[Prevalence of medicare antiviral drugs use and related factors in HIV-infected people in Ningbo]

Objective: To analyze the use of medicare antiviral drugs (ART) and related factors among HIV-infected people in Ningbo City. Methods: The retrospective data was collected related to infection and treatment of HIV-infected people in ART in Ningbo up to February 2023 through the National Infectious Disease Surveillance System. Binary logistic regression was used to analyze the factors related to medicare antiviral drug use in HIV-infected people. R 4.2.2 software was used for statistical analysis. Results: A total of 6 433 HIV-infected people with ART records were collected, among which 5 783 were in ART. The prevalence of medicare drugs use among people in ART was 24.8% (1 435/5 783, 95%CI: 23.7%-25.9%). Beilun District (8.7%, 43/497) and Fenghua District (5.7%, 14/247) had the lowest level in medicare drugs use. Among people in ART using medicare or out-of-pocket drugs, the prevalence of those who had at least one viral load test in the last year (84.9%, 1 352/1 593) was significantly lower than that of those using free drugs (91.4%, 3 829/4 190) (χ2=52.50, P<0.001). The results of multivariate logistic analysis showed that the factors influencing medicare drug use included low educational level (junior high school and below: aOR=0.24, 95%CI:0.17-0.34), farmer or worker (farmer: aOR=0.60, 95%CI: 0.39-0.91; worker: aOR=0.42, 95%CI: 0.27-0.64), low monthly income (<3 000 Yuan: aOR=0.29, 95%CI: 0.18-0.45), the longer interval time between diagnosis and treatment (≥21 days: aOR=0.47, 95%CI: 0.30-0.74). Conclusions: Significant regional differences on the prevalence of medicare antiviral drugs use in HIV-infected people exist in Ningbo City. Follow-up management program of patients should be improved to strengthen patient compliance to mobilize medicare drug promotion. Meanwhile, publicity of medicare drugs should be strengthened for farmers or workers with low education level and patients with delayed treatment.

Developing a Pipeline of African Global Surgery Scholars

Global surgery is developing as new discipline in many countries. Global surgery primarily aims to improve access to quality surgery in low-and-middle Income countries (LMICs). Thus, ensuring appropriate LMIC representation and leadership in global surgery research, projects, and innovations, is essential. There is a paucity of pathways for students and young clinicians in LMICs to attain training in and exposure to global surgery research and projects. If equity in global surgery leadership and scholarship is truly desired, steps need to be taken to ensure that more students and young clinicians in LMICs are exposed to global surgery as an academic discipline and are offered pathways to practice and leadership. This paper explores ways of ensuring this through increased exposure, increased training and increased funding.

[Prevalence and influencing factors of human soil-transmitted nematode infections in Ningbo City from 2016 to 2021]

OBJECTIVE

To investigate the prevalence and influencing factors of soil-transmitted nematode infections in Ningbo City from 2016 to 2021, so as to provide insights into the development of targeted control measures against soil-transmitted nematodiasis.

METHODS

Permanent residents at ages of 3 years and older were sampled in Ningbo City using a multi-stage sampling method each year during the period from 2016 to 2021. Soil-transmitted nematode eggs were detected in stool samples using a modified Kato-Katz thick smear method (two slides for each stool sample), and Enterobius vermicularis eggs were additionally identified among children at ages of 3 to 12 years using the adhesive cellophane-tape perianal swab method. The time- and regions-specific prevalence of soil-transmitted nematode infections was calculated, and the factors affecting hookworm infections were identified using a multivariate logistic regression model.

RESULTS

A total of 11 573 person-times were detected for soil-transmitted nematode infections in Ningbo City from 2016 to 2021, and 296 egg-positives were detected, with a mean prevalence rate of 2.56% [95% confidential interval (CI): (2.28%, 2.87%)]. Hookworm was the predominant species of soil-transmitted nematode among egg-positives in Ningbo City (98.31%, 291/296), and there was a significant difference in the prevalence of hook-worm infections among years (χ² = 190.27, P < 0.01). The highest prevalence of hook-worm infections was observed in Ninghai County (4.06%), and there was a region-specific prevalence rate of hookworm infection in Ningbo City (χ² = 148.43, P < 0.01). Multivariate logistic regression analysis showed that elderly residents at ages of over 60 years [odds ratio (OR)= 1.94, 95% CI: (1.07, 3.54), P < 0.05], males [OR = 2.19, 95% CI: (1.72, 2.80), P < 0.01], farmers [OR = 6.94, 95% CI: (3.37, 14.29), P < 0.01] and residents with a low education level [illiteracy or semi-illiterate: OR = 3.82, 95% CI: (1.56, 9.35), P < 0.05; primary school: OR = 2.70, 95% CI: (1.11, 6.59), P < 0.05] were at a higher risk for hookworm infections.

CONCLUSIONS

The overall prevalence of soil-transmitted nematode infections was low among residents in Ningbo City from 2016 to 2021. The surveillance and health education for human hookworm disease remain to be reinforced among male farmers with a low education level at ages of over 60 years in Ninghai County.

