[Clinical study on application of 3D Slicer software assisted domestic frameless stereotactic robot in biopsy of intracranial lesions]

Objective: To examine the application value of 3D Slicer software assisted domestic frameless stereotactic robot in biopsy of intracranial lesions. Methods: A retrospective analysis was performed on 80 patients who admitted consecutively and underwent intracerebral lesions biopsy with the domestic frameless stereotactic robot at Department of Neurosurgery, Aerospace Central Hospital from January 2019 to December 2021. There were 36 males and 44 females, with a mean age of (38.5±18.0) years (range: 6 to 71 years). Before surgery only enhanced T1-weighted three-dimensional magnetization prepared gradient echo sequences and diffusion tensor imaging scans were performed. Self-reconstruction of intracranial lesions, cerebral cortex and blood vessels was carried out using 3D Slicer software system after the DICOM format imaging data of 80 patients were collected. These imaging data were merged to the workstation of the domestic frameless stereotactic robot for preoperative surgical planning and the surgical puncture path was designed to avoid blood vessels in the brain functional area, cerebral cortex and sulcus. Results: All frameless stereotactic biopsy were successfully performed. Postoperative pathological diagnosis included 50 cases of diffuse astrocytic and oligodendroglioma, 15 cases of lymphoma, 5 cases of metastatic tumors, 5 cases of inflammatory demyelinating disease, 2 cases of inflammatory granuloma, 1 case of hemangioma, 1 case of acute lymphoblastic leukemia intracranial invasion and 1 case of seminoma. The positive diagnosis rate was 100% (80/80). Postoperative imaging confirmed that the puncture path and target were accurately implemented according to the preoperative planning, and the target error was (1.32±0.44) mm (range: 0.55 to 1.99 mm). One case of puncture-related bleeding occurred at the target after surgery and improved after treatment. Conclusion: The three-dimensional multimodal images reconstructed by the 3D Slicer software before operation could help the surgeons make the preoperative planning and reduce the risk of stereotactic brain biopsy.

[The relationship between peripheral blood mitochondrial DNA copy number and incident risk of liver cancer: a case-cohort study]

Objective: To investigate the association between peripheral blood mitochondrial DNA copy number (mtDNAcn) and incident risk of liver cancer. Methods: At the baseline of Dongfeng-Tongji (DFTJ) cohort, 27 009 retirees were recruited from Dongfeng Motor Corporation in 2008. After excluding people without baseline DNA, with current malignant tumor and loss of follow-up, 1 173 participants were randomly selected into a sub-cohort by age-and gender-stratified sampling method at a proportion of 5% among all retirees. A total of 154 incident liver cancer cases identified from the cohort before December 31, 2018 (4 cases had been selected into the sub-cohort) were selected to form the case cohort of liver cancer. For the above 1 323 participants, their baseline levels of mtDNAcn in peripheral blood cells were measured by using quantitative real-time PCR method. The restricted cubic spline analysis was used to fit the shape of the association between baseline mtDNAcn and incident risk of liver cancer. The weighted Cox proportional hazards model was used to estimate the hazard ratio (HR) and 95%CI. Results: In this case-cohort study, the median follow-up time was 10.3 years. The restricted cubic spline analysis indicated that the relationship between peripheral blood mtDNAcn and incident risk of liver cancer followed a U-shaped pattern (P_non-linear<0.05). All case-cohort population were divided into four subgroups by sex-specific quartiles of mtDNAcn levels among sub-cohort participants, when compared to participants in the Q₂ subgroup of mtDNAcn, those in the Q₁ subgroup (HR=2.00,95%CI:1.08-3.70) and Q₄ subgroup (HR=4.11,95%CI:2.32-7.26) both had a significantly elevated risk of liver cancer, while those in the Q₃ subgroup (HR=1.05,95%CI:0.54-2.05) had not. There were no significant multiply interaction effects of aging, gender, tobacco smoking, alcohol drinking and history of chronic hepatitis on the above association (P_interaction>0.05). Conclusion: Both extremely low and high baseline level of mtDNAcn in peripheral blood cells are associated with an increased risk of incident liver cancer, but the underlying mechanisms need to be further clarified.

