Early Antiplatelet for Minor Stroke following Thrombolysis (EAST): Rationale and Design

BACKGROUND

Early neurological deterioration (END) occurs in about 10% of patients after intravenous thrombolysis (IVT), and is related to poor outcome. In theory, early antiplatelet following IVT could reduce END by preventing re-occlusion and stroke progression, but current guidelines recommend starting antiplatelet treatment at 24 hours after IVT due to concerns about hemorrhagic transformation. Given higher risk of hemorrhagic transformation in severe stroke, we hypothesized that minor stroke patients following IVT can safely benefit from early antiplatelet treatment.

AIMS

To explore the efficacy and safety of early antiplatelet in minor stroke patients after IVT.Sample size estimates: A maximum of 1022 patients are required to test the superiority hypothesis with 80% power according to a two-side 0.05 level of significance, stratified by age, gender, history of stroke or transient ischemic attack, history of hypertension, history of diabetes mellitus, systolic blood pressure at admission, time from IVT to treatment, thrombolysis drug, stroke territory, and stroke etiology.

DESIGN

Early antiplatelet for minor stroke following thrombolysis is a prospective, double blinded, multicenter, randomized and placebo-controlled trial. Minor stroke patients within 6h following IVT are randomly assigned into experimental group and control group with the ratio of 1:1. The experimental group is orally administered with 300 mg clopidogrel and 100 mg aspirin, and control group with placebo. Subsequently, both groups received guideline-based antithrombotic treatment from 24 hours after IVT to 90 days.

OUTCOME

The primary efficacy endpoint is excellent functional outcome, defined as the modified Rankin Scale 0-1 at 90 days after randomization, while primary safety endpoint is symptomatic intracerebral hemorrhage, defined as National Institutes of Health Stroke Scale score increase ≥4 caused by intracranial hemorrhage within 36 hours after randomization.

CONCLUSIONS

The results of EAST will provide us powerful early antiplatelet evidence for minor stroke population following intravenous thrombolysis in clinical practice.

First Measurement of High-Energy Reactor Antineutrinos at Daya Bay

This Letter reports the first measurement of high-energy reactor antineutrinos at Daya Bay, with nearly 9000 inverse beta decay candidates in the prompt energy region of 8-12 MeV observed over 1958 days of data collection. A multivariate analysis is used to separate 2500 signal events from background statistically. The hypothesis of no reactor antineutrinos with neutrino energy above 10 MeV is rejected with a significance of 6.2 standard deviations. A 29% antineutrino flux deficit in the prompt energy region of 8-11 MeV is observed compared to a recent model prediction. We provide the unfolded antineutrino spectrum above 7 MeV as a data-based reference for other experiments. This result provides the first direct observation of the production of antineutrinos from several high-Q_{β} isotopes in commercial reactors.

[Progress in the methods for evaluating depth of bone invasion and bone invasion of lower gingival squamous cell carcinoma]

The depth of invasion is a new index in the 8th edition of TNM classification and staging of oral cancer. Currently, there is no standardized evaluation method for the diagnosis of bone invasion and depth of invasion in lower gingival squamous cell carcinoma (LGSCC). The evaluation of LGSCC bone invasion depth not only provides a reference for surgical margin, but also determines the choice of surgical method, and is an independent prognostic factor for predicting cervical lymphatic metastasis. At present, the main evaluation methods of LGSCC bone invasion and invasion depth include X-ray, MRI, CT, positron emission tomography(PET)/CT, PET/MRI, singlephoton emission CT(SPECT)/CT and pathological examination. In this paper, the evaluation methods and effects of LGSCC bone invasion and invasion depth are summarized, and its advantages and disadvantages are analyzed in order to provide reference for clinical application.

Safety and preliminary efficacy of argatroban plus dual antiplatelet therapy for acute mild to moderate ischemic stroke with large artery atherosclerosis

OBJECTIVE

Previous studies suggest the benefit of dual antiplatelet therapy (DAPT) for acute ischemic stroke with large artery atherosclerosis (LAA) etiology, but there is no study about the effect of DAPT plus anticoagulant in this population.

METHODS

A prospective single arm trial was performed to determine the effect of DAPT combined with argatroban on acute mild to moderate ischemic stroke patients with LAA, which was compared with historical populations. The main outcome was the proportion of early neurological deterioration (END). The secondary outcomes included scores of 0 to 1 and 0 to 2 on the modified Rankin Scale (mRS) at 90 days, and changes in National Institutes of Health Stroke Scale (NIHSS) from baseline to day 7 after admission. The safety outcomes included intracranial hemorrhage at 7 days, organ hemorrhage, and all-cause mortality at 90 days.

RESULTS

A total of 120 patients with argatroban plus DAPT were prospectively enrolled and 529 patients with only DAPT were retrospectively collected. There was no significant difference in baseline characteristics between groups. Compared with control group, combined treatment group had lower proportion of END (4.2% vs. 10.0%, adjusted p = .046), more reduction in NIHSS score from the baseline to day 7 after admission (1.06 ± 2.03 vs. 0.39 ± 1.97, adjusted p = .003), and higher proportion of mRS (0-2) at 90 days (87.5% vs. 79.2%, adjusted p = .048). No intracranial hemorrhage was found between groups.

