0659 A Safe and Precise Tongue Base Surgery for Obstructive Sleep Apnea: Real-Time Intraoperative Ultrasound-Assisted Transoral Robotic Surgery

Introduction

Lingual artery (LA) injury is a devastating complication of tongue base surgery. Compared with the anatomic findings of computed tomography angiography (CTA), intraoperative blade of mouth gag might change the thickness of base of tongue (BOT) and anatomy of LA. We aimed to investigate the position of LA in the BOT with intraoperative ultrasound (IOU) imaging during transoral robotic surgery (TORS), and evaluate the bleeding complications when assisted with / without IOU.

Methods

Adult obstructive sleep apnea (OSA) patients who received TORS in BOT resection were recruited since 2016. Assessment tools were pre-op over-night hospital polysomnography (PSG) and anatomy-based Friedman Staging System. Ultrasound imaging was utilized to identify anatomic parameters of LA in BOT, including distance to midline, arterial depth and diameter.

Results

Ninety-three OSA patients (82 male, 88.2%) were analyzed. The mean age was 42.2±10.0 years old and body mass index was 29.2±4.5 kg/m2. The average apnea hypopnea index (AHI) was 58.1±21.4 events/hour. There were 66 (71.0%), 24 (25.8%) and 3 (3.2%) patients in Friedman stages II, III and IV, respectively. Seventy patients underwent TORS with IOU had shorter operation time (191.7±3.8 minutes) than 23 patients without IOU (220.1±6.6 minutes), less total blood loss (11.3±10.8 versus 19.6±26.7 ml), and more BOT tissue reduction volume (7.1±2.5 versus 3.9±1.6 ml). Significant predictors of arterial depth were higher AHI level during rapid-eye-movement (REM) sleep stage (p=0.038), bigger tonsil size (p=0.034) and more elevated Friedman tongue position (p=0.012). Postoperative complication associated with LA injury was not found in the patients with use of IOU.

Conclusion

When tongue retracted with blade, the distance to midline and depth of LA were altered in BOT. With IOU assisted, surgeon could identify LA position confidently. It is expectable to maximize efficiency and minimize catastrophic bleeding complications when OSA patients received TORS in BOT resection.

Support

nil

0032 Timing of Daily Rhythm of Cardiac Autonomic Control Contributes to Weight Loss Resistance, Independent of Daily Energy Intake and Physical Activity Level

Introduction

Obesity is a major health problem. Many treatments have been designed to help overweight/obese people to lose weight, but their effectiveness is highly variable. The same treatments may work for some persons while others have no responses — weight loss resistance. We tested whether the daily rhythm of cardiac autonomic control contributes to weight loss resistance.

Methods

We studied 39 overweight/obese Caucasian women (BMI>25; age: 21–62 years old) who completed (1) an obesity dietary treatment of up to 30 weeks with weekly assessments of body weight, and (2) ambulatory monitoring of electrocardiogram (ECG) for up to 3.5 days. Heartbeat intervals were derived from ECG. Cardiac autonomic control was assessed in each 1-h bin by examining the temporal correlation in heartbeat fluctuations — a nonlinear measure that quantifies the delicate dynamic interplay between sympathetic and vagal outflows. Daily rhythm was estimated using the cosinor analysis.

Results

Weight loss was highly variable (range: 0.68%-21.78 % of initial body weight). The correlation in heartbeat fluctuations displayed a 24-h rhythm (p<0.0001) with fewer correlations (more random) during the nighttime. The phase (peak timing) of the rhythm was highly variable, i.e., 10AM to 8PM for most participants, and after midnight in four participants. Weight loss evolution depended on the phase (p=0.006) in a nonlinear manner. Specifically, participants with the phase between 2PM-8PM lost weight faster than those with phases before 2PM and those after 8PM. The effect was independent of total energy intake, physical activity level, and sleep/wake schedules.

Conclusion

Cardiac autonomic control in overweight/obese women displayed a daily rhythm. The timing of the rhythm had previously un-identified contributions to weight loss. The inter-individual differences in the timing may reflect different circadian regulation of autonomic function and its interaction with the daily behavioral cycle.

Support

This work was supported by NIH grants R01AG048108, RF1AG059867, RF1AG064312, R01AG017917, and R01NS078009.

