Hypofractionated Versus Conventional Fractionated Radiotherapy After Breast-Conserving Surgery in the Modern Treatment Era: A Multicenter, Randomized Controlled Trial From China

PURPOSE

No randomized trials have compared hypofractionated radiotherapy (HFRT) with conventional fractionated radiotherapy (CFRT) after breast-conserving surgery in the Asian population. This study aimed to determine whether a 3.5-week schedule of HFRT is noninferior to a standard 6-week schedule of CFRT in China.

PATIENTS AND METHODS

Patients from 4 Chinese institutions who had undergone breast-conserving surgery and had T1-2N0-3 invasive breast cancers participated this study. Patients were randomly assigned (1:1) using a computer-generated central randomization schedule, without stratification, to receive whole-breast irradiation with or without nodal irradiation, followed by tumor-bed boost, either at a dose of 50 Gy in 25 fractions over 5 weeks with a boost of 10 Gy in five fractions over 1 week (CFRT) or 43.5 Gy in 15 fractions over 3 weeks with a boost of 8.7 Gy in three daily fractions (HFRT). The primary endpoint was 5-year local recurrence (LR), and a 5% margin of 5-year LR was used to establish noninferiority.

RESULTS

Between August 2010 and November 2015, 734 patients were assigned to the HFRT (n = 368) or CFRT (n = 366) group. At a median follow-up of 73.5 months (interquartile range, 60.5-91.4 months), the 5-year cumulative incidence of LR was 1.2% in the HFRT group and 2.0% in the CFRT group (hazard ratio, 0.62; 95% CI, 0.20 to 1.88; P = .017 for noninferiority). There were no significant differences in acute and late toxicities, except that the HFRT group had less grade 2-3 acute skin toxicity than the CFRT group (P = .019).

CONCLUSION

CFRT and HFRT with a tumor-bed boost may have similar low LR and toxicity.

[Subclinical heart injury in patients receiving hypofractionated radiotherapy after breast conserving surgery: a preliminary analysis of prospective study]

Objective: To evaluate the incidence of early cardiac injury in patients with left-sided breast cancer receiving hypofractionated radiotherapy after breast conserving surgery, and to investigate the correlation between cardiac injury and hypofractionated radiotherapy dose. Methods: We prospectively enrolled 103 breast cancer patients who received whole breast with or without regional nodal irradiation after breast conserving surgery using either deep inspiration breath-hold (DIBH) or free breathing (FB) radiotherapy technique. Cardiac examinations that included N-terminal pro-B-type natriuretic peptide (NT-proBNP), electrocardiogram, and myocardial perfusion imaging were performed routinely before and after radiotherapy. The effects of heart dose, systemic therapy and individual factors (Framingham score) on the incidence of cardiac events were analyzed. Results: The median age was 48 years. The mean dose (Dmean) of the heart, left anterior descending coronary artery (LAD), left ventricular (LV), and right ventricular (RV) were 4.0, 16.9, 6.3, and 4.4 Gy, respectively. With a median follow-up of 13.4 months, no patient had clinical cardiac abnormalities. The incidence rates of subclinical cardiac events at 1- 6- and 12-month were 23.5%, 31.6%, and 41.3%, respectively. The DIBH group had a lower mean dose, maximum dose, and V5-V40 in the heart, LAD, LV, and RV than the FB group (P<0.001). Univariate analysis showed an increased incidence of subclinical cardiac events with heart Dmean >4 Gy, LAD V40 > 20%, LV Dmean >6 Gy, RV Dmean >7 Gy, or cumulative doses of anthracycline or taxane > 300 mg/m(2) (All P<0.05). Anti-HER2 targeted therapy, endocrine therapy and Framingham score were not associated with the incidence of subclinical cardiac events (all P>0.05). Multivariate analysis demonstrated that Dmean of LV and RV were independently associated with the increased incidence of subclinical cardiac events. Conclusions: Early subclinical heart injury are found in patients with left-sided breast cancer after hypofractionated radiotherapy. The increased incidence of subclinical cardiac events after radiotherapy is positively associated with the cardiac radiation doses.

