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Michael Woodward,1,* Venkatasubramanian Ramasubramanian,2 Adeeba Kamarulzaman,3 Terapong Tantawichien,4 Minggui Wang,5 Joon Young Song,6 Won Suk Choi,7 Samsuridjal Djauzi,8 Rontgene Solante,9 Wen-Sen Lee,10 Kazuhiko Tateda,11 HongXing Pan,12 Ning-Chi Wang,13 Tikki Pang14,* 1Aged Care Research, Austin Health, Melbourne, VIC, Australia; 2Department of Infectious Diseases, HIV & Tropical Medicine, Apollo Hospitals, Chennai, TN, India; 3Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia; 4Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; 5Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, SH, People’s Republic of China; 6Division of Infectious Diseases, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea; 7Division of Infectious Diseases, Department of Internal Medicine, Korea University Ansan Hospital, Korean University College of Medicine, Ansan, Korea; 8Allergy and Clinical Immunology Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia; 9Adult Infectious Diseases and Tropical Medicine, San Lazaro Hospital, Manila, NCR, Philippines; 10Division of Infectious Diseases, Department of Internal Medicine, New Taipei City Hospital, New Taipei, Taiwan; 11Department of Microbiology and Infectious Diseases, Faculty of Medicine, Toho University, Tokyo, Japan; 12Institution of Vaccine Clinical Trials, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, JS, People’s Republic of China; 13Department of Medicine, Tri-Service Hospital, Taipei, Taiwan; 14Centre for Behavioural and Implementation Science Interventions, Yong Loo Lin School of Medicine, National University of Singapore, Singapore*These authors contributed equally to this workCorrespondence: Tikki Pang, Centre for Behavioural and Implementation Science Interventions, Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, 117597, Singapore, Tel +65 6516 1048, Email mdctep@nus.edu.sgAbstract: The impact of vaccinating the older population against vaccine-preventable diseases in terms of health, social and economic benefits has been increasingly recognised. However, there is a gap in the utilisation of vaccines worldwide. The population is ageing at an unprecedented pace in the Asia-Pacific (APAC) region, with the number of persons older than 65 years set to double by 2050 to around 1.3 billion. More than 18% of the population in Japan, Hong Kong, and China is over the age of 65 years. This highlights the importance of prioritising resources to address societal obligations toward the needs of the ageing generation. This review provides an overview of the challenges to adult vaccination in APAC, drivers to increase vaccination coverage, vaccination insights gained through the COVID-19 pandemic, and potential measures to increase the uptake of adult vaccines in the region.Keywords: adult vaccination, vaccine-preventable diseases, VPD, adult vaccines, COVID-19 vaccination

Abstract Collapse of the edge flow shear as the line-averaged density approaches the Greenwald density limit has been observed as a precursor to the enhanced edge particle flux characteristic of proximity to the density limit regime. Here, we report the use of a biased electrode to sustain the edge shear layer in high density discharges, in which the shear layer would otherwise collapse. A stable increase in line-averaged density is observed along with a strong increase in edge density. These experiments were carried out on the J-TEXT tokamak. The Reynolds stress at the edge is enhanced, and the zonal flow sustained, while density perturbation levels, the flux of turbulence internal energy (i.e., turbulence spreading), and particle and heat flux all decrease significantly. Electron adiabaticity increases, and bias voltage modulation experiments show that an increase in the edge shear leads the increase in adiabaticity. These results suggest that external edge E × B flow shear drive may be of interest for sustaining edge plasma states at high density, and support the hypothesis that collapse of the edge shear layer triggers the onset of the strong transport and turbulence characteristic of the density limit regime.

Enhanced particle transport events are discovered and analyzed as the density limit of the J-TEXT tokamak is approached. Edge shear layer collapse is observed and the ratio of Reynolds power to turbulence production decreases. Simultaneously, the divergence of turbulence internal energy flux (i.e. turbulence spreading) increases, indicating that shear layer collapse triggers an outward spreading event. Studies of correlations show that the enhanced particle transport events are quasi-coherent, and manifested primarily in density fluctuations which exhibit positive skewness. Electron adiabaticity emerges as the critical parameter which signals transport event onset. For α < 0.35 as density approaches the Greenwald density, both turbulence spreading and density fluctuations rise rapidly. Taken together, these results elucidate the connections between edge shear layer, density fluctuations, particle transport events, turbulence spreading and plasma edge cooling as the density limit is approached.

Enhancements of residual Reynolds stresses and symmetry breaking with resonant magnetic perturbations (RMPs) are presented. These experiments were performed using a Langmuir probe array in the edge plasmas of the J-TEXT tokamak. This study aims to explain the mechanisms for generating residual stresses and intrinsic rotations. It is observed that with RMPs, peaked residual stresses, steeper pressure gradients and stronger shear layers all appear around the resonant surface. The toroidal rotation is accelerated in the direction of the plasma current and shows a correlation with turbulence and the measured residual stresses near the resonant surfaces of RMPs. Symmetry breaking induced by magnetic islands is proposed as a new mechanism, which qualitatively explains the enhanced residual stresses and the acceleration of the toroidal rotation. The changes to the residual stresses and symmetry breaking with RMPs near the last closed surface are also discussed.

The temporal-spatial structures of plasma flows and turbulence around tearing mode islands are presented. The experiments were performed using Langmuir probe arrays in the edge plasmas of J-TEXT tokamak. The correlation analyses clearly show that the flows have similar structures of m/n = 3/1 as the magnetic island does (m and n are the poloidal and toroidal mode numbers, respectively). The sign of the potential fluctuations for the flows inverses and the powers significantly reduce at q = 3 surface. Approaching to the last closed flux surface for the magnetic islands, the radially elongated flow structure forms. The flows are concentrated near separatrix and show quadrupole structures. The turbulence is concentrated near X-point and partly trapped inside the magnetic islands.

