[Immunogenicity, safety and immune persistence of the sequential booster with the recombinant protein-based COVID-19 vaccine (CHO cell) in healthy people aged 18-84 years]

Objective: To evaluate the immunogenicity, safety, and immune persistence of the sequential booster with the recombinant protein-based COVID-19 vaccine (CHO cell) in healthy people aged 18-84 years. Methods: An open-label, multi-center trial was conducted in October 2021. The eligible healthy individuals, aged 18-84 years who had completed primary immunization with the inactivated COVID-19 vaccine 3 to 9 months before, were recruited from Shangyu district of Shaoxing and Kaihua county of Quzhou, Zhejiang province. All participants were divided into three groups based on the differences in prime-boost intervals: Group A (3-4 months), Group B (5-6 months) and Group C (7-9 months), with 320 persons per group. All participants received the recombinant COVID-19 vaccine (CHO cell). Blood samples were collected before the vaccination and after receiving the booster at 14 days, 30 days, and 180 days for analysis of GMTs, antibody positivity rates, and seroconversion rates. All adverse events were collected within one month and serious adverse events were collected within six months. The incidences of adverse reactions were analyzed after the booster. Results: The age of 960 participants was (52.3±11.5) years old, and 47.4% were males (455). The GMTs of Groups B and C were 65.26 (54.51-78.12) and 60.97 (50.61-73.45) at 14 days after the booster, both higher than Group A's 44.79 (36.94-54.30) (P value<0.05). The GMTs of Groups B and C were 23.95 (20.18-28.42) and 27.98 (23.45-33.39) at 30 days after the booster, both higher than Group A's 15.71 (13.24-18.63) (P value <0.05). At 14 days after the booster, the antibody positivity rates in Groups A, B, and C were 91.69% (276/301), 94.38% (302/320), and 93.95% (295/314), respectively. The seroconversion rates in the three groups were 90.37% (272/301), 93.75% (300/320), and 93.31% (293/314), respectively. There was no significant difference among these rates in the three groups (all P values >0.05). At 30 days after the booster, antibody positivity rates in Groups A, B, and C were 79.60% (238/299), 87.74% (279/318), and 90.48% (285/315), respectively. The seroconversion rates in the three groups were 76.92% (230/299), 85.85% (273/318), and 88.25% (278/315), respectively. There was a significant difference among these rates in the three groups (all P values <0.001). During the sequential booster immunization, the incidence of adverse events in 960 participants was 15.31% (147/960), with rates of about 14.38% (46/320), 17.50% (56/320), and 14.06% (45/320) in Groups A, B, and C, respectively. The incidence of adverse reactions was 8.02% (77/960), with rates of about 7.50% (24/320), 6.88% (22/320), and 9.69% (31/320) in Groups A, B, and C, respectively. No serious adverse events related to the booster were reported. Conclusion: Healthy individuals aged 18-84 years, who had completed primary immunization with the inactivated COVID-19 vaccine 3 to 9 months before, have good immunogenicity and safety profiles following the sequential booster with the recombinant COVID-19 vaccine (CHO cell).

[Clinical phenotypic and genotypic analysis of 5 pediatric patients with β-ketothiolase deficiency]

Objective: To summarize the clinical and genetic characteristics of children with β-ketothiolase deficiency (BKTD). Methods: The clinical characteristics, biochemical, markers detected by tandem mass spectrometry (MS/MS) and gas chromatography-mass spectrometry (GC/MS), as well as the variants in ACAT1 gene among 5 children with BKTD in Children's Hospital of Chongqing Medical University between October 2018 and December 2022 were retrospectively analyzed. Results: The onset age of the disease in 5 patients (4 males and 1 female) ranged from 9.7 to 28.0 months. During the acute phase, severe metabolic acidosis was observed with a pH of 6.9-7.1, as well as hypoglycaemia (2.3-3.4 mmol/L) and positive urinary ketone bodies (+-++++). Blood levels of methylcrotonyl carnitine, methylmalonyl carnitine and malonyl carnitine were 0.03-0.42, 0.34-1.43 and 0.83-3.53 μmol/L respectively and were significantly elevated. Urinary 2-methyl-3-hydroxybutyric acid was 22-202 and 3-hydroxybutyric acid was 4-6 066, both were higher than the normal levels. Methylcrotonylglycine was mild elevated (0-29). The metabolites detected by MS/MS and GC/MS were significantly reduced after treatment. Analysis of ACAT1 gene mutation was performed in 5 children. Most variants were missense (8/9). Four previously unreported variants were identified: c.678G>T (p.Trp226Cys), c.302A>G (p.Gln101Arg), c.627_629dupTGA (p.Asn209_Glu210insAsp) and c.316C>T (p.Gln106Ter), the first 2 variants were predicted to be damaging by SIFT, PolyPhen-2 and Mutation Taster software. c.316C>T (p.Gln106Ter) is a nonsense variant. Conclusions: β-ketothiolase deficiency is relatively rare, lacks specific clinical manifestations, however severe metabolic acidosis, hypoglycemia, and ketosis during the acute onset were consistent findings. Missense mutations in the ACAT1 gene are common genetic causes of β-ketothiolase deficiency.

Prognostic value of the baseline magnetic resonance score in patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy

AIM

To investigate the prognostic value of the composite posterior circulation Acute Stroke Prognosis Early Computed tomography (CT) Score (ASPECTS)-Collaterals (pcASCO) score, which combines diffusion-weighted imaging (DWI) posterior circulation ASPECTS (pcASPECTS) and the magnetic resonance angiography (MRA)-collateral circulation score at baseline among patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy.

