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Abstract Background This study aims to evaluate the impact of a home-based, post-discharge early intervention (EI) program on reducing parental stress levels in families with preterm infants born between 28+ 0 and 31+ 6 weeks gestational age. Methods A randomized controlled trial was conducted, with families randomly allocated to either the EI or standard care (SC) group. A term reference group was also recruited for comparison. The Parental Stress Index-Short Form was used to assess parental stress levels, yielding a total stress score and three subdomain scores. Assessment was performed at baseline, at the 60-day mark of the study, and when the infants reached six corrected months of age. Parents in the reference group were assessed only at six months of corrected age for infants. The intervention comprised three sections: intellectual, physical, and social training, which was administered to the infants in the EI group immediately after discharge and to those in the SC group after 60 days of enrollment. Results Seventy-three families were enrolled in this study, with 37 allocated to the EI group, and 36 to the SC group. Prior to intervention, higher stress levels were reported by mothers in both groups than fathers, with no difference observed between the EI and SC groups. Re-assessment performed at 60 days of the study showed that mothers and fathers in the EI group had significantly lower total stress score than those in the SC group (82.00 ± 5.64 vs. 94.26 ± 7.99, p

Abstract Artificial intelligence (AI)-based diagnostic systems have been reported to improve fundus disease screening in previous studies. This multicenter prospective self-controlled clinical trial aims to evaluate the diagnostic performance of a deep learning system (DLS) in assisting junior ophthalmologists in detecting 13 major fundus diseases. A total of 1493 fundus images from 748 patients were prospectively collected from five tertiary hospitals in China. Nine junior ophthalmologists were trained and annotated the images with or without the suggestions proposed by the DLS. The diagnostic performance was evaluated among three groups: DLS-assisted junior ophthalmologist group (test group), junior ophthalmologist group (control group) and DLS group. The diagnostic consistency was 84.9% (95%CI, 83.0% ~ 86.9%), 72.9% (95%CI, 70.3% ~ 75.6%) and 85.5% (95%CI, 83.5% ~ 87.4%) in the test group, control group and DLS group, respectively. With the help of the proposed DLS, the diagnostic consistency of junior ophthalmologists improved by approximately 12% (95% CI, 9.1% ~ 14.9%) with statistical significance (P

Abstract Purpose To determine whether the rare NLRP3-Associated Autoinflammatory Disease (NLRP3-AID) is associated with retinal changes and to assess the ocular involvement. Methods A retrospective cohort study of 20 patients(40 eyes) diagnosed with rare NLRP3-AID at Peking Union Medical College Hospital, from April 2015 to August 2022. Patients underwent a comprehensive ophthalmological examination, including visual acuity, intraocular pressure examination, slit-lamp examination, fundus photography, optical coherence tomography(OCT), and fluorescence angiography (FA). Some patients also underwent optical coherence tomography angiography (OCTA). Results This study analyzed 40 eyes of 20 patients (11 [55.0%] male; median age, 25.0 years [range, 12–52 years]) and 13 patients (26 eyes, 65%) demonstrated ocular involvement. The most common ophthalmologic manifestation was conjunctivitis (22 eyes, 84.6%), followed by papilledema (14 eyes, 53.8%), retinopathy (10 eyes, 38.5%), optic atrophy (6 eyes, 23.1%), uveitis (4 eyes, 15.4%), reduced pupil light reflex (3 eyes, 11.5%) and cataracts (2 eyes, 7.7%). Ocular involvement was bilateral in 11 patients (55.0%). Five kinds of retinal lesions were seen in 5 patients (10 eyes, 25%) with NLRP3-AID, including peripheral retinal vascular leakage, microaneurysms, macular ischemia, macular epiretinal membrane formation and drusen. Conclusions Peripheral retinal vascular leakage, macular ischemia, microaneurysms and drusen are newly identified retinal findings in patients with NLRP3-AID, which suggests the importance of detailed retinal examination in these patients.