The acceleration of the co-current toroidal rotations around resonant surfaces by resonant magnetic perturbations (RMPs) through turbulence is presented. These experiments were performed using a Langmuir probe array in the edge plasmas of the J-TEXT tokamak. This study aims at understanding the RMP effects on edge toroidal rotations and exploring its control method. With RMPs, the flat electron temperature T e profile, due to magnetic islands, appears around resonant surfaces (Zhao et al 2015 Nucl. Fusion 55 073022). When the resonant surface is closer to the last closed flux surface, the flat T e profile vanishes with RMPs. In both cases, the toroidal rotations significantly increase in the direction of the plasma current around the resonant surfaces with RMPs. The characteristics of turbulence are significantly affected by RMPs around the resonant surfaces. The turbulence intensity profile changes and the poloidal wave vector k θ increases with RMPs. The power fraction of the turbulence components in the ion diamagnetic drift direction increases with RMPs. The measurements of turbulent Reynolds stresses are consistent with the toroidal flows that can be driven by turbulence. The estimations of the energy transfer between the turbulence and toroidal flows suggest that turbulence energy transfers into toroidal flows. The result has the implication of the intrinsic rotation being driven by RMPs via turbulence.

The first comprehensive measurements of plasma flows and fluctuations nearby static magnetic islands driven by resonant magnetic perturbations are presented. These experiments were performed using multiple Langmuir probe arrays on the edge plasmas of the J-TEXT tokamak. Controlled variations of the island size and location are explored. This study aims to understand the interaction between turbulence and magnetic islands, and to elucidate magnetic island effects on edge turbulence and flow intensity profiles, edge electric fields, and thus confinement regime transitions. Turbulence and low frequency flows (LFFs) all drop inside the magnetic island, but increase at its boundary, as island width increases. The geodesic acoustic mode is damped in most of the edge area with magnetic islands. The sign of the radial electric field changes from negative to positive within the islands. The gradient of turbulent stresses vanishes at the island center, and becomes steeper at the boundaries of the islands. The particle transport induced by the turbulence is reduced inside the magnetic islands. The magnetic island effects on flows and turbulence can lead to an increase in LFFs and enhance Reynolds stresses near the last closed flux surface (LCFS). A stronger radial electric field layer can be formed near the LCFS when magnetic islands are present. The results suggest that magnetic islands can be used as a tool to enhance edge turbulence and flows, edge electric fields, and thus to trigger confinement regime transitions.

Despite the significance of patient expressions of concern in medical interaction, existing research has found that doctors often fail to respond to them or even overlook them. Based on a dataset of video-recorded naturally occurring medical conversations in Chinese pediatric primary care, this study aims to systematically investigate the expressions of concern initiated by the family caregivers of pediatric patients and the responses of doctors. The results show that family caregivers actively initiate expressions of concern, covering a wide range of topics. Doctors respond to these concerns in 68.8% of the cases, while the rest are interrupted, ignored, or minimally acknowledged. In addition, as commonly found in other clinical and cultural contexts, family caregivers rarely express their emotional distress explicitly but rather indicate their underlying emotions implicitly. These findings suggest that a better understanding of the full range of family caregiver's self-initiated expressions of concern and their complexities provide important opportunities for doctors to identify and respond to them empathically.

Herpes zoster (HZ) is a painful, vesicular, cutaneous eruption from reactivation of varicella zoster virus (VZV), which can lead to potentially debilitating complications. The lifetime risk of HZ is estimated to be 20%-30% in the general population, with an increased risk in the elderly and immunocompromised populations. The most effective strategy to prevent HZ and its complications is by vaccination. Two types of HZ vaccines, zoster vaccine live and recombinant zoster vaccine, have been approved for use. This guidance offers recommendations and suggestions for HZ vaccination in adults, aiming to reduce the disease burden of HZ and its complications. It is intended as a guide to first-line healthcare providers, but does not supersede clinical judgement when assessing risk and providing recommendations to individuals. The Working Group on Adult Immunization Practice was appointed by the Infectious Diseases Society of Taiwan (IDST) and recommendations were drafted after a full literature review, using the Grading of Recommendation, Assessment, Development and Evaluation (GRADE) system. The recommendations were reviewed and revised by expert review panels during a series of consensus meetings and endorsed by the IDST, Taiwan Association of Family Medicine, the Taiwanese Dermatological Association, the Taiwan Oncology Society, the Taiwan Society of Blood and Marrow Transplantation, the Transplantation Society of Taiwan, the Taiwan AIDS Society, and the Taiwan College of Rheumatology. This guidance describes the epidemiology of HZ and provides recommendations for HZ vaccination in adults with varying levels of risk, differing history of previous VZV infection and past varicella or zoster vaccinations., Competing Interests: Declaration of competing interest The authors declare no potential conflicts of interest with regards to the research, authorship, or publication of this article., (Copyright © 2024. Published by Elsevier B.V.)

