The impact of air pollutants on spontaneous abortion: a case-control study in Tongchuan City

OBJECTIVES

Studies related to air pollutants and spontaneous abortion in urban northwestern China are scarce, and the main exposure windows of pollutants acting on pregnant women are unclear.

STUDY DESIGN

Case-control study.

METHODS

Data were collected from pregnant women in Tongchuan City from 2018 to 2019. A total of 289 cases of spontaneous abortion and 1156 cases of full-term labor were included and analyzed using a case-control study. Logistic regression models were developed to explore the relationship between air pollutants and spontaneous abortion after Chi square analysis and Air pollutant description.

RESULTS

O3 (odds ratio [OR] = 1.028) is a risk factor for spontaneous abortion throughout pregnancy. PM2.5 (OR = 1.015), PM10 (OR = 1.010), SO2 (OR = 1.026), and NO2 (OR = 1.028) are risk factors for spontaneous abortion in the 30 days before the last menstrual period. PM2.5 (OR = 1.015), PM10 (OR = 1.013), SO2 (OR = 1.036), and NO2 (OR = 1.033) are risk factors for spontaneous abortion in the 30-60 days before the last menstrual period. PM2.5 (OR = 1.028), PM10 (OR = 1.013), SO2 (OR = 1.035), and NO2 (OR = 1.059) are risk factors for spontaneous abortion in the 60-90 days before the last menstrual period.

CONCLUSION

Exposure to high levels of air pollutants may be a cause of increased risk of spontaneous abortion, especially in the first trimester of the last menstrual period.

Clinical Implementation of Weak Magnetic Field Generator in Radiation Therapy

PURPOSE/OBJECTIVE(S)

The application of weak magnetic fields may improve radiation therapy efficacy by manipulating the free radical activity induced by radiation to optimize tumor death. Once the device is commercially available, we will conduct clinical trials to determine the clinical impact of the weak magnetic field. However, the magnetic field generator (MFG) restricts Linac gantry rotation to approximately 180° and this limitation may limit treatment plan quality. This work is a continuation of an ongoing study to determine if the gantry angle restrictions can be compensated for during treatment planning.

MATERIALS/METHODS

Previous work has demonstrated the feasibility for GBM cases. For this work, 10 prostate cancer treatment plans were retrospectively replanned using only coplanar arcs that spanned from 90° to 270° (half-arcs). The prescriptions were 60 Gy for 6 patients, 55.8 Gy for 2 patients, 54 Gy for 1 patient, and 40.05 Gy for 1 patient. The prescription doses were delivered to 95% of the planning target volume (PTV = GTV + 2 cm). The critical structure doses were compared to determine if clinically equivalent plans could be delivered using half-arcs.

RESULTS

The dose criteria that were met by the clinical plans were also met by the half-arc plans except for the cases shown in Table 1. Table 1: Doses that did not meet criteria CONCLUSION: The half-arc plans were able to deliver clinically equivalent dose distributions as the clinical treatment plans. This provides continuing evidence that clinical trials will be able to be developed to evaluate the use of weak magnetic fields for radiation therapy.

One Year Radiographic Response Following Prostrate SBRT: An Exploratory Analysis of a Phase III Randomized Trial

PURPOSE/OBJECTIVE(S)

Radiographic MRI response following prostate radiotherapy, particularly stereotactic body radiotherapy (SBRT), remains poorly understood. Our objective was to describe radiographic changes to the prostate gland and prostate tumor following SBRT of men treated on a prospective, randomized trial.

MATERIALS/METHODS

MIRAGE (NCT04384770) is a single center, randomized phase III trial of patients receiving either CT or MRI guided SBRT for localized prostate cancer. Patients underwent pre-treatment and annual post-treatment MRIs, in addition to routine PSA surveillance. Outcomes reported include percent gland shrinkage, percent PSA response at one year, and presence of residual tumor based on radiographic interpretation. Patient characteristics were compared via two-sample t-test or Fischer's exact test. Both univariate and multivariable logistical analysis were employed to identify potential clinical predictors of residual tumor on 1-year follow up MRI.

RESULTS

This study cohort included 94 eligible patients with baseline characteristics in Table 1. Residual lesions were seen in 13 patients (14%), 5/27 (18.5%) treated without ADT and 8/67 (12%) with ADT. PSA ablation was deep, with a 79% median decrease without ADT and 98% median decrease with ADT. Patients receiving ADT showed more gland shrinkage (17% vs. 34% shrinkage, p = 0.0001), while radiographic non-responders and responders experienced similar gland shrinkage (median 21% vs 29% shrinkage, p > 0.05). No significant clinical predictors of residual tumor were identified on univariate and multivariate analysis. No patient had any clinical or biochemical evidence of failure.

CONCLUSION

A total of 14% of patients were found to have residual tumor detected on MRI one year after SBRT. These data highlight the protracted nature of radiographic tumor response to radiation therapy, even with ablative radiation techniques. The analysis is limited by the lack of biopsy data to quantify whether visualized residual tumor harbor active cancer.

Treatment Delivery Gating of MRI-Guided Stereotactic Radiotherapy for Prostate Cancer: An Exploratory Analysis of a Phase III Randomized Trial of CT-Vs. MR-Guided Radiotherapy (MIRAGE)

PURPOSE/OBJECTIVE(S)

Compared to CT-guided radiotherapy, MRI-guided radiotherapy (MRgRT) has been shown to reduce acute physician-scored and patient-reported gastrointestinal and genitourinary (GU) toxicities associated with prostate stereotactic body radiotherapy (SBRT) in the MIRAGE randomized trial (NCT04384770). We hypothesize that real-time intrafraction tracking/gating is important and is a critical enabler of aggressive margin reduction with MRgRT.

MATERIALS/METHODS

79 patients received MRgRT on the MIRAGE trial with a planning margin of 2mm around the prostate and proximal seminal vesicles, which were treated to 40 Gy in five fractions on an MR-Linac. Tracking was performed at 4 frames/second in the sagittal plane during treatment with a gating boundary of 3mm for automatic beam hold. An in-house tool was developed to extract treatment time and beam gating status based on treatment logs and real-time cine images. The ratio of the time that the target was within the gating window/total time of target inside or outside the gating boundary was defined as the duty cycle (DC). Target contours were extracted from each frame of tracking and overlaid to create a motion-convolved target occupancy map. Minimum isotropic expansions of the prostate to cover 85%, 90% and 95% of the intrafraction motion were calculated with and without gating.