Activation of PI3K/Akt prevents hypoxia/reoxygenation-induced GnRH decline via FOXO3a

Recent studies have suggested that the hypothalamus has an important role in aging by regulating nuclear factor-κB (NF-κB)-directed gonadotropin-releasing hormone (GnRH) decline. Moreover, our previous study has shown that ischemia-reperfusion (IR) injury activates NF-κB to reduce hypothalamic GnRH release, thus suggesting that IR injury may facilitate hypothalamic programming of system aging. In this study, we further examined the role of phosphoinositide 3-kinase (PI3K)/Protein kinase B (Akt) pathway, a critical intracellular signal pathway involved in the repair process after IR, in hypoxia-reoxygenation (HR)-associated GnRH decline in vitro. We used GT1-7 cells and primarily-cultured mouse GnRH neurons as cell models for investigation. Our data revealed that the activation of the PI3K/Akt/Forkhead box protein O3a (FOXO3a) pathway protects GnRH neurons from HR-induced GnRH decline by preventing HR-induced gnrh1 gene inhibition and NF-κB activation. Our results further the understanding of the regulatory mechanisms of HR-associated hypothalamic GnRH decline.

Handwritten New Tai Lue Character Recognition Using Convolutional Prior Features and Deep Variationally Sparse Gaussian Process Modeling

New Tai Lue is widely used in Southwest China and Southeast Asia. Hence, it is important to study related handwritten character recognition. Considering the many similar characters in handwritten New Tai Lue, this paper proposes an offline handwritten New Tai Lue character recognition method based on convolutional prior features and deep variationally sparse Gaussian process (DVSGP) modeling. An offline handwritten database is constructed, a convolutional neural network is trained to extract the convolutional features of New Tai Lue character images as prior features, and a DVSGP model is built. The extracted features are input into the DVSGP model to construct a recognition model. The experimental results show that the accuracy of the model is 97.67% and that the precision, recall, and F1-score are 0.9769, 0.9767, and 0.9767, respectively, which are better than those of other methods. The proposed method also achieves high accuracy on the MNIST recognition task, verifying its universal applicability.

Radiotherapy-induced abscopal effect on the metastatic carcinoma of unknown primary origin: a case report and literature review

OBJECTIVE

Abscopal effect of radiotherapy refers to a clinical phenomenon that is characterized by the eradication of distant metastatic tumors following localized irradiation. Reports on the abscopal effect following pure radiotherapy have been relatively rare.

CASE REPORT

Herein, we reported a 70-year-old male patient, who has been subjected to swelling and pain in the left neck. Computed tomography examination presented a metastatic lymph node of the left cervical and an intra-abdominal mass which was located in hepatogastric space, upward of the pancreatic head. Histopathology of the left cervical lymph node further ensured a poorly-moderately differentiated form of squamous cell carcinoma. But the primary origin was not defined. This patient received radiotherapy on the metastatic lymph nodes of the left cervical (dose: 60 Gray in 30 fractions) only. After treatment, the pain in the left neck dramatically improved and the swelling of the radiation exposure site diminished gradually. Computed tomography examination also confirmed that the abdominal mass was significantly reduced.

CONCLUSIONS

The abscopal effect, in this case, may help us to get a better understanding of the impact of radiotherapy.

P-016 Effects of the different partial deletions in the AZFc locus of Y-chromosome on the ICSI outcome of severe oligospermia patients

Study question

To investigate the effects of different partial deletions in AZFc locus of Y-chromosome on the clinical outcome of severe oligospermia patients by intracytoplasmic single sperm injection (ICSI)

Summary answer

B2/b3 and b2/b4 deletion in the AZFc locus of Y chromosome have no significant effect on pregnancy outcome in patients with severe oligospermia undergoing ICSI.

What is known already

Thanks to the development of high-throughput sequencing for Y chromosome microdeletion, AZFc deletions can be accurately divided into b2/b4, gr/gr, b2/b3 and b1/b3 types. However, there is no relevant research on the effect of different partial deletion types of AZFc on the outcome of assisted reproduction.

Study design, size, duration

According to whether carrying AZFc microdeletions or not, the patients were divided into AZFc-deletion group and control group. And AZFc-deletion group was divided into 3 subgroups by the types of partial deletion.

Participants/materials, setting, methods

A retrospective analysis was conducted on the patients undergoing high-throughput sequencing for Y chromosome microdeletion screening and ICSI treatment in our hospital from December 2017 to February 2019.

Main results and the role of chance

The AZFc b2/b3 deletion group had no significant difference in D3 availability, high-quality embryo rate, blastocyst formation rate, implantation rate, clinical pregnancy rate and live birth rate, and the control group (P &gt; 0.05). The rate of high-quality embryos in patients with the b2/b4 deletion was lower than that of the control group (23.2% vs. 34.3%, P = 0.004), but there was no statistical difference in other indicators.