Background: Cryptococcal meningitis (CM) is a severe central nervous system infection. In patients with HIV infections and coexisting CM, elevated baseline cerebrospinal fluid (CSF) lactate levels can predict increased mortality. However, the CSF lactate level's significance in patients with CM who are HIV negative remains unclear, necessitating further investigation to elucidate the potential distinctions and enhance patient management. This study investigated the significance of CSF lactate levels in patients with CM who were HIV negative., Methods: This retrospective study utilized data from the clinical databases of patients who underwent lumbar punctures at a medical center in Kaohsiung City, southern Taiwan. Demographic data, CSF lactate levels, routine CSF analyses, and hematologic and neurologic findings were evaluated. The optimal CSF lactate threshold value was determined by the Youden index., Results: This retrospective study included 70 patients with CM, among whom 44 (63%) and 26 (37%) tested negative and positive for HIV, respectively. The group without HIV exhibited higher CSF lactate levels, with an optimal CSF lactate cutoff point of 7.935 mmol/L for predicting 90-day mortality, resulting in significant predictive accuracies (area under the curve, 0.755; sensitivity, 57.1%; specificity, 100%); this value was an independent mortality predictor in patients who were HIV negative. In patients with CM who were HIV negative, CSF lactate levels ≥7.935 mmol/L correlated with higher mortality rates but without statistical significance. All patients with CM who were HIV negative and had CSF lactate levels ≥7.935 mmol/L died within 3 months of admission., Conclusions: Patients with CM who were HIV negative had elevated CSF lactate levels that correlated with adverse outcomes, enabling early identification of high-risk individuals., Competing Interests: Potential conflicts of interest. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© The Author(s) 2024. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Sarcopenia is the age-related loss of skeletal muscle mass and function. Computed tomography (CT) assessments of sarcopenia utilize measurements of skeletal muscle cross-sectional area (SMA), radiation attenuation (SMRA), and intramuscular adipose tissue (IMAT). Unadjusted SMA is strongly correlated with both height and body mass index (BMI); therefore, SMA must be adjusted for body size to assess sarcopenic low muscle mass fairly in individuals of different heights and BMI. SMA/height (rather than S M A / h e i g h t 2 ) provides optimal height adjustment, and vertebra-specific relative muscle index (RMI) equations optimally adjust for both height and BMI. Since L3 measurement is not available in all CT scans, sarcopenic low muscle mass may be assessed using other levels. Both a mid-vertebral slice and an inferior slice have been used to define 'L3 SMA', but the effect of vertebral slice location on SMA measurements is unexplored. Healthy reference values for skeletal muscle measures at mid- and inferior vertebra slices between T10 and L5, have not yet been reported. We extracted T10 through L5 SMA, SMRA, and IMAT at a mid-vertebral and inferior slice using non-contrast-enhanced CT scans from healthy, adult kidney donor candidates between age 18 and 73. We compared paired differences in SMA between the mid-vertebral slice versus the inferior slice. We calculated the skeletal muscle gauge as S M G HT = S M R A ∗ S M I HT . We used allometric analysis to find the optimal height scaling power for SMA. To enable comparisons with other published reference cohorts, we computed two height-adjusted measures; S M I HT = S M A / h e i g h t (optimal) and S M I H T 2 = S M A / h e i g h t 2 (traditional). Using the young, healthy reference cohort, we utilized multiple linear regression to calculate relative muscle index z-scores ( R M I HT , R M I H T 2 ), which adjust for both height and BMI, at each vertebra level. We assessed Pearson correlations of each muscle area measure versus age, height, weight, and BMI separately by sex and vertebra number. We assessed the differences in means between age 18-40 versus 20-40 as the healthy, young adult reference group. We reported means, standard deviations, and sarcopenia cutpoints (mean-2SD and 5th percentile) by sex and age group for all measures. Sex-specific allometric analysis showed that height to the power of one was the optimal adjustment for SMA in both men and women at all vertebra levels. Differences between mid-vertebra and inferior slice SMA were statistically significant at each vertebra level, except for T10 in men. S M I HT was uncorrelated with height, whereas S M I H T 2 was negatively correlated with height at all vertebra levels. Both S M I HT and S M I H T 2 were positively correlated with BMI at all vertebra levels. R M I HT was uncorrelated with BMI, weight, and height (minimal positive correlation in women at L3 inf , L4 mid , and L5 inf ) whereas R M I H T 2 was uncorrelated with BMI, but negatively correlated with height and weight at all levels. There were no significant differences in SMA between 18-40 versus 20-40 age groups. Healthy reference values and sarcopenic cutpoints are reported stratified by sex, vertebra level, and age group for each measure. Height to the power of one (SMA/height) is the optimal height adjustment factor for SMA at all levels between T10 mid through L5 inf . The use of S M A / h e i g h t 2 should be discontinued as it retains a significant negative correlation with height and is therefore biased towards identifying sarcopenia in taller individuals. Measurement of SMA at a mid-vertebral slice is significantly different from measurement of SMA at an inferior aspect slice. Reference values should be used for the appropriate slice. We report sarcopenic healthy reference values for skeletal muscle measures at the mid-vertebral and inferior aspect slice for T10 through L5 vertebra levels. Relative muscle index (RMI) equations developed here minimize correlation with both height and BMI, producing unbiased assessments of relative muscle mass across the full range of body sizes. We recommend the use of these RMI equations in other cohorts., (© 2024. The Author(s).)

While it is common for blind and visually impaired (BVI) users to use mobile devices to search for information, little research has explored the accessibility issues they encounter in their interactions with information retrieval systems, in particular digital libraries (DLs). This study represents one of the most comprehensive research projects, investigating accessibility issues, especially help-seeking situations BVI users face in their DL search processes. One hundred and twenty BVI users were recruited to search for information in six DLs on four types of mobile devices (iPhone, iPad, Android phone, and Android tablet), and multiple data collection methods were employed: questionnaires, think-aloud protocols, transaction logs, and interviews. This paper reports part of a large-scale study, including the categories of help-seeking situations BVI users face in their interactions with DLs, focusing on seven types of help-seeking situations related to visual interactions on mobile platforms: difficulty finding a toggle-based search feature, difficulty understanding a video feature, difficulty navigating items on paginated sections, difficulty distinguishing collection labels from thumbnails, difficulty recognizing the content of images, difficulty recognizing the content of graphs, and difficulty interacting with multilayered windows. Moreover, corresponding design recommendations are also proposed: placing meaningful labels for icon-based features in an easy-to-access location, offering intuitive and informative video descriptions for video players, providing structure information about a paginated section, separating collection/item titles from thumbnail descriptions, incorporating artificial intelligence image/graph recognition mechanisms, and limiting screen reader interactions to active windows. Additionally, the limitations of the study and future research are discussed.

