[Risk of bias assessment: (1) overview]

This paper reviews the concept of risk of bias, followed by demonstrating why assessment of risk of bias in systematic reviews should be different from that of quality of evidence, methodological quality, reporting quality, precision, and external validity. We also discuss the recent development of tools for risk of bias assessment, the problems with the tools themselves, and the challenges in using these tools. This review may help systematic reviewers understand risk of bias assessment and the use of assessment tools.

Abstract P3-14-02: Upper extremity edema in the at-risk arm among patients receiving PI3K/mTOR/CDK4/6 inhibitors for metastatic breast cancer

Background: Targeted therapies, including mTOR and CDK 4/6 inhibitors, have changed the landscape of management of hormone receptor-positive (HR+) metastatic breast cancer (MBC). These therapies have shown significant improvement in progression-free survival and are generally well-tolerated. In pre-clinical models, modulation of the PI3K/mTOR pathway can impede lymphoangiogenesis resulting in capillary leakage. In this study, we examined the impact of PI3K, mTOR, and CDK 4/6 inhibitors in the development of upper extremity edema (UEE) in the at-risk arm for breast cancer-related lymphedema (BCRL) in patients with MBC.

Methods: We conducted a retrospective chart review of patients treated with PI3K/mTOR/CDK4/6 inhibitors for MBC. Clinicopathologic data including age, body-mass index (BMI), specific pathway targeted, treatment duration, and presence of edema were recorded. Characteristics of treatment including surgery type and laterality, nodal surgery, radiation regimen, and tumor subtype were also collected.

Results: Among patients with MBC treated with PI3K, mTOR, and/or CDK 4/6 inhibitors (N = 160), the incidence of edema that developed after initiation of the targeted therapy was 11.3% (18/160) for UEE and 31.9% (51/160) for edema in any anatomical location. 50.0% (11/22) of patients treated with a PI3K-a inhibitor, 32.6% (14/43) of patients treated with an mTOR inhibitor, and 33.3% (8/24) of patients treated with a CDK4/6 inhibitor alone developed peripheral edema following initiation of the respective targeted therapy. Further, swelling developed in the at-risk upper extremity after C1D1 in 13.6% (3/22) patients treated with a PI3K-α inhibitor exclusively, 7.0% (3/43) treated with an mTOR inhibitor exclusively, and in 12.5% (3/24) treated with a CDK4/6 inhibitor exclusively. Of the 42 patients treated with a CDK4/6 inhibitor in combination with either an mTOR inhibitor, aromatase inhibitor, or an ER-binding promoter, the incidence of UEE in the at-risk upper extremity after C1D1 was 18.8% (6/32), 0.0% (0/7), and 0.0% (0/3) respectively. In multivariate logistic regression analysis, both therapy with PI3K-a inhibitors (OR: 3.22; p = 0.049) and a relative decrease in serum albumin after 3 months of treatment (OR: 3.35, p = 0.024) increased the risk of developing peripheral edema; however, duration of therapy, and nodal surgery were not significant risk factors. Upon stratification of this cohort by number of BCRL-related risk factors, the incidence of BCRL was 18.3%, 39.5%, and 83.3% in women with one, two, or three BCRL-related risk factors, respectively.

Conclusions: PI3K, mTOR, and CDK 4/6 inhibitors may influence the development of UEE, which may cause or exacerbate progression of BCRL in at-risk arm among patients with MBC. Further research is needed to prospectively evaluate these novel findings as well as elucidate physiologic and clinical impacts of these therapies on peripheral edema and BRCL. Moreover, it is crucial to understand the role of close monitoring for the development or progression of peripheral edema or BCRL to ensure early detection and treatment, thus potentially minimizing the negative impacts on the quality of life of patients with MBC.

Citation Format: Daniell KM, Bardia A, Sun F, Brunelle CL, Gillespie TC, Sayegh HE, Naoum GE, Isakoff SJ, Juric D, Taghian AG. Upper extremity edema in the at-risk arm among patients receiving PI3K/mTOR/CDK4/6 inhibitors for metastatic breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-14-02.

