A Multimodal Imaging-Based Deep Learning Model for Detecting Treatment-Requiring Retinal Vascular Diseases: Model Development and Validation Study

BACKGROUND

Retinal vascular diseases, including diabetic macular edema (DME), neovascular age-related macular degeneration (nAMD), myopic choroidal neovascularization (mCNV), and branch and central retinal vein occlusion (BRVO/CRVO), are considered vision-threatening eye diseases. However, accurate diagnosis depends on multimodal imaging and the expertise of retinal ophthalmologists.

OBJECTIVE

The aim of this study was to develop a deep learning model to detect treatment-requiring retinal vascular diseases using multimodal imaging.

METHODS

This retrospective study enrolled participants with multimodal ophthalmic imaging data from 3 hospitals in Taiwan from 2013 to 2019. Eye-related images were used, including those obtained through retinal fundus photography, optical coherence tomography (OCT), and fluorescein angiography with or without indocyanine green angiography (FA/ICGA). A deep learning model was constructed for detecting DME, nAMD, mCNV, BRVO, and CRVO and identifying treatment-requiring diseases. Model performance was evaluated and is presented as the area under the curve (AUC) for each receiver operating characteristic curve.

RESULTS

A total of 2992 eyes of 2185 patients were studied, with 239, 1209, 1008, 211, 189, and 136 eyes in the control, DME, nAMD, mCNV, BRVO, and CRVO groups, respectively. Among them, 1898 eyes required treatment. The eyes were divided into training, validation, and testing groups in a 5:1:1 ratio. In total, 5117 retinal fundus photos, 9316 OCT images, and 20,922 FA/ICGA images were used. The AUCs for detecting mCNV, DME, nAMD, BRVO, and CRVO were 0.996, 0.995, 0.990, 0.959, and 0.988, respectively. The AUC for detecting treatment-requiring diseases was 0.969. From the heat maps, we observed that the model could identify retinal vascular diseases.

CONCLUSIONS

Our study developed a deep learning model to detect retinal diseases using multimodal ophthalmic imaging. Furthermore, the model demonstrated good performance in detecting treatment-requiring retinal diseases.

[Self-rated health measures and their relations to all-cause and cardiovascular mortality in adults from 10 regions of China]

Objective: To examine the association between self-rated health status (SRH) and all-cause and cardiovascular mortality. Methods: A total of 512 713 adults aged 30-79 years from 10 areas of China were followed from baseline (2004-2008) until 31 December 2016 in the China Kadoorie Biobank study. Global and age-comparative SRH [general self-rated health status (GSRH) and age-comparative self-rated health status (ASRH), respectively] were asked in baseline questionnaires. Causes for mortality were monitored through linkage with established Disease Surveillance Point system and health insurance records. Multivariable Cox proportional regression models were used to estimate the HRs and 95%CIs for the association between SRH measures and all-cause or cardiovascular mortality. Results: During an average of 9.9 years' follow-up, 44 065 deaths were recorded, among which 17 648 were from cardiovascular disease. Compared with excellent GSRH, the HR(95%CI) for all-cause and cardiovascular mortality associated with poor GSRH was 1.84(1.78-1.91) and 1.94(1.82-2.06), respectively. Relative to better ASRH, the HR(95%CI) for all-cause and cardiovascular mortality associated with worse ASRH was 1.75(1.70-1.81) and 1.83(1.73-1.92), respectively. Conclusion: In this large prospective cohort study in China, participants reporting poor GSRH or worse ASRH had significantly higher risk of all-cause and cardiovascular mortality.

[Clinicopathological features of adenocarcinoma of the rete testis]

Objective: To investigate the clinicopathological features, immunophenotype, and differential diagnosis of adenocarcinoma of the rete testis. Methods: Four adenocarcinoma cases of the rete testis diagnosed at West China Hospital, Chengdu, China (3 cases, including 2 consultation cases) and the First Affiliated Hospital of Fujian Medical University, Fuzhou, China (1 case) between January 2009 and December 2017 were included. Their clinical, morphologic and immunohistochemical features were analyzed using histological analysis and immunohistochemical staining. Related literature was reviewed to reveal the characteristics of this tumor. Results: The 4 patients' age range was 26-64 years. The maximum diameters of the tumors were 3.0 and 4.5 cm in 2 cases, respectively. On gross examination, adenocarcinomas of the rete testis appeared as a solid, white to gray or tan to yellow mass that raised at the hilum of the testis. Microscopically, all tumors showed multiple histologic patterns, including corded/trabecular (4/4), glandular, nested, sarcomatoid (3/4), solid (2/4), papillary, cribriform, and slit-like (1/4). Three types of adenocarcinoma cells included cuboidal to columnar (4/4), polygonal (4/4) and spindle-shaped (2/4) with pale eosinophilic and clear cytoplasm. The tumor cell nuclei appeared moderately to markedly atypical and pleomorphic, with a various number of mitoses. Transition from benign to malignant rete epithelium was seen in all cases. Eosinophilic hyaloid globules were found in 1 case. On immunohistochemical study, the tumor cells were diffusely, strongly positive for CKpan (4/4), EMA (4/4), Ber-EP4 (3/3) and CAⅨ(2/2), and focally positive for CK7 (4/4), vimentin (4/4), CD10 (4/4), PAX8 (3/3), PAX2 (3/3). The Ki-67 proliferative index was all>50% (4/4). The prognosis was poor. Two of the 3 patients died within 1 year after the surgical resection. Conclusions: Adenocarcinoma of the rete testis is a rare malignant tumor with several histologic patterns. Transition from benign to malignant rete epithelium is an important diagnostic clue. Detailed clinical history, tumor growth site and immunohistochemistry are helpful for its diagnosis and differential diagnosis.

