Research progress and countermeasures of Alzheimer' s disease signaling pathways / 中国药理学通报

Alzheimer's disease (AD) is a progressive neurodegenerative disease characterized by the gradual loss of memory and cognitive functions. Studies have found the relation between the pathogenesis of AD and the transduction of signaling path-ways. This article combines domestic and foreign literature to review the role of AD-related signaling pathways in pathogenic mechanisms and analysis of countermeasures, aiming to provide new ideas for the treatment of AD and the development of new anti-AD drugs.

Rescue of male infertility through correcting a genetic mutation causing meiotic arrest in spermatogonial stem cells / 亚洲男科学杂志(英文版)

Azoospermia patients who carry a monogenetic mutation that causes meiotic arrest may have their biological child through genetic correction in spermatogonial stem cells (SSCs). However, such therapy for infertility has not been experimentally investigated yet. In this study, a mouse model with an X-linked testis-expressed 11 (TEX11) mutation (Tex11

Construction of emergency medical service system based on 5G communication technology for large-scale social activities / 中华急诊医学杂志

Objective@#To develop medical emergency support information system for large-scale social activities based on 5G communication technology to improve efficiency of emergency medical services.@*Methods@#The project was completed in Hangzhou, China, from March 2016 to September 2019. Based on the medical service of large social activities, five information terminals are constructed, including on-site mobile terminal, on-board first aid terminal, expert remote consultation terminal, hospital terminal, and command dispatch center. The system can realize the real-time communication of medical information, patient's vital signs, audio, picture and video information, and can also make intelligent scheduling decisions for patients.@*Results@#5G Emergency Medical information System for Large-scale Social Activities has been completed, which consists of three parts: command and control platform, on-site rescue platform, and evacuation support platform. The command and monitoring platform displays the information of on-site medical teams, ambulances, hospitals and experts through web pages, and realizes multi-party video communication at any time, as well as text, voice and image information of patients' current condition, so as to realize command, dispatch and display statistical summary information. On-site rescue terminal includes patient information input, video signal acquisition and physiological information acquisition equipment. It realizes multiple methods of patient information input, vital signs and physiological information acquisition, multi-angle video acquisition and transmission to the command center. The evacuation support platform includes vehicle emergency terminal, remote expert consultation terminal, hospital terminal and UAV system. Vehicle terminal can scan and transfer with on-site ambulance team, record physiological information during transit, and also acquire and transmit monitor, electrocardiogram and ultrasound information. Hospital terminals can obtain patient information at the first time and prepare for first-aid in hospital. The remote expert terminal can be dispatched by the command center and the hospital terminal, and can join the remote consultation at any time. Unmanned aerial vehicle (UAV) system can transfer medical material between any locations.@*Conclusions@#This system can guarantee the patients to be transported from the scene to the ambulance and finally to the hospital during the large-scale social activities. In the whole process, the information transmission and dispatching decision-making are initially realized, and the statistical report forms can be made. However, to fully exert its advantages, it still needs the support of the complete 5G network and continuous optimization in real scenarios.

Inhibitory Effect of MiR-449b on Cancer Cell Growth and Invasion through LGR4 in Non-Small-Cell Lung Carcinoma / 华中科技大学学报（医学）（英德文版）

Non-small-cell lung carcinoma (NSCLC) is one of the most frequently diagnosed malignancies worldwide.Previous studies have shown that microRNA-449b (miR-449b) functions as a tumor suppressor in many cancers.However,the role of miR-449b in NSCLC is still unknown.In the present study,miR-449b was significantly downregulated in NSCLC samples and cell lines.Bioinformatics analysis revealed that 3'-UTR region of leucine rich repeat containing G protein-coupled receptor 4 (LGR4) mRNA had putative complementary sequences to miR-449b,which was further confirmed by the luciferase assay.Western blotting showed that restoration of miR-449b in NSCLC cells decreased the expression of LGR4.Interestingly,over-expression of miR-449b inhibited growth and invasion of NSCLC cells in vitro.Furthermore,ectopic expression of LGR4 reversed miR-449b-suppressed proliferation and invasion of NSCLC cells.Therefore,the data of the present study demonstrate that miR-449b inhibits tumor cell growth and invasion by targeting LGR4 in NSCLC.