Association of progression-free or event-free survival with overall survival in diffuse large B-cell lymphoma after immunochemotherapy: a systematic review

To investigate progression-free survival (PFS) and event-free survival (EFS) as early efficacy endpoints in diffuse large B-cell lymphoma (DLBCL), this systematic review included phase III randomized controlled trials (RCTs), phase II trials, and retrospective studies in newly diagnosed DLBCL receiving rituximab-containing chemotherapy through databases search up to 2019. Quality control was performed, where studies with high risk of bias were excluded. Prediction models were first established using the RCTs, and then externally validated in the phase II and retrospective populations. Trial-level surrogacy analysis was conducted by correlating the logarithmic (log) hazard ratio (HR) for PFS or EFS and log HR for OS. Correlation analysis at treatment arm-level was performed between 1-, 2-, 3-, and 5-year PFS or EFS rates and 5-year OS. The correlation was evaluated using the Pearson correlation coefficient r in weighted linear regression, with weight equal to patient size. Sensitivity analyses were performed to assess the consistency of predictive model by leaving one subgroup of trials out at a time. Twenty-six phase III RCTs, 4 phase II trials and 47 retrospective studies were included. In trial-level surrogacy, PFS (r, 0.772; 95% confidence interval [CI], 0.471-0.913) or EFS (r, 0.838; 95% CI, 0.625-0.938) were associated with OS. For rituximab immunochemotherapy treatment arms in RCTs, there was a linear correlation between 1 and 5-year PFS (r, 0.813-0.873) or EFS (r, 0.853-0.931) and 5-year OS. Sensitivity analysis demonstrated reasonable overall consistency. The correlation between PFS and OS was externally validated using independent phase II, and retrospective data (r, 0.795-0.897). We recommend PFS and EFS as earlier efficacy endpoints in patients with DLBCL primarily treated with rituximab-containing immunochemotherapy.

Postmastectomy Radiation Therapy Based on Pathologic Nodal Status in Clinical Node-Positive Stage II to III Breast Cancer Treated with Neoadjuvant Chemotherapy

PURPOSE

The present study aimed to evaluate the effect of postmastectomy radiation therapy (PMRT) after neoadjuvant chemotherapy in patients with node-positive stage II to III (cT1-4N1-2M0) breast cancer.

METHODS AND MATERIALS

A total of 1813 patients from 12 institutions were retrospectively reviewed. Patients were classified into 1 of 3 groups based on the pathologic lymph node status after neoadjuvant chemotherapy: ypN0, ypN1, and ypN2-3. The role of PMRT was separately evaluated in each group. Locoregional control, disease-free survival, and overall survival (OS) were estimated using the Kaplan-Meier method. The effect of PMRT was assessed by propensity score-matched analyses and multivariate Cox analyses.

RESULTS

With a median follow-up of 72.9 months, 5-year locoregional control, disease-free survival, and OS rates were 86.3%, 68.4%, and 83.1% for the entire cohort, respectively. There were 490 (27.0%), 567 (31.3%), and 756 (41.7%) patients in the ypN0, ypN1, and ypN2-3 groups, respectively. PMRT significantly improved 5-year OS in the ypN2-3 group (74.2% vs 55.9%; P < .001) but had no effect on 5-year OS in the ypN0 group (93.1% vs 95.5%; P = .517) and ypN1 group (88.4% vs 87.8%; P = .549).

CONCLUSIONS

With modern systemic therapy, PMRT significantly improved OS in the ypN2-3 group but not in the ypN0 and ypN1 groups. Whether PMRT can be safely omitted in the ypN0 and ypN1 groups should be addressed prospectively.

[Analysis on duplicated reporting of brucellosis in China, 2005-2017]

Objective: To analyze the current status of duplicated reporting of brucellosis in China during 2005-2017, to understand the impact of duplicated reporting on the incidence of brucellosis, analyze the possible causes of duplicated reporting, and put forward propose solutions to further improve the brucellosis surveillance data quality. Methods: Data were from brucellosis case reporting cards in National Notifiable Disease Report System (NNDRS), Excel 2010 software was used to establish the database, the duplicated reporting was identified by using Spark DataFrame aggregation analysis in Python 3.2. Results: During 2005-2017, a total of 499 577 cases of brucellosis were reported, but the duplicated reporting rate was 75.76/10 000 (3 785/499 577). The duplicated reporting rate in same year was 37.21/10 000 (1 859/499 577), the duplicated reporting rate in other year was 39.87/10 000 (1 992/499 577) and the overall duplicated reporting rate increased year by year. The duplicated reporting rate in same institution was 33.59% (1 271/3 785) and the duplicated reporting rate by other institutions was 66.41% (2 514/3 785). Hospitals had the highest number of duplicated reporting (2 757), and community healthcare centers had the highest of duplicated reporting rate (281.27/10 000) (123/4 373). The reported incidence of brucellosis was 2.926 4/100 000 in 2017, the corrected incidence was 2.844 8/100 000 after removing the duplicated reporting, which was the maximum decrease from 2005 to 2017, the corrected incidence decreased by 2.79%. From 2005 to 2017, the average reported incidence of brucellosis in Xinjiang Uygur autonomous region was 14.712 0/100 000, and the corrected incidence was 14.060 0/100 000 after removing the duplicate reporting, with a decrease by 4.43%, the biggest decline in China. The average reported incidence of brucellosis in Ningxia Hui autonomous region was 13.987 1/100 000, and the corrected incidence of brucellosis was 13.662 2/100 000, with a decrease of 2.32%, ranking second in China. The reasons for duplicated reporting of brucellosis included repeated medical care seeking in same or different medical institutions in same year or other year, including the repeated medical care seeking in other areas. Conclusions: During 2005-2017, the number of duplicated reporting of brucellosis cases was on the rise in China. Hospital and community health service centers had highest case number and rate of duplicate reporting respectively, the duplicated reporting was mainly caused by re-reporting by other institutions or in other years. The duplicated reporting of brucellosis had greatly affected the accuracy of surveillance data of brucellosis in some provinces, such as Xinjiang and Ningxia. It is recommended to further strengthen brucellosis reporting management, improve data quality of NNDRS.

