Retinal vascular density as a potential biomarker of diabetic cerebral small vessel disease

AIM

The retina and brain share similar anatomical and physiological features. Thus, retinal imaging by optical coherence tomography angiography (OCTA) might be a potential tool for the early diagnosis of diabetic cerebral small vessel disease (CSVD). In this study, we aimed to evaluate retinal vascular density (VD) in diabetic CSVD by OCTA imaging and explore the associations between retinal VD and cerebral magnetic resonance imaging (MRI) markers and cognitive function.

METHODS

In total, 131 patients were enrolled, including CSVD (n = 43) and non-CSVD groups (n = 88). The VD and foveal avascular zone of the retinal capillary plexus were measured with OCTA. A brain MRI was performed.

RESULTS

MRI imaging showed that in the diabetic CSVD group, white matter hyperintensities (WMHs), particularly deep WMHs (58.82%), are the most common MRI marker, followed by cerebral microbleeds in the subtentorial and cortical areas (34.78%). The CSVD group showed increases in the prevalence of cognitive dysfunction (p = .034) and depression (p = .033) and decreases in visuospatial/executive ability and delayed recall ability. In the CSVD group, VDs of the macular superficial vascular plexus (32.93 ± 7.15% vs. 36.97 ± 6.59%, p = .002), intermediate capillary plexus (20.87 ± 4.30% vs. 23.08 ± 4.30%, p = .005) and deep capillary plexus (23.54 ± 5.00% vs. 26.05 ± 4.20%, p = .003) were lower than those of the non-CSVD group. Multiple linear regression analysis showed that VD of the macular superficial vascular plexus was independently associated with cerebral microbleeds. Meanwhile, VD of the macular intermediate capillary plexus was associated with white matter lacunar infarcts after adjustment.

CONCLUSIONS

Diabetic CSVDs are characterized by MRI markers, including deep WMHs and cerebral microbleeds, and showed impaired cognition with decreased visuospatial/executive ability and delayed recall ability. OCTA imaging revealed a significant decrease in retinal microvascular perfusion in diabetic CSVD, which was related to MRI markers and cognitive function. OCTA might be a valuable potential measurement for the early diagnosis of CSVD.

The value of CT-based radiomics in predicting hemorrhagic transformation in acute ischemic stroke patients without recanalization therapy

Objective

The aim of this study is to investigate the clinical value of radiomics based on non-enhanced head CT in the prediction of hemorrhage transformation in acute ischemic stroke (AIS).

Materials and methods

A total of 140 patients diagnosed with AIS from January 2015 to August 2022 were enrolled. Radiomic features from infarcted areas on non-enhanced CT images were extracted using ITK-SNAP. The max-relevance and min-redundancy (mRMR) and the least absolute shrinkage and selection operator (LASSO) were used to select features. The radiomics signature was then constructed by multiple logistic regressions. The clinicoradiomics nomogram was constructed by combining radiomics signature and clinical characteristics. All predictive models were constructed in the training group, and these were verified in the validation group. All models were evaluated with the receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

Results

Of the 140 patients, 59 experienced hemorrhagic transformation, while 81 remained stable. The radiomics signature was constructed by 10 radiomics features. The clinicoradiomics nomogram was constructed by combining radiomics signature and atrial fibrillation. The area under the ROC curve (AUCs) of the clinical model, radiomics signature, and clinicoradiomics nomogram for predicting hemorrhagic transformation in the training group were 0.64, 0.86, and 0.86, respectively. The AUCs of the clinical model, radiomics signature, and clinicoradiomics nomogram for predicting hemorrhagic transformation in the validation group were 0.63, 0.90, and 0.90, respectively. The DCA curves showed that the radiomics signature performed well as well as the clinicoradiomics nomogram. The DCA curve showed that the clinical application value of the radiomics signature is similar to that of the clinicoradiomics nomogram.

Conclusion

The radiomics signature, constructed without incorporating clinical characteristics, can independently and effectively predict hemorrhagic transformation in AIS patients.

Metabolomics Profiling Predicts Ventricular Arrhythmia in Patients with an Implantable Cardioverter Defibrillator

Implantable cardioverter defibrillators (ICDs) reduce sudden cardiac death (SCD) when patients experience life-threatening ventricular arrhythmias (LTVA). However, current strategies determining ICD patient selection and risk stratification are inefficient. We used metabolomics to assess whether dysregulated metabolites are associated with LTVA and identify potential biomarkers. Baseline plasma samples were collected from 72 patients receiving ICDs. Over a median follow-up of 524.0 days (range 239.0-705.5), LTVA occurred in 23 (31.9%) patients (22 effective ICD treatments and 1 SCD). After confounding risk factors adjustment for age, smoking, secondary prevention, and creatine kinase MB, 23 metabolites were significantly associated with LTVA. Pathway analysis revealed LTVA associations with disrupted metabolism of glycine, serine, threonine, and branched chain amino acids. Pathway enrichment analysis identified a panel of 6 metabolites that potentially predicted LTVA, with an area under the receiver operating characteristic curve of 0.8. Future studies are necessary on biological mechanisms and potential clinical use.

Research on automatic recognition radiomics algorithm for early sacroiliac arthritis based on sacroiliac MRI imaging

OBJECTIVE

To create an automated machine learning model using sacroiliac joint MRI imaging for early sacroiliac arthritis detection, aiming to enhance diagnostic accuracy.

METHODS

We conducted a retrospective analysis involving 71 patients with early sacroiliac arthritis and 85 patients with normal sacroiliac joint MRI scans. Transverse T1WI and T2WI sequences were collected and subjected to radiomics analysis by two physicians. Patients were randomly divided into training and test groups at a 7:3 ratio. Initially, we extracted the region of interest on the sacroiliac joint surface using ITK-SNAP 3.6.0 software and extracted radiomic features. We retained features with an Intraclass Correlation Coefficient > 0.80, followed by filtering using max-relevance and min-redundancy (mRMR) and LASSO algorithms to establish an automatic identification model for sacroiliac joint surface injury. Receiver operating characteristic (ROC) curves were plotted, and the area under the ROC curve (AUC) was calculated. Model performance was assessed by accuracy, sensitivity, and specificity.

RESULTS

We evaluated model performance, achieving an AUC of 0.943 for the SVM-T1WI training group, with accuracy, sensitivity, and specificity values of 0.878, 0.836, and 0.943, respectively. The SVM-T1WI test group exhibited an AUC of 0.875, with corresponding accuracy, sensitivity, and specificity values of 0.909, 0.929, and 0.875, respectively. For the SVM-T2WI training group, the AUC was 0.975, with accuracy, sensitivity, and specificity values of 0.933, 0.889, and 0.750. The SVM-T2WI test group produced an AUC of 0.902, with accuracy, sensitivity, and specificity values of 0.864, 0.889, and 0.800. In the SVM-bimodal training group, we achieved an AUC of 0.974, with accuracy, sensitivity, and specificity values of 0.921, 0.889, and 0.971, respectively. The SVM-bimodal test group exhibited an AUC of 0.964, with accuracy, sensitivity, and specificity values of 0.955, 1.000, and 0.875, respectively.

CONCLUSION

The radiomics-based detection model demonstrates excellent automatic identification performance for early sacroiliitis.

Effect of short-term cardiac function changes after cardiac resynchronization therapy on long-term prognosis in heart failure patients with and without diabetes

Background

The relationship between short-term cardiac function changes and long-term outcomes in heart failure (HF) patients undergoing cardiac resynchronization therapy (CRT) remains uncertain, especially when stratified by diabetes status.

Objectives

This study aims to assess the association between short-term cardiac function changes and outcomes such as all-cause mortality and HF hospitalization in patients undergoing CRT, stratified by diabetes status.

Design

This is a cohort longitudinal retrospective study.

Methods

A total of 666 HF patients, treated with CRT between March 2007 and March 2019, were included in this study. Among them, 166 patients (24.9%) were diagnosed with diabetes. Cardiac function was assessed at baseline and again at 6 months, incorporating evaluations of left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), left atrial diameter (LAD), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and QRS duration. The QRS duration represents the time required for a stimulus to spread through the ventricles (ventricular depolarization). The primary endpoints of the study were all-cause mortality and HF-related hospitalization.

Results

During a median follow-up of 2.51 years, 172 (25.8%) patients died and 197 (29.6%) were hospitalized for HF. Changes in LVEF, LVEDD, and LAD within 6 months had similar effects on adverse outcomes in both diabetic and nondiabetic patients. However, the presence of diabetes significantly modified the association between changes in NT-proBNP and QRS duration and adverse outcomes. Short-term changes in NT-proBNP and QRS duration were positively associated with all-cause mortality and HF hospitalization in patients without diabetes. However, the relationship between short-term changes in NT-proBNP and QRS duration and adverse outcomes was non-linear in diabetic patients.