MATERIALS AND METHODS

Patients with acute posterior circulation ischaemic stroke who underwent mechanical thrombectomy were analysed retrospectively. The DWI-pcASPECTS and MRA-collateral circulation score before treatment and the modified Rankin Scale (mRS) at 90 days after treatment were used as the endpoints. An mRS ≤2 was defined as a good prognosis, and an mRS ≥3 was defined as a poor prognosis. Multivariate logistic regression was used to analyse independent predictors of functional outcome 90 days after mechanical thrombectomy.

RESULTS

Mechanical thrombectomy was performed in 57 patients; 38 patients had a good prognosis, 19 patients had a poor prognosis, and 33 patients were successfully recanalised. Univariate logistic regression found that National Institute of Health Stroke Scale (NIHSS) score (OR: 1.18, p<0.001), pcASPECTS (OR: 1.91, p=0.028) and pcASCO score (OR: 0.51, p=0.001) were factors of good functional outcome. Receiver operating characteristic curve (ROC curve) analysis showed that the diagnostic efficiency of the NIHSS and pcASCO was better (AUC = 0.88, 0.83, p<0.05) than that of the pcASPECTS (AUC = 0.65). The prediction model was established by age, NIHSS, and pcASCO, and the diagnostic efficiency of the prediction model was better (AUC = 0.94).

CONCLUSIONS

The composite MR-pcASCO score can be used as an important predictor of the prognosis of patients with acute posterior circulation ischaemic stroke after mechanical thrombectomy.

Development of fluorophores for the detection of oligomeric aggregates of amyloidogenic proteins found in neurodegenerative diseases

Alzheimer's disease and Parkinson's disease are the two most common neurodegenerative diseases globally. These neurodegenerative diseases have characteristic late-stage symptoms allowing for differential diagnosis; however, they both share the presence of misfolded protein aggregates which appear years before clinical manifestation. Historically, research has focused on the detection of higher-ordered aggregates (or amyloids); however, recent evidence has shown that the oligomeric state of these protein aggregates plays a greater role in disease pathology, resulting in increased efforts to detect oligomers to aid in disease diagnosis. In this review, we summarize some of the exciting new developments towards the development of fluorescent probes that can detect oligomeric aggregates of amyloidogenic proteins present in Alzheimer's and Parkinson's disease patients.

[Influence of disposable diaper dependence on emotional behavior and related factors of preschool-aged children]

Objective: To investigate the influence of disposable diaper dependence (DDD) on emotional behavior and related factors of preschool-aged children. Methods: A total of 3 000 preschool-aged children from 16 kindergartens in Zhengzhou of Henan Province from October 2019 to March 2020 were selected and their parents were investigated by using a basic information questionnaire (including usage of disposable diapers), Strengths and Difficulties Questionnaire (SDQ) and Children's Sleep Questionnaire (PSQ). The differences in baseline and clinical data were compared between the DDD children and normal children, and multiple linear regression models were used to analyze the factors associated with emotional behavior in DDD children. Results: A total of 3 000 questionnaires were distributed and 2 775 (92.50%) were valid. The children ranged in age from 3 to 5 years, including 1 438 boys (51.82%) and 1 337 girls (48.18%). There were 98 (3.53%) children in DDD group and 2 677 (96.47%) children in normal group. The proportion of children living in cities in the DDD group was 58.16%, significantly higher than that of 41.84% in the normal children group (P<0.001). The abnormal detection rate of various factors in SDQ in DDD children, from high to low, were hyperactivity (n=14, 14.29%), peer communication problems (n=12, 12.24%), prosocial behavior (n=11, 11.22%), emotional symptoms (n=10, 10.20%) and conduct problems (n=7, 7.14%). The detection rates of abnormal total difficulty scores in DDD group and normal children were 7.14% (7 cases) and 0.78% (21 cases), respectively, with statistically significant differences (P<0.001). The proportions of emotional symptoms and hyperactivity disorder in DDD group were higher than those in normal group, and the differences were statistically significant (P<0.05). The PSQ score of children in DDD group was 3.01±2.02 which was not significantly different from the PSQ score of the normal group (2.71±2.10, P=0.157). The multi-factor analysis showed that caregiver's education level (β=-1.135,95%CI:-1.910 to -0.359), urinary incontinence (β=2.222, 95%CI: 1.105-3.339), fecal incontinence (β=3.833, 95%CI: 2.691-4.975), urinary and fecal incontinence (β=5.522, 95%CI: 4.145-6.899), and recurrent urinary tract infections(β=3.523,95%CI: 1.798-5.248)were the independent influencing factors of emotional behavioral problems in DDD children (P<0.05). Conclusions: Children with DDD are more likely to have emotional behavioral problems than normal children. Caregiver's education level, urinary incontinence and recurrent urinary tract infections were influencing factors of emotional behavioral problems in DDD children.

[Long-term clinical evaluation of different types of resin-bonded fixed partial denture to replace lost anterior teeth]

