Search

Yan Sun,1,2 Lixin Yu,1,2 Wei Gao,1,2 Jinzhen Cai,1,2 Wentao Jiang,1,2 Wei Lu,3 Yihe Liu,1,2 Hong Zheng1,2 1Organ Transplantation Center, Tianjin First Central Hospital, Tianjin, 300192, People’s Republic of China; 2Tianjin Key Laboratory for Organ Transplantation, Tianjin, People’s Republic of China; 3Liver Cancer Treatment Centre, Tianjin Medical University Cancer Institute and Hospital, Tianjin, People’s Republic of ChinaCorrespondence: Yihe Liu; Hong ZhengOrgan Transplantation Center, Tianjin First Central Hospital, No. 24 of Fukang Street, Nankai District, Tianjin, 300192, People’s Republic of ChinaTel/Fax +8602223627027Email limyihe@163.com; zhemghomgi@21cn.comObjective: This study aimed to investigate the colonization and prevalence of carbapenem-resistant Enterobacteriaceae (CRE) in pediatric liver transplant recipients and analyze the high-risk factors and prognosis of CRE infection.Methods: A prospective study involving 152 pediatric patients undergoing liver transplantation was carried out. Anal swab bacteria cultures were collected when the patients entered the intensive care unit (ICU) and when they left in order to screen for intestinal CRE colonization. The results were grouped according to the occurrence of CRE infection following surgery, and the patients were divided into two groups: a CRE infection group and a non-CRE infection group. Univariate analysis and multiple logistic regression analysis were conducted to determine the independent risk factors of CRE infection and analyze the survival rate.Results: Of the 152 pediatric liver transplant recipients enrolled in the study, there were 13 cases of postoperative CRE infection and 139 cases of non-CRE infection. The incidence of preoperative CRE infection, preoperative cytomegalovirus (CMV) infection, and preoperative sepsis in the CRE infection group was significantly higher than in the non-CRE infection group (P < 0.005). Intraoperative bleeding volume and operation times in the CRE infection group were also significantly higher than in the non-CRE infection group (P < 0.05). Furthermore, postoperative ICU treatment time, postoperative occurrence of unplanned surgery, postoperative mechanical ventilation of more than 24 hours, and the incidence of pre-ICU CRE colonization in the CRE infection group were significantly higher than in the non-CRE infection group (P < 0.05). Finally, the difference between the CRE infection group and the non-CRE infection group in six-month survival rate following surgery was significant (P < 0.001).Conclusion: The independent risk factors of CRE infection following pediatric liver transplantation include preoperative CRE infection and pre-ICU CRE colonization. CRE infection progresses quickly, with a poor prognosis and a high mortality rate. The CRE screening of anal swabs is crucial for the early detection of CRE infection.Keywords: carbapenem-resistant Enterobacteriaceae, CRE, liver transplantation, intestinal colonization, CT screening, anal swabs

Chen-miao Huang,1,2 Jia-jing Cai,1,2 Shao-wu Jin,1,2 Qi-cheng Lin,1,2 Qian-juan Fang,1,2 Ke Nan,1,2 Yuan Han,1,2 Wen-wei Ge,1,2 Yu Liu,1,2 Yuan-xiang Tao,1,3 Hong Cao,1,2 Jun Li1,2 1Department of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People’s Republic of China; 2Zhejiang Province Key Laboratory of Anesthesiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People’s Republic of China; 3Department of Anesthesiology, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, 07103, USACorrespondence: Jun Li; Hong CaoDepartment of Anesthesiology and Perioperative Medicine, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325027, People’s Republic of ChinaTel/Fax +86 577-88002925 Email lijun0068@163.com; caohong1955@21cn.comObjective: Perioperative neurocognitive disorders (PND) are a common complication in the elderly. Histone deacetylases (HDACs) are a class of enzymes that control the acetylation status of intracellular proteins. Thus, we explored whether HDACs trigger the release of high mobility group box 1 (HMGB1) through altering the acetylation status in the hippocampi of aged mice.Materials and Methods: The effect of the Class IIa HDAC in PND was explored using an in vivo form of splenectomy. Sixteen-month-old healthy male C57BL/6J mice were randomly divided into five groups: control, anesthesia plus sham surgery, anesthesia plus splenectomy, LMK235 treatment, and PBS treatment. The hippocampi were harvested on either first, third, or seventh postoperative day. Cognitive function was assessed via a Morris water maze (MWM) test. Quantitative RT-PCR, Western blots and ELISAs were carried out to assess the targeted gene expression at transcriptional and translational levels.Results: Splenectomy led to a significant deficiency in spatial memory acquisition, marked decreases in mRNA and protein levels of HDAC4 and HDAC5 in the hippocampus, and increases in the levels of total HMGB1 and acetylated HMGB1. In a similar fashion to splenectomy, treatment with the HDAC4/5 inhibitor LMK235 produced impaired spatial memory and an increase in the expression of HMGB1 and its acetylated counterpart in the hippocampus.Conclusion: These results suggest that surgery leads to PND through class IIa HDAC downregulation-triggered HMGB1 release in hippocampus of aged mice. HDACs may be a potential therapeutic target for postoperative cognitive dysfunction.Keywords: postoperative cognitive dysfunction, hippocampus, HDAC4, HDAC5, HMGB1, neuroinflammation

Jing Zhang,1 Xiuchao He,1 Wenying Yu,2 Fuming Ying,3 Jun Cai,4 Shengde Deng1 1Department of Imaging Center, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, Zhejiang Province, 315000, People’s Republic of China; 2Ningbo Diagnostic Pathology Center, Ningbo, Zhejiang Province, 315000, People’s Republic of China; 3Department of Hepatobiliary Surgery, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, Zhejiang Province, 315000, People’s Republic of China; 4Department of PET-CT Diagnosis Center, Mingzhou Hospital of Zhejiang University, Ningbo, Zhejiang Province, 315000, People’s Republic of ChinaCorrespondence: Shengde DengDepartment of Imaging Center, The Affiliated Hospital of Medical School of Ningbo University, No. 247 of Renmin Street, Jiangbei District, Ningbo, Zhejiang Province, 315000, People’s Republic of ChinaTel/Fax +86 574 55873876Email demgshemgde@163.comIntroduction: Primary hepatic extraskeletal osteosarcoma (ESOS) is a rare tumor with no specific clinical manifestations, and little is known about it. Here, we describe an elderly patient with primary hepatic osteosarcoma confirmed by pathology results to raise awareness.Case Report: We report an unusual case of a 62-year-old man who presented with right upper quadrant pain. The inflammatory indicators were elevated, and alkaline phosphatase (AKP), carbohydrate antigen (CA-199 and CA-125) were slightly increased. Computed tomography images and magnetic resonance images discovered a 7.8 × 7.4 × 6.6 cm mass with irregular radiated and cotton-like tumor bone between the liver and right kidney space. Pathology revealed the mass to be primary exophytic ESOS of the liver. The patient underwent a surgical operation and standard chemotherapy and is still alive with no recurrence and metastasis to date.Conclusion: Owing to the rarity of the tumor and the lack of clinical characteristics and specific laboratory indexes, it is difficult to make a correct diagnosis. Medical imaging features mainly behave soft tissue entity with tumor bone composition. Surgical resection combined with adjuvant chemotherapy is the main treatment for ESOS.Keywords: extraskeletal, osteosarcoma, hepatic, tumor bone, primary

Haibo Wang,1,* Siyuan Peng,1,* Junhong Cai,2 Shan Bao1 1Department of Gynaecology and Obstetrics, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou, 570311, People’s Republic of China; 2Key Laboratory of Cell and Molecular Genetic Translational Medicine in Hainan Province, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou, 570311, People’s Republic of China*These authors contributed equally to this workCorrespondence: Shan BaoDepartment of Gynaecology and Obstetrics, Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University, Haikou, 570311, People’s Republic of ChinaEmail baoshan3@hainmc.edu.cnBackground: Endometrial cancer (EC) is the fourth most common neoplasm and the eighth leading cause of cancer death in females worldwide. PTPN18 is a member of the protein tyrosine phosphatases (PTP) family, which is associated with the occurrence and progression of various human cancers. PTPN18 was up-regulated in endometrial cancer tissues and high level of PTPN18 promoted proliferation and metastasis of EC cells.Methods: The expression of PTPN18, GPX4 and xCT in endometrial cancer tissues and KLE cells was detected by immunohistochemistry and Western blot, respectively. Lentiviral transfection were used to silence PTPN18 level in KLE cells. The Ros level in KLE cells was examined by ELISA assay.Results: In the present study, we found that silencing of PTPN18 induced ferroptosis in KLE endometrial cancer cells. PTPN18 knockdown increased intracellular ROS level and down-regulated GPX4 and xCT expression. Besides, silencing of PTPN18 also induced the expression of p-p38.Conclusion: We concluded that silencing of PTPN18 might induce ferroptosis by targeting the p-p38/GPX4/xCT axis. The results provide critical insight into the application of PTPN18 knockdown in EC intervention.Keywords: PTPN18, endometrial cancer, ferroptosis, p-p38, GPX4/xCT