CONCLUSIONS

This is the first report that short-term argatroban combined with DAPT seems to be safe and may effectively prevent END and improve neurological prognosis for acute mild to moderate ischemic stroke patients with LAA; however, interpretation of the conclusion required caution due to nonrandomized controlled trial with medium sample size.

The characteristics of intracranial plaques of unilateral, anterior circulation embolic stroke of undetermined source: an analysis of different subtypes based on high-resolution imaging

BACKGROUND AND PURPOSE

To investigate the characteristics of non-stenotic intracranial plaque (NSIP) among embolic stroke of undetermined source (ESUS) subtypes by high-resolution magnetic resonance imaging (HR-MRI).

METHODS

we retrospectively enrolled consecutive patients with ESUS who were mandatory for HR-MRI. Based the location and arterial supply of the infarct, ESUS were categorized into three types: cortical ESUS, subcortical ESUS and mixed ESUS. The NSIP parameters including plaque location, morphology (plaque distribution, remodeling index and plaque burden) and composition (thick fibrous cap, discontinuity of plaque surface, intraplaque hemorrhage and complicated plaque) were evaluated among subtypes.

RESULTS

Among 243 patients, there were 87 (35.8%) cortical ESUS, 127 (52.3%) subcortical ESUS and 29 (11.9%) mixed ESUS. We found significant differences in plaque location (P < 0.001), plaque quadrant (P < 0.001), remodeling index (P < 0.001), plaque burden (P < 0.001), discontinuity of plaque surface (P < 0.001), intraplaque hemorrhage (P = 0.001) and complicated plaque (P < 0.001) of ipsilateral NISP among different ESUS subtypes, except for fibrous cap (P = 0.135). But we found no differences among contralateral NISP. In addition, the clinical characteristics of the differences among ESUS subtypes were striking, including age (P = 0.004), initial National Institute of Health Stroke Scale (P < 0.001), coronary artery disease (P = 0.039), serum urea (P = 0.011) and creatinine (P = 0.002).

CONCLUSION

This is the first report of significantly heterogeneous characteristics of ipsilateral NSIP and clinical findings among ESUS subtypes, which may suggest their different underlying mechanisms.

Atrial cardiopathy and non-stenotic intracranial complicated atherosclerotic plaque in patients with embolic stroke of undetermined source

OBJECTIVE

To assess (1) the association between atrial cardiopathy (AC) and non-stenotic intracranial complicated atherosclerotic plaque (NICAP) in patients with embolic stroke of undetermined source (ESUS) or small-vessel disease (SVD), and (2) the performance of previously proposed biomarkers to identify AC as the underlying aetiology in ESUS.

METHODS

Based on our high-resolution MRI (HR-MRI) cohort, 403 subjects (243 ESUS and 160 SVD) were enrolled in the final analysis. All patients underwent intracranial HR-MRI to assess the presence of ipsilateral NICAP. Biomarkers of AC (ie, P-wave terminal force in lead V1 (PTFV1) on ECG, N-terminal probrain natriuretic peptide (NT-proBNP), high-sensitivity cardiac troponin T and left atrial diameter) were collected within 24 hours after admission.

RESULTS

Among patients without ipsilateral NICAP, we found an association between the presence of AC (adjusted OR (aOR): 4.76, 95% CI 2.48 to 9.14), increased PTFV1 (aOR: 5.70, 95% CI: 2.43 to 13.39) and NT-proBNP (aOR: 1.65, 95% CI: 1.16 to 2.35) with ESUS. This association was not evident among patients with ipsilateral NICAP. The discrimination between ESUS versus SVD by AC/AC-related biomarkers was significantly improved after excluding ipsilateral NICAP. Similarly, the discrimination between ESUS and SVD by ipsilateral NICAP was notably augmented after excluding AC, PTFV1 and NT-proBNP.

INTERPRETATION

AC is more prevalent in patients who had ESUS without ipsilateral NICAP compared with patients with, implying that AC and ipsilateral NICAP are two distinct, competing aetiologies of ESUS. Among the AC biomarkers studied in this analysis, PTFV1 seems to be the most informative.

Joint Determination of Reactor Antineutrino Spectra from ^{235}U and ^{239}Pu Fission by Daya Bay and PROSPECT

A joint determination of the reactor antineutrino spectra resulting from the fission of ^{235}U and ^{239}Pu has been carried out by the Daya Bay and PROSPECT Collaborations. This Letter reports the level of consistency of ^{235}U spectrum measurements from the two experiments and presents new results from a joint analysis of both data sets. The measurements are found to be consistent. The combined analysis reduces the degeneracy between the dominant ^{235}U and ^{239}Pu isotopes and improves the uncertainty of the ^{235}U spectral shape to about 3%. The ^{235}U and ^{239}Pu antineutrino energy spectra are unfolded from the jointly deconvolved reactor spectra using the Wiener-SVD unfolding method, providing a data-based reference for other reactor antineutrino experiments and other applications. This is the first measurement of the ^{235}U and ^{239}Pu spectra based on the combination of experiments at low- and highly enriched uranium reactors.

Identification of LMO2 as a new marker for acinic cell carcinoma of salivary gland

Background

The distinction between acinic cell carcinoma (ACC) and secretory carcinoma (SC) of the salivary gland is hampered by the lack of specific diagnostic markers. It is known the cytoplasm of glandular cells in the salivary gland immunohistochemically expresses LIM Domain Only 2 (LMO2). Herein, we aim to evaluate the expression status of LMO2 in a large cohort of tumors of the salivary gland, with an emphasis on its significance in the distinction of ACC and SC.