Objective: To evaluate the clinical survival rates and influence factors of different types of resin-bonded fixed partial dentures (RBFPD) used in anterior missing teeth restoration. Methods: Ninety-three RBFPD were delivered to 92 patients [92 patients,43 males and 49 females, average age (46.1±12.8) years] who visited Peking University School and Hospital of Stomatology from January 2006 to December 2021 for restoration of 1 or 2 anterior missing teeth. Altogether 32 cases of glass fiber reinforced RBFPD, 39 cases of glass-based ceramic RBFPD and 22 cases of porcelain-fused-to-metal RBFPD were retrospectively analyzed. The complete survival rate, functional survival rate, patients' satisfaction and color matching of the restorations were recorded and evaluated every year since the replacement with RBFPD. The Kaplan-Meier survival curve method was used for survival analysis, and the Log-rank analysis was used to compare the effect of the number of missing teeth, position (maxillary or mandibular), cantilever or non-cantilever and gender on the survival rate of the restorations. Results: The overall survival time for the 93 RBFPD was 13.7 years (95%CI: 12.3-15.1 years). There was a decreasing trend in complete survival and functional survival for all three material RBFPD from year to year, but complete and functional survival rates exceeded 90% at year 5 and exceeded 80% at year 10. The complete survival rate of the glass-ceramic RBFPD was higher than the other two during the follow-up period, with a complete survival rate of 90% (35/39) at year 15. The porcelain-fused-to-metal RBFPD had a higher functional survival rate in years 1-8, but the complete and functional survival rates showed a substantial decrease after year 9. The single-factor Log-rank analysis showed that the success rate of porcelain-fused-to-metal RBFPD was significantly higher than that of glass fiber reinforced RBFPD (χ²=7.33, P=0.007), and the success rate of RBFPD with 1 missing tooth restored was significantly higher than that of RBFPD with 2 missing teeth restored (χ²=3.23, P=0.072). The differences in success rates between different restoration positions (maxillary and mandibular), cantilever or non-cantilever, and gender factors were not statistically significant (χ²=2.26, P=0.133; χ²=0.68, P=0.411; χ²=1.07, P=0.300). Conclusions: For the restoration of individual missing anterior teeth, both porcelain-fused-to-metal RBFPD and glass-based ceramic RBFPD achieve a high long-term clinical success rate, with glass-based ceramic RBFPD being more able to ensure long-term restorative result.

[Clinical research of multisystem inflammatory syndrome in children]

Objective: To analyze the clinical characteristics of children with multisystem inflammatory syndrome (MIS-C) associated with SARS-CoV-2 in China, and to improve the understanding of MIS-C among pediatricians. Methods: Case series study.Collect the clinical characteristics, auxiliary examinations, treatment decisions, and prognosis of 64 patients with MIS-C from 9 hospitals in China from December 2022 to June 2023. Results: Among the 64 MIS-C patients, 36 were boys and 28 were girls, with an onset age being 2.8 (0.3, 14.0) years. All patients suffered from fever, elevated inflammatory indicators, and multiple system involvement. Forty-three patients (67%) were involved in more than 3 systems simultaneously, including skin mucosa 60 cases (94%), blood system 52 cases (89%), circulatory system 54 cases (84%), digestive system 48 cases (75%), and nervous system 24 cases (37%). Common mucocutaneous lesions included rash 54 cases (84%) and conjunctival congestion and (or) lip flushing 45 cases (70%). Hematological abnormalities consisted of coagulation dysfunction 48 cases (75%), thrombocytopenia 9 cases (14%), and lymphopenia 8 cases (13%). Cardiovascular lesions mainly affected cardiac function, of which 11 patients (17%) were accompanied by hypotension or shock, and 7 patients (12%) had coronary artery dilatation.Thirty-six patients (56%) had gastrointestinal symptoms, 23 patients (36%) had neurological symptoms. Forty-five patients (70%) received the initial treatment of intravenous immunoglobulin in combination with glucocorticoids, 5 patients (8%) received the methylprednisolone pulse therapy and 2 patients (3%) treated with biological agents, 7 patients with coronary artery dilation all returned to normal within 6 months. Conclusions: MIS-C patients are mainly characterized by fever, high inflammatory response, and multiple organ damage. The preferred initial treatment is intravenous immunoglobulin combined with glucocorticoids. All patients have a good prognosis.

[Clinical analysis of 10 cases of multi-center tumor necrosis factor receptor-associated periodic syndrome]

Objective: To summarize the clinical characteristics of tumour necrosis factor receptor-associated periodic syndrome (TRAPS) in children. Methods: The clinical manifestations, laboratory tests, genetic testing and follow-up of 10 children with TRAPS from May 2011 to May 2021 in 6 hospitals in China were retrospectively analyzed. Results: Among the 10 patients with TRAPS, including 8 boys and 2 girls. The age of onset was 2 (1, 5) years, the age of diagnosis was (8±4) years, and the time from onset to diagnosis was 3 (1, 7) years. A total of 7 types of TNFRSF1A gene variants were detected, including 5 paternal variations, 1 maternal variation and 4 de novo variations. Six children had a family history of related diseases. Clinical manifestations included recurrent fever in 10 cases, rash in 4 cases, abdominal pain in 6 cases, joint involvement in 6 cases, periorbital edema in 1 case, and myalgia in 4 cases. Two patients had hematological system involvement. The erythrocyte sedimentation rate and C-reactive protein were significantly increased in 10 cases. All patients were negative for autoantibodies. In the course of treatment, 5 cases were treated with glucocorticoids, 7 cases with immunosuppressants, and 7 cases with biological agents. Conclusions: TRAPS is clinically characterized by recurrent fever accompanied by joint, gastrointestinal, skin, and muscle involvement. Inflammatory markers are elevated, and autoantibodies are mostly negative. Treatment mainly involves glucocorticoids, immunosuppressants, and biological agents.