Limitations, reasons for caution

In this study, we included only patients who underwent ICSI with ejaculate sperm for analysis, but not patients who had successfully obtained sperm through surgery.

Wider implications of the findings

This study helps clinicians provide more detailed and comprehensive infertility risk answers during consultations with such patients to reduce the mental stress of patients.

Trial registration number

not applicable

[The relationship between triglyceride glucose index and risk of cardiovascular disease among Kazakh and Uygur population in Xinjiang: a retrospective cohort analysis]

Objective: To analyze whether triglyceride-glucose (TyG) index is associated with increased risk of cardiovascular diseases (CVD) and the value of TyG index in predicting CVD risk among Kazakh and Uighur population of Xinjiang. Methods: In this study, 5 375 Kazakh and Uygur people of Xinyuan county and Jiashi county were selected as the research objects. Subjects were divided into four groups based on the quartile of the TyG index level. Cox regression model was used to analyze the association between TyG index with the risk of CVD. The dose-response relationship between TyG index and CVD risk was described by restricted cubic splines. The area under the receiver operating characteristic curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to estimate the value of TyG index for predicting CVD. Mediating effect analysis was conducted to analyze the mediating effect of TyG index in the association between body mass index and CVD. Results: The age of subjects was 41.06（30.11，53.00）years old, with 46.30%（2 489/5 375）was male. After multivariate adjustment, there was an increasing trend between the risk of CVD and the higher TyG index P_trend<0.001, compared with subjects of TyG index in Q₁, the HR (95%CI) of Q₂, Q₃, and Q₄ groups was 1.53, 1.23 and 1.73, respectively. Restricted cubic splines showed that TyG index was the linearly associated with the risk of CVD. TyG index could improve the prediction ability of Framingham model for the risk of CVD (NRI=0.106,P=0.010; IDI=0.003,P=0.030). The mediating effect analysis showed that in the relationship between body mass index and CVD, the TyG index had a mediating effect (P<0.001), and the ratio of mediating effect was 12.69%. Conclusion: TyG index is an independent predictor of CVD risk among kazakh and Uygur population in Xinjiang and has a good predictive value for the risk of CVD.

AB0206 STUDY ON THE SIGNIFICANCE OF SERUM COMPLEMENT C5 IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Recent studies have pointed out that complement system activation is a major alteration in early atherosclerotic plaques, and complement C5 has promising value as a novel circulating biomarker of atherosclerosis, but the relationship between C5 and carotid atherosclerotic (CAS) plaque in rheumatoid arthritis (RA) is still unclear.

Objectives

To investigate the clinical significance of serum complement C5 and the association with CAS plaque in patients with RA．

Methods

143 patients with RA were included in the study, and 46 cases with age- and sex- matched healthy physical examination without RA or CAS plaque served as a normal control. All RA patients were divided into RA with CAS plaque group and RA without CAS plaque group according to the presence or absence of plaque formation in the carotid artery. The subject’s demographic data, laboratory investigations and serum samples were collected. Body mass index (BMI) and Disease Activity Score 28-joint counts (DAS28) were calculated. Glucocorticoid and DMARDS use were recorded in the past 3 months. ELISA method was used to determine the concentration of complement C5 in the serum of each participation. CAS plaque was determined by color Doppler ultrasound.

Results

Serum complement C5 in RA group was significantly lower than that in control group (P<0.05), whereas C5 level in RA with CAS plaque group was significantly higher than that in RA without CAS plaque group (P<0.05). In RA group, serum C5 level was positively correlated with CAS plaque, high-sensitivity C-reactive protein (hs-CRP) and fibrinogen (FIB) (r=0.204, P=0.017; r=0.225, P=0.009; r=0.186, P=0.029;). In addition, there was no significant correlation between serum C5 and sex, age, BMI, course of disease, DAS28, lipid profile (TG, serum triglyceride; TC, total cholesterol; LDLC, low density lipoprotein cholesterol; HDLC, high density lipoprotein cholesterol; TC/HDLC; LDLC/HDLC), immune markers (RF, rheumatoid factor; anti-CCP, anti-cyclic citrullinated peptide antibodies), cytokine (IL-6, Interleukin-6; TNF-α, Tumor necrosis factor-α), erythrocyte sedimentation rate (ESR) (all P>0.05), or drug therapy (all P>0.05).