A comparison of intestinal integrity, digestive function, and egg quality in laying hens with different ages

Intestinal integrity, digestive enzyme activity, nutrient utilization, and egg quality of laying hens at different ages were evaluated and compared in this study. A total of 192 Hy-line Brown laying hens at 195-d-old (D195 group), 340-d-old (D340 group), and 525-d-old (D525 group) were allocated into one of 3 groups in accordance with their ages. Each group had 8 replicates of 8 birds each, and all birds were fed a maize-soybean meal basal diet for a 2-wk experiment. Compared with the D195 group, intestinal villus height and ratio of villus height to crypt depth, as well as serum D-lactate content increased in the D525 group (P < 0.05). The sucrase and maltase activities in the jejunal mucosa, amylase activity in the pancreas, and trypsin activity in the jejunal chyme of 525-d-old hens were lower than their 195-d-old counterparts (P < 0.05). In addition, there was a decline of trypsin and lipase activities in the ileal chyme of hens from D525 group in comparison with D195 or D340 group (P < 0.05). Apparent retention of dry matter and crude protein of birds in D340 and D525 group decreased when compared with the D195 group (P < 0.05). Moreover, birds in the D525 group exhibited a lower level of ether extract retention, and higher contents of several excreted amino acids than those in the D195 group (P < 0.05). Compared with the D195 group, eggs harvested from D525 group exhibited lower albumen height, eggshell strength and thickness, and a higher egg weight (P < 0.05). In conclusion, increased intestinal permeability (higher serum D-lactate content), compromised digestive function (lower digestive enzyme activities and apparent nutrient retention, and higher concentrations of excreted amino acids), and poor egg quality (lower albumen height, eggshell strength, and thickness) were observed with increasing age in the laying hens.

[Clinical characteristics and outcome of pregnant patients with myasthenia gravis]

Objective: To study the clinical characteristics of pregnant patients with myasthenia gravis (MG) and the influence of MG to pregnancy. Methods: A retrospective study was conducted including 28 MG patients with 38 pregnancies admitted to the 8th Medical Center of PLA General Hospital between January 2013 and October 2018. Data were collected including clinical scores of MG, serum level of acetylcholine receptor (AChR) antibodies, abnormal repetitive nerve stimulation (RNS) and history of thymectomy before pregnancy. The course of pregnancy, delivery and neonatal outcome were also analyzed. According the outcome of MG, patients were divided into three groups, i.e. improvement group, stable group and deterioration group. Results: (1) The age of MG patients ranged from 21 to 36 (27±4) years. The previous course of MG was 0.5-17.2 (7.4±5.8)years. Based on Osserman clinical type, type ⅡA was the most common one [44.1% (15/34)], followed with type Ⅰ [29.4% (10/34)], type ⅡB [23.5% (8/34)] and type Ⅳ (2.9%).(2)There were 38 pregnancies in 28 women whose pregnancy outcomes resulted in one spontaneous abortion, three embryonic arrest and 34 live births. All abortions developed in the first trimester. Among the 34 pregnancies with live births, the symptoms of MG improved in 16 pregnancies (47.1%), whereas those deteriorated in 10 pregnancies (29.4%) during the first or third trimester and remained stable in 8 pregnancies (23.5%). (3) Compared with improvement group and stable group, the deterioration group had shorter duration of MG [(1.1±0.5) years vs. (7.1±5.1) years, (9.0±5.4) years respectively], higher clinical scores (20.9±6.0 vs. 14.8±6.6,13.3±5.0) and more frequent abnormal RNS(9/10 vs. 8/16, 4/8) and type ⅡB(6/10 vs. 1/16, 1/8) before pregnancy. Positive rate of serum AChR antibody and percentage of thymectomy before pregnancy were comparable between three groups. (4) Spinal anesthesia was performed in 23 pregnancies and 11 cases were vaginal delivery. No transient neonatal MG were found in live-born infants. Conclusions: Pregnancy in patients with under-controlled myasthenia gravis should not be discouraged. The outcome of MG is affected by the duration of MG, MG score and RNS before pregnancy. The first and third trimesters of pregnancy are considered high-risk periods for MG exacerbations. Neonatal transient myasthenia is uncommon, but the newborn should be carefully monitored by obstetricians and neurologists.

Dietary squalene supplementation alleviates diquat-induced oxidative stress and liver damage of broiler chickens

The aim of this study was to explore the protective effects of squalene supplementation on growth performance, oxidative status, and liver function of diquat-challenged broilers. One hundred forty-four 1-day-old male Ross 308 broiler chicks were allocated to 3 groups, and each group consisted of 6 replicates of 8 birds each. The three groups were as follows: 1) nonchallenged broilers fed with a basal diet (control group), 2) diquat-challenged broilers fed a basal diet, and 3) diquat-challenged broilers fed with a basal diet supplemented with 1.0 g/kg of squalene. Broilers were intraperitoneally injected with 20 mg/mL of diquat solution at a dosage of 1 mL/kg of BW or an equivalent amount of saline at 20 d. Compared with the control group, weight gain and BW change rate during 24 h after injection were decreased by diquat challenge (P < 0.05), and the diquat-induced compromised growth performance was improved by squalene supplementation (P < 0.05). Diquat administration reduced plasma superoxide dismutase activity and increased malondialdehyde accumulation and glutathione peroxidase activity in both plasma and the liver (P < 0.05). In contrast, plasma glutathione peroxidase activity in diquat-challenged broilers was reduced by squalene supplementation (P < 0.05). The hepatic glutathione level was reduced by diquat administration (P < 0.05), whereas its level in plasma and the liver of diquat-challenged broilers was increased by squalene supplementation (P < 0.05). The relative liver weight of broilers was increased by diquat challenge (P < 0.05), with its value being intermediate in the squalene-supplemented group (P > 0.05). The plasma aminotransferase activities and total bilirubin concentration were increased by diquat challenge (P < 0.05), which were reduced by squalene supplementation (P < 0.05). The mRNA abundance of hepatic nuclear factor erythroid 2–related factor 2 (P < 0.05) was upregulated by diquat treatment, regardless of squalene supplementation. The mRNA abundance of hepatic glutathione peroxidase 1 and B-cell lymphoma/leukemia 2–associated X protein was upregulated by diquat challenge (P < 0.05), which was reversed by squalene administration (P < 0.05). Squalene increased NAD(P)H quinone dehydrogenase 1 mRNA abundance and decreased caspase 3 mRNA abundance in the liver of diquat-challenged broilers (P < 0.05). The results suggested that squalene can increase weight gain, improve oxidative status, and alleviate liver injury in diquat-challenged broilers.