Methods

Immunohistochemical stains were performed to evaluate the expression of LMO2 in normal tissues and tumors of salivary gland.

Results

LMO2 was expressed in normal serous acinar cells of the salivary gland. We also found the cytoplasmic immunostaining of LMO2 was specific and sensitive for the recognition of ACCs including those with morphological overlaps with SCs, whereas the cytoplasmic expression of LMO2 was not detected in SCs.

Conclusions

LMO2 is useful for the recognition of ACC and is of potential value in distinguishing ACC from SC.

[The implementation of hour-1 bundle for sepsis in medical staff]

To determine the physicians'compliance of hour-1 bundle for sepsis. A management system of hour-1 bundle for sepsis was established. The clinical data of 286 sepsis patients were collected, who were classified into 3 months before the bundle (control group), 9 months during process (observation group) and 3 months after bundle (study group). The compliance of hour-1 bundle implementation was compared in three groups. The results showed that with the application and implementation of the management system, the compliance of hour-1 bundle for sepsis in the control group, observation group and study group was 58.3%(28/48), 69.1%(105/152) and 88.4%(76/86) respectively (χ²=7.053,P=0.029). The 28 day mortality in sepsis patients was 41.7%(20/48), 34.9%(53/152) and 23.3%(20/86) respectively (χ²=5.576,P=0.062).The management system of hour-1 bundle for sepsis can effectively improve the physicians' compliance.

[The influence of cachexia on the immunotherapy efficacy of Sintilimab for non-small cell lung cancer]

Objective: To investigate whether cachexia affects the treatment effect of immune checkpoint inhibitors for non-small cell lung cancer (NSCLC). Methods: The prognosis of 62 patients with advanced NSCLC who received anti-programmed cell death-1 (PD-1) in Henan Provincial People's Hospital from 2019 to 2021 were retrospectively analyzed. The cachexia was evaluated before and after the second course of immunotherapy. Kaplan-Meier and Log rank methods were used for survival analysis, Cox regression model was used for multivariate analysis, and Spearman's correlation analysis was used for correlation analysis. Results: After the second course of immunotherapy, psoas major muscle area (PMMA) values of the cachexia group and the control group were (14.10±4.09) and (11.66±3.22) cm(2) respectively, with statistics significance (P=0.001). The level of Prealbumin and body weight were correlated with cachexia (P<0.05). The 6-month and 1-year survival rates of 62 cases in the whole group were 58.6% and 42.5%, respectively. The progression-free survival (PFS) in the control group (7.6 months) was higher than that in the cachexia group (3.8 months, P=0.006). The PFS in patients with high expression of PD-L1 (7.1 months) was longer than that of patients with low expression (3.8 months, P=0.009). The overall survival (OS) in the cachexia group (6.3 months) was lower than that in the control group (18.2 months, P=0.006). The OS in patients with high expression of PD-L1 (14.5 months) was longer than that of patients with low expression (1 months, P=0.038). The level of Prealbumin, the level of PD-L1 expression and the change rate of PMMA were related to the OS of the patients (P<0.05). The level of Prealbumin and the change rate of PMMA were the independent influencing factors of the OS (P<0.05). The PMMA and the level of Prealbumin were negatively correlated (r=-0.003 8, P<0.05). Conclusion: Cachexia has a negative impact on the outcomes of patients who received anti-PD-1 immune checkpoint inhibitor therapy.

[A randomized controlled trial study of immunogenicity and safety of an inactivated SARS-CoV-2 vaccine in different immunization schedules]

Objective: To compare the immunogenicity and safety of an inactivated SARS-CoV-2 vaccine used for the vaccination in public security officers with different immunization schedules. Methods: From January to February, 2021, 405 public security officers in Taiyuan were randomly divided into 3 groups. Two doses of SARS-CoV-2 inactivated vaccine were injected according to the immunization schedule of 0-14 days, 0-21 days or 0-28 days, respectively. The nucleic acid of SARS-CoV-2 was detected by reverse transcription polymerase chain reaction. The neutralizing antibodies to SARS-CoV-2 were tested by microdose cytopathogenic efficiency assay of live virus. The GMT, seroconversion rate of SARS-CoV-2 neutralizing antibody and safety of the vaccine were analyzed for the 3 groups. Results: The seroconversion rate of SARS-CoV-2 neutralizing antibody was 100% in all the 3 groups. The SARS-CoV-2 neutralizing antibody level of 0-21 day group [166.70 (95%CI: 148.30-185.10)] was similar to that of 0-28 day group [179.50 (95%CI: 156.50-202.60)] (P>0.05), significantly higher than that of 0-14 day group [86.08 (95%CI: 72.36-99.80)] (P<0.001). The incidence rates of adverse reaction in the 3 groups were 1.48% (2/135), 0.74% (1/136) and 1.49% (2/134) respectively (P=0.750), all the adverse reactions were mild. Conclusions: The vaccination of inactivated SARS-CoV-2 vaccine with different immunization schedules in public security officers showed good safety and high seroconversion rate, and the GMTs of SARS-CoV-2 neutralizing antibody in 0-21 day group and 0-28 day group were higher than that in 0-14 day group.