Hui Wang, Shaoxia Du, Jun Cai, Juan Wang, Xiaohong Shen School of Medicine, Nankai University, Tianjin 300071, People’s Republic of ChinaCorrespondence: Xiaohong ShenSchool of Medicine, Nankai University, Nankai District, Tianjin 300071, People’s Republic of ChinaTel +86-22-23501649Email zebial2014@163.comBackground: Apolipoprotein E2 (ApoE2) is reported to be essential for cell metastasis and proliferation and has been considered a potential diagnostic marker in many cancers. However, the function of ApoE2 in the metastasis of pancreatic cancer, as well as the underlying mechanism, remain unclear.Purpose: In this study, we explored the effect of ApoE2 on the migration and invasion abilities of pancreatic cancer cells and explored the underlying molecular mechanism.Methods and Results: Wound healing and Matrigel Transwell assays were used to investigate the role of ApoE2 in cell migration and invasion. Western blotting analysis showed that ApoE2 was overexpressed in pancreatic cancer tissues. Additionally, the overexpression of ApoE2 promoted the process of epithelial–mesenchymal transition (EMT) and enhanced the expression of MMP-2/9 in pancreatic cancer cells. Mechanistically, we found that inhibition of ERK1/2 signaling with PD98059 impaired the ApoE2-mediated promotion of cell migration, invasion and EMT.Conclusion: This study demonstrated that ApoE2/ERK1/2 signaling promoted the migration and invasion of pancreatic cancer cells. ApoE2 might be a potential therapeutic target for the treatment of pancreatic cancer metastasis.Keywords: apolipoprotein E2, ERK1/2, migration, invasion, pancreatic cancer

Jundong Cai,1 Jiuning Huang,1,2 Wulong Wang,1 Jing Zeng,1 Ping Wang1 1Department of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin 300000, People’s Republic of China; 2Department of Radiotherapy, Yantai Affiliated Hospital of Binzhou Medical University, Yantai 264000, Shandong, People’s Republic of ChinaCorrespondence: Ping WangDepartment of Radiotherapy, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Huanhu Xi Road, Tiyuan Bei, Hexi District, Tianjin 300000, People’s Republic of ChinaTel +86-18622221112Email pingwang2020@163.comObjective: To investigate whether miR-124-3p regulates the fibroblast growth factor 2 (FGF2)–epidermal growth factor receptor (EGFR) pathway by targeting MGAT5 to affect the pemetrexed resistance in lung adenocarcinoma cells.Methods: PC9-MTA and H1993-MTA anti-pemetrexed lung adenocarcinoma cell lines were constructed. The cell viability of anti-pemetrexed and parent lung adenocarcinoma cells was analyzed using MTS assay and reverse transcription PCR to determine the expression of miR-124-3p. CCK8 assay, colony formation assay, and flow cytometry were used to determine cells’ proliferation and apoptosis. FGF2–EGFR signaling pathway-related proteins and MGAT5 protein expression were quantified by Western blotting. The target relationship between miR-124-3p and MGAT5 was verified by double luciferase assay. A nude mouse model with a transplanted tumor was established using the anti-pemetrexed lung adenocarcinoma cells. Tumor volume and weight were determined, and the apoptosis of tumor cells was observed.Results: The half-maximal inhibitory concentration of pemetrexed in anti-pemetrexed lung adenocarcinoma cells was higher than that in parent lung adenocarcinoma cells, and the expression of miR-124-3p in the anti-pemetrexed cells was lower than that of the parent cells. In the miR-124-3p overexpression group, MGAT5 silencing group, and miR-124-3p+MGAT5 overexpression group, compared with the control group, the proliferation ability of cells and tumors was markedly reduced; their apoptosis rates were increased significantly; expression levels of FGF2 and p-EGFR/EGFR were decreased; and the growth rate and tumor volume and mass were reduced; however, the opposite results were obtained in the miR-124-3p silencing group (p< 0.05).Conclusion: miR-124-3p may inhibit the FGF2–EGFR pathway by targeting MGAT5 to decrease pemetrexed resistance in lung adenocarcinoma cells.Keywords: miR-124-3p, MGAT5, FGF2-EGFR pathway, lung adenocarcinoma

Yuhui Huang,* Lin Liu,* Jing Cai, Lu Yang, Si Sun, Jing Zhao, Zhoufang Xiong, Zehua Wang Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, Hubei, People’s Republic of China*These authors contributed equally to this workCorrespondence: Zehua Wang; Zhoufang XiongDepartment of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan 430022, Hubei, People’s Republic of ChinaTel/Fax +86 27 85351649Email zehuawang@163.net; xiaoxiongmaomi@aliyun.comObjective: To assess the efficacy of platinum-based neoadjuvant chemotherapy (NACT) in patients with locally advanced cervical cancer (LACC) and investigate the pretreatment predictors of the response.Patients and Methods: A total of 219 patients with International Federation of Gynecology and Obstetrics (FIGO 2009) stage IB2-IIA2 LACC who received platinum-based NACT from December 2007 to December 2017 were reviewed, and their clinical-pathological characteristics and follow-up data were retrospectively collected and analyzed. The baseline characteristics of age, FIGO stage, histology, tumor differentiation, tumor size, and clinical outcomes, including post-operative pathological risk factors, overall survival (OS), and progression-free survival (PFS) were compared between the responders and non-responders.Results: The overall response rate was 58.9% (129/219), and 19 (8.7%) patients achieved pathologically complete remission. NACT responders showed significantly better OS and PFS than non-responders (POS= 0.002, PPFS= 0.002). The response to NACT was identified as an independent risk factor for OS (hazard ratio [HR] = 2.453, 95% confidence intervals [95% CI], 1.125– 5.348, P = 0.024) and PFS (HR = 2.196, 95% CI, 1.183– 4.076, P = 0.013), and patients with IB2/IIA1 and a tumor size of < 5 cm tended to receive better response than patients with IIA2 (P = 0.004) and a tumor size of ≥ 5 cm (P = 0.027).Conclusion: The response rate of platinum-based NACT was approximately 60%. The response to NACT was an independent risk factor for prognosis, and patients with earlier stage and smaller tumor tended to respond better to NACT.Keywords: locally advanced cervical cancer, neoadjuvant chemotherapy, clinical response, predictor, prognosis

Jiaping Zhou,1 Qiaomei Zhou,1 Gaofeng Shu,2 Xiaojie Wang,1 Yuanfei Lu,1 Haiyan Chen,1 Tingting Hu,1 Jinsong Cai,1 Yongzhong Du,2 Risheng Yu1 1Department of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, People’s Republic of China; 2Institute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, People’s Republic of ChinaCorrespondence: Yongzhong DuInstitute of Pharmaceutics, College of Pharmaceutical Sciences, Zhejiang University, 866 Yuhangtang Road, Hangzhou 310058, Zhejiang Province, People’s Republic of ChinaTel +86 571 8820 8435Email duyongzhong@zju.edu.cnRisheng YuDepartment of Radiology, Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou 310009, Zhejiang Province, People’s Republic of ChinaTel +86 571 8778 3925Email risheng-yu@zju.edu.cnPropose: The early diagnosis of hepatocellular carcinoma (HCC) with ferritin heavy chain (Fth) modified by alpha-fetoprotein (AFP) promoter has been studied. However, no study has focused on the considerable upregulation and specific targeting effects of transferrin receptors (TfR) caused by the transfection of plasmids encoded with the AFP promoter. Thus, the objective of our study was to investigate whether the transfection of Fth gene modified with AFP promoter (AFP@Fth) could be used for early diagnosis and enhanced treatment of HCC.Methods: The AFP@Fth plasmid was transfected into AFP positive cells. The expression of intracellular Ferritin was verified by Western blot, and the upregulation of TfR was confirmed by immunofluorescence and flow cytometry analysis. Cellular iron accumulation resulting in decreased imaging signals was examined by magnetic resonance imagining. Doxorubicin liposome modified with transferrin (Tf-LPD) was prepared to investigate the efficiency of the subsequent treatment after transfection. The enhanced drug distribution and effects were investigated both in vitro and in vivo.Results: Both Ferritin and TfR were overexpressed after transfection. The transfected cells showed higher intracellular iron accumulation and resulted in a lower MR T2-weighted imaging (T2WI) intensity, suggesting that the transfection of AFP@Fth could be a potential strategy for early diagnosis of liver cancer. The following treatment efficacy was revealed by Tf-LPD. As compared with un-transfected cells, transfected cells exhibited higher uptake of transferrin-modified liposomes (Tf-LP), which was due to the specific interaction between Tf and TfR overexpressed on the transfected cells. This is also the reason why Tf-LPD showed better in vitro and in vivo anticancer ability than doxorubicin loaded liposome (LPD). These results suggested that transfection of AFP@Fth could result in enhanced therapy of liver cancer.Conclusion: Transfection of AFP@Fth could be used for early diagnosis and for enhanced treatment of live cancers.Keywords: AFP promoter, magnetic resonance imaging, transferrin, targeted drug delivery, hepatocellular carcinoma