Starch and dextrose at 2 levels of rumen-degradable protein in iso-nitrogenous diets: Effects on lactation performance, ruminal measurements, methane emission, digestibility, and nitrogen balance of dairy cows

Our objectives were to determine the effects of readily rumen-available carbohydrate source (refined starch vs. dextrose), the level of rumen-degradable protein (RDP), and their interaction on lactation performance, ruminal measurements, enteric methane (CH4) emission, nutrient digestibility, and nitrogen (N) balance in lactating dairy cows. Eighteen mid-lactation multiparous Holstein cows were used in this split-plot study. The main plots were created by randomly assigning 9 cows to diets of 11 or 9% RDP obtained by altering the percentage of soybean meal, expeller soybean meal, and blood meal in the diet. All diets included 16.4% crude protein. In the subplots, the effects of 0:10, 5:5, and 10:0 refined starch:dextrose ratio (% of dietary dry matter) were determined in three 3 × 3 Latin squares by randomly assigning the 9 cows in each RDP level into squares. Each period lasted 4 wk, with the last 2 wk allotted for sample collection. Carbohydrate source × RDP level interaction tended to influence dry matter intake (DMI), the concentration of urinary N, and urinary urea-N. Replacing refined starch with dextrose increased DMI, the molar percentage of ruminal butyrate and valerate, daily CH4 production (g/d), and fecal N and decreased the molar percentage of ruminal branched-chain volatile fatty acids, feed efficiency (fat- and protein-corrected milk/DMI), and N use efficiency (milk N/intake N) but did not influence nutrient digestibility. Enteric CH4 production was negatively related to the molar percentage of ruminal propionate but positively related to the molar percentage of ruminal butyrate. Treatments did not influence milk production responses, but cows fed 9% RDP diets had lower ruminal ammonia concentration (7.2 vs. 12.3 mg/dL) and tended to excrete less urinary purine derivatives (428 vs. 493 mmol/d) compared with cows fed 11% RDP diets, suggesting lower ruminal synthesis of microbial protein. Reducing the level of RDP in iso-nitrogenous diets had no effect on nutrient apparent total-tract digestibility, manure excretion and composition, N balance, and CH4 production. In this study, treatments did not affect yield (20.0 g of CH4/kg of DMI) or intensity (13.1 g of CH4/kg of fat- and protein-corrected milk), but methane production (g of CH4/d) was 7.0% lower and N use efficiency (conversion of intake N into milk protein) was 7.8% higher for cows fed a diet of 28.1% starch and 4.6% water-soluble carbohydrate compared with diets with lower starch and higher water-soluble carbohydrate contents.

[Introduction on 'assessing the risk of bias of individual studies' in systematic review of health-care intervention programs revised by the Agency for Healthcare Research and Quality]

This paper summarizes the Risk of Bias of Individual Studies in Systematic Reviews of Health Care Interventions revised by the Agency for Healthcare Research and Quality (AHRQ) and introduces how to use Revman software make risk of bias graph or risk of bias summary. AHRQ tool can be used to evaluate following study designs: RCTs, cohort study, case-control study (including nested case-control), case series study and cross-sectional study. The tool evaluates the risk of bias of individual studies from selection bias, performance bias, attrition bias, detection bias and reporting bias. Each of the bias domains contains different items, and each item is available for the assessment of one or more study designs. It is worth noting that the appropriate items should be selected for evaluation different study designs instead of using all items to directly assess the risk of bias. AHRQ tool can be used to evaluate risk of bias individual studies when systematic reviews of health care interventions is including different study designs. Moreover, the tool items are relatively easy to understand and the assessment process is not complicated. AHRQ recommends the use of high, medium and low risk classification methods to assess the overall risk of bias of individual studies. However, AHRQ gives no recommendations on how to determine the overall bias grade. It is expected that future research will give corresponding recommendations.

[Risk of bias assessment: (9) Application of the risk of bias assessment results]

In this last paper of the series about risk of bias assessment, we introduce the application of risk of bias assessment results. Risk of bias assessment is one of the key steps in the assessment of quality of evidence. The risk of bias assessment results could be the "diagnosis" of individual studies, which helps decision making related to the inclusion and exclusion of individual studies, as well as the data analysis in the systematic review process. This paper focuses on how to incorporate risk of bias assessment results in the GRADE assessment for quality of evidence, including the principles and the tips for the application.

[Etiology analysis and vestibular assessment of bilateral vestibular vestibulopathy]

Objective:To define clinical and laboratory characteristics of bilateral vestibulopathy(BVP) and to propose diagnostic criteria of this disorder based on clinical and laboratory vestibular function test findings.Method:Forty-two case series with a clinical suspicion of BVP were retrospectively analyzed, in an attempt to determine etiology. Presenting auditory-vestibular symptoms, bedside dynamic visual acuity tests and laboratory test were reviewed, including bithermal caloric test, rotatory chair tests, video head impulse test (vHIT), vestibular-evoked myogenic potentials (VEMP).Result:Among these 42 patients, dizziness was seen in 42 cases(100%), oscillopsia was seen in 21 cases(50%), hearing loss was seen in 30(71.4%). Eight cases(19%) had tinnitus. Twenty-five cases showed vestibular loss in dynamic visual acuity test (69.4%). Definite diagnosis of complete BVP was made in 36 patients when the patients showed abnormal findings on caloric test, rotatory chair test and vHIT in addition to the symptoms. Whereas probable diagnosis of partial BVP was obtained in 6 patients with abnormal caloric test and rotatory chair test but no pathological vHIT. VEMP (ocular or cervical) could be recorded in 20 patients. Fourteen cases were caused by ototoxic drugs while no causes could be determined in 6 cases among these 42 cases.Conclusion:The diagnosis of BVP is a challenge. Vestibular laboratory test battery which reflect full frequency function of VOR has great value to confirming the diagnosis and differentiate complete BVP to partial BVP. Diagnosis standard shall be made combining clinical history, characteristic symptoms and the results of auditory-vestibular function testing. Ototoxic drugs contribute most considering etiology.

