[Characteristics and correlated factors of preoperative sleep disorders in cardiac surgical patients]

Objective: To investigate the clinical characteristics and correlated factors of preoperative sleep disorders in patients undergoing various types of cardiac surgery. Methods: The data of patients at the Structural Heart Surgery Center of Beijing Anzhen Hospital, Capital Medical University, from April 2023 to February 2024 were retrospectively collected. Patients were categorized into five groups based on cardiac surgical diagnosis: coronary heart disease, valvular disease, large vessel disease, congenital heart disease, and others. Each group was further subdivided into normal sleep (NS) and sleep disorder (SD) groups based on the Pittsburgh Sleep Quality Index (PSQI) scores. Demographic information, cognitive function, psychiatric symptoms, and other relevant data were collected. Clinical characteristics were compared between groups, and factors associated with preoperative sleep disorders were analyzed using multivariate logistic regression. Results: A total of 1 016 patients aged (58.6±12.7) years were included in the study, including 701 males and 315 females. The incidence of SD was 45.6% (463/1 016). Multivariate logistic regression analysis showed that aging was a risk factor for sleep disorders in patients with coronary heart disease (OR=1.050, 95%CI: 1.026-1.077) and valvular disease (OR=1.033, 95%CI: 1.013-1.053). High Self-rating Depression Scale (SDS) score was a risk factor for sleep disorders in patients with valvular disease (OR=1.050, 95%CI: 1.013-1.091). High score on the Montreal Cognitive Assessment (MoCA) subitem-abstraction ability was a protective factor for sleep disorders in patients with coronary heart disease (OR=0.695, 95%CI: 0.490-0.981). Conclusions: The risk factors of preoperative sleep disorders in cardiac surgery patients vary based on the type of cardiac disease. Aging, depression and abstraction ability correlate with sleep disorders in cardiac surgical patients.

Brain-movement relationship during upper-limb functional movements in chronic post-stroke patients

BACKGROUND

Following a stroke, brain activation reorganisation, movement compensatory strategies, motor performance and their evolution through rehabilitation are matters of importance for clinicians. Two non-invasive neuroimaging methods allow for recording task-related brain activation: functional near-infrared spectroscopy (fNIRS) and electroencephalography (fEEG), respectively based on hemodynamic response and neuronal electrical activity. Their simultaneous measurement during movements could allow a better spatiotemporal mapping of brain activation, and when associated to kinematic parameters could unveil underlying mechanisms of functional upper limb (UL) recovery. This study aims to depict the motor cortical activity patterns using combined fNIRS-fEEG and their relationship to motor performance and strategies during UL functional tasks in chronic post-stroke patients.

METHODS

Twenty-one healthy old adults and 21 chronic post-stroke patients were recruited and completed two standardised functional tasks of the UL: a paced-reaching task where they had to reach a target in front of them and a circular steering task where they had to displace a target using a hand-held stylus, as fast as possible inside a circular track projected on a computer screen. The activity of the bilateral motor cortices and motor performance were recorded simultaneously utilizing a fNIRS-fEEG and kinematics platform.

RESULTS AND CONCLUSIONS

Kinematic analysis revealed that post-stroke patients performed worse in the circular steering task and used more trunk compensation in both tasks. Brain analysis of bilateral motor cortices revealed that stroke individuals over-activated during the paretic UL reaching task, which was associated with more trunk usage and a higher level of impairment (clinical scores). This work opens up avenues for using such combined methods to better track and understand brain-movement evolution through stroke rehabilitation.

A phase III trial of adjuvant ribociclib plus endocrine therapy vs endocrine therapy alone in patients with HR+/HER2- early breast cancer: final invasive disease-free survival results from the NATALEE trial

BACKGROUND

NATALEE assessed efficacy and tolerability of 3 years of adjuvant ribociclib plus NSAI compared with a nonsteroidal aromatase inhibitor (NSAI) alone in a broad population of patients with HR+/HER2- early breast cancer, including a select group without nodal involvement. This is the final preplanned analysis of invasive disease-free survival (iDFS).

PATIENTS AND METHODS

Premenopausal/postmenopausal women and men were randomized 1:1 to ribociclib (n=2549; 400 mg/day, 3 weeks on/1 week off for 36 months) plus NSAI (letrozole 2.5 mg/day or anastrozole 1 mg/day for 60 months) or NSAI alone (n=2552). Men and premenopausal women also received goserelin (3.6 mg once every 28 days). Patients had anatomical stage IIA (N0 with additional risk factors or N1), IIB, or III disease. The primary endpoint was iDFS. Secondary efficacy endpoints were recurrence-free survival (RFS), distant DFS (DDFS), and overall survival (OS). This final iDFS analysis was planned after ≈500 events.

RESULTS

At data cutoff (21 July 2023), ribociclib was stopped for 1996 patients (78.3%); 1091 (42.8%) completed 3 years of ribociclib, and ribociclib treatment was ongoing for 528 (20.7%). Median follow-up for iDFS was 33.3 months. Overall, 226 and 283 iDFS events occurred with ribociclib plus NSAI vs NSAI alone, respectively. Ribociclib plus NSAI demonstrated significant iDFS benefit over NSAI alone (Hazard Ratio 0.749, 95% Confidence Interval [CI] 0.628-0.892; P=0.0012). The 3-year iDFS rates were 90.7% (95% CI 89.3%-91.8%) vs 87.6% (95% CI 86.1%-88.9%). A consistent benefit was observed across prespecified subgroups, including stage (II/III) and nodal status (+/-). DDFS and RFS favored ribociclib plus NSAI. OS data were immature. No new safety signals were observed.