[Clinicopathological features and prognosis of gastrointestinal stromal tumors with KIT/PDGFRA gene "homozygous mutation": a multicenter retrospective cohort study]

Objective: To investigate the clinicopathological features of gastrointestinal stromal tumor (GIST) with KIT/PDGFRA "homozygous mutation", the efficacy of targeted therapy and the prognosis. Methods: A retrospective cohort study and propensity score matching were used. "Homozygous mutation" was defined as the detection of KIT/PDGFRA gene status of GIST by Sanger sequencing, which showed that there was only mutant gene sequence in the sequencing map, lack of wild-type sequence or the peak height of mutant gene sequence was much higher than that of wild-type gene sequence (> 3 times). "Heterozygous mutation" was defined as the mutant gene sequences coexisted with wild type gene sequences, and the peak height was similar (3 times or less). The clinicopathological data and follow-up information of 92 GIST patients with KIT/PDGFRA "homozygous mutation" were collected from 4 hospitals in Shanghai from January 2008 to May 2021 (Renji Hospital, Shanghai Jiaotong University School of Medicine: 70 cases; Zhongshan Hospital, Fudan University: 14 cases; Changhai Hospital, Naval Military Medical University: 6 cases and Ruijin Hospital, Shanghai Jiaotong University School of Medicine: 2 cases). Patients with perioperative death, other malignancies, and incomplete clinicopathological information were excluded. The clinicopathological features of the patients and the efficacy of targeted drug therapy were observed and analyzed. The efficacy was evaluated using Choi criteria, which were divided into complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). In addition, a total of 230 patients with high-risk GIST with "heterozygous mutation" in exon 11 of KIT gene and 117 patients with recurrent or metastatic GIST with "heterozygous mutation" in exon 11 of KIT gene were included. The propensity score matching method was used to match GIST patients with "heterozygous" and "homozygous" mutations in exon 11 of KIT gene (1∶1) for survival analysis. The disease-free survival (DFS) between two groups of high-risk GIST patients who underwent complete surgical resection were compared. And progression-free survival (PFS) in patients with recurrent or metastatic GIST were compared. Results: Of the 92 GIST cases with KIT/PDGFRA "homozygous mutation", 58 were males and 34 were females, with a median onset age of 62 (31-91) years. Primary GIST 83 cases. Primary high-risk GIST (53 cases), metastatic GIST (21 cases) and recurrent GIST (9 cases) accounted for 90.2% (83/92). There were 90 cases of KIT gene"homozygous mutation" (exon 11 for 88 cases, exon 13 for 1 case, exon 17 for 1 case), and 2 cases of PDGFRA gene "homozygous mutation" (exon 12 for 1 case, exon 18 for 1 case). The median follow-up time was 49 (8-181) months. Among the 61 cases of primary localized GIST undergoing complete surgical resection, 2 cases were intermediate-risk GIST, 5 cases were low-risk GIST, and 1 case was very low-risk GIST, of whom 1 case of intermediate-risk GIST received 1-year adjuvant imatinib mesylate (IM) therapy after operation, and no tumor recurrence developed during the follow-up period. The remaining 53 cases were high-risk GIST, and follow-up data were obtained from 50 cases, of whom 22 developed tumor recurrence during follow-up. Of 9 patients directly receiving neoadjuvant targeted therapy (IM or avapritinib), 5 had complete imaging follow-up data, and the evaluation of efficacy achieved PR. Of all the 92 GIST cases with KIT/PDGFRA "homozygous mutation", 50 (54.4%) had tumor metastasis or tumor recurrence or progression during follow-up, and 12 (13.0%) died of the tumor. Survival analysis combined with propensity score showed that in 100 cases of high-risk GISTs with complete resection, GISTs with "homozygous mutation" in exon 11 of KIT gene had shorter disease-free survival (DFS) than GISTs with "heterozygous mutation" in exon 11 of KIT gene (median DFS: 72 months vs. 148 months, P=0.015). In 60 cases of recurrent or metastatic GISTs with KIT gene exon 11 mutation, IM was used as the first-line treatment, and the progression-free survival (PFS) of GISTs with "homozygous mutation" was shorter compared to GISTs with "heterozygous mutation" (median PFS: 38 months vs. 69 months, P=0.044). The differences were statistically significant. Conclusions: "Homozygous mutation" in KIT/PDGFRA gene is associated with the progression of GIST. The corresponding targeted therapeutic drugs are still effective for GIST with KIT/PDGFRA gene "homozygous mutation". Compared with GIST patients with "heterozygous mutation" in KIT exon 11, GIST patients with "homozygous mutation" in KIT exon 11 are more likely to relapse after surgery and to develop resistance to IM. Therefore, it is still necessary to seek more effective treatment methods for this subset of cases.