Meng Li,1 Junna Cai,1 Xiaorui Han,2 Yue Ren1 1Department of Gynaecology, Xingtai People’s Hospital, Xingtai, Hebei 054000, People’s Republic of China; 2Department of Obstetrics and Gynecology, Xingtai People’s Hospital, Xingtai, Hebei 054000, People’s Republic of ChinaCorrespondence: Yue RenDepartment of Gynaecology, Xingtai People’s Hospital, Xingtai, Hebei 054000, People’s Republic of ChinaEmail hkmx7bb@163.comBackground: Circular RNA (circRNA) has an essential regulatory role in the chemotherapy resistance of cancers. Nevertheless, the role of circRNA nuclear receptor-interacting protein 1 (circNRIP1) in the paclitaxel (PTX) resistance of ovarian cancer (OC) remains unclear.Material and Methods: The circNRIP1, miR-211-5p and homeobox C8 (HOXC8) expression levels were assessed using qRT-PCR. The PTX resistance of cells was measured by 3-(4, 5-dimethylthiazolyl-2-yl)-2-5 diphenyl tetrazolium bromide (MTT) assay. Furthermore, cell proliferation, apoptosis, migration and invasion were detected by colony formation assay, flow cytometry and transwell assay, respectively. Moreover, the protein levels of proliferation, apoptosis, metastasis-related markers and HOXC8 were determined by Western blot (WB) analysis. Tumor xenograft models were constructed to explore the influence of circNRIP1 on OC tumor growth. The interaction between miR-211-5p and circNRIP1 or HOXC8 was confirmed by dual-luciferase reporter assay and RNA immunoprecipitation (RIP) assay.Results: CircNRIP1 was highly expressed in PTX-resistant OC tissues and cells. Silencing of circNRIP1 repressed the PTX resistance of OC cells in vitro and OC tumor in vivo. Furthermore, circNRIP1 sponged miR-211-5p, and miR-211-5p inhibitor could reverse the inhibitory effect of circNRIP1 knockdown on the PTX resistance of OC cells. In addition, miR-211-5p targeted HOXC8, and HOXC8 overexpression could reverse the suppression effect of miR-211-5p on the PTX resistance of OC cells. Additionally, the expression of HOXC8 was regulated by circNRIP1 and miR-211-5p.Conclusion: CircNRIP1 silencing could inhibit the PTX resistance of OC via regulating the miR-211-5p/HOXC8 axis, showing that circNRIP1 might be a potential target for OC resistance treatment.Keywords: ovarian cancer, PTX resistance, circNRIP1, miR-211-5p, HOXC8

Guo-feng Xie,1,* Luo-dan Zhao,2,3,* Qiang Chen,4,* Dong-xiao Tang,4 Qiong-yu Chen,4 Hong-fei Lu,4 Jia-rong Cai,5 Zheng Chen4 1Department of Radiation Oncology, Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Guangzhou, Guangdong Province 510095, People’s Republic of China; 2Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China; 3Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangzhou Higher Education Institutes, Sun Yat-sen University, Guangzhou, Guangdong Province, People’s Republic of China; 4Department of Stomatology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, People’s Republic of China; 5Department of Urology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, Guangdong Province, People’s Republic of China*These authors contributed equally to this workCorrespondence: Jia-rong CaiDepartment of Urology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong Province, People’s Republic of ChinaTel +86-20-82179727Fax +86-20-85253336Email caijiar@mail.sysu.edu.cnZheng ChenDepartment of Stomatology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, Guangdong Province, People’s Republic of ChinaFax +86-20-85253336Email chenzh68@mail.sysu.edu.cnPurpose: Oral squamous cell carcinoma (OSCC) is a common malignancy of the oral cavity. As the survival rate of OSCC patients is low, it is crucial to explore new markers and therapeutic targets for early diagnosis of the disease. A high level of actinin alpha 1 (ACTN1) in patients could serve as an independent prognostic factor of acute myeloid leukemia. However, the role of ACTN1 in OSCC remains unclear. In the present study, we aimed to investigate the role of ACTN1 in OSCC.Methods: ACTN1 protein levels in tissues were determined by immunohistochemical (IHC) staining. The correlation of ACTN1 expression with clinicopathological features and prognosis was analyzed. Univariate and multivariate analyses were performed. The effect of ACTN1 knockdown on cell proliferation, migration, invasion, apoptosis, epithelial-mesenchymal transition (EMT), and the cell cycle was evaluated using Western blotting, Cell Counting Kit‑8 (CCK8) assays, flow cytometry analysis, transwell assays, wound-healing assays, and nude mouse models of subcutaneous xenograft and pulmonary metastasis.Results: Based on the total score of ACTN1 IHC staining analysis, ACTN1 expression was found to be low in 10 normal mucosal tissues, 48 normal mucosal tissues adjacent to OSCC, and 19 OSCC tissues, but high in 29 OSCC tissues. ACTN1 protein levels were significantly associated with the clinical stage and node metastasis, and a high ACTN1 protein level indicated poor prognosis. Moreover, ACTN1 expression was an independent predictor of poor prognosis of OSCC. Using in vitro assays, we found that ACTN1 knockdown could induce cell cycle arrest, promote apoptosis, and inhibit EMT and cell proliferation, migration, and invasion in the OSCC cell lines, SCC-15 and HSC-3. Moreover, ACTN1 knockdown inhibited subcutaneous tumor growth and pulmonary metastasis in vivo.Conclusion: ACTN1 levels were significantly associated with the clinical stage and node metastasis, and a high ACTN1 protein level indicated poor prognosis. Moreover, ACTN1 knockdown could suppress cell proliferation and metastasis of OSCC. Our results suggested that ACTN1 may serve as a diagnostic and prognostic marker of OSCC.Keywords: actinin alpha 1, poor prognosis, oral squamous cell carcinoma, knockdown, proliferation, metastasis

Jian Cheng,1,2,* Hai-yan Xu,3,* Ming-ming Liu,4 Jian-ping Cai,2 Lei Wang,2 Zhen Hua,2 Xiao-dong Wu,1 Wei-ling Huo,1 Nan-ning Lv4 1Department of Orthopedics, Xuzhou Central Hospital Affiliated to Nanjing University of Chinese Medicine, Xuzhou, Jiangsu 221009, People’s Republic of China; 2Institute of Traumatology & Orthopedics, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210029, People’s Republic of China; 3Department of Human Anatomy, Xuzhou Medical University, Xuzhou, Jiangsu 221004, People’s Republic of China; 4Department of Orthopedic Surgery, Lianyungang Second People’s Hospital, Lianyungang 222023, People’s Republic of China*These authors contributed equally to this workCorrespondence: Ming-ming LiuDepartment of Orthopedic Surgery, Lianyungang Second People’s Hospital, No. 41 Hailian East Road, Haizhou District, Lianyungang, Jiangsu 222023, People’s Republic of ChinaEmail mmliu89@126.comJian-ping CaiInstitute of Traumatology & Orthopedics, Nanjing University of Chinese Medicine, Nanjing, Jiangsu 210029, People’s Republic of ChinaEmail caijianpingcjp@126.comIntroduction: The protective effect of catalpol on diabetic osteoporosis (DOP) and its mechanism remain unclear. This study aimed to explore whether catalpol enhanced the proliferation and differentiation of MC3T3 cells induced by high glucose by inhibiting the expression of KDM7A.Methods: MC3T3 cells were induced by high glucose (HG) and treated with different concentrations of catalpol. The proliferation and mineralization abilities of MC3T3-E1 cells were determined by CCK-8 assay and Alizarin Red Staining, respectively. The expression of differentiation-related osteogenic proteins, KDM7A and related proteins of Wnt/β-catenin signaling pathway was analyzed by Western blot analysis. The alkaline phosphatase (ALP) activity was detected by ALP assay kits.Results: MC3T3-E1 cells induced by high glucose showed decreased proliferation and mineralization abilities and decreased ALP activity, which were all reversed by the treatment of catalpol. High glucose induction inhibited the expression of KDM7A, Total-β-catenin, Nuclear-β-catenin and p-GSK3β, which was reversed by the treatment of catalpol. And KDM7A interference up-regulated the expression of Total-β-catenin, Nuclear-β-catenin and p-GSK3β, which was down-regulated by KDM7A overexpression. Furthermore, the proliferation and mineralization abilities and ALP activity were improved when treated with KDM7A interference and decreased when treated with KDM7A overexpression. However, SKL2001 could improve the proliferation and mineralization abilities and ALP activity of MC3T3-E1 cells.Discussion: Catalpol promotes the proliferation and differentiation of osteoblasts induced by high glucose by regulating the Wnt/β-catenin signaling pathway through KDM7A.Keywords: catalpol, KDM7A, proliferation, differentiation, osteoblasts, high glucose

