[Retinal toxicity study of intravitreal ganciclovir in albino rabbit]

Objective: To elevated the retinal toxicity of intravitreal ganciclovir in albino rabbit eyes. Methods: Experimental study. Twenty-four New Zealand albino rabbits (forty-eight eyes) were divided into four groups by random. Three groups were prepared for ganciclovir experiment, named A, B, C. Each group received intravitreal injection ganciclovir dose at 400 μg/0.05 ml, 2 mg/0.05 ml and 5 mg/0.05 ml respectively. The other group named D served as a control accepted intravitreal injection 0.9% normal saline 0.1 ml. Before and after 1, 2 and 4 weeks, flicker full field electroretina gram (ERG) was recorded. After 1, 2 and 4 weeks light and electron microscopic tests were recorded for further toxicity study. Results: There was significant difference in amplitude of maximal combined response a wave in one week(χ(2)=8.319, P=0.04), and pairwise comparison the 5 mg group (140.50 μV) was significantly lower than the control group (165.00 μV) (χ(2)=-2.830, P=0.028). Maximal combined response b wave in four weeks(χ(2)=-10.626, P=0.014), and pairwise comparison the 5 mg group (261.50 μV) was significantly lower than the control group (398.00 μV) (χ(2)=-2.973, P=0.018). 30 Hz flicker response in one, two and four weeks(χ(2)=17.589, 8.225, 8.997, P=0.001, 0.042, 0.02), and pairwise comparison the 5 mg group (71.3μV, 106.00μV, 63.60μV) was significantly lower than the control group (118.50μV, 129.00μV, 116.50μV) (χ(2)=-4.142, -2.826, -2.713, P=0.000, 0.028, 0.040). There was no histologic retinal toxicity evidence of group 400 μg and control group observed by light microscopy in any stage of the study. Histologic changes of group 2 mg four week later, group 5 mg two and four week later include inner nuclear layer loose arranged, nuclear of ganglia were widened and outer plexiform layer stained less in four week later. By electron microscopic observation, the ultrastructure of retina changed to different degrees and became worse in each experimental group with significant mitochondrial swelling and hydropic changes were seen in the inner segments of photoreceptors, loosely arranged and disordered in the outer segment of photoreceptors four weeks later. Conclusions: The retinal function and morphology were normal in group 400 μg. Group 2 mg and 5 mg had retinal toxicity, and 5 mg was more severe. Therefore, the clinical application of ganciclovir in the treatment of acute retinal necrosis (ARN) should select the minimum effective dose to avoid the occurrence of retinal toxicity. (Chin J Ophthalmol, 2020, 56:279-285).

[Eosinophilic solid and cystic renal cell carcinoma with TSC2 gene mutations in children]

Objective: To study clinical pathological characteristics, immunohistochemical, molecular genetical changes and prognosis in pediatric eosinophilic solid and cystic renal cell carcinoma (ESC RCC) with TSC2 gene mutations. Methods: The tissue samples were collected from two pediatric ESC RCC patients between 2017 and 2018. The tissues were subjected to histological examination and immunohistochemistry using EnVision system. The TFE3, TFEB gene rearrangements were tested using FISH and molecular genetic study. The paraffin sections were used for DNA extraction, PCR amplification and NGS sequencing. Results: The two patients with ESC RCC were both male, aged at 9 years and 8 months, and 13 years, respectively. The tumors were from the right kidney, 5 cm and 7 cm in size, respectively, with solid and cystic changes in cross section, and grey-reddish or grey-whitish fish meat appearance. Microscopic observation revealed the tumors had fibrous capsules, which were infiltrated by the tumor cells. The tumor cells were diffusely distributed, round-shaped, or polygon-shaped, and had voluminous cytoplasm, eosinophilic cytoplasm, various sizes of vacuoles and clear cell-like appearance. There were papillary structures in some areas, with visible fiber septa. The nuclei were round and vesicular, with multi-nucleated cells and megakaryocytes. The mitoses were not seen. A few cystic structures were visible in different sizes, and capsule walls were covered with a single layer of spike-like tumor cells. Thick-walled blood vessels were seen in the stroma, with focal lymphocytic infiltration, eosinophilic necrosis, calcifications and cholesterol crystals. Immunohistochemistry of the tumor cells was positive for PAX8 (diffuse), CK20 (focal), CKpan (focal), CK10 (1 focal, 1 diffuse), INI1, vimentin, CD68, and Ki-67 (5%~10%); the tumor cells were negative for HMB45, S-100, Melan A, p53, desmin, TFE3, CK7, CK19, EMA, CD56, CgA, Syn, CD30, CD117, WT1 and SMA. Molecular genetic study showed that TFE3 and TFEB gene rearrangements were not detected by FISH. NGS sequencing showed TSC2 p.Lys574Ter (0.198) was found in patient one and TSC2 p.Arg406Ter (0.355) in patient two. Conclusions: ESC RCC in children is a rare disease, and can be misdiagnosed easily. It has unique pathological characteristics, and immunohistochemical, molecular and genetic changes. The prognosis is relatively good.

[Diagnostic and therapeutic strategies of lung cancer patients during the outbreak of 2019 novel coronavirus disease (COVID-19)]

With the increasing number of cases and widening geographical spread, the 2019 novel coronavirus disease (COVID-19) has been classified as one of the class B infectious diseases but prevented and controlled as class A infectious disease by the National Health Commission of China. The diagnosis and treatment of lung cancer patients have been challenged greatly because of extraordinary public health measures since the lung cancer patients are a high-risk population during the COVID-19 outbreak period. Strict protection for lung cancer patients is needed to avoid infection. Lung cancer patients are difficult to differentiate from patients with COVID-19 in terms of clinical symptoms, which will bring great trouble to the clinical work and physical and mental health of lung cancer patients. This review will demonstrate how to applicate appropriate and individual management for lung cancer patients to protect them from COVID-19.