[Prognostic comparison of active surveillance and adjuvant chemotherapy in the treatment of patients with stage Ⅰ ovarian immature teratoma after fertility-sparing surgery]

Objective: To compare the survival outcomes between surveillance and adjuvant chemotherapy in patients with stage Ⅰ ovarian immature teratoma (IMT) underwent fertility-sparing surgery. Methods: Clinical and pathological records of patients with stage Ⅰ ovarian IMT between Jan. 2011 to Feb. 2023 were collected from Peking Union Medical College Hospital, except stage Ⅰa grade 1. The consultation of risks and benefits regarding adjuvant chemotherapy was conducted by gynecologic oncologists. A shared decision about surveillance or chemotherapy was made by physician and patients or their guardians. Patients who finally decided to undergo surveillance were included in the surveillance group (n=40), the others were included in the adjuvant chemotherapy group (n=63). Clinical characteristics, treatment and survival outcomes were analyzed and compared between two groups. Results: A total of 103 patients were included. The median age of initial diagnosis was 20 years old (range: 3-39 years old), and the median follow-up time was 31 months (range: 1-254 months). The age, International Federation of Gynecology and Obstetrics (FIGO) stage, pathological grade, surgical method, and preoperative and postoperative alpha-fetoprotein levels in the surveillance group and the adjuvant chemotherapy group were similar (all P>0.05). The surgical approach and maximum tumor diameter between two groups were significantly different (all P<0.05). Forty patients of the surveillance group were identified, only one patient with stage Ⅰa grade 2 IMT who underwent cystectomy had malignant recurrence on the same ovary. Another 63 patients received adjuvant chemotherapy after surgery, five patients had malignant recurrence, and two of them died of disease progression after relapsed. There were no significant differences in disease-free survival (DFS;20 vs 36 months) and overall survival (OS; 23 vs 39 months) between the surveillance group and the adjuvant chemotherapy group (follow-up time censored at 72 months; DFS: P=0.325, OS: P=0.278). Conclusions: There are no differences in survival outcomes between patients with stage Ⅰ ovarian IMT underwent adjuvant chemotherapy or not. Active surveillance might be safe and preferable in stage Ⅰ IMT patients underwent complete resection of tumor.

[Clinical study of mature B-cell lymphoma in 11 children with chromosome 11 long-arm abnormalities]

Objective: To explore the clinical, pathological, diagnostic, treatment, and prognostic features of children with mature B-cell lymphoma (MBCL) . Methods: This retrospective study included pediatric patients with MBCL with chromosome 11 long-arm abnormalities who were diagnosed and treated at our hospital from December 2018 to February 2023. Results: Among the 11 pediatric patients with MBCL, nine were male and two were female, with a median age of 9 (2-13) years and a median disease course of 1.8 (0.5-24) months. The clinical manifestations were cervical lymph node enlargement in four patients, nasal congestion and snoring in four patients, abdominal pain in two patients, and difficulty breathing in one patient. There were seven cases of Burkitt's lymphoma, two of follicular lymphoma, and two of advanced B-cell lymphoma according to the pathological morphology examination. No patients had central nervous system or bone marrow involvement, and no extensive metastasis was observed on B-ultrasound or positron emission tomography-computed tomography (PET/CT). One patient had a huge tumor lesion. The Revised International Pediatric Non-Hodgkin Lymphoma Staging System classified four patients as stage Ⅱ, five as stage Ⅲ, and two as stage Ⅳ. 11q probe detection showed five cases of 11q gain, three of 11q loss, and three of both gain and loss. FISH showed positive MYC expression in three patients, including eight with advanced B-cell lymphoma with 11q abnormalities and three with Burkitt's lymphoma with 11q abnormalities. According to the 2019 edition of the National Health Commission's diagnostic and treatment guidelines for invasive MBCL in children, one patient was classified as Group A, two as Group B, and eight as Group C. Early evaluation of the efficacy showed complete remission. After mid-term evaluation, the intensity of chemotherapy was reduced in Group B and Group C. Among two cases of chemotherapy, the remaining nine cases had a median follow-up of 32 (6-45) months, and none had event-related survival. Conclusion: The incidence of MBCL with 11q abnormalities in children is low, clinical symptoms are mild, and progression is slow. The absence of MYC, BCL2, BCL6 rearrangements, C-MYC negative and 11q abnormalities on FISH is an important diagnostic indicator, and reducing the intensity of chemotherapy can improve prognosis.

[Analysis on the implementation of payment policies for four non-national immunization program vaccines in China]

This study systematically retrieved information on the payment policy of vaccination fees for pneumococcal vaccines, human papillomavirus vaccines, haemophilus influenzae type b vaccines and rotavirus vaccines using a Python-based crawler. The proportion of the population covered by policies among the total applicable population was estimated based on the medical insurance coverage ratio and population data in 2020. This study showed that the payment policies included two categories, government-funded free vaccination policies and medical insurance payment policies. Among the four non-national immunization program vaccines, the free vaccination policies only involved pneumococcal vaccines and human papillomavirus vaccines. Among them, the 13-valent pneumococcal conjugate vaccine, the 23-valent pneumococcal polysaccharide vaccine, and the human papillomavirus vaccine were provided free of charge in 1, 10 and 15 provinces, respectively. For these policies, the corresponding covered population and the proportion among the total applicable population were children aged 6 months to 2 years old (2.5%), older people (1.2% to 21.5%) and middle school girls (1.1% to 12.2%). Medical insurance payment policies were implemented in 14 provinces, and nearly covered the four types of vaccines in the policy implementation areas, with the proportion of the covered population about 10.9% to 41.5% among the total applicable population.

[Analysis of clinical presentation and genetic characteristics of malignant infantile osteopetrosis]