Qin Yang, Yingxiao Zhang, Qinglian Zeng, Chan Yang, Jiale Shi, Chunlin Zhang, Xia Ni, Zhipeng Du, Ziwei Tang, Jinbo Hu, Xuemei Li, Jiahui Cai, Qifu Li, Qingfeng Cheng Department of Endocrinology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of ChinaCorrespondence: Qingfeng ChengThe First Affiliated Hospital of Chongqing Medical University, No. 1, Youyi Road, Yuanjiagang, Yuzhong District, Chongqing 400042, People’s Republic of ChinaTel +86-23-89011510Fax +86-23-890115540Email cqf19760516@163.comPurpose: The present study was designed to determine the relationships between sarcopenia and diabetic peripheral neuropathy (DPN) in patients with type 2 diabetes mellitus (T2DM) and diabetic foot disease (DFD) respectively.Patients and Methods: A total of 1104 patients with T2DM and 257 patients with DFD were included in the study, which was designed as a cross-sectional study. Body composition was assessed using dual-energy X-ray-absorptiometry (DXA). The diagnosis of sarcopenia was based on the Baumgartner criteria. DPN was assessed by Neuropathy symptom score (NSS) and Neuropathy disability score (NDS), and the severity of neuropathy was divided into non-neuropathy symptom (NS), Mild NS, Moderate NS and Severe NS according to NSS. Logistic regression analyses were carried out to determine the relations of sarcopenia and DPN in patients with T2DM and NSS in patients with DFD, respectively.Results: The prevalence of DPN was 80.0% in T2DM patients with sarcopenia and 70.3% in non-sarcopenia patients (P=0.007). Logistic regression analyses showed DPN was one of the independent risk factors for sarcopenia in T2DM patients (OR 1.564 [95% CI: 1.004, 2.435], P=0.048). The prevalence of DPN had no statistical significance in DFD patients with or without sarcopenia. However, the NSS of DFD patients with sarcopenia was higher than that of non-sarcopenia patients. In the multivariate logistic regression analysis, NSS was determined to be associated with sarcopenia in DFD patients (OR 1.387[95% CI: 1.074, 1.789], P=0.012). The appendicular lean mass (ALM) of DFD patients without NS was higher than patients with mild, moderate and severe NS (20.71± 2.73 vs 16.57± 3.62 vs 17.99± 3.54 vs 17.23± 3.29 Kg, P=0.028).Conclusion: DPN is an independent risk factor for sarcopenia in patients with T2DM and NSS is also independently correlated with sarcopenia in patients with DFD, with the latter being more obvious with the aggravation of neurological symptoms in DFD patients.Keywords: type 2 diabetes mellitus, diabetic peripheral neuropathy, diabetic foot disease, sarcopenia, correlation

Shida Yan,1,* Yingyi Wang,2,* Xiao Chen,1,* Yefan Zhang,1 Zhen Huang,1 Jianjun Zhao,1 Jianguo Zhou,1 Zhiyu Li,1 Xinyu Bi,1 Zhiwen Luo,1 Jianqiang Cai,1 Hong Zhao1 1Department of Hepatobiliary Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China; 2Department of Medical Oncology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People’s Republic of China*These authors contributed equally to this workCorrespondence: Jianqiang Cai; Hong ZhaoDepartment of Hepatobiliary Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 17 Panjiayuan Nanli, Chaoyang District, Beijing 100021, People’s Republic of ChinaEmail caijianqiang188@sina.com; zhaohong@cicams.ac.cnPurpose: This study aimed to investigate the clinicopathological features and prognosis of gallbladder neuroendocrine carcinoma (GB-NEC).Patients and Methods: Fifteen patients with GB-NEC and 171 patients with gallbladder adenocarcinoma (GB-ADC) treated in two tertiary medical centers between 2009 and 2015 were included. The clinicopathological features and prognostic risk factors of GB-NEC were analyzed retrospectively. A propensity score matching in a 1:2 ratio was used to compare the prognosis of GB-NEC and GB-ADC.Results: For patients with GB-NEC, the median age of patients was 58.4 years (range 26– 75), with a M:F ratio of 7:8. Based on 2010 WHO classification, ten cases were pathologically confirmed as NECs and five cases as MANECs. For TNM staging, eleven patients were stage III or above; while for Nevin staging, seven patients were stage IV or above. The 1-, 2-, and 3-year overall survival (OS) of GB-NEC were 60.0%, 38.8% and 31.1%, respectively, and the median survival time was 20.4 months. Patients with lymph node metastasis had significantly shorter survival than those without (OS: 10.4 vs 26.0 months, p< 0.05). Accordingly, patients of Nevin stage III had better OS than those of Nevin stage IV (p< 0.05), but other potential risk factors including gender, age, clinical symptoms, TNM stage, histopathologic subtype and treatment showed no significance. After the propensity score matching, the baseline variables had no significant difference between 15 patients with GB-NEC and 30 patients with GB-ADC, survival analysis showed GB-NEC had worse prognosis (3-year overall survival rate: 31.1% vs 63.8%, p< 0.01).Conclusion: Nevin staging helps classify patients of GB-NEC with different prognosis and the lymph node metastasis is a strong negative prognostic factor for OS. The propensity score analysis revealed even with the similar stage and treatment, GB-NEC still had worse OS than GB-ADC.Keywords: gallbladder, neuroendocrine carcinoma, adenocarcinoma, survival, propensity score matching

Min Zhang,1,2,* Hong Zhou,2,* Ryan S Nelson,3 Yong Han,2 Yirong Wang,1,2 Hongping Xiang,2 Jie Cai,4 Jing Zhang,4 Yonghua Yuan1 1Department of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children’s Hospital of Chongqing Medical University, Chongqing 400014, People’s Republic of China; 2Department of Pharmacy, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People’s Republic of China; 3Department of Individualized Cancer Management, Moffitt Cancer Center, Tampa, FL 33612, USA; 4Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, People’s Republic of China*These authors contributed equally to this workCorrespondence: Yonghua YuanDepartment of Pharmacy, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children’s Hospital of Chongqing Medical University, No. 136 Zhongshan Er Road, Yuzhong District, Chongqing 400014, People’s Republic of ChinaTel +86-023-68485161Email 400766@cqmu.edu.cnBackground: Immunosuppressant nonadherence (INA) has been shown to affect outcomes after solid organ transplantation. The aim of the present study was to determine the prevalence of INA in heart transplant recipients and the associated risk factors of INA.Methods: Adult heart transplant recipients who firstly received heart transplantation (discharged for at least 3 months) were consecutively enrolled. Immunosuppressant adherence was assessed using the Basel Assessment of Adherence with Immunosuppressive Medication Scale (BAASIS). INA was categorized into five domains of contributing factors (socio-demographic factors, transplant-related factors, healthcare system access factors, post-transplant treatment-related factors, and patient-related psychosocial factors). These factors were compared between adherent and nonadherent patients. The risk factors of INA were investigated by logistic regression analysis.Results: A total of 168 heart recipients were ultimately included. Among them, 69 (41.1%) recipients were revealed to be nonadherent. Logistic regression analysis indicated that INA was associated with monthly income