[Comparison of serum GP73 and p62 measurement to predict short-term prognosis in patients with HBV-related acute-on-chronic liver failure]

Objective: To analyze the clinical value and predictive difference of serum Golgi protein 73 (GP73) and serum autophagy-related protein p62 levels in the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure (ACLF). Methods: Clinical data of admitted cases to our hospital from October 2018 to April 2020 were retrospectively analyzed. Simultaneously, there were 32 cases with HBV-related ACLF in group A, 65 cases with hepatitis B virus-related cirrhosis in group B and C (Child-Pugh Class A, 34 cases as B group, and Child-Pugh B/C class, 31 cases as group C), and another 30 healthy subjects served as the control group (group D). The serum GP73 and p62 levels of the four selected groups were measured. ACLF group patients were followed up for 3 months to analyze the prognosis of the patients. The serum GP73 and p62 levels of patients who died and survived during hospitalization were compared. The data were analyzed by one-way analysis of variance, independent sample t-test, and Pearson's correlation analysis. Receiver operating characteristic curve (ROC) was used to analyze the predictive value of GP73 and p62 levels in surviving patients. Results: GP73 levels in the four groups A, B, C and D were (284.30 ± 70.55) ng/ml, (125.33 ± 20.57) ng/ml, (159.82 ± 31.20) ng/ml, and (45.46 ± 10.22) ng/ml, respectively. The p62 levels were (1.30 ± 0.35) ng/ml, (2.88 ± 0.58) ng/ml, (2.02 ± 0.545) ng/ml, and (4.68 ± 1.03) ng/ml, respectively. GP73 detection value was significantly higher in group A than the other three groups (P < 0.05). Group D had significantly lower value than the other three groups (P < 0.05), and group C had significantly higher value than group B (P < 0.05). The detection value of p62 in group A was significantly lower than the other three groups (P < 0.05). Group D had significantly higher value than the other three groups (P < 0.05), and group B had slightly higher value than group C, and the differences were statistically significant (P < 0.05). There was a negative correlation between GP73 and p62 (r = -0.695, P < 0.001). Survived patients GP73 level in the ACLF group was significantly lower than dead patients [(212.17 ± 22.47) ng/ml and (340.08 ± 32.91) ng/ml, t = 12.493, P < 0.05], and p62 level was significantly higher than dead patients [(1.46 ± 0.28) ng/ml and (1.18 ± 0.35) ng/ml, t = 2.445, P < 0.05]. According to the ROC curve analysis results, the area under the curve (AUC) of GP73 was 0.865, the AUC of p62 was 0.750, and the combined AUC of the both was 0.968. Conclusion: Both GP73 and p62 have a certain predictive value for the short-term prognosis of HBV-related ACLF patients, but the combination of the two indicators has a higher predictive value.

[Hemolytic uremic syndrome complicated with IgA nephropathy: a clinicopathological study]

Objective: To investigate the clinicopathologic characteristics, treatments, outcomes and mechanisms of hemolytic uremic syndrome (HUS) complicated with IgA nephropathy (IgAN). Methods: The clinical manifestations, treatments, prognosis and histopathological features of renal biopsy tissues were analyzed in two cases of HUS complicated with IgAN from Beijing Children's Hospital, Capital Medical University using light microscopy, immunofluorescence detection and electron microscopy. The related literatures were also reviewed. Results: The clinical manifestations were microvascular hemolytic anemia, thrombocytopenia, acute renal impairment with hematuria, proteinuria, and positive anti-H factor antibody. Histological findings confirmed presence of both HUS and IgAN. Histological features included glomerular mesangial and stromal hyperplasia with endothelial cell proliferation, capillary stenosis, arteriolar thickening, and glomerular ischemia and capillary dilatation. Immunofluorescence detection showed diffuse IgA deposition in the glomerular mesangial matrix. Electron microscopy showed proliferation of mesangial and endothelial cells, thickening of the inner layer of the glomerular basement membrane, deposition of massive electronic densification in the mesangial region, and shrinkage of the segmental basement membrane. The two children were very responsive to plasma exchange and steroid treatments. However, their urine protein and occult blood tests remained continuously positive during the follow-up of 5 years 7 months and 8 months respectively. Conclusions: HUS complicated with IgAN is rare. The diagnosis relies on various pathological examinations, which require the combination of light microscopy, immunofluorescence detection and electron microscopy. Plasma exchange and steroid treatments are effective. However, the long-term prognosis is concerning and may relate to pathological grade and secondary factors. The mechanism of connecting HUS and IgAN is unknown, but may be caused by prodromal or secondary factors.

[Genetic and clinical analysis of X-linked hypophosphatemic rickets]