RESULTS

Median treatment time per fraction including image guidance procedure and beam delivery was 24.3 min (IQR: 22.2-27.7 min). The median time for image guidance 5.4 min (IQR: 4.2-6.7 min). A total of 391 treatment fractions were analyzed and the median DC per fraction was 0.974 (IQR: 0.926 -0.983). 89 (22.8%) and 35 (9.0%) of fractions had DC<90% and <80%, respectively, corresponding to 50/79 (62.3%) and 24/79 (30.4%) of patients having at least one fraction with a DC<90% and <80%, respectively. The minimum duty cycle of all fractions was lower among patients with grade ≥2 GU toxicity compared to those with grade 0-1 GU toxicity (mean 79.8% vs. 85.9%, p = 0.06). The proportion of patients with grade ≥2 GU toxicity was also greater in patients with a minimum gating cycle <80% (37.5% vs. 18.2%, p = 0.06). Gating significantly decreased the minimum isotropic expansion of the prostate to cover 85%, 90% and 95% of the intrafraction motion (p<0.0001 for all). Prostate intrafraction motion tended to be along the bladder-rectum axis secondary to bladder filling, rectal gas and bulk motion. Fractions with large prostate motion were mostly stochastic.

CONCLUSION

A large fraction (30%) of patients had at least of one treatment fraction with DC<80%, which correlated with increased acute GU toxicity. Gating effectively reduces the expansion needed to cover prostate intrafraction motion, and is necessary for real-time motion management given the unpredictable nature of prostate motion.

Dosimetric Implications of Prostate Bed Deformability: An Analysis of the SCIMITAR Clinical Trial

PURPOSE/OBJECTIVE(S)

The post-operative prostate bed is a dynamic target volume due to the deformable nature of the bladder and rectum. These changes can lead to incorrect dosing of the prostate bed and organs at risk (OARs). Our objective was to quantify the dosimetric impact of prostate bed and OAR deformation.

MATERIALS/METHODS

SCIMITAR (NCT03541850) is a prospective phase II clinical trial evaluating stereotactic body radiotherapy (SBRT) in the post-prostatectomy setting. This analysis included a subset of patients who received 5 fractions of 6-6.8 Gy to the prostate bed under CT-based image guidance. The clinical target volume (CTV) and OARs were contoured on fractional CBCT images. Changes in volume, shape (via the dice similarity coefficient [DSC]), and dosimetry were quantified. Student's t-test was used to analyze the differences between planning and daily treatment outcomes.

RESULTS

A total of 29 patients (145 fractional images) were analyzed. We found the CTV volume remained stable (median change 1.1%; IQR: -15.1% - 16.1%), whereas the CTV shape was deformable (DSC of 0.76 [IQR: 0.71 - 0.79]). The bladder and rectum exhibited changes with median volume change of 5.7% (IQR: -24.3% - 51.0%) and 5.5% (IQR: -8.7% - 21.9%), respectively and median DSC of 0.77 (IQR: 0.68 - 0.84) and 0.74 (IQR: 0.69 - 0.80) respectively. The CTV received less radiation dose than planned (volume receiving 95%: 93.2% actual vs 99.6% planned, p < 0.01). 39% (56/145) of total fractions and 52% (15/29) of patients met criteria for CTV under-coverage (volume receiving 95% of the prescription dose < 93%). The rectum received higher dose than planned on several parameters (e.g., V27.5 Gy increased from 15.4% to 21.0% [p = 0.009] and V32.5 Gy increased from 6.0% to 10.9% [p = 0.006]) (Table 1).

CONCLUSION

We found underdosing of the prostate CTV and overdosing of the rectum in patients receiving CT-guided postoperative SBRT. While future work will correlate these dosimetric consequences with toxicity, these data suggest that approaches such as adaptive radiotherapy may be beneficial.

Towards Automated Dosimetric Analysis of the Bladder Trigone: Deep-Learning-Based Joint Segmentation and Landmark Localization

PURPOSE/OBJECTIVE(S)

The bladder trigone dosimetry is hypothesized to have a stronger correlation with post-SBRT urinary toxicity than that of the entire bladder. However, the trigone tends to move significantly between simulation and daily treatment. Its small size, large daily motion, and proximity to the target lead to potentially consequential but unaccounted-for dosimetric uncertainties. Manual segmentation of the structure can be inconsistent and time-consuming, even with MR-guided RT. Here, we propose and demonstrate a deep-learning-based framework for joint segmentation and landmark localization to support deformable registration and comprehensive dosimetric analysis.

MATERIALS/METHODS

A total of 30 patients were randomly selected for training, and 20 were held out for testing. Each patient had 1 simulation and 5 daily pre-treatment images obtained from a clinical 0.35T MR Linac. The trigone is defined as the triangular bladder section among three landmarks (2 ureteral orifices and the internal urethral orifice). In the manual contouring process, the 3 landmarks were identified first, followed by trigone segmentation. The proposed joint method uses a modified 3D nnU-Net with 2 decoders, one for segmentation and the other for landmark localization. The shared encoder is expected to extract features useful for both tasks. The joint framework was compared with a baseline method using two separate 3D nnU-Nets for landmark localization and trigone segmentation, respectively. Since the trigone is small (∼2% of the bladder volume), we further experimented with a second-stage prediction mimicking the human contouring process. The predicted landmarks from the first stage were used to crop the trigone region, and a second network was trained on cropped images. Evaluation metrics included the Dice score, 95% Hausdorff distance (HD95), and average surface distance (ASD) for segmentation, and Euclidean distance (ED) between the predicted and ground truth landmarks for localization.

RESULTS

The quantification metrics are summarized in the table below. The joint approach shows similar Dice performance to the baseline method but markedly better HD95 by 13%. For landmark localization, the proposed method is similar to the baseline, but the integration of the segmentation task stabilizes the training process. The two-stage approach further improves HD95, ASD, and ED by 27%, 24%, and 19%.

CONCLUSION

Combining segmentation and landmark localization exhibits a synergistic effect. The proposed two-stage approach provided additional improvement. Future studies will explore the deformable registration of the trigone based on the segmentation and landmark detection, as well as analyze cumulated dose distribution.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries

OBJECTIVE

To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico.

DESIGN

Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022).

RESULTS

In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing.

CONCLUSION

Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Bifunctional Role of Monocyte Subsets in Modulating Radiotherapy Combined Intra-Tumor αCD40 Agonist Induced Abscopal Effect

PURPOSE/OBJECTIVE(S)

Abscopal effect induced by radiotherapy and immune checkpoint blockade is a promising yet far from satisfactory strategy in clinical. The underlying immune mechanism, especially driven by monocytes remains poorly undefined. Monocytes consist of two phenotypically and functionally distinct subsets distinguished by expression of chemokine receptors CCR2 and CX3CR1: classical inflammatory Ly6ChiCCR2hi monocytes and nonclassical patrolling Ly6CloCCR2loCX3CR1hi monocytes. Monocytes differentiate and transit to other myeloid cells such as dendritic cells and macrophages according to various environmental cues. Herein we investigated the roles of monocyte subsets in modulating tumor control consisting of combination RT and myeloid checkpoint agonist αCD40 to specifically ignite myeloid cell activation.