CONCLUSIONS

With longer follow-up and most patients off ribociclib, NATALEE continues to demonstrate iDFS benefit with ribociclib plus NSAI over NSAI alone in the overall population and across key subgroups. Observed adverse events remained stable.

Final analysis of the ALTTO trial: adjuvant trastuzumab in sequence or in combination with lapatinib in patients with HER2-positive early breast cancer [BIG 2-06/NCCTG N063D (Alliance)]

BACKGROUND

Dual anti-human epidermal growth factor receptor 2 (HER2) blockade has improved the outcomes of patients with early and metastatic HER2-positive breast cancer. Here we present the final 10-year analysis of the ALTTO trial.

PATIENTS AND METHODS

The ALTTO trial (NCT00490139) is a prospective randomized, phase III, open-label, multicenter study that investigated the role of adjuvant chemotherapy and trastuzumab alone, in combination or sequentially with lapatinib. The primary endpoint was disease-free survival (DFS) and secondary endpoints included overall survival (OS), time to distant recurrence and safety.

RESULTS

Overall, 6281 patients with HER2-positive early breast cancer were included in the final efficacy analysis in three treatment groups: trastuzumab (T), lapatinib + trastuzumab (L + T) and trastuzumab followed by lapatinib (T→L). Baseline characteristics were well balanced between groups. At a median follow-up of 9.8 years, the addition of lapatinib to trastuzumab and chemotherapy did not significantly improve DFS nor OS. The 10-year DFS was 77% in T, 79% in L + T and 79% in T→L, and the 10-year OS was 87%, 89% and 89%, respectively. The incidence of any cardiac event was low and similar in the three treatment groups.

CONCLUSIONS

With a longer follow-up, no significant improvement was observed in DFS in patients treated with dual anti-HER2 blockade with lapatinib + trastuzumab compared to trastuzumab alone. The 10-year survival rates for the combination group are consistent with other studies that have explored dual anti-HER2 therapy.

Sodium-glucose cotransporter 2 inhibitors and cancer: a systematic review and meta-analysis

BACKGROUND

The effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors on cancer has yet to be fully elucidated.

OBJECTIVE

This systematic review and meta-analysis investigated the effects of SGLT2 inhibitors on cancer.

METHODS

We searched the PubMed and ClinicalTrials.gov databases up to July 15, 2023, to identify eligible randomized, double-blind, placebo-controlled trials that lasted at least ≥24 weeks. The primary outcome was the overall cancer incidence, and the secondary outcomes were the incidences of various types of cancer. We used the Mantel-Haenszel method, fixed effects model, risk ratio (RR) and 95% confidence interval (CI) to analyze dichotomous variables. Subgroup analysis was performed based on the SGLT2 inhibitor type, baseline conditions, and follow-up duration. All meta-analyses were performed using RevMan5.4.1 and Stata MP 16.0.

RESULTS

A total of 58 publications (59 trials) were included, comprising 113,909 participants with type 2 diabetes mellitus and/or chronic kidney disease and/or high cardiovascular risk and/or heart failure (SGLT2 inhibitor group, 63864; placebo group, 50045). Compared to the placebo SGLT2 inhibitors did not significantly increase the overall incidence of cancer (RR 1.01; 95% CI 0.94-1.08; p = 0.82). However, ertugliflozin did significantly increase the overall incidence of cancer (RR 1.29; 95% CI 1.01-1.64; p = 0.04). SGLT2 inhibitors did not increase the risks of bladder or breast cancer. However, dapagliflozin did significantly reduce the risk of bladder cancer by 47% (RR 0.53; 95% CI 0.35-0.81; p = 0.003). SGLT2 inhibitors had no significant effect on the risks of gastrointestinal, thyroid, skin, respiratory, prostate, uterine/endometrial, hepatic and pancreatic cancers. Dapagliflozin reduced the risk of respiratory cancer by 26% (RR 0.74; 95% CI 0.55-1.00; p = 0.05). SGLT2 inhibitors (particularly mediated by dapagliflozin and ertugliflozin but not statistically significant) were associated with a greater risk of renal cancer than the placebo (RR 1.39; 95% CI 1.04-1.87; p = 0.03).

CONCLUSION

SGLT2 inhibitors did not significantly increase the overall risk of cancer or the risks of bladder and breast cancers. However, the higher risk of renal cancer associated with SGLT2 inhibitors warrants concern.

Temperature-Modulated Evolution of Surface Structures Induces Significant Enhancement of Two-Photon Fluorescent Emission from a Dye Molecule

Fluorescence is an essential property of molecules and materials that plays a pivotal role across various areas such as lighting, sensing, imaging, and other applications. For instance, temperature-sensitive fluorescence emission is widely utilized for chemo-/biosensing but usually decreases the intensity upon the increase in temperature. In this study, we observed a temperature-induced enhancement of up to ∼150 times in two-photon fluorescence (TPF) emission from a dye molecule, 4-(4-diethylaminostyry)-1-methylpyridinium iodide (D289), as it interacted with binary complex vesicles composed of two commonly applied surfactants: sodium dodecyl sulfate (SDS) and cetyltrimethylammonium bromide (CTAB). By employing second harmonic generation (SHG) and TPF techniques, we clearly revealed the temperature-dependent kinetic behavior of D289 on the surface of the vesicles and utilized it to interpret the origin of the significant TPF enhancement. Additionally, we also demonstrated a similar heating-induced enhancement of the TPF emission from D289 on the membrane of phospholipid vesicles, indicating the potential application of TPF in temperature sensing in the biology systems. The embedding of D289 in the tightly packed alkane chains was identified as the key factor in enhancing the TPF emission from D289. This finding may provide valuable information for synthesizing fluorescence materials with a high optical yield.