Objective: To investigate the clinical presentation and genetic characteristics of malignant infantile osteopetrosis. Methods: This was a retrospective case study. Thirty-seven children with malignant infantile osteopetrosis admitted into Beijing Children's Hospital from January 2013 to September 2022 were enrolled in this study. According to the gene mutations, the patients were divided into the CLCN7 group and the TCIRG1 group. Clinical characteristics, laboratory tests, and prognosis were compared between two groups. Wilcoxon test or Fisher exact test were used in inter-group comparison. The survival rate was estimated with the Kaplan-Meier method and the Log-Rank test was used to compare the difference in survival between groups. Results: Among the 37 cases, there were 22 males and 15 females. The age of diagnosis was 0.5 (0.2, 1.0) year. There were 13 patients (35%) and 24 patients (65%) with mutations in CLCN7 and TCIRGI gene respectively. Patients in the CLCN7 group had an older age of diagnosis than those in the TCIRGI group (1.2 (0.4, 3.6) vs. 0.4 (0.2, 0.6) years, Z=-2.60, P=0.008). The levels of serum phosphorus (1.7 (1.3, 1.8) vs. 1.1 (0.8, 1.6) mmol/L, Z=-2.59, P=0.010), creatine kinase isoenzyme (CK-MB) (457 (143, 610) vs. 56 (37, 82) U/L, Z=-3.38, P=0.001) and the level of neutrophils (14.0 (9.9, 18.1) vs. 9.2 (6.7, 11.1) ×109/L, Z=-2.07, P=0.039) at diagnosis were higher in the CLCN7 group than that in the TCIRG1 group. However, the level of D-dimer in the CLCN7 group was lower than that in the TCIRGI group (2.7 (1.0, 3.1) vs. 6.3 (2.5, 9.7) μg/L, Z=2.83, P=0.005). After hematopoietic stem cell transplantation, there was no significant difference in 5-year overall survival rate between the two groups (92.3%±7.4% vs. 83.3%±7.6%, χ²=0.56, P=0.456). Conclusions: TCIRGI gene mutations are more common in children with osteopetrosis. Children with TCIRGI gene mutations have younger age, lower levels of phosphorus, CK-MB, and neutrophils and higher level of D-dimer at the onset. After hematopoietic stem cell transplantation, patients with CLCN7 or TCIRGI gene mutations have similar prognosis.

Optimal biopsy site for the diagnosis of oral pemphigus vulgaris and mucous membrane pemphigoid: a systematic review and meta-analysis

The aim of this study was to critically evaluate the diagnostic yields of direct immunofluorescence (DIF) analysis on perilesional and normal-appearing mucosa biopsy samples, to determine the optimal biopsy site for patients presenting with oral pemphigus vulgaris (PV) or mucous membrane pemphigoid (MMP). Electronic databases and article bibliographies were searched in December 2022. The primary outcome was the rate of DIF positivity. Of 374 records identified after the elimination of duplicates, 21 studies with 1027 samples were ultimately included. Meta-analysis revealed a pooled DIF positivity rate of 99.6% (95% confidence interval (CI) 97.4-100.0%, I2 = 0%) for PV and 92.6% (95% CI 87.9-96.5%, I2 = 44%) for MMP for biopsies from perilesional sites, and of 95.4% (95% CI 88.6-99.5%, I2 = 0%) for PV and 94.1% (95% CI 86.5-99.2%, I2 = 42%) for MMP for biopsies from normal-appearing sites. For MMP, there was no significant difference in the rate of DIF positivity between the two biopsy sites (odds ratio 1.91, 95% CI 0.91-4.01, I2 = 0%). The results suggest that the perilesional mucosa remains the optimal biopsy site for DIF diagnosis of oral PV, while the normal-appearing mucosa biopsy is optimal for oral MMP.

Direct Discharge from the Critical Care Resuscitation Unit: Results from a Longitudinal Assessment

Background

The critical care resuscitation unit (CCRU) facilitates interhospital transfer (IHT) of critically ill patients for immediate interventions. Due to these patients' acuity, it is uncommon for patients to be directly discharged home from this unit, but it does happen on occasion. Since there is no literature regarding outcomes of patients being discharged from a resuscitation unit, our study investigated these patients' outcome at greater than 12 months after being discharged directly from the CCRU.

Methods

We performed a retrospective cohort study of all adult patients directly discharged from the CCRU between January 01, 2017, and December 31, 2020. The primary outcome was number of ED visits or hospitalizations within 6 months. Secondary outcomes were number of ED visits or hospitalizations within 6, 12, and >12 months from CCRU discharge.

Results

We analyzed 145 patients' records. Mean age was 56 (standard deviation [SD] ± 19), with a majority being male (72%) and Caucasian (58%). The most common discharge destination was home (139 patients, 96% of total subjects) versus hospice (2%) or nursing facilities (2%). Most patients (55%) did not have any hospital revisits within the first 6 months of discharge, while 31% had 1-2 revisits, and 14% had ≥3 revisits. The most common discharge diagnoses were soft tissue infection (16.5%), aortic dissection (14%), and stroke (11%). Factors which were associated with a greater likelihood of any return hospital visit within 6 months receiving mechanical ventilation during CCRU stay (coefficient -2.23, 95% CI 0.01-0.87, P=0.036), while high hemoglobin on CCRU discharge was associated with no ED revisit (coeff. 0.42, 95% CI 1.15-2.06, P=0.004).

Conclusions

Most patients who were discharged from the CCRU did not require any hospital revisits in the first 6 months. Requiring mechanical ventilation and having soft tissue infection were associated with high unplanned hospital revisits following discharge. Further research is needed to validate these findings.

[Association of category of dietary intake and physical activity with the risk of mortality in patients with type 2 diabetes mellitus: a prospective cohort study]

