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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Dosimetric Quality of Artificial Intelligence Based Organ at Risk Segmentation

PURPOSE/OBJECTIVE(S)

to compare dosimetric parameters between Artificial intelligence (AI) generated organ at risks (OAR) and Radiation Oncologist approved OARs and evaluation of appropriateness unedited AI- OARs in routine clinical plan optimization and evaluation.

MATERIALS/METHODS

The OARs (lung, spinal cord and heart) for twenty SBRT (stereotactic body radiotherapy) lung CT simulation datasets were derived by AI based segmentation algorithms. These AI- OARs were edited by a staff Radiation Oncologist and then subjected to our SBRT peer-review process at our institution. A SBRT plan based on the approved contours was created. Dosimetric parameters for the unedited AI-OARs and edited physician-approved OARs were then compared.

RESULTS

Lung V20 differences between AI- OAR and physician- OAR varied from 0.01% - 0.7% with a mean value of 0.1% difference (p-value 0.004). Spinal cord D0.03cc varied from 0.02 Gy - 0.9 Gy with a mean value of 0.3 Gy difference (p-value 0.002). Heart D0.03cc varied from 0.01 Gy - 4.3 Gy with mean value 0.9 Gy difference (p-value 0.02).

CONCLUSION

Dosimetric parameters for AI-based lung, spinal cord and heart OARs vs physician approved OARs were different, overall, the differences were generally small. These differences are likely on par with inter-observer differences seen between individual radiation oncologists. Unedited OARs have the promise for routine use in plan optimization and evaluation to further improve efficiency.

Prognostic Value of Tumor Volume Reduction during Radiotherapy in Patients with Locally Advanced Cervical Cancer in Different Risk Groups

PURPOSE/OBJECTIVE(S)

To evaluate the risk factors of patients with locally advanced cervical cancer (LACC) undergoing radical radiotherapy (with or without concurrent chemotherapy) and to assess the prognostic value of tumor volume regression (TVR) based on magnetic resonance imaging (MRI) in different risk groups.

MATERIALS/METHODS

A retrospective analysis was performed on 176 individuals diagnosed with stage IIA-IVA cervical cancer (CC) who underwent radical intensity-modulated radiotherapy in our center between January 2012 and December 2020. The tumor volume before radiotherapy (TVp) and before brachytherapy (TVmid) were evaluated based on three-dimensional MRI images, TVR = (TVp -TVmid)/TVp × 100%. Kaplan-Meier curves were used to assess patient's overall survival (OS) and progression-free survival (PFS). Prognostic factors were identified using Cox proportional hazards models.

RESULTS

For the entire cohort, patients with TVR ≥ 94% had better 5-year OS (82.7% vs 49.8%, p<0.001) and 5-year PFS (82.5% vs 51.1%, p<0.001) compared to TVR < 94%. Patients with TVR ≥ 94% were more likely to receive concurrent chemoradiotherapy (CCRT) than those with TVR < 94% (70.1% vs 40.5%, p<0.05). Among patients undergoing CCRT, those with a TVR ≥ 94% had a better prognosis than those with a TVR < 94%. However, among patients who received RT alone, those with TVR ≥ 94% had better PFS but no statistically significant difference in OS. Likewise, among patients with CYFRA21-1 < 7.7 ng/ml, patients with TVR ≥ 94% had a better prognosis. However, TVR was not a prognostic factor in patients with CYFRA21-1 ≥ 7.7 ng/ml. Both CYFRA21-1 (OS, PFS interaction, p<0.001) and FIGO stage (PFS interaction, p = 0.035) were found to significantly impact predictive effects of TVR.

CONCLUSION

In LACC patients with CRYFA21-1 < 7.7 ng/ml who received CCRT, TVR was an important prognostic factor. However, in patients with CRYFA21-1 ≥ 7.7 ng/ml who received RT alone, the prognostic value of TVR needs to be further explored.

Clinical Outcomes of Image-Guided Volumetric Modulated Arc Therapy for Total Body Irradiation

PURPOSE/OBJECTIVE(S)

Volumetric modulated arc therapy (VMAT)-based total body irradiation (TBI) with image guidance is a novel technique that is increasing in implementation. Compared to conventional TBI, VMAT-TBI offers favorable dose homogeneity, better organ-at-risk sparing, and enhanced patient comfort. However, whether these dosimetric advantages translate to improved clinical outcomes that justify the increased planning and delivery burden is not well understood. Only a single study of clinical outcomes of VMAT-TBI exists in the literature. We present the largest study to date of clinical outcomes of VMAT-TBI.

MATERIALS/METHODS

In this IRB-approved retrospective single-institution study, all patients treated with VMAT-TBI conditioning for allogeneic stem cell transplant, per the institution's published protocol, were identified. Dosimetric data were abstracted from the radiation oncology treatment planning system. Clinical data were abstracted from the electronic medical record. The primary outcome was six-month overall survival (6M OS) from the last day of TBI by Kaplan-Meier method.

RESULTS

Fifty-five patients (47 adult and 8 pediatric) were treated with VMAT-TBI between June 2020 and December 2022. All patients received conditioning chemotherapy with standard-dose TBI of 12 or 13.2 Gy in 8 twice-daily fractions. The PTV coverage (V95%) mean was 95.3% ± 1.2%. Mean lung dose was 9.5 Gy ± 0.6 for adult patients and 8.4 Gy ± 0.9 for pediatric patients. Mean lung dose rate was 18.0 cGy/min ± 4.4. Mean kidney dose was 5.9 Gy ± 0.6. Mean skin dose measured by MOSFET was 12.7 Gy ± 1.2. Median treatment time was 63 minutes (range: 53-104). Median follow-up was 7.7 months. At most recent follow-up, 78% of patients were alive. 6M OS was 82%. Common acute toxicities were fatigue (90.9% of patients, all grade 1-2), diarrhea (70.9%, all grade 1-2), nausea (76.4%, all grade 1-2), mucositis (60% grade 1-2, 12.7% grade 3, 1.8% grade 4, no grade 5), and xerostomia (54.5%, all grade 1). Mean pretreatment FEV1 was 98.3 percent of predicted (%p) ± 11.9%p and mean posttreatment FEV1 was 94.7%p ± 13.8%p. Mean pretreatment GFR was 101.4mL/min/1.73m² ± 17.4, mean 3-month posttreatment GFR was 92.4 ± 20.0, and mean 6-month posttreatment GFR was 97.5 ± 26.48. One patient experienced grade 2 pneumonitis; there were no other cases of pneumonitis. There were no acute grade 3+ toxicities aside from mucositis. Observed late toxicities were cataracts (7.3%, all grades 1-3) and hypothyroidism (12.7%, all grades 1-2). There were no grade 3+ late toxicities. Mild acute graft-versus-host disease (GVHD) was noted in 27.2% of patients and mild chronic GVHD was noted in 14.5% of patients, with no other cases of GVHD.

CONCLUSION

In the largest series to date, VMAT-TBI had excellent oncologic and toxicity outcomes. A randomized trial of VMAT-TBI versus standard TBI is warranted.

Frameless Fractionated Stereotactic Radiosurgery for Brain Metastases: An Institutional Series of 145 Cases

PURPOSE/OBJECTIVE(S)

Cobalt-60 stereotactic radiosurgery (SRS) typically involves single fraction treatment with frame immobilization. However, large tumor size, proximity to critical structures, and prior radiation treatment sometimes necessitate fractionated SRS with mask immobilization. We present a large institutional experience with fractionated mask-based SRS for brain metastases.