The relationship between vitamin A supplementation and myopia has been a topic of debate, with conflicting and inconclusive findings. We aimed to determine whether there is a causal relationship between vitamin A supplementation and the risk of myopia using Mendelian randomization (MR) and meta-analytical methods. Genetic variants from the UK Biobank and FinnGen studies associated with the response to vitamin A supplementation were employed as instrumental variables to evaluate the causal relationship between vitamin A supplementation and myopia. Fixed-effects meta-analysis was then used to combine MR estimates from multiple sources for each outcome. The meta-analysis of MR results found no convincing evidence to support a direct causal relationship between vitamin A supplementation and myopia risk (odds ratio (OR) = 0.99, 95% confidence interval (CI) = 0.82–1.20, I2 = 0%, p = 0.40). The analysis of three out of the four sets of MR analyses indicated no direction of causal effect, whereas the other set of results suggested that higher vitamin A supplementation was associated with a lower risk of myopia (OR = 0.002, 95% CI 1.17 × 10−6–3.099, p = 0.096). This comprehensive MR study and meta-analysis did not find valid evidence of a direct association between vitamin A supplementation and myopia. Vitamin A supplementation may not have an independent effect on myopia, but intraocular processes associated with vitamin A may indirectly contribute to its development.

Regenerating family protein 3 A (Reg3A) is highly expressed in a variety of organs and inflammatory tissues, and is closely related to tumorigenesis and cancer progression. However, clinical statistics show that high expression of Reg3A is associated with better prognosis in colorectal cancer (CRC) patients, suggesting a tumor-suppressive effect. The precise action and underlying mechanism of Reg3A in CRC remain controversial. The present study sought to investigate the relationship among Reg3A expression, CRC development, and immune cell alteration in patients using the TCGA, GEPIA, PrognoScan, TIMER and TISIDB databases. Reg3A-overexpressing LoVo cell line (LoVo-Reg3A), a representative of colon adenocarcinoma (COAD), was constructed and the action of Reg3A was assessed in a xenograft nude mouse model. Our bioinformatical analyses revealed that Reg3A upregulation is highly associated with CRC, along with increased frequency of immune cell infiltration. In the xenograft nude mice, Reg3A overexpression offered a tumor-suppressive effect by inhibiting cell proliferation and promoting apoptosis. The result of RNA-seq suggested a positive regulation of leukocytes and an upregulation of T cells in LoVo-Reg3A tumor tissue. CD4+ and CD8+ T cells in tumors, splenic Reg3A-reactive IFN-γ+/CD4+ T cells, and serum TNF-α, IFN-γ and IL-17 were significantly increased by Reg3A overexpression. In the ex vivo co-culture experiment, elevated cytotoxic effect, increased proportion of CD3ε+ T cells, and upregulated expressions of TNF-α, IFN-γ and IL-17 were detected in the PBMCs isolated from LoVo-Reg3A cell-xenografted nude mice. In conclusion, high expression of Reg3A could activate and recruit T cells in COAD leading to the cytotoxic tumor-suppressive effect.

Objective Hyporesponsiveness to erythropoiesis-stimulating agents (ESAs) is a prevalent problem affecting hemodialysis (HD) patients. Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor that stimulates erythropoiesis and regulates iron metabolism. We explored the ability of roxadustat to increase the hemoglobin (Hb) concentration in ESA-hyporesponsive patients undergoing HD and assessed its effect on iron metabolism and inflammation. Methods This prospective study included 30 patients with ESA-hyporesponsive anemia who had been undergoing stable dialysis. All patients received roxadustat three times per week for 24 weeks. The primary endpoint was the mean change in Hb from baseline to the average level over weeks 20 to 24. Iron metabolism markers, C-reactive protein, interleukin (IL)-6, and safety were also assessed. Results At week 24, roxadustat treatment resulted in a 2.5 ± 1.3 g/dL increase in the Hb level. In total, 28 of 30 patients (93.3%) had an Hb level increase of more than 1.0 g/dL from baseline. Seventeen patients (56.7%) met the endpoint, with a mean Hb level of at least 10.0 g/dL. Iron metabolism and IL-6 levels were also improved. Conclusions Oral roxadustat is effective for ESA-hyporesponsive anemia in maintenance HD patients and may also improve iron metabolism and IL-6 levels.

Abstract Our previous research demonstrated that NOD-like receptor family CARD domain-containing protein 4 (NLRC4) inflammasome was overexpressed in renal tissues of patients with diabetic nephropathy (DN). This study further investigated the effect of circRNAs-miRNAs interaction on NLRC4 and their potential mechanisms. DN mice models were first established using STZ. Then, pyroptosis related marker expression was detected using qPCR, western blot (WB), and immunohistochemistry analysis. After that, differentially expressed circRNAs, miRNAs, and mRNAs were investigated using next-generation sequencing. Additionally, the function and potential mechanism of circ_0000181 and miR-667-5p on pyroptosis were measured in vitro DN cell model using MTS, WB, and Enzyme-linked immunosorbent assay. There was an apparent elevation of NLRC4, Caspase1, IL-1β, and IL-18 levels in DN mice. The next-generation sequencing results revealed that there were 947 circRNAs and 390 miRNAs significantly different between the DN and sham kidney tissue, of which circ_0000181 and miR-667-5p had potential targeting effects with NLRC4. Dual-luciferase and functional rescue experiments demonstrated that circ_0000181 promoted NLRC4 inflammasome activation via competitive sponge of miR-667-5p, promoted the release of IL-1β and IL-18, and caused pyroptosis. Altogether, circ_0000181 regulates miR-667-5p/NLRC4 axis to promote pyroptosis progression in DN.

