Volume 103 · Issue 47 · 2023

In recent years, deep brain stimulation has been widely used in the treatment of various difficult diseases of the nervous system. The rapid development of machine learning algorithms has greatly promoted the application and development of deep brain stimulation. Machine learning can help in preoperative screening of surgical candidates, outcome prediction and surgical planning. It can assist target localization during operation. More importantly, the local field potential signals recorded by macroscopic electrodes can be analyzed in real time after surgery, which provides a basis for the development of a closed-loop stimulation system. Of course, the application of machine learning also has its limitations and challenges, such as dimensionality reduction of high-dimensional data, development and validation of new models and etc, which need to be further explored and improved.

To investigate the effects of electrode activated contact location, volume of tissue activated (VTA) and age on non-motor symptoms, such as emotional symptoms and cognitive function, in Parkinson′s disease (PD) patients with deep brain stimulation (DBS).

PD patients who underwent DBS of subthalamic nucleus (STN) at the Department of Functional Neurosurgery of Beijing Tiantan Hospital from September 1, 2020 to August 31, 2022 were retrospectively enrolled. The International Parkinson and Movement Disorder Society-Unified Parkinson′s Disease Rating Scale (MDS-UPDRS), Hamilton Anxiety Scale (HAMA), Hamilton Depression Scale (HAMD), Montreal Cognitive Assessment (MoCA), and Mini-Mental State Examination Scales (MMSE) were used at the preoperative, 1-month and 12-month postoperative time points. In this study, patients were divided into middle-aged (age<60 years,n=39) and elderly (age≥60 years,n=62) groups to investigate the effect of age factor on the clinical outcome of surgery. Lead-DBS software was used to convert the patients′ electrode reconstruction results into Montreal standard space, and the patients were divided into sensorimotor(n=43) and combined groups(n=53) according to the distribution of activation contact locations in the subzones of the STN. In addition, the patients were divided into a cognitive improvement group(n=57)and a cognitive deterioration group(n=44) based on the results of MoCA at 12 months. The positional information of the electrode activation contacts was collected and the VTA was calculated to analyze the effects on electrode activation electroshock location and activated tissue volume on patients′ non-motor symptoms.

A total of 101 patients with PD were enrolled, including 46 males and 55 females, aged (62.6±8.4) years. Middle-aged patients had significantly higher MoCA scores, delayed recall scores, attention scores, and naming scores than older patients at 12 months postoperatively (all P<0.05). At 12-month follow-up, the improvement rate of MoCA score, HAMA score and HAMD score were -1.77%±20.36%, 39.65%±42.91% and 36.23%±45.45% respectively in sensorimotor group. At 12-month follow-up, the improvement rate of MoCA score, HAMA score and HAMD score was 11.69%±22.24%, 16.62%±68.10% and 2.30%±95.04% respectively in the combined group, and the difference between the two groups was statistically significant (MoCA: P=0.002; HAMA: P=0.040; HAMD: P=0.033) The distribution of VTA in the sensory motor area and marginal area of the left hemisphere STN in patients with improved cognitive function was significantly smaller than that in the deterioration group [(60.53±52.04)mm³vs (84.55±61.00)mm³, P=0.035; (41.81±33.36)mm³vs (59.05±45.46)mm³, P=0.030].

The effect of STN-DBS on emotional symptoms and cognitive function in PD patients is influenced by various factors and is closely related to the patient′s age, electrode activation contact location and VTA.

To analyze the imaging changes of in the early period after subthalamic nucleus (STN) deep brain stimulation (DBS) surgery for Parkinson′s disease (PD) and its impact on electrode impedance by the application of 3.0T MRI-compatible devices.

A retrospective analysis was performed for the data of 43 PD patients who underwent 3.0T MRI-compatible STN-DBS surgery from October 2022 to April 2023 at the First Affiliated Hospital of USTC(Anhui Provincial Hospital), including 27 males and 16 females, aged 43-68 (56±5) years. All patients underwent postoperative 3.0T MRI, CT scans,and impedance measurements 1 week postoperatively.Fifteen patients underwent 3.0T MRI and impedance measurements 1 month postoperatively. The differences in impedance of electrode contacts before and after the 3.0T MRI scans were compared. The occurrence of peri-lead cerebral edema (PLE) in patients was analyzed, as well as the differences in PLE detection rates between the two imaging methods, and the differences in the incidence and volume of PLE at different microelectrode recordings, the occurrence and detection of postoperative PLE, and different microelectrode recording (MER) times and different time nodes were compared. The correlation between electrode impedance and the volume of edema around the nucleus was analyzed.