MATERIALS/METHODS

In this single-institution, IRB-approved study, all patients treated with mask-based fractionated SRS for brain metastases from March 2017 to January 2023 were identified. The primary outcomes were 1- and 2-year local control (LC) by Kaplan-Meier method.

RESULTS

A total of 118 patients with a total of 145 metastases were treated. The median follow-up time was seven months. The median age at treatment was 64.1 years (range: 26-95 years). 55.9% of patients were female. The most common primary tumors were breast (25.5%), non-small cell lung (23.4%), small-cell lung (8.3%), and melanoma (8.3%). For most cases (59.3%), the indication for fractionation was retreatment. Large size (28.3%), critical location (9.7%), and medical comorbidity (2.1%) were other indications. For all cases, the mean maximal linear size was 34.9 mm and mean target volume was 15.6 cc. For cases fractionated due to size, the mean size was 43.9 mm and mean target volume was 23.8 cc. Median total dose was 2,700 cGy (range: 1,620-3,000), and median dose per fraction (fx) was 600 cGy (range: 405-900). The most common prescriptions were 3,000 cGy/5 fx (40.0% of patients) and 2500 cGy in 500 cGy per fraction (37.2% of patients). Mean maximum dose was 4,833 cGy (range: 2,920-7,500). For 75.2% of treatments, the prescription isodose line was 50 to 59% (mean, 56.9%). Target coverage was 100% in all but one case (99%). For lesions near the brainstem, mean brainstem maximum point dose (MPD) was 9.3 Gy ± 9.8 Gy and brainstem mean dose was 3.3 Gy ± 3.3 Gy. For lesions near the optic pathway, mean optic nerve MPD was 14.4 Gy ± 9.2, optic nerve mean dose was 6.4 Gy ± 5.4 Gy, mean optic chiasm MPD was 11.7 Gy ± 7.9 Gy, and optic chiasm mean dose was 5.4 Gy ± 4.7 Gy. 1-year LC was 88.2% and 2-year LC was 80.4%. When retreatments were excluded, 1-year LC was 98.0% and 2-year LC was 98.0%. 18% of patients had acute grade 1-2 toxicities (fatigue, headache, nausea, and/or alopecia), and one patient had acute grade 3 fatigue. There was no other grade 3+ acute toxicities. 14% of patients had grade 1-2 radiation necrosis (RN); there were no cases of grade 3+ RN.

CONCLUSION

Cobalt-60 frameless fractionated SRS for brain metastases offers excellent local control, rigorous sparing of critical structures, and minimal toxicity. Frameless fractionated SRS should be considered for large, retreated, or critically located metastases.

Using kV Triggered Imaging and Liver Dome Position to Reduce the Dosimetric Error Caused by Breath Hold Variability for Liver Stereotactic Body Radiation Therapy

PURPOSE/OBJECTIVE(S)

In a previous study, we demonstrated that manual gating using kV triggered imaging and liver dome position can reduce targeting errors caused by breath hold variability for liver stereotactic body radiation therapy (SBRT). In this study, we quantified the dosimetric error caused by breath hold variability and investigated the effect of liver dome gating on reducing dosimetric error.

MATERIALS/METHODS

Twenty-five liver SBRT patients treated with deep inspiration breath-hold were included in this IRB approved study. Volumetric modulated arc therapy was used to deliver 30-60 Gy in 1-5 fractions. To verify the breath-hold reproducibility during treatment, a KV triggered image was acquired at the beginning of each breath-hold. The liver dome position was visually compared with the expected upper/lower liver boundaries created by expanding/contracting the liver contour 5mm in the superior-inferior direction. If the liver dome position was within the boundaries, delivery continued; otherwise, beam was held manually and the patient was instructed to take another breath hold until the liver dome position was within boundaries. To calculate delivered dose, for each fraction, the treatment plan was divided into sub-beams, each corresponding to one breath hold using delivery log files. The triggered images were registered to the planning CT to determine the liver position during each breath hold. Dose delivered during each breath hold was calculated by shifting the isocenter of the sub-beam according to the liver position. Breath holds discarded by gating were excluded since no dose was delivered during these breath holds. Delivered fractional doses were compared with planned fractional doses using GTV D99 and liver Dmean. To estimate delivered dose without gating, the first "corrective" breath hold taken after the discarded breath holds was replaced with the prior discarded breath hold and dose calculation was repeated.

RESULTS

Seven hundred eleven triggered images from 91 treatment fractions were analyzed. Without gating, in 11 of the 91 fractions from 7 of the 25 patients, delivered GTV D99 reduced > 0.50 Gy from planned value (range 0.51-1.68 Gy, 3-10% of planned fractional GTV D99). Liver dome gating was able to detect/exclude irreproducible breath holds in 8 of the 11 fractions, increasing the delivered GTV D99 by 0.70 Gy per fraction on average (range 0.21-1.63 Gy). With liver dome gating, delivered fractional GTV D99 was comparable to planned value for all fractions (12.96 +/- 5.19 Gy vs 13.04 +/- 5.18 Gy, p > 0.05). Liver mean dose was not affected by breath hold variability or gating. Fractional liver Dmean was 2.26 +/- 1.19 Gy from plan, 2.27 +/- 1.21 Gy for delivery with gating and 2.27 +/- 1.20 Gy for delivery without gating.

CONCLUSION

Breath hold variability may cause tumor underdose. Liver dome gating using kV triggered imaging reduces dosimetric error and ensures tumor coverage for liver SBRT.

Radio-Immune Response of Spatially Fractionated Radiotherapy for VMAT Lattice Plans

PURPOSE/OBJECTIVE(S)

To evaluate radio-immune response of spatially fractionated radiotherapy (SFRT) for large tumors using VMAT Lattice technique in terms of tumor volume under irradiation and dose fractionation schemes after SFRT.

MATERIALS/METHODS

Eleven patients treated with SFRT from a single institution were retrospectively replanned to deliver 15Gy in single fraction using Lattice technique. High dose regions are defined by multiple spheres with the diameter of 1.25 to 1.5cm and their vertex space of 3.0 to 4.0cm inside of GTV. VMAT plans with multiple arcs were developed for SFRT. Four palliative fractionation regimens of 200cGy x 12 (EQD2 = 24Gy with a/b of 10Gy), 400cGy x 5 (23.3Gy), 600cGy x 3 (24Gy) and 800cGy x2 (24Gy) and four definitive regimens of 200cGy x 24 (EQD2 = 48Gy), 400cGy x 10 (46.7Gy), 600cGy x 6 (48Gy) and 800cGy x 4 (48Gy) were considered for radiotherapy to follow SFRT. Linear quadratic (LQ) model is compared with radio-immune (RI) response model in which the activation of cytotoxic T lymphocytes, tumor immune suppression capability and immunotherapy drugs can be considered. Tumor regrowth time (TRT, time to tumor regrowth to the original volume after treatment) from each model was compared as a measure of benefit achieved from the application of SFRT.