PurposeTo assess the optimal time of intravitreal conbercept (IVC) treatment prior to pars plana vitrectomy (PPV) in patients with severe proliferative diabetic retinopathy (PDR).MethodThis study was exploratory in nature. Forty-eight consecutive patients (48 eyes) with PDR were divided into four groups according to different IVC times (0.5 mg/0.05 mL) before PPV: group A (3 days), group B (7 days), group C (14 days), and group D (non-IVC). Intraoperative and postoperative effectiveness were assessed, and vitreous VEGF concentrations were detected.ResultFor intraoperative effectiveness, groups A and D had a higher incidence of intraoperative bleeding than groups B and C (P = 0.041). Furthermore, groups A-C required less surgical time than group D (P < 0.05). For postoperative effectiveness, group B had a significantly higher proportion of visual acuity that improved or remained unchanged than group D (P = 0.014), and groups A-C had lower proportions of postoperative bleeding than group D. The vitreous VEGF concentration of group B (67.04 ± 47.24 pg/mL) was significantly lower than that of group D (178.29 ± 110.50 pg/mL) (P = 0.005).ConclusionIVC treatment that was administered 7 days preoperatively was associated with better effectiveness and a lower vitreous VEGF concentration than its administration at other time points.

Abstract Purpose Evaluate the efficiency of using an artificial intelligence reading label system in the diabetic retinopathy grading training of junior ophthalmology resident doctors and medical students. Methods Loading 520 diabetic retinopathy patients’ colour fundus images into the artificial intelligence reading label system. Thirteen participants, including six junior ophthalmology residents and seven medical students, read the images randomly for eight rounds. They evaluated the grading of images and labeled the typical lesions. The sensitivity, specificity, and kappa scores were determined by comparison with the participants’ results and diagnosis gold standards. Results Through eight rounds of reading, the average kappa score was elevated from 0.67 to 0.81. The average kappa score for rounds 1 to 4 was 0.77, and the average kappa score for rounds 5 to 8 was 0.81. The participants were divided into two groups. The participants in Group 1 were junior ophthalmology resident doctors, and the participants in Group 2 were medical students. The average kappa score of Group 1 was elevated from 0.71 to 0.76. The average kappa score of Group 2 was elevated from 0.63 to 0.84. Conclusion The artificial intelligence reading label system is a valuable tool for training resident doctors and medical students in performing diabetic retinopathy grading.

Background and purposePathologic myopia (PM) is an international public health issue. This study aimed to analyze PM research trends by reporting on publication trends since 2000 and identifying influential journals, countries, authors, and keywords involved in PM.MethodsA bibliometric analysis was performed to evaluate global production and development trends in PM since 2000 and the keywords associated with PM.ResultsA total of 1,435 publications were retrieved. PM has become a fascinating topic (with relative research interest ranging from 0.0018% in 2000 to 0.0044% in 2021) and a global public health issue. The top three countries with the highest number of publications were China, the USA, and Japan. The journals, authors, and institutions that published the most relevant literature came from these three countries. China exhibited the most rapid increase in the number of publications (from 0 in 2000 to 69 in 2021). Retina published the most papers on PM. Kyoko Ohno-Matsui and Tokyo Medical and Dental University contributed the most publications among authors and institutions, respectively. Based on keyword analysis, previous research emphasized myopic choroidal neovascularization and treatment, while recent hotspots include PM changes based on multimodal imaging, treatment, and pathogenesis. Keyword analysis also revealed that deep learning was the latest hotspot and has been used for the detection of PM.ConclusionOur results can help researchers understand the current status and future trends of PM. China, the USA, and Japan have the greatest influence, based on the number of publications, top journals, authors, and institutions. Current research on PM highlights the pathogenesis and application of novel technologies, including multimodal imaging and artificial intelligence.