The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa

BACKGROUND

In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling-up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA has the highest trauma burden of the Cape Metro East health district.   Objectives. The primary objectives of this study were to describe the impact of the Khayelitsha District Hospital (KDH) on acute orthopaedic services for the health district with a focus on the volume and type of orthopaedic services provided without tertiary referral.  Methods. This retrospective analysis described acute orthopaedic cases and their management from Khayelitsha township between 1 January 2018 to 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district were described.  Results. In 2018-2019, KDH performed 2040 orthopaedic operations of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared to other DHs (0.92-1.35). In the Khayelitsha township, 2402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism for acute orthopaedic referrals. 2229 (92.8%) clinic cases were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157, 90.8%).   Conclusions. This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared to other DHs with fewer resources. Further research on the barriers to scaling-up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.

The impact of a decentralised orthopaedic service on tertiary referrals in Cape Town, South Africa

BACKGROUND

In South Africa (SA), district hospitals (DHs) have limited capacity to manage the high burden of traumatic injuries. Scaling up decentralised orthopaedic care could strengthen trauma systems and improve timely access to essential and emergency surgical care (EESC). Khayelitsha township in Cape Town, SA, has the highest trauma burden in the Cape Metro East health district.

OBJECTIVES

The primary objective of this study was to describe the impact of Khayelitsha District Hospital (KDH) on acute orthopaedic services in the health district, with a focus on the volume and type of orthopaedic services provided without tertiary referral.

METHODS

This retrospective analysis described acute orthopaedic cases from Khayelitsha and their management between 1 January 2018 and 31 December 2019. Orthopaedic resources and the proportion of cases referred to the tertiary hospital by all DHs in the Cape Metro East health district are described.

RESULTS

In 2018 - 2019, KDH performed 2 040 orthopaedic operations, of which 91.3% were urgent or emergencies. KDH had the most orthopaedic resources and the lowest referral ratio (0.18) compared with other DHs (0.92 - 1.35). In Khayelitsha, 2 402 acute orthopaedic cases presented to community health clinics. Trauma (86.1%) was the most common mechanism of injury for acute orthopaedic referrals. Of clinic cases, 2 229 (92.8%) were referred to KDH and 173 (7.2%) directly to the tertiary hospital. The most common reason for direct tertiary referral was condition related (n=157; 90.8%).

CONCLUSION

This study outlines a successful example of a decentralised orthopaedic surgical service that increased EESC accessibility and alleviated the high burden of tertiary referrals compared with other DHs with fewer resources. Further research on the barriers to scaling up orthopaedic DH capacity in SA is needed to improve equitable access to surgical care.

A cross-sectional study on the tea consumption effects of ankle-brachial index

OBJECTIVES

This thesis aims to explore the relationship between tea consumption and ankle-brachial index (ABI) and further studies the relationship between tea consumption and lower extremity atherosclerosis.

METHODS

This is a cross-sectional, epidemiological survey of 17,373 subjects selected from the staff of Kailuan Group who had come to Kailuan General Hospital for a health examination from January 2016 to December 2017. Tea consumption was obtained by questionnaires. ABI was measured using an automated analyzer. The other data, such as age, gender, body mass index (BMI), and so on, was collected on the same day of the health examination results. The relationship between tea drinking habits and ABI was studied using logistic regression and multivariate linear regression analysis.

RESULTS

Among the 17,373 analyzed subjects, the difference in age, gender, BMI, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol (TC), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), uric acid (UA), C-reactive protein (CRP), fasting blood-glucose (Fbg), and ABI was statistically significant in the tea-drinking group and the nontea-drinking group (p < 0.05). Multiple logistic regression models revealed that tea consumption was a positive predictor for ABI (odds ratio (OR) = 0.782, confidence interval (CI), 0.615-0.994) (p < 0.05). Multivariate linear regression analysis of the ABI value showed that frequent tea-drinking has a positive correlation with the ABI value (p < 0.05).

CONCLUSIONS

The higher tea consumption is significantly associated with higher ABI which means less risk for lower extremity atherosclerosis.

Exploring pattern recognition: what is the relationship between the recognition of words, faces and other objects?

Debate surrounds processes of visual recognition, with no consensus as to whether recognition of distinct object categories (faces, bodies, cars, and words) is domain specific or subserved by domain-general visual recognition mechanisms. Here, we investigated correlations between the performance of 74 participants on recognition tasks for words, faces and other object categories. Participants completed a counter-balanced test battery of the Cambridge Face, Car and Body Parts Memory tests, as well as a standard four category lexical decision task, with response time and recognition accuracy as dependent variables. Results revealed significant correlations across domains for both recognition accuracy and response time, providing some support for domain-general pattern recognition. Further exploration of the data using principal component analysis (PCA) revealed a two-component model for both the response time and accuracy data. However, how the various word and object recognition tasks fitted these components varied considerably but did hint at familiarity/expertise as a common factor. In sum, we argue a complex relationship exists between domain-specific processing and domain-general processing, but that this is shaped by expertise. To further our understanding of pattern recognition, research investigating the recognition of words, faces and other objects in dyslexic individuals is recommended, as is research exploiting neuroimaging methodologies, with excellent temporal resolution, to chart the temporal specifics of different forms of visual pattern recognition.

