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Transbronchial mediastinal cryobiopsy is a novel sampling technique for mediastinal disease. Despite the possibility of lung cancer misdiagnosis, the improved diagnostic yield of this approach for non-lung-cancer lesions compared with standard endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) highlights its diagnostic potential as a complementary technique to conventional biopsy. We aimed to evaluate the safety profile and added value of the combined use of transbronchial mediastinal cryobiopsy and standard EBUS-TBNA for the diagnosis of mediastinal diseases.We conducted an open-label, randomised trial at three hospital sites in Europe and Asia. Eligible patients were aged 15 years or older, with at least one mediastinal lesion of 1 cm or longer in the short axis that required diagnostic bronchoscopy. Participants were randomly assigned (1:1) using a block randomisation scheme generated by a computer (block size of four participants based on a random table from an independent statistician) to the combined use of EBUS-TBNA and transbronchial mediastinal cryobiopsy (combined group) or EBUS-TBNA alone (control group). Because of the nature of the intervention, neither participants nor investigators were masked to group assignment. The coprimary outcomes were differences in procedure-related complications and diagnostic yield (defined as the proportion of participants for whom mediastinal biopsy led to a definitive diagnosis), assessed in the full analysis set, including all the patients who met the eligibility criteria and had a biopsy. A fully paired, intraindividual diagnostic analysis in participants who had both needle aspiration and mediastinal cryobiopsy was conducted, in addition to interindividual comparisons. This trial is now complete and is registered with ClinicalTrials.gov, NCT04572984.Between Oct 12, 2020, and Sept 9, 2021, 297 consecutive patients were assessed for eligibility and 271 were enrolled and randomly assigned to the combined group (n=136) or the control group (n=135). The addition of cryobiopsy to standard sampling significantly increased the overall diagnostic yield for mediastinal lesions, as shown by both interindividual (126 [93%] of 136 participants in the combined group vs 109 [81%] of 135 in the control group; risk ratio [RR] 1·15 [95% CI 1·04-1·26]; p=0·0039) and intraindividual (126 [94%] of 134 vs 110 [82%] of 134; RR 1·15 [95% CI 1·05-1·25]; p=0·0026) analyses. In subgroup analyses in the intraindividual population, diagnostic yields were similar for mediastinal metastasis (68 [99%] of 69 participants in the combined group vs 68 [99%] of 69 in the control group; RR 1·00 [95% CI 0·96-1·04]; p=1·00), whereas the combined approach was more sensitive than standard needle aspiration in benign disorders (45 [94%] of 48 vs 32 [67%] of 48; RR 1·41 [95% CI 1·14-1·74]; p=0·0009). The combined approach also resulted in an improved suitability of tissue samples for molecular and immunological analyses of non-small-cell lung cancer. The incidence of adverse events related to the biopsy procedure did not differ between trial groups, as grade 3-4 airway bleeding occurred in three (2%) patients in the combined group and two (1%) in the control group (RR 0·67 [95% CI 0·11-3·96]; p=1·00). There were no severe complications causing death or disability.The addition of mediastinal cryobiopsy to standard EBUS-TBNA resulted in a significant improvement in diagnostic yield for mediastinal lesions, with a good safety profile. These data suggest that this combined approach is a valid first-line diagnostic tool for mediastinal diseases.National Natural Science Foundation of China.

Accumulating studies demonstrated that patients with coronavirus disease 2019(COVID-19) could develop a variety of neurological manifestations and long-term neurological sequelae, which may be different from the strains. At the peak of the Omicron variant outbreak in Shanghai, China, no relevant epidemiological data about neurological manifestations associated with this strain was reported.To investigate neurological manifestations and related clinical features in patients with mild to moderate COVID-19 patients with Omicron variant.A self-designed clinical information registration form was used to gather the neurological manifestations of mild to moderate COVID-19 patients admitted to a designated hospital in Shanghai from April 18, 2022 to June 1, 2022. Demographics, clinical presentations, laboratory findings, treatments and clinical outcomes were compared between patients with and without neurological manifestations.One hundred sixty-nine(48.1 %) of 351 patients diagnosed with mild to moderate COVID-19 exhibited neurological manifestations, the most common of which were fatigue/weakness(25.1 %) and myalgia(20.7 %), whereas acute cerebrovascular disease(0.9 %), impaired consciousness(0.6 %) and seizure(0.6 %) were rare. Younger age(p = 0.001), female gender(p = 0.026) and without anticoagulant medication(p = 0.042) were associated with increasing proportions of neurological manifestations as revealed by multivariate logistic regressions. Patients with neurological manifestations had lower creatine kinase and myoglobin levels, as well as higher proportion of patchy shadowing on chest scan. Vaccination status, clinical classification of COVID-19 and clinical outcomes were similar between the two groups.Nearly half of the involved patients have neurological manifestations which were relatively subjective and closely associated with younger age, female gender and without anticoagulation. Patients with neurologic manifestations may be accompanied by increased lung patchy shadowing.