Inhibition of EPS8L3 suppresses liver cancer progression and enhances efficacy of sorafenib treatment

BACKGROUND

Liver cancer is a devastating disease that has second highest cancer mortality rate worldwide. Although surgical resection or liver transplantation sometimes cures early stage liver cancer, few therapeutic options are available for advanced-stage liver cancer, highlighting the importance of a better understanding of the disease to find novel therapeutic targets.

METHODS

Firstly, clinical features of EPS8L3 on liver cancer RNA-seq dataset of The Cancer Genome Atlas (TCGA) database was analyzed, including gene expression levels in tumor tissues in comparison with the normal tissues as well as the patients' OS. To confirm the candidate genes, we used short hairpin RNA (shRNA) to knock down the gene and quantify the cell proliferation, apoptosis, and migration. Then micro-array analysis was did to investigate the intracellular mechanisms of EPS8L3. Moreover, to gain further insights into the translational value of the findings, we treated the liver cancer cells with Sorafenib after knocking down the candidate gene, in order to interrogate the combinatorial inhibitory effects on cell metabolism.

RESULTS

As a result, by comparing gene expression profiles of normal liver and cancerous tissues, we find that epidermal growth factor receptor kinase substrate 8-like protein 3 (EPS8L3), a gene with unknown function, is upregulated in liver cancer, and is associated with poor prognosis. Further gene set analyses on liver cancer cells revealed that EPS8L3 is pertinent to cell division and proliferation. Indeed, knocking down EPS8L3 inhibits cell proliferation and migration, and triggers apoptosis in vitro. Additionally, when inoculated into mice, EPS8L3 knocked down cells exhibit slower growth rate. Moreover, EPS8L3 expression can substantially increase the efficacy of low dosage of Sorafenib treatment. Furthermore, the results of immunohistochemical staining of 90 paired liver cancer and adjacent normal samples demonstrated high expression of EPS8L3 yields poor prognosis in Chinese liver cancer patients.

CONCLUSIONS

Collectively, our results suggest that EPS8L3 has pivotal oncogenic functions in liver cancer and we propose that EPS8L3 could be a potential therapeutic target to treat liver cancer.

Risk-adapted therapy for advanced-stage natural killer/T-cell lymphoma: An analysis from the China Lymphoma Collaborative Group Study

e20041

Background: Few studies focused on the risk-adapted therapy for advanced-stage natural killer/T-cell lymphoma (NKTCL) due to poor prognosis. Methods: Data of 406 patients with advanced-stage NKTCL from 20 Chinese institutions between 2000 and 2015 were retrospectively analyzed. To develop a prognosis index model for advanced-stage NKTCL, all patients were divided into the primary cohort from South China (n = 198) and the validation cohort from North China (n = 208). Clinical factors related to survival in the primary cohort were identified to construct a new prognosis index model. An external validation for the prognosis index model was performed in the validation cohort. Stratified by the prognosis index model, survival benefit for treatment models was assessed. Results: The median age was 42 years with the ratio of male/female of 2.5:1. Extra-nodal involvement was observed in 72.4% of patients. More than one third of patients received asparaginase (Asp)–containing chemotherapy. In addition, radiotherapy was administrated in 135 (33.3%) patients. The overall response rate (ORR) and complete remission (CR) rate were 59.3% and 38.3% in 337 available patients. The expected 3-year progression-free survival (PFS) and overall survival (OS) rates were 26.9% and 37.3%, respectively. Based on 3 clinical variables including ECOG-PS > 1, elevated LDH and solid organs involvement, a new prognosis index model (ASPRIN) was developed and showed superior discrimination than current models including IPI, KPI and PINK in this particular population. The expected 3-year OS rates in the primary and validation cohort were 54.8% and 52.9% in the low risk group (with 0-1 risk factor), 34.4% and 38.0% in the intermediate risk group (with 2 risk factors), 13.8% and 10.6% in the high risk group (with 3-4 risk factors), respectively. Stratified by ASPRIN model, combined radio-chemotherapy provided better survival benefit than chemotherapy alone regardless of chemotherapy regimens in the low risk group (3-year PFS 52.6% vs. 22.6%, P < 0.001; 3-year OS 72.8% vs. 35.8%, P < 0.001), while Asp–containing chemotherapy improved survival with an increase of about 10%-15% in PFS and OS compared with non–Asp–containing chemotherapy in the intermediate and high risk groups. Conclusions: The outcome of advanced-stage NKTCL is still poor and heterogeneous even in the era of Asp–containing chemotherapy, which highlighted the need of establishing more effective risk-adapted therapeutic strategies.