Conclusion

Improvement of cardiac function after CRT implantation can reduce long-term risk of all-cause mortality and HF hospitalization in HF patients. However, the presence of diabetes may affect the association between short-term changes in NT-proBNP and QRS duration and adverse outcomes.

[Clinical, endoscopic, and pathological analyses of 14 cases of gastric adenocarcinoma of the fundic gland type]

Objective: Gastric adenocarcinoma of the fundic gland type (GA-FG) is rare and often occurs in patients who are not infected with Helicobacter pylori. The current study analyzed and summarized the clinical, endoscopic, and pathological features of GA-FG, in an effort to improve its diagnosis. Methods: Patients who were diagnosed with GA-FG and treated with endoscopic submucosal dissection (ESD) resection at the Department of Gastroenterology, First Affiliated Hospital of Zhejiang Chinese Medical University from January 1st 2020 to October 1st 2022 were included in the study. Their clinical manifestations, endoscopic features, pathological immunohistochemistry, and other characteristics were analyzed. Results: A total of 14 patients with GA-FG were included in the study, 5 males and 9 females, with a mean age of 59 years. Most had no substantial clinical manifestations. Twelve patients were H. pylori-negative, all patients underwent ESD resection, and all patients survived during the follow-up period of 13±9 months. Eleven patients had postoperative endoscopic follow-up records, and no recurrence was detected. Fifteen lesions were detected (2 were present in 1 patient). Twelve were located in the upper 1/3 of the stomach, 10 were ≤ 1 cm in diameter, 12 had a morphology of type 0-Ⅱa, 8 had visible discoloration changes, and 12 had visible vasodilation on the surface. Magnified endoscopy and narrow-band imaging indicated that 12 of the lesions had enlarged marginal crypt epithelium, without any obvious microvascular pattern abnormalities and no obvious borderline. After resection the pathological specimens were all without vascular infiltration, and there was no atrophy of the mucosa at the edge of the lesion. In immunohistochemistry analyses MUC-2 was negative in all cases. MUC5AC was negative in 11 cases, MUC-6 was positive in all cases, and Ki-67 was ≤ 5% in 12 cases. Conclusions: GA-FG is a newly identified type of gastric cancer with low malignancy and a good prognosis. Characteristic discoloration and surface dilated vessels are often evident endoscopically. Enlarged marginal crypt epithelium and no visible boundary lines are often apparent in magnification endoscopy and narrow band imaging.

Joint association of sedentary behavior and vitamin D status with mortality among cancer survivors

BACKGROUND

Sedentary behavior and vitamin D deficiency are independent risk factors for mortality in cancer survivors, but their joint association with mortality has not been investigated.

METHODS

We analyzed data from 2914 cancer survivors who participated in the National Health and Nutrition Examination Survey (2007-2018) and followed up with them until December 31, 2019. Sedentary behavior was assessed by self-reported daily hours of sitting, and vitamin D status was measured by serum total 25-hydroxyvitamin D (25(OH)D) levels.

RESULTS

Among 2914 cancer survivors, vitamin D deficiency was more prevalent in those with prolonged daily sitting time. During up to 13.2 years (median, 5.6 years) of follow-up, there were 676 deaths (cancer, 226; cardiovascular disease, 142; other causes, 308). The prolonged sitting time was associated with a higher risk of all-cause and noncancer mortality, and vitamin D deficiency was associated with a higher risk of all-cause and cancer mortality. Furthermore, cancer survivors with both prolonged sitting time (≥ 6 h/day) and vitamin D deficiency had a significantly higher risk of all-cause (HR, 2.05; 95% CI: 1.54-2.72), cancer (HR, 2.33; 95% CI, 1.47-3.70), and noncancer mortality (HR, 1.91; 95% CI, 1.33-2.74) than those with neither risk factor after adjustment for potential confounders.

CONCLUSIONS

In a nationally representative sample of U.S. cancer survivors, the joint presence of sedentary behavior and vitamin D deficiency was significantly associated with an increased risk of all-cause and cancer-specific mortality.

The effect of background elements of pictures on the visual attention among ASD children with intellectual disabilities, children with intellectual disabilities and typical development: Evidence from eye-tracking and fMRI

Traditional picture books for children come with colourful images and a multitude of elements to attract attention and increase the reading interest of typical-developing (TD) children. However, children with Autism Spectrum Disorder (ASD) are less capable of filtering out unimportant elements in pictures and focusing on social items (e.g., human faces). This study proposed that the removal of background and less important elements in the pictures of children's storybooks could facilitate better attention and enhance children with ASD's focus on the main object and thus the intended meaning of the storybook. We adopted pictures from a well-known children's book and modified them by removing the inessential background elements. Then, ASD children with intellectual disabilities (ASD+ID) (n = 40), children with ID (n = 38) and TD (n = 40) were asked to view the original and modified pictures in an eye-tracking experiment, respectively. Additionally, brain activation of ASD+ID participants (n = 10) was recorded as they were viewing those pictures in an fMRI scan. Eye-tracking found that ASD+ID children viewed the modified pictures with significantly longer average fixations, fewer fixations, fewer saccades, and higher fixation/saccade duration ratio. Contrary to the original pictures, no significant differences were found among ASD+ID, ID only and TD. Especially, ASD+ID group showed highly similar visual patterns to the TD participants when viewing the modified pictures and particularly focusing on the main character in the pictures. Additional fMRI evidence on ASD+ID group also revealed that modified pictures were associated with enhanced activation in bilateral fusiform gyri as compared to those from original pictures, which might suggest increased visual attention. Theoretical and practical implications were discussed in light of our findings.

First Dark Matter Search with Nuclear Recoils from the XENONnT Experiment

We report on the first search for nuclear recoils from dark matter in the form of weakly interacting massive particles (WIMPs) with the XENONnT experiment, which is based on a two-phase time projection chamber with a sensitive liquid xenon mass of 5.9 ton. During the (1.09±0.03)  ton yr exposure used for this search, the intrinsic ^{85}Kr and ^{222}Rn concentrations in the liquid target are reduced to unprecedentedly low levels, giving an electronic recoil background rate of (15.8±1.3)  events/ton yr keV in the region of interest. A blind analysis of nuclear recoil events with energies between 3.3 and 60.5 keV finds no significant excess. This leads to a minimum upper limit on the spin-independent WIMP-nucleon cross section of 2.58×10^{-47}  cm^{2} for a WIMP mass of 28  GeV/c^{2} at 90% confidence level. Limits for spin-dependent interactions are also provided. Both the limit and the sensitivity for the full range of WIMP masses analyzed here improve on previous results obtained with the XENON1T experiment for the same exposure.

Searching for Heavy Dark Matter near the Planck Mass with XENON1T

Multiple viable theoretical models predict heavy dark matter particles with a mass close to the Planck mass, a range relatively unexplored by current experimental measurements. We use 219.4 days of data collected with the XENON1T experiment to conduct a blind search for signals from multiply interacting massive particles (MIMPs). Their unique track signature allows a targeted analysis with only 0.05 expected background events from muons. Following unblinding, we observe no signal candidate events. This Letter places strong constraints on spin-independent interactions of dark matter particles with a mass between 1×10^{12} and 2×10^{17}  GeV/c^{2}. In addition, we present the first exclusion limits on spin-dependent MIMP-neutron and MIMP-proton cross sections for dark matter particles with masses close to the Planck scale.

Sex differences in the nonlinear association of triglyceride glucose index with all-cause and cardiovascular mortality in the general population

BACKGROUND

The evidence on the association between the triglyceride glucose (TyG) index and the risk of death in the general population remains controversial. This study aims to investigate the relationship between the TyG index and all-cause and cardiovascular mortality in the general population, with a focus on sex differences.

METHODS

This prospective cohort study analyzed data from the National Health and Nutrition Examination Survey (1999-2002), comprising 7,851 US adults. The study employed multivariate Cox proportional hazards regression and two-segment Cox hazard regression models to evaluate the sex-specific differences in the relationship between the TyG index and all-cause and cardiovascular mortality.

RESULTS

After 11,623 person-years of follow-up, there were 539 deaths, with 10.56% due to all-cause mortality and 2.87% due to cardiovascular mortality. After adjusting for multiple variables, our study found a U-shaped association of the TyG index with all-cause and cardiovascular mortality, with inflection points at 9.36 and 9.52. A significant sex difference was observed in the association between the TyG index and mortality. Below the inflection point, the relationship between the TyG index and mortality was consistent in males and females. However, above the inflection point, only males exhibited a positive association between the TyG index and all-cause mortality (adjusted hazard risk [HR], 1.62, 95% confidence interval [CI], 1.24-2.12) and cardiovascular mortality (adjusted HR, 2.28, 95% CI, 1.32-3.92).

