The impacts of exposure to risk factors during youth on the increasing global trend of early-onset pancreatic cancer

OBJECTIVES

An increasing trend of pancreatic cancer in young adults has emerged in some countries. This study aimed to investigate global trends of pancreatic cancer in young adults and explore the impact of exposure to risk factors on pancreatic cancer incidence during youth.

METHODS

Global and national data on pancreatic cancer incidence, disability-adjusted life-years, attributive mortality, and summary exposure values of risk factors were retrieved from the Global Burden of Disease 2019. The average annual percent change (AAPC) of incidence and mortality was calculated. Additionally, generalized additive models were applied to explore the non-linear associations between the levels and changes in the Human Development Index and AAPC.

RESULTS

Global pancreatic cancer incidence increased during various periods from 1990 to 2019, particularly in adults aged <45 years from 2010 to 2019, at an average annual increase rate of 0.7% (95% confidence interval: 0.4-1.0%). The AAPC of early-onset pancreatic cancer incidence from 2010 to 2019 was negatively correlated with Human Development Index levels in both 2010 and 2019 but positively correlated with Human Development Index acceleration. Significant increases in early-onset pancreatic cancer incidence were observed over this period in 32 of 88 countries, primarily in South America, North America, Oceania, and Africa. Early-onset pancreatic cancer mortality attributed to high body mass index and fasting plasma glucose increased, while that attributed to tobacco use declined.

CONCLUSIONS

An increasing trend has emerged in the global incidence and burden of early-onset pancreatic cancer over the last few decades. This rise may partly be attributed to global epidemics of high body mass index and fasting plasma glucose.

Transition from fractal-dendritic to compact islands for the 2D-ferroelectric SnSe on graphene/Ir(111)

Epitaxial growth is a versatile method to prepare two-dimensional van der Waals ferroelectrics like group IV monochalcogenides which have potential for novel electronic devices and sensors. We systematically study SnSe monolayer islands grown by molecular beam epitaxy, especially the effect of annealing temperature on shape and morphology of the edges. Characterization of the samples by scanning tunneling microscopy reveals that the shape of the islands changes from fractal-dendritic after deposition at room temperature to a compact rhombic shape through annealing, but ripening processes are absent up to the desorption temperature. A two-step growth process leads to large, epitaxially aligned rhombic islands bounded by well-defined110-edges (armchair-like), which we claim to be the equilibrium shape of the stoichiometric SnSe monolayer islands. The relaxation of the energetically favorable edges is detected in atomically resolved STM images. The experimental findings are supported by the results of our first-principles calculations, which provide insights into the energetics of the edges, their reconstructions, and yields the equilibrium shapes of the islands which are in good agreement with the experiment.

[To investigate the role of the AAC-8 scoring in predicting restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with DCB]

Objective: To investigate the role of the Abdominal Aortic Calcification-8 (AAC-8) scoring system in predicting restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with drug-coated balloon (DCB). Methods: In this retrospective study, 62 patients who underwent dilatation and angioplasty with DCB for lower limb atherosclerotic obliterans (ASO) were enrolled from September 2018 to June 2022 in Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School. Among them who aged (73.9±11.3) years, 37 were males and 25 were females. Patients were divided into two groups according to the condition of the lower extremity arteries after dilatation and angioplasty with DCB: recurrence group (n=26) and patency group (n=36). Logistic regression was used to analyze the factors associated with restenosis or occlusion of lower extremity arteries after dilatation and angioplasty with DCB. The predictive value of the AAC-8 score for restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB was analyzed using the receiver operating characteristic curves (ROC curves). Results: The postoperative follow-up was 16.30 (10.97, 24.10) months in the patency group and 9.03 (6.98, 15.31) months in the recurrence group. The results of multifactorial logistic regression analysis showed that an elevated AAC-8 score (OR=1.388, 95%CI: 1.067-1.806, P=0.015) was an associated factor of restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB. The ROC curve analysis showed that the area under the curve (AUC) of the AAC-8 score for predicting restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB was 0.687 (95%CI: 0.550-0.824, P=0.013), with a cut-off value of 5.5 points, a sensitivity of 65.4% and a specificity of 69.5%. Conclusions: Elevated AAC-8 score is associated with restenosis or occlusion of the lower extremity arteries after dilatation and angioplasty with DCB. When the cut-off value is 5.5, the AAC-8 score predicts restenosis or occlusion of the lower extremity arteries after DCB dilation and angioplasty with a sensitivity of 65.4% and a specificity of 69.5%.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Individualised prediction of progression of solitary sub-solid pulmonary nodules based on CT semantic and clinical features: a 3-year follow-up study

AIM

To develop and validate a progressive prediction model for estimating the time to progression (TTP) of sub-solid pulmonary nodules (SSNs).

MATERIALS AND METHODS

A total of 126 cases who met inclusion and exclusion criteria were included in the study. The primary endpoint of the study was TTP of SSNs. Baseline characteristics were assessed in terms of clinical and CT semantic features. Kaplan-Meier analysis and Cox regression analysis were performed to determine the relationship between SSNs TTP and factors from the entire data set. The nomogram was constructed based on the result of multivariate analysis and internal validation was performed using the bootstrapping. The nomogram's performance was assessed with the C-index, calibration curves, and decision curve analysis.

RESULTS

The median follow-up time of the population was 42.5 (21.5) months. On Kaplan-Meier analysis, patients with higher or positive values of the indices had higher cumulative progression rates (p<0.05). Multivariate Cox regression models identified diameter, consolidation tumour ratio (CTR), morphology, and vasodilation sign (VDS) as independent risk factors of TTP. These predictors were included in the final model to estimate individual probabilities of progression in the 3 years, which performed well in the discrimination (the C-index was 0.901 [95%CI: 0.830-0.981] and 0.875 [95%CI: 0.805-0.942] in the training and internally validation sets).

CONCLUSION

The radiological semantic features nomogram is a promising and favourable prognostic biomarker for predicting progression and may aid in clinical risk stratification and decision-making for SSNs.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

[Clinicopathological features and prognosis of 47 adults with Hirschsprung's disease and Hirschsprung's disease allied disorders]

Objective: To improve understanding and treatment of adult Hirschsprung's disease (HD) and Hirschsprung's disease allied disorders (HAD) by investigating the clinicopatho- logical features, diagnostic and treatment methods, and prognosis. Methods: This was a retrospective observational study. The study cohort comprised patients aged 18-65 years admitted to the Sixth Hospital of Sun Yat-sen University between January 2007 and December 2022 who were diagnosed with adult HD or HAD by postoperative pathological examination. Those with severe cardiovascular disease, diabetes mellitus, or cirrhosis of the liver were excluded, leaving 47 patients in the study cohort. Emergency open surgery was performed on patients with life-threatening manifestations, whereas those whose condition was stable received conservative treatment to stabilize them, following which they underwent a standard surgical procedure. Surgical procedures performed included the Duhamel procedure, Soave procedure, subtotal colonic resection, total colonic resection, and creation of a palliative stoma. Variables studied included clinicopathological characteristics, treatment modalities, postoperative complications, and long-term anal function. Complications were evaluated in accordance with the Clavien-Dindo criteria, and long-term anal function according to the 2005 Krickenbeck International Classification Criteria. Results: Of the 47 patients, 33 were men and 14 women, with a median age of 29 (18-51) years. HD was diagnosed in 41 (87.2%) patients and HAD in six (12.8%). The commonest initial symptom was dyspareunia (70.2%,33/47), followed by abdominal distension (57.4%, 27/47) and abdominal pain (44.7%,21/47). The detection rates of HD/HAD by barium enema + defecography, anorectal manometry, and preoperative rectal biopsy were 86.8% (33/38), 16/19, and 7/7, respectively. Three (6.4%) patients had discrepant preoperative clinical and postoperative pathological diagnoses. None of the three misdiagnosed patients had undergone preoperative rectal biopsy. Of the 47 study patients, three chose non-surgical treatment and 44 surgical treatment. All surgeries were successfully completed. Postoperative complications occurred in 19 patients (43.2%), including one death case who had undergone emergency surgery. The median duration of follow-up after surgery was 65 (12-180) months. Three patients in the surgical treatment group were lost to follow-up. Of the remaining 41 patients, 36, three, and two had excellent, good, and poor long-term anal function, respectively. The differences in outcomes between the surgical and non-surgical treatment groups (no patients, one, and two with excellent, good, and poor long-term anal function, respectively) (Z=-3.883, P=0.001) were statistically significant. Of the 44 patients who underwent surgical treatment, 41 underwent standard surgeries and three emergency surgeries because their conditions were life-threatening. The difference in complication rate between standard surgery and emergency surgery groups (39.0% [16/41] vs. 3/3, χ2=2.115, P=0.146) was not statistically significant. However, the rate of postoperative Grade III-V complications was lower in the standard surgery group (4.9% [2/41] vs. 2/3, Z=-2.668, P=0.008). Long-term anal function was significantly better in the standard surgery than emergency surgery group (94.7% [36/38] vs. 0/3, Z=-4.935, P=0.001). The 41 standard surgeries included 11 Duhamel's procedures, six Soave's procedures, 19 subtotal colonic resections, three total colonic resections, and two palliative colostomies. The incidence of postoperative complications was significantly superior in the Duhanmels procedures and palliative colostomies group(1/11 and 0/2, P=0.041). Of the 41 patients who underwent standard surgery, 23 underwent open surgery and 18 minimally invasive laparoscopic surgery. The incidence of postoperative Grade III-V complications and long-term anal function were significantly superior in the laparoscopic group than in the open group (all P<0.05). Conclusion: It is easy to misdiagnose adult HD and HAD, surgical treatment is safe and feasible, and its long-term efficacy is good.