Prognostic Significance of Baseline Neutrophil Count and Lactate Dehydrogenase Level in Patients With Esophageal Squamous Cell Cancer Treated With Radiotherapy

Background: This present study aimed to explore the prognostic value of pretreatment neutrophil and lactate dehydrogenase (LDH) and to develop a prognostic risk scoring model to predict prognosis in esophageal squamous cell cancer (ESCC) patients treated with definitive radiotherapy.

Methods: Retrospectively collected data of patients who received definitive radiotherapy for ESCC at Shantou Central Hospital between January 2009 and December 2015 were included for the analysis. The association between the level of LDH and neutrophil and clinicopathological characteristics were analyzed. We performed univariate and multivariate analyses to identify the prognostic predictors for patients with ESCC. Based on the results, we also developed a prognostic risk scoring model and assessed its predictive ability in the subgroups.

Results: A total of 567 patients who received definitive radiotherapy for ESCC were included in the present study. The optimal cutoff values were 4.5 × 10⁹/L, 3.25, and 220 U/L for neutrophil, neutrophil-to-lymphocyte ratio (NLR), and LDH, respectively. A high level of LDH was significantly associated with advanced N stage (p = 0.031), and neutrophil count was significantly associated with gender (p = 0.001), T stage (p < 0.001), N stage (p = 0.019), clinical stage (p < 0.001), and NLR (p < 0.001). Multivariate survival analysis identified gender (p = 0.006), T stage (p < 0.001), N stage (p = 0.008), treatment modality (p < 0.001), LDH level (p = 0.012), and neutrophil count (p = 0.038) as independent prognostic factors for overall survival. Furthermore, a new prognostic risk scoring (PRS) model based on six prognostic factors was developed, in which the patients were divided into three groups with distinct prognosis (χ2 = 67.94, p < 0.0001).

Conclusions: Elevated baseline LDH level and neutrophil count predicted poor prognosis for ESCC patients treated with definitive radiotherapy. A PRS model comprised of LDH, neutrophil count, and other prognostic factors would help identify the patients who would benefit the most from definitive radiotherapy.

[Application of meticulous anatomy skills with straight bipolar electric coagulation forceps in thyroid surgery]

Objective: To compare the efficacies of the two techniques of "micro-hemostasis and micro-cutting" with straight bipolar electrocoagulation forceps and traditional clamp-ligation for hemostasia in thyroid surgery. Methods: A total of 228 patients who underwent surgical treatment for thyroid neoplasms in our hospital between January 2015 and December 2018 were retrospectively analyzed, including 50 males and 178 females, aged 23-68 years old. Of those, 150 cases as electric knife group received traditional thyroid surgery between January 2015 and December 2018 and 78 cases as bipolar electrocoagulation group received thyroid surgery by using the technique of bipolar electrocoagulation with meticulous anatomy between January 2018 and December 2018. The total operation time, single operation time, intraoperative hemorrhage, postoperative drainage volume on the first day, postoperative hoarseness and hypocalcemia were compared between the two groups. SPSS 16.0 was used to analyze the data. Results: The total operation time and intraoperative hemorrhage in the bipolar electrocoagulation group were significantly lower than those in the electric knife group ((59.33±18.29)min vs (77.21±25.39)min, (14.83±9.22)ml vs (36.86±11.80)ml, all P<0.01). The single operation time of the bipolar electrocoagulation group was shorter than that of the electric knife group((10.25±6.16) min vs (20.34±7.24)min, (16.25±7.15)min vs (35.68±8.25)min, (12.12±5.25)min vs (20.68±7.26)min, t value was 3.948,16.262,8.238, all P<0.01).There was no significant difference between the two groups in postoperative drainage volume on the first day (P>0.05) and the incidence of postoperative hoarseness (P>0.05), while the incidence of hypocalcemia in the bipolar electrocoagulation group(10.26%) was lower than that in the electric knife group(21.33%,χ(2)=4.353, P<0.05). Conclusions: The fine dissection for thyroid operation can be achieved by using straight bipolar electrocoagulation tweezers. The use of "micro-hemostasis" and "micro-cutting" technique with bipolar electrocoagulation tweezers can greatly reduce intraoperative bleeding, operation time and postoperative complication.

P4621Incidence, management, and in-hospital mortality of cardiogenic shock complicating ST-elevated myocardial infarction in China: insights from the China Acute Myocardial Infarction Registry

Background and purpose

Limited data is available on the situation of cardiogenic shock (CS) complicating ST-elevated myocardial infarction (STEMI) in China. This study aims to disclose the incidence, management and in-hospital mortality (IHM) of patients with STEMI complicated by CS (STEMICS) in China and at different levels of hospitals.

Methods

We queried the 2013–2016 China Acute Myocardial Infarction (CAMI) registry databases to identify patients with STEMI and/or CS (developing before or during hospitalization). The overall and different hospital-level incidence of STEMICS and IHM were analyzed.

Results

Of 28230 STEMI patients, 2273 patients (8.05%) had CS. The incidence of STEMICS in provincial, prefectural and county-level hospitals were 5.23%, 8.46% and 13.76% (p<0.001), respectively. Primary PCI (PPCI) was performed on 675 patients (29.7%) with STEMICS. The proportion of STEMICS patients undertaking PPCI in provincial, prefectural and county-level hospitals were 46.53%, 31.48% and 8.00% (p<0.001). The overall IHM rate of patients with STEMICS was 49.8% with no difference among the different hospital levels. However, the IHM rate of prehospital STEMICS in county-level hospitals were significantly higher than that in prefectural and provincial hospitals (42.3% versus 33.3% and 28.3%, respectively; p<0.01), while that of in-hospital STEMICS were similar among the different hospital levels (66.5%, 66.9% and 62.2%; provincial, prefectural and county-level hospitals, respectively). After adjustment, the difference of IHM in prehospital STEMICS between county-level hospitals and the other two levels no longer existed. However, once PPCI was excluded from the multivariable adjustment model, the IHM of prehospital STEMICS remained higher in county-level hospitals.