CONCLUSIONS

Our study showed a U-shaped association between the TyG index and all-cause and cardiovascular mortality in the general population. Furthermore, sex differences were observed in the association between the TyG index and mortality once it exceeded a certain threshold.

[Efficacy of video-assisted thoracoscopic surgical decortication for stage Ⅲ tuberculous empyema]

Objective: To investigate the clinical efficacy, safety and feasibility of "double-portal" video-assisted thoracoscopic surgical(VATS) decortication among patients with stage Ⅲ tuberculous empyema, and then to evaluate the recovery of chest deformity. Method: This study was a single center retrospective study. A total of 49 patients with stage Ⅲ tuberculous empyema who underwent VATS pleural decortication at the Department of Thoracic Surgery, Public Health Clinical Center of Chengdu between June 2017 and April 2021 were enrolled, including 38 males, and 11 females, aged 13-60 (27.5±10.4) years. The safety and feasibility of VATS were further evaluated. The inner circumference of the chest on sternal and xiphoid planes on chest CT scans before and 1, 3, 6, 12months after decortication were collected through the measuring software of the CT. The samples in-pair test was used to compare the changes in the chest to reflect the recovery of the chest deformity. Results: In the 49 patients, The surgical time was (186±61) min, and the volume of blood loss was (366±267) ml. There were 8 cases (16.33%) with postoperative complications during the perioperative period. Constant air leak and pneumonia were the main postoperative complications. No relapse of empyema or dissemination of tuberculosis occured during the period of follow-up. Before surgery, the inner thoracic circumference of the thorax at the level of the carina plane was (655±54) mm, and the inner thoracic circumference of the thorax at the level of the xiphoid plane was (720±69) mm. Patients were followed for 12-36 months. The inner thoracic circumference of the thoracic cavity at the level of carina was (666±51), (667±47) and (671±47) mm at the 3rd, 6th and 12th months after operation, which were significantly larger than that at the level of carina before operation (all P<0.05). The inner thoracic circumference diameter of the thoracic cavity measured at the xiphoid level at the 3rd, 6th and 12th months after the operation was (730±65), (733±63) and (735±63) mm respectively(all P<0.05).The inner thoracic circumference of the thoracic cavity increased significantly than that before surgery (P<0.05). At 6 months after operation, there was significant difference in the improvement of the inner thoracic circumference of the carina plane in patients with age less than 20 years and FEV₁% less than 80% (P=0.015, P=0.003). The improvement in the inner thoracic circumference of the carina plane in patients with pleural thickening≥8 mm compared with those with less than 8 mm was not statistically different(P=0.070). Conclusions: For some patients with stage Ⅲ tuberculous empyema, pleural decortication under thoracoscopy is safe and feasible, and can significantly restore the inner thoracic circumference of the patient's chest, improve the collapse of the patient's chest, and have significant clinical effect. The "double-portal VATS" surgical technology has the advantage of less trauma, wide operation field, large operation space and is easy to master, which is worth further exploring for clinical application.

[Study of incubation period of infection with 2019-nCoV Omicron variant BA.5.1.3]

Objective: To study the incubation period of the infection with 2019-nCoV Omicron variant BA.5.1.3. Methods: Based on the epidemiological survey data of 315 COVID-19 cases and the characteristics of interval censored data structure, log-normal distribution and Gamma distribution were used to estimate the incubation. Bayes estimation was performed for the parameters of each distribution function using discrete time Markov chain Monte Carlo algorithm. Results: The mean age of the 315 COVID-19 cases was (42.01±16.54) years, and men accounted for 30.16%. A total of 156 cases with mean age of (41.65±16.32) years reported the times when symptoms occurred. The log-normal distribution and Gamma distribution indicated that the M (Q₁, Q₃) of the incubation period from exposure to symptom onset was 2.53 (1.86, 3.44) days and 2.64 (1.91, 3.52) days, respectively, and the M (Q₁, Q₃) of the incubation period from exposure to the first positive nucleic acid detection was 2.45 (1.76, 3.40) days and 2.57 (1.81, 3.52) days, respectively. Conclusions: The incubation period by Bayes estimation based on log-normal distribution and Gamma distribution, respectively, was similar to each other, and the best distribution of incubation period was Gamma distribution, the difference between the incubation period from exposure to the first positive nucleic acid detection and the incubation period from exposure to symptom onset was small. The median of incubation period of infection caused by Omicron variant BA.5.1.3 was shorter than those of previous Omicron variants.

Clinical outcome of lesion size index-guided high-power radiofrequency catheter ablation for pulmonary vein isolation in patients with atrial fibrillation: 2-year follow-up

INTRODUCTION

The long-term efficacy of high-power (50 W) ablation guided by lesion size index (LSI-guided HP) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) remains undetermined. Our study sought to assess the clinical efficacy of LSI-guided HP ablation for PVI in patients with AF and explore the potential predictors associated with clinical outcomes.

METHODS

We consecutively included 186 patients with AF who underwent LSI-guided HP (50 W) ablation at Fuwai Hospital from June 2019 to October 2021. The target LSI values of 4.5-5.5 and 4.0-4.5 at the anterior and posterior walls, respectively, were used in our study. The baseline clinical characteristics, procedural and ablation data, and clinical outcomes were evaluated. The independent potential predictors associated with AF recurrence were further evaluated.

RESULTS

The incidence rate of first-pass PVI was 83.9% (156/186). A total of 11 883 lesions were analyzed, and compared with posterior walls of pulmonary veins, anterior walls had significantly lower mean contact force (8.2 ± 3.0 vs. 8.3 ± 2.3 g, p = .015), longer mean radiofrequency duration (16.9 ± 7.2 vs. 12.9 ± 4.5 s, p < .001) and higher mean LSI (4.8 ± 0.2 vs. 4.4 ± 0.2, p < .001). The overall incidence of periprocedural complications was 3.7%, and steam pops without pericardial effusion occurred in three patients (1.6%). During a mean follow-up of 24.0 ± 8.4 months, the overall AF recurrence-free survival was 87.1% after a single procedure. Patients with paroxysmal AF had a higher incidence of freedom from AF recurrence than those with persistent AF (91.2% vs. 80.8%, log-rank p = .034). Higher LSI (HR 0.50, p < .001) and paroxysmal AF (HR 0.39, p = .029) were significantly associated with decreased AF recurrence. By receiver operating characteristic analysis, the LSI of 4.7 and 4.3 for the anterior and posterior walls of the PVs had the highest predictive value for AF recurrence, respectively.

CONCLUSION

LSI-guided HP (50 W) ablation for PVI was an efficient and safe strategy and led to favorable single-procedure 2-year AF recurrence-free survival in patients with AF. Higher LSI and paroxysmal AF were independent predictors of decreased 2-year AF recurrence. The LSI of 4.7 for the anterior wall and 4.3 for the posterior wall of the PVs were the best cutoff values for predicting AF recurrence after LSI-guided HP ablation.

Valgus-varus deformity induced abnormal tissue metabolism, inflammatory damage and apoptosis in broilers

1. This study explored the tissue metabolic status and the relationship with inflammation in valgus-valgus deformity (VVD) broilers with increasing age.2. Tissue and blood from VVD and healthy broilers were collected at two, four and five weeks old. A fully automated biochemical analyser, real-time PCR, HE staining and enzyme-linked immunosorbent assay were used to detect tissue metabolic indexes, mRNA levels of inflammation and apoptosis cytokines in immune organs, histological changes and serum inflammation and immune-related protein contents in VVD broilers.3. The results showed that VVD increased the levels of total protein, albumin, alanine aminotransferase at five weeks of age, aspartate aminotransferase, urea and creatine kinase in blood at two weeks of age. It upregulated the gene expression of inflammatory factors IL-1β, IL-6, IL-8, TNF-α, NF-κB and TGF-β and apoptotic factors FAS, Bcl-2, caspase-3 and 9 in immune organs; increased levels of serum proteins TNF-α, IL-1β and IL-6 and decreased levels of serum immunoglobulins IgY and CD3⁺.4. In addition, with increasing age, IL-10 gene expression gradually increased in the BF and decreased in the spleen.5. In conclusion, VVD broilers have disorders of liver and kidney metabolism, inflammation and apoptosis of immune organs and increased levels of serum inflammatory factor proteins.