[Participation rate and detection of colorectal neoplasms based on multi-round fecal immunochemical testing for colorectal cancer screening in the Chinese population]

Objective: To evaluate the participation rate and detection of colorectal neoplasms based on annual fecal immunochemical testing (FIT) for three consecutive years in a population-based colorectal cancer screening program in China. Methods: Based on a population-based colorectal cancer screening program conducted from May 2018 to May 2021 in 6 centers in China, 7 793 eligible participants aged 50-74 were included and offered free FIT and colonoscopy (for those who were FIT-positive on initial screening). At baseline, all participants were invited to receive FIT. In subsequent screening rounds, only FIT-positive participants who did not undergo colonoscopy or FIT-negative participants were invited to have repeated FIT screening. FIT-positive participants were recommended to undertake colonoscopy and pathological examination (if abnormalities were found during colonoscopy). An overall of three rounds of annual FIT screening were conducted. The primary outcomes of the study were the participation rate of FIT screening, the compliance rate of colonoscopy for FIT-positive participants, and the detection rate of colorectal neoplasms. Results: Among the 7 793 participants included in this study, 3 310 (42.5%) were male, with age of (60.50±6.49) years. The overall participation rates for the first, second and third round of FIT screening were 94.0%(7 327/7 793), 86.8% (6 048/6 968) and 91.3% (6 113/6 693), respectively. Overall, 7 742 out of 7 793 participants (99.3%) attended at least one round of screening, and 5 163 out of 7 793 participants (66.3%) attended all three rounds of screening. The positivity rate was significantly higher in the first (14.6%, 1 071/7 327) round compared with the second (5.6%, 3 41/6 048) and third (5.5%, 3 39/6 113) screening rounds (P<0.001). The overall compliance rates of colonoscopy examination among FIT-positive subjects were over 70% in three rounds, which were 76.3% (817/1 071), 75.7% (258/341) and 71.7% (243/339), respectively. In a multivariate logistic regression model considering factors including sex, education background, smoking, alcohol drinking, previous colonoscopy examination, colonic polyp history and family history of colorectal cancer among first-degree relatives, gender and smoking status were related factors affecting the participation rate of FIT screening, with higher rate in males and non-smokers. In addition, logistic regression analysis also found that age was negatively correlated with the compliance rate of colonoscopy in FIT positive patients. The detection rate of advanced tumors (colorectal cancer + advanced adenoma) declined from the first round to subsequent rounds [1st round: 1.15% (90/7 793); 2nd round: 0.57% (40/6 968); and 3rd round: 0.58% (39/6 693)], however, the positive predictive value for advanced neoplasms increased round by round, and was 11.02% in the first screening round, 15.50% in the second screening round, and 16.05 % in the third screening round. In each screening round, the detection rate for advanced neoplasms was higher in men than that in women, and increased with age. Conclusions: Annual repeated FIT screening has high acceptance and satisfying detection rates in the Chinese population. To optimize and improve the effectiveness of colorectal cancer screening, multi-round repeated FIT screening should be implemented while ensuring high participation rates.

Neoadjuvant nivolumab plus chemotherapy versus chemotherapy for resectable NSCLC: subpopulation analysis of Chinese patients in CheckMate 816

BACKGROUND

Neoadjuvant nivolumab plus chemotherapy significantly improved event-free survival (EFS) and pathologic complete response (pCR) versus chemotherapy alone in patients with resectable non-small-cell lung cancer (NSCLC) in the global phase III CheckMate 816 study. Here, we report post hoc exploratory efficacy, safety, and surgical outcomes in the Chinese subpopulation of this study.

METHODS

Adults with stage IB-IIIA resectable NSCLC were randomized to receive nivolumab 360 mg plus chemotherapy or chemotherapy alone every 3 weeks for three cycles followed by surgery. Primary endpoints included EFS and pCR (both per blinded independent review). EFS and pCR results were from 14 October 2022, and 16 September 2020, database locks, respectively.

RESULTS

The Chinese subpopulation comprised 97 patients (nivolumab plus chemotherapy, 44; chemotherapy, 53). At 38.2 months of minimum follow-up, median EFS was not reached [95% confidence interval (CI) 23.4 months-not reached] in the nivolumab plus chemotherapy arm and 13.9 months (95% CI 8.3-34.3 months) in the chemotherapy arm (hazard ratio 0.47, 95% CI 0.25-0.88). pCR rates were 25.0% (95% CI 13.2% to 40.3%) and 1.9% (95% CI 0.0% to 10.1%), respectively (odds ratio 11.05; 95% CI 1.41-86.49). Of 97 Chinese patients, 36 (82%) in the nivolumab plus chemotherapy arm and 41 (77%) in the chemotherapy arm underwent definitive surgery. Grade 3-4 treatment-related adverse events occurred in 18/43 patients (42%) treated with nivolumab plus chemotherapy and 22/53 patients (42%) treated with chemotherapy.

CONCLUSIONS

Consistent with findings in the global study population of CheckMate 816, neoadjuvant nivolumab plus chemotherapy improved EFS and pCR versus chemotherapy in the Chinese subpopulation without impacting treatment tolerability or the feasibility of surgery. These findings support the use of nivolumab plus chemotherapy as a standard neoadjuvant treatment option for Chinese patients with resectable NSCLC.

[Correlation between C-reactive protein to albumin ratio and restenosis after femoral popliteal stenting in patients with lower extremity arteriosclerotic obliterans]

Objective: To investigate the study of the correlation between C-reactive protein to albumin ratio (CAR) and restenosis after stenting in patients with lower extremity atherosclerotic occlusive disease(LEASO). Methods: The clinical data of 95 patients with LEASO admitted to the Department of Vascular Surgery of Nanjing Drum Tower Hospital from June 2020 to December 2022 were retrospectively analyzed. There were 67 males and 28 females,aged (73.1±9.4) years (range:51 to 92 years). The patients were classified into the restenosis group (n=61) and the patency group (n=34) according to the CT angiography results. Independent sample t test,Mann-Whitney U test and χ2 test were used to compare the data between two groups. Risk factors for restenosis after femoropopliteal artery stenting in patients with LEASO were analyzed using multivariate Cox regression. The relationship between preoperative CAR level and restenosis after stent placement was analyzed. Subject operating characteristic(ROC) curves of CAR were plotted to assess the predictive value of CAR for restenosis after stenting,and the results were expressed as area under the curve (AUC). Results: The aortoiliac calcification grade,number of stents,length of stents,C-reactive protein and CAR levels in restenosis group were higher than those in the patency group,and the serum albumin level was lower than that in the patency group(all P<0.05). And the results of multifactorial Cox regression analysis showed that higher pre-procedure CAR level and lower ABI value was an independent risk factor for in-stent restenosis. The AUC of the ROC curve for restenosis was 0.737(95%CI:0.617 to 0.856),the AUC of the ROC curve for 12-month restenosis was 0.709(95%CI:0.602 to 0.815), and the AUC of the ROC curve for 24-month restenosis was 0.702(95%CI:0.594 to 0.811). Conclusion: Higher pre-procedural CAR levels in patients with LEASO is risk factor for in-stent restenosis,and CAR has a predictive value for restenosis after lower extremity arterial stent dilatation and angioplasty.