Table 1. Differences in IHM of prehospital STEMICS between county-level hospitals and other two levels of hospitals before or after adjustment Provincial hospitals/ County-level hospitals Prefectural hospitals/ County-level hospitals Unadjusted OR (95% CI) 0.54 (0.36, 0.80); P=0.0019 0.68 (0.49, 0.94); P=0.0193 Adjusted OR* (95% CI) 0.63 (0.34, 1.17); P=0.1455 0.64 (0.38, 1.08); P=0.0962 Adjusted OR† (95% CI) 0.49 (0.27, 0.90); P=0.0214 0.54 (0.32, 0.91); P=0.0198 IHM: in-hospital mortality; OR: odd ratio; CI: confidence interval. *Adjusted for baseline characteristics, in-hospital medications and primary PCI; †adjusted for baseline characteristics and in-hospital medications.

Figure 1. Flowchart

Conclusion

The overall incidence and IHM rate of STEMICS in China are still high. Especially, higher IHM rate of prehospital STEMICS is observed in county-level hospitals, which may be attributed to the lower implementation rate of PPCI.

Acknowledgement/Funding

CAMS Innovation Fund for Medical Sciences (CIFMS) (2016-I2M-1-009)

P825Long-term clinical benefit of atorvastatin pretreatment before primary percutaneous coronary intervention in patients with STEMI: a multi-center propensity score-matched study

Aims

We aim to investigate the effect of single dose of statin pretreatment prior to primary Percutaneous Coronary Intervention (PCI) on long-term clinical outcomes in patients with ST-elevation Myocardial Infarction (STEMI).

Methods

Using data from China Acute myocardial Infarction (CAMI) registry, we compared the outcome in STEMI patients with vs without atorvastation pretreatment prior to primary PCI. The primary endpoint was the composite outcome of all-cause mortality, non-fatal MI or stroke events during follow-up. Propensity-score (PS) matching was used to assemble a cohort of patients with similar baseline characteristics. All patients were followed till 24 months since baseline.

Results

Of all 3772 patients who met our inclusion criteria at 108 hospitals in China, 3288 patients (1644 patients in each arm) were included in our PS-matched cohort. In the PS-match cohort, overall 144 (8.65%) and 113 (6.79%) patients in the control group and pretreatment group had the primary endpoint respectively (p=0.048). The estimated HRs were 0.78 (95% CI: 0.606–0.997, p=0.046) in the unadjusted model and 0.76 (95% CI: 0.596–0.984, p=0.032) in the adjusted model (Figure). The HRs were broadly similar for the pretreatment dosage of 40 mg or 80 mg (0.78 vs 0.77, p=0.75). The HRs were even stronger in patients with single-vessel only than multi-vessel coronary artery disease (0.31 vs 0.75, p=0.014).

Conclusion

Among Chinese patients with STEMI, atorvastatin pretreatment before primary PCI may have better long-term composite outcome of all-cause mortality, non-fatal MI, or stroke events.

Acknowledgement/Funding

CAMS Innovation Fund for Medical Sciences (CIFMS) (2016-I2M-1-009)

P4664N-terminal pro-B-type natriuretic peptide and its relationship with cardiac function and prognosis in elderly patients with valvular heart disease

Background

N-terminal pro-B-type natriuretic peptide (NT-proBNP) may provide incremental prognostic value in valvular heart disease (VHD). We aimed to elaborate its value in elder VHD patients and relationship with ventricular function and prognosis.

Methods

From China elDerly Valvular heart Disease (China-DVD) cohort study, elder VHD patients (age ≥60 years) with concomitant echocardiography and NT-proBNP measurements at baseline were included. Patients were followed every six months. The primary endpoint was 1-year all-cause mortality regardless of valvular intervention.

Results

In total, 6025 patients were included in the study (mean age of 71.08±7.61 years, 52.6% male, 78.6% NYHA class > I). The overall median NT-proBNP was 268.92 pmol/L (interquartile range [IQR]: 89.94 to 828.70 pmol/L). Among various VHD, the highest NT-proBNP levels were detected in patients with multivalvular heart disease (379.96 pmol/L [IQR: 146.07 to 1188.53 pmol/L]) and mitral regurgitation (294.88 pmol/L [IQR: 98.44 to 917.75 pmol/L), and the lowest levels were observed in patients with aortic regurgitation (112.04 pmol/L [IQR: 31.92 to 408.04 pmol/L). NT-pro BNP levels correlated with age (r=0.131, p<0.0001). Noteworthily, no significant difference was found between men and women. In general, NT-proBNP correlated with left ventricular ejection fraction (LVEF, r=−0.438, p<0.001), left ventricular end-diastolic dimension (LVEDD, r=0.16, p<0.001) and left atrial dimension (LA, r=0.081, p<0.001). All those correlations were stronger in aortic valve disease than mitral valve disease. Diagnostic ability of NT-proBNP to differentiate severe VHD was limited and varied among different VHD (AUC: 0.62 [0.54, 0.69] in AS, 0.61 [0.53, 0.69] in MS, 0.58 [0.53, 0.63] in AR, 0.49 [0.47, 0.53] in MR). Spline curves revealed a strong association between NT-proBNP and mortality. In the overall population, after adjustment of propensity score accounting for age, sex, coronary heart disease, diabetes, cardiomyopathy, symptoms, severity, LVEF, and valvular intervention, NT-proBNP was a powerful, independent, and incremental predictor of mortality (log transformation, HR: 1.38; [95% CI: 1.30 to 1.46], p<0.001). Moreover, we dichotomized NT-proBNP in severe and nonsevere using median values in various VHD. Except for MS, other VHDs all incurred excess mortality with severe NT-proBNP, especially in aortic stenosis (HR: 17.21; [95% CI: 4.08 to 72.60], p<0.001) and aortic regurgitation (HR: 5.10; [95% CI: 2.13 to 12.22], p<0.001).