Prognostic Value of Four Preimplantation Malnutrition Estimation Tools in Predicting Heart Failure Hospitalization of the Older Diabetic Patients with Right Ventricular Pacing

OBJECTIVES

The prognostic value of preimplantation nutritional status is not yet known for older diabetic patients that received right ventricular pacing (RVP). The study aimed to investigate the clinical value of the four malnutrition screening tools for the prediction of heart failure hospitalization (HFH) in older diabetic patients that received RVP.

DESIGN

Retrospective observational cohort study.

SETTING AND PARTICIPANTS

This study was conducted between January 2017 and January 2018 at the Fuwai Hospital, Beijing, China, and included older (age ≥ 65 years) diabetic patients that received RVP for the first time Measurements: The Prognostic Nutritional Index (PNI), Geriatric Nutritional Risk Index (GNRI), Naples Prognostic Score (NPS), and the Controlling Nutritional Status (CONUT) score were used to estimate the preimplantation nutritional status of the patients. Univariate and multivariate Cox proportional hazard regression analyses were performed to investigate the association between preimplantation malnutrition and HFH.

RESULTS

Overall, 231 older diabetic patients receiving RVP were included. The median follow-up period after RVP was 53 months. HFH was reported for 19.9% of the included patients. Our results showed preimplantation malnutrition for 18.2%, 15.2%, 86.6% and 66.2% of the included patients based on the PNI, GNRI, NPS, and CONUT score, respectively. The cumulative rate of HFH during follow-up period was significantly higher for patients in the preimplantation malnutrition group based on the PNI (log-rank = 13.0, P = 0.001), GNRI (log-rank = 8.5, P = 0.01), and NPS (log-rank = 15.7, P < 0.001) compared to the normal nutrition group, but was not statistically significant for those in the preimplantation malnutrition group based on the CONUT score (log-rank = 2.7, P = 0.3). As continuous variables, all the nutritional indices showed significant correlation with HFH (all P < 0.05). However, multivariate analysis showed that only GNRI was independently associated with HFH (HR = 0.97, 95% CI: 0.937-0.997, P = 0.032). As categorical variables, PNI, GNRI, and NPS showed significant correlation with HFH. After adjustment of confounding factors, moderate-to-severe degree of malnutrition was an independent predictor of HFH based on the PNI (HR = 4.66, 95% CI: 1.03-21.00, P = 0.045) and GNRI (HR = 3.02, 95% CI: 1.02-9.00, P = 0.047).

CONCLUSION

Preimplantation malnutrition was highly prevalent in older diabetic patients that received RVP. The malnutrition prediction tools, PNI and GNRI, showed significant prognostic value in accurately predicting HFH in older diabetic patients with RVP.

The health system and health impacts of primary healthcare reform in China: A systematic review

Background

China has undergone a comprehensive primary healthcare(PHC) reform since 2009 aiming to deliver accessible, higher-quality, and equitable healthcare. However, there is limited understanding of the effectiveness of this reform. This systematic review synthesizes evidence on health system and health impacts of this reform.

Methods

We searched 13 international databases and three Chinese databases for quantitative studies assessing the impacts of this reform published between January 2009 and March 2020. We searched for studies in English or Mandarin. Eligible study designs were RCTs, quasi-experimental studies and controlled before-after studies. We included studies that: assessed PHC policies since 2009; had geographical, temporal or population comparators; and assessed any outcome measures of health expenditures, health service utilisation, quality of care or health outcomes. Study quality was assessed using ROBINS-I, and results synthesized narratively. PROSPERO: CRD42021239991.

Results

Of 35,480 titles, 37 studies were included (27 in English and ten in Mandarin). Eight were considered at low risk of bias. The 37 studies covered all major PHC policies since 2009, but mostly focused on the essential medicine (N = 15) and financing (N = 10). The quantity and quality of studies on service delivery policies(e.g., family physician and essential health services), were low(N = 3,with moderate or serious risk of bias). 17 studies found that the PHC reforms promoted primary care utilisation. Its impacts on quality and health improvement appear limited to people with chronic diseases(N = 11). Evidence on primary care costs and OOPs were not clear. Some evidence showed that the reforms were pro-equity with benefits accrued in disadvantaged regions and groups.

Conclusions

Comprehensive PHC reforms can deliver some benefits related to utilisation and health for high-risk and vulnerable populations. Policymakers should continue to prioritize PHC to achieve Universal Health Coverage.

Key messages

• The finding suggests that large-scale and comprehensive primary healthcare reforms can deliver benefits related to utilisation and health for high-risk and vulnerable populations.

• Future research should include more robust study designs and seek to better understand the impact of major PHC reforms on quality of care, health outcomes and equity.

Combined association of triglyceride-glucose index and systolic blood pressure with all-cause and cardiovascular mortality among the general population

Background

The combined association of triglyceride-glucose (TyG) index and different systolic blood pressure (SBP) levels with all-cause and cardiovascular mortality among the general population remains unclear.

Methods

In this study, 6245 individuals were from the National Health and Nutrition Examination Survey (1999–2002). The study endpoints were all-cause and cardiovascular mortality. Multivariate Cox proportional hazards regression models were used to explore the combined association of TyG index and different SBP levels with all-cause and cardiovascular mortality.

Results

During a mean follow-up period of 66.8 months, a total of 284 all-cause deaths (331/100000 person-years) and 61 cardiovascular deaths (66/100000 person-years) were recorded. Multivariate Cox regression analysis revealed that the combination of low TyG index and low SBP (< 120 mmHg and < 130 mmHg) was associated with a reduced risk of all-cause and cardiovascular mortality than others. However, survival benefit was not observed in the combined group with the low TyG index and SBP < 140 mmHg. Furthermore, the mortality rate in the combined group of low TyG index and low SBP gradually increased with the elevation of SBP level.

Conclusion

The combination of low TyG index and low SBP (< 120 mmHg and < 130 mmHg) was associated with a lower risk of all-cause and cardiovascular mortality. However, no survival benefit was observed in the combined group of low TyG index and SBP < 140 mmHg.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12967-022-03678-z.

Search for New Physics in Electronic Recoil Data from XENONnT

We report on a blinded analysis of low-energy electronic recoil data from the first science run of the XENONnT dark matter experiment. Novel subsystems and the increased 5.9 ton liquid xenon target reduced the background in the (1, 30) keV search region to (15.8±1.3)  events/(ton×year×keV), the lowest ever achieved in a dark matter detector and ∼5 times lower than in XENON1T. With an exposure of 1.16 ton-years, we observe no excess above background and set stringent new limits on solar axions, an enhanced neutrino magnetic moment, and bosonic dark matter.

Toward Better Risk Stratification for Implantable Cardioverter-Defibrillator Recipients: Implications of Explainable Machine Learning Models

Background: Current guideline-based implantable cardioverter-defibrillator (ICD) implants fail to meet the demands for precision medicine. Machine learning (ML) designed for survival analysis might facilitate personalized risk stratification. We aimed to develop explainable ML models predicting mortality and the first appropriate shock and compare these to standard Cox proportional hazards (CPH) regression in ICD recipients. Methods and Results: Forty-five routine clinical variables were collected. Four fine-tuned ML approaches (elastic net Cox regression, random survival forests, survival support vector machine, and XGBoost) were applied and compared with the CPH model on the test set using Harrell’s C-index. Of 887 adult patients enrolled, 199 patients died (5.0 per 100 person-years) and 265 first appropriate shocks occurred (12.4 per 100 person-years) during the follow-up. Patients were randomly split into training (75%) and test (25%) sets. Among ML models predicting death, XGBoost achieved the highest accuracy and outperformed the CPH model (C-index: 0.794 vs. 0.760, p < 0.001). For appropriate shock, survival support vector machine showed the highest accuracy, although not statistically different from the CPH model (0.621 vs. 0.611, p = 0.243). The feature contribution of ML models assessed by SHAP values at individual and overall levels was in accordance with established knowledge. Accordingly, a bi-dimensional risk matrix integrating death and shock risk was built. This risk stratification framework further classified patients with different likelihoods of benefiting from ICD implant. Conclusions: Explainable ML models offer a promising tool to identify different risk scenarios in ICD-eligible patients and aid clinical decision making. Further evaluation is needed.