Inhibitory Effect of MiR-449b on Cancer Cell Growth and Invasion through LGR4 in Non-Small-Cell Lung Carcinoma / 华中科技大学学报（医学）（英德文版）

Non-small-cell lung carcinoma (NSCLC) is one of the most frequently diagnosed malignancies worldwide.Previous studies have shown that microRNA-449b (miR-449b) functions as a tumor suppressor in many cancers.However,the role of miR-449b in NSCLC is still unknown.In the present study,miR-449b was significantly downregulated in NSCLC samples and cell lines.Bioinformatics analysis revealed that 3'-UTR region of leucine rich repeat containing G protein-coupled receptor 4 (LGR4) mRNA had putative complementary sequences to miR-449b,which was further confirmed by the luciferase assay.Western blotting showed that restoration of miR-449b in NSCLC cells decreased the expression of LGR4.Interestingly,over-expression of miR-449b inhibited growth and invasion of NSCLC cells in vitro.Furthermore,ectopic expression of LGR4 reversed miR-449b-suppressed proliferation and invasion of NSCLC cells.Therefore,the data of the present study demonstrate that miR-449b inhibits tumor cell growth and invasion by targeting LGR4 in NSCLC.

Effect of animal medicines for "extinguishing wind to arrest convulsions" on central nervous system diseases / 中国中药杂志

The human health is seriously affected by central nervous system(CNS) diseases, but the pathogenesis of CNS diseases is still not completely clear. Currently, the drugs used to treat CNS diseases are mainly receptor modulators and neurotransmitter inhibitors, which have serious side effects; and there are short of drugs for treating CNS diseases clinically. Studies suggest that animal medicines mainly include protein, polypeptide and small-molecule compounds, and have such pharmacological effects in calming, resisting convulsions and improving brain tissues. Plenty of studies suggest that animal medicines usually have a strong activity and good curative effect on these diseases, with a promising prospect in research and development of drugs treating CNS diseases. Based on systematic reviews of literatures, this paper summarizes active ingredients and main pharmacological effects of animal medicines in "extinguishing wind to arrest convulsions" for the CNS diseases, epilepsy and cerebral ischemia, and discusses their study value and application prospects. The results showed that the studies of protein and peptides were relatively simple, and some animal medicines were still blank. The authors believed that amino acids and small molecular compounds should be transferred to oligopeptide, advanced protein extraction and separation techniques shall be adopted for identifying the protein polypeptide composition structure and studying the efficacy, and the methods of biological technology were used to develop peptide biological products for the treatment of CNS diseases. This paper could provide ideas and reference for developing animal medicine products for the treatment of CNS diseases.

Measuring thyroid density by energy spectrum CT / 医疗卫生装备

Objective To investigate the relationship between the single energy CT value and the tissue density and further evaluate the mass of thyroid.Methods Different substances respectively composed of liquid and solid,liquid and liquid,thyroid gland were selected,and the relationship was investigated between the single energy CT value and the tissue density.Results The CT value was closely related to the content of high atomic number substance.The CT value of thyroid was closely related to the content of iodine.Conclusion It is feasible to measure the thyroid density by the energy spectrum CT.

Effect of P I CP/P III NP on assessing cardiac diastolic dysfunction and collagen remodeling / 解放军医学杂志

Objective To explore the changes of serum procollagen I carboxyl peptide (P I CP)/procollagen III aminoterminal peptide (P III NP) levels in cardiac diastolic dysfunction rabbit model, and the relationship with cardiac diastolic dysfunction and collagen remodeling. Methods Sixty rabbits were randomly divided into control group (control), myocardial infarction group (MI) and left ventricular hypertrophy group (LVH)(20 each). E/e' ratio was detected by flow Doppler and tissue Doppler imaging, and ELISA was performed to detect the P I CP/P III NP level at the 2nd, 4th, 8th and 12th week. The collagen volume fraction (CVF) and I/III collagen ratio were detected with polarized light through picric-acid Sirius red staining at the 12th week. Results The P I CP and P III NP levels increased in MI group and LVH group than in control group with statistically significant difference (P<0.05), and the P I CP and P III NP levels were also increased in MI group than in LVH group (P<0.05) in a time-dependent manner; The E/e' ratio increased in MI group and LVH group than in control group with statistically significant difference (P<0.05) in a time-dependent manner; The CVF increased in MI group and LVH group than in control group with statistically significant difference (P<0.05). The P I CP and P III NP levels were positively correlated with the E/e' ratio (P<0.05), and the P I CP and P III NP ratio was positively correlated with the I/III collagen ratio (P<0.05). Conclusion The P I CP and P III NP levels can be used to evaluate the changes of cardiac diastolic function and myocardial collagen remodeling in different pathological conditions.