1027 Differences in Polysomnography-Based Sleep Disorders Between HIV-Infected Persons and Matched Controls

Introduction

Sleep disturbance is a prevalent problem among HIV-infected persons. The recognition of comorbid sleep disorders in patients with HIV is currently hampered by limited knowledge of sleep-related symptoms, sleep architecture, and types of sleep disorders. We aimed to compare the differences in sleep-related symptoms and polysomnography-based sleep disorders between HIV-infected persons and controls.

Methods

The study included 170 men with a Pittsburgh sleep quality index (PSQI) greater than 5, composed of 44 HIV-infected men and 126 male controls who were frequency-matched by sex, age (-/+ 3.0 years) and BMI (-/+ 3.0 kg/m2). For all participants an overnight sleep study using a Somte V1 monitor was conducted. Differences in sleep-related symptoms and sleep disorders between HIV-infected patients and controls were examined using t-tests or Chi-square tests.

Results

HIV-infected persons with sleep disturbances more often had psychological disturbances (72.7% vs. 40.5%, p<0.001) and suspected rapid eye movement (REM) behavior disorder (RBD) (25.0% vs. 4.8%, p<0.01) than that of controls. The sleep-disordered breathing (SDB) in HIV-infected persons was less common than that in controls (56.8% vs. 87.3%, p<0.001). The mean percentage of REM sleep among HIV-infected patients was higher than that among the controls (20.6% vs. 16.6%, p<0.001). Enuresis was more common in HIV-infected persons than controls (40.9% vs. 22.2%, p=0.02).

Conclusion

Psychological disturbances and SDB can be the possible explanations of sleep disturbances in HIV-infected persons, in which suspected RBD is notable. Further studies are warranted to examine underlying factors of suspected RBD among HIV-infected persons with sleep disturbances.

Support

This work was supported by the Ministry of Science and Technology, Executive Yuan of Taiwan [MOST 105-3011-E-006-002], and National Cheng Kung University Hospital [NCKUH-10702022]

0434 Clinical Application of Computer Aided Cloud Sleep Scoring System

Introduction

According to a survey by World Sleep Society, 45% of the population suffered from sleep disorders. The best way to diagnose these patients is to use Polysomnography (PSG), recording their physiological signals throughout the night. Mostly, sleep technologists manually score sleep stages. Manual scoring is quite subjective and time-consuming. Although the technologist’s judgments are based on scoring standards of the American Academy of Sleep Medicine, fine-tuning scoring results because of different considerations in different sleep centers may be happened. In order to assess the consistency of scoring standards in sleep technologists, we tried to establish a cloud sleep scoring system and evaluate its feasibility in 4 sleep centers in southern Taiwan.

Methods

We constructed a computer-aided cloud sleep scoring system. Each sleep technologist could score the same test data of PSG online without being restricted by places and hardware equipment. After comparing scoring results of all participants, the scoring system could provide the following reports, including an overall agreement, agreement of each sleep stage and each sleep index. Besides, multi-person scoring results of each epoch with displaying physiological signals were analyzed.

Results

Seven sleep technologists from 4 hospitals in Tainan, Taiwan joined this study. Standard deviations (SDs) of each sleep stage included 2.64 in Wake stage, 6.90 in N1, 8.31 in N2, 6.87 in N3, 1.38 in REM, respectively. SDs of sleep indexes were 2.64 in sleep efficiency, 2.14 in sleep onset time, 8.35 in wake after sleep onset time, 10.03 in total sleep time, individually. The overall agreement was 89.6%. The satisfaction of this scoring system operation was 85.7%.

Conclusion

With the cloud sleep scoring system assistance, it was feasible to evaluate the scoring consistency among sleep technologists in different sleep centers.

Support

This work is supported by the Ministry of Science and Technology, Taiwan. (MOST 108-2634-F-006-012)

A Retrospective Quality Analysis of External Ventricular Drain Infection Rates Following Stroke Diagnoses and Other Brain Injuries: Comparison of Emergency Room and ICU/OR Setting

Objective

The purpose of this study was to analyze the incidence of infections in patients following placement of External Ventricular Drain (EVD) in either the Emergency Room (ER) or the Intensive Care Unit (ICU)/ Operating Room (OR) at a single Comprehensive Stroke Center.

Methods

Retrospective analysis of post-procedure infection rates in 710 patients with EVDs placed on site between 2010 and 2018 was performed. We analyzed cases between sex, age, stroke and non-stroke related and further requirement of conversion of the EVD to a ventriculoperitoneal (VP) shunt.