[Five-year immunity persistence following immunization with haemophilus influenzae type b conjugate vaccine]

Objective: To evaluate the immunity persistence five years later after immunization with Haemophilus influenzae type b (Hib) conjugate vaccine in healthy infants/children aged 3 months to 5 years in China. Methods: The children were subjects who completed the whole-schedule immunization in the phase Ⅲ clinical trial in Lianshui county of Jiangsu povince was selected for the collection of blood samples at 5 years after vaccination from November to December, 2019. The enzyme-linked immunosorbent assay (ELISA) was used to detect Hib polyribosyl-ribitol-phosphate antibody (anti-Hib-PRP), and the long-term/short-term protection rate, geometric mean concentration (GMC) and geometric mean concentration increase fold (GMFI) of serum anti-Hib-PRP were calculated. Results: A total of 580 children were enrolled in this study, of which 158, 207 and 215 belonged to 3-5 month age group, 6-11 month age group and 1-5 year age group, respectively. The short-term (≥0.15 μg/ml)/long-term (≥1.0 μg/ml) protection rates of serum anti-PRP in the three groups after immunization were 89.24%, 90.34% and 98.60%, respectively; the GMC were 3.95 μg/ml, 3.11 μg/ml and 10.01 μg/ml respectively, and the GMFI were 29.04, 11.01 and 3.26 respectively. Conclusions: Hib conjugate vaccine can still have good immunogenicity after 5 years of primary immunization in healthy infants/children aged 3 months to 5 years in China.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

[Immunogenicity and safety of a booster vaccination with an inactivated severe acute respiratory syndrome coronavirus 2 vaccine in adults aged 18 to 59 years]

Objective: To assess the immunogenicity and safety of a booster vaccination with an inactivated severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. Methods: The phase Ⅱ trial of an inactivated SARS-CoV-2 vaccine was conducted by Jiangsu Provincial Center for Disease Control and Prevention (CDC) since October 2020. The subjects were healthy adults aged 18-59 years, excluding pregnant, and not breastfeeding women. The primary vaccination schedule groups were 0-14 d 5 μg, 0-14 d 10 μg, 0-28 d 5 μg and 0-28 d 10 μg, respectively. And 50 participants in each group, a total of 200, who have received 2-doses primary vaccination were selected in ascending order of the study number and vaccinated with a booster dose (same dosage as primary vaccination) at the 6th months after post the primary vaccination (30-day window period). Blood samples were collected before and after boosting and tested for the geometric mean titers (GMT) and seroconversion of live virus neutralizing antibody, pseudovirus neutralizing antibody and receptor-binding-domain (RBD) IgG antibody. Adverse events (AE) were collected and assessed within 28 days after boosting. Results: The ages of subjects in group 0-14 d 5 μg, 0-14 d 10 μg, 0-28 d 5 μg and 0-28 d 10 μg were (43.98±9.58), (43.46±9.34), (42.56±9.08) and (43.94±11.05) years old, respectively (P=0.877). Sex ratios were balanced among the 4 groups (P=0.331). The live virus neutralizing antibody GMT (95%CI) in group 0-14 d 5 μg, 0-14 d 10 μg, 0-28 d 5 μg and 0-28 d 10 μg increased from 4.07 (3.30-5.04), 3.75 (3.08-4.55), 8.33 (7.01-11.11) and 7.69 (6.19-9.57) before the booster vaccination to 284.84 (215.28-376.86), 233.05 (178.61-304.08), 274.81 (223.64-337.68) and 280.77 (234.59-336.04) in 28 days after the booster vaccination, respectively. The rates of live virus neutralizing antibody seroconversion were all 100% in the 4 groups. The AE incidences following booster vaccination were 18.0% (9 cases), 4.0% (2 cases), 12% (6 cases), and 12% (6 cases) in the 4 groups(P=0.182). No AE was graded as level 3 or worse. No serious AE was reported. Conclusion: One booster vaccination of an inactivated SARS-CoV-2 vaccine administered 6 months after primary vaccination showed good immunogenicity and safety.

P–067 Utility of evaluating semen samples from adolescents with Klinefelter Syndrome for cryopreservation: A multi-institution evaluation

Study question

Should physicians continue to evaluate semen analysis from adolescents with Klinefelter Syndrome for fertility preservation?

Summary answer

In the largest multi-institutional retrospective database to-date for this patient population, no sperm was found in ejaculate for cryopreservation amongst adolescent males with Klinefelter Syndrome.

What is known already

Klinefelter Syndrome is the most common genetic condition leading to male infertility and non-obstructive azoospermia. The condition causes decreased testicular growth, leading to lower production of testosterone and resulting deficiencies in secondary sexual characteristics. While testosterone therapy may be required for hypogonadism, there may be impact on future fertility potential. Current practice is to have KS adolescent patients provide semen analyses to identify potential sperm for cryopreservation. While the incidence is low, current epidemiological studies have been with limited sample size.

Study design, size, duration

This was a retrospective study of all adolescent Klinefelter Syndrome patients seen at the male infertility clinics of two large academic institutions between the years of 2015 to 2020. Adolescence was defined as the ages of 10 – 19 years old, as per the World Health Organization.

Participants/materials, setting, methods

A total of 116 patients were identified for the retrospective study database. Demographic information including weight, height, comorbidities, concurrent medications were collected. Hormone levels such as FSH, LH, testosterone, and estrogen were included for 77 patients. Additionally, semen analyses were available for 49 patients. Main results and the role of chance: Of the 49 patients with semen analyses, only 3 patients had rare sperm in ejaculate not sufficient for cryopreservation while the remaining had azoospermia. The average ejaculate volume of the provided semen samples was 0.9 cc. The average serum total testosterone level of adolescent Klinefelter Syndrome patients was 236 ng/dL. As expected, gonadotropin levels were found to be elevated (mean: 18.47 IU/L for FSH and 9.12 IU/L for LH).

Limitations, reasons for caution

The main limitation for this study was the sample size.