Triple Function of Amelogenin Peptide-Chitosan Hydrogel for Dentin Repair

Biomimetic strategies like peptide-guided collagen mineralization promise to enhance the effectiveness of dentin remineralization. We recently reported that rationally designed amelogenin-derived peptides P26 and P32 promoted apatite nucleation, mineralized collagen, and showed potential in enamel regrowth and dentin remineralization. To facilitate the clinical application of amelogenin-derived peptides and to uncover their effectiveness in repairing dentin, we have now implemented a chitosan (CS) hydrogel for peptide delivery and have investigated the effects of P26-CS and P32-CS hydrogels on dentin remineralization using 2 in situ experimental models that exhibited different levels of demineralization. The efficacy of the peptide-CS hydrogels in dentin repair was evaluated by characterizing the microstructure, mineral density, mineral phase, and nanomechanical properties of the remineralized samples. The new strategy of atomic force microscopy PeakForce quantitative nanomechanical mapping was used for direct visualization and nanomechanical analysis of repaired dentin lesions across the lesion depth. Results from the 2 models indicated the potential triple functions of peptide-CS hydrogels for dentin repair: building a highly organized protective mineralized layer on dentin, occluding dentinal tubules by peptide-guided in situ mineralization, and promoting biomimetic dentinal collagen remineralization. Importantly, peptides released from the CS hydrogel could diffuse into the dentinal matrix and penetrate the dentinal tubules, leading to both surface and subsurface remineralization and tubule occlusion. Given our previous findings on peptide-CS hydrogels' potential for remineralizing enamel, we see further promise for hydrogels to treat tooth defects involving multiple hard tissues, as in the case of noncarious cervical lesions.

[Value of fecal immunochemical test in colorectal cancer screening]

Screening and early diagnosis and treatment have been proven effective in reducing the incidence and mortality of colorectal cancer. Colonoscopy combined with pathological examination is the gold standard for colorectal cancer screening. However, due to the invasiveness, high cost and the need for professional endoscopists of colonoscopy, it is not feasible to directly use this method for mass population screening. Fecal immunochemical test (FIT) is one of the screening techniques recommended by authoritative international guidelines for colorectal cancer screening, and has been widely used in population-based colorectal cancer screening programs in countries around the world. This paper elaborates on the value of FIT in colorectal cancer screening from different aspects, such as the technical principles, the screening efficiency, the screening strategies, and the population effects and benefits. Additionally, it describes the current situation of colorectal cancer screening in China and summarizes the challenges faced in colorectal cancer screening in order to optimize the FIT-based colorectal cancer screening strategies in the population and provide theoretical reference for effective colorectal cancer screening.

Mobilization of the blaKPC-14 gene among heterogenous plasmids in extensively drug-resistant hypervirulent Klebsiella pneumoniae

Introduction

Ceftazidime/avibactam (CZA) is an effective alternative for the treatment of infections caused by KPC-producing carbapenem-resistant Klebsiella pneumoniae (CRKP). However, KPC variants with CZA resistance have been observed in clinical isolates, further limiting the treatment options of clinical use.

Methods

In this study, we isolated three KPC-14-producing CRKP from two patients in intensive care units without CZA therapy. The antimicrobial susceptibility was determined using the broth microdilution method. Three CRKP were subjected to whole-genome sequencing to analyze the phylogenetic relatedness and the carriage of antimicrobial resistance genes and virulence factors. Long-read sequencing was also performed to obtain the complete sequences of the plasmids. The horizontal transfer of the blaKPC-14 gene was evaluated by conjugation experiments.

Results

Three CRKP displayed resistance or reduced susceptibility to ceftazidime/avibactam, colistin, and tigecycline. Single-nucleotide polymorphism (SNP) analysis demonstrated the close phylogenetic distance between these strains. A highly similar IncFII/IncR plasmid encoding blaKPC-14 was shared by three CRKP, with blaKPC-14 located in an NTEKPC-Ib element with the core region of ISKpn27- blaKPC-14-ISKpn6. This structure containing blaKPC-14 was also observed in another tet(A)-carrying plasmid that belonged to an unknown Inc-type in two out of three isolates. The horizontal transferability of these integrated plasmids to Escherichia coli EC600 was confirmed by the cotransmission of tet(A) and blaKPC-14 genes, but the single transfer of blaKPC-14 on the IncFII/IncR plasmid failed. Three CRKP expressed yersiniabactin and carried a hypervirulence plasmid encoding rmpA2 and aerobactin-related genes, and were thus classified as carbapenem-resistant hypervirulent K. pneumoniae (hvKP).

Discussion

In this study, we reported the evolution of a mosaic plasmid encoding the blaKPC-14 gene via mobile elements in extensively drug-resistant hvKP. The blaKPC-14 gene is prone to integrate into other conjugative plasmids via the NTEKPC-Ib element, further facilitating the spread of ceftazidime/avibactam resistance.

Case Report: Metagenomic Next-Generation Sequencing Confirmed a Case of Spine Infection with Brucella melitensis in Non-Endemic Area

Brucellosis is a zoonotic disease caused by Brucella spp., with the highest prevalence found in the northern cities of China. In this case report, we present an occurrence of spinal infection caused by B. melitensis in a 67-year-old man residing in a non-endemic area of southern China. The patient initially presented with chest and back pain, which was not accurately diagnosed and treated at a local hospital. Subsequently, due to worsening pain, he was admitted to our hospital. To determine the cause of the infection, we performed CT-guided aspiration biopsy and collected biopsy tissue for metagenomic next-generation sequencing (mNGS) on the second day of hospitalization. Imaging investigations revealed involvement of the thoracic vertebrae, specifically thoracic 4-7 with the main focus on 5-6, accompanied by stenosis of the intervertebral space. The mNGS results indicated that the spine infection was caused by B. melitensis. The patient's history as a shepherd and a positive Rose Bengal plate test (RBPT) further supported the diagnosis of brucella spondylitis. In order to alleviate pain and restore spinal function, the patient underwent posterior internal fixation of the thoracic spine. Treatment was initiated with cefoperazone/sulbactam, followed by doxycycline. Subsequently, the patient was switched to a combination therapy of rifampicin and doxycycline for a duration of six weeks. The patient responded well to treatment, and his condition remained stable. In conclusion, brucellosis is a common disease that can be easily misdiagnosed. This case report highlights the potential value of mNGS in early and rapid diagnosis. We believe that mNGS can serve as an effective tool to improve the diagnosis of spine infections caused by this pathogen.

Clinical characteristics and prognostic risk factors of candidemia in non-neutropenic patients: a retrospective cohort study

This study aimed to determine the clinical characteristics and the prognostic risk factors in non-neutropenic patients with candidemia. Data were retrospectively collected through the medical record information system. Non-neutropenic patients with candidemia were relatively aged, with a more than one-third rate of in-hospitalization mortality. In multivariate analysis, APACHE II score (adjusted odds ratio [aOR], 1.138; 95% confidence interval [CI], 1.067-1.213), septic shock (aOR, 5.704; 95% CI, 2.639-12.326) and RRT (aOR, 16.152; 95% CI, 2.628-99.275) (all P < 0.01) were independent related with non-survivors. In conclusion, non-neutropenic patients with candidemia have a high in-hospitalization mortality, and APACHE II, septic shock, and RRT are independently factors.

Linear Breit-Wheeler process driven by compact lasers

We report a proposal to observe the two-photon Breit-Wheeler process in plasma driven by compact lasers. A high-charge electron bunch can be generated from laser plasma wakefield acceleration when a tightly focused laser pulse propagates in a subcritical density plasma. The electron bunch scatters with the laser pulse coming from the opposite direction and resulting in the emission of high brilliance x-ray pulses. In a three-dimensional particle-in-cell simulation with a laser pulse of ∼10 J, one could produce an x-ray pulse with a photon number higher than 3×10^{11} and brilliance above 1.6×10^{23} photons/s/mm^{2}/mrad^{2}/0.1%BW at 1 MeV. The x-ray pulses collide in the plasma and create more than 1.1×10^{5} electron-positron pairs per shot. It is also found that the positrons can be accelerated transversely by a transverse electric field generated in the plasma, which enables the safe detection in the direction away from the laser pulses. This proposal enables the observation of the linear Breit-Wheeler process in a compact device with a single shot.

Gate-controlled suppression of light-driven proton transport through graphene electrodes

Recent experiments demonstrated that proton transport through graphene electrodes can be accelerated by over an order of magnitude with low intensity illumination. Here we show that this photo-effect can be suppressed for a tuneable fraction of the infra-red spectrum by applying a voltage bias. Using photocurrent measurements and Raman spectroscopy, we show that such fraction can be selected by tuning the Fermi energy of electrons in graphene with a bias, a phenomenon controlled by Pauli blocking of photo-excited electrons. These findings demonstrate a dependence between graphene's electronic and proton transport properties and provide fundamental insights into molecularly thin electrode-electrolyte interfaces and their interaction with light.