Transport stress induces heart damage in newly hatched chicks via blocking the cytoprotective heat shock response and augmenting nitric oxide production

Transport stress affects the animal's metabolism and psychological state. As a pro-survival pathway, the heat shock response (HSR) protects healthy cells from stressors. However, it is unclear whether the HSR plays a role in transport stress-induced heart damage. To evaluate the effects of transport stress on heart damage and HSR protection, newly hatched chicks were treated with transport stress for 2 h, 4 h and 8 h. Transport stress caused decreases in body weight and increases in serum creatine kinase (CK) activity, nitric oxide (NO) content in heart tissue, cardiac nitric oxide syntheses (NOS) activity and NOS isoforms transcription. The mRNA expression of heat shock factors (HSFs, including HSF1-3) and heat shock proteins (HSPs, including HSP25, HSP40, HSP47, HSP60, HSP70, HSP90 and HSP110) in the heart of 2 h transport-treated chicks was upregulated. After 8 h of transport stress in chicks, the transcription levels of the same HSPs and HSF2 were reduced in the heart. It was also found that the changes in the HSP60, HSP70 and HSP90 protein levels had similar tendencies. These results suggested that transport stress augmented NO generation through enhancing the activity of NOS and the transcription of NOS isoforms. Therefore, this study provides new evidence that transport stress induces heart damage in the newly hatched chicks by blocking the cytoprotective HSR and augmenting NO production.

Identification of key genes of papillary thyroid cancer using integrated bioinformatics analysis

OBJECTIVE

To identify novel clinically relevant genes in papillary thyroid carcinoma from public databases.

METHODS

Four original microarray datasets, GSE3678, GSE3467, GSE33630 and GSE58545, were downloaded. Differentially expressed genes (DEGs) were filtered from integrated data. Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed, followed by protein-protein interaction (PPI) network construction. The CentiScape pug-in was performed to scale degree. The genes at the top of the degree distribution (≥ 95% percentile) in the significantly perturbed networks were defined as central genes. UALCAN and The Cancer Genome Atlas Clinical Explorer were used to verify clinically relevant genes and perform survival analysis.

RESULT

225 commonly changed DEGs (111 up-regulated and 114 down-regulated) were identified. The DEGs were classified into three groups by GO terms. KEGG pathway enrichment analysis showed DEGs mainly enriched in the PI3K-Akt signaling pathway, pathways in cancer, focal adhesion and proteoglycans in cancer. DEGs' protein-protein interaction (PPI) network complex was developed; six central genes (BCL2, CCND1, FN1, IRS1, COL1A1, CXCL12) were identified. Among them, BCL2, CCND1 and COL1A1 were identified as clinically relevant genes.

CONCLUSION

BCL2, CCND1 and COL1A1 may be key genes for papillary thyroid carcinoma. Further molecular biological experiments are required to confirm the function of the identified genes.

[Correlation between ultrasonographic optic nerve sheath diameter and intracranial pressure]