Objective: To investigate the clinical and genetic features, and treatment of X-linked hypophosphatemic rickets (XLH). Methods: In this retrospective study, we reviewed the medical records of 25 pediatric patients with XLH who were admitted to Department of Endocrinology Genetics and Metabolism,Beijing Children's Hospital from January 2010 to January 2020. The clinical characteristics, PHEX gene variants, as well as clinical outcome of the patients were summarized. To analyze the correlation between genotype and phenotype, the patients were divided into different subgroups according to the location of the variants, including N-terminal-located vs. C-terminal-located variant, and Zn-binding domain exon 17 or 19 variant vs. non-exon 17 or 19 variant. The age at onset, height standard deviation score (HtSDS), intercondylar or intermalleolar distance, fasting serum phosphorus, and HtSDS and intercondylar or intermalleolar distance at the final follow-up were compared by rank sum test or t text. Results: Among the 25 children with XLH, 8 were boys and 17 were girls. The median age of onset was 1.2 (1.0, 1.8) years, and the median age of diagnosis was 2.5 (1.5, 4.3) years. The main clinical manifestations were abnormal gait and lower limb deformity. The HtSDS was -2.0(-3.2, -0.8), and the intercondylar or intermalleolar distance was 4.5 (3.0, 6.0) cm. The fasting serum phosphorus level was 0.8 (0.7, 0.9) mmol/L, while the serum alkaline phosphatase level was (721±41) U/L and the serum calcium level was (2.5±0.1) mmol/L. Three patients (12%) had parathyroid hormone levels above the upper limit of the normal range. Twenty-five patients (100%) showed radiographic changes of active rickets. Nephrocalcinosis was found in 2 cases (9%). Twenty-four different PHEX variations were detected in 25 patients, among whom 11 (44%) had not been reported previously. No hot spot variation was found. No statistical differences (all P>0.05) were identified in clinical features and outcomes either in comparing patients with N-terminal (21 cases) and C-terminal (4 cases) variants, or in comparing patients with variant located in exon 17 or 19 (4 cases) or not (21 cases). Twenty-four cases (96%) were treated regularly with phosphate supplements and active vitamin D. After 2.7 (1.6, 5.0) years of follow-up, clinical symptoms were relieved in 96% (24/25) of the patients. The HtSDS after treatment had no significant difference compared to that before treatment (-2.0(-3.2, -0.8) vs.-2.0(-2.8, -1.1),Z =-0.156, P>0.05), while the intercondylar or intermalleolar distance after treatment was significantly reduced compared to that before treatment (4.5(3.0, 6.0) vs. 1.5(0, 3.3) cm, Z =-3.043, P<0.05). Bone X-rays were reexamined in 17 cases after treatment, and radiographic signs of rickets were improved. Eighteen cases had secondary hyperparathyroidism and 7 cases had nephrocalcinosis. Conclusions: The main clinical manifestations of XLH are abnormal gait, lower limb deformity and short stature. A high proportion of novel variations of PHEX gene but no hot spot variation neither genotype-phenotype correlation are found. Regular treatment with phosphate supplements and active vitamin D can significantly improve the symptoms except for the height. However, the rate of adverse events including secondary hyperparathyroidism and nephrocalcinosis seems to be high.

Alteration of Cholesterol Metabolism by Metformin Is Associated With Improved Outcome in Type II Diabetic Patients With Diffuse Large B-Cell Lymphoma

Recent studies have demonstrated the benefits of metformin on patients with lymphomas. B-cell receptor (BCR)-PI3K-AKT pathway-dependent cholesterol synthesis may represent a positive feedback mechanism responsible for the pathogenesis of BCR-dependent diffuse large B-cell lymphomas (DLBCLs). Thus, restriction of lipid synthesis would affect the integrity of lipid-forming membranes and block the BCR signaling pathway. Our in vitro findings suggested that the blocking effect of metformin on BCR signaling pathway is possibly exerted via blocking the biosynthesis of cholesterol. A retrospective case-control study was subsequently conducted on type II diabetic patients with DLBCL who were on metformin. Metformin was identified to be associated with improved response rate and PFS in diabetic patients and appeared to be an effective therapeutic drug against DLBCL.

Measurement of the Cosmic Ray Helium Energy Spectrum from 70 GeV to 80 TeV with the DAMPE Space Mission

The measurement of the energy spectrum of cosmic ray helium nuclei from 70 GeV to 80 TeV using 4.5 years of data recorded by the Dark Matter Particle Explorer (DAMPE) is reported in this work. A hardening of the spectrum is observed at an energy of about 1.3 TeV, similar to previous observations. In addition, a spectral softening at about 34 TeV is revealed for the first time with large statistics and well controlled systematic uncertainties, with an overall significance of 4.3σ. The DAMPE spectral measurements of both cosmic protons and helium nuclei suggest a particle charge dependent softening energy, although with current uncertainties a dependence on the number of nucleons cannot be ruled out.

A compact stilbene crystal neutron spectrometer for NBI-heated plasma neutron diagnostics at EAST

Stilbene crystal detectors are widely used as fast neutron measurement tools based on recoil proton detection, such as liquid scintillators. A compact stilbene crystal neutron spectrometer (CSCNS) has been installed at the Experimental Advanced Superconducting Tokamak (EAST) to obtain information on fuel ions produced in the plasma core because of its merits of good n/γ discrimination capability, high detection efficiency, and fast response. For the first time, CSCNS has been used for neutron emission spectroscopy measurements in EAST plasmas with neutral beam injection (NBI) heating. The CSCNS has the same horizontal line of sight as the time-of-flight enhanced diagnostics neutron spectrometer. Under NBI heating scenarios, the time trace of the neutron yield monitored by the CSCNS is similar to the one monitored by a standard ²³⁵U fission chamber. The experimental pulse height spectra are also similar to the simulated ones generated by folding the simulated neutron energy spectrum with the detector response functions. These results demonstrate the capability of the CSCNS for neutron diagnostics and the study of fast-ion physics in EAST.