[Application of the CRISPR/Cas system in gene editing and nucleic acid detection of parasitic diseases: a review]

CRISPR/Cas system, an adaptive immune system with clustered regularly interspaced short palindromic repeats, may interfere with exogenous nucleic acids and protect prokaryotes from external damages, is an effective gene editing and nucleic acid detection tools. The CRISPR/Cas system has been widely applied in virology and bacteriology; however, there is relatively less knowledge about the application of the CRISPR/Cas system in parasitic diseases. The review summarizes the mechanisms of action of the CRISPR/Cas system and provides a comprehensive overview of their application in gene editing and nucleic acid detection of parasitic diseases, so as to provide insights into future studies on parasitic diseases.

Diagnostic value of serum squamous cell carcinoma antigen and cytokeratin fragment antigen 21-1 for sinonasal inverted papilloma: an exploratory study

BACKGROUND

Serum tumor markers have not yet been developed for the clinical diagnosis and treatment of sinonasal inverted papilloma (SNIP), one of the most significant sinonasal tumors. Therefore, this study aimed to determine the diagnostic value of serum squamous cell carcinoma antigen (SCCA) and cytokeratin fragment antigen 21-1 (CYFRA 21-1) for SNIP.

METHODS

Clinical data were obtained from 101, 56, and 116 patients with SNIP, sinonasal squamous cell carcinoma (SNSCC), and unilateral chronic rhinosinusitis (CRS), respectively. Preoperative serum SCCA and CYFRA 21-1 levels were compared, and logistic regression analyses were performed to screen serum tumor markers, which may be used to diagnose SNIP. Diagnostic cut-off values were determined using receiver operating characteristic (ROC) curves, and their diagnostic power was verified.

RESULTS

Serum SCCA and CYFRA 21-1 differentiated SNIP from CRS with the cut-off values of 1.97 ng/mL and 2.64 ng/mL and the areas under the ROC curves (AUC) of 0.895 and 0.766, respectively, and the AUC of the combination of the two markers was 0.909. CYFRA 21-1 differentiated SNIP with malignant transformation from that without malignant transformation with a cut-off value of 3.51 ng/mL and an AUC of 0.938. CYFRA 21-1 distinguished SNIP with malignant transformation from SNSCC with a cut-off value of 3.55 ng/mL and an AUC of 0.767.

CONCLUSIONS

This study provides novel potential diagnostic tools for SNIP by demonstrating the use of serum SCCA and CYFRA 21-1 in the diagnosis of SNIP.

Factors Influencing the Utilisation of Mammography Among Ethnic Minorities: A Framework-Driven Systematic Review and Meta-Analysis

Ethnic minority women experience disparities in mammography screening utilisation and breast cancer outcomes. This systematic review and meta-analysis synthesised multidomain and multilevel factors that intersect to influence the utilisation of mammography among ethnic minorities. A literature search was conducted in five databases (PubMed, Ovid MEDLINE, EMBASE, CINAHL, and PsycINFO) from inception to May 2022. Guided by the National Institute on Minority Health and Health Disparity research framework, the retrieved data were synthesised using narrative summaries and meta-analyses. Among the 27 studies, most (n = 24) reported individual, interpersonal, and community factors in the health care system domain. In the sociocultural domain, interpersonal and societal (n = 8) factors, such as modesty and karma beliefs, were less frequently identified than individual (n = 20) factors in relation to acculturation. Only individual-level factors were reported for the biological and physical/built environment (e.g., rural residence) domains. In the behavioural domain, cancer screening behaviours had a high combined prediction ability (odds ratio = 18.23; I2 = 23%), whereas interpersonal (e.g., family obligations) and community (e.g., neighbourhood violence) factors discouraged mammography screening. Special focus should be given to ethnic minority women, especially those living in rural areas, those with considerable family obligations, and those who have suffered from violence and other life pressures, to increase their access to mammography services. Multidomain and multilevel efforts, culturally appropriate strategies, and equity-advancing policies such as geographic access and insurance coverage would help to mitigate the ethnic disparities in mammography screening.

[Feasibility analysis of the application of programmed process endoscopic lateral neck dissection via chest-breast approach in papillary thyroid carcinoma surgery]

Objective: To explore the feasibility of endoscopic lymph node dissection(LND) with programmed breast approach for the treatment of papillary thyroid cancer. Methods: A case series study. The clinical data of 39 patients with papillary thyroid cancer who underwent endoscopic LND treatment with programmed breast approach in Shenzhen People's Hospital from January to November 2022 were retrospectively analyzed. There were 10 males and 29 females, aged (35.95±10.17) years. LND time, total surgical time, intraoperative bleeding volume, postoperative drainage volume, postoperative hospital stay and postoperative complications were analyzed. Results: Among 39 patients, there were 18 cases of unilateral thyroid cancer, 21 cases of bilateral thyroid cancer, 35 cases of unilateral LND, and 4 cases of bilateral LND. The maximum diameter of thyroid cancer lesions was (1.48±0.69) cm, and the maximum diameter of lymph node metastases was (1.63±0.58)cm. The operative time of unilateral neck dissection was (124.11±19.92) min (102-170 min), and the total operative time was (226.42±55.68) min (110-390 min). The number of lymph nodes cleaned was (32.40±10.44)(12-54), the number of metastasis and detection was 207/1 393. The postoperative drainage volume was (174.64±82.33) ml(41-350 ml). There were no neck hematomas, no skin burns or no shrugging disorders in the postoperative period. There were 7 cases of numbness and discomfort in neck skin sensation, which gradually relieved after half a year. Postoperative discharge time (4.77±1.94) d(3-15 d). Conclusion: It is safe and feasible to treat papillary thyroid cancer with endoscopic LND with programmed breast approach, which can improve surgical efficiency and clinical application value.