All 43 patients successfully underwent surgery, with a total of 86 electrodes implanted. There was no significant difference in electrode impedance values before and after the 3.0T MRI examinations at 1 week and 1 month postoperatively. The PLE detection rate with 3.0T MRI was 95.12%(39/43), which is significantly higher than that of CT imaging 17.07% (7/43)(χ²=50.705, P<0.001). One week after surgery, the incidence and volume of PLE were higher in the multiple MER group compared with the single MER group, but the difference was not statistically significant. The volume of PLE [M(Q₁, Q₃) 0 (0, 1.211) cm³] at 1 month was significantly smaller than that at 1 week [0.243 (0, 2.914) cm³] (Z=-3.408, P=0.001). The impedance of electrode contacts within 1 month postoperatively showed a trend of initial decrease followed by an increase, which was negatively correlated with SE volume(r=-0.317, P=0.014).

The application of 3.0T MRI-compatible DBS devices in the surgical treatment of PD patients improves the accuracy of early postoperative imaging assessment. The electrode impedance is more stable as the edema around the nucleus subsided at 1 month after surgery, which is suitable for the first program control.

To investigate the surgical efficacy of neurosurgery robot deep brain stimulation(DBS) in the treatment of elderly Parkinson′s disease(PD).

The clinical data of elderly patients (≥75 years) with PD who underwent neurosurgical robot-assisted DBS surgery in the Department of Neurosurgery of the General Hospital of Northern Theater Command from September 2016 to September 2022 were collected retrospectively. Operation time, electrode implantation duration, postoperative pneumocephalus volume, electrode implantation accuracy, the Tao′s DBS surgery scale, perioperative complications were analyzed.The unified Parkinson′s disease rating scales (UPDRS), UPDRS-Ⅲ, tremor, rigidity, bradykinesia, axial, Barthel Activities of Daily Living (ADL-Barthel), Levodopa Equivalent Daily Dose (LEDD), Montreal Cognitive Assessment (MoCA), Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores and mortality were assessed respectively before operation, 6, 12 and 24 months after operation and last follow-up.

A total of 25 elderly patients were enrolled, including 14 males and 11 females, aged(78.3±3.2) years. Nine patients had underlying diseases. Nine patients (36%) underwent bilateral Globus Pallidus pars Interna deep brain stimulation (GPi-DBS) and 16 patients (64%) underwent bilateral subthalamic nucleus deep brain stimulation (STN-DBS).The operation time was (1.56±0.19) hours, the electrode implantation duration was (1.01±0.19) hours, the pneumocephalus volume was 9.8(4.7, 23.3) cm³, and the electrode implantation accuracy was (0.84±0.24) mm, the Tao′s DBS surgery scale was (80.2±6.2).The follow-up time [M(Q₁, Q₃)] was 57.3(27.9, 75.7) months. No serious complications such as intracranial hemorrhage, infection or poor wound healing occurred during the perioperative period. The improvement rate of UPDRS, UPDRS-Ⅲ, rigidity, bradykinesia, and LEDD at 6 months after surgery was significantly higher than that at 24 months after surgery and at the last follow-up (all P<0.05); the improvement rate of axial symptoms, ADL-Barthel score, and MoCA score at 6 months after surgery was significantly higher than that at the last follow-up (P<0.05). HAMD and HAMA scores showed no significant improvement during follow-up after surgery (both P>0.05). At the last follow-up, 12 patients died, with death time of (35.1±20.2) months after operation, and the death age of [M(Q₁, Q₃)] 80(79, 83)years.

Robot-assisted DBS surgery for elderly patients with PD is accurate and safe, and the postoperative symptoms are significantly improved, and they can benefit from neuromodulation for long term, and the risks are controllable.

To analyze the complications related to deep brain stimulation(DBS) surgery in Parkinson′s disease(PD) patients and to determine whether there is a learning curve effect in terms of complications.

Retrospective analysis of the DBS surgical data of 822 PD patients performed by the same surgeon at the First Affiliated Hospital of the University of Science and Technology of China (Anhui Provincial Hospital) from December 2012 to December 2022. The complications related to DBS were evaluated and analyzed the complications of every 100 DBS surgery were further analyzed.