[Guidelines for the use of post-traumatic tetanus vaccines and passive immune preparation]

Post-traumatic tetanus is the main type of non-neonatal tetanus. To reduce the incidence and mortality rateof tetanus and guide the primary medical institutions to prevent and control tetanus after trauma, the National Immunization Planning Technical Working Group of the Chinese Center for Disease Control and Prevention has compiled this document in the reference with Position Paper by World Health Organization, and the latest research progress both at home and abroad. The guidelines focus on the basic procedures for the prevention and treatment of post-traumatic tetanus, the application of tetanus vaccines and immune preparation, and pre-exposure immunization in high-risk populations of trauma.

[Magnetic resonance imaging of normal anatomy and injury of the peroneal tendon]

Objective: To explore the MR characteristics of normal anatomy and injured peroneal tendon and the diagnostic value of MR in the peroneal tendon injuries. Methods: From February 2018 to December 2018, a total of 20 healthy volunteers (40 ankle joints) were selected, 10 males and 10 females, with an age range of 20-30 (26±3) years. Retrospective analyzed 62 patients with ankle sprain and peroneal tendon injuries confirmed by operation, 34 males and 28 females, with an age range of 14-78(41±14) years. All volunteers and patients underwent MR examination. The MRI characteristics of the normal anatomy of peroneal tendon were analyzed. The patients were classified according to the MR diagnostic criteria of injury. Then the MRI features of different types of injured peroneus longus tendon and peroneus brevis tendon were analyzed. At last, imaging findings were compared with surgical results. Results: The peroneal tendon of 20 healthy volunteers showed oval and elliptical band-like structures on T(1)WI and PD-FS sequences, with natural alignment, clear boundary and uniform low signal. The whole length of the peroneal tendon can't be displayed completely on the same imaging plane. It needed multi-dimensional observation combined with axial, coronal and sagittal directions. There were 62 cases of peroneal tendon injury, including 46 cases of peroneal tendon tear (7 cases of partial-thickness tear, 11.3% of the total injuries, 39 cases of full-thickness tear, 62.9% of the total injuries), 16 cases of peroneal tendon dislocation (15 cases of intrathecal dislocation, 24.2% of the total injuries, 1 case of extrathecal dislocation, 1.6% of the total injuries). In 7 cases of partial-thickness tear (4 cases of peroneus brevis tendon tear, 3 cases of peroneus longus tendon tear), MR showed irregular tendon shape and local continuity interruption. In 39 cases of full-thickness tear (31 cases of peroneus brevis tendon tear, 8 cases of peroneus longus tendon tear), MR showed that the tear was penetrated through the whole layer of tendon from dorsolateral side to plantar side of foot, and the range of tear was different. The torn tendon could be accompanied by tendinitis or effusion of tendon sheath; 15 cases of intrathecal dislocation (3 cases of type A, 12 cases of type B), MR findings of type A dislocation showed that the peroneus longus tendon was located in the deep part of the peroneus brevis tendon, MR findings of type B dislocation showed that the peroneus longus tendon was displaced into the longitudinal tear of peroneus brevis tendon. In 1 case of extrathecal dislocation (type Ⅲ), MR showed that the SPR and the attached cortex of lateral malleolus were avulsed together, and the peroneal tendon was displaced under the avulsed fracture piece. Conclusion: MR can accurately demonstrate the fine anatomical structure of peroneal tendon and the imaging features of injuries. It has important clinical application value for the early diagnosis and accurate treatment of peroneal tendon injuries.

[A three-year follow-up observation of a pedigree of maturity onset diabetes of the young caused by a novel mutation of glucokinase and literature review]