Results

Significant decrease in EVD related infection (ERIs) rates following the shift in EVD placement from ER to ICU/OR (from 13% to 7.7%, p=.03) among all ages, sex and type of brain injury was observed. Furthermore, our data also shows that the rate of conversion of EVDs to VP shunts is independent of the setting where EVD was placed, but increases in patients who develop ERIs. 23.1% of stroke patients that developed an ERI required a conversion to VP shunt while 67.3% of non-stroke patients that developed an ERI required further VP shunt (p<.001) showing that non-stroke EVD patients with infections are more likely to require VP shunt.

Conclusion

This is one of the larger retrospective studies conducted on EVD related infections. ERIs were significantly higher when EVDs were placed in the ER. Moreover, our results highlight the relation between ERIs and further requirement of conversion EVD to VP shunt. These figures highlight the importance of focusing on infection rates, and the implications CSF infection has on the long-term care of patients.

[Split-thickness scalp and allogenic acellular dermal matrix in repairing deep wounds of hands in patients with extremely extensive burns]

Objective: To explore the clinical effects of split-thickness scalp and allogenic acellular dermal matrix (ADM) in repairing deep wounds of hands in patients with extremely extensive burns. Methods: Six patients with extremely extensive burns complicated by deep burn in hands were admitted to our department from December 2014 to December 2017, including 4 males and 2 females, aged 21 to 58 years. Their total burn areas were from 85% to 95% total body surface area (TBSA), and the sum of deep-partial thickness and full-thickness wounds was larger than 50% TBSA. Under general anesthesia, deep wounds of 10 dorsal hands were repaired by combined transplantation of split-thickness scalp and allogenic ADM in 4 to 6 weeks after injury. The skin grafting range was beyond the metacarpophalangeal joint, including partial dorsal digital deep wounds. Survival of skin grafts on dorsal hands, follow-up of hand shape and functional recovery were observed and recorded. Results: Six patients were successfully treated. There was no infection on the dorsal deep wounds of 10 hands after surgery, and the grafts survived well. During follow-up of 1 to 2 years after operation, there were no recurrent tension blisters or dorsal extension deformity of the metacarpophalangeal joints in 10 hands, the shape and function of hands recovered well, and hand Carroll scores were from 90 to 99 points, with functional levels of Ⅴ and Ⅵ. Conclusions: The combined transplantation of split-thickness scalp and allogenic ADM is a good method for repairing deep hand wounds in patients with extremely extensive burns, which can alleviate the cicatrix hyperplasia and contracture of healed hand wounds, and improve the shape and function of hands.

Diffusion Properties of Normal-Appearing White Matter Microstructure and Severity of Motor Impairment in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

The effect of white matter hyperintensities as measured by FLAIR MR imaging on functional impairment and recovery after ischemic stroke has been investigated thoroughly. However, there has been growing interest in investigating normal-appearing white matter microstructural integrity following ischemic stroke onset with techniques such as DTI.

MATERIALS AND METHODS

Fifty-two patients with acute ischemic stroke and 36 without stroke were evaluated with a DTI and FLAIR imaging protocol and clinically assessed for the severity of motor impairment using the Motricity Index within 72 hours of suspected symptom onset.

RESULTS

There were widespread decreases in fractional anisotropy and increases in mean diffusivity and radial diffusivity for the acute stroke group compared with the nonstroke group. There was a significant positive association between fractional anisotropy and motor function and a significant negative association between mean diffusivity/radial diffusivity and motor function. The normal-appearing white matter ROIs that were most sensitive to the Motricity Index were the anterior/posterior limb of the internal capsule in the infarcted hemisphere and the splenium of the corpus callosum, external capsule, posterior limb/retrolenticular part of the internal capsule, superior longitudinal fasciculus, and cingulum (hippocampus) of the intrahemisphere/contralateral hemisphere.

CONCLUSIONS

The microstructural integrity of normal-appearing white matter is a significant parameter to identify neural differences not only between those individuals with and without acute ischemic stroke but also correlated with the severity of acute motor impairment.