PurposeArtificial intelligence (AI) has been applied in the field of retina. The purpose of this study was to analyze the study trends within AI in retina by reporting on publication trends, to identify journals, countries, authors, international collaborations, and keywords involved in AI in retina.Materials and methodsA cross-sectional study. Bibliometric methods were used to evaluate global production and development trends in AI in retina since 2012 using Web of Science Core Collection.ResultsA total of 599 publications were retrieved ultimately. We found that AI in retina is a very attractive topic in scientific and medical community. No journal was found to specialize in AI in retina. The USA, China, and India were the three most productive countries. Authors from Austria, Singapore, and England also had worldwide academic influence. China has shown the greatest rapid increase in publication numbers. International collaboration could increase influence in this field. Keywords revealed that diabetic retinopathy, optical coherence tomography on multiple diseases, algorithm were three popular topics in the field. Most of top journals and top publication on AI in retina were mainly focused on engineering and computing, rather than medicine.ConclusionThese results helped clarify the current status and future trends in researches of AI in retina. This study may be useful for clinicians and scientists to have a general overview of this field, and better understand the main actors in this field (including authors, journals, and countries). Researches are supposed to focus on more retinal diseases, multiple modal imaging, and performance of AI models in real-world clinical application. Collaboration among countries and institutions is common in current research of AI in retina.

Abstract Background Regular membrane peeling vitrectomy for epiretinal membrane (ERM) patients seldom causes large pigment epithelial detachment (PED). We presented an unusual case of the activation of quiescent polypoidal choroidal vasculopathy (PCV) after membrane peeling vitrectomy for ERM, with an uneven therapeutic process. Case presentation A 75-year-old female patient complained of metamorphopsia in her left eye for 2 years. Her best-corrected visual acuity was 20/160 with a moderate nuclear cataract. An irregular ERM and slight PED were shown in optical coherence tomography (OCT). No obvious orange-red lesion was detected. The patient underwent vitrectomy + ERM peeling + cataract surgery. After the operation, large PED emerged, and indocyanine green angiography (ICGA) confirmed PCV. Four monthly injections of intravitreal ranibizumab were administered, but PED persisted. After focal laser therapy targeted to the polyps combined with ranibizumab treatment, PED was absorbed. Conclusions Careful evaluation for PCV before membrane peeling vitrectomy for ERM is important, as indolent PCV may be activated postoperatively. Anti-VEGF therapy accompanied by laser photocoagulation may be more effective for PCV polyps located away from the fovea.

Abstract Objective To prioritize genes that were pleiotropically or potentially causally associated with central corneal thickness (CCT). Methods We applied the summary data-based Mendelian randomization (SMR) method integrating summarized data of genome-wide association study (GWAS) on CCT and expression quantitative trait loci (eQTL) data to identify genes that were pleiotropically associated with CCT. We performed separate SMR analysis using CAGE eQTL data and GTEx eQTL data. SMR analyses were done for participants of European and East Asian ancestries, separately. Results We identified multiple genes showing pleiotropic association with CCT in the participants of European ancestry. CLIC3 (ILMN_1796423; PSMR = 4.15 × 10− 12), PTGDS (ILMN_1664464; PSMR = 6.88 × 10− 9) and C9orf142 (ILMN_1761138; PSMR = 8.09 × 10− 9) were the top three genes using the CAGE eQTL data, and RP11-458F8.4 (ENSG00000273142.1; PSMR = 5.89 × 10− 9), LCNL1 (ENSG00000214402.6; PSMR = 5.67 × 10− 8), and PTGDS (ENSG00000107317.7; PSMR = 1.92 × 10− 7) were the top three genes using the GTEx eQTL data. No genes showed significantly pleiotropic association with CCT in the participants of East Asian ancestry after correction for multiple testing. Conclusion We identified several genes pleiotropically associated with CCT, some of which represented novel genes influencing CCT. Our findings provided important leads to a better understanding of the genetic factors influencing CCT, and revealed potential therapeutic targets for the treatment of primary open-angle glaucoma and keratoconus.