RESULTS

The average volume of GTVs in this study was 776cc (range 58-2944cc). Three different SFRT plans (2D GRID technique with conventional collimator, 2D GRID with step & shoot IMRT, and 3D Lattice) were developed for each patient but only Lattice plans were considered in this study since they produced comparable dose modulation inside the tumor but only Lattice significantly reduced skin and critical organ dose. Radio-immune response model always expects longer TRT than LQ model. For palliative regimens, TRT of RI model is longer than that of LQ model by 14.5±9.9, 15.1±10.6, 17.2±12.4, 17.5±12.8 days for each fractionation scheme. When Lattice plan of 15Gy is delivered before the palliative treatment, the difference becomes 25.9±15.3, 31.5±23.3, 36.7±27.6, 37.5±28.5 days. The benefit of SFRT from RI response is only about 10-20 days. Interestingly, RI response is inversely proportional to tumor volume. When curative dose is considered, the difference of TRT is drastically changed from 25.9±9.8, 460.7±285.8, 1180.8±985.7, 1512.0±1327.5 days to 20.7±4.4, 449.0±411.7, 1725.4±2171.0, 3517.7±4531.7 days. The benefit of SFRT from RI response appears larger for large tumor with hypo-fractionation in definitive regimens.

CONCLUSION

The benefit of SFRT is significant for large tumors with hypo fractionation in the definitive regimens when radio-immune response model is considered which is not apparent in LQ model. Radio-immune response model may help to guide the development of successful treatment scheme large tumor volumes.

Mechanical Performance of 3D-Printed Polyethylene Fibers and Their Durability against Degradation

Polyethylene (PE), one of the most popular thermoplastic polymers, is widely used in various areas, such as materials engineering and biomedical engineering, due to its superior performance, while 3D printing via fused deposition modeling (FDM) provides a facile method of preparing PE products. To optimize the performance and assess the degradation of FDM-printed PE materials, we systematically investigate the influences of printing parameters, such as fiber diameter (stretching) and printer head temperature, and degradation, such as UV exposure and thermal degradation, on the mechanical performance of FDM-printed PE fibers. When FDM-printed PE fibers with a smaller diameter are prepared under a higher collecting speed, they undergo stronger stretching, and thus, show higher tensile strength and Young's modulus values. Meanwhile, the tensile strength and Young's modulus decrease as the printer head temperature increases, due to the lower viscosity, and thus, weaker shearing at high temperatures. However, degradation, such as UV exposure and thermal degradation, cause a decrease in all four mechanical properties, including tensile strength, Young's modulus, tensile strain and toughness. These results will guide the optimization of FDM-printed PE materials and help to assess the durability of PE products against degradation for their practical application.

Measurement of the ^{18}O(α, γ)^{22}Ne Reaction Rate at JUNA and Its Impact on Probing the Origin of SiC Grains

The ^{18}O(α,γ)^{22}Ne reaction is critical for AGB star nucleosynthesis due to its connection to the abundances of several key isotopes, such as ^{21}Ne and ^{22}Ne. However, the ambiguous resonance energy and spin-parity of the dominant 470 keV resonance leads to substantial uncertainty in the ^{18}O(α,γ)^{22}Ne reaction rate for the temperature of interest. We have measured the resonance energies and strengths of the low-energy resonances in ^{18}O(α,γ)^{22}Ne at the Jinping Underground Nuclear Astrophysics experimental facility (JUNA) with improved precision. The key 470 keV resonance energy has been measured to be E_{α}=474.0±1.1  keV, with such high precision achieved for the first time. The spin-parity of this resonance state is determined to be 1^{-}, removing discrepancies in the resonance strengths in earlier studies. The results significantly improve the precision of the ^{18}O(α,γ)^{22}Ne reaction rates by up to about 10 times compared with the previous data at typical AGB temperatures of 0.1-0.3 GK. We demonstrate that such improvement leads to precise ^{21}Ne abundance predictions, with an impact on probing the origin of meteoritic stardust SiC grains from AGB stars.

Measurement of the ν_{e}-Nucleus Charged-Current Double-Differential Cross Section at ⟨E_{ν}⟩=2.4 GeV Using NOvA

The inclusive electron neutrino charged-current cross section is measured in the NOvA near detector using 8.02×10^{20} protons-on-target in the NuMI beam. The sample of GeV electron neutrino interactions is the largest analyzed to date and is limited by ≃17% systematic rather than the ≃7.4% statistical uncertainties. The double-differential cross section in final-state electron energy and angle is presented for the first time, together with the single-differential dependence on Q^{2} (squared four-momentum transfer) and energy, in the range 1  GeV≤E_{ν}<6  GeV. Detailed comparisons are made to the predictions of the GENIE, GiBUU, NEUT, and NuWro neutrino event generators. The data do not strongly favor a model over the others consistently across all three cross sections measured, though some models have especially good or poor agreement in the single differential cross section vs Q^{2}.

Enhancing gosling growth and secretion of somatotrophic and thyrotrophic axis hormones through egg turning during incubation

1. Growth performance of Yangzhou geese hatched from eggs with turning angles of 50° or 70° was evaluated in association with serum hormones and somatotrophic gene mRNA expression.2. Egg turning at 70° significantly (P< 0.05) increased hatchability, gosling quality and hatching weight. Gosling post-hatch body weight, leg and breast muscle weight in the 70° turning group was significantly heavier until 50 d of age.3. Serum concentrations of GH were significantly higher until 30 d of age in the 70° turning group goslings, and those of IGF-I and T3 were higher from hatching to 50 d of age.4. The mRNA expression of GHRH, pituitary GH, liver and leg muscle IGF-I were all significantly higher at 1 and 30 d of age after hatch, but not at 70 d after hatch, in the 70° turning group.5. Egg turning at 70° during incubation improves embryo and gosling quality and growth performance through up-regulation of gene expression and secretion of somatotrophic axis hormones, GHRH, GH and IGF-I, as well as T3.

[Analysis of clinical and psychological characteristics in 250 patients with fibromyalgia]

To analyze the clinical and psychological characteristics of fibromyalgia (FM), so as to further understand and improve the capability of identifying FM. The clinical data of 250 FM patients diagnosed in the outpatient clinic of the Department of Rheumatology, the First Medical Center, Chinese PLA General Hospital, from December 2019 to September 2021, were collected and analyzed. The patients aged 40 (31.0, 52.3) years, including 188 female patients (75.2%) and 62 male patients (24.8%). There was a statistically significant difference in age comparison between female [42.5 (33.0,54.0) years] and male patients [32.5 (27.8,43.5) years] (P<0.001). The score of pain degree was 6 (4, 8), and [7 (5, 8)] of female patients was higher than [6 (4, 7)] of the male patients (P=0.040). The widespread pain index (WPI) was 13 (10,15). The regions with high pain incidence were left shoulder girdle (87.2%, 218/250), right shoulder girdle (86.8%, 217/250), upper back (86.4%, 216/250), neck (79.6%, 199/250) and lower back (77.6%, 194/250) and etc. The incidence of chest pain in female patients (55.3%, 104/188) was lower than that in male patients (75.8%, 47/62) (P=0.004). The symptom severity scale (SSS) score was 8 (7-10). 74.6% (185/248) suffered from anxiety and 77.5% (193/249) suffered from depression in 249 patients. Female patients were more common in FM patients than male patients, the median age of female patients was older than that of male patients, and the median score of pain severity of female patients was higher than male patients. Shoulders girdle, upper back, neck and lower back were the most frequently reported pain regions, and the incidence of chest pain in female patients was lower than that in male patients. The incidence of major non-painful symptoms was high and the proportion with anxiety or depression was high. The above clinical features are very helpful for early diagnosis of FM.