Conclusion

C5 may be a novel circulating marker of atherosclerosis in RA patients, it might promise to assist in risk stratification for cardiovascular disease in the future.

References

[1]Martínez-López D, et al. Complement C5 Protein as a Marker of Subclinical Atherosclerosis. J Am Coll Cardiol. 2020 Apr 28;75(16):1926-1941.

Disclosure of Interests

None declared

Disease Burden and Attributable Risk Factors of Alzheimer's Disease and Dementia in China from 1990 to 2019

BACKGROUND

Updated information on the burden of Alzheimer's disease and other forms of dementia are of great importance for evidence-based health care planning. However, such an estimate has been lacking in Chinese populations at both national and provincial levels.

OBJECTIVE

To estimate the temporal trends and the attributable burdens of selected risk factors of Alzheimer's disease and other forms of dementia in China.

DESIGN, SETTING, AND PARTICIPANTS

This is an observational description of the Global Burden of Diseases Study 2019 (GBD 2019). Data on incidence, mortality, prevalence, disability-adjusted life years (DALYs), years lived with disability (YLDs), and years of life lost (YLLs) of Alzheimer's disease and other forms of dementia were derived from the GBD 2019 study at both national and provincial levels in China.

MEASUREMENTS

Six indicators were used: incidence, mortality, prevalence, DALYs, YLLs, and YLDs. Absolute numbers in detail by age, sex, region, and age-standardized rates (with 95% uncertainty intervals) were calculated.

RESULTS

There were notable increasing trends in the number of deaths (247·9%), incidence (264·8%), prevalence (296·5%), DALYs (228·1%), YLDs (308·7%) and YLLs (201·7%) from 1990 to 2019, respectively. The corresponding age-standardized rates increased by 6·2%, 19·3%, 33·6%, 10·7%, 33·4% and 3·1%. Smoking, high body mass index, high fasting plasma glucose levels, and metabolic risks were the four leading risk factors. Higher burden was observed among females versus males and in the more developed regions.

CONCLUSIONS

The disease burden in China were increasing substantially. Regional differences of the disease burden are accompanied by discrepancies of economic level and geographical location, as well as different levels of exposure to risk factors. Targeted prevention and control strategies are urgently needed to reduce the disease burden.

Use of real-time artificial intelligence in detection of abnormal image patterns in standard sonographic reference planes in screening for fetal intracranial malformations

OBJECTIVES

To develop and validate an artificial intelligence system, the Prenatal ultrasound diagnosis Artificial Intelligence Conduct System (PAICS), to detect different patterns of fetal intracranial abnormality in standard sonographic reference planes for screening for congenital central nervous system (CNS) malformations.

METHODS

Neurosonographic images from normal fetuses and fetuses with CNS malformations at 18-40 gestational weeks were retrieved from the databases of two tertiary hospitals in China and assigned randomly (ratio, 8:1:1) to training, fine-tuning and internal validation datasets to develop and evaluate the PAICS. The system was built based on a real-time convolutional neural network (CNN) algorithm, You Only Look Once, version 3 (YOLOv3). An image dataset from a third tertiary hospital was used to further validate, externally, the performance of the PAICS and to compare its performance with that of sonologists with different levels of expertise. Furthermore, a prospective video dataset was employed to evaluate the performance of the PAICS in a real-time scan scenario. The diagnostic accuracy, sensitivity, specificity and area under the receiver-operating-characteristics curve (AUC) were calculated to assess the performance of the PAICS and to compare this with the performance of sonologists with different levels of experience.

RESULTS

In total, 43 890 images from 16 297 pregnancies and 169 videos from 166 pregnancies were used to develop and validate the PAICS. The system achieved excellent performance in identifying 10 types of intracranial image pattern, with macro- and microaverage AUCs, respectively, of 0.933 (95% CI, 0.798-1.000) and 0.977 (95% CI, 0.970-0.985) for the internal validation image dataset, 0.902 (95% CI, 0.816-0.989) and 0.898 (95% CI, 0.885-0.911) for the external validation image dataset and 0.969 (95% CI, 0.886-1.000) and 0.981 (95% CI, 0.974-0.988) in the real-time scan setting. The performance of the PAICS was comparable to that of expert sonologists in terms of macro- and microaverage accuracy (P = 0.863 and P = 0.775, respectively), sensitivity (P = 0.883, P = 0.846) and AUC (P = 0.891, P = 0.788), but required significantly less time (0.025 s per image for PAICS vs 4.4 s for experts, P < 0.001).