Objective: To explore the clinical characteristics and follow-up outcomes of a pedigree of maturity onset diabetes of the young (MODY) induced by a novel mutation of glucokinase (GCK). Methods: The clinical features and laboratory data of a pedigree diagnosed with GCK-MODY in Peking Union Medical College Hospital was analyzed. Genomic DNA was extracted, and Sanger sequencing was performed to detect the gene mutation of the family members. The proband and her father were followed up for 3 years. Wanfang and PubMed were used to search literatures on follow-up studies for treatment of GCK-MOYD. Results: Both the proband and her father were found to have a novel mutation on the GCK gene located in exo10 c.1348G.T (p. Ala450Thr). The proband was treated with diet and exercise control only. At the end of the follow-up, her fasting plasma glucose (FPG, 6.8 mmol/L), 2 h postprandial plasma glucose (2hPG, 7.4 mmol/L), and glycated hemoglobin (HbA1c, 6.3%) were all within the control targets. Additionally, the levels homeostasis model assessment of insulin resistance (HOMA-IR) tended to improved comparing to that at baseline (4.09 to 2.32), and glucose disposition index (DI) was improved compared with baseline (16.22 to 20.05). As to the proband's father, the treatment with insulin plus acarbose was converted to sulfonylureas monotherapy. His FPG and 2hPG mostly were within the target range, and the levels of HbA1c were significantly reduced by 0.5%-0.7% when compared to that at baseline. The HOMA-IR or islet beta cell function was comparable to those at baseline. Conclusions: Screening patients whose clinical performance meets GCK-MODY and their family members with proper genetic testing is of great importance to reduce misdiagnosis of GCK-MODY, so as to obtain a better glucose control without unnecessary over-treatment and protect islet beta cell function.

[May cross-sectional studies provide causal inferences?]

Due to the flaws inherited in synchronicity, statistical association and survivor bias on variables under measurement, a common 'consensus' has been reached on "cross-sectiional studies (CSS) can lead to failure on causal inference". In this paper, under both causal thinking and diagram, the real and measured cross-sections are clearly defined that these two concepts only exist theoretically. In real CSS research, the temporal orders of measured variables are all non-synchronic, equivalent to the assumption that measurement variables are independent to each other, or there is no differentiated classification bias. Similar to cumulative case-control or historical cohort studies, both exposure and outcome that exist or occur before their measurements in cross-sectional studies, are actions of historical reconstruction or doing 'Archaeology'. One of the common preconditions for causal inference in such studies is that: there must be a causal relation between the measured variables and their historical counterparts. The measured variables are all agents of their corresponding real counterparts, and the temporal orders are not that important in causal inference. It is necessary to better understand the analytic role of the CSS.

Validation of nomogram-revised risk index and comparison with other models for extranodal nasal-type NK/T-cell lymphoma in the modern chemotherapy era: indication for prognostication and clinical decision-making

Derived from our original nomogram study by using the risk variables from multivariable analyses in the derivation cohort of 1383 patients with extranodal NK/T-cell lymphoma, nasal-type (ENKTCL) who were mostly treated with anthracycline-based chemotherapy, we propose an easily used nomogram-revised risk index (NRI), validated it and compared with Ann Arbor staging, the International Prognostic Index (IPI), Korean Prognostic Index (KPI), and prognostic index of natural killer lymphoma (PINK) for overall survival (OS) prediction by examining calibration, discrimination, and decision curve analysis in a validation cohort of 1582 patients primarily treated with non-anthracycline-based chemotherapy. The calibration of the NRI showed satisfactory for predicting 3- and 5-year OS in the validation cohort. The Harrell’s C-index and integrated Brier score (IBS) of the NRI for OS prediction demonstrated a better performance than that of the Ann Arbor staging system, IPI, KPI, and PINK. Decision curve analysis of the NRI also showed a superior outcome. The NRI is a promising tool for stratifying patients with ENKTCL into risk groups for designing clinical trials and for selecting appropriate individualized treatment.

Radiation-Induced Lymphopenia Predicts Poorer Prognosis in Patients With Breast Cancer: A Post Hoc Analysis of a Randomized Controlled Trial of Postmastectomy Hypofractionated Radiation Therapy

PURPOSE

The aim of this study was to determine whether radiation-induced lymphopenia affects the survival of patients with breast cancer.

METHODS AND MATERIALS

Post hoc analysis was conducted on data from 598 patients with breast cancer from a randomized controlled trial comparing postmastectomy hypofractionated radiation therapy (HFRT; 43.5 Gy in 15 fractions over 3 weeks) with conventional fractionated radiation therapy (CFRT; 50 Gy in 25 fractions over 5 weeks). Mean peripheral lymphocyte count (PLC) at different time points in the 2 groups was compared by the t test. Disease-free survival and overall survival were analyzed by the Kaplan-Meier method and compared between groups by the log-rank test.

