, mathematics and English. Expectancy beliefs were assessed with eight items adapted from a measure used in Trautwein et al. . Four itEnglish = .82, αMaths = .83). All items utilized a 4‐point Likert scale from 1 (Completely disagree) to 4 (Completely agree). High scores on these measures indicate high expectancy beliefs and high value beliefs. The schoolwork motivation  items are reported in the Table To measure the value component, we adopted eight items from the Task Value Scale . In weekly studies, where participants have to complete the same questionnaire multiple times, it is common practice to use fewer items  to 4 (Completely agree). High scores on these items indicate more parental schoolwork support. Table Two items were adapted from Dumont et al.  to assesChildren's race , free school meal eligibility, and school types were reported by parents when they completed the first questionnaire.between, Supportbetween). To obtain the within‐person component, a person's mean was subtracted from the individual's value for each week , representing weekly variations from a person's mean. Furthermore, we computed a lag variable for each within‐person component . This variable allows us to predict how expectancy and support in week t  predicts expectancy in the subsequent week t + 1 (Expectancywithin t+1). Thus, this approach allows us to compute auto‐regressive effects (expectancy in week t affects expectancy in the following week t + 1) as well as cross‐lag effects (expectancy in week t affects support in the subsequent week t + 1).The main aim was to disentangle the reciprocal relationship between children's schoolwork motivation  and their perceived parental schoolwork support at the between‐person and within‐person level. Cross‐lagged between‐ and within‐level models were used to analyse the nested data . This strategy requires an analytical strategy involving dummy codes (0/1) and the use of interaction terms with the dummy codes to compute the effects for both dependent variables Expectancywithin_t+1 or with Supportwithin_t+1 , i indexes individual, and t indexes week. γ00 and γ03 indicate the two fixed intercepts. γ01, γ02, γ04, and γ05 represent between‐person level fixed effect. γ10, γ20, γ30 and γ30 represent the within‐person level fixed effect. up0i and uc0i indicate person‐specific random intercepts. up1i, up2i, uc1i and uc2i represent the random slopes of Expectancywithin_t and Supportwithin_t respectively. εit stands for the regression residual for person and week.In this double intercept multilevel model, Y represents the dependent variables  and parental schoolwork support were high. Table We first assessed the variability of children's schoolwork motivation over time. This variability can be examined at the level of raw data, within‐person changes (how much someone changes from wave to wave) and between‐person differences . Figure Intraclass correlations (ICC) were computed to decompose the variance in motivation into between‐person and within‐person components. Table To test our hypotheses, we examined the bidirectional associations between schoolwork motivation and parental schoolwork support at the between‐person and the (cross‐) lagged within‐person levels.B = 0.03; English expectancy as the predictor, B = −0.03) or Maths . Average levels of parental support and average levels of value beliefs did not significantly influence each other in English  or Maths .The between‐person analyses assessed whether average levels of parental support were associated with average levels of motivation (see Tables B's range from −0.07 to – 0.04). The time effects on expectancy beliefs and value showed an overall decrease over time (B's range from −0.01 to – 0.006) except for the Maths value. Results for the Maths value beliefs indicated a slightly increasing time trend. However, these changes did not differ at a statistically significant level (B = 0.002).The results revealed that there was a negative effect of time on parental support  or English . Parental schoolwork support also did not predict subsequent maths schoolwork value  or English schoolwork value . Thus, the results did not indicate that parental support in one week predicted children's motivational beliefs in the subsequent week.Parental schoolwork support did not predict subsequent expectancy beliefs in either Maths . However, weekly variations in English expectancy beliefs were not significantly related to subsequent perceived parental support in English . Both value for English  and maths  did not predict subsequent levels of parent support.There was some evidence that children's motivational beliefs in one week predicted perceived parental support in the subsequent week. Specifically, when children reported higher maths expectancy beliefs than usual, they reported greater perceived parental support in maths in the subsequent week . Specifically, children tended to report lower levels of support in the subsequent weeks following a week in which they reported a high level of perceived support.Additionally, perceived parent support in one week significantly negatively predicted subsequent levels of parent support  was due to the difference between individuals . The second aim of this study was to examine the bidirectional effects between parental support and schoolwork motivation. We found that both individual differences between children and