Objective: To evaluate the association of the ultrasonographic optic nerve sheath diameter (ONSD) and intracranial pressure (ICP), and the feasibility of ultrasonographic ONSD in predicting high ICP. Methods: A prospective study. The outpatients who planned to measure ICP by lumbar puncture in Department of Neurology, Xuanwu Hospital, Capital Medical University were selected from January 2011 to May 2012. All the retrobulbar ONSD measurement with B-scan ultrasound was performed just before lumbar puncture. When high ICP was defined as ICP more than 200 mmH₂O(1 mmH₂O=0.009 8 kPa), the participants were divided into the high ICP group and the normal ICP group. The Pearson correlation coefficient analysis was used to analyze the correlation between ICP and postbulbar ONSD measurements. The difference in ONSD was compared between the high ICP and normal ICP groups with the t test. The receiver operating characteristic (ROC) curve was used to calculate the cutoff value of mean ONSD and evaluate the sensitivity and specificity of the method. Results: A total of 130 participants were involved in this study. There were 71 males and 59 females, aged (38±14) years.The mean ICP was (209.84±79.99) mmH₂O. The mean ONSD was (5.68±0.78) mm in the right eyes, (5.78±0.78) mm in the left eyes, and (5.73±0.71) mm in both eyes. The ICP had a significant correlation with ONSD in the right eyes (r=0.54, P<0.001), ONSD in the left eyes (r=0.56, P<0.001) and ONSD in both eyes (r=0.60, P<0.001), but no correlation with age (r=-0.14, P=0.114) and gender (r=0.20, P=0.817). The ONSD in the high ICP group (n=65) was (6.11±0.66) mm, (6.22±0.56) mm and (6.17±0.50) mm in the right eyes, left eyes, and both eyes, respectively. Compared with the ONSD in the normal ICP group (n=65), which was (5.26±0.64) mm in the right eyes, (5.34±0.72) mm in the left eyes and (5.30±0.62) mm in both eyes, there was a significantly enlarged ONSD in the high ICP group (t=-7.507, -7.778, -8.779, all P<0.001). The ROC analysis showed the ONSD of 5.6 mm was the best cutoff value with a sensitivity of 86% and a specificity of 71% for identifying high ICP. Conclusions: There is a significantly positive correlation between ICP and postbulbar ONSD measured by ultrasound. This non-invasive method may be an alternative approach to predicting the ICP value of patients whose ICP measurement via lumbar puncture is at high risk. However, it can not replace the direct ICP measurement with the invasive method. (Chin J Ophthalmol, 2018, 54: 683-687).

[Risk of bias assessment: (8) Risk of Bias in Systematic Review (ROBIS)]

This paper introduces the Risk of Bias in Systematic Review (ROBIS), including: 1) the development of ROBIS, 2) three phases of ROBIS tool judging the overall risk of bias that related to systematic reviews, and 3) illustration on the application of ROBIS in a published systematic review. ROBIS is the first rigorously developed tool which is specifically designed to assess the risk of bias in systematic reviews. ROBIS will help improve the process of risk assessment on bias which appeared in overviews and guidelines.

[Antibiotic use in emergency departments of class Ⅲ general hospitals in China]

Objective: To investigate the utilization of antibiotics in emergency departments (EDs) of class Ⅲ general hospitals in China. Methods: Data from a national monitoring network for rational use of drugs was used. The data included prescriptions of EDs from 114 class Ⅲ general hospitals in 30 provinces (autonomous regions, municipalities) of China. A total of 10 260 595 prescriptions from October 1, 2014 to December 31, 2016 were extracted. The Anatomical Therapeutic Chemical Classification/Defined Daily Dose (DDD) system was used for the classification of antibiotics and calculation of antibiotic use intensity. An auto-regression model was used to analyze the trend over time and seasonal variation of antibiotic use in EDs. Results: The rate of antibiotic prescriptions was 27.82% in EDs, among the antibiotics prescribed, 25.58% were for the combination therapy with 2 or more antibiotic agents, and injectable antibiotic prescriptions accounted for 60.59%. Besides, the number of DDDs per 100 patient visits was 81.84. Broad-spectrum agents were the most commonly used antibiotics, among which the second and third generation cephalosporins, quinolones and macrolides accounted for 23.83%, 21.68%, 19.17% and 7.89% of all prescribed antibiotics, respectively. The use of antibiotics, including prescription frequency and use intensity, in EDs had a slight but significant increase tendency (P<0.05), and the seasonal variation of antibiotic use in EDs was obvious, characterized by the highest frequency and intensity of antibiotic use in winter, the differences were significant (P<0.05). Conclusion: The antibiotic prescription rate in EDs of classⅢ general hospitals in China was controlled at a low level, but the proportions of broad-spectrum antibiotics and injectable antibiotics were high, and a significant increase trend in antibiotic use in EDs was found.

Effects of high pressure on the ferromagnetism and in-plane electrical transport of (Ba0.904K0.096)(Zn0.805Mn0.195)2As2 single crystal

Pressure technique is an effective way to modify magnetic properties of diluted magnetic semiconductors (DMS). Based on single crystal, in-plane electrical transport properties of a new generation DMS (Ba_0.904K_0.096)(Zn_0.805Mn_0.195)₂As₂ have been measured with hydrostatic pressure up to 1.8 GPa. Magnetic properties of the single crystal sample are effectively tuned by pressure. Upon compression, the in-plane resistivity initially decreases but then increases when pressure is higher than 1.2 GPa. First principle calculations suggest that decrease of the resistivity is due to enhancement of density of state at Femi energy while increase of the resistivity under higher pressure is caused by distorted MnAs₄ tetrahedra. We reveal that the configuration of the MnAs₄ tetrahedra and strength of interlayer As-As bonding are of importance to ferromagnetic coupling of (Ba,K)(Zn,Mn)₂As₂.