[Effects and mechanism of diammonium glycyrrhizinate on liver injury in severely scalded rats]

Objective: To investigate the effects and mechanism of diammonium glycyrrhizinate (DG) on liver injury in severely scalded rats. Methods: The experimental research method was used. Fifty-four female Sprague-Dawley rats aged 7-9 weeks were divided into sham injury group with simulated injury on the back, and simple scald group and scald+DG group with scald of 30% total body surface area on the back, with 18 rats in each group. Rats in sham injury group were not specially treated after injury, and rats in simple scald group and scald+DG group were rehydrated for antishock. Besides, rats in scald+DG group were injected intraperitoneally with 50 mg/kg DG at post injury hour (PIH) 1, 25, and 49. Rats in the three groups were collected, the serum content of liver function injury related indexes including aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH), total protein, and albumin was measured by automatic biochemical assay analyzer, and serum content of ornithine carbamoyl transferase (OCT) was measured by enzyme-linked immunosorbent assay method at PIH 24, 48, and 72; hepatic histopathological changes at PIH 72 were observed by hematoxylin-eosin staining; the mRNA expressions of B-cell lymphoma 2 (Bcl-2), Bcl-2-associated X protein (Bax), glucose regulated protein 78 (GRP78), activating transcription factor 4 (ATF4), and protein kinase R-like endoplasmic reticulum kinase (PERK) in liver tissue were detected by real-time fluorescent quantitative reverse transcription polymerase chain reaction at PIH 24, 48, and 72. The protein expressions of Bcl-2, Bax, GRP78, PERK, and ATF4 in liver tissue were detected by Western blotting at PIH 72 in sham injury group and PIH 24, 48, and 72 in simple scald group and scald+DG group. The number of samples was 6 in each group at each time point. Data were statistically analyzed with analysis of variance for factorial design, one-way analysis of variance, and Bonferroni test. Results: Compared with that in sham injury group, the serum content of AST, ALT, and LDH was significantly increased (P<0.01), and the serum content of total protein and albumin was significantly decreased (P<0.05 or P<0.01) of rats in simple scald group at all post-injury time points. Compared with those in simple scald group, the serum AST content of rats in scald+DG group at PIH 24 was decreased significantly (P<0.05); the serum AST, ALT, and LDH content of rats in scald+DG group at PIH 48 was decreased significantly (P<0.01), and the serum total protein content was increased significantly (P<0.01); the serum AST, ALT, and LDH content of rats in scald+DG group at PIH 72 was decreased significantly (P<0.01), and the serum total protein and albumin content was increased significantly (P<0.01). At PIH 24, 48, and 72, the serum OCT content of rats in simple scald group was (48.5±3.9), (40.8±2.4), and (38.7±2.0) U/L, which was significantly higher than (15.1±2.5), (15.7±2.6), and (16.4±3.7) U/L in sham injury group (P<0.01), and (39.0±4.5), (31.8±2.0), and (22.1±2.6) U/L in scald+DG group (P<0.05 or P<0.01). At PIH 72, the cells in liver tissue of rats in sham injury group had normal morphology and regular arrangement, with no obvious inflammatory cell infiltration; the cells in liver tissue of rats in simple scald group had disordered arrangement, diffuse steatosis, and moderate inflammatory cell infiltration; the cells in liver tissue of rats in scald+DG group arranged regularly, with scattered steatosis and a small amount of inflammatory cell infiltration. Compared with those in sham injury group, the Bcl-2 mRNA (P<0.05 or P<0.01) and protein expressions of liver tissue were significantly decreased, and the mRNA (P<0.01) and protein expressions of Bax were significantly increased in rats in simple scald group at PIH 24, 48, and 72. Compared with those in simple scald group, the mRNA (P<0.05) and protein expressions of Bax in liver tissue of rats in scald+DG group were decreased significantly at PIH 48; the mRNA (P<0.01) and protein expressions of Bax in liver tissue of rats in scald+DG group were significantly decreased, and the mRNA (P<0.01) and protein expressions of Bcl-2 were significantly increased at PIH 72. Compared with those in sham injury group, the mRNA (P<0.05 or P<0.01) and protein expressions of ATF4, GRP78, and PERK in liver tissue were significantly increased in rats in simple scald group at all post-injury time points. Compared with those in simple scald group, the mRNA (P<0.01) and protein expressions of ATF4 in liver tissue of rats in scald+DG group at PIH 48 were significantly decreased, and the mRNA (P<0.05 or P<0.01) and protein expressions of ATF4, GRP78, and PERK were significantly decreased in liver tissue of rats in scald+DG group at PIH 72. Conclusions: DG can effectively reduce the degree of liver injury in rats after severe scald, and the mechanism may involve alleviating endoplasmic reticulum stress and mitigating mitochondrial damage.

Bronchoscopic Treatment of Giant Emphysematous Bullae with Endobronchial Silicone Plugs

Purpose

Surgical bullectomy is the standard treatment of giant emphysematous bulla (GEB). However, bronchoscopic treatment should be considered as an alternative approach for patients who are unfit for surgical treatment. The study aimed to evaluate the clinical efficacy of endobronchial occlusion for the treatment of GEB using silicone plugs.

Methods

This retrospective study recruited four patients with GEB who were unsuitable for surgery. Preoperative planning was performed using high-resolution computed tomography and a virtual bronchoscopic navigation system. Customized silicone plugs were then placed in the target airway via bronchoscopy to cause GEB regression and atelectasis.

Results

All procedures were completed successfully in four patients. Three months after the procedures, compared with baseline, increases in the mean forced expiratory volume in 1 s (from 1.20 L/s to 1.33 L/s), forced vital capacity (from 2.63 L to 2.90 L), diffusion lung capacity for carbon monoxide (from 29% to 41% of the predicted value) and 6-minute walking test (from 412 m to 474 m) were observed. Additionally, the mean total lung capacity (from 6.80 L to 6.35 L), residual volume (from 3.97 L to 3.52 L), and St. George’s Respiratory Questionnaire scores (from 67 to 45) were all lower than baseline data.

Conclusion

Our preliminary results demonstrated that the endobronchial placement of silicone plugs could be a low-cost, safe, and effective choice for the treatment of GEB in surgically unfit patients.

Independent and joint association of N-terminal pro-B-type natriuretic peptide and left ventricular mass index with heart failure risk in elderly diabetic patients with right ventricular pacing

Background

Elevated levels of N-terminal pro-B natriuretic peptide (NT-proBNP) and left ventricular hypertrophy (LVH) are independent risk factors for heart failure (HF). In addition, right ventricular pacing (RVP) is an effective treatment strategy for bradyarrhythmia, but long-term RVP is associated with HF. However, there is limited evidence on the independent and combined association of NT-proBNP and left ventricular mass index (LVMI) with HF risk in elderly diabetic patients with long-term RVP.

Methods

Between January 2017 and January 2018, a total of 224 elderly diabetic patients with RVP at Fuwai Hospital were consecutively included in the study, with a 5-year follow-up period. The study endpoint was the first HF readmission during follow-up. This study aimed to explore the independent and joint relationship of NT-proBNP and LVMI with HF readmission in elderly diabetic patients with long-term RVP, using a multivariate Cox proportional hazards regression model.

Results

A total of 224 (11.56%) elderly diabetic patients with RVP were included in the study. During the 5-year follow-up period, a total of 46 (20.54%) patients suffered HF readmission events. Multivariate Cox proportional hazards regression analysis showed that higher levels of NT-proBNP and LVMI were independent risk factors for HF readmission [NT-proBNP: hazard risk (HR) = 1.05, 95% confidence interval (CI): 1.01–1.10; LVMI: HR = 1.14, 95% CI: 1.02–1.27]. The optimal cut-off point of NT-proBNP was determined to be 330 pg/ml by receiver operating characteristic (ROC) curve analysis. Patients with NT-proBNP &gt; 330 pg/ml and LVH had a higher risk of HF readmission compared to those with NT-proBNP ≤ 330 pg/ml and non-LVH (39.02% vs. 6.17%; HR = 7.72, 95% CI: 1.34–9.31, P &lt; 0.001).

Conclusion

In elderly diabetic patients with long-term RVP, NT-proBNP and LVMI were associated with the risk of HF readmission. Elevated NT-proBNP combined with LVH resulted in a significantly higher risk of HF readmission.

[Progress in clinical diagnosis and treatment of gallbladder cancer]

Due to the lack of effective early diagnosis and treatment, gallbladder cancer(GBC) remains a malignant tumor with extremely high malignancy and poor prognosis. Therefore, high quality studies are required to break through the bottleneck in GBC diagnosis and treatment. This article reviewed the domestic and foreign GBC research published in 2021, presenting a comprehensive summary of the important advances in the field of clinical diagnosis and treatment. Latest epidemiological data and risk factors, emerging diagnostic methods of peripheral blood laboratory tests and imaging, new pathologic classification system, hot topics and controversies of surgical treatment as well as the dynamics of systemic treatment of GBC are reviewed in the article. The present findings may contribute to a more efficient means of diagnosis and treatment for GBC and hold the promise of improved outcomes for patients with GBC.