Conclusion

Levels of NT-proBNP significantly differ by diagnosis in VHD patients and correlate with echocardiographic parameters to varying degrees, reflecting different hemodynamic changes. In patients with VHD other than single mitral stenosis, NT-proBNP is a powerful, independent, and incremental predictor of mortality. Thus, measurement of NT-proBNP should be considered in the VHD population for further risk stratification.

Acknowledgement/Funding

Key Projects in the National Science & Technology Pillar Program during the 12th five-year Plan

P4622Prediction of in-hospital bleeding for AMI patients undergoing PCI using machine learning method

Background

Prediction of in-hospital bleeding is critical for clinical decision making for acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI). Machine learning methods can automatically select the combination of the important features and learn their underlying relationship with the outcome.

Objective

We aim to evaluate the predictive value of machine learning methods to predict in-hospital bleeding for AMI patients.

Methods

We used data from the multicenter China Acute Myocardial Infarction (CAMI) registry. We randomly partitioned the cohort into derivation set (75%) and validation set (25%). Using data from the derivation set, we applied a state-of-art machine learning algorithm, XGBoost, to automatically select features from 106 candidate variables and train a risk prediction model to predict in-hospital bleeding (BARC 3, 5 definition).

Results

16736 AMI patients who underwent PCI were consecutively included in the analysis, while 70 (0.42%) patients had in-hospital bleeding followed the BARC 3,5 definition of bleeding. Fifty-nine features were automatically selected from the candidate features and were used to construct the prediction model. The area under the curve (AUC) of the XGBoost model was 0.816 (95% CI: 0.745–0.887) on the validation set, while AUC of the CRUSADE risk score was 0.723 (95% CI: 0.619–0.828).

Relative contribution of the 12 most important features Feature Relative Importance Direct bilirubin 0.078 Heart rate 0.077 CKMB 0.076 Creatinine 0.064 GPT 0.052 Age 0.048 SBP 0.036 TG 0.035 Glucose 0.035 HCT 0.031 Total bilirubin 0.030 Neutrophil 0.030

ROC of the XGBoost model and CRUSADE

Conclusion

The XGBoost model derived from the CAMI cohort accurately predicts in-hospital bleeding among Chinese AMI patients undergoing PCI.

Acknowledgement/Funding

the CAMS innovation Fund for Medical Sciences (CIFMS) (2016-12M-1-009); the Twelfth Five-year Planning Project of China (2011BAI11B02)

P5544Antiplatelet effects of intraoperative administration of ticagrelor versus clopidogrel in patients undergoing one-stop hybrid coronary revascularization: a single-center randomized controlled trial

Background

“One-stop” hybrid coronary revascularization (HCR) has emerged to be a reliable and attractive alternative for selected patients with multivessel coronary artery disease. However, the optimal antiplatelet regimen of this procedure still remains controversial. Therefore, we conducted a randomized controlled trial to compare antiplatelet effect between ticagrelor and clopidogrel during this hybrid procedure.

Purpose

The study objective was to evaluate the onset of platelet inhibition between ticagrelor and clopidogrel in patients during “one-stop” HCR.

Methods

In a single-center, randomized, open-label study, 60 patients receiving one-stop HCR were randomized equally to received either clopidogrel (300 mg loading dose, 75 mg once per day), or ticagrelor (90 mg loading dose, 90 mg twice daily) after confirmation of LIMA-LAD graft patency. All patients treated with aspirin 100mg once daily during the treatment period. Platelet reaction units (PRU) was assessed by Verify Now™ P2Y12 assay before surgery; after confirmation of LIMA-LAD graft patency before administration study drugs; and at 30 minutes, 1 hour, 2 hours, 6 hours, 12 hours, 24 hours after loading dose. Major adverse cardiac events and bleeding events within a year follow-up were recorded.

Results

Ticagrelor produced further suppression of platelet aggregation in patients undergoing “one-stop” HCR from 2 hours after loading dose (PRU 271.0±51.6 vs 313.2±61.2, P=0.008). The average PRU value was still better at 24 hours after loading dose in the ticagrelor group than in the clopidogrel group (121.1±75.5 vs 284.3±67.0, P<0.001). There were no differences of bleeding or major adverse cardiac events between two groups.

PRU value at various time points T C T vs C, P BS 272.7±48.5 275.5±60.4 0.842 BA 321.4±50.0 324.6±60.2 0.823 0.5 h 335.5±50.7 334.47±58.9 0.940 1 h 309.9±45.3 319.6±64.6 0.503 2 h 271.2±57.6 313.2±61.2 0.008 6 h 215.9±57.5 291.5±56.2 <0.001 12 h 196.9±80.1 295.4±62.8 <0.001 24 h 121.1±75.5 284.3±67.0 <0.001 PRU = platelet reation units; T = ticagrelor; C = clopidogrel; BS = before surgery; BA = before administration (after confrimation of left internal mammal artery graft patency).

The trial flow diagram

Conclusions

In patients receiving “one-stop” HCR, the onset of action was fater and higher with ticagrelor than with clopidogrel.

Acknowledgement/Funding

This study was funded by AstraZeneca (China) Co, Ltd.