Wider implications of the findings: The findings from the largest retrospective study of this patient population imply a need to revisit counseling regarding the need for semen analyses in adolescent Klinefelter Syndrome patients.

Trial registration number

Not applicable

467 FRAILTY IN SITU SIMULATION

Introduction

The ability to recognise and manage frailty and its associated presentations is variable among acute hospital staff. Patients living with frailty who are admitted to hospital are more likely to suffer adverse effects than those without. We created an inter-professional in-situ simulation programme designed to improve recognition and management of frailty and its common adverse events. The programme objectives align with recommendations from the British Geriatric Society’s ‘Frailty Hub’ and Royal College of Physicians’ ‘Acute Care Toolkit’ for frailty.

Method

Over a two month period, seven sessions were completed on the Older Persons Unit (OPU) at St Thomas’ Hospital. These comprised a simulated scenario followed by facilitated debrief—including technical skills and human factors highlighted by the scenario. Quantitative data was collected through pre and post session questionnaires using the Human Factors Skills for Healthcare Instrument (HuFSHI) and frailty based questions. Post session qualitative data was also collected.

Results

30 participants attended the sessions (nursing, medical and allied health professional). All participants completing the post course questionnaire found the sessions useful. When comparing pre and post session data, participant confidence in 10/12 sections of the HuFSHI and 8/9 frailty based questions demonstrated improvement. The qualitative data showed common learning themes around improved communication, teamwork and escalation. Participants found that the sessions were a valuable ‘opportunity to reflect’ and ‘debrief’, and learn together as a multidisciplinary team.

Conclusion

In-situ simulation is an effective tool for improving knowledge and confidence in managing frail patients. It increases awareness and understanding of human factors, which are key to the multidisciplinary approach frail patients require. The course is being expanded across the OPU and now has funding for a departmental manikin. The programme can be disseminated to other units to help improve the care and safety of those with frailty in hospital.

[Meta-analysis on association between TNF-α and CCR5Δ32 gene polymorphisms and influenza A(H1N1)pdm09]

Objective: To investigate the associations between TNF-α and CCR5Δ32 gene polymorphisms and influenza A(H1N1)pdm09. Methods: Studies in PubMed, Cochrane Library, OVID, EBSCO, Web of Science published before February 7, 2019 were retrieved comprehensively. Observational studies related to TNF-alpha and CCR5 gene polymorphisms and influenza A(H1N1) pdm09 were collected. A strict quality evaluation was carried out according to NOS scale. Meta-analysis was performed using software Revman 5.0 and Stata 11.0. Results: After screening, a total of 8 studies were included in this Meta-analysis. The results showed that TNF-α gene polymorphism rs361525 might be associated with the risk of influenza A(H1N1)pdm09 virus infection (A vs. G: OR=2.25, 95%CI: 1.09-4.65, P=0.03; AA vs. GG: OR=4.34, 95%CI: 1.65-11.41, P=0.003; AA vs. AG+GG: OR=4.38, 95%CI: 1.67-11.48, P=0.003), similar trend also found in rs1800750 (AA+AG vs. GG: OR=2.42, 95%CI: 1.24-4.71, P=0.01). The results of subgroup analysis indicated that A allele and AA+AG genotypes of rs361525 were risk factors for influenza A(H1N1) pdm09 virus infection in Caucasians. AA genotype was a risk factor for influenza A(H1N1) pdm09 virus infection in Mexican (P<0.05). There was no significant difference in the genetic polymorphism of CCR5 and the severity of influenza A (H1N1) pdm09 virus indection (P>0.05). Conclusion: People with allele A or genotype AA at rs361525, genotype AA+AG at rs1800750 of TNF-α gene might be more susceptible to influenza A(H1N1) pdm09.

Bowel preparation for colonoscopy: is diet restriction necessary?

BACKGROUND

Bowel preparation is essential for quality colonoscopy. Although most bowel preparation regimens recommend dietary restriction for 24 to 48 hours before the procedure, the evidence for this is poor. This study aimed to investigate whether dietary restriction during bowel preparation improves the quality of colonoscopy.

METHODS

A prospective, randomised controlled pilot study in which the dietary restriction (DR) group (control) was instructed not to ingest high fibre foods for 48 hours prior to the use of a polyethylene glycol (PEG) bowel preparation. The non-dietary restriction (NDR) group were given no dietary instruction but received instructions for the use of the PEGbased preparation. On the day of colonoscopy, the quality of the bowel effluent was assessed, and additional preparation given as necessary. The primary endpoint was quality of bowel cleansing using the Harefield Cleansing Scale during colonoscopy. The secondary endpoints were the need for additional bowel preparation and the quantity of additional bowel preparation given prior to endoscopy. Data were analysed on an intention to treat basis.

RESULTS

Twenty-three participants were randomised to the intervention group and thirty-four to the control group. Patient demographics were similar in both groups. Dietary restriction did not influence the success rate of bowel preparation: 97% successful bowel preparation in the DR group, vs 91% successful bowel preparation in the NDR group (p = 0.559). Additional bowel preparation requirement were similar in both groups: 35% in the DR group vs 39% in the NDR group (p = 0.768). Mean amount of additional bowel preparation required was similar: 560 ml in the DR group vs 460 ml in the NDR group (p = 0.633).

CONCLUSION

The quality of bowel preparation was comparable in patients with and without dietary restrictions prior to colonoscopy. Non-restrictive diets prior to bowel preparation should be considered to increase compliance. The sample size of this pilot study prohibited definite statistical conclusions but demonstrated this to be a reasonable methodology for a larger study.