[Survival analysis since diagnosis of HIV-positive injecting drug users aged 15 years and above in China]

Objective: To understand death's mortality and risk factors among HIV-positive injecting drug users (IDU) aged 15 or above in China and provide further reference to future prevention and treatment policies. Method: Retrospective cohort study was conducted to calculate the mortality rate of HIV-positive IDU based on HIV/AIDS Comprehensive Response Information Management System. Cox proportion hazards regression model was performed to assess the risk factors for deaths. The Excel 2019 and SPSS 22.0 software was used for data cleaning and statistical analysis. Results: Between 2001 and 2020, 119 209 HIV-positive IDU were reported with 59 094 deaths. The all-cause mortality rate was 6.96 per 100 person-years (py), and the AIDS-related mortality rate was 1.91 per 100 py, with a decreasing trend over the years. Multivariate Cox regression indicated for all-cause death risks of HIV-positive IDU, compared with those baseline T⁺ lymphocyte cells (CD4) counts above 500 cells/μl, the HR (95%CI) of those CD4 counts untested, between 0-199, 200-349, 350-500 cells/μl was 2.85 (2.78-2.93), 2.47 (2.40-2.54), 1.58 (1.53-1.62) and 1.24 (1.21-1.28) respectively. The HR (95%CI) of antiretroviral treatment (ART) naïve was 7.13 (6.99-7.27) compared with those under ART. The HR (95%CI) of methadone maintenance treatment (MMT) naïve was 1.07 (1.04-1.10) compared to those receiving MMT. As for AIDS-related death risks, compared with baseline T+ lymphocyte cell CD4 counts >500 cells/μl, the HR (95%CI) of those CD4 counts untested, between 0-199, 200-349, 350-500 cells/μl was 3.26 (3.08-3.46), 5.54 (5.24-5.85), 2.35 (2.21-2.50) and 1.41 (1.32-1.50). HR (95%CI) of ART naïve was 5.96(5.74-6.18) compared to those under ART. Conclusions: Further efforts should be made timely on diagnosis, treatment, and harm reduction programs such as MMT for improvement compliance to reduce mortality risks of HIV-positive IDU.

Optimal Lesion Size Index for Pulmonary Vein Isolation in High-Power Radiofrequency Catheter Ablation of Atrial Fibrillation

Background

Although both high-power (HP) ablation and lesion size index (LSI) are novel approaches to make effective lesions during pulmonary vein isolation (PVI) for atrial fibrillation (AF), the optimal LSI in HP ablation for PVI is still unclear. Our study sought to explore the association between LSI and acute conduction gap formation and investigate the optimal LSI in HP ablation for PVI.

Methods

A total of 105 consecutive patients with AF who underwent HP ablation guided by LSI (LSI-guided HP) for PVI in our institute between June 2019 and July 2020 were retrospectively enrolled. Each ipsilateral PV circle was subdivided into four segments, and ablation power was set to 50 W with target LSI values at 5.0 and 4.0 for anterior and posterior walls, respectively. We compared the LSI values with and without acute conduction gaps after the initial first-pass PVI.

Results

PVI was achieved in all patients, and the incidence of first-pass PVI was 78.1% (82/105). A total of 6,842 lesion sites were analyzed, and the acute conduction gaps were observed in 23 patients (21.9%) with 45 (0.7%) lesion points. The gap formation was significantly associated with lower LSI (3.9 ± 0.4 vs. 4.6 ± 0.4, p < 0.001), lower force-time integral (82.6 ± 24.6 vs. 120.9 ± 40.4 gs, p < 0.001), lower mean contact force (5.7 ± 2.4 vs. 8.5 ± 2.8 g, p < 0.001), shorter ablation duration (10.5 ± 3.6 vs. 15.4 ± 6.4 s, p < 0.001), lower mean temperature (34.4 ± 1.4 vs. 35.6 ± 2.6°C, p < 0.001), and longer interlesion distance (4.4 ± 0.3 vs. 4.3 ± 0.4 mm, p = 0.031). As per the receiver operating characteristic analysis, the LSI had the highest predictive value for gap formation in all PVs segments, with a cutoff of 4.35 for effective ablation (sensitivity 80.0%; specificity 75.4%, areas under the curve: 0.87). The LSI of 4.55 and 3.95 had the highest predictive value for gap formation for the anterior and posterior segments of PVs, respectively.

Conclusion

Using LSI-guided HP ablation for PVI, more than 4.35 of LSI for all PVs segments showed the best predictive value to avoid gap formation for achieving effective first-pass PVI. The LSI of 4.55 for the anterior wall and 3.95 for the posterior wall were the best cutoff values for predicting gap formation, respectively.

Mitral Regurgitation and Body Mass Index Increase the Predictability of Perioperative Bleeding in Anticoagulated Patients With Nonvalvular Atrial Fibrillation

Background

Catheter ablation (CA) effectively restores sinus rhythm in atrial fibrillation (AF) but causes a short-term fluctuation in the coagulation state. Potential risk factors and better management during this perioperative period remain understudied.

Methods

We consecutively included 940 patients with nonvalvular AF who received CA at Fuwai Hospital, Beijing, China. Patients were divided into two groups according to their bleeding status during 3 months' anticoagulation. Any adverse events related to bleeding in the 3 months were evaluated. The HAS-BLED score and ABC-bleeding score, as well as other potential factors, were explored to predict bleeding risk.

Results

In this observational study, 8.0% and 0.9% of the whole population suffered from bleeding and thromboembolic events, respectively. After adjusting for known factors related to bleeding, mitral regurgitation (MR, p for trend &lt;0.001) and body mass index (BMI, odds ratio (OR) = 0.920, 95% CI 0.852–0.993, p = 0.033) were the most significant ones. C-indexes of the HAS-BLED score and ABC-bleeding score for bleeding were 0.558 (0.492–0.624) and 0.585 (0.515–0.655), respectively. The incorporation of MR and BMI significantly improved the predictive value based on HAS-BLED score (C-index = 0.650, 95% CI 0.585–0.715, p = 0.004) and ABC-bleeding score (C-index = 0.671, 95% CI 0.611–0.731, p &lt; 0.001). The relative risk of mild-moderate MR was 4.500 (95% CI 1.625–12.460) in patients with AF having HAS-BLED = 1 and 4.654 (95% CI 1.496–14.475) in HAS-BLED ≥ 2, while it was not observed in patients with HAS-BLED = 0 (p = 0.722).

Conclusion

More severe MR and lower BMI are associated with a higher incidence of perioperative bleeding, which helps improve the predictability of increased individual bleeding risk of a patient with nonvalvular AF who has received CA therapy and oral anticoagulants.

N-Terminal Pro-B-Type Natriuretic Peptide in Risk Stratification of Heart Failure Patients With Implantable Cardioverter-Defibrillator

Background

The prognostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in heart failure (HF) is well-established. However, whether it could facilitate the risk stratification of HF patients with implantable cardioverter-defibrillator (ICD) is still unclear.

Objective

To determine the associations between baseline NT-proBNP and outcomes of all-cause mortality and first appropriate shock due to sustained ventricular tachycardia/ventricular fibrillation (VT/VF) in ICD recipients.

Methods and results

N-terminal pro-B-type natriuretic peptide was measured before ICD implant in 500 patients (mean age 60.2 ± 12.0 years; 415 (83.0%) men; 231 (46.2%) Non-ischemic dilated cardiomyopathy (DCM); 136 (27.2%) primary prevention). The median NT-proBNP was 854.3 pg/ml (interquartile range [IQR]: 402.0 to 1,817.8 pg/ml). We categorized NT-proBNP levels into quartiles and used a restricted cubic spline to evaluate its nonlinear association with outcomes. The incidence rates of mortality and first appropriate shock were 5.6 and 9.1%, respectively. After adjusting for confounding factors, multivariable Cox regression showed a rise in NT-proBNP was associated with an increased risk of all-cause mortality. Compared with the lowest quartile, the hazard ratios (HRs) with 95% CI across increasing quartiles were 1.77 (0.71, 4.43), 3.98 (1.71, 9.25), and 5.90 (2.43, 14.30) for NT-proBNP (p for trend &lt; 0.001). A restricted cubic spline demonstrated a similar pattern with an inflection point found at 3,231.4 pg/ml, beyond which the increase in NT-proBNP was not associated with increased mortality (p for nonlinearity &lt; 0.001). Fine-Gray regression was used to evaluate the association between NT-proBNP and first appropriate shock accounting for the competing risk of death. In the unadjusted, partial, and fully adjusted analysis, however, no significant association could be found regardless of NT-proBNP as a categorical variable or log-transformed continuous variable (all p &gt; 0.05). No nonlinearity was found, either (p = 0.666). Interactions between NT-proBNP and predefined factors were not found (all p &gt; 0.1).