P2744Age distribution of valvular heart disease in China: from a national multicenter prospective cohort study

Background

Valvular heart disease (VHD) has been caught in two important cross-currents in recent decades: aging demography and the rise of multimodality imaging and transcatheter valve therapy. In this setting, we aim to identify the distribution, characteristics, and management of Chinese VHD patients according to age.

Methods

China Valvular Heart Disease Cohort Study (China-VHD) was conducted from March to September 2019 in 46 centers over China. It included prospectively 12331 adults with native moderate or severe VHD, of which we described the distribution, management, and in-hospital events according to age (18–44, 45–54, 55–64, 65–74, ≥75). Multivariate Logistic regression was employed to investigate the impact of age on in-hospital events composed of in-hospital mortality, acute heart failure, and stoke.

Results

In Chinese VHD population, overall percentage peaked in 55–64 year olds. The frequency of multivalvular heart disease (MVHD) saw an increasing trend with age (p for trend <0.001). Of single valvular heart disease, mitral regurgitation (MR) was the most frequent left-sided VHD followed by aortic regurgitation (AR), aortic stenosis (AS), and mitral stenosis (MS). AS frequency significantly grew with age (p for trend = 0.02) while AR peaked in 18–44 year olds and fluctuated at a lower level in the older population. In contrast, mitral valve disease (MS, MR, and mixed mitral valve disease) was most frequent in 45–54 year olds and dropped with age (p for trend all <0.001). Noteworthily, all aortic valve disease was notably frequent in men whereas mitral valve disease and MVHD more common in women. Similar to developed countries, degenerative etiology rose steeply while rheumatic and congenital origin fell with age. Regarding management, surgical valve replacement rate was similar in age groups lower than 75 years old with increasing frequency of concomitant CABG. No matter aortic or mitral, the percentage of bio-prosthesis rocketed after 65 years (aortic: 74.7%, mitral: 70.6%). In multivariate logistic regression, covariables included age, sex, BMI, hypertension, diabetes, coronary heart disease, aortic disease, cardiomyopathy, COPD, NYHA class and valvular intervention. Compared to patients younger than 45, in-hospital events significantly higher in patients over 75 only (OR: 1.69 [95% CI: 1.07–2.66], p<0.02). Moreover, women showed a lower risk of in-hospital events (OR: 0.78 [95% CI: 0.63–0.96], p<0.01).

Age distribution of VHD

Conclusion

Age plays a crucial role in valvular heart disease, best illustrated in AS. Unlike the western world, AR and MR are more frequent than AS but show a slightly decreasing trend with age. As expected, degenerative etiology is becoming more prevalent whereas rheumatism decreases. Age over 75 and male are associated with growing in-hospital events. Degenerative VHD thus present an important public-health burden.

Acknowledgement/Funding

Innovation project of Chinese academy of medical science

P4629Long-term outcomes in patients with ST-segment elevation myocardial infarction according to modalities of reperfusion therapy: data from china acute myocardial infarction (CAMI) registry

Background

Although primary percutaneous coronary intervention (pPCI) is the optimal reperfusion method for ST-segment elevation myocardial infarction (STEMI), it remains difficult to implement in many areas. Some STEMI patients have to accept fibrinolytic therapy and no reperfusion therapy instead.

Purpose

The aim of this study was to describe the impact of reperfusion therapy on the long-term outcomes of STEMI patients in China.

Methods

Using data from the China Acute Myocardial Infarction (CAMI) registry, we analyzed the 2-year outcomes of 18,075 STEMI patients symptom onset within 7 days from January 2013 to September 2014 according to the type of reperfusion therapy. The primary endpoint was a composite of major adverse cardiovascular event (MACE), defined as all-cause mortality, myocardial infarction or stroke.

Results

7798 (43%) were treated with pPCI and 1798 (10%) underwent fibrinolysis; 8479 (47%) did not receive any reperfusion. The 2-year MACE was 9.6% following pPCI, 15.7% following fibrinolysis, and 21.5% for patients without reperfusion therapy (P<0.0001). Adjusted hazard ratios for 2-year MACE were 0.71 (95% confidence interval [CI] 0.65–0.78, P<0.0001) for pPCI versus no reperfusion and 0.92 (95% CI 0.82–1.03, P=0.16) for fibrinolysis versus no reperfusion. Compared with patients without reperfusion, fibrinolysis only showed benefit in patients presented within 3 hours of symptom onset (HR 0.70, 95% CI 0.57–0.85, P=0.0005), whereas pPCI was associated with significantly decreased 2-year MACE rate in patients presented within 3 hours (HR 0.53, 95% CI 0.44–0.64, P<0.0001), 3–6 hours (HR 0.60, 95% CI 0.51–0.71, P<0.0001) and >6 hours (HR 0.86, 95% CI 0.76–0.97, P=0.01) of symptom onset.

Adjusted cumulative MACE rate

Conclusions

In a real-world setting, early reperfusion is the optimal strategy for STEMI. Fibrinolysis was not associated with better outcome in STEMI patients admitted >3 hours of symptom onset in Chinese real world setting.

Acknowledgement/Funding

Ministry of Science and Technology of China (Grant No. 2011BAI11B02)

[PTPN11 and the deafness]

Summary PTPN11 gene encodes tyrosine phosphatase SHP-2 which locates on chromosome 12（12q24.1）, expresses in most embryonic and adult tissues, and plays pivotal roles in cell proliferation, differentiation, survival and cell death. SHP-2 apparently participates in signaling events downstream of RAS-MAPK and JAK/STAT. Diseases related to PTPN11 gene mutations include the Noonan syndrome（NS） and the NS with Multiple Lentigines（NSML）. Both NS and NSML contain the phenotypes of deafness, craniofacial anomalies, short stature, congenital heart defects, skin disorders, ophthalmologic abnormalities and cancer predisposition.