Novel chyme reinfusion device for gastrointestinal fistulas and stomas: feasibility study

Background

High-output enterostomies and enteroatmospheric fistulas are common causes of intestinal failure, and may necessitate parenteral nutrition and prolonged hospital stay. Reinfusing lost chyme into the distal gut is known to be beneficial, but implementation has been limited because manual reinfusion is unpleasant and labour-intensive, and no devices are available. A new device is presented for reinfusing chyme easily and efficiently, with first-in-human data.

Methods

The device comprises a compact centrifugal pump that fits inside a standard stoma appliance. The pump is connected to an intestinal feeding tube inserted into the distal intestinal limb. The pump is activated across the appliance by magnetic coupling to a hand-held driver unit, effecting intermittent bolus reinfusion while avoiding effluent contact. Safety, technical and clinical factors were evaluated.

Results

Following microbiological safety testing, the device was evaluated in ten patients (median duration of installation 39·5 days; total 740 days). Indications included remediation of high-output losses (8 patients), dependency on parenteral nutrition (5), and gut rehabilitation before surgery (10). Reinfusion was well tolerated with use of regular boluses of approximately 200 ml, and no device-related serious adverse events occurred. Clinical benefits included resumption of oral diet, cessation of parenteral nutrition (4 of 5 patients), correction of electrolytes and liver enzymes, and hospital discharge (6 of 10). Of seven patients with intestinal continuity restored, one experienced postoperative ileus.

Conclusion

A novel chyme reinfusion device was developed and found to be safe, demonstrating potential benefits in remediating high-output losses, improving fluid and electrolyte balance, weaning off parenteral nutrition and improving surgical recovery. Pivotal trials and regulatory approvals are now in process.

Salidroside Reduces Inflammation and Brain Injury After Permanent Middle Cerebral Artery Occlusion in Rats by Regulating PI3K/PKB/Nrf2/NFκB Signaling Rather than Complement C3 Activity

Salidroside, an active constituent of Rhodiola rosea, is neuroprotective after transient middle cerebral artery occlusion (tMCAO). However, its effects in other experimental stroke models are less understood. Here, we investigated the effect of daily intraperitoneal injections of salidroside in rats after permanent MCAO (pMCAO). Cerebral infarct volumes at 1 day after pMCAO were significantly reduced by treatment with 100 mg/kg/day salidroside, but not by 25 or 50 mg/kg/day, and this benefit of salidroside increased significantly over at least 7 days of treatment, when it was also accompanied by decreased neurological deficit scores. These observations led us to investigate the underlying mechanism of action of salidroside. 100 mg/kg salidroside for 1 day increased NeuN, Nrf2, and its downstream mediator HO-1, while it reduced nuclear NFκB p50, IL-6, and TNFα. Brusatol, a Nrf2 inhibitor, blocked the actions of salidroside on Nrf2, NFκB p50, IL-6, and TNFα. Salidroside also increased the ratio of p-PKB/PKB at 1 day after pMCAO even in the presence of brusatol. LY294002, a PI3K inhibitor, prevented all these effects of salidroside, including those on NeuN, p-PKB/PKB, Nrf2, HO-1, and pro-inflammatory mediators. In contrast, salidroside had no significant effect on the level of cerebral complement C3 after pMCAO, or on the activity of C3 as measured by the expression of cerebral Egr1. Our findings therefore suggest that salidroside reduces neuroinflammation and neural damage by regulating the PI3K/PKB/Nrf2/NFκB signaling pathway after pMCAO, and that this neuroprotective effect does not involve modulation of complement C3 activity.

The application of PRP combined with TCP in repairing avascular necrosis of the femoral head after femoral neck fracture in rabbit

OBJECTIVE

In view of the high occurrence of avascular necrosis of the femoral head (ANFH) after femoral neck fracture and the difficulties in the treatment, our work aimed to explore the effects of platelet-rich plasma (PRP) combined with tri-calcium phosphate (TCP) on the repair of ANFH after femoral neck fracture and to provide reference for clinical treatment.

MATERIALS AND METHODS

Thirty New Zealand white rabbits were randomly divided into control group, TCP group, and PRP+TCP group. The rabbit ANFH model was established and femoral head tissues were collected. HE staining was used for histological observation. Image analysis and statistical analysis were used to calculate the New Bone Area fraction (NBA %). The levels of bone morphogenetic protein (BMP)-7, transforming growth factor (TGF)-β1, basic fibroblast growth factor (bFGF), interleukin (IL)-6 and tumor necrosis factor (TNF)-a in serum were detected by Enzyme-Linked ImmunoSorbent Assay (ELISA).

RESULTS

The new bone area of TCP group was significantly lower than that of PRP+TCP group (p<0.05). Compared with the control group, the levels of BMP-7, TGF-β1 and bFGF were significantly increased in both TCP and PRP+TCP groups (p<0.05), and the increase in PRP+TCP group was higher than that in TCP group. TCP and PRP+TCP can both significantly reduce the content of IL-6 and TNF-a (p<0.05); however, higher decrease was found in PRP+TCP group compared with the TCP group at 8 weeks after injection.

CONCLUSIONS

PRP combined with TCP, which can promote new bone formation and inhibit inflammatory response, showed higher efficiency in repairing ANFH than internal fixation alone.