[Human chorionic gonadotropin-secreting gonadoblastomas in a girl of 45, X Turner syndrome: a case report and literature review]

Objective: To summarize the experience in diagnosis and treatment of 45, X Turner syndrome (TS) with gonadal Y chromosome mosaicism and bilateral gonadoblastoma (Gb) secreting human chorionic gonadotrophin(HCG). Methods: A female patient aged 5 years and 3 months was admitted to the hospital with a complaint of "enlarged breasts for 27 months, and elevated blood β-HCG for 8 months". The clinical data were summarized, and related literature up to March 2022 with the key words"Turner syndrome" "Gonadoblastoma" "Y chromosome" "human chorionic gonadotropin" "precocious" in PubMed, CNKI and Wanfang databases were reviewed. Results: The girl went to the local hospital for 2-month breast development at age of 3 years, and was found with a heart murmur diagnosed with "pulmonary venous malformation and atrial septal defect (secondary foramen type)". Surgical correction was performed. She experienced the progressive breast development, rapid linear growth and markedly advanced skeletal age, which cannot be explained by partial activation in the hypothalamic-pituitary-gonadal axis determined at the age of 3 years and 7 months in local hospital. Then whole-exome sequencing revealed chromosome number abnormality 45, X, which was confirmed by Karyotyping. At the age of 4 years and 6 months, serum β-HCG was found to be elevated (24.9 U/L) with no lesion found at the local hospital. On physical examination, she was found with breast development, pubic hair development and clitoromegaly with elevated serum testosterone (1.96 μg/L) and β-HCG (32.3 U/L). Sex determining region Y(SRY) gene was negative in peripheral blood sample. Thoracic and abdominal CT, head and pelvic magnetic resonance imaging were normal. Exploratory laparotomy confirmed the presence of a left adnexal tumor and a right fibrous streak gonad. During surgery, simultaneous samples of bilateral gonadal and peripheral venous blood were obtained and serum β-HCG, estradiol and testosteron concentrations was higher to lower from left gonadal venous blood, right gonadal venous blood, to peripheral venous blood. Bilateral gonadectomy was performed. Histopathology revealed bilateral gonadoblastomas. SRY was positive in bilateral gonadal tissues. After surgery, serum E₂, testerone and β-HCG returned to normal. So far 4 cases of HCG-secreting gonadoblastoma had been reported worldwide. The phenotypes of the 4 cases were all female, with virilization or amenorrhea, and the preoperative peripheral blood β-HCG concentrations were 74.4, 5.0, 40 456.0, and 42.4 U/L, respectively. Conclusions: There is a high risk of Gb in TS with Y chromosome components. Gb is infrequently presented with breast development, and Gb associated with HCG secretion is rare. Karyotyping should be performed in a phenotypic female with masculinization, and virilization in TS indicates the presence of Y chromosome material with concurrent androgen secreting tumors.

Deep Underground Laboratory Measurement of ^{13}C(α,n)^{16}O in the Gamow Windows of the s and i Processes

The ^{13}C(α,n)^{16}O reaction is the main neutron source for the slow-neutron-capture process in asymptotic giant branch stars and for the intermediate process. Direct measurements at astrophysical energies in above-ground laboratories are hindered by the extremely small cross sections and vast cosmic-ray-induced background. We performed the first consistent direct measurement in the range of E_{c.m.}=0.24 to 1.9 MeV using the accelerators at the China Jinping Underground Laboratory and Sichuan University. Our measurement covers almost the entire intermediate process Gamow window in which the large uncertainty of the previous experiments has been reduced from 60% down to 15%, eliminates the large systematic uncertainty in the extrapolation arising from the inconsistency of existing datasets, and provides a more reliable reaction rate for the studies of the slow-neutron-capture and intermediate processes along with the first direct determination of the alpha strength for the near-threshold state.

Factors associated with depression in residents in the post-epidemic era

OBJECTIVE

To explore the factors associated with depression in residents in the post-epidemic era of COVID-19.

METHODS

A multi-stage stratified random sampling method was used to conduct a questionnaire survey among community residents through self-designed questionnaires and self-rating depression scale (SDS). Multivariate logistic regression analysis was performed on the influencing factors of depressive symptoms.

RESULTS

A total of 1993 residues completed the survey of depression status. The incidence of depressive symptoms was 27.04%. The multivariate logistic regression analysis showed that female (odds ratio (OR): 6.239, 95% confidence interval (CI): 2.743-10.698), body mass index (BMI) > 24 (OR: 2.684, 95% CI: 1.059-3.759) and drinking (OR: 1.730, 95% CI: 1.480-3.153) were the risk factors for developing depressive symptoms. Married (OR: 0.417, 95% CI: 0.240-0.652), monthly income (3001-5000 yuan, OR: 0.624, 95% CI: 0.280-0.756; >5000 yuan, OR: 0.348, 95% CI: 0.117-0.625), ordinary residents (OR: 0.722, 95% CI: 0.248-0.924) and urban residents (OR: 0.655, 95% CI: 0.394-0.829) were the protective factors of depressive symptoms.

CONCLUSIONS

Under the post-epidemic era of COVID-19, depressive symptoms are still common among community residents in China. Gender, BMI, drinking, marriage, monthly income and nature of personnel and residential area are associated with the incidence of depressive symptoms.

PFAS concentrations in soil versus soil porewater: Mass distributions and the impact of adsorption at air-water interfaces

Determining the risk posed by PFAS leaching from soil to groundwater requires quantification of the magnitude and temporal/spatial variability of PFAS mass discharge from the vadose zone, which is governed in part by the concentrations of PFAS in soil porewater. Porewater concentrations are impacted and mediated by the properties of the PFAS and soil, multiple transport and fate processes, and site conditions. The objective of this research was to delineate the relationship between soil porewater concentrations and soil concentrations, based on a comprehensive model of PFAS mass distribution within a soil sample volume. Measured parameters representing solid-phase sorption and air-water interfacial adsorption are used to illustrate the impact of soil and PFAS properties on the distribution of representative PFAS between soil and soil porewater. Literature data reported for soil and soil porewater concentrations of several PFAS obtained from outdoor lysimeter experiments are used to test the distribution model. Soil-to-porewater concentration ratios predicted with the model compared very well to the measured concentration ratios. The nondimensional distribution coefficient that describes the distribution of PFAS mass amongst all domains within a soil sample was observed to be a function of PFAS molecular size. Numerical simulations conducted for a model fire-training source area were used to illustrate the ranges in magnitude of soil versus porewater concentrations for representative field conditions. The results of the measured and simulated data sets demonstrated the importance of air-water interfacial adsorption for the distribution of the longer-chain PFAS within soil samples. PFAS soil porewater concentrations are anticipated to range from ng/L to mg/L depending upon soil concentrations, which in turn depend upon the nature of the site.

Scintillation light detection in the 6-m drift-length ProtoDUNE Dual Phase liquid argon TPC

DUNE is a dual-site experiment for long-baseline neutrino oscillation studies, neutrino astrophysics and nucleon decay searches. ProtoDUNE Dual Phase (DP) is a 6  ×  6  ×  6 m 3 liquid argon time-projection-chamber (LArTPC) that recorded cosmic-muon data at the CERN Neutrino Platform in 2019-2020 as a prototype of the DUNE Far Detector. Charged particles propagating through the LArTPC produce ionization and scintillation light. The scintillation light signal in these detectors can provide the trigger for non-beam events. In addition, it adds precise timing capabilities and improves the calorimetry measurements. In ProtoDUNE-DP, scintillation and electroluminescence light produced by cosmic muons in the LArTPC is collected by photomultiplier tubes placed up to 7 m away from the ionizing track. In this paper, the ProtoDUNE-DP photon detection system performance is evaluated with a particular focus on the different wavelength shifters, such as PEN and TPB, and the use of Xe-doped LAr, considering its future use in giant LArTPCs. The scintillation light production and propagation processes are analyzed and a comparison of simulation to data is performed, improving understanding of the liquid argon properties.