[Safety and immunogenicity analysis of recombinant （hansenula polymorpha) hepatitis B vaccine （CpG ODN adjuvant) among adults: the preliminary results of phase I clinical trial]

Objective: To evaluate the safety and immune effect of recombinant hepatitis B vaccine （CpG ODN adjuvant). Methods: On Oct. 26, 2016, we launched volunteer recruitment in Kaihua county, Quzhou city, Zhejiang Province. In the randomized, double-blind, controlled trial, a total of 48 subjects with negative HBV screening tests and normal hepatorenal function among 18 and 60 years old were selected and divided into two groups randomly, 24 cases each. The experimental group was given 250 μg of CpG ODN recombinant （Hansenula polymorpha) Hepatitis B vaccine and the control group was given 10 μg of commercial Hepatitis B vaccine with timed at 0, 1and 6 months. The inoculation reactions were compared the difference between the two groups after observed and recorded in time periods. We also collected serum before and after immunization to compare the two groups of anti-HBs positive rate, geometric mean concentration（GMC). Results: During the study period, the incidence of adverse events was 66.67%（16/24) in the experimental group and 54.17%（13/24) in the control group, with no significant difference（P=0.556). The severities of adverse events were level 1 or level 2, and no level 3 or above adverse reactions occurred. After full-course immunization, in the FAS data set, the anti-HBs GMC in the experimental group [2 598.56（1 127.90-5 986.90) mIU/ml] was higher than that in the control group[371.97（164.54-840.91) mIU/ml] In the PPS set, the GMC of test group was 7 808.21（3 377.00-18 052.00) mIU/ml, which was higher than that of the control group [843.22（213.80-3 325.90) mIU/ml]. The anti-HBs positive rate of FAS（PPS) was 95.83%（100.00%) in the experimental group and the control group; The anti-HBs strongly positive rate of FAS（PPS) was 79.17%（90.00%) in the experimental group and 33.33%（50.00%) in the control group, with statistically significant differences among the FAS set（P=0.003) and no statistically significance differences among the PPS set（P=0.074). Conclusion: CpG Hepatitis B Vaccine is safe and shows better immunogenicity than the control vaccine.

[A multicentric study on clinical characteristics and antibiotic sensitivity in children with methicillin-resistant Staphylococcus aureus infection]

Objective: To investigate the clinical characteristics of pediatric methicillin-resistant Staphylococcus aureus (MRSA) infection and the antibiotic sensitivity of the isolates. Methods: The clinical data of children with MRSA infection and antibiotic sensitivity of the isolates from 11 children's hospitals in Infectious Diseases Surveillance of Paediatrics (ISPED) group of China between January 1, 2018 and December 31, 2018 were collected retrospectively. The children's general condition, high-risk factors, antimicrobial therapy and prognosis, differences in clinical disease and laboratory test results between different age groups, and differences of antibiotic sensitivity between community-acquired (CA)-MRSA and hospital-acquired (HA)-MRSA were analyzed. The t test and Wilcoxon rank sum test were used for statistical analysis of the quantitative data and Chi-square test were used for comparison of rates. Results: Among the 452 patients, 264 were males and 188 were females, aged from 2 days to 17 years. There were 233 cases (51.5%) in the ≤1 year old group, 79 cases (17.5%) in the>1-3 years old group, 29 cases (6.4%) in the >3-5 years old group, 65 cases (14.4%) in the >5-10 years old group, and 46 cases (10.2%) in the>10 years old group. The main distributions of onset seasons were 55 cases (12.2%) in December, 47 cases (10.4%) in February, 46 cases (10.2%) in November, 45 cases (10.0%) in January, 40 cases (8.8%) in March. There were 335 cases (74.1%) CA-MRSA and 117 (25.9%) cases HA-MRSA. Among all cases, 174 cases (38.5%) had basic diseases or long-term use of hormone and immunosuppressive drugs. During the period of hospitalization, 209 cases (46.2%) received medical interventions. There were 182 patients (40.3%) had used antibiotics (β-lactams, glycopeptides, macrolides, carbapenems, oxazolones, sulfonamides etc) 3 months before admission. The most common clinical disease was pneumonia (203 cases), followed by skin soft-tissue infection (133 cases), sepsis (92 cases), deep tissue abscess (42 cases), osteomyelitis (40 cases), and septic arthritis (26 cases), suppurative meningitis (10 cases). The proportion of pneumonia in the ≤1 year old group was higher than the >1-3 years old group,>3-5 years old group,>5-10 years old group,>10 years old group (57.5% (134/233) vs. 30.4% (24/79), 31.0% (9/29), 38.5% (25/65), 23.9% (11/46), χ(2)=17.374, 7.293, 7.410, 17.373, all P<0.01) The proportion of skin and soft tissue infections caused by CA-MRSA infection was higher than HA-MRSA (33.4% (112/335) vs. 17.9% (21/117), χ(2)=10.010, P=0.002), and the proportion of pneumonia caused by HA-MRSA infection was higher than CA-MRSA (53.0% (62/117) vs. 42.1% (141/335), χ(2)=4.166, P=0.041). The first white blood cell count of the ≤1 year old group was higher than that children > 1 year old ((15±8)×10(9)/L vs. (13±7)×10(9)/L, t=2.697, P=0.007), while the C-reactive protein of the ≤1 year old group was lower than the 1-3 years old group,>5-10 years old group,>10 years old group (8.00 (0.04-194.00) vs.17.00 (0.50-316.00), 15.20 (0.23-312.00), 21.79(0.13-219.00) mg/L, Z=3.207, 2.044, 2.513, all P<0.05), there were no significant differences in procalcitonin (PCT) between different age groups (all P>0.05). After the treatment, 131 cases were cured, 278 cases were improved, 21 cases were not cured, 12 cases died, and 10 cases were abandoned. The 452 MRSA isolates were all sensitive to vancomycin (100.0%), linezolid (100.0%), 100.0% resistant to penicillin, highly resistant to erythromycin (85.0%, 375/441), clindamycin (67.7%, 294/434), less resistant to sulfonamides (5.9%, 23/391), levofloxacin (4.5%, 19/423), gentamicin (3.2%, 14/438), rifampicin (1.8%, 8/440), minocycline (1.1%, 1/91). The antimicrobial resistance rates were not significantly different between the CA-MRSA and HA-MRSA groups (all P>0.05). Conclusions: The infection of MRSA is mainly found in infants under 3 years old. The prevalent seasons are winter and spring, and MRSA is mainly acquired in the community. The main clinical diseases are pneumonia, skin soft-tissue infection and sepsis. No MRSA isolate is resistant to vancomycin, linezolid. MRSA isolates are generally sensitive to sulfonamides, levofloxacin, gentamicin, rifampicin, minocycline, and were highly resistant to erythromycin and clindamycin. To achieve better prognosis. clinicians should initiate anti-infective treatment for children with MRSA infection according to the clinical characteristics of patients and drug sensitivity of the isolates timely and effectively.