Simultaneous recovery of both bright and dim structures from noisy fluorescence microscopy images using a modified TV constraint

The quality and information content of biological images can be significantly enhanced by postacquisition processing using deconvolution and denoising. However, when imaging complex biological samples, such as neurons, stained with fluorescence labels, the signal level of different structures can differ by several orders of magnitude. This poses a challenge as current image reconstruction algorithms are focused on recovering low signals and generally have sample-dependent performance, requiring tedious manual tuning. This is one of the main hurdles for their wide adoption by nonspecialists. In this work, we modify the general constrained reconstruction method (in our case utilizing a total variation constraint) so that both bright and dim structures can drive the deconvolution with equal force. In this way, we can simultaneously obtain high-quality reconstruction across a wide range of signals within a single image or image sequence. The algorithm is tested on both simulated and experimental data. When compared with current state-of-art algorithms, our algorithm outperforms others in terms of maintaining the resolution in the high-signal areas and reducing artefacts in the low-signal areas. The algorithm was also tested on image sequences where one set of parameters are used to reconstruct all images, with blind evaluation by a group of biologists demonstrating a marked preference for the images produced by our method. This means that our method is suitable for batch processing of image sequences obtained from either spatial or temporal scanning. LAY DESCRIPTION: Fluorescence microscopy images of complex biological samples contain a wide range of signal levels. This signal variation leads current reconstruction algorithms, which aim to enhance the quality of the raw images, to have sample-dependent performance. In this work, we design a new optimization that allows the reconstruction to "pay equal eqattention to" both bright and dim structures. In this way, we can simultaneously recover both bright and dim structures within a single image or image sequence, as validated when the algorithm was quantitatively tested on both simulated and experimental data. When our method was evaluated alongside current state of art algorithms by a group of biologists, our algorithm was considered qualitatively superior.

Abstract P1-05-03: JNK signaling regulates tumor cell–tumor-associated macrophage cross-talk in triple-negative breast cancer

Despite advances in our understanding of the molecular mechanisms underlying the aggressiveness of triple-negative breast cancer (TNBC), the contribution of tumor-associated macrophages (TAMs) to TNBC pathogenesis has not been therapeutically exploited. TAMs are the most abundant cell types in the tumor microenvironment (TME) and the key contributor to tumor progression and invasion. We have found that c-Jun NH2-terminal kinase (JNK), a member of the MAPK family and a major regulator of inflammation, contributes to TNBC tumorigenesis by promoting the cancer stem-like cell phenotype. However, whether the JNK pathway regulates TAMs and their cross-talk with tumor cells in TNBC remains unknown. Here, we tested the hypothesis that JNK signaling contributes to TNBC aggressiveness by promoting the tumor cell–TAM cross-talk that facilitates TNBC cell invasiveness.

We found that, among 80 patients with primary inflammatory breast cancer (IBC), TNBC tumors (n=18) had 2-fold more TAMs than non-TNBC tumors (n=62, P=0.05) and that high TAM counts were correlated with shorter disease-free survival of patients with IBC (P=0.05). Both JNK1 and c-Jun were highly activated in TAMs, and JNK-IN-8, a pan-inhibitor of JNK, suppressed c-Jun activation. JNK-IN-8 also increased expression of M1 macrophage markers (CD80 and HLA-DR) but reduced expression of TAM markers (CD163 and CD206), suggesting that JNK suppresses M1 macrophage differentiation but promotes TAM differentiation. Co-culture with TAMs significantly enhanced migration and invasion of HCC70 and MDA-MB-468 human and 4T1 murine TNBC cells. Similarly, an enhancement in TNBC cells migration and invasion was observed following culture with TAM-conditioned medium, suggesting that TAMs enhance TNBC cellular activities through paracrine signaling. In addition, inhibition of JNK signaling in TNBC cells or in TAMs by JNK-IN-8 significantly suppressed TAM-promoted enhancement of TNBC cell migration and invasion. These studies strongly suggest that JNK regulates M1/TAM differentiation and TNBC cell–TAM cross-talk. Furthermore, cytokine/chemokine profiling analysis showed that, of the identified molecules, MCP-1 (secreted by TAMs) and VEGF (secreted by TNBC cells) had the highest expression levels and that their expression was dramatically reduced following JNK-IN-8 treatment. Stimulation with recombinant VEGF increased proliferation of MDA-MB-468 cells, and stimulation with recombinant MCP-1 enhanced migration of the cells. These findings suggest that VEGF and MCP-1 are involved in JNK-mediated TNBC cell–TAM cross-talk.

Together, our results suggest that JNK signaling regulates tumor cell–TAM cross-talk through MCP-1– and/or VEGF-mediated paracrine signaling and that JNK is an important therapeutic target in TNBC. Further animal studies using JNK-knockout TNBC cells co-injected with TAMs are needed to confirm our in vitro findings.

Citation Format: Xie X, Otsuka S, Chu K, Lu AY, Tripathy D, Dalby KN, Hittelman WN, Van Laere S, Bartholomeusz C, Ueno NT. JNK signaling regulates tumor cell–tumor-associated macrophage cross-talk in triple-negative breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-05-03.