Rectifying cow infertility under heat stress by immunization against inhibin and supplementation of progesterone

This study was undertaken for the development of novel techniques that are based on immunoneutralization of inhibin bioactivity to improve Holstein cow fertility. A series of 4 experiments were carried out on 2 farms that were located in subtropical or temperate regions, to test the effects of immunization against inhibin alpha subunit on cow fertility under varying degrees of heat stress conditions. Though immunization against inhibin alone improved conception rate (CR) after TAI moderately in cows under mild heat stress conditions, the treatment plus progesterone supplementation substantially enhanced CR in the range of 25 to 35 percentages from severe heat stress to comfortable weather conditions. There existed an additive effect between immunization against inhibin and progesterone supplementation that maximally enhanced CR. Further, immunization against inhibin increased both FSH and activin A concentrations in blood during both follicular and luteal phases. It also significantly increased blood concentrations of E2 in the follicular phase but decreased P4 concentrations during the early pregnancy. However, interferon-tau concentrations in blood around the time of pregnancy recognition were doubled in the inhibin immunized cows. In conclusion, immunization against inhibin plus P4 treatment enhances ovarian follicle and the subsequent early embryo developments that help to greatly improve the fertility of Holstein dairy cows.

Making remote measurement technology work in multiple sclerosis, epilepsy and depression: survey of healthcare professionals

Background

Epilepsy, multiple sclerosis (MS) and depression are long term, central nervous system disorders which have a significant impact on everyday life. Evaluating symptoms of these conditions is problematic and typically involves repeated visits to a clinic. Remote measurement technology (RMT), consisting of smartphone apps and wearables, may offer a way to improve upon existing methods of managing these conditions. The present study aimed to establish the practical requirements that would enable clinical integration of data from patients’ RMT, according to healthcare professionals.

Methods

This paper reports findings from an online survey of 1006 healthcare professionals currently working in the care of people with epilepsy, MS or depression. The survey included questions on types of data considered useful, how often data should be collected, the value of RMT data, preferred methods of accessing the data, benefits and challenges to RMT implementation, impact of RMT data on clinical practice, and requirement for technical support. The survey was presented on the JISC online surveys platform.

Results

Among this sample of 1006 healthcare professionals, respondents were positive about the benefits of RMT, with 73.2% indicating their service would be likely or highly likely to benefit from the implementation of RMT in patient care plans. The data from patients’ RMT devices should be made available to all nursing and medical team members and could be reviewed between consultations where flagged by the system. However, results suggest it is also likely that RMT data would be reviewed in preparation for and during a consultation with a patient. Time to review information is likely to be one of the greatest barriers to successful implementation of RMT in clinical practice.

Conclusions

While further work would be required to quantify the benefits of RMT in clinical practice, the findings from this survey suggest that a wide array of clinical team members treating epilepsy, MS and depression would find benefit from RMT data in the care of their patients. Findings presented could inform the implementation of RMT and other digital interventions in the clinical management of a range of neurological and mental health conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01856-z.

Direct measurement of the 19F(p, αγ)16O reaction in JUNA

The 19F(p, αγ)16O reaction is of crucial importance for Galactic 19F abundances and CNO cycle loss in first generation Population III stars. Due to its extremely small cross sections, the 19F(p, αγ)16O reaction has not been measured in the low energy part of the Gamow window(70-200 keV). As a day-one campaign, the experiment was performed under the extremely low cosmicray-induced background environment of the China JinPing Underground Laboratory(CJPL), one of the deepest underground laboratories in the world. The γ-ray yields were measured over Ec.m. =72.4–344 keV, covering the full Gamow window for the first time. The direct experimental data will help people to expound the fluorine over-abundances, energy generation, as well as heavy-element nuclosynthesis scenario in asymptotic giant branch (AGB) stars, with the astrophysical model on the firm ground.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

[Causal inference methods and its application in the study of health effects of air pollution]

The adverse health effects of air pollution remains a daunting public health problem globally. The research of the health effects of air pollution provides important evidence for ambient air quality standard establishments and air pollution interventions. In recent years, causal inference has been gradually introduced into the observational study of environmental epidemiology, which provides more statistical method options for the study of causal relationships between air pollution and population health effects. Controlling confounders in observational studies is a major challenge for causal inference. This study introduces the causal inference methods for the identification and control of confounding factors currently used in the study of air pollution and population health effects, in order to provide methodological reference and basis for the causal inference study of air pollution and population health effects in China.

[Oxymatrine improves renal fibrosis and inflammation in diabetic rats by modulating CHK1/2 phosphorylation]

OBJECTIVE

To explore the role of cell cycle checkpoint kinase 1/2 (CHK1/2) in mediating the inhibitory effect of oxymatrine (OMT) against renal inflammation and fibrosis in diabetic rats.

METHODS

SD rats were randomly divided into normal control group, diabetes model group (DM) and OMT treatment group (n=6). HE and Masson staining were used to observe histopathological changes of the renal tissue, and the expressions of CHK1, CHK2, p-CHK1 and p-CHK2 were localized by immunohistochemical staining. The contents of interleukin-6 (IL-6) and IL-1β in the renal tissue were detected using ELISA, and the expression levels of CHK1, CHK2, p-CHK1, p-CHK2, type Ⅲ collagen (Col-Ⅲ), type Ⅳ collagen (Col-Ⅳ), and fibronectin (FN) were determined using Western blotting. The changes in the expressions of CHK1, CHK2, p-CHK1, p-CHK2, Col-Ⅲ, Col-Ⅳ and FN proteins were also examined with Western blotting in NRK-52E cells in response to high glucose exposure, OMT treatment and siRNA-mediated CHK1/2 knockdown.

RESULTS

In diabetic rats, OMT treatment significantly decreased the levels of blood glucose, serum creatinine and 24 h urinary protein (P < 0.05) and obviously improved inflammatory cell infiltration and fibrosis phenotype in the renal tissue (P < 0.05). CHK1 and CHK2 were mainly expressed in the cytoplasm and nuclei of renal tubule cells, and their phosphorylation levels were significantly higher in DM group than in the control group and OMT group. OMT treatment significantly decreased the protein expression levels of p-CHK1, p-CHK2, Col-Ⅲ, Col-Ⅳ and FN in the renal tissue of diabetic rats and in NRK-52E cells exposed to high glucose (P < 0.05). In NRK-52E cells, CHK1/2 knockdown resulted in significant reduction of the protein expressions of p-CHK1/2, Col-Ⅲ, Col-Ⅳ and FN (P < 0.05).

CONCLUSION

The inhibitory effects of OMT against renal inflammation and fibrosis in diabetic rats are mediated probably by lowered phosphorylation levels of CHK1 and CHK2, which result in reduced release of the downstream inflammatory mediators and decreased secretion and deposition of extracellular matrix.

The impact of data from remote measurement technology on the clinical practice of healthcare professionals in depression, epilepsy and multiple sclerosis: survey

BACKGROUND

A variety of smartphone apps and wearables are available both to help patients monitor their health and to support health care professionals (HCPs) in providing clinical care. As part of the RADAR-CNS consortium, we have conducted research into the application of wearables and smartphone apps in the care of people with multiple sclerosis, epilepsy, or depression.