[Establishment of clinical features and prognostic scoring model in early-stage hepatitis B-related acute-on-chronic liver failure]

Objective: To explore the clinical characteristics and establish a corresponding prognostic scoring model in patients with early-stage clinical features of hepatitis B-induced acute-on-chronic liver failure (HBV-ACLF). Methods: Clinical characteristics of 725 cases with hepatitis B-related acute-on-chronic hepatic dysfunction (HBV-ACHD) were retrospectively analyzed using Chinese group on the study of severe hepatitis B (COSSH). The independent risk factors associated with 90-day prognosis to establish a prognostic scoring model was analyzed by multivariate Cox regression, and was validated by 500 internal and 390 external HBV-ACHD patients. Results: Among 725 cases with HBV-ACHD, 76.8% were male, 96.8% had cirrhosis base,66.5% had complications of ascites, 4.1% had coagulation failure in respect to organ failure, and 9.2% had 90-day mortality rate. Multivariate Cox regression analysis showed that TBil, WBC and ALP were the best predictors of 90-day mortality rate in HBV-ACHD patients. The established scoring model was COSS-HACHADs = 0.75 × ln(WBC) + 0.57 × ln(TBil)-0.94 × ln(ALP) +10. The area under the receiver operating characteristic curve (AUROC) of subjects was significantly higher than MELD, MELD-Na, CTP and CLIF-C ADs(P < 0.05). An analysis of 500 and 390 cases of internal random selection group and external group had similar verified results. Conclusion: HBV-ACHD patients are a group of people with decompensated cirrhosis combined with small number of organ failure, and the 90-day mortality rate is 9.2%. COSSH-ACHDs have a higher predictive effect on HBV-ACHD patients' 90-day prognosis, and thus provide evidence-based medicine for early clinical diagnosis and treatment.

[Primary skull base chondrosarcoma: a clinicopathological analysis]

Objective: To investigate the clinicopathological features, immunophenotype, molecular characteristics and differential diagnosis of primary skull base chondrosarcoma. Methods: Nine cases of primary skull base chondrosarcoma were collected at the First Affiliated Hospital of Fujian Medical University, from January 2006 to June 2019, reviewed for the clinical and radiologic data and morphologic features, immunophenotype and molecular characteristics. Results: Among all the 9 cases, six were male, three were frmale, with average age 47 years, and median age 47 years; five cases were WHO gradeⅠ, and four were WHO grade Ⅱ. Microscopically, the tumor showed lobulated growth pattern with low-medium cellularity within a chondroid or mucoid background. The tumor cells showed mild-moderate atypia, with binucleated forms, and mitosis was rare or occasional. Immunohistochemistry (IHC) showed tumor cells were positive for S-100 protein, vimentin, SOX-9 and D2-40, and negative for Brachyury, CK, EMA and CK8/18; the Ki-67 index was low (1% to 5%). Molecular analysis showed IDH1 R132C mutation in four cases. Conclusions: Skull base chondrosarcoma is a rare cartilaginous malignant tumor with a good prognosis. Its characteristic morphologies, combined with IHC and molecular detection are helpful for the differential diagnosis.

Relative posture between head and finger determines perceived tactile direction of motion

The hand explores the environment for obtaining tactile information that can be fruitfully integrated with other functions, such as vision, audition, and movement. In theory, somatosensory signals gathered by the hand are accurately mapped in the world-centered (allocentric) reference frame such that the multi-modal information signals, whether visual-tactile or motor-tactile, are perfectly aligned. However, an accumulating body of evidence indicates that the perceived tactile orientation or direction is inaccurate; yielding a surprisingly large perceptual bias. To investigate such perceptual bias, this study presented tactile motion stimuli to healthy adult participants in a variety of finger and head postures, and requested the participants to report the perceived direction of motion mapped on a video screen placed on the frontoparallel plane in front of the eyes. Experimental results showed that the perceptual bias could be divided into systematic and nonsystematic biases. Systematic bias, defined as the mean difference between the perceived and veridical directions, correlated linearly with the relative posture between the finger and the head. By contrast, nonsystematic bias, defined as minor difference in bias for different stimulus directions, was highly individualized, phase-locked to stimulus orientation presented on the skin. Overall, the present findings on systematic bias indicate that the transformation bias among the reference frames is dominated by the finger-to-head posture. Moreover, the highly individualized nature of nonsystematic bias reflects how information is obtained by the orientation-selective units in the S1 cortex.

Functional Recovery Patterns of Hemorrhagic and Ischemic Stroke Patients Under Post-Acute Care Rehabilitation Program

BACKGROUND

Tailored rehabilitation programs for stroke patients cannot be made without knowledge of their recovery potential. The aim of this study is to characterize the functional recovery patterns of ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients under post-acute care stroke rehabilitation.