Cheng Zheng,1,2,* Jiachang Cai,3,* Haizhou Liu,1,4,* Shufang Zhang,5 Li Zhong,1,6 Nanxia Xuan,1 Hongwei Zhou,3 Kai Zhang,1 Yesong Wang,1 Xijiang Zhang,2 Baoping Tian,1 Zhaocai Zhang,1 Changming Wang,2 Wei Cui,1 Gensheng Zhang1 1Department of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People’s Republic of China; 2Department of Critical Care Medicine, Taizhou Municipal Hospital, Taizhou, Zhejiang, People’s Republic of China; 3Clinical Microbiology Laboratory, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People’s Republic of China; 4Department of Critical Care Medicine, Zhejiang Rehabilitation Hospital, Hangzhou, Zhejiang, People’s Republic of China; 5Department of Cardiology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang 310009, People’s Republic of China; 6Department of Critical Care Medicine, Huzhou First People’s Hospital, Huzhou, Zhejiang, People’s Republic of China*These authors contributed equally to this workCorrespondence: Gensheng ZhangDepartment of Critical Care Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, People’s Republic of ChinaTel +86-571-8778-3636Fax +86-571- 87022776Email genshengzhang@zju.edu.cnPurpose: Although the enterococcal bloodstream infections (EBSI) are often observed in clinic, the mixed-EBSI are few reported. The aim of this study was to investigate the clinical characteristics and risk factors of mixed-EBSI in comparison with monomicrobial EBSI (mono-EBSI).Methods: A single-center retrospective observational study was performed between Jan 1, 2013 and Dec 31, 2018 in a tertiary hospital. All patients with EBSI were enrolled, and their data were collected by reviewing electronic medical records.Results: A total of 451 patients with EBSI were enrolled including 157 cases (34.8%) with mixed-EBSI. The most common co-pathogens were Coagulase-negative Staphylococcus (26.86%), followed by Acinetobacter baumannii (23.43%) and Klebsiella pneumoniae (8.57%). In multivariable analysis, burn injury (adjusted odds ratio [aOR], 7.39; 95% confidence interval [CI], 2.69–20.28), and length of prior hospital stay (aOR, 1.01; 95% CI, 1.00–1.02) were associated with mixed-EBSI. Patients with mixed-EBSI developed with more proportion of septic shock (19% vs. 31.8%, p=0.002), prolonged length of intensive care unit (ICU) stay [9(0,25) vs. 15(2.5,36), p

Siping Zhu,1,* Wei Lin,1,* Shu Chen,1,* Hanmei Qi,1 Siting Wang,2 Aisen Zhang,1 Jinmei Cai,1 Bing Lai,1 Yunlu Sheng,1 Guoxian Ding11Division of Geriatric Endocrinology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People’s Republic of China; 2Division of Intensive Care Unit, Nanjing Jiangning Hospital, Nanjing, Jiangsu, People’s Republic of China*These authors contributed equally to this workBackground: Sarcopenia is typically defined as the loss of muscle mass, strength and low physical performance with aging. Ultrasound is a safe and easy method for evaluating muscle mass and quality by muscle thickness (MT) and pennation angle (PA), respectively. Although the positive correlations between MT and muscle mass and handgrip strength were observed, the relationship between MT, PA and physical performance remains unclear.Purpose: This study aimed to investigate the correlation of aforementioned ultrasound parameters with muscle mass, muscle strength and physical performance and explore the utility of ultrasound in predicting sarcopenia.Patients and methods: A total of 265 elderly Chinese community dwellers were included. MT of both forearm and lower leg as well as PA of gastrocnemius was assessed by ultrasound. Muscle mass was assessed by dual-energy X-ray absorptiometry. Muscle strength was measured by a Jamar hand dynamometer. Physical performance was assessed by the Short Physical Performance Battery (SPPB).Results: Anterior radial MT in men and regional MTs except posterior fibula in women were negatively correlated with the age. No significant correlation was observed between PA and the age in both genders. Posterior tibial MT and posterior fibula MT were positively correlated with the relative appendicular skeletal muscle mass in men and women, respectively. Anterior ulnar MT was positively correlated with grip strength in both genders. Moreover, gastrocnemius medialis PA showed a positive association with gait speed and SPPB in women but not in men.Conclusion: A combination of posterior fibula MT, anterior ulnar MT and gastrocnemius medialis PA measured by muscle ultrasound is helpful for the assessment of sarcopenia in Chinese elderly women. In addition, a combination of posterior tibial MT and anterior ulnar MT measured by muscle ultrasound is helpful for the assessment of sarcopenia in Chinese elderly men.Keywords: B-mode ultrasound, muscle thickness, pennation angle, muscle mass, muscle strength, physical performance

Junxiu Cai,1,2,* Yan Zhang,3,* Rebiya Nuli,4 Yangyi Zhang,5 Manfutong Abudusemaiti,5 Aizhatiguli Kadeer,6 Xiaoli Tian,5 Hui Xiao5 1Department of Occupational and Environmental Health, School of Public Health, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China; 2Medical Department, Fifth Affiliated Hospital, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China; 3Department of Pathology, Basic Medical Science Institute, International Education College, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China; 4Department of Human Parasitology, Basic Medical Science Institute, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China; 5Department of Nutrition and Food Hygiene, School of Public Health, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China; 6Department of Epidemiology and Statistics, School of Public Health, Xinjiang Medical University, Urumqi 830011, Xinjiang Uygur Autonomous Region, China *These authors contributed equally to this work Purpose: This study aimed to characterize dietary patterns in the Uyghur population and examined the relationship between dietary pattern, TCF7L2 single-nucleotide polymorphisms (SNPs), and the risk of type 2 diabetes mellitus (T2DM).Patients and methods: Dietary patterns were defined using factor analysis, and associations between dietary patterns were evaluated using multivariate logistic regression analyses. Genotyping of seven SNPs of TCF7L2 (rs11196205, rs12255372, rs12573128, rs4506565, rs7895340, rs7901695, and rs7903146) was conducted, and the association between these seven SNPs and the risk of T2DM was evaluated. Interactions between SNPs, homeostasis model assessment-insulin resistance, and dietary patterns were also analyzed.Results: A total of 828 participants were enrolled in this study, including 491 people with T2DM and 337 healthy controls. Five dietary patterns were defined, and the results indicated that the “fruit” and “vegetables” dietary patterns were associated with a significant decrease in the risk of T2DM, whereas the “meats” and “grains” dietary patterns were associated with an increased risk of T2DM. Moreover, the “dairy product” dietary pattern showed no association with the risk of T2DM. Furthermore, our results revealed that the TCF7L2 SNP, rs12573128, is associated with an increased risk of T2DM. SNPs rs4506565 and rs7903146 significantly interacted with dietary pattern.Conclusion: Our studies suggest that dietary pattern and genetic polymorphisms of TCF7L2 are associated with the development of T2DM in the Uyghur population of China. Keywords: type 2 diabetes mellitus, dietary patterns, TCF7L2, polymorphism, Uyghur

Jiangyu Cai,1,* Juan Wang,2,* Kaiqiang Ye,2 Dandan Li,2 Chengchong Ai,1 Dandan Sheng,1 Wenhe Jin,1 Xingwang Liu,1 Yunlong Zhi,1 Jia Jiang,1 Jun Chen,1,3,4 Xiumei Mo,2 Shiyi Chen1 1Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China; 2State Key Laboratory for Modification of Chemical Fibers and Polymer Materials, College of Chemistry, Chemical Engineering and Biotechnology, Donghua University, Shanghai 201620, China; 3Shanghai BJ-KMC Medical Technology Co., Ltd, Shanghai 201707, China; 4State Key Laboratory of Molecular Engineering of Polymers, Fudan University, Shanghai 200433, China *These authors contributed equally to this work Background: Tendon/ligament injuries are common sports injuries. Clinically, the repair of a ruptured tendon or ligament to its bony insertion is needed, but the enthesis structure is not well reestablished following surgical repair. Herein, we fabricated dual-layer aligned-random scaffold (ARS) by electrospinning and aimed to investigate the effect of the scaffold on tendon-to-bone healing in vivo. Materials and methods: The random and dual-layer aligned-random silk fbroin poly(L-lactic acid-co-e-caprolactone) (P(LLA-CL)) nanofibrous scaffolds were successfully fabricated by electrospinning methods. Ninety New Zealand white rabbits were randomly divided into three groups (random scaffold [RS], ARS, and control groups), and they were subjected to surgery to establish an extra-articular tendon-to-bone healing model with autologous Achilles tendon. Results: Histological assessment showed that the ARS significantly increased the area of metachromasia, decreased the interface width, and improved collagen maturation and organization at the tendon–bone interface compared with the RS and control groups. Microcomputed tomography analysis showed that the bone tunnel area of RS and ARS groups was significantly smaller than those of the control group. Real-time polymerase chain reaction showed that BMP-2 and osteopontin expression levels of the tissue at the interface between the bone and graft in the RS and ARS groups were higher than those of the control group at 6 weeks. Collagen I expression level of the ARS group was significantly higher than those of the RS and control groups at 6 and 12 weeks. Moreover, the ARS groups had a better ultimate load-to-failure and stiffness than the RS and control groups. Conclusion: ARS could effectively augment the tendon-to-bone integration and improve gradient microstructure in a rabbit extra-articular model by inducing the new bone formation, increasing the area of fibrocartilage, and improving collagen organization and maturation. The dual-layer aligned-random silk fibroin/P(LLA-CL) nanofibrous scaffold is proved to be a promising biomaterial for tendon-to-bone healing. Keywords: tendon-to-bone healing, electrospinning, aligned, random, dual-layer