[Clinical observation of iron sucrose combined with recombinant human erythropoietin in the treatment of anemia of hip fracture in elderly patients]

OBJECTIVE

To explore the clinical efficacy of iron sucrose combined with recombinant human erythropoietin(EPO) for the treatment of anemia in elderly patients with hip fracture.

METHODS

From February 2016 to April 2018, 96 elderly anemia patients who underwent hip fracture surgery were divided into three groups according to the treatment methods. All the three groups received anti-anemia treatment 3 days before operation. Among them, 32 cases in group A were treated with iron sucrose alone, 32 cases in group B were treated with recombinant human erythropoietin alone, and 32 cases in group C were treated with iron sucrose combined with recombinant human erythropoietin. The therapeutic effects of the three groups were observed and compared.

RESULTS

The clinical effective rate in group C was significantly higher than that in group A and B (P<0.05). There was no significant difference in perioperative blood loss among the three groups(P>0.05), but the transfusion rate in group C was significantly lower than that in group A and B (P<0.05). There was no significant difference in hemoglobin and erythrocyte counts among the three groups before treatment(P>0.05), but the above indexes in group C were significantly higher than those in group A and B(P<0.05) at 1, 3 and 5 days after operation. There was no significant difference in the incidence of adverse drug reactions among the three groups(P>0.05).

CONCLUSIONS

Compared with single drug, the combined use of sucrose and iron and recombinant human erythropoietin in the treatment of elderly hip fracture anemia has a definite effect. It can not only effectively improve the level of hemoglobin, ensure the smooth operation, but also reduce the blood transfusion rate of patients and promote their recovery after operation.

Impact of sex on the prognosis of patients with esophageal squamous cell cancer underwent definitive radiotherapy: a propensity score-matched analysis

Background

The impact of sex on prognosis of patients with esophageal squamous cell cancer (ESCC) who underwent definitive radiotherapy remained unclear. The present study aimed to determine the impact of sex on the prognosis of patients with ESCC underwent definitive radiotherapy.

Methods

Between January 2009 and December 2015, patients with ESCC underwent definitive radiotherapy in Shantou Central Hospital were included in this study. The Progression-free survival (PFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. The PFS and OS were compared between female and male patients. The Cox regression model was used to identify prognostic factors. Propensity score-matched analysis was performed to balance baseline characteristics between female and male patients.

Results

A total of 683 ESCC patients treated with definitive radiotherapy were included, with 497 male and 186 female patients. In the whole cohort, female patients had a significantly longer median PFS (14.0 months vs 10.6 months, P = 0.0001, HR = 0.688, 95% CI, 0.567–0.836) and OS (20.8 months vs 15.9 months, P = 0.0005, HR = 0.702, 95% CI, 0.575–0.857). In the matched cohort, female patients still had a significantly longer median PFS (13.5 months vs 11.6 months) and OS (19.6 months vs 16.1 months). Multivariate analysis showed that sex was an independent prognostic factor for PFS (HR = 0.746, 95% CI, 0.611–0.910, P = 0.004) and OS (HR = 0.755, 95% CI, 0.615–0.926, P = 0.007).

Conclusions

This present study indicated that sex was an independent prognostic factor in Chinese patients with ESCC underwent definitive radiotherapy, with better survival outcome for women than men. Efforts should be made to investigate the underlying biological mechanism.

Electronic supplementary material

The online version of this article (10.1186/s13014-019-1278-0) contains supplementary material, which is available to authorized users.

[Prognostic value of TIMI and GRACE risk scores for in-hospital mortality in Chinese patients with non-ST-segment elevation myocardial infarction]

Objective: To evaluate the prognostic value of the thrombolysis in myocardial infarction (TIMI) and global registry of acute coronary events (GRACE) risk scores for in-hospital mortality in Chinese non-ST-segment elevation myocardial infarction (NSTEMI) patients. Methods: Data of present study derived from the prospective, multi-center registry trial of Chinese AMI (CAMI). Among 31 provinces, municipalities or autonomous districts in China, at least one tertiary and secondary hospital was selected. From January 2013 to September 2014, 5 896 consecutive non-ST-segment elevation myocardial infarction patients who were admitted to 107 hospitals within 7 days of symptom onset were enrolled. For each patient, TIMI and GRACE risk scores were calculated using specific variables collected at admission. Their prognostic value was evaluated by the endpoint of in-hospital mortality. Results: Among 5 896 NSTEMI patients (age was (65.4±12.1) years old), 68.2% (n=4 020) were males. The in-hospital mortality was 6.0% (n=353) and the median length of hospital stay was 10.0 (7.0, 13.0) days. The incidence of pre-hospital cardiac arrest was 3.6% (n=213) among 5 896 NSTEMI patients. Six hundreds and forty five patients (10.9%) received primary percutaneous coronary intervention, and 6 patients underwent emergent coronary artery bypass grafting surgery (0.1%), and the median time of reperfusion was 529.5 (256.0, 1 065.0) minutes. The prescription percentage of statins, β-blocker, angiotensin converting enzyme inhibitors or angiotensin Ⅱ receptor blockers, and aldosterone antagonists were 94.8% (n=5 587), 71.7% (n=4 228), 65.5% (n=3 864) and 26.0% (n=1 533) respectively. The area under the curve of GRACE risk score for in-hospital mortality (0.7930 (95%CI 0.767-0.818)) was better than that of TIMI risk score (0.5588 (95%CI 0.532-0.586), P<0.001). Conclusion: GRACE risk score demonstrates better predictive accuracy than TIMI risk score for in-hospital mortality in NSTEMI patients in this patient cohort.