Background: Intraocular pressure (IOP) is a major modifiable risk factor for glaucoma. However, the mechanisms underlying the controlling of IOP remain to be elucidated. Objective: To prioritize genes that are pleiotropically associated with IOP. Methods: We adopted a two-sample Mendelian randomization method, named summary-based Mendelian randomization (SMR), to examine the pleiotropic effect of gene expression on IOP. The SMR analyses were based on summarized data from a genome-wide association study (GWAS) on IOP. We conducted separate SMR analyses using Genotype-Tissue Expression (GTEx) and Consortium for the Architecture of Gene Expression (CAGE) expression quantitative trait loci (eQTL) data. Additionally, we performed a transcriptome-wide association study (TWAS) to identify genes whose cis-regulated expression levels were associated with IOP. Results: We identified 19 and 25 genes showing pleiotropic association with IOP using the GTEx and CAGE eQTL data, respectively. RP11-259G18.3 (PSMR = 2.66 × 10−6), KANSL1-AS1 (PSMR = 2.78 × 10−6), and RP11-259G18.2 (PSMR = 2.91 × 10−6) were the top three genes using the GTEx eQTL data. LRRC37A4 (PSMR = 1.19 × 10−5), MGC57346 (PSMR = 1.19 × 10−5), and RNF167 (PSMR = 1.53 × 10−5) were the top three genes using the CAGE eQTL data. Most of the identified genes were found in or near the 17q21.31 genomic region. Additionally, our TWAS analysis identified 18 significant genes whose expression was associated with IOP. Of these, 12 and 4 were also identified by the SMR analysis using the GTEx and CAGE eQTL data, respectively. Conclusions: Our findings suggest that the 17q21.31 genomic region may play a critical role in the regulation of IOP.

Abstract NLRP3-associated autoinflammatory disease (NLRP3-AID) is a rare autosomal dominant disorder involving multiple systems. We aim to assess the ocular manifestations of Chinese adult patients with NLRP3-AID. Twelve adult patients (> 18 years old) were diagnosed as NLRP3-AID at the Department of Rheumatology, Peking Union Medical College Hospital. All patients underwent ophthalmologic evaluation by an ophthalmologist. Clinical and genetic features of these patients were collected and compared with those from Caucasian population. A total of 7 NLRP3-AID patients (58%) 14 eyes had ocular manifestations. Five NLRP3 variants were identified, and 3 patients (43%) with severe ocular damages were all found to have the NLRP3 T348M variant. The incidences of papilledema and optic atrophy in the Chinese adult NLRP3-AID patients of moderate type were similar to those in the Caucasian NLRP3-AID patients of severe type. This is the first cohort of Chinese adult NLRP3-AID patients with ocular involvement. Ocular manifestations were diverse and even severe in NLRP3-AID, particularly in patients with the moderate phenotype, and may have relationship with genotypes. Awareness of these manifestations by rheumatologists and ophthalmologists could help to avoid the irreversible ocular damages.

Purpose: To explore the impact of coronavirus disease 2019 (COVID-19) on the prognosis of patients with neovascular age-related macular degeneration (nAMD) and polypoidal choroidal vasculopathy (PCV), and share the experience in managing them during pandemics. Method: This is a retrospective study of nAMD and PCV patients treated at Peking Union Medical College Hospital from 31 December 2019 to 1 August 2020. Baseline demographic and clinical characteristics, best corrected visual acuity (BCVA), optical coherence tomography (OCT) features, duration of delayed treatment and number of anti-vascular endothelial growth factor (VEGF) injections were analyzed. Results: A total of 130 nAMD patients (155 eyes) and 76 PCV patients (89 eyes) were identified. Compared to the conditions before COVID-19, the BCVA of delayed cases decreased significantly, and the proportion of patients presenting with sub-macular scar was significantly greater in the delayed treatment group ( p

Objectives:NLRP3-associated autoinflammatory disease (NLRP3-AID) and Behçet's syndrome (BS) both belong to autoinflammatory diseases and rarely co-occur. Here we reported a Chinese pedigree of NLRP3-AID presented with BS.Methods: We recorded a Chinese pedigree of NLRP3-AID presented with BS. Whole-exome sequencing was performed to find the hereditary susceptibility gene, and Sanger sequencing was performed on a consecutive cohort of 30 BS patients. We also reviewed the English literature on vasculitis associated with NLRP3-AID.Results: The proband was a 45-year-old Chinese Han woman. She and her 12-year-old daughter presented with recurrent fevers, cold-induced urticaria, oral, and genital ulcers, conjunctivitis, uveitis, optic atrophy, erythema nodosum, headache, and hearing loss. They were initially suspected of having BS, and both responded poorly to corticosteroids and immunosuppressants, while anti-TNF therapy was moderately effective. Pedigree analysis revealed another four relatives with similar symptoms, and a heterozygous NLRP3 gene mutation c.1316C>T, p.Ala439Val was identified by whole-exome sequencing and Sanger sequencing. However, we did not discover NLRP3 gene mutation by Sanger sequencing in a confirmative cohort of 30 BS cases. A few case reports of vasculitis coexisting with NLRP3-AID, including a case of glomerulonephritis, and five cases of retinal vasculitis, were summarized through literature review.Conclusions: Our study is the first report of NLRP3-AID associated with BS. The coexistence of NLRP3-AID and BS reveals the extensive heterogeneity of the pathogenesis of systemic autoinflammatory diseases and calls for specific therapeutics.