Exploration of AI-Assisted On-Board Perfusion Imaging Technique on Patients Undergoing Thoraxradiotherapy

PURPOSE/OBJECTIVE(S)

Pulmonary function of lung cancer patients can significantly change along the radiation therapy (RT) course. Scholars have synthesized lung function maps from computed tomography (CT) images. Still, there is lack of study exploring the feasibility of generating lung perfusion information from cone-beam CT (CBCT). Our study aims to fill up this gap in the body of literatures.

MATERIALS/METHODS

One-hundred-and-six pairs of planning CT and CBCT images of thoracic cancer patients from XX hospital were collected retrospectively. All CT images were registered to CBCT with a deformable algorithm, and referred as deformed planning CT (dCT). A 2D convolutional neural network (CNN) model built with cycle generative adversarial network (cycle-GAN) was trained to correct CBCT image artifacts and HU value discrepancies. The corrected CBCT was named enhanced CBCT (eCBCT) in this study. All CBCT, eCBCT and dCT images were then input to a pre-trained CT-to-perfusion deep learning (DL) model to synthesize perfusion images (PI), namely PICBCT, PIeCBCT and PIdCT respectively. For model training, 80 image pairs were assigned to the training set while others to the testing set. dCT and PIdCT were respectively regarded as the ground truth in two consecutive models. One extra validation case acquired with SPECT perfusion scan was collected for model performance test. Quantitative evaluation was done between the ground truth and the synthesized images. Peak signal-to-noise ratio (PSNR) and mean absolute error (MAE) were computed to assess efficacy of CBCT enhancement. Correlation (R) and Dice similarity coefficient (DSC) were used to evaluate voxel-wise and function-wise concurrence in CBCT-derived perfusion mapping.

RESULTS

In CBCT enhancement, [eCBCT-dCT] pairs demonstrated higher agreement than [CBCT-dCT] pairs. Quantitatively, PSNR and MAE were improved from 21.10±1.60 to 24.08±1.76, and 68.99±13.51 to 47.06±11.31 (p<0.01), respectively. For perfusion translation, higher correlation was demonstrated in both voxel-wise and function-wise evaluation within [PIeCBCT-PIdCT] than [PICBCT-PIdCT]. R correlation increased from 0.84±0.09 to 0.89±0.06 (p<0.01), whereas DSC in high-functional regions increased from 0.77±0.06 to 0.82±0.05 (p<0.01). In the validation case, strong correlation was observed between SPECT perfusion scan and PIeCBCT, with R increasing from 0.57 to 0.65 when compared to PICBCT.

CONCLUSION

We proposed a novel DL framework that synthesized perfusion images from fractionally acquired CBCT. Our framework met the clinical needs in providing real-time lung perfusion maps. It can be used to track the continuously changing pulmonary function status throughout the RT course using routinely scanned CBCT, without additional imaging modalities. The framework can facilitate functionally guided adaptive radiation therapy by providing immediate pulmonary function information.

[Clinical analysis of surgical treatment of infection after interventional operation for major iliac artery disease in 6 cases]

Objective: To explore the surgical treatment strategy of stent graft infection after interventional treatment of major iliac artery related diseases. Methods: Retrospective analysis was performed on the clinical data of 6 patients with secondary stent graft infection after interventional treatment for major iliac artery related diseases admitted to the Department of Vascular Surgery,Affiliated Drum Tower Hospital,Medical School of Nanjing University from November 2021 to August 2022.There were 5 males and 1 female,with a mean age of 64 years (range:49 to 79 years).The infection time was 53 to 3 165 days.All the 6 patients received surgical treatment,including 3 patients who underwent anatomic bypass grafting (axillary arterial-femoral artery bypass,femoral arterial-femoral artery bypass) using artificial vessels,and 3 patients who underwent in situ abdominal aorta reconstruction using bovine pericardium.The perioperative situation,postoperative infection and the occurrence of serious adverse events were recorded,and the safety of different treatment methods and materials was evaluated. Results: All patients successfully completed the operation and no death occurred during hospitalization.Intraoperative blood loss was 2 000~5 000 ml,and intraoperative blood transfusion was 1 600 to 5 350 ml.All the patients were followed up for 81 to 395 days after surgery,and the incision healed well,and no reinfection occurred.Postoperative gastrointestinal bleeding occurred in 1 patient,secondary surgery (retroperitoneal hematoma removal) was performed in 1 patient due to postoperative bleeding at the vascular anastomosis,both lower limb amputations were performed in 1 patient due to postoperative lower limb ischemia,and intermittent claudication occurred in 2 patients.All patients were alive at the last follow-up. Conclusion: For patients with aortic stent graft infection,when the infection is not serious and there is enough space to block the proximal and distal aorta,in situ aortic reconstruction is an effective treatment,and different materials can achieve satisfactory results in a short period of time.

[A survey of performance of public health risk assessment in emergencies of institutions for disease control and prevention at different levels in China]

Objective: To understand the performance of public health risk assessment in emergencies of institutions for disease control and prevention at different levels in China, and provide suggestions for the improvement of public health risk assessment. Methods: A self-administered survey was conducted in professionals involved in public health risk assessment in emergencies from national institution, provincial institutions and some prefectural institutions for disease control and prevention (1-2 prefectural institutions were selected using convenience sampling in each province) between March and April in 2021. Results: A total of 79 institutions for disease control and prevention were investigated, including 1 national institution, 32 provincial institutions and 46 prefectural institutions. By April 2021, all the 79 institutions surveyed had conducted risk assessment of public health emergencies, in which 61 (77.2%) had established departments responsible for the public health risk assessment, i.e. emergency management office or communicable disease prevention and control office (section), and regular risk assessment mechanisms. The main sources of information for public health risk assessment were public health surveillance systems, including the National Notifiable Diseases Reporting System (100.0%) and Public Health Emergencies Management Information System (97.5%). Compared with the provincial institutions, the prefectural institutions were more likely to use specific disease surveillance systems (84.8% vs. 62.5%; χ2=5.09, P=0.024). The risk management recommendations made by 43 institutions for disease control and prevention (54.4%) after the risk assessment were accepted by the superior health administrative departments and used in epidemic prevention and control. Conclusions: Public health risk assessment in emergencies has been widely carried out by national, provincial and prefectural institutions for disease control and prevention in China. Specialized departments and mechanisms have been established, but the information sources are still confined to public health surveillance systems and the application of the risk assessment results still needs to be further improved.

[Effect of different respiratory motion correction methods on PET image quality in chest PET/MRI]

Objective: To investigate the effect of different respiratory motion correction methods on PET images during chest PET/MRI scans. Methods: The data of 35 patients (24 males and 11 females, aged from 29 to 84 year) of pulmonary lesions with significantly high uptake in thoracic PET/MRI scan were retrospective collected from Jingling Hospital. Four different methods were used to reconstruct the PET data. Group A was the full-time 20 min without respiratory motion correction static acquisition (Static) as a control, group B was the end-expiration static collection (Q.Static), and group C was the multi-bins respiratory gating (Gated-Respiratory). In addition, the influence of the time being considered, group D was added for reconstruction in the first 1/3 period (6 min 40 s) of group A. Then, the maximum value (L-SUVmax) and the mean value (L-SUVmean) of the SUV of the lesion, the mean value (B-SUVmean) and the standard deviation (B-SUVsd) of the SUV of the background under each reconstruction results were measured, and for each lesion the signal-to-noise ratio (L-SNR) was calculated. In order to exclude the interference of the background, the mean of the relative SUV (L-dSUVmean) of the L-SUVmean relative to the B-SUVmean was also calculated. Finally, One-Way Repeated Measures ANOVA was used, and the post-hoc pairwise comparison between groups was tested by Bonferroni's modified test. Results: There was statistically significant difference among group B or group C compared to group A and group D in L-SUVmax, L-SUVmean and L-dSUVmean [L-SUVmax:group B vs group A or group D was 8.06±3.57 vs 7.73±3.45 or 7.61±3.50, group C vs group A or group D was 8.04±3.56 vs 7.73±3.45 or 7.61±3.50 (all P<0.05); L-SUVmean: group B vs group A or group D was 4.12±1.78 vs 3.98±1.72 or 3.91±1.71, group C vs group A or group D was 4.13±1.78 vs 3.98±1.72 or 3.91±1.71 (all P<0.05); L-dSUVmean: group B vs group A or group D was 3.52±0.16 vs 3.39±0.18 or 3.31±0.18, group C vs group A or group D was 3.53±0.18 vs 3.39±0.18 or 3.31±0.18 (all P<0.05)], but there was no statistically significant difference between group B and group C (all P>0.05). There were statistically significant differences between group D and group A in B-SUVsd (0.07±0.00 vs 0.07±0.00, P=0.023) and L-SNR (69.80±44.57 vs 85.35±68.98, P=0.001). There was no statistically significant difference between group D and group A in L-SUVmax, L-SUVmean, B-SUVmean and L-dSUVmean (all P>0.05). Conclusions: There was no significant difference in PET image quality between the Q.static and Gated-Respiratory group, both of the two groups were better than the Static group which with no Gated-Respiratory motion correction. If non-respiratory gated Static is used, the PET acquisition time is recommended to be 6 min 40 s.