[The ocular manifestations of human immunodeficiency virus and syphilis coinfection]

Objective: To investigate the ocular manifestations of human immunodeficiency virus (HIV) and syphilis coinfection. Methods: A retrospective analysis of the ocular manifestations was carried out in 27 patients (54 eyes) diagnosed as syphilis and HIV coinfection by the Department of Infectious Medicine in Peking Union Medical College Hospital during the years of 2006-2017. The research included 26 males and 1 female, aging from 24 to 76 years old, with a mean age of 40.40±12.94 years old. Ocular anterior segments were examined with slit-lamp microscope. Fundus examinations were conducted with papillary dilation, fundus photography. Results: At the first visit, there were 2 eyes without light perception, 4 eyes with light perception, 1 eye with hand movement, 1 eye with finger counting, 2 eyes with 0.01-0.09 eyesight, 8 eyes with 0.1-0.2 eyesight, 12 eyes with 0.25-0.4 eyesight, 15 eyes with 0.5-0.9 eyesight, 9 eyes with 1.0-1.5 eyesight. Among the 27 patients (54 eyes) coinfected with HIV and syphilis, keratic precipitates were identified in 20 eyes, aqueous flare positive in 20 eyes, float positive in 15 eyes, and iris posterior synechias in 7 eyes. Nineteen eyes were diagnosed as syphilis uveitis, including 2 eyes with syphilis anterior uveitis and 17 eyes with syphilis panuveitis, among which, vitreous inflammatory opacity was observed in all 19 eyes, disk atrophy in 2 eyes, optic edema in 1 eye, vitreous hemorrhage in 1 eye, retinal detachment in 2 eyes, retinal hemorrhage and white vein in 1 eye. In addition, 8 eyes were diagnosed as HIV retinopathy, all manifested as cotton-wool spot. Among the 8 eyes, 4 were diagnosed as cytomegalovirus retinitis, 3 showed retinal yellow-white lesions, and 1 was in late phase which showed retinal pigmentation. The incidence of both HIV and syphilis coinfection patients and male homosexuality population increased. The most common ocular manifestation of HIV and syphilis coinfection was syphilis panuveitis. Six patients first visited the Department of Ophthalmology, and were then diagnosed as HIV and syphilis coinfection. Conclusions: The ocular manifestations of HIV and syphilis coinfection are diversified, which can be manifested as fundus necrotic lesions as well as anterior and posterior inflammatory. For HIV positive patients, syphilis serologic test should be routinely performed. The same, syphilis positive patients should be tested for HIV serum antibodies, in order to improve the diagnosis level of HIV/syphilis coinfection and give timely etiological treatment, which is of vital importance for saving visual acuity. (Chin J Ophthalmol, 2019, 55:267-272).

[Plasma relative abundance of epidermal growth factor receptor mutations predicts clinical response to epidermal growth factor receptor-tyrosine kinase inhibitors in patients with advanced lung adenocarcinoma]

Objective: To determine whether relative abundance of epidermal growth factor receptor (EGFR) mutations in plasma predicts clinical response to epidermal growth factor receptor-tyrosine kinase inhibitors (EGFR-TKIs) in patients with advanced lung adenocarcinoma. Methods: In this prospective study, adult patients with advanced lung adenocarcinoma were enrolled in our hospital from 1 April 2016 to 1 January 2017. EGFR mutations in tumor tissues were detected by ADx-amplification refractory mutation system (ADx-ARMS). EGFR mutations of plasma free tumor DNA were detected by ADx-ARMS and ADx-super amplification refractory mutation system (ADx-SuperARMS) at the same time. Patients with EGFR-mutant in tumor tissues and receiving EGFR-TKIs were finally enrolled. Plasma mutation-positive patients with both methods were high abundance group.Patients with positive mutations by ADx-SuperARMS but negative by ADx-ARMS were medium abundance group. Mutation-negative patients with both methods were recognized as low abundance group. The correlation between EGFR mutation abundance and clinical response to EGFR-TKIs were analyzed. Results: Among 71 patients enrolled, 42 harbored EGFR mutations in plasma were detected by ADx-ARMS, while 53 were found by ADx-SuperARMS.There were 42 patients in high abundance group, 11 in medium group while the other 18 in low group. The objective response rates (ORRs) were 69.0%, 7/11 and 10/18 in high, medium and low groups, respectively. The difference was significant between high and low abundances groups (P=0.006). Median progression-free survival (PFS) in high, medium and low groups were 11.0, 8.5 and 9.0 monthes, respectively (P<0.001). In patients with tumor 19-Del, the ORRs were 70.4%, 5/7 and 6/11 in high, medium and low abundance groups, respectively. The median PFS of high abundance group was significantly longer than the other two groups (12.0 monthes vs 9.0, 9.0 monthes). As to subjects with L858R mutation, the ORRs were 10/15, 2/4 and 3/6, respectively, with median PFS 9.6, 5.5 and 9.5 monthes. Conclusions: The relative abundance of EGFR mutations in plasma predicts clinical response to EGFR-TKIs in patients with advanced lung adenocarcinoma. The higher the mutation abundance is, the better the efficacy of EGFR-TKIs is.

Analysis of definitive chemo-radiotherapy for esophageal cancer with supra-clavicular node metastasis based on CT in a single institutional retrospective study: a propensity score matching analysis

Background

The prognostic value of supra-clavicular lymph node (SCLN) metastases in esophageal cancer (EC) is still not clear.

Method

From January 2009 to December 2015, a survival analysis was performed to retrospectively identify the prognostic value of SCLN metastasis on survival on 751 patients with EC treated with definitive chemo-radiotherapy (dCRT).