Objective: The clinical utility of high-density lipoprotein cholesterol (HDL-C) in risk classification is limited, especially in midlife women. Novel metrics of HDL may better reflect this risk. We clustered a comprehensive profile of HDL metrics into favorable and unfavorable clusters and assessed how these two clusters are related to future subclinical atherosclerosis (carotid intima media thickness [cIMT], interadventitial diameter [IAD], and carotid plaque presence) in midlife women., Methods: Four hundred sixty-one women (baseline age: 50.4 [2.7] years; 272 White, 137 Black, 52 Chinese) from the Study of Women's Health Across the Nation HDL ancillary study who had baseline measures of HDL cholesterol efflux capacity (HDL-CEC), lipid contents (HDL-phospholipids [HDL-PL] and HDL triglycerides [HDL-Tg]), and HDL particle (HDL-P) distribution and size, followed by carotid ultrasound (average 12.9 [SD: 2.6] years later), were included. Using latent cluster analysis, women were clustered into a favorable (high HDL-CEC, HDL-PL, large and medium HDL-P, less HDL-Tg and small HDL-P, larger size) or an unfavorable HDL cluster (low HDL-CEC, HDL-PL, large and medium HDL-P, more HDL-Tg, and small HDL-P, smaller size) and then linked to future subclinical atherosclerosis using linear or logistic regression., Results: The favorable HDL cluster was associated with lower cIMT, IAD, and odds of carotid plaque presence. These associations were attenuated by body mass index, except in Chinese women where the association with cIMT persisted (0.72 [0.63, 0.83])., Conclusions: The association between favorable HDL clusters and a better postmenopausal subclinical atherosclerosis profile is largely explained by body mass index; however, racial/ethnic differences may exist., Competing Interests: Financial disclosure/conflicts of interest: Maria M. Brooks is a Data and Safety Monitoring Board member for Cerus Corporation. The other authors have nothing to disclose., (Copyright © 2024 by The Menopause Society.)

Background: Real-world experience with combinations of short-course rifapentine-based regimens and integrase strand-transfer inhibitor-containing antiretroviral therapy (ART) in management of latent tuberculous infection (LTBI) is limited among people with human immunodeficiency virus (PWH)., Methods: From August 2019 to October 2022, PWH receiving 3 months of weekly rifapentine plus isoniazid (3HP) or 1 month of daily rifapentine plus isoniazid (1HP) in combination with ART were included. The primary outcome was virologic response within 12 months after LTBI treatment; secondary outcomes included treatment completion rate and safety of LTBI regimens., Results: During the study period, 479 PWH (94.6% male; median age, 43 years) were included: 142 received 1HP and bictegravir (BIC)-containing regimens (1HP/BIC group), 46 1HP and dolutegravir (DTG)-containing regimens (1HP/DTG group), 38 3HP and BIC-containing regimens (3HP/BIC group), 214 3HP and DTG-containing regimens (3HP/DTG group), 17 1HP and other ART regimens (1HP/others group), and 22 3HP/other ART regimens (3HP/others group). In the intention-to-treat analysis, the proportions of PWH maintaining plasma HIV-1 RNA <200 copies/mL within 12 months after LTBI treatment completion were 96.5% (1HP/BIC), 100% (1HP/DTG), 100% (3HP/BIC), 95.8% (3HP/DTG), 100% (1HP/others), and 100% (3HP/others). The overall completion rates were >80% for all treatment groups, whereas >50% of the included PWH experienced any adverse event. LTBI regimens and ART combinations were not associated with virologic response and completion rate., Conclusions: Combinations of short-course rifapentine-based regimens and integrase strand-transfer inhibitor-containing ART maintained viral suppression for most PWH within 12 months of LTBI treatment completion with low rates of grade 3 or higher adverse events., Competing Interests: Potential conflicts of interest. C. C. H. has received research support from Gilead Sciences and speaker honoraria from Gilead Sciences and served on advisory boards for Gilead Sciences. H. Y. S. has received research support from Gilead Sciences. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Antibiotic overprescription in China has long been considered a problem on the supply side, linked to the financial incentives of physicians. Based on the conversation analysis of 187 video-recorded naturally occurring medical consultations in Chinese paediatric primary care settings, this study finds that the driving force behind the problem of antibiotic overprescription in China has changed. Physicians use a low-authority communication style to recommend treatment, displaying a low level of medical authority and a willingness to accommodate caregivers' preferences in antibiotic prescribing decisions. The problem is now attributed to physician-caregiver interaction, doctor-patient relationship and the antibiotic-saturated prescribing culture. Practice implications involve deepening the understanding of the evolving nature of the antibiotic overprescription problem in China, building trust between physicians and patients/caregivers in order to facilitate the physicians' role as the gatekeeper of antibiotics and providing training programmes to help physicians develop effective communication skills., (© 2023 Foundation for the Sociology of Health & Illness.)