Multi-ancestry genome-wide analysis identifies shared genetic effects and common genetic variants for self-reported sleep duration

Both short (≤6 h per night) and long sleep duration (≥9 h per night) are associated with increased risk of chronic diseases. Despite evidence linking habitual sleep duration and risk of disease, the genetic determinants of sleep duration in the general population are poorly understood, especially outside of European (EUR) populations. Here, we report that a polygenic score of 78 European ancestry sleep duration single-nucleotide polymorphisms (SNPs) is associated with sleep duration in an African (n = 7288; P = 0.003), an East Asian (n = 13 618; P = 6 × 10-4) and a South Asian (n = 7485; P = 0.025) genetic ancestry cohort, but not in a Hispanic/Latino cohort (n = 8726; P = 0.71). Furthermore, in a pan-ancestry (N = 483 235) meta-analysis of genome-wide association studies (GWAS) for habitual sleep duration, 73 loci are associated with genome-wide statistical significance. Follow-up of five loci (near HACD2, COG5, PRR12, SH3RF1 and KCNQ5) identified expression-quantitative trait loci for PRR12 and COG5 in brain tissues and pleiotropic associations with cardiovascular and neuropsychiatric traits. Overall, our results suggest that the genetic basis of sleep duration is at least partially shared across diverse ancestry groups.

[Research on applying genetic and environmental risk score in risk-adapted colorectal cancer screening]

Objective: To evaluate the effectiveness of a risk-adapted colorectal cancer screening strategy constructed utilizing genetic and environmental risk score (ERS). Methods: A polygenic risk score (PRS) was constructed based on 20 previously published single nucleotide polymorphisms for colorectal cancer in East Asian populations, using 2 160 samples with MassARRAY test results from a multicenter randomized controlled trial of colorectal cancer screening in China. The ERS was calculated using the Asia-Pacific Colorectal Screening Score system. Logistic regression was used to analyze the association between PRS alone and PRS combined with ERS and colorectal neoplasms risk, respectively. We also designed a risk-adapted screening strategy based on PRS and ERS (high-risk participants undergo a single colonoscopy, low-risk participants undergo an annual fecal immunochemical test, and those with positive results undergo further diagnostic colonoscopy) and compared its effectiveness with the all-acceptance colonoscopy strategy. Results: The high PRS group had a 26% increased risk of colorectal neoplasms compared with the low PRS group (OR=1.26, 95%CI: 1.03-1.54, P=0.026). Participants with the highest PRS and ERS were 3.03 times more likely to develop advanced colorectal neoplasms than those with the lowest score (95%CI: 1.87-4.90, P<0.001). As the risk-adapted screening simulation reached the third round, the detection rate of the PRS combined with ERS strategy was not statistically different from the all-acceptance colonoscopy strategy (8.79% vs. 10.46%, P=0.075) and had a higher positive predictive value (14.11% vs. 10.46%, P<0.001) and lower number of colonoscopies per advanced neoplasms detected (7.1 vs. 9.6, P<0.001). Conclusion: The risk-adapted screening strategy combining PRS and ERS helps achieve population risk stratification and better effectiveness than the traditional colonoscopy-based screening strategy.

Modelling interventions and contact networks to reduce the spread of carbapenem-resistant organisms between individuals in the ICU

BACKGROUND

Contact precautions are widely used to prevent the transmission of carbapenem-resistant organisms (CROs) in hospital wards. However, evidence for their effectiveness in natural hospital environments is limited.

OBJECTIVE

To determine which contact precautions, healthcare worker (HCW)-patient interactions, and patient and ward characteristics are associated with greater risk of CRO infection or colonization.

DESIGN, SETTING AND PARTICIPANTS

CRO clinical and surveillance cultures from two high-acuity wards were assessed through probabilistic modelling to characterize a susceptible patient's risk of CRO infection or colonization during a ward stay. User- and time-stamped electronic health records were used to build HCW-mediated contact networks between patients. Probabilistic models were adjusted for patient (e.g. antibiotic administration) and ward (e.g. hand hygiene compliance, environmental cleaning) characteristics. The effects of risk factors were assessed by adjusted odds ratio (aOR) and 95% Bayesian credible intervals (CrI).

EXPOSURES

The degree of interaction with CRO-positive patients, stratified by whether CRO-positive patients were on contact precautions.

MAIN OUTCOMES AND MEASURES

The prevalence of CROs and number of new carriers (i.e. incident CRO aquisition).

RESULTS

Among 2193 ward visits, 126 (5.8%) patients became colonized or infected with CROs. Susceptible patients had 4.8 daily interactions with CRO-positive individuals on contact precautions (vs 1.9 interactions with those not on contact precautions). The use of contact precautions for CRO-positive patients was associated with a reduced rate (7.4 vs 93.5 per 1000 patient-days at risk) and odds (aOR 0.03, 95% CrI 0.01-0.17) of CRO acquisition among susceptible patients, resulting in an estimated absolute risk reduction of 9.0% (95% CrI 7.6-9.2%). Also, carbapenem administration to susceptible patients was associated with increased odds of CRO acquisition (aOR 2.38, 95% CrI 1.70-3.29).

CONCLUSIONS AND RELEVANCE

In this population-based cohort study, the use of contact precautions for patients colonized or infected with CROs was associated with lower risk of CRO acquisition among susceptible patients, even after adjusting for antibiotic exposure. Further studies that include organism genotyping are needed to confirm these findings.

Co-occurrence of multiple plasmid-borne linezolid resistance genes-optrA, cfr, poxtA2 and cfr(D) in an Enterococcus faecalis isolate from retail meat

OBJECTIVES

To investigate the molecular characteristics and transferability of plasmid-borne linezolid resistance genes optrA, cfr, poxtA2 and cfr(D) genes in one linezolid-resistant Enterococcus faecalis DM86 from retail meat.

METHODS

E. faecalis DM86 was screened for the presence of known linezolid resistance genes via PCR analysis. Conjugation experiments were used to evaluate the transferability of the resistance genes. The complete genome of E. faecalis DM86 was obtained using both the Illumina and Nanopore platforms.

RESULTS

Analysis of the complete sequence showed that E. faecalis DM86 belonged to sequence type 116 (ST116). Four linezolid resistance genes were identified on three plasmids, designated as pDM86-2-cfr, pDM86-3-optrA and pDM86-4-poxtA [cfr(D) co-located]. IS1216 mobile elements were found to flank the cfr and optrA locus on these two plasmids. pDM86-3-optrA encoded the RDK-type OptrA protein and a common genetic array of 'IS1216-fexA-optrA-erm(A)-IS1216' was identified on this plasmid. The cfr(D) gene was closely associated with the poxtA2 gene on pDM86-4-poxtA, and similar plasmids and structures were reported recently in the E. faecalis of animal origin. The intra- and inter-species horizontal transferability of this plasmid to E. faecalis JH2-2, Enterococcus faecium BM4105RF and Staphylococcus aureus RN4220 was also proved, with a frequency of 2.8 × 10-3, 1.7 × 10-3 and 3.4 × 10-5, respectively.

CONCLUSIONS

This was the first report of the co-existence of up to four plasmid-borne linezolid resistance genes in one E. faecalis. Thus, efficient actions should be exerted to circumvent the microbiota contamination of food and the further spread of these antimicrobial resistance reservoirs.