A total of 822 PD patients, 453 males and 369 females, aged 31-80 years old, were included. The minimum follow-up period after DBS surgery is 6 months. Surgical related complications occurred in 55 patients (6.69%), including 5 patients (0.61%) with slight bleeding around the electrode, 1 patient (0.12%) with cerebral infarction, 4 patients (0.49%) with postoperative epilepsy, 42 patients (5.11%) with postoperative delirium, 2 patients (0.24%) with respiratory distress, and 1 patient (0.12%) with acute cardiac insufficiency. There were 16 cases (1.94%) of hardware related complications in DBS, of which 4 cases (0.48%) had infection, 1 case (0.12%) had a broken angle at the connection between the pulse generator and the extension wire, 8 cases (0.97%) had an excessively tight extension wire, and 3 cases (0.36%) had an IPG bag hematoma. In the infected cases, 2 patients removed IPG and extension wires. There were 7 cases (0.85%) of stimulus related complications, including 4 cases (0.61%) with programmed sensory abnormalities, 1 case (0.12%) with postoperative abnormal movements and dance like movements, and 2 cases (0.24%) with psychiatric symptoms. A comprehensive analysis was conducted on the above complications, among which 8 cases (0.97%) were relatively serious complications. After active treatment, satisfactory results were achieved, and none of them affected the patient′s DBS treatment effect and no patients died. For every 100 cases of DBS surgery complications were analyzed, the percentage of complications decreased significantly from 14.50% (58 cases) in the first 400 cases to 4.73% (20 cases) in the last 400 cases (P<0.001).

DBS surgery is safe and has an acceptable low incidence of complications. The incidence of complications also decreases with the accumulation of experience, showing a learning curve effect.

To evaluate the clinical application performance of a domestic D-dimer assay reagent (ADX D-dimer).

A total of 546 residual sodium citrate anticoagulated plasma samples (530 of which were used for comparability validation and 16 for sample preparation of other validation components) were selected after the completion of clinical testing at Peking Union Medical College Hospital from Jun 2022 to May 2023. According to the American Clinical Laboratory Standards Institute (CLSI) guidelines, national health industry standards and relevant references, the performance of ADX D-dimer used in Sysmex CS 5100 fully automated coagulation analyzer which included accuracy, precision, linear range, carryover rate, interference resistance capability and reference interval were validated and the agreement compared with two mainstream imported detection reagents (reagent A: Vidas D-dimer reagent; reagent B: Innovance D-dimer detection reagent) was evaluated. The clinical diagnostic efficacy of the ADX D-dimer was evaluated using the ELISA D-dimer (reagent A) test results as criteria.

The linear correlation coefficient of the 6-point calibrated absorbance and target value was 0.998, the bias of accuracy met the requirements (-2.8%-8.4%), and the coefficient of variation (CV) of within-run and between-day precision of the two levels were 1.0%-2.7% and 2.7%-4.1%, respectively, which were less than the requirements of the manufacturer′s statement and the national health industry standard. The linear range within 0.33-9.69 mg/L FEU was verified and the carryover rate was 0. There was no significant interference with the assay results at bilirubin F≤0.22 g/L, bilirubin C≤0.22 g/L, hemoglobin≤5.5 g/L and celiac≤2 800 FTU. The manufacturer′s reference interval≤0.5 mg/L FEU was verified suitable for this laboratory. For 358 samples without suspicious heterophilic antibody whose D-dimer levels range from 0.06 to143.63 mg/L FEU, the correlation between ADX D-dimer and another two assay was good, with r values being 0.968 and 0.975, respectively, the percentage of deviation and relative deviation beyond the 95% confidence interval was 3.4%-4.5% and 5.3%-7.0%. The correlation between ADX D-dimer and ELISA D-dimer was better than that of reagent B in the concentration range of 0.06-1.00 mg/L FEU (r=0.858, 0.134). For 172 samples with heterophilic antibody, the correlation between ADX D-dimer and ELISA D-dimer was still good(r=0.827), with the percentage of deviation and relative deviation being 6.4% (11/172). The diagnostic efficacy was evaluated using 530 samples, and the sensitivity, specificity, positive predictive value, negative predictive value of ADX D-dimer was 97.4%, 77.6%, 91.9%, 91.9%. The area under the curve was 0.976 (95%CI: 0.964-0.987, P<0.001).

The ADX D-dimer reagent has superior assay and diagnostic performance, and can meet the needs of clinical laboratories.

To investigate the correlation between dynamic enhanced energy spectral CT parameters and Ki-67 high expression in hepatocellular carcinoma (HCC).