Trastuzumab deruxtecan versus trastuzumab emtansine in HER2-positive metastatic breast cancer patients with brain metastases from the randomized DESTINY-Breast03 trial

BACKGROUND

DESTINY-Breast03 is a randomized, multicenter, open-label, phase III study of trastuzumab deruxtecan (T-DXd) versus trastuzumab emtansine (T-DM1) in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (mBC) previously treated with trastuzumab and a taxane. A statistically significant improvement in progression-free survival (PFS) versus T-DM1 was reported in the primary analysis. Here, we report exploratory efficacy data in patients with and without brain metastases (BMs) at baseline.

PATIENTS AND METHODS

Patients were randomly assigned 1 : 1 to receive T-DXd 5.4 mg/kg or T-DM1 3.6 mg/kg. Patients with clinically inactive/asymptomatic BMs were eligible. Lesions were measured as per modified RECIST, version 1.1. Outcomes included PFS by blinded independent central review (BICR), objective response rate (ORR), and intracranial ORR as per BICR.

RESULTS

As of 21 May 2021, 43/261 patients randomized to T-DXd and 39/263 patients randomized to T-DM1 had BMs at baseline, as per investigator assessment. Among patients with baseline BMs, 20/43 in the T-DXd arm and 19/39 in the T-DM1 arm had not received prior local BM treatment. For patients with BMs, median PFS was 15.0 months [95% confidence interval (CI) 12.5-22.2 months] for T-DXd versus 3.0 months (95% CI 2.8-5.8 months) for T-DM1; hazard ratio (HR) 0.25 (95% CI 0.13-0.45). For patients without BMs, median PFS was not reached (95% CI 22.4 months-not estimable) for T-DXd versus 7.1 months (95% CI 5.6-9.7 months) for T-DM1; HR 0.30 (95% CI 0.22-0.40). Confirmed systemic ORR was 67.4% for T-DXd versus 20.5% for T-DM1 and 82.1% for T-DXd versus 36.6% for T-DM1 for patients with and without BMs, respectively. Intracranial ORR was 65.7% with T-DXd versus 34.3% with T-DM1.

CONCLUSIONS

Patients with HER2-positive mBC whose disease progressed after trastuzumab and a taxane achieved a substantial benefit from treatment with T-DXd compared with T-DM1, including those with baseline BMs.

Klotho-mediated activation of the anti-oxidant Nrf2/ARE signal pathway affects cell apoptosis, senescence and mobility in hypoxic human trophoblasts: involvement of Klotho in the pathogenesis of preeclampsia

The anti-aging gene Klotho is implicated in the pathogenesis of preeclampsia (PE), which is a pregnancy disease characterized by hypertension and proteinuria. Oxidative stress is closely associated with the worse outcomes in PE, and Klotho can eliminate Reactive Oxygen Species (ROS), but it is still unclear whether Klotho regulates PE pathogenesis through modulating oxidative damages. Here, by analyzing the clinical data, we found that Klotho was aberrantly downregulated in PE umbilical cord serum and placental tissues, compared to their normal counterparts. In in vitro experiments, the human trophoblasts were subjected to hypoxic pressure to establish the PE models, and we confirmed that hypoxia also decreased the expression levels of Klotho in those trophoblasts. In addition, through performing functional experiments, we confirmed that hypoxia promoted oxidative damages, cell apoptosis and senescence, whereas suppressed cell invasion in human trophoblasts, which were all reversed overexpressing Klotho. The following mechanical experiments verified that Klotho increased the levels of nuclear Nrf2, total Nrf2, SOD2 and NQO1 to activate the anti-oxidant Nrf2/ARE signal pathway, and silencing of Nrf2 abrogated the protective effects of Klotho overexpression on hypoxic human trophoblasts. Consistently, in in vivo experiments, Klotho overexpression restrained oxidative damages and facilitated cell mitosis in PE rats' placental tissues. In conclusion, this study validated that Klotho activated the Nrf2/ARE signal pathway to eliminate hypoxia-induced oxidative damages, cell apoptosis and senescence to recover normal cellular functions in human trophoblasts, and our data supported that Klotho could be used as novel biomarker for PE diagnosis and treatment.

[Application of gastric plication in the treatment of obesity]

Bariatric surgery, as the most effective approach to treating obesity at present, encompasses a wide array of procedures. However, due to the significant anatomical changes to the gastrointestinal tract caused by most of these procedures, they are associated with certain risks of complications. In the pursuit of minimizing trauma, bariatric surgeons have begun exploring new surgeries in addition to traditional procedures. Gastric plication surgeries encompass various procedures such as gastric fundoplication, gastric greater curvature plication, endoscopic sleeve gastroplasty, combined gastric fundoplication with gastric greater curvature plication, and combined gastric fundoplication with sleeve gastrectomy, among others. The efficacy and risks of complications associated with these procedures fall between those of medical therapy and sleeve gastrectomy. Gastric fundoplication, functioning as an anti-reflux procedure, can also be integrated into weight loss surgical interventions to effectively address obesity-related gastroesophageal reflux disease in obese patients. Both gastric greater curvature plication and endoscopic sleeve gastroplasty yield favorable weight loss outcomes. Beyond the impact of folding procedures on body mass, gastric plication surgeries can also be combined with other techniques. The combination of gastric fundoplication with sleeve gastrectomy or greater curvature plication can reduce body mass and mitigate reflux, while the combination of greater curvature plication with gastric bypass and similar procedures can further enhance weight loss and metabolic improvements.