[Concordance between three integrated scores based on prostate biopsy and grade-grouping of radical prostatectomy specimen]

Objective: To analyze three different integrated scoring schemes of prostate biopsy and to compare their concordance with the scoring of radical prostatectomy specimens. Methods: A retrospective analysis of 556 patients with radical prostatectomy performed in Nanjing Drum Tower Hospital, Nanjing, China from 2017 to 2020. In these cases, whole organ sections were performed, the pathological data based on biopsy and radical prostatectomy specimens were summarized, and 3 integrated scores of prostate biopsy were calculated, namely the global score, the highest score and score of the largest volume. Results: Among the 556 patients, 104 cases (18.7%) were classified as WHO/ISUP grade group 1, 227 cases (40.8%) as grade group 2 (3+4=7); 143 cases (25.7%) as grade group 3 (4+3=7); 44 cases (7.9%) as grade group 4 (4+4=8) and 38 cases (6.8%) as grade group 5. Among the three comprehensive scoring methods for prostate cancer biopsy, the consistency of global score was the highest (62.4%). In the correlation analysis, the correlation between the scores of radical specimens and the global scores was highest (R=0.730, P<0.01), while the correlations of the scores based on radical specimens with highest scores and scores of the largest volume based on biopsy were insignificant (R=0.719, P<0.01; R=0.631, P<0.01, respectively). Univariate and multivariate analyses showed tPSA group and the three integrated scores of prostate biopsy were statistically correlated with extraglandular invasion, lymph node metastasis, perineural invasion and biochemical recurrence. Elevated global score was an independent prognostic risk factor for extraglandular invasion and biochemical recurrence in patients; increased serum tPSA was an independent prognostic risk factor for extraglandular invasion; increased hjighest score was an independent risk factor for perineural invasion. Conclusions: In this study, among the three different integrated scores, the overall score is most likely corresponded to the radical specimen grade group, but there is difference in various subgroup analyses. Integrated score of prostate biopsy can reflect grade group of radical prostatectomy specimens, thereby providing more clinical information for assisting in optimal patient management and consultation.

Clinical characteristics, risk factors and outcomes of Klebsiella pneumoniae pneumonia developing secondary Klebsiella pneumoniae bloodstream infection

Purpose

The clinical characteristics of Klebsiella pneumoniae (KP) pneumonia and KP bloodstream infection (KP-BSI) are often reported, while the risk factors for KP pneumonia developing into secondary KP-BSI (KP-pneumonia/KP-BSI) are largely unknown. Therefore, this study attempted to investigate the clinical characteristics, risk factors and outcomes of KP-pneumonia/KP-BSI.

Methods

A retrospective observational study was conducted at a tertiary hospital between January 1, 2018, and December 31, 2020. The patients were divided into groups of KP pneumonia alone and KP pneumonia/KP-BSI, and the clinical information were collected from medical records electronic system.

Results

A total of 409 patients were finally recruited. According to the multivariate logistic regression analysis, male sex (adjusted odds ratio [aOR] 3.7; 95% CI, 1.44–9.5), immunosuppression (aOR, 13.52; 95% CI, 2.53,72.22), APACHE II score higher than 21 (aOR, 3.39; 95% CI, 1.41–8.12), serum procalcitonin (PCT) levels above 1.8 ng/ml (aOR, 6.37; 95% CI, 2.67–15.27), ICU stay of more than 2.5 days before pneumonia onset (aOR, 1.09; 95% CI, 1.02,1.17), mechanical ventilation (aOR, 4.96; 95% CI, 1.2,20.5), Klebsiella pneumoniae isolates producing extended spectrum β-lactamase (ESBL-positive KP) (aOR, 12.93; 95% CI, 5.26–31.76), and inappropriate antibacterial therapy (aOR, 12.38; 95% CI, 5.36–28.58) were independent factors of KP pneumonia/KP BSI. In comparison with the patients with KP pneumonia alone, the patients with KP pneumonia/KP BSI showed an almost 3 times higher incidence of septic shock (64.4% vs. 20.1%, p < 0.01), a longer duration of mechanical ventilation, and longer lengths of ICU stay and total hospital stay (median days, 15 vs. 4,19 vs. 6, 34 vs. 17, respectively, both p < 0.01). Additionally, the overall in-hospital crude mortality rate in the patients with KP-pneumonia/KP-BSI was more than two times higher than that in those with KP pneumonia alone (61.5% vs. 27.4%, p < 0.01).

Conclusion

Factors including male sex, immunosuppression, APACHE II score higher than 21, serum PCT levels above 1.8 ng/ml, ICU stay of more than 2.5 days before pneumonia onset, mechanical ventilation, ESBL-positive KP, and inappropriate antibacterial therapy are independent risk factors for KP pneumonia/KP-BSI. Of note, the outcomes in patients with KP pneumonia worsen once they develop secondary KP-BSI, which merits more attention.

An Optimized Screening Approach for the Oxazolidinone Resistance Gene optrA Yielded a Higher Fecal Carriage Rate among Healthy Individuals in Hangzhou, China

The linezolid resistance mediated by optrA has exhibited an increasing trend among Gram-positive bacteria, which greatly limits the treatment options for severe bacterial infections. However, the prevalence of optrA was usually underestimated based on the existing screening methods. In this study, we used a traditional method and an improved method that included a high-salinity condition treatment after enrichment to screen for optrA-carrying bacteria from stool samples from 1,018 healthy donors in Hangzhou, China. The fecal carriage rate of optrA-carrying bacteria was 19.25% when screened by the improved method (196/1,018), which was much higher than that of the traditional method at 5.89% (60/1,018). Enterococci were the majority of the optrA-positive isolates, while five nonenterococcal isolates were also obtained, including two Streptococcus gallolyticus, one Vagococcus lutrae, one Lactococcus garvieae, and one Lactococcus formosensis isolate. Whole-genome sequencing analysis identified four novel OptrA variants, IDKKGPM, IDKKGP, KLDK, and EYDDI, in these isolates, whose optrA-flanking regions with a fexA gene downstream were bounded by different insertion sequences. In conclusion, our optimized method displayed high sensitivity in the detection of optrA-positive bacteria in fecal samples and revealed a high carriage rate in a healthy population. Although enterococci are dominant, multiple optrA-carrying Gram-positive bacteria were also found. IMPORTANCE This study represented an optimized screening approach for the optrA gene, which is an important mechanism of antimicrobial resistance to linezolid as a last resort for the treatment of infections caused by multiresistant Gram-positive bacteria. We revealed a high fecal carriage rate of the optrA gene among adults by this method and reported the first identification of optrA in Lactococcus formosensis as well as the identification of this gene in Vagococcus lutrae and of the poxtA gene in Ligilactobacillus salivarius of human origin, suggesting the wide spread of the optrA gene in the Gram-positive bacterial community.

Clinical characteristics of and risk factors for secondary bloodstream infection after pneumonia among patients infected with methicillin-resistant Staphylococcus aureus

Purpose

To investigate the clinical features and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) pneumonia (MP) with secondary MRSA bloodstream infections (MRSA-BSI) (termed MP-BSI) compared with MP alone and to study the incidence of MP-BSI among patients with MP.

Methods

This was a retrospective, single-center study with clinical data derived from previous medical records. The cases were divided into groups: MP alone and MP-BSI. The determination of independent risk factors for MP-BSI relied on logistic regression analysis. Additionally, the crude outcomes were compared.

Results

A total of 435 patients with MP were recruited, with 18.9% (82/435) having MP-BSI. The median age was 62 (interquartile range, 51,72) years, and 74.5% of the patients were male. Multivariate analysis revealed that immunosuppression, community-acquired MP (CA-MP), time from initial to targeted antibiotic use, high Sequential Organ Failure Assessment (SOFA) score, increased respiratory rate, and elevated γ-GT level (all p < 0.05) were independent risk factors for MP-BSI, while targeted treatment with linezolid was a protective factor. Patients with MP-BSI had a longer duration of hospitalization (median days, 27.5 vs. 19, p = 0.001), a higher 28-day mortality rate (24.4% vs. 11.0%, p = 0.001), and a higher in-hospital mortality rate (26.8% vs. 14.7%, p = 0.009) than those with MP alone.

Conclusion

Secondary MRSA-BSI among patients with MP is not rare. Immunosuppression, CA-MP, time from initial to targeted antibiotic use, high SOFA score, increased respiratory rate and elevated γ-GT level are all independent risk factors for MP-BSI; however, linezolid, as a targeted antibiotic, is a protective factor. Moreover, patients with MP may have worse clinical outcomes when they develop MRSA-BSI.