[Increased risk of cardiovascular disease in elderly population with carotid plaque and low ankle brachial index]

Objective: To investigate whether the co-presence of carotid plaques and low ankle-brachial index (ABI) might increase the risks of ischemic cardiovascular and cerebrovascular event in elderly population. Methods: It was a prospective study. Participants from the elderly cohort of the Kailuan Study, who completed a carotid sonography and ABI examination, were included in this study. Participants underwent physical examinations between 2010 and 2011 and were divided into 3 groups: no carotid plaque and ABI>0.9 group (n=526), carotid plaque and ABI>0.9 group (n=1 067), and carotid plaques and ABI≤0.9 group (n=49). Follow up ended on the 31 December 2016. The incidence of ischemic cardiovascular and cerebrovascular event was compared between the 3 groups, the relationship between carotid plaque and low ABI with ischemic cardiovascular and cerebrovascular event was analyzed. Results: A total of 1 642 participants were included (age, (67.1±6.4) years). There were 1 028 males (62.6%) and 1 028 females(37.4%). The average follow-up time was 5.41 years, the incidence of ischemic cardiovascular and cerebrovascular event in the 3 group was 2.1%(11/526), 5.5%(59/1 067), and 12.2%(6/49),respectively; the incidence of myocardial infarction in the 3 group was 0.2%(1/526), 1.6%(17/1 067), 10.2%(5/49), respectively; the incidence of cerebral infarction in the 3 group was 1.9%(10/526), 3.9%(42/1 067) and 2.0%(1/49), respectively. Multivariate Cox risk proportional regression analysis showed that compared with the group without carotid plaque and ABI>0.9, the HR values (95%CI) of ischemic cardiovascular and cerebrovascular event in the group with carotid plaque and ABI>0.9, carotid plaques and ABI≤0.9 group were 3.52 (1.49-8.35), 7.16(2.11-24.26) respectively, after adjusting for sex,age,systolic blood pressure,fast blood glucose,body mass index,total cholesterol,smoke,alcohol consumption and lipid-lowering medication and antihypertensive medication. Conclusions: Co-presence of carotid plaques and low ankle-brachial index may further increase the risk of ischemic cardiovascular and cerebrovascular event among elderly population in this cohort.

[Clinical characteristics and risk factors of post polypectomy electrocoagulation syndrome in children]

Objective: To study the clinical characteristics and risk factors of post polypectomy electrocoagulation syndrome (PPECS) in children. Methods: Clinical data of 23 children with PPECS in Children's Hospital Affiliated to Zhengzhou University from January 2015 to December 2019 were retrospectively analyzed. Additionally, 115 children without PPECS who had polypectomy performed by the same endoscopist at the same time were collected into the control group. The morbidity, clinical characteristics and therapeutic protocol were analyzed, and the risk factors of PPECS were analyzed by Logistic regression. Results: Among the total 2 083 children who had endoscopic polypectomy with electrocautery, 23 children (1.1%) developed PPECS. All had abdominal pain and fever. The average age of the children with PPECS was (3.5±1.5) years, including 19 cases (82.6%) younger than 3 years. There were 18 cases with polyps larger than 25 mm (78.3%). The endoscopic operation time ((56±15) vs. (24±8) min, t=18.086, P<0.01), the rate of piecemeal resection (78.3% (18/23) vs. 17.4% (20/115), χ²=17.358, P<0.01), the lesion size ((38.4±3.7) vs. (15.8±4.3) mm, t=15.127, P<0.01), the proportion of polyps located in the right hemicolon (47.8% (11/23) vs. 23.5% (27/115), χ²=7.035, P<0.05), and the proportion of broad-based polyps (78.3% (18/23) vs. 25.2% (29/115), χ² = 29.259, P<0.01) in the PPECS group were all significantly higher than those in the non-PPECS group. Similarly, the leukocyte counts ((17.4±4.5)×10⁹/L vs. (8.5±1.2)×10⁹/L, t=6.085, P<0.05) and C-reactive protein ((25.8±3.6) vs. (1.1±0.6) mg/L, t=5.531, P<0.05) in the PPECS group were higher than those in the non-PPECS group. The results of multivariate Logistic regression analysis indicated that lesion size ≥25 mm (OR=7.554, 95%CI 3.135-20.158, P=0.001), broad-based polyps (OR=5.676, 95%CI 1.153-9.596, P=0.002) and lesion located in the right hemicolon (OR=5.845, 95%CI 1.737-9.297, P=0.008) were independent risk factors of PPECS. Conclusions: The clinical features of PPECS in children are fever, abdominal pain and leukocytosis after the procedure. The lesion size ≥ 25 mm, broad-based polyps and lesion located in the right hemicolon are the independent risk factors of pediatric PPECS.

Intracranial Atherosclerotic Plaque as a Potential Cause of Embolic Stroke of Undetermined Source

BACKGROUND

Previous studies investigated the potential mechanism of embolic stroke of undetermined source (ESUS) from extracranial artery plaque, but there has been no study other than a case report on high-risk intracranial plaque in ESUS.

OBJECTIVES

The aim of this study was to investigate the issue by evaluating the morphology and composition of intracranial plaque in patients with ESUS and small-vessel disease (SVD) using 3.0-T high-resolution magnetic resonance imaging.

METHODS

Two hundred forty-three consecutive patients with ESUS and 160 patients with SVD-associated stroke between January 2015 and December 2019 were retrospectively enrolled. Multidimensional parameters involving the presence of plaque on both sides, including remodeling index (RI), plaque burden, presence of discontinuity of plaque surface, thick fibrous cap, intraplaque hemorrhage, and complicated American Heart Association type VI plaque at the maximal luminal narrowing site, were evaluated using intracranial high-resolution magnetic resonance imaging.