METHODS

This retrospective study analyzed the data of patients enrolled in the Post-Acute Care-Cerebrovascular Disease (PAC-CVD) rehabilitation program, which provides an individualized 1- to 3-hour intensive physical, occupational, and speech and language therapy for post-acute stroke patients in Taoyuan Chang Gung Memorial hospital in Taiwan. Our primary endpoint measure was Barthel Index (BI), and secondary endpoint measures included other 12 functional measures.

RESULTS

A total of 489 patients were included for analysis. Patients with stroke history had less BI improvement than those who suffered their first-ever stroke. In first-ever stroke patients who had completed 6 to 12 weeks of PAC-CVD program, subcortical ICH patients had greater BI, quality of life, sensation, and balance improvements, and had greater late-phase recovery than their IS counterparts. In IS patients, those with age >75 had less BI improvement; those with National Institute of Health Stroke Scale (NIHSS) score 1-5 had greater Motor Activity Log quality of use (MAL-quality) improvement than those with NIHSS score >5; those with Mini-Mental State Examination (MMSE) score ≥24 had greater BI and instrumental activities of daily living (IADL) improvement. Using the general linear model, previous stroke (ß: -6.148, p=0.01) and subcortical ICH (ß: 5.04, p=0.03) were factors associated with BI improvement.

CONCLUSION

Subcortical ICH patients have greater functional improvement and greater late-phase recovery than their IS counterparts following PAC rehabilitation. More studies are needed to validate our findings and unravel the underlying mechanisms of stroke recovery to optimize the treatment strategy following a stroke.

Dietary mannan oligosaccharide ameliorates cyclic heat stress-induced damages on intestinal oxidative status and barrier integrity of broilers

This study investigated protective effects of mannan oligosaccharide (MOS) inclusion on growth performance, intestinal oxidative status, and barrier integrity of cyclic heat-stressed broilers. A total of 240 one-day-old chicks were allocated into 3 treatments of 10 replicates each. Control broilers reared at a thermoneutral temperature were fed a basal diet, whereas broilers in heat stress and MOS groups raised at a cyclic high temperature (32 to 33°C for 8 h/d) were given the basal diet supplemented with 0 or 250 mg/kg MOS, respectively. Compared with control group, heat stress decreased (P < 0.05) average daily gain and feed conversion ratio during grower, finisher, and entire periods, average daily feed intake during finisher and entire periods, and ileal superoxide dismutase activity at 42 D, whereas increased (P < 0.05) rectal temperature at 21 and 42 D and jejunal malondialdehyde content at 42 D. Dietary MOS increased (P < 0.05) average daily gain, average daily feed intake, and feed conversion ratio during finisher and entire periods, but decreased (P < 0.05) jejunal malondialdehyde concentration of heat-stressed broilers at 42 D. Heat stress decreased (P < 0.05) jejunal villus height (VH) and claudin-3 gene expression at 21 D, and VH and VH: crypt depth (CD) ratio in jejunum and ileum as well as mRNA abundances of jejunal mucin 2 and occludin, and ileal mucin 2, zonula occludens-1, and occludin, and claudin-3 at 42 D, whereas increased (P < 0.05) serum D-lactate acid content at 21 and 42 D, and serum diamine oxidase activity and jejunal CD at 42 D. The MOS supplementation increased (P < 0.05) jejunal VH at 21 D, VH and VH: CD of jejunum and ileum at 42 D, mRNA abundances of jejunal occludin and ileal mucin 2, zonula occludens-1, and occludin at 42 D, whereas reduced (P < 0.05) ileal CD at 42 D. These results suggested that MOS improved growth performance, and oxidative status and barrier integrity in the intestine of broilers under cyclic heat stress.

Association of Dysplastic Coronoid Process with Long-Face Morphology

Vertical malocclusion is a developmental condition, resulting from complex interactions among multiple etiological factors during the growth period. As a tricky dentofacial deformity clinically, long-face (LF) morphology is characterized by excessive vertical facial growth with severe disarrangement of jaws and teeth. Since the improvement of LF patients on facial profile and occlusion is often difficult and lacks long-term stability, it becomes important to unravel the etiology of LF pattern formation for early prevention and treatment. In the current studies, we identified a transgenic mouse model that exhibited a dysplastic coronoid process and LF morphology. Although the mutant mice exhibited jaw structures and occlusion comparable to controls at birth, they all acquired typical LF morphology with anterior open bite during postnatal growth, resembling clinical features of the selected skeletal class III patients. Since the coronoid process provides an insertion site for the temporalis attachment, we examined the initial development and differentiation of the temporalis and found identical results in both control and mutant mice before E17.5 when the temporal muscle makes attachment to the coronoid process. However, thereafter, we observed altered orientation and reduced size of the cross-sectional area of the temporalis in mutant mice, which persisted to the weaning stage. Biomechanical analysis and simulation modeling further support the idea that altered morphology of the coronoid process may impair the efficiency of the vertical temporalis contraction and appears to correlate with LF formation. Consistently, we present evidence that a dysplastic mandibular coronoid process was also seen in some human patients with skeletal III LF morphology. Taken together, the results presented in this study establish an association of the craniofacial bony structures with vertical patterning, which will have implications in earlier prediction for clinical precaution and intervention.

[Effects of n-hexane on learning and memory and the expressions of nerve growth factor mRNA and nerve growth factor receptor mRNA of brain tissue in mice exposed to N-hexane]