[Effect of low density carotid plaque on the development of cerebral small vessel disease in patients with carotid stenosis]

Objective: To investigate the correlation between cerebral small vessel disease (CSVD) and carotid low-density plaque on multi-slice spiral CT angiography (MSCTA) in patient with carotid stenosis. Methods: The clinical data of 221 patients with carotid stenosis who admitted to Nanjing Drum Tower Hospital, the Affiliated Hospital of Nanjing University Medical School, from January 2016 to January 2021 were retrospectively analyzed. There were 195 males and 26 females, with the age of (70.0±8.4) years (range: 48 to 88 years). According to MRI, the patients were divided into carotid stenosis combined with CSVD group (the CSVD group) and carotid stenosis without CSVD group (the non-CSVD group). Lowest density in the carotid atherosclerotic plaque area (CAPALD) was analyzed by MSCTA. The t-test, Mann-Whitney U test and Chi-square test were used for comparison between the two groups. Univariate and multivariate Logistic regression analysis were performed on CAPALD and other clinical indicators with CSVD. Receiver operating characteristic (ROC) curves of CAPALD and CAPALD combined with the demographics (sex, age and body mass index) were plotted for predicting CSVD, and the area under the curve (AUC), sensitivity and specificity were calculated. Results: There were 169 patients in the CSVD group and 52 patients in the non-CSVD group. In the CSVD group, 88.8% (150/169) were males and 11.2% (19/169) were females, with the age of (70.5±8.2) years (range: 48 to 88 years). In the non-CSVD group, 86.5% (45/52) were males and 13.5% (7/52) were females, with the age of (68.4±9.1) years (range: 51 to 85 years). CAPALD and the score of Montreal cognitive assessment were lower in the CSVD group than those in the non-CSVD group (21.0 HU vs. 35.0 HU, Z=-3.760, P<0.01; 22.6±3.9 vs. 24.8±3.3, t=-2.064, P<0.05). Multivariate Logistic regression analysis showed that CAPALD was an independent factor for CSVD (OR=1.044, 95%CI:1.020 to 1.070, P<0.01). The AUC of the ROC curve for CAPALD predicting carotid stenosis with CSVD was 0.672 (P<0.01), with cut-off value of 34.5 HU, sensitivity of 82.8%, and specificity of 50.0%. The AUC of ROC curve for CAPALD combined with the demographics predicting CSVD was 0.733 (P<0.01), with sensitivity of 82.9% and specificity of 64.0%. Conclusions: The decreased CAPALD is a risk factor for CSVD in patients with carotid stenosis. The analysis of carotid plaque density by MSCTA may help to identify the patients at high risk of CSVD.

The Value of Preoperative Phase-Contrast MRI in Predicting the Clinical Outcome of Moyamoya Disease after Encephalo-Duro-Arterial Synangiosis Surgery

BACKGROUND AND PURPOSE

In patients with Moyamoya disease, the relationship between preoperative hemodynamic status and prognosis after encephalo-duro-arterial synangiosis (EDAS) surgery was unclear. We aimed to explore the value of the preoperative hemodynamic status acquired by cine phase-contrast MR imaging in predicting collateral formation and clinical outcomes after EDAS surgery in patients with Moyamoya disease.

MATERIALS AND METHODS

Participants with Moyamoya disease were prospectively recruited and underwent preoperative phase-contrast MR imaging. All participants were classified into good and poor groups according to the collateral formation after EDAS surgery. On the basis of the change in the mRS system, participants were classified into the improved mRS group and the poor response group. Hemodynamic status including mean velocity, peak velocity, and blood volume flow of the superficial temporal artery was compared between groups. Logistic regression was performed to relate the phase-contrast MR imaging parameters to collateral formation and clinical outcomes.

RESULTS

A total of 45 patients with Moyamoya disease with unilateral EDAS surgery were finally included. Mean velocity, peak velocity, and blood volume flow of the ipsilateral superficial temporal artery were significantly greater in patients with good collateral formation compared with those with poor collateral formation (P = .011, .004, and .013, respectively). The mean velocity, peak velocity, and blood volume flow were independently associated with postoperative collateral formation after adjusting for confounding factors. Furthermore, the peak velocity of the ipsilateral superficial temporal artery was also significantly associated with improvement of the mRS score.

CONCLUSIONS

Good hemodynamic status of the ipsilateral superficial temporal artery as a donor artery evaluated by phase-contrast MR imaging was significantly associated with better collateral formation and improved mRS after EDAS surgery in patients with Moyamoya disease.

Incidence, clinical characteristics, risk factors and outcomes of patients with mixed Candida/bacterial bloodstream infections: a retrospective study

Purpose

The mixed Candida/bacterial bloodstream infections (mixed C/B-BSIs) is worthy of particular attention recently, and we analyzed the incidence, co-pathogens, clinical characteristics, risk factors, and outcomes of mixed C/B-BSIs compared with monomicrobial candidemia (mono-candidemia) in adult patients in China.

Methods

All hospitalized adults with candidemia were recruited for this retrospective observational study from January 1, 2013, to December 31, 2019.

Results

Of the 296 patients with candidemia, 78 cases (26.3%) were mixed C/B-BSIs. Candida albicans (C. albicans) was the most common Candida species among all candidemia, and Klebsiella pneumoniae (K. pneumoniae) was the most concomitant bacteria (30.6%), followed by Acinetobacter baumannii (A. baumannii) (12.9%) and Enterococcus faecium (E. faecium) (11.8%) in mixed C/B-BSIs. In the multivariable analysis, prior β-lactams exposure [adjusted odds ratio (aOR), 1.97; 95% confidence interval (CI), 1.01–3.87], burn injury (aOR, 6.35; 95% CI 1.82–22.21) and continuous renal replacement therapy (CRRT) (aOR, 3.00; 95% CI 1.46–6.17) were independent risk factors for mixed C/B-BSIs. Compared with mono-candidemia, patients with mixed C/B-BSIs developed with more proportion of septic shock (55.1% vs. 39.9%, P < 0.05), prolonged stay in ICU [22.0(12.0–57.0) vs. 9.5(0.0–37.0) days, P < 0.001] and longer mechanical ventilation time [19.0(4.5–40.8) vs. 6.0(0.0–24.8) days, P < 0.001]. The in-hospital mortality in patients with mixed C/B-BSIs was higher than those with mono-candidemia (59.0% vs. 34.9%, P < 0.001). Survival analysis revealed that 28-day and 60-day mortality were significantly higher in patients with mixed C/B-BSI than in those with mono-candidemia (57.7% vs. 31.7%, P < 0.001; 59.0% vs. 34.9%, P < 0.001; respectively).

Conclusions

There is a high rate of mixed C/B-BSIs cases among candidemia, and K. pneumoniae is the predominant coexisting species. Prior β-lactams exposure, burn injury, and CRRT are independent risk factors for mixed C/B-BSIs. The mortality of patients with mixed C/B-BSIs is significantly higher than those with mono-candidemia, this deserves further attention for clinicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12941-022-00538-y.

Distribution and spread of the mobilised RND efflux pump gene cluster tmexCD-toprJ in clinical Gram-negative bacteria: a molecular epidemiological study

BACKGROUND

TMexCD1-TOprJ1, which is associated with phenotypic resistance to multiple classes of antibiotics, is a transmissible resistance-nodulation-division (RND) family efflux pump. However, the prevalence and genomic and phenotypic characteristics of clinical isolates with this important resistance determinant are poorly understood. In this study, we aimed to survey tmexCD-toprJ among clinical Gram-negative isolates collected from hospitals in China between 1991 and 2020 and characterise tmexCD-toprJ-positive clinical isolates.

METHODS

We conducted online data retrieval and active nationwide surveillance in China to screen tmexCD-toprJ-positive strains. We characterised tmexCD-toprJ-positive clinical strains for their antimicrobial susceptibility, genetic and functional characteristics, and the potential inter-species transmission route of tmexCD-toprJ with whole genome sequencing and bioinformatics analyses. The function of tmexCD-toprJ in Pseudomonas sp and Proteus sp was investigated by tmexD gene knockdown using an isopropylthio-β-galactoside-inducible CRISPR interference system.

FINDINGS

Data retrieval obtained 53 strains carrying tmexCD-toprJ, comprising 32 Pseudomonas spp, 11 Klebsiella pneumoniae, one Aeromonas spp, one Citrobacter freundii, and one uncultured bacterium from diverse niches. 48 (0·64%) of 7517 clinical isolates from China, including seven Klebsiella spp, one Proteus mirabilis, and 40 Pseudomonas spp, carried tmexCD-toprJ. These isolates exhibited multidrug resistance phenotypes and co-harboured resistance genes, such as mcr and carbapenemases genes. tmexCD-toprJ was encoded on both plasmids and chromosomes in all Klebsiella spp that carried plasmid-borne tmexCD-toprJ (n=7), P mirabilis carried chromosome-borne tmexCD-toprJ, and Pseudomonas spp carried either plasmid-borne (n=19) or chromosome-borne (n=21) ones. tmexCD-toprJ had undergone clonal and horizontal transmission among clinical pathogens. Eight different types of genetic context of tmexCD-toprJ were identified, each of which was associated with different mobile elements, including IntI, IS6100, TnAs1-like, ISRor5, ISVsa3, ISCfr-like, Tn5393, and IS222-like, which might facilitate its transmission. Knockdown of tmexD led to a four times decrease in tigecycline minimum inhibitory concentrations in both Pseudomonas spp and Proteus spp.