Detection of human bocavirus in children with acute respiratory tract infections in Lanzhou and Nanjing, China / 生物医学与环境科学（英文）

<p><b>OBJECTIVE</b>The aim of this study was to explore the prevalent characteristics of HBoV1 and its co-infection.</p><p><b>METHODS</b>PCR was used to detect HBoV1-DNA (HBoV1) and other viruses. A multivariate logistic regression model was used to explore possibility of co-detected for related viruses.</p><p><b>RESULTS</b>The positivity rates in Nanjing and Lanzhou were 9.38% (74/789) and 11.62% (161/1386), respectively (P>0.05). The HBoV1 positive group was younger than negative group (P<0.05). Seasonal differences were noted, with a higher frequency of infection in December and July. HBoV1-positive children [72.34% (169/235)] were co-infected with other respiratory viruses. Multifactorial analysis showed no correlations between HBoV1 and the clinical classification, region, gender, age, or treatment as an outpatient or in a hospital. Correlations were identified between HBoV1 infections with ADV (OR=1.53, 95% CI 1.03-2.28), RSV (OR=0.71, 95% CI 0.52-0.98), and IFVA (OR=1.77, 95% CI 1.00-3.13).</p><p><b>CONCLUSION</b>Presence of HBoV1 in nasopharyngeal aspirates did not correlate with region or gender, although the prevalence of HBoV1 was higher in younger children. There were no correlations between HBoV1 and other variables, except for the season and ADV, RSV, or IFVA infections.</p>

Short-term inhalation of nitric oxide inhibits activations of toll-like receptor 2 and 4 in the lung after ischemia-reperfusion injury in mice / 华中科技大学学报（医学）（英德文版）

In order to investigate the effects of different terms of inhaled nitric oxide (NO) preconditioning with low concentration on the activations of Toll-like receptor 2 and 4 (TLR2/4) in the lung ischemia-reperfusion (IR) injury in mice, we divided the male C57BL mice into five groups: sham (S) group, IR group, NO 1-min preconditioning group (15 ppm NO inhalation for 1 min before ischemia, NO 1-min), NO 10-min preconditioning group (15 ppm NO inhalation for 10 min before ischemia, NO 10-min), NO 60-min preconditioning group (15 ppm NO inhalation for 60 min before ischemia, NO 60-min). The changes of partial pressure of oxygen in artery (PaO2), left lung wet-to-dry weight ratio (W/D), and myeloperoxidase (MPO) in the injured lung were measured in every group at 6th h of reperfusion after 60 min of left lung ischemia. The changes of TLR2/4 activations and plasma TNF-α were measured in this procedure in additional mice. As compared with IR group, PaO2 increased, MPO and W/D decreased evidently after reperfusion in NO 10-min group. The changes in NO 60-min group were similar to those in NO 10-min group. There was no difference between NO 1-min and IR group. In NO inhalation group, the expressions levels of TLR2/4 mRNA and proteins were diminished, TNF-α concentrations were decreased, and the lung injuries were ameliorated effectively. We concluded that short term inhalation of NO protected lung IR injury. But the protective effect of NO was not increased with extension of inhaled NO. Inhaled NO could inhibit the activations of TLR2/4 in the lung after IR injury. TLR signal pathway might contribute to the effect of protection with NO in this model.