Conclusion

In HF patients with ICD, the rise in NT-proBNP is independently associated with increased mortality until it reaches the inflection point. However, its association with the first appropriate shock was not found. Patients with higher NT-proBNP levels might derive less benefit from ICD implant.

Nomogram predicting death and heart transplantation before appropriate ICD shock in dilated cardiomyopathy

Aims

This study aimed to develop and validate a competing risk nomogram for predicting all‐cause mortality and heart transplantation (HT) before first appropriate shock in non‐ischaemic dilated cardiomyopathy (DCM) patients receiving implantable cardioverter‐defibrillators (ICD).

Methods and results

A total of 218 consecutive DCM patients implanted with ICD between 2010 and 2019 at our institution were retrospectively enrolled. Cox proportional hazards model was primarily built to identify variables associated with death and HT. Then, a Fine–Gray model, accounting for the appropriate shock as a competing risk, was constructed using these selected variables along with implantation indication (primary vs. secondary). Finally, a nomogram based on the Fine–Gray model was established to predict 1‐, 3‐, and 5‐year probabilities of all‐cause mortality and HT before first appropriate shock. The area under the receiver operating characteristic (ROC) curve (AUC), Harrell's C‐index, and calibration curves were used to evaluate and internally validate the performance of this model. The decision curve analysis was applied to assess its clinical utility. The 1‐, 3‐, and 5‐year cumulative incidence of all‐cause mortality and HT without former appropriate shock were 5.3% [95% confidence interval (CI) 2.9–9.9%], 16.6% (95% CI 11–25.0%), and 25.3% (95% CI 17.2–37.1%), respectively. Five variables including implantation indication, left ventricular end‐diastolic diameter, N‐terminal pro‐brain natriuretic peptide, angiotensin‐converting enzyme inhibitor/angiotensin receptor blocker, and amiodarone treatment were independently associated with it (all P < 0.05) and were used for constructing the nomogram. The 1‐, 3‐, and 5‐year AUC of the nomogram were 0.83 (95% CI 0.73–0.94, P < 0.001), 0.84 (95% CI 0.75–0.93, P < 0.001), and 0.85 (95% CI 0.77–0.94, P < 0.001), respectively. The Harrell's C‐index was 0.788 (95% CI 0.697–0.877, P < 0.001; 0.762 for the optimism‐corrected C‐index), showing the good discriminative ability of the model. The calibration was acceptable (optimism‐corrected slope 0.896). Decision curve analysis identified our model was clinically useful within the entire range of potential treatment thresholds for ICD implantation. Three risk groups stratified by scores were significantly different between cumulative incidence curves (P < 0.001). The identified high‐risk group composed 17.9% of our population and did not derive long‐term benefit from ICD.

Conclusions

The proposed nomogram is a simple, useful risk stratification tool for selecting potential ICD recipients in DCM patients. It might facilitate the shared decision‐making between patients and clinicians.

[Epidemiological characteristics of newly reported HIV-infected adolescents aged 15-17 years outside school in China, 2011-2019]

Objective: To understand the epidemiological characteristics of HIV-infected adolescents outside school in China and provide reference to targeted prevention and control of HIV infection in this population. Methods: All the HIV-infected adolescents aged 15-17 years outside school reported during 2011-2019 were included this study. The information about their demographics, transmission routes and migration were collected from HIV/AIDS Comprehensive Response Information Management System. The χ² test was done for comparison among groups. The Joinpoint 4.9.0 software was applied to the annual percent change (APC) for time trends analysis using the Joinpoint regression model. The Excel 2019 and SPSS 22.0 software were used for data cleaning and statistical analysis. Results: A total of 4 919 HIV-infected adolescents aged 15-17 years outside school were reported accumulatively in China between 2011 and 2019, accounting for 63.4% (4 919/7 757) of total reported HIV-infected cases in this age group. Analysis on trend revealed that the new HIV infection diagnosis rate has become stable since 2016 (APC=2.5%, P=0.173) after the increase between 2011 and 2015 (APC=36.4%, P<0.001). The migration across provinces was discovered in 13.9% (684/4 919) of the HIV-infected adolescents outside school. Males, workers, and those diagnosed in detention centers or transmitted by injecting drugs or homosexual contacts accounted for a larger proportion in migrated cases compared with non-migrated cases. The adolescents outside school mainly got HIV infected by sexual contacts route, in which 66.5% (280/421) of the males were infected by homosexual contacts, while 97.8% (182/186) of the females were infected by heterosexual contacts in 2019. Conclusions: HIV-infected adolescents aged 15-17 years outside school were mainly infected by sexual contacts. However, adolescents outside school have low awareness of sexual health and high mobility, to whom close attention should be paid to improve their awareness of sexual health and to provide them with appropriate HIV infection prevention and treatment service.

A Comparison of the Electrophysiological and Anatomic Characteristics of Pacing Different Branches of the Left Bundle Conduction System

Introduction: Left bundle branch pacing (LBBP) is a rapidly growing conduction system pacing technique. However, little is known regarding the electrophysiological characteristics of different types of LBBP. We aimed to evaluate the electrophysiological characteristics and anatomic lead location with pacing different branches of the left bundle branch.

Methods: Consecutive bradycardia patients with successful LBBP were enrolled and classified into groups according to the paced electrocardiogram and the lead location. Electrocardiogram, pacing properties, vectorcardiogram, and lead tip location were analyzed.

Results: Ninety-one patients were enrolled, including 48 with the left bundle trunk pacing (LBTP) and 43 with the left bundle fascicular pacing (LBFP). The paced QRS duration in the LBTP group was significantly shorter than that in the LBFP group (108.1 ± 9.9 vs. 112.9 ± 11.2 ms, p = 0.03), with a more rightward QRS transition zone (p = 0.01). The paced QRS area in the LBTP group was similar to that during intrinsic rhythm (35.1 ± 15.8 vs. 34.7 ± 16.6 μVs, p = 0.98), whereas in the LBFP group, the paced QRS area was significantly larger compared to intrinsic rhythm (43.4 ± 15.8 vs. 35.7 ± 18.0 μVs, p = 0.01). The lead tip site for LBTP was located in a small fan-shaped area with the tricuspid valve annulus summit as the origin, whereas fascicular pacing sites were more likely in a larger and more distal area.

Conclusions: Pacing the proximal left bundle main trunk produced better electrical synchrony compared with pacing the distal left bundle fascicles. A visualization technique can facilitate achieving LBTP.

Conduction System Pacing for Post Transcatheter Aortic Valve Replacement Patients: Comparison With Right Ventricular Pacing

Introduction: For patients who develop atrioventricular block (AVB) following transcatheter aortic valve replacement (TAVR), right ventricular pacing (RVP) may be associated with adverse outcomes. We assessed the feasibility of conduction system pacing (CSP) in patients who developed AVB following TAVR and compared the procedural and clinical outcomes with RVP. Methods: Consecutive patients who developed AVB following TAVR were prospectively enrolled, and were implanted with RVP or CSP. Procedural and clinical outcomes were compared among different pacing modalities. Results: A total of 60 patients were enrolled, including 10 who were implanted with His bundle pacing (HBP), 20 with left bundle branch pacing (LBBP), and 30 with RVP. The HBP group had significantly lower implant success rate, higher capture threshold, and lower R-wave amplitude than the LBBP and RVP groups (p < 0.01, respectively). The RVP group had a significantly longer paced QRS duration (153.5 ± 6.8 ms, p < 0.01) than the other two groups (HBP: 121.8 ± 8.6 ms; LBBP: 120.2 ± 10.6 ms). During a mean follow-up of 15.0 ± 9.1 months, the LBBP group had significantly higher left ventricular ejection fraction (LVEF) (54.9 ± 6.7% vs. 48.9 ± 9.1%, p < 0.05) and shorter left ventricular end-diastolic diameter (LVEDD) (49.7 ± 5.6 mm vs. 55.0 ± 7.7 mm, p < 0.05) than the RVP group. While the HBP group showed trends of higher LVEF (p = 0.016) and shorter LVEDD (p = 0.017) than the RVP group. Four patients in the RVP group died-three deaths were due to progressive heart failure and one was due to non-cardiac reasons. One death in the LBBP group was due to the non-cardiac reasons. Conclusions: CSP achieved shorter paced QRS duration and better cardiac structure and function in post-TAVR patients than RVP. LBBP had a higher implant success rate and better pacing parameters than HBP.