MATERIALS/METHODS

To establish abscopal model, contralateral tumors were implanted in each mouse, while only one side were treated with RT (8 Gy × 3) + αCD40 agonist (50 μg, intra-tumor). Tumor volume and mice survival were compared in each group (control, RT, αCD40 and RT + αCD40). Ccr2RFP/+ Cx3cr1GFP/+ (R2 × 3), Ccr2RFP/RFPCx3cr1+/+ (R2-KO) and Ccr2+/+Cx3cr1GFP/GFP (X3-KO) mice were used for cell tracking and to dissect chemokine receptor CCR2 and CX3CR1 on monocyte. Tumor infiltrating immune cells were analyzed by flowcytometry and RNA-seq.

RESULTS

RT combined with αCD40 significantly dampened tumor growth on both ipsilateral and contralateral sides in abscopal model (p< 0.01), accompanied by upregulation of chemokine receptors CCR2 and CX3CR1 on myeloid cells were both increased in tumor and peripheral blood. Chemokine ligands CCL2, CCL3, CCL5, CCL7, CCL12 and CX3CL1 were upregulated in tumor after RT and αCD40 treatment, recruiting CCR2 and CX3CR1 expressing monocytes in situ. To elucidate the roles of CCR2 and CX3CR1 in mediating local and systemic anti-tumor immunity, R2 × 3, R2-KO and X3-KO mice with combined treatment were used. Tumor size on ipsilateral leg were similar among groups. However, tumor growth was significantly delayed on contralateral side in X3-KO mice while accelerated in R2-KO mice compared with that in R2 × 3 mice. Mechanistically, remarkable decrease of antigen presenting dendritic cells (MHCII+Ly6ChiCD11c+) were observed in R2-KO mice. Moreover, phagocytosis was strengthened in macrophages (F4/80+CD11b+) of X3-KO mice.

CONCLUSION

CX3CR1 deletion ignite anti-tumor immunity elicited by RT and αCD40 through enhanced phagocytosis in macrophages, while CCR2 deletion renders inferior tumor control through reduction of dendritic cells. Preferential targeting nonclassical patrolling monocyte may lead to enhanced local and systemic tumor control.

[Clinical characteristics and prognostic factors of patients with anti-melanoma differentiation-associated gene 5 antibody-positive dermatomyositis associated interstitial lung disease]

Objective: To analyze the clinical characteristics and prognostic factors of patients with anti-melanoma differentiation-associated gene 5 (anti-MDA5)-positive dermatomyositis associated interstitial lung disease (DM-ILD). Methods: The patients with MDA5+DM-ILD who were admitted to Department of Respiratory Medicine, Nanjing Drum Tower Hospital from January 2017 to March 2021 were enrolled. The clinical data and survival information were analyzed retrospectively. Patients were divided into survival group or death group, and rapid progressive ILD (RP-ILD) group or non-rapid progressive ILD group, according to their survival status and clinical progression. Results: A total of 105 patients with anti-MDA5+DM-ILD (median age of onset 54 years) were enrolled, 58% being female (61 cases). The main sub-type of dermatomyositis was amyopathic dermatomyositis (n=74, 70%), followed by dermatomyositis (n=31, 30%). The main extrapulmonary manifestations were skin lesions (n=60, 57.1%), muscle manifestations(n=20, 19%) and arthralgia/arthritis (n=20, 19%). 15.4% of the patients had positive ANA (antibody titer≥1∶320), and 61.9% of the patients had anti-RO-52 kDa antibody. A total of 66 patients (62.8%) developed RP-ILD, and 58 patients (56.3%) died. Lower oxygenation index (OR=0.974, 95%CI:0.954-0.994, P=0.012) and no joint pain (OR=0.032, 95%CI: 0.002-0.663 P=0.026) were independent risk factors for RP-ILD. Cox regression analysis showed that RP-ILD (HR=3.194, 95%CI:1.025-9.954, P=0.045), older than 53 years (HR=3.450, 95%CI: 1.388-8.577, P=0.008), ferritin level more than 1 330.5 ng/ml (HR=3.032, 95%CI 1.208-7.610, P=0.018) and C-reactive protein (CRP) above 16.95 mg/L (HR=2.794, 95%CI:1.102-7.084, P=0.030) were independent predictors of mortality. Conclusions: The clinical manifestations of patients with anti-MDA5+DM-ILD presenting to the respiratory department were heterogeneous, with most being amyopathic dermatomyositis, and both the incidence of RP-ILD and the risk of death were high. Even in the absence of associated rash, joint, or muscle manifestations, anti-MDA5 antibody screening should be considered in patients with rapidly progressive ILD who were negative on baseline autoantibody screening but positive for anti-RO52kDa antibody.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

[Exploration of the effect of blood lipids on the lesion distribution pattern in acute ischemic stroke based on MRI study with population standard spatial analysis]

Objective: To explore the effect of blood lipids on the lesion distribution pattern in patients with acute ischemic stroke by using MRI technology based on population standard spatial analysis. Methods: The MRI data of 1 202 patients with acute ischemic stroke in General Hospital of Eastern Theater Command from January 2015 to December 2020 and Nanjing First Hospital from January 2013 to December 2021 were retrospectively collected, including 871 males and 331 females, aged 26 to 94 (64±11) years. According to the condition of blood lipids, they were divided into the dyslipidemia group (n=683) and the normal blood lipids group (n=519). After the automatic segmentation of diffusion-weighted imaging (DWI) images by artificial intelligence, the infarct sites were registered to the standard space which was used to draw the frequency heat map. The chi-square test was used to compare the difference in lesion location between the two groups. Generalized linear model regression analysis was used to observe the correlation between each blood lipid index and lesion site, and inter-group comparison and correlation analysis were used to observe the relationship between each blood lipid index and lesion volume. Results: Compared with the normal blood lipid group, the lesions in the dyslipidemia group were more extensive, mostly distributed in the occipital temporal region of the right posterior cerebral artery and the frontal region of the left middle cerebral artery. The brain regions of higher triglyceride(TG) and higher low-density lipoprotein cholesterol(LDL-C) groups were concentrated in the posterior circulation. The brain regions in the higher total cholesterol(TC) and lower high-density lipoprotein cholesterol(HDL-C) groups were concentrated in the anterior circulation(all P<0.05). In the anterior circulation infarct volume, the higher TC group was significantly higher than the normal TC group[(27.58±5.34) vs (17.73±1.18)ml, P=0.029]. In the posterior circulation infarct volume, the higher LDL-C group and the TG group were significantly higher than the normal LDL-C and TG groups[(7.55±2.51) vs (3.55±0.31) ml; (5.76±1.19) vs (3.36±0.30) ml](both P<0.05). Correlation analysis showed that TC and LDL-C were non-linearly (U-shaped) correlated with anterior circulation infarct volume (both P<0.05). Conclusions: Different blood lipids have effects on the distribution pattern and volume of ischemic stroke infarcts. Different hyperlipidemia is related to the specific distribution site and the larger extent of infarction.