Objective: To Effects of n-hexane on learning and memory and the expressions of nerve growth factor (NGF) mRNA and nerve growth factor receptor (NGFR) mRNA of brain tissue in mice exposed to N-hexane. Methods: 40 Kunming mice were randomly divided into low-dose group, meddle-dose group, high-dose dose group and control group, with 10 mice in each group. All the groups were orally exposed to n-hexane in different doses: low-dose group with 43.5 mg/kg, middle-dose group with 86.5 mg/kg and high-dose group with 173.0 mg/kg, 1 time per day for 20 d. After the poisoning, the Y-arm test and the expressions of NGF mRNA and NGFR mRNA and the concentrations of NGF and NGFR in the brain tissues of each group were measured. Results: In the first Y-arm test, there existed a significant difference in correct reaction rate generally in all groups (P<0.05), and correct reaction rate in the middle-dose group and the high-dose group were low significantly compared with that in the control group(P<0.05). In the second Y-arm test, there existed a significant differences in total electric shock time and correct reaction rate generally in all groups (P<0.01), and the total electric shock time prolonged significantly and the correct response rate decreased significantly in 3 dose groups compared with those of the control group(P<0.05). The expression levels of NGF mRNA in brain tissues of low, meddle and high dose-groups were 0.81±0.66, 0.67±0.37 and 0.69±0.26, and the expression levels of NGFR mRNA were 1.22±0.42, 1.98±0.84 and 2.01±2.01, respectively. Compared with the control group, the expressions of NGF mRNA in the 3 dose groups decreased significantly (P<0.05), and the expression of NGFR mRNA in middle-and high-dose groups increased significantly (P<0.05). The concentrations of NGF in brain tissues of low,meddle and high dose-groups were 39.97±7.24 ng/L, 39.26±7.88 ng/L,31.70±8.21 ng/L,and the concentrations of NGFR were 17.37±6.82 ng/L,21.37±7.16 ng/L, 22.46±7.70 ng/L, respectively. Compared with the control group, the concentrations of NGF in high-dose groups decreased significantly(P<0.05), and the concentrations of NGFR in middle-and high-dose groups increased significantly (P<0.05). Conclusion: N-hexane exposure can result in decrease of learning and memory in mice, which may be related to abnormal expression of NGF mRNA and NGFR mRNA in brain tissue.

[Clinicopathological features and molecular genetics of paediatric-type follicular lymphoma: report of eight cases]

Objective: To investigate the clinical presentation pathological diagnostic features and molecular genetics of paediatric-type follicular lymphoma (PTFL). Methods: Eight cases of PTFL at Fujian Cancer Hospital between January 2003 and May 2018 were analyzed by hematoxylin-eosin stain, immunohistochemistry, polymerase chain reaction (PCR) and fluorescence in situ hybridization (FISH). The relevant literature review was performed. Results: All patients were male with age ranging from 12 to 27 years (median age of 18 years and average age of 19 years). Clinical manifestations included painless lymph adenopathy, primarily involving head and neck lymph nodes (6/8). According to Ann Arbor stage, there were 7 patients at stage Ⅰ A and 1 patient at stage Ⅱ A. Histologically, the structure of the lymph nodes was effaced with pushing borders visible at the tumor periphery. The lesions consisted of expanding, irregular follicles that were arranged in back to back fashion along with thinning or disappearing sleeves. The starry sky phenomenon in the follicle was prominent with loss of polarity. Under high power magnification, the follicles were composed of uniform, medium-sized blastic cells in 5 cases or centroblast in 3 cases. The neoplastic cells were positive for B cell markers and germinal center markers primarily confined to the germinal center. Bcl-2 was negative in 7 cases and 1 case showed weak bcl-2 staining. MUM1 was negative in all cases. Ki-67 demonstrated a high proliferation index of great than 70% in 7 of 8 cases. Eight cases showed Ig clonal rearrangement. No bcl-2, bcl-6, and IRF4/MUM1 gene rearrangements by FISH were detected in all cases. One patient was treated with 6 cycles of CHOP after surgical resection. Other patients underwent only simple surgical resection. All patients were alive upon clinical follow-up. Conclusion: PTFL is a rare subtype of B cell lymphoma with unique clinical and pathological features. It should be distinguished from reactive follicular hyperplasia, nodal marginal lymphoma in children, large B-cell lymphoma with IRF4 rearrangement and usual follicular lymphoma.

[A multicentric clinical study on clinical characteristics and drug sensitivity of children with pneumococcal meningitis in China]

Objective: To understand clinical characteristics of children with pneumococcal meningitis (PM) in China and to analyze the drug sensitivity of Streptococcus pneumoniae isolates and associated impacts on death and sequelae. Methods: The clinical data, follow-up results and antimicrobial sensitivity of isolated strains of 155 children (including 98 males and 57 females, age ranged from 2 months to 15 years) with PM in 10 tertiary-grade A class hospitals of Infectious Diseases Surveillance of Pediatrics (ISPED) from 2013 to 2017 were collected and analyzed retrospectively. Patients were divided into different groups according to the following standards: ≤1 year old group,>1-3 years old group and >3 years old group according to age; death group and non-death group according to the death within 30 days after PM diagnosis; complication group and non-complication group according to the abnormal cranial imaging diagnosis; sequelae group and no-sequelae group according to the follow-up results. Bonfereoni chi-square segmentation and Kruskal-Wallis H test were used for statistical analysis. Results: There were 64 cases (41.3%) in the ≤1 year old group, 39 cases in the >1-3 years old group (25.2%), and 52 cases (33.5%) in the >3 years old group. The most common clinical manifestation was fever (151 cases, 97.4%). The mortality was 16.8% (26/155) during hospitalization. The neurological complication rate was 49.7% (77/155) during hospitalization, including the most common complication, subdural effusion and (or) empyema in 50 cases (32.3%) and hearing impairment in 6 cases. During follow-up after discharge, no death was found and focal neurological deficits were found in 47 cases (30.3%), including the frequent neurological sequelae: cognitive and mental retardation of different degree in 22 cases and hearing impairment in 14 cases (9.0%). The rate of cure and improvement on discharge was 74.8% (116/155) and the lost to follow-up rate was 8.4% (13/155). The proportions of died cases, neurological complications during hospitalization and proportions of peripheral white blood cell count <12 × 10(9)/L before admission in ≤1 year old group were significantly higher than those in >3 years old group (25.0% (16/64) vs. 5.8% (3/52), 75.0% (48/64) vs. 25.0% (13/52), 48.4% (31/64) vs. 15.4% (8/52), χ(2)=7.747, 28.767, 14.044; P=0.005, 0.000, 0.000). The proportions of headache, vomiting, neck resistance and high risk factors of purulent meningitis in >3 years old group were significantly higher than those in ≤ 1 year old group (67.3%(35/52) vs. 1.6%(1/64), 80.8% (42/52) vs. 48.4% (31/64), 69.2% (36/52) vs. 37.5% (24/64), 55.8% (29/52) vs. 14.1%(9/64), χ(2)=57.940, 12.856, 11.568, 22.656; P=0.000, 0.000, 0.001, 0.000). Streptococcus pneumoniae isolates were completely sensitive to vancomycin (100.0%, 152/152), linezolid (100.0%, 126/126), moxifloxacin (100.0%, 93/93) and ofloxacin (100.0%,41/41); highly sensitive to levofloxacin (99.3%, 142/143) and ertapenem (84.6%, 66/78); moderately sensitive to ceftriaxone (48.4%, 45/93), cefotaxime (40.0%, 44/110) and meropenem (38.0%, 38/100); less sensitive to penicillin (19.6%, 27/138) and erythromycin (4.2%, 5/120). The proportions of non-sensitive strains of penicillin (21/21) and meropenem (17/18) in the death group were significantly higher than those (90/117, 45/82) in the survived group(χ(2)=4.648 and 9.808, P=0.031 and 0.002). Conclusions: The children's PM is mainly found in infants under 3 years old in China. Death and neurological complications are more common in PM children under 1 year old. The clinical manifestations and peripheral blood inflammatory markers of PM patients under 1 year old are not typical. Fever is the most common clinical manifestation and subdural effusion and (or) empyema is the most common complication. Long-term hearing impairment is common in PM and the follow-up time must be prolonged. The dead PM cases had high in sensitive rates to penicillin and meropenem.