Improvement of Streptococcus suis glutamate dehydrogenase expression in Escherichia coli through genetic modification of acetate synthesis pathway

Escherichia coli generates acetate as an undesirable by-product that has several negative effects on protein expression, and the reduction of acetate accumulation by modifying genes of acetate synthesis pathway can improve the expression of recombinant proteins. In the present study, the effect of phosphotransacetylase (pta) or/and acetate kinase (ackA) deletion on glutamate dehydrogenase (GDH) expression was investigated. The results indicated that the disruptions of pta or/and ackA decreased the acetate accumulation and synthesis of per gram cell, and increased cell density, and GDH expression and synthesis of per gram cell. The pta gene was more important for acetate formation than the ackA gene. Using the strain with deletions of pta-ackA (SSGPA) for GDH expression, acetate accumulation (2·61 g l^-1 ) and acetate synthesis of per gram cell (0·229 g g^-1 ) were lowest, decreasing by 28·29 and 41·43% compared with those of the parental strain (SSG) respectively. The flux of acetate synthesis (6·6%) was decreased by 72·15% compared with that of SSG, and the highest cell density (11·38 g l^-1 ), GDH expression (2·78 mg ml^-1 ), and GDH formation of per gram cell (0·2442 mg mg^-1 ) were obtained, which were 1·22-, 1·43- and 1·17-times higher than the parental strain respectively. SIGNIFICANCE AND IMPACT OF THE STUDY: Significance and Impact of the Study: Acetate is the key undesirable by-product in Escherichia coli cultivation, and both biomass and production of desired products are increased by the reduction of acetate accumulation. In the present study, the strains with deletions of pta or/and ackA were constructed to reduce the acetate accumulation and improve the GDH expression, and the highest expression level of GDH was obtained using the strain with lesion in pta-ackA that was 1·17-times higher than that of the parental strain. The construction strategy of recombinant E. coli for decreasing the acetate excretion can be used for high expression level of other desired products.

Imatinib enhances the anti-tumour effect of doxorubicin in canine B-cell lymphoma cell line

Canine lymphoma is one of the most common malignant tumours occurring in dogs and has a high incidence worldwide. Despite advances in cancer prevention, the treatment of neoplastic diseases still requires improvement. Some cancer cells may resist the effect of chemotherapeutic agents by up-regulating drug transporters leading to increased drug efflux, resulting in intrinsic or acquired drug resistance, which is a mechanism commonly seen in doxorubicin-resistant tumour cells. In this study, canine B-cell lymphoma cell line CLBL1-8.0, a doxorubicin-resistant B cell lymphoma cell line derived from CLBL-1 by increasing the doxorubicin concentration during culturing, exhibited high expression of P-glycoprotein (P-gp, ATP-binding cassette sub-family B member 1 [ABCB1]). These proteins are commonly involved in cancer cell resistance to doxorubicin. Imatinib, a tyrosine kinase inhibitor significantly potentiated the sensitivity of doxorubicin in P-gp-overexpressing doxorubicin-resistant cells. Moreover, a combination of these two drugs may increase the retention of doxorubicin by decreasing the efflux of doxorubicin without affecting P-gp protein overexpression. In conclusion, imatinib reversed doxorubicin resistance by decreasing drug efflux in P-gp-overexpressing doxorubicin-resistant canine lymphoma cells. These results suggest that combining doxorubicin, one of the most widely used chemotherapeutic drugs in the treatment of canine lymphoma, with imatinib might potentially overcome doxorubicin resistance in a clinical setting.

Single-Cell Transcriptomics Reveals Heterogeneity and Drug Response of Human Colorectal Cancer Organoids

Organoids are three-dimensional cell cultures that mimic organ functions and structures. The organoid model has been developed as a versatile in vitro platform for stem cell biology and diseases modeling. Tumor organoids are shown to share ~ 90% of genetic mutations with biopsies from same patients. However, it's not clear whether tumor organoids recapitulate the cellular heterogeneity observed in patient tumors. Here, we used single-cell RNA-Seq to investigate the transcriptomics of tumor organoids derived from human colorectal tumors, and applied machine learning methods to unbiasedly cluster subtypes in tumor organoids. Computational analysis reveals cancer heterogeneity sustained in tumor organoids, and the subtypes in organoids displayed high diversity. Furthermore, we treated the tumor organoids with a first-line cancer drug, Oxaliplatin, and investigated drug response in single-cell scale. Diversity of tumor cell populations in organoids were significantly perturbed by drug treatment. Single-cell analysis detected the depletion of chemosensitive subgroups and emergence of new drug tolerant subgroups after drug treatment. Our study suggests that the organoid model is capable of recapitulating clinical heterogeneity and its evolution in response to chemotherapy.