Siheng Wang,1,* Yunshen Ge,1,* Chengchong Ai,1 Jia Jiang,1 Jiangyu Cai,1 Dandan Sheng,1 Fang Wan,1 Xingwang Liu,1 Yuefeng Hao,2 Jun Chen,1 Shiyi Chen1 1Department of Sports Medicine and Arthroscopy Surgery, Huashan Hospital, Shanghai, People’s Republic of China; 2Sports Medicine Center, Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, People’s Republic of China *These authors contributed equally to this work Purpose: This study was designed to evaluate the biocompatibility and osseointegration of polyethylene terephthalate ligament after coating with hydroxyapatite (PET/HA) by using the plasma spraying technique in vitro and in vivo. Methods: In this study, PET/HA sheets were prepared by using the plasma spraying technique. The characterization, the viability of bone marrow stromal cells (BMSCs), and the mRNA expression of bone formation-related genes were evaluated in vitro. The osseointegration in vivo was investigated in the rabbit anterior cruciate ligament (ACL) reconstruction model by micro-computed tomography (micro-CT) analysis, histological evaluation, and biomechanical tests. Results: Scanning electron microscopy (SEM) results showed that the surface of polyethylene terephthalate (PET) becomes rough after spraying with hydroxyapatite (HA) nanoparticles, and the water contact angle was 75.4°±10.4° in the PET/HA-plasma group compared to 105.3°±10.9° in the control group (p

Xueliang Zuo,1,* Juan Cai,2,* Zhiqiang Chen,3,* Yao Zhang,3 Jian Wu,1 Liangyu Wu,4 Jinguo Wang1 1Department of Gastrointestinal Surgery, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China; 2Department of Oncology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, China; 3Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, China; 4Department of General Surgery, Qingyang County People’s Hospital, Qingyang, China *These authors contributed equally to this work Purpose: Unplanned reoperation (URO) after radical gastrectomy for gastric cancer (GC) mostly results from serious postoperative complications. At present, there is still controversy over the predictive factors for URO. Our goal was to identify the risk factors for URO and to investigate its potential impact on long-term survival. Patients and methods: We included 2,852 GC patients who underwent a gastrectomy. Multivariate logistic regression analyses were performed to determine the risk factors for URO. Patients were randomly selected from the non-URO group by 1:4 propensity score matching with multiple parameters with patients from the URO group. The survival disparity of 34 URO patients and 136 non-URO patients was examined using the Kaplan–Meier method and the multivariate Cox proportional hazard model. Results: The incidence of URO was 1.4% (39/2, 852). The primary cause of URO was intra-abdominal bleeding (53.9%, 21/39). Multivariate logistic regression analyses revealed that male gender (OR = 4.630, 95% CI = 1.412–15.152, P = 0.011), diabetes (OR = 4.189, 95% CI = 1.705–10.290, P = 0.002), and preoperative hypoproteinemia (OR = 2.305, 95% CI = 1.079–4.923, P = 0.031) were independent risk factors for URO. With regard to early surgical outcomes, patients undergoing URO had a longer hospital stay (P < 0.001), higher incidence of postoperative complications (P < 0.001), and greater mortality (P < 0.001) compared with the non-URO group. No significant correlation was found between URO and cancer-specific survival in univariate (P = 0.275) and multivariate (P = 0.090) survival analyses. Conclusion: Male gender, diabetes, and preoperative hypoproteinemia were suggested as independent risk factors for URO. URO was associated with longer hospital stay and increased perioperative mortality, but might not be correlated with long-term mortality. Keywords: reoperation, stomach neoplasm, gastrectomy, postoperative complications

Juan Cai,1,* Xueliang Zuo,2,* Zhiqiang Chen,3,4,* Wenying Zhao,1 Yiping Zhu,1 Zhengxiang Zhang,1 Xiaobing Ye1 1Department of Oncology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; 2Department of Gastrointestinal Surgery, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China; 3Hepatobiliary Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China; 4Key Laboratory of Liver Transplantation, Chinese Academy of Medical Sciences, Nanjing, Jiangsu, China *These authors contributed equally to this work Purpose: This meta-analysis aimed to assess the prognostic value of long noncoding RNA cancer susceptibility candidate 2 (CASC2) in human tumors. Materials and methods: We searched the available databases up to December 2017. Pooled hazard ratios (HRs) and the corresponding 95% confidence intervals (CIs) were used to examine the prognostic impact of CASC2 on overall survival (OS) in patients diagnosed with malignancies. Results: A total of eight studies with 663 cancer patients were enrolled. Our results showed that high CASC2 expression level was associated with a favorable OS (HR=0.437, 95% CI: 0.345–0.554). The significant results were not altered by stratified analysis according to cancer type, sample size, follow-up months, and HR estimation method. A significant association of glioma tumor stage with CASC2 expression was detected (III–IV vs I–II: odds ratio=2.126, 95% CI: 1.032–4.378). CASC2 could be used as an independent prognostic factor for OS (HR=0.450, 95% CI: 0.336–0.602). Sensitivity analysis showed that no single study changed the pooled results significantly. Begg’s funnel plot and Egger’s test showed that no publication bias was detected. Conclusion: High expression level of CASC2 is associated with favorable survival outcome for cancer patients, and CASC2 could be used as a prognostic predictor for cancers. Keywords: CASC2, long noncoding RNA, prognosis, meta-analysis

Teng Ma,1–3,* Jian Cai,4,* Yin-Sheng Zhu,5 Xue-Feng Chu,5 Yong Wang,5 Guo-Ping Shi,5 Zheng-Dong Wang,5 Shun Yao,1–3 Xiao-Feng Wang,1–3 Xiao-Yan Jiang6–8 1Unit of Epidemiology, Ministry of Education Key Laboratory of Contemporary Anthropology, Fudan University, Shanghai, People’s Republic of China; 2State Key Laboratory of Genetic Engineering, School of Life Sciences, Fudan University, Shanghai, People’s Republic of China; 3National Clinical Research Center for Aging and Medicine (Huashan), Huashan Hospital, Fudan University, Shanghai, People’s Republic of China; 4Department of Neurology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China; 5Rugao People’s Hospital, Rugao, Jiangsu, People’s Republic of China; 6Key Laboratory of Arrhythmias of the Ministry of Education of China, Tongji University School of Medicine, Shanghai, People’s Republic of China; 7Department of Pathology and Pathophysiology, Tongji University School of Medicine, Shanghai, People’s Republic of China; 8Institute of Medical Genetics, Tongji University, Shanghai, People’s Republic of China *These authors contributed equally to this work Background: Risk factors for heart rate-corrected QT interval (QTc) proglongation should be explored to stratify high-risk individuals to aid the prevention of incident cardiovascular events and mortality. The diversity of risk factors for QTc prolongation suggests that use of the frailty index (FI), indicating general health deficits, may be an effective approach, especially in the elderly, to identify the risk of QTc prolongation. Methods: We used the data of 1,780 individuals aged 70–87 years from the Rugao Longevity and Ageing Study (RuLAS), a community-based longitudinal study. The FI was constructed using 20 routine laboratory tests, plus the body mass index and measures of systolic and diastolic blood pressures (FI-Lab). Results: The mean FI-Lab value was 0.24±0.09. The mean heart rate-corrected QT interval (QTc) was 407±38 ms. The prevalence of QTc prolongation was 5.2% in elderly community populations aged 70–87 years. A higher FI-Lab value was associated with a higher risk for QTc prolongation. Each 10% increase in the FI-Lab value increased the odds ratio (OR) by 33% (OR: 1.33; 95% CI: 1.07–1.64). Compared with the lowest quartile, the top quartile FI-Lab score was associated with a 2.50-fold QTc prolongation risk in elderly individuals (95% CI: 1.21–5.19). Conclusion: An FI based on routine laboratory data can identify older adults at increased risk for QTc prolongation. The FI approach may therefore be useful for the risk stratification of QTc prolongation. Keywords: QTc prolongation, frailty, frailty index, Chinese elderly