A cross-sectional study. This retrospective case-control study analyzed the clinical data of 101 patients with pathologically confirmed HCC in Xiamen Hospital of Traditional Chinese Medicine and Zhongshan Hospital of Xiamen University from December 2017 to March 2023. These 101 patients included 84 males and 17 females, and the age[M(Q₁, Q₃)] was 59.0(49.0,66.0)years. These patients were divided into two groups according to the immunohistochemical Ki-67 expression levels in tumor tissues: the high expression group (Ki-67%>20%, n=59) and the low expression group (Ki-67%≤20%, n=42).CT values on 70 keV and 140 keV monochromatic energy images (HU_{70 keV-a}, HU_{140 keV-a}, HU_{70 keV-p}, HU_{140 keV-p}) and water density (D_water-a, D_water-p) were measured in arterial phase and portal vein phase, and the difference of HU_{70 keV}, HU_{140 keV}, D_water values between portal vein and arterial phase (ΔHU_{70 keV}, ΔHU_{140 keV}, ΔD_water), as well as ratio of HU_{70 keV}, HU_{140 keV}, D_watervalues between portal vein and arterial phase (HU_{70 keV}ratio, HU_{140 keV}ratio, D_waterratio) were calculated. Spearman correlation analysis was used to analyze the correlation between the CT spectral parameters and Ki-67%. Multivariate logistic regression model was used to determine the factors associated with high expression of Ki-67. The receiver operating characteristics (ROC) curves were used to indicate the efficacy of dynamic enhanced spectral CT in evaluating Ki-67 high expression in HCC.

The high Ki-67 expression group revealed higher alpha fetal protein levels, larger tumor diameter and more irregular tumor shape compared with the low Ki-67 expression group,and the differences were statistically significant (all P<0.05). Spearman correlation analysis showed that the HU_{140 keV-p}, D_water-p, HU_{70 keV} ratio, HU_{140 keV} ratio, D_water ratio, ΔHU_{70 keV}, ΔHU_{140 keV}, ΔD_water were positively correlated with Ki-67 positivity rate (r:0.31-0.50, all P<0.05). The spectral CT parameters (HU_{70 keV-p}, HU_{140 keV-p}, D_water-p, HU_{70 keV} ratio, HU_{140 keV} ratio, D_water ratio, ΔHU_{70 keV}, ΔHU_{140 keV}, ΔD_water) in high Ki-67 expression group were significantly higher than those in low Ki-67 expression group (all P<0.05). Multivariate logistic regression model shows that D_water-p(OR=1.16, 95%CI: 1.05-1.29, P=0.005), ΔHU_{140 keV}(OR=1.39, 95%CI: 1.20-1.62, P<0.001) and irregular tumor morphology (OR=5.25, 95%CI: 1.61-17.12, P=0.006) were correlative factors for high Ki-67 expression. The HU_{140 keV} ratio and ΔHU_{140 keV} alone evaluated the highest AUC of high Ki-67 high expression in HCC, which were 0.82 (95%CI: 0.74-0.90), the sensitivity were 61.0%, and the specificity were 88.1% and 85.7%. The combined analysis of D_water-p, ΔHU_{140 keV} and irregular tumor morphology had an increased AUC of 0.88 (95%CI: 0.81-0.95) in assessment high Ki-67 expression, with the sensitivity of 84.7% and the specificity of 78.6%.

Dynamic enhanced spectral CT parameters were positively correlated with the Ki-67 expression in HCC. Spectral CT provides a non-invasive method to evaluate the proliferation status of HCC cells, and the efficiency could be improved by multi-parameter analysis combining spectral CT parameters and morphologic features.

To propose a method to determine the unreasonableness of the fixed angle in posterior atlantoaxial fusion surgery based on the ratio of line segments between anatomical landmarks of the atlantoaxial joint.

A cross-sectional study was conducted. According to the inclusion criteria, a screening was performed on the database of asymptomatic volunteers who had full-spine lateral X-ray films taken at the Second Affiliated Hospital of Wenzhou Medical University from May 2016 to May 2021. A total of 207 volunteers were included, comprising 98 males with an age of (40.68±13.87) years and 109 females with an age of (42.64±14.45) years. On the lateral X-ray film, a line (L) parallel to the posterior margin of the odontoid process was drawn at the posterior edge of the lower articular surface of the axis (a), intersecting the atlas at points b, c, and d. The line segments ab, bd, bc, and the C₁-C₂ angle were measured, and the ratios of bd/ab and bc/ab were calculated. The ability of bd/ab and bc/ab to predict the unreasonable fixed angle of the atlantoaxial joint (≥22°) was analyzed by receiver operating characteristic (ROC) curve analysis in both male and female. The areas under the ROC curves (AUC) were calculated, and the performance of the two prediction methods was compared using the Delong′s test. The cutoff value for distinguishing the unreasonableness of the C₁-C₂ angle and the sensitivity and specificity were calculated.