[Qualitative pathological assessment of liver fibrosis regression after antiviral therapy in patients with chronic hepatitis B]

Objective: To investigate the methods for qualitative pathological assessment of dynamic changes in liver fibrosis/cirrhosis after antiviral therapy in patients with chronic hepatitis B (CHB), since antiviral therapy can partially reverse liver fibrosis and cirrhosis caused by hepatitis B and semi-quantitative, rather than qualitative, pathological assessment is often used for the research on liver fibrosis regression. Methods: Previously untreated CHB patients with liver fibrosis and cirrhosis were enrolled, and liver biopsy was performed before treatment and at 78 weeks after the antiviral therapy based on entecavir. The follow-up assessment was performed once every half a year. Based on the proportion of different types of fibrous septum, we put forward the new qualitative criteria called P-I-R classification (predominantly progressive, predominantly regressive, and indeterminate) for evaluating dynamic changes in liver fibrosis. This classification or Ishak fibrosis stage was used to evaluate the change in liver fibrosis after treatment and Ishak liver inflammation score was used to evaluate the change in liver inflammation after treatment. Results: A total of 112 CHB patients who underwent liver biopsy before and after treatment were enrolled, and among these patients, 71 with an Ishak stage of ≥3 and qualified results of live biopsy were included in the final analysis. Based on the P-I-R classification, 58% (41/71) were classified as predominantly progressive, 29% (21/71) were classified as indeterminate, and 13% (9/71) were classified as predominantly regressive; there were no significant differences between the three groups in alanine aminotransferase, aspartate aminotransferase, albumin, HBeAg positive rate, HBV DNA, and liver stiffness (P < 0.05). After treatment, the proportion of predominantly progressive, indeterminate, or predominantly regressive patients changed to 11% (8/71), 11% (8/71), and 78% (55/71), respectively. Among the 35 patients who had no change in Ishak stage after treatment, 72% (25/35) were classified as predominantly regressive and had certain reductions in the Laennec score, percentage of collagen area, and liver stiffness. Conclusion: This new P-I-R classification can be used to assess the dynamic changes in liver fibrosis after antiviral therapy in CHB patients.

[Clinical effect and safety of pegylated interferon-α-2b injection (Y shape, 40 kD) in treatment of HBeAg-positive chronic hepatitis B patients]

Objective: To investigate the clinical effect and safety of long-acting pegylated interferon-α-2b (Peg-IFN-α-2b) (Y shape, 40 kD) injection (180 μg/week) in the treatment of HBeAg-positive chronic hepatitis B (CHB) patients, with standard-dose Peg-IFN-α-2a as positive control. Methods: This study was a multicenter, randomized, open-label, and positive-controlled phase III clinical trial. Eligible HBeAg-positive CHB patients were screened out and randomized to Peg-IFN-α-2b (Y shape, 40 kD) trial group and Peg-IFN-α-2a control group at a ratio of 2:1. The course of treatment was 48 weeks and the patients were followed up for 24 weeks after drug withdrawal. Plasma samples were collected at screening, baseline, and 12, 24, 36, 48, 60, and 72 weeks for centralized detection. COBAS® Ampliprep/COBAS® TaqMan® HBV Test was used to measure HBV DNA level by quantitative real-time PCR. Electrochemiluminescence immunoassay with Elecsys kit was used to measure HBV markers (HBsAg, anti-HBs, HBeAg, anti-HBe). Adverse events were recorded in detail. The primary outcome measure was HBeAg seroconversion rate after the 24-week follow-up, and non-inferiority was also tested. The difference in HBeAg seroconversion rate after treatment between the trial group and the control group and two-sided confidence interval (CI) were calculated, and non-inferiority was demonstrated if the lower limit of 95% CI was > -10%. The t-test, chi-square test, or rank sum test was used according to the types and features of data. Results: A total of 855 HBeAg-positive CHB patients were enrolled and 820 of them received treatment (538 in the trial group and 282 in the control group). The data of the full analysis set showed that HBeAg seroconversion rate at week 72 was 27.32% in the trial group and 22.70% in the control group with a rate difference of 4.63% (95% CI -1.54% to 10.80%, P = 0.1493). The data of the per-protocol set showed that HBeAg seroconversion rate at week 72 was 30.75% in the trial group and 27.14% in the control group with a rate difference of 3.61% (95% CI -3.87% to 11.09%, P = 0.3436). 95% CI met the non-inferiority criteria, and the trial group was non-inferior to the control group. The two groups had similar incidence rates of adverse events, serious adverse events, and common adverse events. Conclusion: In Peg-IFN-α regimen for HBeAg-positive CHB patients, the new drug Peg-IFN-α-2b (Y shape, 40 kD) has comparable effect and safety to the control drug Peg-IFN-α-2a.