INTERPRETATION

Our study provides evidence to suggest that tmexCD-toprJ contributes to the antimicrobial resistance phenotypes in different bacterial species. tmexCD-toprJ has disseminated among diverse species of clinical pathogens, which warrants timely monitoring in clinical pathogens.

FUNDING

National Natural Science Foundation of China, Guangdong Major Project of Basic and Applied Basic Research, Natural Science Foundation of Jiangsu Province.

Wien effect in interfacial water dissociation through proton-permeable graphene electrodes

Strong electric fields can accelerate molecular dissociation reactions. The phenomenon known as the Wien effect was previously observed using high-voltage electrolysis cells that produced fields of about 10⁷ V m^-1, sufficient to accelerate the dissociation of weakly bound molecules (e.g., organics and weak electrolytes). The observation of the Wien effect for the common case of water dissociation (H₂O [Formula: see text] H⁺ + OH^-) has remained elusive. Here we study the dissociation of interfacial water adjacent to proton-permeable graphene electrodes and observe strong acceleration of the reaction in fields reaching above 10⁸ V m^-1. The use of graphene electrodes allows measuring the proton currents arising exclusively from the dissociation of interfacial water, while the electric field driving the reaction is monitored through the carrier density induced in graphene by the same field. The observed exponential increase in proton currents is in quantitative agreement with Onsager's theory. Our results also demonstrate that graphene electrodes can be valuable for the investigation of various interfacial phenomena involving proton transport.

Analysis results of 169 cases of chorionic villus samples of missed abortion using high throughput sequencing

OBJECTIVE

This study aimed to evaluate the use of high-throughput sequencing (HTS) technology to detect chromosomes in chorionic villus samples of missed abortion embryos and investigate its utility in the genetic diagnosis of missed abortion.

PATIENTS AND METHODS

HTS was used to assess chorionic villus samples obtained from 169 patients with missed abortions from August 2020 to March 2022, at the Second Affiliated Hospital of Guangxi Medical University. The test results were statistically analyzed. To investigate the impact of advanced age on the incidence of chromosomal abnormalities, the patients were divided into two groups: elderly (≥35 years) and nonelderly pregnant women (<35 years).

RESULTS

(1) Among the samples of 169 patients, 100 (59.17%) cases of chromosomal abnormalities were detected. Among these 100, 90 (90%) had chromosomal numerical abnormalities and 10 (10%) had chromosomal structural abnormalities. (2) Chromosomal numerical abnormality was abnormalities mainly included aneuploidy (92.22%, 83/90), with trisomy (62.22%, 56/90) and monosomy (22.22%, 20/90) accounting for the majority. The top three numerical abnormalities included 18 cases of Turner syndrome (monosomy X; 20%, 18/90), 10 cases of trisomy 16 (11.11%, 10/90), and 10 cases of trisomy 22 (11.11%, 10/90). (3) Villous chromosomal abnormalities were found in 48 (70.59%) elderly pregnant women, and 52 (51.48%) nonelderly pregnant women, with statistically significant differences (p < 0.05).

CONCLUSIONS

(1) Chromosomal abnormality is an important cause of missed abortion, it majorly includes chromosomal numerical abnormality, of which most cases are of aneuploidy. (2) Advanced age may increase the risk of embryonic chromosomal abnormalities. (3) Villus chromosome detection using HTS has a positive value and can be used for analyzing and determining the causes of missed abortion.

Clonal Dissemination of Aeromonas hydrophila With Binary Carriage of blaKPC-2-Bearing Plasmids in a Chinese Hospital

Dissemination of the Klebsiella pneumoniae carbapenemase (KPC)-encoding gene among Enterobacterales is common but relatively rare in Aeromonas spp. In this study, we characterized two KPC-2-producing Aeromonas hydrophila strains (Ah2101 and Ah2111), each isolated from a patient in different intensive care units (ICUs) of a Chinese hospital. Whole-genome sequencing (WGS) revealed simultaneous carriage of the bla_KPC−2 and imiH genes, both of which encode high-level carbapenem resistance in these two A. hydrophila isolates. The two isolates were shown to be clonally related and each isolate harbored two distinguishable bla_KPC−2-bearing plasmids, only one of which was transferrable to A. hydrophila, but not Escherichia coli EC600 via conjugation. The genetic element that contains bla_KPC−2 in these two plasmids, namely ISKpn27-Δbla_TEM−1-bla_KPC−2-ISKpn6, was structurally identical, commonly detected in Enterobacterales, and associated with Tn3-based transposons. In addition, more than sixty putative genes that encode various virulence factors were identified in these two A. hydrophila isolates. This is the first study that reports clonal dissemination of carbapenem-resistant A. hydrophila strains carrying structurally different bla_KPC−2-bearing plasmids. Further investigation is warranted to monitor the future transmission of bla_KPC−2-bearing plasmids in A. hydrophila in clinical settings.

Use of a urinary catheter as a guidewire to facilitate safe nasotracheal intubation following iatrogenic retropharyngeal perforation

Nasotracheal intubation facilitates adequate access for surgical procedures in the oral cavity, is not limited by mouth opening and can be better tolerated by patients in intensive care. Complications of nasotracheal intubation can include epistaxis, turbinate injury and sinusitis. Retropharyngeal submucosal perforation by the tracheal tube has also been infrequently reported. Here, we report a case of difficult nasotracheal intubation resulting in retropharyngeal submucosal perforation in a patient with a history of obstructive sleep apnoea listed for uvulopalatopharyngoplasty. To facilitate successful tracheal re-intubation, we used a soft urinary catheter via the other nostril. In this report, we discuss the reasons why this complication may have occurred, how submucosal perforation could be avoided, and reflect on our management of this rare complication. Difficult nasotracheal intubation can present unique challenges, and airway management plans should be made accordingly.

[Analysis of perioperative efficacy and safety of cytoreductive surgery in the treatment of colorectal cancer peritoneal metastases]

Objective: To analyzed perioperative safety of cytoreductive surgery (CRS) for patients with colorectal cancer peritoneal metastasis (CRPM) and to construct a predictive model for serious advese events (SAE). Methods: A descriptive case-series study was conducted to retrospectively collect the clinicopathological data and treatment status (operation time, number of organ resection, number of peritoneal resection, and blood loss, etc.) of 100 patients with peritoneal metastases from colorectal cancer or appendix mucinous adenocarcinoma who underwent CRS at the Sixth Affiliated Hospital of Sun Yat-sen University from January 2019 to August 2021. There were 53 males and 47 females. The median age was 52.0 (39.0-61.8) years old. Fifty-two patients had synchronous peritoneal metastasis and 48 had metachronous peritoneal metastasis. Fifty-two patients received preoperative neoadjuvant therapy. Primary tumor was located in the left colon, the right colon and the rectum in 43, 28 and 14 cases, respectively. Fifteen patients had appendix mucinous adenocarcinoma. Measures of skewed distribution are expressed as M (range). Perioperative safety was analyzed, perioperative grade III or higher was defined as SAE. Risk factors associated with the occurrence of SAEs were analyzed using multivariate logistic regression. A nomogram was plotted by R software to predict SAE, the efficacy of which was evaluated using the area under the ROC curve (AUC) and correction curves. Results: The median peritoneal cancer index (PCI) score was 16 (1-39). Sixty-eight (68.0%) patients achieved complete tumor reduction (tumor reduction score: 0-1). Sixty-two patients were treated with intraperitoneal hyperthermic perfusion chemotherapy (HIPEC). Twenty-one (21.0%) patients developed 37 SAEs of grade III-IV, including 2 cases of ureteral injury, 6 cases of perioperative massive hemorrhage or anemia, 7 cases of digestive system, 15 cases of respiratory system, 4 cases of cardiovascular system, 1 case of skin incision dehiscence, and 2 cases of abdominal infection. No grade V SAE was found. Multivariate logistic regression analysis showed that CEA (OR: 8.980, 95%CI: 1.428-56.457, P=0.019), PCI score (OR: 7.924, 95%CI: 1.486-42.259, P=0.015), intraoperative albumin infusion (OR: 48.959, 95%CI: 2.115-1133.289, P=0.015) and total volume of infusion (OR: 24.729, 95%CI: 3.956-154.562, P=0.001) were independent risk factors for perioperative SAE in CRS (all P<0.05). Based on the result of multivariate regression models, a predictive nomogram was constructed. Internal verification showed that the AUC of the nomogram was 0.926 (95%CI: 0.872-0.980), indicating good prediction accuracy and consistency. Conclusions: CRS is a safe and effective method to treat CRPM. Strict screening of patients and perioperative fluid management are important guarantees for reducing the morbidity of SAE.