Objective: To investigate the association between dietary intake and physical activity category and their combined effects on all-cause and cause-specific mortality risk in patients with type 2 diabetes mellitus (T2DM). Methods: Between December 2013 and December 2021, a prospective cohort study was conducted on 19 863 T2DM patients in Changshu City, Qingjiangpu District (formerly Qinghe District), and Huai'an District, included in the national basic health service management. Information on deaths and underlying causes of death was obtained from the Jiangsu Provincial CDC and Prevention Death Surveillance System. Cox proportional hazards models were used to estimate the intensity of associations between dietary intake, physical activity, and their combined effects with all-cause and cause-specific mortality in patients with T2DM. Results: As of December 31, 2021, the research subjects had been followed up for 150 283 person-years, with a median follow-up time of 8.15 years. During the follow-up period, 3 293 people died, including 1 124 deaths from cardiovascular disease (CVD) and 875 deaths from cancer. Cox regression analysis showed that compared with the population of 0-1 recommended food group, those having more than five recommended food groups had a 19% lower risk of all-cause mortality [hazard ratio (HR)=0.81, 95%CI: 0.70-0.94] and a 33% lower risk of all-cause mortality (HR=0.67, 95%CI: 0.52-0.87). Compared with the T2DM population in the physical activity Q1 group, the risk of all-cause mortality, CVD mortality, and cancer mortality among the physical activity Q4 group reduced by 50% (HR=0.50, 95%CI: 0.45-0.56), 50% (HR=0.50, 95%CI: 0.41-0.61), and 27% (HR=0.73, 95%CI: 0.60-0.88), respectively. The combined effect showed that compared with the population in the intake of food categories 0-2 and low physical activity groups, the risk of all-cause, CVD mortality, and cancer mortality in the intake of food categories 4-9 and high physical activity groups reduced by 55% (HR=0.45, 95%CI: 0.38-0.53), 56% (HR=0.44, 95%CI: 0.32-0.59), and 40% (HR=0.60, 95%CI: 0.44-0.82), respectively. Conclusion: Type of dietary intake, physical activity, and their combined effects are associated with a reduced mortality risk in patients with T2DM.

[Clinical characteristics of children with SARS-CoV-2 Omicron variant infection in Kunming]

Objective: To investigate the clinical characteristics of hospitalized children infected with the Omicron variant in Kunming after the withdrawal of non-pharmaceutical interventions (NPI) and analyze the risk factors of severe cases. Methods: Clinical data was retrospectively collected from 1 145 children with SARS-CoV-2 Omicron infection who were hospitalized in six tertiary grade A hospitals in Kunming from December 10th, 2022 to January 9th, 2023. According to clinical severity, these patients were divided into the general and severe SARS-CoV-2 groups, and their clinical and laboratory data were compared. Between-group comparison was performed using t-test, chi-square test and Mann-Whitney U test. Spearman correlation test and multivariate Logistic regression analysis were used to determine the risk factors of severe illness. Results: A total of 1 145 hospitalized patients were included, of whom 677 were male and 468 female. The age of these patients at visit was 1.7 (0.5, 4.1) years. Specifically, there were 758 patients (66.2%) aged ≤3 years at visit and 387 patients (33.8%) aged >3 years. Of these children, 89 cases (7.8%) had underline diseases and the remaining 1 056 cases (92.2%) had no combined diseases. Additionally, of all the patients, 319 cases (27.9%) were vaccinated with one or two doses of SARS-CoV-2 vaccine, 748 cases (65.3%) had acute upper respiratory tract infection (AURTI), and six cases died (0.5%). A total of 1 051 cases (91.8%) were grouped into general SARS-CoV-2 group and 94 cases (8.2%) were grouped into severe SARS-CoV-2 group. Compared with the general cases, the severe cases showed a lower rate of SARS-CoV-2 vaccination and younger median age, lower lymphocyte count, as well as proportions of CD8+T lymphocyte (36 cases (38.3%) vs. 283 cases (26.9%), 0.5 (2.6, 8.0) vs. 1.6 (0.5, 3.9) years, 1.3 (1.0, 2.7) ×109 vs. 2.7 (1.3,4.4)×109/L, 0.17 (0.12, 0.24) vs. 0.21 (0.15, 0.16), respectively, χ2=4.88, Z=-2.21,-5.03,-2.53, all P<0.05). On the other hand, the length of hospital stay, proportion of underline diseases, ALT, AST, creatine kinase isoenzyme, and troponin T were higher in the severe group compared to those in the general group ((11.6±5.9) vs. (5.3±1.8) d, 41 cases (43.6%) vs. 48 cases (4.6%), 67 (26,120) vs. 20 (15, 32) U/L, 51 (33, 123) vs. 44 (34, 58) U/L、56.9 (23.0, 219.3) vs. 3.6 (1.9, 17.9) U/L, 12.0 (4.9, 56.5) vs. 3.0 (3.0, 7.0) ×10-3 pg/L,respectively, t=-20.43, χ2=183.52, Z=-9.14,-3.12,-6.38,-3.81, all P<0.05). Multivariate regression analysis indicated that increased leukocyte count (OR=1.88, 95%CI 1.18-2.97, P<0.01), CRP (OR=1.18, 95%CI 1.06-1.31, P<0.01), ferritin (OR=1.01, 95%CI 1.00-1.00, P<0.01), interleukin (IL)-6 (OR=1.05, 95%CI 1.01-1.08, P=0.012), D-dimer (OR=2.56, 95%CI 1.44-4.56, P<0.01) and decreased CD4+T lymphocyte (OR=0.84, 95%CI 0.73-0.98, P=0.030) were independently associated with the risk of severe SARS-CoV-2 in hospitalized children with Omicron infection. Conclusions: After the withdrawal of NPI, the pediatric inpatients with Omicron infection in Kunming were predominantly children younger than 3 years of age, and mainly manifested as AURTI with relatively low rate of severe SARS-CoV-2 infection and mortality. Elevated leukocyte counts, CRP, ferritin, IL-6, D-dimer, and decreased CD4+T lymphocytes are significant risk factors for developing severe SARS-CoV-2 infection.

Long-Term Outcomes of Stereotactic Body Radiation Therapy with or without PD-1 Inhibitors in Metastatic Nasopharyngeal Carcinoma

PURPOSE/OBJECTIVE(S)

Data on the benefit of stereotactic body radiation therapy (SBRT) in patients with metastatic nasopharyngeal carcinoma (mNPC) remain limited. The purpose of this study is to assess the outcomes of mNPC treated with SBRT and programmed death-ligand 1 (PD-1) inhibitors.