Genetic Predisposition to Bleeding during Oral Anticoagulant Therapy: Evidence for Common Founder Mutations (FIXVal-10 and FIXThr-10) and an Independent CpG Hotspot Mutation (FIXThr-10)

The recent discovery of five patients with coumarin sensitive FIX-variants due to a missense mutation in the FIX propeptide, either Ala-10Val or Ala-10Thr, has highlighted a novel type of genetic predisposition to bleeding during oral anticoagulant therapy (OAT). In the present study, we report six additional patients with such FIX variants. Haplotype analysis of FIX polymorphisms revealed a founder effect in the five German and Swiss patients with the Val-10 variant. Also, four Thr-10 variants detected in Germany, Switzerland and Great Britain derived from a common founder. Two Thr-10 variants from USA showed an independent de novo origin at a CpG dinucleotide that in general represents a mutation hotspot. These findings implicate the existence of additional subjects with corresponding variants in the populations of various countries. Even though the rare occurrence of these variants does not justify a general aPTT screening during OAT, it is recommended to monitor each bleeding event during OAT in males in order to exclude a genetic predisposition to bleeding by means of the following testing strategy: a) aPTT-testing in each bleeding complication of male patients during OAT, b) if aPTT is disproportionately prolonged, determination of FIX:C, and c) if FIX:C is disproportionately decreased as compared to FII:C, FVII:C and FX:C, sequencing of exon 2 of the FIX gene. This strategy will provide a cost-effective and safe procedure to identify patients that carry the FIX variants. Moreover, such a strategy accumulates data about the prevalence of these FIX mutations in a given population.

The use and discontinuation of hormone replacement therapy in women in South China

OBJECTIVE

The use of hormone replacement therapy (HRT) started later in China than in European countries. The purpose of the present study was to investigate HRT patterns and reasons for the initiation and discontinuation of HRT among women in South China.

METHODS

A telephone survey about menopausal status, the use of HRT, reasons for HRT discontinuation and duration of HRT treatment was conducted in 2014.

RESULTS

A total of 825 telephone surveys were carried out, and 217 previous HRT users and 390 current users were recruited for this study. Among these 607 subjects, 50.7% of the women sought out HRT for hot flushes, 41.6% for fatigue and 41.5% for sleeplessness. Approximately one-third (35.9%) of the patients abandoned HRT during the following year. The reasons for stopping HRT were mainly fear of breast and uterine cancer (28.4%), reduced menopausal symptoms (22.9%) and the inconvenience of taking pills or seeing a doctor (17.9%). The factors related to HRT discontinuation were the age when HRT was initiated (odds ratio 1.59, 95% confidence interval 1.19-2.13) and education level (odds ratio 0.78, 95% confidence interval 0.62-0.98).

CONCLUSIONS

The duration of HRT use in women in south China was short, and a high proportion of the women discontinued HRT. Given the high discontinuation rate and the low medical compliance, Chinese health-care providers still have much to do to let women know about the advantages and disadvantages of HRT and to encourage the use of HRT appropriately.

Utility of digital subtraction angiography-based collateral evaluation in medically treated acute symptomatic basilar artery stenosis

BACKGROUND AND PURPOSE

Although a stroke from atherosclerosis in the basilar artery (BA) often presents with mild initial stroke severity, it has heterogeneous clinical courses. We investigated the efficacy of digital subtraction angiography (DSA)-based collateral perfusion evaluation in association with long-term outcomes of medically treated symptomatic basilar artery stenosis.

METHODS

From a registry database of all consecutive patients with stroke, we included 98 medically treated patients (due to mild initial stroke severity) [National Institute of Health Stroke Scale (NIHSS) scores ≤ 4; symptomatic basilar artery stenosis, 70-99%] with available initial diagnostic DSA. Basilar collateral scoring was performed via the DSA, using a modified version of the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system in both the superior cerebellar artery and anterior/posterior-inferior cerebellar artery territories (score 0-8). The outcomes were designated as the 90-day modified Rankin Scale (mRS90) score (poor, 3-6). Student's t-test, chi-square test and logistic regression analyses were used to identify factors associated with a poor outcome.

RESULTS

The median initial NIHSS score was 2 [interquartile range (IQR), 0-3], median posterior circulation Alberta Stroke Program Early CT Score was 8 (IQR, 7-10), median collateral score was 7 (IQR, 7-8) and 20 (20.4%) had poor mRS90 scores. In multivariate analysis, poorer collateral scores (P = 0.003), higher NIHSS scores (P = 0.005) and lower posterior circulation Alberta Stroke Program Early CT Score (P = 0.017) were independently associated with a poor mRS90 score.

CONCLUSIONS

The DSA-based collateral scoring of the BA large branches might predict long-term outcome in medically treated symptomatic basilar artery stenosis with mild initial severity. Evaluation of BA collateral perfusion status might be useful to determine appropriate treatment strategies.

[Primary varicose veins treated with HE's fire needle therapy: a randomized controlled trial]

OBJECTIVE

To evaluate the clinical efficacy on primary varicose veins treated with He's fire needle therapy.

METHODS

Fifty patients of primary varicose veins were randomized into an observation group (25 cases) and a control group (25 cases). In the observation group, He's fire needle therapy was applied for 8 weeks. The fire needling was done on the sites of varicose veins till the bleeding stopped automatically. Additionally, acupuncture with filiform needle was applied to Heyang (BL 55), Chengjin (BL 56), Chengshan (BL 57) and Kunlun (BL 60) on the affected side. In the control group, no intervention was given. The follow-up visit was conducted regularly and since the 8th week, the same treatment as the observation group was provided in the control group. The revised venous clinical severity score (RVCSS) was used for the evaluation of the primary outcomes. The methods for the evaluation of the secondary efficacy outcomes included the venous insufficiency epidemiologic and economic study of quality of life questionnaire scale (VEINES-QOL/sym questionnaire), the venous insufficiency epidemiologic and economic study of symptom score (VEINES-Sym score), the venous insufficiency epidemiologic and economic study of quality of life scale (VEINES-QOL score) and the Homburg varicose vein severity score (HVVSS). The evaluation was conducted at the baseline, at the end of the 4th week and the 8th week separately. The follow-up evaluation was done at the end of the 16th week in the observation group.