RESULTS

Baseline PLC (pre-PLC) was comparable between HFRT and CFRT patients (1.60 ± 0.57 × 10⁹/L vs 1.56 ± 0.52 × 10⁹/L; P = .33). In both groups, the PLC declined steadily during the course of radiation therapy but started to recover at 1 month after radiation therapy. Incidence of lymphopenia was significantly lower in HFRT patients (45.4% vs 55.7%; P = .01). Nadir-PLC was significantly higher in HFRT patients (1.08 ± 0.37 × 10⁹/L vs 0.97 ± 0.31× 10⁹/L; P < .001), as was the nadir-PLC/pre-PLC ratio (0.72 ± 0.28 vs 0.67 ± 0.28; P = .02). Median follow-up was 57.6 months (interquartile range, 38.5-81.4). The 5-year disease-free survival was significantly lower in patients with a nadir-PLC/pre-PLC ratio <0.8 than in those with a ratio ≥0.8 (71.8% vs 82.6%; P = .01); however, overall survival was comparable between the groups (85.8% vs 90.6%; P = .24).

CONCLUSIONS

The risk of radiation-induced lymphopenia in patients with breast cancer is lower with HFRT than with CFRT. A low nadir-PLC/pre-PLC ratio may predict poor prognosis.

[Characteristics of peripheral blood leukocyte differential counts in patients with COVID-19]

To investigate the early changes of peripheral blood leukocyte differential counts in patients with COVID-19. Ten patients with COVID-19 and 30 patients with other viral pneumonia (non-COVID-19) admitted to Shanghai Jiao Tong University Affiliated Sixth People's Hospital and Jinshan Branch Hospital from January 22 to February 17, 2020 were enrolled in this study. The differential counts of white blood cells were analyzed. Patients in COVID-19 group showed relatively lower absolute white blood cell (WBC) count 4.95(3.90,6.03)×10(9)/L, lymphocyte absolute count 1.20(0.98,1.50)×10(9)/L and eosinophil absolute count 0.01(0.01,0.01)×10(9)/L. Leukopenia developed in two patients(2/10), lymphocytopenia also in two patients(2/10). Seven over ten patients presented with eosinophil cytopenia. In non-COVID-19 group, absolute WBC count was 8.20 (6.78,9.03) ×10(9)/L (P<0.001), lymphocyte absolute count 1.75(1.20,2.53)×10(9)/L(P=0.036), eosinophil absolute count 0.02(0.01,0.03)×10(9)/L(P=0.05). Lymphocytopenia occurred in (16.7%) patients, eosinophil cytopenia in 16.7% patients too. In conclusion, leukopenia, lymphocytopenia and eosinophil cytopenia are more common in COVID-19 patients than those in non- COVID-19 patients.

[Current consensus and controversy in neoadjuvant therapy for pancreatic cancer]

Pancreatic cancer is malignant and has a poor prognosis.At present, the treatment mode has changed from "Surgery First" to systemic therapy under multi-disciplinary team, but surgical resection is still the only way to cure pancreatic cancer. In systemic treatment of pancreatic cancer, the effect of postoperative adjuvant therapy is significant, and preoperative neoadjuvant therapy has gradually attracted widespread attention. Neoadjuvant therapy can improve the rate of R0 resection in patients with pancreatic cancer.There is a consensus on neoadjuvant therapy for patients who with borderline resectable and locally advanced, but for the patients who with resectable remains controversial.

Pancreatic Fat is not significantly correlated with β-cell Dysfunction in Patients with new-onset Type 2 Diabetes Mellitus using quantitative Computed Tomography

Objective: Type 2 diabetes mellitus (T2DM) is a chronic condition resulting from insulin resistance and insufficient β-cell secretion, leading to improper glycaemic regulation. Previous studies have found that excessive fat deposits in organs such as the liver and muscle can cause insulin resistance through lipotoxicity that affects β-cell function. The relationships between fat deposits in pancreatic tissue, the function of β-cells, the method of visceral fat evaluation and T2DM have been sought by researchers. This study aims to elucidate the role of pancreatic fat deposits in the development of T2DM using quantitative computed tomography (QCT), especially their effects on islet β-cell function. Methods: We examined 106 subjects at the onset of T2DM who had undergone abdominal QCT. Estimated pancreatic fat and liver fat were quantified using QCT and calculated. We analysed the correlations with Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) scores and other oral glucose tolerance test-derived parameters that reflect islet function. Furthermore, correlations of estimated pancreatic fat and liver fat with the area under the curve for insulin (AUC_INS) and HOMA-IR were assessed with partial correlation analysis and demonstrated by scatter plots. Results: Associations were found between estimated liver fat and HOMA-IR, AUC_INS, the modified β-cell function index (MBCI) and Homeostatic Model Assessment β (HOMA-β). However, no significant differences existed between estimated pancreas fat and those parameters. Similarly, after adjustment for sex, age and body mass index, only estimated liver fat was correlated with HOMA-IR and AUC_INS. Conclusions: This study suggests no significant correlation between pancreatic fat deposition and β-cell dysfunction in the early stages of T2DM using QCT as a screening tool. The deposits of fat in the pancreas and the resulting lipotoxicity may play an important role in the late stage of islet cell function dysfunction as the course of T2DM progresses.