The ROC curve analysis in the male group showed that the AUC of bc/ab for predicting the unreasonable C₁-C₂ angle was 0.791 (95%CI: 0.696-0.867, P<0.001), with a cutoff value of 0.449, sensitivity of 97.3%, and specificity of 70.0%. The performance was significantly better than that of bd/ab (cutoff value 1.100, AUC=0.532, 95%CI: 0.428-0.634, sensitivity 26.3%, specificity 83.3%, P<0.001). The ROC curve analysis in the female group showed that the AUC of bc/ab for predicting the unreasonable C₁-C₂ angle was 0.804 (95%CI: 0.745-0.852, P<0.001), with a cutoff value of 0.488, sensitivity of 90.5%, and specificity of 58.6%. The performance was significantly better than that of bd/ab (cutoff value 0.960, AUC=0.687, 95%CI: 0.624-0.748, sensitivity 90.5%, specificity 44.8%, P=0.041).

The bc/ab value can be used as an effective indicator to predict the unreasonable C₁-C₂ angle in posterior atlantoaxial fusion surgery with high diagnostic accuracy. The cutoff value for males is<0.449, and for females is<0.488.

To investigate the etiology of multiple primary malignant neoplasms occurred in one patient. Retrospective analysis was performed on a 52-year-old female patient who was admitted to the Department of Endocrinology, the First Affiliated Hospital of Sun Yat-Sen University on October 7, 2021, due to "thyroid occupying lesion for one week". A complete systemic positron emission tomography examination of the patient indicated that the metabolic characteristics of the left thyroid nodules were consistent with medullary thyroid carcinoma, those of the right thyroid nodules were consistent with papillary thyroid carcinoma, and the metabolic characteristics of the T_6-7 level were consistent with meningioma, and teratoma was found in the right ovarian region. Intradural subdural mass resection was performed on October 20, 2021, and bilateral total thyroidectomy, isthmus thyroidectomy, bilateral central lymph node dissection and left cervical lymph node dissection were performed on November 2, 2021. The postoperative pathologic diagnosises were meningioma (WHO Grade 1), medullary thyroid carcinoma (left side), and papillary thyroid carcinoma (right side).Whole exon gene sequencing revealed the presence of mutations in the ACAN and FLNB genes, which are associated with dysplasia, as well as mutations in the DDX41 and JAK2 genes, which are linked to active pro-proliferation signaling and tumor susceptibility. In this study, a gene mutation pattern which could lead to multiple primary malignant neoplasms was found.

Platelet satellite phenomenon is a type of pseudopenia of platelets, which refers to the in vitro phenomenon of platelets forming rosettes around polymorphonuclear neutrophils. This patient, a 64-year-old male, went to the Department of Cardiology, the Second Affiliated Hospital of Shandong First Medical University due to "chest tightness and palpitation". The blood routine results showed a decrease in platelet count and an increase in lymphocyte proportion. A rare platelet satellite phenomenon around lymphocytes was found in the re-examination of peripheral blood smear. This phenomenon is judged by combining with other clinical physical examination results, and it is considered to be related to lymphoma. Based on this, patients are suggested to improve relevant laboratory examinations and change the diagnostic direction of patients. The diagnosis of mantle cell lymphoma was confirmed after the examination of blood diseases was completed. After 1 course of treatment with R-CHOP regimen, the patient's condition was well controlled, the clinical symptoms were significantly improved, the platelet count, lymphocyte percentage and neutrophil percentage returned to normal, and the platelet satellite phenomenon in peripheral blood smear disappeared, which won valuable time for the patient's treatment.

The 65-year-old female was admitted to the Second Affiliated Hospital of Wenzhou Medical University due to "waist pain caused by falling for more than 3 months" and was diagnosed with thoracolumbar compression fracture. The patient underwent "thoracolumbar fracture resection and internal fixation + nail tract enhancement + thoracic 9 percutaneous vertebroplasty" under general anesthesia. After tracheal extubation, the patient had sudden chills, high fever, shortness of breath, hypoxemia and hypertensive crisis. After symptomatic treatment, the patient's chills and hypertensive crisis were relieved. Bedside chest ultrasound examination considered shortness of breath and hypoxemia caused by intrapulmonary shunt. Electrocardiogram and cardiac color ultrasound showed that the patient had new "lead III deep Q wave" and "mild pulmonary hypertension" than before operation. Combined with chest radiograph and CT, it was finally diagnosed as rare perianesthetic cement pulmonary embolism (PCE). The patient recovered well after symptomatic treatment. Although the incidence of PCE is not high, its clinical manifestations are diversified and its diagnosis is difficult. Surgeons and anesthesiologists need to improve their awareness and vigilance on perianesthetic PCE.