A randomized trial of eribulin monotherapy versus eribulin plus anlotinib in patients with locally recurrent or metastatic breast cancer

BACKGROUND

Eribulin mesylate is a novel, nontaxane, microtubule dynamics inhibitor. In this study, we assessed the efficacy and safety of eribulin versus eribulin plus the oral small-molecule tyrosine kinase inhibitor anlotinib in patients with locally recurrent or metastatic breast cancer.

PATIENTS AND METHODS

In this single-center, open-label, phase II clinical study (NCT05206656) conducted in a Chinese hospital, patients with human epidermal growth factor receptor 2 (HER2)-negative, locally recurrent or metastatic breast cancer previously treated with anthracycline- or taxane-based chemotherapy were randomized (1 : 1) to receive eribulin alone or in combination with anlotinib. The primary efficacy endpoint was investigator-assessed progression-free survival (PFS).

RESULTS

From June 2020 to April 2022, a total of 80 patients were randomly assigned to either eribulin monotherapy or eribulin plus anlotinib combination therapy, with 40 patients in each group. The data cut-off was 10 August 2022. The median PFS was 3.5 months [95% confidence interval (CI) 2.8-5.5 months] for eribulin and 5.1 months (95% CI 4.5-6.9 months) for eribulin plus anlotinib (hazard ratio = 0.56, 95% CI 0.32-0.98; P = 0.04). The objective response rates were 32.5% versus 52.5% (P = 0.07), respectively, and disease control rates were 67.5% versus 92.5% (P = 0.01), respectively. Patients <50 years of age, with an Eastern Cooperative Oncology Group performance status score of 0, visceral metastasis, number of treatment lines of four or more, hormone receptor negative (triple-negative), and HER2 low expression appeared to benefit more from combined treatment. The most common adverse events in both groups were leukopenia (n = 28, 70.0%, patients in the eribulin monotherapy group versus n = 35, 87.5%, patients in the combination therapy group), aspartate aminotransferase elevations (n = 28, 70.0%, versus n = 35, 87.5%), neutropenia (n = 25, 62.5%, versus n = 31, 77.5%), and alanine aminotransferase elevations (n = 25, 62.5%, versus n = 30, 75.0%).

CONCLUSION

Eribulin plus anlotinib can be considered an alternative treatment option for HER2-negative locally advanced or metastatic breast cancer.

Australian healthcare professionals' perspectives on the ethical and practical issues associated with genomic newborn screening

Newborn bloodspot screening (NBS) is a successful public health initiative that seeks to identify serious, treatable medical conditions. The increasing use of genomic sequencing (GS) in a wide range of medical settings has reignited the discussion on whether GS can and should be integrated into NBS. Yet, the perspectives of healthcare professionals (HCPs) in Australia on the ethical and practical issues associated with the implementation of genomic newborn screening (GNBS) are underexplored. To address this, we conducted semi-structured interviews with 16 Australian HCPs with clinical or policy experience in NBS and/or GS to explore their perspectives on the ethical, social, and practical issues raised by integrating GS into NBS. Interviews were analyzed using inductive content analysis. When asked whether GS should be incorporated into NBS, HCPs did not feel it was currently appropriate but there was a strong consensus it may be implemented within the next decade. However, HCPs had differing perspectives on what conditions should be included and how to best handle the volume of data generated from GNBS. Our findings have important implications for determining at what point and how genomics can be integrated into NBS. The differing views expressed amongst HCPs suggest that further research is needed to explore the reasons behind this. Importantly, our participants highlighted a potential role for genetic counselors in the implementation of GNBS on a larger scale by developing educational resources to facilitate obtaining informed consent and return of results.

Role of synovial lymphatic function in osteoarthritis

BACKGROUND

Osteoarthritis (OA) affects the entire joint, initially with a low degree of inflammation. Synovitis is correlated with the severity of OA clinical symptoms and cartilage degradation. The synovial lymphatic system (SLS) plays a prominent role in clearing macromolecules within the joint, including the pro-inflammatory cytokines in arthritic status. Scattered evidence shows that impaired SLS drainage function leads to the accumulation of inflammatory factors in the joint and aggravates the progression of OA, and the role of SLS function in OA is less studied.

DESIGN

This review summarizes the current understanding of synovial lymphatic function in OA progression and potential regulatory pathways and aims to provide a framework of knowledge for the development of OA treatments targeting lymphatic structure and functions.

RESULTS

SLS locates in the subintima layer of the synovium and consists of lymphatic capillaries and lymphatic collecting vessels. Vascular endothelial growth factor C (VEGF-C) is the most critical regulating factor of lymphatic endothelial cells (LECs) and SLS. Nitric oxide production-induced impairment of lymphatic muscle cells (LMCs) and contractile function may attribute to drainage dysfunction. Preclinical evidence suggests that promoting lymphatic drainage may help restore intra-articular homeostasis to attenuate the progression of OA.

CONCLUSION

SLS is actively involved in the homeostatic maintenance of the joint. Understanding the drainage function of the SLS at different stages of OA development is essential for further design of therapies targeting the function of these vessels.

Chronic Opioid Use and Sleep Disorders

Opioid medications are considered a significant component in the multidisciplinary management of chronic pain. In the past two decades, the use of opioid medications has dramatically risen in part because of an increased awareness by health care providers to treat chronic pain more effectively. In addition, patients are encouraged to seek treatment. The release of a sentinel joint statement in 1997 by the American Academy of Pain Medicine and the American Pain Society in a national effort to increase awareness and support the treatment of chronic pain has undoubtedly contributed to the opioid crisis.

Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology

Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.