MATERIALS/METHODS

We reviewed all SBRT performed in patients with mNPC during the period of 2013-2022 in our institution. Treatments carried out with ablative intent in stereotactic conditions with dose/fraction ≥ 5 Gy were considered. The local control (LC), overall survival (OS), and progression-free survival (PFS) rates were calculated using Kaplan-Meier analyses. Risk factors were assessed through univariate and multivariate analysis by Cox regression.

RESULTS

A total of 55 patients with 77 metastatic lesions treated with SBRT were analyzed. All of these patients received systemic treatment, either chemotherapy alone (n = 34) or chemotherapy with PD-1 inhibitors (n = 21). 28 patients (50.9%) had ≤ five metastatic lesions in the metastatic sites. The number of irradiated tumors ranged from 1 to 6, and 36 patients (65.5%) with 47 lesions received a physical dose ≥48 Gy (BED≥75Gy, α/β = 10). After a median follow-up of 43.6 months (range 1.9-115.3 months), 20 patients (36.4%) experienced local recurrence after completion of SBRT for metastatic lesions. The 1- and 3-year LC rates were 76.9% and 61.9%, respectively. The 1- and 3-year OS rates were 84.4% and 58.2%, and the 1- and 3-year PFS rates were 50.0% and 29.9%, respectively. Patients with ≤ 2 metastatic lesions (n = 24, 43.6%) had significant better LC (HR 0.11, 95% CI 0.036-0.313, p<0.001), OS (HR 0.24, 95% CI 0.08-0.74, p = 0.013) and PFS (HR 0.16, 95% CI 0.063-0.42, p<0.001) than patients with>2 metastatic lesions. Total dose≥48 Gy was also found to be a significant prognostic factor for better OS (HR 0.44, 95% CI 0.18-1.09, p = 0.044) and PFS (HR 0.42, 95% CI 0.17-0.88, p = 0.005), but not LC (HR 0.84, 95% CI 0.36-1.97, p = 0.678). In addition, adding PD-1 inhibitors to SBRT showed a significant benefit, improving the 2-year LC to 87.7% vs. 50.6% for SBRT (HR 0.27, 95% CI 0.18 - 0.41, p = 0.002). No patients experienced grade 4 or 5 toxicity.

CONCLUSION

SBRT is an effective and safe treatment option for mNPC patients. Adding PD-1 inhibitors to SBRT offers a benefit in LC. Additional studies exploring the clinical benefit and predictive biomarkers of combined SBRT and PD-1 directed immunotherapy are warranted.

A Cascaded Deep Learning-Based Cardiac Substructures Segmentation Frame and on Non-Gated Non-Enhanced Planning CT Scans in Breast Cancer Patients

PURPOSE/OBJECTIVE(S)

To develop a deep learning-based segmentation frame for cardiac substructures especially coronary arteries (CAs) on non-gated non-enhanced planning computed tomography (CT) scans in breast cancer (BC) patients.

MATERIALS/METHODS

Non-gated non-enhanced CT scans of 39 BC patients receiving adjuvant radiotherapy (RT) were collected. Cardiac substructures were manually labelled, including four chambers, left main (LM), left anterior descending (LAD), left circumflex (LCX) and right coronary artery (RCA). The training, validation, and test sample is 28, 7 and 4, respectively. A cascaded network, using nnUNet as the backbone, is proposed to use chambers as prior information to constrain the segmentation of CAs. The mean Dice similarity coefficient (DSC), 95th percentile Hausdorff distance (HD95) and average symmetrical surface distance (ASSD) were used as geometric metrics. Dosimetric parameters of cardiac substructures was calculated based on the segmentation frame and manually labeled contouring, respectively. The data of cardiac examination including ultrasonography, electrocardiogram before and during the follow-up after RT were retrospectively collected. The cardiac event was any symptomatic heart disease or new-onset abnormality in the cardiac examination after RT.

RESULTS

The mean DSC of heart, atriums and ventricles of the proposed frame was 0.93, 0.90, and 0.93, respectively. As shown in Table 1, compared with direct segmentation (as baseline), the proposed frame had a better performance in terms of HD95, ASSD, and the mean dose (Dmean) absolute error for all CAs. Compared to the dosimetric parameters of the heart collected based on the manual labelled contours, the relative errors of D5, D95, and V15Gy for LAD was 4.3±7.8%, 11.7±5.9%, and 14.6±13.0% collected based on the direct segmentation contours and 2.4±4.4%, 3.9±3.1%, 8.5±6.9% collected based on the auto-segmented contours, respectively. Multivariate analysis showed that increased V15Gy of LAD was an independent cardiac toxicity risk factor ([HR] = 1.07, 95% CI 1-1.15, p = 0.0387).

CONCLUSION

We developed a cascaded network for cardiac substructures segmentation with dosimetric validation on non-enhanced CT scans in breast cancer radiotherapy. This is the first attempt to use chambers as prior information for CAs' segmentation and had a superior stable performance. Accurate segmentation will help radiation oncologists to better evaluate DVHs based on substructures and thus to estimate cardiovascular risk. An optimized cardiac substructure-based dosimetric constrain may be proposed accordingly.

High Dose Hyperfractionated Thoracic Radiotherapy vs. Standard Dose for Limited Stage Small-Cell Lung Cancer: A Multicenter, Open-Label Randomized, Phase 3 Trial

PURPOSE/OBJECTIVE(S)

Limited stage small-cell lung cancer (LS-SCLC) is associated with poor prognosis. We aimed to assess the efficacy and safety of high-dose, hyperfractionated thoracic radiotherapy of 54 Gy in 30 fractions compared with standard dose (45 Gy in 30 fractions) as a first-line treatment for LS-SCLC.