METHODS

We conducted a large online survey study to explore the experiences of HCPs working with patients who have one or more of these conditions. The survey covered smartphone apps and wearables used by clinicians and their patients, and how data from these technologies impacted on the respondents' clinical practice. The survey was conducted between February 2019 and March 2020 via a web-based platform. Detailed statistical analysis was performed on the answers.

RESULTS

Of 1009 survey responses from HCPs, 1006 were included in the analysis after data cleaning. Smartphone apps are used by more than half of responding HCPs and more than three quarters of their patients use smartphone apps or wearable devices for health-related purposes. HCPs widely believe the data that patients collect using these devices impacts their clinical practice. Subgroup analyses show that views on the impact of this data on different aspects of clinical work varies according to whether respondents use apps themselves, and, to a lesser extent, according to their clinical setting and job role.

CONCLUSIONS

Use of smartphone apps is widespread among HCPs participating in this large European survey and caring for people with epilepsy, multiple sclerosis and depression. The majority of respondents indicate that they treat patients who use wearables and other devices for health-related purposes and that data from these devices has an impact on clinical practice.

Direct Measurement of the Astrophysical ^{19}F(p,αγ)^{16}O Reaction in the Deepest Operational Underground Laboratory

Fluorine is one of the most interesting elements in nuclear astrophysics, where the ^{19}F(p,α)^{16}O reaction is of crucial importance for Galactic ^{19}F abundances and CNO cycle loss in first generation Population III stars. As a day-one campaign at the Jinping Underground Nuclear Astrophysics experimental facility, we report direct measurements of the essential ^{19}F(p,αγ)^{16}O reaction channel. The γ-ray yields were measured over E_{c.m.}=72.4-344  keV, covering the Gamow window; our energy of 72.4 keV is unprecedentedly low, reported here for the first time. The experiment was performed under the extremely low cosmic-ray-induced background environment of the China JinPing Underground Laboratory, one of the deepest underground laboratories in the world. The present low-energy S factors deviate significantly from previous theoretical predictions, and the uncertainties are significantly reduced. The thermonuclear ^{19}F(p,αγ)^{16}O reaction rate has been determined directly at the relevant astrophysical energies.

The effects of aerobic exercise on the intestinal tumors and flora of the ApcMin/+ mouse

INTRODUCTION

Intestinal tumor is one of the most common tumors that seriously threaten the health of residents all over the world. Studies suggest that the imbalance of intestinal flora is associated with tumorgenesis; meanwhile, long-term regular aerobic exercise can improve the occurrence and development of tumors. However, moderate aerobic exercise affecting the development of intestinal tumors and their related flora has not been explored. Thus, the purpose of our study is to explore the effects of aerobic exercise on intestinal tumor growth and flora changes in Apc^Min/+ mice, and try to answer whether there is a correlation between them after exercise intervention.

METHODS

In this study, 18 required Apc^Min/+ mice were randomly divided into Model group (n = 6), Exercise group (n = 6), and Aspirin group (positive control, n = 6), while C57BL/6 J wild-type mice were used as the blank control group. Each group is given corresponding intervention. Weight monitoring, tumor counts, hematoxylin-eosin staining, TdT-mediated dUTP nick-end labeling (TUNEL) fluorescence assay, immunohistochemistry (IHC), fecal sampling and grouping, and bacterial 16S rDNA gene analysis were completed after 12 weeks' intervention for each group of mice.

RESULTS

As a result, we were able to show significant improvements in mice' body weight changing rates (Exercise group 8.6% higher than Model control group), tumor numbers (Exercise group 4.33 ± 0.94 vs. Model control group 7.33 ± 2.49, Then put the slides into xylenewith tumor inhibition rate 40.93%), tumor pathological staging (Exercise group mainly low-grade tumorous adenomas vs. Model group mainly high-grade adenomas), and TUNEL staining (Exercise group 8.59% higher positive rate of apoptotic cells in tumors than Model group). The 16s rRNA sequencing analysis results showed that aerobic exercise could regulate the abundance of some genus (16/149, P < 0.01), and the number of intestinal tumors correlates with changes in the abundance of some bacteria in the intestinal flora (positive correlation with probiotics abundance and negative correlation with conditioned pathogens).

DISCUSSION

Changes in flora abundance may be one of the reasons for aerobic exercise to reduce the number of intestinal tumors, probably mediated by cell apoptosis. Future studies should focus on the potential mechanism of aerobic exercise in preventing intestinal tumorgenesis, especially the molecular mechanism through intestinal flora.

CONCLUSION

Aerobic exercise has a preventive effect on intestinal tumors in Apc^Min/+ mice, and can regulate the abundance of intestinal flora.

Salvage mandibular reconstruction: multi-institutional analysis of 17 patients

Unsuccessful mandibular reconstruction occasionally occurs, leaving the patient with undesirable function and contours. In such cases, second- or third-time corrective operations are challenging. However, published studies on the complicated retreatment of such patients are scarce. A retrospective analysis covering the years 2015-2019 was conducted in three centers. All 17 patients included had undergone prior failed mandibular reconstructions in other institutions. Salvage secondary or tertiary reconstructive surgeries were attempted and the results are presented. Major factors for these failed reconstructions included exposed non-vascularized bone grafts (n = 7, 41.2%), flap loss (n = 4, 23.5%), exposed artificial joint (n = 3, 17.6%), skewed occlusion with deformity (n = 1, 5.9%), non-union (n = 1, 5.9%), and recurrence (n = 1, 5.9%). Fibula flaps were transferred in 15 patients, while iliac flaps were used in two patients for mandibular re-do reconstructions. Virtual surgical designs were conducted in nine (52.9%) patients, with navigation-guided approaches performed in three cases. Postoperative functions were relatively favorable in these complicated mandibular re-do reconstruction cases. Mandibular symmetry (mandibular length and height; P = 0.002) and condylar position (P < 0.001) were regained after these re-do attempts. Secondary or tertiary mandibular re-do reconstruction can still achieve good functional outcomes with appropriate preoperative selection and well-conceived designs, especially with the aid of virtual surgery and navigation.

Prospects for beyond the Standard Model physics searches at the Deep Underground Neutrino Experiment: DUNE Collaboration

The Deep Underground Neutrino Experiment (DUNE) will be a powerful tool for a variety of physics topics. The high-intensity proton beams provide a large neutrino flux, sampled by a near detector system consisting of a combination of capable precision detectors, and by the massive far detector system located deep underground. This configuration sets up DUNE as a machine for discovery, as it enables opportunities not only to perform precision neutrino measurements that may uncover deviations from the present three-flavor mixing paradigm, but also to discover new particles and unveil new interactions and symmetries beyond those predicted in the Standard Model (SM). Of the many potential beyond the Standard Model (BSM) topics DUNE will probe, this paper presents a selection of studies quantifying DUNE's sensitivities to sterile neutrino mixing, heavy neutral leptons, non-standard interactions, CPT symmetry violation, Lorentz invariance violation, neutrino trident production, dark matter from both beam induced and cosmogenic sources, baryon number violation, and other new physics topics that complement those at high-energy colliders and significantly extend the present reach.