[Idiopathic pleuroparenehymal fibroelastosis: five case reports and review of literature]

Objective: To raise the awareness of idiopathic pleuroparenehymal fibroelastosis (iPPFE) through investigating the clinical, radiographic and pathological features. Methods: Five cases of iPPFE proved by pathology. The clinical data were studied respectively, and the relevant literature was reviewed. Results: All the cases of iPPFE were manifested by cough and dyspnea. The patients including 3 males and 2 females, aged from 30 to 70 years Chest CT scan showed pleural thickening, subpleural consolidation in both upper lungs complicated with tractive bronchiectasis.Computed tomography-guided percutaneous lung biopsy or surgical lung were performed and the same pathological showed pleura and subpleural dense elastic and collagen fibers. The elastic fibers stain was also positive,which was consistent with PPFE. One patient received low-dose corticosteroid, two received pirfenidone therapy, the others received no treatment. Three patients were stable during the follow-up. Conclusions: iPPFE has characteristic pathological features. However, the number of clinically reported cases is low due to missed diagnosis or misdiagnosed. Improving the understanding of features of iPPFE is helpful for the dianosis, therapy, and prognosis of this disease.

The Effects of an Integrated Exercise Intervention on the Attenuation of Frailty in Elderly Nursing Homes: A Cluster Randomized Controlled Trial

OBJECTIVES

The frail elderly have an increased risk of frailty because of reduced physical activity, cognitive ability and quality of life. This study aims to evaluate the effects of integrated exercise intervention on the attenuation of frailty in elderly nursing home residents.

DESIGN

This study was a cluster randomized controlled trial.

SETTING AND PARTICIPANTS

146 elderly frailty people from 8 elderly nursing homes in Harbin, China, were randomly assigned into the intervention group and control group after obtaining their informed consent.

INTERVENTION

The intervention group performed integrated exercise interventions for 12 months, while the control group only continued with their daily activities.

MEASUREMENTS

Sociodemographic, health-related data, frailty levels, gait parameters, cognition, and quality of life were evaluated.

RESULTS

The mean age of participants was 80.74± 2.89 years, and 70.37% (n=95) were female. The Difference-in-difference regression showed that, compared with the control group, phenotypic frailty score (β3 =-1.40, p < 0.001) and stride time (β3 = -0.38, p <0.001) decreased significantly in the intervention group, stride velocity (β3 = 0.24, p < 0.001), step length (β3 = 0.08, p <0.001), cadence (β3 = 17.79, p < 0.001), MMSE total score (β3 = 1.90, p < 0.001) and QOL total score (β3 = 11.84, p < 0.001) increased significantly in the intervention group.

CONCLUSION

The integrated exercise intervention can effectively improve the attenuation of frailty, gait parameters, cognitive function, and quality of life in elderly nursing homes. We can use the findings of this study as a reference for the design of activities for the elderly nursing home residents, to provide them with appropriate exercises, improve their physical functions, and improve or delay their frailty level, which is principally important for developing countries in east Asia where rehabilitation resources are generally scarce.

The Effect of Obstructive Sleep Apnea Treatment and Severity on Choroidal Thickness in Patients With Central Serous Chorioretinopathy

Purpose:

This work aimed to analyze the association of obstructive sleep apnea (OSA) with choroidal thickness (CT) in patients with central serous chorioretinopathy (CSC).

Methods:

We identified patients in the Stanford Research Repository with a diagnosis of CSC and OSA. Age- and sex-matched controls with either CSC or OSA only were also identified. CT was measured at 5 points (subfoveal, and 1500 and 3000 µm nasal and temporal) by 2 graders. In addition to OSA treatment and severity, we also investigated the association of Oxygen Desaturation Index and nocturnal oxygen saturation nadir with subfoveal CT (SFCT).

Results:

A total of 57 patients and 72 eyes met the study inclusion criteria. The mean SFCT was significantly different across the 3 groups: OSA-only was the thinnest, followed by CSC with OSA, and CSC-only was the thickest (194.2 μm, 295.1 μm, and 357.8 μm, respectively, P < .001). SFCT was thicker in CSC with OSA compared with those with only OSA ( P < .05). OSA treatment status and OSA severity did not show a significant difference in SFCT in multivariable modeling. Nocturnal oxygen saturation nadir was positively associated with SFCT, but this did not reach significance..

Conclusions:

SFCT is significantly different in patients with OSA alone, CSC with OSA, and CSC alone. While OSA treatment status did not demonstrate a significant difference in SFCT in this study, future studies should evaluate patients for OSA in patients known to have CSC and atypically thin CT to further investigate the novel metrics leveraged in this study.

Silicosis: enlarged cervical lymph nodes, pericardial effusion and lung abnormalities

Silicosis is an occupational lung parenchymal disease caused by inhaling silica. It requires differentiation from a malignant tumour and granulomatous disease. We describe the case of a woman with silicosis who exhibited enlargement of bilateral cervical lymph nodes, pericardial effusion and lung abnormalities. She was diagnosed with silicosis based on histological examination of a resected cervical lymph node, lung tissue biopsy and history of silica exposure. She underwent glucocorticoid therapy during hospitalization. The lung abnormalities, enlarged cervical lymph nodes and pericardial effusion were ameliorated by glucocorticoid therapy, but she relapsed shortly thereafter. In conclusion, silicosis with cervical lymph node enlargement and pericardial effusion is rare and should be differentiated from a malignant tumour and granulomatous disease. Some patients may respond well to steroids in the short term.

Study on the regulation mechanism of lipopolysaccharide on oxidative stress and lipid metabolism of bovine mammary epithelial cells

The long-term feeding of a high-concentrate diet (the concentrate ratio is greater than 60 %) leads to mammary gland inflammatory response in ruminants and decreased quality in dairy cows and affects the robust development of the dairy industry. The main reason is closely related to elevated lipopolysaccharide (LPS) in the body. In this experiment, a bovine mammary epithelial cell line (MAC-T) was used as a model, and LPS at different concentrations (0 ng/ml, 1 ng/ml, 10 ng/ml, 100 ng/ml, 1000 ng/ml, 10000 ng/ml) was added to the cells. The cell survival rate, oxidative stress indicators, total lipid droplet area, triglyceride content and key genes regulating lipid metabolism were detected by 3-(4,5)-dimethylthiahiazo(-z-y1)-3,5-di-phenytetrazoliumromide (MTT), assay kit, microscope observation and RT-PCR methods to explore the regulatory mechanism of mammary health and milk fat synthesis. The results showed that compared with those of the control group, the survival rates of cells were significantly decreased after 9 h of stimulation with 1000 ng/ml and 10000 ng/ml LPS (P<0.01). The contents of superoxide dismutase (SOD), catalase (CAT) and total antioxidant capacity (T-AOC) in cells were significantly decreased (P<0.05). Compared with that of the control group, the content of malondialdehyde (MDA) in cells was significantly increased (P<0.05) after stimulation with 10000 ng/ml LPS for 9 h. After 9 h of stimulation with 100 ng/ml, 1000 ng/ml and 10000 ng/ml LPS, the total lipid drop area and triglyceride (TG) content of MAC-T cells were significantly decreased (P<0.05). The expression levels of fatty acid synthesis-related genes Acetyl-CoA carboxylase (ACC) and Stearoyl-CoA desaturase 1 (SCD-1) were significantly decreased after 9 h of stimulation with 100 ng/ml, 1000 ng/ml and 10000 ng/ml LPS (P<0.05), while the expression levels of Fatty Acid synthetase (FAS) were significantly decreased after stimulation with 1000 ng/ml and 10000 ng/ml LPS (P<0.05). TG synthesis by the related gene Diacylglycerol acyltransferase-1 (DGAT1) was significantly lower than that of the control group after stimulation with 1000 ng/ml and 10000 ng/ml LPS for 9 h (P<0.05), and Diacylglycerol acyltransferase-2 (DGAT2) also showed a significant decrease after 10000 ng/ml LPS stimulation (P<0.05). In conclusion, adding different concentrations of LPS to MAC-T cells not only led to a decrease in cell activity, resulting in oxidative damage, but also affected fatty acid and TG synthesis, which may ultimately be closely related to the decrease in milk fat synthesis.