Results

The median follow-up duration for living patients was 56.6 months. The median overall survival (OS) for all patients was 16.6 months. Patients with SCLN metastasis had a much poorer prognosis for OS (χ² = 17.342, P < 0.001), distant metastasis-free survival (DMFS) (χ² = 24.793, P < 0.001) and progression-free survival (PFS) (χ² = 25.802, P < 0.001) than those without SCLN metastasis. The same results were found after propensity score matching. Nonetheless, the prognosis of patients with cervical or upper thoracic EC metastasis in SCLN was better than those of patients with middle or lower thoracic EC metastasis in SCLN for OS (χ² = 4.516, P = 0.038), DMFS (χ² = 8.326, P = 0.004) and PFS (χ² = 6.255, P = 0.012). Univariate analysis showed that gender, middle or lower thoracic EC with SCLN metastasis, tumor length, tumor diameter, concurrent chemo-radiotherapy (CCR) and number of lymph nodes were prognostic factors for PFS. Gender, age, middle or lower thoracic EC with SCLN metastasis, tumor diameter, tumor length, and number of lymph nodes were prognostic factors for DMFS. According to the multivariate analysis, only middle or lower thoracic EC with SCLN metastasis and number of lymph nodes were independent prognostic factors for DMFS and PFS.

Conclusion

For patients with cervical or upper thoracic EC, metastasis in SCLN should be considered to be regional lymph nodes and treated with curative intent if the total number of lymph nodes is limited. However, for patients with middle or lower thoracic EC, metastasis should be considered to be a higher level N stage or M1 stage, and it is thus necessary to provide consolidation chemotherapy after dCRT.

[Diagnostic performance of T-SPOT.TB on peripheral blood in combination with adenosine deaminase on pleural fluid for the diagnosis of tuberculous pleurisy within different age group]

Objective: To evaluate the performance of T cell enzyme-linked immuno-spot assay (T-SPOT) on peripheral blood in combination with adenosine deaminase (ADA) on pleural fluid for diagnosis of tuberculous (TB) pleurisy within different age groups. Methods: The data of patients with pleural effusion from the Department of Pulmonary and Critical Care Medicine of the First Affiliated Hospital of Wenzhou Medical University from April 2012 to November 2016 were retrospectively analyzed, and the diagnoses of these patients were histopathologically confirmed through medical thoracoscopy. The cases who had confirmed diagnosis, in the same time, received peripheral blood T-SPOT.TB were enrolled. The performance of peripheral blood T-SPOT.TB in combination with pleural fluid ADA on diagnosing TB pleurisy in the younger patients (16-59 years old) and elderly patients (≥60 years old) were analyzed respectively. The sensitivity, specificity and the receiver operating characteristic (ROC) curve were adopted for statistical analysis. Results: A total of 448 cases were finally enrolled, 341(76.1%) confirmed with TB pleurisy, 224 males, 117 females, (47±19) years old; and 107 (23.9%) classified as non-TB pleurisy, 65 males, 42 females, (61±14) years old. There were 285 cases who were classified as younger group, and the other 163 cases were classified as elderly group. The sensitivity and specificity of peripheral blood T-SPOT.TB were 85.4% (204/239) and 71.7% (33/46) in the younger patients, 76.5% (78/102) and 59.0% (36/61) respectively in the elderly patients. The sensitivity of peripheral blood T-SPOT.TB in the younger patients was significantly higher than that in the elderly patients (P=0.047). The sensitivity and specificity were 99.2% and 95.7% in combination with peripheral blood T-SPOT.TB and pleural fluid ADA respectively in the younger patients. The area under ROC curve (AUC) of T-SPOT.TB in the younger patients was 0.833, AUC of T-SPOT.TB combined with ADA was 0.911. The combination test of 2 tests had the sensitivity of 96.1% and the specificity of 90.2% respectively in the elderly patients. The AUC of T-SPOT.TB in the elderly patients was 0.747, AUC of T-SPOT.TB combined with ADA was 0.911. Conclusion: Peripheral blood T-SPOT.TB combined with pleural fluid ADA can improve the diagnostic performance for TB pleurisy with different ages, especially for elderly patients who can't tolerate pleural biopsy.

Identifying the germ cells during embryogenesis and gametogenesis by germ-line gene vasa in an anadromous fish, American shad Alosa sapidissima

American shad Alosa sapidissima, an anadromous clupeid, exhibits variation in reproductive strategies, including semelparity and iteroparity. It provides an excellent model for studying the behaviour of germ cells in anadromous fish during their migration from sea to river. The vasa gene was characterized in A. sapidissima as a germ-cell marker to elaborate the process of germ-cell development and differentiation in anadromous species. A complementary (c)DNA fragment of 819 bp, partial open reading frame (ORF), was cloned by degenerate PCR and named as ASvas. In adult A. sapidissima, vasa transcript was exclusively detected in gonads by reverse-transcription (RT)-PCR. Through chromogenic in situ hybridization, the vasa messenger (m)RNA was specifically detected in primordial germ cells (PGC) in embryos and germ cells at early stages in ovary and testis. Besides, the cellular distribution profile of Vasa protein also proved that vasa gene could be used as a germ-line marker to trace the PGCs migration during embryogenesis and the germ-cell differentiation during gametogenesis in A. sapidissima. During embryogenesis, the migrating PGCs were clearly detected at tail-bud stage and the PGCs reached the genital ridge at the stage of pre-hatching stage in A. sapidissima embryos. During gametogenesis, the Vasa protein was dynamically expressed in differentiating germ cells at different stages in adult gonads. As far as we know, this is the first report to demonstrate the PGCs migration and germ-cell differentiation through vasa gene expression in the anadromous species. The findings will pave a way for investigating germ-cell development and maturation in the A. sapidissima and other anadromous fish.