CONCLUSIONS

Both in the image dataset and in the real-time scan setting, the PAICS achieved excellent diagnostic performance for various fetal CNS abnormalities. Its performance was comparable to that of experts, but it required less time. A CNN algorithm can be trained to detect fetal CNS abnormalities. The PAICS has the potential to be an effective and efficient tool in screening for fetal CNS malformations in clinical practice. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

A118 UPPER GASTROINTESTINAL HEMORRHAGE SECONDARY TO SUPERIOR MESENTERIC ARTERY PSEUDOANEURYSM: CASE REPORT AND REVIEW OF LITERATURE

Background

Visceral artery pseudoaneurysms (VAPAs) are rare with an estimated incidence of 0.1%-0.2%. Due to various etiologies, a tear occurs in the vessel wall with subsequent formation of a peri-artery hematoma. A ruptured VAPA is a clinical emergency due to life-threatening hemorrhage and is associated with mortality rates of 25%-75%.

Aims

We report a case of upper gastrointestinal (GI) hemorrhage secondary to a ruptured superior mesenteric artery (SMA) pseudoaneurysm. A review of the literature regarding management of VAPAs and SMA pseudoaneurysms was performed using relevant medical subject headings on PubMed.

Methods

A 66-year-old woman presented to hospital with sudden large volume hematemesis and melena. Her daily medications included Aspirin and Atorvastatin. She had no prior history of peptic ulcers or chronic liver disease. She was found to be tachycardic and hypotensive. Initial investigations demonstrated a hemoglobin of 42g/L and a blood urea nitrogen of 17.5mmol/L. She was resuscitated and referred for an emergent upper endoscopy. On endoscopy, in the third portion of the duodenum, a 4cm solid-appearing subepithelial lesion with central umbilication and an apparent visible vessel was identified. Upon inspection of the lesion, the umbilicated area spontaneously began spurting blood (Image 1). A hemoclip was immediately placed next to the lesion for localization, then hemostatic powder was applied to the area. An immediate computerized tomography (CT) angiography of the abdomen revealed a 3.9 x 2.1 cm pseudoaneurysm arising from the superior mesenteric artery impressing upon the duodenum.

Results

Transcathether arterial embolization of the SMA pseudoaneurysm was performed, during which two Nester coils were deposited in the ileocolic outflow vessel. A covered endovascular stent was also deployed across the culprit arterial branch to exclude the pseudoaneurysm. Following the procedure, the patient stabilized and had no further GI bleeding. Traditionally, visceral angiography has been the gold standard diagnostic test for VAPAs, but has now been supplanted by CT angiography. Treatment strategies of VAPAs can be broadly separated into endovascular methods (coils, vascular plugs, stents, liquid embolic agents) and surgical methods (aneurysmectomy with patching, end-to-end anastomosis, bypass grafting).

Conclusions

SMA pseudoaneurysms are a rare yet life-threatening cause of GI bleeding. Endoscopically, they resemble solid subepithelial masses, such as GI stromal tumor, nerve sheath tumor or a lipoma, which may lead to inappropriate attempts to biopsy the lesion or apply direct endoscopic therapy. Prompt diagnosis with imaging, such as CT angiography, is paramount with a view to definitive treatment of the pseudoaneurysm via endovascular methods.

Actively hemorrhagic SMA pseudoaneurysm

Funding Agencies

None

Docosahexaenoic Acid Reverses Epithelial-Mesenchymal Transition and Drug Resistance by Impairing the PI3K/AKT/ Nrf2/GPX4 Signalling Pathway in Docetaxel-Resistant PC3 Prostate Cancer Cells