Transcriptional responses of toxigenic and atoxigenic isolates of Aspergillus flavus to oxidative stress in aflatoxin-conducive and non-conducive media

Aflatoxin production by isolates of Aspergillus flavus varies, ranging from highly toxigenic to completely atoxigenic. Several mechanisms have been identified which regulate aflatoxin production including medium carbon source and oxidative stress. In recent studies, aflatoxin production has been implicated in partially ameliorating oxidative stress in A. flavus. To better understand the role of aflatoxin production in oxidative stress responses, a selection of toxigenic and atoxigenic isolates of A. flavus with moderate to high oxidative stress tolerance were exposed to increasing concentrations of H2O2 in both aflatoxin-conducive and non-conducive media. Mycelial mats were collected for global transcriptome sequencing followed by differential expression, functional prediction, and weighted co-expression analyses. Oxidative stress and medium carbon source had a significant effect on the expression of several secondary metabolite gene clusters including those for aflatoxin, aflatrem, aflavarin, cyclopiazonic acid, and kojic acid. Atoxigenic biological control isolates showed less differential expression under stress than other atoxigenic isolates suggesting expression profiles may be useful in screening. Increasing stress also resulted in regulation of SakA/Hog1 and MpkA MAP kinase signalling pathways pointing to their potential roles in regulating oxidative stress responses. Their expression was also influenced by medium carbon source. These results suggest that aflatoxin production along with that of other mycotoxins may occur as part of a concerted coping mechanism for oxidative stress and its effects in the environment. This mechanism is also regulated by availability of simple sugars and glycolytic compounds for their biosynthesis.

Transcriptional responses of toxigenic and atoxigenic isolates of Aspergillus flavus to oxidative stress in aflatoxin-conducive and non-conducive media

Aflatoxin production by isolates of Aspergillus flavus varies, ranging from highly toxigenic to completely atoxigenic. Several mechanisms have been identified which regulate aflatoxin production including medium carbon source and oxidative stress. In recent studies, aflatoxin production has been implicated in partially ameliorating oxidative stress in A. flavus. To better understand the role of aflatoxin production in oxidative stress responses, a selection of toxigenic and atoxigenic isolates of A. flavus with moderate to high oxidative stress tolerance were exposed to increasing concentrations of H2O2 in both aflatoxin-conducive and non-conducive media. Mycelial mats were collected for global transcriptome sequencing followed by differential expression, functional prediction, and weighted co-expression analyses. Oxidative stress and medium carbon source had a significant effect on the expression of several secondary metabolite gene clusters including those for aflatoxin, aflatrem, aflavarin, cyclopiazonic acid, and kojic acid. Atoxigenic biological control isolates showed less differential expression under stress than other atoxigenic isolates suggesting expression profiles may be useful in screening. Increasing stress also resulted in regulation of SakA/Hog1 and MpkA MAP kinase signalling pathways pointing to their potential roles in regulating oxidative stress responses. Their expression was also influenced by medium carbon source. These results suggest that aflatoxin production along with that of other mycotoxins may occur as part of a concerted coping mechanism for oxidative stress and its effects in the environment. This mechanism is also regulated by availability of simple sugars and glycolytic compounds for their biosynthesis.

Effects of lncRNA ANRIL on proliferation and apoptosis of oral squamous cell carcinoma cells by regulating TGF-β/Smad pathway

OBJECTIVE

To investigate the role of the long non-coding ribonucleic acid (lncRNA) antisense non-coding RNA in the INK4 locus (ANRIL) in the proliferation and apoptosis of the oral squamous cell carcinoma (OSCC) cells by regulating the transforming growth factor-beta (TGF-β)/Smad pathway.

PATIENTS AND METHODS

Human OSCC cells were cultured, and then transfected with small interfering (si)-ANRIL to inhibit the lncRNA ANRIL and ANRIL-OE to overexpress the lncRNA ANRIL. Next, the flow cytometry was carried out to detect the apoptosis rate, the proliferation was determined via methyl thiazolyl tetrazolium (MTT) assay, and the changes in the protein level were detected through Western blotting (WB).

RESULTS

The lncRNA ANRIL was highly expressed in the tissues and serum of patients. The proliferation ability of the cells transfected with si-ANRIL was significantly reduced, while that of the cells transfected with ANRIL-OE was overtly increased. The apoptosis rate was (9.21±5.22)%, (22.3±1.34)%, and (13.21±6.22)% in lncRNA ANRIL-OE group, si-ANRIL group and control group, respectively. The protein expression level of the apoptotic protein active caspase-3 was lowered after the treatment with ANRIL-OE, and the key molecules of the TGF-β/Smad pathway were notably down-regulated after inhibiting ANRIL with si-ANRIL.

CONCLUSIONS

The lncRNA ANRIL regulates the TGF-β/Smad signaling pathway to promote the proliferation and suppress the apoptosis of OSCC cells.

Stillbirths in China: a nationwide survey

Objective

To estimate a stillbirth rate at 24 or more gestational weeks in 2015–2016 and to explore potentially preventable causes in China.

Design

A multi‐centre cross‐sectional study.

Setting

Ninety‐six hospitals distributed in 24 (of 34) provinces in China.

Population

A total of 75 132 births at 24 completed weeks of gestation or more.

Methods

COX Proportional Hazard Models were performed to examine risk factors for antepartum and intrapartum stillbirths. Population attributable risk percentage was calculated for major risk factors. Correspondence analysis was used to explore region‐specific risk factors for stillbirths.

Main outcome measures

Stillbirth rate and risk factors for stillbirth.

Results

A total of 75 132 births including 949 stillbirths were used for the final analysis, giving a weighted stillbirth rate of 13.2 per 1000 births (95% CI 7.9–18.5). Small for gestational age (SGA) and pre‐eclampsia/eclampsia increased antepartum stillbirths by 26.2% and 11.7%, respectively. Fetal anomalies increased antepartum and intrapartum stillbirths by 17.9% and 7.4%, respectively. Overall, 31.4% of all stillbirths were potentially preventable. Advanced maternal age, pre‐pregnant obesity, chronic hypertension and diabetes mellitus were important risk factors in East China; low education and SGA were major risk factors in Northwest, Southwest, Northeast and South China; and pre‐eclampsia/eclampsia and intrapartum complications were significant risk factors in Central China.

Conclusions

The prevalence of stillbirth was 13.2 per 1000 births in China in 2015–2016. Nearly one‐third of all stillbirths may be preventable. Strategies based on regional characteristics should be considered to reduce further the burden of stillbirths in China.

Tweetable abstract

The stillbirth rate was 13.2 per 1000 births in China in 2015–2016 and nearly one‐third of all stillbirths may be preventable.

The stillbirth rate was 13.2 per 1000 births in China in 2015–2016 and nearly one‐third of all stillbirths may be preventable.