Periodontitis is a chronic inflammation that occurs in all periodontal supporting tissues and is caused by bacteria in the plaque that invade the periodontal tissue. Carotid stenosis is a common cardiovascular disease, and atherosclerosis is the main cause. In recent years, a large number of studies have elucidated the correlation between periodontitis and carotid stenosis, but the specific mechanism by which periodontitis increases the prevalence and severity of carotid stenosis has not been clarified. This paper summarizes the relationship and classical mechanism between periodontitis and carotid artery stenosis, reflects the hemodynamic changes in the process of periodontitis promoting carotid artery stenosis through representative hemodynamic parameters, and emphasizes the research progress of the mechanism of periodontitis promoting carotid artery stenosis from the new hemodynamic angle, in order to promote the screening and prevention of periodontitis and carotid artery stenosis.

Recombinant metabolic networks support the survival, proliferation and malignant development of tumor cells, which are important features of tumors. Glutamine metabolism is reprogrammed in tumor cells, which take up glutamine in large quantities, providing carbon and nitrogen sources for energy supply and biosynthesis. With the in-depth research on tumor metabolomics, it has been found that glutamine metabolic recombination can also participate in various physiological processes such as signal transduction, maintenance of redox homeostasis, epigenetic modification, autophagy regulation and immune escape, and play an important role in tumor development. This paper reviews the characteristics and regulatory mechanisms of glutamine metabolism in tumor cells, summarizes the role of glutamine metabolic recombination in tumor development, and finally explores the great potential of targeted glutamine metabolism in tumor therapy.

With the development of neuromodulation technology, deep brain electrical stimulation (DBS) has become an important method for treating functional brain diseases. The application and development of DBS in China has been 25 years. This paper reviews and summarizes the application and research progress of DBS in China for 25 years, combs the history and looks forward to the future development direction. At present, the number of units carried out by DBS and the number of operations are increasing rapidly, and the spectrum of diseases treated by DBS is becoming increasingly broad (covering movement disorders, neurodegenerative diseases, mental diseases, etc.). These advances are inseparable from the popularization of brain stereotactic technology in China and the development of domestic DBS equipment. At present, domestic DBS equipment has advanced functions such as frequency conversion stimulation, high field strength magnetic resonance compatibility, closed loop stimulation, remote program control, etc., which provides a good technical foundation for serving patients. Of course, the development of DBS still faces many challenges, such as the neural mechanism of DBS, the selection of optimal targets and the prediction of efficacy, etc., which still need further exploration and research.

Global lead exposure has declined significantly since the phase-out of leaded gasoline, but sources of lead remain abundant, particularly in low-and middle-income countries. Lead exposure ranks fourth among environmental health risk factors, behind environmental particulate air pollution, indoor solid fuel air pollution, and unsafe household drinking water, sanitation, and hand washing, according to the 2019 Global Burden of Disease, Injury, and Risk Factors Study. Lead exposure increases the risk of cardiovascular disease, chronic kidney disease, and idiopathic intellectual developmental disabilities. The goal of the study was to assess the global burden and cost of IQ loss and cardiovascular disease mortality from lead exposure.

Acute ischemic stroke (AIS) accounts for more than 70% of stroke cases, with a high disability rate and high mortality rate. For anterior circulation AIS, the results of multiple randomized controlled trials (RCTs) have shown that the use of general anesthesia during endovascular intervention will achieve better or similar functional outcomes than conscious sedation, but there is still a lack of RCT studies corresponding to posterior circulation AIS.

The annotation "TIM3" in Figure 4C on page 2792 of the article "Phenotypic characteristics in the immune microenvironment of gastric cancer patients and their relationship with clinicopathological parameters and prognosis" on page 2786 of this journal, Issue 35, 2023⁺Foxp3⁺"should be" CD8⁺Foxp3⁺”； "CD8" in Table 8 Influencing Factors on page 2793⁺TIM3⁺"should be" CD8⁺Foxp3⁺”； Correction is hereby made!