Drug resistance is a serious problem in cancer therapy. Growing evidence has shown that docosahexaenoic acid has anti-inflammatory and chemopreventive abilities. Studies have shown that autophagy inhibition and ferroptosis are promising therapeutic strategies for overcoming multidrug resistance. This study was aimed to examine whether docosahexaenoic acid (DHA) could reverse docetaxel resistance in prostate cancer cells. Cell survival was examined by MTT and colony formation. Protein expression was determined by Western blot. Reactive oxygen species (ROS) production was measured by flow cytometry. DHA displayed anti-cancer effects on proliferation, colony formation, migration, apoptosis, autophagy and epithelial mesenchymal transition. Glutathione-S-transferase π is an enzyme that plays an important role in drug resistance. DHA inhibited GSTπ protein expression and induced cytoprotective autophagy by regulating the PI3K/AKT signalling pathway in PC3R cells. DHA combined with PI3K inhibitor (LY294002) enhanced apoptosis by alleviating the expression of LC3B, (pro-) caspase- 3 and (uncleaved) PARP. DHA induced ferroptosis by attenuating the expression of glutathione peroxidase 4 (GPX4) and nuclear erythroid 2-related factor 2 (Nrf2). DHA-treated PC3R cells produced ROS. The ROS and cytotoxicity were reversed by treatment with ferrostatin-1. DHA combined with docetaxel inhibited EMT by regulating the expression of E-cadhein and N-cadherin. In summary, DHA reversed drug resistance and induced cytoprotective autophagy and ferroptosis by regulating the PI3K/AKT/Nrf2/GPX4 signalling pathway in PC3R cells. We propose that DHA could be developed as a chemosensitizer and that the PI3K/AKT /Nrf2/GPX4 signalling pathway might be a promising therapeutic target for overcoming cancer drug resistance.

Reconciling Assumptions in Bottom-Up and Top-Down Approaches for Estimating Aerosol Emission Rates From Wildland Fires Using Observations From FIREX-AQ

Accurate fire emissions inventories are crucial to predict the impacts of wildland fires on air quality and atmospheric composition. Two traditional approaches are widely used to calculate fire emissions: a satellite-based top-down approach and a fuels-based bottom-up approach. However, these methods often considerably disagree on the amount of particulate mass emitted from fires. Previously available observational datasets tended to be sparse, and lacked the statistics needed to resolve these methodological discrepancies. Here, we leverage the extensive and comprehensive airborne in situ and remote sensing measurements of smoke plumes from the recent Fire Influence on Regional to Global Environments and Air Quality (FIREX-AQ) campaign to statistically assess the skill of the two traditional approaches. We use detailed campaign observations to calculate and compare emission rates at an exceptionally high-resolution using three separate approaches: top-down, bottom-up, and a novel approach based entirely on integrated airborne in situ measurements. We then compute the daily average of these high-resolution estimates and compare with estimates from lower resolution, global top-down and bottom-up inventories. We uncover strong, linear relationships between all of the high-resolution emission rate estimates in aggregate, however no single approach is capable of capturing the emission characteristics of every fire. Global inventory emission rate estimates exhibited weaker correlations with the high-resolution approaches and displayed evidence of systematic bias. The disparity between the low-resolution global inventories and the high-resolution approaches is likely caused by high levels of uncertainty in essential variables used in bottom-up inventories and imperfect assumptions in top-down inventories.

P–044 A non-classical splice site variant in ANOS1 gene leading to Kallmann syndrome

Study question

Genetic risk of the non-classical splice site variant in ANOS1 gene

Summary answer

A non-classical ANOS1 splice site variant, c.1062 + 4T&gt;C, causes Kallmann syndrome.

What is known already

Genetic abnormalities play a key role in the development of Kallmann syndrome. Although an overwhelming majority of missense and nonsense mutations occur in the exons of a gene, intron mutations can also be pathogenic.

Study design, size, duration

The research object is a family. Eight patients of the family were recruited in this study, three of them were diagnosed with Kallmann syndrome.

Participants/materials, setting, methods

Genomic DNA was extracted from peripheral blood and whole-exome sequencing (WES) was performed to identify the genetic abnormalities. PCR was performed to verify the WES results. The functional splicing reporter mini gene assay was performed to assess the impact of sequence variants on splicing.

Main results and the role of chance

The proband and other two patients exhibited the typical clinical features of KS. A non-classical splice site variant, c.1062 + 4T&gt;C in ANOS1 gene was identified, whereas the other unaffected family members did not have this mutation. This mutation caused the disappearance of the splicing site of intron 7 and the splicing position became the 156th base of exon 7, which caused a frame-shift mutation, leading to a premature termination of translation.

Limitations, reasons for caution

Since the ANOS1 gene is almost not expressed in the blood, in order to uncover the effect of this splice site variant of ANOS1, we carried out a functional splicing reporter mini gene assay in the mini gene vector pEGFP-N1.

Wider implications of the findings: This study shows that mutations in non-classical splicing regions are also pathogenic. Therefore, it is recommended that the detection and analysis of this gene should pay attention to the non-classical splice site variant.

Trial registration number

Not applicable