[Post-marketing safety analysis of inactivated enterovirus A71 vaccines]

Objectives: To evaluate the safety of inactivated enterovirus A71(EV-A71) vaccines after large-scale immunization in the community. Methods: We selected EV-A71 susceptible people (healthy children) aged 6-59 months in vaccination clinics from 89 counties in Zhejiang Province between April 2016 and March 2018. All local and systematic adverse actions were collected by 30 min on-site inspection, within 3 days and 4-30 days follow-up. Chi-square test and Fisher's exact test were used to compare the difference of AEs incidence in various characteristics among two groups. Results: A total of 71 663 doses of vaccines were included for active safety analysis, which included 37 331 doses in boys and 34 332 doses in girls. Among all the doses, children aged 6 to 11 months, 12 to 23 months and 24 to 59 months were received 13 707, 32 639 and 25 317 doses respectively. The incidence of adverse reactions within 30 min, 3 days and 4-30 days were 0.33% (239 doses), 1.58% (1 133 doses) and 0.34% (244 doses) respectively. Adverse reactions within 3 days were 1 372 doses, with a incidence of 1.91%; among all the cases, 539 doses (0.75%) were grade 1, 677 doses (0.94%) were grade 2 and 156 doses (0.22%) were grade 3, no grade-4 adverse reaction was reported. The common local adverse reactions were redness, swelling and pruritus, with the incidence rates were 0.05% (39 doses), 0.02% (16 doses) and 0.02% (12 doses), respectively, while the most common systemic adverse reaction was pyrexia with an incidence of 1.19% (856 doses), followed by diarrhea and anorexia with the incidence rates were 0.15% (104 doses) and 0.13% (90 doses) respectively. Conclusion: Most adverse actions of EV-A71 vaccines were mild and moderate and majority of them were common adverse actions. No new adverse reactions were found in the study.

Betaine improves the growth performance and muscle growth of partridge shank broiler chickens via altering myogenic gene expression and insulin-like growth factor-1 signaling pathway

This study was conducted to investigate the effect of betaine on growth performance, carcass characteristics, myogenic gene expression, and insulin-like growth factor-1 (IGF-1) signaling pathway in partridge shank broiler chickens. A total of 192 one-day-old partridge shank broiler chickens were randomly divided into 4 groups with 6 replicates of 8 chickens for a 52-d feeding trial. Broilers were fed a basal diet supplemented with 0 (control), 250 (B250), 500 (B500), or 1,000 (B1000) mg/kg betaine. Compared with the control group, the B500 and B1000 groups had higher (P < 0.05) body weight gain (BWG), and the B500 group had a lower (P < 0.05) feed/gain ratio (F:G) during the whole trial period. Moreover, the B1000 group increased (P < 0.05) the breast muscle yield and decreased (P < 0.05) relative abdominal fat weight. The mRNA expression of myocyte enhancer factor 2B (MEF2B) and mechanistic target of rapamycin (mTOR) and mTOR phosporylation were higher (P < 0.05) in both breast and thigh muscles in the B500 and B1000 groups than those in the control group. The higher (P < 0.05) concentration and mRNA expression of IGF-1 were also observed in breast muscle in the B500 and B1000 groups. Additionally, the B1000 group up-regulated (P < 0.05) the mRNA level of myogenic differentiation factor 1 (MyoD1) in breast muscle and myogenin (MyoG) in thigh muscle. In conclusion, diets supplemented with 500 or 1,000 mg/kg betaine improved the growth performance of partridge shank broiler chickens during the whole trial period, and the B1000 group significantly improved the breast muscle growth. These improvements might result from increased mRNA expression of MyoD1 and MEF2B in breast muscle and MyoG and MEF2B in thigh muscle, and through alterations in IGF-1/mTOR signaling pathway.

[Clinicopathological characteristics of adult T cell leukemia/lymphoma]

Objective: To investigate the clinical presentation, clinicopathologic features, diagnosis and differential diagnosis of adult T cell leukemia/lymphoma (ATLL). Methods: Four cases of ATLL from Fujian Cancer Hospital between October 2017 and May 2018 were analyzed using hematoxylin-eosin and immunohistochemical stains and polymerase chain reaction (PCR) for HTLV-1 provirus genes. The relevant literature was reviewed. Results: There were two males and two females, age range 38-80 years. All patients were from coastal cities of Fujian province. Clinical presentations including lymphadenopathy, hepatomegaly and splenomegaly were detected in most patients; skin lesion, hypercalcemia and lymphocytosis were also commonly detected.Histologically, there was diffuse effacement of the normal architecture by tumor cells infiltration. The inflammatory background is usually sparse, with scanty eosinophils. The atypical lymphoid cells were typically medium to large sized with pronounced nuclear pleomorphism, irregular nuclei, chromatin clumping and prominent nucleoli. Blast-like cells with transformed nuclei were present in variable proportions. Giant cells with convoluted or cerebriform nuclear contours may be present. Rare cases may be composed predominantly of anaplastic tumor cells. Characteristic "flower cells" with large multi-lobated nuclei can be seen. The tumor cells were strongly positive for CD2, CD3, CD5, CD4 and CD25, but negative for CD7, CD8 and cytotoxic molecules (including TIA-1, Granzyme B and perforin). In three cases, the large transformed cells were positive for CD30. In one case, the anaplastic large cells were diffusely and strongly positive for CD30. All cases were negative for EBER, but positive for HTLV-1 provirus. Conclusions: ATLL is a rare type of T cell lymphoma with unique clinical and pathological features, and should be distinguished from peripheral T cell lymphoma, NOS, ALK negative anaplastic large cell lymphoma and mycosis fungoides. Hypercalcemia, systemic disease, characteristic "flower cells" and specific immunophenotypic profile of CD3(+), CD4(+), CD25(+), and CD7(-) are highly suggestive. However, ATLL can only be confirmed if the presence of HTLV-1 provirus.