Short-term inhalation of nitric oxide inhibits activations of toll-like receptor 2 and 4 in the lung after ischemia-reperfusion injury in mice / 华中科技大学学报（医学）（英德文版）

In order to investigate the effects of different terms of inhaled nitric oxide (NO) preconditioning with low concentration on the activations of Toll-like receptor 2 and 4 (TLR2/4) in the lung ischemia-reperfusion (IR) injury in mice, we divided the male C57BL mice into five groups: sham (S) group, IR group, NO 1-min preconditioning group (15 ppm NO inhalation for 1 min before ischemia, NO 1-min), NO 10-min preconditioning group (15 ppm NO inhalation for 10 min before ischemia, NO 10-min), NO 60-min preconditioning group (15 ppm NO inhalation for 60 min before ischemia, NO 60-min). The changes of partial pressure of oxygen in artery (PaO2), left lung wet-to-dry weight ratio (W/D), and myeloperoxidase (MPO) in the injured lung were measured in every group at 6th h of reperfusion after 60 min of left lung ischemia. The changes of TLR2/4 activations and plasma TNF-α were measured in this procedure in additional mice. As compared with IR group, PaO2 increased, MPO and W/D decreased evidently after reperfusion in NO 10-min group. The changes in NO 60-min group were similar to those in NO 10-min group. There was no difference between NO 1-min and IR group. In NO inhalation group, the expressions levels of TLR2/4 mRNA and proteins were diminished, TNF-α concentrations were decreased, and the lung injuries were ameliorated effectively. We concluded that short term inhalation of NO protected lung IR injury. But the protective effect of NO was not increased with extension of inhaled NO. Inhaled NO could inhibit the activations of TLR2/4 in the lung after IR injury. TLR signal pathway might contribute to the effect of protection with NO in this model.

Enzyme-linked immunospot test detected specific cellular immune response induced by human bocavirus VP2 virus-like particles / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To discuss the enzyme linked immune spot test (ELISPOT) detected the cellular immune response induced by human Bocavirus (HBoV) VP2 virus-like particles (VLPs).</p><p><b>METHODS</b>After immunized by HBoV VP2 VLPs, the specific cellular immune response in mice were detected by ELISPOT assay, observe the ELISPOT results at the conditions of different polypeptide stimulate, different cell culture time, different cell concentration and different specific stimulus peptide concentration, then screening the right ELISPOT experimental conditions and establish the ELISPOT method.</p><p><b>RESULTS</b>The spots induced by HBoV1 VLPs immunized mice spleen lymphocytes stimulate with polypeptide P3 (GYIPIENEL) and P5 (LYQMPFFLL)were 233 spots/10(6) cells and 157 spots/10(6) cells,spots induced by HBoV2 VLPs immunized mice spleen lymphocytes stimulate with polypeptide P8 (GYIPVIHEL) were 113 spots/10(6) cells; 24 hours is the best time for culture, at this time HBoV1 and HBoV2 groups specificity secretion IFN-gamma ratio were 232 spots/10(6) cells and 119/10(6) cells; Best concentration of mice spleen lymphocyte is 5 x 10(5), right now HBoV1 and HBoV2 group specificity secretion IFN-gamma ratio were 232 spots/10(6) cells and 108/10(6) cells; Best concentration of polypeptides is 10 microg/ml, HBoV1 and HBoV2 group specificity secretion IFN -gamma ratio were 233 spots/10(6) cells and 96/10(6) cells.</p><p><b>CONCLUSIONS</b>HBoV1 and HBoV2 specificT-cell epitope in BABL/c mice were P3, P5 (HBoV1) and P8 (HBoV2). The best experiment condition were: cell cultivated for 24 h, cells concentration for 5 x 10(5) cells/well, stimulating polyperides concentration for 10 microg/ml, it can use to study the cellular immune induced by HBoV in mice.</p>

Establishment and clinical application of TapMan real-time RT-PCR method for detection of HHV-6 / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To establish a rapid, sensitive and specific real-time PCR method for detection of Human Herpesvirus-6 (HHV-6).</p><p><b>METHODS</b>According to the reference, a pair of primers and a probe were designed located in U65-66 gene and to set up the standards. We established a real-time RT-PCR method for detection of HHV-6, and to verify the specificity, sensitivity, reproducibility.</p><p><b>RESULTS</b>The correlation coefficient was 0.999, E = 97.9%, the coefficient of variation values of Ct were 0.61% and 3.13% in real-time PCR assay for inter and intra assay, respectively. The results of all viruses were negative except of HHV-6 for the assay. The quantitative detection limit of the assay was 3 x 10(0) copies/microl.</p><p><b>CONCLUSION</b>The real-time PCR assay is highly specific, sensitive and reproducible, which can be used to quatitative detecting clinical samples.</p>