Impact of Removing Race Adjustment When Estimating GFR on Chronic Kidney Disease Staging

Introduction/Objective

Determination of glomerular filtration rate (GFR) is essential in assessment of kidney function, particularly in patients with chronic kidney disease (CKD). Formulas were developed to calculate estimated GFR (eGFR), as direct measurement is cumbersome and not amenable to routine monitoring. CKD-EPI is the most widely used formula for eGFR, using parameters of serum creatinine, gender, race, and age. A race adjustment was added from an unfounded assumption that Black patients have more muscle mass, increasing their eGFR by about 16%. There is concern on the impact of “correcting” for Black race on patient management, utility of eGFR, and its possible contribution to healthcare disparities. This study examined the impact of eliminating race adjustment from the CKD- EPI formula on CKD staging in patients at a large safety-net hospital in an academic medical center.

Methods/Case Report

80090 serum creatinine values from 56676 adult patients (31.4% Black, 67.5% female, median age 51 yrs) were collected from the electronic medical record (Epic, Verona, WI) over a 16-month timeframe. Values were excluded if they lacked age, gender, self-identified race, or serum creatinine. eGFR was calculated using the CKD-EPI equation with and without race modifier, and CKD staging was performed using 2012 Kidney Disease: Improving Global Outcomes guidelines.

Results (if a Case Study enter NA)

In our cohort, only 50.8% of Black patients are in CKD1, indicative of no CKD, compared to 67.9% of non-Black patients. Given that these two cohorts are demographically similar, this shows a discrepancy in kidney function even before removing the race adjustment. After removal of the race modifier, 28.1% of Black patients were reclassified into a more severe CKD stage. The most restaging occurred from CKD3A to 3B (39%).

Conclusion

Many Black patients in our study were reclassified to a more severe CKD stage, with the highest percentage of patients restaged to CKD3B, which would have attracted clinical attention for nephrology referral. We recommend removal of the race adjustment in eGFR, given its basis in the incorrect belief in biological differences between races. It perpetuates systemic racism and discrimination in healthcare, and its removal will provide more equitable care and reduce healthcare disparities. Future studies should examine the increase in resources required to provide adequate medical care to patients who will be placed into a more severe CKD stage.

Left ventricular involvement assessed by LGE-CMR in predicting the risk of adverse outcomes of arrhythmogenic cardiomyopathy with ICDs

BACKGROUND

Arrhythmogenic cardiomyopathy (ACM) is characterized by a high incidence of ventricular tachyarrhythmia and sudden death. Implantable cardioverter-defibrillator (ICD) implantation is the cornerstone of management.

OBJECTIVE

This study aims to reveal the prognostic value of the contrast-enhanced cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) amount in predicting varying lethal outcomes among ACM patients with ICDs.

METHODS

The 88 patients with definite ACM who were all referred for contrast-enhanced CMR received an ICD and were followed up for a median of 4.0 years.

RESULTS

Fifty-four patients had no left ventricular (LV) involvement and sixteen had an LV LGE amount > 15%. During the follow-up time, appropriate ICD therapy was seen in 57, electrical storm (ES) in 19, and cardiac death in 9 patients. Compared with those without LV involvement, patients with LV LGE amount > 15% had a higher risk of cardiac death (log-rank P = 0.021). LV LGE amount was associated with an increased risk of ICD therapy [adjusted hazard ratio (HR) 1.035, 95% confidence interval (CI) 1.008-1.062, P = 0.010], and cardiac death (adjusted HR 1.082, 95% 1.006-1.164, P = 0.034), independently of LV ejection fraction. LV LGE mass of >15% demonstrated an over 2-fold increase in ICD therapy (adjusted HR 2.180, 95%CI 1.058-4.488, P = 0.035) and an over 7-fold increase in cardiac death (unadjusted HR 7.198, 95%CI 1.399-37.043, P = 0.018) than those without LV involvement, respectively.

CONCLUSIONS

The LV LGE-CMR in ACM shows a dose-dependent association with ICD therapy and cardiac death. And LV LGE amount of >15% is a strong predictor.

Metal-Insulator Transition and Emergent Gapped Phase in the Surface-Doped 2D Semiconductor 2H-MoTe_{2}

Artificially created two-dimensional (2D) interfaces or structures are ideal for seeking exotic phase transitions due to their highly tunable carrier density and interfacially enhanced many-body interactions. Here, we report the discovery of a metal-insulator transition (MIT) and an emergent gapped phase in the metal-semiconductor interface that is created in 2H-MoTe_{2} via alkali-metal deposition. Using angle-resolved photoemission spectroscopy, we found that the electron-phonon coupling is strong at the interface as characterized by a clear observation of replica shake-off bands. Such strong electron-phonon coupling interplays with disorder scattering, leading to an Anderson localization of polarons which could explain the MIT. The domelike emergent gapped phase could then be attributed to a polaron extended state or phonon-mediated superconductivity. Our results demonstrate the capability of alkali-metal deposition as an effective method to enhance the many-body interactions in 2D semiconductors. The surface-doped 2H-MoTe_{2} is a promising candidate for realizing polaronic insulator and high-T_{c} superconductivity.

[Analysis on death trend in AIDS patients and related risk factors in China]

Objective: To understand the basic characteristics of death cases, analyze the death trends in AIDS patients and the risk factors in China and provide evidence for the development of AIDS prevention and control strategy. Methods: The data were collected from the national basic information system of HIV/AIDS. The information of the cases in AIDS phase were used. The death number and mortality trends in AIDS cases were described, and Cox Proportion Hazards Regression Model was constructed to assess hazard ratios (HR) for independent variables. Results: By the end of 2019, a total of 582 472 AIDS cases, including 168 391 deaths, had been reported in China. Among the death cases, males accounted for 76.8% (129 343/168 391), heterosexual contact was the main transmission route, accounting for 60.9% (102 516/168 391). The proportion of the death cases who had ever received ART was 54.0% (90 888/168 391). The inter-quartile (P₂₅, P₇₅) of first CD₄^＋T cells counts (CD₄) was 34 cells/μl, 240 cells/μl. Up to 43.5% (73 191/168 391) of the deaths occurred within one year after diagnosis. From 2007 to 2019, the annual death number increased from 5 485 to 18 737, the mortality rates decreased form 10.9%% to 4.3%. The average time interval from diagnosis to death ranged from 1.4 year to 4.0 years, showing increase trend by year. The results of Cox regression analysis showed that older age (50- years old: HR=1.50; ≥65 years old: HR=2.00), being male (HR=1.44)、being in minority ethnic group (HR=1.10), having lower first CD₄ levels (0- cells/μl, HR=2.73;200- cells/μl, HR=1.33; 350- cells/μl,HR=1.13), heterosexual transmission route (HR=1.64) and injecting drug use (HR=1.79) were the risk factors related to deaths in AIDS patients. The higher educational levels (junior middle school: HR=0.86, senior high school and above: HR=0.59) and receiving antiviral treatrment (HR=0.09) were protective factors. Conclusions: The number of death cases increased, meanwhile the mortality rates decrease year by year in AIDS patients in China during 2007-2019. It is necessary to strengthen the early detection and treatment of AIDS to reduce the mortality.

[Estimation of newly HIV infection trend by using the back-calculation method in Honghe Hani and Yi autonomous prefecture]

Objective: Using the changing patterns of CD(4)(+) lymphocytes (CD(4)) counts of HIV/AIDS cases, we tried to estimate the number of newly infected HIV in Honghe Hani and Yi autonomous prefecture (Honghe prefecture) Yunnan province, and to provide reference for evaluating the trend of local HIV epidemic. Methods: Among diagnosed HIV infections, those who were at ≥15 years old, having available initial CD(4) records of testing, initiating antiviral therapy before the end of 2018, were selected from the case reporting system of Honghe prefecture, Yunnan province. Both Depletion model of the square root on CD(4) and the time of infection were used to back-calculate the seroconversion time of each individual. Both direct probability distribution method and life table method were used to calculate the distribution rates of diagnosis and the weight of delay. The number of diagnoses over the years was used to reversely estimate the total number of newly HIV infections. Results: At the end of 2018, the total number of HIV infections was estimated 35 977 with the rate of diagnosis as 77.50% in Honghe prefecture of Yunnan province. The number of new HIV infections appeared as 23 792 in 2008-2018. Cumulatively, the number of new HIV infections was 12 185 up to 2007. The estimated number of new HIV infections decreased from 2 602 in 2008 to 1 480 in 2018. The weight of diagnostic delay decreased from 5.49 in one year to 1.00 in 20 years, and the diagnosis rate increased from 18.2% to 100.0% during 20 years. Conclusion: In Honghe prefecture of Yunnan province, the number of newly infection showed a declining trend but the diagnostic rate was still far from reaching the "first 90% target" . It is expected to expand the timeliness on detection and case-finding so as to reduce the risk of HIV transmission.