Summary: Background: By 2050, almost 5 billion people globally are projected to have myopia, of whom 20% are likely to have high myopia with clinically significant risk of sight-threatening complications such as myopic macular degeneration. These are diagnoses that typically require specialist assessment or measurement with multiple unconnected pieces of equipment. Artificial intelligence (AI) approaches might be effective for risk stratification and to identify individuals at highest risk of visual loss. However, unresolved challenges for AI medical studies remain, including paucity of transparency, auditability, and traceability. Methods: In this retrospective multicohort study, we developed and tested retinal photograph-based deep learning algorithms for detection of myopic macular degeneration and high myopia, using a total of 226 686 retinal images. First we trained and internally validated the algorithms on datasets from Singapore, and then externally tested them on datasets from China, Taiwan, India, Russia, and the UK. We also compared the performance of the deep learning algorithms against six human experts in the grading of a randomly selected dataset of 400 images from the external datasets. As proof of concept, we used a blockchain-based AI platform to demonstrate the real-world application of secure data transfer, model transfer, and model testing across three sites in Singapore and China. Findings: The deep learning algorithms showed robust diagnostic performance with areas under the receiver operating characteristic curves [AUC] of 0·969 (95% CI 0·959–0·977) or higher for myopic macular degeneration and 0·913 (0·906–0·920) or higher for high myopia across the external testing datasets with available data. In the randomly selected dataset, the deep learning algorithms outperformed all six expert graders in detection of each condition (AUC of 0·978 [0·957–0·994] for myopic macular degeneration and 0·973 [0·941–0·995] for high myopia). We also successfully used blockchain technology for data transfer, model transfer, and model testing between sites and across two countries. Interpretation: Deep learning algorithms can be effective tools for risk stratification and screening of myopic macular degeneration and high myopia among the large global population with myopia. The blockchain platform developed here could potentially serve as a trusted platform for performance testing of future AI models in medicine. Funding: None.

Objective. To investigate the changes of serum zinc-α2-glycoprotein (ZAG) in type 2 diabetes mellitus (T2DM) with eGFR mild decrease. Subjects and Methods. A total of 438 T2DM patients (61.3 ± 4.0 y) were recruited and the demographic, anthropometric, and biochemical parameters were all collected. Serum ZAG levels were determined by commercially available ELISA kits. Results. The proportion of T2DM patients with the high tertile ZAG levels was 11.9% higher in patients with mildly decreased estimated glomerular filtration rate (eGFR) (

The smart-house technology aims to increase home automation and security with reduced energy consumption. A smart house consists of various intelligent sensors and actuators operating on different platforms with conflicting objectives. This paper proposes a multi-agent system (MAS) design framework to achieve smart house automation. The novelties of this work include the developments of (1) belief, desire and intention (BDI) agent behavior models; (2) a regulation policy-based multi-agent collaboration mechanism; and (3) a set of metrics for MAS performance evaluation. Simulations of case studies are performed using the Java Agent Development Environment (JADE) to demonstrate the advantages of the proposed method.

Objective. To examine the association of three most common obesity measures including body mass index (BMI), waist circumference (WC), and waist-to-hip ratio (WHR) with chronic kidney disease (CKD) risk in patients with type 2 diabetes mellitus (T2D). Design. Cross-sectional evaluation of the effect of anthropometric measures on CKD risk. Setting. Outpatient Department. Subjects. T2D patients who were treated between October 2012 and May 2013. Intervention. None. Main Outcome Measure. CKD risk. Results. On average, the patients had a mean age of 60.2 years, and 40% were males. CKD was present in 46% of all the patients. In multivariate logistic regression using the imputed data, higher WC was associated with greater odds of CKD (OR = 1.019, 95% CI = 1.002–1.006, P=0.030), but not BMI and WHR. Interestingly, we found that patients with very small WC seemed to have greater odds of CKD. We observed age-specific effect of WC such that the effect of WC on CKD risk is significant only in middle-aged T2D patients. Conclusion. Our study provides evidence for the association of WC with CKD in Chinese patients with T2D. T2D patients, especially middle-aged T2D patients, should reduce their WC to decrease CKD risk.