Strong halo-femoral traction with wide posterior spinal release and three dimensional spinal correction for the treatment of severe adolescent idiopathic scoliosis / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Many investigators advocate anterior release combined with halo-femoral traction and posterior fusion when treating stiff thoracic curves in patient with adolescent idiopathic scoliosis (AIS). But the anterior operations often induce severe complications. Some surgeons choose posterior-only surgery with halo-femoral traction, posterior wide release and correction. But to the best of our knowledge, there are only rare prospective studies on these posterior-only surgeries for AIS patients who have a rigid curve more than 80° and flexibility less than 35%.</p><p><b>METHODS</b>Sixty-four AIS patients were recruited from September 2006 to June 2009. All patients had rigid curves and underwent spinal correction. They were randomly divided into group A (combined anteroposterior surgery) and group B (posterior-only surgery). Images and scoliosis research society-22 questionnaire (SRS-22) scores were performed pre- and post-operation and during follow-up visits. The operation time, blood loss, hospital days, and hospital charges were compared between the two groups.</p><p><b>RESULTS</b>These patients were followed for an average of 37.5 months (range, 24 - 65 months). No serious complications were observed. There were no significant differences between the two groups in gender, age, preoperative radiographic data, or preoperative SRS-22 score. The average operation time, blood loss, hospital days and hospital charges in group B were less than those in group A. The SRS-22 score in group B was better than in group A at post-operation and at final follow-up.</p><p><b>CONCLUSIONS</b>In AIS with a rigid curve more than 80° and flexibility less than 35%, strong halo-femoral traction with wide posterior spinal release and three dimensional spinal correction can provide better SRS-22 scores, comparable curve correction, shorter operation time, less blood loss, shorter hospital stays and lower charges when compared to combined anterior and posterior surgery.</p>

Evaluation of the protective performance of a positive pressure bio-protective clothing against viral aerosol / 中华预防医学杂志

<p><b>OBJECTIVE</b>To evaluate the protective performance of a positive pressure bio-protective clothing against viral aerosol.</p><p><b>METHODS</b>The suspension of indicating virus phage Phi-X174 was made for viral aerosol generating in a hermetic cabin. The diameter of viral aerosol particles were measured with a aerodynamics size analyzer. By adjusting the inner humidity of the cabin, the protective efficiency of the positive pressure bio-protective clothing against viral aerosol in high and low windshield conditions was determined with Andersen six-stage air sampler sampling and plage forming unit (PFU) counting, respectively.</p><p><b>RESULTS</b>The mass median diameter of Phage Phi-X174 aerosol particles was about 0.922 µm and the background concentration is beyond 2 × 10⁴ particles/m³. The protective efficiency of the clothing against phage Phi-X174 aerosol particles was above 99.9% under different test conditions with the range of viral aerosol concentration between 0 - 23 PFU/m³. Airflow (P = 0.84), environment humidity conditions (P = 0.33) and sampling time (P = 0.07) did not affect the protective efficiency statistically.</p><p><b>CONCLUSION</b>The positive pressure bio-protective clothing provided a relatively high efficiency against phage Phi-X174 aerosol regardless of airflow rate, environment humidity and sampling time.</p>

Clinical study of submental artery island myocutaneous flap for reconstruction of oral and maxillofacial defects following operation / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To evaluate the outcome and indication of the reconstruction of oral and maxillofacial postoperative defects by submental artery island myocutaneous flaps.</p><p><b>METHODS</b>Sixty eight cases with the reconstruction of oral and maxillofacial defects by submental artery island myocutaneous flaps from January 2006 to May 2010 were analysed retrospectively. Primary lesions included carcinomas originating from tongue (28 cases), palate (13 cases), mouth floor (9 cases), gingiva (4 cases), buccal mucosa (6 cases), lip (3 cases), and other malignant or benign tumors (5 cases). The ages ranged from 25 to 84 years (mean 58 years); 47 males and 21 females. The sizes of skin paddle varied from a minimum of 4 cm × 4 cm to a maximum of 15 cm × 10 cm.</p><p><b>RESULTS</b>Of the 68 flaps, 62 were survival, 4 had partial necrosis but healed with treatments, and 2 failed due to complete necrosis. Appearance and functions of recipient sites were satisfactory. The followed-up time was 3 - 24 months, local recurrence occurred in 5 cases and cervical lymph node metastases were found in 15 patients.</p><p><b>CONCLUSION</b>Submental island flap is reliable for the reconstruction of postoperative defects in early oral cancer without regional lymph node metastasis or in benign tumor.</p>