Objectives: WHO has recommended same-day antiretroviral therapy (SDART) initiation since 2017; however, higher attrition rates were noted in developing countries., Methods: We included newly diagnosed people with HIV (PWH) from 2018 to 2022 at 18 hospitals around Taiwan. SDART initiation was defined as starting ART on the same day of HIV diagnosis and rapid initiation as starting ART within 14 days of diagnosis. A composite unfavorable outcome was defined as death after 30 days of diagnosis, loss to follow-up (LTFU), or virologic failure or rebound at 12 months., Results: At 12 months, PWH on SDART initiation and those on rapid ART initiation showed similar rates of engagement in care with plasma HIV-1 RNA <50 copies/mL (87.5% vs 87.7%) and composite unfavorable outcome (7.7% vs 7.7%). PWH aged >30 years were less likely to have LTFU (aHR 0.44, 95% CI 0.28-0.70). PWH aged >30 years (aHR 0.59, 95% CI 0.41-0.85) and gay, bisexual, and men who have sex with men (GBMSM) (aHR 0.50, 95% CI 0.32-0.79) were less likely to have composite unfavorable outcomes., Conclusions: SDART and rapid ART initiation resulted in comparable clinical outcomes and viral suppression rates. PWH aged >30 years and GBMSM were less likely to have unfavorable outcomes., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective: To investigate the relationship between the expression levels of Plakoglobin protein in residual lesions after neoadjuvant chemotherapy (NAC) and the prognosis of breast cancer patients. Methods: Clinical and pathological data from 174 breast cancer patients who underwent surgery after receiving NAC at the Cancer Hospital of Chinese Academy of Medical Sciences from January 2009 to December 2017 were collected. The expression level of Plakoglobin in residual cancer lesions was evaluated by immunohistochemistry. The correlation between Plakoglobin expression level and clinicopathological features was analyzed. Survival analysis was performed using the Kaplan-Meier method, and Cox proportional hazard regression models were used for factor analysis. Results: Among the 174 patients, 140 had low expression of Plakoglobin, and 34 had high expression. The median disease-free survival (DFS) and overall survival (OS) in the Plakoglobin low expression group were 59.46 and 71.68 months, respectively, both of which were higher than those in the high expression group (36.58 and 47.26 months, respectively, both P <0.05). Univariate analysis showed that Plakoglobin expression, pathological N stage, lymphovascular invasion status, histological grade, Ki-67, and molecular subtypes were associated with OS (all P <0.05), while pathological N stage, histological grade, and Ki-67 were associated with DFS (all P <0.05). Multivariate analysis revealed that Plakoglobin expression ( HR =2.438, 95% CI: 1.256-4.735, P =0.008) was an independent predictor for OS, and Ki-67 ( HR =2.228, 95% CI: 1.316-3.773, P =0.003) was an independent predictor for DFS. Conclusion: In breast cancer patients with residual lesions after NAC, those with low Plakoglobin expression have relatively longer OS and Plakoglobin is an independent prognostic factor for OS.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines based on variant strains have been in use as booster doses to update immunity against circulating variants. Here we present the results of a phase one prospective, randomized, and open-labeled trial to study the safety and immunogenicity of a booster dose consisting of a subunit vaccine based on the stabilized prefusion SARS-CoV-2 spike protein, MVC-COV1901, or its Beta version, MVC-COV1901-Beta. Participants aged ≥18 and <55 years who received two or three prior doses of MVC-COV1901 vaccines were enrolled and were to receive a booster dose of either 15 mcg of MVC-COV1901, 15 mcg, or 25 mcg of MVC-COV1901-Beta in a 1:1:1 ratio. Adverse reactions after either MVC-COV1901 or MVC-COV1901-Beta booster doses after two or three doses of MVC-COV1901 were comparable and mostly mild and transient. At four weeks after the booster dose, participants with two prior doses of MVC-COV1901 had higher levels of neutralizing antibodies against ancestral SARS-CoV-2, Beta, and Omicron variants than participants with three prior doses of MVC-COV1901, regardless of the type of booster used. MVC-COV1901 and MVC-COV1901-Beta can both be effectively used as booster doses against SARS-CoV-2, including the BA.4/BA.5 Omicron variants.

Background: Implantable cardioverter-defibrillation (ICD) shocks after left ventricular assist device therapy (LVAD) are associated with adverse clinical outcomes. Little is known about the association of pre-LVAD ICD shocks on post-LVAD clinical outcomes and whether LVAD therapy affects the prevalence of ICD shocks., Objectives: The purpose of this study was to determine whether pre-LVAD ICD shocks are associated with adverse clinical outcomes post-LVAD and to compare the prevalence of ICD shocks before and after LVAD therapy., Methods: Patients 18 years or older with continuous-flow LVADs and ICDs were retrospectively identified within the University of Pittsburgh Medical Center system from 2006-2020. We analyzed the association between appropriate ICD shocks within 1 year pre-LVAD with a primary composite outcome of death, stroke, and pump thrombosis and secondary outcomes of post-LVAD ICD shocks and ICD shock hospitalizations., Results: Among 309 individuals, average age was 57 ± 12 years, 87% were male, 80% had ischemic cardiomyopathy, and 42% were bridge to transplantation. Seventy-one patients (23%) experienced pre-LVAD shocks, and 69 (22%) experienced post-LVAD shocks. The overall prevalence of shocks pre-LVAD and post-LVAD were not different. Pre-LVAD ICD shocks were not associated with the composite outcome. Pre-LVAD ICD shocks were found to predict post-LVAD shocks (hazard ratio [HR] 5.7; 95% confidence interval [CI] 3.42-9.48; P <.0001) and hospitalizations related to ICD shocks from ventricular arrhythmia (HR 10.34; 95% CI 4.1-25.7; P <.0001)., Conclusion: Pre-LVAD ICD shocks predicted post-LVAD ICD shocks and hospitalizations but were not associated with the composite outcome of death, pump thrombosis, or stroke at 1 year. The prevalence of appropriate ICD shocks was similar before and after LVAD implantation in the entire cohort., (© 2023 Heart Rhythm Society. Published by Elsevier Inc.)

Background Over the next few years, atrial fibrillation (AF)-related morbidity and costs will increase significantly. Thus, it is prudent to examine the impact of AF treatment on health care resource use. This study examined the impact of AF ablation on hospitalization, length of stay, and resource use for patients undergoing AF ablation in a multihospital system. Methods and Results In an observational analysis, outcomes of total, cardiovascular, and AF hospitalizations, emergency department visits, and length of stay were compared for 3417 patients between 12 months before and 24 months following AF ablation. Use of electrical cardioversions and antiarrhythmic use were also compared 1 year before to 2 years after AF ablation. There were fewer total (0.7±1.3 versus 0.3±0.7; P <0.001), cardiovascular (0.7±1.2 versus 0.2±0.6; P <0.001), and AF (0.6±1.1 versus 0.1±0.3; P <0.001) hospitalizations and emergency department visits (0.8±2.1 versus 0.4±0.9; P <0.001) per patient-year for the 2 years following AF ablation compared with 1 year before. Average length of stay per patient-year (1.4±7.9 versus 3.6±5.3 days; P <0.0001), the percentage of patients on antiarrhythmic therapy (21.2% versus 58.5%; P <0.0001), and those undergoing electrical cardioversions (16.1% versus 28.1%; P <0.0001) were lower 2 years following AF ablation versus 1 year before. Conclusions We noted a decrease in total, cardiovascular, and AF hospitalizations and health care resource use during the 2-year period after index AF ablation, compared with the 1 year before. AF ablation may portend a decline in patient morbidity and health care costs.