Ping Fang,1 Peng-fei Tang,1 Ren-ai Xu,2 Xiang Zheng,1 Jian Wen,1 Su-su Bao,1 Jian-ping Cai,3 Guo-xin Hu1 1Department of Pharmacology, School of Pharmacy, Wenzhou Medical University, 2Department of Pharmacy, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 3The Ministry of Health (MOH) Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, China Aim: Human cytochrome P450 3A4 is the most abundant isoform of P450 enzyme in the liver. It plays an important role in the metabolism of wide variety of xenobiotic and endogenous substrates. So far, there are few reports about the functional characterization of CYP3A4 variants in terms of specific substrates. The aim of this study was to systematically investigate the genetic polymorphisms of 23 CYP3A4 alleles and evaluate their catalytic activities on the metabolism of lidocaine in vitro.Methods and results: The wild-type and 22 CYP3A4 variants were expressed in Spodoptera frugiperda 21 insect cells. Then the insect microsomes were incubated with the CYP3A4-specific substrate lidocaine. Reactions were performed with 50–3,000 µM for 60 min at 37°C. Lidocaine and its metabolite monoethylglycinexylidide were analyzed by ultra-performance liquid chromatography-tandem mass spectrometry system. Of the 23 CYP3A4 allelic variants tested, 2 variants (CYP3A4*17 and CYP3A4*30) had no detectable enzyme activity; and 5 variants (CYP3A4*2, CYP3A4*5, CYP3A4*9, CYP3A4*16 and CYP3A4*24) showed significantly decreased intrinsic clearance values compared with wild-type CYP3A4*1.Conclusion: As the first study of all these CYP3A4 alleles for lidocaine metabolism, our results in vitro assessment may provide novel insights into the allele-specific and substrate-specific activity of CYP3A4 and may also offer a reference to the personalized treatment of lidocaine in a clinical setting. Keywords: CYP3A4, genetic polymorphism, drug metabolism, lidocaine, personalized treatment

Chengchong Ai, Dandan Sheng, Jun Chen, Jiangyu Cai, Siheng Wang, Jia Jiang, Shiyi Chen Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, People’s Republic of China Abstract: Ultra-high-molecular-weight polyethylene (UHMWPE) has been applied in orthopedics, as the materials of joint prosthesis, artificial ligaments, and sutures due to its advantages such as high tensile strength, good wear resistance, and chemical stability. However, postoperative osteolysis induced by UHMWPE wear particles and poor bone–implant healing interface due to scarcity of osseointegration is a significant problem and should be solved imperatively. In order to enhance its affinity to bone tissue, vascular endothelial growth factor (VEGF) was loaded on the surface of materials, the loading was performed by silk fibroin (SF) coating to achieve a controlled-release delivery. Several techniques including field emission scanning electron microscopy (FESEM) and attenuated total reflectance (ATR)-Fourier transform infrared (FTIR) and water contact angle measurement were used to validate the effectiveness of introduction of SF/VEGF. The result of ELISA demonstrated that the release of VEGF was well maintained up to 4 weeks. The modified UHMWPE was evaluated by both in vitro and in vivo experiments. According to the results of FESEM and cell counting kit-8 (CCK-8) assay, bone marrow mesenchymal stem cells cultured on the UHMWPE coated with SF/VEGF and SF exhibited a better proliferation performance than that of the pristine UHMWPE. The model rabbit of anterior cruciate ligament reconstruction was used to observe the graft–bone healing process in vivo. The results of histological evaluation, microcomputed tomography (micro-CT) analysis, and biomechanical tests performed at 6 and 12 weeks after surgery demonstrated that graft–bone healing could be significantly improved due to the effect of VEGF on angiogenesis, which was loaded on the surface by SF coating. This study showed that the method loading VEGF on UHMWPE by SF coating played an effective role on the biological performance of UHMWPE and displayed a great potential application for anterior cruciate ligament reconstruction. Keywords: UHMWPE, surface modification, VEGF, silk fibroin, graft–bone healing

Fuxiang Chen,1 Xingfen Su,1 Zhangya Lin,1 Yuanxiang Lin,1 Lianghong Yu,1 Jiawei Cai,1 Dezhi Kang,1 Liwen Hu2 1Department of Neurosurgery, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China; 2Department of Pathology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China Abstract: Necroptosis is programmed cell death that has been recently proposed and reported to be involved in several neurologic diseases. However, the role of necroptosis in early brain injury after subarachnoid hemorrhage (SAH) is still unknown. The purpose of this study was to investigate whether necroptosis was involved in SAH-induced early brain injury, and to assess the possible neuroprotective effect of necrostatin-1 using an endovascular perforation rat model of SAH. Our results showed that the expression levels of necroptosis-related proteins including RIP1, RIP3 and MLKL in the basal cortex all increased at 3 hours after SAH (P

Susan C Bolge,1 Natalia M Flores,2 Shu Huang,3 Jennifer Cai1 1Janssen Scientific Affairs, LLC, Titusville, NJ, 2Kantar Health, Foster City, CA, 3Kantar Health, New York, NY, USA Purpose: This study describes how health care providers approach canagliflozin for the treatment of patients with type 2 diabetes mellitus (T2DM) in the real world.Patients and methods: An Internet-based questionnaire was completed by 101 endocrinologists, 101 primary care physicians, and 100 nurse practitioners/physician assistants (NP/PAs). Health care providers were required to have experience prescribing or managing patients using canagliflozin to be included in the study. Health care providers compared canagliflozin with other T2DM medication classes on clinical characteristics, costs, and patient satisfaction. Confidence in canagliflozin was also measured. Health care providers reported their canagliflozin prescribing experience and good candidate characteristics for treatment. Finally, providers reported on patient outcomes among those receiving canagliflozin. All variables were compared across provider type.Results: Health care providers reported higher favorability for canagliflozin for blood pressure and body weight compared with dipeptidyl peptidase-4 (DPP-4) inhibitors and higher favorability for effect on blood pressure, body weight, treatment satisfaction, and glycosylated hemoglobin (HbA1c) compared with sulfonylureas (SUs), with differences observed for effect on blood pressure. Health care providers reported being very/extremely confident (55%–74%) with canagliflozin as a second- to fourth-line treatment. The top 3 characteristics reported by the providers, in terms of describing a good candidate for canagliflozin, include those concerned about their weight, insurance coverage/affordability, and avoiding injectable treatments. Finally, providers reported often/always observing patients’ lowering or controlling HbA1c (82%–88%) and improvement in overall quality of life (QoL; 50%–53%) with canagliflozin treatment. No differences were observed across provider type for confidence, good candidate characteristics, or patient outcomes.Conclusion: Health care providers reported favorable experiences with canagliflozin and witnessed improvements in patients’ clinical outcomes and QoL. Keywords: diabetes, SGLT2-inhibitors, management goals, real-world evidence, prescribing experience

Kena Ma,1,2,* Lingling Gong,1,* Xinjie Cai,1,2 Pin Huang,1 Jing Cai,1 Dan Huang,1 Tao Jiang1,2 1The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) and Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, 2Department of Prosthodontics, Hospital of Stomatology, Wuhan University, Wuhan, People’s Republic of China*These authors contributed equally to this workAbstract: Implant-associated infections still pose a serious threat leading to several complications. This study reported an environmentally benign Ag-containing nanocomposite coating with efficient antibacterial property fabricated on the metal implant via electrophoretic deposition (EPD). In such coatings, Ag2O/AgCl mixed with chitosan/gelatin (CS/G) polymers work together to exert the antibacterial property which could act as an alternative to traditional Ag nanoparticles. Scanning electron microscopy images showed the shuttle fiber-like morphology distributed lamellarly and some nanoparticles carved uniformly into the cross section. Transmission electron microscopy results revealed a core–shell-like structure of the released nanoparticles in experimental groups. The Ag-containing coatings exhibited strong antibacterial properties against Staphylococcus aureus strains and Escherichia coli strains. Meanwhile, the CCK-8 tests showed that after assembling with chitosan and gelatin polymers, the cytotoxicity of Ag was largely decreased. In addition, such coatings also exhibited strong bond strength with metal substrates and good degradable properties. Therefore, such Ag-containing CS/G coatings fabricated via EPD may be a promising candidate to be administrated in controlling the implant-associated infections.Keywords: infection, green chemistry, chitosan, gelatin, EPD

Nicole M Gerlanc,1 Jennifer Cai,2 Joseph Tkacz,1 Susan C Bolge,2 Brenna L Brady1 1Health Analytics, LLC Columbia, MD, USA; 2Janssen Scientific Affairs, LLC Titusville, NJ, USA Objective: Type 2 diabetes mellitus (T2DM) is a chronic condition complicated by being overweight or obese. This study used a patient survey to assess health, satisfaction, and diabetes self-management in relation to weight management.Methods: A survey including the Current Health Satisfaction Questionnaire, Diabetes Distress Scale, and Diabetes Treatment Satisfaction Questionnaire was administered using an online platform to a sample of 205 patients with T2DM prescribed canagliflozin. Patients were placed into 5 groups based on their self-reported weight change since initiation of canagliflozin: Lost >10 lbs, Lost 5–10 lbs, Lost 10 lbs were more likely to be engaged in a weight loss program for at least 6 months. Patients in the Lost >10 lbs and Lost 5–10 lbs groups reported the greatest satisfaction with canagliflozin (p10 lbs was associated with reduced diabetes distress, improved A1c and blood glucose levels, and decreased perceived frequency of hyperglycemia (p