[Clinical efficacy of cyberknife in patients with primary large hepatocellular carcinoma over 70 years old]

Objective: To analyze the clinical efficacy and safety of cyberknife in the treatment of patients with primary large hepatocellular carcinoma over 70 years old. Methods: A total of 82 patients (58 males and 24 females) with large hepatocellular carcinoma aged over 70 years (70 to 85 years, (75±4) years) with a median tumor diameter of 6.7 cm (5.0~10.0 cm) were retrospectively collected. All patients were diagnosed by pathology or radiography in the Cancer Radiotherapy Center of the Fifth Medical Center of the PLA General Hospital from March 2014 to December 2018, and treated with cyberknife stereotactic radiotherapy. Progression free survival rate (PFS), local control rate (LC), overall survival rate (OS) and adverse reactions were observed at 1, 2 and 3 years. Kaplan-Meier was used for survival analysis, and Cox regression model was used to analyze survival-related factors. Results: All 82 patients successfully completed radiation therapy with a median survival time of 20 months, a median PFS of 10 months, an objective response rate of 64.63% (53/82), and a disease control rate of 85.37% (70/82). After treatment, the PFS at 1, 2, and 3 years were 39.0% (32/82), 22.1% (18/82), and 17.1% (14/82), respectively; the LC at 1, 2, and 3 years were 95.1% (78/82), 92.3% (76/82), and 92.3% (76/82), respectively; and the OS at 1, 2, and 3 years were 68.3% (56/82), 48.8% (40/82) and 31.7% (26/82), respectively. Nine patients suffered from radiation-induced liver disease (RILD), and there were no deaths due to RILD. Cox regression analysis showed that alpha-fetoprotein (AFP) was an independent risk factor for OS (HR=2.304, 95%CI 1.118-4.747;P<0.05). Conclusion: Cyberknife treatment for patients with primary large hepatocellular cancer over 70 years old has higher LC and OS, better curative effect, and less treatment-related adverse reactions.

Constraining the External Capture to the ^{16}O Ground State and the E2 S Factor of the ^{12}C(α,γ)^{16}O Reaction

The ^{12}C(α,γ)^{16}O reaction is one of the most crucial reactions in nuclear astrophysics. The E2 external capture to the ^{16}O ground state (GS) has not been emphasized in previous analyses but may make a significant contribution to the ^{12}C(α,γ)^{16}O cross section depending on the value of the GS asymptotic normalization coefficient (ANC). In the present work, we determine this ANC to be 337±45  fm^{-1/2} through the ^{12}C(^{11}B,^{7}Li)^{16}O reaction using a high-precision magnetic spectrograph. This sheds light on the existing large discrepancy of more than 2 orders of magnitude between the previously reported ANC values. Based on the new ANC, we experimentally constrain the GS external capture and show that through interference with the high energy tail of the 2^{+} subthreshold state, a substantial enhancement in the GS S_{E2}(300) factor can be obtained (70±7  keV b) compared to that of a recent review (45 keV b), resulting in an increase of the total S factor from 140 to 162 keV b, which is now in good agreement with the value obtained by reproducing supernova nucleosynthesis calculations with the solar-system abundances. This work emphasizes that the external capture contribution for the ground state transition cannot be neglected in future analyses of the ^{12}C(α,γ)^{16}O reaction.

[Research on the effects of CPAP for OSA combined CHD long-term prognosis]

Objective:To investigate the effects of CPAP for obstructive sleep apnea（OSA） combined CHD（coronary heart disease） long-term prognosis. Method:One hundred and twenty cases of OSA combind CHD in gansu province people's hospital sleep center were randomly divided into two groups according to apnea hypopnea index（AHI）, group A（light, medium OSA and CHD） 60 cases, group B（severe OSA and CHD） 60 cases. Contrast analysis and comparison between two groups PSG（Polysomnography） parameters, and the differences between the degree of coronary artery lesions and CPAP therapy effect on coronary long-term prognosis. Result:Compared group B with A, AHI, BMI, LSaO2, Epworth sleepiness scale（ESS） score, the amino acid homocysteine, the prevalence of hypertension, type 2 diabetes, the prevalence of acute myocardial infarction（ami） and vascular lesions and SYNTAX score increased significantly（P<0.05）. The ejection fraction decreased significantly（P<0.05）. The BNP（Brain natriuretic peptide） and cTNT（cardiac troponin, cTn） concentration there was no significant difference between the two groups（P>0.05）. CPAP treatment（30.0±4.2） months later, Group B: CAPA + conventional treatment group, compared with the simple routine LSaO2, ejection fraction increased significantly（P<0.05）, AHI, cardiovascular adverse events, vascular lesions, SYNTAX score, the BNP and TNT concentration significantly reduced（P<0.05）; Group A: AHI, decreased significantly（P<0.05）, LSaO2increased significantly（P<0.05）, ejection fraction, cardiovascular adverse events, vascular lesions, SYNTAX score, there was no significant difference between the BNP and TNT concentration; Survival analysis showed that: Group A CPAP+conventional treatment group cumulative survival rate higher than the conventional treatment group, but there was no statistically significant difference（P=0.260）. Group B: CPAP+conventional treatment group total survival rate was significantly higher than that of the conventional treatment group（P<0.001）; Conclusion:With the increase of the severity of OSA, OSA merge CHD coronary artery pathological changes degree aggravating, CPAP therapeutic benefit the long-term prognosis of CHD.

Effect of celecoxib on protein expression of FAK and Cx43 in DMBA induced rat tongue carcinoma cells

OBJECTIVE

The pathogenesis of tongue cancer (TA) has not been fully illustrated. Cyclooxygenase-2 (COX-2) is correlated with the precancerous lesion of oral cavity mucosa and malignant transformation. The focal adhesion kinase (FAK) and gap junction protein connexin 43 (Cx43) are involved in the occurrence and progression of tumors. This study aimed to investigate the effect of celecoxib on the proliferation, malignant transformation, and expression of FAK and Cx43 proteins.

MATERIALS AND METHODS

Healthy male Sprague-Dawley (SD) rats (4 months old) were divided into control, model and celecoxib group. 7,12-dimethylbenzanthracene (DMBA) was used to generate tongue mucosal carcinoma, coupled with celecoxib intervention. At 8, 12, 16, and 20 weeks after induction, the rat survival status, the tumor formation rate and the tongue tissue morphology were observed. Meanwhile, the expression of FAK and Cx43 was also evaluated by using immunohistochemistry (IHC).

RESULTS

Tumor occurrence rates after induction were 0, 26.67%, 66.67%, and 80% at 8, 12, 16, and 20 weeks, respectively. The celecoxib treatment decreased such rats to 0, 0, 0, and 13.33%, respectively (p<0.05 compared to model group). No significant change was observed in control group, whilst model group had mild to severe hyperplasia and squamous carcinoma with elongated time. Celecoxib treatment significantly improved the tissue morphology (p<0.05). The model group also had elevated FAK and depressed Cx43 protein expression (p<0.05). With elongated time, the FAK expression was further increased whilst Cx43 protein was depressed (p<0.05 compared to model group).

CONCLUSIONS

The focal application of celecoxib effectively inhibited the DMBA-induced rat TA, possibly via regulating FAK and CX43 protein expression, and inhibiting oral epidermal hyperplasia.

First measurement of neutrino oscillation parameters using neutrinos and antineutrinos by NOvA

The NOvA experiment has seen a 4.4σ signal of ν[over ¯]_{e} appearance in a 2 GeV ν[over ¯]_{μ} beam at a distance of 810 km. Using 12.33×10^{20} protons on target delivered to the Fermilab NuMI neutrino beamline, the experiment recorded 27 ν[over ¯]_{μ}→ν[over ¯]_{e} candidates with a background of 10.3 and 102 ν[over ¯]_{μ}→ν[over ¯]_{μ} candidates. This new antineutrino data are combined with neutrino data to measure the parameters |Δm_{32}^{2}|=2.48_{-0.06}^{+0.11}×10^{-3}  eV^{2}/c^{4} and sin^{2}θ_{23} in the ranges from (0.53-0.60) and (0.45-0.48) in the normal neutrino mass hierarchy. The data exclude most values near δ_{CP}=π/2 for the inverted mass hierarchy by more than 3σ and favor the normal neutrino mass hierarchy by 1.9σ and θ_{23} values in the upper octant by 1.6σ.