B cells and tertiary lymphoid structures are associated with survival in papillary thyroid cancer

PURPOSE

The function of B cells in papillary thyroid cancer (PTC) is controversial. The role of B-cell-related tertiary lymphoid structures (TLSs) is still unclear. Whether B cells exert their anti-tumor effect through forming TLS in PTC needs further investigation.

METHODS

We detected the percentage of B cells in PTC tissues by multi-parameter flow cytometry. Paraffin-embedded tumor tissues of 125 PTC patients were collected and stained with Haematoxylin-Eosin (H&E) for inflammatory infiltration analysis in combination with clinical features. Multiplexed immunohistochemistry (mIHC) was performed to verify the TLSs in above inflammatory infiltration. Correlation of B cells and TLSs with prognosis was analyzed using the TCGA database.

RESULTS

We observed that PTC patients with higher expression of B lineage cell genes had improved survival and the percentage of B cells in the PTC tumor tissues was variable. Moreover, PTC tumor tissues with more B cells were surrounded by immune cell aggregates of varying sizes. We furtherly confirmed the immune cell aggregates as TLSs with different maturation stages. By analyzing PTC data from TCGA database, we found the maturation stages of TLSs were associated with genders and clinical stages among PTC patients. Moreover, patients with high TLSs survived longer and had a better prognosis.

CONCLUSION

B cells are associated with the existence of TLSs which have different maturation stages in PTC. Both B cells and TLSs are associated with the survival rate of PTC. These observations indicate that the anti-tumor effects of B cells in PTC are associated with TLSs formation.

[Post-ischemic treatment of nalmefene hydrochloride attenuated lung ischemia-reperfusion injury in rats via the Sirt1/Nrf2/HO-1 pathway with inhibition of ferroptosis]

Objective: To study the effect and mechanism of post-ischemic treatment of nalmefene in alleviating the lung ischemia-reperfusion injury by inhibiting ferroptosis through activation of the Sirt 1/Nrf 2/HO-1 axis. Methods: A total of 60 rats were randomly divided into six groups equally (n=10): the sham group, the model group(I/R), the nalmefene group, the nalmefene+EX527 group, the nalmefene+ML385 group, the nalmefene+Fe-citrate group (nalmefene+Fe group). The sham group without drug treatment was not treated with ischemia-reperfusion. The pulmonary ischemia-reperfusion model was established by occlusion of the left pulmonary hilum in the model group without drug treatment. After ischemic treatment, the nalmefene group was injected with nalmefene (15 μg/kg) via the tail vein at 5 minutes before reperfusion. The nalmefene+EX527 group, the nalmefene+ML385 group, and the nalmefene+Fe group were injected intraperitoneally with EX527 (5 mg/kg), ML385 (30 mg/kg), Fe-citrate(15 mg/kg), respectively, 2 h before moulding and then injected with nalmefene (15 μg/kg) via the tail vein at 5 minutes before reperfusion. All rats were sacrificed three hours after reperfusion, and the specimens from the upper lobe of the left lung tissue were preserved. The degree of lung tissue injury and the wet/dry weight ratio were assessed in each group of rats. Fe 2+, MDA, TNF-α, and IL-6 content, GSH activity and the expression levels of Sirt1, Nrf2, HO-1, ACSL4 and GPX4 were determined. Results: Compared with the sham group, the wet/dry weight ratio, lung tissue injury score, ACSL 4 expression level, Fe 2+, TNF-α, IL-6 and MDA content, Sirt 1, Nrf 2, HO-1 messenger RNA and protein expression levels were significantly increased (P<0.01), while GPX 4 expression level and GSH activity were significantly decreased in the model group (P<0.01). Compared with the model group, wet/dry weight ratio, lung tissue injury score, ACSL 4 expression level, Fe 2+, TNF-α, IL-6, and MDA content decreased significantly (P<0.01), Nrf 2, HO-1 messenger RNA and protein, GPX 4 expression, and GSH activity were significantly increased in the nalmefene group and the nalmefene+EX527 group (P<0.01). Sirt 1 messenger RNA and protein expression increased significantly in the nalmefene (P<0.01) and the nalmefene+EX527 groups (P>0.05). In the nalmefene+ML385 group, the wet/dry weight ratio, lung tissue injury score, TNF-α and IL-6 content were decreased significantly (P<0.01), while Sirt 1 messenger RNA and protein expression levels were significantly increased (P<0.01), but there were no significant changes in Nrf 2, HO-1 messenger RNA and protein expression levels, ACSL 4 and GPX 4 expression levels, Fe 2+, MDA content, and GSH activity (P>0.05). In the nalmefene+Fe group, wet/dry weight ratio, lung-injury score, TNF-α, IL-6, MDA content were decreased significantly (P<0.01), messenger RNA and protein expression levels of Sirt 1, Nrf 2, HO-1, and GSH activity were increased significantly (P<0.01), but there were no significant changes in Fe 2+content, ACSL 4 and GPX 4 expression levels (P>0.05). Compared with the nalmefene group, in the nalmefene+EX527 group, the nalmefene+ML385 group and the nalmefene+Fe group, wet/dry weight ratio, lung tissue damage score, ACSL 4 expression level, TNF-α, IL-6 and MDA content were significantly increased (P<0.01), the expression level of GPX 4 and GSH activity were significantly decreased (P<0.01). The expression levels of Sirt 1, Nrf 2, HO-1 messenger RNA and protein were significantly decreased in the nalmefene+EX527 group (P<0.01). The expression levels of Nrf 2, HO-1 messenger RNA and protein decreased significantly in the namemefene+ML385 group (P<0.01), but there was no significant change in Sirt 1 messenger RNA and protein expression level (P>0.05). Sirt 1, Nrf 2, HO-1 messenger RNA-protein expression levels did not change significantly in the nalmefene+Fe group (P>0.05). Conclusion: Post-ischemic treatment with nalmefene hydrochloride may alleviate pulmonary ischemia-reperfusion injury by inhibiting ferroptosis through activation of the Sirt 1/Nrf 2/HO-1 axis.