within‐person fluctuations in children's perception of parental support did not predict children's schoolwork motivation. Another finding was that higher maths expectancies predicted higher parental support for maths schoolwork at the within‐person level. Overall, these results shed new light on the association between perceived parental support and children's schoolwork motivation at the between‐person and within‐person levels.When splitting variance in children's schoolwork expectancies and value, there is a substantial trait‐like proportion and a smaller within person time‐variant proportion. Most of the variance in students' expectancies and value were located at the between‐person level, which is in accordance with findings that there are large individual differences in children's motivation . Children lower in motivation and those without good internet access are likely less represented in our sample. However, the consistently high level of motivation in this sample points to high levels of resilience among these children. In the academic context, resilience is viewed as the student's ability to successfully adjust to adverse life events Martin, . StudentOn the question of the association between parental support and schoolwork motivation, our study found that parental support did not predict students' expectancy or value beliefs at the between‐person level. This finding is contrary to our expectations and previous cross‐sectional and traditional longitudinal studies (with longer time lags) that have suggested that parental support seems to facilitate students' motivation  typically showed low relations (Gaspard et al., We found no evidence of within‐person associations between schoolwork values and parental support. The lack of association may have occurred because motivational values are more stable than expectancy beliefs (Gaspard et al., Furthermore, children perceived less parental support and had lower expectancy and value over time. Children and parents may have been overwhelmed with home learning, parents felt unable to help, or parents had limited understanding of the schoolwork material. There was also a negative association between parent support in one week and the subsequent week, which may have resulted from parents believing that their children were able to complete schoolwork independently after parents previously provided a high level of support. Thus, parents might have provided less support with schoolwork subsequently. Our findings illustrate the importance of schoolwork motivation for subsequent parental support. One practical implication is that parents should be advised to pay special attention to children who have low maths schoolwork motivation because these children are less likely to receive parental support.The weekly diary study design allowed us to examine the association between parental support and schoolwork motivation at between‐person and within‐person levels. Nonetheless, some limitations should be noted. First, the generalisability of these results is subject to certain limitations because our results are based on an opportunity sample from years 7 to 9. The extent to which our findings generalize to other ages is unknown. Second, this study's duration was fairly brief at only five weeks and took part in a very specific context of the first UK lockdown when children were forced to study at home rather than in school. Findings may differ under typical circumstances where children attend school in person and parental support is limited to homework outside school. It is difficult to know if the findings would generalize when children learn in school rather than at home. We suspect that parents would continue to be affected by their children even when children are in school. There is much past work suggesting that parents often help children with homework (for a review, see Wilder, In conclusion, at the between‐person level, there was no evidence of bidirectional effects between motivation and support; at the within‐person level, more parental support did not predict subsequent increases in motivation. However, there was some evidence supporting the presence of child‐driven effects on parental support. The present study adds to the growing body of research exploring schoolwork motivation and its bidirectional relations with parental help. This study goes beyond previous research by using an intensive weekly diary approach to assess schoolwork motivation and parental support. Taken together, the results of this study highlighted the predictive power of schoolwork expectancy on parental support. The findings suggest that children influence parents. Future research needs to incorporate an understanding of children as actors to better understand the development of academic motivation.Yao Wu: Conceptualization; data curation; formal analysis; investigation; methodology; project administration; software; visualization; writing – original draft; writing – review and editing. Peter Hilpert: Formal analysis; software; visualization; writing – review and editing. Harriet Tenenbaum: Conceptualization; methodology; writing – review and editing. Terry Ng‐Knight: Conceptualization; data curation; formal analysis; investigation; methodology; software; visualization; writing – review and editing.The authors do not have a conflict of interest.Appendix S1Click here for additional data file.