RESULTS

Among 243 patients with ESUS, the prevalence of intracranial plaque was much higher in the ipsilateral than the contralateral side (63.8% vs. 42.8%; odds ratio [OR]: 5.25; 95% confidence interval [CI]: 2.83 to 9.73), a finding that was not evident in patients with SVD (35.6% vs. 30.6%; OR: 2.14; 95% CI: 0.87 to 5.26; p = 0.134). Logistic analysis showed that RI was independently associated with ESUS in model 1 (OR: 2.329; 95% CI: 1.686 to 3.217; p < 0.001) and model 2 (OR: 2.295; 95% CI: 1.661 to 3.172; p < 0.001). RI alone with an optimal cutoff of 1.162, corresponding to an area under the curve of 0.740, had good diagnostic efficiency for ESUS.

CONCLUSIONS

The present study supports an etiologic role of high-risk nonstenotic intracranial plaque in ESUS.

The clinicopathological relevance of uniform CD56 expression in anaplastic large cell lymphoma: a retrospective analysis of 18 cases

Background

Anaplastic large cell lymphoma (ALCL) with uniform CD56 expression is a rare condition, that has been described in limited literature, and its clinicopathological features have not yet been well illustrated. The aim of our study was to fully investigate the clinical, histological, immunohistochemical and molecular features of CD56+ ALCL.

Methods

The clinical and histological characteristics of CD56+ ALCL cases were retrospectively evaluated. The immunohistochemical phenotype, status of Epstein-Barr virus (EBV) and T-cell receptor (TCR) gene rearrangement were examined. Overall survival was also analyzed.

Results

Eighteen (5.8%) cases with diffuse CD56 expression were identified out of 313 archived ALCL cases with CD56 test. CD56 expression was significantly higher in ALK+ systemic ALCLs (sALCLs) (13/64, 20.3%) than in ALK- sALCLs (3/101, 3.0%) (p < 0.001) as well as primary cutaneous ALCLs (2/148, 1.4%) (p < 0.001). Regarding the CD56+ ALK+ sALCLs, the median age was 20 years (range, 8–60 years) with a male-to-female ratio of 2.3:1, and these cases more frequently affected extranodal sites (11/38, 28.9%) rather than lymph nodes (2/26, 7.7%) (p = 0.038). Eleven (84.6%) cases presented with stage I-II diseases, which was significantly more than their CD56- ALK+ counterparts (45.5%) (p = 0.015). Histologically, 2 ALK+ cases were of small cell variant and all the others displayed characteristic morphology of classic ALCL. Regarding the immunophenotype, both CD30 and CD56 were diffusely positive in all cases. CD3, CD43, anaplastic lymphoma kinase-1 (ALK1), TIA-1, EMA expression was observed in 30.8% (4/13), 90.9% (10/11), 100% (13/13), 100% (9/9), and 80.0% (8/10) cases, respectively. EBV infection was consistently absent. Monoclonal TCR gene rearrangement was found in 100% (5/5) of investigated ALK+ cases. Chemotherapy with a CHOP regimen was most frequently employed. The 3-year overall survival (OS) rate for CD56+ ALK+ patients was 92.0%, compared with 73.0% for their CD56- counterparts, but there was no significant difference in OS between the two groups (p = 0.264).

Conclusions

Uniform CD56 expression is an unexpected condition in ALCL. Of ALK+ ALCLs, CD56 expression correlated with a high frequency of early stage and an extranodal predominance. It is of great importance to raise awareness of this condition and familiarity with its characteristic features to avoid diagnostic and therapeutic pitfalls. Further investigations are warranted for a better understanding of this unusual phenotype and the significance of CD56 expression in ALCL.

[Clinical effects of combined application of skin-stretching device and vacuum sealing drainage in repairing the diabetic foot wounds]

Objective: To investigate the clinical effects of skin-stretching device (hereinafter referred to as stretcher) combined with vacuum sealing drainage (VSD) in repairing diabetic foot wounds. Methods: From March 2016 to January 2020, 25 patients with diabetic foot wounds were admitted to the First Affiliated Hospital of Air Force Medical University, including 18 males and 7 females, with age of 40 to 70 years. After debridement, intermittent VSD was performed for 3 to 10 days, with negative pressure value of -10.67 kPa. Then, the wound area was 5.0 cm×3.0 cm to 10.0 cm×7.0 cm. After infection control and detumescence, the wound was treated with stretcher for 3 to 5 days. The wound area after stretching ranged from 5.0 cm×0.3 cm to 10.0 cm×0.5 cm. The wound was closed with full-thickness suture. Two weeks after the suturing operation, the healing grade of the foot wound of patients was observed, and the serious complications such as recurrence of ulcer wound and gangrene on the foot, scar condition of the wound were observed during follow-up. Results: Two weeks after the suturing operation, the wounds of 23 patients were healed with grade A. Soft tissue infection ulcer relapsed in 2 patients during the stretch period. After anti-infection, thorough debridement, and VSD, the wounds were healed after another 16 days of stretch treatment. During the follow-up of 3 to 36 months, 23 patients had linear scar left on the stretch wounds, and the skin elasticity, color, sensation was similar to the surrounding normal tissue, and the limb mobility was good, and 2 patients had obvious scar hyperplasia. One patient had recurrence of diabetic foot and serious vascular occlusion and gangrene in the affected limb at follow-up of 10 months, which was treated with amputation of the lower leg. Conclusions: The use of stretcher combined with VSD in treating diabetic foot wound can avoid donor site injury, with healed wound achieving similar appearance to adjacent skin and satisfactory repair effects.