[Investigation and analysis of oral health resources allocation status in Yunnan Province]

Objective: To investigate and analyze the allocation status of oral health resources in Yunnan Province at the end of the 13th Five-Year Plan, providing a scientific basis for the rational resource allocation and formulation regional oral health plan for government health administrative departments. Methods: With the method of general survey, a cross-sectional study was conducted to investigate the allocation of material and human resources of all kinds of stomatological medical institutions registered in the health administrative departments in Yunnan before January 1, 2020. The general situation of oral health resources was analyzed by descriptive statistical analysis. Results: There were 2 712 stomatological medical institutions in Yunnan, 634 public and 2 078 non-public included. The largest number was in Kunming (1 167) and the least in Diqing (19). There were 9 018 dental chairs in total, among which 2 584 in public and 6 434 in non-public. Kunming had the largest number of chairs (3 612) and Nujiang had the least (57). There were 702 oral and maxillofacial surgical beds, all of which were distributed in public. There were 15 148 stomatological personnel, including 3 667 in public and 11 481 in non-public. The average ratio of stomatologist to population was 1∶6 615. Dehong (1∶6 620) was close to this average level, while Kunming (1∶2 283) and Yuxi (1∶4 936) were lower than the average and the other 13 states (cities) were higher. The population ratio of licensed stomatologist was only 1∶9 110. The average ratio of stomatologist to nurses was 1∶0.94. Honghe (1∶1.05), Kunming (1∶1.00), Yuxi (1∶1.18) and Qujing (1∶0.94) was better than or reached the average level, while the other 13 states (cities) were lower than this average. And this ratio in public comprehensive medical institutions was only 1∶0.38. Conclusions: The distribution of oral health resources in Yunnan was unbalanced between public and non-public institutions and among states (cities), mainly distributed in economically developed states (cities) and non-public institutions. For the oral health in Yunnan Province, the workforce was insufficient and the structure was unreasonable, and the proportion of nurses was seriously insufficient in public comprehensive medical institutions.

Respiratory Motion Compensation Using Xsight Diaphragm Tracking for Liver Tumor in CK Synchrony Treatment: A Feasibility Study

PURPOSE/OBJECTIVE(S)

This study investigates the feasibility of using Xsight Diaphragm Tracking (XDT) for liver tumors located near or in the diaphragm during CyberKnife Synchrony Treatment.

MATERIALS/METHODS

Eight patients (46 fractions) with liver tumors located near or in the diaphragm were reviewed retrospectively. Prior to motion data analysis, baselines were flattened to remove the portions with significant changes and improve accuracy. To reduce the uncertainty about sudden irregular breathing, respiratory data were calculated as a rolling average. The overall tracking accuracy based on the patient-specific respiratory curve was evaluated using E2E testing with CIRS (18023-A) dynamic phantom.

RESULTS

Three main trajectories were observed in this work: Linearity (1/8), Linear radial type (6/8) and Hysteresis (1/1). The mean amplitude was 8.56±4.54 mm, 2.77±2.83 mm, and 4.23±3.92 mm for S-I, L-R, and A-P components. The linear trajectory patient had a more concentrated amplitude distribution. The baseline shifts were 5.88 mm (S-I), 2.53 mm (L-R), and 3.48 mm (A-P). Except for patient 2, all standard deviations of the center phase shift were less than 1 mm. The values of XDT correlation and prediction errors were 1.38±0.65 mm vs. 0.65±0.16 mm (S-I), 1.28±0.48 mm vs. 0.34±0.10 mm (L-R), and 0.96±0.32 mm vs. 0.22±0.072 mm (A-P), respectively. The strong positive correlations were amplitude vs. prediction error, SD of center phase vs. prediction error, and SD of center phase vs. amplitude. The median patient curve-based targeting accuracy was less than 1mm. Additionally, the mean target coverage for all patients with a 3 mm margin was 98.03±1.54%.

CONCLUSION

This study proved that the diaphragm could be used as a tracking surrogate for liver tumors located in or near the diaphragm instead of placing golden fiducial markers. A reduction in motion amplitude and respiration training were necessary during liver SABR treatment, along with respiration control and evaluation.

Exploring the Efficacy and Molecular Mechanism of Systemic Therapy-Based Split-Course Stereotactic Body Radiation Therapy for Solid Tumors

PURPOSE/OBJECTIVE(S)

Considering the therapeutic toxicity, the question of how to administer adequate chemotherapy to synchronize Stereotactic body radiation therapy (SBRT) treatment strategy for maximizing the benefits of neoadjuvant therapy to improve prognosis is a challenging and debatable issue. This study explores the feasibility and theoretical advantages of the simultaneous implementation of split-course SBRT with systemic treatment.