Molecular and epidemiological study on viral diarrhea among infants in Lanzhou / 中华实验和临床病毒学杂志

<p><b>OBJECTIVE</b>To study the epidemiologic characteristics of viral diarrhea in children under 5 years old in Lanzhou, understand the four major virus in children of distribution.</p><p><b>METHODS</b>In the first hospital of Lanzhou university from Jul 2009 to Jun 2010,we collected 290 stool specimens from children with diarrhea and 114 asymptomatic controls. Rotavirus was detected by ELISA,further strain characterization was carried out by nested PCR. The human calicivirus, astrovirus, adenovirus were detected by RT-multiplex PCR and PCR.</p><p><b>RESULTS</b>At least one of the four viral agents was found in 60% of the specimens. Rotavirus, human calicivirus, adenovirus, and astrovirus were identified in 39.31%, 11.38%, 10.69%, and 4.83% in 290 specimens respectively. Rotavirus G3 was the most prevailing serotype, P [8] was the most common genotype. In the 114 control samples, 7 sample was positived for calicivirus, 5 samples were positived for human adenovirus and 1 sample was positived for astrovirus.</p><p><b>CONCLUSION</b>The results indicated clearly the impact of viral agents causing diarrhea and the importance of long-term systematic surveillance.</p>

Study on concentration of nuorovirus genegroup II from environmental water / 病毒学报

A new viral sampling concentration device was designed which was equipped with a new cationic filter membrane-Nanoceram suitable for field sampling. Norovirus Genegroup II was detected from environmental water with the aid of this device. The effects on virus recovery of prefiltration, various second-concentration methods, and different eluants were investigated through pre-experiment. The concentration optimized process, and the optimal concentration process were then determined. The results showed that the prefiltration had a profound effect on virus recovery, and two second-concentration method: PEG-NaC1 precipitation and celite adsorption, had almost the same concentration effects. The Na2 HPO4 solution of 0.15 mol/L was selected as the final eluant to elute the adsorbed Nuorovirus from the celite. The virus recovery of Nanoceram was determined to be 3.02%. Finally, successful detection of Norovirus GII in sewage from Yangqiao River, Fengtai District, Beijing was acheived. All these data had shown that the Naneceram filter concentration method could concentrate Norovirus from environmental water with a steady effects.

A novel method for multiplex detection of gastroenteritis-associated viruses / 病毒学报

To develop and optimize a simultaneous detection method of RotavirusA, Norovirus GI, GII, Sapovirus, human astrovirus, enteric adenoviruses and HBoV2 with GenomeLab GeXP analysis system. The sensitivity was verified to be 10(4) copies/microL with plasmids containing the viral targets in triplicate on different days, and no cross-reaction with enterovirus71, human Parechovirus and PicobirnavirusII was observed. Finally, we successfully developed a high throughout, rapid and maneuverable multiplex RT-PCR assay for simultaneous detection of seven viruses related with viral gastroenteritis, which provide a novel method for the molecular diagnosis of diarrhea-associated virus.

A review of clinical and histological parameters associated with contralateral neck metastases in oral squamous cell carcinoma / 国际口腔科学杂志·英文版

Oral squamous cell carcinoma (OSCC) has a high incidence of cervical micrometastases and sometimes metastasizes contralaterally because of the rich lymphatic intercommunications relative to submucosal plexus of oral cavity that freely communicate across the midline, and it can facilitate the spread of neoplastic cells to any area of the neck consequently. Clinical and histopathologic factors continue to provide predictive information to contralateral neck metastases (CLNM) in OSCC, which determine prophylactic and adjuvant treatments for an individual patient. This review describes the predictive value of clinical-histopathologic factors, which relate to primary tumor and cervical lymph nodes, and surgical dissection and adjuvant treatments. In addition, the indications for elective contralateral neck dissection and adjuvant radiotherapy (aRT) and strategies for follow-up are offered, which is strongly focused by clinicians to prevent later CLNM and poor prognosis subsequently.