Qin Guo,1,* Jie Cai,1,2,* Pengyu Li,1 Dongling Xu,1 Xiaomin Ni,1 Hui Wen,3 Dan Liu,3 Suizhen Lin,3 Haiyan Hu1 1School of Pharmaceutical Sciences, Sun Yat-sen University, 2Guangzhou First People’s Hospital, Guangzhou Medical University, 3Guangzhou Cellprotek Pharmaceutical Co., Ltd., Science Park, Guangzhou, People’s Republic of China *These authors contributed equally to this work Abstract: Androst-3β,5α,6β-triol (Triol) is a promising neuroprotective agent, but its poor solubility restricts its development into parenteral preparations. In this study, Triol is significantly solubilized by bile salt/phosphatidylcholine mixed micelles (BS/PC-MM). All BS/PC-MM systems are tested to remarkably improve the drug solubility with various stabilities after drug loading. Among them, the sodium glycocholate (SGC)/egg phosphatidylcholine (EPC) system with 2:1 ratio in weight and the total concentration of SGC and EPC of 100 mg/mL is proved to produce stable mixed micelles with high drug loading. It is found that the stability of drug-loaded mixed micelles is quite different, which might be related to the change in critical micelle concentration (CMC) after incorporating drugs. SGC/EPC and SGC/soya phosphatidylcholine (SPC) remain transparent under accelerated conditions and manifest a decreased CMC (dropping from 0.105 to 0.056 mg/mL and from 0.067 to 0.024 mg/mL, respectively). In contrast, swine bile acid-sodium salt (SBA-Na)/PC and sodium deoxycholate (SDC)/PC are accompanied by drug precipitation and reached the maximum CMC on the first and the third days, respectively. Interestingly, the variation of CMC under accelerated testing conditions highly matches the drug-precipitating event in the primary stability experiment. In brief, the bile salt/phosphatidylcholine system exists as a potential strategy of improving sterol drug solubility. CMC variation under accelerated testing conditions might be a simple and easy method to predict the stability of drug-loaded mixed micelles. Keywords: bile salt/phosphatidylcholine, mixed micelles, sterols, solubilizing, stability

Na Li,1-3* Yumei Wang,1-3* Xiaochuan Zhao,1-3 Yuanyuan Gao,1-3 Mei Song,1-3 Lulu Yu,1-3 Lan Wang,1-3 Ning Li,1-3 Qianqian Chen,1-3 Yunpeng Li,1-3 Jiajia Cai,1-3 Xueyi Wang1-31Department of Psychiatry, The First Hospital of Hebei Medical University, 2Mental Health Institute of Hebei Medical University, 3Brain Ageing and Cognitive Neuroscience Laboratory, Hebei, People’s Republic of China *These authors contributed equally to this work Objective: The present study aimed to investigate the long-term effect of 1976 Tangshan earthquake exposure in early life on performance of working memory in adulthood.Methods: A total of 907 study subjects born and raised in Tangshan were enrolled in this study. They were divided into three groups according to the dates of birth: infant exposure (3–12 months, n=274), prenatal exposure (n=269), and no exposure (born at least 1 year after the earthquake, n=364). The prenatal group was further divided into first, second, and third trimester subgroups based on the timing of exposure during pregnancy. Hopkins Verbal Learning Test-Revised and Brief Visuospatial Memory Test-Revised (BVMT-R) were used to measure the performance of working memory. Unconditional logistic regression analysis was used to analyze the influential factors for impaired working memory.Results: The Hopkins Verbal Learning Test-Revised scores did not show significant difference across the three groups. Compared with no exposure group, the BVMT-R scores were slightly lower in the prenatal exposure group and markedly decreased in the infant exposure group. When the BVMT-R scores were analyzed in three subgroups, the results showed that the subjects whose mothers were exposed to earthquake in the second and third trimesters of pregnancy had significantly lower BVMT-R scores compared with those in the first trimester. Education level and early-life earthquake exposure were identified as independent risk factors for reduced performance of visuospatial memory indicated by lower BVMT-R scores.Conclusion: Infant exposure to earthquake-related stress impairs visuospatial memory in adulthood. Fetuses in the middle and late stages of development are more vulnerable to stress-induced damage that consequently results in impaired visuospatial memory. Education and early-life trauma can also influence the performance of working memory in adulthood. Keywords: Tangshan earthquake, early life stress, working memory, chronic effect

Jun Cai,1 Yi Zhu,1 Weibo Zhang,1 Yanfeng Wang,1 Chen Zhang2 1Center for Disease Control and Prevention, Shanghai Mental Health Center, 2Schizophrenia Program, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, People’s Republic of China Background: Antipsychotic medication has limited abilities to improve the cognitive impairments that accompany schizophrenia. Adding psychosocial treatment may result in marked improvements in cognitive function, as compared to antipsychotic treatment alone. We hypothesized that a combination of individual and family interventions may be a useful cognitive rehabilitation paradigm for schizophrenia. Materials and methods: An 18-month follow-up clinical trial of 256 stabilized patients with schizophrenia at six communities in Shanghai, People’s Republic of China were randomly assigned to into either a comprehensive family therapy (CFT) group or a usual daily care (UDC) group. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and the Positive and Negative Syndrome Scale (PANSS) were the primary outcome instruments for this study. Results: There was no significant difference between the CFT and UDC for all demographic characteristics at the baseline assessment. During the 18-month follow-up observation, changes in RBANS total score indicated that patients undergoing CFT showed greater improvement from baseline to the follow-up assessments in cognitive function than those in the UDC group (F=9.77, P=0.002). Post hoc analysis showed that the CFT group presented with significant differences in the RBANS total score, immediate memory, visuospatial skill, language, attention, and delayed memory sections compared with the UDC after 18 months of follow-up (all P

Li-Yong Zhang,1,* Tao Xing,1,* Li-Xin Du,1,* Qing-Min Li,2 Wei-Dong Liu,1 Ji-Yue Wang,1 Jing Cai31Department of neurosurgery, Liaocheng People’s Hospital, Liaocheng, Shandong, People’s Republic of China; 2Department of Neurosurgery, Tai’an Central Hospital, Tai’an, Shandong, People’s Republic of China; 3Department of Neurosurgery, LinYi People Hospital, LinYi, Shandong, People’s Republic of China*These authors contributed equally to this workBackground: Glial cell line-derived neurotrophic factor (GDNF) is a small protein that potently promotes the survival of many types of neurons. Detection of GDNF is vital to monitoring the survival of sympathetic and sensory neurons. However, the specific method for GDNF detection is also un-discovered. The purpose of this study is to explore the method for protein detection of GDNF.Methods: A novel visual detection method based on a molecular translator and isothermal strand-displacement polymerization reaction (ISDPR) has been proposed for the detection of GDNF. In this study, a molecular translator was employed to convert the input protein to output deoxyribonucleic acid signal, which was further amplified by ISDPR. The product of ISDPR was detected by a lateral flow biosensor within 30 minutes.Results: This novel visual detection method based on a molecular translator and ISDPR has very high sensitivity and selectivity, with a dynamic response ranging from 1 pg/mL to 10 ng/mL, and the detection limit was 1 pg/mL of GDNF.Conclusion: This novel visual detection method exhibits high sensitivity and selectivity, which is very simple and universal for GDNF detection to help disease therapy in clinical practice.Keywords: lateral flow biosensor, molecular translator, isothermal strand-displacement polymerization reaction

Cui-Tao Lu,1 Ying-Zheng Zhao,2,3 Ho Lun Wong,4 Jun Cai,5 Lei Peng,2 Xin-Qiao Tian1 1The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang Province, People’s Republic of China; 2Hainan Medical College, Haikou City, Hainan Province, People’s Republic of China; 3College of Pharmaceutical Sciences, Wenzhou Medical University, Zhejiang Province, People’s Republic of China; 4School of Pharmacy, Temple University, Philadelphia, PA, USA; 5Departments of Pediatrics and Anatomical Sciences and Neurobiology, University of Louisville School of Medicine Louisville, KY, USA Abstract: Although many agents have therapeutic potentials for central nervous system (CNS) diseases, few of these agents have been clinically used because of the brain barriers. As the protective barrier of the CNS, the blood–brain barrier and the blood–cerebrospinal fluid barrier maintain the brain microenvironment, neuronal activity, and proper functioning of the CNS. Different strategies for efficient CNS delivery have been studied. This article reviews the current approaches to open or facilitate penetration across these barriers for enhanced drug delivery to the CNS. These approaches are summarized into three broad categories: noninvasive, invasive, and miscellaneous techniques. The progresses made using these approaches are reviewed, and the associated mechanisms and problems are discussed. Keywords: drug delivery system, blood–brain barrier (BBB), central nervous system, brain-targeted therapy, cerebrospinal fluid (CSF)