MATERIALS/METHODS

We evaluated the effect of three irradiation regimens (conventional radiotherapy (C-R, 15×2 Gy, (D1-5, D8-12, D15-19)), continuous SBRT (C-S, 3×7 Gy, (D1-3)), split SBRT (S-S, 3×7 Gy, (D1, D10, D19)) in combination with systemic therapy (chemotherapy (gemcitabine), PD-1 inhibitor (Anti-mouse PD-1 antibody) and angiogenesis-targeting agent (Anlotinib)) on tumor growth and survival by using the immunologically active C57BL/6 bilateral subcutaneous model with different cancer cells. At different time points after treatment, we monitored changes in the tumor microenvironment and explored the possible mechanisms.

RESULTS

In the case of radiotherapy alone, we found similar tumor control in all groups but the best survival in the S-S group. When combined with systemic therapy, the S-S group has shown advantages in tumor control and survival. And the S-S combination group induced more CD4+ and CD8+ T lymphocyte infiltration in the tumor, which had the highest number of tumor vessels and the smallest area of hypoxia. Tumor cell PD-L1 expression was increased after radiotherapy in all but the most elevated and persistent S-S combination treatment group. CD3+ T cells, CD4+ T cells and CD8+ T cells peaked at weeks 2-3 after treatment, and all remained at the highest level for 6 weeks in the S-S combination group. Meanwhile, PD-L1 expression was significantly higher in all tumors in the third week than in other groups. The most significant reduction in the hypoxic area and increase in perfusion level was observed in the S-S group in the third week. RNA sequencing analysis revealed that immune response-related pathways were upregulated on the irradiated and non-irradiated side, tumor proliferation and invasion on the non-irradiated side, and angiogenesis-related pathways were down-regulated in the fractionated SBRT combination treatment group. In both irradiated side and non-irradiated side tumor tissues where the abscopal effect was observed, immune response-related pathways were upregulated in the S-S group relative to the C-R group, and tumor proliferation and invasion and angiogenesis-related pathways were found to be downregulated in the non-irradiated side.

CONCLUSION

In preclinical models, the combination of split SBRT with systemic therapy has been shown to be more advantageous than conventional segmentation, possibly by affecting immune cell infiltration in the tumor microenvironment and reducing tumor hypoxia.

The Role of Radiotherapy in Patients with Refractory Hodgkin Lymphoma after Brentuximab Vedotin and -/or Immune Checkpoint Inhibitors

PURPOSE/OBJECTIVE(S)

Brentuximab vedotin (BV) and immune checkpoint inhibitors (ICIs) had important roles in the treatment of relapse or refractory (R/R) Hodgkin lymphoma (HL). Treatment of refractory disease after BV and -/or ICIs remains a challenge. This study was conducted to evaluate the efficacy and safety of radiotherapy for R/R HL after failure to BV or ICIs.

MATERIALS/METHODS

We retrospectively analyzed patients in two institutions with R/R HL who had failed after first-line therapy, and were refractory to BV or ICIs, and received radiotherapy (RT) thereafter. The overall response rate (ORR), duration of response (DOR), progression-free survival (PFS) and overall survival (OS) were analyzed.

RESULTS

A total of 19 patients were enrolled. First-line systemic therapy consisted of ABVD (84.2%), AVD + ICIs (10.5%) and BEACOPP (5.3%), respectively. After first-line therapy, 15 patients (78.9%) were refractory, and 4 patients (21.1%) relapsed. After diagnosis of R/R HL, 8 patients (42.1%) received BV, and 17 patients (89.5%) received ICIs. RT was delivered in all 19 patients who failed after BV or ICIs. In 16 efficacy-evaluable patients, the ORR and CR rate were 100% and 100%. The median DOR was 17.2 months (range, 7.9 to 46.7 months). 3 patients progressed at outside of the radiation field. The in-field-response rate was 100%. The 12-month PFS and OS were 84.4% and 100%, respectively. No patients were reported with sever adverse events.

CONCLUSION

This study concluded that radiotherapy was effective and safe for refractory HL after BV or ICIs. Further prospective studies were warranted.

Safety and Efficacy of Spatially Fractionated Radiation Therapy Using Lattice Radiation for Metastatic and/or Bulky Disease

PURPOSE/OBJECTIVE(S)

Spatially fractionated radiation therapy (Lattice) delivers ablative doses to metastatic and/or unresectable tumors with a curative or palliative goal. Through different forms of three-dimensional focusing, lattice forms several spherical high-dose areas(vertices) within the tumor, to produce a more obvious peak-valley effect and limit exposure to surrounding normal tissue. This study aimed to evaluate the efficacy and toxicity of patients with metastatic and/or bulky tumors treated with Lattice radiation.

MATERIALS/METHODS

Between April 2017 and February 2021, 76 patients with metastatic or bulky tumors treated with spatially-fractionated high-dose external beam radiation using the Lattice technique were included. A median dose of 15 Gy/1 fraction (range 10-45 Gy in 1/3 fractions) was delivered to the vertices in the gross tumor volumes (GTV). 46 patients were treated with Lattice radiation combined with conventional fractionated external irradiation, and 30 patients were treated with Lattice alone. Patients were evaluated for clinical response, survival, and toxicity.

RESULTS

A total of 76 patients with 85 sites were included in the analysis, 63 (82.9%) patients had metastatic diseases. Median GTV was 138.6cc (range 4.9-3784.1cc) in volume and 6.2 cm (range:2.3-21.4cm) in greatest axial diameter. 38 tumors were in the thorax, 13 abdomen/pelvis, 19 metastatic lymph nodes, 8 bone, 5 head and neck, and 2 extremities. The median follow-up was 11.6 months (range 1.27-57.37 months). At the time of analysis, 23 patients (29.9%) were alive, without the progression of disease. 90.7% of the deceased patients died of disease progression. Median overall survival (OS) was 11.4 months (95% CI: 8.4-17.6), the 1-year OS and cancer specific survival were 46.8% and 48.7% respectively. The disease control rate (DCR) was 91.8%, including 2.4% complete remission, 48.2% partial remission, and 41.2% stable disease. Symptomatic improvement was observed in 98.7% of patients. No mortality was associated with Lattice therapy. There was no treatment-associated acute or late grade 3+ toxicity.