MATERIALS/METHODS

The study was an open-label, randomized, phase 3 trial, done at 16 public hospitals in China. Key inclusion criteria were patients aged 18-70 years, with previously histologically or cytologically confirmed LS-SCLC, previously untreated or received 1-2 courses of intravenous cisplatin (75 mg/m²of body-surface area, on day 1 or divided into two days of each cycle) or carboplatin (area under the curve of 5 mg/mL per min, day 1 of each cycle)and intravenous etoposide (100 mg/m²of body-surface area, on days 1-3 of each cycle), and an Eastern Cooperative Oncology Group (ECOG) performance status of 0-1.Eligible patients were randomly assigned (1:1) to receive volumetric-modulated arc radiotherapy (VMAT) of 45 Gy in 30 fractions or the simultaneous integrated boost VMAT (SIB-VMAT) of 54 Gy in 30 fractions to the primary lung tumor and lymph node metastases starting 0-42 days after the first chemotherapy course. Both groups of patients received thoracic radiotherapy twice per day and 10 fractions per week. Prophylactic cranial radiation (PCI, 25 Gy in 10 fractions) was implemented to patients with responsive disease. The primary endpoint was overall survival. Safety was analyzed in the as-treated population.

RESULTS

Between June 30, 2017, and April 6, 2021, 224 eligible patients were enrolled and randomly assigned to 54 Gy (n = 108) or 45 Gy (n = 116). Median follow-up for the primary analysis was 45 months (IQR 41-48). Median overall survival was significantly improved in the 54 Gy group (62.4 months) compared with the 45 Gy group (43.1 months; p = 0.001). Median progression-free survival was significantly improved in the 54 Gy group (30.5 months) compared with the 45 Gy group (16.7 months; p = 0.044). The most common grade 3-4 adverse events were neutropenia (30 [28%] of 108 patients in the 54 Gy group vs 27 [23%] of 116 patients in the 45 Gy group), neutropenic infections (6 [6%] vs 2 [2%]), thrombocytopenia (13 [12%] vs 12 [10%]), anemia (6 [6%] vs 4 [3%]), and esophagitis (1 [1%] vs 3 [3%]). Treatment-related serious adverse events occurred in 9 [8%] patients in the 54 Gy group and 16 [14%] patients in the 45 Gy group. There were one treatment-related deaths in 54 Gy group (myocardial infarction).

CONCLUSION

Compared with standard thoracic radiotherapy dose of 45 Gy, the high dose of 54 Gy improved overall survival and progression-free survival without increasing toxicities in patients with LS-SCLC, supporting twice-daily hyperfractionated thoracic radiotherapy of 54 Gy with concurrent chemotherapy is an alternative treatment option for LS-SCLC. This study is complete and registered with ClinicalTrials.gov, NCT03214003.

Effect of Anemia on Tumor Response to Preoperative Neoadjuvant Chemoradiotherapy for Locally Advanced Rectal Cancer

PURPOSE/OBJECTIVE(S)

Preoperative neoadjuvant chemoradiotherapy (nCRT) and total rectal mesenteric resection (TME) are the primary treatment options for locally advanced rectal cancer (LARC), but their efficacy varies. This study aimed to investigate the impact of anemia on the tumor response of patients with LARC receiving preoperative neoadjuvant chemoradiotherapy.

MATERIALS/METHODS

This study was a retrospective analysis of clinical and pathological data from patients with LARC who underwent nCRT and TME from January 2019 to May 2022 at a single institution. The tumor response was evaluated based on the tumor regression grade (TRG) and T-stage change of the primary tumor. Hemoglobin concentration was measured and graded to determine the presence of anemia. Anemia was categorized into four groups based on the hemoglobin levels: mild anemia (90-120 g/L), moderate anemia (60-90 g/L), severe anemia (30-60 g/L), and extreme anemia (less than 30 g/L). Finally, tumor response was quantified histologically using the AJCC 8th edition tumor regression grading system for rectal cancer and pre- and post-treatment T-grading.

RESULTS

A total of 88 patients with LARC who received nCRT and TME were included in the study, with 17 females and 71 males. Of these patients, 9 were moderately anemic and 37 were mildly anemic. The radiation therapy regimen was administered at a dose of 1.8-2 Gy per fraction, five times a week, for a total dose of 45-50.4 Gy. Capecitabine chemotherapy was also administered orally (825 mg/m2, twice a day) on the days of radiation therapy. Other chemotherapy regimens included XELOX and mFOLFOX6. The TRG was significantly different in anemic patients compared to non-anemic patients (P = 0.039). Only 2 out of 46 anemic patients (4%) showed an excellent response (TRG0), while 8 out of 42 non-anemic patients (19%) showed an excellent response (p = 0.043). There was also a significant difference in the incidence of anemia between cT3 and cT4 stages (p = 0.048), with 44% of cT3 patients and 67% of cT4 patients being anemic. The number of patients with poor response (TRG2-3) decreased as the degree of anemia decreased, but no significant difference was found. The incidence of TRG3 was 11% in patients with moderate anemia and 7% in non-anemic patients (P = 0.863). There was no significant difference in postoperative pathological T-stage between anemic and non-anemic patients. 89% of anemic patients had a pathological stage of ypT3 or less after chemoradiotherapy, while 95% of non-anemic patients did (P = 0.167). The pre- and post-treatment pathological staging did not significantly differ between anemic and non-anemic patients. 67% of anemic patients had descending tumors, while 59.5% of non-anemic patients had descending tumors (p = 0.509).

CONCLUSION

Patients with LARC who have normal hemoglobin concentrations during nCRT have better tumor regression compared to patients with anemia. Additionally, the incidence of anemia was higher among patients with advanced T-stage prior to treatment.