An innovative application of follicular unit extraction technique in the treatment of bromhidrosis

BACKGROUND

Surgery is the most effective way to treat bromhidrosis, but postoperative complications are still the biggest obstacles for patients to choose surgical treatment.

OBJECTIVES

To introduce an innovative application of follicular unit extraction (FUE) in the treatment of bromhidrosis.

METHODS

We conducted a case series study on 20 patients who received FUE technique for the treatment of bromhidrosis. The axillary hair follicles were extracted with a one-millimetre punch. The released hair follicles were collected for histological examination. After the operation, the wounds were wrapped with moderate pressure. The dressing was removed 24 h after the FUE operation. The postoperative complications were collected, and the improvement of malodour was evaluated by the 10-point visual analogue scale.

RESULTS

Immediately postoperation, many needle-shaped holes appeared in the armpits. The holes healed 7 days after the operation, with no scar or pinpoint-like scars. Except for a female who complained of mild pain in the left armpit, no other patients had any discomfort. The malodour level varied between 0 and 4 during the follow-up period. The tissue examination showed that more than 90% of the completely plucked hair follicles were accompanied by apocrine glands, and many blocked and dilated apocrine glands were observed. The lumens of the blocked glands were filled with decapitation products, which were positive for K5, Brst-2 and CEA.

CONCLUSIONS

Patients with bromhidrosis have a positive response to FUE technique. The FUE technique is well-tolerated, with only a few postoperative complications, which deserves to be widely promoted.

Acute on Chronic Neuromuscular Respiratory Failure in the Intensive Care Unit: Optimization of Triage, Ventilation Modes, and Extubation

Critical care management of acute respiratory failure in patients with neuromuscular disease (NMD) such as amyotrophic lateral sclerosis (ALS) is not standardized and is challenging for many critical care specialists. Progressive hypercapnic respiratory failure and ineffective airway clearance are key issues in this patient population. Often at the time of hospital presentation, patients are already supported by home mechanical ventilatory support with noninvasive ventilation (NIV) and an airway clearance regimen. Prognosis is poor once a patient develops acute respiratory failure requiring intubation and invasive mechanical ventilatory support, commonly leading to tracheostomy or palliative-focused care. 

We focus on this understudied group of patients with ALS without tracheostomy and incorporate existing data to propose a technical approach to the triage and management of acute respiratory failure, primarily for those who require intubation and mechanical ventilatory support for reversible causes, and also for progression of end-stage disease. Optimizing management in this setting improves both quality and quantity of life.

Neuromuscular patients with acute respiratory failure require protocolized and personalized triage and treatment. Here, we describe the technical methods used at our single institution. The triage phase incorporates comprehensive evaluation for new etiologies of hypoxia and hypercapnia, which are not initially presumed to be secondary to progression or end-stage neuromuscular respiratory failure. In select patients, this may involve intubation or advanced adjustments of NIV machines. Next, once the acute etiology(s) is identified and treated, the focus shifts: training and use of mechanical airway clearance to optimize pulmonary function, facilitation of NIV wean or successful extubation to NIV, and transition to a stable regimen for home ventilation. The comprehensive protocol described here incorporates multi-institutional approaches and effectively optimizes acute respiratory failure in patients with neuromuscular pulmonary disease. 

[Analysis of the time for observation and related factors at clinics after vaccination among children's parents]

Objective: To understand the time for observation and related factors in the clinics after vaccination among children's parents. Methods: From December 2019 to January 2020, parents of children aged 0-3 years were recruited by multiple-stage sampling from 34 vaccination clinics in 12 districts and counties in 6 provinces (Shandong, Guangdong, Henan, Sichuan, Inner Mongolia, and Liaoning). A questionnaire survey on the time of observation after vaccination was conducted. A multivariate logistic regression model was used to analyze the related factors of parental observation time after vaccination. Results: A total of 3 292 parents of 0-3 year's old children were selected, and 3 178 parents were finally included in the analysis. 87.85%(2 792/3 178) of the parents reported that the observation time after vaccination at clinics was ≥30 minutes. Multivariate logistic regression analysis showed that, after adjusting for the regions, the main factors affecting the observation time at clinics after vaccination among parents appeared as observation time informed by physicians at the clinic appeared ≥30 minutes (OR=31.622, 95%CI: 19.847-50.384), parents were medical personnel (OR=2.779, 95%CI: 1.505-5.133), parents being volunteers working on vaccination-related publicity and education activities (OR=1.986, 95%CI: 1.438-2.743), parents aged 35 years old or above (OR=1.900, 95%CI: 1.215-2.971), being parents of the first child (OR=1.663, 95%CI: 1.282-2.156), per capita annual income of the family as 8 000- Yuan (OR=1.646, 95%CI: 1.168-2.319), children aged 0-12 months old (OR=1.646, 95%CI: 1.203-2.252) or 13-24 months old (OR=1.506, 95%CI: 1.064-2.133), obedient to physicians' advice at the clinic (OR=1.481, 95%CI: 1.067-2.055). Conclusions: The proportions of parents observed for ≥30 minutes at the clinics of vaccination were high. When the information was from the physicians at the vaccination clinic, the observation time was the most critical factor for parents to observe at clinics as required.