CONCLUSION

Lattice radiation is feasible and well-tolerated in the treatment of metastatic and/or bulky diseases, and may provide a high DCR. In light of these preliminary results, it seems that this therapy may be a new paradigm for treating patients with advanced cancers.

Quantitative image features of gadoxetic acid-enhanced MRI for predicting glypican-3 expression of small hepatocellular carcinoma ≤3 cm

AIM

To explore the value of quantitative image features of gadoxetic acid-enhanced magnetic resonance imaging (MRI) for predicting Gglypican-3 (GPC3) expression of single hepatocellular carcinoma (HCC) ≤3 cm.

MATERIALS AND METHODS

One hundred and forty-nine patients with histopathologically confirmed HCC were included retrospectively. Quantitative image features and clinicopathological parameters were analysed. The significant predictors for GPC3 expression were identified using multivariate logistic regression analyses. Nomograms were constructed from the prediction model and the progression-free survival (PFS) rate was evaluated by the Kaplan-Meier method.

RESULTS

The tumour-to-liver signal intensity (SI) ratio on the hepatobiliary phase (HBP; odds ratio [OR] = 0.004; p=0.001), serum alpha-fetoprotein (AFP) > 20 ng/ml (OR=6.175; p<0.001), and non-smooth tumour margin (OR=4.866; p=0.002) were independent significant factors for GPC3 expression. When the three factors were combined, the diagnostic specificity was 97.7% (42/43). The nomogram based on the predictive model performed satisfactorily (C-index: 0.852). Kaplan-Meier curves showed that patients with GPC3-positive HCCs have lower PFS rates than patients with GPC3-negative HCCs (Log-rank test, p=0.006).

CONCLUSION

The tumour-to-liver SI ratio on the HBP combined with serum AFP >20 ng/ml and non-smooth tumour margin are potential predictive factors for GPC3 expression of small HCC ≤3cm. GPC3 expression is correlated with a poor prognosis in HCC patients.

The Robotic System for the Treatment of Locally Advanced Cervical Cancer with Stereotactic Body Radiotherapy Boost: Results of a Phantom-Based and Preliminary Study

PURPOSE/OBJECTIVE(S)

To fix uterocervical position, compensate uterocervical intrafraction motion, and thus improve the accuracy of dose delivery based on the robotic system for the treatment of locally advanced cervical cancer with stereotactic body radiotherapy boost.

MATERIALS/METHODS

CT images were acquired after robot arm implanted a fixator with fiducial markers into the cervix of pelvic phantom. The treatment plans were designed by contoured a simulated tumor lesion site. The fiducial markers position was obtained by real-time image guidance system and was registered with digitally reconstructed radiographs to calculate correlation error of six directions. The correlation error was delivered to the robotic arm to precisely adjust the position and posture of the fixator, and thus compensated uterocervical intrafraction movement through the interactive interface of the robotic system. The pressure sensor at the head of the fixator provided real-time feedback on the pressure value at the contact surface between the fixer and the cervix. The correlation error of six directions and the pressure value were extracted and analyzed from the log file.

RESULTS

The data from the log file indicated that the three translational direction correlation error of x, y and z were 0.19mm, 0.20mm and 0.10mm, respectively. The three rotational direction correlation error of roll, pitch and yaw were 0.25°, 0.21° and 0.23°, respectively. With the increase of the relative distance between cervix and pressure sensor, the mean value of pressure variation decreases gradually. When the relative distance is 0.5mm and 3mm, the mean value of pressure variation is approximately 76% and 32%, respectively.

CONCLUSION

The correlation accuracy of the robotic system meets the clinical requirements. The robot arm can fix and monitor the cervical motion in real time during radiotherapy. The robot system adjusts the position of the fixator to correct the uterocervical intrafraction motion error, which is feasible and has good clinical application prospect.

Tuning the Multiferroic Properties of BiFeO_{3} under Uniaxial Strain

More than twenty years ago, multiferroic compounds combining in particular magnetism and ferroelectricity were rediscovered. Since then, BiFeO_{3} has emerged as the most outstanding multiferroic by combining at room temperature almost all the fundamental or applicative properties that may be desired: electroactive spin wave excitations called electromagnons, conductive domain walls, or a low band gap of interest for magnonic devices. All these properties have so far only been discontinuously strain engineered in thin films according to the lattice parameter imposed by the substrate. Here we explore the ferroelectricity and the dynamic magnetic response of BiFeO_{3} bulk under continuously tunable uniaxial strain. Using elasto-Raman spectroscopy, we show that the ferroelectric soft mode is strongly enhanced under tensile strain and driven by the volume preserving deformation at low strain. The magnonic response is entirely modified with low energy magnon modes being suppressed for tensile strain above pointing out a transition from a cycloid to an homogeneous magnetic state. Effective Hamiltonian calculations show that the ferroelectric and the antiferrodistortive modes compete in the tensile regime. In addition, the homogeneous antiferromagnetic state becomes more stable compared to the cycloidal state above a +2% tensile strain close to the experimental value. Finally, we reveal the ferroelectric and magnetic orders of BiFeO_{3} under uniaxial strain and how the tensile strain allows us to unlock and to modify in a differentiated way the polarization and the magnetic structure.