[Guidelines for the use of post-traumatic tetanus vaccines and passive immune preparation]

Post-traumatic tetanus is the main type of non-neonatal tetanus. To reduce the incidence and mortality rate of tetanus and guide the primary medical institutions to prevent and control tetanus after trauma, National Immunization Planning Technical Working Group of the Chinese Center for Disease Control and Prevention has compiled this document in the reference with Position Paper by World Health Organization, the latest research progress from home and abroad. The guidelines focus on the basic procedures for the prevention and disposition of post-traumatic tetanus, the application of tetanus vaccines and immune preparation, and the pre-exposure immunization in high-risk populations of trauma.

Capture Deformation Twinning in Mg during Shock Compression with Ultrafast Synchrotron X-Ray Diffraction

Deformation twinning plays a vital role in accommodating plastic deformation of hexagonal-close-packed (hcp) metals, but its mechanisms are still unsettled under high strain rate shock compression. Here we investigate deformation twinning in shock-compressed Mg as a typical hcp metal with in situ, ultrafast synchrotron x-ray diffraction. Extension twinning occurs upon shock compression along ⟨112[over ¯]0⟩ and ⟨101[over ¯]0⟩, but only upon release for loading along ⟨0001⟩. Such deformation mechanisms are a result of the polarity of deformation twinning, which depends on directionality and relative magnitude of resolved shear stress and may be common for Mg and its alloys in a wide range of strain rates.

[Magnetic resonance imaging of the elbow joint tendon: imaging technique and clinical application]

Objective: To explore the magnetic resonance imaging (MRI) imaging technique and the clinical application in ligament and tendons of elbow. Methods: The study was reviewed and approved by an institutional review board of Beijing Jishuitan Hospital. A total of 20 normal volunteers with 40 elbows including 12 males and 8 females, aged from 20 to 55 years, with an average age of 35 years and 38 patients with 38 elbows who complained elbow pain with elbow injuries including 23 males and 15 females, ranged in age from 9 to 77 years, with an average age of 41 years old were chosen to undergo magnetic resonance examination between May 2013 and October 2018.All subjects underwent examination on coronal T(1)WI scan and PD-FS on three planes respectively in a prone position. Then the MRI characteristics of tendons in elbow of healthy volunteers and patients with elbow injuries were studied and the MRI features of tendon injury were compared with the surgical results and confirmed by double-blind method. Results: Twenty normal volunteers without tendons or ligament injures showed homogeneous low-signal-intensity on T(1)-weighted and proton fat saturation sequence (PD-FS) images.In the 38 patients with elbow injuries, there were 44 tendon injuries, including 14 cases of common extensor tendon injuries, 10 cases of common flexor tendon injuries, 3 cases of biceps tendon injuries, 7 cases of brachialis tendon injuries and 10 cases of triceps tendon injuries. The injuried tendons became thicker and discontinuity in T(1)WI and demonstrated heterogeneously increased signal intensity with effusion of tendon sheath in PD-FS. Partial tear showed discontinuity and thickening of tendons and the complete tear showed that the tendons were interrupted, retracted, the fiber structure disappeared and was filled with liquid, and the surrounding soft tissue edema was found. Conclusions: MRI can demonstrate the anatomy and injuries features of tendons in elbow joint accurately. It is significance for the early diagnosis and treatment protocols of the tendons injuries.

Transcriptome analysis reveals corresponding genes and key pathways involved in heat stress in Hu sheep

Heat stress (HS) seriously affects animal performance. In view of global warming, it is essential to understand the regulatory mechanisms by which animals adapt to heat stress. In this study, our aim was to explore the genes and pathways involved in heat stress in sheep. To this end, we used transcriptome analysis to understand the molecular responses to heat stress and thereby identify means to protect sheep from heat shock. To obtain an overview of the effects of heat stress on sheep, we used the hypothalamus for transcriptome sequencing and identified differentially expressed genes (DEGs; false discovery rate (FDR) < 0.01; fold change > 2) during heat stress. A total of 1423 DEGs (1122 upregulated and 301 downregulated) were identified and classified into Gene Ontology (GO) categories and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways. Heat stress triggered dramatic and complex alterations in gene expression in the hypothalamus. We hypothesized that heat stress induced apoptosis and dysfunction in cells and vital organs and affected growth, development, reproduction, and circadian entrainment via the calcium signaling pathway, which influences ribosome assembly and function. Real-time PCR was used to evaluate the expression of the genes regulating important biological functions or whose expression profiles were significantly changed after acute heat stress (FDR < 0.01; fold change > 4), and the results showed that the expression patterns of these genes were consistent with the results of transcriptome sequencing, indicating that the credibility of the sequencing results. Our data indicated that heat stress induced calcium dyshomeostasis, blocked biogenesis, caused ROS accumulation, impaired the antioxidant system and innate defense, and induced apoptosis through the P53 signaling pathway activated by PEG3, decreased growth and development, and enhanced organ damage. These data is very important and helpful to elucidate the molecular mechanism of heat stress and finally to find ways to deal with heat stress damage in sheep.