[Impact of additional time spent for vaccination services on overall satisfaction rate in parents]

Objective: To understand the overall satisfaction rate with vaccination services in parents of children, and the impact of additional time consumed for vaccination service on overall satisfaction rate. Methods: From December 2019 to January 2020, a total of 3 178 parents of 0-3 years old children were investigated to collect the information about their basic characteristics, additional time spent for vaccination service and overall satisfaction through questionnaires. Binary logistic regression model and restricted cubic spline model were used to evaluate the impact of additional time spend on the overall satisfaction rate. Results: The overall satisfaction rate of parents with vaccination services was 92.32%. The median time for parents to move from home to vaccination clinic was 10.00 (10.00, 20.00) minutes, the median waiting time to make an appointment was 10.00 (5.00, 15.00) minutes, the median waiting time for vaccination was 5.00 (3.00, 10.00) minutes, and the median total additional time spent was 30.00 (20.00, 45.00) minutes. The binary logistic regression analysis showed that after adjusting the relevant factors, the main factors affecting the overall satisfaction rate were the waiting time for making an appointment (the 4- minutes group vs. 8- minutes group: OR=1.863, 95%CI: 1.307-2.657), waiting time for vaccination (the <4 minutes group vs. 8- minutes group: OR=1.529, 95%CI: 1.102-2.120; the 4- minutes group vs. 8- minutes group: OR=1.534, 95%CI: 1.104-2.130), total additional time spent (the 15- minutes group vs. 30- minutes group: OR=1.470, 95%CI: 1.094-1.976). Restricted cubic spline analysis showed that the waiting time for making an appointment (non-linear: χ²=13.18, P=0.001), the waiting time for vaccination (non-linear: χ²=13.50, P=0.001), and the total additional time consumed (non-linear: χ²=9.38, P=0.009) showed a non-linear inverted "V" dose response relationship to the overall satisfaction of vaccination services. Conclusions: The waiting time for parents to make an appointment, the waiting time for vaccination and the total additional time spent for receiving vaccination services affected the overall satisfaction rate of the vaccination services. And the waiting time for making an appointment was the most important factor, and it is necessary to shorten the waiting time for appointment. It is suggested that the vaccination clinic should make use of information technology (such as WeChat public account, APP) to make accurate appointments, make appointments to the time period to control the number of people within time period.

Seed dormancy profiles for forest dynamics plot data: focusing on a tropical seasonal rainforest in Xishuangbanna, southwest China

Long-term forest dynamics monitoring plots provide information on number of individual species in the plot, allowing us for the first time to construct seed dormancy profiles at the species and individual levels for a specific site. Focusing on the Xishuangbanna tropical season rainforest plot (XTRDP), we used data from nine forest dynamics plots (two for tropical, four for subtropical and three for temperate) and information on kind of seed dormancy to generate seed dormancy profiles for communities across tropical to temperate latitudes at the species and individual levels. Seed dormancy information was collected from previous publications, and some data were provided by two germplasm banks that test seed germination of wild plants in China. In XTRDP, 35% of the species and 58% of individuals have non-dormant seeds; the dominant species have non-dormant seeds. In all plots, the most common kind of dormancy among species and individuals with dormant seeds was physiological dormancy. At the species level, the profile for tropical, subtropical and temperate plots was similar to profiles for each of these vegetation regions. In all plots, except one subtropical plot, the percentage of species versus individuals with dormant seeds differed. All temperate plots had a higher percentage of individuals than species with dormant seeds, but this pattern was not consistent for tropical or subtropical plots. We show that dormancy increases with latitude at both the species and individual levels. Dormancy profiles at the individual tree level provide new insight into seed dormancy relationships within plant communities.

[Using structured decision-making to identify the appropriate type of entity for the centers for disease control and prevention of China]

Objective: To develop evidence-based appropriate type of entity for the Centers for Disease Control and Prevention in order to improve the performance of disease control and prevention system in China. Methods: This study firstly proposed the core functions and essential public health programs for the Centers for Disease Control and Prevention. Using Structured Decision-Making, this study presented three alternative options for type of entity to make essential public health programs succeed, and reviewed the pros and cons of alternative options based on 15 evaluation indicators. Questionnaires were distributed to 47 stakeholders between April 10 and April 20 of 2020. Finally, an appropriate type of entity for the Centers for Disease Control and Prevention was identified by using both qualitative and quantitative methods. Results: A total of 47 stakeholders ranked alternative options. Aggregated scores of each alternative option was computed after weighting each indicators. The results shows that Option 1(professional technical civil service organization)has the highest score (58.22). Conclusion: Professional technical civil service organization is appropriate type of entity for Centers for Disease Control and Prevention.

A challenging case of hypercapnic respiratory failure during pregnancy

We describe a 40-year-old female who presented with progressive breathlessness and hypercapnic respiratory failure during pregnancy secondary to undiagnosed muscle-specific kinase myasthenia gravis. Her presentation was progressive and protracted, having over five contacts with healthcare professionals over nine months, many of these predating her pregnancy. Her atypical presentation for myasthenia with minimal limb weakness led to consideration of other causes of hypercapnic respiratory failure. Once diagnosed, she was treated with intravenous immunoglobulin and non-invasive ventilation. She gave birth to a pre-term infant by planned caesarean section. Her insidious presentation and the progressive nature of her breathlessness were unusual and our report highlights the predominant involvement of respiratory muscles in muscle-specific kinase myasthenia. Her pregnancy may have further delayed her diagnosis due the attribution of some symptoms to normal pregnancy. Early recognition and treatment of myasthenia gravis are important to prevent life-threatening complications.

The Effect of Obstructive Sleep Apnea on Absolute Risk of Central Serous Chorioretinopathy

PURPOSE

To determine the incidence of central serous chorioretinopathy (CSC) stratified by age, sex, and diagnosis with obstructive sleep apnea (OSA), and to determine whether some patients with newly diagnosed CSC may be candidates for OSA evaluation.

DESIGN

Retrospective cohort study.

METHODS

We used the IBM MarketScan database to select 59,016,145 commercially insured patients in the United States between 2007 and 2016. We identified patients' first diagnosis with CSC, and defined patients as having OSA if they had a diagnosis following a sleep study. We specified Cox proportional hazard models with interactions between age, sex, and OSA status to determine patients' risk of developing CSC. We estimated the positive predictive value (PPV) that a new diagnosis of CSC would have in predicting a subsequent diagnosis of OSA.

RESULTS

Risk of CSC increased with age in years (hazard ratio [HR] = 1.030, P < .001) and OSA diagnosis (HR = 1.081, P < .033), and was lower in women (HR = 0.284, P < .001). We estimated the annual incidence of CSC was 9.6 and 23.4 per 100,000 women and men, respectively. Incidence was higher in women and men with OSA (17.2 and 40.8 per 100,000). The PPV of CSC diagnosis as a predictor of OSA was highest in the fifth decade of life.