Introduction and Hypothesis: Our objective was to evaluate the amount of opioids used by patients undergoing surgery for pelvic floor disorders and identify risk factors for opioid consumption greater than the median., Methods: This was a prospective cohort study of 18- to 89-year-old women undergoing major urogynecological surgery between 1 November2020 and 15 October 2021. Subjects completed one preoperative questionnaire ("questionnaire 1") that surveyed factors expected to influence postoperative pain and opioid use. At approximately 1 and 2 weeks following surgery, patients completed two additional questionnaires ("questionnaire 2" and "questionnaire 3") about their pain scores and opioid use. Risk factors for opioid use greater than the median were assessed. Finally, a calculator was created to predict the amount of opioid used at 1 week following surgery., Results: One hundred and ninety patients were included. The median amount of milligram morphine equivalents prescribed was 100 (IQR 100-120), whereas the median amount used by questionnaire 2 was 15 (IQR 0-50) and by questionnaire 3 was 20 (IQR 0-75). On multivariate logistic regression, longer operative time (aOR 1.64 per hour of operative time, 95% CI 1.07-2.58) was associated with using greater than the median opioid consumption at the time of questionnaire 2; whereas for questionnaire 3, a diagnosis of fibromyalgia (aOR=16.9, 95% CI 2.24-362.9) was associated. A preliminary calculator was created using the information collected through questionnaires and chart review., Conclusions: Patients undergoing surgery for pelvic floor disorders use far fewer opioids than they are prescribed., (© 2023. The International Urogynecological Association.)

Background: The short-term impact of sofosbuvir (SOF)-based direct-acting antivirals (DAAs) combined with antiretroviral therapy (ART) on renal function in patients with HIV/HCV-coinfection remains controversial., Methods: This multicenter, retrospective study aimed to sequentially record the estimated glomerular filtration rate (eGFR) at baseline, end of therapy (EOT), 12 weeks off-treatment (SVR12), and at time points after SVR12 (post-SVR12) and to identify the factors associated with an eGFR decline to <60 ml/min/1.73 m 2 in HIV/HCV-coinfected patients receiving DAAs. The evolution of mean eGFRs between different ART and DAAs combinations among patients of different HIV transmission routes were compared using a generalized linear mixed effects model. The periods between baseline and EOT, between EOT and post-SVR12, and between baseline and post-SVR12 were defined as the on-treatment, post-treatment, and all-course periods, respectively. Acute kidney disease (AKD) was defined as a decline of eGFR to <60 ml/min/1.73 m 2 ., Result: A total of 445 patients with baseline eGFRs >60 ml/min/1.73 m 2 were included. We found that eGFRs declined during the on-treatment period in the tenofovir-containing ART and SOF-based DAA groups. There were no differences in the slope coefficient during the on-treatment and post-treatment periods among all risk groups except for people who inject drug. Increasing age and plasma HIV RNA >20 copies/ml before DAA treatment were factors independently associated with AKD during the on-treatment period while increasing age was independently associated with AKD during the all-course period., Conclusion: Only increasing age was an independent factor associated with AKD among HIV/HCV-coinfected patients during and after DAA treatments., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2023. Published by Elsevier B.V.)

In a wireless sensor network (WSN), geocasting is a location-based routing protocol used for data collection or information delivery. In geocasting, a target region usually contains many sensor nodes with limited battery capacity, and sensor nodes in multiple target regions need to transmit data to the sink. Therefore, how to use location information to construct an energy efficient geocasting path is a very important issue. FERMA is a geocasting scheme for WSNs based on Fermat points. In this paper, an efficient grid-based geocasting scheme for WSNs, which is called GB-FERMA, is proposed. The scheme uses the Fermat point theorem to search for the specific nodes as Fermat points in a grid-based WSN, and it selects the optimal relay nodes (gateways) in the grid structure to realize energy-aware forwarding. In the simulations, when the initial power 0.25 J, the average energy consumption of GB-FERMA is about 53% of FERMA-QL, 37% of FERMA, and 23% of GEAR; however, when with the initial power 0.5 J, the average energy consumption of GB-FERMA is about 77% of FERMA-QL, 65% of FERMA, and 43% of GEAR. The proposed GB-FERMA can effectively reduce the energy consumption and thus prolong the lifetime of the WSN.