As a green sustainable material, lignin-derived porous carbon (LPC) exhibits great application potential when used as the anode material in lithium-ion batteries (LIBs), but the applications are limited by the heterogeneity of the lignin precursor. Therefore, it is crucial to reveal the relationship among lignin properties, porous carbon structure and the kinetics of lithium-ion storage. Herein, LPCs from fractionated lignin have been prepared by an eco-friendly and recyclable activator. The structure of the LPCs was regulated by adjusting the molecular weight, linkage abundance and glass transition temperature (T

For the Newtonian (gravitational) $n$-body problem in the Euclidean $d$-dimensional space, $d\ge 2$, the simplest possible periodic solutions are provided by circular relative equilibria, (RE) for short, namely solutions in which each body rigidly rotates about the center of mass and the configuration of the whole system is constant in time and central (or, more generally, balanced) configuration. For $d\le 3$, the only possible (RE) are planar, but in dimension four it is possible to get truly four dimensional (RE). A classical problem in celestial mechanics aims at relating the (in-)stability properties of a (RE) to the index properties of the central (or, more generally, balanced) configuration generating it. In this paper, we provide sufficient conditions that imply the spectral instability of planar and non-planar (RE) in $\mathbb R^4$ generated by a central configuration, thus answering some of the questions raised in \cite[Page 63]{Moe14}. As a corollary, we retrieve a classical result of Hu and Sun \cite{HS09} on the linear instability of planar (RE) whose generating central configuration is non-degenerate and has odd Morse index, and fix a gap in the statement of \cite[Theorem 1]{BJP14} about the spectral instability of planar (RE) whose (possibly degenerate) generating central configuration has odd Morse index. The key ingredients are a new formula of independent interest that allows to compute the spectral flow of a path of symmetric matrices having degenerate starting point, and a symplectic decomposition of the phase space of the linearized Hamiltonian system along a given (RE) which is inspired by Meyer and Schmidt's planar decomposition \cite{MS05} and which allows us to rule out the uninteresting part of the dynamics corresponding to the translational and (partially) to the rotational symmetry of the problem., Comment: 30 Pages, comments welcome

Previous studies have shown that empathy has a positive impact on the professional identity of nursing students. And developing psychological resilience can improve the professional identity of nursing students. However, studies investigating the mechanism of the relationship between empathy and psychological resilience on professional identity remain few.Among Chinese nursing students, we sought to determine whether psychological resilience mediates the association between empathy and professional identity.A total of 495 undergraduate and postgraduate nursing students in a medical university nursing college in Hefei were investigated by demographic data questionnaire, nursing students' empathy scale, nursing students' professional identity questionnaire, and psychological resilience questionnaire. Structural equation modeling was used to analyze the mediating effect of psychological resilience between empathy and the professional identity of nursing students.The total score of professional identity of nursing students was 57.07 ± 10.38. Psychological resilience (r = 0.316, P 0.01) and professional identity (r = 0.313, P 0.01) both had positive correlations with empathy, respectively. Additionally, there was a strong correlation between psychological resilience and professional identity (r = 0.488, P 0.01). Empathy had an indirect effect on professional identity through psychological resilience, with a direct effect of 0.256 and an indirect effect of 0.145, and the indirect effect accounted for 36.16 % of the total effect.Nursing educators should pay attention to the cultivation of empathy ability and psychological resilience to enhance nursing students' professional identity.

This paper proposes an adaptive dual control with outlier detection that is robust to the occurrence of outliers in uncertain systems. Outliers occasionally exist in system process noise and observation noise, which could cause poor parameter estimation and degraded control performance of uncertain systems. For this reason, we devise an online outlier detection mechanism to filter the outliers so as to enhance the parameter estimation of uncertain systems. The devised mechanism makes decisions on outlier detection via the generated predicted regions where the newly arriving data is expected to locate, and the predicted regions are updated in real-time according to the historical data. The detection mechanism is integrated into the design of adaptive dual control, which is derived based on the bicriterial method. Compared with classical dual control merely considering uncertainty in input and output data stream, we are the first to include the uncontrollable excitations into the structure of dual control to fit practical scenarios, and this inclusion also provides an extensive cover on outliers to be detected. The improved performance of the proposed approach is verified using a mathematical model through one-time simulation and Monte Carlo simulations under different conditions, and we also evaluate our method in the control of fermentation sterilization process for more convincing results.

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Acute liver failure (ALF) has an abrupt onset with a frequently fatal outcome. Previous studies have found that oral antibiotics prevent drug-induced liver injury in animal experiments, indicating that the gut microbiota plays a critical role in the pathophysiological process. However, the underlying mechanism has not been fully understood. This study explored the comprehensive role of the gut microbiota in ALF using multi-omics. A cocktail of broad-spectrum antibiotics (Abx) pretreatment by gavage for four weeks improved the survival of D-(+)-galactosamine hydrochloride (D-Gal)/lipopolysaccharide (LPS)-induced ALF in C57BL/6 mice. RNA sequencing showed that inflammatory responses were inhibited and metabolic pathways were upregulated in the liver of Abx-treated ALF mice. The 16S rRNA gene sequencing revealed that Abx reshaped the composition and function of the gut microbiota, with an increased proportion of tryptophan (Trp) metabolism. In addition, global metabolic profiling by ultra-performance liquid chromatography–mass spectrometry (UPLC–MS) indicated that the gut microbiota post-Abx intervention reduced Trp excretion, liberated more Trp to the host, and enhanced the kynurenine (Kyn) pathway with increased production of Kyn. As an endogenous aryl hydrocarbon receptor (AhR) ligand, Kyn has anti-inflammatory and immunosuppressive effects. Furthermore, AhR-targeted treatments affected the outcome of ALF mice with or without Abx pretreatment, indicating that AhR directly regulated susceptibility to ALF, at least in part. This study demonstrates that the gut microbiota-dependent control of the Trp metabolism could regulate host susceptibility to ALF by modulating the activity of AhR, and thus provides a promising target for better management of ALF.