CONCLUSION

The incidence of CSC in our patient sample is higher than previously reported. Risk of CSC is higher in men than in women, and OSA increases risk of CSC in both men and women. Some patients, particularly older male patients, may be good candidates for OSA evaluation following a CSC diagnosis.

Noninvasive Ventilator Devices and Modes

Noninvasive ventilation has become an increasingly common treatment strategy for patients with diverse conditions involving chronic respiratory failure. An intimate understanding of various advanced respiratory devices and modes is essential in the management of these patients. Pressure-limited modes of ventilation are more commonly used than volume modes for noninvasive ventilation owing to enhanced patient comfort and synchrony with the ventilator, as well as improved leak compensation. Common pressure modes include spontaneous/timed and pressure control, with volume-assured pressure support being an additive feature available on certain devices. Evidence guiding the optimal mode of ventilation for specific diseases is limited.

The association of bisphenol A exposure with premature ovarian insufficiency: a case-control study

BACKGROUND

A few epidemiological investigations and animal studies have demonstrated that bisphenol A (BPA) may affect female reproductive health. However, no epidemiologic study has investigated the relationship between BPA exposure and the risk of premature ovarian insufficiency (POI).

METHODS

In this case-control study, urinary concentrations of BPA and serum levels of reproductive hormone were measured. Associations between BPA concentrations and the risk of POI and POI-related hormone levels were estimated.

RESULTS

Among BPA quartiles, no obvious association was found between BPA levels and the risk of POI (p = 0.603). Although the adjusted odds ratio (OR) of POI was slightly increased for participants in the highest BPA concentration quartile, the association was not statistically significant (OR = 1.282, 95% confidence interval [CI] 0.615-2.049 for the highest vs. lowest quartile, p = 0.508). Although follicle stimulating hormone (FSH) and anti-Mullerian hormone (AMH) levels showed no tendency of an association with BPA (p = 0.941 and p = 0.876 for FSH and AMH, respectively), the highest quartile of luteinizing hormone was significantly positively associated with BPA levels (OR = 1.333, 95% CI 0.986-1.803, p = 0.042).

CONCLUSIONS

The urinary concentrations of BPA determined in this study were consistent with the range of exposure currently observed in Chinese women. However, BPA exposure at a relatively low level is not associated with POI in Chinese women. Further epidemiological studies are needed to confirm our findings.

Protective effect of alpha-pinene against isoproterenol-induced myocardial infarction through NF-κB signaling pathway

Monoterpenes present in the essential oils exhibit anti-inflammatory properties. In this study, we investigated the preventive effect of alpha-pinene (AP), a monoterpene, against isoproterenol (ISO)-induced myocardial infarction and inflammation in Wistar rats. Male Wistar rats were pretreated with AP (50 mg/kg body weight (bw)) administration for 21 days and ISO (85 mg/kg bw) was administered subcutaneously for last two consecutive days (20th day and 21st day). We noticed that there was an increased activity of cardiac marker enzymes in ISO-treated rats. We also observed that elevated levels of lipid peroxidative indices decreased activities of antioxidant status in plasma, erythrocyte, and heart tissue in ISO-induced rats. Furthermore, ISO-treated rats showed an increase in the levels of inflammatory mediators like tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) in the serum. Besides, we confirmed the upregulated expression of TNF-α, IL-6, and nuclear factor kappa-light-chain-enhancer of activated B cells in ISO-induced rat heart tissue. Conversely, we found that AP pretreatment significantly decreased levels of cardiac markers like serum cardiac troponin T and cardiac troponin I, lipid peroxidative markers, and restored antioxidants status in ISO-treated rats. Besides, AP administration attenuated ISO-induced inflammatory marker expression. The present findings demonstrated that AP significantly protects the myocardium and exerts cardioprotective and anti-inflammatory effects in experimental rats.

Strategies in the Management of Adolescent Obesity

Purpose of Review

We review the current options to manage adolescent obesity which include nutrition, physical activity, behavior modification, sleep management, pharmacotherapy and surgery. Since lifestyle interventions alone are often not effective in adolescents, a multi-disciplinary treatment approach is necessary in management.

Recent Findings

Medications (often used off-label) and metabolic/bariatric surgery are effective treatment strategies to treat adolescents with severe obesity.

Summary

The use of pharmacotherapy and surgery is limited due to lack of pediatric obesity tertiary care centers. With more centers, the treatment of adolescent obesity will improve and aid to decrease the prevalence of adult obesity.

Consensus-Based Care Recommendations for Pulmonologists Treating Adults with Myotonic Dystrophy Type 1

PURPOSE OF REVIEW

Myotonic dystrophy type 1 (DM1) is a severe, progressive genetic disease that affects approximately 1 in 2,500 individuals globally [Ashizawa et al.: Neurol Clin Pract 2018;8(6):507-20]. In patients with DM1, respiratory muscle weakness frequently evolves, leading to respiratory failure as the main cause of death in this patient population, followed by cardiac complications [de Die-Smulders et al.: Brain 1998;121(Pt 8):1557-63], [Mathieu et al.: Neurology 1999;52(8):1658-62], [Groh et al.: Muscle Nerve 2011;43(5):648-51]. This paper provides a more detailed outline on the diagnostic and management protocols, which can guide pulmonologists who may not have experience with DM1 or who are not part of a neuromuscular multidisciplinary clinic. A group of neuromuscular experts in DM1 including pulmonologists, respiratory physiotherapists and sleep specialists discussed respiratory testing and management at baseline and during follow-up visits, based on their clinical experience with patients with DM1. The details are presented in this report.

RECENT FINDINGS

Myotonic recruited 66 international clinicians experienced in the treatment of people living with DM1 to develop and publish consensus-based care recommendations targeting all body systems affected by this disease [Ashizawa et al.: Neurol Clin Pract. 2018;8(6):507-20]. Myotonic then worked with 12 international respiratory therapists, pulmonologists and neurologists with long-standing experience in DM respiratory care to develop consensus-based care recommendations for pulmonologists using a methodology called the Single Text Procedure. This process generated a 7-page document that provides detailed respiratory care recommendations for the management of patients living with DM1. This consensus is completely based on expert opinion and not backed up by empirical evidence due to limited clinical care data available for respiratory care management in DM patients. Nevertheless, we believe it is of relevance for professionals treating adults with myotonic dystrophy because it addresses practical issues related to respiratory management and care, which have been adapted to meet the specific issues in patients with DM1.

SUMMARY

The resulting recommendations are intended to improve respiratory care for the most vulnerable of DM1 patients and lower the risk of untoward respiratory complications and mortality by providing pulmonologist who are less experienced with DM1 with practical indications on which tests and when to perform them, adapting the general respiratory knowledge to specific issues related to this multiorgan disease.