Background: Atrial fibrillation (AF) affects millions of Americans each year and can lead to high levels of resource utilization through emergency department (ED) visits and inpatient stays., Hypothesis: We hypothesized that referral of patients to a dedicated Center for AF from the ED would reduce costs of care., Methods: The University of Pittsburgh Center for AF serves as a rapid referral center for patients with AF to avoid unnecessary inpatient admissions and provide specialized care. Patients that presented to the ED with AF and met prespecified criteria were directed to rapid outpatient follow-up instead of inpatient admission. The primary outcome of interest was 30-day total costs. Secondary outcomes included outpatient costs, inpatient costs, 90-day costs, and inpatient stay characteristics., Results: We identified 96 patients (median age 65, 38% women) referred to the center for AF for a new diagnosis of AF between October 2017 and December 2019 and matched 96 control patients. After 30 days of follow-up, patients referred to the center for AF had a lower average cost ($619 vs. $1252, p < 0.001) compared to controls, driven by lower costs of ED care tempered by slightly higher outpatient costs. Thirty-day admissions and lengths of stay were also lower. These differences were persistent at 90 days., Conclusion: Directing patients with AF that present to the ED to follow-up at a dedicated Center for AF significantly reduced overall costs, while reducing subsequent inpatient admissions and total lengths of stay in the hospital., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Objectives: Protein disulfide isomerase (PDI) family members are specific endoplasmic reticulum proteins associated with inflammation, obesity, and cancer. In HIV infection, the role of PDI family A, member 4 (PDIA4), is unclear. This study aimed to clarify the association between plasma PDIA4 levels and inflammation in people living with HIV (PLWH)., Methods: In this study, 287 PLWH and 74 healthy participants were enrolled. The plasma PDIA4 values, demographic data, laboratory data, and other inflammatory markers were recorded. The association between PDIA4 level and inflammatory extent was analyzed using logistic regression and Spearman rank-order correlations. Other results were analyzed using Student's t-test or chi-square test., Results: In PLWH, the PDIA4 levels were positively associated with the inflammatory markers, interleukin 6 (r = 0.209, p = 0.001), and tumor necrosis factor-α (r = 0.162, p = 0.01) levels, but not with high-sensitivity C-reactive protein levels. Moreover, the plasma PDIA4 level of PLWH decreased after anti-viral treatment (p = 0.0001)., Conclusion: Plasma PDIA4 levels are closely associated with inflammation in PLWH and have a positive correlation with the viral load during anti-viral therapy., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: This study aimed to assess the safety and immunogenicity of MVC-COV1901, a recombinant COVID-19 protein vaccine, containing S-2P protein adjuvanted with CpG 1018 and aluminum hydroxide, for people living with HIV (PWH)., Methods: A total of 57 PWH of ≥20 years of age who are on stable antiretroviral therapy were compared with 882 HIV-negative participants. Participants received two doses of MVC-COV1901 28 days apart., Results: No vaccine-related serious adverse events (SAEs) were recorded. Seroconversion rates (SCRs) of 100% and 99.8% were achieved in PWH and comparators, respectively, 28 days after the second dose. After adjusting for sex, age, BMI category, and comorbidity, the adjusted GMT ratio of comparator/PWH was 3.2 (95% CI 2.5-4). A higher CD4/CD8 ratio was associated with a higher GMT (R = 0.27, p = 0.039). MVC-COV1901 has shown robust safety but elicited weaker immune responses in PWH., Conclusions: Further investigations may be needed to determine whether PWH require distinct immunization strategies with improved immunogenicity. The main study is registered at ClinicalTrials.gov (NCT04695652).

A wireless sensor network (WSN) consists of a very large number of sensors which are deployed in the specific area of interest. A sensor is an electronic device equipped with a small processor and has a small-capacity memory. The WSN has the functions of low cost, easy deployment, and random reconfiguration. In this paper, an energy-efficient load balancing tree-based data aggregation scheme (LB-TBDAS) for grid-based WSNs is proposed. In this scheme, the sensing area is partitioned into many cells of a grid and then the sensor node with the maximum residual energy is elected to be the cell head in each cell. Then, the tree-like path is established by using the minimum spanning tree algorithm. In the tree construction, it must meet the three constraints, which are the minimum energy consumption spanning tree, the network depth, and the maximum number of child nodes. In the data transmission process, the cell head is responsible for collecting the sensing data in each cell, and the collected data are transmitted along the tree-like path to the base station (BS). Simulation results show that the total energy consumption of LB-TBDAS is significantly less than that of GB-PEDAP and PEDAP. Compared to GB-PEDAP and PEDAP, the proposed LB-TBDAS extends the network lifetime by more than 100%. The proposed LB-TBDAS can avoid excessive energy consumption of sensor nodes during multi-hop data transmission and can also avoid the hotspot problem of WSNs.

Antibiotic resistance is one of the most serious global public health crises. Inappropriate use of antibiotics is an important contributor. Using a cross-sectional survey, we recruited 3056 caregivers from 21 provinces in China to complete a questionnaire pertaining to their most recent medical visits for children's acute respiratory tract infection (ARTI) symptoms in October 2013. The findings show that the prevalence of caregivers giving children non-prescribed antibiotics before their medical visit was as high as 38%. Caring for an older child and having lower educational attainment increased the likelihood of self-medication with antibiotics; among Chinese residential areas, caregivers living in tier 2 urban districts were most likely to administer non-prescribed antibiotics before their visit. Physicians' prescribing of antibiotics was significantly associated with caregivers' self-reported pre-visit use of non-prescribed antibiotics. Misuse should be addressed by regulating the sale of antibiotics and improving communication at medical consultations.

Background Utility of high-density lipoprotein cholesterol (HDL-C) in assessing the antiatherogenic properties of HDL may be limited in midlife women. Novel metrics of HDL function, lipid contents, and subclasses may better reflect the atheroprotective capacities of HDL, supporting the need to evaluate how cardiovascular health affects these metrics in women. We assessed the relationship of early midlife Life's Simple 7 (LS7) score and its health behavior components with future HDL function (HDL-cholesterol efflux capacity), HDL-phospholipid, HDL-triglyceride, HDL particles (HDL-P) and size, and the relationship between LS7 score and changes in HDL metrics over time. Methods and Results We analyzed 529 women (baseline age: 46.4 [2.6] years, 57% White) from the SWAN HDL (Study of Women's Health Across the Nation HDL) study who had baseline LS7 followed by future repeated HDL metrics. Multivariable linear mixed models were used. Higher LS7 score was associated with favorable future HDL profile (higher HDL-phospholipid, total HDL-P and large HDL-P, lower HDL-triglyceride, and larger overall HDL size). Ideal body mass index was associated with higher HDL-cholesterol efflux capacity, HDL-phospholipid, and large HDL-P, lower HDL-triglyceride and small HDL-P, and larger overall HDL size. Ideal physical activity was associated with higher HDL-phospholipid, and total, large, and medium HDL-P. Ideal smoking was associated with less HDL-triglycerides. Diet was not related to HDL metrics. Higher LS7 score and ideal body mass index were associated with slower progression of HDL size over time. Conclusions Novel HDL metrics may better reflect the clinical utility of HDL. Improving lifestyle at midlife, particularly maintaining ideal body mass index, is associated with better future HDL phenotype.