5106A pattern-discovery-based outcome predictive tool integrated with clinical data repository: design and a case study on contrast related acute kidney injury

Introduction

Clinical data repositories (CDR) including electronic health record (EHR) data have great potential for outcome prediction and risk modeling. However, most CDRs were only used for data displaying, and using data from CDR for outcome prediction often requires careful study design and sophisticated modeling techniques before a hypothesis can be tested.

Purpose

We built a prediction tool integrated with CDR based on pattern discovery aiming to bridge the above gap and demonstrated a case study on contrast related acute kidney injury (AKI) with the system.

Methods

A cardiovascular CDR integrated with multiple hospital informatics systems was established. For the case study on AKI, we included patients undergoing cardiac catheterization from January 13, 2015 to April 27, 2017, excluding those with dialysis, end-stage renal disease, renal transplant, and missing pre- or post-procedural creatinine. To handle missing data, a prior-history-note composer was designed to fill in structured data of 14 diseases related to cardiovascular problem. Crucial data such as ejective fraction was extracted from the structured reports. AKI was defined according to Acute Kidney Injury Network by increase of serum creatinine from most recent baseline to the post-procedure 7-day peak. To build predictive modeling, we selected 17 variables covered in existing AKI models. Pattern discovery was recently developed as an interpretable predictive model which works on incomplete noisy data. In this study, we developed a pattern discovery based visual analytics tool, and trained it on 70% data up to August 2016 with three interactive knowledge incorporation modes to develop 3 models: 1) pure data-driven, 2) domain knowledge, and 3) clinician-interactive. In last two modes, a physician using the visual analytics could change the variables and further refine the model, respectively. We tested and compared it with other models on the 30% consecutive patients dated afterwards, which is shown in Figure 1.

Results

Among 2,560 patients in the final dataset with 17 pre-procedure variables derived from CDR data, 169 (7.3%) had AKI. We measured 4 existing models, whose areas under curves (AUCs) of receiver operating characteristics curve for the test set were 0.70 (Mehran's), 0.72 (Chen's), 0.67 (Gao's) and 0.62 (AGEF), respectively. A pure data-driven machine learning method achieves AUC of 0.72 (Easy Ensemble). The AUCs of our 3 models are 0.77, 0.80, 0.82, respectively, with the last being top where physician knowledge is incorporated.

Demo and demonstration

Conclusions

We developed a novel pattern-discovery-based outcome prediction tool integrated with CDR and purely using EHR data. On the case of predicting contrast related AKI, the tool showed user-friendliness by physicians, and demonstrated a competitive performance in comparison with the state-of-the-art models.

[The 8th edition of the American Joint Committee on Cancer staging system provide improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients]

Objective: To validate whether the prognostic stage groups by the 8th edition of the American Joint Committee on Cancer (AJCC) staging system provides improved prognostic accuracy in T1-2N1M0 postmastectomy breast cancer patients compared to 7th edition. Methods: a total of 1 823 female patients with T1-2N1M0 breast cancer who underwent mastectomy and axillary lymph node dissection without neoadjuvant chemotherapy were analyzed and restaged according to 8th edition. Univariate analysis of prognostic factors was evaluated by using log-rank test. Multivariate analysis was estimated by using the Cox proportional hazards model. The prognostic accuracy of the two staging systems was compared using receiver operating characteristic (ROC) analyses and the concordance index (C-index). Results: 5-year locoregional recurrence rate (LRR) for the whole group was 6.0%, 5-year distant metastasis (DM) rate was 11.5%, 5-year disease-free survival (DFS) was 85.0%, and 5-year overall survival (OS) was 93.1%. Cox analysis showed that 7th edition of the AJCC staging system and progesterone receptor status were independent risk factors for LRR, DM, DFS and OS (P<0.05). Compared with stage by 7th edition, 1 278(70.1%) were assigned to a different prognostic stage group: 1 088 (85.1%) to a lower stage and 190 (14.9%) to a higher stage. LRR, DM, DFS and OS were significantly different between prognostic stage ⅠA, ⅠB, ⅡA, ⅡB and ⅢA according to 8th edition of the AJCC staging system(P<0.001). Prognostic stage had significantly higher C-indexes and provided better estimation of prognosis compared to stage by 7th edition of the AJCC staging system (P<0.001). Conclusion: The prognostic stage groups of 8th edition AJCC staging system has superior prognostic accuracy compared to 7th edition in T1-2N1M0 breast cancer, and has better clinical therapeutic guidance value.