RESULTS

During the study, 5 cases were dropped out, accounting for 10%. RVCSS score in the observation group was lower than that in the control group at the end of the 4th and 8th weeks separately (both P < 0.05). VEINES-QOL score and HVVSS score in the observation group were higher than those in the control group at the end of the 4th and 8th weeks separately (P < 0.05, P < 0.01). VEINES-Sym score in the observation group was increased as compared with that of the control group at the end of the 4th and 8th weeks, but the difference was significant at the end of the 8th week (P < 0.01). HVVSS score at the end of the 8th and 16th weeks was reduced as compared with that at the end of the 4th week in the observation group (both P < 0.05).

CONCLUSION

HE's fire needle therapy is effective on primary varicose veins. It significantly reduces the severity of disease, the severity of symptoms and the attack frequency of symptoms so that the quality of life is improved in the patients. Additionally, the good long-term efficacy is maintained in 8 weeks after treatment. When the duration of treatment is increased from 4 weeks to 8 weeks, HE's fire needle therapy remarkably improves the efficacy for reducing the symptom severity.

Clinical Applications of Simultaneous PET/MR Imaging Using (R)-[11C]-Verapamil with Cyclosporin A: Preliminary Results on a Surrogate Marker of Drug-Resistant Epilepsy

BACKGROUND AND PURPOSE

The development of resistance to antiepileptic drugs is explained well by the transporter hypothesis, which suggests that drug resistance is caused by inadequate penetration of drugs into the brain barrier as a result of increased levels of efflux transporter such as p-glycoprotein. To evaluate the brain expression of p-glycoprotein in patients with drug-resistant epilepsy, including neocortical epilepsy, we developed a noninvsive quantitative analysis including asymmetry indices based on (R)-[(11)C]-verapamil PET/MR imaging with cyclosporin A, a p-glycoprotein inhibitor.

MATERIALS AND METHODS

Six patients with drug-resistant epilepsy, 5 patients with drug-sensitive epilepsy, and 8 healthy controls underwent dynamic (R)-[(11)C]-verapamil PET/MR imaging with an intravenous infusion of cyclosporin A. Asymmetry indices [(Right Region - Left Region)/(Right Region + Left Region) × 200%] of the standard uptake values in each of the paired lobes were calculated.

RESULTS

All patients with drug-resistant epilepsy had significantly different asymmetry from the healthy controls, whereas all patients with drug-sensitive epilepsy had asymmetry similar to that in healthy controls. In the temporal lobe, the asymmetry indices of patients with left temporal lobe drug-resistant epilepsy were more positive than those of healthy controls (healthy controls: 4.0413 ± 1.7452; patients: 7.2184 ± 1.8237; P = .048), and those of patients with right temporal drug-resistant epilepsy were more negative (patients: -1.6496 ± 3.4136; P = .044). In addition, specific regions that had significant asymmetry were different between the lateral and medial temporal lobe epilepsy groups. In the frontal lobe, the asymmetry index of patients with right frontal lobe drug-resistant epilepsy was more negative than that in healthy controls.

CONCLUSIONS

We confirmed that statistical parametric mapping analysis by using asymmetry indices of (R)-[(11)C]-verapamil PET/MR imaging with cyclosporin A could be used as a surrogate marker for drug-resistant epilepsy, and this approach might be helpful for localizing or lateralizing the epileptic zone.

Promoterless gene targeting without nucleases ameliorates haemophilia B in mice

Site-specific gene addition can allow stable transgene expression for gene therapy. When possible, this is preferred over the use of promiscuously integrating vectors, which are sometimes associated with clonal expansion and oncogenesis. Site-specific endonucleases that can induce high rates of targeted genome editing are finding increasing applications in biological discovery and gene therapy. However, two safety concerns persist: endonuclease-associated adverse effects, both on-target and off-target; and oncogene activation caused by promoter integration, even without nucleases. Here we perform recombinant adeno-associated virus (rAAV)-mediated promoterless gene targeting without nucleases and demonstrate amelioration of the bleeding diathesis in haemophilia B mice. In particular, we target a promoterless human coagulation factor IX (F9) gene to the liver-expressed mouse albumin (Alb) locus. F9 is targeted, along with a preceding 2A-peptide coding sequence, to be integrated just upstream to the Alb stop codon. While F9 is fused to Alb at the DNA and RNA levels, two separate proteins are synthesized by way of ribosomal skipping. Thus, F9 expression is linked to robust hepatic albumin expression without disrupting it. We injected an AAV8-F9 vector into neonatal and adult mice and achieved on-target integration into ∼0.5% of the albumin alleles in hepatocytes. We established that F9 was produced only from on-target integration, and ribosomal skipping was highly efficient. Stable F9 plasma levels at 7-20% of normal were obtained, and treated F9-deficient mice had normal coagulation times. In conclusion, transgene integration as a 2A-fusion to a highly expressed endogenous gene may obviate the requirement for nucleases and/or vector-borne promoters. This method may allow for safe and efficacious gene targeting in both infants and adults by greatly diminishing off-target effects while still providing therapeutic levels of expression from integration.