Objective . Seven types of MRI artifacts, including acquisition and preprocessing errors, were simulated to test a machine learning brain tumor segmentation model for potential failure modes. Introduction . Real-world medical deployments of machine learning algorithms are less common than the number of medical research papers using machine learning. Part of the gap between the performance of models in research and deployment comes from a lack of hard test cases in the data used to train a model. Methods . These failure modes were simulated for a pretrained brain tumor segmentation model that utilizes standard MRI and used to evaluate the performance of the model under duress. These simulated MRI artifacts consisted of motion, susceptibility induced signal loss, aliasing, field inhomogeneity, sequence mislabeling, sequence misalignment, and skull stripping failures. Results . The artifact with the largest effect was the simplest, sequence mislabeling, though motion, field inhomogeneity, and sequence misalignment also caused significant performance decreases. The model was most susceptible to artifacts affecting the FLAIR (fluid attenuation inversion recovery) sequence. Conclusion . Overall, these simulated artifacts could be used to test other brain MRI models, but this approach could be used across medical imaging applications., Competing Interests: The authors declare that there is no conflict of interest regarding the publication of this article.

Background: Coronavirus disease 2019 (COVID-19) is a global pandemic. Breast cancer is the most commonly diagnosed malignant cancer in China. Considering the specific national conditions, no evidence is available for factors associated with COVID-19 vaccination in patients with breast cancer., Methods: This was a cross-sectional survey, fielded from June 21 through June 27, 2021. A total of 944 nationally representative samples of Chinese breast cancer patients participating in the survey were included. Participant surveys included questions addressing who finished COVID-19 vaccination with the question "Have you taken the COVID-19 vaccine?", and response options were "Yes" and "No"., Results: Overall, 730 (77.33%) women with breast cancer were unvaccinated, and only 214 (22.67%) were vaccinated with the COVID-19 vaccine. After adjusting for potential confounders, including both sociodemographic and clinical characteristics, we found that external support, including positive doctor suggestions (odds ratio (OR): 5.52; 95% confidence interval (CI): 3.50 - 8.71; P < 0.0001), positive support from surrounding people (OR: 11.65; 95% CI: 7.57 - 17.91; P < 0.0001), and negative initiative from the community (OR: 0.15; 95% CI: 0.06 - 0.35; P < 0.0001), was associated with COVID-19 vaccination rates among breast cancer patients. These results remain stable in subgroup analyses. We found that most participants (82.52%) understood the necessity of COVID-19 vaccinations in China was strong; however, the recognition regarding the COVID-19 vaccine showed different patterns between vaccinated and unvaccinated participants., Conclusions: Our findings suggest external support, including vaccination suggestions from surgeons or oncologists, vaccination suggestions from associated people, and residents' committee mandated vaccinations, was associated with the COVID-19 vaccination rates. Interventions regarding these factors and improving publicity as well as education regarding COVID-19 vaccines among breast cancer patients are warranted., Competing Interests: The authors declare no conflict of interest., (Copyright 2022, Wang et al.)

This is the first report describing atrioventricular junction ablation during sinus rhythm in a patient with persistent left superior vena cava. Electroanatomic mapping systems and awareness of anatomic and electrogram variations may decrease procedure time, decrease fluoroscopy time, and minimize delivery of ineffective ablation lesions., Competing Interests: Dr. Jain receives research support from Abbott, Boston Scientific, and Medtronic. The remaining authors have no conflicts of interest., (© 2022 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of Japanese Heart Rhythm Society.)

Context: The menopause transition is accompanied by declines in the atheroprotective features of high-density lipoprotein (HDL), which are linked to deleterious cardiovascular (CV) outcomes., Objective: This work aimed to assess the relationship between abdominal and CV visceral adipose tissues (VAT) with future HDL metrics in midlife women, and the role of insulin resistance (IR) on these associations., Methods: Temporal associations compared abdominal and CV fat with later measures of HDL metrics. This community-based cohort comprised 299 women, baseline mean age 51.1 years (SD: 2.8 years), 67% White, 33% Black, from the Study of Women's Health Across the Nation (SWAN) HDL ancillary study. Exposures included volumes of abdominal VAT, epicardial AT (EAT), paracardial AT (PAT), or perivascular AT (PVAT). Main outcomes included HDL cholesterol efflux capacity (HDL-CEC); HDL phospholipids (HDL-PL), triglycerides (HDL-Tgs), and cholesterol (HDL-C); apolipoprotein A-I (ApoA-I), and HDL particles (HDL-P) and size., Results: In multivariable models, higher abdominal VAT was associated with lower HDL-CEC, HDL-PL, HDL-C, and large HDL-P and smaller HDL size. Higher PAT was associated with lower HDL-PL, HDL-C, and large HDL-P and smaller HDL size. Higher EAT was associated with higher small HDL-P. Higher PVAT volume was associated with lower HDL-CEC. The Homeostatic Model Assessment of Insulin Resistance partially mediated the associations between abdominal AT depots with HDL-CEC, HDL-C, large HDL-P, and HDL size; between PVAT with HDL-CEC; and PAT with HDL-C, large HDL-P, and HDL size., Conclusion: In midlife women, higher VAT volumes predict HDL metrics 2 years later in life, possibly linking them to future CV disease. Managing IR may preclude the unfavorable effect of visceral fat on HDL metrics., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Endocrine Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)